Erotomanic Delusions

1. Overview — What Are Erotomanic Delusions?

An erotomanic delusion (often simply called Erotomania or De Clérambault’s syndrome) is a type of delusional belief whose core is a fixed conviction that

someone is truly “in love” or “infatuated” with us.

This persists even though, in the real world:

the other person has no romantic relationship with us at all,

in many cases barely even knows we exist,

or may even clearly state that they are not interested / feel disturbed or harassed.

Yet the person with the delusion still firmly believes that “they definitely love me, it’s just that…” and then fills in their own reasons.

In general, the person who is believed to “love us” is often someone with higher status or who is difficult to access, such as:

celebrities, idols, singers, actors

treating physicians, university lecturers, workplace supervisors

politicians, public figures, or people who are prominent in some field

This “high / special / placed-on-a-pedestal” status of the target is frequently woven into the delusional narrative, for example:

“They can’t say it openly because it would damage their image/career.”

“So they have to use secret signals instead.”

What makes erotomanic delusions different from a simple crush, daydreaming, or regular fandom is:

Level of confidence in the belief

Ordinary people:
“I kind of fantasize that maybe they like me a bit.” → There is still self-doubt / awareness that they are imagining things.

Erotomania:
“They absolutely love me. I’m 100% sure.” → The belief exists at the level of “reality of life”, not just fantasy.

Resistance to contradictory evidence

Even when faced with very strong evidence such as:

they already have a partner/children,

they clearly say they’re not interested,

they ask for all contact to stop,

people with erotomanic delusions will often “reinterpret” these facts so that they can still maintain the same belief.

For example:

“They only said that because someone forced them.”

“They’re afraid others will find out.”

“They have to act cold and harsh in public to protect us.”

Interpreting everything around them as signs of love (ideas/delusions of reference)

Ordinary, everyday events that are not actually special become read as “personal messages” or “code”:

For example:

They post a sad song → “They miss me. They’re expressing how painful it is to be apart.”

They wear the same color shirt I wore the other day → “They did it on purpose to match with me.”

They glance in my direction briefly → “They’re sending a signal that they see me.”

The whole world becomes a “field of secret signals” through which the other person is believed to be sending love.

Behaviors that are consistent with the belief

Although erotomania is diagnosed primarily from the belief, in real life we often see corresponding behaviors, such as:

Repeated attempts to contact: phone calls, chats, DMs, emails, replying to every comment or post

Sending gifts, letters, pictures, or items that have “special meaning in their own mind”

Attempts to get physically closer: waiting outside the workplace, clinic, studio, or places they think the other person will be

From the person’s own perspective, these behaviors are:

“responding to love”, or

“protecting the secret relationship”.

But from the other person’s perspective → they are often experienced as harassment / stalking / intimidation.

Other areas of functioning may look very “normal”

A considerable number of people with erotomanic delusions:

can work well and have formal education,

can talk about everyday matters in a reasonable way,

do not have prominent hallucinations or bizarre behavior in every domain of life.

The disturbance is “focused on the theme of romantic love with this particular person”, as if there is a “delusional island” in their life.

This picture fits the framework of Delusional Disorder, where we often see:

“The patient appears normal in almost every respect, except for the specific area that is delusional.”

In the history of psychiatry, erotomanic delusions were classically described by the French psychiatrist Gaëtan Gatian de Clérambault, which is why this condition is also referred to as De Clérambault’s syndrome in some textbooks.
He emphasized that erotomania often has the following pattern:

The patient believes that the other person is the one who fell in love first.

The other person then uses “indirect signals” to communicate their love.

The patient sees themselves as “the chosen one” by someone higher in status.

Over time, if the imagined relationship does not unfold as hoped, their feelings may shift from “delight and hope” to “anger, resentment, and feeling emotionally injured”.

Another important point is that erotomanic delusions do not exist in only one disorder.

For some people, they occur within the framework of Delusional Disorder, Erotomanic type (where this is the main feature of the disorder).

For others, they are part of Schizophrenia / Schizoaffective Disorder / Bipolar Disorder / Major Depressive Disorder with psychotic features.

Some cases appear after dementia, brain injury, epilepsy, or brain tumors → which are classified as “organic erotomania” (erotomania secondary to an organic brain condition).

In short, in a “summary box” style:

Erotomanic delusions are a condition in which a person is firmly convinced that someone else is truly in love with them.
This belief
– clearly contradicts reality,
– resists contradictory evidence,
– is sustained by interpreting the entire world as “signs of love”,
– and often pulls behavior, emotions, and daily life into orbit around “a love story that exists more in their mind than in reality”.

2. Core Symptoms — Core Features Commonly Observed

Overall: Erotomanic Delusions are a pattern of belief + interpretation of stimuli + behavior that revolves around a single central theme:

“They love me / We have something going on between us.”

This persists even though, in reality, the other person does not show such behaviors at all—or may even clearly reject them.

