De Clérambault's syndrome: diagnostic and therapeutic challenge

Abstracts

A síndrome de Clérambault, ou erotomania, é descrita como uma convicção delirante, apresentada, geralmente, por uma mulher que acredita que um homem, mais velho e de posição social mais elevada, ama-a. O paciente persegue o objeto de amor e, por isso, eventualmente, envolve-se em retaliações e ameaças em resposta às repetidas rejeições. Relata-se o caso de uma mulher de 42 anos que iniciou quadro delirante há 19 anos, após primeira gestação. Foi admitida em nosso serviço há 3 meses. No início do tratamento, quando o antipsicótico foi introduzido, apresentou remissão do delírio. Essa síndrome é incomum, mas não significa que seja rara em nossa prática. Um bom entendimento da extensão psicopatológica pode aumentar o reconhecimento dessa condição psiquiátrica.

Erotomania; síndrome de Clérambault; psicose; delírio

CASE REPORT

De Clérambault's syndrome: diagnostic and therapeutic challenge

Thais de Moraes Sampaio^I; Arthur Guerra de Andrade^II; Danilo Antônio Baltieri^III

^IResident in Psychiatry, Faculdade de Medicina do ABC, Santo André, SP, Brazil

^IIProfessor, Psychiatry and Medical Psychology, Faculdade de Medicina do ABC

^IIICoordinator, Program of Medical Residence in Psychiatry, Faculdade de Medicina do ABC

^{Correspondence}

ABSTRACT

De Clérambault's syndrome or erotomania is described as a delusional conviction, in which a woman usually believes that an older man of higher social status is passionately in love with her. The patient's relentless pursuit of the delusional love object can eventually involve threats or retaliation, in response to repeated rejection. This case report is about a 42-year-old female who initiated the delusional conviction 19 years ago, after her first pregnancy. She was admitted to our service 3 months ago. In the beginning of the treatment, when the antipsychotic was introduced the patient exhibited decreasing of delusions. This disorder is uncommon but it does not mean that it is rare in our practice. A greater awareness of psychopathological extension may increase the recognition of this psychiatric condition.

Keywords: Erotomania, Clérambault's syndrome, psychosis, delusion.

Introduction

Reports from the 17th and 18th century described the so-called "variants" of pathological love, such as nymphomania (furor uterinus), erotomania (amor insanus) and erotic melancholy. Throughout history, there have been much disagreement between several authors, physicians or not, about the behavior of individuals in love or lovers. The terms passion and madness were often used simultaneously and with varied meanings.^1,2

In the 19th century, Emil Kraepelin, in his exceptional work Maniac-Depressive Insanity and Paranoia, discussed the boundaries between dementia praecox (schizophrenia), manic-depressive insanity and paranoia. In the latter entity, erotomania was considered a subtype. Kraepelin then defined paranoia as an indestructible delusion, with insidious onset, resulting from internal causes and followed by total preservation of thought form and course.³

Despite the definition of erotomania as a form of paranoia proposed by Kraepelin, it became known as de Clérambault syndrome, after the publication of the eminent work Les Delires Passionels. Gaëtan Gatian de Clérambault, in 1921, described a mental condition in which there is a delusional conviction, and an individual, generally a woman, believes that they are loved by someone who usually has prominent financial and social status. The patient tends to insist that the object of love falls in love first and makes the first love attempts, i.e., it is the object that declares initial sexual interest.⁴

The individual usually described the evidence of corresponded love in detail, through messages by looks, verbal or nonverbal communication, gestures and even telepathy, which are intentionally performed by the object.^5,6

Erotomania tends to persist, despite the efforts by the loved object in denying such interest. Such denial can be interpreted paradoxically by the patient as a "disguise" of the love declaration.^2,7

Incidence or erotomania has not been well established yet. There are reports showing that it can affect 0.3% of the population. They are considered rare entities, with few reports in the literature.²

According to Mullen & Pathé, love pathologies occur in women and men, homosexuals or heterosexuals, in Western and Eastern cultures. They are variable as to age, race and socioeconomic status.^2,8

Female patients are prevalent in general clinical samples; however, in forensic samples, most patients are male.^2,9

It is not possible to affirm the influence of heredity in this syndrome due to the reduced number of described cases, despite some studies reporting occurrence of this disorder in the same family.¹⁰

Some authors classify erotomania in different forms. Ellis & Mellsop,¹¹ for example, classify it into primary and secondary. The former is rare, not associated with any other psychiatric disorder, has sudden onset and low response to drug therapy. The other form, which corresponds to most cases, has insidious onset and occurs secondarily to other psychiatric disorders.^12,13

In the Brazilian medical literature, there are even less cases of erotomania. In addition, it seems to be underdiagnosed, which contributes even more to the chronicity already present in this disease.

