Delusional Disorder: What It Is and How to Help

Delusional Disorder Is a Distinct Psychiatric Condition

Interviewer: Every so often, someone reaches out to University of Utah Health convinced that they've been secretly implanted with a tracking device, followed by a stranger, or targeted in a way that no one else can really see. And it's really tempting to write that off as pure conspiracy thinking, but it's actually a recognized clinical experience, and it's just one shape of a much broader and misunderstood condition: delusional disorder.

Today, we're going to be talking with Dr. Tyler Durns, the forensic fellowship director at University of Utah's Huntsman Mental Health Institute. And his work sits at the intersection of both mental illness, family life, and the legal system.

So, Dr. Durns, just to start out, what is delusional disorder?

Dr. Durns: Delusional disorder, at least as our diagnostic manual, the DSM-5-TR, defines it, is a psychotic disorder in which a person has one or more fixed false beliefs or delusions that last at least one month without otherwise meeting criteria for schizophrenia or having another causal explanation for why they're having these symptoms, such as substance use.

Delusional Disorder Is Not Schizophrenia

Interviewer: And so, I guess, how is that different than, say, schizophrenia?

Dr. Durns: In terms of definition, schizophrenia has multiple, what we call, core symptoms. The diagnosis requires at least two of delusions, hallucinations, disorganized speech or behaviors, or negative symptoms, whereas a delusional disorder is really just the delusions in isolation, so those fixed false beliefs, but otherwise maintaining a good level of functioning, not exhibiting hallucinations, or not showing any of that disorganized thought pattern.

False Beliefs Are Not Always Delusions

Interviewer: How is delusional disorder different than just believing something that's untrue?

Dr. Durns: There is something that's not recognized in our DSM, but is pretty well characterized in the medical literature, called extreme overvalued beliefs. These are also fixed false beliefs, but rather than coming purely from the brain, being an organic disorder like delusional disorders, these are things that are maybe culturally reinforced. They might align with people's beliefs. They entail a lot of social psychology that reinforces the beliefs.

Whereas a delusional disorder is coming purely from the brain. It's a medical illness. And of course, there's a lot of psychosocial context around it, but at its core, it's a biological illness.

Delusional Disorder Usually Appears Later in Life

Interviewer: And so, if it's biological, how common is this situation, and what types of people are typically affected?

Dr. Durns: Unlike schizophrenia and other psychotic disorders or disorders that people are exhibiting psychotic symptoms that present in . . . Well, usually in males, they'll first arise in kind of the early 20s, in that period, late adolescence maybe. Females, a little bit later. Whereas delusional disorders have a much later age of onset. The average age, depending on which study you look at, is usually around 40.

And as far as where they come from, we don't fully know. It's in part defined by how resistant to any alternative explanations to their beliefs, or how resistant they are to contradictory evidence. And in terms of actual practical application, partially defined by their response to treatment as well.

Most Delusions Center Around a Single Theme

Interviewer: So I guess that leads me to ask how can someone be utterly convinced in something that is untrue but still seems completely rational everywhere else in their life? Is it just one belief, or is it a series of beliefs that happen when it comes to delusional disorder?

Dr. Durns: Typically, there will be, if not one belief, sort of in one kind of class of belief. For example, persecutory delusions. It might not mean that they just think the one person is after them, but it might be there's a whole network. And there's maybe some wiggle room within that, but it is centered around one core fixed false belief.

And as far as how that presents or why, maybe the best analogy here is when you think of somebody with dementia, right? We're trying to imagine, "Well, how could you forget where your home was?" or, "How can you forget your grandkid's name?" Well, it's because those parts of their brain aren't functioning in the way they are with a normal, healthy brain.

Interviewer: So if the beliefs are so varied, what are some of the different themes that these kinds of delusions can take, and how can we start to recognize those?

Dr. Durns: The DSM does have several . . . we call them specifiers for the delusional disorder diagnosis. So this would be different types of delusions. The most common by far are what we call persecutory type. These are defined as a belief that the individual is being harmed or conspired against, followed, poisoned, harassed, things of that nature.

But there are other types of delusions across all psychotic disorders. Some of these are an erotomanic type of delusion. This is a belief that another person is in love with the individual. It might have some hypersexual themes.

