DSM: Diagnosis Seen in Movies
By Birgit Wolz, Ph.D., MFT
Jerry A. Baerwitz, Richard Gere, Debra Greenfield, Alan Greisman
Eric Roth, Michael Cristofer
Richard Gere, Lena Olin, Anne Bancroft, Tom Irwin
Year of Release:
In one of the first scenes of this movie, Mr. Jones drives to a construction site. He succeeds in persuading the contractor to hire him because he is highly attuned to the nuances of those around him and therefore picks up on the contractor's upstate New York accent. Jones appears charismatic, seductive , provocative , and euphoric . In a grandiose fashion, he claims that he can do the work of two men. He offers to work free for the first day, but expects to be paid double for his second day. By the third day, Jones predicts that he will have taken over the foreman's job.
But as he starts working, Mr. Jones appears very distractible . He is unaware of the normal work hazards and does not take necessary precautions. While hammering nails, he starts a counter-rhythm to the other men's strikes. He believes that he is clairvoyant in guessing how many children one of his co-workers has. When a plane flies overhead, Jones becomes fascinated by it and tries to calculate whether the speed of a crosswind might allow him to fly.
Before walking out on a perch of the roof, Mr. Jones insists that Howard, his newfound friend and co-worker, accept a $100 bill. Jones instructs his co-worker to take his family out to dinner. When Howard realizes that Jonesr really believes that he can fly, he persuades him to move away from the beam where he is teetering. With a report that he had been agitated , delusional, and having auditory hallucinations, an ambulance takes Jones to a local psychiatric emergency unit for an involuntary admission.
In his intake session with psychiatrist, Dr. Elizabeth Bowen, Jones displays his personal charm. Based on the wrong diagnosis, he is given inappropriate medications and released the next day because he no longer meets the grounds for involuntary committal.
Within hours of being discharged from the hospital, Mr. Jones goes to his bank and charms the teller, Susan, into joining him for the day. He withdraws over $12,000 and closes an account that he had just opened five days earlier. Then Jones gives a $100 bill to Susan, because she "will need it to take him to lunch". He buys cloths for her to wear to the opera that evening, takes her to an expensive hotel, and gives extremely generous tips to a hot dog vendor and a bellboy.
Mr. Jones manages to spend all his money in a couple of days, indicating a self-destructive pattern. He purchases a baby grand piano just minutes after walking into the store
and then attends a concert. During an evening at the Symphony with Susan, his passion for music overwhelms him. Jones jumps on stage to wrest control from the conductor because he is convinced that Beethoven would have wanted his "Ode to Joy" played at a much faster tempo.
As a result of this civil disruption, he gets arrested and once again is hospitalized. This time Mr. Jones arrives in a state of agitation and manic exhaustion. He gets accurately diagnosed and treated by Dr. Bowen. To protect himself from hurting himself or others, he initially is placed in a four-point restraint and given a sedative, to help him rest.
During their therapy sessions, Mr. Jones gives the psychiatrist a summary of his life. At age three he started to play Mozart, by twelve he had read "everything," and at eighteen he was the "center of the universe. "And then I woke up one day and I was in a mental institution," he explains. Jones was first diagnosed with manic-depressive illness in late adolescence and had
several hospitalizations for more than 20 years. He talks about a serious suicide attempt in college, but then makes light of it by adding a joke.
Pretty soon Mr. Jones spirals into a depression. First his concentration decreases as he loses an unusual skill with numbers; then he appears listless and sullen . He becomes so apathetic that he can't even wash himself. He wanders around, not enjoying anything that usually appeals to him. He moves slowly, appears lost , and ultimately accepts help. After he realizes that he "can't stop the sadness ", he takes his prescribed medication.
Not long after this phase, his mood starts to escalate again. His speech speeds up , and he shows a sense of humor . But instead of his previous qualities of
expansiveness or elation, Jones now demonstrates irritability.
The rest of the movie involves an unethical romantic relationship between Jones and Dr. Bowen, who has serious problems in her marriage and eventually
resigns from the hospital.
