THE LANCET

Case report

Pathology of love
Frank R Farnham, Craig W Ritchie, David V James,
H G Kennedy
A 22-year-old man was transferred from prison to a
medium-secure hospital, in August, 1996, under section
48/49 of the 1983 Mental Health Act after concerns had
been raised about his mental health. He had been
remanded on a charge of criminal damage and was
awaiting trial. It was alleged that he had been paying
persistent unwanted attention to (stalking) a 28-year-old
woman neighbour for several months. 6 weeks before
admission, he had gone to the neighbour’s flat and, upon
discovering that she was not in, had forced entry and
begun to move in his belongings. When apprehended by
police officers for criminal damage to the door, he
maintained that the neighbour was in fact his fiancée and
said that they were going to live together forever. He had
been diagnosed as having grand mal epilepsy 5 years
earlier. He described his epilepsy as being previously well
controlled with one seizure every 3 or 4 months, but
maintained that in the months before the offence he had
been having a seizure every 2 weeks. At this time,
examination showed a fit young man with reasonable
rapport. He occasionally became agitated and spent time
posturing and flexing his muscles. His speech was at
times pressured and loud. He described his mood as
normal and, apart from occasional irritability, he
appeared euthymic. His sleep pattern had deteriorated
recently, with recent bizarre and vivid dreams. He
described erotomanic delusional ideation, saying that he
and the victim had a special “spiritual understanding like
a love potion”. He had seen incontrovertible evidence of
her devotion in apparently insignificant actions and
gestures. He described déjà vu experiences and symptoms
of derealisation and depersonalisation. He believed that
people had been able to read his thoughts, and described
how he had experimented with changing his train of
thought in order to “catch people out”. Cognitive testing
suggested substantial impairment of his verbal memory.
He appeared to have little insight, maintaining that he
was not ill and that he did not need to be in hospital or to
receive treatment. His presentation and mental state
suggested a diagnosis of a paranoid psychosis with a
prominent erotomanic component. Treatment with
haloperidol produced an increase in his seizure frequency
and a worsening of his psychosis. He was subsequently
convicted and returned to hospital under section 37 of
the 1983 Mental Health Act.
Lancet 1997; 350: 710
Royal Free Hospital Medical School, London NW3 2PF, UK
(F R Farnham MRCPsych, D V James MRCPsych); and Camlet Lodge
Regional Secure Unit, Enfield, Middlesex (C W Ritchie MRCPsych,
H G Kennedy MRCPsych)
Correspondence to: Dr Frank R Farnham

710

Magnetic resonance imaging scan shortly after admission

Because of his history of deteriorating epilepsy, the
finding of impaired verbal memory, and symptoms
suggestive of temporal-lobe epilepsy, a magnetic
resonance scan of his brain was done. This showed a
large arteriovenous malformation in his left frontal lobe,
impinging upon the anterior pole of the left temporal lobe
(figure). His seizures were successfully controlled with
lamotrigine, and his psychotic symptoms resolved. The
arteriovenous malformation was subsequently treated by
two embolisation procedures. Reviewed 2 months later,
he remained free of seizures, on lamotrigine and
carbamazepine, and free from psychotic symptoms.
There have been no further episodes of stalking in the 12
months since the offence.
This case is, apparently, the first report of erotomania
and stalking behaviour secondary to an undiagnosed
vascular lesion. A new Act concerning stalking has
recently been passed into law in the UK.1 Psychiatric
conditions associated with stalking behaviour include
erotomania, the symptoms and presentation of which are
well established in the psychiatric literature.3 The link
between epilepsy and psychosis is also well described,4
and an association between epilepsy and criminal
behaviour has long been debated.5 Public anger at
intrusive forms of antisocial behaviour should not blind
clinicians to the possibility of underlying organic
pathology.
References
1
2
3
4
5

The Protection from Harassment Act 1997, Chapter 40.
Taylor P, Mahendra B, Gunn J. Erotomania in males. Psychol Med
1983; 13: 645–50.
Mullen P, Pathe M. Stalking and the pathologies of love. Aust NZ J
Psychiatry 1994; 28: 469–77.
Slater E, Beard AW, Glithero E. The schizophrenia like psychoses of
epilepsy. Br J Psychiatry 1963; 109: 95.
Delgado-Escueta AV, Mattson RH, King L, et al. The nature of
aggression during epileptic seizures. N Engl J Med 1981; 305: 711–16.

Vol 350 • September 6, 1997