Other Psychotic Disorders
11.1 Schizophreniform Disorder
Gabriel Langfeldt (1895-1983) first used the term schizophreniform in 1939, at the University Psychiatric Clinic in Oslo, Norway, to describe a condition with sudden onset and benign course associated with mood symptoms and clouding of consciousness. The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes schizophreniform disorder as similar to schizophrenia, except that its symptoms last at least 1 month but less than 6 months. Patients with schizophreniform disorder return to their baseline level of functioning once the disorder has resolved. In contrast, for a patient to meet the diagnostic criteria for schizophrenia, the symptoms must have been present for at least 6 months.
EPIDEMIOLOGY
Little is known about the incidence, prevalence, and sex ratio of schizophreniform disorder. The disorder is most common in adolescents and young adults and is less than half as common as schizophrenia. A lifetime prevalence rate of 0.2 percent and a 1-year prevalence rate of 0.1 percent have been reported.
Several studies have shown that the relatives of patients with schizophreniform disorder are at high risk of having other psychiatric disorders, but the distribution of the disorders differs from the distribution seen in the relatives of patients with schizophrenia and bipolar disorders. Specifically, the relatives of patients with schizophreniform disorders are more likely to have mood disorders than are the relatives of patients with schizophrenia. In addition, the relatives of patients with schizophreniform disorder are more likely to have a diagnosis of a psychotic mood disorder than are the relatives of patients with bipolar disorders.
ETIOLOGY
The cause of schizophreniform disorder is not known. As Langfeldt noted in 1939, patients with this diagnostic label are likely to be heterogeneous. In general, some patients have a disorder similar to schizophrenia, whereas others have a disorder similar to a mood disorder. Because of the generally good outcome, the disorder probably has similarities to the episodic nature of mood disorders. Some data, however, indicate a close relation to schizophrenia.
In support of the relation to mood disorders, several studies have shown that patients with schizophreniform disorder, as a group, have more affective symptoms (especially mania) and a better outcome than patients with schizophrenia. In addition, the increased occurrence of mood disorders in the relatives of patients with schizophreniform disorder indicates a relation to mood disorders. Thus, the biological and epidemiological data are most consistent with the hypothesis that the current diagnostic category defines a group of patients some of whom have a disorder similar to schizophrenia, whereas others have a disorder resembling a mood disorder.
Brain Imaging
A relative activation deficit in the inferior prefrontal region of the brain while the patient is performing a region-specific psychological task (the Wisconsin Card Sorting Test), as reported for patients with schizophrenia, has been reported in patients with schizophreniform disorder. One study showed the deficit to be limited to the left hemisphere and also found impaired striatal activity suppression limited to the left hemisphere during the activation procedure. The data can be interpreted to indicate a physiological similarity between the psychosis of schizophrenia and the psychosis of schizophreniform disorder. Additional central nervous system factors, as yet unidentified, may lead to either the long-term course of schizophrenia or the foreshortened course of schizophreniform disorder.
Although some data indicate that patients with schizophreniform disorder may have enlarged cerebral ventricles, as determined by computed tomography and magnetic resonance imaging, other data indicate that, unlike the enlargement seen in schizophrenia, the ventricular enlargement in schizophreniform disorder is not correlated with either outcome or other biological measures.
Other Biological Measures
Although brain imaging studies point to a similarity between schizophreniform disorder and schizophrenia, at least one study of electrodermal activity indicated a difference. Patients with schizophrenia who were born during the winter and spring months (a period of high risk for the birth of these patients) had hyporesponsive skin conductances, but this association was absent in patients with schizophreniform disorder. The significance and the meaning of this single study are difficult to interpret, but the results do suggest caution in assuming similarity between patients with schizophrenia and those with schizophreniform disorder. Data from at least one study of eye tracking in the two groups also indicate that they may differ in some biological measures.
DIAGNOSTIC AND CLINICAL FEATURES
The DSM-IV-TR criteria for schizophreniform disorder are listed in Table 11.1-1. Schizophreniform disorder is an acute psychotic disorder that has a rapid onset and lacks a long prodromal phase. Although many patients with schizophreniform disorder may experience functional impairment at the time of an episode, they are unlikely to report a progressive decline in social and occupational functioning. The initial symptom profile is the same as that of schizophrenia in that two or more psychotic symptoms (hallucinations, delusions, disorganized speech and behavior, or negative symptoms) must be present. Schneiderian first-rank symptoms are frequently observed. In addition, an increased likelihood is found of emotional turmoil and confusion, the presence of which may indicate a good prognosis. Although negative symptoms may be present, they are relatively uncommon in schizophreniform disorder and are considered poor prognostic features. In a small series of first-admission patients with schizophreniform disorder, one fourth had moderate to severe negative symptoms. Almost all were initially categorized as “schizophreniform disorder without good prognostic features,” and 2 years later, 73 percent were rediagnosed with schizophrenia, compared with 38 percent of those with “good prognostic features.”
Table 11.1-1 DSM-IV-TR Diagnostic Criteria for Schizophreniform Disorder | ||||||||||||||||||||||||||||||
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By definition, patients with schizophreniform disorder return to their baseline state within 6 months. In some instances, the illness is episodic, with more than one episode occurring after long periods of full remission. If the combined duration of symptomatology exceeds 6 months, however, then schizophrenia should be considered.
Ms. V was a 30-year-old white woman from a working-class family. She was born prematurely and as a toddler had a seizure disorder that was treated with phenobarbital (Luminal, Solfoton) for 1 year. She did well in school, but dropped out in the 12th grade, obtained a General Educational Development (GED) diploma, and began working at 18 years of age. She described her adolescence as a time when she was happy, outgoing, and had several friends. She married at 21 years of age and had two children, but 9 months before her initial hospitalization, she and her husband separated. Ms. V began working in a local factory, and she and her children moved in with her mother. About 6 weeks before her initial admission, Ms. V started feeling that drug dealers and gangsters were out to hurt her and that people were poisoning her food. She also did not let her children eat, fearing they would die from food poisoning. She was admitted to the hospital for 2 weeks but did not receive any medications at that time. Three weeks after discharge, she was readmitted with the same symptoms and also experienced thought broadcasting, thought insertion, and olfactory hallucinations. She was treated with haloperidol (Haldol) and was discharged after 1 month. She later moved to Florida with her mother and children, worked full time, and remained free of symptoms without treatment for 9 years. At that time, she again became psychotic, but after treatment with olanzapine (Zyprexa) for 1 month, she recovered fully and resumed her usual social and occupational functioning. (Courtesy of Bushra Naz, M.D., Laura J. Fochtmann, M.D., and Evelyn J. Bromet, M.D.)
DIFFERENTIAL DIAGNOSIS
It is important to first differentiate schizophreniform disorder from psychoses that can arise from medical conditions. This is accomplished by taking a detailed history and physical examination and, when indicated, performing laboratory tests or imaging studies. A detailed history of medication use, including over-the-counter medications and herbal products, is essential because many therapeutic agents can also produce an acute psychosis. Although it is not always possible to distinguish substance-induced psychosis from other psychotic disorders cross-sectionally, a rapid onset of psychotic symptoms in a patient with a significant substance history should raise the suspicion of a substance-induced psychosis. A detailed substance use history and toxicological screen are also important for treatment planning in an individual with a new onset of psychosis.
The duration of psychotic symptoms is one of the factors that distinguish schizophreniform disorder from other syndromes. Schizophrenia is diagnosed if the duration of the prodromal, active, and residual phases lasts for more than 6 months, whereas symptoms that occur for less than 1 month indicate a brief psychotic disorder. In DSM-IV-TR, a diagnosis of brief psychotic disorder does not require that a major stressor be present.
It is sometimes difficult to distinguish mood disorders with psychotic features from schizophreniform disorder. Furthermore, schizophreniform disorder and schizophrenia can be highly comorbid with mood and anxiety disorders. Additional confounds are that mood symptoms, such as loss of interest and pleasure, may be difficult to distinguish from negative symptoms, avolition, and anhedonia. Some mood symptoms may also be present during the early course of schizophrenia. A thorough longitudinal history is important in elucidating the diagnosis because the presence of psychotic symptoms exclusively during periods of mood disturbance is an indication of a primary mood disorder.
