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Recent Developments in the Management of Delusional Disorders Christopher F

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Recent Developments in the Management of Delusional Disorders Christopher F Advances in psychiatric treatment (2013), vol. 19, 212–220 doi: 10.1192/apt.bp.111.010082 ARTICLE Recent developments in the management of delusional disorders Christopher F. Fear Chris Fear is a ‘jobbing’ general condition and most people with it manage to avoid SUMMARY psychiatrist. His MD researched coming to the attention of services. Although this cognitive processes in delusional Delusional disorder, rare in clinical practice, suggests a degree of insight or mindfulness, those and obsessive disorders and he remains one of the most enigmatic conditions who do present have often come into conflict studied cognitive therapy with in psychiatry. Linked to schizophrenia spectrum delusional disorders. He has with those around them on the basis of their disorders since the mid-20th century, recent retained an obsession for these work has confirmed 19th-century notions of an incorrigible beliefs. The rarity of such patients areas for nearly two decades. in clinic practice is often compensated for by the He is also interested in psycho­ aetiology based on attentional biases and per- pharmacology, transcultural sonality dimensions. Unfortunately, the literature strangeness of their circumstances, making them psychiatry, electroconvulsive therapy exists largely as case reports and series, often common as subjects for case presentations and and palaeozoic fossil fishes. published as ‘curiosities’, and therefore lacks the curiosities in journals. Correspondence Dr Christopher rigour of formal diagnosis. This article reviews Delusional disorders are difficult and unreward- Fear, Consultant Psychiatrist and Associate Medical Director, 2gether current thinking on aetiology and epidemiology, ing to study. Individuals are reluctant to cooperate NHS Foundation Trust, Albion considers diagnosis, and reviews recent work on with treatment, often fail to take medication and Chambers, 111 Eastgate Street, physical and psychological therapies. It concludes can be frustratingly garrulous during therapy Gloucester GL1 1PY, UK. Email: chris. that delusional disorder is likely to respond well to sessions. They offer endless evidence to support [email protected] treatment with standard antipsychotics, often at their beliefs while creating ever more elaborate low doses, but that adherence and concordance remain particular problems. Cognitive therapy ways of refuting evidence against them through has been shown to be beneficial but is time- appeals to coincidence, misunderstanding or consuming and resource-intensive. Selective alternative interpretations of the ‘facts’. As a result, serotonin reuptake inhibitors may profit further and despite limited research evidence, individuals investigation. There remains considerable scope with the disorder have continued to be classified for investigation of this fascinating condition. on the basis of delusional content, derived from DECLARATION OF INTEREST the many early eponymous ‘syndromes’ (see Enoch 1991), and are placed within schizophrenia None. spectrum disorders. Both DSM-IV and ICD-10 (World Health Organization 1992) agree on the essential charac- Delusional phenomena, so clearly described in teristics of delusional disorder: the presence of psychiatric textbooks, are rarely unambiguous persistent delusions, independent of any transient in practice. The textbook characteristics of in- mood disorder and not fitting criteria for schizo- corrigibility, demonstrable falseness and cultural phrenia. There are, however, notable differences incongruity are rarely clear-cut in real life, and between ICD and DSM criteria: DSM requires 1 normal beliefs pass into a continuum of delusion- month of stable delusions, whereas ICD requires 3 like experiences, overvalued ideas, preoccupa- months; ICD will allow transitory hallucinations tions, obsessions, partial delusions and delusions in any modality (including auditory but not ‘third proper, which can exist at varying levels of convic- person’ or ‘running commentary’), whereas DSM tion and bizarreness. Nowhere is this complexity will allow only tactile and olfactory hallucinations. more apparent than in the diagnostic category of In the proposals for DSM-5 these are unchanged, delusional disorders, resurrected from Kraepelin’s although the confusing subjectivity in deciding ‘paranoia’ in DSM-III-R and continuing largely whether the behaviour is ‘non-bizarre’ has been unchanged into DSM-IV (American Psychiatric removed. The only significant change proposed in Association 1987, 1994) and, reportedly, DSM-5 DSM-5 is to distance delusional disorders further (www.dsm5.org). from a promising line of evidence that may link them to obsessive spectrum disorders