Movies have long been utilized to highlight varied areas in the field of psychiatry, including the role of the psychiatrist, issues in medical ethics, and the stigma toward people with mental illness. Furthermore, courses designed to teach psychopathology to trainees have traditionally used examples from art and literature to emphasize major teaching points. The integration of creative methods to teach psychiatry residents is essential as course directors are met with the challenge of captivating trainees with increasing demands on time and resources. Teachers must continue to strive to create learning environments that give residents opportunities to apply, analyze, synthesize, and evaluate information (1). According to Bloom (2), furnishing such opportunities is necessary for integration of knowledge. To reach this goal, the use of film for teaching may have advantages over traditional didactics. Films are efficient, and they present a controlled patient scenario that can be used repeatedly from year to year. Psychiatry residency curricula that have incorporated viewing contemporary films were found to be useful and enjoyable, pertaining to the field of psychiatry in general (3) as well as specific issues within psychiatry, such as acculturation (4). The construction of a formal movie club has also been shown to be a novel way to teach psychiatry residents various aspects of psychiatry (5).
This article introduces REDRUM (Reviewing [Mental] Disease with a Rudimentary Understanding of the Macabre), our Psychopathology curriculum for PGY-1 and -2 residents at the UMDNJ–Robert Wood Johnson Medical School. REDRUM teaches topics in mental illnesses by use of the horror genre. The main objective of the REDRUM Psychopathology course is to enhance learning through creative discussion of examples of psychopathology that come from film and literature. This is achieved by selected works serving a metaphorical or symbolic role in the etiology, clinical presentation, course, and prognosis of the mental illnesses highlighted in our course syllabus. Discussions of these examples from film and literature sometimes include the historical context of the setting or the author’s life, which adds an even richer layer of understanding to the social interpretation of these stories.
REDRUM differs from previously-described curricula in that the psychopathology examples from film and literature are discussed in a metaphorical context. Although the selected works are primarily "monster movies," great care is taken not to perpetuate the stigma of mental illness or to portray patients as “monsters.” Residents are directed not to take the movies at face value. Instead, we focus on an abstract and symbolic understanding of the plot summary or aspects of character analysis that allow psychiatry residents to discuss major teaching points germane to a full spectrum of adult mental illnesses. Techniques for teaching literary interpretation by examining key elements such as plot, theme, character, and motive, are also applied. Multiple examples of this construct follow and are described below.
The REDRUM Psychopathology course is held weekly for 1 hour over one semester (about 15 weeks). The 1-hour didactic is supplemented by weekly readings and film viewings that take approximately 1–2 hours per week outside of the classroom. Residents are encouraged to read selected chapters from the required textbook, Kaplan & Sadock’s Synopsis of Psychiatry (6), before the instructor-led didactic presentation. The salient feature of the course is that we supplement traditional classroom didactic with a discussion of selected movies or excerpts from literature. Chapters from the course reading list are posted on the resident forum on the university’s intranet, and movies are available for loan through our department’s DVD library. REDRUM is broken down into three modules: 1) Necromancy; 2) Review of the Top Classical Monsters; and 3) Review of the Top Contemporary Monsters.
The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (7) lists delirium, dementia, and the mood disorders among its initial contents. Three renowned ghost stories that we reference to introduce the categories that comprise our first module include The Tragedy of Macbeth, The Legend of Sleepy Hollow, and The Phantom of the Opera, respectively (Table 1).
Shakespeare’s The Tragedy of Macbeth is a play written in the early 1600s, drawn from Raphael Holinshed's Chronicles of England, Scotland, and Ireland (1587), which accounts General Macbeth’s ascension to the throne of Scotland. The Shakespearian play is an excellent clinical example of delirium, with lengthy descriptions of the bizarre behavior of one of the most tragic characters in literature, Lady Macbeth.
