Background and Aims:
Shared psychotic disorder (folie à deux) is a rare psychiatric condition in which delusional beliefs are transmitted from one individual with psychosis (the primary) to another closely associated individual (the secondary). Such cases typically occur in the context of prolonged social isolation, emotional dependence, and absence of external reality testing. Adolescents in dependent caregiving relationships are particularly vulnerable. This case report presents a striking example involving a neglected adolescent boy and his mother with untreated schizophrenia. The aim is to describe the clinical presentation, challenges in diagnosis and management, and the outcome following biological intervention using modified electroconvulsive therapy (MECT).
Methods:
A 19-year-old male and his 45-year-old mother were brought to our tertiary care neuropsychiatric hospital by his uncle after neighbors reported that the boy was shouting that someone was trying to kill him. Police and firefighters forcibly entered the home after his mother refused to open the door. The boy had been withdrawn from school in 8th grade due to maternal concerns over bullying and perceived threats. He completed 10th grade through open schooling but was subsequently kept in near-total confinement by his mother, who prevented external contact and destroyed communication devices.
On admission, the boy was severely malnourished, emotionally dysregulated, and exhibited persecutory delusions identical to those of his mother. His mother, previously a nurse, had untreated schizophrenia, with symptoms worsening after her own mother’s death in 2021. The dyad had no social engagement for over four years, relying solely on a housemaid for essential supplies.
The son was separated from his mother and started on antipsychotics but showed minimal response, developed extrapyramidal symptoms, and continued to refuse food.
Results:
Due to inadequate response and declining physical condition, MECT was initiated. After six sessions, he demonstrated significant clinical improvement, with full remission by the tenth session. At one-year follow-up, he was living with his father, attending special education, and displayed no psychotic symptoms, although mild obsessive-compulsive traits were noted. His years of sensory deprivation seems to have added to his poor cognitive skills, but is improving socially, as he now spoke cordially with his extended family members. His mother was however transferred to a long-term psychiatric rehabilitation facility, as her poor insight and refusal to take medications made her difficult to manage. The mother’s family, despite a strong medical background, had denied the existence of psychiatric illness for years, delaying intervention.
Conclusion:
This case highlights the severe psychological and developmental consequences of untreated parental psychosis and prolonged isolation. It emphasizes the importance of identifying vulnerable secondaries within pathological dyads and initiating timely, multidisciplinary interventions. MECT proved effective in this refractory case, underlining its utility in managing severe, treatment-resistant shared psychosis. Greater awareness and culturally sensitive approaches are essential for early detection and intervention in such complex presentations.
Samantha Labett Langstieh
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