Delusional (paranoid) disorders: etiologic and taxonomic considerations. II. A possible relationship between delusional and affective disorders

Dimensional structure of first episode psychosis

AIM

Current diagnostic systems, DSM-5 and ICD-10, still adopt a categorical approach to classify psychotic disorders. The present study was aimed at investigating the structure of psychotic symptomatology in both affective and non-affective psychosis from a dimensional approach.

METHODS

Participants with a first episode psychosis (FEP) were recruited from a cluster-randomized controlled trial (GET-UP PIANO TRIAL), offered to all Community Mental Health Centres (CMHCs) located across two northern Italian regions. After clinical stabilization, patients were assessed with a comprehensive set of psychopathological measures including the Positive and Negative Syndrome Scale, the Hamilton Depression Rating Scale and the Bech-Rafaelsen Mania Rating Scale. A two-step cluster analysis was performed.

RESULTS

Overall, 257 FEP patients (male, n = 171, 66.5%; mean age = 24.96 ± 4.56) were included in the study. The cluster analysis revealed a robust four-cluster solution: delusional-persecutory (n = 82; 31.9%), depressed (n = 95; 37%), excited (n = 26; 10.1%) and negative-disorganized (n = 54; 21%), thus suggesting a quadripartite structure with both affective and non-affective dimensions. Among non-affective dimensions, negative and disorganization symptoms constituted a unique construct apart from positive symptoms.

CONCLUSIONS

Symptom dimensions may represent a useful tool for dissecting the indistinct and non-specific psychopathology of FEP in order to better target specific interventions.

Pharmacotherapy for primary delusional jealousy, a retrospective observational study of 32 cases with Othello syndrome

To determine whether primary delusional jealousy can be treated effectively with antipsychotics or antidepressants, and whether any clinical variables are associated with response to pharmacotherapy, we carried out a retrospective case series observational study by reviewing clinical records of patients with an International Classification of Disease, 9th ed., diagnostic code of 297 (delusional disorders) who were treated at the Department of Psychiatry of a university affiliated hospital from January 2010 to December 2015. Only those records showing obvious delusional jealousy not secondary to other medical conditions, dementia, or schizophrenia were scrutinized thoroughly with respect to types of pharmacotherapy, treatment response, and other demographic and clinical variables likely to be associated with clinical outcomes. All except one of 32 patients, 16 men and 16 women, between 37 and 79 (60.9±10.6) years of age, were treated with low-dose antipsychotics. The general response was favorable as 19 (59.4%) were rated as good and 13 as inadequate responders (seven partial and six limited). Compared with antipsychotic monotherapy, concomitant therapy with antidepressants had a higher rate of good response, although statistically insignificant (75 vs. 53%, P=0.21). Younger age (P=0.01) and presentation at the index visit with their suspected unfaithful spouse were associated with a good response (P=0.036); comorbidity with delusions other than the jealous type was associated with a poor response (P=0.006). The overall outcome for delusional jealousy looks promising if the patients can accept pharmacotherapy in an outpatient setting.

A study of HLA-linked genes in a monosymptomatic psychotic disorder in an Indian Bengali population

OBJECTIVE

The etiology of delusional disorder is imperfectly understood. Involvement of biological factors has long been suspected. We examined the incidence of class I human leukocyte antigens (HLAs) in patients with delusional disorder to understand the role of HLA genes and explore a possible immunogenetic etiology for delusional disorder.

METHODS

We used a nested case-control study design. Psychiatric reference data were available for 27 500 patients registered between 1998 and 2003. Initially, we enrolled 150 patients with delusional disorder from the India-born Bengali population, using DSM-IV diagnostic criteria. After longitudinal follow-up, 80 patients were found to have only delusional disorder, while the remaining 70 patients represented different illnesses with paranoid symptoms and were excluded. We performed serological typing on all 150 patients and applied the polymerase chain reaction-based high-resolution molecular typing method to the 80 patients with delusional disorder. Eighty healthy donors of the same ethnic background, matched for age, sex, and other socioeconomic variables, formed the control group.

RESULTS

Some of the HLA alleles were associated with delusional disorder, and the gene HLA-A*03 was found to be significantly more frequent. This gene may influence patients' susceptibility to delusional disorder.

CONCLUSION

The study reveals important associations between HLA genes and delusional disorder. This preliminary observation may help our understanding of this disorder's genetic basis.

