Vampirism As Mental Illness: Myth, Madness and The Loss of Meaning in Psychiatry

Social History of Medicine Vol. 24, No. 2 pp.
445 460
Vampirism as Mental Illness: Myth, Madness and the Loss of Meaning in Psychiatry
Seamus Mac Suibhne* and Brendan D. Kelly
Downloaded from http://shm.oxfordjournals.org/ at Universidade Federal de So Joo del Rei on January 28, 2014
Summary. Vampirism, as a clinical presentation, was formerly much discussed in psychiatric literature. In recent years this has not been the case. This article begins by exploring the history of vampiric phenomena and the various medical theories of vampirism. It discusses the change in emphasis in psychiatry from a psychotherapeutically-influenced exploration of the meaning of a particular symptom to a more ostensibly evidence-based, checklist approach. This reflects a wider shift in psychiatric culture. Articles from the psychiatric literature dealing with vampirism are reviewed in depth. The article argues that the clinical interpretation of vampirism may be useful as an indicator of shifting attitudes within psychiatric discourse. Keywords: vampirism; psychiatry; psychosis; phenomenology; DSM-IV
The vampire legend is of great interest to psychiatry, wrote Lawrence Kayton in 1972.1 Today, it would be difficult to find psychiatrists who would profess any particular interest in the vampire legend. Yet this has not always been so. In the 1960s and 1970s, detailed papers on vampiric phenomena appeared in mainstream psychiatric journals in which the meaning of vampirism to a particular patient would be discussed in some detail. This change suggests a fundamental shift in how psychiatry sees itself and its patients. This article first examines the phenomenon of vampirism over the centuries. It discusses the contrast between the folkloric vampire, as exemplified in reports from the Serbian provinces of the Austrian Empire in the 1700s, and that of popular culture. It then examines the status of vampirism as a clinical entity, and how it was discussed in the psychiatric literature. Finally, it looks at what wider lessons can be drawn from this story, and how
*Special Lecturer and Senior Registrar in Psychiatry, St Vincents University Hospital/University College Dublin, Elm Park, Dublin 4, Ireland. Email: seamus.macsuibhne@ucd.ie Senior Lecturer and Consultant Psychiatrist, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland. E-mail: brendankelly35@gmail.com Seamus MacSuibhne is a locum Consultant Psychiatrist at Cork University Hospital, Cork. He is currently completing a MA in Philosophy and Ethics of Mental Health and a MMEd in Medical Education. He has published in the Lancet, British Medical Journal, Medical Teacher and Reflective Practice, and has an editorial forthcoming in the British Journal of Psychiatry on the legacy of Erving Goffmans Asylums. His research interests are identifying clinical outcomes for research in medical education and classical models of mental health and illness. Brendan D. Kelly is a Consultant Psychiatrist at the Mater Misericordiae University Hospital, Dublin, and Senior Lecturer in Psychiatry at University College Dublin. He holds a doctorate in medicine (MD) and Masters degree in epidemiology (MSc) and health-care management (MA). He has published in the Lancet, British Medical Journal, American Journal of Psychiatry and British Journal of Psychiatry. Research interests include the epidemiology of psychosis, mental health and globalisation, and the history of psychiatry.
1
Kayton 1972, p. 303.
The Author 2010. Published by Oxford University Press on behalf of the Society for the Social History of Medicine. All rights reserved. doi:10.1093/shm/hkq055 Advance Access published 19 October 2010
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Seamus Mac Suibhne and Brendan D. Kelly
changes in the way vampirism is perceived by psychiatry reflects changes in psychiatry that have not yet been fully appreciated by the wider culture. Of these changes, the most germane to the topic of the paper is the dominance of categorical manuals of diagnosis such as the Diagnostic and Statistical Manual of Mental and Behavioural Diseases, produced by the American Psychiatric Association. This topic has been previously discussed in this journal.2 This approach to diagnosis and treatment takes an ostensibly more evidence-based approach, reflecting another significant theme in the discourse of medical disciplines of the late twentieth and early twenty-first centuries. Our aim is to discuss vampirism in the context of the dominance of these trends, and to use it as an illustration of the conceptual richness of approaches eclipsed, at least partially, by these reductionist tendencies. This paper takes an eclectic approach to the selection of examples of historic and folkloric vampirism, which no doubt reflects the authors cultural backgrounds. We draw on reports of vampirism in the mass media and discussed in scholarly publications. We discuss, in broad terms but with specific examples, the gap between the public perception of psychiatry and the realities of practice, and relate this to a clinical de-emphasis on the meaning of symptoms in psychosis to the individual experiencing them.
