[Here, Andreasen considers Shakespeare's astute clinical observation of mental illness in Macbeth, Hamlet, and King Lear in light of the Renaissance classification and treatment of mental disorders, and concludes that "Shakespeare the artist was a better observer by far than the physicians of his own time. "]

Shakespeare was fascinated with the idea of madness. In fact, most Elizabethans were. Elizabethan drama began with a play about insanity—The Spanish Tragedy, or Hieronimo Is Mad Again. For the Elizabethan, a trip to the theatre was a movie, a television documentary, a Broadway musical, and a visit to a zoo or amusement park, all in one. Shakespeare was show-man enough to capitalize on his audience's taste for the varied and bizarre. Each of his four major tragedies is a sensitive exploration of psychopathology. Hamlet portrays manic-depressive illness in Hamlet and schizoaffective disorder in Ophelia. Macbeth shows both major characters suffering from ambition that leads to crime and the punishment of depression. Lear has a mild organic brain syndrome that develops under stress into a reactive psychosis, while Gloucester becomes depressed and Edgar feigns classic schizophrenia as Poor Tom. Othello develops a suspiciousness bordering on paranoia, while Iago's delight in malice for its own sake borders on sociopathy. Shakespeare's portrayals in these plays suggest that he was an astute clinical observer of mental illness. One wishes Renaissance physicians—or any physicians describing psychiatric syndromes before the 19th century—had done as well.

Renaissance Psychiatric Nosology

Few primary sources describing psychiatric nosology during the Renaissance are available. Relevant sources are of two types. First, there are a series of tracts on demonology and witchcraft that often describe psychiatric symptomatology. These are primarily polemic tracts rather than scientific descriptions, but since John Weyer and Reginald Scot attempted to plead for more humane treatment of witches because they were often mentally ill, usually from melancholia, and their delusions and hallucinations were based on such illness, these treatises shed some light on attitudes toward psychiatric symptoms.

Second, a small body of medical literature on mental illness existed, but there was no widely accepted set of theories about mental illness. Most medical ideas of the period derived from Galen, the originator of the humoral theory that Ben Jonson put to such good dramatic use. According to this theory, the body was composed of four basic fluids—blood, phlegm, yellow bile, and black bile. All forms of illness, including mental aberrations such as melancholy and purely somatic ailments such as gout, were thought to be due to an imbalance in the humors. Competing with the humoral school was the solidist school, which taught that illness was due to pathological changes in specific solid organs such as the brain or bones.

In the few descriptions of mental illness available in the era, some specific psychiatric illnesses were delineated. Phrenitis or "frenzy" was an illness characterized by confusion and agitation accompanied by fever, and it probably encompassed encephalitis, meningitis, and delirium. Mania, also known as madness or lunacy, was characterized by confusion, agitation, and bizarre behavior. It differed from phrenitis primarily in that it was not accompanied by fever. This diagnosis was broadly used and probably included such varied disorders as schizophrenia, mania (in the modern sense), and various organic psychoses. Finally, melancholia or depression was quite well recognized. In 1586, Timothy Bright wrote A Treatise of Melancholic the first psychiatric monograph written in English. In it he described the various classic symptoms such as insomnia or loss of appetite, the more unusual symptoms such as delusions consistent with the depressed mood, and the intermittent periods of elation and high energy occurring in some melancholics.

Shakespeare appears to have been familiar with the witchcraft tracts and with contemporary medical theories. But Shakespeare was an unusually keen observer of human behavior, and in his plays, one finds clinical portrayals of psychiatric syndromes far more sophisticated than those seen in medical treatises of his time. Physicians were just beginning to realize that one might learn more about disease from observing actual patients than from reading textbooks. Perhaps Shakespeare was fond of visiting Elizabethan madhouses and observing the behavior and speech of the inmates, for he sometimes depicts syndromes so accurately that they could serve as brief case vignettes for modern psychiatric residents. Shakespeare was also a child of his own era, of course, and so we find medically sound descriptions mixed with notions drawn from demonology and witchcraft. Macbeth provides an illustration of his complex blending of medical literature, realistic observation, and instinctive stage sense.

