Literary psychiatric observation and diagnosis through the ages: King Lear revisited.

ABSTRACT: Shakespeare's plays, and in particular King Lear, have been a favorite source of clinical observation and diagnosis for psychiatrists for the past two centuries. Most authors agree that the description of Lear's mental symptoms is remarkably consistent and close to life. This article summarizes previous attempts to diagnose the mental illness of King Lear, featuring, among others, such entities as mania, senile dementia, delirium, depression, and brief reactive psychosis, and offers a new diagnosis according to the modern diagnostic criteria, namely, bipolar I disorder, most recent episode manic, severe with psychotic features.

THE INTEREST of professional psychiatrists in the descriptions of insanity from Shakespeare's plays goes back in time 200 years or more. In England in 1795, Ferriar (1) recommended "Aretaeus . . . Shakespeare and Richardson" to "those who would gain a knowledge of the symptoms of madness from books." Bucknill (2) maintained in 1859 that "abnormal conditions of mind had attracted Shakespeare's diligent observation, and had been his favorite study," stating also that "on no other subject . . . has he written with such mighty power." In America, such prominent psychiatrists of the 19th century as Brigham, Ray, and Kellogg published articles and books on the diagnosis of mental diseases from the works of Shakespeare. All these authors, reviewing Shakespeare's insane characters, paid particular attention to the madness of King Lear.

In the 20th century, the play King Lear served as inspiration for numerous psychiatrists, psychoanalysts, psychologists, and gerontologists. Lear was used as a clinical case, an object of psychoanalysis, and a psychosocial model. The psychiatric diagnoses assigned to him show a remarkable variety. However, there seems to have been little communication between the authors who wrote on this subject. A review that would summarize the existing diagnostic ideas and a diagnosis in accordance with the most recent criteria are therefore in order.

Various reasons for the remarkable accuracy of Shakespeare's psychiatric descriptions have been proposed. Some authors, such as Kellogg, (3) attribute this accuracy to poetic inspiration; others, to his tremendous capacity for observation of life and for extrapolating the noticed facts to numberless ordinary and extraordinary situations, to synthesize an unmistakable "clinical picture" that would remain true to life throughout the entire existence of the characters on the pages of his plays. According to Bucknill, (2) "the peculiarities of a certain character being observed, the great mind that contains all possibilities within itself, imagines the act of mental transmigration, and combining the knowledge of others with the knowledge of self, every variety of character possible in nature would become possible in conception and delineation." Ray (4) stated that "Shakespeare, from a single trait of mental disease he did observe, was enabled to infer the existence of many others that he did not observe." The sa me author maintained that, contrary to the metaphysicians, who looked at the mind "in the abstract," Shakespeare looked at it "in the concrete," the logical result being the undisputed superiority of his descriptions. Along the same lines, Andreasen (5) calls Shakespeare "a 'behavioral scientist' in what is now recognized as the empirical tradition," his merits being a keen ability for observation and a literary talent.

Other authors, such as Kail (6) and Colman, (7) suggest that Shakespeare may have read some of the first tracts on mental illness available in his time, as well as the writings of his son-in-law, who was a physician. Moreover, his opportunities for observing insanity were not so infrequent as some think. (4) Many sources (2,6,8) attest to the fact that, in the time of Shakespeare, "lunatics" (as the mentally ill were commonly called then) were not strictly isolated, but, in the words of Bucknill, (2) "if their liberty was in any degree tolerable, it was tolerated, and they were permitted to live in the family circle, or to wander the country." Shakespeare himself provides the best demonstration of it in King Lear. Says Edgar:

The country gives me proof and precedent

Of Bedlam beggars, who, with roaring voices,

Strike in their numbed and mortified bare arms

Pins, wooden pricks, nails, sprigs of rosemary;

And with this horrible object, from low farms,

Poor pelting villages, sheepcotes, and mills,

Sometime with lunatic bans, sometime with prayers,

Enforce their charity. (Act II, Scene 3)

Strictly speaking, this sentence is an anachronism. The Bethlehem Hospital (also known as "Bethlem" or "Bedlam") started accepting psychiatric patients only at the end of the 14th century, (6,9) some 2,000 years after Lear's time. This statement would have been more appropriate for Shakespeare himself, since for him such beggars must have been a familiar sight. The same hospital also exposed its mentally ill patients to the public for money, which was a common practice both in England and on the Continent, providing great amusement to the spectators and severe distress to the inmates. (6,10) This circumstance the poet might have also used to advantage for his free-lance psychiatric studies.

