Folie à Deux and Shared

Psychotic Disorder
Mitsue Shimizu, MD, PhD, Yasutaka Kubota, MD, PhD,
Motomi Toichi, MD, PhD, and Hisamitsu Baba, MD, PhD

Corresponding author
Mitsue Shimizu, MD, PhD years after the first report of FAD, “induced psychotic
Medical Center for Student Health/Department of Biosignal disorder” was branched off from FAD in an American diag-
Pathophysiology, Graduate School of Medicine, Kobe University, nostic manual known as DSM III-R, and the disorder was
1-1 Rokkodai-cho, Nada-ku, Kobe, 657-8501 Japan. renamed “shared psychotic disorder” in the fourth edition
E-mail: shimizu@kobe-u.ac.jp
of that same manual. Thus, we need to consider the his-
Current Psychiatry Reports 2007, 9:200–205 torical background of FAD in order to understand the very
Current Medicine Group LLC ISSN 1523-3812
Copyright © 2007 by Current Medicine Group LLC recent conceptualization of “shared psychotic disorder,”
even though DSM regards these two terms as synonyms.
The present study illustrates the historical devel-
opment of the concept from FAD to shared psychotic
Folie à deux (FAD) was first described in 19th century
disorder and then discusses the recent findings on FAD
France. Since then, the concept has been elaborated,
or shared psychotic disorder.
and several subtypes of FAD have been successively
Various terms, such as “inducer-induced,” “principal-
reported in France. In contrast, studies in German-
associate,” or “primary-secondary,” have been used
speaking psychiatry mainly focused on the conceptual
to distinguish the partners in FAD. In this paper, we
boundary between reactive/endogenous psychosis and
use only “inducer-recipient” in order to avoid termino-
etiological hypothesis (ie, psychogenesis vs genetic
logical confusion.
predisposition). In North America, Gralnick wrote a
seminal review and redefined four subtypes of FAD
by adopting the European classical concepts. More
Historical Development of the Concept
recently, “shared psychotic disorder” in DSM or
France
“induced delusional disorder” in ICD-10 was branched
Although the term folie à deux was first coined by Lasègue
off from FAD. However, several classical subcategories
and Falret [1] in 1877, as has been described often in the
of FAD were not included in these recent definitions,
literature, equivalent phenomena to this term had been
the nosological significance of which should not be
previously alluded to by other French psychiatrists. For
underestimated. We examined demographic data of
example, in 1860, Baillarger called it “folie communiquée”
FAD case reports published from the 19th to the 21st
(communicated psychosis) [2]. Then, Legrand du Saulle [3]
century and found that some of the earlier hypotheses,
reported “idée de persecution communiquée ou délire à
such as females being more susceptible, older and
deux et à trois personnes” (communicated persecutory idea
more intelligent individuals being more likely to be
or delusion at two and three persons) in 1871. He indicated
inducers, and sister-sister pairs being the most common
that the psychiatric contagion of delusions from one person
relationship, were not supported. The controversial
to another is possible under certain conditions (eg, one who
issue of the etiology of FAD—association of subjects
is apparently more powerful, intelligent, and active than
or genetically driven psychosis—was re-examined in
another becomes inducer). Finally, Lasègue and Falret [1]
light of recent studies.
