Erotomania and Recommendations for Treatment

Abstract

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.

Full text

Erotomania
Seeman, M.V. Erotomania and Recommendations for Treatment.
Psychiatric Quarterly, 2016; 87(2):355-364.
SPRINGER
Abstract
Objective: The aim of this paper is to help clinicians better understand how erotomania
originates in order to facilitate treatment and make it more effective. Method: 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. Results: 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. Conclusion:
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.

Erotomania
Keywords: Erotomania; de Clérambault’s Syndrome; Cognitive Biases
Introduction
As described by de Clérambault [1], erotomania is the mistaken but firmly held belief that
one is passionately loved by a very socially desirable person who must remain, for
diplomatic reasons, inaccessible and aloof. The precursors, the onset, and the development
of this delusion is of interest to clinicians because erotomania can lead to severe distress
for the patient and to menace for the supposed admirer.
Erotomanic fantasies exist along a wide spectrum, from the wishful imaginings of
adolescent crushes on teenage idols to the intractable delusions of individuals with severe
mental illness. Delusional ideation occurs in a substantial swath of the population.
Approximately 1-3% of the nonclinical population have been reported to express
delusions at a level of severity that is comparable to that of clinical cases of psychosis. A
further 15-20% to 15% show less severe but regular delusional ideation. [2].
As a psychiatric disorder, it is equally prevalent in women and men and starts after puberty
[3], when ideals of love and idealized love objects first begin to take shape. Why is the
object or target of erotomanic delusions usually a person of relatively high social status?
Wanting to be loved is a central human motivation [4] and romantic attraction increases
according to a partner’s desirability in a variety of social spheres – physical attractiveness,
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perceived authority, socioeconomic status, general renown. Who is vulnerable to the
delusion of being secretly loved by such an individual? Usually it is persons who feel
socially rejected and who, in the face of perceived rejection, resort to the fantasy that an
acknowledged superior human being adores them. Socially isolated persons with little
relational experience and persons inordinately preoccupied with their own needs are
vulnerable because they are relatively blind to cues that indicate the possibility, or not, of
romantic attraction. Such persons may perceive a message where none was intended [5]
because they have misinterpreted a facial expression [6] or misconstrued the meaning of a
glance [7]. They, thus, are susceptible to an idiosyncratic interpretation of other people’s
feelings and intentions.
The timing of the eruption of erotomania is often one of heightened emotional distress [8],
the recent loss of an attachment figure for instance [9]. The origin of delusional beliefs in
general can often be traced back to a mood of heightened emotionality [9]. Erotomanic
delusions arising during periods of stress are not surprising because it is at such times that
humans are motivated for security reasons to seek an attachment to a powerful attachment
figure [11].
The erotomanic delusion begins when a vulnerable person encounters someone who
corresponds to a previously imagined romantic ideal, and who appears to be interested.
The perception of interest is faulty; nevertheless it gives birth to the belief that ardor has
been aroused in the other person. The experience of the delusional person at the inception
of the delusion is that something uncanny has happened. The feeling evolves over time,
especially if the person remains socially isolated. Because making sense of a new
relationship requires dialogue, because human meaning-making is a shared and mutual
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activity [12] that relies to a large extent on prevailing social norms, isolated persons are
disadvantaged in this area. Because many isolated and delusion-prone people have a
relative inability to put themselves in the shoes of others [13], they end up elaborating
meaning based primarily on wishful thinking [14]. As time goes on, the delusional
conviction becomes fixed. This is almost inevitable because the delusion serves an
important intrapsychic purpose. It provides a stable, if virtual, attachment figure; it bolsters
self-esteem, and it allows the wishful thinker to incorporate by identification the qualities
of the idealized person – to feel as attractive, powerful, rich, and skilled as the idealized
other. In this sense, erotomania is a grandiose delusion [15], difficult to influence
therapeutically because the improved mood and heightened self-esteem engendered by the
delusion makes any intervention seem superfluous.
