Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : VR01 - VR04 Full Version

Erotomania: A Rare Psychiatric Condition- A Case Series


Published: November 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57016.17081
Amritha Chandrasekaran Sashikar, Nivetha Vasanthan, Priya Subhashini

1. Junior Resident, Department of Psychiatry, Government Stanley Medical College, Chennai, Tamil Nadu, India. 2. Junior Resident, Department of Psychiatry, Government Stanley Medical College, Chennai, Tamil Nadu, India. 3. Associate Professor, Department of Psychiatry, Government Stanley Medical College, Chennai, Tamil Nadu, India.

Correspondence Address :
Amritha Chandrasekaran Sashikar,
317, Stanley Medical College, PG Ladies Hostel, Old Washerman Pet,
Chennai, Tamil Nadu, India.
E-mail: amrithasashikar@gmail.com

Abstract

Erotomania is a rare psychiatric condition which is characterised by the delusion that a person who is of a higher social status is in love with them. Three cases of secondary erotomania have been discussed which includes a 26-year-old female patient who had a delusion that a well-known actor was in love with her. The second patient was a 23-year-old female patient who harboured a delusion that a popular guy from her school was in love with her. Another patient was a 38-year-old female patient who was deluded that a church personnel was in love with her. All three patients shared similar features that they all developed symptoms of schizophrenia during the course of the illness following the delusion, had poor insight, had poor compliance to treatment and follow-up. Management was resorted to pharmacotherapy and psychosocial rehabilitation in all cases, which yielded improvement although there was no complete remission of the delusion in a two year follow-up in either of the cases. Since erotomania is a rare and unique phenomenon, discussion about the presentation of erotomania in association with schizophrenia, provides a knowledge regarding the condition and management.

Keywords

De Clerambault syndrome, Delusion, Female, Schizophrenia

Delusion is defined as false, fixed, unshakeable belief not amenable to changes even with the evidences to the contrary depending on the socio-cultural educational backgrounds. Erotomania or psychoses passionelle is one such delusion, first described by G.G. De Clerambault in 1921 (1). He made his first comment on erotomania upon a paper published in 1913. In 1920, he reported a case of a French women in love with King George V was in love with her. In 1923 he published his final papers on erotomania and accepted the term ‘secondary erotomania’ proposed by Truelle and Reboul-Lachaux (2). Mostly occurs in single women and is characterised by false belief that a person of higher social status is in love with her. The subject has strong conviction and gives detailed explanation about the delusion, even-though the subject has little or no contact with the other person (3). The subject tries to contact the other person through phone call, social media, sending gifts and even stalking. The subject interprets a new meaning to the actions done by the object that is paradoxical or contrary to the other persons behaviour (4). De Clerambault described the core features of erotomania and since then it was called as De Clerambault syndrome (5). De Clerambault described two forms of erotomania the pure or the primary form and the secondary form.

In the pure form, a single erotic delusion is formed and then other forms of delusion is formed with regard to the initially formed delusion. In the secondary form the erotic delusion are present with other psychotic conditions like schizophrenia, Bipolar Affective Disorder (BPAD), depressive disorder (6). Peter Ellis and Graham Mellshop framed nine diagnostic criteria for erotomania which are as follows (a) A delusional conviction of being in amorous communication with another person. (b) This person is of much higher rank (In terms of social status and other aspects of life higher than the subject). (c) This other person had been the first to fall in love. (d) The other person has to be the first to make advances. (e) The onset is sudden. (f) The object of the amorous delusions remains unchanged. (g) The patient provides an explanation for the paradoxical behaviour of the loved one. (h) The course is chronic. (j) Hallucinations are absent (7). This case series presents secondary form of erotomania in three different women with schizophrenia.

Case Report

Case 1

A 26-year-old single woman, an engineering graduate with no known medical or psychiatric co-morbidities and good premorbid functioning presented to the psychiatry Outpatient Department (OPD) along with her parents and brother from whom history was obtained. Her father was an employee in a private firm and so was her elder brother who was two years elder to her while her mother managed the household. The symptoms surfaced soon after her parents starting seeking matrimonial profiles for her. Onset of symptoms was sudden as she claimed that a well-known Kollywood actor was in love with her as he approached her with his love proposal. Although occasional initially, the intensity of her belief grew over two months and she started stalking the actor in social media and tried to meet him in person. Her parents tried to talk her out of it but she refused to consider the contrary possibility and was inconvincible. This led to the development of persecutory ideas about her parents that they were engaging in attempts to break up her relationship.

