Schizophrenia in the dramatic film “Occupied” (2011) and its critics by Miguel A. Faria, MD

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Saturday, January 20, 2018

Before I get to the meat of this commentary, I need to provide background material to the readers. Given the descent of Hollywood movies into indecency, obscenity, vulgarity and cruelty over the last three decades, and because I don’t watch the equally tawdry television or cable programs of about that period of time, my wife indulges me by watching a variety of films and documentaries on DVDs. We have a large collection of movies (that is only exceeded by my collection of books). These films are frequently old and classic movies, but we also amuse ourselves with other genres, including horror and science fiction. A preferred genre is historic or epic films.

Those movies that turn out to be exceedingly good, such as, “Julius Caesar” (1953; with James Mason playing Brutus), “The Eagle” (2011) or “Gladiator” (2000), I review, rate, and add to the list of “Classic Movies and Documentaries" on this website. The comment section where posters can leave comments about the films becomes very active from time to time, and once or twice, we have received notes of appreciation from parents for listing those exceptional movies to choose for their children.

Our search for good movies is difficult. It seems the writers and producers compensate for the lack of good writing and originality with the use of obscenity and gratuitous sex and violence. Vocabularies are incredibly short today, and the glorification of antiheroes is the rule rather than the exception.

Occuplied (2011) movieAnd so it was that in our search I came across an obscure 2011 film entitled “Occupied.” I was enthralled by the movie, a psychological thriller, and I’ve watched it two other times. My wife liked it even better the second time. The movie basically has two characters: Sarah, a 21-year-old girl who has just completed her freshman year in college, played by Liza Binkley; and her younger cousin Charlotte, played by Lucy Bock, a talkative and vivacious, sometimes irritatingly so, eleven or twelve year old, who Sarah has come to babysit for the weekend. The house is set in an isolated redwood forest in California, and it is in that isolated home and the surrounding woods that the film takes place.

Initially, the cousins get along jovially, and Sarah puts up with Charlotte’s ebullient talkative energy. But then Sarah’s behavior begins to change. Charlotte is perplexed by the transformation gradually taking place in her presence — namely, the onset of Sarah’s incipient schizophrenia. After a full psychotic episode erupts at the dinner table, Charlotte becomes frantic and scared unable to understand what was going on, not to mention the fact she was alone, helpless, and powerless to stop Sarah’s further mental breakdown. 

Liza Binkley’s brilliant performance of the psychologically and rapidly decompensating Sarah could be used for teaching purposes in a mental health film. Schizophrenia, after all is a psychosis that affects over 200,000 Americans per year, often presenting itself in young adults suddenly and devastatingly so, as portrayed by Ms. Binkley. 

“Occupied” was the directorial debut of writer-director Mollie Binkley, sister of the star of the film. Both the Binkley and Bock families produced the film. As a neurosurgeon with an interest in neuropsychiatry I became curious about the movie and suspected that someone in one of the families must have experienced a schizophrenic breakdown and served as a model for such a realistic and dramatic performance by Liza. And I was surprised to find little about them or the film, except that Liza had prepared well for her role. Otherwise, all I found were the derogatory comments in both IMDb and Amazon comment sections.

Suffice to say, the film was panned by audiences in the discourteous and substandard milieu of the present popular culture because the "reviewers" did not understand what was happening and did not appreciate the actresses superb performances. Instead, they expected the usual blood, gore, violence, the cheap thrills, and the special effects that now replace good script and literate dialogue. 

Consider a typical comment in IMDb: “Wow! 90 minutes of nothing happening. Nothing at all. A girl goes to a secluded cabin to babysit her younger cousin. The babysitter begins to have symptoms resembling mild PMS mixed with emotions of having lost a lover. Seriously, that is it. There is more dramatic events happening in my household on a daily basis…”

And comments were not that much better on Amazon: “This movie has almost no redeeming qualities. The only one I can think of is that it was a really good original concept — but there are just so many missed opportunities to make it more interesting, and so much bad acting.... it honestly watches like some film major's sophomore year project. It's just bad.”

Another viewer was not sure if the film was about depression or the paranormal. Social scientists have noted the short attention span of audiences today. These “reviews” appear to verify that. But has the level of public education and the much-touted critical thinking it claims to inculcate, sunk so low that self-appointed film inquisitors cannot recognize the tragic onset of a serious psychosis and make those shallow but condemnatory remarks?

