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Journal of the History of the
Neurosciences: Basic and Clinical
Perspectives
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Friedrich Nietzsche and his Illness:
A Neurophilosophical Approach to
Introspection
Lampros Perogamvros a , Stephen Perrig a , Julien Bogousslavsky b &
Panteleimon Giannakopoulos c
a Division of Neuropsychiatry, Department of Psychiatry, University
Hospitals of Geneva, Chemin du Petit-Bel-Air, Geneva, Switzerland
b Center for Brain and Nervous System Disorders, Genolier
Swiss Medical Network, and Department of Neurology and
Neurorehabilitation, Clinique Valmont, Glion/Montreux, Switzerland
c Division of Mental Health and Psychiatry, Department of Psychiatry,
University Hospitals of Geneva, Chemin du Petit-Bel-Air, Geneva,
Switzerland
To cite this article: Lampros Perogamvros , Stephen Perrig , Julien Bogousslavsky & Panteleimon
Giannakopoulos (2013): Friedrich Nietzsche and his Illness: A Neurophilosophical Approach to
Introspection, Journal of the History of the Neurosciences: Basic and Clinical Perspectives, 22:2,
174-182
To link to this article: http://dx.doi.org/10.1080/0964704X.2012.712825
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Journal of the History of the Neurosciences, 22:174–182, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 0964-704X print / 1744-5213 online
DOI: 10.1080/0964704X.2012.712825
Friedrich Nietzsche and his Illness:
A Neurophilosophical Approach to Introspection
LAMPROS PEROGAMVROS,1STEPHEN PERRIG,1
JULIEN BOGOUSSLAVSKY,2AND PANTELEIMON
GIANNAKOPOULOS3
1Division of Neuropsychiatry, Department of Psychiatry, University Hospitals of
Geneva, Chemin du Petit-Bel-Air, Geneva, Switzerland
2Center for Brain and Nervous System Disorders, Genolier Swiss Medical
Network, and Department of Neurology and Neurorehabilitation, Clinique
Valmont, Glion/Montreux, Switzerland
3Division of Mental Health and Psychiatry, Department of Psychiatry, University
Hospitals of Geneva, Chemin du Petit-Bel-Air, Geneva, Switzerland
There are some arguments that Friedrich Nietzsche suffered from the autosomal dom-
inant vascular microangiopathy: Cerebral Autosomal Dominant Arteriopathy with
Subcortical Infarcts and Leukoencephalopathy (CADASIL). Here, a hypothesis is for-
mulated supporting that CADASIL presenting with symptoms of bipolar disorder and
Gastaut-Geschwind syndrome would contribute to the increased insight and creativity
of a philosopher whose perceptions and intuitions often bear out the results of modern
neuroscience. Alterations of the brain default and reward networks would account for
such an increased level of introspection and creativity. A new framework on approach-
ing illness is proposed, which, in conformity with Nietzsche’s positive view, outlines the
enabling aspects of some otherwise highly disabling neuropsychiatric disorders.
Keywords Friedrich Nietzsche, CADASIL, bipolar disorder, Gastaut-Geschwind syn-
drome, introspection, creativity, illness
Introduction
Completely cut off from life by his illness, he turns toward the only object of
search remaining to him: the Ego.
S. Freud on F. Nietzsche
October, 1908
(Nunberg, 1967, p. 35)
Friedrich Nietzsche (1844–1900) was one of the most influential modern thinkers, whose
work left its mark on philosophy and intellectual movements in the twentieth and twenty-
first centuries. With concepts like “will to power,” “death of God,” and “eternal recurrence,”
Nietzsche suggested a reevaluation of the foundations of human values and a reincarnation
Address correspondence to Lampros Perogamvros, MD, Division of Neuropsychiatry,
Department of Psychiatry, University Hospitals of Geneva, Chemin du Petit-Bel-Air 2, 1225, Geneva,
Switzerland. E-mail: lampros.perogamvros@hcuge.ch
174
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Nietzsche and Neuroscience 175
of human creative abilities. This anthropocentricity made a great contribution to the devel-
opment of modern human sciences, modern psychology, and neuroscience. Nietzsche’s
philosophy is characterized by a unique and profound level of introspection, creativity,
and self-awareness, which led S. Freud to recognize in Nietzsche “the first psychologist”
(Assoun, 1998, p. 10) (Figure 1).
