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Fiodor Dostoievski: between epilepsy and neurosis

 

 

Carlos G. Musso

Nephrology Division

Hospital Italiano de Buenos Aires - Argentina

 

 

                                   “ The devil fights against God and the battlefield is the human heart”

  

                                                                                                                            Fiodor Dostoievski

 

 

Summary

 

Fiodor Dostoievski is one of the greatest writers in history; the cornerstone of his work are issues about which he was worried all his life; like guilt around imagined patricide, his addiction to gambling, the meaning of suffering, and the agonies of psychological suffering.

Even though it has been mentioned that he suffered from epilepsy, there is some controversy surrounds the reliability of this diagnosis. Authors such as Sigmund Freud believe that Dostoievski suffered from a serious hysterical neurosis which simulates epileptic fits a condition known as epileptiform hysteria. Among the strongest arguments in support of his view, Freud notes that the crisis began after his father’s death for which he had felt as responsible as if he had caused it. The epileptic fits might be understood as little “transactional” deaths with which he tried to soothe his patricidal guilt. 

His illness is reflected in several of his novels, such as the seizures of Prince Muchkin in “The Idiot” and in the illegitimate son of old Pavlovitch, in “The Karamazov Brothers”.

            An alternative diagnosis for his clinical condition is the convulsive variant of  vasovagal syncope.  Finally, my choice among these differential diagnoses is epilepsy, not only because the clinical description of his fits, is typical of epilepsy with a generalized tonic/clonic seizures, but also it is very difficult that a person suffering from hysteria-neurosis with such severe symptomatology to have had enough available energy to sublimate it in the creation of such literary masterpieces as the ones created by Fiodor Dostoievski.  

Introduction

Fiodor Dostoievski is one of the greatest writers in history and even though he magisterially described the labyrinths of the human soul, as Sophocles and Shakespeare did, he also knew how to reflect its inconsistency and ambiguities.  Tthrough his strong influence on Sigmund Freud who greatly admired him as a writer, he can be considered the father of modern psychology.

The cornerstones of his work are matters about which he worried all his life:

·  Guilt around imagined patricide

·  His addiction to gambling

· The meaning of suffering or suffering as a learning experience

· The agonies of psychological suffering.

Dostoievski: His life

The Russia in which he lived was very different than Western Europe. In the middle of the nineteenth century his country was still feud.

Fiodor Dostoievski ´s father worked in the Poor People Hospital in Moscow, where he was born in 1821 and where he and his whole family continued to live.

His childhood was influenced by the sad hospital environment, by his father´s  rudeness and  the forebearance and sweetness of his mother. She died in 1837 and his father decided to send their children to the Military School in Saint Petersburg while he left his medical job to administer the family farm.

The military school was an old royal castle where according to a legend the mad and cruel Tzar Paul the First had been assassinated by his son, the future Alexander I. This story of madness and patricide deeply impressed the young Dostoievski who saw this drama reflected in his own conflict with his father; a feeling that would color his literary work and life.

At that time, he began to show the first symptoms of compulsive gambling, a sickness that would cause him great problems and much misfortune.

In 1839, the peasants who worked in his father ´s field, tired of their master ´s abuse of themselves and their families assassinated him.  When Fiodor received the news he felt as guilty as if he had committed the crime himself because this was something that he had long wanted to do.  At this time he suffered an epileptic fit for the first time.  In 1845, he wrote his first piece named: the poor people that immediately became an impressive success, spoilt him by the favourable critical comments and gave him and early taste of glory.  However, his later works were judged severely by the same critics, which led to feelings of frustration and a deep depression. He started to go regularly to underground intellectual circles where antitzarist ideas were common. One day the Tzar´s police broke into one of those meetings and all those present, including Fiodor, were taken to prison. After eight months of imprisonment, he was condemned to death but, at the moment he was about to be shot, the Tzar’s pardon arrived and the execution was cancelled. The feeling of being on the verge of death, which was stamped on his soul, he later described in his story, “The Idiot”.  Even though he was pardoned, his crime had not been forgiven so he was sent to Siberia where he worked in harsh conditions for four years and then he served as a frontier soldier. During this time of suffering he turned to religion and came to the conclusion that adversity is the best fountain of learning.

