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Delusional Disorder: Overview, Diagnosis, Epidemiology

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Delusional Disorder: Overview, Diagnosis, Epidemiology

Author:JamesABourgeois,OD,MD,MPAChiefEditor:DavidBienenfeld,MDmore...

Updated:May28,2015

Overview
Delusionaldisorderisanillnesscharacterizedbyatleast1monthofdelusionsbut
nootherpsychoticsymptomsaccordingtotheAmericanPsychiatricAssociations
DiagnosticandStatisticalManualofMentalDisorders,FifthEdition(DSM5).[1]
Delusionsarefalsebeliefsbasedonincorrectinferenceaboutexternalrealitythat
persistdespitetheevidencetothecontraryandthesebeliefsarenotordinarily
acceptedbyothermembersoftheperson'scultureorsubculture.Delusionscanbe
characterizedaspersecutory(i.e.,beliefoneisgoingtobeharmedbyanindividual,
organizationorgroup),referential(i.e.,beliefgestures,comments,orenvironmental
cuesaredirectedatoneself),grandiose(i.e.,beliefthattheindividualhas
exceptionalabilities,wealth,orfame),erotomanic(i.e.,anindividualsfalsebelief
thatanotherindividualisinlovewiththem),nihilistic(i.e.,convictionthatamajor
catastrophewilloccur),orsomatic(i.e.,beliefsfocusedonbodilyfunctionor
sensation).
Nonbizarredelusionsareaboutsituationsthatcouldoccurinreallife,suchasbeing
followed,beingloved,havinganinfection,andbeingdeceivedbyone'sspouse.
Bizarredelusionsareclearlyimplausible.Delusionsthatexpressalossofcontrol
overmindorbodyaregenerallyconsideredtobebizarreandincludebeliefthat
onesthoughtshavebeenremovedbyanoutsideforce,thatalienthoughtshave
beenputintoonesmind,orthatonesbodyoractionsarebeingactedonor
manipulatedbyanoutsideforce.[1]
Makingadistinctionbetweenadelusionandanovervaluedideaisimportant,the
latterrepresentinganunreasonablebeliefthatisnotfirmlyheld.[1]Additionally,
personalbeliefsshouldbeevaluatedwithgreatrespecttocomplexityofculturaland
religiousdifferencessomecultureshavewidelyacceptedbeliefsthatmaybe
considereddelusionalinothercultures.
Unfortunately,patientswithdelusionaldisorderdonothavegoodinsightintotheir
pathologicalexperiences.Interestingly,despitesignificantdelusions,manyother
psychosocialabilitiesremainintact,asifthedelusionsarecircumscribed.Indeed,
thisisoneofthekeydifferencesbetweendelusionaldisorderandotherprimary
psychoticdisorders.However,theindividualmayrarelyseekpsychiatrichelp,
remainisolated,andoftenpresenttointernists,surgeons,dermatologists,
policemen,andlawyersratherthanpsychiatrists.

Casestudy
Mrs.Kisa39yearoldwomanwhowasbroughttotheinpatientpsychiatricunitby
policeafterbeingarrestedfortrespassingonMr.Lsproperty.Uponarrival,Mrs.K
wasadamantaboutbeingreleased,statingthatshewassimplyenteringher
husbandshome,adamantlydeclaringthatMr.Lwasherhusband.Sheelaborateda
storyabouthowmuchthetwoofthemlovedeachother,whentheygotmarried,and
howshewascurrentlypregnantwithhischild.Inactuality,Mr.LusedtobeMrs.Ks
boss,andhadfiredherbecauseofherinappropriateromanticadvancesseveral
yearsprior.Mrs.KwasmarriedtoanothermaninFlorida,withwhomshedenied
anyrelationship,statingthatshewaskidnappedfor4years,andafterescaping,had
cometoCaliforniatobewithherhusband,Mr.L.Mrs.Kwasdiagnosedwith
delusionaldisorder,erotomanictype,andwasstartedonrisperidone.

Diagnosis
Patientevaluation
TheoManschreck[19]outlined3stepsintheinitialevaluationofpatientswhopresent
withdelusions.
First,establishwhetherpathologyispresent.Thisrepresentsaclinicaljudgmentthat
issometimesdifficulttomake.Somecommentsthatappeardelusionalmaybetrue.
Incontrast,somereportsthatinitiallyseembelievablemaylaterbeidentifiedas
delusionsasthesymptomsworsen,thedelusionsbecomelessencapsulated(i.e.,
begintoextendtomorepeopleorsituations),andmoreinformationcomestolight.
Theclinicaljudgmentthatdelusionsarepresentshouldbemadeaftertakinginto
accountthedegreeofplausibility,systemization,andthepossiblepresenceof
culturallysanctionedbeliefsthataredifferentfromone'sownbeliefs.Makingthe
distinctionbetweenatrueobservation,afirmbelief,anovervaluedidea,anda
delusionissometimesachallengingtask.Often,theextremenessand
inappropriatenessofthepatient'sbehaviors,ratherthanthesimpletruthorfalsityof
thebelief,indicateitsdelusionalnature.[19,4]
Thesecondstepisdeterminingthepresenceorabsenceofimportantcharacteristics
andsymptomsoftenassociatedwithdelusions,suchasconfusion,agitation,
perceptualdisturbances,physicalsymptoms,andprominentmoodabnormalities.[19]
Studieshaveshownthatthemostcommonsymptomsreportedwereselfreference
(40%),irritability(30%),depressivemood(20%),andaggressiveness(15%).[20]
Thethirdstepistopresentasystematicdifferentialdiagnosis.Athoroughhistory,
mentalstatusexamination,andlaboratory/radiologicevaluationshouldbeperformed
toruleoutothermedicalandpsychiatricconditionsthatarecommonlypresentwith

