History

Fact Explanation
Non bizarre delusions at least for 1 month of duration. Delusions that involves situations in real life- such as being followed, loved, poisoned, infected, deceived by a spouse or a lover) [1]
Criteria for schizophrenia has never been met. Criterion A for schizophrenia: Characteristic symptoms: Two or more of the following, each present for much of the time during a one-month period. 1)Delusions 2)Hallucinations 3)Disorganized speech (frequent derailment or incoherence) 4)Grossly disorganized or catatonic behavior. 5)Negative symptoms: Blunted affect, alogia (poverty of speech), or avolition (lack of drive or motivation) If the delusions are bizarre, or hallucinations consist of one voice participating in a running commentary or of hearing two or more voices conversing with each other(3rd person hallucinations), only that symptom is required for the diagnosis. Auditory and visual hallucinations, if present, are not prominent as in schizophrenia. Olfactory and tactile hallucinations may be present and prominent when they are related to the delusional theme. [1]
Day to day functioning is not markedly impaired and behavior is not obviously odd or bizarre. Because the personality is well preserved, other than the odd behavior which is directly related to the person's delusions, his/her daily functioning is normal. [1]
If mood episodes have occured concurrently with delusion, their total duration has been brief when relative to the duration of delusions. Major depressive disorder can give rise to nihilistic delusions. [1]
The delusions are not due to a direct physiological effect of a substance or a general medical condition. Substance like cocaine and medical conditions like, Alzheimer's disease , Systemic Lupus Erythematosus (SLE). [1]
References
  1. YASSA R, SURANYI-CADOTTE B. Clinical characteristics of late-onset schizophrenia and delusional disorder. Schizophr Bull [online] 1993, 19(4):701-7 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8303221

Examination

Fact Explanation
Mental State Examination: Appearance Preoccupied, withdrawn, inactive, restless. Crumpled clothes, self neglect suggests alcoholism,substance abuse or severe psychotic symptoms. Exclude co-morbid conditions like depression where vertical furrows in the brow, hunched shoulders, turned down face can be seen. [1]
Mental State Examination: Speech May be difficult to follow. May speak slowly if the patient has co morbid depression. [1]
Mental State Examination: Mood Blunt in congruity. [1]
Mental State Examination: Thinking Vagueness, disorders of stream of thoughts- pressure of thoughts,poverty of thoughts, thought blocking. Primary or secondary delusions.Suicidal thoughts in severe depression. [1] Types of delusions can be as follows, this known as the delusional theme: 1)Erotomanic type- delusions that another person, who is usually of higher status is in love with the individual. 2)Grandiose type- delusions of inflated worth, power, knowledge, identity, or special relationship to a famous person. 3)Jealous type- delusions that the individual's sexual partner is unfaithful. 4)Somatic type- delusions that the person has some physical defect or general medical condition. 5)Persecutory type- delusions that the person is malevolently treated some way. 6)Mixed type- Delusions characteristic of more than one of the above types but no one theme predominates. 7)Unspecified type [4]
Mental State Examination: Perception Normal. [1]
Mental State Examination: Cognitive functions Orientation normal. Attention and concentration and memory can be impaired. [1]
Mental State Examination: Insight Insight is impaired. [1]
Thorough nervous system examination. To exclude medical conditions that can cause delusions like dementia, look for residual signs of past strokes in vascular dementia (face, are, leg weakness). [2]
Tachycardia, elevated body temperature, elevated blood pressure, dilated pupils, sings of undernourishment. Look for signs of substance abuse- cocaine.[3]
References
  1. IBANEZ-CASAS I, DE PORTUGAL E, GONZALEZ N, MCKENNEY KA, HARO JM, USALL J, PEREZ-GARCIA M, CERVILLA JA. Deficits in Executive and Memory Processes in Delusional Disorder: A Case-Control Study PLoS One [online] , 8(7):e67341 [viewed 09 June 2014] Available from: doi:10.1371/journal.pone.0067341
  2. KIRAN C, CHAUDHURY S. Understanding delusions Ind Psychiatry J [online] 2009, 18(1):3-18 [viewed 09 June 2014] Available from: doi:10.4103/0972-6748.57851
  3. ROUNSAVILLE BJ. DSM-V Research Agenda: Substance Abuse/Psychosis Comorbidity Schizophr Bull [online] 2007 Jul, 33(4):947-952 [viewed 09 June 2014] Available from: doi:10.1093/schbul/sbm054
  4. GONZáLEZ-RODRíGUEZ A, MOLINA-ANDREU O, NAVARRO ODRIOZOLA V, GASTó FERRER C, PENADéS R, CATALáN R. Suicidal Ideation and Suicidal Behaviour in Delusional Disorder: A Clinical Overview Psychiatry J [online] 2014:834901 [viewed 05 June 2014] Available from: doi:10.1155/2014/834901