She became increasingly persistent and managed to get herself into the actor’s house and reached out to his parents a few times. They initially warned her and tried to convince her of the reality that he was already married with kids and that it was impossible for him to be having the said relationship with her. She refused to accept their response and to leave their house. She then had to be escorted to her house by the police.

A few months later her parents noticed her to be muttering to herself at home. She claimed that she was being sexually assaulted by the actor when she was asleep. She also believed to have been physically manipulated by chips inserted into her body which produced low frequency waves bringing her under an external control. She was found to be vigilant as she believed she was being watched by cameras placed around the house. Over a one-year period, there was a drop in vegetative, social and occupational functioning and hence she was brought to psychiatry OPD. Mental status examination revealed a vigilant appearance, coherent speech and anxious affect with prominent delusions of love, persecution which fulfilled all the criteria for delusion (conviction, bizareness, extension, disorganisation, pressure, affective response, deviant behaviour) and commenting type of auditory hallucinations with impaired judgement and poor insight. Projective psychological assessment revealed paranoid ideations with immature tendencies. Blood investigations including complete haemogram, blood sugar, liver and renal function tests were normal. Neuroimaging with Computed Tomography (CT) brain was unremarkable. A diagnosis of Schizophrenia was made (with secondary erotomania) according to International Classification of Diseases (ICD-10)-10 (8). Treatment was initiated on an OPD basis which included Tab. Risperidone 4 mg, Tab. Trihexyphenidyl 2 mg and Tab. Diazepam 5 mg and was advised follow-up after 2 weeks.

However, she was irregular to follow-up after two months and resumed attempts to stalk the actor in shooting spots and finally reached out to him in his house. He was taken by surprise and denied her accusations of ever being in a romantic relationship with her and politely asked her to leave. Offended by his attitude, she threw a tantrum and refused to leave the place unless he reciprocated his love for her, following which she was handed over to the police. She tried to lodge a police complaint against him for fraudulent behaviour which was dismissed by the authorities. She hence returned home enraged and attempted suicide by consuming 20 tablets of 2 mg Risperidone and drank phenol in the presence of her parents. She was immediately admitted in the hospital. Serial monitoring of blood parameters including complete haemogram, electrolytes, liver and renal function tests were normal. She was restarted on her previous psychiatric medications in the same dose after a week once her general condition stabilised. She showed improvement in vegetative symptoms and reduction in hallucinatory behaviour in five days. Psychotherapy sessions were initiated however did not benefit due to her lack of cooperation. She continued harbouring the delusion of love during discharge after two weeks, six months and two years and was irregular to follow-up.

Case 2

A 23-year-old woman, high school pass-out, married and separated, with no known psychiatric or medical co-morbidities and good pre-morbid functioning, was brought for psychiatric consultation by her parents from whom history was obtained. Her mother managed the household and her father was working in the field of agriculture. The history dated back six years ago, when she was in her tenth grade and claimed that a boy belonging to the twelfth grade who was popular for his good looks was in love with her. She said she was sure of it as she was convinced by the hints, he gave even though he did not personally profess his love for her for the sake of anonymity. Her father enquired around school and came to know that there existed a boy of her description who passed out years before but in no way corresponded to her claims.

Her father was informed that the boy belonged to an affluent family and never had a clue about his daughter. His whereabouts were unknown but she continued to believe that he was madly in love with her and was playing hard to get to accentuate her feelings for him. Being preoccupied with these thoughts, she struggled academically and failed in her twelth board exams which she cleared after multiple attempts. She then started going around the neighborhood and picking fights with strangers saying they were keeping her boyfriend in hiding. Mortified by her behaviour, she was put in college to keep her distracted.

