Overview

Delusional disorder is an illness characterized by at least 1 month of delusions but no other

psychotic symptoms according to the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). [1] Delusions are false beliefs
based on incorrect inference about external reality that persist despite the evidence to the
contrary and these beliefs are not ordinarily accepted by other members of the person's culture or
subculture. Delusions can be characterized as persecutory (i.e., belief one is going to be harmed
by an individual, organization or group), referential (i.e., belief gestures, comments, or
environmental cues are directed at oneself), grandiose (i.e., belief that the individual has
exceptional abilities, wealth, or fame), erotomanic (i.e., ani ndividual’s false belief that another
individual is in love with them), nihilistic (i.e., conviction that a major catastrophe will occur), or
somatic (i.e., beliefs focused on bodily function or sensation).

Nonbizarre delusions are about situations that could occur in real life, such as being followed,
being loved, having an infection, and being deceived by one's spouse. Bizarre delusions are
clearly implausible. Delusions that express a loss of control over mind or body are generally
considered to be bizarre and include belief that one’s thoughts have been removed by an outside
force, that alien thoughts have been put into one’s mind, or that one’s body or actions are being
acted on or manipulated by an outside force. [1]

Making a distinction between a delusion and an overvalued idea is important, the latter
representing an unreasonable belief that is not firmly held. [1] Additionally, personal beliefs
should be evaluated with great respect to complexity of cultural and religious differences; some
cultures have widely accepted beliefs that may be considered delusional in other cultures.

Unfortunately, patients with delusional disorder do not have good insight into their pathological
experiences. Interestingly, despite significant delusions, many other psychosocial abilities remain
intact, as if the delusions are circumscribed. Indeed, this is one of the key differences between
delusional disorder and other primary psychotic disorders. However, the individual may rarely
seek psychiatric help, remain isolated, and often present to internists, surgeons, dermatologists,
policemen, and lawyers rather than psychiatrists.

Case study

Mrs. K is a 39-year-old woman who was brought to the inpatient psychiatric unit by police after
being arrested for trespassing on Mr. L’s property. Upon arrival, Mrs. K was adamant about
being released, stating that she was simply entering her husband’s home, adamantly declaring
that Mr. L was her husband. She elaborated a story about how much the two of them loved each
other, when they got married, and how she was currently pregnant with his child. In actuality,
Mr. L used to be Mrs. K’s boss, and had fired her because of her inappropriate romantic
advances several years prior. Mrs. K was married to another man in Florida, with whom she
denied any relationship, stating that she was kidnapped for 4 years, and after escaping, had come
to California to be with her husband, Mr. L. Mrs. K was diagnosed with delusional disorder,
erotomanic type, and was started on risperidone.
Diagnosis
Patient evaluation

Theo Manschreck [19] outlined 3 steps in the initial evaluation of patients who present with
delusions.

First, establish whether pathology is present. This represents a clinical judgment that is
sometimes difficult to make. Some comments that appear delusional may be true. In contrast,
some reports that initially seem believable may later be identified as delusions as the symptoms
worsen, the delusions become less encapsulated (i.e., begin to extend to more people or
situations), and more information comes to light. The clinical judgment that delusions are present
should be made after taking into account the degree of plausibility, systemization, and the
possible presence of culturally sanctioned beliefs that are different from one's own beliefs.
Making the distinction between a true observation, a firm belief, an overvalued idea, and a
delusion is sometimes a challenging task. Often, the extremeness and inappropriateness of the
patient's behaviors, rather than the simple truth or falsity of the belief, indicate its delusional
nature. [19, 4]

The second step is determining the presence or absence of important characteristics and
symptoms often associated with delusions, such as confusion, agitation, perceptual disturbances,
physical symptoms, and prominent mood abnormalities. [19] Studies have shown that the most
common symptoms reported were self-reference (40%), irritability (30%), depressive mood
(20%), and aggressiveness (15%). [20]

The third step is to present a systematic differential diagnosis. A thorough history, mental status
examination, and laboratory/radiologic evaluation should be performed to rule out other medical
and psychiatric conditions that are commonly present with delusions. CNS illness is high on the
differential diagnosis of any psychotic disorder, especially so in the onset of delusional disorder
in patients older than the typical onset of schizophrenia. Delusional disorder should be seen as a
diagnosis of exclusion. [19]

Diagnostic criteria (DSM-5)

The specific DSM-5 criteria for delusional disorder are as follows: [1]

 Presence of one or more delusions with a duration of one month or longer.

