CURRENT PERSPECTIVES
Delusional (Paranoid) Disorders*
ALISTAIR MUNRO, M.D.'
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. Casesfitting 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 andparanoidschizophrenia, 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.
Ithat"delusional
n DSM-IIIR (I), paranoid disorders are renamed
disorders", firstly, in order to emphasize
the presence of a delusion is the principal clinical
feature and, secondly, to reduce some of the semantic
confusion which always seems to attach itself to the
words "paranoia" and "paranoid". English-speaking
psychiatrists use "paranoid" very loosely, usually
implying that an angry, suspicious individual is
preoccupied with ideas of persecution (2). This has
become the layman's usage and, in fact, is most often
employed to describe someone with a paranoid
personality disorder. DSM-IIIR continues to use the
term "paranoid personality disorder", because its authors
believed that many psychiatrists would be unwilling to
change their diagnostic habit. "Delusional disorder" will
be the subject of this article: paranoid personality
disorder will be discussed only incidentally.
What is a Delusion?
This article's working definition of a delusion is: "A
reality judgement which cannot be accepted by people of
*Manuscript received January 1988.
I Professor and Head, Department of Psychiatry, Dalhousie University,
Halifax, Nova Scotia.
Can. J. Psychiatry Vol. 33, June 1988
399
the same class, education, race, and period of life as the
person who expresses it, and which cannot be changed by
logical argument or evidence against it." (3).
Mullen (4) suggested that the characteristics of a
delusion include:
1. The belief being held with total conviction.
2. It is experienced as a self-evident truth, usually with a
sense of great personal significance.
3. It is not amenable to reason nor modifiable by
experience.
4. The content is inherently unlikely.
5. The belief is not held by those of a common social and
cultural background.
Before the delusion occurs, it may be preceded by a
delusional mood or "Wahnstimmung", which disappears
with the sense of certainty accompanying the delusion.
Delusional Disorders
One must read much of the literature on paranoid
disorders with profound scepticism since most authors
fail to define their diagnostic criteria. DSM-III's (5)
section on paranoid disorders was highly inaccurate,
because it wrongly emphasized the nature of the
delusional content rather than insisting that it was the
prominence of the delusions themselves which defined
the disorder. The description in DSM-IIIR is much
sounder but is over-restrictive. It largely confines itself to
a consideration of paranoia in the Kraepelinian sense (6)
- that is, an encapsulated, monodelusional illness - and
overlooks other candidates for inclusion, especially
paraphrenia, a useful diagnosis still found in leD 9 (7). It
also ignores the proposition that paranoid schizophrenia
might be considered as one of the delusional disorders.
As it stands, DSM-IIIR's description of delusional
disorder leaves it taxonomically isolated: it will be
contended that this isolation is more apparent than real.
General Features of Delusional Disorders (8)
1. The primary feature is the presence of a delusion or
delusions occurring in clear consciousness and not
secondary to another psychiatric disorder. Accord-
ing to the specific type of disorder, there may be a
single encapsulated delusion or multiple and more
diffuse delusions.
2. Hallucinations, in any sensory modality, mayor may
not be present.
3. Thought disorder is generally less severe than in
schizophrenia.
400 CANADIAN JOURNAL OF PSYCHIATRY
4. The content of the delusion will vary although
certain themes tend to recur.
5. Patients show remarkable denial and illogicality
when faced with the contrast between their beliefs
and reality.
6. Suspiciousness is frequent; but profound anxiety,
dejection, and shame are almost as common.
7. Virtually all patients show overalerting, and, many,
insomnia.
8. A previous history of eccentric, isolated, suspicious
or asocial behaviour is common.
9. A history of alcohol or drug abuse, or of cerebral
insult, is often obtained.
10. A family history of psychiatric disorder is frequent,
but usually of conditions other than delusional or
schizophrenic illness (9,10).
11. Induced psychotic disorder (shared paranoid
disorder, folie a deux) is present in a significant
number of cases.
12. These patients are often non-compliant in treatment,
showing irrational disbelief in its efficacy. The
overall attitude is often haughty and sometimes
grandiose.