So, it is because of these derogatory reviews that I write this contrarian note, which in turn criticizes the state of the popular culture, as reflected by the movie audiences, those self-appointed critics who panned this film because of their own ignorance, not only missing what went on in the film, but also in ignoring the credible and outstanding performances of the two actresses for the entire movie.

Thus, I accuse the critics of the “Occupied.” Life is surely unfair, but such criticism stemming from ignorance is unjustifiable, reflecting more adversely on the critics than on the performers. It is unpardonable that such severe unwarranted criticism of this movie may have discouraged the two young actresses and perhaps the director from further pursuing careers in cinematography.

Once upon a time, audiences recognized the art and entertainment in such movies as the comedy-drama, “One Flew Over the Cuckoo’s Nest” (1975). I too enjoyed the movie, forgiving the unrealistic portrayal of patients in a mental institution. Sure, there was action, action that was missing in “Occupied,” as an introspective psychological drama. But I wonder how “One Flew Over the Cuckoo’s Nest” movie would be judged today? And perhaps more apropos, consider the celebrated drama, “The Three Faces of Eve” (1957), a film about a patient with a multiple personality disorder. I also wonder how our modern audiences of fast-paced action and superficial artistic sense would judge this acclaimed but slow-paced drama? Certainly, there was very little action in “The Three Faces of Eve,” nevertheless both critics and general audiences recognized Joanne Woodward’s excellent performance for what it was, and Woodward deservingly won an Oscar for Best Actress. I wonder how such performance would be acclaimed today?

With this dissenting opinion, perhaps, future and more intelligent audiences will fairly judge “Occupied.” As to the two young actresses and director, I tip my hat and congratulate them for their superb performances, even if they went unrecognized, and I wish them well with the professional interests they presently pursue.

Written by Dr. Miguel Faria

Miguel A. Faria, M.D., Associate Editor in Chief in socioeconomics, politics, medicine, and world affairs of Surgical Neurology International (SNI). He is the author of a three part series: Violence, mental illness and the brain —A Brief History of Psychosurgery” published in SNI and available at his website.

This article may be cited as: Faria MA. Schizophrenia in the dramatic film “Occupied” (2011) and its critics. HaciendaPublishing.com, January 20, 2018. Available from: http://www.haciendapublishing.com/articles/schizophrenia-dramatic-film-%E2%80%9Coccupied%E2%80%9D-2011-and-its-critics-miguel-faria-md

Copyright ©2018 Miguel A. Faria, Jr., M.D.

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Comments on this post

Schizoid Man

Thanks for the review. I so seldom go to movies, since I do not want to financially support my enemies in Hollywood (generally) and no longer look to movies for anything other than a sedative at night. The subject of schizophrenia does interest me, however.

21st Century Schizoid Man was the extent of my knowledge of the subject until a close friend of mine began acting oddly. The first sign I remember was him telling me about a Star Trek episode. He claimed Cpt Kurt impatiently exclaimed to Spock with whom he was arguing: "Well, transfer freak!” We grew up on that show, and I never remembered nor do I think freak was ever used toward Spock.

We were stationed at different bases in Deutschland, but we saw each other occasionally. He seemed more depressed than anything. Back in the US the signs grew. Once we drove to a nearby town to purchase beer, as I lived in a dry county. He asked me if I noticed anything different. There was, but I could not place what was wrong. He then asked me when the last time I had seen a road sign. Sure enough, he had at some point earlier used his truck bumper to slowly bend each sign parallel to the ground. He had done this to many road signs.

Later, he drove his truck into a school wall and over some playground equipment at night. Then came a shooting into passing car windows, which thankfully no one was hurt, largely due to the small caliber used--.22 caliber. He is now in a VA facility in another state.

As I understand the disease, his case is not unusual. The late teens or early 20s is when the schizophrenia manifests itself. I think it is a chemical imbalance. Please correct me if I am incorrect on this.

I am looking forward to the movie. Kathleen Quinlan’s portrayal of a woman’s descent into madness in the movie “I Never Promised You a Rose Garden” affected me for some time. The hallucinations were bizarre though, but who has, after all, ever seen an actual acid trip portrayed anywhere near the real thing? Without giving away the surprises, did you find that the signs displayed in the movie were consistent with the disease? How about the treatment in the movie? The military back in the 70s mostly just handed out thorazine to the psych patients.

I am curious to what you saw as a physician that made you recommend the movie. Also, this is one of the reasons I come to this site: so much relevant information. Plus, no Fake News allowed. Ha.

