Oct 28: Silence of the Lambs (1991)


Following The Texas Chainsaw Massacre (1974), we go back-to-back with Silence of the Lambs, the screen adaptation of the Thomas Harris novel by the same name and sequel to the 1986 film, Manhunter (itself an adaptation of the Harris novel Red Dragon). Both films (as well as the trilogy-completing novel/film, Hannibal) feature Dr. Hannibal Lecter, a brilliant and cultured psychiatrist turned man-eating serial murderer. Silence of the Lambs begins with FBI trainee, Clarice Starling, assigned to interview Lecter in the hope of providing information on a serial killer at large known as “Buffalo Bill” who has murdered 5 women and is believed to be holding a Senator’s daughter. Lecter, who is imprisoned in a “hospital for the criminally insane,” agrees to assist Starling, provided she acts to facilitate his transfer from the facility and discloses details of her troubled childhood. Although Lecter’s assistance proves invaluable in Starling’s search for Buffalo Bill, his ulterior motives eventually become clear.

At Rutgers Robert Wood Johnson Medical School, a triple feature of Psycho (1960), The Texas Chainsaw Massacre (1974), and The Silence of the Lambs is required viewing given that Ed Gein inspired the creation of all 3 films. Ed Gein, the Wisconsin Butcher, was a serial killer and body snatcher who fashioned trophies and keepsakes from the bones and skin of his victims.


Throughout the series, Thomas Harris repeatedly uses early childhood trauma as a catalytic event in producing personality and psychopathology (presented in greater detail in the novels). Notably, Hannibal Lecter, Jame “Buffalo Bill” Gumb, and Clarice Starling have all suffered abandonment by their parents and subsequent trauma.

Lecter was born to a wealthy family in Lithuania where his parents were killed by a Nazi air raid at age 11. He and his sister, Mischa, survived, only to be captured by Nazi sympathizers who murdered Mischa, cooked her remains, and fed them to Lecter.
Buffalo Bill is revealed as having been orphaned by his mother, an alcoholic prostitute, and was in foster care for 10 years before being adopted by his grandparents, whom he later murders. Following the killing of his grandparents, he is sent to an inpatient psychiatric facility where he learns to be a tailor and discovers his issues with gender identity.

Around the age of 10, Starling’s father, a town sheriff, was shot and killed after responding to a robbery. Her distraught mother was unable to provide for her and sent Clarice to Montana to live on the family farm. However, the sound of sheep being slaughtered was too much for her to bear, haunting her dreams into adulthood.

At the outset of the film, Gumb has murdered 5 women, removing swaths of flesh from each of his victims in order to create a patchwork bodysuit made of women’s skin. While Gumb is a crossdresser who has previously been denied gender reaffirming surgery due to psychiatric instability, the vast majority of sufferers of gender dysphoria are not violent toward others, though there is increased risk of self-destructive behaviors, substance abuse, mood disorder and suicide. Gender dysphoria is a new diagnosis to the DSM-5, with distinct differences from its DSM-IV precursor, Gender Identity Disorder. [Notably, the DSM-III (published in 1980 and in use at the time of the book and film) was the first edition to address incongruence between anatomic sex and gender identity specifically denoting a difference between gender identity (self-image) and gender role (outward portrayal of gender).] In DSM-IV, Gender Identity Disorder is classified as a sexual disorder, with diagnosis based on incongruence in identity. The DSM-5 takes a more progressive stance, accepting that gender identity incongruence in and of itself may not be pathological, but that distress arising from such circumstance is a specific diagnostic entity that may necessitate specific treatment goals and therapeutic strategies and social support.

Both Hannibal Lecter and Jame Gumb demonstrate behavior and attitudes consistent with Antisocial Personality Disorder (APD). This personality disorder is characterized by violent tendencies, disregard for laws and social norms, and a failure to feel guilt or remorse. While not all persons with APD demonstrate a propensity for violence, they frequently show blatant disregard for the rights and feelings of others, often acting to exploit others for their own personal gain. While the terms “sociopath’ and “psychopath’ have no consensus definition, they are often used interchangeably in the context of APD. The disorder is often seen with comorbid substance abuse and is common among incarcerated persons, with some estimates nearing 80% of all male prison inmates and 25% of female inmates.

Oct 26: Thirteen Ghosts (Thir13en Ghosts) (2001)


Thirteen Ghosts (Thir13en Ghosts) is a remake of the 1960 horror film, 13 Ghosts, written by Robb White. When the original film premiered, scenes involving ghosts were shown in Illusion-O: audiences received viewers with red and blue cellophane filters, giving them a choice to see the ghosts (look through the red filter) or not (blue filter “removed” the ghosts).


One by one, the 12 ghosts of the black zodiac are released, each of which has a biography rich in mental illness. The film allows for the discussion of Antisocial Personality Disorder from 12 converging perspectives, each explained by the biographies of the 12 ghosts of the black zodiac (Table. 1).