Vampires in Myth and Possible Reality

Blood has a special status in every culture. Given its crucial biological role in maintaining life, it is no surprise that the metaphorical use of blood to denote essential qualities of individuals and groups, as well as vigour, vitality and earthiness, is so ubiquitousexamples include red-blooded, full-blooded, blood is thicker than water and could be indefinitely prolonged. Rituals are often associated with circumstances in which blood is shed or lost. Leviticus, in its concern with the shedding of bodily fluids and issues such as purity after menstruation, illustrates this. Dietary restrictions in Judaism and Islam surrounding the blood of slaughtered animals reflect a similar preoccupation. The Christian Eucharist has been interpreted as a ritualised drinking of blood. Entities engaging in blood-sucking are present in the mythology of most cultures. Lilith, a Mesopotamian night demon who in Hebrew folklore is identified as Adams first wife, is seen as one of the first manifestations of the vampire myth. Some authors have linked the vampire folklore with the anti-Semitic blood libelJews were stigmatised as outsiders, preying on the body politic as evinced by their alienation from the body of the Church.3 The word vampire itself is most immediately derived from the German vampir, and in turn from the Old Slavic oper and Old Church Slavonic opiri. These words may have been ultimately derived from the north Turkish uber meaning witch. Vampire is defined in the Oxford English Dictionary (2nd edn) as a preternatural being of a malignant nature (in the original and usual form of the belief, a reanimated corpse), supposed to seek nourishment, or do harm, by sucking the blood of sleeping persons; a man or woman abnormally endowed with similar habits. Its first recorded appearance in English was in 1745.4 The classic vampire myth of the cinema and popular fictionas exemplified by Bram Stokers Dracula and the sundry adaptations and revisions of that textis based most
2 3
Berrios 2006. Stephens 2002.
Oxford English Dictionary 1989.
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directly on the folklore of Serbia, Transylvania and other regions of the Balkans. However, there are important differences, which have deceived medical interpreters of the vampire legend. For instance, the idea that vampires are pale and avoid sunlight is true of the vampire of films and other twentieth-century media but not the folkloric vampire. For instance, folkloric vampires were ruddy-faced. Some diseases, such as pellagra and congenital erythropoietic porphyria, have been identified as possible sources of vampire scares.5 Others have vigorously pointed out that these conditions are extremely rare, and their symptoms do not reflect the folkloric but rather elements of the media vampire legend.6 It seems that while some diseases may have contributed to vampire scares, they are not a sufficient explanation for the cultural phenomenon of belief in vampires. Vampirism itself has a range of definitions, as outlined by Gubb et al., who extend the definition of psychic vampirism to include the consumers of the energy of others, rather than their blood or other bodily fluids and make the association between psychic vampirism and sexual activity.7 Vampire outbreaks have been taken seriously by officialdom. In 1755, the Austrian Empress Maria Theresa dispatched her personal physician to produce a report on an outbreak of reported vampire cases in the Serbian territories ruled by the Habsburgs. This followed the cases of Arnold Paole and Peter Plogojovitz, who had both reportedly returned from the dead to their relatives. The French theologian Antoine Augustin Calmet produced a treatise supporting the existence of undead phenomenona. The Empresss physician finally produced a report declaring that the cases were not vampirism. Already, however, a substantial body of literature had been produced that seemed to support the existence of vampires.8 While occurring in a very different cultural and social context, the case of Mercy Brown in New England in 1892 also provided fuel for believing in vampirism. Nineteen year-old Mercy Brown died in Exeter, Rhode Island. Her mother and her elder sister had earlier died of tuberculosis, and Mercys younger brother, Edwin, developed the disease after her demise. Her father opened the family crypt to find Mercys body still relatively well preserved. With the aid of a family doctor, he cut out her heart and burnt it, mixing the ashes with water to make a drink given to Mercys brother. However, Edwin also died.9 Ignorance of the variety of processes of decomposition and putrefaction after death seems to underlie many of the documented reports of alleged vampire phenomena. Thus, it is not uncommon for the face to become erythematous, and for the mouth to fill with blood after death.10 Social factors certainly contributed to belief in vampirism. It is undeniable that living burials were more common at a time and in a location in which medical care and reliable confirmation of death was not readily available. As outlined above, some have found links between a fear of vampirism and anti-Semitism, both manifested in peasant locations easily threatened by dangerous others. Finally, documented real-life cases of vampirism have occurred, most notably the German Fritz Haarman, dubbed the Hanover Vampire, who killed about 24 adolescent males in the early twentieth century. Cases of cannibalism and the mutilation of corpses often have
5 6 8 9
Hampl and Hampl 1997; Boffey 1985. Cox 1995. 7 Gubb et al. 2006.
Barber 1988. Ibid. 10 Ibid.
