Erotomania: A case series.

Erotomania is an unusual psychotic disorder exemplified by an individual's delusions of another person being infatuated with them. The condition is usually, but not exclusively, observed in females who are shy, dependent, and sexually inexperienced. The object of the delusion is usually beyond reach, being of much higher social or financial status, already married or disinterested. We present a case series of three patients suffering from this uncommon disorder. Copyright:

References to erotomania has been found in the works of Hippocrates, Galen, and Freud. Erotomania was defined by Sir Alexander Morrison (1848) as: Typified by delusions…… the patient ….is wholly occupied by the object of his adoration, whom if he approaches, it is with respect.….the stable and perpetual delusions accompanying erotomania at times goad those harbouring the delusion to obliterate themselves or others. He also noted that the condition is commoner in women than men. In 1921, the French Psychiatrist De Clerambault described a syndrome which he called “psychose passionelle.” Since then it has been called “erotic paranoia,” “erotic self-referent delusion” delusional loving, delusions of passion, phantom lover syndrome,” “psychotic erotic transference reaction and delusional loving” “melacholie erotique and amor insanus” (insane love) until the common usage of the terms erotomania and de Clérambault's syndrome. Kraepelin, Bernard, Winokur, Kendler, and Munro have added to the understanding of the disorder.[123] De Clerambault described two forms of erotomania: Pure or primary and secondary or recurrent.[4] Diagnostic criteria for primary erotomania are (a) A delusion of being in love with another person. (b) This person is of much higher social status. (c) The other person has initially fallen in love. (d) The other person had made the initial advances. (e) The onset is swift. (f) The love object is constant. (g) The subject explains the unpredictable behaviour of the loved one. (h) The course is chronic. (j) Hallucinations are absent. In the secondary form, the disorder is associated with other forms of psychoses most commonly, paranoid schizophrenia or bipolar affective disorder. It is often seen with a wider range of persecutory themes, hallucinations, and grandiose ideas. In secondary erotomania, the delusion occurs during other psychoses, and the delusions are less in intensity. Erotomania has been reported from all over the world. However, a review and analysis of five new cases and 53 cases for the literature concluded that none of the cases completely satisfied the diagnostic criteria and the majority of the patients suffered from another psychiatric disorder, most commonly schizophrenia. They strongly argued against retaining the syndrome as a separate disorder.[45] We report a case series of erotomania patients with different presentations including both primary and secondary erotomania.

CASE REPORTS

Case 1

A 45-year-old married female, mother of two children, used to work as helper at a school, was brought to psychiatric OPD by her husband with complaints of irritability, low mood, disturbed sleep, reduced communication with family members from the past 5–6 months, he also added she would frequently run out of the house chasing cars and would return back late in the evening, he also added that her appetite reduced from past 10–15 days and she has not been eating at all grin the past 3 days, on enquiring about the reason for her behavior, she said that the head master of her school is in love with her and she loves him too and he asked her not to eat food till he would come to meet her, she also said he would frequently ask her to visit him at the nearby temple but never shows up as he is a very busy man, she further said he loves her a lot and that's the reason he arranged their school annual function on seventeenth which also happens to be her birthday, on enquiring further, she accepts that she has never met him in person, but is sure of his love for her. Her physical examination revealed severe pallor but otherwise was unremarkable. On mental status examination (MSE), she was well kept and moderately nourished dressed appropriate to her age, her speech was relevant and coherent, her affect was dysthymic and her thought revealed well-systematized delusion of erotomania. She denied any perceptual abnormality, lacked insight into her illness and her judgement was poor. All routine investigations were within normal limits. She was started on tablet haloperidol 5 mg once daily which was gradually uptitrated to 20 mg per day. She showed response in terms of mood and bio functions but the belief that her headmaster is in love with her is still intact.

Case 2

A 22-year-old girl, educated till 12th standard, unmarried, Hindu by religion, Hindi and Marathi speaking, belonging to middle socioeconomic class, right-handed, living with parents and brother, known case of bipolar affective disorder since 2019, currently off treatment was brought to the emergency department by her parents who are reliable and adequate informants with complaints of aggressive and violent behavior excessive usage of the phone, tantrums to get married to a boy, wearing Mangal sutra and sindoor Repeatedly going to temples since 1½ month. The patient is a known case of Bipolar affective disorder on tablet dicorate ER 250 mg twice daily and tablet quetiapine 50 mg once in the night, she was not very compliant with her medications. Her father observed that late into the night she would be talking to someone on phone, and when asked about the same she 1 day confessed that she is talking to her boyfriend. She would chant prayers all day, and would not accept food, stating that she will only accept it if she's married off to the boy. With reluctance, her father contacted the boy to find out that he had never promised her for marriage and that she kept insisting and messaging him despite his constant refusal and blocking her from multiple accounts.

