Delusional Disorder

1. DELUSIONAL DISORDERDELUSIONAL DISORDER
Prof. Dr Miroslava Jašović-GašićProf. Dr Miroslava Jašović-Gašić

2. DELUSIONAL DISORDERDELUSIONAL DISORDER
DEFINITION: DEFINITION:
a psychiatric disorder in which the a psychiatric disorder in which the
predominant symptoms are delusionspredominant symptoms are delusions
Formerly called paranoia or paranoid Formerly called paranoia or paranoid
disorder.disorder.

3. HISTORYHISTORY
The former term The former term paranoiaparanoia was derived was derived
from from Greek wordsGreek words meaning “beside” and meaning “beside” and
“mind”.“mind”.
In In modern usagemodern usage, paranoia is taken to , paranoia is taken to
mean extreme suspiciousness, usually not mean extreme suspiciousness, usually not
based on realistic assessment of the based on realistic assessment of the
situation.situation.

4. HISTORYHISTORY
Esquirol Esquirol (1838)(1838) - monomania - monomania --
characterize delusions with no associated characterize delusions with no associated
defect in logical reasoning or general defect in logical reasoning or general
behavior.behavior.
Kahlbaum Kahlbaum (1863) (1863) – paranoia– paranoia - - partial partial
insanity that affects the intellect but not insanity that affects the intellect but not
other areas of functioningother areas of functioning

5. HISTORYHISTORY
KraepelinKraepelin – paranoia – paranoia - - persistent persistent
delusional system in the absence of delusional system in the absence of
hallucinations and personality hallucinations and personality
deteriorationdeterioration
BleulerBleuler – paranoia: distinct from – paranoia: distinct from
schizophrenia; rare conditionschizophrenia; rare condition
FreudFreud – hypothesis that paranoid – hypothesis that paranoid
delusions develop from repressed delusions develop from repressed
homosexual impulseshomosexual impulses

6. EPIDEMIOLOGYEPIDEMIOLOGY
relatively rare (the prevalence = 0,03).relatively rare (the prevalence = 0,03).
underreported - delusional patients rarely seek psychiatric underreported - delusional patients rarely seek psychiatric
helphelp
annual incidence: 1-3 new cases per 100,000 people, annual incidence: 1-3 new cases per 100,000 people,
about 4% of all first admissions to psychiatric hospitals.about 4% of all first admissions to psychiatric hospitals.
mean age of onset: 40 yearsmean age of onset: 40 years
–range for the age of onset runs from 18 to the 90s.range for the age of onset runs from 18 to the 90s.
slight preponderance of female patients.slight preponderance of female patients.
many patients are married and employed.many patients are married and employed.
some association with recent immigration and low some association with recent immigration and low
socioeconomic statussocioeconomic status

7. ETIOLOGYETIOLOGY
As with all major psychiatric disorders, the As with all major psychiatric disorders, the
cause of delusional disorder is unknown.cause of delusional disorder is unknown.
Family studiesFamily studies
–increased prevalence of delusional disorder increased prevalence of delusional disorder
and related personality traits (egg. and related personality traits (egg.
suspiciousness, jealousy, and secretiveness) suspiciousness, jealousy, and secretiveness)
in the relatives of delusional disorder in the relatives of delusional disorder
probands.probands.

8. ETIOLOGYETIOLOGY
Biological factors Biological factors
–neurological conditions most commonly associated neurological conditions most commonly associated
with delusions are conditions that affect the limbic with delusions are conditions that affect the limbic
system and the basal ganglia.system and the basal ganglia.
–patients whose delusions are caused by neurological patients whose delusions are caused by neurological
disease that does not affect cerebral cortex tend to disease that does not affect cerebral cortex tend to
have complex delusions, similar to those in-patients have complex delusions, similar to those in-patients
with delusional disorder.with delusional disorder.
–conversely, patients with neurological disorder with conversely, patients with neurological disorder with
intellectual impairments often have simple delusions, intellectual impairments often have simple delusions,
unlike those in-patients with delusional disorder.unlike those in-patients with delusional disorder.

