“The Wizard of Oz,” a musical produced in 1939, based on Frank Baum’s classic children’s book, “The Wonderful World of Oz,” has become one of the most famous films of all time (1). The story’s enduring place in American cultural and film history is supported by the 13 Oz sequels Baum wrote in response to popular demand, the annual airing of the movie by television networks since the 1950s, and the successful contemporary Broadway production of “Wicked,” the backstory to the original production.
The musical depicts Dorothy, a young girl discontented with her life on a rural Kansas farm, who is knocked unconscious during a tornado and dreams of a magical trip to a land called Oz, peopled with familiar faces from her life. Her journey ends when she realizes her own power to return home, and develops a new gratitude for her relationships in the waking world. The story lends itself to interpretation, and “The Wizard of Oz” has been viewed as an allegory for the American debate over the gold standard (2), adolescent sexual development (3), and the lesbian and gay movement’s struggle for cultural acceptance (4). It has also been called a “parable of injury, loss, and redemption” (5): “when you have lost your brain, you might want to go on a journey to find a wizard to give you a new one.” If extended further, this comment points to the film being a useful depiction of the complications and course of traumatic brain injury (TBI) survivorship. More specifically, Dorothy’s dream of the Scarecrow, the Tin Man, and the Cowardly Lion accurately represents the three traumatic brain injury syndromes often experienced by brain-injured patients, namely, the syndromes of dysexecutive confusion, apathy, and disinhibition. We have found a usefulness in the famous “Wizard of Oz” story both for understanding and learning these complex clinical syndromes associated with TBI.
As detailed in a recent volume of the journal Psychiatric Annals (6), awareness of the effects of traumatic brain injury is an important educational goal for psychiatric residents in training in the 21st century. Traumatic brain injury is the signature injury of soldiers and veterans of the current wars in the Middle East. Sports organizations and occupational health organizations are increasingly concerned about the prevalence and acute and long-term effects of all severities of brain injury, including concussions. Psychiatric residents will find themselves caring for TBI survivors in all treatment settings, as TBI-related symptoms and disability are common in patients with mental illness, can complicate the diagnosis and treatment of mental disorders, and predispose patients to future psychiatric morbidity (5). However, the syndromes of TBI are given little attention in most psychiatry residency training curricula. For practitioners not formally trained in behavioral neurology and brain circuitry, it can be challenging to relate to and retain specific information about these syndromes.
The three characters of the Scarecrow, the Tin Man, and the Cowardly Lion as exemplars of dysexecutive confusion, apathy, and disinhibition, fit naturally with our human tendency to retain information in triads, and provide an animated resource on which to hang a description of these presentations that most psychiatrists will encounter in some context. Teaching and describing these syndromes is simple, but developing a teaching method that enlivens the information and provides a mechanism to store the information is another matter altogether. We believe that “The Wizard of Oz,” as a metaphor for brain injury, is quite powerful in this endeavor, and is easily used in didactic settings for residents and medical students to educate them about the sequelae of TBI.
“The Wizard of Oz” begins with Dorothy’s various interactions with members of her family, their farm, and her rural Kansas community. A tornado tears through the neighborhood, and Dorothy is knocked unconscious by a window shutter torn from its frame. She dreams of her house being thrown by the wind and deposited in the Land of Oz, a colorful and fantastical counterpoint to her gray, confining life in Kansas. There, she meets the Munchkins and discovers that she has accidentally killed the Wicked Witch of the East. She sets out on a journey along the Yellow Brick Road in the dead witch’s ruby-red slippers to find the Emerald City and the famed Wizard of Oz, to seek his assistance in returning home.
Dorothy’s first encounter is with the Scarecrow, who answers her at a fork in the road when she wonders aloud which way to go. The Scarecrow tells her first one direction, then the other, and then finally admits, “That's the trouble. I can't make up my mind. I haven't got a brain.” In his famous song (7), accompanied by his typical clumsy motoric style, the Scarecrow describes what he would do “if I only had a brain:”
Gosh, it would be awful pleasin’
For things I can't explain.
The Scarecrow and Dorothy then set off together to find the Wizard of Oz.