Case 3

A 37-year-old female, educated till 10th grade, married for 20 years, having 2 children was brought to the psychiatry OPD with complaints of the belief that she's married to her cousin and they are in love, making inappropriate advances toward cousin brother, irritability and abusive behavior for 10 days. The patient was apparently alright 3 years ago when she suddenly reduced communication with her husband and would only respond to him over important household matters. She would interact normally with her children. Initially, her husband thought she was just upset with him but upon asking, she spoke to him about this with conviction as if it was true. Physical examination was within normal limits. On MSE, her speech was spontaneous with normal rate, tone and volume and her thought revealed a well-systematized delusion of love. She was started on tablet olanzapine 20 mg along with supportive psychotherapy. Currently, the patient is on regular treatment and is not acting on her delusion, but her belief that her cousin is in love with her still persists.

Case 4

A 22-year-old male, educated up to 8th Std., unmarried, unemployed, living with his parents and hailing from Solapur, belonging to a lower socioeconomic background, known case of paranoid schizophrenia since 2019, off treatment since the past 6 months, wandered from his home and reached the psychiatry OPD looking for his doctor. Upon contacting the mother (to let her know his whereabouts), she gave the history of irritability, suspiciousness, muttering to self, claiming that his doctor is calling him to meet her, wandering behavior and reduced sleep since the past 4 months. Symptoms were insidious in onset and progressive. On enquiry, the patient claimed to hear the voice of his doctor telling him to come to visit her at the hospital and that he had come with the intention of marrying her, as the doctor was in love with him. He believed that the doctor fell in love with him during the first admission but did not have the courage to reveal her true feelings. There is the history of symptoms of irritability, suspiciousness and muttering to self in the past where in patient was admitted for 15 days and started on psychotropic medications. The patient discontinued the medicines during the lockdown. There is no significant history and no family history of psychiatric illness. The patient denies any substance use. Physical examination was normal. MSE revealed a kempt, appropriately dressed boy with increased psychomotor activity, anxious affect and a well-systematized delusion of love, the delusion of persecution and 2nd person conversing type of Auditory hallucinations with an impaired insight and judgment. The patient restarted on the antipsychotic tablet olanzapine 10 mg twice a day BD and monitored for the response. Gradually his sleep improved, his hallucinations ceased completely and the patient was no longer irritable or suspicious towards his mother, but the delusion of love remained but was encapsulated.

DISCUSSION

Erotomania is a delusional disorder where according to Taylor et al., the symptoms are summarized as that the patient has a delusional belief that someone of a higher standing or someone who is not attainable is in love with them, the object of desire may have little or no contact with the patient, the patient perceives the object of desire as watching over or protecting the patient.[6] Our first and third cases fulfilled all the above-mentioned criteria. Our second and fourth patient falls under the category of secondary erotomania. It is also said that the object of desire can be shifting in secondary erotomania, which was the scenario with our second patient. Similarly analyzing the cases as per De Clerembault's criteria also we find that the first, third and fourth cases met all the criteria [Table 1]. The contrary findings of Ellis and Melsopp could have been because it was mainly a retrospective analyses of reported cases in the literature.[5] The case summaries may not have included the full details of the case leading to an erroneous conclusion. We would therefore propose that while secondary erotomania may be more common but Pure Erotomania does exist as a separate nosological entity. In most of the cases reported in the literature, the response to treatment is poor. Some patients failed to show improvement even after long term treatment with sedatives, antipsychotic drugs, and electroconvulsive therapy.[7] Even in our case series, there has been improvement in terms of biofunctions, but all the primary erotomania patients and one with secondary erotomania held on to their encapsulated delusions.

Table 1

Characteristics of four patients with erotomania

Case number	Diagnostic criteria of erotomania									Marital status	Duration of illness	Outcome of erotomania	Other diagnosis
	A	B	C	D	E	F	G	H	J
1	+	+	+	+	+	+	+	+	+	Married	5 months	Delusion encapsulated	-
2	+	+	+	+	+	−	+	+	+	Unmarried	2 years	Episodic recovery	Bipolar disorder
3	+	+	+	+	+	+	+	+	+	Married	3 years	Delusion encapsulated	-
4	+	+	+	+	+	+	+	+	+	Unmarried	2 years	Delusion encapsulated	Paranoid schizophrenia

+ present;- absent

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.