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Med Humanities 38:7-14 doi:10.1136/medhum-2011-010075
  • Original article

Manic depression in literature: the case of Virginia Woolf

  1. Katerina Koutsantoni
  1. Correspondence to Dr Katerina Koutsantoni, Institute of Psychiatry, King's College London, B3.06 Addictions Sciences Building, 4 Windsor Walk, London SE5 8AF, UK; katerina.koutsantoni{at}kcl.ac.uk
  • Accepted 9 January 2012
  • Published Online First 2 March 2012

Abstract

The steady growth of the discipline of medical humanities has facilitated better understanding of the symptoms and signs of mental health conditions and the feelings of the humans experiencing them. In this project, the arts have been seen as enabling re-engagement of the practitioner with the patient's own perceptions and feelings. With respect to the association between creativity and bipolar disorder in particular, work within medical humanities has meant that mentally ill creative individuals have been subject to scientific scrutiny and investigation, rather than continuing to be viewed as naively romanticised cases of mental illness. This paper is an attempt to supplement traditional literary criticism by examining Virginia Woolf's history of bipolar disorder through a medical humanities lens. I will provide an overview of Woolf's history of manic-depressive episodes, their symptoms and manifestation, look back on her circumstances during their occurrence, and observe the author's losing battle to salvage her identity in the throes of the disease. The aim is to offer further insight into Woolf's psychopathology and to gain some understanding of the causes and progression of the condition that led to her death by suicide.

Creativity and madness

There has long been anecdotal interest in the coexistence of 'great wits and madness' and in the correlation between genius and mental illness. The idea that madness and creative genius are related predates modern psychiatry. Such ancient Greek philosophers as Socrates (469–399 BC) and his student Plato (428–348 BC) lauded the benefits of divine madness, which they believed was literally a gift from the gods (Kottler, p 5).1 The concept of madness, as deployed by Plato and Socrates, encompassed a wide range of states of thought and emotion, not just psychosis, but the emphasis was upon a profoundly altered state of consciousness and feeling. In subsequent decades, Aristotle (384–322 BC) focused on the link between melancholia, madness and inspiration, asking the question: “Why is it that all men who are outstanding in philosophy, poetry or the arts are melancholic?” (Aristotle in Hett, pp 155–57).2

While this association between creativity and madness has emerged and been discussed in the humanities, it has often been dismissed in the sciences as a naive romanticisation of mental illness or a miscomprehension of the diversity of imagination and temperament necessary for original work (Jamison, p 351).3 Historically, the fascination madness exerts on contemporary theory has rested on a paradox: on the one hand, literature and the humanities have given voice to madness by being the sole channel by which madness has been able to speak in its own name; on the other, the scientific world has commonly asserted that literature itself is obsolete, thus denying and repressing its contribution (Felman, p 15).4 Biological psychiatrists have historically displayed little interest in studying mood disorders in artists, writers or musicians. As Oyebode suggests, there is probably something about the scientific stance that detaches the medical practitioner from the subjective experience of patients (Oyebode, p 397).5 Certainly those in the arts have similarly been less than enthusiastic about being seen through a biological or diagnostic grid (Jamison, p 3).6

Literature, if we trust its strength and accept that to become its student is to undertake something always rich and often difficult, is a way of understanding what it is to be human. One central gift it can give to those with a scientific training is that, because it is not reductive, it can bring home the fact that there are ways of understanding that cannot be tested by multiple-choice questions (Skelton in Oyebode, p 88).7 At the same time, applying scientific theories, specifically those of psychopathology, to the link between creativity and mental illness can help foster a deeper understanding of affected people's experiences and symptoms (Kyaga et al, p 373).8

In order to address both the objective realities of science and the subjective realities of humans and their societies, a multifaceted approach was necessary (Flynn, p 38).9 The end of the 20th century and the start of the new millennium marked the beginning of the project to bring together the disciplines of psychiatry and the humanities so as to understand the symptoms and signs of mental health conditions in conjunction with the humans experiencing them, rather than adopting a practice of separating the person from the condition. The arts or the humanities were seen as enabling the re-engagement of the practitioner with the patient's own perceptions and feelings, which was facilitated by the growing movement of medical humanities.

In this paper, I want to examine Virginia Woolf's history of bipolar disorder through a slightly more scientific lens than usual, thus applying the benefits contributed by medical humanities and adding to the existing body of literary criticism on the subject. Although there has been research within literary criticism on Woolf's disorder (manic-depressive illness), this is often unsophisticated, overlooks the complexity of her case and does not utilise medical insights to explain it. At the same time, within psychiatric literature itself manic depression, despite advances in clinical and basic neuroscience, has been relatively neglected as regards its connection with creativity (Jamison, p 4).6 This paper will try to address both perspectives with reference to Woolf.