However, Shakespeare's descriptions of mental illness may have also been influenced by the contemporary theatrical conventions. The simulated madness of Edgar in King Lear shows many gross exaggerations, such as his attempts at moralizing, when he claims that his "mental illness" is a punishment for his sins. Thereby he is, according to Ray, (4) "talking so clearly about his own case, while indulging in unlimited incoherence and rambling about everything else" and showing "a strain of acute moralizing succeeded, more than once, by a trait of mental imbecility." Andreasen (5) first states that "Edgar feigns classic schizophrenia as Poor Tom," but later suggests that it was a pitfall of the contemporary convention of interpreting mental disease as a consequence of moral shortcomings, into which Shakespeare had fallen when he made Edgar deliver his self-castigating lines. Conversely, Ray (4) maintains that Shakespeare purposefully created a distorted presentation of madness, thus revealing to the trained eye an example of a factitious mental disease. Kellogg (3) is not convinced by Edgar's psychiatric symptoms either, mentioning "how admirably the genuine disease [in Lear] contrasts with the counterfeit." In his turn, Bark (11) poses a question of "how far Poor Tom's simulated madness is drawn from the simulated madness of those who pretended to be mad beggars, rather than the truly mad," thereby implying that Shakespeare either was unable to tell the difference between the two groups that he observed, or that he needed to create an image of a dramatic, exaggerating impostor, and did just that. Another possible explanation of this phenomenon may be Shakespeare's sarcastic treatment of the theatrical and philosophical cliches of the time.

Furthermore, according to Colman, (7) there existed a "stage convention whereby the fathers of adult or adolescent sons or daughters [were] usually elderly, and frequently irascible too." Indeed, the frequency with which such characters appear in Shakespeare's plays is striking. This description applies also to Lear. It will have an important bearing on his conduct and later, on his madness. Thus, Colman (7) advises us to keep in mind that no matter how life-like in some aspects, the characters under study are not real people, and inferences regarding their personality types or their psychiatric history should be discouraged.

Contrary to this point of view, Brigham, (12) who was one of the pillars of American psychiatric thought in the middle of the 19th century, maintains that "the insane . . . [Shakespeare] has described are not imaginary characters, but may now be found in every large Asylum." He then proceeds to enumerate such characters as Macbeth, Hamlet, King Lear, and Ophelia, as they would appear in his hospital (the State Lunatic Asylum in Utica, NY).

KING LEAR IN PSYCHIATRIC LITERATURE

Several important questions arise about Lear. First, what is the diagnosis of his psychotic episode? Even more importantly, was he mentally ill even at the beginning of the play; if so, what was the illness? Most authors conclude that the king's mental disease is evident from the opening scene of the tragedy. Brigham (12) plainly states that Lear "was insane ... from the beginning of the play, when he gave his kingdom away, and banished as it were Cordelia and Kent .... The ill-usage of his daughters only aggravated the disease and drove him to raving madness." His reaction to his daughters' asking him "to change his course in a mild manner," is an unnatural and violent burst of rage," which is followed in the storm scene by "a paroxysm of rage and violence" (here and elsewhere in the text, the italics are original). Brigham (12) concludes that the story of Lear is "a faithful history of a case of senile insanity, or the insanity of old age.

According to Ray, (4) healthy and pathologic features of Lear's mind are so "mingled and assimilated," that "we feel at last as if it were the most natural thing in the world that Lear should go mad." "There existed in his case," as Ray notes in his beautifully written article from 1847, "a strong predisposition to insanity, and ... if it had not been developed by the approach of the old age, or the conduct of his daughters, it would have been by something else." The hasty, irrational actions of Lear in the beginning of the play, such as his sudden decision to divide the kingdom, his rejection of Cordelia, and the banishment of his dedicated vassal Kent, who attempted to defend her, indicate to Ray "an ill-balanced mind, if not the actual invasion of disease." He then traces the development of these morbid features into a full-blown mania. In his time, this term meant both the mania of bipolar illness and an actual psychosis, regardless of etiology. Nevertheless, there is a clear indication that Ray intended the former as his diagnosis, because for him it is the "mental excitement" that lies at the root of Lear's disease. He mentions agitation as one of the main prodromal symptoms in Lear. About the onset of the psychotic episode itself, Ray remarks: "At every interview reason has seemed to have lost somewhat of its control; the mental excitement has been steadily increasing, until now having reached its height, he is ... looking, acting and talking like a madman." Explaining the nature of Lear's alleged hallucinations, he writes: "In consequence of the cerebral excitement, impressions long since made ... are so vividly and distinctly recalled, that they appear to be outward realities.... The images raised in the mind by this morbid excitement, are also rapidly changing, thus giving to the thoughts that phantasmagoric character by which they are so distinguished in mania... Precisely so it is in mania which may, with some propriety, be designated as dreaming with the senses all open, the morbid excitement rendering the images unnaturally vivid." These quotations leave little doubt regarding Ray's diagnosis of the king's mental illness.

