Long-term course and outcome in delusional disorder

Reactive Psychosis: Discrepancy Between Nosological Concepts and Descriptive Categories

ABSTRACT

Reactive psychosis (RP) is a trauma-induced category whose meaning has varied in relation to the role attributed to lived experiences or vulnerable personality. It has long been described in different countries, but seldom investigated under the influence of symptom-based psychiatric classifications. This article aims to examine the development of RP since the early 20th century, outline how it has been incorporated in modern diagnostic classifications, and set out empirical findings. It is likely that variations in terminology and diagnostic practice have affected estimates of the frequency and hampered the validity of RP in earlier studies. To enhance reliability, RP underwent several changes in successive Diagnostic and Statistical Manual of Mental Disorders and ICD versions and was eventually replaced with descriptive categories for short-lived psychotic disorders. Clinical observations during the COVID-19 pandemic attest the durability of RP, but the current categories prove unhelpful in identifying it and have failed to encourage research.

Effectiveness of pharmacotherapies for delusional disorder in a Swedish national cohort of 9076 patients

BACKGROUND

Little is known on the effective pharmacological treatment of delusional disorder.

AIMS

Study the comparative effectiveness of pharmacotherapies in the prevention of hospitalization due to psychosis and work disability in delusional disorder.

METHODS

Observational registry based cohort study including everyone in Sweden diagnosed with delusional disorder (N = 9076;mean follow-up time 4.9 years). The primary analysis was Cox Proportional Hazards within-individual analysis. Results are reported as adjusted hazard ratios (HRs).

RESULTS

Among the cohort (4835 males/4241 females;mean [SD] age 44.1 [12.5] years), 2074 persons had at least one hospitalization due to psychosis. Risk for hospitalization due to psychosis was 46% lower when any antipsychotic was used (HR 0.54, 95%CI 0.38-0.77, p < 0.001). Use of clozapine (HR 0.24, 95%CI 0.07-0.77, p = 0.016), any long-acting injectable (LAI; HR 0.28, 95%CI 0.16-0.49, p < 0.0001) and oral olanzapine (HR 0.36, 95%CI 0.20-0.67, p = 0.001) were associated with lowest risk. Among those not on disability pension at start of follow-up (n = 5025), in comparison to no use of antipsychotics, use of clozapine (HR 0.08, 95%CI 0.01-0.52, p = 0.008), any LAI (HR 0.44, 95%CI 0.25-0.79, p = 0.006) and oral aripiprazole (HR 0.52, 95%CI 0.31-0.85, p = 0.009) were associated with lowest risk of work disability.

CONCLUSIONS

Use of antipsychotics was associated with a reduced risk of hospitalization due to psychosis and work disability in delusional disorder, with use of clozapine and long-acting injectables being associated with the lowest risk for these very relevant end-points for both individual suffering and costs to society. Clinical trials with these treatments are urgently needed to make informed clinical treatment recommendations.

Short-term outcome of first episode delusional disorder in an early intervention population

BACKGROUND

Previous evidence suggests that delusional disorder has a later onset and better functional outcomes compared to schizophrenia. However, studies have not examined longitudinal outcomes in a first episode population, where confounding factors may be adjusted for.

METHODS

A nested case control study was designed within the National EDEN study; a cohort of 1027 first episode psychosis patients. Patients with a baseline diagnosis of delusional disorder (n = 48) were compared with schizophrenia (n = 262) at 6 and 12 months with respect to symptomatic and functional outcomes. Regression analysis was used to adjust for possible confounders.

RESULTS

Delusional disorder patients had a shorter duration of untreated psychosis compared to schizophrenia but were similar in other baseline characteristics. At baseline, delusional disorder patients had lower symptom scores but higher function scores compared to those with schizophrenia. At 12 months the differences persisted for symptoms scores but not overall function scores. After adjusting for baseline score, age and duration of untreated psychosis, differences between the groups remained significant only for Positive and Negative Syndrome Scale (PANNS) negative, general and total scores and recovery rates. There were no differences in changes in outcomes scores.

CONCLUSIONS

Delusional disorder in a first episode psychosis population presents with less severe symptoms, higher recovery rates and better functioning than schizophrenia, but at 12 months differences are ameliorated when adjusting for baseline differences.