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an element of blood-drinking.11 In 1989, Tracey Wigginton killed a man in Brisbane, Queensland, claiming that she needed to drink his blood.12 In 1972, Lawrence Kayton wrote that todays belief in vampires is largely confined to the peasant peoples of Greece, Albania, White Russia, the Ukraine, and Poland, the Serbs of Yugoslavia, the Czechs of Czechoslovakia, the Slavonic peoples of Austria, and the Icelanders.13 Now it is difficult to ascertain if any belief in vampires as a form of undead continues to persist. On news sites with a global reach, there are sporadic reports of vampire scares from disparate cultures; for example, in Malawi in 2002, mobs engaged in stoning and rioting in response to fears that their local government was co-operating with vampires.14 In February 2004, relatives of a recently deceased Romanian man dug up his body, removed his heart, burnt it and drank the ashes mixed with water believing he was a vampirereportedly reflecting a widespread and persisting folk belief in Southern Romania.15 The chupacabra, an entity reported in Central America, is described as drinking the blood of livestock. As the chupacabra was first reported in Puerto Rico in 1992, it has been believed to be a contemporary manifestation of mass hysteria. It has been postulated that the spread of the chupacabra reflects anxieties about economic liberalisation and other forms of social change. It is notable, however, that the chupacabra is often identified with an extra-terrestrial life-form rather than as an undead entity.16 Contemporary mythic figures seem to be interpreted in science-fiction terms as much as mystically or in quasi-religious form. Popular and psychiatric literature on the vampire theme is one replete with sexualised imagery and concerns, such as forced entry, the exchange of bodily fluids, and the overpowering of human nature by an inhuman, undead force. Vampirism has been connected with panics about infectious diseases, such as tuberculosis and HIV/AIDS.17 Parallel to these occasional reports and scares, in the west, a sub-culture embracing the vampire lifestyle has emerged.18 The vampireor vampyre as many like to spell the word to distinguish themselves from the vampire of horror movies and to add a Gothic touchsub-culture can roughly be divided into sanguarians who report a craving for blood as part of their inner nature and do not publicise their vampiric tendencies, and other lifestylers who affect the clothes and mannerisms of the traditional vampire. It should be noted that the latter group generally emulate the Hollywood vampire rather than the traditional folkloric one. This seems to be related to the popularity of the fictions of Anne Rice and Stephanie Meyer, as well as TV shows such as Buffy the Vampire Slayer, and it is difficult to distinguish to what degree lifestylers are indulging in role-playing. It is interesting to note that much of the depiction of vampires in modern popular culture, as exemplified in the novels of Anne Rice, is sympathetic to the
11 12
Prins 1985. Daily Telegraph (Australia), 2008. 13 Kayton 1972, p. 304. 14 Report at http://news.bbc.co.uk/2/hi/africa/2602461 .stm (accessed 30 March 2010). 15 Report at http://seattletimes.nwsource.com/html/ nationworld/2001891951_vampires31.html (accessed 30 March 2010).
16 17
Jordan 2008. Yurguris 2002. A full consideration of the role of gender politics in the vampire myth is beyond the scope of this article. 18 Connolly 2002.
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vampire and to the problems associated with immortality.19 Portrayals of vampirism reflect contemporary concerns. For example, F. W. Murnaus Nosferatu (1922) reflected the postFirst World War influenza epidemic which claimed more lives than the war to end all wars, while Werner Herzogs 1979 remake mirrors a disillusionment with scientific method, with an ineffectual Dr Van Helsing insisting on proceeding wissenschaftlich scientificallythough with disastrous results. Jaff and DiCataldos conclusion that reality-based speculations cannot fully account for the vampire myth, which is too psychologically complex and deeply embedded in ancient powerful beliefs and symbols is to the point.20 Even if rare diseases and occasional incidents of actual vampiric behaviour have contributed to the myth, it cannot explain its durability, its intense power, how often vampire stories are told and retold, and how distressing and disturbing vampirism can be as a symptom of mental illnessboth to experience and to contemplate. Thus McCully has written on the vampire image: Is it merely fascination with the macabre which has insured its survival and kept its form virtually intact? Does its sheer atavism and destructively negative nature justify its survival? Can one simply say that the perverse nature of man would conjure up a vampire image at any stage so as to define evil or to contrast it with the good? Perhaps so, but there are many vehicles for so doing, and they are often culture-specific, whereas the vampire image has a strangely universal quality. Is it not reasonable then to assume that the image may have more import than its face value, and that its meaning and universal persistence suggest roots which penetrate deeply into the development of our psychic substance?21
PsychiatryPopular Image and Modern Reality

The popular image of psychiatry, as evinced in TV shows such as The Sopranos and myriad single-panel cartoons, is still primarily based on a simple caricature of Freudianism. We see analysts investigating dreams, using free associations, delving into the echoes of the past in current relationships. The rise of psychopharmacologywhich has transformed the practice of psychiatryhas also made inroads into popular culture.22 Popular presentations of the tension between psychological and psychopharmalogical tendencies in psychiatry tend to present them as dichotomous and in opposition to each other.23 This does not, however, reflect current practice. The most popular form of psychotherapy and the one promoted by Lord Layard, the British Governments one-time Happiness Czar, as central to the spread of talk therapy centres around the UK as part of Government policyis Cognitive Behavioural Therapy (CBT).24 CBT is explicitly focused on the here-and-now, aims at solving a particular problem (social anxiety, a phobia) or reducing the impact of a specific problem (thus a patient hearing voices will learn how to manage hearing the voice). It does not involve the exploration of dreams, or hypothesising
19 20 24
Stephens 2002. Jaff and DiCataldo 1994. 21 McCully 1964. 22 Ban 2001; Wurtzel 1994. 23 Kramer 1993.
See, for instance, http://www.bps.org.uk/dcp/news/ layard.cfm (accessed 10 January 2009) for a discussion of how Layards proposals will effect the need for training of CBT therapists.
