Psychiatrist Breaks Down Psychotic Episodes In Movies GQ

Okay. Do you want to play rough? Okay. Say hello to my little friend. They said hello to his little friend. That's actually a line that's kind of funny because cocaine can also cause erectile dysfunction. That's something to just keep in mind while this is going on too. Hey GQ, I'm Dr. Eric Bender. I'm a psychiatrist who specializes in child, adolescent, adult, and forensic psychiatry. And this is The Breakdown. First up, Fight Club. For six months, I couldn't sleep. I couldn't sleep, I couldn't sleep. With insomnia, nothing's real. Right away, the narrator talks about being sleep deprived, insomnia for six months. When you are sleep deprived, you do not think clearly. In fact, it's considered unethical to sleep deprive someone more than 48 hours. In some places, sleep deprivation is considered a form of torture. Everything's far away. Everything's a copy of a copy of a copy. You can see that quick flash of Tyler Durden coming up and he's saying everything's a copy of a copy of a copy and you see him kind of sleeping. Fight Club is, I'm guessing purposefully, unclear as to what is going on with the narrator. Here, you see him have this hallucination. This is very common with sleep deprivation. When you have sleep deprivation, you can first start to get very confused. And then after time, you can have some delusions and some hallucinations. And the hallucinations in sleep deprivation can be complex. You can actually have auditory and visual hallucinations. You can actually have distortions, even of your own body, sensing that your body is changing. And as we know, the narrator looks quite different from Tyler Durden. So there's quite a change in how he appears. You can also believe you are someone else. In fact, in studies of sleep-deprived individuals, some of them said, I felt like I was another person. A lot of themes in Fight Club have to do with consumerism and belonging. The idea that a club, a place to belong, here you have this group of men fighting each other and beating each other to a pulp. You have to wonder if they're getting in some nice shots to the head, and does that actually make people have more delusions or more hallucinations? In the beginning of the movie, after he goes to the group, there is a moment when he cries and then he sleeps. There can be a very cathartic experience, meaning this release of something that helps you move on with it in your life. It can be a release of emotions when you cry, and it doesn't surprise me that he would sleep. The data show you actually need to sleep about 50% of the time you've been deprived in order to get back to a baseline functioning cognitively and behaviorally the way you were before. He clearly didn't do that, and maybe that's why we actually see Tyler Durden more and more present, because he's more and more sleep-deprived. There was a study that was done showing how people that were sleep-deprived responded to certain texts, just reading texts. Those that were sleep-deprived for about 35 hours looked at the texts, and they actually did a scan of the brain. They showed that the connections between the amygdala, where your emotions are kind of centered in your brain, and the frontal cortex, where you can actually organize them and keep stable, it doesn't connect the way it should when your sleep state is actually good. When you're sleep-deprived, there's not a connection, and instead you go into this fight-or-flight reaction, and fight, club, or flight, I guess, is more appropriate in this case. Next up, Scarface. **** you with this! This is Tony Montana, who's become this cocaine emperor, essentially. He is so high that he has missed on the screens earlier that all these people are invading his home. He's also becoming more and more paranoid throughout the movie. When Tony's talking to his sister here, it's possible that that's some of the psychosis he's experiencing, that everything's gonna be fine as he's talking to his dead sister. He's now got this incredible drive to kill everybody around him. This is cocaine-induced psychosis, quite possibly, or at least the effects of using cocaine. Cocaine's a drug that can make someone feel like they have more energy. It increases the dopamine in the system by blocking dopamine from being taken up by the brain, and dopamine is the pleasure chemical that your brain makes. It also can make you feel more confident. It can make you feel paranoid and delusional. So throughout the film, we've seen Tony get more paranoid. Here, he's pretty delusional. He's gonna take down all of these agents while they're coming into his house. Before this, you've seen a mountain of coke on his desk, and he's just snorting it or even dropping his head into it. So there's definitely some cocaine on board. You wanna play rough? Pause here. There is the delusion that he's gonna just take everybody out himself. They said hello to his little friend. That's actually a line that's kind of funny because cocaine can also cause erectile dysfunction. That's something to just keep in mind while this is going on, too. Again, violence is not inherent for people who have mental illness. There are certain situations where violence can occur. We've talked about when somebody might have a delusion and they wanna protect themselves, and it's an acute psychosis issue. Another place where you might have more violence is actually with substances, and cocaine is one of those. You can get more aggressive. So grabbing a grenade launcher certainly is a sign of aggression. Tony's reaction here, the cocaine is working in his system. He's not feeling like he's doing anything