Reading: What was the Mental Disease that Afflicted King Saul?

2CASE PRESENTATION

In this article, I evaluate King Sauls mental disorder as described in the Bible. The

study focuses on biblical passages associated with the kings inappropriate and dangerous

behavior, which apparently indicated a psychotic state, assesses the protracted course of

this mental illness, and analyses the kings subsequent recovery. Viewed by a modern

physician, the story of King Saul unfolds as possibly the earliest description of a patients

mental illness. The case highlights the challenges encountered in this diagnostic experi-

ence.

3PRESENTING COMPLAINTS AND

HISTORY FROM A MODERN PERSPECTIVE

King Saul, the first King of Israel, ruled the country 3,000 years ago. The son of

Kish, he was a tall and handsome child, a choice young man, and a goodly : and there

was not among the children of Israel a goodlier person than he : from his shoulders and

upward he was higher than any of the people(1 Sam. 9:2). When Saul grew up, he was

chosen to be the king because he was higher than any of the people from his shoulders

and upward and there is none like him among all the people. And all the people

shouted, and said God save the King (1 Sam. 10:23, 24). When Saul became king, he

participated in endless wars So Saul took the kingdom over Israel, and fought against all

his enemies on every side (1 Sam. 14:47). However, later in his life, signs of mental dis-

tress appeared: an evil spirit from the Lord troubled him (1 Sam. 16:14). Conse-

quently, Sauls servants summoned David to play his harp, and he [the king] loved him

greatly : and he became his armourbearer (1 Sam. 16:21). On hearing the music, the

symptoms of Sauls mental distress disappeared: David took an harp, and played with his

hand : so Saul was refreshed, and was well, and the evil spirit departed from him (1 Sam.

16:23). When David killed Goliath, a terrifying giant from the area of Gat, and subse-

quently defeated the Philistines, King Saul began to hate David. The roots of this hatred

were associated with the fact that the people believed that Saul hath slain his thousands,

and David his ten thousands [Philistines] (1 Sam. 18:7). The king developed feelings of

suspicion and jealousy toward David, and experienced uncontrolled impulses, which

led to a psychotic state the evil spirit of God came upon Saul....AndSaul cast the jave-

lin : for he said, I will smite David even to the wall with it. And David avoided out of his

presence twice (1 Sam. 18:10, 11). After attempting to kill David, signs of mental illness

subsided and the king gave David his daughter Michal in marriage. David again fought

the Philistines and defeated them in another battle. This victory had a negative impact

on the kings mental state: And the evil spirit from the Lord was upon Saul....AndSaul

sought to smite David even to the wall with his javelin : but he slipped away out of Sauls

presence, and he smote the javelin into the wall : and David fled, and escaped that night

(1 Sam. 19:9, 10). King Saul pursued David for the rest of his life sto destroy him. In the

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end, David had an opportunity to kill Saul, but he did not do it. So, the king called him

my son David, understanding that David rewarded me good, where as I have

rewarded thee evil (1 Sam. 24:17, 18) and appointed David to be the king after him.

Thus, the signs of kings illness disappeared. What can we learn from this story?

4ASSESSMENT

How would a modern physician assess such a patient? In this specific case all rele-

vant information was extracted from the patients medical file (the biblical text),

recorded 3,000 years ago. Because there is no word about mental illness in his child-

hood, it can be assumed that the kings premorbid status was unremarkable. However,

later in his life, the first signs of mental disorder appeared: an evil spirit from the Lord

troubled him. Fortunately, after listening to the music of Davids harp, the signs of this

mental disorder subsided. Later, however, the mental disorder reappeared, but this time

in more severe form. The king developed unreasonable and uncontrolled suspicions

and planned to destroy David. After some time, symptoms of mental illness subsided

again. King Saul became very friendly to David and gave his daughter to David in mar-

riage. Later, however, the King began once again to pursue David to kill him. The symp-

toms of mental illness reappeared. Finally, King Saul called David his son and appointed

David to be the king after him. Thus, a full recovery occurred. The assessment of all King

Sauls disturbed behavior indicates that he was afflicted with some kind of mental dis-

order.

