Delusion Delusional 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.

Delusion A false belief based on incorrect inference about external reality that is firmly sustained despite what
almost everyone else believes and despite what constitutes incontrovertible and obvious proof of evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's culture or subculture (e.g., it is not an article of religious faith). When a false belief involves a value judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility. Delusional conviction occurs on a continuum and can sometimes be inferred from an individual's behavior. It is often difficult to distinguish between a delusion and an overvalued idea (in which case the individual has an unreasonable belief or idea but does not hold it as firmly as is the case with a delusion).

Delusions are subdivided according to their content :

Bizarre A delusion that involves a phenomenon that the person's culture would regard as totally implausible. 'Delusional jealousy The delusion that one's sexual partner is unfaithful. Erotomanic A delusion that another person, usually of higher status, is in love with the individual. Grandiose A delusion of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Of being controlled A delusion in which feelings, impulses, thoughts, or actions are experienced as being under the control of some external force rather than being under one's own control. Of reference A delusion whose theme is that events, objects, or other persons in one's immediate environment have a particular and unusual significance. These delusions are usually of a negative or pejorative nature, but also may be grandiose in content. This differs from an idea of reference, in which the false belief is not as firmly held nor as fully organized into a true belief. Persecutory A delusion in which the central theme is that one (or someone to whom one is close) is being attacked, harassed, cheated, persecuted, or conspired against. Somatic A delusion whose main content pertains to the appearance or functioning of one's body. Thought broadcasting The delusion that one's thoughts are being broadcast out loud so that they can be perceived by others. Thought insertion The delusion that certain of one's thought are not one's own, but rather are inserted into one's mind. Mood-congruent psychotic features Delusions or hallucinations whose content is entirely consistent with the typical themes of a depressed or manic mood. If the mood is depressed, the content of the delusions or hallucinations would involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. The content of the delusion may include themes of persecution if these are based on self-derogatory concepts such as deserved punishment. If the mood is manic, the content of the delusions or hallucinations would involve themes of inflated worth, power, knowledge, or identity, or a special relationship to a deity or a famous person. The content of the delusion may include themes of persecution if these are based on concepts such as inflated worth or deserved punishment. Mood-incongruent psychotic features Delusions or hallucinations whose content is not consistent with the typical themes of a depressed or manic mood. In the case of depression, the delusions or hallucinations would not involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. In the case of mania, the delusions or hallucinations would not involve themes of inflated worth, power, knowledge, or identity, or a special relationship to a deity or a famous person. Examples of mood-incongruent psychotic features include persecutory delusions (without self-derogatory or grandiose content), thought insertion, thought broadcasting, and delusions of being controlled whose content has no apparent relationship to any of the themes listed above.

Etiology :
As with all major psychiatric disorders, the cause of delusional disorder is unknown. Family studies increased prevalence of delusional disorder and related personality traits (egg. suspiciousness, jealousy, and secretiveness) in the relatives of delusional disorder probands.

Biological factors

neurological conditions most commonly associated with delusions are conditions that affect the limbic system and the basal ganglia. patients whose delusions are caused by neurological disease that does not affect cerebral cortex 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. Psychodynamic factors Freud`s contributions In Dr Schreber case, Freud theorized that denial and projection defend against unconscious homosexual tendencies. Because homosexuality is consciously inadmissible to some patients, male patients deny this feeling of I love him and change them by reaction formation into I do not love him. Patient further transform these feelings through projection into It is not I who hate him; it is he who hates me. In a full-blown paranoid state, the feeling is elaborated into I am persecuted by him. In erotomanic delusions, male patients change I love him to I love her. In delusional grandiosity I do not love him becomes I love myself. Freud also believed that unconscious homosexuality causes delusions of jealousy the man whom a paranoid patient suspects his wife of loving is a man to whom the patient feels sexually attracted. Clinical evidence has not supported Freud`s thesis. Paranoid 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 factor Hypersensitivity and feelings of inferiority have been hypothezed to lead, through reaction formation and projection, to delusions of superiority and grandiosity. Delusions of erotic ideas have been suggested as replacements for feelings of rejection. Critical and frightening delusions are often described as projections of superego criticism. Somatic delusions can be psychodynamically explaned as a regression to the infantile narcissistic state, in which patients withdraw emotional involvement from other people and fixate on their physical selves.

Type : DSM-IV specifies seven types of delusional disorder

Erotomanic type: delusions that another person, usually of higher status, is in love with the individual. Grandiose type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Jealous type: delusions that individuals sexual partner is unfaithful. Persecutory type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way. Somatic type: delusions that the person has some physical defect or general medical condition. Mixed type: delusions characteristic of more then one of the above types but no one theme predominates. Unspecified type: Persecutory and jealous types are most common, and erotomanic and somatic types are the most unusual. Other delusions Capgrass syndrome is the delusion that familiar people have been replaced by identical impositors. Fregolis phenomenon is the delusion that a persecutor is taking on a variety of faces, like an actor. Lycanthropy is the delusion of being a werewolf. Heutoscopy is the false belief that one has a double. Cotards syndrome was originally called delire de negation; those with the syndrome may believe that they have lost everything possessions, strenght, and even bodily organs, such as the heart.

