Sindroame psihiatrice eponime cu originea în literatură: de la Aventurile Baronului Munchausen la Povestea lui Pygmalion (II)

Introduction

Archetypal characters presented in literary works and famous writers themselves have been the origin of various eponymous psychiatric syndromes, with different nosographic impacts. While some of these syndromes resisted the passage of time, others disappeared, either being replaced with newer diagnostic labels, or slipping into obscurity, acknowledged only for their historical value. Most of the syndromes discussed in this review refer to phenomena at the border between normal behavior and pathology, but some are synonyms for currently recognized nosographic entities. In several cases, a distinction between normality, borderline pathological aspects and diagnostic categories is difficult to make (e.g., excessive sexual drive – Don Juanism – compulsive sexual behavior disorder), while in other cases, eponymous syndromes benefit from well-established sets of criteria (as in the case of Diogenes syndrome, for example). Also, there are syndromes in this category that have been created in order to avoid excessive pathologization, as is the case of Ulysses syndrome for migrants and refugees, which is conceptualized as a milder, subclinical form of maladjustment, different from mood, anxiety and stress and trauma-related disorders⁽¹⁾.

When exploring these eponymous syndromes, the mental health specialist needs to be aware of the current diagnostic classification in order to preserve the distinction between clinical and nonclinical phenomenology and to determine the most appropriate way to intervene when confronted with such challenges. Differential diagnosis and therapeutic management are two of the most important reasons to explore these types of psychopathological entities. A broader perspective on the various forms of mental suffering may take can only be beneficial for psychiatrists, clinical psychologists and psychotherapists interested in finding adequate ways to be helpful for their patients.

Methodology

The methodology of this narrative review was presented in the first of a three-part series, “Eponymous psychiatric syndromes inspired by literature (I): From Alice in Wonderland to The Picture of Dorian Gray”⁽²⁾.

Specific literary eponymous syndromes

The literary eponymous syndromes described in this second part of the review are: the Munchausen syndrome, the Ophelia syndrome, the Othello syndrome, the Peter Pan syndrome, pygmalionism, sadism and masochism. Each syndrome is analyzed in a multidimensional manner, to the extent that the data identified in the literature permit such an approach.

Fiction as a way of living: Munchausen syndrome

The name of this syndrome traces back to Baron Munchausen, a real German aristocrat famed (and satirized) for telling wildly exaggerated, often impossible adventure stories. These tall tales were popularized in 1785 by Rudolf Erich Raspe in The Adventures of Baron Munchausen⁽³⁾. Since then, the fictionalized baron became synonymous with dramatic, fabricated narratives.

In 1951, British physician Richard Asher borrowed the baron’s name to label a clinical phenomenon he observed and described in a three-case series – i.e., patients who deliberately fabricated or induced illness in themselves to assume the sick role, often moving from hospital to hospital and providing elaborate medical histories⁽⁴⁾. These persons have traveled extensively, and their stories share the lack of veridicity and dramatic features with those of the famous literary character⁽⁴⁾. In the original description of this syndrome, Asher wrote: “(the patient) is found to have attended, and deceived, an astounding number of other hospitals; and he nearly always discharges himself against advice, after quarreling violently with both doctors and nurses”⁽⁴⁾. The British physician considered the following elements as being indicators of this syndrome: a multiplicity of scars, often in the abdominal area; a mixture of truculence and evasiveness in the relation with physicians; an immediate story that is always acute, but not entirely convincing; a handbag with attendance cards, insurance claim forms and litigious documents⁽⁴⁾. The most frequently identified symptoms by Asher were acute and abdominal manifestations (“laparotomophilia migrans”), various hemorrhages (“hematemesis/hemoptysis merchants”) and neurological symptoms⁽⁴⁾. Unlike the malingerer, these patients do not seem interested in a clear gain, except for unnecessary investigations or surgical interventions⁽⁴⁾. Regarding the possible motives, Asher mentions the desire of the patient to be the center of attention, a grudge against doctors and hospitals, a desire for drugs, a desire to escape from the police and a desire to get free meals and housing⁽⁴⁾.

Regarding etiology, further exploration yielded few new relevant data, as no large-scale research in this area has been conducted. This syndrome is considered a maladaptive response to early life events (such events being identified in 60% of patients in a 20-case series), or emotional and physical abuse in childhood, but also a consistent overlap with behavioral traits of personality disorders⁽⁵⁾. Therefore, affection derived from achieving the sick role may compensate for the lack of affection felt during childhood, searching for relationships may also be a motive originating in the same factor; enjoying being taken care of, a maladaptive coping strategy, lack of consolidated identity, or a sense of satisfaction in deceiving physicians, all have been invoked as etiological factors⁽⁶⁾. Also, factitious disorder has been conceptualized as a behavioral addiction⁽⁷⁾. Hyperperfusion of the right thalamus, changes in EEG patterns and mitochondrial dysfunctions have also been reported in relation to factitious disorder⁽⁶⁾.

