Differential Diagnosis
This is similar to schizophrenia. Psychotic disorder caused by a general
medical condition and substance-induced psychotic dis-order must be ruled out.
General medical conditions to be con-sidered are HIV infection, temporal lobe
epilepsy, CNS tumors and cerebrovascular disease, all of which can also be
associated with relatively short-lived psychotic episodes. The increas-ing
number of reports of psychosis associated with the use of anabolic steroids by
young men who are attempting to build up their muscles to perform better in
athletic activities require care-ful history. Factitious disorder with
predominantly psychological signs and symptoms and malingering may need to be
ruled out in some instances.
This is, as anticipated, variable. The DSM IV specifiers “with good
prognostic features” and “without good prognostic fea-tures” though helpful in
guiding the clinician, require further validation. However, confusion or
perplexity at the height of the psychotic episode is the feature best
correlated with good out-come. Also, the shorter the period of illness, the
better the prog-nosis is likely to be. There is a significant risk of suicide
in these patients. Postpsychotic depression is quite likely and should be
addressed in psychotherapy. Psychotherapy may help speed the recovery and
improve the prognosis. By definition, schizophreni-form disorder resolves
within 6 months with a return to baseline mental functioning.
Hospitalization is often necessary and allows for effective as-sessment,
treatment and supervision of a patient’s behavior. The psychotic symptoms,
usually treated with a 3- to 6-month course of antipsychotic drugs, respond
more rapidly than in patients with schizophrenia. One study found that 75% of
the patients with schizophreniform psychosis compared with 20% of those with
schizophrenia responded to antipsychotic agents within 8 days. ECT may be
indicated for some patients, especially those with marked catatonic features or
depression. If a patient has recurrent episodes, trials of lithium carbonate,
valproic acid, or carbamazepine may be warranted for prophylaxis. Psychotherapy
is usually necessary to help patients integrate the psychotic expe-rience into
their understanding of their minds, brains and lives.
Delusional disorder refers to a group of disorders, the chief feature of
which is the presence of nonbizarre
delusions. People suffer-ing from this illness do not regard themselves as
mentally ill and actively oppose psychiatric referral. Because they may experience
little impairment, they generally remain outside hospital settings, appearing
reclusive, eccentric, or odd, rather than ill. They are more likely to have
contacts with professionals such as lawyers and other medical specialists for
health concerns. The current shift in diagnosis from paranoid to delusional
helps avoid the ambiguity around the term “paranoid”. This also emphasizes that
other delusions besides the paranoid ones are included in this di-agnosis. It
is important to understand the definition of nonbizarre delusion so as to reach
an unambiguous diagnosis. Nonbizarre delusions typically involve situations or
circumstances that can occur in real life (e.g., being followed, infected, or
deceived by a lover) and are believable.
According to DSM-IV-TR, the diagnosis of delusional disorder can be made
when a person exhibits nonbizarre delusions of at least 1 month’s duration that
cannot be attributed to other psychi-atric disorders. Nonbizarre delusions must
be about phenomena that, although not real, are within the realm of being
possible. Ingeneral, the patient’s delusions are well systematized and have
been logically developed. If the person experiences auditory or visual
hallucinations, they are not prominent except for tactile or olfactory
hallucinations where they are tied in to the delusion (e.g., a person who
believes that he emits a foul odor might ex-perience an olfactory hallucination
of that odor). The person’s behavioral and emotional responses to the delusions
appear to be appropriate. Usually the person’s functioning and personality are
well preserved and show minimal deterioration if at all.
Though the existence of delusional disorder has been known for a long
time, relatively little is known about the demographics, incidence and
prevalence. Unfortunately, people suffering from this illness function
reasonably well in the community and lack insight resulting in minimal or no
contact with the mental health system. However, the crude incidence is roughly
0.7 to 3.0 per 100 000 with a more frequent occurrence in females.
Etiology of the delusional disorder is unknown. Risk factors associated
with the disorder include advanced age, sensory im-pairment/isolation, family
history, social isolation, personality features (e.g. unusual interpersonal
sensitivity) and recent im-migration. Some have reported higher association of
delusional disorder with widowhood, celibacy and history of substance abuse.
Age of onset is later than schizophrenia and earlier in men compared with
women.
