From http://www.minddisorders.

com/Br-Del/Delusional-
disorder.html
FOR NHZ (^_^)
Definition
Delusional disorder is characterized by the presence of recurrent, persistent non-bizarre
delusions.

Delusions are irrational beliefs, held with a high level of conviction, that are highly resistant to
change even when the delusional person is exposed to forms of proof that contradict the belief.
Non-bizarre delusions are considered to be plausible; that is, there is a possibility that what the
person believes to be true could actually occur a small proportion of the time. Conversely,
bizarre delusions focus on matters that would be impossible in reality. For example, a non-
bizarre delusion might be the belief that one's activities are constantly under observation by
federal law enforcement or intelligence agencies, which actually does occur for a small number
of people. By contrast, a man who believes he is pregnant with German Shepherd puppies holds
a belief that could never come to pass in reality. Also, for beliefs to be considered delusional, the
content or themes of the beliefs must be uncommon in the person's culture or religion. 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 .

Description
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. Expanding on the
previous example, people who believe they are under government observation might seem
typical in most ways but could refuse to have a telephone or use credit cards in order to make it
harder for "those Federal agents" to monitor purchases and conversations. Most mental health
professionals would concur that until the person with delusional disorder discusses the areas of
life affected by the delusions, it would be difficult to distinguish the sufferer from members of
the general public who are not psychiatrically disturbed. Another distinction of delusional
disorder compared with other psychotic disorders is that hallucinations are either absent or occur
infrequently.

The person with delusional disorder may or may not come to the attention of mental health
providers. Typically, while delusional disorder sufferers may be distressed about the delusional
"reality," they may not have the insight to see that anything is wrong with the way they are
thinking or functioning. Regarding the earlier example, those suffering delusion might state that
the only thing wrong or upsetting in their lives is that the government is spying, and if the
surveillance would cease, so would the problems. Similarly, the people suffering the disorder
attribute any obstacles or problems in functioning to the delusional reality, separating it from
their internal control. Furthermore, whether unable to get a good job or maintain a romantic
relationship, the difficulties would be blamed on "government interference" rather than on their
own failures or omissions. Unless the form of the delusions causes illegal behavior, somehow
affects an ability to work, or otherwise deal with daily activities, the delusional disorder sufferer
may adapt well enough to navigate life without coming to clinical attention. When people with
delusional disorder decide to seek mental health care, the motivation for getting treatment is
usually to decrease the negative emotions of depression, fearfulness, rage, or constant worry
caused by living under the cloud of delusional beliefs, not to change the unusual thoughts
themselves.

Forms of delusional disorder

An important aspect of delusional disorder is the identification of the form of delusion from
which a person suffers. The most common form of delusional disorder is the persecutory or
paranoid subtype, in which the patients are certain that others are striving to harm them.

In the erotomanic form of delusional disorder, the primary delusional belief is that some
important person is secretly in love with the sufferer. The erotomanic type is more common in
women than men. Erotomanic delusions may prompt stalking the love object and even violence
against the beloved or those viewed as potential romantic rivals.

The grandiose subtype of delusional disorder involves the conviction of one's importance and
uniqueness, and takes a variety of forms: believing that one has a distinguished role, has some
remarkable connections with important persons, or enjoys some extraordinary powers or
abilities.

In the somatic subtype, there is excessive concern and irrational ideas about bodily functioning,
which may include worries regarding infestation with parasites or insects, imagined physical
deformity, or a conviction that one is emitting a foul stench when there is no problematic odor.

The form of disorder most associated with violent behavior, usually between romantic partners,
is the jealous subtype of delusional disorder. Patients are firmly convinced of the infidelity of a
spouse or partner, despite contrary evidence and based on minimal data (like a messy bedspread
or more cigarettes than usual in an ashtray, for instance). Delusional jealousy sufferers may
gather scraps of conjectured "evidence," and may try to constrict their partners' activities or
confine them to home. Delusional disorder cases involving aggression and injury toward others
have been most associated with this subtype.

Delusion and other disorders

Even though the main characteristic of delusional disorder is a noticeable system of delusional
beliefs, delusions may occur in the course of a large number of other psychiatric disorders.
Delusions are often observed in persons with other psychotic disorders such as schizophrenia and
schizoaffective disorder. In addition to occurring in the psychotic disorders, delusions also may
be evident as part of a response to physical, medical conditions (such as brain injury or brain
tumors), or reactions to ingestion of a drug.

