What disorder did the joker have

As a psychiatrist, I was blown away by the latest Joker

Culture
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Mental health

This was published 3 years ago

Opinion

By Kamran Ahmed

October 26, 2019 — 12.00am

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Like many others, I recently went to watch Joker aware of the controversy surrounding the film: is it an irresponsible portrayal of mental illness likely to incite copycat violence, or a cinematic masterpiece and powerful political statement?

Being a psychiatrist, I abhor negative depictions of the mentally ill but as an ardent Batman fan I was hopeful. As it happens, I was blown away. Joaquin Phoenix’s towering performance and Todd Phillips’ masterful direction undoubtedly helped, but mostly it was the way it approached mental illness.

Joaquin Phoenix plays the eponymous character in Todd Phillips' Joker.

The film poses an important question vocalised in no uncertain terms by the Joker at its climax. "What do you get when you cross a mentally ill loner with a society that abandons him and treats him like trash? ... You get what you f---in’ deserve," he proclaims as he murders the talk show host before him.

Although this response and the violence in the scene are vicious, it is a stark metaphor for the disastrous consequences that can arise if we do not give mental illness the importance it deserves.

The Joker (or Arthur) appears to have a complex mix of diagnoses, including pseudobulbar affect – a rare condition consisting of uncontrollable laugher or crying, and possibly a psychotic illness, evidenced by his apparent hallucinations about the subject of his affections (played by Zazie Beetz). In addition, he displays features of certain personality traits that are not technically considered to be mental illnesses – psychopathy (he feels no empathy for the victims of his violence) and narcissism (which makes him crave attention and adulation by any means necessary).

Phillips has clearly done his research and illustrates the path to the development of these conditions elegantly. We are told Arthur suffered early life trauma – horrific abuse as a child at the hands of his mother’s partner including head injury, which is a risk factor for serious mental illness including pseudobulbar affect. He also has a family history – his mother has delusional disorder and narcissistic personality disorder, and he experienced abandonment as a child and the absence of a father figure, which can predispose to certain psychiatric conditions.

To those with mental illness, some aspects of the film will be immediately relatable. The loneliness, isolation, and "constant negative thoughts" Arthur describes are problems my patients face every day. An entry in his notebook, "the worst part of having a mental illness is that people expect you to behave as if you don’t", is poignant and those with a mental health issue of any description will relate. I have social anxiety – a relatively less serious mental health condition – but I can’t turn up to a dinner party and open with "I’m freaking out right now" just as someone hearing voices can’t disclose this experience to those around them.

But the major difference between the Joker and other less favourable on-screen accounts of mental illness is the attempt to explain how Arthur got to this point. This is not your typical stigmatising tale of a crazed villain who should be exterminated by the hero. Even The Dark Knight was occasionally guilty of this, with Batman’s pejorative description of the Joker as a "schizophrenic clown". Nor is it a film ridiculing the mentally ill like the detestable Me, Myself & Irene. We are not laughing at Arthur nor distancing ourselves from him; instead we are forced to empathise with the protagonist.

Any suggestion of a strong link between mental illness with violence is, of course, inaccurate and although the Joker does commit unspeakable atrocities, these appear to be driven by his personality traits and not his mental illness. In reality, some mental illnesses can at times make people do tragic, awful things because they are scared, paranoid or desperate. But what are we going to do about it? Fund services that can help and treat them with sympathy and respect, or deprive them of assistance, discriminate against them and leave them and others to suffer the consequences?

In the current political climate all over the world, public health services are shamefully underfunded and public sector health workers feel devalued. The scene where the jaded social worker interviewing Arthur tells him "they don’t give a shit about people like you … and they don’t give a shit about people like me either" will resonate with the mentally ill who feel abandoned and the healthcare professionals struggling to help them.

Although concerns have been raised that this film will incite violence (perhaps intensified by the 2012 mass shooting in Colorado during a screening of The Dark Knight), the same could be said of any film featuring a violent anti-hero. Targeting Joker specifically seems unjust. Joker searingly addresses some of today’s most pressing issues – mental illness and the disenfranchisement of the underprivileged, which should be our focus. It invites the public to try to understand mental illness and empathise with those suffering from them. It also challenges governments around the world to fund mental health services adequately and reduce inequality The question is will they take it seriously, or write it off as a bad joke?

