Delusional Disorders : History, Classification

History of Delusional Disorder

• Delusional disorders were once referred to as paranoid disorders or paranoia.
• In the early 19th century, Johann Heinroth and later Jean Esquirol identified patients with irrational beliefs and logical thinking. They identified patients having delusional disorders.
• In 1863, Karl Kahlbaum coined the term “diastrephia” for patients having predominantly delusions.
• An important thing observed in patients with delusions is that personality is preserved during illness.
• Kraeplin has classified delusional disorders into schizophrenia and mood disorders. Paranoia is the third form of psychosis.
  • The patients have chronic, non-bizarre, well-systematized delusions without typical deterioration of dementia praecox.
  • Kraeplin described the paranoia in the elderly, which is now known as paraphrenia.

Diagnostic Classification Of Delusional Disorder

• DSM-II - Paranoid states were regarded as variants of schizophrenia.
• DSM-III - Paranoia, including non-bizarre delusions without prominent hallucinations.
  • In DSM III, the name paranoia was changed to delusional disorders.
• DSM V - The requirement that delusion should be non-bizarre was removed.
  • One of the specifiers was added in DSM V, which states if a patient has a bizarre delusion, it is known as a delusion with bizarre content.
  • Course and current severity have been added as specifiers.

Epidemiology Of Delusional Disorder

• The prevalence of delusional disorders is 0.2 to 0.3 percent.
• The mean age of onset is 40 years, and the range of age group can be 18 to 90 years.
• More likely to occur in females than males.
  • Delusion of persecution is more likely to be seen in males.
  • Delusion of erotomania is more likely to be seen in females.
• Marital status and employment have been linked to delusional disorders.
• Recent immigration and lower socioeconomic status have some association with delusional disorders.

Etiology Of Delusional Disorder

• The exact etiology of delusional disorders is not well established. However, some of the etiological factors are listed below:
  • Genetic Factors 
    •  Family studies have shown there is an increased prevalence of delusional disorders and related personality traits, including suspiciousness, jealousy, and secretiveness in relatives of delusional disorder probands.
    • Studies have failed to identify strong genetic links between schizophrenia and delusional disorders.
    • Neither an increased incidence of schizophrenia and mood disorders was observed in families of delusional disorder probands, nor an increased incidence of delusional disorders was seen in families of probands and schizophrenia.
  • Biological Factors
    • A wide range of non-psychiatric medical conditions and substances can cause delusions.
    • Delusional disorders are more likely to affect the limbic system and basal ganglia.
    • Neurological conditions most commonly associated with delusional disorders with no intellectual impairment are more likely to be complex delusions.
    • Patients with impaired intellectual abilities tend to have simple delusions.
    • Delusional disorders may involve the limbic system or basal ganglia in patients who have intact cerebral cortical functioning.
    • Delusional disorders might arise as a normal response to abnormal experiences in the environment or the nervous system.
    • Patients might have hallucinatory experiences that need to be explained.
• Psychodynamic Factors
  • One of the major contributions of Freud was he demonstrated the role of projection in the formation of delusional thought.
  • Persecutory delusions occur as a protective psychological response to conflicts, representing a threat to self, leading to affective withdrawal.
  • The person also uses defensive mechanisms such as projection.
  • The defensive mechanisms fail to decrease the anxiety, leading to a maladaptive state. This ultimately leads to the formation of delusional disorders.
  • Norman Cameron stated seven situations favoring the development of delusional disorders. The person may develop delusional disorders in the following situations:
    • Increasing expectation of receiving sadistic treatment
    • Social isolation.
    • Increasing envy and jealousy.
    • Increasing distrust and suspicion.
    • Lowering self-esteem.
    • Increasing potential for ruminations over probable meanings and motivations.
  • Frustration from these situations can exceed the tolerable limits, making the person withdrawn and anxious.
    • The person might realize something is wrong and seek an explanation for problems, followed by the crystallization of a delusional system.
  • Elaboration of delusion includes the attribution of hostile motivation to both real and imaginary persons, resulting in the organization of a pseudo-community, which is a perceived community of plotters.
    • Pseudo community binds projected fears, justifies the patient’s aggression, and provides targets for the patient’s hostility.
  • Paranoid patients have a lack of trust in relationships because of a consistently hostile family environment, often due to an over-controlling mother and distant or sadistic father. Other psychodynamic factors include the following:
    • Defense Mechanisms
      • The defense mechanisms which can lead to delusions include projection, denial, and reaction formation.
      • Projection: the person projects his own anger and hostility onto others to protect themselves from recognizing their own unacceptable impulses.
      • Denial is used to avoid awareness of painful reality.
      • Reaction formation is used as a defense against aggression and dependence needs, which is converted into independence.
• Cognitive Factors
  • Patients with persecutory delusions selectively attend to threatening information and jump to conclusions on insufficient information.
  • The patient attributes negative events to external personal causes and has difficulty contemplating other’s intentions.
  • The patient might have preferential recall of threatening events.

