Folie à Deux, Dissociative Identity Disorder and Crime

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This file is an analysis of how psychiatric problems in a family can lead to malicious prosecution of innocent people. In the more serious, otherwise similar situation, there can be false allegations of sexual abuse. In other situations usually involving divorce there is the allied psychiatric condition of Parental Alienation Syndrome. The first generation is someone with schizophrenia, the second generation is a high- functioning dissociative identity disorder person(DID) {substantially what was previously termed multiple personality disorder (MPD)}. The delusions of this psychotic person are then induced in the third generation of family members as folie à deux separately and in combination as folie à famille, a form of contagious delusion.

Multiple Personality Disorder


S. L. Mitchill is usually credited with the first description of a case of multiple personality disorder in 1816. The patient was a young English woman , Mary Reynolds. She was a bright and healthy child but during her teenage years developed fits and other symptoms of psychological disturbance.
"Unexpectedly and without any kind of forewarning , she fell into a profound sleep, which continued several hours beyond the ordinary term. On waking she was discovered to have lost every trait of acquired knowledge. Her memory was tabula rasa;all vestiges both of words and things , were obliterated and gone. It was found necessary for her to learn everything again .... after a few months another fit of somnolency invaded her. On rousing from it, she found herself restored to the state she was before the paroxysm; but she was wholly ignorant of every event and occurrence that had befallen her afterwards .... she is as unconscious of her double character as two distinct persons are of their respective natures .... During four years and upwards, she has undergone periodical transitions from one of these states to the other"
(Mitchill, 1816)
The old and the new personalities continued to alternate until her death. This patient , like many others, attracted a great deal of interest from the medical profession and lay public alike, and she became known as la dame de MacNish after an account written by a MacNish. The small number of references to the condition in the first half of the 19th century included two British reports of dual consciousness (Mayo 1845 and Skae 1845). No cases of the disorder were published between 1847 and 1873.
After the turn of the century , Morton Prince reviewed a collection of 20 patients and later published a celebrated account of one patient , Christine Beauchamp. From this time , most cases were reported as having more than 2 personalities and the condition became known as multiple personality disorder (MPD)
In the 20th century public awareness of the condition has been raised following the release of dramatised , written and cinematic, biographies of sufferers e.g.
"Eve" Thigpen and Cleckley, 1984
"Sybil" film of 1976 with Sally Field as the lead
"Her Deadly Rival" film of 1995. According to the tailpiece of this film it was based on real events. I have not been able to establish the original case - if anyone is aware could they relay details to me.
Other or previous names for MPD are multiplex personality, double existences, dual personalities, double personality, plural personality, dissociated personality, split personality and most recently dissociative identity disorder (DID).


From Diagnostic and Statistical Manual of Mental Disorders (DSM) IV
a) the presence of two or more distinct identities or personality states which recurrently take control of the person's behaviour
b) an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness and is not due to the effects of a substance or a general medical condition.
Adding to the mystique is the delay in making the diagnosis, often taking six to eight years of treatment before MPD is recognised. Putnam et al 1986 circulated a 386-item questionare, employing symptom check- lists to 400 clinicians with a known interest in MPD, seeking information on cases of MPD meeting the earlier DSM-III criteria. One hundred cases were selected, including 92 females. The average age of diagnosis was 31 years. The patients were well educated and many had achieved high occupational status. Ninety-five percent had received one or more psychiatric or neurological diagnoses prior to the diagnosis of MPD. The interval between first presentation and diagnosis of MPD was an average of 7 years. The patients presented with an array of symptoms, most prominently depression, anxiety, eating disorders and auditory and visual hallucinations. Many presented with "hysterical" or "dissociative" symptoms including fugue episodes in half the cases. The number of personalities ranged from 2 to 60, the average being 13. In 85 cases one of the alternates was reported to be a child. In 61 percent suicidal behaviour was associated with the alternative personality. Violent behaviour towards others was commonly attributed to others and homicidal behaviour alleged in 6% of cases . 50 percent of patients feared or lost sexual impulse control ranging from heterosexual and homosexual promiscuity to sadomasochism, paedophilia, bestiality, exhibitionism, menage à trois and erotic asphasia. Amnesia was a symptom in 95% of the patients. (Bliss, 1980) Bliss has stressed the importance of amnesia and lost time as symptoms that should raise the clinical suspicion of MPD. MPD can present with a diversity of symptoms, including those commonly associated with schizophrenia. Unlike schizophrenia, reality testing is said to be well preserved. Examples of memory problems associated with MPD include patients unable to recall what was done at certain times, reports of finding their belongings in strange places or finding strange items among their belongings. Also independent third-party reports of comments on their behaviour which is uncharacteristic and about which they have no recollection. Under hypnosis these alternate personalities can often account for the lost times and memory problems. The amnesia is frequently asymetric. The more passive personalities tend to have more constricted memories, whereas the more hostile, controlling or protector personalities have more complete memories. Evidence of amnesia may be uncovered by reports from others who have witnessed behaviour that is denied by the patient. There may be loss of memory not only for recurrent periods of time but also loss of biographical memory for protracted periods of childhood. Transition between identities is often triggered by psychological stress. The time required to switch from one identity to another is usually a matter of seconds but, less frequently, can be gradual.
MPD patients can be "high functioning multiples" people who elude hospitalisation and can achieve considerable stability and success in their lives. A useful screening instrument for dissociatiative disorders is the (DES) Dissociative Experiences Scale which is a 28 item self-report questionaire. A similar but more recent screening tool is the (DIS-Q) Dissociative Questionaire developed in Holland.