It is now considered that Nietzsche’s poor health had a major impact on the content and
form of his philosophy. The objectives of this article are to explore and determine which
was the most prevalent neuropsychiatric diagnosis of Nietzsche, to examine its impact on
Nietzsche’s philosophy, life, and level of insight, and to investigate a potential link between
a specific neurobiological predisposition and the tendency towards introspection.
Figure 1. Nietzsche, analyzing and analyzed (Frédéric Pajak, drawing from “L’Immense solitude,”
Noir sur Blanc Editions, 2012).
Nietzsche’s Neuropsychiatric Illness
One of the cardinal symptoms of Nietzsche’s illness were the headaches that began dur-
ing adolescence, were located mostly on the right side and were accompanied by nausea,
vomiting, photophobia, and phonophobia — symptoms that were preceded or followed by
visual or sensitive phenomena. These headaches would now fulfill the criteria for a diagno-
sis of migraine with aura. The second major pathology involves the mental disorder of the
philosopher. At the age of 28, Nietzsche had his first major depressive episode, marked by
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176 Lampros Perogamvros et al.
suicidal thoughts. It recurred five years later (Hemelsoet et al., 2008). Hypomanic/manic
symptoms including periods of euphoria, accelerated thoughts, and megalomania were
also documented from 1882 (Danesh-Meyer & Young, 2010) and were especially promi-
nent in his philosophic works. “Nietzsche contra Wagner,” “Twilight of the Idols,” “The
Antichrist,” and “Ecce Homo” were all completed in less than three months, and their
chapter titles reveal thoughts of grandiosity (e.g., “Why I am So Wise,” “Why I am So
Clever”). The hypomanic/manic symptoms, which were often accompanied by recurrent
psychotic symptoms, like delusions (e.g., he believed he had deposed both the Pope and the
German Emperor) and visual hallucinations (he saw imaginary flowers, constantly grow-
ing), worsened during and after his mental collapse in 1888 (Assoun, 1998, p. 196). All
the aforementioned psychiatric symptoms would now fulfill the criteria of bipolar disorder
Type I. A progressive cognitive decline developed since the age of 45; symptoms like mem-
ory decline and behavioral problems (apathy, irritability, aggression, personality change)
would now fulfill the criteria for dementia. In the last years of his life, Nietzsche developed
neurological symptoms like speech and motor problems (left hemiplegia, facial paresis)
that could be compatible with stroke. Interestingly, the medical history of his father reveals
similar symptoms throughout his short life: migraine, depression, epileptic seizures, and
visual and speech problems. He died at 35 years old after a massive stroke.
There have been several hypotheses about Nietzsche’s neuropsychiatric illness. In the
beginning of the twentieth century, diagnoses of progressive paralysis and neurosyphilis
were given, but later contested (Podach, 1931/1974), because they were mainly based on
a cursory examination and on the assumption in the 1890s that dementia in a middle-aged
man could safely be assumed to be paretic syphilis (Sax, 2003). Later on, frontotemporal
dementia (Orth & Trimble, 2006), right frontotemporal tumor (e.g., meningioma) (Owen,
Schaller, & Binder, 2007; Sax, 2003), or mitochondrial encephalomyopathy (Koszka,
2009) were suggested. Most of the aforementioned hypotheses have been recently con-
sidered insufficient to explain all symptoms (Danesh-Meyer & Young, 2010; Hemelsoet
et al., 2008) and, to date, the most prevalent diagnosis seems to be Cerebral Autosomal
Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL;
Butler, 2011; Hemelsoet et al., 2008), which can account for almost all of Nietzsche’s
neurological and psychiatric symptoms throughout his life. CADASIL is an inherited
autosomal dominant vascular microangiopathy caused by mutations on the Notch3 gene
localized on chromosome 19p13.1 (Joutel et al., 1997). Nietzsche presented all main clin-
ical manifestations of CADASIL (young age [<50 years old], migraine, stroke events,
mood disturbances, subcortical dementia, family history).
Further evidence supporting this hypothesis comes from recent studies showing that
mood disorders, the primary mental illness displayed by Nietzsche, usually precede neuro-
logical symptoms of CADASIL (Valenti et al., 2011). Unipolar disorder is found in 48% of
the patients and bipolar disorder in 26% of the patients (Valenti et al., 2011). It should
also be noted that CADASIL as a cause for Nietzsche’s illness is a testable hypothe-
sis: acquisition of nuclear DNA by salivary samples (e.g., in envelope folds or stamps)
and amplification of the Notch3 gene via Polymerase Chain Reaction (PCR) techniques is
actually pursued (Butler, 2011).