This is the most common form of delusional disorder. Here the person
affected believes that he or she is being followed, spied on, poisoned or
drugged, harassed, or conspired against. The person affected may become
preoccupied by small slights that can become incorporated into the delusional
system. These indi-viduals may resort to legal actions to remedy perceived
injustice. Individuals suffering from these delusions often become resent-ful
and angry with a potential to become violent against those believed to be
against them.
Individuals
with this subtype have the delusional belief that their spouses/lovers are
unfaithful. This is often wrongly inferred from small bits of benign evidence
which is used to justify the delusion. Delusions of infidelity have also been
called conjugal
paranoia. The term Othello syndrome has been used to describe morbid jealousy. This
delusion usually affects men, with no history of prior psychiatric problems.
The condition is difficult to treat and may diminish only on separation,
divorce or death of the spouse. Marked jealousy (pathological jealousy or
morbid jealousy) is a symptom of many disorders including schizophrenia and not
unique to delusional disorder. Jealousy is a powerful emotion and when it
occurs in delusional disorder or as part of another condi-tion, it can be
potentially dangerous and has been associated with violence including suicidal
and homicidal behavior.
These
patients have delusions of secret lovers. Most frequently, the patient is a
woman, though men are also susceptible to these delusions. The patient believes
that a suitor, usually more sociallyprominent
than herself, is in love with her. This can become cen-tral focus of the
patient’s existence and the onset can be sudden. Erotomania is also referred to
as de Clerambault’s syndrome. Again,
these delusions can occur as part of other disorders too. Generally women (but
not exclusively so), unattractive in appear-ance, working at a lower-level
jobs, who lead withdrawn, lonely single lives with few sexual contacts are
reported to be more prone to develop this condition. They select lovers who are
sub-stantially different from them. They exhibit what has been called
paradoxical conduct, the delusional phenomenon of interpreting all denials of
love no matter how clear as secret affirmations of love. Separation from the
love object may be the only satisfac-tory means of intervention. When it
affects men, it can manifest with more aggressive and possibly violent pursuit
of love. Thus, such people are often in the forensic system. The object of
ag-gression is often companions or protectors of the love object who are viewed
as trying to come between the lovers. However, re-sentment and rage in response
to an absence of reaction from all forms of love communication may escalate to
a point that the love object may be in danger too.
Approximately
10% of stalkers have a primary diagnosis of erotomania. Menezies and colleagues
(1995) conducted the first predictive study of violence among erotomanic males
and found that serious antisocial behavior (a criminal history) unrelated to
the delusion and concurrent multiple objects of fixations discrim-inated
between the dangerous and the nondangerous men. In a review by Meloy (1996), if
violence occurred the object of love was target at least 80% of the time. The
next most likely target was a third party perceived as impeding access to the
object. He referred to this latter behavior as triangulation. Triangulation when present in
jealousy, whether delusional or not, is motivated by a perceived competition
for the love object.
Delusional disorder with somatic delusions has been called monosymptomatic hypochondriacal psychosis.
This disorder differs from other
conditions with hypochondriacal symptoms in degree of reality impairment Munro
(1991) has described the largest series of cases and has used content of
delusions to define three main types.
Delusions of Infestations
(Including Parasitosis) Delu-sional parasitosis is one of
the most common presentations of monohypochondriacal psychosis, which occurs in
absence of other psychiatric illness. The onset is insidious and chronic.
Matchbox sign describes
the common phenomenon that occurred not so long ago in patients suffering from this condition.
During their clinic visit, the patient would present with peeled skin, and
other substances connected to delusional thinking in an empty old-fashioned
matchbox as evidence that they were infested with insects. Delusional
parasitosis has been described in associa-tion with many physical illnesses
such as vitamin B12 deficiency, pellagra, neurosyphilis, multiple sclerosis,
thalamic dysfunction, hypophyseal tumors, diabetes mellitus, severe renal
disease, hep-atitis, hypothyroidism, mediastinal lymphoma and leprosy. Use of
cocaine and presence of dementia has also been reported.
