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Did Mozart suffer from Asperger syndrome?
Journal of Medical Biography 23(2) 84–92 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0967772013503763 jmb.sagepub.com
Michele Raja
Abstract The most reliable biographies of Mozart highlight elements that are compatible with current diagnostic criteria for Asperger syndrome including qualitative impairment in social interaction and stereotyped and repetitive motor mannerisms. Furthermore, numerous features are documented including difficulty in communicating his emotional state and in inferring the mental state of his interlocutors, motor clumsiness, specific skills and genius, left-handedness, special sense of humour, physical developmental abnormalities, bizarre thinking, overvalued ideas and delusions.
Introduction ‘Nullum magnum ingenium sine mixtura dementiae fuit’ (Seneca)
It has been suggested that Mozart suffered from Asperger syndrome1,2 (AS) while two papers3,4 have instead suggested a diagnosis of Gilles de la Tourette Syndrome (GTS). According to the Diagnostic and Statistical Manual of Mental Disorders-IV Edition-Text-Revision (DSM-IV-TR), AS is part of the group of Pervasive Developmental Disorders (PDD) and refers to people with autistic, odd and eccentric behaviour yet with well-developed language skills. Were Mozart’s behaviour, feelings and thoughts compatible with AS diagnosis, according to DSM-IV-TR? Was Mozart impaired in non-verbal behaviour – eye-to-eye gaze, facial expression, body postures and gestures – regulating social interaction? The difficulty that those with AS have in recognising their own and others’ feelings results in an emotionally inexpressive or inadequate face that appears strange, indecipherable, odd or cold. Biographers emphasised the absence of facial expression: The physical type of Mozart, lacking expressiveness, was the most suitable embodiment of a musical spirit tending inwards . . . while the face of Beethoven, reproduced by painters and sculptors, is now well imprinted in the minds of all people in a faithful version, the most diverse and bizarre opinions about the appearance of Mozart still reign.5
Some subjects with AS exhibit difficulty in establishing eye contact with others since maintaining eye contact
provokes anxiety, while others maintain fixed eye contact, as in staring at an inanimate object, which an outsider may perceive as disturbing. Paumgartner’s description of Mozart’s gaze is suggestive: ‘Almost indefinable, restless, eye position, a bit dreamy and distracted gaze, as short-sighted without glasses, that only the music lighted of a singular light’.6 Mozart’s failure to develop peer relationships appropriate to developmental level is clear. During his early years Mozart neither frequented peers nor had companions with whom to play and spend time. His father forced the child Wolfgang to spend hours and hours studying and playing music. However, such constraints would have not been successful with a child other than Wolfgang, a child inclined to interactions with peers, and with a healthy physical vitality, with characteristics that make it virtually impossible for children 3–4 years sitting and applying for hours in repetitive studies. Hildesheimer writes7 ‘The severity and harshness that characterised his early years were neither intended as such by his father nor suffered as such by himself. He was never considered to have been subject to tasks beyond his strength; more likely, he felt able immediately to deal all that was required. Mozart did not meet other children nor know any other game than the piano and the violin . . . the only known relationship with another child is that with his sister. . . one can imagine that days spent only playing music traumatised Wolfgang but we do not have
via Prisciano 26, Rome, Italy Corresponding author: Michele Raja, via Prisciano 26, Rome 00136, Italy. Email: [email protected]
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sufficient basis for this supposition; on the contrary, despite the excessive demands, he must have felt happy’. The lack of a spontaneous search to share enjoyment, interests and achievements with other people is not substantiated: ‘Yet Mozart was anything but a cantankerous misanthrope: he loved happy company, even when a little rough. The hum of cheerful and exalted voices, warm laughter, petulant jingling of glasses chased the daily worries from him’.8 Biographical data suggest lack of social and emotional reciprocity for Mozart’s shortage of affection. He never had a true friend, never had an intense affective relationship with his parents and did not suffer particularly at their death, and never showed a passionate love for his wife and children: ‘Mozart never revealed the true depth of his soul to any of his peers although this lonely heart was burning for a lifelong desire to find a true friend, worthy to be such for him’.9 According to Hildesheimer,10 Mozart did not even feel the lack of friendship: ‘One wonders whether he has ever had a friend . . . probably not, he did not know human bonds as we live them, he did not even need them’. Emotional detachment is evident in Mozart’s reactions to life events. He wrote to his father on 3 July 1778 and mentioned his mother’s illness, Voltaire’s death and the execution of the symphony ‘Pariser’, all in perfect handwriting: ‘so finished to look like an exemplary document drawn for the admiration of posterity’.11 What Mozart omitted in the letter is that his mother had died only three hours earlier: ‘In this letter we have the impression that Mozart’s upset does not exceed the limit of baroque convention and it seems the librettists of Opera intruded here’.12 On the death of his father, Mozart wrote an emotionally cold letter to his sister and ‘In this letter all the affective content is limited to the first sentence. But it also sounds artificial and forced . . . The rest of the letter is dispassionate, realistic’.13 Two days later, a bird died in a cage in Mozart’s study. He dedicated an elegy to the bird . . . We cannot not think about an object more worthy of our tears. But we will not infer differences in Mozart’s relationship with these two unequal victims of death – the father and the bird.14
On a sentimental level the lack of passionate involvement toward women is impressive: Two women constituted the cornerstones of his love life: the slim, attractive, very musical Aloysia Weber . . . and the lovely cousin, the intimate companion of his deplorable amusements. The Mozart marriage
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seems to have been happy. . . . If he sometimes came out of the binary of marriage, his wife turned a blind eye, ‘‘as long as they are maids’’ she said . . . The woman was for Mozart a source of careless joy, free of feeling, and he was able to open his intuitive genius not to a single biased ideal but to the entire range of games, passion and tenderness of the sparkling demon. This is why he was also able to render love in art with so much variety and warmth of life.15 In the field of human relations Mozart remained perpetually a fool, a stranger. This also explains his relationship with his wife of whom we have not heard of reciprocal feelings.16
Mozart’s solitude at the end of his life provides evidence of his difficult human relationships: In front of St Stephen’s Cathedral, it plays a funeral of economic class. Mozart’s body, just blessed, is enclosed in a coffin and hoisted on to a cart to be taken to the cemetery. There are few friends. His wife Constanze, overwhelmed by one of her sicknesses, no. For a while, the few persons present follow the coffin which starts slowly but none reached St Marcus’ Cemetery where Count van Swieten prepared the burial in a mass grave. Constanze went to the cemetery much later and found a series of unnamed mounds and a new gravedigger who was unable to give any indication. The tomb was never again found.17 The lack of a tombstone, the indeterminacy of the place of burial, the anonymity of interment confirm the suspicion that Mozart was neglected or mistreated . . . Constanze had reason to be angry with a husband and a father who had abandoned his family forever.18
Lack of social and emotional reciprocity was evident in Mozart’s artistic performances: ‘A cold detachment always benefited Mozart who knew the secret for success in creating lyric operas: emotions, provided not his own’.19 ‘On what really overtook him, he almost never wasted a word with strangers’.20 Musicians provide creative force in their performances by empathising with the audience. Hildesheimer assumed that Mozart instead reached the height of his talent in playing music when he could detach from everything and everyone: These must have been the times when he was delighting in blissful forgetfulness of self, in which he broke all contact with the outside world; then, he was the most direct Mozart . . . Here, and perhaps only here, he arrived at the true enjoyment of his genius, here he ‘performed’ it to the depths, here he became the absolute Mozart.21
