Sindroame psihiatrice eponime cu originea în literatură: de la Stendhal la Suferințele tânărului Werther (III)

Introduction

Continuing the investigation of eponymous psychiatric syndromes with literary origins (EPSLO), this final part of the review highlights new phenomenological concepts with origins in visual art and ancient and classical literature. In this way, the complex interplay between cultural history and psychopathology, as well as the need to look beyond the modern nosological framework, becomes more evident from both clinical and theoretical perspectives. The ultimate aim of this review is to increase the likelihood that a well-informed psychiatrist will identify psychopathological entities that are not included in the current diagnostic systems (ICD-11, DSM-5-TR), but are still responsible for significant discomfort at the individual and, in several cases, at the micro- and macrosocietal levels^(1,2).

Methodology

The methods used for this narrative review were presented in the first part of this series, which describes the EPSLO⁽³⁾.

Analysis of the psychiatric eponymous syndromes with literary origin

In this section of the review, historical and phenomenological aspects of Stendhal syndrome, Ulysses syndrome and Werther and Papageno effects are described. All relevant data on each of these syndromes were distributed across historical, phenomenological, etiological and therapeutic categories, which made this approach possible.

The power of art: Stendhal syndrome

Also named “esthetic syndrome”, “hyperkulturemia” or “Florence syndrome”, this construct has as its core feature the onset of dysautonomic symptoms in the presence of a beautiful painting, statue, or architectural work, in art-loving tourists visiting the famous Italian city^(4-6). Clinical manifestations include both physical and mental symptoms, such as tachycardia, diaphoresis, chest pain, stomach aches, hallucinations, altered perception of sounds and colors, vertigo, feelings of strangeness or alienation, delusions of being persecuted, confusion and loss of consciousness^(4,7-9). The syndrome is intriguingly situated at the intersection of psychiatry, neurology and esthetics, but there is an emerging corpus of data supporting its existence as a unique neuropsychiatric phenomenon⁽¹⁰⁾. However, critics question whether this syndrome is a valid entity, warning of insufficient scientific research in this field and highlighting reliance solely on anecdotal reports⁽¹¹⁾.

An Italian psychiatrist, Dr. Graziella Magherini, was the one who pinpointed this term in 1989, drawing on the Romantic writer Marie-Henri Beyle (1783-1842), famous under his pseudonym “Stendhal”⁽⁴⁾. The characteristics of this syndrome were derived from an analysis of 106 cases of foreign visitors to the Basilica di Santa Croce and various museums and galleries in Florence, who were evaluated at the Santa Maria Nuova Hospital in the same city, and were collected over 20 years of clinical practice⁽⁴⁾. The main symptoms they presented were dizziness, palpitations, hallucinations, disorientation, depersonalization and severe exhaustion⁽⁴⁾. The duration of these manifestations, as reported by Dr. Magherini, was 2 to 8 days^(4,7). Three subtypes of this syndrome were identified by the Italian psychiatrist: 66% presented mainly neuropsychiatric symptoms, 39% presented severe mood disorders, and 5% presented panic attacks and dysautonomic symptoms⁽⁴⁾. According to Magherini, small details in famous paintings or sculptures triggered outbursts of anxiety that may reach a psychotic intensity^(5,7). The underlying foundation of this phenomenon is considered to be latent psychiatric disorders, or unresolved internal conflicts that gain a clinically significant appearance in reaction to emotionally salient stimuli⁽³⁾. Personality structures prone to dissociation, anxiety or mood lability are also important risk factors for this syndrome⁽⁷⁾. Psychological profiles of these individuals included high levels of impressionability and sensitivity, with most tourists being relatively young and single, and contemplating artworks without a professional guide^(7,9). Western European tourists seemed to be more vulnerable to this syndrome than American visitors, and no Italian was affected in the case series reported by Magherini⁽⁷⁾. Jet lag and stress, intrinsically related to traveling, are also invoked as potential risk factors⁽¹²⁾.

The origins of the term lie in Stendhal’s experience while visiting the Basilica di Santa Croce. In his own words: “J’étais arrivé à ce point d’émotion où se rencontrent les sensations célestes données par les beaux-arts et les sentiments passionnés. En quittant Santa Croce, j’avais un battement de cœur, la vie était épuisée chez moi, je marchais avec la crainte de tomber”⁽¹³⁾. The context of the experience is also important, Stendhal stating: “En entrant dans l’église de Santa Croce, je fus saisi d’une émotion profonde. Je vis les tombeaux de Michel-Ange, de Machiavel, d’Alfieri. Je n’avais jamais éprouvé une pareille impression. J’étais déjà dans une sorte d’extase, par l’idée d’être à Florence, et le voisinage des grands hommes dont je venais de voir les tombeaux”⁽¹³⁾. Stendhal described sensations that could be assimilated to the phenomenon of déjà vu after watching works of art in Florence, in the sense of immediate, intimate familiarity with the beauty of the city itself⁽⁵⁾. Also, phenomenological descriptions of anxiety (e.g., palpitations, fear of collapse, strong emotions with functional impact) can be derived from Stendhal’s written memories about his contact with art masterpieces⁽⁵⁾.