Delusional disorder as a partial psychosis

In his textbook from 1838, Esquirol made the first comprehensive psychopathological description of paranoia, which he labeled partial psychosis. This was a condition with encapsulated, well organized, and persistent delusions. These are defended with a great deal of emotions and sharp argument. The individual appears quite convincing, especially because he or she otherwise behaves rationally. The intellectual capacity is used to achieve defined goals according to the delusional content. This condition is difficult to uncover because of dissimulation and adaptation. The frequency in the population is unknown, but the condition is rare in psychiatric treatment facilities, and usually only when the persons become litigious or criminal. In Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the condition is covered by the concept of delusional disorder, but that concept also comprises benign acute/subacute conditions as well as cases that turn out to have the diagnosis changed to schizophrenia.

Delusional disorders--are they simply paranoid schizophrenia?

OBJECTIVES

This article tries to give an answer to the question of whether International Classification of Diseases (ICD-10) persistent delusional disorder (PDD) or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) delusional disorder (DD) is simply paranoid schizophrenia (PS). Because ICD-10 PDD and DSM-IV DD are identical, we use DD as a synonym.

METHODS

A prospective and longitudinal study compared all inpatients with DD treated at the Halle-Wittenberg university hospital during a 14-year period with a previously investigated selected cohort of patients with PS. Sociodemographic data, symptomatology, course, and outcome parameters were examined using standardized instruments. The duration of the follow-up period in patients with DD was 10.8 years and for the PS patients 12.9 years.

RESULTS

Significant differences between DD and PS were found: DD patients are, in comparison to patients with PS, significantly older at onset. Less of their first-degree relatives have mental disorders. They less frequently come from a broken home situation. First-rank symptoms, relevant negative symptoms, and primary hallucinations did not occur in patients with DD. Patients with DD were less frequently hospitalized, and the duration of their hospitalization was shorter. Their outcome is much better regarding employment, early retirement due to the disorder, and psychopharmacological medication. They more often had stable heterosexual partnerships and were autarkic. They had lower scores in the Disability Assessment Scale and in Positive and Negative Syndrome Scale. The diagnosis of DD is very stable over time.

CONCLUSIONS

The findings of this study support the assumption that DDs are a separate entity and only exceptionally can be a prodrome of schizophrenia.

Clinical course and personality in reactive, compared with nonreactive, delusional disorder

OBJECTIVE

Reactive delusional disorder (DD) (with a precipitating factor) has been postulated to differ clinically from nonreactive DD and to show a better prognosis. Our study tests this hypothesis in a sample of patients with persistent DD (International Classification of Diseases, 10th Revision) or DD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) followed during a period of more than 10 years.

METHOD

As part of a long-term study on DD, 19 patients with DD and a stressful life event preceding the onset of the disorder were compared with 24 DD patients without such a life event. Diagnoses, social and biographical data, life events, and outcome were assessed by a semistructured interview and validated rating scales. Personality features were assessed by the NEO Five-Factor Inventory and by the Inventory of Clinical Personality Accentuations.

RESULTS

Patients with reactive DD tended to be somewhat younger but showed otherwise little differences to patients with nonreactive DD. In particular, there were no differences in the course of the disorder. However, patients with reactive DD were significantly more often in a stable relationship and showed higher values on neuroticism and more pronounced dependent and borderline personality accentuations in dimensional personality measures.

CONCLUSIONS

Reactive DD was not found to have a better prognosis than nonreactive DD. However, the results suggest an increased vulnerability for interpersonal conflicts in these patients.

Acute and transient psychotic disorders versus persistent delusional disorders: a comparative longitudinal study

AIM

The aim of this work is to investigate differences between two non-schizophrenic, non-organic psychotic disorders, namely persistent delusional disorders (PDD) and acute and transient psychotic disorders (ATPD) according to ICD-10.

METHOD

In a prospective and longitudinal study, we compared all 43 inpatients with PDD who were treated at Halle-Wittenberg University Hospital during a 14-year period to a previously investigated cohort of 41 patients with ATPD in regard to demography, long-term symptomatic outcome, and social consequences. Sociobiographical data were collected using a semi-structured interview. Follow-up investigations were performed at a mean of 10-12 years after the onset of the disorder using standardized instruments.

