Delusions — Part 3 of 3

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Many individuals get confused with the terms, illusions, delusions and hallucinations. I’ve discussed the topic of illusions here. Part 1 is an overview of delusions. Part 2 covers the types of delusions. Today, I will discuss the medical conditions associated with development of delusions.

delusionA delusion is commonly defined as a fixed false belief and is used in everyday language to describe a belief that is either false, fanciful or derived from deception. Delusions typically occur in the context of neurological or mental illness, although they are not tied to any particular disease and have been found to occur in the context of many pathological states (both physical and mental).

Medical Conditions

Examples

Neurodegenerative disorders

Alzheimer disease, Pick disease, Huntington disease, basal ganglia calcification, multiple sclerosis, metachromatic leukodystrophy

Other CNS disorders

Brain tumors, especially temporal lobe and deep hemispheric tumors; epilepsy, especially complex partial seizure disorder; head trauma (subdural hematoma); anoxic brain injury; fat embolism

Vascular disease

Atherosclerotic vascular disease, especially when associated with diffuse, temporoparietal, or subcortical lesions; hypertensive encephalopathy; subarachnoid hemorrhage, temporal arteritis

Infectious disease

Human immunodeficiency virus/acquired immune deficiency syndrome, encephalitis lethargica, Creutzfeldt-Jakob disease, syphilis, malaria, acute viral encephalitis

Metabolic disorder

Hypercalcemia, hyponatremia, hypoglycemia, uremia, hepatic encephalopathy, porphyria

Endocrinopathies

Addison disease, Cushing syndrome, hyperthyroidism or hypothyroidism, panhypopituitarism

Vitamin deficiencies

Vitamin B-12 deficiency, folate deficiency, thiamine deficiency, niacin deficiency

Medications

Adrenocorticotropic hormones, anabolic steroids, corticosteroids, cimetidine, antibiotics (cephalosporins, penicillin), disulfiram, anticholinergic agents

Substances

Amphetamines, cocaine, alcohol, cannabis, hallucinogens

Toxins

Mercury, arsenic, manganese, thallium

Medical Conditions

Examples

Neurodegenerative disorders

Alzheimer disease, Pick disease, Huntington disease, basal ganglia calcification, multiple sclerosis, metachromatic leukodystrophy

Other CNS disorders

Brain tumors, especially temporal lobe and deep hemispheric tumors; epilepsy, especially complex partial seizure disorder; head trauma (subdural hematoma); anoxic brain injury; fat embolism

Vascular disease

Atherosclerotic vascular disease, especially when associated with diffuse, temporoparietal, or subcortical lesions; hypertensive encephalopathy; subarachnoid hemorrhage, temporal arteritis

Infectious disease

Human immunodeficiency virus/acquired immune deficiency syndrome, encephalitis lethargica, Creutzfeldt-Jakob disease, syphilis, malaria, acute viral encephalitis

Metabolic disorder

Hypercalcemia, hyponatremia, hypoglycemia, uremia, hepatic encephalopathy, porphyria

Endocrinopathies

Addison disease, Cushing syndrome, hyperthyroidism or hypothyroidism, panhypopituitarism

Vitamin deficiencies

Vitamin B-12 deficiency, folate deficiency, thiamine deficiency, niacin deficiency

Medications

Adrenocorticotropic hormones, anabolic steroids, corticosteroids, cimetidine, antibiotics (cephalosporins, penicillin), disulfiram, anticholinergic agents

Substances

Amphetamines, cocaine, alcohol, cannabis, hallucinogens

Toxins

Mercury, arsenic, manganese, thallium

Disorder

Differentiating Features

Delirium

Fluctuating level of consciousness 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 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 the general population’s in a 10-year follow-up period (Leinonen, 2004).

Substance-related disorders (intoxication, withdrawal, substance-induced psychotic disorder with delusion)

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 common condition, which may present with tactile or somatic delusions). Prescribed substances (especially steroids, dopamine agonists), OTC medications (especially sympathomimetics), and 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 disorders with delusional symptoms (manic or depressive type)

Mood symptoms are common in persons with delusional disorder and often represent an appropriate 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 symptoms of mood disorders contrary to mood symptoms of delusional disorder are prominent and meet criteria for a full 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.

Schizophrenia

Delusions of schizophrenia are bizarre in nature, and hallucinations are common. Additionally, disorganized thought process, speech, or behaviors is present. Negative symptoms and deterioration in function are prominent. Cognitive deficits are common.

Hypochondriasis

Patients with hypochondriasis are usually able to doubt (at least for a short while) their convictions of having illness when presented with reassuring data. Most of them have a long history of preoccupation, and their fears are usually not limited to a single symptom or organ system.

Body dysmorphic disorder (BDD)

Many patients with BDD hold their beliefs with conviction that reaches level of delusions, leading to a significant overlap between these conditions.

Obsessive-compulsive disorder (OCD)

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.

Paranoid personality disorder

Differentiation between extreme suspiciousness and frank delusions may be difficult. History of pervasive distrust beginning by early adulthood is suggestive of personality disorder, while the delusional disorder most commonly presents as an acute illness of middle life. Additionally, patients with paranoid personality disorder frequently appear to be unemotional and lack warmth in their relationships.

Shared psychotic disorder

Symptoms emerge in the context of a close relationship with another person with delusional beliefs and diminish with separation from that other person.

Disorder

Differentiating Features

Delirium

Fluctuating level of consciousness 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 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 the general population’s in a 10-year follow-up period (Leinonen, 2004).

Substance-related disorders (intoxication, withdrawal, substance-induced psychotic disorder with delusion)

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 common condition, which may present with tactile or somatic delusions). Prescribed substances (especially steroids, dopamine agonists), OTC medications (especially sympathomimetics), and 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 disorders with delusional symptoms (manic or depressive type)

Mood symptoms are common in persons with delusional disorder and often represent an appropriate 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 symptoms of mood disorders contrary to mood symptoms of delusional disorder are prominent and meet criteria for a full 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.

Schizophrenia

Delusions of schizophrenia are bizarre in nature, and hallucinations are common. Additionally, disorganized thought process, speech, or behaviors is present. Negative symptoms and deterioration in function are prominent. Cognitive deficits are common.

Hypochondriasis

Patients with hypochondriasis are usually able to doubt (at least for a short while) their convictions of having illness when presented with reassuring data. Most of them have a long history of preoccupation, and their fears are usually not limited to a single symptom or organ system.

Body dysmorphic disorder (BDD)

Many patients with BDD hold their beliefs with conviction that reaches level of delusions, leading to a significant overlap between these conditions.

Obsessive-compulsive disorder (OCD)

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.

Paranoid personality disorder

Differentiation between extreme suspiciousness and frank delusions may be difficult. History of pervasive distrust beginning by early adulthood is suggestive of personality disorder, while the delusional disorder most commonly presents as an acute illness of middle life. Additionally, patients with paranoid personality disorder frequently appear to be unemotional and lack warmth in their relationships.

Shared psychotic disorder

Symptoms emerge in the context of a close relationship with another person with delusional beliefs and diminish with separation from that other person.

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.

Often the treatment approach covers patient education, but educating the family about the symptoms and course of the disorder is also useful. This is especially true since the family frequently feels the impact of the disorder the most.

Warmly………David

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