Psychogenic
parasitosis was also known as Ekbom’s syn-drome before being referred to as delusional parasitosis. Females
experienced this disorder twice as often as males. Entomologists, pest control
specialists and dermatologists had often seen the pa-tient before seen by a
psychiatrist. All investigators have been impressed by the concurrent medical
illnesses associated withthis condition. Others have
attempted to distinguish between de-lusional and nondelusional aspects of
presentation to establish clearer diagnosis and thus management.
Delusions of Dymorphophobia This condition includes de-lusions such as of misshapenness, personal
ugliness, or exagger-ated size of body parts.
Delusions of Foul Body Odors or
Halitosis This is also called olfactory reference
syndrome.
The frequency of these conditions is low, but they may be under
diagnosed because patients present to dermatologists, plas-tic surgeons and
infectious disease specialists more often than to psychiatrists. Patients with
these conditions do respond to pimoz-ide, a typical antipsychotic medication
and also to SSRIs. Usually prognosis is poor without treatment. It affects both
sexes equally. Suicide apparently motivated by anguish is not uncommon.
This is also referred to as megalomania.
In this subtype, the cen-tral theme of the delusion is the grandiosity of
having made some important discovery or having great talent. Sometimes there
may be a religious theme to the delusional thinking such that the per-son
believes that he or she has a special message from god.
This subtype is reserved for those with two or more delusional themes.
However, it should be used only where it is difficult to clearly discern one
theme of delusion.
This
subtype is used for cases in which the predominant delu-sion cannot be subtyped
within the above mentioned categories. A possible example is certain delusions
of misidentification, for example, Capgras’s syndrome, named after the French psychia-trist who
described the ‘illusions of doubles’. The delusion here is the belief that a
familiar person has been replaced by an imposter. A variant of this is Fregoli’s syndrome where
the delusion is that the persecutors or familiar persons can assume the guise of
stran-gers and the very rare delusion that familiar persons could change
themselves into other persons at will (intermetamorphosis). Each disorder is
not only a rare delusion but is highly associated with other conditions such as
schizophrenia and dementia.
Though the onset can occur in adolescence, generally it begins from
middle to late adulthood with variable patterns of course, including lifelong
disorder in some cases. Delusional disorder does not lead to severe impairment
or change in personality, but rather to a gradual, progressive involvement with
the delusional concern. Suicide has often been associated with this disorder.
The base rate of spontaneous recovery may not be as low as pre-viously thought,
especially because only the more severely af-flicted are referred for
psychiatric treatment. The more chronic forms of the illness tend to have their
onset early in the fifth dec-ade. Onset is acute in nearly two-thirds of the
cases and gradual in the remainder. In almost half of the cases the delusion
disap-pears at follow-up, improves in 10%, and is unchanged in 31%. In the more
acute forms of the illness, the age of onset is in the fourth decade, a lasting
remission occurs in over half of the pa-tients and a pattern of chronicity
develops in only 10%; a relaps-ing course has been observed in 37%. Thus, the
more acute and earlier the onset of the illness, the more favorable the
prognosisThe presence of precipitating factors, married status and female
gender are associated with better outcome. The persistence of delusional
thinking is most favorable for cases with persecutory delusions and somewhat
less favorable for delusions of grandeur and jealousy. However, the outcome in
terms of overall function-ing appears somewhat more favorable for the jealous
subtype.
Depression occurs frequently and is often an independent disor-der in
these patients.
Though generally considered resistant to treatment and interven-tions,
the management is focused on managing the morbidity of the disorder by reducing
the impact of the delusion on the pa-tient’s (and family’s) life. However, in
recent years the outlook has become less pessimistic or restricted in planning
effective treatment for these conditions. An effective and therapeutic
clini-cian–patient relationship is important but difficult to establish.
Overall,
treatment results suggest that 80.8% of cases recover either fully or
partially. Pimozide, the most frequently reported treatment produced full
remission in 68.5% and partial recovery in 22.4% (N 5 143).
There are reports of treatment with other typical antipsychotic agents with
variable success in small number of sub-jects. SSRIs have been used and
reported to be helpful. The newer atypical antipsychotic agents have been used
in small number of cases with success but the data is anecdotal. Bhatia and
colleagues (2000) report that pimozide, fluoxetine and amitriptyline were used
in their study with pimozide showing good response.
