Folie à deux: the madness of two

Folie à deux, or the ‘madness of two’, is the kind of psychological phenomenon that occasionally captures the imagination of the media. Two people, otherwise normal, suddenly go insane. Like the two Swedish sisters who recently, during a visit to the UK, started behaving erratically.

It’s a premise that we can ghoulishly enjoy from afar because it seems like it could never happen to us. But I’m not so sure. From intra-family murder to Theranos to our own odder moments, I think shared madness is something that is much more common than you’d think.

¶A brief history

In the 1860’s, neurologist Jules Baillarger initially used the term folie communiqué, or ‘communicated madness’, to describe a couple so caught up in each others’ delusions physicians were unable to tell who became psychotic first. By the last 1870’s this phenomenon had become known as folie à deux through the work of Charles Lasegue and Jean-Pierre Farlet, doctors of some renown at the time.

Typically, these doctors observed a relationship in which the more dominant figure would be experiencing delusions of some kind and the other person would either come to either believe the delusions, or even perhaps begin to share them. But occasionally, rather than folie imposée, where one person’s set of delusions are ‘imposed’ on the other, we might see folie simultanée, in which both parties may already be delusory individually, but as they interact, their delusions coalesce. And folie did not need to come in pairs. We also had folie à trois, the madness of three, or folie à famille, the madness of a family, and eventually the less romantic, but less constraining ‘shared psychotic disorder’. In each of these cases, the delusions of one person comes to drive the behaviour of others.

¶Are we all at risk of folie?

One would kind of imagine that such a phenomenon is kind of uncommon. The sharing of some psychotic episode seems like something from TV. But I’m not so sure. The literature on the subject is not particularly busy. But we might expect that: there are fairly stringent requirements to conclusively diagnose a case. There needs to be a commonality of delusion (of course), intimacy in the relationship, and acceptance or support of each others’ delusions. The details of these features aren’t always apparent to an outsider. Nor are closely coupled people often willing to share the intimicies of their connection to another.

News articles will only ever present newsworthy cases. But there is something interesting in them. We see cases in places as far flung as Saharan Africa, in India. Folie, then, is not the invention of the U.S. media. If not common, it is certainly diverse—there isn’t a cultural limit to the sharing of madness.

And indeed, there is a common thread; intimacy in the context of social isolation. Folie à deux is perhaps the most intriguing example of the crucial nature of our need to be social. It exemplifies, in its own puzzling way, the lengths the mind will go to to feel connected to something bigger. It’s also emblematic of the myriad peculiarities of love.

There is always some madness in love.

Nietzche, Thus Spake Zarathustra

¶A ‘spectacularity bias’ hides how common it really is

A spectacular case of folie à famille occured in Australia recently. In this case, the family fled their farm for hundreds of kilometres in apparent terror of some following threat. Some family members escaped the chaotic week-long journey unaffected, but others seemed to be in various altered states. This episode was preceded by no apparent drug use or history of mental illness. And the members of the family reporting afterwards seem as puzzled by the episode as anyone. For example:

It’s very confusing, I still feel confused

Or from another:

You do start thinking the same way… you can get sick in some way

Even more recent were the Burari family deaths in India. Eleven members of a family dead by apparent suicide, their faces swathed in tape and cotton and cloth. Indeed many suspected cases of shared folie regard people who died doing something baffling. These may not be cases of shared delusion, but the number of suspected cases does not line up well with the number of reported cases.

In larger numbers, this makes one wonder how many of these members shared the delusion, and how many simply went along (or were forced along) for the ride? In the case of the Australian family, one member, Mitchell, explicitly reported that he did not share his family’s fear. He simply “couldn’t leave them”. This kind of half-hearted participation would surely make it hard to diagnose a shared madness. Given the stringent criteria for diagnoses, one wonders how many examples simply escape our notice, particularly outside of the more focused dyadic cases.

The second feature to consider is that many, many cases of shared madness involve violence. Murder, suicide, and injury. We might even say that these cases are overrepresented. Psychoses run the full gamut of bizarre perceptions and beliefs, not simply those that end in pain. So why is shared psychosis so much more harmful?

The answer may be that perhaps it’s not.

Theranos was a multibillion dollar biotech startup headed by the now infamous Elizabeth Holmes. The company raised huge sums with claims of a revolutionary blood test. The bizarre antics of Elizabeth Holmes and her boyfriend/business partner Balwani have become jokes, after the downfall of the company. A pretend wolf permitted to roam the sterile halls of the company, freely shitting anywhere it likes. Holmes speaking in different voices. Rampant paranoia.

On page 143 in the book Bad Blood, the author reports suggestions that this may have been a case of folie à deux. The couple, Holmes and Balwani, may have been living some elaborate shared delusion. A delusion that sucked in thousands who, like Mitchell from the Australian family earlier, were not necessarily sharing the delusion but simply “couldn’t leave” for one reason or another.

Which leads me to another question: how many cases of folie are missed, simply because they aren’t spectacular enough? Or put another, more interesting way, are the more spectacular nature of the reported cases distracting us from something more fundamental?

I said before that the common thread in cases of shared madness is intimacy in the context of social isolation. Social isolation is a unexpectedly dangerous thing for humans. I’ve said it before, but loneliness is emerging as one of the single greatest threats to human health, both mentally and physically. When we combine isolation with new intimacies, perhaps it shouldn’t surprise us that things can start to look a little strange. Given the widespread nature of social isolation, I think we can be sure that the faces of shared madness are more varied, and more subtle, than we can imagine.