The Scarecrow is a fine example of the first neurobehavioral syndrome often seen in traumatic brain injury, the dysexecutive syndrome. It is extremely common, occurring in up to 90% of patients at some point after severe head injury (8). As the name implies, patients with this syndrome have lost their brain’s ability to act as an “executive” that evaluates information, devises strategies, and makes decisions about how to behave. Just as the Scarecrow cannot figure out directions, solve riddles, or provide explanations of things, patients with dysexecutive syndrome may have difficulties retrieving stored memories or information, generating word-lists, changing set in response to changing criteria, planning sequential steps of a complex task, constructing a visuospatial object, ignoring distracting stimuli, alternating between tasks, manipulating abstractions, and inhibiting reflexive responses (9).
Patients with these dysexecutive symptoms typically have a traumatic brain injury affecting the frontal-subcortical neural circuit subserving the dorsolateral frontal cortex. This cortical territory, located on the lateral frontal convexity at approximately Brodmann’s areas 9, 10, and 46 (10), mediates working memory, representations of the world, and contingent responses (9). (See Figure 1.)
The three frontal cortical areas and Brodmann areas corresponding to the three neurobehavioral syndromes-dorsolateral frontal cortex: yellow (Scarecrow; dysexecutive syndrome), anterior cingulate cortex: red (Tin Man; apathy syndrome), and orbital frontal cortex: blue (Cowardly Lion; disinhibition syndrome). From Comprehensive Clinical Psychiatry. Edited by Stern TA, Rosenbaum FM, Biederman JL, et al. Philadelphia, PA, Mosby Elsevier, 2008, p 977. Reprinted by permission
The dorsolateral frontal cortex is connected to subcortical structures in a closed neural circuit loop that is parallel to and segregated from circuits of other frontal lobe cortical territories, including the motor cortex, orbitofrontal cortex, and medial-frontal cortex (11). This common structure of frontal-subcortical circuits consists of the following: cortex→striatum→pallidum→thalamus→cortex (12). These frontal-subcortical circuits are a dominant conceptual framework across neuropsychiatric disorders and have been implicated by neuroimaging in the pathogenesis of disorders such as schizophrenia, Huntington’s disease, and obsessive-compulsive disorder (13). Damage to the dorsolateral frontal circuit anywhere along its path—the cortical area itself, the dorsolateral caudate nucleus, the lateral dorsomedial globus pallidus, and the ventral anterior and mediodorsal nuclei of the thalamus—can result in the dysexecutive syndrome (12).
The Scarecrow and Dorothy then come across the Tin Man, standing in the middle of the road. He cannot move and can hardly talk, barely getting out the words “oil can.” Once Dorothy oils his mouth and joints, he reveals to them that he rusted stiff in the rain a year ago, and instructs them to pound on his hollow chest (7):
The tinsmith forgot to give me a heart… .
And really feel the part,
I could stay young and chipper,
And I'd lock it with a zipper,
If I only had a heart...!
Over half of patients with traumatic brain injury may present without emotion, or more specifically, with a syndrome of apathy (14). Just like the “heartless” Tin Man, they do not experience desire, passion, or motivation. Such patients will report indifference to pain, thirst, or hunger; lack of psychic initiative—or, if they do express a goal, lack of motoric activity toward that goal; lack of spontaneous movement or speech; and a lack of emotional expression (9). This amotivational syndrome can range in severity, from a mild apathy in which a patient possesses few strong preferences or convictions, to a severe form called akinetic mutism, in which a patient does not move, speak, or answer questions voluntarily, and may only follow the examiner with his or her eyes. It resembles other seemingly vegetative states such as parkinsonism, catatonia, and locked-in syndrome, but without characteristic features of these such as tremor, rigidity, echolalia, or paralysis. Instruments to assess the syndrome (15) ask such questions as: “Is the patient interested in things?” “Does the patient put effort into anything?” and “Is the patient concerned about his/her problems less than others [are]?”
Patients with an apathy syndrome after a traumatic event have a defect in the neural circuit subserving the anterior cingulate cortex, located at Brodmann’s areas 24 and 32 (10). The anterior cingulate cortex circuit projects first to the nucleus accumbens, then to the rostrolateral globus pallidus, and finally to the mediodorsal nucleus of the thalamus, before ascending back to the anterior cingulate cortex (12). This circuit is hypothesized to mediate decision-making, integrating neural input from ventral and dorsal prefrontal areas, and responding to visceral information from the hypothalamus, brainstem, and insular cortex (9).
