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De Clerambault

De Clerambault’s Syndrome

Nemowtee Anita Ramdinny*,Netranee Anju Ramdinny-Purryag**

Consultant, St. Jean Pharmacy, Mauritios*,**

Definition

De Clerambault’s Syndrome is also called Erotomania. De Clerambault’s Syndrome has been named after the French psychiatrist Gatian de Clerambault (1872-1934) who published a comprehensive review paper on the subject (Les psychoses passionelles) in 1921. De Clerambault’s Syndrome has been referred to in such exotic terms as ‘phantom lover syndrome’, psychotic erotic transference reaction and delusional loving1, 2, erotomania3, melancholie erotique4 and amor insanus5. It consists of a specific delusion in which the patient believes that a man, who is generally of higher social status and chronologically older, is intensively in love with her. The illness often occurs during psychosis, especially in patients with schizophrenia or bipolar mania.6


History


GE Berrios and N Kennedy outlined in ‘Erotomania: a conceptual history (2002)7 several periods of history through which the concept of erotomania has changed.

Four historical convergences are thus identified in the history of erotomania:

1.       According to the first, which lasted from classical times to the early 18th century, erotomania was a general disease caused by unrequited love.

2.       According to the second, erotomania was a disease of excessive physical love (nymphomania) and this view remained active well into the 19th century.

3.       The third convergence focuses on the view that erotomania is a form of mental disorder and this was held throughout the 20th century.

4.       The fourth and current definition (a development of the third stage) sees erotomania as ‘a delusional belief of being loved by someone else.’

Incidence

The incidence of erotomania is not known. It does not appear to be confined to any one culture, society, continent, age, sex, race or socioeconomic status. It is probably often not recognised as a distinct syndrome and is consequently classified under one of the larger psychiatric categories. Nor do all persons with this syndrome come to the attention of mental health professionals. Doust and Christie8 report 20 recent cases, including the 15 cases discussed by Enoch et al.9

Etiology

Visuospatial functioning deficits or limbic lesions10, particularly in the temporal lobes in combination with isolative and ambivalent romantic experiences, may contribute to misinterpretations in erotomania and deficits in cognitive flexibility may contribute to the maintenance of the delusional belief.

Available information suggests that diffuse brain dysfunction may contribute to erotomania, perhaps by interfering with the operations of the cerebral regions subserving the complex emotional functions. A woman developed the delusional syndrome four years after subarachnoid haemorrhage from a ruptured basilar artery aneurysm.11

Delusional disorders occurring late in life suggest a hereditary predisposition. Researchers also suggest that these conditions are the result of early childhood experiences with an authoritarian family structure. According to other researchers, any person with a sensitive personality is particularly vulnerable to developing a delusional disorder.

Although its exact cause is unknown, it is believed that genetic, biochemical and environmental factors play a significant role in the development of delusional disorder.

It has been suggested12 that the heterosexual attachment, delusional in nature, is substituted for denied unconscious homosexual impulses. This reflects Freud’s belief that erotomania is one of several permutations of the core conflict of paranoia in a male. Here, through the defensive operations of denial, displacement and projection, a formula evolves: ‘I do not love him; rather I love her because she loves me’. One could easily substitute ‘she’ for ‘he’ and vice versa in Freud’s formula; hence for women, this would be transformed into ‘I do not love her. I love him because he loves me’.

Enoch et al13 further add that erotomania evolves out of the search for a safe and unattainable erotized father figure and the need to ward off homosexual impulses.

Feder14 views erotomania as a ‘defensive facade of delusional, histrionic, romantic love behind which lies the drama of an ontogenetically earlier phase of life elaborated in psychosis.’ He further relates that under conditions of regression, there is an attempt at restoration of the earlier blissful union with the mother figure.

Raskin and Sullivan15 view erotomania as an adaptive function, warding off depression and loneliness and providing an outside source of nurturance, protection and control, following periods of loss.

Hollender and Callatian16 advance the notion brought forward by Raskin and Sullivan and suggest that this type of delusional thinking is the result of ego deficit and may be shaped mainly by an intrapsychic struggle and the individual life experiences of being unloved; a narcissistic blow is overcome by a grandiose feeling of love.

