Treatment of Limerence Using a Cognitive Behavioral Approach: A Case Study (2024)

Abstract

Limerence is an underresearched condition of unknown prevalence that causes significant loss of productivity and emotional distress to sufferers. Individuals with limerence display an obsessive attachment to a particular person or “limerent object” (LO) that interferes with daily functioning and the formation and maintenance of healthy relationships. The current study proposes a conceptualization of the condition in a 28-year-old individual and describes a treatment approach using cognitive-behavioral techniques, most notably exposure responsive prevention as used in the treatment of obsessive-compulsive disorder. The number and type of compulsive rituals performed by the treated individual were notably decreased at 9-month follow-up after treatment, and a subjective assessment of dysfunctional thought patterns related to the LO also suggested improvement. A novel screening instrument is presented, as validated screening instruments do not yet exist. Implications for diagnosis and treatment are discussed.

Keywords: cognitive behavioral therapy, obsessive-compulsive disorder, anxiety

Introduction

Psychologist Dorothy Tennov coined the term limerence in the early 1970s after conducting over 300 interviews to gather qualitative data on the experience of romantic love (1). Tennov noted a particular manifestation of “being in love” that many of her interviewees described in a similar way – an involuntary, overwhelming longing for another person's attention and positive regard. This attachment was typically unrequited, developing for someone unavailable to reciprocate feelings.

Uncertainty is the driving force behind the development and maintenance of limerence (2). The individual experiencing limerence feels an attraction towards a particular “limerent object” (LO) whose willingness to reciprocate is uncertain. The greater the degree of uncertainty, the more intensely the individual ruminates about the LO, and the greater the desire for reciprocation. This pattern of uncertainty about the LO's feelings and availability may distinguish limerence from the early stages of a typical romantic relationship, in which both partners often experience infatuation or obsession with each other.

Individuals experiencing limerence struggle with near-constant rumination about the LO (3). They may also engage in rituals that interfere with their other responsibilities, such as staring at photos of the LO or repeatedly reading messages from them. Frequently, the sufferer mentally replays past interactions with the LO, searching for indications of how the LO might feel towards them. When the LO shows affection or approval, the limerent individual's mood soars to ecstatic, and in the face of actual or perceived disapproval, the mood plummets to despair (3).

Wakin and Vo furthered Tennov's work with a proposed model of limerence that drew parallels with both obsessive-compulsive disorder (OCD) and substance use disorder (SUD) yet distinguished it as a unique condition (3). Due to the presence of both intrusive thoughts and compulsive rituals, individuals experiencing limerence may meet diagnostic criteria for OCD if these thoughts and rituals cause significant distress and impairment in functioning (4). Wakin and Vo further noted that separation from the LO results in withdrawal symptoms such as pain in the chest or abdomen, sleep disturbance, irritability, and depression. Additionally, the compulsive behavior that accompanies limerence is reminiscent of a substance use disorder, namely the amount of time that is spent planning for and gaining access to the LO, even when the limerent individual is fully aware of the negative effects of this behavior (3). Fisher et al. further assert that romantic love may itself be a form of addiction, because brain scanning has revealed that feelings of intense romantic love involve the same regions of the brain, referred to as the reward center, that are also activated in behavioral addictions, for example, gambling, or SUD (5).

Tennov reported that limerent episodes may occur just once in a person's life or sequentially for a series of different limerent objects. Each episode may last for a few weeks or for decades, with the average episode lasting between 18 months and 3 years (1). Individuals of all ages and genders may be affected, and the LO is not necessarily of the same gender to which the individual is sexually attracted, implying that limerence is distinct from sexual attraction (6). As Tennov notes, “sex is neither essential nor, in itself, adequate to satisfy the limerent need…Limerence is a desire for more than sex…” [emphasis original] (1).

Clinical descriptions of the course and treatment of limerence are extremely scarce outside of Tennov's seminal book (1) and Willmott and Bentley's more recent work (6). Therefore, in the absence of established diagnostic criteria and treatment protocols for limerence, clinicians may reasonably use evidence-based treatment for OCD, most notably exposure response prevention (ERP), to treat an individual presenting with limerence. ERP is a behavioral therapy that involves deliberately exposing an individual to a feared stimulus and preventing the individual from engaging in rituals that alleviate their anxiety (7,8). In the case of limerence, one may imagine the feared stimulus as separation from or rejection by the LO.

Description

The current case study describes treatment incorporating exposure response prevention (ERP), cognitive restructuring, and behavioral activation techniques with a 28-year old female reporting a lifelong history of limerence. The individual undergoing treatment was the author (“BW”), and therefore consent to present this case study in article format is assumed. BW began treatment for limerence with a licensed clinical social worker in March 2016 as a 28-year old single, white cisgender female. Consent for treatment was obtained prior to beginning services. BW received individual, 45 min psychotherapy sessions once every 2 weeks throughout the treatment period.

Lessons Learned

Results from this case study demonstrate that exposure-response prevention, cognitive restructuring, and behavioral activation techniques were effective in reducing the frequency and number of compulsions as well as distorted beliefs in an individual with self-diagnosed limerence. Without a clinical definition or recognition by the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), even prevalence estimates of limerence are lacking. Treatment protocols are even more distant; most behavioral health clinicians have never heard the term “limerence,” much less knowingly treated it (3). Treatment approaches for this case were adapted from those used for anxiety disorders such as OCD.