published a long paper called “La folie à deux ou folie com-
muniquée,” which includes vivid and detailed descriptions
Introduction of clinical cases and clearly detailed conditions that enable
Folie à deux (FAD) was first described in late 19th century psychiatric contagion. That is, the following are true: 1) a
France as the presence of the same psychiatric symptom, more active and intelligent individual produces the delu-
usually persecutory delusion, in two individuals in close sional ideas, whereas a passive, less intelligent individual
association. Since then, this French term has been prevalent gradually assimilates the delusional ideas; 2) both live in
in many countries without translation, and its conception close association, having in common emotions, interests,
has been examined and elaborated. Approximately 100 and opinions while living in relative social isolation; and
 Folie à Deux and Shared Psychotic Disorder Shimizu et al. 201
3) the delusional ideas are somewhat related to reality and
bear reference to common experience, hopes, and anxiet-
ies. Furthermore, according to Lasègue and Falret [1], the
recipient is just a “reflection” of the inducer, who is a “real
patient,” and if the inducer and recipient are separated, the
delusion of the latter will disappear spontaneously. There-
fore, the authors’ discussion indicates a mechanism of what
we call reactive psychosis, not endogenous or somehow
genetically driven psychosis. On the other hand, Régis
[4] in 1880 demonstrated that sharing delusion is pos-
sible between two individuals who have genetic disposition
toward psychosis. In this case, two individuals who have
lived in close and perpetual association develop a delusion
at the same time under the influence of the same acciden-
tal event. Contrary to the cases presented by Lasègue and
Falret [1], separation of the two patients does not always
dissolve the delusion in both patients. Régis [4] called this
type of shared psychosis, in which there is no communica-
tion but there is simultaneity, “folie simultanée.” In 1894,
Marandon de Montyel [5] singled out a new subtype of
delusional contagion from those previously studied by
Lasègue and Falret and by Régis. In this type, inducer’s
delusion is transferred to a healthy person without genetic
disposition toward psychosis after a long resistance from
the latter (recipient), and even if they are separated, the
symptoms of the recipient last long. He called this subtype
“folie communiquée” and redefined the subtype previously
reported by Lasègue and Falret as “folie imposée.” Later, it
was verified that in this subtype of FAD, the delusion of the
recipient is partially communicated from the inducer; how-
ever, it is also partially formed uniquely and originally by
the recipient’s personality and disposition [6]. Clérambeaut
[7] published eight original papers on FAD over a 20-year
period beginning in 1902. He thought that Régis was
wrong in assuming that there is no communication when
the delusion is transferred in FAD. Instead, he found a
reciprocal role of subjects when constructing the delusional
association and introduced a new notion called “induction
réciproque” (reciprocal induction) and “division du tra-
vail” (division of labor). That is, the inducer first develops
a delusion and the recipient accepts and even elaborates it,
then the inducer this time is influenced by the elaborated
delusion of the recipient. Clérambeaut [7] also insisted that
delusional ideas can be transferred, but “automatism men-
tale” cannot. Automatism mentale is Clérambeaut’s term
that describes a basic mechanism producing the psychiat-
ric symptoms, including those of psychose hallucinatoire
chronique (chronic hallucinatory psychosis), which is one
of the most unusual concepts of French psychiatry but
seems roughly equivalent to some part of paranoid type or
undifferentiated type of schizophrenia in DSM.
Briefly, in the French psychiatry world from the late
19th century to the early 20th century, FAD was first
described, then, based on detailed clinical observation,
the notion of that disorder was elaborated, and new sub-
types were named and reported successively.
Germany and Switzerland (German-speaking)
In German-speaking psychiatry, FAD was tradition-
ally called “induziertes Irresein,” which was coined
by Lehman [8] and Scharfetter [9] and literally means
“induced psychosis.”
In 1906, Ast [10,11] insisted that if the recipient has
a genetic factor of psychosis, we should not regard this
case as induced psychosis but as normal psychosis trig-
gered by genetic disposition of the recipient. Bonhoeffer
[11,12] distinguished induced psychosis from dementia
praecox (schizophrenia), whose symptoms should not
be psychogenic from his standpoint, and restricted
induced psychosis within obviously psychogenic cases.
Jaspers [13], in his famous textbook Allgemeine Psycho-
pathologie (general psychopathology) in 1953, admitted
that psychogenic reaction is possible even in subjects
with schizophrenia; on the other hand, he believed that
contagion of delusion is always psychogenic. Finally,
he concluded that subjects with schizophrenia can be
“induced.” However, it should be interpreted as reactive
psychosis in patients with schizophrenia. He also insisted
that it is not possible for the pathological “process” of the
psychosis to be contagious. His term “process” assumes
somewhat unknown neurological changes in the brain that
may explain the pathogenesis of delusions and hallucina-
tions in schizophrenia. It is interesting that his hypothesis
seems similar to that of Clérambeaut [7], that delusional
idea can be transferred, but automatism mentale cannot.
Schneider [14], whose work was influential in subsequent
diagnostic systems such as DSM and ICD, opposed the
term induced psychosis because he believed that “psycho-
sis” was incompatible with “induction,” that psychosis is
not reactive but necessarily somatically founded.
As we have described, studies on FAD (induced psy-
chosis) in German-speaking psychiatry seem to have
focused on the conceptual boundary between reactive/
endogenous psychosis and etiological hypothesis (ie, psy-
chogenesis vs genetic predisposition, in contrast to the
literature of French psychiatry, which is mostly based on
clinical description of phenomenology).
North America
In 1942, Gralnick [15] published a seminal review, “Folie
à deux—the psychosis of association.” He presented a
concise and effective definition of FAD as “a psychiatric
entity characterized by the transference of delusional
ideas and/or abnormal behavior from one person to one
or more others who have been in close association with
the primarily affected patient.” He also distinguished four
subtypes of FAD, adopting European historic concepts:
Folie imposée (by Lasègue and Falret [1]) refers to a
case in which the delusions of a psychotic individual are
transferred to a psychiatrically normal one. The recipient
offers little resistance in accepting the delusions and does
not elaborate them. Separation from the inducer tends to
cause the recipient to abandon delusions.
