Juniper Publishers-300: Psychiatry Taught Through the Lens of Film and Natural History
Journal of Psychology-JuniperPublishers
Abstract
Objective: Movies have long been utilized to
highlight varied areas in the field of psychiatry. We have previously
described a course [1]
that teaches psychopathy to psychiatry residents based on the horror
genre. Methods: Course directors subsequently created a medical student
elective (SCREAM) that serves as a steering committee for the
residents's course. As art imitates life, the primary focus of SCREAM is
to enhance residents' didactics by incorporating media inspired by true
stories. Such teaching not only takes advantage of the strengths of
fictional case studies [1],
but also appreciates that the films are often inspired by actual
events. Results: This paper reviews three historical events that
occurred 100 years apart and relates them to both the movies they
inspired and their relevance to the field of psychiatry. Conclusions:
Courses that use media to teach are found to be engaging and are an
innovative way to educate future physicians. Key words: Film-Medical
Education- Media-Psychopathology
Introduction
Courses designed to teach psychopathology to trainees
have traditionally used examples from art and literature to emphasize
major teaching points. Reviewing [Mental] Disorders with a Reverent
Understanding of the Macabre (REDRUM) is a psychopathology course at our
institution that teaches topics in mental illnesses through the horror
film genre [1]. With about 95% of medical students pursuing careers outside of psychiatry [2]
, it is imperative that innovative curricula such as REDRUM be
accessible to medical students. With the high prevalence of co-occurring
psychiatric disorders in the general medical population, it's likely
that the 3rd-year psychiatry clerkship will be the final
opportunity for future physicians to learn about the mental disorders
they'll see in future practice.
Accordingly, course directors of REDRUM developed a
1-credit medical student elective to act as a steering committee for the
residents’s psychopathology course. The course is available to
fourth-year students who satisfactorily completed their core psychiatry
clerkship. The Steering Committee on Resident Education and Media
(SCREAM) is directed by the Associate Program Director of residency
training with the objective to enhance and evolve the residents'
didactic through novel discoveries related to media such as film.
Methods
The REDRUM Psychopathology course is held weekly for
one hour over one semester (about 15 weeks). The one-hour didactic is
supplemented by weekly readings and film viewings that take place
approximately two hours per week outside of the classroom setting.
SCREAM meets monthly to discuss historical and current events in art and
literature that can directly contribute to the resident curriculum.
Discussions generated at each session result in course work that takes
approximately two hours per week outside of the meetings. For example,
with the recent success of the Showtime series, Penny Dreadful,
the committee discussed the career of Dr. Victor Frankenstein and turned
their focus on how major natural events in 1816 influenced Mary
Shelley's creation.
Our discussion segued to notable events that occurred
one hundred years later (1916) that consequently put the impact of
winter storm Jonas (2016) in a unique perspective. From January 22-24,
2016, Jonas produced up to three feet of snow in parts of the
Mid-Atlantic and Northeastern United States. With all institutional
operations suspended due to record snowfall [3]
, many students were housebound. Following the devastation of
"Snowzilla," the course director encouraged SCREAM students to watch two
"snowbound" films - The Shining (1980) and The Thing
(1982) - in preparation for the next month's meeting. At the one-year
anniversary of Jonas, this paper revisits the outcome of our discussion
and conceptualizes three natural events (each 100 years apart) as
inspiration for movies used to teach mental illness in the residents’s
REDRUM didactic.
Discussion
1816: Mount Tambora
In April 1815, an Indonesian volcano erupted ejecting
an estimated 25 cubic miles of debris into the stratosphere. The
largest eruption in the last 10,000 years, a stratospheric cloud
stretched around the earth leading to unprecedented climate change in
parts of the world, including Europe. As depicted in the movie, Gothic
(1986), Mary Godwin, Percy Shelley, Lord Byron, Claire Clairmont, and a
young physician named John William Polidori rented a villa in Cologny,
Switzerland in 1816. As a result of the seismic activity from Mount
Tambora, an "incessant rain" [4]
confined the group in the house for days. The company amused themselves
by reading German ghost stories, prompting Byron to suggest they each
write their own supernatural tale.