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continuing ongoing conflicts based on childhood experiences.25 It is also seen as complementary to biomedical models of mental illness. Another aspect of the traditional view of psychiatryone that dovetails closely with the psychiatrists supposed concern with dreams and dream imageryis that psychiatrists have an interest in folktales and legends. Jung is now perhaps best known for his ideas about archetypes and the collective unconscious, while Otto Rank discussed mythological and folkloric themes such as the idea of the Double and the story of Don Juan.26 Jungian ideas have been taken up by the wider culture to nearly the same extent as Freudianism. Indeed one could argue that they are more influential among cultural commentators than modern psychiatrists.27 Again, the general tenor of modern psychiatry is more hard nosed and realistic than this. The Structured Clinical Interview for DSM-IV (SCID), a standardised assessment for schizophrenia, asks if delusions are mood congruent (reflecting the patients mood; for instance, a depressed patient with delusions may have very nihilistic delusions) or bizarreboth these parameters are yes or no questions, and the actual content of a delusion is not explored beyond this.28 The presence or absence of delusional beliefs is what is seen to be important. SCID reflects the popularity of diagnostic classifications such as the ICD-10 and DSM-IV. These make no reference to the actual content of delusions. From a risk management point of view, the presence or absence of command hallucinations is seen to be central. Command hallucinations are voices explicitly instructing someone to perform a certain actwhen they are of a suicidal or homicidal form they are considered to be a major concern. However, again the specific content of the command hallucination is less important than the mere fact that it exists. Delusions not infrequently have a sexual component, and with the abandonment within mainstream psychiatric practice of Freudian formulations of psychosis as an expression of frustrated libidinal impulses, this aspect of delusions is also ignored in contemporary psychiatric practice. In summary, in contemporary mainstream psychiatric practice, what matters from a diagnostic and therapeutic point of view is not the meaning of a particular delusion but the existence or otherwise of the delusion. This is perhaps taken to its logical conclusion in CBT approaches to psychotic phenomena, which take a strictly neutral view on the existence or otherwise of these phenomena and simply aim to make them tolerable. The CBT approach to command hallucinations is focused on changing the patients response to these hallucinations. The meaning of the hallucinations as such are not believed to be relevant.29 This shift from a meaning-laden discourse to a manualised approach to psychosis mirrors the distance between psychiatry in popular discourse and where the discipline has travelled to. The discourse in the psychiatric literature on clinical vampirism exemplifies this shift from an approach that sought to understand the meaning of a psychotic experience for the individual, to one that simply noted the fact that a psychotic experience occurred. We will now discuss this discourse, with close attention to specific examples, and will return to the implications for the wider history of psychiatry within society at a later stage.
25 26
Beck 1975. Rank 1971. 27 See, for instance, Booker 2004. 28 Spitzer and Williams 1986.
29
CBT is part of the National Institute for Clinical Excellences 2002 Guideline for the Management of Schizophrenia. Its role is still somewhat controversial. It is debated, for instance, at Turkington and McKenna 2003.
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The Rise and Fall of Vampirism as a Clinical Entity

Clinical vampirism is not a major diagnosis in modern psychiatry. This has not always been the case. Many papers from the psychiatric literature of the 1960s and 1970s discuss clinical vampirism. Papers of the 1990s on vampirism tend to claim that the vampire motif has its origins in porphyria or pellagra or a similar metabolic disease. For example, McCully in 1972 took a traditional psychodynamic approach to a case of auto-vampirism, with prominent use of the interpretation of Rorschach ink blots.30 In 1993 Morse discussed the phenomenon in terms of stress-related behaviour, one which could potentially be seen as positive in the context of temporary escape from stressors.31 Medline produces 19 results for the term vampirism.32 Excluding one result which is an article about the management of phlebotomy systems in a major hospital, and another which is a discussion of a nineteenth-century book entitled Some Sketches Of Impostures, Deceptions and Credulity, four are from the 2000s, five are from the 1990s, five are from the 1980s, one is from the 1970s and two are from the 1960s. However, Medline is known to be biased in favour of recent papers. Among these, the majority from the 1990s postulate or dismiss various possible physical illnesses as candidates for explaining vampirism.33 Gubb et al.s 2006 review (part of a case report of a case of vampirism presented to their practice in South Africa) returns to a biopsychosocial approach, observing that simply dismissing Thabos [the case study they discuss is given the pseudonym Thabo] delusional systems as being coincidental to his biologically driven disease state may not be helpful to the clinician in developing a deeper understanding of this mans psychic universe or his perceptions of the world.34 It is worth examining some of the papers on vampirism in more detail.35 In 1965, Vandenbergh and Kelly defined vampirism as the act of drawing blood from an object (usually a love object) and receiving resultant sexual excitement and pleasure: The scientific literature on the subject of vampirism is extremely meagre the authors feel that such behaviour and fantasies are more common and important than their relative absence in the literature would suggest. For though it is true that cases of pure vampirism are rare, it is also true that vampiristic content, wishes, and fantasies often are seen as reaction formations and sublimations.36 The references to defence mechanisms of reaction formation and sublimation suggest a Freudian influence. This is unsurprising, given the strong Freudian presence in American psychiatry at that time. Vandenbergh and Kelly discuss two cases. The first is a prisoner, found to be trading sexual favours for the opportunity to suck blood from other prisoners. The authors
30 31
McCully 1964. Morse 1993. 32 20 December 2006 returned 19 results. A search on 9 January 2009 returned 18 results, with the article on phlebotomy systems management not appearing in the search. 33 Hampl and Hampl 1997; Boffey 1985; Cox 1995. See also de Pauw 1985.