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Can the vast body of musical works created by Mozart and the biographical news testifying that he fully dedicated his life to music be labelled as ‘Restricted repetitive and stereotyped patterns of behaviour, interests, and activities’? Of course, while a deaf behavioural scientist could consider Mozart’s encompassing preoccupation with one restricted pattern of interest (the music!) ‘abnormal either in intensity or focus’, his artistic production cannot be considered repetitive or stereotyped. There is neither evidence of inflexible adherence to specific, non-functional routines or rituals, nor persistent preoccupation with parts of objects. However, Mozart’s restlessness can be considered a form of stereotyped and repetitive motor mannerisms. Subjects with AS often manifest stereotyped and repetitive motor behaviours.22 These are repeated in more clicks and appear more voluntary and closer to rituals than to nervous tics, usually faster, less rhythmical and less symmetrical.23 Motor hyperactivity disorder is observed frequently in PDD.24,25 Mozart’s biographers often refer to his motor abnormalities: ‘Mozart was not still a moment and when he was forced to immobility he felt compelled at least to beat his heels,’26 ‘perpetually restless, drummed on all objects at hand as if he played the piano’.27 Simkin reported witnesses of Mozart’s motor hyperactivity,3 including Schlichtegroll’s Obituary – ‘His body was perpetually in motion; he liked to play incessantly with his hands or tap restlessly on the floor with his feet’ and Nissen’s Obituary – ‘Even when he was washing his hands he walked up and down in the room . . . never standing still, tapped one heel against the other . . . his hand and his feet were always in motion, he was always playing with something’. Did these AS traits cause impairment in Mozart’s functioning? Mozart’s life, burdened by setbacks, frustrations and failures in human relationships, justifies this doubt. Intellectual abilities and quaint interests of patients with AS often coexist with major deficits and the intersection of these deficits results in inability to meet the demands of everyday life and to fulfil the aspirations of vocational and social relationships.13 According to Paumgartner, Mozart never had much wisdom of life in the fullest sense of the term, and this was a source of concern for his eternally anxious father and a source of constant disappointment for himself . . . Mozart constantly found himself disarmed . . . a generous and friendly benefactor, so early mature in art, but remained eternally a child in all the contingencies of life.28
Hildesheimer emphasises Mozart’s responsibility for his own troubles: We take the liberty of charging his contemporaries the fault of his misery, as it were obvious that we would have immediately recognised his greatness and cleared away every obstacle. However, his personal contribution to his own misery remains to be established.29
In conclusion, since the remaining DSM-IV-TR criteria for AS diagnosis are met (no speech delay, no delay in cognitive development, no other specific PDD or schizophrenia), the diagnosis seems well founded. However, DSM-TR-IV criteria seem too generic and indefinite to infer a diagnosis of AS on the basis of biographical data alone. Perhaps greater support for the diagnosis comes from the presence of clinical features associated with AS, more specific and easily documented, that are not mentioned in current diagnostic criteria because of their small contribution.30
Associated features in Mozart’s life Impaired theory of mind Subjects with AS show poor ability to attribute mental states both to themselves and to others, have difficulty in perceiving and communicating their emotions and they understand and predict behaviours poorly.31 They have an impaired ‘theory of mind’.32 Mozart was enigmatic in emotional communication, so to appear aloof and strange: He spoke without posing, without enlarging the rhythm, without extravagant dynamics; he was sitting composed, barely moving his head, showing no feelings. He was not an expert of his soul nor interested in measuring it. Consequently, he never revealed it.33 . . . I tried to look for signs of emotional impulses in the autograph scores of Mozart but here, as always, writing proves that the act of writing is purely manual, a path ordered, without minimum correction. Once again, therefore: no revelation.34
Witnesses document that Mozart had difficulty to infer the mental state of interlocutors and had to rely on their explicit statements. Andreas Schachtner, trumpet player of the Salzburg Court, wrote: ‘It happened that he asked me ten times a day if I loved him, and if I sometimes, jokingly, told him no, his eyes filled with glistening tears’.35 ‘The lack of psychological penetration is most striking in the letters written by Mannheim and Paris. In them, there is evidence of how he had a misconception of his father’.36
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Motor clumsiness Asperger37 described a tendency toward uncoordinated, clumsy movements. The DSM-IV-TR and other sources38,39 mention motor clumsiness as a common feature of AS. The reported signs are absence of facial expression, poor motor coordination, lack of fluency in locomotion and odd posture. Solomon reports ‘The child disappeared, replaced by a teenager and then by an adult rather strange and clumsy’.40 Mozart’s difficulty in using his hands – seems confirmed by Nissen who wrote: ‘Except in playing the piano, he was very awkward in the use of hands, he could not cut meat and his wife had to cut the meat for him, as if he were a child’.41 Mozart’s clumsy use of his hands has been attributed to rheumatic disease from childhood. However, rheumatism seldom affects the small joints of the hands and evidence is lacking that Mozart complained of joint pain in his hands or that he was prevented in the execution of his performances from joint pain, his handwriting remained regular and elegant and his ability to play billiards never failed42 while the obvious clumsiness in the use of hands miraculously disappeared in musical performance and writing.
Specific skills Asperger37 described the growing development of isolated skills in several patients. Emerging evidence suggests these skills are typical of AS. Patients with AS often have excellent perception and prodigious memory.32 Often they learn extraordinary amounts of information about circumscribed topics. Since childhood Mozart had a prodigious ability to play and compose music. His father’s records note ‘Minuet and trio learned by Wolfgang in half an hour one day before his fifth birthday’.43 ‘The prodigious musical memory was the manifestation of an unprecedented capacity for synthesis. He could easily compose in mind most of his works and later lay them on paper so quickly, effortlessly and with absolute certainty’.44 ‘Mozart held in mind his compositions for days before writing them’.45 In a letter to Annamaria Pertl dated 14 April 1770 Leopold Mozart wrote In Rome we often hear about the famous Miserere [composed by Allegri], held in such high regard that it has been forbidden to the musicians of the chapel, under pain of excommunication, to bring out just one part, copy or give it to anyone. We already have it, however. Wolfgang has transcribed it from memory.46
Those with AS may have high reading capacity, hyperlexia and the ability to remember a book after reading it only once. Burney wrote
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Imagine a child of eight years who reads with dramatic intensity a monologue of Shakespeare never seen before. Suppose that the same child reads offhand three different comments on the monologue, one in Greek, the second in Hebrew, the third in Etruscan . . . imagining all this, you will have an idea of what the little Wolfang is capable.47
Genius Creative genius has been associated with mood disorders, psychosis, AS and alcohol/drug abuse. Mozart did not abuse substances. The coexistence of musical brilliance and low intelligence has been reported in some idiot-savants.48 Mozart did not lack intelligence. However, the discrepancy between his genius in music and his usual way of life and thought is clear. There have also been merciless judgments: ‘Except for his artistic genius for music, Mozart was a nullity’.49
Handedness Unlike autism, AS has been attributed to right hemisphere dysfunction. Paradoxically, left-handedness seems commoner among patients with AS.50–53 Helbing’s portrait of Mozart suggests left-handedness but the authenticity of this portrait has been questioned. Two other portraits of Mozart with the ring given to him by Maria Theresa do not settle the question because the ring is on his right hand in one and on his left hand in the other. ‘In Naples, it is said, he was accused of bringing a magical ring to help his exceptionally skilful left hand’.54
Humour Individuals with AS are sometimes impaired in humour appreciation although anecdotal and parental reports provide evidence to the contrary.55 Paradoxically, some subjects with AS have a developed sense of humour with special ability in punning, language games and satire. Some patients with AS are able to coin original verbal expressions and to create imaginary worlds in words and pictures.32 Patients with AS sometimes have a special sense of humour related to their verbal ability to catch assonances, to grasp the ambiguous sense of sentences, to substitute assonance for key words, strangely associated with lack of emotional participation.51,56 According to Paumgartner, Mozart had to a great extent the playfulness of spirit that is unconsciously opposed to the adversities of life. From it, he issued the inimitable humour, sometimes a little mischievous and quite vulgar, as well as saying vulgar
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Journal of Medical Biography 23(2) nonsense, combining nonsense rhymes games, upsetting words . . . childish rhymes, witty sayings of the road.57
Simkin3 cites examples of this tendency: Another Mozartean vocal peculiarity was his penchant for nonsense words and make believe, odd sounding names, and nicknames. He had nicknames for Baron von Jacquin’s musical circle: Hinkity Honky, Punkititi, Schlaba Pumfa, Royka-Pumpa, Natschibinitschibi, Sagadarata.
