International Journal of Psychiatry in Clinical Practice, 2006; 10(3): 220
222

CASE REPORT

Coexistence of folie communiquée and folie simultanée

TAMÁS TÉNYI, ANIKÓ SOMOGYI, EDINA HAMVAS, RÓBERT HEROLD,

VIKTOR VÖRÖS & MÁTYÁS TRIXLER

Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Pécs, Pécs, Hungary

Abstract
Objective. The authors report a case during which they observed serious subtypes of induced delusional psychosis (folie
communiquée and folie simultanée ) without any common genetic background or premorbid psychosis in the case of the
secondary patient. Method. The clinical phenomenology of the case is described. Results. Mild intellectual disability and
environmental
psychological factors (social isolation and the symbiotic-like interpersonal relatedness) play an essential
aetiological role in the case of the secondary recipient patient. Conclusion. The authors emphasize the importance of
subclassification of induced delusional psychosis for further aetiological and clinical research.

Key Words: Induced delusional psychosis, folie a deux, folie communiquée, folie simultanée, shared paranoid psychosis,
subclassification of folie a deux

Folie a deux is a French term which literally means
‘‘psychosis of two’’. It was first coined by Lasegue
and Falret in 1877 [1]. Folie a deux , also known as
induced delusional disorder or shared paranoid
disorder [2], is a psychiatric condition characterized
by the presence of similar psychotic symptoms,
usually delusions, in two or more individuals. De-
whurst and Todd [3] stated three criteria for the
diagnoses: (1) the partners should have a very close
association; (2) the content of the delusions should
be identical or similar; (3) the partners should
accept, share, and support each other’s delusions.
In his review article, which examined 103 cases
reported between 1877 and 1942, Alexander Gral-
nick [4] defined and differentiated four similar, but
not identical subgroups: (a) folie imposée (the transfer
of the delusions of a psychotic person to a non-
psychotic one, the delusions of the latter disappears
after separating from the former first published by
Lasegue and Falret in 1877 [1]; (b) folie simultanée
(the simultaneous appearance of paranoid or depres-
sive delusions in two morbidly predisposed persons
first described by Regis in 1880 [5]; (c) folie
communiquée (the transfer of the delusions from
one person to another, and the continuation of the
psychopathology after separation from the first one
described first by Marandon de Montyel in 1881 [6];
(d) folie induite (the development of new delusions by
the person to whom the delusion was transferred
published first by Lehmann in 1883 [7]). Besides its
psychopathological importance, Gralnick’s subclas-
sification
which has been widely used and con-
firmed by a number of authors [8
10]
can be
considered as relevant in the light of the recent
interest on the interaction of genetic and environ-
mental factors in the aetiology of induced delusional
disorder [2,11
14].
While the subclassification introduced by Gralnick
was deeply influential on later psychopathological
descriptions of cases of induced delusional disorder
[8,9], and it has helped to encourage clinicians to
speculate on the role of heredity and psychological
factors in the aetiology of induced delusional dis-
order [11,14], we could not find reports about the
coexistent appearance of the particular subtypes. In
this paper we report on the coexistence of folie
communiquée and folie simultanée in the case of a
married couple, where in the case of the recipient,
secondary patient, the phenomenology of both
subtypes could be observed during her paranoid
reaction.
Case report
The patients were a 69-year-old male with the
diagnosis of schizophrenia paranoid type, who ap-
peared as the inductor, primary patient, and his 52-
year-old wife, who was the recipient, secondary

Correspondence: Tamás Tényi , M.D., Ph.D., H-7623 Pécs, Rét u. 2., Hungary. E-mail: tamas.tenyi@aok.pte.hu

(Received 28 June 2005; accepted 3 January 2006)

ISSN 1365-1501 print/ISSN 1471-1788 online # 2006 Taylor & Francis
DOI: 10.1080/13651500600579365

patient, during our observation of the folie a deux
phenomenon. Both patients had a long history of
psychiatric problems, as the inductor husband had
been in psychiatric care for the last 45 years, he had
six hospitalizations because of relapses, and had
shown marked negative symptomatology (blunted
affect, alogia, social withdrawal) between the acute
periods of his illness. The inductor husband was on
maintenance medication of haloperidol (10 mg/day)
and quetiapine (400 mg/day). His wife was hospita-
lized twice because of adjustment disorder with
depressive symptoms related to stressful life situa-
tions (conflict with nurses), her disturbed adjust-
ment behaviour was rooted in her diagnosed lower
intellectual level with unknown aetiology, shown as
values of IQ 75, VQ 81 and PQ 73 on Wechler’s
Scale for Measurement of Intelligence. A Rorschach
test had been evaluated 1 year before her present
admission and had shown a neurotic level of
psychological functioning, with the dominant use
of ego defences such as repression and isolation;
psychotic process or personality disorder were ex-
cluded. The wife was on clonazepam (2 mg/day)
before the current reported admission. The couple
lived in a hospital for chronic mental patients, mainly
because of the husband’s disease; the seriously
disturbed quality of life of both individuals had
resulted in the situation that they were placed in
this institution 8 years before the present reported
admission. They were both isolated socially, having
very few contacts with other patients and nurses,
living in a double room together, and developing a
symbiotic-like, very close, but sometimes hostile
relationship. They expressed verbal aggression to-
ward each other around everyday life issues, such as
who would finish the cake they had got or who would
have the last cigarette. The primary, inductor
patient’s intellectual level was much higher than
the secondary patient’s, and the husband was seen as
dominant compared to the wife, who was more
submissive in the relationship.
Three weeks before the present admission the
would-be inductor, primary patient husband became
noncompliant with his medications, many times
nurses noticed that he was trying to spit them;
parallel to this, a rapid decompensation developed.
He became delusional, conceiving ideas that the
nurses in the chronic hospital tried to kill him and
his wife using poisons. He became an agitated and
difficult to treat during these 3 weeks, and his partial
compliance resulted in an acute decompensation of
his schizophrenic disorder. After the end of the
second week of his relapse, his wife started to
verbalize the same persecutory delusions around
the issue that the nurses tried to poison and kill
them. At this stage of their shared psychopathology,
the case showed the classical picture of folie commu-
niquée , as the inductor schizophrenic patient’s delu-
sions were transferred to the recipient’s thought
Coexistence of subtypes of folie a deux 221
contents. Since the later separation from the induc-
tor did not lead to the spontaneous disappearance of
this delusion, this part of our case was detected as
folie communiquée rather than folie imposée.
As a next step, however, at this stage a new
phenomenon started to modify and colour the
clinical picture. The recipient, secondary patient
wife
during the third week of the inductor’s relapse

