Literary case study of psychosis: The Vegetarian

Abstract

In the award-winning and widely-acclaimed fictional novel, The Vegetarian, the author, Han Kang, relates a compelling and dramatic story of inexorable psychotic deterioration from the perspective of a tragically affected young woman and her close family members. Apart from a variety of interpretations of psychosis from historical, social, psychological, and feminist perspectives, the book also presents a detailed and realistic picture of objective psychotic symptoms that reveals insights into historic and nearly forgotten phenomenological concepts. In this literary case study, we analyze the symptoms remarkably described by the author and briefly review the medical literature on the phenomena of catatonia, schizophrenic autism, paragnomen and the praecox-feeling.

Key Words: The Vegetarian; Catatonia; Case study; Paragnomen; Praecox-feeling; Autism

Core Tip: In the “The Vegetarian”, author Han Kang presents the dramatic story of a woman afflicted with psychosis. The story is told from the perspective of both her inner thoughts and the attempts by her family to understand her struggles. In addition to a social, psychological, or feminist interpretation, the novel presents a realistic picture of psychosis that illustrates the historic phenomenological concepts of catatonia, autism, paragnomen and the praecox-feeling which are reviewed herein. Viewed as a literary case study of the impact of psychosis on patients, families and society, The Vegetarian is a fascinating addition to the standard psychiatric curriculum.

INTRODUCTION

In 2016, the prestigious Man Booker International Prize was awarded to Han Kang, a Korean writer, for her novel, The Vegetarian, and to its English translator, Deborah Smith. The English translation was also generally well-received by critics, although doubts were raised about its authenticity[1]. First published in Korean in 2007, the book chronicles the psychiatric illness of a young woman in contemporary South Korea. Brutally raw, stirring, and anxiety-provoking, yet captivatingly poetic (Han Kang is also a poet), the book baffled critics and readers alike. “Hypnotically strange”, “mesmerizing”, “visceral and terrifying”, and “shocking” are but a few comments by critics that appear in the blurb of the Hogarth Press edition of the book[2].

Like many great works of fiction, The Vegetarian allows for a variety of interpretations from historical, social, psychological, and feminist perspectives, set against the background of modern Korean society which the author suggests is still beset by strong traditional, patriarchal values and their stifling impact on women[3]. Gender inequality, family dysfunction, individualism vs conformism, body image, sexual abuse, autonomy over one’s body and one’s life, violence, victimization, exercise of freedom of choice that is punished by a repressive society, and a tacit, personal rebellion in the form of a radical refusal of human cruelty are some of the explanatory conclusions drawn by critics to interpret the message of this book. Most critics and readers agreed that the protagonist called Yeong-hye could preserve her independence and humanity only by “seeking refuge in mental illness”, manifested as a desire to transform into a tree. The author herself said that in “the protagonist Yeong-hye’s extreme attempt to turn her back on violence by casting off her own human body and transforming into a plant lies a deep despair and doubt about humanity”[4]. This notion is not new; psychiatric illness as a conscious protest against an unjust and repressive society was, and still is, the main tenet of the anti-psychiatry movement, most prominently in its heyday in the 1960s and 1970s. A brief note on The Vegetarian in the medical literature also focuses on the social-psychological aspects of the book[5].

As The Vegetarian is a work of fiction, all of these partly overlapping interpretations are valid and legitimate. However, due to the author’s uncanny ability to describe the rich tapestry of signs and symptoms evoking the development of a severe mental illness, the book also lends itself to a psychopathological interpretation, particularly from a phenomenologically informed direction. Even though The Vegetarian is a work of art and not a psychiatric case study, the book contains enough information - the writer received guidance on psychiatry from a psychiatric hospital[6] - to reconstruct and bring to life several main features of a severe psychotic disorder. However, unlike all of the other above-mentioned psycho-social interpretations, a psychopathological reading of The Vegetarian starkly reveals the relentless deterioration of a severe mental illness that robs its sufferer of her freedom of choice; that is, in Yeong-hye’s case, rebelling against the woes of society by assuming a psychotic position is not really a conscious decision but rather a psychological rationalization to give meaning to a probably mainly biologically-determined descent into madness. For the reader, the admixture of dispassionate and highly emotionally charged text adds to the disquieting inevitability of a tragic outcome.

