Recent advances in the treatment of delusional disorder

Antipsychotic use in a large community sample of patients with delusional disorder

BACKGROUND

To examine clinical and sociodemographic differences between patients with delusional disorder; with and without diagnoses of an additional severe mental disorder (SMD) or cognitive impairment.

METHODS

Population-based study including all individuals diagnosed with DD between 2005 and 2021 from a large catchment area in Madrid, Spain. Sociodemographic and clinical characteristics and the antipsychotic prescription patterns of the study population was described. Patients were divided into (i) patients with DD and no additional diagnosis of SMD or cognitive impairment (DD group), (ii) patients with DD and a diagnosis of an additional SMD (DD-SMD group), and (iii) patients with DD and cognitive impairment (DD-CI group).

RESULTS

Of 1109 patients with a DD diagnosis (62.5 % female), 131 (11.8 %) patients were diagnosed with an additional SMD, and 69 (6.2 %) were diagnosed with cognitive impairment. DD-SMD patients were on average 10 years younger and had longer time between first mental healthcare contact and DD disorder than DD patients. DD-CI patients were on average 10 years older and had a higher proportion of females. Paliperidone (21.9 %) and aripiprazole (20.6 %) were the modal antipsychotic drugs chosen overall. DD-SMD patients were more likely to receive paliperidone and to be prescribed long-acting injectable medication; DD-CI were more likely to receive risperidone or quetiapine; and DD patients were more likely to receive olanzapine.

CONCLUSIONS

Sociodemographic and clinical characteristics and choice of antipsychotic drug and delivery method for individuals with DD vary based on its comorbidity.

Old Dog, New Tricks: A Review of Identifying and Addressing Youth Cannabis Vaping in the Pediatric Clinical Setting

Cannabis vaping has emerged as a predominant mode of cannabis use among United States (US) adolescents and young adults (AYA) primarily due to the popularity of modifiable designs of vaping devices coupled with changes in cannabis policies and increased availability of cannabinoid products. New methods for cannabis vaping by e-liquid/oil vaping, dry plant vaping, and cannabis concentrate vaping (ie, dabbing) have had high uptake among American youth with unclear long-term health implications. Issues with contamination, mislabeling, and expansion of the vaped cannabis market to include not only delta-9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) but also delta-9-THC analogs (eg, delta-8 and delta-10) sold as hemp-derived "legal highs" further complicated this healthcare space. Recent research suggests that cannabis/THC vaping carries distinct and overlapping risks when compared to cannabis smoking and may be associated with greater risk for acute lung injuries, seizures, and acute psychiatric symptoms. Primary care clinicians providing care for AYA are in an ideal position to identify cannabis misuse and intervene early to address cannabis vaping. To improve public health outcomes, a need exists for pediatric clinicians to be educated about different ways/methods that youth are vaping cannabinoid products and associated risks related to cannabinoid vaping. Further, pediatric clinicians need to be trained how to effectively screen for and discuss cannabis vaping with their youth patients. In the current article, we present a clinically focused review of cannabis vaping among young people with 3 main aims to: (1) identify and describe the cannabis vaping products commonly used by American youth; (2) review the health correlates of youth cannabis vaping; and (3) discuss clinical considerations related to identifying and treating youth who vape cannabis.

Seventy Years of Treating Delusional Disorder with Antipsychotics: A Historical Perspective

For many decades, delusional disorder (DD) has been considered a treatment-resistant disorder, with antipsychotics acknowledged as the best, though imperfect, treatment. It is possible that the discovery of the right drug could turn treatment resistance into treatment response. The goal of this narrative review is to provide a historical perspective of the treatment of DD since the introduction of antipsychotics 70 years ago. The following search terms were used to scan the literature: antipsychotics AND "delusional disorder". Findings were that therapy for DD symptoms has changed over time. Initial reports suggested that the drug of choice was the antipsychotic pimozide, and that this drug was especially effective for the somatic subtype of DD. Subsequent studies demonstrated that other antipsychotics, for instance, risperidone and olanzapine, were also highly effective. Treatment response may vary according to the presence or absence of specific symptoms, such as cognitive defect and depression. Clozapine, partial D2 agonists, and long-acting injectable drugs may be more effective than other drugs, but the evidence is not yet in. Because of the absence of robust evidence, treatment guidelines for the optimal management of DD are not yet available.

Delusions of Glass Under Skin: An Unusual Case of Somatic-Type Delusional Disorder Treated with Olanzapine

Introduction

The management of delusional disorder (DD) remains difficult due to poor patient insight and a lack of definitive treatment guidelines. For the somatic subtype specifically, prior studies have shown successful treatment with the first-generation antipsychotics (FGA) pimozide, but these studies did not specify the nature of the delusions. It has been theorized that pimozide effectiveness is due to its unique ability to relieve itching sensations, which are commonly associated with somatic delusions (e.g., delusions of parasitosis). The use of FGAs is not without risk, however, and should be avoided when possible due to the significant side-effect profile. Thus, there is a need for safer alternatives for the treatment of somatic-type DD. This manuscript discusses a case of DD characterized by painful sensations of glass under the skin managed with the second-generation antipsychotic olanzapine.

