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affective symptoms is brief relative to the total duration of the illness. In manic-depressive illness, delusions and hallucinations primarily occur during periods of mood instability. A DSM-IV diagnosis of schizoaffective disorder requires an uninterrupted period of illness during which there is either a major depressive, manic, or mixed (manic and depressive) episode that is concurrent with active symptoms of schizophrenia. In addition, during the same period of illness, there are delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms, and mood episode symptoms are present for a substantial portion of the active and residual phases of the illness. It is important to make as clear a diagnosis as possible, as the cornerstone of treatment for schizophrenia is antipsychotic medications, whereas mood stabilizers and antidepressants are crucial in treating affective disorders.

15. Does significant depression rule out schizophrenia? Although the diagnosis of schizophrenia emphasizes that psychotic symptoms predominate over mood symptoms, schizophrenic patients may suffer significant depression, which strongly contributes to their increased suicide risk. Increased suicide risk may extend even after an episode of depression resolves, and may result from the patients inability to come to terms with the debilitating effects of schizophrenia. Pharmacologic treatment of depression in schizophrenia is somewhat controversial, because antidepressants apparently reduce the efficacy of antipsychotic medications in acutely ill schizophrenic patients. On the other hand, adjunctive antidepressant medications have been shown to be effective in the acute maintenance treatment of depression in schizophrenic and schizoaffective patients.
BIBLIOGRAPHY
1. Adler LE, et al: Schizophrenia, sensory gating, and nicotinic receptors. Schizophr Bull 24:189-202, 1998. 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994. 3. Buckley PF (ed): Schizophrenia. Psychiatr Clin North Am 21(1), 1998. 4. DeLisi LE (ed): Depression in Schizophrenia. Washington, DC, American Psychiatric Press, 1990. 5. Hales RE, Yudofksy SC, Talbott JA (eds): The American Psychiatric Press Textbook of Psychiatry, 3rd ed. Washington DC, American Psychiatric Press, 1999. 6. Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, 6th ed. Baltimore, Williams & Wilkins, 1995. I. Tamminga CA (ed): Schizophrenia in a Molecular Age. Ann Rev Psychiatry 18(4), 1999. 8. Yudofsky SC, Hales RE (eds): The American Psychiatric Press Textbook of Neuropsychiatry, 3rd ed. Washington DC, American Psychiatric Press, 1997.

1 1 . PARANOID DISORDERS
Theo C. Manschreck, M.D.
1. What are paranoid disorders? The term paranoid disorders refers to a variety of conditions characterized by delusions and related behavior. One of the earliest described of these disorders was paranoia, now called delusional disorder, which is of unknown cause. The cardinal psychopathologic feature is the delusion. Paranoia actually is uncommon; other forms are seen frequently. There are two broad categories of paranoid disorders: disorders with known causes (medical and substance disorders) and idiopathic disorders, which include delusional disorder, paranoid personality disorder, shared psychotic disorder, atypical psychosis (psychotic disorders not otherwise specified), schizophrenia and schizophreniform disorder, mood (psychotic forms of mania and depression) disorder, and schizoaffective disorder.

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2. How did the term paranoia originate? The Greeks used the term paranoia (meaning beside ones self) to designate a symptom that we regard now as a nonspecific and general feature of many mental disorders. The term was not used for almost 2000 years until it was revived by Karl Kahlbaum, who in 1863 identified a disorder he called paranoia. He described this condition as a form of partial insanity, which, throughout the course of the disease, principally affected the sphere of the intellect. Emil Kraepelin, a contemporary of Kahlbaum, was influenced by these observations. He retained the concept of paranoia as a separate disorder in his groundbreaking classification of mental illnesses.

