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Saturday, September 06, 2008

Do Diagnoses Really Matter in Films?

APA In his review of Lars and the Real Girl, Larry Leitner notes, “Lars, a tender and decent man [would] probably earn a DSM diagnosis of schizoid, avoidant, or perhaps even schizotypal personality disorder.”

What diagnosis would you give Lars?

Read the Review
ReviewHealing Through Relationship
By L. M. Leitner
      PsycCRITIQUES, 2008 Vol 53(35)


Thomas Scheff

When I first saw Lars and the Real Girl, I wrote a review which complements Leitner's.

It Takes a Village
Lars Lindstrom is the protagonist of this unusual and touching film. A 27-year-old unmarried man, he has never dated. He lives in the garage of his brother and sister-in-law’s house in a small town in Canada.
Lars shies away from everyone, and wants it to stay that way. His sister-in-law goes to heroic lengths to get him to share a mea, but he resists. Not rude, but it’s clear that he doesn’t want to be included. She then tries to fix him up, but he is obviously not interested.
A strenuous testing of Lars’ ties to his community occurs because by chance he overhears a conversation between two men in the office where he works. They are having a lewd chat about a full-size, anatomically correct female doll for sale online. Lars orders it, and when delivered to his garage, he tells his sister-in-law that he wants to bring his girl friend Bianca to dinner.
They are delighted until he carries the doll into the house. He talks to her and eats from her plate as if she is eating. They realize that he is deluded, thinking that the doll is real. He is not only deluded, but also innocent; rather than using the doll sexually, he treats it as his fiancée.
The family doctor is consulted. She suggests they stay connected by respecting Lars’s delusion. Initially the townspeople, as they learn about the plan, are aghast. But gradually they fall into line. The plan also leads to Lars having regular sessions with the doctor toward a therapeutic end. His belief that Bianca is sick leads him to bring her for frequent visits to the hospital where the doctor (Patricia Clawson) works. She tells him that he might as well chat with her whilst Bianca is supposedly getting physical treatments.
Other citizens of the town also enter affectionately into Lars’s world, the hospital staff and the whole church, including the minister. Because of the way he is treated by the community, Lars gradually recovers from his delusion.
The Big Picture?
What are we to make of this fable? The idea that “it takes a village” is one possibility. A book (1999) by the writer Jay Neugeboren is relevant. Because of his experience with his brother’s mental illness, Neugeboren investigated many cases in which there was improvement or complete recovery. The common thread that he found was that in every instance, at least one person treated the afflicted one with respect, sticking by him or her through thick or thin.
The biography (1998) of John Nash, a Nobel Prize winner, suggests that he had a similar experience. Although Nash’s case is not included in Neugeboren’s book, Nash’s biographer makes clear that Nash’s mother and wife were a factor in his recovery, since they never gave up on him.
However, the film A Beautiful Mind, purportedly based on Nash’s biography, brings up another issue. In the film, Nash, played by Russell Crowe, attribute his complete recovery to “the newer antipsychotic drugs.” But the biography states that Nash’s refused to take drugs after 1970, long before the appearance of the newer antipsychotics. Indeed, the biographer states that his refusal may have been “fortuitous,” enabling his complete recovery (1998, p. 353). Why the film would falsify this matter remains a mystery.
The disparity between Nash’s biography and the film about him suggests an interpretation of the film reviewed here. The questionable effectiveness of conventional psychiatric treatments, especially drugs, has given rise to a school of thought known as “anti-psychiatry.” Writers like Thomas Szasz, R. D. Laing, William Glasser, Erving Goffman and many others have suggested that the medicalizing of mental illness has reaffirmed the labeling and rejection of the mentally ill. Several of these writers have hinted at a social, rather than a medical model, one that would resist the temptation to drug, segregate, and mistreat. But what would such a model look like?
The whole community stood by Lars through his illness, not just a few of his intimates. Seen in this way, the film represents a detailed and explicit moment-by-moment extended spelling out of the resolution of mental illness in a social, rather than a medical model. Perhaps the makers of this film have never heard of anti-psychiatry and the social model of mental illness, but it fits anyway.
Nasar, Sylvia. 1998. A Beautiful Mind. New York: Simon & Schuster
Neugeboren, Jay. 1999. Transforming Madness. New York: William Morrow

Ryan M. Niemiec

Both Larry and Tom do a nice job at pointing out the critical role of community in the film.

