Diagnosis and differential diagnosis

Many covert examples necessarily go unrecognized and so there is a bias towards diagnosis of cases with some sort of acting-out behaviour. Otherwise the most common situation is one where the patient, after years of silent suffering, becomes unhappy enough to be treated for depression and then, during sympathetic history-taking, lets the delusional belief slip out. There is often much accompanying anguish and perhaps anger, and of course the beliefs are regarded as indisputable. Obviously, if the patient has been very secretive, a confirmatory history may be impossible to obtain. In married patients the spouse may be totally unaware of delusions which have lasted for years.

The following disorders may be associated with secondary erotomanic features.

• Schizophrenia, especially paranoid, in which the erotomania coexists with other delusions, florid hallucinations, and more widespread thought disorder.

• Major mood disorder, in depressive or manic phases.

• Organic brain disorders, including epilepsy, post-head-injury states, following long-term substance abuse, senile dementia, and possibly as a side-effect of steroid treatment.

• Mental handicap, in which misunderstanding occurs regarding another's feelings or intentions. However, we must remember that the mentally handicapped are liable to sexual abuse and we must not unthinkingly dismiss sexually laden remarks that they may make about other individuals. Conversely, we must also remember that mental handicap can coexist with psychotic disorders and delusional expressions.

• Delusional misidentification syndrome has occasionally been described with erotomanic features.

• Non-delusional erotomanic beliefs may emerge in unstable individuals, sometimes complicating transference in the course of psychotherapy. If associated with histrionic traits there may be florid acting out, but the beliefs do not have the qualities of a delusion.

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