Delusional disordersIntroductionThe term delusion refers to a belief in something that is not real or illusory. Delusional disorders can either occur independently or in association with other major disorders such as schizophrenia, mood disorders etc. Delusional disorders can be broadly described to be bizarre delusions that disrupts with a persons functioning with respect to the particular object of delusion. Delusions can be of two types- bizarre and non- bizarre. Non bizarre beliefs are those that have the distinct possibility of occurring in the future. An example of a non bizarre delusion is that of a possibility of a bed ridden person dying. This is a reasonable belief based on the present state of the person. A bizarre delusion on the other hand is a belief in something that is irrational or illusory. For instance, if the person is under a strong conviction that a stranger has taken over his internal organs then that is purely illusory or deflecting from reality. Delusional disorders are difficult to diagnose unless they form a part of other major disorders. They are very difficult to be recognized independently in an individual as the person functions smoothly in daily life without any sort of bizarre or odd behavior. The term delusional disorder is used when delusions form the core symptom of the disorder.DefinitionDelusional disorder, previously called paranoid disorder is a serious type of mental illness called psychosis in which a person cannot tell what is real from what is imagined[footnoteRef:2]. A delusion is a false belief based on an incorrect interpretation of reality. 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[footnoteRef:3].It is characterized mainly by unshakeable belief in something that is untrue. People with delusional disorders perceive a situation in a radically different way than that of other individuals. They are often troubled with thoughts such as being followed by someone, someone trying to kill them or poison them etc. [2: http://www.webmd.com/schizophrenia/guide/delusional-disorder] [3: http://www.minddisorders.com/Br-Del/Delusional-disorder.html]

HistoryThe concept of delusional disorder has both a very long and a very short history: while the term delusional disorder was only coined in 1977, the concept of paranoia has been used for centuries. Originally, the word paranoia comes from Greek para, meaning along side, and noos ornous, meaning mind, intelligence. The Greeks used this term to describe any mental abnormalities similar to how we use the term insanity. In the modern world, the term reappeared in the 17th century, and it was largely used as a generic name for mental illness.In 1863, Karl Kahlbaum introduced the concept of paranoia as a separate mental illness: "a form of partial insanity, which throughout the course of disease principally affected the sphere of the intellect". He used this term to describe an illness with persistent delusions and stable course. He noted that delusions may occur in other medical and psychiatric conditions.Later Emil Kraepelin, who observed 19 cases, continued to work on defining the concept of paranoia, which is reflected in several editions of his famous textbook and most closely resembles the modern definition of delusional disorder. Kraepelin viewed paranoia as uncommon, chronic condition different from dementia praecox by the presence of fixed, nonbizarre delusions, lack of deterioration over time, preserved thought process, and relatively slight involvement of affect and volition. He described that delusions of paranoia, contrary to the delusions of dementia praecox, are well systemized, relatively consistent, and often related to real-life events. He identified persecutory, grandiose, jealous, erotomania, and possibly hypochondriacal types of that disorder. He believed that the illness derived from the deficit in the patients' judgments caused by constitutional factors and environmental stress.In 1987, delusional disorder was introduced in DSM-III-R and continued to be present in subsequent editions. General FeaturesPeople suffering from delusional disorders are hard to recognize as they very easily clothe these symptoms thereby making the diagnosis process that much more difficult. These delusions that they have do not disrupt with their normal day to day lives. Hence they appear to be perfectly normal with no sort of odd behavior. However the delusions come to light when the person is spoken to about the particular belief. The person may then show visible indications of change in behavior in the form of irritation, or anxiety or excessive emotional attachment to the particular belief. Sometimes the person may be so preoccupied with their delusional thoughts that they fail to notice the things happening around them. For instance, a person who is under a strong delusional belief that the government is tapping his phone and listening to his private conversations may appear to be perfectly normal when approached. However he may find it very difficult to receive a call over the phone or have a relaxed conversation over the phone for the simple fear of being heard by a third party like the government. Similarly a person who fears being murdered may quit his job and stay at home out of everyones sight[footnoteRef:4]. [4: http://www.drugs.com/health-guide/delusional-disorder.html]

Delusional disorders do not interfere with the cognitive functions of an individual. A person with delusions is not retarded or a person with degenerative cognitive functions. The person is perfectly capable of fulfilling the tasks assigned to him and it does not pose an obstacle to his academic pursuits or professional obligations. The person however may make unusual choices depending on the kind of delusional beliefs that they are under. Delusional disorders often occur in the mid forties or fifties and more likely in women than men[footnoteRef:5]. [5: Supra.n.1]

