HOW TO TREAT PERSISTENT DELUSIONAL DISORDER 2025

HOW TO TREAT PERSISTENT DELUSIONAL DISORDER 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 15

PERSISTENT DELUSIONAL DISORDER

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 15

PERSISTENT DELUSIONAL DISORDER

I. DEFINITION  

Persistent delusional disorder is a psychiatric condition within the schizophrenia spectrum, characterized by the development of one or more interrelated delusions that persist, sometimes for a lifetime. Common themes include persecution, hypochondriasis, grandiosity, litigiousness, and jealousy. It may be accompanied by intermittent depression or hallucinations. The prevalence is approximately 0.05-0.1% of the population, with onset typically in mid-adulthood.

II. ETIOLOGY  

The exact cause remains unclear, but genetic factors, personality traits, and life circumstances are implicated in its pathogenesis.

III. DIAGNOSIS  

1. Definitive Diagnosis (ICD-10)

– Presence of a single delusion or a group of related delusions (e.g., persecution, litigiousness, referential, grandiosity, hypochondriasis, jealousy).  

– Duration of at least 3 months.  

– Does not fully meet criteria for schizophrenia.  

– Absence of persistent hallucinations (transient auditory hallucinations may occur but not third-person voices or continuous commentary).  

– Intermittent depressive symptoms may occur, but delusions persist even without mood disturbance.  

– No evidence of organic brain disease or substance-induced psychosis.

2. Clinical Subtypes  

– Delusional Disorder (F22.0)  

– Other Persistent Delusional Disorders (F22.8)  

– Unspecified Persistent Delusional Disorder (F22.9)  

3. Differential Diagnosis  

– Organic Psychosis  

– Paranoid Personality Disorder  

– Transient Paranoid Reaction  

– Paranoid Schizophrenia  

– Substance-Induced Psychotic Disorder  

4. Ancillary Testing  

4.1. Basic Labs  

– Blood: Hematology, biochemistry, microbiology (HIV, HBV, HCV).  

– Urine: General analysis, drug screening, syphilis serology.  

4.2. Imaging/Functional Tests  

– Chest X-ray, abdominal ultrasound.  

– EEG, ECG, cerebral blood flow, transcranial Doppler.  

– CT/MRI brain (select cases).  

4.3. Psychological Assessments  

– PANSS (Positive and Negative Symptom Scale).  

– Personality: EPI, MMPI.  

– Others: BDI, Zung, HDRS, HARS, HAD, MMSE.

IV. TREATMENT  

1. Treatment Principles  

– Patients often deny illness and resist hospitalization, necessitating coerced, long-term treatment, primarily via pharmacotherapy, with early detection and intervention.  

– Start with monotherapy; if response is poor, combine two antipsychotics, avoiding three or more to limit side effects.  

– Monitor drug use closely to detect and manage antipsychotic side effects promptly.  

– Regular follow-up to ensure continuous medication use, minimizing emotional and behavioral disturbances to a level acceptable to family and society.  

– Identify and address relapse triggers promptly.  

– Maintain treatment post-first episode, with community monitoring to prevent recurrence, integrating psychotherapy throughout.

2. Treatment Framework  

– Pharmacotherapy alongside psychotherapy and community rehabilitation.

3. Specific Treatments  

3.1. Pharmacotherapy  

– Antipsychotics: 1-3 agents (prefer monotherapy; switch or combine up to 3 if ineffective):  

  – Typical:  

    – Chlorpromazine (25 mg tabs/vials; 50-250 mg/24h).  

    – Levomepromazine (25 mg tabs; 25-250 mg/24h).  

    – Haloperidol (1.5-5 mg tabs, 5 mg vials; 5-30 mg/24h).  

    – Thioridazine (50 mg tabs; 100-300 mg/day).  

  – Atypical:  

    – Amisulpride (50-400 mg tabs; 200-800 mg/24h).  

    – Clozapine (25-100 mg tabs; 50-800 mg/24h).  

    – Risperidone (1-2 mg tabs; 1-12 mg/24h).  

    – Olanzapine (5-10 mg tabs; 5-60 mg/24h).  

    – Quetiapine (50-300 mg tabs; 600-800 mg/day).  

    – Aripiprazole (5-30 mg tabs; 10-30 mg/day).  

  – Doses may increase based on condition and response.  

– Long-Acting Injectables (LAIs): For non-compliant patients; test short-acting equivalents first:  

  – Haldol Decanoate (50 mg/ml IM; 25-50 mg every 4 weeks).  

  – Flupentixol Decanoate (20 mg/ml IM; 20-40 mg every 2-4 weeks).  

  – Fluphenazine Decanoate (25 mg/ml IM; 12.5-50 mg, max 100 mg/day, every 3-4 weeks).  

  – Aripiprazole (300-400 mg IM every 4 weeks).  

– Adjunctive Treatments:  

  – Anxiolytics: Benzodiazepines (diazepam, lorazepam, bromazepam, alprazolam), non-benzodiazepines (etifoxine, zopiclone).  

  – Beta-Blockers: Propranolol.  

  – Antidepressants: SSRIs, TCAs, SNRIs, NaSSAs.  

  – Mood Stabilizers: Valproate, divalproex, carbamazepine, oxcarbazepine.  

  – Neuroprotection: Piracetam, ginkgo biloba, vinpocetine, choline alfoscerate, nicergoline.  

  – Nutrition: Vitamins (B-group), minerals, IV feeding if needed.  

  – Hepatic support, cognitive enhancers.  

– Monitoring:  

  – Side Effects:  

    – Extrapyramidal symptoms (acute dystonia, akathisia, parkinsonism): Cholinesterase inhibitors (trihexyphenidyl, benztropine), beta-blockers, sedatives.  

    – Neuroleptic malignant syndrome: Early detection, ICU management.  

    – Metabolic disorders: Monitor BMI, blood tests every 3-6 months.  

    – Clozapine: White blood cell count every 3 months.  

    – Tardive dyskinesia: Muscle relaxants, sedatives, vitamin E, anticholinergics.

3.2. Psychotherapy  

– Individual therapy to enhance illness insight.  

– Family, group, or music therapy to support community reintegration.

3.3. Occupational and Rehabilitation Therapy  

– Start activities at the patient’s capability level to rebuild confidence, gradually increasing intensity without causing stress.  

– Tailor vocational rehabilitation to the patient’s socio-economic-cultural context.

3.4. Physical Therapy and Community Management  

– Ongoing monitoring and treatment in the community.

V. PROGNOSIS AND COMPLICATIONS  

– Generally better prognosis than schizophrenia, though a subset may progress to schizophrenia.

VI. PREVENTION  

– Exact cause unknown, so prevention focuses on:  

  – Fostering independence and adaptability to life’s challenges.  

  – Avoiding stress, learning to share and reduce tension.  

  – Monitoring individuals with a family history of schizophrenia, schizotypal disorder, or delusional disorders for early detection and treatment.  

  – Post-discharge follow-up, sustained treatment, avoiding overexertion/stress, and proactively treating physical illnesses to prevent relapse.

REFERENCES

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