A group of 88 delusional patients has been followed prospectively from first admission. The 2-, 4-, and 8-year course and outcome for 75 patients still alive are presented according to main delusional theme at index admission and from a dimensional approach. From the time of index admission, the groups of patients differ with respect to preceding course and global functioning. In general, these differences are maintained although some become more pronounced. The most optimistic perspective appears for patients with main delusion of reference or a low dimensional severity of delusional beliefs and the most pessimistic for patients with main delusions of persecution or influence and for those with a high dimensional severity of delusional beliefs. Thirty-two patients remained delusional throughout the observation period, in most cases with unchanged thematic content; 57% had an episodic and 43% a chronic course. When distributed according to main delusional theme at index admission, Global Assessment Functioning at 8-year follow-up is: persecution, 43; reference, 69; influence, 34; guilt, 58; others, 55; and, on average, 52. Only minor changes occurred between the three follow-up investigations. After the 8-year observation period, more than 50% of the patients were diagnosed schizophrenia. During the observation period 5 patients committed suicide, which means that delusional first admitters have a risk of suicide which is 31.5 times greater than in the general population. The dimensional severity of delusional beliefs is of importance when course and outcome are concerned and may be complementary to a traditional description.