COURSE AND PROGNOSIS
The course of schizophreniform disorder, for the most part, is defined in the criteria. It is a psychotic illness lasting more than
1 month and less than 6 months. The real issue is what happens to persons with this illness over time. Most estimates of progression to schizophrenia range between 60 and 80 percent. What happens to the other 20 to 40 percent is not known. Some will have a second or third episode during which they will deteriorate into a more chronic condition of schizophrenia. A few, however, may have only this single episode and then continue on with their lives, which is clearly the outcome desired by all clinicians and family members, although it is probably a rare occurrence and should not be held out as likely.
1 month and less than 6 months. The real issue is what happens to persons with this illness over time. Most estimates of progression to schizophrenia range between 60 and 80 percent. What happens to the other 20 to 40 percent is not known. Some will have a second or third episode during which they will deteriorate into a more chronic condition of schizophrenia. A few, however, may have only this single episode and then continue on with their lives, which is clearly the outcome desired by all clinicians and family members, although it is probably a rare occurrence and should not be held out as likely.
TREATMENT
Hospitalization, which is often necessary in treating patients with schizophreniform disorder, allows effective assessment, treatment, and supervision of a patient’s behavior. The psychotic symptoms can usually be treated by a 3- to 6-month course of antipsychotic drugs (e.g., risperidone). Several studies have shown that patients with schizophreniform disorder respond to antipsychotic treatment much more rapidly than do patients with schizophrenia. In one study, about 75 percent of patients with schizophreniform disorder and only 20 percent of the patients with schizophrenia responded to antipsychotic medications within 8 days. A trial of lithium (Eskalith), carbamazepine (Tegretol), or valproate (Depakene) may be warranted for treatment and prophylaxis if a patient has a recurrent episode. Psychotherapy is usually necessary to help patients integrate the psychotic experience into their understanding of their minds and lives. Electroconvulsive therapy may be indicated for some patients, especially those with marked catatonic or depressed features.
Finally, most patients with schizophreniform disorder progress to full-blown schizophrenia despite treatment. In those cases, a course of management consistent with a chronic illness must be formulated.
11.2 Schizoaffective Disorder
As the term implies, schizoaffective disorder has features of both schizophrenia and affective disorders (now called mood disorders). In current diagnostic systems, patients can receive the diagnosis of schizoaffective disorder if they fit into one of the following six categories: (1) patients with schizophrenia who have mood symptoms; (2) patients with mood disorder who have symptoms of schizophrenia; (3) patients with both mood disorder and schizophrenia; (4) patients with a third psychosis unrelated to schizophrenia and mood disorder; (5) patients whose disorder is on a continuum between schizophrenia and mood disorder; and (6) patients with some combination of the foregoing. The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) incorporated the stricter time frame of 1 month’s duration of schizophrenia symptoms and required an “uninterrupted period of illness during which at some time, either there is a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.” DSM-IV-TR also elaborated more on the criterion of duration of the mood symptoms relative to the psychotic symptoms. In the tenth revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10), schizoaffective disorder is a distinct entity and can be applied to patients who have co-occurring mood symptoms and schizophrenic-like mood-incongruent psychosis.
EPIDEMIOLOGY
The lifetime prevalence of schizoaffective disorder is less than 1 percent, possibly in the range of 0.5 to 0.8 percent. These figures, however, are estimates; various studies of schizoaffective disorder have used varying diagnostic criteria. In clinical practice, a preliminary diagnosis of schizoaffective disorder is frequently used when a clinician is uncertain of the diagnosis.
Gender and Age Differences
The literature describing gender and age differences among patients with schizoaffective disorder is limited. The depressive type of schizoaffective disorder may be more common in older persons than in younger persons, and the bipolar type may be more common in young adults than in older adults. The prevalence of the disorder has been reported to be lower in men than in women, particularly married women; the age of onset for women is later than that for men, as in schizophrenia. Men with schizoaffective disorder are likely to exhibit antisocial behavior and to have a markedly flat or inappropriate affect.
ETIOLOGY
The cause of schizoaffective disorder is unknown. The disorder may be a type of schizophrenia, a type of mood disorder, or the simultaneous expression of each. Schizoaffective disorder may also be a distinct third type of psychosis, one that is unrelated to either schizophrenia or a mood disorder. The most likely possibility is that schizoaffective disorder is a heterogeneous group of disorders encompassing all of these possibilities.
Studies designed to explore the etiology have examined family histories, biological markers, short-term treatment responses, and long-term outcomes. Most studies have considered patients with schizoaffective disorder to be a homogeneous group, but recent studies have examined the bipolar and depressive types of schizoaffective disorder separately, and DSM-IV-TR has a classification for each type.