started to think that the reason that her mother
had not visited them in the previous month was
because her mother had been killed by the nurses
from their hospital. This delusion had never been
formed previously by the former inductor husband;
however, the previous inductor had accepted and
integrated this new content to the shared persecu-
tory delusional views on the nursing staff. They had
both strongly shared the delusion that the mother’s
disappearance was evidently connected with the
nurses’ intentions to kill them, and they had also
shared the view that the wife’s mother had already
been killed by the nurses. This second stage of the
induced delusional disorder showed the phenom-
enon of folie simultanée , as a simultaneous appear-
ance of identical paranoid delusions appearing in
two patients with already established premorbid
predispositions (paranoid schizophrenia in the case
of the husband, regressive paranoid reaction on the
basis of mild intellectual disability in the case of the
wife).
After their admission to the emergency setting of
our department the couple were separated. As no
spontaneous recovery was detected in the case of the
wife after 3 days of observation and supportive
psychotherapy, antipsychotic medication (haloperi-
dol 20 mg/day) was introduced, which resulted in
the disappearance of her delusions after 5 days of
treatment. The secondary patient’s case was diag-
nosed as paranoid reaction on the basis of her
mild intellectual disability. During her 12-month
follow-up, the patient was without any antipsycho-
tics and showed remission concerning her brief
delusional reaction. The inductor husband needed
30 mg/day haloperidol and 800 mg/day quetiapine to
reach a moderate improvement. During his 12-
month follow-up his positive symptoms gradually
disappeared, but his negative symptomatology
(blunted affect, alogia, social withdrawal) persisted.
The couple were discharged after 17 days of treat-
ment from the emergency setting, and they were
transferred back to the chronic institution for further
care.
Discussion
The coexistence of two subtypes of induced delu-
sional disorder (folie communiquée and folie simulta-
née) has appeared in this married couple, which is
interesting since common genetic factors can be
excluded in the formation of symptoms. In his
222 T. Tényi et al.
review on 103 cases of induced psychosis, Gralnick
[4] reported on 26 cases where husbands and wives
had been involved. In a current review of the
literature, 64% of the secondary, recipient patients
were found to be first-degree relatives of the primary
cases [15], while in other reviews the cases were
equally distributed among married couples, siblings
and parent
child dyads [16]. In this case the
diagnosis of the primary patient, as in 58
60% of
the cases [2], was schizophrenia, the secondary
patient had a mild intellectual disability with un-
known aetiology. In their classic paper of folie a deux,
Lasegue and Falret [1] stressed that the first condi-
tion for its development in an individual was that ‘‘he
be of low intelligence’’. Tuke [17] also suggested that
induced psychosis is more likely in the ‘‘feeble
minded’’, and Gralnick [4] described folie a deux in
two sisters, one of whom was mentally retarded.
While only a very few reports of the occurrence of
induced delusional disorder in people with mental
retardation have been published [18,19], there is a
known and common association of induced delu-
sional disorder with low intelligence [15]. Our
patient showed the clinical picture of paranoid
reaction and had never been psychotic before
induction. Similar to our case, in a review of 75
cases [15], induced paranoid reaction was found to
be the only diagnosis in 64% of all secondary cases.
An interesting report was published by Cuhadaroglu
Cetin [8] on a case of a family with the phenomenon
of folie a familie, where the members of the family
showed different subtypes of induced delusional
disorder, described by Gralnick [4]. Characteristics
of pathological separation
individuation processes
among family members were detected in their case
[8].
In the present case, more serious subtypes of
induced psychosis (folie communiquée and folie simul-
tanée ) were observed without any common genetic
background or premorbid psychosis in the case of
the secondary patient. Mild intellectual disability
and environmental
psychological factors (social iso-
lation and the symbiotic-like interpersonal related-
ness) played an essential aetiological role in the
secondary patient. Since it is known that the primary
patients diagnosis in identical twin pairs suffering
from folie a deux is delusional disorder [20], which is
in contrast to the reported excess of schizophrenia as
primary diagnosis in non-twin cases of folie a deux
[2,4,20], the importance of a subclassification

originally summarized by Gralnick [4]
for further
research on the aetiology and clinical psychopathol-
ogy of induced delusional psychosis can be empha-
sized.
Key points
. Description of subtypes of induced delusional
psychosis
. The coexistence of the subtypes can inform on
symptom formation in functional psychosis
. The interplay of organic and psychological
aspects is emphasized
Statement of interest
The authors have no conflict of interest with any
commercial or other associations in connection with
the submitted article.
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