Physical developmental abnormalities Patients with PDD often show non-specific physical anomalies, abnormal electroencephalograms and neuroimaging, and autopsy findings58 resulting from damages in early pregnancy suggesting impaired foetal development.59 ‘He had oddly shaped ears, lacking lobes. The pavilions showed the anomaly of the so-called ‘‘hollow missing’’.60 This congenital deformity, known as Mozart Ear, is characterised by a bulging appearance of the anterosuperior portion of the auricle, a convexly protruded cavum conchae and a slit-like narrowing of the orifice of the external auditory meatus.61
Delusions Any speculation about a possible psychiatric diagnosis must consider the appearance of persecutory ideation in the last years of Mozart’s life. In an atmosphere of anxious suspicion wherein the commission of a Requiem Mass was interpreted as a threat of death, Mozart became convinced Salieri had poisoned him. Mozart’s biographers consider the theory of poisoning to be visionary. Actually many clues suggest Mozart became a victim of unfounded persecutory ideation. Elements of rivalry may have been present in the relationship between Mozart and Salieri but there were never signs of grudge or hatred. However, even if Mozart and Salieri were rivals for certain jobs, there is very little evidence that the relationship between the two composers was acrimonious. Rather, each of the two considered the other a colleague and a friend, and supported his work.62
In Mozart’s last letter of 14 October 1791 to his wife a few weeks before his death, he writes words of admiration and gratitude for Salieri. Psychopathological clues suggest the delusional nature of Mozart’s suspicion. He never provided details of the circumstances of the alleged poisoning: ‘Certainly, I have been poisoned!
I cannot get rid of this thought’.63 Mozart abruptly and unpredictably changed his mind with respect to this delusion, sometimes criticising it as absurd and at others remaining dominated by it. Mary Novello reported Mozart’s words: ‘Yes, I understand that I’m a fool to have had an idea as absurd as that of being poisoned . . . Within a few days, however, he was again plagued by the same idea’.64 Mozart, his wife and close friends maintained behaviour that should be considered illogical or inappropriate if the suspect had been based on facts and not considered anguishing creations of a deranged mind. After Mozart’s death his wife sent her younger son to take lessons from Salieri himself. Nobody tried to resolve this doubt. Nobody thought it best to report this suspicion to the Court or to discuss it with physicians to seek their views or to use appropriate remedies or antidotes. The only measures taken in this regard seem to have been the advice of his wife to turn away from those ‘bad thoughts’, the prescription of ‘leisure and rest’ by Dr Closset, and the choice of the same Mozart to continue composing music, in spite of everything. At Salieri’s funeral, his pupil Schubert directed the Requiem that Salieri had written for his own death some time before. Would Schubert have done this in case of doubt that Salieri was Mozart’s murderer? Everybody got the impression that Mozart’s suspicion was just a crazy idea. Was this idea a delusion? Delusions are common in many neuropsychiatric disorders. Nevertheless, their nature is poorly understood, their aetiology is unknown and their nosological status remains problematic.65 Furthermore, overvalued ideas, idiosyncratic views, bizarre ways of thinking, magic and esoteric convictions that are difficult to explain are often observed in psychiatric patients. The relationship between these ideas and delusions may not always be clear. AS is associated with delusional beliefs.66 Imagination and originality are frequent in patients with AS32 and some show extensive imaginary activities or are particularly able to produce creative narratives.67,68 With his sister, Mozart invented a secret language and an imaginary land named ‘the Kingdom of Back’, of which they were king and queen. ‘He became so immersed in its administration that he persuaded Sebastian Winter, the family servant, to make a map of it and dictate the names of all the cities, villages and market towns’.69 Other patients with AS present delusions of persecution or reference similar to those observed in schizophrenia and manic-depressive psychosis.66,70,71 The egocentric viewpoint, typical of AS, might elicit delusional thinking. In patients with AS the frustration of not being understood can evoke persecutory ideas, while interpreting phenomena only as relevant to self may elicit ideas of reference.56
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Thus, whatever may have been Mozart’s suspicion that he had been poisoned, imaginary activity, delusion or overvalued idea, its presence is consistent with the AS diagnosis.
Differential diagnosis Other psychiatric diagnoses have been suggested for Mozart. What is their validity?
Gilles de la Tourette Syndrome (GTS) Fog and Regeur72 raised the possibility that Mozart had GTS. Simkin3 revived this hypothesis after analysing the high incidence of scatology in Mozart’s letters where he uses scatology, echolalia and palilalia like others with GTS. Simkin also reported clustering of scatological letters related to periods of ‘strong emotion’ and ‘Motor or vocal Tourettism’. However, the issues raised by Simkin have noteworthy weaknesses. DSM-IV-TR emphasises the key difference between complex motor tics (typical of GTS) and stereotyped movements (typical of PDD): ‘Stereotyped movements appear to be more driven, rhythmic, self-stimulating or soothing, and intentional whereas tics have a more involuntary quality and generally occur in temporal bouts or clusters’. No biographer alluded to the involuntary nature of Mozart’s movements. Thus, these motor abnormalities cannot be regarded as tics. Monaco et al73 exclude GTS because tics have never been documented. There is evidence that Mozart did not have involuntary movements: He could easily compose in mind his works – and then lay them on paper so quickly, effortlessly and with absolute certainty . . . This ease of synthesis was denied to Beethoven. Beethoven had to fight to win and his notebooks were the fields of the titanic struggle. Step by step, painfully, persistently, through hundreds of versions, the idea came victorious to the unique true form. In Mozart’s case the smoothness of the line reigns supreme. Refined and safe even in handwriting, he loved to mark the division of beats with light dash lines, broken at each pentagram. Very few corrections disturb the flow of writing, fast but clear, equally clear, streamlined and well framed as the musical content.74
Could a person who was suffering from tics, obsessions or compulsions produce so smooth, flowing and regular musical calligraphy, written directly in fine print stream? Furthermore, it is implausible that involuntary vocal utterances, including those of GTS, are transferred to the written form.75 Tics, as obsessions or
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compulsions, are ego-dystonic. Patients typically are annoyed, embarrassed, humiliated and ashamed even for ‘neutral’ tics. ‘Social discomfort, shame, selfconsciousness, demoralisation and sadness frequently occur’ (DSM-IV-TR). ‘Social, academic and occupational functioning may be impaired because of rejection by others or anxiety having tics in social situations’ (DSM-IV-TR). If Mozart wrote scurrilous words, it means he was neither ashamed nor fearful that their disclosure would have derailed his career of musician. He knew so well that his communicative code was fully shared by the addressee of such letters and he could trust. Ashoori and Jankovic4 acknowledge it is uncertain ‘whether such linguistic features suggest coprographia and support the diagnosis of GTS or indicate excessive humour, arrogant behaviour of a savant or impulsive outbursts of stressful life’. However, the main problem is that even true coprographia, unlike coprolalia, does not support the diagnosis of GTS. Further, analysing the phonetic and the semantic of the written vulgarities, it is clear we are not dealing with transcriptions of vocal tics, mechanics, improvised, but puns based on phonetic and semantic similarities, shifts in meaning that aroused an obvious pleasure and enjoyment in the author. They resemble AS patients’ verbal ability to catch assonances, to grasp the ambiguous sense of sentences, to play with assonance and phonetic slips and with allusions and tangential semantic shifts. These same elements can be found in the Zoroastrian puzzles written by Mozart during the carnival of 1786. In this regard Solomon76 writes, ‘Mozart had a passion for word games of all types: neologisms, transpositions, inversions, puns, rhymes, near rhymes and so on’. As Hildesheimer notes, there is neither echolalia nor palilalia: The faecal language turns on the linguistic creativity of Mozart, his irrepressible taste for variations of a word, a theme that crosses just beyond its conceptual content, but in the course of onomatopoeic digressions still remains in this lexical category. Subsequent associations apparently work in rondo` form.77
There is no evidence that Mozart had tics. However, even postulating the presence of tics, the diagnostic hypothesis of AS would be compatible since patients with PDD present tics more frequently than expected by chance.78–81
Mood disorder The late appearance of delusions raises the possibility of a diagnosis of mood disorder. However, the description of the last weeks of Mozart’s life is inconsistent with this hypothesis. In spite of his ideas
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of persecution and poor state of health, he remained lively, active and creative to the last. He was feverishly taken by the rush to complete the Requiem. In one of his last letters82 Mozart reaffirms he can reach peace of mind only when continuing to work. ‘We must work hard and I’m happy to do it’. Even in the last days of his life there were moments of joy. ‘Early in Prague Mozart did not feel well and had to consult doctors’ wrote Niemetschek,83 ‘his complexion was pale and his face sad, though, in the company, his cheerful mood still often resolved in joyful jokes’. Three weeks before death he was euphoric for the success of his last completed work (‘Loudly proclaim our joy’).84 Davies85 suspected a cyclothymic personality disorder. Huguelet and Perroud86 claimed Mozart suffered from depressive episodes. A documented period of clinical depression is not documented and he always remained able to achieve great things. Apart from a brief period in 1790 during which production was low and poor, his work was not restricted by ailments nor did he cancel travel, concerts, commissions or compositions for poor health.87 A reliable indicator of depressive phases in an artist’s life is a decline in creativity but Mozart produced musical smooth and continuous production. Schrade88 notes If we take into account the total number of works composed by Mozart . . . and split it into groups of one hundred compositions, it is evident that every four years Mozart’s production, including quantity, is always more or less constant. An amazing regularity is evident.
