Delusional disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2]

Synonyms and keywords: Apparition; false impression; fantasy; head trip; phantasm; phantom

Overview

Delusional disorder is a psychiatric diagnosis denoting a psychotic mental illness that involves holding one or more non-bizarre delusions in the absence of any other significant psychopathology (signs or symptoms of mental illness). In particular, a person with delusional disorder has never met any other criteria for schizophrenia and does not have any marked hallucinations, although tactile (touch) or olfactory (smell) hallucinations may be present if they are related to the theme of the delusion. Symptoms last at least one month (pg 329: DSM IV-TR, APA 2000) and should pass with group therapy and guidance from a family member or a friend. Someone who suffers momentarily does not hear or see things that are not there but believes in his or her mind that they are invincible or have a defeatus attitude syndrome.

A person with delusional disorder can be quite functional and does not tend to show any odd or bizarre behavior except as a direct result of the delusional belief. "Despite the encapsulation of the delusional system and the realtive sparing of the personality, the patient's way of life is likely to become more and more overwhelmed by the dominating effect of the abnormal beliefs". (Munro, 1999)

It is worth noting that the term paranoia was previously used in psychiatry to denote what is now called 'delusional disorder'. The modern psychiatric use of the word paranoia is subtly different but now rarely refers to this specific diagnosis.

Indicators of a delusion

(Munro, 1999)

1. The patient expresses an idea or belief with unusual persistence or force.
2. That idea appears to exert an undue influence on his or her life, and the way of life is often altered to an inexplicable extent.
3. Despite his profound conviction, there is often a quality of secretiveness or suspicion when the patient is questioned about it.
4. The individual tends to be humorless and oversensitive, especially about the belief.
5. There is a quality of centrality: no matter how unlikely it is that these strange things are happening to him, the patient accepts them relatively unquestioningly.
6. An attempt to contradict the belief is likely to arouse an inappropriately strong emotional reaction, often with irritability and hostility.
7. The belief is, at the least, unlikely.
8. The patient is emotionally over-invested in the idea and it overwhelms other elements of his psyche (psychology).
9. The delusion, if acted out, often leads to behaviors which are abnormal and/or out of character, although perhaps understandable in the light of the delusional beliefs.
10. Individuals who know the patient will observe that his belief and behavior are uncharacteristic and alien.

Features

(Munro, 1999)

1. It is a primary disorder.
2. It is a stable disorder characterized by the presence of delusions to which the patient clings with extraordinary tenacity.
3. The illness is chronic and frequently lifelong.
4. The delusions are logically constructed and internally consistent.
5. The delusions do not interfere with general logical reasoning (although within the delusional system the logic is perverted) and there is usually no general disturbance of behavior. If disturbed behavior does occur, it is directly related to the delusional beliefs.
6. The individual experiences a heightened sense of self-reference. Events which, to others, are insignificant are of enormous significance to him or her, and the atmosphere surrounding the delusions is highly charged.

Types

• Erotomanic Type (see erotomania): delusion that another person, usually of higher status, is in love with the individual.
• Grandiose Type: delusion of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person (e.g. see Jerusalem syndrome)
• Jealous Type: delusion that the individual's sexual partner is unfaithful (see delusional jealousy).
• Persecutory Type: delusion that the person (or someone to whom the person is close) is being malevolently treated in some way.
• Somatic Type: delusions that the person has some physical defect or general medical condition (for example, see delusional parasitosis).

A diagnosis of 'mixed type' or 'unspecified type' may also be given if the delusions fall into several or none of these categories.

Differential Diagnosis

• Obsessive compulsive disorder
• Delirium
• Major neurocognitive disorder
• Psychotic disorder
• Schizophrenia
• Schizophreniform disorder
• Depressive disorder
• Bipolar disorder
• Schizoaffective disorder

Epidemiology and Demographics

Prevalence

The prevalence of delusional disorder is 200 per 100,000 (0.2%) of the overall population.

Risk Factors

• Male gender
• Relatives with schizophrenia
• Relatives with schizotypal personality disorder

Natural History, Complications and Prognosis

Poor prognosis factors are:

• Irritable or dysphoric mood
• Male gender
• Relatives with schizophrenia or schizotypical personality disorder

Diagnosis Criteria

DSM-V Diagnostic Criteria for Dilusional Disorder

“

A. The presence of one (or more) delusions with a duration of 1 month or longer. AND B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation). AND C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd. AND D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. AND E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder. Specify whether: Erotomanie type: This subtype applies when the central theme of the delusion is that another person is in love with the individual. OR Grandiose type: This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery. OR Jealous type: This subtype applies when the central theme of the individual’s delusion is that his or her spouse or lover is unfaithful. OR Persecutory type: This subtype applies when the central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. OR Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations. OR Mixed type: This subtype applies when no one delusional theme predominates. OR Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component). Specify if: With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not understandable, and not derived from ordinary life experiences (e.g., an individual’s belief that a stranger has removed his or her internal organs and replaced them with someone else’s organs without leaving any wounds or scars). Specify if: The following course specifiers are only to be used after a 1-year duration of the disorder: First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled. First episode, currently in partial remission: Partial remission is a time period during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled. First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present. Multiple episodes, currently in acute episode OR Multiple episodes, currently in partial remission OR Multiple episodes, currently in full remission OR Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course. OR Unspecified Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). Note: Diagnosis of delusional disorder can be made without using this severity specifier.

”

Treatment

Getting a patient to seek a mental health professional and getting them to accept treatment is an extremely diificult process. There is no effective insight and because the delusion is held with extrordinary conviction, any attempt at contradiction is met with anger and disdain.

Antipsychotic medication, if the patient will use it, is often ineffective in controling the delusional system.

See also

• Delusion
• Monothematic delusions
• Paranoia
• Psychosis
• Schizophrenia

Further reading

• Munro, A. (1999) Delusional disorder. Cambridge: Cambridge University Press. ISBN 0-521-58180-X
• Sims, A. (1995) Symptoms in the mind: An introduction to descriptive psychopathology. Edinburgh: Elsevier Science Ltd. ISBN 0-7020-2627-1
• APA.(2000) "Diagnostic and Statistical Manual, Fourth Edition, Text Revision". Washington DC: American Psychiatric Association. ISBN 978-0890420249