epilepsy and literary creativeness: fyodor m. dostoevsky · gustave flaubert. gustave flaubert...

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Friulian Journal of Science 3. 2003, 51-67

Epilepsy and Literary creativeness:Fyodor M. Dostoevsky

F R A N C F A R I *

* University of Udine and IRCCS E. Medea, Italy. E-mail [email protected]

Summary. Among the most salient biographical aspects affecting an artistic or literarygenius, chronic diseases generally play a crucial role in the creation and content of lit-erary production. This held true also for the great Russian novelist FyodorMikhailovitch Dostoevsky (1821-1881) who for most of his life suffered from epilepsy.Dostoevsky was greatly influenced by epilepsy. In almost all his novels there is a char-acter affected by this pathology. To identify all possible factors associated with epilepsy,I read the following works by Dostoevky: Poor Folk, The Double, The white nights, Un-cle’s Dream, The House of Dead, The Insulted and Injured, Notes from the Underground,The Gambler, Crime and Punishment, The Eternal Husband, The Idiot, The Devils, TheAdolescent, The Brothers Karamazov. All factors in line with a condition of epilepsy wereclassified as follows: 1) onset of epilepsy, 2) auras (in its various manifestations), 3) cry,4) automatisms, 5) description of seizures, 6) post-ictal symptoms, 7) triggering factors,8) interictal features. For each of these points, an excerpt of the novel, a short summa-ry or a reference will be provided. In my opinion, Dostoevsky’s epileptic symptomatol-ogy allows to hypothesize that the novelist had a focal epilepsy localized in the frontallobe (with involvement of the anterior cingulate gyrus) with a tendency to secondarygeneralization. In describing epilepsy, Dostoevsky probably had two objectives in mind.The first goal was to re-state that people suffering from epilepsy were not monsters.Dostoevky’s second objective was even more ambitious: not only people with epilepsyare like others but they show greater qualities in terms of cognition, philosophical andreligious aspects than normal people.

Key words. Psychomotor seizure, ecstatic aura, Doppelgänger, temporal and frontallobe, philosophy, religion.

Introduction. It is known that auto-biographical aspects may consider-ably influence the work of an artist ora writer with regard to contents andformal aspects. Among the mostsalient biographical aspects affectingan artistic or literary genius, chronicdiseases generally play a crucial rolein the creation and content of literaryproduction. This held true also forthe great Russian novelist FyodorMikhailovitch Dostoevsky (1821-1881) who for most of his life suf-fered from epilepsy. Epilepsy greatlyinfluenced the functioning of Dosto-evsky’s psyche and cannot be simplyconsidered a chronic disease like oth-ers. In this regard, NormanGeschwind clearly stated that “theepilepsy of Dostoevsky and the asth-ma of Proust are not comparable”(Geschwind 1972, p. 333). Epilepsy isa pathology affecting the brain andmay change or influence cognitive, af-fective, vegetative functions, etc.Epilepsy – to different degrees ac-cording to its various forms – may in-fluence the neurofunctional organiza-tion of the brain and the personalitystructure. In some cases, it may evencause some aspects of mental life toemerge that are generally hidden in“normal” individuals, such as déjà-vus, visual hallucinations, emotionalstates of fear and ecstasy, etc. Allthese experiences may lead the artistor writer to have an original concep-tion of the world and may influencehis creativity.

Dostoevsky was greatly influencedby epilepsy. In almost all his novelsthere is a character affected by thispathology. On the one hand, the nov-

elist tried to fight negative and irra-tional pre-conceptions of the timewhereby people with epilepsy weremonsters and, on the other, he re-peatedly stressed the chances epilep-sy could offer to acquire deeperphilosophical and religious knowl-edge, as efficaciously stated in Crimeand Punishment: “Apparitions are, soto speak, shreds and fragments ofother worlds, the first beginnings ofthem. There is, of course, no reasonwhy a healthy man is mainly a beingof this earth, and therefore for com-pleteness and order he must live onlythis earthly life. But as soon as he fallsill, as soon as the normal healthy stateof the organism is disturbed, the pos-sibility of another world begins to ap-pear, and as the illness increases, sodo the contacts with the otherworld”. [Crime and Punishment, PartIV, Chapter I, p. 277].

Psychomotor seizure. In psychomo-tor epilepsy seizures are characterizedby the presence of psychologicalcomponents (aura) and motor com-ponents (e.g., automatisms). Most ofthe patients with psychomotorepilepsy (2/3) show a secondary gen-eralization of seizures. Onset ofseizures occurs generally in late child-hood or adolescence; 1/3 of the pa-tients with psychomotor epilepsy ex-perience important episodes offebrile convulsions in childhood. Psy-chomotor epilepsy, also defined ascomplex partial seizures, is due to ab-normal electrical activity of sometemporal lobe structures (temporo-basal limbic, neocortical lateral tem-poral, opercular insular areas) or

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frontal lobe structures (frontobasal-cingulate portions) (cf. Paradiso et al.1995). The most frequent cause ofpsychomotor seizures is temporallobe epilepsy (TLE). For this reason,epilepsy with psychomotor seizuresand TLE are often considered as syn-onyms.

