How to Recognize Delusional Disorder

In my previous posts, readers learned about delusions both as a symptom and as a condition called delusional disorder. The latter is marked by the presence of delusions in the absence of other significant pathology. It may be difficult to recognize because the delusions are very often believable, such as being cheated on, or some type of persecution. Additionally, the delusions usually don't entirely disrupt the person's ability to function well, making any observable struggles that would lead one to think "this person needs help" almost non-existent

Source: Cody Doherty/unsplash

Sometimes, however, as you get to know someone, it is clear that behind the scenes there is an alternate reality. One of the more detailed examples of this is journalist Pauline Dakin's book, Run, Hide, Repeat: A Memoir of a Fugitive Childhood. This book is made more interesting in that it is a very rare, inside-out view of shared psychotic disorder, or folie à deux.

Folie à deux is a condition whereby one person's delusion becomes believed by one or more others. For example, one person in a couple believes an ex-lover is stalking them. Eventually, they tell their current partner about the matter in order to try to keep them safe, and the current lover follows suit with similar paranoia about being a target because the jealous ex allegedly has a vendetta.

The Relative Normalcy of Delusional Disorder

Mark Cunningham, Ph.D., is a forensic psychologist who also writes and on the topic of detecting delusions. Interestingly, Dr. Cunningham (2018) noted that historical psychiatrist Emil Kraepalin explained the delusions comprising the disorder, "...were largely confined to 'diseased' interpretations of real events." Cunnigham finished by citing Munro (1995), who noted:

"Perhaps the most unique feature of the delusional disorder is the way in which a patient can move between delusional and normal 'modes.' In the former, the individual is overalerted, preoccupied with the delusional theme, and often driven remorselessly by it. In sharp contract, the normal has relatively calm mood, neutral conversation, and some ability to pursue everyday activities. The contrast is striking and often difficult for the lay person to understand."

It is this relative normalcy, this encapsulated madness of sorts, that rendered it early on to be called "partial insanity." Most often, our predecessors noted, delusional material was witnessed in dementia and dementia praecox, an outdated term for schizophrenia, where patients globally deteriorated. Those whose delusions existed in a vacuum, however, experienced an encapsulated insanity, in that the pathology was related to one very specific belief while the rest of their life was intact. (An excellent account of the idea of partial insanity can be found in an article by Eigen [1991] entitled "Delusion in the Courtroom: The Role of partial Insanity in the Early Forensic Testimony.")

Detecting Delusional Disorder

In other psychotic disorders, delusions are often easily detectable in that they are bizarre, extremely grandiose, or come on fast along with other psychotic symptoms, so observers know it is part of an illness episode.

To expand on the historical descriptions, in delusional disorder, the onset of the delusion is often insidious, and the person remains relatively high-functioning, with nothing to give away their brewing alternate reality. If there are clues, they may just seem like quirks to others. For example, a young man becomes convinced a female celebrity he briefly crossed paths with is in love with him, and they could be together if only he could regain her attention and she could leave her husband. Months later, he may still seem smitten and star-struck, which can appear entirely normal for a young man after an encounter with someone famous and gorgeous.

Behind the scenes, though, is a secret world of writing pining "remember me?" love letters addressed to fan clubs in the hopes of forwarding. He spends hours researching media to discover her itineraries and habits to try to arrange another encounter. Others must not know about this for fear of being discouraged and being told it'll never happen; they just don't understand the connection he felt and that his mission must persist in the name of an everlasting, perfect romance.

Clearly, then, it may be difficult to detect delusional disorder. It seems it is often more of a forensic topic, given radicalization of extreme beliefs must be differentiated from actual delusions in the legal arena, than anything one may encounter in a treatment setting.

That is, unless the delusions become pervasive enough to render one hospitalized, such as mounting, crippling paranoia about, say, the mafia following someone in the absence of any personal or family history of organized crime involvement. Here, it is easy for those close to the person to recognize the serious out-of-touch thinking and see the fallout that requires intervention—if, for example, the person all of a sudden arms themselves and tries to convince people associated with them that they could be marked, too.

Psychosis Essential Reads

Cat Ownership and Schizophrenia: A New Perspective

Schizophrenia and Its Many Consequences

If Delusional Disorder is Suspected

First, it must be ruled out that any other significant psychotic pathology is not present. Second, it needs to be clear that the delusion isn't accounted for by another condition that harbors psychotic features, as discussed in "How to Recognize the Different Psychotic Disorders."

Next, it's essential to learn more about the material. It must be understood that a delusion is held with such conviction that it is the person's reality. Therefore, aggressively challenging the material will likely be met with poor results, especially if the person's delusions are persecutory. Rather, it is a good idea to show interest in understanding the person's struggle, whether or not it seems real to you. The material provided can help rule in or out that it is delusional.

It is not unusual that a delusional person will unravel about the topic upon interview, and the material may be hard to follow, irrational, or riddled with misconceptions. For example, say the young man fixated on the female celebrity is arrested for harassing her. When talking about the matter with a forensic psychologist, he asks, "If she wasn't interested in me, why was she so flirty? I mean, she winked at me and said, 'It was so nice meeting a like-minded person.'" He then goes on to explain that the hundreds of letters were justified because he had to let her know he was still waiting for her once she was able to rid herself of her husband.

Source: Cottonbro/Pexels

Treatment for Delusional Disorder

It must be considered that delusions often are rooted in some type of reality, those "diseased interpretations of real events" as Kraepalin put it. Aside from the use of antipsychotic medications, which have been found to be helpful in managing the condition (e.g., Manschreck and Kahn, 2006; Muniz-Negro et al., 2020), uncovering the evolution of the delusion is often helpful, and the input of friends and family can be indispensable. More often than not, it will be discovered that the delusion doesn't "just happen." Rather, it is often either compensatory, such as in someone with grandiose delusions, or, as in the example below, defensive.

To conclude, the following example, which I believe was documented by Freud, can illustrate the delusional dynamic stemming from an existential conflict:

Over several months, an ill man became increasingly resistant about visiting his physician, who was a male. Eventually, he revealed malignant paranoia in that he confessed he feared the doctor was hypersexual, homosexual, and wanted to rape him if given the chance. Upon referral to a psychiatrist, it eventually surfaced that the patient was attracted to his physician. The paranoia evolved as a denial defense about his own homosexuality and interest in sexual relations with the doctor.

With such a case, treatment understandably focuses on the conflict contributing to the paranoia.

Those interested in learning more about the etiology and the delusional/paranoid process to better work with such patients are invited to read Ronald Seigel's Whispers: The Voices of Paranoia, and the works of Theodore Manschrek, M.D.