Delusions also occur in the dementias, which are syndromes wherein psychiatric symptoms and
memory loss result from deterioration of brain tissue. 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.

Because delusions occur in many different disorders, some clinician-researchers have argued that
there is little usefulness in focusing on what diagnosis the person has been given. Those who
ascribe to this view believe it is more important to focus on the symptom of delusional thinking,
and find ways to have an effect on delusions, whether they occur in delusional disorder or
schizophrenia or schizoaffective disorder. The majority of psychotherapy techniques used in
delusional disorder come from symptom-focused (as opposed to diagnosis-focused) researcher-
practitioners.

Causes and symptoms

Causes

Because clear identification of delusional disorder has traditionally been challenging, scientists
have conducted far less research relating to the disorder than studies for schizophrenia or mood
disorders. Still, some theories of causation have developed, which fall into several categories.

GENETIC OR BIOLOGICAL. Close relatives of persons with delusional disorder have

increased rates of delusional disorder and paranoid personality traits. They do not have higher
rates of schizophrenia, schizoaffective disorder or mood disorder compared to relatives of non-
delusional persons. Increased incidence of these psychiatric disorders in individuals closely
genetically related to persons with delusional disorder suggest that there is a genetic component
to the disorder. Furthermore, a number of studies comparing activity of different regions of the
brain in delusional and non-delusional research participants yielded data about differences in the
functioning of the brains between members of the two groups. These differences in brain activity
suggest that persons neurologically with delusions tend to react as if threatening conditions are
consistently present. Non-delusional persons only show such patterns under certain kinds of
conditions where the interpretation of being threatened is more accurate. With both brain activity
evidence and family heritability evidence, a strong chance exists that there is a biological aspect
to delusional disorder.
DYSFUNCTIONAL COGNITIVE PROCESSING. An elaborate term for thinking is
"cognitive processing." Delusions may arise from distorted ways people have of explaining life
to themselves. The most prominent cognitive problems involve the manner in which delusion
sufferers develop conclusions both about other people, and about causation of unusual
perceptions or negative events. Studies examining how people with delusions develop theories
about reality show that the subjects have ideas which which they tend to reach an inference based
on less information than most people use. This "jumping to conclusions" bias can lead to
delusional interpretations of ordinary events. For example, developing flu-like symptoms
coinciding with the week new neighbors move in might lead to the conclusion, "the new
neighbors are poisoning me." The conclusion is drawn without considering alternative
explanations—catching an illness from a relative with the flu, that a virus seems to be going
around at work, or that the tuna salad from lunch at the deli may have been spoiled. Additional
research shows that persons prone to delusions "read" people differently than non-delusional
individuals do. Whether they do so more accurately or particularly poorly is a matter of
controversy. Delusional persons develop interpretations about how others view them that are
distorted. They tend to view life as a continuing series of threatening events. When these two
aspects of thought co-occur, a tendency to develop delusions about others wishing to do them
harm is likely.

MOTIVATED OR DEFENSIVE DELUSIONS. Some predisposed persons might suffer the

onset of an ongoing delusional disorder when coping with life and maintaining high self-esteem
becomes a significant challenge. In order to preserve a positive view of oneself, a person views
others as the cause of personal difficulties that may occur. This can then become an ingrained
pattern of thought.

Symptoms

The criteria that define delusional disorder are furnished in the Diagnostic and Statistical
Manual of Mental Disorders Fourth Edition Text Revision, or DSM-IV-TR , published by the
American Psychiatric Association. The criteria for delusional disorder are as follows:

 non-bizarre delusions which have been present for at least one month
 absence of obviously odd or bizarre behavior
 absence of hallucinations, or hallucinations that only occur infrequently in comparison to
other psychotic disorders
 no memory loss, medical illness or drug or alcohol-related effects are associated with the
development of delusions