Evaluation of this patients mental disorder was mainly based on the records in his

medical file. Other modern assessment tools should include various diagnostic interview

protocols, such as Research Diagnostic Criteria for major depressive disorder, mania, or

schizoaffective disorder, depressed or manic type (Spitzer, Endicott, & Robins, 1987);

the National Institute of Mental Health Diagnostic Interview Schedule (Robins, Helzer,

Croughan, & Ratcliff, 1994), used to assess the diagnostic elements, including symp-

toms and their severity and frequency over time and whether the symptoms were caused

by physical illness or injury, use of drugs or alcohol, or the presence of another psychiat-

ric disorder; and DSM-IV criteria (American Psychiatric Association, 1994).

5CASE CONCEPTUALIZATION

What are the most likely etiological factors for King Sauls mental disorder? In the

absence of a family history of mental disorders, hereditary can be excluded. Other etio-

logical factors include a substance-induced mood disorder, various general medical con-

ditions, and various psychiatric illnesses (American Psychiatric Association, 1994).

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SUBSTANCE-INDUCED MOOD DISORDER

Did King Saul suffer from a substance-induced mood disorder, characterized by a

prominent and persistent disturbance in mood associated with the direct physiological

consequences of a drug abuse, a medication or another somatic treatment for depres-

sion, or toxic exposure (American Psychiatric Association, 1994)? The psychoactive sub-

stances most commonly associated with the development of psychotic syndromes

include alcohol, indole hallucinogens (e.g., lysergic acid diethylamine, amphetamines,

cocaine, mescaline, phencyclidine, ketamine, steroids, and levothyroxine) (Mezzich,

Lin, & Hughes, 2000). In the absence of appropriate anamnestic data, this diagnosis

seems very unlikely.

GENERAL MEDICAL CONDITION

A variety of general medical conditions can cause psychotic symptoms, including

neurological, endocrine, and metabolic conditions; fluid and electrolyte imbalance;

hepatic or renal diseases; and autoimmune disorders with central nervous system

involvement (American Psychiatric Association, 1994). Did the king suffer from a psy-

chotic disorder associated with one of these general medical conditions? In the absence

of appropriate anamnestic, physical, and laboratory findings, this diagnosis seems very

unlikely.

DELUSIONAL DISORDER

The essential feature of delusional disorder is the presence of one or more non-

bizarre delusions (i.e., involving situations that may occur in real life, such as being fol-

lowed, poisoned, infected, or loved at a distance; being deceived by a spouse or lover; or

having a disease) of at least 1 months duration. Functioning is not markedly impaired

and behavior is not obviously odd or bizarre (American Psychiatric Association, 1994).

It is stated that the evil spirit of God came upon Saul. And Saul sought to smite

David even to the wall with his javelin. It can be speculated that the king may have suf-

fered from a disturbance in thought content characterized by a paranoid delusion,

believing falsely that David was following him and sought to harm him and overthrow

him, the king. These delusions may be derived from the attempts to supply compre-

hensible interpretations of abnormal perceptual experiences (David, 1990), wish fanta-

sies and conflicts reaching their peak immediately before the onset of the acute attack

(Freeman, 1981), which led to oversuspiciousness and paranoid activity (Kaplan &

Sadock, 1985). Thus, the kings delusions can be defined as bizarre. Because delusions

of delusional disorder are mainly nonbizarre, the diagnosis of delusional disorder seems

very unlikely.

