OBSESSIONAL JEALOUSY: A BRIEF REVIEW AND CASE SERIES FROM INDIA
Key words: obsessional jealousy, morbid jealousy, pathological jealousy, Othello syndrome, obsessive-compulsive disorder, serotonin reuptake inhibitors
Abstract:
The term morbid or pathological jealousy is taken to be synonymous with delusional jealousy and obsessional jealousy has not gained sufficient recognition, evident by the scarcity of data on jealousy as an obsession and its neglect in mainstream psychiatric literature. Recognition of obsessional jealousy may help to avoid unrewarding use of antipsychotics and needless therapeutic nihilism as such cases show robust response to serotonin reuptake inhibitors. The authors present a succinct review of obsessional jealousy and the first large case series reported from an Asian country.
Introduction:
Jealousy is a complex emotion, which has dominated mankind for ages. Literature abounds in descriptions of morbid jealousy from Roman and Greek mythology to Shakespeare, to whom we owe the colorful term ‘Othello syndrome’. However, as pointed out by many authors, there is no clear notion of what constitutes normal jealousy and where the boundaries should be drawn [1]. After centuries of striving, the concept remains elusive and the terminology unclear, being described by myriad terms such as sexual jealousy, erotic jealousy, morbid jealousy, pathological jealousy, conjugal paranoia, jealous monomania, psychotic, nonpsychotic and obsessional jealousy [2][3]. From time to time, morbid jealousy has been examined from psychoanalytic, cognitive and phenomenological aspects in parallel with the evolution of psychiatry, adding to the bewildering array of terms. From the phenomenological point of view, most researchers’ attention has been focused on delusional jealousy. The fact psychiatric medicine has tended to concentrate on morbid jealousy as a symptom of the psychoses is reflected in the treatment approaches [4]. Less information is available with regard to obsessional jealousy, where the thought has the quality of obsessional ideation [5]. As we encountered several cases of obsessional jealousy in our set up but found little literature on the entity, we decided to attempt a review devoted exclusively to obsessional jealousy (instead of a review of morbid jealousy in general). The literature and cases featured in this paper focus exclusively on obsessional jealousy to bring phenomenological clarity and accentuate its position as a distinct but hitherto under recognized symptom of Obsessive Compulsive Disorder (OCD). This is the first large case series on obsessional jealousy reported from any Asian country to the best of our knowledge.
Literature Search:
Methodology: We conducted a MEDLINE search with predefined keywords to retrieve articles. Search was refined by retrieving cross-references of selected articles. Articles were selected using predefined selection criteria as follows:
1. Articles published in English
2. Articles with jealousy clearly defined as obsessive/ nonpsychotic / non delusional
3. Articles citing jealousy responding to serotonin reuptake inhibitors (SRIs).
Results:
The details of search result are tabulated in Tables 1 and 2. The total number of relevant articles retrieved was 20. The total yield of cases published with clearly defined obsessional jealousy was 23.
Table 1: MEDLINE Search Results
SNo |
Keyword used |
Article Yield |
Relevant |
Overlapping articles |
1. |
Obsessional jealousy |
8 |
6 |
|
2. |
Pathological Jealousy |
43 |
7 |
With 1.-3 |
3. |
Morbid jealousy |
39 |
7 |
With 1.-2, With 2.-1 |
4. |
Obsession of infidelity |
1 |
1 |
None |
5. |
Othello syndrome |
14 |
1 |
With 1.-0, With 2.-1, With 3.-1 |
Table 2: Type of Articles included in Review
Article Type |
Article Yield |
No. of Cases |
Review |
5 |
|
Case Series |
5 |
6 + 4 + 4 |
Single Case Report |
9 |
9 |
Epidemiology |
1 |
|
Total |
20 |
23 |
Obsessional Jealousy: Evolution of concept
The concept of jealousy has changed with the changing social and cultural milieu in history. Jealousy was accorded a role in preserving social esteem in societies where monogamy was a moral and social imperative. Thus the institution of marriage and the instinct of jealousy served the same purpose. However the balance between perceived virtues and vices of jealousy shifted at different historical periods to culminate in the modern view of jealousy as compounded of vices mitigated by little, if any, virtue [1].