9. ETIOLOGYETIOLOGY
Psychodynamic factorsPsychodynamic factors
Freud`s contributions Freud`s contributions
–In Dr Schreber case, Freud theorized that denial and In Dr Schreber case, Freud theorized that denial and
projection defend against unconscious homosexual projection defend against unconscious homosexual
tendencies. Because homosexuality is consciously tendencies. Because homosexuality is consciously
inadmissible to some patients, male patients deny this inadmissible to some patients, male patients deny this
feeling of “I love him” and change them by reaction feeling of “I love him” and change them by reaction
formation into “I do not love him”. Patient further formation into “I do not love him”. Patient further
transform these feelings through projection into “It is transform these feelings through projection into “It is
not I who hate him; it is he who hates me.” In a full-not I who hate him; it is he who hates me.” In a full-
blown paranoid state, the feeling is elaborated into “I blown paranoid state, the feeling is elaborated into “I
am persecuted by him.” am persecuted by him.”

10. ETIOLOGYETIOLOGY
Psychodynamic factorsPsychodynamic factors
Freud`s contributions Freud`s contributions
–In erotomanic delusions, male patients change “I love In erotomanic delusions, male patients change “I love
him” to “I love her.”him” to “I love her.”
–In delusional grandiosity “I do not love him” becomes “I In delusional grandiosity “I do not love him” becomes “I
love myself.”love myself.”
–Freud also believed that unconscious homosexuality Freud also believed that unconscious homosexuality
causes delusions of jealousy – the man whom a causes delusions of jealousy – the man whom a
paranoid patient suspects his wife of loving is a man to paranoid patient suspects his wife of loving is a man to
whom the patient feels sexually attracted.whom the patient feels sexually attracted.
–Clinical evidence has not supported Freud`s thesis.Clinical evidence has not supported Freud`s thesis.

11. ETIOLOGYETIOLOGY
Paranoid pseudocommunityParanoid pseudocommunity
–A perceived community of plotters.A perceived community of plotters.
–This delusional entity hypothetically binds This delusional entity hypothetically binds
together projected fears and wishes to justify together projected fears and wishes to justify
the patient`s aggression and to provide a the patient`s aggression and to provide a
tangible target for the patient`s hostilities.tangible target for the patient`s hostilities.

12. ETIOLOGYETIOLOGY
Other psychodynamic factorOther psychodynamic factor
–Hypersensitivity and feelings of inferiority have been Hypersensitivity and feelings of inferiority have been
hypothezed to lead, through reaction formation and hypothezed to lead, through reaction formation and
projection, to delusions of superiority and grandiosity.projection, to delusions of superiority and grandiosity.
–Delusions of erotic ideas have been suggested as Delusions of erotic ideas have been suggested as
replacements for feelings of rejection.replacements for feelings of rejection.
–Critical and frightening delusions are often described as Critical and frightening delusions are often described as
projections of superego criticism.projections of superego criticism.
–Somatic delusions can be psychodynamically explaned Somatic delusions can be psychodynamically explaned
as a regression to the infantile narcissistic state, in which as a regression to the infantile narcissistic state, in which
patients withdraw emotional involvement from other patients withdraw emotional involvement from other
people and fixate on their physical selves.people and fixate on their physical selves.

13. DIAGNOSISDIAGNOSIS
DSM-IV diagnostic criteria for delusional disorder DSM-IV diagnostic criteria for delusional disorder
–Nonbizarre delusions (ie, involving situations that occur in real life, such as Nonbizarre delusions (ie, involving situations that occur in real life, such as
being followed, poisoned, infected, loved at a distance, or deceived by being followed, poisoned, infected, loved at a distance, or deceived by
spouse or lover, or having a disease) of at least 1 month’s duration.spouse or lover, or having a disease) of at least 1 month’s duration.
–Criterion A for schizophrenia has never been met. Note: Tactile and Criterion A for schizophrenia has never been met. Note: Tactile and
olfactory hallucinations may be present in delusional disorder if they are olfactory hallucinations may be present in delusional disorder if they are
related to the delusional theme.related to the delusional theme.
–Apart from the impact of the delusion(s) or its ramifications, functioning is Apart from the impact of the delusion(s) or its ramifications, functioning is
not markedly impaired and behavior is not obviously odd or bizarre.not markedly impaired and behavior is not obviously odd or bizarre.
–If mood episodes have occured concurrently with delusions, their total; If mood episodes have occured concurrently with delusions, their total;
duration has been brief relative to the duration of delusional periods.duration has been brief relative to the duration of delusional periods.
–The disturbance is not due to the direct psychological effects of substance The disturbance is not due to the direct psychological effects of substance
(eg, a drug abuse, a medication) or a general medical condition.(eg, a drug abuse, a medication) or a general medical condition.

