Practical aspects of treatment

Since so many delusional disorder patients actively resist seeing a psychiatrist, it is best to see them in a non-psychiatric setting where possible, for example in the office of the referring specialist or family physician. The physician who treats cases of delusional disorder needs much patience and tact, and it is common to spend one or more sessions first gaining the individual's confidence and finally persuading him to give a psychotropic medication a trial. Many of them argue vehemently and with well-organized pseudo-logic against the premise that they have a psychiatric illness and use all kinds of sophistry to deny the need for a neuroleptic, but a calm and persistent approach will gain co-operation in a good proportion of cases.

As pimozide does seem to have the best success rate reported so far,(!05) its use is recommended, but whatever neuroleptic one prescribes it is essential to begin with the lowest effective dose (e.g. pimozide 1-2 mg daily, haloperidol 1-2 mg daily). This dose is only raised if required and then very gradually to avoid side-effects which are guaranteed to cause cessation of treatment. The patient should be seen at least once a week as an outpatient in the initial stages. Inpatient treatment is not often indicated, although forensic cases will nearly always be seen in an institutional setting.

It is not unusual to observe minor improvements in a few days, such as reduced agitation, a slight increase in well being, improved sleep, and a little less preoccupation with the delusion. On average it is about 2 weeks before the delusional system is significantly ameliorated, but in some patients this may take 6 weeks or longer.

Quite often if this degree of improvement occurs the patient decides that there is no further need for treatment and stops it. Within days or weeks there is an inevitable return of the delusion with its accompanying agitation and preoccupation. It is then that the treating physician must be available to encourage resumption of medication. Although at this stage the patient still believes in his delusions, the experience of improvement followed by relapse makes a deep impression and, given trust in the therapist, often leads to long-term co-operation.

It is striking that good recovery is often relatively rapid and can be surprisingly complete, even when the illness has been present for many years. Some patients return to a considerable degree of intrapsychic, interpersonal, and occupational functioning, with little evidence of the personality disorder that is supposed to be so prevalent in delusional disorder. Also, many patients require surprisingly little counselling or psychotherapy in resuming a reasonable life, although these should always be available if needed. Such results suggest that this profound illness may be due to a relatively circumscribed brain abnormality and also that, in some cases at least, a very insidious onset may cause initial changes which mimic personality disorder.

In most instances, treatment has to be continued for an indefinite period since delusional disorder is potentially a lifelong illness. Naturally the drug dosage should be the lowest which keeps symptoms under control and this maintenance dose is often very low indeed (e.g. 1-2 mg pimozide daily). Perhaps up to one-third of patients can eventually be weaned successfully from medication, but we have no means of predicting who these will be, so that any reduction in treatment must be carried out with extreme caution. Sadly, a proportion of relapses are due to injudicious withdrawal of treatment by a physician and we must assume the need for treatment to be permanent unless proved otherwise. It is interesting that successfully treated patients, whether on maintenance drugs or not, keep a lookout for subsequent recurrences themselves and may report that tension-inducing circumstances provoke some reappearance of symptoms. Such patients may then request to have their medication raised or resumed.

There is no necessary correlation between acquired insight into the desirability of taking one's medication and true insight into the illness itself. Many patients never fully accept the psychotic nature of their experience, but as long as they are benefiting from treatment and are functioning reasonably there is nothing to be gained from challenging them on this. If, despite treatment, the delusions remain intrusive, cognitive-behavioural therapy and counselling should be available, but exploratory psychotherapy is contraindicated.

Throughout treatment, an optimistic and encouraging attitude by the physician is essential. Early on, frequent appointments are necessary and these are scaled down as improvement occurs. In the longer term it is essential that delusional disorder patients have good ongoing supervision; an insightful family physician is excellent for this but a periodic psychiatric review is recommended.

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