How Mount Tambora relates to psychiatry:
Two hundred years ago on June 6, 1816, Mary Shelley had a waking dream
of her creation: Frankenstein's monster. That same day, John Polidori
conceived the vampire. The two most iconic monsters in literature were
born on the same day and may be referenced to introduce personality
theory and disorders to resident physicians. For example, a biographical
analysis of Mary Shelley frames Frankenstein as a work of sublimation, with each character representing a major archetype of the author's collective unconscious (Table 1).
After reviewing personality theories of Carl Jung and
others, residents are introduced to the personality disorders.
Polidori’s creation, the vampire, inspired Abraham "Bram" Stoker to
write Dracula (1897). Count Dracula embodies a total disregard
for and violation of others' rights. Plot summary and character analysis
supporting the diagnosis of Antisocial Personality Disorder has been
previously described [1].
1916: The Jersey Shore and Jaws
Nearly 60 years before Peter Benchley’s seminal
novel, a real man-eater lurked in the waters of the Jersey shore.
Between July 1 - July 12, 1916 [5], four people were killed and one injured by a rogue shark.
The 1916 shark attacks inspired Jaws, the tale of a
white shark that terrorizes the small island community of Amity. A
remake of Melville’s Moby-Dick, Jaws caused many moviegoers to be afraid
to enter the ocean in the summer of '75 and established the notion of
the great white as nature's number one killing machine.
How Jaws relates to the field of psychiatry:
First described by Walter Bradford Cannon, the hypothalamus influences
various emotional responses including the fight-or-flight response.
Building on Cannon’s work, Jeffrey Alan Gray (1987) described a sequence
of defensive responses that occur depending on one's proximity to
danger:
- Alert or vigilant immobility,
- Escape,
- Fighting,
- Tonic immobility.
While the first three have been extensively studied
in humans, tonic immobility has been primarily investigated in animal
models.
Tonic immobility has been implicated in the diminishing numbers of great white sharks in recent decades [6].
There have been increasing reports of pods of killer whales hunting
great whites utilizing tonic immobility by turning the shark on its
dorsum thus inducing a natural state of paralysis. Tonic immobility is a
limbic system function that serves as an animal model for
dissociative-like symptoms experienced in the anxiety, trauma- and
stressor-related disorders including Post-Traumatic Stress Disorder.
Much like a zombie apocalypse serving as a backdrop to the Romerian group dynamic [7], the imminent threat of the great white shark serves as the setting for the main characters in Jaws
(1975) to interact. Sheriff Brody has a past psychiatric history
significant for specific phobia, natural environment type (irrational
fear of the water) and acts to mediate the conflict between Hooper and
Quint, both of whom also have histories of prior trauma. Hooper had an
experience with a thresher shark that "ate his boat" when he was young.
Quint also shares his encounter with a thresher’s tail when he shows
Hooper a scar on his right leg. Right after, Brody points out a tattoo
on Quint’s left arm of the USS Indianapolis, marking Quint as a survivor
of the greatest single loss of life at sea in the history of the US
Navy. Quint relates the account of the ship that was torpedoed by a
Japanese submarine. Of the 900 men who entered the water, only 317
survived; largely the result of the largest shark frenzy in recorded
history.
Despite having past traumatic experiences, both
Hooper and Quint chose careers at sea. This likely represents their
employing denial and reaction formation, thus developing a counter
phobic attitude [8] that results in them running towards (instead of avoiding) their fear. The final line of the movie, "1 used to hate the water...1 can't imagine why"
illustrates the effect of flooding in extinguishing Brody's learned
(avoidant) behavior. Of course - and ironically - Brody’s "therapy"
takes places when the Orca is flooded after having been rammed by the
great fish; a reenactment of the rogue sperm whale that sank the Essex
in 1820 (inspiration for Moby-Dick).
