ORIGINAL ARTICLE Downloaded from http://journals.lww.com/jonmd by zIyM+QTrhBxelIoRU6oxyCJ26I9mcWugvX1P0fsxxuuiIVDlG7I RmEDUm6dmV/v8uYLbM3C7DorP1tYOEE0KuQeCa+r0C9cSTVWevTq+F9cf+fX+6qnxG2BC92/kMcwh+QLBtGAvNJ+KqCrgd89EdE9 TWTNUn15mt8zI4YbEvUw= on 07/29/2023 Undiagnosing St Joan She Does Not Need a Medical or Psychiatric Diagnosis James Phillips, MD,* Brian Fallon, MD,† Salman Majeed, MD,‡ Keith Meador, MD,§ Joseph Merlino, MD,|| Hunter Neely, MD,¶ Jenifer Nields, MD,* David Saunders, MD, PhD,† and Michael Norko, MD* Abstract: This article traces the history of Joan of Arc through her brief life that includes leading an army in defense of France at the age of 17 and ending with her death at the stake at the age of 19. In her activities, St Joan reported that she was guided by voices and visions in which she communicated with venerated spiritual figures such as St Michael and St Margaret. Questions have arisen about the nature of these experiences, and various medical and psychiatric diagnoses have been offered by contemporary experts. In our effort to evaluate the diagnostic proposals, we have examined the incidence of voices and visions in the Middle Ages, and we have followed that with a review of nonpathologic voice-hearing in our own era. We then move on to an analysis of some proposed medical and psychiatric diagnoses, all of which we find unconvincing. With this background, we argue that St Joan does not warrant a medical or psychiatric diagnosis. Such a conclusion, however, leaves us with another issue, that of Joan's achievements. How do we understand an adolescent being able to lead an army? Addressing this question proves more difficult than deciding whether St Joan warrants a diagnosis. In addition to her achievements in the war against Britain, Joan of Arc stands out as both the most documented person in Western civilization up until her era, and as the only person who has been both condemned and canonized by the Catholic Church. Key Words: Psychiatry, Joan of Arc, diagnosis, history, medieval, voices (J Nerv Ment Dis 2023;211: 559–565) METHODS The principal source of information about St Joan's life is the voluminous documentation of her trials: the Trial of Condemnation in 1431 and the Trial of Rehabilitation in 1456, all found in the archives of France. Our narrative of her life and experiences is based on information from the two trials. For this article, we have relied mainly on three documents: the trial reports themselves, found in T. Douglas Murray, Jeanne D’Arc, Maid of Orléans, Deliverer of France (1902); the Web site, www.Jeanne-darc.info, founded in 1997 by Søren Bie as a free Web site containing all available information about St Joan; and, finally, Regine Pernoud and Marie-Veronique Clin, Joan of Arc: Her Story (1998). In France Pernoud was considered the grande dame of Medieval and St Joan–related history. The official Latin text of the trials was discovered in the official archives of France and brought to light and translated into modern French by Jules Quicherat in the 1840s. The work was translated into English and edited by T. Douglas Murray in 1902. *Yale University School of Medicine, New Haven, Connecticut; †Columbia University School of Medicine, New York, New York; ‡Penn State Hershey Medical Center, Hershey, Pennsylvania; §Vanderbilt University, Nashville, Tennessee; ||Downstate College of Medicine, Brooklyn, New York; and ¶UC Davis Medical Center, Sacramento, California. Send reprint requests to James Phillips, MD, Yale University School of Medicine; 88 Noble Avenue, Milford, CT 06460. E‐mail: james.phillips@yale.edu. Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/23/21108–0559 DOI: 10.1097/NMD.0000000000001654 Finally, we have benefited from Mark Twain's Joan of Arc (Twain, 1896), for which he did extensive research in France and which he considered the best of his books and the one that afforded him the most satisfaction. Introduction Let us begin by turning this introduction over to Mark Twain, who offers us a stark description of St Joan's beginning: In Joan of Arc at the age of sixteen there was no promise of romance. She lived in a dull little village on the frontiers of civilization: she had been nowhere and had seen nothing; she knew none but simple shepherd folk; she had never seen a person of note; she hardly knew what a soldier looked like; she had never ridden a horse, nor had a warlike weapon in her hand; she could neither read nor write; she could spin and sew; she knew her catechism and her prayers and the fabulous histories of the saints, and this was all her learning. That was Joan at sixteen (pp 441–442). How St Joan of Arc emerged from this modest beginning we will leave for further consideration. We begin this essay on St Joan by placing her in the historical context in which her extraordinary experiences occurred. They were both like and unlike other Medieval, mystical phenomena, and correspondingly, her fellow countrymen and her Church both praised her and condemned her. Among her other achievements, she stands as both the most documented person in Western civilization up until her era, and as the only person who has been both condemned and canonized by the Catholic Church. Historical Background Joan of Arc's (Jeanne d'Arc's) story took place in the context of the Hundred Years War, dated somewhat arbitrarily between 1337 and 1453 and consisting of a series of conflicts and wars between the Plantagenet rulers of England and the Valois rulers of France. Beginning with the Norman conquest of England by William the Conqueror in 1066, France and England disputed the role of each in France over the ensuing centuries, involving both property and titles. During this period, France itself was a loose confederation of principalities, often with unclear boundaries. In the early 15th century, after a period of minimal wartime activity, Henry V of England won important victories at Agincourt (1415) and Normandy (1417–1418). Those victories awarded him as his wife, Catherine, daughter of the French Charles VI. He declared that their son would become Henry VI and would be king of the dual monarchy, England and France. That gesture disinherited Catherine's brother Charles, the dauphin, who was to become Charles VII of France. After the English victories, they occupied almost all of northern France, including Paris. Directly south of Paris, on the Loire River, the city of Orléans was the last stronghold between England and southern France. The conquest of Orléans was Henry V's next goal. It was at the English siege of Orléans that Joan's story begins. The Journal of Nervous and Mental