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Delusional disorder and shared psychotic disorder for postgraduates


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Delusional Disorder and Shared Psychotic Disorder

Delusional Disorder and Shared Psychotic Disorder

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  • 1. By Mohamed Abdelghani Delusional Disorder and Shared Psychotic DisorderDelusions are false fixed beliefs not in keeping with the culture.The diagnosis of delusional disorder is made when a person exhibits nonbizarre delusionsof at least 1 months duration that cannot be attributed to other psychiatric disorders.Nonbizarre means that the delusions must be about situations that can occur in real life,such as being followed, infected, loved at a distance, and so on.Epidemiology  Delusional disorder may be underreported because delusional patients rarely seek psychiatric help unless forced by their families or by the courts.  The prevalence of delusional disorder in the United States is 0.025 to 0.03%.  Thus, delusional disorder is much rarer than schizophrenia (1%), and the mood disorders (5%).  The annual incidence of delusional disorder is 1 to 3 new cases/100,000 persons.  According to DSM-IV-TR, delusional disorders account for only 1 to 2 %of all admissions to inpatient mental health facilities.  The mean age of onset is about 40 years, but the range for age of onset runs from 18 years of age to the 90s.  A slight preponderance of female patients exists; however, men are more likely to develop paranoid delusions than women, who are more likely to develop delusions of erotomania.  Many patients are married and employed, but some association is seen with recent immigration and low socioeconomic status.Table 14.3-1 DSM-IV-TR Definition of Delusion and Certain Common TypesAssociated with Delusional DisordersDelusion:  A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof of evidence to the contrary.  The belief is not one ordinarily accepted by other members of the persons culture or subculture (e.g., it is not an article of religious faith).  When a false belief involves a value judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility.  Delusional conviction occurs on a continuum and can sometimes be inferred from an individuals behavior.Page I
  • 2. By Mohamed Abdelghani  It is often difficult to distinguish between a delusion and an overvalued idea (in which case the individual has an unreasonable belief or idea but does not hold it as firmly as is the case with a delusion).  Delusions are subdivided according to their content.Some of the more common types are listed below:  Bizarre: A delusion that involves a phenomenon that the persons culture would regard as totally implausible.  Delusional jealousy: The delusion that ones sexual partner is unfaithful.  Erotomanic: A delusion that another person, usually of higher status, is in love with the individual.  Grandiose: A delusion of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.  Mood-congruent: See mood-congruent psychotic features.  Mood-incongruent:See mood-incongruent psychotic features.  Of being controlled: A delusion in which feelings, impulses, thoughts, or actions are experienced as being under the control of some external force rather than being under ones own control.  Of reference: A delusion that events, objects, or other persons in ones immediate environment have a particular and unusual significance. These delusions are usually of a negative or pejorative nature, but also may be grandiose in content. This differs from an idea of reference, in which the false belief is not as firmly held nor as fully organized into a true belief.  Persecutory: A delusion that one (or someone to whom one is close) is being attacked, harassed, cheated, persecuted, or conspired against.  Somatic: A delusion whose main content pertains to the appearance or functioning of ones body.  Thought broadcasting: The delusion that ones thoughts are being broadcast out loud so that they can be perceived by others.  Thought insertion: The delusion that certain of ones thought are not ones own, but rather are inserted into ones mind.  Mood-congruent psychotic features: Delusions or hallucinations whose content is entirely consistent with the typical themes of a depressed or manic mood. If the mood is depressed, the content of the delusions or hallucinations would involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. The content of the delusion may include themes of persecution if these are based on self-derogatory concepts such as deserved punishment. If the mood is manic, the content of the delusions or hallucinations would involve themes of inflated worth, power, knowledge, or identity, or a special relationship to a deity or a famous person. The content of the delusion may include themes of persecution ifPage II
