Jealousy: Psychiatric Diagnosis
Jealousy refers to an emotional response that emerges when an interpersonal relationship is impacted by another person. Jealousy is functional because it alerts individuals to the presence of a rival and motivates behavioral responses to minimize the impact of a rival on valued interpersonal relationships. For example, people become jealous in response to partner infidelity, new members of social relationships, and parent-sibling interactions. However, some people experience jealousy in the absence of a threat or rival and maintain such beliefs even in the presence of disconfirming evidence (Cipriani et al. 2012). In these cases, jealousy is no longer functional because it can lead to expending energy and resources fending off a rival that does not exist (Kingham and Gordon 2004). In the context of intimate relationships, when jealousy is not based on a real threat and is persistent despite contrary evidence, it is known as delusional jealousy (similar constructs include pathological jealousy, Othello syndrome, morbid jealousy, conjugal paranoia) and is applied to sexual jealousy. There are no psychiatric disorders that encompass pathological jealousy between siblings, friends, or other non-intimate social relationships. A person afflicted with delusional jealousy interprets their partner’s actions based on how they feel, and irrational thoughts about their assumptions being true initiates even more fear, rage, and insecurity (Seeman 2016). This form of jealousy may be characterized by an individual making unfounded accusations to their partner, demanding reassurances, wanting to know the thoughts of their partner, or spying (Seeman 2016).
Delusional jealousy is characterized by a range of irrational thoughts and extreme behavior in response to the belief that one’s partner is being sexually unfaithful (Kingham and Gordon 2004) without reasonable or objective evidence (Easton et al. 2008). These individuals will continue to insist on the occurrence of infidelity, even if evidence to the contrary is presented (Kingham and Gordon 2004).
Delusional Disorder-Jealous Type
Delusional jealousy is not classified as a stand-alone disorder and is often considered a syndrome rather than a diagnosis (Kingham and Gordon 2004). A clinical diagnosis relevant to sexual jealousy is in the Diagnostic and Statistical Manual (DSM-5; American Psychiatric Association 2013) which includes diagnostic criteria for delusional disorder-jealous type. The current criteria for delusional disorder includes: (1) having one or more delusions over the course of a month or longer; (2) does not meet criteria for schizophrenia; (3) a person is not necessarily severely impaired or oddly behaved; (4) if person also presents mania or depression, their duration must be less than the duration of delusions; (5) symptoms are not due to other physiological issues or use of substances and cannot be better explained by another diagnosis. In addition to the general diagnosis, the DSM-5 (APA 2013) uses specifiers to identify the central theme of the delusions being experienced. These include Erotomanic type, Grandiose type, Jealous type, Persecutory type, and Somatic type, Mixed type, or Unspecified type. Diagnoses also specify if there is bizarre content, and after a year’s duration of the disorder, the number of episodes a person has experienced must be identified, in addition to the current state of their episode (acute, in partial remission, or in full remission). While not necessary for diagnosis, there is also a severity specifier to note the frequency of symptoms (APA 2013).
The subtype of delusional disorder, jealous type is applied when the central theme of an individual’s delusion is that his or her spouse or lover is unfaithful. The belief of infidelity is without due cause, based on incorrect interpretations of small bits of evidence. The delusional individual often confronts the partner and attempts to intervene in the imagined infidelity (APA 2013). A problem with the DSM-5 criteria regarding sexual jealousy pathology is an over-emphasis on delusions, which does not account for other types of sexual jealousy such as Othello syndrome, morbid jealousy, or conjugal paranoia. This lack of differentiation leaves it unclear if these represent different types of sexual jealousy or if they are part of a broader category of jealousy-related disorders (Easton et al. 2008).
Prevalence of Delusional Disorder-Jealous Type
Delusional disorder-jealous type is considered the “purest” diagnosis of delusional jealousy, because it is not accompanied by additional psychopathology (Kingham and Gordon 2004). The APA (2013) estimates that the lifetime prevalence of delusional disorder is about 0.02%; however, the estimated prevalence of jealous type specifically is not noted.
Easton et al. (2008) studied case histories that included delusional jealousy and alternative titles that are often used to indicate the same disorder (morbid jealousy, pathological jealousy, conjugal paranoia, and Othello syndrome). All 398 case histories reviewed included some form of morbid jealousy, and 283 of these experienced delusions around partner infidelity for over 1 month. This is the first and most relevant DSM diagnostic criterion for delusional disorder-jealous type. Easton et al. (2008) identified the frequencies of the cases that matched each individual DSM-IV-TR diagnostic criteria for delusional disorder-jealous type, and then ultimately the frequency of cases that met all five of the criteria among psychiatric patients with delusional jealousy. Of the 398 case histories, it was determined only 16 (4%) of cases met all five DSM-IV-TR diagnostic criteria and were thus determined to have delusional disorder-jealousy type (Easton et al. 2008).
The Easton et al. (2008) study elucidates an important point, that individuals who experience delusional jealousy can meet some of the criteria of delusional disorder-jealous type but not enough to earn the diagnosis. Also, considering that only 4% of the jealousy-pathology cases reviewed met all criteria for delusional disorder-jealous type, it is possible that the current criteria are not inclusive enough to capture other jealousy pathologies (Easton et al. 2008).