Case

A 67-year-old female with a past medical history including depression presented to the ED with complaints of glass in her hands and fingernails bilaterally. The patient has been evaluated by several physicians in the past without any evidence of glass being found. She was able factually able to describe that others viewed her complaints as irrational, but she refused to accept this as truth. Cognitive screening testing was normal, and a physical exam showed several areas of excoriation on the hands and arms bilaterally, a removed left thumbnail, and a thin frame (BMI: 18.02). The patient was admitted to the psychiatry service, where organic causes were ruled out (infection, metabolic abnormalities, drug use). The patient received olanzapine 5mg PO nightly treatment with adjunctive psychotherapy and experienced acute psychotic relief after a two-day admission period. She did not endorse any side effects from the medication.

Discussion

To our knowledge, there haven’t been prior studies exploring treatment efficacy in somatic-type DD subdivided by the nature of false bodily sensation. Despite this limitation, it was found that most cases of somatic-type DD characterized by foreign bodies under the skin were treated with pimozide. Although this drug appears to be a reasonable option for the more common presentation involving false pruritis, it might not be recommended for rare presentations that don’t involve itchiness due to the high risk of adverse symptoms. Accordingly, clinicians should consider the nature of the delusions along with the unique side effect profile of the pharmacological therapy as any harm might outweigh the potential benefit. This was highlighted in the current presentation as clinicians determined olanzapine to be the most appropriate treatment despite no similar cases of DD described in the literature. Furthermore, this case exemplified the utility of second-generation antipsychotics in the treatment of somatic-type DD.

Psychosis

PURPOSE OF REVIEW

Psychosis can manifest in primary psychotic disorders, neurologic diseases, and medical conditions. This article reviews the definition of psychotic symptoms and the evaluation and management of psychosis in primary psychiatric and neurologic disorders frequently seen in neurologic practice.

RECENT FINDINGS

Emerging evidence supports significant connections between psychosis and structural and functional brain changes in both primary psychotic and neurologic disorders. In addition to antidopaminergic activity, the mechanism of new-generation antipsychotics shifts to act on serotonin receptors, which potentially contributes to their benefits in the treatment of negative symptoms of psychosis and a lesser frequency of extrapyramidal side effects compared with typical antipsychotics. This is also helpful in the treatment of psychosis in patients who have neurodegenerative diseases and are vulnerable to developing extrapyramidal side effects from typical antipsychotics.

SUMMARY

Even with significant overlap, management of psychosis in primary psychotic disorders differs from the approach of psychosis in neurologic diseases. This article helps clinicians learn how to practically evaluate psychosis from both psychiatric and neurologic perspectives.

Dopamine, Serotonin, and Structure/Function Brain Defects as Biological Bases for Treatment Response in Delusional Disorder: A Systematic Review of Cases and Cohort Studies

Although blockade of dopamine receptors D2 and D3 appears to be the main mechanism of antipsychotic action, treatment response variability calls for an examination of other biological systems. Our aim is to systematically review reports of treatment response in delusional disorder (DD) in order to help determine its biological bases. Computerized searches of ClinicalTrials.gov, PubMed, and Scopus databases (from 1999 to September 2021) were systematically reviewed, in keeping with PRISMA directives. We used the search terms: (treat * OR therap * AND (delusional disorder)). We included all studies that explored the biological mechanisms of treatment response in DD, as diagnosed by ICD or DSM criteria. A total of 4344 records were initially retrieved, from which 14 papers were included: case reports, case series, and cohort studies. Findings point to (1) dopaminergic dysfunction (based on biochemical and genetic studies), (2) serotonergic dysfunction (based on partial agonism/antagonism of drugs), and (3) brain structure/function impairment, especially in the temporal and parietal lobes, as crucial factors in treatment response. Further studies with higher levels of evidence are needed to help clinicians determine treatment.

Guidelines for determining restorability of competency to stand trial and recommendations for involuntary treatment

Over 50,000 defendants are referred for competency to stand trial evaluations each year in the United States (Psychological evaluations for the courts: A handbook for mental health professionals and lawyers, New York, NY: The Guildford Press; 2018). Approximately 20% of those individuals are found by courts to be incompetent and are referred for "restoration" or remediation (Psychological evaluations for the courts: A handbook for mental health professionals and lawyers, 4th edn. New York, NY: The Guildford Press; 2018; Bull Am Acad Psychiatry Law. 1991;19:63-9). The majority of those incompetent defendants meet criteria for psychotic illnesses (J Am Acad Psychiatry Law. 2007;35:34-43). Forensic mental health professionals frequently have such patients/defendants decline recommended treatment with psychotropic medication. For a significant minority of defendants diagnosed with psychotic disorders, treatment with medication is thought to be necessary to restore their competency to stand trial. Without psychiatric intervention to restore competency, defendants may be held for lengthy and costly hospitalizations while criminal proceedings are suspended. In these situations, clinicians are guided by the Supreme Court decision, Sell v. United States (2003). The Sell opinion describes several clinical issues courts must consider when determining whether a defendant can be treated involuntarily solely for the purpose of restoring his/her competency. This paper offers some guidance to clinicians and evaluators who are faced with making recommendations or decisions about involuntary treatment. Using a question and answer format, the authors discuss data that support a decision to request, or not request, court authorization for involuntary treatment. Specifically, eight questions are posed for forensic evaluators to consider in determining the prognosis or viability of successful treatment and restoration. Finally, a clinical vignette is also presented to highlight important factors to consider in Sell-related evaluations.

