What is Delusional Disorder?
A delusional disorder, previously called a paranoid disorder, is a type of serious mental illness called “psychosis” in which a patient cannot distinguish between real and imaginary. The main characteristic of this disorder is the presence of delusions, which are unshakable beliefs about something false. People with delusional disorders experience delusions that are not unusual and include situations that may arise in real life, such as persecution, poisoning, misinformation, conspiracy against, or love from a distance. This nonsense usually involves misinterpreting perceptions or experiences. In reality, however, the situations are either untrue or greatly exaggerated.
People with delusional disorders can often continue to be socially active and function normally outside the subject of their delusions, and usually do not obviously behave strangely or eccentric. This distinguishes them from people with other psychotic disorders, who may also have delusions as a symptom of their disorder. In some cases, however, people with delusional disorder may be so absorbed in their delusional ideas that their lives are ruined.
Despite the fact that delusions can be a symptom of more common disorders, such as schizophrenia, delusional disorders themselves are quite rare. Delusional disorders are most common in mid-life and older age, and more common in women than in men.
In 1918, Heinroth, describing the disorders of the intellect, denoted by the term Verrucktheit, officially suggested that paranoia be considered a separate disease. In 1838, the French psychiatrist Esquirol coined the term to describe delusional disorders not related to a violation of logical thinking or behavior. Kahbaum in 1863 used the term for these patients; He described the disease as unusual, but clearly defined. In 1921, Kraepelin described paraphrenia as a disease with a gradual onset and chronic course, but different from schizophrenia by the absence of hallucinations and other psychotic symptoms, as well as the absence of personality disorders. In DSM – III – R and in other classifications, chronic paranoid (for example, paranoia, parafrenia) is separated from acute paranoid disorders (for example, paranoid states). In some classifications, it is noted that in chronic forms there is a tendency toward a more systematic delusional system than in acute ones. DSM – III – R classifies them as delusional disorders, to emphasize that the content of delusions is not limited only to paranoia and that paranoia is not necessarily included in the development of these disorders.
The prevalence of delusional disorders in the United States, according to currently available data, is 0.03%; this is very different from schizophrenia, the prevalence of which is 1%, and from mood disorders occurring in 5%. In patients with delusional disorders, additional symptoms often occur due to which another diagnosis has to be made. However, it should be noted that in fact this type of pathology is more common, since patients with delusional disorders rarely go to the doctor themselves, unless they are forced to do so by family members and the courts. Annually from 1 to 3 new cases of delusional disorders per 100 thousand population are recorded. This number is approximately 4% of all primary hospital admissions to psychiatric hospitals for inorganic psychosis. The average age of onset is approximately 40 years, varying from 25 to 90 years. There is a slight predominance of women among patients with this disease. Many patients are married and working; There is also some association of incidence rates with recent immigration or low socioeconomic status.
Causes of Delusional Disorder
As with many other psychotic disorders, the exact cause of the delusional disorder is still unknown. However, researchers are studying the role of various genetic, biological, psychological factors, as well as environmental factors.
Genetic factor: The fact that delusional disorder is more common in people who can have families with delusional disorder or suffer from schizophrenia suggests that a genetic factor may be involved. It is believed that, as with other mental disorders, the tendency to develop delusional disorder can be transmitted to children from parents.
Biological factor: Researchers are studying how pathologies of certain areas of the brain can be involved in the development of delusional disorders. An imbalance of certain chemicals in the brain, called neurotransmitters, is also associated with the formation of delusional symptoms. Neurotransmitters are substances that help nerve cells send messages to each other. An imbalance of these substances can negatively affect the transmission of messages, leading to the appearance of symptoms.
Environmental / psychological factor: Evidence suggests that stress can act as a trigger for delusional disorder. Alcohol and drug abuse can also contribute to the development of this condition. People who tend to isolate themselves, such as immigrants, those who are poorly seeing and hearing, are at greater risk of developing delusional disorder.
Family history studies indicate that delusional disorders are a clinically independent disease. In these studies, the more frequent occurrence of delusional disorders and related personality traits among relatives of patients with destructive probands has been noted. Studies of family history also revealed that there was no increase in the number of patients with schizophrenia and mood disorders in the families of patients with delusional disorders; and, on the contrary, in the families of patients with schizophrenia there is no increase in the number of patients with delusional disorders.
