Families in Psychiatry

Families in Psychiatry: Parental alienation and shared delusional disorders



Disturbances in family emotional involvement are best understood at the extremes. At one end, there is extreme cutoff in the controversial diagnosis of parental alienation. At the other end is the extreme enmeshment in shared delusional disorders. What are the mechanisms that allow these conditions to develop? Helping families understand these mechanisms can help them change the trajectory of the family, by moving toward the middle, toward appropriate family emotional involvement.

How does enmeshment begin?

Good parents want to instill good morals, values, and behaviors in their children. Good parents want to teach their children to be good citizens, have good manners, and to treat others with respect. However, sometimes parents desire something more from their children; they want their children to continue a family business, be part of their religious organization, or to be “just like us.” Parental influence is easier when communities are isolated. When shared family beliefs are pervasive and impede the individuation of thoughts, feelings, and behaviors, these families are considered enmeshed and undifferentiated. Enmeshed families are more susceptible to indoctrination. Indoctrination is easier when there is a high level of emotional involvement, meaning that children are kept close, and differentiation and individuation are discouraged.

Using a child for one’s own needs is exploitative;however, many parents might not understand how their own unconscious psychological needs affect their children. This is seen clearly when children are rejected because they are “different.” For example, some parents have stated that a lesbian, gay, bisexual, and transgender sexual orientation is “against their religion,” and demand that their child conform to the family beliefs and norms. In these cases, the adolescent or young adult has to decide whether to leave the family, conform to its beliefs, or hide his or her identity.


Emotional overinvolvement in undifferentiated enmeshed families is central to the diagnosis of shared delusional disorder. One example of a shared delusion is delusional parasitosis. This is a rare delusional disorder where the patient is convinced of being infested with worms, insects, parasites, or bacteria while no objective evidence exists to support this belief. Somatic delusions are shared with one or more members of a family in 5%-15% of cases (J. Behav. Health 2014;3:200-2).

Salvador Minuchin, Ph.D., and his colleagues outlined the impact of enmeshment in families where a child has an eating disorder. They described children so overprotected that there was a virtual moat around the family system, blocking out the world. Interpersonal differentiation in an enmeshed family system was poor, with identity fusion between parent and child. In this dynamic, the child is unable to establish a clear identity apart from the parent. Orthorexia, a term coined in 1997 by Dr. Steven Bratman, is defined as an obsession with “healthy or righteous eating.” The obsession with healthy foods can be structured within family habits. When enmeshment and family isolation are present, orthorexia can show up as a folie à famille (Heru, personal experience).

More exotic examples are known by the French terms folie à deux and folie à famille. Dr. Ernest-Charles Lasegue (Ann. Med. Psychol. 1877;18:321) was the first person to describe folie à deux. He stated that the inducer created the delusions from his/her psychosis and imposed them upon a “passive” individual; the induced subject was not truly psychotic but instead “absurdly credulous.” Several varieties are described. Folie imposée is the one we typically think of, where the naive individual has a resolution of symptoms when removed from the dominant person. Folie simultanée is where simultaneous and identical psychoses occur in two predisposed people who have had a long and intimate association with each other. There is usually no dominant partner, and separation does not alleviate the symptomatology. Folie communiquée involves the transfer of psychotic delusions after a long period of resistance by the passive partner. The recipient of the delusions subsequently develops his own delusions, independent of the primary subject’s, and these persist following separation.

Folie induite, a variant of folie communiquée, is diagnosed when new delusions are added to old ones under the influence of another deluded patient. The secondary person enriches the newly acquired delusions. Another method of classification is based on the number of individuals involved: folie à trois (three), folie à quatre (four), folie à cinq (five), and, as mentioned earlier, folie àfamille.

What is the mechanism for enmeshment? Several predisposing factors can occur: social isolation, the presence of a naive or “absurdly credulous” person, and in the case of relatives, a shared genetic predisposition. It is most common for the dominant person to drive the belief that is then accepted by dependent family members. In the case of children, there is also identification with a parent and a lack of drive for separation.

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