Abstract
In our experience, delusional disorders are common in forensic settings, an experience probably shared by other psychiatrists. Morbid jealousy is a common symptom in delusional disorders. Although there are few references in the literature, we have noticed an association between stalking behaviour and morbid jealousy.
Shepherd describes jealousy as a notoriously dangerous passion that constitutes a well-recognised motive for crimes of violence. By convention, ‘morbid jealousy’ refers to a pathological state arising in the context of a conjugal relationship. But he considers ‘delusions of infidelity’ a better description because it is infidelity that is suspected [1]. Shepherd states that morbid jealousy may arise in association with toxic and organic cerebral disorders, neurotic and personality disorders and functional psychoses.
Until recently, ADHD was considered rare; 3–5% of schoolchildren satisfy DSM-IV criteria and ICD-10 gives a lower prevalence [2]. Estimates of prevalence in adults are based on inference from child data and the natural history of the disorder [3]. It is accepted that the disorder usually ceases by puberty, although it may persist, manifesting as antisocial behaviour and drug abuse [2].
Levy [4] described hyperactivity as one extreme of normal behaviour in children, casting doubt on the validity of ADHD as a ‘disorder’. In his recent review of the evidence in support of adult ADHD, Sachdev [5] concluded that ‘our use of the concept … should proceed with cautious scepticism lest our clinical zeal outpaces scientific credibility’.
Clinical picture
A 42-year-old man, known as Leonard, was admitted through the court under Section 5 of the Criminal Law Mentally Impaired Defendants Act (1996) [6], charged with stalking a policeman, after making threatening telephone calls. The policeman and he had become friends through a local cricket club. Leonard emphatically denied sexual attraction towards this man. The day before his arrest Leonard was stopped by police as he drove repeatedly past his friend's house. Leonard had been drinking and a metal baton was discovered in his car.
Leonard believed his wife had an affair with the policeman. This belief was initially based on her distant manner. Later he had made a series of confirmatory observations. Because she complained of pain on intercourse, Leonard surmised the officer's penis had damaged her cervix. Leonard believed he found semen on bed sheets, which he sent for analysis. No semen was found on the sheet. This (lack of) evidence was discounted by Leonard. During their marriage they used amphetamine and methylenedioxy-methamphetamine recreationally. From reports in the media, Leonard diagnosed himself with ADHD. He presented to a psychiatrist who prescribed dexamphetamine but took more tablets than prescribed.
The first problems occurred on a trip overseas. Leonard became convinced that his wife had been drugged and coerced into sex with an associate. He surmised this from her behaviour in the company of the associate. To confirm this belief Leonard persuaded her to telephone the associate and initiate an obscene conversation while he listened. Leonard has mild hypospadias with an ectopic urethral orifice. He must sit on the toilet to urinate. While he was urinating the associate entered the bathroom and urinated in the handbasin. Leonard believed the man to be demonstrating the superior size of his penis and gloating over the sexual conquest of Leonard's wife.
Upon Leonard's return, the psychiatrist diagnosed psychosis and prescribed risperidone. Leonard took risperidone for 3 months becoming less delusional, then began to abuse amphetamine again. His psychosis returning, Leonard went to more extreme lengths to gather evidence of his wife's infidelity. He repeatedly put his hand down her pants to feel for ‘moistness’. On another occasion Leonard lay beneath the marital home feeling ‘sexual rhythms’ vibrating through the piles.
Organic screen revealed no abnormalities except for evidence of amphetamine in the urine, his IQ was 122. Diagnosis of paranoid psychosis was made and risperidone commenced. Despite the opposition of the police, Leonard was eventually returned to the community on the condition he abstain from stimulants.
Background
Leonard was born in the former Yugoslavia, migrating when he was two. Leonard's father suspected his mother of having an affair and raised doubts about his paternity. Consequently, Leonard's father was abusive towards him. Leonard's parents eventually separated.
Leonard had been married to his wife for 7 years, enjoying ‘threesomes’ with other men throughout. Despite this he called her several times daily to check on her, concealing his suspicions with affectionate interest.
Following an apprenticeship, Leonard started work in a company part-owned by his father, eventually becoming managing director.