Long-term observation of patients suffering from delusional disorders shows that they are rarely diagnosed with schizophrenia or mood disorders afterwards, and, consequently, delusional disorders are not just the initial stage of these other diseases. Moreover, delusional disorders have a later onset than schizophrenia or mood disorders.
When a neuropsychiatric approach to the problem of delusional disorders come from the observation that delusion is a common symptom in a number of pathological conditions of the nervous system, in particular, in pathology extending to the limbic system and the basal ganglia. In patients with nervous diseases, they reveal a complex nonsense, very similar to that observed in patients with delusional disorders, in cases where their organic disease (for example, a tumor or trauma) is characterized by the absence of intellectual disabilities. Conversely, patients suffering from organic diseases with an intelligence disorder (for example, Alzheimer’s disease) often find simple nonsense. It should be remembered that the limbic system has significant reciprocal nervous connections with the basal ganglia, thus creating a system that affects emotions and motivation. This allows us to suggest that local anatomical or molecular damage to either the limbic system or the basal ganglia, with intact cognitive functions, can create a biological basis for the development of delusions and delusional disorders. It is possible, in particular, to assume that reduplicate paramnesias (for example, delusions, which consist in the fact that a patient takes a hospital ward for his own bedroom) come from an irrefutable and uncorrected correction of the familiarity of the situation observed in this patient. In this case, the patient uses the intact part of the cerebral cortex to explain this familiarity sensation, insisting that the hospital room is his own bedroom.
Psychodynamic approaches. Clinical observations show that many patients with delusional disorders are socially isolated, do not reach the expected level of achievement, and often change culturally. More specific psychodynamic theories concerning the etiology and evolution of delusional symptoms include the concept that hypersensitive subjects with various types of emotional insecurity are susceptible to this disorder (for example, such a subject may be afraid of becoming homosexual); such persons also have such ego-mechanisms as the structure of counteraction, projection and denial. These hypotheses were put forward as a result of retrospective psychoanalysis data obtained from patients with delusional disorders. Clinical experience, however, shows that psychotherapeutic treatment based on these theories benefits patients.
Theory of Freud. Freud believed that nonsense is rather not a symptom of the disease, but part of the healing process. In 1896, he described projection as the main defense mechanism for paranoia. Later, Freud read The Memories of My Nervous Disease autobiographical report of gifted lawyer Daniel Paul Schreber. Although he had never met Schreber personally, Freud derived the theory from his autobiographical review of how defenses of unconscious homosexual tendencies came about through denial and projection. Since homosexuality at a conscious level is unacceptable for some paranoid patients, the feeling “I love him” is denied and is replaced by the structure of opposition to “I do not love him, I hate him”. This feeling is further transformed through the projection into “It is not I who hate him, but he hates me.”
In a fully unfolded paranoid state, this feeling is processed into “He is stalking me.” The patient can then rationalize his anger, consciously hating those who he thinks hate him. Instead of realizing his passive homosexual impulses, the patient rejects the love of anyone except himself. In the case of erotomanic delusions, a sick man replaces “I love him” with “I love her”, and this feeling through the projection becomes “She loves me”. Freud also believed that unconscious homosexuality was the cause of delusions of jealousy. Trying to repel fear-causing impulses, the patient is dominated by ideas of jealousy; so, the patient says, “I do not love him, she loves him.” Freud believed that the paranoid patient – a man suspects his wife that she loves the person to whom the patient has sexual desire. According to the classical theory of psychoanalysis, the dynamics of unconscious homosexuality is the same in male and female patients. Clinical observations do not support the hypothesis put forward by Freud. A significant number of delusional patients do not detect homosexual inclinations, and most homosexual personalities do not detect symptoms of paranoia or delusional disorders.
Paranoid pseudo-society. Norman Cameron described at least seven situations that contribute to the development of delusional disorders:
- the exaggerated expectation of the subject that he will meet a sadistic appeal;
- situations that contribute to increased distrust and suspicion;
- social isolation;
- situations in which the feeling of jealousy and jealousy increases;
- situations in which there is a decrease in the level of self-esteem;
- situations that cause the subject to see his own faults in others;
- situations in which the likelihood is increased that the subject will reflect too much on the possible meaning of events and motivations.