3. What is the current meaning of paranoid? In recent years paranoid has referred to a multitude of behaviors, from ordinary suspiciousness
to persecutory delusions. It also has been used to characterize grandiose, litigious, hostile, jealous, and even angry behavior, regardless of the fact that these behaviors may be within the normal spectrum. The key principles for understanding the current meaning of paranoid are: 1. It is a clinical construct used to describe various subjective and objective behavioral features which are deemed to be psychopathologic. These features are interpreted to be abnormal based on evidence accumulated from patients and other informants. This judgment requires some humility and care. It is supported by the occurrence of specific features (see table) as part of a behavior pattern which is extreme, intense, based on false assertions, inappropriate, disturbing to others, and possibly bizarre or dangerous. Often the patient is convinced and resolute in his or her belief; counter evidence and argument fail to persuade. 2. It refers to no specific condition. For example, the presence of paranoid features does not mean that a schizophrenic condition is present. Features of Paranoid Disorders Objective Features Obstinacy Hate Anger Resentment Critical, accusatory behavior Hostility Seclusiveness Humorlessness Defensiveness Secretiveness Fragile self-esteem Hypersensitivity Grandiosity or excessive selfInordinate attention to small details Self-righteousness importance Irritability, quick annoyance Sullenness Grievance collection Litigiousness (letter writing, Suspiciousness Guardedness, evasiveness complaints, legal action) Violence, aggressiveness Subjective Features* Delusions of self-reference,persecution, grandeur, infidelity, love, jealousy, imposture, infestation, disfigurement, and disease

* Part of private mental experience. The patient often discloses these features during the clinical interview, but
may not do so, even with specific questioning.

4. How common are paranoid conditions? Paranoid features are among the most common and serious manifestations of psychopathology. They occur in a variety of psychiatric and medical illnesses and are, perhaps, the most frequently encountered symptoms of severe psychopathology. However, the frequency of some of the idiopathic conditions is less clear. Delusional disorder may be uncommon; shared psychotic disorder is considered rare. Atypical psychosis, because of its lack of specificity, is difficult to estimate. The incidence of organic delusional syndrome (medical and substance disorders) is presumed to be common. The essential strategy in evaluating conditions in which paranoid features are present is a competent and thorough differential diagnosis.

5. What is the etiology of paranoid disorders?

The etiology of paranoid disorders is largely unknown except, of course, in those cases for which an organic factor can be isolated. Paranoid features, including the types of delusions that are

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encountered in delusional disorder, occur in a large number of medical and psychiatric conditions. Many theories exist about the origin of delusions, but evidence to support them is limited.

6. Is there a neuropathology for the paranoid disorders?

Except for those conditions in which a specific organic factor can be identified, determining a specific neuropathology or brain pathology to correlate with the psychopathology of the delusional experience is more hope than reality. Nevertheless, clues based on neuropsychiatric studies suggest where we might find some neuropathologic evidence. For example, patients who have severe cortical disorders, such as Alzheimers disease, tend to experience simple and transient persecutory delusions. Delusions of a more systematized, elaborate, and complex character tend to be more chronic and resistant to treatment and have been associated with subcortical neurologic conditions that generally produce greater cognitive impairment than the typical idiopathic disorders.

7. Define delusional disorder. In recent years delusional disorder has become a better-recognized form of paranoid presentation. The term delusional disorder refers to a condition of unknown cause whose chief feature is a nonbizarre delusion present for at least 1 month. The diagnosis of delusional disorder corresponds closely to an older concept, paranoia, as formulated by Kraepelin and others over a century ago. There are several types of such delusions, and the predominant type is identified to make the diagnosis. Minimal deterioration in personality or function and the relative absence of other psychopathologic symptoms have been considered important evidence for distinguishing this disorder from schizophrenia and other psychotic conditions.

8. What are the clinical features of delusional disorders?

The core feature is persistent, nonbizarre delusions not explained by other psychotic disorders. The delusion may emerge gradually and become chronic, and sometimes is associated with a precipitating event. Behavioral, emotional, and cognitive responses generally are appropriate, and neither mood disorders nor schizophrenic illness is present.

Delusional Disorder (DSM-IV)

Nonbizarre delusion(s) (is., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, being deceived by spouse or lover, or having a disease) of at least 1month duration. The symptom criteria for schizophrenia have never been met. Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme. Apart from the impact of the delusion(s)or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. The disturbance is not caused by the direct physiologic effects of a substance (e.g., a drug of abuse or a medication) or a general medical condition. From the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychiatric Association, 1994; with permission.

9. What is a nonbizarre delusion? Nonbizarre means that the delusion concerns situations that can occur and are possible in real life, such as being followed, having a disease, being secretly in love, and the like.

10. List the types of delusional disorder.

There are five main types and two residual ones. Erotomanic: the predominant theme of the delusion is that a person, usually of higher status, is in love with the subject.