wrong or out of the ordinary. He's also defending his house. Cocaine was used as an anesthetic originally. When he gets shot, many times, it's interesting that he doesn't necessarily fall down right away, but stays upright. Was it that much of an anesthetic? I doubt it, but that was likely more Hollywood. It does actually have some anesthetic purposes. We don't use it for that anymore, obviously. Black Swan. Here we see Nina, who's working really hard, and she's not feeling quite herself. Suddenly in the mirror, it seems like her movements are not happening in real time. That can illustrate an illusion. She might see something go, but it looks like it's larger than it is, or it looks like somebody that she doesn't know. A hallucination would be if it weren't there to begin with. It's not clear exactly what's happening. There's so many factors contributing to why she might be experiencing this. She has this overbearing, overprotective mother, this competitive frenemy. There's some stress levels that are going up. There's also some hints that she has an eating disorder, and when your brain is not fed or nourished, you don't think clearly. So it's possible that all this is contributing to how she's seeing the world around her. That Nina's seeing her reflection differently, that could be more of an illusion that she's seeing her reflection, which is there, but it appears distorted. I don't know that there's any particular significance to the fact that she's seeing herself, other than she's now been really, really focused and obsessive about things, and there does seem to be a level of obsession that can be almost psychotic. It's delusional, that you need to do this or else this is gonna happen. You're gonna lose your part. You're gonna not have friends, whatever it is. So there can be a level of anxiety that almost seems delusional, and maybe she's experiencing that along with seeing these other things. When someone has body dysmorphic disorder, they see their body differently than it actually is. Someone might focus on their ear and think their ear is not formed correctly and see plastic surgeons and wanna change it, and they just don't see how their body's shaped the way it actually is. If she has some form of this, it would make sense that she's not seeing how her body looks in the mirror properly, but this looks more to be like a hallucination or an illusion because it's doing things differently. It's actually moving differently. If Nina is sleep deprived, too, from all the work and time she's putting into her dancing, that can also generate some of these possible hallucinations and worries in the way she sees herself. Shutter Island. Put them at the table, Andrew. We'll dry them off. We'll change their clothes. They'll be our living dolls. Here we see Dolores having just committed this horrible crime. She's talking about her kids who are deceased as if they can be living dolls. She has had a history in the movie of bipolar disorder. That's what they're at least suggesting. In bipolar disorder, you can have psychotic symptoms, too. You can have hallucinations, and it sounds like she either had hallucinations or some delusional beliefs about killing her children. It's not clear exactly what was going on. Was there a command auditory hallucination that told her to do this? Was it delusional thinking? She is really delusional, though, and you can see how Andrew's responding here really upset. Colleague of mine had a 14-year-old boy who was psychotic, and the boy actually asked him, so am I gonna become a serial killer now? That's not what we need to teach people, that because there's mental illness, there's violence. There are some states during which someone with mental illness could be prone to violence, but it's not because they're prone to being violent. They might be trying to defend themselves because of a delusional belief. That kind of violence is actually often most occurring at home. The likelihood of being hurt by someone who's got a mental illness is way less than getting struck by lightning. Set me free. I love you so much. I love you. When Dolores says, set me free, it is possible that she's letting us know just how much she's struggling in her life. What Andrew ends up doing in killing her, he then ends up in this forensic setting on Shutter Island. That's a little unlikely in reality. He knows what he's doing. He knows what he's doing is wrong, and he's even crying about killing her after, crying about the kids. He knows what's going on. That means you would not qualify for a not guilty by reason of insanity defense. That's actually even applied in less than 1% of the cases, and a small fraction of that even go through. That doesn't mean that someone is getting off scot-free. What that actually means is someone goes to a forensic hospital where they're treated for the mental health issue that was present at the time of the crime to help them. In some cases, that amount of time takes longer than someone would have served time in a prison or jail for the crime they committed. What I think happens with Andrew is that he has a traumatic reaction. He realizes what he's done. It's so heinous to him that he dissociates, meaning he is not in touch with what is going on in the world. He's not in touch with many things, and this exercise on Shutter Island would be almost a depersonalization, that he's stepped away, and he's this teddy person in this scenario. This would not happen. Why is he in a forensic hospital when, in fact, he knew what he was doing, knew what he was doing was wrong? He'd probably be in prison. The jumping of the camera angle could possibly represent that now