Delusional Disorder DSM-5 297.

1 (F22)
DSM-5 Category: Schizophrenia Spectrum and Other
Psychotic Disorders
Introduction
Delusional disorder is one of the less common psychotic disorders, in which patients
have delusions but not the other classical symptoms of schizophrenia (thought
disorder, hallucinations, mood disturbance or flat affect). There have been some
changes in diagnostic criteria for this condition in the new edition of the Diagnostic
and Statistical Manual of Mental Disorders, intended to improve the reliability and
stability of the diagnosis and facilitate consistent treatment (American Psychiatric
Association, 2013).
A delusion is a belief that is held with strong conviction despite evidence disproving it
that is stronger than any evidence supporting it. It is distinct from an erroneous belief
caused by incomplete information (misconception or misunderstanding), deficient
memory (confabulation) or incorrect perception (illusion). The psychiatrist and
philosopher Karl Jaspers proposed 3 criteria for delusional beliefs in 1913: certainty
(the belief is held with absolute conviction), incorrigibility (the belief cannot be
changed with any proof to the contrary) and impossibility or falsity (the belief cannot
be true)

(Jaspers, 1967). Delusions are associated with a variety of mental and
neurological disorders, but are of diagnostic importance in the psychotic disorders.
Symptoms of Delusional Disorder
Delusions are generally categorized in 4 groups: bizarre, non-bizarre, mood-
congruent and mood-neutral. Bizarre delusions are strange and implausible, such as
being vivisected by aliens, while non-bizarre delusions are possible but unlikely, such
as being under surveillance. Mood-congruent delusions are false beliefs that are
consistent with the patients mood if disordered, such as power and influence with
mania and rejection and ostracism with depression. Mood-neutral delusions are not
related to the patients mood, such as having two heads or one arm.
Delusions have a great variety of themes, but certain recurrent themes have been
identified

(Spitzer, 1990). These include delusions of control, mind-reading, thought
insertion, reference, persecution, grandeur, self-accusation, jealousy (Othello
syndrome), romance or sexual involvement (erotomania), somatic change or disease
or death (Cotard syndrome). Somatic delusions are associated with mood disorders
and organic dementias, and may constitute their own diagnostic entity (body
dysmorphic disorder)

(Spitzer, 1990), while grandiose or persecutory delusions are
often cardinal symptoms of schizophrenia and related disorders(Freeman, 2004).
Munro identified 10 characteristics of delusions (Munro, 1999). The patient expresses
the delusional belief(s) with unusual force and persistence, and the belief or beliefs
exert and inordinate effect on the patients life, often altering or dominating it. Despite
profound conviction about the delusion, the patient is often secretive or suspicious in
discussing it. Delusional patients tend to be oversensitive and humorless, especially
regarding the delusion. The belief is central to the patients existence, and
questioning it elicits an inappropriately strong emotional reaction. The belief is
nevertheless unlikely, and not in keeping with the patients social, cultural or religious
background. The patient is highly invested emotionally in the belief, and other
elements of the psyche may be overwhelmed. If the belief is acted upon, abnormal
behavior may result which is out of character for the patient, but which may be
understandable in light of the delusion; the belief and behavior are felt to be
uncharacteristic by those who know the patient.
Delusional disorder is a primary disorder, with no medical or neurologic cause
apparent. It is chronic and may be lifelong, but the delusions are internally consistent
and logically constructed. Although the logic of the delusion may be abnormal,
general logical reasoning is unaffected, and there is no general disturbance of
behavior. Abnormal behavior, if it occurs, is specifically related to the delusional
belief. The patient has a heightened sense of self-reference, and trivial or nonspecific
events assume great importance through connection to the delusional belief

(Munro,
1999).
The causes of delusional thinking are unknown. Morimoto et al.

