Transcultural Psychiatry http://tps.sagepub.

com/

The Seven Sleepers: A folie deux case originating from a religious-cultural belief
Menekse Sila Yazar, Evrim Erbek, Nezih Eradamlar and Latif Alpkan Transcultural Psychiatry 2011 48: 684 DOI: 10.1177/1363461511420751 The online version of this article can be found at: http://tps.sagepub.com/content/48/5/684

Published by:
http://www.sagepublications.com

On behalf of:
Division of Social & Transcultural Psychiatry, Department of Psychiatry, McGill University

World Psychiatric Association

Additional services and information for Transcultural Psychiatry can be found at: Email Alerts: http://tps.sagepub.com/cgi/alerts Subscriptions: http://tps.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://tps.sagepub.com/content/48/5/684.refs.html

>> Version of Record - Nov 23, 2011 What is This?

Downloaded from tps.sagepub.com by Aras Roxana on October 9, 2012

Transcultural Psychiatry 48(5) 684692 ! The Author(s) 2011 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1363461511420751 tps.sagepub.com

Case Report

The Seven Sleepers: A folie ` a deux case originating from a religious-cultural belief
Menekse Sila Yazar, Evrim Erbek, Nezih Eradamlar and Latif Alpkan
Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery

Abstract ` Folie a deux is an uncommon psychiatric entity characterized by the transfer of delusional ideas and/or abnormal behavior from one person to another, or many others, who are in ` close contact with the primarily affected patient. In this paper we present a case of folie a deux, involving a married couple who suffered from a shared psychotic disorder with delusional interpretations of specific suras of the Koran. These mystical delusions were derived from the Anatolian legend of The Seven Sleepers. The case resulted in the death of ` the wife. This study illustrates the role of cultural and religious factors in folie a deux. Keywords ` folie a deux, induced psychotic disorder, religious delusion, shared psychotic disorder

` Folie a deux is an uncommon psychiatric entity characterized by the transfer of delusional ideas or abnormal behavior from one person to another who is in close interaction with the primarily aected patient (Kashiwase & Kato, 1997; Lasegue & Falret, 1964). There have been attempts to categorize the disorder into subtypes: folie imposee (imposed psychosis); folie simultanee (simultaneous psychosis); folie communiquee (communicated psychosis); and folie induite (induced psychosis) (Gralnick, 1942). Dewhurst and Todd (1956) reported that for the diagnosis ` of folie a deux, the following three conditions are essential: (a) positive evidence that the partners are intimately associated; (b) similarity of the contents of the shared delusions; and (c) evidence that the subjects accept, share, and support each others delusions. In DSM-IV-TR, the disorder is mentioned as shared psychotic disorder (American Psychiatric Association, 2005). According to DSM-IV

Corresponding author: Menekse Sila Yazar, Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, 12. y Psikiyatri Birimi, Bakrko 34147, Istanbul, Turkiye. Email: msilayazar@hotmail.com

Downloaded from tps.sagepub.com by Aras Roxana on October 9, 2012

Yazar et al.

685

criteria for shared psychotic disorder, a delusion develops in an individual in the context of a close relationship with another person, who has an alreadyestablished delusion and the delusion is similar in content to that of the person who already has the established delusion. Exclusion criteria require that the disturbance is not better accounted for by another psychotic disorder (e.g., schizophrenia) or a mood disorder with psychotic features and is not due to the direct physiological eect of a substance (e.g., drug abuse, medication) or a general medical condition (American Psychiatric Association, 2005). In ICD-10 the disorder is mentioned as induced delusional disorder and ICD-10 describes the disorder as follows:
A delusional disorder shared by two or more people with close emotional links and only one of the people suers from a genuine psychotic disorder; the delusions are induced in the other(s) and usually disappear when the people are separated. (World Health Organization, 1992)

There is still considerable confusion regarding terminology and validated diag` nostic criteria of folie a deux due to the rarity of this syndrome, as well as the relatively limited information about its natural history and prognosis (Arnone, Patel, & Ming-Yee Tan, 2006). ` The majority of the relationships in folie-a-deux cases occur within the nuclear ` family. Thus, folie a deux is also known as family psychosis (Glassman, Magulac, & Darko, 1987). Married or common-law couples have constituted the largest proportion of cases to date (Arnone et al., 2006). Siblings or parentchild dyads are other frequently considered partner associates (Enoch & Ball, 2001). In ` folie a deux, the primarily aected individual is referred to as the dominant partner or principal. The person inuenced by the dominant partner is referred to as the submissive partner or associate. Various terms such as inducer/induced or, pri` mary/secondary have also been used to distinguish the partners of folie a deux (Kashiwase & Kato, 1997). ` Here we present a case of folie a deux resulting in a fatality. The couples delusions were based on suras (sura is the division of the Koran, often referred to as a chapter) of the Koran that related to the story of The Seven Sleepers. Permission to report this case was received from the patient and his wife as well as the hospital.

