Delusional disorder

Psychiatric Disorder

1. DELUSIONAL DISORDER BY Dr. Nitin Choubey

2. CONTENT Definition Epidemiology Etiology Clinical features Differentials Course and Prognosis Treatment

3. Persistent Delusional Disorder This group includes a variety of disorders in which long-standing delusions constitute the only, or the most conspicuous, clinical characteristic and which cannot be classified as organic, schizophrenic, or affective. Delusional Disorder Other persistent delusions Persistent delusional disorder, unspecified ( ICD 10)

4. Definition A false unshakable belief, that is out of keeping with patients social and cultural background. F ish’s clinical psychopathology

5. DELUSION IS DEFINED AS A (1) FALSE BELIEF BASED ON INCORRECT INFERENCE ABOUT EXTERNAL REALITY , ( 2) FIRMLY HELD DESPITE OBJECTIVE & OBVIOUS CONTRADICTORY PROOF OR EVIDENCE. (3) DESPITE THE FACT THAT OTHER MEMBERS OF THE CULTURE DO NOT SHARE THE BELIEF . (CTP)

6. ICD 10 DEFINITION Delusional disorder A group of disorder characterized by the development either of a single delusion or of a set of related delusions which are usually persistent and sometimes lifelong . (ICD 10)

7. EPIDEMIOLOGY An accurate assessment of the epidemiology of delusional disorder is hampered by the relative rareness of the disorder, as well as by its changing definitions in recent history. Moreover, delusional disorder may be underreported because delusional patients rarely seek psychiatric help unless forced to do so by their families or by the courts. (Kaplan synopsis 11 th )

8. Epidemiology The lifetime prevalence of delusional disorder has been estimated at around 0.2%, and the most frequent subtype is persecutory. Delusional disorder, jealous type, is probably more common in males than in females, but there are no major gender differences in the overall frequency of delusional disorder. (DSM5)

9. Epidemiology The overall prevalence of delusional disorder is slightly higher among women than among men. A nd the average age of onset is earlier for men (40 to 49 yrs ) than for women (60 to 69 yrs ). Delusional disorder usually first appears in middle to late adulthood and the socio demographic profile is similar across the cultures

10. ETIOLOGY Etiology : The cause remains unknown. • Biological theories • Psychological theories • Psychosocial theories (Pubmed.com) (Kaplan Synopsis)

11. A. BIOLOGICAL THEORIES 1. Pathology: Cummings et al Involvement of limbic system and basalganglia ( dopamine hyperactivity), have been seen, in those diagnosed with delusional disorder. The clinical efficacy of antipsychotics in acutely psychotic patients with delusional and hallucinatory syndromes is an argument in favour of the hypothesis of dopaminergic hyperactivity in mesolimbic and mesocortical circuits, since these agents have in common their dopamine antagonistic properties. 2 . Biochemistry: Cummings et al Excessive dopaminergic activity or reduced cholinergic activity.

12. 3. Genetics: The HLA-A*03 gene is significantly associated with delusional disorder . The most convincing data come from family studies that reports an increased prevalence of delusional disorder and related personality traits (e.g., suspiciousness, jealousy, and secretiveness) in the relatives of delusional disorder probands .

13. B. PSYCHOSOCIAL THEORIES 1 . Childhood experiences and losses Studies found that – early parental loss ( death or separation ) in 20% of patients, an extremely insecure child in 12%, and poor relationships with parents 50% of the patients . (pubmed.com) 2 . Premorbid personality traits S uspiciousness , mistrust in others, secretiveness, S eclusiveness , constant ideas of reference and unwarranted hostility. All these traits hinder the development of satisfactory interpersonal relationships .

14. 3. Precipitating factors Sex life and marriage Social isolation Somatic illnesses Other factors

15. PSYCHODYNAMIC THEORIES 1 . Sigmund Freud, in 1986 described “projection” as the main defence mechanism in paranoia. A common form of projection occurs when an individual, threatened by his own anger, accuses another of harbouring hostile thoughts. Freud believed that delusions, rather than being symptoms of the disorder, are part of a healing process. In 1911, he published the “ Psychoanalytic notes”. Based on analysis, he explained the various delusions. (CTP)

16. 2 . Norman Cameron – Process of encapsulation -The delusion usually relates to one specific topic or belief but does not pervade, a person’s life or level of functioning. P seudocommunity organization- Imaginary group of person believing in delusion, to be conspiring against and focusing negative energy towards a paranoid individual. 3. Erik Erikson’s concept of trust versus mistrust in early development is a useful model to explain the suspiciousness of a paranoid individual. Clinical observations indicate that many, if not all, paranoid patients experience a lack of trust in relations.