2016: Winter Storm Jonas and The Shining&The Thing
At the Amundsen-Scott South Pole station, most
research personnel leave by the middle of February, leaving a few dozen
"winter-overs" who keep the station functional through the months of
Antarctic night. The winter personnel are isolated between mid-February
and late October. After the last flight has left for the winter, an
annual tradition is a double feature viewing of The Shining and The Thing.
Synopsis: The Shining
Jack Torrance, a writer and recovering alcoholic,
takes a job as a "winter-over" at the isolated Overlook Hotel. His young
son, Danny, possesses psychic abilities and is able to see things from
the past and future such as the ghosts that haunt the Overlook. The film
depicts the trials of the Torrance family, as the abject isolation of
the snowbound hotel serves as the setting for the family's "descent into
madness."
How The Shining relates to the field of psychiatry:
The Shining is a film rich in subversive, psychiatric themes, with
several interpretations rendered by authors, anthropologists, and
historians [9]
and serves as an opportunity to teach the Psychotic and Related
Disorders. Hallucinations, delusions, disorganized and grossly catatonic
behavior, and negative symptoms (affective flattening, apathy, and
anhedonia) are all signs possessed by the patriarchal main character.
While the general consensus is that The Shining explores themes
related to psychosis, Stuart Ullman's disclosure of the 1970 tragedy of a
former caretaker, Grady, "running amok" is foreshadowing of the origin
of the family's psychotic break. Amok is a culturally (Malaysian) bound
syndrome hallmarked by episodes of sudden mass assault following a
period of brooding. A brief examination of the film reveals two themes
that allow for the formulation of another culturally bound syndrome that
explains the behavior of the Torrance family.
A pre-established delusion is identified in an individual-.
Prior to moving into the Overlook, Jack’s son, Danny, has a terrifying
premonition about the hotel that causes him to lose consciousness.
During a medical evaluation, Wendy tells a visiting doctor that her son
has an imaginary friend called "Tony" whose emergence coincided with
Danny going to nursery school around the time Jack dislocated Danny's
shoulder (following a binge episode). While the physician reassures
Wendy that Danny’s imaginary friend is "just a phase," there's reason to
believe Tony is a sign of an underlying mental disorder and therefore
is not developmentally appropriate. While posttraumatic stress disorder
(PTSD) is a provisional diagnosis, two scenes are critical to the
formulation of a differential diagnosis. First, Ullman tells Jack that
the hotel is built on the site of a 1907 Native American burial ground.
Next, a precocious Danny joins the discussion about the Donner party on
the way to the Overlook. The ill-fated settlers had to resort to
cannibalism after their wagon train was trapped by a heavy snowfall
through the Sierra Nevada.
Taken together, we can conclude that Danny is
afflicted with Wendigo psychosis; a culturally bound syndrome that
affects people who think about cannibalism. Originally afflicting
individuals of the Algonquin tribe, the syndrome preserves cultural
taboos by reinforcing the prohibition against cannibalism. Danny's
taking part in the adult discussion about the Donner party constitutes a
significant boundary violation and results in his becoming possessed by
the malevolent cannibalistic spirit.
A delusion develops in the context of a
close relationship with another person that is similar in content to
that of the person who already has the established delusion:
Jack wanders into the Gold Room where a ghostly bartender named Lloyd
serves him bourbon on the rocks. Meanwhile, Danny's curiosity gets the
best of him when he wanders into Room 237 despite the omen not to enter.
When Danny returns from Room 237, he is visibly traumatized, causing
Wendy to think that Jack is abusing Danny again. Wendy shows up in the
Gold Room and informs Jack that Danny told her a "crazy woman in one of
the rooms" was responsible for his injuries.