 The criteria for schizophrenia has never been met. Note: Hallucinations, if present are not
prominent and are related to the delusional theme (e.g., the sensation of being infected
with insects is associated with the delusions of infestation).
 Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly
impaired, and behavior is not obviously bizarre or odd.
 If manic or major depressive episodes have occurred, these have been brief relative to the
duration of the delusional periods.
  The disturbance is not better explained by another mental disorder such as obsessive-
compulsive disorder, and is not attributable to the physiological effects of a substance or
medication or another medical condition.

Subtypes are defined as erotomanic, grandiose, jealous, persecutory, somatic, mixed, and
unspecified. The diagnosis is further specified “with bizarre content” when delusions are clearly
implausible, not understandable, and not derived from ordinary life experiences.

The following duration specifiers are used only after 1-year duration of the disorder:

 First episode, currently in acute episode

 First episode, currently in partial remission
 First episode, currently in full remission
 Multiple episodes, currently in acute episode
 Multiple episodes, currently in partial remission
 Multiple episodes, currently in full remission
 Continuous

Epidemiology
United states statistics

The prevalence of delusional disorder in the United States is estimated in the DSM-5 to be
around 0.02% [1] , which is considerably lower than the prevalence of schizophrenia (1%) and
mood disorders (5%). [7] Our current understanding of delusional disorder, however, is limited by
scarce scientific data that mostly consist of individual case descriptions or small uncontrolled
case studies, which are therefore difficult or impossible to duplicate. [8]

International statistics

A British study reported that of 227 patients presenting to mental health centers with a first
episode of psychosis during the 3-year study period, 7% were diagnosed with persistent
delusional disorder, as compared to 11% with schizophrenia and 19% with psychotic depression.
[10]

Sexual differences in incidence

The female-to-male ratio has been reported to vary from 1.18 [9] -3:1 [5] . Men are more likely than
women to develop paranoid delusions; women are more likely than men to develop delusions of
erotomania. [7] Associated factors include being married, being employed, recent immigration,
low socioeconomic status, celibacy among men, and widowhood among women. [9, 2]

Age-related differences in incidence

The mean age of onset is 40 years and ranges from 18-90 years. [7] A Spanish study conducted by
de Portugal et al (2008) looked at medical records of 370 people diagnosed with delusional
disorder and found that the mean age in this population was 55 years, with 56.5% of the patients
being female.

Etiology
General considerations

The etiology of delusional disorder is unknown, and several difficulties exist in conducting
research in this area:

 Patients currently diagnosed with delusional disorder may represent a heterogeneous

group of patients with delusions as the predominant symptom.
 Patients often do not present for treatment, and thus they do not commonly make
themselves available for research studies.
 However, strong indications exist that delusional disorder is a distinct condition, different
from schizophrenia or mood disorder. Naturalistic studies indicated that delusional
disorder has a relatively stable course.
 The definition of this condition has changed over time and continues to be a work in
progress.

Genetics

The relationship to the more severe psychosis is yet unclear. According to the DSM-5, on
average, global function is generally better than that observed in schizophrenia. Although the
diagnosis is generally stable, a proportion of individuals go on to develop schizophrenia.
Delusional disorder has a significant familial relationship with both schizophrenia and
schizotypal personality disorder. Although it can occur in younger age groups, the condition is
more prevalent in older individuals. [1]

Biochemical factors

Biological factors may play some role in the development of delusional disorder, as delusions are
associated with a wide range of nonpsychiatric medical conditions. Among patients with
neurologic disorders (primarily dementia, head injury, and seizures) problems with the basal
ganglia and temporal lobe are most commonly associated with delusions. [7, 12] However, a case
report of a somatic delusion involving reduplication of body parts implicated the temporal and
parietal lobes, showing hypoperfusion of both regions. [13]