Psychiatric Partial Hospitalization Programs: Following World Health Organization Guidelines with a Special Focus on Women with Delusional Disorder

The World Health Organization (WHO) developed a 7-year Mental Health Action Plan in 2013, which recommends integration of health and social care services into community-based settings, implementation of strategies for health promotion and prevention of illness, and support of research. In this review, we highlight partial hospitalization programs (PHPs) for delusional disorder (DD), with a special focus on the health and psychosocial needs of women. We suggest that PHPs are, in many ways, ideal settings for carrying out WHO recommendations. PHPs are multidisciplinary and consequently are able to provide a wide range of flexible program offerings. Programming in PHPs is able to address, with proven efficacy, individual needs, such as those presented by women at the various stages of their reproductive life. PHPs are a community bridge between hospital and outpatient services and can quickly adapt to specific needs as affected by gender, but also by age and cultural origins. They are ideal settings for professional training and for conducting clinical research. PHPs operate on the principle of shared decision making, and thus more readily than many other treatment sites, engaging difficult-to-treat patients, such as those with DD, by successfully establishing long-term relationships of trust.

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.

Targeting all psychopathological dimensions in the treatment of anorexia nervosa

Efforts to improve the prognosis of subjects with anorexia nervosa [AN] through the development of specific therapeutic interventions have yielded unsatisfactory results. AN can be perceived as a mental disorder that is clinically composed of disturbed psychopathological dimensions found in major depressive disorder, obsessive compulsive disorder, body dysmorphic disorder, and delusional disorder somatic type. Future treatment strategies of patients with AN might target these multiple psychopathological dimensions. Considering that each of these dimensions is known to be best treated with psychopharmacologic drugs such as antidepressants, mood stabilizers and antipsychotic drugs, AN treatment guidelines may need to consider prescribing them to patients.

Aripiprazole for the treatment of delusional disorders: A systematic review

BACKGROUND

Delusional disorder is an uncommon psychotic disorder. The first-line treatments for this chronic and resistant condition are antipsychotic medications, usually associated with several side effects that can exacerbate poor adherence. Conversely, aripiprazole is a well-tolerated antipsychotic drug that is effective in the treatment of other psychotic disorders. Here, we aimed to systematically review and summarize the currently available literature to evaluate the effectiveness and tolerability of aripiprazole in delusional disorders.

METHODS

A comprehensive literature search from inception until February 2020 was performed in PubMed, Cochrane Database of Systematic Reviews, and Scopus databases using The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

We identified 21 single cases of delusional disorders, mostly somatic type, treated with aripiprazole. All studies reported patient clinical improvements after the beginning of the treatment with aripiprazole. The average dose of aripiprazole was 11.1 mg/day, and the average time to achieve a clinical response was 5.7 weeks. Few adverse effects were reported, including asthenia, extrapyramidal symptoms, hyperprolactinemia, and insomnia.

CONCLUSIONS

Our findings suggest that aripiprazole may be an effective treatment for delusional disorders with good tolerability. Further studies comparing aripiprazole with other antipsychotics in the treatment of delusional disorders are needed.

Treating the untreatable? The biopsychosocial treatment of delusional disorder: a case study

OBJECTIVE

Delusional disorder (DD) is well recognised, but its treatment is controversial. This article presents a case study that highlights the therapeutic benefits associated with assertive biopsychosocial treatment of DD.

METHOD

The literature on pharmacological and psychological treatments for DD is briefly reviewed, and a case example from the Queensland Fixated Threat Assessment Centre is given to illustrate a comprehensive biopsychosocial treatment framework.

RESULTS

Combined pharmacological and psychosocial intervention resulted in stabilisation and improvement in mental state for the case described.

CONCLUSIONS

There is an emergent evidence base for an assertive biopsychosocial approach to treating DD. The case study demonstrates that a range of therapeutic goals is achievable.

A systematic review of studies with clinician-rated scales on the pharmacological treatment of delusional disorder

To collect the best available evidence and to compare the first-generation antipsychotics (FGAs) vs. the second-generation antipsychotics (SGAs) in the treatment of delusional disorder (DD). Systematic review including studies evaluating treatment response in DD using clinician-rated scales appearing in PubMed and Web of Science databases from inception till September 2019. Those studies meeting inclusion criteria were selected. Outcomes were summarized into two response categories: (1) response to treatment equal to or greater than 50% and (2) response less than 50%. Biases and quality of the studies were evaluated, and relevant data were extracted. Finally, both narrative review and quantitative synthesis were performed. The final sample included six studies (437 patients, 318 on treatment with SGAs). Antipsychotics achieved a good response in 32.3% of patients. Effectiveness differences between FGA and SGA were only marginal favouring the former. Among the most used antipsychotics, risperidone and olanzapine showed, respectively, 34.3 and 33.7% good response. Pimozide (n = 35) demonstrated a higher response rates compared with other antipsychotics. Inpatients showed the best treatment outcomes. Antipsychotics appeared to be an effective treatment in patients with DD. FGA were slightly superior to SGA. Pimozide does not seem to provide any advantage in most DD subtypes.