compared patients
with delusional disorder to schizophrenics and age-matched normal controls (2002).
Patients with delusional disorder had greater sensitivity to small doses of the
dopamine-blocking neuroleptic haloperidol than did schizophrenic patients. Plasma
levels of the dopamine metabolite homovanillic acid (HVA) were higher in patients
with delusions of persecution than in controls, but not in patients with delusional
jealousy, and elevated HVA levels decreased with haloperidol treatment. Certain
polymorphisms or gene variants associated with the DR2 and DR3 dopamine
receptors and the enzyme tyrosine hydroxylase involved in dopamine synthesis were
significantly more common in delusional disorder than in schizophrenia or normal
controls. These findings suggest that delusional symptoms arise from dopaminergic
hyperactivity and may have a genetic basis.
Delusional disorder is more common among people with impaired hearing or vision,
and with chronic situational stressors

(Maina et al., 2001). These may lead to
inaccurate perceptions of reality and inappropriate defensive reliance upon them.
Devinsky et al.

found a significant association between bilateral frontal lobe and right
cerebral hemisphere lesions and delusions (2009). They suggested that right
hemisphere injury can result in unbalanced left hemisphere overactivity, allowing left
hemisphere language centers to create a story that cannot be compared to reality
by malfunctioning right hemisphere centers. Impaired right-hemisphere monitoring of
the relations between self and environment can also allow an exaggerated self-
referential character to be imparted to thoughts and beliefs, and impairment of frontal
lobe self-monitoring and correction can result in delusional resistance to
counterargument and refutation.
Epidemiology
Delusional disorder is infrequent in psychiatric practice, possibly because many
patients are able to function tolerably well despite their delusions, and perhaps also
because those who believe implicitly in their delusions may not feel the need for
treatment and may resist the suggestions of others that they seek psychiatric
attention. Prevalence is estimated at 24 to 30 cases per 100,000 people, and new
cases each year number 0.7 to 3.0 per 100,000. One to 2 per cent of mental health
hospitalizations and only 0.001 to 0.003 per cent of first-time psychiatric admissions
are due to delusional disorder (Kendler, 1982).
Diagnostic Criteria
Diagnosis of delusional disorder requires the presence of delusions of at least 1
months duration. The patient must never have met Criterion A for schizophrenia,
which means that delusions must not have been accompanied by most types of
hallucinations, disorganized speech (incoherence or derailments into tangents),
grossly disorganized or catatonic behavior, or negative symptoms (flattening of affect,
muteness, loss of volition). Tactile and olfactory hallucinations may be part of
nonschizophrenic delusions, but not auditory or visual ones. Functioning must not be
affected except for the immediate consequences of the delusions, such as hiding
from imagined pursuers or preparing to confront the supposed lover of ones wife.
Episodes of mood disturbance if present must be much briefer in duration than the
delusions: a patient who is despondent all the time because he is sometimes sure
that he has cancer is more likely to be depressed than delusional. The delusion(s)
must not be due to a general medical condition or to the effects of drug abuse or
medication.
Delusions are further classified by type, based on the predominant thene of the
delusion. Erotomanic delusions involve the belief that another person, often of higher
status, is in love with the patient. Grandiose delusions are those of power, wealth,
importance, relationships to famous people, a special relationship to God or even
being a deity. The jealous type are delusions that ones spouse or partner is
unfaithful. Persecutory delusions involve conspiracy against or mistreatment of the
patient. Somatic delusions are those of illness or deformity. Mixed delusions have
more than one theme.
DSM-5 changes the diagnostic criteria for delusional disorder to reflect revision of the
diagnostic criteria for schizophrenia. In previous editions of the manual, delusions
had to be non-bizarre, i.e., having erroneous beliefs related to real life (being
followed or poisoned or persecuted) rather than, for example, the iconic delusion of
being Napoleon Bonaparte. Bizarre delusions, such as detachment or liquefaction of
body parts, can now be identified as manifestations of delusional disorder if they
cannot be better explained by conditions such as body dysmorphic disorder or
obsessive compulsive disorder. In addition, DSM-5 removes the distinction between
delusional disorder and shared delusional disorder, in which two or more individuals
share a delusional belief, historically referred to as folie deux. It was previously
difficult to diagnose delusional beliefs in more than one person if the belief in
question might ordinarily be widely shared in the patients culture, such as demonic
possession at certain times in history or the existence of elves in certain countries.
The revised criteria simply propose that if two patients strongly espouse an
erroneous belief and have the other symptoms described above, then both patients
have delusional disorder.
Treatment of Delusional Disorder
Patients with delusional disorder may be difficult to treat, in part because of the
centrality of the delusions in their lives and in part because the delusions may not be
very disruptive in the absence of other positive or negative psychotic symptoms. The
often-formidable internal logic of the delusional system, even if wrong, may also
militate against treatment adherence. Put another way, if you believed unhesitatingly
that you were President of the United States, or that you were being poisoned, or that
your wife had put you in treatment so she could run off with the postman, would you
take your medication? A nonconfrontational culturally-sensitive approach to agreed-
upon therapeutic goals, that includes the family when possible, is recommended,
outpatient in nature except when violence or harm are concerns and aimed at
maintaining social function and improving quality of life

