Killing fields, Cambodia

Destination 19: Killing fields, Cambodia

The Killing Fields are a number of sites in Cambodia where more than a million people were killed and buried by the Khmer Rouge regime during its rule from 1975 to 1979 (

Related FilmA Nightmare on Elm Street (1984)

A Nightmare on Elm Street (1984) was based on a true story (

The narrative device of Wes Craven’s slasher film, in which knife-for-fingers Freddy Krueger (Robert Englund) kills innocent teenagers in their sleep, is entirely fictionalized. However, Craven based the movie on a Los Angeles Times article.

Craven described the idea for the premise of A Nightmare on Elm Street:

“I’d read an article in the LA Times about a family who had escaped the Killing Fields in Cambodia and managed to get to the U.S. Things were fine and then suddenly the young son was having very disturbing nightmares. He told his parents he was afraid that if he slept, the thing chasing him would get him, so he tried to stay awake for days at a time. When he finally fell asleep, his parents thought this crisis was over. Then they heard screams in the middle of the night. By the time they got to him, he was dead. He died in the middle of a nightmare. Here was a youngster having a vision of a horror that everyone older was denying. That became the central line of Nightmare on Elm Street.”


A Nightmare on Elm Street is a slasher film set in the fictional town of Springwood, Ohio. The plot revolves around Nancy 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 most horrifying, as it is then that you’re put in the exact same position as the main characters.

Interestingly, the opening scene of Shadow People (2013), a supernatural thriller written and directed by Matthew Arnold, is set in 1979 Cambodia, the final year of the Khmer Rouge regime. Arnold’s film addresses the universal fear of the boogieman, linking to the multiple psychiatric themes in Wes Craven’s A Nightmare on Elm Street (Nightmare).

How it relates to the field of psychiatry

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, Nancy is alert and able to recall her dream in detail, thus reinforcing the teaching point that differentiates 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. Nancy), is characterized by hallucinations (seeing the boogeyman), and is genetically predisposed. Metaphorically, Nancy 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 the character of Nancy Thompson. 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. 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 of 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. Nancy 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. Nancy’s sleep pathology is likely due to Posttraumatic Stress Disorder, having been a victim of childhood sexual abuse.

Anthony Tobia, MD, Copyright © 2018 Rutgers Robert Wood Johnson Medical School. All rights reserved.

Erta Ale, Ethiopia

Destination 16: Erta Ale, Ethiopia


Erta Ale is a remote and rarely visited shield volcano in the Afar region of East Africa. Erta Ale is known to have an active lava lake in its summit crater and is surrounded by sulfur pits. Erta Ale has undergone seven eruptions in the past 125 years and has been erupting continuously since 1967.

Related Film: Aladdin (1992)


The location as well as the name of the region (Afar) of East Africa loosely references the villain in Aladdin (1992). Aladdin is a 1992 animated musical produced by Walt Disney Pictures based on the folktale of the same name from One Thousand and One Nights. Jafar is the grand vizier of Agrabah and the main antagonist in the film.

Jafar identifies a street urchin named Aladdin to retrieve a lamp hidden within the Cave of Wonders. Upon its discovery, Aladdin rubs the lamp, releasing its mystical vapors and all the adventures that follow including befriending a genie, flying on carpets, and becoming a prince.

How it relates to the field of psychiatry

Given the contents of the lamp (vapors), one could view One Thousand and One Nights as a hallucinogenic trip caused by inhalant exposure. As such, the adventures that befall Aladdin may be interpreted as psychological symptoms of inhalant intoxication. The physiologic signs of inhalant intoxication can be remembered by magic carpet rides (acronym).

Muscle weakness

Coma or stupor
Ataxia (unsteady gait)
Reflexes depressed
Psychomotor retardation

Rotary nystagmus
Dizziness; Diplopia
Energy decreased or lethargy
Slurred speech

Anthony Tobia, MD. Copyright © 2018 Rutgers Robert Wood Johnson Medical School. All rights reserved.