Early Development

Traumatic childhood experiences, especially of physical abuse and neglect are said to be common in MPD. (Bliss 1984) in a series of 70 patients estimated that 60% had been victims of sexual abuse and 40% were victims of other types of abuse during childhood. Coones & Milstein 1986 found similar rates of 75% and 53% . Putnam et al 1986 reported 97% to have a history of childhood abuse. Sexual abuse , usually incest, was reported in 83% , other physical abuse in 75% and a combination of sexual and physical in 68% . In their study the average age of onset of MPD was estimated at about 6 years. The effects of exposure to situations of extreme ambivalence and abuse in early childhood may be coped with by an elaborate form of denial, so that the child believes the event to be happening to someone else. This process may be facilitated in childhood, a time when there is a rich fantasy life, often including imaginary companions. This elaborate form of defence maybe splitting into all good and all bad alternatives. It is possible that traumatic experiences in childhood may enhance the individual's ability to dissociate.
From the Lewis paper. The 12 murderers in our study were unaware of their DID condition. They had partial or total amnesia for the abuse they had experienced as children. 6 of them were abused by the mother. Contrary to the commonly held assumption that individuals facing the consequences of murder charges will exagarate their childhood misfortunes, in mitigation, these murderers could barely remember anything about their childhoods. Also contrary to popular belief that probing questions will either instil false memories or encourage lying, especially in dissociative patients, of these 12, not one produced false memories or lied after inquiries regarding maltreatment. They either denied or minimised their early abusive experiences. We relied on objective records and on interviews with family and friends to discover that major abuse had occurred. In every case, 3 or more outside sources provided independent evidence of subject's marked change of voice, demeanour, and behaviour and in 11 cases abuses were also verified objectively.
 MPD and altered handwriting
Handwriting from the D. O. Lewis article cited below.
In 10 cases handwriting samples produced before the offences in question documented changes in writing styles and signatures.