Specific Syndromes
1. Delusional Disorder (DSM-IIIR 297.10) (I): This is
synonymous with Kraepelinian paranoia. There is a
stable, clear-cut delusional system in which the primary
delusion predominates and other delusions can usually
be seen to be secondary to it. The diagnosis is based on
the presence of the delusional system and not on the
theme of the content, although the latter is used to
describe several subtypes. The delusions are persistent
but relatively non-bizarre; hallucinations, if present, are
not unduly prominent. Other personality aspects are well
preserved, but the intrusiveness of the delusional belief
can totally dominate the way of life.
The subtypes differ in their delusional contents, but
otherwise the presentations are very similar. They are:
a) Erotomanic. The individual falsely believes that
another person secretly loves him or her. The patient
usually keeps this belief hidden but in some cases acts it
out. This is one form of de Clerambault's Syndrome (11-
13).
b) Grandiose. The delusion is megalomanic, and the
affect may be pleasurable, even ecstatic. The patient is
not apparently perplexed by the contrast between his
belief and the actuality of his existence. Individuals with
this type of delusion are unlikely to seek voluntary
treatment (6).
c) Jealous. Here there is a delusional conviction that
the sexual partner is unfaithful. If the patient reacts with
anger, he may commit violence or even homicide (14,15).
d) Persecutory. The patient has a persistent conviction
of being malevolently treated and reacts with distress,
anger, and sometimes violence. In some cases, patients
have incessant recourse to the law, and this may be
described as "litigious paranoia" (16).
Vol. 33, No.5
e) Somatic. The delusion is hypochondriacal and the
condition is synonymous with monosymptomatic
hypochondriacal psychosis (MHP), in which the patient
has an unremitting belief that some aspect of his
physiology, appearance, or health is abnormal, and
incessantly seeks treatment (8,17).
f) There is an Unspecified category to incorporate
cases with other delusional contents.
When Kraepelin originally described paranoia (6), he
regarded it as rare. In recent years it has been recognized
that it is not that uncommon, and it may have a relatively
specific treatment (see below) (8). It has therefore become
important to distinguish it from the other functional
psychoses.
2. Paraphrenia (ICD 9 297.2) (7): There are cases of
persistent delusional illness in which the delusions are less
well encapsulated than in the previous illness but where
deterioration is significantly less than in paranoid
schizophrenia. The delusions are often multiple and
hallucinations may be prominent, especially auditory,
tactile, or olfactory. Behaviour is less disorganized than
in schizophrenia, mood and islands of personality are
relatively well preserved, and thought disorder is not
unduly severe. It is very possible that paraphrenia is
simply a milder form of paranoid schizophrenia, but it is
a useful diagnosis in delusional cases where personality
functioning, mood, and social judgement are retained to
a considerable degree.
Despite the relative lack of personality deterioration,
many of these patients have markedly abnormal
premorbid personalities, and it is often difficult to be sure
when the insidious onset has actually begun.
Many psychiatrists think of paraphrenia as a diagnosis
of old age, but it can occur in middle-aged and
occasionally younger individuals. This category can
encompass many cases loosely labelled as involutional or
senile paranoid state, late paraphrenia, and even late-
onset schizophrenia. In DSM-IIIR, all such cases will
probably have to be heaped into Psychotic Disorder
NOS (Atypical Psychosis 298.90).
3. As already noted, there are arguments for
considering paranoid schizophrenia as a delusional
disorder, or at least as a bridge between the delusional
disorders and the schizophrenias. There is certainly
strong evidence to indicate that paranoid schizophrenia
should . be regarded as separate from the rest of
schizophrenia (17).
Conditions Which Should Not Be
Diagnosed As Delusional Disorders
There will be some confusion about the change from
DSM-III to DSM-IIIR. We should therefore consider
those conditions which were regarded as paranoid
disorders in the former but not in the latter.
1. Shared Paranoid Disorder (Folie aDeux) 18: This
consists of two phenomena. The first, "folie imposee", is
the commoner and is the situation where two people, one
of whom is deluded, live in close proximity and often in
 June, 1988 DELUSIONAL (PARANOID) DISORDERS
social isolation. By incessant repetition of the delusional
belief, the primary case eventually convinces the other
person that it is true, and both come to share it
unquestioningly. However, the second person is
impressionable rather than deluded: treatment is by
curing the primary case or by separating the two
individuals. In DSM-IIIR, shared paranoid disorder is in
the category of Psychotic Disorders Not Elsewhere
Classified, under the name of "induced psychotic
disorder" (1).
