Delusional Disorder: Paranoia and Related Illnesses - Hardcover

Munro, Alistair

Hardcover

ISBN 10: 052158180X ISBN 13: 9780521581806

Publisher: Cambridge University Press, 1999

Synopsis

Delusional disorder, once termed paranoia, was an important diagnosis in the late nineteenth and early twentieth centuries. Only in 1987 was it reintroduced into modern psychiatric diagnosis after being incorporated with schizophrenia. This book provides a comprehensive review of delusional disorder for psychiatrists and other clinicians. Beginning with the emergence of the concept of delusional disorder, the book goes on to detail its manifold presentations, differential diagnosis and treatment. The author provides many instructive case histories, illustrating manifestations of the various subtypes of delusional disorder, and related conditions in the paranoid spectrum. This is the most wide-ranging and authoritative text on the subject to have appeared for many years, and the first to suggest--based on the author's extensive experience--that the category of delusional disorder should contain not one but several conditions. It also emphasizes that, contrary to traditional belief, delusional disorder is a treatable illness.

About this title

Reviews

In 1987 the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (Washington, D.C.: American Psychiatric Press) distinguished delusional (paranoid) disorder from paranoid schizophrenia. Delusional disorder was defined as a persistent specific delusion not accompanied by the deterioration in personality and negative symptoms of anhedonia, lack of motivation, and social withdrawal that characterize chronic schizophrenia. The variations in the content of the delusion itself prompted further subtyping of the disorder, according to feelings of persecution, somatic preoccupations (e.g., body abnormalities, infestation by insects, and emission of foul odors), jealousy, erotomania, and grandiosity. The prevalence of these disorders is probably much higher than commonly recognized, since the delusions often remain concealed for years and may be manifested only in nonmedical situations, where they can go unrecognized as a medical condition.

In Delusional Disorder: Paranoia and Related Illnesses, Alistair Munro updates and expands on the classic literature by Emil Kraepelin and others who originally described these syndromes. He provides numerous case histories and proposes diagnostic criteria for the many subtypes of delusional disorder. Although these disorders are usually considered refractory to treatment, Munro asserts that they are responsive to treatment, particularly antipsychotic medication.

For all mental disorders, the current approach to diagnosis is limited by the need to rely on the patient's own, subjective reports and on somewhat more objective observations of the patient's behavior. The classification of mental disorders has greatly advanced as objective criteria that improve interrater reliability have been established, but we still do not understand the anatomical, pathophysiologic, or genetic bases of these disorders. Furthermore, mental disorders can often appear to be extreme versions of normal behavior. As a result, it is difficult to establish the boundaries between normality and disorder. Witness the recent debate as to whether Theodore Kaczynski, convicted of a series of deadly bombings, has paranoid schizophrenia, a delusional disorder, or (as he and some others assert) no mental disorder at all. The Kaczynski case emphasizes how the lack of biologic markers for mental diseases contributes to the debates about culpability and punishment.

Munro also argues that several syndromes that are part of a "paranoid spectrum" should be included in the category of delusional disorder. These include paraphrenia, late-onset paraphrenia, delusions of misidentification or impersonation (i.e., conviction that a familiar person is being impersonated by a stranger, also known as Capgras' syndrome), and folie a deux. The part of the book in which Munro makes these arguments is less satisfying than others and, in certain instances, confusing. The most convincing argument is for the inclusion of misidentification syndromes as a subtype of delusion disorder. The term "paraphrenia" was first used by Kraepelin to describe a condition in which there are extraordinary delusions and hallucinations but little thought disorder and better preservation of affective response than in schizophrenia. The argument for inclusion of paraphrenia stirs the long-standing controversy about the justification of a separate diagnosis for paraphrenia. Is paraphrenia one of the many subtypes of schizophrenia? Is it a schizo-affective disorder? Is it a variant of affective disorders, or is late-onset paraphrenia one of the first signs of dementing illness? Moreover, Munro himself later indicates that there is little basis for separating late-onset paraphrenia from schizophrenia. He also indicates that folie a deux is not a delusional disorder, but rather one related to delusional illnesses.

The most useful aspect of the book is its emphasis on treatment. One of the difficult problems in treating patients with delusional disorders is that they do not believe they are ill. They are absolutely convinced that their delusional system is valid and accurately reflects reality. How to get around this roadblock to treatment is a vexing issue. This book includes an excellent discussion of the patience required to help such patients accept antipsychotic medication and emphasizes the importance of minimizing side effects by starting at low dosages that are increased very gradually. Munro reviews the literature on treatment, almost all of which consists of case studies, and concludes that the antipsychotic medication pimozide is effective, since 80 percent of patients who took this drug had either a partial or a full recovery. Although this finding is very encouraging, it remains to be determined whether this response rate will be confirmed in systematic studies. Moreover, pimozide has not yet been compared directly with other antipsychotic medications, and no systematic studies have addressed the length of treatment.

Munro has done members of the medical and legal professions a service by providing a cogent synthesis of difficult material. His book will be of great interest not only to those in the mental health field but also to dermatologists, plastic surgeons, and lawyers, who often unwittingly must deal with delusional persons.

Reviewed by Craig Van Dyke, M.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Edition details

• Publisher: Cambridge University Press
• Publication date: 1999
• Language: English
• ISBN 10: 052158180X
• ISBN 13: 9780521581806
• Binding: Hardcover
• Edition number: 1
• Number of pages: 276