Stendhal syndrome: a case of cultural overload

Abstract

An elderly artist developed a transient paranoid psychosis when on a cultural tour of Florence, a city of particular emotional significance to him. He has since had several milder relapses that quickly settle.

BACKGROUND

This is a case that illustrates, via an interesting history with which many readers will be able to identify, that ostensibly positive life events can lead to relatively severe mental health problems. The psychopathology of, and risk factors for, such events are discussed.

Although Stendhal syndrome has been well described in the Italian scientific literature² and has caught the imagination of the popular media (see, for example, the Wikipedia entry for Stendhal syndrome or the film “The Stendhal syndrome” by Dario Argento), there has been little attention to this area by scientific journals in English.

CASE PRESENTATION

A 72-year-old fine-arts graduate and creative artist presented with insomnia and concerns about being followed and monitored. This started 8 years previously after travelling from southern France to Florence (Italy), the city known as the “cradle of the Renaissance,” to fulfil a lifelong wish to see the art and culture that so inspired him. He described visiting some works of art as “like seeing old friends.” While standing on the Ponte Vecchio bridge (fig 1), the part of Florence he was most eager to visit, he experienced a panic attack and was also observed to have become disorientated in time. This lasted several minutes and was followed by florid persecutory ideation, involving him being monitored by international airlines, the bugging of his hotel room and multiple ideas of reference. These symptoms resolved gradually over the following 3 weeks.

Figure 1.

Ponte Vecchio.

Four years later, he revisited southern France, this time with no intention of returning to Florence. However, visiting this area reminded him of his trip to Florence and triggered another panic attack followed by persecutory beliefs, again involving monitoring by the airlines and which settled within a few days. There have been no anxiety or psychotic episodes since. However, his retrospective insight into these episodes fluctuates with noted deterioration at times of stress, especially if complicated by poor sleep, when he becomes increasingly preoccupied and troubled by these past events.

His only past psychiatric history is a 4-year period of low mood in his thirties at a time of great personal and financial stress that culminated in a 3-month admission. This followed a serious suicide attempt when he jumped in front of a train and fortunately escaped with only minor musculoskeletal injuries.

There is no relevant past medical history. He was on no medications at the times of the above two episodes and had never misused alcohol or illicit drugs. His sister had several “nervous breakdowns,” possibly episodes of depression, that required psychiatric admission on three occasions. There is no other relevant family history.

TREATMENT

He received no treatment until presenting to our service 8 years after the initial visit to Florence. He was clearly distressed by these symptoms, and his wife and friends were concerned about him. However, the relatively swift resolution of his symptoms had reassured them that acute psychiatric help was not imperative. Since presenting to psychiatry services, his symptoms have involved only transient problems with sleeping, which were often associated with mild increases in paranoid ideation that have been ameliorated by low doses of olanzapine.

OUTCOME AND FOLLOW-UP

He made a full recovery, required no extensive follow-up and returned to full-time work.

DISCUSSION

Being psychologically overcome by the artistic beauty and cultural significance of Florence was first personally reported in 1817 by the French author Stendhal.¹ More recently, a Florentine psychiatrist reported a series of 106 visitors admitted to hospital between 1977 and 1986 after experiencing acute transient psychiatric symptoms in response to viewing the art of Florence.² She dubbed this phenomenon “Stendhal syndrome,” a term that was subsequently popularised in the 1996 thriller of the same name by Italian director Dario Argento. Two-thirds experienced paranoid psychoses, while the remainder developed predominantly affective or anxiety states. Many had extensively prepared for the visit and had previous contact with psychiatric services. Western European tourists seemed to be more vulnerable than Americans, while no Italians were affected. The syndrome has also been called “hyperkulturemia”³ but otherwise has received little attention in the scientific literature.

Although Florence is of great cultural and artistic significance, it is unlikely that the syndrome is limited to there. Similar symptoms can be triggered by other extreme cultural experiences, especially if long-anticipated and of great personal significance, most notably in the “Jerusalem syndrome” precipitated by historical and religious sites.⁴

LEARNING POINTS

• It is well known that adverse life events can detrimentally affect mental health, but it is less appreciated that intense experiences, that would otherwise be considered positive, can have similar effects.

• These experiences seem to interact with an individual’s personal predisposition to mental illness and these syndromes occur more commonly in, but are not limited to, those with a past psychiatric history.

• It seems that “pilgrimages,” be they religious or artistic, are particularly likely to induce such psychological reactions.

• Accordingly, it would be prudent to counsel patients with pre-existing mental illness ahead of visits to places of high personal and emotional significance.