Oct 23: A Nightmare on Elm Street (1984)


A Nightmare on Elm Street is a slasher film set in the fictional town of Springwood, Ohio. The plot revolves around Alice and her teenage friends who are stalked and killed in their dreams by the omnipresent, blade-gloved Freddy Krueger. The reason behind Freddie’s rampage lies in the parents’ sinister secret from years ago.

The greatness of Craven’s film is that the identification with the characters doesn’t end with the movie’s final scene. Instead, it continues following the movie. As anyone whose had a nightmare after watching this film will attest, it’s the moment after you wake up from the terrifying dream that is potentially horrifying, as it is then that you’re put in the exact same position as the main characters.


As the title implies, A Nightmare on Elm Street (Nightmare) depicts Nightmare Disorder (ND); repeated awakenings with recollection of terrifying dreams, usually involving threats to survival such as being hunted by a child murderer. Upon awakening from her nightmares, Alice is alert and able to recall the dream in detail. These details differentiate ND from Sleep Terror Disorder. With sleep terrors, there is no detailed recall of the dream. While the above sleep disorders (parasomnias) are in the differential diagnosis for what ails the teenagers in the film, so too is a dyssomnia.

Dyssomnias are disturbances in the quality, amount, or timing of sleep. While a discussion of sleep stages is beyond the scope of this blog, the movie is about a recurrent nightmare (REM sleep) that invades the teenagers’ wakeful states. In this way, Nightmare is a metaphor for a dyssomnia defined by REM invasion into the beta state (wakefulness), specifically, Narcolepsy. Narcolepsy usually has its onset in adolescence (e.g. Alice), is characterized by hallucinations (seeing the boogeyman), and is genetically predisposed. Metaphorically, Alice and her friends carry the (genetic) burden of their parents.

While it is established that Freddie Krueger was a child murderer, the backstory is that he’s afflicted with Pedophilic Disorder. His having a paraphilia provides depth to Nancy’s character. Tina, Glen, and Rod are all murdered in bed, the location being symbolic of Freddie’s sexual disorder. While the history of Freddie as a child murderer is ultimately provided by her mother, Nancy’s discovery is metaphorical of the recovery of her lost memories. When Freddie is pursuing her, she runs to the basement of her home which looks distorted, a product of derealization likely due to anxiety. One focus of Nightmare is the distinction between dreams and reality. Given the film’s ability to transgress “the boundaries between the imaginary and real,” Nancy’s experience in the basement may be a nightmare (sleep) or a flashback

(wakefulness) that is cued by the situation. Specifically, she was likely imprisoned in Freddie’s boiler room (basement). Unlike the other characters, Nancy is “kept alive” by Freddie, and slowly learns the truth/etiology about her nightmares. Freddie considered her special in some respect. Nancy’s mother, Marge, kept Freddie’s hat and glove; bizarre behavior if Freddie was “just a child murderer.” Years prior, Marge likely had an affair with Fred Krueger (which would be consistent with her having separated from her husband in present day), but had a blind eye to her boyfriend’s conduct towards her daughter. Alice and her friends are victims of the sins of their parents.

Nightmare then is not merely about Sleep and Awake Disorders such as Nightmare Disorder or Narcolepsy. Alice’s sleep pathology is likely due to Posttraumatic Stress Disorder, having been a victim of childhood sexual abuse.

Oct 12: Final Destination (2000)


On this date, October 12, 1997, John Denver was killed when his plane crashed into Monterey Bay near Pacific Grove, California. Final Destination (2000) is the first installment in the Final Destination series, a franchise of horror films involving premonitions. Unlike other horror movies, the franchise is iconic for portraying Death as the major antagonist. Specifically, the movies build on the concept that “cheating” Death is impermissible and thus, death is unavoidable.

The film chronicles the events that unfold after Alex Browning, a high school senior, and his classmates board a plane to Paris for a school trip. Shortly before departure, Alex Browning has a premonition of the plane exploding, causing him to frantically warn everyone about the flight. After being escorted off the plane by security, Alex and several of his classmates soon learn that his vision would come to life. The students’ relief of not being on the plane quickly turns to anguish as they attempt to evade Death’s final ultimatum.


The plot of Final Destination revolves around the concept of premonitions; a term used to describe a psychic ability to see into the future. Specifically, Alex’s vision of his plane exploding allows him and several of his peers to “cheat” Death by avoiding an untimely demise.

As an otherwise well-functioning high school senior, Alex’s premonition calls into question his ability to see into the future. Similar tropes in other movies, such as Donnie Darko, portray psychosis as a core sign of major mental illness (schizophrenia and delusional disorder). However, new onset psychosis as part of a psychiatric disorder is viewed as a diagnosis of exclusion. Therefore, one must consider a vast array of possible etiologies for Alex’s premonition.

