DELUSIONAL DISORDER Prof. Dr Miroslava Jašović-Gašić
a psychiatric disorder in which the predominant symptoms are delusions
Formerly called paranoia or paranoid disorder.
The former term paranoia was derived from Greek words meaning “beside” and “mind”.
In modern usage , paranoia is taken to mean extreme suspiciousness, usually not based on realistic assessment of the situation.
Esquirol (1838) - monomania - characterize delusions with no associated defect in logical reasoning or general behavior.
Kahlbaum (1863) – paranoia - partial insanity that affects the intellect but not other areas of functioning
Kraepelin – paranoia - persistent delusional system in the absence of hallucinations and personality deterioration
Bleuler – paranoia: distinct from schizophrenia; rare condition
Freud – hypothesis that paranoid delusions develop from repressed homosexual impulses
relatively rare (the prevalence = 0,03).
underreported - delusional patients rarely seek psychiatric help
annual incidence: 1-3 new cases per 100,000 people, about 4% of all first admissions to psychiatric hospitals.
mean age of onset: 40 years
range for the age of onset runs from 18 to the 90s.
slight preponderance of female patients.
many patients are married and employed.
some association with recent immigration and low socioeconomic status
As with all major psychiatric disorders, the cause of delusional disorder is unknown.
increased prevalence of delusional disorder and related personality traits (egg. suspiciousness, jealousy, and secretiveness) in the relatives of delusional disorder probands.
neurological conditions most commonly associated with delusions are conditions that affect the limbic system and the basal ganglia.
patients whose delusions are caused by neurological disease that does not affect cerebral cortex tend to have complex delusions, similar to those in-patients with delusional disorder.
conversely, patients with neurological disorder with intellectual impairments often have simple delusions, unlike those in-patients with delusional disorder.
In Dr Schreber case, Freud theorized that denial and projection defend against unconscious homosexual tendencies. Because homosexuality is consciously inadmissible to some patients, male patients deny this feeling of “I love him” and change them by reaction formation into “I do not love him”. Patient further transform these feelings through projection into “It is not I who hate him; it is he who hates me.” In a full-blown paranoid state, the feeling is elaborated into “I am persecuted by him.”
In erotomanic delusions, male patients change “I love him” to “I love her.”
In delusional grandiosity “I do not love him” becomes “I love myself.”
Freud also believed that unconscious homosexuality causes delusions of jealousy – the man whom a paranoid patient suspects his wife of loving is a man to whom the patient feels sexually attracted.
Clinical evidence has not supported Freud`s thesis.
A perceived community of plotters.
This delusional entity hypothetically binds together projected fears and wishes to justify the patient`s aggression and to provide a tangible target for the patient`s hostilities.
Other psychodynamic factor
Hypersensitivity and feelings of inferiority have been hypothezed to lead, through reaction formation and projection, to delusions of superiority and grandiosity.
Delusions of erotic ideas have been suggested as replacements for feelings of rejection.
Critical and frightening delusions are often described as projections of superego criticism.
Somatic delusions can be psychodynamically explaned as a regression to the infantile narcissistic state, in which patients withdraw emotional involvement from other people and fixate on their physical selves.
DSM-IV diagnostic criteria for delusional disorder
Nonbizarre delusions (ie, 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.
Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
If mood episodes have occured concurrently with delusions, their total; duration has been brief relative to the duration of delusional periods.
The disturbance is not due to the direct psychological effects of substance (eg, a drug abuse, a medication) or a general medical condition.
TYPES DSM-IV specifies seven types of delusional disorder,
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 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.
Mixed type : delusions characteristic of more then one of the above types but no one theme predominates.
Persecutory and jealous types are most common, and erotomanic and somatic types are the most unusual.
Capgras’s syndrome is the delusion that familiar people have been replaced by identical impositors.
Fregoli’s phenomenon is the delusion that a persecutor is taking on a variety of faces, like an actor.
Lycanthropy is the delusion of being a werewolf.
Heutoscopy is the false belief that one has a double.