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Grandiose: the theme is one of inflated worth, power, knowledge, identity, or special relationship to a deity or important famous person. Jealous: ones sexual partner is unfaithful. Persecutory: the person is being malevolently treated or conspired against in some way. Somatic: the person has some physical defect, disorder, or disease. Mixed: more than one of the above types are present but no one theme is predominant. Unspecified: the delusions do not fit into any of the categories.

11. Why is it difficult to recognize delusional disorder? Delusional disorder is at best uncommon; many clinicians probably have encountered one or two cases, but many have not. It is difficult to recognize because one of its hallmarks is an absence, or modest occurrence, of psychopathology other than delusions. Such patients, if they are patients at all, are in all likelihood misdiagnosed, perhaps as having mild cases of schizophrenia. Because they may seek out internists, dermatologists, lawyers, or the police, they may never be diagnosed at all.

12. Which is the most common type of delusional disorder?

Persecutory, which is also the classic form of the condition. Such individuals frequently are highly litigious and their delusions often are highly systematized (elaborate and detailed).

13. What features are characteristic of the jealous type? This type, sometimes referred to as the Othello syndrome or conjugal paranoia, is common and associated with dangerousness. Jealousy is a powerful emotion. Individuals with this delusion may resort to assault, homicide, even suicide in response to their delusional concerns about a lovers unfaithfulness. It generally affects males, often with no history of psychiatric difficulty. The delusions may appear suddenly and serve to explain a host of remote and recent events involving the spouses fidelity. This type is particularly difficult to treat, often diminishing only upon separation, divorce, or death of the spouse. 14. What is morbid jealousy or pathologic jealousy? These terms are used in relation to other disorders. Jealousy is a common symptom and may derive from several conditions, such as epilepsy, mood disorder, schizophrenia, or substance abuse.

15. What is another name for the erotomanic type? The erotomanic type is called De Clerambaults syndrome when the symptom occurs in other disorders, such as schizophrenia.
16. Describe the characteristic features of erotomania. It is the delusion of secret love, usually from an individual of higher social standing. Although erotomania may occur in both sexes, it is more common in females. Such patients usually pester, and possibly harass, the object of their love with letters, phone calls, or unexpected visits. The delusion typically concerns a more spiritual union or romantic love, rather than sexual attraction.
17. What behavior might a patient with the grandiose type of delusional disorder exhibit? These patients suffer from megalomania. They are inclined to join cults, preach on the street corner, proselytize their beliefs, or attempt to associate with popular or eminent individuals.

18. List other names for the somatic type of delusional disorder. Monosymptomatic hypochondriac psychosis, monodelusional psychosis, delusional parasitosis, delusion of infestation, and epidermozoophobia.
19. What are the characteristics of the somatic type? Somatic patients seek out professional attention for diseases they believe they have. When individual tests fail to detect their diseases, they often move on to other physicians, unable to respond

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to reassurance and the evidence collected in their evaluations. There are several patterns: (1) patients concerned about parasites or insect infestation; ( 2 ) patients convinced that their body, nose, face, or hair has been altered; and (3) patients concerned that they emit foul bodily odors. Patients with such disturbances are more likely to seek help from dermatologists, exterminators, plastic surgeons, and dentists than psychiatrists. Somatic conditions differ from simple hypochondriasis because of the degree of reality impairment associated with them.

20. Define organic delusional syndrome.

Organic delusional syndrome or disorder refers to delusional illness for which a specific etiology can be determined. It is a DSM-111 term that has been replaced in DSM-IV by psychotic disorders due to a general medical condition or substance-induced psychotic disorder. In general, many conditions arising from infectious, neurologic, toxicologic, metabolic, or even genetic or chromosomal sources can be causative. They have been described in both case reports and other observations for many years. For the clinician, of course, it is important to be aware of the most common causes, so that these can be identified and diagnosed rapidly.

21. What are the most common sources of organic delusional disorder?
The most common forms of organic delusional disorder result from substance intoxication and withdrawal. Usual substances are alcohol, stimulants (e.g, cocaine, amphetamine), sympathomimetic agents, antihistamines, steroids, marijuana, and phencyclidine.