17. TYPES: Delusional disorder can be divided into following type : 1. Persecutory type : commonest, 35% of all, The persecutory beliefs are often associated with querulousness, irritability, and anger, and the individual who acts out his or her anger may at times be assaultive or even homicidal. 2 . Jealous type : Delusional disorder with delusions of infidelity has been called conjugal paranoia, when it is limited to the delusion that a spouse has been unfaithful. The eponym Othello syndrome has been used to describe morbid jealousy that can arise from multiple concerns. (Kaplan Synopsis)

18. Types : 3. Erotomanic type : In erotomania , which has also been referred to as de Clérambault syndrome or psychose passionelle , the patient has the delusional conviction that another person, usually of higher status, is in love with him or her. Such patients also tend to be solitary, withdrawn, dependent, and sexually inhibited as well as to have poor levels of social or occupational functioning .

19. TYPES 4. Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations. Delusional infestation Delusional halitosis Delusional dysmorphophobia . 5. 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.

20. UNSPECIFIED TYPES SHARED PSYCHOTIC DISORDER Earlier names : Induced psychotic disorder, shared paranoid disorder, folie a deux , double insanity, folie induite , I nfectious insanity. In DSM-5, this disorder is referred to as “Delusional Symptoms in Partner of Individual with Delusional Disorder”. The essential feature is a delusional system that develops in an individual who is involved in a close relationship with other person who already has a psychotic disorder with prominent delusion.

21. UNSPECIFIED TYPES ACUTE PARANOID DISORDER Earlier name : acute paranoid reaction On rare occasions, delusional disorders may be precipitated by stressors and entirely cleared within six months period . It can be precipitated by sudden changes in environment like imprisonment, immigration, military induction, college enrollment , war or sudden separation from family. Subtypes usually described are -prison psychosis -delusional disorder in immigrants and refugees. -culture bound delusional disorder.

22. UNSPECIFIED TYPES LATE PARAPHRENIA Roth coined the term in 1955, to describe delusional disorders of elderly in whom signs of organic dementia, sustained confusion or primary affective illness could not explain the symptomatology and whose outcomes was much better in respect of mortality than senile and arteriosclerotic dementias DELUSION OF MISIDENTIFICATION (DMS) They all involve a belief that the identity of a person, object, or place has somehow changed or has been altered. As these delusions typically only concern one particular topic, they also fall under the category called monothematic delusions .

23. CLINICAL FEATURES The essential feature of delusional disorder is the presence of persistent non-bizarre delusion, not explained by other psychotic disorders. Swanson et al has described seven features of paranoid thinking; a combination of any of these are present in paranoid disorder: Projective thinking Suspiciousness Viewing the world as a hostile place Fear of loss of autonomy and control Feeling of self as a central point of events Grandiosity Delusions (JAMA’S Journal)

24. Course and Outcome Age : generally middle or late adult life Pattern : acute (presenting within 6 months of onset ) chronic (illness during more than 6 months of onset) In acute forms 50 % of patient recover fully, 37% relapsing course and 10 % go on to chronic illness. In chronic forms 53% were well on follow up, 10 % were better, 31% remained unchanged. Persecutory type has waxing and waning course, jealous type has a more favourable outcome . (JAMA’S Journal)

25. ICD 10 Diagnostic guidelines Delusions constitute the most conspicuous or the only clinical characteristic. They must be present for at least 3 months and be clearly personal rather than subcultural . Depressive symptoms or even a full-blown depressive episode (F32.-) may be present intermittently, provided that the delusions persist at times when there is no disturbance of mood . There must be no evidence of brain disease, no or only occasional auditory hallucinations.

