Conclusions

Paranoia, now delusional disorder, is unique in psychiatry in that it is virtually a newly discovered illness and yet much of the fundamental descriptive work was done a century or more ago. This long hiatus means that most practitioners have scant knowledge or experience of the disorder, and the few who are aware of it usually only see a small part of the fabric. For example, there is the dermatologist who treats a case of delusional parasitosis, the cosmetic surgeon whose difficult patient has a dysmorphic delusion, the lawyer trying to cope with a totally unreasonable litigant, the police officer faced with a jealous murderer or an erotomanic stalker, or the personnel officer who has to deal with an employee who is convinced his fellow workers are persecuting him, and many more. How can we draw all this scattered material together so as to make a whole cloth? The answer at this stage is largely by consciousness raising and education.

Delusional disorder is not rare, but there is good reason to believe that the majority of its sufferers remain in society, still functional to varying degrees, and, even if impaired and suffering, rarely agreeing to be referred to a psychiatrist. Therefore psychiatry's experience of the illness is sketchy and biased, and because of the still-prevailing belief that the illness is untreatable there is little incentive for psychiatrists to seek out cases.

This is a disorder with a considerable impact on society. Somatically deluded patients grossly overuse health services in their demands for inappropriate help. Individuals with persecutory delusions can be very disruptive in their communities, and the law and law-enforcement agencies are involved at various levels with cases which may involve assault and even murder.

To bring order out of the present chaos clinicians must learn to recognize the illness by its characteristic form, using delusional content only afterwards to define the clinical subtypes. Earlier, Jaspers was quoted as saying that delusional disorder is highly recognizable, which is very true, but too many psychiatrists are still seduced by the readily noticeable delusional content and cannot adequately discern the illness underlying it. Not only clinical work on delusional disorder but also research is being held up by lack of clarity in diagnosis.

The delusional disorder which does not yet have official diagnostic status—the delusional misidentification syndrome—has been more clearly defined of late and is being better recognized and more productively researched as a result. It sufficiently resembles paranoia/delusional disorder that one may hope that adaptations of its research methodology could usefully be applied there. This would certainly be facilitated if future DSM and ICD editions included DMIS with delusional disorder in an enlarged category.

The concept of the paranoid spectrum has been discussed earlier in this chapter, and it has been suggested that a significant gap exists in this diagnostic continuum because paraphrenia is currently being ignored. Should paraphrenia be revived in the future it is essential that it not simply be equated with 'late' paraphrenia, a diagnosis that should probably be amalgamated with that of late-onset schizophrenia. Instead, paraphrenia, like delusional disorder, should be recognized as arising in all age groups from early adulthood onwards.

Anyone dealing with the delusional disorders must be aware of two very important associated phenomena, folie à deux and postpsychotic depression, and be able to deal competently with the problems that they pose.

Delusional disorder has much to commend it as a focus for research. It is a chronic and stable illness which may well be caused by a focal disturbance of brain function. Many of its sufferers are reluctant to take medication and so their brains are often unaffected by neuroleptics, which is unusual nowadays in a chronic psychotic illness that we wish to investigate. Those patients who do accept treatment often respond quite rapidly, enabling clear-cut studies to be undertaken on pre-and post-treatment states. Those who refuse are still fascinating because the encapsulation of the delusional system allows one to study abnormality and normality at virtually the same time in the same patient.

In this chapter we have attempted to draw together our extremely fragmented knowledge of the delusional disorders and to demonstrate that it is possible to diagnose and classify them with some assurance. Kendler, an authority in this field, has said, 'The paranoid disorders may be the third great group of functional psychoses, along with affective disorder and schizophrenia'. (1°8) If he is correct, it is clear that this is no trivial task and that the well being of large numbers of patients is dependent on the physician's becoming greatly more skilled and proficient in dealing with the illnesses that have been described.

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