  • 3. By Mohamed Abdelghani these are based on concepts such as inflated worth or deserved punishment.  Mood-incongruent psychotic features: Delusions or hallucinations whose content is not consistent with the typical themes of a depressed or manic mood. In the case of depression, the delusions or hallucinations would not involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. In the case of mania, the delusions or hallucinations would not involve themes of inflated worth, power, knowledge, or identity, or a special relationship to a deity or a famous person. Examples of mood-incongruent psychotic features include persecutory delusions (without self-derogatory or grandiose content), thought insertion, thought broadcasting, and delusions of being controlled whose content has no apparent relationship to any of the themes listed above.Etiology o The cause of delusional disorder is unknown. o The central concept about the cause of delusional disorder is its distinctness from schizophrenia and the mood disorders: a. Delusional disorder is much rarer than schizophrenia or mood disorders. b. A later onset than schizophrenia. c. A much less pronounced female predominance than the mood disorders. o The most convincing data come from family studies that report:  An increased prevalence of delusional disorder and related personality traits (e.g., suspiciousness, jealousy, and secretiveness) in the relatives of delusional disorder probands.  Neither an increased incidence of schizophrenia and mood disorders in the families of delusional disorder probands nor an increased incidence of delusional disorder in the families of probands with schizophrenia. o Long-term follow-up of patients with delusional disorder indicates that the diagnosis of delusional disorder is relatively stable, with:  Less than one fourth of the patients eventually being reclassified as schizophrenia.  Less than 10% of patients eventually being reclassified as a mood disorder. o These data indicate that delusional disorder is not an early stage of one or both of these two more common disorders.i. Biological Factors  A wide range of biological factors, can cause delusions.  The neurological conditions most commonly associated with delusions affect the limbic system and the basal ganglia with intact cerebral cortical functioning:Page III
  • 4. By Mohamed Abdelghani a. Patients whose delusions are caused by neurological diseases and who show no intellectual impairment tend to have complex delusions similar to those in patients with delusional disorder. b. Conversely, patients with neurological disorder with intellectual impairments often have simple delusions unlike those in patients with delusional disorder.  Delusional disorder can arise as a normal response to abnormal experiences in the environment, the peripheral nervous system, or the CNS:  If patients have erroneous sensory experiences of being followed (e.g., hearing footsteps), they may believe that they are being followed.  The presence of such hallucinatory experiences in delusional disorder isnt proved.ii. Psychodynamic Factors Specific psychodynamic theories involve suppositions regarding hypersensitivepersons and specific ego mechanisms: reaction formation, projection, and denial. 1. Freuds Contributions  Sigmund Freud believed that delusions, rather than being symptoms of the disorder, are part of a healing process.  He described projection as the main defense mechanism in paranoia.  He claimed that unconscious homosexual tendencies are defended against by denial and projection.  The dynamics underlying the formation of delusions for a female patient are the same as for a male patient.  Careful studies of patients with delusions have been unable to corroborate Freuds theories, as no higher incidence of homosexual ideation or activity is found in patients with delusions than in other groups. 2. Paranoid Pseudocommunity  Norman Cameron described seven situations that favor the development of delusional disorders: 1. An increased expectation of receiving sadistic treatment. 2. Situations that increase distrust and suspicion. 3. Social isolation. 4. Situations that increase envy and jealousy. 5. Situations that lower self-esteem. 6. Situations that cause persons to see their own defects in others. 7. Situations that increase the potential for rumination over probable meanings and motivations.  When frustration from any combination of these conditions exceeds the tolerable limit, persons become withdrawn and anxious; realizing that something is wrong,Page IV
  • 5. By Mohamed Abdelghani seeking an explanation for the problem, and crystallizing a delusional system as a solution.  Elaboration of the delusion to include imagined persons and attribution of malevolent motivations to both real and imagined persons result in the organization of the pseudocommunity "a perceived community of plotters".  This delusional entity hypothetically binds together projected fears, justifies the patients aggression and provides a tangible target for the patients hostilities. 3. Other Psychodynamic Factors  Clinical observations indicate that many, if not all, paranoid patients experience a lack of trust in relationships.  A hypothesis relates this distrust to a consistently:  Hostile family environment.  An overcontrolling mother.  A distant or sadistic father.  Erik Eriksons concept of trust versus mistrust in early development is a useful model to explain the suspiciousness of the paranoid who never went through the healthy experience of having his or her needs satisfied by what Erikson termed the :outer-providers". 4. Defense Mechanisms o Patients with delusional disorder use primarily the defense mechanisms of reaction formation, denial, and projection: a) Reaction formation: as a defense against aggression, dependence needs, and feelings of affection and transform the need for dependence into staunch independence. b) Denial: to avoid awareness of painful reality. c) Projection: to face responsibility for the rage, they project their resentment and anger onto others and use projection to protect themselves from recognizing unacceptable impulses in themselves. 5. Other Relevant Factors (Table 14.3-2).  Delusions have been linked to a variety of additional factors such as:  Social and sensory isolation.  Socioeconomic deprivation.  Personality disturbance.  The deaf and the visually impaired.  Immigrants with limited ability in a new language.  Advanced age. Table 14.3-2 Risk Factors Associated with Delusional Disorder  Advanced agePage V