I key in on this point with the lens of Positive Psychology and Peterson & Seligman's (2004) work on character strengths. This film clearly speaks to the strength of citizenship falling under the virtue of justice. This strength involves the "team" of a community coming together to help others or to fight for a common cause (e.g., social justice). The film exhibits the contagious effect of community and the profound effect it can have on a vulnerable individual.

In terms of diagnosis, I agree with Larry that Lars would probably meet criteria for schizoid personality at the onset - Lars is isolative, emotionally vacant, and seems to have minimal interest in others. As the film progresses so does Lars and his interest in others becomes anthropomorphized on a doll. This opens him up and changes him. He becomes much less schizoid. However this change was to swap one disorder for another...he develops a distinct delusional disorder. With the community support, Lars eventually feels comfortable enough to "let the delusion go" or "break."

As clinical psychologists, we know that personality disorders typically do not change much, certainly not in such a short period of time. Lars truly a schizoid that transforms his personality...or is he not truly schizoid...or is this a filmmaker & screenwriter who simply did not study psychopathology well enough before making the film?

Peterson, C. & Seligman, M. E. P. (2004). Character strengths and virtues: A handbook and classification. New York: Oxford University Press.

Thomas Scheff


Or is the film a fable, cleverly constructed so as to both amuse and instruct?


M. Ruslan

"The whole community stood by Lars through his illness, not just a few of his intimates. Seen in this way, the film represents a detailed and explicit moment-by-moment extended spelling out of the resolution of mental illness in a social, rather than a medical model. Perhaps the makers of this film have never heard of anti-psychiatry and the social model of mental illness, but it fits anyway." fully agree

Kay Thomas @ Alliant International University

Lars' reclusive accommodations and refusal to join his family for dinner, as well as his difficulty relating to the other people in the town, suggest Schizoid PD. However, the transition from little/no contact to "relationship" with Bianca to real friendships and the implication of a romantic relationship at the end of the movie suggest an "imaginary friend" situation rather than a full-blown delusion.

If Lars had had real friends and romantic partners before Bianca, I would more likely consider diagnosing some sort of psychosis, but otherwise, Lars may just be late in developing the social skills necessary for friendship, etc. and so goes through the "imaginary friend" phase--which might be a way for children to practice having friends before actually having friends--later than developmentally normal.

Of course, his imaginary friend is the result of a process more complex than those underlying the emergence of most imaginary friends (i.e. those that aren't available for purchase on the Internet and don't come in giant wooden crates), so one has to wonder how Lars reconciles the reality that she arrived via FedEx with his seeming belief that she is real. At this point, we're better off closing the DSM, willfully suspending our disbelief, and enjoying the movie, preferably with copious amounts of unhealthy snack food.

kristen, Alliant International University

I loved reading Larry Leitner's review of Lars and the Real Girl! It seemingly mirrored the hope and optimism inherent in Lars's community and the movie itself.

What moved me about this film is that it would have been so easy for the psychologist to label Lars with a personality disorder or some form of psychosis, but she did not. In some ways, I can see this as lending to the fanciful feel of the film; would a person's community truly engage in one person's delusion, purely on good faith? Yet, the importance of doing so cannot be so easily downplayed as fiction. As Leitner asserts, "the psychologist aligns herself with an extensive literature (e.g., Elliott, 2002) showing that honoring the experience of another allows healing to occur." As a result, Lars is allowed to work out his issues in a profoundly supportive environment; it is a beautiful testament to the healing power of relationships, and the need for us to have faith in each other.

I worry about the pressure to make diagnoses, usually under a deadline for insurance purposes. If Lars had been diagnosed, his life would have taken a different course; one most likely predominated by medication and a loneliness more profound than that which he was already experiencing. It is so difficult for us, as professionals, to allow a client space to do work like Lars and still meet the requirements necessary to continue to provide services. This movie is a beautiful glimpse into the "what if."


I would probably diagnose lars with Schizophreniform witha rule out of an adjusment disorder. I would also rule out schizoid personality disorder as well.

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Editor of PsycCRITIQUES

Danny Wedding, PhD

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College of Medicine,
American University of Antigua

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