Delusional disorder is challenging to treat for various reasons, including patients' frequent denial that they have any problem, especially of a psychological nature, difficulties in developing a therapeutic alliance, and social or interpersonal conflicts.
Careful assessment and diagnosis are crucial because delusions commonly represent an underlying organic illness that warrants specific treatment. Additionally, coexisting psychiatric disorders should be recognized and treated accordingly.
Treatment of delusional disorder often involves both psychopharmacology and psychotherapy. Given the chronic nature of this condition, treatment strategies should be tailored to the individual needs of the patient and focus on maintaining social function and improving quality of life. Establishing a therapeutic alliance as well as acceptable symptomatic treatment goals, and educating the patient's family are of paramount importance. Avoiding direct confrontation of the delusional symptoms enhances the possibility of treatment compliance and response. Hospitalization should be considered if a potential for harm or violence exists. Otherwise, outpatient treatment is preferred.
In general, delusional disorders were reported to be fairly responsive to treatment. Use of multiple medications was common, most often including a combination of antipsychotic and antidepressant medication. In addition, patients commonly received more than one antipsychotic over the course of their illness, and medication treatments were also complemented by other interventions, such as cognitive-behavioral therapy.
In addition, no difference was observed between typical and atypical antipsychotic agents. Research has identified that somatic delusions appeared potentially more responsive to antipsychotic therapy than other types of delusions. Early research has indicated that individuals with delusions presumably resistant to previous antipsychotic treatment now demonstrate the effects of clozapine on an improved quality of life and a decrease in symptoms associated with the delusion, although the central delusional theme often persisted.
Antidepressants, such as SSRI and clomipramine, have been successfully used for the treatment of delusional disorder, although primarily of the somatic type.
For most patients with delusional disorder, some form of supportive therapy is helpful. The goals of supportive therapy include facilitating treatment adherence and providing education about the illness and its treatment. Educational and social interventions can include social-skills training (such as not discussing delusional beliefs in social settings) and minimizing risk factors, including sensory impairment, isolation, stress, and precipitants of violence. Providing realistic guidance and assistance in dealing with problems stemming from the delusional system may be very helpful.
Cognitive therapeutic approaches may be useful for some patients. The therapist helps the patient to identify maladaptive thoughts by means of interactive questioning and behavioral experiments, and then to replace them with alternative, more adaptive beliefs and attributions. Discussion of the unrealistic nature of delusional beliefs should be done gently and only after rapport with the patient has been established.
Some controversy exists around insight-oriented therapy where some researchers believe that this type of treatment is rarely indicated and others even contraindicated. However, reports exist of successful treatment. Goals for insight-oriented therapy include development of the therapeutic alliance; containing projected feelings of hatred, badness, and impotence; measured interpretation; and, ultimately, developing a sense of creative doubt in the internal perception of the world through empathy with the patient's defensive position.
In addition to involvement with seeking help, family, friends, and peer groups can provide support and encourage the patient to regain his or her abilities. It is important that goals be attainable, since a patient who feels pressured or repeatedly criticized by others will probably experience stress that may lead to a worsening of symptoms. A positive approach may be helpful—and perhaps more effective in the long run than criticism. This advice applies to everyone who interacts with the person.
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Delusional Disorder. Last reviewed 07/01/2008
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