Aura.The psychological componentof psychomotor seizures is defined as“aura” which in Latin means “breathor breeze”. The aura represents theonset of seizures and is characterizedby cognitive alterations and particularemotional experiences. Among themost frequent cognitive alterationsthere are illusions or distorsions ofperceptions, visual hallucinations(simple or complex), auditory halluci-nations, feeling of familiarity (déjàvu), feeling of strangeness (jamais vu),depersonalization and autoscopicphenomena. The most frequent emo-tional experiences are fear and anxi-ety, while anger, terror, elation, eu-phoria and ecstasy are rarer (cfr.Gloor et al. 1981; Frederiks 1985;Collins 1987). Patients with psy-chomotor seizures generally tend toshow the same aura, with limited variations. Cerebral stimulation dur-ing neurosurgery for removal of the epileptic focus tends to recre-ate in these patients the psychologi-cal experiences typical of aura (Halgren 1982).

Automatisms. In some patients psy-chomotor seizures may be limited on-ly to subjective manifestations of au-ra, in other patients subjective psy-chological phenomena may be fol-

lowed by motor seizures, which gen-erally occur during alterations in thestate of consciousness. For this rea-son, after the seizure these patients donot remember what happened.Preservation of consciousness duringautomatisms is generally associatedwith focal epilepsy of the right tem-poral lobe (Ebner et al. 1994). Au-tomatisms are characterized by suck-ing or chewing movements, or the pa-tient may keep on walking, driving orreading. In other cases, the patientmay make inappropriate actions suchas speaking in an inconsistent manneror undressing in public. Intense out-bursts of anger and violence arerather rare manifestations of psy-chomotor seizures. As has alreadybeen stated, often a psychomotorseizure ends with a generalized tonic-clonic seizure (secondary generalized

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Fyodor Michailovitch Dostoevsky (1821-1881).

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epilepsy). Generally, after a psy-chomotor seizure patients rememberthe aura if they only experienced aseizure characterized by subjectivephenomena. If patients experienced apsychomotor seizure, they rememberthe aura only in 75% of the cases.This percentage decreases to 50% ifafter the aura patients experienced ageneralized tonic-clonic seizure(Schulz et al. 1995).

Interictal seizures. Many studiesshowed that psychomotor seizuresare associated with importantchanges in personality which are notpresent in other types of epilepsy(Bear et al. 1982). These personalitychanges seem to depend on long-term effects of interictal abnormalelectrical activity when the epilepticfocus is localized in the temporal orfrontal lobe (Ebner & Hoppe 1995).According to Geschwind (1983), sub-continuous stimulation of the limbiclobe structures by the epileptic focusis responsible for psychic or personal-ity alterations peculiar to patientswith psychomotor seizures. Patientswith psychomotor seizures tend to beslow and rigid in their thinking, areoften fussy and boring in their con-versation, sometimes they showmood changes, outbursts of angerand aggressiveness and often they areobsessive, excessively sober and gen-erally lack humor. Often these pa-tients show a markedly reduced sexu-al libido and their thinking is fre-quently characterized by philosophi-cal and religious ideas. Moreover,many patients exhibit hypergraphia,that is they write accurate accounts

and diaries of philosophical, moral orreligious observations (cf. Bear 1979).Their main personality traits tend tobe influenced by the lateralization ofthe epileptic focus; if the epileptic fo-cus is localized in the left hemisphere,patients tend to show a more markedtendency to philosophical and reli-gious interests, sense of personal des-tiny and paranoid thinking. If theepileptic focus is localized in the righthemisphere, patients tend to showcircumstantiality, viscosity, hyper-moralism, hyposexuality, hyper-graphia and alterated mood, with eu-phoria alternating with sadness (cfr.Bear & Fedio 1977; Robert et al.1982).

Artistic and religious personalistisaffected by psychomotor epilepsyVincent Van Gogh. One of the mostrenowned painters of last century,Vincent Van Gogh (1863-1890), wasprobably affected by psychomotorseizures (Gastaut 1956). Van Goghhad normal cognitive skills, spoke 4languages, was easy-going andshowed appropriate behavior. Henever displayed generalized convul-sive seizures but showed episodes ofpsychomotor epilepsy. In his lettershe mentioned numerous episodes ofsudden and unmotivated fear or ter-ror which could be interpreted as au-ra of a psychomotor seizure. In hislast years of life he showed many con-fusional episodes characterized bycomplex visual and auditory halluci-nations. Lastly, he described many sit-uations characterized by complex au-tomatisms. One day, for example,while leaving the hospital, he kicked a


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guardian without any reason. On an-other occasion, without any reason,he suddenly threw a glass at hisfriend, Gauguin. Van Gogh’s person-ality shows many traits typical of pa-tients affected by epilepsy with psy-chomotor seizures. For a long time,he exhibited a morbid hypereligiosity,was hypergraphic, showed suddenmood changes with outbursts ofanger and unmotivated violence. Inhis last years of life he also showed amarked lack of interest for sex (hypo-sexuality). Dr. Felix Rey and Dr. Pey-ron, two physicians working at ArlesHospital, who followed Van Gogh in1888 owing to seizures characterizedby confusional states, claimed that thepatient suffered from “non convul-sant epilepsy”. This diagnosis corre-sponds to today’s psychomotorepilepsy.

