Abstract
A 20-year-old woman with a history of migraine presented to her family practitioner with collapse and left hemiplegia. The patient was admitted to the hospital where serial computed tomography (CT) scan showed an evolving haemorrhagic cerebrovascular infarction in the right deep parietal and frontal regions extending into the basal ganglia and including the right caudate nucleus. Duplex ultrasound of the carotids was normal. The infarct was initially thought to be secondary to the use of oral contraceptives and smoking.
The patient made a good recovery with almost total return of function, but 1 month later presented with sudden collapse and transient loss of vision. She was again admitted and developed fever and a flu-like syndrome with headache, nausea and increasing left-sided weakness. On this admission, blood studies for vasculitis and lupus were negative as were carotid ultrasounds and echocardiography. Repeated CT scans of the head showed no change in the previously noted right middle cerebral artery territory lesion and no new haemorrhage or infarct. Headache and nausea persisted and the patient was given a single dose of sumitriptan which led to dramatic improvement in symptoms. The patient was felt to be suffering from severe migraine with hemiplegia and was discharged with instructions to use sumitriptan as needed.
The patient's left hemiplegia diminished with regular exercise over 6 months leaving only very slight hyperreflexia, weakness in her left arm and left leg and slight left facial weakness. She reported some decrease in visual acuity and reduced concentration but was able to finish a course of academic study and then work in various junior management positions. After 2 years, she developed a mutually satisfying intimate relationship with a young man.
However, during the subsequent 3-year period, she became increasingly ‘jealous’ and ‘possessive’ of her partner, accusing him of having sex with his co-workers and with neighbours. The patient became preoccupied with these thoughts, persistently questioning and accusing her partner to the point of causing great distress in their relationship. At one point, the patient could not bear to go to the movies with her partner because of thoughts that he was developing sexual interest in the women in the film. As the relationship deteriorated, the patient became increasingly depressed and threatened to cut her wrists.
She was seen by her general practitioner and started on a tricyclic antidepressant. Several days later, after an accusatory argument with her partner, she took an overdose of approximately 30 25 mg tricyclic tablets and was taken to the hospital emergency room where she rapidly became comatose, had a grand mal seizure and developed ventricular dysrhythmia requiring cardiac defibrillation.
The patient recovered over several days but remained depressed and despondent, expressing the wish that she had died because she felt she ‘could not go on’ feeling as she did about her partner. She continued to be anxiously preoccupied with her imagined relationship problems and accepted referral to the community mental health centre. Mental status exam revealed a well-groomed, cooperative and spontaneous young woman who was tearful and complained of persistent thoughts of her partner's infidelity. The patient was unsure if these ideas were absolutely true but said that she was unable to stop thinking them. She denied other delusions, phobias, compulsions or hallucinations and showed no gross cognitive deficits. A trial of paroxetine was begun.
Psychometric testing revealed an IQ on the 90th percentile; however, it was noted that she did not use her left hand at all during fine coordination subtests. On specific tests of frontal lobe function, she performed poorly, reaching only the 24th percentile on the controlled word association test. Her ‘draw a body’ was of poor quality and scored one standard deviation under the mean score for her age. The tester felt that although there was evidence of right frontal lobe damage, her personality and intelligence allowed her to cover the resulting deficits well.
Clinical review of the patient after 6 weeks on 40 mg paroxetine mane revealed a considerable improvement in mood and an almost complete resolution of the obsessional concerns and preoccupation with the boyfriend's activities and attraction to other women. As she became more confident and less needy, the relationship broke up at the boyfriend's instigation. Although distressed by this and experiencing lowered self-esteem, she managed to tolerate the loss and her delusional jealousy did not resurface. After several months, she entered another relationship without the development of jealousy and she remains on paroxetine.
Discussion
Although relatively rare, the symptom of morbid jealousy has been the focus of psychiatric interest for many years and has recently been examined from psychoanalytic [01, 2]], cognitive [3, 4]] and phenomenological [5] perspectives. Clinical reports have noted the association of morbid jealousy with a wide variety of organic aetiologies including ‘extrapyramidal syndromes, neoplasms, Alzheimer's disease, right and left hemisphere infarction, encephalitis, multiple sclerosis, epilepsy and substance abuse'[6].
Current diagnostic classification is unclear and may vary with the intensity of the belief, the presumed aetiology and whether the jealousy is seen as a symptom or a syndrome. If the jealousy is of psychotic proportion, DSM-PV allows for a specific diagnosis either as ‘delusional disorder, jealous type’ or, if an organic condition is shown to be causal, as a ‘psychotic disorder due to general medical condition’. Psychotic jealousy may also be seen as a symptom of affective psychosis or other psychotic processes. Non-psychotic jealousy has been seen as a part of a narcissistic or paranoid personality disorder and has also been described as a variant of obsessive-compulsive disorder [7]. In the case presented here, the false belief is accompanied by some degree of doubt and therefore may be more obsessional than psychotic. A formal method for assessing the degree of delusionality in such cases has recently been described [8] and could be of use in further delineating the syndrome. Establishing a subset of both psychotic and non-psychotic cases with clear organic aetiology would assist in developing a better diagnostic nomenclature.
While most reports of delusional jealousy have not included adequate neurological evaluation, Malloy and Richardson have estimated that at least 30% of cases in the recent literature most probably had a neurological basis for their delusion of infidelity [9]. It is hypothesised that focal damage to the right hemisphere and frontal lobes plays an important part in the genesis of ‘content specific delusions’ due to the role of the right hemisphere in producing the experience of familiarity and the role of the frontal lobes in correcting misperceptions on the basis of new information. These neurological elements are seen to combine with psychodynamic factors to produce specific delusions.
In the case described here, the deep right parietal and frontal cerebrovascular insult with basal ganglia and caudate involvement does not permit precise localisation. However, the event was followed over a 5-year period by the gradual development of a severe syndrome of pathological jealousy, which in turn led to a near fatal suicide attempt. While the long delay before the development of symptoms raises the possibility that the right hemisphere stroke predisposed the patient to a depressive illness with secondary jealousy, her initial presentation suggested the opposite: that is, that an intense preoccupation with jealous thoughts led to feelings of helplessness and depression. In either case, treatment with an selective serotonin re-uptake inhibitor (SSRI) was of value, possibly by improving both depression and frontal lobe functioning [10].
This case illustrates the importance of understanding delusional jealousy appearing at any age in a broader neuropsychiatric context and the need to consider neurological or neuropsychological evaluation. Also raised is the possibility of a more precise diagnostic terminology.