1. The First Born Son

Biography: The First Born Son is the ghost of Billy Michaels, a boy who died when his neighbor shot an arrow through the back of his head while playing “Cowboys and Indians.” In death, Billy is in his cowboy suit and holding a tomahawk, with the arrow protruding from his head. His ghost whispers “play with me.”

Links to psychiatry: Jigsaw (Saw, 2004, “let’s play a game”); Grady twins (The Shining, 1980, “play with us, Danny”)
Billy Michaels allows for the discussion on Conduct Disorder (CD), as both Saw (John Kramer) and The Shining (Jack Torrance) are movies with main characters depicting Antisocial Personality Disorder (APD). Since APD can only be diagnosed in patients 18 years of age or older and requires the onset of CD prior to the age of 15, the boy-ghost illustrates its cardinal sign: a repetitive and persistent pattern of behavior in which major age-appropriate societal norms are violated.

2. The Torso

Biography: The Torso is the ghost of Jimmy “The Gambler” Gambino. One day, Jimmy bet heavily on a boxing match, and tried to slip out of town when he lost. The mob caught up with Gambino and dumped his corpse into the ocean. His ghost is just his torso, trying to walk around on its hands, while his head lies nearby screaming within the cellophane he was buried in. When his eccentric uncle dies, Arthur Kriticos moves his family into a bequeathed mansion haunted by malevolent ghosts. There is literally danger around every corner, as the spells that keep the ghosts at bay are broken, unleashing the 12 tortured souls onto their new landlord and his family.

Links to psychiatry:
The differential diagnosis of clinically significant gambling includes professional gambling, impulse dysregulation elsewhere classified (e.g. Antisocial Personality Disorder), and Gambling Disorder. Individuals with Antisocial Personality Disorder and Gambling Disorder are at risk for incurring debts (e.g. “chasing” one’s losses) as portrayed by Butch Coolidge.

3. The Bound Woman

Biography: The Bound Woman is the ghost of Susan LeGrow, a privileged girl who cheated on the star football player, Chet Walters, at the prom. The next morning, her body was found buried at the 50-yard line. Her ghost dons a prom dress, hanging suspended by Chet’s tie around her neck.

Links to psychiatry: Carrie (1976)
Given the drama at the prom, The Bound Woman is an allusion to Stephen King’s Carrie. While Antisocial Personality Disorder may once again be in the differential diagnosis, King’s 1976 horror film is symbolic of Anorexia Nervosa.

Anorexia Nervosa may be conceptualized in psychodynamic terms as a reaction to the demand that adolescents behave more independently and increase their sexual functioning. Patients then replace preoccupations about eating for other age-specific pursuits. A character analysis of Carrie reveals an adolescent who is unable to separate psychologically from her mother. Her body is perceived as though it is possessed by an introject of an intrusive, domineering and unempathic mother. Starvation serves as an unconscious means of starving and destroying the internalized mother-object.

4. The Withered Lover

Biography: The Withered Lover is Jean Kriticos, the wife of Arthur, the movie’s protagonist. Jean was burned severely while trying to save her family from a devastating house fire, and later died of her wounds. Unlike the other ghosts, she is not a vengeful spirit.

Links to psychiatry: The Hatfields & McCoys
On January 1, 1888, Randolph (Ran’l) McCoy’s house was burned to the ground and numerous family members slain by the Hatfields. Rand’l’s wife, Sally, was badly injured in the fire, and eventually died in a mental hospital (in a hospital gown). The blood feud between the Hatfields and McCoys is one marked by – you guessed it – Antisocial Personality Disorder. However, what’s more striking is the role alcohol played in inducing and perpetuating the families’ personality traits.

5. The Torn Prince

Biography: The Torn Prince is the ghost of Royce Clayton, a gifted high school baseball player with a superiority complex. In 1957, he was challenged by a greaser to a drag race, but was killed when his car spun out of control and flipped over; the cause of the accident was a cut brake line. His ghost carries a baseball bat, and parts of his face and body are torn from when he was dragged under the car.

Links to psychiatry: The Warriors
The Torn Prince is an allusion to the Baseball Furies of the 1979 cult classic, The Warriors. In his thriller, Walter Hill merges Antisocial Personality Disorder with the gang mentality, and sprinkles in some empathy (the Warriors) to create audience ambivalence.

6. The Angry Princess

Biography: The Angry Princess is the ghost of Dana Newman, “someone so ugly on the inside, she couldn’t bear to go on living if she couldn’t be beautiful on the outside” (Se7en, 1995). Her preoccupation with perfection leads her to find employment with a plastic surgeon, where her wage was paid in cosmetic surgeries. When a self-inflicted procedure goes horribly wrong, she commits suicide. Her naked ghost is holding the very knife she killed herself with.

Links to psychiatry: American Mary (2012)
American Mary is a Canadian horror film directed by the “twisted” Soska sisters that, like The Angry Princess, merges themes of Antisocial Personality Disorder and Body Dysmorphic Disorder.