Other indicators of Munchausen syndrome reported by subsequent research are inconsistencies among symptoms and physical exam results, symptoms inconsistent with anatomical knowledge or physiology, inconsistencies with data from anamnesis and previous medical records, and resistance of the patient to the release of medical records⁽⁶⁾. 

The first official recognition of this syndrome was in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (1980) and in the ninth edition of the World Health Organization’s classification of mental and behavioral disorders (ICD-9) (1975), where it was mentioned as part of “factitious disorders” (as a severe or chronic form, in the American Psychiatric Association’s classification) and as a phenomenological aspect in the descriptive text of the ICD^(8,9). The DSM-IV TR (2000) explicitly mentions the “Munchausen syndrome” as “the most severe and chronic form” of the “factitious disorder with predominantly physical signs and symptoms”⁽¹⁰⁾. “Factitious disorder by proxy” was mentioned in DSM-IV-TR only as an entity that requires additional study⁽¹⁰⁾. DSM-5 TR (2022) includes the “factitious disorder imposed on self” and the “factitious disorder imposed on another (by proxy)”, and does not mention anything about the Munchausen syndrome, distancing itself from eponymous, potentially pejorative terminology and historically inconsistent usage⁽¹¹⁾. ICD-10 (1992) lists Munchausen’s syndrome as a synonym for the code F68.1 (“intentional production or feigning of symptoms or disabilities, either physical or psychological/factitious disorder”); other synonyms include “hospital hopper syndrome” and “peregrinating patient”⁽¹²⁾. ICD-10 also refers to the “Munchausen syndrome by proxy” (T74.8) in a category dedicated to maltreatment syndromes⁽¹²⁾. ICD-11 (2019) acknowledges the same two versions of the factitious disorders as DSM-5-TR, referring to intentional behavior and deception for the purpose of seeking treatment, without obvious external rewards or incentives⁽¹³⁾.

Differential diagnosis includes, first of all, malingering, then conversion disorder and somatic symptom disorder, and also borderline personality disorder or other dysfunctional patterns of personality⁽⁶⁾. The evolution is marked by the risks associated with self-injurious behaviors and repetitive risky medical procedures, and the prognosis is usually considered to be poor, due to the lack of insight and high psychiatric comorbidity rates⁽⁶⁾.

Regarding the case management of Munchausen syndrome, adherence to treatment is often poor, with patients frequently leaving care against medical advice; therefore, the management should rely on a compassionate, multidisciplinary approach that includes coordinated communication between primary care physicians and psychiatrists, open and supportive discussion with the patient, and long-term psychotherapy with ongoing follow-up⁽¹⁴⁾.

In conclusion, although this syndrome was described more than seven decades ago, and it evolved into two distinct DSM and ICD-acknowledged diagnoses, factitious disorder on self and factitious disorder by proxy, the number of good-quality studies is extremely limited. Most of the information on Munchausen syndrome comes from case reports, expert opinion and reviews; therefore, evidence-based guidelines for therapeutic management are lacking^(5,15). Munchausen syndrome is considered a particular form of factitious disorder imposed on self, more prevalent in men and marked by its severity, with a high rate of psychiatric comorbidities, a diagnosis that can be made mainly by elimination, and a prognosis that is often poor^(16,17).

The lack of sufficient information about Munchausen syndrome is intriguing, since it incurs high costs for healthcare systems⁽¹⁵⁾; therefore, factitious disorders warrant more extensive research.

Feminist critique of Hamlet: Ophelia syndrome

This syndrome refers to the young Danish noblewoman in Shakespeare’s drama Hamlet, and elaborates on this character’s mental breakdown, which follows a complex stressful situation combining emotional abandonment, paternal loss and conflicted loyalty⁽¹⁸⁾. Following the narrative in Shakespeare’s drama, the essential elements of Ophelia’s emotional turmoil can be described as a pattern of psychological regression, loss of identity coherence and emotional alienation, typically occurring in the context of intense relational dependency or severe relational stress. More specifically, Ophelia’s descent into madness and her subsequent suicide by drowning follow directly from the psychological trauma she endures after learning that her father has been killed by Hamlet, the man to whom she is emotionally attached⁽¹⁸⁾. The murder of Polonius marks a decisive rupture in Ophelia’s psychic stability, and being caught in a dense web of powerful but conflicting emotions, including grief and love, she became unable to reconcile her internal conflict. The young noblewoman shows no significant ability for self-preservation once her internal equilibrium collapses, and her drowning, marked by a passive framing, reinforces the impression of surrender.

