- Email: [email protected]
For Franz Kafka, insomnia was a literary method
Correspondence
of bleeding without underlying vessel disease (eg, deep perforating vasculopathy or cerebral amyloid angiopathy, which are rare in young patients). In neurology settings, the interaction between underlying vessel diseases and the bleeding itself might add to the complexity of the clinical manifestations. Charidimou and colleagues underline one of the key findings of the Prognosis of Intracerebral Haemorrhage (PITCH) study: cortical superficial siderosis was, in our study, the strongest risk factor for new-onset dementia, especially in patients with lobar intracerebral haemorrhage. Future research should identify the nature of this association. Charidimou and colleagues hypothesise that the risk of dementia in patients with cortical superficial siderosis might be triggered by a higher rate of recurrent bleedings. This is an interesting suggestion that we were not able to explore in our study, as the occurrence of a new stroke (including recurrent intracerebral haemorrhage) and cortical superficial siderosis were studied in two distinct multivariable models. However, the PITCH cohort is still being followed up and we intend to study this hypothesis further. Beyond the discussion of the underlying mechanisms linking cortical superficial siderosis and other MRI biomarkers with recurrent haemorrhage, these biomarkers should now be studied with the aim to prevent new events—not only recurrent intracerebral haemorrhage but also cognitive decline, as these two complications are strongly predictive of poor outcomes in patients with intracerebral haemorrhages. CC was an investigator in the clinical trial A9951024 for Pfizer, fees were paid to ADRINORD or Lille University Hospital research account (no personal funding). DL was an investigator in clinical trials for Bristol-Myers Squibb, Nestlé, Pfizer, Pierre Fabre, AstraZeneca, and Boehringer Ingelheim. His fees
were paid to ADRINORD or Lille University Hospital research account (no personal funding). SM and SB declare no competing interests.
Solene Moulin, Didier Leys, Stéphanie Bombois, *Charlotte Cordonnier [email protected] Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Lille, France (SM, SB, DL, CC) 1
Moulin S, Labreuche J, Bombois S et al. Dementia risk after spontaneous intracerebral haemorrhage: a prospective cohort study. Lancet Neurol 2016; 15: 820–29.
For Franz Kafka, insomnia was a literary method We read with great interest the Focal Point by Antonio Perciaccante and Alessia Coralli1 about Franz Kafka’s insomnia and parasomnias. For all his writing life, Kafka had insomnia and the hypnagogic hallucinations arising from his lack of sleep shaped much of his writing. However, to conclude, as the authors do, that “The Metamorphosis” can be read as a metaphor for ill effects of insomnia would be incorrect. “I believe this sleeplessness comes only because I write”, Kafka noted in one of his diary entries in 1910.2 In 1922, to Max Brod, he writes: “Perhaps there are other forms of writing, but I know only this kind; at night, when fear keeps me from sleeping, I know only this kind.”3 As Aaron Mishara notes, for Kafka, writing is a trance-like Dionysian activity at night, opening the endless inner darkness of self as an abyss without an end.4 Kafka, writing about one of his sleepless nights, mentions a great fire in which everything appears and disappears, which Mishara suggests represents a state of cortical excitability after his withdrawal from social stimuli with sleep deprivation. Kafka was eager for seperation from his
www.thelancet.com/neurology Vol 15 November 2016
family, with whom he spent much of his life (much like Gregor Samsa in The Metamorphosis, who also had a difficult relationship with his family).5 Social withdrawal and photic withdrawal are essential for self-induced hypnagogiclike-trances. Kafka scheduled his writing during the night in a sleepdeprived state purposely because this state of prolonged sleep deprivation could serve as a psychotomimetic state (a psychotic-like state in an otherwise healthy individual). “It is not alertness but self-oblivion that is the precondition of writing”, Kafka writes to Max Brod.3 Drawing from these and numerous other diary entries and letters, we pose that, even if Kafka was tortured by the incessant insomnia, it was his preferred and perhaps his only method of journeying (in Jungian terms) into the depths of his unconscious. His insomnia was not at all dehumanising (as suggested by Perciccante and Correlli), but the exact opposite—ie, humanising the self by bringing to surface elements of unconscious that guide most actions of our waking life. We declare no competing interests.
Saudamini Deo, *Philippe Charlier [email protected] Section of Medical and Forensic Anthropology, UFR of Health Sciences (UVSQ), Montigny-Le-Bretonneux 78180, France (SD, PC); and Centre d’accueil et de soins hospitaliers de Nanterre, Nanterre, France (PC) 1
2 3 4
5
Perciaccante A, Coralli A. Franz Kafka’s insomnia and parasomnias. Lancet Neurol 2016; 15: 1014. Kafka F, Brod M, ed. The diaries 1910–1923. New York: Schocken Books, 1976. Kafka F. Letters to friends, family, and editors. New York: Schocken Books, 1976. Mishara AL. Kafka, paranoic doubles and the brain: hypnagogic vs. hyper-reflexive models of disrupted self in neuropsychiatric disorders and anomalous conscious states. Phil Ethics Human Med 2010; 5: 13. Kafka F. The metamorphosis, in the penal colony, and other stories. New York: Scribner Paperback Fiction, 2000.
