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Diagnosis of Delusions and
Delusional Disorder
Timothy C. Thomason
Northern Arizona University
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“Delusional beliefs are among the most
common and intriguing phenomena in the field
of psychopathology.
They may also be among the most poorly
understood phenomena in psychopathology.”
- Oltmanns & Maher
What is a Delusion?
A delusion is a belief that would be seen
by most members of a society as a
misrepresentation of reality.
It is a disorder of thought content, not process.
-
Essentials of Abnormal Psychology, 2013
Another Definition of Delusions
• Delusions are fixed, blatantly false convictions
deduced from incorrect ideas about reality.
• They are maintained despite obvious,
incontrovertible proof to the contrary.
• They are not widely believed in the person’s
culture or subculture.
• Essential Psychopathology and Its Treatment, 2009
Definition, cont.
• A false belief that involves an extreme value
judgment is a delusion only when it defies
credibility.
• Systematized delusions have a common
theme or event and make up a network of
beliefs.
• Essential Psychopathology and Its Treatment, 2009
Delusions Are Common in
Schizophrenia
• Delusion has been called “the basic
characteristic of madness.”
• Between 50% and 70% of people with
schizophrenia have delusions, hallucinations,
or both.
Delusions Occur in Many Disorders
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Neurological disorders; dementia
Delirium; substance-induced disorders
Mood disorders with psychotic features
Obsessive-compulsive disorder
Body dysmorphic disorder
Hypochondriacal psychosis
Eating disorders
Delusional disorder
Examples
• A cyclist preparing for the Olympics believed
her competitors were sabotaging her efforts
by spraying her bicycle with chemicals that
would slow her down. She was so anxious
about it that she stopped cycling.
• A man believed that he could end starvation
for all the world’s children.
• A man believed his vote would determine the
outcome of a national election.
Examples
• A man who saw the movie The Terminator ten
times inserted 45 needles into his body, believing
they would make him stronger.
• In Southeast Asia, men who have an illness called
koro believe that their penis will retract into the
body, disappear, and cause death.
• In Feb. 2013 in Papua New Guinea, a mob
tortured a woman accused of witchcraft and
burned her alive in front of hundreds of
witnesses.
More Examples of Delusions
• Nihilistic delusion: the person believes he or
she does not exist; they have no internal
organs; the world is about to end; etc.
• Delusion of guilt or sin: the person believes
he or she committed a horrible crime or sin
and should be punished severely; or that they
are responsible for some disaster, such as a
fire or earthquake.
Reference Delusions
• The belief that an external event or person is
sending a message or command of great
importance to the person.
• Eg. A woman believed a man in a TV
commercial was speaking to her specifically,
telling her to buy Ajax detergent (she bought
1200 cans).
Philip K. Dick
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Science fiction author
Had several psychotic episodes
Based many of his novels on his delusions
Believed that humans are controlled by VALIS
(Vast Active Living Intelligence System)
• Believed he was really living in first-century
Rome
How Clinicians Diagnose Delusions
• In practice, a belief is usually considered
delusional if it is either patently bizarre,
causes significant distress, or excessively
preoccupies the person, affects their
functioning, and the person cannot be
convinced by evidence to the contrary.
• But this is not the DSM-IV-TR definition. In
delusional disorder there may be no distress
and functioning may not be impaired.
DSM-IV-TR Definition
• Delusions are erroneous beliefs that usually
involve a misinterpretation of perceptions or
experiences.
• Delusions involve distortions in thought
content.
– Not a distortion in perception (hallucinations)
– Not a distortion in language or thought process
– Not a distortion in behavior
Etiology
• The cause of delusions is unknown.
• Theories:
– genetic
– dysfunctional cognitive processing
– a defensive reaction to stress
– brain damage to the left hemisphere
Two Theories of the Cause
• Motivational view
Delusional beliefs are a way to deal with and
relieve anxiety and stress. The person creates a
story that helps them make sense of their anxiety.
