PSYCHIATRY Nursing SEMINAR

DELUSION DISORDERS
 What is a delusion ?
• Fixed false belief
• Based on an inaccurate interpretation of an external reality
• Cannot be changed by reasoning
• Despite evidence to the contrary
 Delusional disorder
• Characterized by the presence of delusions which have persisted for
at least one month that cannot be explained by another condition
• Patient’s functioning will be relatively stable here
 Epidemiology
• Life time prevalence is about 0.02%
• Annual incidence is one to three new cases per 1,00,000 persons.
• Delusional disorder is much rarer than schizophrenia
• The mean age of onset is about 40 years
• The range for age of onset is from 18 years to the 90s.
• A slight increase of incidence in female patients exists.
• Men are more likely to develop paranoid delusions than women
• Women are more likely to develop delusions of erotomania.
 Etiology
Biological Factors
Family history
Certain substances
Abnormalities in limbic system and the basal ganglia.
Neurological diseases
A normal response to abnormal experiences in the environment
 Psychodynamic Factors
• Social isolation and attaining less than expected levels of achievement.
• Hypersensitive persons
• Specific ego mechanisms like reaction formation, projection, and denial.
• lack of trust in relationships
• consistently hostile family environment, an overcontrolling mother and a
distant or sadistic father
• Mistrust in psychosocial stage
• Personality features (e.g., unusual interpersonal sensitivity)
 Freud's Contributions
Unconscious homosexual tendencies are defended against by denial
and projection.
Studies have been unable to confirm Freud's theories, although they
may be relevant in individual cases.
No higher incidence of homosexual ideation or activity is found in
patients with delusions
Projection as the main ego defense mechanism in delusion
 Situations that favor the development of
delusional disorders
Norman Cameron
An increased expectation of receiving sadistic treatment
Situations that increase distrust and suspicion
Social isolation
Situations that increase jealousy
Situations that lower self-esteem
Situations that cause persons to see their own defects in others
Situations that increase the potential for rumination over probable
meanings and motivations.
 Paranoid Pseudo community
✽ When frustration from any combination of these conditions exceeds
the tolerable limit, persons become withdrawn and anxious
✽They realize that something is wrong, seek an explanation for the
problem
✽ They find a delusional system as an explanation
✽ Elaboration of the delusion with persons results in the organization
of the pseudo community-a perceived community of conspirators
 Other factors
 Sensory deprivation
 Socioeconomic deprivation
 Immigrants with limited ability in a new language
 Advanced age
 Diagnostic criteria- ICD 11
6A24 Delusional disorder
Development of a delusion or set of related delusions that persist for
at least 3 months (usually much longer), which occur in the absence
of a Depressive, Manic, or Mixed mood episode.
Other characteristic symptoms of Schizophrenia (e.g. persistent
auditory hallucinations, disorganized thinking, negative symptoms)
are not present
The symptoms are not a manifestation of another disorder or disease
and are not due to the effect of a substance or medication on the
central nervous system
 6A24.0 Delusional disorder, currently
symptomatic
• All definitional requirements for Delusional disorder in terms of
symptoms and duration are currently met, or have been met within the
past one month.
 6A24.1 Delusional disorder, in partial
remission
All definitional requirements for Delusional disorder in terms of
symptoms and duration were previously met.
Symptoms have been improved such that the diagnostic requirements
for the disorder have not been met for at least one month
But some clinically significant symptoms remain, which may or may not
be associated with functional impairment.
 The partial remission may have occurred in response to medication or
other treatment.
 6A24.2 Delusional disorder, in full
remission
All definitional requirements for Delusional disorder in terms of
symptoms and duration were previously met.
Symptoms have been improved such that no significant symptoms
remain.
The remission may have occurred in response to medication or other
treatment.
6A24.Z Delusional disorder, unspecified
 DSM 5- Delusional Disorder
The presence of one (or more) delusions with a duration of 1 month
or longer.
Criterion A for schizophrenia has never been met.
Hallucinations, if present, are not prominent and are related to the
delusional theme
(e.g., the sensation of being infested with insects associated with
delusions of infestation).
 DSM 5- Delusional Disorder…
Apart from the impact of the delusion or its unpleasant consequences,
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 periods
The disturbance is not attributable to the physiological effects of a
substance or another medical condition
Also this is not better explained by another mental disorder, such as
body dysmorphic disorder or obsessive-compulsive disorder
 DSM 5- Delusional Disorder…
Specify whether
Erotomanic type
Grandiose type
Jealous type
Persecutory type
Somatic type
Mixed type
Unspecified type
 DSM 5, Bizarre delusions
Clearly implausible
Not understandable
Not derived from ordinary life experiences
Eg: An individual’s belief that a stranger has removed his or her
internal organs and replaced them with someone else’s organs
without leaving any wounds
 Types
 Persecutory
 Jealous
 Erotomanic
 Grandiose
 Somatic
 Mixed
 Unspecified
Persecutory
 Persecutory….

