In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is delusional disorder.
Delusional disorder falls within the DSM-5 group of psychotic disorders, which also includes schizophrenia and schizoaffective disorder. However, it’s different, in that its effects are much more compartmentalized. It’s rare, and the vast majority of people who experience delusions do not have delusional disorder.
Symptoms
In delusional disorder, the delusional beliefs are focused on one area of the individual’s life, and they don’t really bleed over into other areas. The delusions are non-bizarre, meaning they’re at least somewhat within the realm of possibility (e.g. being harassed by the neighbours rather than having aliens come down to the chimney to implant listening devices in one’s stomach), but they are still delusional.
Typically, hallucinations aren’t present, but there are sometimes olfactory (smell) or tactile (touch) hallucinations related to the delusional themes.
If someone has met the diagnostic criteria for schizophrenia at some point, they can’t be diagnosed with delusional disorder.
Functioning is generally preserved in areas that aren’t directly related to the delusions. This means that other people might have no idea that the individual was unwell if their interactions didn’t venture into the topic area related to the delusions.
Delusional disorder subtypes
There are several subtypes based on the nature of the delusions:
- Erotomanic: delusions revolve around the belief that someone else is in love with them, and the delusional individual may end up stalking/harassing that person as a result
- Grandiose: these beliefs about having special attributes or abilities are to the intensity and extent that they’re delusional
- Jealous: these delusions tend to focus on the delusional individual’s partner being unfaithful, even when there’s no evidence to indicate that they are
- Persecutory: paranoid beliefs about others harming them, which may lead to pursuing litigation or criminal charges against the person that’s believed to be responsible; this is the most common subtype
- Somatic: these delusions relate to something being wrong with one’s body
It’s worth noting that while delusional disorder is subtyped based on the type of delusions it presents with, the delusions themselves can occur in any type of disorder with psychosis, including schizophrenia or mood disorders.
Other characteristics
Delusional disorder typically arises well into adulthood, with the average onset at age 40. Sometimes it will develop in people who already have paranoid personality disorder. It’s less common than schizophrenia, occurring in only 0.1–0.2% of the population. It doesn’t tend to occur more in one sex than the other, although females are more likely to have the erotomanic subtype, while males are more likely to have jealous or persecutory delusions.
Psychological factors, including social isolation, envy, suspicion, and low self-esteem may contribute to people developing delusional explanations for their inability to cope. A number of potential biological factors have been identified, but nothing clear-cut has been established.
Some of the associated factors with delusional disorder(note: correlation does not equal causation) include being married, being employed, having recently immigrated, low socioeconomic status, being celibate (for men), and being widowed (for women).
Treatment
Anosognosia (lack of insight) is typical with this condition, and it can make treatment and establishing a therapeutic relationship difficult. The focus may be to prevent destructive behaviours related to the delusions. Antipsychotics may help, and sometimes mood stabilizers are used as an adjunctive treatment. However, delusional disorder tends to be much less responsive to medications than other psychotic conditions.
The prognosis is better for females, those whose illness begins before age 30, and those who have a sudden onset of symptoms.
A clinical example
I had a few patients with delusional disorder over the years, but the one I got to know best was my patient at a community mental health team. He had the persecutory subtype, and believed there was a group of people harassing him. While he had zero insight, he was very bright and cognitively intact.
He accepted medication primarily because it helped with sleep, and he was willing to accept mental health support in relation to the stress he experienced secondary to the harassment. There would have been no hint of psychosis if the conversation didn’t venture into the area of this perceived harassment. Had we tried to work on insight with him, I’m quite sure that would have been the end of him agreeing to see us. It’s quite the fascinating disorder, although certainly not something that would be easy to live with.
Is delusional disorder something you’ve ever heard of or encountered?
References
The post Let’s Talk About Psychosis is the hub for all psychosis-related content on Mental Health @ Home.
The Psychology Corner has an overview of terms covered in the What Is… series, along with a collection of scientifically validated psychological tests.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
Very informative article on something rare.
Interesting. I hadn’t heard of it. I see this trait in various public figures, though who knows if it rises to the level of clinical. Denial seems to be part too. A very interesting read: thank you. 😊
That’s more of a paranoid personality flavour. Delusional disorder is very focused and doesn’t have that same pervasiveness. It’s like highly compartmentalized crazy, which is pretty unusual.
The human brain is a very interesting animal.
Absolutely.
Haven’t seen this in my private practice. Great post!
It’s a rare one, but fascinating to encounter.
The wordpress app has officially pissed me off. Subscribing by email so you may not see me commenting as much but I’ll definitely keep reading
WordPress is so annoying!!!
I’m pretty sure my friend has paranoid delusions. she has even called police on me saying I was threatening her when I wasn’t. She’s very unstable but she also has paranoid personality disorder. I would think its a horrible disorder to live with. <3
That sounds really hard!
This same friend stop talking to me last October out of the blue no reason why she didn’t give me any reason she just quit talking to me and blocked me
Oh, I remember you talking about that.
I’d never heard of that, but the subject is fascinating. Thanks for your information! 😀
I have persecutory delusions, but I am able to cope. Still, I find my “beliefs” needing to be challenged a lot. I am working on making fewer assumptions, because I have learned that I am better off not doing that. As an aside, so is everyone else!
As the saying goes, to assume make an ass out of u and me!
