Delusional disorder medical therapy
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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
Medical Therapy
Treatment Principles of Delusional Disorder include the following: | |||||||||||||||||||
| Establish a therapeutic alliance and negotiate acceptable symptomatic treatment goals. Start where "the patient is at," and offer empathy, concern, and interest in the experiences of the individual | |||||||||||||||||||
| Avoid direct confrontation of the delusional symptoms to enhance the possibility of treatment compliance and response | |||||||||||||||||||
| Consider the impact of culture for treatment planning | |||||||||||||||||||
| Use medication judiciously to target core symptoms and associated problems (eg, anger) | |||||||||||||||||||
| Use outpatient treatment unless there is potential for harm or violence | |||||||||||||||||||
| Tailor treatment strategies to the individual needs of the patient and focus on maintaining social function and improving quality of life | |||||||||||||||||||
| Recognize and treat coexisting psychiatric disorders | |||||||||||||||||||
| Inpatient hospitalization should be considered if a patient’s delusions cause him or her to be a threat to self, others, or if he or she is deemed to be gravely disabled | |||||||||||||||||||
Pharmacotherapy
There are no clinical trials comparing antipsychotic medication with placebo in delusional disorders. Published case reports/series, open trials, and our clinical experience suggest that antipsychotic medications can be effective for delusional disorder.
Treatment of patients with delusional disorder with antipsychotic medication requires careful effort because of the patient’s denial of illness and frequent suspicion of clinician motives for pharmacological intervention. The clinician needs to allay concerns and foster a working alliance with the patient. It is particularly important to provide the patient with information about how the medication would be useful, for what target symptoms, with what possible side effects, and the likely length of treatment.
Even begrudging or halfhearted agreement by the patient to take the medication is an important first step. Patients may need to experience improvement on a medication before expressing some acceptance of the treatment. Side effects are very likely to evoke refusal to continue medication.
An antipsychotic agent with as few side effects as possible (consider aripiprazole or ziprasidone) should be used. Start the medication at a low dose and increase gradually over a several days or weeks to assure tolerability. Once a therapeutic dose is achieved, examine for evidence of response at two weeks before increasing the dose further or changing the medication.
As an example, aripiprazole can be started at 2 to 5 mg/day and increased slowly to 10 mg before looking for clinical response to occur. Once a response is detected, observe for a week or more before further dose adjustments. The pharmacology and side effects of antipsychotic medications are described separately. (See "Second-generation antipsychotic medications: Pharmacology, administration, and side effects" and "First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects" and "Pharmacotherapy for schizophrenia: Side effect management".)
If the patient refuses the antipsychotic medication, or if it is ineffective or poorly tolerated, actions to further enhance the alliance may be helpful. Identifying the symptomatic source of the patient’s distress (eg, anxiety, depression, anger, or perhaps physical discomfort) may provide a critical clue to what will help relieve the patient, particularly when antipsychotic agents are not tolerated (or possibly refused). Making inroads by giving relief to symptoms other than delusions may lead to acceptance of antipsychotic medication.
Psychosocial interventions
As described further in the previous section, any psychiatric treatment of delusional disorder should incorporate psychotherapeutic principles of alliance building, support, education, and recognition of the challenges inherent in treating these patients. For patients who deny that their concerns are delusional, a supportive approach to psychotherapy, with a listening and verbally supportive strategy intended to ease distress, may be helpful. (See "Establishing and maintaining a therapeutic relationship in psychiatric practice".)
There have been no clinical trials of specific psychosocial interventions for delusional disorder. Cognitive-behavioral therapy (CBT), core family therapy, and supportive therapy have been suggested for the disorder [3].
Cognitive-behavioral therapy
CBT has been adapted to treat psychotic disorders, principally schizophrenia. The approach aims to identify and address patient features believed to be associated with delusions, such as data gathering biases, interpersonal sensitivity, reasoning style, worry, and insomnia, factors thought to influence how a delusional patient interprets evidence pertinent to delusions or how he or she considers alternative (nonpsychotic) explanations for the phenomena. Discussion and critique of the patient’s explanations for delusional ideas are practical techniques aimed at breaking down the certitude and emotional underpinnings that maintain the idea. (See "Psychosocial interventions for schizophrenia", section on 'Cognitive behavioral therapy'.)
CBT has not been formally tested in patients with delusional disorders. Case reports and preliminary trials that included patients with delusional disorders have not been sufficient to evaluate CBT’s efficacy [42-45].
Supportive psychotherapy=
In supportive psychotherapy, the clinician attempts to gain insight into the often painful quality of these patients’ experiences with delusional disorder and connect with the patient in such areas with understanding and suggestions aimed at reducing discomfort.
Involuntary treatment
Involuntary treatment with antipsychotic medication may have a role in the treatment of a patient with delusional disorder at serious risk of harming oneself or others. Clinical decisions about involuntary treatment are subject to legal regulations that vary by country and locality.