✽ It is a classic symptom of delusional disorder

✽ The most common form along with delusion of jealousy
✽ Patients are convinced that they are being persecuted or harmed.
✽ Delusion of being poisoned or infected are also seen
✽ Associated with querulousness, irritability, and anger, and the
individual may at times be assaultive or even homicidal.
 Case scenario

Mrs. S, 62 years old, was referred to a psychiatrist because of reports

of being unable to sleep. She had previously worked full time taking
care of children, and she played tennis almost every day and managed
her household chores.
 However, she had now become preoccupied with the idea that her
downstairs neighbor was doing a variety of things to harass her and
wanted to get her to move away.
She felt he might be leaving empty bottles of cleaning solutions in the
basement so she would be overcome by fumes.
 Case scenario…

As a result, the patient was fearful of falling asleep, convinced that she might be
asphyxiated and unable to awaken in time to get help.
 She felt somewhat depressed
However, she had not lost weight and still enjoyed playing tennis and
going out with friends.
At one point she considered moving to another apartment but then decided to
fight back.
The episode had gone on for 8 months when her daughter persuaded her to have
a psychiatric assessment.
In the interview, Mrs. S was pleasant and cooperative. Except for mild depressive
symptoms and the specific delusion about being harassed by her neighbor, her
mental status was normal.
 Case scenario…

