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One of the hardest psychiatric disorders both to diagnose and treat is delusional disorder. The reason why diagnosis can be tricky is that the person is often functioning quite normally in the world. The delusions in this disorder are “non-bizarre,” meaning they can actually be plausible even if they’re not true. Those suffering from this disorder often won’t believe they have a problem, so it’s difficult to get them into therapy. And since the most common form of the illness results in paranoia, they will usually be convinced someone is “out to get them,” meaning that prescribing any sort of drugs won’t be possible. Nor will hospitalization.

While paranoia is the most common manifestation, there are other types of delusional disorders as well, such as believing one is the secret love interest of a famous person, being convinced one has extraordinary abilities or is very important, worrying about physical problems or disfigurements that don’t exist, or believing that one’s romantic partner is unfaithful. Mental health treatment is often refused because of these convictions, which are impervious to any sort of disproof. The patient is convinced they are correct; meaning there is nothing to treat.

Medically, only a few current treatments have an effect on this disorder; therefore, the primary type of treatment will be psychosocial. And the best treatments will be indirect, with the therapist perhaps offering depression and anxiety panic treatments instead, since those may also be symptoms of the disorder. The worst thing a therapist can do for a paranoid, suspicious patient is confront them directly about their delusions. They need time to build up some trust, and only then would the doctor begin gently challenging a few of the patient’s beliefs. Drugs would only be used if the patient’s delusional disorder was becoming dangerous or the condition was making them too agitated.

If a therapist is willing to forgo the more usual drugs or typical psychotherapy used for most other types of mental illness, and trying these avenues of slightly alternative treatments instead, then whatever doubts the patient might express about their delusions can be explored. If the two of them, working in partnership, can find alternate, real-world explanations for what the patient observes, this may begin to loosen the hold of the delusional disorder. What the therapist needs most of all is to be tactful and tread very carefully, building a relationship of trust with the patient.

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