Erotomania
or
de Cl\l=e'\rambaultSyndrome
Marc H. Hollender, MD, Alfred S. Callahan III, MD \s=b\ De Cl\l=e'\rambaultfocused attention on a syndrome in which a has the delusional belief that a man, usually of higher social status and considerably older, is much in love with her. If the pawoman
tient's romantic ideas shaped private fantasies instead of determined public behavior, there would be little cause for concern. The situation becomes critical when the fantasies are dramatized in real life with an unsuspecting and usually unwilling man cast in the role of the lover. The woman dwells on the feelings she ascribes to her "suitor." Such delusional thinking, resulting from an ego defect and producing bizarre actions, may be shaped largely by feelings of being unloved or even unloveable; a narcissistic blow is overcome by a grandiose fantasy. Cases in which erotomania is prominent are usually
diagnosed as paranoid state or paranoid schizophrenia. (Arch Gen Psychiatry 32:1574-1576, 1975)
psychose passionnelle, generally Erotomania de Clérambault syndrome, described de Clérambault.1 his
known in detail by According to description, the pa¬ tient, almost always a woman, has a delusional belief that a man, usually considerably older, is much in love with her. The man is likely to occupy a prominent position or be a or
as
was
public figure.
In this report, we will comment on the relationship of erotomania to love, briefly refer to the literature on de Clérambault syndrome, describe four additional cases, and, finally, discuss the nature of the syndrome diagnostically and psychodynamically. NOTES ON THE LITERATURE
Many stories deal with infatuation and passionate love but none is concerned with the grotesque drama we label erotomania. Although occasional instances of erotomania had been observed by psychiatrists, not until de Clérambault's publication was attention focused on it as a spe¬ cific syndrome. Two forms of de Clérambault syndrome have been dif¬ ferentiated: a pure or primary form in which the onset is sudden and the disorder is limited entirely to the eroto¬ mania, and a secondary form in which the onset is gradual and the process superimposed on a preexisting psychosis of a paranoid type. The fundamental assumption made by the woman with erotomania, according to de Clérambault, is that it is the man "who started it all and who loves most or who alone loves." Secondary themes regarded as obvious are that the man can neither find happiness nor be complete without the patient. Moreover, he is free to marry her because his marriage is not valid. De Clérambault also delineated secondary themes that can be demonstrated: The patient watches and protects the man and carries on indirect conversations with him. He makes advances to her using the phenomenal resources at his disposal; his conduct toward her, however, is paraAccepted
publication Feb 14, 1975. Department of Psychiatry, Vanderbilt University School Medicine, Nashville, Tenn. From the
for
of
Reprint requests to the Department of Psychiatry, Vanderbilt University School of Medicine, A-2215 Medical Center, Nashville, TN 37232 (Dr. Hollender).
doxical and contradictory. The response evoked in others by their romance is almost universal acceptance. Para¬ doxical conduct is of the greatest importance and never lacking, but the other themes are seldom all present in one
patient.
In de Clérambault's book, he described five cases of erotomania and referred to one other. Since 1942, fewer than 15 additional patients with the syndrome have been described in the psychiatric literature. The cases prior to 1967 have been reviewed by Enoch et al,2 who added three of their own. Sims and White3 described a patient with both de Clérambault and Capgras syndromes, and Pearce4 described one in whom de Clérambault syndrome and folie à deux were combined. Raskin and Sullivan5 recently re¬ ported two cases in which the man in the delusion was the
patient's psychiatrist.
