- Majority married, living with partners/children, employed, functional
- Follow up consultations among patients were less
Among clinical help seeking patients with delusional jealousy, delusional jealousy is more prevalent among males in their 30s to 50s, with a low economic status, and a low level of education, with the majority of them being married and continuing to live with their partners and children in the same household, and being employed and functional, a local study found.
These findings were made in an original article on the "Frequency of reporting and socio-demographic characteristics of a help seeking clinical population with delusional jealousy in Sri Lanka" which was authored by M.K.O.K. De Silva and N. Fernando (attached to the Department of Clinical Sciences of the General Sir John Kotelawala Defence University), I.H. Rajapakse (attached to the Department of Psychiatry of the Ruhuna University's Medical Faculty) and M. Rajasuriya (attached to the same latter Department of the same Faculty of the Colombo University) and published in the Galle Medical Journal's 27th Volume's Second issue in October, 2022.
Humane emotion
Jealousy is a very human emotional experience which is unequivocally present in interpersonal relationships. The concept of jealousy is ambiguous and imprecise and is hard to define and little understood. In the context of romance, jealousy is generally viewed as a multifaceted negative emotional reaction that is activated when a valued relationship or its quality is threatened by a real or imaginary rival. Today, as noted in M. Marks and P. De Silva's "Multifaceted treatment of a case of morbid jealousy", a majority of clinicians are in consensus that jealousy which is maladaptive and dysfunctional in terms of causing distress and disrupting a relationship is morbid and pathological.
Even though a definition of pathological jealousy based on the delusion of the infidelity of the partner narrows down the clinical scope of jealousy as observed in N. Tarrier, R. Beckett, S. Harwood and N. Bishay's Morbid jealousy: A review and cognitive behavioural formulation, the mandate for clinical diagnosis is the same. The World Health Organization's (WHO) "The International Classification of Diseases - 10th Revision classification of mental and behavioural disorders: Diagnostic criteria for research" and the American Psychiatric Association's Diagnostic and statistical manual of mental disorders (DSM) - Fifth edition define clinical jealousy as a delusional disorder - jealous type, which is the predominant delusional theme in delusional disorder. The delusional disorder - jealous type, according to the WHO, entails that an “individual experiences persistent, unrelenting delusions concerning the fidelity of his/her long term romantic partner without rational or objective evidence that can be explained by a history of schizophrenia, drugs, alcohol abuse or physical illness”. M. Kingham and H. Gordon's "Aspects of morbid jealousy" pointed out that pathological jealousy is also conspicuous as it carries a risk to the patient and others. Therefore, clinicians of all specialties and paradigms are required to be conversant in the diagnosis and management of pathological jealousy. M.D. Enoch and W.H. Trethowan's "Uncommon psychiatric syndromes" stated that morbid jealousy, which is one form of many pathological jealousy based conditions, is an uncommon disorder.
Common occurrence
However, per Kingham et al., there is evidence that clinicians encounter this syndrome routinely. Large population based demographic and health surveys and reproductive health surveys in Haiti have included interview modules on the male possessiveness of women and have exposed growing levels of possessiveness in relationships. However, D.M. Buss's The handbook of evolutionary psychology observes that pathological jealousy is not exclusive to males but rather common in both sexes while H. Gordon, O. Oyebode and C. Minne's "Death by homicide in special hospitals" elaborated that such is observed in both heterosexual and homosexual relationships.
Male and female jealousy is fundamentally different in terms of both function and phenomenology. According to D.M. Buss, R.J. Larsen, D. Westen and J. Semmelroth's "Sex differences in jealousy: Evolution, physiology, and psychology", while males are reportedly more concerned about sexual infidelity due to paternal uncertainty, females were more alarmed by emotional infidelity due to the loss of potential partner investment. M. Daly, M. Wilson and S.J. Weghorst's "Male sexual jealousy" emphasises that a greater number of clinically relevant cases of pathological jealousy have been reported in men.
