Delusional disorder is a type of "psychosis" in which a person cannot tell what is real from what is imagined. The main feature of this disorder is the presence of delusions,which are beliefs in something untrue. People experiencing delusions actually believe that what they are "imagining" is true. These delusions usually involve the misinterpretation of perceptions. The delusions are non-bizarre (i.e a pt believes the government is following them- while in this pt's case it may be untrue, in reality it is something that could happen). In reality though, the situations are either not true at all or are highly exaggerated. I did not know there were so many types of delusions until our last group. I was only familiar with the main ones I see through the ER and on the medical floor. Here are the different types of delusions. I will try to provide case examples for as many as I can following the definitions.
Erotomanic: A belief that another person, (usually someone famous) is in love with him/her. The person might stalk this person or attempt to contact them in the belief that the person of interest wants to talk to the person with the delusion. **I can't recall a patient that I have worked with of this type- but I am sure we can all recall a story that has been published in People, US magazine in which someone believed that a particular celebrity was in love with them and they were then charged and sent to jail for stalking this person.
Grandiose: An over-inflated sense of worth, power, knowledge, or identity. The person may believe that they are famous or an important figure in society. ** I once worked with a patient at Western State Mental Hospital in which she believed she had once been the queen of England. She would only have her nails painted pink b/c this was only what the "queen did".
Jealous: A person with this type of delusional d/o believes that his or her spouse or partner is being unfaithful, even though this is not actually true. ** I had a patient whom ruminated for hours over the fact that his wife was cheating on him with famous people. Now, I may question the cheating piece, but once he started talking about who she was cheating with, it was evident that this was a delusion and not true (especially because there were many famous people involved...not just Tiger Woods (hee hee!)
Persecutory: A belief that the person (or someone close to them) are being mistreated, or that someone is spying on them or planning to harm them. ** I see this a lot- probably the most common delusion I see come through the ER. I had a patient whom believed that his neighbors were all plotting against him and that he could hear conversations through the wall (this would be a hallucination which can accompany the delusions). He was sure that they were plotting his death. Another patient believed that her daughter was trying to poison her and this patient wrote all over her walls at home in attempt to "let police know what date and time" her death was going to occur and who was going to kill her. A patient once believed they were being followed by the FBI and the FBI were hiding in the walls and had cameras all over this patient's house. Another example in which I have encountered many times is when a patient will not take their Rx, food or drink in belief that they are being poisoned and that the staff is trying to "kill" them. This often leads to ITA as this would be considered grave disability.
Somatic: A person with this type of delusional disorder believes that he/she has a medical problem or is sick ** I once had a patient (who came in several times throughout my shifts) and she swore she was pregnant. She was a 50 something year old, homeless lady and she stated every time that her MDs had told her she was pregnant and she believed she had a "pregnant" stomach (and would show us each time) and also believed that she had seen ultra sounds in which she could see the baby. She was definitely not pregnant. Another example is called delusional parasitosis. I have seen patients who believe that they have parasites, bed bugs or lice climbing all over them when in fact they truly don't. They then have visual hallucinations in which they can see the bugs crawling all over them.
Mixed: Two or more of the types of delusions listed above.
The exact cause of delusional disorder is not yet known. Researchers are looking at the role of genetic, biological (certain areas of the brain), environmental or psychological (stress, etoh and drug use) factors. It is important for a MD to do a complete exam to rule out any medical condition that may be causing these behaviors and thought patterns. Many times neurology and psychiatry may need to be involved to rule out medical issue as well. In terms of treatment, CBT, psychotherapy and Rx are the best cocktail. Anti-psychotics block dopamine and serotonin receptors which are neurotransmitters believed to be involved in the development of delusions. Common Rx are: Risperdol, Clozaril, Seroquel, Geodon, and Zyprexa. Tranquilizers and anti-depressants may also be used depending on the severity of the delusions and psychosis and if depression is an issue as well. Hallucinations and Delusions can be scary at times to work with depending on the situation and severity. If the patient feels that you are a threat to them, they come after you and have no sense of reality (which I have had happen). I think it is so important (particularly in the elderly population as we know that UTI sxs and effects can simulate that of a psychosis) to rule out any medical condition and ensure that this is not the cause of the behavior. Another important component to an effective assessment is to look at labs and tox screen as well as BAL.