There are several perspectives on this character’s evolution in the drama, some clearly opposed to each other, reflecting different hermeneutic techniques applied. From a literary and esthetic perspective, in L’eau et les rêves, Gaston Bachelard interprets Ophelia as a poetic archetype of “la mort par l’eau”, highlighting her dissolution into water as a calm, dreamlike return to an elemental, maternal environment⁽¹⁹⁾. Water is peacefully enveloping, and Ophelia is not fighting against it, so the perspective of Bachelard allows for a reframing of this dramatic character into an esthetic image, where feminine death is associated with silence, reverie and beauty⁽¹⁹⁾. Bachelard’s approach thus exemplifies a poetic tradition that estheticizes Ophelia’s death, providing a symbolic framework later questioned by critical discussions of the “Ophelia syndrome”⁽¹⁹⁾. 

The term “Ophelia syndrome” was coined by Elaine Showalter in her critique from a feminist perspective of Hamlet, denouncing the cultural pattern through which female psychological suffering is estheticized, silenced and controlled within patriarchal narratives⁽²⁰⁾. Showalter argues that Ophelia is not treated as a complete psychological subject in Shakespeare’s play but rather as a screen onto which male characters project their fears, desires and anxieties⁽²⁰⁾. Her madness is never narrated from her own perspective; instead, it is described, interpreted and framed by male characters in the drama, especially Polonius, Laertes, Claudius and Hamlet⁽²⁰⁾. As a result, Ophelia is transformed into an object, a sort of passive participant who has no control over her own destiny⁽²⁰⁾. Thus, this syndrome refers to a recurring cultural script in which women’s emotional distress is transformed into esthetic components⁽²⁰⁾. Ophelia’s troubled state is interpreted as harmless and decorative, with the participation of elements such as flowers, songs and watery imagery, rather than being recognized as a response to trauma, loss and systemic silencing⁽²⁰⁾. E. Showalter contrasts Ophelia with Hamlet, whose madness is philosophical, verbal and authoritative⁽²⁰⁾. Ultimately, this syndrome designates a cultural mechanism by which women’s voices disappear during moments of crisis^(20,21). Ophelia’s death marks not only personal tragedy but the final disappearance of female subjectivity^(20,21).

A third interpretation can be conducted in the psychopathological and psychoanalytic framework, and, in this regard, Ophelia syndrome has been used to describe young women who exhibit fragile identity structures, excessive dependency, and vulnerability to depressive or dissociative states in case of high relational stress. From a psychodynamic perspective, Ophelia syndrome may be conceptualized as a failure of separation-individuation, in which the individual’s sense of self remains excessively anchored to significant others⁽²²⁾. Unlike primary psychotic disorders, reality testing may initially remain intact, with deterioration emerging progressively⁽²³⁾. H. Deutsch’s psychoanalytic model helps explain why female breakdowns like Ophelia’s were historically interpreted as natural expressions of feminine passivity and emotional fragility rather than as responses to structural silencing or trauma⁽²⁴⁾.

Although Bowlby does not refer to an Ophelia syndrome, his theory of attachment loss provides a psychologically grounded framework for understanding this character’s collapse as the result of sudden, compounded relational rupture and the absence of supportive mourning structures⁽²⁵⁾.

Otto Kernberg describes a level of personality structure marked by identity diffusion, unstable object relations and reliance on primitive defenses such as splitting⁽²⁶⁾. Individuals organized at this level lack a stable, integrated sense of self, and are particularly vulnerable to regression when confronted with intense affect or object loss⁽²⁶⁾. Under conditions of sudden abandonment or traumatic loss, psychic integration may collapse, leading to disorganization, fragmentation of experience and non-symbolic modes of expression⁽²⁶⁾. 

In her study, J. Lopes (2020) argues that Ophelia’s nervous breakdown in Hamlet is the cumulative result of intersecting relational and social pressures rather than the consequence of a single traumatic event⁽²⁷⁾. Her progressive psychic disintegration is produced by sustained repression and relational conflict, reinforcing interpretations of Ophelia’s fate as socially conditioned rather than intrinsically pathological⁽²⁷⁾.

R.D. Laing described in severe schizophrenia a so-called state of “death-in-life”, in which the individual is biologically alive but existentially dead⁽²⁸⁾. In this condition, both the speech and the behavior no longer express a unified self, and, instead, they appear as fragments, automatisms or “word-salad”⁽²⁸⁾. While Kernberg conceptualizes Ophelia’s collapse as the exposure of a structurally fragile personality organization under relational stress, Laing interprets it as the more radical annihilation of selfhood. Clinically, Laing considers Ophelia’s crisis corresponds to schizophrenia; existentially, she represents a human being whose integral selfhood has collapsed⁽²⁸⁾. In Laing’s interpretation, Ophelia is no longer a subject who speaks, feels or formulates plans in a coherent manner; her songs, gestures and symbolic utterances are not expressions of a hidden meaning waiting to be decoded, but rather, they are the after-effects of a self that has already died⁽²⁸⁾. Psychosis here is viewed as emptiness, or as a vacuum where personhood once existed⁽²⁸⁾. This perspective clearly distinguishes Laing’s view from romantic or esthetic readings of Ophelia’s insanity⁽²⁸⁾.

