| Delusional disorder | |
|---|---|
| Classification and external resources | |
| ICD-10 | F22.0 |
| ICD-9 | 297.1 |
| eMedicine | article/292991 |
| MeSH | D010259 |
Delusional disorder is an uncommon psychiatric condition in which patients present with circumscribed symptoms of non-bizarre delusions, but with the absence of prominent hallucinations and no thought disorder, mood disorder, or significant flattening of affect.[1] 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.[2]
To be diagnosed with delusional disorder, the delusion or 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 diagnosed with schizophrenia. A person with delusional disorder may be high functioning in daily life and may not exhibit odd or bizarre behavior aside from these delusions. The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines six subtypes of the disorder characterized as erotomanic (believes that someone famous is in love with him/her), grandiose (believes that he/she is the greatest, strongest, fastest, richest, and/or most intelligent person ever), jealous (believes that the love partner is cheating on him/her), persecutory (believes that someone is following him/her to do some harm in some way), somatic (believes that he/she has a disease or medical condition), and mixed, i.e., having features of more than one subtypes.[2] Delusions also occur as symptoms of many other mental disorders, especially the other psychotic disorders.
The DSM-IV, and psychologists, generally agree that personal beliefs should be evaluated with great respect to complexity of cultural and religious differences since some cultures have widely accepted beliefs that may be considered delusional in other cultures.[3]
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The following can indicate a delusion:[4]
The following features are found:[4]
Diagnosis of a specific type of delusional disorder can sometimes be made based on the content of the delusions. The Diagnostic and Statistical Manual of Mental Disorders (DSM) enumerates six types:
(Lippincott, 2008).[5]
A 40 year old woman lost a significant amount of weight over the course of 2 years. She originally weighed 60kg. She dropped down to 29kg body weight, which can be unhealthy and potentially life threatening. Initially the doctors diagnosed her with anorexia nervosa, as she was malnutritioned due to her undereating. A further examination of the patient revealed that she was delusional and convinced that eating food would harm her body. Thus, she decided to stop eating. The doctors decided that she didn't suffer from anorexia nervosa, but rather a somatic delusion disorder. She was later treated and the doctors were able to help her get back to a healthy weight. [6]
When delusional disorders occur late in life they suggest a hereditary predisposition. Researchers also suggest that these disorders are the result of early childhood experiences with an authoritarian family structure. According to other researchers, any person with a sensitive personality is particularly vulnerable to developing a delusional disorder.[7]
Although its exact cause is unknown, it is believed that genetic, biochemical and environmental factors play a significant role in the development of delusional disorder.[8]
The symptoms expressed by a delusional disorder can also be part of a much more serious problem, such as bipolar disorder or schizophrenia, therefore diagnosing the delusional disorder is conducted partially by process of elimination. This occurs because delusions can be part of many other illnesses including dementia, schizophrenia and schizoaffective disorder. They may also be part of a response to physical, medical conditions, or reactions when drugs are ingested.[9]
Interviews are useful tools to obtain information about the patient's life situation and past history to help identifying the delusional disorder. Clinicians may review earlier medical records, with the patient's permission. Clinicians also interview the patient's immediate family. This is a very helpful measure in determining the presence of delusions. The mental status examination is used to assess the patient's memory, concentration, and understanding the individual's situation and logical thinking.[9]
Another psychological test used in the diagnosis of the delusional disorder is the Peters Delusion Inventory (PDI) which focuses on identifying and understanding delusional thinking. However, this test is more likely used in research than in clinical practice.[9]
Treatment of delusional disorders includes a combination of drug therapy and psychotherapy although it is a challenging disorder to treat for many reasons such as the patient's denial that they have a problem of a psychological nature.
Atypical antipsychotic medications (also known as novel or newer-generation) are used in the treatment of delusional disorder as well as in schizophrenic disorders. Some examples of such medications are risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa). These medications work by blocking postsynaptic dopamine receptors and reduce the incidence of psychotic symptoms including hallucinations and delusions. They also relieve anxiety and agitation. When these drugs are tried but the symptoms do not improve, other types of antipsychotics may be prescribed. Some examples are: fluphenazine decanoate and fluphenazine enanthate. One very effective drug in delusional disorders is also pimozide.[10]
In some cases agitation may occur as a response to severe or harsh confrontation when dealing with the existence of the delusions.[11] If agitation occurs, different antipsychotics can be administered to conclude its outbreak. For instance, an injection of haloperidol (Haldol) can decrease anxiety and slow behavior, it is often combined with medications including lorazepam (Ativan).
In cases when severely ill patients do not respond to standard treatment, Clozapine may be prescribed although it may cause drowsiness, sedation, excessive salivation, tachycardia, dizziness, seizures and agranulocytosis.[11]
To treat long term symptoms, an oral novel antipsychotic is often prescribed on a daily basis. Antidepressants and anxiolytics are also prescribed to control associated symptoms.[10]
Psychotherapy for patients with delusional disorder include cognitive therapy which is conducted with the use of empathy. During the process, the therapist asks hypothetical questions in a form of therapeutic Socratic dialogue.[11] 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. [12] The therapist is there for support and must not show any signs that implicate that the patient is mentally ill. [13]
Supportive therapy has also 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 applicable to a high number of persons. It should focus on promoting interpersonal competence as well as confidence and comfort when interacting with those individuals perceived as a threat.[14]
Reports have shown successful use of insight-oriented therapy although it may also be contraindicated for delusional disorder. Its goals are to develop therapeutic alliance, containment of projected feelings of hatred, impotence, 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 the empathy with the patient's defensive position.[14]
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