Delusional Disorder Flashcards
Definition
- Characterised by the development of a delusion or a set of related delusions that persist for at least 3 months, which occur in the absence of a depressive, manic or mixed mood episode.
- Other characteristic forms of Schizophrenia are not present, although various forms of perceptual disturbances thematically related to the delusion are still consistent with the diagnosis
- This is basically a fixed, firmly held, false belief that is strongly held despite evidence to the contrary and that is out of keeping with the individual’s educational and cultural background
NOTE TO SELF: this is basically like a psychosis but with ONLY delusions (so treatment pretty much the same)
Epidemiology
Onset often in middle age (usually > 40 years)
More common in those with a hearing impairment
Aetiology
Unknown precise cause, interactions between genetics, social and environmental risk factors
Social and environmental risk factors: stressful life events, childhood adversity, family heritage, cannabis use, other substance use, medication use, early life factors, social isolation, low socioeconomic status, immigration
RFs: old age, FHx, premorbid personality disorder, sensory impairment
Primary No Precedent, out of the blue
Secondary: Underlying mood from another psychiatric phenomenon
Systematised: Well planned and thought out delusion
‘Folie a deux’- where a non-psychotic person with close emotional ties to another person suffering from delusions usually begins to share those delusional ideas themselves- resolve when the two are separated
Symptoms and signs
Expressed delusions may persist throughout life
Often circumscribed, non-bizarre delusions seen
Delusions include:
- Grandiose delusions: exaggerated beliefs of being special or important (e.g. being rich and famous)
- Persecutory delusions: beliefs that others are trying to persecute or cause harm
- Hypochondriacal- belief about having an illness/ disease
- Jealousy (Othello syndrome)- often believe their partner is unfaithful
- Nihilistic- beliefs regarding the absence of something vitally important (e.g. patient is dead, homeless or their organs are rotting)
- Delusions of reference- beliefs that ordinary objects, events or other people’s actions have a special meaning or significance for the patient (e.g. news reports related to them, objects are arranged as a ‘sign’)
- Delusions of control- belief that outside forces control the patient in some way
- Delusion perception - being given a ‘sign’
- Passivity- belief that movement, sensation, emotion or impulse are controlled by an outside force e.g. as if someone has a remote control for the patient’s actions
- Amorous- belief that someone is in love with the patient
- De Clerambault’s syndrome is the presence of a delusion that a famous person is in love with them, with the absence of other psychotic symptoms.
- Capgras syndrome is the delusion that a person closely related to the patient has been replaced by an impostor.
- De Frégoli syndrome is the delusion of identifying a familiar person in various people they encounter.
- Ekbom syndrome is delusional parasitosis and describes the delusion of infestation.
- Delusions of guilt- The belief of having committed an awful sin or crime
- Mood congruent- delusion matches the person’s prevailing mood
- Autochthonous delusion - one that arises out of the blue (and unlike delusional perception is not attached to a real stimulus).
Delusional memory is when a patient recalls an event from the past and interprets it with a delusional meaning. Although this may seem similar to delusional perception, the difference is that the event at the time will not have been invested with a delusional interpretation; it is only afterwards that this occurs.
Signs:
- Affect, speech and behaviour are typically unaffected.
- Personal and social skills usually well-preserved
- Do NOT have hallucinations
- They can function very well- it can go unnoticed
Investigations
Examination
- Bloods (rule out organic causes)
- Urine drug screen
- ECG if indicated
- Comprehensive MDT assessment in secondary care
Diagnostic criteria (DSM-5)
The specific DSM-5 criteria for delusional disorder are as follows:
Presence of one or more delusions with a duration of one month or longer.
The diagnostic criteria for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are clearly thematically related to the delusional theme (e.g., the sensation of being infected with insects is associated with the delusions of infestation).
Apart from the impact of the delusion(s) or its ramifications, patient 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 symptoms.
The disturbance is not better explained by another mental disorder such as obsessive-compulsive disorder, and is not attributable to the physiological effects of a substance or medication or another systemic medical condition.
Differentials
- Substance-induced
- Mood disorder with delusions
- Schizophrenia
- Dementia + delirium
- Body dysmorphia
- OCD
- Hypochondriasis
- Paranoid (personality disorder)
- Epilepsy
Management
RISK ASSESSMENT!