Also, Laing emphasizes that such breakdowns do not occur in isolation, as they are rooted in relational annihilation, particularly within family systems that deny a person’s lived reality⁽²⁸⁾. In Lang’s perspective, the self retreats, fragments and finally disappears when it cannot safely exist for itself or for others⁽²⁸⁾. Thus, Ophelia becomes a paradigm of extreme ontological insecurity, a character who illustrates how madness can represent not chaotic abandonment, but the final annihilation of selfhood. Her tragedy exemplifies Laing’s central claim that schizophrenia is not merely a disease of thought but a catastrophic failure of the whole being⁽²⁸⁾.

Although Ophelia syndrome is not formally recognized by the modern nosographic systems, its phenomenological features overlap with clinical features of major depressive disorder, borderline personality pathology, complex trauma-related disorders and dissociative disorders. Therefore, this syndrome allows for a clinical level analysis only starting from the background disorder or disorders that may accompany it.

In conclusion, the Shakespearean character Ophelia was initially conceptualized as reflecting a cultural and esthetic phenomenon, then integrated into a feminist critique of the Shakespearean play, and gained the status of a syndrome. Bowlby and Kernberg prefigured the psychodynamic background for interpreting such a syndrome, but, at a clinical level, there is not enough specificity to support integration of Ophelia syndrome in a certain diagnosis category. Therefore, Laing’s equation with schizophrenia, even at a phenomenological and existential level, has little support, being considered, from a clinical perspective, hazardous. Still, Ophelia syndrome can be valuable for the history of psychiatry, because it reflects an archetypal dramatic character of a woman placed in an extremely difficult moment, in a cultural context that offered little choice for the understanding of mental suffering.

Delusional jealousy in Shakespeare’s dramas: Othello syndrome

Also called “morbid jealousy syndrome”, “psychotic jealousy”, “pathological jealousy”, “conjugal paranoia”, “delusion of infidelity” or “delusional jealousy”, this condition centers on the patient’s unshakeable conviction that their partner is being unfaithful. This eponymous syndrome was first described by Todd and Dewhurst in 1955, inspired by Shakespeare’s tragic character and the clinical similarities in psychiatric settings where victims may face tragic consequences⁽²⁹⁾.

In clinical descriptions, Othello syndrome refers to a fixed, false belief of a partner’s infidelity that occurs in the context of an intimate romantic relationship, not solely within marriage⁽³⁰⁾. Delusional jealousy has been described independent of gender configuration, both in heterosexual and homosexual relationships⁽³⁰⁾.

The name of this syndrome was contested by Crichton (2008), who argues that Othello himself cannot be diagnosed with a delusional syndrome, because his beliefs were intentionally manipulated by Iago⁽³¹⁾. Therefore, the distinction between deception and delusion is a strong argument for considering Othello syndrome a misnomer⁽³¹⁾. Another aspect of interest in the exploration of this syndrome is the alleged epilepsy of Othello, which is invoked as a vulnerability factor for the development of morbid jealousy in his case, and would indicate an organic etiology, not a purely psychiatric syndrome⁽³¹⁾. Nevertheless, the psychiatric literature has preserved the term, and it remains widely used.

Pathological jealousy consists of irrational thoughts and emotions that lead to extreme or unacceptable behaviors, dominated by the unfounded belief that the partner has been unfaithful^(32,33). According to the French psychiatrist Mairet (1908), three categories of pathological jealousy exist: 1) hyperesthetic jealousy (morbid jealousy without delusion); 2) monomaniac jealousy (emotional monomania – Esquirol); 3) delusional jealousy (equivalent to the modern “delusional disorder, jealous type”)⁽³⁴⁾. Other authors argue that jealousy is best perceived on a continuum, from the normal end of the spectrum, which is an adaptive but uncomfortable emotional response, passing through excessive or maladaptive jealousy (implying controlling behavior, coercion, violence), to the Othello syndrome, defined as the fixed, delusional beliefs of infidelity, associating high violence risk⁽³⁵⁾. This syndrome is of forensic relevance due to such risks, which may include homicide, harassment and other criminal acts^(32,33).

From an evolutionary perspective, sexual jealousy is an ancestral mechanism of a risk-management modeled by selection pressures regarding mating and paternity. Within this framework, pathological forms of jealousy such as Othello syndrome may represent a maladaptive or dysregulated extreme of this system⁽³⁶⁾.  

On a clinical level, Othello syndrome includes delusional interpretation of common events, accusing the partner of cheating, repetitive questioning about different variants of communications, forbidding the partner from new social contacts, checking the partner’s belongings, monitoring the partner’s location and companions, isolating the partner from family and friends, verbal or physical violence, suicidal ideation and avoidance of jealousy‑provoking situations⁽³⁷⁾.