RESULTS

With the exception of the duration of the psychotic symptoms, the PDD patients were significantly different from the ATPD patients on various levels, such as sex ratio (female predominance only in ATPD), age at onset (older in PDD), the number of preceding stressful life-events in the index hospitalization (more frequent in ATPD), richness and variety of symptoms (higher in ATPD), and persistence of positive psychotic symptoms (in PDD). Patients with PDD had significantly less re-hospitalizations during the course of their illness. Long-term outcome was marked by chronicity of delusional symptoms and lower global functioning in PDD than in ATPD, while negative symptoms and loss of independence were infrequent in both conditions.

CONCLUSIONS

PDD differs from ATPD not only in the duration of the psychotic symptoms, but also in a variety of significant variables. They appear to be two separate entities within a psychotic spectrum.

A general neuropsychological model of delusion

INTRODUCTION

Neurocognitive accounts of delusion have traditionally highlighted perceptual misrepresentation, as the primary trigger in addition to other cognitive deficits that maintain the delusion. Here, a general neurocognitive model of delusional disorder (DSM-IV) is proposed, not so much based on perceptual or cognitive deficits after right hemisphere damage as on cognitive propensities, specifically excessive inferencing (especially jumping to conclusions) and excessive reference to the self, due to left hemisphere overactivity.

METHOD

The functional imaging, topographic EEG, and experimental imaging literatures on delusional disorder are reviewed, and 37 previously published cases of postunilateral lesion delusion (DSM-IV type, grandeur, persecution, jealousy, erotomania, or somatic), are reviewed and analysed multivariately.

RESULTS

Functional imaging and EEG topography data were slightly more indicative of left hemisphere overactivity in delusional disorder. In addition, 73% of the postunilateral lesion cases (χ(2)=7.8, p=.005) of delusional disorder (DSM-IV type) had a right hemisphere lesion, whereas only 27% had a left hemisphere lesion.

CONCLUSION

Left hemisphere release appears to be a more primary cause of delusional disorder than right hemisphere impairment, the latter merely entailing loss of inhibition of delusional beliefs. We propose that most patients with DSM-IV diagnoses of delusional disorder could be afflicted by excessive left hemisphere activity, but further research is necessary.

Wimmer's concept of psychogenic psychosis revisited

In the early twentieth century the Danish psychiatrist August Wimmer (1872-1937) developed the concept of psychogenic psychosis (PP) as a category of mental disorders separate from schizophrenia and manic depression. It subsumed a variety of clinical conditions with affective, confusional and paranoid features typically triggered by a psychical trauma.Wimmer's work has established itself as one of the classic texts in Scandinavian psychiatry but, for linguistic reasons, long remained almost unknown in other European countries.Translated into English in 2003, it is now available for historical and psychopathological analyses. This paper describes the original meaning of PP and sets it in context, then discusses the implications arising from the usage of the diagnostic categories introduced to replace PP in modern international classifications.

Dimensions of delusional experiences and their value as predictors of long-term outcome

BACKGROUND

Delusions are categorized as present or not in classificatory systems, but can fluctuate in intensity over time. They are sometimes difficult to describe, and might be better conceptualized as continuous on a number of dimensions. The predictive value of dimensional ratings of delusions was studied.

MATERIAL AND METHODS

Out of 180 first-episode psychotic patients who had been personally followed up after 30 years, a subsample of 41 was randomly drawn, 21 of the 180, 10 of those with GAS scores of 70 or more, and 10 of those with GAS scores of 30 or less at follow-up. They represented three different groups - a good outcome (n = 17), an intermediate outcome (n = 12), and a poor outcome (n = 12) group. Based on case histories at first presentation, scores on the Dimensions of Delusional Experience Scale were recorded.

RESULTS

Poor compared to good outcome patients had delusions at index admission characterized by more conviction, extension, disorganization, bizarreness and pressure. Intermediate outcome patients had scores in between, but closer to the poor outcome group.

CONCLUSIONS

Dimensional rating scales for assessing delusions might have predictive power, and consequently they should be used in future research, and if replicated these findings might have clinical implications.