CADASIL is a slowly progressive disease that usually proceeds with steps of increas-
ing deterioration as a consequence of recurrent strokes. If we were to speculate on stroke
episodes before his “nervous breakdown” at age 44, we would place them in “silent zones”
of the brain, like the right temporal lobe (in a right-handed person such as Nietzsche).
A known but rare syndrome, which is usually associated with temporal lobe epilepsy, is
the Gastaut-Geschwind syndrome (Waxman & Geschwind, 1975). It can also exist in right
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Nietzsche and Neuroscience 177
Table 1
The Bear and Fedio Inventory
– Emotionality (deepening of all emotions, sustained intense affect)
– Elation, euphoria (grandiosity, exhilarated mood, diagnosis of manic-depressive disease)
– Sadness (discouragement, tearfulness, self-depreciation; diagnosis of depression,
suicide attempts)
– Anger (increased temper, irritability)
– Aggression (overt hostility, rage attacks, violent crimes, murder)
– Altered sexual interest (loss of libido, hyposexualism, fetishism, transverstism)
– Guilt (tendency to self-scrutiny and self-recrimination)
– Hypermoralism (attention to rules with inability to distinguish significant minor
infraction; desire to punish offenders)
– Obsessionalism (ritualism, orderliness, compulsive attention to detail)
– Circumstantiality (loquacious, pedantic; overly detailed, peripheral)
– Viscosity (stickiness; tendency to repetition)
– Sense of personal destiny (events given highly charged significance)
– Hypergraphia (extensive diaries, detailed notes, writing autobiography/novel)
– Religiosity (holding deep religious beliefs)
– Philosophic interest (nascent metaphysic or moral speculations, theories)
– Dependence, passivity (cosmic helplessness, at the hands of “fate”)
– Humorlessness, sobriety (ponderous concern; humor lacking)
– Paranoia (suspicious, overinterpretative of motives and events; diagnosis of paranoid
schizophrenia)
temporal stroke patients (Hoffmann, 2008) and is mainly characterized by (a) personality
traits, like viscosity, hypergraphia, and obsessionalism, (b) excessive metaphysical, reli-
gious, or philosophical preoccupation, and (c) altered sexual and emotional drives, like
hyposexuality and mood disorders. Two of these three principal features plus one or more
of the other Bear Fedio Inventory features (Trimble & Freeman, 2006) (Table 1) is needed
for the diagnosis.
Among the exhaustive list of the Gastaut-Geschwind syndrome’s symptoms, we can
notice that Nietzsche possessed several of them, like hypergraphia, religiosity, philosophic
interest, mood alternations, hyposexuality, sense of grandiosity and personal destiny, and
paranoia. He would thus fulfill the criteria for this diagnosis.
Nietzsche’s Personal View of his Illness
Nietzsche’s personal experience of his mental and physical disease is constantly present
in his philosophy. He expressed gratitude towards his illness, saying that “at the very bot-
tom of my soul I am grateful to all my misery and illnesses and whatever is imperfect
in me because they provide a hundred back doors through which I can escape enduring
habits” (The Gay Science, Book IV, §295). He also considered illness as necessary for his
self-accomplishment, by asking himself “whether we can do without illness—even for the
development of our virtue—and whether our thirst for knowledge and self-knowledge in
particular do not need the sick soul as much as the healthy” (Gay Science, Book III/aph.
120). By refusing the notion of normality in health (“there are innumerable healths of the
body and of the soul”), he disagreed with the polarization health-illness on which modern
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178 Lampros Perogamvros et al.
medicine is based. In Human, All Too Human, he considered illness as generative of wis-
dom and of “an extremely acute sense of health and morbidity in works and actions”
(Book 5 §289 “Value of Illness”). For him the term “illness” is at once somatic and moral,
and it uncovers itself completely in old age, with its nihilism, which is the supreme ill-
ness (Assoun, 1998, p. 137). It is not the illness that is pathological for Nietzsche, but ill
will with its passive character of the conception of happiness (“narcosis-drowsiness con-
cept” [Betäubung]), inhibition of affect, and the overdevelopment of memories (nostalgia)
(On the Genealogy of Morals I, §10). The notion of ill will is at least partly similar to
Freud’s concept of neurosis (Assoun, 1998) and to the weak purpose characterizing hysteria
(Kretschmer, 1926).