Case
The police brought a 32-year-old married male teacher and father of three to the emergency room of the Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery in Istanbul. According to ocial information obtained from police records, he and his three children (aged 4, 2, and 1) had spent 3 days in a room with his pregnant wifes corpse. The admitting psychiatrist reported that the husband did not respond to questions and refused to

Downloaded from tps.sagepub.com by Aras Roxana on October 9, 2012

686

Transcultural Psychiatry 48(5)

communicate with hospital sta. However, during follow-up interviews in the emergency room, he cooperated partially and stated that his wife was not dead. He reported that his wife was unresponsive as a result of the will of God and that she would soon be resurrected, and give birth. He believed this was a test by God as detailed in a verse from the Koran. He added that he did not want to speak anymore due to possible consequences. The husband was surprised and anxious when he was told that his wife had died and been buried. Previously the husband had been employed as a teacher for 5 years without incident. His family and colleagues described him as introverted, asocial, and passive in interpersonal relations. He was extremely religious, so much so that his determination to maintain extreme and inexible religious rituals led to an unconventional and strict religious lifestyle. His wife was a 32-year-old architect who stayed home with the children. According to information obtained from the wifes family, she was active, intelligent, and while she was very religious, her behaviors were in no way extreme. After the couple married, they became increasingly more introverted and socially isolated, becoming obsessed with religious subjects. In the early stages, the couple socialized almost solely with other strictly religious people who shared their devotion to reading the Koran. However, the couple left the group as they found it insucient for their religious needs. The couple eventually cut o all social ties and began spending all their free time reading the Koran, especially verses related to the cruelty of nonbelievers. During this period of time, it appears that the husband was making all the decisions about their lifestyle. The wife, believing in traditional husbandwife relationships accepted her husbands decisions and shared his lifestyle. During this time the couple had two children. By the third year of their marriage, the couple was living in complete social isolation and the husband resigned from his 5-year teaching career in order to devote more time to reading the Koran. One year later, the husband had his rst documented psychotic episode while fullling his obligatory military service and was declared unsuitable for military duty. He was under the delusion that his own parents were going to harm his wife and children. His hallucinations included visions of his children on a train and hearing their voices calling for help. In reaction to this he shot at a train in a military zone. Following this incident he was hospitalized for 1 month and diagnosed with schizophreniform disorder. Partial recovery was achieved following a treatment of 10 mg haloperidol per day. His hallucinations disappeared completely and the severity of his delusions decreased. Although his wife shared in his thoughts of persecution, she never sought professional help. After the patient was discharged from the hospital he stopped taking his medication and ceased psychiatric care. Following this, the family moved from Istanbul to dierent provinces in order to distance themselves from possible harm caused by nonbelievers. During this time they had one more child and were eventually forced to move in with the husbands family due to nancial diculties. While living with the husbands family, they locked themselves and their children into a room and ceased contact with others living in the house. They requested that their meals be left outside their door.

Downloaded from tps.sagepub.com by Aras Roxana on October 9, 2012

Yazar et al.

