Jeremy Clyman Psy.D.

Reel Therapy

Diagnosing "Awake"

What the official guidebook of psychological disorders says about "Awake"

Posted May 22, 2012

A quick word on the two worlds: To differentiate between the two Britten wears a red rubber band in what will heretofore be termed the ‘Hanna-reality’ and a green one in the ‘Rex-reality.’ For those film buffs out there, the former is shot in warm tones, and the latter in cool ones. Also, Britten visits a psychiatrist in both worlds. In the Hanna-reality Britten is analyzed by department-recommended psychiatrist Dr. Lee, and in the Rex-reality he meets with his personal psychiatrist Dr. Evans. Each doctor insists the other reality is fake, and Britten remains unsure of which one, if either, is actually real, and (understandably) begins to worry about his sanity after details from the two worlds begin to cross over during the cases that he investigates as a detective.

The aim of this blog post is to determine what ‘real-world’ official psychiatric diagnoses, if any, can explain this psychological premise of Britten’s mind. The short answer, quite predictably, is that no diagnosis in the current nosology effectively captures this rather fantastical subjective experience. However, flipping through the relevant sections of the Diagnostic and Statistical Manual (DSM), otherwise known as the psychiatrist and psychologist playbook on mental health, makes for some intriguing ‘almost’ diagnoses. Considering that the DSM-V is a categorized history of the various ‘strange’ and ‘painful’ psychological experiences that have emerged  over the course of human history, its perhaps a surprise that some disorders even approach Britten’s case.

*This blog will use the diagnostic criteria from the latest, ‘almost-published’ version - the DSM-V. All disorders are posted with ‘incomplete’ criteria.

So iff Britten was to enter my office with this ‘dual-world’ presenting complaint I might first turn to the section on Neurocognitive Disorders. Meaning, I might listen to Britten’s tale of the car accident and his experience of awakening into his alternating realities, and I might start to think about anterograde amnesia. This condition is marked by the loss of the ability to create new memories after the amnesia-inducing event. Perhaps Britten has created ‘two homes’ – one with a son and one with a wife, and he consistently ‘forgets’ about one while visiting the other. Ok, so I can already see a hundred holes in this theory but it’s a condition that has been excellently portrayed in other feats of television/movies - Memento and The Lookout, - so it was worth a shot. While the DSM Cognitive Disorders section is not organized by the presence or absence of anterograde amnesia the following disorder might be relevant:

Neurocognitive Disorder Due to Traumatic Brain Injury - here, we have a symptom set that includes loss of consciousness, posttraumatic amnesia, disorientation and confusion, neurological hiccups like seizures and fluctuating cognitive difficulties with attention and learning.

Britten experiences none of these symptoms. Plus, this explanation would be the most uninspired choice by the show. Let’s move on.

Psychosis - He could be hallucinating one or both of the realities. Psychosis is perhaps the easiest and cheapest explanation for the show to offer, but let’s see if it fits. As it happens, a psychotic episode (a temporary state of detachment from reality) can be induced by a surprisingly wide range of causes - a mood disorder like depression or Bipolar Disorder, a botched medical procedure, which leads to Delirium, which leads to Psychosis, overuse of certain medications/substances, and onset of dementia. Surprisingly, brain trauma doesn’t make the list.

How about the psychotic disorders (the more chronic condition)? Well, Britten is too young to be experiencing an onset of Schizophrenia (most schizophrenics are diagnosed by early adulthood although there are certainly cases in later adulthood); Britten is too ‘high functioning’ and ‘normal-seeming’ to have Schizoaffective Disorder and he’s been suffering this dual-world phenomenon for too long to have Schizophreniform Disorder

Perhaps the most relevant diagnosis in this vein is found under ‘Delusional Disorder’ -  the classification for individuals suffering from hallucinations/delusions that are clearly NOT Schizophrenic and are able to maintain ‘normal’ functioning in other domains of life.

Ok, so cognitive dysfunction and psychosis are unlikely candidates. How about Dissociative Disorders? These cluster of symptoms capture experiences in which an individual seems to drift from reality in degrees while remaining somewhat tethered to the here-and-now (versus psychosis)

We could consider Dissociative Identity Disorder (DID) - the infamous ‘multiple personalities’ affliction. This diagnosis would fit if we were, in fact, watching Britton live out an inner drama in which he plays HIMSELF and HIS SON and HIS WIFE. What a creepy, disturbing possibility. For some reason I really hope Britten doesn’t have DID… 

Dissociative Amnesia is a more flexible application of the basic idea outlined in my anterograde amnesia/neurocognitive disorder section. It captures an individual’s struggle to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. So, in-line with the show’s psychiatrists, perhaps one or both of the worlds is a creation of his mind in an effort to dull/distract from the pain of loss.

The next dissociative disorder candidate is Depresonalization-Derealization Disorder. A mouthful, I know.

This disorder is characterized by the presence of persistent or recurrent depersonalization (experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions) or derealization (experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted). Also, during such states the individual’s reality-testing would remain intact. 

This disorder provides the hypothesis that Britten tends to drift outside of himself and experiences 'real life' as a 'dream.' Basically, this is the reverse of the show's premise that Britten's "dreams" are being confused as "reality."

Finally, it’s worth checking out the sleep disorders. After all, the bridge between the two worlds is his bed. Perhaps Britten thinks he’s awakening to one world when, in fact, he’s still in a state of sleep…dysfunctional sleep that is. 

Multiple sleep disorders provide interesting, albeit incomplete possibilities.

There’s ‘Nightmare Disorder’ (sounds pretty awful doesn’t it!), in which an individual experiences repeated occurrences of extended, extremely dysphoric, vivid dreams that usually involve efforts to avoid threats to survival; and upon awakening from the dysphoric dreams, the sufferer rapidly becomes oriented and alert. This disorder is worth some thought because Britten’s adamant stance that nothing ‘feels like a dream’ could simply by his mind being tricked by ‘vivid dreaming.’ Also, his ‘day job’ of investigations often involve themes of threat/survival (as his psychiatrists eagerly point out), and now that I’m thinking about it Britten does seem to jump out of bed in the kind of ‘rapidly oriented’ fashion that this disorder describes...

And there’s ‘Rapid Eye Movement Sleep Behavior Disorder’ or the ‘sleep walking’ experience. Technically, the symptom cluster is as follows: repeated episodes of arousal during sleep associated with vocal and motor which may result in injury to the individual or bed partner. Again, the individual is completely alert and oriented upon awakening. With this disorder your mind is asleep but your body is awake and so you’re ‘living out’ your dreams and there’s a high likelihood you’ll hurt yourself (i.e. if in your dream you are being chased then back in reality you’re likely to run head-first into a wall!). Britten would potentially suffer something along these lines….if his colleagues ever said anything to suggest as much. But they don’t.

These last two disorders are grounded in the high-probability explanation that one of Britten's realities is simply a dream, however, neither diagnosis fits even a little if we were to take Britten's personal account of life at face value.

So, that’s a quick journey through the DSM-V. It’s not too surprising that Britten’s circumstances seem beyond what we’d currently categorize as ‘humanely possible’ but it’s interesting to note just how many disorders partially approach this kind of predicament!