When the frustration resulting from a combination of these conditions exceeds the limit that a given subject can withstand, the patient becomes withdrawn and anxious; he feels that something is wrong and is trying to find an explanation for the situation. Crystallization of the delusional system is the possible destruction of the problem. As a result of the development of delirium, including imaginary persons and attributing to both real and imaginary personalities that are unfriendly to the patient, actions create a “pseudo-society” —that is, an imaginary society of conspirators. The delusional essence binds together the projected fears and desires to justify the aggression of the patient and provide an achievable goal. Other psychodynamic approaches. Clinical observations show that some paranoid patients feel a lack of confidence in the formation of relationships with others.
It is assumed that this lack of trust is associated with persistent hostile attitudes in the family, where there is often excessive control by the mother and distancing or sadistic tendencies on the part of the father. Patients with delusional disorders early start using the protective mechanisms of the structure of counteraction, denial and projection. The structure of opposition is used as protection against aggression, satisfaction of needs for dependence and affection. The need for dependence is transformed into unshakable independence. Denial is used to avoid a painful reality. Exhausted by anger and hostility and not being able to pour out his rage on those who caused it, the patient begins to project his outrage and anger on others. A projection is used to protect the subject from realizing unacceptable impulses in himself.
Hypersensitivity and the feeling of inferiority lead, as is supposed, through the structure of opposition and projection to the delirium of greatness and grandeur. Nonsense erotic content is considered to be associated with a sense of unrecognized, rejection. Other clinicians say that a child who is expected to do everything flawlessly, and who is unjustly punished if he does not meet these expectations, can develop fantasies that are a way for him to heal the wounds inflicted on his self-esteem. These secret dreams can sometimes turn into nonsense. Threatening and terrible nonsense is supposed to be the result of the superego’s criticism. For example, the ravings of paranoid sick women often include a charge of prostitution. As a child, a woman who later became a paranoid patient sought a mother’s love from her father, which she did not find in her mother. Incestuous desires developed. Later, heterosexual intercourse became an unconscious reminder of the incestuous desires experienced in childhood; protection against these desires was carried out with the help of superego projection, as a result of which the paranoid patient developed delusions of prostitution.
Somatic delusions from the standpoint of a psychodynamic approach can be explained as a regression into the infantile narcissistic phase, in which the patient is emotionally separated from other people and fixed on his own physical “me”. In erotic delusions, love can be conceptualized as narcissistic love, used as a defense against low self-esteem and deep narcissistic impairment. The ravings of grandeur can be a regression of the sense of omnipotence experienced in childhood, in which the senses of omnipotence and invincible strength prevail.
Symptoms of Delusional Disorder
Types of delusional disorder
There are several types of delusional disorder depending on the subject of the delusion the patient has. The types of delusional disorder include the following:
Erotomania-related disorder: a person with this type of disorder believes that another person, often someone important or famous, is in love with him or her. This person may attempt to communicate with the object of the delusion, and the behavior of the persecution is quite common.
A disorder associated with overvalued ideas: A person with this type of delusional disorder has an overestimated sense of significance, power, knowledge or identity. A person may believe that he or she has a great talent or that he or she made a great discovery.
Disorder due to jealousy: A person with this type of delusional disorder believes that his or her spouse / spouse is incorrect.
Persecution Disorder: People with this type of delusional disorder believe that they (or anyone close to them) are abused, or that someone is watching them or planning to harm them. Quite often, people with this delusional disorder write periodically recurring complaints to the legal authorities.
A somatic disorder: A person with this type of delusional disorder believes that he or she has a physical defect or medical problem.
Mixed type: People with this type of delusional disorder have two or more of the delusions listed above.
The most obvious symptom of this disorder is the presence of non-eccentric delusions. Other symptoms that may occur include:
– Irritated, angry or in a bad mood
– Hallucinations (seeing, hearing or feeling things that are not actually in this place) that are associated with delusions (For example, a man or a woman who believes that he / she has a smell problem may smell bad.)
