Delusional disorder


Delusional disorder is a mental disorder in which a person has delusions, but with no accompanying prominent hallucinations, thought disorder, mood disorder, or significant flattening of affect. Delusions are a specific symptom of psychosis. Delusions can be bizarre or non-bizarre in content; non-bizarre delusions are fixed false beliefs that involve situations that could occur in real life, such as being harmed or poisoned. Apart from their delusion or delusions, people with delusional disorder may continue to socialize and function in a normal manner and their behavior may not necessarily seem odd. However, the preoccupation with delusional ideas can be disruptive to their overall lives.
For the diagnosis to be made, auditory and visual hallucinations cannot be prominent, though olfactory or tactile hallucinations related to the content of the delusion may be present. The delusions cannot be due to the effects of a drug, medication, or general medical condition, and delusional disorder cannot be diagnosed in an individual previously properly diagnosed with schizophrenia. A person with delusional disorder may be high-functioning in daily life as measured, for example, by the Global Assessment of Functioning. Recent and comprehensive meta-analyses of scientific studies point to an association with a deterioration in aspects of IQ in psychotic patients, in particular, perceptual reasoning, although the between-group differences were small.
According to German psychiatrist Emil Kraepelin, patients with delusional disorder remain coherent, sensible, and reasonable. The Diagnostic and Statistical Manual of Mental Disorders defines six subtypes of the disorder: erotomanic, grandiose, jealous, persecutory, somatic, and mixed. Delusions also occur as symptoms of many other mental disorders, especially the other psychotic disorders.
The DSM-IV and psychologists agree that personal beliefs should be evaluated with great respect to cultural and religious differences, as some cultures have normalized beliefs that may be considered delusional in other cultures.
An earlier, now-obsolete, nosological name for delusional disorder was "paranoia". This should not be confused with the modern definition of paranoia.

Classification

The International Classification of Diseases classifies delusional disorder as a mental and behavioural disorder.
Diagnosis of a specific type of delusional disorder can sometimes be made based on the content of the delusions, to wit, the Diagnostic and Statistical Manual of Mental Disorders enumerates seven types:
  • Erotomanic type : delusion that another person, often a prominent figure, is in love with the individual. The individual may breach the law as they try to obsessively make contact with the desired person.
  • Grandiose type : delusion of inflated worth, power, knowledge, identity or believing oneself to be a famous person, claiming the actual person is an impostor or an impersonator.
  • Jealous type: delusion that the individual's sexual partner is unfaithful when it is untrue. The patient may follow the partner, check text messages, emails, phone calls etc. in an attempt to find "evidence" of the infidelity.
  • Persecutory type: This delusion is a common subtype. It includes the belief that the person is being malevolently treated in some way. The patient may believe that they have been drugged, spied upon, harmed, harassed and so on and may seek "justice" by making reports, taking action or even acting violently.
  • Somatic type: delusions that the person has some physical defect or general medical condition
  • Mixed type: delusions with characteristics of more than one of the above types but with no one theme predominating.
  • Unspecified type: delusions that cannot be clearly determined or characterized in any of the categories in the specific types.

    Signs and symptoms

The following can indicate a delusion:
  1. An individual expresses an idea or belief with unusual persistence or force, even when evidence suggests the contrary.
  2. That idea appears to have an undue influence on the person's life, and the way of life is often altered to an inexplicable extent.
  3. Despite their profound conviction, there is often a quality of secretiveness or suspicion when the person 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 the person, they accept them relatively unquestioningly.
  6. An attempt to contradict the belief is likely to arouse an inappropriately strong emotional reaction, often with irritability and hostility. They will not accept any other opinions.
  7. The belief is, at the least, unlikely, and out of keeping with the individual's social, cultural, and religious background.
  8. The person is emotionally over-invested in the idea and it overwhelms other elements of their psyche.
  9. The delusion, if acted out, often leads to behaviors which are abnormal, and out of character, although perhaps understandable in light of the delusional beliefs.
  10. Other people who know the individual observe that the belief and behavior are uncharacteristic and alien.
Additional characteristic of delusional disorder include the following:
  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 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 nonsignificant are of enormous significance to them, and the atmosphere surrounding the delusions is highly charged.
However, this should not be confused with gaslighting, where a person denies the truth, and causes the one being gaslit to think that they are being delusional.