A final argument in support of the diagnosis of AS is the difficulty in recognising the syndrome. Individuals with AS are often mistaken for persons with strange, odd, bizarre character. The underlying biological abnormality is often under-recognised or misdiagnosed, even by physicians. Awareness of the diagnosis is best in those interested in the area89 and so it is not surprising that neither Mozart’s contemporaries nor his biographers recognised the disorder. On the contrary, since ancient times melancholia and mania are easily recognised. The diagnosis of tics is self-evident. Indeed, the diagnosis of GTS is often made not by physicians but by patients and their relatives.90
Conclusions The limitations of the survey (limited biographical data, no direct analysis of primary sources and poor validity of current psychiatric diagnostic criteria) do not allow firm conclusions but the evidence seems to point towards AS.
Acknowledgements The author is grateful to Professor Mauro Porta for his constructive criticism.
References 1. Attwood T. Autism Asperger’s digest. November/ December 2000 edition. (www.autismdigest.com) (accessed 4 June 2013). 2. Fitzgerald M. The genesis of artistic creativity: Asperger’s syndrome and the arts. London: Jessica Kingsley Publishers, 2005. 3. Simkin B. Mozart’s scatological disorder. British Medical Journal 1992; 305: 1563–1567. 4. Ashoori A and Jankovic J. Mozart’s movements and behaviour: A case of Tourette’ syndrome? Journal of Neurology, Neurosurgery, and Psychiatry 2007; 78: 1171–1175. 5. Paumgartner B. Mozart. Zu¨rich un Freiburg im Breisgau: Atlantis Verlag, 1945, 3rd Italian Edition. Torino: Einaudi, 1978, p.18. 6. Ibid., p.19. 7. Hildesheimer W. Mozart. Frankfurt am Main: Suhrkamp Verlag, 1977, Italian Edition. Firenze: Sansoni, 1979, pp.37–38. 8. Paumgartner B. Mozart. Zu¨rich un Freiburg im Breisgau: Atlantis Verlag, 1945, 3rd Italian Edition. Torino: Einaudi, 1978, pp.23–24. 9. Ibid., p.23. 10. Hildesheimer W. Mozart. Frankfurt am Main: Suhrkamp Verlag, 1977, Italian Edition. Firenze: Sansoni, 1979, pp.265–266. 11. Ibid., pp.91–92. 12. Ibid., pp.91. 13. Ibid., pp.225–226. 14. Ibid., pp.227–228. 15. Paumgartner B. Mozart. Zu¨rich un Freiburg im Breisgau: Atlantis Verlag, 1945, 3rd Italian Edition. Torino: Einaudi, 1978, pp.26–27. 16. Hildesheimer W. Mozart. Frankfurt am Main: Suhrkamp Verlag, 1977, Italian Edition. Firenze: Sansoni, 1979, pp.107–108. 17. Raja M. Don Giovanni di Mozart. Sorrento (Napoli): Di Mauro Editore, 2011, pp.146–147. 18. Solomon M. Mozart. A life, 1995. Italian Edition. Milano: Arnoldo Mondadori Editore, 1st Oscar Edition, 1996, p.455. 19. Hildesheimer W. Mozart. Frankfurt am Main: Suhrkamp Verlag, 1977, Italian Edition. Firenze: Sansoni, 1979, p.117. 20. Ibid., p.211. 21. Ibid., p.304. 22. South M, Ozonoff S and McMahon WM. Repetitive behavior profiles in Asperger syndrome and high-functioning autism. Journal of Autism and Developmental Disorders 2005; 35: 145–158. 23. Rapin I. Autism spectrum disorders: Relevance to Tourette syndrome. Advances in Neurology 2001; 85: 89–101.
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24. Ghanizadeh A. Co-morbidity and factor analysis on attention deficit hyperactivity disorder and autism spectrum disorder DSM-IV-derived items. Journal of Research in Medical Sciences 2012; 17: 368–372. 25. Taurines R, Schwenck C, Westerwald E, et al. ADHD and autism: Differential diagnosis or overlapping traits? A selective review. Attention Deficit and Hyperactivity Disorder 2012; 4: 115–139. 26. Paumgartner B. Mozart. Zu¨rich un Freiburg im Breisgau: Atlantis Verlag, 1945, 3rd Italian Edition. Torino: Einaudi, 1978, p.19. 27. Ibid., p.18. 28. Ibid., p.22. 29. Hildesheimer W. Mozart. Frankfurt am Main: Suhrkamp Verlag, 1977, Italian Edition. Firenze: Sansoni, 1979, pp.23–24. 30. Raja M. The diagnosis of Asperger’s syndrome. Directions in Psychiatry 2006; 26: 89–103. 31. Gamliel I and Yirmiya N. Assessment of social behavior in autism spectrum disorders. In: Goldstein S, Naglieri JA and Ozonoff S (eds) Assessment of autism spectrum disorders. New York, London: The Guildford Press, 2009, pp.156–157. 32. Frith U. Emanuel Miller lecture: Confusions and controversies about Asperger syndrome. Journal of Child Psychology and Psychiatry 2004; 45: 672–686. 33. Hildesheimer W. Mozart. Frankfurt am Main: Suhrkamp Verlag, 1977, Italian Edition. Firenze: Sansoni, 1979, p.61. 34. Ibid., pp.98–99. 35. Solomon M. Mozart. A life, 1995. Italian Edition. Milano: Arnoldo Mondadori Editore, 1st Oscar Edition, 1996, p.9. 36. Hildesheimer W. Mozart. Frankfurt am Main: Suhrkamp Verlag, 1977, Italian Edition. Firenze: Sansoni, 1979, p.140. 37. Asperger H. Die ‘Autistischen Psychopathen’ im Kindesalter. Archiv fur psychiatrie und nervenkrankheiten 1944; 117: 76–136. 38. Gillberg IC and Gillberg C. Asperger syndrome – some epidemiological considerations: A research note. Journal of Child Psychology and Psychiatry 1989; 30: 631–638. 39. Green D, Baird G, Barnett AL, et al. The severity and nature of motor impairment in Asperger’s syndrome: A comparison with specific developmental disorder of motor function. Journal of Child Psychology and Psychiatry 2002; 43: 655–668. 40. Solomon M. Mozart. A life, 1995. Italian Edition. Milano: Arnoldo Mondadori Editore, 1st Oscar Edition, 1996, p.10. 41. Ibid., pp.282–283. 42. Ibid., p.283. 43. Ibid., p.41. 44. Paumgartner B. Mozart. Zu¨rich un Freiburg im Breisgau: Atlantis Verlag, 1945, 3rd Italian Edition. Torino: Einaudi, 1978, p.20. 45. Hildesheimer W. Mozart. Frankfurt am Main: Suhrkamp Verlag, 1977, Italian Edition. Firenze: Sansoni, 1979, p.229.