The research

Research into the link between creativity and madness since the late 20th century has already suggested that the mental disorders associated with creativity are psychoses, the group of illnesses deemed to be the severest form of psychopathology.i With respect to gifted artists, especially writers, systematic studies have demonstrated a causal nexus between creative genius and madness, thus encompassing all possible subcategories of psychopathology. Hans Eysenck investigated the impact of personality on creativity and vice versa, elaborating on the link between creativity and psychoticism, a dimension of personality and temperament.12 13 In 1994, Felix Post researched the connection between creativity and psychopathology through the study of the biographies of 291 famous men, examining aspects such as family, physical health or sexuality and drawing conclusions about schizophrenia, affective disorders and suicide.14

Among such studies, the pioneering research by Nancy Andreasen and Ray Kay Jamison presented key findings on the association between creativity and various forms of madness. In 1987, Nancy Andreasen studied rates of mental illness in 30 creative writers (27 men and three women) living in Iowa, 30 matched control subjects and the first-degree relatives of both groups. Andreasen's study showed high rates of affective disorder. More specifically, 80% of the writers she interviewed had had an episode of affective illness at some time in their lives, compared with 30% of the control subjects. A surprising proportion of the affective disorder was bipolar in nature: 43% of the writers had experienced bipolar illness compared with 10% of control subjects. Both of these differences were statistically significant (Andreasen, p 1289).15 Andreasen paved the way towards better demonstrating the presence of affective disorder, especially of the bipolar subtype, in creative people and their first-degree relatives, suggesting that these traits run in families and could be genetically mediated.

Five years after Andreasen, in her 1993 book Touched with Fire: Manic-depressive Illness and the Artistic Temperament, Kay Redfield Jamison discussed the clear link between creativity and manic depression. Having initially investigated more widely the relationship between mood disorders and creativity in her 1989 publication,16 Jamison interviewed a group of 47 eminent British writers and artists and found high levels of mood disturbance. Although only a very small percentage in her sample—38%—had been treated for bipolar disorder (most having received treatment for depression), many described episodes in which they had experienced mood and energy changes consistent with hypomania, a common symptom of manic depression (Bentall, p 114).17 Jamison concluded that there is a much higher than expected rate of manic-depressive illness, depression and suicide in exceptionally creative artists and writers, as opposed to non-creative individuals. While only 1% of the general population is diagnosed with manic-depressive illness, her findings indicate that the percentage can be as high as 38% among artists and writers. It is as if mental illness is a requirement for creative success.

Studies such as the above have been seen as problematic with limited reliability as any diagnoses made derive from biographical information rather than subject interviews and do not use standardised diagnostic criteria (Santosa et al, p 32).18 Moreover, the criticism of weakness and inconsistency compared to scientific evidence on the association between creativity and madness is because, as MacCabe et al explain, genius is so rare, as is severe mental illness, that only small case–control studies on highly selected samples have been possible (MacCabe et al, p 109).19 Studies in later years tried to overcome this difficulty and provided further evidence to establish the link between creativity and bipolar disorder, albeit not strictly in an artistic context. An association between bipolar illness and high achievement was found in a 10-year study of individuals in the Swedish national school register. It was demonstrated that those who excelled academically, achieving A grades especially in humanities, had increased risk for bipolar illness (MacCabe et al, p 112).19 From an occupational perspective, the report by Kyaga et al who studied a vast sample of 300 000 Swedish people with severe mental disorder, showed that those with bipolar disorder were significantly over-represented in the creative professions, while the first-degree relatives of those with bipolar disorder were also more likely to pursue creative professions in comparison to control subjects (Kyaga et al, p 376).8

To date, Jamison is still careful to note that there are, of course, very many artists, writers, poets and composers who do not have a diagnosable psychiatric illness. As recently as 2009, a debate at a seminar held at the Institute of Psychiatry, King's College London, challenged the link between madness and genius. A member of the invited panel, Michael Trimble, a professor of behavioural neurology and consultant physician, argued that, although there are undoubtedly instances of genius in the mentally ill and schizophrenic population, these are purely coincidental.20 No one would argue that there is a straightforward correlation between psychopathology and creativity. Studies to date, however, do suggest that there is a disproportionate rate of psychopathology, especially bipolar disorder, in highly creative individuals (Jamison, p 352).3

Virginia Woolf is one example of a writer who struggled with the chaos of her tumultuous thoughts and feelings, being adversely affected for long periods of time when her violent, desolate moods overcame her but also managing to transform these heightened moments of fragmented, melancholic, inconstant thoughts by giving them an eloquent voice in artistic creations. While literary criticism has mainly speculated on Woolf's illness, work by the above researchers and ongoing studies within the field of psychiatry can offer insights into Woolf's own psychopathology and facilitate understanding of its causes, nature and development.

Definition and symptomatology

Manic-depressive illness, a condition that encompasses a wide range of mood disorders and temperaments, is more commonly defined as a biologically based cycling of moods that takes a subject from a state of crippling depression to euphoric agitation (Kottler, p 5).1 In general, the scientific community uses the term ‘bipolar disorder’ to describe the illness. When making reference to Woolf in this paper I will be using the term ‘manic-depressive illness’, which in its European and historical sense, as Jamison explains, encompasses the severe, recurrent melancholias of the illness (Jamison, p 17).6 Melancholic states with their flatness of mood, morbidity and gradual slowing of all aspects of human thought, feeling and behaviour, no doubt had a very deep and meaningful impact on Woolf's life and work and as such carry a very personal resonance. In this sense, ‘manic-depressive illness’ as opposed to ‘bipolar disorder’ feels more appropriate when referring to Woolf's case.

A distinction is drawn between bipolar I and bipolar II mood disorders. The first, known as ‘classic manic-depressive illness’, constitutes the severe, although intermittent, form with individuals experiencing both mania and major depressive illness. Patients of this type almost invariably require hospitalisation and long-term somatic therapy. With bipolar II mood disorder, the individual may have a history of at least one major depressive episode and a series of less severe but recurring manic episodes or hypomanias. Many find this instability of mood painful and it usually requires somatic treatment. Although hypomanias are less intense than manias, bipolar II entails greater comorbidity, as evidenced by the individual spending more time in a depressive versus a hypomanic state, and as such may prove more dangerous.