Campana et al [14] used eye tracking movement tests to understand the relationship between
frontal field functions and clinical symptoms of delusional disorder. They found that compared
with normal participants, patients with delusional disorder showed abnormalities of voluntary
saccadic eye movements and smooth pursuit eye movements, a dysfunction similar to that seen
in patients with schizophrenia.
Hyperdopaminergic states have been implicated in the development of delusions. Recently,
Morimoto et al [15] reported that 13 patients with delusional disorder were reported to have
increased levels of plasma homovanillic acid (HVA) (a dopamine metabolite) compared with
control subjects. Patients responded well to treatment with low-dose haloperidol (average 2.7
mg/d) and showed decreased posttreatment plasma level of HVA, which correlated with the
improvement of their symptoms.

The same authors reported an increased prevalence of a polymorphism at the D2 receptor gene at
amino acid 311 (cysteine-for-serine substitution) among individuals with delusional disorder in
their sample, particularly those with persecutory delusions. Individuals that had more TCAT
repeats within the first intron of the tyrosine hydroxylase gene had higher levels of HVA,
although it is unclear if they corrected for multiple statistical comparisons. [15]

Psychological factors

The fields of cognitive and experimental psychology suggest that persons with delusions
selectively attend to available information, which appears to overlap with hypochondriacal
patient populations. [16] They make conclusions based on insufficient information, attribute
negative events to external personal causes, and have difficulty in envisaging others’ intentions
and motivations. [4]

Conway et al [17] reported that patients with delusional disorder made probability decisions based
on fewer data compared with normal controls. Despite using fewer data, they were as certain as
controls regarding the accuracy of their decisions.

Two neuropsychological models proposed for schizophrenia may also have some validity in
delusional disorder. A cognitive bias model (CBM) proposes that paranoia is a defense against
thoughts that threaten the idealized self, to protect a fragile self-esteem. Positive events are
attributed to the self whereas negative events are ascribed to the external environment. In
contrast, the cognitive deficit model (CDM) focuses on cognitive impairments and distortions of
threat evaluating mechanisms as the cause for delusion formation. [18]

Clinical Features
The status examination (including cognitive examination) is usually normal with exception of the
presence of abnormal delusional beliefs.

In general, patients are well groomed and well-dressed without evidence of gross impairment.
Speech, psychomotor activity, and eye contact may be affected by the emotional state associated
with delusions, but are otherwise normal.

Mood and affect are consistent with delusional content; for example, patients with persecutory
delusions may be suspicious and anxious. Mild dysphoria may be present without regard of type
of delusions.
Tactile and olfactory hallucinations may be present and may be prominent if they are related to
the delusional theme (eg, the sensation of being infested by insects, the perception of body odor).
[6]
Systemic or CNS causes of tactile and olfactory hallucinations, such as substance intoxication
and withdrawal, and temporal lobe epilepsy, should be ruled out. Auditory or visual
hallucinations are characteristic of more severe psychotic disorders (eg, schizophrenia) and
should lead away from a diagnosis of delusional disorder.

Memory and cognition are intact. Level of consciousness is unimpaired.

Patients usually have little insight and impaired judgment regarding their pathology. Police,
family members, coworkers, and physicians other than psychiatrists are usually the first to
suspect the problem and seek psychiatric consultation. Seeking corroborative information, when
permitted by the patient, is often crucial. Recall that it is permissible to seek collateral history but
that collateral history should not be withheld from the patient.

Assessment of homicidal or suicidal ideation is extremely important in evaluating patients with

delusional disorder. The presence of homicidal or suicidal thoughts related to delusions should
be actively screened for and the risk of carrying out violent plans should be carefully assessed.
Reid (2005) pointed out that some types of this illness—erotomanic, jealous, and persecutory—
are associated with higher risk for violence than others. [21] History of previous violent acts as
well as history of how aggressive feelings were managed in the past may help to assess the risk.
Access to weapons should be explored.