Macbeth: Melancholia and Witchcraft

Macbeth was probably written with the intent of pleasing James I. It appears to have been written for presentation at court—at night by candlelight if its dark imagery is any clue—and it is designed as a history play that would dramatize the greatness of James' forebears and his Scottish background just as the English history plays had done for Elizabeth. It draws on a topic certain to be of great interest to James: witchcraft and demonology.

James VI of Scotland had published his Daemonologie in 1597 to dispute and disprove the thesis of Scot and Weyer that "witchcraft" could be explained by natural rather than supernatural causes. After his accession as James I of England, he republished the book in 1603, and in 1604 he introduced a new Witchcraft Act to replace a milder Elizabethan one. Because of its severities, the Witchcraft Act became a two-edged sword. In an era that was indeed becoming more sophisticated and enlightened about both mental illness and demonology, accused witches were more closely examined than before the Act because of the terrible penalties they would incur if found guilty. The notion that so-called witches might in fact be mentally ill was by now accepted widely enough that doctors were sometimes called in to examine the accused and to testify at trials. Thus, witches indeed got close scrutiny as James wished, but it may have worked to their advantage.

Although Macbeth was probably written primarily to please James I, it contains elements that would please both sides in the controversy. Superficially, as was inevitable in a court play, it presents the side of James I. The play clearly portrays Macbeth as tempted by his consuming ambition to traffic with witches and eventually as possessed by demonic forces. But secondarily it shows him and especially Lady Macbeth as suffering from mental illness in the form of melancholia or depression.

Macbeth: Depression or Possession?—Macbeth and Lady Macbeth are similar but contrasting characters. Both suffer from excessive ambition; both plan and commit murder to fulfill it; and both experience guilt and depression. But their ability to cope with the consequences of their actions is quite different. Macbeth is presented as yet another Faustian character who sells his soul to the devil, although for power rather than for knowledge. He becomes the evil that he does and emerges as a diabolic figure at the end. Initially, he is "noble Macbeth," startled and frightened by the witches. Banquo, a contrast to Macbeth throughout the play in his enduring sanity and morality, doubts the witches, while Macbeth is inclined to believe in their reality. Macbeth, on first hearing their prophecy that he will become King of Scotland, is entranced and obsessed by it. Only a few lines later, he is already planning murder. Ironically, by believing in the witches, he ultimately gives in to them, thereby faring less well than the skeptical Banquo, the legendary forebear of James I.

After the murder, both Macbeth and Lady Macbeth suffer from guilt and symptoms of depression. In their first scene together after the murder, Macbeth is complaining of "The torture of the mind to lie / In restless ecstasy" (act III, scene 2, lines 21-22). But Macbeth is troubled at least as much by the prophecy that Banquo will beget kings. He formulates a plan to murder Banquo and Fleance without even consulting Lady Macbeth. Yet in act III, scene 4, the banquet scene, he is still suffering enough from pangs of conscience to have terrifying hallucinations. Most medical writings of the era describe hallucinations as the result of melancholy and deranged imagination, although some writings on witchcraft interpreted them instead as due to possession. The portrayal in Macbeth is open to either interpretation, and Macbeth can be seen at this moment as both remorsefully depressed and as demonically possessed.

Morally and psychologically, the banquet scene is a fulcrum, and thereafter the balance of Macbeth's character is tipped in the direction of being diabolic rather than mentally ill. Immediately afterward, he seeks out the witches himself. Macduff's wife and children are mercilessly murdered. Various characters describe him as a "tyrant bloody sceptered" (act IV, scene 3, line 104) and as "devilish Macbeth" (act IV, scene 3, line 175). His eloquent soliloquy on the death of Lady Macbeth is his own testimony to his internal desperation and nihilism.

