Erotomania : epidemiology and management

I tweet, therefore I am: a systematic review on social media use and disorders of the social brain

With rapid technological advances, social media has become an everyday form of human social interactions. For the first time in evolutionary history, people can now interact in virtual spaces where temporal, spatial, and embodied cues are decoupled from one another. What implications do these recent changes have for socio-cognitive phenotypes and mental disorders? We have conducted a systematic review on the relationships between social media use and mental disorders involving the social brain. The main findings indicate evidence of increased social media usage in individuals with psychotic spectrum phenotypes and especially among individuals with disorders characterized by alterations in the basic self, most notably narcissism, body dysmorphism, and eating disorders. These findings can be understood in the context of a new conceptual model, referred to here as 'Delusion Amplification by Social Media', whereby this suite of disorders and symptoms centrally involves forms of mentalistic delusions, linked with altered perception and perpetuation of distorted manifestations of the self, that are enabled and exacerbated by social media. In particular, an underdeveloped and incoherent sense of self, in conjunction with 'real life' social isolation that inhibits identify formation and facilitates virtual social interactions, may lead to use of social media to generate and maintain a more or less delusional sense of self identity. The delusions involved may be mental (as in narcissism and erotomania), or somatic (as in body dysmorphic disorder and eating disorders, encompassing either the entire body or specific body parts). In each case, the virtual nature of social media facilitates the delusionality because the self is defined and bolstered in this highly mentalistic environment, where real-life exposure of the delusion can be largely avoided. Current evidence also suggests that increased social media usage, via its disembodied and isolative nature, may be associated with psychotic spectrum phenotypes, especially delusionality, by the decoupling of inter and intra-corporeal cues integral to shared reality testing, leading to the blurring of self-other boundaries.

Induced erotomania by online romance fraud - a novel form of de Clérambault's syndrome

BACKGROUND

Although the impact of internet usage on mental health is extensively documented, there is a notable scarcity of reports in the literature concerning internet-induced erotomania. Erotomania is a rare and likely underdiagnosed delusional disorder. It is characterized by an irrational belief held by the affected persons that someone of higher socioeconomic status harbor romantic feelings toward them. Here, we describe the psychopathology of erotomanic delusion induced by online romantic fraud in a female patient. Employing this case as a focal point, we illuminate novel aspects of erotomania that warrant attention and examination.

CASE PRESENTATION

We present a compelling case involving a 70-year-old married Caucasian woman diagnosed with medically controlled persistent depressive disorder for several years. The intricacies of her condition became evident as she became deeply engrossed in online profiles featuring the image of a renowned musician, inadvertently falling victim to an online romantic fraud. Subsequently, this distressing experience triggered the emergence of erotomanic delusions and a suicide attempt. The patient's history reveals an array of medical conditions and stressful life events, contributing to her vulnerability. The diagnosis of erotomanic delusional disorder, dysthymia, and mild cognitive impairment with cerebral vascular background was established. Treatment involved her previous antidepressant with low-dose risperidone, alongside supportive individual and group therapy. Her delusion showed remission four weeks later, prompting her discharge for outpatient follow-up. Although she retained some false beliefs, the intensity of the symptoms had notably diminished and her functionality improved.

CONCLUSION

This case underscores the complex interplay between mental health, online activities, and the consequences of delusions, including suicidal thoughts, shedding light on the need for a comprehensive approach in addressing such challenging psychiatric scenarios.

Erotomania and phenotypic continuum in a family frameshift variant of AUTS2: a case report and review

BACKGROUND

Pathogenic variants of the AUTS2 (Autism Susceptibility candidate 2) gene predispose to intellectual disability, autism spectrum disorder, attention deficit hyperactivity disorder, facial dysmorphism and short stature. This phenotype is therefore associated with neurocognitive disturbances and social cognition, indicating potential functional maladjustment in the affected subjects, and a potentially significant impact on quality of life. Although many isolated cases have been reported in the literature, to date no families have been described. This case reports on a family (three generations) with a frameshift variant in the AUTS2 gene.

CASE PRESENTATION

The proband is 13 years old with short stature, dysmorphic features, moderate intellectual disability and autism spectrum disorder. His mother is 49 years old and also has short stature and similar dysmorphic features. She does not have autism disorder but presents an erotomaniac delusion. Her cognitive performance is heterogeneous. The two aunts are also of short stature. The 50-year-old aunt has isolated social cognition disorders. The 45-year-old aunt has severe cognitive impairment and autism spectrum disorder. The molecular analysis of the three sisters and the proband shows the same AUTS2 heterozygous duplication leading to a frame shift expected to produce a premature stop codon, p.(Met593Tyrfs*85). Previously reported isolated cases revealed phenotypic and cognitive impairment variability. In this case report, these variabilities are present within the same family, presenting the same variant.

