Delusional Disorder — Persecutory Type

I. IDENTIFYING INFORMATION

Client Name Divya Chauhan (name changed for confidentiality)

Case Number Case No. 9
Age 27 years
Gender Female
Education [Link]. (Nursing) — Completed
Occupation Staff Nurse, Private Hospital, Noida
Marital Status Unmarried
Residence Vaishali, Ghaziabad (lives with parents and younger sister)
Referred For Psychiatric and psychological assessment — persecutory beliefs, social
withdrawal, occupational impairment
Referred By Psychiatrist (Dr. P. Mathur) — referred after initiating Risperidone 2mg;
requested psychological assessment and supportive therapy
Date of Assessment March 22, 2026
Informant Patient (self) and Mother — Usha Chauhan (Age 52)

II. REASON FOR REFERRAL

Divya Chauhan, a 27-year-old staff nurse, was referred by her psychiatrist for psychological assessment and
supportive therapy following initiation of antipsychotic medication. Divya holds a firm, unshakeable belief that her
senior colleague at work — Head Nurse Ms. Verma — is conspiring to get her dismissed from her job by spreading
false rumours, tampering with patient records attributed to her, and influencing other colleagues to turn against
her. She has held this belief for approximately 10 months. Despite requests for evidence, Divya provides only
ambiguous, circumstantial observations which she interprets as confirmation of the conspiracy. Her functioning at
work and at home has deteriorated significantly. She does not believe she has a psychiatric illness and attended the
session under pressure from her parents.
III. BACKGROUND HISTORY

A. Family Background
• Lives with father — Ramesh Chauhan (age 55, private company driver), mother — Usha (age 52,
homemaker), and younger sister (age 23, B.A. student).
• Family described as close-knit and supportive. Parents initially believed Divya's account of workplace
persecution but are now concerned that her interpretation may be distorted.
• No family history of formal psychiatric diagnosis. Mother describes herself as a 'worrier' but no clinical-level
symptoms.
• Younger sister is Divya's closest confidante; corroborates that Divya's account of the workplace situation
has become increasingly elaborate and implausible over time.

B. Personal and Developmental History

• Described as a hardworking, conscientious, and somewhat reserved individual throughout school and
college.
• Completed [Link]. Nursing; worked at current hospital for 3 years prior to the onset of symptoms —
described as a competent, dedicated nurse by previous supervisors.
• No prior psychiatric history. No significant childhood adversity reported.
• A single romantic relationship at age 24 ended after 8 months — described as mutually agreed upon; no
significant trauma associated.
• Has always been somewhat suspicious and private — 'she never trusted easily', according to mother — but
this was within normal limits prior to 10 months ago.

C. Onset and Course of Current Illness

• Approximately 10 months ago: Divya received a formal warning from hospital management regarding a
medication documentation error. She maintains the error was not hers and was deliberately placed in her
file by Head Nurse Ms. Verma.
• Over the following months: belief in persecution expanded — she began interpreting colleagues' neutral
behaviours (whispering, not greeting her, looking in her direction) as evidence of the conspiracy.
• 7 months ago: Divya submitted a formal written complaint to hospital management against Ms. Verma —
the complaint was reviewed and dismissed due to insufficient evidence.
• 5 months ago: began refusing to sign certain patient documents for fear they would be 'used against her';
this created direct patient care and professional conduct issues.
• 3 months ago: parents noticed significant social withdrawal, poor sleep, and reduced appetite at home.
• 2 months ago: brought to psychiatrist by parents; Risperidone 2mg OD initiated. Partial compliance —
Divya takes the medication reluctantly and inconsistently.

D. Medical History
• No prior psychiatric diagnosis or hospitalisation.
• Currently on Risperidone 2mg OD — partially compliant; denies need for medication ('there is nothing
wrong with my mind').
 • No significant medical illness, neurological history, or substance use.
• Sleep: disturbed — wakes repeatedly at night ruminating about the perceived conspiracy; averages 5
hours.

IV. PRESENTING COMPLAINTS

Complaints reported by Divya and corroborated/contextualised by mother (Usha Chauhan):

A. Delusional Beliefs (as reported by patient)

• Head Nurse Ms. Verma is deliberately trying to destroy her career out of professional jealousy.
• Ms. Verma has tampered with her patient documentation to make errors appear as hers.
• Colleagues have been 'told to' avoid and exclude her as part of Ms. Verma's campaign.
• Hospital management is 'in on it' — the formal complaint was dismissed to protect Ms. Verma.
• Believes her phone may be monitored and her locker searched when she is not present.
• Interprets any neutral or ambiguous event at work as further evidence of the conspiracy (ideas of
reference).

