Florence Syndrome: Beautiful Madness

The elegant Italian clock strikes noon. You are standing in the middle of the Cathedral of Santa Maria del Fiore, embraced by the grandeur of time itself. Vibrant Florence fades away into the comfort of tabula rasa (1). The skylight in the intricate, ornate dome above your head serves you a gulp of fresh air. An echo of euphoria expands in your chest: you are free. All will come, but it does not matter because you are alive and you ride the time. Suddenly, the sunlight seeping through the skylight starts getting thick. The weight of time crushes your shoulders. The lace of holy hands towering over you from the paintings on the ceiling circulate in their ritual against you. Are you a sacrificial lamb? The dome closes in around you as you struggle to catch your breath. You are falling and darkness follows you.

The narrative described above demonstrates how positive emotions can take negative dimensions based on the point of view. Although intense positive experiences, such as those associated with sightseeing, are frequently overlooked as potential triggers for psychological disturbances, Florence Syndrome presents distinct cognitive and behavioral patterns in which fascination with art leads to a psychosomatic disorder. Florence Syndrome is a maladaptive response to the exposure to recognized objects of artistic value that manifests as a range of symptoms comorbid in anxiety and affective disorders. This article will investigate the nature of Florence Syndrome from a clinical and cultural perspective. 

Definition

Awestruck visitors of Florence who come to experience the heartwarming and inspiring Italian adventure that the city offers sometimes end up in an emergency room, convinced that they are dying from a heart attack following a day of highly anticipated sightseeing in the city [2]. These visitors are suffering from a psychosomatic (2) condition called Florence syndrome that is also known as Stendhal syndrome. The phenomenon of Florence syndrome is experienced when viewing art of great beauty, artistic/cultural value and antiquity as the aesthetic beauty of human construct. In other words, Florence syndrome might develop if one experiences art work with deep appreciation for its creation and impact on individuals and society [3]. Florence syndrome is characterized by physical, psychological, and emotional symptoms that are consistent with anxiety, panic attacks, and psychosis (3), such as rapid heartbeat, confusion, fainting, hallucinations (4), and delusions (5) [4]. 

History

The first record of Florence syndrome as a distinct phenomenon dates back to the nineteenth century. French author Marie-Henri Beyle, recognized by his pen name Stendhal and renowned for his deep psychological analysis of literary characters, wrote a vivid report of his bizarrely intense emotional experiences while visiting a Florence chapel in 1817. In his memoir, Rome, Naples and Florence, Stendhal described his visit to Basilica of Santa Croce in Florence with the following zealotry: “I had reached that point of emotion that meets the heavenly sensations given by the Fine Arts and passionate feelings. Leaving Santa Croce, I had an irregular heartbeat, life was ebbing out of me, I walked with the fear of falling” [4]. One hundred sixty two years later, the first report documenting the Florence syndrome was published by Dr. Magherini Graziella, who had been studying the syndrome for twenty years at the time. In 1989, Dr. Magherini Graziella named the condition “Stendhal syndrome” after Stendahl, who provided the first written description of his unusual symptoms experienced in Florence. Stendhal syndrome is also recognized as Florence syndrome due to its Florence-specific entity and prevalence.

In addition to Stendahl’s account of his trip to Florence, psychoanalyst Sigmund Freud wrote about severe feelings of alienation and depersonalization upon visiting the Acropolis in a letter to his friend, later described in the personal essay titled “A Disturbance of Memory on the Acropolis'' [4]. Freud’s student, Carl Jung, reported feeling so mentally and physically overwhelmed by his visit to Pompei that he discontinued his journey to Rome. He dreamed of visiting Rome but never dared to accomplish this dream due to the intense impressions that European art and architecture left on him [3]. Furthermore, writer Fedor Dostoevsky experienced severe paralysis and derealization, when faced with Hans Holbein’s grotesque painting The Body of the Dead Christ in a Tomb in Basel, Switzerland [4]. Although numerous people from a variety of backgrounds report similar experiences to Stendahl’s classic account, the city of Florence continues to bear the largest number of reported Florence syndrome cases [9]. In fact, the doctors at Florence's Santa Maria Nuova hospital are accustomed to examining  tourists reporting dizziness or disorientation after viewing the statue of David, the artworks of the Uffizi Gallery, and other attractions that the city offers [2].

Contemporary Perspective

Modern science views Florence Syndrome as an exacerbation of chronic mental illnesses rather than a transient episode [4]. Florence syndrome is believed to be a dysregulated response to overwhelming experiences in sensitive populations rather than a separate medical entity under current DSM-5 classification (6). In the context of Florence syndrome, a dysregulated response can be defined as a reduced ability to regulate emotional response to the stimulus in the form of remarkable art, which results in a range of psychological and physiological responses connected to overwhelming emotional feelings. Florence syndrome may be an unusual manifestation of an already present mental distress, since people who have been previously diagnosed with mental disorders are two times more likely to be affected by Florence syndrome than people without previous mental health disorders [3]. According to Magherini, personal history of psychiatric illness is linked to longer hospitalization, early departure from Florence and seeking treatment in the patients’ home country [15] Furthermore, the symptomatology of Florence syndrome overlaps  with multiple individual disorders (such as general anxiety and panic disorder) and presents itself similarly to the symptoms individuals experience outside of Florence. According to Magherini, thirty-eight percent of patients with Florence syndrome-related thought disorders had a previous psychiatric history [2]. In comparison, fifty-three percent of patients with Florence syndrome-related emotional disorders had a previous psychiatric diagnosis [2].

Unfortunately, for some people, Florence syndrome keeps resurfacing in their lives. A BMJ (7) case study published in 2008 presented the case of a 72-year-old creative artist who reported experiencing recurrent episodes of paranoid psychosis [9]. The paranoid type of psychosis is defined as an abnormal mental state, in which the person experiences irrational erroneous beliefs that they or their loved ones are being mistreated, conspired against, abused or followed with the purpose of harm while otherwise preserving their usual personality  [36]. The artist developed episodes of paranoid psychosis on a cultural tour in Florence, the city he had dreamed about visiting since childhood. In Florence, he had a panic attack while standing on the Ponte Vecchio bridge. Over the course of the following three weeks, the artist was experiencing delusions of being monitored by international airlines. Eight years following the trip to Florence, the aforementioned artist presented to a psychiatric practice with insomnia and concerns about being monitored. He admitted that he had been experiencing sleeping problems and paranoid ideations in mild and quickly settling relapses since his trip to Florence eight years ago, especially at times of stress. He also confessed that he experienced another panic attack followed by delusions of being monitored by international airlines when he visited France that, as he claimed, reminded him of Florence [12]. The artist was treated with low doses of antipsychotic medication and made a full recovery [12].

Symptomatology

The symptomatology of Florence syndrome centers around the overwhelming sense of awe (8) defined as an “experience of admiration and elevation in response to physical beauty, displays of exceptional ability, or moral goodness” [13]. As a psychosomatic disorder, Florence syndrome includes a range of physical symptoms that cause significant discomfort and disturbance to daily functioning but have no medical explanation. Physical manifestations of Florence syndrome include stress-related dizziness, loss of consciousness, exhaustion, insomnia, fast heart rate, heart palpitations, shortness of breath, and sweating [3]. 

Magherini identified three categories of psychological Florence syndrome symptoms: thought disorders, emotional disorders and panic attacks and somatised anxiety disorders. Disorders of thought category includes changes in perception of sounds and colors, visual, auditory and olfactory hallucinations as well as delirious perception of external reality and feelings of persecution (9) [2]. Disorders of thought category also includes feelings of alienation, disorientation, depersonalization, feelings of guilt and fear as well as out-of-body experiences [2]. Emotional disorders category comprises low-energy emotional states such as depression, feelings of worthlessness and feelings of inferiority [2]. Emotional disorders category also constitutes high-energy emotional states such as anxiety, agitation, feelings of superiority and grandeur, euphoria, exaltation, and omnipotent thinking [2]. The low-energy and the high-energy emotional states can frequently fluctuate. Panic attacks and somatised anxiety disorders category encompasses fear of dying or going insane, somatic projections of anguish, chest pains, arrhythmia and visual disorders such as blurred vision [2, 15]. The least reported symptom of Florence syndrome is an individual's desire to destroy the work of art [2].