7. The Pilgrimess

Biography: The Pilgrimess is the ghost of Isabella Smith, a young woman who sailed across the Atlantic in 1675 to start a new life in a New England colony. Upon her arrival, the town’s livestock began to mysteriously die. A local preacher accused her of witchcraft. She was sentenced to a slow death in the stocks where children stoned her, women cursed her, and men spat on her. Her ghost is walking around with her hands still locked in the stocks.

Links to psychiatry: VHS (2012)
In the video tape titled “10/31/98,” a group of friends attempt to rescue a woman undergoing an exorcism. In both cases, young women “who are different” are condemned to death reminiscent of the Salem Witch Trials. While the evil at the heart of a witch may inspire a nature-versus- nurture debate on the etiology of Antisocial Personality Disorder, a substance-induced personality disorder must first be ruled-out. Numerous hypotheses have been formulated to explain the occurrence of the Salem Witch Trials in 1692 (17 years after Isabella was killed). One theory is that of substance-induction, specifically; personality change due to the ingestion of grain contaminated with ergot, a group of fungi of the genus Claviceps that grows on rye and related plants.

8 & 9. The Great Child & The Dire Mother

Biography: The Dire Mother is the ghost of Margaret Shelburne who was a woman who stood at a mere three feet tall. A showman (a la Sam Torr) convinced Margaret that he should exhibit her. Upon agreeing, she was raped by the Tall Man and gave birth to Harold, “The Great Child,” who weighed over 300 pounds. One day, some circus workers decided to play a cruel joke on Harold by kidnapping Margaret. Upon finding his mother dead in the sack she was kept in, Harold violently chopped the workers to death with an axe and placed their remains on display. Later, an angry mob tore Harold apart. Their ghosts are always together and The Great Child still holds the axe he used to kill the circus workers with.

Links to psychiatry: American Horror Story: Freak Show (2014)
Whereas The Bound (underweight) Woman is an allusion to Carrie and her omnipresent mother (the film is a metaphor for Anorexia Nervosa), The Great (Overweight) Child & The Dire Mother are enmeshed, the etiology of Bulimia Nervosa.

Carnivals and “freak shows” serve as rich venues to study the group dynamic that may contribute to antisocial traits. For example, under the guise of being a talent scout, Stanley (American Horror Story: Freak Show) attempts to murder or capture some of the performers to sell them to the Museum of Morbid Curiosities.

10. The Hammer

Biography: The Hammer is the ghost of George Markley, a blacksmith who was wrongfully accused of stealing. A gang led by his accuser hanged his wife and children and burned their bodies. George killed his accuser with his sledgehammer. He was then subjected to a cruel form of “frontier justice,” being chained to a tree and executed by having railroad spikes driven into his body. The mob then cut off his hand and attached the sledgehammer to the wrist. His ghost is seen with the railroad spikes protruding from his body and a sledgehammer for a left hand.

Links to psychiatry: Candyman (1992)
Both “The Hammer” and Candyman myths are about African Americans wrongfully accused, persecuted by a mob, killed, with their hands cut off and replaced by weapons. Hence, both are cultural warnings about revenge (taken by those wrongfully accused), and as urban legends, help a culture lend explanation to random events of violence.

11. The Jackal

Biography: The Jackal is the ghost of Ryan Kuhn. Born to a prostitute in 1887, Ryan began attacking prostitutes by his early adult years. He was committed to Borinwood Asylum where he perished in a suspicious fire. His ghost is in his undone strait-jacket with his head locked in a broken cage.

Links to psychiatry: Charles Manson
Ryan Kuhn is The Jackal, the Manson spirit, aptly named given his shared developmental history with Charles Manson. Hence, the 11th ghost represents severe Antisocial Personality Disorder and sociopathy.

12. The Juggernaut

Biography: The Juggernaut is the ghost of a serial killer named Horace “Breaker” Mahoney. Standing seven feet tall, Mahoney “went mad” following the death of his parents, picking up female hitchhikers and tearing them apart with his bare hands. One day, he picked up an undercover female police officer, who called for backup, bringing in a SWAT team that took Horace down in a hail of bullets. His ghost shows bullet holes all over his clothing, and the round that finished him, in the center of his forehead.

Links to psychiatry: Edmund Kemper
As imposing serial killers go, Breaker Mahoney is the spirit of the “Co-ed Butcher,” Ed Kemper. Standing 6 ft 9 in and weighed about 280 pounds, Kemper killed 10 people, 1 less than his fictional counterpart. Much like the 11th ghost, Mahoney depicts severe Antisocial Personality Disorder and sociopathy.

