Folie & six: a case report on induced psychotic disorder Dippel B, Kemper J, Berger M. Folie a six: a case report on induced psychotic disorder. Acta Psychiatr Scand 1991: 83: 137-141.
6. Dippel’, J. Kernper’, M. Berger’r3
’
Max Planck Institute of Psychiatry, * Private practice, Munich, Department of Psychiatry, University of Freiburg, Freiburg, Federal Republic of Germany
A case of folie a six is described in which the persecutory delusions of
the central figure spread to her husband and their 2 sons, and even to her sister-in-law and a nephew. The main factor in the development of this shared paranoid disorder seems to have been the dominant personality of the inducer. In contrast to reports in the literature, there was no family history of such disorders and there were no adverse social or environI mental circumstances.
Long before “modern psychiatry” had developed, the phenomenon of shared paranoid disorder attracted the interest of physicians. According to Greenberg (l), Harvey’s report in 1651 was probably the first one of its kind. Lasegue & Falret (2) coined the term folie a deux in 1877. Nevertheless, the occurrence of shared paranoid disorder is relatively rare. Gralnick (3) reviewed 103 cases reported in the Anglo-American literature between 1879 and 1942; Floru (4) claimed that 245 cases had been published worldwide by 1972. And the number of reports of delusions shared by more than 2 people is extremely small: Glassman et al. (5) found only about 20 cases of folie a famille in the literature. Dewhurst & Todd (6) suggested the following essential conditions for the diagnosis of folie a deux: positive evidence that the partners are intimately associated; similarity in the content of the shared delusions; and evidence that the subjects accept, share, and support one another’s delusions. In abbreviated form we find the same description in today’s DSM-111, where shared paranoid disorder is characterized as “a persecutory delusional system that develops as a result of a close relationship with another person who already has a disorder with persecutory delusions” (DSM-111: 297.30). There are several conflicting hypotheses on the origin of the disorder. It seems trivial to state that the etiology is multidimensional and involves factors such as hereditary predisposition, premorbid personality, specific features of the relationship between the partners, and adverse social conditions. Regarding the role of genetic factors, Scharfetter (7) maintains that there is an increased risk of
Key words: folie a six; shared psychosis; induced psychosis Mathias Berger, M.D., Department of Psychiatry, University of Freiburg, Hauptstr. 5, D-7800 Freiburg, Federal Republic of Germany Accepted for publication September 1, 1990
schizophrenia in the families of the induced persons, even if the induced and inducer are not consanguineous (38% of the cases he found in the literature). Other authors tend to minimize the importance of heredity because sometimes the course of the paranoid disorder in the induced persons showed dramatic improvement after an environmental manipulation only (8). In his review Scharfetter (7) also summarizes frequent characteristics of the premorbid personality: the inducers are described as often being sthenic and dominant individuals of normal intelligence, the induced persons as asthenic, infantile, and less intelligent. Regarding the emotional relationships among the partners in folie a famille, Glassman et al. ( 5 ) claim several features to be typical. Among these are mutually dependent and ambivalent relationships, and an underlying threat or the frank presence of violent behavior. Psychoanalytic authors (such as Deutsch (9)) have interpreted the shared delusion as an attempt to rescue the object. Through identification with the inducer, induced persons are able to project their aggression onto the environment instead of onto their partner. Discussing the role of social and environmental conditions, Floru (4) and Glassman et al. (5) agree that isolation is a typical feature. Social and economic problems in the midst of an indifferent or rejecting community (4) or repeated crises ( 5 ) also seem to be important. In this article we describe a case of folie a six that in several respects does not seem to fit the characteristic picture just outlined. 137
Dippel et al. Case report
The key figure in the induced paranoid disorder was Mrs. A*, a housewife and former hairdresser. She came to the attention of the second author (J.K.) when in 1980, at the age of 41, she first sought help in his psychiatric practice. At the end of 1985 she was admitted to the Max Planck Institute of Psychiatry as an inpatient, by which time her persecutory delusions had intensified and spread to her husband and their 2 sons, and even to her sister-in-law and a nephew. Here at the Institute all of the induced persons except the nephew (whom we were unable to contact) were interviewed at length (by B.D. and M.B.). The inducer
Mrs. A was born and grew up in a small rural village in Austria. Mrs. A’s father was a day laborer. He died in 1969. She remembered him as a good-looking man, but someone who was strict, easily angered, and emotionally unstable. Her mother was a housewife. She died when the patient was less than 2 years old. A year later Mrs. A’s father remarried. Her stepmother was a widow who brought three children of her own into the new family, and in 1944 gave birth to Mrs. A’s half-sister. Although the stepmother was seriously ill, she was resolute and domineering. She died in 1945. During the following years, the father had a problematic liaison with another woman, who took poor care of Mrs. A. Therefore, Mrs. A temporarily went to live with an aunt, and later, in 1951, was a maid on a farm. After her father had broken off his affair, she returned home, and, with the agreement of the authorities, kept house for him and her half-sister. In 1954 a relative arranged for her to go to Vienna; here she lived in a church-run home and began an apprenticeship with a hairdresser. During these years she experienced emotional warmth for the first time in her life. Mrs. A completed her apprenticeship in 1958, and after a year of employment in Vienna moved to the FRG. Until then she had shown little interest in men and had not been curious about-sex. After a short affair she met her future husband, an engineer four years her senior. They were married in 1962. She described him as being a quiet, even-tempered and reliable person and said they had an “ideal relationship” that was very harmonious. Their first son was born in 1963, their second son in 1965. Though she had always wanted many children, after the second pregnancy she took oral contraceptives for economic reasons; after surgery for a myoma in 1971 she was *not the real initial.
138
sterile. In her opinion her elder son had become more and more intellectual and introverted over the years; she felt she had been both overprotective and strict in raising him. The relationship between them had become ambivalent and difficult. In 1985 he had considered leaving home, but then abandoned the idea after a series of quarrels with her. The younger son is apparently more self-sufficient, is goodlooking and easygoing and does not have any problems living with his parents. The patient described herself as being an energetic and assertive person with a love of life, adding that she was sometimes quick-tempered with the children. She said that social contacts and having a lot of friends were an important part of her life. The first mild symptoms appeared after the family moved to a new apartment in 1976. The family living above them had a new baby, and Mrs. A was extraordinarily upset by the boy’s crying. She complained a lot to the neighbors and the two families began to have quarrels. The situation escalated to the point that she engaged a lawyer. The controversy went on for several years. In 1980 Mrs. A developed mild delusional symptoms, believing that the family above was making noise on purpose. She suffered from headaches and had trouble sleeping. She was first seen by J.K. at this time. Treatment consisted of fluspirilene, relaxation training and behavior therapy. By 1982 the symptoms seemed to have disappeared and she was able to stop taking neuroleptics. In the summer of 1983 Mrs. A developed several unclear somatic complaints. Hospital studies yielded the diagnoses of essential hypotonia, irritable colon, and chronic vasomotor headaches. J.K. again treated Mrs. A with neuroleptics, although only for a short time. During 1984, the delusional symptoms reappeared. When she woke up at night, she heard mumbling and thought she could identify distinct words, for example the name of her elder son, and she had tingling sensations and sharp pains in her feet. She sometimes watched her son while he slept, worrying about him because he tossed and turned and often sat up in bed suddenly. She grew suspicious of the neighbors, fearing they might be trying to manipulate the family with technical devices. When she realized that her electricity bill had gone up and one day a wire hung in front of her window briefly, she felt it was confirmed. By the winter 1984-1985 the delusion had engulfed the rest of the family: Mrs. A’s husband and their 2 sons had symptoms similar to hers during the night and fatigue in the morning. A sister-in-law and a nephew slept in the apartment on request, and they, too, had unclear physical complaints. The family then undertook several activities to prove they were being persecuted
Folie a six
by the neighbors. They hired lawyers and a private detective, and got opinions from the telephone company, an institute for radiology and a friend working with the secret service. During the summer of 1985 they took the offensive. As a counterattack they installed a microphone on the ceiling. Before reporting their findings to the authorities, they asked J.K. for advice. He recommended that Mrs. A first have her health checked, preferably at a sleep research unit. He referred her to our hospital. Mrs. A presented as an attractive woman who looked younger than her age. She was wearing a good-looking sporty outfit and gave the impression of being a very charming and likeable person. She told her story in a very vigorous and convincing manner, captivating her interlocutor’s attention. In addition, she produced a clear feeling of countertransference: this woman cannot possibly be that sick. There were no formal thought disorders, and her affect was always adequate. After about a week in the hospital she reported the following dream: “My two sons, still very small, were walking downstream along a creek that flowed through a green meadow. Suddenly there were other kids there, too. They were carried away by the creek, and suddenly my boys were gone”. The results of Mrs. A’s physical examination, including laboratory screening, EEG and cranial computer tomography, were unremarkable. The examination at the sleep laboratory revealed a disturbed and irregular sleep pattern. The induced
Mr. A was a stocky 50-year-old man who seemed good-natured. He reported that his wife continually talked about her complaints and asked the whole family whether or not they felt “it”. He had in fact woken up more often during the night since the spring of 1984, and when he did he usually felt a slight twitch in his legs. Sometimes he heard a highpitched sound in the room, noticed that the sound from his loudspeakers was suddenly distorted, or saw that the stereo indicator on the television was inexplicably flickering on and off. He was therefore quite sure about the radiation coming from the apartment above them. As to his marriage, Mr. A reported that he and his wife had a very harmonious relationship and often acted like twins. He characterized life with their two sons as being very harmonious as well. Every so often on a Sunday morning the whole family still gathered in the parents’ bed. Mrs. A’s elder son, aged 22, was a gangling young man who seemed cautious and introverted. He had been a university student since the fall of 1984. A few weeks after he entered the university he began to feel
increasingly tired during the day. Six months later hepatitis type B was diagnosed. During this whole period his mother kept telling him about the “actions from above” and asked him to watch himself closely. Beginning in the summer of 1985 he felt a tingling sensation in his legs when falling asleep, a kind of warmth and sometimes even a twitch. At first he was rather skeptical about what his mother said regarding the bad relationship with the neighbors, but then he began to feel more and more that this could be the real reason for the changes. On the whole he tended to believe his mother’s theory. Asked about the family, he described his mother as being very concerned about him and his brother. The real reason why he had considered moving out was that at that time he had experienced his mother as being “a little domineering”. In retrospect he felt that he had exaggerated somewhat. In addition, he said he had had two girlfriends so far. He met the first one in 1980 and went out with her for about 6 months. He got to know the second one in the autumn of 1984, and this relationship had lasted for 3 months. Mrs. A’s younger son was a 20-year-old young man with an athletic build, who gave the impression of being a bright, healthy, and self-contented individual. Since July 1985 he had had more and more difficulty getting up in the morning and had felt more tired during the day than before. Once he had even felt “unpleasant pain” in a joint and several times a twitching of his body. In the past month these sensations had been the main topic of conversation among the members of the family. He was convinced that “something is wrong”. He tended to believe his mother’s explanations. Mrs. A’s sister-in-law, aged about 50, was a psychologist who appeared to be a conventional and unobtrusive woman. She said her relationship with her sister-in-law had generally been difficult and this was why she had been skeptical at first about the whole affair. Then she was asked by the family to stay in the apartment overnight, which she did 3 times. On one occasion she felt a sharp pain in her lower leg and also had a restless night. (In addition, she said that Mrs. A had repeatedly walked around the apartment during the night.) She herself had asked a professor she knew whether such sensations could be caused by radiation. From her own experience she felt Mrs. A’s interpretation could not be ignored. She had advised the family to get a notebook and write down all unusual observations. She described Mrs. A as a woman who always wanted a lot of things, for instance clothes, evenings out, and entertainment. She was sure her brother would not have been able to leave his parents if Mrs. A had not “lent a hand”. She portrayed Mrs. A as an impatient, possessive person who wanted to 139
Dippel et al.
dominate her environment, especially her family, but who was also very protective and who gave her all for them. Nevertheless, she felt a kind of compassion for Mrs. A because the last few years had been very hard for her. Mrs. A’s nephew, her half-sister’s son, was living in Austria and therefore we were not able to interview him. Because he was an electrician, Mrs. A regarded him as an expert for her problems and had invited him to spend a night at the apartment. The members of the family agreed that after this night he had felt painful pressure in his legs and had even reported “a kind of paralysis”. After that he immediately installed the microphone on the ceiling “to prove possible radiation”. Treatment course
We told Mrs. A that despite our investigations we were unable to make any decision about her complaints from the viewpoint of natural science. However, as her physical condition and also the sleep EEG were obviously, for whatever reason, adversely affected, we recommended that she resume taking fluspirilene to stabilize her health. Furthermore, we suggested the family move to another apartment. (We felt this would be the best way for all members of the family to withdraw from their shared delusions.) Mrs. A and her family first accepted this advice, and she received depot neuroleptics once a week. She was discharged and treated again by J.K. in his psychiatric practice. She decided to stay in the apartment with her husband, but the two boys soon moved out. After a total of 9 months on neuroleptics all somatic complaints and the sleep disorder had disappeared. The patient and J.K. then together decided that treatment should be discontinued. At this time the whole family apparently had withdrawn form the shared delusions, and Mrs. A herself admitted that she had suffered from a mental disorder during the past several years. However, in 1988 J.K. learned that Mrs. A was now seeing another psychiatrist. She was again on neuroleptics and was also attending behavior therapy sessions. Discussion
Mrs. A’s symptoms meet the DSM-I11 criteria for paranoia (297.10), but not for schizophrenia of schizophreniform disorder. Over a period of several years a persisting and unshakable persecutory and delusional system had developed, but there were no symptoms such as bizarre delusions, incoherence, or marked loosening of associations. It is even unclear 140