Although not recognized as an independent disorder in the latest editions of DSM or ICD, delusional jealousy is considered a psychotic syndrome that may be met across various mental illnesses. In the DSM‑IV‑TR, Othello syndrome is the equivalent (unrecognized as such) of the “delusional disorder, jealous type”, which refers to non-bizarre delusions of infidelity without clear evidence and in the absence of other psychiatric disorders or general medical conditions; hallucinations, if they appear at all, are not prominent, and are related to the delusional theme⁽¹⁰⁾. In the DSM‑5 TR, the diagnosis is preserved, as well as the minimum duration (≥1 month), with a newly introduced optional “bizarre content” specifier⁽¹¹⁾. The ICD‑10 equivalent is the “persistent delusional disorder”, with the same time minimum limit (≥3 months) and with the exclusion of schizophrenia⁽¹²⁾. ICD‑11 preserves the “delusional disorder” diagnosis, the minimum duration of three months for clinical criteria and the exclusion of affective episodes and schizophrenia⁽¹³⁾.

The delusional disorder has an estimated prevalence of 1.1% among psychiatric inpatients and 7% among neurological patients; sex distribution varies across studies; in forensic samples, men more often commit jealousy‑related homicide or homicide‑suicide^(32,33).

In the differential diagnosis, it must be taken into account that delusional jealousy is seen in the context of a variety of clinical entities, including paranoia/delusional disorder, acute psychotic disorders, organic brain syndromes, neuroses and personality disorders^(38,39). Studies and case series have demonstrated that Othello syndrome occurs most frequently in association with neurological disorders (e.g., dementia, frontal-lobe dysfunction, Parkinson’s disease, stroke, brain trauma); therefore, a notable proportion of cases have an organic basis^(38,39). According to a case analysis (N=93 patients), jealousy ideas have been reported in psychotic disorders (6.7%), but also in psycho‑organic disorders (7%) and mood disorders (0.5%); these ideas have been reported after right orbitofrontal surgery, and can also be induced by various drugs of abuse, such as alcohol, amphetamines and cocaine⁽⁴⁰⁾.

Shrestha et al. (1985) reported that morbid sexual jealousy occurred in almost one-third of patients with alcohol dependence, and was usually non-delusional, with outcomes often improving following relationship changes and reduced alcohol consumption⁽⁴¹⁾. Poorer prognosis, including higher morbidity and mortality, was observed in patients with coexisting cognitive impairment or delusional jealousy⁽⁴¹⁾. Cocaine may induce delusional symptoms in two-thirds to three-quarters of users, while amphetamines are responsible for approximately 30-40% of psychotic disorders^(42-45). Delusional jealousy occurred in 8.7% of patients with neurocognitive disorders (NCDs), with a markedly higher prevalence in NCDs with Lewy bodies (26.3%) versus NCDs due to Alzheimer’s disease (5.5%), supporting an association between Othello syndrome and neurodegenerative pathology⁽⁴⁶⁾. Parkinson’s disease was associated with Othello syndrome in a study (N=67 patients), especially in men and in middle-aged individuals; the anti-Parkinsonian medication (mainly dopamine agonists) was also involved in many cases of Othello syndrome in this group; quetiapine and clozapine were recommended in cases where anti-Parkinsonian medication adjustments were not enough⁽⁴⁷⁾.

Neuroimaging data showed right dorsolateral frontal atrophy in NCDs with delusions of jealousy versus those with only neurodegenerative disorders, suggesting that dysfunctions of this area impair self‑monitoring and social cue interpretation, leading to false beliefs (N=105 patients)⁽³⁹⁾. Right hemisphere and frontal dysfunction may generate “content‑specific delusions” due to the right hemisphere’s role in generating the sensation of familiarity and the frontal lobes’ role in correcting perceptual errors based on new information⁽³⁹⁾.

Other hypotheses support the correlation between right parietal lobe dysfunctions and jealousy delusions in patients with early-onset Alzheimer’s disease⁽⁴⁸⁾. Hypometabolism in the right frontal lobe on SPECT was associated with Othello syndrome, and the administration of 5 mg of donepezil led to symptom remission and improved rCBF in the parietal lobe⁽⁴⁸⁾.

The involvement of serotonergic dysfunction (5-HT2A hyperactivity in the prefrontal cortex), cholinergic deficits (psychosis in Lewy body dementia and Alzheimer’s disease) and glutamatergic/GABAergic dysfunction (NMDA receptor hypofunction in the prefrontal cortex) has been invoked as mechanisms for Othello syndrome^(49,50).

