Background
In the era of the digital age, recent advancements in communication technology have profoundly impacted social interactions [
1]. The popularity of these technologies is attributed to their characteristics of anonymity, openness, interactivity, convergence, decentralization, and globality [
2‐
5]. However, these features have also provided a wide scope for online cybercrimes. One prevalent form of cybercrime is online romance fraud, which has become widespread with the advent of social media and dating apps [
6]. Online romance fraud occurs when a criminal adopts a false online identity to deceive and gain love and trust [
6]. Over the past few years, scammers have increasingly applied artificial intelligence (AI) to overcome language and cultural barriers, adding a new layer of sophistication to their deceptive tactics [
7,
8]. The perpetrator strategically employs manipulation techniques to construct a deceptive facade, deftly fabricating an illusion of a romantic relationship with the unsuspecting victim, within the context of fraudulent activities. Their primary objective is financial exploitation, with little regard for the psychological harm inflicted on the victim as a potential consequence. Individuals contending with mental disorders face heightened risks of exploitation due to increased susceptibility and vulnerability. Specifically, those dealing with psychological and mental health challenges exhibit elevated susceptibility to cybercrimes [
9]. Various factors, including behavior, personality traits, mental state, online activity, response mechanisms, knowledge, and attitudes toward technology, contribute to individuals’ vulnerability to cybercrime [
10,
11]. While the influence of internet usage on mental health has been extensively documented, a noticeable scarcity of information exists in the literature regarding internet-induced erotomania [
12]. This gap underscores the need for further research and exploration into the potential connections between online activities and the emergence or exacerbation of specific psychiatric phenomena, such as erotomania.
Erotomania, also known as de Clérambault’s syndrome is a relatively rare, persistent delusional manifestation, characterized by an irrational belief that another person, usually of higher socioeconomic status, is romantically involved with the patient, despite minimal or no contact between them [
13,
14]. This delusion typically involves morbid infatuation and the projection of the affected individual’s own attitudes onto the perceived “love object” [
14]. It appeared officially as a diagnosis for the first time in DSM-III R. In both ICD-11 and DSM-5-TR. Erotomania is classified as a subtype of delusional disorder. In ICD-11, it is identified under the code MB26.04, with a definition emphasizing a persistent delusion involving the belief that a person of higher social or professional standing is romantically interested. In DSM-5-TR, Erotomania is similarly characterized by a persistent delusion, requiring a minimum duration of one month for diagnostic consideration [
15,
16].
Case presentation
Admission
A 70-year-old married Caucasian woman was admitted to our department following a suicide attempt by benzodiazepine ingestion, as a consequence of repeated conflicts with her husband. The patient revealed her persistent online communication and romantic involvement with a world-renowned musician in his thirties, a relationship spanning more than a year since her husband gifted her a smartphone.
Present situation
The patient’s involvement began innocently, expressing admiration for the musician’s work through positive comments on various profiles featuring his art. Over time, the patient’s feelings intensified, perceiving the musician as talented, elegant, and sexually attractive. She persuaded her husband to attend the musician’s live concert, hoping for a personal encounter. Subsequently, she engaged in frequent, confidential chats on profiles using the musician’s image, receiving positive and encouraging messages. The conversations became increasingly personal, with the patient divulging significant amounts of information.
The patient received messages praising her extensively, creating a deep affection that she felt rejuvenated her life. This emotional involvement prompted her to enhance her appearance using cosmetics and undergo weight loss through dieting. To substantiate her claims, she asserted that the “musician’s secretary” once called her, arranging a telephone conversation during which he professed his love. The patient disclosed her feelings to her husband, who initially dismissed them.
As the online relationship deepened, the patient began receiving requests for significant sums of money, citing various reasons such as charitable causes or covering their phone bills. This led to escalating conflicts within the marriage, with the husband struggling to accept the contradictions of the perceived “love relationship” and expressing concerns about its dangers. The husband filed a police report without the patient’s knowledge, resulting in the cessation of fraudulent profiles. However, the fraudster resumed communication on a new profile, prompting the husband to transfer money in an attempt to stop the claims.
Despite these efforts, the fraudster held additional requests, intensifying her marital discord. The patient, fearing the loss of her “love,” became increasingly distressed. She accused her husband of obstructing her relationship, leading to threats of suicide. When her husband failed to respond, she ingested 30 tablets of 0.5 mg alprazolam.
