Delusional disorder

Delusional disorder
Specialty	Psychiatry, clinical psychology

See also: Delusion

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COMMONLY KNOWN AS CHRISTOPHER LEEDelusional disorder is a psychiatric diagnosis denoting a psychotic mental disorder that is characterized by holding one or more non-bizarre delusions in the absence of any other significant psychopathology. Non-bizarre delusions are fixed beliefs that are certainly and definitely false, but that could possibly be plausible, for example, someone who thinks he or she is under police surveillance. In order for the diagnosis to be made auditory and visual hallucinations cannot be prominent, although olfactory or tactile hallucinations related to the content of the delusion may be present.

To be diagnosed with delusional disorder, the delusion or delusions cannot be due to the effects of a drug, medication, or general medical condition, and delusional disorder cannot be diagnosed in an individual previously diagnosed with schizophrenia. A person with delusional disorder may be high functioning in daily life and may not exhibit odd or bizarre behavior aside from these delusions. The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines six subtypes of the disorder characterized as erotomanic (believes that someone famous is in love with him/her), grandiose (believes that he/she is the greatest, strongest, fastest, most intelligent person ever), jealous (believes that the love partner is cheating on him/her), persecutory (believes that someone is following him/her to do some harm in some way), somatic (believes that he/she has a disease or medical condition), and mixed, i.e., having features of more than one subtypes. Delusions also occur as symptoms of many other mental disorders, especially the other psychotic disorders.

The DSM-IV, and psychologists, generally agree that personal beliefs should be evaluated with great respect to complexity of cultural and religious differences since some cultures have widely accepted beliefs that may be considered delusional in other cultures. Specifically, in order to fall under the definition of a "delusion," a belief must be sustained despite what almost everyone else believes, and not be one ordinarily accepted by other members of the person's culture or subculture (e.g., it is not an article of religious faith).

Indicators of a delusion

The following can indicate a delusion:

1. The patient expresses an idea or belief with unusual persistence or force.
2. That idea appears to exert an undue influence on his or her life, and the way of life is often altered to an inexplicable extent.
3. Despite his/her profound conviction, there is often a quality of secretiveness or suspicion when the patient is questioned about it.
4. The individual tends to be humorless and oversensitive, especially about the belief.
5. There is a quality of centrality: no matter how unlikely it is that these strange things are happening to him, the patient accepts them relatively unquestioningly.
6. An attempt to contradict the belief is likely to arouse an inappropriately strong emotional reaction, often with irritability and hostility.
7. The belief is, at the least, unlikely, and out of keeping with the patient's social, cultural and religious background.
8. The patient is emotionally over-invested in the idea and it overwhelms other elements of his or her psyche.
9. The delusion, if acted out, often leads to behaviors which are abnormal and/or out of character, although perhaps understandable in the light of the delusional beliefs.
10. Individuals who know the patient will observe that his or her belief and behavior are uncharacteristic and alien.

Features

The following features are found:

1. It is a primary disorder.
2. It is a stable disorder characterized by the presence of delusions to which the patient clings with extraordinary tenacity.
3. The illness is chronic and frequently lifelong.
4. The delusions are logically constructed and internally consistent.
5. The delusions do not interfere with general logical reasoning (although within the delusional system the logic is perverted) and there is usually no general disturbance of behavior. If disturbed behavior does occur, it is directly related to the delusional beliefs.
6. The individual experiences a heightened sense of self-reference. Events which, to others, are nonsignificant are of enormous significance to him or her, and the atmosphere surrounding the delusions is highly charged.

Types

Diagnosis of a specific type of delusional disorder can sometimes be made based on the content of the delusions. The Diagnostic and Statistical Manual of Mental Disorders (DSM) enumerates six types:

• Erotomanic Type (erotomania): delusion that another person is in love with the individual, quite frequently a famous person. The individual may breech the law as he/she tries to obsessively make contact with the desired person.
• Grandiose Type: delusion of inflated worth, power, knowledge, identity or believes himself/herself to be a famous person, claiming the actual person is an imposter or an impersonator.
• Jealous Type: delusion that the individual's sexual partner is unfaithful when it is in actual fact untrue. The patient may follow the partner, check text mesages, emails, phone calls etc. in order to find "evidence" of the infidelity.
• Persecutory Type: This delusion is the most common. It includes the belief that the person (or someone to whom the person is close) is being malevolently treated in some way. The patient may believe that he/she has been drugged, spied-on, harassed and so on and may seek "justice" by making police reports, taking court action or even acting violent.
• Somatic Type: delusions that the person has some physical defect or general medical condition (for example, see delusional parasitosis

(Lippincott, 2008).

