Folie a Famille Associated with
Amphetamine Use
Kevin P. Hill, B.A., 1 Ashwin A. Patkar , M.D. ,2
and Stephen P. Weinstein, Ph.D.3
Abstract
S hared Psychotic Disorder involving an entirefamily (folie afamille) is extremely rare. Only
two cases qf Shared Psychotic Disorder linked to stimulant abuse have been documented in the
literature. We report a case qf.folie a famille that involved 5 members of a family , and was
associated with amphetamine use in the primary' individual. Our case shares many clinical and
etiological fa ctors with previously reported cases qf shared psychotic disorders. A wide variety of
psychotic manifestations are associated with amphetamine use and clinicians should be aware qf
this uncommon syndrome among stimulant-using population, particularly due to the recent
increase in methamphetamine use and the link between delusional disorders and violence among
these individuals.
INT RO DUCTI O N
Sh ared Psychotic Disord er (DS M-IV) is a rare a nd unusu al disor d e r cha rac te rized by sh aring of th e sam e delusion s by different person s who typicall y have been
intimat ely associat ed for a long tim e a nd live in relative socia l isolat ion. T he
cond ition was first d escribed by Lasegu e and Falret a nd term ed foli e a d eu x ( I). Most
ofte n, two person s share th e sa me d elu sion in a pa th ological rela tion ship in which
on e individual 's beli efs adv ersely affec t anoth er (2) . Rare cases involvin g 4 or even 5
persons or an en tire fami ly (fo lie a famill e) have been described (3-14). In a lmos t all
reports, th e primary pati ent has been diagn osed to be su ffe ring from sch izop hr enia
or delu sion al dis order.
Although amphet amines and ot he r st im ula nts have been recogn ized to ind uce
schizoph renia-like psychosis, th ere hav e been just two publish ed repo rts of folie a
deux resulting from st im u la nt (me t hylphe nida te) a buse ( 15, 16). T his is particu larly
I Fourth-yea r med ical st ude nt, J elTerson Medi cal Co llege, Phil ad elphia , PA.
2Assistan t Professor of Psychiatry, Division of Subs ta nce Abu se, J elTerson Med ical Co llege,
ThomasJ elTer son U niversity, Phil ad elphia, PA.
3C linica l Pr ofessor , Dep artment of Psychi atry a nd Hu ma n Behavior, J elTerson Med ical College, Thom as J elTer son U niversi ty, Phil ad elphia, PA.
Addres s for corre sponde nce : Ashwin A. Patka r, MD , Depart ment of Psych ia t ry and Hum an
Beh avior, Thomas .JelTerson Univ er sit y, 833 Ea st C hes t n ut Stree t, Sui te 2 10E, Philadelph ia ,
PA, 1910 7. T el (215) 955-2542, Fax: (2 15) 503-2850, e-ma il: Ashwin .Patka r@ ma il.tj u.cdu
26
FOLIE A FAMILLE CASE REPORT
27
surprising, give n th e wid e spread abuse of illicit stim u la nts and increasing prescription of amphetamin es in rec ent years. \'\Ie report a case of folie a famill e associa te d
with amph etamin e usc in the primary individual.
CASE REPORT
Mr P, a 3 l -yea r old un employed weld er and his 26-ye a r old wife were bo t h
referred to th e addiction se rvice s in Nottingh am , En gland for amphet a min e ab use
a nd psychotic sym ptoms .
NIr P first expe rime n te d with amphet amin es in hi s lat e tee ns a nd th en became
dep end ent on it in his ea rly 20s inj ecting up to a gra m a d ay on a dail y basis. H e
stoppe d hi s amph etamines aft er a successful inpati ent detoxification a t 25 yea rs of
age, whi ch coincide d with his findin g a job. Aft er 5 yea rs of a bs tine nce, he rela psed
after he lost his job and rapidly progr essed to intraven ous usc and was inj ecting
approximat ely 2 grams of amphetamin es eve ry d ay at th e tim e of referral.
Over th e six months prior to th e referral, Mr P beli eved th at th e a nt i-dr ug
squad, poli ce and customs officers were cons piring to file fal se cha rges agains t him
as a major drug di stributor in th e city. Towards thi s e nd, he beli eved th a t th ey had
mount ed a n ela bora te su rve illa nce operat ion e nlisting th e help of his neigh bors and
parents-in law to follow him in ca rs a nd in person . H e was convi nced t hat 'tiny
mi crophones' were implant ed into th e wall s of his hou se. H e had obta ine d a letter
from th e previou s tenants ve rifying th at th e house had not und ergon e any brick
removal for repairs or restoration. H e brought to th e out pa tie n t clin ic a bag full of
bri cks, whi ch, according to him, were newly ins ert ed in th e wall s of his house, which
he cou ld tell from 'their different look '. H e felt this proved hi s case th at th e wa lls
were bu gged. Mr P had fr equ ently accused his neighbors of spying on hi m , leading
to viole nt a rg u me nts.