Although much of the family and genetic research in schizoaffective disorder is based on the premise that schizophrenia and the mood disorders are completely separate entities, some data indicate that they may be genetically related. Studies of the relatives of patients with schizoaffective disorder have reported inconsistent results; however, according to DSM-IV-TR, an increased risk of schizophrenia exists among the relatives of probands with schizoaffective disorder.
As a group, patients with schizoaffective disorder have a better prognosis than patients with schizophrenia and a worse prognosis than patients with mood disorders. In addition, as a group, patients with schizoaffective disorder tend to have a nondeteriorating course and respond better to lithium than do patients with schizophrenia.
Consolidation of Data
A reasonable conclusion from the data is that patients with schizoaffective disorder are a heterogeneous group: Some have schizophrenia with prominent affective symptoms, others have a mood disorder with prominent schizophrenic symptoms, and still others have a distinct clinical syndrome. The hypothesis that patients with schizoaffective disorder have both schizophrenia and a mood disorder is untenable because the calculated co-occurrence of the two disorders is much lower than the incidence of schizoaffective disorder.
DIAGNOSIS AND CLINICAL FEATURES
The DSM-IV-TR diagnostic criteria are provided in Table 11.2-1. The diagnostic criteria, however, still leave much to interpretation. The clinician must accurately diagnose the affective illness, making sure it meets the criteria of either a manic or a depressive episode, but also determining the exact length of each episode (not always easy or even possible).
The length of each episode is critical for two reasons. First, to meet Criterion B (psychotic symptoms in the absence of the mood syndrome), it is important to know when the affective episode ends and the psychosis continues. Second, to meet Criterion C, the length of all mood episodes must be combined and compared with the total length of the illness. If the mood component is present for a substantial portion of the total illness, then that criterion is met. Calculating the total length of the episodes can be difficult, and the term “substantial portion” is not defined. In practice, most clinicians look for the mood component to be 15 to 20 percent of the total illness. Patients who have one full manic episode lasting 2 months but who have had symptoms of schizophrenia for 10 years do not meet the criteria for schizoaffective disorder. Instead, the diagnosis would be a mood episode superimposed on schizophrenia. Whether the bipolar and depressive type specifiers are helpful is unclear, but they may direct treatment options. These subtypes are often confused with earlier subtypes (schizophrenic vs. affective type) thought to have implications in course and prognosis. As with most psychiatric diagnoses, schizoaffective disorder should not be used if the symptoms are caused by substance abuse or a secondary medical condition.
Table 11.2-1 DSM-IV-TR Diagnostic Criteria for Schizoaffective Disorder | ||||||||||||||||||
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Mrs. P was a 47-year-old, divorced, unemployed woman who lived alone and was chronically psychotic despite treatment with olanzapine, 20 mg per day, and citalopram (Celexa), 20 mg per day. She believed that she was getting messages from God and the police department to go on a mission to fight drug dealers. She also believed that the Mafia was trying to stop her in this pursuit. The onset of her illness began at 20 years of age, when she experienced the first of several depressive episodes. She also described periods when she felt more energetic, talkative, had decreased need for sleep, and was more active, sometimes cleaning her house the whole night. Approximately 4 years after the onset of her symptoms, she began to hear “voices” that became stronger when she got depressed but were still present and continued to disturb her even when her mood was euthymic. Approximately 10 years after her illness began, she developed the belief that policemen were everywhere and that the neighbors were spying on her. She was hospitalized voluntarily. Two years later, she had another depressive episode, and the voices told her she could not live in her apartment. She was tried on lithium, antidepressants, and antipsychotic medications but continued to be chronically symptomatic with mood symptoms as well as psychosis. (Courtesy of Shmuel Fennig, M.D., Laura J. Fochtmann, M.D., and Gabrielle A. Carlson, M.D.)
