Management and treatment
Recognition
As in all rare cases, the first step to proper management and treatment is prompt recognition of the condition and situation (Suresh Kumar et al.,
2005; Delgado and Bogousslavsky, 2018). It may well be difficult to recognise the existence of a psychosis if expressed beliefs are apparently confirmed by a relative or a close friend. When assessing the condition and situation, it is always important to keep in mind the underlying clinical and social factors which, as described, are important in the production of an environment conducive to the sharing of delusion.
The importance of the “special conditions” becomes apparent when it is realised how few people in close association with deluded individuals actually do acquire the delusion. Large numbers of patients with schizophrenia live in intimate association with their relatives, yet no such sharing of delusions occurs. When it does happen, therefore, there is a need to identify the special factors which are operative in each individual’s case.
On recognising the presence of folie à deux, it is imperative to identify the primary principal patient, i.e. the one who suffers from a true psychosis. Usually this can be done fairly easily, but if there is a difficulty then it may be necessary to hospitalise both patients together or hospitalise one and permit frequent contact. Observing two patients together will often clarify the distinction between an imposed and communicative psychosis and between the primary and secondary partners. In cases of folie à deux, and even more so in folie à famille, an interdisciplinary approach is required, involving psychiatry, psychology, social work, occupational therapy, as well as psychosocial, psycho-educational and psychopharmacological interventions (Berbara et al., 2010).
Separation
With separation of the patients the resolution of the delusions in the secondary patient is influenced by the duration of the condition, the nature of the delusions (those which are of value to the secondary in psychological terms, being given up less readily) and the suggestibility of the secondary subject. Only suggestible people and those under domination in folie à deux give them up more easily. Traditionally, separation of the two partners or family members has been considered to be an essential therapeutic step. Some authors, however, do doubt the value of separation. Mentjox et al. (1993) found seven cases of which only four showed a reduction in intensity of delusional beliefs on separation.
It does appear that separating elderly associates seems less successful (McNeil et al., 1972; Fishbain, 1987). Thus, separation may be contraindicated in the elderly, especially when an elderly couple have been dependent on each other in order to continue to live in the community and separation leads to irreversible institutional care (Draper and Cole, 1990). Even Lasègue and Fairer (1877) themselves proposed separating the primary partner from the secondary partner but were aware that this was not invariably effective. Whereas in some cases separation may be undesirable, in others it might be crucial in order to determine the seriousness of the psychosis in each partner and for the appropriate treatment to be instituted.
Specific treatment of the principal
It has been pointed out that in almost all cases the principal and dominant partner usually suffers from a schizophrenic or allied condition. In the majority of cases, therefore, drug treatment in the form of antipsychotic medication will be necessary. However, in rarer instances the primary condition is affective in nature and an antidepressant drug, lithium therapy and even ECT may be indicated. Admission to hospital is often indicated, and sometimes it is necessary to admit under a compulsory order.
Supportive psychotherapy is also indicated. On discharge, this support should continue as well as a maintenance dose of medication and close supervision. If such follow-up is not forthcoming, then a recurrence of original symptoms leading to further readmission is likely.
Specific treatment of the associate
Treatment of the associate or recipient will depend on his or her condition on separation and above all on the underlying psychiatric disorder. If there is a psychosis which is deep-rooted, then intensive antipsychotic treatment will be necessary including antipsychotic drugs. If, however, the condition is one of learning disability or dementia or other mental or physical disability which contributes to the dependence of the recipient on the inducer, then specific steps must be taken to deal with these.
In cases of folie imposée, recovery often accompanies a recovery of the principal. However, the conditions, including the social factors, must be dealt with to avoid recurrence. In fact, it may be difficult to treat folie à deux because of the refusal of co-operation and the insistence of both patients to remain together. Hence sometimes the need for compulsory admission and treatment even though only one may be truly psychotic (Munro, 1986).
It is significant that one review (McNeil et al., 1972) revealed that in about 25% of cases the recipients suffered from physical disabilities, including partial deafness, strokes and those caused by alcohol abuse. It was therefore essential to treat the underlying physical disorder to avoid continual dependence.
Treatment of the relationship and social conditions
The principal and recipient having been treated specifically, whether by pharmacotherapy or psychotherapy and/or other treatments including separation, attention should be directed towards the relationship and the social conditions of the two. The primary' aim will be to maintain their mental health. It will be done by continuing each individual’s specific treatment and by providing close follow-up. In addition interventions aimed at separation in psychological terms, as well as physical separation, must be considered (Rioux, 1963; Mentjox et al., 1993).
Total isolation must be avoided. Both should be given more support to become more active and have other interests, with the aim of reducing their pathological enmeshment (Sacks, 1988). This will mean, in addition to the involvement of the wider psychiatric team, the specific input of a social worker.
Deeper psychotherapy
This may be possible for one, if not both, patients with the aim of dealing with the issues of dependence, separation and aggression (Sacks, 1988). At this point psychotherapy may be of use in exploring issues of dependence and hostility (Bankier, 1988), facilitating the expression of feelings, exploring poor parental relationships and encouraging modelling of the relationship with a therapist (Potash and Brunel, 1974). The difficulty' is to get one or both patients to commit themselves to a long period of therapy.
In communicated psychosis, Porter et al. (1993) considered that deliberate shifting of dependence could be beneficial, for example from a deluded dominant figure to a sane one, although for the great majority' of patients the aim should be independence. Porter et al. (1993) cite various reports of separation where there is a shift of dependence which results with the resolution of psychosis in the dependent partner. Their own case was treated by a multiplicity of treatments including separation, a neuroleptic and individual and group psychotherapy. This in itself indicated the difficulties of attributing recovery to a single agent. However, family therapy may be an obvious indication and is of importance not only because of the fact that over 90% of cases occur within families but because, as has already been stressed, folie a deux is a defence mechanism, although a pathological one, which mitigates against the effects of social isolation with the threat emanating from a seemingly hostile environment. Thus the family unit is maintained in a status quo, even by having to resort to psychotic symptoms. If lasting improvement is to be brought about, this aspect of the matter must be fully' considered and dealt with thoroughly.
Social intervention and support
This is highly' relevant in the management and can be the most significant factor as illustrated by the case already' mentioned of the two women friends presenting as a suicide pact, who improved markedly with social support which included gaining employment.
The review of Arnone et al. (2006) referred to earlier in this chapter also looked at management outcomes and treatment settings. Essentially, a half of the cases responded to medication only and a further quarter to a combination of medication and physical separation. Only 7% of the cases responded to physical separation alone. The majority (over a half) of both primary and secondary cases were treated in an inpatient setting.
