Delusional Disorder
Delusional disorder is an illness characterized by the presence of nonbizarre delusions in the absence of other mood or psychotic symptoms, according to the Diagnostic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). It defines delusions as false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary and these beliefs are not ordinarily accepted by other members of the person's culture or subculture.
Nonbizarre refers to the fact that this type of delusion is about situations that could occur in real life, such as being followed, being loved, having an infection, and being deceived by one's spouse.
Delusional disorder is on a spectrum between more severe psychosis and overvalued ideas. Bizarre delusions represent the manifestations of more severe types of psychotic illnesses (eg, schizophrenia) and "are clearly implausible, not understandable, and not derived from ordinary life experiences".
On the other end of the spectrum, making a distinction between a delusion and an overvalued idea is important, the latter representing an unreasonable belief that is not firmly held. Additionally, personal beliefs should be evaluated with great respect to complexity of cultural and religious differences: some cultures have widely accepted beliefs that may be considered delusional in other cultures.
Unfortunately, patients with delusional disorder do not have good insight into their pathological experiences. Interestingly, despite significant delusions, many other psychosocial abilities remain intact, as if the delusions are circumscribed. Indeed, this is one of the key differences between delusional disorder and other primary psychotic disorders. However, the individual may rarely seek psychiatric help, remain isolated, and often present to internists, surgeons, dermatologists, policemen, and lawyers rather than psychiatrists. Despite this, their prognosis, while not good, is not as bad as other more severe disorders.
Current Diagnosis Criteria
DSM-IV-TR defines delusional disorder with the following criteria:
A: Nonbizarre delusions (ie, involving situations that occur in real life, such as being followed, poisoned, infected, loved at distance, deceived by spouse or lover, or having a disease) occurring for at least 1 month's duration.
B: Criterion A for schizophrenia has never been met (ie, patients do not have simultaneous hallucinations, disorganized speech, negative symptoms such as affective flattening, or grossly disorganized behavior). Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme.
C: Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
D: If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.
E: The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition.
Subtypes are defined as erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified.
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Diagnoses for Delusional Disorders
- Anxiety
- Disabled family coping
- Disturbed personal identity
- Disturbed sensory perception (visual, auditory)
- Disturbed thought processes
- Fear
- Imbalanced nutrition: Less than body requirements
- Impaired home maintenance
- Impaired social interaction
- Ineffective coping
- Powerlessness
- Risk for injury
- Risk for other-directed violence
- Risk for self-directed violence
- Social isolation
Key outcomes for Delusional Disorders
- The patient will consider alternative interpretations of a situation without becoming hostile or anxious.
- The patient and his family will participate in care and prescribed therapies.
- The patient will identify internal and external factors that trigger delusional episodes.
- The patient will maintain functioning to the fullest extent possible within the limitations of his visual or auditory impairment.
- The patient will remain oriented to person, place, time, and situation.
- The patient will express all fears and concerns.
- The patient will show no signs of malnutrition.
- The patient will recognize symptoms and comply with medication regimen.
- The patient will demonstrate effective social interaction skills in both one-on-one and group settings.
- The patient will demonstrate adaptive coping behaviors.
- The patient will identify and perform activities that decrease delusions.
- The patient will remain free from injury.
- The patient won't harm others.
- The patient won't harm self.
- The patient will maintain family and peer relationships.
Interventions for Delusional Disorders
- In dealing with the patient, be direct, straightforward, and dependable. Whenever possible, elicit his feedback. Move slowly, with a matter-of-fact manner, and respond without anger or defensiveness to his hostile remarks.
- Accept the patient's delusional system. Don't attempt to argue with him about what's real.
- Respect the patient's privacy and space needs. Avoid touching him unnecessarily.
- Take steps to reduce social isolation, if the patient allows. Gradually increase social contacts after he has become comfortable with the staff.
- Watch for refusal of medication or food, resulting from the patient's irrational fear of poisoning.
- Monitor the patient carefully for adverse effects of neuroleptic drugs: drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome.