Letters to the Editor
A Case of de Clérambault Syndrome in a Male Stalker With Paranoid Schizophrenia
Dear Editor:
I describe a case of secondary erotomania in a 43-year-old Moroccan–Canadian single man, a former maintenance worker (collecting disability pension for many years) with a Grade 12 education. Although the syndrome is presumed to be rare in Western patients with schizophrenia, there is evidence for its high prevalence in schizophrenia patients of the paranoid subtype elsewhere. There is also evidence of a robust relation between grandiose delusions and erotomanic symptoms.
Case Report
De Clérambault syndrome, also known as erotomania, erotic paranoid state, delusions of passion, psychose passionelle, and in the DSM-IV–TR, as delusional disorder of the erotomanic type (1), is documented as an uncommon psychiatric syndrome (2). It is an illness that involves the central delusional theme of being loved by another person. Efforts to contact the object of the delusion through telephone calls, letters, gifts, visits, and even surveillance and stalking are common. While most patients with this disorder in clinical samples are female, in forensic samples, the patients are mostly male. A classic feature of the disorder is that many actions of the target are interpreted by the patient as being paradoxical or contradictory (for example, the target may appear to hate the subject when she really loves him). The paradoxical interpretation of the rejection of the patient’s overtures and of the lack of clear confirmation of his beliefs are viewed as a test of his own love for the target.
The patient was referred from an Ontario Provincial Court under the Mental Health Act for an assessment of his psychological status, pursuant to his being charged with criminal harassment over a 22-year period. He had dated the victim for 4 years prior to the commencement of his harassment, during which epoch he both physically and sexually assaulted her and psychologically and emotionally manipulated her. She then moved to another city, about 200 km away, and ended her relationship with him. He refused to accept this, sending her letters asking that he might live with her and her family. He continued to send packages, gifts, cards, and letters to her, many of which were sent from overseas after he moved back to Morocco with his parents for some time. Some contained menacing messages, and on several occasions, the patient ejaculated on the items and letters before sending them. The victim never responded to any of the messages. At one point, the patient was convicted of possessing a prohibited weapon after he attempted to intimidate the victim into entering his motor vehicle, using brass knuckles. After learning that she was married and had children, he began sending gifts for her children as well.
In addition to a mental status examination, the patient was neurologically examined with the Quick Neurological Screening Test II (QNST-II) and was intellectually and neurocognitively examined with the Test of Nonverbal Intelligence-3 (TONI-3) and the Cognistat Neurobehavioural Cognitive Status Examination (NCSE), respectively. He was also psychometrically examined with the Millon Clinical Multiaxial Inventory-II (MCMI-II), the Minnesota Multiphasic Personality Inventory- 2 (MMPI-2), and the Personality Assessment Inventory (PAI). He was further examined with the Spousal Risk Assessment Guide (SARA).
No evidence of gross neurological disease or of neurocognitive impairment was uncovered, although the patient’s level of fluid and nonverbal intellectual functioning appeared to be somewhat limited (that is, within the low average range at the 14th percentile). Further medical assessment also yielded unremarkable findings, other than a self-report of occasional headaches and a documented history of acute dystonia with haloperidol. There was no history of alcohol or drug abuse. He was currently being treated psychopharmacologically with olanzapine (2.5 mg orally at bed time) and fluphenazine decanoate (15 mg IM).
The patient displayed no evidence of a formal thought disorder or of perceptual abnormalities (such as hallucinations) of any kind. However, he was blatantly delusional (for example, he falsely believed he had been raped at knifepoint by a coworker); he was grandiose (he believed he was an eminent inventor of children’s toys, although he had never been recognized as such); and he evinced markedly narcissistic, obsessive–compulsive, and dependent personality features. Also indicated and underlying his intense oppositional resentment and anger were extreme cynicism and suspiciousness and (or) mistrust of others’ motives, along with very low levels of heterosexual activity (his only intimate relationship was with the victim). The combination of impulsiveness, resentment, and good energy levels portended the likelihood that the patient might lash out at those whom he felt had slighted him in some way. The findings were also consistent with one of the prototypes of male spouse abusers, and the patient evinced several risk factors indicating an elevated risk for future spousal or romantic partner assault. The presence of delusions with an absence of prominent disorganized speech, disorganized or catatonic behaviour, or flat or inappropriate affect supported a diagnosis of schizophrenia of the paranoid subtype.
This case exemplifies previous findings of a relation between erotomanic symptoms and schizophrenia of the paranoid subtype and of a robust relation between grandiose delusions and erotomanic symptoms. It further exemplifies Kraepelin’s original 1921 formulation, which classified erotomanic delusions as a subcategory of grandiose delusions (3,4). It remains unclear whether the currently presumed rarity of erotomanic symptoms in Western patients with schizophrenia is a result of a cultural disparity or a consequence of unreported characteristics of schizophrenia. This case illustrates that at least a systematic search for erotomanic symptoms, both during acute episodes of schizophrenia of the paranoid subtype and in the presence of grandiose delusions, should be conducted.
References
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Text revision. Washington (DC): American Psychiatric Association; 2000.
2. Enoch MD, Trethowan WH. Uncommon psychiatric syndromes. 2nd ed. Bristol: John Wright and Sons Ltd; 1979.
3. Phillips MR, West CL, Wang R. Erotomanic symptoms in 42 Chinese schizophrenic patients. Br J Psychiatry 1996;169:501–8.
4. Kraepelin E. Lectures on clinical psychiatry. New York: The MacMillan Company; 1921.
Larry Litman, PhD, Cpsych, FACAPP, FPPR, FSMI, FICPP, FSICPP
London, Ontario
|
