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Delusional disorders: Prevalence in two

socially differentiated neighborhoods
of Barcelona
a b c
Jorge L. Tizón , Noemí Morales , Jordi Artigue , Yanet Quijada
d e f g
, Conxita Pérez , Francesc Pareja & Manel Salamero
a
Ramon Llull University, University Mental Health Institute, Gran
de Gràcia 13, 3° 2ª, Barcelona, 08012, Spain
b
Institut Catalá de la Salut, Early Care for Patients at Risk of
Psychosis (EAPPP), Barcelona, Spain
c
Institut Catalá de la Salut, Early Care for Patients at Risk of
Psychosis (EAPPP), Barcelona, Spain
d
ICS, EAPPP, Barcelona, Spain
e
Institut Catalá de la Salut, Sant Felíu de Guíxols Health Centre,
Barcelona, Spain
f
Institut Catalá de la Salut, Unitat de Salut Mental La Mina,
Barcelona, Spain
g
University Clinic Hospital, University of Barcelona, Barcelona,
Spain
Published online: 06 Mar 2013.

To cite this article: Jorge L. Tizón , Noemí Morales , Jordi Artigue , Yanet Quijada , Conxita Pérez ,
Francesc Pareja & Manel Salamero , Psychosis (2013): Delusional disorders: Prevalence in two
socially differentiated neighborhoods of Barcelona, Psychosis: Psychological, Social and Integrative
Approaches, DOI: 10.1080/17522439.2013.773364

To link to this article: http://dx.doi.org/10.1080/17522439.2013.773364

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 Psychosis, 2013
http://dx.doi.org/10.1080/17522439.2013.773364

Delusional disorders: Prevalence in two socially differentiated

neighborhoods of Barcelona
Jorge L. Tizóna*, Noemí Moralesb, Jordi Artiguec, Yanet Quijadad, Conxita Péreze,
Francesc Parejaf and Manel Salamerog
a
Ramon Llull University, University Mental Health Institute, Gran de Gràcia 13, 3° 2ª,
Barcelona, 08012, Spain; bInstitut Catalá de la Salut, Early Care for Patients at Risk of
Psychosis (EAPPP), Barcelona, Spain; cInstitut Catalá de la Salut, Early Care for Patients
Downloaded by [University of Windsor] at 08:20 28 September 2013

at Risk of Psychosis (EAPPP), Barcelona, Spain; dICS, EAPPP, Barcelona, Spain; eInstitut
Catalá de la Salut, Sant Felíu de Guíxols Health Centre, Barcelona, Spain; fInstitut Catalá
de la Salut, Unitat de Salut Mental La Mina, Barcelona, Spain; gUniversity Clinic Hospital,
University of Barcelona, Barcelona, Spain
(Received 22 November 2012; final version received 1 February 2013)

Objective: To determine and compare the prevalence and other characteristics

of delusional disorder (DD) in two adjacent neighborhoods of Barcelona, La
Verneda and La Mina, which differ greatly in their socioeconomic level and
psychosocial risk factors.
Methods: Cross-sectional study, by neighborhood, of all cases recorded between
1982 and 2000 in the electronic Case Registry of the La Verneda–La Mina
Mental Health Unit. This unit of the Primary Health Care system serves
103,615 inhabitants and has high levels of accessibility.
Results: Of 21,536 mental health case records, 209 patients fulfilled the DD
definition according to SASPE criteria (DSM-IV-TR), representing a population
prevalence of 0.20% and 0.97% of case records. The DD case prevalence was
significantly greater in the neighborhood characterized by an overload of psy-
chosocial risk factors, than in the middle- and working-class neighborhood.
Conclusions: (1) The prevalence of DD indicated in the present community
study is much higher than the prevalence reported by other, mainly hospital-
based, studies. (2) These experiences/disorders are probably more common in
areas characterized by the presence of psychosocial and socioeconomic risk fac-
tors. (3) People with DD in these at-risk environments have higher fecundity
and fertility than the general population of Barcelona and Catalonia.
Key words: delusional disorder; paranoia; prevalence; prevention; socioeconomic
status; psychosocial history; urbanicity; social risk factors; fertility; epidemiology

