At our medical school, the psychopathology curriculum for PGY- 1 and -2 residents (Reviewing Mental Disorders with a Reverent Understanding of the Macabre, Red rum) is taught through reviewing various works in the horror genre [1]. To meet our objective to enhance learning through creative discussion of psychopathology portrayed in film and literature, Red rum is broken down into three modules:

1. Necromancy.

2. Review of the top classical monsters.

3. Review of the top contemporary monsters. This article takes a closer look at Necromancy (Table 1) and discusses Andrew Lloyd Webber’s Ghost Story, The Phantom of the Opera, to introduce teaching points germane to the depressive disorders.

Table 1: Necromancy.

Andrew Lloyd Webber’s The Phantom of the Opera is based on the French novel Le Fantôme de l’Opéra by Gaston Leroux [2]. The musical opened in London’s West End in 1986 and on Broadway in 1988. The story is recounted by Raoul, Vicomte de Chagny, upon melancholically rediscovering a music box at an auction at the Paris Opéra in 1911. Through Raoul’s account, the audience is “illuminated” about the 1881 “strange affair” which serves as a case study of Major Depressive Disorder.

The syllabus for our Psychopathology course has been previously described [1]. For the Depressive Disorders didactic, residents are encouraged to read selected chapters from the required textbook [3]. The salient feature of the Mood Disorders lecture is that we supplement the traditional classroom didactic with a discussion of Andrew Lloyd Webber’s musical. On October 27, 2016, the university’s Masters Educators’ Guild sponsored a Grand Rounds that was co-presented by Miss Julia Udine who had recently completed her Broadway tour as Phantom’s Christine Daaé. The Grand Rounds contained content from our course and was presented as a patient interview where faculty from the Department of Psychiatry prompted answers from Miss Udine who, in character, responded in song. This paper reviews the major points from our event formulating the dialogue as a case of Major Depressive Disorder (MDD). This objective was reached by framing Elisabeth Kübler-Ross’s original stage theory of grief within five selected scenes of Andrew Lloyd Webber’s musical, The Phantom of the Opera (Table 2).

Table 2: Elisabeth Kübler-Ross’ Stages of Grief framed in selected scenes of The Phantom of the Opera.

The Depressive Disorders section in the DSM-5 includes disorders that have a disturbance in mood as the predominant feature. The Phantom of the Opera serves as a rich medium to introduce the classic condition in this group MDD. Course instructors reference Phantom to review multiple aspects of the disorder including etiology, precipitating stressors (e.g. the role of Persistent Complex Bereavement Disorder), specifiers, levels of severity (e.g. severe, with psychotic features), and course of illness.

The discussion of etiologic factors predisposing to and precipitating MDD further allows for review of the changes from the DSM-IV-TR to DSM-5, specifically, that the bereavement exclusion has been removed [4]. This change necessitates that clinicians differentiate between normal grieving associated with a significant loss and a diagnosis of a mental disorder. Viewing Phantom as a fictional case study of Christine Daaé allows for discussion of the role of bereavement in diagnosing MDD. First introduced in her seminal book, On Death and Dying, Elisabeth Kübler-Ross described a process by which people deal with grief and tragedy [5]. Kübler-Ross originally applied these stages to people suffering from terminal illness and later expanded her theory to include any form of catastrophic personal loss including the death of a loved one.

Act one - Paris 1861

Denial (Scenes 2 and 3): Corps de Ballet Dressing Room/The Labyrinth Underground (Little Lotte the Mirro & the Phantom of the Opera) [6]. Denial is considered a Level 1 (pathological) defense mechanism and usually only provides temporary relief to the individual [7]. As the grieving individual processes the loss, denial is generally replaced with a heightened awareness of the situation. Despite three years having passed since her father’s death, Christine has not yet moved past the stage of denial as evidenced by her belief that she is being visited by an Angel of Music. After the gala, Christine is visited by Meg upon entering her dressing room. When Christine discloses that she has been visited by a mysterious angel since her father’s death, it is established that Persistent Complex Bereavement Disorder (PCBD) plays a central role (stressor) in her belief system. Meg expresses concern that Christine is acting bizarrely and that her behavior is a change from previous functioning (Christine, you’re talking in riddles and it’s not like you) [6]. Despite Meg’s concern, Christine’s belief remains fixed and therefore may be interpreted as a delusion within the context of her depressive disorder.

• In the next scene, the new prima donna is reunited with a former love, Raoul. With the increasing stress of a) her recently attaining the role of Elissa in Chalumeau’s ‘Hannibal’.

• Raoul having come back into her life, Christine’s delusion evolves to include auditory hallucinations (Angel! I hear you! Speak - I listen…), then a visual hallucination when she believes she is led by the Phantom through her dressing room mirror. This scene also illustrates the otoscopic illusion; a misperception of an image, called a phantom that appears in a reflective surface [8]. The otoscopic illusion is usually experienced in context with frontal lobe pathologies (such as MDD) with creative personalities (such as those in the performing arts) posing a particular risk [8].

With the accompaniment of “The Phantom of the Opera” (song), the Phantom guides Christine through the mirror into his lair beneath the opera house. The Phantom’s lair – lit candles rising from the water - illustrates Christine’s distortion of reality (denial) and sets the foundation upon which Christine’s ensuing behavior can be further interpreted.