Moderators and mediators of antipsychotic response in delusional disorder: Further steps are needed

Delusional disorder (DD) has been traditionally considered a relatively rare and treatment-resistant psychotic disorder. In the last decade, increasing attention has focused on therapeutic outcomes of individuals affected by this disorder. The aim of this paper is to provide a synthesis of the literature addressing two very important questions arising from DD research: (1) For which patients with DD do antipsychotic medications work best (the moderators of response); and (2) What variables best explain the relationship between such treatments and their effectiveness (the mediators of response). We searched PubMed and Google Scholar databases for English, German, French and Spanish language papers published since 2000. We also included a few classic earlier papers addressing this topic. Variables potentially moderating antipsychotic response in DD are gender, reproductive status, age, duration of illness, the presence of comorbidity (especially psychiatric comorbidity) and its treatment, brain structure, and genetics of neurochemical receptors and drug metabolizing enzymes. Antipsychotic and hormonal blood levels during treatment, as well as functional brain changes, are potential mediating variables. Some, but not all, patients with DD benefit from antipsychotic treatment. Understanding the circumstances under which treatment works best can serve to guide optimal management.

An Australian study of delusional disorder in late life

OBJECTIVES

There is a paucity of available research to guide clinical practice in delusional disorder (DD), particularly in late life. This study aimed to evaluate antipsychotic use and treatment outcomes in patients with DD aged 65 years and older. Secondarily, we sought to examine associated clinical features and socio-demographic variables.

DESIGN AND SETTING

This descriptive study reviewed all consecutive cases of DD referred to an Australian old age psychiatry service over a 12-year period. Fifty-five patients were assessed in the inpatient and/or community setting, with data verified from a review of all individual medical records.

MEASUREMENTS

Data were collected with respect to antipsychotic use, outcomes, and clinical features. Socio-demographic variables of DD cases were compared to a non-matched comparison group (n=278) and an age and gender matched comparison group with a 1:1 ratio (n=55).

RESULTS

The predominant type of DD was persecutory (87%). Non-prominent hallucinations were experienced by 18%, and depressive symptoms occurred in 22%. There was a statistically significant association between having DD and social isolation (χ2= 11.04 (DF=1) p<0.001; McNemar's test p<0.001). Atypical antipsychotic medication was prescribed in 32 cases, with follow-up permitted in 51 of the 55 cases (mean duration 36.6 months). Sustained recovery occurred in 20%, and improvement in an additional 35% of the study sample. Four patients subsequently developed dementia, and two developed mild cognitive impairment.

CONCLUSIONS

Clinical improvement, including sustained recovery, occurred in more than half of those with late life DD. The majority of those who improved (96%) received atypical antipsychotics.

Reflections on working in public-figure threat management

The Fixated Threat Assessment Centre (FTAC) manages the risk posed to public figures by fixated individuals by paying attention to their correspondence and approaches and liaising with the mental health and criminal justice agencies responsible for their management. This paper offers a narrative reflection on the clinical experience of this unusual work. The clinical population is significantly different from that seen in mainstream mental health services, with a preponderance of delusional disorders and paraphrenias. The interface with mental health and criminal justice systems around the UK and internationally also offers a unique perspective on the functioning and malfunctioning of these services, and we attempt to describe and make sense of these experiences.

Aripiprazole and Delusional Disorder

Delusional disorder is a relatively rare psychotic illness characterized by delusions with contents that are theoretically possible but highly unlikely, and an absence of the disorganized thought and negative symptoms characteristic of schizophrenia. The illness is rarely studied systematically and most guidance with regard to the treatment derives from case reports and small case series. Antipsychotic medications are the mainstay of treatment, but it is not clear whether any particular agent is more effective than others. We report the case of a patient with delusional disorder who had failed to respond to risperidone but improved markedly with aripiprazole. Aripiprazole may show promise as a treatment for delusional disorder, possibly as a result of its effects on both dopaminergic and serotonergic receptors.

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.

A systematic review of the operational definitions for antipsychotic response in delusional disorder

This review aimed to examine and analyse the definitions used for antipsychotic response in delusional disorder (DD) and to provide a discussion of the methodology used. A systematic review was performed using the PubMed, Scopus and PsycINFO databases (1990-October 2017) according to the PRISMA statement. In addition, reference searches were performed manually through identified studies to obtain other relevant articles. The search terms included 'antipsychotic response', 'antipsychotics', 'treatment response' and 'delusional disorder'. After the screening and selection processes, 11 studies fulfilled our inclusion criteria using different methods to define antipsychotic response in DD. Studies included chart reviews (n=5) and observer-rated scales (n=6), in which two studies used the Clinical Global Impression-Improvement scale, two studies evaluated antipsychotic response by mean changes from the baseline to endpoint scores [Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale], one study combined the Clinical Global Impression-Improvement scale and mean changes from baseline scores (PANSS) and one study reported responder rates on the basis of a scale-derived cut-off (PANSS). A lack of consensus in the definitions of antipsychotic response in DD and a high degree of heterogeneity of the methods used are reflected. Recent proposals on the use of scale-derived cut-offs to evaluate antipsychotic response in schizophrenia would be highly recommended for DD research.

Stalking risks to celebrities and public figures

Prominent figures are frequently subjected to unwanted and intrusive attentions. Such stalking behaviour is often driven by psychotic illness, angrily blaming the public figure for delusional persecution (resentful motivation), or based on erotomanic delusions (intimacy seeking motivation), for example. This behaviour can cause psychological harm to both perpetrator and victim, and is unlawful. In the rare instances where a public figure has been attacked, the perpetrator has usually had a history of such stalking behaviour and of severe mental illness. For these reasons, early identification and diversion into appropriate care and treatment will be for the benefit of both parties and will prevent more serious violence in a minority of cases. The importance of the provision of education to improve both reporting rates by victims and an appropriate response from the criminal justice system is highlighted. A multi-agency approach involving the criminal justice system and mental health services is the most effective means of achieving these aims.

DECLARATION OF INTEREST

None.

LEARNING OBJECTIVES

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The impact of depressive symptoms on the clinical presentation of Persistent Delusional Disorder

BACKGROUND

Our aim was to investigate the influence of depressive symptoms on the clinical presentation of Persistent Delusional Disorder (PDD).

METHODS

We have previously conducted a retrospective review of patients diagnosed with PDD (n = 455). We divided this sample into two groups according to the presence or absence of co-morbid depressive symptoms - a subsample of PDD with depressive co-morbidity (PDD + D; n = 187) and a subsample of PDD without depressive co-morbidity (PDD only; n = 268).

RESULTS

PDD + D group had a significantly younger age at onset of PDD. The PDD + D group received significantly more antidepressants but had similar response and adherence rates.

CONCLUSIONS

The presence of depressive symptoms in 41% of the study population did not appear to influence the clinical presentation or response to treatment.

Meet the relatives: a reintroduction to the clinical pharmacology of ‘typical’ antipsychotics (Part 2)

This second of two articles on the ‘typical’ (‘first-generation’) antipsychotics covers non-phenothiazines: thioxanthenes (flupentixol and zuclopenthixol), butyrophenones/diphenylbutylpiperidines (including one-time world market-leader haloperidol, and pimozide) and sulpiride, for many years the only substituted benzamide available in the UK. Several tolerability issues ascribed specifically or more frequently to older antipsychotics are also discussed.

Risperidone versus olanzapine in the acute treatment of Persistent Delusional Disorder: A retrospective analysis

There is a dearth of prospective trials studying treatment response in Persistent Delusional Disorder (PDD) to guide clinical practice. Available retrospective data indicate good response to second-generation antipsychotics (SGAs). We selected the data of patients prescribed either olanzapine or risperidone from a retrospective chart review of PDD (n=455) at our centre. We compared the two groups olanzapine (n =86) versus risperidone (n =280) on dose, drug adherence, response and adverse effects. The two groups were comparable on socio-demographic and clinical characteristics of PDD. There was no statistically significant difference between the two groups on adherence (>80%) and response to treatment (>52% good response). Olanzapine was effective at lower mean chlorpromazine equivalents than risperidone. Logistic regression analysis identified shorter mean duration of illness, good adherence and absence of substance dependence as predictors of good response to both drugs. Our study indicates that acute PDD responds well to treatment with both risperidone and olanzapine, provided adherence can be ensured. In the absence of specific treatment guidelines and randomized controlled trials for PDD, our analysis reaffirms the efficacy of SGAs.

A Systematic Review on the Pharmacological Treatment of Delusional Disorder

BACKGROUND

Pharmacological treatment is the criterion standard in delusional disorder (DD). No second-generation antipsychotic (SGA) is specifically authorized for the treatment of DD.

AIMS

To evaluate the evidence available on pharmacological treatments in adults with DD and to compare first-generation antipsychotics (FGA) versus SGA.

METHODS

A systematic review on pharmacological treatment of DD following the PRISMA methodology was conducted. We selected the best evidence available and analyzed it critically assessing both, biases and quality, to finally perform a narrative and quantitative synthesis.

RESULTS

The evidence available was mainly limited to observational studies and case series. There were no randomized clinical trials. Three hundred eighty-five DD cases were included (177 of which were on SGAs). Overall, antipsychotics achieved a good response in 33.6%% of the patients. As a group, FGAs showed significant superiority compared to SGAs (good response rates were 39% vs 28%, respectively). We did not find superiority of any specific antipsychotic over another.

CONCLUSIONS

There is no strong evidence to make definite recommendations, although antipsychotics in general seem to be an effective treatment for DD with a slight superiority in favor of FGAs as compared with SGAs. Existent data are, albeit, scarce and specific clinical trials on DD, are strongly recommended.

Recall of threat material is modulated by self or other referencing in people with high or low levels of non-clinical paranoia

BACKGROUND AND OBJECTIVES

Biased processing of negatively valenced, and particularly threat-related material plays an important role in the development of paranoid thinking. This has been demonstrated by superior memory for threat-related information in patients with persecutory delusions and in non-clinical paranoia-prone participants. This study examined how emotional material was recalled having been encoded in relation to one self or to another person, in people high or low in paranoid ideation. It was predicted that people high in paranoia would recall more threat related material about others than people low in paranoia owing to being particularly alert to threats from other people.

METHODS

Participants who reported high (N = 30) or low (N = 30) levels of sub-clinical paranoid thinking were presented with a series of threat-related and positive words and were asked to process them in terms of the self, or in terms of a fictional character.

RESULTS

As predicted, when words were processed in terms of another person, the high paranoia group recalled more threat-related words than positive words, but when words had been processed in terms of the self, recall of threat-related and positive words did not differ. In contrast, there was no interaction between word-valence and referent in the low paranoia group.

