As Stefanie told you last week, Napoleon likely died from stomach cancer, the same disease that took his father’s life. But despite an abundance of evidence from the autopsy, skeptics have retained their doubts over the centuries. Just last year, on the 200th anniversary of Napoleon’s death, a group of pathologists published a paper trying to quell suspicions that there was foul play involved in his passing; foul play that could have explained his mental illness.
More on the alternative hypothesis for his odd behavior in a moment. First, why is there so much confusion over the cause of death when the autopsy report described ulcers, tumors, and “ground coffee-like” substances in Napoleon’s gut? It’s probably because there’s not just one autopsy report; there are three. The autopsy was conducted by Dr. Francesco Antommarchi, a fellow Corsican who was in charge of Napoleon’s medical care while he was in exile. But it seems Antommarchi’s expertise lay more in anatomy than patient care, and after some blunders, Napoleon lost trust in him completely and refused to be seen by him. Even so, Antommarchi led the autopsy in a room with 16 other people. He published the original report in 1821. Another doctor who observed the autopsy took his own notes that were circulated after he sent them to a friend in 1823. And then Antommarchi confused everyone by publishing an account of the autopsy that conflicted his 1821 report in his memoir in 1825. And these are just the reports that have some credibility. In 2001, the Foundation Napoleon reported that there was extensive evidence that Napoleon had died of tuberculosis that had gone undiagnosed by Antommarchi, but I struggled to find other sources to confirm this (most of the primary sources are in French).
And then there was a 1962 article in Nature that found high levels of arsenic in a sample of Napoleon’s hair and concluded he had been killed by chronic arsenic poisoning. Although arsenic poisoning doesn’t tend to cause behavioral changes, it can have widespread effects on neurotransmission, causing changes in memory and cognition. Translation: it could have affected Napoleon’s brain. We at ULTC like a good poisoning plot as much as the next gal, but a 1982 paper also published in Nature showed using a separate hair sample with more modern techniques did not reveal any evidence of elevated arsenic.
As an aside, you might be wondering why there were multiple hair samples of Napoleon’s floating around over 100 years after his death. It turns out that Antommarchi harvested his organs and other “relics” during the autopsy – including his penis. According to one of Napoleon’s valets, Antommarchi cut it off and it was eventually given to an Italian priest. In 1927, it showed up at an art museum in New York and was then bought by a famous urologist (I can’t even begin) in 1977. Testing has shown it is in fact a penis but it’s unclear if it’s Napoleon’s. What is clear is that Antommarchi was a little whacky (I’m beginning to wonder if these royals ever had a doctor who was competent and above board.) Together with the discrepancies between autopsies and more modern evidence contradicting the poisoning theory, I think it’s safe to say that alternative medical explanations for Napoleon’s behavior are red herrings.
I know you’re dying to find out the diagnosis, but before I get to the neuroscience, let’s take a detour to the field of psychoanalysis. Stefanie mentioned last week that Napoleon’s self-important airs gave rise to the idea of a Napoleon complex, a pattern of aggressive and superior behavior meant to overcompensate for physical or social limitations (usually height). “Complex” is a term popularized by psychologists like Jung and Freud, and the American Psychological Association (APA) describes it as, “a group or system of related ideas or impulses that have a common emotional tone and exert a strong but usually unconscious influence on the individual’s attitudes and behavior”. In Napoleon’s case, psychoanalysts theorize that his obsession with control and power stemmed from his insecurities surrounding his modest upbringing and fears that he was impotent (or his short stature, despite the fact that he was actually around normal height).
Having a complex does not necessarily mean that you have a mental illness. But it does illustrate something important about this week’s subject. In the past, we have discussed concepts like mood, cognition, and perception; well-defined aspects of a person’s inner life. But in the case of Napoleon, the theory is not that he suffered from a deregulated mood or garbled thought process. The idea is that Napoleon’s entire personality was pathological.
One Size Fits None
Personality is an ambiguous concept. If you think back to our discussion on the brain versus the mind, personality belongs solidly in the latter category. You can’t see personality on an MRI or point to it on a model of a brain. There is not one area or neurological process that gives rise to it. According to the APA, personality includes, “individual differences in characteristic patterns of thinking, feeling and behaving”. In other words, personality is what makes you you. And the unique nature of personality makes personality disorders particularly difficult to identify. There are some things we know are not normal, like hearing voices that aren’t there. But there is no one “normal” for personality.
Forgive the extended quotation, but this excerpt from a review by Tryer et al sums this dilemma up beautifully:
The term personality disorder has often been used in a pejorative sense as a diagnosis of exclusion; a label applied to people who were regarded as difficult to help and probably untreatable. Attention to personality disorder in practice has therefore oscillated between attempts to dismiss it altogether as a non-diagnosis, or instead, to regard it as a specialist subject in psychiatry that could be parked outside the scope of mental illnesses that general and other medical practitioners would be expected to identify and treat. Part of the difficulty is that nobody doubts the existence of personality, but what constitutes its disordered form is difficult to specify. Moreover for several reasons, the diagnosis has developed an even more grossly pejorative reputation in the eyes of the public and the profession; it has now become more a term of abuse than a diagnosis.
