Tuesday, November 22, 2016

Nietzsche and Bipolar Disorder

Friedrich Nietzsche (1844-1900) lived at the time when bipolar disorder, also known as manic depression, was not recognised. The first major work that placed this condition on the map of psychiatric nosology was by Emil Kraepelin, a German psychiatrist, who published his findings in a book Manic-depressive Insanity and Paranoia in 1913. Sadly, too late for Nietzsche!

   I first proposed the diagnosis of manic depression in relation to Nietzsche at a conference organized by the Friedrich Nietzsche Society in Manchester in 1996. I also discredited the century-old diagnosis of tertiary syphilis. It still took another four years to publish my findings. Various peer reviewers (the so called ‘experts’) rejected it, not because my paper contained any factual errors but because it challenged their ossified, repeatedly expressed views. I owe much of my determination to pursue my course to Thomas S. Kuhn’s book The Structure of Scientific Revolutions, in which the author famously said that the old paradigms die only with their proponents. The tenacity to adhere to an idea, no matter how discredited, has the intensity of a delusion. I am astonished that anything new is ever published!

   Nietzsche had no signs or symptoms of tertiary syphilis, and the diagnosis was made in accordance with the prevailing paradigm of his time. More than 60% of all inmates in Europe’s mental asylums carried that diagnosis, despite no existing tests for the condition. The first (non-specific) test for syphilis, the Wassermann Test, was invented six years after Nietzsche’s death. The specific tests for Treponema Pallidum (a syphilitic pathogen) were not designed until the mid-20th century. Today, no doctor of a sound mind would have diagnosed syphilis in a patient without performing these tests.

   My full diagnosis of Nietzsche’s mental condition (based on DSM-IV) was “bipolar affective disorder, consisting of brief manic episodes with some psychotic features, alternating with longer depressive phases studded with somatic symptoms”. There was no doubt that in the last 11 years of his life, Nietzsche suffered from dementia, in my view of the multi-infarct type. (For a detailed discussion, please read my original paper here). I arrived at my diagnosis after a careful reading of all Nietzsche’s published and many unpublished works, his letters and accounts of his friends. I also examined his handwriting at Weimar Archive and confirmed that it fluctuated in tandem with his moods (a clue I got when reading Kraepelin). The doctors who originally diagnosed Nietzsche as syphilitic (including the famous Professor Otto Binswanger in Jena) were not acquainted with these sources. Two other researchers independently came to similar conclusions as mine. One of them, Professor Rogé (a psychiatrist) in France, published a book, Le Syndrome de Nietzsche, a year before my paper, and Richard Schain (an American neurologist) published a book The Legend of Nietzsche’s Syphilis. I was very heartened that they used exactly the same arguments against the diagnosis of syphilis as I did. Rogé, like myself, proposed bipolar disorder, while Schain suggested schizophrenia. Schain later publically conceded that bipolar disorder was most likely, and I salute his scholarly integrity.

   Then suddenly it became very fashionable to rediagnose Nietzsche’s condition and a flurry of new publications appeared. I shall briefly discuss a few of them.

   Leonard Sax, who in 2003 proposed a diagnosis of brain tumour, is not a neurosurgeon but a researcher into gender problems of children and adolescents. He ignored the fact that a valid diagnosis of this kind can be made either by post-mortem, inter-operatively, microscopically and/or by a brain CT scan – but not a 100 years after the patient’s death. Dr Sax attributed Nietzsche’s severe migraines (from which the philosopher had suffered since boyhood) to his “slowly growing right-sided retro-orbital meningioma”. In that case, it must have been growing for some 45 years, the longest in medical history! I feel like exclaiming, in the manner of Jesus Christ dying on the cross: “God, forgive this man who knows not what he is saying”.

   A group of neurosurgeons from California (Owen at al.) joined the race in 2007 by proposing “a right-sided medial sphenoid wing meningioma”. To suit their hypothesis, they shifted Nietzsche’s headaches from his boyhood years to his late 20s. Moreover, they suggested to exhume Nietzsche’s remains to prove their point – perhaps a step too far in serving their professional narcissism!

   In 2006, Orth and Trimble suggested that Nietzsche had frontotemporal dementia and argued that it enhanced his creativity. They dated the onset of this illness to around the time when the philosopher was writing On the Genealogy of Morals (1887), which is recognised as his most important philosophical text. Dementia implies a global cognitive impairment, and although occasionally some artistic creativity has been linked with frontotemporal dementia, it is inconceivable that a major philosophical work, which requires a very high level of abstraction and an impeccable use of language, can be a product of a dementing mind.

   In 2008, Hamelsoet at al. proposed that Nietzsche suffered from a rare genetic condition called CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts). Its prevalence is four per 100,000 adults, compared with the much more common bipolar disorder of one-three per 100 adults. This hypothesis, although testable on a live patient with the use of brain imaging and DNA studies, cannot be tested on someone dead for more than a century. Also, one of Nietzsche’s parents should have had this condition and of this there is no evidence. In medicine, rare conditions are rare and this diagnosis should be best passed by in silence.

   What is striking about the above researchers is their tendency to shift facts in Nietzsche’s life to suit their diagnoses. Much has been said about Nietzsche’s so-called blindness, but the possibility of hypochondriasis has not been considered. I have walked in his footsteps and can testify that good eyesight is required to be able to walk in the places he did. In addition, his handwriting, although fluctuating with his moods, was certainly not that of a blind person!  

   Professor Julian Young, in his book Friedrich Nietzsche: A Philosophical Biography (2010), copied my diagnosis verbatim, without acknowledgement. If plagiarism is the highest form of flattery, then I feel immensely flattered. My review of his book appears here.

   When in 1996, I discussed my rediagnosis of Nietzsche with Felix Post, a leading British psychiatrist, he asked me a pertinent question “why does it matter, now?”. My reply at the time was “because in medicine truth matters more than fiction”. However, I continued to ponder over his question and arrived at a more stimulating response: “because bipolar disorder was likely to influence his philosophical thought and creativity”. Much inspired by the research of Professors Nancy Andreasen (condensed in her book The Creative Brain) and Kay Jamison (her book Touched with Fire) into the relationship between bipolar disorder and creativity, I have been focussing on this issue. Many of my findings have been published by the Indo-Pacific Journal of Phenomenology, and there is more to come.