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Altschuler(1) proposes that the central character from Nikolai
Gogol’s 1834 novella, ‘Diary of a Madman’(2) suffers from schizophrenia.
I believe schizo-affective disorder is a more appropriate diagnosis.
Reading literary accounts of madness adds greatly to the trainee’s
knowledge of psychopathology. Making a diagnosis on the basis of the
psychopathology sharpens diagnostic skills.
I have recently had the pleasure of re-reading Gogol’s account of the
diarist’s descent into madness. As a psychiatric trainee I kept my ICD-10
in the other hand!
I would like draw attention to the psychopathology illustrated by his
diary entries and on the basis of the ICD 10 suggest that the preferred
diagnosis should be schizoaffective disorder.
Axenty’s Diary
Axenty Ivanovich is a 42 year old titular councillor (a low-ranking
official) in the St Petersburg bureaucracy who maintains a dairy. In early
entries there is no evidence of any formal thought disorder. However he
appears chaotic to his colleagues. He mentions in his diary that the head
of the office said to him;
‘Why are you always in such a muddle? Sometimes you rush around like
a madman and make such a mess of your work, the devil himself couldn’t
sort it out.’ (p17)
His thoughts about this rebuke show some evidence of grandiose ideas.
He writes;
Seeing me in the Director’s office sharpening His Excellency’s quills
must have made him jealous. (p17)
Later that day he has experiences an auditory hallucination. He hears
two dogs speaking to each other about letters which they had written. He
recognizes that this is strange. He mentions that he does not drink.
He neither returns to these thoughts nor does he have other abnormal
experiences for more than a month.
During this month his thoughts become more grandiose in nature. He is
preoccupied with thoughts regarding his noble birth. He also falls in love
with His Excellency’s daughter. This is out of character for the clerk.
A month later he recalls the conversation he heard between the dogs. Over
the next three days he writes about the content of the dog’s letters. One
of the dogs belongs to His Excellency’s daughter and writes about the
daughters love for a high ranking court official. The content is clearly
delusional.
He does not mention the dogs, the letters, or his love again.
Three weeks later he becomes preoccupied with the difficulties the Spanish
nobility are experiencing finding an heir to the Spanish throne after the
death of King Ferdinand VII.
He cannot put his mind to anything else. He misses work. His housekeeper
mentions to him how distracted he appears. He knows something strange is
going on.
This perplexity is only resolved when he writes;
‘April 43rd, 2000’
‘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. Frankly, it
all came to me in a flash.’ (p33)
He displays a grandiose delusion of being the King of Spain. He
considers his previous work below him. He returns to the office when
coaxed to do so by his colleagues who have not seen him for three weeks.
He reports going for a joke. He revels in what he perceives as his
colleagues astonishment when he signs his name as King Ferdinand VIII.
He becomes more reckless in his behaviour, entering His Excellency’s
daughter’s boudoir and promising her that they will be together.
He shows evidence of increased activity, making a crown from his old
uniform.
He believes his detainment in a mental asylum is a visit to Spain and the
activities and punishments he faces there are tests to prove his status.
His writing is full of neologisms and becomes difficult to follow with
evidence of flight of ideas and loosening of associations. The content is
bizarre.
Discussion of Symptoms and diagnosis on the basis of ICD 10.
The hallucinations he experiences are not first-rank symptoms of
schizophrenia.
He does not experience thought echo, insertion, or withdrawal, made
affect, will or impulse, or passivity phenomenon. He does not have
persistent hallucinations or culturally inappropriate delusions for most
days in a month
He does show neologisms and breaks in his thought process.
There are no catatonic or negative symptoms.
He does show delusional atmosphere and resolution of this with the
knowledge that he is the King of Spain, a delusional intuition. This is
phenomenologically different from a delusional perception, which is a
first-rank symptom.
He suffers from an expansive, irritable mood accompanied by increased
activity, flight of ideas, loss of social inhibitions, inflated self
esteem and reckless behavior. He suffers from grandiose delusions.
According to the diagnostic guidelines from ICD-10; a diagnosis of
schizophrenia should not be made in the presence of manic symptoms unless
it is clear that the psychotic symptoms predate the affective symptoms.(3)
In Axenty’s case symptoms of his affective state are evident from his
first entry. He does not fully meet criteria for schizophrenia.
The exclusion criteria for a diagnosis of Manic Episode with
Psychotic features are that he does not simutaneously meet diagnostic
criteria for a schizophrenic or schizoaffective manic state.
He satisfies criteria for schizoaffective disorder manic type. He has
a disorder in which both affective and schizophrenic symptoms are
prominent.
Although it is difficult with the limited account of his illness and
without the knowledge of the outcome, I believe his diagnosis be revised
to Schizoaffective disorder manic type.
The final diary entry is pitiful. Axenty pictures his mother sitting
by her window in a peasant hut. He cries out, ‘Mother, save your poor son
! Shed a tear on his aching head! See how they’re torturing him. Press a
wretched orphan to your breast! Mother! have pity on your poor little
child…’ (p41)
Schizo-affective disorder appears to have a better prognosis than
schizophrenia occupying a position inbetween the better outcome of
affective psychosis and the poor outcome of schizophrenia.4
With his revised diagnosis we can hope that he has a better outcome.
Arun Chopra
Senior House Officer
Nottingham University (Mid-Trent) Psychiatric Training Rotation
Gogol's madman had schizo-affective disorder
Editor
Altschuler(1) proposes that the central character from Nikolai
Gogol’s 1834 novella, ‘Diary of a Madman’(2) suffers from schizophrenia.
I believe schizo-affective disorder is a more appropriate diagnosis.
Reading literary accounts of madness adds greatly to the trainee’s
knowledge of psychopathology. Making a diagnosis on the basis of the
psychopathology sharpens diagnostic skills.