34 35
Gubb et al. 2006. In 1999, Kelly et al., describing a case study of a clinical presentation of vampirism in a patient subsequently diagnosed with schizophrenia, also reviewed the psychiatric literature on the topic. Kelly et al. 1999, p. 144. 36 Vandenbergh and Kelly 1964, pp. 5434.
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conclusion is suggestive of their approach, and locates their formulation of these symptoms as firmly within the Freudian context of thwarted libidinal desires: The specific symptoms seen in vampirism have their dynamic basis not only in the unresolved conflicts at the oral sadistic level, but at other levels of libidinal development as well. Oedipal wishes, fear of castration, and aggressive hostile wishes, are examples of these many various unresolved conflicts which can be symbolised in the patients mind by the blood.37 The second case is one of autovampirism, in which the patient could manipulate a jet of blood directly from a neck artery to his mouth. McCully also discusses the same case.38 A variety of projective stimulia form of personality assessment in which a person is shown ambiguous stimuli such as abstract shapes or pictures and asked to interpret them in some waywere used, including Rorschach images, a drawing series, Miale-Holsopple Sentence Composition, projective questions and handwriting samples. Few of these methods are in mainstream use today. McCully found that the projective findings showed evidence of depression and a pervasive lack of emotional development. He does not describe evidence of psychosis. The focus in McCullys formulation is also on constraints on development. The patient was found to be virtually unformed in both the emotional and psychosexual spheres and behaving as if he had to keep himself in a tight, compulsive strait jacket, and to get out of it would invite chaos. When asked what animal he would most like to be, the patient wrote: what occurs to me is not really an animal, but something that flies, maybe a hawk or a bird of prey, or better, an albatross.39 McCully embarks on a lengthy interpretation, based on the albatrosss status as a bird of good omen and its role in Coleridges Rime of the Ancient Mariner. McCully proceeds to discuss the case in the light of Erich Neumanns concept of the feminine principle in various cultures, particularly drawing our attention to Neumanns focus on the youth not strong enough or developed enough to resist the forces symbolised by the overpowering mother.40 McCully warns us that this not necessarily literally the individuals mother, or even a parent, but a symbolic process. Self-castration, in McCullys interpretation of Neumann, is the primary expression of a flight from incestual fears. The price of repressing the negative, frightening aspects of the powerful mother is a ban on sexuality. McCully goes on to discuss the vampire image as a symbol of the split between the social nature and animal nature of man, as a wish to seek life and humanity vicariously, using the means of the wild beast. He then asks whether or not the vampirism exhibited by his patient was a sign of impending psychosis. For McCully, contemporary studies in a range of groups seemed to suggest otherwise. He cites investigations of the fantasies of terminally-ill children, of children with abnormally high pain thresholds, and a study of a transsexualite [sic] who had partially changed her sexual characteristics and was determined to remove the rest of her female sexual features.41
37 38
Vandenbergh and Kelly 1964, p. 544. McCully 1964. Jaffe and DiCataldo identified this as the same patient described by Vandenbergh and Kelly; see Jaff and DiCataldo 1994.
39 40
McCully 1964, p. 444. Neumann 1991. 41 McCully 1964, p. 450.
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These studies found relatively little unconscious disruptions, or evidence of emerging psychosis. For McCully, this is a challenging finding. He suggests that contemporary conceptions of the continuum of psychological disorder should include a state hitherto not recognised, a kind of psychic limbo, which enables the individual to adjust to mental states and stressors that would be commonly assumed to lead to psychosis. Perhaps, when symbol becomes fact, there is nothing to project, he concludes, a haunting phrase that perhaps sums up the distance between McCully and the age of DSM-IV.42 As outlined above, vampirism per se would be seen as evidence of psychosis in SCID. McCully adopts a more nuanced, more humble view of the possibility that those who actually perform acts which seem, on the face of them, compatible only with psychosis may not be psychotic. McCullys paper exemplifies many differences between contemporary psychiatric practice and theory and that of 40 years ago. These are crucial to the theme of this article. Taken with Vandenbergh and Kelly, we can list some of these differences: an awareness of the role of mythic archetypes and symbols in clinical presentations and practice; the use of projective stimuli (today generally regarded as lacking validity and reliability); a concern with the content of the fantasy life of patients, reflecting a concern with the patient as an individual; a conceptualisation of mental disorder as arising in disruptions to psychic development; less of a division between the formulations of psychosis and neurosis; and a greater acceptance of Freudian and related views of psychic development being characterised by the interplay of libidinal fears and desires. There are other differences in tone and vocabulary, as well as an absence of the use of rating scales or of a structured diagnostic tool. In 1972 Kayton specifically analysed the relationship of the vampire legend to schizophrenia.43 He used the frameworks of English psychoanalysts such as Klein, Fairburn and particularly Guntrip, to postulate that the vampire legend was a representation of the intense, devouring oral needs of a patient with schizophrenia.44 For Kayton, the vampire theme thus presents psychiatry with a unique phenomenological view of schizophrenia.45 He also discusses the then-current upsurge in depictions of vampirism in popular media. The experience of watching a horror film provides the safe projection and vicarious discharge of primitive oral sadistic impulses in all of us. For Kayton, the power of the vampire myth goes beyond this. We are able to empathise with the vampires dilemma. For the vampire wishes to love and be loved and yet is possessed by enormous oral needs which rule his life.46 This empathy can help in the understanding of some aspects of schizophrenia. Compared to the psychiatric papers from the 1960s discussed above, the focus already is on schizophrenia as being the mental illness related to vampirism, rather than a more generalised psychodynamic view. Vampirism is described as an empathic bridge to aid the phenomenological understanding of schizophrenia. Prins in 1985 reviewed the literature about clinical vampirism and surveyed a group of mental health professionals, mainly either forensic psychiatrists or psychiatrists with a
42 43
McCully 1964, p. 451. Kayton 1972. 44 Kayton 1972, p. 304.
