«Made in United States ofAmerica Reprinted from BULLETIN OF THE MENNINGER,CLINIC Vol. 53, No.6, November 1989 Copyright C The Menninger Foundation, ...»
Made in United States ofAmerica
Reprinted from BULLETIN OF THE MENNINGER,CLINIC
Vol. 53, No.6, November 1989
Copyright C The Menninger Foundation, 1989
Unrequited Love and the Wish to Kill
Diagnosis and Treatment of Borderline Erotomania
Reid Meloy, Ph.D. *
Abstract: The author hypothesizes that erotomania, or de Clerambault's syn
drome, occurs in two forms: the clinically accepted delusional erotomania, in
which patients believe that anOther person is in love with them; and borderline erotomania, in which no delusion is present, yet'an extreme disorder of attachment is apparent in the pursuit of, and in the potential for violence tOward, the un requited love object. The author reviews the empirical literature concerning erot omania and then develops an object relations understanding of the disorder, focusing on the presence of narcissistic, hysterical, paranoid, and psychopathic traits in the erotomanic individual. (Bulletin of the Menninger Clinic, 53, 477 492) You know a few things about me, dear sweetheart Like my obsession with fantasy But what the rabble don't yet understand Is that fantasies become reality in my world.
John Hinckley, Jr.
(cited in Caplan, 1987, p. 62) On February 16,1988, Richard Farley, an unemployed computer technician, shot his way into a Sunnyvale, California, electronics firm that had recently fired him. He killed seven people and wounde.d three others, including Laura Black, a young woman who had consistently rejected his romantic overmres for several years. Two weeks earlier, Black had finally secured a temporary restraining order against Farley and had expressed relief to a friend that her ordeal might finally be over. On February 17, 1988, the Santa Clara County * Chief, Forensic Mental Health Services, San Diego County; Adjunct Professor, University of San Diego School of Law; Assistant Clinical Professor of Psychiatry, University of Californ~ San Diego, School of Medicine, San Diego, California.
';', The views expressed are those of the author and do not necessarily reflect those of the San
Empirical Research The psychiatric and psychological literature has focused on the obviously more pathological fonn of unrequited love called de Clerambault's syndrome, or erotomania, which was first described by Esquirol (1838/1965). The French psychiatrist de Clerambault (1942) carefully defined this delusional disorder and classified it as either pure or secondary (the latter superimposed on a preexisting paranoid disorder; see also Fenichel, 1945). Erotomania has his torically been conceptualized as a female delusional disorder wherein a wom an believes that a man, usually of higher social status, is passionately in love
-, with her. In fact, no such relationship exists, and the love object has had, at
--- most, only brief contact with the delusional individual (Hollender & Callahan, 1975; Seeman, 1978). Recent reports, however, suggest that men also develop this disorder; examples are often found in a forensic context because male erotomania is more likely to result in violent acting out (Goldstein, 1986, 1987a; Taylor, Mahendra, & Gunn, 1983).
Some experts believe that two recent cases of violent acting out that received national attention were forensic examples of de Clerambault's syndrome. (1) Prosenjit Poddar, who murdered Tatiana Tarasoff, developed a delusional fixation on her as a love object. :After a New Year's Eve kiss, followed by her active discouragement of his love, Poddar planned to create a disaster from which he would rescue her and which would result in her recognition that she loved him. His plans ran amok, he stabbed her to death, and the civil suits resulting from her murder changed the parameters of privilege in the doctor-patient psychotherapy relationship (Blum, 1986; Tarasoff v Re-.
gents of the University of California, 1976; Winslade & Ross, 1983). (2) John Hinckley, Jr., tried to assassinate President Ronald Reagan on March 30,."-.
1981, after his repeated failure to romance movie actress Jodie Foster. He :-:~(.
Although not included in DSM-III, de Clerambault's syndrome appears in DSM-III-R (American Psychiatric Association, 1987) as the erotomanic sub type of delusional (paranoid) disorder with the central theme of "an erotic delusion... that one is loved by another" (p. 199). This delusion usually focuses on idealized romance or spiritual union rather than sexual attraction, and the fixated object is often of higher social or economic status. The delusion must be present for at least a month; auditory or visual hallucinations are not prominent; and other behavior is not conspicuously odd or bizarre.
