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I provide a monthly didactic at Rutgers Robert Wood Johnson Medical School called “FIDLER” (hence the title of this blog) that is centered around a feature-length film that we flip as a fictional case study of mental illness. The objective is not to render diagnoses per se, as doing so would run the risk of stigmatizing individuals with mental illness (films universally provide inaccurate portrayals of mental disorders). Instead, the selected film serves to stimulate discussion over social media to educate learners as well as inform the general public about mental illness.
The following blog is a pre-posting of our Twitter discussion on this month’s FIDLER film, Greta (#FIDLERgreta).
Synopsis
Greta (2018) is a psychological thriller directed by Neil Jordan that follows a young woman who befriends a lonely widow who becomes progressively obsessed with her. As of this posting, the film holds a 60 percent Tomatometer rating on Rotten Tomatoes and a score of 6.0 out of 10 on IMDb.
How it relates to the field of psychiatry
Greta is a film that serves to review the biopsychosocial formulation of mental illness; more specifically, the "two-hit" hypothesis (that, in this case, is synonymous with stress-induced psychosis).
Biopsychosocial Formulation
George Engel believed that to understand and treat patients, clinicians must attend to biological, psychological, and social factors contributing to their illness. This holistic approach is critical to understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care (1) and forms the basis for the Two-Hit Hypothesis.
Two-Hit Hypothesis
The Two-Hit Hypothesis is a stress-diathesis model proposed to explain the exacerbations of illness, such as schizophrenia. Schizophrenia risk has often been conceptualized using this model, which requires two “hits” in order to generate the clinical phenotype (exacerbation). The first hit (predisposing factor) serves as early priming, and the second hit is usually a later environmental insult (precipitant).
This hypothesis arose from geneticist Alfred Knudson’s interest in the genetic mechanisms underlying retinoblastoma (1971). While applied to schizophrenia, the hypothesis has also been used to formulate other forms of psychoses as well as non-psychotic mental illness (stress-induced psychosis).
Stress-Induced Psychosis and Greta
It is unclear what Greta’s predisposition (priming) is. While there are no plans for a prequel that would answer this question, our class takes educationally creative liberty in suggesting Greta was a product of incest (biological factor) and is likely to have suffered from anger outbursts (possibly even epilepsy). From an early age, she witnessed her father’s officers torture the homeless that lived near her family's estate, and when 13, gave birth to a child out of wedlock. In order to avoid a scandal, Greta’s father gave the child away (psychological factor).
These early childhood experiences are actually taken from the developmental history of Countess Elizabeth Bathory, a serial killer who, like Greta, is from Hungary and therefore bears an uncanny similarity to the film’s protagonist. Incident to the death of her husband, Count Ferenc Nádasdy, Elizabeth Bathory began murdering her victims, the first of which were poor girls lured to the castle with the promise of work.
If Greta had promised Frances work instead of just keeping her company, the inspiration of Bathory in creating Greta’s character would be even more thought-provoking. Further, it’s revealed that Greta’s daughter is not studying in Paris but is instead deceased, having succumbed to suicide after a long battle with drug addiction. Just as Nádasdy’s death appears to have been the precipitant of Bathory’s serial killings, so too was the untimely death of Greta’s daughter the “second hit” that precipitated her psychosis.
In 1611, the notaries assigned by György Thurzó recorded testimonies from over 300 witnesses. Bathory was ultimately charged with the deaths of 80 girls. One witness claimed to have seen her bath in her victims’ blood (the “Blood Countess”) and observed a book kept by Bathory where she recorded the names of over 650 victims. Although this diary was never truly unearthed, Frances’ discovery of the cache of handbags would have drawn an eerie parallel if they had been colored red instead of black.
Was Greta’s character truly based on what is known as the most prolific serial killer in world history? Not likely. However, their shared country of origin and delusional thought process underlying serial abductions draws enough of a parallel to review the etiology and pathogenesis of mental illness, including the Two-Hit Hypothesis and Stress-Induced Psychosis.
As punishment for her crimes, Elizabeth Bathory was shut up in Csetje Castle, held in solitary confinement in a room whose windows were walled up. Sound familiar? Although Frances was provided a Hollywood ending, Elizabeth was 54 when she died in her walled tomb.
For greater detail of our psychiatric formulation, join the conversation on Twitter on 9/26/2019 at 6:00 EST by following the hashtag #FIDLERgreta.