B. Behavioural Consequences
• Refuses to eat food from the hospital canteen — fears it may be tampered with.
• Has stopped greeting or conversing with colleagues beyond what is professionally necessary.
• Checks her patient files repeatedly before submitting — takes 2–3 times longer than usual.
• Has stopped participating in hospital team meetings and training sessions.
• At home: withdrawn, irritable, and preoccupied; rarely engages with family in the evenings.

C. What Patient Does NOT Report as Problems

• Does not believe she has a psychiatric illness.
• Does not experience hallucinations (denies hearing voices or seeing things).
• Functioning in aspects of life unrelated to the perceived persecution is relatively preserved — she
continues to manage her finances, personal hygiene, and daily routine adequately.

V. BEHAVIOURAL OBSERVATIONS
 • Attended reluctantly — stated at the start: 'I am only here because my parents insisted. There is nothing
wrong with me mentally.'
• Well-groomed and professionally dressed. Maintained appropriate eye contact.
• Composed and articulate — did not appear overtly distressed or agitated.
• Described the perceived persecution in a detailed, organised, internally consistent manner — presented
her 'evidence' methodically, as if making a case.
• Became notably tense and defensive when the clinician gently explored alternative interpretations of
events — 'You sound like the hospital management. Nobody believes me.'
• Showed no loosening of associations, disorganised speech, or perceptual disturbances.
• Good general knowledge, coherent reasoning, and normal social functioning during non-persecution-
related conversation.
• Mother interjected at one point to say the situation at work 'may not be exactly as Divya describes' —
Divya immediately became irritated and redirected the conversation.

VI. MENTAL STATUS EXAMINATION (MSE)

MSE conducted on March 22, 2026.

MSE DOMAIN WHAT TO ASSESS CLINICIAN'S FINDINGS

1. Appearance & Grooming, eye contact, psychomotor Well-groomed; professionally dressed.

Behaviour activity, attitude Appropriate eye contact throughout.
Calm and composed at baseline; became
defensive when delusion was gently
challenged.
Attended reluctantly; stated she does not
believe she needs assessment.

2. Speech Rate, volume, tone, spontaneity, coherence Rate and volume: Normal. Tone: Measured
and controlled.
Coherent, organised, and articulate. No
disorganisation or loosening of associations.
Notably detailed and methodical when
describing perceived persecution.

3. Mood Depressed, anxious, irritable, euthymic? Mood: Mildly irritable and guarded at
baseline; calm during neutral conversation.
Underlying anxiety related to perceived
occupational threat evident.
No pervasive depressed mood; affect not
grossly dysphoric.

3a. Affect Flat, blunted, constricted, full, labile? Affect: Constricted but appropriate to
content — became tense when persecution
theme was challenged, relaxed during
 neutral topics.
No blunting, lability, or incongruence.

3b. Mood-Affect Congruent / Incongruent? Congruent — irritability and guardedness

Congruence consistent with delusional belief system.

4. Thought Process Logical, goal-directed? Loosening, Thought process: Logical, organised, and
tangential? coherent — hallmark of Delusional Disorder
vs. Schizophrenia.
No loosening of associations, flight of ideas,
or thought blocking.
Thinking is goal-directed but rigidly fixed
around the persecution theme.

5. Thought Content Delusions, preoccupations, suicidal Primary delusion: Persecutory — firm,

ideation? unshakeable belief that Head Nurse Ms.
Verma is conspiring to destroy her career.
Ideas of reference: neutral colleague
behaviours (whispering, eye contact)
interpreted as persecution-related.
Delusion is encapsulated — other areas of
thought content are not affected.
No suicidal ideation. No homicidal ideation
reported (patient denies intent to harm Ms.
Verma).

5a. Nature of Delusion Fixed, encapsulated, systematised? Fixed: Cannot be challenged or modified by
evidence or logical argument.
Encapsulated: Does not permeate all areas
of thought — functioning in non-persecution
domains relatively preserved.
Systematised: Internally consistent; patient
has built an elaborate, logically connected
(within her framework) account of the
conspiracy.

5b. Ideas of Reference Present / Absent? Present — interprets neutral stimuli

(colleagues whispering, glances in her
direction, management's email timing) as
specifically directed at and meaningful to
her persecution.

5c. Suicidal / Homicidal Active / Passive / None? No suicidal ideation reported.

Ideation No homicidal intent toward Ms. Verma
reported; anger is present but has been
expressed only through formal complaint
channels.
Risk of impulsive confrontation or escalation
should be monitored.