This report aims at: (a) pointing out possible diagnostic criteria for de Clérambault syndrome; and (b) demonstrating that proper treatment, despite having uncertain outcome, offers better quality of life and prognosis.

Case presentation

Identification

S., 42 years, female, Caucasian, married, three children (♀ 19 years, ♂ 18 years, ♂ 14 years), born in São Bernardo do Campo (SP, Brazil), resident in Santo André (SP, Brazil), unemployed, previous occupation was cleaning assistant, incomplete primary school, evangelic.

Reason for consultation

She was referred from a basic health unit with diagnostic hypothesis of "excessive sexual drive."

History of current disease

The patient has presented increased "sexual appetite" for 5 years. She claims that "only one sexual relationship a day does not satisfy her." Therefore, she usually has sexual relations with her husband up to three times a day. She has an orgasm in all her relations. In addition, she masturbates several times a day (up to four times), using erotic instruments. During masturbation, she imagines being with another man, particularly her brothers-in-law and son-in-law. She believes that many men send her lascivious looks and sexually desire her.

She only had one love relationship before her current marriage. She was a virgin when she got married at 23, and had her first daughter 1 year later.

After her first pregnancy, in which she lost sight of her left eye due to "labor complication" (retinal detachment), she started feeling interested in other men.

At the age of 25, she was advised by her older sister to seek psychiatric treatment, because she was "dating too many men." She was hospitalized for 2 days at a psychiatric hospital. After hospital discharge, she did not adhere to the outpatient treatment.

At the age of 35, she resumed her outpatient psychiatric treatment. During her visits to the psychiatrist, she used to say that her physician had a great sexual interest in her: "he was in love with me;" "we even had a sexual relationship in his office."

After a 6-month treatment, she was referred to psychotherapy, but did not undergo it and interrupted medication, whose name she could not remember.

She denies sexual abuse and homosexual relationships. She denies hallucinations.

In her first interview in our service - Ambulatory for the Treatment of Sexual Disorders of the ABC Medical School (ABSex) - she asked her physician how old he was and told him she thought he was very handsome. Such behavior was repeated in subsequent visits.

Objective anamnesis (older sister)

After the birth of her first daughter, the patient started relating to other men and said that she wanted to get involved with someone "that could provide her with a better life."

Her mother passed away when she was 15, and her father married again 2 years later. Her father had a closer relationship to S. than to his other children.

He emphasized that men would easily fall in love with her. Her sister thought the patient's relationship with her previous physician was strange, because she described details of his personal life and also said he was in love with her.

She has always had difficulty in getting a job: "she is limited." Her sister even hired her to work for her company, but it was not possible to maintain her in the position due to "lack of skills and performance." She has poor social contacts and mainly relates to family members.

Progress

In her first visit, risperidone was introduced. She took this medication for only 3 weeks, due to "weakness and sleepiness." She also complained of reduction in sexual desire and frequency of orgasms after taking the medication.

She maintained a delusional speech that her brothers-in-law and son-in-law were sexually interested in her. We then chose to change the antipsychotic drug for haloperidol depot (one ampoule every 15 days).

After change in medication, she reported feeling "much better." Erotic delusion was less intense. However, after 2 months taking haloperidol, she presented signs and symptoms of extrapyramidal release. Oral biperiden 2 mg was then prescribed.

When the patient returned, she refused to continue the treatment with that antipsychotic, replacing it by trifluoperazine and maintaining oral biperiden.

After 7 days, she suspended taking the medications on her own and presented the following speech: "I'm afraid to be stiff again."

She was paranoid about the medical team and medications, gazed look, blunted affect. She often claimed she would abandon the treatment: "I'd rather be as I was before;" "my husband agrees;" "I can't do anything, stiff like that."

Her family was called by the medical staff to clear some doubts about her pathology and to support adhering to the outpatient treatment.

The patient remained without antipsychotic for 15 days, when delusional and erotic thoughts returned.

Thioridazine was then started. Its dosage had to be increased in the 2 following weeks to 100 mg, due to maintenance of delusional status. The patient maintains regular use of the medication, with poor family support, despite repeated warnings by the medical team. Her relatives reject hospitalization.

Personal history

- She is the second daughter of four siblings.