Gustave Flaubert. Gustave Flaubert(1821-1880), the writer of MadameBovary, Bouvard et Pécuchet, was oneof the most significant novelists of theXIX century. At the age of 22, he ex-perienced the first seizure character-ized by an aura in the right visual fieldwith a concurrent and unmotivatedfear, followed by generalized seizures.The disease showed a variable evolu-tion. From 1844 to 1850 he experi-enced many seizures, whereas from1850 to 1870 he showed few seizures.Seizures became very frequent againfrom 1870 to 1875. Flaubert sufferedfrom psychomotor epilepsy (complexpartial seizure) with a symptomatol-ogy characterized by an aura withfear, complex hallucinations, forcedthinking and sometimes aphasia.Complex partial seizures generallyended with generalized convulsions.Flaubert also showed a personalitystructure that under many aspects co-incided with that of patients withtemporal focal epilepsy. Over theyears his interest for sex considerablydecreased (hyposexuality). He hadbecome very impulsive and had devel-oped a morbid devotion to writing. Inthe last few years he showed consider-ably slow ideation. Moreover, he ex-hibited significant word-finding diffi-culties or difficulties in recalling lifeevents (“Je souis souvent plusieursheures à chercher un mot”; cf. Gastaut& Gastaut 1982, p. 487). Accordingto his brother who was a physician(Achille Flaubert), Gustave sufferedfrom “larvate epilepsy” which corre-sponds to today’s psychomotorepilepsy. Gastaut & Gastaut (1982)accurately studied the neurological

Vincent Van Gogh (1853-1890).

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symptomatology showed by G.Flaubert and suggested a diagnosis ofpartial epilepsy with an epileptic fo-cus localized in the left occipito-tem-poral lobe.

Jeanne D’Arc. In her short life, JeanneD’Arc (1412-1431) never showedgeneralized convulsive seizures; how-ever, the different symptoms she dis-played are in line with the hypothesisof a temporal lobe epilepsy (Foote-Smith & Bayne 1991). The complexvisual and auditory hallucinationswith God talking to her and askingher to rid France of English usurpersmay be considered as actual phenom-ena of epileptic aura. Jeanne D’Archad “visions” at the age of 13, andvery often hallucinations were elicitedby the sound of church bells (reflexmusicogenic epilepsy). Apart fromhallucinations and her mystic-militarymission, Jeanne D’Arc was describedas modest, sensible and without evi-dent psychopathological alterations.

However, she showed some personal-ity traits typical of patients with com-plex partial seizures. She was wellaware of being predestined to an im-portant task, and in carrying it out sheshowed excitation, euphoria and ela-tion. She did not show any interest forsex (hyposexuality) in her life. Undersome circumstances related to hermilitary campaigns she showed con-siderable impulsiveness and aggres-siveness.

St. Paul. In his letters St. Paul oftenmentioned he suffered from a chron-ic disease, despite which he carriedout his mission as Christ’s apostle.Some of his writings seem to suggestthat he was affected with epilepsy. “Iwas given a thorn in the flesh, an an-gel of Satan to rack me and keep mefrom being puffed up” (2 Corinthians12,7). “You did not scoff at me norspurn me” (Galatians 4, 14). In an-cient times, the expression “torn inthe flesh” was used as synonym forepilepsy; in the same way, to “spurn”or “reject” (Galatians 4, 14) is a trans-lation of the verb whose literarymeaning is “to spit out at”, hence“you did not spit out at me”. Epilep-sy was sometimes called “morbus quisputatur” because during seizures pa-tients often spat as superstitious reac-tion (cf. Landsborough 1987). In St.Paul’s letters and in the Acts manyepisodes of his life are reported whichcould be interpreted as “critical” phe-nomena of psychomotor seizures.The following are verses of the NewTestament which could refer to auras:“I simply know that in the body orout of the body (God knows which)

Gustave Flaubert (1821-1880).


