Friday, 16 June 2017

ABC's of the DSM-V: E is for Erotomania

So far it seems the DSM alphabet has been leaning towards delusional disorders and this week is no different. Erotomania is a delusional disorder where the person believes another person is in love with them, usually celebrities but can happen in the case of strangers. It’s commonly diagnosed in schizophrenic patients, but other psychotic disorders have been known to overlap too. I’ve actually come across this before during my experience on a psychiatric ward and it is a very interesting disorder; to say the least.

Well how do they know this person is in love with them? It’s not like Lady Gaga has gone up to you and told you herself, so where does the conviction stem from?

Several places. Telepathy, secretly, through the TV or newspapers, special signals, ANYTHING. That’s what makes the delusion strong – something as simple as a TV interview discussing foods, could turn into a case where the sufferer believes it’s about them because it’s a food they commonly enjoy, or Katy Perry being signed to Capitol Music Group is definitely a signal to the sufferer because they’re from LA where the studios are located. There is no possible way this belief can be shaken, it is the core root of the delusion and what makes it so strong – there is a strong confirmation bias in these cases which only make beliefs stronger.

In my own experience of the disorder, James* was convinced popular a popular singer was in love with him, and he was in love with her. The delusional backstory was when they were younger, she had “stolen” bodily fluids from him, and birthed a child in secret which he has found on Facebook – the “child” in question is around 13, which is the correct age she would be had this actually happened, and now that she’s a famous singer she can only send him messages through the media and her songs. There was no possible way of getting the idea that it was all untrue out of him; in his mind, it was as real as the existence of water on Earth.

The last I saw of him he was being treated with several antipsychotic medications but that was proving difficult due to non-compliance. I’ll never know if he got better, but I know that he had a brilliant team on the ward working with him. It’s a difficult disorder to treat, mainly done with lots of talking therapies and antipsychotic medication – beliefs can be strong, and therapy allows the patient to turn their belief on its head and look at it from a rational point of view.

Because of the delusional aspect of the disorder, it is not usually diagnosed as a distinct disorder, but rather compiled with others, particularly paranoid schizophrenia. The danger in erotomania usually occurs when the sufferer has a history of antisocial behaviour and the strength of the delusion, as it could lead them to stalking and in extreme cases, harming their “admirers” because of a lack of reciprocal feelings. In cases otherwise, mainly with celebrities who are difficult to access, it is relatively harmless.

Due to the rarity of the disorder, the cause is not fully understood but one idea from an evolutionary perspective, is that erotomania is a form of mating strategy. In the case of women having it, it can be a need to ensure paternity of offspring, whereas in males it ensures a need for loyalty and an alpha status. The alpha males are the one that ensure paternity and so sexual jealousy arises with the fear of a lack of loyalty, which in turn can lead to aggressive behaviours such as controlling and violence to ensure it.

From a neuroanatomical perspective, deficits in visuospatial and limbic areas, mainly in the temporal lobe (which is also affected in schizophrenia and epilepsy) leading to misinterpretation of the environment, which in this case is the behaviours of the “admirer.” Case studies have found issues with memory as well, showing the possibility that it may be a risk factor for memory loss, or disorders such as dementia. This is all speculative of course, more research is required to understand fully the cause of it, but a combination of the rarity and little interest in it, it may be a good while before that happens.

One of the most famous cases of erotomania (We’re moving into Murderino territory here because this was fleetingly mentioned in an episode once!) is Margaret Mary Ray and David Letterman. From May 1998, Ray stalked letterman – camping out on his property, stealing his things (his car under the guise of his wife!) and repeatedly breaking into his house. She was arrested several times and eventually was institutionalised where she got better and was released, but stopped taking her medication after that. It led to her stalking another person – Story Musgrave, an astronaut, who she wrote letters to, made phone calls, sent packages and once again impersonated someone to get close to him – this time it was a reporter who was interviewing him. She was once again arrested and institutionalised, where she got better, was released and then stopped taking the medication. She eventually committed suicide; laying her body on train tracks, 10 years after her fascination with Letterman began.

Although she had broken the law and breached their privacy, both Musgrave and Letterman were sympathetic towards her; understanding that she was troubled and was suffering from something she couldn’t help. I think that really helped shed a light on mental health disorders at the time, and that people shouldn’t be bullied for something they can’t do anything about, but rather helped.

A grim ending, but take solace in knowing that treatment is real, people don’t have to suffer – antipsychotics, inpatient treatment and therapy can really change people. If you know someone suffering from this, then you can at least understand a little bit that it’s not a case of just being strange, but instead an irrational thought process that requires treatment. The case of Margaret Mary Ray is also an important reminder to take your medication! No matter how good you feel or how much you don't like the side effects - you either find a way to deal with it, troop on, or try a different pill - just don't stop taking them unless suggested by a professional!

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