
Understanding and Addressing Delusional Disorder

Challenges of Treating Delusional Disorder

Talking About Medications with Delusional Patients

How to Talk to Patients with Delusions

Speaker 1: The one thing in delusional disorder that patients don't want to give up is the very thing that we're trying to change. How do we even start the conversation? Welcome to the Carlite Psychiatry podcast, keeping psychiatry honest since 2003. 

Speaker 2: I'm Chris Aiken, the editor-in-chief of the Carlite Psychiatry report. 

Speaker 1: And I'm Kelly Newsom, a psychiatric NP and a dedicated reader of every issue. With all that's written about psychopharmacology in our field, it can seem like psychiatry is all about understanding medications, side effects, and drug interactions. But psychopharmacology is the easy part of our work. 

The greater challenge is connecting with people who think and feel very different from ourselves. In this month's report, we feature a review of delusional disorder. There are a few medication tips in there, like why Pemazide is no longer first line. But overall, we conclude that the evidence for antipsychotics is sorely lacking in delusional disorder. 

Speaker 2: There are many types of psychosis, manic psychosis, depressive psychosis, drug-induced dementia-related, medical-related, schizophrenia, schizotypal, and delusional disorder. You know, it's funny in psychiatry how we spend so much time parsing apart the disorders and then expect that they're all going to respond to the same treatment like in this case, in antipsychotic. That would be like expecting every fever to respond to penicillin. 

And indeed, they don't. Delusional disorder can respond to antipsychotics, but the response is not as great as what we see with schizophrenia. Today, we talk with psychiatrist Michael Posternak on how to help patients manage their delusions when they don't respond to medications. Michael, you have a long-standing interest in delusions. How did that start? 

Speaker 3: I served out in the mental health field working as a mental health counselor for three years. So I spent three years working as an inpatient unit and fell in love with the field and and ended up going to med school after that. There was one patient who I recall who really stood out, and she was a nurse, very bright, very articulate, but she had this unusual belief that her soul had been transposed by someone from the 14th century, and that gave her special powers. And I was fascinated by the fact that she was very bright, intelligent, and in every respect, she was normal, but she had a very unusual set of beliefs. 

These powers that she had suggested to her that she could do things like make the moon move at will and speak eight languages and that type of thing. So remember, I asked her to come outside with me and she was willing to go along and say, can you show me how you make the moon move? So we went outside and she was not successful doing it. 

And we went back inside and since I speak French, I asked her to write down a sentence in French that translate for me and she struggled with that. And the interesting thing was she tried to do it. She put the pen to the paper, but she was not successful. When I asked her, why couldn't you make the moon move and why do you think you couldn't speak eight languages? She sort of said things like, well, it was kind of cloudy outside and she said, I was tired and I had a long day. So there was something about the fact that she wasn't able to correct her belief system and that she was going to fit whatever happened into her beliefs. 

Speaker 2: What have you learned along the way about how to talk to patients with delusions? 

Speaker 3: Delusional patients, I think, are uniquely challenging. We don't see it much. I mean, delusions are rare in an outpatient practice where I work under one percent of patients in clinical practice, both in mine and in other practices that people have looked at, do have delusions. 

So it's not something we encounter a lot of, which means we may not have a lot of experience dealing with it. And I think delusions present the challenge because oftentimes, just like this patient, they're very intelligent and they're very bright and they often understand that other people perceive them to be crazy and they're walking into a psychiatrist's office and so they're very anxious about the fact that you may stamp them or I may stamp them with a notion that they're crazy and they're often very convinced of what they're saying is correct. And so it's a balancing act in trying to validate their experience, but not try to support their false belief. 

Speaker 2: And how do you support the patient without supporting their delusions? 

Speaker 3: The most common delusion that people suffer from is paranoid delusions and oftentimes they come in, no one says I'm delusional. Oftentimes they come in because they'll say my husband or my wife or my mother or my father or somebody says I need to see a psychiatrist and they're highly stressed and they're coming in at someone else's request. And so someone may say something like there's 20 people out there, I don't know who they are, but they've hacked my computer and they follow me around wherever I go and I'm in my car. 

And so that's sort of a typical story, let's say for someone with a paranoid tickosis. They may have gone to the police several times, they may have contacted the CIA, obviously they're running into dead ends, each place they go to. And so what they want for me is they want to validate that they're correct and obviously that's a trap not to get into. I want to first hear their whole story, not just about their delusions about their whole life, their life story. But when we get delusions, I really want to try to sidestep this question of am I going to judge them or not? 