687

They spent all their time reading the teachings of the Koran. The husbands family tried to oer help by lecturing the couple on how their lifestyle was harming the children and themselves, but this attempt at help was perceived as an act of intervention on the behalf of nonbelievers in order to harm them because of their religious beliefs. When the familys attempt to help intensied, the couple left the home without warning. The couple and their children moved again to another province and began living with the wifes parents. They continued the same lifestyle of locking themselves and their children into a room and spending all of their time reading the Koran. The husband explained that when they randomly opened the Koran, they generally came across and read the suras of Al Kahf and Sad. The sura of Al Kahf states: They sheltered in a cave. The couple interpreted that coincidence as a holy sign that they should stay in their room to protect themselves just like the sheltering of Asab- Kahf (the seven sleepers in the cave) in order to escape from the cruelty of nonbelievers. During the night they retrieved and ate the meals that were left outside their door only if they read the verse: They sent one of them out to bring food. They did not eat anything if they did not randomly open to this verse and read it. The familys condition worsened and they no longer ate. Whenever they read the sura of Sad that said: We questioned him (Solomon the prophet) and left him on the ground as a corpse. They interpreted this to mean that one member of the family would be questioned and wondered who the chosen one would be. The husband said that when his wife was in pain and began to cry and then her body went cold, he interpreted this as the realization of the verse. Like Solomon the prophet, the wife was examined, and then was left to be on the assumption that she would soon be resurrected as outlined in the verse. Finally, when there was no communication from the couple for 10 days and the children were continuously heard crying, the wifes family broke down the door and entered the room. What they witnessed was a horric scene; there was an intense odor, the room was full of human waste, the wife was dead, and the children were severely malnourished. The autopsy of the wife revealed that she had been 4 months pregnant. She had miscarried 3 days before and died as a result of blood loss. The husband described the condition as: She fell asleep for a period like Asab- Kahf. She was going to wake up and deliver the fourth baby followed by three othersthe seven sleepers. He said she should not have been buried because she was alive. The husband was consequently hospitalized. The ndings from a psychiatric examination showed the patient was lacking in personal hygiene and exhibited a diminished psychomotor activity. His cooperation in the psychiatric evaluation was limited and at times he was completely uncooperative. His aect was restricted. Although he had no hallucinations during the examination, he did have delusions of persecution and a delirious perception of the death of his wife, and their bizarre lifestyle of being barricaded in a room. These were based on his delusional

Downloaded from tps.sagepub.com by Aras Roxana on October 9, 2012

688

Transcultural Psychiatry 48(5)

interpretation of some verses of the Koran. According to the information obtained from the husband, the husbands family, the family of the deceased wife, and police records, the entire psychotic process was shared between the husband and the wife. Upon physical and neurological examinations of the husband there were no pathological ndings. He had no history of alcohol or any other substance abuse. Blood and urine analyses, liver function tests, urea and creatinine levels, thyroid function tests, B12 and folic acid levels were within normal limits. His wife also had had no history of alcohol or substance abuse, or mental disorder. The patient received seven sessions of electroconvulsive treatment and then was prescribed 300 mg clozapine per day. In 8 weeks complete clinical remission was achieved and the patient was discharged from the hospital. The patient willingly continued with the outpatient clinic treatment for 1 year. During this period, complete clinical remission was maintained and functionality improved noticeably. During this time he resided with his brother, a teacher of theology, in southeastern Turkey. After 1 year, he moved out of his brothers home and moved to another province closer to his hometown. He did not exhibit any psychiatric symptoms and started to work as a volunteer teacher. Two years after his hospitalization, he remarried and his children, who had been living with relatives, once again began to live with him. He had remained on the clozapine (300 mg per day) treatment until the marriage. The patients brother reported that the patient stopped taking his medication in order to hide his condition from his new wife. Three years following his initial hospitalization, the husband was rehospitalized after he began sending numerous religious messages to his relatives via mobile phone. In these messages, he told them to obey God otherwise God would punish them. Once again, he began to relocate his wife and children in order to avoid possible harm from nonbelievers. The new wife protested this lifestyle but he ignored her protests. Finally, they returned home and started to live in complete social isolation. As a result of her protests, he locked his wife in the home, but she managed to escape through the window. During that period, he did not talk with anyone and expressed all his wishes via written notes. He was extremely occupied with religious practice. He was hospitalized and during his psychiatric examination he stated that I promised God that I would not talk as outlined in the sura of Mariam in the Koran, therefore, I cannot speak. His aect was restricted. He had no hallucinations during the examination but did have persecution delusions and delusional interpretation of verses of the Koran. He was diagnosed with schizophrenia. He was discharged from the hospital and again prescribed with clozapine, 300 mg per day. This treatment led to complete improvement in his major psychiatric symptoms.

Discussion
` The case involves a unique form of folie a deux. The husbands anamnesis and the accounts of the families of both the husband and wife indicate that after marriage the couple developed a close relationship and isolated themselves from society.

Downloaded from tps.sagepub.com by Aras Roxana on October 9, 2012

Yazar et al.