• Deficit view
Delusional beliefs result from brain dysfunctions
that create disordered thoughts or perceptions.
Delusions Are False Beliefs
• But the words “false” and “belief” are
contradictory and therefore incorrect usage.
• Belief requires no objective test of truth or
falsity.
– Eg. Children believe in Santa Claus.
– Eg. People used to believe the earth was flat.
– Eg. Religions are based on beliefs, not facts.
• Beliefs are neither true nor false.
Ernest Hemingway
• He believed that federal agents were pursuing
him: “It’s the worst hell. They’ve bugged
everything. My car’s bugged. Can’t use the
phone. My mail is intercepted.”
• People around him thought he was delusional.
• After his death, it was revealed that the FBI
had actually bugged his telephone.
The Martha Mitchell Effect
• Some “delusions” may turn out to be true.
Martha Mitchell, the wife of the attorney
general, said illegal activities were occurring in the
Nixon White House. At the time it was thought she
was mentally ill. The Watergate scandal proved her
claim was true.
A homeless woman living on the beach in Florida
claimed to be the cousin of the British Ambassador
to the United States. It turned out she was correct.
Delusions Are Pathological
• According to the DSM-IV, delusions are always
pathological (unlike hallucinations).
• Albert Ellis: People are inherently irrational, so
it is not pathological for people to have
delusional beliefs (beliefs that are clearly
contrary to evidence).
• Aaron Beck: People are inherently irrational,
but this is pathological and can be treated.
Dr. Sandra Murray’s Research
• Delusions are so common in humans that they
are practically universal.
• Some delusions serve a positive function.
Eg. My spouse/partner is exceptionally smart,
attractive, caring, supportive, etc.
Happily married people view their spouses much
more positively than others who know them well.
Being delusional about our spouse makes us
happier and helps the relationship work.
Positive Delusions
• Positive delusions (false beliefs) about yourself
may be good for your mental health.
• People who are clinically depressed are more
accurate in their self-assessments than are the
non-depressed.
• Self-delusion may be adaptive because it
makes us feel better and promote ourselves
better to others.
Implications
• Some delusional thinking is not pathological.
• People can have strange, or even bizarre
beliefs, and not be pathological.
• The brains of some delusional people may be
normal.
• But the DSM-IV says that delusions are always
pathological.
DSM-IV-TR Glossary Definition
A delusion is a false belief based on an
incorrect inference about external reality that is
firmly sustained despite what almost everyone
else believes and despite obvious proof or
evidence to the contrary.
Two Exemptions: Culture & Religion
• The belief is not one ordinarily accepted by other
members of the person’s culture or subculture.
But who determines whether the person’s
experience is culturally congruent?
• Religious beliefs that are commonly accepted
within a specific religion are not delusions.
But this assumes clinicians are familiar with the
normative beliefs of all cultures, subcultures, and religions.
Are the Exemptions Valid?
Either:
The rationality of ideas is determined by social
consensus.
Or:
The reason for the exemptions is to avoid
controversy.
Who Decides Whether a Belief is
Delusional?
• According to the DSM, the majority is right.
• But why can’t the majority be wrong?
• Eg. In the Soviet Union, political dissidents
were defined as delusional and they were put
in mental institutions.
The Cultural Exemption
• Why are cultural beliefs, no matter how
bizarre, not considered delusional?
• Presumably, because it is not pathological to
hold the same beliefs as almost everyone
where you live.
Delusions as Symptoms are Relative
• Delusional beliefs can only be evaluated from
within the patient’s culture.
• The same belief may be delusional in one
culture but not in another culture.
• But this implies that beliefs are not
pathological (the DSM says they are).
• Beliefs may be adaptive within a specific
group but maladaptive with the rest of
society.
The Religious Exemption
• Why are religious beliefs, no matter how
bizarre, not considered delusions?
• Presumably, because it is not pathological to
hold the same beliefs as almost everyone else
who is a member of your religion.
Some Beliefs are Neither
True Nor False
• Delusions are defined as fixed false beliefs.