In 1854 he married a young widow. His marriage was unhappy and she died 10 years later in 1864.  In 1867 he married for the second time to the woman who used to be his shorthand secretary. That period was one of the worst in his gambling history, so he lived in debt hiding from his creditors. However, due to Fiodor´s gift for writing and his wife’s pragmatic sense and administrative capability, they survived and reached the point when they could live without worries. However, misfortune returned when their little daughter, Alioska, died in 1878.  Between 1879 – 1880 he wrote the book, “The Karamasov Brothers”, that many consider his masterpiece.  Dostoievski died on February 9, 1881 of emphysema, just a month before the death of Tzar Alexandre the II, who had pardoned him 24 years earlier.

Dostoievski: His Illness

Controversy surrounds the authenticity of his epilepsy. Authors such as Sigmund Freud believe that Fiodor suffered from a serious hysterical neurosis which simulates epileptic fits a condition known as hysteria – epilepsy. Among the strongest arguments for this view, Freud notes that the crisis began after his father’s death for which he had felt as responsible as if he had caused it. The epileptic fits might be understood as little “transactional” deaths with which he tried to soothe his patricidal guilt.  These feelings of regret were subliminally present in all his work, especially in “The Kamarazov Brothers“      

The only time when he had no epileptic fits was during the four years he worked in Siberia, possibly because in prison he endured enough punishment to assuage his guilt.

Today we know that  most of the cases labelled as witchcraft in the Middle Ages was probably hysteria-epilepsy. Characteristic of these was the presence of  stigmata diaboli (devil marks), by which Satan marked his victims, patches of skin or mucosal of anesthesia or physical crisis where the victim arches his/her spine (opisthotonus). The interpretation of these signs and symptoms as witchcraft persisted until the end of the nineteenth century, when Charcot  studied hysteria and realized that the ancient signs of witchcraft matched those of hysteria: the old stigmata diaboli became the patterns of hysteria: a psychiatric disease but not a neurological one.

Some authors make the distinction between hysteria-epilepsy and epileptiform hysteria. Those who speak of hysteria-epilepsy believe that it is a hybrid of hysteria and epilepsy, and reserve the name, epileptiform hysteria, for the crisis represented by hysteria-neurosis. It is also possible that these entities coexist, in which case each aspect of the crisis maintains its particular characteristics.

Discussion

 

Generally Dostoievki´s illness is known as epilepsy.

Epilepsy refers to a group of chronic entities whose common clinical manifestation is seizures of sudden onset, sudden attacks with loss of consciousness and involuntary movements. However, although fits are an important sign in the diagnosis of epilepsy, not all fits are due to epilepsy. In 70% of adults and 40% of epileptic children, the seizures are partial (focal). In most of these patients a non-specific cause is found, nevertheless its presence indicates a degree of disturbances in neuronal activity.   

This illness is reflected in several of Dostoievki´s novels. We see it in the seizures of Prince Muchkin in his book “The Idiot” and in the bastard son of old Pavlovitch, in “The Karamazov Brothers”. Even when the author describes epilepsy in one of his characters, he is playing with the classical idea of the divine nature of this illness (the illness of the Gods), the notion of its supernatural origin of the character, as is the case of Principe Muchkin, who apparently is a mixture of Christ and Don Quixote.  

Differential diagnosis of his illness

A) Below I describe some of the characteristics of this illness that coincide with events in the life of this great writer: 

Contemporary descriptions of his crisis correspond to a type of epilepsy called epilepsy with generalized tonic clonic crises.

His friend Strakhov was present at one of his fits:

"He stopped for a moment as if he was looking for a word to express his thoughts and he opened his mouth.. Suddenly, a strange noise came out of his half opened lips, prolonged, absurd, and he fell to the floor unconscious, in the middle of the room".

- The average age when epilepsy appears is from six to 35 years old, with a peak at 17. Dostoievski had his first fit at Military School, at the moment he received the tragic news of his father’s murder, when he was 14.