In very rare cases is a person diagnosed with delusional disorders in isolation. In most of the cases they form a symptom or component of other major disorders such as schizophrenia or mood disorders. Schizophrenia is a classic case where the person is also under a firm irrational belief. Here the persons belief is so intense that it impairs his/her functioning in many spheres of his/her life. Similarly they can also form a part of mood disorders where the person faces frequent mood swings in the form of fear, anxiety, euphoria, irritability etcTypes of delusional disorders[footnoteRef:6] [6: Supra.n.1]

Delusional disorders can be classified into certain categories based on their frequent occurrence and the irrational beliefs that they are based on. Some of the popular types include-1) De Clerambault syndrome (erotomania): Related terms include psychose passionelle and old maids insanity. In this case the person is under a delusion that another person who holds a superior or an influential position is in love with them. This occurs more likely in women than men. The object of delusion is generally perceived to belong to a higher social class, being married or otherwise unattainable. Delusional love is usually intense in nature. Signs of denial of love by the object of delusion are frequently falsely interpreted as affirmation of love. Here the person may try to contact his/her object of interest and may even stalk that particular individual.

2) Grandiose: A person with this type of delusional disorder has an over inflated ego and firmly believes that he/she possesses enormous wealth or talent or made an important discovery. They have a very strong conviction that they are very wealthy, powerful, influential and talented. Grandiose delusions in the absence of mania are relatively uncommon, and the distinction of this subtype of disorder is debatable. Many patients with paranoid type show some degree of grandiosity in their delusions.

3) Persecutory: Here the persons harbour a strong notion that someone is trying to harm them or someone close to them. They constantly have thoughts of someone following them, keeping track of their movements, spying on them etc. If it attains immense proportions, then the patients may even quit their job and stay at home hiding themselves from the rest of the world. It is also common that such people frequently approach the legal authorities demanding for protection and safety. In contrast to persecutory delusions of schizophrenia, the delusions are systematized, coherent and defended with clear logic. No deterioration in social functioning and personality is observed. Patients often face some degree of emotional distress such as irritability, anger and resentment. In extreme situations they may resort to violence against those who they believe are hurting them. The distinction between normality, overvalued ideas and delusions is difficult to make in some of these cases.

4) Jealous: Related terms include conjugal paranoia, Othello syndrome and pathological or morbid jealousy. Here the person believes that his/her spouse or significant other is being unfaithful. They are very suspicious of their partners movements and constantly keep track of their every move, hoping to catch them in their infidel act. Patients may attempt to confront their spouses. Jealousy may evoke anger and empower the individual with a sense of righteousness to justify their acts of aggression. This disorder can sometimes lead to acts of violence, including suicide and homicide.5) Somatic: In this case, the person genuinely believes that he/she has some disease or health problem or that something is genuinely wrong with their health. The person here constantly visits hospitals and demands for treatment to be given. The person can be seen getting multiple scans and tests done in the belief of being diagnosed with some disease. This also includes delusional parasitosis, where the person has thoughts of insects crawling over them or bugs being under their skin[footnoteRef:7]. Patients are totally convinced in physical nature of this disorder, which is contrary to patients with hypochondriasis who may admit that their fear of having a medical illness is groundless. [7: http://www.webmd.boots.com/mental-health/mental-health-delusional-disorder]

6) Mixed: People here have any two or more types of delusions listed above. They also may have a shared delusion with another person.7) Unspecified type- Delusional themes fall outside the specific categories or cannot be clearly determined. Misidentification syndromes such as Capgras syndrome which is characterized by the belief that a familiar person has been replaced by an identical imposter fall into this category. These are rare and are frequently associated with other psychiatric conditions such as schizophrenia or organic illnesses. Another syndrome is that of Cotard syndrome where the patients believe that they have lost all their possessions, status and strength as well as their entire being including their organs. Symptoms[footnoteRef:8] [8: https://www.psychologytoday.com/conditions/delusional-disorder]

The criteria that indicate delusional disorders are laid down in the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR, published by the American Psychiatric Association[footnoteRef:9]. The criteria are as follows- [9: Supra.n.2]

a) Non bizarre delusions which have been present for at least one month.b) Non fulfillment of symptoms of schizophrenia except for tactile and olfactory delusions which may be present if consistent with delusional themes.c) Behavior is normal with no marked odd or peculiar actions. Functioning of the person in a social or professional set up is not hampered.d) Duration of mood symptoms is brief in comparison to duration of delusions.e) Disorder is not caused due to use of medicines or any other substances. The person is not under any medication.f) Absence of hallucinations.g) There is no memory loss or degeneration of cognitive functions.DiagnosisIt is very difficult to diagnose delusional disorders as the individuals do not show any visible signs. One of the effective modes of diagnosis of delusional disorders is the elimination technique that is used. By using this technique the person can be diagnosed of either delusional disorders existing independently or in association with other mental illness. For instance, if there is no marked memory loss, then dementia can be ruled out. Similarly schizophrenia can be eliminated in the event of absence of specific symptoms. A diagnosis of delusional disorder is made if a person has non-bizarre delusions for at least one month and does not have the characteristic symptoms of other psychotic disorders[footnoteRef:10]. [10: Supra.n.1]