Hallucinations that occur while falling asleep are termed “hypnagogic.” These disturbances in reality occur while one transitions from the awake to sleep state. Commonly associated with narcolepsy, hypnagogic hallucinations often occur in adolescents and are indistinguishable from reality. Other potential causes for altered reality in Alex include substance ingestion. According to the National Institute on Drug Abuse (2014), 27.2% of high school students surveyed reported use of an illicit drug. Hallucinogens, inhalants, and other illicit substances are well-documented causes for psychosis in teenagers.

Following Alex’s premonition, unusual events begin to unfold in the lives of others on the plane. The events are forewarned by “Rocky Mountain High’ throughout the film, reminding the survivors that John Denver died in a plane crash. Thirty-nine days after the plane explosion, a memorial service is held for victims of the tragedy. Later that evening Alex’s friend, Tod, was found strangulated to death in his bathtub. The film depicts his death as a series of events beginning with a leaky toilet; the water on the floor causes him to trip into a clothesline ultimately leading to death by strangulation. Tod’s cause of death is ultimately ruled a suicide.

Posttraumatic stress disorder (PTSD) is a psychiatric condition triggered by exposure to life- threatening or horrifying personal experiences. It is characterized by persistent re-experiencing, hypervigilance, and avoidance of stimuli associated with the traumatic event. When these symptoms last longer than one month, it is diagnosed as PTSD. Acute stress disorder (ASD) is a similar diagnosis when symptoms have persisted for less than one month. PTSD carries a significant association with suicidal attempt. Perhaps Tod truly suffered from an underlying anxiety disorder stemming from the plane explosion he witnessed. One could argue that Tod’s death was a consequence of his untreated psychiatric disorder, PTSD.

Finally, the concept of Death as a personified entity has played a role in many films (The Ring, 2002) and mythologies. For Alex and several other characters in the movie, Death plays a prominent role in their daily functioning. Throughout the movie, these characters work together to outsmart Death and prevent their demise. Their constant belief in this embodiment, despite no factual evidence of its existence, relates to the psychiatric condition termed delusional disorder.

Delusional disorder is the presence of one or more delusions (fixed, false beliefs) that last for at least one month. These beliefs cannot be due to a psychotic disorder (schizophrenia), mood disorder, substance use (e.g., cocaine), or other medical conditions (e.g., infections, dementia, endocrinopathies). Alex’s fixed belief in the presence of Death is consistent with a plausible delusional disorder diagnosis.

The franchise moves forward with Final Destination 2, which picks up with Clear (the last survivor of the plane explosion) voluntarily admitted to a psychiatric hospital. Evidently the role of psychiatry in the franchise is not solely implicit after all.

CUBE (1997)


Cube is a SciFi horror film about a group of ‘subjects’ who awaken in a room with anterograde amnesia as to how (or why) they got there. The characters discover that their new prison cell is one of 17,576 rooms that form a government-sanctioned cube with booby-traps that impede their search for an exit. The strangers must overcome significant trust issues and work together to solve the puzzle of the cube to gain their salvation.


The original group of 4 characters finds Kazan, an occupant of the cube who is stricken with an adult autistic disorder, likely Asperger’s syndrome. Two psychiatric comorbidities affecting people with Asperger’s syndrome include Social Anxiety Disorder (SAD) and Posttraumatic Stress Disorder (PTSD). Cube serves to review these 2 disorders through analysis of its 2 main characters. The group travels silently through a room with a sound-activated trap. After Kazan makes a sound and nearly causes Quentin’s death, Quentin threaten’s Kazan. This interaction moves the narrative forward, as these 2 characters symbolize the yin-yang of the group’s efforts to escape.

Affecting 1 in 68 children (CDC, 2014), individuals with an autism spectrum disorder have high levels of psychiatric comorbidity including SAD. The film serves as a metaphorical platform to discuss the treatments for SAD including group therapy, flooding (in vivo exposure therapy), and novel psychopharmacological therapies such as 3,4-methylenedioxy-methamphetamine (MDMA). MDMA (ecstasy) produces effects characteristic of psychedelics (hallucinogens) and amphetamines. Renewed research interest in MDMA and anxiety builds on earlier studies of lysergic acid diethylamide (LSD) and psilocybin in treating autistic minors (misdiagnosed as having childhood schizophrenia). The drug’s hallucinogenic effect may also explain Kazan’s subjective reality of being imprisoned in the cubic colossus.

Another comorbidity of Asperger’s syndrome is PTSD. This illness is likely depicted by Quentin, a police officer. NMDA inhibits the activity of the left amygdala (lessens the fear response) while increasing the activity in the prefrontal cortex (Mithoefer, 2011) thus dampening the conditioned fear response. [Spoiler Alert] Kazan and Quentin are the last men standing, with the former leaving through the hatch into the bright light, a metaphor for a breakthrough in psychotherapy.

Last week’s movie: 30 Days of Night (2007)
Next week’s movie: A Perfect Getaway (2009)