J is 28 years old and has been married to her husband, M, for the past three years; the couple have been together for seven years and have a two year old son. Recently they have decided to have some renovation work done to their house and as such their home has been turned into something of a building site. M has been complaining of increased pressure at work and has been returning home later in the evening than is normal. J has been struggling at work as well and has been feeling particularly stressed with the on-going workmen’s presence. She begins to note items out of place around the house, for example seeing a hard hat left outside an upstairs bathroom after the workmen had left. She realises that M has been lying to her about his workload and that in reality he has actually begun an affair with the foreman of the contracted builders. She confronts him with this realisation and when he denies her allegations she strikes him with her hand and then takes their son to stay with her mother. Her mother is concerned regarding J’s behaviour and arranges for her to meet with her GP in relation to the stress she is under.
J is eventually assessed in A&E and admitted, informally, to a local psychiatric hospital. There her treating team diagnose her with Othello Syndrome and recommend a course of antipsychotic medication.
Othello Syndrome is a form of delusional disorder; that is an experience characterised by the presence of delusional thought that is not deemed to be schizophrenic or affective in nature. Typically, delusions will develop over longer periods of time than in J’s case; however acute and distressing delusions may develop that can lead to dangerous behavioural response including suicide or violence, although this is very rare (but still a classic mainstay of psychiatric membership exams for some reason).
Typically, individual’s suffering from distressing experiences in relation to possible delusional disorder will be offered psychotropic medication; commonly antipsychotics or anxiolytics. Psychological therapies may also be offered. But what is the evidence base for using these treatments in delusional disorder? To answer this question Skelton, Khokar and Thacker have conducted a Cochrane systematic review seeking:
To evaluate the effectiveness of medication (antipsychotic medication, antidepressants, mood stabilisers) and psychotherapy, in comparison with placebo in delusional disorder.
- The authors conducted a systematic search of the Cochrane Schizophrenia Group’s Trials Register, looking to identify randomised controlled trials in which some form of active treatment was compared with a ‘placebo’ control. Assessments of psychopharmacological and psychological interventions were sought.
- Identified studies from the search strategy were assessed for inclusion in the review, the methodological quality of included studies was appraised according to standard Cochrane review criteria.
- The authors planned to extract data from identified papers to allow comparison. Unfortunately this did not prove to be necessary.
The initial search strategy used by the authors identified 141 possible studies. Of these, only one met the inclusion criteria for their final review. Typical reasons for exclusion included:
- Trials not being completed
- No subgroup analysis of delusional disorder
The one included trial included 24 participants, of whom 17 completed the trial. The methodology sought to compare Cognitive Behavioural Therapy with supportive psychotherapy (referred to as Attention placebo control). Participants were randomised to interventions; all those completing the trial were on psychotropic mediation in addition to receiving psychotherapy, which was framed as an augmentation strategy in comparison with treatment as usual with psychotropics alone.
The review authors were able to extract data from the identified study relating only to social function (self-worth rating) and participants leaving the trial early. The remaining data could not be analysed. The trial did favour CBT in terms of social functioning, although the actual measure used is questionable for its generalisability. Fewer people dropped out from the CBT arm of the trial early in comparison with the placebo control, although the small trial size limits the impact of this finding.
The reviewers concluded:
Despite international recognition of this disorder in psychiatric classification systems such as ICD-10 and DSM-5, there is a paucity of high quality randomised trials on delusional disorder. There is currently insufficient evidence to make evidence-based recommendations for treatments of any type for people with delusional disorder.
There can be little discussion building on the conclusions that the authors draw from this review. More research is clearly needed and the authors call for randomised controlled trials and subgroup analysis of participants meeting the criteria for delusional disorder within other larger clinical trials.
I would add my own comment to this by saying that in my experience many people live quite settled lives in the presence of belief that others may term delusional. ‘Noisy’ and distressing cases such as that of J may not be the norm. Further phenomenological work should therefore be undertaken, to explore the experience of delusional disorder, before any large scale trial is conducted, to ensure that we target measures of significance to service users.
The case of J described above is a bastardisation of a clinical case from my own practice, together with classic case material commonly quoted in relation to Othello Syndrome. In combining these materials I have sought to try and maintain pertinent features while protecting anonymity.
Skelton M, Khokhar WA, Thacker SP. Treatments for delusional disorder. Cochrane Database of Systematic Reviews 2015, Issue 5. Art. No.: CD009785. DOI: 10.1002/14651858.CD009785.pub2.