I have recently had the pleasure of re-reading Gogol’s account of the
diarist’s descent into madness. As a psychiatric trainee I kept my ICD-10
in the other hand!
I would like draw attention to the psychopathology illustrated by his
diary entries and on the basis of the ICD 10 suggest that the preferred
diagnosis should be schizoaffective disorder.
Axenty’s Diary
Axenty Ivanovich is a 42 year old titular councillor (a low-ranking
official) in the St Petersburg bureaucracy who maintains a dairy. In early
entries there is no evidence of any formal thought disorder. However he
appears chaotic to his colleagues. He mentions in his diary that the head
of the office said to him;
‘Why are you always in such a muddle? Sometimes you rush around like
a madman and make such a mess of your work, the devil himself couldn’t
sort it out.’ (p17)
His thoughts about this rebuke show some evidence of grandiose ideas.
He writes;
Seeing me in the Director’s office sharpening His Excellency’s quills
must have made him jealous. (p17)
Later that day he has experiences an auditory hallucination. He hears
two dogs speaking to each other about letters which they had written. He
recognizes that this is strange. He mentions that he does not drink.
He neither returns to these thoughts nor does he have other abnormal
experiences for more than a month.
During this month his thoughts become more grandiose in nature. He is
preoccupied with thoughts regarding his noble birth. He also falls in love
with His Excellency’s daughter. This is out of character for the clerk.
A month later he recalls the conversation he heard between the dogs. Over
the next three days he writes about the content of the dog’s letters. One
of the dogs belongs to His Excellency’s daughter and writes about the
daughters love for a high ranking court official. The content is clearly
delusional.
He does not mention the dogs, the letters, or his love again.
Three weeks later he becomes preoccupied with the difficulties the Spanish
nobility are experiencing finding an heir to the Spanish throne after the
death of King Ferdinand VII.
He cannot put his mind to anything else. He misses work. His housekeeper
mentions to him how distracted he appears. He knows something strange is
going on.
This perplexity is only resolved when he writes;
‘April 43rd, 2000’
‘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. Frankly, it
all came to me in a flash.’ (p33)
He displays a grandiose delusion of being the King of Spain. He
considers his previous work below him. He returns to the office when
coaxed to do so by his colleagues who have not seen him for three weeks.
He reports going for a joke. He revels in what he perceives as his
colleagues astonishment when he signs his name as King Ferdinand VIII.
He becomes more reckless in his behaviour, entering His Excellency’s
daughter’s boudoir and promising her that they will be together.
He shows evidence of increased activity, making a crown from his old
uniform.
He believes his detainment in a mental asylum is a visit to Spain and the
activities and punishments he faces there are tests to prove his status.
His writing is full of neologisms and becomes difficult to follow with
evidence of flight of ideas and loosening of associations. The content is
bizarre.
Discussion of Symptoms and diagnosis on the basis of ICD 10.
The hallucinations he experiences are not first-rank symptoms of
schizophrenia.
He does not experience thought echo, insertion, or withdrawal, made
affect, will or impulse, or passivity phenomenon. He does not have
persistent hallucinations or culturally inappropriate delusions for most
days in a month
He does show neologisms and breaks in his thought process.
There are no catatonic or negative symptoms.
He does show delusional atmosphere and resolution of this with the
knowledge that he is the King of Spain, a delusional intuition. This is
phenomenologically different from a delusional perception, which is a
first-rank symptom.
He suffers from an expansive, irritable mood accompanied by increased
activity, flight of ideas, loss of social inhibitions, inflated self
esteem and reckless behavior. He suffers from grandiose delusions.
According to the diagnostic guidelines from ICD-10; a diagnosis of
schizophrenia should not be made in the presence of manic symptoms unless
it is clear that the psychotic symptoms predate the affective symptoms.(3)
In Axenty’s case symptoms of his affective state are evident from his
first entry. He does not fully meet criteria for schizophrenia.
The exclusion criteria for a diagnosis of Manic Episode with
Psychotic features are that he does not simutaneously meet diagnostic
criteria for a schizophrenic or schizoaffective manic state.
He satisfies criteria for schizoaffective disorder manic type. He has
a disorder in which both affective and schizophrenic symptoms are
prominent.
Although it is difficult with the limited account of his illness and
without the knowledge of the outcome, I believe his diagnosis be revised
to Schizoaffective disorder manic type.
The final diary entry is pitiful. Axenty pictures his mother sitting
by her window in a peasant hut. He cries out, ‘Mother, save your poor son
! Shed a tear on his aching head! See how they’re torturing him. Press a
wretched orphan to your breast! Mother! have pity on your poor little
child…’ (p41)
Schizo-affective disorder appears to have a better prognosis than
schizophrenia occupying a position inbetween the better outcome of
affective psychosis and the poor outcome of schizophrenia.4
With his revised diagnosis we can hope that he has a better outcome.
Arun Chopra
Senior House Officer
Nottingham University (Mid-Trent) Psychiatric Training Rotation
Queens Medical Centre, Derby Road, Nottingham,UK
Correspondence arun2111@hotmail.com
References
1. Altschuler, EL. One of the oldest cases of schizophrenia in
Gogol’s Diary of a Madman. BMJ 2001; 323; 1475-1477
2. Gogol N. Diary of a madman and other stories. (Translated from
Russian by R Wilks). London: Penguin Books, 1972.
3. ICD-10 Classification of Mental and Behavioural Disorders. WHO
Geneva: Churchill Livingstone, 1994.)
4. Harrow, M. & Grossman H. S. (1984) Outcome in schizoaffective
disorders: a critical review of the literature. Schizophrenia Bulletin,
10. 87-108.
Competing interests:
None declared
Competing interests: No competing interests