Religious pilgrims or spiritually motivated travelers may develop symptoms reminiscent of Stendhal syndrome when confronted with places that embody intense emotional and cultural investment⁽¹⁴⁾. For example, the Jerusalem syndrome is causally related to Stendhal syndrome, although phenomenologically distinct, and consists of an acute psychotic state developed by pilgrims in relation to religious fervor^(14,15). On average, 100 patients per year presented with this syndrome in Jerusalem, and 40 of them required admission⁽¹⁵⁾. Tourism-related affective and emotional experiences, the overwhelming intensity of perceptions and multiple social relationships developed in short periods can all contribute to major changes in self- and others-perception⁽¹⁶⁾.

David syndrome is another related phenomenon, described by Magherini in a more recent book, centered on Michelangelo’s masterpiece David⁽¹⁷⁾. The spectacular sculptural portrait represents a high density of physical and emotional energy, symbolizing civic virtues of heroism, freedom and primacy of intelligence over brute force^(17,18). By consulting the entries in the guest record book, Dr. Magherini observed the responses triggered by observation of the statue: from an awing association with the perfection of the artwork, to the reporting of imperfections in the statue’s structure, and from positive feelings and admiration, even enamoration, to negative feelings, painful emotions, hostility, competitiveness and an intense desire to destroy the statue itself^(17,19).

In a case report, a creative artist aged 72 presented with sleep impairments and worries of being followed and monitored, symptoms that had their onset eight years after travelling to Florence and visiting Ponte Vecchio⁽²⁰⁾. Feelings of déjà vu were reported in this case, as well as panic attacks and time disorientation for several minutes, followed by persecutory ideation and ideas of reference at the time of exposure⁽²⁰⁾. These symptoms remitted after three weeks, but the patient relapsed after visiting southern France, four years later⁽²⁰⁾. The clinical manifestations in this patient were congruent with cases described by Magherini (1989), as two-thirds of the patients presented with paranoid symptoms⁽²⁰⁾. However, in this patient, the psychiatric history was more complex, since he also had a serious suicide attempt by jumping in front of a train and a four-year period of depressed mood culminating with a three-month admission; therefore, the insertion of the Stendhal syndrome in his clinical evolution requires careful delineation from a concomitant mood disorder⁽²⁰⁾.

Both Jung and Freud have reportedly been confronted with at least a partial form of Stendhal syndrome^(7,21). Freud was deeply affected by his trip to Greece, while visiting the Acropolis in Athens, and he explored, in his paper Das Unheimliche, the unease and alienation felt during this travel experience^(14,21,22). In his autobiography, Jung recounts an event in which he was deeply influenced, mentally and physically, by artworks seen in Pompeii, during which he lost his senses and could not continue the journey^(14,21). Also, an interesting situation is that of Dostoevsky, who was suffering from epilepsy, with probably partial seizures and secondary generalization, most likely involving the temporal lobe^(9,23). According to the second wife of the writer, Anna Grigorievna, during Dostoevsky’s stay in Basle, where he went to see the painting Dead Christ, by Hans Holbein the Younger, the writer experienced a state resembling an epileptic attack – he was petrified in front of the painting illustrating the corpse of Christ after enduring terrifying agony^(24,25). The Russian writer described the conclusions drawn from viewing this painting in his novel The Idiot, emphasizing the emotions aroused by exposure to such an artwork⁽²⁵⁾. During this encounter with the exceptional artwork by the German-Swiss painter, Dostoevsky is supposed to have experienced a Stendhal syndrome, with enthusiasm alternating with terror, physical malaise, ecstasy and perplexity for half an hour or more⁽²³⁾.

The syndrome also drew the attention of movie directors, and the 1996 Italian thriller “Stendhal syndrome” by Dario Argento explored experiences similar to those associated with Stendhal syndrome in the main character as she visits the Uffizi Gallery^(26,27). Although far from a clinical analysis of Stendhal syndrome, the vanishing of the boundary between self and paintings, the feeling of “being absorbed into the art world” and disorientation are approached in the movie through cinematographic means^(26,27).

An evaluation based on questionnaires administered to participants at a neurohistory meeting (2008; N=48 individuals, age; 50±9 years old) sought to illustrate the existence of Stendhal syndrome in a homogeneous group of travelers⁽¹⁸⁾. Out of the group of respondents, 25% answered positively to a possible, partial Stendhal syndrome at some moment in their lives⁽¹⁸⁾. The most frequently reported symptoms were pleasure (83%) and emotion (62%), but no panic attacks or thought disorders were indicated by the respondents⁽¹⁸⁾. In this context, neurologists who completed the questionnaire also reported mild or slightly unpleasant reactions, such as changes in perception, feelings of guilt, insecurity and inadequacy, as well as somatic symptoms⁽¹⁸⁾.