If symptoms of the disorder are present, then the doctor may conduct a complete physical exam. The doctor may even have a blood test done of the patient to eliminate the possibility of any physical illness attributing to the symptoms. Later the doctor may consult the patient to a psychiatric or psychologist who will study the medical history of the patient and make an in depth observation and analysis of the patients behavior and attitude. Both the observations made by the concerned psychiatrist and the doctor would be taken into consideration while determining the patients mental condition.Causes[footnoteRef:11] [11: Supra.n.6]

There is no exact cause or factor that can be said to contribute to delusional disorders. However the following factors may be taken into account-a) Biological causes: In certain cases, biological causes have been said to contribute to delusional disorders. Abnormalities in certain areas of brain may lead to delusional disorders. Neurotransmitters in the brain help in transmission of signals from one part of the body to another. If there is an imbalance of any sorts in these neurotransmitters, it can lead to delusional disorders. Recent studies have shown that schizophrenia can now be attributed to biological causes as well which can be in the form of deficiency of neurotransmitters or other chemical imbalance.b) Genetic causes: On an observation, it is seen that most people who have or develop delusional disorders are people whose family members also have schizophrenia or other mental disorders. Hence, over the years it is strongly believed that delusional disorders have a genetic origin and have the possibility of being passed on to future generations.c) Environmental causes: Studies have shown that certain environmental factors also play a role in the development of delusional disorders. Stress is said to contribute to its development. Similarly over consumption of alcohol and drug abuse can also lead to delusional disorders. People who are isolated are also more prone to developing delusions.Treatment[footnoteRef:12] [12: http://www.med.uokufa.edu.iq/dr/arfat/lectures/Delusional%20Disorder.pdf]

Delusional disorder is challenging to treat for various reasons, including patients' frequent denial that they have any problem, especially of a psychological nature, difficulties in developing a therapeutic alliance, and social/interpersonal conflicts. Careful assessment and diagnosis are crucial because delusions commonly represent an underlying organic illness that warrants specific treatment. Additionally, coexisting psychiatric disorders should be recognized and treated accordingly.Treatment of delusional disorder often involves both psychopharmacology and psychotherapy. Given the chronic nature of this condition, treatment strategies should be tailored to the individual needs of patients and focus on maintaining social function and improving quality of life. Establishing a therapeutic alliance, establishing acceptable symptomatic treatment goals, and educating the patient's family are of paramount importance. Avoiding direct confrontation of the delusional symptoms enhances the possibility of treatment compliance and response. Hospitalization should be considered if a potential for harm or violence exists. Otherwise, outpatient treatment is preferred.PsychotherapyFor most patients with delusional disorder, some form of supportive therapy is helpful. The goals of supportive therapy include facilitating treatment adherence and providing education about the illness and its treatment. Educational and social interventions can include social skills training (eg, not discussing delusional beliefs in social settings) and minimizing risk factors, including sensory impairment, isolation, stress, and precipitants of violence. Providing realistic guidance and assistance in dealing with problems stemming from the delusional system may be very helpful.Cognitive therapeutic approaches may be useful for some patients. The therapist helps the patient to identify maladaptive thoughts by means of Socratic questioning and behavioral experiments, and then replace them with alternative, more adaptive beliefs and attributions. Discussion of the unrealistic nature of delusional beliefs should be done gently and only after rapport with the patient has been established.Some authors believe that insight-oriented therapy is rarely indicated or even contraindicated. However, reports exist of successful treatment. Goals in insight-oriented therapy include development of the therapeutic alliance; containing projected feelings of hatred, badness, and impotence; measured interpretation; and, ultimately, developing a sense of creative doubt in the internal perception of world through empathy with the patient's defensive position.

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Bibliography1) Psychology, S.R. Myneni, 1st Edition.2) http://www.webmd.com/schizophrenia/guide/delusional-disorder3) http://www.minddisorders.com/Br-Del/Delusional-disorder.html4) http://www.drugs.com/health-guide/delusional-disorder.html5) http://www.webmd.boots.com/mental-health/mental-health-delusional-disorder6) https://www.psychologytoday.com/conditions/delusional-disorder7) http://www.med.uokufa.edu.iq/dr/arfat/lectures/Delusional%20Disorder.pdf