DSM-III at the Cinema: Madness in the Movies

Steven E. Hyler

A kaleidoscopic view of commercial film and television depiction of mental disorders is presented.
Films portraying various types of mental disorder, from psychoses through personality disorders,
are identified and examined in terms of DSM-III diagnostic criteria. It is concluded that although few
generalizations can be made, a surprisingly large number of films are reasonably accurate in their
representations of various disorders, and some may even be considered prototypal in their portrayal
of the mentally ill.
o 1988 by &me & Stratton, inc.

I
F THE NUMBER of commerical films depicting mental disorder is any
indication, Hollywood certainly is fascinated by all things “psychiatric.” Over
the past several years, a great many films have dealt with psychiatrists and mental
illness, including-to name just a few of the more popular ones-Lovesick (1982),
Frances (1982), Still of the Night (1982), The Man Who Loved Women (1983).
Zelig (1983), Birdy (1984), and Agnes of God (1985).
It would be difficult to ignore the potential influence such films have on the views
that many people-especially those who have had little or no personal involvement
with psychiatrists or mental illness-hold about psychiatry and mental disorders.
For better or for worse, movies and television contribute significantly to shaping the
public’s perception of the mentally ill and those who treat them. Mirroring the
increasing number of recent films depicting various aspects of psychiatry is the
number of articles and books on the topic. Schneider has explored the parallels
between the development of the movie industry and the development of psychiatry’
and, in a recent article,2 examines the practice of “movie psychiatry.” Greenberg3
and Dervin4 have looked at a group of popular films and filmmakers from a
psychoanalytic perspective. Gabbard and Gabbard have discussed countertransfer-
ence in the movies’; and their recent book, Psychiatry in the Cinema,6 in which they
identify more than 250 films dealing with psychiatry, serves as a definitive reference
source on the subject.
How accurate-or honest-are the media’s portrayals of mental illness? Do
mentally ill characters, whether or not they are identified as patients, display
symptoms of mental disorder that would be diagnosable by our current criteria, i.e.,
those presented in the recently revised DSM-III? To attempt to answer these
questions, I have reviewed several dozen films in which either psychiatry and mental
illness were prominent elements or one or more of the characters suffered from a
fairly evident mental disorder.

PSYCHOSES

The DSM-III definition of psychosis requires the presence of hallucinations,

delusions, prominent thought disorder, or grossly disorganized behavior. Few of the

From the New York State Psychiatric Institute, New York.

Address reprint requests to Steven E. Hyler. M.D.. New York State Psychiatrir Institute, 722 West
168th Street. New York, NY 10032.
0 1988 by Grune & Stratton. Inc.
OIOO-440X/88/2902-0014$03.00/0

Comprehensive Psychiatry, Vol. 29, No. 2 (March/April), 1988: pp 195-206 195

196 STEVEN E. HYLER

films reviewed were considered documentaries with the expressed goal of accurate
portrayal of mental disorder, but a surprisingly large number were found to depict
characters whose behavior met the criteria for the presence of a specific psychotic
disorder.
The Cabinet of Dr. Caligari (1919), a classic German film by Robert Weine,
presents the story of a malevolent director of a psychiatric hospital, Dr. Caligari,
who uses a somnambulist to commit senseless murders. At the end of the story it is
revealed that the storyteller is actually a patient in the hospital, and that the story he
has convincingly related is, in fact, a systematized delusion of persecution. The
storyteller’s DSM-III diagnosis would be schizophrenia, paranoid type, because of
his paranoid belief that he is being persecuted by the hospital director, a belief that
has no basis in reality, but leads him to attack the director and results in his being
physically restrained.
A more recent film portraying schizophrenia, based on Hannah Green’s book of
the same title, is I Never Promised You a Rose Garden (1977). In this film the
patient is a young girl who displays many signs and symptoms of schizophrenia,
including autistic thinking, inappropriate affect, command hallucinations leading to
self-destructive behavior, and marked deterioration in functioning. One of the more
impressive scenes occurs at the beginning of the film, when the patient first meets
her therapist at the hospital; the experience of psychosis is depicted from the
subjective viewpoint of the patient as iron bars dropping between her and the
therapist, who is gradually drawn farther and farther away from her, and a voice
telling the patient not to talk. Seen through the therapist’s eyes, the patient is mute
and noncommunicative, and her abrupt termination of the interview is considered a
sign of thought blocking.
Other films that present reasonably accurate portrayals of schizophrenic disor-
ders are The Snake Pit (1948), in which Olivia de Havilland plays the role of a
patient who would most likely be diagnosed as suffering from a schizophreniform
disorder; The Bell far (1979), the movie version of a novel by Sylvia Plath, which
presents a fairly accurate picture of the prodromal period of schizophrenia
preceding a psychotic episode that leads to hospitalization-though the final
diagnosis is less clear-cut; and Possessed (1947), starring Joan Crawford, which
dramatically depicts catatonic schizophrenia, complete with mutism, negativism,
and waxy flexibility, together with a state-of-the-art neuropsychiatric evaluation
circa the late ’40s.
Perhaps the most compelling portrayal of schizophrenia is that in the recent,
highly acclaimed, TV movie Promise (1986), featuring James Garner, the caretak-
er, by default, of his schizophrenic brother, played by James Woods. The emphasis
of this film is on the difficulties of living with and caring for a schizophrenic family
member. The scenes depicting many of the negative symptoms of schizophrenia,
including social isolation (fear of leaving the house), peculiar behavior (compulsive
handwashing), magical thinking, and lack of initiative, are particularly well done.
However, toward the end of the film we see the character played by James Woods in
an acutely psychotic state that resembles psychotic mania. This casts doubt on the
diagnosis of chronic schizophrenia in favor of a schizoaffective disorder, and I
couldn’t help wondering why the character would never have been given a trial of
lithium carbonate.
In contrast to these more or less accurate depictions of psychoses is Hollywood’s
DSM-III AT THE CINEMA 197