Regarding the treatment, tiapride (a selective D2 antagonist with low potency) has been shown to be useful in case reports, and pimozide has been effective in some cases, but with adverse effects^(51,52). In a systematic review (N=73), antipsychotics were used in approximately 60% of cases, and symptom remission was achieved in 70%, with the most commonly used antipsychotics being pimozide, risperidone, quetiapine and olanzapine, as well as sulpiride⁽⁵¹⁾. As previously suggested, in patients with Parkinson’s disease, the pro-dopaminergic medication should be adjusted, and quetiapine or clozapine may be added. The combination of antidepressant and antipsychotic showed slightly better results (75% versus 53%)⁽⁵²⁾.

Although not a distinct nosological entity, Othello syndrome appears in schizophrenia spectrum disorders, affective disorders, substance use disorders and neurological diseases (especially Parkinson’s disease, frontotemporal dementia and Alzheimer’s disease). The syndrome has a well-established identity in the psychiatric literature, and is continuously explored, using modern neuroimaging techniques, as indicated in this review. For clinicians, it is very important to be familiarized with its existence, especially due to the risk of forensic developments.

Never-ending adolescence: Peter Pan syndrome

The American psychologist and family therapist Dan Kiley conceptualized the Peter Pan syndrome in the '80s as a configuration of dependency, avoidance of adulthood and fragile self-esteem, with origins in developmental arrest and reinforced by dysfunctional interpersonal dynamics⁽⁵³⁾. Inspired by the literary character Peter Pan, created by J.M. Barrie, who is an illustration of a boy who famously refuses to grow up and remains perpetually childlike, Kiley’s book popularized the term “Peter Pan syndrome” and established it as a culturally influential metaphor for prolonged psychological adolescence^(53,54).

From his perspective on Peter Pan syndrome, Kiley describes a recurrent configuration of emotional, relational and behavioral features rather than a formal set of diagnostic criteria. These elements refer to arrested emotional development, inappropriate affective expressions at the individual’s age, passivity and procrastination, difficulty forming and sustaining mature social bonds and a marked avoidance of adult responsibility and accountability⁽⁵³⁾. Kiley further emphasizes disturbed relational patterns, notably unresolved maternal dependency that is often displaced onto romantic partners, cold or conflictual relationships with fathers and other male relevant figures, romantic insecurities defined by fear of rejection, and a preference for submissive partners⁽⁵³⁾.

Approaching the subject of Peter Pan syndrome without adequate knowledge of the basic concepts of developmental psychology is an endeavor of little value. Therefore, several perspectives on this topic will be brought to readers’ attention to provide a working background for understanding this syndrome. According to E.H. Erikson, adolescence represents a critical psychosocial stage culminating in the resolution of identity versus role confusion, during a process that requires introjection of adult roles, values and responsibilities⁽⁵⁵⁾. Viewed in this context, the Peter Pan syndrome is a prolonged, chronic failure to solve such a developmental crisis, resulting in identity diffusion, avoidance of adult commitments and dependence on external validation.

Another developmental perspective is that of Peter Blos, who describes adolescence as a second, crucial phase of individuation, requiring psychic separation from parental objects and the consolidation of autonomous identity⁽⁵⁶⁾. In this framework, Peter Pan syndrome stands as a failure of individuation, in which the subject remains psychologically anchored to the childhood stage, while biologically entering adulthood.

Psychoanalysts like Otto Kernberg view identity diffusion as a failure to integrate self- and object-representations into a coherent and stable sense of self, which can lead to severe personality pathology⁽⁵⁷⁾. From the perspective of Peter Pan syndrome, identity diffusion explains the persistent immaturity, unstable self-concept and reliance on external validation observed in individuals who avoid adult roles and commitments. Psychodynamically, the syndrome has been conceptualized as a defense against separation anxiety, fear of dependency and unconscious conflicts surrounding individuation^(58,59). Avoidance of adulthood serves as a mechanism to preserve a fragile self-concept and to evade perceived threats associated with commitment, authority, and loss of freedom^(58,59).

In his longitudinal analysis of personality disorders, J. Paris emphasizes that personality pathology often shows both continuity and gradual change over time, with many individuals retaining immature coping styles and identity patterns well into adulthood⁽⁶⁰⁾. This perspective may support the view that developmental arrest, particularly in identity consolidation and responsibility-taking, can persist in a stable but subclinical form, without necessarily meeting the criteria for severe personality disorder, as is the case with Peter Pan syndrome.

From a clinical and psychological perspective, Peter Pan syndrome describes adults – most often men in the original formulations – who exhibit difficulty assuming social, occupational and relational responsibilities typically associated with adulthood. The behavior is frequently viewed as nonproblematic by the individual with this syndrome, being ego-syntonic and reinforced by permissive or infantilizing environments^(53,59).

Smith, Stoehr and Stewart (2020) developed a psychometric scale to quantify the manifestations of Peter Pan syndrome in adult men, based on several key dimensions, such as escapism from responsibility, power perception and persistent adolescent behavior, offering one of the few empirical measurement approaches in the field of psychiatric eponymous syndromes inspired by literary characters⁽⁶¹⁾. The Peter Pan Syndrome Scale is a 22-item self-report measurement, and each item is evaluated on a five-point scale⁽⁶¹⁾. The scale’s internal consistency was good, with Cronbach’s alpha value found to be 0.88 for the total scale⁽⁶¹⁾.

