Beethoven's creative illness

One phase of Beethoven's life, between his 45th and 50th year, characterized by very low creativity and overwhelming stress situations, is subjected to a psychiatric interpretation. The historical background is briefly sketched and 5 precipitating stress factors are outlined. The symptoms of his illness are described, using Beethoven's letters as source material. A brief discussion of Beethoven's musical style prior to and after his illness is based on quotations from three eminent musical scholars. A resume of Beethoven's physical and psychological disorders during his life are given and the conclusion is reached that between 1815 and 1820, Beethoven experienced a creative illness which was psychotic in type, ended in recovery and radically changed his musical creativity.     

Tennessee Williams.

Tennessee Williams was one of the greatest American playwrights of all time. Born into a family with a strong history of serious mental illness, Williams seemed to have had several major depressive episodes during his early adulthood, along with severe and worsening alcohol and drug dependence and abuse involving sedatives and stimulants throughout his adult life. He received treatment of variable quality and duration in middle and old age. Despite his mental illness, Williams continued to be a productive writer even after age 60, although his later works were less successful. The authors consider both the strengths and limitations of Williams' coping mechanisms.     

The illness of Vincent van Gogh

Vincent van Gogh (1853-1890) had an eccentric personality and unstable moods, suffered from recurrent psychotic episodes during the last 2 years of his extraordinary life, and committed suicide at the age of 37. Despite limited evidence, well over 150 physicians have ventured a perplexing variety of diagnoses of his illness. Henri Gastaut, in a study of the artist's life and medical history published in 1956, identified van Gogh's major illness during the last 2 years of his life as temporal lobe epilepsy precipitated by the use of absinthe in the presence of an early limbic lesion. In essence, Gastaut confirmed the diagnosis originally made by the French physicians who had treated van Gogh. However, van Gogh had earlier suffered two distinct episodes of reactive depression, and there are clearly bipolar aspects to his history. Both episodes of depression were followed by sustained periods of increasingly high energy and enthusiasm, first as an evangelist and then as an artist. The highlights of van Gogh's life and letters are reviewed and discussed in an effort toward better understanding of the complexity of his illness.     

L'apport d'une classification internationale des troubles mentaux dans la compréhension de la psychopathologie de Wolfgang Amadeus Mozart (1756-1791)

The ICD-10 (International classification of diseases, 10th revision), in its chapter dealing with mental disorders, has been constructed in a way that allows it to be used in various cultural settings. This classification can also provide a tool for diagnosing people who lived before the conceptualization of modern psychiatric nosology. Mozart (1756-1791) is perhaps one of the most famous composers, due to the genius of his music but also as a result of his controversial "temperament". Beyond the reputation that arises from these sources, the exact personality and psychiatric disorder(s) from which Mozart may have suffered are still not sufficiently understood. The study of Mozart's letters and his biography leads us to consider the psychiatric disorders from which he may have suffered. We detail some elements of his biography in connection with plausible psychopathological episodes, thus drawing new conclusions about the disorders from which he suffered. Mozart was born in Salzburg in 1756 to a musician father and a mother who had already given birth to six other infants, only one of whom was still living at the time, a four-year-old sister. He became a talented composer but was described as unpretentious, kind, cheerful and extraverted. During his adolescence, there is no indication of the presence of any mental disorder. But later, in accordance with previous literature, it seems that he demonstrated depressive episodes, some of which were severe and correspond to the criteria of the international classification ICD-10. In June 1788 for example, Mozart wrote: "… if such black thoughts did not come to me so often, thoughts which I banish by a tremendous effort, things would be even better." This remark constitutes a relatively specific element in favor of a depressive episode, even if no other clues appear in his letters from this period. In 1790, Mozart's words then explicitly indicate that he suffered from a severe depressive episode: he mentioned a depressed mood, a markedly diminished interest in his activities (e.g. in composing), a diminished ability to concentrate, loss of energy and feelings of excessive guilt. Thus, Mozart described five criteria for the diagnosis of a major depressive episode. "If people could see into my heart, I should almost feel ashamed - to me everything is cold - cold as ice." However, others have claimed the occurrence of some depressive episodes (for instance after the death of his mother) that are excluded by this nosological conception. Also, the arguments put forward by other authors supporting the occurrence of manic or hypomanic episodes (thus constituting a bipolar disorder diagnosis) are not supported by sufficient historic proof. He wrote letters which were incoherent in some parts; but hypomanic episodes can be excluded, as letters written the days before and after these above-mentioned ones are clearly and adequately conceived. This excludes the likelihood of a hypomanic state of duration of more than four days, as required by ICD-10 criteria. Thus, there are no diagnostic criteria for a bipolar II disorder (i.e. the presence of depressive and hypomanic episodes). The diagnosis of a cyclothymic disorder is more difficult to exclude: the length of hypomanic periods is not specified in classifications, but the symptoms must cause clinically significant distress or impairment in social functioning. Mozart suffered social and interpersonal difficulties (i.e. lack of security, affective loneliness), which are at least partially related to some of his behaviors and/or mood instability. This could be due to the presence of a personality disorder. Mozart featured personality traits which correspond to the criteria for dependent personality: difficulties acting on his own (for instance with regard to his relationship with his father); need to be nurtured and supported by others (i.e. his wife); feeling uneasy or helpless when alone. Traits of the borderline personality disorder can also be drawn from his correspondence: efforts to avoid real or imagined abandonment; impulsiveness (also described in some of his biographies); affective instability due to a marked reactivity of mood (which may account for some clinical situations having been described as depressive episodes); and a feeling of emptiness. The current conceptualization of psychiatric disorders allows us to conclude that Mozart suffered from depressive episodes in the background of a personality disorder characterized by dependent as well as borderline traits. Nevertheless, this conclusion may be challenged by authors who consider that the mood lability and brief hypomanic-like episodes that Mozart featured represent core characteristics of the so-called "soft bipolar spectrum" rather than a personality disorder feature. Indeed, there is a growing trend to lower the time criterion for hypomania and even to include hyperthymic traits (which are indisputably present in Mozart) as a constitutive element of a bipolar II disorder in the presence of depressive episodes. Thus, the psychiatric history of Mozart exemplifies nosological uncertainties that are still a source of debate in today's psychiatric research.     

