7/28/2019 19210101 Clerambault

1/3

Ga6tanGatiande Cl6rambault(r87z-re34)de Cl6rambault was born in Bourges, in Central France. As a studenthe was attracted by artistic design, then law and finally medicine andpsychiatry. His first senior psychiatric position was in a hospital forthe criminally insane in Paris and he remained there for 30 years/eventually becoming its director. His two best-known contributionsto psychiatric thought are his concept of mental automatism, anorganic model of how certain mental functions could be split off fromothers; and erotomania, the false belief that one is loved, part of awider concept of the psychoses derived from his notion of thepassions.

The present extract traceshis ideas on the nature of suchpassion-basedpsychosesand presents his views on erotomania, acondition which has been much discussedsince'

Psychoses f PassionG. de Cl6rambault (19214)(Lespsychosespassionelles,pp. 323-7of oeuarePsychiatrique,vol.1. Paris: Presses Universitaires de France, republished1942)

The nature of delusional statesof passionThe term delusionalstates f passion enotes all those delusional stateswhich have as their basis a prolonged emotion, whether desire oranger. Any intense feeling can serve as the nucleus for such a state: afeellng of ownership, a sense of injustice, maternal love, religioussentiments, etc. The emotion will have been linked from the beginningwith a distinct idea, and this'ideo-affective association' then forms anindissoluble bond without affecting the general pattern of thinking.This state of affairs is not seen in misinterpretative or polymorphousstates.

Autonomous states of passion exist without hallucinations, globalthought disorder or dementia. There do exist, however, mixed states,where the delusional stateof passion is part of some other Process;wecall these secondary or prodromal, depending on whether they suc-ceed or precede the principal condition. The appearance of such,syndromes of passion' in patients with an already abnorrnal mental

Psychosesf passion 183background is explained in the following way.Patients suffering frommental disorder do not suddenly lose their affective responses, butthey may at first react more intensely than normal to events. At thisstage of the illness their imagination is often more active than usual,while at the same time their critical faculties are diminished. In fact, itis surprising that the freeing of the constraints on passion does notcause more problems in the course of a psychiatric illness . . . Anappropriate guideline is that the intensity of experienced emotion isdirectly proportional to the autonomy of the condition, i.e. absenceofother abnormal mental phenomena . . For example, a normal mindhas to be subjected to considerable emotion before reaching a firmconviction which goes against conventional beliefs. In this case the'ideo-affective knot' is predominantly emotional in origin. If there is apre-existing abnormality of psychological functioning, imaginativemechanisms become more important in the development of this 'ideo-affective knot'; a patient with general paralysis of the insane, forexample, may say that he is the queen's lover, but he may not evenwrite to her or show concern about not seeing her . . .

In addition to pure, secondary and prodromal delusional statesofpassion there are also the associated delusional states of passion,where two or more distinct delusions co-exist.The separatedelusionsare both based on strong emotions, but are different manifestations ofthem, for example ambition and sensitivity. Although the delusionsmay interact, they remain relatively independent in the way theyinf luence behaviour.

Finally, there are abortive or attenuated forms of these states,wherethe delusion is not strongly maintained or is transient in its hold on thesubject . . .Other causes of a secondury delusional stateof passion are affectivepsychosis and obsessional and phobic neurosis. We regard these as

physiological in origin because they derive from a primitive over-arousal, unlike pure erotomania where an'ideogenic'basis exists forthe overarousal. It is not easy, however, to distinguish delusionswhich arise in the course of a manic-depressive or obsessional llnessfrom those which are the central feature of delusional statesof passion.Both are to some extent physiological in origin, but in the former casesthe attached idea in the ideo-affective knot is unstable and easilychanges to another one; in the latter case, he knot is stronger, and theidea more permanent.Delusions secondary to a 'progressive systematic psychosis' arenlore easily distinguished from pure delusional states of passion. In

7/28/2019 19210101 Clerambault

2/3

184 G. G. deCldrambaultthe former case he whole range of ideas is in turmoil and other mentalfunctions are affected. In paranoid, confabulatory and hallucinatorystates, for example, it is obvious that iudgement, imagination andperception, respectively, are at the root of the disorder'

Pure erotomaniaThe following patient is a case of pure erotomania, one of the bestdefined examples of a delusional state of passion'

There are no hallucinations, no generalised persecutory beliefs andno confabulatory or grandiose ideas. Erotomania is the only evidenceof psychosis, the ideas are based entirely on passion and there is nop.ogr"rrive impairment of other mental functions' The striking fea-tures are the stiength of her desire, the intensity of her reactions andthe absolute conviction with which she holds her delusional beliefs.There has been no change in the content of her delusion, as one sees npolymorphous states; the belief itself is remarkably stable, and doesnot give way to frustration or hate. All her misinterpretations referuniquely to the original theme and any persecutory ideas are consistentwith the primarY belief.

Her delusional state remained unchanged for seven years' Therewas no change in the object of her desire during this time and nodevelopment of persecutory, grandiose or mystical delusions'

Thepatientbelieved hat acivil servant, he secretary f agovernmentcommission,was n lovewith her. According to her, he ooked at herlovingly, soughther out, usedsubordinatesand prostitutes o perse-cuteher and would, sooneror later, give in to her wishes. she wasaware hat the man was marriedand did not deny hat sheherselfhada lover whom she was about to marry. None of these acts, n hermind, constitutedan obstacleo her belief

The historydatedback o 1915when the patientneededa safe-con-duct pass n order to enter the military zone. The civil servant inquestionhad refused o giveher this pass.She hen plaguedhis officewith repeateddemands or the pass,and wrote seductive etters nthe hope of gaining his permission.All was to no avail. Shebecameangryand suspectedhat shewas beingunfairly treated.At onepointthe office lost her birth certificateand she took this as a personalaffront. She resorted o extreme actics turning up at the office ntears, hreatening uicide nd writing angry etters.Shewas admittedto psychiatric ospitals n several ccasionsecause f her behaviour.

Shewas aged34when she irstcameundermy care n7979, er ifth

Psychosesfpassion 185admission in all. From our enquiries and her previous psychiatricnotes, the following factsemerged. She had firstbeen admitted to theBictreasylum at the ageof 12. She remained there for four years withthe diagnosis of 'mental retardation, depression and suicidal tenden-cies'. Her mother had had a depressive illness and had committedsuicide after a stillbirth. After her discharge she had become aprostitute. Then at the age of 19 she became convinced that a doctorwas persecuting her. This was mainly attributable to anger, but it hadan erotic component, and may have been the prelude to her eventualerotomania. She hen lost contactwith her relatives until the age of 33 ,when she had her second psychiatric admission in 1918.There weretwo more admissions in this year. Each time it was noted that she hadpersecutory ideas, that she drank heavily and that she was pursuinga civil servant whom she claimed was in love with her. She had threemore admissions between then and 7922,each with the same present-ing features.

The symptoms were the same in all her admissions. She had beenfollowing the civil servant and making a nuisance of herself byaccostinghim, attacking him and circulating scandalousstories abouthim. She believecl hat the man was in love with her, protected her insecret and, despite her conduct towards him, continued to loveher...

The patient was misdiagnosed, in my view, by several eminentpsychiatrists. Several considered that she was incapable of an indepen-dent existence but the reasons given were either her disorganisation,her impulsiveness or her alcoholism. The quarrelsome aspect to herbehaviour was ignored and the erotomania went unnoticed for years.

The widespread tendency to overlook erotomania has several ori-gins. Chief among these are the unfamiliarity of the clinical picture,and the lack of an agreed method of interviewing these patients tobring out their delusions .

The best interviewing technique requires a thorough acquaintancewith the condition itself. An intuitive approach is of l ittle value unlessone knows what one is looking for. However, one should not proceedas if one were questioning an examination candidate. In the first place,one rarely obtains a formal declaration of the passion in question, andspecific questions on this topic are either ignored or brushed aside. It isbest to proceed in a more casual way, but with occasional references tothe sort of ideas that one is seeking. In this way we can lead our patientgently to a state of mind in which he will feel ready to talk freely anddiscuss the morbid ideas, or at least feel obliged to drop hints or topretend that he does not understand the purpose of the questions.

