Secondary psychotic syndromes should be excluded before assuming idiopathic digital “Folie à trois”

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Dear Editor, we were interested to read a recent article in your journal «Shared Psychotic Disorder in the Digital Age: A Case Series of Virtual “Folie à Trois”», dedicated to a case series of virtual folie à trois. The case series highlighted a novel manifestation of shared psychotic disorder in digital cohabitation, underscoring that psychological proximity, rather than physical closeness, may suffice for the transmission of delusional beliefs in the modern age [1]. The article was very interesting, but we have some questions to ask:

First, why did the author describe aripiprazole as a second-generation antipsychotic? Aripiprazole is widely accepted as a third-generation antipsychotic [2]. It is very important to be rigorous while classifying the drugs we use to treat our patients, in order to get a better theragnosis. Please allow me to remind you of a useful mnemonic for the most commonly used third-generation antipsychotics: ABC, for aripiprazole, brexpiprazole, and cariprazine [3].

Second, why did the author not introduce the World Health Organization’s International Classification of Diseases (ICD) codes for any of the three patients? Readers may easily assume that Case B (Recipient 1) and Case B (Recipient 2) suffered from shared psychoses. Induced delusional disorder, code F24, at ICD-10, or other specified primary psychotic disorder, code 6A2Y, at ICD-11, as the most recent nosology system do not have a specific code for these kinds of cases. But what about Case A (Inducer)? What was the diagnosis? Was it schizophrenia, code F20, at ICD-10, or code 6A20, at ICD-11? Or was it another psychosis? While the recipients may have schizophrenia, affective disorder, depression, dementia, or intellectual disability, the commonest diagnoses in the inducer are delusional disorders, schizophrenia and affective disorder [4].

Still, we have read cases of shared psychosis where the inducer had psychosis due to drug abuse [5, 6] or organic psychosis [7]. Again, it is obligatory to be specific while attributing labels to our patients to provide the most accurate diagnosis. Beware of secondary schizophrenia, pseudo-schizophrenia, and schizophrenia-like psychosis [8]!

Third, why did the author assume that all patients had a primary psychotic condition, and not a secondary psychotic condition, code F06, at ICD-10, or 6E61, at ICD-11? All the three patients should have been studied with, exempli gratia, brain magnetic resonance imaging to exclude encephalic anomaly, electroencephalogram to exclude signs of epilepsy, neuropsychological assessment to exclude intellectual impairment; lumbar puncture to exclude encephalitis; bloodwork to exclude hormonal, vitamin, infectious, auto-immune, and/or genetic causes; drug urinalysis to exclude cannabis, cocaine, amphetamine, ketamine, and/or phencyclidine misuse, et cetera. Folie à trois or schizophrenia can be imitated by many imitators that should be discarded before the clinician assumes the diagnosis of a primary/functional/idiopathic.

Remember: schizophrenia is one the greatest imitated syndromes of medicine [9].

Funding: The research was carried out without additional funding.

Conflict of interest: The author declares no conflicts of interest.

Generative AI use statement: Nothing to disclose.

About the authors

João Gama-Marques

Author for correspondence.
Email: joaogamamarques@gmail.com
ORCID iD: 0000-0003-0662-5178

MD, MSc, PhD, Invited Assistant Professor, Faculdade de Medicina, Centro Académico de Medicina de Lisboa, Consulta de Esquizofrenia Resistente, Unidade Local de Saúde de São José, Centro Clínico Académico de Lisboa

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Parent article DOI https://doi.org/10.17816/CP15689