  • 6. By Mohamed Abdelghani  Sensory impairment or isolation  Family history  Social isolation  Personality features (e.g., unusual interpersonal sensitivity)  Recent immigrationDiagnosis and Clinical Features Table 14.3-3 DSM-IV-TR Diagnostic Criteria for Delusional Disorder A. Nonbizarre 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 months duration. B. 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. 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.Specify type (the following types are assigned based on the predominant delusionaltheme): 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 individuals 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 than one of the above types but no onePage VI
  • 7. By Mohamed Abdelghani theme predominates Unspecified type Table 14.3-4 ICD-10 Diagnostic Criteria for Delusional DisordersDelusional disorder A. A delusion or a set of related delusions, other than those listed as typically schizophrenic in Criterion G1(1)b or d for paranoid, hebephrenic, or catatonic schizophrenia (i.e., other than completely impossible or culturally inappropriate), must be present. The commonest examples are persecutory, grandiose, hypochondriacal, jealous (zelotypic), or erotic delusions. B. The delusion(s) in Criterion A must be present for at least 3 months. C. The general criteria for schizophrenia are not fulfilled. D. There must be no persistent hallucinations in any modality (but there may be transitory or occasional auditory hallucinations that are not in the third person or giving a running commentary). E. Depressive symptoms (or even a depressive episode) may be present intermittently, provided that the delusions persist at times when there is no disturbance of mood. F. Most commonly used exclusion clause. There must be no evidence of primary or secondary organic mental disorder as listed under organic, including symptomatic, mental disorders, or of a psychotic disorder due to psychoactive substance use.Specification for possible subtypesThe following types may be specified if desired: persecutory; litigious; self-referential;grandiose; hypochondriacal (somatic); jealous; erotomanic.Other persistent delusional disordersThis is a residual category for persistent delusional disorders that do not meet the criteriafor delusional disorder. Disorders in which delusions are accompanied by persistenthallucinatory voices or by schizophrenic symptoms that are insufficient to meet criteria forschizophrenia should be coded here. Delusional disorders that have lasted for less than 3months should, however, be coded, at least temporarily, under acute and transientpsychotic disorders.Persistent delusional disorder, unspecifiedPage VII
  • 8. By Mohamed Abdelghanii. Mental Status a) General Description  Patients are usually well groomed and well dressed, without evidence of gross disintegration of personality or of daily activities, yet they may seem eccentric, odd, suspicious, or hostile.  They are sometimes litigious and may make this inclination clear to the examiner.  The most remarkable feature is that the mental status examination shows them to be quite normal except for a markedly abnormal delusional system.  Patients may attempt to engage clinicians as allies in their delusions, but a clinician should not pretend to accept the delusion; this collusion further confounds reality and sets the stage for eventual distrust between the patient and the therapist. b) Mood, Feelings, and Affect  Patients moods are consistent with the content of their delusions:  A patient with grandiose delusions is euphoric.  One with persecutory delusions is suspicious.  Whatever the nature of the delusional system, the examiner may sense some mild depressive qualities. c) Perceptual Disturbances o By definition, patients with delusional disorder do not have prominent or sustained hallucinations. o According to DSM-IV-TR, tactile or olfactory hallucinations may be present if they are consistent with the delusion (e.g., somatic delusion of body odor). o A few delusional patients have other hallucinatory experiences; virtually always auditory rather than visual. d) 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; for example, delusions of being persecuted, being infected with a virus, or being loved by a famous person.  These examples of delusional content contrast with the bizarre and impossible delusional content in some patients with schizophrenia.  The delusional system itself can be complex or simple.  Patients lack other signs of thought disorder, although some may be verbose, circumstantial, or idiosyncratic in speech when talking about their delusions.Page VIII
  • 9. By Mohamed Abdelghani  Clinicians should not assume that all unlikely scenarios are delusional; the veracity of a patients beliefs should be checked before deeming their content to be delusional. e) Sensorium and Cognition  Orientation No abnormality in orientation unless they have a specific delusion about a person, place, or time.  Memory Memory and other cognitive processes are intact in delusional disorder. f) Impulse Control  Clinicians must evaluate patients for ideation or plans to act on their delusional material by suicide, homicide, or other violence.  Although the incidence of these behaviors is not known, therapists should not hesitate to ask patients about their suicidal, homicidal, or other violent plans.  Destructive aggression is most common in patients with a history of violence; if aggressive feelings existed in the past, therapists should ask patients how they managed those feelings.  If patients cannot control their impulses, hospitalization is probably necessary.  Therapists can sometimes help foster a therapeutic alliance by openly discussing how hospitalization can help patients gain additional control of their impulses. g) Judgment and Insight o Patients have virtually no insight into their condition and are almost brought to the hospital by the police, family members, or employers. o Judgment can best be assessed by evaluating the patients past, present, and planned behavior. h) Reliability  Patients are usually reliable in their information, except when it impinges on their delusional system.ii. Types 1) Persecutory Type  The delusion of persecution is a classic symptom of delusional disorder; persecutory-type and jealousy-type delusions are probably the forms seen most frequently by psychiatrists.  Patients are convinced that they are being persecuted or harmed. The persecutory beliefs are often associated with querulousness, irritability, and anger, and the individual may at times be assaultive or even homicidal. Page IX
  • 10. By Mohamed Abdelghani  In contrast to persecutory delusions in schizophrenia, the clarity, logic, and systematic elaboration of the persecutory theme in delusional disorder leave a remarkable stamp on this condition.  The absence of other psychopathology, of deterioration in personality, or of deterioration in most areas of functioning also contrasts with the typical manifestations of schizophrenia. 2) Jealous Type o Delusional disorder with delusions of infidelity has been called conjugal paranoia when it is limited to the delusion that a spouse has been unfaithful. o The eponym Othello syndrome has been used to describe morbid jealousy that can arise from multiple concerns. The delusion usually afflicts men, often those with no prior psychiatric illness. o It may appear suddenly and serve to explain the spouses behavior. o The condition is difficult to treat and may diminish only on separation, divorce, or death of the spouse. o Marked jealousy (usually termed pathological or morbid jealousy) may thus be a symptom of many disorders; including schizophrenia (in which female patients more commonly display this feature), epilepsy, mood disorders, drug abuse, and alcoholism; for which treatment is directed at the primary disorder. o Jealousy can be potentially dangerous and has been associated with violence, notably both suicide and homicide (Fig. 14.3-1). o The forensic aspects of the symptom have been noted repeatedly, especially its role as a motive for murder. o However, physical and verbal abuse occurs more frequently than do extreme actions among individuals with this symptom. o Caution and care in deciding how to deal with such presentations are essential not only for diagnosis, but also from the point of view of safety.Page X
  • 11. By Mohamed AbdelghaniFIGURE 14.3-1 A detail from the painting An Allegory with Venus and Cupid by Bronzino depicting a jealouslover. There is a high risk of homicide when morbid jealousy becomes the dominant theme in a relationship inwhich one partner is jealous of the other. That rage is well-depicted in Bronzinos painting. 3) Erotomanic Type  Referred to as de Clerambault syndrome or psychose passionelle.  The patient has the delusional conviction that another person, usually of higher status, is in love with him or her.  Such patients also tend to be solitary, withdrawn, dependent, and sexually inhibited as well as to have poor levels of social or occupational functioning.  The following operational criteria for the diagnosis of erotomania have been suggested: (1) A delusional conviction of amorous communication; (2) Object of much higher rank. (3) Object being the first to fall in love. (4) Object being the first to make advances. (5) Sudden onset (within a 7-day period). (6) Object remains unchanged.Page XI
