Delusional Disorder

Definition

Delusional disorder refers to a condition associated with one or more nonbizarre delusions of thinking—such as expressing beliefs that occur in real life such as being poisoned, being stalked, being loved or deceived, or having an illness, provided no other symptoms of schizophrenia are exhibited.

Delusions may seem believable at face value, and patients may appear normal as long as an outsider does not touch upon their delusional themes. Mood episodes are relatively brief compared with the total duration of the delusional periods. Also, these delusions are not due to a medical condition or substance abuse.

Themes of delusions may fall into the following types: erotomanic type (patient believes that a person, usually of higher social standing, is in love with the individual); grandiose type (patient believes that he has some great but unrecognized talent or insight, a special identity, knowledge, power, self-worth, or special relationship with someone famous or with God); jealous type (patient believes his partner has been unfaithful); persecutory type (patient believes he is being cheated, spied on, drugged, followed, slandered, or somehow mistreated); somatic type (patient believes he is experiencing physical sensations or bodily dysfunctions—such as foul odors or insects crawling on or under the skin—or is suffering from a general medical condition or defect); mixed type (characteristics of more than one of the above types, but no one theme dominates); or unspecified type (patient's delusions do not fall in described categories).

Symptoms

  • Nonbizarre delusions—delusional thoughts reflecting situations that occur in real life—with duration of one month or longer
  • Other symptoms of schizophrenia have never been met, except tactile and olfactory delusions may be present if consistent with delusional themes
  • Functioning and behavior are not markedly impaired, nor odd or bizarre, aside from delusions
  • Duration of any mood symptoms accompanying delusional symptoms has been brief in comparison to duration of delusions
  • Disorder is not caused directly by use of substances or medical condition
  • Onset can vary from adolescence to late adulthood but tends to appear later in life (This disorder is quite uncommon)

Causes

There are a variety of associated features to the delusional disorder including the development of an irritable or gloomy mood as a reaction to their delusional beliefs. Especially with persecutory and jealous types, marked anger and violent behavior can occur. Hearing deficiency or severe stressors—such as low socioeconomic status—may predispose a person to some types of delusional disorder such as the paranoid type. Legal difficulties or engaging in litigious behavior can occur in the jealous type or erotomanic types. Subjecting oneself to unnecessary medical tests and procedures may be associated with the somatic type.

Treatments

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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Sources

  • National Institutes of Health
  • American Psychiatric Association
  • Fochtmann LJ. Treatment of other psychotic disorders. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 8th ed
  • Guryanova, I., Smith, E. G. & Toricelli, M. Delusional Disorder
  • Hayashi H, Oshino S, Ishikawa J. Human Psychopharmacology
  • Manschreck TC. Delusional and Shared Psychotic Disorder. Kaplan & Sadock's Comprehensive Textbook of Psychiatry 7th ed
  • Munro A. Delusional disorder: paranoia and related illness
  • Silva SP, Kim CK, Hofmann SG, Loula EC. Harvard Review of Psychiatry
  • Sondheimer A. Journal of American Academy Child Adolescent Psychiatry
  • Turkington D, Kington D, Weiden P. Cognitive-behaviour therapy for schizophrenia: a review. Current Opinions Psychiatry. 2005; 18(2):159-63.
  • Wada T, Kawakatsu S, Nadaoka T. International Clinical Psychopharmacology
Last reviewed 02/17/2015