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this man was caught up to paradiseand heard sacred secrets which nohuman lips can repeat” (2 Corinthi-ans 12,3-4). In different episodes of“ekstasia” St. Paul saw and spoke toJesus (Acts 16,9; 18,9; 22,17-21). Onthe way to Damascus he suddenly sawa light and heard Jesus calling him(Acts 9,3-9). On the same occasion,he fell to ground (motor symptom)and after this episode he remainedcompletely blind for three years(post-ictal blindness). Also, St. Paul’spersonality shows many traits (inter-ictal state) peculiar to patients withpsychomotor seizures. Among these,his sudden religious conversion, hisgreat interest for religious or moral is-sues, hypergraphia, his poor interestfor sex (hyposexuality). Furthermore,it seems that he had production diffi-culties (2 Corinthinians 10,10). Thissymptom is often reported in patientswith left hemisphere focal epilepsy.

Material and Method. Fyodor Mikhai-lovitch Dostoevsky was born in 1821and died in 1881. What is most cer-tainly known about his medical histo-ry is that he suffered from epilepsy.He was examined and treated bymany physicians in Russia and abroad(Trousseau in Paris, Romberg inBerlin and probably even Herpin,one of the most renowned epileptolo-gists of the time). However, it seemsthat he was never regularly treated forepilepsy (cf. Voskuil 1983, p. 665;Dostoevskaja 1991, p. 49).

To identify all possible factors as-sociated with epilepsy, I read the fol-lowing works by Dostoevky: PoorFolk (1846), The Double (1846), Thewhite nights (1948) Uncle’s Dream(1859), The House of Dead (1861),The Insulted and Injured (1862),Notes from the Underground (1864),The Gambler (1865), Crime and Pun-ishment (1866), The Eternal Husband

St. Paul (I C.E.).

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(1869), The Idiot (1868-1869), TheDevils (1871-1872), The Adolescent(1875), The Brothers Karamazov(1879-1880).

All factors in line with a conditionof epilepsy were classified as follows:1) onset of epilepsy, 2) auras (in itsvarious manifestations), 3) cry, 4) au-tomatisms, 5) description of seizures,6) post-ictal symptoms, 7) triggeringfactors, 8) interictal features. Foreach of these points, an excerpt of thenovel, a short summary or a referencewill be provided.

ResultsFirst attack and frequency of seizures.It is not clear when Dostoevsky’sseizures began. Most of his biogra-phers admit that he suffered his firstfit when he was 7 years old (Alajou-nine 1963). In his life Dostoevsky ex-perienced different types of convul-sive seizures as he himself admitted ina letter to his brother “I have all sortsof attacks …” (1865); probably he be-lieved that the onset of epilepsy wasconcurrent with the first generalizedconvulsive seizure he experienced inwaking state in public. This hap-pened in January 1846 in the pres-ence of his friend Grigorowitch. It istherefore possible that before 1846Dostoevsky had already sufferedmany psychomotor seizures but thesewere never considered real epilepticfits as they were not associated withgeneralized convulsive seizures. Thefirst generalized convulsive seizureswhich Dostoevsky experienced andwhich were seen by a physician (Dr.Janowsky) occurred between 1846and 1849 (Voskuil 1983). The defini-

tive diagnosis of epilepsy was made inFebruary 1857 following some severeseizures a few days after his first mar-riage (Voskuil 1983, p. 660).

Since the first generalized seizuresoccurred, Dostoevsky experienced 2of them a day up to a seizure everyfour months, with an average of oneseizure at a month in the following 35years. In 1861 Dostoevsky had anepisode of status epilepticus. The fre-quency of fits greatly increased be-tween 1860 and 1870. While he waswriting The Devils (1870) he experi-enced many fits. In that period he al-so showed marked difficulties withhis declarative memory, he could nolonger recognize people he knew andoften he had to read again what hehad written as he could not remem-ber what was happening in the novel(Voskuil 1983). Seizures gradually de-creased after 1875 until complete dis-appearance in his last 4 years of life(Geschwind 1984). Most of his fitsoccurred in the first part of sleep. AsDostoevsky used to go to bed verylate (towards 2-3 in the morning),they usually occurred at around 4 o’-clock in the morning (cf. Gastaut1979). He had four children (twosons and two daughters), one of hissons (Alexis) died at the age of 2 yearsand 9 months (1878) owing to a sta-tus epilepticus which lasted about 5hours (Dostoevskaja 1991).

Auras. One of the major difficultiesarising from the definition of Dosto-evsky’s epilepsy is the presence of anaura preceding generalized seizures.Almost all neurologists who studiedDostoevsky’s epilepsy agree on the


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hypothesis that his epilepsy was pre-ceded by an aura (Alajounine 1963;Geshwind 1972; Voskuil 1983). Of adifferent opinion is Gastaut (1983)who claimed that the famous “aura”of ecstasy was a poetic and mysticalexpression of his deep aspiration for aworld of bliss and Christian love (p.193). In his novels Dostoevsky de-scribed many characters who experi-enced psychomotor seizures with dif-ferent types of aura. There are indeedexcellent descriptions of auras withecstasy, auras with fear and terror (cf.Poor folk, Chapter II; The insultedand Injured, Part I, Chapter X andPart II, Chapter I), phenomena of déjàvu or jamais vu (cf. The Instead andInjured, Part I, Chapter X; The Idiot,I, V; The Adolescent, Part II, ChapterIX) and auras with autoscopic phe-nomena (vision spéculaire, Doppel-gänger). Subsequent neurologicalstudies confirmed the hypothesis thatthese phenomena were associatedwith psychomotor seizures. Of partic-ular importance is the fact that Dos-toevsky described some of thesesymptoms associating them withepilepsy when neuroscience had notyet recognized them as such (cf.Gataut 1977). This is a clear indica-tion of the fact that in his novels hereported autobiographical experi-ences.

