One of the oldest cases of schizophrenia in Gogol's Diary of a Madman

One of the oldest cases of schizophrenia in Gogol's Diary of a Madman
Eric Lewin Altschuler, assistant director
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Besides intrinsic historical and literary interest and clinical usefulness by providing good exemplar cases, the study of the history of a disease can provide clues to its pathogenesis—it is necessary, but not sufficient, that the cause of a disease be at least as old as the disease itself. Here I note one of the oldest and most complete descriptions of schizophrenia, in Nicolai Gogol's classic short story Diary of a Madman (1834).1

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Summary points

Nicolai Gogol's classic short story Diary of a Madman (1834) contains one of the earliest, and most complete, descriptions of schizophrenia
Beyond intrinsic and historical interest, this case is important because it has implications for the antiquity, and possibly the aetiology, of schizophrenia
From a literary point of view, the story can be appreciated as a sketch—albeit a most brilliant one—of the disease
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History of schizophrenia
It might seem unnecessary to need to prove that schizophrenia is an old disease because “every town had a fool.” However, the only case of schizophrenia that possibly meets the diagnostic criteria for the disease (see box) much before 1800 is that of Edgar or Poor Tom in Shakespeare's King Lear.3–5 This has led to the tentative suggestion that some factor—a virus, environmental toxin, or perhaps “modernity itself”—in play since 1800 has greatly increased the incidence of schizophrenia.3 As the signs of schizophrenia can be noticed without any laboratory test or even specialised training, the extreme dearth of old cases of schizophrenia cannot trivially be due to lack of advanced diagnostic equipment or medical education in days of yore. The “mad” ravings of a local town “fool” could have been secondary to mania, temporal lobe epilepsy,6 substance misuse or withdrawal, vitamin deficiencies, or heavy metal poisoning.

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Diagnostic criteria for schizophrenia (according to Diagnostic and Statistical Manual, third edition2)

The person must have at least two out of five symptoms—(i) delusions, (ii) hallucinations, (iii) disorganised speech, (iv) grossly disorganised or catatonic behaviour, or (v) negative symptoms (such as alogia, avolition, etc)—for a substantial portion of a one month period
Continuous signs of disturbance must continue for at least six months
Since the onset of disturbance, the person must have substantial social or occupational dysfunction
Required exclusion criteria are substance misuse or dependence, general medical condition, mood disorder, and pervasive developmental disorder
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Nicolai Gogol
Nicolai Gogol was born in the Ukraine in 1809. He moved to St Petersburg in 1829 and got a job through a friend at a government ministry. From 1834 to 1842 he published five tales about the Ukraine, including Diary of a Madman (1834), The Nose (1836), and The Overcoat (1842). During this time he also wrote numerous other stories, plays, and essays. In 1842 he published part one of his great novels, Dead Souls.

Gogol spent much of his later years outside of Russia. In 1848 he made a pilgrimage to Jerusalem and apparently had increasing religious mania in his final years. He completed part two of Dead Souls in 1852 but then burnt the manuscript on 10-11 February of that year and died on 21 February, perhaps from self starvation.1 Gogol is one of the greatest Russian writers and served as an inspiration to later writers such as Nabokov and Dostoevsky.1

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Diary of a Madman and diagnosis of Poprishchin
Diary of a Madman is in the form of the diary of Axenty Ivanovich Poprishchin, a Ukrainian civil servant in his 40s. The story starts with an entry for 3 October (year 1). (The story does not list years. I use them as a chronological aid in discussing the story.) The day does not start well for Poprishchin, who gets up late and is late for work. Poprishchin notes in his diary that later that day he thinks he hears two dogs talking to each other in Russian. He further notes: “‘It can’t be true, I must be drunk.' But I hardly ever drink.” Things go downhill quickly: Poprishchin has increased trouble at work, and on 13 November (year 1) he notes that he reads letters from the dogs to each other.

On 5 December (year 1) Poprishchin records that he read in the newspaper about the dispute of the succession of King Ferdinand VII of Spain (1833). On a date written “April 43rd, 2000” (April of year 2?) he writes: “Today is a day of great triumph. There is a king of Spain. He has been found at last. That king is me. I only discovered this today.” The date for the next entry in the diary is “86th Martober, between day and night” (October of year 2?). Poprishchin goes to work after a three week absence and then proceeds to greatly offend his boss and coworkers. Later, in an entry dated as “No date,” Poprishchin writes that he had been in a large crowd but “did not reveal [his] identity [as King Ferdinand VIII]” The date of the last entry of the diary is An external file that holds a picture, illustration, etc.
Object name is alte5378.f1.gif (February of year 3?). Poprishchin notes that people are pouring cold water over his head, his head is spinning, the sky whirls.

