Dear Dr. Melfi: Regarding Your Patient, Mr. Tony Soprano

It’s been 20 years. Is science closer to explaining Tony Soprano’s behavior?

Posted Jul 08, 2019

Gdcgraphics/Wikimedia Commons
Patient: Anthony Soprano
Source: Gdcgraphics/Wikimedia Commons

In 1999, the world was introduced to the Soprano family from North Caldwell, New Jersey. The Sopranos arrested cable television audiences for years to come and, in celebration of the show’s 20th anniversary, it seems appropriate to reexamine the character of Mr. Anthony (Tony) Soprano, a made man who we love to hate and hate to love. In the last 20 years, science has revealed surprising new insights into what makes people tick, which are described in the form of a letter to Mr. Soprano’s daring but frustrated therapist, Dr. Jennifer Melfi.

Dear Dr. Melfi,

Let me say up front that this letter is not meant to devalue the psychiatric services you provide to your patients. But let’s face it: You’ve treated Mr. Anthony Soprano, who claims to be a waste management consultant, for six years with very little success. I would like to provide you with some reasons why Mr. Soprano may be so recalcitrant to psychotherapy.

Mr. Soprano may be under the influence of a number of biological factors that he could be helpless to change. Remember the time Mr. Soprano ran down a gentleman named Alex Mahaffey with his car, then proceeded to beat him up because he owed a gambling debt? Mr. Soprano’s proclivity for such violence could, in part, be in his genes. You may be aware that several large-scale studies have identified gene variants that are associated with aggressive behavior.

For example, a variation in the MAOA (monoamine oxidase A) gene has been associated with hostility and criminal activity, especially when the individual was subjected to child abuse, which Mr. Soprano clearly suffered. The variant MAOA gene produces abnormal levels of certain neurotransmitters in the brain, potentially predisposing the carrier to impulsive mood swings and belligerence.

Another example is a gene called 5-HT1B, which makes a receptor in the brain that binds to serotonin, a neurotransmitter that plays a crucial role in the stability of mood and temperament. The deletion of this gene in a normally timid mouse turns it into a ferocious beast that quickly attacks other mice. This striking change in behavior prompted neuroscientist Rene Hen to call mice lacking 5-HT1B “outlaw mice.” Studies of violent criminals have supported the association between serotonin gene variants and aggression.

As mentioned, Mr. Soprano admits that he had a less than nurturing childhood. Mr. Soprano was exposed to horrifying violence at a young age, such as when he caught his father chopping off Mr. Satriale’s finger with a meat cleaver. Young Soprano was also constantly manipulated by a callous mother who likened children to dogs. Mr. Soprano likes to think that he’s tough—he’s no poor baby who needs a Whitman’s sampler. But adverse childhood experiences, or ACEs, have been linked to silencing genes that are critical to managing stress through a process called epigenetics. Epigenetics refers to chemical changes taking place on DNA itself or the proteins associating with DNA.

Relevant to this case, scientist Isabelle Ouellet-Morin showed that serotonin transporter genes are shut down through chemical modification of DNA in abused children. The resulting imbalance in neurotransmitters disrupts the child’s normal stress response, and consequently, they grow up at risk of being socially inept and overly aggressive.

We also know that Mr. Soprano played football while attending West Essex High School, and he’s been in many fistfights and car accidents. I wouldn’t be surprised if he suffers from chronic traumatic encephalopathy (CTE). CTE has been implicated in some cases of famous athletes who underwent sudden and dramatic changes in their behavior, sometimes leading to violent outbursts. CTE is a likely factor in Mr. Soprano’s inability to control his temper. CTE may also explain his increasing gaffes when speaking, such as when he referred to Hannibal Lecter as Hannibal Lecture, or when he stated he was “prostate” with grief.

Speaking of his unusually high number of car wrecks reminds me of another peculiar factor that could partially explain his unruly behavior: a parasite called Toxoplasma gondii. Toxoplasma is a brain parasite we can get from cats, undercooked meat, or unwashed vegetables. Look at the possibilities: There was a cat hanging around the Bada Bing! Lounge, Mr. Soprano seems to be an “I’ll have my steak rare” kind of guy, and he could have eaten unwashed tomatoes from his garden, all of which put him at risk of contracting the parasitic infection. Infection with Toxoplasma has been linked to risk-taking behavior, intermittent explosive (rage) disorder, and other neurological issues. To my earlier point, one study shows that people infected with Toxoplasma are nearly three times more likely to be involved in traffic accidents.

It’s also no secret that Mr. Soprano has a love of processed meats—salami, prosciutto, Lincoln Logs, gabagool—all of which are packed with nitrates as preservatives. Emerging studies indicate that excess nitrates in the diet could have adverse neurological effects. A 2018 study showed that people hospitalized for an episode of mania are more likely to be consumers of nitrate-cured meats. Similar findings have been shown in rats, which also exhibit mania-like hyperactivity after researchers added nitrates to their chow.

As you can see, there are many biological explanations that may conspire to bring about Mr. Soprano’s criminal behavior, so I hope you are not too hard on yourself when therapy fails to attain positive results. I applaud and admire your empathy and tireless effort in treating these difficult patients. I remain optimistic that as we learn more about the underlying biology associated with hostility and aggression, scientists will develop much more effective pharmacological treatments to augment psychotherapy. The ending will not fade to black and leave us wondering, but our wondering will shed light on our dark side.

Don’t stop believin’,

Bill Sullivan