689

According to DSM-IV criteria, the husband was suering from a psychotic disorder. The wife, who had a close emotional relation with the husband, experienced hallucinations and delusions of persecution which had the same content as her husbands. There was no indication that the wife had had any prior mental disorder or addictions; in other words, the wifes disturbance would not be better accounted for by another mental disorder. There was no change in the husbands condition after the death of the wife and his condition continued with the same intensity. Furthermore there was no prior evidence of the wife having any mental deciency that would help to explain the situation. Despite the lack of a psychiatric evaluation of the wife, all indications lead to the conclusion that the husband was the primary partner and the wife was the secondary partner. In addition, there was documented evidence that prior to the onset of the shared psychotic disorder the husband was diagnosed with a schizophreniform disorder. It has been reported that primaries in ` folie-a-deux cases have often been previously diagnosed with schizophrenia (Lazarus, 1985; Soni & Rockley, 1974). Social isolation and intimate relationship are reported as the major predisposing ` factors in the development of folie a deux (Arnone et al., 2006; Glassman et al., 1987; Reif & Pfuhlmann, 2004; Soni & Rockley, 1974). Complications such as ` fatality or suicide have been reported in folie a deux (Bourgeois, Duhamel, & Verdoux, 1992; Manseld, 2005). It may be especially dicult to predict the risk ` of fatalities in cases of folie a deux involving religious delusions because families may nd it dicult to label other family members as exhibiting psychiatric illness, if part of their religious beliefs appears to be normal (Kraya & Patrick, 1997). In this particular case, because of the Koran-based ideas of the couple, the severity and reality of their psychotic lifestyle was not identied by extended family at the onset and psychiatric intervention was delayed. The rst reaction of family and peers was to accept and respect them as being very religious and they were much occupied with religious ideas and activities. But when the couple began living with the extended family, the families realized the couples behaviors were not normal and were concerned about the welfare of the couple and their children. Family members were surprised that their attempts to help were interpreted by the couple as attempts to harm. The story of The Seven Sleepers, which forms the delusional content of this case, is a legend found in various forms in Anatolian and Middle Eastern cultures and is part of both Muslim and Christian religions. The Islamic version of The Seven Sleepers is referenced in a sura of Chapter 18: Al-Kahf (The Cave) of the Koran. There are numerous caves in Anatolia and many other countries including Spain, Algeria, Egypt, Jordan, Syria, Afghanistan, and East Turkestan where The Seven Sleepers legend is believed to have taken place. The basic premise of the story of The Seven Sleepers is as follows:
During the Roman persecutions seven young men were accused of practicing Christianity. One day they climbed up a mountain to pray, and fell asleep in a

Downloaded from tps.sagepub.com by Aras Roxana on October 9, 2012

690

Transcultural Psychiatry 48(5)

cave. The emperor, seeing that their dedication to paganism had not changed, ordered the mouth of the cave to be sealed. After a few hundred years, the current landowner decided to open up the sealed mouth of the cave to use it as a cattle pen. He opened the cave to nd the seven sleepers still inside. Upon awakening they believed that they had only been asleep for 1 day. One member of the group went into town to buy bread. The townspeople were surprised to see him trying to spend old coins. The bishop was summoned to question the sleepers; they told him their miraculous story, and died praising the name of God. (Jones, 2005)

The Islamic version of The Seven Sleepers is related in sura Chapter 18: Al-Kahf (The Cave) of the Koran and includes 110 verses. Among them, verses 914 are related to the delusion. The holy Koran tells the story of the sleepers in detail. An inscription in the cave is as follows:
Do you think that the Fellows of the Cave and the Inscription were of Our wonderful signs? When the youths sought refuge in the cave, they said: Our Lord! grant us mercy from Thee, and provide for us a right course in our aair.

The other sura that formed a foundation to the delusion of the couple was Sad sura. It is the 38th sura of the Koran and includes 88 verses. Among them, the verses that are related to the delusion are verses 3436: We swore that we Questioned Solomon and left a corpse over his throne. Later it turned to its previous form with repentance. The background of the last psychiatric symptoms of our case is Mariam sura. It is the 19th sura and includes 98 verses. Among them, the 26th verse was connected to the delusion: Eat and drink. We are happy for you. If you see any human being, tell him that I devoted the merciful God to fast. I will not speak with anyone today (Alioglu, Yldz, & Winter, 1992). It is suggested that this sura was sent as an answer to the question as to how Mary became pregnant without engaging in sexual intercourse. ` Recognition and understanding of folie a deux cases may provide better under` standing of the nature of psychotic relationships. This particular folie-a-deux case, in which delusions develop from a cultural-religious background, provides an opportunity both to evaluate the relationship between the cultural-religious factors ` and folie-a-deux phenomenon, and to alert medical professionals to the potential for fatal risks in the presence of religious delusions. Acknowledgements
This case was presented as a poster presentation at the World Psychiatric Association (WPA) International Congress 2007, Melbourne, Australia.