1. Introduction
The definition and diagnosis of delusional disorder (DD) have been subject to debate
since the time of Kraepelin, who developed the modern concept of paranoia
(Kraepelin, 1919). For almost a century, as evidenced in the most cited meta-analysis
on the subject (Kendler, 1982), DD was considered to be an infrequent condition.
However, in recent years, better definitions and a growing body of literature on the

*Corresponding author. Email: jtizong@gmail.com

Ó 2013 Taylor & Francis

 2 J.L. Tizón et al.

subject have revitalized efforts to understand DD, although it remains a relatively

little-studied disorder (Marneros, Pillmann, & Wustmann, 2012; Saha, Scott,
Varghese, & McGrath, 2011;Wustmann et al., 2012). The current definition is based
on the presence of well-systematized, non-extravagant delusions, accompanied by an
affective state coherent with ideation. Generally, there are no hallucinations, and
there is an apparent conservation of the clarity and organization of thought, volition
and behavior (Ibanez-Casas & Cervilla, 2012; Manschreck, 2000; Marneros et al.,
2012; Thewissen et al., 2011). Although the disorder follows a chronic course, a
deterioration of the personality is not observed (Kendler, 1982; Kendler & Walsh,
1995; Wustmann et al., 2012).
Using the DSM IV definition (American Psychiatric Association [APA], 2004),
current literature estimates a prevalence around 0.03% and an annual incidence
between 0.001% and 0.003%, including in our own context (de Portugal, Gonzalez,
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Haro, Autonell, and Cervilla, 2008; Salavert et al., 2003). Therefore, barring excep-
tion, it is probable that people suffering from DD are only detected after hospital
admissions or emergency visits, or as a consequence of delusional (paranoid,
jealous, erotomanic) or delinquent behavior (Bouchard & Brulin-Solignac, 2012;
Sarlon et al., 2012). Decades ago, a broad demographic study in a sample of
psychiatric hospital patients in the USA, Canada, England and Ireland, reported a
1–4% prevalence of DD (Kendler, 1982).
In general, people with DD live in the community without seeking out clinical
intervention, although they often present varying degrees of social isolation and
social and relational conflict (Castilla, 1998; Danelia et al., 2011; Kendler, 1982,
1995; Marneros et al., 2012; Nelson, Fusar-Poli, & Yung, 2012; Saha et al., 2011).
Today’s systems of understanding, detecting and diagnosing psychopathology in the
community appear to have a biological bias, making diagnosis of DD more difficult.
On the other hand, there is increasing evidence that personality factors (Ibanez-
Casas & Cervilla, 2012; Thewissen et al., 2011) and life experiences (Varese et al.,
2012) play an important role as risk factors and dimensions of vulnerability for this
type of disorder. Studies such as Castilla (1998) and Salavert et al. (2003), for
example, have explored the environmental, psychological and/or social factors that
are most relevant to the onset of a disorder in a vulnerable personality.

2. Methodology
2.1. Design
The detailed design of SASPE (Señales de Alerta y Síntomas Prodrómicos de la
Esquizofrenia en atención primaria; in English: “Warning signs and prodromic symp-
toms of schizophrenia in primary care”), the transversal, descriptive study from which
this analysis was constructed, was previously published (Tizón et al., 2007, 2009).
The SASPE project studied the prodromal and early manifestations of the psychosis
in public community settings: PHC, SS, Childhood Services, Justice Services, etc.

2.2. Location and subjects

The defined catchment area of 103,615 inhabitants includes 21,536 patients
registered by the Mental Health Unit with some record of psychopathology.
Researchers have access to the electronic health record of basic psychosocial and
 Psychosis 3

Table 1. Inclusion criteria of “cases” in the SASPE⁄ project.

Disorder Codes
Schizophrenia 295.10, 295.20, 295.30,
295.60, 295.90
Schizophreniform 295.40
Schizoaffective 295.70
Delusional 207.1⁄
Brief psychotic 298.8
Shared psychotic disorder 297.3
Psychotic disorder induced by medical illness 293.3⁄⁄
Psychotic disorder induced by substance abuse 292.11
Non-specified psychotic 298.90
Psychotic disorder of infancy: pervasive developmental 299.00, 299.10, 299.80
disorder
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Plus SASPE criteria

A1: Diagnoses according to the DSM-IV criteria
A2: Maintained for a minimum of 6 months
A3: And 3 or more visits in the Mental Health Unit

Or:
B: Two or more hospitalizations in a psychiatric hospital or in
hospitals with a specialist and any Criterion A diagnosis on
discharge.