Differential Diagnoses

Fact Explanation
Delusions due to general medical conditions. Dementia in Alzheimer's disease, delirium due to medical conditions like organ failure, sepsis, thyroid diseases. [1]
Substance induced psychotic disorder. Due to stimulants such as amphetamines, cocaine. [2]
Schizophrenia or schizophreniform disorder. But in delusional disorder, the characteristic features of schizophrenia is absent. For example - Prominent auditory or visual hallucinations thought echo thought broadcasting, catatonic behavior, negative symptoms). [3]
Mood disorders with psychotic symptoms. Mood disorders with psychotic features also involve non bizarre delusions like in delusional disorder. The diagnosis depends on the temporal relationship between the delusional symptoms and the mood symptoms. The delusional disorder is diagnosed only if the total duration of all mood symptoms remain brief when compared to the total duration of delusional disturbance. And in delusional disorder, mood symptoms are mild. [4]
Shared psychotic disorder. The delusions arise in the context of a close relationship with somebody, who is having delusions, and the delusions are similar in form to the other person's. [5]
Brief psychotic disorder. Differentiated from the psychotic disorder from the fact that the delusions persist less than 1month of duration.[4]
Psychotic disorder not otherwise specified. When available information is insufficient to come to an diagnosis. [5]
Hypochondriasis. Hypochondriasis is the fear of having a series of diseases. which is not held in a firm belief as in delusions. Patients can be convinced of the possibility of him/her not having a disease. [5]
Body dimorphic disorder. The person is preoccupied with some imagined defect in the appearance. But the belief is not as strong as in delusional disorders. [5]
Obsessive compulsive disorder. Unlike in delusional disorder, patients know that their obsessions and compulsions are unreasonable and excessive. [5]
References
  1. IGLEWICZ A, MEEKS TW, JESTE DV. New Wine in Old Bottle: Late-Life Psychosis Psychiatr Clin North Am [online] 2011 Jun, 34(2):295-318 [viewed 09 June 2014] Available from: doi:10.1016/j.psc.2011.02.008
  2. KUEPPER R., VAN OS J., LIEB R., WITTCHEN H.-U., HOFLER M., HENQUET C.. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study. BMJ [online] December, 342(mar01 1):d738-d738 [viewed 05 June 2014] Available from: doi:10.1136/bmj.d738
  3. GROVER S, NEHRA R, BHATEJA G, KULHARA P, KUMAR S. A comparative study of cognitive deficits in patients with delusional disorder and paranoid schizophrenia Ind Psychiatry J [online] 2011, 20(2):107-114 [viewed 09 June 2014] Available from: doi:10.4103/0972-6748.102499
  4. KIRAN C, CHAUDHURY S. Understanding delusions Ind Psychiatry J [online] 2009, 18(1):3-18 [viewed 09 June 2014] Available from: doi:10.4103/0972-6748.57851
  5. GONZáLEZ-RODRíGUEZ A, MOLINA-ANDREU O, NAVARRO ODRIOZOLA V, GASTó FERRER C, PENADéS R, CATALáN R. Suicidal Ideation and Suicidal Behaviour in Delusional Disorder: A Clinical Overview Psychiatry J [online] 2014:834901 [viewed 09 June 2014] Available from: doi:10.1155/2014/834901

Investigations - for Diagnosis

Fact Explanation
Imaging (MRI brain) To exclude organic causes for psychotic symptoms. (Dementia - Alzheimer's, vascular types). [1]
Thyroid function tests. (TSH, T4) Hypothyroidism can give rise to psychotic symptoms. [1]
Urine testing for hallucinogenic drugs. Exclude the use of cocaine, amphetamines, and cannabinoids can give rise to psychotic symptoms. [2]
References
  1. IGLEWICZ A, MEEKS TW, JESTE DV. New Wine in Old Bottle: Late-Life Psychosis Psychiatr Clin North Am [online] 2011 Jun, 34(2):295-318 [viewed 09 June 2014] Available from: doi:10.1016/j.psc.2011.02.008 [1]
  2. FREUDENMANN RW, LEPPING P. Delusional Infestation Clin Microbiol Rev [online] 2009 Oct, 22(4):690-732 [viewed 09 June 2014] Available from: doi:10.1128/CMR.00018-09

