Psychiatry in Kerala

PSYCHIATRIC DISORDERS IN MALAYALAM CINEMA

INTRODUCTION

Malayalam is the language spoken by people of Kerala, the south-western most state of India. Cinema is an important form of entertainment in the state, and its film industry currently releases more than 100 films in a year. Malayalam cinema is known for its aesthetic values and has won numerous awards and accolades at national and international levels. Numerous Malayalam films have dealt with social issues like dowry, corruption, etc., and mental illness have been portrayed in numerous films from Yakshi released in 1968 to Nee-Na released earlier this year.

The reach of cinema has spread beyond the cinema theatres through compact discs (CD), digital video discs (DVD), cable television and the internet, and the information disseminated through cinema now reach a far wider audience. Cinema, being a powerful medium, can shape the way a viewer forms opinions on an issue. In this scenario, we felt it is important to analyze the portrayals of mental illnesses in Malayalam cinema. We searched the literature for any past articles that analyzed the depiction of mental illnesses in Malayalam movies, and were able to find only one review. ¹That article had examined only 20 films from 1986-2006. Thus, to the best of our knowledge, ours is the first comprehensive review and analysis of depictions of psychiatric disorders in Malayalam movies of all times. (Another article from us in this issue of Kerala Journal of Psychiatry examines the portrayals of suicide, grief, stigma, etc., and stereotypical portrayals of mental illnesses, psychiatric treatments, etc. in Malayalam cinema. ²)

METHODOLOGY

We included any Malayalam movie, released between 1968 and 2015, that met any of the following criteria:

1. Depicted a character suffering from mental illness or portrayed a characteristic symptom of a psychiatric disorder like obsessive compulsive symptoms or pervasive mood changes.

2. A psychiatric diagnosis is mentioned.

3. Films which depict the various ways in which a psychiatric disorder, like psychotic disorders, can present.

We were unable to find any credible database which lists all Malayalam films released till date. Hence, to collect information about movies, we depended on two resources that have attempted to comprehensively list Malayalam films according to their year of release:

1. Wikipedia, which has listed films released from the 1960’s to present (https://en.wikipedia.org/wiki/List_of_Malayalam_films).

2. The official website of Association of Malayalam Movie Artists which has listed films released from 1986 to present (http://www.malayalamcinema.com/filmList.php).

Using these lists, whether a movie fits our criteria or not was determined from the personal experience of the authors, various online resources, and from the opinions of various experts in psychiatry who are interested in the field of cinema and mental health (and are listed in the acknowledgment section).

We identified nearly 110 films, and all of them were personally viewed by the authors through CDs or DVDs, in theatres, or at legal web pages. When more than 4-5 movies depicting a condition were found, it was decided to mention in this review only the most relevant 4-5 movies about which some important points worth a discussion were found.

ORGANIC MENTAL DISORDERS

Dementia has been portrayed in Thanmatra (2005) and the story segment The Bridge in Kerala Café (2009). In Thanmatra, the central character has Early-Onset Alzheimer’s disease. The movie depicts how the memory loss affects his activities of daily living, and shows his forgetfulness, personality changes, paraphasias, perseveration in speech, etc. Caregiver burden is depicted well, and the therapist even explains the relevance of addressing this burden. However, though Alzheimer’s disease is a gradually progressing disease, the movie depicted the development of symptoms at a relatively rapid pace, and didn’t bother to show the way the disease gradually progresses over the years. The Bridge depicted caregiver burden, where an elderly lady is shown to have forgetfulness, difficulties in taking care of herself and decline in navigation skills, with her family eventually forced to abandon her. Both these films have been able to sensitize the viewers about caregiver burden in dementia.

In Sapthamasree Thaskara (2012), a central character is shown to develop personality changes like impulsivity and decreased emotional reactivity following head injury. Towards the end of the film, he is shown holding one crore rupees, unable to comprehend the significance of such an amount of money. Though the depicted symptoms were not exactly those of a frontal lobe syndrome, the portrayal does send a message that personality is a product of the brain and that it can change after injuries to the head.

