Delusional Disorder DSM-5 297.1 (F22)

DSM-5 Category: Schizophrenia Spectrum and Other Psychotic Disorders

Introduction

Delusional disorder is one of the less common psychotic disorders, in which patients

have delusions but not the other classical symptoms of schizophrenia (thought

disorder, hallucinations, mood disturbance or flat affect). There have been some

changes in diagnostic criteria for this condition in the new edition of the Diagnostic

and Statistical Manual of Mental Disorders, intended to improve the reliability and

stability of the diagnosis and facilitate consistent treatment (American Psychiatric

Association, 2013).

A delusion is a belief that is held with strong conviction despite evidence disproving it

that is stronger than any evidence supporting it. It is distinct from an erroneous belief

caused by incomplete information (misconception or misunderstanding), deficient

memory (confabulation) or incorrect perception (illusion). The psychiatrist and

philosopher Karl Jaspers proposed 3 criteria for delusional beliefs in 1913: certainty

(the belief is held with absolute conviction), incorrigibility (the belief cannot be

changed with any proof to the contrary) and impossibility or falsity (the belief cannot

be true) (Jaspers, 1967). Delusions are associated with a variety of mental and

neurological disorders, but are of diagnostic importance in the psychotic disorders.

Symptoms of Delusional Disorder

Delusions are generally categorized in 4 groups: bizarre, non-bizarre, mood-

congruent and mood-neutral. Bizarre delusions are strange and implausible, such as

being vivisected by aliens, while non-bizarre delusions are possible but unlikely, such

as being under surveillance. Mood-congruent delusions are false beliefs that are

consistent with the patient’s mood if disordered, such as power and influence with

mania and rejection and ostracism with depression. Mood-neutral delusions are not

related to the patient’s mood, such as having two heads or one arm.

Delusions have a great variety of themes, but certain recurrent themes have been

identified (Spitzer, 1990). These include delusions of control, mind-reading, thought

insertion, reference, persecution, grandeur, self-accusation, jealousy (Othello

syndrome), romance or sexual involvement (erotomania), somatic change or disease

or death (Cotard syndrome). Somatic delusions are associated with mood disorders

and organic dementias, and may constitute their own diagnostic entity (body

dysmorphic disorder) (Spitzer, 1990), while grandiose or persecutory delusions are

often cardinal symptoms of schizophrenia and related disorders(Freeman, 2004).

Munro identified 10 characteristics of delusions (Munro, 1999). The patient expresses

the delusional belief(s) with unusual force and persistence, and the belief or beliefs

exert and inordinate effect on the patient’s life, often altering or dominating it. Despite

profound conviction about the delusion, the patient is often secretive or suspicious in

discussing it. Delusional patients tend to be oversensitive and humorless, especially

regarding the delusion. The belief is central to the patient’s existence, and

questioning it elicits an inappropriately strong emotional reaction. The belief is

nevertheless unlikely, and not in keeping with the patient’s social, cultural or religious

background. The patient is highly invested emotionally in the belief, and other

elements of the psyche may be overwhelmed. If the belief is acted upon, abnormal

behavior may result which is out of character for the patient, but which may be

understandable in light of the delusion; the belief and behavior are felt to be

uncharacteristic by those who know the patient.

Delusional disorder is a primary disorder, with no medical or neurologic cause

apparent. It is chronic and may be lifelong, but the delusions are internally consistent

and logically constructed. Although the logic of the delusion may be abnormal,

general logical reasoning is unaffected, and there is no general disturbance of

behavior. Abnormal behavior, if it occurs, is specifically related to the delusional

belief. The patient has a heightened sense of self-reference, and trivial or nonspecific

events assume great importance through connection to the delusional belief (Munro,

1999).

The causes of delusional thinking are unknown. Morimoto et al. compared patients

with delusional disorder to schizophrenics and age-matched normal controls (2002).