  • 12. By Mohamed Abdelghani (7) Patient rationalizes paradoxical behavior of the object. (8) Chronic course. (9) Absence of hallucinations.  Besides delusional disorder, it is known to occur in schizophrenia, mood disorder, and other organic disorders.  Patients with erotomania frequently show certain characteristics: They are generally unattractive women in low-level jobs who lead withdrawn, lonely lives; they are single and have few sexual contacts.  They select secret lovers who differ substantially from them.  They exhibit what has been called paradoxical conduct, the delusional phenomenon of interpreting all denials of love, no matter how clear, as secret affirmations of love.  The course may be chronic, recurrent, or brief. Separation from the love object may be the only satisfactory intervention.  Although men are less commonly afflicted by this condition than women, they may be more aggressive and possibly violent in their pursuit of love.  Hence, in forensic populations:  Men with this condition predominate.  The object of aggression may not be the loved individual but companions or protectors of the love object who are viewed as trying to come between the lovers.  The tendency toward violence among men with erotomania may lead initially to police, rather than psychiatric, contact.  So-called stalkers, who continually follow their perceived lovers, frequently have delusions.  Although most stalkers are men, women also stalk and both groups have a high potential for violence. 4) Somatic Type  Also called monosymptomatic hypochondriacal psychosis.  The condition differs from other conditions with hypochondriacal symptoms in the degree of reality impairment: a) In delusional disorder, the delusion is fixed, unarguable, and presented intensely, because the patient is totally convinced of the physical nature of the disorder. b) In contrast, persons with hypochondriasis often admit that their fear of illness is largely groundless.  The three main types "which may overlap" are:Page XII
  • 13. By Mohamed Abdelghani (1) Delusions of infestation (including parasitosis). (2) Delusions of dysmorphophobia, such as of misshapenness, personal ugliness, or exaggerated size of body parts (this category seems closest to that of body dysmorphic disorder). (3) Delusions of foul body odors or halitosis, sometimes referred to as olfactory reference syndrome: its different from the category of delusions of infestation in that patients with the former have an earlier age of onset (mean 25 years), male predominance, single status, and absence of past psychiatric treatment.  The onset of symptoms may be gradual or sudden.  In most patients, the illness is unremitting, although the severity may fluctuate.  Hyperalertness and high anxiety also characterize patients with this subtype.  Some themes recur, such as concerns about infestation in delusional parasitosis, preoccupation with body features with the dysmorphic delusions, and delusional concerns about body odor, which are sometimes referred to as bromosis.  In delusional parasitosis, tactile sensory phenomena are often linked to the delusional beliefs.  Patients with the somatic type of delusional disorder are more often encountered by dermatologists, plastic surgeons, urologists, acquired immune deficiency syndrome (AIDS) specialists, and sometimes dentists or gastroenterologists and rarely present for psychiatric evaluation, and when they do, it is usually in the context of a psychiatric consultation or liaison service. 5) Grandiose Type  Delusions of grandeur (megalomania) have been noted for years. First described by Kraepelin. 6) Mixed Type  The category mixed type applies to patients with two or more delusional themes.  This diagnosis should be reserved for cases in which no single delusional type predominates. 7) Unspecified Type o The category is reserved for cases in which the predominant delusion cannot be subtyped within the previous categories. o A possible example is certain delusions of misidentification: a) Capgras syndrome:  Named for the French psychiatrist who described the illusion des sosies, or the illusion of doubles.  The delusion is the belief that a familiar person has been replaced by an impostor. b) Variants of the Capgras syndrome:Page XIII
  • 14. By Mohamed Abdelghani 1) Fregolis phenomenon  The delusion that persecutors or familiar persons can assume the guise of strangers. 2) Intermetamorphosis  Very rare delusion that familiar persons can change themselves into other persons at will. o Each disorder is not only rare but may be associated with schizophrenia, dementia, epilepsy, and other organic disorders. o Reported cases have been predominantly in women, have had associated paranoid features, and have included feelings of depersonalization or derealization. o The delusion may be short lived, recurrent, or persistent, and has appeared after sudden brain damage. o Certainly, the Fregoli and intermetamorphosis delusions have bizarre content and are unlikely, but the delusion in Capgras syndrome is a possible candidate for delusional disorder. o Cotard syndrome :  Also called delire de negation or nihilistic delusional disorder.  Patients with the syndrome complain of having lost not only possessions, status, and strength, but also their heart, blood, and intestines and the world beyond them is reduced to nothingness.  This relatively rare syndrome is usually considered a precursor to a schizophrenic or depressive episode.  With the common use today of antipsychotic drugs, the syndrome is seen even less frequently than in the past.N.B.: Shared Psychotic Disorder  Also called shared paranoid disorder, induced psychotic disorder, folie a deux, folie impose, and double insanity.  First described by two French psychiatrists, Lasegue and Falret in 1877.  It is probably rare, but incidence and prevalence figures are lacking.  The disorder is characterized by the transfer of delusions from one person to another.  Both persons are closely associated for a long time and typically live together in relative social isolation.  In its most common form, the individual who first has the delusion (the primary case) is often chronically ill and typically is the influential member of a close relationship with a more suggestible person (the secondary case) who also develops the delusion.Page XIV
  • 15. By Mohamed Abdelghani  The person in the secondary case is frequently less intelligent, more gullible, more passive, or more lacking in self-esteem than the person in the primary case.  If the pair separates, the secondary person may abandon the delusion as the occurrence of the delusion is attributed to the strong influence of the more dominant member.  Old age, low intelligence, sensory impairment, cerebrovascular disease, and alcohol abuse are among the factors associated with this disorder.  A genetic predisposition to idiopathic psychoses has also been suggested as a possible risk factor.  Other special forms have been reported, such as folie simultanee, in which two persons become psychotic simultaneously and share the same delusion.  Occasionally, more than two individuals are involved (e.g., folie a trois, quatre, cinq; also folie a famille), but such cases are especially rare.  The most common relationships in folie a deux are sister-sister, husband-wife, and mother-child, but other combinations have also been described.  Almost all cases involve members of a single family. Table 14.3-5 DSM-IV-TR Diagnostic Criteria for Shared Psychotic Disorder A. A delusion develops in an individual in the context of a close relationship with another person(s), who has an already-established delusion. B. The delusion is similar in content to that of the person who already has the established delusion. C. The disturbance is not better accounted for by another psychotic disorder (e.g., schizophrenia) or a mood disorder with psychotic features and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Table 14.3-6 ICD-10 Diagnostic Criteria for Induced Delusional Disorder A. The individual(s) must develop a delusion or delusional system originally held by someone else with a disorder classified in schizophrenia, schizotypal disorder, persistent delusional disorder, or acute and transient psychotic disorders. B. The people concerned must have an unusually close relationship with one another, and be relatively isolated from other people. C. The individual(s) must not have held the belief in question before contact with the other person, and must not have suffered from any other disorder classified in schizophrenia, schizotypal disorder, persistent delusional disorder, or acute and transient psychotic disorders in the past.Page XV
  • 16. By Mohamed AbdelghaniDifferential Diagnosis1. Medical Conditions (Table 14.3-7) o The first step is to eliminate medical disorders as a potential cause of delusions. o Many medical conditions can be associated with the development of delusions at times accompanying a delirious state. o Toxic-metabolic conditions and disorders affecting the limbic system and basal ganglia are most often associated with the emergence of delusional beliefs. o Complex delusions occur more frequently in patients with subcortical pathology:  Huntingtons disease  Idiopathic basal ganglia calcifications. o After right cerebral infarction, types of delusions that are more prevalent include anosognosia and reduplicative paramnesia (i.e., individuals believing they are in different places at the same time). o Capgras syndrome has been observed in a number of medical disorders, including CNS lesions, vitamin B12 deficiency, hepatic encephalopathy, diabetes, and hypothyroidism. o Focal syndromes have more often involved the right rather than the left hemisphere. o Delusions of infestation, lycanthropy (i.e., the false belief that the patient is an animal, often a wolf or "werewolf"), heutoscopy (i.e., the false belief that one has a double), and erotomania have been reported in small numbers of patients with epilepsy, CNS lesions, or toxic-metabolic disorders.Table 14.3-7 Potential Medical Etiologies of Delusional Syndromes Disease or Examples Disorder Class Alzheimers disease, Picks disease, Huntingtons disease, basal Neurodegenerative ganglia calcification, multiple sclerosis, metachromatic disorders leukodystrophy Brain tumors, especially temporal lobe and deep hemispheric Other central nervous tumors; epilepsy, especially complex partial seizure disorder; system disorders head trauma (subdural hematoma); anoxic brain injury; fat embolism Atherosclerotic vascular disease, especially when associated with Vascular disease diffuse, temporoparietal, or subcortical lesions; hypertensive encephalopathy; subarachnoid hemorrhage, temporal arteritis Infectious disease Human immunodeficiency virus or acquired immune deficiencyPage XVI
