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DELUSIONAL DISORDERS&

ACUTE & TRANSIENT PSYCHOSIS

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

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• WidowhoodVery 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 emanatesfrom 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 schizophrenia

Delusional disorder

Paranoid personality disorder

General behaviour

Eccentricities, mannerisms, stereotypies, decreased self care, social withdrawal, guarded & evasive.

Eccentricities, decreased social interaction.

Restrained social interaction.

Personality Disorganised Disturbed in delusional areas, normal in other areas.

No deterioration.

Thought disorder Delusions, loosening of association, formal thought disorder, delusions may be bizarre.

Non- bizarre delusions, are well systematized. No other thought disorder.

No thought disorder.

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Hallucinations Auditory common Uncommon. If present, not persistent.

absent

Contact with reality Markedly disturbed Disturbed in areas of delusional beliefs.

Intact

Insight absent absent present

Affect/ mood in relation to thought

Often inappropriate

Usually inappropriate

Usually 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.

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.

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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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