Ecstatic epilepsy is a condition originating in the activation of the anterior insular cortex, which is connected with neural networks involved in introspection, social cognition, emotional processing and memory⁽²⁸⁾. Some authors group together ecstatic epilepsy (i.e., core ecstatic symptoms such as sudden feelings of bliss, euphoria or intense joy, profound emotional significance of the moment, clarvoyance), orgasmic epilepsy (i.e., spontaneous orgasms during epileptic seizures), musicogenic epilepsy (i.e., seizures triggered by emotions elicited when listening to a particular music fragment), autoscopic phenomena (i.e., extracorporeal experiences) and Stendhal syndrome, because these share common features, such as pleasant emotions and other various affective symptoms of high impact for the affected individuals⁽²⁸⁾. Empathy and mirror neurons may also provide the neuropsychological basis for a conceptual framework necessary for understanding the strong emotions triggered in the viewer by an artwork⁽¹⁸⁾.

An exploration of Stendhal syndrome from multiple perspectives, such as psychoanalysis and neuroscience, raised interesting questions and important challenges for considering this phenomenon a distinct entity: are there accurate measurements of variables related to overwhelming emotions triggered by art stimuli (e.g., neurovegetative symptoms, emotions, euphoria, neurological changes)?; is a single, unified, theoretical framework possible for explaining the syndrome from a psychoanalytic perspective?; is there a congruence between the theoretical modelling and the practical measurements?⁽¹¹⁾. From a psychoanalytic perspective, Dr. Magherini envisages Stendhal syndrome as the result of multiple factors: the primary esthetic experience would have its origins in the primitive mother-child esthetic experience (i.e., the art reactivates this primordial sensorial-affective field), the strangeness would be related to the return of repressed elements (i.e., the artwork may open access to the repressed emotional memories), and the selected fact would correspond to the key moment in the perception of the artwork that can modulate the reaction triggered in the observer (i.e., a particular color, a gesture in the painted figure, or a spatial detail determine the intensity of the reaction); also, the artistic value of the stimulus, with its symbolism, stylistics, cultural and historical associations, plays an important part in the onset of the syndrome⁽¹⁷⁾. Primary impulses and various conflicts are represented across the artworks worldwide and across time, as the artistic language is imbued with such phenomena; the viewer’s internal conflicts may resonate with the symbolic representations of similar tensions, allowing for an evocation of repressed elements and for moving from a passive status of observer to an active one, of internally recreating the work of art⁽¹⁸⁾.

The classification of this syndrome in the current nosological systems would be quite difficult, since it is a clinical mixture of anxious, dissociative, conversive and even psychotic symptoms. Therefore, “other specified anxiety disorder”, “other specified dissociative disorder”, “other specified somatic symptom and related disorder”, or “brief psychotic disorder, with marked stressor” (only in a minority of cases), could be possible matches in the DSM-5-TR⁽²⁾. With many authors considering the core symptoms sufficient to classify it as a psychosomatic response^(14,10,20), it would be logical to classify Stendhal syndrome under “Psychological factors affecting a medical condition” in the DSM-5-TR. That being said, there is no official diagnosis of Stendhal syndrome in any of the World Health Organization (WHO) or American Psychiatric Association (APA) nosological systems, and, based on the paucity of epidemiological and clinical studies identified through the literature search, the probability of such an inclusion in the near future is not foreseeable.

Since no validated criteria exist for this syndrome, no prospective clinical trial has been conducted to evaluate potentially useful therapeutic strategies. Therefore, while no treatment has been proven efficacious, as a preventative measure, tourists are advised to pace themselves in the art museum and to rest before exposure to powerful masterpieces⁽¹⁰⁾.

In conclusion, as Wei (2024) plastically formulated it, Stendhal syndrome “stands as a testament to the power of art to transcend mere visual appreciation”, provoking deep emotional responses and physiological correlates⁽¹⁰⁾. This is another testimony of the power of art and its potential side effects, indicating the need for clinicians to be aware of the intricacies between the visual arts and psychiatry^(29,30).

The two faces of Ulysses syndrome

Also known as the syndrome of the migrant with chronic and multiple stressors, the Ulysses syndrome was coined by the Spanish psychiatrist Joseba Achotegui, starting from the Greek hero who suffered enormous endeavor during the way back from the Trojan war to his beloved ones, in Ithaca⁽³¹⁾. Loneliness due to separation from the family and significant others is one of the most important triggers for this syndrome⁽³²⁾. Anguish and concern for the situation of the family members left behind, the fight for survival, the feelings of hopelessness and helplessness, all contribute to a heightened level of stress⁽³²⁾. The stressors in this case are going beyond the classic acculturative phenomenon⁽³³⁾. Multiplicity, chronicity, lack of control over stressors (learned helplessness), the high intensity of stressors in survival situations and lack of social support are important etiological factors of Ulysses syndrome⁽³²⁾.