History
The patient, a retired cook, resides with her husband and reported feeling neglected by her family throughout her life. Her childhood and adolescence were uneventful, but she perceived familial neglect, exacerbated by her mother’s depression and dementia. Marrying a military officer at 17, her husband became her sole relationship. Over the past three decades, cumulative organ diseases have contributed to a depressive mood, decreased work capacity, and heightened isolation. Despite residing near her son and grandchildren, loneliness persisted due to infrequent visits, and her husband’s social engagement.
The medical history included bilateral deep vein thrombosis, diabetes mellitus with polyneuropathy, hypercholesterolemia, spondylosis, lumbar spondylarthrosis, osteoporosis, lumboischialgia, vertebrobasilar syndrome, and tinnitus. She took 50 mg of sertraline and 0.25 mg of alprazolam daily for dysthymia and anxiety, maintaining a compensated psychiatric status since the age of 55. No prior psychotic symptoms were noted.
Diagnostics
Physical examination revealed moderate obesity, sensory disturbances associated with polyneuropathy in the lower limbs, mild cognitive impairment, poor thinking, depressed mood, emotional lability, slowed psychomotor activity, erotomanic delusions and suicidal thoughts. The patient reported loss of appetite and sleep disturbances.
Initial laboratory tests revealed elevated serum benzodiazepine levels and slightly increased hemoglobin A1C, cholesterol, and LDL-cholesterol values. Brain Magnetic Resonance Imaging (MRI) confirmed microvascular lesions (Fazekas I. stage).
After addressing benzodiazepine intoxication and improving affective symptoms, psychological tests (Minnesota Multiphasic Personality Inventory (MMPI), Structured Clinical Interview for DSM-5 - Personality Disorders (SCID-5-PD)) indicated a characteropathic mode of functioning with A- and C-cluster traits, psychotic and organic symptoms, limiting the perception of reality, insight, and judgment skills. Patient scored 27/30 points on the Mini Mental State Examination (MMSE) test and had 71/100 points on the Addenbrooke’s Cognitive Examination III (ACE-III) test.
Examinations revealed a diagnosis of mild cognitive impairment, delusional disorder of the erotomanic subtype, and organic affective disorder with a cerebral vascular background. We consider this case as an online romance fraud induced, secondary erotomania, on the basis of another psychiatric and organic disorder.
Treatment
Treatment involved previous antidepressant medication (sertraline 50 mg/day) in combination with low-dose risperidone (2 mg/day), alongside supportive individual and group therapy. Despite the treating physician and psychologist presenting the patient with harsh facts, initially she remained ambivalent, and her erotomanic content persisted. After establishing an empathetic, accepting, and supportive relationship, we addressed emotional background, marital conflict, and previous negative events. Cognitive-behavioral therapy focused on processing the double-disappointment (deception and emotional loss) experience, while gradual feedback aimed to strengthen her insight into the unrealistic elements of the online “love relationship.” Couple-counseling resolved marital crises, leading to a more balanced relationship. Four weeks into treatment, dysthymia and anxiety resolved, psychotic symptoms improved, and the patient partially realized the fraud. Continuing psychopharmacological and supportive treatment on an outpatient basis was recommended.
Discussion
In the early eighteenth century, erotomania was conceptualized as a general disease, the causal factor of which was thought to be unrequited love [
17]. From the early nineteenth century to the beginning of the twentieth century, there was a conceptual transformation, with erotomania being recognized as a form of mental disorder primarily linked to unrequited love [
17]. The evolution of this understanding continued into the early twentieth century and persists to the present day. In the contemporary context, erotomania is defined as a psychotic, delusional belief. Modern psychiatry postulates that the intricate interplay between stress, personality patterns; and environmental, genetic, psychological, pharmacological, and physiological factors may trigger erotomania in predisposed individuals.
The literature has recognized instances of erotomania induced by pre-Internet media (celebrity magazine, radio, TV, movie) referred to as “
Cinderella syndrome” and more recently, social media networks have been implicated in psychotic disorders. With the widespread adoption of online communication and rapid technological advancements, it is predictable that romantic deceptions will become increasingly prevalent [
59]. Faden and Prasad each separately emphasize the role of social media in individual case studies [
12,
60]. The application of artificial intelligence (AI), such as Chat-GPT, breaks down linguistic barriers, making deceits more accessible, as romantic communication becomes possible even when the perpetrator is not fluent in the victim’s native language [
61]. However, there is limited documentation on the impact of online romantic fraud on mentally impaired individuals [
62].