LIMITATIONS

These findings are drawn from an analogue sample. Replication in a sample of clinical participants who report persecutory delusions is required.

CONCLUSIONS

People high in sub-clinical paranoid ideation recalled threat preferentially in relation to other people. Such information processing biases may help understand the development and maintenance of persecutory beliefs.

Clinical Presentation and Course of Persistent Delusional Disorder: Data From a Tertiary Care Center in India

OBJECTIVE

Despite its long history as a psychiatric diagnosis, little is known about the sociodemographic and clinical profile of persistent delusional disorder (PDD) or its subtypes, treatment response, and outcomes, particularly in India. We examined the clinical characteristics and course of PDD in patients presenting to a tertiary neuropsychiatry center in India.

METHOD

A retrospective chart review of patients diagnosed with PDD (ICD-10) between January 2000 and May 2014 was conducted. Sociodemographic and clinical data including age at onset, total duration of the illness, clinical symptoms and treatment, hospitalizations, occupational functioning, and follow-up were extracted from the files. The study was approved by the institute ethics committee.

RESULTS

The sample (N = 455) consisted of 236 men and 219 women. The mean age at onset was 32.36 ± 10.47 years. The most common delusion was infidelity (n = 203, 44.6%) followed by persecution (n = 149, 32.7%). Hallucinations were present in 78 (17.1%), depressive symptoms in 187 (41.1%), and comorbid substance dependence in 61 (13.4%) subjects; 141 subjects (31.0%) had a family history of mental illness. Follow-up data were available for 308 subjects, of whom 285 (92.5%) reported good compliance with medication. Of the subjects, 163 (52.9%) showed a good response to treatment. The diagnosis of PDD remained unchanged in 274 of 308 subjects (88.9%).

CONCLUSION

In our center, PDD appears to be uncommon and has a near-equal gender representation. Infidelity was the most common delusion, which is in contrast to the reported literature. The diagnosis of PDD appears to be stable with good response to atypical antipsychotics if compliance can be ensured.

Depression predicts persistence of paranoia in clinical high-risk patients to psychosis: results of the EPOS project

BACKGROUND

The link between depression and paranoia has long been discussed in psychiatric literature. Because the causality of this association is difficult to study in patients with full-blown psychosis, we aimed to investigate how clinical depression relates to the presence and occurrence of paranoid symptoms in clinical high-risk (CHR) patients.

METHODS

In all, 245 young help-seeking CHR patients were assessed for suspiciousness and paranoid symptoms with the structured interview for prodromal syndromes at baseline, 9- and 18-month follow-up. At baseline, clinical diagnoses were assessed by the Structured Clinical Interview for DSM-IV, childhood adversities by the Trauma and Distress Scale, trait-like suspiciousness by the Schizotypal Personality Questionnaire, and anxiety and depressiveness by the Positive and Negative Syndrome Scale.

RESULTS

At baseline, 54.3% of CHR patients reported at least moderate paranoid symptoms. At 9- and 18-month follow-ups, the corresponding figures were 28.3 and 24.4%. Depressive, obsessive-compulsive and somatoform disorders, emotional and sexual abuse, and anxiety and suspiciousness associated with paranoid symptoms. In multivariate modelling, depressive and obsessive-compulsive disorders, sexual abuse, and anxiety predicted persistence of paranoid symptoms.

CONCLUSION

Depressive disorder was one of the major clinical factors predicting persistence of paranoid symptoms in CHR patients. In addition, obsessive-compulsive disorder, childhood sexual abuse, and anxiety associated with paranoia. Effective pharmacological and psychotherapeutic treatment of these disorders and anxiety may reduce paranoid symptoms in CHR patients.

Treatments for delusional disorder

BACKGROUND

Delusional disorder is commonly considered to be difficult to treat. Antipsychotic medications are frequently used and there is growing interest in a potential role for psychological therapies such as cognitive behavioural therapy (CBT) in the treatment of delusional disorder.

OBJECTIVES

To evaluate the effectiveness of medication (antipsychotic medication, antidepressants, mood stabilisers) and psychotherapy, in comparison with placebo in delusional disorder.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (28 February 2012).

SELECTION CRITERIA

Relevant randomised controlled trials (RCTs) investigating treatments in delusional disorder.

DATA COLLECTION AND ANALYSIS

All review authors extracted data independently for the one eligible trial. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis with a fixed-effect model. Where possible, we calculated illustrative comparative risks for primary outcomes. For continuous data, we calculated mean differences (MD), again with a fixed-effect model. We assessed the risk of bias of the included study and used the GRADE approach to rate the quality of the evidence.

MAIN RESULTS

Only one randomised trial met our inclusion criteria, despite our initial search yielding 141 citations. This was a small study, with 17 people completing a trial comparing CBT to an attention placebo (supportive psychotherapy) for people with delusional disorder. Most participants were already taking medication and this was continued during the trial. We were not able to include any randomised trials on medications of any type due to poor data reporting, which left us with no usable data for these trials. For the included study, usable data were limited, risk of bias varied and the numbers involved were small, making interpretation of data difficult. In particular there were no data on outcomes such as global state and behaviour, nor any information on possible adverse effects.A positive effect for CBT was found for social self esteem using the Social Self-Esteem Inventory (1 RCT, n = 17, MD 30.5, CI 7.51 to 53.49, very low quality evidence), however this is only a measure of self worth in social situations and may thus not be well correlated to social function. More people left the study early if they were in the supportive psychotherapy group with 6/12 leaving early compared to 1/6 from the CBT group, but the difference was not significant (1 RCT, n = 17, RR 0.17, CI 0.02 to 1.18, moderate quality evidence). For mental state outcomes the results were skewed making interpretation difficult, especially given the small sample.

