Medical and artistic professionals generally accept that a relationship exists between some creative persons and mental illness. Bipolar disorder, specifically, is seen at a high rate among writers, artists, and musicians. Some well-known classical musicians have been the subject of much rumination as to the nature and effects of their illness on their performance and their art. Robert Schumann, for instance, had periods of great creativity and periods of utter despair. His suicide attempts and long-term institutionalization in a sanitarium for the mentally ill attest to the severity of his illness.
Bipolar disorder is debilitating both in its high points of manic energy and its lows of depression. In this short series of articles, we will look at what bipolar disorder is and the ways it affects classical singers in their present and future careers.
What Bipolar Is and Is Not
Bipolar disorder, also known as manic-depression, is a mental illness characterized by disorders of mood. Symptoms include alternations of great bursts of energy, creativity, productivity, and feelings of well-being with states of gloom, hopelessness, despair, and depression. In the extreme, manic states can lead to psychosis and delusional states (often with feelings of grandeur and self-importance with highly risky behaviors) and depressive states can lead to self-harm and ultimately suicide.
Generally the sufferer exhibits alternating periods of highs and lows of some duration, but not all sufferers cycle in a regular pattern of days or weeks. Some sufferers experience a “mixed-states” form in which manic energies run concurrently with feelings of anxiety and depression. Bipolar I involves true manic states; Bipolar II involves “hypomania,” which does not involve the extremes of impairment of true mania or the possible psychosis associated with it. Other symptoms include sleeplessness or sleep disorders, racing thoughts, impulsivity, poor judgment, social impairment, criminality, and hypersexuality. Cyclothymia is a low-grade form of mood disorder that involves mood cycling but not to the level of Bipolar I or II.
Bipolar disorder is not schizophrenia, which is a disorder related to perception of reality (although one can enter a state called manic psychosis in its extreme form). It is not obsessive-compulsive disorder, which involves uncontrollable, repetitive actions or behaviors. It is not the lows and irritabilities suffered by premenstrual women, nor is it the strange and uncomfortable jolts and drops in emotions and feelings associated with the hormonal changes of menopause. It is not seasonal affective disorder (SAD), where the gloom of winter and darkness can cause depression.
And it is not the “diva personality”—that lovely set of characteristics among us singers, including that of the prototypical, eccentric, demanding, exacting, irritable, and hypersensitive prima donna. It is not drug or alcohol abuse—though bipolar individuals may attempt to self-medicate through use of alcohol and nonprescription drugs. It is not the normal coping mechanisms brought to bear from extreme trauma or loss. And it is not the general moodiness or ups-and-downs associated with the normal trials and tribulations of life. Indeed, sometimes the mood shifts of bipolar disorder bear no relation to the cycles or circumstances of reality.
Bipolar disorder usually is diagnosed in early adulthood but it is not uncommon among teens and even children. For a musician and singer, the illness will manifest in how you sing and practice and rehearse and study and teach and perform. You may find you hardly have the will to practice. You may begin to feel you have a horrible voice and no talent—even if you are attending a prestigious music school or are already performing in an opera company.
You may wonder whether to continue at all. You may lack energy to attend classes, and when you are there, what you are doing seems meaningless. Everybody sings better than you do. Nothing you do musically is good enough. There are problems with your voice you never noticed before, but maybe it just does not matter anymore anyway. What is the point? You feel as if your future is over, and maybe you begin drinking or using drugs to escape the terrible feeling of dread that you wake up with and go to sleep to escape. Even your nightmares are full of things like standing on the stage singing naked—or singing and snakes are coming out of your mouth. You get extremely tired for no reason, and sleep sometimes seems better than doing anything else. You wonder if this is normal and if it will pass. And it usually does.
Because sometimes, however, you just might feel like you are the greatest singer in the world, but the world cannot appreciate you because it is not intelligent enough to recognize your superior voice. You know the reason you were not chosen for that lead is because the conductor is an idiot and you are the one who knows what true Bel Canto is. You buy several new gowns for the recitals you have not planned yet and max out your credit card.
You find you cannot sleep because you have so much energy. You might stay up late practicing until the school shuts the practice rooms—and then stay up all night learning your new role or song cycle. The next day, when you are talking so fast and are so excited, you are happy that you feel in the zone and on your game—and usually you do perform the next audition or masterclass very well.
You might find that everything seems intense and you feel every single thing—and maybe even hear nuances in your voice and other voices you are sure no one else can possibly hear, because you are a superior being. In rehearsal you may get a little rude at times because the energy running through you makes you a little short tempered. But you are a diva, after all! You are entitled to work faster and better than everyone else!
But then for no apparent reason—or reasons you may try to figure out for months or years before seeking help—you wake up one day to find you are as hopeless and pointless and useless as you were the month or week before you felt so, so good. And maybe somewhere along the line, you will be able to recognize you might need some serious help.
Once you have recognized that something is the matter and seek help, care is available from medical, psychological, and sociological approaches. Types of intervention include the following:
· Immediate hospitalization: For an overdose or suicide attempt causing injury.
· Inpatient hospitalization: For suicidal thoughts or attempt after visit to emergency room; can be short term of a week to 10 days to permanent hospitalization for the severely mentally ill.