Common Causes of Organic Delusions

Alcohol abuse Drug abuse (especially CNS stimulants) Iatrogenic: anticholinergic poisoning, steroid poisoning, diet pills, sedative-hypnoticwithdrawal Delirium Dementia Other neurologic sources: human immunodeficiencyvirus (HIV) syndromes, brain tumors, epileptic disorder, especially complex partial seizure disorder

22. What are the features of organic delusional syndrome? The essential feature is prominent delusions resulting from a specific organic factor. The diagnosis is not made if the delusions occur in the context of difficulties in the maintenance of attention The nature of the delusions is or orientation, as in confusion (a syndrome referred to as delirium). variable and, to some extent, depends on the etiology of the disorder. Persecutory delusions are probably the most common type. Amphetamine use, as well as that of cocaine and other stimulants, has been associated with the development of organic delusional syndrome, but other sources are unrelated to substance abuse. It has been found in temporal lobe epilepsy (complex partial seizure disorder), as an interictal syndrome often indistinguishable from schizophrenia, and in cases of Huntingtons disease. Additionally, cerebral lesions of the right hemisphere have resulted in this disorder. Hallucinations may be present, but they are usually not the prominent characteristic. Associated features include mild cognitive impairment and the presence of various symptoms, many of them found in schizophrenia, such as perplexity, unusual dress and behavior, abnormalities of psychomotor activity, unusual speech, and dysphoric mood. In contrast to delusional disorder in which impairment is uncommon or modest, these conditions are associated with impairments in social, cognitive, and occupational functioning.

23. What is shared psychotic disorder?

Also called induced paranoid disorder, double insanity (folie a deux), and other terms, it was first described by Lasegue and Falret in 1877. It is believed to be rare, but accurate incidence and prevalence figures are not available. The literature consists almost entirely of single case reports.

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The delusion is characterized by its transfer from one individual to another. Involved persons may have been intimately associated for a long time and typically live in relative social isolation from other people. In its most common form, the individual who first has the delusion is chronically ill and is the influential member of a close relationship with a more suggestible person; the weaker partner becomes the induced psychotic disorder patient. Typically the latter is less clever, more gullible, submissive, and passive, and lower in self-esteem. Old age, low intelligence, impairment of sensory function, alcohol abuse, and cerebrovascular disease have been among the factors that have been associated with this peculiar disorder. A genetic predisposition to idiopathic psychosis has been suggested as a possible risk factor. There is some question as to whether such people are truly delusional or merely highly impressionable. Frequently, there is passive acceptance of the delusional beliefs of the dominant person, until they are separated, at which point the unusual belief may remit spontaneously. The criteria for the diagnosis require an absence of psychotic disorder before onset of the induced delusion.

24. What is paranoid personality disorder?

Paranoid personality disorder is a nonpsychotic condition involving a marked change in personality traits as the individual becomes a young adult. These traits include a pervasive and unwanted tendency to interpret the actions of other people as demeaning or threatening. Behaviors include expecting to be exploited, questioning the loyalty or trust of friends or associates, reading hidden meanings into benign remarks or events, bearing grudges, not confiding in others because of fear that the information will be used against the person, tending to be easily slighted and quick to react with anger, questioning the fidelity of spouses or sexual partners, and intense changes in mood. Little is known about this disorders prevalence, association with familial transmission patterns, and predispositions. Its relationship to schizophrenia and even to other paranoid disorders is also unclear. It is an interesting clinical phenomenon about which we need considerably more information.

25. What is Capgras syndrome? In 1923, Capgras and Reboul-Lachaux described a syndrome consisting of the delusion that doubles of important or significant others and of oneself exist. For example, the patient may claim that his or her spouse has been replaced by an impostor. The syndrome is not related to hallucinations, simple misrecognition, or illusions. It is a delusion. In 1983, Berson summarized 133 cases of this syndrome reported in the literature. His conclusions were that the disorder appears in both men and women, over a wide range of ages, and with a wide range of other mental disorders. The most common diagnosis in such cases has generally been schizophrenia (about 60%);23% of patients identified with this disorder suffered from diagnosable brain disorder.

