Delusional Disorder In Adults

Delusional Disorder involves the presence of one or more delusions with a duration of 1 month or longer. One can only have delusional disorder if it has been established that the individual does not have schizophrenia.  Specifically, the following schizophrenia symptoms must be absent:

• Hallucinations (if present, hallucinations are not prominent and are related to the delusional theme)
• Disorganized speech (e.g., frequent derailment or incoherence)
• Grossly disorganized or catatonic behavior
• Negative symptoms (i.e., diminished emotional expression or avolition)

In addition, the following criteria apply:

• Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.
• If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.
• 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 body dysmorphic disorder or obsessive-compulsive disorder.

Delusions and delusional disorder typically fall into one of the following categories:

• 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.
• Jealous type: This subtype applies when the central theme of the individual’s delusions 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 delusions involves bodily functions or sensations.
• 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).

In addition, delusions may or may not be bizarre. 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).

Nonbizarre delusions are about situations that could occur in real life, such as being followed, being loved from a distance, being poisoned, having an infection, or being deceived by one's spouse. These delusions usually involve the misinterpretation of perceptions or experiences. In reality, however, the situations are either not true at all or highly exaggerated.

People with delusional disorder often can continue to socialize and function normally, apart from the subject of their delusions, and generally do not behave in an obviously odd or bizarre manner. This is unlike people with other schizophrenia spectrum and other psychotic disorders, who also might have delusions as a symptom of their disorder. In some cases, however, people with delusional disorder might become so preoccupied with their delusions that their lives are disrupted. Many individuals with delusional disorder develop irritable, anxious or depressed mood, which can be a reaction to maladaptive delusional beliefs. Anger and violent behavior can occur with persecutory, jealous, and erotomanic types of delusional disorder. Those with persecutory delusions may engage in litigious or antagonistic behavior. Legal difficulties often occur in jealous and erotomanic types.

Making a distinction between a delusion and an overvalued idea is important, the latter representing an unreasonable belief that is not firmly held. Additionally, personal beliefs should be evaluated with great respect to complexity of cultural and religious differences; some cultures have widely accepted beliefs that may be considered delusional in other cultures.

There appears to be a genetic component to delusional disorder, and there is a significant familial relationship with Schizophrenia and Schizotypal Personality Disorder.

Some studies show that close to half of patients treated with antipsychotic medications show at least partial improvement. However, there are few studies which confirm the use of any specific medications for this disorder.

• Antipsychotic medications may improve symptoms that accompany delusions, such as anxiety, agitation, and psychosis
• Depot forms of antipsychotic medications may be helpful in persecutory or other subtypes
• Antidepressants and anxiolytics are sometimes also prescribed

Psychotherapy

Delusional disorder can be very difficult to treat because its sufferers may lack insight that psychiatric problem exists. Indeed, this is one of the key differences between delusional disorder and other primary psychotic disorders. However, individuals may not seek psychiatric help, may remain isolated, and may present instead to internists, surgeons, dermatologists, policemen, and lawyers rather than mental health professionals.

The overriding factor in determining psychotherapy success is the quality of the patient/therapist relationship. 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. 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. Even if the client is willing, therapy is likely to take a fair amount of time, from at least 6 months to a year.

Psychotherapies that may be helpful in delusional disorder include the following:

• Individual supportive psychotherapy: Initial treatment may focus on coping with accompanying anxiety or depression and transition to challenging delusional beliefs after rapport has been established. Can help the person recognize and correct the underlying thinking that has become distorted.
• Cognitive-behavioral therapy (CBT): This treatment helps individuals to learn to recognize and change thought patterns and behaviors that lead to troublesome feelings (e.g., depression and anxiety), and examine evidence for irrational and delusional beliefs.
• Family therapy: This treatment helps families deal more effectively with a loved one who has delusional disorder, enabling them to contribute to a better outcome for the person. It is very important that confidentiality and boundaries be maintained, so as not to reinforce persecutory delusions.
• Hospitalization: Individuals with severe symptoms or who are at risk of hurting themselves or others might need to be hospitalized until the condition is stabilized. Hospitalization is indicated only if a potential for danger is present; otherwise outpatient management is preferable. Hospitalization may reinforce delusions and/or increase distrust and resentment.

Non-Recommended Treatments

Because of the potential for harm and/or reactivity, the following treatments are not recommended:

• Insight-oriented psychotherapy
• Electroconvulsive therapy (ECT)
• Insulin shock therapy
• Psychosurgery
• Group therapy
• Self-help
• Vitamins or dietary supplements

Additional Treatments to Consider

• Exercise to help deal with accompanying anxiety and depression