Dr Kamran Ahmed is a psychiatrist.

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Analysing Joker: an attempt to establish diagnosis for a film icon

Review

. 2021 Dec;45(6):329-332.

doi: 10.1192/bjb.2020.146.

Valentin Yurievich Skryabin¹

Affiliations

Affiliation

¹ Moscow Research and Practical Centre for Narcology, Russia.

PMID: 33407973
PMCID: PMC8727382
DOI: 10.1192/bjb.2020.146

Free PMC article

Review

Valentin Yurievich Skryabin. BJPsych Bull. 2021 Dec.

Free PMC article

. 2021 Dec;45(6):329-332.

doi: 10.1192/bjb.2020.146.

Author

Valentin Yurievich Skryabin¹

Affiliation

¹ Moscow Research and Practical Centre for Narcology, Russia.

PMID: 33407973
PMCID: PMC8727382
DOI: 10.1192/bjb.2020.146

Abstract

Todd Phillips's film Joker, a 2019 psychological thriller, has stirred up strong reactions to the portrayal of the lead character's mental disorder, which is never specified. I used DSM-5 criteria to study whether Joker/Arthur Fleck showed signs of a real mental disorder. The psychopathology Arthur exhibits is unclear, preventing diagnosis of psychotic disorder or schizophrenia; the unusual combination of symptoms suggests a complex mix of features of certain personality traits, namely psychopathy and narcissism (he meets DSM-5 criteria for narcissistic personality disorder). He also shows the symptoms of pseudobulbar affect due to traumatic brain injury. This apparent co-occurrence of both mental disorder and a neurological condition may be confusing for audiences trying to understand mental illness.

Keywords: DSM-5; Mental health; personality disorders; psychopathology; stigma and discrimination.

Conflict of interest statement

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Publication types

90,000 Mockingberry Disease - BBC News Ukrainian

David Robson
BBC Future

10 Chervnya 2016

Author photo, Thinkstock

Some people - they can not be held, so that they do not stand in order at every opportunity or not. As the BBC Future columnist points out, this could be a sign of a specific neurological disorder.

Derek's wife put up with her husband's behavior for much longer than anyone else would, but she finally decided to call the doctor.

Almost every night her husband woke her up to tell her the next joke that came to his mind. Demanding to finally get some sleep, she convinced him to write down jokes and puns rather than share them in the middle of the night.

Derek soon wrote 50 pages of jokes like this. "I come to check my eyesight somehow to get a driver's license. The doctor shows me the letters, and I tell him:" A, B, C, D, E, E, E, F, give me a license already. "

Or : "How to satisfy hunger? We need to move away from the buffet."

Derek the mockingbird (not his real name) was obviously not a talent for Oscar Wilde, but every time he said them, he laughed uncontrollably. Many of the jokes were quite rude and we won't repeat them here.

It is easy to guess that after five years of tireless husband puns, the wife's patience snapped. In addition, she was worried about other oddities in Derek's behavior - for example, a tendency to steal candy from local stores.

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"I woke up and spoke with a French accent"

She finally made an appointment with UCLA neurologist Mario Mendez. "Derek was joking so much at the appointment that it was hard to stop him," recalls Mendes, who published an account of the case in a professional neuroscience journal.

Mendez diagnosed a patient with a neurological disorder that bears the German name Witzelsucht and is expressed in an impulsive desire to pour out jokes and puns, not always witty. The cause of the strange pathology could be two strokes that the man suffered with an interval of five years.

Derek's family learned from experience that there is nothing funny about this disorder. However, his research may shed light on the complex thought processes that underlie the ordinary human sense of humor.

Image copyright, Thinkstock

Caption before photo,

It can be difficult for a family if jokes, puns and anecdotes are incessant

One of the first reported cases of impulsive jokes was discovered in 1929 by the German neurologist Otfried Foerster under rather unusual circumstances.

Dr. Foerster once operated on a tumor on a patient who was conscious, as is often the case with brain operations.

When Foerster began manipulating the cancerous tumor, the man suddenly burst into a torrent of words, making one joke worse than another.

In the same year, psychiatrist Abraham Brill reported that he had also encountered similar cases in his practice. Some of his patients were constantly mocking, and not only when they were on the operating table.

