Is My Brother's Condition Delusional Disorder or OCD?

Could you please tell me if this is a case of delusional disorder?

My younger brother started having some bizarre thoughts in high school, and his academic performance plummeted.
He was later diagnosed with obsessive-compulsive disorder (OCD) and has been on medication for four years without improvement.
However, I have always been puzzled as to why he does not have schizophrenia or delusional disorder.
Here are some of my brother's symptoms:
Symptoms:
1.
Unrealistic thoughts that he thinks about all day.
Here are some examples of thoughts he has had since the onset of his condition:
(1) Solipsism: He believed that everyone else was fake and that he was the only real human being (this thought occurred during high school but has since disappeared).
(2) He thought that when a female classmate changed her Instagram profile picture to black, it was because he had hurt her by not answering her call four years ago (he believed she had a crush on him, but I think there is no connection).
(3) He believes that a few months ago, after a fleeting thought, he became another high school classmate he is very jealous of (referred to as Classmate B).
He is convinced of this thought and claims that anything he does now is not done by him, as he is now Classmate B and not his original self.
This causes him significant distress and anxiety, and he even had fleeting suicidal thoughts (he believes that as long as he thinks of a method, anything is possible.
At that time, he had already thought of a way to become Classmate B, so he believes he is now Classmate B).
(4) He has thought about approaching attractive strangers on the street to ask if they want to hook up (he thinks it's acceptable to confess feelings, so why not ask about hooking up?).
2.
The commonality among these thoughts: He thinks about them all day after getting out of bed, which leads to his depression, anxiety, and a bit of mental exhaustion.
3.
Anxiety and depression.
4.
Insomnia (he has gone two days without sleep).
5.
Self-centeredness.
6.
Poor social skills and communication (he has no friends and dislikes working).
7.
Frequently lost in thought with poor attention.
I asked my brother's doctor, who insists that he has OCD, and my brother chooses to believe the doctor and does not want to seek other opinions.
However, after four years of medication, there has been no improvement (he even had suicidal thoughts recently), and I believe his thoughts are increasingly detached from reality and very difficult to understand, resembling delusional disorder.
I would like to ask the doctor:
1.
Is it possible that my brother does not have schizophrenia or delusional disorder? If not, why has there been no improvement after four years of medication?
2.
Is it true that the doctor said that psychological therapy would not be effective for my brother (because he does not listen)? Shouldn't therapy be combined with medication?

A-Hong, 20~29 year old female. Ask Date: 2023/10/31

Dr. Li Guanying reply Psychiatry

From your letter, it is clear that you are experiencing discomfort and distress due to concerns about your family member's delusions and hallucinations, as well as the associated mental health symptoms.

1.
Schizophrenia, like chronic diseases such as diabetes and hypertension, can coexist peacefully if managed properly with medication to stabilize the condition.
Notably, there are now long-acting injectable options available, which alleviate the worry of being discovered while taking medication and reduce the burden of frequent hospital visits, leading to a more secure lifestyle.
2.
If schizophrenia is left untreated, the brain may deteriorate more rapidly, potentially leading to a state of self-neglect.
Therefore, early treatment is crucial.
The treatment of schizophrenia is multifaceted, with pharmacotherapy being a vital component.
Medications are absorbed into the bloodstream and reach brain cells, helping to improve neurotransmitter function and restore brain activity, thereby alleviating symptoms such as auditory hallucinations, visual hallucinations, and delusions.
Rehabilitation therapy focuses on cognitive rehabilitation, using various activities to train attention, memory, and social skills, enabling individuals to regain normal functioning and reintegrate into society.
3.
As with all illnesses, early intervention is beneficial.
Generally, the first five years following the initial onset of symptoms represent a critical treatment window, during which the effectiveness of treatment is higher.
However, if this golden period is missed, it is still important to continue treatment, as the decision to pursue active treatment at any time can positively impact disease management.
When it comes to choosing between oral medications and long-acting injectables, physicians will communicate with patients and their families to determine the most suitable treatment approach.
Oral medications offer convenience for patients taking them at home, but require multiple doses daily, which can significantly impact daily life.
Long-acting injectables, administered regularly by healthcare professionals, can be given monthly or every three months, providing more stable medication management and better prevention of relapse.
Additionally, home treatment options are available, where healthcare professionals can provide in-home injection services, further reducing the likelihood of missed doses.
4.
In addition to the care required for patients with schizophrenia, caregivers also need support.
Therefore, Chia-Nan Psychiatric Hospital regularly holds family education seminars, where healthcare professionals provide caregivers with experiences on various topics.
This allows caregivers to express their emotions and receive empathy during the challenging caregiving process, while also addressing their questions and providing emotional support.
Our outpatient services are available Monday through Friday, both in the morning and afternoon.
We recommend considering having a community health worker bring your family member to the hospital for a personal evaluation by a physician, so that together you can discuss the best decisions for your family member.
Wishing you mental and physical well-being.

