Folie à Deux During Self-Quarantine in the COVID-19 Pandemic: a Case Report

Folie à deux is also known as psychosis of association or shared paranoid disorder. We describe a mother and her two daughters who experienced shared delusions and hallucinations during self-quarantine in COVID-19 pandemic. The mother was later diagnosed with schizophrenia and prescribed brexpiprazole, whereas her two daughters were diagnosed with psychosis of association affected by their mother.

Key words: COVID-19; Quarantine; Shared paranoid disorder

Introduction

Folie à deux, also known as psychosis of association or shared paranoid disorder, is characterised by the transference of delusional ideas and/or abnormal behaviour from one individual to another or more individuals in close association.¹We describe a mother and her two daughters who experienced shared delusions and hallucinations during self-quarantine.

Case Presentation

In January 2020, a family of five (father, mother, two daughters, and a son) moved to an apartment. The primary patient was a 34-year-old woman who worked as a door-to-door salesperson for a food corporation. Her personality was not dominating and she was shy with strangers. The secondary patients were her 13-year-old daughter, a junior-high-school student, and her 11-year-old daughter, an elementary school student. All three patients had unremarkable medical history, except for the younger daughter who had irritable bowel syndrome when she was 10 years old. The woman’s husband was travelling for business before the coronavirus disease- 2019 (COVID-19) pandemic.

Between March 2020 and May 2020, the Japanese government closed all public schools to combat the spread of COVID-19. Most of the Japanese population underwent self-quarantine. In April 2020, the general public had difficulty in procuring masks and disinfectants. The family stayed at home except when shopping for daily necessities. The mother could contact her husband and her office through telephone. In mid-April, the mother experienced an auditory hallucination. She thought that she heard the neighbour saying “Now I will come into your room and kill you.” She also experienced persecutory delusions that the neighbour would kill her. In May, the two daughters shared the same persecutory delusion, and the older daughter shared the same auditory hallucination. During this time, the son was living at his grandparents’ house, as he did not believe in his mother’s delusions and wanted to stay away from her.

At the end of May, public schools reopened. However, the two daughters refused to attend school because they believed that they would get killed there. The mother requested her husband to return and help them. In view of the prolonged absence, school officials contacted her husband. In July, the mother and her two daughters visited our hospital as outpatients. The mother underwent computed tomography of the head and blood investigations, with no abnormalities detected. The mother was later diagnosed with schizophrenia according to the DSM-5, and her two daughters were diagnosed with psychosis of association affected by their mother.

The mother (and her husband) declined hospitalisation and preferred to be an outpatient. She did not exhibit any harmful behaviour and took good care of her children. Separation of the affected patients is recommended for treating psychosis of association,²but it was difficult in this case. The mother was prescribed brexpiprazole, and the daughters were considered to require no pharmacotherapy. A nurse was assigned to visit their home periodically to prevent them from isolating from society. The patients’ progress was shared with the treating psychiatrist, the home- visit nurse, a psychiatric social worker, a school social worker, and the husband. The mother’s psychosis resolved promptly with residual mild auditory hallucinations. She subsequently returned to work. Her two daughters forgot their delusions gradually and returned to school.

Discussion

The condition of our three patients was likely caused by the conviction that they must remain isolated during the self quarantine, and the mother’s psychotic symptoms affected her daughters. Although they lived in the countryside, they had cell phones and could use social media and access information outside home. Nonetheless, the COVID-19 pandemic causes emotional isolation and increases the risk of associated psychiatric illness.³Children and teenagers respond strongly to the stress of this crisis,⁴and isolation is the main causative factor for folie à deux.⁵In our three patients, psychosis of association was developed within a short period. Support from the home-visit nurse, treating psychiatrist, social workers, school officials, and the husband was instrumental in early intervention and recovery.

Psychiatrists should be aware that folie à deux is associated with social isolation, and that early intervention can prevent psychosis of association caused by extreme isolation.

Contributors

The author designed the study, acquired the data, analysed the data, drafted the manuscript, and critically revised the manuscript for important intellectual content. The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

Conflicts of interest

All authors have disclosed no conflicts of interest.

Funding/support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data Availability

All data generated or analysed during the present study are available from the corresponding author on reasonable request.

Ethics approval

The patients were treated in accordance with the tenets of the Declaration of Helsinki. The primary patient and her husband provided written informed consent for all treatments and procedures and for publication.

References

Gralnick A. Folie a deux—the psychosis of association; A review of 103 cases and the entire English literature, with case presentations. Psych Quar 1942;16:230-63. ^Crossref
Lasegue C, Falret J. La folie à deux. Am J Psychiatry, Michaud R, translator. 1964;121:2-23.
Pfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med 2020;383:510-2. ^Crossref
Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): coping with stress; 2020. Available from: https://www. cdc.gov/coronavirus/2019-ncov/daily-life-coping/stress-coping/index. html Accessed 13 April 2021.
Lozzi B, Michetti F, Alliani D, Preziosa P, Loriedo C, Vella G. Relationship patterns in ‘folie a deux’. Ann ist super sanita 1992;28:295-8.

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