Amnesia following trauma to the head or an accident has been shown in Innale (1989), Mumbai Police (2013), Medulla Oblom Katta (2014), Premam (2015), Muppathirandam Adhyayam Irupathimoonnam Vakyam (2015) and Ormayundo Ee Mugham (2014). Ormayundo Ee Mugham depicted anterograde amnesia, with the heroine forgetting the events occurring in a single day. Being a remake of the Hollywood film 50 First Dates (2004), this movie too repeated the error committed by the movie on which it is based — a portrayal of amnesia that does not resemble any existing neurological or psychiatric disorders.³

All the others films listed depicted retrograde amnesia, with some like Innale and Muppathirandam Adhyayam Irupathimoonnam Vaakyam depicting massive amnesia for events.

SUBSTANCE USE DISORDERS

Pranamam (1986) portrayed how broken families and peer pressure are important in the causation of substance abuse among the youth. Chuzhi (1973), Oru Kanni Koodi (1990) and Spirit (2011) depicted how alcohol dependence disrupts relationships and jobs. Spirit also depicted pathological intoxications, craving and withdrawal symptoms. Nee-Na (2015) portrayed treatment of alcohol dependence, both detoxification and relapse prevention, in detail.

On the other hand, Memories (2013) depicted treating alcohol dependence with gradual weaning off from alcohol — a method that is mostly ineffective and not usually recommended. Idukki Gold (2013), Kili Poyi (2013) and Honey Bee (2013) depicted recreational use of cannabis, without any portrayal of its harmful effects except for hallucinations which the protagonists were shown to enjoy.

PSYCHOTIC DISORDERS

Malayalam cinema is a treasure trove of presentations of psychotic disorders. Many films have focused on psychoanalytic models of development of psychosis. For example, in Njangalude Veettile Athithikal (2014), following the accidental death of her daughter due to a mistake committed by her husband, the heroine hallucinates a male figure and develops secondary delusion of love towards him. The events in the film present her psychosis as an attempt to evoke more guilt on the already grieving husband.⁴ Yakshi (1968), and its remake Akam (2013), portrayed delusional projection of the protagonists’ sexual dysfunction and facial disfigurement to their wives. The protagonists are depicted to have delusions and multimodal hallucinations that the spouses are the mythical female ghosts, “Yakshi”, who spell death and doom to people related to them. Protagonist of Anantharam (1987) is an orphaned child denied love and opportunities who develops hallucinations of his step brother’s fiancé showering him with love and compassion; These psychotic symptoms could have developed to compensate for the lack of such a figure in his real life. (The film also depicts him gradually developing negative symptoms of asociality, avolition and anhedonia.)

Childhood stressors have been shown as a background for psychosis in various films. The antagonist in Oruvan (2007) harbors delusions that women are always of ill repute and need to be persecuted, as a response to his unpleasant childhood experiences with his stepmother and sister. The male protagonists in Aham (1992) and Time (2007), who have a background of deprivation of love and affection in childhood, are shown conversing with their deceased spouses. While in Time it is seen as coping mechanism to his lonely life, in Aham the protagonist commits a murder in response to his commanding auditory hallucinations. In Sadgamaya (2010), the heroine, diagnosed to have schizophrenia, has visual hallucinations of vultures, related to a fearful event in her childhood.

Some movies have shown societal changes to influence the onset and symptoms of psychosis. Elippathayam (1989) portrayed a man’s descent into paranoia, being unable to cope with the changes happening in the society around him. Bhoothakkannadi (1997) and Veruthe Oru Bharya (2008) depicted fathers who are fearful that the increasing vices in the society will be a danger to their daughters and eventually develop hallucinations and persecutory delusions.

