Delusional Disorder

Delusional Disorder

Delusional Disorder

Delusional disorder (originally called paranoid disorder) is a rare mental health condition characterized by the presence of delusions —fixed false beliefs held with absolute certainty, despite strong evidence to the contrary.

Delusions can be bizarre or non-bizarre. Non-bizarre delusions involve situations that could realistically occur, such as being hurt, deceived, or conspired against. These delusions are usually inconsistent with a person’s cultural beliefs.

Prevalence

About 0.2% of people have delusional disorder, with the main type being persecutory. Delusional disorder tends to develop in mid to later life and affects women and men equally.

Schizophrenia vs Delusional Disorder

Unlike schizophrenia, mood symptoms in delusional disorder tend to be brief or absent, and hallucinations are not usually present. If they are, they are often minimal.

Symptoms of Delusional Disorder:

Some of the signs and symptoms that might appear quite normal in some cultures could be misdiagnosed in other cultures as being delusional in nature, such as seeing visions or hearing voices.


  • Difficulty recognizing what is real and what is not
  • Appears to function normally but thinks about the delusion(s) as if it is truly happening or has happened, such as being followed (non-bizarre) or someone in a movie talking directly to the viewer (bizarre)
  • Anger, irritability, hostility, sullenness – particularly if questioned or contradicted about the belief
  • Hallucinations – misreading information relayed by the five senses such as voices, colors, smells, tastes, touch
  • The fixation on the delusion is somewhat/possibly disruptive to daily life, for example, if the delusion causes the person to refuse to leave the house
  • Secretive and sensitive about the delusion
  • Decreased intuitive reasoning abilities
  • Beliefs are not in line with what friends and family know to be true of the person

Diagnosis of Delusional Disorder:

The diagnosis of delusional disorder can be difficult as many people are unwilling to divulge the details of their delusions. The input of family members in regards to the person’s behavior and attitude can reveal a more thorough list of the symptoms.

A full medical exam, lab work, possibly brain scans, and a look at a person’s mental health history will be done first to rule out any possible medical reasons for the symptoms — such as Alzheimer’s.

DSM-5’s diagnostic criteria for delusional disorder are as follows:

  • The presence of one (or more) delusions with a duration of 1 month or longer.
  • Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).
  • Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.
  • If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.
  • The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.

DSM-5 lists seven subtypes of delusional disorder based on the content of the delusions:

  • Erotomanic type (erotomania): The central theme of the delusion is that another person is in love with the individual. The individual may breach the law as s/he obsessively tries to make contact with the desired person.
  • Grandiose type (megalomania): The central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery.
  • Jealous type: The central theme of the individual’s delusion is that his or her spouse or lover is unfaithful. The patient may follow the partner and check text messages, emails, phone calls, etc. in an attempt to find “evidence” of the infidelity.
  • Persecutory type: The central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. They may seek “justice” by making reports, taking action, or even acting violently.
  • Somatic type: The central theme of the delusion involves bodily functions or sensations.
  • Mixed type: No one delusional theme predominates.
  • Unspecified type: Delusions that cannot be clearly determined or characterized in any of the categories above.

Once someone has had the disorder for 12 months or more, the diagnosis can be further specified by the number of episodes and their severity.

  • Episodes: Acute episode, partial remission, full remission, multiple episodes, continuous, or unspecified.
  • Severity: Each symptom is rated on a five-point scale.

Causes of Delusional Disorder:

The exact cause of delusional disorder remains unknown; however, genetic, biological, and environmental factors have both been implicated.


  • Environmental – Immigration (generally because immigrants are persecuted), being married, being employed, poverty, low social position in society, lack of sex or companionship, stress, poor hearing, poor eyesight
  • Genetic – More common when family members have a psychotic disorder
  • Biological – The brains of those with delusional disorder might have certain abnormalities related to perception and thinking that have caused delusional symptoms to develop.

