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Shared Psychotic Disorder 1
Shared Psychotic Disorder
Lauren Nowak
Saginaw Valley State University
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Introduction
Shared Psychotic Disorder is also known as Folie a deux, and it is a relatively rare
syndrome. It is a psychosis in which the primary case imposes delusions upon a secondary case
in a close relationship. There are now four clinical subtypes including; folie impose, folie
simultanee, folie comminque, and folie induite. Folie impose is where the primary person or
psychotic persons transfers their delusions to the mentally healthy person. Folie simultanee is
where the psychosis develops at the same time in the two people. Folie communiqué is where
delusions form after a period of resistance to them occurs. Folie induite is where a previous
psychotic person’s delusions are heightened by another person (Hartman, 2001). This paper will
further discuss the Diagnostic and Statistical Manual of Mental Disorders- fourth edition- text
revision (DSM IV- TR) description, etiology, pathophysiology, clinical course, symptomatology,
prognosis, impact on occupational performance, occupational therapy’s role in treatment, general
treatment, and local community support agencies.
DSM Description
The DSM IV- TR edition’s code for Shared Psychotic Disorder (SPD) is 297.3 (Folie a
Deux). The condition is characterized by a delusion that develops from a close relationship with
another person who already has a psychotic disorder with delusions. The first criterion of SPD is
when the individual shares the beliefs of the delusion in part or wholly. The second criterion is
ruling out other causes of delusions, making sure it is not from a direct physiological effect of a
substance or general medical condition. The third criterion is that schizophrenia is the most
common diagnosis of the primary case, but other diagnoses are; delusional disorder and mood
disorder with psychotic features (Cleveland Clinic, 2009).
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Etiology
The etiology of SPD is unknown, but there are some theories available. The first believes
that this condition is caused by unusually close relationships either by blood or marriage. People
in these relationships have lived together for a long time and live in social isolation. In these
relationships there is usually the dominate role filled by the primary case, or commonly the
person with schizophrenia. The secondary case is usually the submissive or dependent person in
the relationship that is the mentally healthy person. It can also occur in families where the
parents are the primary case and the children are the secondary. In secondary cases, 55% have
first degree relatives diagnosed with psychiatric disorders; this does not include the primary case
(Gob, 2007).
Other factors that play a role in the development of SPD are stress, social isolation,
closeness of the relationship to the person with the primary diagnosis, the length of time the
relationship existed, and the dominance- submission relationship. Most often the secondary case
fits the criteria for dependent personality disorder (Idan, 2009).
Pathophysiology
The pathophysiology of the primary case of SPD is the same as schizophrenia, mood
disorder, and delusional disorder with psychotic features. For the secondary case of SPD, the
pathophysiology is unknown besides possibly having dependent personality disorder. In
schizophrenia there is problem with dopamine levels in the brain. New information states that
Serotonin levels may be off, as well as NMDA receptor dysfunction. Dependent personality
disorder is traditionally believed to be caused by dysfunctional early environments that inhibits
the development of adaptive patterns of perception, response, and defense (Idan, 2009).
Clinical Course
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There is little known about the age of onset of SPD, but there is evidence that states that
it appears to be quite variable. Without treatment, SPD is chronic because it is involved with
long standing relationships that are static and resistant to change. With the onset of separation of
the primary and secondary case, symptoms can either disappear quickly or slowly depending on
the individual (Idan, 2009).
Symptomatology
Most commonly the symptoms associated with SPD are perplexed thinking,
hallucinations, delusions, weird and potentially dangerous behavior, incoherent and nonsensical
speech, abnormal and slow movements, problems in interpersonal relationships, a decrease or
loss of interest in personal hygiene and looking presentable, mood swings and depression,
isolation and an incapability to express oneself, and a decrease or loss of interest in mental and
physical activities. The most common is the unwavering belief of the secondary partner in the
primary partner’s delusion. Usually, the delusions are less bizarre than those of which are
experienced by schizophrenics and are considered a possibility. This makes it easier for the
secondary partner to believe in the delusions (Idan, 2009).