The Ulysses syndrome cannot be properly understood without exploring several sociological concepts related to the adaptation (or lack thereof) to a new culture upon migration. Acculturation refers to the process through which individuals or groups acquire aspects of a culture different from their culture of origin as a result of contact between distinct systems of meaning⁽³⁴⁾. This process often occurs within contexts of unequal power relations, where one cultural group tends to dominate the other, giving rise to acculturative stress. In the context of migration, migrants enter a host society and gradually adopt aspects of the receiving culture⁽³⁴⁾. Within this framework, acculturation can manifest in four main strategies: integration, in which individuals preserve elements of their original culture while also adopting aspects of the host culture within a society that values cultural diversity; assimilation, characterized by the abandonment of the original cultural identity in favor of the host culture; separation, in which individuals maintain their culture of origin while rejecting engagement with the host society; and marginalization, marked by the loss of connection to both the original and the host cultures, resulting in social isolation⁽³⁵⁾. Acculturation does not occur in isolation but is closely intertwined with other cultural processes experienced during migration. Deculturation refers to the partial loss of elements of the culture of origin that may occur when individuals live within a different cultural environment, whereas enculturation describes the process through which the host society transmits its norms, values and rules, defining what is considered appropriate or unacceptable within the respective social framework⁽³⁴⁾. In parallel, transculturation highlights the bidirectional nature of cultural exchange in migration contexts, whereby both migrants and host societies adopt and transform customs originating from one another’s cultures⁽³⁴⁾. Together, these processes interact with acculturative strategies, such as integration, assimilation, separation and marginalization, to shape migrants’ identity construction, social adaptation and psychological well-being within the receiving society.

The importance of exploring psychopathological phenomena in migrants and refugees cannot be overstated. To analyze only the situation in our country, 52,000 new migrants obtained a residence permit for more than 12 months in 2024, up 5.7% from 2023⁽³⁶⁾. Also, 1800 short-term permits were issued to international students and 2600 to temporary and seasonal labor migrants (non-EU countries)⁽³⁶⁾. Regarding asylum seekers, 2300 applications were registered in Romania in the same year⁽³⁶⁾. The increasing number of migrants and asylum seekers highlights not only a demographic reality but also a significant clinical and public health challenge. From a mental health perspective, these figures translate into a growing population at risk of stress-related conditions, somatization and misdiagnosis within primary care and emergency settings. Without adequate training and awareness, healthcare professionals may focus on isolated symptoms rather than the broader migratory context, increasing the risk of unnecessary investigations, inappropriate treatments and delayed psychological support.

While most migrants demonstrate resilience, certain subpopulations experience a disproportionate burden of mental disorders associated with changes in their country or residence⁽³⁷⁾. It is also important to note, as Achotegui puts it, that humans can process migratory mourning because migration is a very frequent event in our species’ history⁽³²⁾. Stress-related conditions are more prevalent among refugees of all ages compared to the general population, and migrants with precarious legal status may have a higher risk of depression and anxiety disorders relative to refugees⁽³⁷⁾. A combination of factors, such as trauma exposures during the migration process, poverty after resettlement and limited social support, enhances the risk for psychiatric disorders in refugees and migrants⁽³⁷⁾. Therefore, migration in itself is a risk factor, but not a sufficient explanation for a mental disorder^(32,38). When combined with vulnerability factors (e.g., traumatic history, child abandonment, disabilities) and/or adjustment difficulties to the new country and culture (e.g., the environment is perceived as hostile), the Ulysses syndrome may appear⁽³²⁾. In countries receiving immigrants, this phenomenon may become a serious health problem, since the Ulysses syndrome is “the by-product of the unjust globalization and of the worsening of the living and health conditions” of migrants⁽³⁸⁾. The vulnerability is related to premigratory (such as age, personality, gender, language, occupation, expectations), migratory (losses, grief, posttraumatic stress) and postmigratory factors (e.g., cultural shock, civilizational conflict, discrepancies between aspirations and real-life conditions, discriminatory tendencies)⁽³⁴⁾.

Ulysses syndrome is not intended to be a diagnostic psychiatric category like depression or post-traumatic stress disorder, but rather a conceptual framework to understand the psychological impact of extended exposure to multiple stressors that exceed the capacity for normal adaptation⁽³⁹⁾. Achotegui places this syndrome in the middle of a continuum that starts with balanced emotional status, passes through mental health problems (stress, nervousness, sadness), and goes through Ulysses syndrome, mental health disorders, and finishes with mental health crises (which pose dangers to oneself or others)⁽⁴⁰⁾.

Migration can be conceived psychodynamically as a process of mourning, as the individual moves away from family and loved ones, as well as from their own country and culture⁽⁴¹⁾. There are three forms: the simple mourning, which is worked through in good conditions, complicated mourning, with serious difficulties in the working through of the migratory experience, and extreme mourning, which occurs in a problematic way that cannot be processed, when the Ulysses syndrome appears⁽⁴²⁾. Achotegui describes seven types of grief in migration: (1) grief for family and loved ones; (2) grief due to language; (3) grief of culture (including religion, traditional values); (4) grief of homeland; (5) grief of social status; (6) grief in relationship to the group of belonging (e.g., discrimination, xenophobia, racism); (7) grief due to the risk of physical integrity endangerment⁽³²⁾. Other losses have been highlighted by different authors, such as (8) grief related to the fractured personal history, since migration involves a breach from the past, representing a type of existential narrative rupture, and (9) grief related to the loss of previous identity – i.e., the original identity is no longer validated by loss of contact with previous significant others, therefore the migrant become a stranger, an “outsider”⁽⁴³⁾.

