Delusional disorder

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Delusional disorder
Other namesDelusional insanity, [1] paranoia[ citation needed ]
Theodore Gericault - Man with Delusions of Military Command - WGA08633.jpg
Painting by Théodore Géricault portraying an old man with a grandiose delusion of power and military command. Grandiose delusions are common in delusional disorder.
Specialty Psychiatry, clinical psychology   OOjs UI icon edit-ltr-progressive.svg
Symptoms Strong false belief(s) despite superior evidence to the contrary
Usual onset18–90 years old (mean of about age 40) [2]
TypesErotomanic type, grandiose type, jealous type, persecutory type, somatic type, mixed type, unspecified type
CausesGenetic and environmental [3]
Risk factors Family history, chronic stress, low SES, substance abuse
Differential diagnosis Paranoid personality disorder, manic-depressive illness, schizophrenia, substance-induced psychosis [3]
Frequency0.02-0.1% of general population [4] [5]

Delusional disorder, traditionally synonymous with paranoia , is a mental illness in which a person has delusions, but with no accompanying prominent hallucinations, thought disorder, mood disorder, or significant flattening of affect. [6] [7] Delusions are a specific symptom of psychosis. Delusions can be bizarre or non-bizarre in content; [7] non-bizarre delusions are fixed false beliefs that involve situations that could occur in real life, such as being harmed or poisoned. [8] Apart from their delusion or delusions, people with delusional disorder may continue to socialize and function in a normal manner and their behavior does not necessarily seem odd. [9] However, the preoccupation with delusional ideas can be disruptive to their overall lives. [9]

Contents

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. [7] 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. 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. [10] [11] [12]

According to German psychiatrist Emil Kraepelin, patients with delusional disorder remain coherent, sensible and reasonable. [13] [ dubious – discuss ] The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines six subtypes of the disorder: erotomanic (belief that someone is in love with one), grandiose (belief that one is the greatest, strongest, fastest, richest, or most intelligent person ever), jealous (belief that one is being cheated on), persecutory (delusions that one or someone one is close to is being malevolently treated in some way), somatic (belief that one has a disease or medical condition), and mixed, i.e., having features of more than one subtype. [7]

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. [14]

An earlier, now-obsolete, nosological name for delusional disorder was "paranoia". This should not be confused with the modern definition of paranoia (i.e., persecutory ideation specifically).

Classification

The International Classification of Diseases classifies delusional disorder as a mental and behavioural disorder. [15] 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 (DSM) enumerates seven types:

Signs and symptoms

The following can indicate a delusion: [17]

  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: [17]

  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 (although within the delusional system the logic is perverted) 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, [8] but genetic, biochemical, and environmental factors may play a significant role in its development.[ better source needed ] Some people with delusional disorders may have an imbalance in neurotransmitters, the chemicals that send and receive messages to the brain. [18] There does seem to be some familial component, and immigration (generally for persecutory reasons), [8] drug abuse, excessive stress, [19] being married, being employed, low socioeconomic status, celibacy among men, and widowhood among women may also be risk factors. [20] 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. [21]

Diagnosis

Differential diagnosis includes ruling out other causes such as drug-induced conditions, dementia, infections, metabolic disorders, and endocrine disorders. [8] 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. [8]

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 (PDI) 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 [22] [ better source needed ] notes, "All of these situations could be true or possible, but the person suffering from this disorder knows them not to be (e.g., through fact-checking, third-person confirmation, etc.)."

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. [8] 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. [8] Individual psychotherapy is recommended rather than group psychotherapy, as patients are often quite suspicious and sensitive. [8] 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. [8] Antipsychotics may be more useful in managing agitation that can accompany delusional disorder. [8] Until further evidence is found, it seems reasonable to offer treatments which have efficacy in other psychotic disorders. [23]

There is a certain amount of evidence that alternative treatment-regimes (beyond conventional attempted treatment with antipsychotics) may include clomipramine for people with the somatic subtype of paranoia. [24] [25] 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 (specifically with customary delusional features) and appeared favourable in its treatment. [26]

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. [27] 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. [28]

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. [29]

Insight-oriented therapy is rarely indicated or contraindicated; yet there are reports of successful treatment. [29] 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. [29]

Epidemiology

Delusional disorders are uncommon in psychiatric practice, though this may be an underestimation due to the fact that those with the condition lack insight and thus avoid psychiatric assessment. The prevalence of this condition stands at about 24 to 30 cases per 100,000 people while 0.7 to 3.0 new cases per 100,000 people are reported every year. Delusional disorder accounts for 1–2% of admissions to inpatient mental health facilities. [7] [30] The incidence of first admissions for delusional disorder is lower, from 0.001 to 0.003%. [31]