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MANIC EPISODE

Criteria for diagnosing a manic episode include persistently elevated, expansive, or

irritable mood, lasting at least 1 week, accompanied by at least three of the following

symptoms: inflated self-esteem or grandiosity, decreased need for sleep, being more talk-

ative than usual or under pressure to keep talking, flights of fancy or the subjective expe-

rience that thoughts are racing, being easily distracted, and excessive involvement in

pleasurable activities that have a high potential for painful consequences (American Psy-

chiatric Association, 1994). Manic episode may be associated with isolated psychotic

phases accompanied by inappropriate or bizarre speech or behavior, grandiose or reli-

gious delusions, and paranoid trends. The episode is characterized by intervening symp-

tom-free periods of normal functioning, good productivity, and successful interpersonal

relationships (Egeland, Hostetter, & Eshleman, 1983). Relapse rates as high as 60% over

a period of 2 years after recovery may occur (Gabbard, 2000).

Did King Saul suffer from a manic episode? It can be assumed that the passages an

evil spirit from the Lord troubled him and the evil spirit of God came upon Saul....

And Saul cast the javelin : for he said, I will smite David even to the wall with it indicate

an irritable mood, a decreased need for sleep, low concentration, aggression against

David, a disturbance in the content of thoughtdelusions or in perceptionhallucina-

tions, indicating a psychotic state. Did this patient suffer from an abnormal thinking or

severe thought disorder, characterized by excess of odd, unusual, or bizarre thinking

occur in manic patient (Grossman, Harrow, & Sands, 1986)?

It seems likely that the whole course of King Sauls mental disorder, with its recur-

rent unreasonable intentions to destroy David, alternating with normal-functioning

phases indicates a severe, recurrent, and pernicious disorder that may occur in a manic

patient (Harrow, Goldberg, Grossman, & Meltzer, 1990). Psychotic features, including

delusions and hallucinations, that may have afflicted King Saul are common and occur

in about 72% of patients of mania (Tohen, Waternaux, & Tsuang, 1990). Thus, there are

enough criteria to meet the diagnosis of manic episode accompanied by psychotic

phases. Hypomanic episode seems unlikely, because this disorder is neither psychotic

nor nondisruptive (Akiskal, 2000).

MAJOR DEPRESSIVE DISORDER

Did King Saul suffer from major depressive disorder, single or recurrent episodes?

Major depressive disorder (unipolar depression) is the most common mood disorder,

which may manifest as a single episode or as recurrent illness (Keller, Shapiro, Lavori, &

Wolfe, 1982 WHICH REF?; Solomon et al., 2000). It is estimated that only about 50%

of patients recover after 1 year (Keller, Shapiro, Lavori, & Wolfe, 1982 WHICH REF?),

and 79% after 2 years (Keller et al., 1984). This disorder is characterized either by a

severely depressed mood or by the loss of interest or pleasure in nearly all activities with

the change in previous functioning lasting for at least 2 weeks. At least a further four

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symptoms are required to define the disorder, including changes in appetite or weight,

insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy,

feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or

concentrate or indecisiveness, or recurrent unfocused thoughts of death or suicide, or

suicide attempt (American Psychiatric Association, 1994). Psychotic features includ-

ing hallucinations and delusions may occur in 14% of patients with major depression

(Johnson, Horwath, & Weissman, 1991).

Do the passages an evil spirit from the Lord troubled him, and Saul was

refreshed, and was well, and the evil spirit departed from him, and the evil spirit of God

came upon Saul....AndSaul cast the javelin : for he said, I will smite David even to the

wall with it indicate major depression disorder accompanied by psychotic symptoms?

Because there is a subgroup of depressed patients who are distinctly vulnerable to psy-

chosis (Glassman & Roose, 1981; Kettinger, Harrow, Grossman, & Meltzer, 1987), it is

possible either that the king was afflicted by depression, which later developed into psy-

chotic state, or that major depression with psychotic features appeared together with the

onset of mental disorder.

In depressive disorder with psychotic features, negative thinking reaches grossly

delusional proportions and is maintained with such conviction that convictions are not

amenable to change by evidence to the contrary (Akiskal, 2000). According to Kurt

Schneider, delusional thinking in depression derives from humankinds four basic inse-

curities, those regarding health, financial status, moral worth, and relationship to others.