6. Perceptions Hallucinations, illusions, dissociation? No hallucinations reported — patient

explicitly denies hearing voices or seeing
things.
No illusions or dissociation.
 Absence of hallucinations is a critical
diagnostic feature distinguishing Delusional
Disorder from Schizophrenia.

7. Cognition Overall cognitive functioning Cognitive functioning intact — above-

average estimated intelligence.
Concentration, memory, and orientation all
unimpaired.
This is consistent with Delusional Disorder —
cognition is typically preserved.

7a. Orientation Person / Place / Time / Situation? Fully oriented.

7b. Attention & Serial 7s, digit span? Intact — serial 7s completed without error.
Concentration Digit span normal.

7c. Memory Immediate, recent, remote? Intact — 3/3 words; full recall at 5 minutes.
Remote memory intact.

7d. Abstract Thinking Proverbs, similarities? Intact. Demonstrated sophisticated

reasoning — consistent with nursing
education and above-average intelligence.

7e. Intelligence (Estimate) Average / Above / Below? Estimated above-average. [Link]. Nursing
graduate; articulate, professional.

8. Insight Grade 1–6? Grade 1 — Complete absence of insight.

Firmly denies having a psychiatric illness:
'There is nothing wrong with my mind. The
problem is with Ms. Verma, not me.'
Partial medication compliance only — takes
Risperidone inconsistently; does not believe
it is necessary.
Absence of insight is the most significant
barrier to treatment.

9. Judgement Social and occupational judgement? Occupational judgement significantly

impaired within the delusional domain —
refusing to sign documents, avoiding team
meetings, submitting formal complaints
without sufficient evidence.
Social judgement intact in non-delusional
contexts.
Risk of further occupational consequences
(suspension, dismissal) due to delusional-
driven behaviour is high.

10. Risk Summary Suicide, harm to others, occupational risk? Suicide risk: Low — no ideation; anger
directed externally.
Harm to others risk: Low-Moderate — no
stated intent; monitor for escalation given
intensity of belief.
Occupational risk: High — delusional
behaviour (refusing to sign documents,
formal complaints) may lead to disciplinary
 action or dismissal.
Medication non-compliance risk: High —
must be addressed urgently.

Additional Observations:
Divya's presentation is clinically distinctive — she is well-groomed, articulate, coherent, and professionally
competent in areas outside the delusional theme. This preserved functioning alongside a fixed, encapsulated, non-
bizarre persecutory delusion in the absence of hallucinations or formal thought disorder is the hallmark of
Delusional Disorder. The complete absence of insight and partial medication compliance are the primary clinical
challenges.

VII. PSYCHOLOGICAL TESTS ADMINISTERED

Tests administered on March 22, 2026. Note: formal psychometric testing in Delusional Disorder is limited by the
patient's denial of illness. Tests chosen assess symptom severity, comorbid mood, and insight.

Abbreviations:

Abbreviation Full Form What It Measures

PANSS Positive and Negative Syndrome Scale Clinician-rated psychosis symptom severity across
positive, negative, and general domains

PSYRATS Psychotic Symptom Rating Scales Measures characteristics of delusions (conviction,

preoccupation, distress, disruption)

SAI-E Schedule for Assessment of Insight — Formally assesses level of insight into illness — critical in
Expanded delusional disorder

BDI-II Beck Depression Inventory — Second Edition Measures depressive symptoms — rules out psychotic
depression

BAI Beck Anxiety Inventory Measures anxiety severity comorbid with delusional
presentation

[Link]. Test Full Name Score / Result Interpretation

1. PANSS Positive and Negative Syndrome Positive: 18 | Negative: Moderate psychosis

Scale 9 | General: 28 | Total: severity — positive
55 symptoms (delusions,
suspiciousness) prominent;
negative symptoms
minimal; consistent with
Delusional Disorder profile

2. PSYRATS — Psychotic Symptom Rating Scales Conviction: 4/4 | High delusional conviction
 Delusions (Delusion subscale) Preoccupation: 3/4 | and preoccupation;
Distress: 3/4 | significant distress and
Disruption: 3/4 | Total: occupational disruption;
13/16 delusion is clinically severe

3. SAI-E Schedule for Assessment of Insight Total: 4/14 (Severely Complete denial of illness;
— Expanded impaired insight) does not attribute
symptoms to a psychiatric
cause; partially compliant
with medication only due
to parental pressure

4. BDI-II Beck Depression Inventory — Score: 13 (Mild Mild depressive symptoms

Second Edition Depression) — secondary to perceived
persecution and
occupational stress; not
psychotic depression

5. BAI Beck Anxiety Inventory Score: 17 (Moderate Moderate anxiety —

Anxiety) driven by perceived threat
from Ms. Verma and
uncertainty about
occupational security