REPORT OF CASES Case 1.—Miss G announced to her fellow workers at a medical school that she was getting married. Everyone was happy for her, and plans were made to give her a shower. When someone finally asked who was "the lucky man," the office workers were flabber¬ gasted to be informed that it was the chairman of the Department of Ophthalmology, a distinguished physician, who, as far as any of them knew, was happily married. When asked for more details, Miss G responded that Dr. would not be marrying her for a few weeks, but they planned to spend the coming weekend in "sexual expression of their love." Miss G was 42 years old, small, unattractive, and 90% blind due to uveitis dating back to childhood. Her first psychiatric hospital¬ ization 11 years before was for "a complex paranoid delusional system," including the notion that her mother and two sisters, with whom she lived, were trying to poison her. A year later, she was again hospitalized when she locked her family out of the house and called the police for protection. Shortly after announcing the name of the man she planned to marry, Miss G engaged in sexual talk out of character for her. She mentioned men she would "take care of" and stated that she had heard voices of men asking to make love to her. She went to a dance where she met a man with whom she spent the weekend. During this (her first) sexual relationship, she called her partner by the name of the ophthalmologist. Case 2.-Miss D went to the home of a television newscaster whom she had never met and announced that they were to be mar¬ ried. She then attempted to eject the newscaster's wife from the home. The police were summoned, and Miss D was taken to a psy¬ chiatric hospital. Miss D, 36 years of age, less than 1.5 meters tall, and strikingly unattractive, had been interested in watching television and had been doing practically nothing else for more than two years. She came to believe that the newsmen on the screen could see and hear her and that they sometimes spoke directly to her. Believing that they were romantically involved with her, she repeatedly tele¬ phoned them. In response to complaints, the Sheriff's Department threatened to remove her telephone, after which her father dis¬ connected the telephone whenever he left the house. Miss D's only previous psychiatric hospitalization occurred when she was 17 years old. According to the report, she was hav¬ ing difficulties at school and at home and refused to eat. She was fed by gastric tube and given ten electroshock treatments with satisfactory results.
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Miss D was the middle of three daughters; one was three years older and the other seven years younger. Unlike her sisters, she developed no interest in cooking or sewing and refused to help with housework. In school she made poor grades, had no friends, and was subjected to ridicule by classmates, probably mainly be¬ cause of her short stature and obesity. Following graduation from high school, Miss D entered business
college where, after three or four weeks, she suddenly became in¬
fatuated with a young man and refused to leave him. To get away from her, he promised to meet her that evening but did not do so. The following day, Miss D was so upset that she had to be forcibly removed from school by her father. Later she insisted that she had married the young man, become pregnant, and had a mis¬
carriage.
Efforts at vocational rehabilitation were unsuccessful and Miss D worked only a few days. She lived on a farm with her parents until her mother died, and afterwards lived alone with her father. Her only outside activity was weekly attendance at a church ser¬ vice. At home she neither helped with cleaning nor food prepara¬ tion. Various phenothiazines, given during a period of months, did not alter Miss D's delusion. While hospitalized, long periods of withdrawal alternated with episodes of hyperactivity during which her mood was elevated, she was suspicious, and possibly hallucinated. first came to psychiatric attention when Case 3.-Mrs. brought to a state hospital by the police whom she called seeking assistance in locating a well-known country music star. The bus trip from rural Kentucky to Nashville was her fourth, all made in response to messages "received" from this musician asking her to come so they could be married. Mrs. B, a 36-year-old woman, looked much older. Her "romance" extended for a period of 15 years. She stated that when she first met the musician at a department store, hugged him, and asked him to go home with her, his response was to cry. Although her trips to Nashville were unsuccessful in one sense, according to her they were successful in another for they had saved the lives of several Grand Ole Opry stars. These stars had been threatened by and were capable of great evil. women who had tormented Mrs. They once caused her clothes to ignite spontaneously (although she escaped without injury), and made a toad frog jump out of her new record player. Mrs. had never been involved sexually with anyone other than her husband to whom she had been married for six years, until their separation a year before. She explained that she had "got right with the Lord" when she was 14 and tried to lead "a good Christian life." She added, "I love C good enough to go to bed with him, but I would want to get married to him first. I was brought up to be a good girl. I ain't going to lie to you about nothing." Mrs. was the ninth of ten children. She left eighth grade at the age of 12 years. Her full scale IQ was 62. According to a fam¬ ily member, she always gathered pictures of music stars and wanted to see movie actors. Occasionally, she hallucinated the voices of both men and women emanating from the walls. On psy¬ chological testing, there was also evidence of psychosis. Mrs. B's delusion proved impervious to reason and remained un¬ modified following treatment with a major tranquilizer. Case 4.-Miss S, 53 years old, was dignified, attractive, and welldressed, almost the stereotyped picture of a southern lady. She stated that acquaintances had informed her that the minister of the church she attended was in love with her. Her response, so she related, was to laugh and insist that he must still be in love with the woman to whom he had been married for 40 years. To this statement, the acquaintances supposedly responded, "He isn't. He wants to find out whether you will marry him or not." After agreeing to accept the proposal, she went on to describe their plans: a trip to France where they would live in his villa, with time spent on the Mediterranean on the yacht he would buy her.