Mrs. S had a past history of depression 30 years before, which

followed the death of a close friend. She saw a counselor for several
months and found this helpful, but she was not treated with
medication.
 For the current episode, she agreed to take medications, although
she believed her neighbor was more in need of treatment than she
was.
Her symptoms improved somewhat with risperidone (Risperdal) 2 mg
at bedtime and clonazepam (Klonopin) 0.5 mg every morning and at
bedtime.
 Jealous type
Morbid jealousy/Conjugal paranoia/Othello syndrome
The delusion usually affects men, often those with
no prior psychiatric illness.
 It may appear suddenly
 The condition is difficult to treat
 Usually diminish only on separation, divorce, or death of the spouse.
 Jealous type
A symptom of many disorders-including schizophrenia, epilepsy,
mood disorders, drug abuse, and alcoholism-for which treatment is
directed at the primary disorder.
Physical and verbal abuse occur more frequently
Potentially dangerous and has been associated with violence, suicide
and homicide
Its role as a motive for murder is also noted
 Case scenario
 Mr. M was a 51-year-old married white man who lived with his wife
in their own home and who worked full time driving a sanitation
truck.
 He became concerned that his wife was having an affair. He began to
follow her, kept notes on his observations, and repeatedly asked her
about this, often waking her up in the middle of the night to make
accusations.
 Shortly before admission, these arguments led to physical violence,
and he was brought to the hospital by police.
 In addition to concerns about his wife's fidelity, Mr. M reported
feelings of depression over his wife’s betrayal
 Case scenario…
 He noted no changes in sleep, appetite, or work-related functioning.
He was treated with a low dose of an antipsychotic medication and
described being less concerned about his wife's behavior.
 After discharge, he remained on medications and was seen by a
psychiatrist monthly
 But 10 years later, he continued to believe that his wife was
unfaithful.
 His wife noted that he sometimes became upset about the delusion
but that he had not become aggressive or required readmission.
 Erotomania
• De Clerambault syndrome or psychose passionelle
• Delusional belief that one is loved by another person, generally of a
higher social status
• More common in women
• Very rarely in men
 Characteristics of the personnel involved
 Solitary
Withdrawn
Unattractive
Single
Few sexual contacts
Dependent
Sexually inhibited
Poor levels of social or occupational functioning
 Erotomania…
 A delusional conviction of amorous communication
 Object of much higher rank
 Object being the first to fall in love
 Object being the first to make advances
 Sudden onset (within a 7-day period)
 Object remains unchanged
 Patient rationalizes paradoxical behavior of the object
 Chronic course
 Absence of hallucinations
 Erotomania…
 The subject has had very little previous contact with the object of
love, which is superior and unattainable in some way
They interpret all denials of love, no matter how clear, as secret
affirmations of love
Men who are affected may be more aggressive and possibly violent
 Erotomania….
¨Stages of evolution of Erotomania: Hope, resentment and grudge
¨Last stages may put the love object in danger
¨The object of aggression can be the loved individual but companions or
protectors of the love object who are viewed as trying to come between
¨So-called stalkers, who continually follow their perceived lovers,
frequently have delusions.
¨Separation from the love object will be effective
 Grandiose delusions
∞ Its also called as megalomania
∞ False beliefs that one has special powers, wealth, mission, or identity.
∞Occurs generally in Mania, BPAD, Schizophrenia ,Schizoaffective
disorder, delusion disorders, substance use disorders, organic brain
syndrome etc
 Etiology – Grandiose delusions
o Beliefs provided a sense of purpose, belonging, or positive identity,
often in difficult circumstances
o Explanation for anomalous experiences
o Mood-elevating relationship between symptoms of mania and
grandiosity is also noticed
o Reasoning biases
 Grandiose delusions…
 Harm may occur to self or others.
Physical, sexual, social, occupational, and emotional harm ⲳ
 Case scenario…
A 5 1-year-old man was arrested for disturbing the peace.
Police had been called to a local park to stop him from carving his
initials and those of a recently formed religious cult into various trees
surrounding a pond in the park.
When confronted, he had argued that having been chosen to begin a
new town-wide religious revival, it was necessary for him to publicize
his intent in a permanent fashion.
The police were unsuccessful in preventing the man from cutting
another tree and arrested him.
 Case scenario…
Psychiatric examination was ordered at the state hospital, and the
patient was observed there for several weeks.
He denied any emotional difficulty
 He had no history of euphoria or mood swings.
The patient was angry about being hospitalized and only gradually
permitted the doctor to interview him.
 Case scenario…
In a few days, however, he was busy preaching to his fellow patients
and letting them know that he had been given a special mandate from
God to bring in new converts through his ability to heal.
 Eventually, his preoccupation with special powers diminished, and no
other evidence of psychopathology was observed.
The patient was discharged, having received no medication at all.
Two months later he was arrested at a local theater, this time for
disrupting the showing a film that depicted subjects he believed to be
satanic.
 Somatic delusions
• Monosymptomatic hypochondriacal psychosis.
• Reality impairment which could be noticed extensively here
compared to hypochondriasis
• 3 types
Delusions of infestation
Delusions of dysmorphophobia
Delusions of foul body odors or halitosis
 Delusions of infestation