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delusions.CNSillnessishighonthedifferentialdiagnosisofanypsychoticdisorder,
especiallysointheonsetofdelusionaldisorderinpatientsolderthanthetypical
onsetofschizophrenia.Delusionaldisordershouldbeseenasadiagnosisof
exclusion.[19]

Diagnosticcriteria(DSM5)
ThespecificDSM5criteriafordelusionaldisorderareasfollows:[1]
Presenceofoneormoredelusionswithadurationofonemonthorlonger.
Thecriteriaforschizophreniahasneverbeenmet.Note:Hallucinations,if
presentarenotprominentandarerelatedtothedelusionaltheme(e.g.,the
sensationofbeinginfectedwithinsectsisassociatedwiththedelusionsof
infestation).
Apartfromtheimpactofthedelusion(s)oritsramifications,functioningisnot
markedlyimpaired,andbehaviorisnotobviouslybizarreorodd.
Ifmanicormajordepressiveepisodeshaveoccurred,thesehavebeenbrief
relativetothedurationofthedelusionalperiods.
Thedisturbanceisnotbetterexplainedbyanothermentaldisordersuchas
obsessivecompulsivedisorder,andisnotattributabletothephysiological
effectsofasubstanceormedicationoranothermedicalcondition.
Subtypesaredefinedaserotomanic,grandiose,jealous,persecutory,somatic,
mixed,andunspecified.Thediagnosisisfurtherspecifiedwithbizarrecontent
whendelusionsareclearlyimplausible,notunderstandable,andnotderivedfrom
ordinarylifeexperiences.
Thefollowingdurationspecifiersareusedonlyafter1yeardurationofthedisorder:
Firstepisode,currentlyinacuteepisode
Firstepisode,currentlyinpartialremission
Firstepisode,currentlyinfullremission
Multipleepisodes,currentlyinacuteepisode
Multipleepisodes,currentlyinpartialremission
Multipleepisodes,currentlyinfullremission
Continuous

Epidemiology
Unitedstatesstatistics
TheprevalenceofdelusionaldisorderintheUnitedStatesisestimatedintheDSM5
tobearound0.02%[1],whichisconsiderablylowerthantheprevalenceof
schizophrenia(1%)andmooddisorders(5%).[7]Ourcurrentunderstandingof
delusionaldisorder,however,islimitedbyscarcescientificdatathatmostlyconsist
ofindividualcasedescriptionsorsmalluncontrolledcasestudies,whichare
thereforedifficultorimpossibletoduplicate.[8]

Internationalstatistics
ABritishstudyreportedthatof227patientspresentingtomentalhealthcenterswith
afirstepisodeofpsychosisduringthe3yearstudyperiod,7%werediagnosedwith
persistentdelusionaldisorder,ascomparedto11%withschizophreniaand19%with
psychoticdepression.[10]

Sexualdifferencesinincidence
Thefemaletomaleratiohasbeenreportedtovaryfrom1.18[9]3:1[5].Menare
morelikelythanwomentodevelopparanoiddelusionswomenaremorelikelythan
mentodevelopdelusionsoferotomania.[7]Associatedfactorsincludebeingmarried,
beingemployed,recentimmigration,lowsocioeconomicstatus,celibacyamong
men,andwidowhoodamongwomen.[9,2]

Agerelateddifferencesinincidence
Themeanageofonsetis40yearsandrangesfrom1890years.[7]ASpanishstudy
conductedbydePortugaletal(2008)lookedatmedicalrecordsof370people
diagnosedwithdelusionaldisorderandfoundthatthemeanageinthispopulation
was55years,with56.5%ofthepatientsbeingfemale.

Etiology
Generalconsiderations
Theetiologyofdelusionaldisorderisunknown,andseveraldifficultiesexistin
conductingresearchinthisarea:
Patientscurrentlydiagnosedwithdelusionaldisordermayrepresenta
heterogeneousgroupofpatientswithdelusionsasthepredominant
symptom.
Patientsoftendonotpresentfortreatment,andthustheydonotcommonly
makethemselvesavailableforresearchstudies.
However,strongindicationsexistthatdelusionaldisorderisadistinct

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condition,differentfromschizophreniaormooddisorder.Naturalisticstudies
indicatedthatdelusionaldisorderhasarelativelystablecourse.
Thedefinitionofthisconditionhaschangedovertimeandcontinuestobea
workinprogress.