Persistence and stability of delusions over time

Traditional descriptions of delusions have emphasized the conviction with which they are held and their resistance to change. This study utilizes data from a large cohort of delusional subjects to assess the persistence and stability of delusional beliefs, and the predictors of change. Data were collected from 1,136 acutely hospitalized psychiatric patients, reinterviewed at 10-week intervals for 1 year. Persistence of delusional beliefs was determined for those delusional subjects with at least one follow-up visit (n = 405), and stability for the subset with delusions at two or more points in time (n = 262). Marked plasticity in delusional beliefs was observed, with one third of delusional subjects at any interview no longer delusional 10 weeks later. Persistence of delusions was associated with schizophrenia, global psychopathology, and having acted on a delusion, among other variables. Most subjects showed variation in the content of their primary delusion over time. Delusions appear to be more fluid over relatively short periods of time than has been suggested by many classic descriptions and contemporary formulations.

Reactive psychosis and other brief psychotic episodes

Modern classification systems have ignored the reactive psychoses, and little has been published using this concept during the last years. Nevertheless, the term is of interest in clinical practice where its presence is dependent on clinical skills and empathy. It is also important for a general understanding of the development of psychosis. The delineation from other acute psychoses needs clarification. Studies on reliability and validity are promising, but need extension. Traditionally, the concept of reactive psychosis has hardly been used outside Scandinavia, and it is encouraging that interest in brief psychoses seems growing in other cultures as well.

Factor analysis of delusional disorder symptomatology

Delusional disorder symptomatology has been poorly investigated with factor analytic studies. Most attempts to identify its symptomatologic structure were made with schizophrenic or mixed psychotic populations and included only delusional symptoms. The purpose of this study was to analyze the whole symptomatologic structure of delusional disorder. One hundred eight inpatients with delusional disorder (DSM-III-R) were evaluated for lifetime symptoms using the Operational Criteria (OPCRIT) checklist for psychotic illness and included in a factorial analysis. Four factors were evaluated: (1) core depressive symptoms, (2) hallucinations, (3) delusions, and (4) irritability symptoms. Thus, when scored by the OPCRIT checklist, delusional symptomatology consisted of four independent factors, indicating a substantial heterogeneity of this diagnostic category.

Late paraphrenia: a variant of schizophrenia manifest in late life or an organic clinical syndrome? A review of recent evidence

A large amount of research has been devoted during the past 15 years to the clinical and neurobiological aspects of the disorder named as 'late paraphrenia' (LP) in 1955. The symptomatology and diagnosis of the disorder, its prognosis, the cognitive functioning of those affected, the structural changes in the brain as revealed by modern techniques of brain imaging and its postmortem neuropathology have all been submitted to investigation. The results have been widely regarded as consistent with the concept of LP as an organic disease of the brain, but increased knowledge of the neurobiology of schizophrenia and of the age-related changes that occur in the brains of elderly people casts doubt on the validity of this interpretation. The findings are consistent with the view that LP is the form in which schizophrenia is manifest in old age. The proposal that LP has a closer kinship with affective disorder than with schizophrenia is part of a general theory of the sex differences in schizophrenia. In LP it becomes entangled with the organicity hypothesis, suggesting that neither of these explanations is adequate, and most of the evidence points to a unitary concept which views LP as a variant of a single disorder, namely schizophrenia, which, however, requires a broad definition. This concept has implications for fresh paths of enquiry.

Schizophreniform disorder, delusional disorder and psychotic disorder not otherwise specified: clinical features, outcome and familial psychopathology

The relationship between DSM-III-R schizophreniform disorder, delusional disorder (DD) and psychotic disorder not otherwise specified (PD-NOS) and schizophrenia and affective illness (AI) remains uncertain. We explore this question in the Roscommon Family Study by examining symptoms, outcome and patterns of psychopathology in relatives. Probands were selected from a population-based case registry in the west of Ireland with an ICD-9 diagnosis of schizophrenia or AI. Personal interviews were conducted with 88% of traceable, living probands, a mean of 16 years after onset, and 86% of traceable, living first-degree relatives. Best-estimate diagnoses were made at follow-up. Schizophreniform disorder, DD and PD-NOS constituted 6.4%, 2.8% and 7.5%, respectively, of all probands with a registry diagnosis of schizophrenia. Probands with schizophreniform disorder had prominent positive psychotic symptoms, negligible negative symptoms and a good outcome, comparable to that seen in AI probands. Their relatives had an excess risk of schizophrenia spectrum illness but not AI. Probands with DD had prominent delusions but no other psychotic symptoms, few negative symptoms, fair to good outcome and an increased risk in relatives for alcoholism. Probands with PD-NOS had both moderate positive and negative psychotic symptoms, a poor to fair outcome and a substantially elevated risk in relatives of schizophrenia and schizophrenia spectrum disorders but not AI.(ABSTRACT TRUNCATED AT 250 WORDS)

