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Delusions

Delusional disorder is characterized by persistent, non-bizarre delusions and is distinct from schizophrenia and mood disorders. It has a low prevalence and is often underdiagnosed, with patients frequently denying their illness and presenting with minimal additional symptoms. The disorder's etiology remains unknown, and treatment can be challenging due to its resistance and the complexity of associated features.

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Delusions

Delusional disorder is characterized by persistent, non-bizarre delusions and is distinct from schizophrenia and mood disorders. It has a low prevalence and is often underdiagnosed, with patients frequently denying their illness and presenting with minimal additional symptoms. The disorder's etiology remains unknown, and treatment can be challenging due to its resistance and the complexity of associated features.

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Delusional disorder Theo Manschreck Harvard Universiy Summary of findings Grade of evidence Epidemiology B Age of onset Be Presentation B urse and progression Be Suspected neuropathology c Suspected neurochemical abnormalities c Genetic factors ce Other risk factors ce Treatment © Introduction 6 Based on nineteenth-century descriptions of paranoia (particularly those of Karl Kahlbaum (1863) and Emil Kraepelin)(1919), delusional disorder is a recent addition to the classification of mental disorders. Indeed, the DSM IV and ICD-10 definitions (Tables 7.1 & 7.2) have revived the concept of paranoia, refined the criteria for this disorder, delineated better boundaries with other psychotic disorders, especially schizophrenia, and emphasized careful differential diagnosis including exclusion of diseases with known causes and idiopathic disorders (such as bipolar or schizophrenic disorders) (Manschreck, 2000). Despite this promising framework, progress in building knowledge of the features, natural history, neuropathology, and biology of delusional disorder has developed slowly (Table 7.3). The reasons are instructive. The untreated and unrecognized prevalence of this disorder is substantial. Individuals with this condition are frequently free of symptoms besides the delusion, In some cases their ‘The Spectrum of Psychotic Disorders: Neurobiology, Etiology, and Pathogenesis, ed. Daryl Fujii and Igbal Ahmed. Published by Cambridge University Press. © Cambridge University Press 2007. heipsuidolorg/t0.1017/¢8097805"1 4 FAMRE PARTON RAOOFIAs Auersity Press, 2009 17 Delusional disorder Table 7.1. DSM IV diagnostic criteria for 297.1 delusional disorder A, Non-bizarte delusion(s) of at least 1-month’s duration, B, Criterion A for schizophrenia not met, Tactile and olfactory hallucinations may be present, if they are related to the delusional theme. Auditory and visual hallucinations, if present, are not prominent. C. Behavior is not obviously odd nor bizarre, functioning not markedly impaired apart from impact of delusion(s) or its ramifications. D, Ifmood episodes have occurred concurrently with the delusions, their total duration has been brief relative to the duration of the delusional periods. E, Has never met criteria for schizophrenia, and it cannot be established that a general medical condition or the direct physiological effects of a substance initiated and maintained the disturbance ‘Types: Erotomanic, Grandiose, Jealous, Persecutory, Somatic, Mixed, Unspecified. Source: (American Psychiatric Association, 1994) Table 7.2. ICD-10 delusional disorder A delusion or a set of related delusions other than those listed as typically schizophrenic, (ie, other than completely impossible or culturally inappropriate) must be present. ‘The delusion(s) must be present for at least 3 months. ‘The eriteria for schizophrenia are not fulfilled. No persistent hallucinations in any modality (except transitory or occasional auditory hallucinations but not in the third person or giving a running commentary), Depressive symptoms or episodes may be present, provided the delusion(s) persist at times when there is no disturbance of mood. No organic mental disorder. Specified types: Persecutory, Litiginous, Self-referential, Grandiose, Hypochondriacal (somatic), Jealous, Erotomanic. Source: (World Health Organization, 1993) Chief feature is a plausible delusion, Not a common disorder, nor rare. ‘Minimal additional symptoms. Several subtypes based on predominant theme (erotic, persecutory, etc.) Difficult to treat and possibly treatment resistant. Distinct from schizophrenia and mood disorder. Etiology is unknown, heipsuidoiorg/t0.1017/¢8097805"» s male Source: (Kendler, 1982; Munro, 1999; Manschreck, 2000) apparent normality may help them avoid drawing attention to their behavior and delusional preoccupations. They deny they are ill, and even the suggestion that they suffer from psychiatric disorder may provoke anger. Further, delusional disorder is a syndrome with an unknown etiology and associated with a number of delusion types. The latter include crotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified. This fact has ramifications for diagnosis (there is no diagnostic test), and for its validation as a distinct entity (is it part of a spectrum of related psychotic conditions or one of many heterogeneous disorders with overlapping phenomenologies?) (Serretti et al, 1999). Moreover, the low prevalence of delusional disorder has limited the feasibility of carrying out large-scale studies. Further complicating its infrequent occurrence, delu- sional disorder patients often present