Delusions are distinguished from mistaken beliefs in that delusional beliefs remain unchanged in the face of clear, reasonable evidence to the contrary; this distinction is sometimes difficult to make when the beliefs are more plausible (eg, that a spouse is unfaithful).
Delusional disorder is distinguished from schizophrenia by the presence of delusions without any other symptoms of psychosis Symptoms and Signs Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect... read more (eg, hallucinations, disorganized speech or behavior, negative symptoms). The delusions may be
Nonbizarre: They involve situations that could occur, such as being followed, poisoned, infected, loved at a distance, or deceived by one’s spouse or lover.
Bizarre: They involve implausible situations such as believing that someone removed their internal organs without leaving a scar.
In contrast to schizophrenia Schizophrenia Schizophrenia is characterized by psychosis (loss of contact with reality), hallucinations (false perceptions), delusions (false beliefs), disorganized speech and behavior, flattened affect... read more , delusional disorder is relatively uncommon. Onset is generally involutional, occurring in middle or late adult life. Psychosocial functioning is not as impaired as it is in schizophrenia, and impairments usually arise directly from the delusional belief.
When delusional disorder occurs in older patients, it is sometimes called paraphrenia. It may coexist with mild dementia Dementia Dementia is chronic, global, usually irreversible deterioration of cognition. Diagnosis is clinical; laboratory and imaging tests are usually used to identify treatable causes. Treatment is... read more . The physician must be careful to distinguish delusions from elder abuse Elder Abuse Elder abuse is physical or psychologic mistreatment, neglect, or financial exploitation of older adults. Common types of elder abuse include physical abuse, psychologic abuse, neglect, and financial... read more being reported by a mildly demented older patient.
(See also Introduction to Schizophrenia and Related Disorders Introduction to Schizophrenia and Related Disorders Schizophrenia and related psychotic disorders— brief psychotic disorder, delusional disorder, schizoaffective disorder, schizophreniform disorder, and schizotypal personality disorder—are characterized... read more .)
Symptoms and Signs of Delusional Disorder
Delusional disorder may arise from a preexisting paranoid personality disorder Paranoid Personality Disorder (PPD) Paranoid personality disorders is characterized by a pervasive pattern of unwarranted distrust and suspicion of others that involves interpreting their motives as malicious. Diagnosis is by... read more . In such people, a pervasive distrust and suspiciousness of others and their motives begin in early adulthood and extend throughout life.
Early symptoms may include the feeling of being exploited, preoccupation with the loyalty or trustworthiness of friends, a tendency to read threatening meanings into benign remarks or events, persistent bearing of grudges, and a readiness to respond to perceived slights.
Several subtypes of delusional disorder are recognized:
Erotomanic: Patients believe that another person is in love with them. Efforts to contact the object of the delusion through telephone calls, letters, surveillance, or stalking are common. People with this subtype may have conflicts with the law related to this behavior.
Grandiose: Patients believe they have a great talent or have made an important discovery.
Jealous: Patients believe that their spouse or lover is unfaithful. This belief is based on incorrect inferences supported by dubious evidence. They may resort to physical assault.
Persecutory: Patients believe that they are being plotted against, spied on, maligned, or harassed. They may repeatedly attempt to obtain justice through appeals to courts and other government agencies and may resort to violence in retaliation for the imagined persecution.
Somatic: The delusion relates to a bodily function; eg, patients believe they have a physical deformity, odor, or parasite.
Patients' behavior is not obviously bizarre or odd, and apart from the possible consequences of their delusions (eg, social isolation or stigmatization, marital or work difficulties), patients' functioning is not markedly impaired.
Diagnosis of Delusional Disorder
Clinical evaluation
Diagnosis depends largely on making a clinical assessment, obtaining a thorough history, and ruling out other specific conditions associated with delusions (eg, substance use Overview of Substance Use Substance-related disorders involve substances that directly activate the brain's reward system. The activation of the reward system typically causes feelings of pleasure; the specific characteristics... read more , Alzheimer disease Alzheimer Disease Alzheimer disease causes progressive cognitive deterioration and is characterized by beta-amyloid deposits and neurofibrillary tangles in the cerebral cortex and subcortical gray matter. Diagnosis... read more , epilepsy Seizure Disorders A seizure is an abnormal, unregulated electrical discharge that occurs within the brain’s cortical gray matter and transiently interrupts normal brain function. A seizure typically causes altered... read more , obsessive-compulsive disorder Obsessive-Compulsive Disorder (OCD) Obsessive-compulsive disorder (OCD) is characterized by recurrent, persistent, unwanted, and intrusive thoughts, urges, or images (obsessions) and/or by repetitive behaviors or repetitive mental... read more , delirium Delirium Delirium is an acute, transient, usually reversible, fluctuating disturbance in attention, cognition, and consciousness level. Causes include almost any disorder or drug. Diagnosis is clinical... read more , other schizophrenia spectrum disorders Other Schizophrenia Spectrum and Psychotic Disorders Some significant episodes of psychotic symptoms do not fulfill criteria for other diagnoses in the schizophrenia spectrum. Psychosis refers to symptoms such as delusions, hallucinations, disorganized... read more ).
Assessment of potential dangerousness, especially the extent to which patients are willing to act on their delusion, is very important.
Prognosis for Delusional Disorder
Delusional disorder does not usually lead to severe impairment or change in personality, but delusional concerns may gradually progress. Most patients can remain employed as long as their work does not involve things related to their delusions.
Treatment of Delusional Disorder
Establishment of an effective physician-patient relationship
Management of complications
Sometimes antipsychotics
Treatment aims to establish an effective physician-patient relationship and to manage complications. Substantial lack of insight is a challenge to treatment.
If patients are assessed to be dangerous, hospitalization may be required.
Insufficient data are available to support the use of any particular drug, although antipsychotics sometimes suppress symptoms.
A long-term treatment goal of shifting the patient’s major area of concern away from the delusional locus to a more constructive and gratifying area is difficult but reasonable.
