Psychosis Vs Depression Case Study

The Phantom of the Opera: A Case Study of Severe Major Depressive Disorder with Psychotic Features

Anthony Tobia*, Roseanne Dobkin, Shawen Ilaria, Rehan Aziz, Viwek Bisen, Adam Trenton and Kenneth Kaufman

Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, USA

*Corresponding Author:
Anthony Tobia
Department of Psychiatry
Rutgers Robert Wood Johnson Medical School, USA
Tel: + 732-2354403
E-mail:[email protected]

Received date: June 04, 2017; Accepted date: June 20, 2017; Published date: June 23, 2017

Citation: Tobia A, Dobkin R, Ilaria S, Aziz R, Bisen V, et al. (2017) The Phantom of the Opera: A Case Study of Severe Major Depressive Disorder with Psychotic Features. J Depress Anxiety 6:282. doi:10.4172/2167-1044.1000282

Copyright: © 2017 Tobia A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Objective: Portrayals of psychiatry in the arts have been enjoyed by audiences for almost a century. Courses designed to teach psychopathology have used examples from the arts to emphasize major teaching points. This paper frames Elisabeth Kübler-Ross’s stage theory of grief within selected scenes of Andrew Lloyd Webber’s musical, The Phantom of the Opera, to achieve course objectives such as the etiology, course, and levels of severity of Major Depressive Disorder.

Methods: Course content from our Psychopathology course was transformed into a dialogue between an examining psychiatrist and a Broadway performer who was in character. The performance was part of a special Grand Rounds reviewing the Mood Disorders.

Results: Goals and objectives were readily achieved with over 450 faculties in attendance. Conclusions: Organizing a curriculum with performing arts is an innovative teaching method that allows for review of mental disorders such as those demonstrated in The Phantom of the Opera.


Media; Teaching methods; Depression; Psychopathology


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.

Mental IllnessFilmSummary
The Ghost Stories
DeliriumThe Tragedy of MacbethThrough character analysis, Shakespeare’s play serves to review the etiologies of Delirium
Mood DisordersThe Phantom of the Opera (musical)Christine Daaé’s case of Persistent Complex Bereavement Disorder is told through Andrew Lloyd Webber’s score and lyrics and Elizabeth Kubler-Ross’ stages of grief
Stephen King’s Tales of Possession
Major Neurocognitive DisorderDuma KeyElizabeth Eastlake battles “her demons” to recover lost memories of the secret of Duma Key
Psychotic DisordersThe ShiningJack Torrence demonstrates psychotic symptoms in the context of a close relationship with his delusional son upon assuming the position of caretaker at the Overlook Hotel
Eating DisordersCarrieThe adaptation of Stephen King’s novel is a psychodynamic formulation of Anorexia Nervosa
Dissociative DisordersItThe “Losers Club” overcomes dissociative amnesia to battle an inter-dimensional predatory life form

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).

Act (Scenes)StageOn Death and DyingSong from PhantomaLyrics from PhantomaComment
DenialA temporary defense allowing the individual to distort reality.The Phantom of the OperaAnd do
I dream again?
For now
I find the Phantom of the Opera is there - inside my mind…
In coping with the loss of her father, Christine explains that her father sent her an “Angel of Music” upon his death; Christine displays some insight that her beliefs are a product of her own mind.
BargainingThe reaction to feelings of helplessness is often a need to regain control.  Cognitive processing results in “If only…” or “What if…” statements.Wishing You Were Somehow Here AgainWishing you were somehow here again…
Knowing we must say goodbye…
Try to forgive… teach me to live…
Give me the strength to try…
Christine is not only trying to come to grips with her father’s death but also bargains with him: If you “let me go,” I can live my own life.”
DepressionDefense mechanisms are stripped away resulting in the exposure of raw feelings such as regret.  Individuals may also quietly prepare to separate from their loved one.The Point of No ReturnPast the point
of no return,
the final threshold -
what warm, unspoken secrets
will we learn?
Beyond the point
of no return . . .
Christine is seduced to join the Opera Ghost, a metaphor for her contemplating suicide.
AngerAs the effects of denial begin to wear off, reality of the loss threatens conscious awareness.  The intense emotion is redirected as displaced anger. Down Once More/Track Down This MurdererThe tears I might have shed for your dark fate grow cold and turn to tears of hate…Christine displays anger directed at the Phantom, a displaced father-object.
AcceptanceRecognition that the new reality is permanent.Down Once More/Track Down This MurdererSay you’ll share with
me, one
love, one lifetime…
say the word
and I will follow you…
In finally accepting her father’s death, Christine is able to give herself to Raoul.  As a result, she allows her father’s soul to “take flight.”