However, limerence is in many ways distinct from OCD. While most with OCD have little ability to tolerate uncertainty, for BW, uncertainty was a driving force of the limerence. BW believed that should the LO express interest in a committed, deeper relationship, the limerence would dissipate, which is consistent with Tennov's reported observations (1). The attraction of the LO is her unavailability. As Tennov notes, “your degree of involvement increases if obstacles are externally imposed or if you doubt LO's feelings for you (1).” None of BW's LOs identified as lesbian or bisexual, and many were too many years older than she was at the time to be viable partners, for example, a 25 year-old teacher when BW was a young teenager. While not a universal experience of all individuals with limerence, BW's pattern of LOs reflects Tennov's description of “hero worship” by a young girl or woman towards an older woman (1). In addition to a desire to become physically and emotionally close to the LO, BW also experienced thoughts and feelings of idolization towards her series of LOs, whom she viewed as superior to herself in terms of personality characteristics, physical characteristics, and academic or professional achievements. She sought not only to become close to them but to emulate them. This idolization is a defining feature of limerence, though contrary to expectation, Bringle et al found that learning more information about a desired love object did not decrease obsessiveness (11).

Individuals with limerence experience a chronic, debilitating need to ruminate, idealize, and connect to the LO through rituals and compulsions. BW would often walk past or drive past an LO's home or workplace when she felt restless due to anxiety, boredom, or both. She explained that this ritual made her feel reassured that she knew how to reach the LO “if I needed her” and that her objective in walking or driving past was not to “stalk” the LO by taking note of whether she was present and what she might be doing.

BW initially demonstrated little interest in a romantic relationship, expressing a fear of losing her independence. Later in treatment, she acknowledged that her reluctance to seek out a reciprocal relationship was partly due to the sense of safety and euphoria that thoughts of the LO offered her. BW struggled to give up various safety behaviors throughout treatment, as perceived access to an LO had been consistent and reassuring throughout her life.

Limerence is distinct from the romantic or sexual attraction typically experienced by most individuals. Willmott and Bentley refuted Tennov's claim that the LO must be a potential sexual partner, noting that many limerent individuals deny sexual attraction to their LOs and experience sexual attraction to the opposite gender of the LO (6). Despite her limerent objects always having been female, BW noted that she had experienced romantic interest for males throughout her adolescence and adult life. She recounted a few specific instances of having a “crush” on an available male around her same age at the time. In each of these instances, limerence existed simultaneously for a female LO, and the thoughts and emotions associated with limerence far exceeded the intensity of her feelings of attraction for the male on which she had a crush. She would spend time fantasizing about a potential interaction with an LO in which she received a simple kind word in a passing conversation, while ignoring the potential for a more fulfilling relationship with an available partner in whom she was interested.

The present study has a few limitations. At the time of the treatment described here, no published screening instruments existed for limerence. Since then, Wolf has proposed a tool to measure limerence and conducted initial work towards validation (12). Carswell and Impett point to the lack of a consistent measure of attraction as a key limitation in the existing research on limerence (2). As this is a single case study, generalization of the results to other patients with limerence cannot be assumed before interventions are demonstrated effective in multiple trials. Additionally, a standard diagnosis of limerence does not yet exist, as it does not appear in the DSM-V. Finally, assessments of both the behavioral and cognitive symptoms of limerence were self-reported by BW and therefore subject to reporting bias and possible placebo effect.

Conclusions

This case study describes the experience of an individual experiencing obsessive thoughts and compulsive rituals intended to maintain real or imagined proximity to an attachment figure, a condition that has been called “limerence” in prior work. The individual benefitted from outpatient psychotherapy utilizing cognitive behavioral techniques, as evidenced by a subjective report of improved functioning.

Multiple descriptions of limerence's debilitating consequences exist in popular media, self-help books, and in Internet-based self-help groups (3). Despite increasing attention to the condition in recent years, the clinical community lacks validated screening instruments and treatment protocols. In fact, many mental health clinicians are largely unaware of even the concept of limerence (3). Further research is imperative to address this gap as well as to estimate the burden of limerence to society, as the financial cost of lost productivity when individuals with the condition remain untreated. Neuroimaging studies would provide evidence regarding the hypothesized similarity between limerence and substance abuse disorder. The intention of sharing this case study is to encourage these critically needed research studies as well as provide a resource for clinicians and individuals who struggle with limerence, a condition that has previously remained almost invisible to the behavioral health community.

Acknowledgments

The author acknowledges that the work is the author's own. This manuscript has not been previously published and is not under consideration for publication elsewhere. As this is a single case study, approval from an Institutional Review Board was not necessary. Because the patient in this case study was the author, no steps to ensure confidentiality were necessary.

Author Biography

Brandy E. Wyant is a clinical social worker and psychotherapist.

Appendix A

Original Screening Tool to Assess Symptoms of Limerence.

As you answer questions #1–8, think about the past 2 weeks.

For items #9–20, indicate how strongly you agree with the statement.

Footnotes

References