Dr. Miller is Associate Professor, Department of Advanced Practice Nursing, Mr. Kummerow is Special Purpose Faculty, and Dr. Mgutshini is Associate Professor, Department of Baccalaureate Nursing Completion, Indiana State University, Terre Haute, Indiana.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Marcia A. Miller, PhD, RN, Associate Professor, Department of Advanced Practice Nursing, Indiana State University, 749 Chestnut Street, Terre Haute, IN 47809; e-mail: Marcia.Miller@indstate.edu.
Jealousy, fears of infidelity, and the potential for violence toward self or significant others are the hallmarks of Othello syndrome, a rare delusional disorder. Othello syndrome is named after the main character in one of Shakespeare’s plays, The Tragedy of Othello, the Moor of Venice, written in 1603. In the play, Othello is married to Desdemona but grows increasingly suspicious that she is having an affair with one of his lieutenants. In a jealous rage, Othello smothers Desdemona to death. Othello later discovers that she was not unfaithful, but that he had been the victim of deceit and manipulation from an envious rival, Iago. Feeling extreme remorse, Othello commits suicide.
Othello syndrome, sometimes referred to as delusional, pathological, morbid, or erotic jealousy, is a delusional disorder with high-risk implications. The potential for violence to not only self but also others makes this syndrome of interest to clinical practitioners in psychiatric settings. Because Othello syndrome is rare, practitioners may have encountered patients with this delusional disorder without proper identification. In providing care for patients with Othello syndrome, nurses need to focus on assessments and interventions that are appropriate to the etiology and symptoms. This article presents an overview of the causes, symptoms, assessment strategies, and interventions for this type of jealous delusional disorder.
Interest was initially stimulated by the care of a patient with Othello syndrome in a community mental health center. During the interprofessional team conference, the physician presented the diagnosis as Othello syndrome. Although the mental health staff was confident in caring for patients with delusional disorders, many were not familiar with this diagnosis. As the clinical nursing educator at the facility and member of an affiliate university, one of the authors (M.A.M.) was an integral member of a staff training program related to this diagnosis. The cornerstone of the staff development program was based on an actual patient. Several years later, this author encountered a second patient at a community health care facility, corroborating the suggestion by Kingham and Gordon (2004) that although Othello syndrome is rare, most clinicians are likely to encounter individuals with this disorder. Additional expertise on the topic is provided by another witnessed patient and presented in the following individual example, in which one of the authors (T.M.) participated as a member of the care team.
The patient, a 54-year-old man, had been transferred from a forensic psychiatric unit after 4 years of compulsory inpatient treatment after being found guilty of strangling his wife to death during an episode of severe psychotic jealousy. In the months leading up to the incident, reports indicated that the patient had become delusionally obsessed with the belief that his wife was having numerous adulterous relationships with most of the male customers who came to their jointly owned liquor store.
The patient had stated that his wife was overly friendly with male customers and that this was evidence enough of her tendency toward extramarital relationships. The patient added that when his wife spoke, he had visualizations of her being intimate with other men. In the weeks leading up to the incident, the patient had voiced his accusations to his siblings and was often overheard yelling threats of violence toward his wife.
On the day the patient strangled his wife, the two had an argument about his accusations. In a moment of rage, the patient strangled his wife and then tried to kill himself by taking an overdose of alcohol and sedative medication. An assessment of the patient’s behavior leading up to the incident and reports from previous relationships revealed he had consistent obsessive jealous tendencies that often culminated in violence toward his partners.
During the patient’s hospitalization, pimozide (Orap®) 2 mg twice daily and lorazepam (Ativan®) 2 mg as needed every 4 hours were administered for a 6-month period. The patient experienced initial improvement in sleep, and his delusions decreased in duration and frequency. Follow-up treatment included regular therapy sessions from the team psychologist for an additional 18 months.
The patient did not experience any exacerbations of the delusional symptoms after the medication was discontinued. However, equally notable was the fact that he had not been involved in an intimate relationship since his discharge from the forensic unit and therefore had not been exposed to the type of relationships that posed the highest risk of relapse up to the point of discharge. Even so, the patient’s responsiveness to both the pharmacological and psychological interventions was taken as indicative of treatment success. The patient agreed to and complied with a postdischarge monitoring plan that involved monthly review by a local psychiatrist.
Delusional thoughts in general are common and have been well described in the literature. However, a more specific search for Othello syndrome reveals the limited attention given to this condition within the literature. Some confusion remains on the terminology when describing Othello syndrome, but regardless of the name, its occurrence is rare. Although the majority of the literature on the topic is from the 1980s and 1990s, a literature search yielded several recent articles.