Koro-like symptoms in a recurrent depressive disorder

We report the case of a German male with a major depressive episode who also suffered from the terrifying perception that his penis was shrinking. These so-called koro-like symptoms (KLS) had also been present in earlier depressive episodes and subsided in the symptom-free interval of the recurrent depressive disorder. Under sufficient antidepressant medication with venlafaxine and lithium not only KLS but also the depressive symptoms remitted. The course of illness provides further evidence that KLS are not a distinct clinical entity in Western countries, but represent a concomitant syndrome that requires treatment of the underlying illness.     

The naturalistic course of unipolar major depression in the absence of somatic therapy

The goal of the study was to describe the naturalistic course of unipolar major depression in subjects not receiving somatic therapy for their depressive illness. Affectively ill individuals were recruited into the Collaborative Depression Study and followed prospectively for up to 15 years. One hundred thirty subjects who recovered from their intake episode of major depression subsequently experienced a recurrence that went untreated for at least 4 weeks following onset of the recurrence. The duration of the recurrent episode was examined using survival analytic techniques. Of the 130 subjects, 46 obtained somatic therapy at some time during the course of their depressive illness, while 84 subjects received no somatic therapy throughout their entire depressive episode. Survival analysis, which accounts for these 46 individuals by censoring their episodes at the time treatment was obtained, yielded a median time to recovery of 23 weeks. In the subsample of 84 subjects whose depressive illness went untreated from its inception through its resolution, the median time to recovery was 13 weeks. These results suggest that there is a high rate of recovery in individuals not receiving somatic treatment of their depressive illness, particularly in the first 3 months of an episode. Because treatment-seeking behavior is known to be associated with a worse prognosis, 23 weeks probably represents a lower-limit approximation of the median duration of an untreated depressive episode.     

Precursors of depression in World War II veterans 40 years after the war

The impact of wartime stress and other psychosocial and health variables on depressive illness in the 40 years since the Second World War is examined in this study of Australian male prisoners of the Japanese and other veterans. A random sample of 170 surviving members of the captured Eighth Division of the Australian Army residing in Sydney in 1983 (POWs) was compared with a similar sample of 172 veterans who fought in Southeast Asia during the war but were not imprisoned (non-POWs). Multiple regression analysis involving nine predictor variables revealed that self-reported nervous illness during the war and depressive illness since the war had pronounced independent effects on current depression as measured by the Zung Scale. Being married and better educated had significant protective effects against depression for the non-POWs while being employed and having higher socioeconomic status were protective for POWs. A clear linkage was shown from wartime nervous illness to postwar depressive illness to present-day depression.     

Impact of medical comorbid disease on antidepressant treatment of major depressive disorder

A major factor in evaluating and treating depression is the presence of comorbid medical problems. In this paper, the authors will first evaluate studies showing that medical illness is a risk factor for depression. The authors will review a series of randomized, controlled studies of antidepressant treatment in subjects with major depressive disorder (MDD) and comorbid medical illnesses (myocardial infarction, stroke, diabetes, cancer, and rheumatoid arthritis). Most of these studies report an advantage for an active antidepressant over placebo in improvement of depressive symptoms. The authors also will review a series of studies in which the outcome of antidepressant treatment is compared between subjects with MDD with and without comorbid medical illness. In these studies, subjects with medical illness tend to have lower improvement of depressive symptoms and higher rates of depressive relapse with antidepressant treatment compared with MDD subjects with no medical comorbidity. In addition, the authors will review hypotheses on the mechanism of the interaction between medical illness and clinical response in MDD. The paper will conclude that medical comorbidity is a predictor of treatment resistance in MDD.     