A patient diagnosed with bipolar disorder may experience recurring episodes of debilitating depression, uncontrollable mania, hypomania or a mixed state (a manic and depressive episode). Depression manifests itself with symptoms of apathy, lethargy, hopelessness, slowed physical movement, impaired memory and concentration, and loss of pleasure. Manic symptoms may range from euphoria, clear, fast and creative associations, frenzied, expansive, bizarre and seductive behaviour to an inflated perception of self-esteem, and engagement in such activities as reckless driving or excessive spending. With hypomanias, the sufferer can appear reclusive, sluggish, irritable or violently agitated, can experience delusional thinking and visual and auditory hallucinations, and can be dangerously suicidal (Jamison, p 47).17 Research has shown an association between hypomania and suicidality, thus indicating that hypomania represents a true subgroup of the bipolar spectrum (Angst, p 149).11 Cyclothymia, consisting of cycles of fluctuating moods and energy levels that serve as a background to constantly changing thoughts, behaviours, feelings, sleep and energy levels, can also be a symptom of manic depression, even though it is considered a heterogeneous condition. Cyclothymia is best described as a form of subthreshold bipolar disorder, manifesting itself with brief episodes of depression and hypomania that fail to meet duration criteria for major affective syndromes (Fava et al, p 136).21

The symptoms of bipolar illness are complex and erratic, oscillating between extremes and resulting in an intricately textured clinical picture in the patient. During their manifestation, patients search for an underlying sense of self, which is of key importance. They need to know that such a self, despite experiencing waves of mania, bouts of violence, anger and aggression, periods of melancholia, hyperactivity, excitability and cyclothymia, will remain solid—albeit fragile—with hope of recovery. When the sufferer finds that identity to be irrecoverable and lost forever, the result can be tragic.

The case of Virginia Woolf: genetics and history of episodes

The history of mental undercurrents and emotional problems in Virginia Woolf's family should be considered when her mental problems are examined. Woolf's father, Sir Leslie Stephen, was reported to have had a troubled childhood due to difficult parents. His unpredictable mood swings, although never very severe, were most likely cyclothymic. As described above, cyclothymia is a heterogeneous condition and as such is distinguished from major mood disorders like bipolar disorder by its chronicity (ie, duration of at least 2 years) and subsyndromal quality (ie, symptoms are less severe, fewer in number, or of insufficient duration) (Howland and Thase, p 485).22 Leslie Stephen is thought to have experienced numerous episodes of mental collapse throughout his life, the duration and severity of which probably did not qualify them as manic-depressive psychosis but which were still both unpredictable and frightening for his children (Kottler, p 107).1

Leslie Stephen's own father, the gloomy, self-mortifying Sir James, was a man thought to have a ‘double nature’. Powered by social conscience and a rigid sense of justice, he was severe and unremittingly vigilant over his children's behaviour. He was also, however, a person who always anticipated the worst, was often full of self-disgust, and very sensitive, with a tendency to sink into depression and hopeless dejection (Lee, p 61).23 His son and Leslie's brother, Fitzjames, was a blustering journalist, penalising judge and scourge of liberal opinion. In old age, Fitzjames is recorded as experiencing a decaying mental health, developing senile dementia and dying a broken man in 1894 (Lee, p 61).23 Leslie's brother's condition seemed to have affected his own son, James Kenneth Stephen. Leslie's nephew and Virginia's cousin, had a somewhat dubious reputation. A brilliantly promising young man, an athletic star at Eton, an Apostle at Cambridge and a tutor to the Duke of Clarence, he did not seem to be a psychopathic individual. Yet James's, or Jem's, manic-depressive outbursts developed in his late twenties after a blow on the head from a windmill sail, leading to alarming and violently sexual behaviour. A regular inmate and visitor at the Stephen's house, he pursued Virginia's half sister, Stella, with whom he was in love and to whom he wrote pathetic, self-pitying letters, a practice Stella herself tolerated out of pity. He was eventually sent to an asylum where he alternated between depression and violence, refused food and starved himself to death within months of admission (Lee, pp 64–65).23

Leslie Stephen's first marriage to Minnie Thackeray had produced one child, Laura Makepeace Thackeray. Some critics argue that Laura had childhood schizophrenia. Jean Love, in particular, writes about Leslie Stephen's complaints of his daughter's irrelevant remarks with the most provoking good temper, her strange mannerisms, her “spasmodic uttering”, “queer squeaking” or “semi-stammering”. She writes about his frustration at her spitting meat out of her mouth at mealtimes at the age of 7 or complaining of choking through meals by age 14, making her extremely “disturbing and pathetic” (Love, p 162).24 In Moments of Being, Woolf herself writes about “the vacant-eyed girl whose idiocy was becoming daily more obvious, who could hardly read, who would throw scissors into the fire, who was tongue-tied and stammered and yet had to appear at table with the rest of us” (Woolf, p 182).25 Laura also displayed behavioural problems at the interpersonal level. While probably keen for social contact, she struggled to mix and to maintain friendships or any type of relationship (Bates in Oyebode, p 130).26 It is most likely that she had Asperger's syndrome. Her parents considered her uncooperative and stubborn and attempted unsuccessfully to discipline her. She was kept a prisoner in the attic throughout much of her childhood before being sent off to an asylum (Kottler, p 107).1 In 1891 Laura was placed in a home for ‘the imbecile and weak-minded’ at Earlswood, and spent the rest of her life in a series of similar establishments, eventually dying in an asylum in York in 1945.