Delusional disorder tends to appear in middle to late adult life, and for the most part first admissions to hospital for delusional disorder occur between age 33 and 55. [8] It is more common in women than men, and immigrants seem to be at higher risk. [8]

Criticism

In some situations, the delusion may turn out to be true belief. [32] For example, in delusional jealousy, where a person believes that the partner is being unfaithful (in extreme cases perhaps going so far as to follow the partner into the bathroom, believing the other to be seeing a lover even during the briefest of separations), it may actually be true that the partner is having sexual relations with another person. In this case, the delusion does not cease to be a delusion because the content later turns out to be verified as true or the partner actually chose to engage in the behavior of which they were being accused.

In other cases, a belief may be incorrectly deemed delusional by a doctor or psychiatrist who subjectively concludes that a patient's assertions are unlikely, bizarre, or held with excessive conviction. Psychiatrists rarely have the time or resources to check the validity of a person's claims leading some true beliefs to be erroneously classified as delusional. [33] This is known as the Martha Mitchell effect, named after the wife of US Attorney General John Mitchell and derived from the initial response to her allegations of illegal activity taking place in the White House. At the time, her claims were thought to be signs of mental illness; only after the Watergate scandal broke were her claims corroborated and her sanity thus confirmed.

Similar factors have led to criticisms of Jaspers' definition of delusion as being ultimately 'un-understandable'. Critics (such as R. D. Laing) have argued that this leads to the diagnosis of delusions being based on the subjective understanding of a particular psychiatrist, who may not have access to all the information that might make a belief otherwise interpretable.

Another difficulty with the diagnosis of delusions is that almost all of these features can be found in "normal" beliefs. Many religious beliefs hold exactly the same features, yet are not universally considered delusional. For instance, if a person was holding a true belief then they will of course persist with it. This can cause the disorder to be misdiagnosed by psychiatrists. These factors have led the psychiatrist Anthony David to write that "there is no acceptable (rather than accepted) definition of a delusion." [34]

In the 2010 psychological thriller Shutter Island , directed by Martin Scorsese and starring Leonardo DiCaprio, delusional disorder is portrayed along with other disorders. [35] [36] An Indian movie Anantaram (Thereafter) directed by Adoor Gopalakrishnan also portrays the complex nature of delusions. [37] [38] The plot of the French movie He Loves Me... He Loves Me Not revolves around a case of erotomania, as does the plot of the Ian McEwan novel, Enduring Love .

See also

Related Research Articles

A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is also characterized by a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior, often in a social context. Such disturbances may occur as single episodes, may be persistent, or may be relapsing–remitting. There are many different types of mental disorders, with signs and symptoms that vary widely between specific disorders. A mental disorder is one aspect of mental health.

Psychosis is a condition of the mind or psyche that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are incoherent speech and behavior that is inappropriate for a given situation. There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities. Psychosis can have serious adverse outcomes.

Paranoia is an instinct or thought process that is believed to be heavily influenced by anxiety, suspicion, or fear, often to the point of delusion and irrationality. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy concerning a perceived threat towards oneself. Paranoia is distinct from phobias, which also involve irrational fear, but usually no blame.

A delusion is a false fixed belief that is not amenable to change in light of conflicting evidence. As a pathology, it is distinct from a belief based on false or incomplete information, confabulation, dogma, illusion, hallucination, or some other misleading effects of perception, as individuals with those beliefs are able to change or readjust their beliefs upon reviewing the evidence. However:

<span class="mw-page-title-main">Erotomania</span> Romantic delusional disorder

Erotomania, also known as de Clérambault's syndrome, is a relatively uncommon paranoid condition that is characterized by an individual's delusions of another person being infatuated with them. It is listed in the DSM-5 as a subtype of a delusional disorder. Commonly, the onset of erotomania is sudden, and the course is chronic.

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia (psychosis) and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses. Many people with schizoaffective disorder have other mental disorders including anxiety disorders.

<span class="mw-page-title-main">Thought disorder</span> Disorder of thought form, content or stream

A thought disorder (TD) is a disturbance in cognition which affects language, thought and communication. Psychiatric and psychological glossaries in 2015 and 2017 identified thought disorders as encompassing poverty of ideas, neologisms, paralogia, word salad, and delusions—all disturbances of thought content and form. Two specific terms have been suggested—content thought disorder (CTD) and formal thought disorder (FTD). CTD has been defined as a thought disturbance characterized by multiple fragmented delusions, and the term thought disorder is often used to refer to an FTD: a disruption of the form of thought. Also known as disorganized thinking, FTD results in disorganized speech and is recognized as a major feature of schizophrenia and other psychoses. Disorganized speech leads to an inference of disorganized thought. Thought disorders include derailment, pressured speech, poverty of speech, tangentiality, verbigeration, and thought blocking. One of the first known cases of thought disorders, or specifically OCD as it is known today, was in 1691. John Moore, who was a bishop, had a speech in front of Queen Mary II, about "religious melancholy."