- She denies use of alcohol, tobacco or illegal drugs.

- She is visually impaired in her left eye ("retinal detachment").

- Sterilization 14 years ago.

- Psychiatric hospitalization 18 years ago.

- Irregular psychiatric follow-up for 8 years.

Family history

- Diabetic father.

- Hypertensive mother, died at the age of 35 due to heart disease.

- Two maternal aunts with "psychiatric problems."

Psychic examination

At admission

Vigil. Auto- and allopsychically oriented. Preserved attention.

Preserved memory. Thought without formal changes, but characterized by delusional and erotic ideas. No hallucinatory indirect signs. Euthymic with congruent affection. Impaired criticism.

Current

Conscious. Auto- and allopsychically oriented. Reduced voluntary attention. Reverberant and slow thought, with response latency and delusional and persecutory ideas (against the medical team). No hallucinatory indirect signs. Euthymic, blunted affect (probably as a result of taking antipsychotics). No suicidal ideation or plans. Impaired intelligence (does not make simple calculations and does not abstract). Impaired judgment of reality and criticism of morbidity.

Physical examination

- No abnormalities.

Neurological examination

- No abnormalities.

Laboratory tests

- No changes were identified.

Electroencephalogram

- Performed during waking, within normality limits.

Imaging examinations

- Cranial magnetic nuclear resonance showing cisterns and widened cortical sulci. Moderate dilation of the supratentorial ventricular system. Several lesions affecting the bilateral brain parenchyma, with prevalence along the bilateral periventricular white matter, characterized by focuses of enhanced signal in T2 and DP of an unspecific nature. Important deformity in the left ocular globe, which has reduced size (Figure 1).

Multiaxial diagnosis - Diagnostic and Statistical Manual of Mental Disorders - Text Revision (DSM-IV-TR)

- Axis I: delusional disorder, erotomanic type.

- Axis II: mild mental retardation.

- Axis III: visually impaired in left eye.

- Axis IV: economic and occupational problems.

- Axis V: 65 (AGF).

Discussion

Our patient was referred to ABSex with diagnostic hypothesis of excessive sexual drive. However, she did not present search for sex itself, but hoped to receive love from the main object of her delusion. There were no behavioral changes, such as self-destruction, obsessions, fantasies, withdraw from social, occupational or entertainment activities as a consequence of searching for sex.¹⁴

Unknowing the syndrome and the poor quality of anamnesis performed probably compromised adequate initial management of her status. Inadequate family support, associated with loss of patient's criticism, strongly contributes to an even more desirable prognosis, considering the repeated references in the literature about poor therapeutic response of primary chronic delusional disorders to traditional antipsychotic drugs.

Some authors have postulated theories about the psychodynamic and organic etiology of de Clérambault syndrome. Segal, for example, observed that patients usually have some characteristics in common. They are not physically attractive, are lonely, immature, intellectually limited, socially inhibited, sexually inexperienced, with low-prestige jobs. The author considered that these individuals try to mitigate their inferiority through psychological compensations, projecting narcissistic delusional constructions in people who are more socially valued.⁵

Freud had already proposed that erotomania would be one of the varied manifestations of the center of paranoia conflict and that it would be directly associated with an unsatisfactory relationship with the individual's own mother. This would be reflected in difficulties in having close relationships, thus compromising married life.¹⁵

Jordan claimed that erotomania could be developed based on the search for a safe father figure, eroticized and unreachable, as well as on the need of the patient has of pushing away homosexual drives.¹⁶

As can be seen, there are multiple forms of psychodynamically learning the phenomenon of de Clérambault syndrome.

Corroborating the characteristics found in the literature, the patient was worried about her appearance (she often asked the interviewer if she was in a good presentation), showed disturbance toward her visual impairment, low schooling level, few love relationships before marriage, jobs with low social status, and difficulties in performing tasks. She lost her mother when she was an adolescent and maintained a strong bond with her father figure.

Such experiences may have brought consequences and influences on S.' psychic functioning. Probably, throughout psychotherapy sessions, these implications could be explained and then related to the etiology of erotic delusion.

Besides psychodynamic factors, organic factors have already been related to this syndrome.