The intense psychological stressors suffered by migrants can lead to a cluster of physical symptoms, which can allow for framing the Ulysses syndrome as a prodrome of a potentially severe psychosomatic disorder^(43,44). Physical symptoms reflect the psychological burden, as individuals are pushed into a perpetual crisis state during the migration phase^(43,44). Symptoms of this syndrome may vary, but they result from an effort to adjust to extreme situations. Achotegui circumscribes depressive symptoms, without reaching the severity of a major depression, anxiety manifestations, somatic symptoms (e.g., digestive discomfort, headaches), attentional and memory difficulties, and culturally specific symptoms (e.g., “evil eye”, witchcraft)⁽³²⁾.

The defense mechanisms activated by the migration, which can explain the Ulysses syndrome, are regression (for avoiding the contact with the reality in a mature and realistic way, possibly explaining overdiagnosing of anxiety and depression in this population), negation (“everything is the same here and in my country”, “I have noted no differences between life here and in my country”, which avoid confrontation with the pain related to separation from home), projection (everything that is bad is related to the adoptive country, reflected in thoughts such as “this is a country of aggressive individuals”, “they don’t know anything about religion”), idealization of the native country, or even of the adoptive country (“in my country everything was perfect, or at least superior to what I found in this new country”), ambivalence (“the migration may mimic the Oedipian triangle, with the old and new country being symbolically represented by the parents), reactive formation (hyperadaptation and negation of own traditions), rationalization (in an unconscious attempt to overcome difficult and humiliating situations), dissociation (confronted with negative and destructive emotions, the individual may separate the idea of migration to obtain a better life and the painful reality of migration) and splitting (negation of own origins and refusal of cultural identity, or combined with projection of persecutory ideas may lead to paranoid delusions)⁽³³⁾.

According to a systematic review focused on the gender aspects of Ulysses syndrome, there are insufficient data on this line of research, with most reports being gender-neutral⁽⁴⁵⁾. This entails designing studies that explicitly measure and compare gender-specific stress responses, disaggregate data, and account for structural determinants that uniquely affect women and men, thereby refining understanding of Ulysses syndrome and informing gender-sensitive public health and policy responses to migrant mental health needs⁽⁴⁵⁾.

The differential diagnosis of Ulysses syndrome includes depressive disorders (but core symptoms of depression are missing, such as recurrent ideas of death or psychomotor retardation), adjustment disorders (there is a response proportionally to the stressful situation – i.e., migration) and post-traumatic stress syndrome (still, no intrusive thoughts related to traumatic situations, or avoidance of reminders of the trauma exist)⁽³²⁾. Migration is associated with a very high prevalence of posttraumatic stress disorder (PTSD; 46%), as a review demonstrated, especially among refugees, who experience a nearly double rate compared to the migrant workers⁽⁴¹⁾. Therefore, PTSD and acute stress disorder (ASD) should be at the forefront of the differential diagnosis in cases of Ulysses syndrome.

A systematic review (n=5 studies; N=487 participants) explored the relation between migratory grief and psychological distress, and the results showed a significant association between these two variables⁽⁴⁶⁾. The quality of the included studies was limited, but in migrants and refugees migratory grief should be considered as a potential source of significant distress⁽⁴⁶⁾. The prevalence rates of depression among labor migrants reached 20%, and in refugees – 44%, while anxiety disorders reached a prevalence of 21% and 40%, respectively⁽⁴⁷⁾. Also, prolonged grief disorder was reported in migrants as presenting a prevalence of 33.2%⁽⁴⁸⁾.

Authors investigating the prevention and management of Ulysses syndrome highlight the fact that policies and public health interventions have an essential role in addressing the mental health consequences of forced migration⁽³⁹⁾. A central recommendation is that policies facilitating a sense of belonging, through secure residency status, access to healthcare, social integration measures and opportunities for meaningful participation in society, can reduce the intensity and duration of stress responses associated with Ulysses syndrome⁽³⁹⁾. Such policies not only address immediate mental health needs but also contribute to restoring dignity and agency for refugees and asylum seekers, aligning with the broader humanitarian imperative to support individuals’ right to homecoming and safe settlement⁽³⁹⁾.

The second, less explored, perspective on the Ulysses syndrome views it as a form of “wandering” in the search for a diagnosis, akin to the Trojan War hero’s adventures^(49,50). Patients may get lost in the medical system or even be subjected to multiple investigations and follow-up appointments due to physicians’ tendency to make the best evidence-based therapeutic decision^(49,50).