Table 1. Thirteen Ghosts (Thir13en Ghosts) &
13 Teaching Points about Antisocial Personality Disorder (APD)
# Ghost of the Black Zodiac Name Links Antisocial Personality Disorder
1 The First Born Son Billy Michaels Saw (2004); The Shining (1980) Since Billy is just a boy, his story reminds that for diagnosis of APD, one must have evidence of Conduct Disorder prior to the age 15
2 The Torso Jimmy "The Gambler" Gambino Pulp Fiction (1994) Along with Gambling Disorder, APD is in the differential diagnosis of compulsive gambling
3 The Bound Woman Susan LeGrow Carrie (1976) Etiology (nurture): Absent father and cold, domineering mother contribute to APD and other mental disorders (see Nos. 8 & 9)
4 The Withered Lover Jean Kriticos The Hatfields & McCoys The role of alcohol in antisocial traits (see #7)
5 The Torn Prince Royce Clayton The Warriors (1979) The "gang mentality" ' males adopting APD traits (see #7)
6 The Angry Princess Dana Newman American Annie (2012) Etiology (psychodynamic): APD and "acting out" as a form of non-verbal communication similar to somatic symptom disorder
7 The Pilgrimess Isabella Smith VHS (2012) The "gang mentality" ' females adopting APD traits (see #5); substance-induced personality disorder (see #4)
8 The Great Child Margaret Shelburne American Horror Story: Freak Show (2014) Etiology (nurture): The enmeshed family contributes to APD and other mental disorders (see #3)
9 The Dire Mother Harold Shelburne American Horror Story: Freak Show (2014) Etiology (nurture): The enmeshed family contributes to APD and other mental disorders (see #3)
10 The Hammer George Markley Candyman (1992) The role urban legends play in explaining random events of violence
11 The Jackal Ryan Kuhn Charles Manson APD and sociopathy
12 The Juggernaut Horace "Breaker" Mahoney Edmund Kemper APD and sociopathy
13 The Broken Heart Arthur Kriticos The Grinch; Elphaba (Wicked, 2003) There are several examples of people whose hearts grow cold; the 2 listed are favorites who are "green" with envy.

Oct 25: House on Haunted Hill (1959)


On this date in 1993, we lost arguably the most iconic actor in the world of horror when Vincent Price lost his battle with lung cancer. Price starred in numerous classics including House of Wax, The Mad Magician, The Fly, Return of the Fly, House on Haunted Hill, and The Tingler. Today marks the 22nd anniversary of his death and in honor of his work, we at Rutgers Robert Wood Johnson Medical School; review the House on Haunted Hill (1959).

Considered an American horror classic, House on Haunted Hill is a film that depicts a haunted house party, where the goal of the festivities is to survive a night of ghosts and spirits. Frederick Loren, an eccentric millionaire, and his fourth wife, Annabelle, invite five “strangers” to stay in an alleged haunted house with the award of $10,000 for each individual that survives the night. As the night progresses, the ghosts make their presence known to each of the guests. However, it is revealed [Spoiler Alert] that these events are an elaborate scheme for Annabelle and her secret lover, Dr. Trent, to stage the perfect murder. What they don’t know is that Mr. Loren is also playing along in their little game.


Several characters in the film provide salient teaching points on the multi-axial system from the DSM-IV criteria used to assess a patient in the clinical setting.

Axis I: Post-Traumatic Stress Disorder
Watson Pritchard, the house’s owner, provides an example of a patient with axis I diagnoses; suffering from Post-Traumatic Stress Disorder (PTSD), psychotic features, and Alcohol Use Disorder. At the beginning of the film, Watson stated there were seven deaths in the house, including his own brother, and that the one time he stayed in the home he was found the next day “almost dead.” These traumatic events provide the foundation in support of the diagnosis of PTSD. Watson’s interactions with the other guests illustrate the symptoms associated with PTSD such as his irritability, difficulty concentrating, and hypervigilance. As the film progresses, Watson begins to display stress-induced psychosis evident by his paranoia which leads him to display abnormal behavior and delusions about the house. He is seen walking around the house with a knife, staring at Mrs. Loren’s body to see if the spirits will take her, and sitting in his room with a cocked gun pointing to the door. Even after Frederick Loren confessed that he had killed his wife and her secret lover, Dr. Trent (after they had planned to kill him by driving Nora “into hysteria”), Watson remained fixed in his belief that ghosts and spirits were responsible for these events. Additionally, Watson is seen drinking alcohol throughout the night to the point where Mr. Loren becomes concerned about his consumption. Alcohol and/or substance use disorder is often seen co-occurring with PTSD and can worsen the severity of a patient’s symptoms.

Axis II: Antisocial Personality Disorder
As the host, Frederick Loren demonstrates traits of Antisocial Personality Disorder. At the beginning of the film, Mr. Loren is approachable and charming to his guests. He offers them beverages, sides with their observations, and listens to their concerns. However, when alone or in the presence of Annabelle, Mr. Loren displays irritation, aggression, and a lack of concern for the dangerous situations in which he places his “guests.” This ability to use empathy to manipulate and fulfill his own needs is a great illustration of sociopathy. Additionally, Mr. Loren shows no remorse for the killing of Annabelle and Mr. Trent, and in fact displayed a level of sadistic pleasure during the act. Robb White’s decision to make Mr. Loren a millionaire CEO is interesting; as such traits may be advantageous in vocations requiring cunning and control.