whether the patient had hallucinations or perhaps only illusionary misjudgments when she reported identifying noises from the apartment above as words. On the other hand, the patient responded very well to neuroleptics; considering the usual finding on the course of paranoia, this raises some doubts about our diagnosis. From a psychodynamic point of view, preserving family security and unity might be seen as the main theme of Mrs. A’s paranoia. This would be easy to understand because in her difficult childhood Mrs. A never had any sense of security and emotional warmth within her family. Although she grew up to be a strong and powerful person, she retained the desire to have a large family and to control her object relations. Probably the myoma operation and her subsequent sterility were a frustration of these wishes. Early signs of pathological development occurred when the neighbors had a baby. One might speculate that Mrs. A’s vehemence in fighting against the noise molestation might have been conducive to suppressing her sorrow over her sterility. However, the first real paranoid symptoms did not appear until 1980, at the time her elder son met his first girlfriend and re-exacerbated in 1984, when he entered university and had his second affair. Finally, the delusions spread to the family in 1985, at the time when he was considering moving out. Thus the delusion enabled Mrs. A to project her annoyance and aggression about her son wanting to leave onto her neighbors and gave her a reason for mothering him again. Beyond these speculations, it seems important to reconstruct the factors that supported the spreading of the delusion to the whole family. First we must emphasize that we do not know of any predisposition to psychotic disorders in either Mrs. A’s or her husband’s family. Of course we do not have complete information about Mrs. A’s relatives, especially on her mother’s side, but we can exclude any genetic factors playing a role in the induced persons not consanguineous to Mrs. A (her husband and sisterin-law). This clearly contradicts the findings of Scharfetter (7). Mrs. A’s premorbid personality with dominance and willfulness exemplifies the features described in the literature. As to the induced persons, only one of them seems to meet the criteria mentioned by Scharfetter (7), the husband, who is a rather passive, good-natured and weak person. The sons at most have certain features of ambivalence or indecisiveness. However, the sister-in-law seems to be a rather self-reliant person. In our opinion, these observations emphasize the persuasive and suggestive power emanating from Mrs. A’s strong personality, which was quite impressive even to us. From such an experience, one can understand why previous
Folie a six authors have pointed out a similarity between folie a deux and hypnosis (6, 10). Each family member had a different type of emotional relationship with Mrs. A. The husband and the younger son clearly had stable, positive emotional ties to her. The elder son and the sister-in-law had a much more ambivalent attitude towards her and the whole family. However, the psychoanalytic explanation given by Deutsch (9) is correct for the elder son at best. By identifying with Mrs. A he was able to be angry towards the neighbors instead of his mother. Regarding the sister-in-law, it is open to question whether this mechanism could work as there was no reason for her to give up her anger and ambivalence towards Mrs. A. Instead, possibly out of compassion or pity, an unconscious desire to help Mrs. A by showing solidarity may have played a role. In any case, there were only subtle peculiarities in the emotional relationships among the family members. Dramatic features such as constant threats of violent behavior, as mentioned by Glassman et al. (5), were not evident in our case. The same can be said about the social and environmental conditions, which were entirely normal and average. Social isolation, poor economic conditions or living in a rejecting community (4) did not have any etiological relevance. In summary, the main factor in the development of the shared paranoid disorder described here seems to have been the domineering personality of the key person and her ability to influence others by
suggestion. This was paired with features in the induced persons such as a passive character (husband) or an easygoing, somewhat indecisive personality (younger son). Beyond this, one might speculate about the role of unconscious dynamics such as “identification with the aggressor” (elder son) or “identification out of pity” (sister-in-law). The absence of adverse social and environmental conditions and in particular of a predisposition to paranoia seem to account for the uncomplicated disappearance of the induced paranoid disorder. References 1. GREENBERG HP. Crime and folie a deux: review and case
history. J Ment Sci 1956: 102: 772-779. 2. LASEGUEC, FALRET J. La folie a deux (ou folie communiquee). Ann Med Psycho1 (Paris) 1877: 18: 321. 3. GRALNICK A. Folie a deux. Psychiatr Q 1942: 16: 230-263. 4. FLORUL. Der induzierte Wahn: theoretischer uberblick und Bemerkungen am Rande von 12 Fallen. Fortschr Neurol Psychiatr 1974: 42: 76-96. 5 . GLASSMAN JNS, MAGULAC M, DARKODF. Folie a famille: shared paranoid disorder in a Vietnam veteran and his family. Am J Psychiatry 1987: 144: 658-660. K, TODDJ. The psychosis of association - folie 6. DEWHURST a deux. J Nerv Ment Dis 1956: 124: 541-459. C. Symbiotische Psychosen: Studie iiber 7. SCHARFETTER Schizophreniartige “induzierte Psychosen”. Bern: Verlag Hans Huber, 1970. 8. TSENGWS. A paranoid family in Taiwan: a dynamic study of folie A famille. Arch Gen Psychiatry 1969: 21: 55-63. 9. DEUTSCHH. Folie a deux. Psychoanal Q 1938: 7: 307-318. 10. WALTZERH. A psychotic family - folie douze. J Nerv Ment Dis 1963: 137: 67-15.
