DELHI PSYCHIATRY JOURNAL Vol. 17 No. 1 APRIL 2074 Review Article Current Understanding of Organic Delusional Disorder —A Recent Update Shruti rivastava', Manjeet S. Bhati , Priyanka Gautam’, Anubhav Rathi* Department of Psychiatry, University College of Medical Sciences & Guru Teg Bahadur Hospital, Dilshad Garden, Delhi-110095 Contact: Shruti Srivastava, E mail:srivastava_shruti@hotmail.com Introduction Delusion disorders earlier known as paranoid disorders are known since ancient times. Emil Kraepelin described paranoia as stable, non bizarre, well-systematized delusions with a chronic course, although the course lacked the typical deterioration of dementia praecox. The difference between paranoid disorder and paranoid schizophrenia was maintained by Eugen Bleuler, This view was expressed in the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM- I), in which paranoid states were regarded as possible variants of schizophrenia. Winokur renamed this illness as delusional disorder (DD). Kendler elaborated Winokur’s criteria and suggested a division into simple delusional disorder which are without hallucina-tions and hallucinatory delusional disorder.** The topic of validity of this diagnosis is also a matter of debate but recently Marneros et al, has validated DD as separate entity stable over fourteen year follow up study.‘ Organic delusional disorders are syndromes produced by neurological disease or toxic metabotic disorders and are associated, mainly with limbic system and basal ganglia dysfunction.’ Epidemiology Delusional disorders are not uncommon and according to epidemiological studies, rate for DD in inpatient admissions was reported as 0.3-0.5%? and a8 0.5-9%.* In India 1% of the total outpatients have delusional disorder including half with delusional parasitosis.” Epidemiology of organic delusional disorder is not very well studied and according to Lo Y et al prevalence of organic delusional disorders is 0.4 % of total admissions and 2.9% of organic mental disorders.* Methodology Relevant articles were searched using the words “Organic Delusional Disorder” using Google Scholar, Pubmed and standard textbooks of Psychiatry and Neurology. 241 articles were retrieved on pubmed. Additional search was carried out to find out the etio-pathogenesis and treatment. Nosological Status The nosological status of delusion disorder has been a matter of debate, The revised third edition of the DSM (DSM III R) and fourth edition of the (DSM IV) recognized the Kraepelin's concept Table 1 shows the difference between criteria of delusional disorder in various classificatory systems." In ICD 10 the following types may be specified, if desired: persecutory type, litigious type, self referential type, grandiose type, hypochondriacal (somatic) type, jealous type, erotomanic type while In DSM IV erotomania, persecutory, somatic, jealous, grandiose, mixed, unspecified are the subtypes ‘According to ICD 10 the diagnosis code for organic delusional disorder is F06.2 named as Organic delusional [schizophrenia like] disorder. Tt requires general criteria for F06 to be met, which are objective evidence from physical, neurological examination and laboratory tests and/or history of 5 Delhi Psychiatry Jounal 2014; 17:(1) © Delhi Psychiatric SocietyAPRIL 2014 DELHI PSYCHIATRY JOURNAL Vol. 17 No. + Table-1; Features of delusion disorders (functional) in various classificatory systems. Features DSM MTR (297.10) DSM 5 (297.1) ICD 10 (F22) and DSM IV (297.10) Non Bizarre + = = Hallucination Olfactory and tactile TT present not Persistent halucinations in any modality must halhucination can be prominent and snot be present (but transitory or occasional present if Related to related to Delusion auditory hallucinations thet are notin the third Delusion Theme There person or giving a running commentary), may be present. Duration 1 Month | Month 3 Months Intact Functioning + - ‘Mood Disorders Tf present, relatively should be for brief duration daration Tf present, relatively should be for bref Depressive symptams or even a depressive ‘episode may be present intermittently, provided that the delusions persist at times ‘when there is no disturbance of mood. cerebral insult or of systemic disorder known to cause cerebral disease. There should be a presumed relationship between development of the organic disease and mental disorder. Recovery of mental symptoms should be there on improvement of underlying cause and alternative causation of mental disorder should be absent, For F06.2 clinical picture should be dominated by delusions and consciousness should be clear." In DSM IIIR there was a separate category named organic delusional disorder, code (293.81) but in DSM IV and DSM Sit is diagnosed as psychotic disorder due to another medical condition with delusions (293.81)."°"? Characteristics of Organic Delusional Disorders Organic delusional disorders provide insight into the biological causation of psychiatric disorders, Delusions present in Organic delusional disorders, share characteristics of the functional delusional disorders but these organic syndromes differ from delusional disorders in various important aspects. There are studies done in this area, which compare characteristic features of these two groups.