Infanticide in a Case of Folie à Deux

“Ms. A,” the mother of two young children (ages 18 months and 4 months), is a 29-year-old African American woman with a history of schizoaffective disorder. Her psychotic symptoms began after she married in her early twenties. She was involuntarily hospitalized a number of times with symptoms that included hallucinations, disorganized speech and behavior, and delusions of religious themes. Prior to one hospitalization, she was seen running door to door with a Bible in her hands. She believed that her husband was “one of the two witnesses in the Book of Revelations,” although at one point she also thought he was the antichrist. It was her belief that all people were possessed by demons.

By the time of the infant’s death, Ms. A was chronically incapable of performing most basic everyday functions, such as paying bills, driving a car, buying groceries, and cooking meals, and she would sometimes stop eating for days at a time. She refused all medical and psychiatric treatment, believing that doctors, drug companies, the government, and infant formula companies were corrupt and conspired to make profits. Furthermore, when it came to her children’s care and nutrition, she was extremely controlling; she kept her baby wrapped up in an obsessive protective fashion. She frequently would not allow others to hold or feed him.

Two weeks before the death of the infant, Ms. A was observed to be incoherent. Instead of feeding infant formula to the child, she made a mixture of water, oat cereal, and “something healthy” to serve as his main source of sustenance. When the baby stopped breathing, she and her husband took him to the emergency department, but the infant was already dead. To the dismay of the emergency room staff, they proceeded to pray together for the baby to come back to life, asserting that their son’s eyes actually started to move. Both were arrested and underwent psychiatric assessments.

Ms. A was found to be so mentally ill at the time of her arrest that she could not understand the legal process. She was subsequently adjudicated incompetent to stand trial and was ordered by the court to receive treatment at a forensic hospital to restore her competency. A determination of her criminal responsibility at the time of the offense was on hold until her competency could be restored. While hospitalized, she gave birth to a third child.

“Mr. A,” the father of both children, a 26-year-old white man, was first evaluated by a forensic psychiatrist (T.R.) retained by the defense 2 months after Mr. A was charged with the murder of his child. Mr. A’s parents reported that he had a normal childhood and development and that his family was not particularly religious. He completed a bachelor’s degree in physical education and had a full-scale IQ of 108 at the time of his forensic assessment. Mr. A had occasionally used cannabis and alcohol in high school and college. He had been charged with underage drinking at age 17 and possession of cannabis while in college. He had no other past psychiatric history or diagnosis, and no history of violence.

Mr. A met his future wife at a church retreat, and after becoming interested in Christianity and beginning international ministry work with his wife, he gave up cannabis completely. A devoutly religious couple, they were happily married for 5 years. To support his family, Mr. A worked several jobs, including as a parking valet, a painter, and a fitness center trainer, leaving little time to devote to his children. He began to share many beliefs with his wife, such as the collusion of drug companies to corruptly control prices. He was, furthermore, fascinated by spiritual leaders who promoted “natural remedies” and who, he believed, had the power to heal. He stated that “hospitals were being put out of business” by prayers and spiritual healers. As his wife became increasingly psychotic and delusional, he too began to adhere to a rigidly held notion that God literally controlled everything. As a consequence, he began to reject traditional health care, including psychiatric care for his wife, and eventually refused all medical care for himself and his family. He also began to believe, as did his wife, that everyone was possessed by demons, although he thought that prayer could keep such demons at bay. His parents began to worry about him and challenged the couple’s extreme beliefs. As a result, he would often become defensive, rigidly defending his delusional belief system. When asked why his son died, he stated, “He probably starved to death.” When asked why he let this happen, he gave a long explanation about how hard work, prayer, and the sovereignty of God were all that mattered to him and that the baby was now in heaven. He believed that prayer would help his wife to become a good mother and that his job was to provide for the family. He even set timers to remind her to feed the baby. He defended their refusal to feed the child infant formula, as well as their shunning of doctors and traditional health care.