The major symptom structure can be divided into 4 main axes:

Core belief theme

Interpreting neutral stimuli as secret signals (reference / “secret messages”)

Emotions and behaviors resulting from the belief

What is not core (helps differentiate from other disorders)

So when considering erotomania, we shouldn’t look only at “they believe someone loves them,” but must consider belief + interpretation + behavior + context together.

A) Core Belief Theme

This is the “heart” of the erotomanic delusion.

1. Main content of the belief

The belief often takes forms like:

“They definitely love me, but their status/duty prevents them from saying it.”

“We are already in a relationship. They’re always communicating with me, just in indirect ways.”

“They are my soulmate / my destiny.” (Sometimes with a spiritual/destiny layer added on.)

Clinically, this often comes together with an image of the other person as “higher status / difficult to access”, such as:

celebrities, politicians, idols, public figures

treating doctors, lecturers, bosses

people who hold power in bureaucratic systems or organizations

This higher status gives the delusion extra “fuel”, for example:

“They must hide it because of their image or position.”

“They must love me so much to risk this much.” (Everything is interpreted to support the belief.)

2. The “delusion” quality, not just fantasy

This belief has clear characteristics of a delusion:

100% certainty
It’s not just “It kind of feels like…” but “They definitely love me.”

Very difficult to disprove
Even if given direct, contradictory evidence (they are married, they say clearly that they are annoyed, or a restraining order is issued), the person usually “reinterprets” everything to fit the prior belief.

Beyond reality / not congruent with context
For example, the celebrity doesn’t even know they exist, but the person believes they are in an actual relationship or that they communicate via “special powers”.

Example illustration (in everyday-language form)

A 30-year-old woman believes that the doctor treating her is “secretly in a romantic relationship” with her.

– The doctor only asks about her symptoms in a routine manner; she interprets this as “He worries about me more than his other patients.”

– When the doctor starts to keep more distance, she thinks, “He has to act distant because he’s afraid the hospital will find out.”

– She repeatedly sends love letters and gifts to the doctor. Even when he returns them and clearly says that it is inappropriate, she still maintains the same belief.

3. Classic pattern: “They fell in love first”

In classic erotomania (de Clérambault), the narrative is often:

The other person is “the one who fell in love first”.
The other person “sent signals first”.
The patient is “the chosen one” or “being pursued by the other’s energy/secret communication”.

So it’s not just “I love them,” but:

“They love me, and they are trying to get close to me.”

B) Interpreting Everything as “Secret Signals / Indirect Communication”

Another core part of the erotomanic delusion is interpreting surrounding events as coded messages or “delusions of reference”.

1. From ordinary events → into personalized messages

Examples of things commonly misread as ambiguous or romantic signals:

Music in a store / live stream / story
→ “They specifically chose this song for me.”

The color of clothing they wear
→ “They wore this color because they know I like it.”

Social media posts about “someone special” in general
→ “They mean me. They are writing directly about me.”

Advertisements, digital clocks, license plates, logos
→ These become “codes” or “secret numbers”.

Crucially, these stimuli have no true personal connection to the person with the delusion. They are just common stimuli that everyone sees. But their brain immediately binds them to the erotomanic belief.

2. In the online era: erotomania + social media = endless loop

The online world provides infinite “raw material for misinterpretation”, such as:

Someone liking an old post → “They have been secretly watching me all along.”
A celebrity goes live and reads out certain comments → “They deliberately read mine / sent a response signal back.”
They post something similar to what we talked about in a public chat → “They are speaking to me through this post / using social media as a secret channel.”

And if the other person:

disappears,
blocks,
or ghosts them,

it can still be interpreted as:

“People around them forced them to distance themselves from me.”
“They must protect me from the eyes of others, so they cannot respond publicly.”

In other words, no matter what happens, the brain spins a narrative that always leads back to the original belief.

C) Typical Emotional and Behavioral Patterns

Erotomanic delusions are not just beliefs; they also drag emotions and behaviors along with them.

1. Emotional trajectory: from hope → frustration → resentment

A fairly classic emotional arc:

Early phase — hope / thrill / secret excitement

They feel as if they have a “secret love”.
They view surrounding “signals” and feel that “the world is showering them with rose petals.”

Middle phase — confusion / hurt / feeling conflicted

They start encountering situations that don’t fit their belief (for example, the person doesn’t respond, avoids them, or makes it clear they’re annoyed).
Feelings like “Why don’t they dare be clear?” / “Why are they being so cruel to me?” arise.

Later phase — irritation / anger / resentment

They begin to interpret the other person as “playing games with me” / “deliberately hurting me.”
Anger mixed with disappointment may lead to verbal attacks, insults, or aggressive behavior (verbally, online, or even offline).

The intensity of each phase depends on co-occurring factors such as personality traits, coexisting disorders, and family or social support.

2. Behaviors that commonly follow

Not everyone will show all of these, but these patterns are frequently observed.

Repeated contact attempts

Calls / chats / DMs / emails
Even in the absence of any reply, they continue contacting with the narrative: “They answer in their heart / They must be reading it but can’t reply.”

Sending gifts / romantic gestures

Sending gifts, love letters, flowers, drawings, etc.
If rejected, they reinterpret: “There must be some underlying reason.”

Physical proximity / stalking

Waiting at workplaces, homes, or places where the other is expected to appear
“Walking past the office/clinic frequently” with various pretexts

Intense online monitoring

Checking every platform, digging through all posts, saving every story
Creating multiple accounts to lurk, message, or comment

The key point is:
From the patient’s point of view, this is “responding to love” or “protecting the relationship”.
From the target’s perspective → it is often experienced as harassment / stalking / intimidation, which carries significant legal and safety risks.

D) What Is Not Core (To Differentiate from Other Disorders)

When writing about or explaining erotomania to readers, it’s crucial to clarify:

1. Prominent hallucinations are not required

Many people with erotomanic delusions do not have clear auditory or visual hallucinations like in schizophrenia.

If hallucinations do occur, they are often framed differently, e.g., “I hear them talking to me spiritually.” But in classic erotomania, the main axis is belief + reference, not heavy hallucinations.

2. Disorganized speech / bizarre behavior typical of full-blown schizophrenia is not required

Their speech is often logically structured within their internal world.

To the average listener, the content may sound bizarre, but the sentence structure, language, and internal logic remain intact (unlike genuine disorganized speech, where language structure itself collapses).

3. Other areas of functioning may be “relatively intact”

They may:

work,
write emails,
discuss finances/work matters competently,

and generally appear “normal” in almost every domain except:

their “relationship” with the delusional target,
which is driven entirely by the erotomanic narrative.

This is a classic picture of Delusional Disorder overall:

The world is mostly normal, except for a “small island of fixed false belief” that is deeply embedded.

4. Quick comparison: what erotomanic delusions are not

Not just a crush / infatuation / fantasy

Crush = I like them.
Erotomania = They definitely love me, they just can’t say it / must use secret methods.

Not just a typical parasocial relationship (fan-celebrity)

Fans may fantasize but still accept that “They don’t really know I exist.”
Erotomania = belief that there is an actual relationship, two-way communication, and a secret love story.

Not relationship OCD

OCD centers on intrusive thoughts (obsessions) + rituals/behaviors to reduce anxiety (compulsions), and the person recognizes their thoughts as excessive.
Erotomania = the person believes it is real and does not see their thinking as exaggerated.

3. Diagnostic Criteria — Clinical Diagnostic Framework

In practice, when clinicians diagnose Erotomanic Delusions, they typically do so within the frameworks:

DSM-5-TR: Delusional Disorder, Erotomanic type

ICD-11: Delusional disorder (6A24) with specification that the delusional content is erotomanic

The core principles are:

First confirm that “this is truly a delusion.”

Check that “the theme is erotomanic.”

Differentiate it from schizophrenia, bipolar disorder with psychotic features, schizoaffective disorder, and psychosis due to substances/medical conditions.

Assess duration and impact on life.

A) Major Principles Used Clinically (Broken Down)

1) Presence of at least one delusion, persisting for the required duration

According to the DSM framework for delusional disorder → there must be ≥ 1 delusion lasting at least 1 month.

This is not just “a passing thought” or “brief mental noise” from acute stress or a few sleepless nights, but a pattern of belief with persistence over time.

In the erotomanic type:

The delusion = a fixed belief that there is someone who “loves us / is in a secret relationship with us.”

Clinicians will consider:

How long this belief has been present,

Whether it has ever remitted, or is almost constant,

Whether the target changes frequently (changing love objects one by one but retaining the same erotomanic theme).

2) Delusional content is specifically erotomanic

This is the “type-defining” point.

The person:

believes that someone is “in love with / infatuated with / wants romantic and/or sexual intimacy” with them,

often with auxiliary details like “They use secret signals,” “They communicate with me through TV/social media,” “Their organization forces them to stay silent,” etc.

When taking a history, clinicians may ask:

“How do you think they feel about you?”

“How do you know they love you?”

“Has there ever been clear, direct evidence, like they said it to you or showed it in an explicit message?”

Answers that fit the erotomanic pattern are:

Emphasis on “They absolutely love me” + using “indirect events / secret signals” as evidence,

Reinterpreting any fact to fit the existing belief, even if it contradicts it.

3) Criteria for full schizophrenia are not met

This point matters because in some people, erotomanic delusions may be part of Schizophrenia / Schizoaffective / Bipolar with psychosis.

For Delusional Disorder, Erotomanic type we must see that:

There are no other prominent, continuous symptoms of schizophrenia, such as:

Severely disorganized speech or behavior,
Marked negative symptoms (avolition, alogia, flat affect) that pervasively affect most of life,
Multiple, prominent hallucinations.

Simply put:

If overall life is “fragmented” and detached from reality in many domains → clinicians tend to think of schizophrenia rather than a pure delusional disorder.

But if:

Most of life remains manageable, and

There is a “delusional island” centered specifically on love/relationship with a particular person,

→ Then the picture leans more toward delusional disorder.

4) Relationship with mood: differentiating from bipolar / major depression with psychotic features

Erotomanic delusions can occur in mood disorders such as:

Bipolar I/II with psychotic features (especially during manic/hypomanic episodes),

Major Depressive Episode with psychotic features.

When differentiating, clinicians look at:

Timing

Does the delusion appear only when mood is severely altered (severe depression / mania) and disappear when mood normalizes?

Or does the delusion persist “even when mood has returned to baseline”?

Which is the “primary driver” of the illness?

If mood (depression / mania) is the central axis and the delusion is just “one symptom within that episode”
→ It tends to be classified as a mood disorder with psychotic features.

If the delusion is a long-standing main feature and mood shifts are just “a thin layer” that sometimes overlays the delusion
→ It leans more toward delusional disorder.

Short guiding formula

Psychotic features of mood disorder = psychosis appears together with and tied to clear mood changes.

Delusional disorder (erotomanic) = psychosis (the delusion) is the main story that remains even when mood does not meet criteria for a mood episode.

5) Excluding causes due to substances / medications / medical-neurological illness

Before labeling a primary psychotic disorder like delusional disorder, clinicians must check:

Substance use / stimulants / medications that may induce psychosis, such as:

methamphetamine, cocaine, high-dose cannabis,
corticosteroids at high doses, dopaminergic agents, etc.

Medical or neurological conditions that could cause psychosis, such as:

dementia, temporal lobe epilepsy, brain tumors, specific brain lesions, encephalitis, etc.

The principle:

If a “medical condition / substance” can adequately account for the psychotic picture → the diagnosis should fall under secondary / induced psychosis, not a primary delusional disorder.

B) Example Diagnostic Narratives (Clinical-Style Vignettes)

Case 1 — Classic Erotomanic Delusion

A 34-year-old woman, single, office worker, is firmly convinced that a famous male singer is “secretly in love with her and has been for a long time.”

– She explains that this singer “sends love signals” through the songs he selects for concerts, the colors of clothing he wears, and through his social media posts.

– Every time he posts about “loneliness” or “the woman of his dreams”, she is sure he is referring to her.

– She sends him DMs every day. Even though she has never received a reply, she believes “He reads them all. He just can’t reply because his management forbids it.”

– Over the past year, she has started traveling to events and studios where she expects him to appear. Even when staff keep her away, she interprets it as “He’s protecting me from the media.”

Assessment of other domains shows she functions well at work, discusses finances and daily life logically, and has no obvious hallucinations or disorganization.
→ Overall, this fits Delusional Disorder, Erotomanic type.

Case 2 — Erotomania in a Medical Professional Context

A 42-year-old married man with two children has a chronic medical condition requiring monthly visits to the same female physician.

– He begins to believe that the doctor “likes and secretly loves him” because she remembers his name every time, asks about his symptoms in detail, and smiles when talking to him.

– He starts interpreting every gesture from her as a sign of love, such as a light touch on the shoulder to comfort him or leaning slightly toward him when speaking.

– He subsequently sends numerous personal gifts and letters to the hospital.

– When the physician clearly states that this is inappropriate and avoids private

conversation, he interprets this as “Her husband is jealous and forces her to act cold toward me.”

– He has repeatedly waited near the hospital parking lot, believing, “She will be happy to see me when no one else is around.”

Despite warnings from the hospital and his family, he firmly maintains his belief and refuses to accept that the doctor is simply acting in a professional capacity.
→ This illustrates an erotomanic delusion with clear safety and legal risks.

Case 3 — Differentiating Erotomanic Delusions from Mood Disorder

A 27-year-old woman has a history of severe depressive episodes with psychotic symptoms in the past (diagnosed as Major Depressive Disorder with psychotic features).

– During a depressive episode, she once believed that a male celebrity “secretly sent her encouragement” through songs. But when the depressive episode improved, this belief completely disappeared.

– At present, she has no erotomanic belief of any kind.

This case is not Delusional Disorder, Erotomanic type, but rather psychotic features tied to mood (mood-congruent psychotic features) during an episode of MDD.

4. Subtypes or Specifiers — Common Subtypes/Specifiers

A) Primary vs Secondary Erotomania

Primary (or “pure” erotomania / de Clérambault):
Erotomanic delusion is the main, dominant feature; other psychotic symptoms are not prominent.

Secondary:
Occurs as part of another disorder, such as schizophrenia, bipolar disorder, major mood disorder with psychotic features, etc. PMC+1

B) Specifiers Commonly Used with Delusional Disorder (Conceptual Level)

Erotomanic type (love theme)

Some individuals have mixed persecutory/grandiose themes (especially in secondary erotomania), making the overall picture “more complex and risky”. Wikipedia+1

C) Course Pattern (Described in the Literature)

Fixed chronic:
Long-standing, firmly held, with little change in target.