Genetics
Therelationshiptothemoreseverepsychosisisyetunclear.AccordingtotheDSM
5,onaverage,globalfunctionisgenerallybetterthanthatobservedin
schizophrenia.Althoughthediagnosisisgenerallystable,aproportionofindividuals
goontodevelopschizophrenia.Delusionaldisorderhasasignificantfamilial
relationshipwithbothschizophreniaandschizotypalpersonalitydisorder.Althoughit
canoccurinyoungeragegroups,theconditionismoreprevalentinolder
individuals.[1]

Biochemicalfactors
Biologicalfactorsmayplaysomeroleinthedevelopmentofdelusionaldisorder,as
delusionsareassociatedwithawiderangeofnonpsychiatricmedicalconditions.
Amongpatientswithneurologicdisorders(primarilydementia,headinjury,and
seizures)problemswiththebasalgangliaandtemporallobearemostcommonly
associatedwithdelusions.[7,12]However,acasereportofasomaticdelusion
involvingreduplicationofbodypartsimplicatedthetemporalandparietallobes,
showinghypoperfusionofbothregions.[13]
Campanaetal[14]usedeyetrackingmovementteststounderstandtherelationship
betweenfrontalfieldfunctionsandclinicalsymptomsofdelusionaldisorder.They
foundthatcomparedwithnormalparticipants,patientswithdelusionaldisorder
showedabnormalitiesofvoluntarysaccadiceyemovementsandsmoothpursuiteye
movements,adysfunctionsimilartothatseeninpatientswithschizophrenia.
Hyperdopaminergicstateshavebeenimplicatedinthedevelopmentofdelusions.
Recently,Morimotoetal[15]reportedthat13patientswithdelusionaldisorderwere
reportedtohaveincreasedlevelsofplasmahomovanillicacid(HVA)(adopamine
metabolite)comparedwithcontrolsubjects.Patientsrespondedwelltotreatment
withlowdosehaloperidol(average2.7mg/d)andshoweddecreasedposttreatment
plasmalevelofHVA,whichcorrelatedwiththeimprovementoftheirsymptoms.
ThesameauthorsreportedanincreasedprevalenceofapolymorphismattheD2
receptorgeneataminoacid311(cysteineforserinesubstitution)amongindividuals
withdelusionaldisorderintheirsample,particularlythosewithpersecutory
delusions.IndividualsthathadmoreTCATrepeatswithinthefirstintronofthe
tyrosinehydroxylasegenehadhigherlevelsofHVA,althoughitisunclearifthey
correctedformultiplestatisticalcomparisons.[15]

Psychologicalfactors
Thefieldsofcognitiveandexperimentalpsychologysuggestthatpersonswith
delusionsselectivelyattendtoavailableinformation,whichappearstooverlapwith
hypochondriacalpatientpopulations.[16]Theymakeconclusionsbasedon
insufficientinformation,attributenegativeeventstoexternalpersonalcauses,and
havedifficultyinenvisagingothersintentionsandmotivations.[4]
Conwayetal[17]reportedthatpatientswithdelusionaldisordermadeprobability
decisionsbasedonfewerdatacomparedwithnormalcontrols.Despiteusingfewer
data,theywereascertainascontrolsregardingtheaccuracyoftheirdecisions.
Twoneuropsychologicalmodelsproposedforschizophreniamayalsohavesome
validityindelusionaldisorder.Acognitivebiasmodel(CBM)proposesthatparanoia
isadefenseagainstthoughtsthatthreatentheidealizedself,toprotectafragileself
esteem.Positiveeventsareattributedtotheselfwhereasnegativeeventsare
ascribedtotheexternalenvironment.Incontrast,thecognitivedeficitmodel(CDM)
focusesoncognitiveimpairmentsanddistortionsofthreatevaluatingmechanisms
asthecausefordelusionformation.[18]

ClinicalFeatures
Thestatusexamination(includingcognitiveexamination)isusuallynormalwith
exceptionofthepresenceofabnormaldelusionalbeliefs.
Ingeneral,patientsarewellgroomedandwelldressedwithoutevidenceofgross
impairment.Speech,psychomotoractivity,andeyecontactmaybeaffectedbythe
emotionalstateassociatedwithdelusions,butareotherwisenormal.
Moodandaffectareconsistentwithdelusionalcontentforexample,patientswith
persecutorydelusionsmaybesuspiciousandanxious.Milddysphoriamaybe
presentwithoutregardoftypeofdelusions.
Tactileandolfactoryhallucinationsmaybepresentandmaybeprominentiftheyare
relatedtothedelusionaltheme(eg,thesensationofbeinginfestedbyinsects,the
perceptionofbodyodor).[6]SystemicorCNScausesoftactileandolfactory
hallucinations,suchassubstanceintoxicationandwithdrawal,andtemporallobe
epilepsy,shouldberuledout.Auditoryorvisualhallucinationsarecharacteristicof
moreseverepsychoticdisorders(eg,schizophrenia)andshouldleadawayfroma
diagnosisofdelusionaldisorder.

