What is the recommended management approach for erotomania?

Management of Erotomania

Erotomania should be treated with a combination of atypical antipsychotic medication (particularly risperidone) and psychosocial interventions, with careful attention to risk management strategies. 1

Understanding Erotomania

Erotomania is a delusional disorder characterized by the false belief that another person (usually of higher social status) is in love with the patient. It is classified as a delusional disorder in contemporary classification systems (DSM-IV and ICD-10).

Key characteristics:

• Incidence: Approximately 15 cases per 100,000 population per year
• Gender ratio: Female to male ratio of 3:1 1
• Types: Primary (occurring independently) and secondary (associated with underlying organic or psychiatric conditions)

Diagnostic Assessment

History Taking

• Determine if symptoms are primary or secondary to another psychiatric condition (e.g., bipolar disorder) 2
• Assess for presence of:
  • Delusional beliefs about being loved by another person
  • Evidence of stalking or harassment behaviors
  • Misperceptions and misattributions that maintain the delusion
  • Social isolation that may protect the delusional beliefs
  • Pre-existing psychiatric conditions (especially bipolar disorder) 2

Psychological Factors to Identify

• Low self-esteem preceding the emergence of delusions
• Emotional arousal states
• Narcissism and shame as potential underlying factors 3, 4
• Social isolation patterns

Treatment Algorithm

Step 1: Pharmacological Management

• First-line treatment: Atypical antipsychotics

  • Risperidone has shown positive outcomes and improved tolerability compared to older agents 1, 5
  • Clozapine may be considered in treatment-resistant cases 1

• For secondary erotomania:

  • Treat the underlying psychiatric condition first
  • For erotomania secondary to bipolar disorder, a combination of risperidone and lithium has shown effectiveness 2

Step 2: Psychosocial Interventions

• Establish a therapeutic alliance focusing on understanding psychological factors contributing to the delusion
• Provide social support and strategies to restore self-esteem
• Gradually introduce techniques to correct cognitive biases 3
• Address misperceptions and misattributions that maintain the delusion

Step 3: Risk Management

• Assess risk of stalking or harassment behaviors toward the object of delusion
• Implement appropriate safety measures for potential victims
• Consider legal interventions if necessary (restraining orders, etc.)
• Monitor for treatment adherence, as improved sense of well-being may lead to discontinuation of treatment 3

Treatment Challenges

• Patients often have limited insight into their condition
• The delusional belief provides a sense of well-being, making patients resistant to treatment
• Social isolation protects the delusion from external disconfirmation
• Medication adherence may be poor due to side effects or denial of illness

Monitoring and Follow-up

• Regular assessment of delusional intensity and associated behaviors
• Monitoring for medication side effects
• Ongoing risk assessment for potential stalking or harassment behaviors
• Gradual reintegration into social environments with appropriate support

Prognosis

The prognosis for erotomania varies:

• Cases secondary to other psychiatric conditions may improve with treatment of the underlying disorder
• Primary erotomania may be more persistent and require long-term management
• Early intervention appears to improve outcomes, particularly when combining pharmacological and psychosocial approaches

While older literature suggested pimozide as the treatment of choice, current evidence supports the use of atypical antipsychotics like risperidone as first-line treatment due to their more favorable side effect profile 2, 1, 5.