Recurrent/episodic:
The delusion comes and goes, or the “object” changes over time. Wikipedia+1

5. Brain & Neurobiology — Brain and Neurobiological Mechanisms Involved

First, to be completely straightforward:
At present, there is no large, systematic neurobiological research that is specific to erotomania. Most of the literature consists of:

Case reports in dementia, brain injury, epilepsy, followed by the emergence of erotomania. PubMed+2 Frontiers+2

Review articles on erotomania that broadly state it is “likely related to the same networks involved in other delusions,” such as delusional jealousy or persecutory delusions. PMC+1

Therefore, what we can do is:

Take the general delusion/psychosis models → and examine how they align with erotomania,

Using case reports of organic erotomania as anchor points.

5A) Aberrant Salience Circuit — “Misplaced Significance” & Belief Formation

In psychosis research, there is a major concept called aberrant salience.
Put simply:

The dopamine system + salience network malfunction → the brain “tags” trivial or random events as highly significant → we feel “This must mean something” → the brain must construct a story to explain it → the end product is a delusion.

This model has been proposed as a good explanation for psychosis in general, especially delusions in the schizophrenia spectrum. ScienceDirect+1

When matched with erotomanic delusions, it looks like this:

Random events / ordinary gestures from the “target,” such as:

a polite smile,
looking up and making brief eye contact by chance,
posting a sad song on a Sunday,

The salience system misfires → the brain feels:

“This is special for me.”
“That wasn’t just a normal smile; there’s something hidden in it.”

The brain must find a narrative to explain this misplaced significance →
→ “They are sending me love signals.”
→ “They posted this song just for me.”

Then the belief becomes reinforced:

Every time similar stimuli appear → salience spikes again.
The brain repeatedly reinterprets them to fit the existing story.
The erotomanic belief becomes more deeply entrenched.

At the circuit level, this model is often linked with:

Mesolimbic dopamine pathway (ventral tegmental area → nucleus accumbens)
– associated with assigning reward/importance to stimuli

Salience network (anterior cingulate cortex, anterior insula)
– used to detect “what matters / what stands out”

Executive network / prefrontal cortex
– used to check “Does this story actually make sense?” If this system is weak, distorted beliefs pass through more easily. ResearchGate+1

Key point:
In erotomania, these “signals” are generally tied to themes of love/relationship. So aberrant salience + loneliness / need for validation → are more likely to crystalize into a belief of “They love me”, rather than “They want to kill me” (persecutory), in some individuals.

5B) Social Cognition & Theory of Mind — Mind-Reading Systems & the Social Brain

Erotomania is a delusion with extremely strong social flavor:

It’s not just “A secret agency is following me” or “A spirit is tracking me,”

It is specifically “Another person is in love with me / sending messages to me,”

which heavily engages social cognition systems.

1. Likely Brain Regions Involved

Research on social cognition and delusions often points to the following networks:

Medial prefrontal cortex (mPFC) — reading others’ intentions and emotions

Temporoparietal junction (TPJ) — “Theory of Mind” / inferring what others think

Posterior cingulate cortex + precuneus — part of the default mode network involved in self-referential thought

Amygdala — evaluating emotional significance from facial and situational cues

When these networks function abnormally, we may:

perceive intentions that are not actually there (over-mentalizing),

interpret neutral gestures as “special attention or romantic interest,”

believe others are thinking about us or secretly communicating with us.

Case reports of erotomania in frontotemporal dementia, dementia with Lewy bodies, and Alzheimer’s disease often describe co-occurring problems in social cognition and misreading faces/intentions. Frontiers+2 ResearchGate+2

2. Over-attribution of intention = “They must have done this for me”

In erotomania:

A polite tone of voice → read as “They’re especially gentle with me.”

Remembering someone’s name in a professional role → “They care about me more than others.”

Replying to an inbox once → “They’ve been thinking about me all along and finally dared to respond.”

This is a social-cognitive bias amplified by misfiring social brain systems.
When combined with aberrant salience → every glance, greeting, or post becomes a “significant romantic signal.”

5C) Default Mode Network (DMN) & the Narrative Self — The Brain’s Storyline Machine

Another likely component is the Default Mode Network (DMN), a brain network that:

is active when “the mind is wandering,” thinking about past and future,

integrates information about “self” and “our relationships” with others.

In many forms of psychosis/delusion, models propose that:

DMN dysfunction → leads to overactive self-referential thinking,

random external events → are constantly drawn in and “linked back to the self.” SpringerLink+1

For erotomania:

Events involving the target (their posts, public appearances, interviews)
→ are heavily processed in the DMN,
→ generating long, elaborate narratives such as “how our relationship is developing.”

Examples:

Today they wore a blue shirt = yesterday I posted a picture in a blue shirt → they must have seen it and wore blue to match me.

Today they posted a sad song = they can’t stand missing me anymore.

Today they didn’t post at all = they are protecting me from the media / someone is pressuring them not to reveal themselves.

As a result, the erotomanic story keeps expanding and becomes very structured.
The DMN essentially becomes:

“A director of a love movie produced entirely by the brain,”
using small stimuli from the real world as raw material.

