The Illness Trajectory in Marilyn Monroe‘s Psychological Autopsy: From Autism Spectrum Disorder to Borderline Personality Disorder and Bipolar Disorder with Catatonia

Abstract

Objective

A mounting body of literature is showing that, in the clinical and general population, autism spectrum disorder (ASD) or autistic traits (ATs) would appear to be spread along a continuum, reaching the highest levels among individuals affected by other mental disorders, such as borderline personality disorder (BPD) and bipolar disorder (BD). Furthermore, individuals with ASD or ATs appear to be more vulnerable to psychological traumas, with greater likelihood of developing post-traumatic stress disorder (PTSD) and BD. Marilyn Monroe was a famous actress, singer and model, as well as one of the most admired stars of American cinema and a timeless icon. The present report debates the possibility to explore Marilyn Monroe’s case under a neurodevelopmental perspective according to which a ASD favored, on one hand, her worldwide success and, on the other, her mental illness trajectory.

Method

The analysis is based on the review of her four biographies written by psychiatrists and clinical psychologists, her complete filmography, interviews, filmed material and personal scripts.

Results

The present work reconstructed a hypothetical illness trajectory originating from a ASD and culminating in a BD with unspecified catatonia, followed by premature death whose cause has never been clarified. The description of this illness trajectory also confirms the strong impact of psychological traumas on the substrate of ASD vulnerability and its correlation with the development of BPD and BD.

Conclusions

This paper suggests Marilyn Monroe as a possible prototypical case of BPD under a neurodevelopmental perspective that accounts the ASD, as reported in DSM-5-TR (2022), in verbal adult without intellectual impairment, high-functioning autism (HFA), as vulnerability background predisposing to the progression to BPD and BD with unspecified catatonia, triggered by multiple traumas.

Introduction

Autism spectrum refers to a psychopathological dimension, characterized by impairment of verbal and non-verbal communication, restricted pattern of interests and behaviors and alterations of social-emotional reciprocity, distributed in the clinical and general population according to a continuum of severity ranging from subthreshold conditions up to a full-blown mental disorder, the autism spectrum disorder (ASD) (Dell’Osso et al., 2016). According to the Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), ASD is characterized by persistent deficits in social communication and social interaction across multiple contexts (criterion A), restricted and repetitive patterns of behavior, interests, or activities (criterion B). Furthermore, symptoms must be present in the early developmental period (criterion C), cause clinically significant impairment in social, occupational, or other important areas of current functioning (criterion D) and not be better explained by intellectual developmental disorder or global developmental delay (criterion E) (APA, 2022).

Sub-threshold autistic traits (ATs), which are less severe but share the same characteristics as the clinical symptoms of ASD, were initially identified in studies conducted among unaffected first-degree relatives of individuals with ASD (Losh et al., 2009; Billeci et al., 2016) and subsequently found to varying degrees in the general population (Skylark et al., 2017; Dell'Osso et al., 2017), reaching the highest levels in subjects affected by other mental disorders (Dell’Osso et al., 2018, 2019b), such as borderline personality disorder (BPD). In the DSM-5-TR (APA, 2022), as in previous editions, BPD is defined as a pervasive pattern of instability in interpersonal relationships, self-image, and affect, characterized by marked impulsivity, present since early adulthood and in various contexts. According to Rydén et al., 15% of 41 females affected by BPD met the diagnostic criteria for ASD (Rydén et al., 2008). From a clinical perspective, phenomena such as acting out (expressing negative experiences through motor reactions rather than verbal communication), difficulty in interpreting emotions, transient paranoid ideation, feelings of anger, and self-injurious behaviors are common in both disorders (Dudas et al., 2017; Dell'Osso et al., 2023). Neuropsychological studies have also highlighted similar difficulties in theory of mind and accurate emotion interpretation (Niedtfeld et al., 2017; Minzenberg et al., 2006; Mitchell et al., 2014). In patients with BPD and ASD, the altered social perception may further compromise more complex neurocognitive abilities such as mentalization, the ability to predict others' behavior based on their mental state, leading to reduced adaptive management of relationships with emotional disturbances, impulsive behaviors, and self-harm (Chabrol & Raynal, 2018; Kocourkova et al., 2013). Several researches have emphasized that self-injurious behaviors, extremely frequents in BPD, can also occur among individuals with ASD, in percentage varying between 47% to 56%, more frequent in adolescents than in children (Duerden et al., 2012).