It is very possible that a genetic predisposition to emotional problems within Leslie Stephen's family was passed onto Woolf. A letter by Baron et al in Nature, which investigates the X-linkage (the female sex chromosome) hypothesis of bipolar illness, has received considerable attention from the psychiatric and genetic community. According to researchers, because at least one of the primary genes seems to be transmitted by the X chromosome, the illness is passed from father to daughter or from mother to sons and daughters but rarely from father to son. An excess of females with the condition has been observed, while there is also a striking absence of male-to-male transmission, both connected to X-linked dominant inheritance (Baron et al, p 289).27 None of Stella's (Virginia Woolf's mother) children by her first husband, namely George, Gerald and Julia Duckworth, had a mental illness, and neither of Leslie Stephen's own sons with Julia, Adrian and Thoby, exhibited symptoms of a bipolar condition. However, as one of his two daughters with Julia, Virginia most likely inherited her manic-depressive disorder from her father, in the same way as Laura, his first daughter with Minnie Thackeray.

Virginia Woolf's history of mental illness and suicidal attempts started at an early age. Her mother's death from influenza in 1895, followed by her father's half-crazed mourning for her, led Virginia to experience her first manic episode at age 13. Her response to Julia's death can be described as strange at least on the morning of 5 May 1895 when the Stephen children were invited to view the still-warm corpse of their mother. In A Sketch of the Past, Woolf writes:I remember very clearly how even as I was taken to the bedside I noticed that one nurse was sobbing, and a desire to laugh came over me, and I said to myself as I have often done at moments of crisis since, “I feel nothing whatever”. Then I stooped and kissed my mother's face. It was still warm. (Woolf, p 92)25

In his biography of his aunt, Quentin Bell writes that: “[Virginia] became painfully excitable and nervous and then intolerably depressed… She went through a period of morbid self-criticism, blamed herself for being vain and egotistical, compared herself unfavourably to Vanessa and was at the same time intensely irritable” (Bell, p 45).28 To treat her nervousness, excitability and depression, Dr Seton, the family doctor, was called in to prescribe a simple life and outdoor exercise.

The effects of Virginia Woolf's first episode, displaying both manic and depressive symptoms, were still evident 2 years later. In 1897, Stella suddenly died of peritonitis leaving Virginia highly distraught at the age of 15. In November of the same year, her father, Leslie, wrote to George Warr, Professor of Classical Literature at King's College London, where he had himself studied from 1848 until 1850 and where his daughter was attending Greek, Latin and German classes, as he was anxious about her fragile state:My daughter is attending your Greek class. I hope you will allow me to give you one hint. She has been on very nervous state, wh[ich], though […] explicable, has given me some anxiety. I have allowed her to go to the class, for wh[ich] she was very anxious; because I think that it does her some good to have the occupation. […] I should be grateful if you would just remember this & let her off with light work. (Snaith, p 30)29

In 1904, Leslie Stephen died of bowel cancer which caused Virginia to suffer a second episode of illness at the age of 22. Reports state that she entered a manic state and required three nurses to keep her under control. She was psychotic for several months, spewing unintelligible torrents of abuse and anger, mostly directed towards her sister Vanessa. It was during this episode that Woolf famously believed that King Edward was stalking her, hiding out beneath her window and taunting her. She became so distraught that she launched herself out of a first floor window in an attempt at suicide (Kottler, p 115).1 The severity of the episode was such that brief hospitalisation was necessary.

After this and later less severe episodes, the physician George Savage was called in to treat Woolf with the renowned ‘rest cure’. This treatment was developed in the USA by the American physician Silas Weir Mitchell in 1873 for treating locomotor ataxia and later other conditions. Poirier quotes a description of the cure as extracted from Mitchell's Doctor and Patient:In carrying out my general plan of treatment it is my habit to ask the patient to remain in bed from six weeks to two months. At first and in some cases for four or five weeks, I do not permit the patient to sit up or sew or write or read. The only action allowed is that needed to clean the teeth. In some instances I have not permitted the patient to turn over without aid… In such cases I arrange to have the bowels and water passed while lying down, and the patient is lifted on to a lounge at bedtime and sponged, and then lifted back again into the newly-made bed. In all cases of weakness, treated by rest, I insist on the patient being fed by the nurse, and, when well enough to sit up in bed, I insist that meats shall be cut up, so as to make it easier for the patient to feed herself. (Poirier, p 20)30

Mitchell's treatment was adopted in England around 1880 by the British neurologist Dr Playfair, and by Woolf's doctor, George Savage, who echoed the absolute authority of its inventor. Both contemporary nerve specialists, Silas Weir Mitchell and George Savage were known for treating bereaved women as mentally unbalanced. They both assumed a causal link between grief and madness without any analysis or explicit justification (Bennett-Smith, p 310).31 They assured patients and their families that the only possible treatment was to refrain from any physical or mental activity, which could prove strenuous and dangerous, and adopt a healthy, dairy-rich diet. Woolf's own fear of her unexplainable swings of temperament, consistent with manic-depressive symptoms, coupled with lay ignorance about psychology, prevented her from rejecting the rest cure implemented via a milk regimen.