Or:
C: Two or more visits to the emergency unit of a general
hospital or psychiatric hospital with any Criterion A
diagnosis on discharge.
⁄
“Warning signs and prodromal symptoms of schizophrenia” (SASPE) Project (Tizón et al., 2007,
2009).

psychopathologic data for each patient. Using strict diagnostic and clinical criteria
to analyze the records of 838 patients with psychotic disorders contained in the
SASPE database, we identified 476 diagnosed with “schizophrenic disorders” and
362 “affected by other psychoses” (including 209 diagnosed as DD).
The research criteria, also used in previous studies (Tizón et al., 2007, 2009),
are summarized in Table 1.

3. Results
3.1. Prevalence of delusional disorder
The prevalence of DD with respect to the general population of the neighborhoods
was 20.17/10,000 inhabitants (95%CI: 17.4–22.9). Detailed analysis is presented in
Table 2. Two-thirds of the patients were older than 35 years at the time of their first
visit.

3.2. Population differences

The 209 identified cases of DD (Tables 3 and 4) were regrouped according to the
neighborhood of origin (La Verneda/La Mina) to compare sociodemographic
 4 J.L. Tizón et al.

Table 2. Specifications of the cases of schizophrenia and “other psychoses” diagnosed in

the MHUSM⁄ active records in 2000.

DSM-IV diagnosis Frequency Percentage

Schizophrenia
Schizophrenia 404 48.2
Schizophreniform disorder 38 4.5
Schizoaffective disorder 34 4.1
Other psychosis
Delusional disorder 209 24.9
Other psychosis in adulthood
Non-specified psychotic disorder 62 7.4
Brief psychotic disorder 11 1.3
Psychotic disorder induced by substance abuse 10 1.2
Psychotic disorder due to medical illness 9 1.1
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Shared psychotic disorder 1 0.1

Childhood psychosis⁄⁄ 60 7.2
Total 838 100
⁄
Mental Health Unit of Sant Martí; ⁄⁄psychotic disorder of infancy (0–14 years): pervasive develop-
mental disorder – DSM IV criteria: 299.00, 299.10, 299.80.

Table 3. Comparison of prevalence of delusional disorder by district.

La Verneda La Mina Difference

(n = 79.958) (n = 23.657) (95%CI)
Delusional N Prevalence per 10,000 N Prevalence per 10,000
disorder 145 18.13 64 27 8.9 (1.6–16.2)

variables of both subpopulations, which have been previously studied by other

researchers (Consorci, 2007; Dal Cin, De Mesones, & Tizón, 1995). In summary,
DD prevalence in La Mina neighborhood, which has an overload of psychosocial
risk factors (e.g. family instability; cultural, economic, childhood and adolescence
problems; urban deterioration; marginality; criminality), was significantly greater
than in the more socioeconomically advantaged La Verneda neighborhood: a
working-class and middle-class neighborhood.

3.3. Fertility and fecundity comparisons of the sample with the general
population of Catalonia in 2001
As a prevention team, we are interested in family and offspring health (Tizón,
Artigue, Quijada, Oriol, & Parra, 2011). Patients with DD in our sample have a
superior fertility rate than the general Catalan population: 64.1% of the 209 patients
with DD have children. This sample was compared with the general population of
Catalonia at the time of the study (Idescat, 2001a, 2001b) to observe possible simi-
larities and/or differences between the two groups (Table 5). There are statistical
differences in employment situation, fecundity and fertility: the fecundity index of
the patients with DD (i.e. mean number of children/mother) is greater than in the
general population (GP) (p = 0.0001), and in the populations of both La Verneda
(p = 0.0001) and La Mina (p = 0.0001) neighborhoods.
 Psychosis 5

Table 4. Comparison of sociodemographic variables of subjects with DD.

