The Stephen King Challenge: "Pet Sematary"

I provide a monthly didactic at Rutgers Robert Wood Johnson Medical School called “FIDLER” that is centered around a feature-length film that we flip as a fictional case study of mental illness. This month, we’re excited to merge FIDLER with a challenge proposed by USDish.com. We readily accepted the Stephen King challenge and seamlessly chose to show Pet Sematary for FIDLER.

Our selected Stephen King film serves to stimulate discussion over social media at #FIDLERpet to educate learners as well as inform the public about mental illness. The following blog is a pre-posting of this month's FIDLER discussion of Pet Sematary on Twitter.

Synopsis: Pet Sematary (1989, 2019) is a horror film based on a Stephen King novel of the same name that follows the Creed family upon their discovery of a mysterious graveyard in the woods behind their new home.

How it relates to the field of psychiatry: The films allow for the case formulation of psychosis with co-occurring mood symptoms. The initial way to differentiate the various illnesses that can present with both psychotic and mood symptoms is to aggressively evaluate for an underlying medical condition or active substance use that can explain the patient’s pathology. In the case of Pet Sematary, there does not appear to be an organic etiology to the psychotic/affective state of the Creed family.

The 1989 film: The past psychiatric history of Louis and Rachel is revealed to include the latter suffering from a chronic mood disturbance due to unresolved guilt stemming from the death of her terminally ill sister, Zelda, while she was under her care. Rachel’s affective disorder (rule-out Persistent Depressive Disorder) is juxtaposed with Louis’ acute grief reaction precipitating from Gage’s death.

Upon Gage’s death, Rachel and their daughter, Ellie, leave for Chicago to spend time with Rachel’s parents while Louis remains home. It is at this time during Louis’ bereavement that he adopts the belief that if he buries Gage in the soured ground that his son will return from the dead.

Rachel is predisposed to severe mental illness as a result of her Persistent Depressive Disorder. However, it is Louis who becomes delusional after Gage’s death (shared precipitant).

While predisposing and precipitating factors are central to case formulation, so too are protective factors. It’s no coincidence that Louis manifests a fixed belief of Gage returning from the dead while Rachel is visiting her parents. Rachel’s support system protects her from developing a more severe course of her affective disorder, while Louis’ parents aren’t in the picture (literally).

The 2019 remake: [Spoiler Alert] In the remake, Ellie—not Gage—is struck and killed by the 18-wheeler. The final scene shows a trapped Gage approached by the reanimated Louis, Rachel, and Ellie after they set fire to Jud’s house. The film ends with a resurrected Louis gesturing to Gage to unlock the car door.

In this version, Rachel (and Gage) spends time with her parents, as well. Despite the social support, her fate does not meet with the same favorable outcome as it had in 1989. The 2019 remake, therefore, more realistically highlights the complexity of patient and trauma factors that impact resilience and adaptive outcomes (1).