The Music of Bipolar Disorder

1) Background: Bipolar or manic-depressive disorder is a malign mental disease that frequently faces social stigma. Educational and thinking models are needed to increase people’s awareness and understanding of the disorder. The arts have potential to achieve this goal. 2) Methods: This paper builds on the recent use of heavy metal music as a thinking and education model. It emphasizes the artistic component of heavy metal and its potential to characterize the symptomatology during the episodes of (hypo)mania and depression and the recurrence of these episodes. Heavy metal music has diversified into subgenres that become allegorical to both the symptoms of episodes and the recurrence of bipolar cycles. 3) Results: Examples of songs are given that mirror distinct facets of the disorder. 4) Conclusion: Although the links drawn between art (music) and science (psychiatry) are inherently subjective, such connections might be used to trigger a learning process, facilitate judgment and decision-making, and induce affective reactions and memory formation in the listener. The approach may facilitate collaborative efforts and serve healthcare professionals and educators as a communication tool to aid the public’s comprehension of the disease and an associated social paradox: On one hand, bipolar disorder incurs substantial costs to society. On the other hand, it benefits from the creative artistic and scientific endeavors of bipolar individuals from which cultural and political gains may ensue.


Introduction
Bipolar or manic-depressive disorder is a chronic debilitating mental disease with substantial morbidity and mortality due to suicide.The disorder is characterized by pronounced mood fluctuations with recurrent cycles of (hypo)mania and severe depression episodes that manifest with high variability among patients.Between 3 to 8% of the human population are estimated to fall within the bipolar spectrum [1].The numbers may even be higher given diagnostic problems and difficulties differentiating between unipolar and bipolar depressions [2].Thus, a significant number of people may suffer from the illness.
A common problem with bipolar disorder is social stigma and self-stigma that can result in poor functioning, social adjustment and (inter)personal integrity [3 -5].Approaches are needed to cope with stigma to improve self-esteem, functioning and the social integration and acceptance of people affected by the illness.
This paper explores the use of heavy metal music as an educational tool to increase laypeople's awareness about the illness, emphasizing the artistic component of the music.The use of metal music as a critical thinking and educational tool has been recently suggested [6,7].Heavy metal music is a genre of rock music that arose ca 50 years ago mainly in the USA and the UK, and which has rapidly diversified into more than 20 subgenres out of traditional or classic heavy metal [8].These subgenres, which are primarily characterized by dense and distorted instrumentation, resounding rhythms, and persuasive vocals, cover a broad spectrum of song structures, lyrics, and instrumentation and vary in their degree of harshness.
From an artistic viewpoint, forms of heavy metal music, but also other genres (e.g., New complexity School, Post Punk), have consistently surpassed accepted frontiers in the acoustic arts [9].This suggests that metal can serve as a tool that builds on shock and surprise tactics, which may help boosting thinking and learning by taking people out of comfort zones [10], similar to episodes that take bipolar patients out of comfort zones of cognitive, behavioral and social functioning.Elements of shock and surprise are valuable for communication because novelty stimulates learning and longterm memory formation [11].Learning and thinking may also be facilitated in people for whom metal resides in their comfort zone by making new associations between the music and bipolar disorder, suggesting the broader use of metal as an artistic communication tool.Some metal genres seem especially suitable for characterizing bipolar disorder because many of their song characteristics (harshness, aggressiveness, vigorous energy, speed, sexual connotations, chaos, doom, despair) mirror much of the symptomatology and cyclicity of the episodes.
The aim of this paper is not to give an exhaustive overview of bipolar disorder, as this has been dealt with in the psychiatric literature; rather the goal is to use aspects of the disease and their artistic expressions through metal songs to communicate to laypeople the complexity of the disease.Although the approach of this paper is utterly subjective, this subjectivity is exploited for engaging people in a thought and questioning process and trigger curiosity [12].This approach borrows from environmental communication and art-science collaborations, which inform people and heighten awareness about the nature of environmental problems and search for solutions and public action to deal with these [13].
In this vein, the paper aims to show how artistic approaches can facilitate collaborations between healthcare professionals, artists, educators and participants from other social spheres for communicating to the public the nature of mental illnesses, including bipolar disorder.Citizen´s education about mental disorders is warranted to inform about and potentially deal with an apparent social paradox: On one hand, costs are not only related to the suffering of patients and their families but also to an increased economic burden for society, which is often borne by taxpayers contributions [2].On the other hand, bipolar people often excel in creative artistic and scientific endeavors and thus contribute to cultural and political gains for society [14 -16].For instance, mentally ill political leaders often demonstrated capacity to successfully navigate societies through crisis [15].Such potential might reduce long-term costs for societies, which could otherwise explode with bad crisis management (e.g., invasion of Irak after the 9/11 attacks).
Artistic approaches to describe mental illness as the one presented here might potentially address not only issues of social stigma; they may find potentially use in clinical applications to deal with self-stigma [17] by creating through art a sense of community membership among patients.However, such an application is currently hypothetical and speculative at best but may merit further exploration.