• Some religious and spiritual beliefs are not
falsifiable, so they cannot be described as true
or false.
• Many religious beliefs have the same features
as delusions, but are not delusions.
Do Clinicians Diagnose Some Religious
Beliefs as Pathological?
• Does the specific content of a religious belief
influence the diagnosis of psychopathology?
• In a study of 110 clinicians, the beliefs of a
mainstream religion were rated as less
pathological than the beliefs of two less
mainstream religions.
– Catholicism
– Mormonism
– Nation of Islam
Clinicians Often Make Errors When
Assessing Religious Ideation
• The results were significant, and the effect size
was large.
• The more mainstream the religion, the less
pathological its beliefs are thought to be.
• The beliefs of the less mainstream religions
were rated as symptoms of serious mental
illness.
• These results suggest that many clinicians do
not follow DSM-IV recommendations.
Implications & Questions
• Clinicians consider some religious beliefs to be
inherently pathological, regardless of whether
they are shared.
• Are some beliefs pathological, even if held by
a subculture?
• Why should culture and religion be exempted?
• Were the beliefs of the Heaven’s Gate group
or the Jim Jones community pathological?
Implications, cont.
• Why can’t there be mass delusion?
• Do beliefs not matter as long as they are
shared?
• How many people must share the belief?
• Are groups of believers (eg. Muslim
extremists) who wage war on nonbelievers
delusional or pathological? According to the
DSM, they are not delusional.
Implications, cont.
• Non-mainstream religions are probably wise
to keep their beliefs secret, since many people
(including clinicians) consider them delusions.
• Eg. Mormon theology says members will be
transformed into gods after they die.
• Eg. Scientologists believe that humans were
brought to earth is a spaceship by a galactic
warlord named Xenu 75 million years ago.
Individual and Shared Delusions
• Delusions occur in individuals, not groups.
• Exception in DSM: shared psychotic disorder
(folie a deux): two people share a delusional
belief. It can also occur “among a larger
number of individuals” such as a family, in
which children adopt the parents’ delusional
beliefs.
Shared Delusions
• Folie a deux: 90% of cases are within families
– Eg. Randy & Evi Quaid
– Occurs in delusional parasitosis
– Occurs in some twins
Folie a trois, etc.
• Cults (eg., “we are God’s chosen ones”)
• Munchausen by proxy syndrome
– The parent and child believe the child is sick.
Differentiation
• Shared psychotic disorder
– Two or more people share a delusion
• Mass psychogenic illness
– Several people share physical symptoms (eg,
blindness, paralysis, tics).
– Previously called “mass hysteria.”
– A form of conversion disorder (somatic symptoms
due to psychological mechanisms).
– These people do not have a delusion.
DSM-IV Definition, cont.
• When a false belief involves a value judgment,
it is regarded as a delusion only when the
judgment is so extreme as to defy credibility.
• Delusional conviction occurs on a continuum.
• An overvalued idea is a strongly held belief
that is not held as strongly as a delusion.
The Continuum
• Rational thinking
– Eg. “There is no evidence of the supernatural.”
• Magical thinking (superstitions)
– Eg. Knock wood to prevent something bad.
• Overvalued ideas (unreasonable beliefs held
with less intensity than delusions)
– Eg. “Only a good diet can cure cancer.”
• Delusions
Types of Magical Thinking
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Belief in superstitions
Belief in the paranormal
Belief in the supernatural
Belief in religious miracles
How Did You Score on the Intuitive
Thinking Questionnaire?
• Add up all the numbers in the blanks.
• Divide the total by 10 to get your score.
Intuitive Thinking Questionnaire
• Score of 0: highly rational thinking
• Score of 10: extreme magical thinking
• Many people score in the middle.
The questionnaire is from the book Better Than Normal
by D. Archer, 2012.
Most People Have Some Magical/
Supernatural/Superstitious Thinking
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Our brains predispose us to magical thinking.
Our perceptual systems look for patterns.
We find meaning even in random stimuli.
