DELUSIONAL DISORDERS

&
ACUTE & TRANSIENT
PSYCHOSIS

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 INDEX
• Definition of psychosis
• Types
• Delusional disorders
• Epidemiology
• Aetiology
• Associated medical conditions
• Clinical types
• Clinical Features
• Differential diagnosis
• Course and prognosis
• Management
• Acute & Transient psychotic disorders
• Types
• Differential diagnosis
• Prognosis
• Treatment

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 DEFINITION
Psychosis –
• Gross impairment in reality testing(‘not in contact’
with reality)
• Marked disturbance in personality, with impairment
in social, interpersonal, occupational functioning.
• Marked impairment in judgement & absent
understanding of current symptoms & behaviour(loss
of insight)
• Presence of characteristic symptoms like delusions &
hallucinations.

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 TYPES OF NON-ORGANIC PSYCHOSIS
• Delusional disorders
• Acute & Transient psychotic disorders
• Schizoaffective disorders
• Postpartum psychosis

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DELUSIONAL DISORDERS

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 DELUSIONAL DISORDERS
• A group of disorders where long standing,
non-bizarre delusions are the primary or only
manifestation of the illness.
• Included in ICD-10
• Must be persistent for atleast 3 months.

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 EPIDEMIOLOGY
• Prevalence rate- 0.24%-0.3%
• Late middle age (42-15 years)
• Female:Male – 3:1
• More common among relatives of
Schizophrenia

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 AETIOLOGY/RISK FACTORS
• Social isolation
• Migration
• Sensory impairment(deafness>blindness)
• Celibacy
• Widowhood
Very common among substance
abusers(cocaine).

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 ASSOCIATED MEDICAL CONDITIONS
• Multiple sclerosis
• Vitamin deficiency(B12 & nicotinic acid)
• Hepatitis
• Hypothyroidism
• Diabetes mellitus
• Dementia

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 CLINICAL TYPES
• Somatic type
• Persecutory type
• Grandiose type
• Jealous type
• Erotomanic type

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 SOMATIC TYPE
• Also called Monosymptomatic hypochondriacal
psychosis.
• Delusions related to body.
Eg. – patient might feel that foul smell emanates
from them.
That some of their body parts are mishapen(eg.
nose) or non-functioning(eg. intestine).
That lice or other parasites have infested their body.

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 PERSECUTORY TYPE
• Most common type
• Patient believes that he is
conspired against & harassed
or bodily injured, spied or followed
or poisoned by others.
• Resentful, may resort to legal
methods in order to be redressed.
OR
• May resort to violence against
his alleged persecutors.

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 GRANDIOSE TYPE
• Exalted ideas about oneself, of birth,
possessions & achievements.
• In a religious context may believe that they
are the chosen prophets of GOD & have
mysterious powers to head the masses.

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 JEALOUS TYPE
• More common in males.
• Also called-Sexual jealousy, erotic jealousy, morbid
jealousy, psychiatric jealousy, Othello syndrome.
• Allegations of infidelity are made against the spouse
supported by evidence collected in the form of changes
& manner of dress, behaviour or remarks made by the
partner.
• The inferences drawn are wrong & not factual.
• Held firmly on inadeguate grounds & are unchanged
even in the face of evidence that they are false.

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Cont..
• Other secondary delusions may be present like he
is drugged or poisoned to be put to sleep or to
lose virility.
• Mood- sadness, misery, apprehension, rage.
• Patient resorts to spying or coercing confession
from the partner often through violence that they
are true.
• Elaborate steps are taken to catch the paramour
‘red handed’ & private detectives may be
engaged to watch the movements of his spouse.
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Cont..
• He promises ‘to forget the whole thing & forgive
them’&’not to persue the matter anymore’ once
she confesses.
• The unsuspecting wife is a bid to put an end to
further turmoil ‘confesses’ which aggravates her
partner’s suspicion who attempts to coerce her
more with greater fervor.
• Very resistent to treatment
• Continues till divorce or separation or death of
spouse.
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Cont..
• Assaults often continued even after
separation as he pleads his wife to come back
and live together again.
• Potentially dangerous & may lead to suicide or
homicide.
Delusion of infidelity

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 EROTOMANIC TYPE
• More prevalent in females.
• Also known as- Clerambault’s Syndrome
• Patient believes that another person, usually of a
higher status or endowed with greater qualities, is
loving her.
• Persue their objects of delusion physically or through
letters & presents.
• Very often the affected woman is not attractive, hails
from a poor socio-economic strata & works at a lower
level job.
• If males affected- may be violent or aggressive with the
objects of love.
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 CLINICAL FEATURES
Presence of delusion- single or a set of related
delusions for atleast 3 months-
• Well systematised
• Non-bizarre
• Involve situations which can occur in normal
life
• ‘Encapsulated’ – they do not affect the other
life spheres of the patient.
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Cont..
• Hallucinations are absent.If present, are
transient & rudimentary & are auditory, tactile
or olfactory.
• Only when the area of delusion is probed or
confronted , the dysfunction becomes evident.