As mentioned earlier, developing a therapeutic relationship is very
important and yet significantly difficult, and requires a frank and supportive
attitude. Supportive therapy is very helpful in deal-ing with emotions of
anxiety and dysphoria generated because of delusional thinking. Cognitive
therapy, when accepted and im-plemented, is helpful. Confrontation of the
delusional thinking usually does not work and can further alienate the patient.
Shared psychotic disorder is a rare disorder, which is also re-ferred to
as shared paranoid disorder, induced
psychotic dis-order, folie a deux and
double insanity. In this disorder, the
transfer of delusions takes place from one person to another. Both persons
are closely associated for a long time and typically live together in relative
social isolation. In its more common form, folie
imposee, the individual who first has the delusion is often chronically ill
and typically is the influential member of the close relationship with another
individual, who is more suggestible and who develops the delusion too. The
second indi-vidual is frequently less intelligent, more gullible, more passive,
or more lacking in self-esteem than the primary case. If the two people
involved are separated, the second individual may aban-don the delusion.
However, this is not seen consistently. Other forms of shared psychotic
disorder reported are folie simulta-nee,
where similar delusional systems develop independently in two closely associated people. The most common dyadic
rela-tionships who develop this disorder are sister–sister, husband– wife and
mother–child. Almost all cases involve members of a single family
More than 95% of all cases of shared psychotic disorder involve two members
of the same family. About a third of the cases involve two sisters, another
one-third involve husband and wife or a mother and her child. The dominant
person is usually af-fected by schizophrenia or a similar psychotic disorder.
In 25% of all cases, the submissive person is usually affected with physical
disabilities such as deafness, cerebrovascular diseases, or other disability
that increases the submissive person’s dependence on the dominant person. This
condition is more common in people from low socioeconomic groups and in women.
There is some data that suggest that people suffering from shared
psychotic disorder may have a family history of schizophrenia. The dominant
person suffering from this illness often has schiz-ophrenia or a related
psychotic illness. The dominant person is usually older, more intelligent,
better educated and has stronger personality traits than the submissive person,
who is usually de-pendent on the dominant person. The affected individuals
usually live together or have an extremely close personal relationship,
as-sociated with shared life experiences, common needs and hopes, and, often, a
deep emotional rapport with each other. The relation-ship between the people
involved is usually somewhat or com-pletely isolated from external societal
cultural inputs. The sub-missive person may be predisposed to a mental disorder
and may have a history of a personality disorder with dependent or sug-gestible
qualities as well as a history of depression, suspiciousness and social
isolation. The dominant person’s psychotic symptoms may develop in the
submissive person through the process of iden-tification. By adopting the
psychotic symptoms of the dominant person, the submissive person gains
acceptance by the other.
An important feature in the diagnosis is that the person with shared
psychotic disorder does not have a preexisting psychotic disorder. The
delusions arise in the context of a close relationship with a person who
suffers from delusional thinking and resolve on separation from that person.
The key symptom of shared psychosis is the unquestioning ac-ceptance of
another person’s delusions. The delusions themselves are often in the realm of
possibility and usually not as bizarre as those seen in patients with
schizophrenia. The content of the delusion is often persecutory or
hypochondriacal. Symptoms of a coexisting personality disorder may be present,
but signs and symptoms that meet criteria for schizophrenia, mood disorders and
delusional disorder are absent. The patient may have ideation about suicide or
pacts about homicide; clinicians must elicit this information during the
interview.
Malingering, factitious disorder with predominantly psychologi-cal sign
and symptoms, psychotic disorder due to a general medi-cal condition and
substance-induced psychotic disorder must be considered.
Though separation of submissive person from the dominant per-son should
resolve the psychosis, this probably occurs only in 10 to 40% of the cases.
Unfortunately, when these individuals are discharged from hospital, they
usually move back together.
The initial step in treatment is to separate the affected person from
the source of the delusions, the dominant individual. An-tipsychotic agents may
be used if the symptoms have not abated in a week after separation.
Psychotherapy with the nondelusional members of the patient’s family should be
undertaken, and psy-chotherapy with both the patient and the person sharing the
delu-sion may be indicated later in the course of treatment. To prevent
redevelopment of the syndrome the family may need family ther-apy and social
support to modify the family dynamics and to pre-vent redevelopment of the
syndrome. Steps to decrease the social isolation may also help prevent the
syndrome from reemerging.
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