Particular features of delusions in delusional disorder

In addition to any of the above, in delusional disorder we find several other elements which are of importance in leading to the diagnosis.

1. The delusional system is stable and is expressed or defended with intense affect and with highly rehearsed arguments. The form of the logic used by the patient is very consistent but the propositions are based on false premises. Since the individual is so focused on his beliefs he often succeeds in making the enquirer feel inept with his or her self-assurance.

2. The delusional system is markedly 'encapsulated', so that the beliefs therein and their accompanying symptoms are to a considerable extent separate from the rest of the personality which retains a good deal of normal function. However, the compelling force of the delusions often overshadows these normal aspects and this is increasingly so with advancing chronicity of the illness, when the tendency to express and act out the delusions may well increase.

3. When the individual is preoccupied with the delusional system there is strong emotional and physiological arousal, but when he or she is engaged on neutral topics, the arousal abates and an ordinary conversation can take place. Switching between normal and abnormal 'modes', sometimes very rapidly, is virtually pathognomonic of delusional disorder.

4. Because of the encapsulation of the delusions and the normal- abnormal switch just described, the patient may have phases of relative normality interspersed with psychotic periods. The switch can occur spontaneously or as a result of external provocation; the two are difficult to disentangle since the hypervigilant individual may perceive provocation in almost anything. Since it is a chronic illness the symptoms never remit, but if they are temporarily in the background the patient may converse and function almost normally and may have sufficient quasi-insight to keep the delusions concealed. Total denial of mental abnormality and resistance to psychiatric referral are almost universal in cases of delusional disorder and lead to severe underestimation of the illness's frequency.

5. As a result of the features just described, many delusional disorder patients can continue to exist in society, sometimes with very abnormal but harmless beliefs but in other instances with highly malignant delusions which they may or may not act out.

6. As will be repeatedly emphasized, delusional disorder must be diagnosed on the form of the illness and the content of the delusion is not used to make the primary diagnosis. On the other hand, the particular content is employed to categorize into subgroups, as will shortly be described.

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