Isolation allows the delusion to flourish. Isolation protects the wrong belief from
questioning or revision. Everyday events seem to provide confirmatory signs of the chosen
person’s love [16]. The delusional person begins to believe that the lover is communicating
in subtle, nonverbal ways. For instance, the number of green cars passing the window
takes on special meaning. Door knocks are messages in Morse code, as can be the flashing
lights of overhead airplanes. Numbers on license plates seem pre-arranged in meaningful
patterns. Stimuli that others would see as neutral are experienced as if endowed with
personal significance. This cognitive bias, the assumption that that every occurrence refers
to oneself, has been called the egocentric bias [17] or self-centrality [18]. Delusional
persons perceive themselves as being at the centre of everything that happens around them.
Another cognitive bias, the intentionality bias [17] makes neutral objects in the
environment appear to be arranged in a pattern intended to convey a personal message.
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Colors, postures, gestures, glances are all weighted with meaning. Nothing is perceived as
accidental [19].
The aim of this paper is to help clinicians better understand how erotomania originates in
order to make treatment more effective.
Method
Details of onset and progression of the delusion are taken from six previously reported
cases of erotomania [20-23]. Treatment recommendations are derived from a consideration
of the literature on therapeutic alliance, enhancement of self-esteem, monitoring and
treatment of cognitive biases, as well as the use of medications and the implementation of
safety measures.
Case A.
When first assessed for erotomania, A. was a woman in her 50s who attended
a mental health service for depression. A fellow service user had committed
suicide, which greatly upset her. She blamed herself because of something
she had not long before said to the suicide victim. At the funeral home, many
fellow service users were in attendance. The way A. described it, a beam of
sunlight coming through the stained glass paneled windows of the funeral
home struck the glasses of one of the young men, which made A. look at him
more closely. She saw tears glistening in his eyes and had a sudden
overwhelming conviction that this man was in love with her. He was crying,
she rationalized, because his heart was overflowing with love. After the
service, A. tried to talk to him, but he seemed to avoid her. He even swore at
her when she persisted and told her to keep away, but she ‘knew’ it was to
cover up the intensity of his love, which couldn’t be spoken because they
were in a house of mourning. The next day, A. bought herself an engagement
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ring so that the young man would know she would always be true to him.
She told the other patients in the health service that she and he were engaged.
They didn’t believe her and laughed at her, which did not discourage her.
The case of A. illustrates the importance of context and prevailing mood at the time of
the ‘revelation’. A. found herself in unfamiliar surroundings, emotionally upset and
feeling overwhelmingly guilty. The perception of tears in a man’s eyes made him appear
empathic and emotional. In her mind, his tears could only be about her. Because he was
young, he possessed qualities she fervently wished for herself – youth, energy, vitality.
Unlike many people suffering from erotomania, A. was not totally isolated; she belonged
to a group with whom she shared her delusional conviction. Her peers scoffed at her, but
this was not enough to dissuade her. It could not outweigh the immense psychological
benefit she gained by her delusion. The thought that she would be one with someone so
young, rejuvenated her. Her depression dissipated.
Case B.
B. was a married woman in her late 20s with a history of mood swings that
had never been treated. During a long and difficult labor, her obstetrician
stayed up with her throughout the night. After the delivery, B. experienced a
sudden ‘insight’ as to why her obstetrician had gone out of his way for her. It
was, she ‘realized’, because he had fallen in love with her. She understood
that he had to hide his feelings because it was unethical for doctors to enter
into relationships with their patients, but she could tell how he felt from his
facial expression. She showered him with thank you gifts, all of which he
refused, which only made her more convinced of his romantic interest. She
spent her time reading the literature on relationships between doctors and
patients, which gave her hope that, in the end, they would be together. She
studied the license plates of cars passing her on the road and deciphered a
pattern to the numbers, which she interpreted as covert messages of love
from the obstetrician. She felt wonderful.
Childbirth is a time of hormonal, physiologic, and psychological flux, a mix that can set
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the scene for a delusional mood. The obstetrician was perceived as a miracle worker who
had sacrificed his own comfort to that of his patient and brought her the gift of a child.