AUTHORS' CONCLUSIONS

Despite international recognition of this disorder in psychiatric classification systems such as ICD-10 and DSM-5, there is a paucity of high quality randomised trials on delusional disorder. There is currently insufficient evidence to make evidence-based recommendations for treatments of any type for people with delusional disorder. The limited evidence that we found is not generalisable to the population of people with delusional disorder. Until further evidence is found, it seems reasonable to offer treatments which have efficacy in other psychotic disorders. Further research is needed in this area and could be enhanced in two ways: firstly, by conducting randomised trials specifically for people with delusional disorder and, secondly, by high quality reporting of results for people with delusional disorder who are often recruited into larger studies for people with a variety of psychoses.

Delusional disorder: no gender differences in age at onset, suicidal ideation, or suicidal behavior

OBJECTIVE

To investigate gender differences in age at onset, psychopathology, and suicidal behavior rates in delusional disorder (DD).

METHODS

We conducted a prospective longitudinal study of 97 patients with DD. Demographic and clinical data at baseline were recorded. Gender differences were investigated by applying analysis of covariance, using age at onset and age at first psychiatric consultation as dependent variables, comorbid depression and gender as between-subject factors, and employment status, social support, and DD types as covariates.

RESULTS

Seventy-six percent of the patients were women. The average age at onset was 48.76 ± 12.67 years, mean age at first psychiatric consultation was 54.13 ± 13.67 years, and men were more likely to be employed than women (p = 0.041). Despite the earlier age at onset and at first psychiatric consultation in men, these differences tended to disappear when adjusted for potential confounders. There were no significant gender differences in depressive comorbidity, presence of suicidal ideation and behavior, or compliance rates at follow-up.

CONCLUSIONS

Our findings could not confirm that male and female DD patients differ in age at onset, age at first psychiatric consultation, or suicidal ideation and behavior, even after controlling for potential confounders.

Comparative efficacy and acceptability of existing pharmacotherapies for delusional disorder: a retrospective case series and review of the literature

Delusional disorder is an uncommon, yet not rare, psychotic disorder. Because of the distinct lack of high-evidence-level research conducted in this area, no definitive clinical guidelines are available on its treatment. The aim of this article was to summarize the current literature on the pharmacological treatment of delusional disorder in the form of a review, as well as to analyze a series of 6 cases treated at the Department of Psychiatry at "Charité-University Medicine Berlin, Campus Benjamin Franklin" between 2005 and 2011; in each case paying special attention to the relative efficacy and acceptability of the antipsychotics used.

REVIEW

A MEDLINE search was conducted to capture all articles on the treatment of delusional disorder published since 2004. After viewing titles and abstracts, these articles were then assessed for relevance.

CASE SERIES

The files of 6 cases of delusional disorder treated at the previously mentioned clinic were analyzed and information regarding the type of medication, dose, and duration of treatment as well as adverse effects was extracted and summarized. In line with previous studies, it was found that delusional disorder has a moderate prognosis when adequately treated and that noncompliance is often the reason for poor treatment results. Various novel antipsychotics as well as a combination of medication treatment and psychotherapy produced positive results. Generally, adverse effects were easily managed by a reduction in dose or a switch to another antipsychotic, and it was often necessary to try out a number of antipsychotics before arriving at a satisfactory solution.

Dangerous passion: Othello syndrome and dementia

Jealousy is a complex emotion that most people have experienced at some time in life; pathological jealousy refers primarily to an irrational state. Othello syndrome is a psychotic disorder characterized by delusion of infidelity or jealousy; it often occurs in the context of medical, psychiatric or neurological disorders. At least 30% of cases in the literature show a neurological basis for their delusion of infidelity, although its biological basis is not fully understood. The purpose of this paper is to examine the phenomenon of pathological jealousy in people with dementia. We searched the electronic databases for original research and review articles on Othello syndrome in demented patients using the search terms 'Othello syndrome, morbid jealousy, pathological jealousy, delusional disorders, dementia'. Convictions about the partner's infidelities may form the content of psychopathological phenomena, such as delusions. Delusional jealousy is a frequent problem in dementia. Coexistent delusions and hallucinations are frequent. The violence in demented patients suffering from this syndrome is well documented and forensic aspects are highlighted. There are no systematic researches about the clinical characteristics of Othello syndrome in persons suffering from dementia, but only case reports and it is not possible to differentiate or compare differences of delusional jealousy across the various type of dementia or distinguish the syndrome in demented patients from the syndrome in other psychiatric disorders. Frontal lobe dysfunction may be called into question in delineating the cause of the delusional jealousy seen in Othello syndrome.

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.