Diagnosis of Poprishchin

Starting in possibly April of year 2, Poprishchin has the persistent delusion that he is King of Spain. This delusion continues for the rest of the story, a period of at least three weeks (that he did not go to work) and probably months or longer. His condition worsens progressively, and throughout this time he shows disorganised behaviour by not going to work and then acting bizarrely when he does. This is also occupational dysfunction. Before the start of his delusion that he is King of Spain (probably not coincidentally the diary entry with a bizarre date “April 43, 2000”), Poprishchin experiences a “prodromal” period, which includes the hallucinations that dogs are speaking to each other in a human language and the hallucination or delusion that the dogs are writing letters to each other. The text of the diary indicates that Poprishchin's speech is becoming increasingly disordered, the date of the final entry of the diary being only one example. When Poprishchin reads about the trouble with the succession of the King of Spain, he seems to take the problem personally (which is ridiculous because he is not even a citizen of Spain). This is an example of the sign of “ideas of reference” (perhaps the oldest such example), which is often seen in schizophrenia.2 In modern times ideas of reference commonly manifest as the notion that a television newscaster or other television personality is speaking directly to the schizophrenic patient.

There is no evidence for pervasive developmental disorder, major depression, temporal lobe epilepsy, or a general medical condition in Poprishchin. He does not demonstrate any of the typical behavioural signs of mania such as going without sleep, hypersexuality, or profligate spending. Mania can produce delusions such as that one is a king. However, we might expect such a delusion to manifest itself differently in a manic patient than it does in Poprishchin. Indeed, in the diary entry dated “No date,” Poprishchin says that he was in a crowd but did not point out to anyone that they were in the presence of a king. A manic patient would perhaps take such an opportunity to make a grand pronouncement. There is no evidence of substance misuse or dependence by Poprishchin, and alcoholism is explicitly ruled out: “But I hardly ever drink” (3 October (year 1)). This exclusion is important as alcohol misuse or dependence is not uncommon in Gogol's writings. The fifth decade of life is an old but certainly not unheard of age for a psychotic break.7

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Context of Gogol's story
Gogol's story thus contains one of the oldest and the most extensive description of schizophrenia. Given that the story contains all the inclusion and exclusion criteria for schizophrenia, and the story's unity and title, it suggests there must have been a case(s) in the Ukraine or Russia that Gogol observed. However, it cannot be ruled out that Poprishchin is a montage constructed from pathological features that Gogol observed in various individuals or in literary characters such as Kapellemeister Kreisler, a creation of German writer E T A Hoffmann (1776-1822). Indeed, the original title of Gogol's story apparently was “The Diary of a Mad Musician”8—a clear reference to Hoffmann. Hoffmann's works are extensive and complex, and contain many curious characters. In them I have not yet found a case of schizophrenia, and certainly no descriptions laid out with the clarity and unequivocal manner of Gogol's case. Gogol may have been inspired by reports in newspapers such as The Northern Bee (which Gogol ridiculed and satirised in Diary of a Madman) of inmates at insane asylums.8 Further study of these reports and the works of Hoffmann for cases of schizophrenia might be warranted. Gogol's apparent case of schizophrenia in the Ukraine or Russia (or Germany) no later than 1834, taken in conjunction with other cases in England and France in 1809,9,10 show that schizophrenia was already widely disseminated in Europe by early in the 19th century, making it increasingly unlikely, though not impossible, that schizophrenia was largely unheard of before 1800.

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Discussion
If schizophrenia is an old disease then why are there so few early reports? There are at least four possible explanations. Firstly, the increase in the reported number of cases of schizophrenia may be an artefact of the tremendous increase in the number of physicians and medical researchers in the past 200 years. Secondly, modern descriptions of schizophrenia, starting with Kraepelin's work on dementia precox,11 have greatly facilitated the recognition of schizophrenia by clinicians, thus possibly accounting for the tremendous increase in cases. Thirdly, since a diagnosis of schizophrenia requires diminished social functioning, most people with schizophrenia in the past would have been unable to write or ensure dissemination of information about their condition. Furthermore, given the typical downtrodden plight of people with chronic (untreated) schizophrenia, those with the disease may not have been an enticing topic for description by non-patient authors. Finally, there may indeed have been some aetiological agent new since 1800 responsible for the great increase in the number of cases. The apparent dearth of old cases of schizophrenia is consistent with an ingenious hypothesis put forward to explain a preponderance of patients with schizophrenia in the northern hemisphere having been born in the first quarter of the year12: schizophrenia occurs in individuals with “loaded” genetic backgrounds whose mothers had low levels of vitamin D in the second and third trimesters of pregnancy.