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Postby Alex47 » Fri Oct 24, 2003 4:24 pm

Last edited by Alex47 on Fri Oct 24, 2003 5:36 pm, edited 2 times in total.
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Postby Alex47 » Fri Oct 24, 2003 5:09 pm


Delusional Disorder: Paranoia & Related Illnesses
By Alistair Munro
Port Chester, NY, USA, Cambridge University Press, 1999
This is not necessarily an easy book to find, depending on where you live. If your local branch library does not have a copy it may be available through the Inter-Library Loan system. Some Libraries classify Munro's book as a "text book" and that means it's likely available for 1/2 price or less at college bookstores or on-line as a "used text book." (Barnes & Noble wants $80 for a new copy.)
"Delusional Disorder: Paranoia and Related Illnesses" by Alistair Munro is actually available online for free!
Go to
and click on the link "Read the full text of this book" in the right margin. This will take you to an electronic library ("ebrary"), where you can read the book online for free.

The ebrary site does require you to register and supply a credit card number; they will charge a minimum of $5.00, which gives you $5.00 credit in your ebrary account. You will use up this money only of you print or copy text from the book. But if you only read the book online in your web browser, you get access to the whole 274 pages of this book for free . Plus you can of course read any other book in the "ebrary" for free too... If you really insist on printing out pages from this book, you can also get the first 56 pages (up to the end of Chapter 1) of the book for free here:
http://assets.cambridge.org/052158180X/ ... 80Xweb.pdf


I Am Not Sick, I Don't Need Help
By Dr. Xavier Amador with Anna-Lisa Johanson


Free 37-page pamphlet on Delusional Disorder
(available ONLINE in HTML, PDF and MS Word formats)
http://www.mentalhealth.org.nz/conditio ... itionID=11

GRB comments:
Some of this pamphlet is specific to New Zealand, but most of it is generally applicable and pretty useful.
Last edited by Alex47 on Fri Oct 24, 2003 5:31 pm, edited 2 times in total.
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Postby Alex47 » Fri Oct 24, 2003 5:22 pm


GRB comments on Alistair Munro's Book "Delusional Disorder..."

I highly recommend the website http://shop.ebrary.com/ , where you can read the above book online for free. The information below is taken from p. 232-234, which deserve to be read in their entirety. For me, this section of the book has given me some modest hope, as it paints a picture of the treatment process and some possible favorable outcomes. There is also some practical advice for the psychiatrist.

By necessity, I will paraphrase Munro:

Because of the patients reluctance to trust psychiatrists, ideally, assessment and treatment should be by a family physician... but they may not always have the necessary familiarity with this condition and recent advances in its treatment.

The psychiatrist must be patient and will often have to spend more than one session gaining the patients confidence before even trying to persuade them to take meds. The patient will usually vehemently argue against taking medications, "but calm persistence does finally pay off in a reasonable proporatioon of cases".

Medication should be started with a "very low" dose which is then raised "gradually and cautiously", to prevent sudden onset of side effects, "an event guaranteed to induce immediate noncompliance." Munro recommends that the patient see the psychiatrist at least once a week during this early stage. Munro is a champion of the drug pimozide, used in low doses ("starting with 1 or 2 mg daily...and in most cases [will need to be gardually raised to] no higher than 4 to 6 mg per day"). He has used this drug primarily to treat delusional disorder of the somatic subtype, with good results.

Minor improvements may be seen within a few days (e.g., reduced agitation, somewhat reduced preoccupation with the delusion), but it takes about two weeks (on the average; sometimes as much as 6 weeks) of treatment (assuming the patient is compliant and responding to the medication), before significant amelioration of the delusion is observed.

I will quote the following passage in whole, as it addresses a scenario which has caused me worries (the person stops taking their meds), and actually manages to turn it around into something hopeful:

Quite often the patient feels sufficiently improved early on in treatment that he or she decides to stop the medication. Inevitably the delusion and the accompanying agitation and preoccupation start to reappear and it is then that the treating physician has the best opportunity to obtain ongoing co-operation. Even when the patient is still adamant that his beliefs are real, the experience of improvement followed by incipient relapse seems to make a deep impression and if the patient now trusts the physician he or she will often become extremely compliant. In successful cases the complete turnaround from rejection to trust is both remarkable and heartily gratifying.

