In this case, the object of love is of higher status, is famous and has wealth. The object of love is inaccessible.
There may be a distinct time/event when the patient became convinced of the ‘special relationship’. This may have been a brief meeting or sighting, e.g. at a pop concert.
A typical history will include that the love object initiated the relationship, that the patient communicates with him via covert mechanisms, and that there are messages from him in everyday life for her, e.g. on television.
Enquire about stalking behaviour. Often, a person with erotomania follows the person relentlessly and attempts to make contact by various means.
This may be an isolated delusional disorder or secondary to other conditions, particularly schizophrenia and mania.
A relevant MSE is important. There is usually an absence of hallucinations and no cognitive impairment.
Risk
It is important to ask about:
Any stalking behaviour now or in the past Previous offences/trouble with the police
THE EXAMINER’S MARK SHEET
Communication Risk
Clinical features Answering other questions
Station 12: Erotomania 161
Feelings of aggression towards the love object or others Previous love objects/relationships (any aggression?)
ASK WHETHER SHE HAS ANY QUESTIONS
THANK HER
FOR EXTRA MARKS
More common in women than men. Often a chronic disorder.
To gain top marks, it is necessary to get a clear picture of the delusionary system, which can be intricate. There may be evidence of a complex set of beliefs around the perceived relationship. Try to get as much information as possible.
Another form of presentation includes the ‘local’ woman who becomes fixated on a ‘local’ man. In this case, the woman can become aggressive towards the man’s wife or others whom she believes to be ‘in the way’. FURTHER READING
Segal JH. Erotomania revisited: from Kraepelin to DSM-III-R. Am J Psychiatry 1989; 146: 1261–6.
STATION 1
A GP has been put through to you on the telephone. He has just seen a patient with a 5-year history of bipolar affective disorder. She has remained very well for
approximately 2 years, having required an admission 3 years ago when she was manic, psychotic and neglecting her own self-care. She has been taking an antidepressant and a mood stabiliser for the past 18 months. She does not take lithium.
She has been in a stable relationship with her boyfriend for 6 years and they would like to start a family. It is important for her to be able to breastfeed. The GP tells you that she asked about her medication and whether she should stop it before trying to conceive.
The GP asks your advice with regard to these issues.
[advice on page 168]
STATION 2
This man is self-presenting to drug services for the first time following a 3-year history of opiate misuse. He is noticed to be aggressive.
He wants to know how you can help him.
[advice on page 171]
STATION 3
A 72-year-old woman has been brought to A&E. She has become increasingly confused. She has a history of bipolar affective disorder, but no other details are available. She was able to tell the paramedics that her doctor had recently prescribed her a ‘blood-pressure tablet’. The medical senior house officer has faxed you some results and asks for your opinion.
What are the abnormal findings?
What is the likely aetiology for this presentation? What other investigations would you recommend?
Stations 165
[advice on page 173]
STATION 4
This 24-year-old man has been a heavy user of cannabis for the past 6 years. His parents have noticed that he has become more withdrawn and feel his behaviour can be ‘strange’. He has not been able to find work and spends much of his time smoking and listening to music.
Assess his mental state and explain the risks associated with cannabis.
[advice on page 175] Test Result Units Reference range
Glucose 5.6 mmol/L
TSH 2.86 mU/L 0.3—5.5
Vitamin B12 312 ng/L 180—1100
Folate 5.4 ug/L 3.0—13.0
Vitamin B12/folate/ferritin 27 ug/L 20—200
WBC 9 109/L 4—11 RBC 5.1 1012/L 3.8—5.8 Hb 13.2 g/dL 11.5—15.5 PCV 0.47 L/L 0.37—0.47 MCV 80 fl 79—96 PLT 176 109/L 150—450 Na 132 mmol/L 135—145 K 3.2 mmol/L 3.5—5.0 Creat 102 umol/L 45—120 Ca 2.32 mmol/L 2.20—2.60 Phosph 1.10 mmol/L 0.80—1.40 Corr Ca 2.32 mmol/L T Prot 63 g/L 60—80 Albumin 43 g/L 35—50 T Bil 5 umol/L 3—20
Alk Phosph 94 u/L 30—130
AST 30 u/L 10—50
GGT 45 u/L 1—55
Urine dipstick Mild protein
STATION 5
This patient is due his depot medication. There is no one else available to give it to him. Give him his IM depot medication.
[advice on page 177]
STATION 6
Mr Thompson, a 32-year-old married accountant, has become increasingly
preoccupied with personal cleanliness and orderliness in his house. He has been late for work persistently, delayed by a need to check that his appliances have been unplugged. You are the first psychiatric professional to see him.
Assess him for obsessions.
He wants to know whether he will get better.
[advice on page 180]
STATION 7
This patient has collapsed on the ward.
Perform a neurological examination of his lower limbs.
[advice on page 182]
STATION 8
Assess suicidal ideation in this gentleman, who was persuaded by his friend to attend the A&E department after hearing him speaking about wanting to die.
[advice on page 185]
STATION 9
You are the most senior psychiatrist on site. A more junior colleague has phoned you for some advice. He has just seen a 27-year-old man on the ward who is extremely agitated and seems to be disturbed by auditory hallucinations. He has pulled the fire extinguisher from the wall and has been smashing windows and attempting to injure staff and patients. The emergency team was called and has him in restraint. He has a diagnosis of schizophrenia and is already prescribed risperidone.
What advice will you give to your junior colleague?
Stations 167
STATION 10
This woman has been referred to your clinic having asked her family doctor if she could see a psychiatrist. She reports tiredness and low mood in winter over the past few years.
She wants to know whether she has seasonal affective disorder.
[advice on page 190]
STATION 11
You are seeing an 81-year-old woman on the ward. She has not been coping at home. An MRI scan shows small-vessel disease and evidence of an ischaemic region in the left temporal area, probably an old cerebrovascular accident (CVA). As part of your cognitive assessment, you wish to consider her temporal lobe function. Assess her temporal lobe function.
[advice on page 192]
STATION 12
This woman attends the community clinic wanting to speak to her husband’s psychiatrist. She is angry that their sex life has deteriorated as a result of him taking an SSRI antidepressant.
Speak to this woman.
STATION 1: PREGNANCY AND
BREASTFEEDING
INTRODUCE YOURSELF
‘Hello, my name’s Dr Smith.’
Remember to avoid lay terminology in this station.
SET THE SCENE
‘Thank you for calling. This is a common problem for young women who are considering starting a family.’
Explain that you will try to help as much as possible, but that in the interests of safety you will be contacting the pharmacy drug information service in the hospital, or the nearest mother and baby unit team, for further advice.
FIND OUT WHAT THEY ALREADY KNOW
Ask the GP:
What drugs is the patient taking, and at what dosages?
Does the patient have any other children? If so, was she unwell at the time? What happened on that occasion?
Does she have any other relevant past medical history?