|Ahead of print publication
Shared psychotic disorder in children of parents with untreated schizophrenia: A case series
Hrishikesh B Nachane
Department of Psychiatry, T.N.M.C and B.Y.L. Nair Ch. Hospital, Mumbai, Maharashtra, India
|Date of Submission||28-Mar-2020|
|Date of Decision||07-Jun-2020|
|Date of Acceptance||03-Jul-2020|
Hrishikesh B Nachane,
63, Sharmishtha, Tara Ngan, Thane – West - 400 606, Maharashtra
Source of Support: None, Conflict of Interest: None
Shared psychotic disorder (folie à deux) is a unique disorder with varied clinical presentation, posing difficulties in management. Parent–child dyads have been described to be commonly affected by this disorder but very few cases from India are available. Three cases who had parents suffering from untreated schizophrenia and shared their psychotic symptoms presented to the department. Two of these were twins with comorbid attention deficit hyperactivity disorder (ADHD), who required management for the ADHD. Social isolation was a common and the most important risk factor. All three cases showed improvement in psychosis with separation from the primary and none required the use of antipsychotics. Implications and treatment strategies for shared psychotic disorder in children are also discussed.
Keywords: Folie à deux, parent–child, schizophrenia, shared psychosis
| Introduction|| |
Shared psychotic disorder or folie à deux, first described by “Lasègue and Falret” is the transference of delusional ideas from a primary affected individual to one or more secondaries, usually in close association. There is some discrepancy between eastern and western data as to the largest population affected and commonest presentations. Role of the parent is crucial in child's early development and children pick up several skills by learning and interacting with their parents. This puts them at risk of developing shared psychotic disorder when their parents are suffering from a primary psychotic disorder. The following case reports discussed are of three children who presented with psychotic symptoms, out of which two were fraternal twins (their case conceptualization is presented together). The presentations, associated factors and management of these cases are discussed.
| Case Reports|| |
Case 1 and case 2
Master R, a 10-year-old boy presented with complaints of difficulty in sitting in one place, lack of attention in tasks, misplacing things at school, difficulty in awaiting turns, and impulsive behaviors. These symptoms were present since 1 year and there were frequent complaints from school in the same regard. His academic performance had also declined gradually. On examination, he appeared extremely fidgety and could not sit in one place for the entire interview. He was answering questions relevantly, his affect was reactive and there were no obvious disorders of thought or perception. A diagnosis of attention deficit hyperactivity disorder was made and he was started on atomoxetine 5 mg. He followed up with his twin sister and his father, off medications for 15 days, with new complaints of visual hallucinations in which he could see his dead mother, who would frequently abuse his sister. She would talk to them and would scare them frequently at night.
Miss U, the twin sister of Master R, presented to us with similar complaints of inattention, hyperactivity and impulsivity, clinically evident in three settings (home, school, and hospital). She also had complaints of seeing her dead mother and sometimes another woman (whom she referred to as “chhoti mummy”), who would frequently talk to her, hit her from time to time and abuse her, prevalent since 1 month. She would wake up in the middle of the night screaming and go to her father, complaining that this other woman is troubling her. She would describe her vividly, including her clothes, her appearance, her position, and what she was doing at the time. When the father of these twins was interviewed separately, he said that there is a woman who comes and abuses his children, who possibly is a ghost of his dead wife (his wife had passed away 1 year after the birth of the twins due to hepatic disease). After talking to the father, it became evident that father had a long standing history of mental illness. The twins were then admitted.
During their ward stay, it further came to light that the father had filmed his wife's death and would frequently show it to his children. He would talk about their mother's death with them. The father's sister was subsequently traced who gave history of him having suspiciousness, muttering to self, severe socio-occupational impairment, for almost the past 15–20 years. Their families were separated and only the father and the twins lived together. The father was then started on tablet penfluridol 20 mg tablet once a week (as he was reluctant to take daily medications). Miss U was started on T. Methylphenidate 10 mg daily and Master R was restarted on atomoxetine. The children were separated from the father in the ward, wherein they were kept in a closed ward and caretaker was appointed for them. The father's interaction with the children was limited. The doses were gradually up titrated. On discharge, it was ensured that they spent majority of their time at day care or with other relatives, so as to have minimum interaction with their father. However, it was not possible to completely separate them from the father after discharge as he was their primary caregiver. They followed up a couple of times on discharge, every time with their father and there was complete resolution of psychosis in Master R, and partial improvement in Miss U (more than 50% of the symptoms resolved).
Miss S, a 13-year-old girl, presented with psychotic symptoms that the neighbors are plotting against her and her family. She was also convinced that they frequently kept talking about them and was able to give necessary explanations for the same. She was also not going to school and had sleep and appetite issues. On talking to her aunt, it came to our notice that her mother was a known case of schizophrenia, who was currently admitted for the same. She and her two children lived alone and she would frequently take her children on a roaming spree. On enquiry, her mother had the same phenomenology of psychosis. The child had presented to us with her aunt, who was subsequently counseled regarding her condition and the need to distance the child from the mother. She was also informed about the need for regular treatment of the child's mother. The child was only observed and advised to stay away from her mother. The aunt then took the responsibility for the child and was made the child's primary caregiver. The child stayed with her until her mother's episode remitted. After that, the child's psychotic symptoms completely abated. She followed up for 1 month with her aunt to our outpatient department and was found to be asymptomatic even on follow-up.
| Discussion|| |
[Table 1] shows summarization of the three cases. Children of patients with schizophrenia are prone for the development of psychosis due to both genetic susceptibility and environmental causes. In all three cases, parents were the primary. It was difficult in the first case to ascertain who the primary was, as he shared the same phenomenology as his sister, it could have been her. However, since the psychotic symptoms started at about the same time in both the twins, the father is likely to be the primary case in both. Research has stated that it is indeed sometimes difficult to distinguish between the inductor and the recipient, owing to the circular character of induced psychotic disorder and similar semiology. Diagnosis in all three primaries was schizophrenia, which was untreated and this has been shown to be the most common diagnosis in the primary. Psychotic symptoms in all three children improved if not completely resolved on separation. Two of the three cases required the treatment of their underlying psychiatric disorders. Twins might be more susceptible due to greater sharing of heredity and environment. Socially isolated dyads are more susceptible to shared psychosis as was evident in all three cases. Other risk factors include passive personality, cognitive impairment, language difficulties/learning disabilities, and negative life events. Mother–child and spouses form some of the most common presentations of folie à deux., Western literature states hallucinations as the most prevalent presenting symptom in the secondary, whereas eastern literature states delusions., Both were almost equally represented in our cases. Separation is the first line of treatment for shared psychosis and this was successful completely in two cases and partly in one case. Separation is often difficult in parent–child dyads as parents are their primary caregivers. This leaves scope for recurrence. It is thus imperative to assess the family dynamics in detail in case of children coming with psychosis and follow them up closely. Adult psychiatrists should equally consider the impact of chronic parental psychiatric disorder on their developing children, particularly in isolated families. Active intervention with antipsychotics may not be necessary. The involvement of other normal caregivers such as aunt, uncle, or grandparents can be recommended.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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