Soyka and Schmidt (2011) analyzed case histories from 2000–2008 at a psychiatric inpatient facility in Germany. Seventy-two of 14,309 case histories were found to have delusional jealousy, with delusional disorders accounting for 11.1% of these cases specifically (Soyka and Schmidt 2011). This study did not separate delusional disorder-jealous type from other typologies, thus the relative frequency cannot be determined. The case histories analyzed in this study all had psychiatric diagnoses, so in the other 88.9% of cases, delusional jealousy was attributed to another mental disorder (Soyka and Schmidt 2011).
Other DSM-5 Diagnoses
In the DSM-5, there are psychiatric diagnoses that are comorbid with jealousy. Depression can accompany delusions of infidelity that stem from feeling inadequate in the context of a romantic relationship, though it is unclear if the depression leads to the delusions or is a result of them (Kingham and Gordon 2004). In Easton’s (2008) sample which had some form of pathological jealousy, 309 of the 398 cases reviewed were determined to have some type of psychological disorder, 40 (12.9%) of which were diagnosed with depression, making it the second most common psychological disorder in which pathological jealousy was present. The case analysis conducted by Soyka and Schmidt (2011) did not examine depression specifically but found that mood disorders (as diagnosed by the ICD-10) accounted for 19.4% of cases identified as having delusional jealousy. To distinguish the cause of delusions in these cases, it is important to review the chronology of the mood disturbance, the delusions, and the severity of mood symptoms (APA 2013). If delusions are only present in a depressive or bipolar disorder during a mood episode, the primary diagnosis would be that particular mood disorder (i.e., “bipolar disorder psychotic features” would be added as a specifier to explain delusional jealousy as being present during an episode; APA 2013).
Soyka and Schmidt (2011) found that the highest prevalence of delusional jealousy occurred in patients diagnosed with a psychotic disorder, and Easton et al. (2008) found that 27 of 309 cases with delusional jealousy also had an official diagnosis of schizophrenia/paranoid schizophrenia. Delusions of infidelity may arise as a component of schizophrenia, in the form of persecutory delusions experienced during psychosis (Kingham and Gordon 2004). However, the bizarre associations that are characteristic of schizophrenia are not necessarily focused on sexual infidelity, and these individuals experience other unrelated symptoms of psychosis. Individuals with delusional disorder-jealous type do not describe bizarre associations,but coherent descriptions of plausible situations in which their partner is being unfaithful (Kingham and Gordon 2004). The DSM-5 confirms that individuals diagnosed with delusional disorder will not exhibit symptoms characteristic of schizophrenia, such as “prominent auditory or visual hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms” (p. 104).
Organic brain disorders can also lead to delusional jealousy. In fact, delusional jealousy has been found to occur most frequently in patients with neurological disorders (Graff-Radford et al. 2012). At least 30% of cases with a delusion of infidelity can be linked to some form of neurological condition (Cipriani et al. 2012). For example, delusional jealousy is not uncommon in different forms of dementia, such as Alzheimer’s disease (Tsai et al. 1997; Cipriani et al. 2012).
In their analysis of clinical and imaging features, Graff-Radford et al. (2012) found that of the 105 patients that met criteria delusional jealousy, 73 met criteria for a neurological disorder. Neurodegenerative disorders accounted for 76.7% of these neurological disorders, most commonly Alzheimer’s disease, Lewy body disease, and a behavioral variant of frontotemporal dementia (Graff-Radford et al. 2012). Compared to matched neurodegenerative patients without delusional jealousy, those with it exhibited greater grey matter loss predominantly in the dorsolateral frontal lobes of the brain. Graff-Radford et al.’s (2012) main finding was that delusional jealousy is found in a variety disorders often related to frontal lobe dysfunction and/or damage.
An individual with a neurocognitive disorder may present with the same symptoms identified in delusional disorder-jealous type. As with mood disorders, it is important to review the chronology of the onset or exacerbation of delusional jealousy to see if it parallels the course of the neurological disorder or damage to the brain. If it does, the associated DSM-5 diagnosis would be a neurocognitive disorder, with delusional jealousy as a result of this disorder (APA 2013).
Similarly, an individual with substance or medication induced psychotic disorder could meet the criteria for delusional disorder. In reviewing the timeline of substance use and onset and remission of the delusions, the substance can be considered or ruled out as the cause (APA 2013). For example, dopaminergic medications used to treat Parkinson’s disease have been linked to delusional jealousy (Poletti et al. 2012). Graff-Radford et al. (2012) found that individuals who had Parkinson’s disease without dementia exhibited delusional jealousy after an increase in dopamine agonist medication. When the medication was reduced or stopped, the delusions dissipated. They found a similar trend with patients who were treated with stimulant medications, which also affect dopamine (Graff-Radford et al. 2012).
Delusional jealousy is not currently recognized as a stand-alone diagnosis, even in the most recent version of the DSM (APA 2013). While Delusional disorder-jealous type does capture the presentation of delusional jealousy, the exclusion criteria for this specific disorder leave many instances of pathological jealousy unidentified. Perhaps if delusional jealousy were an independent disorder, it could be categorized into typologies by its relation to different disorders (i.e., delusional jealousy, resulting from active mood disorder). This way, if delusional jealousy were a prevalent psychological condition, it could be clinically identified and given more specific attention in the context of treatment. The identification of delusional jealousy could also be the presenting symptom that may lead to the identification of treatable underlying conditions such as disorders of mood, psychosis, and neurology. It also could inform the treatment of such underlying disorders, perhaps alerting providers to find alternatives to medications that are dopaminergic in nature or using an antipsychotic medication to counter its effects.