Saturday, July 18, 2015

Nikolai Gogol and Schizophrenia

 


“The longer and more carefully we look at a funny story, the sadder it becomes.”  ― Nikolai   Gogol

Dr Ruwan M Jayatunge  

Nikolai Vasilievich Gogol could be described as one of the most idiosyncratic Russian novelists and in the West he is regarded as the Russian Charles Dickens.  He earned the title - father of modern Russian realism. His novels, short stories and dramas were so exceptional because Gogol combined realism, fantasy, comedy and tragedy in his work. His novels and short stories made profound impact on Dostoyevsky and Leo Tolstoy.

Nikolai Gogol published his sardonic tale -Diary of a Madman (Zapiski Sumasshedshego) in 1834 which described the inner psychic conflict of a person named Axenty Ivanovich Poprishchin.  According to the short story the protagonist Axenty Ivanovich Poprishchin shows some positive psychotic features that are characteristic in Schizophrenia.

Is Gogol’s Diary of a Madman Coinciding with the Description of Schizophrenia? According to Altschuler (2001) Nikolai Gogol's classic short story Diary of a Madman (1834) contains one of the earliest, and most complete, descriptions of schizophrenia. Furthermore Nicolai Gogol’s writings came way before the mental health clinicians defined Schizophrenia as a separate mental illness.

Schizophrenia is a mental illness that is characterized by distorted thinking, hallucinations and reduced ability to feel normal emotions. Schizophrenia has an altered perception of reality.

Schizophrenia is a universal disorder. Schizophrenia has been described in all cultures and socioeconomic groups throughout the world (Versola-Russo, 2006). International Pilot Study of Schizophrenia, a multinational research project conducted by WHO, has demonstrated, that the incidence of the core symptoms of schizophrenia is similar across diverse cultural settings (Sayar, 2000).

In anthropological circles, it is commonly argued that the term "schizophrenia" is part of a powerful discursive practice that not only authoritatively names but also materially shapes the objects of its attention. But this does not radically distinguish it from other "disease entities" in the psychiatric (or biomedical) taxonomy (Good, 1994; Hopper & Wanderling, 2000).
  

Modern descriptions of schizophrenia, starting with the German psychiatrist Emile Kraepelin's laborious work and in 1878  Emil Kraepelin coined the term dementia praecox gaudily describing the clinical picture of Schizophrenia. In 1911 Eugene Beuler first used the term schizophrenia elucidating the major symptomatology such as blunted emotions, disordered thoughts, and loss of awareness. Bleuler deepened" psychopathology, which depicted schizophrenic symptoms and their relation, and the importance of psychoanalysis for psychiatry (Tölle, 2008).

Schizophrenia involves profound transformations of the self. Eugen Bleuler (1911) noted that the patient's ego tends to undergo "the most manifold alterations," including splitting of the self and loss of the feeling of activity or the ability to direct thoughts. Kraepelin (1896) considered "loss of inner unity" of consciousness ("orchestra without a conductor") to be a core feature of schizophrenia (Sass & Parnas, 2003). 

Eugen Bleuler's belief in the clinical unity of what Kraepelin had described as dementia praecox required him to search for alternative characterizing features that would allow scientific description and classification (Maatz et al., 2015). Bleuler's ideas were more powerfully influenced by Pierre Janet (Moskowitz & Heim, 2001). However he had an ambivalent relationship with Sigmund Freud. Although Bleuler did distance himself from the psychoanalytic movement; he remained consistent in his views on Freud's theories (Dalzell, 2007).

Sigmund Freud’s (1911) hypothesis explains the basic disorder in schizophrenia consists in the patient’s inability to maintain the libidinal cathexis of objects. The fact that patients suffering from the two principal types of schizophrenia present signs of real and fantasy object relationships has been taken as evidence that the illness cannot be based on a decathexis of object representations. According to the psychodynamic approach   schizophrenia occurs as the result of the disintegration of the ego.

Freud based his theory of schizophrenia on a prestructural libido model (Goldstein, 1978).  Dixon (2005) states that the central model for both Sigmund Freud and Carl Gustav Jung for the generation of schizophrenia’s hallucinations and delusional system is described as the intrusion of nighttime dream states into the waking consciousness. Freud predicted that paranoid delusions are motivated by unconscious homosexual impulses (Lester, 1975). 

Schizophrenia is best understood as a particular kind of disorder of consciousness and self-experience. Specific alterations of self-experience and the self-world relationship are fundamental to the illness, especially diminished self-affection, hyperreflexivity, and related disruptions of the field of awareness. (Sass & Parnas, 2003). 

Throughout history, insanity--including dementia praecox--has been a complex problem (Palha & Esteves, 1997). The historical roots of dementia praecox and schizophrenia are described in the context of current nosology and continuing controversies surrounding this nosology (Adityanjee et al., 1999). Paradoxically before Emile Kraepelin , Freud or Eugene Beuler in 1834 Nicolai Gogol epitomized the inner world of a schizophrenic patient via his short story Diary of a Madman. It can be considered as one of the best case vignette of Schizophrenia.

According to the DSM-IV classification anyone having at least two positive symptoms (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) and/or negative symptoms (flat affect, anhedonia (inability to experience pleasure), abolition (lack of drive), or alogia (poverty of speech)) for a significant portion of one month, and general disturbance for at least six months, as clinically diagnosable with schizophrenia (APA, 2000).

There are several types of schizophrenia. In Paranoid schizophrenia the patient has delusions and auditory hallucinations. The delusions can often be about being persecuted unfairly or being some other person who is famous like Napoleon Bonaparte or Albert Einstein. They can exhibit anger, unfriendliness, anxiety, and argumentativeness.

Disorganized schizophrenia is characterized by speech and behavior that are disorganized or difficult to understand, and flattening or inappropriate emotions. Patient’s disorganized behavior may disrupt normal activities. In Catatonic-type schizophrenia disturbances of movement can be observed. In undifferentiated-type schizophrenia a mixed picture is often seen.

Schizophrenia is characterized by profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thought, perception, affect, and sense of self. Also the sufferers experience a numerous features such as hallucinations, delusions, apathy, lack of emotion, poor social functioning disorganized thoughts, difficulty in concentrating and memory problems. These features become central to Gogol’s fictional character Axenty Ivanovich Poprishchin.

Aksenty Poprishchin is a titular councilor who longs for promotion in the civil service and a romantic union with his director’s daughter, and whose blocked ambitions lead to madness and incarceration (Porter 2011). 

As described in Gogol’s short story Poprishchin who is in his 40s experiences bizarre events when he sees two dogs talk to them in Russian. According to another entry Poprishchin thinks that he is the substitute for the King Ferdinand VII of Spain. Poprishchin has persistent delusions, disorganized behavior and occupational dysfunction.

Diary of a Madman is an inner turmoil of a man with a conflict in his perceptions. The story follows in a diary entry format and the entries reveal that Poprishchin goes in to gradual slide into insanity. It is an extraordinary sketch of psychopathology.

Up to this time Spain had been somewhat of a mystery to me. Their native customs and court etiquette are really most peculiar. I don’t understand, I really do not understand them. Today they shaved my head even though I shrieked as loud as I could that I didn’t want to be a monk. And I have only a faint memory of what happened when they poured cold water over my head.

(From Diary of a Madman by Nikolai Gogol)

Poprishchin’s story mixed with humor, sadness, and tragedy and explicates the gradual personality deterioration and how he struggles with his disintegrating psyche. Gogol dives in to Poprishchin’s mind and vibrantly presents the bizarre events that he experienced. 

I hadn’t been there more than a minute when I heard a faint little voice: “Hello, Medji!” Well, I never! Who was that talking?… What was going on, for heaven’s sake? Then I saw Medji sniffing round a little dog following the two ladies. “Aha,” I said to myself, “it can’t be true, I must be drunk.” But I hardly ever drink. “No Fidèle,” I told myself, “you’re quite mistaken.” With my own eyes I actually saw Medji mouth these words: “I’ve been, bow wow, very ill, bow wow.” Ah, you nasty little dog! I must confess I was staggered to hear it speak just like a human being.

(From Diary of a Madman by Nikolai Gogol)

Another entry from Poprishchin’s diary gives a clear clue of the distorted cognition that he experienced.

But afterwards, when I’d time to think about it, my amazement wore off. In fact, several similar cases have already been reported. It’s said that in England a fish swam to the surface and said two words in such a strange language the professors have been racking their brains for three years now

(From Diary of a Madman by Nikolai   Gogol)

People with schizophrenia can have certain types of cognitive dysfunctions. The cognitive dysfunctions are accurately detected by neuropsychological tests. Some patient’s loss the ability to absorb and interpret information and make decisions based on that information. They have inability to sustain attention, and problems with working memory or to keep recently learned information.

With schizophrenia the person’s inner world and behavior change notably. These behavioral changes might include social withdrawal, intense anxiety and a feeling of being unreal (Depersonalization), poor self care , experiencing hallucinations, sense of being controlled by outside forces , delusions, or making up words without a meaning (neologisms). Schizophrenia makes it difficult for a person to tell the difference between real and unreal experiences, to think logically, to have appropriate emotional responses to others and to behave appropriately in social situations. Nikolai Gogol vibrantly describes these cognitive and social dysfunctions in his short story.

Following entry symbolizes Poprishchin’s apparent delusions…..

I did write to you, Fidèle. Polkan couldn’t have delivered my letter.” I’d stake a month’s salary that that was what the dog said. Never in my life have I heard of a dog that could write. Only noblemen know how to write correctly. Of course, you’ll always find some traders or shopkeepers, even serfs, who can scribble away: but they write like machines – no commas or full stops.

(From Diary of a Madman by Nikolai Gogol)

These writings indicate that Gogol had an insight about schizophrenia and its psycho-social impact.

Gogol was the founder of the critical realism in Russian literature. His influence greatly benefited to Nabokov and Dostoevsky.  Fyodor Dostoevsky once stated: We have all come out of Gogol's Overcoat'.  As elucidated by Samier and Lumby (2008) the Overcoat" explores the effects of bureaucratization on the individual, portraying the alienation, futile activity and servility caused in lower level functionaries through problems of loss of identity, the absence of meaningful work, and a lack of separation between public and private life.

Maguire (1994) wrote   Nikolai Gogol has been proclaimed a realist and a fantast; a subtle student of the human heart and a creator of cardboard characters; a revolutionary and a reactionary; a monger of the lewd and a hierophant of the sublime; a pathological liar and an honest anatomist of the soul; a self-promoter and a self-immolator; a typical Russian and a typical Ukrainian; a narrow nationalist and a universal genius; a jejune jokester and a tragic poet.

Nikolai Gogol wrote a number of humorous stories showing the discrepancies in human nature. But also stated that the longer and more carefully we look at a funny story, the sadder it becomes. May be he was correct. Deep down there are human suffering and tragedy in Gogol’s writings. Perhaps he showed the genuine nature of the mankind.

He wrote: “What is stronger in us — passion or habit? Or are all the violent impulses, all the whirl of our desires and turbulent passions, only the consequence of our ardent age, and is it only through youth that they seem deep and shattering?
He also wrote:  “Everywhere across whatever sorrows of which our life is woven, some radiant joy will gaily flash past.

Most of Gogol’s literary characters   do not have a persona. For instance his short story nose was based on an unrealistic story-(the nose leaves his face and develops a life of its own). D.S. Mirsky wrote that "The Nose is a piece of sheer play, almost sheer nonsense. In it more than anywhere else Gogol displays his extraordinary magic power of making great comic art out of nothing. According to Altschule (2015, Personal Communication) the Nose is clearly a fugue state.  His sardonic tale -Diary of a Madman shows the gradual personality decay in Axenty Ivanovich Poprishchin.

Ironically Gogol too experienced schizophrenic symptoms later in his life. Probably Gogol experienced pre Schizophrenic symptoms at the time when he was writing this short story. Without any background in psychology or medicine Nikolai Gogol vibrantly described the inner world of a schizophrenic patient via his short story. Therefore Gogol’s short story Diary of a Madman has   a literary as well as a clinical significance.


Moshe and the team (2002) identified five phases during Gogol’s adult life, strikingly matching the writer’s productivity and his mental condition: prodromal, predominant elation, prominent mood swings, overpowering depressions, and decline. Both the quantity and the quality of Gogol’s literary work matched the stages of his chronic illness.

Gogol may have had Schizotypal personality traits. As described by Brosey and Woodward (2015) Schizotypal personality traits are markedly elevated in psychotic disorders, especially schizophrenia spectrum disorders, relatively weakly correlated with positive and negative psychotic symptoms, and associated with greater cognitive impairment and lower quality of life. Perhaps Gogol’s Schizotypal personality trait gradually developed in to full blown Schizophrenia. However Moshe, Learner and Witztum (2002) hypothesized that Gogol was suffering from bipolar II disorder and had a narcissistic personality disorder. 

There are certain commonalties between Schizophrenia and Bipolar Disorder. Mania is the basis for the diagnosis of bipolar disorder (Altamura &Goikolea, 2008). However the positive symptoms of schizophrenia can resemble manic episodes.

 Faget-Agius and Lançon (2015) indicate that acute delirium is common in decompensated schizophrenia and bipolar disorder. Acute confusional states were seen in Gogol in his final years. These confusional states characterized by inattention and cognitive dysfunctions.  Moreover Vreeker and colleagues (2015) are of the view that Cognitive dysfunction is a core feature of schizophrenia and is also present in bipolar disorder.  

A study done by Cannon and colleagues (1997) showed that both schizophrenic patients and patients with bipolar disorder exhibit premorbid social maladjustment. The degree of functional deterioration among patients with bipolar disorder is not as severe as that seen in schizophrenic patients.


Gogol was described as an unusual person by his peers since his school days. He was named "mysterious dwarf". He had the inability to build or maintain satisfactory interpersonal relationships with his peers. He had a negative self picture about his personal appearance and he was immensely impacted by it. Gogol had a number of social maladjustments. Gogol’s fall and redemption represents Gogol’s view of the tragedy and absurdity of life.  

Gogol's whole spiritual effort, most critics see an 'attack of mental illness (Zenkovsky, 2014). In 1846 the critic Vissarion Belinsky suspected unsound mental health conditions in Gogol. Janka Z. (2004) believed that Gogol showed   cyclothymic symptoms. Upthegrove (2014) states that Gogol’s own mental illness, with features of religious mania and depressive stupor began after the composition of Diary and led to his untimely death in 1852. 

Moreover there were numerous signs to concur that Nikolai Gogol was impacted by the Diogenes syndrome in his old age. Cipriani et al (2014) highlighted that Diogenes syndrome (DS) is a behavioral disorder described in the clinical literature in elderly individuals: the classical constellations of symptoms of this condition include extreme neglected physical state, social isolation, domestic squalor, and tendency to hoard excessively (syllogomania). Gogol vividly wrote about syllogomania in Plyushkin. Plyushkin is a fictional Russian hoarder in Nikolai Gogol's novel Dead Souls that was published in 1842.

In the latter part of his life Gogol became a prisoner of a fanatical religious ideology. Fanatical religious ideology is one of the features of Schizophrenia. Rudaleviciene and colleagues (2008) viewed that religious delusions related to religiosity in schizophrenia and Grover and colleagues (2014) indicate that patients with schizophrenia also exhibit religious delusions and hallucinations.

