Panda’s Top Tip 🐼
Erotomania may lead to stalking behaviours and pose numerous risks. It is important to explore risks in detail, asking about specific individuals in the patient’s family/work/friendship circle.
Key Knowledge
ICD-11 classifies erotomania under delusional disorder (6A24). Specifically, it is characterised by a delusional belief that another person, usually of higher status, is deeply in love with the individual.
Core features include:
●Delusional belief of being loved: The person is convinced that someone is in love with them.
●Fixed and unshakeable conviction: The belief is held with delusional intensity and cannot be altered by reasoning or contradictory evidence.
●The object is often of higher status: Commonly a celebrity, employer, doctor, public figure, or someone perceived as unattainable.
●Rationalisation of contradictory evidence: Denials or rejections by the individual are reinterpreted as secret communication or tests of love (e.g., “She has to deny it publicly to protect us”).
●Attempts at contact: The person may send letters, gifts, or messages, make repeated phone calls, or attempt to visit the individual. In some cases, stalking behaviours occur.
Typical stages (described by de Clérambault):
●Hope: Initial conviction that the object loves them; euphoria and preoccupation
●Resentment: If contact is rebuffed, the person may become angry or believe the object is being prevented from reciprocating
●Spite or resignation: Persistent rejection may lead to resentment, grievance, or (less commonly) acceptance
Duration and course:
●Erotomania is typically chronic and difficult to treat. Some cases resolve spontaneously, but many persist for years. Insight is absent.
Delusional disorders are more common in women, though men are more likely to engage in stalking or violent behaviours
Differential Diagnosis for Erotomania
1. Schizophrenia
Key distinctions: In schizophrenia, erotomanic delusions may occur alongside other psychotic symptoms (hallucinations, thought disorder, negative symptoms). Functional impairment is broader. In delusional disorder, functioning outside the delusion is relatively preserved.
2. Manic episode (bipolar disorder)
Key distinctions: Grandiose or romantic delusions can occur in mania but are part of a broader manic syndrome (elevated mood, pressured speech, decreased need for sleep, reckless behaviour). Symptoms are episodic and resolve with treatment of mania.
3. Obsessive love or infatuation (non-delusional)
Key distinctions: Intense romantic preoccupation can occur without delusional conviction. The person may acknowledge uncertainty (“I’m not sure if they like me”) or eventually accept rejection. In erotomania, the belief is fixed and unshakeable.
4. Stalking or harassment without delusion
Key distinctions: Stalking can occur without delusional beliefs (e.g., motivated by anger, control, or rejected romantic interest). In erotomania, the person genuinely believes the object loves them.
5. Borderline personality disorder (BPD)
Key distinctions: People with BPD may have intense, unstable relationships and fear of abandonment, but do not hold fixed delusional beliefs about being loved. They often have a history of difficulty with relationships with several different people, rather than one specific individual, as seen in erotomania.
6. Substance-induced psychotic disorder
Key distinctions: Stimulants can cause paranoid or grandiose delusions, including romantic delusions. Onset is related to substance use, and symptoms resolve with abstinence.
Risk Assessment in Erotomania
To self:
●Social and occupational impairment – loss of friendships, loss of employment, financial costs of contact attempts
●Legal consequences – Arrest for harassment, stalking, restraining orders
●Depression and suicide – If delusion collapses or person experiences persistent rejection
●Self-neglect – Preoccupation may interfere with self-care
To others:
●Harassment and stalking of the object – Letters, calls, visits, following, online contact
●Threats or violence towards the object – Risk is higher in men
●Threats or violence towards perceived rivals – Anyone believed to be preventing the relationship (partner, bodyguard, family)
●Public disruption – Attempts to approach the individual in public settings
From others:
●Risk of victimisation if the person discloses the delusion publicly
Communication Tips
Erotomania requires careful, non-confrontational exploration. Avoid directly challenging the delusion initially, and focus on understanding the person’s experience and assessing risk.
Opening:
●”I’d like to understand what’s been going on for you. Can you tell me what’s been on your mind recently?”
Exploring the delusion:
●”Can you tell me about this person?”
●”How do you know they have feelings for you?”
●”How did this start? When did you first realise?”
●”What has happened that makes you sure they love you?”
