“For me, it is far better to grasp the Universe as it really is than to persist in delusion, however

satisfying and reassuring.” ― Carl Sagan,

What is delusion?

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of

Mental Disorders, Fifth Edition (DSM-5). Delusions are fixed beliefs that are not amenable to

change in light of conflicting evidence. Their content may include a variety of themes (e.g.,

persecutory, referential, somatic, religious, grandiose). Persecutory delusions (i.e., belief that one

is going to be harmed, harassed, and so forth by an individual, organization, or other group) are

most common. Referential delusions (i.e., belief that certain gestures, comments, environmental

cues, and so forth are directed at oneself) are also common. Grandiose delusions (i.e., when an

individual believes that he or she has exceptional abilities, wealth, or fame) and érotomanie

delusions (i.e., when an individual believes falsely that another person is in love with him or her)

are also seen. Nihilistic delusions involve the conviction that a major catastrophe will occur, and

somatic delusions focus on preoccupations regarding health and organ function.

EXAMPLES OF THE DELUSIONS

Delusions are deemed bizarre if they are clearly implausible and not understandable to same-

culture peers and do not derive from ordinary life experiences. An example of a bizarre delusion

is the belief that an outside force has removed his or her internal organs and replaced them with

someone else's organs without leaving any wounds or scars. An example of a non bizarre

delusion is the belief that one is under surveillance by the police, despite a lack of convincing

evidence. Delusions that express a loss of control over mind or body are generally considered to

be bizarre; these include the belief that one's thoughts have been "removed" by some outside
force {thought withdrawal), that alien thoughts have been put into one's mind (thought insertion),

or that one's body or actions are being acted on or manipulated by some outside force (delusions

of control). The distinction between a delusion and a strongly held idea is sometimes difficult to

make and depends in part on the degree of conviction with which the belief is held despite clear

or reasonable contradictory evidence regarding its veracity.

NATURE AND SYMPTOMS OF DELUSION

While the essential feature of this disorder is simply the existence of one or more delusions that

occur for at least 1 month, the following are all used to make a correct diagnosis of delusional

disorder:

 The individual has one or more delusions that persist for at least a month or more.

 Criterion A for schizophrenia is not and never has been met.

 Aside from the delusion(s) direct effects, functioning is not obviously impaired, and

behavior is not noticeably strange.

 Any manic or major depressive episodes have been brief, compared to the length of the

delusional period.

 The disturbance cannot be attributed to the physiological effects of a substance, another

medical condition, or another mental disorder.

The severity of the delusions should be noted, and it should also be specified if delusions involve

bizarre content or are clearly implausible. Additionally, there are a few subtypes with specific

delusional themes that should be specified:

  Erotomanic type: This involves delusions about another person being in love with the

affected individual.

 Grandiose type: Individuals with the grandiose type of delusional disorder believe they

have a great talent (which is unrecognized) or made a great, important discovery.

 Jealous type: This involves delusions about his or her lover being unfaithful.

 Persecutory type: This subtype pertains to individuals with delusions involving their

beliefs that they are being conspired against, spied or cheated on, poisoned or drugged,

harassed or followed, or generally obstructed in the pursuit of long-term goals.

 Somatic type: Individuals with the somatic type of delusional disorder have delusions

involving bodily functions/and or sensations.

 Mixed type: There is not one delusional theme that persists over others.

 Unspecified type: The dominant delusional belief cannot be clearly determined or does

not fall into the descriptions of the specific types.

Specify if:

With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not

understandable, and not derived from ordinary life experiences (e.g., an individual’s belief that a

stranger has removed his or her internal organs and replaced them with someone else’s organs

without leaving any wounds or scars).

Specify if:

The following course specifiers are only to be used after a 1 -year duration of the disorder: First

episode, currently in acute episode: First manifestation of the disorder meeting the defining

diagnostic symptom and time criteria. An acute episode is a time period in which the symptom

criteria are fulfilled. First episode, currently in partial remission: Partial remission is a time
period during which an improvement after a previous episode is maintained and in which the

defining criteria of the disorder are only partially fulfilled. First episode, currently in full

remission: Full remission is a period of time after a previous episode during which no disorder-

specific symptoms are present. lUlultiple episodes, currently in acute episode Multiple episodes,

currently in partial remission Multiple episodes, currently in full remission Continuous:

Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the

majority of the illness course, with subthreshold symptom periods being very brief relative to the

overall course. Unspecified

Specify current severity:

Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including

delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative

symptoms. Each of these symptoms may be rated for its current severity (most severe in the last

7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician-

Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”)

Note: Diagnosis of delusional disorder can be made without using this severity specifie.

ETIOLOGY

As with many other psychotic disorders, the exact cause of delusional disorder is not yet known.

Researchers are, however, looking at the role of various genetic, biological, and environmental

or psychological factors.

 Genetic. The fact that delusional disorder is more common in people who have family

members with delusional disorder or schizophrenia suggests there might be a genetic

 factor involved. It is believed that, as with other mental disorders, a tendency to develop

delusional disorder might be passed on from parents to their children.

 Biological. Researchers are studying how abnormalities of certain areas of the brain

might be involved in the development of delusional disorders. An imbalance of certain

chemicals in the brain, called neurotransmitters, also has been linked to the formation of

delusional symptoms. Neurotransmitters are substances that help nerve cells in the brain

send messages to each other. An imbalance in these chemicals can interfere with the

transmission of messages, leading to symptoms.

 Environmental/psychological. Evidence suggests that delusional disorder can be

triggered by stress. Alcohol and drug abuse also might contribute to the condition. People

who tend to be isolated, such as immigrants or those with poor sight and hearing, appear

to be more vulnerable to developing delusional disorder.

SYMPTOMS

The presence of non-bizarre delusions is the most obvious symptom of this disorder. Other

symptoms that might appear include:

 An irritable, angry, or low mood

 Hallucinations (seeing, hearing, or feeling things that are not really there) that are related

to the delusion (For example, a person who believes he or she has an odor problem may

smell a bad odor.)

DIFFERENTIAL DIAGNOSIS
Obsessive-compulsive and related disorders. If an individual with obsessive-compulsive disorder

is completely convinced that his or her obsessive-compulsive disorder beliefs are true, then the

diagnosis of obsessive-compulsive disorder, with absent insight/delusional beliefs specifier,

should be given rather than a diagnosis of delusional disorder. Similarly, if an individual with

body dysmorphic disorder is completely convinced that his or her body dysmorphic disorder

beliefs are true, then the diagnosis of body dysmorphic disorder, with absent insight/delusional

beliefs specifier, should be given rather than a diagnosis of delusional disorder.

Delirium, major neurocognitive disorder, psychotic disorder due to another medical condition,

and substance/medication-induced psychotic disorder. Individuals with these disorders may

present with symptoms that suggest delusional disorder. For example, simple persecutory

delusions in the context of major neurocognitive disorder would be diagnosed as major

neurocognitive disorder, with behavioral disturbance. A substance/ medication-induced

psychotic disorder cross-sectionally may be identical in symptomatology to delusional disorder

but can be distinguished by the chronological relationship of substance use to the onset and

remission of the delusional beliefs.

EPIDEMILOGY

The lifetime morbid risk of delusional disorder in the general population has been estimated to

range from 0.05 to 0.1%, based on data from various sources including case registries, case

series, and population-based samples. According to the DSM-V, the lifetime prevalence of the

delusional disorder is about 0.02%.[3] The prevalence of the delusional disorder is much rarer

than other conditions like schizophrenia, bipolar disorder, and other mood disorders; this may be

in part due to underreporting of delusional disorder as those with delusional disorder may not

seek mental health attention unless forced by family or friends. Age mean age of onset is about
40 years, but the range is from 18 years to 90 years. The persecutory and jealous type of delusion

is more common in males, while the erotomanic variety is more common in females.

THEORITICAL FRAMEWORK

Treatment for delusional disorder most often includes medication and psychotherapy (a type of

counseling. Psychotherapy is the primary treatment for delusional disorder. It provides a safe

environment for patients to discuss their symptoms while encouraging healthier and more

functional attitudes and behaviors.

 Individual psychotherapy can help the person recognize and correct the underlying

thinking that has become distorted.

 Cognitive-behavioral therapy (CBT) helps the person learn to recognize and change

thought patterns and behaviors that lead to troublesome feelings. CBT works by helping

you examine how you think about a situation, how you act based on your thoughts, and

how your thinking and behavior together affect how you feel. If your thoughts and

actions are making you feel bad — or making it difficult for you to function — the goal

of therapy is to change them and thus alleviate distress and dysfunction.

 Family therapy can help families deal more effectively with a loved one who has

delusional disorder, enabling them to contribute to a better outcome for the person.