5D) Right Hemisphere / Frontal–Temporal Lesions in Organic Erotomania

A relatively concrete area of evidence comes from reports of erotomania after clear brain damage:

Cases of erotomania after surgery for subarachnoid hemorrhage + epilepsy
→ authors concluded that erotomania “clings to” damage in right frontal and temporal regions, etc. PubMed

Erotomania in frontotemporal dementia, Alzheimer’s disease, and dementia with Lewy bodies
→ show degeneration in frontal/temporal lobes along with behavioral changes and impaired social cognition. Frontiers+2 OUP Academic+2

From such cases, neurologists and psychiatrists suggest that:

The right hemisphere, especially frontal–temporal regions,
plays an important role in interpreting social/emotional signals and in not personalizing everything.

When these regions are damaged, we see:

impaired reading of others’ facial expressions and emotions,

difficulty separating one’s own thoughts from reality,

poor impulse control in approaching the target (e.g., waiting, calling, sending repeated letters).

This helps explain why, in organic erotomania, we often see patterns like:

targets are often nearby figures in caregiving settings (doctors, nurses, caregivers),

patients poorly register the discomfort or fear of the other person,

behaviors are unrestrained, such as persistent pursuit despite warnings.

5E) Neurochemical Level — Dopamine, Glutamate, and the General Psychosis Pathway

Here we must be honest:
There are no studies specifically testing dopamine/glutamate in erotomania alone.
However, because erotomania often occurs in:

Schizophrenia / schizoaffective disorder,

Bipolar disorder with psychotic features,

Delusional disorder (linked with psychosis pathways), PMC+2 Cambridge University Press & Assessment+2

we can reasonably infer from the general psychosis framework:

Dopamine dysregulation (especially in the mesolimbic pathway)
→ assigns aberrant salience to stimuli.

Glutamate (NMDA hypofunction) + GABA disturbances
→ disrupt cortical–subcortical circuits responsible for meaning processing and belief formation.

Combined:

the brain is more prone to “believe self-generated stories”,

reality testing from the prefrontal cortex is weakened.

In erotomania, the endpoint of these circuits becomes a “love-themed delusion” because they intersect with each person’s memories, needs for love and attachment, and personal history.

5F) Cognitive-Level Model — From Brain to Thought Patterns

To make this understandable to a general audience, you can summarize the neurobiology into a cognitive model like this:

Aberrant salience
– The brain tags ordinary stimuli (looks, smiles, posts) as “important.

Social-cognitive bias
– Over-personalizing others’ intentions → “They did this for me.”

Reasoning bias
– Jumping to conclusions, confirmation bias, rarely seeking evidence that disconfirms the belief.

Emotional needs / attachment
– Loneliness, low self-esteem, need to feel “special.”

Default mode network overdrive
– Turning every “signal” into a long-term romantic narrative.

This model connects:

Brain mechanisms (neurobiology) → thought patterns (cognition) → erotomanic content (“They love me”).

6. Causes & Risk Factors — Causes and Risk Factors

Big picture: There is no single cause.
Instead, erotomania represents a combination of:

Biological vulnerability,

Personality and life experiences (psychological factors),

Environment and culture (social/environmental factors),

interacting within a vulnerability–stress model.

Erotomania most often arises as:

Secondary erotomania = sitting atop another disorder (schizophrenia, bipolar disorder, mood disorder, organic brain disease, etc.) rather than being a purely isolated condition. PMC+2 Cambridge University Press & Assessment+2

6A) Biological / Clinical Factors

1. Psychiatric disorders in the psychotic & mood categories

Large erotomania reviews have found that:

Many erotomania cases occur in the context of:

Schizophrenia,
Schizoaffective disorder,
Bipolar disorder with psychotic features,
Major depressive episodes with psychotic features.

“Primary erotomania” in the pure sense (no other diagnoses at all) appears to be a minority (some reviews estimate ~20%). Cambridge University Press & Assessment+2 PMC+2

Meaning:

For most cases, erotomanic delusions are one theme of psychosis within a broader disorder, not a standalone condition with no surrounding pathology.

2. Organic brain disease / medical conditions affecting the CNS

Multiple case reports note erotomania arising after:

brain injury or surgery (e.g., subarachnoid haemorrhage + epilepsy), PubMed

frontotemporal dementia (bvFTD),

dementia with Lewy bodies,

Alzheimer’s disease and other dementias. Frontiers+2 OUP Academic+2

These support the idea that:

when frontal–temporal–limbic structures are damaged → salience and social cognition networks fail,

making it easier for “love/infatuation-type” delusions to develop.