to other medical specialists, judges, attorneys, the police, even pest exterminators, but seldom to psychiatrists. Also, clinical determination that a delusion is not bizarre (implausible and not understandable nor consistent with ordinary life experiences) may be difficult, especially across different cultures. Finally, the temporal stability of the diagnosis, has been challenged in some reports (Fennig, Craig, & Bromet, 1996). Nevertheless, gains in understanding delusional disorder have occurred. The purpose of this chapter is to outline in greater detail evidence about this unusual and important psychotic disorder, Epidemiology Prevalence Delusional disorder is not a common condition. Many have considered it rare. Unfortunately, reliable epidemiologic information is meager. Kendler (1982) assembled various data from 1912 through the 1970s to create estimates of incidence and prevalence (Table 7.4). The relevance of these numbers in relation to the disorder we currently call delusional disorder is questionable. As criteria are refined and applied in population studies, different numbers will probably develop heipsuidolorg/t0.1017/¢8097805"1 4 FAMREI PARED RTE RRA URIAas nuersity Press, 2009 119 Delusional disorder (Copeland et al, 1998). Nevertheless, these are useful to guide our thinking. In summary, compared to schizophrenia and mood disorders, prevalence of delusional disorder is much less common. The persecutory type is the most common. Gender differences and other factors Individuals with delusional disorder are somewhat more likely to be female and to be more socially and educationally disadvantaged compared to individuals with mood disorders where a substantial preponderance of patients are female. In contrast, there is a more equal distribution of gender in the incidence of schizophrenia. Women tend to be older than men when they are diagnosed. It is widely believed that jealous type delusional disorder occurs more often in men than women. Age of onset The range is fairly wide (18—80 years) but most patients are middle aged at illness onset. Age of onset is later on average than in schizophrenia (by approximately two decades) yet, like schizophrenia, men tend to develop delusional disorder at earlier ages than women, Female cases may predominate in new cases among individuals of advanced age but do not approach the sex ratios characteristic of mood disorder. In one study (Yamada, Nakajima, & Noguchi, 1998), age of onset differed according to delusion type, the oldest age of onset being associated with the persecutory type and the youngest with the somatic type. Presentation ‘The cardinal feature of delusional disorder is a persistent, non-bizarre delusion not explained by other disorders according to DSM-IV, Onset can be acute or sudden following a precipitating event, or the condition may emerge gradually and become chronic. Insidious onset appears to be the more common pattern. The behavioral and emotional responses associated with delusional disorder are generally consistent with the content of the delusion (Table 7.5). The volitional, thinking, and emotional disturbances of schizophrenia are not present (including most hallucinations which are restricted in delusional disorder). Patients with delusional disorder show little impairment or disorganization in their general behavior or in the clarity and form of their thinking. Mood symptoms, even disorder, are associated with this condition, with onset usually after that of delusional disorder. heipsuidolorg/t0.1017/¢8097805"1 4 FAMRE PAR ERCOKRTUE RRARUKIAas nuersity Press, 2009 120 ‘Theo Manschreck Table 7.5. Features associated with delusions Observed features Anger, ictt Critical, accusatory behavior Defensiveness lity, quick annoyance Grandiosity, narcissistic or excessive self-importance Hostility, sarcasm Humorlessness Hypersensitivity Litigiousness Obstinaey Seclusiveness Selfrighteousness Suspiciousness Violence, aggressiveness Subjective features Overvalued, near delusional ideas Frank delusions (persecutory, jealousy, somatic, erotomanic, grandiose) ‘The delusions are indeed unusual yet they refer to experiences that can occur in real life, such as being cheated on, physically il, in love, jealous, or persecuted. Winokur (1977) has suggested that these are possible rather than totally incredible and bizarre delusions, as are commonly found in schizophrenia. Delusions are categorized according to their content. The most common are characterized by persecution, disease (somatic), and jealousy. Delusions are persistent and unarguable. Individuals interpret facts to fit the delusion rather than modifying the delusion to fit the facts. Systemization is present: a single theme or series of connected themes is present which links to the predominant delusion, Normal life and functioning may gradually give way to the intensity of these delusional concerns. Herein lies the source of the dysfunction and impairment in social, occupational, and personal adjustment that accompany this illness. Some have suggested that there is a continuum of psychotic disorder into which delusional disorder falls, somewhere between paranoid personality and the paranoid subtype of schizophrenia, the continuum characterized in terms of behavioral disorganization and impairment of functioning. However, little evidence supports the concept that these disorders share more than overlapping psychopathology. Nevertheless, there have been proposals that a number of delusional conditions such as the Capgras and related syndromes, cycloid and heipsuidolorg/t0.1017/¢8097805"1 4 FAMREI PARED RTE RRA URIAas nuersity Press, 