Monday, October 15, 2007

The Bloody Bride

Roy pointed out recently that I haven't posted in nearly a month. Oops. I like hanging out with Roy and Dinah and I do like the blog, but sometimes you just have to think about something other than psychiatry.

Like opera, for instance. This weekend I saw Donizetti's Lucia di Lammermoor. It was great. The storyline is that Lucia, the heroine, is betrothed to a total stranger in order to restore the fortunes of her family. In order to guarantee the betrothal her brother forges a letter from Lucia's true love (who is off somewhere in a foreign country) telling her that he has found someone else. Lucia marries against her will, then on the wedding night she stabs her husband to death and wanders around in a bloody wedding dress singing a seventeen minute aria about her hallucinations.

This opera was first shown in 1835. Many sopranos have sung the role since then and they all developed their own particular way of portraying insanity. In this particular version of the mad scene, singer Natalie Dessay wanders the stage while waving a knife, looking dazed, screaming, laughing for no reason, thowing herself down and rolling down the stairs. At one point she tears up her veil and cradles the pieces like a baby. Eventually a doctor comes on stage and gives her an injection.

Color me cynical but most psychotic folks I've known don't do a lot of that. It was good drama, but not real. I thought that considering our reason podcast talking about the portrayal of psychiatrists in the media it might be good to mention the portrayal of insanity.

The ironic thing about this opera is that while Donizetti was writing it he was becoming ill with bipolar disorder himself. He ended up institutionalized. Sadly, he died about a hundred years before there were any injections or pills to help him.


Anonymous said...

Donizetti's wife had three kids but none survived. His wife died of cholera within a year of both of his parents. That is quite a lot of stress. Even without external stressors, the guy had syphilis which is sometimes confues with bipolar symptoms and you kind of have to ask the question, if psychiatrists today often disagree on diagnoses, why would the state of things have been any better in the mid 1800s?
So should he have been on Lithium or something for the syphilis? And, maybe throw in a little bit of grief counselling plus a little bit of education on STDs. They didn't have a lot of things back then. Plus ca change, plus c'est la meme chose. I don't think he would have been any better off today really. Go ask Kurt or Janis or someone like that.

Sarebear said...

I didn't know this sort of stuff was in operas. I mean, I guess I knew that "madness" is a likely theme in any kind of theatrical genre, that covers life in all its vagaries, but I'd never really thought of an 18 minute aria about hallucinations.

Bringing light to how mental health issues, the mentally ill, the disordered, and how mental health professionals are portrayed, are all great subjects for discussion and in need of more, nowadays.

Thanks Clink, and it is good to "see" you. er, via your words, not implying that the pic is you!

ClinkShrink said... sounds like you don't think psychiatry has made any progress in the last 150 years?

As far as what Donizetti needed, as you pointed out it's hard to tell in retrospect. At a minimum a good diagnostic workup. At least in modern times all my prison patients get tested for syphillis at intake.

ClinkShrink said...

Thanks for the welcome back SareBear.

The day after the opera I saw a musical that contained loads of pastry-related puns. You would have loved it.

Anonymous said...

Pastry related puns?? Sweet!

Glad you had a good time. 17 minutes of hallucinations could get a little trying.

Glad you're back. Sorry you're leaving.
The Red Sox are losing.

Anonymous said...

Of course 17 minutes of hallucinations can be a bit trying. And to think people payed to see that when hallucinations are free for some people. Free hallucinations all around and throw in a syphillis test too(dunno if they ever tested me for that but they do an automatic HIV test).
No, psychiatry has probably not improved all that much. All the theories can be tested and the tests can be verified but it still constitutes proof of nothing and the DSM version 289 due out in another 100 years will demonstrate that.

Roy said...

Still can't get away from Psychiatry, huh? Even at the Opera.

I agree with at least the flavor of the first anon. Plus ca change.

In 150 years we have gotten much better at "diagnosing"; at using roughly the same term to describe the same condition. Granted, it ain't perfect. It still takes 8-10 yrs for someone to get diagnosed with their bipolar disorder (but much less than that if they start out with a psychiatrist).
Or Autism.
Or What have you.

And we have gotten MUCH better at treating conditions. We could be better. But we are not much worse off than treating heart disease.

What we have not reached yet is the WHY.
WHY does someone have bipolar disorder?
WHY do they hear voices?
WHY do some people get addicted after their first drink?

But... it is better. And, I can nearly guarantee that we WILL have genetic tests in the next 10 years that will help us sort out which type of condition this is, and which type of drug is best used or avoided.