Disease • Volume 211, Number 8, August 2023 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.jonmd.com 559 Phillips et al. The Journal of Nervous and Mental Disease • Volume 211, Number 8, August 2023 Downloaded from http://journals.lww.com/jonmd by zIyM+QTrhBxelIoRU6oxyCJ26I9mcWugvX1P0fsxxuuiIVDlG7I RmEDUm6dmV/v8uYLbM3C7DorP1tYOEE0KuQeCa+r0C9cSTVWevTq+F9cf+fX+6qnxG2BC92/kMcwh+QLBtGAvNJ+KqCrgd89EdE9 TWTNUn15mt8zI4YbEvUw= on 07/29/2023 Joan of Arc, who was always referred to as the Maid (la Pucelle), was born in Domremy, in the province of Lorraine, in 1412. Although Lorraine was technically not part of France, Domremy considered itself part of the French kingdom and strongly on the side of the Dauphin (Charles, heir to the throne) and the national party. Joan's parents owned about 50 acres of land, which her father farmed along with raising animals. Joan spent her early life tending to household affairs, caring for the family animals, and mastering her skills as a seamstress. At the age of 13, she began experiencing mystical visions urging her to piety, and then more specific visions of St Michael and St Catherine designating her as the savior of France. As the English were at this time laying siege to Orléans, the saints encouraged her to seek an audience with the Dauphin to request that he allow her to raise the siege of Orléans, install him as the rightful king, and banish the English from France. In 1428, at the age of 16, the visions instructed her to go to Vaucouleurs and contact Robert de Baudricourt, the garrison commander and a supporter of Charles, the Dauphin. He would be able to lead her to Chinon, southwest of Orléans, where the Dauphin was residing. She arrived in Vaucouleurs on May 13, 1428. Baudricourt found her program ridiculous and refused her request. She returned to her home in Domremy but returned 2 months later to Vaucouleurs with her parents, little sister, and three brothers. After her parents returned home, Joan took up residence in Vaucouleurs, trying to meet again with Baudricourt. In the following year, at the time of Lent, she met with him, and he again rejected her request for passage to Chinon. When a squire in the household of Baudricourt teased and questioned her, she responded: I came here to the king's chamber [that is, into royal territory] to speak to Robert de Baudricourt so that he would either bring me or have me brought to the king, but he pays no attention to me or to my words; nevertheless, it is important that I be at the king's side before mid-Lent arrives, even if it means I have to walk until my feet are worn down to my knees; there is in fact no one else, neither a king nor a duke nor the daughter of the king of Scotland, nor any other who can recover the kingdom of France, and he will have no help, if not through me, even though I would prefer to stay home and spin wool with my poor mother, for this is not my station, but I must do it, because my Lord wills that I do so (Pernoud, 1955, p 19). When asked by the squire, “but who is your Lord?” the maid answered, “God.” And he continued, “And so I promised the Maid, by placing my hands in hers as a sign of good faith, that I would with God's aid lead her to the king; and I begged her to tell me when she wanted to leave; and she said, ‘Better today than tomorrow, better tomorrow than later’” (p 19). In the meantime, the people of Vaucouleurs were becoming increasingly sympathetic with Joan's cause, and Baudricourt, encouraged by the squire and the people of Vaucouleurs, finally relented to get her to Chinon, the site of Charles' court. He gave her a horse and an escort of several soldiers. She cropped her hair and dressed in men's clothes for the 11-day journey across enemy territory to Chinon. They traveled mostly at night to avoid highwaymen, the English, or Burgundians (the French of Burgundy, who sided with the English). Her male fellow travelers reported that Joan slept next to them, but tightly bound, so that there was no issue of “carnal impulse.” They found her “without fault or weakness, exemplary in piety and charity, inflexible in resolve” (Pernoud and Clin, 1998, p 21). At first, Charles was not certain what to make of this peasant girl who asked for an audience and professed she could save France. Charles was himself only 26 years old and had never lived in Paris, as it was occupied by the English. He was full of doubt about himself and his role in the royal structure, and he did not understand why he had not been anointed king. Joan, however, won him over when she correctly identified him, dressed incognito, in a crowd of members of his 560 www.jonmd.com court. The two had a private conversation during which it is said that Joan revealed details of a solemn prayer Charles had made to God to save France. He remained uncertain; some of his counselors were impressed by Joan, others considered her mad. Joan had already demonstrated to him her skills in wielding a lance and riding a horse. In his uncertainty and not wanting to be made a fool of, Charles sent her and her entourage to Poitiers, a center of theological learning, for an intensive, 3-week evaluation. Poitiers was only day's journey (35 miles) from Chinon. Here is an example of her evaluation by the theologians of Poitiers—a clear instance of the 17-year-old's wit in the face of her inquisitors. I asked her what language her voice spoke. She answered, “Better than yours.” Me, I spoke the dialect of Limoges; and then I asked her if she believed in God; she answered, “yes, better than you.” And I then said to her that God wouldn't want us to believe in her unless something made us think that we should do so. I could not advise the king simply on her assertion that he should entrust men-at-arms to her so that she might lead them into peril, unless she could at least tell him something further. And she answered, “In God's name, I did not come to Poiters to produce signs. But lead me to Orléans, and I will show you the sign for which I was sent” (p 29). Joan was also subjected to a physical examination in which it was determined that she was “a woman, a virgin, and a maid.” The clergymen and theologians reported they found nothing improper with Joan, only piety, chastity, and humility. They recommended to the Dauphin that he accept her aid and send her to Orléans. Charles then relented and gave the 17-year-old Joan of Arc armor and a horse and allowed her to accompany the army to Orléans, the site of the English siege. Word had traveled fast, and by the time she reached Orléans, she was already heralded as the Maid who would raise the siege. She traveled with John, Count