*!? Table 2 shows comparison between organic delusional disorder and delusional disorder whereas Table 3 shows comparison between organic delusional disorder and schizophrenia, Etiology Genetics Catalano et al studying genotype of schizo- phrenia, normal and subjects with delusional disorder found that involvement of genetic variation in the Dopamine D4 receptor gene confirmed susceptibility Table 2. Comparison of organic delusional disorders and delusional disorders/Sehizophrenia Organic delusional disorder Delusional Disorders? Age of onset Late onset Relatively early onset Family history Present less often Present more often Hospital stay Longer Shorter Treatment Require less dosage of anti psychotics Require comparatively more dosages of antipsychotic Table 3. Comparison between organic delusional disorder and schizophreni Organic delusional disorder Schizophrenia? Intellectual impairment More common Sensorium May be altered Hallucinations illucinations of Smell, taste ot touch are more prevalent Affect Preserved Thought process Intact [Less common Intact Less common Flat Disorganized Delhi Psychiatry Jounal 2014; 17:(1) © Delhi Psychiatric Society 19DELHI PSYCHIATRY JOURNAL Vol. 17 No. 1 APRIL 2014 to delusional disorder." Ina molecular genetic study of delusional disorder, Morimoto et al found genotype frequency of the DRD2 gene Ser31ICys to be higher in cases with persecutory type DD (21%), ‘compared to schizophrenia cases and controls (6% each).!* In other studies, a strong association was observed HLAA3 and AIL, '* Neuroimaging There are various neuroimaging studies done to localize the brain area involved in delusions and it hhas been that various areas like orbitofrontal cortex, amygdala, striatum, thalamus are affected."” Delusional misidentification syndromes have been seen to be associated with impairment of face recognition which is @ condition appears to be associated with lesions affecting limbic structure and both frontal and parietal lobes with predomi-nance of right sided lesions."* In Table 3, neuroimaging findings of few studies hhas been given which shows the evidence that certain brain areas are affected in patients with delusions, isulfiram®), Substances (e.g cocaine, and Toxins (e.g. Mercury)..” alcoho!) Psychodynamic theories According to psychodynamic theories persecutory delusion are protective psychological responses to conflicts that are threat to self. Delusions are seen as a personal unconscious inner state or conflict which is turned outwards and attributed to the external world. Freud considered that latent homosexual tendencies especially formed the basis of paranoid delusions. Later, psychoanalytical theorist suggested that delusions might be a compensation for any, not necessarily sexuality-related kind of mental weakness, e.g, lack of self-confidence, chronic anxiety or identity disturbances. ' Other Theories Cognitive and experimental psychologists suggests that person with persecutory delusions selectively attend to threatening information; atribute Table-3: Neuroimaging findings of studies in patients with various delusions ‘Type of Delusion Brain areas involved Authors Delusion of parasitosis ‘MRI showed damaged striatum and it was found that Huber M et al 2007)" dopamine transporte functioning was also decreased Somatic Deision Cotard Delusion Misidentification syndromes Persecutory Delusions and cingulated gyrus Hypoperfusion of left temporo parietal cortices Non dominant temporoparctal corex involvement MRI showed right frontal white matter lesions !MRI showed involvement of Left frontal, right caudate Wada t al (1999) eam J otal (2002)" Luca M etal 2013)" Blackwood NJ etal (2000) Medical causes It is not uncommon for medical diseases to present as delusional disorder. The various important causes implicated in the etiology of Organic delusional disorder are as follows: Infectious diseases (e.g Creutzfeldt-Jakob disease’), Neurodegenerative disorders (e.g Alzheimer’s disease,:* Huntington’s disea Brain tumors, leptomeningeal metastases from a systemic cancer, Head trauma®, Vascular disease (e.g. atherosclerotic vascular disease, hyper- tension)", Metabolic and endocrinal causes (e.g Hypercalcemia, hyperparathyroidism," hypothyroi- dism™), Vitamin deficiencies (e.g Vitamin B,, deficiency), Medications (e.g corticosteroids,”* negative events to external personal causes. In shared psychotic disorders etiological theories are ‘based on family and interpersonal dynamics.