One of the more unnerving confrontations a clinician can have is with a patient-who presents with delusional jealousy. Typically, such patients have little insight into their condition, project most difficulties onto the environment, and repudiate treatment. Worse yet, the clinician must worry about the capacity of these patients to harm those they are jealous of, or the perceived objects of their love. Silva and co-authors, reviewing the subject of delusional jealousy, have found that 65 percent of those in their series had threatened to kill their spouses because of alleged infidelity, and 60 percent had actually harmed spouses.

Compounding the risk of violence are command hallucinations, alcohol use, underlying brain dysfunction and organicity. Most perpetrators were males, and used hands to inflict harm. The one female in the series shot and wounded her husband. Silva et al do not comment on suicidal urges or actions among those who suffer from delusional jealousy. In my experience, a history of suicidal thoughts or actions increases the risk of violence directed others. Also not fully described by the authors is the escalation of jealousy to-stalking behavior. There is a continuum of danger among those with pathologic jealousy. At one end of the spectrum are intermittent thoughts about the alleged infidelity of the 'victim.' These feelings are somewhat unwanted and take the form of a fear of loss rather than shading over into anger or outrage. At the other end of the range is more malignant tracking, in which the patient shadows the victim, resorts to listening devices or video documentation, and becomes completely enveloped by the suspicion. When a patient's life becomes swallowed up by jealousy, it is an ominous sign.

Silva et al imply more optimism about psychopharmacologic treatment of delusional jealousy than is customarily cited in the literature. SSRI drugs may be useful for underlying depression. Antiobsessional agents may benefit the occasional patient with intractable delusions. Unfortunately, however, patients with delusional jealousy are very difficult to manage and do not easily form therapeutic alliances. It may be important to meet with the potential victim for clinical and medicolegal purposes. Also, sometimes victims behave in subtle ways that exacerbate a patient's suspicions and apprehensions. Silva, J.A., Ferrari, M.M., Leong, G.B .,and Penny, G. (1998). The dangerousness of persons with delusional jealousy J. Am. Acad. Psychiatry Law, Vol. 26, No.4, pp.607-623.