Clients with bipolar disorder transition between the poles of mood states . According to the DSM-V-TR, Bipolar I disorder is diagnosed when a person has manic and (in most cases) depressive episodes (296.0x - single manic episode, 296.40 - most recent episode hypomanic, 296.4x - most recent episode manic, 296.6x - most recent episode mixed, 296.5x - most recent episode depressed, 296.7 - most recent episode unspecified). The diagnosis of Bipolar II disorder is reserved for those who have primarily one or more depressive episodes , with occasional (at least one) hypomanic episodes . (296.89)
An episode is defined as a mood disturbance that has either a full recovery or switches to the opposite polarity. "X" defines the severity of current or most recent episode: 1 - mild, 2 - moderate, 3 - severe without psychotic features, 4 - with psychotic features, 5 - in partial remission, 6 - in full remission, 0 - unspecified.
In Bipolar II disorder the hypomanic episodes themselves usually do not cause the impairment and may even be associated with good functioning and enhanced productivity . Without proper treatment hypomania can develop into mania in some people or can switch into depression.
In both Bipolar I and Bipolar II disorders, symptoms of persistent depressed mood, loss of interest in daily activities, poor concentration, slow movements, feelings of hopelessness, apathy, suicidal ideation, and changes in eating and sleeping patterns can characterize the major depressive episode. Concentration, motivation, self-esteem, and energy level are areas most often affected.
Manic episodes tend to be extreme. There is a significant impairment of occupational and social functioning. A person often experiences marked elevated, euphoric, and expansive mood, increased energy, restlessness, racing thoughts, distractibility, lack of concentration, little sleep, unrealistic beliefs in own abilities, poor judgment, spending sprees, increased sexual drive, attraction to drugs, particularly cocaine, alcohol and sleeping medications, and denial that anything is wrong. Extreme excitation can lead to engagement in high-risk behaviors, sometimes interrupted by outbursts of irritability or even violence.
Mr. Jones's example helps us understand the multifaceted nature of this illness for the purposes of an accurate diagnosis that supports effective treatment planning, as well as communication with insurance companies. The film's protagonist appears to illustrate symptoms of Bipolar I disorder. Like many manic clients, he has a contagious quality to his manic moods, and lifts the spirits of those around him. He quickly becomes the center of attention, and seems to thrive on making others around him more animated. He is confident, daring , and charismatic. When Jones gives away money, he demonstrates excessive involvement in activity that will likely result in painful consequences .
During their first meeting, Mr. Jones notices that Dr. Bowen has an area on her ring finger that is less tanned than the rest of her hand, and comments that she must have suffered a "recent emotional setback."
During manic episodes, clients have finely honed powers of observation and deduction. They have an uncanny ability to pick up on people's weaknesses or areas of sensitivity. Because their energy levels are increased and inhibitions have all but disappeared, it is common for such clients to go on to exploit their discoveries. Frequently, this manifests itself in testing the limits of those around them.
Upon Mr. Jones' first arrival at the hospital, Dr. Bowen bases her preliminarily diagnosis of Paranoid Schizophrenia on the wrong initial report of auditory hallucinations. He is not paranoid or hears voices or sounds. Only after a second encounter with her patient, she corrects her mistake. This happens when he gets released from the hospital and Dr. Bowen arrives for work at the same time. He talks very fast and intrusively , asking her how she feels about choral music and Beethoven's 9 th Symphony. Jones also demonstrates
pressured speech. His ideas are logical, but flow at a rate too fast for Bowen to keep up with. Now Bowen reports to her supervisor that he might have displayed mood-congruent psychotic episodes when he had the delusion that he can fly but that he is not schizophrenic.
Manic and Depressive Episodes can be accompanied by mood-congruent (content consistent with manic or depressive themes) and mood-incongruent (content does not involve manic or depressive themes) psychotic features. Psychotic features are delusions or hallucinations (.x4).
