The Dangerousness of Persons with Delusional Jealousy J. Arturo Silva, MD, Michelle M. Ferrari, MD, reg or^ 9. Leong, MD, and Gary Penny, MD Delusional jealousy is an important subject for forensic psychiatry because of its well-known association with violence, especially as directed toward spouses. In this article, we report a study of 20 individuals who suffered from delusional jealousy. Important biopsychosocial parameters, the relation between jealousy and aggression, and directions for future study are explored. Delusional jealousy has received increasing it from the perspective of a forensic psy- recent attention from the psychiatric com- ~hiatrist.~.Even less work has been done munityIp4 and the public.5 This renewed to develop a comprehensive biopsychoso- interest is related to a greater appreciation cia1 perspective of delusional jealousy by of the linkage between delusional jealousy integrating neurobiological, psychologi- and subsequent aggression, especially ag- cal, ecological. and cultural parameters. gression associated with domestic vio- The objectives of this article are as fol- len~e.~63 Delusional jealousy may thus be lows: (1) to report important psychiatric one of the important variables to be studied and psychosocial characteristics in a sam- when addressing violence prevention or set- ple of 20 cases of delusional jealousy; (2) ting social policy in domestic or similar to explore the degree of dangerousness dyads. posed by these subjects; and (3) to initiate Despite renewed interest in the study of the development of a biopsychosocial delusional jealousy, relatively little sys- framework for understanding dangerous tematic work has been done to investigate delusional jealousy.8 Two cases of delu- sional jealousy are presented to highlight Dr. Silva is staff psychiatrist, National Center for Post- traumatic Stress Disorder, Clinical/Education Division, important characteristics of this poten- Palo Alto Veterans Health Care System, Menlo Park tially violent psychotic condition. Division, Palo Alto, CA. Dr. Ferrari is staff psychiatrist, Kaiser-Permanente Medical Group, Santa Clara, CA. Dr. Leong is Associate Professor of Psychiatry, Ohio State University College of Medicine, and Chief of Mental Health and Behavioral Science Service, Veterans Case 1 Affairs Outpatient Clinic, Columbus, OH. Dr. Penny is Mr. A is a 39-year-old Latino male Assistant Clinical Professor of Psychiatry, University of Texas Health Science Center at San Antonio. Address who was admitted to a psychiatric hospi- correspondence to: J. Arturo Silva, MD, Psychiatry Ser- tal secondary to experiencing feelings of vices (I70SJC). Veterans Affairs Outpatient Clinic, 80 Great Oaks Blvd., San Jose, CA 95 1 19. hostility toward his wife of 14 years be- J Am Acad Psychiatry Law, Vol. 26, No. 4, 1998 607 Silva, Ferrari, Leong, etal. cause he believed that she had engaged in stinence from alcohol resolved both his over 50 sexual relationships with other delusional jealousy and his hostility. men during their marriage. He accused his wife of having sexual intercourse with Case 2 a number of his family members, cowork- Mr. B is a 58-year-old white male who ers of his and Mrs. A, as well as with was admitted to a psychiatric inpatient many strangers. She denied these allega- unit because of increasing paranoid delu- tions, and no objective evidence could be sions, hostility toward his wife of 26 found to support Mr. A's accusations of years, and marked insomnia. He believed her infidelity. For the four years before that his wife had been sexually involved the index hospitalization, Mr. A had hit with several men that he had never met. his wife with his hands on a regular basis He also believed that his older daughter's hoping to extract a confession from her. husband had had sexual relations with On one occasion he had been jailed after Mrs. B. His wife corroborated that he had causing her a skull injury along with sig- exhibited ideas of jealousy commencing nificant facial bleeding. shortly after their marriage. During the four years before this admission, Mr. B Mr. A drank alcohol heavily and regu- frequently washed the bathroom, espe- larly. While intoxicated, his hostility, cially the toilet, to prevent being infected paranoia, and jealousy increased substan- with any sexually transmitted disease tially. He had no known history of vio- caused by Mrs. B's alleged sexual liai- lence independent of that associated with sons. Mr. B's history of physical aggres- jealousy. Mr. A also complained of in- sion directed at his wife, secondary to his somnia and ideas of reference. He had no anger toward her for alleged infidelity, nonpsychiatric medical disorders other consisted of pushing her twice. Recently, than non-insulin-dependent diabetes. however, he had begun threatening to cut which was controlled by diet. There was her with a knife or to kill her in her sleep. no positive family psychiatric history. Mr. B's escalating threats of violence fi- Mr. A's physical examination, includ- nally led to the index hospitalization. ing