Risks from Delusional Disorder:

Apart from their delusion(s), people with delusional disorder don’t usually experience any impairment in functioning; in fact, they can often be high functioning, and their behavior does not necessarily seem odd or unusual.

However, the preoccupation with delusional beliefs can be disruptive to their overall lives, especially if they cause them to self-isolate.

Treatment of Delusional Disorder:

Treatment for delusional disorder includes medication and psychotherapy. Because the delusions appear so real, the person might refuse any form of treatment.

Hospitalization for delusional disorder is only considered if the person is at risk of self-harm or of harming others.

  • Individual therapy – to help process the anxiety and insomnia related to the delusional thinking
  • Cognitive behavioral therapy – to identify delusions and examine them for truth, to research where those thoughts might have originated from, to develop ways to change thoughts to reflect reality, and to learn grounding methods when symptoms begin — in order to give the person more control over future episodes.
  • Family therapy – to help family members recognize when delusional thinking begins and learn strategies to help prevent them from developing further. These strategies can have the effect of gently bringing the loved one back to reality in an environment of trust rather than arguing about it
  • Supportive therapy – to encourage the person to stay on all medication and continue with psychotherapy sessions, along with education about the disorder
  • Social skills training – helps build confidence around having conversations with people, what to talk about, and how to avoid social isolation
  • Insight-oriented therapy – to build deeper levels of insight into perceptions and learn how to question them and slow down instant assumptions or conclusions, and to learn how to process feelings of powerlessness

Medications for Delusional Disorder:

Delusions might not lessen with antipsychotics, so they are usually only used if extreme agitation accompanies the delusion.

  • Antipsychotics – such as quetiapine to calm the psychotic thoughts, or ziprasidone to help lessen short-term agitation
  • Sedatives – to reduce agitation in the acute stage of delusion
  • Antidepressants – for related anxiety and depression

Delusional disorder can be very difficult to treat, in part because people with this condition often have poor insight and do not recognize that a psychiatric problem exists. However, about 50% of all people treated with antipsychotics show some improvement.

 

Symptoms of Delusional Disorder:

Some of the signs and symptoms that might appear quite normal in some cultures could be misdiagnosed in other cultures as being delusional in nature, such as seeing visions or hearing voices.


  • Difficulty recognizing what is real and what is not
  • Appears to function normally but thinks about the delusion(s) as if it is truly happening or has happened, such as being followed (non-bizarre) or someone in a movie talking directly to the viewer (bizarre)
  • Anger, irritability, hostility, sullenness – particularly if questioned or contradicted about the belief
  • Hallucinations – misreading information relayed by the five senses such as voices, colors, smells, tastes, touch
  • The fixation on the delusion is somewhat/possibly disruptive to daily life, for example, if the delusion causes the person to refuse to leave the house
  • Secretive and sensitive about the delusion
  • Decreased intuitive reasoning abilities
  • Beliefs are not in line with what friends and family know to be true of the person
 

Diagnosis of Delusional Disorder:

The diagnosis of delusional disorder can be difficult as many people are unwilling to divulge the details of their delusions. The input of family members in regards to the person’s behavior and attitude can reveal a more thorough list of the symptoms.

A full medical exam, lab work, possibly brain scans, and a look at a person’s mental health history will be done first to rule out any possible medical reasons for the symptoms — such as Alzheimer’s.

DSM-5’s diagnostic criteria for delusional disorder are as follows:

  • The presence of one (or more) delusions with a duration of 1 month or longer.
  • Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).
  • Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.
  • If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.
  • The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.