In 1912, Virginia married Leonard Woolf but a year later experienced her third severe episode of illness. On 9 September 1913, she again tried to commit suicide at the age of 31. Kottler suggests that this second attempt was triggered by an argument Virginia had with Leonard after her return from a trip with Vita Sackville-West and based on Leonard's jealousy of the women's erotic relationship (Kottler, p 119).1 Woolf consumed 100 grains of Veronal (barbiturate) pills leading to her hospitalisation, during which period Dr Savage's rest cure was again administered.

Woolf persevered with the treatment. In fact, she did not hesitate to tell wonderful stories of the lunatics to her husband during the rest cure she underwent at Jean Thomas' nursing home at Twickenham. As Henke writes, Woolf often invoked terms like ‘lunacy’ and ‘madness’ sardonically and humorously, both to associate her psychological instability with literary geniuses like William Blake and to distinguish her own mental illness from the diagnosis of idiocy imposed on her half-sister Laura, who was institutionalised when Virginia was 13 (Henke, p 4).32 At the same time, however, Woolf was also angry and sometimes frightened, but always aware that the voices she heard in her head were all too real and that Dr Savage's methods of combating them did not always work (Poirier, p 34).30 What she questioned in his cure, what she ridiculed and despised him for, was the fact that he denigrated the value of establishing a distinctive sense of self; instead Savage brushed aside his patient's experience of her illness, cared more about identifying sanity with social conformity, and saw the connection between identity and mood or perception as immaterial (Caramagno, p 13).33 Woolf's experience was that her physician dismissed her need to preserve her identity.

The idea of the self is of vital importance in manic-depressive patients, and for Woolf herself it was central to her body of work. For example, the essays she wrote throughout her writing career, with the intermittent publication of successful novels, belong to a genre in which the writer experiments with their cognitive powers and limits. It is a subjective form of expression, relatively free from the constraints of academic argument. Montaigne, the 16th century French essayist (and founder of the essay genre), wrote: “So Reader, I am myself the subject of my book” (Montaigne, p 1).34 In her own essays about letter-writers, memoirists, diarists and poets, about obscure people, and about the ordinary reader and his role, Woolf makes clear that the involvement of the ‘I’ is of paramount importance. It is the very subject of each piece, a means by which the author voices her opinion and at the same time connects with the reading audience, thus avoiding any authoritarian imposition of views (Koutsantoni, p 31).35 This link between subjectivity and a dialogic intent was key in Woolf's work and this she found was undermined by Savage's rest cure, hence her open ridicule of his treatment regime which appeared in Mrs Dalloway. In this novel, the author describes her experiences through the character of Septimus (Woolf, pp 71–73)36:

Graphic

Following her third manic-depressive episode in 1913, ill health continued on and off until 1917. The absence of diary entries until August of that year, is replaced by a summary by Anne Olivier Bell, the diary editor:[F]rom then onwards [1915], with increasingly sleepless nights and restless aching days, she slid inexorably into madness. By 4 March she was beyond Leonard's care, and professional nurses were called in. Weeks passed during which she was incoherent, excited and violent, for many months more she was under constant surveillance. She took against Leonard, and for two months he dared not see her. It seemed that she might never return to sanity. (Bell, p 39)37

From 1916 until her death in 1941, Woolf experienced many periods of depression, anxiety and exhilaration, which gradually wore her out. Leonard Woolf writes in his Autobiography about that time:For years I had been accustomed to watch for signs of danger in Virginia's mind; and the warning symptoms had come on slowly and unmistakably; the headache, the sleeplessness, the inability to concentrate. We had learnt that a breakdown could always be avoided, if she immediately retired into a hibernation or cocoon of quiescence when the symptoms showed themselves. But this time there were no warning symptoms of this kind. The depression struck her like a sudden blow. (Woolf, p 79)38

While Leonard Woolf refers to depression being the core of Virginia's symptoms at that time, other symptoms commensurate with bipolar II were also manifesting themselves. This very same period proved extremely prolific for Woolf, although it seems counterintuitive that such painful experiences would be associated with any kind of creativity and productivity. Some of her most successful works, like Mrs Dalloway (1925), To the Lighthouse (1927), Orlando (1928), A Room of One's Own (1929) and The Waves (1931), appeared after her first three severe episodes (1895, 1904 and 1913) and the 4-year quiet period that ensued for recovery after the last one. Especially after the publication of The Waves and during the 1930s, Woolf gradually became very vocal, speaking before audiences on behalf of the rights of women, their plight and oppression, even telling the story of her own childhood traumas. These formed the foundation of powerful works like Three Guineas (1938).