frequent perpetuation of the lay misconception that schizophrenia involves a “split

personality.” Probably the most significant film contribution to the split personality
myth is the Hitchcock film Psycho (1960), in which the alter ego of Norman Bates.
the mild-mannered proprietor of an out-of-the-way motel, dons his murdered
mother’s clothes before killing young women to whom he is attracted. By the end of
the film, the clinical picture turns to one of catatonic schizophrenia, Norman being
“taken over” by his mother’s spirit. The tour de force of the film is the psychody-
namic formulation presented by the psychiatrist, played by Simon Oakland, who, at
the end of the film, explains the etiology of Norman’s illness to the audience.
A similar portrayal of a split personality, one of whom is a murderer, is that of
Ronald Colman as Anthony John in Cukor’s A Double Life (1947). Other films
exploiting the idea of a split personality are Dark Mirror (1946), in which Olivia de
Havilland plays a dual role of identical twins, one good and one evil; de Palma’s
Sisters (1973), in which the two personalities are Siamese twins; and Dressed to
Kill (1980), also by de Palma, in which a psychiatrist possesses both a good and an
evil personality. All these films seem to reflect Freudian psychodynamic theory
gone amok.

BIPOLAR DISORDER
Though only recently, in DSM-III, have diagnostic criteria allowed more reliable
distinctions to be made between schizophrenia and bipolar disorder, mania has been
portrayed with some degree of accuracy for some time. Manic behavior in its
nonpathological and most humorous sense was a large part of the comedy of the
Marx brothers. In the 1932 film Horsefeathers, Groucho Marx, as Professor
Wagstaff, in accepting the position as president of Huxley University, is shown in an
elated mood, with pressured speech, flight of ideas, distractibility, punning, and
grandiosity-meeting just about all the criteria required for mania except marked
impairment in functioning.
A more clinical presentation of psychotic mania occurs in the characterization of
Colonel Bliss (sic) in the 1963 film Captain ZVewman, M.D. This character, played
by Eddie Albert, is grandiose and irritable and meets the full criteria for mania; he
is also quite intelligent, and when he realizes how sick he is, not even Gregory Peck,
in the title role of a military psychiatrist, can prevent his ultimate suicide.
Another character who seems to have bipolar disorder (though in the movie his
brother refers to his having paranoid schizophrenia) is the character Nathan, played
by Kevin Kline, in Sophie’s Choice (1982). Several episodes of clearly manic
behavior are portrayed, and even when not manic, Nathan is either hypomanic or
depressed. This film, too, contains a suicide-a double suicide or a murder-suicide,
depending on how one chooses to interpret it. The confusion between bipolar
disorder and paranoid schizophrenia is perhaps a reflection of the setting of the film,
the late 1940s when many patients in the United States who were suffering from
what we would now term bipolar disorder were probably being diagnosed as having
schizophrenia.