Because of her habitually low self-esteem, she could not conceive of anyone doing so
much for her unless he were motivated by love. His profession did not allow him to
declare his love; she understood this but, because she saw him as scientifically skillful and
smart, she was certain he would find a way to communicate his feelings, and, because of
the secrecy required, coded number patterns on license plates somehow made sense to her.
Case C.
C. was a middle aged single woman, a would-be writer, with no psychiatric
history. She went overseas to London to attend a younger sister’s wedding.
At the wedding reception, she danced a waltz with a friend of the family, a
prominent (and married) newspaperman who told her he enjoyed dancing
with her. Upon her return to Canada, she thought about her trip and the
realization dawned that the man with whom she had danced had fallen in
love with her and wanted to marry her. She considered this a happy
coincidence because her sister had also met the man who was now her
husband at an overseas wedding. C. wrote to the man, uncertain whether he
would respond. She spoke about him to a girlfriend who told her she was
being silly, that there was nothing to suggest that the man was the least bit
interested. Her friend’s reaction brought her down to earth and C. put the
meeting out of her mind. However, the man in question answered her letter
with a polite note and this was sufficient to reawaken C.’s conviction that he
was in love with her. She kept writing although she received no further
replies. She began to listen to the BBC news and she decoded a pattern in the
words of the broadcasts that seemed to answer the very questions she had
posed in her letters. She was certain that the man was planning to leave his
marriage to be with her, and she was certain that, under his mentorship, she
would soon acquire the skills and connections she needed to become a
successful writer.
C. was jet lagged and somewhat intoxicated when she met the newspaperman. This and
the mixed feelings about her sister getting married while she herself remained single added
to the belief that weddings were occasions where love matches could originate, contributed
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to the initial mood of arousal. The delusional conviction was at first not firmly held and, in
fact, dissolved until ‘tangible proof’ in the form of a letter crystallized it. Her girlfriend’s
words had an appreciable effect early in the delusion, but, later, the opinion of others no
longer seemed to matter. The delusion was reinforced by a sense of inevitability because of
her younger sister’s experience and because of the hope that this man would not only be a
lover, but a mentor and colleague as well, and that her career would flourish because of
him.
Case D.
Ms. D., a woman in her thirties with no prior psychiatric history, attended a
New Year’s Eve party at a friend’s house. Because she was experiencing
menstrual cramps, she took pain pills with codeine and then drank more than
was usual for her at the party. She was seated next to an older man she had
previously heard about, but had never before met. He was a former football
hero. Though married for many years, his wife was not at the party. D. felt
uninhibited and flirted with the man, who flirted back. That night, unable to
sleep, she put two and two together: it was New Year’s and the man’s wife
was not at the party. She concluded that meant they were not on good terms;
that meant he was free; that was why he flirted with her and that meant he
had fallen in love with her. She attributed a magic significance to their
meeting at the precise moment when one year merged with the next. D. was a
relatively isolated person who told no one about what had happened,
allowing the delusion to grow. She had no further contact with the man at the
party but the conviction that he loved her served an immediate purpose.
Certain that she was loved by this famous person, she left a longstanding
boyfriend, a move she had been contemplating for a long time.
Case D. again demonstrates than an atypical state of mind is a breeding ground for
delusions, brought on in this case by opiates and alcohol. The tendency to jump to
unwarranted conclusions is illustrated by D.’s conviction that a wife not attending a New
Year’s party could only mean that the marriage was in trouble. Maintenance of the
delusion was reinforced by her pride in being able to take a step (breaking up with her
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boyfriend) that she had been unable to take until then.
Case E.
E. was a new immigrant to Canada, a single 35-year-old librarian with a
history of depression, currently untreated, who lived alone. Home from work
one day (which happened to be her birthday) with a high fever, she opened
the newspaper and saw a photograph of Pierre Trudeau, then Prime Minister
of Canada. He was smiling directly at her and she was sure he was sending
her a message. The message was that he loved her. Her destiny, she realized,
was to be First Lady of Canada. E. watched the television news daily after
that. Trudeau was constantly in the news, and she could always tell by his
eyes that he was speaking directly to her. She no longer felt like an outsider
in Canada because the Prime Minister of the country loved her.