Referring to that period in his book Virginia Woolf's Illnesses, Douglass Orr refuses to view the author as manic-depressive, basing his argument on the fact that from 1915 until her death in 1941 she did not experience any severe episodes and did not display incapacitating manic excitement or profound depression, apart from minor migraine headaches, flu, debilitating anxiety, nervous exhaustion and recurrent toothaches. Woolf's prolific writing during that period would not have been possible, in Orr's opinion, had the writer indeed been suffering from a chronic psychiatric disorder. Instead, Orr argues:I take Virginia's five or six experiences of “madness” to be separate and distinct illnesses having quite different proximate causes. This view differs from the common assumption that Virginia had a single, life-long psychiatric disease, such as manic-depressive disorder, or manic depression. (Orr in Chapman, p XI)39

Suzette Henke agrees with Orr, arguing for a diagnosis of post-traumatic stress disorder, as opposed to manic depression, which she feels is reasonable when one considers the series of traumas Woolf sustained in childhood and early adulthood, including numerous family deaths and sexual abuse. The deaths of Julia, Leslie, Stella, Thoby, and the sexual assault by her half-brother, George Duckworth, are rightly viewed by Henke as triggers most likely to have contributed to Woolf's episodes, and to have caused intense post-traumatic anxieties, what the critic calls her episodes of “so called madness”. Because the traumas occurred early on, Henke agrees with Orr that these are linked to the five or six breakdowns the author had experienced by the year 1915 but which then stopped. They were indeed responsible for bouts of psychological distress, which, however, was (mis)diagnosed as mania and/or depression (Henke, p 7).32

Research findings to date in the field of psychiatry challenge the above, possibly simplistic and unsophisticated, literary critics' views by offering evidence which supports a diagnosis of bipolar disorder in Woolf's case. Jamison writes of how a range of cognitive, mood, behavioural, energy and temperament factors associated with bipolar disorder enhance creativity (Jamison, p 352).3 Individuals with bipolar disorder show exaggerated emotional responses which may facilitate their artistic talents, and this clearly was the case with Woolf. Elevated mood and rapidity of thought often facilitate creative work and in Woolf the rapid shifts in her moods and thoughts, brought on by her illness, led to her perceiving the natural world as transient and volatile which in turn transformed into creativity. A year after the publication of Mrs Dalloway, Woolf wrote about these shifts from a depressive state to rapidity of thought and creativity:My own brainHere is a whole nervous breakdown in miniature. We came on Tuesday, sank into a chair, could scarcely rise; everything insipid; tasteless, colourless. Enormous desire for rest. Wednesday - only wish to be alone in the open air. Air delicious - avoided speech; could not read. Thought of my own power of writing with veneration, as of something incredible, belonging to someone else; never again to be enjoyed by me. Mind a blank. Slept in my chair. Thursday. No pleasure in life whatsoever… Friday. Sense of physical tiredness; but slight activity of the brain…Returning healthThis is shown by the power to make images: the suggestive power of every sight & word enormously increased.(31 July 1926, Diary 3, pp 103-04)40

Research has also demonstrated that the creative output of individuals with bipolar disorder often coincides with periods of hypomania. During the two decades after 1917, Woolf's manic symptoms were less severe, lasting days rather than months, and thus possibly coinciding with a hypomanic state. During the writing of Jacob's Room, her symptoms can be described as hypomanic:[T]hose days spent in wearisome headache, jumping pulse, aching back, frets, fidgets, lying awake, sleeping draughts, sedatives, digitalis, going for a little walk, & plunging back into bed again – all the horrors of the dark cupboard of illness once more displayed for my diversion. (8 August 1921, Diary 2, p 125)41

People with hypomania have enhanced access to vocabulary, memory and other cognitive resources, linked in innovative ways, and thus can often be witty and inventive. Moreover, they have an extraordinary and tireless capacity for sustained concentration (MacCabe et al, p 114).19 Kyaga et al have similarly suggested that the increased creativity in bipolar disorder might be driven by hypomanic periods with ensuing augmented fluency which is an important aspect of creativity (Kyaga et al, p 378).8

A summary of observations so far to help make a case for Woolf's diagnosis is as follows. Support for the assumption that Woolf's bipolar disorder had a genetic aspect is provided by the research of Baron et al presented earlier that concurs with the findings of Winokur et al who reiterate that, since the 1960s, it has been established that patients with manic-depressive illness have familial affective illness, with a history of mania in their families (Winokur et al, p 1176).42 Studies have also demonstrated a trend for an increased prevalence of bipolar II disorder in the families of subjects with cyclothymia, the two disorders differing only in the severity of their depressive periods (Howland and Thase, p 487–89).22 This is commensurate with Virginia Woolf's own family history on her father's side: Laura Makepeace Stephen's psychotic behaviour and institutionalisation, Leslie Stephen's cyclothymic symptoms and irritability, and a history of mental illness among members of his own family. The argument for a genetic predisposition to the disease is further supported by the study of MacCabe et al who found that individuals with bipolar disorder are more likely to have an older father and generally better educated parents, which was definitely so in Woolf's case (MacCabe et al, p 110).19

Woolf's disorder included mania, especially during the three or four severe episodes around 1915, which were periods of major depression and hypomania, with cyclothymia also being common. In fact, the characteristics of bipolar II disorder associated with cyclothymia, which Akiskal et al discuss in their 2003 paper, seem to agree with Woolf's symptomatology (Akiskal et al, p 53)43: onset of the illness at a young age, worse depression and hypomania, more intense and irritable risk-taking during hypomania (which means more negative consequences), higher rate of comorbidity, more inter-episodic mixed features and instability all developed at one point or another over Woolf's lifetime following her first episode in 1895. Because of the variety of her symptoms and their inconsistent, fluctuating manifestation over the years, Woolf was probably diagnosed with an erratic personality disorder.