3. Genetics & family background

There is no research identifying specific “erotomania genes.”
However, since erotomania is associated with:

the schizophrenia spectrum,

bipolar disorder,

and delusional disorder in general,

it is highly plausible that genetic factors that increase risk for psychosis/mood disorders also indirectly increase vulnerability to erotomania. malacards.org+1

6B) Psychological Factors

Multiple sources converge in describing that people with erotomania tend to have backgrounds like:

Low self-esteem + feelings of rejection/loneliness

WebMD and several review summaries consistently mention:

low self-esteem,

feelings of loneliness,

histories of rejection in relationships,

social isolation / difficulty forming relationships. WebMD+2 withpower.com+2

This makes:

having a “higher-status/special person” love them → a fantasy that fills an emotional void.

When combined with aberrant salience, this fantasy does not remain mere daydream, but grows into a delusion.

Idealization & fantasy proneness

Some psychodynamic/behavioral works note that erotomania often involves:

strong idealization of the target:
“They’re perfect—intelligent, capable, successful.”

using the target as a “symbol” of success/acceptance in life,

personality traits leaning toward “high fantasy proneness,” spending a lot of time immersed in imagination. jaapl.org+2 ResearchGate+2

Thus the erotomanic belief becomes:

“A large-scale project of the mind” to shield the self from feelings of emptiness or worthlessness.

Insecure attachment style

Although erotomania is not formally mapped to specific attachment styles, many psychodynamic articles propose that:

people with anxious / preoccupied attachment or histories of abandonment
may use erotomanic delusions as a “shield” against confronting real rejection.

De Clérambault has been described in some works as:

“a defensive façade of romantic fantasy built to cover the deep drama of early developmental abandonment.” jaapl.org

In simpler terms:

Instead of accepting “No one loves me,”
the psyche creates the story “A very special person loves me; it’s just that the world doesn’t understand.”

Certain personality traits

Some reviews and papers suggest that people with erotomania may have:

a tendency toward high personalization = frequently tying unrelated events back to themselves,

beliefs about being “special” (narcissistic traits) or “chosen,”

low tolerance for ambiguity (intolerance of uncertainty) → prompting them to resolve uncertainty with the narrative “They love me.”

A review of 246 erotomania cases even applies Sexual Strategies Theory (SST) to explain gender differences in behavior—for example, women often present with long-term, “bonding” erotomania, while some men display more vengeful/aggressive reactions. ScienceDirect+1

6C) Social / Environmental Factors

Social isolation, restricted life, lack of social feedback

Many sources highlight social isolation as a clear risk factor for erotomania:

living alone for long periods,

having few friends or shallow relationships,

living in a narrow social world with no one to challenge their narratives. WebMD+2 withpower.com+2

Consequences:

there is no “voice from outside” to gently say, “Hey, maybe this is just in your head,”

spending most of life online makes it easier to circulate within content that reinforces their own beliefs.

Media culture / parasocial relationships / online environment

In earlier eras, erotomania was often tied to priests, clergy, or powerful figures who were not easily reachable.
Now it has shifted onto:

celebrities / influencers,

streamers / VTubers,

doctors/therapists/coaches online, where interaction is often non-physical.

The online environment allows:

seeing the target almost daily (posts, stories, live streams),

receiving minor feedback (likes, emojis, replies) that can be read as “personal signals,”

private channels (DMs) that make people feel they have intimate access.

There are also cases of “induced erotomania by online romance fraud”:

A scammer conducts an online romance scam,

The victim develops an erotomanic belief that the scammer genuinely loves them,

Even after discovering the fraud, the delusion can remain very difficult to dismantle. PMC

Stressful life events: loss, divorce, major status changes

Many erotomania cases report onset after:

a breakup, divorce, being abandoned,

moving city/country (losing previous social networks),

retirement, job loss, or chronic illness leading to plummeting self-esteem. ResearchGate+1

These events act as triggers, pulling out an underlying vulnerability and turning erotomanic delusions into a psychological shock absorber.

6D) Safety Factors (Risk for Stalking / Violence / Legal Issues)

Not every erotomania case leads to dangerous behavior,
but in forensic contexts, certain patterns require close attention:

Gender differences in behavior

Large erotomania case reviews have found that:

Women often present with “classic” erotomania: believing the other loves them → sending letters/gifts → maintaining the belief long-term.

Some men show tendencies toward:

appearing in public places to get close physically,
aggressive reactions when feeling rejected,
more frequent intimidation or physical harm to the target. ScienceDirect+2 PMC+2

Risk factors for acting on the delusion

Factors that tend to increase risk:

prior history of violence,

concurrent substance or alcohol use (lowered inhibition),

physical proximity to the target (same workplace, same neighborhood),

ongoing patterns of harassment (calls, following, threatening letters),

erotomanic narratives that shift toward persecutory themes, e.g.:

“They are deliberately hurting me by denying me,”
“They’re playing games with my heart; I need to teach them a lesson.” PMC+2 Karger Publishers+2

Legal measures and protection

In many countries, erotomania cases appear in court fairly often, especially involving public figures.
Forensic literature describes:

restraining orders,

repeated violations of such orders because the patient does not perceive themselves as “doing anything wrong,” but rather “trying to see the person they love.” jaapl.org+1

This aspect is crucial for psychoeducational content:

You must convey that erotomania is not just romantic fantasy, but has the potential to develop into real safety issues—especially when combined with other disorders, substance use, and certain personality traits.