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of bleeding without underlying vessel disease (eg, deep perforating vasculopathy or cerebral amyloid angiopathy, which are rare in young patients). In neurology settings, the interaction between underlying vessel diseases and the bleeding itself might add to the complexity of the clinical manifestations. Charidimou and colleagues underline one of the key findings of the Prognosis of Intracerebral Haemorrhage (PITCH) study: cortical superficial siderosis was, in our study, the strongest risk factor for new-onset dementia, especially in patients with lobar intracerebral haemorrhage. Future research should identify the nature of this association. Charidimou and colleagues hypothesise that the risk of dementia in patients with cortical superficial siderosis might be triggered by a higher rate of recurrent bleedings. This is an interesting suggestion that we were not able to explore in our study, as the occurrence of a new stroke (including recurrent intracerebral haemorrhage) and cortical superficial siderosis were studied in two distinct multivariable models. However, the PITCH cohort is still being followed up and we intend to study this hypothesis further. Beyond the discussion of the underlying mechanisms linking cortical superficial siderosis and other MRI biomarkers with recurrent haemorrhage, these biomarkers should now be studied with the aim to prevent new events—not only recurrent intracerebral haemorrhage but also cognitive decline, as these two complications are strongly predictive of poor outcomes in patients with intracerebral haemorrhages. CC was an investigator in the clinical trial A9951024 for Pfizer, fees were paid to ADRINORD or Lille University Hospital research account (no personal funding). DL was an investigator in clinical trials for Bristol-Myers Squibb, Nestlé, Pfizer, Pierre Fabre, AstraZeneca, and Boehringer Ingelheim. His fees
were paid to ADRINORD or Lille University Hospital research account (no personal funding). SM and SB declare no competing interests.
Solene Moulin, Didier Leys, Stéphanie Bombois, *Charlotte Cordonnier [email protected] Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Lille, France (SM, SB, DL, CC) 1
Moulin S, Labreuche J, Bombois S et al. Dementia risk after spontaneous intracerebral haemorrhage: a prospective cohort study. Lancet Neurol 2016; 15: 820–29.
For Franz Kafka, insomnia was a literary method We read with great interest the Focal Point by Antonio Perciaccante and Alessia Coralli1 about Franz Kafka’s insomnia and parasomnias. For all his writing life, Kafka had insomnia and the hypnagogic hallucinations arising from his lack of sleep shaped much of his writing. However, to conclude, as the authors do, that “The Metamorphosis” can be read as a metaphor for ill effects of insomnia would be incorrect. “I believe this sleeplessness comes only because I write”, Kafka noted in one of his diary entries in 1910.2 In 1922, to Max Brod, he writes: “Perhaps there are other forms of writing, but I know only this kind; at night, when fear keeps me from sleeping, I know only this kind.”3 As Aaron Mishara notes, for Kafka, writing is a trance-like Dionysian activity at night, opening the endless inner darkness of self as an abyss without an end.4 Kafka, writing about one of his sleepless nights, mentions a great fire in which everything appears and disappears, which Mishara suggests represents a state of cortical excitability after his withdrawal from social stimuli with sleep deprivation. Kafka was eager for seperation from his
www.thelancet.com/neurology Vol 15 November 2016
family, with whom he spent much of his life (much like Gregor Samsa in The Metamorphosis, who also had a difficult relationship with his family).5 Social withdrawal and photic withdrawal are essential for self-induced hypnagogiclike-trances. Kafka scheduled his writing during the night in a sleepdeprived state purposely because this state of prolonged sleep deprivation could serve as a psychotomimetic state (a psychotic-like state in an otherwise healthy individual). “It is not alertness but self-oblivion that is the precondition of writing”, Kafka writes to Max Brod.3 Drawing from these and numerous other diary entries and letters, we pose that, even if Kafka was tortured by the incessant insomnia, it was his preferred and perhaps his only method of journeying (in Jungian terms) into the depths of his unconscious. His insomnia was not at all dehumanising (as suggested by Perciccante and Correlli), but the exact opposite—ie, humanising the self by bringing to surface elements of unconscious that guide most actions of our waking life. We declare no competing interests.
Saudamini Deo, *Philippe Charlier [email protected] Section of Medical and Forensic Anthropology, UFR of Health Sciences (UVSQ), Montigny-Le-Bretonneux 78180, France (SD, PC); and Centre d’accueil et de soins hospitaliers de Nanterre, Nanterre, France (PC) 1
2 3 4
5
Perciaccante A, Coralli A. Franz Kafka’s insomnia and parasomnias. Lancet Neurol 2016; 15: 1014. Kafka F, Brod M, ed. The diaries 1910–1923. New York: Schocken Books, 1976. Kafka F. Letters to friends, family, and editors. New York: Schocken Books, 1976. Mishara AL. Kafka, paranoic doubles and the brain: hypnagogic vs. hyper-reflexive models of disrupted self in neuropsychiatric disorders and anomalous conscious states. Phil Ethics Human Med 2010; 5: 13. Kafka F. The metamorphosis, in the penal colony, and other stories. New York: Scribner Paperback Fiction, 2000.
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