History
A 45-year-old publican presents to his general practitioner complaining of being unable to cope with his wife’s behaviour. He goes on to tell the GP that his wife of over 20 years has recently begun to have numerous affairs with customers at the pub they run. He can tell who his wife has had an affair with because of the ‘way she looks at them’. He has confronted her about this on several occasions but she denies his accusations. As a result of his suspicions, he keeps a log of the mileage of her car to check where she has been. His wife has become very upset by the change in his behaviour and has moved into the spare bedroom. He has taken this as further confirmation that she is having an affair. He first became concerned about his wife’s behaviour a month ago. Since that time his mood has been low and he has become increasing preoccupied by thoughts of her infidelity. His sleep, appetite and concentration are poor. He has begun to have financial problems as he is finding it hard to run the public house due to the stress he is under. He has previously suffered from moderate depressive episodes and stopped his anti- depressant medication over a year ago. There is no other past medical or psychiatric history of note. He describes himself as a ‘social drinker’ due to his job. On direct questioning he admits to a gradual increase in his alcohol intake over the last couple of years. He is now drinking every day and typically consumes in excess of 60 units per week. There is no history of illicit substance abuse.
Mental state examination
He has good eye contact, and is perspiring. He presents as an overweight middle-aged man who is slightly unkempt and smells of alcohol. He is initially reluctant to talk about his difficulties, repeatedly saying that his wife would not be having affairs if he was ‘a real man’. He reports that his mood is ‘terrible’ and objectively he appears low. His thought content is mainly concerned with the belief that his wife is being unfaithful. He is unwilling to even accept the possibility that he may be mistaken, yet has no concrete evidence upon which he has reached this conclusion. There is no abnormality of perception and his cognition is grossly intact. He does not think he is mentally unwell, but is willing to accept help to deal with the stress he is under.
Physical examination
The only abnormality upon physical examination is palmar erythema and mild hepatomegaly.
• Depressive episode with psychotic symptoms – evidence of sustained low mood with decreased sleep, appetite and concentration. Psychotic symptoms are in keeping with low mood (i.e. mood congruent).
• Delusional disorder – presence of delusional beliefs with an absence of other symptoms such as hallucinations.
• Schizophrenia – presence of delusions and hallucinations with an absence of prominent mood symptoms.
• Schizoaffective disorder – mood and psychotic symptoms are equally prominent but psychotic symptoms may not be in keeping with the expressed mood (i.e. mood incongruent).
• Organic psychosis – may be due to alcohol/ illicit substance abuse or underlying physical disorder such as brain tumour or temporal lobe epilepsy (TLE).
• Paranoid personality disorder – lifelong pattern of suspicion of the motives of others with a tendency to misperceive neutral events as hostile and threatening.
• Asperger syndrome with misinterpretation of the motives of others.
Differential diagnosis of pathological jealousy
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ANSWER 53
This patient falsely believes that his wife is being unfaithful. He has reached this conclusion in the absence of any appropriate evidence and despite evidence to the contrary. He holds this belief with absolute conviction and he is becoming increasing preoccupied by this belief. This presentation is often referred to as pathological jealousy (also known as morbid jealousy or Othello syndrome). Pathological jealousy is a descriptive term rather than a diagnosis and its differential diagnosis is shown in the box below.
Those with pathological jealousy are distressed by their false belief in their partner’s infidelity and show unreasonable behaviour (such as checking for proof that their partner is being unfaithful and frequent accusations). This can escalate to become increasingly extreme. This combination of strong emotions and acting upon delusional beliefs is particularly dangerous. The patient’s partner may be at increased risk and the risk of homicide in such situations can be high. Other people could also be at risk from the patient if he believes that they are involved in his partner’s infidelity. Finally, the patient himself is at increased risk of suicide due to the high level of distress and conviction that his partner is being unfaithful. These risks will be further increased in the presence of alcohol/illicit substance abuse.
• Pathological jealousy is a descriptive term, not a diagnosis and a careful assessment should be made to obtain an underlying diagnosis.
• Those presenting with these symptoms may pose a risk to themselves, their partners and others. Co-morbid substance misuse is often present and further increases the risk of harm to others and self.
• A detailed risk assessment must be conducted in all cases of pathological jealousy.
KEY POINTS