Shared Psychosis: A Guide To Recovering From Folie à Deux

People may sometimes experience a disconnect from reality called psychosis. This disconnect may involve hallucinations and delusions, and in some cases, psychosis may spread to others as well in a condition referred to as “shared psychotic disorder.” This situation may leave you overwhelmed, scared, and unsure of how to help or move forward. Understanding what may be causing this phenomenon may help you understand how to proceed. Here, we’ll explain what shared psychosis is and how the condition may be treated.

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Understanding shared psychosis

Shared psychosis was first entered in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) as "shared paranoid disorder." The condition is now known as shared psychotic disorder and is listed under the “other specified schizophrenia spectrum and other psychotic disorders” category in the DSM-5. This rare disorder is estimated to affect 1.7–2.6% of psychiatric hospital admissions. Shared psychosis involves a delusion—a firm but false belief—that is adopted by two or more individuals, typically those with a close emotional bond. Their false, unshakeable conviction lacks a basis in reality and often centers on bizarre and/or persecutory ideas. 

What causes shared psychosis, or folie à deux (madness of two)?

The precise origins of shared psychosis remain unclear. However, research suggests that the condition often involves a dominant figure with an existing psychotic disorder and a more submissive or suggestible secondary individual with whom they have a close and long-term relationship. Over time, the dominant person's strong, delusional beliefs may influence the more susceptible person, leading to a shared experience of distorted reality. While a primary mental disorder like schizophrenia might be the driving force of the delusion in some cases, shared psychosis can also occur without the dominant person having a separate diagnosis. Stressful life events, social isolation, and limited exposure to diverse viewpoints might sometimes cultivate the environment for false beliefs to take hold and spread between closely connected people.

Recognizing the signs and symptoms of shared psychosis

Only a trained healthcare professional can provide a clinical diagnosis of shared psychosis or another mental illness. That said, becoming familiar with common signs of shared psychosis could help you recognize when the condition may be occurring in loved ones so you can encourage them to seek support.

Symptoms of shared psychotic disorder

Here are some possible symptoms that may manifest in individuals with shared psychosis:

• Unusual beliefs. The individuals express strange, often persecutory ideas that are firmly held and lack any foundation in reality.
• Shared conviction. The delusional belief is embraced by both/all of the individuals involved with seemingly unwavering certainty.
• A close relationship. There's a strong and typically long-term bond between the individuals, often characterized by social isolation or dependence.
• Behavioral changes. You might also observe unusual behaviors, withdrawal from social activities, and/or an intense preoccupation with the delusion.

If separated from the dominant individual, the submissive person's belief might lessen or even disappear. However, the primary person's delusions often persist even without reinforcement.

The diagnostic process for shared delusional disorder

Again, only a qualified mental health care professional can properly diagnose shared psychosis. First, they’ll likely assess the individual for any underlying conditions. For example, they may do an evaluation to determine whether the dominant person is showing signs of a primary psychotic disorder like schizophrenia spectrum disorder or bipolar disorder. They may also request a medical evaluation to rule out any neurological issues, substance use, or other medical conditions that can sometimes cause or mimic symptoms of psychosis.

If you are struggling with substance use, contact the SAMHSA National Helpline at (800) 662-4357 to receive support and resources. Support is available 24/7.

Finally, the clinician will make their diagnosis, if applicable, and suggest a treatment plan accordingly. Determining if there's any risk of harm to self or others will be a priority during a professional assessment as well, and treatment suggestions will take this factor into account.

Treatment options for folie à deux (madness of two)

Shared psychosis is a complex phenomenon, so treatment is typically multifaceted and generally needs to be customized to the specific situation. Some common components of treatment may include:

Addressing the dominant individual

If the dominant person has a psychotic disorder, treating their underlying condition is typically a key focus. This often involves some form(s) of psychotherapy, sometimes in combination with medication.

Supporting the submissive individual

Separation from the dominant person often lessens or resolves the shared delusion for the submissive individual. Counseling and therapy can then focus on helping them build coping skills, self-esteem, and resilience.