26. How important is the differential diagnosis?

It is the most important process in the evaluation of patients with paranoid disorders. Most of these disorders are, at the very least, uncommon, and they are idiopathic. In addition, they have features characteristic of many medical and psychiatric conditions. Diagnosis of paranoid disorders requires the exclusion of other conditions and the matching of the features of a particular case to the appropriate criteria.

27. What are the steps in forming a differential diagnosis for paranoid disorders? First, recognize, characterize, and judge as pathologic those features that are identified as possibly paranoid. Be sensitive to the range of subjective and objective characteristics frequently found in paranoid conditions. This step is critical as well as difficult because of the patients unwillingness to reveal him- or herself in the process of the interview or to cooperate with clinical investigation. Careful interviewing of the patient and other informants is usually the basis for determining that the behavior is psychopathologic. Second, having determined that a paranoid condition is present, evaluate premorbid characteristics, the course of the disease, associated symptoms, and so on. Important in this process is the discovery of confusion, perceptual disturbances, mood and motor disturbances, signs of physical

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illness, or confusing symptoms that may suggest different causes for paranoid features. Isolated acute symptoms of paranoid behavior often are present in early stages of medical conditions. Third, conduct a compete medical and psychiatric history, with special attention to alcohol and drug use. A thorough physical examination includes neurologic and mental status exams and appropriate laboratory studies-particularly serologic, toxic, endocrinologic, and microbiologic features-as well as radiographic and electroencephalographic investigations. Where possible, CT and possibly MRI studies should be performed to identify structural brain disease (e.g, a tumor, or multiinfarct dementia) associated with psychopathologic changes.

28. What are the most important conditions to consider in the differential diagnosis? Certain conditions with delusional features should be routinely considered in a differential diagnosis because of their seriousness or frequency and because they are the most likely sources of delusional presentations. Medical diseases and syndromes: typically feature a disturbance of perception, especially of visual or auditory functioning. Drug intoxications are particularly relevant; abused drugs and even prescribed drugs, such as steroids and L-dopa, have been known to cause delusional syndromes, often without cognitive impairment. Among elderly people, dementia should be considered. Mental status exam should uncover the characteristic cognitive changes that generally do not occur in delusional disorder. Delirium, for example, has a fluctuating course, with confusion, memory impairment, and transient delusions that contrast with the persistent delusions in most idiopathic paranoid disorders. Schizophrenia: should be considered when the delusions are bizarre; affect is blunted or incongruent with thinking; thought disorder, if present, is pervasive; and role functioning is impaired. Paranoid schizophrenic patients may have somewhat less bizarre delusions than patients with other types of delusions; however, their role functioning is impaired, and auditory hallucinations are prominent. Mood disorders: in particular, depression and mania. Profound changes in mood suggest depression. In paranoid disorders, mood may be depressed, but the change usually is not as overwhelming and pervasive as in depression. Delusions in depression frequently are related to the mood of depression, the so-called mood congruent delusions. The key is to consider the associated psychopathologic features. Depression refers to a group of signs and symptoms, such as changes in appetite, sleep, libido, concentration, decisiveness, interest, and energy. Depression often is cyclical, and may follow a fluctuating course. It also may be associated with a positive family history. Manic delusions often are grandiose and, therefore, to some extent mood-congruent. They usually occur during severe stages of mania and are relatively easy to recognize as part of the manic syndrome. Marked instability of mood, intense euphoria or irritability, reduced need for sleep, increased energy, lack of inhibition, and increased activity levels distinguish mania from paranoid disorder. 29. Name other conditions that should be considered in the differential. Other personality disorder: paranoid features can occur in schizoid and schizotypal personality disorders as well as in paranoid personality disorders. The decisive distinction with most of the other paranoid disorders is the presence of clear-cut delusions, hallucinations, and other psychotic features. Obsessive-compulsivedisorder: delusions and hallucinations typically are absent in these disorders. Fears, rituals, rumination, and preoccupation are generally more pervasive and more likely to influence functioning than in delusional or paranoid disorders. Somatoform disorder: Body dysmorphic disorder may be difficult to distinguish. The degree of conviction about imagined disfigurement may be helpful in making this distinction. Other psychopathologic features are more likely to be present in somatoform disorders as well. Hypochondriasis may present some difficulty in differential diagnosis. Patients almost always retain, however, some degree of uncertainty about their health concerns.
30. What principles apply to the differential diagnosis of elderly paranoid patients? In the elderly, the differential diagnosis is, if anything, even broader due to disorders associated with aging. Although it is possible for idiopathic paranoid disorders lo begin late in life, the

