Asian Journal of Psychiatry 4 (2011) 258–260

Organic causation of morbid jealousy

K.A.L.A. Kuruppuarachchi a,*, A.N. Seneviratne b

a Department of Psychiatry, Faculty of Medicine, University of Kelaniya, PO Box 06, Thalagolla Rd., Ragama, Sri Lankab Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Sri Lanka

A R T I C L E I N F O

Article history:

Received 3 February 2010

Received in revised form 29 June 2011

Accepted 13 September 2011

Keywords:

Organic

Othello syndrome

Morbid jealousy

Sri Lanka

A B S T R A C T

This article describes the organic contribution to morbid jealousy. Although the true prevalence of

morbid jealousy is unknown, organic factors contribute significantly to its development. We present an

assortment of five case histories to highlight the importance of organic causation in this phenomenon.

The first two cases portray organic delusional disorder arising as an aftermath of cerebral infarcts.

They are both associated with left sided brain lesions.

Though organic processes generally respond poorly to treatment, case 3 (patient with head injury), is

unusual as it describes a young man whose symptoms resolve on recovering from the effects of a head

injury.

Likewise, case 4 (patient with a meningioma) who made a complete recovery following surgery,

emphasizes the need for early detection of reversible causes.

The difficulty in identifying the common substrate for a phenomenon with such a wide variety of

causations is amply displayed by the abundance of theories forwarded. The blurred demarcation between

normal jealousy and pathological jealousy leads to further uncertainty. The excess representation of

morbid jealousy in organic conditions is not enlightened by these theories. Organic pathology, by

affecting the higher centers of the brain, may remove the control over instinctual behaviour. Evidence for

this is hard to establish but the evolutionary perspective of jealousy akin to that of the animal kingdom

alludes to possible explanations.

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1. Introduction

The emotion of jealousy entwined with the accompanied sensethat the loved one belongs to oneself is a normal human experience(Sims, 2003). It has a social value in preserving the family and anadvantage in evolutionary terms of preserving one’s own gene pool(Daly et al., 1982). However, jealousy which is maladaptive anddysfunctional causing disruption and distress in the relationshipcan be regarded as morbid (Marks and De Silva, 1991).

In marital and other long-term relationships assumptions aboutthe exclusivity of the couple and the priority one should have for theothercanleadtheindividualconcernedtointerpretcertainbehavioursas violations of these understandings, and to fear that they are losingtheir place in the partner’s affection. This can give rise to jealousy (Desilva, 2004). Morbid jealousy is a disorder of content of thought (Sims,2003), and the term ‘‘delusion of jealousy’’ is in fact a misnomer, as it isthe fidelity of the partner which is suspected (Shepherd, 1961). It maymanifest in various forms such as a delusion, an overvalued idea or anobsessional thought and the underlying morbid process could beschizophrenia, depression, delusional disorder, personality disorder,

* Corresponding author. Fax: +94 11 2958337.

E-mail address: lalithkuruppu@lycos.com (K.A.L.A. Kuruppuarachchi).

1876-2018/$ – see front matter � 2011 Elsevier B.V. All rights reserved.

doi:10.1016/j.ajp.2011.09.003

alcohol abuse or organic disorders. Morbid jealousy, also known asOthello Syndrome, therefore can be regarded as a syndrome and not adisorder. It can be identified as a descriptive term.

The true prevalence of morbid jealousy is unknown. Even thoughEnoch and Trethowan considered it as an uncommon disorder,clinicians encounter this syndrome routinely (Michael and Harvey,2004). Among those who suffer from it, almost 15% were found tohave an organic psychosyndrome (Mullen and Maack, 1985). A widevariety of cerebral insults have been shown to be associated with it(Cobb, 1979). Association of this syndrome with head injury such asPunch-Drunk syndrome in boxers following multiple contra-coupcontusions has also been described (Lishman, 1998). A recent casereport suggested lesions in the right orbito-frontal cortex indevelopment of morbid jealousy (Narumoto et al., 2006). However,this condition has also been shown in patients with non-focalcerebral conditions such as Normal Pressure Hydrocephalus (Yusimet al., 2008) and Parkinson’s disease (Cobb, 1979). We present thefollowing case histories to highlight some of the important aspects oforganic causation of morbid jealousy.

2. Case 1

A 68-year old father of four children developed persistent righthomonymous hemianopia and a degree of expressive dysphasia

K.A.L.A. Kuruppuarachchi, A.N. Seneviratne / Asian Journal of Psychiatry 4 (2011) 258–260 259

during the 6 months prior to the admission. Although pre-morbidly he was a carefree sportsman, a loving husband and aconcerned father, over the last 2 months he has become fullyconvinced of his wife’s unfaithfulness and has been denying thepaternity of his youngest son. This was found from the wife’saccount and non-verbal clues such as the following: He has beenfollowing his wife, cross checking her, accusing her of infidelity anddemanding sexual relations with her. He had threatened aneighbor believing him to be his wife’s lover. He was irritableand was seen to be crying at times. His sleep was poor; he had lostweight.