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46. Solomon M. Mozart. A life, 1995. Italian Edition. Milano: Arnoldo Mondadori Editore, 1st Oscar Edition, 1996, p.87. 47. Ibid., p.7. 48. Hermelin B, O’Connor N and Lee S. Musical inventiveness of five idiots-savants. Psychological Medicine 1987; 17: 685–694. 49. Ko¨hler KH and Herre G. (eds) Ludwig van Beethoven Konversations-hefte, volume 8, Lipsia, 1981, cit. in Solomon, 1995, p.85. 50. Soper HV, Satz P, Orsini DL, et al. Handedness patterns in autism suggest subtypes. Journal of Autism and Developmental Disorders 1986; 16: 155–167. 51. Raja M and Azzoni A. Asperger’s disorder in the emergency psychiatric setting. General Hospital Psychiatry 2001; 23: 285–293. 52. Dane S and Balci N. Handedness, eyedness and nasal cycle in children with autism. International Journal of Developmental Neurosciences 2007; 25: 223–226. 53. Goez H and Zelnik N. Handedness in patients with developmental coordination disorder. Journal of Child Neurology 2008; 23: 151–154. 54. Solomon M. Mozart. A life, 1995. Italian Edition. Milano: Arnoldo Mondadori Editore, 1st Oscar Edition, 1996, p.9. 55. Lyons V and Fitzgerald M. Humor in autism and Asperger syndrome. Journal of Autism and Developmental Disorders 2004; 34: 521–531. 56. Raja M and Azzoni A. Thought disorder in Asperger syndrome and schizophrenia: Issues in the differential diagnosis. A series of case reports. World Journal of Biological Psychiatry 2007; 26: 1–9. 57. Paumgartner B. Mozart. Zu¨rich un Freiburg im Breisgau: Atlantis Verlag, 1945, 3rd Italian Edition. Torino: Einaudi, 1978, p.23. 58. Coleman M and Gillberg C. The biology of the autistic syndromes. New York: Praeger, 1985. 59. Smalley SL, Asarnow RF and Spence MA. Autism and genetics. Archives of General Psychiatry 1988; 45: 953–961. 60. Paumgartner B. Mozart. Zu¨rich un Freiburg im Breisgau: Atlantis Verlag, 1945, 3rd Italian Edition. Torino: Einaudi, 1978, p.19. 61. Yamashita K, Yotsuyanagi T, Saito T, et al. Mozart ear: Diagnosis, treatment, and literature review. Annals of Plastic Surgery 2011; 67: 547–550. 62. http://it.wikipedia.org/wiki/Antonio_Salieri (accessed 4 June 2013). 63. Solomon M. Mozart. A life, 1995. Italian Edition. Milano: Arnoldo Mondadori Editore, 1st Oscar Edition, 1996, p.502. 64. Ibid., p.449. 65. Spitzer M. On defining delusions. Comprehensive Psychiatry 1990; 31: 377–397. 66. Abell F and Hare DJ. An experimental investigation of the phenomenology of delusional beliefs in people with Asperger syndrome. Autism 2005; 9: 515–531. 67. Tantam D. Asperger syndrome in adulthood. In: Frith U (ed.) Autism and Asperger syndrome. Cambridge: Cambridge University Press, 1991, pp.147–183.
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68. Craig J and Baron-Cohen S. Story-telling ability in children with autism or Asperger syndrome: A window into the imagination. Israel Journal of Psychiatry and Related Sciences 2000; 37: 64–70. 69. http://wamozartsite.tripod.com/ (accessed 4 June 2013). 70. Blackshaw AJ, Kinderman P, Hare DJ, et al. Theory of mind, causal attribution and paranoia in Asperger syndrome. Autism 2001; 5: 147–163. 71. Craig JS, Hatton C, Craig FB, et al. Persecutory beliefs, attributions and theory of mind: Comparison of patients with paranoid delusions, Asperger’s syndrome and healthy controls. Schizophrenia Research 2004; 69: 29–33. 72. Fog R and Regeur L. Did WA Mozart suffer from Tourette’s syndrome? In: World Congress of Psychiatry, Vienna, 1983. (Cited in Simkin, 1992.). 73. Monaco F, Servo S and Cavanna E. Famous people with Gilles de la Tourette syndrome? Journal of Psychosomatic Research 2009; 67: 485–490. 74. Paumgartner B. Mozart. Zu¨rich un Freiburg im Breisgau: Atlantis Verlag, 1945, 3rd Italian Edition. Torino: Einaudi, 1978, p.20. 75. Kammert T. Mozart in the neurological department – who has the tic? Frontiers of Neurology and Neuroscience 2007; 22: 184–192. 76. Solomon M. Mozart. A life, 1995. Italian Edition. Milano: Arnoldo Mondadori Editore, 1st Oscar Edition, 1996, p.321. 77. Hildesheimer W. Mozart. Frankfurt am Main: Suhrkamp Verlag, 1977, Italian Edition. Firenze: Sansoni, 1979, p.125. 78. Comings DE and Comings BG. Clinical and genetic relationships between autism, pervasive developmental
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83. 84. 85. 86.
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disorder and Tourette syndrome: A study of 19 cases. American Journal of Medical Genetics 1991; 39: 180–191. Nass R and Gutman R. Boys with Asperger’s disorder, exceptional verbal intelligence, tics, and clumsiness. Developmental Medicine and Child Neurology 1997; 39: 691–695. Ringman JM and Jankovic J. Occurrence of tics in Asperger’s syndrome and autistic disorder. Journal of Child Neurology 2000; 15: 394–400. Canitano R and Vivanti G. Tics and Tourette syndrome in autism spectrum disorders. Autism 2007; 11: 19–28. Solomon M. Mozart. A life, 1995. Italian Edition. Milano: Arnoldo Mondadori Editore, 1st Oscar Edition, 1996, p.447. Ibid., p.445. Ibid., p.449. Davies PJ. Letter to the editor. British Medical Journal 1993; 306: 521–522. Huguelet P and Perroud N. Wolfgang Amadeus Mozart’s psychopathology in light of the current conceptualization of psychiatric disorders. Psychiatry 2005; 68: 130–139. Hildesheimer W. Mozart. Frankfurt am Main: Suhrkamp Verlag, 1977, Italian Edition. Firenze: Sansoni, 1979, p.372. Shrade LWA. Mozart, Bern und Munchen, 1964, p.23. (Cited in Hildesheimer, p.194). Engstro¨m I, Ekstro¨m L and Emilsson B. Psychosocial functioning in a group of Swedish adults with Asperger syndrome or high-functioning autism. Autism 2003; 7: 99–110. Jancovic J and Kurlan R. Tourette syndrome: Evolving concepts. Movement Disorders 2011; 26: 1149–1156.
Author biography Michele Raja, neurologist and psychiatrist, worked for 30 years in Italian hospitals and has been Chief Psychiatrist in the Psychiatric Intensive Care Unit of Santo Spirito Hospital in Rome. He practises privately in Rome and teaches Psychopharmacology and Psychiatric Semeiotics at the Hospital Medical School of Rome. His areas of interest embrace mood disorders, schizophrenia and neuropsychiatric disorders including movement disorders and pervasive developmental disorders.
Leslie Turnberg was President of the Royal College of Physicians and his reflections on his many interests have been published by the College as Forks in the road; A life in and out of the NHS (ISBN 978-1-86016-527-6). The College publishes elegant paperbacks and the 175 pages in this volume cover the author’s time in Manchester, at the College and at the House of Lords, in a life in medicine, a profession described here as unique.
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Journal of Medical Biography 23(2)
Did Mozart suffer from Asperger syndrome?
Journal of Medical Biography 23(2) 84–92 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0967772013503763 jmb.sagepub.com
Michele Raja
Abstract The most reliable biographies of Mozart highlight elements that are compatible with current diagnostic criteria for Asperger syndrome including qualitative impairment in social interaction and stereotyped and repetitive motor mannerisms. Furthermore, numerous features are documented including difficulty in communicating his emotional state and in inferring the mental state of his interlocutors, motor clumsiness, specific skills and genius, left-handedness, special sense of humour, physical developmental abnormalities, bizarre thinking, overvalued ideas and delusions.
