The Psychological Meaning of "Folie à Deux"

The term Folie à Deux is a real and recognised psychological condition. It is also known as shared psychotic disorder. Although it is not explicitly listed as a separate category in the DSM-5, it falls under the broader classification of psychotic disorders, particularly delusional disorders. In the UK, it is acknowledged within the field of psychiatry and psychology, with case studies and clinical experiences documenting its occurrence. The condition involves the transmission of delusional beliefs from one individual to another, typically within a close relationship.

The term "Folie à Deux" has gained attention recently due to the upcoming film "Joker: Folie à Deux," starring Joaquin Phoenix and Lady Gaga. This term, which translates to "madness of two" in French, describes a rare psychological syndrome wherein symptoms of a delusional belief are transmitted from one individual to another. This article explores the psychological underpinnings of Folie à Deux, relevant studies, real-life cases, and its depiction in cinema, including the upcoming film and its relevance to the DSM-5 diagnostic criteria.

Research on Folie à Deux is limited due to its rarity. However, several case studies provide insight into the condition. For instance, a study published in the journal Psychiatry Research detailed a case involving a mother and daughter who shared persecutory delusions. The daughter, initially the primary individual, influenced her mother to adopt the same delusional beliefs. This case underscores the importance of the close emotional bond and the shared environment in the development and maintenance of shared psychotic disorder.

Real-Life Cases

Case 1: The Elderly Couple

One documented case involved an elderly couple, both of whom shared the delusion that their neighbours were spying on them and planning to steal their property. The primary inducer was the husband, who initially developed the delusion. The wife, spending almost all her time with him and trusting his perceptions, began to share these beliefs. The delusion was maintained through their constant reinforcement of each other's beliefs and the absence of external social interactions to challenge these ideas.

Case 2: The Siblings

In another instance, two siblings who lived together in an isolated rural area developed a shared belief that their house was built on sacred ground and that they were being haunted by spirits. The older sibling, experiencing stress and having a history of minor mental health issues, was the primary inducer. The younger sibling, influenced by the authority and closeness of the elder, adopted the same delusional beliefs. Their isolated living situation and lack of social interaction helped maintain the delusion.

Several factors contribute to the induction and maintenance of shared delusions:

Close Relationship: A strong emotional bond and a high degree of dependency between the individuals are critical.
Isolation: Limited social interaction with others can prevent external reality checks.
Stress: High levels of stress or traumatic events can trigger delusional thinking.
Psychological Vulnerability: The secondary individual often has a dependent or submissive personality, making them more susceptible to adopting the primary individual's delusions.

Folie à Deux in Film

The film "Joker: Folie à Deux" is anticipated to delve into the complex, interdependent relationship between the Joker (Arthur Fleck) and Harley Quinn (Dr. Harleen Quinzel). The title itself suggests a mutual descent into madness, reflecting the core concept of shared psychotic disorder. The Joker, as the primary individual, may influence Harley Quinn, who transitions from his psychiatrist to his partner in crime, adopting his delusional worldview.

Apart from the upcoming Joker film, Folie à Deux has been depicted in other movies. In "Heavenly Creatures" (1994), directed by Peter Jackson, the intense bond between two teenage girls leads them to share elaborate fantasies and delusions, culminating in a violent act. Another example is "Bug" (2006), where a couple's shared delusions escalate into a spiral of paranoia and self-destruction.

Controversies Surrounding Folie à Deux
While Folie à Deux is a recognised psychological condition, it is not without controversy. There are some contentious aspects related to its portrayal in media, diagnostic challenges, ethical concerns, impact on families, and research limitations.

One significant source of controversy is how Folie à Deux is portrayed in films and television. Media often dramatizes mental health conditions for entertainment, leading to misunderstandings and stigmatization. For instance, the upcoming film "Joker: Folie à Deux" may sensationalise the condition, potentially distorting public perception. Such portrayals can misrepresent the clinical realities of shared psychotic disorder, focusing on extreme behaviours and reinforcing negative stereotypes about mental illness.

Diagnostic Challenges

Folie à Deux is a rare and complex condition, making it difficult to study and understand comprehensively. This rarity can lead to debates among mental health professionals about its classification and diagnostic criteria. In the DSM-5, Folie à Deux falls under the category of delusional disorders rather than being listed as a separate entity. This classification can lead to disagreements about its diagnostic placement and the most appropriate treatment approaches.

Ethical Concerns

The treatment of Folie à Deux often involves separating the individuals to break the cycle of shared delusions. This method can be controversial, raising ethical questions about the autonomy of the individuals and the potential emotional impact of separation. Ensuring informed consent for treatment can also be challenging, particularly if the judgment of those involved is impaired by delusional beliefs. Addressing the condition requires sensitivity to these dynamics, and treatment can be controversial when it disrupts established family structures. Additionally, families affected by Folie à Deux may face stigma and misunderstanding from society, adding to their emotional and psychological burden.

Delusions in One Person and DSM-5 Criteria

Delusions are false beliefs based on incorrect inference about external reality, firmly held despite clear evidence to the contrary. They can occur in various psychiatric disorders, including schizophrenia, delusional disorder, and mood disorders with psychotic features.

Types of Delusions

Persecutory Delusions: Belief that one is being plotted against, spied on, or persecuted.
Grandiose Delusions: Belief in having exceptional abilities, wealth, or fame.
Somatic Delusions: Belief that one has a physical defect or medical condition.
Erotomanic Delusions: Belief that another person, often of higher status, is in love with the individual.
Nihilistic Delusions: Belief that a major catastrophe will occur or that one is dead or dying.

DSM-5 Diagnostic Criteria

According to the DSM-5, delusional disorder is characterised by the presence of one or more delusions for at least one month. The diagnostic criteria include:

• Delusions lasting one month or longer.
• Criteria for schizophrenia have never been met.
• Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behaviour is not obviously odd or bizarre.
• If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.
• The disturbance is not attributable to the physiological effects of a substance or another medical condition.

Impact on Individuals and Treatment

Life Problems
Individuals with delusional disorder can experience significant life disruptions, including social isolation, strained relationships, and difficulty maintaining employment. The delusions can lead to risky behaviours, legal issues, and in extreme cases, harm to self or others.

Treatment Approaches

Treatment typically involves a combination of antipsychotic medications and psychotherapy. Cognitive-behavioural therapy (CBT) is particularly effective in helping individuals recognise and challenge their delusional beliefs. Building a strong therapeutic alliance is crucial, as individuals with delusional disorder often mistrust others.

Folie à Deux Treatment

Treatment for Folie à Deux involves separating the individuals to break the cycle of shared delusions. Psychotherapy is crucial in helping both the primary and secondary individuals recognise and challenge their delusional beliefs. Antipsychotic medications may also be prescribed to manage symptoms. Early intervention is essential to prevent the condition from escalating and causing major life problems.

"Folie à Deux" is a fascinating and complex psychological condition that has captured the imagination of filmmakers and the public alike. The upcoming film "Joker: Folie à Deux" is expected to explore this phenomenon through the relationship between the Joker and Harley Quinn, bringing to light the intricacies of shared psychotic disorder. Understanding the psychological basis, real-life implications, and treatment of this condition is crucial for both mental health professionals and the general public, emphasising the importance of early intervention and appropriate care. Delusions, whether shared or experienced by an individual, present significant challenges but can be managed effectively with the right therapeutic approaches.