A 9-year-old black Brazilian boy, accompanied by his grandmother, was referred to our hospital by the Emergency Unit owing to auditory and visual hallucinations. Because of his increasingly aggressive behavior at school, our patient was being treated in a Basic Health Unit near his home. The prescribed treatment was carbamazepine at night, which resulted in partial control of his symptoms. However, at the time of admission, he had stopped taking the medication for 2 days, causing the visual hallucinations to return. He had no fever or other changes in this period and denied the use of drugs or other illegal substances, except prescribed haloperidol and promethazine. When he arrived at our hospital he was calm and had no other complaints.
His treatment started approximately 2 years prior to the current admission when he started hearing voices that commanded him not to have friends and to kill himself. Such hallucinations always occurred at home, at around 6 p.m., and included visual perceptions of distinct characters. These visions often took the shape of bloody human beings: one was black, one was a baby, and some could change shape (get fatter or thinner, or become larger or smaller). The hallucinations were perceived as a meeting but our patient was unable to understand the language spoken. At the end of this meeting, one of the characters would tell him that he should kill himself. He was convinced that they were talking about him and sending him a special message. Our patient reported sleep deprivation due to these hallucinations.
According to his grandmother, our patient had bizarre behaviors, such as writing on the wall, throwing things on the ground, littering the closet, and walking around with a knife, without being aware of them soon after the event. She also reported recent aggressive behavior around his school colleagues and daily mood swings.
Our patient denied thoughts of worthlessness, anhedonia, or episodes of fast thinking and euphoria. He did not report a history of head trauma, seizures, or other medical conditions that could cause psychosis.
Our patient’s father, mother, maternal grandparents, two uncles, and two half-brothers from the same father had a history of mental disorders. Our patient lived with his grandmother, his mother, and two younger siblings. His parents were not caregivers, nor did they provide proper supervision. His father, who did not live in the same house, had attempted suicide three times; at this time he was functionally impaired and supported by a government program. His mother, although living in the same house, was not his caregiver nor had any responsibility for his siblings. Only his grandmother showed any characteristics of caregiving. According to his grandmother, our patient attended school without cognitive impairment and was in fifth grade. He had never failed a school year.
His physical examination was unremarkable, with only warts found on his hand and nose. The warts led us to suspect sexual abuse, which was later discarded owing to the diagnosis of common warts, the absence of lesions in the genital region, and our patient’s denial of a history of abuse. Laboratory tests, electroencephalogram and neuroimaging were performed on our patient according to standard protocol in such cases, which showed no abnormalities.
Our patient was hospitalized and prescribed risperidone. During this period, he recovered from his symptoms. Following advice from our psychiatric department, our patient was discharged after 3 days and prescribed 1 mg of risperidone per day. Our psychiatric department requested to talk with our patient and his grandmother separately, because of a suspicion that the grandmother was influencing our patient’s responses and auditory and visual hallucinations.
Our patient and his grandmother returned 15 days later and were interviewed separately. Our patient reported that the symptoms improved after he started taking the drug, but said that he felt more isolated now because his schoolmates began to call him crazy. He also reported that his father, who has alcoholism, is an Indian and has no contact with him because he lives with an Indian tribe in the woods. He said he hardly sees his mother because she is never home and believed to be working. He reported that he spends most of the time at home with his grandmother and two younger sisters. When questioned about his relationship with his grandmother, he said they get along very well and that she is always telling a story about a haunted house where she had lived before he was born, and where people could see shadows, bloody murders, and ghosts, and hear voices telling them to kill themselves.
During the interview with the grandmother, she stated that she has a kind of “super power” that allows her to sense everything that is going on with the people in her family, including the murder of some family members, and that all family members are aware of her power and admire it. She did not have stable work, spent most of her time at home, and showed great affection for the patient. She reported a haunted house, where she used to live 15 years ago with her family and where she saw ghosts and heard voices. When asked about more details of those events, she said that objects in the house would break for no reason, and that it was possible to see bloody people changing shape, becoming fatter or thinner. Among those people there was a black man, a baby, and a woman who would tell her to kill herself. We asked if those were visions similar to her grandson’s hallucinations and she said they were and that even though he has never lived in that house, he has had similar visions. She added that by the age of 2 years he had already had those same visions, which disappeared for a time but returned in the past 2 years.
According to their social worker, our patient had a good academic performance and had been monitored since 2008 by the Child Protection Council, owing to the fact that he was abandoned by his mother, had an alcoholic father, and was being raised by his grandmother.
The hypothesis of a shared psychotic disorder, also known as folie à deux, was raised based on the similarity of the delusions and hallucinations of the boy and the grandmother and their close relationship. A mental status examination did not show enough psychopathological criteria to support any other differential diagnoses, such as (1) schizophrenia, because the diagnosis requires cognitive and social dysfunction and a careful clinical follow-up, which was not seen in this case; (2) bipolar disorders, because patients have psychotic symptoms during episodes of mania or depression, but in this case our patient did not show any prominent affective or mood symptoms, which are essential to establish the diagnosis; (3) other psychoses due to general medical disease, which were excluded because results from physical and complementary examinations were normal; 4) mental retardation or developmental disorders, which were excluded owing to the lack of cognitive or language deficit; and (5) substance abuse, because there were no signs of substance abuse in this case.