• Mixed Type: delusions with characteristics of more than one of the above types but with no one theme predominating.

A diagnosis of 'unspecified type' may also be given if the delusions fall into several or none of these categories.

Causes

When delusional disorders occur late in life they suggest a hereditary predisposition. Researchers also suggest that these disorders are the result of early childhood experiences with an authoritarian family structure. According to other researchers, any person with a sensitive personality is particularly vulnerable to developing a delusional disorder.

Although its exact cause is unknown, it is believed that genetic, biochemical and environmental factors play a significant role in the development of delusional disorder.

Diagnosis

The symptoms expressed by a delusional disorder can also be part of a much more serious problem, such as bipolar disorder or schizophrenia, therefore, diagnosing the delusional disorder is conducted partially by process of elimination. This occurs because delusions can be part of many other illnesses including dementia, schizophrenia and schizoaffective disorder. They may also be part of a response to physical, medical conditions, or reactions when drugs are ingested.

Interviews are useful tools to obtain information about the patient's life situation and past history to help identifying the delusional disorder. Clinicians may review earlier medical records, with the patient's permission. Clinicians also interview the patient's immediate family. This is a very helpful measure in determining the presence of delusions. The mental status examination is used to assess the patient's memory, concentration, and understanding the individual's situation and logical thinking.

Another psychological test used in the diagnosis of the delusional disorder is the Peters Delusion Inventory (PDI) which focuses on identifying and understanding delusional thinking. However, this test is more likely used in research than in clinical practice.

Treatment

Treatment of delusional disorders includes a combination of drug therapy and psychotherapy although it is a challenging disorder to treat for many reasons such as the patient's denial that they have a problem of a psychological nature.

Atypical antipsychotic medications (also known as novel or newer-generation) are used in the treatment of delusional disorder as well as in schizophrenic disorders. Some examples of such medications are risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa). These medications work by blocking postsynaptic dopamine receptors and reduce the incidence of psychotic symptoms including hallucinations and delusions. They also relieve anxiety and agitation. When these drugs are tried but the symptoms do not improve, other types of antipsychotics may be prescribed. Some examples are: fluphenazine decanoate and fluphenazine enanthate. One very effective drug in delusional disorders is also pimozide.

In some cases agitation may occur as a response to severe or harsh confrontation when dealing with the existence of the delusions. If agitation occurs, different antipsychotics can be administered in order to conclude its outbreak. For instance, an injection of haloperidol (Haldol) can be administered in order to decrease anxiety and slow behavior, it is often combined with medications including lorazepam(Ativan).

In cases when severely ill patients do not respond to standard treatment, Clozapine may be prescribed although it may cause drowsiness, sedation, excessive salivation, tachycardia, dizziness, seizures and agranulocytosis.

In order to treat the symptoms in the long term an oral novel antipsychotic is often prescribed on a daily basis. Antidepressants and anxiolytics are also prescribed to control associated symptoms.

Psychotherapy for patients with delusional disorder include cognitive therapy which is conducted with the use of empathy. During the process, the therapist asks hypothetical questions in a form of therapeutic Socratic dialogue. This therapy has been mostly studied in patients with the persecutory type.The combination of pharmacotherapy with cognitive therapy integrates treating the possible underlying biological problems and decreasing the symptoms with psychotherapy as well.

Supportive therapy has also shown to be helpful. Its goal is to facilitate treatment adherence and provide education about the illness and its treatment.

Furthermore, providing social skills training has been applicable to a high number of persons. It should focus on promoting interpersonal competence as well as confidence and comfort when interacting with those individuals perceived as a threat.

Reports have shown successful use of insight-oriented therapy although it may also be contraindicated for delusional disorder. Its goals are to develop therapeutic alliance, containment of projected feelings of hatred, impotence, and badness; measured interpretation as well as the development of a sense of creative doubt in the internal perception of the world. The latter requires the empathy with the patient's defensive position.

See also

• Monothematic delusions
• Paranoia
• Systematized delusions

Further reading

• Sims, A. (1995) Symptoms in the mind: An introduction to descriptive psychopathology. Edinburgh: Elsevier Science Ltd. ISBN 0-7020-2627-1.
• American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, (4th ed., text revision). Washington, DC: American Psychiatric Association. ISBN 978-0-89042-024-9

External links

• Mental Health Matters: Delusional Disorder
• Psych Forums: Delusional Disorder Forum