Emperor Claudius’ Neuropsychiatric Presentation: From Tics to Behavioral Symptoms

To the Editor: Roman historian Suetonius reported in his work The Twelve Caesars that emperor Claudius [Figure 1] “throughout almost the whole course of his childhood and youth […] suffered so severely from various obstinate disorders, so that the vigour of both his mind and his body was dulled, and even when he reached the proper age he was not thought capable of any public or private business” (Suetonius, De vita Caesarum V,2).¹ The real causes for these disabilities are still a medical mystery. The traditionally proposed explanations have included cerebral palsy and dystonia.² More recently, it has been suggested that Claudius might have suffered from a form of Gilles de la Tourette syndrome (GTS), based on his gait disturbances, head tics, and complex speech impediment.²

GTS is a multifaceted neuropsychiatric condition characterized by multiple motor and vocal tics, which are chronic and tend to follow a waxing and waning course. Suetonius’ biography provides several examples of Claudius’ tics, along with hallmark features such as stress-induced exacerbations: “[Claudius] stumbled as he walked along, owing to the weakness of his knees, and also because if excited by either play or business, he had several disagreeable traits. These included an uncontrolled laugh, a horrible habit under stress of anger of slobbering at the mouth, and running at the nose, a stammer, and a persistent nervous tic – which grew so bad under emotional stress that his head would toss from side to side” (Suetonius, De vita Caesarum V,30).¹ In about 90% of patients with GTS, simple and complex tics are accompanied by specific behavioral problems, ranging from obsessions and compulsions to socially inappropriate behaviors, aggressiveness, and impulse dyscontrol.³ Of particular interest in this context are Suetonius’ other comments on Claudius making inept remarks: “he often showed such heedlessness in word and act that one would suppose that he did not know or care to whom, with whom, when, or where he was speaking. When a debate was going on about the butchers and vintners, he cried out in the house: ‘Now, pray, who can live without a snack’, and then went on to describe the abundance of the old taverns to whom he himself used to go for wine in earlier days” and “every day, and almost every hour and minute, he would make such remarks as these: ‘What! do you take me for a Telegenius [a mythical or historical figure from Roman times who was famous for his stupidity]?’ ‘Scold me, but hands off!’ and many others of the same kind which would be unbecoming even in private citizens” (Suetonius, De vita Caesarum V,40).¹

We believe that Suetonius’ account reveals aspects of Claudius’ biography, which are consistent with the full-blown clinical picture of GTS, including both tics and abnormal behaviors. Specifically, the presence of specific socially inappropriate behaviors, in the presence of an otherwise intact cognition and in the context of the emperor’s tic repertoire, strengthens our confidence in Claudius’ retrospective diagnosis of GTS, as in other historical⁴ and fictional⁵ characters. Taken together, Suetonius’ descriptions of Claudius’ tics and repetitive behaviors could represent the first recorded documentation in history of what we now refer to as GTS.