In the relationship between BPD and autistic traits, it is important to mention the potential mediating role of trauma. Vulnerability to trauma is another common feature between ASD and BPD, resulting in the development of psychological distress and potential worsening of the clinical picture (Rydén et al., 2008; Dell’osso et al., 2008, 2019d). In patients with BPD, a condition often associated with a post-traumatic component (van der Kolk, 1994; Luyten et al., 2020; Krause-Utz, 2022), the presence of autistic traits has been identified as a predisposing factor. The autism spectrum substrate would thus represent a vulnerability factor for the development of post-traumatic stress disorder (PTSD), even in the case of persistent mild traumas, both due to the greater ease of exposure to the event and the reduced ability to internalize and express traumatic experiences (Cattane et al., 2017; Dudas et al., 2017). A recent study has shown that in a sample of individuals with BPD, autistic traits were more strongly represented compared to control subjects, also exhibiting a significant impact on clinical features such as suicidality and lifetime exposure to physical and/or sexual abuse (Dell’Osso et al., 2018). In this regard, different studies have shown how the recognition and diagnosis of ASD, even in its subthreshold expression represented by ATs, appears to be extremely important in preventing suicidal behaviors and thoughts (Sterling et al., 2008; Hannon et al., 2013; Kato et al., 2012; Dell’Osso et al., 2018, 2019a, 2019b, 2019c). The accumulation of traumas in individuals with autistic traits could thus lead to the development of a clinical picture referred to as complex PTSD (cPTSD), characterized by clinical manifestations very similar to those of BPD (Dell'Osso et al., 2018, 2023) and associated with a high risk of suicide (Jannini et al., 2023).

The aim of this paper is to describe the psychopathological trajectory of the icon Marilyn Monroe, specifically investigating the presence of autistic traits and their role in the famous actress' illness path.

Case report

Norma Jeane Baker was born in Los Angeles (USA), on June 1st 1926. Her father was unknown and her mother, Gladys Monroe, had two divorces and other children fostered. Gladys, diagnosed as manic-depressive and later as paranoid schizophrenic, was hospitalized several times ending to be institutionalized when Norma Jeane was eight years old. The family history was also positive in other ancestors. Her grandmother Della suffered from manic-depressive illness and died in a psychiatric hospital. Her great-grandfather died of suicide. Gladys was unable to raise her child because of her psychopathology, so Norma Jeane counted as many as twelve foster families and two periods in a Los Angeles orphanage. In different occasions, Norma Jeane reported episodes of sexual harassment in her childhood acted by two of her foster parents. Accordingly to her maid Pepitone’s biography (Pepitone & Stadiem, 1979), she would have had an undesired pregnancy at the age of fifteen, and she had to leave her baby soon after delivery.

About Marilyn’s childhood and adolescence, some biographies report a probable dyslexia and slight stutter (Spoto, 1993) which occasionally re-emerged in adulthood. She was described as a shy, submissive girl, who seemed not to get on well with her peers, daydreaming about becoming a star.

When she was sixteen years old she got married for the first time. One year later, Marilyn began her model career and ended her marriage. She then started love affairs with photographers and show business agents and she also probably became an escort and shot some recently published red light movies.

The first marriage was followed by two more. Between the marriages, and also during them, she accounted a great number of love affairs and relationships, showing an extreme easiness to start useful sexual relationships that soon turned into a chronic affective instability. Sexual obsessive doubts and rumination about her gender identity have also been reported by both and her last psychoanalyst and a close friend (Schneider, 2011; Slatzer, 1975).

The onset of the psychiatric symptoms has been reported around the age of twenty-four (Slatzer, 1975), with alcohol and substance abuse, long perfectionist make-up rituals, and probable psychotic symptoms (Dawson, 2013). Interestingly, about at the same age (1950) took place the official change from Norma Jeane Baker to Marilyn Monroe. This represented not only the adoption of a stage name, but also a total change in her look, also built up by means of some of the first plastic surgery interventions on her nose, chin and breasts (Mailer, 1973). The aesthetic change is concurrent with a more global change of identity that made it difficult to distinguish, later in her life, the real subject from the role she acted in public occasions, i.e Norma Jeane from the "Marilyn mask", an invented character, the result of a skillful work of camouflaging, overcompensating for her social deficit. This role allowed her to reach the highest peaks of fame.

The first psychiatric treatment dates back officially to the age of twenty-nine (1955), when she started showing severe maladjustment at work largely motivated by a severe alcohol and polidrug abuse. For those reasons, Marilyn asked for Margaret Hohenberg’s help, the first of the five psychoanalysts who treated her until her death (Anna Freud, Marianne Kris, Ralph Greenson and Milton Wexler). Marilyn used to do 3 to 5 sessions a week, and take also medications for anxiety and insomnia.

A year later, while shooting in England, Marilyn was being treated by Anna Freud. She had shown increasing dysfunctional behaviors: continuous and prolonged lateness, unjustified absences, lack of concentration, mood swings. The Anna Freud's diagnosis of borderline paranoid schizophrenia strengthened Marilyn’s terror of going crazy like her mother. Later, Marianne Kris, who followed the actress in New York, and Ralph Greenson, who was her therapist in Los Angeles in the last two years of her life, confirmed this diagnosis. Greenson only added “addictive”.