MAJOR DEPRESSION
Depression is a common condition in films, as it is in real life; many film
characters meet DSM-III criteria for major depression. In the 1945 film The
Seventh Veil, the protagonist, Francesca Cunningham, played by Ann Todd, is
198 STEVEN E. HYLER

clinically depressed, and we meet her at the beginning of the film as she sneaks out
of a hospital and jumps from a bridge. She survives, and the remainder of the film
delves into the reasons for her depression and suicide attempt. Another film
character with depression is Jim Downs, portrayed by Jose Ferrer, in The Shrike
(1955). Once his depression has lifted, Jim Downs’ difficulty is convincing the
doctors that he is well, i.e., sane enough to leave the hospital. This film obviously
predates deinstitutionalization and diagnosis-related groups (DRGs).
In Capra’s It’s a Wonderful Life (1946), George Bailey, played by James
Stewart, is depressed, but not necessarily depressed enough to warrant intervention
by a psychiatrist. In this case the diagnosis is more likely an adjustment disorder
with depressed mood, the stressor being the financial crisis that George faces, which
is serious enough to make him contemplate suicide. Therapy is not needed, thanks to
the divine intervention of his guardian angel, Clarence.
The character portrayed by Henry Fonda in The Wrong Man (1957) became
clinically depressed when he was wrongfully accused of murder and the proceedings
destroyed his job, family life, and self-esteem. This seems another instance of
adjustment disorder with depressed mood. Clinical improvement came only with the
hero’s exoneration of the crime of which he had been accused.

SUBSTANCE DEPENDENCE AND SUBSTANCE-INDUCED

MENTAL DISORDER
Substance dependence and substance-induced mental disorder are commonly
portrayed in films.
The character of Don Vernon, played by Ray Milland in an Academy Award-
winning portrayal of an alcoholic in The Lost Weekend (1945) (which also won the
Oscar for best picture) is particularly convincing: he clearly meets the DSM-III
criteria for alcohol dependence. He spends an inordinate amount of time ensuring
that he will always have a bottle available (one is shown hanging from a window;
another is secreted in a chandelier); he always seems to drink more, and for a longer
period, than he intended; he has failed in repeated attempts to cut down on and
control his drinking and, in fact, was on his way for detoxification when he became
sidetracked and went on a binge. His drinking has definitely impaired Don’s
performance as a writer, and he is shown attempting to pawn his typewriter to get
money to buy alcohol. Toward the end of the film, there is a frightening depiction of
alcohol withdrawal delirium: Don experiences terrifying visual hallucinations of a
rat eating through a wall and being attacked by a bat that is flying around the room;
the scene ends with the bat attacking the rat, and the rat’s blood dripping down the
wall and Don screaming aloud in terror. Other popular films depicting alcohol abuse
or dependence include Days of Wine and Roses (1962) and Harvey (1950).
For many years the film industry adhered to a voluntary code of restrictions on
the portrayal of substance abuse/dependence other than of alcohol, ostensibly so as
not to corrupt the morals of the audience.7*8 (One exception was Reefer Madness
[ 19371, which presented a more hysterical than realistic depiction of the “evil weed”
and the dangers its use invited.) This code was broken in the 1950s by several films
that dealt with the nation’s growing problem of opioid abuse and dependence.
The Man with the Golden Arm (1956), by Preminger, with Frank Sinatra in the
leading role, presents a vivid picture of heroin addiction. The film is most notable for
its portrayal of the cravings of the addict, the social and occupational complications
DSM-III AT THE CINEMA 199

