Australian and New Zealand Journal of Psychiatry (1976) 10: 47
JEALOUSY AS A SYMPTOM OF PSYCHIATRIC DISORDER* by P. C. 5. HOAKEN**
1. Classidirshtion Jealousy is a state of thinking and feeling characterized by resentment directed toward another person or area of interest because of known or suspected rivalry in a triadic relationship involving a subject, object, and rival. (Fig. 1 ) . The object is viewed with conscious ambivalence, the positive aspect of which is usually not an altruistic love, but a possessive desire. A suspicion of sexual infidelity is the outstanding feature in cases of jealousy, and it is surprising how frequently jealousy about diversion of interest is translated into a question of sexual fidelity. Nevertheless, this is not an essential feature, complaints sometimes being only on the basis of diversion of interest. Triadic jealousy is classified in Fig. 2. Unprovoked jealousy is called morbid or pathological jealousy. Provoked jealousy is also of interest even though it may be normal. In spite of the destructive aspects of this emotion, it may be completely understandable as a reaction to a person’s frustrated desire to preserve a significant emotional relationship. Normal jealousy, which runs a natural course, is experienced in relation to a blow to self-esteem, raising doubts that may have had their origin in early experiences. According t o the Transactional Analysis point of view, we are all to some extent “not O.K.”. More adventuresome views of close relationships sanction and even encourage other sexual encounters.
Distressed drop-outs from these arrangements may berate themselves for being weak or immature, although the jealousy they feel is only what the psychiatrist expects. For example, a 22 year old woman in psychotherapy became the common-law wife of a fellow student who persuaded her that he should be allowed to continue his sexual relationship with another girl. She concurred with his criticism that she was selfish because of her jealous feelings and pleas that he give up the other woman, despite her conventional background that made her jealousy completely understandable.
*Presented at the First Pacific Congress of Psychiatry; Melbourne, May 1975. **Psychiatrist-in-Chief, Hotel Dieu Hospital, Ontario, Canada.
For example, a 34 year old woman sought psychiatric treatment because of emotional turmoil related to ten years of marital dispute following the discovery that her husband had had an affair with a neighbour
Norms for affectionate human relationships vary from one culture to another. Ruth Benedict (1946) wrote of the Dobu people: “Faithfulness is not expected between husband and wife, and no Dobuan will admit that a man and woman are together even for the shortest interval except for sexual purposes’’; but of the Zuni she wrote that unfaithfulness is seen only as a first step in changing husbands. The Todas tribe of southern India, both polygamous and polyandrous, do not know jealousy in the western sense (Ford, Beach, 1951), but jealousy has been reported in polygamous unions in Kenya (Hunter, 1974). Provoked excessive jealousy, termed “neurotic” by Karen Horney (1937), is different from normal jealousy only in degree. In some cases there is only one provoking event that results in an agony of jealousy for the afflicted partner.
Downloaded from anp.sagepub.com at Bobst Library, New York University on April 26, 2015
JEALOUSYAS
48 JEALOUSY
I
SUBJECT
- THE
A
SYMPTOM OF PSYCHIATRIC DISORDER
TRIAD
I
1 . \ “S”
AMBIVALENCE
JEALOUSY
AFFECTION? SEXUAL INTEREST? RIVAL “R”
Figure 1. Jealousy - the Triad. when she was pregnant for their first child. She had found respite from recurrent feelings of suspicion and jealousy only during a two year “separation” throughout which she and her husband continued their sexual relationship. Once they reunited, her inability to forgive him and her suspicious accusations against him resumed. Of interest here, was the association of the patient’s jealousy with de facto marriage, i.e. living together, which she took as a
