Whether or not you have seen the Joker1 movie, it is bound to have an impact on public opinion about psychiatric disorders. A generation ago One Flew Over the Cuckoo's Nest,2 which starred Jack Nicholson, stigmatized electroconvulsive therapy (and psychiatric care in general) but it did not stigmatize those with psychiatric disorders—instead, in that movie, the psychiatric inpatients were sympathetic heroes. In contrast, the Joker shows the development of a battered, damaged, and lost soul who becomes a violent, evil villain. He presents with emotional lability with uncontrollable laughing followed by coughing and gagging, a trait that causes him terrible problems so much so that he carries around a card to give to people so that they can forgive him when he laughs inappropriately. His syndrome is consistent with pseudobulbar affect.3
The most modern criteria for pseudobulbar affect include:
Essential criteria: episodes of involuntary or exaggerated emotional expression that result from a brain disorder, including episodes of laughing, crying, or related emotional displays; episodes represent a change in the patient's usual emotional reactivity, are exaggerated or incongruent with the patient's subjective emotional state, and are independent or in excess of the eliciting stimulus; episodes cause clinically significant distress or impairment in social or occupational functioning; the symptoms cannot be attributed to another neurologic or psychiatric disorder or to the effects of a substance.3
Supportive criteria: patients may experience accompanying autonomic changes (eg, flushing of face) and pseudobulbar signs (eg, increased jaw jerk, exaggerated gag reflex, tongue weakness, dysarthria, and dysphagia); patients may exhibit a proneness to anger.4
The transformation from the meek and harmless Arthur Fleck (portrayed by Joaquin Phoenix) to the murderous Joker character (also portrayed by Phoenix) in the movie occurs with increasingly unbearable and cringe-worthy humiliations heaped upon a nonspecified set of psychiatric disorders (for which he is taking multiple unknown medications), the cessation of those medications (because of the removal of funding for social services), and his increasing delusions of a nonexistent romantic relationship with a neighbor. The back story of Arthur's mother is that she had a delusional romantic relationship with Bruce Wayne's (or Batman) father who adopted Arthur but seriously abused him (including head trauma), and this becomes the explanation for Arthur's troubles. The Joker goes on to become an anti-hero to anti-elitists and a cold-blooded murderer. Sadly, the movie will increase stigma for those with psychiatric disorders and make people afraid. It will take great efforts to combat this setback in the battle against stigma.
- Phillips T, Silver S. Joker [movie]. Burbank, CA: Warner Bros. October4, 2019.
- Hauben L, Goldman B. One Flew Over the Cuckoo's Nest [movie]. Hollywood, CA: United Artists. November19, 1975.
- Sauve WM. Recognizing and treating pseudobulbar affect. CNS Spectr. 2016;21(suppl 1):S34–S44. doi:10.1017/S1092852916000791 [CrossRef]
- Miller A, Pratt H, Schiffer RB. Pseudobulbar affect: the spectrum of clinical presentations, etiologies and treatments. Expert Rev Neurother. 2011;11(7):1077–1088. doi:10.1586/ern.11.68 [CrossRef]21539437