The prevalence of Othello syndrome relative to generic paranoid disorders is rare. Although the actual number of individuals with Othello syndrome is unclear, the American Psychiatric Association (APA) (2000) estimates the prevalence of delusional disorder—jealous type is <1% of the population, as reported in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR).
Much of the literature suggests that a complete medical work-up in addition to psychiatric support is essential for determining possible etiologies in patients with Othello syndrome. Verbal and physical aggression, suicide, and homicide of both the partner and alleged lover have been reported (Goggins, Emerson, & Nowers, 2004; Kingham & Gordon, 2004; Mukai, 2003; Yusim et al., 2008).
Kingham and Gordon (2004) suggested that Othello syndrome may be a misleading term. They stated that morbid jealousy is not a unitary syndrome as the name suggests but rather a “result of a number of psychopathologies within separate psychiatric diagnosis” (p. 207). The authors reported that Othello syndrome is more prevalent in men, is unrelated to ethnicity, and has an average age of onset of 38. Comorbidities such as personality disorders, mental illness, and substance misuse are typically associated with morbid jealousy. Kingham and Gordon (2004) believed that morbid jealousy is a syndrome rather than a diagnosis, and as such, the diagnosis should be treated rather than the syndrome. With the syndrome’s risk for serious harm, the authors concluded that early identification and diligent treatment is key to preventing serious harm.
Mukai (2003) reported on a 98-year old Japanese man with no psychiatric history who accused his 89-year-old wife of infidelity after she had been admitted to a nursing home for dementia. He demanded that she be allowed to return home although he was not capable of taking care of her. Computed tomography revealed brain atrophy with multiple cerebral infarctions, and he was also diagnosed with dementia. In addition, a diagnosis of Othello syndrome was included as he continued to insist that his spouse was unfaithful despite contradictory evidence. The patient was started on a regimen of lorazepam for disturbance in sleeping patterns and tiapride (Tiapridal® and others), a dopamine antagonist, for relief of delusions with good results. The patient’s jealousy resolved within months of adherence to the medication regimen.
Goggins et al. (2004) reported on the possible relationship between hyperparathyroidism and Othello syndrome. The authors reported a 75-year-old woman with no previous psychiatric history who developed a delusional belief that her husband was having an affair with a neighbor. The patient’s family reported that she had exhibited increased agitation and aggressive behavior toward her husband 1 month prior to admission, and the family also confirmed that an actual affair was unlikely. Routine bloodwork showed hypercalcemia and hypophosphatemia. Further investigation revealed an adenoma on the right upper pole, and the patient was diagnosed with primary hyperparathyroidism. The patient refused surgical removal of the adenoma, citing that she felt well and that the risk outweighed the benefit. Ultimately, the patient was started on quetiapine (Seroquel®) and her morbid jealousy subsided.
Yusim et al. (2008) described a 71-year-old Eastern European woman with a history of mild depression and anxiety for the past 6 years without professional intervention. The patient accused her 76-year-old husband of 50 years of cheating on her with every woman he saw. As her suspicions increased, her aggression increased and was described by her family as uncharacteristic. The patient’s symptoms included severe headaches, ataxia, mild incontinence, and jealous delusions. Magnetic resonance imaging of her brain revealed normal pressure hydrocephalus related to narrowing of the aqueduct of Sylvius. The patient underwent a ventriculostomy, which led to improvements in her ataxia and incontinence but no resolution to the delusions. Several drug regimens were attempted including donepezil (Aricept®), memantine (Namenda®), quetiapine, ziprasidone (Geodon®), olanzapine (Zyprexa®), pimozide, and valproate (Depacon®) without significant improvements.
Defining Delusional Disorders
According to the DSM-IV-TR (APA, 2000), a person who is experiencing a delusional episode would have false fixed beliefs that cannot be changed through logic and reason. Delusions may be a symptom related to other psychiatric disorders such as psychosis, delusional disorders, organic mental disorders, and substance abuse. In cases of delusional disorders, the delusion is plausible and involves situations that could occur in everyday life and that have been reported for at least 1 month.
Common subtypes of delusions include grandeur, persecution, somatic, mixed type, and jealousy. Numerous terms have been used to describe delusional jealousy including morbid jealousy, delusions of infidelity, and Othello syndrome. The content of the morbid jealousy delusion may be well defined with great details and be consistently repeated.
Symptoms associated with Othello syndrome or morbid jealousy have been treated with myriad approaches. The basis for its treatment and associated nursing interventions must be understood in the context of etiological theories, with the most prominent focusing on the acknowledgement that pathological jealousy may result from biological or cognitive and behavioral disturbance. These competing explanatory frameworks confirm the fact that Othello syndrome represents a broad range of possible diagnostic and prognostic categories that include but are not exclusive to delusional disorders.
