Is there a method to Hamlet’s madness?

DSM Diagnostic Analysis of Shakespeare's Hamlet

Emily SchompAP English and LiteratureNashoba Regional High School

Major Questions● What behaviors, emotions, and cognitions does Hamlet display that could

indicate symptoms of a psychiatric disorder?○ according to modern diagnostic criteria: DSM IV 5○ psych disorder: persistently harmful thoughts, feelings, actions,

behaviors that are deviant, distressful, and dysfunctional● With what, if any, disorder could we diagnose Hamlet with using textual

evidence?● If Hamlet’s brain was analysis using MRI or fMRI scan and

neurotransmitter tests, what could we expect to see (based on neuroscientific studies)?

Criteria For A Manic EpisodeA distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week

he puts on this confusion, Grating so harshly all his days of quietWith turbulent and dangerous lunacy? (III. i. 2-4)

inflated self-esteem or grandiosity Hamlet. Sir, I lack advancement.Rosencrantz. How can that be, when you have the voice of the King himself for your succession in Denmark?Hamlet. Ay, sir, but 'while the grass grows'- the proverb is something musty. (III. ii. 368-373)

decreased need for sleep Sir, in my heart there was a kind of fighting That would not let me sleep. Methought I lay Worse than the mutinies in the bilboes. (V. ii. 4-6)

more talkative than usual or pressure to keep talking One speech in't I chiefly lov'd....If it live in your memory, begin at this line- let me see, let me see: 'The rugged Pyrrhus, like th' Hyrcanian beast-' ...(continues for 23 lines)...Old grandsire Priam seeks.' So, proceed you. (II. ii. 470-490)

Criteria For A Manic Episode Cont.flight of ideas or subjective experience that thoughts are racing

Hamlet. Why, let the strucken deer go weep, The hart ungalled play;For some must watch, while some must sleep: Thus runs the world away. Would not this, sir, and a forest of feathers- if the rest of my fortunes turn Turk with me-with two Provincial roses on my raz'd shoes, get me a fellowship in a cry of players, sir?Horatio. Half a share.Hamlet. A whole one I! For thou dost know, O Damon dear, This realm dismantled was Of Jove himself; and now reigns hereA very, very- pajock.Horatio. You might have rhym'd. (III. ii. 297-311)

distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

Hamlet. Do you see yonder cloud that's almost in shape of a camel?Polonius. By th' mass, and 'tis like a camel indeed.Hamlet. Methinks it is like a weasel.Polonius. It is back'd like a weasel.Hamlet. Or like a whale.Polonius. Very like a whale. (III. ii. 406-412)

Criteria For A Manic Episode Cont.increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

Hold, hold, my heart! And you, my sinews, grow not instant old, But bear me stiffly up....Yea, from the table of my memory I'll wipe away all trivial fond records, ...books, all forms, all pressures past That youth and observation copied there, And thy commandment all alone shall liveWithin...my brain, Unmix'd with baser matter. (I.v.100-111)

The mood disturbance is sufficiently severe to cause marked impairment In occupational functioning or in usual social activities or relationships with others

O, what a noble mind is here o'erthrown!...Now see that noble and most sovereign reason, Like sweet bells jangled, out of tune and harsh; That unmatch'd form and feature of blown youth Blasted with ecstasy. (III. i. 163-174)

'Tis dangerous when the baser nature comes Between the pass and fell incensed points Of mighty opposites. (V. ii. 67-69)

The symptoms are not due to the direct physiological effects of a substance or a general medical condition

Claudius. Here's to thy health...Give him the cup.Hamlet. I'll play this bout first; set it by awhile. (V. ii. 307-309)

Criteria For Major Depressive EpisodeFive (or more) of the following symptoms present during the same 2- week period and represent a change from previous functioning; either (1) depressed mood or (2) loss of interest or pleasure

How weary, stale, flat, and unprofitable Seem to me all the uses of this world! Fie on't! ah, fie! 'Tis an unweeded garden That grows to seed; things rank and gross in naturePossess it merely. That it should come to this! But two months dead! Nay, not so much, not two. (I. ii. 137-142)

Depressed mood most of the day, nearly every day How is it that the clouds still hang on you?...to persever In obstinate condolement is a course Of impious stubbornness. 'Tis unmanly ...heart unfortified, a mind impatient, (I. ii. 68-101)

Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

I have of late- but wherefore I know not- lost all my mirth, forgone all custom of exercises (II. ii. 318-320)

Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.

Insomnia or hypersomnia nearly every day.