Metal and Bipolar Disorder
Subgenres of metal music have song structures that become allegorical to and can symbolize specific aspects of the symptomatology of bipolar episodes and their recurrence (Table 1), although other music genres might serve a similar purpose.Songs from these subgenres can be linked with symptoms artistically; however, these links are subjective, as the expression and perception of art is in general.I showcase this potential with selected examples (Table 1).Band and song names are not relevant for symbolizing these sentiments.Although the songs were not composed to explicitly make the connection to bipolarity, it is possible to compare the sounds/lyrics of the music and the emotions bipolar people experience during episodes.In the examples below, emphasis is placed on (1) contextualizing metal songs with specific symptoms of (hypo)manic and depressive phases, and (2) the cyclicity of the illness.These allegories are intended to conceptualize hearing as inquiring to trigger a chain of questioning.For instance: What is the illness?Why do people have it?How does it affect patients, their families and society?How might people feel during episodes?How does this sickness affect work?Are there gender aspects?How can this disease be treated?This process can improve learning and facilitate laypeople´s understanding of the disease as a broader social phenomenon wherein scientists, clinicians, patients, educators, families, the pharmaceutical industry and employers of patients interact.A combination of metal with visual or other acoustic art works, particularly those created by bipolar people, may further bolster people´s connection to the disorder. 2Might also occur in sever bipolar depression (e.g., Goodwin and Jamison 2007). 3Manifested in section 1:50 -2:11. 4Transition at 1:14.

Mania and Hypomania Episodes
Manic episodes, and lighter versions of them (hypomania), are characterized by a spectrum of symptoms that affect bipolar individuals in distinct combinations and express with distinct degrees of severity [18].These symptoms are manifested in increased energy levels, a decreased need for sleep, racing thoughts, pressure of speech, frequently agitation, confusion and distraction, heightened libido, and in extreme forms hallucinations and delusions (Table 1).Heavy metal songs from different subgenres have the necessary diversity to artistically represent these symptoms; they may serve as a vehicle to capture and express the deviation from "normal" emotional baselines in individuals having these symptoms relative to healthy individuals.That is, most of the songs belong to generally harsh and aggressive subgenres.These include death metal and speed metal with fast tempos that can symbolize heightened energy, racing thoughts and pressured speech.The unrhythmic song structure of mathcore and grindcore can express distractibility and confusion.Thrash metal and other screamed genres can reflect agitation, and the sex ideology in pornogring becomes allegorical to heightened libido.The psychedelic nature of stoner metal and alien metal might be associated with substance abuse and psychosis symptoms, respectively.Power metal, which aims to inspire joy and courage, may serve to symbolize grandiosity and self-esteem.Some metal songs may also help envisioning the onset and intensification of manic episodes by increasing intensity and complexity in instrumentation and singing (Table 1).Brief characteristics of these subgenres and their potential to symbolize symptoms of bipolar (hypo)mania are summarized in Table 1.A detailed description of these subgenres can be found in [8].