  • 17. By Mohamed Abdelghani syndrome, encephalitis lethargica, Creutzfeldt-Jakob disease, syphilis, malaria, acute viral encephalitis Hypercalcemia, hyponatremia, hypoglycemia, uremia, hepatic Metabolic disorder encephalopathy, porphyria Addisons disease, Cushings syndrome, hyper- or Endocrinopathies hypothyroidism, panhypopituitarism Vitamin B12 deficiency, folate deficiency, thiamine deficiency, Vitamin deficiencies niacin deficiency Adrenocorticotropic hormones, anabolic steroids, corticosteroids, Medications cimetidine, antibiotics (cephalosporins, penicillin), disulfiram, anticholinergic agents Substances Amphetamines, cocaine, alcohol, cannabis, hallucinogens Toxins Mercury, arsenic, manganese, thallium2. Delirium, Dementia, and Substance-Related Disorders  Should be considered in the differential diagnosis of a patient with delusions.  Delirium can be differentiated by the presence of a fluctuating level of consciousness or impaired cognitive abilities.  Delusions early in the course of a dementing illness, as in dementia of the Alzheimers type, can give the appearance of a delusional disorder; however, neuropsychological testing usually detects cognitive impairment.  Although alcohol abuse is an associated feature for patients with delusional disorder, delusional disorder should be distinguished from alcohol-induced psychotic disorder with hallucinations.  Intoxication with sympathomimetics (including amphetamine), marijuana, or L- dopa is likely to result in delusional symptoms.3. Other Disorders  The psychiatric differential diagnosis for delusional disorder includes:  Malingering and factitious disorder.  Schizophrenia.  Mood disorders.  Obsessive-compulsive disorder.  Somatoform disorders.  Paranoid personality disorder.Page XVII
  • 18. By Mohamed Abdelghani  Delusional disorder is distinguished from schizophrenia by the absence of other schizophrenic symptoms, by the nonbizarre quality of the delusions and lack the impaired functioning seen in schizophrenia.  The somatic type of delusional disorder is differentiated from depressive disorders by the absence of other signs of depression and the lack of a pervasive quality to the depression.  Delusional disorder can be differentiated from somatoform disorders by the degree to which the somatic belief is held by the patient:  Patients with somatoform disorders allow for the possibility that their disorder does not exist, whereas patients with delusional disorder do not doubt its reality.  Separating paranoid personality disorder from delusional disorder requires the clinical distinction between extreme suspiciousness and frank delusion.N.B.: In general, if clinicians doubt that a symptom is a delusion, the diagnosis ofdelusional disorder should not be made.Course and Prognosis o Some research data indicate that an identifiable psychosocial stressor often accompanies the onset of delusional disorder. o Examples of such stressors are recent immigration, social conflict and social isolation. o A sudden onset is generally thought to be more common than an insidious onset. o Some clinicians believe that a person with delusional disorder is likely to have:  Below-average intelligence.  Premorbid personality: extroverted, dominant, and hypersensitive. o The persons initial suspicions gradually become elaborate, consume much of the persons attention, and finally become delusional. o As mentioned, delusional disorder is considered a fairly stable diagnosis. o About 50% of patients have recovered at long-term follow-up, 20% show decreased symptoms, and 30% exhibit no change. o The factors correlate with a good prognosis: 1. High levels of occupational, social, and functional adjustments. 2. Female sex. 3. Onset before age 30. 4. Sudden onset. 5. Short duration of illness. 6. Presence of precipitating factors. 7. Patients with persecutory, somatic, and erotic delusions have a better prognosis than patients with grandiose and jealous delusions.Page XVIII
  • 19. By Mohamed Abdelghani Treatment Table 14.3-8 Diagnosis and Management of Delusional Disorder  Rule out other causes of paranoid features  Confirm the absence of other psychopathology  Assess consequences of delusion-related behavior:  Demoralization  Despondency  Anger, fear  Depression  Impact of search for: medical diagnosis, legal solution, proof of infidelity, etc. (i.e., financial, legal, personal, occupational, etc.)  Assess anxiety and agitation  Assess potential for violence, suicide  Assess need for hospitalization  Institute pharmacological and psychological therapies  Maintain connection through recovery  Delusional disorder was generally regarded as resistant to treatment.  Interventions often focused on managing the morbidity of the disorder by reducing the impact of the delusion on the patients (and familys) life.  The goals of treatment are: To establish the diagnosis, To decide on appropriate interventions, and To manage complications.  The success of these goals depends on an effective and therapeutic doctor-patient relationship.  The patients often enter treatment against their will; even the psychiatrist may be drawn into their delusional nets.  In shared psychiatric disorder: a. The patients must be separated. b. If hospitalization is indicated, they should be placed on different units and have no contact. c. In general, the healthier of the two will give up the delusional belief (sometimes without any other therapeutic intervention). d. The sicker of the two will maintain the false fixed belief.i. Psychotherapy Page XIX