Ecstatic aura. In his life, Dostoevskydescribed his auras to at least threepeople: Sofia Kovalevskaja, Strakhov,and Baron Wrangel (cf. Gastaut1979; Voskuil 1983). In her “Child-hood Recollections” Kovalenskaja(Vospominanija i pis’ma. Moskva

1961, p. 105-106) reported a conver-sation that she and her sister had withDostoevsky, in 1885, during which hedescribed one of the fits he had expe-rienced when he was prisoner inSiberia (between 1854 and 1857) andunexpectedly was visited by an oldfriend. They spent the whole eveningtogether discussing philosophical andreligious issues. Suddenly, during thediscussion, Dostoevsky excitedlyshouted: “God exists, He exists…”.At the same moment, the bells of theneighboring church began to toll toannounce the first Easter Mass. Dos-toevsky went on to say “ The air wasfilled with a big noise and I tried tomove. I felt the heaven was goingdown upon the earth and that it hadengulfed me. I have really touchedGod. He came into me myself, yesGod exists, I cried, and I don’t re-member anything else. You all,healthy people, he said, can’t imaginethat happiness which we epilepticsfell during the second before our fit.Mahomet, in his Koran, said he hadseen Paradise and had gone into it.All these stupid clever men are quitesure that he was a liar and a charlatan.But no, he did not lie, he really hadbeen in Paradise during an attack ofepilepsy; he was a victim of this dis-ease like I was. I don’t know if this fe-licity lasts for seconds, hours ormonths, but believe me, for all thejoys that may bring, I would not ex-change this one” (cf. Alajouanine1963, p. 212). In a direct declarationDostoevsky (Biografija, pis’ma i za-metki iz zapisnoj knizki F.M. Dosto-evskogo, Sankt-Petersburg 1883, p.214) described his auras using these

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words: “During a few moments I feelsuch happiness that is impossible torealize at other times, and other peo-ple cannot imagine it. I feel a com-plete harmony within myself and inthe world, and this feeling is so strongand so sweet that for a few seconds ofthis enjoyment one would readily ex-change ten years of one’s life – per-haps even one’s whole life” (cf. Ala-jouanine 1963, p. 212).

“... and how many dreams I madewhen I was young, how many experi-ences I felt with my whole heart andsoul during those golden and passion-ate fevers, as if I had been under opi-um! Those were the fullest, most sa-cred and purest moments of my life”(Petersburg’s dreams in verses andprose, 1861). This autobiographicalaccount is very important as it sug-gests that Dostoevsky started to expe-rience auras already in his late child-hood and sometimes auras were ac-companied by ecstasy. Only after theage of 20, he started to show sec-ondary generalization phenomena.The novelist compared the ecstasy heexperienced in adolescence with theeffects of opium which he sometimestook as drug (cf. Voskuil 1983, p.661). “For that very thing had hap-pened. He had had time to say tohimself at the particular second that,for the infinite happiness he had feltin it, it might be well worth the wholeof his life. «At that moment», he hadonce told Ragozhin in Moscow dur-ing their meetings there, “at that mo-ment the extraordinary saying thatthere shall be time no longer [Apoca-lypse 10,6] becomes, somehow, com-prehensible to me. I suppose”, he

added, smiling, “this is the very sec-ond in which there was not timeenough for the water from the pitch-er of the epileptic Mahomet to spill,while he had plenty of time in thatvery second to behold all thedwellings of Allah” (The Idiot, II, V).

“There are seconds, they comeonly five or six at a time, and you sud-denly feel the presence of eternal har-mony, fully achieved. It is nothingearthly; not that it’s heavenly, but mancannot endure it in his earthly state.One must change physically or die.The feeling is clear and undisputable.As if you suddenly sense the whole ofnature and suddenly say: yes, this istrue. God, when he was creating theworld, said at the end of each day ofcreation: «Yes, this is true, this isgood». This... this is not tenderheart-edness, but simply joy. You don’t for-give anything, because there’s nolonger anything to forgive. You don’treally love – oh, what is here is high-er than love! What’s most frighteningis that it’s so terribly clear, and there’ssuch joy. If it were longer than fiveseconds – the soul couldn’t endure itand would vanish. In those five sec-onds I live my life through, and forthem I would give my whole life, be-cause it’s worth it. To endure ten sec-onds one would have to change physi-cally” (Demons, 1871, III, Chapter V).