Right on! So true…
I had never heard of this, so through your writing, I again learned something new. Thank you for sharing your knowledge with us here. 😊
Ashley, I am always amazed with how you capture and share so much is such a concise and informed way. This is such a difficult diagnosis to understand and treat. I really appreciate the insight around treatment not being aimed at insight. I think many clients who can genuinely benefit from the therapeutic relationship and sometimes eyes on (for safety) don’t stay. And, this brings a whole host of other issues. Thank you for sharing this.
Ashley, I am always impressed with how you capture and share such relevant information is such a concise and informed way. This is such a difficult diagnosis to understand and treat. I really appreciate the insight around treatment not being aimed at insight. I think many clients who can genuinely benefit from the therapeutic relationship and sometimes eyes on (for safety) don’t stay. And, this brings a whole host of other issues. Thank you for sharing this.
It’s amazing what a therapeutic relationship can accomplish even when there’s fundamental disagreement about the source of an individual’s problems.
I agree. 💗
Great article does it do this with ADHD medication as well
Delusional disorder isn’t drug-induced, but meds can cause psychotic symptoms.
Lol I commented on the wrong post I meant about the one on medication half-life sorry
Or is there a way to extend the half-life of adhd meds
A medication’s half-life can’t be changed, but extended release formulations can slow the rate that the drug enters the circulation.
Lol I figured that’s why I switched to two a day because the half-life of concerta was getting shorter and shorter
Can I ask you something on Twitter email you about advice on my new psychiatrist
Sure, email me.
I had erotomanic delusions, for sure, seeing the impact of it on me in those few years. I was performing okay at work. Despite the rejections, I just could not get out of it at all. I hope someone could have stepped in and helped me but no one cared even though I did open up. Eventually, I managed to move on after starting my new journey in doing PhD for better understanding mental health.
That must have been very hard, but I’m glad you were eventually able to move on. ❤️
Yes luckily. I am indeed blessed. I was so addicted to the false beliefs. Some helpful things help me to move on and be more careful not to have any relapse.
Judging by my past thoughts and behaviors, I see what I have to look forward to in my next decade. Forewarned is forearmed.
Hmm… now you’ve explained erotomanic, that sounds a lot like what a relative did a while back… wouldn’t surprise me!
Yeah, erotomanic delusions can be interesting. There’s an erotomanic subtype to delusional disorders, but erotomanic delusions can happen in any illness with psychosis, including bipolar.
My best friend of 32 years, who is like a sister, believes that she was working for a secret in-house operation that has cultic language and is able to “ride” on people and speak through and control them. She also believed that the people in charge were grabbing her and doing operations in the office, such as hysterectomies or neck, shoulders and back operations. I pointed out that I had been trained as a nurse’s aide and had nursed three people with serious diseases. There were no stitches, or any sign of body penetration. I asked her if she could show me the aftermath at all. She got upset and told me that “you never believe me.”
The problem is that she is also a sexual abuse victim of her family. There is credible evidence that her family was into sexual human trafficking. But she can never be an open voice for victims because frankly she comes across like a nut when she talks about her memories. Like recently she said she had been shot years ago. I told her that I had nursed gun shots, including my own father who was shot by robbers when I was a kid. I asked some hard medical questions, which she ignored. I asked whether she went to the hospital. She said no, the bullet fell out or disappeared, she wasn’t sure. And probably someone took it and hid it. But she was “shot all right” in her leg. I told her that was nuts and as my brother got all shot up in Vietnam and had to recuperate, how come that hadn’t happened to her?
She doubled down on what she said and went on talking as if I wasn’t even there.
Recently, in June she started bleeding one day some five years after menopause and three years after the supposed removal of her uterus. I made her go to a female doctor. She examined her and found a cervix and a uterus. She then took a pap smear and suggested she get an MRI. Guess who was not interested in the follow up?
Now I am really worried about her. She complains of pain day and night but she insists that she is “so much better” due to these secret in office visits, operations and pain shots. I tell her that this is impossible for obvious reasons such as insurance not covering secret medical operations, possible lawsuits, etc. She just clams up and mutters under her breath about pain meds in her arms during her lunch hour and folks following her around to help protect her. The people on
Recently, in June she started bleeding one day some five years after menopause and three years after the supposed removal of her uterus. I made her go to a female doctor. She examined her and found a cervix and a uterus. She then took a pap smear and suggested she get an MRI. Guess who was not interested in the follow up?
Now I am really worried about her. She complains of pain day and night but she insists that she is “so much better” due to these secret in office visits, operations and pain shots. I tell her that this is impossible for obvious reasons such as insurance not covering secret medical operations, possible lawsuits, etc. She just clams up and mutters under her breath about pain meds in her arms during her lunch hour and folks following her around to help protect her. The people on the corners begging for spare change are really their company’s operatives in disguise. Also if something goes wrong it is part of the conspiracy to control her.
She also has a Master’s In Psychology and works with people who are in recovery from drugs and alcohol. As such she goes to a therapist every three years. When I ask her whether she mentions this stuff she says she can’t because it’s a government secret and she would get in trouble. So, she always says she can’t be mentally ill because the therapist would notice. I tell her that this is like going to confession and leaving out the sin of murder.
Is there anything that I can do to help her? I think she has Mixed Delusional Disorder. Is there some way to know? Anything you can do to help her would be useful. She also coughs heavily all the time and struggles with shortness of breath and standing up for more than 20 minutes. Is there any physical illness that fits here?
I know you can’t diagnose blindly, but please help me keep her.
Exact moi