Poveglia Island, Italy

Destination 12: Poveglia Island, Italy


“In the South Lagoon between Venice and Lido sits the small Italian island of Poveglia that for centuries has been a refuge, stronghold, place of exile, and a dumping ground for the diseased, dying, and deceased.” The island is considered to be the most haunted place in Italy because of two separate historical events.

“In the late 1800s, the area’s mentally ill resided in an asylum on Poveglia. The asylum was poorly constructed and used as a place of exile rather than rehabilitation. There are rumors that in the 1930s, a doctor performed strange experiments on the patients here; eventually the doctor went mad and threw himself from the asylum’s tall bell tower.”

Earlier, “in 1348 the Bubonic Plague arrived in Venice and Poveglia, like many other small islands, it became a quarantine colony.” It is this early event that we will discuss Poveglia Island and related it to film and psychiatry.

Related Film: The Fog (1980)


The Fog is a film directed by John Carpenter told as a campfire tale about a town haunted by corpses from a 100-year-old shipwreck. The fishermen’s legend foretells that at midnight on April 21, when the fog rolls in, corpses will arise from the sea in search of the campfire that originally “lead them to their dark, icy death.”

The movie is set in Spivey Point, 1980, where local fishermen spot a ghost ship carrying corporeal undead. While the US culture has focused on vampires, skeletons, mummies, and zombies, The Fog likely depicts undead fiends from Norse mythology; draugrs. Literally “after-walker,” draugrs are undead creatures that guard treasures (derivation of the term Dragon). Draugrs can rise from the grave as wisps of fog, possess superhuman strength, have the ability to control the weather, and curse a victim.

On the centennial anniversary of the Antonio Bay, a local radio DJ is given a piece of driftwood inscribed with the word “DANE.” In addition to being the name of the ill-fated ship, the inscription also establishes Norse mythology as the origin of the curse. To establish the town charter, 6 townspeople deliberately sunk the ship owned by a wealthy man with leprosy who wanted to establish a leper colony. As guardians of treasures after death, draugrs will exact revenge on the descendants who deliberately murdered, plundered, and founded the town of Antonio Bay.

How it relates to the field of psychiatry

The ability to curse a victim is the major theme of another nautical tale: The Rime of the Ancient Mariner, a Samuel Taylor Coleridge poem inspired by the Flying Dutchman, a ghost ship captained by Vanderdecken. In The Rime of the Ancient Mariner, a ship encounters the ghostly Flying Dutchman. On board are Death (actually, the undead; a skeleton) and the “Life-in-Death” (a deathly-pale woman) playing dice for the souls of the crew. Life-in-Death wins the life of the Mariner; he will endure a fate worse than death as punishment for his offense (killing the albatross). As penance for shooting the albatross, the Mariner is forced to wander the earth and tell his story, teaching a lesson to those he meets.

Since The Fog is told as a campfire tale, the storyteller’s character parallels that of the Mariner who was forced to wander the earth and tell his story. The storyteller’s cautionary tale is that we are the product of our early experiences. While set in the fictional town of Spivey Point, the story’s real setting is the vast ocean and all of its mystery. Just as all the danger lies below the ocean’s surface, so too do our early experiences shape our unconscious (subcortical hippocampus and amygdala).

In Coleridge’s poem, the Mariner is cursed by Life-in-Death for killing an albatross. In Carpenter’s adaptation, the town of Antonio Bay is cursed for its own “albatross”; in 1880, 6 of the town founders deliberately sank a clipper ship named the Elizabeth Dane. The ship was owned by a wealthy man named Blake, who wanted to establish a leper colony near Antonio Bay. One foggy night, the 6 conspirators lit a fire on the beach near treacherous rocks. Deceived by the false beacon, the ship crashed into the rocks and perished.

Anthony Tobia, MD. Copyright © 2018 Rutgers Robert Wood Johnson Medical School. All rights reserved.