People report feeling a special connection to the artwork that triggers the symptoms of Florence syndrome, like an artist who likened observing his favorite Florentian attractions to “seeing old friends” [4]. Taken together, Florence syndrome is characterized by physical, cognitive, and emotional manifestations that have the potential to transform typical behavior into distress and dysfunction.

Pathology

Akin to adjustment disorders, Florence syndrome is caused by a major impact that an individual experiences when they encounter a substantially different culture and lifestyle than the ones to which they are accustomed [16]. Culture shock (10) can potentially contribute to the onset of the Florence syndrome by causing stress, anxiety, depression, disorientation and the feeling of helplessness [18]. The psychological response that an individual sustains during Florence syndrome is similar to an emotional reaction towards events of great personal significance, but it presents itself in an exaggerated way. 

A person is more likely to experience Florence syndrome if they experience a conflict between expectations that they have of Florence as the cradle of Renaissance and reality that Florence projects upon their arrival [19]. This conflict might occur, if for example, the attractions of Florence look less appealing among the tourist crowds than expected from what was seen on the edited photos online. The conflict might also occur, if the attractions of Florence turn out to be more impressive than expected. As a result, Florence syndrome is often associated with places that are heavily romanticized by historical tradition and popular culture like Paris or Jerusalem. 

Psychological and psychosomatic symptoms of Florence syndrome tend to resolve spontaneously after leaving the place that triggered these symptoms. People diagnosed with Florence syndrome usually recover completely without long-term  cognitive, emotional or physical deficits. There are, however, a few exceptions: the symptoms have the potential to relapse spontaneously after the initial episode or following an exposure to concepts associated with the initial trigger [9]. 

Brain images acquired with fMRI (11) and PET (12) scans reveal similar patterns of neural activation for those diagnosed with Florence syndrome (13). Neural activation occurs in regions of the brain that are associated with reports of mystical and religious experiences, in particular, in the anterior insular cortex. There are also similar activation patterns between people with Florence syndrome and those who experience epileptic seizures associated with emotional response to music, orgasm and ecstasy, and out-of-body experiences. Florence syndrome shares symptoms and mechanisms with ecstatic experiences that are characterized by an activation of a neural network of regions in the brain that are responsible for introspection, social cognition, emotional processing, and memory [24]. This finding may partially explain the mechanism of Florence syndrome. 

According to the neuroaesthetics (14) study by Innocenti and the colleagues, emotionally impressive visual stimuli is processed through the faster, unconscious visual system, and so, the bodily response to emotion occurs before the conscious understanding [15]. This can result in a decreased emotional self-regulation present in Florence syndrome [15]. Sensory processes, triggered by a strong stimuli and focused on external surroundings rather than on one’s internal state, are related to a decreased neural activation in the Default Mode Network (15) of the brain [15]. The Default Mode Network is composed of multiple brain regions and is responsible for self-related cognitions, adaptability to circumstances, social evaluative tasks and moral decision making [15]. In particular, the Default Mode Network involves the medial prefrontal cortex area of the brain, which is responsible for mental and visual-spatial imagery, mentalization (16), emotional processing and self-regulation [15]. The exposure to artistic masterpieces can lead to a decrease in the neural activity of the Default Mode Network, specifically in the medial prefrontal cortex, resulting in a disruption of cognitive and emotional processing that are evident in Florence syndrome [15].The aforementioned findings illustrate a neuropsychological nature of Florence syndrome as a psychosomatic disorder and help to understand the physio-psychological processes underlying the syndrome’s pathophysiology. 

Mirror neurons, defined as brain cells that respond equally when one performs an action and when one witnesses someone else perform the same action, are another mechanism at work in Florence syndrome [37]. Mirror neurons are thought to trigger the feeling of empathy that people feel towards the story portrayed in the artwork. This idea is based on findings that demonstrate higher activation in brain areas associated with thinking about personal experiences that occurs during exposure to the objects of art and is believed to occur due to the mirror neurons [15]. Therefore, observing magnificent Renaissance paintings that were created to induce admiration, fear, and worship to the divine can trigger an observer's personal traumas. Since many emotionally-unsettling paintings, such as the Expulsion from the Garden of Eden, can be found in Florentian historical neighborhoods, visitors of Florence have a higher chance to feel emotional disturbances than visitors of places less rich in Renaissance culture.