Demographics
The base rate of delusional disorder in adults is unclear. The prevalence is estimated at 0.025-
0.03%, lower than the rates for schizophrenia (1%). Delusional disorder may account for 1–2%
of admissions to inpatient psychiatric hospitals. Age at onset ranges from 18–90 years, with a
mean age of 40 years. More females than males (overall) suffer from delusional disorder,
especially the late onset form that is observed in the elderly.
Diagnosis
Client interviews focused on obtaining information about the sufferer's life situation and past
history aid in identification of delusional disorder. With the client's permission, the clinician
obtains details from earlier medical records, and engages in thorough discussion with the client's
immediate family—helpful measures in determining whether delusions are present. The clinician
may use a semi-structured interview called a mental status examination to assess the patient's
concentration, memory, understanding the individual's situation and logical thinking. The mental
status examination is intended to reveal peculiar thought processes in the patient. The Peters
Delusion Inventory (PDI) is a psychological test that focuses on identifying and understanding
delusional thinking; but its use is more common in research than in clinical practice.

Even using the DSM-IV-TR criteria listed above, classification of delusional disorder is relatively
subjective. The criteria "non-bizarre" and "resistant to change" and "not culturally accepted" are
all subject to very individual interpretations. They create variability in how professionals
diagnose the illness. The utility of diagnosing the syndrome rather than focusing on successful
treatment of delusion in any form of illness is debated in the medical community. Some
researchers further contend that delusional disorder, currently classified as a psychotic disorder,
is actually a variation of depression and might respond better to antidepressants or therapy more
similar to that utilized for depression. Also, the meaning and implications of "culturally
accepted" can create problems. The cultural relativity of "delusions,"—most evident where the
beliefs shown are typical of the person's subculture or religion yet would be viewed as strange or
delusional by the dominant culture—can force complex choices to be made in diagnosis and
treatment. An example could be that of a Haitian immigrant to the United States who believed in
voodoo. If that person became aggressive toward neighbors issuing curses or hexes, believing
that death is imminent at the hands of those neighbors, a question arises. The belief is typical of
the individual's subculture, so the issue is whether it should be diagnosed or treated. If it were to
be treated, whether the remedy should come through Western medicine, or be conducted through
voodoo shamanistic treatment is the problem to be solved.

Treatments
Delusional disorder treatment often involves atypical (also called novel or newer-generation )
antipsychotic medications, which can be effective in some patients. Risperidone (Risperdal),
quetiapine (Seroquel), and olanzapine (Zyprexa) are all examples of atypical or novel
antipsychotic medications. If agitation occurs, a number of different antipsychotics can be used
to conclude the outbreak of acute agitation. Agitation, a state of frantic activity experienced
concurrently with anger or exaggerated fearfulness, increases the risk that the client will
endanger self or others. To decrease anxiety and slow behavior in emergency situations where
agitation is a factor, an injection of haloperidol (Haldol) is often given usually in combination
with other medications (often lorazepam , also known as Ativan). Agitation in delusional
disorder is a typical response to severe or harsh confrontation when dealing with the existence of
the delusions. It can also be a result of blocking the individual from performing inappropriate
actions the client views as urgent in light of the delusional reality. A novel antipsychotic is
generally given orally on a daily basis for ongoing treatment meant for long-term effect on the
symptoms. Response to antipsychotics in delusional disorder seems to follow the "rule of thirds,"
in which about one-third of patients respond somewhat positively, one-third show little change,
and one-third worsen or are unable to comply.

Cognitive therapy has shown promise as an emerging treatment for delusions. The cognitive
therapist tries to capitalize on any doubt the individual has about the delusions; then attempts to
develop a joint effort with the sufferer to generate alternative explanations, assisting the client in
checking the evidence. This examination proceeds in favor of the various explanations. Much of
the work is done by use of empathy, asking hypothetical questions in a form of therapeutic
Socratic dialogue—a process that follows a basic question and answer format, figuring out what
is known and unknown before reaching a logical conclusion. Combining pharmacotherapy with
cognitive therapy integrates both treating the possible underlying biological problems and
decreasing the symptoms with psychotherapy.

Prognosis
Evidence collected to date indicates about 10% of cases will show some improvement of
delusional symptoms though irrational beliefs may remain; 33–50% may show complete
remission; and, in 30–40% of cases there will be persistent non-improving symptoms. The
prognosis for clients with delusional disorder is largely related to the level of conviction
regarding the delusions and the openness the person has for allowing information that contradicts
the delusion.

Prevention
Little work has been done thus far regarding prevention of the disorder. Effective means of
prevention have not been identified.