Folie à deux dissociative in prepubertal children: report of two cases with EEGs

Folie à deux desordem dissociativa em crianças antes da puberdade: relato de dois casos com EEGs

FOLIE À DEUX DISSOCIATIVE DISORDER IN PREPUBERTAL CHILDREN

REPORT OF TWO CASES WITH EEGS

A.H. CHAPMAN^*, DJALMA VIEIRA E SILVA^**

ABSTRACT - A case of folie à deux dissociative (dissociative hysteria) disorder in an 8 and 12 year-old sister and brother is presented. Illnesses of this type are very rare and there is little medical literature on this subject. Our patients, almost simultaneously, abruptly had complete loss of memory, disorientation, loss of awareness about who they were, and much anxiety, which lasted about 15 hours. Both patients were physically well and no abnormalities were found on physical examination, routines laboratory tests and EEG studies. Speculations about the emotional and interpersonal causes of this illness in these two patients are given.

KEY WORDS: folie à deux, dissociative disorder, hysteria.

Folie à deux desordem dissociativa em crianças antes da puberdade: relato de dois casos com EEGs

RESUMO - É apresentado um caso da desordem dissociativa folie à deux (histeria dissociativa) em um casal de irmãos, sendo que o menino tem 12 anos e a menina 8. Doenças desse tipo são raras e existem poucas referências sobre o assunto na literatura médica. Os pacientes por nós atendidos, de repente e quase simultaneamente, apresentaram distúrbios acentuados da memória, desorientação, perda de auto-identidade e muita ansiedade; esse estado confusional durou aproximadamente 15 horas. Os dois tinham boa saúde física e não apresentavam anormalidades no exame clínico. Os exames laboratoriais de rotina estavam normais. Foram avaliados por meio de EEGs que estavam dentro dos limites da normalidade. Na discussão, são apresentadas considerações especulativas sobre as causas emocionais e interpessoais que possam ter propiciado o aparecimento dessa desordem nos dois pacientes.

PALAVRAS-CHAVES: folie à deux, desordem dissociativa, histeria.

Folie à deux dissociative disorders are extremely rare in prepubertal children^1-3. In an extensive study of the literature we have found only 2 cases, recorded by Kanner³ and seen by him among the several thousand children he observed in his 4 decades as head of the Harriet Lane Children's Psychiatric Hospital and Outpatient Clinic of the Johns Hopkins Medical School in Baltimore, Maryland, USA. Folie à deux disorders are sometimes referred to as communicated, induced or simultaneous conditions and the term dissociative disorder is a synonym of dissociative hysteria.

We have recently seen a case of this disorder in a brother and sister, aged 12 years and 1 month and 8 years and 7 months.

CASE REPORT

AFJ, a girl, had an uneventful medical and general history until the age of 7 years and 7 months. She was a well-adjusted child who got along well in her home, at school where she made average progress, and in the community at large. She was the fourth of 5 children; her siblings were a 17-year-old sister, a 15-year-old brother, a 12-year-old brother (HFJ, who was at a later time to join her in a folie à deux dissociative disorder), and a 5-year-old brother. Her mother was 36 and her father, a self-employed farm laborer, was 37. The family lived on a 6 hectare farm, which they owned, in the southern part of the state of Bahia; the family depended economically on the success of the yearly crop of cotton which they raised. Some of the nearby small farms belonged to A's grandparents and other members of the extended family. She was a pleasant child who was neither overly dependent nor aggressive and who got along comfortably with all members of her family. The parents' marriage was stable.

On January 21, Monday, 1997, at about 8 o'clock in the evening she suddenly lost her memory completely. She recognized no one except her mother, she did not know where she was, she could not state the names of herself or anyone else except her mother, whom she merely called "Mother". She did not know the date or the time of year, and was oblivious to all formerly familiar things around her. In reply to all questions about the people around her she said "an animal".

She was taken that night to the hospital in the nearest sizeable town, 36 kilometers away, and was hospitalized on a pediatric ward where her mother was allowed to remain constantly at her bedside. Her amnesia and her panic continued in the hospital. She received small dose of diazepam and bromazepam and slept well during the latter part of the night. Her physician at the hospital was the same pediatrician who had cared for her minor illnesses during most of her life. A had never previously had an upset of this sort and had not had any other kind of psychiatric disturbance. In the hospital she had routine blood, urine and feces examinations and chest X-ray. All were normal, as was physical examination.

At about 10 o'clock on the morning on her third hospital day she abruptly recovered her memory and returned to her usual level of emotional, intellectual and interpersonal functioning. However she had no memory for the 3 days of her amnesic disorder. The pediatrician reassured the patient and her family and on the fourth hospital day she was discharged. At home she continued for 2 weeks on small doses of the same medications she had received in the hospital. She then remained well slightly more than a year.