of heroin use, and the agony of the “cold turkey” withdrawal experienced by the
protagonist. Another film of similar vintage that dealt with heroin dependence was
A Hat&d of Rain (1957), with Don Murray. In both of these films, the “heroes”
were able to kick their habits through the support of a loving wife or girlfriend. By
the 1960s the treatment of drug addiction was being depicted more realistically.
Synanon (1965), for example, was an early attempt to present the therapeutic
community approach that was to become increasingly popular.
In the 1970s cocaine seems to have begun to supersede heroin as the substance of
choice of many film and TV characters. The movie The Seven Percent Solution
( 1976) presents an account of Sherlock Holmes’ cocaine addiction, which is treated
and eventually cured by a rapid psychoanalysis by none other than Freud, played
here by Alan Arkin. The major contribution of this film to cinema accuracy in
picturing mental disorder occurs at the very beginning of the film, when Dr. Watson
is called to evaluate Sherlock Holmes, who, after several days of intravenous abuse
of cocaine, has barricaded himself in his apartment. Holmes is shown in the midst of
a cocaine-induced delusional disorder in which he first refuses to let Watson into the
apartment, then draws a pistol to protect himself, and proceeds, in an irritable and
highly pressured manner, to claim that he is being persecuted by Moriarty. In a
close-up, the audience even sees Holmes’ dilated pupils from the sympathomimetic
effects of the cocaine.
A somewhat less realistic portrayal of a substance-induced organic mental
disorder is that of Barbara Gordon, as played by Jill Clayburgh, in I’m Dancing as
Fast as I Can (1981). Here the diagnosis appears to be a diazepam withdrawal
psychosis, which in DSM-III would come under the heading of “anxiolytic
withdrawal delirium,” though the film portrayal is not very convincing. In the
throes of her illness, Barbara’s behavior becomes increasingly bizarre: she displays
irritability, paranoia, seizures, and tactile hallucinations. In one scene she is shown
trying to understand human relationships through drawings of triangles on the wall
of her apartment.

MENTAL RETARDATION
Mental retardation would seem, superficially, to lack the dramatic appeal
necessary for commercial film or TV success. Nonetheless, there have been several
noteworthy depictions of adult mental retardation. One of the best is in the film
Charly (1968), adapted from Daniel Keyes’s novel Flowers for Algernon. Here the
leading role is expertly played by Cliff Robertson, who won a “best actor” Oscar for
his portrayal. Charly is the butt of practical jokes played on him by his coworkers;
for example, in one segment they place yeast and dough in his locker, and, because
of the heat therein, the mixture explodes when Charly opens the locker, much to the
amusement of the pranksters. An experimental procedure boosts Charley’s IQ to
that of a supergenius. The effect is only temporary, however; and despite his heroic
efforts, while he is functioning in the genius range, to prevent a relapse, by the end of
the film Charly has reverted to his childlike self.
Another excellent and sensitive film portrayal of mental retardation is in, the
documentary Best Boy (1979), by Irving Wohl, about his 52-year-old cousin Phil
who is preparing to become independent. Also notable are the TV films Bill (198 1)
and Bill, On His Own (1982), in which Mickey Rooney plays the part of a mentally
retarded adult.
200 STEVEN E. HYLER

DISSOCIATIVE DISORDERS
The mental disorders that Hollywood seems most enamored of are the dissocia-
tive disorders, which are portrayed in films far out of proportion to their actual
prevalence.
The 1945 Hitchcock film Spellbound presents a variety of dissociative disorders.
Gregory Peck, who assumes the role of the new director of Green Manors
Psychiatric Hospital, seems to have a complete loss of memory of his identity. He
comes under suspicion for the murder of the actual new director, but is eventually
cured by a pseudopsychoanalysis undertaken by a staff psychiatrist, played by
Ingrid Bergman. Diagnostically, the character played by Gregory Peck meets
DSM-III criteria for psychogenic amnesia and psychogenic fugue. Another case of
psychogenic amnesia is presented in the character played by Elizabeth Taylor in the
1959 film version of Tennessee Williams’s Suddenly Last Summer.
Few psychiatrists have ever encountered a genuine case of a patient with multiple
personalities, yet any lay person would recognize one from the dramatic film
portrayal by Joanne Woodward in the 1957 film The Three Faces of Eve. In this
film, the subject is depicted as having two distinct personalities: Eve White, a
dreary, unassertive, unhappy housewife and mother, and Eve Black, a fun-loving,
seductive, impulsive, and irresponsible woman who wants no part of her husband
and daughter. Both personalities are inadequate, and it takes skillful therapy by a
psychiatrist, played by Lee J. Cobb, to help the patient relive the original traumatic
event that contributed to the dissociation and to coalesce the two personalities into a
new, composite personality, Jane.
The other famous case of multiple personality is that of Sybil, in a 1976 TV
movie. In this film Joanne Woodward plays the psychiatrist, and Sally Fields plays
Sybil, a woman with as many as 16 different personalities. These multiple
personalities span the spectrum from “schizophrenic” to “borderline” to “avoidant”
personality. Again, thanks to the skillful and dogged efforts of the therapist, the
story has a happy ending.

