FANDOM


DSM-II

In DSM-II, this disorder is a category called Paranoid states

These are psychotic disorders in which a delusion, generally persecutory or grandiose, is the essential abnormality. Disturbances in mood, behavior and thinking (including hallucinations) are derived from this delusion. This distinguishes paranoid states from the affective psychoses and schizophrenias, in which mood and thought disorders, respectively, are the central abnormalities. Most authorities, however, question whether disorders in this group are distinct clinical entities and not merely variants of schizophrenia or paranoid personality.

Disorders

  1. Paranoia
  2. Involutional paranoid state (Involutional paraphrenia)
  3. Other paranoid state

DSM-III

In DSM-III, this disorder is a category called Paranoid Disorders

Disorders

  1. Paranoia
  2. Shared Paranoid Disorder
  3. Acute Paranoid Disorder

Diagnostic Criteria

A. Persistent persecutory delusions or delusional jealousy.

B. Emotion and behavior appropriate to the content of the delusional system.

C. Duration of illness of at least one week.

D. None of the symptoms of criterion A of Schizophrenia, such as bizarre delusions, incoherence, or marked loosening of associations.

E. No prominent hallucinations.

F. The full depressive or manic syndrome (criteria A and B of major depressive or manic episode) is either not present, developed after any psychotic symptoms, or was brief in duration relative to the duration of the psychotic symptoms.

G. Not due to an Organic Mental Disorder.

Differential Diagnosis

Organic Delusional Syndromes

In Organic Delusional Syndromes, particularly those induced by amphetamines, persecutory delusions are common.

Schizophrenia and Schizophreniform Disorder

In Schizophrenia, Paranoid Type, or Schizophreniform Disorder, there are certain symptoms, such as incoherence, marked loosening of associations, prominent hallucinations, and bizarre delusions (e.g., delusions of control, thought broadcasting, withdrawal, or insertion), that are not present in Paranoid Disorders. Although delusions that others are attempting to control the individual's behavior are common in both Paranoid and Schizophrenic Disorders, the experience of being controlled by alien forces suggests Schizophrenia or Schizophreniform Disorder. In addition, delusions in Schizophrenia are more likely to be fragmented and multiple rather than systematized, as in Paranoid Disorders.

Paranoid Personality Disorder

In Paranoid Personality Disorder there may be paranoid ideation or pathological jealousy, but there are no delusions. Whenever an individual with a Paranoid Disorder has a preexisting Personality Disorder, including Paranoid Personality Disorder, the Personality Disorder should be listed followed by the phrase "Premorbid" in parentheses.

DSM-IV

Diagnostic Criteria

A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration.

B. Criterion A for Schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme.

C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.

D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.

E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify type (the following types are assigned based on the predominant delusional theme):

  • Erotomanic Type: delusions that another person, usually of higher status, is in love with the individual
  • Grandiose Type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person
  • Jealous Type: delusions that involve the indivdiual's sexual partner is unfaithful
  • Persecutory Type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way
  • Somatic Type: delusions that the person has some physical defect or general medical condition
  • Mixed Type: delusions characteristic of more than one of the above types but no one theme predominates
  • Unspecified Type

Subtypes

The type of Delusional Disorder may be specified based on the predominant delusional theme:

Erotomanic Type

This subtype applies when the central theme of the delusion is that another person is in love with the individual. The delusion often concerns idealized romantic love and spiritual union rather than sexual attraction. The person about whom this conviction is held is usually of higher status (e.g., a famous person or a superior at work), but can be a complete stranger. Efforts to contact the object of the delusion (through telephone calls, letters, gifts, visits, and even surveillance and stalking) are common, although occasionally the person keeps the delusion secret. Most individuals with this subtype in clinical samples are female; most individuals with this subtype in forensic samples are male. Some individuals with this subtype, particularly males, come into conflict with the law in their efforts to pursue the object of their delusion or in a misguided effort to "rescue" him or her from some imagined danger.

Grandiose Type

This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery. Less commonly, the individual may have the delusion of having a special relationship with a prominent person (e.g., an adviser to the President) or being a prominent person (in which case the actual person may be regarded as an impostor). Grandiose delusions may have a religious content (e.g., the person believes that he or she has a special message from a deity).

Jealous Type

This subtype applies when the central theme of the person's delusion is that his or her spouse or lover is unfaithful. This belief is arrived at without due cause and is based on incorrect inferences supported by small bits of "evidence" (e.g., disarrayed clothing or spots on the sheets), which are collected and used to justify the delusion. The individual with the delusion usually confronts the spouse or lover and attempts to intervene in the imagined infidelity (e.g., restricting the spouse's autonomy, secretly following the spouse, investigating the imagined lover, attacking the spouse).

Persecutory Type

This subtype applies when the central theme of the delusion involves the person's belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. Small slights may be exaggerated and become the focus of a delusional system. The focus of the delusion is often on some injustice that must be remedied by legal action ("querulous paranoia"), and the affected person may engage in repeated attempts to obtain satisfaction by appeal to the courts and other government agencies. Individuals with persecutory delusions are often resentful and angry and may resort to violence against those they believe are hurting them.