Upto the turn of the 19th century, the condition was always regarded as being associated with alcohol, when von Kraft Ebing (1903) described its delusional form in other mental illnesses, both functional and organic2. Following Mairet’s comprehensive description in 1908, states of abnormal sexual jealousy have invariably been separated into 3 distinct clinical entities, albeit using different descriptive terms, a compilation of which is presented in Table 3 [2][3]. One presentation takes the form of an excessive possessiveness which appears in otherwise undisturbed personalities and is thought to represent an exaggeration of normal jealousy. At the other extreme is delusional jealousy that may complicate a schizophrenic, affective or organic psychosis. The third form, described as jealous monomania by Mairet, has been noted to be characterized by thoughts of infidelity which is intense, preoccupying and leading to continual accusation, interrogation, checking and excessive sexual demands on spouse. It was described to have a chronic course for years with exacerbations and improvements but without development of psychosis or personality deterioration and with poor response to neuroleptics [6]. This form of morbid jealousy was recognized as a manifestation of Obsessive-compulsive Neurosis by authors like Shepherd, Mooney and Vauhkonen [7]. According to Shepherd, morbid jealousy accompanies several psychiatric states and treatment depends on the nature of the illness [7].
Table 3: The Changing Terminology of Jealousy
Mairet (1908) |
Hyperesthetique |
Monomanie |
Folie |
Jaspers (1910) |
Personality development |
___ |
Process occurrence |
Freud (1922) |
Projected |
___ |
Delusional |
Lagache (1947) |
Reactive |
Personality development |
Process |
Ey (1950) |
Emotionally jealous |
___ |
Delusions of jealousy |
Revitch (1954) |
Emotionally insecure |
Conjugal paranoia |
Psychotic |
Mooney (1965) |
Excessive |
Obsessive |
Delusional |
The first clearly defined case of obsessional jealousy was by Mooney (1965) [8]. He reported 15 cases, 4 of which were identified as obsessive. He also pooled data of 4 authors. It is difficult to draw reliable conclusions from his analysis of pooled data due to indirect reporting, retrospective analysis and differing classificatory methods used. However, the 4 cases of obsessive jealousy he examined personally showed partial improvement with low doses of trifluoperazine but with poor tolerance to high doses, a noteworthy difference from the deluded group (Table 4 a & b).
Table 4 (a) List of Individual cases seen by Mooney, 1965 8
Mairet (1908) Hyperesthetique Monomanie Folie Mairet (1908) Hyperesthetique Monomanie Folie |
Table 4(b) Cases seen by Mooney, combined with 4 other authors 8
Classificn. |
No. of Cases |
Mean Age |
M: F |
Family H |
Diagnosis |
Rx & improvement |
Delusional Obsessional Normal Projective |
Total:138 |
Late teens-60 years |
3:1 |
Mood D Jealousy Alcoholism Suicide |
Delusional: 50% Obsessional:< 50% |
Del: 33% Overall: 62%
|
Docherty and Ellis (1976) raised the issue of obsessive jealousy [3]. However, their formulation was mainly psychodynamic and phenomenology was not stressed upon. Hoaken (1979) defined obsessive suspicions as unwelcome, repetitively intrusive thoughts recognized by the patient as ego dystonic [9]. However, Mc Kenna (1984) reviewed that such persons have a solitary abnormal belief and described it as an overvalued idea rather than an obsession [6].
With the advent of behavior therapy for obsessive-compulsive disorder, the concept of obsessive jealousy moved a step further as several authors delineated its distinct phenomenology and response to behavioral interventions. Cobb and Marks (1979) defined jealous ruminations as obsessive thoughts with the resultant compulsive rituals of checking on spouse [7]. In their prospective study, they identified 4 cases of obsessive-compulsive disorder presenting as morbid jealousy and were the first to report treatment of such patients with behavior therapy. They concluded that morbid jealousy in OCD is treatable and rituals respond better than ruminations (Table 5).