his neurological examination, was Mr. B had a history of continuous al- within normal limits. His serum chemis- cohol abuse starting in adolescence. Mrs. tries were within normal limits except for B complained that he invariably became an admitting serum glucose level of 176 more hostile and jealous when intoxi- mg%. His complete blood count, urinal- cated. While intoxicated he responded to ysis, and electroencephalograph (EEG) visually hallucinated companions. He de- were normal. The computed tomographic nied any history of experiencing alcohol (CT) scan of his brain revealed diffuse withdrawal symptoms, and no withdrawal atrophy. Mr. A met DSM-IV criteria for symptoms or signs were observed during paranoid schizophrenia and alcohol de- the index hospitalization. Mr. B displayed penden~e.~One month of treatment with mood lability. Independently of paranoia 4 mg of risperidone daily along with ab- related to his delusional jealousy, he also 608 J Am Acad Psychiatry Law, Vol. 26, No. 4, 1998 Dangerousness of Persons with Delusional Jealousy believed that he was continually moni- and EEG results. Table 3 presents infor- tored by others who wanted to harm him, mation pertaining to the object of the particularly passers-by in front of his delusional jealousy and on aggression as- house. Mr. B had no previous history of sociated with delusional jealousy. Table 4 psychiatric hospitalization and had never describes psychotic symptoms that co- been in prison. occurred with delusional jealousy in our Mr. B's physical and neurological ex- sample. aminations were within normal limits. Concerning the identity of the putative His complete blood count, serum chem- paramour of the spouse, 12 individuals istries, urinalysis, urine drug screen, and stated that at least some of these par- EEG were unremarkable. A brain CT amours were known. Three were relatives scan showed diffuse cerebral atrophy. of the jealous individual, including two Mr. B met DSM-IV criteria for para- sons-in-law and one brother-in-law. Four noid schizophrenia." Treatment with 6 were acquaintances of the jealous person, mg of risperidone daily in combination and five were acquaintances of the alleg- with abstinence from alcohol signifi- edly unfaithful spouse. None of the puta- cantly decreased but did not completely tive paramours that were identified were resolve his delusional jealousy. However, attacked, and no serious threats of harm his hostility toward his wife essentially to them by the jealous person were re- disappeared. corded. Treatment outcome was globally re- Methods and Results corded from the medical charts according Delusional jealousy has been defined to whether delusional jealousy and other as the belief in the infidelity of one's accompanying psychotic symptoms ei- spouse or lover that reaches delusional ther resolved, improved, or no change intensity." " Our clinical sample con- was noted. All 12 subjects with schizo- sists of 20 subjects who suffered from phrenia were treated with neuroleptic delusional jealousy and who were evalu- medication. Two of these experienced ated by the authors between 1990 and complete resolution of their delusional 1995. The sample was derived from var- jealousy: and six experienced some iin- ious hospitals and locked forensic psychi- provement. Four of the 12 were treated atric facilities. Relevant clinical and fo- with atypical neuroleptics. two with clo- rensic data were gathered retrospectively zapineI2 and two with risperidone.'" by record review. Diagnoses were made Those treated with clozapine experienced to conform to DSM-IV criteria." some improvement. Of the two treated Table 1 details demographic informa- with risperidone. one experienced total tion of our sample and information re- resolution of delusional jealousy. while garding the onset of psychosis and delu- the other experienced some improvement. sional jealousy. Table 2 provides 111 addition to neuroleptics, treatment for information regarding diagnosis, sub- three of those with schizophrenia, cases stance use, and available neuroimaging 13, 14, and 19. also included valproic J Am Acad Psychiatry Law, Vol. 26, No. 4, 1998 Silva, Ferrari, Leong, et al. Table 1 Demographics and Temporal Course of Delusional Jealousva Case Marital Age of Onset No. Status Ethnicity Psychosis Delusional Jealousy 2 3 2 2 3 3 2 2 1 3 1 3 2 3 1 1 1 2 3 2 "M = male; F = female. m = married; s = single; d - divorced; sp = separated. 1 = black; 2 = white Hispanic; 3 = other white. acid, phenytoin, and carbamazepine, re- to risperidone. Two of the three subjects spectively. All three experienced some (cases 6 and 15) with direct brain pathol- reduction of delusional jealousy. ogy improved with the use of neuroleptic Case 4, who suffered from a psychotic medication; however, one of these two disorder not otherwise specified and was also received carbamazepine and a tricy- treated with neuroleptic medication, ex- clic antidepressant. The third individual perienced no improvement in his delu- with brain pathology (case 12) had no sional jealousy.