sanction for her resentful possessiveness. Similar cases of a sole indiscretion have been noted by Todd and Dewhurst (1955). Most cases of neurotic jealousy occur because of repeated or prolonged provocation. Two remarkably similar cases were army wives in their 30’s who had been married in their early 20’s to handsome, young looking men. Each marital relationship had features of a mother-adolescent son relationship. However, the jealous reactions of these women when their husbands were unfaithful were entirely different. Whereas one was outraged and angry, hiding the car keys from her husband and attacking him physically, the other was depressed and listless, crying pitifully, taking anxiolytics and seeking admission to hospital. The rival need not be human. It can be a pet animal or some activity of the object which the subject does not share and therefore resents because it takes too much of the object’s interest. This type of jealousy, though only a part of the clinical picture, is revealing of underlying problems. Unprovoked (morbid) jealousy is of three types: a personality trait; an obsessive suspicion; and lastly, a welcomed suspicion or fixed delusion. “Unprovoked” implies no other rival, not that the jealous subject does not see provocation. He frequently finds it in the object’s everyday behaviour. Obsessive suspicions, like other obsessions, are unwelcome, repetitively intrusive thoughts. The patient with jealous suspicions or delusions easily finds evidence to support them. There are likely to be other paranoid features in such patients like ideas of being poisoned, of sexual potency being impaired, and of contracting VD. In light of newer theories
CLASSIFICATION OF TRIADIC JEALOUSY
/
I P R O V NEUROTIC") OKED
\
UNPROVOKED (IRRATIONAL. ALWAYS EXCESSIVE)
NORMAL
INITIALLY PROVOKED
REPEATEDLY
I
PERSONALITY TRAIT
iROVOKED1 HUMAN NON HUMAN RIVAL RIVAL
OBSESSIVE DELUSIONAL
Figure 2. Downloaded from anp.sagepub.com at Bobst Library, New York University on April 26, 2015
P. C. S . HOAKEN of paranoid development, it is interesting to compare delusions of infidelity (which we might term the phantom or imaginary rival syndrome) with the phantom lover syndrome (Seeman, 1971) and Clerambault’s erotomania where the lover is not a phantom, but only an acquaintance. 11. Clinical Syndromes and Exaunples Morbid jealousy can be a symptom of several disorders, organic as well as functional. Restriction of space precludes accounts of specific organic examples, although worth mentioning is an example of a brother and sister, children of a suspicious and jealous father, who developed delusions of infidelity as the presenting symptoms of presenile dementia.
Of the functional disorders, a diagnosis of paranoid schizophrenia is common when there are delusions of infidelity although these are not likely to be such a prominent feature as they are in other paranoid syndromes The usual examples of delusional jealousy is usually consistent with a diagnosis of conjugal paranoid state. Mrs. R., a 50 year old Roman Catholic mother of five, developed angry accusations of infidelity against her husband. He had been elected reeve of the township a year earlier at the same time a 45 year old female secretary had been appointed to take minutes of the evening meetings. Mrs. R. had found evidence of her husband’s indiscretion: lipstick and semen stains in his handkerchief and dirty marks on the knees and elbows of his suits. Independent investigation left no doubt that Mr. R. was being falsely accused. A follow up of this patient eleven years after her treatment indicated that she had recovered from her illness completely without relapse. Important causal factors in her illness were thought to be: ( 1 ) A strict upbringing; her parents had taught her “you might better die than do wrong”. (2) An early marriage that precluded enjoyment of casual adolescent dating. (3) Intensification of sexual desire after the menopause when concern about pregnancy had abated. (4) Husband’s heart trouble and older age resulting in a decline in sexual interest on his part. ( 5 ) Her personality, reported as “always somewhat jealous”. Shepherd‘s study (1961) of 81 cases found 6 in which morbid jealousy occurred within the course of a major depressive illness, often related to the depressed person’s feelings of unworthiness. An example is that of a 34 year old woman who always recognized a problem with confidence and self-esteem. She developed the idea that her husband was having an affair with her close friend. Her condition was diagnosed as a serious depression which remitted after six ECT. Embarrassed about her formerly held belief, she apologized to her friend and to her husband. Obsessive jealous thoughts are different from jealous suspicions in that they are quite easily recognized by the patient as ego dystonic.
