Approach Considerations

The new standard of treatment for shared psychotic disorders includes the use of 2 agents. The atypical newer neuroleptics are the accepted mode of treatment for the spectrum of these disorders. Newer-generation anticonvulsants are also highly effective. Aripiprazole [14] (Abilify) and quetiapine (Seroquel) are extremely effective in these cases.

Initiation of aripiprazole at 5-10 mg PO qd with a titration upward by 5-10 mg PO every 3-5 days until a 25-60 mg PO qd dosage is achieved should thwart and alleviate the symptoms of the psychoses. Quetiapine is initiated at 25-50 mg PO bid and increased by 50 mg PO bid every 3 days until symptom resolution is achieved. Maintenance doses of 200-600 mg can be achieved easily.

The following case studies share many similarities and shed light on the seriousness of the disease; the complications associated with the disease; and the dire need for hospitalization, chemical therapies, and separation of the enmeshed pair as a primary form of treatment. These do follow the subtypes.

Case Report 1- Treating Subtype B

Potash and Brunell suggest multiple-conjoint psychotherapy for the treatment of folie à deux in identical twins. [15] In this case, twins were noted to have adapted roles resembling their abusive parents. Each twin took on the role of one parent, and, together, they reinvented their unhealthy past within their relationship. The twins developed a coping mechanism whereby they became inseparable until their hospitalization.

Mental status

The mental status was consistent with alert and oriented individuals whose thought content was significant for paranoia and preoccupations. Reasoning, judgment and insight was lacking. Attention was diminished and concentration was limited. EC was limited. Passive suicidal ideation with no acute plan, as well as violent and homicidal thinking was undertoned. Mood was irritable and affect was labile.

The twins presented with visual paranoia and shared delusional experiences; general hostility; feelings of betrayal and being taken advantage of; signs of depression, suicidal ideation, inseparability, despair about the future, and work problems; refusal to discuss the past for fear of reinjury; obsession with sex and/or promiscuity; and supporting, believing, and assuming identification with each other's delusions.

Indications for hospitalization

Hospitalization was required in order to ensure that the twins would remain separate throughout their treatment, would remain in a safe and controlled environment, and would not follow through on their suicidal threats. The twins feared the delusions and the confusion, and the hospital provided them with the sense of security that they would not come into danger when they were in a "blacked-out" state. Previous efforts at separating the twins proved ineffective, until hospitalization. Once hospitalization was established, the twins were treated with a regimen of multiple-conjoint psychotherapy and the issue of the twins echoing each other's delusions, going into depression, and making suicidal threats was thwarted.

The treatment in the hospital consisted of multiple-conjoint therapy. Through this treatment process, the twins met with a male and female therapist and were given the opportunity to have transference of their angry and confused feelings onto the therapist who most closely represented the sex of the mother and father. Through the treatment process and the expression of otherwise dangerous emotions in a safe setting, each patient had the opportunity to discover that her anger cannot harm her dependent partner or others and that the hostility she feels no longer needs to be denied or deflected into a delusional system.

Patient progress

Through the separation experience, each twin learned that being an individual provides safety and that being alone does not have to make one feel lonely and separate. Through this process of breaking dependency, each learned that she had her own ideas, beliefs, and interests that could be shared without the other having to accept it as her own reality. Working with both a male and female therapist, each twin was able to resolve many of her intimacy issues related to the same- or other-sex parent. Each developed a sense of health, using this chance to resolve many of the childhood dependency issues through the validation of the therapists and by developing their own individual identities.

In some cases, the interaction with the therapist was the girls' first experience with being treated with sensitivity. At the end of each session, in order to encourage discussion of the twins' differing perspectives, the therapists would direct any delusional thoughts to be more specific and to be attached to the feelings they covered up. This supported positive feelings that were then exchanged between the therapists and the patients themselves.

As the therapist would move progressively from the delusions to reality and feelings, the need for the twins to echo each other's delusions gradually disappeared. This process enabled the twins to recognize some of their distortions and pathology as they replaced them with healthy behaviors. Usually, by the end of the meeting, the twins expressed their fear and anger more directly and formed more constructive avenues for addressing their real-life complexities. As the patients' confidence increased and as positive transference occurred, the twins' childhood and family issues emerged and were dealt with constructively. Consequently, each twin began dealing with her own problems and feelings. So far, the multiple-conjoint model is the most beneficial means of treatment for folie à deux.

Case Report 2- Treating Subtype D

Emde, Boyd, and Mayo resolve folie à deux by allowing the patient to be responsible for developing healthy activities and relations while hospitalized and receiving medication therapies. [16] They examined a case of folie à deux involving a mother and daughter who were both diagnosed as having schizophrenic thinking disorder and a shared delusion that the husband/father was trying to poison them.

Mental status

The patients present alert and oriented. Relatedness and eye contact were fair. Speech was logical. Mood was irritable and affect was labile. TC was characterized by delusions, obsessive rumination, and hypervigilance. Psychomotor agitation is present. Attention and concentration are preserved. Reasoning and judgment are poor and insight is lacking. No evidence has presented for suicidal or homicidal ideation.

The mother and daughter both exhibited signs of distortions in their communication, emotional distancing from others, masking of feelings in conflict situations, deviant behavior, isolation, and shift of roles across generational and sexual lines, including incest and homosexuality. The daughter behaved in a sexually explicit manner, attracting the father and the attention of other men, while she maintained a delusion of him wanting to impregnate her. The mother was diagnosed with catatonic schizophrenia. Both mother and child slept, ate, and bathed together.

Indication for hospitalization

Removing the daughter from the home before overt incest could occur was imperative. The mother needed to be hospitalized so that she could stop worrying and trying to control her daughter's behavior. She was overprotective and fearful that her daughter would be harmed. The mother and daughter switched roles when the daughter reached puberty, and the father began to pursue her as if she were the adult in the relationship with him. The mother behaved like a child, and the daughter became her caretaker. The dominant personality could not be determined in the psychosis; the role of parent and child interchanged frequently between the two. The mother and daughter were inseparable, and hospitalization was necessary in order to approach each of their complex symptoms.

Through hospitalization, separation was gradually introduced for the mother and daughter in order to establish role separation within the family and promote the development of healthy appropriate boundaries. The therapy for each included electroshock therapy and insulin, which facilitated temporary gains. However, these therapies achieved substantial improvement when coupled with phenothiazine therapy.

After 3 weeks, the daughter's speech became coherent and she returned to a school setting within the hospital. However, the fact that the daughter was still protective of her mother indicated that the similarity of folie à deux still existed between them. By the second month of hospitalization, both mother and daughter showed improvement, and the role of reeducating them was the major feature of the therapeutic setting. The mother was increasingly engaged in social and recreational activities together with a work assignment, while the daughter was more involved with school and with friends her own age. After 3 months of hospitalization, symbiosis was no longer present; both had independent feelings and reactions.

Patient progress

The mother was discharged with an understanding of her illness and a desire to make a better marriage with her husband. The daughter remained in the hospital for further support in her schooling, in building peer relationships, and in developing a stronger sense of independence and a distinctly separate identity. In the sixth month, the daughter and her mother were reexamined with psychological testing. By that time, both of their mental ideations were healthy and their stories were bound in reality; both recognized their early symptomatology and took responsibility for not returning to the unhealthiness of their earlier experiences. The father/husband was given opportunity to spend time with the daughter, developing a healthy relationship. The mother's jealousy was addressed as she and her husband worked toward developing intimacy in their relationship, separate from the daughter.

Case Report 3- Treating Subtype A

Brenman suggests a therapy of reconstruction in early folie à deux. [17] In looking at early childhood experiences, one must consider the effects of the outer environment on the unconscious inner environment.

Mental status

A 28-year-old woman sought help regarding a suicidal depression, feelings of helplessness, and total inability to work. She was aware of her irrational, hateful, and angry feelings and thought she had been provided misinformation in her primary relationships. For example, her career was not satisfying because she felt her parents had pressured her choice, although she changed her career several times. She was very bright but could not complete her education. She called off several engagements when the pressures of intimacy became intolerable. She exhibited anxiety and fear when working with the therapist, and she would not allow him to diagnose her, believing that her own assessment would be correct. She was in denial and became fixated on achieving a sense of justice through an overactive superego.