Miss S had been hospitalized twice previously, the first time 25 years before for five months (treated with insulin coma and electroshock therapy) and the second time one year before. In most respects, Miss S's conversation seemed entirely appro¬ priate. Only a few selected questions would trigger her delusional thinking. For example, when asked about difficulties with neigh¬ bors, she related the following story: "He (the man next door) had these little lights that would go from He would drive me up the wall every night by room to room. shining the light into my eyes. Then he would say, guess I'll have to kill S (the patient)'.... The other night I was sitting in the and he said, 'Doesn't living room and I had on a pair of shorts she have the most beautiful legs you ever saw?' I had a sweater He then kept say¬ and I just reached over and put it on my lap ing, wish S would go to bed?' His wife asked, 'Why do you want S to go to bed?' He said, 'Because I want to see her undressed.' Of course I settled down on the couch for the night. Finally someone and I guess they shot the man. They said they called the police shot and killed him, but I don't believe it because I haven't seen anything in the paper about it." Several years had passed since Miss S's last date with a man. She described herself as "just another nondescript American." She suggested that the minister may have thought that she was lonely. She had been a binge drinker and had been drinking prior to this hospitalization. In speaking of the minister, she com¬ mented that everyone admired him. "He is just a marvelous per¬ son." She also stated that she was getting ready to move her clothes to his house. Miss S was an only child who lost her mother before she was 2 years old and her father before she was 10. She was raised by a maiden aunt who cared for her and indulged her. Miss S and the aunt continued to live together until the aunt's death at the age of 90, three years prior to this hospitalization. Case 5.—Not all instances of de Clérambault syndrome come to psychiatric attention. While arranging for the disposition of one of our patients, we were told about a similar case known to a com¬ munity agency. A 70-year-old woman, described as "neat, clean, small" and said to be almost blind, had traveled repeatedly to Washington, DC, and once to Kansas City, Mo, to wait for a wellknown singer to come to marry her. She claimed to be engaged to him. Contact with us was refused on the grounds that A (the singer) would be pleased to tell us anything about the "patient" we wanted to know. ...
.
.
.
...
...
COMMENT If patients with de Clérambault syndrome were all teenagers whose romantic notions shaped private fan¬
tasies rather than determined public actions, little atten¬ tion would be paid to them. Such fantasies, fostered by personal development forces, would not in themselves create an unusual situation. What makes the situation no¬ table is the fact that the fantasies are not contained within the mind by an intact ego; instead, they are drama¬ tized in real life, casting an unsuspecting and usually un¬ willing man of some importance in the role of the lover. If placed on a scale, erotomania lies beyond hetero¬ sexual love that begins with a school girl's fantasies, pro¬ gresses to infatuation, and then ultimately to mutual and abiding affection. In erotomania, the focus is not on what the woman feels for her would-be lover but on the feelings she imputes to him; not on how she loves him but on how he loves her. A primary (or pure) form of erotomania has been differ¬ entiated from a secondary form that is superimposed on a preexisting paranoid psychosis. Both clinical pictures, however, are actually subtypes of other disorders, the pri-
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mary form a subtype of paranoid state and the secondary form of paranoid schizophrenia. In the former, the psy¬ chopathological disorder is limited almost entirely to eroto¬ mania with associated delusions, while in the latter, it includes many other thought disorders, sometimes long predating the erotomania. The first three patients de¬ scribed here clearly fit the diagnosis of paranoid schizo¬ phrenia, whereas the condition of the fourth patient prob¬ ably fits the diagnosis of paranoid state. As previously mentioned, the combinations of de Clé¬ rambault syndrome and Capgras syndrome and of de Clé¬ rambault syndrome and folie à deux have been reported. In discussing the former combination, Sims and White3 stated, "It is considered that these two syndromes are de¬ scriptions of a specific type of delusional content and are not distinct disease entities." In our view, too, de Clérambault syndrome is not a distinct entity. Rather, it is a particular delusional configuration, a subtype usually of paranoid schizophrenia, less often of a paranoid state. Delusional thinking, which may lead to bizarre behav¬ ior, results from some change in or defect of the ego. The specific content of the delusion, however, is largely shaped by life experiences that probably result in a feeling of being unloved, or, perhaps even worse, unloveable. Three of the four women described here were physically unat¬ tractive, intellectually limited, and socially, and probably sexually, inhibited. One also had severely impaired vision, another was mentally retarded, and a third was alcoholic. It is easy to understand how they might attempt to over¬ come narcissistic blows by turning to grandiose fantasies. What better way for a woman to combat her poor image than by imagining that an important man finds her irre¬
sistible? Since the descriptions of the physical, intellectual, and social characteristics of women with de Clérambault syn¬ drome in the psychiatric literature are sketchy, it is diffi¬ cult to know how many of them were like the three in our sample. Several women, however, had been married and had children, and at least one, like the fourth woman in our series, was described as pleasant and attractive. The possibility remains, nevertheless, that narcissistic blows still served to shape the erotomania. As is well known, even an attractive woman may struggle with a poor body image and self-concept, the product of early traumatic ex¬ periences. Under circumstances when she feels rejected, the old picture may come into sharp focus. Raskin and Sullivan5 noted that in both of their patients "the delusional system seemed to arise around separation from their husbands and was exacerbated by the termi¬ nation of treatment with their therapists." In both in¬ stances, according to the authors, there were hints that the symptoms served to ward off depression and loneli¬ ness.