Delusional disorder: the predictive validity of the concept

A sample of 72 first-admitted patients with delusional disorder was personally re-examined after a mean of 10 years, and 42 of them after an average of 27 years. The mean observation period for all patients from admission to last follow-up was 20 years (3-39). There was a trend that patients with delusions of jealousy did better on course variables, but similar outcomes were revealed in groups with delusions of jealousy, persecution and a mixed group with different main delusions. Duration of symptoms prior to admission was a significant predictor of outcome, indicating dividing lines of 1 and 6 months at 10-year follow-up and 3 and 6 months at long-term follow-up. Based on the data, a minimal duration of 6 months is proposed for persistent delusional disorder.

Predicting course and outcome in delusional psychoses

Eighty-four of 90 patients with delusional syndromes of different nosological attribution underwent a 7-year follow-up. From 179 items covering the whole spectrum of psychiatric description of index examination, 20 were found to be statistically significant in predicting different aspects of course and outcome by stepwise discriminant analysis. Course and outcome were defined by 6 criteria (course of illness, course of delusion, development of deficiency, length of inpatient care, adequate activity and social adjustment) encompassing separate (but only partly independent) aspects of a disorder. In contrast to the literature, clinical and psychopathological variables have major prognostic weight for different psychopathological as well as psychosocial aspects of outcome. Ten of the 20 significant items cover psychopathology, 4 pre-index course, 3 precipating events, 2 data from childhood, and 1 premorbid personality. Our results stress the importance of sensitive data collection and a clear separation of different outcome variables.

Long-term clinical outcome of schizophrenia with special reference to gender differences

A sample of 94 first-admitted schizophrenics and 47 patients with schizophreniform disorder (DSM-III) was personally re-examined after a mean of 10 years (by Retterstöl), and 110 of the patients after a mean of 31 years (by the author). Nearly half of the patients were admitted in 1946-1948 (long-term) and the remaining in 1958-1961 (short-term). Average outcome was significantly more favourable for short-term than for long-term patients. Single marital status and no, minimal or mild psychosocial stressor at onset (Axis IV) predicted poor long-term outcome. At 10-year follow-up there was no difference between men and women in clinical outcome. No substantial change was revealed in men at last follow-up, whereas on average women had clearly deteriorated.

Delusional disorders. I. Comparative long-term outcome

Of 301 first-admitted patients with delusional psychoses, 94 met DSM-III criteria of schizophrenia (S), 53 paranoid disorder (PD), 47 schizophreniform disorder (SFD), 35 schizoaffective disorder (SAD), 54 major affective disorder (AD), and 18 other disorders (OD). Retterstöl selected the patients and personally interviewed them after 5-18 years, and later the author interviewed them after 22-39 (mean 30) years. At last follow-up good functioning was noticed in 42%, moderate symptoms in 22%, severe defect in 20%, and very severe defect in 16%; 40% were still delusional. On average S patients did poorest, and OD patients slightly better. AD patients had superior outcome, while PD, SFD and SAD patients showed an intermediate position, but a little closer to AD than to S. However, heterogeneous course and outcome was noticed in all diagnostic groups.

Long-term course and outcome in unipolar affective and schizoaffective psychoses

Of 301 first-time admitted patients with delusional psychoses, 50 met DSM-III criteria for major depressive disorder (MDD), 33 schizoaffective disorder, depressive type (SADD), and 94 schizophrenia. At personal follow-up after 3-39 (mean 22) years, the SADD group was recorded in between on course and outcome variables, but closer to MDD. The findings in MDD and SADD were respectively: remission 66% vs. 42%, personality disorders 14% vs. 12%, anxiety disorder or alcohol abuse 2% vs. 6%, psychosis 18% vs. 36% (with bipolar development in 2% vs. 6%, paranoid disorder 2% vs. 3%, schizophrenia 4% vs. 3%). Chronic psychosis was recorded in 10% vs. 27%. No significant outcome difference was found between early onset MDD and SADD cases and those who fell ill at a higher age. The assumption that antidepressants may induce mania could not be confirmed. Normal premorbid personality seemed to predict a favourable course.