Delusional disorder medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]
Overview
Medical Therapy
Treatment Principles of Delusional Disorder 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 | |||||||||||||||||||
| Avoid direct confrontation of the delusional symptoms to enhance the possibility of treatment compliance and response | |||||||||||||||||||
| Consider the impact of culture for treatment planning | |||||||||||||||||||
| 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 | |||||||||||||||||||
Pharmacotherapy
- Treatment of patients with delusional disorder with antipsychotic medication requires careful effort because of the patient’s denial of illness. It is particularly important to discuss and provide the patient with information about how the antipsychotic medication would be useful, for what target symptoms, what are possible side effects of antipsychotics, and the likely length of treatment of the delusional disorder.
- An antipsychotic agent with as few side effects as possible such as ariprazole or ziprasidone should be used.
- Start the medication at a low dose and increase the dose gradually over a several days or weeks to assure tolerability.
- Once a therapeutic dose is achieved, examine for evidence of response at two weeks before changing the medication or increasing the dose further.
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.
Psychosocial interventions
Any psychiatric treatment of delusional disorder should incorporate the following psychotherapeutic principles:
- Alliance building
- Education
- Support
- Recognition of the challenges inherent in treating these patients.
For patients who deny that their concerns are delusional, a supportive approach to psychotherapy, with a verbally and listening supportive strategy intended to ease distress, is helpful. However, there have been no clinical trials of specific psychosocial interventions for delusional disorder. The following therapies have been suggested for the delusional disordre:
- Cognitive-behavioral therapy
- Core family therapy
- Supportive therapy
Cognitive-behavioral therapy
- Psychotherapy for patients with delusional disorder can include cognitive therapy which is conducted with the use of empathy. During the process, the therapist can ask hypothetical questions in a form of therapeutic Socratic questioning. This therapy has been mostly studied in patients with the persecutory type. The combination of pharmacotherapy with cognitive therapy integrates treating the possible underlying biological problems and decreasing the symptoms with psychotherapy as well. Psychotherapy has been said to be the most useful form of treatment because of the trust formed in a patient and therapist relationship. Individual psychotherapy is recommended rather than group psychotherapy, as patients are often quite suspicious and sensitive. The therapist is there for support and must not show any signs implying that the patient is mentally ill.
- The cognitive-behavioral therapy aims to identify and address patient features believed to be associated with delusions, such as data gathering biases, interpersonal sensitivity, worry, insomnia, and reasoning style, factors thought to influence how a delusional patient interprets evidence pertinent to delusions or how they considers alternative explanations for the phenomena.
- Discussion and analysis of the patient’s explanations for delusional ideas are practical techniques aimed at breaking down the conviction and emotional underpinnings that maintain the idea.
- CBT has not been formally tested in patients with delusional disorders. Preliminary trials and case reports that included patients with delusional disorders have not been found to be sufficient to evaluate CBT’s efficacy. [1][2][3] However, CBT produced more of an impact when compared to attention placebo control (APC) on strength of conviction, positive actions of beliefs, and affect relating to belief, which suggest that CBT is a successful means of treating delusional disorder.
Supportive psychotherapy
In supportive psychotherapy, the clinician attempts to gain insight into the painful quality of the patients’ experiences with delusional disorder and connect with the patient in these areas with understanding and suggestions aimed at reducing discomfort. Supportive therapy has also been shown to be helpful. Its goal is to facilitate treatment adherence and provide education about the illness and its treatment. Furthermore, providing social skills training has helped many persons. It can promote interpersonal competence as well as confidence and comfort when interacting with those individuals perceived as a threat.
Involuntary treatment
Involuntary treatment with antipsychotic medication may have a role in the treatment of a patient with delusional disorder at serious risk of harming oneself or others. Clinical decisions about involuntary treatment are subject to legal regulations that vary by country and locality.
References
- ↑ Skelton M, Khokhar WA, Thacker SP (2015). "Treatments for delusional disorder". Cochrane Database Syst Rev. 5: CD009785. doi:10.1002/14651858.CD009785.pub2. PMID 25997589.
- ↑ Myers E, Startup H, Freeman D (2011). "Cognitive behavioural treatment of insomnia in individuals with persistent persecutory delusions: a pilot trial". J Behav Ther Exp Psychiatry. 42 (3): 330–6. doi:10.1016/j.jbtep.2011.02.004. PMC 3566479. PMID 21367359.
- ↑ Hepworth C, Startup H, Freeman D (2011). "Developing treatments of persistent persecutory delusions: the impact of an emotional processing and metacognitive awareness intervention". J Nerv Ment Dis. 199 (9): 653–8. doi:10.1097/NMD.0b013e318229cfa8. PMID 21878778.