Captagone & Morbid Jealousy

Abstract

This study aimed to explore the relationship between Captagon usage and the development of delusions of infidelity. The study sample; 101 male patients, was recruited from patients admitted to Eradah Complex for Mental Health and addiction, Jeddah, Saudi Arabia, with the diagnosis of amphetamine (Captagon) induced psychosis during the period from September 2021 to March 2022. All patients underwent an extensive psychiatric interview; including interview with patients’ families; a demographic sheet, a drug use questionnaire, the structured clinical interview for DSM-IV (SCID 1), routine medical investigation, and urine screening for drugs. Patients’ ages ranged from 19 to 46 years old with Mean ± SD 30.87 ± 6.58. 57.4 % were single, 77.2% have finished their high school, and 22.8% had no work. Captagon using age ranged from 14–40 years old, and regular daily dose ranged from 1–15 tablet, while maximum daily dose ranged from 2–25 tablets. Twenty-six patients (25.7%) of the study group have developed infidelity delusions. A higher divorce rate was present among patients who developed infidelity delusions (53.8%) in comparison to patients who developed other types of delusions (6.7%). Infidelity delusions are common among patients diagnosed with Captagon induce psychosis, and they harmfully influence their social lives.

Introduction

Although the use of Captagon is currently banned around the world, it is still illegally, manufactured and used in different Eastern European and Middle Eastern countries. It is one of the most used illegal substances in Saudi Arabia.¹

Fenethylline is the psychoactive substance in Captagon which is mainly responsible for its central nervous system stimulant effect.²

Amphetamine induced psychosis is prevalent among individuals who use these drugs. Psychosis appears while an individual is under the influence of the drug, and disappears when the drug is no longer in the body.³

The dominant theme in morbid jealousy is a preoccupation with a partner’s sexual unfaithfulness. In contrast to healthy people, morbidly jealous individuals interpret conclusive evidence of infidelity from irrelevant occurrences. Delusions, obsessions, and overvalued ideas are the most commonly psychopathological forms in morbid jealousy.⁴

Although its prevalence is not precisely known, morbid jealousy is not uncommonly encountered in daily clinical practice. It can be presented as the patient sole complaint or as a component of the psychopathology of other psychiatric disorders. According to Singh, Bhandari, and Singh,⁵ its frequency in psychiatric outdoor was found to be 7.59% with delusional jealousy being the commonest followed by overvalued idea and obsession.

The hypothesis behind this work is based on a clinical observation that a reasonable number of patients who use Captagone develop delusional jealousy more than patients using other substances do.

Patients and Methods

Study design:

A cross sectional questionnaire-based study.

Study subjects:

• – Patients were recruited from patients admitted to Erada complex for mental health and addiction, Jeddah, Saudi Arabia during the period from September 2021 to March 2022.

Inclusion criteria:

• – Patients admitted with the diagnosis of amphetamine (Captagon) induced psychosis.

• – No history of primary psychiatric illness such as bipolar affective disorder (BAD), delusional disorders, or schizophrenia.

• – Patients were using only Captagon at least during the last 12 months.

• – Patients ages ranged between 18 and 60 years old.

• – All patients were males.

• – Consent to participate in the study.

Exclusion criteria:

• – Patients who had a history of primary psychiatric illness, such as BAD, delusional disorders, or schizophrenia.

• – Patients who used other substances such as cannabis or alcohol at least during the last 12 months.

• – Patients refusing to consent to participate in the study.

Patients were subject to the following:

• – All patients underwent an extensive psychiatric interview including interview with patients’ families.

• – A demographic sheet.

• – A drug use questionnaire.

• – The structured clinical interview for DSM-IV (SCID 1).

• – A routine medical investigation (e.g., renal function tests, liver function tests, CBC).

• – Urine screening for drugs.

Ethics

The Committee for Research Ethics at Jeddah research and Studies Department, Jeddah Health Affairs, Saudi Arabia, has approved this study.

Statistics

Data were analyzed using SPSS 20.⁶ The Fischer exact test was used to test whether or not two categorical variables were associated with each other. Mann-Whitney U test was used to compare between two independent nonparametric variables. A p-value of less than 0.05 was considered significant.

Results

Patients’ ages ranged from 19 to 46 years old (Mean ± SD = 30.87 ± 6.58. 57). Fifty-eight patients (57.4%) were single, 77.2% have finished their high school, and 22.8% had no work. (Table 1)

Table 1. Patients’ Demographics.

Variable		Frequency		Percentage %
Age		Mean ± SD 30.87 ± 6.58
Marital status
Single		58		57.4
Married		23		22.8
Divorced		19		18.8
Widow		1		1
Education
Primary		7		6.9
High		78		77.2
College		16		15.8
Occupation
Doesn’t work		23		22.8
Employee		71		70.3
Freelancer		2		2
Retired		5		5

Captagon using age ranged from 14 to 40 years old (Mean ± SD = 20.4 ± 5.45), and regular daily dose ranged from 1–15 tablet (Mean ± SD = 3.7 ± 2.2), while maximum daily dose ranged from 2–25 tablets (Mean ± SD = 7.2 ± 4.8). Sixty-eight patients (67.3%) have tried to stop using Captagon at least once.