Munro also observes that in the cases where the patient makes a "good recovery", it is often "relatively rapid and notably complete... even when the delusion has been present for a very long time". Sounds great, doesn't it? [icon_smile.gif]

He also talks about long-term maintenance of treatment (which not surprisingly typically involves continuing meds indefinitely), and mentions that of the (admittedly small) group of patients he has been able to follow up with over the long term, about 1/3 have actually been weaned from meds. These occasionally have relapses, but apparently have sufficient insight at that point that they actually voluntarily resume medication.

I also found the following passage very interesting:
There is a dissociation between acquired insight as to the desirability of continuing treatment and in-depth insight into the illness itself. Many patients never accept fully the psychotic nature of their experience, but so long as they agree to take treatment, it seems unimportant, and probably unkind, to face them with the fact that they were delusional before the medication took effect.

Munro concludes with a few thoughts on non-drug treatment of delusional disorder, stating essentially that psychological ("talk") treatment is essentially not helpful until possibly, in some cases, after the delusions have been resolved using medication. A final warning is given: "There is a general consensus that psychotherapy of an exploratory, uncovering type is not appropriate in delusional disorder. "

I'll say it again, this section of the book deserves to be read by anybody dealing with a loved one suffering from delusional disorder. It helped me, and I hope it will help you, too.


Roger C comments on "I am Not Sick, I Do Not Need Help"
by Dr. Xavier Amador

Dr. Amador writes from his own personal experience, both as brother of a schizophrenia patient, and as a clinical psychologist. A large problem with treating people with schizophrenia and other serious mental disorders is that many times they won't stay in treatment. The usual explanation for this is that they lack insight into their illness. That is, they are not aware they have a mental illness, or in many cases even that they are exhibiting symptoms. Attempts to reason with such patients about their illness are futile.

Dr. Amador postulates that this inability to perceive their illness is caused by the same kind of brain disfunction that is responsible for the illness itself. Experiments have proven this to be true.

So, since most of these patients are incapable of understanding that they are ill, how can doctors and family members convince them to stay in treatment programs? Dr. Amador gives a four-step method for providing patients with insight into the benefit of treatment, thus giving them motivation to stay in treatment.

For example, one schizophrenic patient wanted very much to be able to hold down a job, but had only a few jobs over the years, most of which lasted only a short time. Rather than simply telling this patient that a job was out of the question, the doctor empathized with the patient's desire, and then helped the patient look back to the times when he was able to get a job, and the events that led up to losing the job, and related these events to the patient's treatment program (or lack thereof). This helped the patient to gain insight into the benefit of treatment.

The book finishes with a couple of chapters about knowing when to commit a loved one, and how to go about it.

All the advice sounds reasonable, and Dr. Amador's track record of success with it speaks for itself. It should be universally applicable, since the method is based on identifying issues that are important to the patient himself; anything he is dissatisfied with and wants to change will provide a means to motivate the patient to stay in treatment.

Sean et al comments:
I saw Dr. Amador speak at the 2003 NAMI National Convention, if you ever have a chance I suggest seeing him. He spent a great deal of time at the end of the session answering questions from people with a mentalli ill loved one. His sympathy and understanding towards the person with the illness was incredible.

As he spoke he explained Schizophrenia and the inability to recognize the illness in simple terms:

He asked someone from the audience to give a brief bio about themself. The woman who volunteered (I'll call her Susan) was a Psychologist with a loving husband and two children. She gave a brief description of her job, her family, and her life in general.

Then Dr. Amador then went on to talk directly to Susan, saying basically the following:
Susan, I have some bad news for you. You aren't really a Psychologist, in fact, the practice where you think you work called me and asked that I tell you to stop going there every day. There's more though, you aren't really married. Tom also has asked me to help you get help and to stop going to his house. Those children aren't yours, and the house isn't yours. You're sick Susan, and I'm going to take you to the hospital and get you some help.