He also had other depressive symptoms with suicidal ideas. Hewas violent and refused admission. On neuropsychiatric evalua-tion he had nominal aphasia, acalculia, dysgraphia and right-leftdisorientation (Gerstmann’s Syndrome). Abstract reasoning andassociations were also affected. A CT scan showed old infarctsinvolving left temporal, parietal and occipital lobes. He wasdiagnosed as having organic delusional disorder with secondarydepression. His psychotic and depressive symptoms improved tosome extent with a combination of Quetiapine and Sertraline andthe family was able to contain him (Table 1).

3. Case 2

A man in his fifties was admitted for displaying hostility towardshis wife and children for a period of 2 years. He was suspicious andinsisted that his wife taste the food served to him. He accused hiswife of infidelity. There were restrictions imposed on her and hefrequently checked on her whereabouts and interrogated her. Whenalone, he heard voices talking about him. He had attempted suicideby ingesting varnish 2 months prior to the presentation. He had apast history of heavy alcohol misuse, though he stopped drinking 3years ago. He was also undergoing treatment for hypertension butthe compliance was poor. Pre-morbidly he had been a caring personbut sensitive to criticisms. In the ward he was withdrawn andirritable. He constantly watched his wife during her visits. He hadlong standing gait ataxia and left sided cerebellar signs. He wasdiagnosed as having organic delusional disorder. A CT scan of thebrain showed lacunar infarctions in left corona radiata, left externalcapsule, and right caudate nucleus. Thyroid and hepatic screens

Table 1Summary of the five case histories.

Case 1 Case 2

Age 68 years 58 years

Sex Male Male

Occupation Retired shop owner Ex-Policeman

Marital status Married Married

Diagnosis Organic delusional disorder

with secondary depression

due to cerebrovascular accident

Organic delusional

disorder due to

cerebrovascular events

Neurocognitive

signs and

symptoms

Right homonymous hemianopia,

expressive dysphasia, nominal

aphasia, acalculia, dysgraphia,

right–left disorientation

(Gerstmann’s Syndrome)

Gait ataxia, left sided

cerebellar signs

CT scan Old infarcts involving left

temporal, parietal, occipital

lobes

Lacunar infarctions in

left corona radiate,

left external capsule,

right caudate nucleus

Treatment Quetiapine Sertraline Quetiapine

Response Some improvement Poor

were normal. He was started on Quetiapine and the response after 2months of treatment remained poor.

4. Case 3

A 32-year old man presented 2–3 weeks after a head injury. Hesuspected his wife of having extramarital affairs and was verballyand physically aggressive towards her. He had delusions ofjealousy. He had concentration difficulties and short-term memoryimpairment as well. The CT scan of the brain showed changesconsistent with a contusion of the left temporoparietal region.

Pre-morbidly he had been sociable, outgoing and well adjusted.He was treated with Olanzapine and Carbamazepine (given as aprophylactic against seizures) and his symptoms resolvedcompletely after several months of treatment. The repeat CT scanof the brain after recovery was normal and medication wassuccessfully tailed off.

5. Case 4

A previously stable 40-year old school teacher was brought fortreatment with suspiciousness of 6–8 months duration. She firmlybelieved that her husband was having sexual relationships withyounger women and that he was trying to poison her. She also hadword finding difficulties. Though pre-morbidly shy, during the lastfew months she had become aggressive and violent towards thehusband. Her response to antipsychotics remained poor and the CTscan of the brain done subsequently revealed a meningioma of theleft parietal lobe. Her psychotic symptoms improved to a greatextent following surgery.

6. Case 5

A 70-year old female was brought in because she firmlybelieved that her husband was having affairs with younger womenwho were coming to him in the night. She desperately attemptedto close the doors and windows and became increasinglyaggressive. There was a history of progressive memory impairmentfor a period of 1 year. Previously she had been a less sociable butindependent housewife. She needed assistance in activities of dailyliving and her Mini Mental State Examination (MMSE) score was

Case 3 Case 4 Case 5

32 years 40 years 70 year

Male Female Female

Truck driver Teacher Housewife

Married Married Married

Organic delusional

disorder following

head injury - cerebral

contusion

Organic delusional

disorder due to

meningioma

Organic delusional

disorder due to

Alzheimer’s dementia

Difficulty in

concentrating, short

term memory

impairment

Word finding difficulties Progressive memory

impairement,

MMSE = 12/30

Left temporo-parietal

brain contusion

Meningioma of left

parietal lobe

Generalized cortical

cerebral atrophy

Olanzapine

carbamazepine (for

seizure prophylaxis)