Table 2 showed the prevalence of both delusions and hallucinations among the study group. Fifty-four patients (53.5%) have developed more than one type of delusions. Twenty-four patients (25.7%) of the study group have developed infidelity delusions.

Table 2. Frequency of Psychotic Features Among Study Population.

		Number of patients		Percentage of total number of patients
Delusions
Delusion of persecution		79		78.2%
Delusion of reference		40		39.6%
Delusion of infidelity		26		25.7%
Delusion of grandiosity		4		4%
Others		3		3%
Hallucinations
Auditory hallucination		58		57.4%
Visual hallucination		29		28.7%
Somatic hallucination		9		8.9%
Olfactory hallucination		1		1%

A higher divorce rate was present among patients who developed infidelity delusions (30.4%) in comparison to patients who developed other types of delusions (9.1%). (Table 3)

Table 3. Relationship Between Infidelity Delusions and Divorce.

		Presence of infidelity delusions		Absence of infidelity delusion		Fischer exact test		Sig.
Divorced		14 (53.8%)		5 (6.7%)		25.035		0.0001
Not divorced		12 (46.2%)		70 (93.3%)
Count		26 (100%)		75 (100%)

No differences were found between patients who developed infidelity delusions and those who did not regarding education, work, Captagone using age, daily Captagone dose, maximum Captagon dose, or trials to stop Captagone. Ages of patients with infidelity delusions were greater than those of patients with other types of delusions. (Table 4)

Table 4. Comparison Between Patients with Infidelity Delusions and Patients Without Regarding some Demographics.

		Presence of infidelity delusions		Absence of infidelity delusion		Mann-Whitney U test		Sig.
Age		34.52 ± 4.75		29.68 ± 6.72		–3.372		0.001
Daily Captagone dose		3.45 ± 1.88		3.77 ± 2.26		–0.267		0.79
Maximum Captagone dose		6.38 ± 3.81		7.47 ± 5.17		–0.595		0.552
Captagone using age		21.81 ± 6.69		19.91 ± 4.89		–1.354		0.176

Discussion

Delusional jealousy is the psychotic variant of morbid jealousy. Its prevalence was estimated among psychiatric inpatients to be 1.1% by Soyka et al.⁷ Delusional jealousy could be a presentation of organic disorders, personality disorder, substance use disorder, schizophrenia, or affective disorder.⁸ Women suffering from delusional jealousy commonly have the diagnosis of schizophrenia while alcohol-related psychosis is the common diagnosis among men.⁴

In their study, Singh, Bhandari, and Singh⁵ revealed that 20% of the patients presented with morbid jealousy; whether delusional or not; reported substance abuse like alcohol, cannabis, nicotine etc. either currently or in the past. They found also that delusional jealousy was commonly associated with substance use disorders.

Alcoholism was particularly linked in the literature with the occurrence of morbid jealousy. Michael et al,⁹ assessed morbid jealousy in 207 male patients with the diagnosis of alcohol dependence and they found that 34% suffered from morbid jealousy which had different manifestations including delusional disorder.

In their systematic review on antipsychotics for amphetamine psychosis, Fluyau, Mitra, and Lorthe,³ found that amphetamine users experienced different psychotic manifestations with high frequency of persecutory delusions, delusions of reference, and both auditory and visual hallucinations. Delusions of jealousy were not as common as delusions of persecutions or reference. This is in partial agreement with the results of this study as delusion of persecution were the most common type of delusions followed by delusion of reference. Also, auditory hallucination was the most common type of hallucinations followed by visual hallucination. The frequency of both delusions of reference and visual hallucinations were not so high as in Fluyau, Mitra, and Lorthe³ study. Also, delusions of jealousy were not uncommon as found in their study affecting about one fourth of our study population.

In their study which addressed amphetamine Versus Non-Amphetamine-Related First Episode Psychosis in Saudi Arabian Patients, El-dosoky et al,¹⁰ revealed a similar pattern of psychotic manifestations in patients diagnosed with amphetamine induced psychosis. Auditory and visual hallucinations, and delusions of reference and persecutions were the common psychotic manifestations in these patients. However delusional jealousy was not addressed in their study.

According to Batinic, Duisin & Barisic,⁸ morbid jealousy may be a presentation of substance use disorder such as cocaine or amphetamine. In an interesting case report, a man with a history of treatment for ADHD with dexamphetamine has developed infidelity delusions against his wife.¹¹

In the present study no differences were found between patients who developed infidelity delusions and those who did not regarding patients’ demographics or demographics of Captagon use except for age variable. In Singh, Bhandari, and Singh⁵ study, morbid jealousy was more common in educated participants who attended intermediate level or university.

In the present study patients who developed delusional jealousy showed a higher divorce rate than patients with other types of delusions. Divorce may be a major social consequences of developing infidelity delusions but is not the most serious one. It is not uncommon for patients diagnosed with infidelity delusions to show both verbal and physical aggression toward their wives to a degree that endanger their lives. According to Singh, Bhandari, and Singh,⁵ delusional jealousy could give rise to fatal violence against the partner which may be followed by suicide.

This is an initial investigation of the association between using Captagon and the development of infidelity delusions. There is a need to replicate this study on a wider scale and to avoid limitations which included the non-randomized nature of the study, and lack of specific scale for morbid jealousy.

Conclusion

Infidelity delusions are common among patients diagnosed with Captagon induce psychosis, and they harmfully influence their social lives.