Mr. Jones shows symptoms of a specific form of Bipolar disorder: "with rapid cycling". He shifts from mania to depression and back to mania again in a short period of time.
Bipolar I or Bipolar II disorder with the specifier "with rapid cycling" describes a pattern where four or more mood episodes occur within a 12-month time span. Other than the compressed time frame, the episodes of mania and depression are no different than in the non-cycling type, in which the depressive episode may last three to six months before the person swings to a manic phase. Some people experience mixed episode. They suffer from the symptoms of a mania and depression
almost simultaneously, which is very unpleasant and often accompanied by suicidal ideation .
Dr. Bowen also learns that medication had helped Jones to improve to an even mood state in the past. But he fought against drugs and against the "whole depressing world of normality". Consequently, an important relationship ended when a woman he deeply loved could no longer deal with his mood swings. Jones explains that he needs his highs in order to enjoy life and to feel good about himself. He never feels more alive than during his manic episodes, and he prefers to have them even with the significant problems he endured. Jones says of his even mood states that he "doesn't like living down here any more." He rejects drugs also because they make his hands shake.
Pharmacological treatments sometimes not effective because of problems with adherence and compliance .
During one of their sessions Jones tells Bowen, "...the fact is, maybe I never get the blues. Maybe I'm just a happy-go-lucky guy all the time..."
Most people with Bipolar I disorder experience both depression and mania, although approximately 10 to 20 percent experience only manic episodes.
This movie illustrates correctly that bipolar disorder is a long-term illness that must be carefully managed throughout a client's life.
One important function of psychotherapy and psychoeducation with clients who suffer from bipolar disorder is to help them maintain their adherence to mood stabilizing medication. Mood stabilizers (lithium, divalproex, and olanzapine) are used for acute bipolar manic episodes while lithium and certain antidepressants have shown to be effective during acute bipolar depression. Several new anticonvulsants and "atypical" antipsychotics are undergoing research as promising antimanic agents.
Psychotherapy usually focuses on grief and loss, interpersonal disputes, and role transitions that are associated with this illness.
Cognitive behavioral therapy uses strategies to change negative thought patterns and behaviors associated with bipolar disorder.
Psychoeducation involves teaching clients and their family members about the multifaceted nature of this disorder, its treatment, and how to recognize signs of relapse so that early intervention can prevent a full-blown episode. It can also be an effective tool to improve necessary skills and coping mechanisms.
In couples' and family therapy, problem solving and communication training can help reduce the level of distress within the couple or family that contributes to or results from the ill person's symptoms.
If treated successfully, people with bipolar disorder can lead full and productive lives.
Birgit Wolz wrote the following continuing education online courses:
Cinema Therapy - Using the Power of Movies In the Therapeutic Process, which guides the reader through the basic principles of Cinema Therapy.
Cinema Therapy with Children and Adolescents - This course teaches Cinema Therapy with young clients. It includes numerous movie suggestions, which are categorized according to age and issues. It serves therapists, teachers, and parents.
Positive Psychology and the Movies: Transformational Effects of Movies through Positive Cinema Therapy - This course teaches how to develop clinical interventions by using films effectively in combination with positive psychotherapy. It serves for mental health practitioners and anybody who is interested in personal growth and emotional healing.
Therapeutic Ethics in the Movies - What Films Can Teach Psychotherapists About Ethics and Boundaries in Therapy, which covers: confidentiality, self-disclosure, touch, dual relationships and out-of-office experiences (i.e., home visits, in-vivo exposures, attending a wedding, incidental encounters, etc.)
Boundaries and the Movies - Learning about Therapeutic Boundaries through the Movies, which covers informed consent, gifts, home office, clothing, language, humor and silence, proximity and distance between therapist and client, and, finally, sexual relations between therapist and client.
DSM: Diagnoses Seen in Movies - Using Movies to Understand Common DSM Diagnoses.
Psychodynamic Diagnostic Manual (PDM) - A New Approach to Diagnosis in Psychotherapy