DIFFERENTIAL DIAGNOSIS
The psychiatric differential diagnosis includes all the possibilities usually considered for mood disorders and for schizophrenia. In any differential diagnosis of psychotic disorders, a complete medical workup should be performed to rule out organic causes for the symptoms. A history of substance use (with or without positive results on a toxicology screening test) may indicate a substance-induced disorder. Preexisting medical conditions, their treatment, or both can cause psychotic and mood disorders. Any suspicion of a neurological abnormality warrants consideration of a brain scan to rule out anatomical pathology and an electroencephalogram to determine any possible seizure disorders (e.g., temporal lobe epilepsy). Psychotic disorder caused by seizure disorder is more common than that seen in the general population. It tends to be characterized by paranoia, hallucinations, and ideas of reference. Patients with epilepsy with psychosis are believed to have a better level of function than patients with schizophrenic spectrum disorders. Better control of the seizures can reduce the psychosis.
COURSE AND PROGNOSIS
Considering the uncertainty and evolving diagnosis of schizoaffective disorder, it is difficult to determine the long-term course
and prognosis. Given the definition of the diagnosis, patients with schizoaffective disorder might be expected to have a course similar to an episodic mood disorder, a chronic schizophrenic course, or some intermediate outcome. It has been presumed that an increasing presence of schizophrenic symptoms predicted worse prognosis. After 1 year, patients with schizoaffective disorder had different outcomes depending on whether their predominant symptoms were affective (better prognosis) or schizophrenic (worse prognosis). One study that followed patients diagnosed with schizoaffective disorder for 8 years found that the outcomes of these patients more closely resembled outcomes of patients with schizophrenia than outcomes of patients with a mood disorder with psychotic features.
and prognosis. Given the definition of the diagnosis, patients with schizoaffective disorder might be expected to have a course similar to an episodic mood disorder, a chronic schizophrenic course, or some intermediate outcome. It has been presumed that an increasing presence of schizophrenic symptoms predicted worse prognosis. After 1 year, patients with schizoaffective disorder had different outcomes depending on whether their predominant symptoms were affective (better prognosis) or schizophrenic (worse prognosis). One study that followed patients diagnosed with schizoaffective disorder for 8 years found that the outcomes of these patients more closely resembled outcomes of patients with schizophrenia than outcomes of patients with a mood disorder with psychotic features.
TREATMENT
Mood stabilizers are a mainstay of treatment for bipolar disorders and would be expected to be important in the treatment of patients with schizoaffective disorder. One study that compared lithium with carbamazepine (Tegretol) found that carbamazepine was superior for schizoaffective disorder, depressive type, but found no difference in the two agents for the bipolar type. In practice, however, these medications are used extensively alone, in combination with each other, or with an antipsychotic agent. In manic episodes, patients who are schizoaffective should be treated aggressively with doses of a mood stabilizer in the middle-to-high therapeutic blood concentration range. As the patient enters maintenance phase, the dose can be reduced to low to middle range to avoid adverse effects and potential effects on organ systems (e.g., thyroid and kidney) and to improve ease of use and compliance. Laboratory monitoring of plasma drug concentrations and periodic screening of thyroid, kidney, and hematological functioning should be performed.
By definition, many patients who are schizoaffective have major depressive episodes. Treatment with antidepressants mirrors treatment of bipolar depression. Care should be taken not to precipitate a cycle of rapid switches from depression to mania with the antidepressant. The choice of antidepressant should take into account previous antidepressant successes or failures. Selective serotonin reuptake inhibitors (e.g., fluoxetine [Prozac] and sertraline [Zoloft]) are often used as first-line agents because they have less effect on cardiac status and have a favorable overdose profile. Agitated or insomniac patients, however, may benefit from a tricyclic drug. As in all cases of intractable mania, the use of electroconvulsive therapy should be considered. As mentioned, antipsychotic agents are important in the treatment of the psychotic symptoms of schizoaffective disorder.
Psychosocial Treatment
Patients benefit from a combination of family therapy, social skills training, and cognitive rehabilitation. Because the psychiatric field has had difficulty deciding on the exact diagnosis and prognosis of schizoaffective disorder, this uncertainty must be explained to the patient. The range of symptoms can be vast as patients contend with both ongoing psychosis and varying mood states. It can be very difficult for family members to keep up with the changing nature and needs of these patients. Medication regimens can be complicated, with multiple medications from all classes of drugs.