Capuchin Catacombs

Destination 11: Capuchin Catacombs


“Found on the outer limits of the city, the Capuchin catacombs hold the remains of over 8000 souls, their disembodied shells propped up against the walls or resting in open caskets. Down in the cold, dry basement of the monastery, the relentless march of decomposition takes its sweet time. Though some bodies have been reduced to skulls and bones, the majority of corpses are still rotting, and their half-decomposed husks are the stuff of nightmares.”

The state of decomposition in the Capuchin catacombs parallels that of Mercy Brown: one of the most infamous cases of the exhumation of a corpse in order to perform rituals to banish the undead. Details of the Mercy Brown vampire incident may be found here. For purposes of this post, it is important to know that the proceedings of 1892 Rhode Island in part inspired the creation of Bram Stoker’s Dracula.

Related Film (novel): Dracula (1897)


Inspired by Lord Byron’s Fragment of a Novel (1819), John Polidori’s novella, The Vampyre, introduces the mysterious Lord Ruthven and his interludes with Aubrey around Europe. In Greece, Ruthven is mortally wounded when the pair is attacked by bandits. Before he dies, Ruthven makes Aubrey swear an oath that he will not mention his death for a year and a day. Aubrey returns to London and is astounded when Ruthven reappears seemingly unharmed.

Aubrey soon realizes that everyone whom Ruthven meets ends up suffering. Aubrey’s discovery exposes Ruthven’s deceitfulness as evidenced by his repeated lying and conning others for personal pleasure. As he seduces Aubrey’s sister, Aubrey is rendered helpless when Ruthven reminds him of his oath. Ruthven and Aubrey’s sister are engaged to marry on the day the oath ends. Just before he dies, Aubrey writes a letter to his sister revealing Ruthven’s history, but it does not arrive before the wedding vows. On the wedding night, the new bride is discovered dead having been drained of her blood with Ruthven having mysteriously vanished.

How it relates to the field of psychiatry [1]

The origins of one of the greatest myths depicting Antisocial personality Disorder: The Mercy Brown vampire incident, John Polidori’s novella, and texts such as An Extraordinary and Shocking History of a Great Berserker Called Prince Dracula served as inspiration for Abraham “Bram” Stoker’s Dracula. Stoker’s working papers for Dracula were discovered in the Rosenbach Museum in Philadelphia, confirming that he knew about the existence of the “Voivode Dracula,” with Stoker subsequently changing his vampire-creation’s original name, Count Wampyr, to “Dracula” after reading An Account of the Principalities of Wallachia and Moldavia.

In 1389, Mehmed II sent 10,000 cavalry to defeat Vlad III when Vlad refused to pay “jizya” (tax) to the sultan. Passing through a narrow pass north of Giurgiu, Vlad launched a surprise attack, surrounding the Turks and capturing thousands. Vlad’s military tactics serve to teach trainees that while not all violence rises to the level of antisocial personality, even in times of war, it is by no means necessary that “combatants exhibit abnormalities of personality.” Such is the case with Vlad III who upon impaling thousands of the Sultan’s men on wooden stakes, became known as Vlad the Impaler. In Stoker’s novel, this battle is referenced by Van Helsing when describing Count Dracula, “He must, indeed, have been that Voivode Dracula who won his name against the Turk, over the great river on the very frontier of Turkey-land.” Following the killing of Mehmed II, Vlad III wrote to Matthias Corvinus, King of Hungary. His letter illustrates his lack of remorse in committing these heinous acts:

I have killed peasants men and women, old and young, who lived at Oblucitza and Novoselo, where the Danube flows into the sea, up to Rahova, which is located near Chilia, from the lower Danube up to such places as Samovit and Ghighen. We killed 23,884 Turks without counting those whom we burned in homes or the Turks whose heads were cut by our soldiers.