 It includes delusion of
parasitosis
 Patient’s fixed false
belief that their skin
and body is infected
by small, vivid
pathogens although
there is no medical
evidence for this
 Delusions of dysmorphophobia
• Delusions regarding perceived defect in physical appearance that is
either non existent or significantly exaggerated by patient
• Its non delusional variant is body dysmorphic disorder
 Delusions of foul body odors
• Sometimes referred to as olfactory reference syndrome
• Persistent false belief that one emits a foul or offensive body odor.
• Odors include almost anything foul- smelling
• Eg: Halitosis, Genital odor, Flatulence, Anal odor, Sweat, Non bodily
odors like ammonia, detergent etc
 Somatic delusions…
• Three groups, although individually low in prevalence, appear to
overlap.
• Hyper alertness and high anxiety
• More often these cases are reported through consultation liaison
psychiatry
 Mixed Type
 Applies to patients with two or more delusional themes.
Reserve for cases in which no single delusional type predominates.
 Unspecified type
∞ The predominant delusion cannot be subtyped within the previous
categories.
∞ It includes the types of delusions like certain delusions of
misidentification
 Delusions of misidentification
Capgras syndrome
• A person to whom the client is close has an exact double
 Fregoli syndrome
Delusional belief that various people client meet actually are same and
persecutors or familiar persons can assume the appearance of strangers.
 Syndrome of intermetamorphosis
Familiar persons can change themselves into other persons at will
It includes both physical and psychological identity
 Cotard syndrome
Rare
Patient complains of having lost not only possessions, status, and
strength but also his heart, blood or body parts to insist that one has
lost one’s soul or is dead
This is usually considered a precursor to a schizophrenic or
depressive episode
Patients more responsive to ECT than pharmacological treatment
 Shared psychotic disorder
Also referred to as Induced psychotic disorder, Jolie impose, and
double insanity
In DSM4, Shared psychotic disorder
In DSM5, this disorder is referred to as "Delusional Symptoms in
Partner of Individual with Delusional Disorder,“
ICD 10, Induced delusion disorder
 It is probably rare
Incidence and prevalence figures are lacking, literature also very few
 Shared psychotic disorder…
Transfer of delusions from one person to one or several others .
Persons are closely associated for a long time and typically live
together in relative social isolation.
The individual who first has the delusion is the primary case. Inducer
The second one is the secondary case, Induced individual
 Risk factors of Shared Psychotic disorder
Genetic predisposition
Old age
Sensory impairment
Gender, Female
 Stressful life events
Social isolation
Personality- Introvert, Neurotic, Emotionally immature, Schizoid,
Schizotypal
Untreated mental illness in primary
Nature and length of relationship
 Risk factors in secondary case
o Low intelligence
o Poor judgment
o Cognitive impairment
o Comorbid mental illness
 Most common relationships involved
Sister-sister
Husband-wife
Mother-child
Almost all cases involve members of a single family.
 Types
Folie impose (Imposed psychosis)
✽ The delusions are transferred from an individual with psychosis to an
individual without psychosis in an intimate relationship.
✽The delusions in the induced individual soon disappear once the two
are separated.
Folie simultanee (simultaneous psychosis)
 Both partners share the psychosis simultaneously.
They both have risk factors through long social interactions that
predispose them to develop this condition.
 Folie communiquee (communicated
psychosis)
• Similar to folie impose
• The delusion in the secondary partner occurs after a long period of
resistance.
• Secondary partner will maintain the delusion even after separation
from their partner
 Folie induite (Induced psychosis)
 New delusions are assumed by an individual with psychosis who is
being influenced by another individual with psychosis.
 Characteristics of the personnel involved
Characteristics of primary case
Psychotic/ delusional disorder
 The influential member of a close relationship with dominance
Characteristics of secondary case
Suggestible person
Less intelligent
Easily persuaded to believe something
More passive
More lacking in self-esteem
 Shared psychotic disorder…
If the pair separates, the secondary person may abandon the
delusion, but this outcome is not seen uniformly
Occasionally, more than two individuals are involved, but such cases
are especially rare.
If a family is involved, folie a famille
 Induced delusional disorder
• ICD 10 classification, Not retained in ICD 11
• A delusional disorder shared by two or more people with close
emotional links.
• Only one of the people suffers from a genuine psychotic disorder; the
delusions are induced in the other(s)
• Usually disappear when the people are separated.
 Differential diagnosis
Obsessive-compulsive and related disorders
Delirium, major neurocognitive disorder, psychotic disorder due to
another medical condition, and substance/medication-induced
psychotic disorder.
Schizophrenia and schizophreniform disorder
Depressive and bipolar disorders and schizoaffective disorder
 Course and prognosis
 About 50 percent of patients have recovered at long-term follow-up
20 percent show decreased symptoms
 30 percent exhibit no change.
 Factors correlating with a good prognosis
✽High levels of occupational, social, and functional adjustments
✽Female sex
✽Onset before age 30 years
✽Sudden onset
✽Short duration of illness