CONCLUSIONS

The possibility of a phenotypic spectrum within the same family highlights the need for joint psychiatry and genetics research.

De Clérambault's syndrome revisited: a case report of Erotomania in a male

BACKGROUND

Erotomania, also known as "de Clérambault's Syndrome", is a psychiatric syndrome characterized by the delusional belief that one is loved by another person of, generally of a higher social status. Erotomania has always been a target of attempts of conceptualization, and the utility of regarding Erotomania as an independent syndrome has been questioned to this day. Erotomania has a much higher prevalence in the female sex, and male Erotomania is a rare and probably underdiagnosed condition. Male Erotomania is only more prevalent in forensic samples, since male sex is one of the risk factors for violent behavior in this disorder. In this article, we aim to describe an uncommon case of Erotomania occurring in a male, hoping to add to literature and to reflect on the implications of the occurrence of Erotomania in men. By discussing the case in light of the different described clinical pictures, proposed diagnostic criteria and classifications, we also aim to contribute to the ongoing attempt to conceptualize this syndrome and to understand the pertinence of considering it an independent nosological entity.

CASE PRESENTATION

We describe a case of Erotomania in a middle-aged Caucasian Portuguese male, with consecutive erotic delusions, followed by a classic turn to a persecutory delusion. The patient was admitted as an inpatient in a psychiatry unit and he was medicated with risperidone 3 mg and diazepam 3 mg daily. His persecutory delusion remitted a 4 days later, he gained insight and was discharged to follow-up as an outpatient. He retains his erotic delusional beliefs, but these are less intense, and has not presented further aggressive behavior.

CONCLUSIONS

We can conclude that it seems reasonable to retain the operative concept of Erotomania as a subtype of Persistent Delusional Disorder/Delusional Disorder, since cases fitting the classical descriptions of the syndrome have been reported, including the presented case. The diagnosis of Erotomania has implications in case management, treatment and prognosis, and missing it, especially in men, may culminate in violent situations that can have legal implications. The developed diagnostic criteria and classifications seem to retain use and should be kept in mind, in the sense that they facilitate making an important diagnosis.

The de Clérambault syndrome: more than just a delusional disorder?

The de Clérambault syndrome, commonly known as erotomania, is a delusional disorder in which the patient is convinced that another person has fallen in love with him or her. The syndrome is more frequent in female patients, who usually believe that their lover is a man belonging to a higher social and economic class, or is married, unknown, or even imaginary or deceased person. The course of the syndrome is usually chronic, with serious problematic behavioural consequences, including stalking behaviours, such as repetitive calling, unexpected visits or continuous attempts to send gifts or letters. According to the DSM-5, this syndrome is included in the erotomanic type of the delusional disorder, however, it is usually neglected in psychiatric practice and almost forgotten by modern psychiatrists.

Love as delusion, delusions of love: erotomania, narcissism and shame

Erotomania has a long, colourful history in psychiatry. It is a rare condition in which the patient ('subject') develops the belief that he or she is loved from afar by another person ('object'). The subject is generally female, though men predominate in forensic samples. The object is generally perceived to belong to a higher social class, reflecting a sociopolitical element in the construction of love. Erotomania requires active treatment and risk management as it can be associated with stalking and other offending behaviour. In addition to featuring in the psychiatry literature, erotomania features in the biography of the economist John Maynard Keynes (the apparent 'object' of a woman's erotomanic delusions in the early 1900s) and in fiction (eg, Ian McEwan's Enduring Love); this reflects, in part, the general popularity of romantic themes in broader literature and society. In psychological terms, certain cases of erotomania might be underpinned by combinations of longing, disappointment, shame and narcissism in specific social contexts. Lesser forms of delusional exaggeration of true love might also exist in some stable relationships, and might even be essential for their continued existence. Overall, the division between love and delusions of love is not as distinct as one might imagine. The potential presence of an element of delusional love in many relationships might well serve important social functions, conferring specific advantages on the parties involved and increasing social and community stability. After all, delusions persist; love dies.

Recent developments in the management of delusional disorders

Delusional disorder, rare in clinical practice, remains one of the most enigmatic conditions in psychiatry. Linked to schizophrenia spectrum disorders since the mid-20th century, recent work has confirmed 19th-century notions of an aetiology based on attentional biases and personality dimensions. Unfortunately, the literature exists largely as case reports and series, often published as ‘curiosities’, and therefore lacks the rigour of formal diagnosis. This article reviews current thinking on aetiology and epidemiology, considers diagnosis, and reviews recent work on physical and psychological therapies. It concludes that delusional disorder is likely to respond well to treatment with standard antipsychotics, often at low doses, but that adherence and concordance remain particular problems. Cognitive therapy has been shown to be beneficial but is time-consuming and resource-intensive. Selective serotonin reuptake inhibitors may profit further investigation. There remains considerable scope for investigation of this fascinating condition.