Once in college, she began calling up random phone numbers enquiring about her said boyfriend. She soon was acquainted to a fraudulent person who claimed to be the boyfriend she was in search of and manipulated her. Her parents then had to take legal action against the man behind it. She however did not give up her plight of finding her boyfriend and went around the neighborhood enquiring. Her parents then decided to get her married and asked her willingness. She agreed to it and soon they found a desirable match and arranged for the wedding. On the day of the ceremony, she appeared apprehensive and suddenly refused to get married. She claimed that she agreed to the wedding in hope that her boyfriend would come to her rescue at the last moment. Her parents were taken aback but managed to keep her from stopping the ceremony. They convinced her and sent her off with her husband and in-laws. On the way home she removed her ‘thaali’ (mangalsutra) and threw it away and announced to her husband and in-laws that she was in love with another man and returned home to her parents.

Her belief and fantasy grew in intensity over a period of five years as she spent her time planning a wedding with her boyfriend, writing numerous pages of love letters, poems and songs for him. She was noticed to be muttering to herself gradually. She would occasionally laugh alone for no apparent reason. She would stay up all night mumbling in an inaudible voice. Her parents were worried and took her to a psychiatric hospital where she was treated as inpatient of which no details were available. Her sleep improved and she was discharged on request in a week. She discontinued medications after discharge as she developed persecutory ideas about her parents that they were attempting to kill her with some medicines. She accused them of never being her parents and that as her birth parents abandoned her, the fosters raised her for sacrifice at the right time. She blamed them for her self-claim of contracting ‘blood cancer’ as per their plan. She came up with seemingly diverse suspicions over her parents over the next six months. She accused her father of sexual assault and started spitting over herself, all round her house and around the neighbourhood.

She became verbally and physically assaultive and her self-care worsened hence was brought to our psychiatry OPD. Mental status examination revealed an unkempt, shabby appearance with hallucinatory behaviour. Speech was irrelevant at times and affect was restricted. Her thought was circumstantial with content of delusions of persecution, reference, grandiosity which fulfilled all the criteria for delusion (conviction, bizzareness, extension, disorganisation, pressure, affective response, deviant behaviour) and love alongside perceptual abnormalities in the form of commanding and commenting auditory hallucinations. She had impaired judgement and lacked insight. She was admitted and was investigated with routine blood investigations including haemogram profile, electrolytes, renal and liver function tests all remaining normal. CT brain was unremarkable. A diagnosis of schizophrenia (along with secondary erotomania) was made according to ICD-10 (8) which was supported by psychological projective test. She was treated with Tab. Risperidone 8 mg, Tab. Trihexyphenidyl 2 mg and Tab. Diazepam 5 mg. Her symptoms gradually improved over 4 weeks. Hallucinatory behaviour reduced; self-care improved with sleep normalising during hospital stay. Psychotherapy was initiated prior to discharge at one month. She was followed-up at two months, three months, one year and two years. She retained the delusion of love despite being fairly functional during the follow-ups.

Case 3

A 38-year-old spinster, educated up to seventh standard, living with mother, engaged in charity work in church with no known medical or psychiatric co-morbidities and good premorbid functioning presented to the psychiatry OPD. Chief informants were mother and sister. Her mother was managing the household while her sister who was recently married was working as a nursing staff.

A month prior to consultation, she was visited by her younger sister who was married recently. Seeing her sister have a partner made her long for a family of her own. The following day, she claimed there was a person in her church who was in love with her. She said she wanted to marry him and that he has been keen on drawing her attention in many possible ways over the past.

Her family members were taken by surprise as she was a person who believed in devoting her life to the needs of the church rather than personal pleasures. Gradually she conversed more frequently about her admirer and was found preoccupied with thoughts and plans for her wedding. Her brothers inquired with the church pastor about her claims only to find out that there was a person of her description few years ago but his whereabouts were unknown and they were also informed that he was not interested in their sister in any way as he was already married and belonged to a much higher social status. When notified about the same, she refused to accept it and was stubborn in her claims.

Over two weeks, she became restless and did not sleep at night. It was noticed that she has been talking to herself and gesturing at walls. She was convinced that the church pastor was plotting to separate her from her admirer and that she had to stop them. She threw tantrums to eat food saying she would eat only if he came to visit her. She developed persecutory ideas over her family members and became defensive when they tried to persuade her to eat or change clothes. Her self-care deteriorated drastically and she refused to maintain personal hygiene. She kept chanting bible verses incessantly to evade all the bad omen trying to separate her from her admirer.