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Memoryandcognitionareintact.Levelofconsciousnessisunimpaired.
Patientsusuallyhavelittleinsightandimpairedjudgmentregardingtheirpathology.
Police,familymembers,coworkers,andphysiciansotherthanpsychiatristsare
usuallythefirsttosuspecttheproblemandseekpsychiatricconsultation.Seeking
corroborativeinformation,whenpermittedbythepatient,isoftencrucial.Recallthat
itispermissibletoseekcollateralhistorybutthatcollateralhistoryshouldnotbe
withheldfromthepatient.
Assessmentofhomicidalorsuicidalideationisextremelyimportantinevaluating
patientswithdelusionaldisorder.Thepresenceofhomicidalorsuicidalthoughts
relatedtodelusionsshouldbeactivelyscreenedforandtheriskofcarryingout
violentplansshouldbecarefullyassessed.Reid(2005)pointedoutthatsometypes
ofthisillnesserotomanic,jealous,andpersecutoryareassociatedwithhigher
riskforviolencethanothers.[21]Historyofpreviousviolentactsaswellashistoryof
howaggressivefeelingsweremanagedinthepastmayhelptoassesstherisk.
Accesstoweaponsshouldbeexplored.

Erotomanictype
Relatedtermsincludeerotomania,psychosepassionelle,Clerambaultsyndrome,
andoldmaid'sinsanity.[2,4,5]
Thecentralthemeofdelusionsisthatanotherperson,usuallyofhigherstatus,isin
lovewiththepatient.Theobjectofdelusionisgenerallyperceivedtobelongtoa
highersocialclass,beingmarried,orotherwiseunattainable.[3,5]
Patientswiththistypeofdelusionaregenerallyfemale,althoughmalespredominate
inforensicsamples.[1,5]
Delusionalloveisusuallyintenseinnature.Signsofdenialoflovebytheobjectof
thedelusionarefrequentlyfalselyinterpretedasaffirmationoflove.[2,5]
Patientsmayattempttocontacttheobjectofthedelusionbymakingphonecalls,
sendinglettersandgifts,makingvisits,andevenstalking.Somecasesleadto
assaultivebehaviorsasaresultofattemptstopursuetheobjectofdelusionalloveor
attemptingto"rescue"her/himfromsomeimagineddanger.[1]

Grandiosetype
Patientsbelievethattheypossesssomegreatandunrecognizedtalent,havemade
someimportantdiscovery,haveaspecialrelationshipwithaprominentperson,or
havespecialreligiousinsight.[1]
Grandiosedelusionsintheabsenceofmaniaarerelativelyuncommon,andthe
distinctionofthissubtypeofdisorderisdebatable.Manypatientswithparanoidtype
showsomedegreeofgrandiosityintheirdelusions.[4]
Grandiosityinnarcissisticpersonalitydisorderisbydefinitionnonpsychoticandnot
directlyrelatedtoanelevatedmoodstate,asinbipolardisorders.Narcissistic
patientswillconcurrentlyshowalackofempathy,exploitivebehavior,andasenseof
entitlementinadditiontograndiosity.

Jealoustype
Relatedtermsincludeconjugalparanoia,Othellosyndrome,andpathologicalor
morbidjealousy.[19,7,22,23]
Themainthemeofthedelusionsisthatherorhisspouseorloverisunfaithful.
Somedegreeofinfidelitymayoccurhowever,patientswithdelusionaljealousy
supporttheiraccusationwithdelusionalinterpretationof"evidence"(eg,disarrayed
clothing,spotsonthesheets).[1,4]
Patientsmayattempttoconfronttheirspousesandinterveneinimaginedinfidelity.
Jealousymayevokeangerandempowerthejealousindividualwithasenseof
righteousnesstojustifytheiractsofaggression.Boththeintimatepartnerandthe
(perceived)lovermaybethetargetsofaggressionandviolence.Thisdisordercan
sometimesleadtoactsofviolence,includingsuicideandhomicide.[4]

Persecutorytype
Thisisthemostcommontypeofdelusionaldisorder.[20,25]
Patientswiththistypebelievethattheyarebeingpersecutedandharmed.[4]In
contrasttopersecutorydelusionsofschizophrenia,thedelusionsaresystematized,
coherent,anddefendedwithclearlogic.Nodeteriorationinsocialfunctioningand
personalityisobserved.[2]
Patientsareofteninvolvedinformallitigationagainsttheirperceivedpersecutors.
Munro[3]referstoanarticlebyFreckeltonwhoidentifiesthefollowingcharacteristics
ofdeludedlitigants:determinationtosucceedagainstallodds,tendencytoidentify
thebarriersasconspiracies,endlessdrivetorightawrong,quarrelsomebehaviors,
and"saturatingthefield"withmultiplecomplaintsandsuspiciousness.[3]
Patientsoftenexperiencesomedegreeofemotionaldistresssuchasirritability,
anger,andresentment.[4]Inextremesituations,theymayresorttoviolenceagainst

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thosewhotheybelievearehurtingthem.[1]
Thedistinctionbetweennormality,overvaluedideas,anddelusionsisdifficultto
makeinsomeofthecases.[4]

Somatictype
Thecorebeliefofthistypeofdisorderisdelusionsaroundbodilyfunctionsand
sensations.Themostcommonarethebeliefthatoneisinfestedwithinsectsor
parasites,emittingafoulodor,partsofthebodyarenotfunctioning,thebeliefthat
theirbodyorpartsofthebodyaremisshapenorugly,andthereduplicationofbody
parts.[1,13]
Patientsaretotallyconvincedinphysicalnatureofthisdisorder,whichiscontraryto
patientswithhypochondriasiswhomayadmitthattheirfearofhavingamedical
illnessisgroundless.[2]
Patientsareusuallyfirstseenbydermatologists,cosmeticsurgeons,urologists,
gastroenterologists,andothermedicalspecialists.[4]
Sensoryexperiencesassociatedwiththisillness(eg,sensationofparasitescrawling
undertheskin)areviewedascomponentsofsystemizeddelusions.[4]Thismustbe
distinguishedfrombizarresomaticdelusionsoccasionallyseeninschizophrenia(eg,
adelusionthatacolonyoflobstersislivinginthepatientsstomach).