49
An example is that of a 25 year old man married two years, who was referred for psychiatric assessment because he had become plagued with recurrent doubts about his wife’s fidelity. This case was a fortuitious example of a one session cure. In the course of the interview, the young man confessed one episode of infidelity himself, shortly after his marriage. Toward the end of the interview he asked me: “Doc, do you suppose it’s my own guilt coming back at me?” The usual type of patient with recurrent jealous suspicions has a personality disorder with features of unrecognized dependency needs, uncertain selfesteem, possessiveness, and, frequently, alcohol abuse. Mr. T., a 19 year old man, had been bothered by recurrent suspicions about his wife’s infidelity. He was so possessive of her that he prevented her from seeing a doctor during her pregnancy because he could not stand the thought of another man putting his hands on her. During his wife’s first pregnancy, he became so suspicious and angry with his wife when he was drinking that he kicked her in the abdomen. According to Shepherd (1961) such patients are usually men, and jealousy “constitutes an indissoluable component of their attitudes toward their sexual partners”. Stress makes the jealousy worse, often inducing pathological delusions which recede after tho crisis subsides.
HI. Etiology Jaspers ( 1963) distinguished jealousy as a personality trait from jealousy as a new process, i.e. a symptom appearing in the course of an acute disorder. Freud (1922) described the three layers or stages of jealousy as ( 1 ) competitive or normal, ( 2 ) projected, ( 3 ) delusional. The roots of normal jealousy for Freud are found in the oedipal complex. Projected jealousy results from repression of the jealous subject’s experiences or impulses, and as an absolution of his conscience. JEALOUSY FORMULATIONS FREUD I LOVE HIM. (DENIED) I DO NOT LOVE HIM: SHE LOVES HIM. (SUBJECT) (OBJECT) (RIVAL) SULLIVAN I AM NOT GOOD ENOUGH (AS A LOVER) TO BE LOVED: I AM UNLOVABLE. THEREFORE SHE LOVES HIM WHO IS BE?TER. SCHWARTZ SHE DOES NOT LOVE ME BECAUSE I AM UNLOVABLE. NOBODY CARES WHAT I HAVE (DENIED) EVERYBODY WANTS WHAT I HAVE. ~
Figure 3.
Downloaded from anp.sagepub.com at Bobst Library, New York University on April 26, 2015
50
JEALOUSYAS
A SYMPTOM OF PSYCHIATRIC
Delusional jealousy, Freud believed, results from repressed impulses toward unfaithfulness with the same sex, an acidulated homosexuality: “I do not love him; she loves him”. Although this formulation has been retained in psychoanalytic theory, it has not found favour with most post-freudian theorists who have written about jealousy. While acknowledging the validity of the theory of projected jealousy, they have elaborated on possessiveness and emotional dependence as they relate to feelings of inferiority, a theme not fully developed in orthodox psychoanalytic writing, although Fenichel ( 1945) mentions this aspect of jealousy. Sullivan (1956) and recent theorists such as Salzman (1963), Ovesey (1955), Schwartz (1963), and Langfeldt (1962), have all favoured a poor selfesteem model variously described as inferiority, social humiliation, feeling unlovable. They have ignored or repudiated Freud’s repressed homosexuality formula and have suggested alternative formulations (Fig. 3 ) .
IV. Provoking or Aggravating Factors Alcohol abuse by the patient with the jealous personality usually brings out jealous attitudes, probably because of its disinhibiting effect on the CNS and its inhibition of erectile potency. Mooney (1965) found that of his 12 cases, patients with a jealous personality tended to be male alcohol abusers with a family history of jealousy; whereas the converse was true for patients whose disorder arose as a new process. Since infidelity was so common in the jealous personality patients reported by Shepherd (1961), this may be a significant aggravating factor for those with jealous personalities as well as the most important provoking factor in cases of obsessive jealousy. The most important factor in new process morbid jealousy is some disparity in sexual desire between the subject and object. In all 5 female patients reported by Modlin (1963) reduction in frequency of intercourse preceded the development of delusions. Interpersonal feedback is important: the object who is repeatedly accused falsely is not likely to feel warmly towards the accuser, adding to the reasons for the jealousy especially in someone with an insatiable need for affection.
V. Parlnem of Jealous Subjects The circumspect behaviour required of unjustly accused partners is so stressful that they will present as patients as often as will the jealous accusers. Depression is the commonest disorder diagnosed. Some will show a neurotic complimentarity, like the wife of Mr. T. who, when asked how she felt about her husband’s violence, suggested: “I guess he just loves me a lot”.