14. TYPESTYPES
DSM-IV specifies seven types of delusional disorder, DSM-IV specifies seven types of delusional disorder,
Erotomanic typeErotomanic type: delusions : delusions
that another person, usually of that another person, usually of
higher status, is in love with higher status, is in love with
the individual.the individual.
Grandiose typeGrandiose type:: delusions of delusions of
inflated worth, power, inflated worth, power,
knowledge, identity, or special knowledge, identity, or special
relationship to a deity or relationship to a deity or
famous person.famous person.
–Jealous typeJealous type: delusions that : delusions that
individual’s sexual partner is individual’s sexual partner is
unfaithful.unfaithful.
–Persecutory typePersecutory type: delusions : delusions
that the person (or someone that the person (or someone
to whom the person is close) to whom the person is close)
is being malevolently treated is being malevolently treated
in some way.in some way.
Somatic typeSomatic type:: delusions that delusions that
the person has some physical the person has some physical
defect or general medical defect or general medical
condition.condition.
Mixed typeMixed type:: delusions delusions
characteristic of more then one characteristic of more then one
of the above types but no one of the above types but no one
theme predominates.theme predominates.
Unspecified typeUnspecified type
Persecutory and jealous types Persecutory and jealous types
are most common, and are most common, and
erotomanic and somatic types erotomanic and somatic types
are the most unusual.are the most unusual.

15. TYPESTYPES
Other delusionsOther delusions
–Capgras’s syndromeCapgras’s syndrome is the delusion that familiar is the delusion that familiar
people have been replaced by identical impositors.people have been replaced by identical impositors.
–Fregoli’s phenomenonFregoli’s phenomenon is the delusion that a persecutor is the delusion that a persecutor
is taking on a variety of faces, like an actor.is taking on a variety of faces, like an actor.
–LycanthropyLycanthropy is the delusion of being a werewolf. is the delusion of being a werewolf.
–HeutoscopyHeutoscopy is the false belief that one has a double. is the false belief that one has a double.
–Cotard’s syndromeCotard’s syndrome was originally called was originally called delire de delire de
negationnegation; those with the syndrome may believe that ; those with the syndrome may believe that
they have lost everything – possessions, strenght, and they have lost everything – possessions, strenght, and
even bodily organs, such as the heart.even bodily organs, such as the heart.

16. MENTAL STATUSMENTAL STATUS
General descriptionGeneral description..MMental status examination is usually ental status examination is usually
remarkably normal except for the presence of markdly remarkably normal except for the presence of markdly
abnormal delusional system. abnormal delusional system.
Mood, feelings and affectMood, feelings and affect..Patients' moods are consistent with Patients' moods are consistent with
the content of their delusions( e.g. patient with grandiose the content of their delusions( e.g. patient with grandiose
delusion is euphoric; one with persecutory delusions is delusion is euphoric; one with persecutory delusions is
suspicious ).suspicious ).
Perceptual disturbancesPerceptual disturbances..Patients with delusional disorder do Patients with delusional disorder do
not have prominent or sustained hallucinations. Tactile or not have prominent or sustained hallucinations. Tactile or
olfactory hallucinations may be present if they are consistent olfactory hallucinations may be present if they are consistent
with the delusion (e.g. somatic delusion of body odor). with the delusion (e.g. somatic delusion of body odor).
CLINICAL FEATURESCLINICAL FEATURES

17. MENTAL STATUSMENTAL STATUS

Thought .Thought . Disorder of thought content in the form of Disorder of thought content in the form of
delusions is the key symptom of the disorder. The delusions is the key symptom of the disorder. The
delusions are usually systematized and are characterized delusions are usually systematized and are characterized
as being possible (e.g. delusions of being persecuted , of as being possible (e.g. delusions of being persecuted , of
having an unfaithful spouse , of being infected with a having an unfaithful spouse , of being infected with a
virus, etc.). This examples of delusional content contrast virus, etc.). This examples of delusional content contrast
with the bizarre and impossible delusional content in with the bizarre and impossible delusional content in
some patients with schizophrenia. The delusional system some patients with schizophrenia. The delusional system
itself may be complex or simple. itself may be complex or simple.
CLINICAL FEATURESCLINICAL FEATURES

