It is rather funny to assume that I would ever feel love-struck. As a person who has never experienced romantic love (#sadface), I struggle to understand characters in books and films where they fall in love and go to such extreme lengths as sacrificing themselves for the other to live. Of course, some might argue that this is the essence of humanity. That the love between people is what sustains us. Indeed, this is what we are indoctrinated at a young age - love is the strongest weapon of all. Unless you are trapped in a psychiatric ward.
Without contravening the age-old maxim of patient confidentiality, I decide to approach this in a very general manner. It is a classical love story. Girl meets boy. Girl loves boy. Girl sends flowers to boy every Monday morning before he goes to work. Girl peeks from her window to boy's house every five minutes, conscious of what he is doing behind those secretly guarded doors. Girl has developed - derived from her 'sixth sense', a way to tell if boy loves her back or not. If boy leaves the window open that day, he loves her back. If he doesn't, it doesn't mean he doesn't love her. It only means he is 'yet' to open them. Girl labours under the belief of true love until the fateful day when she sees another woman in the house. That woman - that horrid vixen! - kisses boy on the cheek. Girl races across the street and punches her finger on the doorbell. Boy opens door and asks what the matter is. 'Sorry, I don't know you.' Boy says innocently. Girl pushes away boy and barges into the house. Girl finds the 'other woman' and shouts at her, 'How dare you lay your hands on my boyfriend! He is mine!' Girl takes out a knife from her bosom and stabs the woman with it.
This might be taking the meaning of 'lovestruck' a little too far. However, in patients with schizophrenia or drug-induced psychosis, such delusions are not inexplicable. In fact, if we embrace the idea that delusions can take any form, this is far from surprising. But then, before we carry this idea farther, what do we mean by 'delusions'? Delusions are unshakeable, false beliefs which the patient does not share with others, given the same cultural context. [1] Of course, in psychiatry, we return to the comparison between the norm and the minority. Indeed, it is hard for us to say, for sure, that a belief is a delusion. A belief, it is feared, might be false if the truth is dictated by popular opinion. This is what happened in 1984. But then, critics have usually missed the point. The key word here is 'unshakeable'. When we talk about beliefs and opinions, we do stand by what we think and use evidence to back up our arguments. However, sometimes, we do concede. We recognise that there are merits in what our opponents say. We then, perhaps, alter our arguments slightly and change our positions in varying degrees based on a better understanding of the topic. In patients with delusions, this mechanism is absent. They hold on to beliefs so tenaciously that no form of opposition is sufficient to change their mind. Rationality is scarce and, usually, no factual basis can be found to countenance their claims.
There are different themes inherent to delusions. [2] The most common are persecutory delusions, experienced by over 70 percent of patients suffering from their first episode of psychosis. Persecutory delusions are best summarised by stories of people labouring under the thought that they hold some secret information concerning national safety and some political conspiracy. The MI6 are after them, and they have to expose such information for the greater good. Interestingly, there has been a court case with similar facts. [3] Then, we have grandiose delusions, delusions of reference, erotomanic delusions, nihilistic delusions and somatic delusions. [2, 4] Grandiose delusions are entangled with ideas of pomposity and innate superiority, while delusions of reference can make patients distressed at the thought of everyone talking about them. Nihilistic delusions are beliefs regarding catastrophes. Somatic delusions concern, as the name suggests, bodily problems. Some might even think they are putrefying and devoured by maggots. [5] Erotomanic delusions are the ones that make a patient labour under the belief that someone is in love with them.
Also known as de Clarembault Syndrome, the disorder was first described in 1885. [6] The disorder can last for an indefinite period of time, ranging from weeks, to months, to years. The case study in [6] records an episode that lasted for eight years. Violence, though rare, can occur in erotomania, where it is proposed to be associated with psychopathic, narcissistic, paranoid and hysterical traits. [7] Sigmund Freud, a world-renowned psychoanalyst (before his reputation went to tatters after the scientific community turned their back on him) postulated that these delusions, usually manifested in a heterosexual capacity, are reflective of an attempt to suppress and deny one's homosexual impulses. [8] However, this is questionable on multiple premises. To make such a claim, he erroneously assumed that everyone who had this disorder, were homosexual. Secondly, this was rather scientifically unsound. If such patients were doing it to suppress homosexual impulses, was Freud suggesting that they were done as a show to others? An exhibition that they were heterosexual after all? Freud's theory dismantles the core meaning of medicine: healing. It is always advised to give patients the benefit of doubt. They are the ones who are suffering and do not deserve another volley of interrogations, especially those questioning whether their suffering is real.