The DSM-IV-TR categorizes Othello syndrome as existing in either psychotic or nonpsychotic form (APA, 2000). Delusional phenomenon is most associated with the psychotic jealousy subtype, whereas non-psychotic pathological jealousy is reported primarily as narcissistic-paranoid personality disorder or variant obsessive-compulsive disorder. Depending on the nature of the symptoms, different treatment approaches are indicated (Table 1). The treatment of Othello syndrome must be preceded by a comprehensive assessment, not only to confirm the existence of a diagnosis but also to differentiate between delusional psychotic and nonpsychotic jealousy types, which dictates the choice of treatment most likely to be successful.
Table 1: Overview of Pathological Jealousy and Treatment Options
The initial assessment of patients includes a medical history and physical examination. A family history of psychosis or a past hospitalization for schizophrenia, schizophreniform, or schizoaffective disorders may support a diagnosis of a more pervasive psychiatric disorder. The physical assessment must also examine for any recent or past brain injury or infection. Laboratory values and diagnostic tests may also indicate an alteration in the physiological integrity of the neurological system, which may broaden the scope of treatment beyond antipsychotic medications. A family history of domestic violence and the reality of past infidelity should also be investigated with a reliable historian.
Assessment of delusional thoughts should be accomplished through nonintrusive, gentle questioning. Ideally, clinicians should establish a basic trust or at least an initial rapport with patients. Examples of assessment questions are listed in Table 2. All questions and answers should be validated with a supportive other.
Table 2: Patient Assessment of Delusional Jealousy
Treatment of Psychotic Jealousy
Delusional jealousy in the psychotic-paranoid spectrum tends to be persistent, intractable, and unresponsive to interpersonal discussion. This limits the potential for meaningful initial engagement in talking therapies. This presentation concurs with schizophreniform disorder, and as with any classic psychotic delusional disorder, the objective of treatment is to alleviate psychotic delusional symptoms.
A low-dose antipsychotic agent is the first line of pharmacological treatment, especially when a level of psychosis has been assessed. Pimozide 2 mg daily for several weeks is specifically indicated for monosymptomatic delusional states such as paranoid jealousy ideations and obsessive-compulsive disorder. Haloperidol (Haldol®) 5 mg daily, quetiapine 200 mg daily, and aripiprazole (Abilify®) 15 mg are alternatives to pimozide. All of these pharmacological interventions are moderately successful in short-term management of delusional ideation but often result in extrapyramidal side effects when used long term. This limits their utility as a long-term management intervention.
To ameliorate this, pharmacological interventions should be complemented with a talking therapy that supports meaningful changes in the patient’s affect, behavior, and cognition, and it is in this stage of treatment where the principles of dialectical behavior therapy (DBT) have proven useful in modifying maladaptive emotional and behavioral responses. The staged treatment of paranoid-delusional disorders first with antipsychotic pharmacological intervention followed by cognitive-behavioral approaches is widely accepted as the preferred approach to treatment. In several studies by the United Kingdom’s National Institute for Health and Clinical Excellence (NICE) (2002), this approach to treatment has proven to be 33% to 50% more effective than traditional single-therapy interventions.
Treatment of Nonpsychotic Jealousy
Developed by Linehan (1993), DBT is the psychological treatment of choice for a range of borderline personality disorders and offers transferable benefits to patients with pathological jealousy, especially when psychotic and delusional symptoms have been dismissed or are minimal and patients can engage in therapeutic discussion. Based on the combined application of traditional cognitive-behavioral techniques for impulse and emotional self-regulation and reality testing with the Buddhism-derived concept of mindful awareness, the framework for DBT is centered on two codependent philosophical tenets:
- Pathologically jealous patients are likely to have backgrounds that have, in some way, invalidated them, and for any progress to occur, they should be given unconditional acceptance as a basis for a beneficial, therapeutic alliance.
- Any DBT interventions must be supported by a total commitment from patients to accept at some level a need for change. This acceptance must be based on patients’ acknowledgement that their emotional responses (in the context of their primary personal relationship) have been a source of difficulties (Dimeff & Linehan, 2001).
DBT has four modules that describe the therapeutic milestones patients must be supported through by the clinician. As indicated in Linehan’s work and other subsequent manuals on DBT (Bateman & Fonagy, 2000; Verheul et al., 2003), therapy should be conducted by trained clinicians who apply each of the expected therapeutic steps and also have the expertise to skillfully work with patients who may initially lack insight and motivation to address their jealousy as a condition that warrants treatment.