Erotomanic type

Related terms include erotomania, psychose passionelle, Clerambault syndrome, and old maid's
insanity. [2, 4, 5]

The central theme of delusions is that another person, usually of higher status, is in love with the
patient. The object of delusion is generally perceived to belong to a higher social class, being
married, or otherwise unattainable. [3, 5]

Patients with this type of delusion are generally female, although males predominate in forensic
samples. [1, 5]

Delusional love is usually intense in nature. Signs of denial of love by the object of the delusion
are frequently falsely interpreted as affirmation of love. [2, 5]

Patients may attempt to contact the object of the delusion by making phone calls, sending letters
and gifts, making visits, and even stalking. Some cases lead to assaultive behaviors as a result of
attempts to pursue the object of delusional love or attempting to "rescue" her/him from some
imagined danger. [1]

Grandiose type
Patients believe that they possess some great and unrecognized talent, have made some important
discovery, have a special relationship with a prominent person, or have special religious insight.
[1]

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. [4]

Grandiosity in narcissistic personality disorder is by definition nonpsychotic and not directly

related to an elevated mood state, as in bipolar disorders. Narcissistic patients will concurrently
show a lack of empathy, exploitive behavior, and a sense of entitlement in addition to
grandiosity.

Jealous type

Related terms include conjugal paranoia, Othello syndrome, and pathological or morbid jealousy.
[19, 7, 22, 23]

The main theme of the delusions is that her or his spouse or lover is unfaithful. Some degree of
infidelity may occur; however, patients with delusional jealousy support their accusation with
delusional interpretation of "evidence" (eg, disarrayed clothing, spots on the sheets). [1, 4]

Patients may attempt to confront their spouses and intervene in imagined infidelity. Jealousy may
evoke anger and empower the jealous individual with a sense of righteousness to justify their
acts of aggression. Both the intimate partner and the (perceived) lover may be the targets of
aggression and violence. This disorder can sometimes lead to acts of violence, including suicide
and homicide. [4]

Persecutory type

This is the most common type of delusional disorder. [20, 25]

Patients with this type believe that they are being persecuted and harmed. [4] 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. [2]

Patients are often involved in formal litigation against their perceived persecutors. Munro [3]
refers to an article by Freckelton who identifies the following characteristics of deluded litigants:
determination to succeed against all odds, tendency to identify the barriers as conspiracies,
endless drive to right a wrong, quarrelsome behaviors, and "saturating the field" with multiple
complaints and suspiciousness. [3]

Patients often experience some degree of emotional distress such as irritability, anger, and
resentment. [4] In extreme situations, they may resort to violence against those who they believe
are hurting them. [1]
The distinction between normality, overvalued ideas, and delusions is difficult to make in some
of the cases. [4]

Somatic type

The core belief of this type of disorder is delusions around bodily functions and sensations. The
most common are the belief that one is infested with insects or parasites, emitting a foul odor,
parts of the body are not functioning, the belief that their body or parts of the body are misshapen
or ugly, and the reduplication of body parts. [1, 13]

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. [2]

Patients are usually first seen by dermatologists, cosmetic surgeons, urologists,

gastroenterologists, and other medical specialists. [4]

Sensory experiences associated with this illness (eg, sensation of parasites crawling under the
skin) are viewed as components of systemized delusions. [4] This must be distinguished from
bizarre somatic delusions occasionally seen in schizophrenia (eg, a delusion that a colony of
lobsters is living in the patient’s stomach).

Mixed type

Patients exhibit more than one of the delusions simultaneously [4] , and no one delusional theme
predominates. [1]

Unspecified type

Delusional themes fall outside the specific categories or cannot be clearly determined. [1]

Misidentification syndromes such as Capgras syndrome (characterized by a belief that a familiar

person has been replaced by an identical impostor) or Fregoli syndrome (a belief that a familiar
person is disguised as someone else) fall into this category. Misidentification syndromes are rare
and frequently are associated with other psychiatric conditions (eg, schizophrenia) or organic
illnesses (eg, dementia, epilepsy). [4]