Since patients with de Clérambault syndrome are not candidates for insight-oriented psychotherapy, it is only possible to speculate on the psychodynamic factors that shape the content of the delusion. It has been suggested that the love involved may be self-love, denied and pro¬ jected onto a man.6 This mechanism, based on the infor¬ mation available, does not seem plausible. If projection is involved—but, as previously stated, we believe erotomania results from grandiosity and not projection—it is the pro-
of the woman's love of a prominent man, not of self-love. Instead of stating that she loves him, she im¬ putes her feelings of love to him and states that he loves her. In paranoid disorders, the projection of feelings of hostility is easy to understand; the projection of feelings of affection, whether of self-love or the love of another, is difficult to understand. Negative or unacceptable feelings are often disowned, not positive or acceptable ones. It has also been suggested that the heterosexual attach¬ ment, delusional in nature, is substituted for denied un¬ conscious homosexual impulses.6 This thesis, which has little face-value validity, is not supported by our ad¬ mittedly limited clinical data. Pearce,4 who reported on a patient with de Clérambault syndrome and folie à deux, stated, "With the revolution¬ ary socio-cultural changes that have taken place in the Western World over the last half century coupled with the it far greater freedom of expression in sexual matters seems likely that this particular syndrome will become an even greater rarity than it is at the moment." Since the content of the delusion, in our view, is shaped mainly by an intrapsychic struggle, it seems unlikely that the syn¬ drome will become a greater rarity. Some might question how uncommon de Clérambault syndrome actually is today. Its seeming rarity may indi¬ cate only that relatively few psychiatrists place a special label on this delusional state. None of the four patients de¬ scribed here would have had conditions diagnosed as de Clérambault syndrome if the possibility had not been sug¬ gested by one of the authors (M.H.H.). Enoch et al,2 in commenting on the outcome in some
jection
...
stated; patients may bring
cases,
The
chaos to the lives of their
victims, who
These pa¬ tients may even be dangerous and may finish up by making an at¬ tempt on the life of their victim or members of his family. This is particularly liable to occur when the patient reaches the stage of resentment or hatred which replaces love, after repeated advances
usually give them
no
encouragement whatsoever.
.
.
are
.
unrequited.
Although none of our patients went on to this extreme, it is certainly easy to understand how others might. The delusions in de Clérambault syndrome may be held with much tenacity, persisting for years even when treated with psychotherapy and medication. Our finding in this respect is similar to that reported by others. Jeannette . Ringold, PhD, assisted in this sections of de Clérambault's writings.
investigation by translating
References 1. de Cl\l=e'\rambaultGG: Oeuvre Psychiatrique. Paris, Presses Universitaires de France, 1942. 2. Enoch MD, Trethowan WH, Barker JC: Some Uncommon Psychiatric Syndromes. Bristol, England, John Wright & Sons Ltd, 1967. 3. Sims A, White A: Coexistence of the Capgras and de Cl\l=e'\rambaultsyndromes: A case history. Br J Psychiatry 123:635-
637, 1973.
4. Pearce A: de Cl\l=e'\rambaultsyndrome associated with folie \l=a'\ deux. Br J Psychiatry 121:116, 1972. 5. Raskin DE, Sullivan KE: Erotomania. Am J Psychiatry 131:1033-1035, 1974. 6. Cameron N: Paranoid conditions and paranoia, in Arieti S (ed): American Handbook of Psychiatry. New York, Basic Books Inc, 1959, pp 525-526.