Lead character of Arikil Oral (2013) has a form of delusion of doubles, where he believes an evil form of his friend exists. Earlier in the film the concept of doppelganger phenomenon is discussed with him, wrongly implying that delusional beliefs can be induced in mentally healthy people through suggestibility. Auditory hallucinations of the sound of a beetle have been depicted in Bhramaram (2009), and the movie got its name from this source of the lead character’s hallucinations. Ulladakkam (1991) depicted a character with delusion of having a horse inside his abdomen, and the Psychiatrist’s futile attempt to correct that belief by providing contradicting evidence. Jawan of Vellimala (2012) portrays Charles Bonnet Syndrome and explains its occurrence in the visually challenged.

Delusion of infidelity is depicted in Poomukhappadiyil Ninneyum Kathu (1986) and Vadakkunokkiyanthram (1989). In the latter, it is shown to stem from the husband’s insecurity of his physical shortcomings in comparison to his beautiful wife. Vazhve Mayam (1970), Venkalam (1993), Kumkumacheppu (1996), Kaliyattom (1997), Mazha (2000), Naalu Penungal (2007) and Advocate Lakshmanan Ladies Only (2010) showed spouses suspecting the fidelity of their partners. Such doubts are shown to arise out of manipulations by persons with dubious agendas or due to doubtful circumstances. But the suspicious behavior of the characters has been portrayed to be much beyond what would be expected of the manipulations, suggesting the possibility of delusions or overvalued ideas.

In Thalavattom (1986) the hero is diagnosed with “schizophrenia”, but in the movie he does not display any symptoms of the illness. Such erratic depictions can create misconceptions and misunderstandings about the illness in minds of the public.

MOOD DISORDERS

Though depression is the most common mental illness, not many Malayalam films have portrayed it. Ore Kadal (2007) rendered the heroine’s postpartum depression. In Krishna Gopalakrishna (2002), the protagonist who suffer from marital and personal stressors get hospitalized with a pervasive low mood. Novemberinte Nashtam (1982) depicted the female protagonist to have low mood, decreased sleep and fearfulness after rejection by her lover. The heroine of Sanmanasullavarku Samadhanam (1986) is shown to develop depression and need hospitalization for the same after accidentally causing death of her father.

Diagnosis of bipolar disorder is mentioned in Vadakumnathan (2006), Left Right Left (2013) and Silence (2013). However, none of these movies portrayed the pervasive mood changes characteristic of the disorder. One of the female protagonists in Anuragi (1988) is shown to have postpartum onset of bipolar disorder.

ANXIETY DISORDERS

In Aham and North 24 Katham (2013), the male protagonists had obsessive compulsive disorder and anankastic personality traits and demonstrated excessive cleanliness and checking behaviour and a preoccupation with symmetry. In Aham, these symptoms are included as unique traits in the protagonist’s character. Protagonist of Kunjanthande Kada (2013) had obsessions related to his shop. In all these movies, such symptoms are portrayed to affect interpersonal and family relationships of these characters.

The male protagonist of North 24 Katham avoids elevators, suggesting that he also suffers from claustrophobia. Panic disorder has had a comical presentation in Bhargavacharitham Moonnaam Khandam (2006), where a gangster gets sudden episodes of immense anxiety, tremors and fearfulness while confronting his rivals. The protagonist in David and Goliath (2013) is depicted to have social anxiety, is anxious to face a crowd, and fears of being ridiculed.

Post-traumatic stress disorder is depicted in Ulladakam (1991). After being raped and witnessing her lover’s murder, the female lead develops initial periods of intense anxiety and fearfulness, followed by a pervasive low mood. She is seen to become anxious and aggressive upon encountering situations and scenarios related to her rape, which include the sea and the sound of drums.

DISSOCIATIVE DISORDERS

Trance and possession states have been depicted in Adaminte Variyellu (1983), Manichithrathazhu (1993) and One By Two (2014). In Adaminte Variyellu, a female protagonist who experiences poor social support and domestic abuse by her husband and mother-in-law copes by developing possession by her late father-in law who had been the feared member of the family.