Table 5: Cases treated with behavior therapy by Cobb and Marks, 1979 7
Cases |
Age/Sex |
Duration (Years) |
Compliance with BT |
Medications |
Result (Rituals) |
Result (Ruminations) |
1 |
26/F |
5 |
Poor |
Not mentioned |
No improvement |
No improvement |
2 |
37/F |
20 |
Poor |
Not mentioned |
Much improvement |
No improvement |
3 |
30/M |
10 |
Good |
+(Desipramine) |
Improvement |
No improvement |
4 |
27/F |
5 |
Good |
Not mentioned |
Much improvement |
Much improvement |
Tarrier (1990) also described non-psychotic jealousy and likened jealous thoughts to obsessions, being intrusive, unpleasant, irrational and accompanied by behavioral actions like checking or reassurance seeking [4]. The preoccupation, confirmatory behavior, avoidance, distress and rumination described in non psychotic cases was suggestive of obsessions and responded to behavioral strategies commonly used in OCD. Dolan and Bishay (1996) used cognitive behavioral strategies to treat 30 patients of non-psychotic morbid jealousy and reported significant improvement in all jealousy measures, although they did not specify whether the patients were obsessive [10].
Since the arrival of antiobsesional drugs in the scene, several authors have described cases of obsessional jealousy showing good response to SSRI and clomipramine, a synopsis of which is presented in Table 6 [11-17]. These patients commonly presented with thoughts of possible infidelity of partner, recognized as unwanted and doubtful, resulting in anxiety on separation. Most patients harangued, asked for reassurance of spouse and spied on them. Ego dystonicity varied in patients, and Lane justified egosyntonic thoughts by the fact that OCD patients view their preoccupation as realistic when compulsions are prevented [11]. Taking this variability into consideration, Stein and Hollander (1994) put forth the notion of a spectrum from obsessional to delusional [13]. Parker and Barrett noticed absence of ego-dystony, resistance and guilt and called jealousy a variant of OCD [15]. Gangdev disputed the term ‘variant of OCD’, advocating the abandonment of the imprecise term morbid jealousy in favor of delusion or obsession [16]. The review by Kingham and Gordon (2004) emphasizing on form of psychopathology (obsession, overvalued idea or delusion) rather than content (jealousy) was thus timely to bring clarity to the concept [18].
Last but not the least, psychiatry is continually evolving from psychodynamic, cognitive and behavioral schools towards biological bases of psychiatric disorders, and sophisticated imaging techniques have implicated the basal ganglia and its circuits in the pathogenesis of obsessive-compulsive disorder. This is borne out by several organic cases of obsessional jealousy reported (Table 7), which reported good response to SSRIs [19][20][21].
Table 6: Cases seen by various authors after advent of antiobsessional drugs
Author |
Age/ Sex |
Comorbidity |
Family History |
Medication |
Time for response |
Result |
Duration of illness |
Belief strength |
Lane, 1990 11 |
39/M |
Mood D Panic D |
Nil |
Imipramine 350 mg Fluoxetine 60 mg/d |
- 8 wk |
- v. improved |
18 m |
Unsure |
Gross, 1991 12 |
34/F |
Anxiety |
Not mentioned |
Fluoxetine 20 mg/d |
4 wk |
v. improved |
19yrs |
unsure |
Stein, Hollander, 1994 13 |
35/M 38/M 33/M 43/F 42/F
55/F |
OCD OCD Dysthymia OCD, S. phobia None
OCD |
Not mentioned |