Mr P had no previou s psychiatric, m edi cal or for en sic history. Hi s previous
det oxifi cation was not associat ed with psychosis. Hi s parents we re divorced a nd he
had no co n tac t with his father since age 7. H e wa s close to hi s mo t he r, M rs M, who
was 60 yea rs of age and described as passive. H e had two olde r sisters, Ms Sand Ms
V with whom he had a goo d relation ship. All hi s fam ily mem bers lived on th e same
st ree t as Mr P and he sa w th em on a regular basis. There was no hist ory of a
psychiatric illn ess in th e famil y. Mr P was d escribed as a lon er who d ropped ou t of
school and worked as a weld er for 10 yea rs. H e wa s married for 6 years a nd had 3
child re n. H e had a domineering rel ationship with his wife, a nd a t ti m es he sus pec te d
that his wife was spying on him.
Mr P present ed as a tall , confide nt, well-built person who had we ll-sys tematized
pe rsec u to ry d elu sions a nd was a ng ry t ha t nob ody beli eved hi m. H e d id no t exhibit
a ny mood sym pto ms, a ud ito ry hallucin ation s or a ny di sor gan ized t ho ug ht processes.
H e had no insight a nd refu sed urin e a nd blo od investi gation s, me dica tion and
hospit al ization. H e was di agn osed to be suffe ring fro m Amph et a mi ne-induced
psych otic di sorder.
His follow up was diffi cult as he oft en fail ed to keep a ppoin t me n ts. Relu cta n tly,
28
J EFFERSON J O URNAL OF PSYCHIATRY
he agree d to try haloperidol 5 mg per d ay, but th en discontinu ed it due to sid e
effec ts. H e stopped inj ecting amphet amin es for a bout 3-wee ks and his psychosis
a ppea re d to hav e remitted pa rti all y. Contact wa s lost aft er 3 months and he was
referred afte r 6 months wh en he fa iled to a tte nd . Subseq ue nt ly, he was remand ed to
pri son for malicious ly wo und ing his wife .
M rs P was assessed a t hom e a nd was 8 months pr egn an t. She was introduced to
drugs by her hu sb and a nd had been inj ecting am phe ta m ines for a year. Sh e had no
pr evious history of an y psychiatric di sord er, illicit drug or alcoho l use, or a famil y
history of a psychi atric di sord er. She present ed as a slim a t tractive wom an who
in sist ed that she was bein g followed , th eir hou se was bu gged and th at th ere were
tunn els undern eath th e hou se. She point ed out some ' loose bricks ' in th e hou se to th e
visit ing team to j us ti fy th at th e wa lls we re ta m pe red with. Wh en cha lle nge d, she
becam e a ng ry, in sisting tha t th e t reat m en t team was pa rt of t he cons piracy a nd
becam e un coop erative . There was no evide nce of halluci nations, mood symptoms or
an y cog nitive impairm ent. H er family lived locall y a nd she had good relat ionship
with her parents until recently, wh en she beli eved th ey were pa rt of a cons piracy
agains t herself a nd her hu sb and . She also beli eved th a t her pa re nts had mis inform ed
th e soc ia l se rvices a nd th e schoo l th at th eir children were not ca re d for.
Mrs P d id no t wish a ny t reat men t or follow up. W it h gr eat difficu lty, sh e ag reed
to be seen at hom e by th e com mu n ity nurse. H er pa re nt s were vel)' con cerned a bou t
her .condition. She sto pped inj ecting a m phe ta m ines a fter a few weeks of follow up
and did not receiv e any m edi cation s. Shortly a fte rwa rds she sto pped be lieving in her
husband 's pe rsecutory ideas but went a long wit h hi m sin ce she was fright en ed of
him . She deli vered a heal th y bab y and rest a rt ed inj ecting amph etamin es in a couple
of week s. A few days lat e r, she beca m e ab usive towards th e community nurse and
terminat ed follow up.
Mrs M and Ms V (Mr P's mo t her a nd sister respectively) were se en a t th e clinic
togeth er with Mr P at th e initial assessme n t. Th ey cor ro bo ra te d Mr P's history, bein g
convince d by his expla na tions and not beli eving th at M r P was psyc hiatrically ill.
Th ey were a ng ry a t th e local soc ia l services a nd police for not stopping Mr P's
surve illa nce .
Ms S (M r P's siste r) ca lled th e soc ial wor ker on t he treatm ent team expre ssing
th e sa me se t of beli efs as Mr P a nd insisting th at 'som et hing shou ld be don e'. To th e
best of our knowled ge, on e of Mr P's family had used a m phe tami nes or oth er drugs
and had no pr evious psychiatric history. It was not possibl e to follow up a ny of th e
family members.
