Delusional Disorder: An Unusual Presentation

By Noel, Joseph; Krishnadas, Ranjit et al. | Indian Journal of Psychological Medicine, October-December 2014 | Go to article overview

Delusional Disorder: An Unusual Presentation


Noel, Joseph, Krishnadas, Ranjit, Gopalakrishnan, Rajesh, Kuruvilla, Anju, Indian Journal of Psychological Medicine


Byline: Joseph. Noel, Ranjit. Krishnadas, Rajesh. Gopalakrishnan, Anju. Kuruvilla

Delusions with a sexual theme are rare, but when present are usually seen in patients with schizophrenia or other chronic psychotic disorders. We report a case of delusional disorder, with a single belief of a sexual theme. This report focuses on the management issues, wherein a combination of pharmacological and nonpharmacological interventions proved helpful.

Introduction

Delusional disorder is an uncommon psychiatric condition characterized by nonbizarre delusions of a single theme, in the absence of other mood or psychotic symptoms. [sup][1] It is differentiated from schizophrenia by the absence of bizarre delusions and impairment of functioning only in relation to the delusional belief. The lifetime prevalence rate is reported to be about 0.2% in the United States, [sup][1] whereas in India rates of about 1% have been reported in a psychiatric clinic population. [sup][2]

The disorder is divided into erotomanic, grandiose, jealous, persecutory and somatic subtypes based on the content of the delusion. [sup][1] The most commonly reported subtypes are the persecutory subtype [sup][3] in western literature, whereas delusional parasitosis is most commonly reported in Indian literature. [sup][2] Although delusions of a sexual nature are not unusual in schizophrenia and affective disorder, reports of this presenting as a delusional disorder are uncommon. We report a case of a young male who presented with a single delusion regarding his sexual physiology.

Case Report

Mr. A is a 19-year-old single engineering student, from a middle socioeconomic background. Over the previous year and a half, he firmly believed that every time he assumed an upright posture, he attained penile erection. He believed that others were able to identify his physiological state by the appearance of his groin and therefore were laughing at him and making derogatory comments. He had made attempts to mask these perceived bodily changes by changing the way he dressed. Secondary to these beliefs he had also become socially withdrawn, was frequently absent from class and had had significant academic decline. The patient had even shifted colleges because of the perceived ridicule by others. He also avoided situations, which required him to stand upright, such as crowded buses, elevators, and shops. He had attempted self-harm a year earlier by slashing his wrist due to the distress related to his beliefs. These beliefs persisted though several attempts were made to persuade him otherwise. There were no other unusual beliefs or abnormalities of perception reported by the patient. There were no first rank symptoms of schizophrenia or obsessive compulsive symptoms. There was no history suggestive of seizures, other organic illness or substance abuse. The patient had been on fluvoxamine and risperidone for about 7 months at the time of presentation.

Physical examination, including a detailed neurological and genital examination did not reveal any abnormalities. He was evaluated in the Department of Andrology where physical abnormalities were ruled out. Blood investigations including hormonal assays were within the normal limits. Mental status examination revealed a well groomed young man with normal psychomotor activity and speech. He was distressed by the sexual problems that he perceived he had, but denied suicidal ideation. He had a fixed belief that he attained penile erection whenever in an erect posture. This belief persisted despite evidence to the contrary. There were no other delusions or perceptual abnormalities. There were no obsessive compulsive symptoms or volitional abnormalities. He was alert and oriented with normal attention and concentration. His intelligence was estimated to be average; insight and judgment were poor.

The degree of conviction with which the patient held his belief despite evidence to the contrary suggested it to be a delusion, upon which he was acting. …

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