Case Studies

Kluft 1986, Published report describes MPD in 3 individuals of high accomplishment whose pathology was extremely well disguised in both their lives and in their clinical presentations. They neither demonstrated nor acknowledged signs suggestive of a dissociative disorder, anxiety disorder, schizophrenia, seizure disorder, affective disorder or borderline personality disorder. Such cases can be described as "good neurotic" or mild character neurotic or high-functioning MPD. The intention was to raise the index of suspicion for MPD in apparently stable and successful patients whose initial presentations give no overt indications of MPD.
Case 1
A 30 year-old female physician applied to a psychoanalytic clinic . Two periods of less intensive psychiatric treatment had failed to change masochistic tendencies in her relationships with men. Her evaluation included interviews with a senior and 2 graduate analysts and discussion of their findings by 6 others. No treating psychiatrist, evaluator, or committee member raised consideration of MPD. Once analysis began, she was very resistant. Latenesses were frequent. She claimed she lost track of time and suddenly realised she was already late for her session. As the transference intensified, she became quite uncomfortable. The latenesses increased in frequency and duration. Long silences became commonplace. Midway through her fourth year of analysis , during a session she abruptly got up from the couch, turned to the analyst, and said, "You can analyse HER, but I'm leaving!" The patient spoke in a markedly different voice that was familiar to the analyst, but which he, until that moment , had attributed to transient regression. The analyst regained his composure and responded, "You are in analysis too. Please return to the couch and let us continue. " After several minutes of indecision , the patient did go back to the couch.
The personality the analyst recognised as his patient returned a few minutes later, complaining of a headache and vaguely aware that "something upsetting" had occurred. A few weeks later, she showed the analyst diaries in handwriting she did not recognise as her own. She talked about several occasions on which the analyst had commented on her out-of-character clothing and told him that on those days she did not recall dressing. There were garments in her possession that she could not remember buying. She feared she might have multiple personalities. Within weeks, four additional personalities entered the analysis . One readily admitted she opposed the analysis and had acted obstructively in the hope that the analyst would give up on the patient. Once she became co-operative, the latenesses and silences ceased.
The painfully good and constricted woman had one personality that led a separate life with drastically different friends, clothes and habits. A third occasionally took over. When out, she functioned within the patient's usual personal and professional relationships, but was far less inhibited. Both were quite distinct. The other two included a punitive alternate ego who frequently inconvenienced the patient, but never interacted openly with other individuals , and a child personality that rarely emerged. The patient had been aware of many evidences that suggested she had MPD, but had withheld them. For example, she offered extensive rationalisations for her amnesias or behaved so as to appear contrary rather than amnesic. She integrated gradually, and showed no signs of MPD during the last 2 years of a 7. 5 year classical psychoanalysis.
Case 2
A 40 year-old research scientist of substantial attainment already had been seen by four psychiatrists in connection with a traumatic divorce, major relocations, and the pressures of combining career and family responsibilities. None had suspected a dissociative disorder. Seeking treatment to resolve major difficulties in her relationships with men, she declined to enter classical psychoanalysis, which had been recommended, citing the burden of her children's college expenses and the time pressures of heading a professional organisation. Instead, she entered a psychoanalytic psychotherapy that proved quite successful . Two years after termination she returned, engaged to a suitable man, but concerned about problems in dealing with her children.
.... She simply did what was told by another personality she knew as "the kid". Her own function was to handle interpersonal relationships adroitly. She was afraid she would be considered schizophrenic if she revealed her situation. This woman had 19 personalities, 12 of which were quite distinct, most of which came out only in private, and some of which restricted their emergence to times when she was amongst strangers, or was in social situations that were quite superficial ....
Case 3
A physician in her late 20s had seen a series of psychiatrists since her teens in order to work out problems in her relationships with men. Initial medical inquiries by an analyst revealed the patient was left-handed. However, while the patient was writing down some basic information, she did so with her right hand. The analyst asked a question while she was writing. The patient appeared dazed momentarily, and then resumed writing, but with her left hand. She also appeared dazed when asked whether she had suffered any abuse during her childhood. These incidents led the analyst to ask about memory problems, disremembered behaviours described to her by others, headaches, and passive influence experiences (not fully emerged identities, unexplained strong emotions or pains). On several occasions, these questions were followed by the patient's complaining of a headache, looking dazed, and behaving somewhat differently for a few moments. These behaviours suggested the unacknowledged switching of personalities. Finally a personality identified herself to the analyst by a name different from that of the presenting personality and expressed relief at "finally telling someone what's really going on". This patient had 9 personalities, seven of which were very distinct and autonomous. In one, she had pursued a career as an exotic dancer in addition to studying medicine.
End of case studies
Many of the patients had evolved complex strategies to conceal their disorder. Clinicians consider MPD rare because they expect to see and readily confirm "a steady and public history of certain dramatic phenomena in order to consider the diagnosis and to document it". Over 90% of those later diagnosed as MPD have tried to hide such manifestations, and over 50% who are approached with hypnosis or amytal interviews to clarify their diagnosis withhold evidence of MPD at their first such assessments.
In all these (Kluft)12 cases, the presenting personality withheld data that might have raised the index of suspicion for MPD. Many were able to cover over amnesia or to offer plausible rationalisations for it. When asked about the amnesias and out-of-character behaviours that occurred during analysis, patient 1 behaved in a distractingly provocative and contentious manner. She researched the psychoanalytic literature on forgetting. Sometimes she confabulated, sometimes she deduced what had happened and represented her conclusions or what others had told her as if it were memory, and sometimes she deliberately offered astute psychoanalytic explanations of her forgetfulness. She did not admit awareness of having separate diaries and wardrobes for several years. In patient 2 most of the alters were aware of one another. One personality was only aware that "she needed more sleep than the average person" . She believed she fell asleep at 9 pm. The others led their lives between 9 pm and midnight or 1 am. The presenting personality was in treatment for 4 years before admitting there was evidence that things happened while she believed she was asleep. Patient 3, usually a reserved and demure individual, danced in sleazy bars and stripped to virtual nudity. Another personality could never believe she was "actually doing it" but was titillated at the idea of having a secret other life.
Another Case Study from the P. Mollon book
Angie a moderately successful young artist, presented initially with anxiety, panic attacks, low self-esteem, an anorexic eating disorder, and disturbed interpersonal relationships. On being taken into therapy it rapidly became apparent that dissociative processes pervaded her life. For example , she lived with one man, whilst having a relationship with another man, neither of these men knowing about the other. With the man she lived with she was quiet and sexually inhibited, whilst she would also, unbeknown to him, lead another life in which she was a sexual "femme fatale", very lively, wearing different clothes, speaking with a different voice and relating to a quite separate group of friends. When asked if she felt guilty, in relation to her cohabiting partner, regarding her relationship with the other man, she explained that she did not, because when she was with her partner the other relationship seemed like something another person was doing .... A recurrent feature of the therapist's experience was of being bombarded by a contradictory and confusing array of beliefs, attitudes and arguments which showed no regard to logic. She would for example speak rage-fully of her parent's behaviour towards her, whilst at the same arguing that they were absolutely correct. Any line of interpretation which the therapist attempted to explore would be met by a barrage of confusing disputation which would leave him feeling helpless and enraged. Gradually it became clearer that she was conveying something of her own experience of the confusing and contradictory behaviour of her mother - and also that she was giving expression to a very sadistic part of herself that continually condemned her. It seemed her mother would express contradictory attitudes at different times, and would implicitly forbid her to point these out.
Once a high-functioning MPD patient is identified her treatment can be a delicate matter. The rule is "do no harm". Often their careers or professions are the stabilising centres of their lives. They fear becoming dysfunctional. Their apprehension about losing their careers is not unrealistic.