Organic factors, of course, must be ruled out.
Dietz (1988a), who gathered data from an empirical study of letters sent to celebrities and politicians and from other case studies, reported several findings from a sample of 65 erotomanic individuals: (1) erotomania should not be considered a rare disorder, (2) it is not a predominantly female disorder, (3) the most likely recipient of violence is the person perceived to be standing in the way of the desired object, and (4) fewer than 5% of erotomanic individuals are violent. Dietz also noted that erotomanic individuals do not necessarily remain fixated on one object, but may shift to other targets. The mobility and tenacity of erotomanic persons tend to make their celebrity love ~
Erotomanic delusional disorder is clinically quite obvious because of its psychotic nature. Th~se patients, even when faced with substantial evidence
• Dietz (1988a) also reported that of the 214 subjects who wrote to celebrities, 16% had eroromanic delusions. Eleven subjects believed they were married to the celebrity. Among the 100 subjects who wrote to senators and congressmen, five had erotomanic delusions and twO believed they were married [0 the politician.
480 MELOY I • to the contrary, remain convinced that their fixated object passionately loves in return. It is clinically critical, however, to consider erotomania in the absence of the delusional belief that the love object feels the same way. In other words, these individuals may pursue their love object, yet be aware that the love object does not reciprocate. This argument was raised in the Hinckley trial by the prosecution psychiatrists, who maintained that there was no evidence that Hinckley delusionally believed Jodie Foster loved him. His bizarre behavior was fueled, they contended, by the frustration of knowing she did not care for him, and he therefore pursued a course of events designed to bring him to her attention (Low, Jeffries, & Bonnie, 1986). This differential diagnosis between delusional erotomania and what I would call borderline erotomania is clinically significant and also has legal implications concerning pleas of insanity. The former implies the presence of psychosis; the latter indicates a gross disturbance of attachment or bonding, but not necessarily a loss of reality testing.
I selected the term borderline because it captures the intense and tumultuous attachment problem of this nondelusional form of erotomania. Other writers have developed the relationship between separation, loss, and erotomania, but always in the context of delusional thinking (e.g., Evans, Jeckel, & Slott's 1982 formulation of erotomania as a variant of pathological mourning in some patients). Borderline erotomania implies a level of personality organi zation (Kernberg, 1984), which I will describe in detail later. Although cenain erotomanic individuals may fulfill the criteria for the diagnosis of borderline personality disorder in DSM-III-R, I am not implying that all nondelusional erotomanic individuals should be so diagnosed.
Implicit in this distinction between delusional erotomania and borderline erotomania is the nature of the attachment between erotomanic persons an.d their objects. In delusional erotomania, there has usually been no actual historical attachment. The attachment, or cathexis, is directed toward an object concept (Meloy, 1985) in a mind embellished with meaning and emo tions that have no basis in reality. This fantastic object concept may be perceptually supported by external stimuli that are sought out by the ero tomanic individual: photos of the love object, responses to fan mail, public appearances by a celebrity love object, or arranged private encounters perhaps unknown to the erotomanic person's target. In extreme cases, the erotomanic delusion includes beliefs of union or merger with the love object that suggest an intrapsychic loss of representational boundaries between self and other object concepts. Such beliefs are usually accompanied by a loss of perceptual distinctiveness between self and others. In common parlance, the
LOVE AND VIOLENCEindividual is psychotic. My evaluation of a 38-year-old erotomanic male
illustrates this phenomenon during the n:tental status examination:
The patient does report, at times, hearing Linda's voice (the erotomanic target).
Although he denies the voice is heard like a sound, he does believe that she is communicating with him in an extrasensory fashion. He also reports seeing her face in a "vision" and reports incidents of mistaken identity (Capgras syndrome) on the street when he was sure he saw her. He repOrts one incident of dissociation from his own body, and also reports the experience of autoscopy, the visual seeing of himself. He reports that he believes Linda's husband, George, is con trolling her mind. This control, however, is "not magical, but influential."