Among the most perspicacious comments on King Lear are those of Bucknill. (2) He wrote: "The willfulness with which critics have refused to see the symptoms of insanity in Lear, until the reasoning power itself has become undeniably alienated, is founded upon that view of mental disease ... that insanity is an affection of the intellectual, and not the emotional part of man's nature. According to Bucknill, (2) "disorders of the intellectual faculties," unless they arise from sources of an unquestionably physical nature, ... are often, indeed, to be recognized as the morbid emotions transformed into perverted action of the reason...." In their "futile attempts to define insanity by its accidents and not by its essence, ... the literary critics of Shakespeare have completely overlooked the early symptoms of Lear's insanity; and ... have postponed its recognition until he is running about a frantic, raving, madman...." From this example, and perhaps somewhat generalizing, the author concludes that "the emotiona l disturbance is the cause and condition of insanity." Bucknill (2) is certain that the higher intellectual functions in Lear are by no means lost but rather acutely clouded by the morbid emotional state: "In Lear, [Shakespeare's] most perfect and elaborate representation of madness, he never represents the mental power as utterly lost; at no time is the intellectual aberration so complete that the old king is incapable of wise and just remark...." As we see, the 19th century English psychiatrist has identified the morbid mood component in Lear's disease and held it to be the underlying factor in the ensuing cognitive derangement.

A later author, Kellogg (3) in 1866 equated the original mental disorder in Lear to senile dementia. In his book we read: "The very first act of Lear ... evinces that well-known imbecility incident to old age, and which frequently results in confirmed, senile insanity." Although in his analysis of the king's early odd behavior he does not attribute it, as most literary critics of all times have done, to "merely the ebullitions of a temper and disposition naturally fiery perhaps, and now rendered unbearable through the infirmities incident to old age," Kellogg continues to represent Lear's further psychologic derangement as the progression of dementia. He does not fail to mention, however, that the "withering imprecation" delivered by Lear upon Goneril's head "reminds one so strongly of what is frequently heard from the mouths of highly excited patients in the wards of a lunatic asylum."

In 1929, Somerville (13) reviewed the case of the old king from the positions of contemporary British psychiatry, with a few psychoanalytical references. The author remarks that from the very outset of events Lear shows "signs of mental deterioration due to old age," and that "for all useful purposes his career is finished." This "mental decrepitude" exaggerated "his natural mental shortcomings," such as excessive generosity, rashness, and hastiness, the reasoning power and judgment that were "never very good," his fiery temper, and inflated self-esteem. However, "this kind of 'madness' is very different, indeed, from that which subsequently took possession of him" when he became "an out-and-out maniac," the dramatic events in his life "culminating in a more than usually severe attack of mania." That Somerville understood mania in the modern sense of this word we conclude from the following definition in his book: "manic-depressive--a kind of varying mentality in which a person appears at times over-excited a nd at other times over-depressed." Furthermore, Lear's "limit of tolerance was reached on the night when he went out into the storm," signifying his "transition into definite insanity," or psychosis, but only after "his excitement becomes intense." Here also, as in Ray's writings, there is a suggestion that Lear's hallucinations in the hovel (Act III, Scene 4) are, actually, "a sort of dream-work." He therefore "is 'seeing' the content of his mental conflicts projected before him, but he is not seeing them with his eyes." As we shall see later, some observers subsequently chose to regard these "visions" as true visual hallucinations, and inferred on their basis an existence of an organic mental disorder in the king. Somerville also states that throughout the play Lear had not one, but several attacks of "acute mania," which were precipitated by various events. He also mentions Lear's flight of ideas, which is revealed in his incoherent speech in Act IV, resulting from the fact that "the thoughts from his subc onscious mind run too rapidly for expression in words." According to Somerville, "such 'thought-executing' swiftness is one of the most striking characteristics of a mind in a state of acute mania." We can consider this to be his final diagnosis of the case.

In 1953, Donnelly, (14) a psychiatrist and analyst, described "the type of reaction from which Lear suffers as either a delirium or an acute schizophrenic-like episode," but strongly favored the former. He denies any premorbid symptoms in Lear, thus indicating that at the beginning of the play the king's mind was sound. He states that the division of the kingdom by Lear was a wise step, made to avoid a civil war after his death. (Actually, this move appears to inspire hostility between Lear's sons-in-law rather than assuage it. Says Kent in Act III, Scene 1:

There is division,

Although as yet the face of it is covered,

With mutual cunning, 'twixt Albany and Cornwall

The irrational actions of Lear in the beginning of the play, according to Donnelly, result from his being "proud, vain, subject to flattery, hasty in action," and "the epitome of the 'choleric' temperament as it was known in Shakespeare's day, and even today is regarded as an unusual type of personality rather than insanity." The author lists such features of delirium as "rapid onset, disturbance of affect, usually fear, ... incoherency and irrationality; hallucinations, visual, auditory and even olfactory; ... lucid intervals," as well as "disorientation for time, place and person," "physical and nervous exhaustion," "amnesia for events occurring during the time of delirium." Although Donnelly mentions a possibility of existence in the sufferers from delirium of "some underlying emotional abnormality with which in 'normal' health they can cope in a sufficiently satisfactory way," he does not investigate its presence in Lear. He also rules out the diagnosis of an "acute schizophrenic-like episode" (probably t he equivalent of the modern brief reactive psychosis) on the basis of the allegedly shorter duration of Lear's psychotic symptoms (6 to 8 days according to Donnelly) than would be necessary to satisfy his diagnostic criteria for the disorder.

