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
The optimal therapy for delusional disorder includes pharmacotherapy, cognitive-behavioral therapy, supportive psychotherapy, involuntary treatment, and insight oriented therapy.[1][2][3][4][5][6][7][8][9]
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.
- Olanzapine and risperidone are the most common atypical antipsychotics used for the treatment of delusional disorder. Five case reports of individuals with delusions presumably refractory to previous antipsychotic treatment have reported that clozapine was associated with a decrease in symptoms associated with the delusion and an improved quality of life, although the central delusional theme persisted. However, some cases of delusional disorder appear refractory even to clozapine treatment.
- Antidepressants have been successfully used for the treatment of primarily somatic type of delusional disorder. Various case reports have showed improvement of delusional disorder with selective serotonin reuptake inhibitor (SSRI) and clomipramine treatments. A single case report of successful ECT use for somatic delusions exists. A standard trial of an antipsychotic or, for somatic delusions, an SSRI at starting doses is commonly used to treat psychotic or mood disorders.[1][2][3][4][5][6][7][8]
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 disorder:[10]
- 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. 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.[9][11][12][13]
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.[9]
Involuntary treatment
In patients with delusional disorder who are at serious risk of harming others, involuntary treatment with antipsychotic medication may have a role. Clinical decisions regarding involuntary treatment are subject to legal regulations that vary by country and locality.[9]
Insight oriented therapy
Insight-oriented therapy is rarely indicated or contraindicated; yet there are reports of successful treatment. Its goals are to develop therapeutic alliance, containment of projected feelings of hatred, impotence, and badness; measured interpretation as well as the development of a sense of creative doubt in the internal perception of the world. The latter requires empathy with the patient's defensive position.[9]
References
- ↑ 1.0 1.1 Freudenmann RW, Lepping P (2008). "Second-generation antipsychotics in primary and secondary delusional parasitosis: outcome and efficacy". J Clin Psychopharmacol. 28 (5): 500–8. doi:10.1097/JCP.0b013e318185e774. PMID 18794644.
- ↑ 2.0 2.1 Freudenmann RW, Schönfeldt-Lecuona C, Lepping P (2007). "Primary delusional parasitosis treated with olanzapine". Int Psychogeriatr. 19 (6): 1161–8. doi:10.1017/S1041610207004814. PMID 17397562.
- ↑ 3.0 3.1 Manschreck TC, Khan NL (2006). "Recent advances in the treatment of delusional disorder". Can J Psychiatry. 51 (2): 114–9. PMID 16989110.
- ↑ 4.0 4.1 Hayashi H, Oshino S, Ishikawa J, Kawakatsu S, Otani K (2004). "Paroxetine treatment of delusional disorder, somatic type". Hum Psychopharmacol. 19 (5): 351–2, 1p following 352. doi:10.1002/hup.590. PMID 15252828.
- ↑ 5.0 5.1 Sondheimer A (1988). "Clomipramine treatment of delusional disorder-somatic type". J Am Acad Child Adolesc Psychiatry. 27 (2): 188–92. PMID 3360722.
- ↑ 6.0 6.1 Wada T, Kawakatsu S, Nadaoka T, Okuyama N, Otani K (1999). "Clomipramine treatment of delusional disorder, somatic type". Int Clin Psychopharmacol. 14 (3): 181–3. PMID 10435772.
- ↑ 7.0 7.1 Nagata T, van Vliet I, Yamada H, Kataoka K, Iketani T, Kiriike N (2006). "An open trial of paroxetine for the "offensive subtype" of taijin kyofusho and social anxiety disorder". Depress Anxiety. 23 (3): 168–74. doi:10.1002/da.20153. PMID 16456863.
- ↑ 8.0 8.1 Ota M, Mizukami K, Katano T, Sato S, Takeda T, Asada T (2003). "A case of delusional disorder, somatic type with remarkable improvement of clinical symptoms and single photon emission computed tomograpy findings following modified electroconvulsive therapy". Prog Neuropsychopharmacol Biol Psychiatry. 27 (5): 881–4. doi:10.1016/S0278-5846(03)00118-0. PMID 12921924.
- ↑ 9.0 9.1 9.2 9.3 9.4 Delusional disorder. Wikipedia(2015) https://en.wikipedia.org/wiki/Delusional_disorder Accessed on November 30, 2015
- ↑ Munro, Alistair. Delusional disorder : paranoia and related illnesses. Cambridge New York: Cambridge University Press, 2006. Print.
- ↑ 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.