Severely depressed patients may have delusions of worthlessness, sinfulness, and perse-

cution. They believe they are being singled out for their past mistakes and that everyone

is aware of their errors. Paranoid thinking in depression is often persecutory, because it

derives from the belief that the person deserves punishment for his or her transgressions

(Akiskal, 2000).

It seems that King Sauls negative system of thinking developed as a consequence

of his relationship with David. The whole system of their relationship reached delu-

sional proportions, in which Sauls persecutory ideation was not dispelled by any reason-

able facts. These persecutory delusions were associated with a conviction that David

deserved a severe punishment, which lead to a violent behavior toward the object of his

hatred, David.

MIXED EPISODE

A mixed episode is characterized by a period of time, lasting at least 1 week, during

which the criteria for both manic episode and major depression episode are met nearly

every day. The individual may experience rapidly alternating moods (sadness, irritability,

euphoria) accompanied by symptoms of a manic episode and major depression episode

(American Psychiatric Association, 1994). Because the biblical passages cited previously

may indicate either manic episode or major depression, it is likely that the king suffered

from a mixed episode.

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BIPOLAR I DISORDER

Bipolar I disorder is characterized by one or more manic or mixed episodes. Often,

individuals also have had one or more major depressive episodes (American Psychiatric

Association, 1994). Severe psychotic features may accompany this disorder. As described

previously, the king may have been afflicted with either manic episode or mixed or major

depressive disorder with psychotic features. Thus, it is likely that the king suffered from

bipolar I disorder. Bipolar II disorder can be ruled out, because there are not enough cri-

teria to indicate a hypomanic episode, as described previously.

CYCLOTHYMIC DISORDER

Criteria for this disorder include numerous episodes of hypomanic and depressive

symptoms (Akiskal, 2000). In the absence of sufficient evidence for hypomanic disorder,

as mentioned previously, this diagnosis seems very unlikely.

DYSTHYMIC DISORDER

This disorder refers to a chronic mild depressive syndrome, with insidious onset

often commencing in childhood or adolescence, characterized by less acute, less severe,

and less disabling depressive symptoms, symptomatically subsyndromal and psychologi-

cally intractable to change, which are present for at least 2 years and may last for many

years (Akiskal, 1983; American Psychiatric Association, 1994, 2000; Lehmann, 1985;

McCullough et al., 1988).

Did King Saul suffer from this disorder? Although the words an evil spirit from the

Lord troubled him may indicate a first episode due to dysthymic disorder, in the pres-

ence of subsequent severe illness accompanied by psychotic episodes (American Psychi-

atric Association, 1994), this diagnosis seems very unlikely.

People with dysthymia, of at least 2 years duration, frequently have a superimposed

major depressive disorder, a condition often referred to as double major depressive disor-

der (American Psychiatric Association, 2000; Keller & Shapiro, 1982). However, if this

diagnosis is accepted there is no explanation as to what kind of disorder was associated

with the psychotic symptoms. Moreover, a small number of patients with dysthymic dis-

order may develop bipolar disorder (Klein, Schwartz, Rose, & Leader, 2000). Thus, it is

possible that King Sauls mental disorder began as dysthymic disorder but later devel-

oped into bipolar disorder.

SCHIZOPHRENIA, PARANOID TYPE

The essential feature of paranoid type of schizophrenia is a preoccupation with one

or more delusions or auditory hallucinations in the context of relative preservation of

cognitive functioning and affect. Symptoms such as disorganized speech, disorganized

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or catatonic behavior, or flat or inappropriate affect are not prominent. Delusions are

typically persecutory or grandiose, or both, but delusions with other themes also may

occur. The combination of persecutory and grandiose delusions with anger may predis-

pose the individual to violence (American Psychiatric Association, 1994). A significant

proportion of people with schizophrenia is driven to commit offences as a result of their

symptoms (Humphreys, Johstone, MacMillan, & Taylor, 1992). As the illness pro-

gresses, the delusions become more complex and irresistible, and the risk of dangerous

behavior increases (Taylor, 1985; Taylor & Gunn, 1984).