The Scarecrow, Tin Man, and Dorothy then follow the Yellow Brick Road into a threatening forest, where they are accosted by the Cowardly Lion. He growls and roars at the group, causing them to scatter into the underbrush, at which point he begins putting on aggressive and grandiose airs (7):
Put 'em up! Put 'em up! Which one of you first?
I'll fight you both together if you want!
I'll fight you with one paw tied behind my back.
I'll fight you standing on one foot.
Come on—get up and fight, you shivering junk yard!
Put your hands up, you lop-sided bag of hay!
However, as soon as the Lion begins to threaten and chase Toto, Dorothy’s dog, she confronts him and slaps him on the nose, which makes him cry. When Dorothy scolds him for picking on her little dog and for being a coward, the Lion admits as much:
Yeah, it's sad; believe me, Missy
When you're born to be a sissy,
Without the vim and verve.
But I could show my prowess—
The Cowardly Lion’s behaviors in this episode, swinging from aggression to submission, unable to control his fearful impulses, exemplify the disinhibition syndrome, which occurs in up to three-quarters of patients with severe TBI (16). Patients may exhibit a lack of social tact; be inappropriately jocular, sexual, or antisocial; or lack inhibition, judgment, or a sense of responsibility. They may also be inattentive, distractible, and hyperkinetic, and may demonstrate imitation or utilization behavior, in which they compulsively reach for objects in their environment or imitate the gestures of others (9). This syndrome may be easily mistaken for the mania of bipolar disorder, the inattention of ADHD, the sociopathy of antisocial personality, the irritability of borderline personality, and the self-destructiveness associated with substance abuse.
The disinhibition syndrome is seen in patients with traumatic injury to the neural circuit subserving the orbital frontal cortex in Brodmann’s areas 10 and 11 (10). The orbital frontal cortex is thought to be responsible for mediating social behavior and environmental reward- and punishment-assessment (9). The circuit projects from the orbital frontal cortex to the ventromedial caudate nucleus, then to the medial dorsomedial globus pallidus, and finally to the ventral anterior and mediodorsal nuclei of the thalamus, before returning to the orbital frontal cortex (12).
Dorothy’s encounters with the Scarecrow, the Tin Man, and the Cowardly Lion in the Land of Oz form a narrative that can serve as an instructional film and mnemonic device to remember the three neurobehavioral syndromes: dysexecutive confusion, apathy, and disinhibition. Film clips of “The Wizard of Oz” juxtaposed with clinical vignettes of TBI patients with the relevant syndromes and their circuitry would be a memorable and engaging teaching method for students of psychiatry, neurology, and psychology, as trainees may find neuroanatomy intimidating or conceptually difficult to organize.
The potential teaching value of The Wizard of Oz in brain injury lies not only in the representation of these specific syndromes, but also as an allegory for the rehabilitation from any brain injury. Brain-injured patients may find themselves in a strange new world after their injury, in which the people they know and places they remember are radically different, either because of the effects of neurological deficits, or due to the world’s reaction to the patient’s disabling condition. A sense of painful alienation from the life the patient once led—and a poignant desire to return to that familiar life—may be acutely felt (“There’s no place like home”) (5). Psychiatrists who are familiar with the common obstacles, disappointments, and complications of TBI will be better able to empower their brain-injury patients to use the undamaged parts of their brains to assist in the performance of the essential activities of their lives, as well as engage in activities that may promote the brain’s ability to heal itself via neuroplastic processes (14). This principle is conveyed by Glinda, the good witch of the North, speaking to Dorothy (7):
You don't need to be helped any longer.
You've always had the power to go back to Kansas.
Glinda presents a powerful metaphor of focusing on capacity and potential, rather than on deficits, to maximize one’s functions in the world and to overcome adversity. Remembering Dorothy and her helpful friends in the Land of Oz may give psychiatric practitioners the power to recall the frequently-encountered neurobehavioral syndromes of traumatic brain injury, and assist their patients toward functional and meaningful recovery.