The Complexity and Challenges of Delusional Disorder

Psychiatric disorders can be especially frightening and confusing when they involve a loss of touch with reality. In clinical terms, this is known as psychosis. There are several types of psychotic disorders, with schizophrenia being one of the most common. Individuals with schizophrenia often experience hallucinations (e.g. seeing or hearing things that aren't there) and delusions (a persistent belief that something is very real but isn't).

Some people, however, develop delusions that have nothing to do with schizophrenia. They are the primary symptom of a much less common psychotic condition known as delusional disorder. Richard's story is a classic example:

Richard is a 69-year-old retired widower. Although he had always been a healthy, high-functioning man with no history of mental illness, his adult children had become concerned about him. He had become increasingly paranoid over the past few months.

Richard had told them weeks ago that that the FBI was tapping his phone and constantly watching him via hidden cameras that had been placed in every room of his home. Recently he stated that he believed they (the government) wanted him dead. He was certain they had poisoned his food and water and tampered with his blood pressure medications.

Due to his delusions, Richard's behavior had become more and more bizarre. He was losing weight and at risk of dehydration as he was eating very little and would drink only soda or bottled water that he had just purchased at the store. He had completely stopped taking his blood pressure medication.

His children had tried being supportive, constantly reassuring him that no one was "out to get him" or spying on him. Unfortunately, he was starting to become suspicious that they might be part of the conspiracy as well.

They had scheduled an appointment with a psychiatrist for the following week, but realized they needed to take immediate when a worried neighbor called Richard's daughter early that evening. According to the frantic neighbor, Richard had said he was planning to purchase several boxes of ammunition for an old hunting rifle. He wanted to have it loaded and "ready to shoot" when the FBI agents came to get him.

Worried that he would be uncooperative and try to flee or even jump out of the car, his children contacted the police for assistance. He was brought to the emergency room of a local hospital for an evaluation, transported by the police and accompanied by his adult children. Of course, this only fueled Richard's belief that people were "out to get him".

A medical exam and lab results ruled out psychosis due to substances or a medical condition. Richard was diagnosed with delusional disorder and involuntarily admitted to the inpatient psychiatric unit later that night.

Symptoms

The primary symptom of delusional disorder, as the name implies, is the presence of one or more delusions. A delusion is essentially an unshakable, but false, belief. Delusions fit into one of two categories: bizarre and non-bizarre. A bizarre delusion involves an impossible situation or scenario, such as believing that an alien from another planet has taken over your spouse's mind and body. A non-bizarre delusion, on the other hand, involves a scenario or situation that could potentially happen. Examples of non-bizarre delusions would be the belief that you have a serious medical condition or that a Hollywood celebrity is madly in love with you.

Delusional disorder involves non-bizarre delusions only. Richard's belief that he was the target of a government conspiracy - although highly unlikely - wasn't beyond the realm of possibility. When bizarre delusions are present delusional disorder is ruled out and another diagnosis must be considered.

A key characteristic of a delusion is that the belief is held very firmly. In other words, no matter how much evidence is presented to the contrary, the delusion continues. For example, if your delusion involved the belief you were dying from cancer, no amount of irrefutable evidence (e.g. multiple exams and lab tests) to the contrary would change your mind. The delusional belief is also not shared by others.

It's not unusual for someone with delusional disorder to have hallucinations as well, although they aren't prominent. The hallucinations are typically related to the delusion. For example, someone like Richard, who thinks his food is poisoned, may "smell" the toxic substance in his food. He's not really smelling anything, of course; rather, he's experiencing an olfactory hallucination (olfactory pertains to smell).

Most Common Types of Delusions

Delusions almost always have a particular theme. Some of the most common themes are:

  • Somatic - the belief that you have a specific medical condition or physical defect
  • Grandiose - the belief that you are superior, exceptional, or special in some way
  • Persecutory / paranoid - the belief that you are being targeted, followed, spied upon,
  • harassed, or ridiculed, or that someone is trying to hurt you
  • Erotomanic - the belief that a person (often a celebrity) is in love with you
  • Jealous - that belief that your partner or spouse is having an affair

Some people with delusional disorder have a "mixed" delusion - one that involves more than one theme. An example would be a woman who believes a famous politician is in love with her and that his jealous wife is conspiring to have her killed.

Related Factors

Many individuals who develop delusional disorder have no prior psychiatric history. Unlike schizophrenia, which usually develops in late adolescence or early to mid-twenties, delusional disorder often strikes at a later age. Most people who develop the disorder are middle-aged or older, but a few do develop it earlier in life. For reasons not fully understood, delusional disorder appears to affect women slightly more often than men.

Treatment

The primary challenge with delusional disorder is getting the person into treatment. Since delusions, by their very nature, are firmly held beliefs despite evidence to the contrary, it's very difficult to get the delusional individual to recognize or accept that they need help. It's not uncommon for people with this disorder - particularly those with persecutory or paranoid delusions - to believe that those trying to help are part of some conspiracy. This typically makes them resistant to treatment and often renders therapy ineffective.

Individuals with delusional disorder rarely have any insight into their illness. They believe any problems brought on by their illness are due to external factors. Some individuals live with the disorder for years without anyone realizing they are seriously ill. They skillfully adapt their lives in such a way that no one notices the clues. Others exhibit behaviors that draw attention and concern. Like Richard, they may do things that make them potentially dangerous to themselves or others. They may become violent or aggressive, suicidal, stockpile weapons, or refuse to eat or take their medication. As a result they may end up hospitalized involuntarily until they are stable enough to safely continue treatment in an outpatient setting.

If individuals with delusional disorder do seek treatment on their own, it's almost always due to secondary symptoms. In other words, they're not seeking treatment for their psychosis; rather, they're seeking treatment for insomnia, depression, anxiety, or some other troubling symptom that their delusions are causing.

Delusional disorder is typically treated with a combination of antipsychotic medication and psychotherapy. The efficacy of treatment depends on a variety of factors. For example, someone with a lot of support and a willingness to comply with treatment has a much better chance of recovering, although there's no guarantee even then. Some people recover fully with treatment while others experience only some reduction in symptoms. Therapy is usually ineffective unless the psychosis has abated to some degree.

Currently, there is no way to predict or prevent delusional disorder. Those with a family history of delusional disorder, schizophrenia, or another psychotic disorder may have a greater risk of developing the disorder themselves. However, like most psychiatric conditions, anyone can potentially develop the disorder regardless of family history.

Posted on December 17th, 2012

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