The Psychiatrist: In the throes of a grand delusion

One of the dilemmas of being a doctor is that, occasionally, a patient falls for you. This can occur at any time in your career, no matter how bad- or good-looking you are. Requests for additional appointments, the odd letter or present, some extra perfume at the consultation can all be indicators that, perhaps, medical advice is not the only thing the patient is seeking.

The General Medical Council is quite clear about what you should and shouldn’t do: the answer is, very simply, maintain your clinical distance. Sometimes an urgent home visit can find you out on a limb, so taking a nurse or student chaperon with you is almost de rigueur when you don’t know who you are going to see. There is no arrogance in this – just an understanding that when visiting troubled patients, you never quite know what they are thinking or what might happen.

Mrs B came to see me with a depressive illness. It was a standard referral by a GP and she had all the hallmarks of a severe condition. That is to say, she was slowed down, not sleeping, couldn’t concentrate, felt she was a “bad” person and wondered what she had done to deserve her current state of despair.

She had half-responded to antidepressants but remained in an uncertain state of mind with a perplexing state of “depersonalisation/derealisation” – a component of some mood disorders when you feel that you, or the world, is somehow unreal.

After several reviews the letters began arriving. They were beautifully written on heavy and scented note paper. She asked if I would like to meet her by the fountain (where Outpatients was) at Barts Hospital in London, since she had seen my “message” in The Daily Telegraph. Having not touched the Telegraph for the past 40 years, this seemed odd. Further letters came and at the next consultation I arranged for two students to be with me. She was clearly perplexed, delusional and convinced that I was sending her messages.

Mrs B had developed what we know as erotomania or de Clérambault’s Syndrome, a delusional belief that someone else (usually, but not necessarily, of a higher social class), is in love with you. This can affect people in the context of a depressive or manic illness, or without any illness at all, or in the context of a psychosis such as schizophrenia. Most commonly targeted are the famous, film stars or princes (royalty are especially vulnerable when they wave at you from the TV). In a few cases, stalking can ensue.

Given that the state of being in love is equated by many experts in psychopathology as the nearest to delusion that most “ordinary” folk get, it is not surprising there is an overlap. Apart from training medical students to beware, what to do about it when it does happen?

With regard to my scented letter-writer, I wrote to the GP, advised of what was happening, and asked for someone else to take over her treatment. To my relief, a letter of sincere apology arrived six months later, endorsed by the GP and explaining the now-recovered patient’s utter embarrassment at what she had done. I was lucky. A colleague of mine was pursued from Australia, another besieged in her house.

But we shouldn’t be surprised. As Shakespeare observed in A Midsummer Night’s Dream (Act V, Scene 1): “The Lunaticke, the Lover, and the Poet/Are of imagination all compact.”

Trevor Turner is a consultant psychiatrist working in east London. Some details have been changed to protect identity