Jealousy was widely observed in monogamous societies where monogamy was both a moral and social imperative. Jealousy for one’s spouse or partner is conventionally viewed as a necessary emotion to preserve social bonds. It rendered the function of preserving social esteem in societies. D. Bhugra's "Cross-cultural aspects of jealousy" observes that therefore, both the institution of marriage and the instinct of jealousy served fundamentally the same purpose.
Motivated by culture?
Furthermore, Bhugra is of the view that motives for jealousy are a product of culture. Social structures, economic, political, and legal systems, and patterns of kinship are all involved in jealousy as an end product. Some societies are more prone to jealousy for they treat their partners as possessions and place more importance on the exclusive ownership of a partner. In such cultures, jealousy is considered as part and parcel of a normal sexual relationship. Despite jealousy being an undesirable and unpleasant experience, in such societies, it is yet a valid justification for marital discord. Societies that are inclined to consider partners as possessions also place much importance on gender role behaviour. The male partner is assumed to be dominant over the female partner. Therefore, Bhugra adds that the dominant male has a sense of sexual ownership over the submissive female partner which is by and large tolerated by the latter. Similarly, these conventional societies generally discourage the autonomy of female partners. Therefore, there is a tendency of interpreting any independent activity by a partner as proof of unfaithfulness towards the other. However, Bhugra also notes that there are certain other societies which place less importance on exclusivity and thus inhabitants of such societies are less vulnerable to jealousy and its negative influences.
The SL type
C. Kapugama, C. Suraweera, W. Kotalawala, V. Wijesiri, M. Dalpatadu and R. Hanwella's "Prevalence of morbid jealousy among inpatients in a psychiatry unit in Sri Lanka" which was a study carried out with psychiatric inpatients in the Colombo University’s Psychiatry Unit of the National Hospital, found that the prevalence of morbid jealousy among psychiatric inpatients was only 1.3%. D. De Silva and P. De Silva's Morbid jealousy in an Asian country: A clinical exploration from Sri Lanka explained how the Sri Lankan culture may have a role in morbid jealousy and its epidemiology.
A multi-centre, descriptive, cross-sectional study was conducted from May, 2017, to August, 2017, at the National Institute of Mental Health (NIMH), the Colombo University Psychiatry Unit of the National Hospital, the University Psychiatry Unit of the Karapitiya Teaching Hospital, and a private psychiatric clinic at the Norris Clinic. All the patients who presented to any of the study settings during the said period with a complaint related to infidelity of his/her partner that makes the patient hold a strong false belief (delusion) that their partner is unfaithful, causes distress in one or both partners, and causes a disruption of the relationship, were recruited as study participants. Patients with a past history of schizophrenia, a limiting language impairment for communication, being acutely ill (with delusions, thought disorders where they cannot rationally communicate and are medically ill), violent and/or disturbed, and patients who cannot declare consent were excluded.
Data were obtained from a self-administered general information sheet and a structured interview conducted by the primary investigator.
A total of 76 patients with delusional jealousy reported to the four study settings over the three months period. A total of 22 patients reported to the NIMH (11 in-patients and 11 out-patients) while 10 (90.9%) out of 11 in-patients and five (45.4%) out of 11 out-patients who reported to the NIMH were new cases of delusional jealousy. A total of 32 patients reported to the National Hospital (12 in-patients and 20 out-patients) while 10 (50%) out of 20 out-patients at the National Hospital were referred by the courts and all 12 (100%) in-patients and 12 (60%) out of 20 out-patients were new cases of delusional jealousy and seven (70%) out of 10 patients referred by the courts were new cases of delusional jealousy. A total of 14 patients reported to the Karapitiya Teaching Hospital (eight in-patients and six out-patients), and five (62.5%) out of eight in-patients and two (33%) out of six out-patients were new cases of delusional jealousy. A total of eight out-patients were reported to the Norris Clinic while seven (87.5%) out of eight out-patients reported to the Norris Clinic were new cases of delusional jealousy. A total of 55 out of 76 patients reported during the study period participated in the study.
