delusional disorder complete chapter

1. Delusional Disorder
- Jeet Nadpara.

2. Epidemiology
Etiology
Clinical Features
Differential Diagnosis
Course and Prognosis
Treatment

3. Epidemiology
Studies suggest that between 2 and 8 percent of the elderly population experience some type of paranoid
symptoms.
One study indicated that although only approximately 2 percent of elderly psychiatric patients met DSM-III criteria
for paranoid disorder, another 13 percent had paranoid ideation.
The DSM-IV-TR estimates the population prevalence of delusional disorder to be approximately .03 percent.
Delusional disorder usually first appears in middle to late adulthood and the socio demographic profile is similar
across cultures.
The overall prevalence of delusional disorder is slightly higher among women than among men, and the average age
of onset is earlier for men (40 to 49 years) than for women (60 to 69 years).
Owing to its later age at onset, the lifetime morbidity risk is estimated by the DSM-IV-TR to range between 0.05 and
0.1 percent.

4. Etiology
• Biological theories
• Psychological theories
• Psychosocial theories

5. BIOLOGICAL THEORIES
1. Pathology: Cummings et al, Involvement of limbic system.
Lo et al, significant neurological problems.
2. Biochemistry: Cummings et al, disease characterized by excessive dopaminergic activity or reduced cholinergic activity.
3. Genetics: its relationship to schizophrenia and mood disorder.
4. Psychobiological mechanism: de Clerambault abnormal neurological events like, infections, intoxications, lesions, other
damages. it leads to automatisms.
- Maher, conceptualized delusion as explanations for anomalous experince.
5. Information processing theory: Ellis and Young – delusional misidentification syndrome, Spitzer – neurocomputational
Approach.

6. PSYCHOLOGICAL THEORIES
1. Psychodynamic Mechanisms: Freud described projection as the main defense mechanism in paranoia; in 1896.
In 1911, he published the “Psychoanalytic notes”.
Based on analysis, he explained the various delusions as follows:
• Delusion of persecution
• Delusion of love (erotomanic delusion)
• Delusion of Jealousy
• Delusion of Grandeur ( Grandiosity )
2. Cameron – process of encapsulation, pseudocommunity organization.
3. Klien and Horowitz – studied 80 paranoid patients, “basic trust”

7. 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.
2. Premorbid personality traits
Very anxious, tense, fearful and insecure.
Among the traits – suspiciousness, mistrust in others, secretiveness, seclusiveness, constant ideas of reference and
unwarranted hostility.
All these traits hinder the development of satisfactory interpersonal relationships.
3. Precipitating factors
• Sex life and marriage:
• Social isolation:
• Somatic illnesses:
• Other factors:

8. 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

9. Delusional disorder can be divided into following type :
1. Persecutory type: commonest, 35% of all, also called querulous paranoia, litigious paranoia, paranoia
persecutorica.
2. Jealous type: (earlier name: conjugal paranoia, delire passionel, jealous husband syndrome) first described in
1879 by Schaefer, central theme is a delusion of spouse’s infidelity and a pre occupation with this delusion.
3. Erotomanic type: (les psychosis passionelles, erotomania, old maid’s insanity, nymphomania, furor uterinus, amor
insanus, erotic melancholy) descriptions are seen in writings of Hippocrates, Plutarch, Galen and other physicians
of seventeenth century. De Clerambault divided it into two categories : pure cases and secondary cases.
4. Somatic type: (Monosymptomatic hypochondriacal psychosis, paranoia somatica)
Delusional infestation
Delusional halitosis
Delusional dysmorphophobia.
Miscellaneous disorder.
5. Grandiose type:
( Megalomania, Ambitious paranoia, Negative Paranoia, Folie des Grandeurs )

10. SHARED PSYCHOTIC DISORDER
Earlier names : Induced psychotic disorder, shared paranoid disorder, folie a deux, double insanity, folie induite,
infectious insanity, mystic paranoia, influenced psychosis, collective insanity, reciprocal insanity, familial mental
infection, psychic infection, psychosis of association.
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.
Disorder is divided into four clinical subtypes:
1. Imposed psychotic disorder (folie imposee)
2. Simultaneous psychotic disorder (folie simultanee)
3. Communicated psychotic disorder (folie communiquee)
4. Induced psychotic disorder (folie induite)

11. 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.
In ICD-10, delusions should not persist for more than 3 months.
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.

12. 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)
1. Capgras delusion
2. Fregoli’s delusion
3. Intermetamorphosis
4. Subjective doubles delusion

13. DIFFERENTIAL DIAGNOSIS
- Organic delusional disorder
- Substance induced psychotic disorder
- Schizophrenia
- Major Depression
- Mania
- OCD
- Somatoform disorder
- Paranoid Personality Disorder

14. 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 favorable outcome.
PROGNOSTIC FACTORS

15. No Variables Good prognostic factor Bad prognostic factor
1 Age of onset Early (<30 years) Late
2 Mode of onset Acute Chronic
3 Precipitating factor Present Absent
4 Sex Female Male
5 Marital status Married Unmarried
6 Duration of psychosis <6 months Longer duration before
hospitalization
7 Diagnosis Reactive paranoid psychosis Absence of reactive factors
8 Content of delusion Persecutory, jealousy Grandeur, reference, somatic,
primary, delusion of influence
9 Systematization of delusion Poor systematization Good systematization
10 Associated depressed mood Present Absent
11 Hallucination Absent Present
12 Emotional contact Good Poor
13 Response to treatment with Good Poor

16. MANAGEMENT
1. Psychopharmacological treatment
2. Hospitalization
3. Electroconvulsive therapy
4. Psychotherapy
5. Cognitive therapy

17. Thank you !