Delusional jealousy with partner assault and alcohol dependence (MEQ)

(i) Constructs and differential. Morbid/pathological jealousy is a clinical spectrum; here features suggest delusional (Othello) jealousy — fixed false belief of partner infidelity organising checking and violence. Map to DSM-5-TR delusional disorder, jealous type if primary and criteria met after exclusions. Differential: alcohol-related delusion/jealousy, stimulant paranoia, schizophrenia-spectrum multi-domain psychosis, mood disorder with psychotic features, obsessional non-delusional jealousy, coercive control without frank delusion, organic causes. Alcohol can cause or amplify secondary jealous delusions; reassess after detoxification before locking a primary label.^[1][2]

(ii) Risk and immediate safety. Partner is the primary victim; children are exposed and need protection assessment. Inventory prior IPV, weapons, ongoing threats, digital stalking, and willingness to separate. Do not open with conjoint couples therapy. Separate interviews; crisis accommodation/protection pathways as local law allows; police involvement already present. Document homicide and suicide ideation including extended themes. Delusional jealousy series show substantial partner-directed dangerousness and stalking behaviours — take dynamic risk seriously even though population domestic homicide is not mostly "mental illness only".^[3][4][8]

(iii) Investigations. Breath/serial alcohol, UDS, withdrawal scores, FBC/UEC/LFT, B12/folate/TFT as indicated, ECG before QT-risk agents, cognitive screen if atypical, neuroimaging if focal or late atypical features. Collateral: partner, GP, prior justice contacts, child protection as required by local mandatory reporting principles (no invented sections).^[2][5]

(iv) Short-term management. Medical management of alcohol withdrawal; thiamine where indicated by alcohol pathway standards; safe custody/hospital placement if risk uncontainable. If primary delusional jealousy persists when sober, start an antipsychotic with monitoring — e.g. risperidone oral 1–2 mg daily initially, titrate toward approximately 2–6 mg daily as tolerated, monitoring EPS, prolactin, weight, glucose/lipids; or olanzapine 5 mg nocte initially (common range about 5–20 mg daily) with metabolic monitoring; or aripiprazole 5–10 mg daily initially. Evidence base is thinner than schizophrenia RCTs but antipsychotics remain first-line practice for delusional disorder.^[5][6]

(v) Longer-term interfaces. Alcohol rehabilitation, adherence support, victim advocacy, stalking/IPV multi-agency risk management principles, child protection follow-through, and forensic court reports if charged — reconstruct mental state at offence without equating diagnosis with mental-impairment defence. Review risk over time; partial insight is common.^[3][7][8]