Othello Syndrome Secondary to
Right Cerebrovascular Infarction
Emily D. Richardson, PhD; Paul F. Malloy, PhD; Janet Grace, PhD
Abstract

___________________________________________________________

The Othello syndrome, or delusional jealousy, occurs in idiopathic psychoses and in neurodegenerative diseases, but has
rarely been described in patients with cerebrovascular infarction. A patient was observed to exhibit the delusion shortly
after cerebral ischemic injury in the absence of other psychiatric symptoms. The underlying pathology was consistent
with recent reports on content-specific delusions, implicating right hemisphere and frontal lobe involvement in the misinterpretation and misidentification of complex information. Psychological factors were hypothesized to shape the content
of the delusional misinterpretations. (J Geriatr Psychiatry Neurol
1991;4:160-165).

he Othello syndrome, or delusional jealousy,

content-specific delusion characterized
the
but false conviction of the
unshakable
by
spouse’s infidelity. By definition, this delusion is often persistent, unremitting, and totally unresponsive to discussion or argument. It has been reported
is

a

to occur most often in association with chronic alco-

holism’ and as a feature of schizophrenia or affective
disorder.’ There is little information regarding the
incidence of this disorder. However, Crowe and his

colleagues’ found that paranoid jealousy occurred in
0.17% of all admissions to a psychiatric facility over

61-year period.
As the syndrome is generally viewed as a &dquo;functional&dquo; psychosis, most previous reports have focused on possible dynamic or intrapsychic causes for
the delusions.’ Delusional jealousy secondary to demonstrable or presumed cerebral dysfunction has
only recently been described. 5,6 It has been most often mentioned in conjunction with diffuse or degena

erative disease, such as Alzheimer’s dementia and
Huntington’s chorea.~ In these reports, however, lit-

tle information has been provided regarding premorbid psychological status, development and

course

of the illness, or neuroradiologic and neu-

ropsychological findings. Furthermore, although
morbid jealousy has been clinically observed in association with the general paranoid reactions of postinfarction aphasia, there has been a dearth of
published reports on this association.
We present the case of a previously happily married elderly man who developed the delusion of his
wife’s infidelity shortly following recovery from a
large right middle cerebral artery infarction. The current case represents the first complete report of the
Othello syndrome developing secondary to a focal
structural cerebral lesion. Key features of the syndrome, which are not discernible in previous reports
on organic cases, are described, including the extent
to which the delusion was (1) persistent, rather than
merely a transient symptom; (2) monosymptomatic,
ie, not imbedded in the context of general paranoia;
and (3) incongruent with premorbid personality
functioning. Furthermore, the neuroradiologic findings, described below, are consistent with the
burgeoning neuropsychiatric literature on other
content-specific delusions that implicate right hemisphere pathology superimposed on dysfunctional
frontal systems.’

Received Dec 29, 1990. Received revised Feb 26, 1991. Accepted for publication April 11, 1991.
From the Department of Psychiatry (Drs Richardson, Malloy,
and Grace), Brown University Medical School, and Butler Hospital (Drs Richardson and Malloy), Providence, and Memorial Hospital of Rhode Island (Dr Grace), Pawtucket, RI.
Address correspondence to Dr Emily D. Richardson, Assistant Clinical Professor, Department of Psychiatry, Butler Hospital,
345 Blackstone Boulevard, Providence, RI 02906.

160

Case Description
Presentation
A 68-year-old, right-handed, married male was admitted to the psychiatric facility for evaluation of ag-

gressive behavior toward his wife, whom he
believed was having an affair with their 25-year-old
neighbor. The patient developed the belief of his
wife’s infidelity shortly after a right cerebrovascular
infarction 1 year earlier. He became impotent after
the infarction, and a urologic consult discovered no
other identifiable medical etiology. The patient became suspicious of the alleged affair when he began
&dquo;putting together&dquo; evidence from various sources.
For example, he noticed that his wife began leaving
the first floor bedroom window open at night, presumably to allow her &dquo;lover&dquo; to enter the room
while the patient was asleep. He found tracks in the
snow beneath the window, and he noticed that the
dust was disturbed on the window sill, which he
took as evidence that the neighbor had entered
through the window. On one occasion, he thought
he had heard voices in the kitchen, but when he entered the room, only his wife was there preparing
breakfast. The patient assumed that his wife had
been making breakfast for the neighbor, who fled
through the front door on hearing the patient’s approach. When asked why he thought his wife would
be interested in the neighbor, the patient stated that
he recalled his wife remarking that &dquo;that boy is a
nice-looking fellow.&dquo; On another occasion, the patient discovered that his neighbor had generously
offered to perform routine chores around the couple’s home, including fertilizing their lawn. The patient’s physical disabilities prevented him from
performing such chores, and he interpreted this gesture as a threat to his marriage.
In response to the patient’s accusations, his wife
began severely restricting her activities. She became
fearful of getting up at night to go to the bathroom
because the patient often awoke to reassert his belief
that she was getting up to meet with her lover.
Furthermore, despite his impotence, he became sexually aggressive with his wife, repeatedly approach-

