Medical Minute: Delusional Disorders and need for acute psychiatric evaluation

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August 19, 2014 by dailybolusoflr

By Amanda Crichlow, MD
Case: 48 yo F presents to ED with chief complaint of “bugs burrowing in me and making me bleed”. This has been occurring for at least 2 years. Evidence of excoriations on skin and sites of dried blood in areas of excessive scratching found on physical exam.
Question of the day: does this patient require emergent psychiatric evaluation in the ED?
What is a Delusional Disorder?

Definition of Delusional Disorder (DSM-5)
A.     The presence of 1 or more delusions with a duration of 1 month or longer
B.     * Criterion A for schizophrenia has never been met.
Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).
C.     Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.
D.     If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.
E.      The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.
* Criterion A for schizophrenia
Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1.      Delusions.
2.      Hallucinations.
3.      Disorganized speech (e.g., frequent derailment or incoherence).
4.      Grossly disorganized or catatonic behavior.
5.      Negative symptoms (i.e., diminished emotional expression or avolition).
Subtypes:
1.      Erotomanic type – the central theme of the delusion is that another person is in love with the individual.
2.      Grandiose type – the central theme of the delusion is the conviction of having some great talent or insight or of having made some important discovery
3.      Persecutory type – the central theme of the delusion involves the individual’s belief of being conspired against, cheated, spied on, followed, poisoned, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.
4.      Somatic type, the central theme of the delusion involves bodily functions or sensations (like ou Somatic delusions can occur in several forms. Most common is the belief that the individual emits a foul odor; that there is an infestation of insects on or in the skin; that there is an internal parasite; that certain parts of the body are misshapen or ugly; or that parts of the body are not functioning.
Psychosis in and of itself may not be cause for emergency intervention. However, when the psychosis leads a patient to dangerous behavior or thoughts (eg, command auditory hallucinations telling a patient to harm others or self; confusion leading a patient to wander into busy traffic with no concern for his own safety), such symptoms are of major concern.
Conclusion: Having a delusional disorder is not in itself a reason for emergent psychiatric evaluation unless the patient is suicidal or lacks regard for his/her own life.
References:
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition
Zeller S. Treatment of Psychiatric Patients in Emergency Settings. Primary Psychiatry. 2010;17(6):35-41.

Richards CF, Gurr DE. Psychoses. Emergency Medicine Clinics of North America. 2000:18(2):253-262.

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