141
6. Dippel’, J. Kernper’, M. Berger’r3
’
Max Planck Institute of Psychiatry, * Private practice, Munich, Department of Psychiatry, University of Freiburg, Freiburg, Federal Republic of Germany
A case of folie a six is described in which the persecutory delusions of
the central figure spread to her husband and their 2 sons, and even to her sister-in-law and a nephew. The main factor in the development of this shared paranoid disorder seems to have been the dominant personality of the inducer. In contrast to reports in the literature, there was no family history of such disorders and there were no adverse social or environI mental circumstances.
Long before “modern psychiatry” had developed, the phenomenon of shared paranoid disorder attracted the interest of physicians. According to Greenberg (l), Harvey’s report in 1651 was probably the first one of its kind. Lasegue & Falret (2) coined the term folie a deux in 1877. Nevertheless, the occurrence of shared paranoid disorder is relatively rare. Gralnick (3) reviewed 103 cases reported in the Anglo-American literature between 1879 and 1942; Floru (4) claimed that 245 cases had been published worldwide by 1972. And the number of reports of delusions shared by more than 2 people is extremely small: Glassman et al. (5) found only about 20 cases of folie a famille in the literature. Dewhurst & Todd (6) suggested the following essential conditions for the diagnosis of folie a deux: positive evidence that the partners are intimately associated; similarity in the content of the shared delusions; and evidence that the subjects accept, share, and support one another’s delusions. In abbreviated form we find the same description in today’s DSM-111, where shared paranoid disorder is characterized as “a persecutory delusional system that develops as a result of a close relationship with another person who already has a disorder with persecutory delusions” (DSM-111: 297.30). There are several conflicting hypotheses on the origin of the disorder. It seems trivial to state that the etiology is multidimensional and involves factors such as hereditary predisposition, premorbid personality, specific features of the relationship between the partners, and adverse social conditions. Regarding the role of genetic factors, Scharfetter (7) maintains that there is an increased risk of
Key words: folie a six; shared psychosis; induced psychosis Mathias Berger, M.D., Department of Psychiatry, University of Freiburg, Hauptstr. 5, D-7800 Freiburg, Federal Republic of Germany Accepted for publication September 1, 1990
schizophrenia in the families of the induced persons, even if the induced and inducer are not consanguineous (38% of the cases he found in the literature). Other authors tend to minimize the importance of heredity because sometimes the course of the paranoid disorder in the induced persons showed dramatic improvement after an environmental manipulation only (8). In his review Scharfetter (7) also summarizes frequent characteristics of the premorbid personality: the inducers are described as often being sthenic and dominant individuals of normal intelligence, the induced persons as asthenic, infantile, and less intelligent. Regarding the emotional relationships among the partners in folie a famille, Glassman et al. ( 5 ) claim several features to be typical. Among these are mutually dependent and ambivalent relationships, and an underlying threat or the frank presence of violent behavior. Psychoanalytic authors (such as Deutsch (9)) have interpreted the shared delusion as an attempt to rescue the object. Through identification with the inducer, induced persons are able to project their aggression onto the environment instead of onto their partner. Discussing the role of social and environmental conditions, Floru (4) and Glassman et al. (5) agree that isolation is a typical feature. Social and economic problems in the midst of an indifferent or rejecting community (4) or repeated crises ( 5 ) also seem to be important. In this article we describe a case of folie a six that in several respects does not seem to fit the characteristic picture just outlined. 137
Dippel et al. Case report
The key figure in the induced paranoid disorder was Mrs. A*, a housewife and former hairdresser. She came to the attention of the second author (J.K.) when in 1980, at the age of 41, she first sought help in his psychiatric practice. At the end of 1985 she was admitted to the Max Planck Institute of Psychiatry as an inpatient, by which time her persecutory delusions had intensified and spread to her husband and their 2 sons, and even to her sister-in-law and a nephew. Here at the Institute all of the induced persons except the nephew (whom we were unable to contact) were interviewed at length (by B.D. and M.B.). The inducer
Mrs. A was born and grew up in a small rural village in Austria. Mrs. A’s father was a day laborer. He died in 1969. She remembered him as a good-looking man, but someone who was strict, easily angered, and emotionally unstable. Her mother was a housewife. She died when the patient was less than 2 years old. A year later Mrs. A’s father remarried. Her stepmother was a widow who brought three children of her own into the new family, and in 1944 gave birth to Mrs. A’s half-sister. Although the stepmother was seriously ill, she was resolute and domineering. She died in 1945. During the following years, the father had a problematic liaison with another woman, who took poor care of Mrs. A. Therefore, Mrs. A temporarily went to live with an aunt, and later, in 1951, was a maid on a farm. After her father had broken off his affair, she returned home, and, with the agreement of the authorities, kept house for him and her half-sister. In 1954 a relative arranged for her to go to Vienna; here she lived in a church-run home and began an apprenticeship with a hairdresser. During these years she experienced emotional warmth for the first time in her life. Mrs. A completed her apprenticeship in 1958, and after a year of employment in Vienna moved to the FRG. Until then she had shown little interest in men and had not been curious about-sex. After a short affair she met her future husband, an engineer four years her senior. They were married in 1962. She described him as being a quiet, even-tempered and reliable person and said they had an “ideal relationship” that was very harmonious. Their first son was born in 1963, their second son in 1965. Though she had always wanted many children, after the second pregnancy she took oral contraceptives for economic reasons; after surgery for a myoma in 1971 she was *not the real initial.