Lady Macbeth: Depression as Punishment for Crime.—Lady Macbeth's characterization is quite different. She is portrayed as stronger, more pragmatic, and perhaps more moral. Because she achieves greater insight about the moral consequences of her behavior, she may be the true tragic character in the play. In the early scenes, she is sketched deftly as a woman of "undaunted mettle" (act I, scene 7, line 73), ambitious for her husband, more persistent than he in planning the murder of Duncan and in tidying up the bloody details afterward. Yet she suffers qualms when she notes that Duncan resembles her father as he sleeps, and she faints when she hears her husband describe his murder of the grooms.

When we next see her in act III, scene 2, she is already experiencing symptoms of depression. She too has insomnia, and she is worried about the personality changes she is noting in him. When he hallucinates in the banquet scene, she attempts in her practical way to talk him out of his ghastly visions. When she next appears (in the sleep-walking scene at the end of the play), her profound depression is based in part on the realization that the murder has transformed her husband from a man into a monster. The physician called to diagnose and treat her recognizes that she suffers from mental illness: "Infected minds / To their deaf pillows will discharge their secrets" (act V, scene 1, lines 80-81). His following remark, "More needs she the divine than the physician" (act V, scene 1, line 82), is ambiguous. In one sense, it might imply that she as well as Macbeth is truly bewitched and that the proper treatment should be given by a cleric rather than by a doctor. But on the other hand, the doctor's recognition of the risk of suicide in her guilt-ridden condition and his "God, God forgive us all!" (act V, scene 1, line 83) seem to imply more strongly that she suffers from a severe depression as a result of remorse about her actions and their effect on her husband.

Hamlet: Aspects of Affective Disorder

Hamlet shares many themes with Macbeth, but it is far simpler to deal with in terms of psychiatric nosology. In Macbeth, Shakespeare portrays both major characters as suffering from classic symptoms of depression such as insomnia, despair, and guilt, but he is ambiguous about whether they suffer from true depression or from being bewitched, seeming to imply the former for Lady Macbeth and the latter for Macbeth. In Hamlet, bewitchment is no problem. Hamlet's seeking of revenge is much delayed, in fact, because he is so concerned about the problem of bewitchment and must determine whether his father's ghost is a true one or one sent from the devil to mislead him. The perplexing diagnostic issue in Hamlet is not witchcraft or the nature of Hamlet's illness, but the extent to which Hamlet's illness is feigned or real.

Hamlet as a Melancholic.—There is little doubt that Hamlet suffers from melancholia. His first soliloquy shows him already so depressed that he is contemplating suicide and lamenting how "weary, stale, flat, and unprofitable" (act I, scene 2, line 133) life is. This mood is maintained throughout most of the play and is sustained by a series of soliloquies that are among the most eloquent expressions of the subjective symptoms of depression in English: the temptations of suicide in "To be or not to be" (act III, scene 1, line 56), guilt and self-deprecation in "Oh, what a rogue and peasant slave am I!" (act II, scene 2, line 576), lethargy and inability to make decisions or initiate actions in "How all occasions do inform against me / And spur my dull revenge!" (act IV, scene 5, lines 31-32). His symptoms of depression are thus classic.

It is interesting to note that the depression portrayed in Hamlet is given abundant precipitating factors. Shakespeare seems to imply that at least five things triggered Hamlet's depression by putting explanations in the mouths of various characters in the play: (1) grief over his father's unexpected and premature death; (2) disappointment and disillusionment with his mother because of her "o'er hasty marriage" (and some might say because of his unresolved Oedipal conflicts); (3) the treachery and perfidy of Claudius, his own uncle and stepfather; (4) Ophelia's rejection of his love; (5) the dishonesty and betrayal of his old school friends, Rosencrantz and Gildenstern. Hamlet suffers five significant object losses, and thus Hamlet's depression might be due to introjecting his anger about abandonment by significant figures in his life. In any case, Shakespeare does not seem to have a concept of depression as endogenous. Hamlet, Macbeth, and Lady Macbeth all experience precipitating stresses. Perhaps this is because it is more dramaturgically effective to portray motivations in characters, and perhaps it is because of a more philosophical or religious need to seek the causes for all effects, especially intellectually or ethically troubling ones.