The Characterological Basis of Multiple Personality, Ira Brenner American Journal of Psychotherapy, Vol 50, No2, Spring 1996, 154-166
Objective Documentation of Child Abuse and Dissociation in 12 Murdurers with DID, D O Lewis, American Journal of Psychiatry, 154:12, Dec 1997, 1703-1710
The Diagnosis of MPD, Thomas Fahy, British Journal of Psychiatry, 1988, 153, 597-606
High-Functioning Multiple Personality Patients, R C Kluft, Journal of Nervous and Mental Disease, 1986, 174, No 12, 722-726
Multiple Selves, Multiple Voices by Phil Mollon, Wiley, 1995

Folie à Deux

"When you live in the shadow of insanity, the appearance of another mind that thinks and talks as yours does is something close to a blessed event" Robert M Pirzig - Zen and the Art of Motorcycle Maintenance 1974


Paranoid disorders and the spread of delusional ideas to family members is in the literature since the 17th century. Few people in close association with deluded individuals acquire their delusions as attested by the rarity of published cases. 100 reports of folie a deux from 1877 to 1942 and 280 1943 to 1996. Other terms for folie a deux now known as Induced Psychotic Disorder (IPD) are and were; infectious insanity, psychic infection, contagious insanity, collective insanity, double insanity, influenced psychoses, mystic paranoia, induced psychosis , associational psychosis, epacti psychosis and dyadic psychosis.
One investigator reported a frequency of 29 individuals (1. 7% ) with folie a deux in 1700 consecutive admissions. Many cases may go unnoticed because they are classified individually or because only one member of a pair is admitted. The more a hospital is oriented toward family evaluations and diagnoses, the more likely a partner in a shared psychotic disorder will be found. Representative of 103 actual pairs include 2 sisters 40 , husband and wife 26 , mother and child 24, 2 brothers 11 , brother and sister 6 , father and child 2. The greater susceptibility of women to the disease is probably due to the more restricted and submissive roles imposed on them socially. Also the added greater likelihood to seek help and be hospitalised. Folie a deux has been implicated in such notorious or bizarre events as the serial killers Ian Brady and Myra Hindley, Fred and Rose West; mass suicides of the People's Temple cult in Guyana (912 people in 1978), Heaven's Gate cult recently; The League of Geniuses, the Men in Black "seen" by flying saucer watchers/alien abductees and even Adolf Hitler and the German nation. Suicide Pact in Dublin of the Mulrooney (Mullrooney in a register) family, 3604, 425337, 00.html , 20 Jan 2001. On the day of writing this , 14 June, 2002 were two reported incidents. Three people jump off 200 ft cliffs at Salcombe Cliffs near Sidmouth Devon [ later report 20, Apr 2004,3604,1195597,00.html ] and in New Zealand two Seventh-Day Adventists are jailed for 5 years for not allowing medical treatment to their 6 month old son Caleb Moorhead. You start to see possible cases of Folie a Deux all over the place.

Nature v. Nurture

Craig 1945 reported a case of folie a deux in monozygotic twin sisters who shared similar paranoid delusions although they had been separated from the age of nine months. Most shared disorders are consanguineous (91% by Gralnick) and that a similar inheritance forms the basis for the phenomenon. The possibility of inheritance was recognised 120 years ago. At least 2 lines of evidence support the concept that genetic vulnerability to psychosis is important in the development of a folie a deux. First it has been shown empirically that psychotic symptoms and delusional ideas are seldom "transmitted" from a psychotic individual to a healthy one merely upon prolonged exposure. In other words unless one is somehow predisposed, rarely does a person in close contact with a deluded individual actually acquire the latter person's delusions. The passive person involved in a folie a deux usually has a "prepsychotic" personality (i.e. a marked personality disturbance with suspicious, histrionic, dependent or antisocial traits) and may well have developed a mental disorder even if he/she had not been in contact with a psychotic individual. The critical question is not whether a genetic predisposition to psychosis, in particular schizophrenia, is operative in folie a deux; rather the critical question is whether it is necessary for the development of the disorder. Scharfetter 1972 concluded that a hereditary schizophrenic predisposition was required for the development of folie a deux "only persons with a genetically determined predisposition are likely to develop a schizophreniform psychosis themselves under the influence of a primary schizophrenic partner".
(From Waltzer 1963)One cannot minimise the developmental significance of noxious agents, namely the parents and the disturbed environment which was relatively constant and identical for all the children, in the precipitation of delusional thinking. A relationship appears to exist between the tenacity with which the delusions are held and the duration of exposure to these noxious stimuli.