6E) Summary of Causes & Risk Factors (For Use in a Box/Infographic)

If you want a bullet-style summary for the end of the section:

Biological / Clinical

Psychotic disorders (schizophrenia, schizoaffective)

Mood disorders with psychosis (bipolar disorder, MDD with psychotic features)

Organic brain diseases (frontotemporal dementia, DLB, Alzheimer’s disease, brain injury, epilepsy)

Neurochemical vulnerabilities (dopamine / glutamate) similar to those in psychosis generally

Psychological

low self-esteem, feeling rejected, loneliness

high fantasy proneness, strong idealization

insecure attachment, relationship trauma history

high personalization, belief in being “special”

Social / Environmental

social isolation, lack of supportive networks

media/online culture, parasocial relationships, romance fraud

major stressors: divorce, relocation, job loss, bereavement

Safety / Forensic Risk

some groups of men, aggressive traits, history of violence

substance use

repeated harassment/stalking of the target + erotomanic beliefs that are shifting toward persecutory themes

7. Treatment & Management — Treatment and Management

A) First Principle: Risk Management

Assess risk of harassment/stalking/violence, risk of retaliation, and legal risk.

Formulate a plan for “contact boundaries” and safety together with family and the treatment team (in cases with stalking, this must be taken very seriously).

B) Pharmacological Treatment (Medication)

In practice, antipsychotic medications are usually the mainstay, adjusted according to comorbid diagnoses (e.g., if bipolar disorder is present, mood stabilizers, etc.).

Some cases show limited response and require ongoing follow-up and attention to medication adherence (this is a classic issue in delusional disorder generally). PMC+1

C) Psychotherapy

Evidence-based approaches for delusions/psychosis commonly involve:

CBT for psychosis / CBT with a focus on belief testing, coping strategies, and reducing behaviors driven by the delusion.

Reviews and psychotherapy research suggest CBT can reduce delusional conviction and associated distress/behaviors to some extent. Wiadomości Lekarskie

D) Working with Family / Social Systems

Psychoeducation: educate relatives about avoiding direct confrontational “reality smackdowns” and instead using communication that reduces conflict.

Trigger management: reducing consumption of content / online tracking of the target, setting ground rules for social media use.

If legal/safety issues exist: coordinate with a multi-disciplinary team.

8. Notes — Common Points Often Misunderstood in Content

Don’t confuse erotomania with crushes/infatuation: erotomanic delusions are “They already love me” firmly, not “I’m very into them.”

Delusions of reference are often the driving force, which is why “contrary evidence” doesn’t help—because the brain will always find “new evidence.” Wikipedia

In secondary erotomania, the picture is typically not romantic at all—often mixed with persecutory/grandiose themes and higher behavioral risk. PMC+1

Cases involving celebrities/officials/power figures carry high forensic relevance: repeated attempts to contact may lead to real legal consequences.

Read Schizophrenia

References

Jordan HW. De Clerambault Syndrome (Erotomania): A Review and Case Report. Psychiatric Journal of the University of Ottawa. 1980. PMC

Sampogna G, et al. The de Clérambault syndrome: more than just a delusional disorder. International Journal of Social Psychiatry. 2020. PubMed

Oliveira C, et al. Erotomania – A Review of De Clérambault’s Syndrome. European Psychiatry. 2016. ScienceDirect+1

ICD-11 – 6A24 Delusional disorder. World Health Organization, Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental Disorders. Drugs and Alcohol+1

Suehiro T, et al. Case Report: De Clerambault’s Syndrome in Dementia With Lewy Bodies. Psychogeriatrics. 2021. PMC+1

Brüne M. Erotomanic stalking in evolutionary perspective. Behavioral Sciences & the Law. 2003. PubMed+1

El Gaddal YY. De Clerambault’s Syndrome (Erotomania) in Organic Delusional Syndrome. British Journal of Psychiatry. 1989. Cambridge University Press & Assessment

Mullen PE, et al. Study of Stalkers. American Journal of Psychiatry. 1999. (Includes analysis of erotomanic stalkers.) Psychiatry Online+1

Wikipedia – Erotomania. (Use for overview/general description, not as primary research evidence but helpful for a broad picture.) Wikipedia

erotomanic delusions / erotomania / de Clerambault’s syndrome / romantic delusional disorder / delusional disorder erotomanic type / belief of being loved / delusion of being loved / delusions of reference / psychosis and love / erotomanic stalking / primary erotomania / secondary erotomania / erotomania in schizophrenia / erotomania in bipolar disorder / ICD-11 6A24 delusional disorder / DSM-5 erotomanic type / organic erotomania / erotomania in dementia / forensic psychiatry erotomania / dangerous obsessions erotomania / parasocial erotomania / online stalking and erotomania / treatment of erotomanic delusions / CBT for delusions / antipsychotics for erotomania

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