Diagnosis and Management
Primary Diagnosis
This patient has alcohol-induced psychotic disorder (delusions of infidelity) with alcohol dependence syndrome, complicated by recent delirium (now resolved) and deliberate self-harm. 1, 2
The delusions of infidelity (Othello syndrome) in the context of chronic alcohol use represent alcohol-induced psychotic disorder rather than primary delusional disorder, as the psychotic symptoms are directly related to alcohol use and brain damage from chronic alcoholism. 2
Immediate Psychiatric Management
Suicide Risk Assessment and Safety Planning
- Conduct structured suicide risk assessment using multiple methods (clinical interview plus self-report measures), as no single tool reliably stratifies risk. 1
- Assess for ongoing suicidal ideation, intent, plan, access to means, protective factors, and history of previous attempts. 1
- Implement one-to-one observation or close monitoring given the recent deliberate self-harm attempt. 1
- Remove access to potentially lethal means (medications, sharp objects, ligatures). 1
Management of Alcohol Withdrawal (if ongoing)
- Continue symptom-triggered benzodiazepine therapy using CIWA-Ar scores, as withdrawal symptoms can persist beyond 72 hours and require treatment until complete resolution. 3
- Given the history of acute kidney injury and dyselectrolemia, use lorazepam 1-4 mg orally or IV every 4-8 hours (preferred in renal/hepatic dysfunction over long-acting benzodiazepines). 3, 4
- Administer thiamine 100-300 mg/day orally (or parenterally if high-risk) before any glucose-containing solutions to prevent Wernicke's encephalopathy. 3, 5, 4
- Monitor vital signs frequently for autonomic instability (tachycardia, hypertension, hyperthermia). 3
- Limit benzodiazepine treatment to 7-10 days to prevent iatrogenic dependence. 5, 4
Pharmacological Treatment of Delusions
Antipsychotic Therapy
- Initiate haloperidol 0.5-5 mg orally every 8-12 hours or 2-5 mg IM as needed for persistent delusions and agitation. 4
- Antipsychotics should be used as adjuncts to address psychotic symptoms but never as monotherapy for alcohol withdrawal. 1, 4
- Monitor for extrapyramidal side effects and tardive dyskinesia risk with prolonged use. 6
- Alternative: Consider pimozide if delusions persist despite adequate trial of haloperidol, as delusional disorders may respond preferentially to pimozide. 7
Antidepressant Consideration
- Screen for comorbid major depression using structured assessment, as alcohol-induced delusions may occur with depressive features. 1, 6
- If depressive symptoms with psychotic features are present, combine antipsychotic with SSRI (sertraline 25 mg initially, titrate to 50-200 mg daily). 1, 6
- Delusional depression requires combination antidepressant-antipsychotic therapy, as antidepressants alone have only 20-25% response rate versus 68-95% with combination. 6
Post-Detoxification Relapse Prevention
Pharmacotherapy for Alcohol Dependence
- Initiate acamprosate 1,998 mg/day (for patients ≥60 kg) starting 3-7 days after last alcohol consumption once withdrawal symptoms resolve. 5
- Alternative: Naltrexone 25 mg for 1-3 days, then 50 mg daily (avoid if significant liver disease persists). 5, 4
- Alternative: Baclofen up to 80 mg/day is safe in liver disease and may reduce alcohol craving. 3, 5
- Continue thiamine 100-300 mg/day orally for 4-12 weeks as 30-80% of alcohol-dependent patients have thiamine deficiency. 3, 4
Psychosocial Interventions
Evidence-Based Psychotherapy
- Implement cognitive behavioral therapy (CBT) to reduce suicidal ideation and behavior, as CBT cuts the risk of repeat suicide attempts by 50% compared to treatment as usual. 1
- CBT should target problematic thinking patterns, develop coping skills for alcohol cravings, and address the sense of alienation and emotional instability common in alcohol dependence. 1, 5, 8
- Consider dialectical behavior therapy (DBT) if borderline personality traits or recurrent self-harm behaviors are present, as DBT reduces self-directed violence by >50%. 1
- Most patients benefit from fewer than 12 CBT sessions. 1
Family and Group Therapy
- Involve family members in treatment, as alcohol dependence is often a dysfunctional family disorder, and address interpersonal problems that may have contributed to delusions of infidelity. 5, 2
- Refer to Alcoholics Anonymous or similar mutual help groups for ongoing peer support. 3, 5, 4
- Provide education to family about alcohol dependence, psychotic symptoms, and suicide risk. 5
Treatment Duration and Monitoring
Continuation Phase
- Continue antipsychotic therapy for at least 6 months at the lowest effective dose that maintains remission of delusions. 6
- Once delusions fully resolve, gradually taper antipsychotic over several months while monitoring closely for symptom re-emergence. 6
- If delusions recur during antipsychotic taper, reinstate combination treatment and assess more frequently due to increased tardive dyskinesia risk with prolonged use. 6
Follow-up Schedule
- Schedule weekly follow-up for the first month to monitor abstinence, medication adherence, side effects, and suicide risk. 5, 4
- Transition to biweekly then monthly follow-up as stability improves. 5
- Monitor for signs of relapse to alcohol use or re-emergence of psychotic symptoms. 5, 4
Critical Pitfalls to Avoid
- Do not use antipsychotics as monotherapy for alcohol withdrawal, as they lower seizure threshold and worsen outcomes. 3, 4
- Do not discontinue benzodiazepines prematurely based on day of admission alone—treat until complete symptom resolution. 3
- Do not administer glucose-containing solutions before thiamine, as this can precipitate acute Wernicke's encephalopathy. 5, 4
- Do not rely on a single suicide risk assessment tool, as no instrument can sufficiently determine risk level. 1
- Do not assume delusions will resolve with alcohol abstinence alone—active antipsychotic treatment is required. 7, 2
- Do not overlook screening for infection (pneumonia, urinary tract infection) as a complicating factor in delirium and withdrawal. 1, 3