Dolores is recognizing what she's done, so suddenly it shifts from this place where she's not clear about things or maybe had some delusional belief to realizing what happened, because that's when she actually says to Andrew, set me free. Split. You killed me. Wait, wait, wait, wait, wait. No, no, no, no, don't do that. Don't do that. He can't handle reality. The character in Split is showing signs of what is now called dissociative identity disorder. A former term was multiple personality disorder. Typically, someone has had chronic trauma in their lives early on and has dissociated, meaning they've separated from that experience because it's too much to handle emotionally, and another personality develops. It's not another person. It's another personality. An alter is what the name is for that other personality develops, and these alters help the individual deal with the trauma that they've experienced. My name is Jade. Has Dr. Fletcher been getting our emails? This is what we have to do. We can, as in 1008, when Ana de Paula suffered the Shahi's most crushing defeat. So in this scene, we see James McAvoy go through Jade, and then there's another one, and there's Barry. Everybody just take a minute. And then we come to the Beast, the last one that all the other personalities supposedly have been helping to keep these girls captive. Personalities that are alters are there to help the host or the person who has all these alters deal with trauma. They are not going to gather captives for another one of the personalities. This is not a weaponization of an individual. This is a way to cope. As you watch the changes from one alter to the next, you could see there's a difference in how they were speaking. That can actually happen. The research that used neuroimaging to look at the alters showed that the alters function differently in the brain regions. You can have some that have different accents. You can have some that are left-handed, some might be right-handed. You can have some that show physical changes. In fact, when you look at the last change here into what seems to be the Beast finally, it looks as if James McAvoy's almost stronger in some way. In order to have a diagnosis of dissociative identity disorder, you need to have at least one additional alter or a feeling of being possessed. You can have memory lapses, and that can often be believed to happen as you transition from one alter to the other. How fast somebody transitions from an alter, I think this is somewhat of a plot-driven device to have this all come down to this moment in the movie. During therapy, you work with a therapist to ultimately integrate the personalities, but it's not so much about integrating the personalities as it is about processing the trauma that someone has gone through and understanding how this has affected their life, how it's affected their confidence, how it's affected their sense of what's safe and secure. So you really want to work with somebody in a gentle way to go through some of this trauma and as you deal with that, the idea is that some of these alters and these personalities get integrated more into the one host personality. This depiction's highly dramatized. You can have up to 100 personalities. This character has 23. The average is 10 from the literature, and some of the literature suggests the personalities can start to develop as early as age 5.9. It's realistic in the sense of having multiple personalities in the one host. The violent piece is not accurate. You're not gonna have a personality that is just out to be violent. Again, it's gonna be more protective. There might be a personality that has beef with the other personalities or other people that are in the person's life, but you're not gonna have somebody who's gonna go out and just wreak havoc. Legally, if someone actually did commit a crime, just because they have dissociative identity disorder doesn't mean they would go to a forensic hospital or meet criteria for not guilty by reason of insanity defense. You look at whether that alter knew right and wrong and knew the nature and quality of what they were doing. Primal fear. Is Aaron Stampler capable of murder? No, he is not. He is far too traumatized to express normal anger and frustration. He keeps his emotions repressed, which is why he created Roy, who is capable of such a crime. Objection, your honor. The idea that when he's in trouble, he calls you, that does fit an idea of if someone were to have dissociative identity disorder, that a personality would be protective. It's a way of dealing with trauma. So it loosely fits that idea that there's some protection from the alter. What's not accurate in primal fear is the way this plays out. No further questions, your honor. Where the hell do you think you're going? Excuse me. Aaron's on trial, and suddenly this Roy alter comes up and threatens someone in the court. The judge ends up ending the trial mid-jury and saying, let's adjudicate this not guilty by reason of insanity. Aaron goes to a forensic hospital. In reality, even if it were legally okay to stop a trial mid-trial and change the way it's functioning, California, the legal statute is, do you know what you're doing or do you know what you're doing is wrong? Roy knew what he was doing, knew what he was doing was wrong. Even if at the end of the movie he reveals that he's faking the way he's doing in the movie, he wouldn't go to a forensic hospital. They make it so that it can't be changed in the movie, but again, the direction it goes is just a little off. There are actually measures you can do when you interview someone to make sure they're not faking. This