A Post About Coraline: She's as Cute as a Button

Viewing the film "Coraline" through a psychiatrist's lens.

Posted Feb 20, 2019

The Participatory Cinema at the Rutgers Center of Alcohol Studies is a monthly full-day seminar centered around a feature-length film that we flip as a fictional case study of mental illness. The purpose of the seminar is not to render diagnoses per se, as it would run the risk of stigmatizing individuals with mental illness (films too often provide inaccurate portrayals of mental disorders). Instead, the selected film serves to stimulate discussion about the seminar’s topic. The following post is a synopsis of this month’s Participatory Cinema discussion on Coraline.

Synopsis

Coraline (2009) is a stop-motion animated dark fantasy based on Neil Gaiman’s 2002 graphic novel of the same name. The film follows Coraline Jones and her parents on their move from Michigan to an old Oregon mansion, where Coraline discovers a small door that leads to “the otherverse.” As of this posting, the film holds a 90% rating on Rotten Tomatoes and a score of 7.7 out of 10 on IMDb.

Differentiating the Abnormal from the Normal

It’s worthwhile for clinicians to initially frame our patients’ behaviors as normal “until proven otherwise.” Working within this framework allows healthcare providers to identify behaviors that blur the boundary between normal and abnormal, such as Adjustment Disorders, Bereavement, and culturally sanctioned beliefs. Once we have exhausted “our search for the normal,” we can then begin a differential diagnosis of the abnormal behavior (e.g., visiting another world through a little door discovered in a bedroom).

In Coraline’s case, her discovery initially appears to be in the context of normal behavior. Her childhood fantasy is consistent with children who engage in fantasy play during times of isolation (or in Coraline’s case, neglect). As a matter of fact, after returning from the otherverse for the first time, Coraline takes part in the textbook example of fantasy play—a tea party! However, Coraline’s experience is not age-appropriate as she is 11. Additionally, fantasy play and imaginary friends should not lead to significant distress or impairment. Therefore, Coraline’s childhood experiences are the result of abnormal behavior. Because they result in distress, her behavior may further be classified as “disordered,” thus allowing us to continue with our case formulation.

Investigate an Organic Cause

In the DSM-5, clinicians are routinely guided to assess whether the identified behavior is due to another medical condition or the direct physiologic effects of a substance. As for the former, we aren’t given any indication that Coraline’s trips to the otherverse are due to a medical condition. In a way, this film is similar to certifying exams in medicine: If the patient is a young female, one may assume good health unless presented evidence to the contrary (the same unfortunately can’t be said of old males). A clinician would be wise not to adopt a similar approach when investigating the potential role substances play in the presentation of a patient’s behavior. Therefore, even though we don’t observe Coraline using any substances, we must keep a substance-induced mental disorder in our differential diagnosis.

Localize the Lesion

The next step in furnishing a most likely diagnosis is to decide whether your patient appears afflicted with a) a mood-anxiety cluster or b) a psychotic-dissociative cluster. ‘Choice A’ would implicate the catecholamines (including the indolamine, serotonin) while ‘Choice B’ localizes to the mesolimbic and mesocortical tracts in the central nervous system. Coraline’s behavior is consistent with a psychotic-dissociative cluster as evidenced by her experiencing an alternate universe as well as incorporating fixed beliefs. As these are critical parts of the plot, it is best to formulate Coraline’s behavior along a psychotic-dissociative spectrum.

Streamline the Diagnosis

At this stage in our formulation, it is best to arbitrarily choose Schizophrenia as a provisional diagnosis. While Coraline “checks the boxes” for the inclusion criteria of Schizophrenia, clinicians must appreciate that this condition is a diagnosis of exclusion. To verify Schizophrenia, we must rule-out an Autism Spectrum Disorder (ASD), Schizoaffective Disorder, and a primary mood disorder.

Taking these one at a time, Coraline’s perceptual disturbances and fixed beliefs preclude an ASD as fully explaining her symptoms. Even if Coraline had an established ASD, these observed symptoms allow the clinician to render a secondary diagnosis. 

Childhood-onset Schizoaffective Disorder (and Schizophrenia for that matter) is extremely rare, affecting 1 in 30,000 children. Could Neil Gaiman have written about that 0.003333333333 percentile case? Perhaps. But there may be another mental disorder that’s more likely depicted in Coraline.

A primary mood disorder may be the single best answer to what is afflicting Coraline. Her escape to the alternate universe depicts social isolation, and we are provided some context within which the behaviors occur (recent move, few friends, and parental neglect). At this point, definitively ruling-out the role of substances (see above) is the clinician’s final step.

What Coraline is Really About!  

There are several clues provided throughout the story that when taken together provide the answer to what ails Coraline (Table 1).

 Anthony Tobia, M.D.
Table 1. Whats Ails Coraline.
Source: Anthony Tobia, M.D.

Putting the Clues Together

Coraline’s mother is growing protocurarine, an herb nicknamed “pot curare” because it was originally packed in terra cotta pots (seen in the film). Protocurarine poisoning mimics a condition called the locked-in syndrome that causes paralysis of voluntarily skeletal muscles except for the lungs and eyes. A person with the locked-in syndrome may have a perspective similar to looking up from a well. In 'total locked-in syndrome' due to protocurarine poisoning, the respiratory muscles are also paralyzed (TOTAL) but the victim can be kept alive by mechanical ventilation symbolized in the film by the black cat. In this way, “stealing breath” is a setting on a respirator that takes excess CO2 away and corrects a medical condition (acid-base disturbance) called Metabolic Acidosis (MA). A well-known acronym used to recall the possible causes of a subcategory of MA is CAT MUDPIES which just so happens to be in the script of the movie (“Mud facials, mud baths, mud pies”). Interestingly, the acronym has been revised to CAT MUDPILES to include lactic acidosis which occurs when lactic acid is overproduced in ischemic tissue during oxygen deficit (e.g., from protocurarine poisoning). Coraline’s observation at 00:14:15 uncovers the motive of the poisoning, making the film about a case of Munchausen’s by Proxy (Factitious Disorder imposed on another). This sheds light on why YB’s grandma, who owns the Pink Palace Apartments, “won't rent to people with kids,” and why Coraline named her other imaginary friend ‘Why-Were-You-Born,’ having heard her mother ponder that very question. Finally, the reaction from the audience of “I didn’t see that at all!” closely parallels Factitious Disorder imposed on another in clinical practice and explains why it is among the most difficult diagnoses to make in all of medicine.