In 1976, Andreasen (5) stated that "Lear's madness can be explained in part as the development of a psychotic disorganization precipitated by severe stress in an elderly man already showing some signs of senile organic brain disease." Therefore, in her interpretation, "Lear has a mild organic brain syndrome that develops under stress into a reactive psychosis." Recounted are such "symptoms of organicity" in Lear as "poor judgment, in rejecting first the loving Cordelia and later the loving Kent." One can note, however, that such actions as banishment of one's favorite daughter and the right-hand man probably go further than simple poor judgment and represent rather a judgment driven by a grossly altered affect. Andreasen (5) also mentions Lear's "magnificent cursing rages" directed at Goneril and Regan, but does not connect them with an abnormal state of affect.

In his 1983 article, Kail (6) takes an interesting excursion into the history of psychiatry, as it relates to Shakespeare, and also diagnoses in Lear "a case of progressive senile dementia" that is "accompanied by attacks of what could be described today as acute mania, as demonstrated by his faulty judgment, disorientation and irrational behavior." Kail (6) further states, "From his first appearance to the last, Lear appears deprived of reason." This idea, already disputed by Bucknill, (2) will be discussed later. The author concludes by saying that "the final stages of [Lear's] progressive senility ending in dementia are briefly described by Kent."

Colman (7) established for Lear a diagnosis of brief reactive psychosis with a background of organic mental disorder, perhaps of a vascular origin, exemplified by the king's visual hallucinations and an intimation of a stroke just before Lear's death, since "he asks for help to undo one of his buttons." Colman (7) considers this diagnosis to be more "compatible with the long phases of extreme clarity of mind depicted in Lear ..., as in the sermon that he preaches to Gloucester," than one of senile dementia, offered by Kail. (6)

Finally, in 1988, we encounter a work by Trethowan, (15) who thinks that Lear was actually depressed, a victim of "involutional melancholia," which is described as a pathologic, though not uncommon, psychologic reaction to the physical and social disabilities brought on by the advancing old age. To him, the king "appears in the play as a melancholic, characteristically hell-bent on self destruction." The author mentions Lear's "previously unstable personality" (as discussed by his daughters Regan and Goneril), several examples of his "self-denigration" and forgetfulness, which suggests that degenerative changes leading to senile dementia are beginning to supervene, as is not uncommon in melancholia." Trethowan (15) also attributes to Lear suicidal thoughts, based on his statement to Cordelia in Act IV, Scene 7: "If you have poison for me, I will drink it." However, this phrase is caused by the king's remorse over his former ill treatment of his daughter, rather than an actual suicidal ideation. In conclusion, the author states that "senility would surely have been Lear's fate," if the "shock and distress" of finding Cordelia murdered had not killed him.

KING LEAR IN PSYCHOANALYSIS AND PSYCHOLOGY

Another fascinating and completely different interpretation of Lear comes from Freud and his followers, who considered the play extremely rich material for analysis. As we learn from a compendium of psychoanalytic writings collected and edited by Holland, (16) Freud himself was a great enthusiast of Shakespeare and constantly re-read and quoted his plays. Since the times of Freud, who wrote an essay and a letter on King Lear, and following his example, it has been customary among psychoanalysts to regard Lear both as an old man and a child.

As an old man, Lear is "harboring incestuous desires for his daughters," giving rise to a notion of the "Lear complex," according to which the "father eliminates his wife and marries his daughters." The youngest daughter, Cordelia, is Lear's favorite; when she refuses to love him totally (and, therefore, incestuously):

Haply, when I shall wed,

The lord whose hand must take my plight shall carry

Half my Love with him, half my care and duty.

Sure I shall never marry like my sisters,

To love my father all. (Act I, Scene 1)

he regresses to the level of a child, showing a "child's impotent rage." The ravings of Lear's psychotic episode, as well as the symbology of the play itself, according to analysts, are heavily loaded with sexual innuendo. (14,16)

In viewing Lear as having regressed to the state of a child, the psychoanalytic school regards him as overwhelmed by sadistic and masochistic impulses. According to Holland (16) (interpreting Ella Sharpe), "Lear's resigning of the government suggests Lear's ceasing to govern himself, giving way to the mad and incontinent impulses of infancy."

