Delusional Disorder: Causes, Symptoms, Diagnosis, Treatment

Delusional disorder is characterized by delusions (false beliefs) close to everyday life, which last at least 1 month, while there are no other symptoms of schizophrenia.

In the literature on the relationship of mental disorders and crimes, especially with the use of violence, delusional disorders are often considered together with schizophrenia and, consequently, results related to schizophrenia can be applied to delusional disorders. Of particular value are the above results relating to delusional disorders.

Delusional disorder differs from schizophrenia in that nonsense predominates in the absence of other symptoms of schizophrenia. Delusional ideas look outwardly realistic and affect situations that may occur, such as harassment, poisoning, infection, love at a distance or deceit by a spouse or loved one.

Unlike schizophrenia, delusional disorder is relatively rare. The onset is usually observed in middle or late age. Psychosocial functioning is usually not disrupted, as in schizophrenia, violations are usually associated directly with the delusions of delirium.

When a delusional disorder is observed in elderly patients, it is sometimes called paraphrenia. It can co-exist with moderate dementia. The physician should be attentive when examining elderly patients with moderate dementia to distinguish between delusions and reliable information about ill-treatment by others in relation to the elderly person.

Instruction for the diagnosis of delusional disorder is given in ICD-10. In it, the term "delusional disorder" replaced the formerly used term "paranoid disorder". These disorders include persecutory subtypes, severe paranoia, and what Mullen calls disorders related to passion (erotomania and pathological jealousy). Individuals suffering from these disorders are treated infrequently for psychiatric help, but they are brought to the attention of the judicial services in cases where the commission of a crime entails a court decision on forensic psychiatric examination in conditions of isolation from society. Beliefs denoted as "delusions" exist in a continuum with normal emotions and beliefs. This is especially true of morbid jealousy, in which overvalued ideas are imperceptibly organically intertwined with delirium. Delusional disorders can act as primary disorders, but may also be a symptom complex in another disorder, for example schizophrenia.

[1], [2], [3], [4], [5], [6], [7]

Symptoms of delusional disorder

Delusional disorder can develop in the context of an existing paranoid personality disorder. In such people, constant distrust and suspicion of others and their motivations begin in early adulthood and persist throughout life. Early symptoms may include a feeling that the patient is exploited, a concern for the loyalty and creditworthiness of friends, a tendency to see threatening meanings in minor statements or events, constant discontent and a willingness to respond to neglect.

There are several types of delusional disorder. In the erotomanic version, the patient believes that another person is in love with him. There are often attempts to contact delusional objects through phone calls, letters, surveillance or harassment. People with this version of the disorder may have conflicts with the law because of their behavior. In the variant with ideas of greatness, the patient believes that he is talented or that he made an important discovery. In the variant with ideas of jealousy, the patient thinks that the spouse or loved one is cheating on him. These ideas are based on incorrect reasoning, based on questionable evidence. A significant danger can be a threat of physical attack. In the variant with persecution ideas, the patient believes that surveillance is organized against him, he is harmed and plagued. The patient can make repeated attempts to achieve justice by appealing to the court and other government structures, as well as resorting to violence as retribution for the alleged persecution. In the somatic version, delusional ideas are associated with bodily functioning, i. E. The patient believes that he has a physical defect, parasites or from it emits a smell.

The diagnosis largely depends on the conduct of clinical evaluation, obtaining detailed anamnestic information and excluding other specific conditions accompanied by delirium. It is extremely important to assess the danger, especially the extent to which the patient is willing to act in accordance with his delusional ideas.

Delusional disorder associated with passion: pathological jealousy and erotomania

This group of disorders is comprehensively examined by Mullen. The core of persuasion in case of morbid jealousy is formed by the submission of the subject about infidelity to him / her. This idea dominates thinking and acting and reaches a pathological level. Jealousy - a normal phenomenon, and its adoption in society is partly due to the entocultural characteristics of the population. Mullen assumes that there is a continuum from the degree of profound conviction in normal persons - to supervalued ideas and further - to delusional ideas, characteristic both for morbid jealousy and for erotomania. In studies of women victims of domestic violence, it has been established that the jealous partner is an important cause of violence. Usually, it is partners who suffer from attacks, while imaginary rivals are rarely victims. According to modern ideas, in addition to physical assault, partners of persons suffering from pathological jealousy may experience severe psychological distress, including post-traumatic stress disorder.