Magical ideas like “everything happens for a
reason” or a belief in destiny helps people see
life as a coherent narrative.
• But at the extreme, magical thinking can lead
to obsession, fatalism, or psychosis.
Superstitions Are Common
• President Obama always played basketball on
election days, thinking it was lucky.
• John McCain always carries a lucky feather,
compass, penny, nickel, and quarter.
• Wade Boggs (NY Yankees third baseman) ate
chicken every day for over 20 years, thinking it
made him hit better. His pre-game ritual took
five hours to complete before every game.
Magical Beliefs and Rituals are
Common in OCD
• The belief that rituals work is supernatural.
• Rituals produce a sense of control.
• The illusion of control can reduce anxiety and
enhance self-confidence.
• This can improve our performance and
indirectly affect what we do.
• Eg. Golfers who used a “lucky” ball got 35%
more golf putts than those with a regular ball.
How Did You Score on the
Belief Questionnaire?
• How many of the ten items did you check?
The questionnaire contains the items in Gallup Polls
of adult Americans. Results from polls conducted in
1990, 1996, 2001, and 2005 were highly consistent.
Most Americans Believe in the
Paranormal
• 73% have at least one of 10 paranormal beliefs
41%
37%
32%
31%
26%
25%
extrasensory perception
haunted houses
ghosts
21%
telepathy
21%
clairvoyance
20%
astrology
9%
comm. w. the dead
witches
reincarnation
channeling entities
• 1% have all 10 paranormal beliefs
• 27% have none of the 10 paranormal beliefs
At Least 80% of Americans have
Supernatural Beliefs
• Paranormal beliefs can be seen as secular
supernatural beliefs.
• There are also religious supernatural beliefs.
Supernatural belief is at the core of almost every
known religion.
Around 80% of Americans identify themselves as
religious; 20% have no religious affiliation.
Pew Research Center Poll, 2012
How Did You Score on the
Assessment of Delusional Thinking?
Add up the numbers in the blanks to get your
total score.
Assessment of Delusional Thinking
The “correct” total score is 0.
No religious beliefs are considered delusions.
No cultural beliefs are considered delusions.
Potential exception:
Item #20: People who take religious teachings
literally may be considered delusional.
The Content of Delusions May Include
a Variety of Themes
• Persecutory
The most common kind of delusion; belief that one is
being tormented, followed, spied on, etc.
• Referential
Also common. The person believes certain gestures,
comments, passages in books, song lyrics, etc. are
specifically directed at them.
• Somatic
• Religious
• Etc.
Religious Delusions
• Any delusion with a religious content.
“I am Jesus Christ.”
“God talks to me.”
“God chose me to be his agent on earth.”
How would you distinguish bizarre religious
delusions from non-bizarre religious delusions?
Thomas Szasz wrote:
“If you talk to God, you are praying. If God
talks to you, you have schizophrenia.
If the dead talk to you, you are a spiritualist. If
you talk to the dead, you are a schizophrenic.”
Religious Delusions
• Many psychotic patients have delusions with
religious themes or content.
• Religious beliefs are not delusions per se, but
people may have religious delusions.
– Eg. “I am John the Baptist.”
– Eg. “God sent the hurricane to punish the sinful
city of New Orleans.”
– Eg. “God told me I am the Antichrist, and I must
kill my children.”
Examples of Religious Delusions
• Several men have castrated themselves after
reading Matthew 19:12, which says some men
made themselves eunuchs for the sake of the
kingdom of heaven.
• Several people have removed their own eyes
after reading the Matthew 5:29, which says “if
thy right eye offend thee, pluck it out.”
Religious Delusions?
• 39 members of the Heaven’s Gate religion
committed suicide, believing their souls would
fly to a spaceship and they would transform
into supernatural beings.
• A monk asked a surgeon to remove his penis
in order to eliminate his sexual desires,
because they interfered with his spirituality.
Religious Delusions?
• David Koresh believed himself to be chosen by
God to be a prophet of the Branch Davidians.