This slim novel of only 188 pages in paperback edition[2] is set in contemporary urban South Korea in the context of an “ordinary” lower-middle-class family. The book is composed of three parts that were first published separately in South Korea in the 1990s, and recounts Yeong-hye’s descending path to a severe psychotic illness that has all the hallmarks of schizophrenia. The first part narrates the sudden beginning of Yeong-hye’s illness from the perspective of her husband, a decidedly “average”, conformist salesman; the second part describes the unabating progress of Yeong-hye’s illness through the eyes of her brother-in-law; and the third part presents her sister’s observations of Yeong-hye’s downward spiral to the stormy end-state of psychosis, by which time she has completely lost her original self and become closed to human society. Yeong-hye hardly ever speaks in the book, but her dreams and inner monologues, printed in italics, appear frequently throughout the text.

A BRIEF SYNOPSIS

Part 1

Yeong-hye is described by her husband as “a woman of few words”, a “completely unremarkable…passive personality…the most run-of-the-mill woman in the world…a completely ordinary wife”. She is a part-time assistant instructor in a graphic design college who lives a solitary life in a loveless, childless marriage and spends most of her free time in her room reading. Her only unusual habit is that she never wears a bra, an embarrassing practice frowned upon in mainstream Korean society, because she feels constricted, perhaps an early sign of her indifference to societal norms expected of women. The husband’s description of Yeong-hye coldly and distantly reminds the reader of Kafka’s factual account of people and situations, and occasionally, it is such a dry and alienating description of a human being that it borders on the bizarrely comic.

One night, the husband is utterly surprised to find Yeong-hye standing in front of the fridge “motionless”, “ramrod straight”, and “completely unresponsive, as though lost in her own world”. The only explanation Yeong-hye gives is, “I had a dream”, and she retires to the living room where she proceeds to lie down in a fetal position. The next morning, Yeong-hye is silently throwing all meat products from the fridge onto the floor while repeating the same short sentence as a few hours ago. When the husband grabs her wrist to stop her, he is stunned “to find her fiercely tugging back against me”. The exasperated husband concludes, “You are insane!”, while witnessing the “strange behavior of my even-stranger wife”.

In the context of this unexpected, strange scene, Yeong-hye does not explain her behavior other than to repeat, “I had a dream”. However, her horrific, nightmarish dreams or inner monologues stemming from traumatic childhood experiences of how animals were treated in the countryside is described as: “...great blood-red gashes of meat, blood still dripping down…there is no end to the meat, and no exit. Blood in my mouth, blood-soaked clothes sucked into my skin”.

From here, Yeong-hye consequently adheres to a vegan diet and quickly loses weight. She becomes increasingly isolated and beset by insomnia. She is withdrawing into an autistic mode of existence, paying no attention to social norms and being seemingly oblivious and indifferent to cringeworthy social situations created by her own behavior. For instance, she attends her husband’s business dinner, with his bosses, without wearing a bra, which causes huge embarrassment, and sits mostly silent, giving no explanation about her dietary choice. Over the subsequent weeks, her husband realizes that Yeong-hye has undergone an irreversible “drastic transformation”. In a family gathering, upset by her stubborn refusal to eat animal products without offering any rational explanation, her father hits Yeong-hye and forces a piece of meat into her mouth. In response, Yeong-hye grabs a knife and cuts her wrist and is eventually taken to a hospital. Apart from the turbulent event of self-harm, outwardly, Yeong-hye displays an indifferent, distant, overall inappropriate affect and neutral mood, although she is overwhelmed with violent, blood-soaked childhood memories related to a dog bite. She feels pain in her chest: “Something is stuck in my solar plexus…it [has] lodged there permanently…I can feel this lump all the time…Because of meat. I ate too much meat. The lives of animals I ate have all lodged there. Blood and flesh, all those butchered bodies…and though the physical remnants were excreted, their lives still stick stubbornly to my insides.”. Eventually she ends up in a psychiatric ward, where she receives unspecified treatment for several months.