11.3 Delusional Disorder and Shared Psychotic Disorder
Delusions are false fixed beliefs not in keeping with the culture. They are among the most interesting of psychiatric symptoms because of the great variety of false beliefs that can be held by so many people and because they are so difficult to treat. The diagnosis of delusional disorder is made when a person exhibits nonbizarre delusions of at least 1 month’s duration that cannot be attributed to other psychiatric disorders. Nonbizarre means that the delusions must be about situations that can occur in real life, such as being followed, infected, loved at a distance, and so on; that is, they usually have to do with phenomena that, although not real, are nonetheless possible. Several types of delusions may be present, and the predominant type is specified when the diagnosis is made.
EPIDEMIOLOGY
An accurate assessment of the epidemiology of delusional disorder is hampered by the relative rareness of the disorder, as well as by its changing definitions in recent history. Moreover, delusional disorder may be underreported because delusional patients rarely seek psychiatric help unless forced to do so by their families or by the courts. Even with these limitations, however, the literature does support the contention that delusional disorder, although uncommon, has a relatively steady rate.
The prevalence of delusional disorder in the United States is estimated to be 0.025 to 0.03 percent. Thus, delusional disorder is much rarer than schizophrenia, which has a prevalence of about 1 percent, and the mood disorders, which have a prevalence of about 5 percent. The annual incidence of delusional disorder is 1 to 3 new cases per 100,000 persons. According to the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), delusional disorders account for only 1 to 2 percent of all admissions to inpatient mental health facilities. The mean age of onset is about 40 years, but the range for age of onset runs from 18 years of age to the 90s. A slight preponderance of female patients exists. Men are more likely to develop paranoid delusions than women, who are more likely to develop delusions of erotomania. Many patients are married and employed, but some association is seen with recent immigration and low socioeconomic status.
ETIOLOGY
As with all major psychiatric disorders, the cause of delusional disorder is unknown. Moreover, patients currently classified as having delusional disorder probably have a heterogeneous group of conditions with delusions as the predominant symptom. The central concept about the cause of delusional disorder is its distinctness from schizophrenia and the mood disorders. Delusional disorder is much rarer than either schizophrenia or mood disorders, with a later onset than schizophrenia and a much less pronounced female predominance than the mood disorders. The most convincing data come from family studies that report an
increased prevalence of delusional disorder and related personality traits (e.g., suspiciousness, jealousy, and secretiveness) in the relatives of delusional disorder probands. Family studies have reported neither an increased incidence of schizophrenia and mood disorders in the families of delusional disorder probands nor an increased incidence of delusional disorder in the families of probands with schizophrenia. Long-term follow-up of patients with delusional disorder indicates that the diagnosis of delusional disorder is relatively stable, with less than one fourth of the patients eventually being reclassified as having schizophrenia and less than 10 percent of patients eventually being reclassified as having a mood disorder. These data indicate that delusional disorder is not simply an early stage in the development of one or both of these two more common disorders.
increased prevalence of delusional disorder and related personality traits (e.g., suspiciousness, jealousy, and secretiveness) in the relatives of delusional disorder probands. Family studies have reported neither an increased incidence of schizophrenia and mood disorders in the families of delusional disorder probands nor an increased incidence of delusional disorder in the families of probands with schizophrenia. Long-term follow-up of patients with delusional disorder indicates that the diagnosis of delusional disorder is relatively stable, with less than one fourth of the patients eventually being reclassified as having schizophrenia and less than 10 percent of patients eventually being reclassified as having a mood disorder. These data indicate that delusional disorder is not simply an early stage in the development of one or both of these two more common disorders.
Biological Factors
A wide range of nonpsychiatric medical conditions and substances, including clear-cut biological factors, can cause delusions, but not everyone with a brain tumor, for example, has delusions. Unique, and not yet understood, factors in a patient’s brain and personality are likely to be relevant to the specific pathophysiology of delusional disorder.
The neurological conditions most commonly associated with delusions affect the limbic system and the basal ganglia. Patients whose delusions are caused by neurological diseases and who show no intellectual impairment tend to have complex delusions similar to those in patients with delusional disorder. Conversely, patients with neurological disorder with intellectual impairments often have simple delusions unlike those in patients with delusional disorder. Thus, delusional disorder may involve the limbic system or basal ganglia in patients who have intact cerebral cortical functioning.
Delusional disorder can arise as a normal response to abnormal experiences in the environment, the peripheral nervous system, or the central nervous system (CNS). Thus, if patients have erroneous sensory experiences of being followed (e.g., hearing footsteps), they may come to believe that they are actually being followed. This hypothesis hinges on the presence of hallucinatory-like experiences that need to be explained. The presence of such hallucinatory experiences in delusional disorder has not been proved.