  1. Tobia, A., Katsamanis, Draschil, T., Sportelli, D., M., Williams, J. The Horror!: A Creative Framework to Teach Psychopathology Via Metaphorical Analyses of Horror Films, Academic Psychiatry, March/April, 2013

Anthony Tobia, MD. Copyright © 2018 Rutgers Robert Wood Johnson Medical School. All rights reserved.

Auschwitz Death Camp

Destination 13: Auschwitz Death Camp

Located on a former military base in southern Poland, Auschwitz, the largest of all the Nazi death camps, opened in the spring of 1940. Under the direction of Eduard Wirths, prisoners were subjected to unethical human experiments.

Related Film: The Human Centipede (2009); The Skin I Live In (2011)


While both Doctors Heiter and Ledgard portray “mad scientists” synonymous with human rights violations, we choose to focus on Robert Ledgard. In The Skin I Live In, Ledgard abducts, physically abuses, and psychologically tortures someone he believes drove his daughter to suicide. His prisoner becomes the subject for Ledgard’s human experiments previously rejected by the medical establishment.

How it relates to the field of psychiatry


Badly burnt and disfigured in a terrible car crash, Gal lived in total darkness. One day, she hears her daughter, Norma, singing in the garden. When she walks over to the balcony to find her daughter, Gal accidentally saw her own reflection in the window. Traumatized by the sight, she jumped to her death.

Posttraumatic Stress Disorder

Witness to her mother’s suicide, Norma was recently discharged from an 8-year inpatient psychiatric hospitalization. Later, she demonstrates an exaggerated startle response when Vincent forcibly pins her to the ground. The traumatic event acts as a precipitant for her suicide, as Norma kills herself in the same manner that her mother did.

Cluster B Personality Disorders

Robert Ledgard personifies arrogance and haughtiness, traits that define the Narcissistic Personality Disorder. His grandiosity results in the abduction of Vera (explained next). While imprisoning her, Ledgard demonstrates a disregard for and violation of Vera’s rights. This hallmark of Antisocial Personality Disorder allows for The Skin I Live In to be formulated as a case study of sociopathy.

Gender Dysphoria

[Spoiler alert] At the end of the film, it is revealed that Vera is Vincent. Having blamed Vincent for his daughter’s death, Ledgard tortured him by performing radical gender reassignment surgery, making him in the image of his deceased wife, Gal. While the portrayed torture bears no relation to Gender Dysphoria (GD), Vincent’s marked dysphoria and incongruence between his experienced gender (male) and that assigned by Ledgard (female) reinforces the DSM-5 definition of GD.

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

Odessa Catacombs, Ukraine

Destination 14: Odessa Catacombs, Ukraine

The Odessa Catacombs are the backdrop for the tragic tale of Masha, an innocent partygoer who ventured down into the depths of the catacombs with some friends, took a wrong turn, and was never heard from again. Despite there being little documentation to support the legend, Masha only added to the mythology of the Ukrainian landmark. The lure of the Odessa Catacombs is multidimensional; among many, there are rumors that there’s a solid gold replica of the Titanic.

Related Film: Movie: As Above, So Below (2014)


In search of the legendary philosopher’s stone capable of turning metal into gold and granting eternal life, Scarlett Marlowe discovers the Rose Key. With the key, Scarlett translates a headstone that leads her to believe the philosopher’s stone is hidden 370 feet underneath the streets of Paris.

How it relates to the field of psychiatry

The legend and film differ with regard to the motivation behind the respective ventures into the catacombs. Where as in the Ukraine, Masha’s intent is unknown; Scarlett Marlowe is in search of buried treasure and eternal life. Scarlett’s quest just so happens to characterize two traits that “prove the existence” of a witch (underlined). Is Scarlett Marlowe a witch? Was her character based on Adrienne d’Heur?

Similar to the movie, Adrienne d’Heur lived in France. Interestingly, she was also intelligent, well-educated, and accused of having murdered her husband (in the film, the mysterious death of the heroine’s father replaces that of the husband). Scarlet’s fascination with alchemy may have been inspired more by her husband, Pierre Bacqueson, being a goldsmith than a solid gold replica of the Titanic.