●”Have they said or done anything directly?” (Assess for misinterpretation)
●”How do they communicate their feelings to you?”
Exploring contact and behaviours:
●”Have you tried to contact them? How?”
●”How often do you send messages/letters/gifts?”
●”Have you tried to visit or meet them?”
●”How have they responded?”
Exploring rationalisation:
●”If they deny it, how do you understand that?”
●”Do you think there’s a reason they haven’t openly acknowledged their feelings?”
Risk assessment (specific to erotomania):
●”How do you feel when they don’t respond or reject contact?”
●”Do you ever feel angry or frustrated about the situation?”
●”Is there anyone you feel is getting in the way of you being together?”
●”Have you ever thought about confronting them or anyone else?”
Impact on functioning:
●”How much time do you spend thinking about this person?”
●”Has this affected your work, relationships, or daily life?”
Screen for other psychotic symptoms:
●”Do you hear voices or see things others don’t?”
●”Do you have any other concerns or worries?”
Insight:
●”Have others expressed concern about this?”
●”Do you think it’s possible you might be mistaken?”
CASC Practice Scenarios
Scenario 1: History Taking
Candidate Instructions:
You are the SpR on the acute psychiatric ward. Ms Naomi Sullivan, a 34-year-old unemployed woman, was admitted yesterday under Section 2 of the Mental Health Act following repeated attendances at a local radio station where she attempted to see the breakfast show presenter. Police were called after she refused to leave and became agitated. She has no previous psychiatric history. She is currently on intermittent observations and has not yet been started on medication.
Please take a psychiatric history and perform a risk assessment.
Scenario Summary:
Naomi Sullivan is a 34-year-old woman with erotomania. She holds a fixed, unshakeable belief that Jake Morrison, a local radio presenter, is in love with her and has been communicating with her through coded messages in his broadcasts. She has been attempting to contact him for the past eight months, initially via letters and phone calls, escalating to repeated visits to the radio station. She interprets his on-air denials as evidence that he must hide their relationship publicly. She has sent gifts, waited outside the building, and recently attempted to enter his workplace, leading to police involvement. She has no hallucinations, thought disorder, or other psychotic features. She is not depressed. She has no insight. There is risk of stalking, harassment, and potential escalation.
Actor Brief:
You are Naomi Sullivan, a 34-year-old woman who has been living in a bedsit for the past three years. You’re unemployed. You used to work in retail but left your last job about nine months ago because you needed to focus on something more important. You’ve been sectioned, which is unfair, because you haven’t done anything wrong. You were just trying to see Jake, and everyone’s acting like you’re dangerous.
Jake Morrison is a breakfast radio presenter on Heart FM. You’ve been listening to him every morning for over a year. About eight months ago, you realized he was sending you messages through his show. At first, it was subtle—he’d play certain songs that felt like they were chosen just for you, or he’d say things that seemed directed at you. Then it became clearer. He started using phrases like “you know who you are” or “someone special is listening.” He played your song “Nothing’s Gonna Stop Us Now” by Starship, which you’d mentioned in a letter you sent him. That was the moment you knew for sure he loved you.
Since then, you’ve been trying to reach him. You’ve sent him dozens of letters, some with small gifts, including a bookmark, a photo of yourself, a scarf you knitted. You’ve called the radio station many times asking to speak to him, but the receptionists always say he’s not available, which you understand because he has to be careful because he’s in the public eye and your relationship has to be kept private for now. You’ve waited outside the radio station several times, hoping to see him when he finishes his shift. You’ve seen him a few times from a distance, and once you think he looked at you and smiled, though he didn’t stop.
Yesterday, you went to the radio station because you needed to see him urgently. You’ve been feeling that things between you are reaching a turning point. You went inside and asked to see him, but the receptionist refused and called security. You didn’t leave because you knew Jake would want to see you, and you got upset and raised your voice. Then the police came and brought you here. You’re furious because you’ve done nothing wrong. You just want to be with the person you love, and everyone is treating you like a criminal. You never thought that the police would be called, and you strongly disagree that you were doing anything illegal.