Clinical Features

1.       Patient has unshakeable conviction that he/she is loved by a specific individual who is often of higher social standing and sometimes is a prominent figure or even a celebrity.

2.       Although the other person has had little (or absolutely no) previous contact with the patient, the latter usually believes that the other initiated the relationship.

3.       The patient usually has strong erotic feelings towards the other person, although sometimes the relationship is regarded as platonic.

4.       The other person is usually unattainable in some way, for example because of marital status or high social visibility. In many cases, the patient never makes any attempt to contact the love-object, often writing letters or buying presents but never sending them. Even when given a chance to make real contact, the patient will frequently avoid doing so and will devise spurious explanation to account for this.

5.       In those individuals who do not make contact with the other person, reasons are found to explain the paradoxical (i.e rejecting) behaviour which is naturally shown by the latter. In some instances, there may be anger about this perceived rejection associated with acting out behaviour.

6.       Sometimes the other person is believed to protect, watch or follow the patient and all kinds of behaviours are misinterpretated as evidence of passionate interest.

7.       The onset of erotomania may be sudden or gradual.

8.       Hallucinations may be present and some individuals with tactile hallucinations may believe that they have been visited by a lover during the night, a phenomenon known as incubus syndrome.17

9.       When the case is one of ‘pure’ or ‘primary’ erotomania, the accompanying features are those of delusional disorder, that is it is a monodelusional disorder with relative preservation of normal personality features and often some capacity to remain functional in society. In these cases, the patient frequently is able to conceal the abnormal belief from other people.18

Differential Diagnosis

1.       Delusional Disorder, erotomanic disorder

2.       Schizophrenia, especially of paranoid type: here, usually there will be other delusions with a variety of themes, hallucinations and relatively widespread thought disorder.

3.       Major Mood Disorders: Erotomania has been noted in association with unipolar and bipolar affective disorders 19 and there is a description based on one case which suggests that it can appear as a variant of pathological mourning.20

4.       Various21 organic brain disorders: There have been descriptions of erotomania occurring in epilepsy, as part of the after-effects of head injury and among the late effects of substance abuse.21 It has also been seen in senile dementia and apparently as a side effect of certain therapeutic drugs including oral contraceptives and steroids.

5.       Mental Handicap: Callacot (1987) and Ghaziuddin and Tsai (1991) have reported erotomanic delusions in mentally retarded individuals.

6.       Delusional misidentification syndrome: Erotomania has been described in association with the syndrome in a small number of cases.22

7.       Shared psychotic disorder

8.       Non delusional erotomanic beliefs: It does appear that certain people may have very powerful erotomanic emotions which are in the nature of over-valued ideas rather than delusions.23

Treatment

De Clerambault’s cases are rare, sporadic, colourful and interesting and have with very few exceptions so far, eluded effective treatment. In 1883, Winslow24 described a case of erotomania in which cure was, apparently a perfect one; the mind was restored to health.

Sims et al25 also report satisfactory adjustment in their two patients following initial treatment with chlorpromazine 100mg tds and later fluphenazine decanoate 50mg every 2 weeks and administration of trifluoperazine for his other patient, both of whom were compound cases of De Clerambault’s and Capgras Syndromes.

Enoch et al 26 reported that chemotherapy, electroconvulsive treatments and insight oriented psychotherapy proved ineffective for one patient and temporarily effective for another, but that the delusions soon returned and thereafter remained resistant to all treatments.

Peace27 reports that the delusions in his case of erotomania in association with folie a deux remained in spite of 6 weeks of intensive antipsychotic therapy.

Hollender and Callahan28 indicate that these patients are not suited for insight oriented psychotherapy and that their delusions appear unmodified following treatment with various phenothiazines. Doust and Christie29 on long range follow ups, report no change in their patients’ delusions after various prolonged treatments with ataractic drugs, phenothiazines and electroconvulsive therapy.

Prognosis

The outcome for these persons appears dismal as Enoch et al26 conclude that ‘these patients may even be dangerous and may finish up by making an attempt on the life of their victim or members of his or her family (or their own).29 This is particularly liable to occur when the patient reaches the stage of resentment or hatred which replaces love, after repeated advances are unrequited and they may thus require prolonged hospitalisation to prevent them from acting out threats which are contained in their letters.’