a. The Phantom of the Opera, Original Cast Recording, 1987.

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.

Discussion and Conclusion

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).

DiagnosisTeaching PointsPhantom of the Opera
BereavementPathological when associated with a) guilt, b) thoughts of death, c) morbid preoccupation with worthlessness, d) marked psychomotor retardation, e) marked functional impairment, and f) hallucinatory experiences.While the onset of Christine's symptoms appears to be incident to her father's death, they have progressed to include dysphoria, suicidal ideation, and related symptoms including perceptual disturbances other than thinking she hears the voice (or transiently sees the image) of her father.
Bereavement exclusion (DSM-5): Evidence of bereavement no longer rules against MDD; bereavement is a severe psychosocial stressor that can precipitate a major depressive episode.
Major Depressive Disorder
The diagnosis of MDD requires that depressive symptoms are not better accounted for by a mixed episode, the effects of a substance, or another medical condition.Christine doesn't display the requisite signs or symptoms of mania. Her symptoms do not appear to be due to the direct physiologic effects of a substance or an underlying medical condition.   The diagnosis of severe MDD is considered because of Christine’s history of Bereavement and the time course of psychotic symptoms; specifically, that they are in the context of a mood episode.
Dysthymic DisorderTime course: Depressed mood and associated symptoms (Criterion B) for at least 2 years; no episode of MDD has been present during the first 2 years of the disturbance.Even though Christine’s symptoms appear to be for at least 2 years, evidence of suicidality and psychotic symptoms favor a diagnosis of MDD, recurrent episode, over Dysthymic Disorder.

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.

Conflict of Interest Statement

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


  1. Tobia A, Draschil T, Sportelli D, Katsamanis M, Rosenberg S, et al.(2013) The horror: A creative framework for teaching psychopathology via metaphorical analyses of horror films. Acad Psychiatry37: 131-136.
  2. Leroux G (1911) The phantom of the opera. The Bobbs-Merrill Company, New York, Indianapolis.p. 357.
  3. Sadock BJ, Sadock VA, Kaplan HI (2003) Kaplan and Sadock's Synopsis of psychiatry: Behavioral sciences/clinical psychiatry. (9th edn). Philadelphia: Lippincott Williams & Wilkins; 1460 pp.
  4. American Psychiatric Association(2013) Diagnostic and statistical manual of mental disorders: DSM-5. (5th edn). Arlington,VA: 947 p.
  5. Kübler-Ross E (1969) On death and dying. Macmillan, New York 8: 260.
  6. Lloyd A (2014) Webber’s The Phantom of the Opera. Showcase Magazine. Academy of Music, Broadway/Philadelphia, PA.
  7. Cramer P (2006) Protecting the self: Defense mechanisms in action. Guilford Press, New Yorkp. 384.
  8. Sadock BJ, Sadock VA, Kaplan HI (2003) Kaplan andSadock's Synopsis of psychiatry: Behavioral sciences/clinical psychiatry. (9th edn). Philadelphia: Lippincott Williams & Wilkins p: 525-526.
  9. Udine SI, Anthony T (2017)ThePhantom of the Opera.
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We present a case study using the Evidence Based Medicine approach and have attempted to work through a common problem. The aim of the process was to underpin our clinical decision with relevant research evidence.


A 39-year-old married housewife with 2 children aged 16 and 12 years was electively admitted for treatment of worsening depression.