Imipramine, 300 mg Fluoxetine 80mg Fluoxetine 80 mg +pimozide 1mg Fluoxetine 80 mg Fluoxetine 30 mg Clomipramine 50 mg, +pimozide 1 mg Sertraline 200 mg |
- 12 wk 12 wk 12 wk 12 wk 12 wk
12 wk |
- mod. Improved mod. improved much improved much improved v. much improved min improved |
20 y Adolescence Few yrs Not mentioned 2 y
3 y |
Unsure Excessive No insight Excessive Near delusion
excessive |
Wright, 199414 |
36/F |
Dysthymia |
OCD (esp. jealousy) |
Fluoxetine 40 mg |
6 wk |
v.much improved |
15 y |
Recognized as irrational |
Parker, Barrett, 199715 |
54/M |
Mood D OCPD Trichotillomania |
Not mentioned |
Clomipramine, ERP |
4 wk |
v. much improved |
4 wks |
Recognized as excessive |
Gangdev, 1997 16 |
25/F |
Depression Gambling |
Not mentioned |
Fluoxetine 20 mg |
2 wk |
v.much improved |
adolescence |
Recognized as untrue |
Lawrie, 199817 |
33/F |
None |
Mood disorder |
Clomipramine 60 mg |
3 wk |
v.much improved |
9 m |
excessive |
Table 7: Organic Obsessional Jealousy
Author |
Age/Sex |
Organic Disorder |
Duration of illness |
Medication |
Response |
Wing (1994)19 |
37/M |
Head injury |
5 yrs |
Fluoxetine 20 mg/d |
Improved |
Westlake (1999)20 |
20/F |
Cerebrovascular Infarction (R parietal & basal ganglia) |
3 yrs |
Paroxetine 40mg/d (6 wks) |
Improved |
Chacko (2000)21 |
76/F |
Bilateral basal ganglia infarct |
4 yrs |
Fluoxetine 40mg/d |
Improved |
The 7 cases reported in the series were from a General Hospital Psychiatry Unit in India seen by us over a span of 2 years. An illustrative case is presented below. The clinical characteristics and treatment results of all patients are tabulated in Table 8.
Illustrative Case:
Mr. A., a 38-year-old married man had repeated thoughts about his wife’s possible infidelity since their marriage 19 years ago. He had repeated thoughts that his wife was not faithful and would object to his wife talking with any male. He was unsure about the truth of these thoughts, considering them excessive and unreasonable and developed guilt as a result. With the birth of their first child a year after marriage, he had repeated doubts that the child was not his. These thoughts led to checking on his wife all the time, questioning her meticulously regarding her whereabouts, leading to marital discord. In addition his occupational performance as a typist deteriorated markedly due to repeated thoughts. He continued to suffer similarly for 19 years and never sought psychiatric consultation. Mr. A also attempted to harm himself thrice due to guilt over his unwanted thoughts during his illness. 2 months before presentation to our institution, he developed depressive features in addition. His sister persuaded him and brought him to the psychiatrist for consultation. On evaluation, Mr. A. admitted that most likely his doubts were excessive and unnecessary. There were no other obsessions/ compulsions or delusions or substance misuse. Family history revealed similar illness in his maternal grandfather and obsessions of contamination in his accompanying sister. A diagnosis of obsessional jealousy was entertained on the basis of findings. Baseline assessment on YBOCS severity scale revealed score of 28. Mr. A. responded to Fluoxetine 40 mg/d with Clomipramine 25 mg/d. Within 4wks there was 50 % improvement and at 12 weeks he reported complete improvement and YBOCS rating was 0. He scored 1 (very much improved) on Clinical Global Improvement scale. He was maintained on the same dose and improvement was sustained.
