The Death of Mr Lazarescu
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7526.1209-a (Published 17 November 2005) Cite this as: BMJ 2005;331:1209Data supplement
Unknown White Male
Piyal Sen
lead consultant, men’s services, and consultant forensic psychiatrist, Priory/Blenheim Secure Services, Chadwick Lodge, Milton Keynes
Directed by Rupert Murray
Shown at the London Film Festival on 20 and 21 October
A young British man wakes up on a subway train in New York City to realise that he has lost all past memory. He is a man without an identity. What subsequently follows is his search to rediscover himself. The chance discovery of a telephone number on his person leads him to a friend. He is thus able to find out about his home, job, friends, and family. Doctors investigate his condition but can find nothing wrong apart from a pituitary tumour. The tumour is taken out but this does not improve his memory. His procedural memory is completely preserved. What he has lost is semantic memory, memory for past events. The most likely diagnosis is psychogenic amnesia. He is advised that his memory will return but with no time frame. Undaunted, he sets about trying to rebuild his life.
The film is based on a true story. The director, Rupert Murray, an old friend of the principal protagonist, Doug, spends more than a year filming various episodes in Doug’s life, like his reunion with family and friends, visits to doctors, attempt to restart his career, and starting a new relationship. He also speaks to people who knew Doug from before and also to experts, both doctors and philosophers. The result is not just a fascinating case history, but also a balanced exploration of how identity can be a double-edged sword.
Psychogenic generalised amnesia is an extremely uncommon condition. It generally tends to follow markedly stressful life events. Recovery is usually complete. There was no obvious precipitant for Doug, though his amnesia makes this hard to corroborate. One could speculate whether this was due to deliberate avoidance of unpleasant memories, or unconscious repression. Doug himself wishes to spend more time building up his new life instead of finding out why he lost his old. Friends, family, and work supervisors find the new Doug to be more reflective, less cynical, but miss his old sparkling wit and sense of humour. However, there is a sense that he is reclaiming some of his old personality traits with time. He does feel a connection with his older sister and regrets losing all memories of his dead mother.
Philosophers discuss whether Doug is the same man, but a different person. Some profound questions are raised about the very nature of identity. Carl Jung coined the term "collective unconscious," which links every individual’s personality development to numerous life experiences from birth. The adult personality is formed by a dynamic interaction between the genetic endowment at birth and formative life experiences. However, like Doug, if one loses the total life experience from conscious memory, does the experience remain in the unconscious and influence the future personality, or does one start with only the genetic endowment and build up a collective unconscious all over again? This film might provide some answers. Most of all, it reminds us of the educational power of individual case reports in rare conditions. A psychiatrist named Freud would have been very pleased.
15 Park Avenue
Piyal Sen
lead consultant, men’s services, and consultant forensic psychiatrist, Priory/Blenheim Secure Services, Chadwick Lodge, Milton Keynes
Directed by Aparna Sen
Shown at the London Film Festival on 27 and 30 October
"She is looking for something she cannot find. Aren’t we all?" This is how Meethi’s psychiatrist tries to explain her behaviour to her demanding and highly educated elder sister, Anjali. Meethi is looking for an address, 15 Park Avenue, where she lives with her four children and husband, Jojo. The address exists only in her fantasy world. She retreats into this world following a highly traumatic rape and her fiancé, Jojo, deserting her subsequently. She is looked after by a carer, who convinces her mother to call in a witch-doctor. This leads to a suicidal attempt and hospital admission. Two painful realities of psychiatric practice in India are exposed subsequently, treatment only after advance cash payment and the mandatory involvement of the police, suicide being still a criminal offence. Meethi is treated with antipsychotic medication and electroconvulsive therapy (ECT). She drinks fluids and eats excessively. Despite ongoing treatment, her delusions remain fixed. Her elder sister refuses to go abroad leaving her behind and eventually breaks up from her fiancé.
In a final twist, Meethi comes across Jojo while on holiday. Jojo is married by now with two children. She does not recognise him, but Jojo starts visiting her and opens up some splits within the family, as Meethi tries to use him against her elder sister. He eventually ends up accompanying her on the mythical search for 15 Park Avenue. Her elder sister and the psychiatrist have struck up a relationship by now and end up joining the same search.
The film portrays well the dilemmas and conflict inherent in a family where a member has schizophrenia. While doing this, it strikes the right balance between advocacy and accuracy. The information provided about the illness, its genetic link, precipitating factors, course and modes of treatment, was remarkably accurate. There is also an explanation of the role of ECT and its potential benefits. This is almost revolutionary, as almost every film on psychiatry has portrayed this practice as primitive and barbaric. The association between schizophrenia and excessive fluid ingestion, and the link between antipsychotic medication and hunger, leading to weight gain, is well illustrated.
Perhaps most importantly, the film highlights two key issues in the management of schizophrenia. Firstly, it demonstrates the high expressed emotion (EE) in families with schizophrenia, a key target for family therapy to reduce the possibility of relapse. Secondly, it illustrates the point that delusions can at times be protective of the psyche. Attacking such delusions with cognitive behavioural therapy (CBT) is not always the answer.
Regarding drawbacks, the demonstration of seizures in Meethi was confusing, as epilepsy can be protective of schizophrenia. The development of intimacy between Anjali and the psychiatrist could send out the wrong message regarding personal conduct of psychiatrists.
That said, this is a refreshingly original film on a much stigmatised topic. It should be essential viewing for any professional who has ever come into contact with a patient of schizophrenia. The themes explored are universal, and not just confined to the Indian sub-continent.
See more
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