· Day hospital or “partial” program: You function but not 100 percent; usually short term of five to six hours a day for a few days to a few weeks.
· Private counseling/psychotherapy: One to three times per week, indefinitely.
· Group therapy/support group: Might not work for some people who prefer one-on-one interaction.
· Regular psychiatric care: Essential for those on medications; some require regular blood testing.
· Speech therapy: For pressured speech, if warranted.
· Gathering and maintaining a network of social support: From family, friends, and colleagues.
· Regular voice lessons/coaching: To be maintained at all costs.
Once a psychiatrist has seen you, the wide world of psychotropic drugs will be made known to you. There are mood stabilizers, antidepressants, antipsychotics, benzodiazepines, and anticonvulsants. Be aware, as a singer, that these medications can cause side effects that will affect your voice. Some will cause dry throat and thus chafe the delicate mucosa of the vocal folds. Some will increase heartburn, which will cause gastric reflux, burning and damaging the vocal folds. Some can cause slowness of speech, which is a horrid thing for any singer. Some can cause lethargy. Some cause weight gain, which is very difficult to lose once it is gained.
You must explain that you are a student or professional singer and that you need medication that will treat your condition but affect your voice the least amount possible. Sometimes you will not know if something affects your singing until you try it. But you must be firm and insistent that your psychiatrist work with you on this.
Some treatment regimes recommend keeping a “symptom journal” so you can keep record of your highs and lows and see if a pattern can be established. This is a very good idea, especially if you are performing and have some leeway as to scheduling times and dates. If you happen to go through a depressive cycle which is regular enough, you might be able to schedule a recital or teaching seminar to avoid that down period (I know some opera singers do this with opera companies to avoid singing premenstrually). This charting can also help determine if any meds you are taking are causing any ill effects on your voice.
Perhaps the most significant sequelae of taking medication for the treatment of a mood disorder is the loss of creative “edge” that many of us have felt while taking them. It can also be described as “emotional numbness,” “attenuation,” or “blighted” emotions. One has to wonder sometimes which is worse for a singer—to have too strong of an extreme in the feeling of moods or to not have any feelings at all? Meds can often be “tweaked” to minimize side effects while providing therapeutic relief or management of bipolar symptoms. You ultimately have to weigh the benefits versus the risks of each med you take. Which way does the scale fall? It is this predicament that I explore in “To Be or Not to Be Medicated” (see sidebar, p. 24).
Bipolar on the Anatomical Level
Most psychiatrists, voice teachers, voice doctors, speech therapists, and counselors that have encountered me know that I am bipolar as soon as I open my mouth. I exhibit “pressured speech”—strong adduction of vocal folds with increased subglottal pressure. It is one of the hallmark manifestations of bipolar disorder. I know what to do, I know all the technical solutions to it, and I can do it if asked—but I hate being someone I am not and speaking in a way that is not reflective of who I truly am. This has tempered, as the rest of my symptomatology, as I have aged. However, I do carry a mild chronic prenodule formation on my vocal folds, which is probably a combination of dry mucosa from medications and the stresses that pressured speech has always put on delicate vocal fold tissue.
Singers with pressured speech can do the following to work to overcome this:
· Before speaking, take deep abdominal breaths as you would for singing and support as if you were singing when you speak. Speak more “singing-ly.”
· Pause a half second before speaking, then release a bit of air before you speak with continuous, rather than jerky, abdominal contractions. A slight move toward “breathiness” can ease the tension of strong adduction.
· Learn to speak “on the breath” and to take longer pauses between phrases to relax the larynx.
· Pitching the speaking voice a bit higher than normal can keep the soft palate high and voice resonant as well as minimize a “depressed” sound to the speaking voice.
· Avoid “vocal fry” and “glottal scraping” in speaking at all costs.
· Try to accept even a modest change in your speaking voice identity. It will seem less fake if you change even a little bit, and every little bit will help soothe and heal your vocal mechanism.
· Stop talking if your voice is tired. Write it down, text, e-mail, or just wait until that evening or the next day to speak.
Signs and Symptoms Warning
· If you see yourself starting to withdraw, skip classes, drop out of school, not taking/canceling gigs or performances, stop practicing, stop going to concerts, calling in sick, canceling your students, spending lots of time alone (not creatively), sleeping too much (or too little), enduring crying spells, drugging or drinking, seek help before the situation engulfs you!
· If you see yourself spending too much money shopping, feeling “buzzed,” feeling “out of control” but not caring that you are, having racing thoughts at a million ideas a minute, getting speeding tickets, desiring an escalation in your sex life, making many impulsive choices that you regret later on, getting easily irritated and angry even at the ones you care about most, seek help before the situation engulfs you!
· If you feel like or think about killing yourself (or think about ways to kill yourself), if you cut or hurt yourself in any way, or if you think you have a drug or alcohol addiction, seek help even if you do not want to! Medicine of any kind rarely tastes good, but the right one can help and might save your life!
In the next issue we will look at prognosis, tips for coping and survival, career advice and alternatives, and living as a classical singer with bipolar disorder.