Management - General Measures

Fact Explanation
Identify the cases that require immediate or emergency care and admission to hospital. Patients with acute symptom onset with obvious somatic disease, delirium, substance withdrawal or acute intoxication, or may have rare cases of psychiatric risk, such as self-neglect, risk of suicide or aggression. These patients require immediate attention of a medical person. [1]
Ask patients about signs of depression, about suicidal ideation and evaluate any possible risk to others. Patients with psychotic symptoms may have secondary depression which need to be diagnosed. And has to take necessary steps to ensure patient's and others' safety. [1]
Inform the patient about the disorder and educate them. Indicate that this may be due to over-activity in the nervous system in the brain. [2]
Educate them about the treatment options available. Introduce anti psychotics as the only substances helpful against these processes, as suggested by current research. [2]
Educate the family and friends regarding the patient's condition. Frequently, the delusional ideas and behaviors are more distressing to family members or neighbors than they are to the patient. [3]
References
  1. TARGUM SD. Treating Psychotic Symptoms in Elderly Patients Prim Care Companion J Clin Psychiatry [online] 2001, 3(4):156-163 [viewed 09 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181181
  2. KIRAN C, CHAUDHURY S. Understanding delusions Ind Psychiatry J [online] 2009, 18(1):3-18 [viewed 09 June 2014] Available from: doi:10.4103/0972-6748.57851
  3. FREUDENMANN RW, LEPPING P. Delusional Infestation Clin Microbiol Rev [online] 2009 Oct, 22(4):690-732 [viewed 09 June 2014] Available from: doi:10.1128/CMR.00018-09

Management - Specific Treatments

Fact Explanation
Pharmacological Therapy: Typical Antipsychotics. Conventional anti psychotics - haloperidol, thioridazine, clopromazine, pimozide, trifluperazine. [1] they are dopamine (D2) post synaptic receptor antagonists. Side effects- Extra pyramidal symptoms (EPS) : dystonia, dyskinesia, bradykinesia, and akathisia, Tardive Dyskinesia. Anticholinergic effects: Dry mouth, urinary retention, constipation. blurred vision, angle closure glaucoma (rare). Antiadrenergic effects : postural hypotension, ejaculatory delay. cardiovascular side effects: Postural hypotension, tachycardia, arrhythmia. Hyperprolactineamia: menstrual abnormalities, galactorrhoea, gynaecomastia, impotence. [2] Intramuscular application of traditional depot anti psychotics, require less cooperation than oral medication. So more suitable for patients who are not compliant with the treatment. [3]
Pharmacological Therapy: Atypical Antipsychotics. Atypical antipsychotic drugs- clozapine, quetiapine, olanzapine, risperidone, ziprasidone, aripiprazole. Side effects- has lower liability for EPS and tardive dyskinesia when compared to conventional anti psychotics. Metabolic side effects: weight gain, diabetes, hyperlipideamia, metabolic syndrome. Hyperprolactineamia: menstrual abnormalities, galactorrhoea, gynaecomastia, impotence. [1] Amisulpride- action resembles that of typical antipsychotics without the same high probability of side-effects. [3]
References
  1. TARGUM SD. Treating Psychotic Symptoms in Elderly Patients Prim Care Companion J Clin Psychiatry [online] 2001, 3(4):156-163 [viewed 09 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181181
  2. MAIXNER SM, MELLOW AM, TANDON R. The efficacy, safety, and tolerability of antipsychotics in the elderly. J Clin Psychiatry [online] 1999:29-41 [viewed 09 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10335669
  3. LEPPING P., RUSSELL I., FREUDENMANN R. W.. Antipsychotic treatment of primary delusional parasitosis: Systematic review. The British Journal of Psychiatry [online] 2007 September, 191(3):198-205 [viewed 09 June 2014] Available from: doi:10.1192/bjp.bp.106.029660