De Clérambault's syndrome

Synonyms: erotomania (a delusion of passion), erotomanic delusion, paranoia erotica, psychose passionnelle

What is de Clérambault's syndrome?

A form of paranoid delusion with an amorous quality. The patient, often a single woman (but cases in males are reported)¹ believes that a very famous, or well respected person is in love with her. This condition was originally described by de Clérambault as having a phase of hope followed by a phase of resentment.

• The victim of the delusion, with whom only a brief acquaintance exists, is usually older and out of their usual social circle. The victim may well be quite removed, such as a public figure in politics, on the screen, stage or television, or more local such as a doctor² or priest.

• There has usually been little, or virtually no contact and nothing has been done to stimulate or encourage such a belief.

• The victim is at first unaware, but is later likely to be embarrassed by telephone calls, letters and amorous advances.

The condition is classified as a delusional disorder, with erotomania as a subtype in contemporary systems such as DSM-5 and ICD-11. It is often a neglected diagnosis in modern psychiatry.

History³

• Gaetan Gatian de Clérambault (1872-1934) was born near Paris and became successful in both medicine and art (many of his paintings are now in museums).

• His work in psychiatry focused on hallucinations and delusions. He suggested that 'mental automatism' might be responsible for experiences of hallucination.⁴

• De Clérambault described the syndrome in 1927 as 'psychose passionnelle'.⁵

How common is de Clérambault's syndrome? (Epidemiology)

• Age at onset is usually middle, or late adulthood and the course is variable.

• The incidence of De Clérambault's syndrome is unknown but the prevalence of delusional disorder in the general population has been reported as approximately 0.05-0.10% of the population per year.⁶ It is much rarer than other psychiatric diagnoses.

• Delusional disorders in general have a female:male ratio of 3:1.

• Familial transmission is suspected and comorbidity (frequently mood disorders) may exist.

• Subjects are often isolated, unemployed and with few social contacts.

De Clérambault's syndrome symptoms (presentation)^{7 8}

• The diagnosis of primary erotomanic delusions requires at least one month's duration of the delusion, otherwise generally normal appearance and behaviour and the exclusion of schizophrenia, mood disorder, substance-induced toxicity and medical disease.

• Typically, patients are unaware of the psychiatric nature of the condition.

• Usually the supposed lover is inaccessible - eg, a famous television performer whom they only sees whilst watching the television.

• Social media use may be a contributing factor.⁹

• Patients often believe that it is the subject of their delusion who is more in love with them than they are with him/her. They take great pride in this. They may feel that the subject cannot live happily without them.

• Patients may believe that the subject of their delusion cannot make his/her feelings known because of various reasons - for example, difficulties in approaching them.

• This type of delusional disorder may lead to stalking or other potentially threatening and dangerous behaviour.¹⁰ The police may become involved in trying to keep the patient from pestering the subject but this may be perceived as a paradoxical sign of affection.

• The patient may continue to pester the subject and may develop delusions of persecution following the delusions of passion.

• They may also be violent against those they believe stand in the way of their delusional love.

• A thorough psychiatric evaluation is essential in diagnosis and assessment of possible comorbidity.

Investigations

Very occasionally, if a neurological problem is suspected, tests such as an electroencephalogram (EEG), MRI or CT scan may be performed.

Associated diseases

• Erotomania may be primary (no associated psychiatric problem) but is often associated with other psychiatric illness (secondary) such as paranoid schizophrenia, schizo-affective disorder, major depression, bipolar disorder⁵ , dementia¹¹ or Alzheimer's disease.

• It is occasionally associated with other delusions - eg, persecutory, grandiose, jealous or somatic.⁴

• Other associations include epilepsy and a left frontal lobe lesion.

De Clérambault's syndrome treatment and management

• Management of any associated disorder.

• Successful management is difficult and may include psychotherapy and antipsychotic pharmacotherapy.⁶

• Pimozide, risperidone and electroconvulsive therapy (ECT) have been tried with varying degrees of success.¹²

Prognosis

• The prognosis is variable but various treatment modalities have been shown to be successful, especially for primary erotomania and erotomania secondary to bipolar affective disorder, with subjects becoming less dangerous and engaged in less harassment of victims.¹³

• Delusional disorder is typically a chronic condition but, with appropriate treatment, a remission of delusional symptoms occurs in up to 50% of patients.⁶

• However, because of their strong belief in the reality of their delusions and a lack of insight into their condition, individuals may never seek treatment, or may be resistant to exploring their condition in psychotherapy.