202 Nonschizophrenic Psychotic Disorders
Table 1. Diagnostic criteria in DSM and ICD
DSM III-R 297.30. Induced psychotic disorder (folie à deux)
A. A delusion develops (in a second person) in the
context of a close relationship with another person,
or persons, with an already-established delusion (the
primary case)
B. The delusion in the second person is similar in
content to that in the primary case
C. Immediately before the onset of the induced delusion,
the second person did not have a psychotic disorder or
the prodromal symptoms of schizophrenia
DSM IV 297.3. Shared psychotic disorder (folie à deux)
A. A delusion develops in an individual in the context
of a close relationship with another person, or persons,
with an already-established delusion
B. The delusion is similar in content to that of the person
who already has an established delusion
C. The disturbance is not better accounted for by another
psychotic disorder (eg, schizophrenia) or a mood disor-
der with psychotic features and is not the result of the
direct physiologic effects of a substance (eg, drug abuse,
medication) or a general medical condition
ICD-10 F.24. Induced delusional disorder (folie à deux)
A. Two people share the same delusion or delusional
system and support each other in this belief
B. They have an unusually close relationship
C. There is temporal or contextual evidence that the
delusion was induced in the passive member by
contact with the active member
Folie simultanée (by Régis [4]) means that identical
psychoses characterized by depression and persecutory
ideas appear simultaneously in two individuals predis-
posed to a true psychotic illness. This subtype of FAD has
no evidence of mental contagion, unlike other subtypes.
Folie communiquée (by Marandon de Montyel [5])
is a contagion of delusions, but only after the recipient
has resisted them for a long time. After the recipient
has finally adopted the delusions, both maintain them
even after separation, which means both individuals
have true psychotic illness.
Folie induite (by Lehman [8]) was first described in
1885. According to Gralnick [15], in this subtype, new
delusions are added to a psychotic individual’s preexist-
ing delusions under the influence of another patient. Some
researchers [16,17] have questioned the usefulness and
theoretical validity of the previously mentioned subclas-
sification by Gralnick [15]; nevertheless, this classification
is at least relevant for describing various clinical patterns
of delusional communication between subjects involved.
In 1980, DSM III defined FAD as “shared paranoid
disorder” in which there is a persecutory delusional sys-
tem that develops as a result of a close relationship with
a person who already has an established paranoid psy-
chosis. Munro [17] indicated that this criterion combines
folie imposée and folie simultanée within its definition.
DSM III-R [18] renamed shared paranoid disorder as
“induced psychotic disorder” and added a new crite-
rion that the recipient did not have a psychotic disorder
immediately prior to the induced delusion (Table 1). Con-
sequently, folie induite (Lehman-Gralnick) was excluded
from this disorder. Mentjox et al. [19] argued that there is
a circular causality in delusion induction, and this makes
it impossible to distinguish between the already-psychotic
individuals and those who were not psychotic before
induction. Finally, in DSM IV [20], “induced psychotic
disorder” (DSM III-R) was renamed again as “shared
psychotic disorder” and included more strict exclusion
criteria against other psychotic disorders or mood disor-
ders (Table 1). This definition of shared psychotic disorder
only includes folie imposée (imposed type) and does not
regard other types of delusional induction. DSM is said to
be based on phenomenology and not to assume etiological
mechanism. However, as a result of excluding comorbid-
ity of other psychiatric disorders such as schizophrenia
or paranoid disorder, only psychogenic FAD remained in
these criteria. It should be noted that these criteria seem
paradoxically based on an etiological theory of psycho-
genesis. As seen in Table 2, many clinical psychiatrists
continue to report the cases of FAD in which the recipi-
ent has high rate of psychotic comorbidity, so that does
not meet the DSM criteria of shared psychotic disorder.
Taken together, the present conceptualization of shared
psychotic disorder in DSM IV may have an advantage
of being nosologically less heterogeneous than previous
editions of DSM, or even than FAD. However, this inevi-
tably leads to limitations in describing certain patterns of
delusion contagion, such as folie simultanée or folie com-
muniquée, that were sporadically observed clinically.
As for ICD, the 10th edition [21] defined FAD as
“induced delusional disorder” (Table 1). ICD does
not contain very strict exclusion criteria for psychotic
comorbidity but emphasizes the traditional theory of the
condition of induction—that the delusion is induced from
active inducer to passive recipient.