(Fochtmann, 2005).
Studies of medication treatment are mostly in classes C (series of cases) and D
(single case studies) of the evidence-based medicine hierarchy, with little or no class
A (randomized controlled trial) or B (systematic but nonblinded or nonrandomized
trials) evidence. Studies between 1966 and 1985 involved about 1000 delusional
disorder patients, of whom 257 were well-described, and found recovery with
antipsychotic drug treatment in 52.6 per cent and improvement in 28.2 per cent, while
19.2 per cent did not improve. Pimozide (68.5 per cent recovery and 22.4 per cent
improvement) was better than other typical neuroleptics (22.6 per cent recovery and
45.3 per cent improvement)

(Munro, 1995). Studies since 1985 used primarily
atypical neuroleptics, such as respiridone (Risperdal), quetiapine (Seroquel) and
olanazapine (Zyprexa), in a small number of patients (224 reported, 134 well
described). Ninety per cent of patients had symptom improvement while 50 per cent
were symptom-free, often after polypharmacy or with other treatment modalities used
as well. No differences in response were found between pimozide and other typical
neuroleptics, or between typical and atypical antipsychotic agents, but patients with
persecutory delusions did worse (50 per cent improvement and no complete
recovery)

(Freudenmann & Lepping, 2008). Antidepressants, particularly SSRI agents
and clomipramine, have been occasionally helpful, mainly with somatic delusions
(Hayashi et al., 2004).
Supportive psychotherapy is helpful for most patients, chiefly cognitive treatment that
uses Socratic questioning to identify maladaptive thoughts and replace them with
more adaptive beliefs, but is careful not to address the unrealistic nature of the
delusions too early in the treatment process

(Silva et al., 2003). Cognitive behavioral
therapy (CBT) and attention placebo control (APC) have been compared in their
effect on the Maudsley Assessment of Delusions Schedule (MADS), and both
produced improvement, but CBT was more effective in lessening strength of
delusional conviction, decreasing affect related to delusional beliefs and diminishing
action on the beliefs

(OConnor, Stip & Pelissier, 2007). Training patients in
behavioral principles and social skills so that they feel more in control of their
situations and are better able to interact with those they think are judging or harming
them has been shown to dissipate feelings of powerlessness that reinforce
delusions

(Liberman, 2008). Some feel that insight-oriented psychotherapy is
ineffective or even contraindicated in delusional disorders, but case reports have
suggested that patients may sometimes be helped to contain feelings of impotence,
badness and hatred, to question their internal view of the world and to accept an
alliance with therapists