Somatic Type

This subtype applies when the central theme of the delusion involves bodily functions or sensations. Somatic delusions can occur in several forms. Most common are the person's conviction that he or she emits a foul odor from the skin, mouth, rectum, or vagina; that there is an infestation of insects on or in the skin; that there is an internal parasite; that certain parts of the body are definitely (contrary to all evidence) misshapen or ugly; or that parts of the body (e.g., the large intestine) are not functioning.

Mixed Type

This subtype applies when no one delusional theme predominates.

Unspecified Type

This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component).

Differential Diagnosis

General Medical Conditions and Substance-Related Disorders

The diagnosis of Delusional Disorder is made only when the delusion is not due to the direct physiological effects of a substance or a general medical condition. A delirium, a dementia, and Psychotic Disorder Due to a General Medical Condition may present with symptoms that suggest Delusional Disorder. For example, simple persecutory delusions (e.g., "someone comes into my room at night and steals my clothes") in the early phase of Dementia of the Alzheimer's Type would be diagnosed as Dementia of the Alzheimer's Type, With Delusions. A Substance-Induced Psychotic Disorder, especially due to stimulants such as amphetamines or cocaine, cross-sectionally may be identical in symptomatology to Delusional Disorder, but can usually be distinguished by the chronological relationship of substance use to the onset and remission of the delusional beliefs.

Schizophrenia and Schizophreniform Disorder

Delusional Disorder can be distinguished from Schizophrenia and Schizophreniform Disorder by the absence of the other characteristic symptoms of the active phase of Schizophrenia (e.g., prominent auditory or visual hallucinations, bizarre delusions, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms). Compared with Schizophrenia, Delusional Disorder usually produces less impairment in occupational and social functioning.

Mood Disorders With Psychotic Features

It can be difficult to differentiate Mood Disorders With Psychotic Features from Delusional Disorder, because the psychotic features associated with Mood Disorders usually involve nonbizarre delusions without prominent hallucinations, and Delusional Disorder frequently has associated mood symptoms. The distinction depends on the temporal relationship between the mood disturbance and the delusions and on the severity of the mood symptoms. If delusions occur exclusively during mood episodes, the diagnosis is Mood Disorder With Psychotic Features. Although depressive symptoms are common in Delusional Disorder, they are usually mild, remit while the delusional symptoms persist, and do not warrant a separate Mood Disorder diagnosis. Occasionally, mood symptoms that meet the full criteria for a mood episode are superimposed on the delusional disturbance. Delusional Disorder can be diagnosed only if the total duration of all mood episodes remains brief relative to the total duration of the delusional disturbance. If symptoms that meet criteria for a mood episode are present for a substantial portion of the delusional disturbance (i.e.g, the delusional equivalent of Schizoaffective Disorder), then a diagnosis of Psychotic Disorder Not Otherwise Specified accompanied by either Depressive Disorder Not Otherwise Specified or Bipolar Disorder Not Otherwise Specified is appropriate.

Other Psychotic Disorders

Individuals with Shared Psychotic Disorder can present with symptoms that are similar to those seen in Delusional Disorder, but the disturbance has a characteristic etiology and course. In Shared Psychotic Disorder, the delusions arise in the context of a close relationship with another person, are identical in form to the delusions of that other person, and diminish or disappear when the individual with Shared Psychotic Disorder is separated from the individual with the primary Psychotic Disorder. Brief Psychotic Disorder is differentiated from Delusional Disorder by the fact that the delusional symptoms last less than 1 month. A diagnosis of Psychotic Disorder Not Otherwise Specified may be made if insufficient information is available to choose between Delusional Disorder and other Psychotic Disorders or to determine whether the presenting symptoms are substance induced or the result of a general medical condition

Anxiety Disorders

It may be difficult to differentiate Hypochrondriasis (especially With Poor Insight) from Delusional Disorder. In Hypochrondriasis, the fears of having a serious disease or the concern that one has such a serious disease are held with less than delusional intensity (i.e., the individual can entertain the possibility that the feared disease is not present). Body Dysmorphic Disorder involves a preoccupation with some imagined defect in appearance. Many individuals with this disorder hold their beliefs with less than delusional intensity and recognize that their view of their appearance is distorted. However, a significant proportion of individuals whose symptoms meet criteria for Body Dysmorphic Disorder hold their beliefs with delusional intensity. When criteria for both disorders are met, both Body Dysmorphic Disorder and Delusional Disorder, Somatic Type, may be diagnosed. The boundary between Obsessive-Compulsive Disorder (especially With Poor Insight) and Delusional Disorder can sometimes be difficult to establish. The ability of individuals with Obsessive-Compulsive Disorder to recognize that the obessions or compulsions are excessive or unreasonable occurs on a continuum. In some individuals, reality testing may be lost, and the obsessions may reach delusional proportions (e.g., the belief that one has caused the death of another person by having willed it). If the obsessions develop into sustained delusional beliefs that represent a major part of the clinical picture, an additional diagnosis of Delusional Disorder may be appropriate.

