Erotomania and psychotic depression

To the Editor

Although cases can be traced back to Hippocrates, erotomania is a relatively uncommon and under-researched disorder. Characteristically, erotomania affects women, and manifests with the delusional belief that a man/figure, typically of a higher status, is in a romantic or sexual relationship with the patient (McGuire et al., 1994). We report on a case of secondary erotomania associated with psychotic depression.

JS, a 65-year-old lady, was brought to the emergency department by her husband. She described a 3-week history of hearing the voice of Jesus Christ and engaging in a ‘sexual relationship’ with his spirit. Sexual episodes were described as featuring intense desire, sexual talk and a tactile ‘meeting of kindred spirits’. Outside the sexual context, the voice was persecutory and focused on themes of ungratefulness, insubordination and deserving punishment. JS shared these beliefs, founded on a brief drug addiction in her 20s for which she felt extreme guilt. The voice also commanded her to perform humiliating acts as retribution, including removing clothing ‘at the mailbox’ and simulating sex.

This episode occurred in the setting of 3 years of worsening depressive symptoms, secondary to isolation and an unintimate marriage. Psychodynamically, JS experienced an unaffectionate upbringing, which may have influenced poor attachment and an inability to form meaningful adult relationships. Furthermore, depression severity and a history of fervent religiosity may have contributed to the bizarre construct of her delusions, an unusual feature of depressive psychosis.

Organic causes were excluded and a provisional diagnosis of psychotic depression with erotomanic features was made. She was initiated on 5 mg olanzapine daily, which resulted in improvement in her psychotic and mood symptoms.

Erotomania may be classified as a primary (Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition [DSM-V] delusional disorder) or secondary condition, associated with schizophrenia, bipolar affective disorder and major depression. Aetiologically, hypothesised contributing factors (Jordan et al., 2006) include the following:

1. Neurochemical deficits based on an association with high-dose venlafaxine in one study,

2. Genetic inheritance,

3. Psychodynamic associations: maladaptive functioning to cope with loss, loneliness or assumptions of being unlovable.

Primary erotomania typically follows a chronic, treatment-resistant course. Conversely, secondary erotomania responds well to psychopharmacological strategies. Historically, older antipsychotics (e.g. Pimozide) were the mainstay of treatment; however, the improved side effect profile of atypical antipsychotics is driving current use (Kelly, 2005). Although case reports support the effectiveness of antidepressants and electroconvulsive therapy, further research is needed to identify aetiological factors, clinical presentations and appropriate management.