In the opening act, Macbeth’s future is foretold by three witches, setting forth one of the play’s main themes and one that is shared with delirium: the interaction of external and internal forces that guide human behavior. Moved by the thought of attaining the throne, Macbeth conspires with his wife to kill King Duncan. Macbeth murders the king, as Lady Macbeth plays a prominent role in framing the chamberlains for the stabbing. As the newly-crowned King of Scotland, Macbeth then orders the death of “the only man in Scotland whom he fears,” Banquo. After his friend’s murder, Macbeth is horrified to see Banquo’s ghost sitting at the head of a banquet table. His is the first of a line of perceptual disturbances that culminates in Lady Macbeth’s bizarre behavior, and one of the most memorable scenes in all of literature.
Out, damn'd spot! out, I say! — Macbeth; Act 5, Scene 1.
Upon observing Lady Macbeth’s agitation, a physician in the castle queries, “In this slumbery agitation, besides her walking and other actual performances, what, at any time, have you heard her say? (8)” The physician’s description of “slumbery agitation” depicts a disturbance of conscious awareness, a defining component of delirium. He then references her motor behavior (“performances”), specifically mentioning her disorganized gait. In a clinical context, such behavior is often seen as posing a risk of danger to the delirium patient and others. Finally, the physician inquires about her language, an example of a cognitive change that further defines delirium.
Beyond serving as a case study of delirium, Shakespeare’s femme fatale also serves as a reference for the specific etiologies of this illness. Although not linked to the plot of the play, “I ♥ LADYMACBETH” (Table 2) is an acronym used to teach residents the potential causes of and routine tests for the evaluation of delirium.
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Module 2: Top Classic Monsters
In the 1940s and 1950s, William “Bud” Abbott and Lou Costello formed one of the most famous comedy duos of all time. In Abbott & Costello Meet Frankenstein (1948), the duo battles Frankenstein’s monster, Count Dracula, and the Wolfman. In 1954, they starred in Abbott & Costello Meet Dr. Jekyll and Mr. Hyde and, a year later, in Abbott & Costello Meet the Mummy. These classic movie monsters comprise our second module. Each monster possesses a salient characteristic that allows for discussion about a particular psychopathology. The following is a description of one of these classic movie monsters: Bram Stoker’s Dracula, and how it relates to one of the course topics in REDRUM: the Personality Disorders.
The transition from Module 1: Necromancy to the next module is highlighted by viewing Abbott & Costello Meet Frankenstein, as well as commemorating the date of May 25, 1816. It was on this date that Mary Godwin, Percy Shelley, Lord Byron, Claire Clairmont, and a young physician named John William Polidori rented a villa in Cologny, Switzerland. This summer meeting produced two of the most eminent characters in English literature. An “incessant rain” (9) confined the group in the house for days, which spawned discussions on varied topics, including galvanism and the reanimation of dead matter. The company also amused themselves by reading German ghost stories, prompting Byron to suggest they each write their own supernatural tale. Shortly after, the iconic monsters from Frankenstein (Shelly) and The Vampyre, a Tale (Polidori) were conceived. Both works are highlighted in our second module, where Frankenstein and Dracula serve to introduce Personality Theory and The Personality Disorders, respectively. An example from our didactic on The Personality Disorders follows, illustrating various aspects of Antisocial Personality Disorder.
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The Vampyre: A Tale introduces Lord Ruthven: Deceitfulness
Inspired by Lord Byron's Fragment of a Novel (1819), Polidori's novella 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.
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Vlad III, Prince of Wallachia: Reckless Disregard for Safety; Lack of Remorse
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 (10),” 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 (11).
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 (12). Vlad’s military tactics serve to teach trainees that, whereas 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" (13). Such is the case with Vlad III, who, upon impaling thousands of the Sultan’s men on wooden stakes (12), became known as "Vlad the Impaler." In Stoker’s novel (14), 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.” After the killing of Mehmed II, Vlad III wrote to Matthias Corvinus, King of Hungary (15):
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.
His letter illustrates his lack of remorse in committing these heinous acts. Table 3 summarizes several additional characteristics Vlad III shared with the fictional Count Dracula.