Peter Pan syndrome is not recognized as a formal diagnostic category in DSM-5-TR or ICD-11. Instead, it overlaps phenomenologically with dependent personality traits, narcissistic vulnerability, identity diffusion and, in some cases, attention-deficit/hyperactivity disorder persisting into adulthood.

Although Peter Pan syndrome is not a formal diagnostic category, and no good quality clinical studies have been performed on this specific pathology, it can be assumed that therapeutic interventions should be guided by the underlying developmental and personality features. For example, in a psychoanalytic framework, the therapy needs to be focused on identity diffusion, dependency and avoidance of separation-individuation, aiming to facilitate the consolidation of a coherent adult identity. In milder or high-functioning cases, cognitive-behavioral strategies may be useful for the attenuation of avoidant behaviors and entitlement beliefs, whereas couple/family therapy can be efficient when relational dynamics reinforce dependency and irresponsibility.

Eponymous syndromes in the realm of paraphilias: pygmalionism, sadism and masochism

The term “pygmalionism” originates in classical mythology, and it is derived from the story of Pygmalion, canonically recounted by Ovid in Metamorphoses (Book X)⁽⁶²⁾. In this narrative, Pygmalion, a Cypriot sculptor, develops an intense erotic attraction toward the female statue he has created, idealizing an inanimate anthropomorphic object to the point of confusing it with a living partner. From Antiquity onward, the myth has functioned as a cultural archetype of the eroticization of artificial creations endowed with human form, and it is usually synonymous with agalmatophilia (gr. ἄγαλμα = statue, image, and φιλία = love, attraction). Other examples from the literature of pygmalionism cases are Laodamia’s attachment to her husband’s wax effigy in Ovid’s Heroides and excerpts from Priapea poems⁽⁶³⁾.

However, the synonymity of pygmalionism and agalmatophilia is challenged by some authors, who consider that the myth of Pygmalion can refer “only to those who actually bring statues to life, and not to those who use statues for their own sexual purposes without bringing them to life”⁽⁶⁴⁾. Within this framework, agalmatophilia should indicate only sexual attraction to statues or inanimate human-like objects, while pygmalionism is centered on desire for an imagined or enacted animation of the object.

During the 19^th and early 20^th centuries, descriptive sexology appropriated this literary archetype in an attempt to classify atypical sexual behaviors, with authors such as von Krafft-Ebing and H. Ellis explicitly or implicitly mentioning in their works the pathological erotic attraction to statues, mannequins and artificial anthropomorphic figures, situating it within the domain of object-oriented fetishism^(65,66). In this context, the term “pygmalionism” was used occasionally as a literary eponym to describe a specific form of erotic orientation, although, subsequently, modern sexological literature favored the more specific term agalmatophilia, considered phenomenologically more precise.

Contemporary psychiatric classifications do not recognize pygmalionism as a distinct nosological entity. According to DSM-5 TR, pygmalionism could be placed in the category of “other specified paraphilic disorders” or subsumed to “fetishistic disorder”, if it causes marked distress or impairment; otherwise, it is considered a variant of sexual interest⁽¹¹⁾. ICD-11 would incorporate pygmalionism/agalmatophilia in the “Other paraphilic disorders” if clinical criteria exist (impairment, distress, risks of injury or death); in the absence of such criteria, these phenomena would be regarded as paraphilic interests, not disorders⁽¹³⁾.

In contemporary contexts, pygmalionism gains new significance due to the emergence of AI-animated dolls and humanoid companions, which increasingly blur the boundary between inanimate objects’ reactions and human interactions⁽⁶⁷⁾. Unlike classical agalmatophilia, oriented toward immobility and esthetic fixation, modern pygmalionism is based on the fantasy of animation, reciprocity and emotional attunement, translating the myth of Pygmalion into a technological register. This contemporary reactivation of the pygmalionism concept illustrates how literary eponyms may regain heuristic relevance when social, technological, or cultural conditions are changed.

Sadism and masochism represent two of the clearest and most enduring examples of psychopathological concepts with explicit literary eponymous origins. Unlike many psychiatric terms derived from clinical observation alone, both concepts were named after identifiable literary figures whose works vividly portrayed the behavioral and psychological patterns later described in psychiatry⁽⁶⁵⁾.

The term “sadism” derives from the name of Donatien Alphonse François de Sade, whose novels and philosophical writings depict erotic gratification derived from the infliction of pain, humiliation or domination over others^(65,68). These themes were not merely narrative devices but recurring psychological motifs, characterized by the eroticization of cruelty, power and suffering. The systematic nature of these depictions led late nineteenth-century sexologists to adopt the author’s name as a descriptive label for a distinct pattern of sexual behavior.