Tests planned for next visit:

[Link]. Test Full Name Used For

1. PDI-21 Peters Delusions Inventory — 21 item Assess delusional ideation across multiple
dimensions — distress, preoccupation,
conviction

2. WHOQOL-BREF WHO Quality of Life Scale — Brief Assess impact of delusional disorder on
overall quality of life

3. PHQ-9 Patient Health Questionnaire — 9 item Track depressive symptoms longitudinally

VIII. DETAILS ABOUT SIGNIFICANT OTHERS

Mother — Usha Chauhan (Age Primary caregiver and informant. Initially believed Divya's account entirely.
52) Now concerned that Divya's interpretation of events is distorted — notices
her account has become increasingly elaborate.
Ensures Divya takes medication as far as possible; describes significant
household tension when medication compliance is discussed.
Supportive and motivated to engage with family psychoeducation.

Father — Ramesh Chauhan Private company driver; present at home in evenings.

(Age 55) Supportive but overwhelmed — does not know how to respond to Divya's
persecution accounts.
Needs psychoeducation about Delusional Disorder and communication
strategies.

Younger Sister (Age 23) Closest to Divya; initially supported her account but now notices
inconsistencies and elaboration.
Has gently tried to offer alternative perspectives — Divya has reacted with
anger and accusation of 'not believing her.'
Experiencing emotional strain; herself needs psychoeducation and support.

Psychiatrist — Dr. P. Mathur Initiated Risperidone 2mg OD two months ago.

Referred for psychological assessment and supportive therapy alongside
pharmacotherapy.
Regular coordination between therapy and psychiatrist planned —
medication compliance is a shared priority.

IX. ANY OTHER RELEVANT INFORMATION

• The formal documentation error that precipitated the onset of symptoms may or may not have been
genuinely Divya's fault — this remains ambiguous and should not be explored in a manner that reinforces
or challenges the delusion directly.
• Medication non-compliance is the most urgent clinical issue — Risperidone 2mg is below the typical
therapeutic dose range for psychosis and inconsistent use makes treatment ineffective. Coordination with
Dr. Mathur for compliance strategies is essential.
• Occupational risk is high — Divya's refusal to sign patient documents and avoidance of team meetings
constitutes a professional conduct issue that may lead to suspension or dismissal, further entrenching the
persecutory narrative.
• Therapeutic approach must avoid directly confronting or arguing against the delusion — this will rupture
alliance. Instead, Cognitive Behavioural Therapy for Psychosis (CBTp) uses indirect, Socratic questioning to
gently introduce doubt without direct confrontation.
• Family accommodation — parents currently accommodate Divya's delusional framework to avoid conflict;
this maintains the delusion and must be gently and gradually addressed through family psychoeducation.
• Duration of untreated psychosis (approximately 10 months) is a significant prognostic factor — earlier
treatment is associated with better outcomes in delusional disorder.

X. OBSERVATIONS OF THE CASE

 • Well-groomed, articulate, and coherent — preserved functioning outside the delusional theme is the
hallmark of Delusional Disorder and distinguishes it from Schizophrenia.
• Described persecution in a detailed, organised, internally consistent manner — presenting 'evidence'
methodically rather than chaotically.
• Became defensive when alternative interpretations were gently introduced — 'You sound like hospital
management. Nobody believes me.'
• No hallucinations reported or observed — critical diagnostic feature confirming Delusional Disorder over
Schizophrenia.
• PANSS total = 55 (Moderate) — positive symptoms prominent (P6 Suspiciousness = 5; P1 Delusions = 6);
negative symptoms minimal (N = 9); consistent with Delusional Disorder profile.
• PSYRATS Delusion subscale = 13/16 — high conviction (4/4), preoccupation (3/4), distress (3/4), and
disruption (3/4); delusion is clinically severe and entrenched.
• SAI-E = 4/14 — severely impaired insight; complete denial of psychiatric illness; medication taken only
under parental pressure.
• BDI-II = 13 (Mild Depression) and BAI = 17 (Moderate Anxiety) — secondary to perceived persecution and
occupational threat; not independent mood or anxiety disorders.
• Occupational risk is high — refusing to sign documents and avoiding team meetings constitutes
professional misconduct risk.
• No suicidal ideation. Harm to others risk is low-moderate — no stated intent toward Ms. Verma; anger
channelled through formal complaints.

