The Trouble with Delusions

Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.


Where to begin.

The DSM-IV diagnostic criteria for delusional disorders are A: Nonbizarre delusions of at least one months duration. B: Criterion A for schizophrenia has never been met. C: Apart from the impact of the delusion 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 or a general medical condition. And there are "types"...Grandiose, Jealous, Persecutory...etc....

There was apparently a discussion of delusional disorder at the American Psychiatric Association's 2004 Annual Meeting, because I found a good article about it in Medscape (www.medscape.com/viewarticle/480915). On page four, under The Fundamental Puzzle of Delusions, we read, Since the delusions by DSM-IV definition must be of a somewhat plausible "nonbizarre" nature, they tend to blend with thinking that may be considered a variant of normal. In a study in a normal population, the rate of belief in paranormal phenomena such as contact with the dead, prophecy, telepathy, UFO's , and reincarnation was high and correlated negatively with the strength of religious conviction. In nominal and nonbelievers, the rate of at least moderate acceptance of paranormal phenomena was 30% to 50%.

The trouble is, a good delusional disorder is actually fairly rare...or, rather fairly rarely seen in our particular environment. I've worked with maybe 4 or 5 instances that I thought were this in 20 years...and the thing was in each case, the patient sounded plausible in his or her accounts of their situation, was not obviously impaired, until the delusional material was confronted...its remarkable fixed quality in the face of contrary evidence ... the stubborn adherence to actions not in their own best interests, shall we say...shout "disorder!!" to us...there's no mistaking this person is crazy. We tend to lump these people into the category schizophrenia, which similarly involves a lot of delusional stuff, but there are distinct differences. And these differences make it important for us to notice when someone with a FDD happens along...treating a patient with a Fixed Delusional Disorder as though she(or he) were schizophrenic, would be a mistake.

Treating a patient with a Fixed Delusiona Disorder is a lot like trying to understand why the entire Muslim world is rioting over a few cartoons...or why President Bush ever thought the Iraqi people would greet us as liberators, with flowers ... .I mean, really, some religious beliefs are as extreme as those of a given "fixed delusional disorder" patient, and equally unprovable...with the major difference being that our patient has managed to cross paths with us...and that certainly does say something about the severity of the disorder....

Think about al of this and before you know it, you realize that we all have delusions, great and small...

Here, in this environment, we experience "group think". I know I have. In "group think", we exchange our thoughts and experiences of a patient and distill, together, a picture of him. This picture is an abstract, evoked by key words and phrases. We say, "borderline" and everyone in the room knows this patient will seek attention via self harm; we say "schizophrenic" and we all picture psychosis, and so on. We use these words and phrases to outline a sketch of the patient that can be passed on to the next shift. Because we are human, this is an imperfect process. It frequently happens that the sketch is misinformed, warped by staff's own emotional state or world view. Together we distill it, hone it, embellish it. We all come to think of the patient in the same way...but its wrong. It's always wrong...we can't ever really get the whole picture because we don't have either the time or the manpower to do it...but sometimes we're farther off than others...and these are our delusions.

I think we also have the delusion that our patients are too ill to function in society... I think that we're way overprotective about that. I think, this is America! We have an inalienable right to be delusional! Our country was founded on this principle!! You just can't hurt anybody. That's a firm and fast rule. And, being delusional is no bar to being a participant in society. Surely we all know this...look at your neighbors! Your families! Come on!

And I think we're delusional about our powerlessness. I think when we disagree with the referring center about the disposition for a patient, we have more ability to impact that decision that we think we do...we just lack the will...we have the delusion that it's not worth doing, it's too much trouble, we don't have time.

I saw another delusion at work ... someone thinks that filling out a form with more checks than usual will result in more attention being paid to the patient....I speak, of course of the ubiquitous obs forms...and the general annoying delusion that a form fixes a problem or provides a treatment of some kind.

Ah, well.