Films that reference witchcraft depict possession and therefore serve as metaphors for dissociation. Accordingly, these films may be viewed as illustrations of mental disorders including dissociative and related disorders (e.g. feeding and eating disorders). The Feeding and Eating Disorder section of the DSM-5 includes feeding and eating disorders of infancy or early childhood as well as 3 specific diagnoses including Anorexia Nervosa and Bulimia Nervosa. Extensive research followed the dissemination of preliminary criteria for Binge Eating Disorder in Appendix B of DSM-IV, and findings supported the clinical utility and validity of its inclusion in the DSM-5.

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

Captain’s Log: Month 1 of The Orville

In Old Wounds (S1E1), we are introduced to the cast of characters who will demonstrate universal themes of the human condition: take 1 part person(s), 1 part close quarters, and fold in an external threat and let’s see what rises. The pilot episode therefore introduces the same dynamic as Gene Roddenberry’s original series, Jaws (1975), 90% of zombie films since George A. Romero created The Night of the Living Dead (1968), and all alien encounters including The Twilight Zone original The Monsters Are Due on Maple Street (1960). One external threat introduced was infidelity and divorce. For CDC statistics related to divorce, click here.

The concerns of aging come to mind when we learn of the time ray, especially as we watch the death of the crew member who is tossed into it. The ray’s effects can be seen as a metaphor for the very television show we are watching. By its decisions to parallel the Star Trek universe and its narrative structure, The Orville is fundamentally asking whether an old style of television (it should be noted, the producers have demonstrated affection for classic space TV, i.e. Cosmos) can be useful and successful today. At the end of the episode, we learn that [spoiler alert] aging can be constructive when the time ray grows a mighty tree and destroys the enemy ship. This leads us to wonder if the space opera, as originally envisioned by Roddenberry fifty-one years ago and now reimagined by the producers, can be framed in Erikson’s stage of generativity vs stagnation.

In Command Performance (S1, E2), we are introduced to Eda’s parents, [spoiler alert] albeit via a hologram simulation. As Ed and Kelly prepare to heed a distress signal, Ed’s mother discloses her son’s “gastrointestinal issues.” It is at this time that Ed tells Kelly that his mother despises her.

The scene poses the question whether Ed is depressed. He reassures his parents, crew, and millions of viewers that there’s nothing wrong with him. Taking his report at face value, one potential reason for his GI distress may be Major Depressive Disorder (MDD). The “colon” in the original acronym for the signs and symptoms of MDD (SIG: E CAPS) stood to remind that the condition may manifest through GI complaints. As a result of his parents’ disgust for Kelly, Ed’s ex-wife packs cannabis brownies prior to boarding the distressed ship raising the question if she too is experiencing anxiety and depression.

In About a Girl (S1, E3), issues related to gender identity are juxtaposed with cultural (Moclan) diversity. Introducing the mental disorder named Gender Dysphoria, this conflict is resolved when Bortus (Moclan) accepts the teachings of a Christian holiday (told through Rudolph the Red-Nosed Reindeer, 1964). While religion and spirituality are often synonymous with social (of biopsychosocial) antecedents of behavior, this episode ingeniously separates them into two opposing factors.

As the title If the Stars Should Appear (S1E4) suggests, the plot focuses on the religion of a people and in doing so, continues the narrative of the previous episode. However, close inspection reveals that just before and immediately following the role of religion of the ship-meets-ecosystem, there are two observations worth considering. First, Kelly identifies ice cream as “comfort food,” further evidence that she may be depressed (also referenced in the previous episode). In the final scene, the symbolism of the retractable roof highlights the importance of the diurnal day-night variation as a protective factor (similar to religion/spirituality) of mental disorders such as depression.