XI. INTERVENTION PROVIDED / RECOMMENDED

A. Interventions Provided in This Session

• Comprehensive psychosis assessment (PANSS, PSYRATS, SAI-E, BDI-II, BAI) administered and interpreted.
• Therapeutic alliance established carefully — avoided confronting or validating the delusion; focused on
Divya's distress and functional impact rather than the truth of her beliefs.
• Psychoeducation provided to mother (Usha) regarding Delusional Disorder — explained the nature of fixed
beliefs, why arguing against them is counterproductive, and the importance of medication compliance.
• Coordinated referral note sent to Dr. P. Mathur regarding partial medication compliance and the need for
compliance strategies.

B. Recommended Interventions
Cognitive Behavioural Therapy for Psychosis (CBTp) is the primary recommended psychological intervention. Given
the complete absence of insight, the therapeutic approach must begin with engagement and alliance-building
rather than direct delusional work. Initial sessions should focus on Divya's distress and occupational concerns (goals
she endorses) rather than challenging her beliefs directly. Gradual Socratic questioning — introducing gentle doubt
about the certainty of her interpretations rather than arguing against them — will be the primary cognitive
technique. Behavioural work will focus on reducing delusional-driven behaviours (e.g., document-refusal, canteen
avoidance) that are causing occupational harm. Medication compliance enhancement is an urgent priority —
motivational interviewing techniques will be used to explore her ambivalence about medication without triggering
defensiveness. Family psychoeducation is essential — parents and younger sister need guidance on communication
strategies (neither reinforcing nor directly confronting the delusion), reducing expressed emotion, and supporting
medication adherence. Coordination with Dr. Mathur for possible dose optimisation of Risperidone is
recommended given partial compliance and current 2mg dose. Occupational risk management should be discussed
— exploring whether Divya can take temporary leave or be reassigned pending treatment response, to prevent
dismissal from entrenching the persecution narrative.

XII. CLINICAL FORMULATION

Divya presents with Delusional Disorder, Persecutory Type , of approximately 10 months duration. The disorder was
likely precipitated by a real workplace event (the documentation error and formal warning) which activated a pre-
existing suspicious, mistrustful cognitive style and escalated into a fixed, encapsulated persecutory delusion centred
on Head Nurse Ms. Verma. The delusion is non-bizarre (plausible in real-world terms), systematised (internally
consistent), and encapsulated (does not contaminate all domains of functioning). There are no hallucinations or
formal thought disorder — the preservation of otherwise intact cognition and functioning clearly distinguishes this
from Schizophrenia. Secondary mild depression (BDI-II = 13) and moderate anxiety (BAI = 17) reflect the emotional
burden of the perceived persecution rather than independent primary diagnoses. The complete absence of insight
(SAI-E = 4/14) and partial medication compliance are the primary obstacles to treatment. The 10-month duration of
untreated/undertreated psychosis, family accommodation of the delusional framework, and ongoing occupational
consequences are significant maintaining factors.

XIII. DIAGNOSTIC IMPRESSION

Primary Diagnosis Delusional Disorder — Persecutory Type

Specifier: Persecutory — belief that Head Nurse Ms. Verma is conspiring to
destroy her career
Duration: Approximately 10 months
Severity: Moderate (PANSS = 55; PSYRATS Delusion = 13/16)

Comorbid Conditions Mild Depressive Symptoms (BDI-II = 13) — secondary to perceived

persecution
Moderate Anxiety (BAI = 17) — secondary to occupational threat and
uncertainty

Rule Out Schizophrenia — ruled out: no hallucinations, no negative symptoms, no

formal thought disorder, functioning preserved outside delusional theme
Brief Psychotic Disorder — ruled out: duration exceeds 1 month
Substance-Induced Psychotic Disorder — ruled out: no substance use
 identified
Psychotic Depression — ruled out: mood symptoms secondary and mild;
delusion predates mood symptoms

Associated Features Ideas of reference, complete absence of insight, partial medication

compliance, occupational impairment, family accommodation, social
withdrawal

XIV. PROGNOSIS

The prognosis for Delusional Disorder is guarded. Divya's preserved cognitive functioning, professional competence
in non-delusional domains, and family support are protective factors. However, the complete absence of insight
(SAI-E = 4/14), partial medication compliance, 10-month duration of illness, and ongoing occupational
consequences are significant challenges. Delusional Disorder does not respond as reliably to antipsychotics as
Schizophrenia, and insight-poor presentations are particularly difficult to engage in therapy. With consistent CBTp,
pharmacotherapy optimisation, family psychoeducation, and careful attention to the therapeutic alliance, a gradual
reduction in delusional conviction and improvement in occupational functioning is the realistic goal. Full remission
of the delusion is possible but cannot be guaranteed. Preventing occupational dismissal — which would powerfully
reinforce the persecutory narrative — is a critical short-term clinical priority.