Othello Syndrome: Delusional Disorder - Jealous Type ≠ Violence.

BACKGROUND: Othello syndrome, also known as morbid jealousy, pathological jealousy, and conjugal paranoia, is a rare delusional disorder related to partner's infidelity. There are no large scale or comprehensive studies on delusional jealousy, and only few case reports and cases series leave delusional disorder jealous type (DDJT) largely unknown. Herein, we report a case of DDJT, its possible etiology and describe its characteristics, comorbidities, and interventions.

CASE DESCRIPTION: A 65-year-old married, retired, and disabled Caucasian male with a history of closed traumatic brain injury and chronic pain presented for outpatient care accompanied by his wife with a chief complaint of paranoid delusions. The patient was a car racer when he sustained over 25% total body surface area burns after his motor vehicle crashed at the speed of almost 160 mph. The patient was in a coma for more than nine weeks, coded three times, and was resuscitated each time. Per imaging, the patient suffered subarachnoid hemorrhage to the right outer parietal and left front parietal lobes. The patient developed chronic pain from the extensive burns and has been on opioids for many years until he gradually tapered himself off about six years ago. For the last couple of years, the patient has experienced cognitive decline associated with disorientation and memory deficit. The patient has been perseverative on his wife's trip two years ago during which the patient believed that she had an affair with one of their mutual acquaintances. The patient denied visual or auditory hallucinations and continued to express his love and affection toward his wife. Although his wife has continually provided reassurance, and multiple family members confirmed her faithfulness, the patient had minimal insight into his delusion and expressed disappointment in loss of sexual intimacy between him and his wife. The patient has been prescribed duloxetine 60mg and trazodone 150mg, and his mood, anxiety, and sleep have been stable. The patient has also started taking pimozide 1mg nightly since beginning of this year with good response.

DISCUSSION: The DSM estimates the prevalence of DDJT to be less than 1%. At least a third of cases show neurological basis involving frontal lobe dysfunction associated with strokes, Parkinson's disease, brain trauma and tumors, neurodegenerative disorder, encephalitis, multiple sclerosis, and even normal pressure hydrocephalus. Association with alcohol, amphetamine, cocaine, and dopamine therapy (pergolide, ropinirole, levodopa, amantadine, and pramipexole) were reported. Finally, DDJT is known to be a risk factor of violent crimes including homicide. Treatment with pimozide shows the strongest evidence, and most patients show improvement with any antipsychotic medication along with CBT. Continued research and further clinical trials are warranted for DDJT considering patients' positive response to interventions, and because DDJT can become a dangerous condition in forensic situations.