VI. Assessanent Tactics Chronicity of jealousy or recurrent bouts of jealousy suggest a jealous personality; whereas a disorder of recent onset in a person with a good premorbid
DISORDER
personality suggests an acute disorder of which depression, especially one marked by defensive projection, is the most common. If the dominant feeling is sadness and whatever anger exists is directed toward the rival, a diagnosis of depression is most likely. A predominant feeling of anger toward the object suggests a paranoid syndrome. If the rival is a phantom, and if the psychiatrist has difficulty empathizing with the patient, the diagnosis of paranoid schizophrenia is likely. How does the patient judge the jealous beliefs? If they are completely ego-alien it is likely a case of obsessive jealousy. The more easily accepted they are, the more invested with interest and affect, the more likely the diagnoses of depressive psychosis or paranoid state. It is important to determine how firmly the beliefs are held. A hypothetical question is useful. (Can the patient imagine that there could be evidence proving his suspicions and accusations false?) Patients with fixed delusions cannot imagine this.
VI1. Management of the Functional Disorders Be aware of overt or covert depressive illness in patients who have morbid jealousy as a new process. The presence of fixed delusions favours the use of ECT. Although patients with paranoid schizophrenia are most often helped by neuroleptics, patients with paranoid state are not predictably helped, although these agents are likely worth a try. Control of excessive drinking may be the most important part of treatment for the patient with a jealous personality. One of Shepherd‘s patients was, in effect, cured when she became abstinent. The psychotherapist should try to appreciate how badly the jealous patient feels, allowing him a limited and appropriate discharge of anger. If the ideas are not fixed, the therapist may be able indirectly to open areas of doubt about the conclusions the patient has drawn, and to help the patient focus on his exaggerated need for affection, and his poor self esteem. The jealous subject usually feels completely at the mercy of the object, and emotional dependence intensifies the anguish. If the patient can realize that he himself is responsible for his feelings and choices, he can also take significant steps to help himself. Patients with strongly jealous personalities are difficult to treat. Recently, Marks (1975) reported the use of behaviour therapy in treating a man with recurrent jealous suspicions. Forensic aspects should not be overlooked. The psychiatrist should ask himself “Would it be consistent with this person’s life style for him to take violent revenge and/or kill himself in despair?” Psychiatrists are kept aware of such cases by the dramatic murders and murder-suicides that are reported in the daily press.
Downloaded from anp.sagepub.com at Bobst Library, New York University on April 26, 2015
Jealousy as a symptom of psychiatric disorder has been neglected. For example, the 1600 page Comprehensive Textbook of Psychiatry contains only 15 lines devoted to jealousy, and yet jealousy is a symptom appearing frequently in patients. This overview may serve as a reminder of its importance in our work.
REFEREN'CES Benedict, Ruth. (1946). Patterns of Culture. New American Library, New York. Fenichel, 0. ( 1945). The Psychoanalytic Theory of Neurosis. W. W. Norton & Co. Inc., New York. Ford, C. S., and Beach, F. A. (1951). Pafterns of Sexual Behavior. Harper & Bros., New York. Freud, S. (1959). Certain neurotic mechanisms in jealousy, paranoia and homosexuality (1922) in Collected Papers, Vol. 111. Basic Books Inc, New York. Homey, K. (1937). The Neurotic Personality of Our Time. W. W . Norton & Co. Inc., New York. Hunter, M. (1974). Me and the local witch doctor, Cnnadian Doctor, 40: 57. Jaspers, K. (1963). General Psychopathology. University of Chicago Press, Chicago, Illinois. Langfeldt, G. (1962). The erotic jealousy syndrome. Journal of Neuropsychiatry, 3: 317.