He gave up his literary career. Just as his fictional character Poprishchin, Gogol had intra psychic conflicts and distorted perception. He became delusional and detached from reality. According to an eyewitness testimony Gogol experienced hallucinations and often reacted violently. He became paranoid and burned all his manuscripts, including the second part of Dead Souls.

In the final days he refused his meals. Refusal of food and self induced starvation has been noticed in Schizophrenia patients. Seeman (2014) stated that food refusal signals a severe and dangerous stage of psychotic illness. Disturbances in eating behaviors in patients with schizophrenia have been described as pica, gorging, anhedonic displeasure from food, and starvation associated with paranoid delusions (Yum et al., 2009).

In the early nineteenth century, Eugen Bleuler has reported cases of schizophrenia with eating disorders that were related to delusional ideas (Foulon, 2003). Bou Khalil and the team (2011) observed male patients known to suffer from schizophrenia and who develops distorted eating cognitions and disordered behaviors.

Gogol starved himself to death.  Gogol died in 1852 denouncing his great literary legacy.  Although Nikolai Gogol was a historical figure and his medical reports are unclear and most of them are unavailable it’s reasonable to think that Gogol suffered from Schizophrenia like his fictional character Axenty Ivanovich Poprishchin that was depicted in Diary of a Madman. His apparent pre symptoms helped him to create Axenty Ivanovich Poprishchin’s character more accurately describing inner psychological conflicts.  

 

Personal Communication

1)    Eric L Altschuler, MD, PhD  -Associate Professor, Department of Physical Medicine and Rehabilitation Temple University School of Medicine


Acknowledgements

1)     Dr. Mary Seeman, MDCM, FRCPC, DSc- Professor Emerita in the Department of Psychiatry University of Toronto 

2)    Professor Richard Lalonde – Department of Psychology York University Canada


References


Adityanjee, Aderibigbe, Y.A, Theodoridis, D, Vieweg, V.R.(1999).Dementia praecox to schizophrenia: the first 100 years.Psychiatry Clin Neurosci. ;53(4):437-48.

Altschuler, E.L.(2001).One of the oldest cases of schizophrenia in Gogol's Diary of a Madman. British Medical Journal. 323.7327:1475-1477.  

Altamura, A.C., Goikolea, J.M.(2008).Differential diagnoses and management strategies in patients with schizophrenia and bipolar disorder. Neuropsychiatr Dis Treat. ;4(1):311-7.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.)

Bou Khalil, R., Hachem, D., Richa, S.(2011). Eating disorders and schizophrenia in male patients: a review. Eat Weight Disord.  ;16(3):e150-6

Brosey, E. , Woodward, N.D .(2015).Schizotypy and clinical symptoms, cognitive function, and quality of life in individuals with a psychotic disorder. Schizophr Res.   19. pii: S0920-9964(15)00233-9.

Cipriani, G., Lucetti, C., Vedovello, M., Nuti, A.(2012). Diogenes syndrome in patients suffering from dementia.Dialogues Clin Neurosci .14(4):455-460.

Cannon, M., Jones ,P., Gilvarry, C., Rifkin, L., McKenzie, K., Foerster, A., Murray, R.M.(1997).Premorbid social functioning in schizophrenia and bipolar disorder: similarities and differences. Am J Psychiatry.  ;154(11):1544-50.

Dalzell, T.G.(2007).Eugen Bleuler 150: Bleuler's reception of Freud.Hist Psychiatry.  ;18(72 Pt 4):471-82.

Dixon, P.W.(2005). An extension of freud and jung’s theory of the relation of dream states to schizophrenia Current Psychology. Volume 24, Issue 1, pp 4-23.

Faget-Agius C, Lançon C.(2015). Acute delirium in decompensated schizophrenia and bipolar disorder. Rev Prat. ;65(2):235-40.

Foulon, C. (2003).Schizophrenia and eating disorders. Encephale;29(5):463-6.  

Goldstein, W . N. (1978). Toward an integrated theory of schizophrenia. Schizophrenia Bulletin, Vol 4(3),   426-435.