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likelihood is low. There is, however, a high risk for paranoid features to recur in depression, schizophrenia, and as a result of organic factors. The sudden onset of paranoid features should be considered a sign of medical illness, possibly cerebrovascular disease, and an acute onset may be a harbinger of acute organic delusional syndrome. The incidence of many medical diseases associated with paranoid features increases with age. Other sources of increased risk for paranoid disturbance among older individuals include a lack of stimulating company, physical illness, aging itself, and reductions in sensory functioning, such as visual acuity and hearing.

31. Are laboratory tests of value in the assessment of paranoid disorders? Yes, they often are critical to reaching a proper diagnosis. A range of assessments usually is necessary, but some are more likely to detect key factors in particular cases. Drug screening measures (urine toxicology) are essential. Check for commonly abused substances such as alcohol, marijuana, stimulants such as cocaine and amphetamine compunds, and hallucinogens sush as phencyclidine; substance-induced delusional responses are frequent. Prescribed substances such as sedatives and hypnotics also can be detected. Other routine laboratory tests (e.g., blood counts, HIV assays, thyroid, liver functions, electrolytes, blood sugar) as well as EEG and brain radiography (CT scan) often help to disclose the presence of pathology (e.g., temporal lobe seizure disorders, mass lesions) that can be related to paranoid presentations. Neuropsychological assessment may help disclose evidence of impaired intellectual functioning and suggest brain abnormalities. Assessment of intelligence through I.Q. testing may show discrepancies between verbal and performance scores as well as scatter in overall performance, suggesting the need for further assessment of medical disorders. 32. What is the treatment for paranoid disorders? No set treatment guidelines apply to all cases of paranoid disorders. Each of the conditions is sufficiently different to require a separate approach. Consider paranoid personality, which, in addition to being uncommon, is unlikely to come to the attention of clinicians. Such patients may, because of depressive symptomatology or anxiety, eventually fall into the care of psychiatric professionals. But generally speaking, these patients maintain an arms-length distance from any health care, and specifically psychiatric, facility. Symptomatic therapies and supportive counseling frequently are attempted in such cases. Success is, at best, modest. Organic delusional syndrome, on the other hand, may be treatable so long as the treatment focuses on the underlying organic factor that initiated and perpetuated the delusional presentation. For example, in substance abuse, removal of the initiating factor may result in a rapid improvement in the patients mental state. Often such patients also require treatment with antipsychotic medication (e.g., risperidone, haloperidol), which may have the added effect of reducing the agitation, suspiciousness, and even the delusional thinking associated with these conditions. However, if the original initiating factor remains, the prognosis is likely to be poor unless symptomatic treatment is continued. With progressive disorders, such treatment may only serve to delay severe deterioration.
33. Is delusional disorder treatable? Delusional disorder may be treatable. Due to the conditions very nature, the patient may have difficulty admitting a psychiatric illness exists and is not likely to seek care. Psychotherapy, medication, and even hospitalization can be important components of care, but in refractory conditions the delusion will not remit with these interventions.

34. Is psychotherapy helpful? Psychotherapy creates a therapeutic alliance that can allow patients with delusional disorder to deal with whatever stressors and concerns contribute to the overall impairment associated with the delusional experience. For example, if the patient is dysphoric and finds it difficult to work, a chance to share some of these concerns with a sympathetic clinician may provide considerable relief. 35. What role does pharmacology play in the treatment of delusional disorder? Medications have been promoted recently, but the data concerning their use is limited. Certainly there is value in considering an antipsychotic: delusion is, after all, a major symptom of psychosis,

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and it stands to reason that an antipsychotic agent might have some role in treatment. In practice, however, the success of such interventions as well as other somatic treatment is meager. Hypochondriacal delusions of the somatic type have been reported to respond to pimozide, a potent dopamine blocking agent and antipsychotic medication. These observations have been based on a small series of cases and are uncontrolled. Antidepressants have been promoted by some individuals who have treated patients with delusional disorder. Again, the observation is that patients who have dysphoric mood in association with presence of the delusions respond nicely.