The other, less frequent, situation is where two
individuals, often genetically related, live together and
both develop delusional illnesses. By close association,
they come to share the same false beliefs. This is known as
"folie simultanee" and does not require a separate
diagnostic category, since both patients can be diagnosed
as suffering from a delusional disorder.
2. Acute Paranoid Disorder was an unsatisfactory
description in DSM-III since chronicity is usually a
feature of delusional disorders. It was also realized that
cases in this category were similar to many other short-
lived psychoses (19). In DSM-IIIR, cases like this are
now satisfactorily included with the Brief Reactive
Psychoses (1).
There are at least two other situations in which
diagnostic confusion often arises, largely due to the
overlap of symptomatology between delusional disorders
and schizophrenia on one hand, and mood disorder on
the other. Elsewhere (20), the present author has
criticized the use of the term "schizoaffective disorder",
but has suggested two areas where the term may be
justifiable. In both of these there is the possibility of
misdiagnosing delusional disorders. They are:
1. where certain individuals have inherited strong traits
of both mood disorder and schizophrenia, and present
with a mixture of delusions and affective symptoms,
and
2. the condition of "Cycloid Psychosis" (21), in which
the patient presents with a schizophrenic or delusional
picture, but the course is periodic in the manner of a
mood disorder. This illness is said to be strongly
familial and the symptoms are thought to respond
best to antidepressant treatment. The condition is
uncommon but has to be distinguished from
delusional disorders because of the completely
different treatment and outcome.
The Frequency of Delusional Disorders
We have no means of knowing how common these
illnesses are, because there have been so many changes of
conceptualization and nomenclature. They are probably
considerably less frequent than the other functional
psychoses (22), but the more that psychiatrists are made
aware of them, the more they are reported. It is almost
certain that there is a considerable reservoir of patients in
the community who do not seek medical, and particularly
psychiatric help because of their "paranoid" attitudes.
Patients with infestation delusions, for example, attend
401
dermatologists, not psychiatrists (23,24), litigious
patients haunt the law courts, and jealousy/delusional
patients get into trouble with the police, so that
psychiatrists are often contacted last or not at all.
The Differential Diagnosis
of Delusional Disorder
The following conditions must be excluded:
a) Organic mental disorder, including organic delu-
sional syndromes: However, some otherwise typical
cases of delusional disorder have a definite history of
substance abuse or head injury in their past, and at
least a proportion of these cases respond well to
antipsychotic treatment.
b) Paranoid schizophrenia, where the symptoms are
grosser, more pervasive, and interfere more seriously
with social and occupational functioning.
c) Mood (affective) disorders with psychotic features:
this can sometimes be difficult, because affective
features may actually occur at different stages of
delusional disorders (25).
d) The schizo affective disorders described above.
e) Body dysmorphic disorder (dysmorphophobia) (1) is
a condition in which the patient has a preoccupation
with health or bodily appearance but in the form of an
overvalued idea rather than a delusion.
f) Paranoid personality disorder where there are usually
querulousness and suspiciousness but no delusions.
The Paranoid Spectrum and
Etiological Considerations
Several authors, particularly Kendler and Watt (9,10),
argue that delusional disorders and schizophrenia are
quite separate, largely on the grounds that genetic studies
usually show no excess of schizophrenia in the relatives of
paranoid psychosis patients. This agrees with the present
author's findings in monodelusional disorders (8). On the
other hand, it has been documented that about ten
percent of paranoia cases (that is, delusional disorder,
DSM-IIIR), deteriorate to paraphrenia and even
schizophrenia (26). There is also a minimal amount of
evidence that, if psychosis supervenes in a patient with a
paranoid personality disorder, that psychosis is likely to
present as a delusional disorder or as a paranoid
schizophrenia (21,27). Finally, delusional disorders and
schizophrenia tend to respond to the same types of
treatment.
Therefore, the traditional concept of a "paranoid
spectrum" continues to have some usefulness (28-30). In
its simplest form this would be as seen in Figure I.