Gogol, N. (1972).Diary of a madman and other stories. London: Penguin Books.

Good, B. (1994).Medicine, Rationality and Experience. New York, NY: Cambridge.

Grover, S., Davuluri, T., Chakrabarti, S.(2014).Religion, spirituality, and schizophrenia: a review.Indian J Psychol Med.  ;36(2):119-24.

Hopper, K., Wanderling, J. (2000).Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHOcollaborative follow-up project. International Study of Schizophrenia. Schizophr Bull; 26: 835–46. 22.

Janka, Z. (2004). Artistic creativity and bipolar mood disorder.Orv Hetil. 15;145(33):1709-18.

Lester, D.(1975). The relationship between paranoid delusions and homosexuality.Archives of Sexual Behavior.Volume 4, Issue 3, pp 285-294.

Maatz, A., Hoff, P., Angst, J. (2015).Eugen Bleuler's schizophrenia-a modern perspective.Dialogues Clin Neurosci. ;17(1):43-9.

Maguire, R . A.(1994). Exploring Gogol. Stanford: Stanford U.P., 1994.

Moshe, K., Learner ,V., Witztum , E.  (2002) Creativity and Affective IllnessAmerican Journal of Psychiatry, 159(4), pp. 675-a–676.

Moskowitz, A, Heim, G.(2001).Schizophr Bull.  ;37(3):471-9.Eugen Bleuler's Dementia praecox or the group of schizophrenias (1911): a centenary appreciation and reconsideration.

Palha, A.P., Esteves, M.F.(1997).The origin of dementia praecox..Schizophr Res. 19;28(2-3):99-103.

Porter, J.E.(2011). Money and Mad Ambition: Economies of Russian Literature 1830-1850.Retrieved from http://digitalassets.lib.berkeley.edu/etd/ucb/text/Porter_berkeley_0028E_11639.pdf

Rudaleviciene, P., Stompe, T., Narbekovas, A., Raskauskiene, N, Bunevicius, R.(2008).Are religious delusions related to religiosity in schizophrenia? Medicina (Kaunas). 44(7):529-35.

Samier, E.,Lumby, J.(2008). Corruption, futility and madness: relating Gogol's portrayal of bureaupathology to an accountability era.

Sass, L.A., Parnas, J. (2003). Schizophrenia, Consciousness, and the Self.Schizophrenia Bulletin, Vol. 29, No. 3.   pp. 427–444.

Sayar,K.(2000). Schizophrenia and Culture. Retrieved from

Seeman, M.V.(2014).   Eating disorders and psychosis: Seven hypotheses World J Psychiatry.  22;4(4):112-9.   

Tölle, R.(2008).Eugen Bleuler (1857-1939) and German psychiatry.Nervenarzt.  79(1):90-6, 98.

Upthegrove, R. (2014).On Nikolai Gogol’s Diary of a Madman – reflection The British Journal of Psychiatry.(2) 156; DOI: 10.1192/bjp.bp.113.128322.

Versola-Russo, J.  (2006).Cultural and Demographic Factors of Schizophrenia.    International Journal of Psychosocial Rehabilitation.  10 (2), 89-103 .

Vreeker A, van Bergen AH, Kahn RS.(2015).Cognitive enhancing agents in schizophrenia and bipolar disorder.Eur Neuropsychopharmacol. 18. pii: S0924-977X(15)00117-0.

Yum, S.Y., Caracci, G., Hwang ,M.Y.(2009).Schizophrenia and eating disorders. Psychiatr Clin North Am.  ;32(4):809-19.

Zenkovsky , V.V.(2014) History Russian Philosophy.Routledge. 

3 comments:

  1. Interesting. So, there have been other famous figures than Nash. This motivates to read the BMJ paper too.

    ReplyDelete
    Replies
    1. Please, which BMJ paper?

      Delete
  2. Yes there had been several famous people with Schizophrenia

    ReplyDelete

Appreciate your constructive and meaningful comments

Find Us On Facebook