Did King Saul suffer from paranoid schizophrenia? Does the first passage an evil

spirit from the Lord troubled him indicate co-occurring depressive symptoms in a

patient experiencing the first episode of schizophrenia as a core part of an acute illness or

a subjective reaction to the experience of psychotic decompensation (House, Bostock, &

Cooper, 1987; D.A.W. Johnson, 1981; Koreen et al., 1993; Siris, 2000)? Do the passages

the evil spirit of God came upon Saul....AndSaul cast the javelin : for he said, I will

smite David even to the wall with it and And the evil spirit from the Lord was upon

Saul....AndSaul sought to smite David even to the wall with his javelin indicate preoc-

cupation with persecutory delusions or hallucinations based on jealousy, which led to a

violent behavior?

Kraepelin distinguished manic-depressive psychosis from dementia praecox or, as

they are termed today, unipolar and bipolar affective disorders from schizophrenia. In

dementia praecox, patients follow a progressively deteriorating course with no return to a

premorbid level of function, whereas in manic-depressive psychosis psychopathology

alternates with periods of normal patient functioning (Lehmann, 1985). In the presence

of recurrent episodes of psychotic state alternating with normal functioning as in King

Sauls case, the diagnosis of schizophrenia seems very unlikely.

SCHIZOAFFECTIVE DISORDER

The essential feature of this disorder is an uninterrupted period of illness during

which, at some time, there is a major depressive or manic or mixed episode concurrent

with two or more symptoms of schizophrenia, such as delusions, hallucinations, disorga-

nized speech, grossly disorganized or catatonic behavior, and negative symptoms

affective flattening, alogia, or avolitionlasting at least 6 months (American Psychiatric

Association, 1994). Did the king suffer from this disorder? In the presence of recurrent

episodes of psychotic symptoms interrupted by periods of recovery, this diagnosis seems

very unlikely.

SCHIZOPHRENIFORM DISORDER

The essential features of this disorder are identical to those of schizophrenia. The

total duration of the illness is at least 1 month but less than 6 months (Akiskal, 2000).

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Because the total duration of King Sauls mental disorder is estimated at more than 6

months, this diagnosis seems very unlikely.

SHARED PSYCHOTIC DISORDER

Shared psychotic disorder is characterized by the development of a delusion in an

individual in the context of a close relationship with another person who has an already-

established delusion. The new delusion is similar in content to that of the other person

(American Psychiatric Association, 1994). In the absence of another person close to the

king who had developed similar delusions, this diagnosis seems very unlikely.

BRIEF PSYCHOTIC DISORDER

The essential feature of brief psychotic disorder is a disturbance involving the sud-

den onset of at least one of the following symptoms: delusions, hallucinations, disorga-

nized speech, and grossly disorganized or catatonic behavior. The duration of an episode

of this disturbance is at least 1 day but less than 1 month, with eventual full return to

premorbid level of functioning (American Psychiatric Association, 1994). Although the

king may have suffered from brief psychotic disorder, it is more likely that his mental dis-

order lasted more than 1 month. Therefore, this diagnosis seems very unlikely.

NONSPECIFIED PSYCHOTIC DISORDER

This category includes psychotic symptomatology, in which there is inadequate

information to make a specific diagnosis or there is contradictory information or disor-

ders with psychotic symptoms that do not meet the criteria for any specific psychotic dis-

order (American Psychiatric Association, 1994).

Did King Saul suffer from this disorder? Because the king may have been affected

by a psychotic state, as described previously, in the absence of accurate information for a

specific diagnosis, the diagnosis of nonspecific psychotic disorder is possible. However,

the diagnosis of bipolar I disorder, as discussed previously, provides a better explanation

of the kings disturbed behavior as a whole.

