Journal of Psychiatry

Rehabilitating Challenges: A Case Report of Folie À Famille

Michael Olutoki^1,2*, Bassey Edet^1,2, Yakasai Ba³ and Joseph Okegbe^{2 1}Department of Psychiatry, University of Calabar, Calabar, Cross River State, Nigeria
²Federal Neuropsychiatric Hospital, Calabar, Cross River State, Nigeria
³Department of Neuropsychiatry, Kaduna State University, Kaduna State, Nigeria
^*Correspondence: Dr. Michael Olutoki, Department of Psychiatry, University of Calabar, Calabar, Cross River State, Nigeria, Email:

Received: 01-Nov-2021 Published: 22-Nov-2021

Introduction

Folie á famille is a form of shared psychotic disorder an extention of folie á deux (delusions shared by two individuals) [1,2] occurring within a family and involving more than two members of the family. The affected family members have an unusually close relationship and they seems to exist in the world of their own.

Folie á quatre which are delusions shared by more than four individuals is extremely rare, only a few cases has been reported [3-5]. Recently we treated a case of foli á famille involving a family of five with a proband who is a forty four year old man with a ten years history of second person auditory hallucination, wandering, grandiose delusion and tangentiality who successfully transferred these symptoms to his thirty three year old wife and three of his children; a four year old, a three year old and a two year old respectively.

The female gender are affected more, lower intelligent quotient than the primary patient, very close relationship to the primary patient, low self-esteem [6], and life events have been suggested as the vulnerability factors. The aetiology is still unknown.

Folie á deux was first described in 1877 by Laségue and Falret [7]. The only available report from a very diligent literature search in Nigeria or elsewhere in Africa is that reported by Ilechukwu and Okyere amongst two sisters [8]. The current report involves a whole family. Available literature on Folie á famille is scant, Onofia et al. [9] reported a case in Abeokuta, Nigeria a case that was largely interfered with by the mental health workers.

We report a case folie á famille in the rural setting of Bekwara Local Government of Cross River state, Nigeria and its management at the Federal Neuro Psychiatric hospital Calabar.

Case Study

He presented with a ten years history of hearing a strange voice, wandering and unusual beliefs. The poor performance of his pure water business precipitated the illness; he went through a month’s fasting as prescribed by his pastor.

Thereafter he began to hear a strange voice through his ears, talking to him while he was awake. He believed the voice was that of God. The voice usually gave him instructions, which he obeyed like telling him to go into full time ministry. He started in his local church, a year later he left for Bayelsa and while there, he was further instructed by the voice to go back to Ogoja, his village. This was when he started wandering from his house in Abuja, roaming the streets at times begging for alms. Moving to different towns, initially alone and subsequently with his family, neglecting personal hygiene. He destroyed household properties including his father’s pension documents claiming that it was the cause of his problem. He claimed he was an apostle, ordained by God to save humanity from sin. And dressing in filthy clothes will bring peace to the world.

He is the seventh of eight children (3 alive) in a monogamous family setting. Father is a retired civil servant; he died 5 years before the commencement of the illness at the age of 75 years, cause of death not known. The mother also died eight years before the commencement of the illness at the age of 67, cause of death also unknown. His siblings were; A 57 year old woman married with children and resides at their village, she is well and alive.

The second is a 53 year old pastor, married with children and resides at Lagos, he is well and alive. The third born is a female died 20 years ago at the age of 20 years from unknown cause. The fourth and the sixth born were males, dead, details not available, the fifth and his wife are dead details not available.

The eight is a 42 year old male, his whereabouts is unknown. He has accepted all his family losses. No known history of mental illness in his family and the relationship between him and other members of his family were not cordial. Had a secondary school education, performance was average? Worked as a factory worker in Kano in 1997 and in 2002 worked in Abuja in a pure water factory and in 2008 established a pure water factory and cold room business which he later abandoned.

He met his wife a 33 year old school certificate holder, at his pure water factory; they began to live together after he obtained consent from some of her family members in Abuja.

She was previously married with a 13 year old daughter who resides in the village. She had 5 children for him, one female, four male; (8 years, 6 years, 4 years, 3 years and a 2 years old) the girl is the 3 year old.

All alive and well, the first 2 children were taken away by the wife’s family at the onset of the illness because he had not completed the traditional marriage rites.

He has never abuse psychoactive substances before. Pre-morbidly, his personality was described as a calm, quiet, respectful and hardworking man, who keeps few friends. He was deeply religious and superstitious, loved reading the Bible and mostly happy.

Mental state examination revealed an unkempt man, dressed in very filthy rags with overgrown hair and beards matted together.

Speech was spontaneous, coherent, irrelevant, normal tone and volume, with irritable affect. There was tangentiality, grandiose delusion and second person auditory hallucination (commanding). Cognitive function was good. Insight was absent. Physical examination was normal globally.

He was managed as a case of paranoid schizophrenia. He was separated from his other family members. He was managed in a ward and the wife and the three children were managed together in another separate ward. And during the latter part of their management when they were more stable they were allowed to visit themselves occasionally in their separate wards.

It was only the man that was given drug treatment and psychosocial management. The separation and psychosocial management was enough to take all the other members of the family back to a stable mental state.

Series of biological and psychological investigations were carried out and the results came out normal. Vocational skills assessment was also carried out.

The relatives were contacted to further corroborate the history and for other social investigations, especially to locate the first two children with the intention of reuniting them with their parents. Phone calls were made to both the man and his wife’s village in Ukpah in Ogoja and Agbani in Enugu respectively. Home visits were also done to both villages as well. No family member was able to come forward to render social support to this family.

Despite the wide publicity this case generated in the public space, no family, or governmental support was obtained for these patients. They were managed with the meagre resources available from the hospital management and a philanthropist who provide some day to day ward materials to the patients and also assist with occupational rehabilitation and accommodation for this family following their discharge from the hospital.

He was managed on haloperidol 10 mg daily. He became well after about four weeks of drug and psychosocial management. But could not be discharged home until about two months later as a result of challenges with his occupational rehabilitation and getting a good accommodation for his family was resolved.

Figure 1: The family of five.

Discussion

As described by Gralnick [10] that the delusion of an individual transferred to another person that was previously mentally stable because of the intimate connections between them, confirmed by the disappearance of the delusion in the recipient by just separating them. This present case of folie á famille is of Folie Imposée [11] type, involving the parents and their three children. The primary case was the father, whilst the wife and her three children were the secondary cases.

Drug treatment of the primary case, psychological and separation from other family members was effective in management. The primary case is usually older, have superior intelligence than the secondary cases [12,13]. Religious colouration of delusion can be a factor in the initiation and maintenance of folie á famille.

The florid religious theme which characterise this case with the spiritual believes that made these family to regularly move from one village to the other with the claim of evangelising the gospel to the world and trying to gain more converts to their side delayed the presentation to psychiatric services as people thought they were into a genuine evangelical assignment. Lots of life events, Poor social support, and social rejection maintained this illness.

Folie á famille, according to the literature is a rare disorder. And should be looked out for when delusions are found in more than one members of a family.

Conclusion

The fact that delusional disorders can be contagious is noteworthy. And also religious sentiments can affect the mental health negatively. Poor social support with abandonment can worsen the mental state of an individual and can be a major setback in the successful management of such case.

Declaration of Interest

None declared

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