Delusional Disorders

1. Delusional DisordersDelusional Disorders
NCM 401
Ma. Tosca Cybil A. Torres, RN

2. Key terms:
•Delusions:Delusions: false beliefs based on incorrect
inference about external reality that persist
despite the evidence to the contrary and these
beliefs are not ordinarily accepted by other
members of the person's culture or subculture
•Bizarre delusions:Bizarre delusions: clearly implausible, not
understandable, and not derived from ordinary
life experiences
•Non-bizarre delusions:Non-bizarre delusions: beliefs of something
occurring in a person's life which is not out of the
realm of possibility

3. characterized by the presence of non-non-
bizarrebizarre delusions which have persisted for
at least one month at least one month
People who have this disorder generally
don't experience a marked impairment in
their daily functioning in a social,
occupational or other important setting
Outward behavior is not noticeably bizarre
or objectively characterized as out-of-the-
ordinary

4. ETIOLOGICAL THEORIESETIOLOGICAL THEORIES
•Psychodynamics
Emotional development is delayed because of a lack of maternal
stimulation/attention. The infant is deprived of a sense of security and fails
to establish basic trust. A fragile ego results in severely impaired self-
esteem, a sense of loss of control, fear, and severe anxiety. A suspicious
attitude toward others is manifested and may continue throughout life.
Projection is the most common mechanism used as a defense against
feelings.
•Biological
A relatively strong familial pattern of involvement appears to be associated
with these disorders. Individuals whose family members manifest symptoms
of these disorders are at greater risk for development than the general
population. Twin studies have also suggested genetic involvement.
•Family Dynamics
Some theorists believe that paranoid persons had parents who were
distant, rigid, demanding, and perfectionistic, engendering rage, a sense of
exaggerated self-importance, and mistrust in the individual. The clients
become vulnerable as adults because of this early experience.
•Neurobiologic Perspective
thought to involve an abnormality in the neural impulse transmission of the
neurochemicals dopamine, serotonin and norephineprine.

5. Behavioral Clinical Findings:Behavioral Clinical Findings:
A.exhibits an elaborate, highly organized paranoid
delusional system while preserving other functions of
the personality
B.Apart from the impact of the delusions, thinking and
functioning is not interfered with, nor is it bizarre.
C.Personality function continues
D.Delusions are drawn from real life situations and have a
coherent theme.
E.Hallucination is not prominent; if present, usually
auditory and are related to delusional theme
F.Predominant theme of delusions determines type of
paranoia

7. Related terms include erotomania, psychose
passionelle, Clerambault syndrome, and old
maid's insanity
The central theme of delusions is that
another person, usually of higher status, is in
love with the patient. The object of delusion
is generally perceived to belong to a higher
social class, being married, or otherwise
unattainable
Patients with this type of delusion are
generally female, although males
predominate in forensic samples
Delusional love is usually intense in nature.
Signs of denial of love by the object of the
delusion are frequently falsely interpreted as
affirmation of love
Patients may attempt to contact the object
of the delusion by making phone calls,
sending letters and gifts, making visits, and
even stalking. Some cases lead to assaultive
behaviors as a result of attempts to pursue
the object of delusional love or attempting
to "rescue" her/him from some imagined
danger
ErotomaniErotomani
cc TypeType

8. Gran di os e T y peGran di os e T y pe
Patients believe that they
possess some great and
unrecognized talent, have made
some important discovery, have
a special relationship with a
prominent person, or have
special religious insight
Grandiose delusions in the
absence of mania are relatively
uncommon, and the distinction of
this subtype of disorder is
debatable. Many patients with
paranoid type show some
degree of grandiosity in their
delusions

9. Je al ou s t yp eJe al ou s t yp e
Related terms include conjugal
paranoia, Othello syndrome, and
pathological or morbid jealousy
The main theme of the delusions is
that her or his spouse or lover is
unfaithful. Some degree of infidelity
may occur; however, patients with
delusional jealousy support their
accusation with delusional
interpretation of "evidence" (eg,
disarrayed clothing, spots on the
sheets)
Patients may attempt to confront
their spouses and intervene in
imagined infidelity. Jealousy may
evoke anger and empower the
jealous individual with a sense of
righteousness to justify their acts of
aggression. This disorder can
sometimes lead to acts of violence,
including suicide and homicide.