In Manichithrathazhu, the female lead is shown to be possessed by Nagavally, a deceased courtesan believed to have been haunting her home, and the portrayal fetched the female lead the National Film Award for Best Actress. However, during a discussion between the psychiatrist and a traditional faith healer, her condition is wrongly described as a state of psychosis.

One By Two , a film which dealt with illegal clinical trials, shows the protagonist, an engineer by profession, to take up possession states of his murdered twin brother, a neurosurgeon, and also that of a patient treated by the brother and whose death can be attributed to illegal clinical trials. The possession states of the twin brother can be seen as an effort by the protagonist to cope with the brother’s death, and that of the patient could have been taken up in an effort to act against his brother’s and the patient’s perpetrators. However, a portrayal of the possession state of the brother is very inaccurate, where the character is seen to conduct neurosurgery without any hesitation or failure.

The central characters of Manichithrathazhu and One By Two are shown to have faced difficulties in coping with anxiety in their childhood, a possible contribution to their dissociation. However, both the films erroneously portray dissociation as a state with high chance of aggression and homicidal tendencies.

Dissociative fugue has been the central theme of Alice: A True Story (2014). Following a love failure, the heroine takes up a new identity and role in the society. The portrayal was accurate, with the character seen to be oblivious about her past identity despite repeated reminders by people from her past. In Swapnaadanam (1976), the protagonist is initially seen in a state of fugue, wandering in a distant city, unaware of his identity and unable to remember how he reached there. He is shown to recall his past during narcoanalysis.

Multiple personality disorder had inaccurate portrayals in Dr. Patient (2009) and Naranathu thamburan (2001). The diagnosis is described in Dr. Patient, where the lead character is seen taking up the role of a psychiatrist, and his condition is described as a mechanism to cope with traumatic childhood experiences or hatred towards his own personality. In Naranathu thamburan, the hero is shown to play the role of a doctor one day, and a lawyer, police officer, etc. on other days.

In Flash (2007), the heroine has dissociative amnesia towards a specific stressful event, the murder of her father. The central character in Adikkurippu (1989) is shown to have amnesia of his past after surviving a shipwreck and is seen to regain it following hypnosis.

MENTAL RETARDATION

Many Malayalam films have portrayed central characters with mental retardation (MR). They have been portrayed to be kind-hearted and capable of emotions, empathy, and sacrificing for their loved ones. Ithiri Neram Othiri Karyam (1982) and Shudhamadhalam (1993) portrayed their longing for companionship and depicted stigma of marriage to an intellectually disabled person. Compartment (2015) had central characters played by children with MR and also depicted issues of caregivers, like worry about the children’s future after their demise. Caregiver issues have also been addressed in Kaakkathollayiram (1991) and Alice in Wonderland (2005), where brothers of the female protagonists are seen to sacrifice their marital lives to care for the affected siblings. Such films have the capability to sensitize the audience of the plights of these patients and their caregivers.

Even though he has a below average intelligence, the hero in Chakkaramuthu (2006) is portrayed to be a tailor, suggesting people with MR can be skilful in certain areas.

Suryamanasam (1992) and Karumadikuttan (2001) had negative portrayals where such characters are considered easily exploitable and to possess immense physical strength. Pachakuthira (2006) and Ithiri Neram Othiri Karyam portrayed how society views them as a nuisance. Iruttinte Athmavu (1967) had a mentally retarded character being called “Bhranthan” or Vattan”, colloquial terms for mentally ill, when in fact they are not.

PERSONALITY DISORDERS

Each character in a film has their own personality. But, to add to the drama of the narrative, certain aspects of one’s character can be exaggerated to the point where personality traits and even disorders can be identified. Films have been used to teach medical students about personality disorders. ⁵

The female leads in Ente Suryaputhrikku (1991), Mazha Ethum Munpe (1995), Njangal Santhushtaranu (1999), Sradha (2000),), and Thinkal Muthal Velli Vare (2015) portrayed Cluster B traits like need for admiration, instability in relationships, attention seeking, impulsivity and acts of deliberate self harm. Sargam (1992) and Manathe Vellitheru (1994) had male protagonists with emotionally unstable personality traits.

