Non-bizarre
delusions including feelings of being followed, poisoned, infected,
deceived or conspired against, or loved at a distance. Non-bizarre
referred to real life situations which could be true, but are
not or are greatly exaggerated. Bizarre delusions, which would
rule out this disorder, are those such as believing that your
stomach is missing or that aliens are seeking you out to be their
leader. Delusional disorder can be subtyped into the following
categories: erotomanic, grandiose, jealous, persecutory, somatic,
and mixed. Symptoms include:
Nonbizarre delusions for at least one month.
Absence of obviously odd or bizarre behavior.
Schizoaffective Disorder
and Mood Disorder with Psychotic
Features have been ruled out.
Absence of evidence that an organic factor initiated and maintained
this psychotic disturbance.
Absence of prominent hallucinations of a voice for at least one
week. Absence of visual hallucinations for at least one week.
Has never met the criteria for the active phase of Schizophrenia.
Subtypes
Erotomanic
Type: Predominately erotomanic delusions.
Grandiose
Type: Predominately grandiose delusions.
Jealous
Type: Predominately delusions of jealousy.
Persecutory
Type: Predominately persecutory delusions.
Somatic
Type: Predominately somatic delusions.
Unspecified
Type: Doesn't fit any of the previous categories.
These patients,
who tend to be in their 40's, may be may not realise that they
have a delusional disorder until it is pointed out by family or
friends. Even the diagnosis may be difficult because many do not
voluntarily seek treatment. They are frequently hypersensitive
and argumentative. Although they may perform well occupationally
and in areas distant from their delusions, they tend to be social
isolates either by preference or as a result of their interpersonal
inhospitality (i.e., spouses frequently abandon them). Social
and occupational dysfunction, when it occurs, usually is in direct
response to their delusions.
Associated
Features:
Psychosis
Depressed
Mood
Somatic
or Sexual Dysfunction
Odd
or Eccentric or Suspicious Personality
Differential
Diagnosis :
Some disorders have similar symptoms. The clinician, therefore,
in his diagnostic attempt has to differentiate against the following
disorders which need to be ruled out to establish a precise diagnosis.
Schizophrenia
Mood
Disorders
Psychosis NOS
Paranoid
Personality Disorder
Body Dysmorphic Disorder
Parkinson's Disease
Huntington's
Vitamin Deficiency
Delirium
Dementia
Drug-Induced
Endocrinopathies
Limbic System Pathology
Serious Liver and Kidney disease.
Cause:
The cause
of delusional disorder is not known. Some studies suggest a biological
component due to increased prevalence in first degree relatives
of individuals with the disorder. There is a tendency for their
family relationships to be characterized by turbulence, callousness,
and coldness yet the significance of the patter is unclear typical
defense mechanisms seen in these patients include denial, projection,
and regression.
A delusional
disorder appears to run distinct from schizophrenia
and mood disorders, and does
not appear to be a prodrome to either of these conditions.
Biologic
Theories: the relatively common occurrence of delusions
in neurological illness has led investigators to speculate on
the role of the limbic system, basal ganglia, and neocortical
association areas. No good current unifying theory
Psychodynamic
Theories: use of the defense mechanisms of reaction
formation, denial, projection: e.g. paranoia
Treatment:
Hospitalize if patient is
a danger to self or others, need a rapid diagnostic work-up. Antipsychotic
drugs are the drugs of choice, efficacy is not clear.
Counseling
and Psychotherapy [ See
Therapy Section ]:
Pharmacotherapy
[ See Psychopharmacology
Section ] :
Medications
can be helpful but are often refused due to the nature of the
disorder. Some individuals function quite normally, while others
may react to their delusion in ways that can greatly disrupt
their life.
Antipsychotics:
Doses and Side Effects for Chronic Use
Antipsychotics.
Chlorpromazine.
Thioridazine.
Trifluoperazine.
Thiothixene.
Fluphenazine.
Haloperidol.
Special Antipsychotic Adverse Reactions
Neuroleptic Malignant Syndrome. May occur at any point during
the course of treatment. Includes symptoms of autonomic instability,
altered mental status, which may progress to hyperthermia, stupor,
and muscle hypertonicity. Death may occur. Cause: Neuroleptics
(phenothiazines, etc.) Characteristics. Same symptoms as malignant
hyperthermia (see below) but generally develops over days instead
of minutes. Treatment: As per malignant hyperthermia.
Malignant Hyperthermia. Cause. 1:20,000 in response to a muscle-relaxing
agent (such as succinylcholine) or an inhaled anesthetic (such
as halothane). Is hereditary. May also be secondary to physical
or emotional stress. Characteristics. Hyperthermia, muscle rigidity,
tachycardia, acidosis, shock, coma, rhabdomyolysis. Treatment
includes IV dantrolene 1 to 10 mg/kg IV titrated to effect, management
of acidosis and shock, peripheral cooling (see management of heat
stroke below).
Tardive Dyskinesia. Involuntary movements of the tongue, face,
mouth, or jaw associated with long-term administration of antipsychotics.
Elderly females at highest risk. May be irreversible.