Risk Factors Of Delusional Disorders

• The risk factors for delusional disorders include the following:
  • Sensory impairment.
  • Social isolation.
  • Recent immigration.
  • Advanced age.
  • Family history.
  • Personality features.

Clinical Features Of Delusional Disorders

General Appearance

• The patient might appear well groomed and well dressed, with no evidence of gross disintegration of personality or of daily activities.
• The patient might appear odd, eccentric, suspicious, and hostile.
• Marked abnormality would be noticed in the delusional system.
• The mood appears to be consistent with the delusional content.
  • Patients with delusions of grandiosity might be euphoric.
  • Patients with delusions of persecution might appear suspicious.
• Mild depressive features may be present.

Thoughts In Delusional Disorders

• Delusions are the most important or key features of delusional disorders and can be bizarre or non-bizarre.
• Delusions are systemized. 
• The following vectors or areas of abnormalities are seen in patients with delusional disorders:
  • Conviction
  • Extension
  • Bizarreness
  • Disorganization 
  • Pressure
  • Affective response
  • Deviant behavior
• Patients must be evaluated for ideation of plans to act on their delusions.
• Destructive aggression is most common in patients with a history of violence.
• Hallucinations are usually absent or may be present. If they are present, they are auditory rather than visual.
• Orientation, memory, and other cognitive processes are usually intact.
• No judgment, no insight in these patients

Specific Types Of Delusional Disorders

1. Persecutory type 
   • It is one of the best types of delusional disorder and is the most common one.
   • The patient is convinced someone wants to harm him, leading to irritability, anger, aggression, or homicidal behavior.
   • Persecutory delusion can be seen in schizophrenia and delusional disorder. Delusions would be systematized coherently in delusional disorders. 
   • There will be clarity, logic, and systematic elaboration of the persecutory theme.
   • Absence of other psychopathy.
   • Impairment is related to delusion itself.
   • Social functioning is not impaired.
2. Jealous Type
   • The most common delusion of jealousy is a belief that one’s spouse or partner is unfaithful, known as the delusion of infidelity.
   • The magnitude of the jealous response would be very high.
   • The partner may take on delusional qualities.
   • Seen more in men and can lead to harm to a partner or others.
   • Symptoms of jealous-type delusion disorders can be seen in the following:
     • Schizophrenia.
     • Mood disorders.
     • Drug abuse.
     • Alcoholism.
   • Also known as Othello syndrome or morbid jealousy.
3. Erotomanic Type
   • It is also known as De Clerambault syndrome or psychose passionelle.
   • The patient has a delusional belief that another person of a higher stature is in love with the patient.
   • Patients often tend to be:
     • Solitary.
     • Withdrawn.
     • Dependent.
     • Sexually inhibited.
   • Poor level of social or occupational functioning might be observed in such patients.
   • Patients often exhibit paradoxical conduct.
   • 3.a)Operational Criteria
     • Delusional conviction of sexual communication.
     • The object is of much higher rank.
     • The love object has fallen in love first.
     • The love object has made advances first.
     • The love object remains unchanged.
     • Rationalizing paradoxical behavior of objects.
     • The onset is acute, and it is within seven days.
     • Absence of hallucinations with chronic course of action.
   • Stalking and aggressive behaviour are seen,  more often in men.
4. Somatic Type
   • Not included in Kraepelin’s original description of paranoia.
   • The central theme of somatic delusions is hypochondriacal or somatic in nature.
   • Somatic-type delusions have also been known as monochromatic hypochondriasis.
   • The onset is sudden or gradual.
   • In most patients, the illness is unremitting, and the severity may fluctuate.
   • The different types of somatic type of delusions include:

5. Grandiose Type Of Delusional Disorder

• The grandiose Type Of Delusional Disorder is also known as megalomania.
• The patient has false beliefs that he has supernatural powers.
• The patients are relatively rare to encounter.
• The patient has symptoms of mania if the diagnosis is a bipolar disorder with psychotic features, or if the patient has other psychotic symptoms, the diagnosis is schizophrenia.

6. Mixed Type

• Patients might have symptoms of >1 subtype.
• The delusions may be bizarre in nature.

7. Unspecified Type

• Other delusions that may occur include misidentification syndromes, which include Capgras syndrome(illusion of double) and Fregoli syndrome(a familiar person is imposing as a stranger and can make multiple appearances).

• The delusional disorders might be seen in other disorders, including:
  • Schizophrenia.
  • Dementia.
  • Epilepsy.
  • Other organic disorders.
• The other unspecified type of delusional disorder is Cotard syndrome, described by Jules Cotard.
  • Cotard syndrome is a precursor to schizophrenia and depressive episodes.

Diagnostic Criteria For Delusional Disorders

1. One or more delusional disorders should be present for more than one month.
2. Criteria A of schizophrenia has never been met.
3. Hallucinations, if present, are not prominent and are related to delusional themes.
4. Functioning is not markedly impaired, and behavior is not bizarre or odd.
5. If mania or mood depressive episodes have occurred, they are briefly relative to the duration of delusion.
6. They are not attributable to any substance or another medical condition or to another mental disorder such as OCD or body dysmorphic disorder.

• The content of delusions must have bizarre content. 
• The course of the disease:
  • First Episode
    • Acute Episode
    • Partial Remission
    • Full Remission
  • Multiple Episodes
    • Acute Episode
    • Partial Remission
    • Full Remission
  • Continuous
  • Unspecified
• The severity of the disease:
  • Current Severity: Quantitative Assessment of 1 symptom of psychosis Delusion, Hallucination, Disorganized speech, Abnormal psychomotor Beh., Negative Syndrome
  • Rated for current severity
  • 5 Point - Scale (0-4)
  • Clinician - Rated Dimensions of Psychosis Syndrome Severity.

Differential Diagnosis of Delusional Disorder

• The key feature or first step in clinical assessment is delusion; only then a diagnosis of delusional disorder can be made.
• As symptoms of delusions worsen, the encapsulation of the symptoms becomes less severe, and delusions become more clear.
• Information should be taken from different sources, such as family members, friends, etc.
• There might be behavioral symptoms.
• The inappropriateness of the patient’s behavior or emotional responses may suggest it’s a delusion.
• General medical conditions
  • It is important to rule out general medical conditions while diagnosing delusional disorders. 
  • The general medical conditions where delusions can be seen include:
    • Brain tumors, especially of the temporal lobe and deep hemispheric tumor.
    • Epilepsy is especially more complex than partial seizures.
    • Head trauma, including subdural hematoma.
    • Metabolic disorders affecting the limbic system and basal ganglia.
      • The patient might have complex delusions in subcortical pathology.
      • Example: in Huntington's disease-idiopathic basal ganglia calcification, 50% of patients show delusions.
    • Anosognosia is characterized by nonrecognition of disability.
    • Reduplicative paramnesia.
    • Right cerebral infarctions.
    • Capgras syndrome.
      • CNS lesions include focal lesions on the right side.
      • Vitamin B12 deficiency.
      • Hepatic encephalopathy.
      • Diabetes.
      • Hypothyroidism.
• Delusions of infestation
  • Lycanthropy- a false belief that the patient is a wolf or werewolf.
  • Erotomania

Dementia and delirium

• Most delusions are simple and seen in 15 to 50% of patients.
• A minority of delusions are complex and well-systematized.
• Cognitive impairment is seen in dementia.
• Delusion of persecution is seen in patients with dementia.
• Delirium can be a differential diagnosis of delusions, but fluctuating levels of consciousness help it distinguish from delusions.