2009 Delusional disorder reactive psychoses in the European literature, may be related to delusional disorder (Munro, 1999). Associated clinical features A striking aspect in the clinical presentation of patients with delusional disorder is, the absence of specific psychological or mental complaints or striking observable psychiatric features. In fact, there is active denial of the presence of symptoms. To the surprise of most clinicians is the discovery that appearance, thinking, orientation, mood and affect, attentional processes, memory capacity, perceptual processes, and often personality are intact. Thinking is coherent, yet may be abnormal (occasionally bordering on illogical) when delusional beliefs are expressed. In fact, evidence of delusional concerns and absence of insight may be the only observed characteristic features. There may be sarcasm, hostility, and even lack of cooperation because the patient's agenda is not being addressed and the examiner appears to be on the trail of symptoms the individual denies having. Mental status examination can disclose level of impulsiveness and potential for violent or suicidal behavior. The deluded individual's degree of self-righteousness and the intensity of the delusional experience, as well as its emotional impact, may be clues to the potential for violent behavior. Plans for harming other people, including homicide and suicidal thinking, axe equally important possible features. As comorbidity with depression is high, impulses for self-harm that arise because of frustration, demoralization, and depressed mood or despair are common, Delusions of jealousy, persecution, and erotomania are especially important as they may be associated with possible aggression and violence, Stalking, history of abuse, and arrest records are occasionally encountered. Positive symptoms First-rank symptoms of schizophrenia as described by Schneider (1959) are not characteristic of delusional disorder. Indeed, the occurrence of first-rank symptoms points to the differential diagnostic possibilities of schizophrenia or another medical condition with features of psychotic psychopathology. Indeed, positive symptoms other than the delusion are not typical. Negative symptoms Similarly, negative symptoms, a critical dimension of the psychopathology of schizophrenia, are not typically found in delusional disorders. Comorbid mood disorder, such as depression, may result in episodes of reduced motivation and/or ambition and interest, and psychomotor slowing, but not the trait-like durability of negative symptoms typical of schizophrenia. Such “secondary” negative symptoms are also associated with antipsychotic treatment. heipsuidolorg/t0.1017/¢8097805"1S4FAMRE PARTON RE RRA URIAas nuersity Press, 2009 122 Emotional Neuropsychological fi ‘Theo Manschreck ions The presence of hallucinations in delusional disorder cases has been controversial, with some arguing that schizophrenia is a more likely diagnosis and others that delusional disorder is still diagnosable as long as hallucinations are not marked or persistent. There is no final resolution of this issue; DSM-IV (and ICD-10) considers infrequent, poorly organized, simple hallucinations that are not a prominent feature in the mental state to be consistent with delusional disorder. Such hallucinations may be auditory or visual; other types of hallucinations have also been reported. These include tactile or olfactory hallucinations which not only may be present but prominent if they are related to the delusional theme. They tend to be more common in acute cases. and behavioral symptoms Patients with delusional disorder show emotional and behavioral response consistent with their experience of delusional concerns (Table 7.5). They may exhibit ideas of reference such that events, comments, looks from others, ete. have special significance for their delusional beliefs. Similarly, dysphoric or irritable mood may be present and understandable as a reaction to their beliefs. Overt anger and potential for violence may characterize individuals with jealousy or persecutory delusional beliefs, On the other hand, somatic delusional individuals, may show largely normal moods. Litigious behavior, on the part of persecutory deluded individuals, can be pronounced: bringing suit, letter writing, hiring attorneys, and filing complaints can be common. ‘There are comorbid conditions that can be somewhat difficult to distinguish and may add to the psychopathology. Among these, depression and other mood disorders frequently co-occur in the setting of delusional disorder (Maina et al., 2001; Manschreck, 2000; Munro, 1999). Individuals with comorbid disorders (72%) had an earlier age of onset and presentation of delusional disorder, with the comorbid disorder occurring usually subsequent to the delusional disorder illness. The most common subtype of delusional disorder with comorbid condition (usually mood disorder) is persecutory (54% in Maina et al., 2001), ings Psychological assessment may be helpful in revealing evidence of impaired intellectual functioning and may suggest brain abnormality. Differences in the verbal and performance spheres as well as scatter in the overall profile may provide clues indicating a different diagnosis. The limited data that we have on delusional disorder, especially among more chronic cases, suggests that the average patient shows normal or marginally low intelligence which is fairly characteristic of the condition. A comparison of 14 stable outpatients with late-onset delusional heipsuidolorg/t0.r017/¢8097805"1 s

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