138
sterile. In her opinion her elder son had become more and more intellectual and introverted over the years; she felt she had been both overprotective and strict in raising him. The relationship between them had become ambivalent and difficult. In 1985 he had considered leaving home, but then abandoned the idea after a series of quarrels with her. The younger son is apparently more self-sufficient, is goodlooking and easygoing and does not have any problems living with his parents. The patient described herself as being an energetic and assertive person with a love of life, adding that she was sometimes quick-tempered with the children. She said that social contacts and having a lot of friends were an important part of her life. The first mild symptoms appeared after the family moved to a new apartment in 1976. The family living above them had a new baby, and Mrs. A was extraordinarily upset by the boy’s crying. She complained a lot to the neighbors and the two families began to have quarrels. The situation escalated to the point that she engaged a lawyer. The controversy went on for several years. In 1980 Mrs. A developed mild delusional symptoms, believing that the family above was making noise on purpose. She suffered from headaches and had trouble sleeping. She was first seen by J.K. at this time. Treatment consisted of fluspirilene, relaxation training and behavior therapy. By 1982 the symptoms seemed to have disappeared and she was able to stop taking neuroleptics. In the summer of 1983 Mrs. A developed several unclear somatic complaints. Hospital studies yielded the diagnoses of essential hypotonia, irritable colon, and chronic vasomotor headaches. J.K. again treated Mrs. A with neuroleptics, although only for a short time. During 1984, the delusional symptoms reappeared. When she woke up at night, she heard mumbling and thought she could identify distinct words, for example the name of her elder son, and she had tingling sensations and sharp pains in her feet. She sometimes watched her son while he slept, worrying about him because he tossed and turned and often sat up in bed suddenly. She grew suspicious of the neighbors, fearing they might be trying to manipulate the family with technical devices. When she realized that her electricity bill had gone up and one day a wire hung in front of her window briefly, she felt it was confirmed. By the winter 1984-1985 the delusion had engulfed the rest of the family: Mrs. A’s husband and their 2 sons had symptoms similar to hers during the night and fatigue in the morning. A sister-in-law and a nephew slept in the apartment on request, and they, too, had unclear physical complaints. The family then undertook several activities to prove they were being persecuted
Folie a six
by the neighbors. They hired lawyers and a private detective, and got opinions from the telephone company, an institute for radiology and a friend working with the secret service. During the summer of 1985 they took the offensive. As a counterattack they installed a microphone on the ceiling. Before reporting their findings to the authorities, they asked J.K. for advice. He recommended that Mrs. A first have her health checked, preferably at a sleep research unit. He referred her to our hospital. Mrs. A presented as an attractive woman who looked younger than her age. She was wearing a good-looking sporty outfit and gave the impression of being a very charming and likeable person. She told her story in a very vigorous and convincing manner, captivating her interlocutor’s attention. In addition, she produced a clear feeling of countertransference: this woman cannot possibly be that sick. There were no formal thought disorders, and her affect was always adequate. After about a week in the hospital she reported the following dream: “My two sons, still very small, were walking downstream along a creek that flowed through a green meadow. Suddenly there were other kids there, too. They were carried away by the creek, and suddenly my boys were gone”. The results of Mrs. A’s physical examination, including laboratory screening, EEG and cranial computer tomography, were unremarkable. The examination at the sleep laboratory revealed a disturbed and irregular sleep pattern. The induced
Mr. A was a stocky 50-year-old man who seemed good-natured. He reported that his wife continually talked about her complaints and asked the whole family whether or not they felt “it”. He had in fact woken up more often during the night since the spring of 1984, and when he did he usually felt a slight twitch in his legs. Sometimes he heard a highpitched sound in the room, noticed that the sound from his loudspeakers was suddenly distorted, or saw that the stereo indicator on the television was inexplicably flickering on and off. He was therefore quite sure about the radiation coming from the apartment above them. As to his marriage, Mr. A reported that he and his wife had a very harmonious relationship and often acted like twins. He characterized life with their two sons as being very harmonious as well. Every so often on a Sunday morning the whole family still gathered in the parents’ bed. Mrs. A’s elder son, aged 22, was a gangling young man who seemed cautious and introverted. He had been a university student since the fall of 1984. A few weeks after he entered the university he began to feel