DISC USSIO N
Thi s case shares m an y clinical a nd et iolog ica l facto rs wit h prev iousl y report ed
ca ses of sha re d psych otic di sorders. According to'D SM-IV ( 17), for a cas e to merit th e
di agnosis of shared psychotic disord er, it mu st m eet three crite ria. First, an ind ividual d evelops a delusion in th e conte x t of a clo se relati on ship with a no t he r ind ividual ,
who has a n a lready-es ta blishe d delu sion . In our case, M rs P present ed with perse-
FOLIE A FAMILLE CASE REPORT
29
cu tory d elusions whi ch seem to be cu ltiva te d by her relat ion sh ip wit h he r husband .
Secondly, th e individual must sh are delusions sim ila r in con tent to t hat of the
inducer, whi ch was the case in Mrs P's psychopathology. Similar con text ual cond itions a nd delusional beli efs a lso occurred a mo ng other family members (Mr P's
mother and sisters) , although th eir delusions were not as promine nt as Mrs P's.
Fin all y, another psychotic di sorde r, a mood di sorder with psych ot ic features, or th e
direct ph ysiological effec ts of a subs tance must not ca us e th e illn ess. Du e to th e fact
th at some of th e family us ed a m phe ta m ine s, nam ely Mr a nd Mrs P, th e asso ciation
of amph etamine abuse with sha re d psychotic di sord er is st ressed in t he present
report.
Glassman (18) d escribed six typi cal features of famili es who develop folie a
famille: I) the famili es exist in social isolation, 2) relation ships bet wee n family
members tend to be mutually dep endent and a mbiva le nt, 3) th e fa mi lies are
rep eat edly in a stat e of crisis, 4) th ere is oft en a n underlying threat or t he frank
pr es en ce of violent behaviors, 5) th e family m embership is sta ble over a lon g period
of time, and 6) th ere is a dominant famil y m ember, th e inducer, aro u nd whom th e
d elu sional beliefs evolve. Th e inducer holds th e delusion al beli efs wit h th e strongest
conviction (19 ), fulfillin g th e dominant role in th e family (20) . Th e ot her famil y
m embers, th e induced , ha ve been shown to ofte n be less int ell igent , fem a le, a nd
passive, d ep endent , sugges tible, or hi strioni c (7, 11 ,12). T he case re port described
a bove fits th ese crite ria we ll.
One particul arly int eresting feature of t his case seems to be t he role of
am p he ta m ines in d evelopm ent of psych op a th ology. Mr P, th e prim ary pati ent
suffe re d fro m a n a m phetam ine-ind uce d psych ot ic di sord e r. Th e clos e association
between psych osis a nd am phetamine use, parti al rem ission on discontinuation of
am p he tam ines, relap se on res ump tion of th e d ru gs a nd absence of pa st hist ory of
psych osis makes a di agnosis of schizo phre nia less likely in h is cas e. It also seem s th a t
am phe tamines cont rib ute d to M rs P's psych oti c symptoms a lthough it rem ains
un clear to what ex te n t Mrs P a nd ot he r fa m ily members were tr u ly del usional rath er
th an be ing highly impression abl e a nd passively accep ting Mr P's de lusion a l beli efs.
Ano t he r unusual fea ture was th e large nu mb e r of ind ivid ua ls (five) sharing th e sa me
delu sion al syste m . A di sturbing a nd unfortunat e ou tcom e was t he vio len t assa u lt by
Mr P on his wife, whi ch see ms to have been link ed to his d elu sion s.
Folie a d eux is beli eved to be a va ria n t of d elu sion al di sord er, a nd ge netic as well
as psych olo gical fact or s hav e been consi de re d to be rel evant in its d evelopm e nt (21).
It is th erefore su rpr ising th at th ere are hardly a ny rep ort s of amp he tamin e or
coca ine -re la te d foli e syndrom es, especially since d elu sion al di sord e rs a re frequ ently
associa te d with stimul ant use (22). On e possibl e reason could be sim ply t he chao tic
life styles of subs ta nce a buse rs, whi ch ofte n m ak e it d ifficult to int ervi ew relatives
a nd partn ers of su ch pati ents, whi ch is esse ntia l to di agn ose th e disorder. Ano th er
possibil ity is th at paran oid psych oses are less fr equ ent with coca ine t han a mphet a m ine use due to difficulty in sus ta ining high chron ic blood leve ls of coca ine (23) a nd
th e fact t ha t coca ine (crack coca ine) has largely repl aced amphetamin e as th e
preferred stim ula nt in th e past 20 yea rs in th e U n it ed Sta tes (24). Nevertheless,
30
JEFFERSO N J O URNAL OF PSYCH IATRY
clinicians should be aware of thi s un common co ndit io n a mo ng st imu lant-using
population as well as du ally di agnosed pati ents , particularly du e to it s potential for
viol en ce, if unrecognized and untreated . Moreov er, recent e pidemio logic trends
indicat e th at a m phe ta m ine s, particul arly m ethamphet a m in es and m ethylenedioxyme t ha m p he tam ine (MD l\ilA, ecs tasy) are becoming increasi ngly popular among
adolesce nts (25), a nd, in th e future, clinicians may be more lik el y to see more and
more us e of suc h drugs and th e problems th at accompany th ei r use.
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