Staff Development for Best Practice
Due to the unique nature of Othello syndrome, inservice sessions for all members of the treatment team should be provided to help refresh the care of delusional patients in general and as an opportunity to present the available research related to this syndrome.
Safety of Self and Others
Patients with Othello syndrome exhibit complex delusional thinking that heightens the need to consider patient safety issues. Central to this issue is the need to identify all individuals who might be at risk. The primary responsibility of nurses is the safety of patients and any other individuals who may be affected. If there is an imminent danger to patients or other identifiable individuals, nurses are bound by the principle of duty to warn to breach patient confidentiality and make reasonable attempts to notify individuals at risk of harm, as well as others in a position to protect those individuals from harm. These individuals may include spouses, significant others, or their alleged lovers.
Suicide risk must be considered. In inpatient settings, no-suicide contracts are often used between patients and nurses. These contracts typically have an explicit written or verbal statement in which patients agree not to harm or kill themselves within an agreed-on time frame in which patients believe they can remain safe. Initially, the duration of these contracts may be as short as an hour and increase to the length of a shift, and then end when suicidal thoughts have ceased. The use of no-suicide contracts has become somewhat controversial, with little research supporting their effectiveness; however, many institutions continue to use some form of the contract.
On entering an inpatient facility, patients should be searched for dangerous objects including drugs or medication, lighters, matches, sharp objects, weapons, and knives, as well as for belts, shoelaces, draw-strings, or anything else that could be used for strangulation. It should be explained to patients that any items found will be returned and that the search is intended for their safety. If patients are suicidal, it may be necessary to keep them within line of sight at all times, and a search of their belongings may be justified once per shift and as needed to ensure safety.
It is important to validate patients’ thought content with a reliable historian to determine whether content is indeed delusional and not reality. Occasionally, an outrageous story that has been assumed to be delusional during treatment has been discovered to be true.
Managing Delusional Disorder
Basic communication principles of managing patients with delusions should be reviewed. Varcarolis and Halter (2010) recommend a variety of therapeutic communication techniques. These include:
- Using a matter-of-fact and supportive response to suspicions.
- Avoiding arguments or debates with patients about delusional content.
- Assessing the content of the delusion by asking patients to describe the delusion.
- Encouraging reality-based conversation.
- Attempting to cast the possibility of doubt (e.g., “Could that really be true?”) after patients accept the possibility that their thoughts may not be true.
Roberts and Stock (2008) categorize the care of delusional patients into the three domains of biological, social, and psychological. In the biological domain, nurses establish consistent activities of daily living related to nutrition, hygiene, and sleep. Nurses should also promote psychotropic medications and treatment adherence. In the social domain, nurses provide family education about the syndrome, information about treatments, and possible resources for support. Psychological care should start with the establishment of a trusting relationship, followed by helping patients set realistic treatment goals. Nurses should help patients identify triggers or precipitating factors. Patients should be encouraged to demonstrate a variety of coping skills including problem solving and reality testing with a trusted support person (Roberts & Stock, 2008).
Prior to discharge, nurses should assist patients and their family to develop a crisis plan to prevent violent acting-out behavior. Postdischarge follow-up care may include family therapy to foster open communication, problem solving, and medication evaluation. If initial symptoms were precipitated by an underlying medical condition, ongoing medical care should be arranged to prevent reoccurrence.
The risk of serious harm and the potential for homicide or suicide related to Othello syndrome make early identification and aggressive treatment imperative. The delusional jealous thoughts make it necessary to protect not only patients but also all individuals whom patients suspect may be involved. Precautions should be initiated to protect patients, and nurses should be familiar with the principle of duty to warn, which allows nurses to breach confidentiality to notify any individuals who may be at risk through patients’ actions.
A complete history and medical work-up is required to effectively treat any comorbidity that may be the precipitating factor in delusional thoughts. A thorough assessment is required not only to confirm the diagnosis but also to differentiate between psychotic and nonpsychotic jealousy to more effectively treat patients. As with any psychiatric assessment, it is essential to first establish rapport with patients; nonintrusive questioning can then provide insight into assessment of delusional jealousy.
Myriad approaches have been used to treat delusions, including both pharmacological and non-pharmacological approaches. Although psychotic jealousy may best be treated with a pharmacological agents, nonpsychotic jealousy may best be treated with DBT.
Although Othello syndrome is rare, most psychiatric clinicians will eventually be exposed to a patient exhibiting such symptoms. Considering the potential for serious consequences of this syndrome, staff inservice training is recommended to help staff more easily identify and act prudently with patients who have delusional disorders and help avert the possibly tragic consequences associated with Othello syndrome.