Axis III: Head trauma (Delirium coded on Axis I)
Lance Schroeder, a test pilot, provides a great example of a psychiatric disorder due to the direct physiological effects of a general medical condition (GMC). Lance decides to investigate the many cellar doors in the house. As he enters one of the rooms, he is forcefully pushed into the room with the door locked behind him. When the guests come to save Lance, the door easily opens to find him unconscious with a head laceration. Lance’s physical trauma contributes to his psychiatric state. After Lance’s head trauma, he indicates that he is experiencing confusion about what had happened to him in the cellar and then displays several moments of agitation and irritability, particularly towards Mr. Loren. A GMC such as head trauma likely influenced his altered mental status. This can be seen as changes in a person’s behavior, thought process, or level of orientation.

Axis IV: Financial Stress
Nora Manning, an employee of one of Mr. Loren’s companies, shows how life stressors can affect a person’s mental health. When Mr. Loren is introducing the audience to his five guests, he indicates that Nora is in need of the ward because she financially supports her entire family. In a stress-diathesis model, her psychosocial stressors precipitate what Dr. Trent calls “hysteria.” Dr. Trent and Annabelle were aware of Nora’s weaknesses and use her situation to drive her to killing Mr. Loren.

[Spoiler Alert] Since she kills the film’s antagonist, we’ll formulate a global assessment of functioning (GAF) score for Nora. The GAF score, which is documented in axis V of the assessment, gives the clinician insight on how a person’s biological, social, and psychological processes affect their capacity to function. Nora’s stressors and the brief psychotic disorder from which she suffers in the house make her GAF score low, indicating that she is at risk of hurting herself and/or others, which is evident when she shoots Dr. Loren in her “hysterical” state.

Final Assessment
Axis I: Post-Traumatic Stress Disorder in
Axis II: Antisocial Personality Disorder
Axis III: Head trauma and laceration to right temple (Delirium coded on Axis I)
Axis IV: Financial Stress
Axis V: Current GAF 5 (imminent danger to others)

Oct 24: Urban Legend (1998)


We go back-to-back with Robert Englund films and analyze Urban Legend (1998), a slasher film that follows a killer at a New England university who murders students in ways similar to those described in various urban legends. The film follows a group of friends who attend Pendleton University, the setting of student murders just as it supposedly was during the “Stanley Hall Massacre.” Natalie, the female protagonist, must try to find out who the killer is as her friends are killed systematically, all in ways that resemble urban legends (Table 1).

Table 1. Infamous Urban Legends Portrayed in the Film
Urban Legend Victim Comment
The Killer in the Backseat Michelle
Bloody Mary N/A Brenda and Natalie try to conjure
The Babysitter and The Man Upstairs N/A Mentioned by Professor Wexler
Hookman Damon
Headlight Flashing N/A Re-enacted by the killer on Natalie
Aren't You Glad You Didn't Turn On the Light Natalie's roommate
The Kidney Heist N/A Brenda tries to re-enact on Natalie


As the title suggest, urban legends are a large part of popular culture and often speak to the fears, anxieties, and biases of that culture. In doing so, they provide insight and give us an idea of the moral fabric of a community. Urban legends are cautionary tales of contemporary folklore that identify taboos represented in all cultures that capture four common themes: a) misunderstandings, b) poetic justice, c) business rip-offs, and d) revenge.

The main theme captured in Urban Legend is revenge. While not an ego defense mechanism per se, revenge may be related to acting out; defined as a direct observable action on an unconscious conflict to avoid being conscious of the conflict. In the film, the murderous impulses are not discharged towards the actual victims, [spoiler alert] but instead towards the protagonist, Natalie, who was involved in the accidental death of the killer’s boyfriend. This vengeance is the killer’s way of coping with the death of her boyfriend (anger stage of grief), which speaks volumes about her poor coping skills. One would query a developmental history of a broken family life or poor support system that did not allow her to heal properly following the death.

The film also depicts free-floating anxiety, mass hysteria, and a sense of foreshortened future as the students realize that the murders share a similarity to common urban legends. These folkloric tales suddenly become reality for the students, therefore causing them intense anxiety. It is all too real, particularly because the school was implicated in the murders from so many years ago. Fear is a hypothalamic emotion, driving people to extreme behaviors; in the film, students experience doubt of the murders, grow suspicious of each other, while others simply choose to ignore them altogether. No matter the reaction, the murderer had no preference. She did not single out the weak students or those who were most afraid. Rather, she was systematic and organized. These were researched murders that indicate a cunning, methodical mind at work.

Finally, the film itself takes on the aura of an urban legend as it relates to the urban legends so closely that you feel as though they may in fact be grounded in reality.

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 22: Orphan (2009)


Orphan (2009) is a mystery/thriller, horror film featuring Kate and John Coleman who, following the death of their daughter, try to pick up the pieces of their lives and adopt a 9-year- old girl, Esther, from a nearby orphanage. The innocent, sweet, educated, well-spoken Esther is not who she claims to be. Kate, her adopted mother, becomes suspicious, unraveling a plot that reveals [spoiler alert] Esther to be a 33-year-old Russian woman named Leena who suffers from panhypopituitarism.


