Remembering Marilyn

Marilyn would have been 85 on June 1. I wrote this 10 or 11 years ago for mcmanweb. I would write a much different piece today, with far less emphasis on bipolar, and hopefully I will get around to writing that piece. In the meantime ...

On April 10, 1962, Marilyn Monroe arrived on the set of the bedroom farce, "Something’s Got To Give," for costume and screen tests. Producer Henry Weinstein described her as "at her best," but later that same evening he found her unconscious from an apparent sleeping pill overdose. Weinstein pleaded with the executives at Fox to delay shooting, but with the studio teetering on financial collapse as a result of the white elephant, "Cleopatra," they badly needed their most bankable star to bail them out.

Marilyn most likely was dealing with bipolar. And, of course, she was Marilyn. An AMC documentary from the early 2000s, "Marilyn Monroe - The Final Days," recounts what happened next:

Shooting was delayed a week while Marilyn went to New York to be with her mentors, Lee and Paula Strasberg. She returned energized, but with a bad cold that rendered her cinematically hors de combat. The studio rejected their own doctor's recommendation that production be postponed a month. One week later, Marilyn reported to work, only to collapse on the set the next day.

A short time earlier, US Attorney General Robert F Kennedy had entered Marilyn’s life. Marilyn confided in Weinstein of her impending first date and sought his advice on what kind of questions she should be asking. A week later, when Weinstein enquired how it was going, Marilyn cheerfully replied, "I don’t need any more questions."

Then there was Robert’s older brother, President John F Kennedy. Marilyn skipped a day of shooting to pant her famous rendition of "Happy Birthday, Mr President" in a gown that anticipated Jennifer Lopez by 40 years.

Meanwhile, the set at Fox resembled an armed camp, with director George Cukor at odds with both Marilyn and producer Weinstein, frustrated actors, an unhappy crew, and Fox executives on the warpath over Marilyn’s absences.

But the Marilyn captured on film completely belies the sound and fury behind the scenes. The screen fairly lights up with her presence, and a nude pool scene, painstakingly reconstructed from footage in the vault, stands as Exhibit A for why there has been no one like her before or since.

But soon after the pool scene, she disappeared for the weekend, then called in sick. When she returned to the set, she seemed to lack focus. Speculation has it that RFK may have broken off the affair.
By now, filming was 11 days behind schedule. Marilyn had worked for but 13 of 30 production days.

When she called in sick for the 17th time, Fox fired her. Marilyn was humiliated and began believing reports that she was all washed up, but then she rebounded to wage a spirited public relations campaign which resulted in the studio doing a complete about-face, signing her to a $1,000,000 two-picture contract. With shooting on "Something’s Got To Give" set to resume with a new director, Marilyn was back with a vengeance.

Then, days later, on the morning of August 5, Marilyn’s housekeeper noticed lights on in her room. She opened the door to discover why. Marilyn was dead from an overdose of sleeping pills. She was 36.

Marilyn’s bipolar is the most likely explanation for the incredible and unpredictable ups and downs that governed her final days and resulted in her tragic ending. Testimony from her personal physician and the fact that her mother was institutionalized lend credence to this view. Clearly another factor was the sheer magnitude of her personality (with elements of narcissism and borderline personality disorder entering into it).

A vulnerable person physically and mentally not ready for the demands of shooting another film, she had been placed in the impossible position of carrying an entire studio’s fortunes on her shoulders. Add to that her fears that maybe she could no longer live up to her larger than life Marilyn Monroe persona, and add to that the deflation of her grandiose bubble that she could be a future President’s wife. Who knows what else was going through her mind? Something had to give. Something did.

Rerun: Treating Marilyn

My most recent blog piece touched on a section of a grand rounds I delivered on meds compliance two years ago at a psychiatric facility in Princeton. That section, "The Problem Clinician," received a decidedly frosty reception from my audience of clinicians. This section, from "The Problem Patient," went over a lot better.

This piece first appeared on my blog in Feb, 2009.

The following is based on the first part of a talk I gave to clinicians on meds compliance as part of a grand rounds at a psychiatric facility in Princeton:

'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"

Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.

Maybe we need to ask Marilyn a few more questions, I suggested. Consider:

Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?

Hypomania is the first thing to come to mind when thinking of Marilyn, but the operative word from the DSM regarding this type of behavior is "uncharacteristic."

"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."

In support, I cited Ronald Fieve MD of Columbia University, who coined the term, "the hypomanic advantage."