Many of the villains in films can be said to have antisocial traits. However, we would like to cite two films which can be good character studies to understand antisocial personality disorder. Irakal (1985) portrayed the leading man with antisocial traits, who did not conform to the rules of the society, and would resort to violence and murder to attain his needs without any remorse. In Mukundetta, Sumitra Vilikkunu (1988), the antagonist is seen to be very manipulative and able to gain the trust of a number of people with his manipulation and lies. Devoid of any remorse for his actions, his prime motive is always cheating and embezzlement of others, including those in dire straits.

Male protagonists of Ore Kadal, Veruthe Oru Bharya and The Artist (2013) portrayed narcissist personality traits. Their narcissism causes problems in interpersonal relationship with family members, and they are seen to become hostile when not given due importance. Ore Kadal had a portrayal of covert narcissism, where the male protagonist would manipulate others to respect him.

Akale (2004) and Mili (2015) had female leads with anxious avoidant personality traits who suffered from fear of and hypersensitivity to criticism, social isolation, issues with self-esteem and shyness in spite of their desire for close companionship. Aham, Time and North 24 Katham had leading men with anankastic personality traits who showed preoccupation with perfectionism, confirmation to rules and regulations, excessive devotion to work, and stubbornness and rigidity in their character.

SEXUAL DISORDERS

Sexual dysfunction has been portrayed in Yakshi, Akam, Punarjanmam (1972), Oridathoru Phayalvan (1981) and Ee Adutha Kalathu (2012). Ee Adutha Kalathu depicted the central character suffering from erectile dysfunction following a trauma. In an attempt to hide his dysfunction, he frequently finds ways to portray his beautiful wife as incapable of arousing him. The lead character of Punarjanmam suffered from a lack of sexual desire towards his wife, as he associates the wife with his mother who passed away months before the marriage. In Oridathoru Phayalvan, the male protagonist, a wrestler, maintains a life of celibacy, apparently due to a misconception that wrestlers should not waste their time or energy for sexual acts and should rather focus their strengths and concentration on upcoming matches. He is seen to wet his loin cloth and wear it tightly, apparently to prevent erections.

Fetish for women’s perfume has been depicted in a central character in Beware of D.O.G.S (2014), whereas sadism and voyeurism has been depicted in one of the antagonists in Iyyobinte Pusthakam (2014).

OTHER DISORDERS

Mimics Parade (1991), Kasargode Khaderbhai (1992) and Inchakadan Mathai and Sons (1993) had characters with kleptomania, and succeeded in portraying the urge to steal rather than monetary benefits as the motive for the behaviour.

Lead character of Alexander the Great (2010) suffered from pervasive developmental disorder. He has difficulties in socialization and strict conformation to rituals, is rigid and stubborn in nature, and is depicted as a savant with immense mathematical capabilities and vast general knowledge.

Sleep walking in a comical form has been portrayed in Aakashakkottayile Sulthan (1991) and Swapnalokathe Balabhaskaran (1996). These films had portrayed the characters to venture far away from their homes during their sleep, which is an uncommon presentation of sleep walking.

Apart from the possible depiction of conduct disorder in films like Spadikam (1995), and the depictions of inmates of juvenile homes who suffer from conduct disorder in Mudra (1989) and Pottas Bomb (2013), we were unable to identify any another portrayal that could qualify for childhood psychiatric disorders.

DISCUSSION

Our review proves that Malayalam cinema is rich in portrayals of mental illnesses. It has to be commended that many type of psychiatric disorders, including various personality traits, find place in the characters it has portrayed. Majority of the depictions has been from a third person point of view, which is us the audience. But there has been films depicting illness from the caregiver’s perspective as in Thanmatra and even from the patient’s perspective as in Anantaram. The dilemma and challenges faced by the psychiatrist has been portrayed in Ulladakkom, Thalavattom, etc.