Clinical schizophrenia

Charlotte’s giddiness, not unusual for her age, and tremendous activity output like the energizer bunny, on top of whatever had been in Sarah’a unsettling past experience as noted in her journal, real or imagined, were contributing factors. The isolated cabin setting in the woods, the fear and the responsibility for Charlotte were finally too much for Sarah, and she decompensated. She went into a schizophrenic crisis with increasingly confused and paranoid thinking, auditory hallucinations, and finally aggressiveness that horrified Charlotte.

Liza Binkley’s performance of a first serious schizophrenic attack reminded me of my first schizophrenic patient in medical school. The role was so well portrayed and paralleled the clinical history of my first patient that it was eerily realistic. Her performance could be used for teaching purposes, as I said. Since that first case, of course, I treated many other patients with mental illness. As a neurosurgeon I was consulted on patients with mental disorders who turned out to have brain tumors or seizure disorders.

Schizophrenia is very common, and devastatingly so, has the onset in young people. The disease is treated with different medications and psychotherapy. Very effective are the haloperidol (haldol) and phenothiazine drugs, such as Chlorpromazine (Thorazine). These drugs reduce catecholamine and dopaminergic neurotransmission in the brain. The disease, at least in part, is due to a chemical imbalance with increase dopaminergic activity. Depression, on the other hand, seems to be related to the opposite — i.e., decreased catecholamine activity, although affecting different areas of the brain. Thus, depression is treated at least in part with anti-depressant drugs that increase catecholamine, including dopaminergic activity.

Yet, despite the Hollywood movies, severe psychotic illness, such as intractable schizophrenia, at one end, and depression, at the other end, not responsive to drugs, may both be treated with electroconvulsive therapy (ECT), sometimes very effectively.

For additional reading, Koba, and a tangential view of the problem, especially more related to your friend's case, I recommend reading my three part series, “Violence mental illness and the Brain — A Brief History of Psychosurgery,” posted here.

Schizophrenia & cigarette smoking

There are, of course, the auto-immune theories for explaining schizophrenia, similar to how some believe many neuropsychiatric disorders are caused by a hyperactive immune system not recognizing the brain as part of the rest of the body, and subsequently attacking it. In some severe cases of strep throat, such phenomena have been observed. I suppose when the infection is severe and overwhelming, immature forms of leukocytes might be discharged from the bone marrow, and are at the stage where they are still unable to differentiate foreign invaders from healthy tissue belonging the organism. I am not sure I ever subscribed to this, and I am not alone. Striato-nigral

One thing I do know is that (as many have observed) schizophrenics tend to be heavy smokers. Given the effects of cigarettes on the nicotinic acetylcholinergic receptors (they bind to the receptors, but do not displace acetylcholine from them), it is not too hard to understand why. The simple reason is because if you have an excess of dopamine, and add a nicotinic agonist (such as nicotine), there will be restoration of "balance" between dopamine and acetylcholine in the brain, as in many ways acetylcholine and dopamine can be thought of as "opposites" in the mesolimbic and nigral-striatal systems. Indeed, nicotine patches can be used with success in Parkinson's patients, and likely have been tried in an effort to combat the tardive dyskinesia movement disorders that develop after chronic anti-psychotic treatment.

Meso-limbic

BUT, I would look elsewhere if I were looking for etiologies in autoimmune theories. Statistics show that the average schizophrenic, while a heavy smoker, has a MUCH LOWER incidence of lung cancer than others free of mental disorders who smoke the same amount. I believe that might include some of their close family. Why is that? I have not done a literature search in a while, but last time I did do one on this subject, it was still unknown. If this relationship is really true, there must be a tremendous yield of helpful data that will be discovered with the reason. As late as 2005, these statistics were still popular, but unless they have since been debunked, I would hope there are people out there still looking into it. --ARB

Tubero-infundibular

Addendum- The third cerebral system to employ dopamine as its major neurotransmitter, the tubero-infundibular, gives us the reason why these drugs cause so much weight gain. They are not selective enough to limit their activity to the meso-limbic system, though the 2nd generation anti-psychotics are a bit better at that. But neurosurgeons are probably aware that dopamine drives that 3rd system, if you still employ Bromocriptine to treat microadenomas.