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Module 3: Top Contemporary Monsters
Background From its peak in popularity enjoyed with Alfred Hitchcock’s Psycho in 1960, the horror film industry experienced a rebirth when William Peter Blatty’s The Exorcist became the top-grossing horror film of all time in 1973. Many of the films that followed have portrayed iconic monsters that have chilled audiences and created cult followings. Their appeal lies in part to their archetypal warnings and messages of morality. In addition to the enjoyment shared with the general public, residents-in-training also benefit from finding meaning from these films as they serve as teaching tools for various mental illnesses and syndromes. Accordingly, Victor Miller’s Friday the 13th introduces the campfire horror story of Camp Crystal Lake, which exemplifies our third module (Table 4).
Friday the 13th is a 1980 film written by Victor Miller about a group of teenagers who are murdered one-by-one while attempting to reopen an abandoned campsite. Filmed in Blairstown, New Jersey, the movie begins in the summer of 1957, with two camp counselors being murdered by an unseen assailant after they sneak away to a cabin to “party.” The film then jumps to present day, and chronicles the ill-fated attempt of a group of counselors to reopen Camp Crystal Lake. Friday the 13th introduces the "über-slasher," Jason Voorhees, an imposing giant who dons a goalie mask and wields a machete.
Despite his reputation, avid horror fans “should know that Jason's mother, Mrs. Voorhees, was the original killer (16),” with Pamela Voorhees revealing herself in the movie’s penultimate scene. She discloses that her son, Jason, drowned in Crystal Lake years before because camp counselors were drinking and having sex instead of watching him. A lengthy chase ensues, which ends with the character Alice decapitating Mrs. Voorhees.
The second part of the Substance-Related Disorders section in the DSM-IV is the category of Substance-Induced Disorders. Substance-Induced Disorders may include substance intoxication, substance withdrawal, substance-induced neuropsychiatric syndromes (e.g., Alcohol-Induced Mood Disorder), and other syndromes caused by the ingestion of a substance (e.g., fetal alcohol syndrome, overdose, etc.). Friday the 13th serves two major teaching points of the Substance-Induced Disorders and Syndromes: 1) the introduction of the fetal alcohol syndrome (FAS), through plot summary; and 2) reviewing the stereotypic facies of children afflicted with FAS. For example, the motive behind the mass murders at Camp Crystal Lake serves as a metaphor for FAS. Just as FAS results from the teratogenic effects of alcohol in utero, the creation of the abominable Jason Voorhees is the direct result of alcohol’s influence on camp counselors, who were partying instead of supervising the 11-year-old boy swimming in Crystal Lake.
For decades, films have entertained people and affected their attitudes regarding a multitude of issues and conditions. Course directors in higher education, both in undergraduate (17, 18) and postgraduate courses (3, 4), often reference film to depict aspects of human behavior. At the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, we have created a novel resident didactic where psychopathology is taught through a movie club. Our course fits in the postgraduate training curriculum, building on basic science and clinical knowledge obtained in medical school. Our project is different from other programs that use films to teach psychopathology in that REDRUM references movies that serve a metaphorical role in the depiction of a mental illness. Through plot summary and character analysis, participating residents engage in discussion that the lecturer facilitates to reach the course objectives.
The use of films in teaching psychiatry is not without controversy (18). The bulk of films are made for commercial reasons (see Table 5), not for educational purposes, often compromising diagnostic accuracy (5, 18). Also, in none of the examples we discuss is there exact concordance between the character and the DSM syndrome it is being used to exemplify. We acknowledge this limitation, but use this as a teaching point to underscore that rarely in clinical practice do the patients we encounter demonstrate exact concordance with a particular DSM syndrome. This highlights our reasons to continue to use film and literature in training residents about psychopathology. We believe this is a technique that makes learning stimulating and inspires curiosity in our residents, but, perhaps more importantly, to show the complexities of psychopathology and diagnosis, including areas of clinical overlap and ambiguity.
We also take the responsibility seriously not to perpetuate the stereotypes of mental illness often portrayed in cinema. Although we discuss plot summaries and character analyses of movie monsters to symbolically bring about major teaching points in psychopathology, measures are taken not to perpetuate the stigma often associated with mental illness. Residents are encouraged to complete anonymous course evaluations addressing feelings of being offended, and they are reminded that they can meet with the course director at any time to discuss their concerns. We also conspicuously avoid movies that deal directly with mental illness, such as One Flew Over the Cuckoo’s Nest.