Another interesting vignette, provided by Freud himself, is the idea that Lear's choosing Cordelia as the favorite among the three daughters represents a child's choosing himself a mother, who, being silent (as Cordelia was), from the folkloristic point of view also represents the mute Death. Having originally rejected her, Lear reconciles himself with his death at the end of the play, carrying Cordelia in his arms.

As for the actual psychiatric diagnosis of Lear, Freud maintained that the king's behavior did not "justify a diagnosis of hysteria" or "represent a consistent psychosis." (17) Thus, Shakespeare's description, according to Freud, might not have been entirely clinically consistent. Overall, the plethora of psychoanalytic writings on King Lear before and after Holland's book is so impressive as to defy any attempt at enumeration here.

It is necessary to mention several psychologic works on the subject. Lear was used as a model for the theory of disengagement of the aged, (18) as well as a model for anomalous aging. (19) Hess (20) states that from the case of Lear we can learn "not only that aging is experienced as a narcissistic injury but that it contains the threat of helplessness, dependency and loneliness, which is often defended against by a tyrannical control of the elderly person's world and his objects." Therefore, the main problem of Lear, according to Hess, is his narcissistic personality threatened by "feelings of dependency and vulnerability," giving rise to envy, "increasing loneliness and inability to be reached." Lear's verbal assaults on his daughters are equated with "ferocious vengefulness" caused by his "inability to mourn his lost power as a king, as a man, and most importantly as a father."

CLINICAL ANALYSIS OF THE PLAY

Regarding King Lear, one can say that it is absolutely necessary to perform a close textual analysis of the play to arrive at the most likely diagnosis. If one undertakes such a task just on the basis of a general recollection of the tragedy's plot from one's childhood readings, the psychotic episode itself towers over the prodromal symptoms and, presenting itself out of context, probably dictates the diagnosis of brief reactive psychosis, with marked stressors. A closer look at Lear, however, vividly evokes the image of a manic, dysphoric elderly patient, committed by the court to the psychiatric hospital for treatment because of the existing real potential for inflicting self-harm (by squandering all his earthly possessions in 1 day, or by leaving his home in an uncertain direction during a storm). One can see him thundering curses at his long-suffering family. At times, he may become so excited as to start "hearing voices" and to show an incoherent speech and irrational behavior; however, there would be i ntermittent lucid periods in his mental status. A similar deja vu from the mental institution upon reading King Lear is experienced also by Kellogg (3) and Brigham. (12) The latter expressed it with a touch of humor: "Here, also, is King Lear, in a paroxysm of wrath, at some trivial occurrence, but much of the time venting all his rage upon his relations and friends, for abuse of him; and then occasionally in good humor, and conversing with much apparent satisfaction with some demented or half-idiotic patient, whom he considers a 'Philosopher and most learned Theban.'"

Let us now consider the details of Lear's clinical presentation. Lear is in the state of mania even at the time of his first appearance. In the beginning of the play, he emerges and unexpectedly announces his resignation of power:

Meantime we shall explain our darker purpose.

Give me the map there. Know that we have divided

In three our kingdom; and tis our fast intent

To shake all cares and business from our age...

(Act I, Scene 1)

The fact that this decision is absolutely spontaneous and represents complete news to everyone, including the king's closest advisors, is revealed by the following bewildered questions of the Earl of Gloucester:

And the King gone tonight? prescribed his pow'r?

Confined to exhibition? All this done

Upon the gad? (Act I, Scene 2)

The motives of Lear, however, are not altogether altruistic. He intends to retain "the name, and all th'addition to a king," which means that he wants to unburden himself of governing the country while retaining the power and the honor of his original status. This is a risky step, with a high potential for negative consequences, indicating a severe impairment in Lear's "occupational functioning."

This is not his only insane, expansive plan. Donow (19) notices that "his plans for retirement--proposing to trail his huge retinue in monthly odysseys from the northern reaches of Albany hundreds of miles to Cornwall and back--hardly bespeaks a course of senescent reflection." Such a decision is closer to a plan made in a manic state, in which a train of a hundred knights, their squires, servants, and all other attributes of a court moves swiftly and effortlessly over great distances, like so many pieces across a chess-board. The disease has definitely affected Lear's power of decisionmaking, which deteriorates proportionately to the increase of his mania. Each next important decision that he makes is worse than the previous one, from the division of the kingdom (which is at least somehow understandable), to the banishment of his favorite daughter and his dedicated vassal, to leaving Goneril's castle after the first altercation, to riding out into a storm without any other place to go--into nowhere.

Throughout the entire first three acts, Lear's mood is either expansive, as in the beginning of the play, or irritable. Irritability, especially if the patient's wishes are thwarted, can be a predominant mood in mania. Says Goneril:

By day and night he wrongs me. Every hour

He flashes into one gross crime or other

That sets us all at odds. I'll not endure it.