Mixedtype
Patientsexhibitmorethanoneofthedelusionssimultaneously[4],andnoone
delusionalthemepredominates.[1]

Unspecifiedtype
Delusionalthemesfalloutsidethespecificcategoriesorcannotbeclearly
determined.[1]
MisidentificationsyndromessuchasCapgrassyndrome(characterizedbyabelief
thatafamiliarpersonhasbeenreplacedbyanidenticalimpostor)orFregoli
syndrome(abeliefthatafamiliarpersonisdisguisedassomeoneelse)fallintothis
category.Misidentificationsyndromesarerareandfrequentlyareassociatedwith
otherpsychiatricconditions(eg,schizophrenia)ororganicillnesses(eg,dementia,
epilepsy).[4]
AnotherunusualsyndromeisCotardsyndrome,inwhichpatientsbelievethatthey
havelostalltheirpossessions,status,andstrengthaswellastheirentirebeing,
includingtheirorgans.[4]Describedfirstinthe19thcentury,itisararecondition,
whichisusuallyconsideredaprecursortoaschizophrenicordepressiveepisode.[2]

DifferentialDiagnosis
Table1.MedicalConditionsAssociatedWithDevelopmentofDelusions[4](Open
Tableinanewwindow)
Medical
Conditions

Examples

Alzheimerdisease,Pickdisease,Huntingtondisease,
Neurodegenerative
ParkinsonDisease,basalgangliacalcification(Fahrdisease),
disorders
multiplesclerosis,metachromaticleukodystrophy
OtherCNS
disorders

Braintumors,especiallytemporallobeanddeephemispheric
tumorsepilepsy,especiallycomplexpartialseizuredisorder
headtrauma(subduralhematoma)anoxicbraininjuryfat
embolism

Vasculardisease

Atheroscleroticvasculardisease,especiallywhenassociated
withdiffuse,temporoparietal,orsubcorticallesions
hypertensiveencephalopathysubarachnoidhemorrhage,
temporalarteritis

Infectiousdisease

Humanimmunodeficiencyvirus/acquiredimmunedeficiency
syndrome(AIDS),opportunisticinfectionsinAIDS,
encephalitislethargica,CreutzfeldtJakobdisease,syphilis,
malaria,acuteviralencephalitis

Metabolicdisorder

Hypercalcemia,hyponatremia,hypoglycemia,uremia,hepatic
encephalopathy,porphyria

Endocrinopathies

Addisondisease,Cushingsyndrome,hyperthyroidismor
hypothyroidism,panhypopituitarism

Vitamin
deficiencies

VitaminB12deficiency,folatedeficiency,thiaminedeficiency,
niacindeficiency

Medications

Adrenocorticotropichormones,anabolicsteroids,
corticosteroids,cimetidine,antibiotics(eg,cephalosporins,
penicillin),disulfiram,anticholinergicagents

Substances

Amphetamines,cocaine,alcohol,cannabis,hallucinogens

Toxins

Mercury,arsenic,manganese,thallium

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Delusionalsymptomsarepreferentiallyassociatedwithdisordersinvolvingthelimbic
systemandbasalganglia.[4]
FiftypercentofpatientswithHuntingtondiseaseandindividualswithidiopathicbasal
gangliacalcificationsdevelopeddelusionsatsomepointoftheirillness.[4]
Headtraumahasbeenassociatedwithdevelopmentofdelusions.Koponenetal[27]
foundpatientswithtraumaticbraininjurywerediagnosedwithdelusionaldisorderin
5%ofthecasesduringa30yearfollowup(3outof60assessedpatients).
Table2.RelatedPsychiatricDisordersandDifferentiatingFeatures(OpenTableina
newwindow)
Disorder

DifferentiatingFeatures

Delirium

Fluctuatinglevelofconsciousness,alteredsleep/wakecycle,
hallucinationsandimpairedcognitionarefeaturesofdelirium
thatareabsentindelusionaldisorder.

Dementia

Delusions(usuallypersecutory)arecommoninAlzheimerand
othertypesofdementia(theprevalencerangesfrom1550%)
andmaypresentfirst,beforesubclinicalcognitivedeficits
becomeapparent.Neuropsychologicaltestingmaybewarranted
todetectcognitiveimpairments.Additionally,elderlypatientswith
delusionaldisorderwerefoundtohaveanincidenceofdementia
thatwastwiceashighasinthegeneralpopulationovera10
yearfollowupperiod.[28]

Substance
related
disorders
(intoxication,
withdrawal,
substance
induced
psychotic
disorderwith
delusion)

Amphetaminesandcocainearethemostcommonlydescribed
substancestobeassociatedwithdelusions,typicallyof
persecutorytype.Otherillicitdrugs(especiallyhallucinogens,
anabolicsteroids)andalcoholhavebeenrelatedtothe
developmentofdelusions.(Forexample,alcoholwithdrawalisa
commoncondition,whichmaypresentwithtactileorsomatic
delusions).Prescribedsubstances(especiallysteroids,
dopamineagonists),OTCmedications(especially
sympathomimetics),andherbalproductsmayalsobeassociated
withdelusions.Carefulsubstanceandmedicationusehistory
withspecificattentiontotemporalrelationshipbetween
substanceuseandonset/persistenceofdelusionalsymptoms
mayaidindifferentialdiagnosis.

