In my clinical work I've noticed that people have many layers to their life experience. Psychological suffering also has layers. Case in point - psychotic disorders. Before I discuss the recent portraits of psychosis in cinema, a quick anecdote about psychosis in real life.
I recently encountered a woman in a primary care clinic that I work at once a week. We sat down, and the layers of her distress unraveled slowly but surely. She started out by describing some 'mild' suffering. When asked what has been causing distress in her life she mentioned a crappy relationship that she had been in a few years ago, and how she'd had two abortions as a result. Sometimes she ruminates about the abortions and how bad of a person she was for getting them. She feels guilty as a result and sinks into intermittent bouts of depression.
At that point in the conversation I was thinking to myself, "Alright, we're talking a major depression disorder in response to some understandably depressing circumstances - get her on an anti-depressant, and some cognitive therapy which will attack the maladaptive ruminative thought patterns fueling the depressive fire. Maybe even a little behavioral activation like exercise and pleasure event planning..."
But she continues.
Sometimes her professors do things (and she can't clearly articulate what) that make her feel like a failure. It zaps her motivation, and her grades plummet.
Then the woman's eyes narrowed and a spontaneous memory emerged. A few years ago the skin on her chest blistered. Doctors told her it was an allergy but she thought it was from STD. Her speech started to accelerate at this point, and her energy level picked up. She went on to describe an affair she'd had with a really nice, much older gentleman. She'd engaged in the affair because she was desperate for help with the rash. She ended the diatribe with a spirited confession - the affair had neither helped her rash nor her relationship troubles.
"Time out," I'm thinking. How did we get from a rash to an affair? In a matter of seconds, and merely a few sentences, the woman had some demonstrated a few cognitive hiccups unique to psychotic disorders.
It's a whole new ballgame.
Then things really started to heat up.
Sometimes people called her awful names on the street - yelling from windows. If it's a really bad day she'll believe what the strangers are yelling at her. And sometimes complete strangers approach her and do sexually provocative things to her in public places like making masturbatory gestures and threatening to assault her. No, other people who were with her in these public places did not react to the sexually inappropriate behaviors and, no, she didn't seem to care that that was the case. Why does that matter, she asked.
She continued, unfazed.
Sometimes people shoot her funny looks from across the street, and she feels scared for a few hours. Then she leaned forward and whispered, and sometimes people can hear what I'm thinking and it puts me on edge.
I would imagine so.
I looked at her carefully. She didn't seem bothered by these experiences. Maybe she had been at the time, but certainly not now, in the moment.
And then, like a lawyer slamming a hand emphatically on the table and ending his closing arguments with irrefutable evidence, the woman sipped some water, scratched her head, and admitted that for the past nine months she had been hearing a voice when she awoke in the mornings. It's always the same voice, and it's definitely not her own. It's angry too. It doesn't tell her what to do, but it makes her feel scared.
Layers of suffering, indeed.
I looked at my watch. In less than an hour we had jumped from the mild misperceptions of a mood disorder to the harsh breaks from reality of a psychotic episode. Auditory and visual hallucinations, pervasive delusions, thought insertion, thought broadcasting, disorganized and pressured speech - all the signs of psychosis could be checked off. Further, all these symptoms revolved around the theme of paranoia - everyone was out to get her, always, and for no particular reason. Perhaps if I had continued the inquiry a larger narrative would have emerged (i.e. the FBI is out to get me).
Treatment just got more complicated, I realized. Whether she would eventually be diagnosed with schizophrenia, paranoid personality disorder, or a delusional disorder, anti-psychotic medication was a no-brainer, an immediate and critical first step in the treatment process. Long-term, a better living environment and weekly counseling geared toward enhancing skills of daily living, reality testing and self-awareness would be warranted.
As I thought about how to introduce into the conversation the need for such treatment (in response to her currently untreated, undiagnosed psychotic disorder), I thought about her prognosis. Even if she consistently engaged in high quality psychiatric and psychological treatment for the rest of her life, she would still in all likelihood suffer from bouts of paranoia...
I snapped back to reality.
The woman was looking at me expectantly. There had been no previously conceived agenda for this meeting. In fact, when we had first sat down, she mentioned that she had come for a routine medical exam. Little did she know the meeting was going to involve a gentle confrontation about a possible psychotic disorder, and a referral for psychiatric evaluation and medication...
I took a deep breath, leaned forward, and launched into a conversation designed to convince her that the world she had come to know was not quite the world she needed to live in.
Psychosis in film
This recent clinic encounter got me thinking about the standout cinematic portrayals of psychosis.
Within the genre of 'psychotic' cinema perhaps the two biggest blockbusters of the past decade have been the two highest quality films. Fortunately for the mentally ill community they have trended toward accurate portrayals of paranoid schizophrenics with an emphasis on the exceptional gifts of creativity often associated with the mental disorder.
There's "A Beautiful Mind," the story of Nobel Prize Winner John Nash played exquisitely by Russell Crowe, and presented delicately by Ron Howard. Then there's the equally entertaining and balanced motion picture, "The Soloist," in which Jamie Foxx transforms himself into Nathaniel Ayers, a Julliard-trained musician whose battle with hallucinations render him homeless.Both stories show the chronicity and impairment of schizophrenia while also suggesting that treatment, and social support can facilitate redemption along with major gains in functioning.
Also of note are a few darker, somewhat cartoonish portraits of psychosis, namely David Cronenberg's "Spider" in which a man who is now living in a London halfway house after being institutionalized for 20 years slowly slips back into madness as he replays childhood traumas.
And the relatively recent "Shutter Island," offers a superbly acted mystery tale that discusses the state of mental institutions in the 1950's and introduces to a previously stable protagonist who now suffers delusions due to a family tragedy (a notion that is not supported by research).
Please email with other notables from the 'psychosis' genre.