And he, repulsed, a short tale to make, Fell into a sadness, then into a fast,Thence to a watch, thence into a weakness, Thence to a lightness, and, by this declension, Into the madness wherein now he raves, (II. ii. 155-160)

Criteria For Major Depressive Episode Cont.Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

There's something in his soul O'er which his melancholy sits on brood; And I do doubt the hatch and the disclose Will be some danger; (III.i.178-181)

Fatigue or loss of energy nearly every day. Tis e'en so. The hand of little employment hath the daintiersense. (V.i.71-72)

Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

I am very proud, revengeful, ambitious; with more offences at my beck than I have thoughts to put them in, imagination to give them shape, or time to act them in...fellows as I...are arrant knaves (III.i.132-139)

Diminished ability to think or concentrate, or indecisiveness, nearly every day

Did these bones cost no more the breeding but to play at loggets with 'em? Mine ache to think on't. (V. i. 93-95)

Criteria For Major Depressive Episode Cont.Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

You cannot, sir, take from me anything that I will more willingly part withal- except my life, except my life, except my life, (II.ii.233-235)

To die- to sleep- No more; and by a sleep to say we end The heartache, and the thousand natural shocksThat flesh is heir to. 'Tis a consummation Devoutly to be wish'd. To die- to sleep. (III.i.68-72)

The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

all forms, moods, shapes of grief...are actions that a man might play; But I have that within which passeth show- These but the trappings and the suits of woe. (I.ii.85-89)

Good my lord, what is your cause of distemper? You do surelybar the door upon your own liberty, if you deny your griefs to your friend. (III.ii.365-367)

The symptoms are not due to the direct physiological effects of a substance or a general medical condition

same as mania

Symptoms of Psychosis: Delusions● misinterpretation of perceptions or experience

usually with theme of persecution (being tricked, spied upon, subjected to ridicule) or can religious themes and feelings of being cosmically important

● Major Depressive Disorder delusions commonly involve obsession of guilt, sinfulness, poverty, feelings of persecution and extreme hypochondria

● Bipolar delusions are often grandiose and frequently religious, with voices (auditory hallucinations) perceived as commands from a being

● Schizophrenia delusions can be bizarre and tend to persist for long periods of time

Why, look you now, how unworthy a thing you make of me! You would play upon me;...'Sblood, do you think I am easier to be play'd on than a pipe? (III. ii. 393-400)

O what a rogue and peasant slave am I!...A dull and muddy-mettled rascal...can say nothing! No, not for a king,...'Swounds, I should take it!...But I am pigeon-liver'd and lack gall...Remorseless, treacherous, lecherous, kindless villain!O, vengeance! Why, what an ass am I!... (II. ii. 577-615)

the <devil> hath power T' assume a pleasing shape; yea, and perhaps,Out of my weakness and my melancholy, As he is very potent with such spirits, Abuses me to damn me (II.ii.628-632)

'Tis now the very witching time of night, ...Now could I drink hot blood And do such bitter business as the day Would quake to look on....My tongue and soul in this be hypocrites- How in my words somever she be shent, To give them seals never, my soul, consent! (III.ii.419-432)

Symptoms of Psychosis Cont.Hallucinations:

● commonly involve hearing one or several voices perceived as distinct from the person’s own thoughts, and are often experienced as critical and threatening

● Hallucinations can also occur in the other senses (seeing, smelling, taste and touch)

On him, on him! Look you how pale he glares! His form and cause conjoin'd, preaching to stones,Would make them capable.- Do not look upon me, Lest with this piteous action you convert My stern effects. Then what I have to do Will want true colour- tears perchance for blood. (III. iv. 142-148)

Grossly disorganized or catatonic behavior: ● ranges from childlike silliness and inappropriate

reactions, to totally unpredictable agitation● often bizarrely disturbed (posturing, grimacing),

appearance markedly disheveled, with frequent untriggered agitation, particularly swearing, shouting and negativism

you do bend your eye on vacancyAnd with the incorporal air do hold discourse...Forth at your eyes your spirits wildly peep;And...Your bedded hair...Starts up, and stands on end. O gentle son,Upon the heat and flame of thy distemperSprinkle cool patience. Whereon do you look?(III. iv. 134-141)

Symptoms of Psychosis Cont.Disorganized speech:

● individual may “slip off the track” (derailment), answers to questions may be totally unrelated (tangential) or even severely disorganized (incoherence, “word salad,” “loosening of associations”)

● common form of disorganized speech is perseveration. This refers to a person “getting stuck” on a theme or topic and returning to that topic over and over.

That skull had a tongue in it, and could sing once...This might be the pate of a Politician,...Or of a courtier,...Alexander died, Alexander was buried, Alexander returneth into dust; the dust is earth; of earth we make loam; and why of that loam whereto he was converted might they not stop a beer barrel?Imperious Caesar, dead and turn'd to clay, Might stop a hole to keep the wind away. O, that that earth which kept the world in awe Should patch a wall t' expel the winter's flaw! (V. i. 77-223)

Brain Features For General Mood Disorders● hippocampus shrinkage, diminished hippocampal neurogenesis● Cortisol imbalance

○ abnormal control of corticotropin releasing factor by hypothalamus○ pituitary gland adrenocorticotropic hormone

● abnormal gene that creates brain derived neurotrophic factor (BDNF) causes neurons to grow● abnormal cell atrophy and death:

○ hypofrontality decrease in fuel supply, through decreased glucose transport-sluggishness in circulation and metabolism

○ too much glutamate "excitatory" neurotransmitter in the central nervous system that allows too much calcium to enter the cell which leads to damaged mitochondria