There is a somatic type of delusional disorder. These are delusions involving bodily functions or sensations. It might be somebody convinced that they're actually dead, their flesh is rotting, things of that sort.

There's also a jealous type, which I suppose is a little bit self-explanatory, and a grandiose type. These would be people believing that they have some exceptional ability, knowledge, identity, status, or an important discovery.

People With Delusional Disorder Truly Believe Their Delusions

Interviewer: And is that just fabricated or exaggerated, or is that something that they are actually experiencing?

Dr. Durns: I do work both in clinical psychiatry as an inpatient and outpatient doctor but also do some forensic work. And in my forensic work, that's certainly a question we have to ask often where there's really some secondary gain or benefit that could be had, like maybe be found incompetent to stand trial or enter a guilty with a mental condition plea. So those are things where, yes, at times people do feign delusions.

But I mean, certainly in clinical contexts where it wouldn't benefit them to believe that, there's no secondary gain, no monetary gain, no relief from criminal sentencing, then these are certainly quite genuine and real to them.

Genetics and Life Experiences May Both Contribute to Delusional Disorder

Interviewer: And do we know any potential things that could cause delusional disorder? If it's something like genetics, brain chemistry, circumstances of life?

Dr. Durns: Yeah. The biopsychosocial model really fits well with delusional disorder along with a lot of our others. There are a few different hypotheses out there called the multi-hit hypothesis. And you'll see this across a lot of our different disorders.

The idea here being that everyone is born with a certain level of vulnerability to certain things based off your genetics, your biology. However, some people are going to be born with a greater or less vulnerability, and then through various lifestyle factors . . . I mean, this could be something more overt like chronic drug use, but also something out of people's control, like trauma, things like that. That could also influence how mental disorders present, or if they present at all.

Interviewer: Now, I know earlier we mentioned that delusional disorder often appears later in life. And we know that some people might be predisposed. But is there something that can trigger a delusional disorder, something to take effect or to come to the surface?

Dr. Durns: The offspring of delusions could come from a lot of different places. I wouldn't say there is any kind of one clear nexus between some factor versus another.

That said, we do have some biological targets, specifically antipsychotics. While less effective in treating delusional disorders in schizophrenia, we do see some improvement pretty frequently with delusional disorders, at least some improvement. And that at least tells us there is something going on in the brain here, whether it's too much dopamine, or an excess of dopamine, which are targeted with antipsychotics, or any number of neurotransmitters in the pathways that those medications somehow modify.

I know that was a loose answer, but psychiatry is still a young field. Fortunately, we do have a lot of treatments that work really well, but we are admittedly lagging behind in terms of our understanding of where some of the disorders come from in the first place.

Medication Can Reduce the Intensity of Delusions

Interviewer: And what kind of treatment is there for something like this?

Dr. Durns: As far as the medications, again, antipsychotics are extremely effective in treating schizophrenia. They could be helpful with bipolar, even some others, depressed mood and things like that.

They do help with delusions. Most of the data show that they are a little bit less effective with treating delusional disorders, but nonetheless, you'll typically see at least some relief in symptoms.

For example, an individual taking an antipsychotic with a delusional disorder, they might be less distressed, less perseverative or ruminative about their delusional beliefs, although an aspect of them might still continue to believe it.

This response is variable. And a lot of our data in terms of how effective these medications are, are limited by a few things. One, delusional disorder relative to many of our other disorders, including schizophrenia, is much more rare. And the other aspect is a lot of these folks suffering with this don't come to treatment.

Many People With Delusional Disorder Continue Daily Life

Part of delusional disorder is you're having these delusions in isolation. So they're otherwise generally fairly well-functioning. These are people who could keep working, engage in various recreational activities, unlike, say, schizophrenia, which tends to be kind of more globally impairing where people aren't able to organize their thoughts and behaviors. I think most of the data say about 2% of people with schizophrenia can maintain employment, for example.

So a lot of people with delusional disorders don't walk into your clinic and say, "Hey, I'm delusional," because it's real to them. They're functioning well, and they think that what they're believing is true.

The term for this that we use is called anosognosia. It essentially means impaired insight into their own illness, so the inability to recognize that their belief is, in fact, false.

Psychotherapy Can Improve Insight and Reduce Distress

Interviewer: Now, is this something that gets better or is it a lifelong chronic condition?