of Orléans, also called the Bastard of Orléans, who was technically the Commander of the French forces. Joan had brought a separate French force, and the two individuals were frequently in conflict, the Bastard preferring to lie back and wait, while Joan argued for directly confronting the English. Here is a sample of their conversation: “Is it you who said that I was to come on this side [of the river] and that I should not go direct to the other side where Talbot and the English are?” “Yes, and those more wise than I are of the same opinion, for our greater success and safety?” “In God's name,” she then said, “the counsel of my Lord is safer and wiser than yours. You thought to deceive me, and it is yourselves who are deceived, for I bring you better succor than has ever come to any general or town whatsoever – the succor of the King of Heaven. The succor comes not from me but from God Himself ” (Murray, 1902, p 234). This statement is a superb example of Joan's style: a firm conviction that she speaks for God, and that anyone who disagrees must bow to the voice of God. Some took relief in her certainty, and others questioned the authority of this 17-year-old girl. In view of this article's question as to whether Joan warrants a medical or psychiatric diagnosis, this statement and the events that ensued demonstrate a degree of intelligence and competence that speak against attributing her behavior to either form of pathology. Joan's commanding style motivated the hesitant troops to move aggressively forward, and in a series of battles between May 4 and May 7, 1429, the French troops took control of the English fortifications. Joan was wounded but later returned to the front to encourage a final assault. By mid-June, the French had routed the English and, in doing so, crushed their perceived invincibility as well. Although it seemed that Charles had accepted Joan's mission, he did not display full trust in her judgment or advice. After the victory at Orléans, she kept encouraging him to hurry to Reims to be crowned © 2023 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. The Journal of Nervous and Mental Disease • Volume 211, Number 8, August 2023 Downloaded from http://journals.lww.com/jonmd by zIyM+QTrhBxelIoRU6oxyCJ26I9mcWugvX1P0fsxxuuiIVDlG7I RmEDUm6dmV/v8uYLbM3C7DorP1tYOEE0KuQeCa+r0C9cSTVWevTq+F9cf+fX+6qnxG2BC92/kMcwh+QLBtGAvNJ+KqCrgd89EdE9 TWTNUn15mt8zI4YbEvUw= on 07/29/2023 king, but he and his advisors were more cautious. In the meantime, the English were regrouping in Patay, not far from Orléans. As the two forces were drawing near to one another in an open field, the Bastard of Orléans, along with the Duke of Alecon, both leaders of the French, questioned Joan, and she responded that everyone should have “good spurs.” Asked if that meant that they were running away from the battle, Joan responded that they needed the spurs to chase after the fleeing English. She was right, the English took flight and 4000 of them were taken prisoners. The Battle of Patay on June 18, 1429, is considered Joan's greatest victory. After the battle and a little more dithering, the Dauphin agreed to go to Reims for his coronation. They left on June 29, 1429, on what was technically a foolhardy mission, as Reims was far away in northern France and in Burgundian territory. On July 17 they entered Reims, and on the following day, the Dauphin was crowned Charles VII. Joan was at his side, occupying a visible place at the ceremonies. In the aftermath of the coronation, Joan the Maid began her downhill course. This began with resentment among the other leaders that they had not been put on equal footing with Joan at the coronation. Only she stood with the King, and only she brought her banner to the ceremony. There was, however, a larger issue at play in Joan's fate. Northern France and Paris were already occupied by the English and the England-supporting Burgundians, and they had no interest in giving up their possessions. This put them in dramatic disagreement with Joan's goal to liberate France from the English. Simply put, they wanted Joan out of the way. Charles, as always, weak, evasive, and suspicious, sided with Joan's enemies. Wanting to make peace with the English and the Burgundians, he gave up the goal of banishing the English from France and ordered Joan to abandon her efforts to take Paris. He gave Joan only minor assignments and, in that context, ordered her in the spring of 1430 to proceed to the small town of Compiègne to confront the Burgundians. During the battle, she was thrown off her horse and left outside the town's gates. The Burgundians took her captive and held her for several months, negotiating with the English, who saw her as a valuable propaganda prize. Finally, the Burgundians exchanged Joan for 10,000 francs. Charles VII was unsure what to do. Still not convinced of Joan's divine inspiration, he distanced himself and made no attempt to have her released. The English occupation army turned her over to church officials, who insisted that she be tried as a heretic. She was charged with 70 counts, including witchcraft, heresy, and dressing like a man. Initially, the trial was held in public, but it went private when Joan bettered her accusers. Between February 21 and March 24, 1431, she was interrogated nearly a dozen times by a tribunal, always keeping her humility and steadfast claim of innocence. Instead of being held in a church prison with nuns as guards, she was held in a military prison, where she was threatened with rape and torture, although there is no record that either actually occurred. She protected herself by tying her soldiers' clothes tightly together with a number of cords. Frustrated that they could not break her, the tribunal eventually used her military dress against her, charging that she dressed like a man. Her trial is recorded in voluminous court records, considered authentic because the registrar recording the proceedings was not under the authority of the tribunal. The trial record reported Joan's description of her voices, such as this: “It instructed me to be good and to go often to Church; it told me it was necessary for me to come into France…. It said to me: ‘Go, raise the siege which is being made before the City of Orléans. Go!’” (Murray, 1902, pp 10–11). In the trial, Joan's behavior was remarkable. Constantly pressured by the vicious inquisitors of the tribunal, the illiterate 19-year-old responded with the calm assertiveness and intelligence we have already recognized in her. Here are samples from the beginning of the trial: Undiagnosing St Joan Asked to place her hand on the bible