Folie à deux: how it fits in DSM-5

2013/2014 Susana Filipa Rodrigues Martins Alves Folie à deux: how it fits in DSM-5 março, 2014 Mestrado Integrado em Medicina Área: Psiquiatria e Saúde Mental Trabalho efetuado sob a Orientação de: Dra. Susana Margarida Fernandes da Fonseca Trabalho organizado de acordo com as normas da revista: The International Journal of Psychiatry in Medicine Susana Filipa Rodrigues Martins Alves Folie à deux: how it fits in DSM-5 março, 2014 Aos meus pais, irmão e tio-avô pelo incentivo e apoio que sempre me deram. À Natália, pelo entusiasmo que sempre trouxe às nossas conversas sobre este projeto. À minha cunhada Júlia, por se ter tornado a irmã que nunca tive. Caminha, vai, dá mais um passo, todas as grandes coisas começam pequeninas. Toda grande jornada começa com um passo. Redime o pensamento de fraqueza, Deus te guiará. Não olhes para trás, nem pares no caminho. Vês lá no fim da estrada aquele arbusto pequenino? Não é arbusto, não, é a árvore mais alta que encontrarás. Senta-te à sombra dela e te dirá: "Eu nasci de uma simples sementinha!" Else Sant'Anna Brum 1 Title: Folie à deux: How it fits in DSM-5 Authors Susana F. R. M. Alves, Degree in Basic Health Sciences, Faculty of Medicine of Porto University Susana M. F. Fonseca, M.D., Psychiatrist, Faculty of Medicine of Porto University and Centro Hospitalar São João, Porto Contact Rua António Costa Pereira, nº25, apart 202 4465-283 S. Mamede de Infesta, Matosinhos, Portugal filipamartinsalves @gmail.com phone: +351 926655333 2 Abstract Objective: Folie à deux (FD) describes a phenomenon in which mental symptoms, usually delusions, are communicated from a psychiatrically ill person (primary pacient) to another individual (secondary pacient), who accepts them as true. We propose to evaluate the setting of the disease in the DSM-5 classification and its clinical implications. Methods: 31 articles, including revisions deemed relevant, were selected from the Medline and Scopus databases, from 2009 to 2013, in Portuguese, English and French. Of these, 12 articles were included. Books of reference in the field of psychiatry were also taken in consideration, as well as the DSM-IV-TR and DSM-5 classifications. Results: The literature considered the criteria for FD insufficient or inadequate. DSM-5 does not consider Shared Psychotic Disorder (Folie à Deux) as a separate entity. It is for the physician to classify the case of the secondary patient in the “Delusional Disorder” or in the “Other Specified Schizophrenia Spectrum and Other Psychotic Disorder”, attending the specifications and proposing the appropriate treatment. Conclusion: Although the diagnosis of FD is not included in the DSM-5, we consider that this classical concept should not be forgotten. The treatment should be personalized, taking account of the functional and psychosocial repercussions that the mental disorder may have on the patients’ relationships. Key-words: Shared Paranoid Disorder, Folie à Deux, DSM-5, Int J Psychiatry Med ISSN 0091-2174 3 Introduction Folie à deux (FD) describes a phenomenon in which mental symptoms, usually delusions, are communicated from a psychiatrically ill individual (primary patient) to another individual (secondary patient), who accepts them as true[1]. The key features are the unquestionable acceptance of delusional beliefs and the temporal sequence of the disorder’s development, with one or more individuals having an earlier onset[2]. The acceptance of these beliefs results from a lack of critical evaluation by both members of the dyad and in the secondary patient it may be aggravated by the social isolation recurrent in these patients[3]. Lasègue and Flaret, in 1877, pointed out three necessary conditions for the contagion to occur: a) the primary patient creates a delusion and gradually imposes it on the secondary, who, although initially resistant, ends up slowly accepting it, rectifying and coordinating the delusion, which becomes common to both of them; b) for this to happen it is necessary that they live for a long time in a close relationship, sharing their lifestyle, feelings, beliefs and hopes without any outside influence and c) the delusion has to be plausible, remain within the boundaries of possibility and be grounded on facts of the past or beliefs and hopes envisioned for the future[4,5]. According to the literature, the primary patient has been described as being older, more intelligent and having stronger personality features than the secondary patient[6], who is portrayed as having a submissive role in the relationship. Personality factors or intellectual limitations justify the secondary’s susceptibility[2]. There are risk factors for the secondary patient to be taken into consideration: female sex, suggestibility, passivity, low intelligence, low self-esteem and poverty[7,8]. FD’s incidence is calculated in 1.7% to 2.6%[4]. 