Patients with delusional disorder had greater sensitivity to small doses of the

dopamine-blocking neuroleptic haloperidol than did schizophrenic patients. Plasma

levels of the dopamine metabolite homovanillic acid (HVA) were higher in patients

with delusions of persecution than in controls, but not in patients with delusional

jealousy, and elevated HVA levels decreased with haloperidol treatment. Certain

polymorphisms or gene variants associated with the DR2 and DR3 dopamine

receptors and the enzyme tyrosine hydroxylase involved in dopamine synthesis were

significantly more common in delusional disorder than in schizophrenia or normal

controls. These findings suggest that delusional symptoms arise from dopaminergic

hyperactivity and may have a genetic basis.

Delusional disorder is more common among people with impaired hearing or vision,

and with chronic situational stressors (Maina et al., 2001). These may lead to

inaccurate perceptions of reality and inappropriate defensive reliance upon them.

Devinsky et al. found a significant association between bilateral frontal lobe and right

cerebral hemisphere lesions and delusions (2009). They suggested that right

hemisphere injury can result in unbalanced left hemisphere overactivity, allowing left

hemisphere language centers to “create a story” that cannot be compared to reality

by malfunctioning right hemisphere centers. Impaired right-hemisphere monitoring of

the relations between self and environment can also allow an exaggerated self-

referential character to be imparted to thoughts and beliefs, and impairment of frontal

lobe self-monitoring and correction can result in delusional resistance to

counterargument and refutation.

Epidemiology

Delusional disorder is infrequent in psychiatric practice, possibly because many

patients are able to function tolerably well despite their delusions, and perhaps also

because those who believe implicitly in their delusions may not feel the need for

treatment and may resist the suggestions of others that they seek psychiatric

attention. Prevalence is estimated at 24 to 30 cases per 100,000 people, and new

cases each year number 0.7 to 3.0 per 100,000. One to 2 per cent of mental health

hospitalizations and only 0.001 to 0.003 per cent of first-time psychiatric admissions

are due to delusional disorder (Kendler, 1982).

Diagnostic Criteria

Diagnosis of delusional disorder requires the presence of delusions of at least 1

month’s duration. The patient must never have met Criterion A for schizophrenia,

which means that delusions must not have been accompanied by most types of

hallucinations, disorganized speech (incoherence or derailments into tangents),

grossly disorganized or catatonic behavior, or negative symptoms (flattening of

affect, muteness, loss of volition). Tactile and olfactory hallucinations may be part of

nonschizophrenic delusions, but not auditory or visual ones. Functioning must not be

affected except for the immediate consequences of the delusions, such as hiding

from imagined pursuers or preparing to confront the supposed lover of one’s wife.

Episodes of mood disturbance if present must be much briefer in duration than the

delusions: a patient who is despondent all the time because he is sometimes sure

that he has cancer is more likely to be depressed than delusional. The delusion(s)

must not be due to a general medical condition or to the effects of drug abuse or

medication.

Delusions are further classified by type, based on the predominant thene of the

delusion. Erotomanic delusions involve the belief that another person, often of higher

status, is in love with the patient. Grandiose delusions are those of power, wealth,

importance, relationships to famous people, a special relationship to God or even

being a deity. The jealous type are delusions that one’s spouse or partner is

unfaithful. Persecutory delusions involve conspiracy against or mistreatment of the

patient. Somatic delusions are those of illness or deformity. Mixed delusions have

more than one theme.

DSM-5 changes the diagnostic criteria for delusional disorder to reflect revision of the

diagnostic criteria for schizophrenia. In previous editions of the manual, delusions

had to be “non-bizarre”, i.e., having erroneous beliefs related to real life (being

followed or poisoned or persecuted) rather than, for example, the iconic delusion of

being Napoleon Bonaparte. Bizarre delusions, such as detachment or liquefaction of

body parts, can now be identified as manifestations of delusional disorder if they

cannot be better explained by conditions such as body dysmorphic disorder or

obsessive compulsive disorder. In addition, DSM-5 removes the distinction between

delusional disorder and shared delusional disorder, in which two or more individuals

share a delusional belief, historically referred to as folie à deux. It was previously

difficult to diagnose delusional beliefs in more than one person if the belief in

question might ordinarily be widely shared in the patients’ culture, such as demonic

possession at certain times in history or the existence of elves in certain countries.