His knights grow riotous, and himself upbraids us

On every trifle. (Act I, Scene 3)

Lear also displays a highly labile affect, signified by the rapid change of mood from expansive to irritable, and from irritation to crying (Act I, Scene 4, and Act II, Scene 4).

Lear's stupendous denunciations of everyone who provokes him, however slightly, represent both irritability and pressured speech, since his thundering monologues are longer than the cues of any other character in the play, if not all of them combined. The richness, the variety, the awesome quality of his curses, and the rapid rate with which grandiloquent metaphors follow each other in his speech, testify to the same cause. Says Lear to Cordelia:

The barbarous Scythian,

Or he that makes his generations messes

To gorge his appetite, shall to my bosom

Be as well neighbored, pitied, and relieved,

As thou my sometime daughter (Act I, Scene 1);

or to Goneril:

Hear, Nature, hear: dear goddess, hear:

Suspend thy purpose if thou didst intend

To make this creature fruitful.

Into her womb convey sterility,

Dry up in her the organs of increase,

And from her derogate body never spring

A babe to honor her. If she must teem,

Create her child of spleen, that it may live

And be a thwart disnatured torment to her.

(Act I, Scene 4).

In the latter address to his eldest daughter, Lear shows a perfect example of manic anger and an inability to let go of the string of curses that keep coming to his mind, though they all mean the same, and thus he wishes Goneril to become infertile four times.

If we closely examine Shakespeare's verse with regard to poetic technique, a few aspects of the previous two quotes appear striking. Both exhibit an almost constant use of enjambment, a technique wherein the sense is protracted beyond the end of a line of poetry, so that the thought continues to run on in a rapid succession to encompass several lines. The quote from Act I, Scene 1 is a continuous enjambment. This technique is used to speed up verses, thus increasing tension in the stanza. Furthermore, although Shakespeare most frequently uses iambic pentameter in his poetic writings, the lines cited contain many pyrrhic feet, or metric units that consist of two unstressed syllables and are pronounced faster than iambic ones, thus also increasing the speed of reciting the lines. Occasional lines containing three feet instead of five serve the same purpose. All these techniques convey a subde but unmistakable impression of a pressured speech.

A similar but even increased trend is seen in Lear's monologues during the storm, in which he calls all the natural and divine calamities upon the world and his own head. Flight of ideas is also suggested by Lear himself, who says in Act III:

The tempest in my mind

Doth from my senses take all feelings else

Save what beats there. (Scene 4)

It is difficult to assess the presence of an inflated self-esteem or grandiosity in an absolute monarch, but if such categories apply to royalty, Lear would doubtless qualify. As Harbage (21) noted in his commentary on the play concerning the division of the country: "He holds a map in his hands like a Titan holding a kingdom.... Thus he disposes of a sector of the earth, this ring-giver, this warrior-leader, this chosen one, his only landlord God!" This definitely suggests grandiosity, which is not habitual in Lear (compare his discourses with the Fool, in which the king is at his baseline, simple and humorous). Somerville (13) attests to the same: "Indeed this display of his in his public announcement of the division of his kingdom was hardly more than a little dramatic performance in disguise."

Lear also shows a decreased need for sleep or rest, which is obvious from the haste with which he rode out into the storm, and in his rejection of rest and shelter later on:

KENT

Here is the place, my lord. Good my lord, enter.

The tyranny of the open night's too rough

For nature to endure.

Storm still.

LEAR

Let me alone. (Act III, Scene 4)

In fact, one wonders if Lear is not on the high road to Bell's mania, for at the end of the same scene he is too tired to eat: "We'll go to supper i'th'morning."

Another feature of a manic episode, distractibility, is manifested in Lear's behavior many times, ie, in the distraction that Kent's defense of Cordelia creates in the king's thought, his attention (and wrath) being momentarily redirected. Also in Act II, Scene 4, Lear is talking with Regan and Cornwall, while his thoughts keep skipping from the subject of the conversation to the fact that his messenger had been put in stocks; later, he becomes completely distracted by the appearance of Oswald, an object of his contempt. Further, in Act IV, Scene 6, Lear sets out to tutor Gloucester on the meaning of life:

When we are born, we cry that we are come

To this great stage of fools....

We never learn what other insights the king would reveal, because his train of thought gets derailed, possibly by his seeing Edgar's felt hat. Such instances abound. in the play.

Since the illness is taking hold of Lear's mind by degrees, we encounter many episodes during which he is trying to check the growing anger, to keep his emotions at bay. His reason, already clouded by mania, is struggling with the disease, when the king exclaims:

O, let me not be mad, not mad, sweet heaven!

Keep me in temper; I would not he mad!