The aura characterized by ecstasyis rarely described in the literature.Until 1980 no detailed account of acase of partial complex epilepsy withecstasic aura had been provided (Ala-jouanine 1963; Cirignotta et al. 1980).For this reason, in an article of 1977Gastaut erroneously claimed that au-


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ra with ecstasy was a poetic inventionof the novelist. Lack of descriptionsof ecstatic auras at the time of Dosto-evsky, together with the existence ofthis symptomatology, is a strong indi-cation of the fact that the novelist de-scribed this phenomenon on the basisof his personal experiences.

Auras with autoscopic phenomena.Autoscopy is a complex psychosenso-ry hallucination that consists in seeingoneself projected in the external visu-al space (Frederiks 1985). Most of thetimes it consists in the mirror-like im-age of oneself (vision spéculaire). Theimage may appear in front of the pa-tient, at a certain distance, or in oneof the two visual fields. Generally itappears for a short period of time(some seconds), and more rarely dopermanent autoscopic phenomenaoccur. At other times the patient mayintensively perceive a presence closeto him/her (a guardian angel, ahelper, a hostile presence, a Doppel-gänger cf. Brugger et al. 1996). Gen-erally, the patient experiences thepresence of the Doppelgänger withsurprise and negative feelings (anxi-ety, loathing, fear). Sometimes the pa-tient thinks he/she is his/her own Dop-pelgänger (out-of-the body experience,cf. Vulleumier et al. 1997). The mostfrequent cause of autoscopy is an auradue to focal epilepsy.

The phenomenon of autoscopy, inits various forms (perception of apresence, mirror-like image of theDoppelgänger), was used by Dosto-evsky in his novels from 1846 to 1880(cf. Poor Folk, The Letter; September13th; The Double, Chapter V and VI;

Crime and Punishment, Part VI,Chapter I; Demons, Appendix, I; TheKaramazov Brothers, Part IV, BookXI and IX). As experienced by pa-tients with focal epilepsy, in Dosto-evsky’s short stories autoscopic phe-nomena are associated with astonish-ment, fear, anxiety and loathing. Onmany occasions, the characters de-scribed by the novelist immediatelyafter he experienced autoscopic phe-nomena showed loss of conscious-ness. This is indicative of the pres-ence of secondary generalization ofpartial complex seizures character-ized by auras. Moreover, this associa-tion tends to exclude other causes ofautoscopy (fever, alcoholism, mi-graine). Only on one occasion did theauthor state the side in which the“Doppelgänger” appeared, and thiswas the right side (The Double, 1846,VI). This lateralization is in line withfindings in the literature that report ahigher frequency of autoscopic phe-nomena in the right visual field(Brugger et al. 1996). The high fre-quency and the exactness with whichautoscopic phenomena are describedin Dostoevsky’s novels, in a period inwhich neurology knew little of thisphenomenon, lead to think that Dos-toevsky described this phenomenonon the basis of his personal experi-ences rather than pure literary inven-tion (Lhermitte 1951).

The cry. Epileptic generalized sei-zures occurring during waking statesometimes were preceded by a crywhich was repeatedly described byboth Dostoevsky’s second wife andhis friends. It was a protracted and in-

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human cry, like a howl, and immedi-ately after it the author experienced ageneralized convulsive seizure. This“inhuman” vocalization could be thecry that frequently accompanies thefirst phase of a generalized tonic-clonic seizure or it could be a symp-tom typical of frontal epilepsy (Ala-jounine, 1963, p. 211; Laskowitz1995). The description of the cryfound in Dostoevsky’s novels seemsto suggest that it was a symptom ofpsychomotor seizures (frontal epilep-sy) as during its vocalization the maincharacter seemed to be still consciousand capable of hearing it (cf. The In-sulted and Injured, Part II, ChapterVI; Part IV, Chapter IX; The Idiot, II,V; Demons, III; The Brothers Karama-zov, Part II, Book V, VII).

Automatisms. Automatisms are fre-quent components of psychomotorseizures. They follow phenomena ofaura and may be simple or complex.During complex automatisms the pa-tient may still perform complex activ-ities (such as walking, driving, read-ing, etc.) or make inappropriate ac-tions. Automatisms generally occur inthe absence of contact with reality.For this reason, after seizures patientsdo not remember what happened.The automatisms described by Dos-toevsky are of complex type and arecharacterized by the subject’s lack ofawareness of what happened (cf.Demons, I, cap. II and III). If au-tomatisms described in his novels areof autobiographical nature, thiswould suggest that the author wasprobably affected by left hemispherefocal epilepsy (Ebner et al. 1994).