Medication for managing shared delusional disorder

Antipsychotic medications might aid in managing delusional symptoms in some cases, particularly when there’s an underlying psychotic disorder(s) experienced by any of the individuals.

Psychotherapy

Individual and family therapy can offer space to address underlying emotional vulnerabilities, improve communication skills, and help the individuals involved and their loved ones process this challenging experience.

Education and support

Learning more about shared psychosis and strategies for managing the condition may help everyone involved feel more informed and empowered.

Shared psychosis affects everyone differently and each situation is unique. Reaching out to a mental health professional for support related to signs of any mental health condition is typically recommended, as they can personalize support and suggest strategies that fit your specific situation and needs.

How loved ones can offer support

While shared psychosis requires professional intervention to address, the support of loved ones can be helpful during recovery and beyond. Here are some suggestions for how you might offer support while also prioritizing your own well-being:

• Educate yourself. Learning what you can about shared psychosis and mental disorders like schizophrenia, if applicable to your loved one’s situation, can help you approach the situation with knowledge and empathy.
• Keep the lines of communication open. If safe to do so, you might let your loved ones know you're there for them. Gently expressing your concern in a non-judgmental way may open the door for a supportive conversation about seeking help.
• Avoid confrontation. Challenging the delusion directly often backfires. Instead, focusing on listening with empathy and validating their feelings may help build trust and a sense of safety.
• Encourage professional help. Gently encouraging your loved ones to seek an evaluation from a mental health professional can be helpful. Offering to help them find resources or even accompanying them to appointments could reinforce your support.
• Set boundaries. Supporting someone with a mental illness doesn't mean sacrificing your own well-being. Setting boundaries and practicing self-care may help you maintain your mental and physical health.
• Find a support network. Connecting with support groups for loved ones of people with mental illness—or shared psychosis in particular, if possible—may allow you to share experiences and get support from others who understand.

Also keep in mind that if there are concerns about harm to self or others, addressing these immediately can prevent potential crises. Having a safety plan in place and seeking professional help if needed can be helpful. Requesting emergency assistance may be necessary in crisis situations.

In addition, minimizing day-to-day stress for your loved ones may be helpful. A calm, predictable environment may reduce agitation and make delusional symptoms less intense. Avoiding arguments is generally also beneficial, as trying to reason with someone in a delusional state is often unhelpful and can increase distress for everyone involved. Finally, engaging in enjoyable distractions like shared hobbies, listening to calming music, or spending time in nature might help shift focus away from the delusion.

Maintaining hope during treatment for shared psychotic disorder

While shared psychosis might seem overwhelming, recovery and successful management can be possible. During the process, it can help to remember that treatments like therapy and medication can be effective. You might also remind yourself of the power of separation, as the submissive partner’s delusional beliefs often fade with separation from the dominant individual. Plus, the long-term benefits of treatment can be significant for the mental health of all the individuals involved in the shared delusion. With time, therapy, and support, they may develop skills to better cope with stress, manage difficult emotions, and manage their mental health.

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Seeking support for shared psychosis

The complexities of shared psychosis often require specialized support. Although not appropriate in every case, such as when an individual has an underlying condition and is experiencing acute psychosis and/or is at risk of harming themselves or others, online therapy can bridge some of the gaps and make care more readily available. Finding affordable options and the right therapist for a given situation is often easier with an online platform. Online therapy can also make it easier for those supporting individuals living with shared psychosis to seek care for their own mental well-being.

The benefits of online therapy 

Research indicates that online therapy may make managing psychotic disorders easier. For example, some studies suggest that online sessions can be easier to attend regularly and may boost engagement in many cases. This consistency could mean faster progress toward a life with improved mental well-being. Remember, even if full recovery isn't possible, shared psychosis can often be managed. A collaborative approach between a mental health professional and supportive loved ones may improve the daily and long-term well-being of the individuals involved.