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or
de Cl\l=e'\rambaultSyndrome
Marc H. Hollender, MD, Alfred S. Callahan III, MD \s=b\ De Cl\l=e'\rambaultfocused attention on a syndrome in which a has the delusional belief that a man, usually of higher social status and considerably older, is much in love with her. If the pawoman
tient's romantic ideas shaped private fantasies instead of determined public behavior, there would be little cause for concern. The situation becomes critical when the fantasies are dramatized in real life with an unsuspecting and usually unwilling man cast in the role of the lover. The woman dwells on the feelings she ascribes to her "suitor." Such delusional thinking, resulting from an ego defect and producing bizarre actions, may be shaped largely by feelings of being unloved or even unloveable; a narcissistic blow is overcome by a grandiose fantasy. Cases in which erotomania is prominent are usually
diagnosed as paranoid state or paranoid schizophrenia. (Arch Gen Psychiatry 32:1574-1576, 1975)
psychose passionnelle, generally Erotomania de Clérambault syndrome, described de Clérambault.1 his
known in detail by According to description, the pa¬ tient, almost always a woman, has a delusional belief that a man, usually considerably older, is much in love with her. The man is likely to occupy a prominent position or be a or
as
was
public figure.
In this report, we will comment on the relationship of erotomania to love, briefly refer to the literature on de Clérambault syndrome, describe four additional cases, and, finally, discuss the nature of the syndrome diagnostically and psychodynamically. NOTES ON THE LITERATURE
Many stories deal with infatuation and passionate love but none is concerned with the grotesque drama we label erotomania. Although occasional instances of erotomania had been observed by psychiatrists, not until de Clérambault's publication was attention focused on it as a spe¬ cific syndrome. Two forms of de Clérambault syndrome have been dif¬ ferentiated: a pure or primary form in which the onset is sudden and the disorder is limited entirely to the eroto¬ mania, and a secondary form in which the onset is gradual and the process superimposed on a preexisting psychosis of a paranoid type. The fundamental assumption made by the woman with erotomania, according to de Clérambault, is that it is the man "who started it all and who loves most or who alone loves." Secondary themes regarded as obvious are that the man can neither find happiness nor be complete without the patient. Moreover, he is free to marry her because his marriage is not valid. De Clérambault also delineated secondary themes that can be demonstrated: The patient watches and protects the man and carries on indirect conversations with him. He makes advances to her using the phenomenal resources at his disposal; his conduct toward her, however, is paraAccepted
publication Feb 14, 1975. Department of Psychiatry, Vanderbilt University School Medicine, Nashville, Tenn. From the
for
of
Reprint requests to the Department of Psychiatry, Vanderbilt University School of Medicine, A-2215 Medical Center, Nashville, TN 37232 (Dr. Hollender).
doxical and contradictory. The response evoked in others by their romance is almost universal acceptance. Para¬ doxical conduct is of the greatest importance and never lacking, but the other themes are seldom all present in one
patient.
In de Clérambault's book, he described five cases of erotomania and referred to one other. Since 1942, fewer than 15 additional patients with the syndrome have been described in the psychiatric literature. The cases prior to 1967 have been reviewed by Enoch et al,2 who added three of their own. Sims and White3 described a patient with both de Clérambault and Capgras syndromes, and Pearce4 described one in whom de Clérambault syndrome and folie à deux were combined. Raskin and Sullivan5 recently re¬ ported two cases in which the man in the delusion was the
patient's psychiatrist.