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Summary of the three Dopaminergic pathways putatively involved in schizophrenia, depression and Parkinson’s disease discussed by Dr. Bogart:

Mesocortical pathway connects the ventral tegmentum (in the floor of the midbrain) of the brainstem to the prefrontal cortex (involved in cognition, motivation and emotional responses). It’s dysfunctional in psychoses including schizophrenia.

Nigrostriatal pathway connects the substantial nigra pars compact (midbrain) with the dorsal striatum (caudate nucleus and putamen). It involves movement disorders. These neurons are part of the basal ganglia motor loop that synapse with GABAergic neurons. Loss of neurons in the pars compacta of the SN results in dopamine depletion and Parkinson’s disease.

Tubero-infundibular pathways connects the arcuate nucleus (infundibular nucleus in the tuberal region of the hypothalamus to the median eminence in the boundary of the inferior hypothalamus and the pituitary stalk in front of the cerebral peduncles. This pathway is involved in prolactin secretion the is blocked by the drug Bromocriptine).---MAF

Rebutting a critic of "Occupied"

Belatedly, I did find a more serious review of "Occupied" by writer Octavio Ramos (June 23, 2014) for AXS Reviews. He writes:

“The movie’s faults lie principally with writer-director Mollie Binkley. Binkley does show a knack for effectively handling actors and a certain flair for writing intense scenes, but her use of visual metaphor to convey the nature of madness does not work. As a result, 'Occupied' does not meet the needs of the audience and thus does not work as worthwhile entertainment.”

Obviously, I disagree. The movie did not work for most audiences simply for reasons I discussed at length in my review. Admittedly, I’m not a reviewer for the masses and certainly for an introspective films of this type, I am not a good guide for shallow thinkers in a herd, but for independent and deeper thinkers. I’m simply praising the realistic portrayal of the onset of a serious mental illness in film — schizophrenia that affects adolescents and young adults — and the dramatic interaction between the two actresses. Obviously, I’m not writing for commercial success either. Ramos continues:

“[Sarah] agrees to babysit her cousin, Charlotte, who lives in a small cabin in the redwoods above Silicon Valley. Charlotte (Lucy Bock), who is about six or seven years old, lives alone a lot of the time, as her mother has passed away and her father is either often on travel or locked away in his office. Indeed, the father is not all the stable,[sic] as he always keeps his office/bedroom locked and has placed several security cameras about the place.”

I’ve many problems with that paragraph. To begin with Charlotte is not six or seven years old, but at least ten, and most likely eleven or twelve, and so poorly judging her age may be an indication of how Ramos (and most audiences) seem to have so poorly judge the movie and the performance.

Then I believe, he tries to say that the father is not at all stable for reasons stated. And yet there are numerous explanations for his purportedly "odd" behavior. It is not unusual for people to place security cameras to watch desolate areas outside homes and watch baby sitters on the inside, as well as general security. Charlotte even offers her own plausible explanation about her father's possible work for the government. As for inquisitive and hyperactive Charlotte, it may not have been a bad idea for her father to lock the rooms where firearms or important material may be kept, gone for a weekend, especially if he works for the FBI or CIA. These are trivial things but worth mentioning given the sinister importance that Ramos gives to the surveillance cameras. In his penultimate paragraph, Ramos further opines:

“Although the story’s overall structure is good and both girls turn in strong performances, Occupied remains a frustrating film principally because there are few narrative strings that hint at the reasons why Sarah has succumbed to insanity and even suicide.”

But there is as yet no "specific reason" why young people are stricken with schizophrenia; it is partly a genetic disorder and knowledge is incomplete in the understanding of neurotransmitters in the brain and the various neural structures and pathways that are affected. A critical stage is reached in the genetically susceptible individual by external factors at which point psychological decompensation ensues. I have written about this in my own review. As for Ramos seemingly sudden praise for the "the story’s overall structure" and the two actresses as “commendable ”performances, seem evanescent platitudes, when in the next paragraph, Ramos concludes:

“Despite these performances, I cannot recommend Occupied, as most will find it an exercise in frustration.” Ramos in the end goes with the pack in panning this movie, but as of yet, it he has been the most coherent, if still contradictory, of all the unfavorable comments and "reviews" I have come across. Perhaps his contradiction originates not really in his dislike for the movie but out of the need to explain the majoritarian judgement and avoid antagonizing the voice of the people. I do not impose on myself such conventional impositions.

No eccentric in Ramos

Yes, so he doesn't fit into that category of people who understand enough medicine and science to know if a movie is portraying science accurately or not. Sounds like a common PC reviewer to me, and not worth any more time.