90% of the cases occur among members of the same family and 50% of the cases happen between the dyads sister- 4 sister and mother-daughter[4,7]. The average age is 46-53 years and there are also reports in teenagers that don’t belong to the same family[9]. The most usual themes are the persecutory, as well as religious, of grandiosity and delusional parasitosis[3]. Almost all cases of FD are reported in association with schizophrenia, delusional disorder and major depressive disorder with delusions[1]. It may coexist with nonpsychotic disorders such as obsessive-compulsive disorder, somatoform disorder and histrionic-dissociative personality disorder[1]. Several authors argue that the delusion would be beneficial for both individuals, because it allows the cohesion and protection against what is perceived as threatening and hostile in the external environment[10]. With this paper we intend to fit in the DSM-5[11] classification patients previously diagnosed as suffering from Folie à deux / Shared Psychotic Disorder, identifying the repercussions that the new classification can bring in clinical practice. Methods 31 articles, including revisions deemed relevant, were selected from the Medline and Scopus databases, from 2009 to 2013, in Portuguese, English and French. Of these, 12 articles were included. Books of reference in the field of psychiatry were also taken in consideration, as well as the DSM-IV-TR and DSM-5 classifications. Results In the DSM-IV-TR[12] classification, Folie à deux appears as Shared Psychotic Disorder (Table 1), which requires the development of the delusion in the secondary 11 12. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fourth edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. 13. Mergui J, Jaworowski S, Greenberg D, Lerner V. Shared obsessivecompulsive disorder: broadening the concept of shared psychotic disorder. Aust N Z J Psychiatry 2010; 44: 859-62. 14. Arnone D, Patel A, Tan GMY. The nosological significance of Folie à Deux: A review of the literature. Annals of General Psychiatry 2006; 5: 11. 15. Auxéméry Y. La folie contagieuse: Étude de différentes entités et de leurs conditions d'apparition. Annales Medico-Psychologiques 2012; 170: 527-532. 16. Gralnick A. Folie à deux – the psychosis of association: a review of 103 cases and the entire English literature, with case presentation. Psychiatric Q 1942; 16: 230-63. 12 Table 1: Diagnostic criteria for Folie à deux – Shared Psychotic Disorder in DSM-IVTR (American Psychiatric Association, 2000)[12] DSM-IV-TR Shared psychotic disorder A. Delusion develops in an individual in the context of a close relationship with another person(s), who has an already-established delusion. B. The delusion is similar in content to that of the person who already has the established delusion. C. The disturbance is not better accounted for by another psychotic disorder (e.g., schizophrenia) or a mood disorder with psychotic features and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. 13 Table 2: Diagnostic criteria Delusional Disorder in DSM-5 (American Psychiatric Association, 2013)[11] DSM-5 Delusional Disorder A. The presence of one (or more) delusions with a duration of 1 month or longer. B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation). C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd. D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder. Types: Erotomanie; Grandiose; Jealous; Persecutory; Somatic; Mixed; Unspecified. Agradeço à minha orientadora, Dra. Susana Margarida Fernandes Fonseca, pela disponibilidade, apoio e sugestões e ao Departamento de Neurociências Clínicas e Saúde Mental da FMUP, na pessoa do Prof. Dr. Rui Coelho, pela oportunidade de realizar este projeto. Anexos International Journal of Psychiatry in Medicine Instructions to Authors Submit manuscript by email to: John R. Freedy, M.D., PhD. Associate Professor of Family Medicine Medical University of South Carolina 9228 Medical Plaza Dr. Charleston, SC 29406 USA [email protected] Instructions are in accordance with the Uniform Requirements f or Manuscripts submitted to Biomedical Journals: Writing and Editing for Biomedical Publication , International Committee of Medical Journal Editors. For further details, with the exception of abbreviating journal title s in the reference section (see number 12 in the Detailed Instructions below) see: www.icmje.org Detailed Instructions for Original Research Manuscripts: 1. 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