Age irrelevant
The age of the patients ranged from 24 to 73 years. The mean age of the patients was 44.15 (standard deviation [SD] 11.58) years. The sample consisted of 39 (70.9%) male and 16 (29.1%) female patients. The age ranged from 24 to 73 years in the male patients with a mean age of 44.9 (SD 11.67) years. The age of the female patients ranged from 23 to 63 years with a mean age of 43.31 (SD 11.68) years. When the age of the partners was considered, the age ranged from 21 to 75 years with a mean age of 42.94 (SD 12.82) years. The age difference between the patients and the partners ranged from zero to 38 years with a mean age difference of 4.63 (SD 5.77).
A total of 37 (67.2%) were married and living with their spouses, 15 (27.2%) were married but lived separately, two (3.6%) were unmarried, in an intimate relationship and living separately, and one (1.8%) experienced jealousy in relation to the extramarital lover.
Among them, 50 (90.9%) patients were Buddhists, four (7.3%) were Christians, and one (1.8%) was a follower of Hinduism. When the ethnicity was considered, 54 (98.2%) and one (1.8%) belonged to the Sinhalese and Tamil ethnicities, respectively.
A total of 50 (90.9%) patients had children together with the partner. The mean number of children was 2.32 (SD 0.913).
In the sample, four (7.40%) patients had received formal higher education, nine (16.66%) were General Certificate of Education Advanced Level (GCE A/L) qualified, 18 (33.33%) were GCE Ordinary Level (O/L) qualified, 23 (42.59%) did not complete GCE O/L and two (3.7%) had not studied beyond Grade Five. Among the partners, five (9.61%) of the partners of delusional jealousy patients had received formal higher education, seven (13.46%) were GCE A/L qualified, 14 (26.92%) were GCE O/L qualified, 26 (50%) were not GCE O/L qualified and three (5.76%) had not attended school beyond Grade Five.
When the employment status was considered, 36 (66.7%) patients were employed. Among the partners, 33 (61.1%) partners of patients were employed. However, 10 (55.6%) of the unemployed patients and seven (38.9%) of the unemployed partners had another source of income. The monthly income of the patients ranged from Rs. 1,250 to Rs. 690,000 with a mean of Rs. 36,172.41 (SD Rs. 14,035.84). The monthly income of the partners ranged from Rs. 2,500 to Rs. 460,000 with a mean of Rs. 27,210.53 (SD Rs. 15,586.95).
The majority of the patients that reported to the four mental health settings were new cases of delusional jealousy. A lesser number of follow up patients was reported in the out-patient clinics.
Men are more jealous
Delusional jealousy was more common in males and people with low educational and economic backgrounds. It was observed in patients in the early 20s through to the 70s; however, it was more frequent in the 30s to 50s age group. The majority of the patients with delusional jealousy were employed or had another source of income. No correlation between ethnicity and religion with delusional jealousy was observed. The majority of the patients were living together with their partners and children in the same house.