Interestingly, Sigmund Freud avoided drawing a Nietzschean psychography “because
of a psycho-organic illness literally barring access to Nietzsche’s conflicts” (Assoun, 1998,
p. 23). However, he corroborates Nietzsche’s positive vision of illness, by claiming the
existence of “a bond between paralysis and an aptitude for self-analysis” and arguing that
“the degree of introspection achieved by Nietzsche had never been achieved by anyone, nor
is it likely ever to be reached again. It is the process of relaxation due to paralysis that has
rendered him capable of passing through all the recesses and recognizing the drives that are
at the base of everything. So he placed his paralytic disposition at the service of Science”
(Nunberg, 1967, p. 37).
A Neurophilosophical Approach to Introspection and Creativity
Nietzsche and Freud seem to share a common positive perception of the impact that an
illness can sometimes have on a person’s work and life. Recent studies reporting how
people with mood disorders perceive their illness support this initially surprising view.
In a sample of 335 patients with a mood disorder, 62.2% of the bipolar and 22.4% of
the unipolar patients stated that their mental state offers them increased empathy, self-
awareness, and introspection and a heightened appreciation of life (Parker et al., 2011).
Recent neuroimaging studies shed new light on the relationship between neuropsychiatric
illness and increased introspection. The brain’s default network is a brain system activated
while the person is left to think to himself/herself undisturbed and is not focused on the
external environment (“default” here is synonymous to “baseline”) (Raichle et al., 2001).
This system is suspended during specific goal-directed behaviors and activated when indi-
viduals are engaged in internally focused tasks including mentalization, autobiographical
memory retrieval, imagination, and philosophical introspection (Buckner et al., 2008). Its
neural correlates are mainly related to activations in the medial temporal lobe (Greicius
et al., 2004), anterior prefrontal cortex (Fleming et al., 2010), left inferior frontal cortex
(Kelley et al., 2002), posterior cingulate cortex (Vogt & Laureys, 2005), and angular gyri
(Guggisberg et al., 2011). Abnormally increased thalamic and subgenual cingulate activity
and connectivity with the default network was found in major depression (Greicius et al.,
2007) and has been linked to increased self-reflective tendencies in this disease. Some of
the aforementioned temporolimbic areas would be also affected in the Gastaut-Geschwind
syndrome, explaining the presence of self-centered attitudes, like philosophic interest, reli-
giosity, sense of personal destiny, increased writing of cosmic and philosophic nature, and
guilt (see Table 1).
Bipolar disorder has been also associated with creative accomplishment by poets,
musicians, and philosophers (Johnson et al., 2012; Santosa et al., 2007). Individuals with
bipolar disorder and healthy siblings of people with schizophrenia or bipolar disorder seem
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Nietzsche and Neuroscience 179
to be overrepresented in creative professions compared to controls (Kyaga et al., 2011).
Creativity, which is related to an increased goal-driven approach motivation rising from
the mesolimbic dopaminergic reward system (Flaherty, 2011), has been specifically linked
to hypomania (Jamison, 1989), which is characterized by focused goal-directed activity.
In addition, a self-reflective ruminatory attitude found in depression could lead not only
to increased insight but also to creativity (Verhaeghen et al., 2005), bringing to mind the
case of Miró, whose bipolar depressive symptoms have been linked to his artistic creativity
(Bogousslavsky, 2005). Biographical, epidemiological, and empirical studies now suggest
that creativity and production of original works is enhanced by temperamental factors of
bipolar disorder, rather than the manic-depressive illness per se (McCrea, 2008).
Migraine with aura could also participate in the formation of Nietzsche’s philosophy.