Description of seizures. In his novelsDostoevsky reported many epilepticfits and all seemed to be due to onlyone type of epilepsy, that is psy-chomotor seizures (partial complexepilepsy) with secondary generaliza-tion (cf. The Idiot, II, V; The Adoles-cent, Part I; The Brothers Karamazov,Part I, Book III, VI). The followingare the symptoms of psychomotorseizures reported by the author: 1)different types of aura (phenomena ofwhich the author was aware); 2) sec-ondary tonic-clonic generalization (ofwhich the author was not aware; Dos-toevsky’s descriptions depend on oth-er people’s descriptions or on articlesand books on epilepsy); 3) post-ictalperiod, of which the author was par-tially aware. As in the case of complexpartial seizures, some fits were char-acterized by subjective phenomena ofaura without secondary generaliza-tion. Dostoevsky also described somecases of incoming epileptic fits (statusepilepticus; cf. The Brothers Karama-zov, Part II, Book V, VI). It is knownthat he suffered such an attack at leastonce in 1861 (Voskuil 1983, p. 661).

Post-ictal symtoms. Often Dostoevskyand Anna Griogor’evna described thespeaking and writing difficulties heshowed after convulsions, whichcould last for some hours (cf. The In-sulted and Injured; Part IV, Chapter I;The Gambler, XVI). In this regard,Dostoevsky said: “I was a long timebefore I could speak”, and “Whenwriting I still made mistakes with thewords” (Alajounine 1963, p. 211). Atthe clinical level, this would provideevidence for focal epilepsy, with the


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focus being localized in the left cere-bral hemisphere. Another type ofpost-ictal symptoms were automa-tisms. After a generalized seizure onApril 8, 1855 he said “... [I was] com-pletely unconscious, after I got upfrom the floor, I was sitting androlling cigarettes one after another. Ihad made four, but very badly”. InMay 1870 he wrote “After regainingconsciousness, I was a long time be-fore my head became clear and I re-member that I was going here andthere in the hotel talking about my at-tack to the people I met” (Alajounine1963, p. 211). A very unpleasant con-sequence of his seizures was depres-sion which followed some days afterthe attack. He could not write nor doanything else. Another disorder dueto seizures was a “weakening” of hismemory (Dostoevskaja 1991).

Triggering factors. Dostoevsky’s sec-ond wife remembers that factors trig-gering epileptic fits were above allconcerns and grief (Dostoevskaja1991). Two convulsive seizures weretriggered by drugs or when drinking.Just after his marriage with Anna G.(February 1867) he experienced sev-eral fits after many evenings of diningwith champagne. On April 8, 1875 anhour and a half before the seizure hetook 40 drops of opii banzoedi withwater (cf. Voskuil 1983, pp. 660-661).

Interictal features. In his paper onDovstoevsky’s epilepsy, Geschwindsummarized and discussed the manypersonality features that are known tobe common among patients with tem-poral lobe epilepsy. As has already

been said, one of the most frequentcharacteristics is the great interest forphilosophical and religious issues, to-gether with a great emphasis onmorality. These characteristics werepresent both in Dostoevsky’s daily lifeand in most of his novels. Another per-sonality feature of the novelist was hislack of humor and the lack of concernwith sex or female beauty. “His daugh-ter pointed out in her biography thatshe found it astonishing that in hisyouth there was no woman in his life –no betrothed, no mistress, not even afiltration” (Geschwind 1972, p. 331).Lack of humor and hyposexuality arewell-known common personality traitsin temporal lobe epilepsy. Dostoevskyshowed two other traits typical of pa-tients with TLE: hypergraphia and thetendency to fill pages with complexand repetitive drawings (Robert et al.1982; Murai et al. 1998), Figure 1.

Figure 1.

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Like many other patients withTLE (cf. Robert et al. 1982), Dosto-evsky showed an obsessive personali-ty with a tendency to precision, orderand details, as recalled by Anna G.“The items on his desk were alwaysplaced in a rigorous order, the writerdid not tolerate the slightest sign ofmess” (Dostoevskaja 1991, p. 140).

Conclusions. In his paper of 1983 (p.664), Voskuil clearly and effectivelydescribed the most salient features ofDostoevsky’s epilepsy: (a) “a littlebreeze”; (b) ecstatic aura; (c) expres-sive dysphasia (once described beforean attack); (d) pallor; (e) adversivemovements of the head; (f) symptomsof fear; (g) a cry; (h) generalized con-vulsive movements; (i) long-lastingconfused states with automatisms,speaking and writing disorders, andpost-ictal depression; and (j) increas-ing disturbances of memory func-tions. Given this symptomatology,Alajouanine (1963) was the first tosuggest that Dostoevsky suffered lefttemporal lobe epilepsy. He drew thisconclusion on the basis of the auracharacterized by fear or ecstatic phe-nomena typical of TLE and the pres-ence of speech disorders which fol-lowed some attacks. These languagedeficits indicate an involvement of theleft temporal lobe. A similar conclu-sion was drawn by Geschwind (1972)who, however, did not suggest whichof the two brain hemispheres was af-fected: “It seems that one must diag-nose Dostoevsky as a sufferer fromtemporal lobe epilepsy” (p. 330).