Marks, Isaac. (1975). The Current Status of Behavioural Psychotherapy: Theory and Practice. Presented at the 128th Annual Meeting, American Psychiatric Association, Anaheim, California, May 7. Modlin, H. C. (1963). Psychodynamics and management of paranoid states in women. Archives of General Psychiatry, 8: 263. Mooney, H. B. (1965). Pathologic jealousy and psychochemotherapy. British Journal of Psychiatry, 111: 1023. Ovesey, L. ( 1955). Pseudohomosexuality, the paranoid mechanism and paranoia. Psychiatry, 1 6 163. Salzman, L. ( 1963). Paranoid state - theory and therapy. Archives of General Psychiatry, 8: 263. Schwartz, D. A. (1963). A re-view of the "Paranoid" concept. Archives of General Psychiatry, 8: 349. Seeman, Mary V. (1971). The search for Cupid or the phantom-lover syndrome. Journal of the Canadian Psychiatric Association, 16: 183. Shepherd, M. (1961). Morbid jealousy: some clinical and social aspects of a psychiatric symptom. Journal of Mental Science, 107: 687. Sullivan, H. S. (1956). Clinical Studies in Psychiatry. W. W. Norton & Co. Inc., New York. Todd, J., and Dewhurst, K. (1955). The Othello syndrome. Jortrnal of Nervous and Mental Disease, 122: 367.
Reprint requests to: P. C. S. Hoaken, M.D. Psychiatrist-in-Chief Hotel Dieu Hospital Department of Psychiatry (Queen's University) Kingston, Ontario Canada Downloaded from anp.sagepub.com at Bobst Library, New York University on April 26, 2015
JEALOUSY AS A SYMPTOM OF PSYCHIATRIC DISORDER* by P. C. 5. HOAKEN**
1. Classidirshtion Jealousy is a state of thinking and feeling characterized by resentment directed toward another person or area of interest because of known or suspected rivalry in a triadic relationship involving a subject, object, and rival. (Fig. 1 ) . The object is viewed with conscious ambivalence, the positive aspect of which is usually not an altruistic love, but a possessive desire. A suspicion of sexual infidelity is the outstanding feature in cases of jealousy, and it is surprising how frequently jealousy about diversion of interest is translated into a question of sexual fidelity. Nevertheless, this is not an essential feature, complaints sometimes being only on the basis of diversion of interest. Triadic jealousy is classified in Fig. 2. Unprovoked jealousy is called morbid or pathological jealousy. Provoked jealousy is also of interest even though it may be normal. In spite of the destructive aspects of this emotion, it may be completely understandable as a reaction to a person’s frustrated desire to preserve a significant emotional relationship. Normal jealousy, which runs a natural course, is experienced in relation to a blow to self-esteem, raising doubts that may have had their origin in early experiences. According t o the Transactional Analysis point of view, we are all to some extent “not O.K.”. More adventuresome views of close relationships sanction and even encourage other sexual encounters.
Distressed drop-outs from these arrangements may berate themselves for being weak or immature, although the jealousy they feel is only what the psychiatrist expects. For example, a 22 year old woman in psychotherapy became the common-law wife of a fellow student who persuaded her that he should be allowed to continue his sexual relationship with another girl. She concurred with his criticism that she was selfish because of her jealous feelings and pleas that he give up the other woman, despite her conventional background that made her jealousy completely understandable.
*Presented at the First Pacific Congress of Psychiatry; Melbourne, May 1975. **Psychiatrist-in-Chief, Hotel Dieu Hospital, Ontario, Canada.
For example, a 34 year old woman sought psychiatric treatment because of emotional turmoil related to ten years of marital dispute following the discovery that her husband had had an affair with a neighbour
Norms for affectionate human relationships vary from one culture to another. Ruth Benedict (1946) wrote of the Dobu people: “Faithfulness is not expected between husband and wife, and no Dobuan will admit that a man and woman are together even for the shortest interval except for sexual purposes’’; but of the Zuni she wrote that unfaithfulness is seen only as a first step in changing husbands. The Todas tribe of southern India, both polygamous and polyandrous, do not know jealousy in the western sense (Ford, Beach, 1951), but jealousy has been reported in polygamous unions in Kenya (Hunter, 1974). Provoked excessive jealousy, termed “neurotic” by Karen Horney (1937), is different from normal jealousy only in degree. In some cases there is only one provoking event that results in an agony of jealousy for the afflicted partner.