In contrast to delusional erotomania, borderline erotomania usually in volves some history of actual emotional engagement with the object. This relationship may vary from a friendly glance and smile to a tenninated re lationship that included emotional and sexual dimensions. The degree of disturbance is the amount of discrepancy between the attachment behavior of the love object and the intensity of the erotomanic person's own emotional attachment to the love object. Borderline erotomanic individuals view sepa ration as abandonment, and rejection by the object evokes abandonment rage.
Rejection, in the mind of the delusional erotomanic person, may be con ceived in autistic fantasy without any actual precipitating behavior by the object; on the other hand, rejection in the mind of the borderline erotomanic person is usually a grandiosely elaborated and distorted childhood abandon ment fantasy that is recapitulated in the present by the object. Such actual rejection may represent the culmination of a pattern of selecting love objects who are unable or unwilling to respond to the erotomanic individual's affec tions, what Kemberg (1988) has called pathological, or masochistic, infania tIon.
My clinical experience with the few erotomanic patients I have evaluated in a forensic setting indicates that there is invariably a DSM-III-R personality disorder, usually descriptively diagnosed as narcissistic, histrionic, antisocial, borderline, or paranoid~ or a combinationthereof. If there is a true erotomanic delusion, then there will usually be both an Axis I and an Axis II diagnosis.
Delusional erotoma~ic symptoms may also appear in patients with schizo phrenia, organic mental disorder, schizoaffective disorder, or other mood disorders.
Kernberg's (1984) model of personality organization helps to elucidate this clinical phenomenon. The erotomanic individual is usually organized at a 482 MELOY borderline level, with distinctive defensive operations and identity issues, and with only marginally adequate reality tes~ing.
The genotypic defensive operation of splitting (Freud, 1938/1964; Grot stein, 1980) underscores the blatantly contradictory perceptions and affect states of the person with erotomania: The love object is initially idealized, but then ragefully devalued; intense love and intense hatred exist concurrently, but are experienced only in alternate, split-off affect states; and the narcissism and grandiosity of the violent act betray the defensive projection of devalued parts of the self into the victim (Klein, 1946/1957b). This final defensive maneuver of projective identification is most apparent in the omnipotent control and devaluation of the victims during, the act of violence itself. Richard Farley, the erotomanic man who killed and injured the people in the elec tronics firm, stated that he wanted only to wound his unrequited love so that she would know the suffering her behavior had caused.
The delusional erotomanic person will also exhibit defenses characteristic of borderline disorders but, as Kernberg (1984) noted, at a psychotic level of personality organization these defenses protect the patient from experiencing further disintegration of boundaries between self and object, both intrapsy c chic perceptual representations and actual interoceptive-exteroceptive sen sory-perceptual experience. In such circumstances, the more fixed and false the erotomanic belief, the more regressed to a psychotic level of personality organization the erotomanic individual has become. Paradoxically, the in tensity of attachment to the actual object may lessen (evidenced by less proximity-seeking behavior) as the erotomanic individual retreats to more autistic levels of relatedness to fantasied object concepts and percepts (Meloy, 1985).
Identity disturbance in erotomanic individuals is evidenced by their intense, yet tumultuous, attachment to their love 0 bjects. They yearn for affection, yet may eventually wish to destroy the love object, or at least devalue the person's life. Klein's (1957/1975a) notion of envy is paramount here: the motivation to destroy the good object in the face of inevitable frustration.
These contradictory self-concepts of lover and destroyer directed toward the same object are symptomatic of poorly integrated identity and are kept apart through splitting defenses such as denial and dissociation. Other erotomanic c· individuals may, through aspiring narcissism, seek a rwinship alliance (Kohut,
1971) by their acts of violence and eventual identification in history with the famous, unrequited love. In other words, erotomanic individuals pursue a narcissistic wish to be like the love object to enhance their own grandiosity.