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). Alcohol and sedatives/hypnotics Alcohol (intoxication or withdrawal), barbiturates and benzodiazepines (particularly withdrawal) Anabolic steroids Testosterone, methyltestosterone Analgesics Meperidine, pentazocine, indomethacin Anticholinergics Atropine, scopolamine Antidepressants Bupropion, others if triggering a manic switch Antiepileptics Zonisamide, other anticonvulsants at high doses Antimalarial Mefloquine, chloroquine Anti-parkinsonian Levodopa, selegiline, amantadine, pramipexole, bromocriptine Antivirals Abacavir, efavirenz, nevirapine, acyclovir Cannabinoids Marijuana, synthetic cannabinoids (ie, "spice"), dronabinol Cardiovascular Digoxin, disopyramide, propafenone, quinidine Corticosteroids Prednisone, dexamethasone, etc Hallucinogens LSD, PCP (phencyclidine), ketamine, psilocybin-containing mushrooms, mescaline, synthetic "designer drugs" (eg, 2-CB, "N-Bomb" [25I-NBOMe]) , salvia divinorum Inhalants Toluene, butane, gasoline Interferons Interferon alfa-2a/2b Over-the-counter (OTC) Dextromethorphan (DXM), diphenhydramine, some decongestants Stimulants Cocaine, amphetamine/methamphetamine, methylphenidate, certain diet pills, "bath salts" (MDPV, mephedrone), MDMA/ecstasy Toxins Carbon monoxide, organophosphates, heavy metals (eg, arsenic, manganese, mercury, thallium)
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