Erotomania and delirium of sexual aggression: the boarding school of having been abused or abusive

Erotomania

Erotomania consists in the strong belief that someone (even a stranger), is in love with us. Although erotomania mainly affects womeneven men can experience it, sometimes coming to develop insistent or even dangerous behaviors.

The cases of victims of stalking (Follow, storm of messages, who have undergone violations of their home …) by people who believed they had a secret bond with them.

Erotomania: a delirium of greatness?

In terms of cognitive models, it is believed that erotomania has the nature of a delirium of grandeur: if someone – especially someone important, famous or an authoritarian figure – is in love with us, this makes us somehow “special” (Isham; 2021).

Knowles and colleagues (2011) proposed that i delusions of grandeur can be explained by one of the following two models:

1. The first, by Freeman et al. (1998), speaks of delirium as a defense, for which the person would develop a delirium to counter a negative situation in which he finds himself and to protect his own self -esteem from feelings of unworthiness and solitude.
2. The second suggests that these delusions tend to develop in those who already have a high vision of themselves (Smith et al. 2005).

In the case of erotomania, given the typical profile of those who tend to develop these delusions (Single, alone, shy), it seems that the first model (delirium as defense) is more suitable.

Furthermore, there is not necessarily an attempt to reach one higher social status or a need for power (as in those who believe they are better than the others) since the belief is often kept secret (Lecomte, Francoeur & Cloutier, 2024).

Good practices for treatment (and for coexistence)

It is not a good idea “to target” (to contrast, deny, judge how incorrect or “absurd” …) the Herotomanic deliro, neither in therapy nor in the space of the relationship in general.

In fact, it is more useful in therapy to explore the perception of self -esteem of the person And to understand if his life (secret relationship aside) is satisfactory or not.

Specific objectives such as finding a rewarding job or developing friendships who can lead the person to feel proud, appreciated by others and supported, have a more direct impact on delusional thoughts compared to facing the belief frontally.

When things start to improve and the person feels desired by someone who is actually interested in her, the illusion can sometimes disappear instantly (Lecomte, Francoeur & Cloutier, 2024).

The delusions of sexual aggression

Are found Two types of delusions related to sexual aggression:

1. The erroneous belief of having suffered sexual abuse (more frequent form);
2. The erroneous belief of having personally abused others.

As for the first case, the person can accuse a family member, a neighbor or hospital staff (for example) of having sexually abused her.

Other times the abuse is reported as happened in childhood or within one delusional and hallucinatory history. This type of conviction is considered delirium when it is too complex to look realistic.

We know, thanks to retrospective and prospective studies (Bourgeois et al. 2020) and Metanalysis (Bailey et al. 2018; Varese et al. 2012) that childhood trauma, including sexual abuse trauma, are quite frequent in people who develop psychotic symptoms, in particular delusions and sexual theme hallucinations (Blom & Mangoenkarso 2018).

The following figure translates the model proposed by Beck and Van Der Kolk (1987) which suggests that the post traumatic disorder deriving from sexual abuse can hesitate in emotional overestimation. This in turn determines the disorganization of thought processes.

When the person is subsequently confronted with sexual stimuli (typically in adolescence), this can trigger a very high level of Arousal: the person (disappeared and pervaded by thoughts relating to sex) can develop a Sexual theme delirium.

Cognitive behavioral therapy

Experts in the sector strongly suggest that the CBT for psychotic patients (CBTP) is integrated with interventions focused on trauma (Experiential reworking, exposure …) that allow the person to revisit psychological trauma, describe it and learn to talk about it without being overwhelmed by difficult symptoms and emotions (Keen et al. 2017).

Having said that, these patients call into question another at all simple possibility, or the case of those who experience real pain and strongly believe they have suffered abuse but whose history cannot be verified or remembered.

These patients could unjustly (or not) accuse someone of being their attacker, creating tension and social removal from services, family members, doctors, etc. In these cases one thing is certain: the absence of facts will not lead the person to doubt the correctness of his beliefs.

In the CBTP, Lecomte, Francoeur & Cloutier (2024) suggest, “when the facts cannot be verified, We then aim to reduce the discomfort. For example, trying to help patients realize that they can survive their pain. To understand that going to court or officially accuse someone without sufficient evidence will not lead to anything. Even if we cannot afford “luxury” to revisit the real traumatic event, we can talk about pain and how it affects patients in their daily life. (…)

It is therefore possible to start exploring emotions adjustment strategiesor to use metaphors, such as those used in acceptance and commitment therapy (Act; Hayes et al. 1999) “(p.231). In a nutshell: when we work with patients with delusions of sexual aggression, it is not a question of establishing whether the belief is connected to something real or not, it is a question of facing the pain linked to the belief that is there.

The belief of having abused someone

Another delirium of sexual aggression that we mentioned is the one for which it is mistakenly believed to have abused others.