ing her whenever she came to bed and demanding
verbally and physically that she engage in intercourse with him. His advances would keep his wife
awake all night, so that she eventually moved to a
second bedroom, a decision that was interpreted by
the patient as further proof that his wife was having
an affair. Psychiatric hospitalization was finally precipitated by the patient’s increased threats to assault
his wife if she did not discontinue her alleged affair.
At one point, the patient became angered at her denials of infidelity, and he tried to strike her with his
cane, finally throwing it at her.
Confrontation with the illogical aspects of the
patient’s belief did not sway his conviction. For ex-

ample, the patient was confronted with the age discrepancy between the neighbor (age 25 years) and
the patient’s wife (in her early 60s); however, he responded by stating that his wife was an attractive
woman who &dquo;had needs.&dquo; The fact that the neighbor
was a newlywed also did not seem to sway the patient’s belief in the affair, as he merely contended
that the neighbor’s new bride was also having an affair with another neighbor.
Medical History
The patient had no previous psychiatric history or
family history of psychiatric disorder. He denied alcohol or other substance abuse, and developmental
history was unremarkable. The patient and his wife
denied marital difficulties prior to the infarction. In
fact, they described their marriage as &dquo;ideal&dquo; and
stated that they had always had an active and mutually satisfying sexual relationship. The opinion that
this couple had a jealousy-free marriage was corroborated by this couple’s adult children. The patient
and his wife had just completed a trip abroad when
the patient suffered left-sided hemiparesis, with left
facial droop and loss of motor strength and sensation in the upper and lower extremities on the left.
The patient was hospitalized at a medical facility
where it was determined that he had a cerebrovascular accident, likely embolic in nature. Computed
tomography (CT) scan demonstrated infarction in
the right middle cerebral artery territory. He underwent physical rehabilitation and, within 2 months
after recovery, the patient developed delusional jealousy. The couple became involved in marital counseling, but little change in the patient’s delusion
over the course of 6 months was noted. Increasing
dosages of antidepressant (nortriptyline and trazodone) and neuroleptic medications (haloperidol
and molindone hydrochloride) were tried, with either little lasting effect or exacerbation of symptoms.
Medical history, in addition to the cerebral ischemic injury, was significant for atherosclerotic cardiovascular disease, controlled hypertension, myocardial infarction (10 years previous to this illness),
gout, and duodenal ulcer. Five months after the
cerebrovascular event (and 3 months after the development of the delusion), the patient experienced a
4-minute episode of involuntary movement of the
right upper extremity, which stopped spontaneously. There was no associated loss of conscious-

drowsiness/lethargy, and
voluntary movements were noted throughout this
period. He was thought to have had a focal motor
seizure and was placed on phenytoin, 100 mg qid.
ness,

incontinence,

or

161

Records

indicating whether an electroencephalo-

gram (EEG) was done at that time could not be
obtained (a subsequent EEG is described below).
There were no other episodes or previous history of
seizures. On admission to the psychiatric facility,
medications included haloperidol (1 mg prn), phenytoin, cimetidine (for ulcer), baclofen (muscle relaxant), and acebutolol hydrochloride (for hyperten-

sion).

Psychiatric Evaluation
Psychiatric examination was notable for depressed
affect, decreased thought productivity, and generalized anxiety, with prominent preoccupation regarding his wife’s alleged infidelity. On admission, he
obtained a 26/30 on the Mini-Mental State Examination,’ having lost points for orientation, recall of
items, and copy of a design.

Neurologic Evaluation
Examination revealed left-sided spastic hemiparesis,
bilateral hyperreflexia greater on the left, positive
Babinski reflex on the left, flattened facial expression
on the left, and labile affect. The patient was found
to have a left lower quadrant visual field cut and a
left-sided extinction to double simultaneous stimuli.
A tendency to neglect both the left and bilateral
lower visual fields was exhibited. He exhibited left
hemiparesis, with an awkward gait, and he required
use of a cane to ambulate. An EEG was notable for
lateralizing disturbance in the right hemisphere,
consistent with a structural abnormality, and bifrontal generalized slowing with bisynchronous spike
phenomenon, suggesting associated changes at the
deep midline pacemaker level. A repeat CT scan was
consistent with the patient’s history, revealing an
old, large ischemic infarct affecting frontal, temporal, and parietal lobes on the right (Figure 1). Other
findings included mild generalized cortical atrophy.
There were no structural abnormalities evident in
the left hemisphere.