Dr. Durns: These disorders can be somewhat mitigated, often by antipsychotic medications. But also, psychotherapy does come into play here. And it comes into play in a few different ways, whether it's addressing those cognitive errors and kind of gradually getting the person to be open to challenging these beliefs or questioning them.

And also sometimes, these beliefs, however fixed they might be, how can we make this so it's not so impairing or distressing to you or your loved ones and just all around not impacting you in a significant way, even if they are still held to some degree?

Supporting Someone With Delusional Disorder

Interviewer: Now, I want us to shift gears a little bit here. If there's maybe a family member or a friend who has had someone say, "Hey, I've been implanted with a tracking device," for example, or believe something else that's untrue or, frankly, kind of troubling, how should they respond to that first conversation?

Safety Should Always Come First

Dr. Durns: I mean, the first step is always evaluating the safety of that person and others around them. And of course, if that person is at risk or you're concerned about them being at risk or concerned about them harming others, then absolutely contact . . . There are a lot of great mental health outreach teams that we have, but also police. You have to make sure everyone's safe before they can get better, right?

Interviewer: And is that a 988 call?

Dr. Durns: Yeah, or the suicide hotline, 988. They might be able to redirect people or at least help in getting the mental health outreach team to them.

Arguing Against a Delusion Rarely Helps

The other practical advice is delusions are categorically fixed. And so challenging them directly isn't necessarily going to change things, at least, again, not without medications or kind of the gradual progress of psychotherapy.

In fact, sometimes they can inflame people. And you do worry about family members and loved ones kind of becoming intertwined in that delusional belief system. You could imagine if somebody thinks the government or their neighbors are conspiring against them and then their parents are telling them, "No, that's not true at all." It's not too easy to flip that script to where, "Okay, now my parents are in on it."

Beyond that, it's also just not likely to get a lot of benefit. So one of the best things you can do, aside from making sure everyone's safe and trying to get them willing to seek treatment in one manner or another, is continuing to have some rapport.

Without that rapport, the person who's afflicted can become more closed off, and then you won't necessarily know what they're thinking. You won't necessarily be able to help them. So challenging a true delusion is typically not helpful.

Building Trust Encourages Treatment

Interviewer: So does that mean that someone should play along with the delusion? How do we keep a rapport with this person without completely becoming confrontational?

Dr. Durns: Great question. And yeah, you don't want to necessarily, say, play along with it. If I had a friend who was suffering with a delusional disorder, I wouldn't also start checking my house for government taps or testing my food for poison or anything like that. You certainly don't want to help solidify it or validate the belief.

But it might be more of validating their distress around it and still being a welcome place for them to talk about this, to seek relief, to keep sharing their thoughts and concerns. But yeah, you certainly don't want to entrench them further.

Interviewer: I mean, if a person doesn't believe that anything is wrong with their belief, and if this is a true delusional disorder, how does a family or a friend or a loved one even get them in the door to get care?

Dr. Durns: It's really kind of bimodal in how I often see these present, in that the outpatient side of things, the delusional disorders I've seen, people are often coming in maybe with a sense that something else is wrong, or they think they're depressed, or maybe they are depressed.

And as we're discussing their symptoms, the circumstances, and everything more, then I might hear some sliver of, "Well, that was bizarre. That didn't make sense," and kind of paying attention to that. Then you poke at it a little, ask them to expand on things more, and then the floodgates open and you might hear more about it.

That's different than, say, the inpatient or a lot of forensic contexts where, at that point, it's already escalated, whether it's due to the nature of their beliefs or the strength of their beliefs, to something where there is a risk of harm to themselves or others, or maybe even worse, as in some forensic contexts, the harm has already happened.

Early Professional Support Can Make a Difference

Interviewer: So if someone is listening and may be worried that a family member or a loved one might be experiencing delusional disorder, where is a good place to start?

Dr. Durns: The first step is to consider your safety and their safety. If that is an acute concern, then that means seeking emergency services. If it's, "Well, no, this is just kind of a more harmless delusion," then it might be to continue talking with them and see if they'd be willing to see an outpatient provider, be it a therapist or psychiatrist.

And don't challenge. Continue to be their ally, but also don't over-validate and give them some external indication that their delusions might be right. So really, keeping that alliance is very important.