REPORT OF CASES Case 1.—Miss G announced to her fellow workers at a medical school that she was getting married. Everyone was happy for her, and plans were made to give her a shower. When someone finally asked who was "the lucky man," the office workers were flabber¬ gasted to be informed that it was the chairman of the Department of Ophthalmology, a distinguished physician, who, as far as any of them knew, was happily married. When asked for more details, Miss G responded that Dr. would not be marrying her for a few weeks, but they planned to spend the coming weekend in "sexual expression of their love." Miss G was 42 years old, small, unattractive, and 90% blind due to uveitis dating back to childhood. Her first psychiatric hospital¬ ization 11 years before was for "a complex paranoid delusional system," including the notion that her mother and two sisters, with whom she lived, were trying to poison her. A year later, she was again hospitalized when she locked her family out of the house and called the police for protection. Shortly after announcing the name of the man she planned to marry, Miss G engaged in sexual talk out of character for her. She mentioned men she would "take care of" and stated that she had heard voices of men asking to make love to her. She went to a dance where she met a man with whom she spent the weekend. During this (her first) sexual relationship, she called her partner by the name of the ophthalmologist. Case 2.-Miss D went to the home of a television newscaster whom she had never met and announced that they were to be mar¬ ried. She then attempted to eject the newscaster's wife from the home. The police were summoned, and Miss D was taken to a psy¬ chiatric hospital. Miss D, 36 years of age, less than 1.5 meters tall, and strikingly unattractive, had been interested in watching television and had been doing practically nothing else for more than two years. She came to believe that the newsmen on the screen could see and hear her and that they sometimes spoke directly to her. Believing that they were romantically involved with her, she repeatedly tele¬ phoned them. In response to complaints, the Sheriff's Department threatened to remove her telephone, after which her father dis¬ connected the telephone whenever he left the house. Miss D's only previous psychiatric hospitalization occurred when she was 17 years old. According to the report, she was hav¬ ing difficulties at school and at home and refused to eat. She was fed by gastric tube and given ten electroshock treatments with satisfactory results.
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Miss D was the middle of three daughters; one was three years older and the other seven years younger. Unlike her sisters, she developed no interest in cooking or sewing and refused to help with housework. In school she made poor grades, had no friends, and was subjected to ridicule by classmates, probably mainly be¬ cause of her short stature and obesity. Following graduation from high school, Miss D entered business
college where, after three or four weeks, she suddenly became in¬
fatuated with a young man and refused to leave him. To get away from her, he promised to meet her that evening but did not do so. The following day, Miss D was so upset that she had to be forcibly removed from school by her father. Later she insisted that she had married the young man, become pregnant, and had a mis¬
carriage.
Efforts at vocational rehabilitation were unsuccessful and Miss D worked only a few days. She lived on a farm with her parents until her mother died, and afterwards lived alone with her father. Her only outside activity was weekly attendance at a church ser¬ vice. At home she neither helped with cleaning nor food prepara¬ tion. Various phenothiazines, given during a period of months, did not alter Miss D's delusion. While hospitalized, long periods of withdrawal alternated with episodes of hyperactivity during which her mood was elevated, she was suspicious, and possibly hallucinated. first came to psychiatric attention when Case 3.-Mrs. brought to a state hospital by the police whom she called seeking assistance in locating a well-known country music star. The bus trip from rural Kentucky to Nashville was her fourth, all made in response to messages "received" from this musician asking her to come so they could be married. Mrs. B, a 36-year-old woman, looked much older. Her "romance" extended for a period of 15 years. She stated that when she first met the musician at a department store, hugged him, and asked him to go home with her, his response was to cry. Although her trips to Nashville were unsuccessful in one sense, according to her they were successful in another for they had saved the lives of several Grand Ole Opry stars. These stars had been threatened by and were capable of great evil. women who had tormented Mrs. They once caused her clothes to ignite spontaneously (although she escaped without injury), and made a toad frog jump out of her new record player. Mrs. had never been involved sexually with anyone other than her husband to whom she had been married for six years, until their separation a year before. She explained that she had "got right with the Lord" when she was 14 and tried to lead "a good Christian life." She added, "I love C good enough to go to bed with him, but I would want to get married to him first. I was brought up to be a good girl. I ain't going to lie to you about nothing." Mrs. was the ninth of ten children. She left eighth grade at the age of 12 years. Her full scale IQ was 62. According to a fam¬ ily member, she always gathered pictures of music stars and wanted to see movie actors. Occasionally, she hallucinated the voices of both men and women emanating from the walls. On psy¬ chological testing, there was also evidence of psychosis. Mrs. B's delusion proved impervious to reason and remained un¬ modified following treatment with a major tranquilizer. Case 4.-Miss S, 53 years old, was dignified, attractive, and welldressed, almost the stereotyped picture of a southern lady. She stated that acquaintances had informed her that the minister of the church she attended was in love with her. Her response, so she related, was to laugh and insist that he must still be in love with the woman to whom he had been married for 40 years. To this statement, the acquaintances supposedly responded, "He isn't. He wants to find out whether you will marry him or not." After agreeing to accept the proposal, she went on to describe their plans: a trip to France where they would live in his villa, with time spent on the Mediterranean on the yacht he would buy her.