Honest portrayals of various character types, psychopathology, and sociocultural and family backgrounds of patients and their caregivers can help to sensitize the audience about the plights faced by the mental ill and those related to them. However, despite the rich portrayals of mental illness, majority of films don’t have a scientifically credible portrayal. Films like Manichitrathazhu, Kilukkam, etc. are extremely popular among Keralites, but they also happen to be the least credible, and the depictions play to the prejudices that the audience already harbor towards the mentally ill. Byrne has found this same scenario prevalent in films from Western countries.⁶ Thanmatra, Anantaram, North 24 Katham, Spirit, Neena,⁷ etc. are some films where the portrayal of mental illnesses are more or less scientifically sound and have been appreciated by both the society and the mental health professionals. Such films are rare, and literature show that most portrayals of mental illness in media, including cinema, around the world have been negative and inaccurate, and such portrayals have contributed much to the stigma towards mental illness.⁸

Byrne, in his review on psychiatry in movies, hypothesized the following reasons for inaccurate depiction of mental illness in films:⁹ Majority of films are commercial films whose main aim is profit, and the filmmakers’ intention is to captivate the audience. In the process, cinematic liberties are taken and compromises are made in the portrayal of mental illness in order to suit the audience’s taste. Also, every new film made draws inspiration from films made earlier in the same genre. An old method used by the filmmaker to successfully portray the mentally ill maybe used by filmmakers succeeding him, leading to repetition of stereotypical, negative and inaccurate portrayals. And, as in majority of commercial films, violence, death or injury are necessary elements in a film which adds further to the stigmatizing portrayal of the mentally ill. These could be the reasons why depictions of the mentally ill and their treatment have not changed drastically over all these years. Perhaps, films like Thanmatra, North 24 Katham, Spirit and Nee-Na, all released in this century, could lay foundation to a change in the depiction of mental illness in Malayalam films in the future.

According to Cape, films have the ability to captivate the audience, and, through their ability to engage the viewer, films can be used as a teaching tool. ¹⁰ Thus, another scope of these films is that they can be used to teach psychiatry. Students, in their clinics, get only a cross sectional view of the lives of their patients. Movies, with their narrative, can help in understanding the impacts a mental illness can have during its course. Fritz and Poe were the first to describe use of seminars on cinema for psychiatric education.¹¹ “Cinemeducation” is the term coined by Alexander who used commercial films to teach psychosocial approach in medical care.¹² Full length films can be used for teaching purposes using the movie club approach, or even self-learning by undergraduate and postgraduate students.^13,14 Special study modules for teaching psychiatry and films have been formed in St. George’s University of London, and King’s College, London.^15,16A “cinemeducation seminar” has also been attempted by combining film viewing, seminar and patient interview in teaching psychiatry.¹⁷ The prime objectives of these measure were to sensitize undergraduate medical students to various symptoms in psychiatry, to dispel negative attitudes that exist towards psychiatric patients, to generate interest in psychiatry as a future career option, and also as a teaching tool to discuss various aspects of psychiatry for postgraduate students. However, one should remember that even the best portrayal of a mental illness may not be the most accurate representation of the illness.^18,19 If the educators are not careful while selecting the film or explaining about it, the audience might take home a wrong representation of the disorder. On the other hand, if dealt with care, education through movies can be a valuable addition to the pedagogy of teaching psychiatry in the state.

Acknowledgements: We would like to acknowledge Dr. CJ John, Past President, Indian Psychiatric Society Kerala State Branch; Dr. Jayaprakashan KP, Secretary, Indian Psychiatric Society Kerala State Branch; Dr. Shahul Ameen, Editor, Kerala Journal of Psychiatry; Dr. Jomon Joy, Assistant Professor, Travancore Medical College, Kollam; Dr. Lallchand Anilal, Assistant Professor, Government Medical College, Thiruvananthapuram; Dr. Harish Prabhakaran, Consultant Psychiatrist, Sri Ramakrishna Mission Hospital, Thiruvananthapuram; and members of the Facebook group “Psychiatry and Cinema” for their valuable contributions to our article.

REFERENCES