Paranoid Personality Disorder

In contrast to Delusional Disorder, there are no clear-cut or persisting delusional beliefs in Paranoid Personality Disorder. Whenever a person with a Delusional Disorder has a preexisting Personality Disorder, the Personality Disorder should be listed, followed by "Premorbid" in parentheses.

DSM-5

Diagnostic Criteria

A. The presence of one (or more) delusions with a duration of 1 month or longer.

B. Criterion A for schizophrenia has never been met. (Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).

C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.

D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.

Specify whether:

  • Erotomanic type: This subtype applies when the central theme of the delusion is that another person is in love with the individual.
  • Grandiose type: This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery.
  • Jealous type: This subtype applies when the central theme of the delusion is that his or her spouse or lover is unfaithful.
  • Persecutory type: This subtype applies when the central theme of the delusion involves the individual's belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.
  • Somatic type: This subtype applies when the central theme of the delusion involves bodily functions or sensations.
  • Mixed type: This subtype applies when no one delusional theme predominates.
  • Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component).

Specify if:

  • With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not understandable, and not derived from ordinary life experiences (e.g., an individual's belief that a stranger has removed his or her internal organs and replaced them with someone else's organs without leaving any wounds or scars).

Specify if:

The following course specifiers are only to be used after a 1-year duration of the disorder:

  • First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
  • First episode, currently in partial remission: Partial remission is a time period during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
  • First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
  • Multiple episodes, currently in acute episode
  • Multiple episodes, currently in partial remission
  • Multiple episodes, currently in full remission
  • Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
  • Unspecified

Specify current severity:

Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe).

Note: Diagnosis of delusional disorder can be made without using this severity specifier.

Subtypes

In eromanic type, the central theme of the delusion is that another person is in love with the individual. The person about whom this conviction is held is usually of higher status (e.g., a famous individual or a superior at work) but can be a complete stranger. Efforts to contact the object of the delusion are common.

In grandiose type, the central theme of the delusion is the conviction of having some great talent or insight or of having made some important discovery. Less commonly, the individual may have the delusion of having a special relationship with a prominent individual or of being a prominent person (in which case the actual individual may be regarded as an impostor). Grandiose delusions may have a religious content.

In jealous type, the central theme of the delusion is that of an unfaithful partner. The belief is arrived at without due cause and is based on incorrect inferences supported by small bits of "evidence" (e.g., disarrayed clothing). The individual with the delusion usually confronts the spouse or lover and attempts to intervene in the imagined infidelity.

In persecutory type, the central theme of the delusion involved the individual's belief of being conspired against, cheated, spied on, followed, poisoned, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. Small slights may be exaggerated and become the focus of a delusional system. The affected individual may engage in repeated attempts to obtain satisfaction by legal or legislative action. Individuals with persecutory delusions are often resentful and angry and may resort to violence against those they believe are hurting them.

In somantic type, the central theme of the delusion involved bodily functions or sensations. Somantic delusions can occur in several forms. Most common is the belief that the individual emits a foul odor; that there is an infestation of insects on or in the skin; that there is an internal parasite; that certain parts of the body are misshapen or ugly; or that parts of the body are not functioning.

Differential Diagnosis

Obsessive-compulsive and related disorders

If an individual with obsessive-compulsive disorder is completely convinced that his or her obsessive-compulsive disorder beliefs are true, then the diagnosis of obsessive-compulsive disorder, with absent insight/delusional beliefs specifier, should be given rather than a diagnosis of delusional disorder. Similarly, if an individual with body dysmorphic disorder is completely convinced that his or her body dysmorphic disorder beliefs are true, then the diagnosis of body dysmorphic disorder, with absent insight/delusional beliefs specifier, should be given rather than a diagnosis of delusional disorder.

Delirium, major neurocognitive disorder, psychotic disorder due to another medical condition, and substance/medication-induced psychotic disorder

Individuals with these disorders may present with symptoms that suggest delusional disorder. For example, simple persecutory delusions in the context of major neurocognitive disorder would be diagnosed as major neurocognitive disorder, with behavioral disturbance. A substance/medication-induced psychotic disorder cross-sectionally may be identical in symptomatology to delusional disorder but can be distinguished by the chronological relationship of substance use to the onset and remission of the delusional beliefs.

Schizophrenia and schizophreniform disorder

Delusional disorder can be distinguished from schizophrenia and schizophreniform disorder by the absence of the other characteristic symptoms of the active phase of schizophrenia.

Depressive and bipolar disorders and schizoaffective disorder

These disorders may be distinguished from delusional disorder by the temporal relationship between the mood disturbance and the delusions and by the severity of the mood symptoms. If delusions occur exclusively during mood episodes, the diagnosis is depressive or bipolar disorder with psychotic features. Mood symptoms that meet full criteria for a mood episode can be superimposed on delusional disorder. Delusional disorder can be diagnosed only if the total duration of all mood episodes remains brief relative to the total duration of the delusional disturbance. If not, then a diagnosis of other specified or unspecified schizophrenia spectrum and other psychotic disorder accompanied by other specified depressive disorder, unspecified depressive disorder, other specified bipolar and related disorder, or unspecified bipolar and related disorder is appropriate.