character's doing what's called malingering. That's presenting as if you have mental illness, faking it, essentially, in order to get something, usually what's called a secondary gain, meaning something outside yourself like food, clothing, shelter, or a different treatment. In this case, to not go to prison and go somewhere else. If the ruling becomes not guilty by reason of insanity, the individual would go to a forensic hospital and have their mental health issue treated. Malingering does happen, and there are ways to detect whether or not someone is malingering, and that's very important. That's an important role for a forensic psychiatrist, to interview someone and make sure there's not evidence suggesting that the person is feigning symptoms just to get something. The Dark Knight Rises. I told you I was immortal. Here, Batman, Bruce Wayne, has just had his back broken by Bane. He's alone, so there's a question of is the solitary confinement, so to speak, has that caused him to have some hallucinations? What this actually could be is delirium. Delirium's a state where your thinking is waxing and waning, meaning sometimes it's accurate, sometimes it's not, and it can happen with pain, it can happen with infection. It often happens in the hospital and the ICU for patients, particularly at night. It can be called sundowning, where at night, suddenly, somebody's completely restless, tries to rip out all the IVs that they have, maybe rip out a Foley catheter, and that's part of delirium. It's this changing in their cognition. That might be part of what's going on. Bruce Wayne's getting ideas about Ra's al Ghul. He might be seeing him. Hallucinations can occur. That's my thought on why he might be experiencing this the way he is. On the way to sleep, sometimes your thoughts get all strange. They call that hypnagogic hallucinations, where things kind of seem strange, and when you wake up, it's called hypnopompic. It's possible if he's delirious, where he's kind of in and out of thinking clearly, maybe his thoughts are all getting mixed together. In the same way when you're on your way to sleep and you sometimes get an idea for something, you could have an idea like this come up when you're delirious. It's just unclear whether you'd actually remember it or who knows exactly what's going on in someone's mind when this occurs. It's also possible that Bruce Wayne's experiencing sensory deprivation hallucinations, meaning that he hasn't been in touch with anything in this solitary confinement that he's in. The pain that he's experiencing can also be contributing to him possibly having hallucinations. Pain can be a reason why people have hallucinations in multiple settings. When they experience that much discomfort from pain, that can really cause some psychotic symptoms at times. Old boy. Here we see Dae-su, who's been kept in this room and not been allowed to get out. He starts to see that there are ants coming out of his skin and all over his body. That is a visual hallucination, meaning he's seeing something that's not there. It's actually a particular type. There's a name for this. There's something called Ekbom syndrome, which is when you believe that you're infested with parasites. Now, ants aren't parasites. And I think ants represent something particularly in this film. But the idea that there's something infesting you, some kind of parasite, is a delusion. So that's a delusion, meaning that you believe something that's not true. Visual hallucinations are more common with drugs and substance use, particularly stimulants. But there might be something that is happening here we don't see. We don't see what he's being given. We know that the captors in his mind want to take him out of the room at times and bring him back. They probably do this through drugging him. So this could be a visual hallucination due to whatever he's being given. Another delusion that Dae-su might be experiencing is Cotard syndrome. There's a range of things that someone with Cotard syndrome can believe, but you can believe you're rotting to death or you can actually believe you're dead. And in the end here, we see him dying. These are hallucinations that he's seeing too. So this is a psychotic issue he's having. So at first, when you see Dae-su itching, that's actually a term called formication. And again, that can be from drug use. You might remember the Chappelle show where he's itching all over the place after using crack. Yeah, that's the idea. Formication, you itch all over the place. And often it's because you think it's due to things crawling on your skin. When someone is left in solitary confinement, they can develop hallucinations. There are all kinds of research that has been done in the correctional population showing even that after a few days, you can have some kind of hallucinations in solitary confinement. After 15 days, there's a consideration of it not being ethical. And there's some research that suggests even after a short amount of time, you could have permanent mental health issues as a result of solitary confinement. Hallucinations are things that aren't really there. So you won't die from a hallucination. You could die if you acted on something because of delusional thinking or because of paranoia and you act on something, then you could die. It's actually extremely important to ask patients who are psychotic about suicide. Just because they have psychosis doesn't mean they also have other symptoms of mental health issues. In about 15% of suicides, psychotic thinking or psychotic belief was involved. Thanks so much for watching these clips with me. I hope you learned something. Until next time.