Orphan serves as an opportunity to teach Antisocial Personality Disorder (APD) and “sociopathy.” Esther is an intelligent, highly manipulative, and superficially charming “child.” She easily induces fear, empathy, and even admiration when it suits her ambitions, as evidenced by the first time Kate and John meet her in the orphanage.

It is evident that she is charming and manipulative at her own whim in her interactions with John. Her agenda is to seduce him, so she behaves accordingly for his continued approval. This is not the case with the other characters in the film, especially with Kate. Esther preys on Kate because she believes she took her family for granted. This trope parallels that of John Kramer (Jigsaw), the antagonist from the Saw franchise who also demonstrates sociopathic traits. In response to her discordant relationship with Kate, Esther brings John closer and closer.

Kate depicts a “dry drunk,” absent spiritual recovery when she discloses to her mother-in-law that she “simply stopped drinking.” While Kate serves as a case study of Alcohol Use Disorder, Esther turns her attention to John. One component of Esther’s desire to seduce her adoptive father stems from her fixation at the phallic stage. The phallic stage, according to Freud, is the third stage of psychosexual development that occurs between 3-6 years of age when the child becomes aware of their bodies and the bodies of others. Esther’s fixation at this stage could be due to the abuse she experienced as a child at the hands of her biological father. In support of this, the European psychiatrist tells Kate that Esther has a history of having seduced her father. Her sexual feelings towards the opposite sex, and hostile feelings towards the same sex, are examples of being fixated in the phallic stage; an unresolved Oedipus Electra complex. Interestingly, if Jaume Collet-Serra would have written the character of Esther to be a 6-year-old child (rather than 9), her reported age would have ironically been consistent with her psychosexual age.

Sister Abigail comes to the house to warn Kate and John that there is something suspicious about Esther; she is always “around” when bad things happen. Just as Kate suspected, Esther has a
history of crime (she burned down the Saarne Institute), legal problems, and impulsive/aggressive behavior; features consistent with APD.

In the scenes where Esther smashes a bird with a rock, pushes a girl off a slide (breaking her leg), and murders Sister Abigail, her lack of remorse and calm demeanor depict the cold and emotionless features of APD. This reinforces her lack of a moral compass. When Esther cuts the special roses to give to Kate, she knows that they were part of Jessica’s memorial (the unborn child) and that Kate would be devastated. Esther can feel what other people feel (empathy) and exploit that. These features of APD and sociopathy reinforce her disregard for, and violation of, the rights of others.

Orphan approaches commentary on the etiology of APD (nature versus nurture) when it’s revealed that Esther was born on April 20 (the birthdate of Adolph Hitler). Much like Rhoda Penmark (The Bad Seed, 1954), Esther was originally written as having fair skin, delicate features, and platinum blonde hair (IMDB) until Isabelle Fuhrman auditioned for the part.

One must also consider whether Esther’s antisocial traits are the direct physiologic effect of an underlying medical condition. Beyond the endocrinologic effects, signs of panhypopituitarism may generally be attributable to the underlying cause. While a space-occupying lesion may present with headaches, double-vision or visual-field deficits, a pituitary tumor would not be as likely as a frontal lobe tumor (such as John Kramer) to cause antisocial traits. Despite this, another fictional orphan with antisocial traits is thought to suffer from panhypopituitarism.

In J. M. Barrie’s 1904 play, The Boy Who Wouldn’t Grow Up, Peter Pan was introduced to the world while chasing his shadow. Named after the mischievous Greek god of the woodlands, Pan may be interpreted as chasing his Jungian dark side (shadow archetype) on his quest to disobey adults and authority figures. Like Peter Pan, Esther is both physiologically and emotionally stunted; serving as a re-make of “Peter Pan-hypopituitarism.”

Oct 21: The Rocky Horror Picture Show (1975)


Today, October 21, 2015, is Back to the Future Day. It’s also the date we’ll pay homage to another movie about time travel; The Rocky Horror Picture Show is the 1975 film adaptation of the British classic rock musical, The Rocky Horror Show, written by Richard O’Brien. Over the decades, a cult of fans has cheered for “lips” (Science Fiction, Double Feature) to usher in the fantastic tale of the wild and untamed Victor Frankenstein-meets-Count Dracula. Author Jeffrey Weinstock asserts that O’Brien’s reference to George Pal (and his bride) is a mistake, as Pal was the producer of When Worlds Collide and not its star. Ironically, this gaffe also happens to be a foreshadowing of the film’s central theme.

But When Worlds Collide,
Said George Pal to his bride,
“I’m gonna give you some terrible thrills,” Like a…
– Science Fiction, Double Feature


“Worlds Collide” relates to the battle between the id and superego symbolized by the main characters in the movie. The film begins with Brad and Janet, a traditional, all-American couple suffering a flat tire in the middle of nowhere on a stormy night. When they knock on the door of a nearby castle hoping to use the telephone, they are taken prisoner (a la Jonathon Harker) by the occupant, Dr. Frank-N-Furter, an allusion to Bram Stoker’s Dracula.

According to Freudian psychodynamic theory, the superego is the component of the personality composed of our internalized ideals acquired from our parents and from society (e.g. teachers). The superego works to suppress the urges of the id and tries to make the ego “behave morally.” It is relevant that Brad and Janet were on their way to meet Dr. Scott (their former professor) when they got the flat tire.

In addition to basic psychodynamic theory, Frank-N-Furter serves as a case study for Transvestic Disorder, a paraphilia (sexual deviancy) characterized by recurrent and intense sexual arousal from cross-dressing (Sweet Transvestite). The condition may be associated with Gender Dysphoria (DSM-5). Dr. Frank-N-Furter reports that he’s from Transsexual (of the galaxy Transylvania), his planet sharing its name with the DSM-IV forerunner of Gender Dysphoria. The new DSM-5 diagnosis emphasizes the phenomenon of “gender incongruence” rather than cross-gender identification per se. The risk of Gender Dysphoria is increased in Dr. Frank-N- Furter since he’s sexually aroused by thoughts and images of “himself” as a female (autodynephilia).

Frank-N-Furter exists in a world where everything pretends to be something else, and in which the present is pasted together from the bits and pieces of movies past, so that life becomes an
endless vaudeville revue. Fashioned after Dr. Frankenstein, he creates a simulation of a person in the form of Rocky Horror, who is intended to be a living symbolic arena for the acting out of sexual desires. Rocky’s central theme is the adolescent turmoil experienced when searching for sexual identity, and the role confusion (represented by Brad and Janet’s puzzlement following the bedroom scenes) that results when things go awry (e.g. getting a flat tire).


  • The Rocky Horror Picture Show and the Emergence of Recreational Evil, http://www.transparencynow.com/Evil.htm
  • “Rocky” for Tiny Fools who Quake with Fear by Alex Blaze.
  • Lem, Stanlislaw. The Futurological Congress, trans. Michael Kandel (New York: Avon Books, 1974) pp. 96-102.

Oct 20: Insidious (2013)


Two-Sentence Horror Stories have populated the internet. Among the most unsettling include:

  • I always thought my cat had a staring problem – she always seemed fixated on my face. Until one day, when I realized that she was always looking just behind me1.
  • I awoke to the sound of the baby monitor crackling with a voice comforting my firstborn child. As I adjusted to a new position, my arm brushed against my wife, sleeping next to me2

These two shocking themes merge in Insidious, a horror movie that centers on Josh and Renai Lambert whose son, Dalton, inexplicably becomes comatose. When a family friend, Elise, informs the Lamberts that Dalton is an astral projectionist who is lost in a ghost dimension, there’s a race against time to recover Dalton’s “soul” from The Further before malevolent spirits can possess his body.


Insidious serves as an opportunity to teach the differential diagnoses of the Dissociative Disorders. Inherent in DSM nosology, there is a hierarchy within which the clinician must remain diagnostically loyal. For example, if Katie from our previous Paranormal Activity post experienced unreality or detachment (cardinal features of Depersonalization/Derealization Disorder), she wouldn’t be diagnosed with Depersonalization/Derealization Disorder because Dissociative Identity Disorder (DID) takes precedence.

Depersonalization/Derealization Disorder
Dalton’s astral projection is a literal example of an “out-of-body experience” defining of Depersonalization/Derealization Disorder. He recalls his experiences as dreams, so his condition is not likely due to Dissociative Amnesia or a fugue state.

Dissociative Amnesia
If Dalton’s father, Josh, is instead the focus of clinical attention, then Insidious captures the salient feature of Dissociative Amnesia as evidenced by Josh’s inability to recall important autobiographical information. By definition, the information is usually stressful in nature such as being haunted by the Bride in Black. Of course, the true etiology of Josh’s trauma isn’t fully revealed until Insidious: Chapter 2 (2013).

Dissociative Amnesia, with Dissociative Fugue
Continuing the formulation of Josh’s most likely diagnosis, we discover [SPOILER ALERT] that one memory of which Josh is amnestic is his ability to astral project. He, too, is what Elise would call “a traveler.” Unlike his son, Dalton, Josh’s travel is purposeful and associated with amnesia, making Insidious a case study of (provisional diagnosis) Dissociative Amnesia, with Dissociative Fugue.

Dissociative Identity Disorder
While Josh is astral projecting to find Dalton, his empty vessel is possessed by the Bride in Black. In the final seconds of Insidious (and all of Insidious: Chapter 2), Josh has a disruption of identity that is experienced as possession. We therefore must reject the provisional diagnosis of Dissociative Amnesia, with Dissociative Fugue in lieu of the most likely diagnosis; Dissociative Identity Disorder.

1. Hangukbrian, http://thoughtcatalog.com/michael-koh/2013/07/40-freaking-creepy-ass- two-sentence-stories/
2. https://www.reddit.com/user/doctordevice

Oct 19: 30 Days of Night (2007)


On this date in 2007, the polar night descended on Barrow, Alaska, the setting for 30 Days of Night, a horror film based on the comic book miniseries of the same name. Barrow, Alaska is preparing for its annual month-long polar night when a stranger rows ashore from a large ship. When detained, the stranger (the Harbinger archetype) taunts the townsfolk, telling them that death is coming. The mysterious visitor is the reincarnation of Renfield, the chosen one who prepares for the coming of the vampire scourge in Bram Stoker’s Dracula.