● Too Much Dopamine in frontal (left) cortex○ defect in the COMT gene, causing a 75% reduction in the enzyme responsible for

regulating dopamine○ said to cause hypofrontality

Hamlet’s Hormones

Cerebral gray matter volume deficits (top panel) and excess (bottom panel)from Yu, Kevin, et al. Matched Study

Key● Blue clusters were driven mainly (greater than 80% distribution) by schizophrenia studies● Yellow clusters were driven mainly (greater than 80% distribution) by bipolar studies● Green clusters were contributed by studies of both disorders ● Left side of brain is on left side of the panel

Grey Matter Abnormalities for both Schizophrenia and Bipolar Disorder

● lower right insula volume○ volume negatively correlated with episodes and psychotic symptoms○ left insula decrease only in schizophrenia

● lower gray matter volume ○ bilateral frontal cortex- self awareness, inhibition○ thalamus- signal transmission○ left middle temporal gyrus- facial recognition, spatial○ anterior cingulate cortex-component of the limbic system and reward-learning pathway○ caudate nucleus (motivational and learning skills) head

■ head volume deficit- mainly responsible for feedback processing (prefrontal cortex)● Enlargement

○ caudate nucleus body and tail■ involved in stimulus-category learning■ linked to visual infero-temporal cortex

○ left putamen volume■ regulates dopamine (stimulation and pleasure)■ releases GABA (neral inhibitor)■ receives glutamate (released in neural synapses, toxic if overproduced)■ receives serotonin (regulation of mood, appetite, and sleep)

Exclusive Characteristics for EachBrain Features For Bipolar Disorder

● decreased activity and/or reduction in gray matter volume in brain network associated with regulation of emotions

○ right inferior frontal gyrus○ right superior frontal gyrus○ anterior cingulate

● increased and size activity in brain structures that mediate the experience of emotions and generation of emotional responses

○ parahippocampal gyrus ○ amygdala (more episodes -> larger)

Brain Features for Psychosis● smaller hippocampus● lower brain volume (especially in left hemisphere)

○ breakdown in the bi-hemispheric co-ordination of language○ postulated that disruption of communication between two hemispheres could be perceived as “voices”

● lateral ventricular enlargement● lower volumes in temporal, limbic, and subcortical regions

So How Could We Diagnose Hamlet?Bipolar II: depressive episodes are the most notable and disabling feature, and must be accompanied by at least one hypomanic episode. These periods of hypomania often do not cause clinically significant distress, but people with this form of Bipolar illness are disabled by serious depressive episodes and mood fluctuations.

Mood Episode With Melancholic Features: during the most severe stage of the episode there is a near complete absence of the capacity for pleasure. Striking biologic signs and symptoms: Weight loss, early morning wakening, listlessness, extreme fatigue (the worst time of day is the morning). Feelings of sadness cheerlessness, indecisiveness, withdrawal and intense guilt.

Mood Episode With Psychotic Features: This is the most serious form of depression and can involve suicidality and catatonia. Delusions often are “mood congruent” (they are consistent with the depressed mood and reinforce it.) For example people may have unshakable beliefs that they are extremely sinful, bankrupt, decaying inside or about to die.

Review/ Thesis

● Hamlet displays emotions, behaviors, and thoughts congruent to episodes of depression, mania, and psychosis

● We could characterise Hamlet with having a mood disorder in the functional spectrum with psychotic features

Works CitedDSM IV Criteria and Research

Burland, Joyce, and Teri Brister. "Class 2: Handout # 4 Symptoms of Psychosis" NAMI Family-to-Family: Participant Manual 2014

5 (2014): n. pag. NAMI: National Alliance on Mental Illness. Web. 6 Mar. 2014. <https://www.nami.org/Content/NavigationMenu/Intranet/Family-to-Family_Intranet1/F2F_14_Pa_SumChange_NewPgs.pdf>.“Criteria for Major Depressive Episode: DSM 5.”“Criteria for Manic Episode: DSM 5.”“Class 4: Handout # 5 Research on Cortical Blood Flow and Metabolism.” “Class 4: Handout #6 Research on Cortical Dysfunction.”

Brain Anatomy and Physiology StudiesBalasanova, Alena A., and Gillian Lieberman. Diagnostic Imaging in Psychiatric Disorders: A Closer Look at the Use of MRI in

Schizophrenia. Harvard: Beth Isriel Deaconess Medical Center, 2010. Lieberman's eRadiology. Web. 10 Mar. 2014. <http://eradiology.bidmc.harvard.edu/LearningLab/central/balasanova.pdf>.

Yu, Kevin, et al. "Are bipolar disorder and schizophrenia neuroanatomically distinct? An anatomical likelihood meta-analysis." Frontiers in

Human Neuroscience 4.00189 (2010): n. pag. Frontiers: Peer Reviewed Articles - Open Access Journals. Web. 10 Mar. 2014. <http://www.frontiersin.org/Journal/Abstract.aspx?s=537&name=human_neuroscience&ART_DOI=10.3389/fnhum.2010.00189>.

The Text

Shakespeare, William. Hamlet. New York: Pocket, 1952. Print.