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Margaret Henderson, a tiny sparrow of a woman, sat perched on the front of her waiting room chair. On her lap she tightly clutched her scuffed black handbag; her gray hair was caught up in a fierce little bun at the back of her head. Through spectacles as thick as highball glasses, she darted myopic, suspicious glances about the room. She had already spent 45 minutes with the consultant behind closed doors. Now she was waiting while her husband, Michael, had a turn.
Michael confirmed much of what Margaret had already said. The couple had been married for over 40 years, had two children, and had lived in the same neighborhood (the same house, in fact) nearly all of their married life. Both were retired from the telephone company, and they shared an interest in gardening.
That was where it all started, in the garden, said Michael. It was last summer, when I was out trimming the rose bushes in the front yard. Margaret said she caught me looking at the house across the street. The widow woman who lives there is younger than we are, maybe 50. We nod and say hi, but in ten years, Ive never even been inside her front door. But Margaret said I was taking too long on those rose bushes, that I was waiting for our neighborher name is Mrs. Jessupto come out of the house. Of course, I denied it, but she insisted. Kept talking about it for days.
In the following months, Margaret pursued the idea of Michaels supposed extramarital relationship. At first she only suggested that he had been trying to lure Mrs. Jessup out for a meeting. Within a few weeks, she knew that they had been together. Still later, this had turned into a sex orgy.
Margaret had talked of little else and had begun to incorporate many commonplace observations into her suspicions. A button undone on Michaels shirt meant that he bad just returned from a visit with the woman. The adjustment of the living room venetian blinds tipped her off that he had been trying to semaphore messages the night before. A private detective Margaret hired for surveillance only stopped by to chat with Michael, submitted a bill for $50, and resigned.
continued to do the cooking and washing for herself, but Michael now had to take
care of his own meals and laundry. She slept normally, ate well, and, when she
wasnt with him, seemed to be in good spirits. Michael, on the other hand,
was becoming a nervous wreck. She listened in on his telephone calls and steamed
open his mail. Once she told him that she would file for divorce, but she didnt
want the children to find out. Twice he had awakened at night to find her
wrapped tightly in her bathrobe and standing beside his bed, glowering down at
him and waiting for him to make his move. Last week she had strewn the hallway
outside his room with thumbtacks, so that he would cry out and awaken her when
he sneaked away for one of his late-night, sexual rendezvous.
First, consider symptoms. Delusions are the only psychotic symptom allowed to any important degree in Delusional Disorder. The delusion can be any of the six types listed in the Coding Notes. In Margarets case, they were of the Jealous Type, but the Persecutory and Grandiose Types are also common. Note that with the exception of olfactory or tactile hallucinations that reinforce the content of certain delusions, Delusional Disorder patients will never fulfill the A criteria for Schizophrenia.
The duration of the delusions need be only one month; however, most patients, like Margaret, have been ill much longer by the time they come to professional attention. The consequences are mild for Delusional Disorder. Indeed, outside of the direct effects of the delusion (in Margarets case, her marital harmony), work and social life may not be affected much at all.
However, the exclusions are pretty much the same as for Schizophrenia. Always rule out a general medical condition or cognitive disorder, especially a dementia with delusions, when evaluating delusional patients. This is especially important in older patients, who can be quite crafty at disguising the fact that they are cognitively impaired. Substance-Induced Psychotic Disorders can closely mimic Delusional Disorder. This is especially true for Amphetamine-Induced Psychotic Disorder With Onset During Withdrawal, in which fully oriented patients may describe how they are being attacked by gangs of pursuers.
Margaret Henderson had neither history nor symptoms to support any of the foregoing disorders; however, laboratory and toxicology studies may be needed for many patients. Other than irritability when she was with her husband, she had no symptoms of a mood disorder. Even then, her affect was quite appropriate to the content of her thought. However, many of these patients can develop mood syndromes secondary to the delusions. Then the diagnosis depends on the chronology and severity of mood symptoms. Information from relatives or other third parties is often required to determine which came first. Also, the mood symptoms must be relatively mild and brief to sustain a diagnosis of Delusional Disorder.
Although these patients may have associated conditions, including Body Dysmorphic Disorder, ObsessiveCompulsive Disorder, or Avoidant, Paranoid, or Schizoid Personality Disorder, there was no evidence for any of these in Margaret Henderson.
from: DSM-IV Made Easy, James Morrison, M.D: The Guilford Press, 1995.
Reflection Exercise #1
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