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

Delusional disorder must be differentiated from other diseases that cause delusions, such as substrate deficiency, neurodegenerative disorders, vascular disease, other CNS disorders, infectious diseases, vitamin deficiencies, metabolic disorders, endocrinopathies, medications, toxins, substances, and other mental disorders such as schizophrenia and mood disorders.[1][2][3]

Differential Diagnosis

The cases of primary delusional disorder are uncommon. The occurrence of delusional thinking has many sources, mostly secondary to other conditions. Hence a practical principle is to detect or rule out other possible, usually more common causes of delusions, before arriving at the diagnosis.[4][2] These include the following:

Medical conditions associated with development of delusions is shown below in a tabular form:[5]

Medical Conditions Examples
Substrate deficiency
  • Hypoglycemia*
  • Cerebral hypoxia* causes of cerebral hypoxia include cardiac insufficiency, pulmonary insufficiency, and severe anemia.
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, temporal lobe epilepsy
  • Stroke*
  • Brain abscess*
  • CNS infection (meningitis, encephalitis)*
  • Interictal psychosis
  • Head trauma (subdural hematoma)*
  • Anoxic brain injury
  • Fat embolism
  • Brain abscess*
  • Landau Kleffner syndrome
  • SSPE*
Vitamin deficiences
  • Vitamin B-12 deficiency
  • Folate deficiency
  • Thiamine deficiency
  • Niacin deficiency
Metabolic disorder
  • Hypercalcemia
  • Hyponatremia
  • Hypoglycemia
  • Uremia
  • Hepatic encephalopathy
  • Porphyria
  • Electrolyte disturbance*Δ
  • Hepatic failure*
  • Postpartum psychosis*
  • Electrolyte disturbance*Δ
Endocrinopathies
  • Addison disease
  • Cushing syndrome
  • Hyperthyroidism or hypothyroidism
  • Panhypopituitarism
  • Hashimoto thyroiditis (Hashimoto encephalopathy)
  • Thyroid storm*
  • Antiphospholipid syndrome
  • Hashimoto thyroiditis (Hashimoto encephalopathy)
Medications
  • Analgesics such as meperidine, pentazocine, indomethacin
  • Adrenocorticotropic hormones
  • Anabolic steroids such as testosterone, methyltestosterone
  • Anticholinergics such as atropine, scopolamine
  • Antidepressants such as bupropion, others if triggering a manic switch
  • Antiepileptics such as zonisamide, other anticonvulsants at high doses
  • antimalarial such as mefloquine, chloroquine
  • Anti-parkinsonian drugs such as levodopa, selegiline, amantadine, pramipexole, bromocriptine
  • Antivirals such as abacavir, efavirenz, nevirapine, acyclovir
  • Cardiovascular drugs such as digoxin, disopyramide, propafenone, quinidine
  • Corticosteroids such as prednisone, dexamethasone, etc
  • Inhalants such as toluene, butane, gasoline
  • Interferons such as interferon alfa-2a/2b
  • Over-the-counter (OTC) such as dextromethorphan (DXM), diphenhydramine, some decongestants
  • Cimetidine
  • Antibiotics (eg, cephalosporins, penicillin), disulfiram
Toxins
  • Carbon monoxide
  • Organophosphates
  • Heavy metals (eg, arsenic, manganese, mercury, thallium)
Other

Systemic lupus erythematosus

Substances
  • Amphetamines
  • Cannabinoids such as marijuana, synthetic cannabinoids (ie, "spice"), dronabinol
  • Alcohol and sedatives/hypnotics such as alcohol (intoxication or withdrawal), barbiturates and benzodiazepines (particularly withdrawal)
  • Cannabis
  • Stimulants such as cocaine, amphetamine/methamphetamine, methylphenidate, certain diet pills, "bath salts" (MDPV, mephedrone), MDMA/ecstasy
  • Hallucinogens such as LSD, PCP (phencyclidine), ketamine, psilocybin-containing mushrooms, mescaline, synthetic "designer drugs" (eg, 2-CB, "N-Bomb" [25I-NBOMe]) , salvia divinorum

CNS: central nervous syndrome; SSPE: subacute sclerosing panencephalitis; SLE: systemic lupus erythematosus.

  • Life-threatening.

Δ Acute psychosis may be seen with hypocalcemia and hypomagnesemia. Hypo- or hypernatremia may cause encephalopathy with delirium.

  • Differential Diagnoses for delusional disorder (Adapted from Manschreck, 1996) [6]
Disorder Delusions Hallucinations Awareness Other features
Delusional disorder Present Occasional Alert Relatively free of psychopathology
Psychotic disorder due to a general medical condition, with delusion Present Present May be impaired Cognitive changes; perceptual changes;substance abuse history; impairment of functioning frequent
Substance-induced psychotic disorder Present (can be bizarre) Present Acute:impaired,Chronic:may be alert History of substance abuse; impaired functioning likely
Schizophrenia Present (bizarre) Present Alert Emotional changes, pervasive thought disorder; role impairment
Major depressive episode Present (usually mood congruent) May or may not present Alert Concerted changes in mood and neurovegetative features
Manic Episode Present (usually mood congruent) May or may not present Alert Concerted changes in mood, decreased need for sleep, energy, lack of inhibition
Obsessive–Compulsive disorder Not present Not present Alert Not psychotic; impaired functioning likely
Personality disorder Not present Not present Alert Not psychotic
Somatoform disorder Not present Not present Alert Not psychotic
Shared psychotic disorder Present Not present Alert Close associate has same delusions

References

  1. Sadock, Benjamin J., Harold I. Kaplan, and Virginia A. Sadock. Kaplan & Sadock's synopsis of psychiatry : behavioral sciences/clinical psychiatry. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins, 2007. Print.
  2. 2.0 2.1 Manschreck TC, Petri M (1978). "The paranoid syndrome". Lancet. 2 (8083): 251–3. PMID 79043.
  3. Manschreck, THEO C. "Delusional disorder and shared psychotic disorder." Comprehensive textbook of psychiatry 1 (2000): 1243-64.
  4. Sadock, Benjamin J., Harold I. Kaplan, and Virginia A. Sadock. Kaplan & Sadock's synopsis of psychiatry : behavioral sciences/clinical psychiatry. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins, 2007. Print.
  5. Sadock, Benjamin J., Harold I. Kaplan, and Virginia A. Sadock. Kaplan & Sadock's synopsis of psychiatry : behavioral sciences/clinical psychiatry. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins, 2007. Print.
  6. Manschreck, THEO C. "Delusional disorder and shared psychotic disorder." Comprehensive textbook of psychiatry 1 (2000): 1243-64.


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