Case |
Age/ Sex |
Durn. Of illness |
Other Obsession/ Compulsion |
Family H |
Comorbid diagnosis |
Previous Rx |
CGI score (previous treatment) |
Current Rx |
CGI score |
Time for best response |
1. |
38/M |
18 yrs |
None |
OCD |
Depression |
None |
Not applicable |
Fluoxetine40 mg+ clomipramine 25 mg |
1 |
12 wk |
2. |
24/M |
4yrs |
None |
OCPD |
None |
Olanzapine (1 month) |
4 |
Fluoxetine 60 mg |
1 |
12 wk |
3. |
34/M |
3 1/2yrs |
Counting |
None |
OCPD |
Haloperidol (3 months) |
4 |
Fluoxetine 40 mg+ clonazepam 0.5 mg |
1 |
6 wk |
4. |
22/M |
6m |
Fear of disease, checking |
Not known |
None |
None |
Not applicable |
Clomipramine 50 mg |
1 |
2 wk |
5. |
34/F |
17 yrs |
Counting |
Mood D |
None |
None |
Not applicable |
Fluoxetine 40 mg |
1 |
12 wks |
6. |
25/M |
1 yr |
Checking, washing, touching |
None |
None |
None |
Not applicable |
Fluoxetine, Clomipramine |
1 |
3 wks |
7. |
45/M |
20 yrs |
None |
None |
Impulse control, Tics |
None |
Not applicable |
Clomipramine 62.5 mg |
1 |
8 wk |
Table 8: Clinical Characteristics of patients and treatment response
Clinical Global Impression (CGI) Key: 1: very much improved, 2: much improved, 3: minimally improved, 4: no change, 5: minimally worse, 6: much worse
Discussion:
The study of jealousy has the problem of attempting a scientific account of a term derived from everyday language, resulting in a conceptual fuzziness. Moreover, the concept of morbid jealousy has been influenced by the changing face of psychiatry and the influences of psychoanalytic, cognitive, social and biological schools of thought, thus becoming the proverbial elephant, easier to recognize than define. Its initial recognition as a syndrome is understandable in this context, but the need has come to modify this concept. Emphasis on content (i.e. jealousy) was relevant for the psychoanalytic and cognitive schools of thought, but with the growing importance of phenomenology and later psychopharmacology, delineation of form (obsession, overvalued idea and delusion) became increasingly important for adopting appropriate interventions.
The sprinkling of case reports on obsessional jealousy have not found their way into standard psychiatric literature like reference textbooks and even exhaustive checklists like YBOCS, probably leading to a vicious cycle of under recognition and underreporting. Perhaps the prime reason for diagnostic confusion is its difference from classical OCD. From the literature reviewed and our case series, we were able to delineate some of the differences (Table 9). Non-recognition may lead to cases being treated as a variant of delusional disorder, albeit responding poorly to neuroleptics. However, Kozak and Foa (1994) have questioned the traditional assumption of insight and resistance in OCD [21] and DSM IV has recognized poor insight in OCD.
Table 9
OCD or Variant of OCD? Key differences from OCD
|
|
|
|
|
|
Thus an emphasis on the form of thought as delusion, or obsession rather than content during evaluation of the jealous patient will help clinicians avoid such dilemmas. Kingham and Gordon (2004) have provided a guideline for assessing the jealous patient, which is a progressive step towards recognition of this entity [18].
The apparent rarity of the symptom as evidenced by our literature search was not validated in our clinical practice where we encountered several such cases. Apart from the non-recognition of symptoms, possible reasons for this might be a reluctance to consult psychiatrists due to patient’s secretiveness, failure to recognize it as a sign of illness (as interrogation is borne by spouse) and the shame and guilt associated with obsessive thoughts. Delayed psychiatric consultation and the chronic course described in literature is evident from the long treatment gap in most of our cases.
Obsessional jealousy might have social, legal and forensic implications, highlighted by authors like Mooney, Hoaken and Kingham [8][9][18]. In our cases, a trip to the psychiatrist was the last resort to save the marriage. Many such cases probably end in divorce especially in the west, while in our society the spouse suffers in silence. In western literature, women also have been reported frequently to have obsessional jealousy, whereas we have encountered only one woman, which may be due to our social set up. Domestic violence and homicide are reported to be risks in such patients, as evidenced by murders and murder-suicides reported. Harm to self is a distinct possibility as in the case cited by Mooney [8]. In our patients, we did not find domestic violence in any case, although one of our patients did attempt suicide several times before presenting at our center. As there is a possibility that many such cases end in divorce, the question arises what can be done for these failed marriages?