And is what they're saying true or not? And generally what I'll say is something to the effect that listen, I'm not a private detective, some people are followed out there, maybe you're one of them, I'm not sure, but my job is not to sort of say who's right you or your family, I'm just trying to try to help you deal with this really stressful experience and let's see if we can figure out a way to do that. 

Speaker 2: And how do you help them function better in the world? 

Speaker 3: You know, typically by the time they come into your office, it won't be a week or two that they'll have been delusional, often be a year or much longer than that. And so, you know, they'll talk about these great conspiracies, but I'll ask them, what have they done to you so far? I mean, have they, you know, they might say they've been hacked, but I'll ask them, you know, is it possible they're trying to hurt you, trying to kill you? 

You know, what are they trying to do? And the answer of course is no, obviously if they wanted to kill you, they would have killed you by now and they fully acknowledged that. We established the fact that they're not in any type of danger or jeopardy because if they were, it would have already happened by now. So basically, they're being followed, there's this potential conspiracy out there. And now our task is how do we deal with this conspiracy? The FBI doesn't seem like they're going to help, the police are going to think you're crazy, and they generally can acknowledge that. So now we have to live with the fact that there's people out there doing this, how can we best do that? 

Speaker 2: Do you get to work with families in these cases? 

Speaker 3: Well, I would say not that I get to work, I would say it's almost mandatory to have to work with patients because it's the families that's most affected, the patients, while they're delusional, don't realize they have any psychiatric illness, the family of course is very aware that this sounds crazy, it's not possible, and they're often engaged in repeated dialogues over and over arguments about whether this is true or not true, that are just completely dead ends. And so anytime someone comes in with delusions, it's really mandatory to invite the families in. And I do it in conjunction with the patients, I certainly don't want to do it behind their backs and have a discussion with the families about how to cope with this difference in perspectives that exist between the family and the patient. 

Speaker 2: What are some of the common solutions you come up with with families? 

Speaker 3: Is it ever hard to figure out if the delusions are true? 

Speaker 3: Another example is about the fidelity of a spouse. 

Speaker 2: If the patient's goal is to save their marriage, the solution is to stop badgering their spouse tracking everywhere they go. 

Speaker 3: How do you talk about medications with people who have delusional disorder? 

Speaker 3: What are some of the common solutions you come up with with the delusions? What are some of the common solutions you come up with with the delusions? 

Speaker 2: What are some of the common solutions you come up with with the delusions? 

Speaker 3: What are some of the common solutions you come up with with the delusions? Any other tips you have? 

Speaker 2: One of the things I always try to keep in my mind is the movie The Terminator. I try 

Speaker 3: to remind myself that to be humble about what's going on and to really think about the situation at an emotional level and go where the patient's coming from. 

Speaker 1: Michael Posternak is a psychiatrist in private practice in Boston, Massachusetts. His research, which includes over 50 peer-reviewed publications, has advanced our understanding of antidepressant therapy and he is a regular contributor to the CARLAT Report. And now for the word of the day, the Beads Task. 

Speaker 2: The Beads Task was the first study to suggest that delusional disorder is about something more than just false beliefs. Delusional disorder also involves a different way of thinking and processing information. In the study, participants were shown two jars of beads. One of them was mostly filled with pink beads, which was 85% pink and 15% green. And the other was a mostly green jar, 85% green and only 15% pink. The jars were then hidden and the participants were shown a sequence of beads drawn from the container and asked to guess which container it was drawn from. So, if you're seeing a lot of pink, you're going to guess it's from the pink jar. But how many beads would you wait until you ventured your guess? 

Maybe two, maybe five, maybe ten? In this study, people with delusional disorder ventured a guess after way fewer beads were drawn than everyday people did. In other words, they were jumping to conclusion on limited data and willing to accept hypotheses based on scarce evidence. Since then, over a dozen similar studies have documented the same thing. And look carefully, it's something that you'll see in your practice. For example, just as you start to talk about a medication or a behavioral intervention or any idea with a patient who has delusional disorder, they might just jump in, reaching conclusions that you've barely suggested by your words. Knowing that, you gotta parse what you say carefully. 

Speaker 1: You can read the full articles and earn CME credits at thecarlotreport.com where we have a special offer for our podcast listeners. You can get $30 off your first year subscription with the promo code podcast. 

Speaker 2: The Carlot Report is one of few CME publications that depends entirely on its subscribers for support. Thank you for helping us stay free of industry support. 

How to Talk to Patients with Delusions

from The Carlat Psychiatry Podcast

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Derek Harmanli

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How to Talk to Patients with Delusions

from The Carlat Psychiatry Podcast

Media

Links

Key Points

Summary

Transcript

Disclaimer and Important Information

Derek Harmanli

Leave a Reply

Related Posts

Categories