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If you suspect morbid jealousy you must assess risk thoroughly. For CASC this is likely to be a forensic station.
Key Knowledge
What is Morbid Jealousy?
Morbid jealousy is a type of delusional belief, whereby a person believes their partner is unfaithful. It has been called ‘Othello syndrome’, but it is not a formal diagnosis within the ICD or DSM. As any delusion, it is an unshakeable belief not shared by others.
It is a ‘classic’ presentation for a delusional disorder, i.e. where there are not prominent features of other primary psychotic disorders, such as schizophrenia (e.g. thought disorder, disorganised speech, negative symptoms).
It can be associated with escalating behaviours (spying, phone-checking, confrontation, sometimes violence).
Differential Diagnosis for Morbid Jealousy
1. Differentials as for all delusional presentations, e.g. other primary psychotic disorder, organic psychosis
2. Personality disorder (PD) e.g. paranoid PD or emotionally unstable PD – belief of infidelity would be an overvalued idea rather than a true delusion (e.g. person can sometimes entertain doubt), and belief may intensify at times of emotional dysregulation
Risk Assessment in Morbid Jealousy
● Risk to Partner: obsessive monitoring, escalating confrontational behaviours, physical intimidation or violence, e.g. wanting to “extract a confession”
● Risk to Others: If the delusion extends to involving another individual i.e. who the partner is allegedly having an affair with, there is risk of physical threat or assault.
Ask about prior violence, weapons, contact with police or criminal record.
● Risk to Self: Emotional exhaustion, loss of employment or social support, escalating alcohol or substance use. Risk of self-harm can increase if the relationship ends or if beliefs are challenged.
● Protective Factors: engagement with psychiatric services.
Communication Tips
As always, be curious and non-judgmental, it is vitally important that the patient trusts you enough to share his thoughts and plans, to allow you to thoroughly assess risk.
CASC Practice Scenarios
Scenario 1: History Taking with a Focus on Risk
Candidate Instructions
You are working in a general adult community mental health team. Assess Mr. Mark Bennett, a 38-year-old man, who requires urgent review following referral from his GP.
Actor Instructions
You are Mark Bennett, a 38-year-old plumber. You are in a state of constant tension, which simmers just beneath the surface. You feel profoundly misunderstood and unjustly accused of being “crazy” by your GP for referring you to a psychiatrist. You have agreed to this appointment only because your GP said if you did not attend it would be documented on your record.
It all started six months ago when your partner, Sarah, a 35-year-old nurse, came home from work and mentioned there was a new physiotherapist on her ward, Tony. As she said this, she had a look in her eye and seemed to smile slightly. You have replayed that moment in your mind thousands of times and have come to the unshakeable conclusion that this was the first evidence that she was having an affair with Tony.
What started as an initial suspicion has now consumed your life.
You spend every waking moment, and many sleepless nights, thinking about the affair. You have become a private investigator in your own home. You compulsively check Sarah’s phone, read her messages, track her movements on a “Find My iPhone” app, and secretly search her bag and car. Because you have never found a message from Tony, you are convinced she has a second phone.
You have found Tony’s name on a private physiotherapy services website and obsessively look at his profile. You have memorised his car registration number and often drive past the hospital’s car park to see if his car is there. When you notice his car is there when Sarah is at work, you believe this is further evidence that they are having an affair.
You are a self-employed plumber but you have turned down a number of jobs so that you can conduct surveillance operations. You are now using your savings to pay monthly bills. Your sleep is poor, so you drink 3-4 cans of strong lager every evening to help. This has increased significantly over the last six months. Sarah has noticed this, and your generally erratic behaviour, and insisted you go to see your GP about it. She said if you didn’t she would move out. You believe she wants an excuse to leave you for Tony and that this will happen soon.
If asked about confronting Sarah about her affair, you admit you’ve considered blocking the door to prevent her from leaving the house until she confesses. You deny that you would use physical force against her (“I would never hit a woman”). However, you are planning to confront Tony in the ‘next few days’. You will wait by his car to ‘talk to him’, but admit that you might carry a hammer for self-defence, ‘in case things get ugly’.
If asked you don’t hear voices talking to you, or think you are being controlled by someone else. You have no history of mood problems. You currently feel ‘stressed out’. You believe 100% that Sarah and Tony are having an affair. You do not have any children.
If asked, you explain that you have a previous conviction for assault. You were in your early twenties and suspected your girlfriend was cheating on you with another man. You confronted him and it ended up in a fist fight. You broke his nose with a punch. You avoided jail but were given a community order. You maintain that in that situation you ‘did what I had to do.’ You have never had any other mental health issues, and you do not use illicit drugs.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
Determine that Mark’s belief in Sarah’s infidelity is fixed and unshakeable (of delusional intensity)
Screen for symptoms of other psychotic disorders
Systematically assess risk including inquiring about children in the house, access to a weapon and forensic history (establishes previous conviction for assault)
Assess impacts e.g. on sleep, alcohol intake, work/finances
If the scenario asks for a management plan, you may need to indicate to the patient that you are very concerned and that admission to a psychiatric hospital is required. In the real world, you will need to seek urgent advice from seniors / a forensic psychiatrist. In circumstances where there is a risk to public safety, breaching confidentiality may be justified, but again this would be a team discussion.
Communication
A good candidate will:
Focus on the distress the belief is causing Mark and impacts on his health and work in order to gain his trust for further psychiatric intervention
Example phrases:
“I can see how much this is affecting your life—all this stress, the checking, missing work, drinking more. My priority is to keep everyone safe and get you support.”
Scenario 2: Example Video – Morbid Jealousy Explanation
Candidate Instructions:
Mr. Daniel Foster is a 34-year-old man with a diagnosis of delusional disorder characterized by morbid jealousy. He was previously admitted to a medium-secure unit after incidents of stalking and aggression related to his fixed and false belief that his partner was unfaithful.
He was treated with antipsychotics and showed improvement but has recently relapsed with similar symptoms triggered by perceived evidence of infidelity. He has been observed monitoring his partner’s movements, checking her phone, and expressing hostile intentions towards a coworker she knows. The clinical team plans to offer further treatment, possibly including admission, to manage his risk and symptoms.
Please explain the diagnosis and management plan to his partner, Rosie Norton, addressing her concerns.
Authors/Reviewers
Dr Damir Rafi is a psychiatry speciality registrar in forensics, currently working in London.
Dr Sarah Barber is a psychiatry registrar, currently taking time out of clinical work to complete a PhD in psychiatric epidemiology.
Dr Sophie Kyrke-Smith is a psychiatry speciality registrar in forensics, working in London.
References and Resources
1 World Health Organization (2022). ICD-11: International classification of diseases (11th revision).
2 Cleall, D., Perera, S., & Travers, C. (Eds.). (2021). The Maudsley Trainee Guide to the CASC: Preparing for the MRCPsych CASC Examination. RCPsych Publications.
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
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