45 46
Kayton 1972, p. 303. Kayton 1972, p. 313.
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particular interest in serious deviancy.47 Prins admitted that this sample was very small, highly selective and confined mainly but not exclusively to the UK. Thirty-three responding psychiatrists suggested that the vampirism they had encountered was always associated with another mental illness, and therefore vampirism seemed to them unlikely to be a single clinical entity. The associated mental illnesses were identified by them as being, in order, schizophreniform disorders, hysteria, severe psychopathic disorder, and mental retardation.48 They also linked vampirism to serious sexual offending. Overall, however, the strongest association with vampiric behaviour was in individuals functioning at a very primitive mental and emotional level. This, Prins writes, may explain the close connection perceived by his respondents between clinical vampirism and schizophrenic disorders. Prins discusses vampiristic activity and ideation in terms of psychodynamic theories of the development of schizophrenia, noting that the psychoanalytical view, incomplete and untestable though it may be in many respects, finds some degree of support in the clinical descriptions of some of the cases already mentioned, suggesting that while vampirism as a single clinical condition may be a most rare phenomenon, there may be grounds to suppose that it is more common than hitherto supposed.49 Prinss view of schizophrenia still shows the influence of Freudian theory, and also we see the association between primitive development and schizophrenia. Thus there are contrasts and continuities in the papers discussed above. The association between vampirism and schizophrenia is made more explicit and stronger in the later papers. McCully found no evidence to support a finding of psychosis in his case study, and postulated a previously undescribed mental state which would allow the individual to undergo or perform certain acts which one would assume would lead to or be associated with psychosis, but may not be. Later authors do not doubt an association with psychotic disorder, but their conceptualisation of psychosis is one that sees it as primarily a developmental disorder. There is a broader concern than simple diagnosis and labelling. While the lacuna in the literature that follows is, as outlined above, relieved only by discussions of possible physical illnesses explaining the vampire myth, Gubb et al. suggest that insights from psychodynamic and sociocultural views of vampirism may be returning to clinical practice.50 Unable to find a single case report of psychic vampirism in the professional literature, they discuss vampirism from a psychodynamic perspective, and as a multi-axial psychopathology. From the psychodynamic point of view, they draw on the work of Abraham, Klein and Fairbairn to relate vampirism to oral fantasies of aggression in response to maternal deprivation. They also postulate that vampirism can be seen as a form of narcissism, allowing the patient to relate to others without relating. Others are objectspassive, submissive and under control. They note the paradox of vampirisms status as a symbol of renewal and of the life force, as well as an act of violence. They also discuss a psychodynamic view of psychosis which posits psychotic states as a regression to a narcissistic level whereby boundaries between the self and the outside world are weak, leading to the fusion of these worlds in fantasy that becomes personal reality.
47 48
Prins 1985, pp. 6678. Prins 1985, p. 666.
49 50
Prins 1985, p. 668. Gubb et al. 2006.