I could write a book (well, OK, maybe a great deal of an exaggeration), but paradigms on schizophrenia have changed somewhat. I will mention just two to illustrate what I mean.

One is the idea the excitatory neurotransmitters like glutamate are what is really the driving force behind schizophrenia. The dopamine changes are secondary. Evidence for this has been shown by experimental studies which show improvement in schizophrenic symptoms (negative and positive) when glutamate antagonists are administered.

Another is that there is highly suggestive evidence that the basal ganglia are heavily involved, as (in particular) the substantia nigra is overactive, and secreting an excess of dopamine. Anyone who has seen the ritualistic and compulsive quasi-involuntary movements of some schizophrenics might give this a thought. Reduction of dopamine levels by first and second generation anti-psychotics does improve schizophrenia, and in many cases causes transient Parkinsonism, which you would expect if a hyperactive substantia nigra was pharmacologically depressed. Also, Tourette's Syndrome usually responds to the same drugs given for schizophrenia, and the pathology, while still unknown, has long been suspected to be in the basal ganglia. Interesting as well is that psychiatric concomitants are so high in the TS population.

Prior to introduction of the antipsychotics Thorazine and Reserpine in the 1950s, the main drugs used to treat the schizophrenic were choral hydrate, barbiturates, and paraldehyde. Psychiatrists knew these were mere soporifics, but the more the patient slept, the less they were tormented. The serendipitous story of Isoniazid I will not touch upon right now.

Now it is thought by many physicians and researchers that 1st generation anti-psychotics, while claimed for many year to be a specific treatment for psychosis, may not have been much better than the above mentioned soporifics. The inpatient of a state institution who is there for life is usually so dysfunctional, that such drugs are given in high enough doses so they do sleep all day. Perhaps when the symptoms are mild and the patient can lived independently, 1st generation anti-psychotics can be taken in low enough doses that sleepiness, while present, may be minimized. But the forms of schizophrenia are usually so malignant, that higher doses are usually given, and then they do become little more than sleeping pills.

In my four years as a researcher at the Nathan Kline Institute for Psychiatric Research in Orangeburg, NY, as we were on the grounds of Rockland State Hospital, we made a deal with them to give a full T1 and T2 weighted MRI to every new admission. I think the idea was excellent, as even if a neurological exam is performed upon admission, it is usually by a psychiatric resident, and I wouldn't trust it. But the yield was low. I only remember one large pituitary adenoma which I did not think extended far enough out of the sella to compress the frontal or temporal lobes. The other was a research technician of ours who was a subject for an engineer testing the machine after some repairs he made. He had no idea he had a huge acoustic neuroma, and after surgery, it took him many months to recover. Last I heard, his balance still isn't so great. --ARB

No X-ray image of demons!

Reading this review, I could not help but think of another movie classic that mainly used psychology instead of special effect to thrill the viewer — The Exorcist. There were a few supernatural scenes which look comical to us viewing them through the lens of 2018, but much of the movie contained scenes that could have almost been fairly typical real life situations on the surface. A while back, I had posted this elsewhere:

Linda Blair undergoing HYPOCYCLOIDAL TOMOGRAPHY in The Exorcist, 1973.

Linda Blair from The Exorcist

CT was just introduced clinically, so the movie did not portray it. The older technique of analogue section was still quite in vogue for the neurologist. But Satan was not found in the skull. We also see Linda in another scene undergoing direct carotid puncture by a radiologist for angiography. That is considered too dangerous now to do. Funny thing is the angiogram was shown as a result of the tomogram seen here, which was supposed to be a pneumocistpneumoencephalogram. Hollywood often doesn't get the science right.

I know the viewer cannot appreciate the motion of the x-ray tube from the still, but seen the clip one would see describe it as "hypocycloid." This was done in conjunction with pneumoencephalography to blur out the facial skeleton and produce a sharper view of the lateral ventricles. Or, if examining the 4th ventricle, to remove the heavy x-ray shadow of the bone of the posterior fossa. The second photo shows a frame capture of what was shown in the movie as a result of the tomographic examination of demon-possessed Linda Blair .
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They are more concerned with superficial entertainment (a la panem et circenses) and social agendas than portray medical or scientific accuracy. A few directors do take more care but they are the exception rather than the rule, for example the film adaptation of Michael Crichton's "Terminal Man," which I mentioned in Part 3 of my Psychosurgery series.--- MAF