Case Studies

Case 1
Mrs A a 47 year-old ... (delusions about neighbours) ...... Her son B was 20 years old ..... he had always lived with his mother and described his relationship with her as good. At first he thought his mother may be unwell and did not believe her story. However when interviewed on the second meeting he admitted to believing 80-90% of his mother's story ........ He later shared with professionals that if she was found to be ill, so be it and she could be treated, on the other hand, if she was found to be well then all the business about her neighbours would be "proven to be true". When she was treated and improved; his beliefs dissolved and disappeared without medication.
This case illustrates the legal problems which can arise in practice when treating a case of folie a deux. During her first admission Mrs A was very disturbed and tried to leave the hospital. However her son shared her beliefs at the time and was resistant to ideas of detaining his mother under the Mental Health Act 1983. Both individuals were irrational, but only the mother was psychotic and required admission. When the "nearest relative" (the son B) objects to an application being made with regards to a section 3 of the 1983 Mental Health Act then an approved social worker has to obtain consent of the nearest relative. The nearest relative can be set aside on application to a county court (section 29) on the grounds that he is unable to act as the nearest relative by reason of his "mental disorder" or unreasonableness.
Case 2
A 43 year-old housewife-writer was admitted to the hospital in a severely agitated state. Her history revealed a delusional state of 10 years duration regarding a conspiracy in the literary world. Her husband and 3 adolescent children shared these beliefs ..... The patient's family were not hospitalised since they functioned well outside the home without any need to mention the conspiracy. The patient herself had managed to function remarkably well during her marriage as a housekeeper and mother by keeping the delusions within the family. Her primary diagnosis was paranoid state with a schizophreniform psychosis. A diagnosis of induced psychotic disorder was made in the husband and children. The patient responded quickly to neuroleptic medication. The children and husband agreed after 2 visits that they had mistakenly gone along with the patient's "over intense imagination" although the treatment team was quite convinced that the husband was just being compliant. He was an impassive college physics teacher who seemed to be an odd caricature of an absent minded professor. Although attached to his family he expressed it by distant concerned observation rather than by participation in family activities.
Follow-up over a 6 year period revealed the diagnosis in the primary to be a chronic paranoid state with periodic affective disruptions usually related to some cumulative unexpressed anger at her husband or apprehension about her children ..... A decreased need to convince the family of her persistent delusions was sufficient to permit the 3 children to begin to separate from the family and to enter college without untoward incident, although one of the children showed tendencies toward being isolated and without friends. They had an "imposed psychosis" or folie imposée. The husband continued to share his wife's delusions although he accepted his wife's need for treatment to prevent her from getting too "excited" about things. He seemed to have a "communicated psychosis" or folie communiquée.
Mild supportive intervention with the occasional use of medication had a dramatic effect on this folie à famille. Over time it became clear that much of the wife's passionate and angry involvement with the literary establishment was a displacement from the husband who supported it because it enabled him to maintain a comfortable emotional distance in the relationship. Conjoin therapy was not recommended in this case because of a tactical decision to enlist the husband as an ally with the therapist in "helping his wife with her over- reaction".


There is shock and strain suffered by the as yet non-psychotic partner when first witnessing the psychotic affliction of the inducer. It seems reasonable to suppose that the former may be impelled to identify herself with the latter as a result of the psychological phenomenon of sympathy and/or imitation. The stability of the weaker partner's psychosis also depends to some extent on her suggestibility. A person highly vulnerable to suggestion can acquire delusional ideas with great speed and facility; but such ideas are unstable as they are easily displaced by counter-suggestions. A less suggestible individual will take longer to acquire such delusional ideas but will doubtless hold them with greater persistence. There are marked similarities between what transpires in the development of a folie a deux and the process of brainwashing. Three phases are present in both. The first phase may be viewed as the "disorganising or regressive phase" and consists of the breakdown of existing defences and resistances. In brainwashing and folie a deux this is accomplished through social isolation , sensory and ideational deprivation. During the second phase identification with the aggressor, who is viewed as the rescuer, takes place. The submissive individual identifies with the dominant person who is consciously or unconsciously carrying out the operation. The brainwashee is exposed to kindness and consideration during this phase. The third phase is the re-indoctrination period. Constant monoideational stimulation is maintained until the ideas are incorporated by the individual who is in a submissive role. The second and third phases are only possible after the first has been successful.
There is also a similarity to hypnosis. Hypnosis is dependant on the establishment of a degree of dominance by the exponent over the subject. Under these circumstances the former can induce the latter to accept suggestion without critical appraisal of its validity. In psychosis of association, the submissive partner is being induced by the process of suggestion to accept the delusional ideas of the dominant one.
Most cases of folie à deux show a pattern of dominance and submission. 90% of cases are reported to occur in families. The primary agent must be in close proximity, be a figure of authority or identification, and be in the early or less severe stages of psychotic de-compensation in order to be in touch with reality enough to influence the other. In addition the secondary partner must derive some gain from adopting the symptoms. The underlying process is one of identification by the submissive party, which may be unconscious. Folie a deux is an example of a pathological relationship in which the dominant party strives to maintain a link with reality while the other fulfils dependency needs. The recipient is not necessarily entirely a submissive partner since in most cases he or she becomes delusional after considerable resistance and this may impact on the primary sufficiently to modify her delusions. The secondary partner seeks to preserve the relationship with the dominant one by adopting her delusions because the threat of loss is greater than the fear of psychosis. All families share a common reality and family myths which help the family to maintain a stable cohesiveness in the midst of internal or external threats.
Both criminal acts and suicide pacts can occur in shared psychotic disorder .