Warp Speed Hits

Old Wounds (S1, E1)

One thing that bears watching is if our helmsman, Gordon, may be afflicted with Alcohol Use Disorder. Gordon perhaps fulfilled a DSM criterion by having put himself in a physically hazardous situation while drinking.

Command Performance (S1, E2)

Cannabis sativa (cannabis) is an annual herbaceous plant with many compounds. Each part of cannabis such as marijuana and hemp is harvested differently depending on its intended use. Marijuana contains delta-9 tetrahydrocannabinol (THC), the most psychoactive component (mind-altering “high”) of cannabis. Hemp is used to produce cannabidiol (CBD) which is not psychoactive.

For those keeping score at home, the number of episodes we’ve now had with Gordon not showing signs of alcoholism (Alcohol use Disorder) is: 1.

About a Girl (S1, E3)

Yaphit feigns illness in order to get to see Dr. Finn (external incentive). Yaphit therefore demonstrates the defining quality of malingering.

Lt. Gordon Malloy reveals that his father was an alcoholic (Alcohol Use Disorder), “[leaving a child with 2 drunk dudes] reminds me of my dad” (minute :24). A first-degree relative with Alcohol Use Disorder confers biological risk (biopsychosocial) to develop the disorder.

If the Stars Should Appear (S1, E4)

In this episode, the role of religion is tackled. This relates to the importance of inquiring about religion and spirituality in a routine psychiatric assessment.

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

Snake Island, Brazil

Destination 10: Snake Island, Brazil

Off the shore of Brazil lies an island untouched by humans known as “Snake Island.” Researchers estimate that there are five snakes per square meter. The snakes are a family of pit vipers – the golden lanceheads. Locals in Brazil love to recount two grisly tales of death on Snake Island that can be found at

Related Film: Sinister (2012)


Sinister is a 2012 supernatural horror film chronicling the existential crisis of Ellison Oswalt, a fictional crime author who is trying to resurrect his fledgling career. Following an opening scene that shows an unnamed family being hanged from a tree, we meet the Oswalts who are moving into their new Pennsylvania home. On moving day, they are met by the town sheriff, who after admonishing his deputy for soliciting an autograph, tries to convince Ellison to load his boxes back onto the moving truck and leave. The sheriff ‘s warning, a harbinger, serves as foreshadowing of the Oswalts’ fate, as it is ultimately learned that the house they are moving into is the former “Stevenson home;” a Pennsylvania house that’s become an urban legend because it was the site of the horrific hanging depicted in the movie’s opening scene.

While Sinister isn’t set on an island, the film does focus on a snake. A professor of occult crimes informs us that a snake, scorpion, and dog are the precursors to the arrival of Bugghul, a demonic entity who feeds on the souls of children.

How it relates to the field of psychiatry

Approximately 90 minutes into the film, Deputy So and So contacts Ellison to inform him that he’s discovered the pattern of the murders. If the deputy’s explanation is deemed unreliable, the entire plot changes and allows for a diagnostic formulation that promotes Sinister as a movie depicting severe mental illness. For the full text article that explains how the plot of Sinister may be manipulated to depict a case study of the dissociative disorders, click here.

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

Darien Gap, Panama

Destination 9: Darien Gap, Panama

The Pan-American Highway stretches from Cape Horn, Chile to Alaska with one 90 km break of undeveloped swampland that separates Central and South America (the Darien Gap). Among the many things that make this one of the most dangerous places on earth (travel/guided tours had been suspended due to kidnappings and political turmoil in Colombia), it is full of insects and plants that “spit poison and kill” (

Related Film: Movie: The Day of the Triffids (1951)


While The Day of the Triffids ‘ a British B flick about carnivorous plants prone to aggressive behavior – no doubt contains themes to teach aspects of psychiatry, it is important to note that the film is referenced in the opening song (When Worlds Collide) of The Rocky Horror Picture Show (1975).