Moodsymptomsarecommoninpersonswithdelusional
disorderandoftenrepresentaproportionateemotionalresponse
toperceiveddelusionalexperiences.However,giventhatmood
disordersarecommoninthegeneralpopulation,theymay
Mooddisorders presentascomorbidconditions,oftenpredatingdelusional
withdelusional disorder.Moodsymptomsofmooddisorderscontrarytomood
symptoms
symptomsofdelusionaldisorderareprominentandmeetcriteria
(manicor
forafullmoodepisode(depressive,manic,ormixed).Delusions
depressivetype) associatedwithmooddisordersusuallydevelopaftertheonset
ofmoodsymptomsandprogresssecondarytomood
abnormalities.Moodsymptomsofdelusionaldisorderare
generallymildanddelusionsusuallyexistintheabsenceof
moodabnormalities.

Schizophrenia

Delusionsofschizophreniaarebizarreinnature,and
thematicallyassociatedhallucinationsarecommon.Additionally,
disorganizedthoughtprocess,speech,orbehaviorsispresent.
Negativesymptomsanddeteriorationinfunctionareprominent.
Cognitivedeficitsarecommon.

Patientswithhypochondriasisareusuallyabletodoubt(atleast
forashortwhile)theirconvictionsofhavingillnesswhen
Hypochondriasis presentedwithreassuringdata.Mostofthemhavealonghistory
ofillnesspreoccupation,andtheirfearsareusuallynotlimitedto
asinglesymptomororgansystem.
Body
dysmorphic
disorder(BDD)

ManypatientswithBDDholdtheirbeliefswithconvictionthat
reacheslevelofdelusions,leadingtoasignificantoverlap
betweentheseconditions.

Obsessive
compulsive
disorder(OCD)

PatientswithOCDshowavaryingdegreeofinsightintotheir
obsessionsandcompulsions.Ifrealitytestingislostand
convictionintheirbeliefsreachesthelevelofdelusions,both
disordersmaybepresent.

Paranoid
personality
disorder

Differentiationbetweenextremecharacterological
suspiciousnessandfrankdelusionsmaybedifficult.Historyof
pervasivedistrustbeginningbyearlyadulthoodissuggestiveof
personalitydisorder,whilethedelusionaldisordermost
commonlypresentsasanacuteillnessofmiddlelife.
Additionally,patientswithparanoidpersonalitydisorder
frequentlyappeartobeunemotionalandlackwarmthintheir
relationships.

Shared
psychotic
disorder

Symptomsemergeinthecontextofacloserelationshipwith
anotherpersonwithdelusionalbeliefsanddiminishwith
separationfromthatotherperson.

Treatment&Management
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Generalconsiderations
Delusionaldisorderischallengingtotreatforvariousreasons,includingpatients'
frequentdenialthattheyhaveanyproblem,especiallyofapsychologicalnature,
difficultiesindevelopingatherapeuticalliance,andsocial/interpersonalconflicts.
Treatmentprinciplesincludethefollowing:
Establishatherapeuticallianceandnegotiateacceptablesymptomatic
treatmentgoals.Startwhere"thepatientisat,"andofferempathy,concern,
andinterestintheexperiencesoftheindividual.
Withtheappropriatepermissionfromthepatient,includethepatient'sfamily
indecisionmakingandeducatethem.
Considertheimpactofculturefortreatmentplanning.
Avoiddirectconfrontationofthedelusionalsymptomstoenhancethe
possibilityoftreatmentcomplianceandresponse.
Usemedicationjudiciouslytotargetcoresymptomsandassociatedproblems
(eg,anger).
Useoutpatienttreatmentunlessthereispotentialforharmorviolence.
Tailortreatmentstrategiestotheindividualneedsofthepatientandfocuson
maintainingsocialfunctionandimprovingqualityoflife.
Recognizeandtreatcoexistingpsychiatricdisorders.
Inpatienthospitalizationshouldbeconsideredifapatientsdelusionscause
himorhertobeathreattoself,others,orifheorsheisdeemedtobe
gravelydisabled.

