Dopamine agonists and Othello's syndrome

Violence and delusional jealousy in Parkinson's disease

Psychosis in Parkinson's disease (PD) can have a hugely detrimental effect on patient outcomes and quality of life. It can be a feature of PD itself, or can be exacerbated by the very pharmacological agents that are prescribed to treat the motor symptoms of the disease. The treatment of psychosis in PD is often complex, with clinicians having to balance the debilitating physical symptoms of PD against the risk of exacerbating the psychosis. We describe the case of an octogenarian who presented with violence motivated by delusional jealousy in the context of PD, who was treated in a specialist psychiatric inpatient environment.

A Bayesian predictive processing account of Othello syndrome in Parkinson's disease

Introduction: Although delusions in Parkinson's disease (PD) are rare, when they occur they frequently take the form of "Othello syndrome": the irrational belief that a spouse or partner is being unfaithful. Hitherto dismissed as either a by-product of dopamine therapy or cognitive impairment, there are still no convincing theoretical accounts to explain why only some patients fall prey to this delusion, or why it persists despite clear disconfirmatory evidence.Methods: We discuss the limitations of existing explanations of this delusion, namely hyperdopaminergia-induced anomalous perceptual experiences and cognitive impairment, before describing how Bayesian predictive processing accounts can provide a more comprehensive explanation by foregrounding the importance of prior experience and its impact upon computation of probability. We illustrate this new conceptualisation with three case vignettes.Results: We suggest that in those with prior experience of romantic betrayal, hyperdominergic-induced aberrant prediction errors enable anomalous perceptual experiences to accrue greater prominence, which is then maintained through Bayes-optimal inferencing to confirm cognitive distortions, eliciting and shaping this dangerous delusion.Conclusions: We propose the first comprehensive mechanistic account of Othello syndrome in PD and discuss implications for clinical interventions.

A comparison of older and younger offenders with delusional jealousy

We sought to determine whether or not there were differences in medical, criminological and legal factors between older and younger offenders with diagnoses of delusional jealousy by undertaking a retrospective case-file search of Australian legal databases. Our results demonstrate that older offenders were more likely to have comorbid dementia whereas younger offenders were more likely to have comorbid substance use and chronic psychotic conditions. A history of domestic violence frequently predated the index offence but we were unable to determine if this was due to psychosis or a pre-existing tendency for violence. Despite a common diagnosis, the older offenders were more likely to be made forensic patients rather than sentenced prisoners when compared with the younger offenders. Consequently, different factors might mediate the pathway to violence in older and younger people suffering from delusional jealousy and could be additional targets for clinical intervention.

Concomitant Othello syndrome and impulse control disorders in a patient with Parkinson’s disease: A case report

BACKGROUND

Othello syndrome (OS) is characterized by delusional beliefs concerning the infidelity of a spouse or sexual partner, which may lead to extreme behaviors. Impulse control disorders refer to behaviors involving repetitive, excessive, and compulsive activities driven by an intense desire. Both OS and impulse control disorders in Parkinson’s disease (PD) may be side effects of dopamine agonists. At present, there are only a few case reports and studies related to PD with concomitant OS and impulse control disorders.

CASE SUMMARY

We describe a 70-year-old male patient with PD, OS, and impulse control disorders, who presented with a six-month history of the delusional belief that his wife was having an affair with someone. He began to show an obvious increase in libido presenting as frequent masturbation. He had been diagnosed with PD ten years earlier and had no past psychiatric history. In his fourth year of PD, he engaged in binge eating, which lasted approximately one year. Both OS and hypersexuality were alleviated substantially after a reduction of his pramipexole dosage and a prescription of quetiapine.

CONCLUSION

Given its potential for severe consequences, OS should be identified early, especially in patients undergoing treatment with dopamine agonists.

Othello syndrome in Parkinson's disease: a systematic review and report of a case series

INTRODUCTION

Psychosis in Parkinson's disease (PD) is common and consists of hallucinations, illusions, and delusions. Among the latter, delusional jealousy, also named Othello syndrome (OS), might impair the quality of life of both patients and their partners. We aimed to perform a systematic review and report a series of PD patients presenting with OS.