As in most cases involving delusions of sexual abuse, it is essential to take into consideration the possibility that the person may have suffered sexual abuse (Glasser et al. 2001; Shulman and Horne 2006). If so, the treatment will be similar to the one described above.

However, it is also possible that the person has never undergone sexual abuse, nor has he ever abused.

A clinical case

In the reflection that present Lecomte, Francoeur & Cloutier (2024) we find a response thanks to the presentation of a clinical case. This patient, regardless of the number of times in which his alleged victims said that he was innocent, still believed he had been sexually abusive. In the conceptualization reconstructed by the authors we read that this gentleman, after viewing pornographic material, had imagined doing some of the things he had seen with some women around him (two family members). This mix of sexual images, desire and guilt/shame would have created great anguish and would have become a delusional belief (of sexual aggression).

The authors describe some ways in which they tried to work with this enormously suffering patient – are summarized below:

1. Focus on the central emotions expressed, in this case the shame and the sense of guilt; Ask if he feels in the same way after seeing pornographic material. Discuss on pornography, on what he likes and what does not. Explore the images that remain in his mind or not after looking at pornography and trying to see how he feels about these images (for example, disturbed, excited, full of shame …).
2. Suggest that pornography and the belief of having sexually harassed two women (moreover family) could be connected to these emotions (“could there be a connection between pornography, the mental presence of those images and the belief of being a sexual molester?).
3. Talking openly about sexuality, asking how his sex life was in the past and recently. Normalize the needs and sexual desires, helping the patient to open up on his needs and his use of pornography.
4. Discuss the possible difficulties in encountering women and having sex with someone. Ask the patient: “If he had a girl, how would you imagine sex? Would it be like in pornography or different? “. If the patient admits to fantasize about forced sex, then explore how these thoughts make him feel, even if he does not implement any real behavior.
5. Offer psychoeducation on how people can have sexual fantasies without them translating into real acts. Discuss if it can be considered normal to have a “deviant” imagination.

As you understand, the general idea is to help the patient a regulate the fault for sexual desires and shame In looking at pornography/Living his sexuality, certainly not in directly refuting the erroneous belief.

In conclusion

The romantic or sexual theme delusions are not what they seem: they could mask a delirium of grandeur, suggest a childhood trauma, of a sexual nature or not.

The point is to maintain an open mind and explore the meaning behind the belief while trying to grasp where the patient’s profound suffering is found because when there is a delirium, sexual or other, there is always some form of deep suffering.

CBTP therapy aims to help patients decrease, facing it, this discomfort to obtain a more satisfying and satisfying life.

Bibliography

• Unger, R. (2024). Decoding disappointments: A Clinician’s Guide to Working with Disput and Other Extreme Beliefs: Edited by Kate V. Hardy and Douglas Turkington, Washington, DC, American Psychiatric Association Publishing.
• Bailey, T., Alvarez-Jimenez, M., Garcia-Sanchez, AM (2018) Childhood Trauma is associated with Severity of Hallucinations and disappointments in Psychotic Disorders: A Systematic Review and Meta-analysis. Schizophrenia Bulletin 44 (5): 1111–1122.
• Beck, JC, Van der Kolk, B. (1987) Reports of Childhood Incest and Current Behavior of Chronically Hospitalized Psychotic Women. American Journal of Psychiatry 144: 1474–1476.
• Blom, JD, Mangoenkarso, E. (2018) Sexual Hallucinations in Schizophrenia Spectrum Disorders and Their Relation With Childhood Trauma. Frontiers in Psychiatry 9: 193.
• Bourgeois, C., Lecomte, T., McDuff, P., Daigneault, I. (2020) Child Sexual Abuse and Age at Onset of Psychotic Disorders: A Matched-Cohort Study. The Canadian Journal of Psychiatry 66: 569– 576.
• Glasser, M., Kolvin, I., Campbell, D. (2001) Cycle of Child Sexual Abuse: Links Bethaeen Being in Victim and Becoming in Perpettor. The British Journal of Psychiatry 179: 482–494.
• Hardy, A., Emsley, R., Freeman, D. (2016) Psychological Mechanisms Mediating Effects Bethaeen Trauma and Psychotic Sympoms: The Role of affecto regulation, intrusive memory trauma, Beliefs, and depression. Schizophrenia Bulletin 42 (Suppl 1): S34 -S43.
• Keen, N., Hunter, ECM, Peters, E. (2017) Integrated Trauma-Focused Cognitive-Bahavioural Therapy for Post-Traumatic Stress and Psychotic Sympoms: A Case-Series Study USA Imaginal Reprocessing Strategies. Frontiers in Psychiatry 8:92.
• Tai, S., Turkington, D. (2009) The Evolution of Cognitive Behavior Therapy for Schizophrenia: Current Practice and recent Developments. Schizophrenia Bulletin 35 (5): 865–873.