On January 31, Friday, 1998. A's 12-year-old brother H, at about 7 o'clock in the evening had the sudden onset of an amnesic dissociative disorder identical in all respects to A's illness one year earlier. He could remember nothing, he could only say "Mother" and "an animal", he was very frightened, and he clung physically to his mother. At about 8 o'clock the same night A had the onset of a dissociative disorder which was similar in all respects to her brother's ongoing disorder and her own upset of the previous year. Both children were that night hospitalized in adjoining beds in pediatric ward of the same hospital where A had been hospitalized a year earlier; their mother remained constantly with them and the attending physician was once again their long-time pediatrician. Both were given the same mild sedation that A had received for her first illness, and the same physical and laboratory examinations were done, with normal findings.

At about 10:30 the next morning H rapidly recovered completely except for total amnesia for the preceding 15 hours. About half an hour later A recovered in a similar manner. On the fourth hospital day they were both discharged, took for 2 weeks small doses of diazepam and bromazepam, and have remained well since then. Both children continued to have persistent amnesias for all events that occurred during their illnesses.

H, like his sister, was a well-adjusted child who got along well at home, did better than average at school and adjusted satisfactorily in the community. He, like his sister, had never had a previous dissociative illness nor any other type of psychiatric disturbance. Neither child had any signs of pubertal sexual change at the time of this disorder. EEGs were done one week later in our laboratory and hospital, about 200 kilometers distant from their home community; they were normal (see Figures 1 and 2). At this time we had an opportunity to study these children psychiatrically on an outpatient basis. We could, with one exception which will be discussed later, elicit no evidence of emotional stress or trauma in these children and their family.

H, like A, was described as being neither overly dependent nor aggressive, and A and H were not closer to each other than to their other siblings. No member of the nuclear or extended family had ever had any kind of dissociative disorder or other psychiatric illness; these children had not seen, or heard about, dissociative disorders in any person in their community. The only positive finding in their histories was that H for about 4 months prior to this time had been having occasional frontal and periorbital headaches which were attributed to "eyestrain".

DISCUSSION

As noted above, we could uncover no causative or precipitating emotional or other factors for this folie à deux dissociative disorder, with the exception of a general socioeconomic one.

The welfare of this family depends each year on the success of their cotton crop, which is the main economic support of their region. The cotton crop in turn depends on good rainfall in November, December and, at times, early January. During the rest of the year the rainfall is insuficcient to produce a salable cash crop but it can support a certain amount of cassava and the maintenance of a limited number of goats, poultry and small livestock. In January, 1997, when A had her first illness, the rains had been sparse, but enough of the cotton crop survived to support the family in a meager way through 1997. In January, 1998 the rains had failed entirely, perhaps influenced by the El Niño weather phenomenon that year, and the entire cotton crop was lost.

The family faced a disaster; they could survive only if the father left home to work as an unskilled laborer in São Paulo, 1200 kilometers away, or some other city in southern Brazil, and sent part of his wages home each month. This was being much discussed in the family toward the end of January, 1998, and had been mentioned but not pursued, in January, 1997. This pattern is common in northeastern Brazil when climatic disasters strike. It also is tragically common, and well known by most persons from middle childhood onward, that such fathers sometimes form relationships in the South with other women, start "second families" and in time stop sending money northward. Disintegration of the northern family then in some cases begins, with adolescent children of both sexes drifting off to the large cities to live marginally while the mother and the younger children become objects of unreliable charity from their relatives and neighbors and from persons in nearby small towns and villages. This family knew of various such cases in their neighborhood.

We speculate that this may have been a significant factor in causing the simultaneous dissociative disorders in our two patients. They were, perhaps, quite literally "blotting out" for a brief time the possible calamities that seemed to be descending upon them⁴.

Since there is so little literature on folie à deux dissociative disorders in prepubertal children we cannot give a general discussion of this subject. We can only present this case, offer our speculations about its causes and wait until more cases of this unusual condition are reported.

Dr. A.H. Chapman - Caixa Postal 98 - Hospital Samur - 45100-000 Vitória da Conquista BA - Brasil.

• 1. Chapman AH, Chapman MCMS. Harry Stack Sullivan's concepts of personality development and psychiatric illness. New York: Bruner/Mazel, 1980;86,101, 132, 136-144.
• 2. Chapman AH, Chapman-Santana M. The handbook of problem-oriented psychotherapy. Northvale NJ: Jason Aronson, 1997:48,55-79,64.
• 3. Kanner L. Child psychiatry. Springfield Illinois: Charles C. Thomas, 1972:618-641.
• 4. Chapman AH, Vieira e Silva D. Base para uma psiquiatria científica. Arq Neuropsiquiatr 1980;38:76-80.

*

From the Samur Hospital, Vitória da Conquista, Bahia, Brazil:

Supervisor of the EEG Service;

**

Attending psychiatrist. The EEGs were done by Silvana Vieira Almeida and Eliete Almeida de Lacerda, EEG technicians. Aceite: 23-maio-1998.

Publication Dates

• Publication in this collection
  06 Dec 2000
• Date of issue
  Sept 1998

History

• Accepted
  23 May 1998