Demographic Characteristics of
Published Cases
Demographic data from four review papers published
from the 19th to the 21st century [1,15,22,23] are listed
in chronological order in Table 2. It should be stressed
that in each paper, the definition of the target disorder is
different, reflecting the controversial history of conceptu-
alization of FAD. However, the definition by Lasègue and
Falret [1] is roughly equivalent to those in DSM III-R and
DSM IV, so that the data from Lasègue and Falret [1] and
those from Silveira and Seeman [22], whose case research
is based on DSM III-R or DSM IV, may be reasonably
comparable. Silveira and Seeman [22] found that there
was no statistical difference between the total number of
Table 2. Demographic characteristics of previously published cases of folie à deux
Lasègue and Falret [1] Gralnick [15] Silveira and Seeman [22] Arnone et al. [23]
Searched period, Period not described, N = 7 1879–1942, N = 103 1942–1993, N = 75 1993–2005, N = 64
number
Definition or way Delusions of psychotic individual transferred to Shown in text DSM III-R or DSM IV Database (eg, MEDLINE) search with
to identify cases a mentally sound one who has been in close keywords “induced delusional disorder,”
association with the first one. Separation “shared delusional disorder,” or “folie à
causes recipient to abandon the delusions deux” (there is variability of diagnostic criteria)
Sex Females more often affected than males, Female more often Females more affected Females and males are equally affected both
both as inducer and as recipient affected than males, than males in inducer as inducer and as recipient
both as inducer and group; females and
as recipient males equally affected
in recipient group
Age Recipient younger than inducer Recipient younger Age difference between Age difference between inducer and
than inducer inducer and recipient recipient not significant
not significant
Relationships Limited information due to very small 2 sisters (most common), Incidence in married or Married or common law couples,
sample size husband and wife, common law couples sisters (50% twin)
mother and child, 2 equal to that in siblings
brothers, brother and (sisters more common
sister, pairs of friends, than brothers)
entire families
Dominance and Inducer is more active, older, and more Not found Not found Not described
submission intelligent than recipient
Comorbidity Not clearly described (but in some cases, More than one half Comorbidity described in Comorbidity described in 28.6% of recipients:
of recipient slight mental retardation seems to of recipients affect 62.8% of cases; relatively schizophrenia (14.3%), depression (7.1%),
be suspected) “dementia praecox, high frequencies of bipolar disorder (4.8%)
paranoid” (paranoid depression, dementia,
type schizophrenia) and mental retardation
Treatment Separation effective, especially in recipient Same therapeutic mea- Effective treatment of Separation by itself insufficient; effective
sures as in psychoses in recipient requires neu- treatment of secondary requires neurolep-
general, and separation roleptics and separation tics and separation from primary
from inducer
Folie à Deux and Shared Psychotic Disorder Shimizu et al. 203
204 Nonschizophrenic Psychotic Disorders
males and females affected as recipients, although it is not
the case for inducers. It is in contrast to the earlier hypoth-
eses by Lasègue and Falret and by Gralnick that females
are more susceptible to FAD. Furthermore, in a more
recent investigation by Arnone et al. [23], the difference
in number between male and female both in the inducer
and recipient was not statistically significant. In terms of
age, recent investigations have found that the recipient
had an equal chance of being either younger or older than
the inducer, failing to support the previously held assump-
tion of susceptibility due to dominance of the inducer on
the basis of older age. As for the relationship between the
partners in FAD, previous literature had reported that sis-
ter-sister pairs were the most common overall; however,
more recent data include a higher percentage of married
or common law couples. These findings are largely con-
sistent with the suggestions by Sharon et al. [24•], who
compared the traditional views with new findings on FAD
based on literature analysis.
All of these data were reported from Western coun-
tries. Kashiwase and Kato [25] examined 97 cases of FAD
in the Japanese literature covering the time period from
1904 to 1994. The authors compared the Japanese data
to Western data and found that sister-sister pairs were less
common, younger subjects influence the older ones more,
and acute religious delusion is more common in Japan
than in Western countries. These differences are analyzed
based on sociocultural characteristics specific to Japan.
Their findings are interesting from the standpoint of exog-
enous or sociocultural–genetic theory of FAD. Further
study in this line is needed in other Asian or non-Western
countries, as the relatively rapid Westernization process in
Japan and some other non-Western countries may bring
about substantial changes in the profile of FAD data.
Aporia of FAD: Association of the Subjects or
Genetically Driven Psychosis?
