De Clèrambault's syndrome: second case study in Portuguese

Abstracts

A síndrome de De Clèrambault, ou erotomania, é a convicção delirante que um paciente pode desenvolver de estar sendo amado por alguém de posição social muito proeminente. A síndrome está alocada entre os transtornos delirantes. Relata-se o caso de uma paciente de 46 anos de idade cujos delírios persistem há 32 anos, mantendo um médico como núcleo de seu sistema delirante.

Síndrome de Clèrambault; erotomania; psicose; delírio; psicopatologia; transferência; relações médico-paciente

CASE REPORT

De Clèrambault's syndrome: second case study in Portuguese

El síndrome de De Clèrambault: el segundo estudio de caso en portugués

Luís Carlos Calil^I; João Ricardo Terra^II

^IProfessor of Psychiatry, Faculdade de Medicina do Triângulo Mineiro (FMTM), Uberaba, MG, Brazil. Master's Degree in Mental Health, FMRP-USP, Brazil

^IIVolunteer physician in the Psychiatry course, FMTM, Uberaba, MG, Brazil

^{Correspondence}

ABSTRACT

De Clèrambault's syndrome or erotomania is a condition in which a patient develops a delusional belief of being loved by someone belonging to a higher social status. The syndrome is classified as a delusional disorder. The present study describes the case of a 46-year old woman whose symptoms have persisted for 32 years. The focus of her delusional system is a medical practitioner.

Keywords: Clèrambault's syndrome, erotomania, psychosis, delusion, psychopathology, transference, doctor-patient relationship.

RESUMEN

El síntoma básico del síndrome de De Clèrambault o erotomanía, es la convicción delirante que un enfermo puede desarrollar de estar siendo amado por otra persona de posición social más alta. Se ha clasificado la erotomanía entre los desórdenes delirantes. Se ha descrito el caso de una paciente de 46 años de edad cuyos síntomas persisten hace 32 años, manteniendo un médico como núcleo de su sistema delirante.

Palabras clave: Síndrome de Clèrambault, erotomanía, psicosis, delirio, psicopatología, transferencia, relación médico-paciente.

INTRODUCTION

Erotomania is the deluded conviction, on the part of the patient, that someone in an elevated social position is in love with them and is communicating this love to them by means of coded messages.^1,2 It occurs in a number of different cultures and its incidence is unknown.³

Erotomanic delusions may develop to satisfy the search for sexual experiences,² or as a means of adapting to personal difficulties in life.³ They also appear to be associated with neurological deficits that result in cognitive inflexibility,^4,5 and which progress chronically.⁶ After repeated rejections, the patient begins to retaliate against the object of their love, to stalk them and to attempt to enter into conversations with them, which they interpret delusionally.^7,8

De Clèrambault divides erotomania into a pure form, with rapid onset, and a secondary form with gradual onset.³ Seeman subdivides the syndrome into a fixed form, with persistent delusions, and a recurrent form.⁹

Ellis and Mellsop¹⁰ suggested operational criteria for the diagnosis of erotomania: rapid onset of delusions, a conviction that amorous communication has taken place, the loved object having a distinctive social position, who would have fallen in love first and begun romantic proceedings, the patient rationalizing the apparently paradoxical behavior of their love object, a chronic clinical course and, finally, no hallucinations.

The condition was included in the ICD-10 as a subtype of the Persistent Delusional Disorders (F22.0).¹¹ In the DSM-IV it appears among the Delusional Disorders, Erotomanic subtype (297.10).¹² It exhibits a poor response to both pharmaceutical and psychotherapy treatment.¹³ Neuroleptics are the most indicated drugs, while some studies indicate a good response to risperidone.⁵

This is the second report published in the medical literature in Portuguese3 (based on a search of the LILACS and MEDLINE databases, from 1982 and 1951 on, respectively).

CASE DESCRIPTION

A 46-year-old woman, receiving psychiatric therapy since the age of 40 by one of the authors of the present article. Her erotomanic delusions began at 14 when her father took her to see one of the city's preeminent doctors for a clinical condition.

She got married at 16, pregnant. She had two sons and a daughter and got divorced at 23 because her husband abused her physically. She worked as a seamstress for 14 years and has retired due to incapacity related to mental disorder.

She has previously been treated by three other psychiatrists. She was given phenothiazines, which sedated her and lead to her first absences from work. She gained 28 kilos and her body mass index (BMI), reached 37,3 kg/m², which made it harder for her to comply with subsequent treatments.

During the current treatment she presented depressive crises on a number of occasions, occasionally exhibiting suicidal ideation and sometimes elation. She claims to have a different vagina, photographs of which she says her former doctor had sold for large sums of money to be published in scientific books. She spoke of amorous affairs that she had had, with important men who courted her. More than anything she mentioned the doctor, the nucleus of her deluded ideation, who she says is constantly tracking her, flying over her house in airplanes or helicopters, hiring influential people to perform surveillance of her. She also claims that the doctor's wife sends people to rape and murder her.

She began to comply better with treatment with the prescription of risperidone whose profile is favorable as it does not sedate or promote weight gain. She takes two milligrams daily. She now does the housework, is doing water aerobics and her BMI is 28.6 kg/m². When asked about the doctor who had persecuted her, she still expresses great revulsion for the man who she says ruined her life, however, she does not have aggressive plans or thoughts that put her physical integrity at risk.