Erotomania, however, gives us an insight of what love actually means. As a person who has never dated, my vision of love is rather unadulterated: the pure spiritual connection between two souls, intertwined and reserved just for the other. Love manifests through its multitude of ways. My female friends always say that they take into account a lot of things when judging if their boyfriends love them. This is not confined to just a sweeping affirmation comprising three words. It's a broad, stringent examination: gestures, tone of speech, choice of language, presence of smile and so forth. Indeed, this is not limited to established relationships. When I go out to the bar (the rare occasion, when I need alcohol to summon enough courage to talk to a girl), body language is vital in determining if somebody fancies me. The substance of the conversation can be insubstantial - after all, any conversation in such a setting would take place on a rudimentary foundation of understanding of each other. The direction of her gaze, the tenseness around her lips when she smiles and the frequency of swallowing are all the subtle clues I look for. My more ape-like friends might look for clues which are more pertinent to procreation, but the matter is not the substance of the clues. It is the presence of such clues in the first place. We use 'clues', not just oral or written language, to deliver messages. If we have established that as the foundation, then erotomania can be understood as having interpreted these clues too far. The patient with erotomania might think the doctor who makes regular ward rounds fancies her, in virtue of the fact that he pays the effort to visit the ward every morning.
However, we as mankind have been interpreting clues since the dawn of our species. It is very rare for any of us to persist in thinking that somebody falls for us even after receiving multiple signals suggesting the opposite. Such tenacious grip on certain signs, in order to affirm the pre-established conviction, in patients with erotomania, might point to something else. I think this can be traced to attachment in formative years. Let's think about it - where and how do we first know love? Love is the time when we, as babies, are nurtured by our parents. It is the time when parents try their best (I know, they actually get the grammar terribly wrong) to imitate our baby-talk. It is the time when they show us they love us by playing peek-a-boo and pushing us back and forth on the swing. It is the time when they tell us bedtime stories and spend time with us. These moments, though long forgotten, form the basis of how we understand 'love'. When we are with our parents, this attachment solidifies. Gabor Mate, Canadian physician, explained that ADD (attention-deficit disorder) might be an attachment issue, traced all the way back to the eye contact between the primary caregiver and the infant. [9] The infant is usually the receiver of love, thus he/she is free to turn his/her head away from the caregiver. The infant is, in the normal case, always certain that, when he/she turns back to the caregiver, those parental gems of eyes will still be there to hold their gaze. However, in patients with ADD, attachment becomes an issue since the infant cannot take this for granted. A seemingly minute detail - eye contact, turns out to be significant in one's formative development. In erotomania, if there is a deficit in attachment, admixed with a turbulent childhood where love is scarce, it is likely that they have a warped understanding of love. Love to them might mean the successful formation of an attachment, since both, involving elation, activate the reward pathway. The want of attachment in childhood does not only affect the formation of their identity, it also manifests in the form of looking more actively for clues when striking relationships, since they are used to being the main contributor (going back to the eye contact, such infants have to take up the normal 'parental' role and cannot rely on their parents' gaze). This obsession over clues, plus the need for compensating for attachment and an impaired understanding of love, lead to behaviours redolent of those performed by patients with erotomania.
Being lovestruck in a psychiatric ward is usually different from being lovestruck in an obstetric ward. In an obstetric ward, it is usually quite heart-warming (or feeling mellow and down upon reflecting on the fact that I'm still single) to see couples witnessing the birth of their baby. The moment when they truly realised the strength of their bond. In a psychiatric ward, you will be hard-pressed to find a similar situation. However, thinking about it, perhaps erotomania isn't about romantic love after all. It is more about the desperation of being accepted and embraced for who they are.
[1] Types of psychosis. Mind. (2020). Retrieved 9 November 2020, from https://www.mind.org.uk/information-support/types-of-mental-health-problems/psychosis/types-of-psychosis/.
[2] Filer N. (2019). The Heartland (p. 180). Faber and Faber.
[3] R v Shayler [2001] 1 WLR 2206. In this case, the defendant was a former employee of the MI5. He held information regarding national security and decided to expose it, in contravention of an agreement of confidentiality he signed prior to joining the authority. The key legal question was whether he did so under necessity. It was ruled that the defence of necessity was not available to him, since the scope of the defence was meant to be narrow enough to avoid abuse.
[4] Picardi A, Fonzi L, Pallagrosi M, Gigantesco A, & Biondi M. (2018). Delusional Themes Across Affective and Non-Affective Psychoses. Frontiers In Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00132.
[5] This is also known as Cotard's delusion, described as going to such lengths as negating one's sense of self and construing one as immortal. See Grover S, Aneja J, Mahajan S, & Varma S. (2014). Cotard’s syndrome: Two case reports and a brief review of literature. Journal Of Neurosciences In Rural Practice, 05(S 01), S059-S062. https://doi.org/10.4103/0976-3147.145206.
[6] Jordan HW, Howe G (1980). De Clerambault Syndrome (Erotomania): A Review and Case Presentation. J Natl Med Assoc. Oct; 72(10): 979–985.
[7] Meloy JR. (1989). Unrequited love and the wish to kill. Bulletin of the Menninger Clinic, 53(6), 477-492.
[8] Urbach J, Khalily C, & Mitchell P. (1992). Erotomania in an adolescent: clinical and theoretical considerations. Journal Of Adolescence, 15(3), 231-240. https://doi.org/10.1016/0140-1971(92)90027-3.
[9] Maté G. (1999). Scattered minds: A new look at the origins and healing of attention deficit disorder. Toronto: A.A. Knopf Canada.