Downloaded from anp.sagepub.com at Bobst Library, New York University on April 26, 2015
JEALOUSYAS
48 JEALOUSY
I
SUBJECT
- THE
A
SYMPTOM OF PSYCHIATRIC DISORDER
TRIAD
I
1 . \ “S”
AMBIVALENCE
JEALOUSY
AFFECTION? SEXUAL INTEREST? RIVAL “R”
Figure 1. Jealousy - the Triad. when she was pregnant for their first child. She had found respite from recurrent feelings of suspicion and jealousy only during a two year “separation” throughout which she and her husband continued their sexual relationship. Once they reunited, her inability to forgive him and her suspicious accusations against him resumed. Of interest here, was the association of the patient’s jealousy with de facto marriage, i.e. living together, which she took as a
sanction for her resentful possessiveness. Similar cases of a sole indiscretion have been noted by Todd and Dewhurst (1955). Most cases of neurotic jealousy occur because of repeated or prolonged provocation. Two remarkably similar cases were army wives in their 30’s who had been married in their early 20’s to handsome, young looking men. Each marital relationship had features of a mother-adolescent son relationship. However, the jealous reactions of these women when their husbands were unfaithful were entirely different. Whereas one was outraged and angry, hiding the car keys from her husband and attacking him physically, the other was depressed and listless, crying pitifully, taking anxiolytics and seeking admission to hospital. The rival need not be human. It can be a pet animal or some activity of the object which the subject does not share and therefore resents because it takes too much of the object’s interest. This type of jealousy, though only a part of the clinical picture, is revealing of underlying problems. Unprovoked (morbid) jealousy is of three types: a personality trait; an obsessive suspicion; and lastly, a welcomed suspicion or fixed delusion. “Unprovoked” implies no other rival, not that the jealous subject does not see provocation. He frequently finds it in the object’s everyday behaviour. Obsessive suspicions, like other obsessions, are unwelcome, repetitively intrusive thoughts. The patient with jealous suspicions or delusions easily finds evidence to support them. There are likely to be other paranoid features in such patients like ideas of being poisoned, of sexual potency being impaired, and of contracting VD. In light of newer theories
CLASSIFICATION OF TRIADIC JEALOUSY
/
I P R O V NEUROTIC") OKED
\
UNPROVOKED (IRRATIONAL. ALWAYS EXCESSIVE)
NORMAL
INITIALLY PROVOKED
REPEATEDLY
I
PERSONALITY TRAIT
iROVOKED1 HUMAN NON HUMAN RIVAL RIVAL
OBSESSIVE DELUSIONAL
Figure 2. Downloaded from anp.sagepub.com at Bobst Library, New York University on April 26, 2015
P. C. S . HOAKEN of paranoid development, it is interesting to compare delusions of infidelity (which we might term the phantom or imaginary rival syndrome) with the phantom lover syndrome (Seeman, 1971) and Clerambault’s erotomania where the lover is not a phantom, but only an acquaintance. 11. Clinical Syndromes and Exaunples Morbid jealousy can be a symptom of several disorders, organic as well as functional. Restriction of space precludes accounts of specific organic examples, although worth mentioning is an example of a brother and sister, children of a suspicious and jealous father, who developed delusions of infidelity as the presenting symptoms of presenile dementia.