“ Differential Diagnosis Many different conditions may present with suspiciousness and persecutory delusions among the elderly. Differential, in addition to above mentioned medical conditions are dementia, persistent delusional disorder, depression with psychotic features, schizophrenia, shared psychotic disorder and personality disorders Management Assessment As there are numerous conditions that can 20 Delhi Psychiatry Jounal 2014; 17:(1) © Delhi Psychiatric SocietyAPRIL 2016 DELHI PSYCHIATRY JOURNAL Vol. 17 No. 1 present with delusion disorder, it requires thorough investigation and hence outline of the required work up is presented. Detailed psychiatric history taking, review of substance use, past treatment and current medication, forms the backbone of any psy casework up and rule out known causes, Detailed general physical, systemic examina tion and central nervous system examination will provide us with the clue towards the organic cause. Mental status examination and higher mental function with detailed cognitive function assessment will establish delusion and rule out any detirium, dementia or other organic disorders, Investigations would include complete blood count, erythrocyte sedimentation rate, liver function tests, kidney function tests, serum electrolytes, Thyroid function tests, urine examination, toxicology screening, Vitamin B,, levels, Brain imaging. ‘Treatment Much of the literature on treatment of organic delusional disorder is in the form of reports on individual or very small series of cases. Treatment ‘would mainly depend upon the cause detected. For persistent symptoms various treatment modality are used. The introduction of oral Pimoride! and its use in the treatment of delusional disorder has led some researchers to claim its therapeutic specificity for delusional disorder, which is not shared by other antipsychotics. From last two decades antipsy- chotics remain the main stay of the therapy but currently with the increasing research in psychosocial interventions, highly structured, integrated programs like cognitive behavioral and psycho education are being used. Here we are discussing about newer treatment modalities, Non-Pharmacological 1. Cognitive-behavioral therapy (CBT) has been effective in treating delusions, both in schizophrenia and delusional disorder. CBT produced more impact on the Maudsley ‘Assessment of Delusions Schedule (MADS) dimensions for Affect Relating to Belief, Strength of Conviction, and Positive Actions on Beliefs." 2. A significant improvement has been seen in individuals with persistent delusion disorder with cognitive behavioral worry intervention, a specialized form of CBT targeting worry, which, according to research is associated with distressing paranoia. 3. The Maudsley Review Training Program me: It aimed to target reasoning processes, particularly the ‘Jumping to Conclusions? (ITC) bias and belief flexibility, which are thought to play a part in maintaining delusional conviction. It is a computerized programme comprising a general introduction to JTC and five training tasks. It was designed to be completed together with a therapist, who emphasized key messages and provided feedback on participants’ comments, for example by reinforcing useful insights and normalizing ITC. When comparing the average baseline and post-intervention periods there were significant improvements in belief flexibility and delusional conviction in sample that is resistant to change using either traditional CBT for psychosis and/or anti- psychotic medication. Pharmacological ‘With the advent of newer antipsychotics, more and more research is going on in measuring the efficacy of these medications in resolving persistent delusional disorders. Among the newer anti- psychotics, Blonanserin'*, Paliperidone*’ have been successfully used in the treatment of the delusional disorder. Even all the currently available long acting injectable antipsychotics are used in the treatment of delusional disorder as first line treatment.!# In addition to antipsychotics, other forms of therapy such as Selective serotonin reuptake inhi- bitors, Monoamine oxidase inhibitors, Clomipramine, and Blectroconvulsive therapy have also been shown to have beneficial effects in patients with chronic delusions.” In anecdotal case reports it has been seen that apart from the neurosurgical interventions, there is a need for antipsychotics! and other ‘medical intervention.**3° Conclusion Delusional disorders forms a separate entity as evident through research carried in last few decades and it finds a place of its own in currently used classificatory systems, though more research is required to refine the nosological status of organic Delhi Psychiatry Jounal 2014; 17:(1) © Delhi Psychiatric Society 2DELHI PSYCHIATRY JOURNAL Vol. 17 No. 1 APRIL 2014 disorders. Organic delusional disorders provide a great opportunity to study biological aspects of schizophrenia and other psychotic disorders as specific findings in each delusions are being discovered, Organic causes are not uncommon for the delusions disorders and diagnosis requires a detailed assessment through history, physical examination, mental status and detailed cognitive assessments followed by required investigations, We should thoroughly assess for potentially treatable neuro - medical causes to prevent morbidity and mortality and improve overall quality of life References 1. Fochtmann LJ, Mojtabai R, Bromet EJ. Delusional Disorder And Shared Psychotic Disorder In: Sadock BJ, Sadock VA , editors. Kaplan and Sadock’s Comprehensive Text Book of Psychiatry. Nol, I. Philadelphia: Lippincott Williams and Wilkins; 2009; 1605-1628, 2. Winokur G. Delusional Disorder (Paranoia). Comprehensive Psychiatry 1977; 18 : 511-521. 3. Kendler KS. 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