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LETTER TO EDITOR  
Year : 2019  |  Volume : 61  |  Issue : 1  |  Page : 107-108
An adolescent crush or delusion of erotomania? Dissecting the normal from the pathological


1 Department of Psychiatry, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Psychiatry, KIMS, Bhubaneswar, Odisha, India

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Date of Web Publication9-Jan-2019
 

How to cite this article:
Mishra BR, Das S, Nath S. An adolescent crush or delusion of erotomania? Dissecting the normal from the pathological. Indian J Psychiatry 2019;61:107-8

How to cite this URL:
Mishra BR, Das S, Nath S. An adolescent crush or delusion of erotomania? Dissecting the normal from the pathological. Indian J Psychiatry [serial online] 2019 [cited 2019 Sep 21];61:107-8. Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/1/107/249674




Sir,

Erotic love is a powerful and passionate force that often influences individual behavior and reasoning. Many would have sensed a feeling of being possibly loved by someone of the opposite gender by subtle hints and body gestures which serve as an indication. Irrespective of its consequences, there are instances where the adolescent has continued to harbor these passionate emotions till its proper appraisal.[1],[2] A psychological construct which has phenomenological similarity to adolescent love is erotomania or De Clerambault syndrome, a psychotic disorder, in which an individual has a delusion that a person of higher social status falls in love with him/her.[3],[4] It can sometimes be difficult in demarcating one from the other. We present two cases in which the clinical presentation was similar to an adolescent crush but subsequently assumed a psychotic coloring while looking into the subtle differences between them.

A 25-year-old male student, child of divorced parents and well-adjusted premorbidly, presented with a 2 years' history of insidious symptom onset featured by the delusional conviction of being loved by a girl from different ethnicity and persecutory delusions against other students of the same ethnicity as that of the girl. There was a history of poor medication compliance and propensity to develop extrapyramidal symptoms (EPS). His mental status examination (MSE) revealed normal speech and psychomotor activity, anxious affect, thought content revealing delusion of love with secondary delusion of persecution, impaired judgment, and Grade-1 insight. The patient was diagnosed to be suffering from persistent delusional disorder. Given his poor response to various antipsychotics and propensity for EPS, tablet clozapine was started with dose up to 400 mg/day; however, he continued to harbor his delusions with the same conviction.

A 23-year-old male, well-adjusted premorbidly, presented with 8 months' history of insidious symptom onset featured by initial 2 months of conviction of being loved by a girl of his class and depression following rejection. He was treated with tablet escitalopram 10 mg/day that led to a manic switch during which his MSE revealed delusion of love and grandiosity, impaired judgment, and Grade-1 insight. The patient had dystonia with tablet haloperidol 5 mg/day and weight gain with tablet olanzapine. In view of such, he was treated and showed good response with tablet sodium valproate 1300 mg/day and tablet quetiapine 300 mg/day. There was drug discontinuation following which delusion of love returned without any other affective display. His MSE suggested the delusion of love and delusional memory (having a secret baby from the girl, following accidental impregnation of the girl by him during her first display of interest for him). He later responded to tablet clozapine 200 mg/day with a significant reduction in preoccupation and conviction in his delusion.

The delusion of erotomania has been described as the delusional conviction of being loved by another person, usually of higher social rank. There is a lack of literature about the background, classification, treatment, and outcome of this disorder. The deluded participant first falls in love and subsequently makes advances. Paradoxically, the participant (mostly socially isolated), however, believes that the fantasy lover was the first to make the move with an underlying eroticism.[3],[4] The onset is usually acute, and other psychotic features such as hallucinations are usually absent. Therapeutically, they require psychotropics; however, the prognosis is not always good.[5]

An adolescent crush has a striking resemblance to the above entity. The individual offers elaborate explanations to friends regarding the subtle hints from a fantasy partner while spending days dreaming about the partner. He/she uses the defense mechanism of projection of love on to the partner, which enables to maintain the equilibrium of his/her ego. Freud's representation of this defense is aptly depicted in the formulation, “I don't love him; I love her because she loves me.”[4] In contrast to the hidden erotic passion in delusion of erotomania, a predominantly platonic element characterizes adolescent crush. The crush usually resolves either by repeated peer confrontation or by partner rejection. Fortunately, the person does not need psychotropics. Occasionally, an exaggerated adolescent crush can take a psychopathic coloring with disastrous consequences.[3],[5]

In both the cases, the initial presentation looked like an adolescent crush, with the reluctance to accept the initial rejection and the persistence with their passionate emotions till its positive approval. The underlying shading of psychosis was difficult to be predicted initially. Moreover, the onset was insidious, the fantasy lovers belonged to similar sociocultural background, and there was a lack of any account of initial advances made by their fantasy lover, as typically reported by a patient having erotomania. There was the prominence of affective display, particularly in the second case, which further obscured the clinical picture. The propensity for EPS was again going against a diagnosis of nonaffective psychosis. However, the morbid origin of the delusion of love and the pathological explanations given by both the patients to justify their delusions during the later course of their illness helped in demarcating their morbid psychotic state.

Few typical components of erotomania such as the fantasy lover being of higher social rank, socially isolated status of the subject, and lack of affective display were distinctively lacking in both the cases and the shades of platonism further obscured the underlying psychotic state. In the first case, the decision to start antipsychotic was delayed, whereas in the second, antidepressant resulted in a switch. The propensity for EPS added to the diagnostic confusion as well as the institution of the proper antipsychotic, ultimately, both the cases were maintained on clozapine. In conclusion, it needs mention that it can be quite challenging initially to differentiate a normal phenomenon from a pathological entity for which one needs to be sensitive and careful enough to clarify the faint boundaries between them.

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.

Acknowledgment

The authors are thankful to Dr. Biswa Mohan Padhy and Dr. Rituparna Maiti, from the Department of Pharmacology, AIIMS, Bhubaneswar, India, for their support and help. There is no financial interest or any conflict of interest for declaration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bergner RM. Love and barriers to love. An analysis for psychotherapists and others. Am J Psychother 2000;54:1-7.  Back to cited text no. 1
    
2.
Levine SB. What is love anyway? J Sex Marital Ther 2005;31:143-51.  Back to cited text no. 2
    
3.
Jordan HW, Lockert EW, Johnson-Warren M, Cabell C, Cooke T, Greer W, et al. Erotomania revisited: Thirty-four years later. J Natl Med Assoc 2006;98:787-93.  Back to cited text no. 3
    
4.
Jordan HW, Howe G. De clerambault syndrome (erotomania): A review and case presentation. J Natl Med Assoc 1980;72:979-85.  Back to cited text no. 4
    
5.
Kennedy N, McDonough M, Kelly B, Berrios GE. Erotomania revisited: Clinical course and treatment. Compr Psychiatry 2002;43:1-6.  Back to cited text no. 5
    

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Correspondence Address:
Santanu Nath
Department of Psychiatry, All India Institute of Medical Sciences, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_90_18

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