Erotomania is characterized by a painful conviction of falling in love with another person. Mullen offers three main criteria:

• The belief that love is mutual, in spite of the fact that the alleged "lover" does not show it in any way.
• Propensity to reinterpret words and actions of the object of attention in order to maintain the existing belief.
• Load of supposed love, which becomes the center of existence of the subject.

And the subject does not need to consider that his love is mutual (painful love for insanity). Like morbid jealousy, erotomania can act as part of another disorder, usually schizophrenia and mood disorders. The difference between subjects suffering from schizophrenia from cases of "pure" erotomania is that the object of their love or passion can change over time, as well as the presence of a more pronounced sexual element. Objects of attention erotomanov usually from their immediate surroundings, although the media like to talk about cases with famous persons, movie stars, etc. There is a great chance of becoming a victim of erotomania among doctors, including psychiatrists, who are engaged in helping vulnerable people.

According to Mullen, erotomanic disorders are almost inevitably accompanied by stalking, that is, persecution. Stalking involves a determined attempt to enter into contact or to engage in communication with the object of attention of the stalker. If the attempt of contact fails or encounters resistance, then threats, insults, intimidation - either by direct contact or by means of communication (by mail, by phone, etc.) follow. Menzies et al. Reports of frank sexual intimidation or attacks in a group of male erotomaniacs studied. Both Mullen & Pathe and Menzies et al. Note the high levels of threats and attacks among the stalkers they studied, although both populations were judicial, that is, with a preponderance of the actual risk of attack. Victims of stalking can suffer hard from repeated and unpredictable interventions in their lives by stalkers. Many of them limit their social life, change their place of work, and in extreme cases even go to another country to get rid of intrusive attention.

[8], [9], [10], [11], [12], [13]

Prognosis and treatment of delusional disorder

Delusional disorder usually does not lead to a pronounced disorder or change in personality, but delusional symptoms can gradually progress. Most patients can remain able-bodied.

The goals of treatment of benign disorders are to establish an effective relationship between the doctor and the patient and to eliminate the consequences associated with the disease. If the patient is regarded as dangerous, hospitalization may be required. Currently, there is insufficient data for the use of any particular drug, but the administration of antipsychotics leads to a reduction in symptoms. The long-term goal of treatment, consisting in moving the patient's sphere of interests from the field of delusional ideas to a more constructive area, is difficult to achieve, but justified.

Medico-legal aspects of delusional disorder

Remarks related to the medical and legal aspects of schizophrenia are equally applicable to patients with delusional disorders. As for the group of patients with delusional disorder, which manifests with morbid jealousy or erotomania, then there are some features.

Where the cause of jealousy is delusional disorder, the basis for recommendations for psychiatric treatment or protection in cases of murder on the basis of reduced liability may be the underlying mental illness. Where jealousy is not delusional, but has a neurotic nature, the medical and legal aspects are not so clear. So, there can be a personality disorder falling into the category of "psychopathic disorder". Possible the presence of other disorders that can be classified as a mental illness. However, excessive jealousy, in the absence of the underlying disease, can not be used for protection on medical grounds.

When delirious jealousy should be very carefully approach the regime of the safety of psychiatric treatment. The persistent nature of this disorder and its potential danger are well known. It is necessary to carefully examine the patient for his willingness to cooperate with the therapist, as well as assess the risks of escape and committing a violent crime. If it is known that the subject does not cooperate, that he used violence against his wife and ran away, then he should initially be treated in a service with an enhanced security regime. Treatment may not be easy. The greatest chances for improvement are given by medicinal (antipsychotics or antidepressants) and cognitive therapy.

At present, attention is being paid to the medical and legal aspects of stalking. In these cases, psychiatrists can be brought to the courtroom to testify about the harm done to the victim of stalking - just as a general practitioner is involved in describing the harm done to a person who suffered from a physical attack. This gives grounds for accusations of causing "serious bodily harm" (English Grevious Bodily Harm, GBH) of a psychological nature. The psychiatrist can also be involved in working with the offender. As in the situation with morbid jealousy, the treatment of painful love or passion is a difficult matter, and the results of such treatment are unpredictable. Taking into account the stability of these disorders and the tenacity with which the subjects hold onto their beliefs, the only possibility of some protection against stalkers can only be their treatment and support by the mental health system. It is likely that in the future, the participation of psychiatric and, especially, forensic psychiatric services in developing recommendations for courts and possible treatment of stalkers will be increasingly demanded.