The occasion for the delusional mood in Case E. was a fever and the special
meaningfulness of the day (her birthday). Not only did the delusion offer the love of an
important person but it also, at the same time, eliminated the distress she felt at being an
outsider in a strange country.
Case F.
F. was on medication for a chronic form of schizophrenia and had been
changed from an oral to a depot antipsychotic. She was fearful of the needle
when she came to the nursing station for her first injection. The nurse said,
“Dr. G. ordered this.” F. heard a voice in her head telling her that Dr. G., her
psychiatrist, had deliberately ordered the needle on that particular day (her
ovulation day) in order to impregnate her because of his overwhelming love
for her. She gladly took the monthly injection and soon felt she was pregnant
and that Dr. G. was the father. F.’s parents, with whom she lived, humored
her belief because, no matter how illogical, this fantasy made her happy.
Whenever F. saw a wedding on TV, she understood it to mean that she and
Dr. G. would be married soon; she spent her days in planning for her
upcoming wedding and was not troubled by the length of time her pregnancy
was taking.
F. had suffered from delusions since age 16 and the delusion about Dr. G. was not her only
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one, but it became pivotal to her life. Dr. G. did everything in his power to convince her
that he was not interested. He transferred her care to another doctor. He sent her lawyers’
letters telling her to stop and desist from telephoning him and opening the door of his
office when he was seeing patients. Dr. G. transferring her care to another doctor only
made matters worse. F. interpreted it to mean that the doctor/lover would now be free to
pursue her romantically. Lawyers’ letters, the actual content of which F. found difficult to
understand, meant to her that the relationship was ‘official’.
Discussion
An emotional background of unusual arousal preceded all six delusions. It was described
as an unusual-for-the-person mood brought on by fear, alcohol, high fever, dehydration,
high emotion, pharmacological agents, hormone disruption or other combinations of mind-
altering factors. The immediate postpartum period, as in the case of B., illustrates how
multiple interacting factors can produce a very special state [24]. The literature on
erotomania provides examples of precipitation by antidepressants [25] and other drugs.
Alcohol is often involved. Alcohol and related substances permit shy, isolated persons to
engage in social situations, but they put vulnerable people at risk for an unusual-for-them
emotional state which can lead to delusions.
In all cases, the heightened arousal generated an atmosphere charged with excitement,
unpredictability, and inexplicability. Nothing seemed familiar and everything seemed
significant [26], including the people the women happened to meet at this time. During
arousal, the body’s catecholamines are recruited via the hypothalamic–pituitary–adrenal
axis and they make the perception of somatic sensations more acute. This meant that
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somatic markers - rapid heart rate, flushing, hard breathing, and racing thoughts - that
accompany arousal were felt intensely and were readily associated to feelings of love [27]
attributed by a process of projection to the most eligible person in the immediate vicinity.
Wishful thinking played into the attribution [14].
The timing and site of the event are perceived as momentous, with the pre-delusional
person inhabiting the centre of an intricate web of meaning [18]. The initial meeting is seen
not as a convergence of coincidences [19], but as a preordained coming together. The
chosen person is often a respected figure or a much-admired celebrity, or someone
embodying a wished-for condition – youth, as in the case of A., wisdom, power, talent or
wealth. Perhaps one reason why the target is usually someone of relatively high social
status is that the very fact of being in the presence of such a person in itself elicits
emotional arousal. As was the case with B. and F., physicians are frequently the objects of
erotomanic delusions [28]. This may be because the benevolent, attentive behavior of
physicians toward patients permits misinterpretation of intent, benevolence being
misperceived as erotic interest, a form of delusional transference [28-30]. Public figures
who wave and smile at assembled crowds are similarly in danger of their gestures being
misinterpreted [31], as was the Prime Minister of Canada in the case of E., despite the
barrier of newsprint.