The apparent lack of genetic factors for schizophrenia
in delusional disorder patients is difficult to reconcile
with the clinical similarities between these conditions and
the occasional tendency for one to deteriorate towards
the other. However, the present author has pointed out
that subtle organic brain factors may be of importance in
the etiology of delusional disorders (31), and there is
increasing evidence that there may be important organic
402 CANADIAN JOURNAL OF PSYCHIATRY
Paranoid Paranoid
Personality Delusional Disorder--Paraphrenia Schizophrenia
Disorder
...-- Paranoid Spectrum -------.
The conditions on the spectrum have a considerable degree of
diagnostic stability, but if deterioration occurs, it will be from left
to right.
Figure 1. Paranoid Spectrum.
etiological factors in certain cases of schizophrenia
(32,33).
Since the symptoms of delusional disorders are more
selective than those of schizophrenia, the hypothesis is
proposed here that delusional disorders and schizophre-
nia are indeed on a continuum, with the former having
low genetic loading and significant organic etiology and
the latter having high genetic loading, with or without
accompanying organic factors. By adopting this view,
delusional disorders no longer seem so isolated, and their
traditional link with schizophrenia can be maintained,
while accepting their separate phenomenologies.
However, it should also be noted that evidence is
accumulating of a link between delusional and mood
disorders (25). Many patients with delusional disorder,
for example, have marked secondary depressive
symptoms and, at times, suicidal thinking; and post-
psychotic depressive symptoms are not uncommon in the
recovery phase of a treated delusional disorder (8).
Psychological Background to Delusional Disorders
There is a great deal of speculation in the literature
about underlying psychopathology. Since most authors
use the term "paranoid" so loosely, it is often impossible
to know what they are speculating about. When there is a
discussion about delusions, authors usually concentrate
on content and feel they have explained the illness, if they
have "explained" this. Orthodox psychoanalytic theory,
for example, postulates that the origin of paranoia is the
presence of latent homosexuality (34), but there is no real
evidence for this and no convincing argument as to why
such conflicts should lead to a delusional illness only in
certain individuals. One author, seeking a reason for
delusions, suggested that schizophrenics exhibit autistic
withdrawal because of ineffective defence manoeuvres
against the outside world, whereas the paranoid uses his
delusion to cope with the world (35). In a common sense
way, this seems fairly credible.
In fact, at present there are no convincing explanations
at all of delusions, paranoid attitudes, or delusional
illnesses. What is needed is an agreed definition of what
constitutes a delusion, agreed definitions of what
constitutes the delusional illnesses, then careful
observations on the phenomenology associated with each
of them. So far this has not occurred and if it did, we
could then begin to study these illnesses with some
expectation of obtaining reproducible data.
Vol. 33, No.5
Psychophysiology of "Paranoid" Disorders
Since the majority of psychophysiological findings in
delusional disorders have been obtained from studies on
very heterogeneous groups of "paranoid" illnesses, it is
impossible to be precise about them. However, apart
from the delusions themsleves, individuals with
delusional disorders show some combination of the
following characteristics:
1. Hyperalerting appears to be a sine qua non of acutely
delusional patients (36), and the greater the alerting,
the more intense the delusional belief.
2. "Paranoid" individuals seem to have exaggerated
autonomic responses (37).
3. Paranoid schizophrenics appear to perform very
quickly in cognitive tasks involving attention and
motor speed (38).
4. One study (39) suggests that paranoid schizophrenics
have difficulty in assessing the emotional state of
other people which may predispose to suspicion in
already over-alert individuals.
5. Paranoid schizophrenics appear to be excessively
ready to respond to stimuli and often respond in
advance of stimuli (40).
6. Paranoid schizophrenics are said to show an "inertia
factor" in problem solving, rigidly continuing to use
the same criteria for decision-making even when these
prove repeatedly inappropriate (41).
7. There are some indications of hemispheric dysfunc-
tion and overactivation, especially left-sided, in
paranoid schizophrenics; and it has been reported that
left temporal epileptic foci are especially liable to
produce pseudo-schizophrenic symptoms (42).