10. Persecutory TypePersecutory Type
Patients believe that they are being
persecuted and harmed
In contrast to persecutory delusions of
schizophrenia, the delusions are
systematized, coherent, and defended
with clear logic. No deterioration in social
functioning and personality is observed
Patients often experience some degree of
emotional distress such as irritability,
anger, and resentment (Fennig, 2005). In
extreme situations, they may resort to
violence against those who they believe
are hurting them
The distinction between normality,
overvalued ideas, and delusions is
difficult to make in some of the cases

11. Somatic TypeSomatic Type
Related terms include
monosymptomatic hypochondriasis
The core belief of this type of disorder
is delusions around bodily functions
and sensations. The most common are
the belief that one is infested with
insects or parasites, the belief of
emitting a foul odor, the belief that
parts of the body are not functioning,
and the belief that their body or parts of
the body are misshapen or ugly
Patients are totally convinced in
physical nature of this disorder, which
is contrary to patients with
hypochondriasis who may admit that
their fear of having a medical illness is
groundless
Patients are usually first seen by
dermatologists, cosmetic surgeons,
urologists, gastroenterologists, and
other medical specialists
Sensory experiences associated with
this illness (eg, sensation of parasites
crawling under the skin) are viewed as
components of systemized delusions

12. Nihilistic TypeNihilistic Type
"delusions of
nothingness“
The sufferer may
believe that they or
the world has
ceased to exist, that
they are dead, or
that parts of the
body or mind have
vanished.

13. Mixed TypeMixed Type
Patients exhibit more than one of the Patients exhibit more than one of the
delusions simultaneously and no one delusions simultaneously and no one
delusional theme predominatesdelusional theme predominates

14. Unspecified TypeUnspecified Type
Delusional themes fall outside the specific categories or
cannot be clearly determined
Misidentification syndromes such as Capgras syndrome
(characterized by a belief that a familiar person has been
replaced by an identical impostor) or Fregoli syndrome (a
belief that a familiar person is disguised as someone else)
fall into this category. Misidentification syndromes are rare
and frequently are associated with other psychiatric
conditions (eg, schizophrenia) or organic illnesses (eg,
dementia, epilepsy)
Another unusual syndrome is Cotard syndrome, in which
patients believe that they have lost all their possessions,
status, and strength as well as their entire being, including
their organs. Described first in the 19th century, it is a rare
condition, which is usually considered a precursor to a
schizophrenic or depressive episode.

15. Specific Diagnostic Criteria Specific Diagnostic Criteria
for Delusional Disorderfor Delusional Disorder
•Nonbizarre delusionsNonbizarre delusions (i.e., involving situations
that occur in real life, such as 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.
•Criterion A for Schizophrenia has never been
met.
Note: Tactile and olfactory hallucinations may be
present in Delusional Disorder if they are related to the
delusional theme.

16. Criterion A of Schizophrenia requires two (or more)
of the following, each present for a significant
portion of time during a 1-month period (or less if
successfully treated):
delusions
hallucinations
disorganized speech (e.g., frequent derailment or
incoherence)
grossly disorganized or catatonic behavior
negative symptoms, i.e., affective flattening, alogia, or
avolition
Note:Note: Criteria A of Schizophrenia requires only one
symptom if delusions are bizarre or hallucinations
consist of a voice keeping up a running
commentary on the person's behavior or thoughts,
or two or more voices conversing with each other.

17. C. Apart from the impact of the delusion(s) or
its ramifications, functioning is not
markedly impaired and behavior is not
obviously odd or bizarre.
D. If mood episodes have occurred
concurrently with delusions, their total
duration has been brief relative to the
duration of the delusional periods.
E. The disturbance is not due to the direct
physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a
general medical condition.