La Verneda La Mina
N = 145 N = 64
(69.4%) (30.6%) n Statistics P
Age at first visit
< 35 39 (26.9%) 24 (37.5%) 209 χ2 = 2.377 0.305
35–55 67 (46.2%) 25 (39.1%)
> 55 39 (26.9%) 15 (23.4%)
Sex
Females 78 (53.8%) 30 (46.9%) 209 χ2 = 0.851 0.356
Males 67 (46.2%) 34 (53.1%)
Civil status
Married 73 (51.4%) 35 (57.4%) 203 χ2 = 0.611 0.435
Other 69 (48.6%) 26 (42.6%)
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Employment situation
Work/study 46 (36.5%) 17 (28.8%) 185 χ2 = 5.412 0.248
Unemployed 12 (9.5%) 4 (6.8%)
Pensioners/disabled 29 (23.0%) 22 (37.3%)
Housework 23 (18.3%) 12 (20.3%)
Other 16 (12.7%) 4 (6.8%)
Siblings
Yes 111 (77.1%) 59 (92.2%) 208 χ2 = 6.770 0.009⁄⁄
No 33 (22.9%) 5 (7.8%)
Mean number of siblings 2.9 ± 2.6 5.0 ± 2.8 208 t = 5.288 0.000⁄⁄⁄
Fertility – global 87 (60.0%) 47 (74.3%) 209 χ2 = 3.485 0.062
Fertility – women 52 (67.7%) 25 (83.3%) 108 χ2 = 2.941 0.086
Fertility – men 35 (52.2%) 22 (64.7%) 101 χ2 = 1.426 0.232
Mean number of children – global 1.5 ± 1.5 2.5 ± 2.4 209 t = 3.572 0.000⁄⁄⁄
Mean number of children – women 1.5 ± 1.4 2.6 ± 2.0 108 t = 3.340 0.001⁄⁄⁄
Mean number of children – men 1.5 ± 1.7 2.3 ± 2.8 101 t = 1.955 0.053
Fecundity – global 2.4 ± 1.2 3.4 ± 2.3 134 t = 3.012 0.003⁄⁄
Fecundity – women 2.2 ± 1.2 3.2 ± 1.7 77 t = 2.769 0.007⁄⁄
Fecundity – men 2.8 ± 1.3 3.6 ± 2.8 57 t = 1.508 0.137
Mean number of children per 2.3 ± 1.4 3.5 ± 2.4 108 t = 3.343 0.001⁄⁄⁄
marriage
⁄ ⁄⁄⁄ ⁄⁄ ⁄
Statistically significant results o < 0.001; < 0.01; < 0.05.

In addition, the mean number of children per couple is also significantly higher
for the 209 patients with DD compared to the general population (GP) and in com-
parison to each neighborhood studied (GP p = 0.0001; La Verneda, P 0.0001; La
Mina, p = 0.0029).

4. Discussion
A 21% prevalence of psychopathology was detected in the catchment area between
1982 and 2000, a figure suggesting that the services of the Mental Health Unit were
highly accessible to the population of La Verneda and La Mina.
In comparison with the prevalence described in current psychiatric reference
manuals, the prevalence of DD in the present study is very high, especially in La
Mina (Table 3). However, psychiatric studies such as those by de Portugal et al.
(2008, 2011) tend to reference data on admitted patients and do not pay specific
attention to socioeconomic factors or to the accumulated psychosocial risk factors
within the samples. Moreover, screening tests and scores have a very limited valid-
 6 J.L. Tizón et al.

Table 5. Comparison of patients with DD detected in the SASPE study with the general
population of Catalonia in 2001.

General Patients DD
Population USM SM-LM Patients DD Patients DD
La Verneda La Mina
N = 6,343,110 N = 209 N = 145 N = 64
Sex
Female 3,235,538 (51.0%) 108 (1.7%) 78 (53.8%) 30 (46.9%)
Male 3,107,572 (49.0%) 101 (8.3%) 67 (46.2%) 34 (53.1%)
Total 6,343,110 209 145 64
Statistics χ2 = 0.214 χ2 = 0.681 χ2 = 0.146
P 0.6435 0.4094 0.7022
Marital status
Married 3,016,083 (55.5%) 108 (53.2%) 73 (51.4%) 35 (57.4%)
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Other 2,416,773 (44.5%) 95 (46.8%) 69 (48.6%) 26 (42.2%)