The vampire genre found its popularity with publication of Bram Stoker’s Dracula in 1897. Texts such as An Extraordinary and Shocking History of a Great Berserker Called Prince Dracula served as inspiration for Stoker’s monster. Stoker’s working papers for Dracula were discovered in the Rosenbach Museum in Philadelphia, confirming that he knew about the existence of Vlad Dracula, otherwise known as Vlad the Impaler. While the vampires in 30 Days of Night have features reminiscent of Nosferatu, the film pays homage to Stoker’s seminal novel. For example, when investigating the power outage, Eben goes to the telecommunications center and finds the operator’s head on a spike. Stoker’s eponymous character being killed with a spike through the heart was inspired by Vlad Dracula’s impaling thousands of the Sultan’s men on wooden stakes. With the creation of the vampire inspired by “Prince Dracula,” the apex predator then serves as a metaphor for Antisocial Personality Disorder (APD) given that the Count demonstrates reckless disregard for and violation of Jonathon Harker’s and other’s rights.

The town of Barrow succumbs to “30 days of night,” making the movie an allegory of Major Depressive Disorder with seasonal pattern (Seasonal Affective Disorder). This condition manifests with depressive symptoms at characteristic times of the year (episodes usually begin in fall or winter and remit in spring). Since the characters’ behavior is significantly influenced by the vampiric plague, with vampires serving as metaphors for APD, then 30 Days of Night may be interpreted as a case of “Secondary Depression;” a condition characterized by depressive symptoms thought to be caused by an underlying (e.g. antisocial) personality disorder.

Oct 18: The Ring (2002)


On this date in 2002, the world was introduced to Samara Morgan, evil incarnate. The Ring is a remake of Ringu, a 1998 Japanese horror film that draws on the folk tale, BanchoI Sarayashiki. As legend tells it, there was once a beautiful servant named Okiku who worked for a samurai, Aoyama Tessan. Okiku often refused his amorous advances. Despite his trickery, Okiku remained solemn. Aoyama became enraged, and threw her down a well to her death. It is said that Okiku became a vengeful spirit (OnryoI) who tormented her murderer.

In the 2002 American adaptation, a group of teens watch “a video tape that kills you when you watch it.” After watching the tape, the phone rings, and a voice on the other end utters “seven days.” Exactly one week later, you die. The film depicts Rachel Keller, an investigative reporter, who is looking into her niece’s death when she discovers the urban legend.

The Ring may have also been inspired by The Tragedy at Road Hill House. In June 1860, 3- year-old Francis “Saville” Kent disappeared from his home. His body was found in a privy on the property. While the boy’s nursemaid, Elizabeth, was initially arrested, Francis’s sister, Constance Kent, would confess to the murder five years later.

Yet another perspective comes from the study of the corporeal undead. Also known as “utburd,” mylings are phantasmal incarnations of the souls of unbaptized children who are forced to roam the earth until they could persuade someone to bury them properly. Mylings ‘ translated as “that which is taken outside” – refer to the practice of abandoning unwanted children (usually in the woods where death is almost certain). In The Ring, the teens discover Samara’s myth in a cabin in the woods. Interestingly, another Asian (Tai) horror film depicting a “floaty girl” continues this narrative. Written and directed by Banjong Pisanthanakun, Shutter (2004) illustrates how mylings chase lone wanderers at night and jump on their backs, demanding to be carried to the graveyard so they can rest in hallowed ground. In The Ring, Rachel discovers Samara’s body, and she’s given a proper burial in 7 days.


Two taglines from the movie highlight teaching points in psychiatry. First, “she never sleeps” hallmarks the inevitability of death. Interestingly, a story with the same moral, Appointment in Samarra, shares its title name (synonym) with The Ring’s evil antagonist. Second, “she only wants to be heard” represents a major theme in patient-centered medicine, with patient histories – and the need for patients to convey them in a milieu of unconditional positive regard (Carl Rogers) – being a critical component of healthcare.

Another teaching point focuses on whether Samara is “pure evil.” The Ring is a fictional case study of a “bad seed” (see Damien from The Omen, 1976) in the “nature versus nurture’ discussion of the etiology of Antisocial Personality Disorder.

Finally, a third psychiatric teaching point focuses on the nonverbal communication of horses. In the film, the horses at the Morgan ranch went mad and drowned themselves, a fate similar to the horse on the ferry on the way to Richard Morgan’s island home. The animal’s intuition is scientifically based. As prey animals, horses have hearts 5x the size of humans’. Their electromagnetic pulse (torus) results in a coherent heart rate that synchronizes with humans (or mylings). Institutions of higher education such as Rutgers Robert Wood Johnson Medical School take advantage of the coherent heart rate of horses by partnering with equine centers (Spring Reins of Hope) to run innovative curricula that use horses to teach medical students nonverbal communication to improve bedside manners.