and swear to tell the truth to all questions asked of her: To which she did reply: “I know not upon what you wish to question me: perhaps you may ask me of which I ought not to tell you.” “Swear,’ we did say to her, to speak truth on the things which shall be asked you concerning the Faith, and of which you know.” “Of my father and my mother and of what I did after taking the road to France, willingly will I swear; but of the revelations which have come to me from God, to no one will I speak or reveal them, save only to Charles my King; and to you I will not reveal them, even if it cost me my head; because I have received them in visions and by secret counsel, and am forbidden to reveal them. Before eight days are gone, I shall know if I may reveal them to you” (Pernoud and Clin, 1998, p 109). On May 29, 1431, the tribunal announced that Joan the Maid was guilty of heresy. On the morning of May 30, she was taken to the marketplace in Rouen and burned at the stake before an estimated crowd of 10,000 people. She was 19 years old. One legend surrounding the event tells of how her heart survived the fire unaffected. Her ashes were gathered and scattered in the Seine. After Joan's death, there quickly developed a negative reaction to what had taken place in Rouen. In a mood of defensive anxiety, Bishop Pierre Cauchon, who had directed the trial, ordered all those involved in the case to issue statements accusing Joan of heresy, thus affirming her guilt and relieving the state and Church of responsibility. The Hundred Years War continued for another 22 years. France slowly began recapturing more of the land occupied by the English, including all of Normandy, of which Rouen was the capital. At the same time, sympathy for Joan was growing. Charles had been crowned king and was feeling more secure in his position. When he learned that the townspeople of Rouen were attempting to retake the city, he marched there quickly on November 10, 1449, to lead the French forces to victory over the English. When he heard the people of Rouen describe the execution of Joan in 1431, he had the records of the trial and execution brought to him and on February 15, ordered the following letter to be distributed to the country: As heretofore Joan the Maid was taken and seized by our ancient enemies and brought to the city of Rouen, against whom they caused to take place a certain trial by certain persons who had been chosen and given this task by them, in the process of which they made and committed many falsifications and abuses, so much that, by means of this trial and the great hatred our enemies have against her, they caused her death iniquitously and against reason, very cruelly indeed; for this reason we wish to know the truth of the aforesaid trial, and the manner according to which it was carried out. We command you, instruct you, and expressly enjoin you to inquire and inform yourself well and diligently on what was said; and that you bring before us and the men of our council the information that you will have gathered on this event under a closed seal…for we give you power, commission, and special instruction by these presents to carry this out. Given at Rouen, the 15th day of February, the Year of Grace 1449 [[2], p 149]. A very active inquest followed this letter. It was decided that, since Joan's first trial had been conducted by the Church, with a final conviction for heresy, any further inquest or trial should also be conducted by the Church. As a first gesture, the papal delegates developed a list of 27 articles, the first 12 of which corresponded to the 12 articles on which Joan had been condemned. The formal trial, called the nullification trial, took place during 1455 and 1456. A total of 115 individuals were interrogated, some of whom had been witnesses in the earlier © 2023 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.jonmd.com 561 The Journal of Nervous and Mental Disease • Volume 211, Number 8, August 2023 Phillips et al. Downloaded from http://journals.lww.com/jonmd by zIyM+QTrhBxelIoRU6oxyCJ26I9mcWugvX1P0fsxxuuiIVDlG7I RmEDUm6dmV/v8uYLbM3C7DorP1tYOEE0KuQeCa+r0C9cSTVWevTq+F9cf+fX+6qnxG2BC92/kMcwh+QLBtGAvNJ+KqCrgd89EdE9 TWTNUn15mt8zI4YbEvUw= on 07/29/2023 inquest, and most having been involved in the abuses carried out on Joan. All were given immunity. Another group of delegates were sent to Joan's hometown, Domremy, to inquire about her childhood. These witnesses provided a picture of Joan as young girl like any other in the village: a friendly child who enjoyed playing with the other children, who helped with family chores such as tending the animals, helping around the house, developing her skills as a seamstress, and quite observant in church services. The stark question posed by these reports of her childhood, and probably never to be answered, is, how did this ordinary young girl become Joan of Arc? The result of the nullification trial was that Joan was found innocent of all charges and designated as a martyr. She was canonized as a saint on May 16, 1920, and is the patron saint of France. Voices and Visions in the Middle Ages With this historical background, we can wonder about Joan's voices and visions and place them in their historical context. In the first trial, the prosecutors pressed Joan repeatedly about her experiences. She refused many of their questions about details of the voices but did offer some description of them, including this statement that ends in the words quoted earlier. I was thirteen when I had a Voice from God for my help and guidance. The first time I heard this Voice, I was very much frightened; it was mid-day, in the summer, in my father's garden. I had not fasted the day before. I heard the Voice to my right, toward the Church; rarely do I hear it without its being accompanied also by a light. This light comes from the same side as the Voice. Generally it is a great light. Since I came into France I have often heard this Voice…. I believe it was sent me from God. When I heard it for the third time, I recognized that it was the Voice of an Angel. This voice has always guarded me well, and I have always understood it; it instructed me to be good and to go often to Church; it told me it was necessary for me to come into France. You ask me under what form this Voice appeared to me? You will hear no more of it from me this time. It said to me two or three times a week: ‘You must go into France.’ My father knew nothing of my going. The Voice said to me: ‘Go into France!’ I could stay no longer. It said to me: ‘Go, raise the siege which is being made before the City of Orléans’ (Murray, 1902, pp 10–11). Such experiences were very likely more common in Joan's era than in the modern world, although we will question that in the following section. Corinne Saunders has summarized Medieval experiences in a comprehensive manner. She writes: “The medieval period is of special interest because its thought-world takes for granted the possibility of the supernatural and its theories of medicine and psychology offer powerful explanatory modes for hallucinatory experience. Some of the greatest religious writing in the period is inspired by hearing voices, while its fictions also play creatively with voice-hearing” (Saunders, 2016, p 2136). Regarding the latter, Saunders invokes Geoffrey Chaucer, writing in the late 14th century, for whom the emotion exciting such experiences is often love. He “depicts the physiology of love with precise detail. In his Knight's Tale, the lover Arcite, struck in the heart by love, is transformed both physically, becoming pale, cold, and hollow-eyed, and mentally, so that his ‘cell fantastic’, his imagination, obsessively brings forth the images of his lady” (p 2136). In addition, in his epic romance Troilus and Criseyde, Troilus, “the archetypal betrayed lover, is literally unmade by love, his illness so extreme that he wastes away to a type of melancholy - emaciated, swooning, withdrawn, suffering from nightmares. His memory repeatedly circles back to images but also to the voice of his beloved, whose melodious singing he seems to hear ‘in his soul’” (p 2136). 562 www.jonmd.com Addressing the religious context, Saunders calls on the 11th century abbess and theologian, Hildegard of Bingen, as well as two English mystics, Julian of Norwich, an anchorite, and Margery Kempe, a married mother of 12, to illustrate the medieval, mystical practice of voices and visions. As Saunders describes these women, each in her own way, they enjoyed lives that were peopled by voices and conversations. Margery, for instance, vividly describes her conversations with God and with Jesus. Dame Julian's Revelations of Divine Love is the first book written in English by a woman and is the oldest book in English written by a mystic. Hearing Voices in Contemporary Times How does our contemporary world compare with the Middle Ages in the manner of voices and visions? They are not part of our commonplace world, as they were in Joan's, but there is in fact a large literature asserting that hearing voices is a rather common experience that does not necessarily imply medical illness or psychopathology. One main witness to this reality is the Hearing Voices Network (HVN) and its associated Hearing Voices Movement, both located at Durham University in the United Kingdom. The Hearing Voices Movement is a vast, peer-support undertaking that gathers voice hearers of all sorts, some with psychiatric disorders, others not. The experiences are as varied and different as the individuals reporting them. As Angela Woods, of the Hearing the Voice project at Durham University, Durham, UK, puts it: “…people hear voices in a wide range of circumstances: for some it is an unremarkable feature of everyday experience, for others it is part of religious and spiritual devotion, an aspect of bereavement, or a source of intense creativity. Studies have shown that voice-hearing in the general population is more common than is usually thought and that up to 13% of people will hear voices at some point during their adult lives” (Woods, 2015, p. 2386). In a thorough review of the literature of voice-hearing, Beavan and colleagues report that in studies of voice-hearing, the prevalence in the general population ranged from 0.6% to 84%, with an interquartile range of 3.2% to 19.5%. They suggest at the end of the article that we can think of the prevalence as 3% to 15%. The differences among studies are due to definitions and methodologies, as well as variations in sex, ethnicity, and environmental factors (Beavan et al., 2011; see also Fernyhough, 2014, and Hartigan et al., 2014). A number of studies have emerged from researchers working within the HVN. In one of them, Corstens and colleagues reviewed the history of HVN and recommend the involvement of voice hearers in research, as well as a greater use of narrative and qualitative approaches (Corstens et al., 2014). Among the HVN-related studies, several involve the benefits of self-help groups. Dillon and Homsteir (2013) found that self-help groups can be more effective than conventional treatment. In interviews of self-help group participants, Oakland and Berry (2015) found that the feeling of hope was an important, common experience. Longden et al. (2018) describe the benefits of self-help groups as “the opportunities to meet other voice hearers, provision of support that was unavailable elsewhere, and confidential place to discuss difficult issues.” Daalman et al. (2011) compared a group of individuals with psychotic diagnoses with another group of individuals with no psychotic history. They found that “The perceived location of voices (inside/ outside the head), the number of voices, loudness, and personification did not differentiate between psychotic and healthy individuals.” Features that did differentiate the groups were emotional valence of the content, frequency of AVHs, degree of control over the AHVs, and younger age of many nonpsychotics. “In our sample, the negative emotional valence of the content of AVHs could accurately predict the presence of a psychotic disorder in 88% of the participants.” The latter point may be important in judging the putative pathology of St Joan's voices. © 2023 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. The Journal of Nervous and Mental Disease • Volume 211, Number 8, August 2023 Downloaded from http://journals.lww.com/jonmd by zIyM+QTrhBxelIoRU6oxyCJ26I9mcWugvX1P0fsxxuuiIVDlG7I RmEDUm6dmV/v8uYLbM3C7DorP1tYOEE0KuQeCa+r0C9cSTVWevTq+F9cf+fX+6qnxG2BC92/kMcwh+QLBtGAvNJ+KqCrgd89EdE9 TWTNUn15mt8zI4YbEvUw= on 07/29/2023 Outside the HVN, Powers 3rd et al. (2017) found the hallucinatory experiences of psychiatric voice hearers to be very similar to those of patients with psychiatric diagnoses (see also Pierre 2010). In this section we have reviewed various analyses of differences (and lack of differences) between those voice hearers who carry a psychiatric (psychotic) diagnosis and those who do not. What we have not heard enough about is contemporary experiences like those of Joan— voices that are positive, inspiring, and effective. Angela Woods, from the Hearing the Voice movement in Durham, UK, quoted above in a different article, addresses this phenomenon: If we