Neurochemical Factors in Delusional Disorders
Amphetamine, a dopaminergic substance, can
produce delusional disorders indistinguishable from
paranoia or paranoid schizophrenia (43), and similar
symptoms have been produced by L-dopa and
methyldopa (44). Stress and amphetamines may be
mutually provocative, so that a chronically hyperalerted
individual may be more sensitive to the pathological
effects of amphetamines. The dopamine theory of
schizophrenia and delusional disorders has strong
support from many quarters, and it is frequently pointed
out that antidopaminergic drugs are the most effective in
these conditions (45).
The Treatment of Delusional Disorders
The first essential is careful differential diagnosis and
diagnosis. Treatment of the monodelusional disorders
(those now described by DSM-IIIR as subtypes of
delusional disorder) was traditionally regarded as
hopeless. There is now fair consensus that pimozide is a
specific and effective treatment for the somatic subtype
(8,23) and there is a small amount of anecdotal evidence
that it is also specifically effective in the jealousy
(15,46,47) and erotomanic (13) subtypes. The dose of
pimozide is usually not large, mostly between 4 and 6 mg
 June, 1988 DELUSIONAL (PARANOID) DISORDERS
daily, but with some individual variation. In many cases,
treatment has to be continued indefinitely; but a
proportion of patients can gradually be weaned off their
medication, although subsequent stress and hyperalert-
ing tend to reawaken symptoms. In some cases, especially
where compliance is dubious, the parenteral analogue of
pimozide - fluspirilene - is useful. In recent years, there
have been some anecdotal accounts of response of
delusional disorder cases to various antidepressants (48-
50), but it is unclear if this is further evidence of overlap
between delusional and mood disorders or whether the
diagnosis of the cases can be called in doubt.
In paraphrenia and paranoid schizophrenia, many
neuroleptics may be effective in controlling psychotic
symptoms, and there appears to be much less specificity
of response than in the delusional disorders.
When severe post-psychotic depression occurs in the
recovery phase of any of these illnesses, it is best to
continue with the antipsychotic therapy and to add
antidepressant treatment, either a tricyclic antidepres-
sant or, if necessary, ECT (8).
In those few cases which actually are not delusional
disorders but where the illness is more typical of a
"cycloid psychosis" (see previously), antidepressant
treatment is apparently most effective (21).
Prognosis of Delusional Disorders
In the monodelusional disorders, the prognosis is now
quite good. The present author, in a series of 50 cases of
MHP, reported that 64 percent had an excellent, and a
further 18 percent a fair outcome withpimozide (8).
Other studies report similar figures (23).
In paraphrenia and paranoid schizophrenia, the illness
often responds well to antipsychotic medication, but
some patients have difficulty in reintegrating socially.
Compliance with treatment is frequently quite poor,
because suspiciousness is often a feature of these
disorders, and this has an adverse effect on outcome.
Elderly paraphrenics, even when they do fairly well, often
seem to be difficult to discharge from hospital. This may
be due in many instances to their habitually isolated
existences and lack of community supports.
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Resume
Bien que mains frequents que les troubles de /'humeur
et que la schizophrenie, les troubles paranoides et les
idees delirantes sont peut-etre plus frequents qu 'on ne le
croit habituellement. Le DSM-III R reconnait desormais
de facon claire au moins l'un de ces groupes. II est
interessant de noter que ce changement est dl1 en partie au
fait de la decouverte d'un traitement ejJicace qui a
contribue aune meilleure description de ce groupe.
Pourtant, la classification proposee par Ie DSM-III R
est trop limitative, et c'est a tort que l'on a exclu le
diagnostic de paraphrenie. Les cas qui repondent acette
description devront etre relegues dans la categoric des
troubles psychotiques (NOS), ce qui conduira inevitable-
ment a un ramassis de toutes sortes de diagnostics.
Notons egalemetu que le DSM-III R nefait pas ressortir
le lien qui existe entre les idees delirantes et la
schizophrenic paranoide, ni le chevauchement moins
bien defini avec les troubles affectifs, qui tous deux
donnent lieu aune grande confusion diagnostique et ades
traitements inappropries.
II est essentiel de bien connaitre les antecedents
psychiatriques du patient et deproceder aun bon exam en
de l'etat mental, et surtout, il est crucial de bien connaitre
la nature des idees delirantes pour pouvoir poser un
diagnostic juste et proposer un traitement approprie.