On interview, the patient presented well, with a normal affect commensurate with having been held on remand in an overcrowded prison. Because an initial examination at the behest of his solicitor had produced a diagnosis of schizophrenia, cognitive, physical, and laboratory examinations were instigated, but proved normal, as was the EEG. There was no disorder of form of thought, and hallucinations were absent. There was no evidence of other Schneiderian front-rank symptoms for schizophrenia (Schneider 1959). P showed above-average visuo-spatial abilities, abstraction, and concentration. His WAIS scores were: verbal 130, performance 110, full-scale 120. In the Benton test he showed no cognitive impairment. On the Weschler Memory Scale his short-term memory was intact for simple and complex material.
P stated that he knew R still loved him, as was evidenced by his having intervened to save P from killing himself. Also, at a procedural hearing in court, P had received a “message of love” from R. P regretted his attempt on R’s life and felt that whatever lay ahead of him was a test, both of his faith in God and of his love for R. The patient was articulate and coherent in these assertions. The impression formed was of a well-encapsulated delusional system. Chemotherapy (5mg pimozide daily) and gently challenging insight-directed therapy were prescribed, but over a six-month period were observed to have no impact. Eventually the court ruled that P should be held indefinitely at a secure mental hospital. P was seen six months after admission, and despite a change of chemotherapy, the delusions appeared unremitted, P asserting as confidently as before his belief that R’s love for him was undiminished and that through his suffering he would one day bring R to God. P writes daily to R from hospital. His letters are collected by the nursing staff but are not forwarded, in order to protect R from further distress. The patient will continue to be followed.
Discussion
Ellis & Mellsop (1985) concluded that de Clerambault’s syndrome is an etiologically heterogeneous disorder. Theories of etiology have encompassed alcoholism, abortion, postamphetamine depression, epilepsy, head trauma, and neurological disorders. None of these is relevant in this case. Reviewing various descriptions of the premorbid personality in pure cases, Mullen & Pathe summarize by invoking “a socially inept individual isolated from others, be it by sensitivity, suspiciousness, or assumed superiority. These people tend to be described as living socially empty lives … the desire for a relationship is balanced by a fear of rejection or a fear of intimacy, both sexual and emotional.”
The important change in this patient’s life was the inheritance of his mother’s house; a lifetime’s failure to form close relationships culminated in a new arrangement whereby P, freed from the necessity of earning his living, was able to sever his remaining contacts with colleagues at the language school and his landlady and withdraw. It was at this time of increased loneliness that he became aware that he faced a test. On a country walk he was initiated into a makeshift community of passersby struggling to tether a balloon caught in strong winds. Such a transformation, from a “socially empty” life to intense teamwork, may have been the dominating factor in precipitating the syndrome, for it was when the drama was over that he became “aware” of R’s love; the inception of a delusional relationship ensured that P would not have to return to his former isolation. Arieti & Meth (1959) have suggested that erotomania may act as a defense against depression and loneliness by creating a full intrapsychic world.
Also relevant to Mullen & Pathe’s profile is the patient’s fear of sexual intimacy. Questioned in interview about his erotic ambitions with regard to R, P was evasive and even offended. Although many male patients have specific and intrusive sexual designs on their subjects, others, as well as many female patients, have self-protectively vague notions of what they actually want from the love-object. Enoch & Trethowan quote Esquirol (1845), who observed that “the subjects of erotomania never pass the limits of propriety, they remain chaste.” And Bucknell & Tuke, writing in the mid-nineteenth century, associated “erotomania proper” with a “sentimental form.”
This case confirms the reports of some commentators (Trethowan 1967; Seeman 1978; Mullen & Pathe) on the relevance of absent or missing fathers. It must remain a matter for conjecture at this stage whether R, aged forty-seven, represented a father figure to P, or whether, as a successful, socially integrated individual, he represented an ideal to which P aspired.
Strong associations have been made, especially in recent work, between male erotomania and dangerousness (Gagne & Desparois 1995; Harmon, Rosner, & Owens 1995; Menzies, Fedoroff, Green, & Isaacson 1995). Hospitalization may be necessary in order to protect the love-object from assault by the patient (Enoch & Trethowan; Mullen & Pathe). In this case, where criminal charges had been brought, the issue of dangerousness, particularly in regard to outcome, was central. P stationed himself in a restaurant to watch the contract killing of R. When the attack went wrong, he tried to intervene. Later he showed remorse and redirected the violence against himself in the presence of R and M. As long as P’s delusion continued unremitted, his potential for violence remained, and admission to a secure hospital was appropriate.
Lovett Doust & Christie, in their review of eight cases, suggest that “a close relationship may be posited between some pathological aspects of love and the tenets of the church for religious believers.” It is reasonable to assume that the inhibitions placed on sexual expression by certain sects could be implicated in some pathologies. Furthermore, celibate priests, by reason of their unavailability, may be favored subjects for de Clerambault sufferers. Other ministers of the church have been subjects of erotic delusions due to the status they enjoy within congregations (Enoch & Trethowan). However, P belonged to no particular denomination or sect, and the object of his delusion was an atheist. P’s religious beliefs pre-dated the psychopathology, but those beliefs intensified once he had moved into his mother’s house and his isolation was complete. His relationship with God was personal, and served as a substitute for other intimate relationships. The mission to “bring R to God” may be seen as an attempt to achieve a fully integrated intrapsychic world in which internalized religious sentiment and delusional love became one. In interview, P insisted that he had never heard the voice of God, nor seen any manifestations of his presence. He became “aware” of God’s will or purpose in the generalized fashion of many people of intense religious persuasion. A search of the literature did not reveal another case of pure erotomania in which religious feeling or a love of God is similarly implicated.