It may take a bit longer to sort out the WHY. But, hey, the brain is a complex organ. Why wouldn't it be the last organ we figure out.

Anonymous said...

Wow, I was just counting and it took me about 16 years to get diagnosed with BP. And that was even by the tender age of 23!

Medicine is still an imperfect science, but it certainly has come a long way. I look at all of the options I have as far as treatment goes, and I consider myself *lucky*. They aren't choices I like to make, but at least I have choices that keep me out of institutions for the rest of my life. I'm also happy to have more than just Vitamin L and all its unpleasant side effects to choose from.

Is psychiatry able to diagnose with more precision? Hey, you caught me early, didn't you? Some people get all up in arms about rising diagnosis rates among children and teens, but having been one of those children/teens, I really see the possibility of what more accurate and proactive diagnosis can do. I lost 16 very formative years of my life because I went undiagnosed and untreated for so long.

Genetic tests...I donated my DNA about 6 months ago to a large research project studying the genetic links of bipolar disorder. Hopefully they'll find some genetic markers that can help them! It would be great to see a test come out in my lifetime.

Sarebear said...

Dinah beat me to the punch, this time! Er, pastry! But some punch WOULD be good with that . . . spiked with 7-Up.

Michelle, I wish I had been seen as a child & early teen myself. Having the formative years happen in the middle of stuff just not being in place, functional/developmental wise, to allow healthy development, is a PITA, as an understatement.

Yeah, Roy, totally makes sense to me (most of what you say in that comment.) Alot of it is what my thoughts have been on the subject, too.

I had some DNA taken for a prostate cancer study about 10 years ago (this may sound like ancient history, but this was a year or 18 months before most of the big announcements about discovering specific genes respensible for, related or contributing to, various cancers, like breast, etc . . . that feels so long ago, now, like it's almost taken for granted . . .)

I most certainly don't have a prostate, but they were studying to see how the pattern for prostate cancer in families with a strong history of it, expressed itself down through the family tree. Part of it was to see how strong of a tendency to pass it down could go from father, through the daughter's genes, to the daughter's son(s).

To quote one of my fave musicals, "I haven't GOT any sons; you never GAVE me any sons!" Or something like that . . . hee. OH! And the best part about that study, was that with all of us giving blood samples, they had the middle to older age men go get PSA tests to have a baseline number for where they were at. This was in-between my Dad's annual physicals, and wouldn't you know it but they caught his cancer REALLY early!

So genetic studies save lives. Sometimes from just participating in the study.

Okay, I've wandered . . . somebody dangled images of pastries in front of me and I just could not cope (8^D)

Anonymous said...

I was actually happy to see the reports that diagnosis of bipolar disorder in teens and kids is up PROVIDED the diagnoses are VALID. I saw a huge uproar about 'over-pathologizing' kids in several quarters of the health community and general public, but to have actually lived it myself, I can tell you how damaging it is to just leave these kids undiagnosed and untreated. It's ridiculous to pretend that these disorders don't happen in children and that kids are 'resilient' enough to cope with it on their own or that the use of any medications in children is pure evil (eye roll). (Caution is certainly advised with medications for anyone obviously, duh;). To me, this is one of the areas I hope psychiatry will advance in most. Early dx is crucial to good prognosis, I think.

Have the shrinks done a blog post on this already?

Anonymous said...

Totally off topic...

When do we get to talk about the results of the "Favorite Mood Stabilizer" poll? I have a whole bunch of questions I'd like to ask about who's voting for Zypreza and why?

Anonymous said...

Oy Roy,
That "roughly better" is pretty rough. With pretty much the same symptom set or presentation or however you want to call it, I have received diagnoses that are all over the map.Each one of the professionals doing the diagnosing is convinvced that they are correct, and even in cases where two clinicians actually agreed, they prescribed radically different treatments. It took way longer than 8-10 years to get a bipolar diagnosis, but I do understand the mathematics of averages.I cannot discount that I may have received the bipolar diagnosis because that is what they are giving out these days. There is also such a high incidence of comorbid conditions and too often the comorbid conditions have so many of the same criteria that the docs might as well say :we don't quite know what to call it but we know what it looks like. That is about as far as I have seen the common language go.
Genetic tests don't mean a whole lot unless they can prove that if you carry the bipolar gene you have bipolar. For many illnesses, you can have the gene and never develop the condition yourself. What about all the people who will have the testing done and discover that they do not have the gene but are still unwell? We went the genetic testing route for another disorder and got the following line: if you have the gene, your chances of developing the disorder are increased but you may never develop it. You may pass the gene on to a child who will develop the disorder. You may have the gene and develop the disorder, but not because of the gene necessarily since the disorder can appear randomly in the population as well.

