COMMENTARY

'All I've Got Are Negative Thoughts': Reflections on The Joker

Dr Sivan Mauer

December 23, 2019

This text has spoilers.

The Joker is a huge blockbuster film and has been receiving positive reviews, but it has also sparked much discussion about psychiatry. For some, the most critical issue is Arthur Fleck's, or The Joker's, diagnosis and a disease that goes through people's minds is schizophrenia. One of the main reasons for that is the presence of psychotic symptoms (such as delusional thoughts, and auditory, visual, or tactile hallucinations), and the fact that the character has bouts of laughter for no apparent reason.

Not only in the film but also in real life, symptomatic diagnosis in psychiatry is a longstanding issue, a problem that has increased since the publication of the first Diagnostic and Statistical Manual of Mental Disorders (DSM). An example is that in the 1970s, there was a vast difference in the prevalence of schizophrenia between the United States and the UK. In the USA, schizophrenia was seen with a much broader spectrum of symptoms than in the UK. From this question arose one of the great seminal articles of the specialty, explaining the reasons for this difference. [1]

In the same period, Robins and Guze also published an essential article on schizophrenia. In their understanding, a psychiatric illness would have scientific validity only by verifying the following criteria: symptoms, disease course, response to treatment, family history/genetics, and biological markers. [2]  Thus, Arthur may have several diagnoses, from schizophrenia to pseudobulbar syndrome. To try to arrive at a diagnosis for this character, it would be necessary to analyse, besides the symptoms and signs described, the other validators mentioned above.

Analysing the Joker's family history is hard, given that it's not really clear who the character's parents are. One hypothesis is that he is the son of Penny Fleck, a woman diagnosed with psychosis and narcissistic personality disorder, and a history of psychiatric hospital stays. What we must understand is that psychosis is an entirely nonspecific diagnosis; actually, it is just a set of symptoms. Narcissistic personality disorder, even according to personality disorder specialists, would not be a scientifically validated diagnosis, ie, it is no different from other personality disorders.[]However, the film presents the possibility that the character was adopted by Penny and suffered severe childhood abuse. In these settings, there is no way to determine the family history conclusively.

Regarding the course of the disease, Arthur seems to have recurrent episodes, especially when he stops taking his medications. The movie tells us the character has already been in a psychiatric facility and attends psychotherapy follow-up. However, the information is insufficient to understand the course of the disease.

Nevertheless, I do not feel that the diagnosis is the central psychiatric issue of this film, but rather society's relationship with mental illness. This relationship is presented in several forms, such as violence, stigma, and poverty. Even today, there is a general perception that there is a link between mental illness and violence. This is often reinforced by media sensationalism, which produces films and series about crimes committed by people with mental illness when, in reality, the population of criminals suffering from some form of mental illness is small. One study found that in order to prevent a murder, you would need to arrest 35,000 schizophrenic individuals at risk of perpetrating violent acts. This data clearly goes against the common belief that patients with severe mental illness would be a threat.[4]

Another study showed that the highest prevalence of violence lies among patients during acute episodes. [5]  Here, it is essential to remember that Arthur becomes The Joker when the government stops providing his medications, so it triggers an episode of anger, mood swings, psychotic symptoms, and violence.

"The worst part about having a mental illness is that people expect you to behave as if you don't have it." This is an important phrase from the movie, said by The Joker. This statement shows the character's perception of society and having a mental illness. Arthur understands that to live in that society he cannot disclose his disease, because his vulnerability brings consequences, such as being a victim of violence. Importantly, it's not just in Gotham City that people can't relate to the different. To this day, the stigma of mental illness is deeply rooted in our society. The stigma of mental illness is related to the act of labelling and associating different people with negative stereotypes. The loss of status in society is part of the concept.[6]

Poverty and social inequalities are essential elements in Arthur's story and the evolution of his mental illness. Arthur is treated by a social worker, and also depends on his medication being dispensed by public services.

Another critical moment in the movie is when Arthur speaks to his therapist: "You ask the same questions every day: 'How is your work going?' 'Are you having negative thoughts?' All I've got are negative thoughts."

Of course, Arthur is not well, and the therapist has no means to help him. To make matters worse, she announces that appointments will be discontinued and, consequently, the supply of medicines. The Joker is born!

All of these components are very relevant to the life of a mentally ill person. Would The Joker exist if Arthur were in Bruce Wayne's shoes? The answer is: probably not. The Joker is a complex and important film for society, including for physicians to rethink their attitude toward the different and toward mental illness. Did Arthur want to kill, or was Arthur asking for help?

Translated and adapted from Medscape in Spanish

References

  1. Kendell, R. E. et al. Diagnostic Criteria of American and British Psychiatrists. Arch. Gen. Psychiatry 25, 123–130 (1971).

  2. Robins, E. & Guze, S. B. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am. J. Psychiatry 126, 983–987 (1970).

  3. Bernstein, D. P., Iscan, C. & Maser, J. Opinions of personality disorder experts regarding the DSM-IV personality disorders classification system. J. Pers. Disord. 21, 536 (2007).

  4. Large Matthew, M., Ryan Christopher, J., Singh Swaran, P., Paton Michael, B. & Nielssen Olav, B. The Predictive Value of Risk Categorization in Schizophrenia. Harv. Rev. Psychiatry 19, 25–33 (2011).

  5. Choe, J. Y., Teplin, L. A. & Abram, K. M. Perpetration of Violence, Violent Victimization, and Severe Mental Illness: Balancing Public Health Concerns. Psychiatr. Serv. 59, 153–164 (2008).

  6. Gaebel, W., Zäske, H. & Baumann, A. E. The relationship between mental illness severity and stigma. Acta Psychiatr. Scand. 113, 41–45 (2006).

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