DISCUSSION

Freud,¹⁴ calls attention to the problems that doctors may encounter when managing transferential love and to its significance as a force resisting analytical treatment. When the patient's desires are reciprocated it is a great triumph for the patient, but of great prejudice to their treatment.

Nevertheless, Freud mentions that there is a class of women with whom the attempt to preserve erotic transference for the purposes of the analytical work, without satisfying it, will not be successful. "These are women with powerful passions who do not tolerate substitutes. They will feel humiliated and will not hesitate to revenge themselves for this".¹⁴ Is Freud referring to a group of deluded patients? Or could transferred love exist between the tenuous limits of neurotic defense and delusions?

Laplanche & Pontalis¹⁵ cite transference neurosis, an expression introduced by Jung, in opposition to psychosis, in which the libido is introverted or invested in the ego according to Abraham and Freud.¹⁵ These are narcissistic neuroses, which demand technical modifications in the approach, because they are intense and oscillating transferences.¹⁶

A cast of five proposals are therefore available for erotomania diagnosis:

1) The "pure form" of the disease described by De Clèrambault could be questioned as improbable because, since onset the delusions were organized and nuclear. The possibility that a latent delusional system hatches over time must be considered.

2) The fixed form described by Seeman refers to a schizoid profile, and his recurrent form, with its unstable course, refers to a histrionic personality.

3) Bipolar disorder is ruled out because the delusions are not secondary to the mood disturbances.

4) erotomania with schizophrenic symptoms.

5) erotomania as a chronic delusional disorder.

In the case described, when the delusions had onset, the patient may have idealized the doctor with omnipotent fantasies. Progressively the delusions gained structure, reinforced by the misfortunes of life.

The hostility manifested during initial appointments has been substituted by an acceptance of treatment. The patient comes spontaneously and pays for her own treatment. Despite the appointments not being frequent, which we see as a limiting factor, the interpretation of transference, the relationship with the current psychiatrist, and compliance with the risperidone, although below the desired dosage, can together make it possible, over the long term, for the patient to regain contact with reality in a non-delusional manner.

REFERENCES

Received on July 16, 2004.

Revised on September 21, 2004.

Accepted on October 06, 2004.

The present work was carried out as part of the course of Psychiatry at Faculdade de Medicina do Triângulo Mineiro (FMTM), Uberaba, MG, Brazil.

• 1. Gillet T, Eminson SR, Hassanyeh F. Primary and secondary erotomania: clinical characteristics and follow-up. Acta Psychiatr Scand. 1990;82(1):65-9.
• 2. Segal JH. Erotomania revisited: from Kraepelin to DSM-III-R. Am J Psychiatry. 1989;146(10):1261-6.
• 3. Jordan HW, Howe G. De Clèrambault's syndrome (erotomania): a review and case presentation. J Natl Med Assoc. 1980;72(10):979-85.
• 4. Fujii DE, Ahmed I, Takeshita J. Neuropsychologic implications in erotomania: two case studies. Neuropsychiatry Neuropsychol Behav Neurol. 1999;12(2):110-6.
• 5. Kelly BD, Kennedy N, Shanley D. Delusion and desire: erotomania revisited. Acta Psychiatr Scand. 2000;102(1):74-5.
• 6. Goldstein RL, Laskin AM. De Clerambault's syndrome (erotomania) and claims of psychiatric malpractice. J Forensic Sci. 2002;47(4):852-5.
• 7. Kennedy N, McDonough M, Kelly B, Berripos GE. Erotomania revisited: clinical course and treatment. Compr Psychiatry. 2002;43(1):1-6.
• 8. Ferrari Filho CA. Erotomania, considerações diagnósticas e relato de um caso. Rev Psiquiatr RS. 1993;15(2):117-22.
• 9. Seeman M. Delusional loving. Arch Gen Psychiatry. 1978;35:1265-7.
• 10. Ellis P, Mellsop G. De Clèrambault's syndrome - a nosological entity? Br J Psychiatry. 1985;146:90-5.
• ¹¹
  Organização Mundial da Saúde. Classificação de transtornos mentais e de comportamento da CID-10: descrições clínicas e diretrizes diagnósticas. Porto Alegre: Artes Médicas; 1993.
• ¹²
  Associação Americana de Psiquiatria. DSM-IV - manual diagnóstico e estatístico de transtornos mentais. 4ª ed. Porto Alegre: Artes Médicas; 1995.
• 13. Rudden M, Sweeney J, Frances A. Diagnosis and clinical course of erotomanic and other delusional patients. Am J Psychiatry. 1990;147(5):625-8.
• 14. Freud S. Observações sobre o amor transferencial (novas recomendações sobre a técnica da psicanálise III). In: Edição standard brasileira das obras de Sigmund Freud. Rio de Janeiro: Imago; 1977. v. XII. p. 208-21.
• 15. Laplanche J, Pontalis JB. Vocabulário da psicanálise. 9Ş ed. São Paulo: Martins Fontes; 1986. p. 397-400.
• 16. Rosenfeld HA. Impasse e interpretação: fatores terapêuticos e antiterapêuticos no tratamento psicanalítico de pacientes neuróticos, psicóticos e fronteiriços. Rio de Janeiro: Imago; 1988. p. 316-47.

Publication Dates

• Publication in this collection
  15 Sept 2005
• Date of issue
  Apr 2005

History

• Accepted
  06 Oct 2004
• Received
  16 July 2004
• Reviewed
  21 Sept 2004