Hamlet and Bipolar Affective Disorder.—Thus, Hamlet is clearly depressed. Whether he also suffers from bursts of mania or whether his "antic-disposition" is truly feigned is a more difficult question. Clues within the play suggest that Shakespeare did intend to portray Hamlet as a "bipolar" (ie, having symptoms of both mania and depression). Hamlet has two episodes of inappropriate gaiety in the midst of his melancholic mood before he puts on his antic disposition. Both are with Horatio, first in act I, scene 2 when he jokes about using food from his father's funeral at his mother's wedding, and later when he bursts with energy and impetuosity over seeing his father's ghost. Thus, he is intermittently hypomanic even in the early scenes in the play.

Part of the confusion about the reality of Hamlet's madness arises, however, from the fact that he never becomes more than hypomanic, even after he puts on his antic disposition. He never suffers from grandiose delusions or markedly poor judgment. Rather, even when high he shows some insight and control, leading Polonius to note the method of his madness. The speeches in which he seems most severely deranged, the speeches in which he shows such classic manic symptoms as flight of ideas or clang associations or preoccupation with sex, have a playful quality to them that is only partly hypomanic gaiety. For example, in act III, scene 2 when Ophelia is "loosed" to him by Polonius and Claudius so that his behavior can be observed, he is insightful enough to ask her where her father is and to catch her in a lie at the same time that he permits his thoughts to race loosely, is inappropriately irritable and cruel to her, and talks repeatedly about wantonness and breeding. The observers are not certain as to whether he is truly mad, because of his mixture of insight and inappropriateness. Ophelia observes "What a noble mind is here o'erthrown" (act III, scene 2, line 157), while Claudius notes that "What he spake, though it lacked form a little, was not like madness" (act III, scene 2, lines 171-172). The simple fact is that Hamlet is hypomanic: momentarily high enough to behave naturally and seem somewhat mad, high enough to make inappropriately gay or hostile statements even when he is with trusted friends and need not feign madness, but never so high that he completely loses insight or control.

One cannot leave Hamlet without taking note of the illness found in the other "mad" character in the play, Ophelia. Shakespeare may have had Bright's Treatise available to enhance his innate gifts for observation and lead him to make an excellent clinical portrayal of bipolar affective disorder in Hamlet. Ophelia, however, provides another excellent portrayal of a classic psychiatric illness, but one which was not described until the 20th century: schizoaffective disorder. Her list of characteristics reads like a textbook description: she has a good premorbid personality, suffers several devastating precipitating factors in the death of her father and Hamlet's cruelty, develops a depressive mood combined with incoherent speech and autistic behavior. Her death by suicide is a not-uncommon consequence of untreated schizoaffective disorder.

King Lear: Medical Madness for Poetic Purpose

King Lear is a complex play with many levels of meaning, and Shakespeare's use of madness enriches these many levels. Even in terms of the types of psychiatric illness portrayed, there is an embarrassment of riches. Leaving aside the florid psychopathology in malevolent characters like Edmund, Goneril, and Regan, we are still left with three cases of madness in Lear, Gloucester, and Poor Tom.