Indications for hospitalization

In this case, no indication for hospitalization was present. Rather, the therapist treated her with a regimen of analysis and he generally attempted to assist the patient in realizing that her perspective did not foster the healthy successful lifestyle she sought.

Over the course of a year, the therapist tried to help the patient give up her need to control his opinion of her. The patient did not allow the analyst to develop a real experience of her feelings. After a while, he felt compelled to abandon his views and admire hers, creating a relationship between them that resembled a dependent relationship often seen in folie à deux.

Patient progress

Through psychoanalysis and reconstruction, the therapist attempted to develop the relationship between them to be one in which honesty in expressing feelings could serve to relieve the pressure of her past grievances from negative relationships. The value of the reconstruction was intended to allow her to express the distortions she perceived, to begin to see the truth of the matter, and to develop a different relationship to the stimulus that caused her pain. This provided her with a foundation for constructing new experiences and relationships. The purpose of reconstructing the transference was to analyze what was wrong in the past in order to form new foundations. The patient recovered a year later and regained the experience of her own feelings.

Case Report 4- Treating Subtype C

Bankier recommends treating folie à deux with antipsychotic medication and psychotherapy. [18] He studied role reversal in folie à deux, in which a man with alcoholism was sexually engaged with prostitutes. When his wife discovered his activity, he developed delusions that "prostitutes were following him with cars," and successfully convinced his wife of his delusions.

Mental status

Mental status is significant for alert and oriented mentation. Speech is logical and coherent. Attention and concentration are preserved. Mood is irritable to euthymic. Affect is labile. Reasoning and judgment are limited and insight is lacking. The patients are limited in relatedness, delusional, and obsessive. They present with psychomotor excitation. No evidence is present for suicidal or homicidal ideation.

The patients, a husband and wife team, were both socially active, employed in professional positions, and affiliated with a religious/church life. The husband was an active alcoholic, was engaged in sexual promiscuity with prostitutes, and was spending large amounts of money. He began having paranoid delusions quickly thereafter. He would see prostitutes following him in cars, watching him on the streets, making improper phone calls to his home, and stealing the little bit of money he had left.

He became anxious and convinced his wife that his delusions were true. His wife, having no previous mental illness, believed him, and together they watched for suspect prostitutes and reported their harassment to the local police. She became ill following her husband's developing paranoid psychosis, suggesting a folie à deux. When she became very ill, she developed the delusion that prostitutes were entering her house to embarrass and harm her. She planned for her husband to kidnap a police officer in exchange for ransom, and, later, he was arrested for attempting to blow up the building that housed the headquarters of their supposed persecutors.

Indication for hospitalization

The wife was not charged as a partner in crime, and she refused hospitalization. She attended outpatient therapy for several weeks and reluctantly took a small dose of neuroleptic medication. The husband made an excellent recovery from paranoid schizophrenic illness following a hospital stay.

Clearly, the case is one of folie à deux, with both the husband and wife having shared delusions. They were associated intimately, supported each other's pathology, and reversed roles during the illness. At first, the husband was the dominant partner. When the wife became more ill, she believed the delusions to be true and took on a more dominant role, while he became submissive and enabled her illness to progress. The problem reached severe proportions when the wife convinced her husband to blow up the headquarters of their perceived persecutors; they were reported to the police.

Patient progress

After her initial anger at her husband subsided during the course of his hospitalization, the separation between the two allowed the wife to cease her psychotic behavior and make significant progress in his absence. The husband recovered completely from a diagnosis of a typical paranoid schizophrenic illness with treatment consisting of neuroleptic medications, group therapy, and occupational therapy. However, the wife was suspected of not taking her medication and, when last seen, still had delusional beliefs.

Conclusion

Bankier, following the traditional literature, recommends physical separation, antipsychotic medication, and psychotherapy to treat folie à deux. [18] He is supportive of conjoint-psychotherapy as an alternative therapy, together with neuroleptic medications to handle the treatment. Each of these methods has been used to a certain degree of success. However, many psychiatrists today are of the opinion that multiple-conjoint therapy further helps patients to deal with feelings of rejection, inducer-induced dimensions, anger, dependency, hostility, and distorted communication and provides healthier contrast to distortions in perspective. In some cases, medications may have to be administered jointly with the therapy to accelerate the process of recovery and further ensure successful completion of the readily accepted protocol for recovery.