delusional disorder is an uncommon psychiatric condition characterized by nonbizarre delusions of a single theme , in the absence of other mood or psychotic symptoms .
it is differentiated from schizophrenia by the absence of bizarre delusions and impairment of functioning only in relation to the delusional belief .
the lifetime prevalence rate is reported to be about 0.2% in the united states , whereas in india rates of about 1% have been reported in a psychiatric clinic population .
the disorder is divided into erotomanic , grandiose , jealous , persecutory and somatic subtypes based on the content of the delusion .
the most commonly reported subtypes are the persecutory subtype in western literature , whereas delusional parasitosis is most commonly reported in indian literature .
although delusions of a sexual nature are not unusual in schizophrenia and affective disorder , reports of this presenting as a delusional disorder are uncommon .
we report a case of a young male who presented with a single delusion regarding his sexual physiology .
mr . a is a 19-year - old single engineering student , from a middle socioeconomic background . over the previous year and a half
, he firmly believed that every time he assumed an upright posture , he attained penile erection .
he believed that others were able to identify his physiological state by the appearance of his groin and therefore were laughing at him and making derogatory comments .
he had made attempts to mask these perceived bodily changes by changing the way he dressed .
secondary to these beliefs he had also become socially withdrawn , was frequently absent from class and had had significant academic decline .
he also avoided situations , which required him to stand upright , such as crowded buses , elevators , and shops .
he had attempted self - harm a year earlier by slashing his wrist due to the distress related to his beliefs .
the patient had been on fluvoxamine and risperidone for about 7 months at the time of presentation . physical examination , including a detailed neurological and genital examination did not reveal any abnormalities .
mental status examination revealed a well groomed young man with normal psychomotor activity and speech .
he was distressed by the sexual problems that he perceived he had , but denied suicidal ideation .
he had a fixed belief that he attained penile erection whenever in an erect posture .
the degree of conviction with which the patient held his belief despite evidence to the contrary suggested it to be a delusion , upon which he was acting .
a diagnosis of delusional disorder was considered in view of the single delusional theme in the absence of first rank symptoms or affective features .
the management focused on establishing rapport with the patient along with eliciting and understanding the explanatory model for his beliefs .
socratic questioning was used to identify negative thoughts and dysfunctional assumptions , which were reflected to the patient .
a hierarchy of situations based on distress and avoidance were charted down and he was asked to expose himself to the least anxiety provoking situation . the patient was also encouraged to do some behavioral experiments in these situations to confirm or disprove his assumptions .
the antidepressant medication was tapered and stopped , while the dose of risperidone was gradually increased to 4 mg / day .
delusions with sexual content , although not as common as other delusions , have been reported in psychotic disorders such as schizophrenia , depression , and organic conditions .
the content of these delusions include that of self - mutilation , delusional pseudo - transsexualism , bizarre sexual mechanisms , threat to genitalia , variations of erotomania , pregnancy , procreation , and homosexuality . in a qualitative review of bizarre delusions among a sample of patients with schizophrenia in india , de et al . found that delusions with sexual content included false beliefs about sexual relationship between humans , animals and/or supernatural beings ; forceful change in sexual gender or identity and threats to genitalia .
while sexual delusions are encountered as one among other types of delusions in schizophrenia , it is not commonly reported in the form of a delusional disorder . in this case , organic illness was ruled out and the delusional nature of the belief was confirmed . in the absence of other psychotic symptoms ,
the patient reported distress secondary to the belief and its consequences , and there was no evidence of a primary mood disorder or other psychotic symptoms .
delusional disorder is managed with pharmacological and nonpharmacological strategies . in this case treatment with antipsychotic agents was combined with supportive measures along with cognitive and behavioural strategies , to allay the patient 's anxiety , acknowledge his distress , explore the consequences of his beliefs and modify them .
isolated delusions with a sexual theme are rare . as with any other delusional disorder , the treatment is challenging and involves both psychopharmacology and psychotherapy . given the chronic nature of this condition , treatment strategies should be tailored to the individual needs of the patients with a focus on maintaining social function and improving quality of life .
 delusions with a sexual theme are rare , but when present are usually seen in patients with schizophrenia or other chronic psychotic disorders . 
 we report a case of delusional disorder , with a single belief of a sexual theme . 
 this report focuses on the management issues , wherein a combination of pharmacological and nonpharmacological interventions proved helpful . 