Delusional disorders are largely under-diagnosed because patients retain relatively high functioning in the community, actively denying disability and avoiding help from psychiatrists, who also avoid these patients because of their litigious and confrontational nature. These individuals drift between delusional and normal modes and confound all but the most experienced clinicians . Often passing as eccentrics until they cause harm or significant conflict in the family or community, including suicides and murder-suicides. Other medical specialists, non-medical professionals and law enforcement officers are the likely first contacts. Inexperience and lack of skill in identifying and eliciting paranoid phenomena leads professionals to accept delusionaly based reasons for patient's actions as rational if they are not immediately bizarre. Delusional patients often do not meet criteria for involuntary treatment, leaving professionals with few opportunities to remove children from potentially harmful situations. Guidelines for the involuntary commitment of adults are often in conflict with child protection legislation.
Paranoid patients are often litigious and make threats when issues of the safety of their children are raised. They feel persecuted and sometimes make delusionaly based threats against professionals that they actually act upon. This causes professionals to approach such situations with extreme caution.
Children in such families vary in their involvement in the delusional beliefs. They struggle with 2 divergent belief systems; the delusional, based at home and that of the larger society.
Paranoid parents tend to demand secrecy and loyalty , interrogating their children to confirm their beliefs. The children present with internalising symptoms, which they develop to prevent open conflict with the dominant delusional parent. They do not challenge the beliefs because they fear the parent's anger and retaliation, which in turn awaken separation and abandonment fears. A similar situation exists for children who are the victims of parental incest, whose obligation to secrecy is necessary to preserve their abnormal relationship with the parent.
The risk of the second parent becoming delusional is significant. Other emotional responses in the second parent include anger, perplexity, protective feelings, help-seeking behaviour, or withdrawal and uncertainty whether the partner is ill or not.
If the psychotic parent acts on her delusions, children are endangered, especially if the other parent cannot protect the children. There is a major concern when the delusional parent is violent towards the other parent.
Delusions bring the parents into conflict with the authorities who attempt to rescue the children. This fuels the persecutory delusional beliefs, and authorities are seen as provocateurs by the ill parent(s), who feel undermined and may flee.
Child protection agencies, school authorities, public health nurses and mental health professionals become involved. These patients though clearly ill, are often deemed not certifiable, and the use of child protection and education(truancy) legislation to bring attention to the plight of such children is common. This often results in potentially violent confrontation with the family, precipitating their departure from the jurisdiction -"pursuit of isolation".


(Munro, 1986) "in truth , the majority of individuals with folie à deux are not psychotic; they tend to be impressionable people who adopt untrue beliefs as a result of a long and over-close association with a deluded person".
Treatment of Inducer
When an inducer with a clearly recognised mental illness such as schizophrenia can be identified, appropriate treatment, preferably as an inpatient, is indicated. Admission may be under a section of the Mental Health Act since there is generally resistance to admission from such patients. Treatment with supportive psychotherapy has been reported to be successful in a non-schizophrenic patient. After discharge, maintenance treatment to prevent recurrence in schizophrenic patients is necessary.
Treatment of recipient
For the recipient, separation is an essential therapeutic step, particularly in cases of folie imposée. Separation should be full and prolonged, but leads to recovery in only 40% of such cases, despite the popular belief that this always proves effective. If the recipient has a true psychosis, treatment with appropriate antipsychotic medication is indicated as strongly as for the inducing member of the pair.
The isolation from friends and community in induced psychotic disorders is often self-imposed and results from the hostile and rejecting attitude that accompanies the delusions. Whatever the origin of the sequestration of the partners there is the loss of the possibility of any balancing dialogue or self-correcting impact on the delusional formation. Similar underlying needs in the partners allow a delusion to be transmitted because it is "tailor made". It may not be communicated, transmitted, or forcibly imposed but adopted. It is still the common belief that the delusion is often imposed by a persistent wearing away of the recipient's resistance.
Delusions function as psychotic defences. In folie a deux the mutual acceptance of delusions enables the inducer to stay in contact with at least one other person despite the loss of contact with reality. The more dependent recipient is willing to accept delusions as the price of maintaining the connection.


The Psychosis of Association - Folie a Deux, Kenneth Dewhurst, J. of Nervous & Mental Disease, 1956, 124, 451-9
Folie a Deux, M H Sacks, Comprehensive Psychiatry, 29, No 3, May 1988, 270-277
Mummification & Folie a Deux, D P Boughton, Comprehensive Psychiatry, 30, No 1, Jan 1989, 26-30
Induced Psychosis, R Howard, British Journal of Hospital Medicine, 1994, v 51, No 6, 304-307
The Delusional Parent, TPM Ulzen, Canadian Journal of Psychiatry, 42, Aug 1997, 617-622
Folie a Deux in a Seychellois mother and adult son, Hospital Medicine, Nov 1999, V 60, No 11, 832-835
A Psychotic Family - Folie a Deux, H Waltzer, J of Nervous and Mental Disease, 1963, v137, 67-75
Folie a Deux: Psychosis by Association or Genetic Determinism, A Lazarus, Comprehensive Psychiatry, Mar 1985, 129-135
Two Cases of Folie a Deux in Husband and Wife, GN Christodoulou, Acta Psychiatrica Scandinavia, 1970, 46(4), 413-419

Thanks to the staff and facilities of
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Royal South Hants Hospital

I watched a TV documentary about the life of Diana, Princess of Wales. Some people (not psychiatrists) in her lifetime had diagnosed her , in absentia, as having Borderline Personality Disorder. Probably very true but I noticed traits of MPD/DID and behaviours that I had become familiar with, including eating disorder, bullying, pathological lying. I borrowed a copy of a book by Sally Bedell Smith from the library, not the usual fawning drivel on Di. US title is Diana: In search of herself and in UK Diana: The Life of a Troubled Princess.