When their compound was raided, they
resisted arrest and 76 people died in a fire.
• Jim Jones believed he was called by God to
lead the People’s Temple. He moved the
church to Jonestown Guyana, and 914 of the
members died in a mass suicide in 1978.
Religious Beliefs on a Continuum
People who adhere to religious beliefs but
practice them only moderately are not in danger
of being diagnosed as delusional. People who
try to act wholeheartedly upon a set of religious
beliefs are in some danger of being diagnosed as
delusional.
Case Example: John
• John believed that he would die unless he
killed someone everyday and tore out their
heart.
• Was his belief a delusion?
Case Example: The Aztecs
• The Aztecs believed that daily human sacrifice
was necessary to keep the sun moving on its
course. It is estimated they killed about
20,000 people per year as sacrifices to the
gods.
• The sacrifices “worked” (the sun kept rising).
• Was their belief a delusion?
A Practical Definition
• A belief becomes a delusion when the
clinician judges that no one wants to hear it
and the patient does not care to adjust the
belief in the direction of social value.
• The truth or falsity of the belief is not part of
the diagnostic process.
• But the DSM says a delusion is a false belief.
Proposed Subtype: Political Delusion
• In 2012 an attorney suggested that
Republicans who have beliefs that are proven
inaccurate by indisputable evidence (eg.,
Obama is a Muslim; Obama is not an
American) have a delusional disorder.
• Does this meet the DSM criteria for a
delusional disorder?
Delusions May be Bizarre or
Non-bizarre
• Delusions are bizarre if they are clearly
implausible and not understandable and do
not derive from ordinary life experiences.
• Bizarre delusions are absurd and weird.
• Example: A person says “A stranger removed
my internal organs and replaced them with
someone else’s organs” without leaving any
wounds or scars.
Two Kinds of Delusions
• Bizarre delusions are impossible.
• Non-bizarre delusions are improbably.
Examples of Bizarre Delusions
• Thought withdrawal.
“The space aliens took my thoughts.”
• Thought insertion.
“The space aliens planted thoughts in my mind.”
• Delusions of control.
“The space aliens made me do what I did.”
Bizarre Delusions are Characteristic of
Schizophrenia
• In DSM-IV, this one symptom (having bizarre
delusions) is enough to satisfy Criterion A for
schizophrenia (even if the person has no
hallucinations, disorganized speech or
behavior, or negative symptoms).
• In DSM-5, the proposal is to eliminate this
special treatment of bizarre delusions in
Criterion A for schizophrenia.
Examples
• John Nash (mathematician and Nobel Prize
winner) thought he was the Emperor of
Antarctica and the left foot of God and could
communicate with aliens. [A Beautiful Mind]
• Milton Rokeach’s book The Three Christs of
Yipsilanti he describes his work with three
patients who claimed to be Jesus Christ.
“Bizarreness” May be Difficult to Judge
• There is poor inter-rater reliability for ratings
of bizarre beliefs.
• Especially across cultures
• “Some cultures have widely held and
culturally sanctioned beliefs that might be
considered delusional in other cultures.”
• “The content of delusions varies in different
cultures and subcultures.”
(from DSM-IV-TR)
Cotard’s Syndrome
• Example of a bizarre delusion
• People with this delusion believe they are
dead. They believe they are, in effect,
zombies, existing in dead, rotting bodies.
• Their belief that they are already dead leads
to their taking risks and neglecting self-care.
They may stop eating and taking medications.
Neurological Delusional Disorder
• Capgras Syndrome: the person has the
delusion that their close friend or family
member has been replaced with a lookalike.
• Case Example: Following a car crash, Alan
Davies became convinced that his wife
Christine had died in the accident and had
been replaced by someone he called Christine
Two. He refused to interact with her.
Lycanthropic Delusion
• The delusional belief that one has been
transformed into a wild dog or wolf or other
animal.
• The person may live outside, walk on all fours,
eat wild foods, grow long hair and nails, and
behave like a wild dog or wolf.
