Reply

Editor:

I thank Dr. Tamburello for highlighting the question of delusional disorder in this case. He calls attention to the findings of Herbel and Stelmach,¹ and I firmly agree that their article is worth a careful read.

As Tamburello notes, a formal diagnosis of delusional disorder is unlikely to be correct. I raised this possibility to combat a common assumption that any poor, odd person labeled schizophrenic is properly diagnosed with schizophrenia. Yes, this patient probably does have schizophrenia. But remember, formal diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) hinges on whether a patient's beliefs are bizarre, and DSM-IV-TR cautions that “bizarreness may be difficult to judge, especially across different cultures” (Ref. 2, p 324). We are at a disadvantage when attempting to discern the limits of local belief systems from across the country.

I also raised the possibility of delusional disorder to combat a common assumption that psychotic symptoms imply the efficacy of antipsychotic treatment. On this point, Herbel and Stelmach¹ make for very interesting reading. Their literature review notes the absence of empirical support for (my) opinion that delusional disorder responds poorly to treatment, but it also notes no clinically significant improvement from medication during the only double-blind medication trial described. They offer much to contemplate.

From a purely clinical perspective, the findings of Herbel and Stelmach are hard to apply to a pregnant woman. Their cases involved 22 incarcerated men, no women, and, in over a third, weapons. It is a retrospective review, implicitly open-labeled and unblinded. Perhaps pertinent to a woman who is expecting in less than two months, 10 of their 17 responders “did not show significant improvement until…at least three months of continuous treatment” (Ref. 1, p 55).

I support Tamburello's assertion that further investigation into delusional disorder is of interest to forensic psychiatry. Readers will have to decide for themselves how effectively and how quickly to expect medication to subdue circumscribed delusions in the absence of hallucinations and disorganization.