Delusional Disorder

(Exam writing notes, edited by Dr Sachin Arora, for

psychiatry residents revision series)
 Headings
• Definition

• Epidemiology

• Etiology

• Biological Factors
• Diagnosis and clinical features

• Types

• Shared Psychotic Disorder

• D/D

• Treatment.
Definition:

Fish’s clinical psychopathology defines delusion as

false, unshakeable belief that is out of keeping with the
pts social and cultural background.
 Epidemiology
• 0.2- 0.3% in USA

• Annual incidence 1-3 new cases per 100,000

• Mean age of onset - 40yrs

• Range for age of onset- 18 yrs- 90 yrs

• A slight preponderance of female pts exists.

 Etiology
• Cause is unknown.

• Family studies report, increased prevalence of delusional

disorder and related personality traits in relatives of
delusional disorder proband.

• long term follow up of pts show < 1/4 th pts being

reclassified as schz and < 10 % of pts reclassified as mood
disorder.

These data indicate: Delusional disorder is not an early stage

in development of more common disorders.
 Biological factors

• Non Psychiatric medical conditions and substances

• Delusional disorder may involve the limbic system or

basal ganglia in pts who have intact cerebral cortical
functioning.
 Risk factors associated with delusional disorder (Kaplan)

• Advanced age

• Sensory impairment or isolation

• Family history

• Social isolation

• Personality features (e.g, unusual interpersonal

sensitivity)

• Recent immigration
 Diagnosis and Clinical
Features
• Mental Status

General Description: Patients are usually well groomed and

well dressed, without evidence of gross disintegration of
personality or daily activity.

Yet they may seem eccentric, odd, suspicious, hostile.

Most remarkable feature of patients, MSE shows them quite

normal expect for markedly abnormal delusional system.
• Mood, Feeling, and Affect.

Pts mood are consistent with the content of delusion.

Grandiose pt is euphoric

Persecutory delusion is suspicious

some mild depressive qualities may be observed.

• Perceptual Disturbances:

A few pts have Hallucinatory exp- Auditory

rarely visual.
• Thought:

Key symptom of disorder.

Delusions are usually, systematised and characterised

as being possible.

Contrast with bizarre and impossible delusional content

in some pts with Schz.

Complex or Simple

Circumstantial, Verbose or idiosyncratic.

Sensorium and cognition:

Orientation: pts with delusional disorder usually have no

abnormality in orientation unless they have a specific delusion
about a person, place or time.

Memory: memory and other cognitive process are intact.

Impulse control: suicide, homicide, or other violence.

Destructive aggression most common in patients with history

of violence.

Hospitalisation in pts with impulse control inadequacy.

• Judgement and Insight:

Virtually no insight

judgement can be assessed by evaluating pts past,

present and planned behaviour.

Reliability: usually reliable expect when impinges on their

delusional system.
 Types of delusions
• Persecutory

• Jealous

• Erotomatic

• Somatic

• Grandiose

• Mixed type

• Unspecified type
• Persecutory Type:

• pts with this subtype are convinced that they are

being persecuted or harmed.

• associated with irritability and anger.

• May be assaultive or homicidal

• Contrast with patients of Schz

• logic, clarity and systematisation of persecutory

theme.
• Jealous Type:

Conjugal paranoia: limited to delusion of an unfaithful spouse

Othello syndrome: morbid jealousy that can arise from multiple

concerns.

Pathological or morbid jealousy.

Symptom of other disorders like, schz, epilepsy, mood disorder,

drug abuse, and alcoholism.

Caution and care: high risk for sucide and homicide.

 Erotomanic type
• clerambault syndrome or psychosis passionelle

• pt has delusional conviction that another prsn usually

of higher status, is in love with him/her

• pts tend to be solitary, withdrawn, dependent, sexually

inhibited

• poor level of socio occupational function.

• the following operational criteria for diagnosis have been suggested

1. a delusional conviction of amorous communication

2. object of much higher rank

3. object being the first to fall in love

4. object being the first to make advances

5. sudden onset( 7 day period)

6. object remains unchanged.

7. pt rationalises paradoxical behaviour of the object

8. chronic course

9. absence of hallucinations.

also known to occur in schz, mood disorder, and other organic

disorder.

pts exhibit paradoxical conduct: the delusional phenomenon of

interpreting all denials of love, no matter how clear, as secret
affirmations.

The course may be chronic, recurrent or brief.

Intervention in form of separation from love object.

Tendency of violent behaviour.

• Grandiose Type.

