Year : 2016 | Volume
: 21 | Issue : 1 | Page : 64--65
A case of persistent delusional disorder: Role of dimensions of delusion reappraised
Arghya Pal1, Arpit Parmar2, Piyali Mandal2, Rajesh Sagar2,
1 Department of Psychiatry, Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Psychiatry and NDDTC, AIIMS, New Delhi, India
Department of Psychiatry, AIIMS, New Delhi
The themes of delusion have been a subject of interest due to the complex underpinning of several socio-cultural aspects. Although it is defined to be out of keeping with the socio-cultural background, the interplay often poses a diagnostic dilemma. Here, we report an unusual case of persistent delusional disorder involving surgically inserted “Gas” in the background of beliefs arising from relatives, lay press, and nontraditional medicine.
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Pal A, Parmar A, Mandal P, Sagar R. A case of persistent delusional disorder: Role of dimensions of delusion reappraised.J Mental Health Hum Behav 2016;21:64-65
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Pal A, Parmar A, Mandal P, Sagar R. A case of persistent delusional disorder: Role of dimensions of delusion reappraised. J Mental Health Hum Behav [serial online] 2016 [cited 2022 Dec 9 ];21:64-65
Available from: https://www.jmhhb.org/text.asp?2016/21/1/64/182095
The development of delusional belief has always been a subject of interest for mental health professionals. As formation of a delusional belief relates to the preexisting beliefs and the cultural and religious background, the variability of their presentation evokes interests across the globe. We present an interesting case of persistent delusional disorder in which the delusion involves “Gas” which was believed to gain access to the body through laparoscopic surgery.
A 45-year-old diabetic woman with past history of a depressive episode, presented with an illness of 7 years, which started after the patient underwent laparoscopic tubal ligation. Informed consent about the procedure included the fact of inflation of abdomen. One week postsurgery, she started experiencing abdominal bloating followed by a burning and crawling sensation over her abdomen followed by the involvement of whole body. Subsequently, she also complained of multiple symptoms such as headache, pain in abdomen, deafness, tingling-numbness, joint pain lasting for up to few hours, and occurring intermittently.
She concluded that the air inserted during surgery was the cause of all these symptoms. She would explain that the air moving inside different body parts and organs was causing varying symptoms. She would believe that the air could even move inside the vessels or bones. However, neither she would detail the process about how the air could invade nor she would describe any visceral sensation. Within some time, she started consulting various physicians who denied such possibility of air causing symptoms and underwent multiple investigations including noncontrast computed tomography head, magnetic resonance imaging brain, thyroid function tests, ultrasonography (USG) abdomen, and other routine investigations. She herself underwent a few investigations including X-ray and USG of the abdomen without being advised by doctor for the same. All of the investigations were found to be normal. She would blame test's inability to detect air inside the body or would consider it as a result of air's property of passing from one place to other suddenly leading to nondetection.
She also reported that during her ventures for consultations, an ayurvedic physician had explained about “Gas” causing such symptoms although the details could not be verified. The patient also told that it is known that “Gas” can cause certain symptoms such as headache and pain abdomen, which she had also encountered in the lay press and amongst her relatives. However, she appeared convinced that the “Gas” was responsible for other symptoms such as deafness and crawling sensation although she accepted that such views were not shared by her relatives.
Her general physical condition revealed no abnormality. She was already on 200 mg amisulpride and 120 mg duloxetine at the time of presentation. She held the belief with extraordinary conviction and demanded for CT head.
The case was classified as “persistent delusional disorder” according to the International Classification of Diseases-10. The differential diagnosis of paranoid schizophrenia and somatoform disorder was also considered. The former was rejected considering the presence of a single delusion that is nonbizarre and absence of other symptoms of schizophrenia while the later was refuted due to the clear psychotic nature of the illness. The unshakeable conviction rules out the possibility of an over-valued idea although the socio-cultural norms lend some support to the belief.
It has been postulated that imprecise interpretation of sensory perceptions render them significant and various cognitive procedures come into explaining the imprecise interpretations leading to the development of delusions. The themes of those delusions have also been found to be heavily influenced by the socio-cultural beliefs of the patient. “Air” or “vata” is considered as one of the five basic elements (panchamahabhutas) of Ayurvedas. The “vata” dosha is composed of “air” and any vitiation of air leads to vitiation of “vata” which is traditionally believed to be associated with illnesses such as flatulence, gout, rheumatism, and even irritable bowel syndrome. However, traditional beliefs about air causing multiple somatic complaints has mostly been due aberration and misreporting of the concepts of Ayurveda. More importantly, due to this popular prevalent belief this delusion has not been classified as a bizarre delusion; hence, this case was not classified as schizophrenia.
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition nomenclature for the corresponding category is “delusional disorder” which contains a number of specific types among which “somatic” type would be one for which our case qualifies where the theme of the belief involves one's own body. The nature of delusions may be very variable. Affected individuals typically complain of infestation, deformity, personal ugliness, exaggerated sizes of body parts, foul body odor, or halitosis. Among the above-mentioned themes, one of the most enthusiastically described has been “delusional parasitosis.” This case closely resembles one of delusional parasitosis and from which an analogy can be drawn.
The previous literature shows various similarities between our patient with delusional parasitosis such as later age of onset (fifth decade), female preponderance, and long drawn course, with an average presentation after about 4 years, association with organic illnesses such as diabetes or other psychiatric comorbidities such as mental retardation, affective illnesses like depression. However, no evidence of any sharing of the same delusional belief in the family members could be found unlike other reported cases.
Major challenge in management was to build up a sustainable therapeutic relationship. Pharmacotherapy along with eclectic psychotherapy, which had been the most common approach, was instituted but the patient dropped out within few weeks of follow-up.
This case highlights the possible role of socio-cultural beliefs in shaping the content of delusion, dilemma in labeling the psychopathology due to the same and also the difficulties in managing such a case.
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Conflicts of interest
There are no conflicts of interest.
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