Part 2

The second part takes place 2 years later. Yeong-hye is now divorced and lives in a small apartment withdrawing into an even more solitary existence than before. Her brother-in-law, a mediocre video artist, is planning a project involving a video of a nude female body painted with flowers. He has been sexually infatuated with Yeong-hye, particularly since learning that she has a flower-like blue Mongolian mark on her buttock. He easily convinces Yeong-hye to let herself be painted naked and filmed, which eventually leads to a sexual encounter between the two. Semi-mute, vague, and perplexed, she participates in the painting and the sexual act as an automaton, hardly speaking or conceiving what is happening, acting almost like an inanimate object and too passive to resist sexual abuse. The sexual encounter is discovered by Yeong-hye’s sister, who instantly realizes the abuse of her mentally ill sister by her amoral husband and alerts the authorities. Yeong-hye is then admitted to a psychiatric hospital again. By then, Yeong-hye’s illness had progressed further, in that she is inward-looking and has completely lost social grace, common sense, and interest in the outside world.

Part 3

In the third part, psychosis is accelerating as Yeong-hye deteriorates to the deepest possible autistic existence, depicted by her attempts to transform into a tree. She is now in a severe catatonic state on a long-term ward in a psychiatric hospital, emaciated, hardly and selectively speaking, posturing bizarrely, and refusing nutrition. She has started posturing in a handstand, based on her bizarre delusional idea that she should be a tree, as trees stand on their “heads” and push their “hands” as roots into the ground, and she could sprout leaves and flowers from her body. She can be removed from this position only by force. She believes that she no longer needs food, only water and sunshine, and tells her sister that her inner organs have atrophied, and she is not a wild animal anymore. Attempts to forcibly feed her are unsuccessful as she actively resists. While in a life-threatening condition, she still manages to abscond into the neighboring woods for a brief period.

The strict handling of the delusionally tormented, semi-stuporous woman by desperate staff is deeply upsetting, although presented in a matter-of-fact manner and probably not grossly exaggerated. Active treatments, such as pharmacotherapy or electroconvulsive therapy, are not mentioned. Due to gastric bleeding during the insertion of a feeding tube, Yeong-hye is transferred to an acute psychiatric facility, and the novel ends with the ambulance leaving the hospital. The contrast between the poetic descriptions of the surrounding nature and the harsh reality of psychiatric hospital staff struggling with a severely ill Yeong-hye underscores the tragedy of a severe mental illness. By then, she has long been abandoned by her family, except for her caregiver sister who is deeply affected by Yeong-hye’s condition and facing her own demons.

DISCUSSION

Paragnomen

Yeong-hye’s first, sudden, entirely unexpected, and inexplicable act of turning vegetarian, which heralds the start of her psychiatric illness, can be described using a now-obscure psychopathological term, “paragnomen”, defined as an isolated “thought or behavior contrary to expectations”[7]. These are suddenly emerging thoughts or behaviors perceived as entirely unexpected and baffling to others against the background of social norms and the personality and biography of the person, thereby constituting the first clearly appreciable fissure in the naturally flowing continuity of one’s life. As such, paragnomen has been observed and described as occurring occasionally as an initial, isolated sign of schizophrenia[8,9]. It is clear that Yeong-hye’s abrupt refusal to eat meat or any animal products has nothing to do with vegetarianism or veganism practiced by millions of people - including many in South Korea - or anorexia as a psychiatric disorder; rather, it signals the beginning of the psychotic phase of schizophrenia.

Paragnomen was described by the Polish psychiatrist Eugeniusz Brzezicki[7]. In the case of a behavior classified as paragnomen, neither an observable, strong affective component nor an impairment of consciousness is present. This is the basis for distinguishing paragnomen from situational emotional outbursts or fugue states[8,10]. Nowadays, paragnomen is not a well-known psychopathological phenomenon, although a greater familiarity with the concept would be useful for the early identification of an impending psychosis.