Since then, many similar cases have been described. Oddly enough, most of these patients - and Derek among them - do not laugh at other people's jokes, although they find their own incredibly witty.

All this may be a sign of characteristic damage to the frontal lobes of the brain.

Image copyright, iStock

Image caption,

Man's behavior changed after stroke

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For example, Derek suffered a cerebral hemorrhage about 10 years ago that damaged his right forehead. After this incident, his behavior changed: he began to carefully search the trash cans to find scrap that could be recycled.

However, the man's sense of humor at this stage remained the same as before. Then, it seems, he had a second stroke, which injured the so-called caudate nucleus of the brain. This deeply hidden area acts as a link between the forehead and the rest of the brain and is responsible for conscious, analytical thinking.

It was after this that Derek developed a craving for endless jokes, which brought his wife to white heat.

To understand how such brain damage can cause mocking tendencies, it is first worth considering how the brain processes humor in general.

Let's take an anecdote, recognized by researchers from Oxford as one of the funniest in the world:

Three people on a deserted island found a lamp with a genie who agreed to fulfill one wish for each. One wanted to return home. The second one also asked to go home. When the genie fulfilled their wish, the third one said: "Something has become boring. Bring these two back"

Perhaps this joke is funny when told by a professional comedian. But the main thing is that most of these jokes are built on the discrepancy between the final phrase and the expected development of events, and the brain has to draw several conclusions in order to understand the point of the joke.

You need to imagine yourself in the place of people who find themselves on a desert island, and how they feel when their secret desire is fulfilled, and then an unexpected ending awaits us. The process of solving this logical chain irritates the brain's pleasure centers, and the person laughs (or at least smiles politely).

"The moment we laugh at a joke is the moment we understand it," explains Jason Warren of University College London.

These thought processes take place in the frontal lobes of the brain, the same areas responsible for analytical thinking, and damage to which has been observed in Derek and other patients with a similar disorder.

"They don't see the link between the catchphrase and the beginning of the joke, so they don't show surprise," explains Dr. Mendez.

But at the same time, such brain damage seems to disrupt the signaling circuits that connect the frontal lobes to the pleasure centers. So while the witticisms of others may not seem funny to such patients, their own thoughts and feelings, arising from random associations, can lead to releases of the neurotransmitter dopamine and cause fits of laughter.

At least that's what the theory says. And there are good reasons for further study of this disorder.

Warren works with patients with frontotemporal dementia, which occurs in people in their prime. Among its symptoms is the emergence of difficulties in recognizing the feelings and motivations of other people.

"As a result, the social abilities of the patients are greatly reduced," the specialist explains. These problems are often accompanied by a disturbed or inappropriate sense of humor.

One of the patients diagnosed with impulsive banter by Mendes also suffered from frontotemporal dementia, although the two disorders are not always related.

Image copyright, Thinkstock

Image caption,

These patients usually have difficulty understanding complex wordplay jokes and prefer crude humor

Prof. Warren recently asked his patients to review and rate various collections of cartoons, comparing their responses to snapshots of brain activity.

It turned out that most of these patients do not understand complex, ambiguous jokes, preferring rough, direct humor. For example, a drawing of a bewildered woman whose dress was torn off by a passing car.

The more difficult the task seemed to the patients, the more severe damage was observed in their brain system responsible for humor.

Importantly, changes in sense of humor can be the first sign of a disorder. Doctors should listen to the opinion of the patient's family members on this matter. "There have been cases where such changes were reported by relatives of the patient years (in one case, nine years) before the diagnosis was made," Warren notes.

It is possible that over time, scientists will develop a standard test of sense of humor that will track changes in people's social abilities.

Well, in the end, this is another reason to think about what a complex series of conclusions the brain must make in order to understand the interlocutor's joke.

"Humor is a very complex phenomenon, but we often take it for granted," is Professor Warren's final phrase.

"Joker": what mental illness causes the laughter of the hero Joaquin Phoenix?

Laura Plitt
BBC Mundo

14 October 2019

Image copyright, Warner Bros

Image caption,

The Joker's laugh sounds forced and unnatural, but he can't help it

Warning: text contains spoilers .