References

1.        Seeman MV. The search for Cupid or the phantom lover syndrome. Can Psychiatr Assoc Journal 1971;16: 183-184.

2.        Seeman MV. Delusional loving. Arch Gen Psychiatry 1978;35:1265-1267.

3.        Freud S: Psycho-analytic notes on an autobiographical account of a case of paranoia. In the complete psychological works of Sigmund Freud. London, The Hogarth Press 1958; 12: 63.

4.        Hunter R, Macapline I. 300 years of Psychiatry, 1535-1860. Lond, Oxford Univ Press 1963; 891-897.

5.        Enoch MD, Trethowan WH, Barker JC. Some uncommon psychiatric syndromes. Bristol; England: John Wright 1967; 13-24.

6.        Remington GJ, Jeffries JJ. Erotomanic delusions and Electroconvulsive Therapy: a case series. Journal Clin Psychiatry 1994; 55(7): 306-308.

7.        Berrios GE, Kennedy N. Erotomania: a conceptual history. History of Psychiatry 2002; 13:381-400.

8.        Seeman S: Psychotic and erotic loving- the difference. Int J Psychother 1977; 6: 494-495.

9.        Rather LJ: Mind and Body in the 18th Century Medicine. London, The Wellcome Historical Medical Library 1965: 169-184.

10.     Daryl E, Iqbal A, Takeshita J. Neuropsychological Implications in Erotomania: 2 case studies. Neuropsychiatry, Neuropsychology and Behavioural Neurology 1999; Vol 12: Issue 2.

11.     Anderson A, Jacob C, Christopher M. Erotomania after Aneurysmal Subarachnoid haemorrhage. J Neuropsychiatry Clin Neurosci 1998;10: 330-337.

12.     Cameron N. Paranoid conditions and paranoia, In Arieti S (ed): American Handbook of Psychiatry 1959: 525-526.

13.     Enoch MD, Trethowan WH, Barker JC. Some uncommon psychiatric syndromes. Bristol England. John Wright 1967: 13-24.

14.     Feder S. Clerambault in the guetto: Pure erotomania reconsidered. J Psychonal Psychotherap 1973; 2: 240-247.

15.     Raskin DE, Sullivan KE. Erotomania. AJP 1974; 131(9): 1033-1035.

16.     Munro A. Defining the diagnosis of erotomania. Am J Psychiatr 1990; 147: 820.

17.     Raschka LB. The incubus syndrome, a variant of erotomania. Can J. Psychiatry 1979; 24: 549-553.

18.     Munro A. Defining the diagnosis of erotomania. Am J Psychiatr 1990; 147: 820.

19.     Remington G, Book H. Case report of de Clerambault Syndrome, Bipolar Affective Disorder and response to Lithium. AJP 1984; 141: 1285-1287.

20.     Evans DL, Jeckel LL, Slot NE. Erotomania: a variant of pathological mourning. Bull Menninger Clin 1982; 46: 507-520.

21.     Lovett Doust JW, Christie H. The pathology of love: some clinical variants of de Clerambault’s syndrome. Soc Sci 1978; 12: 99-106.

22.     Signer SF, Isbister SR. Capgras Syndrome, de Clerambault’s syndrome and folie a deux. BJP 1987; 151: 402-404.

23.     Seeman MV. Delusional loving. Arch Gen Psychiatr 1978; 35: 1265-1267.

24.     Winslow F. Obscure diseases of the brain and mind. London, Davies 1883; 3: 151.

25.     Sims A, Reddy M. The De Clerambault and Capgras History. Br J Psychiatry 1976; 129: 95-96.

26.     Enoch MD, Trethowan WH, Barker JC. Some Uncommon Psychiatric Syndromes. Bristol, England: John Wright 1967:13-24.

27.     Pearce A: De Clerambault’s Syndrome associated with Folie a Deux. Br J Psychiatry 1972; 121: 116-117.

28.     Hollender MH, Callahan AS. Erotomania or de Clerambault’s Syndrome. Arch Gen Psychiatry 1975; 32: 1574-1576.

29.     Doust JW, Christie H. The pathology of love: Some clinical variants of de Clerambault’s Syndrome. Soc Sci Med 1978; 12: 99-106.