geropsych pearls
delusions
First Q to ask: Is this really a delusional disorder?
Look at the criteria with your very best Jeff Foxworthy inner voice. (You might be a redneck if…)
You might have a delusional disorder if….
- Delusions are not bizarre. They involve situations that occur in real life.
- Delusions generally last a month or longer.
- Pt does not meet criteria for schizophrenia.
- Behavior is generally normal, not bizarre or odd.
Also, keep this in mind: Patients whose delusional beliefs are transient probably do NOT have a delusional disorder.
DDx:
If paranoia and delusions seem to get worse around age 60-70, try to find a family member to collaborate.
- If pt was always a bit paranoid/suspicious, but was able to cover it up, then it might be a delusional disorder.
- If this is fairly new for pt with abrupt onset, consider delirium.
- If this is fairly new for pt with slow and insidious onset, consider that they might be brewing a dementia.
Tidbits:
Sadly, antipsychotics really don’t work for pure delusional disorder, but try them anyway. Goal is to reduce the distress.
- If delusions interfere with sleep, try a pinch of quetiapine at HS.
- If they are really bad, try a smidgen of low dose risperidone, also has a nice anxiolytic benefit.
Here’s an interesting factoid: Sometimes adding an antipsychotic makes it seem like they get worse – but it’s often because they were quietly delusional before, and now they are a bit more loose and verbal. Actually an improvement, so don’t change antipsychotics, it's working. Stay the course and cautiously increase the dose.
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