It seems almost impossible that someone so much in the public eye as Princess Di could have functioned for years with so few people twigging that she had a serious personality disorder. An exploration of a pathological liar or was it someone displaying different alters. She was often referred to as being manipulative. But someone manipulative covers their tracks not her sort of behaviour, saying one thing to a person one day and plainly contradicting it to that same person the next. Someone manipulative has a goal in mind and sticks with it through consistent lying not inconsistent lying.

The following is quotes from that book.
"Because of her quicksilver temperament , Diana could slip easily from one mood to another, confounding those around her ... She was a curious mixture of incredible maturity and immaturity, like a split personality. "
"She had real difficulty telling the truth purely because she liked to embellish things. " It was hard to take Diana's word at face value, since she so often said things to make a point, whether or not she contradicted a previous account.
The following certainly smacks of MPD, October 1981
Instead of prescribing an antidepressant , the doctors gave Diana the tranquiliser Vallium, which she rejected, believing that they only wanted to remove her as a problem by sedating her. Diana revealed her rage, resentment and denial: "She spoke in the third person, as if about someone else" - classic MPD/DID behaviour.
Diana panicked when Charles didn't arrive home on time, which drove her to tears because she thought" something dreadful had happened to him"
Diana said different things to different friends - yet another reason she preferred that they not compare notes.
The Hoare household started getting anonymous telephone calls to their home. The calls began in 1992 and numbered as many as 20 a week, some as late as midnight. Each time the caller remained silent. The police equipped their phone with a computerised code that could activate tracers. All the calls originated from 4 lines at Diana's addresses and her mobile phone. The phone calls had to stop because the police were involved and prosecution under nuisance call laws was being considered. At this point , the calls ended.
In 1994 even the Sun newspaper under the heading "Two faces of Tormented Di" contained details of her "Jekyl and Hyde" personality
Bashir (a TV presenter) had informers but as explanation for source of this knowledge had easily convinced Diana that her house was bugged.
From Jane Atkinson "It was a very funny 20 minutes, light-hearted and girlie and laughing. Suddenly she switched off and left the room. She was outgoing, and then suddenly shut down. "
Besides her sons, Diana looked to a dwindling number of friends she could count on.
Diana was now "telling pointless lies more and more frequently"
Tiggy Legge-Bourke (nanny) was photographed pouring champagne for Diana's 2 boys which made Diana "hit the roof". Diana instructed the press to convey her withering criticism. After printing , Diana put out a statement that "it was untrue and she admired Tiggy"
From a reporter Arthur Edwards covering the romp with the Fayeds in the Med. "he had never seen her act more bizarrely ... hiding from the camera one minute and walking around like a supermodel the next"
Diana reported hearing voices that instructed her

