Multimedia Reviews: La-La Land Meets DSM-IV: The Pleasures and Pitfalls of Celluloid Diagnostics

Cinema went essentially unexamined by psychoanalysts for decades. Freud's overt disinterest in film arguably put the kibosh on other potential investigators, although our founding father may have been a covert cinephile. (Several years ago, a Manhattan attorney told me that he and his uncle, an ardent fan of both psychoanalysis and cinema, saw Freud in l936 or l937 at the Kreuzkino, a small theater in downtown Vienna that featured subtitled Hollywood fare—westerns, detective movies, so forth [1]). One wonders whether the increasing shortage of live analysands eventually compelled clinicians to begin probing the inner conflicts of characters on the silver screen. On whatever grounds, "applied analysis" of cinema has steadily increased over the past three decades. Movies are now regularly discussed at conferences and are also being used by educators to illustrate a panoply of psychological symptoms and syndromes.

The pedagogical value of Tinseltown's depiction of mental illness must nevertheless be rated a vexed question. Instructional docudramas originating in academia, often funded by the drug industry, tend to be as dry as dust. Hollywood enactments of DSM-IV are usually more engaging. But one must be ever mindful that movies are crafted to reap megabucks, not to instruct psychiatric residents.

As in past Hollywood "psycho-pics," clinical accuracy at the Bijou today is likely to be sacrificed for entertainment value. Egregious diagnostic distortions and oversimplification flourish, with emphasis on the more spectacular DSM-IV syndromes. Mainstream cinema especially, if not always reliably, foregrounds amnesia, multiple personality disorder, and other dissociative reactions because of their inherent melodramatic potential.

Gifted individuals with schizophrenia have recently proven highly bankable—for example, the psychotic virtuoso depicted in Shine and the paranoid mathematical genius of A Beautiful Mind, which was hailed by a surprising number of psychiatrists for its supposed diagnostic acumen. Although the film certainly has proven to be a beautiful gold mine for Universal Studios, it's filled with gross biographical falsifications, nosologic misprisions, and therapeutic howlers.

For example, John Nash, played by Russell Crowe, was never any sort of Cold War warrior; nor did he suffer from a tightly organized delusional system involving a Russian "big bomb" conspiracy scenario. The film implies that visual hallucinations are typical of schizophrenia, whereas in reality auditory hallucinations are a far more common feature of the disease, especially in its acute phase. In addition, A Beautiful Mind egregiously indulges Hollywood's usual fondness for displaying every shake, rattle, and roll of electroconvulsive therapy. By report Nash actually received insulin therapy. Convulsions during this treatment, if they occurred, would be considered an untoward side effect. Nash's wife would hardly have been asked to watch either treatment as she does in the film, to her obvious—and dramatic—distress.

Consistent with another Hollywood bromide, it is his wife's unstinting affection that redeems the mad professor, not the burning out of his psychosis with time, nor his receiving a Nobel prize, and most certainly not the dubious ministrations of a sinister psychiatrist. The movie's pernicious prescription gives the lie to its much vaunted tutelary virtues: if you've become unglued, don't let the shrinks shoot electricity through your brain or pump you with drugs that ravage your manhood. A little common sense, a little help from your friends, and—chiefly—the love of a good woman should put you just about right.

Paradoxically, many movies are most instructive about mental illness or psychodynamics when they aren't particularly striving for clinical verisimilitude. The Hours' most obvious "case" is Virginia Woolf. Her portrayal in the film as the chronically loony Queen of Bloomsbury is as fictitious as Nicole Kidman's phony schnozz. Although Woolf did suffer repeated devastating episodes of affective illness, she was at the peak of her powers when she undertook Mrs. Dalloway. She was both enormously productive and reasonably sane throughout most of her life.

Julianne Moore's heartbreaking impersonation of Laura Brown, The Hours' suburban California housewife, offers an infinitely more perceptive cinematic representation of major depressive illness, its symptoms, the shame of its exposure, and its devastating impact on relatives—here, a vulnerable child. Laura is first seen awakening to yet another morning in which she must paint a happy face over the agonizing melancholy she dare not reveal to her utterly unknowing husband or her small son.

She doesn't lack the courage to kill herself; indeed, death would come as a blessed relief from her "darkness visible." But suicide would also kill her unborn child and savage the boy she clearly loves more than her spouse. Poignantly, the boy perceives the torment his mother is ashamed to name, and—like many children of depressed patients—is agonizingly attuned to the minutest alteration in her precarious stability, chronically fearful of her abandonment.

In Memento, a brilliant neurological film noir, insurance investigator Leonard Shelby, played by Guy Pearce, seeks to avenge the murder of his wife by a burglar who simultaneously bludgeoned him into a state of permanent anterograde amnesia. A scenario replete with the requisite noir femme fatale and existential despair is defamiliarized by its radical subversion of traditional linear narrative, with multiple colliding temporalities.

Memento cunningly, unsettlingly enables the viewer to experience the confused perceptions of its hero firsthand. But it is highly unlikely that someone with Shelby's profound brain damage could ever function with the ruthless competence he so prominently features throughout the film. Memento is much more acute about Shelby's complex posttraumatic psychopathology. The profound emotional upheaval frequently associated with massive cerebral trauma is conflated with, and escalates, Shelby's unremitting grief. Unable to move forward in time, he lacks the psychic foundation for effective mourning. His lost love remains always intolerably at the forefront of his shattered mind: "I can't remember how to forget you," he says of her.

HBO's The Sopranos has been widely hailed for its supposedly penetrating portrayal of a New Jersey capo's panic disorder, and Tony's treatment by a compassionate paisan psychiatrist, Dr. Jennifer Melfi. In point of fact, the childhood material Melfi adduces as the meaty source of Tony's crippling anxiety comprises a prime example of ham-fisted Hollywood Freudiana: kid Tony passes out, watching his loan shark dad romance mom over a rib roast that Soprano senior boosted as vigorish from a butcher whose finger he's just amputated. By the series' third season, Melfi has become increasingly maladroit, a classic Tinseltown female shrink with no life of her own, and a clear crush on her male patient.

However, the series' adroit grasp of the chronic alexithymia afflicting Tony, his crew, and the rest of the wise-guy world has gone generally unremarked by film critics and the psychiatric profession. To the inarticulate unknowingness of these yobbos add affective instability and a pinch of attention-deficit hyperactivity disorder; stir further with overweening greed, defective impulse control, and the glaring superego defects sanctioned by a deviant antisocial subculture, and the results of this witches' brew are predictably lethal, off- and onscreen.

Notwithstanding the punctate clinical accuracy occasionally discovered in works such as Memento and The Sopranos, the big picture of emotional illness generally continues to elude the makers of big pictures. Smaller "indie" productions rarely do much better. Psychiatric neophytes are therefore advised to learn our trade by observing flesh-and-blood clients rather than their celluloid simulacra.

Dr. Greenberg is clinical professor of psychiatry at Albert Einstein College of Medicine at Yeshiva University, 1300 Morris Park Avenue, Bronx, New York 10461 (e-mail, [email protected]). Ian E. Alger, M.D., is editor of this column.