Neurophysiological tests suggested that erotomania could be associated with deficits in cognitive flexibility and associative reading (mediated by the subcortical frontal system) and with deficits in verbal and visual skills.¹⁷

Impairments in functioning of spatial vision or lesions in the limbic system, especially in the temporal lobes, combined with ambivalent loving experiences and affective isolation, could contribute to delusional interpretations. On the other hand, deficits in cognitive flexibility could contribute to maintenance of delusional beliefs (delusional content, however, would be determined by culture and personal experiences of each patient).^17,18

In this report, there were no changes in the electroencephalogram. Cranial magnetic nuclear resonance showed several cortical changes and in the white matter that can be involved with delusional disorder and limited cognitive development. However, new investigations are needed (including serological tests) to associate occurrence of this syndrome with brain impairment.

There are controversies between many authors as to the classification of erotomania into primary or secondary. According to a study by Gillet et al., it is very difficult to consider a case as a pure form.¹³ To be considered as such, the patient should present the following criteria proposed by Ellis & Melssop:¹¹

- Delusional conviction of love communication;

- The object of love has a high socioeconomic level;

- The object is the first to fall in love;

- It has sudden onset (within a 7-day period);

- The object is fixed (or at least can be replaced by another);

- The patient rationalizes the object's paradoxical behavior;

- Chronic course;

- Absence of hallucinations;

- Delusion must be created without changes in consciousness level.

According to these authors, patients considered as having the pure form only reach 80% of those criteria.

The characteristics of secondary erotomania are:⁹

- Delusion should have its origin in an underlying mental disorder (and can occur before, during or after such disorder);

- Clinical characteristics of the primary psychiatric disorder are present, besides erotic delusion;

- Erotomania is resolved when the underlying disease is treated.

Disorders that are mostly associated with erotic delusion are schizophrenia (34%), depressive syndrome (13%), bipolar affective disorder (9%) and paranoia (9%).

De Clérambault considered that erotomania could be a transient clinical syndrome combined with paranoid disorders, as well as one of the prodromes of schizophrenia, or even an autonomous clinical entity.⁴

We observed that the patient presented sufficient criteria of the pure syndrome. Conversely, in the literature there are no references about the association between brain morphological changes and this syndrome.

It is common to find premorbid personality traits, especially in pure erotomania. These individuals are described as timid, delicate, sensitive, suspicious, little sociable. In a study by Mullen & Pathé, antisocial personality is predominant, followed by avoidance, narcissistic and paranoid personalities.⁹

When premorbid antisocial personality traits are present, the patient commonly presents a promiscuous and violent behavior, besides paraphilic sexual fantasies (especially necrophilia, voyeurism and sadism).^9,19

According to Goldstein, there is a potential risk for violent behavior by erotomanic patients. In his forensic sample, 57% of the patients were involved in violent situations (threat, persecution, rape, homicide). Most of them were male and many were associated with a primary diagnosis of schizophrenia and personality disorder.¹⁹

When the sample is obtained from prisons or rehabilitation units, the incidence among men is higher than among women. In the general population, men account for only 20-30% of cases of erotomania.²⁰

Aggressiveness is usually a consequence of repeated rejections suffered by the patient by their object of love.

In S.' history, there were no violent behaviors. However, it is possible that she had investigated personal data about the life of her previous psychiatrist, since, according to her sister, she knew about many details of her object's intimacy.

Based on the DSM-IV-TR criteria (American Psychiatric Association),²¹ the patient was diagnosed as having a delusional disorder, but the delusions were not bizarre, lasting more than 1 month, and did not have criteria that met other pathologies, such as schizophrenia, bipolar affective disorder, depressive syndrome and use of psychoactive substances. According to the main theme of her delusion, it was classified as erotomanic subtype.¹⁴

De Clérambault syndrome is a chronic disease, considered relatively refractory to the treatment, both pharmacological and psychotherapeutic.²

It is recommended to guide the clinical management to mitigate the delusion, as an attempt to reduce the stress level to which both the patient and the object of love are submitted.⁹

These patients bring problems to the victim's life and social and psychological disorders as a consequence of merciless persecution, which can last for years.

With regard to the treatment, typical antipsychotics are most widely used, although their effects are considered modest, with little action on the delusional core (authors cite pimozide as an alternative drug, especially in cases in which there is an association of erotic-paranoid delusions and somatic sexual hallucinations). Only a few patients reach complete remission of their symptoms.

Nowadays, atypical antipsychotics are recommended, especially risperidone at doses lower than 6 mg a day. There are reports of fast resolution of erotic delusions when hospitalization is associated.^1,9,12

Occasionally, electric convulsive therapy can be indicated, but unsuccessful outcomes have also been reported.^2,9

There is no evidence that psychotherapy helps these patients, especially if it is the only form of treatment. Some individuals, when separated from their objects of love (legal problems, hospitalizations), can present improvement in their delusion, especially when treated adequately.⁵

Conclusion

Due to few articles on this theme, little can be said about the etiology of these cases. Psychodynamic theories and some organic findings have been indicated, but individually. Neurobiological findings can contribute to a better understanding of this syndrome.