Another unusual syndrome is Cotard syndrome, in which patients believe that they have lost all
their possessions, status, and strength as well as their entire being, including their organs. [4]
Described first in the 19th century, it is a rare condition, which is usually considered a precursor
to a schizophrenic or depressive episode. [2]

Differential Diagnosis
Table 1. Medical Conditions Associated With Development of Delusions [4] (Open Table in a
new window)
Medical Conditions Examples
Alzheimer disease, Pick disease, Huntington disease, Parkinson Disease,
Neurodegenerative
basal ganglia calcification (Fahr disease), multiple sclerosis,
disorders
metachromatic leukodystrophy
Brain tumors, especially temporal lobe and deep hemispheric tumors;
Other CNS disorders epilepsy, especially complex partial seizure disorder; head trauma
(subdural hematoma); anoxic brain injury; fat embolism
Atherosclerotic vascular disease, especially when associated with diffuse,
Vascular disease temporoparietal, or subcortical lesions; hypertensive encephalopathy;
subarachnoid hemorrhage, temporal arteritis
Human immunodeficiency virus/acquired immune deficiency syndrome
Infectious disease (AIDS), opportunistic infections in AIDS, encephalitis lethargica,
Creutzfeldt-Jakob disease, syphilis, malaria, acute viral encephalitis
Hypercalcemia, hyponatremia, hypoglycemia, uremia, hepatic
Metabolic disorder
encephalopathy, porphyria
Addison disease, Cushing syndrome, hyperthyroidism or hypothyroidism,
Endocrinopathies
panhypopituitarism
Vitamin B-12 deficiency, folate deficiency, thiamine deficiency, niacin
Vitamin deficiencies
deficiency
Adrenocorticotropic hormones, anabolic steroids, corticosteroids,
Medications cimetidine, antibiotics (eg, cephalosporins, penicillin), disulfiram,
anticholinergic agents
Substances Amphetamines, cocaine, alcohol, cannabis, hallucinogens
Toxins Mercury, arsenic, manganese, thallium

Delusional symptoms are preferentially associated with disorders involving the limbic system
and basal ganglia. [4]

Fifty percent of patients with Huntington disease and individuals with idiopathic basal ganglia
calcifications developed delusions at some point of their illness. [4]

Head trauma has been associated with development of delusions. Koponen et al [27] found
patients with traumatic brain injury were diagnosed with delusional disorder in 5% of the cases
during a 30-year follow-up (3 out of 60 assessed patients).

Table 2. Related Psychiatric Disorders and Differentiating Features (Open Table in a new
window)

Disorder Differentiating Features

Fluctuating level of consciousness, altered sleep/wake cycle,
Delirium hallucinations and impaired cognition are features of delirium that
are absent in delusional disorder.
Dementia Delusions (usually persecutory) are common in Alzheimer and
 other types of dementia (the prevalence ranges from 15-50%) and
may present first, before subclinical cognitive deficits become
apparent. Neuropsychological testing may be warranted to detect
cognitive impairments. Additionally, elderly patients with
delusional disorder were found to have an incidence of dementia
that was twice as high as in the general population over a 10-year
follow-up period. [28]
Amphetamines and cocaine are the most commonly described
substances to be associated with delusions, typically of
persecutory type. Other illicit drugs (especially hallucinogens,
anabolic steroids) and alcohol have been related to the
development of delusions. (For example, alcohol withdrawal is a
Substance-related disorders
common condition, which may present with tactile or somatic
(intoxication, withdrawal,
delusions). Prescribed substances (especially steroids, dopamine
substance-induced psychotic
agonists), OTC medications (especially sympathomimetics), and
disorder with delusion)
herbal products may also be associated with delusions. Careful
substance and medication use history with specific attention to
temporal relationship between substance use and
onset/persistence of delusional symptoms may aid in differential
diagnosis.
Mood symptoms are common in persons with delusional disorder
and often represent a proportionate emotional response to
perceived delusional experiences. However, given that mood
disorders are common in the general population, they may present
as comorbid conditions, often predating delusional disorder.
Mood disorders with
Mood symptoms of mood disorders contrary to mood symptoms
delusional symptoms (manic
of delusional disorder are prominent and meet criteria for a full
or depressive type)
mood episode (depressive, manic, or mixed). Delusions
associated with mood disorders usually develop after the onset of
mood symptoms and progress secondary to mood abnormalities.
Mood symptoms of delusional disorder are generally mild and
delusions usually exist in the absence of mood abnormalities.
Delusions of schizophrenia are bizarre in nature, and
thematically-associated hallucinations are common. Additionally,
Schizophrenia disorganized thought process, speech, or behaviors is present.
Negative symptoms and deterioration in function are prominent.
Cognitive deficits are common.
Patients with hypochondriasis are usually able to doubt (at least
for a short while) their convictions of having illness when
Hypochondriasis presented with reassuring data. Most of them have a long history
of illness preoccupation, and their fears are usually not limited to
a single symptom or organ system.
Many patients with BDD hold their beliefs with conviction that
Body dysmorphic disorder
reaches level of delusions, leading to a significant overlap
(BDD)
between these conditions.