In contrast, in a paper of 1977Gastaut claimed that Dostoevsky didnot show focal epilepsy but Primary

Generalized Epilepsy. In his diagnos-tic hypothesis he dwelled above all onthe fact that until then no one hadprovided a clear description of tem-poral epilepsy with ecstatic aura and,therefore, the aura with ecstasy de-scribed by the novelist was only a po-etic invention (pp. 193-196). Someyears later, Cirignotta et al. (1980) re-ported for the first time ever a case oftemporal lobe epilepsy with ecstaticseizures which they suggested calling“Dostoevsky epilepsy”. Dostoevsky’sdescription of a symptom which atthe time was still unknown in the lit-erature strongly points to the fact thatthe ecstatic aura he experienced was agenuine symptom of epilepsy. Someyears later Voskuil (1983) drew theconclusion that Dostoevsky sufferedfrom partial complex epilepsy with amajority of secondary generalizednocturnal attacks (p. 665).

In my opinion, Dostoevsky’sepileptic symptomatology allows tohypothesize that the novelist had a fo-cal epilepsy localized in the frontallobe (with involvement of the anteri-or cingulate gyrus) with a tendency tosecondary generalization (cf. Lebrun& Fabbro 2002). Frontal lobe focalepileptic fits tend to: (1) occur insleep; (2) trigger auras with emotion-al components (intense fear); (3) pro-duce vocalizations; (4) determinepost-ictal aphasia; and (5) tend fre-quently to generalize into secondarytonic-clonic epilepsy (Laskowitz1995). The presence of language dis-orders and depression following con-vulsions supports the hypothesis ofan epileptic focus localized in the leftcerebral hemisphere (Robert et al.1982; Paradiso et al. 1995).


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It cannot be naively stated thatDostoevsky’s epilepsy was the onlysource for his creativity and literary ge-nius. At present, in Europe and NorthAmerica there are millions of peoplewho suffer a similar type of epilepsy(temporal or frontal epilepsy) butamong these there are few successfulnovelists and, unfortunately, no onehas the same literary genius as Dosto-evsky. It must be nonetheless statedthat Dostoevsky’s disease was not asimple chronic disease. Psychomotorseizures affect the organ responsiblefor cognitive and affective functionsand language. Furthermore, this typeof epilepsy, with its subcontinuous ac-tivity, tends to intensify some personal-ity traits, such as philosophical and re-ligious reflections, meticulousness, hy-pergraphia, lack of interest for sex, etc.Dostoevsky, therefore, suffered from adisease that first of all had contributedto shaping his personality and stressingsome traits which had influenced hiswritten production.

A central question is why Dosto-evsky introduced the issue of epilepsyin almost all his novels, whereasFlaubert, for example, – who sufferedfrom the same disease – wrote lessabout it (even if Emma, the maincharacter of Madame Bovary sufferedfrom convulsive seizures, Part II, XI-II). In describing epilepsy, Dosto-evsky probably had two objectives inmind. The first goal was to re-statethat people suffering from epilepsywere not monsters. Not only ordinarypeople but also literary critics and po-litical opponents had used this dis-ease to denigrate him and he had hadto defend himself stressing the factthat to discredit someone just be-

cause he/she was affected by epilepsywas unfair and mean. For example, in1864 in the journal “Epocha” hereplied to some attacks with a shortpaper entitled A Necessary Statement.“Yes, I suffer from epilepsy which,unfortunately, I happened to developtwelve years ago at a sad time in mylife. The disease is not a cause of dis-repute (…). But epilepsy is not a hin-drance to activity. There have beenmany great personalities sufferingfrom epilepsy and one of them evenrevolutionized the world, despite hisdisease. What meanness you show”(cf. Strada 1994, p. XVII).

Dostoevky’s second objective waseven more ambitious: not only peoplewith epilepsy are like others but theyshow greater qualities in terms of cog-nition, philosophical and religious as-pects than normal people. It is not bychance that the main character of TheIdiot, Prince Myshkin, who takes in-spiration from the greatest religiousfigure of the Western world, JesusChrist, was affected by epilepsy. Dur-ing convulsions, Prince Myshkin likeChrist fully understood the sense ofuniverse and time. The idea that a dis-ease, and particularly, psychomotorseizures, are a way to deeper knowl-edge is not only typical of Dostoevskybut is found in many cultures, whereindividuals wanting to become ashaman, that is man of knowledge,must experience a period of both dis-ease and ecstasy (Eliade 1964; Kalweit1992). These experiences allow man toestablish contact with the complexreality that is beyond normal life.This is also reflected in the ancientdefinition of epilepsy as “sacred dis-ease”.

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