Types of Delusions and Their Management
Delusions are classified into distinct types based on their content, with atypical antipsychotics being the first-line pharmacological treatment regardless of delusion type. 1
Types of Delusions
Persecutory delusions: Beliefs that one is being harmed, harassed, or conspired against. These are the most common type and are significantly more frequent in schizophrenia and delusional disorder compared to mood disorders. 2
Grandiose delusions: Beliefs of inflated worth, power, identity, or knowledge. These are most commonly observed in patients with manic symptoms (20% in bipolar mania, 19% in bipolar mixed states, 10% in manic schizoaffective disorder). 2
Guilt/nihilistic delusions: Beliefs of having committed terrible crimes or being responsible for disasters. These are almost pathognomonic for psychotic depressive conditions (40% in psychotic major depression, 30% in psychotic bipolar depression). 2
Somatic delusions: False beliefs about bodily functions or that one has a serious disease. These occur across diagnostic categories and can sometimes lead to violence when patients believe medical professionals are indifferent to their needs. 2, 3
Erotomanic delusions (De Clérambault syndrome): Beliefs that another person, usually of higher status, is deeply in love with the patient. 4
Jealous delusions (Othello syndrome): Pathological beliefs that one's partner is unfaithful. 4
Shared delusions (Folie à deux): When two individuals share the same delusional belief. 4
Management Approaches
Pharmacological Management
First-line treatment: Atypical antipsychotics are recommended for all types of delusions. 1, 5
Medication options:
- Olanzapine: Starting dose 2.5-5 mg orally daily; effective for schizophrenia symptoms including delusions. 5, 6
- Quetiapine: Starting dose 25 mg immediate release orally; particularly useful for delusions with agitation due to sedating properties. 1, 5
- Risperidone: Effective for psychosis symptoms including delusions; doses of 4-6 mg/day show most consistent positive responses. 7
- Aripiprazole: May offer benefit with fewer metabolic side effects. 5
Dosing considerations:
Nonpharmacological Interventions
Cognitive therapy: Focus on identifying and challenging irrational beliefs related to persecution. 1, 5
Exposure therapy: Help patients confront trauma-related situations that may contribute to paranoia. 1, 5
Environmental modifications: Reduce triggers that may exacerbate delusions. 1, 5
Social contact interventions: Improve interpersonal relationships to reduce isolation. 1, 5
Sensory and activities therapy: Tailored to individual needs. 5
Special Considerations
Delusions in Delirium
Delusions in delirium often have rapid onset and fluctuate throughout the day. 8, 1
Delirium can present with three subtypes: hyperactive, hypoactive, or mixed. 8, 1
Management should focus on treating the underlying cause rather than just the delusions. 1
Avoid antipsychotics in patients with mild-to-moderate delirium as they may worsen symptoms. 1
Risk Assessment
Always assess for safety risks, including threats or attempts to harm self or others. 5
Somatic delusions may increase risk of violence, particularly when patients believe medical professionals are indifferent to their needs. 3
Persecutory delusions may carry higher risk of aggressive behavior. 4
Monitoring and Follow-up
Evaluate response to treatment within 30 days; refer to mental health professional if minimal or no improvement. 1, 5
For pharmacological treatments used for delusions, attempt tapering or discontinuation after 6 months of symptom stabilization. 1, 5
Monitor for side effects of antipsychotic medications, particularly extrapyramidal symptoms and metabolic effects. 1, 5
Always assess for underlying medical causes before attributing delusions solely to psychiatric illness. 1, 5