On another hand, people may experience Florence syndrome as a result of dramatic incongruence between their identity and the message perpetrated by the piece of art. For instance, a case study by Magherini describes the story of Franz, who “became stricken before Caravaggio’s Adolescent Bacchus with an identity crisis in the guise of a heart attack”. Magherini believes that Franz developed an identity crisis with psychosomatic symptoms consistent with Florence syndrome as a result of confronting sensual image of a man that was inconsistent with Franz’s own heterosexual identity and compromised his efforts to control his sexuality as a heterosexual male [15]. Magherini reported similar occurrences connected to the Michalengelo’s sculpture of David. Visitors of the Accademia Gallery of Florence experience intense feelings of sexual pleasure, envy, and sexual dysfunction in addition to the usual psychological and physical symptoms of Florence syndrome upon viewing the figure of David [4]. This occurs due to the disparity between the visitors’ image of themselves as imperfect and the image of David that represents physical perfection [4].

In many cases, Florence syndrome instigates the feelings of self-fragmentation in an individual's ego [2]. A twenty-year-old female reported that, after visiting the Uffizi Gallery, she was so overwhelmed by the grandeur of the art presented in the gallery that she felt shredded and agitated as if in a terrorist attack, and kept shouting for help [2]. 

Epidemiology

People who perceive the art of Florence as a matter of personal significance are more likely to experience Florence syndrome [27]. Western Europeans may be more susceptible to Florence syndrome due to their sense of ancestral connection to the attractions of the city [9]. Artists and artistic scholars might be especially prone to Florence syndrome due to feeling overwhelmed by the idea of personal significance that the city with its numerous art masterpieces imposes on them. Tourists can be predisposed to Florence syndrome due to the stress of novel travel to the city, which is the epicenter of Italian cultural heritage. People with interrupted sleep patterns, mental or physical burnout and repressed sexual desires are at risk for developing the Florence syndrome [2, 3]. In fact, the portrait of an average patient at Florence’s main hospital diagnosed with the Florence syndrome is described as an “impressionable, single person between 26-40 years old, who is stressed by travel and may be struggling with jet lag” [28]. Religious people are more likely to develop Florence syndrome due to religious connection that they feel with Florence’s many religion-themed masterpieces [27]. People speaking languages other than Italian may be more likely to develop Florence syndrome on the premise of disconnect between affective bodily experience and conscious apperception (17) that occurs when people use their second language. This idea is highlighted by the absence of Florence syndrome cases among native Italians [15]. Additionally, people at the end of a journey to Florence are predisposed to Florence syndrome by anguish feelings connected to their upcoming leave that intensify their emotional experiences [27]. Lastly, people who have been previously diagnosed with a mental disorder or are at risk of one are particularly vulnerable to Florence syndrome, as it appears to intensify preexisting mental health issues within the emotionally-vibrant setting of Florence [12]. 

Diagnosis and Treatment

Diagnosis of Florence syndrome is made using a holistic clinical picture and an individualized approach [2]. Originally, diagnostic criteria were based on similarities with Stendahl’s notes from his eponymous voyage to Florence. Now, the diagnosis of Florence syndrome requires the presence of psychosomatic symptoms associated with Florence Syndrome that cannot be better explained by another condition [2]. 

Treatment of Florence syndrome revolves around symptom management. Popular treatments for people with psychosis, anxiety and panic attacks, and mood swing symptoms include antipsychotics, anti-anxiety medications, and antidepressants, respectively. Florence syndrome patients may also benefit from psychotherapy, where they can learn to apply efficient emotion-regulation techniques [27]. Since remembering the experience of Florence syndrome may potentially reactivate symptoms, people who experienced Florence syndrome can also seek improvement through desensitization therapy [27]. The desensitization therapeutic approach recreates the triggering event in order to decrease an individual's sensitivity to the stimuli and normalize their body’s response. Desensitization therapy for Florence syndrome may include visiting the site that induced Florence syndrome, but in the company of others to reshape previous experience [27] Treatments in the physical domain depend on the type of psychosomatic manifestations presented. Psychiatrists recommend that tourists “pace themselves” in art museums and get enough rest in-between their immersive experiences in Florence [28].