Conclusion
P’s condition satisfies all but one of the diagnostic criteria for the primary form of de Clerambault’s syndrome suggested by Enoch & Trethowan and referred to above: P experiences a delusional conviction of being in amorous communication with another person, R, who was the first to fall in love and make advances. The onset was sudden. The object of P’s delusion remains unchanged. He is able to rationalize R’s paradoxical behavior, and the course looks set to be chronic. P suffers no hallucinations or cognitive defects. (However, although it could be said that R is of “higher rank,” P could not have known this at their first meeting.) This degree of diagnostic concurrence, and the fact that P shares a number of premorbid characteristics with other patients, lend weight to the view that the syndrome is a nosological entity.
With regard to outcome, most commentators have leaned toward pessimism. De Clerambault described cases of pure erotomania that lasted without significant change for between seven and thirty-seven years. A review of the literature since suggests that this is indeed a most lasting form of love, often terminated only by the death of the patient.
The victims of de Clerambault patients may endure harassment, stress, physical and sexual assault, and even death. While in this case R and M were reconciled and later successfully adopted a child, some victims have had to divorce or emigrate, and others have needed psychiatric treatment because of the distress the patients have caused them. It is therefore important to continue to refine the diagnostic
criteria and that these become broadly known by professionals. Patients with delusional disorders are unlikely to seek help, since they do not regard themselves as ill. Their friends and family may also be reluctant to see them in these terms, for as Mullen & Pathe observe, “the pathological extensions of love not only touch upon but overlap with normal experience, and it is not always easy to accept that one of our most valued experiences may merge into psychopathology.”
References
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Bucknell, J. C. and Tuke, D. H. 1882. A Manual of Psychological Medicine. 2d ed. Churchill, London.
de Clérambault, C. G. 1942. Les Psychoses passionelles. In Oeuvres Psychiatriques, pp. 315–22. Presses Universitaires, Paris.
El-Assra, A. 1989. “Erotomania in a Saudi Woman.” British Journal of Psychiatry 153: 830–33.
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Enoch, M. D. and Trethowan, W. H. 1979. Uncommon Psychiatric Syndromes. John Wright, Bristol.
Esquirol, J.E.D. 1845. Mental Maladies: A Treatise on Insanity, trans. R. de Saussure, 1965. Hafner, New York.
Gagne, P. and Desparois, L. 1995. L’erotomanie male: un type de harcelement sexuel dangereux. Revue Canadienne de Psychiatrie 40: 136–41.
Harmon, R. P., Rosner, R. and Owens, H. 1995. Obsessional harassment in a criminal court population. Journal of Forensic Sciences 42: 188–96.
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Lovett Doust, J. W. and Christie, H. 1978. The pathology of love: some clinical variants of de Clérambault’s syndrome. Social Science and Medicine 12: 99–106.
Menzies, R. P., Federoff, J. P., Green, C. M. and Isaacson, K. 1995. Prediction of dangerous behaviour in male erotomania. British Journal of Psychiatry 166: 529–36.
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Appendix II
Letter collected from Mr. J. Parry, written toward end of third year after admittance. Original filed with patient’s notes. Photocopy forwarded to Dr. R. Wenn at his request.
Tuesday
Dear Joe,
I was awake at dawn. I slipped out of bed, put on my dressing gown, and without disturbing the night staff went and stood by the east window. See how willing I can be when you’re kind to me! You’re right, when the sun comes up behind the trees they turn black. The twigs at the very top are tangled against the sky, like the insides of some machine with wires. But I wasn’t thinking about that, because it was a cloudless day and what rose up above the treetops ten minutes later was nothing less than the resplendence of God’s glory and love. Our love! First bathing me, then warming me through the pane. I stood there, shoulders back, my arms hanging loosely at my sides, taking deep breaths. The old tears streaming. But the joy! The thousandth day, my thousandth letter, and you telling me that what I’m doing is right! At first you didn’t see the sense of it, and you cursed our separation. Now you know that every day I spend here brings you one tiny step closer to that glorious light, His love, and the reason you know it now when you didn’t before is because you are close enough to feel yourself turning helplessly and joyfully toward His warmth. No going back now, Joe! When you are His, you also become mine. This happiness is almost an embarrassment to me. I’m meant to be a prisoner. The bars are on the windows, the ward is locked at night, I spend my days and nights in the company of the shuffling, muttering, dribbling idiots, and the ones who aren’t shuffling have to be restrained. The nurses, especially the men, are brutes who really ought to be inmates and have somehow scraped through to the other side. Cigarette smoke, windows that won’t open, urine, TV ads. That’s the world I’ve described to you a thousand times. I ought to be going under. Instead I feel more purpose than I’ve ever known in my life. I’ve never felt so free. I’m soaring, I’m so happy, Joe! If they’d known how happy I was going to be here, they would have let me out. I have to stop writing to hug myself. I’m earning our happiness day by day and I don’t care if it takes me a lifetime. A thousand days—this is my birthday letter to you. You know it already, but I need to tell you again that I adore you. I live for you. I love you. Thank you for loving me, thank you for accepting me, thank you for recognizing what I am doing for our love. Send me a new message soon, and remember—faith is joy.
Jed
Ian Mcewan, Enduring Love
(Series: # )
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