Clinical Features: Mental Satatus

General description.Mental status examination is usually remarkably normal except for the presence of markdly abnormal delusional system. Mood, feelings and affect.Patients' moods are consistent with the content of their delusions( e.g. patient with grandiose delusion is euphoric; one with persecutory delusions is suspicious ). Perceptual disturbances.Patients with delusional disorder do not have prominent or sustained hallucinations. Tactile or olfactory hallucinations may be present if they are consistent with the delusion (e.g. somatic delusion of body odor). 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 (e.g. delusions of being persecuted , of having an unfaithful spouse , of being infected with a virus, etc.). This examples of

delusional content contrast with the bizarre and impossible delusional content in some patients with schizophrenia. The delusional system itself may be complex or simple. Sensorium and cognition. Patients usually have no abnormality in orientation unless they have a specific delusion about a person, place , or time.Memory and other cognitive processes are intact in these patients. 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. If patients are unable to control their impulses hospitalization is probably necessary. Judgment and insight. These patients have virtually no insight in to their condition and are almost always brought to the hospital by the police, family members or employers.

Differential Diagnosis: Delusions can accompany many medical and neurological illnesses.
Neurological and medical conditions that can present with delusion Basal ganglia disorders-Parkinson's disease, Huntington 's disease Deficiency states B12,folate,thiamine, niacin Delirium Dementia- Alzheimer's disease, Pick's disease Endocrinopathies-adrenal,thyroid,parathyroid Limbic system disorders-epilepsy, cerebrovascular diseases,tumors Systemic - hepatic encephalophathy, hypercalcemia, hyopglycemia, porphiria, uremia malingering and factitious disorder with predominantly psychological signs and symptoms schyzophrenia, mood disorders, obsessive-conpulsive disorder, somatoform disorders and paranoid personality disorder drug- induced amphetamines, anticholinergics, antidepressants, antihipertensives, antituberculoses drugs, antiparkinson agents, cimetidine,cocaine, disulfiram(Antabus),hallucinogenes Delusional disorder is distinguished from schyzophrenia buy the absence of other schyzophrenic symptoms and buy the nonbizarre quality of the delusions. The somatics type of delusional disorder may resemble depressive disorder or somatoform disorder. The somatic type of delusional disorder is differentiated from depressive disorder buy the absence of other signs of depression and buy the lack of a pervasive quality to the depression. Delusional disorder can be differentiated from somatoform disorders buy the degre to which the somatic believ is held buy the pationt. Patients with somatoform disorders allow for possibility that their disorder does not exist, whereas patients with delusional disorder have no duobth of it's reality.

Hallucinations
Imaginary sensations, such as seeing, hearing, or smelling things that do not exist in the real world Type of Hallucinations Auditory Characteristic Hearing noises or sounds most commonly in the form of voice. Audible thoughts in which the patient hears voices that are speaking what the patient is thinking and commands that tell the patient to do something, sometimes harmful or dangerous Observable Behaviour Moving eyes back and forth as if looking to see who or what is talking. Listening intently to another person who is not speaking or to inanimate object such as a piece of furniture. Engaging in conversation with an inanimate object or with an invisible person. Moving mouth as if speaking or responding to a sound. Responding to an odor with terror, as in smelling fire or blood. Throwing a blanket or pouring water on another person as if putting out a fire. Suddenly appearing startled, frightened or terrified by another person, an inanimate object, or by apparent stimulus. Suddenly running into another room .

Visuals

Olfactory

Visual Sees a person or object that is not present. Visual stimuli in the form of flashes of light and figures. Visions can be pleasant or terrifying as in seeing monsters . Perceives an odor that actually is not present. Putrid, foul and rancid smells of a repulsive nature such as blood, urine or feces. Occasionally the odors can be pleasant.

Wrinkling nose as if smelling something horrible Smelling parts of the body Smelling the air while walking toward another person. Responding to an odor with terror, as in smelling fire or blood.

Gustatory

Tactile

Kinesthetic

Experiences a taste that is not present and frequently is bitter or strong. Putrid, foul and rancid tastes of a repulsive nature such as blood, urine or feces Experiences the feeling of a touch Feeling electrical sensations coming from the ground, inanimate objects or other people Feeling body functions such as blood pulsing through veins and arteries, food digesting or urine forming Sensation of movement while standing motionless

Responding to an odor with terror, as in smelling fire or blood. Throwing a blanket or pouring water on another person as if putting out a fire. Spitting out food or a beverage Refusing to eat, drink or take medicines Suddenly leaving the dinner table Slapping self as if putting out a fire Jumping up and down on the floor as if avoiding pain or other stimuli on the feet. Verbalizing and/or obsessing about body processes Refusing to complete a task that may require a part of the body that patient believes is not working Steadying oneself while grabbing onto furniture

Agitation
Definition: -A mental state of extreme emotional disturbance. -The act of agitating something; causing it to move around (usually vigorously) -Kegelisahan atau aktivitas motoric yang berlebihan dan tidak bertujuan, biasanya dihubungkan oleh keadaan tegang atau anxietas. Also called psychomotor agitation

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