Early Intervention Service
- Psychosis is toxic, the longer the patient is psychotic, the more it will affect their cognitive abilities, insight and social situation
- Assessment should be done without delay
- If the service cannot provide urgent intervention, refer to crisis resolution team and home treatment team
Antipsychotics (limited evidence)
1st Line: Atypical antipsychotics
* Olanzapine
* Risperidone (available as depot)
* Quetiapine
* Aripiprazole
* Clozapine
* Amisulpride
NOTE: Avoid using > 1 atypical antipsychotic
Consider starting atypical if:
- 1st episode
- Relapse on typical
- Typical cannot be tolerated
2nd line Typical antipsychotics (older drugs):
- Chlorpromazine
- Haloperidol
- Flupentixol decanoate
NOTE: these can cause extrapyramidal side effects, cheap and effective, provide depot option
3rd line - SSRIs?
Psychological interventions
- Individual CBT
- Not group as individuals are usually suspicious
- Improves outcomes when combined with antipsychotics
- People establish links between thoughts, feelings and actions and their current or past symptoms
- Re-evaluate perceptions, beliefs or reasoning
- Monitor their own thoughts, promoting alternative ways to cope, reducing stress, improving function
- At least 16 sessions
Family Intervention
- Either single family or multi-family group intervention
- Take account of relationship between main carer and patient
- Specific supportive, educational or treatment function- negotiated problem solving or crisis management work
- At least 10 sessions
Social Interventions
- Psychoeducation- vital to reduce relapse
- Needs to address: Education, training and employment
Skills (e.g. budgeting, cooking)
Housing (e.g. supported accommodation, independent flats)
Accessing social activities
Developing personal skills (e.g. creative writing)
General Management
Physical health
- Offer combined healthy eating and physical activity programme
- Offer interventions for metabolic complications of antipsychotics (e.g. weight gain, high cholesterol)
- Help with smoking cessation (consider nicotine replacement therapy or bupropion or varenicline)
- Regularly monitor weight and other CV/ metabolic parameters
- Support for Carers
- Offer support- including education and support programmes
- Inform them of their right to a form carer’s assessment (available for free through social services)
- Consider peer support (support from someone who has recovered from psychosis)
- Monitoring
Baseline measurements before starting an antipsychotic:
- Weight
- Waist circumference
- Pulse and BP
- Fasting glucose, HbA1c, lipid profile, prolactin
- Assessment for any movement disorders
- Assessment of nutritional status, diet and physical activity
- ECG (if CV risk factors present or recommended by chosen medication)
- Children also have their height measured every 6 months
Monitor:
- Response to therapy and side effects
- Emergence of movement disorders
- Waist circumference
- Adherence
- Overall physical health
- Weight : Weekly for 6 weeks, At 12 weeks, At 1 year, Annually thereafter
- Pulse and BP: At 12 weeks. At 1 year, Annually
Types of delusional disorder
De Clerambault syndrome
- Patient thinks that another person (usually of a higher social status) is in love with them, perhaps secretly, and they communicate with them in oblique ways
- Usually believe someone famous
- Person involved sometimes bombards their imagined lover with messages and gifts
- This can lead to stalking or violence if the love is not reciprocated
- Sometimes called Erotomania
- F > M
Cotard Syndrome
- Patient thinks that they, or a part of them are dead or rotting away.
- They may also believe that their internal organs or blood are missing
- It is associated with severe depression and psychotic disorders, as a mood-congruent delusion
Ekbom syndrome
- Patient believes their body is infested by insects/ parasites or animals when it is not
- Associated with this syndrome is also ‘matchbox sign’ where the patient presents a matchbox containing a few pieces of dirt or fluff they suggest is evidence of infestation
NOTE: Willis-Ekbom syndrome: restless legs syndrome
Capgras syndrome
- Also known as ‘imposter syndrome’ where the patient thinks that another person they know has been replaced by an identical imposter
- It most commonly occurs in patients with paranoid schizophrenia but can also occur in those with organic brain disease
Fregoli syndrome
- A single persecutor impersonates several people to the patient
Alien hand syndrome
- Hand is not under patient’s control