The revised criteria simply propose that if two patients strongly espouse an

erroneous belief and have the other symptoms described above, then both patients

have delusional disorder.

Treatment of Delusional Disorder

Patients with delusional disorder may be difficult to treat, in part because of the

centrality of the delusions in their lives and in part because the delusions may not be

very disruptive in the absence of other positive or negative psychotic symptoms. The

often-formidable internal logic of the delusional system, even if wrong, may also

militate against treatment adherence. Put another way, if you believed unhesitatingly

that you were President of the United States, or that you were being poisoned, or that

your wife had put you in treatment so she could run off with the postman, would you

take your medication? A nonconfrontational culturally-sensitive approach to agreed-

upon therapeutic goals, that includes the family when possible, is recommended,

outpatient in nature except when violence or harm are concerns and aimed at

maintaining social function and improving quality of life (Fochtmann, 2005).

Studies of medication treatment are mostly in classes C (series of cases) and D

(single case studies) of the evidence-based medicine hierarchy, with little or no class

A (randomized controlled trial) or B (systematic but nonblinded or nonrandomized

trials) evidence. Studies between 1966 and 1985 involved about 1000 delusional

disorder patients, of whom 257 were well-described, and found recovery with

antipsychotic drug treatment in 52.6 per cent and improvement in 28.2 per cent, while

19.2 per cent did not improve. Pimozide (68.5 per cent recovery and 22.4 per cent

improvement) was better than other typical neuroleptics (22.6 per cent recovery and

45.3 per cent improvement) (Munro, 1995). Studies since 1985 used primarily

atypical neuroleptics, such as respiridone (Risperdal), quetiapine (Seroquel) and

olanazapine (Zyprexa), in a small number of patients (224 reported, 134 well

described). Ninety per cent of patients had symptom improvement while 50 per cent

were symptom-free, often after polypharmacy or with other treatment modalities used

as well. No differences in response were found between pimozide and other typical

neuroleptics, or between typical and atypical antipsychotic agents, but patients with

persecutory delusions did worse (50 per cent improvement and no complete

recovery) (Freudenmann & Lepping, 2008). Antidepressants, particularly SSRI agents

and clomipramine, have been occasionally helpful, mainly with somatic delusions

(Hayashi et al., 2004).

Supportive psychotherapy is helpful for most patients, chiefly cognitive treatment that

uses Socratic questioning to identify maladaptive thoughts and replace them with

more adaptive beliefs, but is careful not to address the unrealistic nature of the

delusions too early in the treatment process (Silva et al., 2003). Cognitive behavioral

therapy (CBT) and attention placebo control (APC) have been compared in their

effect on the Maudsley Assessment of Delusions Schedule (MADS), and both

produced improvement, but CBT was more effective in lessening strength of

delusional conviction, decreasing affect related to delusional beliefs and diminishing

action on the beliefs (O’Connor, Stip & Pelissier, 2007). Training patients in

behavioral principles and social skills so that they feel more in control of their

situations and are better able to interact with those they think are judging or harming

them has been shown to dissipate feelings of powerlessness that reinforce

delusions (Liberman, 2008). Some feel that insight-oriented psychotherapy is

ineffective or even contraindicated in delusional disorders, but case reports have

suggested that patients may sometimes be helped to contain feelings of impotence,

badness and hatred, to question their internal view of the world and to accept an

alliance with therapists (Liberman, 2008).

Author: Miles E. Drake, Jr., M.D

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of

Mental Disorders, ed. 5. Washington, DC: APA Press.

Devinsky, O. (2009). Delusional misidentifications and duplications: Right brain

lesions, left brain delusions. Neurology, 72(1), 80-87.

