Editor—Besides having intrinsic and historical interest, study of a disease throughout history can sometimes yield clues about its aetiology. For example, studies of written records, paintings, and skeletons suggest that rheumatoid arthritis is a relatively new disease in Europe, not appearing there until after the return of explorers from the New World at the end of the 15th century, but having existed in North America for many thousands of years.1 This raises the possibility that some infectious agent from the New World has a role in its pathogenesis.
Few unambiguous descriptions of schizophrenia before 1800 exist,2 although some people argue that the disease has been known for many thousands of years.3 Bark has proposed that in Shakespeare’s King Lear, Edgar, in his guise as Poor Tom, had chronic schizophrenia.4 He had longstanding delusions, hallucinations, and disorganised speech and thought; his socioeconomic status had deteriorated; and he did not have a mood disorder, substance abuse or dependence, or an adverse general medical condition. Thus schizophrenia was in existence around 1600 and known to Shakespeare and his audience. In support of this diagnosis, in addition to having the above mentioned criteria Poor Tom shows the redundant clothing sign, which is fairly specific for schizophrenia.5
Schizophrenic patients often wear redundant or multiple layers of clothing, with no clear correlation to the ambient temperature or other weather conditions. In a study of patients arriving at a psychiatric emergency room Arnold et al found that 18 of 25 patients wearing redundant clothing (for example, multiple shirts, belts, or skirts) had a schizophrenic diagnosis; this finding was significant.5 Why schizophrenic patients wear multiple layers of clothing is not well understood. Arnold et al suggest three possibilities: subtle hypothalamic (or autonomic) dysfunction, wearing layers to achieve a sense of security, or motor or cognitive dysfunction during dressing.
Gloster and Edgar (Poor Tom) have the following conversation in King Lear.6
Gloster: What are you there? Your names?
Edgar: Poor Tom, that eats the swimming frog, the toad, the tadpole, the wallnewt, and the water; that in the fury of his heart, when the foul fiend rages, eats cow dung for sallets, swallows the old rat and the ditch-dog; drinks the green mantle of the standing pool; who is whipped from tithing to tithing, and stock-punish’d, and imprisoned; who hath had three suits to his back and six shirts to his body . . . .
As with so many other aspects of medicine and human relations, the Bard’s description of the wearing of layered clothing by schizophrenic patients is correct, insightful, and most poetic.
References
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