If a person has a delusion, does this mean they are automatically diagnosed w/ delusional d/o? How can one differentiate between delusional d/o and other psychotic d/o that have delusions as a presenting sx?If a person has a delusion, does this mean they are automatically diagnosed w/ delusional d/o? How can one differentiate between delusional d/o and other psychotic d/o that have delusions as a presenting sx?
What a fantastic post Katie. Way to put in the work!!!!
I think your question at the end is perfect because it is a perfect transition into the BIG THREE, DEMENTIA, DELUSIONS, and DELIRIUM and how to differentiate between the three. This is not only important for the test but also for developing some great tangible clinical skills for our practice in quite frankly very difficult situations where time is sensitive and providers aren't very good at compartmentalizing symptoms. However, before we move in this direction because I want it to be our next topic, I want to explore delusions more comprehensively
So I decided to try to attempt to tackle differentiating delusional d/o from other disorders that involve psychodid… A diagnosis of delusional d/o cannot be made if the delusions are attributable to medications or other substances and they would have to persist for at least a month. Delusions are sometimes symptoms indentified in diagnosing schizophrenia. However people with delusional d/o tend not have as great a decrease in functioning like we usually see in people with schizophrenia and unlike schizophrenia there are no other symptoms, such as disorganized speech or hallucinations. The only exception to that would be tactile or olfactory hallucinations that are related to the delusions. It leads me to think of delusional d/o as a lesser of schizophrenia in that if delusions are the only symptom present, then a diagnosis of delusional d/o might be appropriate. However, if more symptoms are present (e.g. auditory/visual hallucinations or disorganized speech/behavior), then maybe start thinking about schizophrenia….
When thinking of a diagnosis of delusional d/o as opposed to mood d/o with psychosis for example, it appears that we should assess what the more prominent symptom is. In this case, are the delusions the primary symptom or is it the patient’s moods? If the delusions are not the most prominent symptom, then a diagnosis of delusional d/o is probably not appropriate.
Reading about the Persecutory delusional d/o brought a pt to mind that I met a few months ago. He has met w/ me 2 times and both times he focused on his fear of the government/SS department. He believes that someone from the Social Security (SS) office is trying to kill him. In addition, he believes that he is being followed and that his privacy is being invaded.
So, the Persecutory delusional d/o sounds familiar to what the pt was describing (i.e. false belief that someone is spying on them or trying to hurt them).
How does this differ from paranoia?
Also, this pt refuses to take meds or meet w/psych. I work in a small medical clinic & my role is to offer support on a voluntary basis. Therefore, I am limited in what I can do w/ this pt & to be honest I am not sure how to help him. For now, I have been a safe place to come and share his concerns but there isn't much else I can do at this point. Any ideas on how to help a pt w/ delusional d/o who refuses to take meds?
Katie, its very difficult to work with someone who is delusional and refusing to take medications. I had a patient last week in the inpatient psychiatric unit with a persecutory delusion that his neighbors in his apartment building were trying to torture and kill him by making excessive noise. The noise manifested as a tactile hallucination in that whenever he heard a sound it felt like tapping on his spine. He refused to take medications and refused to return to his apartment. Needless to say discharge planning became very difficult. The psychiatrist and rest of the team patiently continued to discuss medication options with him and suggested a trial run of risperidone which patient eventually agreed to do. He had a pretty quick response to the medication and did discharge back to his original apartment with support from community mental health.
Brian, thank you for sharing your experience in the ER. I will be looking forward to learning more about this issue & finding ways to support the pt's I work with. Thanks again!
Katie- I have worked with pt's who refuse to take Rx as well. I think there are 2 ways to look at this..... we all have rights to refuse Rx, but when it is caused by a mental health related diagnosis and becomes unsafe for the pt (i.e they are identified as gravely disabled) then this is where it is important to be able to differentiate and know what your options are. I have had to detain multiple pt's because of refusing Rx and some of these were secondary to the persecutory delusion that we were trying to poison them/kill them. I once had a pt who believed that CPS has taken his child away wrongfully and had planted cameras in his home along with microphones. He therefore planned to "explode" the CPS building and was plotting the way he was going to do this. We actually had to notify police and the CPS workers in the building as well.