Obsessive-compulsive
disorder (OCD)
Paranoid personality disorder disorder, while the delusional disorder most commonly presents
Shared psychotic disorder
Patients with OCD show a varying degree of insight into their
obsessions and compulsions. If reality testing is lost and
conviction in their beliefs reaches the level of delusions, both
disorders may be present.
Differentiation between extreme characterological suspiciousness
and frank delusions may be difficult. History of pervasive distrust
beginning by early adulthood is suggestive of personality
as an acute illness of middle life. Additionally, patients with
paranoid personality disorder frequently appear to be unemotional
and lack warmth in their relationships.
Symptoms emerge in the context of a close relationship with
another person with delusional beliefs and diminish with
separation from that other person.

Treatment & Management

General considerations

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.

Treatment principles include the following:

 Establish a therapeutic alliance and negotiate acceptable symptomatic treatment goals.

Start where "the patient is at," and offer empathy, concern, and interest in the experiences
of the individual.
 With the appropriate permission from the patient, include the patient's family in decision-
making and educate them.
 Consider the impact of culture for treatment planning.
 Avoid direct confrontation of the delusional symptoms to enhance the possibility of
treatment compliance and response.
 Use medication judiciously to target core symptoms and associated problems (eg, anger).
 Use outpatient treatment unless there is potential for harm or violence.
 Tailor treatment strategies to the individual needs of the patient and focus on maintaining
social function and improving quality of life.
 Recognize and treat coexisting psychiatric disorders.
 Inpatient hospitalization should be considered if a patient’s delusions cause him or her to
be a threat to self, others, or if he or she is deemed to be gravely disabled.

Psychopharmacological treatment

The evidence for the psychopharmacological treatment of delusional disorder would commonly
be considered "grade C" (case series) or "grade D" (single case studies) evidence in many
evidence-based medicine hierarchies. This is in contrast to randomized, blinded studies (grade A)
or nonrandomized or nonblinded, but still systematically conducted, studies (grade B).

Antipsychotics have been used since the 1970s when the first report was published on the use of
pimozide for the treatment of monosymptomatic hypochondriacal psychosis (now classified as a
delusional disorder, somatic type by DSM-5). Of approximately 1000 treated cases of delusional
disorder from 1965-1985, a subanalysis of 257 best-described cases revealed that delusional
disorder has a relatively good prognosis when adequately treated — 52.6% of the patients
recovered, 28.2% achieved partial recovery, and 19.2% did not improve. Treatment response was
positive regardless of the specific delusional content. The data concluded that pimozide (68.5%
recovery rate and 22.4% partial recovery rate) may be better than other typical antipsychotics
(22.6% recovery and 45.3% partial recovery). [29]

Data since that time still consists mostly of case reports. The most recent review of treatment for
delusional disorder included 224 case reports published since 1995, though only 134 case reports
were well described. [8] The following is the summary of their findings:

 In general, delusional disorders were reported to be fairly responsive to treatment (50%

of the published patients reported symptom-free recovery and 90% of patients showed at
least some improvement).
 Combination treatment was common. Polypharmacy was common, most often including
a combination of antipsychotic and antidepressant medication. In addition, patients
commonly received more than one antipsychotic over the course of their illness, and
medication treatments were also complemented by other interventions, such as cognitive-
behavioral therapy or even (in a single case) electroconvulsive therapy (ECT).
 In contrast to previous findings, no significant difference was observed between
treatment with pimozide and other antipsychotics. Indeed, no difference was observed
between typical and atypical antipsychotic agents.
 Somatic delusions appeared potentially more responsive to antipsychotic therapy than
other types of delusions (regardless of whether this treatment was pimozide or other
antipsychotics). However, this apparent difference may mostly result from the generally
poor response rates for delusional disorder with persecutory delusions (50% improvement
rates, with no reports of complete recovery).
 No other predictors of a positive outcome have been studied or clearly elucidated (eg,
age, gender, symptom severity, positive family history, or premorbid function).

A systematic review of the literature shows that olanzapine and risperidone are the most common
atypical antipsychotics used. [30, 31] Four reports (5 cases) of individuals with delusions
presumably refractory to previous antipsychotic treatment reported that clozapine was associated
with an improved quality of life and a decrease in symptoms associated with the delusion,
although the central delusional theme often persisted. In contrast, as indicated above, some cases
of delusional disorder appear refractory even to clozapine treatment. [8]

Reviews of treatment of delusional disorder have not systematically addressed the question of
what particular dose of antipsychotics is needed to achieve remission of symptoms. However, a
study of 11 patients with delusional disorder appeared to be adequately treated on fairly low
doses of antipsychotic (4.7 mg of haloperidol). [15]

Antidepressants have been successfully used for the treatment of delusional disorder, although
primarily of the somatic type. The data consist of case reports showing improvement with
selective serotonin reuptake inhibitor (SSRI) [32] and clomipramine treatments [33, 34] . Several case
reports documented successful treatment with SSRI for culture-bound syndromes (conditions
that would be diagnosed as somatic type of delusional disorder in Western cultures). [35]

A single case report of successful ECT use for somatic delusions exists. [36]

In summary, a reasonable pharmacological treatment approach for the patient with delusional
disorder is a standard trial of an antipsychotic or, for somatic delusions, an SSRI at starting doses
commonly used to treat psychotic or mood disorders.

Psychotherapy

For 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 that may
increase symptoms, 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. [37]

Cognitive therapeutic approaches may be useful for some patients and this is best studied in
persecutory type. The therapist helps the patient to identify maladaptive thoughts by means of
Socratic questioning and behavioral experiments and then replaces 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. [38, 37, 39]

A recent study evaluated the effectiveness of cognitive-behavioral therapy (CBT) versus

attention placebo control (APC) as a means to treat delusions in delusional disorder. Using the
Maudsley Assessment of Delusions Schedule (MADS), the study found that both APC and CBT
improved belief and mood parameters associated with delusions. However, CBT produced more
of an impact when compared to APC on strength of conviction, affect relating to belief, and
positive actions of beliefs, suggesting CBT as a successful means of treating delusional disorder.
[40]

According to Liberman [41] , another technique that may be applicable to a wider population of
persons with delusional disorder is behavioral principles and social skills training to provide the
individual with effective means of "feeling in control" and less subject to viewing others' efforts
to harm him/her as allowing "them" to be controlling. Social skills training focuses on promoting
interpersonal competence, confidence (with successful use of more competent social skills) and
comfort in interacting with those who the individual feels are judging and having harmful intent
toward him/her. Taking control and initiative can dissipate the feeling of loss of control that
feeds into and reinforces the delusions.

The literature also states that insight-oriented therapy may be indicated, rarely [37] or
contraindicated for delusional disorder [2] . However, reports exist of successful treatment. [38]
Goals in insight-oriented therapy include development of the therapeutic alliance; containment of
projected feelings of hatred, badness, and impotence; measured interpretation; and, ultimately,
development of a sense of creative doubt in the internal perception of the world through empathy
with the patient's defensive position. [38]