Irrational belief in alleged affair could be delusional disorder
CORRECTION: Dropped words "person with untreated delusional disorder" were restored to the second paragraph of the first answer.
DEAR DR. ROACH: My wife and I have been married for over 50 years. A few years ago, she began accusing me of having an affair with a much younger woman, with whom I have never shared a private moment or conversation in my life, nor have I ever wanted to. When I try to reason with her, she becomes irrational and angry to the point that I do not recognize her. She is now convinced that our adult children and many of our friends know about this "affair" and have enabled me by covering it up. She also has begun to talk to me about divorce because she "knows I want to be with her" -- who, by the way, lives with her husband and young child, hundreds of miles away. I love my wife dearly and would like our twilight years to be filled with love and affection, not accusations and suspicion. I have asked her to see a counselor with me, but she says I should go by myself.
She is generally highly rational. When she is not, it relates somehow to her entirely sincere but irrational belief in the alleged affair. Any thoughts? -- T.M.
ANSWER: Assuming you are not having an affair (and I have no reason not to believe you), it is likely that your wife's diagnosis is called delusional disorder, jealous type.
I have seen two cases in my career, and they are very difficult to treat, since the person affected does not think he or she has a disease. Unlike other psychotic disorders ("psychosis" means having a distorted view of reality), such as schizophrenia, the functioning of a person with untreated delusional disorder usually is very good, apart from the area of the delusion.
For the clinician treating a patient with delusional disorders, the first thing to do is establish the reality of the patient's delusions. This will include getting information from multiple sources. A complete medical history, including mental health and substance abuse, is critical.
There are other possibilities. Some types of dementia (especially Lewy body dementia, but Alzheimer's disease as well) may feature prominent delusions, and a thorough history and exam can help make those diagnoses. Delusional disorders commonly present in the 30s or 40s, so it's very important in someone as old as your wife to consider dementia.
The psychiatric literature reports good results with medication therapy in people with delusional disorder. I'm sure you can see, however, that the biggest obstacle to face is getting your wife to admit that there might be a problem (and to consider treatment). To your wife, there is no delusion. Her reality is perfectly clear to her, and, to her, your suggestion of seeing a therapist or a doctor makes no sense, and may even be viewed with suspicion. Some people with this disorder are a risk to themselves or their partner, and require involuntary psychiatric admission.
Getting help from her doctor is a first step. You may get more advice from seeing a psychiatrist yourself. Your children and friends may be able to help. Unfortunately, I don't have an easy answer.
The booklet on Alzheimer's disease gives a detailed presentation of this common illness. Readers can obtain a copy by writing: