- Psychiatrists should identify & manage such
As the distress endured by patients with morbid jealousy and their partners may be much higher than acknowledged, there is a pressing need to explore this phenomenon further in Sri Lanka and for psychiatrists to focus on identifying and managing such persons.
These observations were made in an original paper on the ‘Prevalence of morbid jealousy among in-patients in a psychiatry unit in Sri Lanka’ which was authored by C. Kapugama, C. Suraweera, W. Kotalawala, V. Wijesiri, M. Dalpatadu and R. Hanwella (all six attached at the time to the Colombo National Hospital's Colombo University Psychiatry Unit) and published in the Sri Lanka Journal of Psychiatry's fourth Volume's second Issue in December 2013.
Wider understanding
The wider definition of morbid jealousy, as mentioned in P. De Silva and M. Marks's ‘Jealousy as a clinical problem: Practical issues of assessment and treatment’, refers to jealousy in couple based relationships which leads to distress in one or both of the partners, and causes a disruption of the relationship.
In morbid jealousy, the psychopathology is primarily the preoccupation with a partner’s sexual infidelity. This preoccupation, as observed in M. Kingham and H. Gordon's ‘Aspects of morbid jealousy’, can be a delusion, obsession or an overvalued idea. The distinction between these forms is, as emphasised in B. Batinic, D. Duisin and J. Barisic's ‘Obsessive versus delusional jealousy’, sometimes difficult but important as it has implications in management. Clinical features, as elaborated in P. De Silva's ‘Jealousy in couple relationships: Nature, assessment and therapy’ and N. Tarrier, R. Beckett, S. Harwood and N. Bishay's ‘Morbid jealousy: A review and cognitive behavioural formulation’, consist of a range of irrational thoughts and emotions, and associated unacceptable or abnormal behaviours. The jealous person and more so his/her partner, suffer immense distress due to the behaviours associated with the jealousy. These behaviours range from stalking the partner, restricting the partner’s life, and physical violence to even killing the partner. The behaviours are, as pointed out in P. Mullen and J.L. Martin's ‘Jealousy: A community study’, different in males and females. However, a positive role of jealousy is where it is seen as a sign of love and caring.
M. Soyka, G. Naber and A. Volcker's ‘Prevalence of delusional jealousy in different psychiatric disorders: An analysis of 93 cases’, which is a study of hospitalised patients, reported a prevalence of delusional jealousy of 1.1% while delusional jealousy was most frequently seen in ‘organic psychoses’ and the least seen in affective disorders. The aetiology of morbid jealousy is organic. K.A. Kuruppuarachchi and A.N. Seneviratne's ‘Organic causation of morbid jealousy’ - a series of five cases, describes patients with conditions such as cerebral infarcts (ischemic stroke occurs as a result of the disrupted blood flow to the brain due to problems with the blood vessels that supply it, where a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), head injury following a road traffic accident and meningioma (a primary central nervous system tumor that begins in the brain or the spinal cord), who developed morbid jealousy. According to G. Cipriani, M. Vedovello, A. Nuti and A. di Fiorino's "Dangerous passion: Othello syndrome and dementia’, morbid jealousy is also associated with dementia.
O. Somasundaram's ‘Facets of morbid jealousy: With an anecdote from a historical Tamil romance’ points to the classic example in literature, that of English playwright William Shakespeare’s Othello (The Tragedy of Othello, the Moor of Venice), where the eponymous character kills his wife Desdemona and commits suicide as a result of his morbid jealousy.
Culture plays a role in the expression and clinical manifestations of morbid jealousy. A series of cases from Sri Lanka show that the prevalence is equal in males and females.
Method
Kapugama et al. conducted a descriptive cross sectional study which included all the in-patients admitted to the Colombo National Hospital's Colombo University's Psychiatry Unit during a three months period from October, 2012 to January, 2013. Compared to out-patients who are mostly in remission, in-ward patients are admitted, according to H. Wijesundara, M. Dayabandara, A. Ellepola and R. Hanwella's ‘Psychopathology in patients with schizophrenia attending a psychiatry out-patient clinic at a tertiary care hospital in Sri Lanka’, due to the acute exacerbation of the illness. Morbid jealousy was defined as jealousy that causes distress in the jealous person and/or the target person and disrupts the functioning of one or both of them and the relationship. A detailed clinical interview was conducted by the authors using a semi-structured questionnaire to identify morbid jealousy and was based on the behaviours, emotions and thinking described in the literature. Where possible, the partners of the patients were also interviewed if both the patient and the partner consented. The diagnosis of the primary illness was made according to the World Health Organisation's ‘The International Classification of Diseases 10th Revision Classification of Mental and Behavioural Disorders: Clinical description and diagnostic guidelines’ criteria.
Results
There were 145 in-patients admitted during the study period to the said Unit, 76 of whom were in an intimate relationship (spouse or partner). Of these, 46.05% were males. The mean age for males was 49.6 years and in females, it was 49.6 years. A total of 13 patients had morbid jealousy (nine males and four females). The overall prevalence rate was 17.10%. The mean age of patients with morbid jealousy was 39.53 years. There was one patient aged 70 years. The psychopathology of morbid jealousy was overvalued ideas (seven/53.84%), delusions of jealousy (four/30.76%) and obsessional (two/15.38%). Two patients with morbid jealousy had schizophrenia, one had delusional disorder, one was in an acute manic episode, four were diagnosed with depressive disorder (two of whom were admitted following acts of deliberate self-harm), three had alcohol use disorder (one was admitted following deliberate self-harm), one had obsessive compulsive disorder and one had paranoid personality disorder. All 13 patients made verbal accusations to their partners, 12 interrogated the partners, 11 had checking related behaviours including checking phones (eight), handbags and wallets (six), other belongings (four), and clothes and undergarments (two). One patient checked his wife’s body for telltale signs of sexual encounters. Nine patients regularly checked the partners’ whereabouts and five stalked the partners or employed other people to follow them. Eight patients made threats of violence regularly and had engaged in acts of violence, ranging from hitting the partner to throwing objects at the partner while one patient had attempted to run over the partner using a vehicle. Seven of these were men. An excessive demonstration of love was present in two patients (one male and one female). None were excessively dependent on the partners. Four males made increasing demands for sexual activity. The commonest emotional response to feelings of jealousy was anger (nine including seven males), six patients reported experiencing fear and five experienced sadness. Three said that they had problems in their sexual relationship. Seven males fulfilled the criteria for the harmful use of alcohol or alcohol dependence. One each used cannabis, cigarettes and diazepam (a benzodiazepine used to treat anxiety, alcohol withdrawal, and seizures, relieve muscle spasms and provide sedation, and which works by calming the brain and nerves).
Discussion
The prevalence of morbid jealousy of in-patients was 17.10%. Their psychiatric diagnoses were variable. Verbal accusations, the interrogation of the partner, various checking based behaviours, threats and acts of violence were the commonly associated behaviours. The prevalence of morbid jealousy was high. Several factors may have contributed to the high prevalence in this sample. This study included morbid jealousy in three different forms of psychopathology, namely, delusions of infidelity, overvalued ideas, and obsessions. The majority of the patients had overvalued ideas (53.84%). Information from the patients’ partners may have helped to identify a few hidden cases where the patients did not admit to having features of morbid jealousy. However, it is possible that the actual prevalence in Sri Lanka is higher than in Western countries. The high prevalence of morbid jealousy among psychiatric in-patients may be a reflection of the high prevalence in the community. The extent of the behaviours accepted as normal by the family and the partners’ reaction to such behaviours also need consideration.