METHODS

A systematic review research was performed in PubMed database, excluding non-English articles, single case reports, reviews and neuropathology articles, comments, and articles concerning OS associated with deep brain stimulation (DBS) and levodopa-carbidopa intestinal gel infusion. We also described eleven PD patients (9 M and 2 F) with OS, identified in a cohort of consecutive 153 patients, comparing them with eleven matched no OS (nOS) PD subjects taken from the same cohort.

RESULTS

We included eight articles (four case series and four cross-sectional studies). OS resulted more common among males than females. We did not find higher levodopa dose and levodopa equivalent dose for dopamine agonists and for all anti-parkinsonian drugs in our OS group. In our case series, OS patients showed visual hallucinations (p=0.001) and a trend to have depression (p=0.080) more frequently than nOS ones.

CONCLUSIONS

OS is not a rare disorder in PD, probably due not only to abnormal dopaminergic stimulation but also to serotonergic dysfunction in biologically predisposed subjects. Visual hallucinations and other concomitant psychiatric diseases, in particular depression, might represent a risk factor for the OS development.

Delusional Jealousy (Othello Syndrome) in 67 Patients with Parkinson's Disease

Othello syndrome (OS) is a type of paranoid delusional jealousy, characterized by the false absolute certainty of the infidelity of a partner. Because OS has infrequently occurred in patients with Parkinson’s disease (PD), the characteristics of OS in PD remain unclear. We reviewed the clinical characteristics of this syndrome in PD. We reviewed 67 patients who had PD with OS. OS was more common in men (45 patients) than in women (22 patients), and it frequently occurred in middle-aged patients. Until the onset of OS, the duration of PD (range, 2–19.8 years) and the duration of treatment with PD medications (range, 2 months to 18.5 years) varied. At the onset of OS, cognition was preserved in most patients. 42 of 47 patients had other psychiatric disorders in addition to OS, and 5 patients had isolated OS. Persecutory or other paranoid delusions developed in 34 patients with OS. OS was associated with PD medication in 25 of 26 patients, especially in patients, used the dopamine agonists. The dose of the PD medication associated with OS was decreased or these drugs were withdrawn to facilitate the treatment of OS. In most patients, OS disappeared or the severity of OS was reduced. OS is infrequent in patients with PD, but is likely to be easily detected because OS is commonly accompanied by persistent paranoid and sexual delusions. When clinicians encounter such patients, the withdrawal or reduction of dopamine agonists should be attempted, and if necessary, additional treatment with clozapine is recommended.

Delusional misidentification in Parkinson's disease: report of two cases and a review

Syndromes of delusional misidentification consist of disordered familiarity and have been reported in diverse diagnoses, including Parkinson's disease. Although the most common delusional misidentification is Capgras syndrome, in which the sufferer believes a familiar person has been replaced by an identical imposter, other forms have been also described. The pathogenesis of delusions of misidentification appears to require dysfunction of or connection to a left cerebral cortical area involved in recognition of familiarity, and also right frontal cortex serving belief evaluation. Two cases of Parkinson's disease with an unusual delusional misidentification, intermetamorphosis, are presented, along with their improvement with pimavanserin, a novel atypical antipsychotic medication.

Pathological Jealousy: An Interactive Condition

OBJECTIVE

The aim of this review is to describe the psychopathology, antecedents, and current management of pathological jealousy from an interpersonal perspective.

METHOD

The Google Scholar database was searched with the following terms: delusional jealousy; morbid jealousy; paranoid jealousy; pathological jealousy; Othello syndrome; delusional disorder-jealous type; conjugal paranoia. From a total of 600 articles, 40 were selected based on their currency and pertinence to the interpersonal aspects of jealousy.

RESULTS

Findings were that delusional jealousy is equally prevalent among men and women, with a greater prevalence in the elderly. Antecedents to this condition can be neurologic, drug related, and/or psychological, most often preceded by low self-esteem and excessive dependence on a romantic partner. Pathological jealousy can be triggered by the behavior of the partner and maintained by reasoning biases and by the psychological benefits that it initially bestows on the relationship. In the long run, however, it poses dangerous risks to the patient, the partner, and the imagined rival so that involuntary hospitalization is sometimes required. Treatment recommendations include couple therapy, a strong cognitive focus, antipsychotic medication, and interventions which enhance self-esteem of both partners and which address the solidarity of the existing relationship.