Erotomania and Recommendations for Treatment

The aim of this paper is to help clinicians better understand how erotomania originates in order to facilitate treatment and make it more effective. Data sources are the narratives of six women who spoke in detail about the beginnings of their delusional beliefs and about the nature of the evidence that convinced them that their beliefs were well-founded. In every case, low self-esteem and emotional arousal preceded the emergence of the delusion. Misperceptions and misattributions appeared responsible for keeping the delusion alive. Despite external disconfirmation, social isolation protected the delusional beliefs from revision and extinction. The erotomanic delusion provided a sense of well-being that probably contributed to its maintenance. As well, a delusion-induced boost in well-being delayed help-seeking. Recommendations for treatment include staged interventions, first establishing a therapeutic alliance with a focus on understanding the psychological factors contributing to the origin and maintenance of the delusion. The next stage is the provision of social support and strategies directed at the restoration of self-esteem. The third stage is the gradual introduction of techniques to correct cognitive biases. Medication and risk management form an integral part of overall management. Objective evidence for the effectiveness of this approach is, however, not yet available.

An Unusual Case of Erotomania and Delusional Misidentification Syndrome

Delusional misidentification syndromes and erotomania are rare entities, each with several distinct manifestations and no clearly defined treatment regimen. Here we expand upon an earlier literature review and describe the case of a 40-year-old woman with a history of bipolar I disorder who presented after an extended period of medication nonadherence with symptoms consistent with both of these conditions; she believed that the staff on the unit were in fact disguised celebrities and fictional characters, and she claimed to be married to a famous singer. The exact relationship of these symptoms (and indeed, even their basic etiologies) remains unclear; however, both delusional syndromes resolved with a combination of risperidone and lithium therapy. Although earlier literature has suggested pimozide as the most effective agent for treating delusional syndromes, given the more favorable side-effect profile of atypical versus typical antipsychotics, this case suggests a role for risperidone as a first-line treatment in such situations.

A romantic delusion: de Clerambault's syndrome in dementia

Erotromania (also known as de Clerambault's syndrome) is a rare disorder in which an individual has a delusional belief that a person of a socially higher standing falls in love with her/him. It has rarely been described in older people, but many cases have been reported in conjunction with psychiatric and neurological disorders. The purpose of this paper was to examine the phenomenon of erotomania in people with dementia. We carried out a search of electronic databases for literature on this subject. The search terms used were: erotomania, de Clerambault's syndrome, erotomanic delusion and dementia. The literature on erotomania in the course of dementia consists mostly of case reports and small samples of patients. Misinterpretation of events is common in brain disease, especially with diffuse or multifocal disorders, but erotomania has rarely been reported in dementia. The relationship between dementia and de Clerambault's syndrome remains uncertain. Erotic delusion arising late in life should be thoroughly investigated to rule out organicity.

Modeling erotomania delusion in the laboratory with hypnosis

Erotomania is the delusional belief that one is loved from afar by another person (the target). This study used hypnosis as a novel cognitive neuropsychological research tool to model erotomania. The authors developed 2 versions of a hypnotic erotomania suggestion and tested their impact by asking subjects to recall and interpret a story featuring ambiguous scenarios. They also challenged the delusion by asking subjects to justify their beliefs. The hypnotic erotomania suggestions successfully recreated the features of the clinical delusion for many high hypnotizable subjects. They believed that the target loved them, interpreted ambiguous information consistent with this belief and confabulated evidence in service of their delusion. Some also resisted all challenges to their delusion. These features are strikingly similar to clinical cases and highlight the value of using hypnosis to model clinical delusions. The authors also discuss some limitations of this approach.

Love and attachment: the psychobiology of social bonding

Basic animal studies and human imaging studies have contributed to our understanding of the psychobiology of love and attachment. There are overlaps and distinctions in the neuronal circuitry of maternal love, romantic love, and long-term attachment. In these circuits, important molecules, which have been demonstrated to play a role in the psychobiology of social bonding include dopamine, serotonin, opioids, oxytocin, and vasopressin. Particular genetic and environmental variations contribute to social-bonding phenotypes, consistent with an evolutionary perspective on the value of these behaviors. Advances in the psychobiology of social bonds have led to hypotheses about the pharmacotherapy of disorders of attachment.