Bipolar Depression Episodes
In sharp contrast to the manias, bipolar depression is usually characterized by a significant slowing or decrease in almost all aspects of emotion and behavior.Individuals with bipolar depression experience a combination of chaos, emotional emptiness, despair, doom, anhedonia etc. (Table 1).They generally perceive their mental and physical world as monochromatic and agonizing, with a strong sense of worthlessness and self-guilt.Patients often develop morbid thoughts and a suicidal ideology, and in severe depression states become hallucinatory and delusional, as is the case with mania [1].
This diversity of symptoms can be captured with a range of metal genres with slow tempos, thick sounds and low-tuned guitars.These genres include doom metal, which can symbolize despair, dread, and impending doom.The structure in drone metal songs can reflect the slowed activity, emptiness, and lethargy symptoms.The ambient darkness evoked with funeral doom may be used to symbolize suicide ideology and morbid thoughts about death.Additional symptoms, including chaos, uncertainty, emotional turbulence, and anxiety can be symbolized with war metal (aka bestial black metal) in which songs are generally characterized with unpredictable, abrupt guitar solos, downtuned power chords, and markedly increased speed, often punctuated with abrupt bursts of tempo.

Mixed States
Symptoms of bipolar depression frequently overlap with those of mania to produce "mixed states" (Table 1).Such mixed states often manifest in heightened psychomotor activity coupled with typical depression symptoms such as inhibition of thought, anxiety, and pessimism (agitated depression) or manic symptoms (racing thoughts, pressured speech) with despairing anxiety, absentmindedness and senseless pressure of activity (anxious mania) [1].
There are songs from heavy metal genres that combine singing, rhythm and instrumentation in ways that the emergent song structure becomes reminiscent of the co-existence of manic and depressive symptoms in such mixed states.For instance, death doom combines slow tempos and pessimistic, depressive mood with speed of double kick drumming that can symbolize agitated depression.Anxious mania can be symbolized with the rhythmic speed combined with monotonic, deep, unintelligible growling inherent in brutal death metal.

Recurrence
In addition to the symptoms of (hypo)manic and depressive episodes, a further hallmark of bipolar disorder is the recurrence of these phases, although the cycling patterns can vary substantially, ranging from cycling at a daily basis (ultra-rapid cycling) to forms that have longer recurrence patterns (Bipolar I and II).Heavy metal songs from the metalcore and deathcore genres have potential to symbolize these cycling patterns in musical terms (Table 1).These genres are characterized by "breakdowns", which interrupt the beat of the main verse and chorus of a song by spontaneously slowing the rhythm.During a breakdown the drums play a steady beat and the guitars open strings with a chugging rhythm.After breakdowns songs generally revert to the previous beat and chorus structure.
Inherent to bipolar cycling are phases where patients are symptom-free, states that can be clinically fostered and/or prolonged with pharmacological and therapeutic treatment.Such "normal" periods are attained after bouts of episodes when cognitive, physical and social dysfunction is improved.Such periods of amelioration of depression symptoms can be symbolized with the harmonic and melodic aspects of symphonic metal (Table 1).Bipolar illness is a complex affective mood disorder that includes a spectrum of manifestations of symptoms and severity of (hypo)manic and depressive episodes [18].Heavy metal music, as a form of the auditory arts, is equally complex and has diversified into a variety of subgenres with distinct manifestations of song, rhythm, instrumentation, and vocal structure.This variability becomes reminiscent of and mirrors much of the symptomatology of bipolar disorder, including episode appearances and recurrence.These analogies allow for creating a subjective link between the domains of science (psychiatry) and arts.Combined art-science approaches may facilitate collaborative efforts and serve healthcare professionals and educators as a communication tool to aid the public's comprehension of the disease and its social ramifications.

Table 1 .
Examples of metal allegories symbolizing selected aspects of bipolar disorder.Note that the examples are not exhaustive and meant for demonstration only.Note also that several metal allegories apply to different aspects of bipolar disorder highlighting their wider application for expressing the disease.Links to songs on YouTube are provided.
1Some of the videos are preceded by advertisements that are unrelated to the songs on YouTube.