Patients with delusional disorder can become depressed, often as a result of difficulties associated with delusions. Acting on the basis of delusions can also lead to violence or legal problems; for example, a person with an erotomania delusion who pursues or bothers her or his delusion may be arrested. Moreover, people with this disorder may eventually move away from other people, especially if their delusions interfered or destroyed their relationship.
Diagnosis of Delusional Disorder
If there are symptoms, the doctor will fill out a patient record with a history and perform a clinical examination to determine the cause of the symptoms. Despite the fact that there are no laboratory tests for the specific diagnosis of delusional disorder, the doctor may use various research methods, such as x-rays and a blood test, in order to rule out physical illness as the cause of the symptoms.
If the physician does not find any physical cause of the symptoms, he or she can refer the patient to a psychiatrist or psychologist, mental health professionals who are specially trained in the diagnosis and treatment of mental illness. To assess whether a patient has a psychotic disorder, psychiatrists use a specially designed interview and assessment program.
The doctor or therapist bases his diagnosis on telling the patient about his symptoms, as well as his observations on the patient’s attitude or behavior. The doctor or therapist then determines whether the patient’s symptoms indicate a specific disorder. The diagnosis of delusional disorder is made if the person has disorders that are not eccentric for at least one month and do not have the characteristic symptoms of other psychotic disorders, such as schizophrenia.
Treatment of Delusional Disorder
Treatment of delusional disorder most often includes medications and psychotherapy (type of counseling). Delusional disorder is highly resistant to medication-only treatment.
Psychotherapy is the main treatment for delusional disorder, including psychosocial treatment, which can help the behavioral and psychological problems associated with delusional disorder. Through therapy, patients can also learn to control their symptoms, identify early warning signs of relapse, and develop a plan to prevent relapses.
Psychosocial therapy includes the following:
Individual psychotherapy: It can help the patient to recognize and correct distorted thinking.
Cognitive-behavioral therapy (CBT): Can help a person learn how to recognize and change a train of thought that can lead to troublesome feelings.
Family therapy: Can help families communicate more effectively with their loved one, suffering from delusional disorder, which will help to get a more favorable outcome of the disease.
The initial medications that are used to attempt treatment for delusional disorder are called neuroleptics. Used drugs include the following:
Traditional anti-psychotic drugs: They are also called neuroleptics, and they have been used to treat psychotic disorders since the mid-1950s. They work by blocking dopamine receptors in the brain. Dopamine is a neurotransmitter that is thought to be involved in the development of delusions. Traditional neuroleptics include Thorazine, Prolixin, Haldol, Navane, Stelazine, Trilafon and Mellaril.
Atypical antipsychotics: These new generation drugs have shown their higher efficacy in treating the symptoms of delusional disorder. These drugs work by blocking the dopamine and serotonin receptors in the brain. Serotonin is another neurotransmitter that is also believed to be involved in the development of delusional disorder. These medications include Risperdol, Clozaril, Seroquel, Geodon and Zyprexa.
Other medicines: Tranquilizers and antidepressants can also be used to treat delusional disorder. Tranquilizers can be used if the patient has a very high level of anxiety and / or sleep problems. Antidepressants can be used to treat depression, which often occurs in people with delusional disorder.
Patients with severe symptoms or those at risk of harming themselves or other people may need to be hospitalized until their condition is stabilized.
Perspectives for people with delusional disorder vary depending on the personality, the type of delusional disorder, and the patient’s life situation, including the availability of support and the will to adhere to treatment.
A delusional disorder is usually a chronic (persistent) condition, but with proper treatment, many people with this disorder may find relief from their symptoms. Some patients recover completely, others are prone to episodes of delusions with periods of remission (no symptoms).
Unfortunately, many people with this disorder are not looking for help. Very often for people with mental disorders it is very difficult to admit that they are not all right. In addition, they may be too embarrassed or afraid to ask for help. Without treatment, delusional disorder can be a lifelong disease.
Prevention of Delusional Disorder
There are no known ways to prevent delusional disorder. However, early diagnosis and treatment can help reduce the destruction of a person’s life, family and friendships.