Worlds collide in this 1975 film adaptation of Richard O’Brien’s British classic rock musical, The Rocky Horror Show (1973). Upon suffering an ill-fated flat tire in the middle of nowhere in the middle of the night, Brad and Janet knock on the door of a nearby castle, hoping to use the telephone. They are subsequently imprisoned by the occupant, Dr. Frank-N-Furter, a time-traveling extraterrestrial from the planet Transsexual, of the galaxy Transylvania.

How it relates to the field of psychiatry

With just a “jump to the left,” Dr. Frank-N-Furter travels space and time to occupy a castle where his cross-dressing behavior (rule-out Transvestic Disorder) incorporates traits of sexual masochism. While it’s unclear if his creation (Rocky Horror) derives sexual gratification from being made to physically suffer (masochism), The Rocky Horror Show can be viewed as a case study of the paraphilic disorders as the film includes voyeuristic intention, frotteurism, and pedophilia (Rocky Horror has sex the day he’s born). The film demonstrates that Dr. Frank-N-Furter becomes sexually aroused by thoughts and images of himself as a female (autodynephilia), therefore placing the cross-dressing doctor at risk for developing Gender Dysphoria (DSM-5), a diagnosis confirmed with the knowledge he’s from the planet, Transsexual, the former clinical term (DSM-IV-TR) for Gender Dysphoria.

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

The Boiling Lake, Dominica

Destination 8: The Boiling Lake, Dominica

Located in Morne Trois Pitons National Park, Dominica’s Boiling Lake is the second-largest hot lake in the world (the largest is Frying Pan Lake, New Zealand). Discovered in 1870 by Watt and Nicholls, the Boiling Lake rests at the bottom of a large fumarole. A continuous flux of gas generated by an underlying magmatic intrusion drives water (180 to 197 F) up into the basin. The flooded fumarole is an opening in the Earth’s crust located in close vicinity of the Morne Trois Pitons volcano. The emitted gases escape from molten lava below.

Related Film: Movie: Tremors (1990)


Tremors is a 1990 horror film depicting Val and Earl, two handymen, who, along with Rhonda LaBeck, discover the shocking cause of seismic activity in the desert of Perfection, Nevada.

How it relates to the field of psychiatry

Val and Earl are on horseback looking for help when they discover a buried car. With the owners (Wallace and his wife) missing, they press on when an eruption reveals an enormous burrowing worm-creature. The creature, a graboid, is a metaphor of anxiety. Similar to a lake superheated by underground magma or graboids from below the desert’s surface, anxiety resulting from intra-psychic conflict arising from below one’s level of consciousness. Given the town’s name of Perfection, Tremors can be conceptualized as a case study of Obsessive Compulsive Personality Disorder (OCPD).

OCPD is a personality disorder hallmarked by a pervasive pattern of preoccupation with perfection (as the Nevada town is aptly named) and control that causes clinically significant distress or impairment in social or occupational functioning. The psychodynamic etiology of OCPD focuses on maladaptive defense mechanisms: unconscious ego processes that alleviate anxiety caused by the mismatch between the id (what we want to do) and the superego (what we’re allowed to do).

Three ego defense mechanisms define OCPD. First, isolation of affect (isolation) is objectifying and emotionally detaching oneself from a thought so as to avoid the painful feeling associated with that thought. The second defense mechanism, undoing, is the unconscious attempt to reverse a thought or feeling by performing an action that signifies an opposite feeling (e.g. compulsive hand washing to counter thoughts of infestation). Third, reaction formation includes adopting beliefs, attitudes, and feelings contrary to what you really feel (e.g. the individual expresses inner turmoil as perfect orderliness by having his tie pulled tight and beard always trimmed).

Interestingly, Graboids have as many life-cycle stages as OCPD has characteristic defense mechanisms:

  • The first is the underground dwelling stage (isolation)
  • The second is the walking stage when the graboid leaves its underground skin and grows two legs (undoing)
  • The third is the flight stage where they sprout wings (reaction formation)

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