CONCLUSION

Treatment effectiveness does not yet have a firm evidence base.

Resolution of Othello Syndrome After Subthalamic Nucleus Deep Brain Stimulation in 3 Patients with Parkinson's Disease

Psychiatric symptoms are historically thought a relative contraindication to DBS for advanced Parkinson's disease (PD). However, in the case of drug-induced mental illness, DBS may provide an acceptable alternative for the treatment of motor symptoms. This allows reduction of pharmacological dopaminergic therapy that might otherwise cause negative psychiatric consequences. For example, DBS is increasingly used to ameliorate specific complications of PD treatment, such as impulse control disorders. We present a series of 3 cases of young male patients who developed Othello syndrome (OS) during treatment with dopamine agonists. In each case, the OS resolved with withdrawal of the offending drug. Subsequent treatment with bilateral STN DBS improved motor symptoms and allowed reduction in their dopaminergic drug regimen. We therefore propose that drug-induced psychopathology may be an indication (rather than a contraindication) for DBS in selected cases.

Prefrontal cortex, dopamine, and jealousy endophenotype

Jealousy is a complex emotion characterized by the perception of a threat of loss of something that the person values,particularly in reference to a relationship with a loved one, which includes affective, cognitive, and behavioral components. Neural systems and cognitive processes underlying jealousy are relatively unclear, and only a few neuroimaging studies have investigated them. The current article discusses recent empirical findings on delusional jealousy, which is the most severe form of this feeling, in neurodegenerative diseases. After reviewing empirical findings on neurological and psychiatric disorders with delusional jealousy, and after considering its high prevalence in patients with Parkinson's disease under dopamine agonist treatment, we propose a core neural network and core cognitive processes at the basis of (delusional) jealousy, characterizing this symptom as possible endophenotype. In any case,empirical investigation of the neural bases of jealousy is just beginning, and further studies are strongly needed to elucidate the biological roots of this complex emotion.

Dopamine agonists and delusional jealousy in Parkinson's disease: a cross-sectional prevalence study

BACKGROUND

Delusional jealousy (DJ) has been described in patients with Parkinson's disease (PD) on dopaminergic therapy, but a role for dopaminergic therapy in DJ has not been established.

METHODS

The current cross-sectional study on DJ investigated its association with dopaminergic therapies compared with their associations with hallucinations and its prevalence in PD patients. Eight hundred five consecutive patients with PD were enrolled between January 2009 and June 2010.

RESULTS

DJ was identified in 20 patients (2.48%) and hallucinations in 193 patients (23.98%). In the multivariate logistic regression analyses, dopamine agonists were significantly associated with DJ (odds ratio, 18.1; 95% CI, 3.0-infinity; P = .0002) but not with hallucinations (odds ratio, 0.73; 95% CI, 0.49-1.10; P = .133).

CONCLUSIONS

These findings suggest that dopamine agonist treatment represents a risk factor for DJ in PD independent of the presence of a dementing disorder, and the presence of this additional nonmotor side effect should be investigated in this clinical population.

Clinical and imaging features of Othello's syndrome

BACKGROUND AND PURPOSE

Our objective was to document the clinical and imaging features of Othello's syndrome (delusional jealousy).

METHODS

The study design was a retrospective case series of 105 patients with Othello's syndrome that were identified using the Electronic Medical Record system of Mayo Clinic.

RESULTS

The average age at onset of Othello's syndrome was 68 (25-94) years with 61.9% of patients being male. Othello's syndrome was most commonly associated with a neurological disorder (73/105) compared with psychiatric disorders (32/105). Of the patients with a neurological disorder, 76.7% had a neurodegenerative disorder. Seven of eight patients with a structural lesion associated with Othello's syndrome had right frontal lobe pathology. Voxel-based morphometry showed greater gray matter loss predominantly in the dorsolateral frontal lobes in the neurodegenerative patients with Othello's compared to matched patients with neurodegenerative disorders without Othello's syndrome. Treatment success was notable for patients with dopamine agonist induced Othello's syndrome in which all six patients had improvement in symptoms following decrease in medication.

CONCLUSIONS

This study demonstrates that Othello's syndrome occurs most frequently with neurological disorders. This delusion appears to be associated with dysfunction of the frontal lobes, especially the right frontal lobe.