In February 1961, one month after the divorce from Arthur Miller, Kris, fearing she would commit suicide, compelled her to be admitted first to the Payne Whitney Psychiatric Clinic - at the time of admission, she showed a severe psychomotor agitation and self-injuring behaviors, to the extent that she required temporary isolation - then transferred to the Columbia Presbyterian Medical Center, where she remained for about three weeks. Because of the mental illness, Marilyn worked neither in 1960 nor in 1961. In the last months of the actress’s life, Greenson prescribed barbiturates and chloral hydrate, as evidence of the progressive worsening of the clinical picture.

It is well known that Marilyn’s death, which occurred the night between August 4th and 5th 1962, was officially ruled as “probable suicide” by the coroner’s office, based on precedents of her overdosing.

Discussion

Despite looking radiant until the end, Marilyn Monroe was severely ill. Taking into account the limitations of a retrospective analysis, we could find panic-agoraphobic, as well as social-phobic, obsessive-compulsive and mood spectrum symptoms, besides post-traumatic stress and alcohol and multiple-drug addiction symptoms and, most likely, transient psychotic symptoms consistent with her maternal genetic load. However, in the attempt to overcome the artificial construct of comorbidity, charged by our current nosographic system (Maj, 2005), we would like to reconstruct the illness trajectory in a neurodevelopmental perspective that might explain Marilyn's complex phenotype (Dell’Osso & Dalle Luche, 2016).

Aiming at identifying the background supporting her psychopathology, we suggest that she could suffer from ASD. We can argue that she met criterion A for the diagnosis of ASD according to the DSM5-TR (Dell’Osso & Dalle Luche, 2016), presenting deficits in social-emotional reciprocity, in nonverbal communicative behaviors, and in maintaining interpersonal relationships.. Fernández-Cabana et al. (2013), analyzing Marilyn’s texts compiled in Fragments by means of a linguistic inquiry and word count, recently identified patterns compatibles with low levels of social integration that were related to her risk for suicide. Despite being considered captivating and charming, Marilyn's gaze is stereotyped and lost into empty space, with no actual eye-to-eye contact. This is paradoxically equivalent to the avoidance of the gaze of adults with ASD who easily lose eye contact (Kaye et al., 2014; Attwood, 1998). Marilyn’s gaze is insecure; fleeting without a real focus. The deep atypicality of her mental functioning and communicative style emerge from her so-called monroisms, the little bizarre phrases with which she answered journalists and that looked liked the involuntary humor of a children (Schneider, 2011; Slatezer, 1975; Monroe, 2012).

Furthermore, according to informations obtained from biographies already cited in the text, Marilyn also endorses criterion B of ASD described in the DSM5-TR (APA, 2022), such as highly restricted interest (abnormal in intensity) in becoming a star, ritualized patterns such as long perfectionist make-up rituals and hyper-reactivity to sensory input (for instance, she couldn't stand many types of fabrics and often went around the house naked even if there were strangers).

All public aspects of Marilyn’s character are indicative of her artificial social and professional life, but especially her private testimonies and the story of her symptoms and breakdowns show how much her character, despite famous worldwide, was not sufficient to warrant adaptive roles. It is well known that females with HFA are difficult to diagnose with respect to males (Attwood, 1998). This might be due to the fact that females camouflage better as they learn social rules imitating their non-autistic age-mates, behaving in a conformist way.

We argue that, throughout her early adulthood, the ASD prompted her to create a character that she used to integrate with other people and to build her popular image. On the other hand, the ASD made her vulnerable to psychopathology triggered by traumas. It is likely that the accumulation of traumas, occurring from childhood, led over time to the structuring of a BPD, a mosaic of psychopathological dimensions characterized with frequent removal, reworking and exploitation of traumas, a vicious circle eternally reproduced and associated from dissociative symptoms (Dell’Osso et al., 2019a; King, 2010). In this regard, the clinical psychologist Paul Dawson (2013) searched for the nine DSM criteria for BPD in all Marilyn’s biographies, drawing the conclusion that she did suffer from BPD and Addictive Disorder. According to Dawson (2013) the actress showed, in a constant and dysfunctional way throughout all her life, an intense fear of abandon, instability in relationships, an unstable image of self, impulsive and self-destructive behaviors, suicidal or self-injuring behaviors, wide mood swings, chronic feelings of emptiness, inappropriate fits of anger, brief periods of paranoid suspiciousness and detachment from reality, all borderline behavioral criteria. On the other hand, in his psychiatric monography, Jensen (2012) makes the argument that she fulfills only four of the diagnostic criteria for BPD and describes her as a case of Dependent Personality Disorder, PTSD, and some anxiety disorders.