Gloucester's Depression.—Gloucester's madness is relatively clear-cut. He suffers from a depressive syndrome similar to that noted in Hamlet, suggesting that Shakespeare perhaps had definite notions about the causes and course of melancholia. Like Hamlet, Gloucester is thrown into depression by a series of object losses which are offered as precipitating factors. He first thinks he has been betrayed by Edgar, then realizes that he has falsely placed his trust in Edmund, and finally, after the brutally traumatic blinding scene, is thrown out into the world bereft of worldly goods without even eyesight (a common symbol of rationality in the Renaissance) to guide him. Like Hamlet, he is portrayed as having psychological symptoms of depression rather than somatic ones: despair, hopelessness about the future, suicidal thoughts, apathy, and an overwhelming sense of nihilism and meaninglessness. Gloucester recovers from his depression rather rapidly after his attempted suicide. One wonders if Shakespeare and his audience saw the "fall from the cliff" as a form of shock therapy, for traumatic somatic treatments such as ducking in cold water were sometimes used in the Renaissance era.

Gloucester's personality and his madness are clearly designed to counterpoint and highlight that of Lear.

Their plot lines are parallel: mistaken judgment about the loyalty and honesty of their children, abandonment and betrayal by the children they have wrongly chosen to trust, terrible suffering and desolation that lead into a period of madness, and recovery from the madness with greater wisdom, compassion, and strength. But Lear's madness does not fit so easily into a clearly defined clinical syndrome, at least as understood in Renaissance medicine, perhaps because it is used more heavily to carry tragic and philosophical themes in the play. Thus, we must look at Lear's madness from two points of view, first from the medical or psychiatric perspective and then from a poetic or philosophical perspective.

Lear's Reactive Psychosis.—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. His age is "fourscore and upward" (act rv, scene 7, line 61), and long before he goes mad his daughters remark about symptoms of senile organicity: he is "full of changes" (act I, scene 1, line 291), and "Old fools are babes again" (act I, scene 3, line 18). Also, he displays symptoms of organicity in his behavior. He shows poor judgment, in rejecting first the loving Cordelia and later the loving Kent. He is moody and unpredictable, alternating between obsequiousness and magnificent cursing rages in his dealings with Goneril and Regan. He is also quite labile, for on several occasions he lapses into maudlin self-pity that contrasts sharply with his dignified pride, as when he complains that he is "more sinned against then sinning" (act III, scene 2, line 60).

As an old man becoming somewhat senile, he is ill-equipped to deal with changes of any kind, much less the severe stresses of betrayal, loss of his kingly position and dignity, loss of all familiar friends and associates except the fool, and the violent indifference of nature during the storm. His symptoms during his madness are what Elizabethans included in the very general category of mania and what we today would call a reactive psychosis or a gross stress reaction. His most prominent symptoms are confusion, visual hallucinations, and some disorganization in his thinking. When he is reunited with Cordelia at the end of the play, his physician prescribes sleep as the only necessary treatment, and he awakens fully recovered.

Recovering Sanity Through Insanity.—Lear's symptoms are thus not particularly difficult to understand, nor is even their rapid reversibility. Their uniqueness lies in the magnificence of the tragic theme they carry. In this sense, Lear's madness surmounts any psychiatric syndrome and becomes a poetic device for portraying re-generation through suffering, the archetypal Aeschylean theme of pathei mathos. Paradoxically, Lear is made to recover sanity through insanity. He is portrayed at the beginning as a rigid and tyrannical man with two great failings: he is excessively proud, and his is un-forgiving. He learns to shed these traits through the poetic redemption of suffering madness. The first critical step begins before he goes mad. Having been humbled by being stripped of his crown, his knights, and finally a roof over his head, he for the first time takes physic for his pomp, identifies with the poor naked wretches of the world, and learns "to feel what wretches feel" (act III, scene 4, line 35). In other words, he achieves empathy with and compassion for the ordinary humble people whom he has ruled for many years without understanding their plight. This is given dramatic visual reality in the scene where he feels so much sympathy for Poor Tom's coldness that he strips off his own regal clothing to achieve identity with him. And as pride is cured by humility, the vindictive un forgivingness that led him to reject Cordelia's blunt honesty is replaced by a sense of sin in himself and finally is cured by compassion. Lear moves from feeling "more sinned against than sinning" through the mad purgatory of confronting the world's hypocrisy and injustice to the realization that since all are joined in the community of sin, so all must be joined in a community of forgiveness: "Plate sin with gold, and the strong lance of justice hurtless breaks. / Arm it in rags, a pigmy's straw does pierce it. / None does offend, none, I say, none" (act IV, scene 6, lines 169-172).