The majority of the patients were first visit patients. Follow up consultations were less. The authors of this research observed that it is possible that this is because they are less eager for subsequent visits. R.E. Drake, S.M. Essock, A. Shaner, K.B. Carey, K. Minkoff, L. Kola, D. Lynde, F.C. Osher, R.E. Clark and L. Rickards's “Implementing dual diagnosis services for clients with severe mental illness”, R.E. Drake, K.T. Mueser, M.F. Brunette and G.J. McHugo's “A review of treatments for people with severe mental illnesses and co-occurring substance use disorders”, R. Moos, J. Schaefer, J. Andrassy and B. Moos's "Out-patient mental health care, self‐help groups, and patients’ one-year treatment outcomes", C.A. Boyer, D.D. McAlpine, K.J. Pottick and M. Olfson's Identifying risk factors and key strategies in the linkage to out-patient psychiatric care" and D.C. Daley, I.M. Salloum, A. Zuckoff, L. Kirisci and M.E. Thase's "Increasing treatment adherence among out-patients with depression and cocaine dependence: Results of a pilot study" suggest that continuous care for psychiatric disorders can result in improved treatment outcomes, such as a decreased probability of re-hospitalisation. A.J. Mitchell and T. Selmes's "Why don’t patients attend their appointments? Maintaining engagement with psychiatric services" mentions that in psychiatric patients, continuation and maintenance phase treatment can reduce relapse and improve medication adherence and outcomes. Psychiatric patients who missed out-patient appointments and thus the continuing follow up were more likely to exhibit poor health and social dysfunction than ones who were regular at out-patient appointments with W. Katon, C. Rutter, E.J. Ludman, M. Von Korff, E. Lin, G. Simon, T. Bush, E. Walker and J. Unützer's "A randomized trial of relapse prevention of depression in primary care" noting that they had a greater likelihood of clinic dropout which led to subsequent admissions.
Aggressive approach
A definite majority of the study participants were males. This finding is different from De Silva and De Silva's which reported morbid jealousy in almost equal numbers in males and females; however, the latter study was conducted with patients who reported to a private psychiatric clinic. Only a minority of patients came from the private clinic in the instant study and thus the current study was more representative of the lower and middle socio-economic strata. There could have been more admissions and out-patient visits of male patients in the public sector for the fact that jealousy in men was more severe in nature than that of females as men were more likely to attack their partners while often, the injuries that they inflicted were more serious in nature as emphasised in P. Mullen and L. Maack's "Jealousy, pathological jealousy and aggression. Aggression and dangerousness". Therefore, there is a propensity that more males than females sought help or were directed towards treatments by their families.
Most of the reported cases were of Sinhalese Buddhists. A. Silva, M. Ferrari, G. Leong and G. Penny's "The dangerousness of persons with delusional jealousy" reported that there was no correlation between ethnicity and pathological jealousy.
Over 60% of the patients were living together with their partners in the same house which might precipitate a risk of violence towards the partners. Mullen et al. note violence associated with pathological jealousy. H.B. Mooney's "Pathologic jealousy and psycho-chemotherapy" adds that it also carries a risk for homicides. Partners as well as over 90% of children, which is a significant number, may well be affected from the subjective ambiance associated with delusional jealousy. Kingham et al. highlight how such a chaotic household due to ongoing jealousy related issues of a parent can lead to distress in children.
Delusional jealousy was observed across all social strata as measured by the economic level; however, the problem was not equally dispersed as it was more concentrated in the lower economic levels. The majority of the patients were employed which is indicative of the functionality of the patients, despite the condition. Thus, this may be one reason as to why the problem is under-recognized and under-reported for functionality that can be misinterpreted by the public as normality.
Never underestimate
Similarly, delusional jealousy was also seen in patients from all educational backgrounds; however, the problem was more intense in people with lower educational backgrounds.
The higher frequency of patients with a lower income and education background may be attributable to the origin of the sample. Of all the patients, 85.5% were reported from public institutions providing mental health services. Therefore, data can be more indicative of the lower economic classes. The lower economic and educational backgrounds were analogous.
J.A. Easton, T.K. Shackelford and L.D. Schipper's "Delusional disorder - jealous type: How inclusive are the DSM-Fourth edition diagnostic criteria?" explains that delusional jealousy is only a subset of the larger pathological jealousy patient population. Also, the cases of delusional jealousy reported to tertiary care mental health facilities may not reflect the socio-demographics of low intensity jealousy prevalent in the general population. The study sample was derived from mental health services, therefore, their severity was sufficient for referral. Due to the secretive and stigmatising nature of the symptom of delusional jealousy, it is possible that the frequency of delusional jealousy in this study is lower than the actual frequency.
The study findings suggest that follow up consultations among patients with delusional jealousy were less.