Psychodynamic Factors
Practitioners have a strong clinical impression that many patients with delusional disorder are socially isolated and have attained less-than-expected levels of achievement. Specific psychodynamic theories about the cause and the evolution of delusional symptoms involve suppositions regarding hypersensitive persons and specific ego mechanisms: reaction formation, projection, and denial.
Freud’s Contributions.
Sigmund Freud believed that delusions, rather than being symptoms of the disorder, are part of a healing process. In 1896, he described projection as the main defense mechanism in paranoia. Later, Freud read Memories of My Nervous Illness, an autobiographical account by Daniel Paul Schreber. Although he never met Schreber, Freud theorized from his review of the autobiography that unconscious homosexual tendencies are defended against by denial and projection. According to classic psychodynamic theory, the dynamics underlying the formation of delusions for a female patient are the same as for a male patient. Careful studies of patients with delusions have been unable to corroborate Freud’s theories, although they may be relevant in individual cases. Overall, no higher incidence of homosexual ideation or activity is found in patients with delusions than in other groups. Freud’s major contribution, however, was to demonstrate the role of projection in the formation of delusional thought.
Paranoid Pseudocommunity.
Norman Cameron described seven situations that favor the development of delusional disorders: an increased expectation of receiving sadistic treatment, situations that increase distrust and suspicion, social isolation, situations that increase envy and jealousy, situations that lower self-esteem, situations that cause persons to see their own defects in others, and situations that increase the potential for rumination over probable meanings and motivations. When frustration from any combination of these conditions exceeds the tolerable limit, persons become withdrawn and anxious; they realize that something is wrong, seek an explanation for the problem, and crystallize a delusional system as a solution. Elaboration of the delusion to include imagined persons and attribution of malevolent motivations to both real and imagined persons result in the organization of the pseudocommunity—a perceived community of plotters. This delusional entity hypothetically binds together projected fears and wishes to justify the patient’s aggression and to provide a tangible target for the patient’s hostilities.
Other Psychodynamic Factors.
Clinical observations indicate that many, if not all, paranoid patients experience a lack of trust in relationships. A hypothesis relates this distrust to a consistently hostile family environment, often with an overcontrolling mother and a distant or sadistic father. Erik Erikson’s concept of trust versus mistrust in early development is a useful model to explain the suspiciousness of the paranoid who never went through the healthy experience of having his or her needs satisfied by what Erikson termed the “outer-providers.” Thus, they have a general distrust of their environment.
Defense Mechanisms.
Patients with delusional disorder use primarily the defense mechanisms of reaction formation, denial, and projection. They use reaction formation as a defense against aggression, dependence needs, and feelings of affection and transform the need for dependence into staunch independence. Patients use denial to avoid awareness of painful reality. Consumed with anger and hostility and unable to face responsibility for the rage, they project their resentment and anger onto others and use projection to protect themselves from recognizing unacceptable impulses in themselves.
Other Relevant Factors.
Delusions have been linked to a variety of additional factors such as social and sensory isolation, socioeconomic deprivation, and personality disturbance. The deaf, the visually impaired, and possibly immigrants with limited ability in a new language may be more vulnerable to delusion formation than the normal population. Vulnerability is heightened with advanced age. Delusional disturbance and other paranoid features are common in the elderly. In short, multiple
factors are associated with the formation of delusions, and the source and pathogenesis of delusional disorders per se have yet to be specified.
factors are associated with the formation of delusions, and the source and pathogenesis of delusional disorders per se have yet to be specified.
DIAGNOSIS AND CLINICAL FEATURES
The DSM-IV-TR diagnostic criteria for delusional disorder are listed in Table 11.3-1.
Mental Status
General Description.
Patients are usually well groomed and well dressed, without evidence of gross disintegration of personality or of daily activities, yet they may seem eccentric, odd, suspicious, or hostile. They are sometimes litigious and may make this inclination clear to the examiner. The most remarkable feature of patients with delusional disorder is that the mental status examination shows them to be quite normal except for a markedly abnormal delusional system. Patients may attempt to engage clinicians as allies in their delusions, but a clinician should not pretend to accept the delusion; this collusion further confounds reality and sets the stage for eventual distrust between the patient and the therapist.