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. I should have thrown away my prepared talk at that stage. Seriously, I should have said. We don't want to be like you. Why should that surprise you?

Instead I plowed ahead:

"We don't want to fly too close to the sun," I continued. "But don't clip our wings. Obviously Marilyn needs to be reeled in a bit. But how do we proceed? What do we have to go on?"

Believe it or not, there are zero published studies for treating hypomania. Zip, zilch, nada. The only solid evidence base involves the acute phase of full-blown mania, when we're bouncing off walls, 911 cases.

"So," I asked, "are you thinking of giving someone with hypomania an industrial strength dose?"

What else is going on with Marilyn? Personality issues? Quirky behavior? Does the bipolar itself affect her capacity to think rationally?

"You're the rational ones," I said. "We know where you are coming from. But do you know where your patients are coming from?"

I clicked to two slides: Fear/feeling threatened, problems accepting authority, cognitive distortions ...

The list went on and on. "Looking like a lot of your patients?" I asked.

"Here's the point I'm making," I continued. "Not only are you treating the illness. You are treating any behaviors and attitudes that come in the way of treatment. And you're not going to find that out unless you talk to the patient - and listen."

I wasn't through: "Just sending a patient out the door with a prescription - in my opinion - is not treatment."

Back to Marilyn. She's Marilyn. She has enormous gifts and doesn't want her wings clipped. She has various personality issues. And her illness is affecting her judgment.

"We have the advantage of knowing the tragic outcome," I concluded. "Knowing what you know, are you happy just writing her a prescription and sending her out the door?"

Postscript: This first part of my talk - "The Problem Patient" - went fairly well, perhaps because the audience could spin my message in a way that assigned all blame to the patient. There was no way they could do that with the next two sections, "Problem Meds" and "The Problem Clinician," and I got a very different reaction.

More later ...

Brilliant Lives Cut Short

Marilyn, Van Gogh, Meriwether Lewis, Tchaikovsky - no doubt you detect a common theme.

This one comes out of "the vault," back from a year ago when I was still learning. Please overlook all my rookie mistakes - the message speaks for itself.

Treating Marilyn

The following is based on the first part of a talk I gave to clinicians on meds compliance as part of a grand rounds at a psychiatric facility in Princeton:

'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"

Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.

Maybe we need to ask Marilyn a few more questions, I suggested. Consider:

Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?

Hypomania is the first thing to come to mind when thinking of Marilyn, but the operative word from the DSM regarding this type of behavior is "uncharacteristic."

"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."

In support, I cited Ronald Fieve MD of Columbia University, who coined the term, "the hypomanic advantage."

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. I should have thrown away my prepared talk at that stage. Seriously, I should have said. We don't want to be like you. Why should that surprise you?

Instead I plowed ahead:

"We don't want to fly too close to the sun," I continued. "But don't clip our wings. Obviously Marilyn needs to be reeled in a bit. But how do we proceed? What do we have to go on?"

Believe it or not, there are zero published studies for treating hypomania. Zip, zilch, nada. The only solid evidence base involves the acute phase of full-blown mania, when we're bouncing off walls, 911 cases.

"So," I asked, "are you thinking of giving someone with hypomania an industrial strength dose?"

What else is going on with Marilyn? Personality issues? Quirky behavior? Does the bipolar itself affect her capacity to think rationally?

"You're the rational ones," I said. "We know where you are coming from. But do you know where your patients are coming from?"

I clicked to two slides: Fear/feeling threatened, problems accepting authority, cognitive distortions ...

The list went on and on. "Looking like a lot of your patients?" I asked.

"Here's the point I'm making," I continued. "Not only are you treating the illness. You are treating any behaviors and attitudes that come in the way of treatment. And you're not going to find that out unless you talk to the patient - and listen."

I wasn't through: "Just sending a patient out the door with a prescription - in my opinion - is not treatment."

Back to Marilyn. She's Marilyn. She has enormous gifts and doesn't want her wings clipped. She has various personality issues. And her illness is affecting her judgment.

"We have the advantage of knowing the tragic outcome," I concluded. "Knowing what you know, are you happy just writing her a prescription and sending her out the door?"

Postscript: This first part of my talk - "The Problem Patient" - went fairly well, perhaps because the audience could spin my message in a way that assigned all blame to the patient. There was no way they could do that with the next two sections, "Problem Meds" and "The Problem Clinician," and I got a very different reaction.

More later ...