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 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.[1][2] These include the following:

  • Substrate deficiency
  • Neurodegenerative disorders
  • Vascular disease
  • Other CNS disorders
  • Infectious diseases
  • Vitamin deficiences
  • Metabolic disorders
  • Endocrinopathies
  • Medications
  • Toxins
  • Substances
  • Other mental disorders, including schizophrenia and mood disorder

Medical conditions associated with development of delusions is shown below in a tabular form:[3]

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.

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. Manschreck TC, Petri M (1978). "The paranoid syndrome". Lancet. 2 (8083): 251–3. PMID 79043.
  3. 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.