Cotard’s syndrome was originally called delire de negation ; those with the syndrome may believe that they have lost everything – possessions, strenght, and even bodily organs, such as the heart.
General description . M ental status examination is usually remarkably normal except for the presence of markdly abnormal delusional system.
Mood, feelings and affect . Patients' moods are consistent with the content of their delusions( e.g. patient with grandiose delusion is euphoric; one with persecutory delusions is suspicious ).
Perceptual disturbances . Patients with delusional disorder do not have prominent or sustained hallucinations. Tactile or olfactory hallucinations may be present if they are consistent with the delusion (e.g. somatic delusion of body odor).
Thought . Disorder of thought content in the form of delusions is the key symptom of the disorder. The delusions are usually systematized and are characterized as being possible (e.g. delusions of being persecuted , of having an unfaithful spouse , of being infected with a virus, etc.). This examples of delusional content contrast with the bizarre and impossible delusional content in some patients with schizophrenia. The delusional system itself may be complex or simple.
Sensorium and cognition . Patients usually have no abnormality in orientation unless they have a specific delusion about a person, place , or time.Memory and other cognitive processes are intact in these patients.
Impulse control . Clinicians must evaluate patients with delusional disorder for ideation or plans to act on their delusional material by suicide, homicide or other violence. If patients are unable to control their impulses hospitalization is probably necessary.
Judgment and insight . These patients have virtually no insight in to their condition and are almost always brought to the hospital by the police, family members or employers.
Delusions can accompany many medical and neurological illnesses.
Neurological and medical conditions that can present with delusion
Delusional disorder is distinguished from schyzophrenia buy the absence of other schyzophrenic symptoms and buy the nonbizarre quality of the delusions.
The somatics type of delusional disorder may resemble depressive disorder or somatoform disorder .
The somatic type of delusional disorder is differentiated from depressive disorder buy the absence of other signs of depression and buy the lack of a pervasive quality to the depression.
Delusional disorder can be differentiated from somatoform disorders buy the degre to which the somatic believ is held buy the pationt.
Patients with somatoform disorders allow for possibility that their disorder does not exist, whereas patients with delusional disorder have no duobth of it's reality.
COURSE AND PROGNOSIS
Some research data indicate that indentifiable psychosocial stressor often accompanies the oncet of disorder (eg. resant imigration, social conflict with family members or frends, social isolation etc.)
Sudden onset is more common than insidious one.
Person with delusional disorder is likely to be below average in intelligence and that premorbid personality of such person is likely to be extroverted, dominant and hypersensitive.
COURSE AND PROGNOSIS
Delusional disorder is thought to be life-long , stable diagnosis.
Factors that correlate with a good prognosis are: high levels of occupational, social and functional adjustments, female sex, onset before age 30, sudden onset, short duration of illness and the presence of precipitating factors.
Patients with persecutory, somatic and erotic delusions are thought to have a better prognosis than do patients with grandiose and jealous delusions.
Often needed because patients may need a complete medical and neurological evaluation to determine whether a nonpsychiatric medical condition is causing the delusional symptoms.
Patients may need an assessment of their ability to control violent impulses, such as to commit suicide and homicide.
Patient's behavior about the delusions may have significantly affected their ability to function within their family or occupational settings so they may require professional intervention to stabilize social or occupational relationships.
- In an emergency, severely agitated patients should be given an antipsychotic drug intramuscularly.
- Most clinicians think that antipsychotic drugs are the treatment of choice for delusional disorder.
- If the patient receives no benefit from antipsychotic medication the drug should be discontinued. In patients who do respond to antipsychotic drugs data indicate that maintenance doses can be low.
The essential element is to establish a relationship in which patients begin to trust a therapist.
Individual therapy seems to be more effective than group therapy.
Insight-oriented supportive,cognitive and behavioral therapies are often effective.
The family may benefite from the thrapist's support and may thus be supportive of the patient.
A good therapeutic outcome depends on a psychiatrist's ability to respond to the patient's mistrust of others and the resulting interpersonal conflicts , fustrations and failures.
The mark of succesful treatment may be a satifactory social adjustment rather than an abatement of the patient's delusions.