Shakespeare's portrayal of the classic symptoms of organicity and reactive psychosis is paralleled by his classic portrayal of schizophrenia in the character of Poor Tom, the Bedlam beggar. Perhaps the only outdated element in this portrayal is the moralistic speech in which Tom implies that his illness was brought on by excessive indulgence in fleshy delights at the devil's prompting. But except for this search for a precipitating cause (which appears to have been one of Shakespeare's intellectual habits), other details of the portrayal are still medically respectable today. Poor Tom even describes the Schneiderian first-rank symptom of passivity feelings (the belief that his will and actions are controlled by outside forces): the foul fiend is raging in him and making him eat cow dung. He experiences auditory hallucinations as various devils speak to him or call him. And sometimes when he speaks, his associations are so loose as to approach "word salad": "Do de, de, de. Sessa! Come, march to wakes and fairs and market towns. Poor Tom, thy horn is dry" (act III, scene 6, lines 77-79).

The Artist as Scientist

Shakespeare the artist was a better observer by far than the physicians of his own time. Psychiatry as a science has advanced primarily through using direct empirical observation. While Renaissance physicians were carrying leeches and purgatives in their bags and looking at their patients through eyes clouded by Galenic theories, Shakespeare was looking at them afresh and portraying madmen just as he saw them. His desire to be an artist made him a scientist, just as his desire to be a successful businessman made him an artist. Shakespeare chose themes for his tragedies that guaranteed audience appeal: witchcraft and madness. He then portrayed characters suffering from madness not as books or theologians said they should be but as his own observation said they actually were. No doubt, he early realized that looking closely at actual human behavior led to sound characterization and thereby to successful plays. Shakespeare was not an empiricist for lofty theoretical reasons. He was a practical man. He happened to be a practical man with an incredibly shrewd eye for human behavior combined with incredibly rich verbal gifts. And so it happened that his practical bent made him at once a great artist and a "behavioral scientist" in what is now recognized as the empirical tradition. Hamlet, Lear, Ophelia, and Poor Tom are accurate clinical portrayals of people suffering from discrete psychiatric illnesses. As descriptive medicine, these portrayals anticipate the later work of such superb observers as Kraepelin or Langfeldt.

Bibliographic Note

Quotations from Shakespeare are from G. B. Harrison's edition of Shakespeare: The Major Plays and the Sonnets (New York, Harcourt Brace, 1948). The literature on Shakespeare and his plays is far too enormous to list. A. L. Rowse's Shakespeare The Man (New York, Harper and Row, 1973) is an excellent introduction to Elizabethan history and Shakespeare biography.

Standard texts on the history of psychiatry include Gregory Zilboorg and George W. Henry's A History of Medical Psychology (New York, WW Norton and Co Inc, 1941) and Erwin H. Ackerknecht's A Short History of Psychiatry, ed 2 (New York, Hafner Pub Co Inc, 1968). Richard A. Hunter and Ida Mecal pine's Three Hundred Years of Psychiatry, 1535-1860: A History Presented in Selected English Texts (Oxford, Oxford University Press Inc, 1963) contains primary sources dealing with the witchcraft controversy and Elizabethan nosology, including selections from Reginald Scot, James I, and Timothy Bright. These three have also been reproduced in modern facsimile editions. Mary I. O'Sullivan's "Hamlet and Dr. Timothy Bright" (Publications of the Modern Language Association, 61:667-679, 1946), and Ilza Veith's "Elizabethans on Melancholia" (JAMA 212:127-131, 1970) both contain interesting discussions of Renaissance attitudes toward psychiatric illness.