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This is a fascinating, complex case of an adolescent male who developed an erotomanic attachment for a male peer along with gender identity confusion. John’s symptoms clearly reached delusional proportions; their tenacity over several years speaks to their entrenched nature. An example is John’s unsubstantiated but firm belief that Fred was not returning his love because Fred’s parents disapproved of the relationship. Labeling this belief as a defense mechanism could fill a case conference by itself, given it has elements of “rationalization” (justification of a belief by inventing a fallacy), “distortion” (grossly reshaping outer reality to suit inner needs), and “psychotic denial” (in psychotic denial, the denied reality may be replaced by a delusion)(Kaplan and Saddock, 1988).
John’s erotomanic delusion seems to have abated after just a week of psychosocial treatment, surprisingly, without medication. Little has been written about psychotherapeutic approaches to delusions. One approach postulates that delusions form at a time of agitation associated with emotional conflict, and therapy focuses on addressing underlying affective contributions (Malancharuvil 2004). Or was John downplaying his symptoms to obtain discharge?
This case raises other interesting questions, e.g., Are John’s erotomania and gender identity disturbances etiologically related, or is it possible that “lightning struck twice,” and both disorders developed independently? Certainly the stronger argument would be that these two conditions are related, as there was no evidence of gender identity concerns during John’s preteen years. Gender identity issues commonly surface early in childhood (Bradley and Zucker, 1997), although there is some evidence for a “late onset” type, especially for those who are phenotypic males (Okabe et al., 2008).