26. ICD 10 Diagnostic Guidelines No history of schizophrenic symptoms (delusions of control, thought broadcasting, etc.). Includes: paranoia paranoid psychosis paranoid state paraphrenia (late) sensitiver Beziehungswahn (ideas of reference) Excludes: paranoid personality disorder (F60.0) psychogenic paranoid psychosis (F23.3) paranoid reaction (F23.3) paranoid schizophrenia (F20.0

27. DSM 5 Criteria of Delusion A. The presence of one (or more) delusions with a duration of 1 month or longer. 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 ). C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired , and behaviour is not obviously bizarre or odd .

28. DSM 5 D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. 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 dysmorphic disorder or obsessive-compulsive disorder

29. DSM 5 Specify whether: Erotomanic type: This subtype applies when the central theme of the delusion is that another person is in love with the individual. 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 .

30. DSM 5 Jealous type: This subtype applies when the central theme of the individual’s delusion is that his or her spouse or lover is unfaithful . 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 . Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations.

31. DSM 5 Mixed type: This subtype applies when no one delusional theme predominates. 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 ).

32. DSM 5 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 being the time period in which the symptom criteria are fulfilled . First episode, currently in partial remission: Partial remission being the 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.

33. DSM 5 First episode, currently in full remission: Full remission being a period of time after a previous episode during which no disorder-specific symptoms are present . Multiple episodes , currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with sub threshold symptom periods being very brief relative to the overall course.

34. DSM 5 Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behaviour, 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). (See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures .”) Note: Diagnosis of delusional disorder can be made without using this severity specifier .

35. Differentials Organic delusional disorder - Substance induced psychotic disorder - Schizophrenia - Major Depression - Mania - OCD - Somatoform disorder - Paranoid Personality Disorder

36. Prognostic factors Variables Good prognostic factor Bad prognostic factor Age Early [<30years] Late Mode of onset Acute Chronic Precipitating Factor Present Absent Sex Female Male Marital status Married Unmarried Duration of psychosis <6 Months Longer duration Diagnosis Reactive paranoid psychosis Absence of reactive factors Content of Delusion Persecutory, Jealousy Grandeur, Somatic, Delusion of influence Systematization of Delusion Poor Systematization Good Systematization Associated depressed mood Present Absent Hallucination Absent Present Emotional contact Good Poor Response to treatment Good Poor

37. TREATMENT Psychotherapy: The essential element in effective psychotherapy is to establish a relationship in which patients begin to trust a therapist. Individual therapy seems to be more effective than group therapy; insight-oriented, supportive, cognitive, and behavioural therapies are often effective. Initially , a therapist should neither agree with nor challenge a patient’s delusions. Therapists should be on time and make appointments as regularly as possible, with the goal of developing a solid and trusting relationship with a patient. Overgratification may actually increase patients’ hostility and suspiciousness because ultimately they must realize that not all demands can be met.

38. As the patient becomes less rigid, feelings of weakness and inferiority, associated with some depression, may surface. When a patient allows feelings of vulnerability to enter into the therapy, a positive therapeutic alliance has been established, and constructive therapy becomes possible. A good therapeutic outcome depends on a psychiatrist’s ability to respond to the patient’s mistrust of others and the resulting interpersonal conflicts, frustrations, and failures.

39. Treatment 2. Hospitalization: Patients with delusional disorder can generally be treated as outpatients, but clinicians should consider hospitalization for several reasons. First , patients may need a complete medical and neurological evaluation to determine whether a non psychiatric medical condition is causing the delusional symptoms. Second , patients need an assessment of their ability to control violent impulses (e.g., to commit suicide or homicide) that may be related to the delusional material. Third , patients’ behaviour about the delusions may have significantly affected their ability to function within their family or occupational settings; they may require professional intervention to stabilize social or occupational relationships.

40. Treatment 3.Pharmacological treatment In an emergency, severely agitated patients should be given an antipsychotic drug intramuscularly. Although no adequately conducted clinical trials with large numbers of patients have been conducted. M ost clinicians consider antipsychotic drugs the treatment of choice for delusional disorder . Start with low doses (e.g., 2 mg of haloperidol [Haldol] or 2 mg of R isperidone [Risperdal]) and increase the dose slowly. If a patient fails to respond to the drug at a reasonable dosage in a 6-week trial, antipsychotic drugs from other classes should be tried . Some investigators have indicated that P imozide may be particularly effective in delusional disorder, especially in patients with somatic delusions.

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