Florence is not the only city that appears to induce mysterious psychological reactions. In fact, there are instances of Paris syndrome linked to a disappointment in the reality of Paris that is different from the City of Lights ideal. Paris syndrome involves paranoid delusions, megalomania (18), erotomania (19) and mysticism (20) [15]. Paris syndrome is experienced primarily by the Japanese population [15]. It is believed that Paris syndrome is the most common among the Japanese tourists due to a stark contrast between Japanese and Parisian lifestyles [3]. One case describes an international student without previous psychiatric history, who was admitted to the hospital by the hotel staff since he was experiencing anxiety, anorexia (21) and heard voices “threatening to kill him” [15]. 

There are also instances of Jerusalem syndrome connected to the prominence of the city as the “Holy City”-the birthplace of christianity and the convergence point of major world religions [18]. Approximately one hundred medical cases of Jerusalem syndrome are reported yearly [3]. These reports describe people experiencing the caput mundi, which is defined as “a feeling of lightness associated with spiritual awakening” [3]. People with Jerusalem syndrome also might have delusions of being religious figures, and might engage in compulsive sermon chanting and excessive bathing for the “soul-cleansing” purposes [15]. The Jerusalem syndrome is predominantly experienced by religious pilgrims and people of deep religious faith [3]. One case describes an American tourist with previous psychiatric history, who believed that he is a Biblical character Samson, a symbol of human strength in the Bible [34]. He was preoccupied with an idea that the Western Wall, which is the most religious site in the world for the Jewish people, was in the wrong place [34]. As a result, he went to Jerusalem and tried to move the giant stone blocks forming the Western Wall, causing a public disturbance [34].  

Both Paris and Jerusalem syndromes have similar symptoms to the Florence syndrome. However, they also present accordingly to the ideas that the public has about Paris and Jerusalem respectively.

Conclusion

As traveling becomes mainstream and humanity gets more cosmopolitan (22), will Florence syndrome become a relic of the time, when deserted islands could still be discovered? As a result of an exposure to the Internet, contemporary society is becoming more desensitized to emotionally-triggering information. Furthermore, according to a Pew Research Center survey, 71% of Americans have traveled internationally at some point in their lives [29]. Since Florence syndrome predominantly strikes novice travelers during their first encounter with Florence, or similar cities with a rich culture, it might be reasonable to assume that exposure to the tourist attractions of Florence online and in-person can minimize Florence syndrome experiences in younger generations. Further research on the effects that consumer culture, as a catalyst of widespread traveling, may exert on the manifestations of the Florence syndrome is warranted. Specifically, it might be interesting to explore how promoted by consumerism accessibility of artistic masterpieces influences the Florence syndrome. It also might be valuable to investigate how materialism-based skepticism and shorter attention span that are both cultivated by consumerism relate to the entity of Florence syndrome. 

Footnotes:

1. tabula rasa, (Latin: “scraped tablet”—i.e., “clean slate”) in theory of knowledge and psychology, a supposed condition that empiricists have attributed to the human mind before ideas have been imprinted on it by the reaction of the senses to the external world of objects [1]

2. A type of disorder in which psychological factors are believed to play a significant role in the origin and/or course of disorder [5]

3. Psychosis is an “abnormal mental state involving significant problems with reality testing” (APA, 2022). Psychosis is characterized by serious impairments or disruptions in perception, cognitive processing, emotions and affect and is manifested in behavioral phenomena, such as delusions, hallucinations, and disorganized speech [6]

4. Hallucination is a “false sensory perception that has a compelling sense of reality despite the absence of an external stimulus” (APA, 2022). The most common hallucinations are auditory hallucinations and visual hallucinations. Hallucinations usually signify a presence of a psychotic disorder, but also may result from substance use and neurological abnormalities [7]

5.  Delusion is a “highly personal idea or belief system, not endorsed by one’s culture or subculture, that is maintained with conviction in spite of irrationality or evidence to the contrary” Delusions range from transient and fragmentary to systematized and elaborate. Common delusions include delusional jealousy, delusions of being controlled, delusions of grandeur, delusions of persecution, delusions of ordinary events having a special meaning for an individual, delusions of being dead, and somatic delusions. Delusions are derived from emotions rather than logical errors [8].

6. DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) is the primary psychology diagnostic manual used in the United States that was published in 2013 [10].

7. BMJ Case Reports is one of the world’s most influential and respected general medicine journals that delivers a focused, peer-reviewed, valuable collection of cases in all health-related disciplines [11]

8. The awe-inspiring stimulus is experienced as “vast” and difficult to comprehend. Awe experiences can be overwhelming and can motivate wonderment [13].

9. Persecutory delusion is an erroneous belief that others are conspiring against one or threatening one in any way [14]

10. Culture shock is a state of loneliness, anxiety, and confusion experienced by an individual or group that suddenly experiences a radical cultural change. For example, a Filipino student studying at an American university may experience culture shock, as may a businessperson traveling abroad [17]

11.  Functional Magnetic Resonance Imaging (fMRI) is a form of magnetic resonance imaging used to localize areas of cognitive activation, based on the correlation between brain activity and blood property changes linked to local changes in blood flow to the brain. During periods of cognitive activation, blood flow is always increased to a greater extent than oxygen extraction. In consequence, the proportion of oxygenated hemoglobin in the red blood cells transiently increases in an active region, leading to a local increase in the signal detected by fMRI [20]

12. Positron Emission Tomography (PET) scan is an imaging technique using radiolabeled tracers that emit positively charged particles (positrons) as they are metabolized. Used to evaluate cerebral metabolism and blood flow as well as the binding and transport of neurotransmitter systems in the brain. PET enables documentation of functional changes that occur during the performance of mental activities [21]

13. Insular cortex is an area of the brain located deep within the lateral sulcus of the brain. Insular cortex is responsible for emotional feelings, including maternal and romantic love, anger, fear, sadness, happiness, sexual arousal, disgust, aversion, unfairness, inequity, indignation, uncertainty, disbelief, social exclusion, trust, empathy, sculptural beauty, a ‘state of union with God’, and hallucinogenic states [22; 23]

14. Neuroaesthetics are “the study of the neural processes underlying the psychological processes that are evoked in the creator or the viewer of the object in the course of interacting with it. The psychological processes may involve perceptual, sensory, cognitive, emotional, evaluative, and social aspects, all of which are presumed to have biological-neural-basis” [15].

15. Default Mode Network is an anatomically defined brain system that is activated when the person is engaged in internally focused tasks, including autobiographical memory retrieval, envisioning the future, and conceiving the perspectives of others. It consists of the medial prefrontal cortex, posterior cingulate cortex, angular gyrus, precuneus, and middle frontal gyrus. Some researchers believe that constant unconstrained self-reflective thought might be the natural state of human mind (APA, 2022).

16. Mentalization is the ability to understand one’s own and others’ mental states,and so, to understand one’s own and others’ intentions and affects [25]

17. Apperception is  the process of becoming conscious of a perception, so that perception is recognized and understood [26]

18. Megalomania is a delusion of grandeur; a highly inflated perception of one’s personal importance, power and capabilities that can be often seen in individuals with mania and paranoid schizophrenia. Megalomania might be accompanied or preceded by delusions of persecution [30].

19. Erotomania is a compulsive sexual activity; an erroneous belief that one has a romantic relationship with a public figure [31]

20. Mysticism is the idea that there are credible sources of knowledge and truth that can be acquired by means outside of senses, logic and empirical methods. It is believed that mystical knowledge can be gained through inspiration, revelation and other mystical experiences. Mysticism also describes the belief that the wisdom and unity with the divine can be achieved through personal religious experience [32].

21. Anorexia is an absence or loss of appetite for food. It may be primarily a psychological disorder, as in anorexia nervosa. It may also have physiological causes [33].

22. Cosmopolitan (“citizen of the world”) is derived from the idea of cosmopolitanism. Cosmopolitanism describes a philosophical approach that regards all humanity as a single community [35].

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