The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains.

The syndrome of subjective doubles is a rare delusional misidentification syndrome in which a person experiences the delusion that they have a double or Doppelgänger with the same appearance, but usually with different character traits, that is leading a life of its own. The syndrome is also called the syndrome of doubles of the self, delusion of subjective doubles, or simply subjective doubles. Sometimes, the patient is under the impression that there is more than one double. A double may be projected onto any person, from a stranger to a family member.

Thought broadcasting is a type of delusional condition in which the affected person believes that others can hear their inner thoughts, despite a clear lack of evidence. The person may believe that either those nearby can perceive their thoughts or that they are being transmitted via mediums such as television, radio or the internet. Different people can experience thought broadcasting in different ways. Thought broadcasting is most commonly found among people who have a psychotic disorder, specifically schizophrenia.

Schizophreniform disorder is a mental disorder diagnosed when symptoms of schizophrenia are present for a significant portion of time, but signs of disturbance are not present for the full six months required for the diagnosis of schizophrenia.

Paraphrenia is a mental disorder characterized by an organized system of paranoid delusions with or without hallucinations and without deterioration of intellect or personality.

Olfactory reference syndrome (ORS) is a psychiatric condition in which there is a persistent false belief and preoccupation with the idea of emitting abnormal body odors which the patient thinks are foul and offensive to other individuals. People with this condition often misinterpret others' behaviors, e.g. sniffing, touching their nose or opening a window, as being referential to an unpleasant body odor which in reality is non-existent and cannot be detected by other people.

<span class="mw-page-title-main">Grandiose delusions</span> Subtype of delusion

Grandiose delusions (GDs), also known as delusions of grandeur or expansive delusions, are a subtype of delusion characterized by extraordinary belief that one is famous, omnipotent, wealthy, or otherwise very powerful. Grandiose delusions often have a religious, science fictional, or supernatural theme. Examples include the extraordinary belief that one is a deity or celebrity, or that one possesses extraordinary talents, accomplishments, or superpowers.

Folie à deux, also known as shared psychosis or shared delusional disorder (SDD), is a psychiatric syndrome in which symptoms of a delusional belief are "transmitted" from one individual to another.

<span class="mw-page-title-main">Persecutory delusion</span> Delusion involving perception of persecution

A persecutory delusion is a type of delusional condition in which the affected person believes that harm is going to occur to oneself by a persecutor, despite a clear lack of evidence. The person may believe that they are being targeted by an individual or a group of people. Persecution delusions are very diverse in terms of content and vary from the possible, although improbable, to the completely bizarre. The delusion can be found in various disorders, being more usual in psychotic disorders.

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

The diagnosis of schizophrenia, a psychotic disorder, is based on criteria in either the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, or the World Health Organization's International Classification of Diseases (ICD). Clinical assessment of schizophrenia is carried out by a mental health professional based on observed behavior, reported experiences, and reports of others familiar with the person. Diagnosis is usually made by a psychiatrist. Associated symptoms occur along a continuum in the population and must reach a certain severity and level of impairment before a diagnosis is made. Schizophrenia has a prevalence rate of 0.3-0.7% in the United States.

A religious delusion is defined as a delusion, or fixed belief not amenable to change in light of conflicting evidence, involving religious themes or subject matter. Religious faith, meanwhile, is defined as a belief in a religious doctrine or higher power in the absence of evidence. Psychologists, scientists, and philosophers have debated the distinction between the two, which is subjective and cultural.

The relationship between religion and schizophrenia is of particular interest to psychiatrists because of the similarities between religious experiences and psychotic episodes. Religious experiences often involve reports of auditory and/or visual phenomena, which sounds seemingly similar to those with schizophrenia who also commonly report hallucinations and delusions. These symptoms may resemble the events found within a religious experience. However, the people who report these religious visual and audio hallucinations also claim to have not perceived them with their five senses, rather, they conclude these hallucinations were an entirely internal process. This differs from schizophrenia, where the person is unaware that their own thoughts or inner feelings are not happening outside of them. They report hearing, seeing, smelling, feeling, or tasting something that deludes them to believe it is real. They are unable to distinguish between reality and hallucinations because they experience these hallucinations with their bodily senses that leads them to perceive these events as happening outside of their mind. In general, religion has been found to have "both a protective and a risk increasing effect" for schizophrenia.

References

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