Introduction ‘Nullum magnum ingenium sine mixtura dementiae fuit’ (Seneca)
It has been suggested that Mozart suffered from Asperger syndrome1,2 (AS) while two papers3,4 have instead suggested a diagnosis of Gilles de la Tourette Syndrome (GTS). According to the Diagnostic and Statistical Manual of Mental Disorders-IV Edition-Text-Revision (DSM-IV-TR), AS is part of the group of Pervasive Developmental Disorders (PDD) and refers to people with autistic, odd and eccentric behaviour yet with well-developed language skills. Were Mozart’s behaviour, feelings and thoughts compatible with AS diagnosis, according to DSM-IV-TR? Was Mozart impaired in non-verbal behaviour – eye-to-eye gaze, facial expression, body postures and gestures – regulating social interaction? The difficulty that those with AS have in recognising their own and others’ feelings results in an emotionally inexpressive or inadequate face that appears strange, indecipherable, odd or cold. Biographers emphasised the absence of facial expression: The physical type of Mozart, lacking expressiveness, was the most suitable embodiment of a musical spirit tending inwards . . . while the face of Beethoven, reproduced by painters and sculptors, is now well imprinted in the minds of all people in a faithful version, the most diverse and bizarre opinions about the appearance of Mozart still reign.5
Some subjects with AS exhibit difficulty in establishing eye contact with others since maintaining eye contact
provokes anxiety, while others maintain fixed eye contact, as in staring at an inanimate object, which an outsider may perceive as disturbing. Paumgartner’s description of Mozart’s gaze is suggestive: ‘Almost indefinable, restless, eye position, a bit dreamy and distracted gaze, as short-sighted without glasses, that only the music lighted of a singular light’.6 Mozart’s failure to develop peer relationships appropriate to developmental level is clear. During his early years Mozart neither frequented peers nor had companions with whom to play and spend time. His father forced the child Wolfgang to spend hours and hours studying and playing music. However, such constraints would have not been successful with a child other than Wolfgang, a child inclined to interactions with peers, and with a healthy physical vitality, with characteristics that make it virtually impossible for children 3–4 years sitting and applying for hours in repetitive studies. Hildesheimer writes7 ‘The severity and harshness that characterised his early years were neither intended as such by his father nor suffered as such by himself. He was never considered to have been subject to tasks beyond his strength; more likely, he felt able immediately to deal all that was required. Mozart did not meet other children nor know any other game than the piano and the violin . . . the only known relationship with another child is that with his sister. . . one can imagine that days spent only playing music traumatised Wolfgang but we do not have
via Prisciano 26, Rome, Italy Corresponding author: Michele Raja, via Prisciano 26, Rome 00136, Italy. Email: [email protected]
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sufficient basis for this supposition; on the contrary, despite the excessive demands, he must have felt happy’. The lack of a spontaneous search to share enjoyment, interests and achievements with other people is not substantiated: ‘Yet Mozart was anything but a cantankerous misanthrope: he loved happy company, even when a little rough. The hum of cheerful and exalted voices, warm laughter, petulant jingling of glasses chased the daily worries from him’.8 Biographical data suggest lack of social and emotional reciprocity for Mozart’s shortage of affection. He never had a true friend, never had an intense affective relationship with his parents and did not suffer particularly at their death, and never showed a passionate love for his wife and children: ‘Mozart never revealed the true depth of his soul to any of his peers although this lonely heart was burning for a lifelong desire to find a true friend, worthy to be such for him’.9 According to Hildesheimer,10 Mozart did not even feel the lack of friendship: ‘One wonders whether he has ever had a friend . . . probably not, he did not know human bonds as we live them, he did not even need them’. Emotional detachment is evident in Mozart’s reactions to life events. He wrote to his father on 3 July 1778 and mentioned his mother’s illness, Voltaire’s death and the execution of the symphony ‘Pariser’, all in perfect handwriting: ‘so finished to look like an exemplary document drawn for the admiration of posterity’.11 What Mozart omitted in the letter is that his mother had died only three hours earlier: ‘In this letter we have the impression that Mozart’s upset does not exceed the limit of baroque convention and it seems the librettists of Opera intruded here’.12 On the death of his father, Mozart wrote an emotionally cold letter to his sister and ‘In this letter all the affective content is limited to the first sentence. But it also sounds artificial and forced . . . The rest of the letter is dispassionate, realistic’.13 Two days later, a bird died in a cage in Mozart’s study. He dedicated an elegy to the bird . . . We cannot not think about an object more worthy of our tears. But we will not infer differences in Mozart’s relationship with these two unequal victims of death – the father and the bird.14
On a sentimental level the lack of passionate involvement toward women is impressive: Two women constituted the cornerstones of his love life: the slim, attractive, very musical Aloysia Weber . . . and the lovely cousin, the intimate companion of his deplorable amusements. The Mozart marriage
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seems to have been happy. . . . If he sometimes came out of the binary of marriage, his wife turned a blind eye, ‘‘as long as they are maids’’ she said . . . The woman was for Mozart a source of careless joy, free of feeling, and he was able to open his intuitive genius not to a single biased ideal but to the entire range of games, passion and tenderness of the sparkling demon. This is why he was also able to render love in art with so much variety and warmth of life.15 In the field of human relations Mozart remained perpetually a fool, a stranger. This also explains his relationship with his wife of whom we have not heard of reciprocal feelings.16
Mozart’s solitude at the end of his life provides evidence of his difficult human relationships: In front of St Stephen’s Cathedral, it plays a funeral of economic class. Mozart’s body, just blessed, is enclosed in a coffin and hoisted on to a cart to be taken to the cemetery. There are few friends. His wife Constanze, overwhelmed by one of her sicknesses, no. For a while, the few persons present follow the coffin which starts slowly but none reached St Marcus’ Cemetery where Count van Swieten prepared the burial in a mass grave. Constanze went to the cemetery much later and found a series of unnamed mounds and a new gravedigger who was unable to give any indication. The tomb was never again found.17 The lack of a tombstone, the indeterminacy of the place of burial, the anonymity of interment confirm the suspicion that Mozart was neglected or mistreated . . . Constanze had reason to be angry with a husband and a father who had abandoned his family forever.18
Lack of social and emotional reciprocity was evident in Mozart’s artistic performances: ‘A cold detachment always benefited Mozart who knew the secret for success in creating lyric operas: emotions, provided not his own’.19 ‘On what really overtook him, he almost never wasted a word with strangers’.20 Musicians provide creative force in their performances by empathising with the audience. Hildesheimer assumed that Mozart instead reached the height of his talent in playing music when he could detach from everything and everyone: These must have been the times when he was delighting in blissful forgetfulness of self, in which he broke all contact with the outside world; then, he was the most direct Mozart . . . Here, and perhaps only here, he arrived at the true enjoyment of his genius, here he ‘performed’ it to the depths, here he became the absolute Mozart.21
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Can the vast body of musical works created by Mozart and the biographical news testifying that he fully dedicated his life to music be labelled as ‘Restricted repetitive and stereotyped patterns of behaviour, interests, and activities’? Of course, while a deaf behavioural scientist could consider Mozart’s encompassing preoccupation with one restricted pattern of interest (the music!) ‘abnormal either in intensity or focus’, his artistic production cannot be considered repetitive or stereotyped. There is neither evidence of inflexible adherence to specific, non-functional routines or rituals, nor persistent preoccupation with parts of objects. However, Mozart’s restlessness can be considered a form of stereotyped and repetitive motor mannerisms. Subjects with AS often manifest stereotyped and repetitive motor behaviours.22 These are repeated in more clicks and appear more voluntary and closer to rituals than to nervous tics, usually faster, less rhythmical and less symmetrical.23 Motor hyperactivity disorder is observed frequently in PDD.24,25 Mozart’s biographers often refer to his motor abnormalities: ‘Mozart was not still a moment and when he was forced to immobility he felt compelled at least to beat his heels,’26 ‘perpetually restless, drummed on all objects at hand as if he played the piano’.27 Simkin reported witnesses of Mozart’s motor hyperactivity,3 including Schlichtegroll’s Obituary – ‘His body was perpetually in motion; he liked to play incessantly with his hands or tap restlessly on the floor with his feet’ and Nissen’s Obituary – ‘Even when he was washing his hands he walked up and down in the room . . . never standing still, tapped one heel against the other . . . his hand and his feet were always in motion, he was always playing with something’. Did these AS traits cause impairment in Mozart’s functioning? Mozart’s life, burdened by setbacks, frustrations and failures in human relationships, justifies this doubt. Intellectual abilities and quaint interests of patients with AS often coexist with major deficits and the intersection of these deficits results in inability to meet the demands of everyday life and to fulfil the aspirations of vocational and social relationships.13 According to Paumgartner, Mozart never had much wisdom of life in the fullest sense of the term, and this was a source of concern for his eternally anxious father and a source of constant disappointment for himself . . . Mozart constantly found himself disarmed . . . a generous and friendly benefactor, so early mature in art, but remained eternally a child in all the contingencies of life.28
Hildesheimer emphasises Mozart’s responsibility for his own troubles: We take the liberty of charging his contemporaries the fault of his misery, as it were obvious that we would have immediately recognised his greatness and cleared away every obstacle. However, his personal contribution to his own misery remains to be established.29
In conclusion, since the remaining DSM-IV-TR criteria for AS diagnosis are met (no speech delay, no delay in cognitive development, no other specific PDD or schizophrenia), the diagnosis seems well founded. However, DSM-TR-IV criteria seem too generic and indefinite to infer a diagnosis of AS on the basis of biographical data alone. Perhaps greater support for the diagnosis comes from the presence of clinical features associated with AS, more specific and easily documented, that are not mentioned in current diagnostic criteria because of their small contribution.30
Associated features in Mozart’s life Impaired theory of mind Subjects with AS show poor ability to attribute mental states both to themselves and to others, have difficulty in perceiving and communicating their emotions and they understand and predict behaviours poorly.31 They have an impaired ‘theory of mind’.32 Mozart was enigmatic in emotional communication, so to appear aloof and strange: He spoke without posing, without enlarging the rhythm, without extravagant dynamics; he was sitting composed, barely moving his head, showing no feelings. He was not an expert of his soul nor interested in measuring it. Consequently, he never revealed it.33 . . . I tried to look for signs of emotional impulses in the autograph scores of Mozart but here, as always, writing proves that the act of writing is purely manual, a path ordered, without minimum correction. Once again, therefore: no revelation.34
Witnesses document that Mozart had difficulty to infer the mental state of interlocutors and had to rely on their explicit statements. Andreas Schachtner, trumpet player of the Salzburg Court, wrote: ‘It happened that he asked me ten times a day if I loved him, and if I sometimes, jokingly, told him no, his eyes filled with glistening tears’.35 ‘The lack of psychological penetration is most striking in the letters written by Mannheim and Paris. In them, there is evidence of how he had a misconception of his father’.36
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Motor clumsiness Asperger37 described a tendency toward uncoordinated, clumsy movements. The DSM-IV-TR and other sources38,39 mention motor clumsiness as a common feature of AS. The reported signs are absence of facial expression, poor motor coordination, lack of fluency in locomotion and odd posture. Solomon reports ‘The child disappeared, replaced by a teenager and then by an adult rather strange and clumsy’.40 Mozart’s difficulty in using his hands – seems confirmed by Nissen who wrote: ‘Except in playing the piano, he was very awkward in the use of hands, he could not cut meat and his wife had to cut the meat for him, as if he were a child’.41 Mozart’s clumsy use of his hands has been attributed to rheumatic disease from childhood. However, rheumatism seldom affects the small joints of the hands and evidence is lacking that Mozart complained of joint pain in his hands or that he was prevented in the execution of his performances from joint pain, his handwriting remained regular and elegant and his ability to play billiards never failed42 while the obvious clumsiness in the use of hands miraculously disappeared in musical performance and writing.