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 DIFFERENTIAL DIAGNOSIS
• Paranoid schizophrenia
• Paranoid personality disorder
• Substance induced delusion
• Mood disorders

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Features Paranoid Delusional Paranoid
schizophrenia disorder personality
disorder
General Eccentricities, Eccentricities, Restrained social
behaviour mannerisms, decreased social interaction.
stereotypies, interaction.
decreased self care,
social withdrawal,
guarded & evasive.
Personality Disorganised Disturbed in No deterioration.
delusional areas,
normal in other
areas.
Thought disorder Delusions, loosening Non- bizarre No thought
of association, formal delusions, are well disorder.
thought disorder, systematized. No
delusions may be other thought
bizarre. disorder.

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Hallucinations Auditory common Uncommon. If absent
present, not
persistent.

Contact with reality Markedly disturbed Disturbed in areas Intact

of delusional
beliefs.

Insight absent absent present

Affect/ mood in Often Usually Usually

relation to thought inappropriate inappropriate inappropriate

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 COURSE & PROGNOSIS
• About half the cases have a chronic &
unremitting course
• In some, the symptoms occur periodically &
intervals between the episodes are totally
asymptomatic.
• Suicide is often associated.

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 MANAGEMENT
• Hospitalisation if severe impairment or
suicidal/homicidal threats/ patient non-
cooperative for treatment.
• Antipsychotic + Antidepressant.
• Antipsychotics control agitation & treat the
psychotic features.
• Drug of choice- Pimozide
• 68% full remission, 22% partial remission.
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Cont..
• Antidepressants of SSRI group such as
fluoxetine preferred.
• Many may be refractory to treatment.
• Electro convulsive treatment may be needed
for secondary repression.
• Psychotherapy

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 ACUTE & TRANSIENT PSYCHOTIC
DISORDERS
• These are psychotic disorders characterized by
an abrupt (<48 hours) or an acute(</= 2weeks)
onset of symptoms.
• Precipitated by visible stress like bereavement
but can occur even if no evident stress.

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 TYPES
• Acute polymorphic psychotic disorder without
symptoms of schizophrenia.
• Acute polymorphic psychotic disorder with
symptoms of schizophrenia.
• Acute schizophrenia- like psychotic disorder.
• Other acute predominantly delusional
psychotic disorders.

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 ACUTE POLYMORPHIC PSYCHOTIC
DISORDER WITHOUT SYMPTOMS OF
SCHIZOPHRENIA
• Acute onset within 2 weeks(from non-psychotic to
psychotic state).
• Polymorphic picture(unstable and markedly variable
clinical picture that changes from day to day or hour to
hour).
• Several types of hallucinations and/or delusions,
changing in both type or intensity from day to day or
within the same day.
• Marked emotional turmoil(intense feelings of
happiness & ecstasy to anxiety & irritability).

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ACUTE POLYMORPHIC PSYCHOTIC
DISORDER WITH SYMPTOMS OF
SCHIZOPHRENIA

• Meets the descriptive criteria for acute

polymorphic psychotic disorder but in which
typically schizophrenic symptoms are also
consistently present.
• If schizophrenic symptoms persist for > 1
month, diagnosis changed to schizophrenia.

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 ACUTE SCHIZOPHRENIA-LIKE
PSYCHOTIC DISORDER

• Characterised by acute onset of a psychotic

disorder in which psychotic symptoms are
comparatively stable(& not polymorphic) &
fulfill the criteria for schizophrenia but have
lasted for < 1month.
 OTHER ACUTE PREDOMINANTLY
DELUSIONAL PSYCHOTIC DISORDERS
• Acute onset of a psychotic disorder in which
comparatively stable delusions or
hallucinations are the main clinical features
but do not fulfil the criteria for schizophrenia.
• Delusions of persecution or reference are
common & hallucinations are usually auditory.
• Criteria for acute polymorphic psychotic
disorder or schizophrenia should not be
fulfilled.

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 DIFFERENTIAL DIAGNOSIS
• Organic mental disorders
• Psychoactive substance use disorders
• Schizophrenia
• Mood disorders
• Delusional disorders

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 PROGNOSIS
Good prognostic factors
• Well adjusted premorbid personality
• Absence of family history of schizophrenia
• Presence of severe precipitating stressor before
th onset
• Sudden onset of symptoms
• Presence of affective symptoms, confusion,
perplexity &/or disorientation in clinical pictuer.
• Short duration of symptoms
• First episode
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 TREATMENT
• Antipsychotics- mainstay of treatment. Used
to control agitation & psychotic features.
• Oral or parenteral.
• Antidepressants as adjuvants.
• ECT- in case of marked agitation & emotional
turmoil as well as in cases where there is a
danger to self or others.
• Psychotherapy.
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 REFERENCE
• A short textbook of psychiatry-Niraj Ahuja(7th
edition)
• Concise textbook of psychiatry-Namboodiri(3rd
edition)
• Essentials of psychiatry-N.Kumar
• Kaplan & Sadock’s concise text book of clinical
psychiatry

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