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They then explore the classification of vampirism using the multi-axial system of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental And Behavioural Disorders (4th edn, text revisionknown as DSM IV-TR).51 They concentrate on axis one and axis two. Under axis one, schizophrenia and other schizophreniform disorders are most commonly considered; particularly gruesome cases of vampirism generally present with the massively disorganised oral sadistic regressions, depersonalisation, confused sexuality, multiple concurrent delusions, and thought-form and content disorders that are so commonly seen in schizophrenia. It should be noted that in neither ICD-10 nor DSM-IV do diagnostic criteria for schizophrenia include massively disorganised oral sadistic regressions or confused sexuality. The authors also discuss the relation between vampirism and sexual sadism as an axis one diagnosis. Under axis two disorders, the clinically worrying association between antisocial personality disorder and vampirism is described, with links made to the origin in a forensic setting of many of the cases of vampirism which have been clinically reported. The main body of Gubb et al.s paper is a case report of a 25 year-old African male, given the pseudonym Thabo, who had become withdrawn, began wandering the streets, undressing in public and exhibiting unusual dietary behaviour. He would eat leaves and branches, which he would also try to cook, and drink dirty water from cars he washed. Thabo began to exhibit evidence of being fearful. Initially, his mother took him to a local church, where it was planned he would stay until the disease showed itself. However, this was not possible because of financial constraints, and Thabo was finally admitted to a psychiatric unit and treated with antipsychotics. There was a background history of the murder of his father when Thabo was four, bullying in school as a result, expulsion from school because of drug use and behavioural disturbance, continuing drug use, and a two-year pre-admission preoccupation with the occult and possible involvement in Satanic practices. When interviewed, Thabo himself did not report feeling unwell, saying his experiences were part of the natural course of life. He reported hearing the voice of a flame vampire from the Scriptures of Geeta for a year at least. He also believed that he was Vasever, a vampire lord, and that vampires existed in an invisible form, communicating among themselves and making a pact of secrecy against the rest of the world. Although he reported having to zoom in and out of others in order to survive, Thabo had not engaged in any vampiric acts, or developed other homicidal, cannibalistic, libidinal or sexual features of vampirism. The authors describe Thabos dress (hip hop fashion) and mental state. They also described his clinical course. His discharge diagnosis was one of schizophrenia with antisocial traits. He exhibited no remorse for various acts, including the capture and killing of a pigeon in front of other patients, and physical hostility towards other people. The authors report the absence of objective hallucinations and formal thought disorder on one month post-discharge follow-up, as well as other signs of improvement on antipsychotic medication, although Thabo continued to believe he was a vampire. In their discussion of the case, the authors use a biopsychosocial model, explaining that this eclectic approach provides a useful theoretical framework upon which to dissect the various aspects of his unusual case, with its numerous culturally incongruent themes
51
American Psychiatric Association 2000.
456
and their possible genesis.52 Biologically, they consider the possibility that vampirism should simply be considered as part of the psychotic process of schizophrenia or a schizophrenia-like illness, reflecting little more than the neurochemical imbalances associated with the disease. Thabos continuing vampiric beliefs after discharge could be interpreted as residual psychotic symptoms. However, given that the literature shows that vampirism can be linked with schizophrenia and may even occur in people not recognised as abnormal, the authors feel a broader perspective is necessary.53 As noted above, in their discussion of both axis one and axis two pathology, Gubb et al. tend to use the vocabulary of psychodynamic conceptualisations of schizophrenia and personality disorders. Most of their concluding discussion is taken up with the psychological aspects of the case. The authors describe Thabos childhood aversion to touch. They postulate that he found this an intrusive violation of the self, and to defend against it he found a means of connecting with others without physical contact and by triumphant fantasies of violent physical contact. Through vampirisim, Thabo could triumph over his feelings of having less and being impotent; he has access to all that the other has, and can penetrate them and take hold of their power, which he longs for so desperately.54 The authors also invoke Freuds theory of psychosis as a disavowal of reality by suggesting that Thabo was drawn to the undead, immortal aspect of the vampire legend, as it could connect him to the world of his father. Gubb et al. also discuss the social context of Thabos presentation, stating that vampirism is not part of traditional African folklore. They write of the influence of Western television programmes and movies, in which vampires are often depicted as heroic, powerful entities. Furthermore, the impact of HIV/AIDS on African communities has seen an explosion of myths and urban legends about the illness. Some of these are well known, such as the belief that intercourse with a virgin can cure HIV/AIDS. Others involve rape and not only curing but purging and passing on HIV/AIDS during sex. Blood itself has acquired a paradoxical statusessential for life, yet carrier of death. The authors finally state their belief that a combination of biopsychosocial factors probably produced Thabos set of symptoms.55 Having used these papers as paradigmatic of psychiatric discourse, we are aware that the argument could be made that this handful of papers is not representative of the discipline as a whole. Looking at the institutional affiliations and career information, where available, of the authors of these papers, we can see that they were mainstream figures within the profession. At the time of the publication of the 1972 paper, Kayton was Director of Training, Psychosomatic and Psychiatric Institute, Michael Reese Hospital and Medical Center, Chicago, and Assistant Professor of Psychiatry in Pritzker School of Medicine at the University of Chicago. Kaytons later papers predominantly deal with schizophrenia and give the same institutional affiliation.56 Herschel Prins was described in his 1985 paper as former Director of the School of Social Work at Leicester University. His paper, published in the British Journal of Psychiatry, which was (and is) the flagship journal of the Royal College of Psychiatrists, the body charged with training and
52 53 55 56
Gubb et al. 2006, p. 166. Ibid. 54 Gubb et al. 2006, p. 167.
Ibid. Kayton and Koh 1975; Koh, Kayton and Berry 1973.
457
regulating psychiatric practice in the UK. In 2005, Prins received an Honorary Doctor of Science degree at Loughboroughthe oration beginning with the words Were he less modest, Professor Herschel Prins could properly claim to be influential in the development of criminology and forensic psychiatry in Britain.57 McCully was a psychiatrist at the Medical University of South Carolina. The authors of the most recent paper discussed, Gubb et al.s of 2006, were affiliated to the Division of Psychiatry, Faculty of Health Sciences, University of the Witwatersrand. The institutions are mainstream academic/clinical ones.