listen, really listen, the statement “I am a voice-hearer” issues a twofold invitation: it asks that we bracket any assumptions about the nature of auditory verbal hallucinations and their status as symptom, and it opens up a space for conversation, a space in which it is not only possible but important to ask about who or what the voices are, what they say, and what meaning they have in the context of a person's sense of self and world (Woods et al., 2015). Finally, St. Joan and contemporary voice hearers have both had to contend with the possibility of negative outcomes. For Joan, the risk was being declared a witch and being put to death; for latter-day voice hearers, the risk is being subjected to a psychiatric diagnosis. Regarding the latter, we do not how many women hide their voice-hearing or mystical experiences for fear of being labeled psychotic or crazy. Proposed Medical and Psychiatric Diagnoses In attempting to understand Joan's visions, psychiatrists and others have offered a variety of diagnostic possibilities. We will review a few of the prominent ones. The most frequent medical explanation of Joan's voices has been some form of epilepsy. A study by Foote-Smith and Bayne (1991) reflected the effort to understand the voices as an aura of an epileptic seizure. A more recent study by d'Orsi and Tinuper (2006a) challenges earlier explanations of the voices as auras, and, recognizing that Joan lacks the standard signs of epilepsy, propose a newer diagnostic entity called Idiopathic Partial Epilepsy with Auditory Features (IPEAF). They make this diagnosis through a semiotic analysis of Joan's statements, focusing on symptoms and possible trigger factors, and for this, they rely on the extensive documentation of Joan's trials. In a further letter to the editor, they write: Joan's spells were characterized by a constant auditory component, complex, spontaneous, or evoked by sudden auditory stimuli, that could be associated with an inconstant visual component, sometimes simple and, more often, complex, and verbal disturbance. These spells differ from ecstatic epilepsy with respect to clinical features and involvement of cerebral regions. The negative family history, the ictal semiology, and the possibility that the spells were triggered by acoustic stimuli suggest IPEAF, and the search for the epitempin/LGI1 gene or other new gene mutations on a hair of the Maid of Orléans may enhance our knowledge about her presumed epilepsy (d'Orsi and Tinuper, 2006b, p 281). As Joan was illiterate, her written documents were dictated. All her statements in the trials were reported by the court clerks. Any semiotic (or semantic) analysis of her vocal statements would be an analysis of dictated statements, and these would be of questionable value. As for her actual voice, we of course do not have a recording. Even if we did, since she spoke a French dialect, evaluating it would require knowledge of the dialect—or again, the use of a translation. We consider the suggestion of IPEAF as a serious explanation for her visions and behavior to be of interest but hard to support with the current evidence, given that these documents do not offer much material for a semiotic analysis. Undiagnosing St Joan Another popular diagnosis has been that of some form of tuberculosis. Ratnasuriya (1986) argues of Joan that “[m]any of these facts can be explained by the hypothesis that Joan of Arc suffered from tuberculosis with a temporal lobe tuberculoma and tuberculous pericarditis” (p 234). As she was involved in tending her father's cattle, Ratnasuriya speculates that Joan had a bovine form of the tuberculous condition, which he argues was prevalent in Joan's era. The tubercular hypothesis presents a different kind of challenge to the imagination of the reader than the epileptic hypothesis. Although the epileptic proposal provided no evidence of epileptic behavior, the tubercular hypothesis offers a plethora of such behavior, but with no evidence for asserting such symptoms. He describes cachectic appearance, amenorrhea, psychotic disturbances with audio and visual hallucinations, and disturbances of sexual function. Aside from lack of evidence for the putative symptoms, the symptoms do not seem to fit Joan very well. Regarding cachexia, did Joan have a cachectic appearance while battling troops in full armor? We have no way of knowing whether she was amenorrheic, but if she was, would that be surprising in her circumstances? Suggesting psychosis is a little odd, given that the only evidence for that is the voices that are in question? Disturbances of sexual function? What sexual function? The facts that she cut her hair and dressed like a man were in fact very protective when wearing armor and in protecting herself from rape. It is not difficult to dismiss the epileptic and tubercular hypotheses. We now need to examine the psychiatric alternatives. We will focus on the effort of Henker (1984) to sort out where Joan fits in the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III) classificatory structure. Will the DSM certify her with a diagnosis? Henker recognizes the very unusual nature of this young woman and suggests three general diagnostic categories: psychoses, psychosexual disorders, and personality disorders. In the area of psychoses, Henker (1984) considers the diagnostic criteria for schizophrenia and bipolar mania, and he finds that in each case, Joan's thought and behavior do not meet the criteria. He then takes up psychosexual disorders and writes: We come now to psychosexual disorders, a group much more broadly covered in the current than in the previous classifications. Cross-dressing and adoption of the masculine military role suggest some problem. She was examined twice and found to be indisputably female. For a transsexual classification, the DSM-III criteria require a sense of discomfort and inappropriateness about one's anatomic sex and a wish to be rid of one's own genitals and to live as a member of the other sex. There is no record of Joan's complaining about her sex; rather, she proudly referred to herself as “the maid.” Transvestism might be considered, except that DSM-III presents it entirely as a masculine disorder. Thus, we find no firm basis for a diagnosis of psychosexual disorder. Joan seemed to transcend physical sexuality, being zealously devoted to her mission (p 1489). Finally, Henker addresses personality disorders. This is a very interesting discussion because Joan is such an unusual person. Henker breaks down personality disorders into the three clusters. He recognizes that she does not belong in the odd, eccentric cluster