Othello Syndrome in a Patient With Right Orbitofrontal Lobe Cavernous Sinus Hemorrhage

An 85-year-old retired fisherman, without previous psychiatric history, was referred to the geropsychiatric outpatient clinic due to abnormally increased sexual drive and aggressive behaviors. For about 1–2 years before the clinic visit, he frequently coerced his unwilling and suffering 72-year-old wife into sexual intercourse; he would accuse his wife with jealous delusions against her if she refused his requests. His wife requested a psychiatrist to deal with her emotional problems from the coerced sexual intercourse. About 2–3 years before the first visit, he also developed symptoms associated with a gradual cognitive decline. His neurologic and physical examination showed unremarkable findings. He scored 14 out of 30 on his Mini-Mental State Exam, and his Clinical Dementia Rating Scale score was 1.0. His laboratory exams revealed insignificant findings except for mild elevation of blood urea nitrogen (21 mg/dL; reference: 6–20 mg/dL) and creatinine (1.3 mg/dL; reference: 0.7–1.2 mg/dL). A brain MRI study revealed an old cavernous sinus hemorrhage in the proximal right orbitofrontal gyrus (Figure 1 [A]). A single venous malformation with both a single drainage and collecting cortical veins was visible (Figure 1 [B]); both the right cavernous sinus and the venous anomaly branches covered the neighboring tissue near the old hemorrhage site (Figure 1 [C]). The patient could not tolerate the sedative side effect of quetiapine, even as low as a 12.5-mg bedtime dose. The patient’s behavioral disturbances were well controlled after being treated with haloperidol (1.0 mg/day) for 7 days. There were unremarkable side effects. He remained under the medication with the same dose for the following year, without incident.

After Todd and Dewhurst coined the term “Othello syndrome,” besides delusional disorder, paranoid schizophrenia, bipolar disorder, epilepsy, articles documented other different etiologies, such as cerebral vascular disease,¹ and neurodegenerative conditions, such as Parkinson’s disease.² Our patient’s gradual cognitive and daily-activity functional decline started 2–3 years before his initial appointment, but the onset of hypersexuality with secondary jealous delusions started more than 1 year after onset of initial symptoms. This case is unique in that his OS may be not only because of the brain degeneration or small-vessel disease, but related to the cavernous sinus hemorrhage caused by overflow leakage from an anomalous venous drainage system. Comorbid hypersexuality with OS was reported in a young woman with frontal lobe cerebral infarction,³ but our case is in an older-age man.

Previous reports of OS were related to right-side orbitofrontal lobe lesions, as infarcts.¹ Content-specific delusions, such as jealous-type, are related to frontal lobes.⁴ One study of patients with Alzheimer’s disease with delusions (but not jealous type) showed dysmetabolism in the right prefrontal cortex.⁵ The dangers related to OS include aggression, which may present with hostility. In this case, a rare phenomenon, the patient’s marked interpersonal relationship disruptions with his wife resulted from his hypersexuality, and the consequent suffering resulted from his morbid jealousy.

Past reports about the medical therapy regimens for pathological jealousy include fluoxetine, pimozide, and risperidone,⁶ but treatment focused on OS has rarely been discussed. Our patient could not tolerate the oversedation side effect of quetiapine. He responded well to low doses of haloperidol but more study investigation is warranted for the treatment of OS, especially in elderly patients with low tolerance to the side effects of medications.