7/28/2019 19210101 Clerambault

3/3

18 6 G. G. de CldrambaultEither way we can gain an entry into his system of beliefs without himrealising it. Patients of this kind should not, therefore, be interviewedby a series of direct questions, but rather manoeuared, nd in order toachieve this there is only one method - to touch on and ignite thepassion in question.

The mental state of these patients is largely unrecognised in ourpsychiatric hospitals mainly because hey do not call our attention to itby disturbing the ward, and they retain sufficient faculties to be ontheir guard against discovery of the real nature of their condition.Another reasonwhy they often go unnoticed is that the psychiatrist tooreadily substitutesa simple banal explanation for their statements. Thepsychiatrist is prone to conclude falsely that 'something must havehappened' to arouse their anger. Their complaints and claims of beingloved are thus taken for real or slight exaggerationsof reality. Anothermistake is to regard their statements as consistent with a transientaffective disturbance in an individual with a Personality disorder . . .[De Cl6rambault used the traditional French term ddgenerdor suchindividuals, Tr.l. Finally, the subjectmay be wrongly regarded as sane/responsible for his actions and therefore fit for punishment if he hascontravened the law.There are some patients whom it is difficult to distinguish in one orother of these ways. The majority, however, can easily be separatedinto banalstates f passion ndmorbid states f passionThe distinguishingcriteria are the intensity of the patient'sreactions, he persistence f theirideasand the incorrigibility of their beliefs.

Secondary erotomaniaThe term 'secondary erOtOmania' s mOre accurate than 'associatederotomania' because t covers caseswhich precede (prodromal cases)as well as succeed some other condition. All such casesarise on thebasis of an already disordered psychological substratum, but one canonly use the term if there is already evidence of this other psychiatriccondition. Prodromal erotomania is a retrospective diagnosis.

In secondary cases the erotomania is based more on imaginationthan on passion. It is not a sudden thing, not'love at first sight', but astate which emerges gradually, through being worked out by thesubject. There is also ess energy in the pursuit of the loved one than inpure cases.

I have never seen a case of either pure or secondary erotomania inwhich the love was entirely platonic. In one famous case,whose love

Psychoses t'passion 787was claimed to be platonic, I discovered on interview that the patientbelieved she had been married to the objectof her desire and had givenbirth to a child by him. Another case, a girl of apparently pure andimpeccable virtue, was found to have sent him pictures of nakedwomen with her own name attached.

Prodromal erotomaniaErotomania is a syndrome whose origin lies in the sphere of emotionsbut which has links with the faculty of imagination. In pure cases heemotional component is maximal; in secondary cases, he imaginativeelement predominates. Secondary cases are those where theerotomania is an integral part of a generalised psychosis.The stability of the delusional state and the extent to which thebeliefs determine action are a function of the emotional state. Thus insecondary erotomania, whether prodromal or consequential, subjectsdo not tend to act on their delusions, and the specific se t of beliefsgrows slowly and then gets reabsorbed into a protean ensemble ofother abnormal beliefs and experiences. There are often changes n theobject of their desire, unlike the situation in pure cases. n addition, theobject may be someone whom they have never met but merelyinvented through imagination, misinterpretation or transformation ofthe content of an auditory hallucination. Sometimes the object may bedetermined partly by u real event in the distant past and partly byinvention. We have seen his in the caseof a 60-year-old woman whoseerotomania centred upon someone who had been her real lover butwho had disappeared from her life 30 yearsbefore. She had had a childby him, and in the intervening years had become increasingly angrywith him.

All secondary caseshave a substrate of a more generalisedpsychosis.The pre-existing psychological abnormality allows the syndrome todevelop without the necessityof an emotional state. magination is thedetermining factor. In prodromal forms this psychosis remains latent,and if this is so for several years the erotomania may be mistaken for thepure type. I once saw a case ike this who eventually showed signs ofdementia praecox, bu t who for many years presented all the featuresofpure erotomania.