increasingly tired during the day. Six months later hepatitis type B was diagnosed. During this whole period his mother kept telling him about the “actions from above” and asked him to watch himself closely. Beginning in the summer of 1985 he felt a tingling sensation in his legs when falling asleep, a kind of warmth and sometimes even a twitch. At first he was rather skeptical about what his mother said regarding the bad relationship with the neighbors, but then he began to feel more and more that this could be the real reason for the changes. On the whole he tended to believe his mother’s theory. Asked about the family, he described his mother as being very concerned about him and his brother. The real reason why he had considered moving out was that at that time he had experienced his mother as being “a little domineering”. In retrospect he felt that he had exaggerated somewhat. In addition, he said he had had two girlfriends so far. He met the first one in 1980 and went out with her for about 6 months. He got to know the second one in the autumn of 1984, and this relationship had lasted for 3 months. Mrs. A’s younger son was a 20-year-old young man with an athletic build, who gave the impression of being a bright, healthy, and self-contented individual. Since July 1985 he had had more and more difficulty getting up in the morning and had felt more tired during the day than before. Once he had even felt “unpleasant pain” in a joint and several times a twitching of his body. In the past month these sensations had been the main topic of conversation among the members of the family. He was convinced that “something is wrong”. He tended to believe his mother’s explanations. Mrs. A’s sister-in-law, aged about 50, was a psychologist who appeared to be a conventional and unobtrusive woman. She said her relationship with her sister-in-law had generally been difficult and this was why she had been skeptical at first about the whole affair. Then she was asked by the family to stay in the apartment overnight, which she did 3 times. On one occasion she felt a sharp pain in her lower leg and also had a restless night. (In addition, she said that Mrs. A had repeatedly walked around the apartment during the night.) She herself had asked a professor she knew whether such sensations could be caused by radiation. From her own experience she felt Mrs. A’s interpretation could not be ignored. She had advised the family to get a notebook and write down all unusual observations. She described Mrs. A as a woman who always wanted a lot of things, for instance clothes, evenings out, and entertainment. She was sure her brother would not have been able to leave his parents if Mrs. A had not “lent a hand”. She portrayed Mrs. A as an impatient, possessive person who wanted to 139
Dippel et al.
dominate her environment, especially her family, but who was also very protective and who gave her all for them. Nevertheless, she felt a kind of compassion for Mrs. A because the last few years had been very hard for her. Mrs. A’s nephew, her half-sister’s son, was living in Austria and therefore we were not able to interview him. Because he was an electrician, Mrs. A regarded him as an expert for her problems and had invited him to spend a night at the apartment. The members of the family agreed that after this night he had felt painful pressure in his legs and had even reported “a kind of paralysis”. After that he immediately installed the microphone on the ceiling “to prove possible radiation”. Treatment course
We told Mrs. A that despite our investigations we were unable to make any decision about her complaints from the viewpoint of natural science. However, as her physical condition and also the sleep EEG were obviously, for whatever reason, adversely affected, we recommended that she resume taking fluspirilene to stabilize her health. Furthermore, we suggested the family move to another apartment. (We felt this would be the best way for all members of the family to withdraw from their shared delusions.) Mrs. A and her family first accepted this advice, and she received depot neuroleptics once a week. She was discharged and treated again by J.K. in his psychiatric practice. She decided to stay in the apartment with her husband, but the two boys soon moved out. After a total of 9 months on neuroleptics all somatic complaints and the sleep disorder had disappeared. The patient and J.K. then together decided that treatment should be discontinued. At this time the whole family apparently had withdrawn form the shared delusions, and Mrs. A herself admitted that she had suffered from a mental disorder during the past several years. However, in 1988 J.K. learned that Mrs. A was now seeing another psychiatrist. She was again on neuroleptics and was also attending behavior therapy sessions. Discussion
Mrs. A’s symptoms meet the DSM-I11 criteria for paranoia (297.10), but not for schizophrenia of schizophreniform disorder. Over a period of several years a persisting and unshakable persecutory and delusional system had developed, but there were no symptoms such as bizarre delusions, incoherence, or marked loosening of associations. It is even unclear 140