When the doctor asks about Jake, you explain all of this calmly and clearly. You’re convinced it’s real. If the doctor suggests Jake doesn’t know you or isn’t in a relationship with you, you become frustrated and insist they don’t understand. You have “proof” in the songs he plays and the things he says on air. When he’s denied knowing you publicly, it’s because he has to protect both of you as he’s a public figure, and there could be consequences for his career if your relationship was revealed.
You don’t hear voices. You’re not paranoid about other people. You don’t think you’re being followed or monitored. You don’t have any odd beliefs about anything else. Your mood is fine, you’re not depressed. You’re frustrated and upset about being here, but that’s understandable. You sleep well. You eat normally. You don’t drink alcohol or use recreational drugs. You have no medical problems or psychiatric history. This is your first time having contact with the police and you have never been a violent person.
You live alone. You’re estranged from your family, your mum lives over two hours away, and you haven’t spoken to her in a few years after a falling out. You don’t have close friends. You spend most of your time listening to the radio, writing to Jake, and thinking about your future together. You do not work and are receiving benefits.
You deny any intention to harm Jake or anyone else. You love him, why would you hurt him? You just want to be with him. However, you’re evasive when asked if you’d go to the radio station again or try to contact him, and when asked you say “I don’t know” or “I just want to talk to him.” You don’t see why you should stop trying to see him. If Jake does not reciprocate your feelings you would be very upset but you would not do anything to harm yourself.
You’re cooperative but guarded. You’re polite but become irritated and defensive if the doctor challenges your belief about Jake. You’re not thought-disordered and your speech is clear and coherent. You’re not manic, nor pressured, or overactive. You maintain eye contact. You’re casually dressed. You’re keen to leave the ward because you feel you don’t belong here. You are orientated to time and place.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
●Elicit the key features of erotomania: a fixed, unshakeable delusional belief that another person (usually of higher status) is in love with the patient, despite clear evidence to the contrary, with rationalisation of contradictory evidence (e.g., denials are reinterpreted as necessary secrecy)
●Differentiate erotomania from other psychotic disorders by systematically screening for hallucinations, formal thought disorder, negative symptoms, and other delusions, recognising that delusional disorder involves an encapsulated delusion with relative preservation of functioning outside the delusional system
●Assess the progression and escalation of behaviours over time, from initial contact attempts (letters, calls) to more intrusive behaviours (visiting workplace, attempting direct contact), which informs risk assessment
●Conduct a thorough risk assessment focusing on risks specific to erotomania: harassment and stalking of the object, risk of violence toward the object or perceived rivals and the patient’s own vulnerability to exploitation or distress
●Explore insight carefully, recognising that erotomania is typically characterised by very poor insight, which has significant implications for engagement, capacity, and treatment planning.
Communication
A good candidate will:
●Adopt a curious, non-confrontational approach when exploring the delusional belief, asking open questions, without prematurely challenging or attempting to correct the delusion
●Avoid colluding with the delusion (e.g., agreeing that the object loves the patient) while also avoiding direct confrontation (e.g., “that’s not true”), both of which damage the therapeutic alliance,
●Assess capacity to engage with risk management sensitively, recognising that the patient may lack insight into why others view their behaviour as problematic, and framing questions around safety and consequences rather than morality or criminality
●Demonstrate empathy for the patient’s distress at being detained and separated from the person they believe loves them, validating their emotional experience even while not endorsing their beliefs
●Balance the need to gather information about stalking and harassment behaviours with maintaining rapport, using non-judgmental language and framing such behaviours as attempts at connection rather than criminal acts, which reduces defensiveness
Video Example
Our videos can be found here! CASC Scenario Videos – PsychPanda
Authors/Reviewers
Dr Damir Rafi is a Psychiatry Speciality registrar in forensics, currently working in London.
Dr Rebecca Goodall is a Psychiatry Specialty Registrar, specialising in children & adolescents.
Dr Molly Beazley is a Psychiatry Speciality Registrar specialising in forensics.
References and Resources
World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Kelly, B. D. (2017). Erotomania: Epidemiology and management. CNS Drugs, 19(8), 657–669.
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
Related Articles:
Mania History Taking: https://psychpanda.com/mania/
OCD History Taking, Risk & Management: https://psychpanda.com/ocd/
Understanding & Assessing Delusions: https://psychpanda.com/delusions/