such as body Boundaries of a syndrome dysmorphic disorder by specifying that delusional Many psychiatrists will rarely encounter a patient disorder cannot be diagnosed if ‘the disturbance with true delusional disorder. It is a secretive is not better accounted for by another mental 212 Recent developments in the management of delusional disorders disorder such as body dysmorphic disorder or delusion-like experience occurred in approximately obsessive compulsive disorder’ (DSM-5 Task 8% of their study population (n = 8841) and was Force 2011). more common in individuals who were under In fact, unlike the other disorders in the schizo­­ situations of ‘non-specific psychological stress phrenia spectrum, delusional disorders are not [but] otherwise well’ (Saha 2011). It has since associated with symptoms of thought alien ation, been found that there is an association between passivity and negativity. Patients with these symp- post-traumatic stress disorder (PTSD), trauma toms cannot, by definition, be diagnosed with and delusion-like experience (Scott 2007), with delusional disorder. The limited work on the diag- a positive correlation between traumatisation nostic relationships of delusional disorder include and intensity of delusional ideation. Negative a study of monozygotic/dizygotic concordance cognitions of self were associated with level of rates for schizophrenia spectrum disorders, which delusional ideation, preoccupation and distress, found that delusional disorder is unlikely to be whereas negative cognitions about the world related to them (Farmer 1987). This is supported were associated with paranoia (Calvert 2008). by more recent genetic research evidence, which These findings would support a model of delusion- suggests that delusional disorder has no relation like experiences arising from a ‘pathology of to the dopamine D1 receptor gene (Debnath attention’ in which individuals are sensitised into 2010). There is a school of thought that considers a particular belief system by a real experience, delusional disorder to relate more naturally to a subsequently attending selectively to perceptions currently disparate group of disorders that contain and experiences that support those beliefs through both obsessional and delusional components a mechanism that might have parallels in the re- (Fear 2000; O’Dwyer 2000; see also Hollander experiencing cues of patients with PTSD. This (1993) and Hollander et al (2011) for detailed is supported by findings of the centrality of self commentary). within the discourse of individuals with delusional disorder (Noel-Jorand 2004) and the feature of Constitutional vulnerabilities self-reference found in 40% of a sample of 370 Kraepelin distinguished between dementia people with the disorder (De Portugal 2008). praecox (later renamed schizophrenia) and It seems likely that delusional disorder, in its paranoia (later called delusional disorder) on pure form, is a condition based on constitutional the basis that the former comprised incoherent vulnerabilities that are part of an intact delusions in a disintegrating personality, whereas personality. Under variable levels of psychological in the latter the personality was intact and stress, vulnerable individuals develop delusion-like the delusions coherent. Jaspers (1923/1946) responses which offer scenarios that allow them subsequently made a distinction between the true to manage the stress. The core cognitive bias is a delusions of schizophrenia, ‘which go back to pathology of attention in which a preoccupation primary pathological experiences as their source, with an idea is supported by cues, codes, checking and which demand for their explanation a change and situational expression. Sadly, the lack of in the personality’ (p. 106), and the term delusion- rigour in DSM’s approach to delusional disorder like experiences which is ‘reserved by us for those has allowed a large variety of case reports claiming so-called “delusions” that emerge comprehensibly to describe delusional disorder where the delusions from other psychic events and can be traced back are clearly secondary to other pathology, such as psychologically to certain affects, drives, desires multiple sclerosis (Muzyk 2010), mania (Vicens and fears’ (pp. 106–107). Sérieux and Capgras 2011) and Wilson’s disease with alcoholism postulated a hypertrophy of attention in which (Spyridi 2008); it has, in turn, ignored the clear the individual focuses on particular issues to the links to obsessive spectrum disorders. The clear exclusion of others, recalling the 19th-century parallels between obsessional and delusional concepts of idées fixes (for a review, see Fear forms of jealousy, body dysmorphia, somatoform et al 1998). Kaffman (1981) investigated this with disorders and even anorexia nervosa are discussed people with delusions, finding true experiences at later in this
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