First Case Report of Lycanthropy
In perhaps the earliest recorded example of
mental illness (Daniel 4:33) the Babylonian King
Nebuchadnezzar (605-562 BCE) was said to
transform into an ox. He lived out in the wild,
ate grass like oxen, and let his hair and nails
grow out like a wild animal.
Other Cases of Lycanthropy
• In France (c. 1550) a hermit who believed he
was a wolf attacked, killed, and ate parts of
four children.
• In 1700 a group of nuns in a French convent
believed they were changed into cats and they
meowed and acted like cats.
• There were 12 documented cases of
lycanthropy in Boston in the 1980s.
Vampirism
• Clinical vampirism (aka Renfield’s syndrome).
• The person believes he or she is a vampire and
has an obsession with drinking blood.
The Glass Delusion
The patient believes he or she is made of
glass, and fears being touched or hit since they
think they will break.
Eg. King Charles VI of France
Daniel Paul Schreber
A German judge; Freud wrote a study of him.
Schreber said that he had been chosen by God to
give birth to a new race of men, and he was being
transformed into a woman. He believed he had
been abducted by supernatural forces. He
constantly spoke to God and to dead people. He
said he had no stomach and had a “lung worm.” He
said his penis was turned soft by “impure rays.” He
said 240 Benedictine monks lived inside his skull.
More Examples of Bizarre Delusions
• Some psychotic patients believe they can hear
voices from animals speaking to them (the
“Dr. Dolittle” phenomenon).
• A woman believed that her skull was filled
with bees. She kept her fingers in her ears to
block out the buzzing sounds.
Non-bizarre Delusions
• Involve situations that can conceivably occur
in real life (e.g., being followed, poisoned,
infected, loved at a distance, deceived by
one’s spouse or lover, etc.).
• Example: A person’s false belief that he or she
is under surveillance by the police.
Bizarre or Non-bizarre?
• In the movie Lars and the Real Girl, a shy
young man buys a lifelike doll, names it
Bianca, and comes to believe she is a real
person and is his girlfriend.
“The Truman Show” Delusion
• The belief that one is the star of a reality
television show.
• Some patients say they feel like the
protagonist in the movie “The Truman Show.”
He lives in an unreal town but he thinks it is real. He
begins to question it and discovers the town is fake.
Delusional Disorder
• DSM-IV: The person has one or more nonbizarre delusions that persist at least 1 month.
• DSM-5: The person’s delusions may be bizarre
or non-bizarre. DSM-5 will add a specifier to
Delusional Disorder.
There is no difference in the treatment of
bizarre or non-bizarre delusions.
Diagnostic Criteria for Delusional
Disorder, cont.
• Aside from the direct impact of the delusions,
the person’s psychosocial functioning is not
markedly impaired, and behavior is neither
obviously odd nor bizarre.
• The delusions are not due to the direct effects
of a substance (e.g., cocaine), or a disease.
People with Delusions May Have
Related Hallucinations
If tactile and olfactory hallucinations are
present (and prominent) they are related to the
delusional theme (e.g., the person has the
delusion that they are infested with insects
under their skin, and they say they can feel the
insects moving around).
Types of Delusional Disorder
• Erotomanic type. The person believes that
someone else is in love with them. The person
is usually of higher status (e.g. a famous
person) but may be a complete stranger.
• Efforts to contact the person (and even
stalking) are common.
• Example in a movie: Enduring Love.
An Example of Erotomania
A 25-year-old man named Poddar at the
University of California became obsessed with
another student named Tanya. After she refused
his offer of marriage, he became distraught and
sought counseling. After ten sessions he quit,
and told a friend he was buying a gun. The
friend told the psychiatrist, who told the campus
police, who told Poddar to stay away from
Tanya. He went to her house and murdered her.
More Examples of Erotomania
• Robert Bardo stalked and killed the model
Rebecca Schaffer.
• John Hinckley attempted to kill President
Ronald Reagan. He had the delusion that the
assassination would cause the actress Jodie
Foster to fall in love with him.