Several works, starting from Herman’s book on Complex Trauma (Herman, 1997) have identified BPD as a long-term evolution of traumatic experiences such as sexual abuse, where maladaptive behaviors, including drug abuse and sexual promiscuity, are encoded among symptoms. In this regard, we remember that Marylin referred early sexual abuses by her foster fathers (Banner, 2012; Steinem, 1986). Regarding the correlation between ATs, trauma and BPD, a recent study showed that patients with BPD reported higher AT than healthy individuals and that ATs were shown to exert a significant impact on suicidality and lifetime exposure to physical and/or sexual abuse (Dell’Osso et al., 2018, 2021). In this regard, a very recent review of the current literature, showed that individuals with BPD reported higher scores on tests assessing the presence of ATs than individuals from nonclinical populations, hypothesizing the presence of unrecognized ASD in some BPD patients or vice versa, even describing a shared vulnerability toward traumatic events and an increased risk of suicidality in BPD individuals with high autistic traits (Dell’Osso et al., 2023).

Slatzer (1975) well described Marilyn’s mood instability, also noticed by Kirkland (2012), one of the photographer who took her pictures a few months before her death: one day she was happy, full of life, bursting with joy and enthusiasm; the day after she was sad, silent, even hostile. Slatzer noted she was unable to concentrate and used her charm vicariously; she was very sensitive and always very tense; she abused coffee and compensated with binges of alcohol and anxiolytic drugs (Slatzer, 1975). Also Banner (2012) sustained she had BD as well as Greenson himself, who, at last, reported: “It is now known as bipolar personality, but I think manic-depressive is much more descriptive. Yes, she was definitely manic-depressive. That’s just one of the many things we were up against” (Taraborrelli, 2010).

The late stage of Marilyn’s disease, aggravated by alcohol and barbiturate abuse, was characterized by an alternation of extreme excitement, irritability, insomnia, rumination, dysphoria and and self-injury, and severe psychomotor retardation, suggesting a BD, with unspecified catatonia. In this regard, recent studies has shown that catatonia is not rare between subjects affected by ASD (Billstedt et al., 2005; Wing & Shah, 2000; Wachtel et al., 2009; Dell’Osso et al,, 2023).

The last months of the actress’s life have been repeatedly examined in search for the causes of the progressive worsening of her mental illness, starting with the psychological autopsy ordered by the coroner (Litman, 1996; Botello, 2013). A core figure in this period is Ralph Greenson, who used to meet with her 5 to 6 times a week, in his studio or even at Marilyn’s home. It is not our aim to discuss the appropriateness of the therapeutic treatment Greenson adopted with Marilyn that has been largely criticized (Spoto, 1993; Schneider, 2011; Slatzer, 1975; Jensen, 2012; Mecacci, 2009), but it is important to point out the difficulties and challenges that emerged from her therapy, somehow confirming the extreme severity of her mental disorder, as well as her dependent attachment style and extreme loneliness. Greenson explained the great frequency of their therapy sessions saying he was the only one she could speak to (Spoto, 1993; Schneider, 2011). Furthermore, it is also reported she had previously used amphetamines, narcotic analgesics, chlorpromazine (Dawson, 2013).

Without entering the discussion of the causes hypothesized for Marilyn’s death (Pepitone & Stadiem, 1979; Spoto, 1993; Schneider, 2011; Slatzer, 1975; Forestier, 2008; Wolfe, 1998), we argue, under a psychiatric perspective, that, whether she died from accidental overdose, medical error, suicide or even homicide, her severe psychopathology is perfectly compatible with all of these hypotheses.

According to Sadock’s paradigm (Sadock, 2012), we could define Marilyn’s case as one of “inevitable suicide”, as she showed a combination of several risk factors concurring to her eventual suicide, or, even more appropriately, we could talk about a case of “inevitable death”, no matter from which of the previously mentioned possible causes she died.

In conclusion, we suggest that Norma Jeane was affected by ASD that, in some ways, allowed her to survive her troubled childhood thanks to the construction of a defensive shell. Thanks to some of the ASD features (e.g., obsessive perfectionism, rumination about success, lack of rules) she learned, since her childhood, to cope with her poor condition and with early traumatic experiences, creating a perfect, photogenic and sexually appealing mask that facilitated her rise to success defining her character through an imitation process, totally artificially planned. On the other hand, other ASD features (e.g., deficit in social communication and interaction, rumination, inflexibility, rigidity) would constitute the ground for the onset, later in her life, of a worsening mental illness trajectory resulted - at the time of her death - in a severe mania with mixed features and with catatonia.

The psychopathological trajectory of Marilyn Monroes could in this sense represent a common path for many psychiatric patients, as observed in clinical practice, providing insights for future studies to support the correlation between autistic traits, traumatic events and severe mental disorders such as BPD and BD, which are associated with high risk of suicidality.