Catatonia

Together with the first appearance of paragnomen, Yeong-hye presents with unequivocal signs of catatonia, including near-mutism, withdrawal, staring, posturing, nudism, negativism in the form of food refusal, perseverative tendencies and even possibly Gegenhalten. In fact, according to contemporary clinical practice, using the Bush-Francis Catatonia Rating Scale[11], she would already qualify for a diagnosis of catatonia, the signs and symptoms of which would become pronounced to an extreme degree as her illness progresses. Her inner experiences of horror match her abnormal psychomotor behavior. Nevertheless, the horrifying inner experiences cannot fully explain the motor abnormalities as several forms of psychomotor reaction other than catatonia, such as screaming, agitation, or frank panic, can occur in response to such recurrent frightening images. We found no study that explored whether a full catatonic syndrome can appear in the prodrome of schizophrenia, as convincingly described in Yeong-hye’s case, as an early indicator of an emerging frank schizophrenic psychosis. As catatonic signs and symptoms are not part of early psychosis screening instruments e.g., PQ-16[12], CAARMS[13], specifically designed investigations focused on early signs of the catatonic motor phenomenon are needed to answer this potentially important question.

In the final stage of her illness, the semi-stuporous, negativistic, anorexic, extremely withdrawn, and selectively mute Yeong-hye displays a bizarre posture of handstands, which is the direct consequence of her profound self-disturbance leading to the delusional desire to become a tree. This followed a dream in which she was a tree, and flowers and leaves grew from her body.

Surprisingly, during the revival of interest in catatonia over the past three decades, up to 2020, only two studies[14,15] had explored the subjective experiences of patients during an acute catatonic episode. Recent studies[16-18], however, confirmed preliminary findings and clinical lore suggesting that patients’ subjective experiences are partly correlated with their motor symptoms and include fear/anxiety in approximately 50% of cases[16,17], psychotic experiences in approximately 70% of cases[16], self-disturbances[18], withdrawal/isolation[15,17], ambivalence or dissociation[14,18], or amnesia[14]. Further studies of subjective experiences in catatonia promise a fruitful contribution to catatonia research and treatment[19].

Praecox-feeling

The reaction that Yeong-hye’s husband experienced “seized by strange, ominous premonitions” is similar to what psychiatrists may feel when encountering a patient with schizophrenia or perhaps any psychosis, the so-called “praecox-feeling” (PF) described by the Dutch psychiatrist Cornelius Henricus Rumke as “an indefinable attribute that surrounds all the observed symptoms”[20]. The essence of the PF is the immediate, pre-discursive grasp of the incomprehensibility of, and inability to establish a natural relationship or mutual understanding with a patient with schizophrenia. The fundamentally changed “Gestalt” of his wife’s behavior led the layman husband to conclude that she must be mentally ill, even without any clear-cut psychotic symptoms.

Rumke thought that the lack of empathy, lack of an affective exchange between the patient and examiner, and peculiarities in motor behavior and speech generate PF. In other words, sensing inconsistency and incongruity in emotions, expressive movements, and utterances could give rise to PF. Rumke emphasized that “the investigator feels a curious hesitation and a feeling of strangeness which have to do with the break in the mutual rapport”[20]. The PF emerges in examiners when they intuitively seize “a certain characteristic Gestalt, irreducible to single symptoms or signs distinguished the schizophrenia spectrum from other disorders”[21] or in Jaspers’ words, they apprehend the diagnosis by “intuition of the totality of schizophrenia”[22], which is beyond the sum of individual symptoms.

PF mostly has been abandoned in favor of reductionist, operationalized diagnostic criteria and structured diagnostic interviews that place emphasis on reliability. This development was in reaction against the over-diagnosis of schizophrenia based on subjective feelings or biases of examiners in the absence of precise and replicable definitions of psychotic disorders based on operationalized signs and symptoms. Although PF may not be reliably used in psychiatric diagnosis, it remains important to consider in clinical practice and research, emphasizing the examiner’s self-observation, intuition, feelings toward and reactions to the patient[23].

However, despite this lack of acknowledgment and reliability, PF has probably always been present in clinical practice. A recent cross-cultural comparison spanning over 60 years suggested that the self-reported frequency of PF among psychiatrists from Germany, the United States, France, and Poland was similar, with approximately 80% of psychiatrists using it in their clinical practice, even if they were not familiar with the historical concept of PF[24]. A qualitative analysis of the components of PF, as perceived by 103 Polish psychiatrists confirmed that aloof or incongruent affective responses and an impairment of reality testing were the main factors contributing to PF[25].