Occurrence and clinical correlates of psychiatric co-morbidity in delusional disorder

The present study investigated the occurrence and the clinical correlates of psychiatric co-morbidity in a sample of 64 patients with delusional disorder (DD). Subjects were evaluated with a semi-structured interview for the collection of demographic and clinical features of the disorder; co-morbid axis 1 disorders were determined according to the clinical interview using DSM-IV by Othmer and Othmer. Delusional disorder subjects with and without co-morbid diagnoses were compared to investigate whether the presence of another psychiatric disorder influenced the clinical features of the illness.Seventy-two percent of the subjects had at least one additional lifetime psychiatric diagnosis. High lifetime co-morbidity was found with affective disorders, whose onset generally had been subsequent to the onset of DD. Patients with at least one co-morbid disorder (N = 46) had an earlier age at onset, presented for the first psychiatric consultation at an earlier age, and were younger at index evaluation for this study with respect to patients without co-morbidity (N = 18). Types of DD differed significantly according to the presence/absence of lifetime co-morbid disorders: DD patients with co-morbidity were in most cases persecutory type (54.4%) while DD patients without co-morbidity were mixed type (66.7%). Our data indicate that there is a considerable proportion of patients whose DDr is strictly connected with other co-occurring psychiatric disorders (mainly affective disorders), which exert an influence on the phenomenology of the illness.

Delusional disorder: retrospective analysis of 86 Chinese outpatients

Patients who visited the psychiatric outpatient service of Chang Gung Medical Centre, Tao-Yuan, Taiwan during an 8-year period were studied retrospectively. Among the 10,418 outpatients, 86 (0.83%) were diagnosed as having DSM-IV delusional disorder (DD), including 61 (70.9%) with persecutory type, 12 (14.0%) with the mixed type, seven (8.1%) with jealous type, two (2.3%) with somatic type, two (2.1%) with unspecified type, one (1.2%) with erotomanic type, and another one with grandiose type. The ratio of women to men was 0.86. The mean age at onset was 42.4 +/- 15.41 years, with women being older than men. Thirty-seven cases (43.0%) presented with depressive symptoms at their first visit. Subjects were divided into four groups: persecutory type, jealous type, mixed type and others. There were no significant differences between the four groups in terms of gender, age at onset, time-lapse before seeking psychiatric help, the presence of hallucination or the presence of depression.

Late-onset psychosis with somatic delusions

The authors studied 10 patients who had late-onset psychosis with somatic delusions and 2 comparison groups similar in age and education: 9 late-onset psychosis patients without somatic delusions and 10 normal control subjects. Demographic, clinical, and neuropsychological data were obtained. Brain magnetic resonance imaging was also done and compared. The patients with somatic delusions were somewhat more likely to be women, have been ill longer, and meet DSM-III-R criteria for delusional disorder, compared with late-onset psychotic patients without somatic delusions. Patients with somatic delusions also had lower scores on a full-scale IQ test, compared with the normal comparison subjects. The patients with somatic delusions rarely benefitted from and poorly complied with treatment with psychotropics. The study's limitations, such as small sample size and heterogeneity of diagnosis, as well as the possible clinical implications of these findings are also discussed.

Successful treatment of litigious paranoia with pimozide

A case of querulous-litigious delusional disorder successfully treated with low-dose pimozide is reported. A summary of the contemporary literature on this neglected topic is provided.

The treatment of monodelusional psychosis associated with depression

This is a report of the treatment of four patients suffering from a syndrome consisting of a single delusion in association with depression. The tendency of monodelusional syndromes to respond to a pimozide provides a rationale for nosological organisation.

Delusional (paranoid) disorders

The group of paranoid or delusional disorders, although not nearly as common as the mood and schizophrenic disorders, may be much more frequent than has usually been thought. DSM-IIIR has made a decisive step in recognizably defining at least one group of them. Interestingly, this change partly came about because the advent of an effective treatment helped to define that group more clearly. Nevertheless, DSM-IIIR's classification is too restrictive, and it was wrong to exclude the diagnosis of paraphrenia. Cases fitting this description will have to be consigned to the category of Psychotic Disorder NOS, which will inevitably be a grab-bag of mixed diagnoses. Also, DSM-IIIR does not emphasize the link between the delusional disorders and paranoid schizophrenia, and the somewhat less well defined overlap with affective disorders, both of which give rise to much diagnostic confusion and inappropriate treatment. Precise history taking and mental status examination and, above all, an up-to-date knowledge of their existence are essential to the recognition and appropriate treatment of the delusional disorders.