FOLLOW-UP: Truth or delusion?
At her appointment the next day, Ms. L says things are fine at home and does not bring up the abuse allegations. We then see her every 3 days for 2 weeks, weekly for 4 weeks, and every 3 weeks thereafter as the apparent risk of abuse diminishes. At each visit, she says her caretaker is not beating her but occasionally complains that she is verbally abusive.
Three weeks after her first follow-up, Ms. L enters the examination room agitated and frightened; she says another patient in the waiting room has just tried to strangle her for no apparent reason. Upon questioning, office staff say they saw no attack and note that the accused patient is a feeble woman with no history of violence; we doubt she assaulted Ms. L.
Ms. L suffers from:
- repeated physical abuse
- delusional disorder
- factitious disorder
- malingering
The authors’ observations
Although Ms. L clearly was not assaulted in the waiting room, this complaint is key to understanding her case. Although whether she is being abused at home remains unclear, evidence increasingly suggests that she suffers from delusions.
Delusions are beliefs that are fixed, false, and not ordinarily accepted by others in a patient’s culture or subculture.3 Delusional disorder is characterized by nonbizarre delusions lasting >1 month (>3 months according to ICD-10 criteria)4 with relatively preserved functioning and without prominent hallucinations. DSM-IV-TR defines bizarre delusions as “clearly implausible, not understandable, and not derived from ordinary life experience.”4,5
Ms. L most likely has a paranoid or persecutory type delusional disorder in which she is convinced she is being harmed. Her delusional thoughts might yield mood symptoms such as anger and irritability, and she might become assaultive. Often, such patients are extraordinarily determined to succeed against “the conspirators” and frequently appeal to the legal system or law enforcement.3
Differentiating between a patient’s delusions and reality can be difficult, leading clinicians to seek collateral information from family, past medical records, or providers to establish a diagnosis. The delusions might become less circumscribed over time, or additional information might clear the clinical picture.
Ms. L’s psychological makeup might help us rule out other diagnoses. Her request for hospitalization, for example, could suggest factitious illness, but she is disabled enough to play the sick role without manufacturing symptoms. Also, she seeks hospitalization because she has no family or friends to turn to. We rule out malingering because Ms. L has nothing to gain by accusing a stranger of choking her in the waiting room.
Treating delusional disorder
Pharmacotherapy and psychotherapy typically are used together to treat delusional disorder.
Pharmacotherapy. Antipsychotics such as olanzapine, 5 to 10 mg nightly, or risperidone, 1 to 2 mg nightly, can decrease the delusional thoughts’ intensity and frequency, allowing patients to function more appropriately.3 If 2 or more antipsychotic trials do not control delusional thoughts, consider starting clozapine at 300 mg/d and titrating to 900 mg/d.
Add an antidepressant if delusional thinking causes depression or anxiety. Selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, 10 to 20 mg/d, or fluoxetine, 20 to 40 mg/d, are a good starting point. Consider other antidepressant types if SSRIs do not work.
Adjunctive benzodiazepines such as clonazepam, 1 to 2 mg/d, or lorazepam, 1 to 2 mg bid as needed, can help manage acute anxiety or agitation stemming from delusions.
Once rapport is established, consider challenging delusional beliefs by having the patient list evidence supporting or refuting the delusions. Be careful not to confront delusional thinking too quickly or aggressively, as this approach often does not change the patient’s beliefs and weakens the therapeutic alliance.3
TREATMENT: Fewer complaints
We still see Ms. L every 3 weeks for supportive psychotherapy and medication management. We continue oxcarbazepine, 150 mg bid, and escitalopram, 30 mg/d, and add risperidone, 1 mg at bedtime, to target her delusional thinking, lability, and irritability.
Over 6 months, Ms. L’s complaints of abuse become less emphatic. She endorses the abuse less frequently—every 3 to 4 visits—and only if the clinician specifically asks about it. Most often, she denies abuse is occurring but says it happened previously. At each visit, we document her statements and explain in her chart why we have not notified adult protective services or police.
- National Adult Protective Services Association. Links to adult protection agencies nationwide. www.apsnetwork.org.
- National Center on Elder Abuse. www.elderabusecenter.org.