Types, cont.
• Grandiose type. The person believes they
have some great (but unrecognized) talent,
insight, or discovery.
• Less often, the person may believe they have a
special relationship with a prominent person
(e.g., the president).
• Some grandiose delusions are religious (e.g.,
“God gave me a special message”).
Types, cont.
• Jealous type. The person believes his or her
spouse or lover is unfaithful. This belief is
based on incorrect inferences based on small
bits of “evidence” which are used to justify the
delusion. Eg., Othello.
• The person usually confronts the spouse or
lover, and may secretly follow the spouse,
investigate the lover, or attack the spouse.
Types, cont.
• Persecutory type. The person believes he or
she is being conspired against, cheated, spied
on, followed, poisoned, or harassed.
• The person may file legal actions or appeal to
courts or government agencies.
• They are often angry and resentful and may
resort to violence.
Types, cont.
• Somatic type. The delusion involves bodily
functions or sensations.
• Examples: The belief that one emits a foul odor
from the body (mouth, rectum, etc.); the belief
that the skin is infested with insects; the belief
that there is an internal parasite; the belief that
certain parts of the body are ugly; the belief that
parts of the body are not functioning.
• Eg. “My intestines are not working.”
Examples of Somatic Delusions
• A man believed that he always smelled of
urine. He avoided social interactions and
became depressed.
• A woman believed she had a foul body odor
like rotten fruit. She became severely
depressed but medications provided no relief.
• A man became convinced that his legs did not
belong to him and begged a doctor to remove
them.
Somatic Delusions, cont.
• Jim, a good-looking man of 25, complained of
social difficulties. He was convinced that his
head was square, and that everyone was
staring at his deformity. He wore soft floppy
hats to hide his head, which looked normal to
the clinician.
Delusional Parasitosis
• Morgellon’s disease: characterized by tiny
parasites living under the skin, which
produces fiber-like substances that spring
from lesions.
• A CDC Study (2012) found no evidence of real
parasites; the fibers were pieces of cloth and
skin fragments from repeated scratching.
Joni Mitchell Says She Has Morgellon’s
• “This is not a delusion.”
• “I’m trying to get out of the music business to
battle for Morgellon’s sufferers to receive the
credibility that’s owed to them.”
• Response of physician: “No amount of
evidence will convince such people.”
DSM-5 Changes in Somatic Delusions
• A delusion about “some physical defect” will
be removed from the definition of the somatic
subtype of delusions.
• Delusional body dysmorphic disorder (BDD)
and delusional OCD are variants of BDD and
OCD, not a separate delusional disorder.
Treatment of Delusional Disorder
Medications are not usually helpful.
The preferred treatment is psychotherapy.
A trusting, supportive relationship is key.
Do not directly challenge the delusions.
Reinforce positive gains in the client’s life.
Facilitate the client’s development of selfconfidence and self-reliance.
An Example of “Joining the Delusion”
About one thousand years ago, an Arabic
doctor treated a Persian prince who was
convinced that he was a cow. He mooed,
refused to eat regular food, and said he should
be killed so a stew could be made from him.
The doctor, Ibn Sina, told the prince to lie on
the floor and prepare to be slaughtered. He
raised a knife, but then complained that the
prince was too thin and needed to be fattened
up. The prince gladly began eating, and with
time his delusion faded. Today Ibn Sina is
considered a forefather of psychoanalysis.
Treatment, cont.
• Focus on realistic and concrete problems.
• Gradually you can begin to gently challenge
the client’s delusional beliefs, starting with the
smallest items.
• Be careful to speak directly and plainly.
• Avoid subtlety and sarcasm.
• Stress social skills training and other
behavioral and solution-oriented therapies.
Treatment, cont.
• Avoid hospitalization if possible; day
treatment programs are preferable.
• The prognosis is poor with reluctant clients.
• Even with cooperative clients, psychotherapy
often takes at least six months to a year.
http://works.bepress.com/timothy_th
omason