Specific skills Asperger37 described the growing development of isolated skills in several patients. Emerging evidence suggests these skills are typical of AS. Patients with AS often have excellent perception and prodigious memory.32 Often they learn extraordinary amounts of information about circumscribed topics. Since childhood Mozart had a prodigious ability to play and compose music. His father’s records note ‘Minuet and trio learned by Wolfgang in half an hour one day before his fifth birthday’.43 ‘The prodigious musical memory was the manifestation of an unprecedented capacity for synthesis. He could easily compose in mind most of his works and later lay them on paper so quickly, effortlessly and with absolute certainty’.44 ‘Mozart held in mind his compositions for days before writing them’.45 In a letter to Annamaria Pertl dated 14 April 1770 Leopold Mozart wrote In Rome we often hear about the famous Miserere [composed by Allegri], held in such high regard that it has been forbidden to the musicians of the chapel, under pain of excommunication, to bring out just one part, copy or give it to anyone. We already have it, however. Wolfgang has transcribed it from memory.46
Those with AS may have high reading capacity, hyperlexia and the ability to remember a book after reading it only once. Burney wrote
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Imagine a child of eight years who reads with dramatic intensity a monologue of Shakespeare never seen before. Suppose that the same child reads offhand three different comments on the monologue, one in Greek, the second in Hebrew, the third in Etruscan . . . imagining all this, you will have an idea of what the little Wolfang is capable.47
Genius Creative genius has been associated with mood disorders, psychosis, AS and alcohol/drug abuse. Mozart did not abuse substances. The coexistence of musical brilliance and low intelligence has been reported in some idiot-savants.48 Mozart did not lack intelligence. However, the discrepancy between his genius in music and his usual way of life and thought is clear. There have also been merciless judgments: ‘Except for his artistic genius for music, Mozart was a nullity’.49
Handedness Unlike autism, AS has been attributed to right hemisphere dysfunction. Paradoxically, left-handedness seems commoner among patients with AS.50–53 Helbing’s portrait of Mozart suggests left-handedness but the authenticity of this portrait has been questioned. Two other portraits of Mozart with the ring given to him by Maria Theresa do not settle the question because the ring is on his right hand in one and on his left hand in the other. ‘In Naples, it is said, he was accused of bringing a magical ring to help his exceptionally skilful left hand’.54
Humour Individuals with AS are sometimes impaired in humour appreciation although anecdotal and parental reports provide evidence to the contrary.55 Paradoxically, some subjects with AS have a developed sense of humour with special ability in punning, language games and satire. Some patients with AS are able to coin original verbal expressions and to create imaginary worlds in words and pictures.32 Patients with AS sometimes have a special sense of humour related to their verbal ability to catch assonances, to grasp the ambiguous sense of sentences, to substitute assonance for key words, strangely associated with lack of emotional participation.51,56 According to Paumgartner, Mozart had to a great extent the playfulness of spirit that is unconsciously opposed to the adversities of life. From it, he issued the inimitable humour, sometimes a little mischievous and quite vulgar, as well as saying vulgar
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Journal of Medical Biography 23(2) nonsense, combining nonsense rhymes games, upsetting words . . . childish rhymes, witty sayings of the road.57
Simkin3 cites examples of this tendency: Another Mozartean vocal peculiarity was his penchant for nonsense words and make believe, odd sounding names, and nicknames. He had nicknames for Baron von Jacquin’s musical circle: Hinkity Honky, Punkititi, Schlaba Pumfa, Royka-Pumpa, Natschibinitschibi, Sagadarata.
Physical developmental abnormalities Patients with PDD often show non-specific physical anomalies, abnormal electroencephalograms and neuroimaging, and autopsy findings58 resulting from damages in early pregnancy suggesting impaired foetal development.59 ‘He had oddly shaped ears, lacking lobes. The pavilions showed the anomaly of the so-called ‘‘hollow missing’’.60 This congenital deformity, known as Mozart Ear, is characterised by a bulging appearance of the anterosuperior portion of the auricle, a convexly protruded cavum conchae and a slit-like narrowing of the orifice of the external auditory meatus.61
Delusions Any speculation about a possible psychiatric diagnosis must consider the appearance of persecutory ideation in the last years of Mozart’s life. In an atmosphere of anxious suspicion wherein the commission of a Requiem Mass was interpreted as a threat of death, Mozart became convinced Salieri had poisoned him. Mozart’s biographers consider the theory of poisoning to be visionary. Actually many clues suggest Mozart became a victim of unfounded persecutory ideation. Elements of rivalry may have been present in the relationship between Mozart and Salieri but there were never signs of grudge or hatred. However, even if Mozart and Salieri were rivals for certain jobs, there is very little evidence that the relationship between the two composers was acrimonious. Rather, each of the two considered the other a colleague and a friend, and supported his work.62
In Mozart’s last letter of 14 October 1791 to his wife a few weeks before his death, he writes words of admiration and gratitude for Salieri. Psychopathological clues suggest the delusional nature of Mozart’s suspicion. He never provided details of the circumstances of the alleged poisoning: ‘Certainly, I have been poisoned!