of paranoid, schizoid, and schizoptypal disorders. “She attracted the loyalty of an army, and she easily met others – even royalty.” She also does not fit the fearful, anxious, avoidant group. “Joan was too outwardly aggressive, confident, and secure for any of these.” It is finally the dramatic, emotional, or erratic group of histrionic, narcissistic, antisocial, and borderline disorders that captures Henker's attention. He focuses on histrionic and narcissistic disorders, finding that none of them really applies to Joan. And he concludes: In conclusion, we are left with a spectacularly different individual who approximates but does not meet completely the diagnostic © 2023 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.jonmd.com 563 Phillips et al. The Journal of Nervous and Mental Disease • Volume 211, Number 8, August 2023 Downloaded from http://journals.lww.com/jonmd by zIyM+QTrhBxelIoRU6oxyCJ26I9mcWugvX1P0fsxxuuiIVDlG7I RmEDUm6dmV/v8uYLbM3C7DorP1tYOEE0KuQeCa+r0C9cSTVWevTq+F9cf+fX+6qnxG2BC92/kMcwh+QLBtGAvNJ+KqCrgd89EdE9 TWTNUn15mt8zI4YbEvUw= on 07/29/2023 criteria set forth in DSM III for any of the psychiatric entities. Joan's behavior was likely the product of a messianic identification produced by intense religious indoctrination coupled with repeated exposures to the frustrations and cruelty of military actions upon a highly suggestible and somewhat obsessive adolescent. The voices and visions were likewise influenced by the religious pattern of her time and would in current terms be attributed to eidetic imagery. It is most unfortunate that Joan's life was terminated before more of it could have been followed and recorded for a more complete study (Henker, 1984, p 1490). The last sentence is a little chilling, regretting Joan's execution because it deprived us of the time needed to complete the diagnostic evaluation! (Using DSM-5 rather than DSM-III would not alter Henker's discussion, with one exception: DSM-5 includes a diagnosis of gender dysphoria. St Joan, however, no more qualifies for this diagnosis than for the other psychosexual disorders.) Diagnosing St Joan In this article, we have reviewed St Joan's personal history in the context of 15th century France. We have examined the phenomenon of voice-hearing in both Medieval life and contemporary times. We have taken up well-known medical and psychiatric speculations regarding what disease entities might have caused the voices. It is now time to draw conclusions about her diagnosis. In pursuing the diagnostic trajectory of Joan, we should bear in mind that what we see in the account of her brief life is an astonishing degree of character strength, fortitude, leadership, courage, loyalty, tolerance of suffering—even torture—and faith. All this in a 17-year-old adolescent, an adolescent who spends much of her waking life in a conversation with her God. What are we to make of this? It does not, prima facie, seem to be the picture of a mentally afflicted adolescent who “hears” voices. Any effort to diagnose her will have to face this obstacle of her apparent lack of mental affliction. Indeed, when viewed in the light of these well-documented character strengths, the diagnostic proposals reviewed above seem rather unlikely. When Henker (1984), for instance, writes that “Joan's behavior was likely the product of a messianic identification… upon a highly suggestible and somewhat obsessive adolescent” (p 1490), this does not seem to fit the Joan we have gotten to know from her history. In view of Joan's obvious character strengths, the frequency of nonpathologic voice-hearing and visions in Medieval Europe, and the implausibility of proposed medical and psychiatric diagnoses, we take the position in this article that Joan's voices and visions do not warrant a diagnosis. This conclusion, of course, flies in the face of the medical literature insisting on a medical or psychiatric diagnosis. It is, in fact, striking that none of the medical experts who have studied Joan have argued for absence of diagnosis. We could locate no study contending that Joan does not require a diagnosis. Henker takes a step in that direction in stating that she does not fit into the DSM-III diagnostic grid, but in the end, he seems to feel a need to offer some kind of diagnosis. If the voices were not the product of disease, what then were they? Our answer is that they were, tout court, Medieval experiences —the voices and visions of an extraordinary adolescent in a context where such experiences were not unusual. If the conclusion of no diagnosis is correct, we can wonder why the medical field been so insistent that Joan had a medical or mental disease? Part of the answer to this question is the great reluctance of the medical professionals to consider voices and visions as nonpathologic behavior. Such reluctance must involve a failure to acknowledge both the common experience of voices and visions in the Middle Ages, as well as the frequency of voice-hearing in our own time. It also reflects a hesitancy to think beyond the DSM and biomedical model. 564 www.jonmd.com Dismissing the diagnostic issue, however, does not relieve us of the burden of explaining St Joan. We are, in fact, left with another question. Joan's voices and visions may have been a typical Medieval experience, but that does not explain her achievements—how an adolescent could have led an army. Other Medieval mystics have not demonstrated such achievements, especially as adolescents. We can now recognize that Joan presents us two big questions rather than one. The first of course is the diagnostic question—does she need a diagnosis? The second is the achievement question—how could an illiterate adolescent lead an army? We have stated our conclusion regarding the first—that she does not warrant a diagnosis. However, we now have to address the second. In attempting to answer the achievement question, we end up with a surprise conclusion—we do not have an answer. Although it has not been difficult to dismiss the medical and psychiatric diagnostic claims, the achievement question has left us with empty hands. All efforts to find an explanation have failed. This conclusion may add another dimension to the doctors' insistence on diagnosing Joan. They may share our own mystification at the notion of an adolescent leading an army. How much easier, then, say, to write it off as the psychotic behavior of a deranged adolescent. Rather than accept this as a defeat, we invoke philosophers like Karl Jaspers, Søren Kierkegaard, John Dewey, and others who assert that there is an unknown dimension to any human being—a dimension that defeats