In conclusion, the concept of the “two faces” of Ulysses syndrome refers to its dual nature as both a psychosocial stress-response condition and a clinical-systemic challenge. On one hand, the syndrome represents a pattern of psychological and somatic suffering arising from prolonged exposure to extreme and cumulative migratory stressors that exceed normal adaptive capacities. On the other hand, it manifests as a diagnostic and therapeutic challenge within healthcare systems, where symptoms are frequently misinterpreted, fragmented or over-investigated, leading to repeated consultations and potential medical wandering. At a practical level, healthcare professionals should be equipped with trauma-informed, culturally responsive skills to identify and address migration-related distress early, particularly within primary care settings where migrants most often first seek help⁽⁵¹⁾. Strengthening healthcare systems through training, clear referral pathways and supportive institutional policies can improve access to care and promote better mental health outcomes for migrant populations⁽⁵¹⁾. Failure to recognize this syndrome may lead to overpathologization, misdiagnosis or neglect of structural determinants of suffering. A nuanced understanding of Ulysses syndrome is therefore essential for ethical, effective and culturally responsive mental healthcare for migrant populations. Regarding the second interpretation of the Ulysses syndrome, the mental healthcare specialists should be aware of patients who require multiple medical assessments as a consequence of psychological insecurity, making such patients vulnerable to overdiagnosis and overinvestigation.

Between self-aggression and self-preservation: the Werther and the Papageno effects

These two opposed phenomena can be conceptualized as syndromes in a broader sense, as descriptive and heuristic constructs referring to patterned population-level responses to media representations of suicide. Unlike psychiatric syndromes, which imply relatively stable constellations of symptoms within individuals, these effects describe probabilistic, time-limited influences operating at the interface between media exposure, individual vulnerability, and sociocultural context. The use of the term “syndrome” in a broader, metaphorical sense reflects the recurrent phenomenological configuration through which these media effects manifest, without implying diagnostic status or individual-level pathology.

The Werther effect, named after the main character of J.W. Goethe’s novel The Sorrows of Young Werther (1774), refers to an increase in suicidal behavior following sensationalized or romanticized reporting of suicide, particularly among psychologically vulnerable individuals. The name of this effect was coined by D.P. Phillips in 1974, who published a seminal study showing that publicized suicides were followed by statistically significant increases in suicide rates⁽⁵²⁾. Goethe himself allegedly said: “My friends… thought that they must transform poetry into real life and, in any case, shoot themselves; and what occurred at first among a few took place later among the general public”^(52,53). The authorities at the time considered the phenomenon sufficiently worrisome as to ban the book in several areas, including Italy, Leipzig and Copenhagen⁽⁵²⁾. It is said that many contemporary readers of Goethe’s novel imitate Werther by wearing the same outfit – Werthertracht (Werther attire), consisting of a blue tailcoat, a yellow waistcoat and tall brown boots⁽⁵⁴⁾. The Wertherfieber or Werther-Krankheit (Werther mania or disease) was invoked as a contagion effect that led to tragic copycat suicides^(54,55). Such a cultural phenomenon is not limited in any way to the European space, but transcends societal boundaries; for example, in 1723, Kabuki plays, displaying tragic love stories ending in double suicide on stage, were banned in Japan^(54,56,57). This prohibition was the consequence of reports of couples imitating fictitious suicides in real life^(54,56,57).

Durkheim (1897) explored the link between suicide and psychological contagion, but he concluded there are not sufficient data to support the role of imitation as an influencing factor for the national rate of suicide, although this phenomenon may exert an effect in the immediate vicinity of the well-known suicide^(52,58). After front-page suicide stories, the US suicide rates showed an increase in the period following publication versus the expected baseline levels, an increase that was time-limited, suggesting a short-term imitation effect⁽⁵²⁾. Also, stories that received greater prominence were followed by a larger increase in suicide rates, while less visible reports produced little to no measurable effect⁽⁵²⁾. When a suicide was reported using a specific method, suicides using the same method increased disproportionately afterward, and post-report increases were strongest among groups demographically similar to the person described in the media⁽⁵²⁾. Phillips’ research (1974) was statistically controlled for seasonal variation, long-term suicide trends and economic fluctuations⁽⁵²⁾.

The media coverage of suicide may be dramatic, focused on glorification, rationalization or glamorization of the deceased; also, a thrilling manner of reporting was identified by press analysis, and the suicide being presented as an honorable act of bravery has also been identified in the newspaper reports^(59-61). Contributing further to a positive image of suicide, media reports of these acts as the result of a terminal, painful and invalidating disease, financial crisis, job loss or heartbreak, may legitimize suicide in the eyes of the public^(59,62).

There are authors supporting the lack of solid statistics from the 18^th century, demonstrating a significant increase in the suicide rates immediately after the release of the novel, therefore considering the idea of a “suicide epidemic” triggered by Goethe’s novel an exaggeration⁽⁶³⁾. However, it is possible that an underreporting of copycat suicides by contemporary newspapers could have been strategically implemented in order to contain the spreading of such behaviors⁽⁵⁴⁾. Also, both Catholic and Protestant perspectives on suicide considered it a sin, and it was not uncommon for the press of those days to include moral judgments in cases of suicide⁽⁵⁴⁾. A systematic account of suicides attributed to Goethe’s novel identified 19 individual cases of copycat suicides reported by different contemporary sources, although certain important limitations should be acknowledged (e.g., synthesis is based on media reports, not on death certificates or other official documents)⁽⁵⁴⁾.