Total 5,432,856 203 142 61
Statistics χ2 = 0.020 χ2 = 0.314 χ2 = 0.673
p 0.8886 0.5754 0.4121
Employment situation
Inactive 3,168,943 (50.3%) 115 (62.2%) 75 (60.0%) 40 (67.8%)
Active 3,135,423 (49.7%) 70 (37.8%) 51 (40.0%) 19 (32.2%)
Total 6,304,366 185 126 59
Statistics χ2 = 5.665 χ2 = 3.764 χ2 = 12.250
p 0.0173⁄ 0.0524 0.0005⁄⁄⁄
Fecundity
Statistics 1.29a 2.5 ± 1.4 2.2 ± 1.2 3.2 ± 1.8
p t = 8.7810 t = 7.2164 t = 5.0064
0.0001⁄⁄⁄ 0.0001⁄⁄⁄ 0.0001⁄⁄⁄
Mean number of
children per marriage
Statistics 1.68 2.7 ± 1.9 2.3 ± 1.4 3.5 ± 2,4
p t = 10.3994 t = 8.5500 t = 5.9201
0.0001⁄⁄⁄ 0.0001⁄⁄⁄ 0.00293⁄⁄
a ⁄ ⁄⁄⁄ ⁄⁄ ⁄
Total fertility rate; statistically significant results: o < 0.001; < 0.01; < 0.05.

ity in this field (Cella, Sisti, Rocchi, & Preti, 2011). Therefore, the accessibility of
community services is probably the best gateway to early DD diagnosis (Stephens,
Richard, & McHugh, 2000). Patients with a diagnosis of DD in our setting tend to
access these services before their suffering and/or problems with family or law and
order land them in a hospital, courtroom or jail. This may be attributable to the ease
of access to these services or to the non-medicalized attention that is available.
A possible source of “false positives” that would inflate the present results could
be the faulty diagnosis of DD in the case of paranoid or residual schizophrenia,
schizo-affective disorders, and/or certain paranoid personality disorders. However,
this consideration should be balanced by the alternative “false negatives”: patients
with DD misdiagnosed with one of the potentially confounding disorders. Repeated
diagnosis and treatment of the patients in the sample as DD cases as well as our
earlier research on schizophrenia in the same population (Tizón et al., 2009) cannot
completely exclude this possible source of confusion. For example, patients who
previously would have been diagnosed with a “schizophrenic disorder” might, over
the course of 10, 20 or 30 years, have moved toward adaptation or recovery that is
now sufficient to produce a diagnosis of DD. In our experience, this occurs particu-
 Psychosis 7

larly in the case of women with a relatively stable family life. Nonetheless, this
potential sample bias can only be prevented with highly complex epidemiological
procedures, such as reviewing the evolution of each patient at 5 or 10 years follow-
up – a task that a part of the research team has already undertaken.
The importance of reconsidering the social epidemiology and ecology of these
disorders has multiple facets. Castilla (1998) suggested more than a decade ago that
the oversight with respect to DD was due to a lack of patient acceptance of
therapies and, moreover, to the need for psychological – not only biological –
hypotheses if the disorder were to be fully comprehended. On the other hand, this
oversight is related to the lack of studies concerning the social repercussions of the
disorder. Nonetheless, the relationship between DD and the threat of violence has
been emphasized in some studies (Kendler, 1982; Figuerido, 2000). In addition, the
social conduct of some of these patients at later stages of DD is often borderline or
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actually delinquent or criminal behavior, such as in the case of delusional jealousy

and/or paranoia.
Another data series considered in the present study relates to social and demo-
graphic factors in subjects with DD. We found greater unemployment among DD
patients, with even higher levels in the subsample from La Mina, the neighborhood
with a lower socioeconomic level, an accumulation of risk factors, and social mar-
ginality. We also found an elevated index of fertility and fecundity in patients with
DD; these indexes were higher among patients in La Mina. The mean number of
children in women with DD was 1.5 in La Verneda and 2.5 in La Mina, and fecun-
dity was 2.2 and 3.2, respectively. In the general population of Catalonia at the
time, the total fecundity rate was 1.29. The comparison between neighborhoods
shows us the possible influence of psychosocial risk factors not only in DD
prevalence, but also in the fertility and fecundity indexes, which is similar to our
previous studies on schizophrenia (Tizón et al., 2007, 2009).
In any case, the differences in fertility, in general and by sex, are a starting point
in the consideration of any preventive mental health strategy: the vulnerability of
patients with DD and of their children who are in an at-risk situation, plus the
added socioeconomic risk factors, may lead to a population subgroup at high psy-
chopathologic and psychosocial risk (Grover, Biswas, & Avasthi, 2007; Khashan
et al., 2008; Nelson et al., 2012; Olin et al., 1998; Saha et al., 2011; van Os, Kenis,
& Rutten, 2010; Varese et al., 2012).