✽Presence of precipitating factors.
✽patients with persecutory, somatic, and erotic delusions
 Hospitalization
 Usually these patients don’t require hospitalization.
 But hospitalization is required in the following cases
When patients may need a complete medical and neurological
evaluation to determine whether a medical condition is the etiology
Risk for suicide/ homicide
If the condition has severely affected the patient’s socio-occupational
functioning.
 Pharmacotherapy
• Treatment of choice is antipsychotic drugs
• In an emergency, severely agitated patients - Antipsychotic drug
intramuscularly.
• A patient's history of medication response is the best guide to choose a
drug
• Start with low doses and increase the dose slowly.
• If a patient fails to respond to the drug at a reasonable dosage in a 6-
week trial, antipsychotic drugs from other classes should be tried.
 Pharmacotherapy ...
• Pimozide is particularly effective, especially in somatic delusions
• FGAs are slightly superior according to some researches
• Risperidone and olanzapine are mostly used
• Drug noncompliance should also be evaluated.
• Lithium or anticonvulsants are used for delusional disorder for those
who do not respond to antipsychotic drugs.
• Especially this applies when a patient has either the features of a
mood disorder or a family history of mood disorders
 Psychotherapy
• Establish a trustworthy relationship
• Individual psychotherapy is proven to be more effective than group
psychotherapy
• Insight-oriented, supportive, cognitive, and behavioral therapies
• Studies show CBT is particularly effective
• Family also should be involved.
• Often psychotherapy is given as an adjunct with the drugs
 Nursing diagnosis
 Risk for suicide
 Risk for violence
 Disturbed thought process
 Fear
 Disturbed sleeping pattern
 Impaired social interaction
 Research evidence-1
Suicidal ideation and suicidal behaviour in delusional disorder: a
clinical overview
 Alexandre González-Rodríguez etal
Suicidal ideation and suicidal behaviour in
delusional disorder…
Background
Most of the existing studies suggest that suicide is one of the leading
causes of premature death in patients with chronic psychotic disorders.
However, very few studies have specifically investigated suicidal
behaviour in patients with delusional disorder. Thus, our objective was
to review the literature regarding the percentage of lifetime ideation
and suicidal behaviour in delusional disorder in order to provide
suggestions for clinical practice.
Methodology
MEDLINE and PsycINFO were searched from January 1980 to
September 2012
Suicidal ideation and suicidal behaviour in
delusional disorder…
Results
A total of 10 studies were identified and included in the review. The
percentage of suicidal behaviour in delusional disorder was established
between 8 and 21%, which is similar to schizophrenia. Suicidal ideation and
suicide attempts were more frequent in patients showing persecutory and
somatic delusions in the reviewed studies.
Conclusion
To the best of our knowledge this is the first attempt to specifically review the
suicide phenomenon in patients with delusional disorder. Interestingly, our
results support the notion that percentages of both suicidal ideation and
behaviour in delusional disorder are similar to patients with schizophrenia.
 Research evidence-2
• Violence Associated with Somatic Delusions
• Sanya A Virani 1, John Sobotka 1, Navjot Brainch 1, Lama Bazzi 2 etal
 Violence Associated with Somatic
Delusions
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) characterizes delusional disorder (DD) by the presence of
delusions for longer than one month, without bizarre behavior or
functional impairment. According to Kaplan and Saddock, the lifetime
prevalence of DD (all subtypes) is about 0.2%. The persecutory subtype
of delusional disorder (DD-PS) is the most common and the somatic
subtype (DD-SS) is exceedingly rare.
Violence Associated with Somatic
Delusions…
We aim to describe two cases of patients with somatic delusions, both
presenting as imminently dangerous and threatening. We also discuss
one case that resulted from our extensive literature review where
somatic delusions were implicated in elevating a mass shooter's
violence risk. Both patients whose cases are presented were
involuntarily hospitalized after their doctors called 911 to report that
they were being threatened by a weapon. These patients had no
established psychiatric diagnoses and were evaluated thoroughly and
diagnosed with DD-SS.
Violence Associated with Somatic
Delusions…
Both perceived that their physicians were indifferent to their needs and
cited their frustration as the trigger for planning attacks on the doctors.
Unlike persecutory delusions, somatic delusions are not traditionally
described as increasing danger or risk of violence, and thorough risk
assessments are not usually performed in DD-SS. We demonstrate that
formal psychiatric violence risk assessments remain a useful tool to
methodically stratify and effectively address risk, even in patients we
do not typically expect to demonstrate premeditated violence.
Conclusion
 Reference
KAPLAN & SADOCK'S Behavioral Sciences/Clinical Psychiatry
Alexandre González-Rodríguez 1, Oriol Molina-Andreu 2, Víctor
Navarro Odriozola 3, Cristóbal Gastó Ferrer 3, Rafael Penadés 3, Rosa
Catalán 3 Suicidal ideation and suicidal behaviour in delusional
disorder: a clinical overview
Sanya A Virani 1, John Sobotka 1, Navjot Brainch 1, Lama Bazzi 2
Violence Associated with Somatic Delusions
C Fear etal, Recent developments in the management of delusional
disorders
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