The impact of media on suicide risk has been correlated with the social learning theory (i.e., learning of behaviors through modeling in vulnerable individuals) or identification theory (i.e., individuals facing the same emotional states or problems as the victims with whom they identify themselves, will resort to the same suicidal behaviors)⁽⁵⁹⁾. Also, a “horizontal identification” (i.e., individuals identify with those who share their demographic characteristics) and a “vertical” one (i.e., individuals mimic the behaviors of those who are famous and popular, or considered to be socially superior) have been considered mechanisms of imitating suicidal behaviors⁽⁵⁹⁾. Repetitive reporting of the same suicide and presentation of suicide myths were associated positively with suicide rates in a content analysis and latent class analysis (N=497 suicide-related print media reports published in Austria)⁽⁶⁴⁾. The latent class analysis suggested the “expert opinion” class and the “epidemiological fact” class were positively associated with suicide, while the “mastery of crisis” class was negatively associated with the same behaviors⁽⁶⁴⁾.

The Werther effect was also explored in South Korea, where the impact of reporting celebrity suicides by the media in the period 2005-2018 led to an increase in public suicides by 16.4% within just one day after the reports, with female and younger subgroups being the most vulnerable⁽⁵⁶⁾.

One relatively recent example of a potential cultural source for suicide contagion and intense debates in the scholarly and general public is the release of the television series 13 Reasons Why, a multi-episode fictional production about struggles, suicide included, in the lives of US adolescents⁽⁶⁵⁾. According to a study, an additional 195 suicide deaths were estimated among 10 to 17-year-old youths in the months following the release of the series⁽⁶⁶⁾.

Exposure to explicit, graphic depictions of self-harm on Instagram was the focus of attention from scholars who investigated the potential triggering role of such factors in a vulnerable audience⁽⁶⁷⁾. A two-wave US panel survey among 729 young adults showed that exposure to self-harm on Instagram was associated with suicidal ideation, self-harm and emotional disturbance, even after controlling for exposure to other sources with similar content⁽⁶⁷⁾. Exposure to self-harm on Instagram at the first wave predicted self-harm and suicidality-related outcomes at the second wave, one month later, suggesting a possible role for contagion in vulnerable users⁽⁶⁷⁾.

After the arrival of a new tabloid newspaper in Taiwan, a significant increase in the intensity of suicide competitive reporting in major, traditional newspapers, and such a higher intensity was significantly associated with an increase in actual suicide numbers, even after controlling for social variables⁽⁶⁸⁾. This analysis also suggested a mutual causation – i.e., more suicide reporting predicted more suicides, and more suicides also led to more reporting⁽⁶⁸⁾.

On the contrary, the Papageno effect (named so in honor of Mozart’s “Magic Flute” opera’s character) describes a protective influence of media narratives that emphasize coping, help-seeking, and recovery from suicidal crises, which are associated with reduced suicidal ideation and behavior^(68-71). This last effect was cornered by Niederkrotenhalter et al. (2010) based on the “Magic Flute” libretto, which draws heavily on early literary traditions^(68,69). In the respective opera, Papageno was saved by three boys/spirits from suicide by hanging after he feared that he had lost his loved one^(69,70). This was possible because these additional characters reminded him of other alternatives to dying, therefore reflecting the critical role of social support and finding different, concrete perspectives, overcoming the narrowing of the suicidal individual’s conscience^(69,70,72). The options offered to Papageno by the three boys/three spirits were delaying the act (thus preventing impulsive acting), to use communication instead of self-harm, and to re-frame the situation (by challenging the dysfunctional cognitions); also, they offered empathetic support, countering isolation as a suicide risk factor, focusing on the future and validating hope, encouraging realistic expectations⁽⁷²⁾.

When presented together, these concepts highlight the need for modern guidelines in the domain of responsible suicide reporting, also testifying to the powerful role of media framing in suicide prevention. According to a study that included 108 research papers exploring the impact of media stories on actual suicides, conducted by Domaradzki (2021), the “double-edged sword” of media coverage can be responsible for triggering additional suicides in society⁽⁵⁹⁾. The same study showed that non-fictional presentations of celebrities’ suicides in newspapers and television were associated with the strongest influence on subsequent suicides⁽⁵⁹⁾. However, because the negative reporting style can be modified, the media may become an ally in education and prevention, and it can decrease the risk of contagion⁽⁵⁹⁾.