Anonymous said...

I hate to put it so seemingly insensitively, but some cases will be more difficult than others, and unfortunately, you seem to have drawn a short straw:(. You're like reading Foucault instead of Marx (sorry, I'm a half-sociologist, so pardon the references). He's difficult, multifacted, and abstract and really takes many, many years to fully comprehend (Marx just tells you what he thinks and you're on your way). That doesn't necessarily mean that psychiatry as a whole is doing poorly though. I think psychiatry is pretty good at understanding most of us Marxians, just like medicine in general is pretty good at making most diagnoses of cancer. But there will always be difficult cases that require more time and attention and expertise. Sorry it has to be you:(.

I see your point on genetic testing. I'll also add that bipolar disorder seems to be a polygenetic disorder (from reading I've done, I could be wrong), which increases the complexity of everything you just said. My fear with it will be that I have no identifiable relatives with bipolar disorder, so if I get the test and there are no genetic markers, THEN WHAT? I'm back to square one but with less than what I started with...

Anonymous said...

Reading Michel was more interesting any day than reading Karl. I assume you are referring to Karl, but if you meant Groucho, I like him best of all.
I am relieved to know that you are a Marxian rather than a Marxist. (Imagine if Marxian was what resulted from the union of Martians and Marxists.) When people do colonize the red planet (around the time all those great genetic tests prove something) I would hope that they they don't mess with Marxism. A waste.Anyway, about all the dx-ing, it is kind of like Marx, in the sense that it is a dialectical process but the problem is that we can't seem to reach a synthesis.
About the genetics stuff, they have been discovering different genes for years and years. Some claim to have found a gene that is responsible for bipolar as well as anxiety disorder (very broad) and some to have found a gene related to depression and bipolar (also very broad, and it is funny how some choose to see them as different entities and others take a spectrum approach).
Validity is a tricky word. If a thing cannot be tested, then it cannot be shown to be valid. As there are so far no tests, the validity of the diagnosis should be questioned. One more reason to question the validity of the diagnosis is because the validity of the construct itself is on shaky ground. For example,what qualifies as manic now may not have made the cut years ago. Like urban sprawl sees city boundaries stretching, this is diagnostic sprawl.

Anonymous said...

That was pretty funny:) I'm feeling more like a martian today. I'm having pre-migraine brain scramble. Intelligent thoughts strung together in coherent sentences with few spelling errors are a rarity...

Let me think a while about validity and diagnosing. It's an interesting question, and I want to give it some more thought.

NeoNurseChic said...

One thing I was going to say about genetics is that genetic testing doesn't always mean a gene that can be passed down from one generation to the next. I used to be confused about this in terms of migraine until I had a discussion with one of the neuros. He was talking about genetic testing for migraine, and I was saying how nobody in my family has it but me. He was saying that they are going to find that migraine is going to show up in the genetic code, so I asked him more about it. He explained that it doesn't have to mean a gene that passes from one generation to the next, but just refers to a "faulty gene". How the gene became faulty is up for discussion. Maybe some people had it passed to them from their parents, but others may have just had a sponatenous mutation in the same gene that then lead to migraine. So he was saying that a genetic mutation of some sort is responsible for migraine, but not an exclusively inherited mutation. It's obvious based on case studies and research that migraine IS genetic in the way we think about passing down the family genes, but it is also genetic in terms of a mutation (spontaneous or inherited) occurring that is causing the disease.

Food for thought!

Take care,
Carrie :)

Anonymous said...

Sporadic vs heriditary.

DrivingMissMolly said...


I really enjoyed this post. It would be great if this became part of a series.


Anonymous said...

Ugh, Lily, now Roy's gonna want more google ads for the "Send Clink to the Opera" fund.

ClinkShrink said...

Thanks Lily, I'd love to do that. No Google ads necessary, I'd pay for it myself. I was thinking a little list of operas with insanity theme might be interesting.

FooFoo5 said...

You could have at least announced a "plot spoiler" at the beginning of the post. Now I'll have to go back to Verdi.

ClinkShrink said...

Ooo, sorry about that Foo. Verdi is good too. I love the mad scene in Nabucco where.....oops, almost did it again.