(Act I, Scene 5)

Lear realizes that his power of rational thought is disappearing with the worsening of his rage. He repeatedly tries to curb his excitement:

O, how this mother swells up toward my heart!

Hysterica passio, down, thou climbing sorrow;

or, in the same scene:

Thy element's below (Act II, Scene 4),

O me, my heart, my rising heart! But down!

Later on, however, he experiences a strong foreboding of the impending psychosis: "0 fool, I shall go mad!" (Act II, Scene 4). Lear makes the last attempt to avoid his thoughts' perseveration on the recent offenses:

O Regan, Goneril,

Your old kind father, whose frank heart gave all--

No more of that. (Act III, Scene 4)

O, that way madness lies; let me shun that.

In the same scene his reason is finally overpowered, and plunges into obscurity.

The psychotic features that Lear develops later are well known; suffice it to say that he exhibited delusions, auditory and possibly visual hallucinations (although some authors (4,13) believe that those were vividly imagined situations rather than actual sensory hallucinations), bizarre behavior, and gross alterations of cognition (Acts III and IV). The psychotic phase arises at the highest point of agitation. The recovery is effected by means of a deep sleep induced by soporific herbs. Shakespeare himself seems to realize that it is the state of agitation that keeps the old king insane. When this agitation is quelled, the disease remits, though not without a possibility of relapse if the patient is further disturbed. Says Doctor:

Be comforted, good madam. The great rage

You see is killed in him; and yet it is danger

To make him even o'er the time he has lost.

Desire him to go in. Trouble him no more

Till further settling. (Act IV, Scene 7)

Unfortunately, the disease relapses under the tragic circumstances of the capture of Lear and Cordelia by the enemy in Act V. Then again, Lear is talkative when addressing Cordelia on their way to prison, not even giving her a chance to reply. His affect is inappropriately cheerful, and he exhibits delusions of immortality, when he prepares to outlive in prison "the packs and sects of great ones," ie, whole governments.

Some authors have implied a potential underlying internal disease or an organic brain disorder, but neither is confirmed in the text of the play. Physically, Lear is perfectly fit. He hunts in Act II, resists the wild storm in Act III, runs in the fields rather fast in Act IV, and overpowers and kills a military officer, Cordelia's assailant, in Act V. Furthermore, his short-term and long-term memory is not impaired, since he remembers his daughter's offenses in every detail, remembers even the events that shortly preceded his psychotic episode (as in the case with the disguised Kent), as well as his past glory in battle:

I have seen the day, with my good biting falchion

I would have made them skip. (Act V, Scene 3)

Lear's mental agility is manifested in his unimpaired reasoning and abstract thinking, as in his famous monologue on the necessity and sufficiency in life ("O reason not the need!" in Act II, Scene 4) and his most incisive philosophical remarks addressed to Gloucester in Act IV. It is known that one of the hallmarks of dementia is the patient's inability to grasp the profounder concepts, but Lear does not have this problem. Moreover, even in the midst of his psychosis, according to Ray (1) and Bucknill, (2) Lear mixes "ravings with the shrewdest remarks upon men and things." Thus, the intellectual faculties of the king seem be intact at the beginning of the play.

Lear's lapses in judgment and the "occupational impairment" are also better explained by the diagnosis of mania. As for such statements of Regan and Goneril regarding Lear as "old fools are babes again" (Act I, Scene 3), or "tis the infirmity of his age" (Act I, Scene 1), they can be regarded as deprecatory comments of rapacious and selfish daughters, expressed to justify their seizure of power, rather than accurate descriptions, because of their disrespectful, slanderous tone. In favor of dementia, however, would be an interpretation of these and other similar utterances of Lear's daughters as indicating that he may be undergoing a personality change, ie, that such premorbid traits of his as rashness and irritability are now accentuated. This topic is open to speculation, since no evidence of such changes is given in the text.

In summary, the case of Lear probably warrants the diagnosis of bipolar I disorder, most recent episode manic, severe with psychotic features. The manic episode was primary, and the psychosis developed on its background, provoked by the increasing agitation and physical exertion. (It is of note that when the latter two factors are eliminated, the symptoms recede.)

It is difficult to determine whether the disease was chronic. Certainly, there are indications that Lear may have had episodes of altered mood in the past. Says Regan: "... yet he hath ever but slenderly known himself," and Goneril: "The best and soundest of his time hath been but rash" (Act I, Scene 1). This may indicate that Lear had known worse times in the past, when he was more than "rash," ie, frankly manic. Goneril also mentions his "long-ingraffed condition," which may well refer to bipolar disorder. A new onset of mania is also possible in the elderly. (22,23) It has been shown that the prevalence of first hospital admissions for mania does not decrease, but may actually increase with age, and a first-onset mania in the elderly has a poor prognosis. (22) It is not usually associated. with senile dementia but with other potentially serious varieties of organic brain In this respect, it would be interesting to obtain a CT scan of Lear's brain. Obviously, such derivations can be carried ad absurdum.