But personality disorders do exist and are diagnosed: it’s estimated that 9% of adults in the US have been diagnosed with a personality disorder. The diagnostic criteria relies heavily on evidence that an individual’s patterns of thinking and behavior impair their ability to succeed in their environment, which patients themselves are often unaware of. Across iterations of the DSM, personality disorder is described as abnormal patterns beginning in adolescence and persisting, that impair a person’s ability to make or maintain relationships. Personality disorders are often comorbid with other mental illnesses, especially other personality disorders: there are 10 different kinds of personality disorders that the DSM groups into three “clusters” A, B, and C. (The DSM-V proposed a new method of classification and diagnosis but this has not yet been put into practice). According to Very Well Mind, “Cluster A is defined as odd or eccentric behavior which has been estimated to affect 7.2% of adults in Western nations; cluster C personality disorders consist of fearful and anxious behaviors, affecting 6.7% of adults; cluster B personality disorders are characterized by dramatic, overly emotional, or unpredictable thinking or behaviors and reportedly affect 5.5% of adults.” Cluster A includes things like paranoid and schizotypal personality disorders; cluster B includes narcissistic, borderline, and antisocial personality disorders; and cluster C includes avoidant and dependent personality disorders. Any guesses as to which one Napoleon is speculated to have suffered from?
You’re So Vain, You Probably Think this Blog is About You
That’s right, Napoleon is often held up as an example of narcissistic personality disorder (NPD). Again, I want to reiterate Tyrer’s point that personality disorders are associated with stigma and these labels can be weaponized. Clinical narcissism is not the same as being self-absorbed or egotistical. People with NPD, as all people with personality disorders, have pathological patterns of behavior that impair their relationships. Specifically, NPD is characterized by an inflated sense of self. NPD patterns support this favorable self-perception: patients seek attention, exaggerate their success and status, have unrealistic expectations for what they should receive in relationships, are hypersensitive to criticism, fixate on their achievements, believe others are jealous of them, and are jealous of anyone they view as a competitor. People with NPD also find it difficult to empathize with other people and often manipulate others.
With that description in mind, I think it makes sense that medical historians and armchair psychologists have posthumously diagnosed Napoleon with NPD. Stefanie told us how he set up shop in the king’s old palace and fashioned himself as royalty despite having only the title of Consul. He was overly confident in his military prowess, sending 500,000 men into Russia to have most of them die. The French writer Madame de Staël noted that he lacked the ability to relate to people and mostly used them for personal gain. And even when Napoleon was exiled to the small island of Elba, he acted as if he were still emperor of the European continent and talked about his 18 marines and small boats as if they were an imposing military. All of these are consistent with the hallmarks of NPD: exaggerated sense of self and primacy of self over others.
Unfortunately, because personality does not have strong neural correlates, neuroscientific studies of NPD are lacking. More clinical research has been done on psychopathy, known clinically as antisocial personality disorder (APD). APD is also a cluster B personality disorder, and like NPD, a central feature is lack of empathy. APD is a bit more extreme, in that patients do not feel remorse and are incapable of forming genuine relationships – NPD patients can do both, it’s just harder for them than the average person. The classic hypothesis about the neural basis of APD was that these individuals do not experience fear. This was supported by research that found the amygdala, a key brain region involved in the fear response, showed decreased activation in response to stimuli that normally elicit fear. However, other studies have shown that APD patients actually have increased amygdala activity to certain kinds of emotionally salient stimuli, making this hypothesis unlikely.
The existing literature on NPD patients suggests that a number of cognitive processes, like emotional regulation, are affected. I will focus on just two examples here. First, NPD patients may have altered decision making processes that are directed toward protecting their self esteem. One study found that college students who reported signs of narcissism on a survey had reduced activity compared to their peers in a variety of brain regions when they were given positive feedback. One of these regions is the ventromedial prefrontal cortex, which is involved in decision making. The researchers hypothesized that because these students did not have as strong of a response to compliments, they continue to seek affirmation, attention, and success. Essentially, their brains are not recognizing positive feedback and integrating it into their decision making. In addition, people with NPD have been shown to prefer immediate rewards over larger rewards in the long-term, suggesting a fixation on reward that alters their decision making processes.
Lastly, there is strong evidence that a region of the brain called the insula may be involved in NPD. The insula is a mysterious part of the brain, hidden between the temporal and parietal lobes – to see it on a human brain, you have to physically pull those lobes apart. The insula is involved with a number of different processes such as sensorimotor processing, speech, and attention. Interestingly, it is also linked to decision-making and empathy. People with damaged insulas show impaired decision making in gambling tasks, and patients who had part of their insula removed in surgery showed indifference to the value of potential losses when gambling. The anterior insula activates when people observe others in pain and in interpreting facial expressions of fear, happiness, and disgust. In one study, people who had part of their insula removed as a treatment for epilepsy had difficulty interpreting facial expressions. Not only are these the cognitive domains that are impaired in NPD, but studies of NPD patients have observed decreased insular activation. In addition, a study published last year found that people who had higher scores on an index measuring narcissism had increased volume in several brain regions including the insula.
Me, An Empath, Sensing You’re a Narcissist
Now that Napoleon has given us a lens into the complicated world of personality disorders, I hope you have a fresh perspective on what that diagnosis means. It’s easy to hear “narcissist” and assume someone is just a big jerk, but pathological narcissism is more nuanced. The neuroscientific evidence is still emerging, but it’s clear that the brains of people with NPD don’t work the same. Their need for attention, obsession with success, and overzealous protection of their self esteem have biological roots. Luckily, most people suffering from NPD don’t try to take over entire continents, but they too can hurt others and themselves in their attempt to elevate their status. NPD patients struggle with empathy, but that doesn’t mean that they aren’t worthy of others extending empathy to them.
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