FINAL ASSESSMENT

King Sauls disturbed behavior taken as a whole indicates that he was afflicted by

some kind of a mental disorder. Among the many disorders that could have affected the

king, either manic episode with psychotic phases, major depression with psychotic fea-

tures, mixed episode, bipolar disorder I, dysthymic disorder later developed into bipolar

disorder, or nonspecific psychotic disorder are the most likely. And among these diagno-

ses, bipolar disorder I provides the best explanation for King Sauls disturbed behavior as

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a whole. Examining ancient King Sauls mental illness from a contemporary perspective

reflects the features of mental illness, which have changed little through the ages.

It has been reported that Jewish males have higher rates of major depression

(Levav, Kohn, Golding, & Weissman, 1997) and involutional and manic-depressive psy-

choses than other ethnic or national or religious groups (Sanua, 1989). Thus, the ques-

tion is if roots of bipolar disorder I can be traced back to biblical times?

6FOLLOW-UP

Most patients presenting for the first time with a psychotic affective illness require

several months to recover to the point of no longer meeting DSM-IV diagnostic criteria

for a current episode (Tohen et al., 2000). We can assume that at least several months

have passed from the time when the first psychotic episode occurred until the symptoms

of this episode subsided. But, many years passed from the occurrence of the second psy-

chotic episode until King Saul finally recovered.

7TREATMENT IMPLICATIONS OF THE CASE

Contemporary patients similarly to ancient patients require high level of treat-

ment.

A diagnostic investigation should include laboratory tests such as complete blood

count, biochemical and serological tests, including thyroid-stimulating hormone, vita-

min B12, folate, VDRL test for syphilis, and a computed tomography scan of head, EEG,

ECG, and chest X ray. A modern treatment should be based on supportive, interper-

sonal, and cognitive-behavioral approaches. Pharmacological therapy should include a

mood stabilizer (lithium, Valproate, or carbamazepine) for acute and preventive treat-

ment. Other treatment modalities include the high-potency benzodiazepine anticon-

vulsants (clonazepam or Lorazepam), typical antipsychotics-dopamine receptor antago-

nists (chlorpromazine or haloperidol), atypical antipsychotics-serotonin-dopamine anta-

gonists (risperidone, clozapine, olanzapine, quetiapine, or sertindole), L-type calcium

channel inhibitors (verapamil, nimodipine, or isradapine), the newly approved anti-

convulsant for add-on-therapy (lamotrigine, gabapentin, or topiramate), thyroid prepa-

ration (levothyroxine), and electroconvulsive therapy (Post, 2000). Because there are

many therapeutic approaches, the optimal treatment strategy should be chosen for each

individual patient.

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8RECOMMENDATIONS TO CLINICIANS AND STUDENTS

Modern clinicians and students may be confronted with patients who have devel-

oped a severe and potentially chronic mental illness, the features of which have changed

little over the ages. Although new diagnostic and treatment strategies have been devel-

oped over time, ancient and modern psychiatric patients deserve similar diagnostic

investigation and subsequent treatment. We need to increase our knowledge of ancient

history and learn from the psychiatric cases we find there to improve our treatment of

contemporary patients.

We have not included any commentaries but referred to the words of the Bible just

as written. This article is in addition to previously published work by the author on vari-

ous biblical themes (Ben-Noun, 1997, 1999, 2001, 2002).

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Liubov (Louba) Ben-Noun, MD, is a senior lecturer in Department of Family Medicine, Faculty for Health

Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Clinical and research interests are wide-

ranging, with a special interest in psychiatric research and contemporary medicine in the Bible. A personal

publication list includes 51 publications published worldwide. Among various topics, the development of a

new method in the assessment of obesity and characterization of asthma in primary care clinics. Among psy-

chiatric topics, generalized anxiety disorder in dysfunctional families, characteristicof patients refusing pro-

fessional psychiatric treatment, drinking wine to inebriation in biblical times, family dynamics in biblical

times, and Joseph as a family psychotherapist.