Miss S had been hospitalized twice previously, the first time 25 years before for five months (treated with insulin coma and electroshock therapy) and the second time one year before. In most respects, Miss S's conversation seemed entirely appro¬ priate. Only a few selected questions would trigger her delusional thinking. For example, when asked about difficulties with neigh¬ bors, she related the following story: "He (the man next door) had these little lights that would go from He would drive me up the wall every night by room to room. shining the light into my eyes. Then he would say, guess I'll have to kill S (the patient)'.... The other night I was sitting in the and he said, 'Doesn't living room and I had on a pair of shorts she have the most beautiful legs you ever saw?' I had a sweater He then kept say¬ and I just reached over and put it on my lap ing, wish S would go to bed?' His wife asked, 'Why do you want S to go to bed?' He said, 'Because I want to see her undressed.' Of course I settled down on the couch for the night. Finally someone and I guess they shot the man. They said they called the police shot and killed him, but I don't believe it because I haven't seen anything in the paper about it." Several years had passed since Miss S's last date with a man. She described herself as "just another nondescript American." She suggested that the minister may have thought that she was lonely. She had been a binge drinker and had been drinking prior to this hospitalization. In speaking of the minister, she com¬ mented that everyone admired him. "He is just a marvelous per¬ son." She also stated that she was getting ready to move her clothes to his house. Miss S was an only child who lost her mother before she was 2 years old and her father before she was 10. She was raised by a maiden aunt who cared for her and indulged her. Miss S and the aunt continued to live together until the aunt's death at the age of 90, three years prior to this hospitalization. Case 5.—Not all instances of de Clérambault syndrome come to psychiatric attention. While arranging for the disposition of one of our patients, we were told about a similar case known to a com¬ munity agency. A 70-year-old woman, described as "neat, clean, small" and said to be almost blind, had traveled repeatedly to Washington, DC, and once to Kansas City, Mo, to wait for a wellknown singer to come to marry her. She claimed to be engaged to him. Contact with us was refused on the grounds that A (the singer) would be pleased to tell us anything about the "patient" we wanted to know. ...
.
.
.
...
...
COMMENT If patients with de Clérambault syndrome were all teenagers whose romantic notions shaped private fan¬
tasies rather than determined public actions, little atten¬ tion would be paid to them. Such fantasies, fostered by personal development forces, would not in themselves create an unusual situation. What makes the situation no¬ table is the fact that the fantasies are not contained within the mind by an intact ego; instead, they are drama¬ tized in real life, casting an unsuspecting and usually un¬ willing man of some importance in the role of the lover. If placed on a scale, erotomania lies beyond hetero¬ sexual love that begins with a school girl's fantasies, pro¬ gresses to infatuation, and then ultimately to mutual and abiding affection. In erotomania, the focus is not on what the woman feels for her would-be lover but on the feelings she imputes to him; not on how she loves him but on how he loves her. A primary (or pure) form of erotomania has been differ¬ entiated from a secondary form that is superimposed on a preexisting paranoid psychosis. Both clinical pictures, however, are actually subtypes of other disorders, the pri-
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mary form a subtype of paranoid state and the secondary form of paranoid schizophrenia. In the former, the psy¬ chopathological disorder is limited almost entirely to eroto¬ mania with associated delusions, while in the latter, it includes many other thought disorders, sometimes long predating the erotomania. The first three patients de¬ scribed here clearly fit the diagnosis of paranoid schizo¬ phrenia, whereas the condition of the fourth patient prob¬ ably fits the diagnosis of paranoid state. As previously mentioned, the combinations of de Clé¬ rambault syndrome and Capgras syndrome and of de Clé¬ rambault syndrome and folie à deux have been reported. In discussing the former combination, Sims and White3 stated, "It is considered that these two syndromes are de¬ scriptions of a specific type of delusional content and are not distinct disease entities." In our view, too, de Clérambault syndrome is not a distinct entity. Rather, it is a particular delusional configuration, a subtype usually of paranoid schizophrenia, less often of a paranoid state. Delusional thinking, which may lead to bizarre behav¬ ior, results from some change in or defect of the ego. The specific content of the delusion, however, is largely shaped by life experiences that probably result in a feeling of being unloved, or, perhaps even worse, unloveable. Three of the four women described here were physically unat¬ tractive, intellectually limited, and socially, and probably sexually, inhibited. One also had severely impaired vision, another was mentally retarded, and a third was alcoholic. It is easy to understand how they might attempt to over¬ come narcissistic blows by turning to grandiose fantasies. What better way for a woman to combat her poor image than by imagining that an important man finds her irre¬
sistible? Since the descriptions of the physical, intellectual, and social characteristics of women with de Clérambault syn¬ drome in the psychiatric literature are sketchy, it is diffi¬ cult to know how many of them were like the three in our sample. Several women, however, had been married and had children, and at least one, like the fourth woman in our series, was described as pleasant and attractive. The possibility remains, nevertheless, that narcissistic blows still served to shape the erotomania. As is well known, even an attractive woman may struggle with a poor body image and self-concept, the product of early traumatic ex¬ periences. Under circumstances when she feels rejected, the old picture may come into sharp focus. Raskin and Sullivan5 noted that in both of their patients "the delusional system seemed to arise around separation from their husbands and was exacerbated by the termi¬ nation of treatment with their therapists." In both in¬ stances, according to the authors, there were hints that the symptoms served to ward off depression and loneli¬ ness.