On the other hand, “masochism” takes its name from Leopold von Sacher-Masoch, whose literary works portray protagonists who experience sexual arousal through submission, humiliation and the voluntary endurance of pain inflicted by a dominant partner^(65,68). In these narratives, suffering is not accidental but actively sought, eroticized and integrated into personal identity and desire.

Both terms were formally introduced into psychiatric and sexological discourse by Richard von Krafft-Ebing in Psychopathia Sexualis, where he explicitly acknowledged their literary origins⁽⁶⁵⁾. Krafft-Ebing conceptualized sadism and masochism as complementary forms of sexual psychopathology, emphasizing the directional difference of aggression and submission while recognizing their frequent coexistence within individuals and relationships^(65,68).

From a psychoanalytic perspective, Sigmund Freud initially considered masochism to be a sadism redirected against the self, but later he acknowledged the independent existence of primary masochism⁽⁶⁹⁾. Also, Freud identified three types of masochism: erotogenic (the primary form, with physical background), feminine (fantasies of submission and passivity) and moral (the Ego unconsciously seeks punishment)⁽⁶⁹⁾. Sadism, according to Freud, is Thanatos (the death drive, as opposed to Eros, the life drive) directed outward towards objects, while masochism is Thanatos bound to libido and directed inward⁽⁶⁹⁾.

From a neurobiological perspective, a review of neuroimaging and psychophysiological studies suggests that individuals with sadistic interests show distinct patterns of neural response to others’ pain compared to non-sadistic offenders, supporting the construct’s validity beyond self-report⁽⁷⁰⁾. It was revealed an increased activation of amygdala, anterior insula, ventral striatum/nucleus accumbens and orbitofrontal cortex (responsible for increased emotional salience for other’s suffering, atypical processing of pain and affect, abnormal reward-related action, and altered valuation of social and moral stimuli), with reduced or altered activation of anterior cingulate cortex and medial prefrontal cortex (responsible for empathy for pain, and disrupted mentalization and moral evaluation of others’ suffering)⁽⁷⁰⁾. In synthesis, in individuals with sexual sadism, neural circuits normally associated with empathy and distress are partially replaced or overridden by reward- and salience-related activation, indicating that others’ pain is processed not as aversive but as emotionally and motivationally salient⁽⁷⁰⁾. 

Sexological and forensic literature most often reports pedophilia, sexual sadism, exhibitionism and voyeurism among the paraphilic patterns encountered in clinical and evaluative contexts, with paraphilic interests frequently co-occurring with other sexual, mood and personality disorders⁽⁷¹⁾. There are contemporary authors who emphasize that, in sadomasochism, power exchange, pain and submission are experienced symbolically and contextually, with the objective of fostering intimacy, trust and identity exploration⁽⁷²⁾. Consequently, they challenge traditional psychiatric and forensic models that pathologize sadism and masochism per se, arguing instead that lack of consent, coercion or harm, rather than the erotic content of fantasy or behavior, should constitute the threshold for clinical or legal concern⁽⁷²⁾.

The differentiation between sadism and masochism, on one hand, and sexual sadism/masochism disorders on the other, is a major element to be considered in this context.

Historically, sadism and masochism transitioned from isolated descriptive literary metaphors into clinically operationalized constructs. Modern psychiatric classifications, including DSM-5-TR and ICD-11, recognize sexual sadism disorder and sexual masochism disorder as paraphilic pathology when these interests cause distress, impairment or involve non-consenting individuals^(11,13).

Otherwise, both are considered paraphilic interests and are different from paraphilic disorders in the framework of DSM-5 TR and ICD-11. This formal nosological status distinguishes sadism and masochism from other literary-derived concepts that remain purely descriptive or cultural.

Conclusions

This second part of the review confirms the fecundity of the intersection of psychopathology and the history of literature when new phenomenological constructs need to be adequately named. As shown in the previous section, several syndromes form the basis of diagnoses included in official nosographic systems and, although receiving certain refinement in time, persisted in successive editions of DSM and ICD (e.g., sadism and masochism disorders). Others persisted as synonyms to officially recognized diagnoses, such as the Othello syndrome, or to specific subtypes of such diagnoses, as in the case of the Munchausen syndrome. In the case of pygmalionism, a newer construct – agalmatophilia – gained more popularity and marginalized the older eponym. Ophelia syndrome is an example of the cultural reinterpretation of a syndrome – in this case, through the lens of the feminist movement. Peter Pan syndrome is an interesting but less researched syndrome, although a specific psychometric instrument was created for its evaluation, and its psychodynamic explanation may still undergo further development.

In the last part of this review, a new set of eponymous syndromes will be explored, in an attempt to conclude on the importance of researching such constructs from both a historical and cultural perspective, and a clinical one.

Autor corespondent:  Octavian Vasiliu E-mail: octavvasiliu@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

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