Letters

Editor:

In my reading of the otherwise well-written commentary about the article on a case of psychotic denial of pregnancy in The Journal in 2011, I took exception to Dr. Powsner's discussion of delusional disorder.¹ Setting aside that delusional disorder is easily ruled out in this case, given the bizarre nature of the symptoms presented, I was more concerned by the suggestion that delusional disorder was “much less responsive to pharmacologic management [than schizophrenia] and casts doubt on a recommendation for inpatient psychiatric stabilization” (Ref. 1, p 42). Dr. Powsner provided no reference to support either claim.

Delusional disorder is difficult to study, because affected persons often do not experience distress related to their fixed, false beliefs; they may not experience impairment if their beliefs are not acted on in a way that draws attention; and they usually lack the insight to seek treatment.² Munro³ suggested that an 80 percent success rate from pimozide can be estimated when the existing case reports are considered in aggregate. Of great interest to this subject was the review by Herbel and Stelmach⁴ of 22 forensically hospitalized defendants with a diagnosis of delusional disorder, who were adjudicated incompetent to stand trial, of which 17 (77%) were restored to competency with forced medication. These results, while certainly requiring further validation, hardly contrast with the findings of the PORT study of over 100 trials of antipsychotic medications other than clozapine which cited a 50 to 80 percent improvement of patients with schizophrenia.⁵

Persons with delusional disorder, especially erotomanic, persecutory, jealous, and grandiose types, may engage in criminal behavior (e.g., stalking, assault, or murder) in response to their beliefs. Based on clinical experience (mine and that of colleagues) in correctional facilities and a maximum-security forensic hospital, I think that delusional disorder does concentrate in these settings. I encourage further investigation of this disorder, which should be of special interest to forensic psychiatrists.