In the present case, it becomes evident that the emergence of delusional symptoms was influenced by a combination of the patient’s personality traits, mild cognitive impairment with a vascular background, and ongoing life events (online romance fraud). Stressors associated with age-related changes, such as chronic physical illnesses, retirement, marital conflicts, familial estrangement, loneliness, and isolation, contributed to an identity crisis linked to this life-stage. The crisis was further intensified by the patient’s disharmonious personality traits and dysthymic mood disorders. Unfortunately, the patient lacked adequate coping and problem-solving mechanisms to navigate the crisis, and external assistance was not sought.
The intricate interplay of predisposing factors and emotional vulnerability may have laid the groundwork for the patient to become victim. Her low technical expertise and skills only heightened her vulnerability to cybercrime. Immature and ineffective defense mechanisms, such as projection, splitting, or denial, coupled with cognitive decline, led to a lack of insight into the unreality of the virtual relationship. Challenges in emotion regulation set the stage for a gradual progression toward erotomania, with delusions eventually dominating the individual’s thoughts and behaviors.
Repeated confrontations with the realities of her husband escalated their conflicts. These conflicts, combined with the fear of termination of the romantic relationship, may have contributed to the development of a regressive, narrowed mental state, ultimately culminating in a suicide attempt.
Given the complex interplay of individual and environmental factors underlying these processes, the treatment of emerging or worsening mental disorders necessitates the application of comprehensive bio-psycho-socio-spiritual perspective. In addition to psychopharmacotherapy tailored to psychological symptomatology (antidepressant, anxiolytic, or antipsychotic treatment), providing psychotherapeutic support is essential for processing the negative emotions (depression, grief) caused by deception.
Psychotherapeutic interventions should address two significant aspects. First, we should focus on the double trauma experienced by victims - financial loss and the dissolution of a perceived relationship. Second, acknowledging and addressing victims’ shame upon discovering fraud are vital. By integrating these considerations into the therapeutic approach, clinicians can enhance their effectiveness in helping individuals cope with the aftermath of online romance fraud and erotomanic delusions. The involvement of individuals in the patient’s environment (partner, children, other relatives, etc.) is crucial for treatment, aiming to address the patient’s relationship issues and alleviate social isolation. In addition, adequate psychoeducation is vital for drawing attention to the dangers of online communication, emphasizing the importance of not divulging personal information that could be exploited by online partners. Heightened caution is necessary when a “dear acquaintance” remains elusive and unwilling to engage in personal or video communication.
Recognizing that shame or distorted insight can be barriers to patient disclosure of victimization is vital. Establishing a safe, reliable, and supportive doctor-patient relationship is crucial for overcoming these barriers. Emphasizing the avoidance of victim-blaming is essential for a compassionate and effective approach. Exploring the patients’ personality traits and psychopathological symptoms is crucial, as they may increase the risk of becoming a victim. Factors such as dependent personality traits, content indicating unrealistic idealization, impaired situation awareness, problem-solving, and mentalization skills associated with cognitive decline, loneliness, isolation, and relationship or family issues can contribute to the risk of victimization. The presented case illustrates the role of these factors, as well as the stages of deception. Recognizing these factors is essential, as they increase the likelihood of preventing the worsening of unrealistic emotions and the development of severe psychopathological symptoms in the early stages of victimization.
Conclusions
The presented case highlights the susceptibility of individuals with mental disorders to developing erotomanic delusions in the context of online romance fraud. It is crucial to monitor the online activity of such patients, particularly those with specific risk factors, as they are more likely to become victims. Identifying personality characteristics and psychopathological symptoms that elevate the risk of victimization is essential. These may include dependent personality traits, unrealistic idealization, cognitive function impairment affecting situational awareness, reduced problem-solving abilities, compromised mentalization skills, experiences of loneliness and isolation, and relationship or family problems.
In the course of treatment, avoiding victim blaming is paramount, and establishing a safe, trusting, and supportive therapeutic relationship is essential, which may also form a stable basis for adequate compliance with the treatment, including pharmacotherapy (antipsychotic medication). Psychoeducation should emphasize the risks associated with online personal data communication with strangers. Consultation with affected relatives is an integral component of psychotherapy.
These conclusions emphasize the importance of a comprehensive and multidimensional approach for both prevention and intervention strategies. By understanding the unique vulnerabilities of individuals with mental disorders, mental health professionals can contribute to reducing the incidence and impact of online romance fraud induced erotomania.
However, further comprehensive investigations into the concealed psychological risks associated with online fraud and its potential contribution to the development of erotomania are imperative. This call for in-depth research underscores the necessity of understanding the intricate relationship between online fraud and the emergence of erotomania, with the aim of informing preventive measures and tailored interventions within the realm of mental health.
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