(Liberman, 2008).
Author: Miles E. Drake, Jr., M.D
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of
Mental Disorders, ed. 5. Washington, DC: APA Press.
Devinsky, O. (2009). Delusional misidentifications and duplications: Right brain
lesions, left brain delusions. Neurology, 72(1), 80-87.
Fochtmann, L.J. (2005). Treatment of other psychotic disorder. In Sadock, B.A.,
Kaplan, V.A., Ruiz, P. (Eds). Kaplan and Sadocks Comprehensive Textbook of
Psychiatry, ed. 8. Philadelphia: Lippincott Williams and Wilkins, 1545-1550.
Freeman, D., & Garrity, P.A. (2014). Paranoia: The Psychology of Persecutory
Delusions. Hove: Psychology Press.
Freudenmann, R.W., Lepping, P. (2008). Second-generation antipsychotics in
primary and secondary delusional parasitosis: outcome and efficacy. J Clin
Psychopharmacol, 28(5), 500-508.
Hayashi, H. et al. (2004). Paroxetine treatment of delusional disorder, somatic type.
Hum Psychopharmacol, 19(5), 351-352.
Jaspers, K. (1967). General Psychopathology. Baltimore: Johns Hopkins University
Press, 106.
Kendler, K.S. (1982). Demography of paranoid psychosis (delusional disorder): A
review and comparison with schizophrenia and affective illness. Arch Gen Psychiat,
39(8), 890-902.
Liberman, R.P. (2008). Recovery from Disability: Manual of Psychiatric
Rehabilitation. Arlington, VA: Amer Psychiatric Publishing.
Maina, G., Albert, U., Bad, A., & Bogetto, F. (2001). Occcurrence and clinical
correlates of psychiatric co-morbidity in delusional disorder. Eur Psychiat, 16(4), 222-
228.
Morimoto, K., et al. (2002). Delusional disorder: molecular genetic evidence for
dopamine psychosis. Neuropsychopharmacology, 26(6), 794-801.
Munro, A. (1999). Delusional Disorder: Paranoia and Related Illnesses. Cambridge,
U.K.: Cambridge University Press.
Munro, A., & Mok, H. (1995). An overview of treatment in paranoia/delusional
disorder. Can J Psychiatry, 40(10), 616-622.
OConnor, K. et al. (2007). Treating delusional disorder: a comparison of cognitive-
behavioural therapy and attention placebo control. Can J Psychiatry, 52(3), 182-190.
Silva, S.P., Kim, C,K., Hoffman, S.G., Loula, E.C. (2003). To believe or not to believe:
Cognitive and psychodynamic approaches to delusional disorder. Harv Rev
Psychiatry, 11(1), 20-29.
Spitzer, M. (1990). On defining delusions. Compr Psychiat, 31(5), 377-397.

Delusional Disorder Symptoms
By PSYCH CENTRAL STAFF

Delusional disorder is characterized by the presence of eitherbizarre or non-
bizarre delusions which have persisted for atleast one month. Non-bizarre
delusions typically are beliefs of something occurring in a persons life which is not
out of the realm of possibility. For example, the person may believe their significant
other is cheating on them, that someone close to them is about to die, a friend is
really a government agent, etc. All of these situations could be true or possible, but
the person suffering from this disorder knows them not to be (e.g., through fact-
checking, third-person confirmation, etc.). Delusions are deemed bizarre if they are
clearly implausible, not understandable, and not derived from ordinary life
experiences (e.g., an individuals belief that a stranger has removed his or her
internal organs and replaced them with someone elses organs without leaving any
wounds or scars). Delusions that express a loss of control over mind or body are
generally considered to be bizarre and reflect a lower degree of insight and a
stronger conviction to hold such belief compared to when they are non-bizarre.
Accordingly, if an individual has bizarre delusions, a clinician will specify with bizarre
content when documenting the delusional disorder.
People who have this disorder generally dont experience a marked impairment in
their daily functioning in a social, occupational or other important setting. Outward
behavior is not noticeably bizarre or objectively characterized as out-of-the-ordinary.
The delusions can not be better accounted for by another disorder, such as
schizophrenia, which is also characterized by delusions (which are bizarre). The
delusions also cannot be better accounted for by a mood disorder, if the mood
disturbances have been relatively brief. The lifetime prevalence of delusional disorder
has been estimated at around 0.2% .
Specific Diagnostic Criteria
1. Delusions lasting for at least 1 months duration.
2. Criterion A for Schizophrenia has never been met. Note:Tactile and olfactory
hallucinations may be present in Delusional Disorder if they are related to the
delusional theme.Criterion A of Schizophrenia requires two (or more) of the
following, each present for a significant portion of time during a 1-month
period (or less if successfully treated):
1. delusions
2. hallucinations
3. disorganized speech (e.g., frequent derailment or incoherence)
4. grossly disorganized or catatonic behavior
5. negative symptoms, i.e., affective flattening, alogia, or avolition
6.
Note: Criteria A of Schizophrenia requires only one symptom if delusions are
bizarre or hallucinations consist of a voice keeping up a running commentary
on the persons behavior or thoughts, or two or more voices conversing with
each other.
3. Apart from the impact of the delusion(s) or its ramifications, functioning is
not markedly impaired and behavior is not obviously odd or bizarre.
4. If mood episodes have occurred concurrently with delusions, their total
duration has been brief relative to the duration of the delusional periods.
5. The disturbance is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition.
Specify type (the following types are assigned based on the
predominant delusional theme):
Erotomanic Type: delusions that another person, usually of higher status, is
in love with the individual
Grandiose Type: delusions of inflated worth, power, knowledge, identity, or
special relationship to a deity or famous person
Jealous Type: delusions that the individuals sexual partner is unfaithful
Persecutory Type: delusions that the person (or someone to whom the
person is close) is being malevolently treated in some way
Somatic Type: delusions that the person has some physical defect or general
medical condition
Mixed Type: delusions characteristic of more than one of the above types but
no one theme predominates
Unspecified Type
Treatment for Delusional Disorder