Olanzapine and risperidone disrupt conditioned avoidance responding by selectively weakening motivational salience of conditioned stimulus: further evidence

Suppression of conditioned avoidance response is a preclinical behavioral index of antipsychotic activity. Previous work shows that olanzapine and risperidone disrupt avoidance response elicited by a less salient conditioned stimulus (CS2) to a greater extent than avoidance elicited by a more salient stimulus (CS1), suggesting that antipsychotic drugs may have a weakening action on motivational salience of stimuli. In the present study, we further examined this mechanism of antipsychotic action, focusing on the possible impact of baseline difference of CS1 and CS2 response rates on the avoidance-disruptive effect of olanzapine and risperidone. Rats were first trained to acquire avoidance responding in a procedure in which the number of CS2 trials (i.e. 20) was twice the number of CS1 trials (i.e. 10), but the percentage of CS2-shock pairing was set at 25% lower (15 trials out of 20) than the percentage of CS1-shock pairing (20 trials out of 20). They were then tested daily under olanzapine (0.5 and 1.0 mg/kg, sc) or risperidone (0.33 and 1.0 mg/kg, sc) for 5 consecutive days. Repeated olanzapine and risperidone treatment dose-dependently disrupted avoidance responding to both CS1 and CS2. Both drugs at the high dose disrupted the CS2 avoidance to a greater extent than the CS1 avoidance. In the final challenge test, rats previously treated with olanzapine were tested under risperidone (0.33 mg/kg), whereas rats previously treated with risperidone were tested under olanzapine (0.5 mg/kg). Results show that rats previously treated with risperidone 1.0mg/kg group made significantly fewer avoidance responses than the vehicles under olanzapine at 0.5 mg/kg. These findings confirm that olanzapine and risperidone disrupt avoidance response primarily by selectively attenuating the motivational salience of the CS. The present study also suggests that there is a generality of antipsychotic drug experience that is mediated by a shared interoceptive drug state mechanism.

Paranoid thinking as a heuristic

Paranoid thinking can be viewed as a human heuristic used by individuals to deal with uncertainty during stressful situations. Under stress, individuals are likely to emphasize the threatening value of neutral stimuli and increase the reliance on paranoia-based heuristic to interpreter events and guide their decisions. Paranoid thinking can also be activated by stress arising from the possibility of losing a good opportunity; this may result in an abnormal allocation of attentional resources to social agents. A better understanding of the interplay between cognitive heuristics and emotional processes may help to detect situations in which paranoid thinking is likely to exacerbate and improve intervention for individuals with delusional disorders.

Morbid jealousy: The green-eyed monster

Jealousy is a commonly experienced emotion which has been observed in infants as young as 5-6 months of age and across the lifespan of an individual. In its extreme form jealousy can be pathological, when the belief which may be a delusion, obsession or an overvalued idea, is held on inadequate grounds and is unaffected by rational discussion. Morbid jealousy differs from normal jealousy in its intensity or rationality. It can be thought of as hypersensitive jealousy since jealous reactions are experienced at a much lower threshold than in average individuals. Morbid jealousy is a disorder in which an individual believes that their partner is, or will be, sexually unfaithful. Morbid jealousy can occur when a partner is in fact being unfaithful, provided that the evidence for the infidelity is incorrect and there is an excessive or irrational response to such evidence. The preoccupation with the partner's infidelity is often triggered by vivid mental images of their partner's past or present relationships.

Delusional infestation

This papers aims at familiarizing psychiatric and nonpsychiatric readers with delusional infestation (DI), also known as delusional parasitosis. It is characterized by the fixed belief of being infested with pathogens against all medical evidence. DI is no single disorder but can occur as a delusional disorder of the somatic type (primary DI) or secondary to numerous other conditions. A set of minimal diagnostic criteria and a classification are provided. Patients with DI pose a truly interdisciplinary problem to the medical system. They avoid psychiatrists and consult dermatologists, microbiologists, or general practitioners but often lose faith in professional medicine. Epidemiology and history suggest that the imaginary pathogens change constantly, while the delusional theme "infestation" is stable and ubiquitous. Patients with self-diagnosed "Morgellons disease" can be seen as a variation of this delusional theme. For clinicians, clinical pathways for efficient diagnostics and etiology-specific treatment are provided. Specialized outpatient clinics in dermatology with a liaison psychiatrist are theoretically best placed to provide care. The most intricate problem is to engage patients in psychiatric therapy. In primary DI, antipsychotics are the treatment of choice, according to limited but sufficient evidence. Pimozide is no longer the treatment of choice for reasons of drug safety. Future research should focus on pathophysiology and the neural basis of DI, as well as on conclusive clinical trials, which are widely lacking. Innovative approaches will be needed, since otherwise patients are unlikely to adhere to any study protocol.

Disorder or delusion? Living with Morgellons disease

Whether Morgellons disease is a delusional disorder or even a disease has been a mystery for more than 300 years. Symptoms of Morgellons include crawling and stinging sensations, feeling of "bugs" and/or fiber-like material beneath the skin, disabling fatigue, and memory loss. The cause, transmission, and treatment are unknown. Research about Morgellons is staggeringly sparse and limited in scope. However, in recent years, discussion about Morgellons has become more common because of the Internet and online support groups. Mental health professionals and the general public need to be aware of the signs, symptoms, and treatment of this disease. Focusing on the disease and listening to patients can make a difference in the way health care professionals provide the best possible care for people with Morgellons.