Fochtmann, L.J. (2005). Treatment of other psychotic disorder. In Sadock, B.A.,

Kaplan, V.A., Ruiz, P. (Eds). Kaplan and Sadock’s Comprehensive Textbook of

Psychiatry, ed. 8. Philadelphia: Lippincott Williams and Wilkins, 1545-1550.

Freeman, D., & Garrity, P.A. (2014). Paranoia: The Psychology of Persecutory

Delusions. Hove: Psychology Press.

Freudenmann, R.W., Lepping, P. (2008). Second-generation antipsychotics in

primary and secondary delusional parasitosis: outcome and efficacy. J Clin

Psychopharmacol, 28(5), 500-508.

Hayashi, H. et al. (2004). Paroxetine treatment of delusional disorder, somatic type.

Hum Psychopharmacol, 19(5), 351-352.

Jaspers, K. (1967). General Psychopathology. Baltimore: Johns Hopkins University

Press, 106.

Kendler, K.S. (1982). Demography of paranoid psychosis (delusional disorder): A

review and comparison with schizophrenia and affective illness. Arch Gen Psychiat,

39(8), 890-902.

Liberman, R.P. (2008). Recovery from Disability: Manual of Psychiatric

Rehabilitation. Arlington, VA: Amer Psychiatric Publishing.

Maina, G., Albert, U., Badà, A., & Bogetto, F. (2001). Occcurrence and clinical

correlates of psychiatric co-morbidity in delusional disorder. Eur Psychiat, 16(4), 222-

228.

Morimoto, K., et al. (2002). Delusional disorder: molecular genetic evidence for

dopamine psychosis. Neuropsychopharmacology, 26(6), 794-801.

Munro, A. (1999). Delusional Disorder: Paranoia and Related Illnesses. Cambridge,

U.K.: Cambridge University Press.

Munro, A., & Mok, H. (1995). An overview of treatment in paranoia/delusional

disorder. Can J Psychiatry, 40(10), 616-622.

O’Connor, K. et al. (2007). Treating delusional disorder: a comparison of cognitive-

behavioural therapy and attention placebo control. Can J Psychiatry, 52(3), 182-190.

Silva, S.P., Kim, C,K., Hoffman, S.G., Loula, E.C. (2003). To believe or not to believe:

Cognitive and psychodynamic approaches to delusional disorder. Harv Rev

Psychiatry, 11(1), 20-29.

Spitzer, M. (1990). On defining delusions. Compr Psychiat, 31(5), 377-397.

Delusional Disorder SymptomsBy PSYCH CENTRAL STAFF

Delusional disorder is characterized by the presence of eitherbizarre or non-bizarre delusions which have persisted for atleast one month. Non-bizarre delusions typically are beliefs of something occurring  in a person’s life which is not out of the realm of possibility. For example, the person may believe their significant other is cheating on them, that someone close to them is about to die, a friend is really a government agent, etc. All of these situations could be true or possible, but the person suffering from this disorder knows them not to be (e.g., through fact-checking, third-person confirmation, etc.). 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). Delusions that express a loss of control over mind or body are generally considered to be bizarre and reflect a lower degree of insight and a stronger conviction to hold such belief compared to when they are non-bizarre. Accordingly, if an individual has bizarre delusions, a clinician will specify “with bizarre content” when documenting the delusional disorder.

People who have this disorder generally don’t experience a marked impairment in their daily functioning in a social, occupational or other important setting. Outward behavior is not noticeably bizarre or objectively characterized as out-of-the-ordinary.

The delusions can not be better accounted for by another disorder, such as schizophrenia, which is also characterized by delusions (which are bizarre).  The delusions also cannot be better accounted for by a mood disorder, if the mood disturbances have been relatively brief. The lifetime prevalence of delusional disorder has been estimated at around 0.2% .

Specific Diagnostic Criteria

1. Delusions lasting for at least 1 month’s duration.

2. Criterion A for Schizophrenia has never  been met. Note:Tactile and olfactory hallucinations may be present  in Delusional Disorder if they are related to the delusional theme.Criterion A of Schizophrenia requires two (or more) of the following,  each present for a significant portion of time during a 1-month period  (or less if successfully treated):

1. delusions

2. hallucinations

3. disorganized speech (e.g., frequent derailment or incoherence)

4. grossly disorganized or catatonic behavior

5. negative symptoms, i.e., affective flattening, alogia, or avolition

6.