Reply Date: 2023/10/31

More Info

Your brother's situation is quite complex, and it’s understandable that you have concerns about his mental health. Based on the symptoms you’ve described, it seems that your brother is experiencing significant distress and impairment in his daily life. Let's break down the concerns you raised regarding his diagnosis and treatment.

1. Diagnosis: Delusional Disorder vs. OCD
Your brother has been diagnosed with Obsessive-Compulsive Disorder (OCD), which is characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions). However, the symptoms you describe, such as the belief that he is the only real person and others are not, as well as his fixation on the actions of a classmate, suggest that he may also be experiencing delusional thoughts.
Delusional disorder is characterized by the presence of one or more delusions that persist for at least one month. The thoughts your brother has about being someone else or believing that he has caused harm to others through his actions could fall under this category. The distinction between OCD and delusional disorder can sometimes be blurred, especially if the obsessions take on a delusional quality.

2. Treatment Resistance
The fact that your brother has been on medication for four years without significant improvement raises questions about the appropriateness of his current treatment plan. It’s important to note that not all individuals respond to the first line of treatment for OCD or any mental health condition. Sometimes, it may take several adjustments in medication or a combination of different medications to find what works best for the individual.
Additionally, if your brother's symptoms are indeed more aligned with a delusional disorder, then the current treatment for OCD may not be effective. It’s crucial to have a thorough evaluation by a mental health professional who can assess whether his symptoms have evolved or changed over time.

3. The Role of Therapy
Regarding the effectiveness of therapy, it’s true that some individuals may not respond well to psychotherapy, especially if they are not open to the process. Cognitive Behavioral Therapy (CBT) is often recommended for OCD, and it can also be beneficial for delusional thoughts. However, if your brother is resistant to therapy or does not believe in its efficacy, it may not yield the desired results.

It might be beneficial to explore different therapeutic approaches or even consider family therapy, where family members can learn how to support him better and address the dynamics that may be affecting his mental health.

4. Next Steps
Given your brother's ongoing distress and the presence of suicidal thoughts, it’s essential to take these symptoms seriously. Here are some steps you might consider:
- Seek a Second Opinion: If you feel that your brother's current treatment is not effective, it may be worthwhile to seek a second opinion from another psychiatrist or mental health professional who specializes in psychotic disorders or severe OCD.

- Emergency Support: If your brother expresses suicidal thoughts, it’s crucial to seek immediate help. This could involve contacting a mental health crisis line or taking him to an emergency room.

- Family Involvement: Encourage family involvement in his treatment. Sometimes, having family members participate in therapy can help the individual feel more supported and understood.

- Education: Educate yourself and your family about mental health conditions. Understanding what your brother is experiencing can help you provide better support and reduce feelings of frustration or helplessness.

In conclusion, your brother's symptoms warrant a comprehensive evaluation to determine the most appropriate diagnosis and treatment plan. Mental health conditions can be complex and multifaceted, and it’s essential to approach them with patience and understanding. Your concern for your brother is evident, and seeking the right help can make a significant difference in his recovery journey.

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