Laboratory Evaluation
Laboratory evaluations, including complete blood
count, electrolytes, blood urea nitrogen, creatinine,
serum vitamin B1z and folate levels, thyroid function
tests, serum iron, and iron binding capacity were all
normal, with the exception of extreme elevations in
alkaline phosphatase, presumably secondary to phenytoin.
162

FIGURE 1

Representative CT scan section demonstrating a large lowdensity defect in the right hemisphere involving frontal,
temporal, and parietal lobes. (Right side of image corresponds to right hemisphere.)

Neuropsychological Evaluation
The patient was well oriented, and basic attention
was normal. His speech was mildly dysarthric but
fluent with adequate articulation, grammatically correct, and he conveyed information adequately. Comprehension, repetition and confrontational naming
(Boston Naming Teseo) were normal. Ability to abstract common properties of both verbal and visual
stimuli was normal (Dementia Rating Scalell)e Mild
to moderate impairments on motor sequencing and
go/no-go tasks were evident, with oversimplification
and loss of task set, suggestive of executive (frontal)
dysfunction (Dementia Rating Scalell and Luria
Complex Motor TeStsl2). Spatial perception and visual constructions were moderately to severely impaired (Hooper Visual Organization Test13 and
Boston Parietal Lobe Battery 14). Misplacements, rotations, and distortions were common, especially for
the left aspect of each design. Moreover segmentation of the designs was notable, and the patient
failed to demonstrate awareness of his distortions.
Visual scanning and search of a complex picture was

limited to the right side, and the patient had to be
prompted to view both the bottom and the left side
of the scene.l° Immediate and delayed memory for
verbal material was within broad normal limits;
however, immediate and delayed memory for nonverbal information was mildly to moderately impaired (Wechsler Memory Scale-Revised 15). These
primarily right hemisphere and frontal deficits were
consistent with the right hemisphere infarction on
CT scan and the bifrontal abnormalities noted on
EEG. He was able to discuss the belief in his wife’s
infidelity but denied any other unusual beliefs, hallucinations, or visual misperceptions.

Treatment and Course

During the course of the patient’s 3-week psychiatric
hospitalization, acebutolol hydrochloride and cimetidine medications were tapered to assess for their
contribution to his depressed presentation and mental status changes. The patient evidenced improvement in

his mood, and his affect

brightened.

However, despite increasing dosages of haloperidol,
the patient’s delusion remained fixed, although verbal and physical threats toward his wife diminished.
He spoke of wanting to mend the relationship with
his wife, and was looking forward to their annual
vacation in Florida where &dquo;maybe my wife will be
able to forget [the neighbor] and learn to love me
again.&dquo; The patient was discharged on phenytoin,
200 mg bid, and haloperidol, 1 mg qhs. Acebutolol
hydrochloride and cimetidine were discontinued,
and he was started on nifedipine for hypertension
and allopurinol for gout. Recommendations were
made to the patient and his wife to pursue sexual
counseling regarding alternatives to coitus; however, they postponed a decision in this regard.
Follow-up neurologic and psychiatric evaluations 4 months after discharge from psychiatric hospitalization (and 17 months after the cerebrovascular
accident) revealed continued delusional jealousy,
with variability in the extent to which the patient responded aggressively to his erroneous beliefs. He
reportedly began accusing his wife of having an affair with &dquo;men of different races&dquo; after he became
suspicious of young Latino men during the couple’s
vacation in Florida. No changes in neurologic or
medical status were otherwise observed. Blood levels of phenytoin were demonstrated to be within the
therapeutic range (14.4 mg/L). The patient and his
wife decided at the time of follow-up to comply with

sexual counseling recommendations, and this therapy is currently ongoing.

Discussion

Misrepresentation or misinterpretation of events is
common in brain disease, especially with diffuse or
multifocal disorders such as toxic or metabolic encephalopathy, closed head trauma, or degenerative
disease.’ Delusions associated with toxic/metabolic
disturbances are usually simple in form (ie, persecutory or ideas of reference) and often resolve with
treatment of the underlying disturbance, while those
associated with degenerative dementia tend to remit
as the disease progresses.
Recent attention has been focused on delusions
that have a specific theme or are confined to one
topic. Numerous cases of these monosymptomatic
or content-specific delusions have been reported in
association with identifiable insults8 or degenerative
processes.&dquo; Such delusions as reduplicative paramnesia (the belief that familiar surroundings have
been duplicated), Capgras syndrome (the belief that
one’s family members have been replaced by imposters), and de C16rambault’s syndrome (the belief
that one is involved in an amorous relationship with
a famous person) have been recognized with increasing frequency in association with insults to
right hemisphere and bilateral frontal systems. 8,17,18
Traditionally, the Othello syndrome, and obsessive jealousy in general, has been treated purely as a
symptom of a primary psychiatric disorder. In fact,
delusional jealousy is not uncommonly found in association with chronic alcohol abuse, schizophrenia,
primary delusional (paranoid) disorder, or as a secondary symptom in affective disorder. In this literature, psychodynamic interpretations are usually
offered as the underlying causes of the development
of pathologic jealousy. Certainly, in the present case
one can argue that the patient’s inability to &dquo;fertilize
his lawn&dquo; was a metaphor for his sexual dysfunction, and the fact that the young, presumably virile
neighbor could perform this task served to highlight
the patient’s inadequacies with regards to fulfilling
his wife’s &dquo;needs.&dquo;