A good understanding of the psychopathology of erotomania can increase recognition of this syndrome and provide the best treatment, offering relief to the patient and relatives, besides reducing the possibilities of aggressive and violent behavior directed to the object of love.

References

Received April 5, 2007

Accepted July 18, 2007

• 1. Kelly BD, Kennedy N, Shanley D. Delusion and desire: erotomania revisited. Acta Psychiatr Scand. 2000;102(1):74-5.
• 2. Calil LC, Terra JR. Síndrome de De Clerambault: uma revisão bibliográfica. Rev Psiquiatr RS. 2005;27(2):152-6.
• 3. Kraepelin E. Maniac-depressive insanity and paranoia. Edinburgh: E & S Livingstone; 1921.
• 4. De Clérambault GG.(1042). Les psychoses passionnelles. In: De Clérambault GG. Oevres psychiatriques. Paris: Presses Universitaires; 1942. p. 315-22.
• 5. Segal JH. Erotomania revisited: from Kraepelin to DSM-III-R. Am J Psychiatry. 1989;146(10):1261-6.
• 6. Raskin DE, Sullivan KE. Erotomania. Am J Psychiatry. 1974;131(9):1033-5.
• 7. Rudden M, Sweeney J, Frances A. Diagnosis and clinical course of erotomania and other delusional patients. Am J Psychiatry. 1990;147(5):625-8.
• 8. Phillips MR, West CL, Wang R. Erotomanic symptoms in 42 Chinese schizophrenic patients. Br J Psychiatry. 1996;169(4):501-8.
• 9. Mullen PE, Pathé M. The pathological extensions of love. Br J Psychiatry. 1994;165(5):614-23.
• 10. Berry J, Haden P. Psychose passionnelle in successive generations. Br J Psychiatry. 1980;137:574-5.
• 11. Ellis P, Mellsop G. De Clerambault's syndrome: a nosological entity? Br J Psychiatry. 1985;146:90-5.
• 12. Calil LC, Terra JR. Síndrome de De Clerambault: segundo relato de caso em português. Rev Psiquiatr RS. 2005;27(1):64-9.
• 13. Gillet T, Eminson SR, Hassanyeh F. Primary and secondary erotomania: clinical characteristics and follow-up. Acta Psychiatr Scand. 1990;82(1):65-9.
• 14. Goodman A. Sexual addiction: nosology, diagnosis, etiology and treatment. In: Lowinson JH, Ruyz P, editors. Substance abuse: a comprehensive textbook. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 504-39.
• 15. Freud S. On mechanism of paranoia. In: Rieff P. The collected papers of Sigmund Freud. New York: Collier; 1911. p. 29-48.
• 16. Jordan HW, Howe G. De Clerambault's syndrome (erotomania): a review and case presentation. J Natl Med Assoc. 1980;72(10):979-85.
• 17. Fujii DE, Ahmed I, Takeshita J. Neuropsychologic implications in erotomania: two case studies. Neuropsychiatry Neuropsychol Behav Neurol. 1999;12(2):110-6.
• 18. McGuire BE, Akuffo E, Choon GL. Somatic sexual hallucinations and erotomanic delusions in a mentally handicapped woman. J Intellect Disabil Res. 1994;38(Pt 1):79-83.
• 19. Goldstein RL, Laskin AM. De Clerambault's Syndrome (Erotomania) and claims of psychiatric malpractice. J Forensic Sci. 2002;47(4):852-5.
• 20. Menzies RP, Federoff JP, Green CM, Isaacson K. Prediction of dangerous behavior in male erotomania. Br J Psychiatric. 1995;166(4):529-36.
• ²¹
  American Psychiatric Association (APA). Manual diagnóstico e estatístico de transtornos mentais (DSM-IV-TR). 4ª ed. Porto Alegre: Artmed; 2003.

Correspondence

Thais de Moraes Sampaio

Faculdade de Medicina do ABC

Rua Tupi, 119/33, Valparaíso

CEP 09060-140, Santo André, SP, Brazil

Publication Dates

• Publication in this collection
  13 Dec 2007
• Date of issue
  Aug 2007

History

• Accepted
  18 July 2007
• Received
  05 Apr 2007