The conclusion that the person one has just met has fallen in love can be partly attributed
to pre-existing difficulties in understanding others [13], to the misinterpretation of facial
expressions and gestures [5] and to a cognitive bias so severe that conclusions are readily
reached on little evidence [32], as in the case of D. who was certain that a marriage was in
trouble because a wife did not attend a New Year’s party. The tendency toward a certain
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mode of unusual reasoning may be inborn or may develop over time as a result of faulty
training or aberrant experience.
Unwitting reinforcement is sometimes received from the outside world. It may be
acquaintances naively saying, “How lucky you are that such a great guy likes you” or
family members, as in the case of F., supporting anything that makes a person, ordinarily
so withdrawn, suddenly happy. There is the chance that throwing cold water on the
supposed romance at its inception could put a stop to the progression of the delusion,
although this is not always true, as in the case of A. Very soon, the person starts to provide
her own delusional reinforcement via a subjective, wish-fulfilling interpretation of events,
as happened in all the cases discussed above.
The erotomanic delusion, feeling that one is loved and cherished, comes with powerful
secondary gain that gives zest and meaning to life [4, 33]. The psychological pay off from
the delusion is so great that, when the delusion wanes, depression and even suicide can
ensue. E., described above, killed herself when she understood, after being treated with
antipsychotic medication, that Prime Minister Trudeau did not, after all, love her.
Relationships are created with other people through a process of mutual understanding,
back and forth negotiation, give and take, and reciprocal correction of individual
perceptions. In this sense, the meaning of any interpersonal situation is co-created and can
be continuously revised. But those prone to delusions often start off with diminished trust
in others [34] and, therefore, with diminished motivation to learn from others and to revise
personal beliefs in alignment with those of others [35]. As discussed earlier, persons prone
to delusions often entertain the prior illusion that the world revolves exclusively around
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them [10, 18].
Such referential thinking means that innocuous stimuli hold significance. As a result,
persons prone to referential thinking have a strong cognitive bias against any evidence that
might disconfirm what they have come to believe is true [36]. This tendency makes them
unable to change their beliefs and opinions even when presented with reasonable proof to
the contrary. Some of the firmness of delusional beliefs has been traced back to a
deficiency in self esteem [37, 38]. When self-esteem is low and a delusion helps to bolster
it, it becomes a very difficult delusion to surrender.
In sum, erotomanic delusions are aroused in individuals who perceive themselves as
socially rejected and who have been made susceptible by a variety of experiences and
cognitive tendencies. The arousal takes place at a time or place believed to bear personal
significance and during a period of atypical for the person mood. It is maintained by social
isolation and reinforced by the good feeling that it provides.
Treatment Considerations
Because erotomanic delusions serve as a buffer or compensation for feelings of
incompetence, unworthiness, rejection, and loneliness, the affected person may not feel the
need to seek help, and may only do so at the urging of others. It is, therefore, critical to
build a therapeutic alliance [39] than can be used to cement trust. The next stage is to boost
the patient’s self-esteem before attempting to address the delusion itself. Self-esteem is
addressed in individual ways [40] through psychological understanding, emotional support,
training of social and employment skills, referral to weight reduction and other image-
enhancing programs. Allowing the patient to tell their story in detail is important to a full
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understanding.
As trust develops, cognitive biases need to be investigated, perhaps with specialized tools
such as the Metacognitive Assessment Scale [41], with gradual feedback provided to
patients about impulsivity in reaching conclusions or about ego-centric cognitive
tendencies. Using within therapy examples, it can be demonstrated to patients that they
tend to discount the role of chance in daily occurrences. Attention to cognitive biases needs
to be followed by the gradual introduction of impairment-specific Cognitive Behavioral
Therapy, the specific effectiveness of which has been shown in erotomania only in
individual case illustrations [42]. Medication (antipsychotic and antidepressant and
anxiolytic) usually needs to be added [43]. Because some instances of erotomania go on to
dangerous harassing and stalking behavior, risk management becomes an important part of
an overall treatment strategy [43]. Although objective evidence is, thus far, lacking, an in
depth understanding of the origins and maintenance of a delusion should facilitate
treatment and improve its effectiveness.
Acknowledgement
The author is grateful to the patients whose narratives were key to the recommendations
contained in this article.
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