18. Specify type (the following types are assigned
based on the predominant delusional theme):
•Erotomanic Type: delusions that another person, usually of higher
status, is in love with the individual
•Grandiose Type: delusions of inflated worth, power, knowledge,
identity, or special relationship to a deity or famous person
•Jealous Type: delusions that the individual's sexual partner is
unfaithful
•Persecutory Type: delusions that the person (or someone to whom
the person is close) is being malevolently treated in some way
•Somatic Type: delusions that the person has some physical defect
or general medical condition
•Nihilistic Type: delusion that the world is ending or one is dying
•Religious Type: delusion of having special religious powers
•Sexual Type: delusion that others know about one’s sexual activity
and that the activity causes illness
•Mixed Type: delusions characteristic of more than one of the above
types but no one theme predominates
•Unspecified Type

19. Therapeutic Intervention: PsychotherapyPsychotherapy
•the most effective help in person suffering from
delusional disorder
•The overriding important factor in this therapy
is the quality of the patient/therapist
relationship
•TrustTrust is a key issue, as is unconditional
support
•If the client believes that the therapist really
does think he or she is "crazy," the therapy can
terminate abruptly.
• Early in the therapy, it is vital not to directly
challenge the delusion system or beliefs and
instead to concentrate on realistic and
concrete problems and goals within the
person's life.

20. •Once a firm, supportive therapeutic
relationship has been established, the
therapist can begin reinforcing positive
gains and behaviors the individual makes
in his or her life, such as in educational or
occupational gains. It is important to
reinforce these life events (such as getting
a job), because it reinforces in the patient
a sense of self-confidence and self-
reliance.

21. •Only when the client has begun to feel more
secure in their social or occupational world can
more productive work be accomplished in
therapy. This involves the gradual but gentle
challenging of the client's delusional beliefs,
starting with the smallest and least-important
items. Occasionally making these types of gentle
challenges throughout therapy will give the
clinician a greater understanding of how far
along the individual has come. If the patient
refuses to give up his or her delusion beliefs,
even the smallest ones, then therapy is likely to
be very long-term. Even if the client is willing,
therapy is likely to take a fair amount of time,
from at least 6 months to a year.

22. •Clinicians should always be very direct and
honest, especially with people who suffer from
delusion disorder. Professionals should be even
more careful than usual not to impinge on the
client's privacy or confidentiality, and to say plainly
what they mean in therapy sessions. Subtlety and
sarcasm may be easily misinterpreted by the
patient. Therapy approaches which focus on
insight or self-knowledge may not be as beneficial
as those stressing social skills training and other
behaviorally and solution-oriented therapies.

23. Application of the Nursing Application of the Nursing
Process:Process:
Assessment:Assessment:
2.History taking from client and family
3.Presence of hallucinations and delusional
ideation; may constitute danger to
self/others
4.Presence of suspiciousness; paranoid
feelings are usually limited to specific
areas in the patient’s life
5.Absence of odd/bizarre behavior and
other criteria r/t schizoprenia

24. Nursing Diagnoses:Nursing Diagnoses:
A.Anxiety r/t disturbed processes about specific areas,
mistrust of others, difficulty in dealing with certain
aspects of reality and threats to security
B.Ineffective Individual coping r/t poorly
developed/inappropriate use of defense mechanism
C.Risk for loneliness r/t mistrust of others and threats to
security
D.Self-esteem disturbance r/t perceptual/cognitive
impairment, feelings of grandiosity and/ feelings of
persecution
E.Altered thought processes r/t misinterpretation of events
F.Risk for violence: directed at others r/t feelings of
suspicion/distrust of others and misinterpretation of
stimuli

25. Planning/Implementation:Planning/Implementation:
•Provide an environment with some intellectual
challenges that do not threaten security
•Provide open, honest atmosphere in which client can
begin to trust self/others.
•Accept and recognize the patient’s need for a superior
attitude
•Meet sarcasm and ridicule in a matter-of-fact matter
•Guard patient’s self-esteem from attack by other
patients
•Accept patient’s misinterpretation of events
•Point out reality but do not directly challenge the
patient’s delusions
•Encourage client/family to focus on defining methods for
coping with anxieties and life stressors.
•Promote a sense of self-worth and increased self-
esteem.

26. EvaluatioEvaluatio
n:n:
•Copes with anxiety without the use of threats
or assaultive behavior.
•Recognizes reality; agrees to give up or live
with the delusional system.
•Client/family/SOs participate in therapy (e.g.,
behavioral, group).
•Family/SO(s) provide emotional support for the
client.
•Plan in place to meet needs after discharge.

27. End of Discussion