RECCOMENDATIONS

For persons responding to individuals with delusion, I would recommend:

 Let the person know that you recognize the feelings that can be evoked by the delusions. For

example, you could say: ‘It must feel very frightening to think that there is a conspiracy against
 you.’ Respond to the underlying feelings and encourage discussion of these rather than the

content of the delusion.

 Try to identify triggers and establish if the delusions are related to stress, anxiety or other

feelings or emotions. Try to make this gentle questioning, not an interrogation.

 Through observing, try to notice any interactions or events that seem to increase the person’s

anxiety and delusions (these could include television, radio or particular visitors). Promote

problem-solving by helping the person work out ways in which he or she can cope more

effectively with stressors. It may be useful to remove or substitute certain items in the room to

eliminate potential for misperception or misidentification.

 Develop a symptom management strategy. This could involve encouraging the person to talk

about things that are based in the immediate reality. Suggest that it would be helpful to discuss

other subjects based in the ‘here and now’. Encourage participation in reality-based physical

activities where possible

JAMAICAN/CARIBBEAN PERSPECTIVE

When a person thinks of mental illness, they associate the term with something that is deviant

and abnormal. Many people are of the preconceived notion that mental illness are not biological

or “organic”, which renders it as something that is not worth seeking professional help for. It is

no secret that there is a stigma against mental disorders in developing countries in the Caribbean,

like Jamaica. Unfortunately, this stigma continues to be the driving force as to why Jamaicans
often refuse to seek professional help and care if they or their loved one is suffering from a

mental illness. The Ministry of Health and Wellness in Jamaica has a Mental Health Unit that is

responsible for developing policies and plans to address the promotion of mental health, the

prevention of mental disorders, and to develop a series of services geared towards early

detection, treatment and the rehabilitation of affected persons. In Jamaica, you will find that most

drugs for the treatment of mental disorders are available free of cost or at subsidized rates.

However, to access the free medication, you must be registered with the National Health Fund.

You should have your psychiatrist or family doctor complete the relevant form so you can access

the benefit.

BIBLICAL PERSPECTIVE

We know that one of the consequences of the fall is the corruption of God’s good and perfect

creation of our bodies (2 Cor. 4:16; 1 Cor. 15:42; Psa. 73:26; Isa. 40:30). Our earthly lives are

limited, and eventually, our bodies will fail us. This also applies to our minds. Throughout

Scripture, we see biblical figures such as David (Psa. 38:4), Job (Job 3:26), Elijah (1 Kings

19:4), and Jonah (Jonah 4:3) dealing with deep feelings of despair, anger, depression, and

loneliness. While some of these things can be attributed to spiritual warfare, it can be of a

physical nature. Since we know that our bodies are prone to go awry at times, it’s possible that

what we are experiencing is related to chemical imbalances or other things happening within our

brains. If this is the case, Jesus gives an example of how we should care for one’s physical needs

in the parable of the Good Samaritan. When the Samaritan comes across the badly injured man

on the side of the road, he takes him to be bandaged and cared for until he recovers (Luke 10:34).

Other places throughout Scripture show God’s people using elements from the earth such as
leaves and figs to assist in the healing process from physical ailments (Ezk. 47:12; 1 Tim. 5:23;

Isa. 38:21). Taking medication in the midst of mental illness doesn’t show a lack of faith in the

ability of the Lord to sustain us through the suffering. Rather, it may allow some to experience

God with more clarity.

MENTAL ILLNESS AS A SPIRITUAL ISSUE

Perhaps, in some cases, our depression, anxiety, or any other thing that we would consider to be

mental illness may have a connection to our disobedience and sin toward God. While we know

that those who have placed their trust in Christ have freedom from condemnation for their sins

(Rom. 8:1), we may experience its earthly consequences. When we are confronted with the

brokenness of ourselves and our sin, the conviction may be overwhelming and give us feelings of

grief and despair. We see this take place when David is confronted with his affair with

Bathsheba and the murder of her husband (Psa. 51; 1 Kings 12). We also see characters where

their mental state is somehow connected to their spiritual state (Dan. 4:28-33; 1 Sam. 16:14)

Lastly, there are numerous accounts where the spiritual and physical seem to be connected, such

as the account of Legion in the New Testament (Mark 5:1-20; Luke 8:26-39). From these

examples, the hope we have in the midst of mental suffering is that the Lord knows, hears, can

heal, and is always ready to forgive our sins when we come to him (1 John 1:9).