There was a very interesting piece on NRP about Capgras delusions. It is a very rare type of delusion and one we are probably not likely to see on the test, but I found the issue quite fascinating. Quickly, a Capgras delusion is when a person believes that the people he/she recognizes have been replaced by imposters.
Here is the link: http://www.npr.org/templates/story/story.php?storyId=124745692
Thank you all for contributing to the blog! It is extremely helpful to review differential diagnoses and the variety of delusions, as it has been a couple of years since I learned these in class.
In my time here at Prov, I do not believe I have met with a patient with delusional disorder. Hallucinations and altered mental status come up frequently, but I do not believe I have seen a classic presentation of delusional disorder.
In addition to all of the great info in our blog post, I found the following information obtained in researching this topic online quite helpful.
- Delusional disorder is characterized by the presence of recurrent, persistent non-bizarre delusions (I believe the DSM stipulates that it is for at least 1 month).
- Generally, in delusional disorder, these mistaken beliefs are organized into a consistent world-view that is logical other than being based on an improbable foundation.
- In addition to giving evidence of a cluster of interrelated non-bizarre delusions, persons with delusional disorder experience hallucinations far less frequently than do individuals with schizophrenia or schizoaffective disorder.
- Unlike most other psychotic disorders, the person with delusional disorder typically does not appear obviously odd, strange or peculiar during periods of active illness. Yet the person might make unusual choices in day-to-day life because of the delusional beliefs.
- Because delusions can be shown as part of many illnesses, the diagnosis of delusional disorder is partially conducted by process of elimination. If the delusions are not accompanied by persistent, recurring hallucinations, then schizophrenia and schizoaffective disorder are not appropriate diagnoses. If the delusions are not accompanied by memory loss, then dementia is ruled out. If there is no physical illness or injury or other active biological cause (such as drug ingestion or drug withdrawal), then the delusions cannot be attributed to a general medical problem or drug-related causes. If delusions are the most obvious and pervasive symptom, without hallucinations, medical causation, drug influences or memory loss, then delusional disorder is the most appropriate categorization.
Delusional disorder is a type of "psychosis" in which a person cannot tell what is real from what is imagined. The main feature of this disorder is the presence of delusions,which are beliefs in something untrue. People experiencing delusions actually believe that what they are "imagining" is true. These delusions usually involve the misinterpretation of perceptions. The delusions are non-bizarre (i.e a pt believes the government is following them- while in this pt's case it may be untrue, in reality it is something that could happen). In reality though, the situations are either not true at all or are highly exaggerated. I did not know there were so many types of delusions until our last group. I was only familiar with the main ones I see through the ER and on the medical floor. Here are the different types of delusions. I will try to provide case examples for as many as I can following the definitions.
ReplyDeleteErotomanic: A belief that another person, (usually someone famous) is in love with him/her. The person might stalk this person or attempt to contact them in the belief that the person of interest wants to talk to the person with the delusion.
**I can't recall a patient that I have worked with of this type- but I am sure we can all recall a story that has been published in People, US magazine in which someone believed that a particular celebrity was in love with them and they were then charged and sent to jail for stalking this person.
Grandiose: An over-inflated sense of worth, power, knowledge, or identity. The person may believe that they are famous or an important figure in society.
** I once worked with a patient at Western State Mental Hospital in which she believed she had once been the queen of England. She would only have her nails painted pink b/c this was only what the "queen did".
Jealous: A person with this type of delusional d/o believes that his or her spouse or partner is being unfaithful, even though this is not actually true.
** I had a patient whom ruminated for hours over the fact that his wife was cheating on him with famous people. Now, I may question the cheating piece, but once he started talking about who she was cheating with, it was evident that this was a delusion and not true (especially because there were many famous people involved...not just Tiger Woods (hee hee!)
Persecutory: A belief that the person (or someone close to them) are being mistreated, or that someone is spying on them or planning to harm them.
ReplyDelete** I see this a lot- probably the most common delusion I see come through the ER. I had a patient whom believed that his neighbors were all plotting against him and that he could hear conversations through the wall (this would be a hallucination which can accompany the delusions). He was sure that they were plotting his death. Another patient believed that her daughter was trying to poison her and this patient wrote all over her walls at home in attempt to "let police know what date and time" her death was going to occur and who was going to kill her. A patient once believed they were being followed by the FBI and the FBI were hiding in the walls and had cameras all over this patient's house. Another example in which I have encountered many times is when a patient will not take their Rx, food or drink in belief that they are being poisoned and that the staff is trying to "kill" them. This often leads to ITA as this would be considered grave disability.
Somatic: A person with this type of delusional disorder believes that he/she has a medical problem or is sick
** I once had a patient (who came in several times throughout my shifts) and she swore she was pregnant. She was a 50 something year old, homeless lady and she stated every time that her MDs had told her she was pregnant and she believed she had a "pregnant" stomach (and would show us each time) and also believed that she had seen ultra sounds in which she could see the baby. She was definitely not pregnant. Another example is called delusional parasitosis. I have seen patients who believe that they have parasites, bed bugs or lice climbing all over them when in fact they truly don't. They then have visual hallucinations in which they can see the bugs crawling all over them.
Mixed: Two or more of the types of delusions listed above.
The exact cause of delusional disorder is not yet known. Researchers are looking at the role of genetic, biological (certain areas of the brain), environmental or psychological (stress, etoh and drug use) factors. It is important for a MD to do a complete exam to rule out any medical condition that may be causing these behaviors and thought patterns. Many times neurology and psychiatry may need to be involved to rule out medical issue as well. In terms of treatment, CBT, psychotherapy and Rx are the best cocktail. Anti-psychotics block dopamine and serotonin receptors which are neurotransmitters believed to be involved in the development of delusions. Common Rx are: Risperdol, Clozaril, Seroquel, Geodon, and Zyprexa. Tranquilizers and anti-depressants may also be used depending on the severity of the delusions and psychosis and if depression is an issue as well.
Hallucinations and Delusions can be scary at times to work with depending on the situation and severity. If the patient feels that you are a threat to them, they come after you and have no sense of reality (which I have had happen). I think it is so important (particularly in the elderly population as we know that UTI sxs and effects can simulate that of a psychosis) to rule out any medical condition and ensure that this is not the cause of the behavior. Another important component to an effective assessment is to look at labs and tox screen as well as BAL.
If a person has a delusion, does this mean they are automatically diagnosed w/ delusional d/o? How can one differentiate between delusional d/o and other psychotic d/o that have delusions as a presenting sx?If a person has a delusion, does this mean they are automatically diagnosed w/ delusional d/o? How can one differentiate between delusional d/o and other psychotic d/o that have delusions as a presenting sx?
What a fantastic post Katie. Way to put in the work!!!!
ReplyDeleteI think your question at the end is perfect because it is a perfect transition into the BIG THREE, DEMENTIA, DELUSIONS, and DELIRIUM and how to differentiate between the three. This is not only important for the test but also for developing some great tangible clinical skills for our practice in quite frankly very difficult situations where time is sensitive and providers aren't very good at compartmentalizing symptoms. However, before we move in this direction because I want it to be our next topic, I want to explore delusions more comprehensively
So I decided to try to attempt to tackle differentiating delusional d/o from other disorders that involve psychodid… A diagnosis of delusional d/o cannot be made if the delusions are attributable to medications or other substances and they would have to persist for at least a month. Delusions are sometimes symptoms indentified in diagnosing schizophrenia. However people with delusional d/o tend not have as great a decrease in functioning like we usually see in people with schizophrenia and unlike schizophrenia there are no other symptoms, such as disorganized speech or hallucinations. The only exception to that would be tactile or olfactory hallucinations that are related to the delusions. It leads me to think of delusional d/o as a lesser of schizophrenia in that if delusions are the only symptom present, then a diagnosis of delusional d/o might be appropriate. However, if more symptoms are present (e.g. auditory/visual hallucinations or disorganized speech/behavior), then maybe start thinking about schizophrenia….
ReplyDeleteWhen thinking of a diagnosis of delusional d/o as opposed to mood d/o with psychosis for example, it appears that we should assess what the more prominent symptom is. In this case, are the delusions the primary symptom or is it the patient’s moods? If the delusions are not the most prominent symptom, then a diagnosis of delusional d/o is probably not appropriate.
Test
ReplyDeleteThank you for the great information!
ReplyDeleteReading about the Persecutory delusional d/o brought a pt to mind that I met a few months ago. He has met w/ me 2 times and both times he focused on his fear of the government/SS department. He believes that someone from the Social Security (SS) office is trying to kill him. In addition, he believes that he is being followed and that his privacy is being invaded.