all efforts to “explain” it. Does this mean that Joan with her accomplishments remains something of a mystery? Yes, as with all of us. CONCLUSION In this article, we have argued that St Joan's voices and visions do not require a medical or psychiatric diagnosis, but that her extraordinary behavior calls for an explanation that we do not have. We can associate this conclusion with two other current cultural phenomena. On the one hand, DSM-5 has been accused of diagnostic expansion and a tendency to impose a diagnosis on any unusual behavior. This certainly puts the DSM system on the side of intolerance toward difference and divergence. In addition, in that way, we might understand the DSM-oriented doctors' tendency to pathologize St Joan's behavior. On the other hand, popular culture has been moving toward more acceptance of difference and divergence, easily exemplified by the acceptance of the LGBTQ community. In more general terms, we often see in younger people a tolerance of difference that exceeds that of their elders. We are, of course, treating St Joan's divergence as a behavior that cannot be explained but should not be pathologized. We began this article by inviting Mark Twain to join in the Introduction. It is perhaps fitting that we invite him to join us in the Conclusion. The evidence furnished at the Trials and Rehabilitation sets forth Joan of Arc's strange and beautiful history in clear and minute detail…It gives us a vivid picture of a career and a personality of so extraordinary a character that we are helped to accept them as actualities by the very fact that both are beyond the inventive reach of fiction. The public part of the career occupied only a mere breath of time – it covered but two years; but what a career it was! The personality which made it possible is one to be reverently studied, loved, and marveled at, but not to be wholly understood and accounted for by even the most searching analysis…Taking into account, as I have suggested before, all the circumstances – her origin, youth, sex, illiteracy, early environment, and the obstructing conditions under which she exploited her high gifts and made her conquests in the field and before the courts that tried her for her life – she is easily and by far the most extraordinary person the human race has ever produced (Twain, 1896, p. 452). © 2023 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. The Journal of Nervous and Mental Disease • Volume 211, Number 8, August 2023 Downloaded from http://journals.lww.com/jonmd by zIyM+QTrhBxelIoRU6oxyCJ26I9mcWugvX1P0fsxxuuiIVDlG7I RmEDUm6dmV/v8uYLbM3C7DorP1tYOEE0KuQeCa+r0C9cSTVWevTq+F9cf+fX+6qnxG2BC92/kMcwh+QLBtGAvNJ+KqCrgd89EdE9 TWTNUn15mt8zI4YbEvUw= on 07/29/2023 DISCLOSURES Ethical considerations: There are no human participants in this study. Author contributions: The primary author of this article is James Phillips. The authorship includes the Religion and Psychiatry Committee of GAP (Group for the Advancement of Psychiatry), whose names are listed above. All members participated in the composition of this article, reading through several drafts, suggesting changes (e.g., Jenifer Nields suggested changing the title from “Diagnosing St Joan” to “Undiagnosing St Joan”) and corrections. Michael Norko, chair of the committee, orchestrated communications with the GAP Publications Committee, in addition to making his own suggestions and managing other administrative tasks. There authors declare no conflict of interest. REFERENCES Beavan V, Read J, Cartwright C (2011) The prevalence of voice-hearers in the general population: A literature review. J Ment Health. 20:281–292. doi:10.3109/ 09638237.2011.562262. Corstens D, Longden E, McCarthy-Jones S, Waddingham R, Thomas N (2014) Emerging perspectives from the hearing voices movement: Implication for theory and practice. Schizophr Bull. 40(Suppl):S285–S294. D’Orsi G, Tinuper P (2006a) “I heard voices...”: from semiology, a historical review, and a new hypothesis on the presumed epilepsy of Joan of Arc. Epilepsy Behav. 9: 152–157. D’Orsi G, Tinuper P (2006b) The “voices” of Joan of Arc and epilepsy with auditory features. Epilepsy Behav. 61:281. Daalman K, Boks MP, Diederen KM, de Weijer AD, Blom JD, Kahn RS, Sommer IE (2011) The same or different? A phenomenological comparison of auditory verbal hallucinations in healthy and psychotic individuals. J Clin Psychiatry. 72: 320–325. Dillon J, Homsteir B (2013) Hearing voices peer support groups: A powerful alternative for people in distress. Psychosis. 5:286–295. Undiagnosing St Joan Fernyhough C (2014) Hearing the voice. The Lancet. 384:1090–1091. Foote-Smith E, Bayne L (1991) Joan of arc. Epilepsia. 32:810–815. Hartigan N, McCarthy-Jones S, Hayward M (2014) Here today, not gone tomorrow? An exploratory longitudinal study of auditory verbal hallucinations (hearing voices). Behav Cogn Psychother. 42:117–123. Henker F (1984) Joan of Arc and DSM III. South Med J. 7:1488–1490. Longden E, Read J, Dillon J (2018) Assessing the impact and effectiveness of Hearing Voices Network self-help groups. Community Ment Health J. 54:184–188. Murray TD (1902) Jeanne D'Arc, Main of Orleans, Deliverer of France: Being the story of her life, her achievements and her death, attested on oath and set forth in the original documents. New York: McClure, Phillips Co. (a republication with no copyright and free distribution). Oakland L, Berry K (2015) Lifting the veil: A qualitative analysis of experiences in hearing a voices network groups. Psychosis. 7:115–129. Pernoud R (1955) The retrial of Joan of Arc: the evidence at the trial for her rehabilitation 1450–1456. New York: Harcourt, Brace and Co, 1955. Pernoud R, Clin MV (1998) Joan of Arc: Her Story. Trans and revised by Jeremy du Quesnay Adams. New York: St. Martin's Press, 1998. Pierre JM (2010) Hallucinations in nonpsychotic disorders: Toward a differential diagnosis of “hearing voices”. Harv Rev Psychiatry. 18:22–35. Powers AR 3rd, Kelley MS, Corlett PR (2017) Varieties of voice-hearing: Psychics and the psychosis continuum. Schizophr Bull. 43:84–988. Ratnasuriya R (1986) Joan of arc: Creative psychopath: Is there another explanation? J R Soc Med. 79:234–235. Saunders C (2016) Hearing medieval voices. Lancet. 386:2136–2137. Twain M (1896) Joan of Arc. San Francisco: Ignatious Press. Woods A (2015) Voices, identity, and meaning-making. Lancet. 2:2386–2387. Woods A, Jones N, Alderson-Day B, Callard F, Fernyhough C (2015) Experiences of hearing voices: Analysis of a novel phenomenological survey. Lancet Psychiatry. 2:323–331. © 2023 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.jonmd.com 565