36. When is hospitalizationadvisable? Hospitalization is recommended in circumstances in which the patients behavior has become dangerous or self-destructive. Hospitalization may be a satisfactory temporary solution, allowing the patient to be confronted with the impact of the behavior and the need for greater restraint.

37. Have there been any advances in the somatic treatment of delusional disorder? For years psychiatrists have reported limited success and often negative results from somatic treatment of delusional disorder. A recent examination of some 200 cases reported in the literature since 1961, consistent with DSM-IV criteria and with sufficient detail to make comparisons, showed that approximately 80% of patients either recovered fully or partially with the treatment. The most frequently reported treatment was pimozide, which produced full recovery in 69% and partial recovery in 22%; typical neuroleptics produced full recovery in 23% and partial recovery in 45%. No specific conclusions were drawn regarding treatment with antidepressants, although a number of reports were favorable. The most commonly treated subtype was somatic, but meta-analysis suggested that patterns of response were similar across subtypes of delusional disorder. Reports that included followup indicated that persistent use of medication is necessary to maintain remission. Results of treatment with newer atypical antipsychotic medicines, i.e., clozapine, risperidone, olanzapine, and quetiapine, are preliminary but promising. Several case reports indicate risperidone and clozapine effectiveness. The review concluded that antipsychotic drugs may be effective, and a trial, possibly of pimozide or an atypical agent, is warranted. Certainly trials make sense when the agitation, apprehension, and anxiety that accompany delusions are prominent. Treatment with antipsychotic medication is, of course, not a substitute for treatment of the underlying factor in an organic delusional syndrome. Antipsychotic medication usually is for temporary symptomatic relief.

38. Is there treatment for shared psychotic disorder?

Little is known about treatment for this condition. Observations have had a tantalizing quality in suggesting that separation (e.g., divorce, death) of the two parties may lead to dimunition of the delusion in the induced psychotic partner, even to the point that the patient can no longer be considered delusional. Apart from this, there are no systematic controlled observations about intervention in the literature.

39. What is the therapy for atypical psychosis? Patients who have these conditions must be dealt with individually, identifying the symptoms that constitute the basis of their complaint. If a specific, or particularly prominent, delusional form of thinking is present, antipsychotic medications may be helpful. Again, very little systematic literature is available for this condition, and general guidelines are not possible.
40. Has there been any progress in identifying the cause@)of delusional disorder? The cause of delusional disorder is unknown. However, factors such as advanced age, sensory impairment, family history of delusional psychopathology, and recent immigration are associated with increased risk. Of these, perhaps the best supported is the familial psychopathology. If delusional disorder is merely a form of schizophrenia or mood disorder, then the incidence of these conditions in family studies of delusional disorder patients should be higher than that of the general

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population. However, this is not the consistent finding. In addition, a recent study concluded that patients with delusional disorder are more likely to have family members who exhibit paranoid symptoms (e.g., suspiciousness, jealousy, secretiveness) or have paranoid illness themselves than families of controls. Other studies show that paranoid personality disorder and avoidant personality disorders are more common among relatives of delusional disorder patients than among relatives of normal controls or schizophrenic patients. There is recent evidence for increased risk of alcoholism among relatives of delusional disorder patients compared to those of patients with schizophrenia, other psychotic disorders, and schizophreniform disorder.