DSM-5 lists seven subtypes of delusional disorder based on the content of the delusions:

  • Erotomanic type (erotomania): The central theme of the delusion is that another person is in love with the individual. The individual may breach the law as s/he obsessively tries to make contact with the desired person.
  • Grandiose type (megalomania): The central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery.
  • Jealous type: The central theme of the individual’s delusion is that his or her spouse or lover is unfaithful. The patient may follow the partner and check text messages, emails, phone calls, etc. in an attempt to find “evidence” of the infidelity.
  • Persecutory type: The central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. They may seek “justice” by making reports, taking action, or even acting violently.
  • Somatic type: The central theme of the delusion involves bodily functions or sensations.
  • Mixed type: No one delusional theme predominates.
  • Unspecified type: Delusions that cannot be clearly determined or characterized in any of the categories above.

Once someone has had the disorder for 12 months or more, the diagnosis can be further specified by the number of episodes and their severity.

  • Episodes: Acute episode, partial remission, full remission, multiple episodes, continuous, or unspecified.
  • Severity: Each symptom is rated on a five-point scale.
 

Causes of Delusional Disorder:

The exact cause of delusional disorder remains unknown; however, genetic, biological, and environmental factors have both been implicated.


  • Environmental – Immigration (generally because immigrants are persecuted), being married, being employed, poverty, low social position in society, lack of sex or companionship, stress, poor hearing, poor eyesight
  • Genetic – More common when family members have a psychotic disorder
  • Biological – The brains of those with delusional disorder might have certain abnormalities related to perception and thinking that have caused delusional symptoms to develop.
 

Risks from Delusional Disorder:

Apart from their delusion(s), people with delusional disorder don’t usually experience any impairment in functioning; in fact, they can often be high functioning, and their behavior does not necessarily seem odd or unusual.

However, the preoccupation with delusional beliefs can be disruptive to their overall lives, especially if they cause them to self-isolate.

 

Treatment of Delusional Disorder:

Treatment for delusional disorder includes medication and psychotherapy. Because the delusions appear so real, the person might refuse any form of treatment.

Hospitalization for delusional disorder is only considered if the person is at risk of self-harm or of harming others.

  • Individual therapy – to help process the anxiety and insomnia related to the delusional thinking
  • Cognitive behavioral therapy – to identify delusions and examine them for truth, to research where those thoughts might have originated from, to develop ways to change thoughts to reflect reality, and to learn grounding methods when symptoms begin — in order to give the person more control over future episodes.
  • Family therapy – to help family members recognize when delusional thinking begins and learn strategies to help prevent them from developing further. These strategies can have the effect of gently bringing the loved one back to reality in an environment of trust rather than arguing about it
  • Supportive therapy – to encourage the person to stay on all medication and continue with psychotherapy sessions, along with education about the disorder
  • Social skills training – helps build confidence around having conversations with people, what to talk about, and how to avoid social isolation
  • Insight-oriented therapy – to build deeper levels of insight into perceptions and learn how to question them and slow down instant assumptions or conclusions, and to learn how to process feelings of powerlessness
 

Medications for Delusional Disorder:

Delusions might not lessen with antipsychotics, so they are usually only used if extreme agitation accompanies the delusion.

  • Antipsychotics – such as quetiapine to calm the psychotic thoughts, or ziprasidone to help lessen short-term agitation
  • Sedatives – to reduce agitation in the acute stage of delusion
  • Antidepressants – for related anxiety and depression

Delusional disorder can be very difficult to treat, in part because people with this condition often have poor insight and do not recognize that a psychiatric problem exists. However, about 50% of all people treated with antipsychotics show some improvement.

Sources NAMI – What Happened When I Denied My Symptoms | DRUGS.com – What is Delusional Disorder | MEDSCAPE – Delusional Disorder | PSYCHOLOGY TODAY – Delusional Disorder | BCSS – Steps for Working With Delusions | PSYCH CENTRAL – Psychosis & Schizophrenia | US NEWS – What’s the Difference Between Delusions and Hallucinations | WEBMD – Delusions and Delusional Disorder | RESEARCHGATE – Perceptual organization deficits in psychotic patients | Winokur, George.”Comprehensive Psychiatry-Delusional Disorder”American Psychiatric Association. 1977. p 513