Since patients with de Clérambault syndrome are not candidates for insight-oriented psychotherapy, it is only possible to speculate on the psychodynamic factors that shape the content of the delusion. It has been suggested that the love involved may be self-love, denied and pro¬ jected onto a man.6 This mechanism, based on the infor¬ mation available, does not seem plausible. If projection is involved—but, as previously stated, we believe erotomania results from grandiosity and not projection—it is the pro-
of the woman's love of a prominent man, not of self-love. Instead of stating that she loves him, she im¬ putes her feelings of love to him and states that he loves her. In paranoid disorders, the projection of feelings of hostility is easy to understand; the projection of feelings of affection, whether of self-love or the love of another, is difficult to understand. Negative or unacceptable feelings are often disowned, not positive or acceptable ones. It has also been suggested that the heterosexual attach¬ ment, delusional in nature, is substituted for denied un¬ conscious homosexual impulses.6 This thesis, which has little face-value validity, is not supported by our ad¬ mittedly limited clinical data. Pearce,4 who reported on a patient with de Clérambault syndrome and folie à deux, stated, "With the revolution¬ ary socio-cultural changes that have taken place in the Western World over the last half century coupled with the it far greater freedom of expression in sexual matters seems likely that this particular syndrome will become an even greater rarity than it is at the moment." Since the content of the delusion, in our view, is shaped mainly by an intrapsychic struggle, it seems unlikely that the syn¬ drome will become a greater rarity. Some might question how uncommon de Clérambault syndrome actually is today. Its seeming rarity may indi¬ cate only that relatively few psychiatrists place a special label on this delusional state. None of the four patients de¬ scribed here would have had conditions diagnosed as de Clérambault syndrome if the possibility had not been sug¬ gested by one of the authors (M.H.H.). Enoch et al,2 in commenting on the outcome in some
jection
...
stated; patients may bring
cases,
The
chaos to the lives of their
victims, who
These pa¬ tients may even be dangerous and may finish up by making an at¬ tempt on the life of their victim or members of his family. This is particularly liable to occur when the patient reaches the stage of resentment or hatred which replaces love, after repeated advances
usually give them
no
encouragement whatsoever.
.
.
are
.
unrequited.
Although none of our patients went on to this extreme, it is certainly easy to understand how others might. The delusions in de Clérambault syndrome may be held with much tenacity, persisting for years even when treated with psychotherapy and medication. Our finding in this respect is similar to that reported by others. Jeannette . Ringold, PhD, assisted in this sections of de Clérambault's writings.
investigation by translating
References 1. de Cl\l=e'\rambaultGG: Oeuvre Psychiatrique. Paris, Presses Universitaires de France, 1942. 2. Enoch MD, Trethowan WH, Barker JC: Some Uncommon Psychiatric Syndromes. Bristol, England, John Wright & Sons Ltd, 1967. 3. Sims A, White A: Coexistence of the Capgras and de Cl\l=e'\rambaultsyndromes: A case history. Br J Psychiatry 123:635-
637, 1973.
4. Pearce A: de Cl\l=e'\rambaultsyndrome associated with folie \l=a'\ deux. Br J Psychiatry 121:116, 1972. 5. Raskin DE, Sullivan KE: Erotomania. Am J Psychiatry 131:1033-1035, 1974. 6. Cameron N: Paranoid conditions and paranoia, in Arieti S (ed): American Handbook of Psychiatry. New York, Basic Books Inc, 1959, pp 525-526.
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