Jack investigates Room 237 and has an experience
similar in content to Danny's. Specifically, a mysterious female seduces
Jack, but then turns into a symbolic manifestation of the wicked woman
from Hansel and Gretel (who lured children like Danny with candy before
transforming into a witch). The Hansel and Gretel fairy tale was
foreshadowed when:
- Danny brought up the topic of cannibalism
- Wendy first met Dick Hallorann and said she felt the need to put down breadcrumbs in order to find her way around the Overlook.
Upon returning from Room 237, Jack casts an image in
the mirror when entering the suite. He tells Wendy he found nothing,
explaining that Danny’s bruises were self-inflicted, "I think he did it
to himself" [10].
Faced with this reality, Danny becomes acutely psychotic as evidenced
by his "shining" (grossly catatonic behavior) into his parents'
conversation. This further establishes that Danny is the proband case of
psychosis. Danny's psychotic episode is followed by Jack's exacerbation
(transmission) as evidenced by his becoming verbally abusive
(disorganized behavior) towards Wendy. As he storms out of the suite, he
casts no reflection in the mirror, having truly lost "his soul/who he
is."
In summary, The Shining is a case study of
Shared Psychotic Disorder (SPD). Also referred to as folie a deux, SPD
is a rare psychotic disorder usually found in long-term relationships
with close emotional ties.
Synopsis: The Thing
Based on John W. Campbell, Jr.'s novella, Who Goes
There?, the movie is about a parasitic, extraterrestrial life form that
assimilates organisms at the molecular level, thus allowing it to
phenotypically mimic its host.
Set in Antarctica, The Thing begins with a
Norwegian helicopter pursuing an Alaskan malamute to an American
research station. When the last surviving Norwegian is shot and killed,
the Americans go to the Norwegian base only to find it burned to the
ground. MacReady and the crew learn that the Malamute was alien but
before they could kill it, the thing begins to assimilate the other dogs
and members of the research team.
Considered by John Carpenter to be the first part of an apocalyptic trilogy along with Prince of Darkness and In the Mouth of Madness, The Thing pays homage to Dracula,
depicting the trials of MacReady (modern day Van Helsing), who leads
his team as they try to capture and kill the inhuman scourge before it
can hibernate and move beyond the continent.
How the Thing relates to the field of psychiatry: We discover the goal of the thing is to hibernate or sleep, thus introducing the notion of the dyssomnias;
sleep abnormalities in the amount, quality, or timing of sleep
involving disruptions in mechanisms generating sleep-wake states. One
dyssomnia, Non-24 Hour Sleep-Wake Type (a Circadian Rhythm Sleep- Wake
Disorder), is characterized by abnormal synchronization between the
24-hour light-dark cycle and the endogenous circadian rhythm. Given
that:
- The setting of the film is the Antarctic night,
- The alien's circadian rhythm is longer than 24 hours [11],
- The alien needs to hibernate,
The Thing may be viewed as an exercise in the Circadian Rhythm Sleep-Wake Disorders.
Conclusions
At our medical school, we have created a novel
resident didactic where psychopathology is taught through the horror
film genre. The main objective of REDRUM is to enhance learning through
creative discussion of examples of psychopathology that come from film
and literature. REDRUM is updated annually by a steering committee
comprised of medical students who look at the historical context of
movies that serve a metaphorical role in the depiction of mental
illness. Beginning in June, 1816, three sets of natural events, each
occurring 100 years apart, have influenced the creation of literary
works related to mental illness. These seemingly random events including
the eruption of Mount Tambora (1816), shark attacks down the Jersey
shore (1916), and devastation of winter storm (2016) can be tied
together to create a didactic to teach psychopathology (Table 1). Such creative didactics are essential for residents to apply, analyze, synthesize, and evaluate information [12].
Another benefit of engaging students with innovative
didactics to teach psychopathology is capturing the attention of the 95%
of students [2]
who choose to pursue careers outside of Psychiatry. Only when future
surgeons, internists, and obstetricians recognize the 18.6% of
co-occurring psychiatric conditions [13] and 16% incidence of substance use disorders [14] in their patients will the stigma of mental illness be addressed.
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