SOMATOFORM DISORDERS
The 1963 John Huston film Freud, the Secret Passion is notable for Montgomery
Clift’s portrayal of the young Sigmund Freud, from his neurology training under
Meynert through his presentation of his theory of infantile sexuality and the
etiology of neuroses to a hostile audience of Viennese physicians. Also notable is
Susannah York’s portrayal of Cecile, who appears to be a composite of several
patients from Studies on Hysteria. In DSM-III terms, Cecile, on the basis of her
complex medical history and multitude of shifting complaints, including paralysis,
blindness, and pseudocyesis, would most likely be diagnosed as suffering from
somatization disorder. She is shown assisting Freud in the development of his
psychoanalytic technique.
Stanley Kramer, in the 1949 film Home ofthe Brave, presents the story of a black
soldier who develops paralysis following a combat experience that caused the death
of several soldiers in his outfit. Here the diagnosis is conversion disorder. Such
disorders are frequently portrayed as occurring among men in military service, and
other examples can be noted in Captain Newman, M.D. (1963).
In many of his films, Woody Allen plays a character who believes he has some
DSM-III AT THE CINEMA 201

dread disease. In Hannah and Her Sisters (1985), for instance, he would definitely
meet the DSM-III criteria for hypochondriasis.

ANXIETY DISORDERS
Despite the ubiquity of anxiety disorders in the general population, few films
depict people with such disorders. Usually, the anxiety disorder is a plot device, as in
James Stewart’s fear of heights in Hitchcock’s Vertigo (1958) and parodied in Mel
Brooks’s High Anxiety (1977). Sometimes the subject’s phobia “humanizes” a
character who is otherwise seen as indestructible, as is the case with Indiana Jones’s
“snake phobia” in Raiders of the Lost Ark (198 1).
In the film Ordinary People (1980), the youth Conrad, played by Timothy
Hutton, meets DSM-III criteria for both major depression and posttraumatic stress
disorder. He is shown to experience intrusive, distressing recollections of the boating
accident that killed his brother, flashback episodes of reexperiencing the event; he
avoids activities (e.g., as a member of the swimming team) that arouse recollection
of the event, and displays diminished interest in his friends and former activities,
restricted affect, outbursts of anger upon minimal provocation, and an exaggerated
startle response.

PERSONALITY DISORDERS
Most film characters who obviously suffer from a personality disorder never seek
psychiatric assistance, which is certainly consistent with the ego-syntonic nature of
the majority of such disorders. Many, however, do display traits that are prototypal
of personality disorders.
Paranoid personality is depicted in two films starring Humphrey Bogart. In The
Caine Mutiny (1954), Captain Queeg is even described as having a paranoid
personality by the court-appointed attorney who examined him. This film shows
how the presence of paranoid personality can predispose a person to decompensating
under stress, as Queeg did during a typhoon. In The Treasure of Sierra Madre
(1948), the character portrayed by Bogart becomes intensely paranoid about the
possibility of being cheated or robbed of his gold by his partners.
Robert de Niro, in Taxi Driver (1976), plays the part of an eccentric, socially
inept loner who is willing to drive his taxi “anyplace, anytime.” He displays ideas of
reference and paranoid ideation that become delusional in intensity; he seeks to act
on his ideas by considering assassinating a political candidate and winds up killing
some gangsters to “save” a young prostitute, played by Jodie Foster. The charac-
ter’s premorbid personality would, according to DSM-III, certainly meet the
criteria for schizotypal personality.
It would be difficult to find a Hollywood actress or actor who is not “histrionic.”
Some of their portrayals, however, are so prototypal as to define the histrionic
personality. Vivian Leigh’s Scarlett O’Hara, in Gone with the Wind (1939), is
perhaps the most representative. Especially at the beginning of the film, she is
shown as attention-seeking, overly concerned about her physical appearance,
self-centered, shallow, vain, and in the midst of a temper tantrum when she first
meets Rhett Butler. As Blanche Dubois in Tennessee Williams’s A Streetcar
Named Desire (1951), Vivian Leigh also plays a histrionic personality. In this
instance the course of the disorder is more invidious, and by the end of the film,
Blanche is decompensating into psychosis.
202 STEVEN E. HYLER