WHO initiated a guideline for media reports on suicides, in an attempt to decrease the potentially harmful effects of the Werther phenomenon. The 2023 updated WHO resource highlights that sensationalized or detailed coverage of suicide can increase suicide risk in the population, whereas stories emphasizing survival, hope, help-seeking and recovery can have protective effects⁽⁷³⁾. This updated edition expands previous recommendations to include online, digital and social media contexts and offers practical dos and don’ts for responsible reporting that minimize harm, reduce stigma and encourage support for people in crisis⁽⁷³⁾. For example, WHO guidelines recommend journalists not to position suicide-related content as the top story, not to repeat that story, not to describe the method used, not to name or provide details about the site or location, not to use language or content which sensationalizes, romanticizes or normalizes suicide, or that presents it as a viable solution to problems, not to oversimplify the reason for a suicide and reduce it to a single factor, not to use photographs, video footage, audio recordings or digital or social media links and so on⁽⁷³⁾. On the do’s list, WHO recommends providing accurate information about where to seek help for suicidal thoughts and suicidal crises, educating the public with the facts about suicide and suicide prevention based on accurate information, reporting stories on how to cope with life stressors and/or suicidal thoughts and the importance of help-seeking, applying particular caution when reporting celebrity suicides, applying caution when interviewing bereaved family members or friends or individuals who lived experience of suicide, but also recognizing the fact that media professionals may themselves be affected when covering stories about suicide⁽⁷³⁾.

An analysis of nine media guidelines on the reporting of suicide showed that these sources contain similar recommendations, but they differ in the way they were developed and implemented⁽⁷⁴⁾. The same analysis investigated the impact of these guidelines and reported that the evidence is still limited regarding their impact on the behavior of media professionals or on completed or attempted suicide rates⁽⁷⁴⁾. However, other research confirms a favorable effect of these guidelines for media reporting, suggesting a decline by 75% of suicide rates in the Vienna subway and a reduction of 81 suicides in Australia^(75-77).

A literature review on studies about copycat suicides (n=25) concluded that media effects on suicidality are better understood as being distributed on a continuum between the Werther and Papageno effects⁽⁷⁸⁾. A systematic review and meta-analysis (n=8 studies, N=2350 participants) investigated the impact of stories of hope and recovery on individuals with vulnerability to suicide, pointing out that media narratives focused on positive aspects appear to have a beneficial effect on suicidal ideation (standardized mean difference [SMD]: -0.22), but there is insufficient evidence for an effect on help-seeking attitudes and intentions⁽⁷⁹⁾. Another systematic review (n=56 articles) showed that some interventions-such as media guidelines and journalist training- appear to improve the quality of suicide coverage; the impact of such improvements on actual suicide outcomes remains unclear⁽⁸⁰⁾. Yet another meta-analysis (n=31 studies) showed an increase in the suicide risk with 13% in the period after the media reported the death of a celebrity by suicide (median follow-up: 28 days; range: 7-60 days)⁽⁸¹⁾. When the suicide method used by the celebrity was reported, a 30% increase in death rate by the same method (RR=1.3; CI=1.18-1.44; median follow-up: 28 days; range: 14-60 days), but for general reporting the rate ratio (RR) was 1.002 (CI=0.997-1.008; median follow-up: 1 day; range: 1-8 days)⁽⁸¹⁾. With inherent limitations related to methodological factors and some publication bias in the literature being considered, there is still enough evidence to support a meaningful effect of celebrity suicide reporting on total suicides in the general population⁽⁸¹⁾.

The impact of media reporting depends on multiple interacting factors, including characteristics of the coverage (agent), attributes of individuals exposed to the reports (host) and broader social context (environment)⁽⁸²⁾. Therefore, extensive, detailed or sensational media coverage of suicide is associated with increases in actual suicide⁽⁸²⁾.

A systematic review (n=25 studies) concluded that both Papageno and Werther effects are supported by evidence, and that suicidal content on social media can be both contagious and protective, leaving space for optimism related to dedicated preventive interventions⁽⁸³⁾.

Based on the data collected, both Werther and Papageno effects are topics of interest for mental health specialists, but also for sociologists and anthropologists interested in exploring and preventing the phenomenon of suicide. Integrating the available information, some of it derived from well-designed epidemiological studies, into policies focused on early detection and prophylaxis of self-injurious behaviors could lead to significant improvements in mental healthcare.

Limitations of the review and future directions of research

Due to its narrative design, this review cannot be considered to have included all relevant data in the literature regarding EPSLO. Also, the quality of the data was not assessed, as all retrieved sources were treated as equal from this perspective. A third limitation concerns the potential bias in presenting the etiological considerations, given the absence of irrefutable data for most of the EPSLOs described here. Further research in this field is expected to assess the applicability of data on EPSLO and to stimulate research on diagnostic criteria and therapeutic interventions.

Conclusions

The last part of the review demonstrated the importance of exploring EPSLO not only from a clinical perspective but also from broader sociological and cultural perspectives. Phenomena such as Ulysses syndrome, Werther and Papageno effects shed light on the intricate interplay between psychological factors, such as individual vulnerabilities, sociological aspects, such as migration, and exposure to mass media influences, while also identifying potential targets for effective mental healthcare policies. Stendhal syndrome is an illustration of the intersection between esthetic emotions and psychopathology, and opens the research to other related phenomena, such as David syndrome or Jerusalem syndrome.

This review of the eponymous psychiatric syndromes with literary origins should be integrated into a larger, phenomenological perspective of each mental health specialist interested in genuinely understanding the complex nature of human suffering in various social and cultural contexts.

Conflict of interests: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.