Frightened look, broken voice, nerves on edge - Arthur Fleck is trying to pull himself together before a performance at the Gotham comedy club.

Joker - namely, this is the name Arthur chose for himself ( in English Joker means "jester" or "joker" - approx. edition ) - coherent speech is not easy: every attempt to speak is interrupted by an attack of sharp, strained laughter, which he is unable to stop.

It is this attack that overcomes the character in one of the key scenes of the recently released movie "Joker".

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Late at night, returning from work dressed as a clown, Fleck becomes an unwitting witness to three well-dressed men on the subway molesting a woman. And at the sight of this, he bursts into Homeric laughter.

Image copyright, Warner Bros

Image caption,

In another scene, Arthur is overcome with uncontrollable laughter on the bus

Skirmish

The men think Fleck is laughing at them and start beating him severely. In response, he pulls a revolver from his pocket and kills all three.

By this point in the film, the audience already knows that Arthur is suffering from some kind of mental illness. To cope with his symptoms, he takes seven different medications at once, keeps a diary and sees a therapist regularly.

Is there really a disease that causes uncontrolled fits of nervous laughter?

It turns out, yes. Joaquin Phoenix's character may have a rare form of epilepsy known as laughter epilepsy.

"It's a fairly rare variety - it accounts for only about 0.2% of all seizures," explains neurologist Francisco Javier López, who researches epilepsy, to the BBC.

Image copyright, Getty Images

Image caption,

Joaquin Phoenix's acting is flawless by many critics

"Laughing like that doesn't fit the situation at all. It's not really fun or funny for the patient, it's just that he or she can't control the seizure. " , Lopez adds.

Laughter epilepsy is most commonly caused by a small, benign tumor known to physicians as a hypothalamic hamartoma. It disrupts the normal functioning of the hypothalamus, a part of the brain responsible for a number of critical functions, from regulating body temperature to emotional reactions.

Additional stress

However, sometimes the cause of such laughter can be a tumor in another part of the brain - for example, in the frontal or temporal lobe.

More often than not, patients suffering from this tumor also have occasional seizures.

"In any case, an attack of uncontrollable laughter causes additional stress, because in a normal attack the patient loses consciousness and does not understand what is happening around," explains Lopez. "But if you are conscious and aware that your laughter completely inappropriate, it could cause serious suffering to yourself."

Image copyright, Getty Images

Image caption,

Some brain tumors can cause uncontrollable laughing fits

Anti-epileptic drugs are usually prescribed to reduce the likelihood of such seizures, and sometimes even surgical intervention is offered.

Seizures can occur daily if untreated, but with proper medical care, their frequency can be reduced to one or two per month, and sometimes completely eliminated.

According to Lopez, adults experience this problem more often than children or teenagers.

In addition, such seizures may signal the early development of senile dementia.

Violence

Despite the fact that this is a rather rare disease, the Spanish neurologist says that in his practice he met patients with this pathology at least three times.

Image copyright Warner Bros

Image caption

Laugh epilepsy has nothing to do with violence, experts say

One of them is a court lawyer. Before each meeting, he had to tell those present about his illness and warn that he might have a seizure, as this often happens in a stressful situation.

However, the tendency to violence - an integral and defining feature of the protagonist of the "Joker" - has nothing to do with this disease, the expert claims.

Emotional incontinence

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On the other hand, laughter epilepsy is not the only condition that can cause involuntary and uncontrollable fits of laughter.

There is a disorder known to physicians as "affective lability" or emotional incontinence, characterized by intermittent bouts of laughter and sobbing.

"This term describes uncontrolled emotional reactions that do not fit into the social context and do not reflect the patient's true feelings at the moment," explains neuropsychologist Andy Tierman to the BBC.

"Such a person may appear completely overwhelmed by some circumstance that would previously have caused him only mild disappointment," he adds.

Learn more

What disorder did the joker have

As a psychiatrist, I was blown away by the latest Joker

Opinion

By Kamran Ahmed

From our partners

Analysing Joker: an attempt to establish diagnosis for a film icon

Affiliation

Author

Affiliation

Abstract

Conflict of interest statement

Supplementary material

Similar articles

References

Publication types

"Joker": what mental illness causes the laughter of the hero Joaquin Phoenix?

Skirmish

Additional stress

Violence

Emotional incontinence