This demonstration, more than anything else, made me aware of how frightening it must be to have Schizophrenia and have your reality stolen from you. No wonder someone with such an illness has conspiratorial thoughts. If someone came and told me my entire life was imagined I'd think they were lying. When they went on to say I needed help and then started trying to make me take medication I wouldn't trust them.

I know I haven't done the demonstration justice, but try and imagine yourself hearing those words.

GRB comments on Amador:

One approach is to "empower" the patient to make their own decision about whether to stay on meds, by promising that no one will object if they go off the meds, under the condition that they keep a journal during the periods that they are not taking medications...

Also, a thought on the idea mentioned above, about finding a motivator for the patient to stay in treatment (and which could presumably be used to motivate the person to seek treatment...). Roger had mentioned difficulties in applying this concept in his case. I would agree that this approach would work much better with schizophrenia, for example, than delusional disorder, because in the latter case the person is only affected by the disorder in a limited way, due to the "encapsulated" nature of the delusions. The person suffering from DD is likely to be highly functional within society in general and professionally, whereas the disorder primarily affects interpersonal relationships with those close to him or her. So, I think it is a general truth that many people with DD actually do not perceive a worsened quality of life as a result of their (untreated) condition. They might notice a positive change after starting medication, which might be helpful in assuring future compliance, but the problem of how to get the person into treatment in the first place remains vexing....

Dr. Amador introduces his four steps.
Effective listening is really a skill that needs to be cultivated. You will need to learn to really listen to what your loved one feels, wants, and believes in. Listening without learning is pointless. First, you need to walk in the other person's shoes to gain a clear idea of their experience of the illness and treatment. For the uninitiated, this is not as easy as it may sound on the face of it. Too many times we make assumptions without checking them out with the person about whom we are making assumptions. Knowledge is power. When you know how someone experiences the idea of having a mental illness and taking psychiatric drugs, you will have obtained the leverage you need to begin to build a treatment agreement.
But you will also need to know what their hopes and expectations are for the future, whether or not you believe they're realistic. And finally, you want to identify the cognitive deficits (e.g. problems with memory, attention, focusing thoughts) that are creating barriers between you and the person you're concerned about and between that person and effective treatment.

The second step involves learning when and how to express empathy. If there were a moral to each step and chapter, this one would go something like this: If you want someone to seriously consider your point of view, be certain he feels you have seriously considered his. Quid pro quo. That means that you must empathize with all of the reasons he has for not wanting to accept treatment, even the "crazy" ones. But don't worry; empathizing with how a particular delusion makes one feel is not the same as agreeing that the belief is true. This may seem like a minor point, but, as you will learn, the right kind of empathy will make a tremendous difference on how receptive your loved one is to your concerns and opinions. In the chapter devoted to this step, I give you step-by-step instructions on how to do this using techniques such as reflective listening.

Find common ground and stake it out. Knowing that what you want for the other person is something she does not want for herself can make it seem as if there is no common ground. She doesn't think she needs medication or therapy, and you think she does. Like any conflict of beliefs between two people, to resolve the disagreement to your satisfaction requires that you discover what motivation the other person has to change. Common ground always exists even between the most extreme opposing positions.
The emphasis is on acknowledging that your loved one has personal choice and responsibility for the decisions he makes about his life. During this step, you become a neutral observer, pointing out the various positive and negative consequences of decisions your loved on has made. That means refraining from saying things like, "See if you had taken your medication, you wouldn't have ended up in the hospital." Your focus is on making observations together - identifying facts upon which you can ultimately agree. Rather than making an observation or statement about what happened you ask a lot of questions such as "So what happened after you decided to stop taking your medication?" "Did the voices quiet down after you stopped?" "How long after stopping the medication was it before you went to the hospital?" If you are truly collaborating, asking questions rather than giving advice or direction comes a lot easier than it may sound.

Forming a partnership for recovery is the last and, in my experience, the most satisfying step in this process. The aim of this step is to help you to collaborate on accomplishing the goals you agreed upon. Unlike the previous steps, this one involves both you and your loved one making an explicit decision to work together and to become teammates against a common opponent. You may call the enemy different names, but the names are irrelevant to arriving at a plan of action. The final step culminates in arriving at a treatment agreement.
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