Perhaps the best male portrayal of a histrionic personality is Jackie Gleason’s

Ralph Cramden in the 1950s TV series The Honeymooners. Gleason’s portrayal of
a short-tempered bus driver from Brooklyn demonstrates that histrionicity is by no
means an exclusively feminine trait in films.
Narcissism, too, abounds in Hollywood, as do cinema portrayals of characters
with narcissistic personality. There is a plethora of films depicting the male
narcissist who preys on women: Michael Caine’s A&e (1966), Warren Beatty in
Shampoo (1973, and Richard Gere in American Giggolo (1980) are representative
of the type. They are portrayed as exploitative, grandiose, preoccupied with
themselves, and manipulative. Other films have shown that people with narcissistic
personality may achieve great prominence, importance, or power, examples being
Orson Welles in Citizen Kane (1941), Peter O’Toole as Lawrence ofArabia (1962),
and George C. Scott as Patton (1969).
The best cinema portrayal of borderline personality is in Looking for Mr.
Goodbar (1977), based on the novel by Judith Rossner. The character played by
Diane Keaton is shown getting into impulsive, destructive relationships with men
whom she meets while cruising bars at night. The men, played by Richard Gere and
William Fraker, among others, also demonstrate traits of borderline personality,
including affective instability and frequent displays of temper.
Other excellent film portrayals of borderline personality are to be found in
Scorcese’s After Hours (1985), in the characters played by Teri Garr and Rosanna
Arquette. Though the plot of Frances (1982), with Jessica Lange in the starring
role, pictures the character as a victim of psychiatry, there are several clues to an
underlying borderline personality. Frances is shown throughout the film to be
impulsive, as in her first marriage, to have temper tantrums, to abuse alcohol and
amphetamines, and to exercise terrible judgment concerning the consequences of
her behavior.
Antisocial behavior is pervasive in the movies, and antisocial personalities are
extremely common. An artistic portrayal of the type is seen in Kubrick’s A
Clockwork Orange (197 1) in the character of Alex (played by Malcolm McDow-
ell), who is shown participating in “ultraviolent” acts against others for which he
experiences no remorse. Though this character certainly meets the full criteria for
antisocial personality, the fact that he is under 18 might make the diagnosis
“conduct disorder.”
In contrast to characters with the personality disorders described above, those
with avoidant personality generally are distressed by their maladaptive traits.
Perhaps the most extreme portrayal of avoidant personality is Woody Allen’s Zelig
(1983). Zelig, a human chameleon, desires acceptance to such an extreme that he
adopts the features of everyone with whom he comes into contact: in the presence of
obese men, he becomes obese; in the presence of Nazis, he becomes a Nazi; and in
the presence of his psychiatrist, Eudora Fletcher (played by Mia Farrow), he
becomes a psychiatrist. As is usual in Hollywood, the two principal characters fall in
love, the patient is “cured” of his affliction, and he and his psychiatrist live “happily
ever after.” Bette Davis, as Charlotte Vale in Now Voyager (1942), is troubled by
excessive shyness and reluctance to enter into new relationships; she is eventually
“cured” by her psychiatrist, played by Claude Raines, who suggests that she
embark on a cruise.
Dependent personalities often become involved in self-destructive relationships
DSM-III AT THE CINEMA 203

with people with serious personality disorders of their own, including sociopaths,
sadists, and narcissists. In Sophie’s Choice (1982), Meryl Streep, as Sophie, is
shown in a dependent relationship with Kevin Kline’s Nathan, already discussed as
suffering from bipolar disorder. When the relationship is sado-masochistic, as is
frequently the case, the boundaries between dependent and masochistic (self-
defeating) personalities may be blurred. Examples of film characters with depen-
dent personalities involved in sado-masochistic relationships are presented in
Cavani’s The Night Porter (1973) and Lynche’s Blue Velvet (I 986).
The compulsive personality is best caricatured by the character Speck in the Star
Trek films (1980s) and the earlier television series (1960s). Speck is portrayed as a
man (?) of pure logic who displays perfectionism, excessive devotion to work and
duty, restricted display of emotion, and marked difficulty in decision making unless
all the data are computed. Another character with compulsive personality, with an
emphasis on fanatic orderliness and cleanliness, is Felix Unger in the movie The
Odd Couple (1968) and the subsequent TV series (1970s).

EATING DISORDERS
Eating disorders are represented by two recent, made for TV movies of the
“disease of the month” genre, in which a character and a story are built around a
particular disorder of topical interest. Anorexia nervosa is the subject of The Best
Little Girl in the World (1982), and bulimia, of Kate’s Secret (1986). Though all
the clinical features are right out of DSM-III, the dramatic interest of the
characters and the impact of the films leave much to be desired.