Table 11.3-1 DSM-IV-TR Diagnostic Criteria for Delusional Disorder | ||||||||||||||||||||||||||||||
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Mood, Feelings, and Affect.
Patients’ moods are consistent with the content of their delusions. A patient with grandiose delusions is euphoric; one with persecutory delusions is suspicious. Whatever the nature of the delusional system, the examiner may sense some mild depressive qualities.
Perceptual Disturbances.
By definition, patients with delusional disorder do not have prominent or sustained hallucinations. According to DSM-IV-TR, tactile or olfactory hallucinations may be present if they are consistent with the delusion (e.g., somatic delusion of body odor). A few delusional patients have other hallucinatory experiences—virtually always auditory rather than visual.
Thought.
Disorder of thought content, in the form of delusions, is the key symptom of the disorder. The delusions are usually systematized and are characterized as being possible; for example, delusions of being persecuted, having an unfaithful spouse, being infected with a virus, or being loved by a famous person. These examples of delusional content contrast with the bizarre and impossible delusional content in some patients with schizophrenia. The delusional system itself can be complex or simple. Patients lack other signs of thought disorder, although some may be verbose, circumstantial, or idiosyncratic in their speech when they talk about their delusions. Clinicians should not assume that all unlikely scenarios are delusional; the veracity of a patient’s beliefs should be checked before deeming their content to be delusional.
Sensorium and Cognition
ORIENTATION.
Patients with delusional disorder usually have no abnormality in orientation unless they have a specific delusion about a person, place, or time.
MEMORY.
Memory and other cognitive processes are intact in patients with delusional disorder.
Impulse Control.
Clinicians must evaluate patients with delusional disorder for ideation or plans to act on their delusional material by suicide, homicide, or other violence. Although the incidence of these behaviors is not known, therapists should not hesitate to ask patients about their suicidal, homicidal, or other violent plans. Destructive aggression is most common in patients with a history of violence; if aggressive feelings existed in the past, therapists should ask patients how they managed those feelings. If patients cannot control their impulses, hospitalization is probably necessary. Therapists can sometimes help foster a therapeutic alliance by openly discussing how hospitalization can help patients gain additional control of their impulses.
Judgment and Insight.
Patients with delusional disorder have virtually no insight into their condition and are almost always brought to the hospital by the police, family members, or employers. Judgment can best be assessed by evaluating the patient’s past, present, and planned behavior.
Reliability.
Patients with delusional disorder are usually reliable in their information, except when it impinges on their delusional system.
Types
Persecutory Type.
The delusion of persecution is a classic symptom of delusional disorder; persecutory-type and jealousy-type delusions are probably the forms seen most frequently by psychiatrists. Patients with this subtype are convinced that they are being persecuted or harmed. The persecutory beliefs are often associated with querulousness, irritability, and anger, and the individual who acts out his or her anger may at times be assaultive or even homicidal. At other times, such individuals may become preoccupied with formal litigation against their perceived persecutors. In contrast to persecutory delusions in schizophrenia, the clarity, logic, and systematic elaboration of the persecutory theme in delusional disorder leave a remarkable stamp on this condition. The absence of other psychopathology, deterioration in personality, or deterioration in most areas of functioning also contrasts with the typical manifestations of schizophrenia.
Mrs. S, 62 years of age, was referred to a psychiatrist because of complaints of not being able to sleep. Before this episode, she worked full time taking care of children, played tennis almost every day, and managed her household chores. Her chief complaint was that her downstairs neighbor wanted to get her to move away and was doing a variety of things to harass her. At first, she based her belief on certain looks that he gave her and damage done to her mailbox, but later she believed he might be leaving empty bottles of cleaning solutions in the basement so she would be overcome by fumes. As a result, the patient was fearful of falling asleep, convinced that she might be asphyxiated and not awaken in time to get help. She felt somewhat depressed and believed her appetite might be diminished from the stress of being harassed. She had not lost weight and still enjoyed playing tennis and going out with friends. At one point, she considered moving to another apartment but then decided to fight back. The episode had gone on for 8 months when her daughter persuaded her to have a psychiatric assessment. She was pleasant and cooperative in the interview. Except for the specific delusion and mild depressive symptoms, her mental status was normal.
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