whether the patient had hallucinations or perhaps only illusionary misjudgments when she reported identifying noises from the apartment above as words. On the other hand, the patient responded very well to neuroleptics; considering the usual finding on the course of paranoia, this raises some doubts about our diagnosis. From a psychodynamic point of view, preserving family security and unity might be seen as the main theme of Mrs. A’s paranoia. This would be easy to understand because in her difficult childhood Mrs. A never had any sense of security and emotional warmth within her family. Although she grew up to be a strong and powerful person, she retained the desire to have a large family and to control her object relations. Probably the myoma operation and her subsequent sterility were a frustration of these wishes. Early signs of pathological development occurred when the neighbors had a baby. One might speculate that Mrs. A’s vehemence in fighting against the noise molestation might have been conducive to suppressing her sorrow over her sterility. However, the first real paranoid symptoms did not appear until 1980, at the time her elder son met his first girlfriend and re-exacerbated in 1984, when he entered university and had his second affair. Finally, the delusions spread to the family in 1985, at the time when he was considering moving out. Thus the delusion enabled Mrs. A to project her annoyance and aggression about her son wanting to leave onto her neighbors and gave her a reason for mothering him again. Beyond these speculations, it seems important to reconstruct the factors that supported the spreading of the delusion to the whole family. First we must emphasize that we do not know of any predisposition to psychotic disorders in either Mrs. A’s or her husband’s family. Of course we do not have complete information about Mrs. A’s relatives, especially on her mother’s side, but we can exclude any genetic factors playing a role in the induced persons not consanguineous to Mrs. A (her husband and sisterin-law). This clearly contradicts the findings of Scharfetter (7). Mrs. A’s premorbid personality with dominance and willfulness exemplifies the features described in the literature. As to the induced persons, only one of them seems to meet the criteria mentioned by Scharfetter (7), the husband, who is a rather passive, good-natured and weak person. The sons at most have certain features of ambivalence or indecisiveness. However, the sister-in-law seems to be a rather self-reliant person. In our opinion, these observations emphasize the persuasive and suggestive power emanating from Mrs. A’s strong personality, which was quite impressive even to us. From such an experience, one can understand why previous
Folie a six authors have pointed out a similarity between folie a deux and hypnosis (6, 10). Each family member had a different type of emotional relationship with Mrs. A. The husband and the younger son clearly had stable, positive emotional ties to her. The elder son and the sister-in-law had a much more ambivalent attitude towards her and the whole family. However, the psychoanalytic explanation given by Deutsch (9) is correct for the elder son at best. By identifying with Mrs. A he was able to be angry towards the neighbors instead of his mother. Regarding the sister-in-law, it is open to question whether this mechanism could work as there was no reason for her to give up her anger and ambivalence towards Mrs. A. Instead, possibly out of compassion or pity, an unconscious desire to help Mrs. A by showing solidarity may have played a role. In any case, there were only subtle peculiarities in the emotional relationships among the family members. Dramatic features such as constant threats of violent behavior, as mentioned by Glassman et al. (5), were not evident in our case. The same can be said about the social and environmental conditions, which were entirely normal and average. Social isolation, poor economic conditions or living in a rejecting community (4) did not have any etiological relevance. In summary, the main factor in the development of the shared paranoid disorder described here seems to have been the domineering personality of the key person and her ability to influence others by
suggestion. This was paired with features in the induced persons such as a passive character (husband) or an easygoing, somewhat indecisive personality (younger son). Beyond this, one might speculate about the role of unconscious dynamics such as “identification with the aggressor” (elder son) or “identification out of pity” (sister-in-law). The absence of adverse social and environmental conditions and in particular of a predisposition to paranoia seem to account for the uncomplicated disappearance of the induced paranoid disorder. References 1. GREENBERG HP. Crime and folie a deux: review and case
history. J Ment Sci 1956: 102: 772-779. 2. LASEGUEC, FALRET J. La folie a deux (ou folie communiquee). Ann Med Psycho1 (Paris) 1877: 18: 321. 3. GRALNICK A. Folie a deux. Psychiatr Q 1942: 16: 230-263. 4. FLORUL. Der induzierte Wahn: theoretischer uberblick und Bemerkungen am Rande von 12 Fallen. Fortschr Neurol Psychiatr 1974: 42: 76-96. 5 . GLASSMAN JNS, MAGULAC M, DARKODF. Folie a famille: shared paranoid disorder in a Vietnam veteran and his family. Am J Psychiatry 1987: 144: 658-660. K, TODDJ. The psychosis of association - folie 6. DEWHURST a deux. J Nerv Ment Dis 1956: 124: 541-459. C. Symbiotische Psychosen: Studie iiber 7. SCHARFETTER Schizophreniartige “induzierte Psychosen”. Bern: Verlag Hans Huber, 1970. 8. TSENGWS. A paranoid family in Taiwan: a dynamic study of folie A famille. Arch Gen Psychiatry 1969: 21: 55-63. 9. DEUTSCHH. Folie a deux. Psychoanal Q 1938: 7: 307-318. 10. WALTZERH. A psychotic family - folie douze. J Nerv Ment Dis 1963: 137: 67-15.
141