Of the functional disorders, a diagnosis of paranoid schizophrenia is common when there are delusions of infidelity although these are not likely to be such a prominent feature as they are in other paranoid syndromes The usual examples of delusional jealousy is usually consistent with a diagnosis of conjugal paranoid state. Mrs. R., a 50 year old Roman Catholic mother of five, developed angry accusations of infidelity against her husband. He had been elected reeve of the township a year earlier at the same time a 45 year old female secretary had been appointed to take minutes of the evening meetings. Mrs. R. had found evidence of her husband’s indiscretion: lipstick and semen stains in his handkerchief and dirty marks on the knees and elbows of his suits. Independent investigation left no doubt that Mr. R. was being falsely accused. A follow up of this patient eleven years after her treatment indicated that she had recovered from her illness completely without relapse. Important causal factors in her illness were thought to be: ( 1 ) A strict upbringing; her parents had taught her “you might better die than do wrong”. (2) An early marriage that precluded enjoyment of casual adolescent dating. (3) Intensification of sexual desire after the menopause when concern about pregnancy had abated. (4) Husband’s heart trouble and older age resulting in a decline in sexual interest on his part. ( 5 ) Her personality, reported as “always somewhat jealous”. Shepherd‘s study (1961) of 81 cases found 6 in which morbid jealousy occurred within the course of a major depressive illness, often related to the depressed person’s feelings of unworthiness. An example is that of a 34 year old woman who always recognized a problem with confidence and self-esteem. She developed the idea that her husband was having an affair with her close friend. Her condition was diagnosed as a serious depression which remitted after six ECT. Embarrassed about her formerly held belief, she apologized to her friend and to her husband. Obsessive jealous thoughts are different from jealous suspicions in that they are quite easily recognized by the patient as ego dystonic.
49
An example is that of a 25 year old man married two years, who was referred for psychiatric assessment because he had become plagued with recurrent doubts about his wife’s fidelity. This case was a fortuitious example of a one session cure. In the course of the interview, the young man confessed one episode of infidelity himself, shortly after his marriage. Toward the end of the interview he asked me: “Doc, do you suppose it’s my own guilt coming back at me?” The usual type of patient with recurrent jealous suspicions has a personality disorder with features of unrecognized dependency needs, uncertain selfesteem, possessiveness, and, frequently, alcohol abuse. Mr. T., a 19 year old man, had been bothered by recurrent suspicions about his wife’s infidelity. He was so possessive of her that he prevented her from seeing a doctor during her pregnancy because he could not stand the thought of another man putting his hands on her. During his wife’s first pregnancy, he became so suspicious and angry with his wife when he was drinking that he kicked her in the abdomen. According to Shepherd (1961) such patients are usually men, and jealousy “constitutes an indissoluable component of their attitudes toward their sexual partners”. Stress makes the jealousy worse, often inducing pathological delusions which recede after tho crisis subsides.
HI. Etiology Jaspers ( 1963) distinguished jealousy as a personality trait from jealousy as a new process, i.e. a symptom appearing in the course of an acute disorder. Freud (1922) described the three layers or stages of jealousy as ( 1 ) competitive or normal, ( 2 ) projected, ( 3 ) delusional. The roots of normal jealousy for Freud are found in the oedipal complex. Projected jealousy results from repression of the jealous subject’s experiences or impulses, and as an absolution of his conscience. JEALOUSY FORMULATIONS FREUD I LOVE HIM. (DENIED) I DO NOT LOVE HIM: SHE LOVES HIM. (SUBJECT) (OBJECT) (RIVAL) SULLIVAN I AM NOT GOOD ENOUGH (AS A LOVER) TO BE LOVED: I AM UNLOVABLE. THEREFORE SHE LOVES HIM WHO IS BE?TER. SCHWARTZ SHE DOES NOT LOVE ME BECAUSE I AM UNLOVABLE. NOBODY CARES WHAT I HAVE (DENIED) EVERYBODY WANTS WHAT I HAVE. ~
Figure 3.
Downloaded from anp.sagepub.com at Bobst Library, New York University on April 26, 2015
50
JEALOUSYAS
A SYMPTOM OF PSYCHIATRIC
Delusional jealousy, Freud believed, results from repressed impulses toward unfaithfulness with the same sex, an acidulated homosexuality: “I do not love him; she loves him”. Although this formulation has been retained in psychoanalytic theory, it has not found favour with most post-freudian theorists who have written about jealousy. While acknowledging the validity of the theory of projected jealousy, they have elaborated on possessiveness and emotional dependence as they relate to feelings of inferiority, a theme not fully developed in orthodox psychoanalytic writing, although Fenichel ( 1945) mentions this aspect of jealousy. Sullivan (1956) and recent theorists such as Salzman (1963), Ovesey (1955), Schwartz (1963), and Langfeldt (1962), have all favoured a poor selfesteem model variously described as inferiority, social humiliation, feeling unlovable. They have ignored or repudiated Freud’s repressed homosexuality formula and have suggested alternative formulations (Fig. 3 ) .