Formulation
Leonard presented with stalking behaviour and was morbidly jealous. The jealousy arose from beliefs, considered delusional by the authors, in a marriage characterised by a high level of sexual activity. Leonard's domineering father was hypercritical and abusive towards him. We postulate that the punitive father was internalised in resolution of the oedipal complex when Leonard accepted that his mother was sexually unavailable to him. Involvement within the family business perpetuated the needs to please the hypercritical father.
Initially the fantasy of sexual control over his wife was so complete that Leonard was able to tolerate the inclusion of others within their sex life. The anxiety of losing his wife to a more sexually potent other was probably repressed. Intrapsychic tensions were enacted through television commercial fantasies, wherein Leonard was able to rescue his wife from a rival.
The use of psychostimulants led to an aroused state in which the conflicting desires to punish the infidelity and retain the relationship lead to an intolerable increase in intrapsychic tension. Leonard's persecuting internal object, experienced as an urge to punish and control, was split off and projected onto a friend. The quality of Leonard's relationship with his friend suggests the presence of homosexual feelings that may underlie the projection of persecutory ideas. His wife's involvement in the infidelity as a helpless and unwilling victim enabled her to remain idealised. In the context of a family system characterised by rigid rules based on distrust, apprehensiveness and hostility, this thesis took firm root and flourished [7].
Discussion
This case has many features worthy of comment. The familial context of jealousy is noted. Paradoxically, Leonard developed delusions of infidelity in an ‘open’ marriage. The paradox is resolved when Leonard's behaviour is understood as regression from neurotic (rationalisation, reaction formation and repression) to immature defence mechanisms (projection and splitting).
Even though of a mild degree, the hypospadias was significant. Leonard described having to urinate ‘like a woman’. A man urinating in the conventional manner was perceived to be flaunting his sexual superiority.
Initially, Leonard's distress was enacted in television advertisements. In reality, Leonard believed a policeman was the sexual rival. Escalation of distress lead to stalking behaviour. Numerous telephone calls were made involving threats to kill. Prior to his arrest Leonard was stopped by police, found to be intoxicated and in possession of a baton. Serious injury could have resulted. Assault and homicide have been associated with amphetamine abuse [8].
Mullen [9] notes that psychogenic formulations are sometimes ‘irresistible’ for clinicians working with the morbidly jealous. This case is no exception. Shepherd's original series described the syndrome in a man abusing amphetamine. In Leonard's case, we believe that the misuse of psychostimulants was the catalyst for development of morbid jealousy leading to offending behaviour.
The link between amphetamine use and psychosis has been well described. Connell described a syndrome characterised by ideas of reference and persecution and auditory and visual hallucination in the absence of confusion [10]. He believed that psychosis resolved rapidly as the drug cleared. Kalant thought that symptoms may persist for months to years [11]. The clinical distinction between schizophrenia and amphetamine psychosis is therefore unclear [12].
Psychotic reactions to amphetamine, although not clearly related to dose or duration, are so reliable that amphetamine psychosis is a widely used model of schizophrenia. Therefore it is of some concern to the authors that 9.6 million 5 mg tablets of dexamphetamine were dispensed in Western Australia in 1998 [13]. Western Australia's chief psychiatrist expressed concern about the excessive use of stimulants in ADHD in Western Australia [14]. AMA's Western Australian president describes a 21-fold increase in the rate of prescription of dexamphetamine as ‘a deeply disturbing trend’ [13]. We encounter many patients diagnosed with ADHD and prescribed amphetamines in our prison clinics.
DSM-IV defines mental disorder as a syndrome associated with distress, disability or increased risk of pain, death or loss of freedom [15]. Leonard was a highly successful man, manager of a thriving business. It is not clear that Leonard had a mental disorder at the time of his initial treatment. Fear of litigation is a strong determinant of medical practice. Unfortunately, in our experience of public forensic practice, such cases as this are not rare. We believe that it is only a matter of time before legal forces are brought to bear against practitioners who prescribe these medications for a controversial disorder.
Conclusion
This case has many interesting and unique features. We are unaware of other cases where psychopathology has been ‘acted out’ in television commercials. We highlight the potential serious risk associated with injudicious use of prescribed stimulants for a controversial diagnosis that is gaining popularity: ‘adult ADHD’. Clinicians should be aware that stalking behaviour and risk of serious violence may accompany morbid jealousy.