Salem, Massachusetts

Destination 4: Salem, Massachusetts

In late February of 1692, Reverend Samuel Parris called in a doctor to examine his 9-year-old daughter, Betty, and eleven-year-old niece, Abigail Williams who were suffering from “spontaneous fits.” The children were subsequently diagnosed as victims of witchcraft setting off an outbreak of panic which would sweep throughout Salem Village and become one of the most studied and provocative periods in American history.

Related Film: The Witch (2015)


The Witch (2015) is a historical period supernatural horror film written and directed by Robert Eggers that depicts the trials of Thomasin and her family upon their banishment from a Puritan plantation in 1600’s New England.

How it relates to the field of psychiatry

What is wrong with this picture?

After building a farm by the edge of a large, secluded forest far from the Puritan settlement, Thomasin is caring for her newborn brother, Samuel, when she plays Peek-a-Boo. The game is an exercise in object permanence: the ability of a child (Samuel) to understand that objects exist even if they cannot be seen. In his theory of cognitive development, Jean Piaget believed that infants develop this understanding by the end of the sensorimotor stage. Object permanence is accomplished by placing one’s hand’s over the child’s eyes. In the film, Thomasin (shown) “loses her brother” when she places her hands over her own eyes, thus demonstrating profound deficits in cognitive functioning that is developmentally inappropriate (teenager).

Once one understands that The Witch is a case study of a cognitive disorder, then 3 illnesses should be considered in the differential diagnosis: a) Cognitive Disorders such as dementia (Major Neurocognitive Disorder), b) Psychotic Disorders, or c) Dissociative Disorders. Given her age, Major Neurocognitive Disorder is highly unlikely and therefore may be ruled-out.

At Rutgers Robert Wood Johnson Medical School, the first module – titled Necromancy – of our year-long resident Psychopathology course incorporates ghosts (wraiths) and demons. While the former references disorders that are episodic in nature, tales of demonic possession serve to reinforce teaching points of chronic and persistent illnesses such as the Dissociative Disorders (DD). At the completion of the DD block, participants should appreciate that movies about demonic possession may be metaphorically interpreted as case studies of dissociation. Given the widely-held belief that a witch is a woman who had coitus with the devil, tales of witches may be viewed as accounts of demonic possession. Accordingly, the hallmark characteristic of Dissociative Identity Disorder, a disruption of identity, may be described in some cultures as an experience of possession (DSM-5).

Thomasin experiences a disruption of identity, thus allowing The Witch is be viewed as a fictional case account of Dissociative Identity Disorder (DID). Might this formulation actually explain the origins of the “hysteria” in 1692 Salem? Focusing on the biological antecedents (biopsychosocial), ergotism may have played a role in the events leading up to the Salem Witch trials (Caporael L, Science, vol. 192 Before concluding that DID is the most likely diagnosis, we much first investigate whether Thomasin’s mental status change is not otherwise due to the direct physiologic effects of a substance.

Ergotism is a plant disease that is caused by the consumption of grain contaminated with ergot which is produced by the fungus Claviceps purpurea. Poisoning attributed to Ergot of Rye is referred to as ergotism. Although this fungus is recognized as one species, there are two sets of symptoms: convulsive and gangrenous ergotism (

The clinical features of convulsive ergotism including muscle spasms, mental status changes, hallucinations, sweating, and fever are consistent with the serotonin syndrome. Ergot alkaloids such as dihydroergotamine are serotonin agonists; molecules that bind to serotonin receptors in the brain (mental status changes) and dorsal horn of the spinal cord. (Eadie MJ, Convulsive ergotism: epidemics of the serotonin syndrome?, Lancet Neurol. 2003 Jul; 2(7): 429-34).


Anthony Tobia, MD, Psychation Copyright © 2017 Rutgers Robert Wood Johnson Medical School. All rights reserved.

Gates of Hell – Clifton, NJ

Destination 3: The Gates of Hell, Clifton, NJ

Built as a drainage run-off for Weasel Brook, the Gates of Hell is a tunnel system that has lured and captivated teenagers who have dared to explore what lay deep inside its darkened corridors (

Related Film: Stephen King’s It


Set in the town of Derry, Maine in the 1950’s, Stephen King’s miniseries It depicts a supernatural character, Pennywise the Dancing Clown, that terrorizes a childhood group of friends, the “Losers Club.” Pennywise pulls Georgie to his demise after his paper boat floats into the sewer system deep under the town of Derry. The death of Georgie traumatizes the group and, under his brother’s guidance, they vow to avenge his death and all those devoured by It.

When they hear about a mysterious, unexplained death of a little girl who was brutally murdered 30 years later in Derry, Bill begins to suspect It has returned. They honor their blood pact even if it means re-experiencing their childhood trauma. Stan, the only club member with recall of the events from his childhood, commits suicide, writing the word “IT” on the wall with his blood.

How it relates to the field of psychiatry

It serves as an opportunity to teach the Dissociative Disorders (DD). Much like the presence of the supernatural, demonic (fang teeth and three-fingered creature-like hands) shape-shifter is a chronic reminder of Derry’s sinister past, the DD are severe and persistent mental illnesses defined by a disruption or discontinuity in integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior (1).

Dissociative symptoms occur in the context of traumatic stressors as an attempt to maintain emotional equilibrium, but may result in distress and dysfunction. This is evident in many of the childhood characters in the story. For example, Ben is traumatized by the visions of his dead father (It) trying to lure him into the sewer plant. Eddie struggles with chronic medical illnesses for which he is taunted and harassed. Mike, an African American, has a difficult time transitioning as a new student because of racism and bullying.

In the second half of the story, the losers-as-adults return to Derry to battle the interdimensional predator. All but Stan suffer from severe Dissociative Amnesia, unable to recall the traumatic events of their childhood. They agree to split up and visit the old neighborhood in an effort to recapture their lost memories before It discovers their intentions and devours them. Despite suffering only mild dissociative symptoms, Stan’s completed suicide is a realistic depiction of the impact dissociative disorders can have; an increase risk in suicide attempts among those suffering from DD (2).

The catatonia that Bill’s wife Audra experiences after coming in contact with It’s “deadlights” is a sign seen in extreme cases of dissociation from trauma.


  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
  2. V. Sar and C. Ross, “Dissociative disorders as a confounding factor in psychiatric research,”Psychiatric Clinics of North America”, vol. 29, no. 1, pp. 129’144, 2006


Leya Schwartz, Angela Gitau, and Anthony Tobia, MD, Psychation Copyright © 2017 Rutgers Robert Wood Johnson Medical School. All rights reserved.