Mr. A’s mental status examination was otherwise unremarkable. He functioned normally at work, bought groceries, and paid the bills. He never had hallucinations or disorganized speech or behavior. Personality testing revealed dependent, passive, and narcissistic traits. He initially refused to allow his attorneys to use a psychiatric disorder as a defense, and he did not believe that he suffered from any type of mental illness. His parents later convinced him to follow the advice of his attorneys and use the diagnosis of shared psychotic disorder as a defense. A plea agreement was reached using this defense, and he was sentenced to 30 days in jail, during which time he was allowed only supervised visits with his other children. Six months after separating from his wife, a treating clinician stated that he no longer held the delusions described above.

In Table 1, the shared beliefs of the couple are contrasted with those of the church they attended.

After a crime is committed, psychiatrists may be asked by the defendant’s attorney to retrospectively evaluate whether the defendant was suffering from a mental disorder and whether that mental disorder affected the defendant’s thinking and behavior around the time of the crime. Such a retrospective evaluation may be quite challenging and requires review of collateral information not generally available to clinical practitioners (1).

Folie à deux (“madness of two”) was first described by French psychiatrists Lasègue and Falret in 1877, yet, despite the passage of well over a century, our ability to recognize and evaluate the condition has not improved significantly since that time. Aside from being renamed in the various editions of DSM (induced psychotic disorder, shared psychotic disorder), the assessment of folie à deux is much the same as it was in the late 19th century (2, 3).

Folie à deux classically involves the transmission of delusional symptoms from a psychotic individual (the dominant, or index case) to a more suggestible party (the secondary case). Secondary cases tend to be more gullible and passive, with dependent traits. The shared delusion is usually within the limits of possibility, and the degree of impairment is generally less severe in the secondary case. Separation from the primary case can be both therapeutic and diagnostic if the delusions dissipate (4). Shared delusions of religious content may pose an elevated risk of harm to the family (5).

Mr. A had dependent and passive personality traits, which made him vulnerable to the unusual beliefs tenaciously held by his wife. Outwardly “normal,” Mr. A would quite likely have conducted his everyday life in a manner that would not arouse suspicion that he held such bizarre convictions. Only after careful examination and relevant collateral information was it possible to diagnose Mr. A as suffering from a mental disorder.

The delusions Mr. A held may seem to be explained by mere hyperreligious beliefs, especially since he did not have a previous severe mental illness. In that light, how should mental health professionals distinguish a delusion from other rigidly held beliefs seen in mental life? The neuropsychiatrist Carl Wernicke (best known for Wernicke’s area of the brain and Wernicke-Korsakoff syndrome) once described the concept of an overvalued idea. The definition of an overvalued idea is when one’s beliefs are shared with others in society but are held with an intense emotional commitment. For example, society generally agrees that exercise and being thin are healthy and appealing traits. Patients with anorexia nervosa also regard being slender and exercising as healthy. However, such individuals possess an unusually intense emotional commitment to remaining thin. Their distorted belief is that they are overweight, even to the point of starving themselves to death. Their arguments may seem rational, but their self-destructive behavior is not (6). Similarly, patients with obsessive-compulsive disorder can develop distorted thinking that appears delusional but is kept within their unique boundaries of intrusive, unwanted thoughts and rituals. While Mr. A did not consider his own beliefs to be unacceptable, his thinking was most certainly irrational, making his beliefs delusions rather than overvalued ideas.

Mr. A’s church did not sanction his unusual beliefs, and Christianity does not explicitly prohibit the use of formula to feed an infant, or the use of mainstream medicine. Independently of his church, he rigidly shared many delusional beliefs with his wife, eschewing the attempted intervention of his own family, who recognized the potentially destructive nature of the couple’s behavior. This is a common pattern with psychotic patients, who typically shun family and reject advice, often resulting in a tragic outcome, as in the present case.

English and American law developed the insanity defense to relieve the accused of legal responsibility when his or her thinking and behavior are so impaired at the time of the crime as a result of mental illness that the defendant meets that jurisdiction’s legal definition of insanity. Legal definitions of insanity vary, and some states do not even recognize the insanity defense. The fact that a defendant committed a crime because of a delusional belief is a common basis for an insanity defense. It is therefore critically important that forensic psychiatrists properly identify a defendant’s belief as either a fixed false conviction (a delusion) or as an intense emotional commitment to a commonly held belief shared by other members of his or her cultural group (an overvalued idea).

The authors thank Jeff Janofsky, M.D., for editorial comments.