OTHER MENTAL DISORDERS AND “NONDISORDERS”

In Hollywood not everything that appears in the first reel to be mental disorder
ends up that way by the time the final reel is run. There are many films in which the
audience is privy to a plot against a character who is presented as suffering from a
mental disorder. The best example is the character Paula Alquist, played by Ingrid
Bergman, in Gaslight (1944). Paula is “gaslighted” into appearing to have an
amnestic disorder that progresses to a dementia complete with memory impairment
and visual hallucinations. In truth, since she stays in the destructive relationship
with her husband, played by Charles Boyer, and allows herself to be manipulated,
her condition might better be diagnosed as dependent personality. Other films in
which the audience is aware of the truth, but in which a character appears to be
suffering from paranoid delusions, include Coma (1978), Rosemary’s Baby ( 1968),
and The Stepford Wives ( 1974).
It is uncertain whether the producers of Invasion of the Body Snatchers (1956
and 1978) were aware of the existence of the Capgrass Syndrome. Nonetheless,
their portrayal of a rapidly diminishing number of “sane” people who are aware of
the existence of “pods” from outer space that germinate into exact physical replicas
of people (who disappear) truly concretizes this rare syndrome.
In The Miracle on 34th Street (1947), Kris Kringle is brought to the attention of
psychiatrists and forced to submit to psychological testing and, ultimately, psychiat-
ric hospitalization because of his belief that he is Santa Claus. The audience, and a
young Natalie Wood, are not swayed: they are well aware that he is more than just a
“kindly old man with whiskers.” In Capra’s Mr. Deeds Goes to Town (1936), the
protagonist, played by Gary Cooper, is forced to undergo a psychiatric examination
204 STEVEN E. HYLER

because he is too honest and generous and because several nosy neighbors describe
him as being “pixilated.”

FILM INTERPRETATIONS OF THE ETIOLOGY OF MENTAL DISORDERS

Schneider’ has noted that film interpretations of the etiology of mental disorders
suggest that the occurrence of a single traumatic event, usually in childhood, can
predispose a person to later development of a mental disorder. This is certainly the
case in The Three Faces of Eve (1957), in which the event is the family’s forcing the
young girl to kiss her dead grandmother at the funeral, or in Spellbound (1945), in
which, as a boy, the character played by Gregory Peck developed the seeds of a
“guilt complex” when he accidentally killed his brother. Severe traumatic incidents
are also shown to lead to mental disorder in The Snake Pit (1948) Ordinary People
(1980), Home of the Brave (1949), Suddenly Last Summer (1959), and Possessed
(1947).
The theme of the “schizophrenogenic mother” who appears to be seriously
mentally ill herself, and who induces severe emotional stress and later development
of mental disorder in her child, is seen in Sybil (1980), Carrie (1976) and, to some
extent, in the narcissistic mother of Frances (1982). In the semidocumentary Fear
Strikes Out (1957), it is his father’s negative influence that induces the nervous
breakdown in the baseball player Jim Piersall, played by Anthony Perkins.
Filmmakers occasionally rely on supernatural forces to explain the appearance of
signs and symptoms of mental disorder. Thus, in Agnes of God (1985), Agnes’
symptoms and behavior may have been divinely inspired; and in The Exorcist
(1973), “the devil made her do it.”
From the standpoint of psychiatry, a more ominous etiology of mental disorder as
portrayed in films is that in which the psychiatric establishment classifies “normal”
but eccentric people as mentally ill and then seeks, through therapy to make them
conform to that definition, thus causing them to lose their individuality and
creativity, as in A Fine Madness (1966), or their freedom and, ultimately, their
lives, as in One Flew Over the Cuckoos' Nest (1975). The latter film is particularly
irksome because the character of R.P. MacMurphy, played by Jack Nicholson,
would clearly, in DSM-III terminology, be identified as a malingerer who perhaps
has an underlying antisocial personality. Moreover, in the film almost none of the
other “patients” display recognizable symptoms of any DSM-III disorder. Holly-
wood’s solution is to turn the tables on the psychiatric establishment by “freeing”
the patients, who are more insightful than their “keepers” and would therefore
create a better world-see King of Hearts (1966).