Finally, after discussing Lear himself, it may be worthwhile to establish the clinical diagnosis of Edgar, since most psychiatric works cited here allude to him in one form or other. Without a doubt, his case is one of malingering as an adaptive behavior to escape persecution. Although clinically inconsistent at times, it safeguards his survival.

CONCLUSION

In considering the insanity of King Lear, I have reviewed the writings of distinguished psychiatrists of the past, examined some contemporary comments, and attempted to look at his case in terms of modern diagnostic criteria. Despite the ever-changing nosologic categories, the value of literary psychiatric observation cannot be doubted. For future generations of psychiatrists, King Lear will remain a valuable piece of reading, a keen clinical study, and a persistent diagnostic challenge.

References

(1.) Ferriar J: Medical histories and reflections. Three Hundred Years of Psychiatry. Hunter K, Macalpine I (eds). London, Oxford Press, 1964, p 543

(2.) Bucknill JC: The psychology of Shakespeare. Three Hundred Years of Psychiatry. Hunter R, Macalpine I (eds). London, Oxford Press, 1964, pp 1064-1067

(3.) Kellogg AO: Shakspeare's Delineations of Insanity, Imbecility, and Suicide. NewYork, Hurd and Houghton, 1866

(4.) Ray I: Shakespeare's delineations of insanity. Am J Insanity 1847; 3:287-334

(5.) Andreasen N: The artist as scientist. psychiatric diagnosis in Shakespeare's tragedies. JAMA 1976; 235:1868-1872

(6.) Kail AC: Medicine in Shakespeare: the bard and the Body--2. Mental illness. Med J Aust 1983; 139:399-405

(7.) Colman EAM: Squibb academic lecture: Shakespeare and DSMIII. Aust N ZJ Psychiatry 1986; 20:30-36

(8.) Perry R: Madness in Euripides, Shakespeare, and Kafka. Psychoanalytic Rev 1978; 65:253-279

(9.) Hunter R, Macalpine I (eds): Three Hundred Years of Psychiatry. London, Oxford Press, 1964, p 5

(10.) Kraepelin E: One Hundred Years of Psychiatry. New York, Philosophical Library, 1962, p 20

(11.) Bark NM: Did Shakespeare know schizophrenia? the case of Poor Mad Tom in King Lear. Br] Psychiatry 1985; 146:436-438

(12.) Brigham A: Insanity-illustrated by histories of distinguished men, and by the writings of poets and novelists. Am J Insanity 1844; 1:9

(13.) Somerville H: Madness in Shakespearean Tragedy. London, Richards Press, 1929

(14.) Donnelly J: Incest, ingratitude and insanity: aspects of the psychopathology of King Lear. Psychoanalytic Rev 1953; 40:149-155

(15.) Trethowan WH: Psychiatry and the seven ages of man. J R Soc Med 1988; 81:189-193

(16.) Holland N: Psychoanalysis and Shakespeare. New York, Octagon Books, 1976

(17.) Freud 5: Letter to Richard Flatter. Psychoanalysis and Shakespeare. New York, Octagon Books, 1976, p 65

(18.) Ricciardelli RM: King Lear and the theory of disengagement. Gerontologist 1973; 13:148-152.

(19.) Donow HS: "To everything there is a season": some Shakespearean models of normal and anomalous aging. Gerontologist 1992; 32:733-738

(20.) Hess N: King Lear and some anxieties of old age. Br J Med Psychol 1987; 60:209-215

(21.) Harbage A: Introduction. Shakespeare's King Lear. New York, Penguin Books, 1988, pp 14-27

(22.) Shulman K, Post F: Bipolar affective disorder in old age. Br J Psychiatry 1980; 136:26-32

(23.) Broadhead J, Jacoby R: Mania in old age: the first prospective study. Int J Geriatr Psychiatry 1990; 5:215-222

RELATED ARTICLE: KEY POINTS

* Prominent psychiatrists of the past such as Bucknill, Brigham, Ray, and Kellogg, as well as some modern investigators, have attempted to diagnose the mental disorder of King Lear.

* The diagnoses given to him include senile dementia, mania, delirium, brief reactive psychosis, involutional melancholia, and others.

* King Lear is also an important source of psychoanalytic studies, giving rise to the concept of "Lear's complex."

* Presented here is an argument in favor of the diagnosis of bipolar I disorder, most recent episode manic, severe with psychotic features.

From the Department of Pathology, Johns Hopkins Hospital, Baltimore, Md.

Reprint requests to Alexander M. Truskinovsky, MD, Johns Hopkins Hospital, Pathology 401, 600 N Wolfe St, Baltimore, MD 21287.