Substance Use or Medications May Be Linked to Delusions

• Amphetamine or cocaine are most likely linked to delusions.
• OTC medications and herbal products (ephedra) might lead to delusions.

Other Psychotic Disorders

Mood Disorders

• Overviewed idea vs. depression with lack of insight vs delusion
  • Illness Anxiety Disorder (Hypochondriasis)
    •  Preoccupation with having a serious illness (Based on a Person's Misinterpretation of Bodily Syndrome)

• Body Dysmorphic Disorder
  • Preoccupation with imagined defects in appearance
  • May recognize view is Distorted
  • Some may hold beliefs with Delusional intensity
  • Specifier: “Absent Insight/ Delusional Beliefs”
• Obsessive-compulsive disorder (OCD)
  • A person recognizes obsessions or compulsions that are excessive or unreasonable
  • Specifier: “Absent Insight/ Delusional Beliefs”
• Paranoid personality disorder
  • Persecutory Ideas Å
  • Longitudinal History will help
  • Delusions may be superimposed on an individual's premorbid personality 
  • E.g., Delusional Disorder and Paranoid P.D
• In general, if the clinician has doubts about the diagnosis, then don’t make a diagnosis of delusional disorder. 

Course of Delusional Disorder

• Onset: Mid-late 30’s
• Insidious disease in most of the patients
• Delusional disorder is associated with less deterioration in functioning.
• Symptoms may persist and remain fixed, but generally, the patient is stable.
  • Less than ¼th patients will develop schizophrenia
  • Less than 10% will develop mood disorders.
• Delusional disorder is not just an early stage in the development of any other disorder. Rather, it is a completely different entity in itself.

Prognosis

Treatment

Goals of Treatment

• Assessment, establish diagnosis
• Decide appropriate interventions
• Manage complications

Assessment And Diagnosis

• It is important to rule out other causes.
• Confirm the absence of other psychopathy.
• Assess the consequences of delusion-related behavior.
• Assessment of anxiety, agitation, violence, and suicide is required.
• Assessing the need for hospitalization(manage complications)

Psychological Therapies in Delusional Disorder

• Establish effective and therapeutic doctor-patient relationships.
• It is not easy to gain the patient's trust.
• The psychiatrist must be able to respond to the patient's mistrust of others and towards themselves as well
• Satisfactory social adjustment is more important than abatement of a patient's delusions.
• Individual therapy> group therapy
• The following therapies are effective for delusions:
  • Insight-oriented.
  • Supportive.
  • Cognitive.
  • Behavior.
• Do’s and don’t’s

• The reliability of a therapist is essential.
  • Always be on time
  • Make appointments regularly
  • Overgratification must be avoided.
• As delusions become less rigid some depressive symptoms may surface.
• Hospitalization can be considered:
  • Need of complete evaluation
  • Assessment of violent impulses is needed.
• Significant impact on patients functioning.

Pharmacotherapy in Delusional disorder

• Antipsychotics are first-line drugs.
• Severely agitated patient: IM antipsychotics
• Patients may refuse medication, so don’t insist immediately but rather establish rapport and explain the potential side effects.
• Low-dose antipsychotics can be started and then gradually increased
  • Haloperidol
  • Risperidone
  • Pimozide- effective in somatic delusions

Drug Failure 

• No reasonable response for more than 6 weeks after starting the treatment
• Check for non compliance\Do concurrent psychotherapy
• Stop drugs if there is no benefit
• Antidepressant, lithium, valproate, carbamezapine trial can be done:
  • If there is no response to antipsychotics
  • Features of mood disorders are present
  • A family history of mood disorders is present

Hope you found this blog helpful for your Psychiatry Residency Clinical Psychiatry preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.