Conclusion:
It is the need of the hour to redefine terms like ‘morbid jealousy’ and encourage clinicians to specify the nature of ‘morbid’ belief (like obsession or delusion). It would help if terms like obsessional jealousy are standardized and brought into mainstream psychiatric literature and checklists of obsessive-compulsive disorder. It would be beneficial if future research focuses on systematic studies in patients of OCD to find out the existence of obsessional jealousy in such patients.
REFERENCES:
1. Mullen, PE (1991). Jealousy: The Pathology of Passion. Br J Psychiatry.158, 593-601
2. Enoch, MD, Ball, HN (2004). The Othello Syndrome. In: Enoch MD, Ball HN, Eds.Uncommon Psychiatric Syndromes. Fourth Edition. Arnold, pg.50
3. Docherty, JP, Ellis, J (1976). A new concept and finding in morbid jealousy. Am J Psychiatry,133, 679-83
4. Tarrier, N, Beckett, R, Harwood, S, Bishay, N (1990). Morbid Jealousy: A Review and Cognitive- Behavioral Formulation. Br J Psychiatry, 157, 319-26
5. Marazziti, D, Nasso, E, Masala, I, Baroni, S, Abelli, M, Mengali, F et al (2003). Normal and obsessional jealousy: a study of a population of young adults. Eur Psychiatry,18, 106-11
6. McKenna,PJ (1984). Disorders with overvalued ideas. Br J Psychiatry,145, 579-85
7. Cobb, JP, Marks, IM (1979). Morbid jealousy featuring as Obsessive- Compulsive Neurosis: Treatment by Behavioral psychotherapy. Br J Psychiatry, 134, 301-5
8. Mooney, HB (1965). Pathologic jealousy and Psycho chemotherapy. Br J Psychiatry, 111, 1023-42
9. Hoaken, PCS (1976). Jealousy as a symptom of psychiatric disorder. Australian and New Zealand Journal of Psychiatry, 10, 47-51
10. Dolan, M, Bishay, N (1996). The effectiveness of cognitive therapy in the treatment of non-psychotic morbid jealousy. Br J Psychiatry, 168 , 588-93
11. Lane, RD (1990). Successful Fluoxetine treatment of Pathological Jealousy. J Clin Psychiatry, 51 , 345-6
12. Gross, MD (1991). Treatment of pathological jealousy by Fluoxetine. Am J Psychiatry,148 , 683-4
13. Stein, DJ, Hollander, E, Josephson, SC (1994). Serotonin reuptake blockers for the treatment of Obsessional Jealousy. J Clin Psychiatry, 55 , 30-33
14. Wright, S (1994). Familial obsessive-compulsive disorder presenting as pathological jealousy successfully treated with Fluoxetine. Arch Gen Psychiatry, 51, 430-1
15. Parker, G, Barrett, E (1997). Morbid jealousy as a variant of obsessive- compulsive disorder. Australian and New Zealand Journal of Psychiatry, 31, 133-8
16. Gangdev, PS (1997). Obsession with infidelity: another case and some views. Aust N Z J Psychiatry, 31 , 772-3
17. Lawrie, SM (1998). Attacks of jealousy that responded to Clomipramine. J Clin Psychiatry, 59, 317-8
18. Kingham, M, Gordon, H (2004). Aspects of morbid jealousy. Advances in Psychiatric treatment, 10, 207-15
19. Wing, YK, Lee, S (1994). A patient with coexisting narcolepsy and morbid jealousy showing favourable response to fluoxetine. Postgrad Med J , 70 (819), 34-36
20. Westlake, RJ, Weeks, SM (1999). Pathological jealousy appearing after cerebrovascular infarction in a 25-year-old woman. Aust N Z J Psychiatry , 33 (1), 105-7
21. Chacko, RC, Corbin, MA, Harper, RG (2000). Acquired Obsessive-Compulsive Disorder associated with Basal Ganglia Lesions. J Neuropsychiatry Clin Neurosci, 12, 269-272
22. Foa, EB, Kozak, MJ (1994). Obsessions, Overvalued Ideas and Delusions in Obsessive-Compulsive Disorder. Behav Res Ther, 32 (3), 343-353