She brought out different claims every day, which included being under the control of an external force and being sexually manipulated while being asleep. In about four weeks, she was absolutely fastened to her bed refusing all food and sleep and remained awake for two days without a break.

She became hostile towards her family members as she believed they had a part to play in preventing her from uniting with her admirer. She was brought to Psychiatry OPD.

On examination, she had matted hair and wore dirty clothes. She was chanting bible verses and had a guarded attitude. Her speech was inaudible and was hesitant to answer to the examiner. Her thought had tangential thinking, delusion of love and persecution which fulfilled all the criteria for delusion (conviction, bizareness, extension, disorganisation, pressure, affective response, deviant behaviour). Perceptual abnormalities were not established. She had no insight into the illness and lacked quality judgement. She was hence admitted in the ward and was evaluated with blood investigations including complete haemogram, serum electrolytes and blood sugars all of which were normal. CT brain imaging was insignificant. She was uncooperative for psychological assessment and hence a diagnosis of Schizophrenia (with secondary form of erotomania) was made according to ICD-10 (8) based on history and clinical examination.

The patient was started on parenteral fluids and medications because of non compliance to oral drugs which included Inj. Haloperidol 10 mg and Injection (Inj.) Lorazepam 4 mg for a week. She was then switched to Tablet (Tab.) Risperidone 4 mg, Tab. Trihexyphenidyl 2 mg and Tab Diazepam 5 mg. Her sleep improved in three days and there was a gradual improvement in self-care however, she still held onto the delusion of love when she was discharged at three weeks. Psychotherapy was also initiated at the time. She was irregular to follow-up at six months, one year and two years, during which there was no remission of the symptom of delusion of love.

Discussion

Psychoses passionelle or erotomania is a rare type of delusion, most commonly seen in women. It is also referred as delusional loving, phantom lover syndrome, psychotic erotic transference, melancholia erotique and amorous insanus (8),(9). De Clarambault was the first to describe the characteristic feature of erotomania and proposed that it can be superimposed with other psychiatric condition and sometimes be an independent entity. The fundamental postulate of De Clerambaults syndrome is that the subject believes that she is in an amorous relationship with the object of higher social status, who was the first to fall in love with them and first to make advances (10). Ellis and Mellsop postulated the operational definition of erotomania and applied it to their 53 cases. They concluded that pure form of erotomania is a rare entity and according to their published data 34% of schizophrenia patients are presented with erotomania symptoms (7). In accordance to this finding, cases discussed in the study are all secondary forms of erotomania in Schizophrenia patients.

Seeman’s in 1987 proposed two groups of erotomania: the fixed group and the recurrent group. In the fixed group, the delusional love is fixed and it is not fleeting even with repeated confrontation whereas in the recurrent group, the love is short lived and it is repeated (11). In accordance with Seeman’s descriptions all three cases fall into the fixed group. Since the delusion in erotomania is strongly fixed, it is difficult to shake the delusion and the treatment usually runs a chronic course with most patients still harbouring the delusion. The women in the present study had believed that men of higher socio-cultural status as their love interest and were not convinced even when confronted. And their delusion appeared to be as a defence mechanism for their low self-esteem and sexual inexperience.

All three women were introvert, shy and had poor interpersonal relationship with others in accordance with the study ‘Delusional Loving’ published by Seeman MV (12). All three patients were admitted in the ward and put on oral antipsychotics, despite adequate dosing and care, patients showed no change in the erotomanic symptoms and continue to harbour the erotomanic delusion. Prognosis is considered to be poor in patients with low or no response to antipsychotic medication and continue to have a chronic course (13). Treatment of erotomania involves management of underlying conditions appropriately. Recommendations include pharmacotherapy with supportive therapy and challenging of delusions will aid in the recovery of the patient. All three cases were put on atypical anti-psychotics because of its milder side-effect profile than the typical anti-psychotics, successful improvement was seen in their self-care, hallucinations and they were fairly functional, but they continued to harbour the delusion. Challenging the delusion is of no benefit in the peak of the disease and when there is response to the pharmacological management, confrontation will increase the chance of recovery. In these patients, confrontation was of no benefit and all three patients held on to their belief even in the follow-up period. All diagnosis of erotomania has a separate implication in understanding the case, management, treatment and prognosis of the patient and cannot be overlooked. Also missing out the diagnosis will have legal implications as the patients can get involved in aggressive and violent behaviour whilst pursuing their lovers (5).