Treatment

Various drug treatments were administered to Woolf but their sheer volume made it hard to distinguish between the side effects of the drugs and the symptoms of her illness. In her biography of Woolf, Hermione Lee writes that the author was prescribed Veronal, Adalin, chloral hydrate, paraldehyde, potassium bromide and digitalis. Some of these drugs were meant to act as sedatives, as sleep-inducing hypnotics, taken under quiet conditions. When administered in large doses, however, veronal and chloral hydrate, for instance, can cause excitement, impaired judgement, euphoria, talkativeness and full-blown delirium, all symptoms of mania. Others, like digitalis, chloral and bromide, were prescribed to slow down Woolf's rapid pulse and jumping heart. In large doses, however, they can cause a skin rash and, more seriously, a stultifying, deadening effect on the personality. Lee suggests that this caused Woolf's frequent despair and depression (Lee, pp 184–85).23

The most common prescription drug and mood stabiliser for manic-depressive illness is lithium. Lithium in the form of lithium carbonate has been used to treat bipolar disorder and major depression since the mid-twentieth century. Research evidence, as recorded by Jamison for instance, suggests that lithium treatment in high doses causes decreased social involvement, decreased activity and concentration, decreased initiative and impulsiveness, increased boredom and lethargy, increased indifference, passivity and cognitive change (Jamison, pp 242–43).6 High doses of lithium, normally in the range of 180 mg on a daily basis, cause such adverse effects as dulled personality, reduced emotions, memory loss, tremors and weight gain. These side effects can be so severe and unpleasant that many patients become non-compliant (Lakhan and Vieira, p 2).44

Among creative individuals, this fear of being transformed into “ordinary, dampened, bloodless souls” unable to create, has led artists towards preserving the turmoil and suffering of manic depression, seeing them as integral to their abilities. One such example was the painter Edvard Munch who admitted in the 1900s: “They [my troubles] are part of me and my art. They are indistinguishable from me, and it would destroy my art. I want to keep my sufferings”. The poet Edward Thomas had similarly confessed: “I wonder whether for a person like myself whose most intense moments were those of depression, a cure that destroys the depression may not destroy the intensity—a desperate remedy?” (in Jamison, p 241).6

Offsetting the above, other studies have shown few significant side effects from the use of lithium, with small, if any, changes in intellectual functioning. A 1998 study in a sample of children of parents with lithium-responsive and lithium non-responsive bipolar disorder showed the first group manifesting psychopathology clustering in the affective spectrum, with few comorbid illnesses and an episodic course, while the latter group manifested a range of psychopathology, more comorbid illness and a chronic course. As a result, an excellent response to lithium prophylaxis was designated as a clinical marker of a heterogeneous subgroup of bipolar illness (Duffy et al, p 432).45 An adverse effect of lithium on cognition reported in previous studies may have been due to high lithium doses, short follow-up periods, and inclusion of study subjects with more advanced cognitive deterioration. A study by Forlenza et al on the effects of long-term lithium treatment on mild amnestic cognitive impairment or early dementia argued the above point. In their sample, they demonstrated that cognitive decline in those being treated with long-term lithium was less than in those being administered a simple placebo (Forlenza et al, pp 354–5).46 Any negative cognitive tendencies such as self-blaming, self-criticism, extreme perfectionism and negative automatic thoughts may be linked to mania and hypomania, both syndromes within bipolar disorder, although research has suggested a clearer link with unipolar depression. Well-established mood-stabilising medications such as lithium are helpful, but relapses do occur, so cognitive styles and psychosocial treatment to supplement medication are also considered (Eisner et al, p 154).47

In sum, other factors in addition to lithium determine whether the patient continues to be productive, such as illness severity, dosage administered and the individual's sensitivity to cognitive side effects. Competent treatment with lithium has been shown to result in longer periods of sustained productivity. Lakhan and Vieira support treatment with lithium orotate, available without prescription as opposed to lithium carbonate, with approximately 150 mg daily doses 4–5 times a week, which has been shown to reduce manic and depressive symptoms in bipolar patients. They also refer to treatment with taurine, the amino acid derivative, which can act as an alternative to lithium and block the effects of excess acetylcholine that contributes to bipolar disorder (Lakhan and Vieira, p 4).44 In early December 2011, articles in The Irish Times (2 December)48 and The Guardian (5 December)49 argued in support of the use of lithium in Ireland's drinking water supply in order to reduce suicide rates (the fourth highest in Europe). This suggestion was based on evidence presented by Schrauzer and Shrestha in a 1990 paper,50 reinforced in correspondence in the BJPsych in 2010. In a study of 27 Texas counties over a 10-year period, Schrauzer and Shrestha demonstrated that suicide rates were consistently lower in counties with high natural lithium levels in drinking water than in those with medium or low levels. Rates of homicide, rape, robbery, burglary and theft were also found to be lower (Schrauzer and Shrestha, p 159).51 Manic-depressive illness is a serious and life-threatening illness with a high suicide rate and, as evidenced above, lithium remains to date one of the most effective treatments.

The absence of relevant records suggests that Virginia Woolf was not treated with lithium, probably because of the drug's non-availability for the treatment of manic depression during her lifetime until about the 1950s. Had lithium been an option for Woolf and its side effects made known to her, we cannot know what her reaction would be. Woolf understood very well that she was a clear case of the intertwining of madness and creativity. She knew she was unstable but also realised that it was these same waves of disturbance that allowed her to access levels of her own inventiveness that would not otherwise have been possible (Kottler, p 105).1 She was aware of dream-like images arising within her and recognised they were useful for her writing.