Note: Criteria A of Schizophrenia requires only one symptom if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary

on the person’s behavior or thoughts, or two or more voices conversing with each other.

3. Apart from the impact of the delusion(s) or its ramifications,  functioning is not markedly impaired and behavior is not obviously odd  or bizarre.

4. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.

5. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify type (the following types are assigned based on the predominant delusional theme):

Erotomanic Type:  delusions that another person, usually of higher status, is in love with the individual

Grandiose Type:  delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person

Jealous Type: delusions that the individual’s sexual partner is unfaithful

Persecutory Type:  delusions that the person (or someone to whom the person is close) is being malevolently treated in some way

Somatic Type: delusions that the person has some physical defect or general medical condition

Mixed Type: delusions characteristic of more than one of the above types but no one theme predominates

Unspecified Type

Treatment for Delusional Disorder

 

This entry has been updated for 2013 DSM-5 criteria; diagnostic code: 297.1.

Delusional Disorder TreatmentBy Psych Central Staff

Table of Contents

Psychotherapy

Medications

Self-Help

Psychotherapy

Psychotherapy is usually the most effective help in person suffering from delusional disorder. The overriding important factor in this therapy is the quality of the patient/therapist relationship. Trust is a key issue, as is unconditional support. If the client believes that the therapist really does think he or she is "crazy," the therapy

can terminate abruptly. Early in the therapy, it is vital not to directly challenge the delusion system or beliefs and instead to concentrate on realistic and concrete problems and goals within the person's life.

Once a firm, supportive therapeutic relationship has been established, the therapist can begin reinforcing positive gains and behaviors the individual makes in his or her life, such as in educational or occupational gains. It is important to reinforce these life events (such as getting a job), because it reinforces in the patient a sense of self-confidence and self-reliance.

Only when the client has begun to feel more secure in their social or occupational world can more productive work be accomplished in therapy. This involves the gradual but gentle challenging of the client's delusional beliefs, starting with the smallest and least-important items. Occasionally making these types of gentle challenges throughout therapy will give the clinician a greater understanding of how far along the individual has come. If the patient refuses to give up his or her delusion beliefs, even the smallest ones, then therapy is likely to be very long-term. Even if the client is willing, therapy is likely to take a fair amount of time, from at least 6 months to a year.

Clinicians should always be very direct and honest, especially with people who suffer from delusion disorder. Professionals should be even more careful than usual not to impinge on the client's privacy or confidentiality, and to say plainly what they mean in therapy sessions. Subtlety and sarcasm may be easily misinterpreted by the patient. Therapy approaches which focus on insight or self-knowledge may not be as beneficial as those stressing social skills training and other behaviorally and solution-oriented therapies.

Medications

Suggesting the use of medication for use in this disorder, while possibly indicated to help temporarily relieve the delusions, is usually difficult. The client may be suspicious of any professional suggesting the use of a medication and therefore this treatment approach (and successful maintenance of the individual on the medication) is problematic.

Anti-psychotic medication is the preferred medication used, though, although it is only marginally effective. There are few studies done which confirm the use of any specific medications for this disorder.

Hospitalization should be avoided at all costs, since this will usually go to reinforce the individual's distorted cognitive schema. Partial hospitalization and/or day treatment programs are preferred to help manage the individual under close supervision on a daily basis.

Phillip W. Long, M.D. writes that "other treatments have been tried (electroconvulsive therapy, insulin shock therapy, and psychosurgery), but these approaches are not recommended."

Self-Help

There are not any self-help support groups or communities that we are aware of that would be conducive to someone suffering from this disorder. Such approaches would likely not be very effective because a person with this disorder is likely to be mistrustful and suspicious of others and their motivations, making group help and dynamics unlikely and possibly harmful.