• Somatic Type.
 somatic type
Monosymptomatic hypochondriacal psychosis.

In del disoder, delusion is fixed, unarguable, intensely presented.

In contrast a hypochondriasis pt often admit their fear of illness

is largely groundless

the content of somatic delusions can vary from case to case.

• The three main types are:

1. delusion of infestation

2. delusion of dymorphophobia

3. delusion foul body odours or halitosis: this is also ref

as olfactory reference synd.
• Onset may be gradual or sudden

• hyperalertness and anxiety

• the 3 subtypes appear to overlap.

• In delusional paratosis, tactile sensory phenomena are

often linked to delusional beliefs.

• seldom come come psychiatric evaluation

• pts generally present to other specific medical

speciality for evaluation.
Mixed Type

The category mixed type applies to pts with two or more

delusional themes.

This diagnosis should be reserved for cases in which no

single delusional type predominates.
Unspecified Types:

delusion of misidentification,

Capgras syndrome named after the french psychiatrist

who described the illusion des sosies, or the illusion of
doubles.

belief that a familiar person has been replaced by an

imposter.
• Variants of Capgras syndrome:

Fregoli’s Phenomenon: the delusion that persecutors or

familiar persons can assume the guise of strangers.

Intermetamorphosis: familiar persons can change

themselves into other persons at will.

each disorder is not only rare but may be associated

with schizophrenia, dementia, epilepsy, and organic
disorder.
• Nihilistic delusional disorder or Cotard syndrome.

Given in19th century, by the french psychiatrist Jules Cotard

pts complain of having lost not only possessions, status, and

strength but also

heart, blood, intestines.

the world beyond them is reduced to nothingness.

rare syndrome considered precursor to schz or depressive

episode.

less frequently seen nowadays.

 Shared psychotic disorder

• also referred to as

• shared paranoid disorder,

• induced psychotic disorder,

• Folie impose

• Double insanity.
• Characterised by transfer of delusions from one
person to another.

• Both person are closely associated for a long time.

• Most commonly, Individual with primary case of

delusion is often chronically ill, & influential member
of the close relationship with a more suggestible
person.

• Person as secondary case is frequently more gullible,

more passive.
• If the pair separates, the secondary person may
abandon the delusion

• The occurrence of delusion attributed to strong

influence of more dominant member.

• Factors associated

• Old age, low intelligence, sensory impairment,

cerebrovascular disease, & alcohol abuse.

• Genetic predisposition to idiopathic psychoses also

been suggested as possible risk factor.
 D/D
• Eliminate other medical disorders.

Delirium, Dementia, and Substance related disorder

Delirium can be differentiated by presence of fluctuating

level of consciousness or impaired cognitive functions.

Dementia of Alzheimer’s type can give apperance of

delusional disorder.

Alcohol induced psychotic disorder.

 D/D
• Potential Medical Etiologies of delusional synd.

1. Neurodegenerative disorder: Alzheimer’s disease,

Huntington’s disease, Picks disease.

2. Other central nervous sysytem disorders: Brain

tumours, Epilepsy, Head trauma, anoxic brain injury.

3. Vascular disease: Atherosclerosis, hypertensive

encephalopathy, subarachnoid hemorrhage.
4. Infectious disease: HIV, syphilis, malaria, acute viral
encephalitis.

5. Metabolic disorder: Hypercalcemia, hyponatremia,

hypoglycemia, uremia, hepatic encephalopathy.

6. Endocrinopathies: Addison’s disease, Cushing syndrome.

7. Vitamine deficiencies: vit B12 def, folate def, thiamine def,

niacin def

8. Medications: Adrenocorticotropic hormones, anabolic

steriods, corticosteriods, antibiotics( cephalosporins, penicillin)
9. Substance: Amphetamine, cocaine, alcohol,
cannabis.

10. Toxins: Mercury, arsenic, manganese.

Management of Delusional Disorder

Rule out the other causes of paranoid features Confirm the

absence of other psychopathology.

Assess consequences of delusion- related behaviour

Demoralization

Despondency

Anger, fear

Depression
• Diagnosis and Management….Continue

Impact of search for “medical diagnosis,” “legal solution”

“proof of infidelity,” and so on

Assess anxiety and agitation

Assess potential for violence, suicide,

Assess need for hospitalisation

Institute pharmacological and psychological therapies

Maintain connection through recovery.

Pharmacotherapy

Antipsychotic: Haloperidol or Risperidone

Studies show Pimozide particularly effective with somatic

delusions.

A common cause of drug failure is non compliance

which should be evaluated.