Psychodynamic or functional interpretations for
the development of this patient’s delusion are not
incompatible with the presumed organic etiology of
the delusion. It is our hypothesis that the cerebral
damage sustained by this patient predisposed him
to misinterpret and misperceive everyday occurrences. The content of the resulting delusion, we believe, was influenced by psychological factors, most
notably the patient’s impotence and his wife’s resulting alarm at his constant and aggressive sexual
advances. In the patient’s attempts to understand
his wife’s rejections to his advances, he erroneously

163

concluded that she must be having an affair, and he
looked for the most viable candidate.
Delusional jealousy is rarely reported as a monosymptomatic phenomenon of underlying neurologic
disease. This is the first reported case of the Othello
syndrome that clearly developed in association with
a

structural lesion and in the absence of general

paranoia. The present case illustrates the development of the delusion after ischemic injury to the
brain in the absence of other psychotic features. The
temporal association between the delusional disorder and the ischemic injury, the absence of personal
or family history of psychosis or paranoid personality, and the fact that the patient did not use alcohol
are unique features of this case and are indicative of
the organic basis for the psychiatric presentation.
Furthermore, although the patient did exhibit depressive symptomatology on admission, his delusion persisted despite adequate pharmacologic
amelioration of his affective symptoms.
Neuroradiologic findings in the current case are
consistent with those findings in patients with other
content-specific delusions described by Levine and
Grek.8 This elderly patient sustained massive damage to the right hemisphere, which appeared to be
superimposed on mild cortical atrophy. As suggested by these researchers, the damage sustained
by the right hemisphere may predispose the individual to misinterpret complex information and integrate irrelevant stimuli into false beliefs. The intact
left hemisphere allows the individual to verbalize
these false beliefs. Furthermore, Malloy et all’ have
suggested that, in patients with delusions secondary
to demonstrable neurodiagnostic findings, dysfunctional frontal systems preclude the individual from
correcting his misbelief in the face of contradictory
evidence. Clearly, this inability to alter false conclusions was apparent in our patient. Thus, a pattern of

and increasing attempts at sexual activity with the
partner have also been discussed as commonly accompanying the Othello delusion. This was a difficult problem for the patient presented here who,
paradoxically with his sexual zeal, was impotent.
These apparently paradoxical findings are actually
consistent with the literature on sexual functioning
after brain damage. Sexual dysfunction is a common
sequela of both traumatic brain injury and of cerebrovascular infarction. Coslett and Heilman,2° in
fact, found that individuals with a right hemisphere
infarction are more likely to experience impaired
sexual function than those with a left hemisphere infarction. Perseverative maladaptive attempts to ameliorate the sexual dysfunction may occur, due to
disinhibition secondary to frontal lobe injury.2’ Finally, the literature has suggested that the prognosis
is poor with individuals exhibiting delusional jealousy and other specific secondary delusions.’8 Our
patient has continued to evidence the persistence of
the delusion, although his willingness to act on his
belief has fluctuated.
)
One final point bears mention regarding sexual
functioning of brain-injured individuals. There is a
voluminous literature on sexuality after cerebrovascular infarctions22,23 suggesting not only that sexual
dysfunction is common in this population, but that
sexuality is often ignored by health care professionals. In cases as striking as the present one, for example, it is tempting to focus on the irrationality of the
jealous behaviors and dismiss the psychological impact of the patient’s impotence. However, one then
misses the opportunity to address the central issues
of sexual dysfunction and to explore adjunct, nonpharmacologic interventions to help such couples alleviate or diminish the jealousy.

right hemisphere damage superimposed on dysfunctional frontal systems may be a necessary component to the development of fixed delusions, as
suggested by studies on other content-specific delu-

sions. 17
The current case illustrates several aspects of the
Othello syndrome that have been described in the
psychiatric literature. It has been suggested that the
Othello syndrome occurs more often in males than
in females. This ratio, however, may be a reporting
bias due to the increased likelihood of males to respond in an aggressive manner to the delusion. ~9 In
fact, it was the assaultiveness of the patient presented here that finally brought him to the attention
of the psychiatric community. Excessive sexual zeal

164

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165