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Delusional disorder — Clinical Guidelines

Overview

Delusional disorder is characterized by non-bizarre delusions persisting for at least one month, without prominent hallucinations, disorganized speech, or other psychotic symptoms 1 3. It encompasses various subtypes, including somatic, persecutory, erotomanic, jealous, and grandiose delusions 10 12.

Diagnosis

Key Diagnostic Criteria: Presence of non-bizarre delusions for at least one month, absence of prominent hallucinations, disorganized speech, or other psychotic symptoms 1 3.

Recommended Tests: No specific laboratory tests; diagnosis primarily clinical, often requiring psychiatric evaluation 1 3.

Grading: DSM-5 criteria guide diagnosis; no standardized grading system specifically for delusional disorder 1 3.

Management

First-Line Treatments: Antipsychotics, particularly atypical antipsychotics like risperidone, olanzapine, and quetiapine 8 11.

Adjunctive Treatments: Psychotherapy, including cognitive-behavioral therapy (CBT) adapted for delusional disorders 2 4.

Specific Drug Classes/Doses: Milnacipran (25-50 mg/d) shown effective in somatic type without significant adverse effects 8.

Special Considerations: Tailor treatment to subtype and comorbid conditions; monitor for drug interactions, especially in elderly or polypharmacy patients 8 11.

Special Populations

Elderly: Chronic course and poor treatment response; careful consideration of polypharmacy and drug interactions 8 6.

Comorbidities: Increased risk of depressive symptoms; use psychometric instruments to assess comorbidity 3.

Key Recommendations

Integrate psychiatric consultation in dermatology clinics for managing delusional infestation to enhance patient care and outcomes (Evidence: Moderate 2 4).

Utilize atypical antipsychotics as first-line pharmacological treatment for delusional disorder, considering individual patient factors and potential drug interactions (Evidence: Moderate 8 11).

Screen for depressive symptoms in patients with delusional disorder using validated psychometric instruments to guide comprehensive care (Evidence: Moderate 3).

Consider combined psychiatric and dermatological approaches for patients with delusional infestation to improve management strategies (Evidence: Expert opinion 5).

Evaluate the feasibility of randomized controlled trials in dermatology settings for delusional infestation to advance evidence-based treatment protocols (Evidence: Moderate 7).

References

1 Saberi SM, Manouchehri RH, Ardestani HB, Mahdavi SA, Bazmi E. Delusional disorder and criminal responsibility: A systematic review to help improve Iranian judicial perspectives. The Medico-legal journal 2025. link 2 Brownstone N, Koo J. How to successfully handle the initial encounter with a delusional infestation patient. Clinics in dermatology 2023. link 3 González-Rodríguez A, Monreal JA, Porras-Segovia A, Cervilla JA, Gutiérrez-Rojas L. Psychometric instruments for the assessment of depressive symptoms in patients with delusional disorder: A systematic review. Psychiatry research 2022. link 4 Starzyk T, Koo J. How to improve the interface between dermatology and psychiatry: a review and expert suggestion regarding the management of delusional patients. Dermatology online journal 2021. link 5 Todd S, Squire SB, Bartlett R, Lepping P. Delusional infestation managed in a combined tropical medicine and psychiatry clinic. Transactions of the Royal Society of Tropical Medicine and Hygiene 2019. link 6 Bassirpour G, Mahr G, Lee B, Torres M. The use of hospice care in end-stage psychiatric patients. Journal of palliative medicine 2011. link 7 Lepping P, Baker C, Freudenmann RW. Delusional infestation in dermatology in the UK: prevalence, treatment strategies, and feasibility of a randomized controlled trial. Clinical and experimental dermatology 2010. link 8 Otani K, Miura Y, Suzuki A, Kinoshita O. Effectiveness and safety of milnacipran treatment for a patient with delusional disorder, somatic type taking multiple medications for concomitant physical diseases. Clinical neuropharmacology 2010. link 9 Dressing H, Henn FA, Gass P. Stalking behavior - an overview of the problem and a case report of male-to-male stalking during delusional disorder. Psychopathology 2002. link 10 Sands GE. Three monosymptomatic hypochondriacal syndromes in dermatology. Dermatology nursing 1996. link 11 Steinberg PI, Morrissy J. Psychiatric liaison to family medicine. Patient with delusional disorder. Canadian family physician Medecin de famille canadien 1995. link 12 Bhaumik S, Collacott RA. Erotomanic delusions in a male with a mental handicap. Journal of intellectual disability research : JIDR 1993. link

Delusional disorder