In the previously mentioned review paper, Gralnick [15]
analyzed the explanatory mechanisms of the delusional
association of the partners of FAD, suggesting that FAD
may be better called “psychosis of association.” Schar-
fetter [9] proposed to call FAD “symbiotic psychosis”
because of their origin in a close, mutual participation of
the partners. He indicated that the symbiotic psychoses
are of particular interest in demonstrating that a distinct
psychoreactive development can initiate a schizophrenia-
like psychosis; furthermore, schizophrenia can be related
somehow to inherent predisposition.
Lasègue and Falret [1] already recognized the signifi-
cance of inheritance in familial cases of FAD. It has been
hypothesized that possible genetic dispositions toward
schizophrenia can play an important role in FAD, espe-
cially in the case of twins [26,27]. Paradoxically, however,
the possibility of “psychogenic origin” was also raised in
twins studies [28,29]. Discussion of the psychogenesis of
delusion formation in FAD is confusing because purely
endogenous or exogenous cases can hardly be ascertained.
Rather, the issue should be paraphrased as the following:
What is the characteristic mode of delusion contagion in
the case of subjects with high genetic disposition toward
schizophrenia? The current authors [30•] previously
analyzed the changes in patients’ delusional statements
across the clinical course of FAD, and the observed state-
ments were classified into the following two categories,
based on the subjective pronoun use: 1) we-type (“we are
persecuted”); and 2) non–we-type (mostly “I am perse-
cuted”). Interestingly, we-type was generally observed in
paranoid schizophrenia, paranoid disorder, and shared
psychotic disorder, and in contrast, non–we-type was
predominantly observed in nonparanoid schizophrenia,
such as undifferentiated type and disorganized type. The
difference between we-type and non–we-type statements,
which characterize paranoid schizophrenia and nonpara-
noid schizophrenia, respectively, may reflect different
cognitive deficits, especially ego function, and different
mechanisms of delusional association in FAD. It could be
argued that the we-type suggests the actual establishment
of a delusional community within participants not seen in
the I-type delusion, because the subjective pronoun “we”
rather than “I” may indicate the development of a true
association. However, according to our clinical observa-
tions, in both we-type and I-type delusional contagion,
truly meaningful communication was rarely observed,
as the involved subjects tried to communicate based on
the solipsistic viewpoint inherent to each individual’s psy-
chosis. Therefore, we designated the we-type delusional
viewpoint as paranoid solipsism in FAD and the I-type as
schizophrenic solipsism in FAD [31].
Other Current Clinical and Theoretical Topics
Since the 19th century in France, it has been repeatedly
pointed out that the delusion transferred in FAD is gen-
erally persecutory delusion. On the other hand, some
exceptions have been reported. Patel et al. [32] reported
a case of monozygotic twin sisters who developed bipolar
disorder one after the other, although the recipient had
a previous history of severe head injury complicated by
a right frontal lobe infarct and epilepsy. Dantendorfer
et al. [33] presented a married couple case in which the
husband suffered from paranoid hallucinatory psychosis,
and then his wife also experienced auditory hallucina-
tions (commenting and conversing voices). The current
diagnostic systems, such as DSM and ICD, classify both
of the patients in this case as schizophrenic due to the
presence of auditory hallucinations. The authors criticize
these systems and propose to regard auditory hallucina-
tions as nonspecific symptoms and to diagnose this case
as a specific kind of FAD.
Most major psychiatric disorders are chronic and
characterized by periods of exacerbation and sustained or
 Folie à Deux and Shared Psychotic Disorder Shimizu et al. 205
partial remission. However, patients of FAD sometimes
fully recover from the illness through separation from
other partners (ie, the disorder may be temporary). Joshi
et al. [34•] presented a case of folie à trois in which the
patients committed numerous felonies but were success-
ful in establishing a defense due to “temporary insanity.”
Their case report and review shed light on the new issue
of the relation between the phenomenology of FAD and
criminal responsibility.
Conclusions
FAD is a broader concept than the present definition of
shared psychotic disorder in DSM, having a relatively
long, controversial history of conceptualization and
redefinition that continues to date. FAD seems to include
a syndrome consisting of such disorders as schizophrenia,
paranoid/delusional disorder, and reactive psychosis. On
the other hand, shared psychotic disorder is nosologically
less heterogeneous than ever-proposed concepts. Despite
the heterogeneity, the concept of FAD and several clas-
sical subcategories are important for clinicians primarily
because they are useful in understanding the various
patterns of the delusional contagion, and probably also
helpful in investigating mechanism or etiology of delu-
sional illness in general.
Acknowledgments
None of the authors has a possible conflict of interest,
financial or otherwise.
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folie à trois. J Am Acad Psychiatry Law 2006, 34:511–517.
This study presents a new issue of the relationship between
“temporary insanity” in FAD and criminal responsibility.