I cannot get rid of this thought’.63 Mozart abruptly and unpredictably changed his mind with respect to this delusion, sometimes criticising it as absurd and at others remaining dominated by it. Mary Novello reported Mozart’s words: ‘Yes, I understand that I’m a fool to have had an idea as absurd as that of being poisoned . . . Within a few days, however, he was again plagued by the same idea’.64 Mozart, his wife and close friends maintained behaviour that should be considered illogical or inappropriate if the suspect had been based on facts and not considered anguishing creations of a deranged mind. After Mozart’s death his wife sent her younger son to take lessons from Salieri himself. Nobody tried to resolve this doubt. Nobody thought it best to report this suspicion to the Court or to discuss it with physicians to seek their views or to use appropriate remedies or antidotes. The only measures taken in this regard seem to have been the advice of his wife to turn away from those ‘bad thoughts’, the prescription of ‘leisure and rest’ by Dr Closset, and the choice of the same Mozart to continue composing music, in spite of everything. At Salieri’s funeral, his pupil Schubert directed the Requiem that Salieri had written for his own death some time before. Would Schubert have done this in case of doubt that Salieri was Mozart’s murderer? Everybody got the impression that Mozart’s suspicion was just a crazy idea. Was this idea a delusion? Delusions are common in many neuropsychiatric disorders. Nevertheless, their nature is poorly understood, their aetiology is unknown and their nosological status remains problematic.65 Furthermore, overvalued ideas, idiosyncratic views, bizarre ways of thinking, magic and esoteric convictions that are difficult to explain are often observed in psychiatric patients. The relationship between these ideas and delusions may not always be clear. AS is associated with delusional beliefs.66 Imagination and originality are frequent in patients with AS32 and some show extensive imaginary activities or are particularly able to produce creative narratives.67,68 With his sister, Mozart invented a secret language and an imaginary land named ‘the Kingdom of Back’, of which they were king and queen. ‘He became so immersed in its administration that he persuaded Sebastian Winter, the family servant, to make a map of it and dictate the names of all the cities, villages and market towns’.69 Other patients with AS present delusions of persecution or reference similar to those observed in schizophrenia and manic-depressive psychosis.66,70,71 The egocentric viewpoint, typical of AS, might elicit delusional thinking. In patients with AS the frustration of not being understood can evoke persecutory ideas, while interpreting phenomena only as relevant to self may elicit ideas of reference.56
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Thus, whatever may have been Mozart’s suspicion that he had been poisoned, imaginary activity, delusion or overvalued idea, its presence is consistent with the AS diagnosis.
Differential diagnosis Other psychiatric diagnoses have been suggested for Mozart. What is their validity?
Gilles de la Tourette Syndrome (GTS) Fog and Regeur72 raised the possibility that Mozart had GTS. Simkin3 revived this hypothesis after analysing the high incidence of scatology in Mozart’s letters where he uses scatology, echolalia and palilalia like others with GTS. Simkin also reported clustering of scatological letters related to periods of ‘strong emotion’ and ‘Motor or vocal Tourettism’. However, the issues raised by Simkin have noteworthy weaknesses. DSM-IV-TR emphasises the key difference between complex motor tics (typical of GTS) and stereotyped movements (typical of PDD): ‘Stereotyped movements appear to be more driven, rhythmic, self-stimulating or soothing, and intentional whereas tics have a more involuntary quality and generally occur in temporal bouts or clusters’. No biographer alluded to the involuntary nature of Mozart’s movements. Thus, these motor abnormalities cannot be regarded as tics. Monaco et al73 exclude GTS because tics have never been documented. There is evidence that Mozart did not have involuntary movements: He could easily compose in mind his works – and then lay them on paper so quickly, effortlessly and with absolute certainty . . . This ease of synthesis was denied to Beethoven. Beethoven had to fight to win and his notebooks were the fields of the titanic struggle. Step by step, painfully, persistently, through hundreds of versions, the idea came victorious to the unique true form. In Mozart’s case the smoothness of the line reigns supreme. Refined and safe even in handwriting, he loved to mark the division of beats with light dash lines, broken at each pentagram. Very few corrections disturb the flow of writing, fast but clear, equally clear, streamlined and well framed as the musical content.74
Could a person who was suffering from tics, obsessions or compulsions produce so smooth, flowing and regular musical calligraphy, written directly in fine print stream? Furthermore, it is implausible that involuntary vocal utterances, including those of GTS, are transferred to the written form.75 Tics, as obsessions or
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compulsions, are ego-dystonic. Patients typically are annoyed, embarrassed, humiliated and ashamed even for ‘neutral’ tics. ‘Social discomfort, shame, selfconsciousness, demoralisation and sadness frequently occur’ (DSM-IV-TR). ‘Social, academic and occupational functioning may be impaired because of rejection by others or anxiety having tics in social situations’ (DSM-IV-TR). If Mozart wrote scurrilous words, it means he was neither ashamed nor fearful that their disclosure would have derailed his career of musician. He knew so well that his communicative code was fully shared by the addressee of such letters and he could trust. Ashoori and Jankovic4 acknowledge it is uncertain ‘whether such linguistic features suggest coprographia and support the diagnosis of GTS or indicate excessive humour, arrogant behaviour of a savant or impulsive outbursts of stressful life’. However, the main problem is that even true coprographia, unlike coprolalia, does not support the diagnosis of GTS. Further, analysing the phonetic and the semantic of the written vulgarities, it is clear we are not dealing with transcriptions of vocal tics, mechanics, improvised, but puns based on phonetic and semantic similarities, shifts in meaning that aroused an obvious pleasure and enjoyment in the author. They resemble AS patients’ verbal ability to catch assonances, to grasp the ambiguous sense of sentences, to play with assonance and phonetic slips and with allusions and tangential semantic shifts. These same elements can be found in the Zoroastrian puzzles written by Mozart during the carnival of 1786. In this regard Solomon76 writes, ‘Mozart had a passion for word games of all types: neologisms, transpositions, inversions, puns, rhymes, near rhymes and so on’. As Hildesheimer notes, there is neither echolalia nor palilalia: The faecal language turns on the linguistic creativity of Mozart, his irrepressible taste for variations of a word, a theme that crosses just beyond its conceptual content, but in the course of onomatopoeic digressions still remains in this lexical category. Subsequent associations apparently work in rondo` form.77
There is no evidence that Mozart had tics. However, even postulating the presence of tics, the diagnostic hypothesis of AS would be compatible since patients with PDD present tics more frequently than expected by chance.78–81
Mood disorder The late appearance of delusions raises the possibility of a diagnosis of mood disorder. However, the description of the last weeks of Mozart’s life is inconsistent with this hypothesis. In spite of his ideas
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of persecution and poor state of health, he remained lively, active and creative to the last. He was feverishly taken by the rush to complete the Requiem. In one of his last letters82 Mozart reaffirms he can reach peace of mind only when continuing to work. ‘We must work hard and I’m happy to do it’. Even in the last days of his life there were moments of joy. ‘Early in Prague Mozart did not feel well and had to consult doctors’ wrote Niemetschek,83 ‘his complexion was pale and his face sad, though, in the company, his cheerful mood still often resolved in joyful jokes’. Three weeks before death he was euphoric for the success of his last completed work (‘Loudly proclaim our joy’).84 Davies85 suspected a cyclothymic personality disorder. Huguelet and Perroud86 claimed Mozart suffered from depressive episodes. A documented period of clinical depression is not documented and he always remained able to achieve great things. Apart from a brief period in 1790 during which production was low and poor, his work was not restricted by ailments nor did he cancel travel, concerts, commissions or compositions for poor health.87 A reliable indicator of depressive phases in an artist’s life is a decline in creativity but Mozart produced musical smooth and continuous production. Schrade88 notes If we take into account the total number of works composed by Mozart . . . and split it into groups of one hundred compositions, it is evident that every four years Mozart’s production, including quantity, is always more or less constant. An amazing regularity is evident.
A final argument in support of the diagnosis of AS is the difficulty in recognising the syndrome. Individuals with AS are often mistaken for persons with strange, odd, bizarre character. The underlying biological abnormality is often under-recognised or misdiagnosed, even by physicians. Awareness of the diagnosis is best in those interested in the area89 and so it is not surprising that neither Mozart’s contemporaries nor his biographers recognised the disorder. On the contrary, since ancient times melancholia and mania are easily recognised. The diagnosis of tics is self-evident. Indeed, the diagnosis of GTS is often made not by physicians but by patients and their relatives.90
Conclusions The limitations of the survey (limited biographical data, no direct analysis of primary sources and poor validity of current psychiatric diagnostic criteria) do not allow firm conclusions but the evidence seems to point towards AS.
Acknowledgements The author is grateful to Professor Mauro Porta for his constructive criticism.
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Author biography Michele Raja, neurologist and psychiatrist, worked for 30 years in Italian hospitals and has been Chief Psychiatrist in the Psychiatric Intensive Care Unit of Santo Spirito Hospital in Rome. He practises privately in Rome and teaches Psychopharmacology and Psychiatric Semeiotics at the Hospital Medical School of Rome. His areas of interest embrace mood disorders, schizophrenia and neuropsychiatric disorders including movement disorders and pervasive developmental disorders.
Leslie Turnberg was President of the Royal College of Physicians and his reflections on his many interests have been published by the College as Forks in the road; A life in and out of the NHS (ISBN 978-1-86016-527-6). The College publishes elegant paperbacks and the 175 pages in this volume cover the author’s time in Manchester, at the College and at the House of Lords, in a life in medicine, a profession described here as unique.
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