Funding
This research received no specic grant from any funding agency in the public, or notfor-prot sectors.

Downloaded from tps.sagepub.com by Aras Roxana on October 9, 2012

Yazar et al.

691

References
Alioglu, H., Yldz, Y., & Winter, A. (Trans.) (1992). Al-Kahf Sura, Sad Sura, Mariam Sura. In The Holy Koran with English Translation, 304311 (Mariam Sura), 417 (Al-Kahf Sura), 452 (Sad Sura). Istanbul, Turkey: Acar Press. American Psychiatric Association. (2005). Diagnostic and statistical manual of mental disorder (4th ed. rev. ed.). Washington, DC: American Psychiatric Association. ` Arnone, D., Patel, A., Ming-Yee, & Tan, G. (2006). The nosological significance of folie a deux: A review of the literature. Annals of General Psychiatry, 8, 511. ` Bourgeois, M. L., Duhamel, P., & Verdoux, H. (1992). Delusional parasitosis: Folie a deux and attempted murder of a family doctor. British Journal of Psychiatry, 161, 709711. ` Dewhurst, K., & Todd, J. (1956). The psychosis of association: Folie a deux. Journal of Nervous and Mental Disease, 124, 451459. Enoch, D., & Ball, H. (2001). Uncommon psychiatric syndromes. London, UK: Arnold. Glassman, J. N., Magulac, M., & Darko, D. F. (1987). Folie a famille: Shared paranoid disorder in a Vietnam veteran and his family. American Journal of Psychiatry, 144, 658660. ` Gralnick, A. (1942). Folie a deux The psychosis of association. Part 2. Psychiatry Quarterly, 16, 491520. Jones, L. (2005). Encyclopedia of Religion (2nd ed.). Detroit, MI: Thomson Gale, 8440. ` Kashiwase, H., & Kato, M. (1997). Folie a deux in Japan Analysis of 97 cases in the Japanese literature. Acta Psychiatrica Scandinavica, 96, 231234. ` Kraya, N. A., & Patrick, C. (1997). Folie a deux in a forensic setting. Australian and New Zealand Journal of Psychiatry, 31, 883888. ` Lasegue, C., & Falret, J. P. (1964). La folie a deux (R. Michaud, Trans.). American Journal of Psychiatry, 121, 223. Lazarus A. (1985). Folie a deux: psychosis by association or genetic determinism? Comprehensive Psychiatry, 26, 129135. ` Mansfield, M. (2005). Folie a trois in a multilevel security forensic treatment center: Forensic and ethics-related implications. Journal of the American Academy of Psychiatry and the Law, 33, 310316. ` Reif, A., & Pfuhlmann, B. (2004). Folie a deux versus genetically driven delusional disorder: Case reports and nosological considerations. Comprehensive Psychiatry, 45(2), 155160. ` Soni, S. D., & Rockley, J. G. (1974). Socio-clinical substrates of folie a deux. British Journal of Psychiatry, 125, 230235. World Health Organization. (1992). The ICD-10 classification mental and behavioral disorders. Geneva, Switzerland: WHO.

Menekse Sila Yazar, MD, is Fellow in Psychiatry at the Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery. She works as a resident trainer and her main research interest is schizophrenia. Evrim Erbek, MD, is Resident in Psychiatry at the Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery. She works as a resident and her research interest is family therapy. Nezih Eradamlar, MD, is Fellow in Psychiatry at the Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery. He has been the

Downloaded from tps.sagepub.com by Aras Roxana on October 9, 2012

692

Transcultural Psychiatry 48(5)

assistant to the head of department for 12 years. He is interested in research on schizophrenia and substance related psychosis. Latif Alpkan, MD, is Fellow in Psychiatry at the Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery. He is the head of department. His main research interest is forensic psychiatry and psychotic disorders.

Downloaded from tps.sagepub.com by Aras Roxana on October 9, 2012