Delusional disorder differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Overview

The differential diagnosis of delusional disorder is highly important because the occurrence of delusional thinking has many sources, mostly secondary to other conditions; cases of primary delusional disorder are uncommon. Hence a practical principle is to detect or rule out other possible, usually more common causes, before arriving at the diagnosis [4,20]. These include:

●Medical conditions (table 1) ●Medications (table 2) ●Substance-induced disorders (table 2) ●Other mental disorders, including schizophrenia and mood disorder The clinical evaluation to rule out other causes of psychosis is described above. (See 'Assessment' above.)

Distinguishing features of delusional disorder include the absence of medical illnesses and medications causing psychosis, presence of delusions for at least one month, the absence of other positive symptoms of psychosis (except for hallucinations that are part of the delusional theme), the absence of functional impairment (except that related to the delusional theme), and the absence of overlap (or overlap of a limited duration) between mood symptoms and the delusions [1]. Schizophrenia typically presents with a broader array of positive and negative symptoms and marked functional impairment for at least six months. In bipolar disorder and major depression with psychotic features, delusional thinking is typically accompanied by mania or depression. An algorithm (algorithm 1) depicts the differential diagnosis of delusional disorder.

The differential diagnosis of psychosis is discussed in greater detail separately.

Delusional symptoms are preferentially associated with disorders involving the limbic system and basal ganglia.[4]

Fifty percent of patients with Huntington disease and individuals with idiopathic basal ganglia calcifications developed delusions at some point of their illness.[4]

Head trauma has been associated with development of delusions. Koponen et al[27] found patients with traumatic brain injury were diagnosed with delusional disorder in 5% of the cases during a 30-year follow-up (3 out of 60 assessed patients).

Medical Conditions	Examples
Neurodegenerative disorders	Alzheimer disease Pick disease Huntington disease Parkinson Disease Basal ganglia calcification (Fahr disease) Multiple sclerosis Metachromatic leukodystrophy
Vascular disease	Atherosclerotic vascular disease, especially when associated with diffuse, temporoparietal, or subcortical lesions Hypertensive encephalopathy Subarachnoid hemorrhage Temporal arteritis
Infectious disease	Human immunodeficiency virus/acquired immune deficiency syndrome (AIDS) Opportunistic infections in AIDS Encephalitis lethargica Creutzfeldt-Jakob disease Syphilis Malaria Acute viral encephalitis
Other CNS disorders	Brain tumors, especially temporal lobe and deep hemispheric tumors Epilepsy, especially complex partial seizure disorder Head trauma (subdural hematoma) Anoxic brain injury Fat embolism
Vitamin deficiences	Vitamin B-12 deficiency Folate deficiency Thiamine deficiency Niacin deficiency
Metabolic disorder	Hypercalcemia Hyponatremia Hypoglycemia Uremia Hepatic encephalopathy Porphyria
Endocrinopathies	Addison disease Cushing syndrome Hyperthyroidism or hypothyroidism Panhypopituitarism
Medications	Adrenocorticotropic hormones Anabolic steroids Corticosteroids Cimetidine Antibiotics (eg, cephalosporins, penicillin), disulfiram, anticholinergic agents
Toxins	Mercury Arsenic Manganese Thallium
Medications	Substances Amphetamines Cocaine, Alcohol Cannabis Hallucinogens
Medications	Adrenocorticotropic hormones Anabolic steroids Corticosteroids Cimetidine Antibiotics (eg, cephalosporins, penicillin), disulfiram, anticholinergic agents