This entry has been updated for 2013 DSM-5 criteria; diagnostic code: 297.1.
Delusional Disorder Treatment
By Psych Central Staff
Table of Contents
Psychotherapy
Medications
Self-Help

Psychotherapy
Psychotherapy is usually the most effective help in person suffering from delusional
disorder. The overriding important factor in this therapy is the quality of the
patient/therapist relationship. Trust is a key issue, as is unconditional support. If the
client believes that the therapist really does think he or she is "crazy," the therapy
can terminate abruptly. Early in the therapy, it is vital not to directly challenge the
delusion system or beliefs and instead to concentrate on realistic and concrete
problems and goals within the person's life.
Once a firm, supportive therapeutic relationship has been established, the therapist
can begin reinforcing positive gains and behaviors the individual makes in his or her
life, such as in educational or occupational gains. It is important to reinforce these
life events (such as getting a job), because it reinforces in the patient a sense of
self-confidence and self-reliance.
Only when the client has begun to feel more secure in their social or occupational
world can more productive work be accomplished in therapy. This involves the
gradual but gentle challenging of the client's delusional beliefs, starting with the
smallest and least-important items. Occasionally making these types of gentle
challenges throughout therapy will give the clinician a greater understanding of how
far along the individual has come. If the patient refuses to give up his or her delusion
beliefs, even the smallest ones, then therapy is likely to be very long-term. Even if
the client is willing, therapy is likely to take a fair amount of time, from at least 6
months to a year.
Clinicians should always be very direct and honest, especially with people who suffer
from delusion disorder. Professionals should be even more careful than usual not to
impinge on the client's privacy or confidentiality, and to say plainly what they mean
in therapy sessions. Subtlety and sarcasm may be easily misinterpreted by the
patient. Therapy approaches which focus on insight or self-knowledge may not be as
beneficial as those stressing social skills training and other behaviorally and solution-
oriented therapies.

Medications
Suggesting the use of medication for use in this disorder, while possibly indicated to
help temporarily relieve the delusions, is usually difficult. The client may be
suspicious of any professional suggesting the use of a medication and therefore this
treatment approach (and successful maintenance of the individual on the
medication) is problematic.
Anti-psychotic medication is the preferred medication used, though, although it is
only marginally effective. There are few studies done which confirm the use of any
specific medications for this disorder.
Hospitalization should be avoided at all costs, since this will usually go to reinforce
the individual's distorted cognitive schema. Partial hospitalization and/or day
treatment programs are preferred to help manage the individual under close
supervision on a daily basis.
Phillip W. Long, M.D. writes that "other treatments have been tried
(electroconvulsive therapy, insulin shock therapy, and psychosurgery), but these
approaches are not recommended."

Self-Help
There are not any self-help support groups or communities that we are aware of that
would be conducive to someone suffering from this disorder. Such approaches would
likely not be very effective because a person with this disorder is likely to be
mistrustful and suspicious of others and their motivations, making group help and
dynamics unlikely and possibly harmful.