While the application of PF in clinical practice has always been widespread[26-28], studies to test its validity and specificity in clinical practice[23,29] and to analyze its complex psychopathological nature have been few and far between[30-33]. Recently, representatives of the phenomenologically oriented school have made advances in dissecting PF. Pallagrosi and Fonzi[34] divided PF into two main dimensions: (1) The subjective component, referring to the examiner’s sense of difficulty connecting with or establishing rapport and empathy toward the patient with schizophrenia; and (2) The cognizance of the specific “typified” Gestalt of schizophrenia developed empirically over the course of clinical practice. A four-stage hypothesis was also proposed based on Husserlian phenomenological teaching[35], ranging from an initial non-specific “bizarreness of contact” to “diagnosis by penetration”[35]. Goze’s elegant and plausible hypothesis, as well as the reliability, validity and specificity of PF need further elaboration and testing in controlled studies both experimentally and in clinical practice.

Autism

Obviously, turning vegetarian/vegan is not unusual and does not suggest the presence of psychopathology. Vegetarianism is an accepted and even desired diet in many societies, but the inability of Yeong-hye to coherently and logically explain her choice and actions, apart from internal stimuli and terse comments about her dream, distinguish her behavior as signifying the emerging psychosis. The context and the way in which Yeong-hye acts raise the possibility of a psychopathological interpretation focusing on autism, a complex, historical hallmark of schizophrenia, which captures the psychopathological essence of schizophrenia[9].

Autism, as one of the fundamental “compound functions” of schizophrenia, was conceptualized by Bleuler[36] as a disturbance of relation to reality: “The detachment from reality together with the relative and absolute predominance of the inner life, we term autism”. Bleuler’s autism concept was rather overarching, encompassing a wide variety of idiosyncratic ideas, behavioral patterns, delusions, and even stupor as the extreme variant of autism. As a result, it was difficult to operationalize autism as a symptom of schizophrenia; therefore, Bleuler’s autism concept faded away in the last decades of the 20^th century when the arrival of the DSM-III heralded the beginning of operationalized definitions in psychiatry, focusing on the reliability of objective signs and symptoms. Furthermore, the concept of autism was “hijacked” by child psychiatry[37], and with the recent establishment of autism spectrum disorder in current psychiatric classifications, nowadays the term “autism” refers to a neurodevelopmental disorder and is no longer related to schizophrenia in mainstream psychiatry.

A different way of approaching the problem of autism was proposed by Minkowski[38], who sought “to reduce the whole range of symptoms and clinical pictures currently encompassed by dementia praecox to a fundamental problem, and to specify its nature”. Minkowski defined autism as the loss of vital contact with reality: “Vital contact with reality relates to the very foundation, the essence of the living personality, in its relations with its surroundings…a generative disorder from which all the others arise”.

Loss of vital contact with reality is obviously a slow process, but by the time The Vegetarian starts, Yeong-hye has already lost vital contact with societal norms and her social circle and is also about to lose herself (“…my face, undoubtedly, but never seen before. Or no, not mine, but so familiar… nothing makes sense. [..] Familiar and yet not …that vivid, strange, terribly uncanny feelings”[2]. From the very beginning of the book, even without delusions, hallucinations or thought disorder, which form the basis of the DSM/ICD criteria for schizophrenia, Yeong-hye is profoundly disturbed and essentially presents with the fundamental self-disturbance characteristic of schizophrenia e.g., “I become a different person, a different person rising up inside me, devours me...”[2]. Even pre-morbidly, before overt psychotic symptoms emerge, she is described as isolated, internally pre-occupied, and socially awkward. Subtle perceptual disturbances complement the autistic feeling described in poetic metaphor: “Everything starts feeling unfamiliar. As if I’ve come up to the back of something. Shut up behind a door without a handle”[2]. Due to the profound pathology of the self, Yeong-hye displays a “pragmatic deficit”[38], which is the manifestation of the loss of vital contact in everyday life. “Pragmatic deficit” overlaps with Blankenburg’s “loss of natural evidence” or “common sense” as the essence of autism, the phenomenological underpinning of schizophrenia[39].