18. CLINICAL FEATURESCLINICAL FEATURES
Sensorium and cognitionSensorium and cognition.. Patients usually have no Patients usually have no
abnormality in orientation unless they have a specific abnormality in orientation unless they have a specific
delusion about a person, place , or time.Memory and delusion about a person, place , or time.Memory and
other cognitive processes are intact in these patients. other cognitive processes are intact in these patients.
Impulse controlImpulse control..Clinicians must evaluate patients with Clinicians must evaluate patients with
delusional disorder for ideation or plans to act on their delusional disorder for ideation or plans to act on their
delusional material by suicide, homicide or other violence. delusional material by suicide, homicide or other violence.
If patients are unable to control their impulses If patients are unable to control their impulses
hospitalization is probably necessary.hospitalization is probably necessary.
Judgment and insightJudgment and insight.. These patients have virtually no These patients have virtually no
insight in to their condition and are almost always brought insight in to their condition and are almost always brought
to the hospital by the police, family members or to the hospital by the police, family members or
employers. employers.

19. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
Delusions can accompany many medical and Delusions can accompany many medical and
neurological illnesses.neurological illnesses.
Neurological and medical conditions that can present with Neurological and medical conditions that can present with
delusiondelusion
–Basal ganglia disorders-Parkinson's disease, Huntington 's diseaseBasal ganglia disorders-Parkinson's disease, Huntington 's disease
–Deficiency states –B12,folate,thiamine, niacinDeficiency states –B12,folate,thiamine, niacin
–DeliriumDelirium
–Dementia- Alzheimer's disease, Pick's diseaseDementia- Alzheimer's disease, Pick's disease
–Endocrinopathies-adrenal,thyroid,parathyroidEndocrinopathies-adrenal,thyroid,parathyroid
–Limbic system disorders-epilepsy, cerebrovascular diseases,tumorsLimbic system disorders-epilepsy, cerebrovascular diseases,tumors
–Systemic - hepatic encephalophathy, hypercalcemia, hyopglycemia, Systemic - hepatic encephalophathy, hypercalcemia, hyopglycemia,
porphiria, uremiaporphiria, uremia

20. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
malingering malingering and and factitious disorderfactitious disorder with with
predominantly psychological signs and predominantly psychological signs and
symptomssymptoms
schyzophrenia, mood disorders, obsessive-schyzophrenia, mood disorders, obsessive-
conpulsive disorder, somatoform disorders and conpulsive disorder, somatoform disorders and
paranoid personality disorderparanoid personality disorder
drug- induceddrug- induced –amphetamines, anticholinergics, –amphetamines, anticholinergics,
antidepressants, antihipertensives, antidepressants, antihipertensives,
antituberculoses drugs, antiparkinson agents, antituberculoses drugs, antiparkinson agents,
cimetidine,cocaine, cimetidine,cocaine,
disulfiram(Antabus),hallucinogenesdisulfiram(Antabus),hallucinogenes

21. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
Delusional disorder is distinguished from Delusional disorder is distinguished from
schyzophrenia schyzophrenia buy the absence of other buy the absence of other
schyzophrenic symptoms and buy the schyzophrenic symptoms and buy the
nonbizarre quality of the delusions.nonbizarre quality of the delusions.

22. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
The somatics type of delusional disorder may resemble The somatics type of delusional disorder may resemble
depressive disorder or somatoform disorderdepressive disorder or somatoform disorder. .
–The somatic type of delusional disorder is differentiated from The somatic type of delusional disorder is differentiated from
depressive disorder buy the absence of other signs of depression depressive disorder buy the absence of other signs of depression
and buy the lack of a pervasive quality to the depression. and buy the lack of a pervasive quality to the depression.
–Delusional disorder can be differentiated from somatoform disorders Delusional disorder can be differentiated from somatoform disorders
buy the degre to which the somatic believ is held buy the pationt. buy the degre to which the somatic believ is held buy the pationt.
–Patients with somatoform disorders allow for possibility that their Patients with somatoform disorders allow for possibility that their
disorder does not exist, whereas patients with delusional disorder disorder does not exist, whereas patients with delusional disorder
have no duobth of it's reality.have no duobth of it's reality.

23. COURSE AND PROGNOSISCOURSE AND PROGNOSIS
Some research data indicate that indentifiable Some research data indicate that indentifiable
psychosocial stressorpsychosocial stressor often accompanies the often accompanies the
oncet of disorder (eg. resant imigration, social oncet of disorder (eg. resant imigration, social
conflict with family members or frends, social conflict with family members or frends, social
isolation etc.)isolation etc.)
Sudden Sudden onsetonset is more common than insidious is more common than insidious
one.one.
Person with delusional disorder is likely to be Person with delusional disorder is likely to be
below average in below average in intelligenceintelligence and that and that
premorbid personality of such person is likely to premorbid personality of such person is likely to
be extroverted, dominant and hypersensitive.be extroverted, dominant and hypersensitive.

24. COURSE AND PROGNOSISCOURSE AND PROGNOSIS
Delusional disorder is thought to be Delusional disorder is thought to be life-longlife-long, stable , stable
diagnosis.diagnosis.
Factors that correlate with a Factors that correlate with a good prognosis good prognosis are: high are: high
levels of occupational, social and functional adjustments, levels of occupational, social and functional adjustments,
female sex, onset before age 30, sudden onset, short female sex, onset before age 30, sudden onset, short
duration of illness and the presence of precipitating duration of illness and the presence of precipitating
factors.factors.
Patients with persecutory, somatic and erotic delusions Patients with persecutory, somatic and erotic delusions
are thought to have a are thought to have a better prognosisbetter prognosis than do than do
patients with grandiose and jealous delusions.patients with grandiose and jealous delusions.

25. TREATMENTTREATMENT
Hospitalization.Hospitalization.
Often needed because patients may need a complete Often needed because patients may need a complete
medical and neurological evaluation to determine whether medical and neurological evaluation to determine whether
a nonpsychiatric medical condition is causing the a nonpsychiatric medical condition is causing the
delusional symptoms.delusional symptoms.
Patients may need an assessment of their ability to Patients may need an assessment of their ability to
control violent impulses, such as to commit suicide and control violent impulses, such as to commit suicide and
homicide.homicide.
Patient's behavior about the delusions may have Patient's behavior about the delusions may have
significantly affected their ability to function within their significantly affected their ability to function within their
family or occupational settings so they may require family or occupational settings so they may require
professional intervention to stabilize social or occupational professional intervention to stabilize social or occupational
relationships.relationships.

26. TREATMENTTREATMENT
PharmacotherapyPharmacotherapy
- - In an emergency, severely agitated patients In an emergency, severely agitated patients
should be given an antipsychotic drug should be given an antipsychotic drug
intramuscularly.intramuscularly.
- Most clinicians think that antipsychotic drugs - Most clinicians think that antipsychotic drugs
are the treatment of choice for delusional are the treatment of choice for delusional
disorder.disorder.
- If the patient receives no benefit from - If the patient receives no benefit from
antipsychotic medication the drug should be antipsychotic medication the drug should be
discontinued. In patients who do respond to discontinued. In patients who do respond to
antipsychotic drugs data indicate that antipsychotic drugs data indicate that
maintenance doses can be low.maintenance doses can be low.

27. TREATMENTTREATMENT
PsychotherapyPsychotherapy
The essential element is to establish a The essential element is to establish a
relationship in which patients begin to trust a relationship in which patients begin to trust a
therapist.therapist.
Individual therapy seems to be more effective Individual therapy seems to be more effective
than group therapy.than group therapy.
Insight-oriented supportive,cognitive and Insight-oriented supportive,cognitive and
behavioral therapies are often effective.behavioral therapies are often effective.
The family may benefite from the thrapist's The family may benefite from the thrapist's
support and may thus be supportive of the support and may thus be supportive of the
patient.patient.

28. TREATMENTTREATMENT
A A good therapeutic outcomegood therapeutic outcome depends depends
on a psychiatrist's ability to respond to the on a psychiatrist's ability to respond to the
patient's mistrust of others and the patient's mistrust of others and the
resulting interpersonal conflicts , resulting interpersonal conflicts ,
fustrations and failures.fustrations and failures.
The The mark of succesful treatmentmark of succesful treatment may be may be
a satifactory social adjustment rather than a satifactory social adjustment rather than
an abatement of the patient's delusions.an abatement of the patient's delusions.