Conclusion

Erotomania is rare type of delusion which is present more commonly among women. Studies have reported more secondary forms of erotomania than the primary forms. Either of the types of erotomania requires treatment with antipsychotics. It is difficult to reduce the delusional conviction even after adequate treatment with antipsychotics and so each patient should be tailored with medications which will result in the improvement in daily living and social functions. Since the symptoms are present even on treatment, patient should be closely followed-up till the reduction of the symptoms.

References

1.
Jordan HW, Howe G. De Clerambault Syndrome (Erotomania): A review and case presentation. J Natl Med Assoc. 1980;72(10):979-85.
2.
Berrios GE, Kennedy N. “Erotomania: A conceptual history,” Hist Psychiatry. 2002;13(52 Pt 4):381-400. Doi: 10.1177/0957154X0201305202. [crossref] [PubMed]
3.
Ree SC, Yeh SS, Liu CY. Atypical de Clerambault syndrome: A case report. Taiwanese J Psychiatry. 2000;14(4):320-26.
4.
Litman L. A case of de Clérambault syndrome in a Male Stalker with Paranoid Schizophrenia. Can J Psychiatry. 2004;49(7):498. Doi: 10.1177/070674370404900720. [crossref] [PubMed]
5.
Valadas MTTRT, Bravo LEA. De Clérambault’s syndrome revisited: A case report of Erotomania in a male. BMC Psychiatry. 2020;20(1):516. Doi: 10.1186/s12888-020-02921-5. [crossref] [PubMed]
6.
Teoh JI. “De Clerambault’s syndrome: A review of 4 cases,” Singapore Med J. 1972;13(5):227-34.
7.
Ellis P, Mellsop G. “De Clérambault’s syndrome-A nosological entity?,” Br J Psychiatry J Ment Sci. 1985;146(1):90-93. Doi: 10.1192/bjp.146.1.90. [crossref] [PubMed]
8.
World Health Organization. CD-10: International statistical classification of diseases and related health problems: Tenth revision. World Health Organization, 2004. Accessed: Aug. 05, 2022. [Online]. Available: https://apps.who.int/iris/handle/10665/42980.
9.
Seeman MV. The search for cupid or the phantom-lover syndrome. Can Psychiatr Assoc J. 1971;16(2):183-84. Doi: 10.1177/070674377101600216. [crossref] [PubMed]
10.
Fa?kowska U, Adamczyk K, Adamczyk D, Soroka E, Petit V, Olajossy M. Uncommon psychopathological syndromes in psychiatry. Curr Probl Psychiatry. 2018;19(4):299-22. Doi: 10.2478/cpp-2018-0024. [crossref]
11.
Signer SF. De Clérambault’s concept of erotomania and its place in his thought.Hist Psychiatry, 1991;2(8):409-17. Doi: 10.1177/0957154X9100200804. [crossref] [PubMed]
12.
Seeman MV. Delusional loving. Arch Gen Psychiatry. 1978;35(10):1265-67. Doi: 10.1001/archpsyc.1978.01770340115013. [crossref] [PubMed]
13.
Enoch D, Puri BK, Ball H. Uncommon Psychiatric Syndromes: Fifth Edition. London: Routledge; 2020. Doi: 10.4324/9781315381145. [crossref]

DOI and Others

DOI: 10.7860/JCDR/2022/57016.17081

Date of Submission: Apr 11, 2022
Date of Peer Review: May 30, 2022
Date of Acceptance: Sep 14, 2022
Date of Publishing: Nov 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 14, 2022
• Manual Googling: May 20, 2022
• iThenticate Software: Sep 08, 2022 (5%)

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