What We Know and Still Need to Know about Gender Aspects of Delusional Disorder: A Narrative Review of Recent Work

Induced erotomania by online romance fraud - a novel form of de Clérambault's syndrome

BACKGROUND

Although the impact of internet usage on mental health is extensively documented, there is a notable scarcity of reports in the literature concerning internet-induced erotomania. Erotomania is a rare and likely underdiagnosed delusional disorder. It is characterized by an irrational belief held by the affected persons that someone of higher socioeconomic status harbor romantic feelings toward them. Here, we describe the psychopathology of erotomanic delusion induced by online romantic fraud in a female patient. Employing this case as a focal point, we illuminate novel aspects of erotomania that warrant attention and examination.

CASE PRESENTATION

We present a compelling case involving a 70-year-old married Caucasian woman diagnosed with medically controlled persistent depressive disorder for several years. The intricacies of her condition became evident as she became deeply engrossed in online profiles featuring the image of a renowned musician, inadvertently falling victim to an online romantic fraud. Subsequently, this distressing experience triggered the emergence of erotomanic delusions and a suicide attempt. The patient's history reveals an array of medical conditions and stressful life events, contributing to her vulnerability. The diagnosis of erotomanic delusional disorder, dysthymia, and mild cognitive impairment with cerebral vascular background was established. Treatment involved her previous antidepressant with low-dose risperidone, alongside supportive individual and group therapy. Her delusion showed remission four weeks later, prompting her discharge for outpatient follow-up. Although she retained some false beliefs, the intensity of the symptoms had notably diminished and her functionality improved.

CONCLUSION

This case underscores the complex interplay between mental health, online activities, and the consequences of delusions, including suicidal thoughts, shedding light on the need for a comprehensive approach in addressing such challenging psychiatric scenarios.

Gender differences in the young-onset persistent delusional disorder

We conducted a retrospective chart review to examine the gender differences in young onset Persistent Delusional Disorder (PDD) subjects (N = 236) with onset of illness before the age of 30 years. Gender differences in marital and employment status were significant (p-0.001). Delusion of infidelity and erotomania were more common in females, while males had more body dysmorphic and persecutory delusions (X²-20.45, p-0.009). Males had more substance dependence (X²-21.31, p < 0.001), as well as a family history of substance abuse and PDD (X²-18.5, p < 0.01). To conclude, gender differences in PDD comprised some psychopathology, co-morbidity, and family history among those with young onset PDD.

Differences between delusional disorder and schizophrenia: A mini narrative review

Psychotic syndromes are divided into affective and non-affective forms. Even among the non-affective forms, substantial differences exist. The aim of this relatively brief review is to synthesize what is known about the differences between two non-affective psychoses, schizophrenia and delusional disorder (DD), with respect to clinical, epidemiological, sociodemographic, and treatment response characteristics. A PubMed literature search revealed the following: in schizophrenia, hallucinations, negative symptoms and cognitive symptoms are prominent. They are rare in DD. Compared to schizophrenia patients, individuals with DD maintain relatively good function, and their delusions are believable; many are beliefs that are widely held in the general population. Treatments are generally similar in these two forms of psychosis, with the exception that antidepressants are used more frequently in DD and, for acute treatment, effective antipsychotic doses are lower in DD than in schizophrenia. It is with the hope that the contrasts between these two conditions will aid in the provision of safe and effective treatment for both that this review has been conducted.

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.

Care for Women with Delusional Disorder: Towards a Specialized Approach

Delusional disorder is a difficult-to-treat clinical condition with health needs that are often undertreated. Although individuals with delusional disorder may be high functioning in daily life, they suffer from serious health complaints that may be sex-specific. The main aim of this narrative review is to address these sex-specific health needs and to find ways of integrating their management into service programs. Age is an important issue. Delusional disorder most often first occurs in middle to late adult life, a time that corresponds to menopause in women, and menopausal age correlates with increased development of both somatic and psychological health problems in women. It is associated with a rise in the prevalence of depression and a worsening of prior psychotic symptoms. Importantly, women with delusional disorder show low compliance rates with both psychiatric treatment and with medical/surgical referrals. Intervention at the patient, provider, and systems levels are needed to address these ongoing problems.

Antipsychotic-induced Hyperprolactinemia in aging populations: Prevalence, implications, prevention and management

This paper reviews the prevalence, implications, prevention and management of antipsychotic-induced hyperprolactinemia in aging populations. Antipsychotics are indicated mainly for the treatment of psychotic illness but are also used in other conditions. Complications induced by antipsychotics increase with age, due to age-related changes in drug metabolism and excretion. Almost all antipsychotics lead to hyperprolactinemia by blocking dopamine D2 receptors in the anterior pituitary gland, which counteracts dopamine's inhibitory action on prolactin secretion. The main findings of this narrative review are that, though many of the known side effects of high prolactin levels lose their salience with age, the risk of exacerbating osteoporosis remains critical. Methods of preventing antipsychotic-induced hyperprolactinemia in older individuals include using antipsychotic medication (AP) as sparingly as possible and monitoring AP serum levels, regularly measuring prolactin levels, closely monitoring bone density, treating substance abuse, and teaching patients stress management techniques. When hyperprolactinemia symptoms cannot be otherwise managed, adjunctive drugs are available. Potential helpful adjuncts are: dopamine agonists, antipsychotics with partial agonist properties (e.g. aripiprazole), selective estrogen receptor modulators, and metformin. Because a gold standard for prevention/treatment has not been established, clinical decisions need to be made based on safety and individual circumstance.

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.