  • 20. By Mohamed Abdelghani  The essential element is to establish a relationship in which patients begin to trust a therapist.  Individual therapy is more effective than group therapy.  Insight-oriented, supportive, cognitive, and behavioral therapies are often effective.  Initially, a therapist should neither agree with nor challenge a patients delusions.  Although therapists must ask about a delusion to establish its extent, persistent questioning about it should probably be avoided.  Physicians may stimulate the motivation to receive help by emphasizing a willingness to help patients with their anxiety or irritability, without suggesting that the delusions be treated, but therapists should not actively support the notion that the delusions are real.  The unwavering reliability of therapists is essential in psychotherapy:  Therapists should be on time and make appointments as regularly as possible, with the goal of developing a solid and trusting relationship with a patient.  Overgratification:  May actually increase patients hostility and suspiciousness because ultimately they must realize that not all demands can be met.  Can be avoided by:  Not extending the designated appointment period.  Not giving extra appointments unless absolutely necessary.  Not being lenient about the fee.  Therapists should avoid making disparaging remarks about a patients delusions or ideas but can sympathetically indicate to patients that their preoccupation with their delusions is both distressing to themselves and interferes with a constructive life.  When patients begin to waver in their delusional beliefs, therapists may increase reality testing by asking the patients to clarify their concerns.  A useful approach in building a therapeutic alliance is to empathize with the patients internal experience of being overwhelmed by persecution.  It may be helpful to make such comments as, "You must be exhausted, considering what you have been through".  Without agreeing with every delusional misperception, a therapist can acknowledge that from the patients perspective, such perceptions create much distress.  The ultimate goal is to help patients entertain the possibility of doubt about their perceptions.  As they become less rigid, feelings of weakness and inferiority, associated with some depression, may surface.  When a patient allows feelings of vulnerability to enter into the therapy, a positive therapeutic alliance has been established, and constructive therapy becomes possible.  When family members are available, clinicians may decide to involve them in the treatment plan, without being delusionally seen as siding with the enemy.Page XX
  • 21. By Mohamed Abdelghani  Consequently, both the patient and the family need to understand that the therapist maintains physician-patient confidentiality and that communications from relatives are discussed with the patient.  The family may benefit from the therapists support and, thus, may support the patient.  A good therapeutic outcome depends on a psychiatrists ability to respond to the patients mistrust of others and the resulting interpersonal conflicts, frustrations, and failures.  The mark of successful treatment may be a satisfactory social adjustment rather than abatement of the patients delusions.ii. Hospitalization  Patients can generally be treated as outpatients, but clinicians should consider hospitalization for several reasons:  First, complete medical and neurological evaluation to determine whether a nonpsychiatric medical condition is causing the delusional symptoms.  Second assessment of the pt. ability to control violent impulses (e.g., to commit suicide or homicide) that may be related to the delusional material.  Third, patients behavior about the delusions may affect their ability to function within their family or occupational settings; they may require professional intervention to stabilize social or occupational relationships.  If a physician convinces a patient that hospitalization is inevitable, the patient often voluntarily enters a hospital to avoid legal commitment.iii. Pharmacotherapy o In an emergency, severely agitated patients should be given an antipsychotic drug intramuscularly. o Although no adequately clinical trials, most clinicians consider antipsychotic drugs the treatment of choice for delusional disorder. o Patients are likely to refuse medication because they can easily incorporate the administration of drugs into their delusional systems. o Physicians should not insist on medication immediately after hospitalization but, rather, should spend a few days establishing rapport with the patient. o Physicians should explain potential adverse effects to patients, so that they do not later suspect that the physician lied. o A patients history of medication response is the best guide to choosing a drug. o A physician should often start with low doses (e.g., 2 mg of haloperidol [Haldol] or 2 mg of risperidone [Risperdal]) and increase the dose slowly. o If a patient fails to respond to the drug at a reasonable dosage in a 6-week trial, antipsychotic drugs from other classes should be tried. o Some investigators indicate that pimozide may be particularly effective in delusional disorder, especially in patients with somatic delusions. Page XXI
  • 22. By Mohamed Abdelghani o A common cause of drug failure is noncompliance, which should also be evaluated. o Concurrent psychotherapy facilitates compliance with drug treatment. o If the patient receives no benefit from antipsychotic medication, discontinue use of the drug. o In patients who respond to antipsychotic drugs, some data indicate that maintenance doses can be low. o Although no studies evaluate the use of antidepressants, lithium (Eskalith), or anticonvulsants (e.g., carbamazepine [Tegretol] and valproate [Depakene]) in the treatment of delusional disorder, trials with these drugs may be warranted in: a) Patients who do not respond to antipsychotic drugs. b) Patient has features of a mood disorder or a family history of mood disorders.Page XXII