In a letter to Ethel Smyth she had confessed:To ETHEL SMYTHSunday, 22nd June [1930]As an experience, madness is terrific I can assure you, and not to be sniffed at; and in its lava I still find most of the things I write about. It shoots out of one everything shaped, final, not in mere driblets, as sanity does. (Woolf, p 268)52

In her fluctuations of mood and the exchanging of depression for elatedness, and mania for hypomania, Woolf sought constantly for assurance that a sense of self was present that would help her overcome the outer forces that controlled her and at times overpowered her. The idea of personality, the power of identity, lay at the core of Woolf's existence and was the crux of her work, the repeating pattern and objective of which, as I see it, was this: hers was a dialogic project whereby preserving the author's uniqueness as well as the reader's identity and encouraging the dialogue between these two selves needed to be sustained at all times. Through this intersubjective mechanism, whereby the author's and the reader's selves merged for the sake of art, Woolf's subjectivity and that of her reader did not drown out one another in detrimental homogenisation, but benefitted from each other's uniqueness through a process of mutual privileging, thus achieving a dialogic effect (Koutsantoni, p 173).35 Losing this self and the ability to think through it would have meant the collapse of Woolf's dialogic project, her work's whole rationale, developed over a lifetime. In philosophical terms, thought is by definition the accomplishment of reason, an exercise of sovereignty of a subject capable of truth: “I think, therefore I am not mad; I am not mad, therefore I am”. The being of philosophy is thenceforth located in non-madness, whereas madness is relegated to the status of non-being (Felman, p 39).4 When Woolf acknowledged that she was no longer capable of fighting her internal voices which were dragging her down into madness, when she had lost all hope of rescuing the self within her, of salvaging her identity, when she could no longer think and reason through it, she determined it was time to end her life.

The end

During the last 2 weeks of her life, with Leonard extremely worried about his wife and Virginia feeling the madness approaching again, Woolf accepted a visit from her friend and physician, Octavia Wilberforce. The doctor found Virginia depressed and impatient. She confessed to feeling neither relief nor pride about finishing her latest novel Between the Acts, only disappointment and despair. She complained that after all these years she still felt burdened with grief for her father, but at the same was very resentful. She resented having been deprived of a proper childhood, her innocence having been stolen from her (Kottler, p 123).1 All she had learned to do was to hide inside herself, but clearly she was losing touch with this self recently, which seriously interfered with her struggle to stay in contact with the world and her work. Virginia Woolf's last mental collapse occurred in 1941 and on 28 March, at the age of 59, she committed suicide by drowning in the river Ouse. Her notes to Vanessa and Leonard explain her state of mind:TO VANESSA BELLSunday [23? March 1941]Dearest,You cant think how I loved your letter. But I feel I have gone too far this time to come back again. I am certain now that I am going mad again. It is just as it was the first time, I am always hearing voices and I know I shant get over it now.All I want to say is that Leonard has been so astonishingly good, everyday, always; I cant imagine that anyone could have done more for me than he has. We have been perfectly happy until the last few weeks, when this horror began. Will you assure him of this? I feel he has so much to do that he will go on, better without me, and you will help him.I can hardly think clearly any more. If I could I would tell you what you and the children have meant to me I think you know.I have fought against it, but I cant any longer.Virginia (Woolf, Letters, p 442)52TO LEONARD WOOLF[28 March 1941]Dearest,I want to tell you that you have given me complete happiness. No one could have done more than you have done. Please believe that.But I know that I shall never get over this: and I am wasting your life. It is this madness. Nothing anyone says can persuade me. You can work, and you will be much better without me. You see I cant write this even, which shows I am right. All I want to say is that until this disease came on we were perfectly happy. It was all due to you. No one could have been so good as you have been, from the very first day till now. Everyone knows that.V. (Woolf, Letters, p 443)52

For Woolf, the problem of relatedness—the connection between the ‘sane’ Virginia and the ‘insane’ Virginia—was crucial. As Caramagno has argued (p 13),33 like other patients with manic depression she needed to know that somewhere under the bewildering panoply of symptoms there was a real Virginia beneath her ever-changing consciousness. She managed to live with manic depression until she was 59 years of age, but realising that she was losing herself amidst voices she could no longer fight and which were driving her further into madness she felt she could no longer survive. The hereditary manic depression which enhanced Woolf's creativity eventually killed her.

In this paper I have used the lens of medical humanities to shed new light on Virginia Woolf's mental illness, arguing for a diagnosis of bipolar II disorder. I set out to provide an overview of Woolf's history of manic-depressive episodes by examining them with reference to her circumstances and her writings, the internal mechanisms at work and how they were manifested, and her losing battle to salvage her identity in the throes of the disorder. I conclude by noting that in Woolf's case at least manic-depressive illness and creativity were indeed linked.

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i In 1913, Emil Kraepelin distinguished between two major forms of psychosis: (i) affective psychosis or manic-depressive illness, whereby patients tend to experience alternating episodes of depression and mania (the reversal of depression, with elated mood, racing thoughts, hyperactivity and increased self-esteem) interspersed with symptom-free periods; and (ii) dementia praecox, whereby patients undergo impairment of a wide spectrum of mental functions, including perception (hallucinations), thought (delusions) and language (distorted speech patterns) (Barrantes-Vidal, p 67).10 Within the manic-depressive group, Kraepelin also identified cyclothymia with subjects displaying both manic and cyclothymic temperaments, embracing a continuum from normal temperament to full-blown affective psychosis (Angst, p 149).11

References

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