Finally to open out this study and of assistance to the general public the following is from a very useful book for all aspects relating to witness testimony and other evidence. It is a book that will not be found in the ordinary public library but is available interlibrary loan from the British Library.
Analysing Witness Testimony
A Guide for Legal Practitioners and other Professionals
By Anthony Heaton-Armstrong , Eric Shepherd and David Wolchover
Blackstone Press
8. 2. 1 False Allegations of rape
A Survey (Kanin 1994) in America looked at all rape allegations made in one police agency within a nine-year period and found that 41 per cent were retracted and declared to be false. This study identified three purposes served by the false allegations - providing an alibi, gaining revenge, or seeking sympathy and attention.
a) The allegation as an alibi - more than half were invented to account for the unforeseen consequence of a consensual sexual encounter. Amongst the most common reasons given was a pregnancy for which the alleged 'rape' provided a plausible explanation.
b) The allegation as revenge- slightly over one quarter of the women made allegations against a rejecting man. Usually this followed the break-down of a relationship but occasionally the accusation was made when the man spurned the woman's advances.
c) The allegation to gain sympathy -this was the smallest category and occurred within the context of other relationship difficulties.
Were the retractions valid? The allegations were only declared to be false following police investigation and withdrawal by the women. Many women are reluctant to report sexual assault from fear of the police investigation and court procedures, and prefer to withdraw their accusation. In the past the police have tended to be unsympathetic towards women who reported rape. However, in this study all retractions were made early on and did not follow prolonged investigation or police interviewing. Moreover, the women were told they would be charged with filing a false complaint, a felony which carried a heavy fine and possible custodial sentence. None of the women later withdrew their retraction, and it seems likely that the retractions were legitimate. The women who made false declarations did not differ from women whose' complaints were legitimate, but the complaints differed. The fabricated accounts did not include accusations of forced oral or anal rape, in contrast to a quarter of the substantiated rape complaints. None of the women appeared to be deluded or suffering from obvious psychiatric disorder, but were attempting to deal with a personal crisis or social distress. In a later study of false allegations at two university campuses half of all rape complaints were admitted to be false. Of these, half provided an alibi for the complainant and half were motivated by spite and desire for revenge. Only one was made solely from a wish for attention .
8. 2. 2 Allegations arising from disputed custody
An allegation of sexual abuse is a potent weapon against a despised spouse and in cases where custody is disputed such allegations have a high probability of being false. That is not to imply that there are no true cases of sexual abuse in custody cases , merely that the context offers peculiar temptations to the adults. Divorce and disputes over custody form the background to about 50 per cent of cases of false allegations of sexual abuse involving children. Typically this kind of allegation is a deliberate manipulation by one parent to obtain custody, using the child as an instrument of directed desceipt. Most often it is the mother who accuses the father of abusing the child and sometimes coaxes the child to confirm the allegation. Some children come to believe their stories , while others are simply supporting the parent. Not all accusations are as flagrantly dishonest and some arise from anxious misinterpretation of a child's behaviour. Children who are torn between two parents frequently show signs of distress which can be misconstrued as fear of the non-custodial parent. Occasionally, normal events such as soreness around the vulva or rectal irritation have been wrongly construed as evidence of penetration. 8. 2. 3 Deliberate deceit by children
Deception by the child, not at the bidding of a parent, is unusual. As with adults, when it occurs it is usually opportunistic and motivated by spite or to provide an alibi; for example, an older child may sometimes accuse an adult in order to conceal sexual activity with a peer, and young children have made accusations to avoid being returned to neglecting but not abusing parents.
Not all false allegations are deliberately such. Allegations of sexual abuse may occur as part of a psychiatric illness. Such individuals generally show other features of illness and will respond to treatment of the underlying condition. However, some may come to the attention of investigating authorities before the correct diagnosis is made. The division of mental illness into psychosis and neurosis, though imprecise, remains a useful distinction. As well as mental illness are the various forms of personality disorder which may exist independently of any mental illness but nevertheless cause significant impairment of social functioning. 8. 3. 1 Psychosis
Psychosis is a mental disorder in which there is gross impairment of mental function to such an extent that insight, judgement and contact with reality are affected. The majority of sufferers experience delusions or halucinations, have conspicuous social and personality difficulties and generally do not recognise themselves as unwell.
Case example 8. 1
A professional woman 'knew' instantly that sexual abuse had taken place when she saw her father comfort his grandchild after a fall. The police and child protection authorities were involved and investigations begun before the case was dropped when it became clear that the mother was hypomanic. After treatment with mood-stabilising drugs she withdrew all her allegations and became severely depressed. Two later relapses were ushered in by further accusations. Now well, the patient is ashamed and embarrassed by her allegations, and when depressed they fuel her sense of herself as irredeemably evil. Psychiatric illness is rare in young children , but in adolescents an accusation may sometimes be the first indicator of a developing psychosis
Case example 8. 2
A 12-year-old girl accused her father of repeated rape. An extensive social services enquiry found no evidence, but, as a precaution she was re-housed in her own fiat. When she later stated that her mother, a music teacher, greeted her pupils topless, doubt was cast on her story. Several years later she had clear symptoms of schizophrenia. Accusations may arise out of psychological disturbance involving more than one individual. The folie a deux is a delusional disorder shared by two people;, who have close emotional ties. Commonly the stronger, more dominant person develops a delusion and induces it in the other. The condition generally remits if the dominant person is treated. Some custody disputes may be of this kind, . in which a child takes on the delusion of the parent. Allegations involving children which are later found to be false often involve mothers with a psychotic illness. 8. 3. 2 Neurosis
Neurosis is a psychological reaction to stress, expressed through behaviour or emotion which is either excessive or inappropriate. In contrast to psychosis patients with a neurosis do not strike those around them as out of touch with reality. Rather, their state of mind can be 'understood' and the border between a normal reaction to stress and a neurosis is blurred. Patients may complain of anxiety, phobias, or obsessional-compulsive conditions and some are severely incapacitated by their worries. Their personalities remain relatively intact. Anxious and 'neurotic' individuals are prone to misperceive cues or misinterpret ordinary actions. It is not uncommon that an immature and sexually naive young woman ignores, or fails to recognise, sexual signals. This may in turn be misconstrued by the man as consent to intercourse. By the time the woman realises what she has got herself into she may not have the social skills to extricate herself. Some women are afraid of upsetting or 'rejecting' the man at this point, recognising that to some extent they are to blame for their own predicament. Others attempt to say 'no' at too late a stage or simply acquiesce as the easiest solution. Guilt and shame may later lead such a woman to reinterpret the event as outside her control and herself as injured. External influences, such as the views of friends and relatives, also exert pressure upon a young woman to regard herself as a victim and minimise her role in the sexual encounter. Women who find themselves in this plight may later 'cry rape'. Some cases of so-called 'date rape' may be of this kind. The woman is not deliberately deceitful so much as deceiving herself. Some individuals have difficulty in distinguishing fact from fantasy. Case example 8. 3
At the time of a highly publicised murder investigation, a young woman with personal and family stress reported that two men resembling police "identikit" pictures had attempted to drag her into a green "Volkswagen". Within 24 hours she had retracted her statement and later told how she had longed for her husband's attention. As a result she had woven an imaginary story and had come to believe it. Two years later she still said, "I know it did not happen but it seemed so real I could see the men and the car so vividly , I can still see them".
Folie à Deux a Personal Story

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Oh What a Tangled Web We Weave 70K

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Folie à Deux, Dissociation and Crime 40K , nutteing4

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DNA profiles and their implications, dnapr, nutteingd

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