Psychopharmacologicaltreatment
Theevidenceforthepsychopharmacologicaltreatmentofdelusionaldisorderwould
commonlybeconsidered"gradeC"(caseseries)or"gradeD"(singlecasestudies)
evidenceinmanyevidencebasedmedicinehierarchies.Thisisincontrastto
randomized,blindedstudies(gradeA)ornonrandomizedornonblinded,butstill
systematicallyconducted,studies(gradeB).
Antipsychoticshavebeenusedsincethe1970swhenthefirstreportwaspublished
ontheuseofpimozideforthetreatmentofmonosymptomatichypochondriacal
psychosis(nowclassifiedasadelusionaldisorder,somatictypebyDSM5).Of
approximately1000treatedcasesofdelusionaldisorderfrom19651985,a
subanalysisof257bestdescribedcasesrevealedthatdelusionaldisorderhasa
relativelygoodprognosiswhenadequatelytreated52.6%ofthepatients
recovered,28.2%achievedpartialrecovery,and19.2%didnotimprove.Treatment
responsewaspositiveregardlessofthespecificdelusionalcontent.Thedata
concludedthatpimozide(68.5%recoveryrateand22.4%partialrecoveryrate)may
bebetterthanothertypicalantipsychotics(22.6%recoveryand45.3%partial
recovery).[29]
Datasincethattimestillconsistsmostlyofcasereports.Themostrecentreviewof
treatmentfordelusionaldisorderincluded224casereportspublishedsince1995,
thoughonly134casereportswerewelldescribed.[8]Thefollowingisthesummaryof
theirfindings:
Ingeneral,delusionaldisorderswerereportedtobefairlyresponsiveto
treatment(50%ofthepublishedpatientsreportedsymptomfreerecovery
and90%ofpatientsshowedatleastsomeimprovement).
Combinationtreatmentwascommon.Polypharmacywascommon,most
oftenincludingacombinationofantipsychoticandantidepressantmedication.
Inaddition,patientscommonlyreceivedmorethanoneantipsychoticoverthe
courseoftheirillness,andmedicationtreatmentswerealsocomplemented
byotherinterventions,suchascognitivebehavioraltherapyoreven(ina
singlecase)electroconvulsivetherapy(ECT).
Incontrasttopreviousfindings,nosignificantdifferencewasobserved
betweentreatmentwithpimozideandotherantipsychotics.Indeed,no
differencewasobservedbetweentypicalandatypicalantipsychoticagents.
Somaticdelusionsappearedpotentiallymoreresponsivetoantipsychotic
therapythanothertypesofdelusions(regardlessofwhetherthistreatment
waspimozideorotherantipsychotics).However,thisapparentdifferencemay
mostlyresultfromthegenerallypoorresponseratesfordelusionaldisorder
withpersecutorydelusions(50%improvementrates,withnoreportsof
completerecovery).
Nootherpredictorsofapositiveoutcomehavebeenstudiedorclearly
elucidated(eg,age,gender,symptomseverity,positivefamilyhistory,or
premorbidfunction).
Asystematicreviewoftheliteratureshowsthatolanzapineandrisperidonearethe
mostcommonatypicalantipsychoticsused.[30,31]Fourreports(5cases)of
individualswithdelusionspresumablyrefractorytopreviousantipsychotictreatment
reportedthatclozapinewasassociatedwithanimprovedqualityoflifeanda
decreaseinsymptomsassociatedwiththedelusion,althoughthecentraldelusional
themeoftenpersisted.Incontrast,asindicatedabove,somecasesofdelusional
disorderappearrefractoryeventoclozapinetreatment.[8]
Reviewsoftreatmentofdelusionaldisorderhavenotsystematicallyaddressedthe
questionofwhatparticulardoseofantipsychoticsisneededtoachieveremissionof
symptoms.However,astudyof11patientswithdelusionaldisorderappearedtobe
adequatelytreatedonfairlylowdosesofantipsychotic(4.7mgofhaloperidol).[15]

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Antidepressantshavebeensuccessfullyusedforthetreatmentofdelusional
disorder,althoughprimarilyofthesomatictype.Thedataconsistofcasereports
showingimprovementwithselectiveserotoninreuptakeinhibitor(SSRI)[32]and
clomipraminetreatments[33,34].Severalcasereportsdocumentedsuccessful
treatmentwithSSRIforcultureboundsyndromes(conditionsthatwouldbe
diagnosedassomatictypeofdelusionaldisorderinWesterncultures).[35]
AsinglecasereportofsuccessfulECTuseforsomaticdelusionsexists.[36]
Insummary,areasonablepharmacologicaltreatmentapproachforthepatientwith
delusionaldisorderisastandardtrialofanantipsychoticor,forsomaticdelusions,
anSSRIatstartingdosescommonlyusedtotreatpsychoticormooddisorders.