Recurrent depressive disorder in Caspar David Friedrich. A pathographical approach with operationalized diagnosis

Caspar David Friedrich (1774 - 1840) is one of the most important German Romantic painters. In his paintings, he prototypically represents the melancholy, which has been mentioned by his contemporaries and later biographers. Art scientists have also referred to his melancholy for the interpretation of his work. From a medical point of view, there are only two pathographies which remain inconclusive. Having applied diagnostic criteria for psychiatric disorders to his letters and publications, to statements of his contemporaries and to his art, we propose that he had suffered from a recurrent major depression which occurred in 1799 for the first time. At least three depressive episodes followed before he was struck by a stroke in 1835. There are epidemiological, psychodynamic and personality-typological reasons supporting our diagnostic assumption. The course of his depression corresponds to phases of reduced creativity, to the chosen techniques and motives. Finally we discuss the implications of our approach for the pathographical method in general.     

Course of atypical psychoses]

An attempt was made to classify the atypical psychoses according to cross-sectional psychopathological criteria. We were able to separate two groups from a group of benign schizophrenics. The latter served more as a comparison group and were in every way similar to the nuclear group, except for a better social prognosis. Group C (atypical manic depressive illnesses) which was closer to manic depressive illness than the other two groups, differs from it by thought disorders and delusional experiences. In the further course of the illness, after a few schizophrenic symptoms had appeared once or repeatedly during the acute stage, the typical features of manic depressive illness came more and more to the fore. In group A (mixed psychotic syndrome) manic depressive and schizophrenic symptom complexes appeared for quite some time during the acute stage with approximately equal clarity and significance. In the further course, during which manic depressive phases as well as schizophrenic thrusts can make their appearances, one can often see the development of a 'hypomanic defect'. Systematised delusions, as well as grimacing and circumstantiality, can also persist frequently. On the whole, however, it is difficult to recognize the defect states from their original state once the illness has settled down. A classification of the atypical psychoses and their differentiation from typical manic depressive illness or nuclear schizophrenia is necessary, at least, because of the worse, respectively better, social prognosis of the atypical psychoses. This investigation should be continued further by using as control groups bi- and unipolar affective psychoses and nuclear schizophrenics with a severe course. The subgroups of the atypical psychoses will be used to evaluate different long-term therapies in a further study.     

Differences in incidence of suicide attempts during phases of bipolar I and II disorders

Background:  Differences in the incidence of suicide attempts during various phases of bipolar disorder (BD), or the relative importance of static versus time-varying risk factors for overall risk for suicide attempts, are unknown.
Methods:  We investigated the incidence of suicide attempts in different phases of BD as a part of the Jorvi Bipolar Study (JoBS), a naturalistic, prospective, 18-month study representing psychiatric in- and outpatients with DSM-IV BD in three Finnish cities. Life charts were used to classify time spent in follow-up in the different phases of illness among the 81 BD I and 95 BD II patients.
Results:  Compared to the other phases of the illness, the incidence of suicide attempts was 37-fold higher [95% confidence interval (CI) for relative risk (RR): 11.8–120.3] during combined mixed and depressive mixed states, and 18-fold higher (95% CI: 6.5–50.8) during major depressive phases. In Cox's proportional hazards regression models, combined mixed (mixed or depressive mixed) or major depressive phases and prior suicide attempts independently predicted suicide attempts. No other factor significantly modified the risks related to these time-varying risk factors; their population-attributable fraction was 86%.
Conclusions:  The incidence of suicide attempts varies remarkably between illness phases, with mixed and depressive phases involving the highest risk by time. Time spent in high-risk illness phases is likely the major determinant of overall risk for suicide attempts among BD patients. Studies of suicidal behavior should investigate the role of both static and time-varying risk factors in overall risk; clinically, management of mixed and depressive phases may be crucial in reducing risk.     

Use of a rating scale in transcultural psychiatry]

The Psychopharmacological Studies Group of Fann, Dakar, considered the cultural expression of mental illness as it would help for a new definition of the nosographic frames, and inside of them, the appreciation of symptoms. This new definition would be applied "universally" if it may be considered that some symptoms are "culture-free" and others deeply marked by the discourse held by the person or by his social group. The use of valuation scales for symptomatic change during a treatment (here anti-depressive one) become harder by the undifferenciation of these two types of symptoms. Further, it may exist nosographic masks which can hide more curable substructures ; as often happens here, in masked depressions when the presented symptoms are those of acute or chronic psychotic manifestations. The efficacy of depressive treatment is then remarkable.