IV. Provoking or Aggravating Factors Alcohol abuse by the patient with the jealous personality usually brings out jealous attitudes, probably because of its disinhibiting effect on the CNS and its inhibition of erectile potency. Mooney (1965) found that of his 12 cases, patients with a jealous personality tended to be male alcohol abusers with a family history of jealousy; whereas the converse was true for patients whose disorder arose as a new process. Since infidelity was so common in the jealous personality patients reported by Shepherd (1961), this may be a significant aggravating factor for those with jealous personalities as well as the most important provoking factor in cases of obsessive jealousy. The most important factor in new process morbid jealousy is some disparity in sexual desire between the subject and object. In all 5 female patients reported by Modlin (1963) reduction in frequency of intercourse preceded the development of delusions. Interpersonal feedback is important: the object who is repeatedly accused falsely is not likely to feel warmly towards the accuser, adding to the reasons for the jealousy especially in someone with an insatiable need for affection.
V. Parlnem of Jealous Subjects The circumspect behaviour required of unjustly accused partners is so stressful that they will present as patients as often as will the jealous accusers. Depression is the commonest disorder diagnosed. Some will show a neurotic complimentarity, like the wife of Mr. T. who, when asked how she felt about her husband’s violence, suggested: “I guess he just loves me a lot”.
VI. Assessanent Tactics Chronicity of jealousy or recurrent bouts of jealousy suggest a jealous personality; whereas a disorder of recent onset in a person with a good premorbid
DISORDER
personality suggests an acute disorder of which depression, especially one marked by defensive projection, is the most common. If the dominant feeling is sadness and whatever anger exists is directed toward the rival, a diagnosis of depression is most likely. A predominant feeling of anger toward the object suggests a paranoid syndrome. If the rival is a phantom, and if the psychiatrist has difficulty empathizing with the patient, the diagnosis of paranoid schizophrenia is likely. How does the patient judge the jealous beliefs? If they are completely ego-alien it is likely a case of obsessive jealousy. The more easily accepted they are, the more invested with interest and affect, the more likely the diagnoses of depressive psychosis or paranoid state. It is important to determine how firmly the beliefs are held. A hypothetical question is useful. (Can the patient imagine that there could be evidence proving his suspicions and accusations false?) Patients with fixed delusions cannot imagine this.
VI1. Management of the Functional Disorders Be aware of overt or covert depressive illness in patients who have morbid jealousy as a new process. The presence of fixed delusions favours the use of ECT. Although patients with paranoid schizophrenia are most often helped by neuroleptics, patients with paranoid state are not predictably helped, although these agents are likely worth a try. Control of excessive drinking may be the most important part of treatment for the patient with a jealous personality. One of Shepherd‘s patients was, in effect, cured when she became abstinent. The psychotherapist should try to appreciate how badly the jealous patient feels, allowing him a limited and appropriate discharge of anger. If the ideas are not fixed, the therapist may be able indirectly to open areas of doubt about the conclusions the patient has drawn, and to help the patient focus on his exaggerated need for affection, and his poor self esteem. The jealous subject usually feels completely at the mercy of the object, and emotional dependence intensifies the anguish. If the patient can realize that he himself is responsible for his feelings and choices, he can also take significant steps to help himself. Patients with strongly jealous personalities are difficult to treat. Recently, Marks (1975) reported the use of behaviour therapy in treating a man with recurrent jealous suspicions. Forensic aspects should not be overlooked. The psychiatrist should ask himself “Would it be consistent with this person’s life style for him to take violent revenge and/or kill himself in despair?” Psychiatrists are kept aware of such cases by the dramatic murders and murder-suicides that are reported in the daily press.
Downloaded from anp.sagepub.com at Bobst Library, New York University on April 26, 2015
Jealousy as a symptom of psychiatric disorder has been neglected. For example, the 1600 page Comprehensive Textbook of Psychiatry contains only 15 lines devoted to jealousy, and yet jealousy is a symptom appearing frequently in patients. This overview may serve as a reminder of its importance in our work.
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