X Rocha, M Begolli, L Santos, M O’Brien, F Rivera
X Rocha, M Begolli, L Santos, M O’Brien, F Rivera. Folie A Deux Including A Shared Delusion Of Pregnancy. The Internet Journal of Psychiatry. 2009 Volume 1 Number 1.
Induced delusional disorder (also known as shared paranoid disorder or folie à deux) is an uncommon disturbance characterized by the presence of similar psychotic symptoms in two or more individuals. Most commonly a primary case can be distinguished from other one or more cases, in whom the symptoms are induced. The patients implied in the shared delusional symptoms are frequently linked by close relationship bonds, mostly family ties. Pseudocyesis is a rare psychiatric syndrome, also called false pregnancy, it is a state in which a woman, who is not pregnant, firmly believes that she is pregnant. At the same time she has almost all the signs and symptoms of the pregnancy.
A 58yo woman who states that she is really 40yo and that the year of her birth is off by 18 years is a mistake made by the Medicaid and Disability people. The patient presented to the ED and stated that she was told here at Lincoln that she is pregnant in January and again in February, and that she was currently in active delivery at nine months. She was taken to Labor and Delivery and an Ultrasound revealed no pregnancy and beta-HCG was negative. The patient states that she is visually impaired and that this is why she is wearing dark sunglasses; however, I suspect that the patient wears sunglasses in part related to her paranoia.
She reluctantly believes now that she is not pregnant; after she has been told by doctors today that she is NOT pregnant, but it seems fairly evident that patient still believes that she is pregnant. She states that she had sex about nine months ago with a man with whom she is no longer involved. The patient also stated to the doctor that she had not had her period in two years; so, there are a lot of inconsistencies in account. She states that they have been homeless for the past few months because she could not longer afford the rent and because a neighbor and her children were sneaking into their apartment and damaging their furnishings and smearing feces in the bathroom and elsewhere and that she knew that they were spreading rumors about her and watching her because they used to enter her apartment via the window but then started entering the apartment through the door when they were not home. Although she states that she was told that this was impossible, patient knows that this was going on.
The patient states that she and her daughter have not done well in shelters and that they had lived for ten years in the Yale SRO Hotel until they were put out then they were in a shelter in Brooklyn and then they were placed in the apartment she currently resides. Patient states that she and her daughter need to be together, that they have a system of travelling and sleeping on the subways. She states that she prefers this to the shelter system and to the substandard apartment in which they were placed.
The patient VEHEMENTLY denies any out-patient or in-patient psychiatric treatment. She denies suicidal/homicidal ideations or hallucinations. She is clearly delusional with persecutory delusions and with possible pseudocyesis vs delusion of pregnancy. The patient states that she has also received medical care at another area hospital and multiple ED Visits and several hour stays in the ED there for medical but never for psychiatric reasons. She is not a danger to herself or to others and to admit her would be devastating to both the patient and to her daughter.
Interview with Daughter
The daughter states that she and her mother have been homeless for a few months and that they indeed lived in the Yale SRO Motel for ten years and then were in and out of shelters until they were eventually placed in an apartment in the Bronx and daughter confirms that they have problems in shelters, their belongings were stolen and they would get into fights with other clients. The daughter became very upset when she thought that her mother was going to be kept in Psychiatric inpatient unit asking who was going to carry the other two bags (their worldly belongings are in four bags).
The daughter was brought to this hospital by NYPD in the past when she and her mother became separated in the subway. Daughter explained that a patron swiped their Metro card and NYPD stopped her for fare evasion and she became so upset that they brought her to this ED. The daughter states that she was treated and released (no psych referral) and that she just kept going to all of the places that she and her mother stayed at within the neighborhood and subway system until she found her mother and they were reunited.
The daughter states that she went to an area hospital a few months ago for work-up of dysuria and that she ended up being kept in Psych for three days and was diagnosed with Schizophrenia and given medication which helped her. The patient states that they made this diagnosis because she talked about her voices and her fears and that she kept picking up and saving all sorts of things that she would find in the hospital to save them (hoarding behaviors). She states that she hears a growling male voice and that the voice says things to upset her and disgust her and sometimes sees gory images. She denies ever feeling suicidal, ever making any suicide attempts and ever being assaultive towards others.
The daughter verifies that her mother has never received psychiatric care or been psychiatrically hospitalized or ever made a suicide attempt to her knowledge. She states that she “JUST LIKE HER MOTHER, SHE IS 18YEARS YOUNGER THAN HER RECORDED DOB” and states that a typo had erroneously recorded her year of birth as 1971 that she just turned 21yo and not 39yo. She also states that she believed that her mother was pregnant and that the father of the baby is a doctor and she was looking forward to having a baby brother or sister. She states that she now understands that her mother is not pregnant and seems able to accept this news even though she thought that the reason that mother was transferred from L & D to Psychiatric area was so that the doctors could look harder to find the unborn baby inside of her mother.
The patient presented again to the ED the next day, again referring being pregnant and having abdominal discomfort. An FUA x-ray revealed some possible free air and a CT scan revealed air in the billiary tree (pneumobilia); the patient was admitted to Surgery and was followed by Psychiatry. MRCP was performed which showed common bile duct dilatation which may have be related to prior surgery and instrumentation introduction. While on Surgery service, patient refused to discuss with psychiatry her belief about her pregnancy, but would often ask the nurses to call OB because she believed she was in labor. Patient was started on Risperidone.
The patient remained very concerned about her daughter while she was hospitalized. I ran into the daughter in the hallway as she was leaving the hospital and she states that she has been staying at a Women’s shelter suggesting that she is able to tolerate the shelter system whereas her mother avoids the shelter system and thwarts their chances of getting more stable housing.
The patient most likely has schizophrenia as does mother vs delusional disorder---what is most interesting is that they share certain delusions-e.g. they are each 18years younger than their recorded dates of birth while being totally oriented to year, and moreover, neither can give what they assert to be their real dates of birth. What is more remarkable is that the patient and her daughter have both managed in part probably due to their tight bond and shared beliefs have managed to “survive”, but have travelled beneath the radar which tragically has resulted in neither receiving needed treatment and in their remaining homeless and sleeping on the subway system and not being able to enter the shelter system to obtain housing.
This is a particularly interesting case as both mother and daughter appear to be mentally ill with a shared delusional system (folie a deux)-patient does not meet strictest criteria for pseudocyesis, but the notion of a shared delusions including a delusion of pregnancy is quite unusual. Criteria for the diagnosis of pseudocyesis vs. a shared delusion of pregnancy will be reviewed and implications for treatment and prognosis will be discussed.