Prognosis
If the secondary and primary partners are removed from each other, and proper medical
treatment is rendered the prognosis for recovery is good. If therapy is not given and the family
dynamics remain similar to pretreatment, there could be a relapse. Monitoring by a social service
group is recommended to prevent relapse. If left untreated, the SPD can become chronic. If
treated early, SPD will have less of an impact on the person’s life, family, and friendships. The
most difficult subtype to treat is folie communiqué (Cleveland Clinic, 2009).
Impact on Occupational Performance
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SPD can affect all areas of performance areas and skills and performance patterns. Many
of the anti-psychotic medications used can impair body functions. Areas that are mostly affected
are communication and social skills, self care skills, motor and praxis skills, cognition, sensory
perceptual skills, and work (Bonder, 2010).
OT Role and General Treatment
Treatment of SPD includes separation of the primary and secondary cases. Sometimes
this treatment alone is effective for the secondary case. When it is not, treatment may include
psychotherapy, family therapy, and medication. Psychotherapy is counseling that helps the
patient realize that their thinking has become distorted and to recognize their delusions. In the
case of SPD psychotherapy will also address relationship issues and emotional effects from the
separation. In family therapy, the focus will be on increasing social activities and interest outside
of the family. Anti- psychotic medication may be prescribed if the delusions stop after separation
occurs. If there is anxiety from the separation, tranquilizers or sedative agents may also be used
(Hartman, 2001).
Occupational therapy must be comprehensive with the focus being on occupational
engagement. Occupational therapist need to assess strengths and weaknesses of the patient. By
doing so, OT’s can administer social skills training. Patients may not be able to apply social
skills learned to new environments. Global life skills training is vital to SPD patients to
emphasize role development. SPD patients also need to be able to function in a wide variety of
settings and be able to find leisure activities. This unstructured time is found to be the hardest to
manage (Bonder, 2010).
Local Community Support Agencies
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There are no local support groups for SPD, because it is so rare. There are however, local
schizophrenia support groups in Flint, Bay City, Midland, and Chesaning. For the Flint support
group their name is NAMI Genessee County and their leader is Ramona Deese and she can be
contacted at (810) 735-4935. For the Bay City group, the Tri- County AMI of Bay Co is lead by
Larry Stahl and he can be contacted at (517) 686-6709. The Midland County AMI is lead by
Duane Lehman and can be contacted at (517) 835- 9578. Lastly, located in Chesaning the TriCounty AMI of Saginaw County is lead by Jack Wilson, and he can be contacted at (517) 6425887 (Huebl, 1995).
Conclusion
Shared Psychotic Disorder is classified by the DSM IV-TR by meeting specific criteria.
These include: a person believing the delusions in part or wholly of another person, the ruling
out of other causes of delusions like substance abuse, and a diagnosis of a psychotic disorder of
the primary case. The etiology of SPD is unknown, but there are some factors that can make
individuals more likely to develop this condition such as; social isolation, stress, and a close
relationship. The pathophysiology is similar to schizophrenia with dopamine levels being
imbalanced. There is little known on the clinical course of SPD except that age of onset is
variable, and that it can become chronic if not treated correctly.
The symptoms associated with SPD are similar to schizophrenia with the secondary
case’s symptoms not being as severe. With proper treatment, prognosis for SPD is good, if a
change in the relationship occurs. This condition may affect all areas of occupational
performance. Many of the anti-psychotic drugs frequently used can impair body functions.
General treatment can include psychotherapy, anti-psychotic medication, and family therapy.
The occupational therapy’s role in SPD is focusing on occupational engagement, mainly leisure
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activities and social interaction. There are many support groups in the surrounding areas for
Schizophrenia which is a commonly linked disorder. Although SPD is a rare disorder, with
proper treatment good outcomes are possible.
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References
Bonder, B.R. (2010). Psychopathology and function. Thorofare, NJ: Slack Incorporated.
Cleveland Clinic. (2009.June 8) Shared psychotic disorder.
Gob, Y.L. (2007). Folie a famille. Hong Kong Psychiatry, 64(6).
Hartman, T.S. (2001). Cancer and folie a deux. Cancer Practice, 9(6).
Huebl, H. (1995) Schizophrenia support groups. Retrieved from
http://www.caregiver.com/schizophrenia/supportgroups/states/michigan.htm
Idan, S. (2009, November 7). Shared psychotic disorder. Retrived from
http://emedicine.medscape.com/article/293107-overview