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
- Bateman, A.W. & Fonagy, P. (2000). Effectiveness of psychotherapeutic treatment of personality disorder. British Journal of Psychiatry, 177, 138–143. doi:10.1192/bjp.177.2.138 [CrossRef]
- Dimeff, L. & Linehan, M.M. (2001). Dialectical behavior therapy in a nutshell. The California Psychologist, 34, 10–13.
- Goggins, R., Emerson, C. & Nowers, M. (2004). Othello syndrome in association with primary hyperparathyroidism. Psychiatry Online. Retrieved from the Priory Medical Journals website: http://www.priory.com/psych/othello.htm
- Kingham, M. & Gordon, H. (2004). Aspects of morbid jealousy. Advances in Psychiatric Treatment, 10, 207–215. doi:10.1192/apt.10.3.207 [CrossRef]
- Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
- National Institute for Health and Clinical Excellence. (2002). Clinical guidelines on the core interventions in the treatment and management of paranoid disorder in primary and secondary care. London: Department of Health.
- Mukai, T. (2003). Tiapride for pathological jealousy (Othello syndrome) in elderly patients. Psychogeriatrics, 3(3), 132–134. doi:10.1111/j.1479-8301.2003.00019.x [CrossRef]
- Roberts, N. & Stock, R. (2008). Schizoaffective, delusional, and psychotic disorders. In Boyd, M.A. (Ed.), Psychiatric nursing: Contemporary practice (4th ed., pp. 325–347). Philadelphia: Lippincott Williams & Wilkins.
- Varcarolis, E.M. & Halter, M.J. (Eds.). (2010). Foundations of psychiatric mental health nursing: A clinical approach (6th ed.). St. Louis: Saunders Elsevier.
- Verheul, R., Van Den Bosch, L.M., Koeter, M.W., De Ridder, M.A., Stijnen, T. & Van Den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomized clinical trial in The Netherlands. British Journal of Psychiatry, 182, 135–140. doi:10.1192/bjp.182.2.135 [CrossRef]
- Yusim, A., Anbarasan, D., Bernstein, C., Boksay, I., Dulchin, M. & Lindenmayer, J.P. et al. (2008). Normal pressure hydrocephalus presenting as Othello syndrome: Case presentation and review of the literature. American Journal of Psychiatry, 165, 1119–1125. doi:10.1176/appi.ajp.2008.07111820 [CrossRef]
Overview of Pathological Jealousy and Treatment Options
Delusional disorder “jealous type”
Narcissistic or paranoid personality disorder
Variant obsessive compulsive personality disorder
Low-dose antipsychotic medication (e.g., pimozide [Orap®], 2 mg daily for several weeks, or haloperidol [Haldol®], 5 mg daily for several weeks)
Rapid onset of symptom resolution (within 4 weeks of treatment initiation)
Medicalization of symptoms externalizes the blame for irrational emotional responses by patients
Difficulties with treatment compliance
Extrapyramidal side effects
Risk of overdose contraindicated in high-risk psychopathology
DBT (Linehan, 1993)
No significant risk of unwanted side effects from DBT
Behavioral changes resulting from DBT can be sustained permanently
DBT is a resource-intensive therapy—progress is slow relative to pharmacological interventions (several months compared with 4 weeks with pharmacological treatments)
DBT is clinically researched for personality disorder presentations and is less effective with patients whose illness has an organic basis
Patient Assessment of Delusional Jealousy
|• “Do you ever experience thoughts that others around you do not believe?”
|• “Do other people think your thoughts are strange and unusual?”
|• “Do you have distressing thoughts about your spouse (partner)?
|• “Do you trust your spouse (partner)?
|Be careful not to lead patients into passive agreement about relationship concerns. If suspicion is present, determine whether additional questions are appropriate based on the patient’s anxiety and agitation level.
|• “How long have you had these thoughts?”
|• “How long do these thoughts last?”
|• “Who is included in these thoughts?”
|• “Do these thoughts interfere with your other activities?”
|• “Have you ever acted on any of these thoughts?”
|The initial assessment should also address a risk assessment to the alleged lover, thoughts of suicide, and homicidal ideations toward the spouse or partner.
|• “Have you though about hurting the person you think is having an affair with your spouse (partner)?”
|• “Have you thought about hurting or killing yourself? If yes, on a scale of 0 to 10, with 0 being not at all and 10 being very strong, how serious are you about these thoughts?”
|• “Have you thought about hurting or killing your spouse (partner)?”