by Unknown
There now began the barrage of letters, door-step confrontations and street vigils so familiar in the sad literature of this condition. In an interesting echo of de Clérambault’s famous case, P perceived messages from R in the changing arrangement of the curtains in R’s apartment. P also received information by touching the leaves of a privet hedge and from published articles by R that appeared in print long before their first meeting. R had been living contentedly with his common-law wife, M, and within days this relationship was under strain from P’s determined onslaught. Later they separated. P was mostly euphoric, certain that despite R’s outward hostility, he would come to accept his fate and live with P in his large house. He believed R was ‘playing with him’ and testing his commitment.
Soon the euphoria had turned to resentment. Early on P had managed to steal M’s appointment diary from her place of work. Using the information he had that R was to be at a certain restaurant, P hired contract killers to shoot R. The attempt ended with a diner at a nearby table being shot in the shoulder. P was overcome with remorse and intended to stab himself to death in front of R. This plan failed too and P was arrested and charged not only with the restaurant shooting, but also for having held M at knife point. The court ordered a full psychiatric report.
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 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 he should be held indefinitely at a secure mental hospital. P was seen 6 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 and Mellsop (1985) concluded that de Clérambault’s syndrome is an aetiologically heterogeneous disorder. Theories of aetiology have encompassed alcoholism, abortion, post-amphetamine depression, epilepsy, head trauma and neurological disorders. None of these is relevant in this case. Reviewing various descriptions of the pre-morbid personality in pure cases, Mullen & Pathe summarise 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 passers-by struggling to tether a balloon caught in strong winds. Such a transformation, from a ‘socially empty’ life to intense team-work 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 defence 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 (1772–1840) who observed that ‘the subjects of erotomania never pass the limits of propriety, they remain chaste’. And Bucknell and Tuke writing in the mid-19th 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 47, 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). Hospitalisation 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 re-directed 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 favoured subjects for de Clérambault 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 internalised 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 generalised 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 Clérambault’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 rationalise R’s paradoxical behaviour, 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 pre-morbid characteristics with other patients, lends weight to the view that the syndrome is a nosological entity.
With regard to outcome, most commentators have leaned towards pessimism. De Clérambault described cases of pure erotomania that lasted without significant change for between 7 and 37 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 Clérambault 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, other 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 and 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
ARIETI, S. and METH, M. (eds) (1959) American Handbook of Psychiatry, Vol.1, Basic Books, New York, pp. 525, 551
BUCKNELL, J.C. and TUKE, D.H. (1882) A Manual of Psychological Medicine, 2nd edn, Churchill, London
DE CLERAMBAULT, C.G. (1942) ‘Les Psychoses passionelles’. In Oeuvres Psychiatriques, pp.315–322. Paris; Presses Universitaires
EL-ASSRA, A. (1989) ‘Erotomania in a Saudi Woman’, British Journal of Psychiatry, 153, 830–833
ELLIS, P. and MELLSOP, G. (1985) British Journal of Psychiatry 146, 90
ENOCH, M.D. and TRETHOWAN, W.H. (1979) Uncommon Psychiatric Syndromes, Bristol; John Wright
ESQUIROL, J.E.D. (1845) Mental Maladies: A Treatise On Insanity (trans. R. de Saussure, 1965), New York; Hafner
GAGNE, P. and DESPAROIS, L. (1995) ‘L’erotomanie male: un type de harcelement sexuel dangereux’. Revue Canadienne de Psychiatrie, 40, 136–141
HARMON, R.B. ROSNER, R. and OWENS, H. (1995) ‘Obsessional harassment in a criminal court population’. Journal of Forensic Sciences, 42, 188–196
HOLLANDER, M. H. and CALLAHAN, A.S. (1975) Archives of General Psychiatry, 32, 1574
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, 529–536
MULLEN, P.E. and PATHE, M. (1994) ‘The pathological extensions of love’. British Journal of Psychiatry, 165, 614–623
PEREZ, C. (1993) ‘Stalking: when does obsession become a crime?’. American Journal of Criminal Law, 20, 263–280
RASKIN, D. and SULLIVAN, K.E. (1974) ‘Erotomania’. American Journal of Psychiatry, 131, 1033–1035
SCHNEIDER, K. (1959) ‘Clinical Psychopathology’ (trans. M.W. Hamilton), New York; Grune & Stratton
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Appendix II
Letter collected from Mr J. Parry, written towards end of his 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 towards 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 recognising what I am doing for our love. Send me a new message soon, and remember – faith is joy.
Jed
Table of Contents
Cover
Table of Contents
Copyright
By the same author
Dedication
Acknowledgements
Enduring Love
Chapter One
Chapter Two
Chapter Three
Chapter Four
Chapter Five
Chapter Six
Chapter Seven
Chapter Eight
Chapter Nine
Chapter Ten
Chapter Eleven
Chapter Twelve
Chapter Thirteen
Chapter Fourteen
Chapter Fifteen
Chapter Sixteen
Chapter Seventeen
Chapter Eighteen
Chapter Nineteen
Chapter Twenty
Chapter Twenty-one
Chapter Twenty-two
Chapter Twenty-three
Chapter Twenty-four
Appendix I
Appendix II
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