Psychotherapy
Formostpatientswithdelusionaldisorder,someformofsupportivetherapyis
helpful.Thegoalsofsupportivetherapyincludefacilitatingtreatmentadherenceand
providingeducationabouttheillnessanditstreatment.Educationalandsocial
interventionscanincludesocialskillstraining(eg,notdiscussingdelusionalbeliefs
insocialsettings)andminimizingriskfactorsthatmayincreasesymptoms,including
sensoryimpairment,isolation,stress,andprecipitantsofviolence.Providingrealistic
guidanceandassistanceindealingwithproblemsstemmingfromthedelusional
systemmaybeveryhelpful.[37]
Cognitivetherapeuticapproachesmaybeusefulforsomepatientsandthisisbest
studiedinpersecutorytype.Thetherapisthelpsthepatienttoidentifymaladaptive
thoughtsbymeansofSocraticquestioningandbehavioralexperimentsandthen
replacesthemwithalternative,moreadaptivebeliefsandattributions.Discussionof
theunrealisticnatureofdelusionalbeliefsshouldbedonegentlyandonlyafter
rapportwiththepatienthasbeenestablished.[38,37,39]
Arecentstudyevaluatedtheeffectivenessofcognitivebehavioraltherapy(CBT)
versusattentionplacebocontrol(APC)asameanstotreatdelusionsindelusional
disorder.UsingtheMaudsleyAssessmentofDelusionsSchedule(MADS),thestudy
foundthatbothAPCandCBTimprovedbeliefandmoodparametersassociated
withdelusions.However,CBTproducedmoreofanimpactwhencomparedtoAPC
onstrengthofconviction,affectrelatingtobelief,andpositiveactionsofbeliefs,
suggestingCBTasasuccessfulmeansoftreatingdelusionaldisorder.[40]
AccordingtoLiberman[41],anothertechniquethatmaybeapplicabletoawider
populationofpersonswithdelusionaldisorderisbehavioralprinciplesandsocial
skillstrainingtoprovidetheindividualwitheffectivemeansof"feelingincontrol"and
lesssubjecttoviewingothers'effortstoharmhim/herasallowing"them"tobe
controlling.Socialskillstrainingfocusesonpromotinginterpersonalcompetence,
confidence(withsuccessfuluseofmorecompetentsocialskills)andcomfortin
interactingwiththosewhotheindividualfeelsarejudgingandhavingharmfulintent
towardhim/her.Takingcontrolandinitiativecandissipatethefeelingoflossof
controlthatfeedsintoandreinforcesthedelusions.
Theliteraturealsostatesthatinsightorientedtherapymaybeindicated,rarely[37]or
contraindicatedfordelusionaldisorder[2].However,reportsexistofsuccessful
treatment.[38]Goalsininsightorientedtherapyincludedevelopmentofthe
therapeuticalliancecontainmentofprojectedfeelingsofhatred,badness,and
impotencemeasuredinterpretationand,ultimately,developmentofasenseof
creativedoubtintheinternalperceptionoftheworldthroughempathywiththe
patient'sdefensiveposition.[38]

ContributorInformationandDisclosures
Author
JamesABourgeois,OD,MD,MPAClinicalProfessor,DepartmentofPsychiatry,UniversityofCalifornia,SanFrancisco,SchoolofMedicineFacultyPsychiatrist,
ConsultationLiaisonDivision,DepartmentofPsychiatry,LangleyPorterPsychiatricInstitute,UniversityofCalifornia,SanFrancisco,MedicalCenter
JamesABourgeois,OD,MD,MPAisamemberofthefollowingmedicalsocieties:AcademyofPsychosomaticMedicine,AmericanPsychiatricAssociation,Associationfor
AcademicPsychiatry,AmericanNeuropsychiatricAssociation
Disclosure:Nothingtodisclose.
Coauthor(s)
DonaldMHilty,MDChairandProgramDirector,DepartmentofPsychiatry,KeckSchoolofMedicineoftheUniversityofSouthernCalifornia
DonaldMHilty,MDisamemberofthefollowingmedicalsocieties:AmericanPsychiatricAssociation,AssociationforAcademicPsychiatry,AmericanAssociationfor
TechnologyinPsychiatry,AmericanTelemedicineAssociation
Disclosure:Nothingtodisclose.
RaheelAKhan,DOAssistantClinicalProfessorinPsychosomaticMedicine,DepartmentofPsychiatryandBehavioralSciences,UniversityofCalifornia,DavisMedical
Center
RaheelAKhan,DOisamemberofthefollowingmedicalsocieties:AcademyofPsychosomaticMedicine,AmericanOsteopathicAssociation,AmericanPsychiatric
Association,AssociationforAcademicPsychiatry
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference

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Delusional Disorder: Overview, Diagnosis, Epidemiology

Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
ChiefEditor
DavidBienenfeld,MDProfessor,DepartmentsofPsychiatryandGeriatricMedicine,WrightStateUniversity,BoonshoftSchoolofMedicine
DavidBienenfeld,MDisamemberofthefollowingmedicalsocieties:AmericanMedicalAssociation,AmericanPsychiatricAssociation,AssociationforAcademicPsychiatry
Disclosure:Nothingtodisclose.
Acknowledgements
ShivaniChopra,MDResidentPhysician,DepartmentofPsychiatryandBehavioralSciences,UniversityofCalifornia,Davis,MedicalCenter
ShivaniChopra,MDisamemberofthefollowingmedicalsocieties:AmericanPsychiatricAssociation
Disclosure:Nothingtodisclose.
IreneGuryanova,MDPsychoanalyticPsychotherapyFellow,BostonPsychoanalyticSocietyandInstituteStaffPhysician,DepartmentsofPsychiatryand
Psychopharmacology,UniversityofMassachusettsMedicalSchool.
Disclosure:Nothingtodisclose.
EricGSmith,MD,MPHAssistantProfessor,DepartmentofPsychiatry,UniversityofMassachusettsMedicalSchoolClinicalResearcher,CenterforPsychopharmacologic
ResearchandTreatment,UMassMemorialHealthCare
Disclosure:Nothingtodisclose.
MichaelToricelli,MDHeadofOutpatientMentalHealthDepartment,NavalMedicalCenteratSanDiego
Disclosure:Nothingtodisclose.

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