41. How dangerous are paranoid conditions? It depends. Factors associated with the presentation of paranoid symptoms often are decisive in permitting inference of risk. For example, the intensity of the delusional thinking and its associated mood qualities (such as increased expression of anger and hostility in association with the delusion) are particularly relevant. Other important factors are the presence or likelihood of substance abuse and organized thinking and behavior. Greater personality intactness can increase the risk of dangerousness in individuals afflicted by delusional features. Erotomania and jealousy create powerful emotional energy and have been associated with violent behavior frequently enough to warrant heightened awareness when these symptoms are prominent. Delusional disorder subtypes associated with these delusions occasionally present problems of dangerousness. Notably, of the delusional disorder subtypes, the somatic subtype is low-risk. These patients generally do not show intense anger, hostility, or enraged responses associated with their delusional thinking. 42. What is stalking? Stalking is uninvited and unwelcome pursuit or following, often with harassment and pestering of the victim, who feels threatened and often fearful. It is a behavior in which the stalker directs intense emotions toward the victim. Stalkers may have a variety of psychiatric difficulties, but may be free of psychiatric illness. Of the paranoid conditions, the erotomanic subtype of delusional disorder and other disorders with erotomanic symptomatology are the most likely to be associated with stalking behaviors. These behaviors are known to be particularly onerous to deal with because of their pronounced refractoriness. However, if the delusion can be adequately treated, it is unlikely that these behaviors will persist.
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1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSMIV). Washington DC, American Psychiatric Association, 1994. 2. Berson RJ: Capgras syndrome. Am J Psychiatry 140:969-978, 1983. 3 . Cummings JL: Psychosis in neurologic disease: Neurobiology and pathogenesis. Neuropsychiatry Neuropsychol Behav Neurol5: 144-150, 1992. 4. Gawin FH, Ellinwood E: Cocaine and other stimulants. N Engl J Med 3 18: 1173-1 182, 1988. 5. Howard RJ, Almeida 0, Levy R, et al: Quantitative magnetic resonance imaging volumetry distinguishes delusional disorder from late-onset schizophrenia. Br J Psychiatry 165:474-470, 1995. 6. Kraepelin E: Manic Depressive Insanity and Paranoia. Edinburgh, Livingstone Press, 1921. 7. Krakowski M, Volavka J, Brizer D: Psychopathology and violence: A review of literature. Compr Psychlatry 27:131-148, 1986. 8. Manschreck TC, Petri M: The paranoid syndrome. Lancet 2951-253,1978. 9. Manschreck TC: Delusional disorder and shared psychotic disorder. In Kaplan H, Sadock B (eds): Comprehensive Textbook of Psychiatry, 7th ed. Baltimore, Lippincott, Williams & Wilkins, 2000. 10. Manschreck TC: Pathogenesis of delusions. Psychiatr Clin North Am 18:213-230, 1995. 1 1. Manschreck TC: The assessment of paranoid features. Compr Psychiatry 20(4):37&377, 1979. 12. McAllister T Neuropsychiatric aspects of delusions. Psychiatr Ann 22:269-277, 1992. 13. Meloy JR (ed): The Psychology of Stalking. San Diego, Academic Press, 1998. 14. Munro A: Delusional Disorder. New York, Cambridge University Press, 1999. 15. Munro A, Mok H: An overview of treatment in paranoiddelusional disorder. Can J Psychiatry 40:616422, 1995.

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16. Opler LA, Klahr DM, Ramirez PM: Pharmacologic treatment of delusions. Psychiatr Clin North Am 18:379-391, 1995. 17. Serreti A, Lattuada E, Cusin C, Smeraldi E: Factor analysis of delusional disorder syrnptomatology. Compr Psychiatry 40(2): 143-147, 1999. 18. Stoudemire A, Riether A: Evaluation and treatment of paranoid syndromes in the elderly. Gen Hosp Psychiatry 9:267-274, 1987. 19. Webb W Paranoid conditions seen in psychiatric medicine. Psychiatr Med 8:37-48, 1990.

12. BIPOLAR DISORDERS

Marshall R. Thomas, M.D
1. What is bipolar disorder? How is it different from manic-depressiveillness?
Bipolar disorder encompasses a heterogeneous group of disorders characterized by cyclical disturbances in mood, cognition, and behavior. The diagnosis requires a history of mania for at least 1 week or hypomania for at least 4 days. Bipolar I disorder refers to patients who have had at least one episode of mania. Bipolar I1 disorder refers to patients with a history of hypomania and major depressive episodes. Cyclothymia refers to patients with chronic (at least 2-year duration) mood swings that fluctuate between hypomania and minor but not major depression.

MD Md M mD M = Maaic Egisode D = Major Depressive Episodc

md

m = H y p d c Episode d = Minor Depnssivc Episodc

Modified from Goodwin F, Jamison K: Manic-Depressive Illness. New York, Oxford University Press, 1990.

In 1921, the German psychiatrist Emil Kraepelin introduced the term manic-depressive insanity, which included patients with recurrent unipolar depression as well as bipolar disorder and distinguished both groups from schizophrenia, which he termed dementia praecox. Kraepelin emphasized