Causes

The cause of delusional disorder is unknown, but genetic, biochemical, and environmental factors may play a significant role in its development. Some people with delusional disorders may have an imbalance in neurotransmitters, the chemicals that send and receive messages to the brain. There does seem to be some familial component, and immigration, drug abuse, excessive stress, being married, being employed, low socioeconomic status, celibacy among men, and widowhood among women may also be risk factors. Delusional disorder is currently thought to be on the same spectrum or dimension as schizophrenia, but people with delusional disorder, in general, may have less symptomatology and functional disability.

Diagnosis

includes ruling out other causes such as drug-induced conditions, dementia, infections, metabolic disorders, and endocrine disorders. Other psychiatric disorders must then be ruled out. In delusional disorder, mood symptoms tend to be brief or absent, and unlike schizophrenia, delusions are non-bizarre and hallucinations are minimal or absent.
Interviews are important tools to obtain information about the patient's life situation and history to help make a diagnosis. Clinicians generally review earlier medical records to gather a full history. Clinicians also try to interview the patient's immediate family, as this can be helpful in determining the presence of delusions. The mental status examination is used to assess the patient's current mental condition.
A psychological questionnaire used in the diagnosis of the delusional disorder is the Peters Delusion Inventory which focuses on identifying and understanding delusional thinking. However, this questionnaire is more likely used in research than in clinical practice.
In terms of diagnosing a non-bizarre delusion as a delusion, ample support should be provided through fact checking. In case of non-bizarre delusions, Psych Central notes, "All of these situations could be true or possible, but the person suffering from this disorder knows them not to be."

Treatment

A challenge in the treatment of delusional disorders is that most patients have limited insight, and do not acknowledge that there is a problem. Most patients are treated as out-patients, although hospitalization may be required in some cases if there is a risk of harm to self or others. Individual psychotherapy is recommended rather than group psychotherapy, as patients are often quite suspicious and sensitive. Antipsychotics are not well tested in delusional disorder, but they do not seem to work very well, and often have no effect on the core delusional belief. Antipsychotics may be more useful in managing agitation that can accompany delusional disorder. Until further evidence is found, it seems reasonable to offer treatments which have efficacy in other psychotic disorders.
There is a certain amount of evidence that alternative treatment-regimes may include clomipramine for people with the somatic subtype of paranoia. There is a dearth of well-published studies investigating the effectiveness of trimipramine; another derivative of tricyclic-antidepressant imipramine and one which has modest anti-psychotic properties weakly analogous to those of clozapine; in delusional disorder per-se. However, trimipramine was compared to a combination of amitriptyline and haloperidol in a double-blinded trial involving patients with severe, psychotic depression and appeared favourable in its treatment.
Psychotherapy for patients with delusional disorder can include cognitive therapy which is conducted with the use of empathy. During the process, the therapist can ask hypothetical questions in a form of therapeutic Socratic questioning. This therapy has been mostly studied in patients with the persecutory type. The combination of pharmacotherapy with cognitive therapy integrates treating the possible underlying biological problems and decreasing the symptoms with psychotherapy as well. Psychotherapy has been said to be the most useful form of treatment because of the trust formed in a patient and therapist relationship.
Supportive therapy has also been shown to be helpful. Its goal is to facilitate treatment adherence and provide education about the illness and its treatment.
Furthermore, providing social skills training has been found to be helpful for many people. It can promote interpersonal competence as well as confidence and comfort when interacting with those individuals perceived as a threat.
Insight-oriented therapy is rarely indicated or contraindicated; yet there are reports of successful treatment. Its goals are to develop therapeutic alliance, containment of projected feelings of hatred, powerlessness, and badness; measured interpretation as well as the development of a sense of creative doubt in the internal perception of the world. The latter requires empathy with the patient's defensive position.