THE TREATMENT OF MENTAL DISORDERS AS DEPICTED IN FILMS

Psychiatric treatments in films are as varied as they are in real life; only the
results are different.
The efficacy of psychotherapy, especially when supplemented by either hypnosis
or narcosynthesis, is well documented in films. In Spellbound, The Snake Pit, The
Three Faces of Eve, Suddenly Last Summer, Captain Newman, M.D., and
Ordinary People, we see the “Dr. Marvelous” brand of psychotherapy practiced.
Nightmare Alley (1947) and Dressed to Kill (1980), however, show that psycho-
therapy can be hazardous to one’s wealth and health.
DSM-III AT THE CINEMA 205

In films a cure often occurs serendipitously, as in the therapeutic friendship

between two emotionally disturbed adolescents in David and Lisa (1963), or as
occurs in the support group of friends in Mazursky’s An Unmarried Woman (1977).
In The Snake Pit, the shock of being placed in the company of more seriously ill
mental patients contributes to the protagonist’s remission-a sort of “scared sane”
phenomenon analogous to the “scared straight” technique of exposing juvenile
delinquents to hardened criminals.
Psychotropic medication as shown in films more frequently leads to unhealthy
addiction, e.g., in I’m Dancing as Fast as I Can (198 I), or to severe side effects, e.g.,
in One Flew Over the Cuckoos’ Nest, than to alleviation of symptoms of mental
disorder. In Frances, however, we see the patient responding miraculously to a
single injection of the then-experimental drug reserpine.
Other somatic therapies fare even worse than medication in the movies. Though
electroconvulsive and insulin coma therapy are frequently portrayed-for example,
in Frances, The Bell Jar, and . . . Cuckoos’ Nest-I am aware of no film other than
Fear Strikes Out in which this effective therapy is shown to help patients. Instead,
such treatments are portrayed as “punitive or unfeelingly scientific, virtually as
crimes against humanity.“’ Behavior therapy as depicted in A Clockwork Orange
( 197 1) suffers a similar interpretation.

CONCLUSIONS
Few generalizations can be made concerning the accuracy of portrayals of mental
disorder in commercial films, yet a surprisingly large number of such portrayals are
reasonably accurate. In fact, many of the films cited here might be used by medical
students and residents in psychiatry as supplements to readings on diagnosis.
On the other hand, at least several influential films present a distorted picture of
mental disorder, a conception of what the film-maker believes or imagines mental
disorder to be. This should surprise no one: consider the inaccuracy with which other
occupations and situations are portrayed in films. Is the practice of law really like
what we see in And Justice for AI1 (1979), The Verdict (1982), or Legal Eagles
(1985)? Do films such as Serpico (1973), Dirty Harry (1971), Prince of the City
( 198 1), or The Untouchables (1987) truly depict the operations of law-enforcement
agencies? On balance, psychiatry seems to fare fairly well in films. Few psychia-
trists would find fault with films such as The Seventh Veil, The Three Faces of Eve,
or Ordinary People.
Should the profession vehemently object to negative and inaccurate portrayals of
mental disorder and its treatment such as those in . . . Cuckoos’ Nest, Frances, or
Lovesick? Would it do any good? Would such protests be seen as defensive or
self-serving? Should psychiatrists participate in producing more documentary-type
films, or might the result be more films like The Titicut Follies (1967)?
It is important, I believe, for psychiatrists to be aware of how their profession is
depicted in films, since this is often how our patients, and their families, form their
image of us. In many instances awareness of these images may help us understand
the resistance of patients and/or their families to medication or other types of
therapy, or their unreal expectation, nourished by films, that they will be rapidly
cured once we dramatically uncover the single traumatic event that has caused their
illness.
206 STEVEN E. HYLER

REFERENCES
1. Schneider I: Images of the mind: Psychiatry in the commercial film. Am J Psychiatry 134:613-620,
1977
2. Schneider I: The theory and practice of movie psychiatry. Am J Psychiatry 144:996-1002, 1987
3. Greenberg H: The Movies on Your Mind. New York, Saturday Review Press, 1975
4. Dervin D: Through a Freudian Lens Deeply: A Psychoanalysis of Cinema. Hillsdale, NJ, The
Analytic Press, 1984
5. Gabbard GO, Gabbard K: Countertransference in the movies. Psychoanal Rev 72:171-184, 1985
6. Gabbard K, Gabbard GO: Psychiatry and the Cinema. Chicago, University of Chicago Press,
1987
7. Knight A: The Liveliest Art. New York, Macmillan, 1957, pp 112-l 16
8. Musto D: When it comes to drugs, beware the censor’s fix. The New York Times, Arts and Leisure,
28 June 1987, p 17