Significant results of our study

In a well-defined catchment area, equipped with broadly accessible primary care
and mental health services, we found a much higher prevalence of DD than is
usually reported in the literature. This underlines the importance of the link
between community services, primary health care, and mental health care in realis-
tic research on these disorders (Nelson et al., 2012; Olin et al., 1998; Saha et al.,
2011). In our opinion, the primary reason for our higher prevalence is that patients
in other studies were diagnosed with DD only when they experienced an acute
episode or extreme lack of contention and visited emergency medical services. In
our population, patients tended to make their first visit before experiencing an
acute episode or at least when the situation is less extreme. This is a basic reality
for both preventive and epidemiological studies because the questionnaires and
surveys in the general population are neither very sensitive nor discriminating in
 8 J.L. Tizón et al.

the detection of DD (Easton, Shackelford, & Schipper, 2008; Marneros et al.,

2012).
We also found differences in DD prevalence between two neighborhoods of
differing socioeconomic levels, in concordance with the growing importance of
social factors among the risk factors of DD. Furthermore, we found that fertility
and fecundity in people with DD is higher than in the general population; these
rates are even higher in the more socioeconomically disadvantaged neighborhood.
This finding emphasizes the importance of primary and secondary psychosocial pre-
vention in these patients and their direct family members.
The psychiatric literature has devoted less attention to DD than to other
psychotic disorders, perhaps because the psychological and psychosocial basis of
those disorders are “experiential” more than obviously biological. Nonetheless, the
persistent doubts about its reportedly low prevalence, the important social repercus-
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sions of the disorder, and our lack of information about any interrelationships
between psychological, psychosocial and biological factors argue for greater atten-
tion by the research community (Nelson et al., 2012; Thewissen et al., 2011; Wust-
mann et al., 2012). In future studies we may need to start from a new perspective
on at least the following points.

(1) Delusional beliefs are much more frequent in the general population than
classical psychiatry can discern.
(2) Consequently, conceptual and technical boundaries must be identified that
can establish when a delusion can be considered “pathological” and when
and how to initiate professional treatment. It is possible that we may need to
accept the premise that there are no clear differences between belief, delu-
sional belief, and delusion.
(3) We may also have to accept a more unified concept of psychosis that admits
to a continuum between major distortions of self (“schizophrenia”) and psy-
choses with lesser impact on the self.
(4) This would lead to major differences in the external (behavioral) adaptations
of patients with psychosis.

Weaknesses and limitations of the study

(1) The DD diagnoses detected in electronic health records were not confirmed
by conducting standardized interviews. Nonetheless, strict adherence by the
participating clinics to the DSM-IV criteria and to the SASPE research proto-
col, based on repeatedly confirmed diagnoses (Tizón et al., 2007, Table 1),
was emphasized in our study.
(2) The particular characteristics of the participating Mental Health Unit’s meth-
odology and its high accessibility could make it difficult to replicate this
study or to extrapolate its results.

Acknowledgements
We thank Eva Cirera and Enriqueta Pujol for their help in the statistical analyses of the data,
as well as Josep Ferrando, Belén Parra, Antonia Parés, Marta Gomà, Conxita Pérez,
Françesc Pareja, Marta Sorribes, Belén Marzari and Laia Català for their careful collection
 Psychosis 9

and review of the data and Elaine Lilly, PhD, for translation and assistance with manuscript
preparation.
The study was supported by a grant for the Proyecto SASPE (02E/99) from the
Fundació Seny following the external competitive evaluation by the Agency for the
Evaluation of Medical Research and Technology of Catalunya.
Financial help with translation and manuscript preparation was provided by the Fundació
Jordi Gol i Gurina (Barcelona, Spain).

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