As migraine attacks became more and more frequent in Nietzsche’s life, the philosopher
was allowed to contemplate and think only a few hours per day. Sometimes, the attacks
lasted up to six days (status migrainosus) (Hemelsoet et al., 2008). It was proposed that
this situation may have shaped the stylistical aspect of his philosophy, in particular the use
of aphorisms, which would be written during the brief windows of time when headaches
were absent (Butler, 2011). Besides, migraine with aura, which has been linked to artis-
tic creativity (Fuller & Gale, 1988) and is thought to have inspired painters (Podoll &
Robinson, 2000) and writers (Todd, 1955), may have affected Nietzsche’s way of thinking
per se. Although migraines suspended his thoughts during the attack, they represented an
inspiration for thought after the attack. This would have led to a vicious circle where “the
act of thinking became identical with suffering, and suffering with thinking” (Klossowski,
2005, p. 18). As Lou Salomé notes: “It was when he felt more healthy and more robust, in
complete control of his creative powers, that he came closest to his illness: and it was the
forced rest and idleness that would again allow him to recover and keep the catastrophe in
suspense” (Klossowski, 2005, p. 18).
The Unconscious Life: New Insights from the Nietzsche’s Concepts
The influence of Nietzsche’s philosophy on psychoanalysis is undeniable. All the basic
themes of Freud’s theory had been already explicitly anticipated by Nietzsche some
decades before: conflict, neurosis, unconscious, the Id and the drives, criminality, and
guilt (for a thorough analysis, see Assoun, 1998). Astonishingly, Nietzsche’s intuitions
and perceptions also bear out the results of modern neuroscience. Indeed, 100 years before
Libet (Libet et al., 1983) and Soon (Soon et al., 2008) proposed that free will may be an
illusion, Nietzsche was claiming that the feeling of free will is an epiphenomenon of a
procedure where conscious thoughts are misinterpreted as causal, whereas in reality, pro-
cesses that lie outside consciousness causally determine these thoughts and the consequent
actions (Beyond Good and Evil, Book I, §21). And when in 1988 Paul Churchland argued
against the body-soul dualism, saying that mental properties depend on the brain disposi-
tion (Churchland, 1988), Nietzsche had already stated: “Behind your thoughts and feelings,
my brother, stands a mighty commander, an unknown sage — he is called Self. He lives in
your body, he is your body” (Thus Spoke Zarathustra, The Despisers of the Body).
Contrary to Freud’s interpretative theory of dreams, where the process of elaborating
a latent content from a manifest content, is the principal function of dreams, Nietzsche is
mainly interested in the physiology and the cerebral function of dreams. For him, internal
phenomena excite the brain continually during sleep and sometimes lead to the generation
of motivations for the mind, which is constantly seeking the reasons for these excitations.
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180 Lampros Perogamvros et al.
Dreams represent for Nietzsche a function of a brain that searches for the causes of certain
sensations, that makes hypotheses and that tests their feasibility; dreaming is thus a learning
procedure that prepares both mind and body for the waking life (Thus Spoke Zarathustra,
Book III, Of the Three Evils and Beyond Good and Evil, ch. 5 §193). Nietzsche’s theory
has many similar points with modern theories claiming for a dream contribution to learn-
ing, reward, memory, and emotion regulation processes (Perogamvros & Schwartz, 2012;
Revonsuo, 2000).
How could Nietzsche have devised in the 1880s some of the most distinctive hypothe-
ses of modern psychology and cognitive neuroscience while lacking systematic data and
methods? With respect to the historical, collective, and philosophical influences (e.g., A.
Schopenhauer) that have also partly contributed in shaping his ideas, we claim that the
unique rencontre of Nietzsche with the “angels and demons” of his illness and the subse-
quent birth of increased intuitive and introspective drives, would be one possible answer.
Conclusions
In his seminal book on Nietzsche, Karl Jaspers asks for an urgent investigation of the coin-
cidence between Nietzsche’s spiritual transformation since 1880 and a “newly arising bio-
logical event” in his life (Jaspers, 1935/1997, p. 106).In this article, and along with other
writers (Butler, 2011; Hemelsoet et al., 2008), we provide some evidence on the specific
neuropsychiatric illness of Friedrich Nietzsche (CADASIL), a diagnosis that offers us suffi-
cient explanation for the various neurological and psychiatric symptoms of the philosopher.
We also claim that some enabling mood and neurological (Gastaut-Geschwind syndrome)
features of CADASIL could strongly contribute to the very content of his philosophy
and his approach to life. Finally, our aim is to propose a new framework on approach-
ing illness, which, in conformity with Nietzsche’s view, would reinforce the enabling
aspects (self-awareness, insight, creativity) of some otherwise highly disabling mental and
neuropsychiatric disorders, like bipolar disorder and Gastaut-Geschwind syndrome.
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