Contemporary phenomenologists regard autism as a core feature of schizophrenia, and “perplexity or loss of natural self-evidence is one of its major expressions”[40]. Yeong-hye’s initial act and subsequent presentation clearly demonstrate her autism, a “defect in the elementary perceptual/expressive anchoring of the subject in the outer world”[9]; in other words, she is consistently failing “to resonate with the world, to empathize with others, a pre-reflective immersion in the intersubjective world”[21]. Yeong-hye’s autism and perplexity are illuminatingly described from the very beginning of her illness.

Autism is characterized by a deficiency of affective and cognitive components, creating a specific “schizophrenic” Gestalt that gives rise to pre-reflective, pre-discursive praecox feeling[9]. Yeong-hye’s autistic mode of existence reflects withdrawal from societal norms and a loss of contact with reality and common sense, i.e., a dissolution of natural pre-reflectively accessible continuity and integration of the self and of the self-evident harmony between the self and other persons and society.

CONCLUSION

One reason for calling attention to The Vegetarian is that it can be read as a true, “real-life” narrative of a woman with serious mental illness, relating how the illness unfolds and how it is embedded in the social-psychological fabric of an individual’s life and socio-cultural environment, which can hardly be explored and learned in busy clinical practice or by reading psychiatric textbooks. In this respect, The Vegetarian should be an important and useful addition to the standard psychiatric and psychological training curriculum.

The Vegetarian depicts the course of a severe psychotic illness with complexity and insight beyond the simplified symptoms list approach of contemporary psychiatry as embodied in the successive editions of the DSM and ICD classification systems. The lively, rich description of an impending and slowly emerging mental illness is so telling and lively that it cannot be reconstructed from a factual, dry psychiatric text or even contemporary case reports, which reduce the full subjective experiences of a mentally ill person to a few symptoms. Similarly, the nuanced socio-cultural-psychological context in which a psychosis unfolds, as portrayed in The Vegetarian, is difficult to appreciate in standard clinical practice. The Vegetarian, with its penetrating and vivid descriptions, also brings important historical and mostly forgotten psychopathological phenomena, such as the concepts of autism, paragnomen, and the praecox feeling, to the attention of generations of psychiatrists trained in criteria-based psychiatric classifications. The Vegetarian raises important issues in grasping the essence of schizophrenia as experienced by patients, carers and clinicians, and the recognition of catatonia relevant to psychopathology and psychiatric practice. From these points of view, The Vegetarian has tremendous educational potential in psychiatric training and postgraduate education in addition to literary classics such as books by Gogol or Dostoevsky.

The book devotes several pages to richly illuminating the reactions, stereotypes and stigma of carers, acquaintances, and mental health staff to the severe mental illness of patients[41]. These prejudices underscore the heightened vulnerability of a person compromised by psychosis like Yeong-hye to exploitation or abuse by unscrupulous relatives and frustrated hospital staff members. In fact, the novel is as much about the other key members of her family and their inner fears and uncertainty in confronting schizophrenia and catatonic behavior, written from the point of view of her husband, her brother-in-law, and her sister in turn, as it is about Yeong-hye herself. Yeong-hye’s psychosis profoundly affects her sister, as described with remarkable clarity about how witnessing and not fully understanding Yeong-hye’s psychotic transformation causes inner turmoil, guilt, anxiety, and perplexity in the sister when facing the harsh/frightening reality of mental illness. This experience makes the sister pose metaphysical questions about her own existence and the directions of her own life as it might do to readers as well (Table 1).

Table 1 Salient psychopathological phenomena richly illustrated by the novel The Vegetarian.

	Psychopathological phenomena
Paragnomen	A sudden, unexpected and irrational change in thought or behavior that presages the advent of, or impending psychosis
Catatonia	A psychomotor syndrome encompassing hypokinetic, hyperkinetic or parakinetic symptoms affecting motor, behavioral and affective realms that is often associated with psychosis
Praecox-feeling	The immediate pre-discursive grasp of the incomprehensibility of, and inability to establish a natural relationship or mutual understanding with a schizophrenia patient
Autism	The detachment from reality together with relative and absolute predominance of inner life historically associated with schizophrenia