-Crises usually are preceded by an aura that sometimes consists of an intense feeling of happiness. Dostoievski says:

“for some moments I know such happiness that it  is impossible to conceive in normal times and that people can not even imagine. I experience complete harmony inside me and in the world, and it is so strong, so sweet that I could give ten years of my life or maybe my whole life, for a few seconds of pleasure”

- Loss of sleep tends to increase the frequency of these crises. Some contemporaries say that, on the days before a manuscript was due to an editor, he had gone without hours of sleep, his epileptic crises became more frequent.

The seizures are followed by a period of (post-fit) tiredness that lasts up to 24 hours. A friend said that:

"when he regained consciousness, he felt empty, he had lost his memory and for a few days he could not write. After these crises, he felt as if he had committed a crime".

It is very likely that Dostoievski suffered from epilepsy caused by hereditary factors; his son, Aliosha died after his first fit, from which he did not recover possibly a status epilepticus.

Nonetheless, some authors have suggested different diagnoses for Dostoievski’s illness:

            Thus Sigmund Freud said it was a serious hysterical neurosis with pseudo-epileptic crises, an entity known as hysteria-epilepsy.

It is worth considering that neurosis may be a psychogenic illness whose symptoms are a symbolic expression of a psychological conflict that originated in the subject’s childhood and that constitutes a compromise between desire and defence. Basically in all types of neurosis the basic conflict is related to Oedipus conflict. Anxiety is the main symptom of neurosis, and when an unconscious conflict produces anxiety, the mechanisms of the psychological defence try to reduce it through neurotic symptoms. In hysterical neurosis, conversion is the prototypical mechanism of symptom formation. It is a libidinal energy that transforms into symptomatic innervations that causes the separation of libido from the representation in the process of repression. The separated libidinal energy then passes on to the body, and then an affection innervates a somatic organ giving place to a phenomenon named hysteric conversion. However, somatic symptoms of conversion do not follow any physiological or anatomical laws.

Among the strongest of Freud’s arguments is that Dostoievski ´s crises started after he received the news of his father’s death, for which he felt responsible.  Neurosis, as the father of psychoanalysis says, started when he was still a little boy, in the form of sudden attacks of unmotivated melancholy.

Dostoievski’s brother recalls that, in his early years, before Fiodor went to bed, he used to leave a note by his bed which expressed his fear, of falling into a lethargic state similar to death, while sleeping, and if that happened, he asked his family not to bury him until five days had passed.

His epileptic crises would be explained as short transactional deaths by which he tried to mitigate his guilt for having wished  "patricide".

However, other biographers of Dostoievski refuse this interpretation by Freud, and say that he had his first epileptic crises before being sent to Siberia (and not when he knew about his father ´s murder when he was in the Military College in Saint Petersburg), and also that this crises were most frequent during the period that he spent in prison at Omsk (Siberia).

An alternative diagnosis is syncope that frequently imitates an epileptic crisis. The most frequent symptoms of the vasovagal syncope are a previous feeling of weakness, dizziness, paleness and sweating, followed by a collapse with loss of consciousness. In some cases the syncope is associated with a tonic posture and clonic movements of the limbs; such movements can imitate those of a generalized tonic-clonic crisis (convulsive syncope).

This diagnosis may be supported by noting how easily Dostoiesvki became pale and lost consciousness when faced with emotional situations. In fact, a satiric poem, by the Russian poet Turguenev, a contemporary of Fiodor, describes how Dostoievski had fainted when he was introduced to a pretty girl.

                Hystero-neurosis can also manifest itself as syncopal fits, known as syncopal crises.

 

The differential diagnoses of seizures includes migraine, psychosis, nocturnal paroxysmal dystonia and transient stroke.  However, nothing in the biographical data of this author supports any of these conditions.

Conclusion

In conclusion, my choice of these differential diagnosis is epilepsy, because the clinical description of his fits, is typical of epilepsy with a generalized tonic/clonic crises, but it is also very difficult that a person suffering from hysteria-neurosis with such severe symptomatology had had enough available energy (libido) to sublimate it in the realization of such literary masterpieces as the ones created by Fiodor Dostoievski.  

 

 

 

 

 

 

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