What is the type of bipolar I disorder with psychotic features characterized by rapid and intense infatuation, followed by a return to past affections during psychotic episodes?

Erotomania in Bipolar I Disorder with Psychotic Features

The pattern you're describing is consistent with erotomania (also called de Clérambault's syndrome), which can occur as a psychotic feature during manic episodes in Bipolar I disorder, where patients develop delusional beliefs of being loved by another person, and these delusions characteristically recur with subsequent psychotic episodes.

Understanding Erotomania in Bipolar Disorder

Erotomania represents a specific type of grandiose delusion that can manifest during manic episodes with psychotic features. This is not a separate "type" of Bipolar I disorder, but rather a specific psychotic symptom presentation that can occur within the disorder.

Core Clinical Features

• Grandiose delusions are the most common type of psychotic symptom in bipolar mania, and erotomania falls within this category of grandiose delusional content 1
• More than half of patients with bipolar disorder will experience psychotic symptoms in their lifetime, making psychotic features a common manifestation 1
• Psychotic features in mania are characterized by delusions of grandiose, religious, and paranoid content, with erotomania representing a grandiose belief about romantic connection 2

Pattern of Recurrence

The recurrent nature you describe—where the patient "falls back in love" with past objects of affection during subsequent psychotic episodes—reflects:

• The cyclical nature of bipolar disorder, where psychotic symptoms can recur with each manic episode 3
• Psychotic symptoms in bipolar disorder tend to be mood-congruent, meaning the grandiose romantic delusions align with the elevated mood and inflated self-esteem of mania 3, 1
• Patients whose all episodes are psychotic (the "psychotic group") show consistent patterns of psychotic content across episodes 4

Clinical Characteristics of This Presentation

During Manic Episodes with Erotomania

• Marked euphoria, grandiosity, and decreased need for sleep accompany the delusional romantic beliefs 3
• Racing thoughts and increased psychomotor activity intensify the obsessive quality of the infatuation 5
• The intensity and rapidity of the infatuation reflects the impaired judgment and excessive involvement in activities characteristic of mania 5

Prognostic Implications

• Episodes are more severe and hospitalization rates are higher in patients with psychotic features compared to non-psychotic bipolar patients 4
• Psychotic bipolar patients have more frequent previous hospitalizations (10.6-12.5 episodes vs 7.8-8.6 in non-psychotic patients) 2
• Residual symptoms are more common in psychotic bipolar patients (72% vs 43%) 2
• Response to lithium monotherapy is better in non-psychotic patients, suggesting psychotic features predict more treatment-refractory illness 4

Diagnostic Considerations

Distinguishing Features

• The delusional romantic beliefs represent a significant departure from baseline functioning and are evident across different realms of life, not isolated reactions to actual romantic situations 3
• Associated psychomotor, sleep, and cognitive changes accompany the mood disturbance, distinguishing this from personality-based attachment patterns 3
• The pattern shows episodicity with clear onset during manic phases and potential resolution or shift during depressive or euthymic periods 6

Common Pitfalls to Avoid

• Failing to recognize that the romantic preoccupation is a psychotic symptom rather than a personality trait or relationship issue 7
• Not distinguishing between mood-congruent psychotic symptoms (like erotomania) and mood-incongruent psychotic symptoms, which carry different prognostic implications 1
• Confusing the intense infatuation with borderline personality disorder's unstable relationships, though comorbid personality disorders are more common in psychotic bipolar patients 2

Treatment Implications

Medication Management

• Patients with psychotic features require more aggressive treatment than non-psychotic bipolar patients 4
• Antipsychotic medications are essential for managing the psychotic symptoms, including delusional romantic beliefs 7
• Mood stabilizers alone may be insufficient given the poorer response to lithium monotherapy in psychotic presentations 4

Monitoring Considerations

• Early onset of disease (under age 20) is more common in psychotic bipolar patients, suggesting need for long-term monitoring 2
• Previous suicide attempts are significantly more frequent in psychotic bipolar patients, requiring close safety monitoring 2
• The recurrent nature of the specific delusional content should be documented to help predict and manage future episodes 3