Act Two - Six months later

Bargaining (Scene 5): A Graveyard in Perros (Wishing You Were Somehow Here Again & Wandering Child…/Bravo Monsieur) [6]. This stage involves the hope that the individual can somehow postpone or delay death for one’s self (or another). Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the individual is saying, “I understand I will die, but if I could just have more time.” At a graveyard in Perros, Christine’s bargaining is manifest in “Wishing You Were Somehow Here Again” (song) as she pleads with her father to stop haunting her. As Kübler-Ross later extended her theory to include any form of catastrophic personal loss, Christine’s pleading may be interpreted as needing more time to decide between Raoul and an eternity with the opera ghost. Hearing her prayers, the Phantom appears and again attempts to seduce her. Raoul arrives to protect and ground her, “Whatever you may believe, this man this thing…is not your father.” Raoul’s revelation reinforces that the Phantom is a mental image of Christine’s deceased father, part of a delusional belief system of a severely depressed young woman.

Depression (Scene 7): Don Juan Triumphant (The Point of No Return) [6]. During this stage, the individual begins to understand the certainty of death. Because of this, she may become silent, refuse visitors, and spend much of the time crying and grieving. This process allows the dying person to disconnect herself from objects of love and affection. During the opera, “Don Juan Triumphant,” Christine demonstrates severe depression. The fact that this opera is set in Scene 7 (before the scene that depicts anger) conforms to Kübler-Ross’s revised theory that individuals may not process grief in a given sequence and that one may even regress back to a previous stage [5]. The title of the song, “The Point of No Return,” is metaphorical for suicide; in this scene, Christine is contemplating taking her life. Subsequently, the opera ghost’s marriage proposal, “an eternity of this before her eyes!” may be interpreted as Christine’s ideation to also become a ghost.

Anger (Scene 9): Beyond the Lake (Down Once More/Track down This Murderer) [6]. Once in this stage, the individual may be very difficult to care for due to displaced feelings of rage. Christine’s response to the Phantom’s proposal is illustrative of anger, “…It’s in your soul that the true distortion lies…” When the Phantom captures Raoul with the Punjab lasso, he gives Christine an ultimatum, “Refuse me, and you send your lover to his death!, to which Christine angrily responds, “The tears I might have shed for your dark fate grow cold, and turn to tears of hate…” The following crescendo/decrescendo melody sung by Christine, Raoul, and the Phantom (“Down Once More/Track down This Murderer”) harmonizes with the discordant thoughts that individuals contemplating suicide may experience.

Acceptance (Scene 9): Beyond the Lake (Down Once More/Track down This Murderer) [6]. In the final stage, the individual begins to come to terms with their mortality or that of their loved one. With the decrescendo of “Down Once More/Track down This Murderer,” Christine is confronted by the Phantom, “You try my patience – make your choice!” Christine reflects for a moment, then with resolution, moves slowly towards the Phantom. Quietly, with growing emotion, she responds, “God gave me the courage to show you you are not alone…” When he sees that Christine has accepted her role and would sacrifice her own life for that of Raoul’s, the Phantom frees the young lovers.

The Phantom takes a lighted candle and holds it above Raoul’s head. The suspended rope of the lasso harmlessly falls to the ground, freeing Raoul to guide Christine out of the Phantom’s lair. The candle flame which earlier represented her father’s hold on Christine now becomes the means of breaking that pathological bond. Her ability to make her father’s soul take flight allows Christine to give herself to Raoul; she listens in pity as she walks out of the lair hand in hand with her newfound soul mate.

At our medical school, we have created a novel resident didactic where psychopathology is taught through discussion of the arts with emphasis on thematic movies. Our course fits in the postgraduate training curriculum, building on basic science and clinical knowledge obtained in medical school and differs from previously-described curricula in that the psychopathology examples are discussed in a creative, sometimes metaphorical, context. One piece of art we review is Andrew Lloyd Webber’s The Phantom of the Opera with a focus on the character of Christine Daaé. Close inspection of Christine’s past history and current mental status reveal details consistent with a moodpsychotic cluster.

When we are first introduced to Christine, it is several years after the death of her father. Consequently, the musical score follows Elisabeth Kübler-Ross’s stages of grief and introduces the precipitating role of Persistent Complex Bereavement Disorder in Christine’s pathological experience. With increasing stress, Christine demonstrates delusions, auditory hallucinations, and visual hallucinations that are established as a change from previous functioning. As such, her behavior may be interpreted within a continuum from “normal grief ” to Major Depressive Disorder, Severe with Psychotic Features (Table 3).

Table 3: Formulation of the most likely diagnosis in a patient with depressive symptoms.

In addition to providing a medium to teach psychopathology, popular culture also allows for collaboration with artists outside of the field of medicine who can nonetheless contribute to the education of medical students and residents. For example, at the special Grand Rounds, Miss Udine not only offered her first-person perspective in character (e.g. attesting to her beliefs being fixed and resulting in significant distress), but also enlightened the audience in third person about conservations with her directors, choreographers, and fellow performers regarding “behind the scenes” aspects of Phantom that further added to the formulation of the musical as a case of severe mental illness [9].

Directors of courses intended to teach psychopathology are challenged to adopt creative teaching methods to reinforce major teaching points. The arts and cinema have long been valuable resources for examples of mental illness and related topics. Organizing a curriculum under the “horror genre” is an innovative method that allows for the review of mood and other mental disorders (Table 3) such as those demonstrated in Andrew Lloyd Webber’s The Phantom of the Opera. Merging medical education and the performing arts also offers an opportunity to collaborate with artists who may add a dimension that traditional didactics lack.

The authors would like to acknowledge the contributions of Miss Julia Udine, Marta Papoosha, MD, Deborah Kim, MD, and Ashley Silakoski, MD.

On behalf of all authors, the corresponding author states that there is no conflict of interest to declare.