The Loss of Meaning in Modern Psychiatry

The differing interpretations of clinical vampirism reflect the story of the triumph and decline of Freudian psychoanalysis, especially in the United States. It has been observed that, while in the 1950s, American psychiatrists were invariably well-schooled in Freudian approaches, today psychiatric residents tend hardly to have read him. McCullys paper indicates the degree to which issues of meaning were part of psychiatric discourse. There is lengthy consideration of the patients symptoms, which are related to his stated desire to be, if he had to be any animal, an albatross. The idea that psychotic symptoms have a meaning which is relevant not only to diagnosis but also to management has largely disappeared. Current practice is largely interested in whether or not the symptoms exist, and sees meaning as irrelevant. Contemporary pychotherapeutic approaches to hearing voices are less concerned with meaning than with making them liveable-with. The reader will perhaps have his or her own view as to what has been lost or gained through these changes. What is not in doubt is the dominant trend in medical practice todaythe push towards evidence-based practice. Evidence-based medicine is defined as conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. This means integrating individual clinical expertise with the best available external clinical evidence from systematic research.58 Key words in this definitionjudicious, individual and integratingare often forgotten. Evidence-based medicine is seen as being about systematic reviews of randomised controlled trials. It is beyond the scope of this article to give a full discussion of evidence-based medicine, which has been critiqued by authors both from a medical, scientific viewpoint and that of the social sciences.59 Suffice it to say that in clinical practice, one endeavours to find evidence relating to patients as similar as possible to the individual one is treating. By its very nature, this process involves lumpingreducing the individuality of the patient to conform to one or another category. Patients with bizarre symptoms will tend to have them reduced to fit one of the clusters of symptoms that define a diagnostic entity. This allows the application of a treatment or management protocol based on a particular body of evidence. What may be lost is the individual quality of the symptoms themselves, their meaning for the patient and the other unmet needs that may be suggested by those symptoms. Gubb et al. disclaim
57 58
Loughborough University, 2005. Oxford Centre for Evidence-Based Medicine, Glossary of Terms in Evidence-Based Medicine, http://www. cebm.net/glossary.asp (accessed 30 March 2010).
59
Tobin 2008; Mykhalovsky and Weir 2004.
458
this approach, and put the presentation in a psychological and cultural context. The biopsychosocial approach, however, usually privileges the biological. Psychiatry and the concept of evidence-based medicine both have long histories, but in a recognisably modern form they are relatively new. In the past, zealots from various psychoanalytical schools have waged wars against heresies within psychoanalysis, and a false dichotomy has been created between biological and psychosocial psychiatry. Psychiatry has always been caught in a tension between its biological and psychological, psychodynamic sides. Similarly, the initial crusading zeal of proponents of evidence-based medicine has been tempered with a realisation that the generalisation of randomised controlled trials carried out in centres of excellence needs to be examined, as well as the realisation that case reports, cases series, clinical anecdotes and other low level evidence can help generate the hypotheses without which randomised controlled trials could not be conceived.
Conclusion
A reader may ask, so what? So what if the elaborate edifices of psychodynamic formulations of psychosis have been torn down and replaced by the utilitarian architecture of the DSM era? The papers of previous eras in psychiatric practice may be more attractively written and more resonant than modern ones, but this is not to say that they are more accurate. Psychodynamic theories of psychosis deserve the obloquy into which they have fallen. With their tendencies towards mother- and parent-blame, an entirely needless burden of guilt was placed on families already struggling with the devastation of psychotic illness. The reductionistic approach to diagnosis need not necessarily mean a dismissive or reductionistic approach to meeting the broad needs of the individual. However, a richness has been lost. Also lost is a way of thinking about the phenomena that make up mental illness that tried to put the meaning of the experience for the individual at the centre of our fumbling efforts to understand what is going on. When recovering from a psychotic episode, patients are often haunted by their search for an explanationwhy did this happen to me? The patients search for meaning in their experience is all too often dismissed with vague references to multifactorial causes, the influence of genetics, the possible effect of birth injury or cannabis or some other agent. On an individual level, we never know. For the individual, however, we have a duty to help them find some meaning for them in what has happened. Refocusing our approach on individual meaning could help facilitate this. The story of vampirism as a clinical entity shows how the pendulum in psychiatry has swung from interpreting patients symptoms in an individualised, psychodynamic way towards a reductionistic view which fits symptoms into a diagnostic category. It illustrates many general trends in psychiatry. How vampirism is portrayed in the future in psychiatric and psychological literature will be the marker for how these trends evolve.
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Vampirism As Mental Illness: Myth, Madness and The Loss of Meaning in Psychiatry

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Social History of Medicine Vol. 24, No. 2 pp.

Kayton 1972, p. 303.

Seamus Mac Suibhne and Brendan D. Kelly

Vampires in Myth and Possible Reality

Berrios 2006. Stephens 2002.

Oxford English Dictionary 1989.