So, the Persecutory delusional d/o sounds familiar to what the pt was describing (i.e. false belief that someone is spying on them or trying to hurt them).
How does this differ from paranoia?
Also, this pt refuses to take meds or meet w/psych. I work in a small medical clinic & my role is to offer support on a voluntary basis. Therefore, I am limited in what I can do w/ this pt & to be honest I am not sure how to help him. For now, I have been a safe place to come and share his concerns but there isn't much else I can do at this point. Any ideas on how to help a pt w/ delusional d/o who refuses to take meds?
Thanks- Katie
Katie, its very difficult to work with someone who is delusional and refusing to take medications. I had a patient last week in the inpatient psychiatric unit with a persecutory delusion that his neighbors in his apartment building were trying to torture and kill him by making excessive noise. The noise manifested as a tactile hallucination in that whenever he heard a sound it felt like tapping on his spine.
ReplyDeleteHe refused to take medications and refused to return to his apartment. Needless to say discharge planning became very difficult. The psychiatrist and rest of the team patiently continued to discuss medication options with him and suggested a trial run of risperidone which patient eventually agreed to do. He had a pretty quick response to the medication and did discharge back to his original apartment with support from community mental health.
Nicole, Great way to distinguish the differences between schizophrenia and delusional disorder
ReplyDeleteBrian, thank you for sharing your experience in the ER. I will be looking forward to learning more about this issue & finding ways to support the pt's I work with. Thanks again!
ReplyDeleteKatie- I have worked with pt's who refuse to take Rx as well. I think there are 2 ways to look at this..... we all have rights to refuse Rx, but when it is caused by a mental health related diagnosis and becomes unsafe for the pt (i.e they are identified as gravely disabled) then this is where it is important to be able to differentiate and know what your options are. I have had to detain multiple pt's because of refusing Rx and some of these were secondary to the persecutory delusion that we were trying to poison them/kill them. I once had a pt who believed that CPS has taken his child away wrongfully and had planted cameras in his home along with microphones. He therefore planned to "explode" the CPS building and was plotting the way he was going to do this. We actually had to notify police and the CPS workers in the building as well.
ReplyDeleteThere was a very interesting piece on NRP about Capgras delusions. It is a very rare type of delusion and one we are probably not likely to see on the test, but I found the issue quite fascinating. Quickly, a Capgras delusion is when a person believes that the people he/she recognizes have been replaced by imposters.
ReplyDeleteHere is the link: http://www.npr.org/templates/story/story.php?storyId=124745692
Thank you all for contributing to the blog! It is extremely helpful to review differential diagnoses and the variety of delusions, as it has been a couple of years since I learned these in class.
ReplyDeleteIn my time here at Prov, I do not believe I have met with a patient with delusional disorder. Hallucinations and altered mental status come up frequently, but I do not believe I have seen a classic presentation of delusional disorder.
In addition to all of the great info in our blog post, I found the following information obtained in researching this topic online quite helpful.
- Delusional disorder is characterized by the presence of recurrent, persistent non-bizarre delusions (I believe the DSM stipulates that it is for at least 1 month).
- Generally, in delusional disorder, these mistaken beliefs are organized into a consistent world-view that is logical other than being based on an improbable foundation.
- In addition to giving evidence of a cluster of interrelated non-bizarre delusions, persons with delusional disorder experience hallucinations far less frequently than do individuals with schizophrenia or schizoaffective disorder.
- Unlike most other psychotic disorders, the person with delusional disorder typically does not appear obviously odd, strange or peculiar during periods of active illness. Yet the person might make unusual choices in day-to-day life because of the delusional beliefs.
- Because delusions can be shown as part of many illnesses, the diagnosis of delusional disorder is partially conducted by process of elimination. If the delusions are not accompanied by persistent, recurring hallucinations, then schizophrenia and schizoaffective disorder are not appropriate diagnoses. If the delusions are not accompanied by memory loss, then dementia is ruled out. If there is no physical illness or injury or other active biological cause (such as drug ingestion or drug withdrawal), then the delusions cannot be attributed to a general medical problem or drug-related causes. If delusions are the most obvious and pervasive symptom, without hallucinations, medical causation, drug influences or memory loss, then delusional disorder is the most appropriate categorization.