She had a 5-year history of recurrent severe depressive episodes; there had been no history of mental health problems prior to this. She had been an in-patient for most of the last 5 years, and had required one-to-one nursing on one admission because of self-harming behaviour, which included cutting and trying to set herself on fire.

She had been raped at the age of 12 years; however, prior to her first episode of depression she had a well-adjusted pre-morbid personality, having not had any symptoms suggestive of post traumatic stress disorder prior to her history of depression. A diagnosis of post traumatic stress disorder had been considered, however, rejected because her depressive affective symptoms dominated her clinical presentation, and she did not suffer flashbacks to her index traumatic episode. Other diagnoses that merited consideration included schizoaffective disorder and bipolar disorder, however, she did not suffer from first rank symptoms of schizophrenia or hypomanic/manic episodes which excluded her respectively from both of these diagnoses according to ICD-10.

The depressive symptoms followed soon after a triggering event of a horse-riding accident from which she suffered concussion. A CT scan at the time was reported as normal.

She had a family history of mental disorder, with a sister who suffered from schizophrenia.

During this present admission she had experienced 5-month deterioration in mood. She had a 1-week period of insomnia and increasing suicidal ideation. There was no history of alcohol/substance misuse or any medical problems. She had been receiving ECT treatment twice weekly in the community for the 4 months preceding the admission. The ECT continued after she was admitted. Her medication was:

Lithium carbonate 1000 mg once daily

Mirtazapine 60 mg at night

Olanzapine 20 mg at night

Chlorpromazine 50 mg at night

On MSE, she had psychomotor retardation with poor eye contact and a constant rocking motion. Her affect was melancholic. There was no formal thought or perceptual disorder, or evidence of cognitive impairment.

On 13/8/01 she was started on a 4-day course of dexamethasone, which is an unusual but published treatment for resistant depression (Dexamethasone augmentation in treatment resistant depression Acta Psychiatr Scan 1997; 95 58–61). There were no obvious beneficial effects, and she still felt low in her mood, now with a blunted affect. Her speech was slower and more monotonous. She had decreased motivation. She had worsening suicidal ideation.

On 19/8/01 the patient became very agitated and started lashing out. Several staff members were needed to restrain her and she was sedated with IM lorazepam. The following day she reported hearing voices of her rapists saying derogatory comments to her.

The patient's mirtazapine, chlorpromazine and olanzapine medication were stopped and she was started on haloperidol and amitriptyline. Two days later, she started experiencing second person auditory hallucinations of the rapist who assaulted her in her childhood. She became more restless and agitated. Her suicidal ideation increased and she had difficulty thinking clearly. She continued to receive ECT treatment and her medication was increased to 200 mg amitriptyline and 40 mg of haloperidol.

Formulating an Evidence Based Medicine question

We felt it was important to formulate an EBM question that could be researched in view of possible treatment approaches that we could offer. We had already tried her on a variety of medical treatments, which had limited benefit.

The question formulated was as follows: 'In a patient who has depression with psychotic symptoms, is the use of clozapine and an antidepressant more beneficial than standard treatments for psychotic depression, in improving mood and psychotic symptoms.'

Literature search

The literature search that was conducted used the following databases:

Cochrane Database, ACP Journal Club, CCTR, 1986–2002

Medline 1966–2002.

EMBASE 1993–1996.

PSYCHINFO 1887–2002

The manufacturers of clozapine were also contacted.

The keywords used were:

1 'Depression/Depressive disorder/mood disorder/affective disorder/Psychosis/Psychotic'

2 The above keywords were combined with 'clozapine and antidepressant agents'.

The search was originally limited to the years 1986–2002, English language, and human research (however, the limitations were not valid in Cochrane, ACP, DARE, CCTR). However, an up to date review on the above databases up to 2006 was conducted on follow up of the patient which yielded no further pertinent papers.

The original search initially yielded 147 articles but on further inspection only 8 were thought to be pertinent to the question. The lists of references for these papers were also reviewed.

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