Surgical removal of

meningioma

Quetiapine

Complete recovery Recovered to a

great extent

Poor

K.A.L.A. Kuruppuarachchi, A.N. Seneviratne / Asian Journal of Psychiatry 4 (2011) 258–260260

12/30. Her CT scan of the brain revealed generalized cerebralcortical atrophy and the rest of the dementia screening wasnormal. Her response to antipsychotics was poor.

7. Discussion

Our case histories highlight the wide range of organiccontributions to the symptoms of morbid jealousy. Cobb reporteda variety of organic conditions such as infections, neoplasms, andmetabolic and degenerative conditions which can give rise tomorbid jealousy (Cobb, 1979). Almost 15% of patients with morbidjealousy are shown to have an organic condition (Mullen andMaack, 1985).

Morbid jealousy on the other hand, was found in 7.0% ofpatients with organic psychosis and encountered in 2.5% ofschizophrenic patients (Soyka et al., 1991). This excess represen-tation of morbid jealousy in organic conditions may be the result oforganic insult unearthing the inherent underlying vulnerabilitiesin these patients or the interaction of the organic insult with acompromised system. The literature on organic causality is non-conclusive.

In the first and second cases of our series, the pathology wasmainly located in the left side of the brain. Attempts to localize theunderlying brain pathology have ended up in contradictingresearch findings. Some case reports suggest an association ofmorbid jealousy with the right cerebral hemisphere lesions(Lauaute et al., 2008; Westlake and Weeks, 1999), while otherstudies find no association (Soyka, 1998). Some authors argue thatthe apparent association of delusions with lesions of the righthemisphere is due to the intact left brain with its preserved abilityto give expression to thoughts (Levine and Grek, 1984).

Case 1 also illustrates how meticulous efforts at clinicalassessment led to unmasking of an underlying delusional systemwhich could have been missed due to the understandablecombination of depression with dysphasia. Alcohol may alsocontribute to brain changes and the emergence of this disorder, asseen in Case 2.

Thorough assessment of the first episode of psychosis isimportant. In Case 3, the resolution of the oedema associated withwound contusion might have contributed to the recovery, sinceotherwise, the response to treatment is poor in organic OthelloSyndrome. The prognosis is determined to a great extent by thetreatability of the underlying brain pathology. There may beinstances such as in the Case 4, of treatable tumours likemeningiomas, where the recovery might be near complete, whichalso highlights the value of further investigating in the face of poorresponse.

Emergence of delusions of infidelity is not uncommon in theelderly dementing population.

Management of Alzheimer’s disease such as in Case 5 may bevery challenging; support and assistance to adjust expectations ofcarers, while employing behavioural methods to modify beha-viours, may have worthwhile effects in these patients. Morbidjealousy had been described among patients with neurodegenera-tive disorders such as Parkinson’s disease (Cobb, 1979; Shepherd,1961). A revived interest with the focus turned to treatmentemergent morbid jealousy symptoms in Parkinson’s disease is seenin the recent literature (Cannas et al., 2009; Georgiev et al., 2010).Interestingly, recent observation on the differential association ofdelusional jealousy and other neuropsychiatric symptoms tomotor complications of Parkinson’s disease has led to speculations

about underlying predisposition rather than a mere pharmacolog-ical effect to develop these symptoms (Solla et al., 2011).

Although psychodynamic explanations and attachment theorydo not provide a complete explanation for the development of thepsychopathology of organic morbid jealousy, the psychologicalcontribution cannot be dismissed. The possibility of secondarydelusions arising due to the pathological mood state or disabilitieshas been an important consideration. A close association betweenparanoid and depressive symptoms has been demonstrated(Shepherd, 1961).

It has been mentioned that intense possessive feelings towardsthe sexual partner is common in the animal kingdom and deeplyrooted in primitive proprietary and competitive instincts (Cobb,1979). We can postulate that the organic conditions such as headinjury, degenerative conditions and other traumatic conditionsmay be removing the inhibitions and control of human behaviourand unearthing primitive instincts such as extreme possessivenessof the sexual partner akin to the animal kingdom.

Creating awareness and expectancy among the medicalprofessionals to unravell this symptom would be an importantstep in proper management of a patient with an organic illness.Some conditions will benefit by specific interventions and somemay even reverse. More attention is required to understand ‘‘theunderlying pathology’’ in the organic causation of morbid jealousy.

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