Neuropsychological Review
Inside Out of Memory and Emotions
By Victoria A. Grunberg, M.S.

Inside Out (2015) is an entertaining cartoon film that demonstrates the emotional complexity and development of an 11-year old girl, Riley Andersen, as she experiences the stress of moving across the country with her parents and adjusting to a new school and new friends. From a neuropsychological perspective, the movie demonstrates several facts regarding the impact of emotions on memory, how sleep is related to memory consolidation, and the role of emotions for interpersonal functioning. This film appeals to all ages, and could be used to open discussions with children regarding emotions, challenging situations, and how to cope.  

The representation of the primary emotions is consistent with Paul Ekman’s (1992) universal families of emotions -- enjoyment, anger, fear, disgust, sadness. Ekman also has noted other basic emotions that are important for human functioning, including embarrassment, surprise, excitement, and awe. For simplicity, the film depicts the primary emotions that are universal across cultures.

Inside Out metaphorically demonstrates how memories are made and the key role of emotions to create, store, and retrieve memories. In the beginning of the film, each memory is coded as a different color, representing one of the five primary emotions. When Riley experiences an event, it becomes a colorful ball that is carried into the “Headquarters” (i.e., her mind) and is associated with one of the emotions. In reality, humans often experience multiple emotions while creating memories. For example, meeting a new person can be intimidating, anxiety-provoking, and also joyful. Humans also experience memories that are not emotionally charged. Memories can consist of mundane information and experiences that may not be associated with any specific emotion. Further, the film suggests that specific emotional memories (i.e., “core memories”) are especially important for dictating behavior. This idea of “core memories” is not supported by brain science. The idea of "core memories" comes from computer science.  All memories influence how one perceives and interacts with the world. A person’s identity is an integration of these memories (experiences) as well as genetic and biological variables. The film understandably simplifies the process of emotions and memory for entertainment and age-appropriate audiences. It correctly shows that emotions can influence memory encoding and ultimately behaviors.

The film focuses on autobiographical memories, that is, memories related to events from Riley's experiences. Throughout the movie, all of the "important"  memories in the headquarters of Riley's brain contain an autobiographical life experience. These memories influence Riley, her personality and her behaviors.  Although autobiographical memory (i.e. episodic), and experience, does play an important role in the construction of personal identity (Wilson, & Ross, 2003), other types of memory, such as memory for facts and information (i.e. semantic) are important as well. In one scene Joy and Sadness get lost in Riley’s mind and they come across a library of facts and knowledge. This library is meant to represent semantic memories, rather than autobiographical, but it does not seem to influence Riley’s behaviors or personality. 

In the film, memories are played like movies when Riley is “remembering” and, therefore, they are completely unaltered. When Riley is having a bad dream after her recent move to San Francisco, Joy plays a happy “core memory” of Riley skating with her parents in an effort to replace a bad dream. But in real life memories are not replayed in this way. In fact, every time one thinks about a memory, it is slightly changed. Memories are changeable and time greatly impacts how they are remembered (Loftus, 1994). A more accurate example of this concept is when Sadness begins to change Riley’s memories. In one scene Sadness begins  touching all the memories so they would now be remembered as sad,  This scene is a metaphor for how easy it is to change a memory and how emotions can greatly impact how they are retrieved.           

In general, research supports the overall message of this film – emotions are important for memory. Events that are remembered more often and/or memories with emotional significance are more likely to be stored in long-term memory (Reisberg & Hertel, 2005) however the emotional quality of a memory, and the story of the episode itself can change after later emotional experiences that may "color" the memory. Although “core memories” do not exist, the film appropriately highlights how emotions can be used to encode and retrieve information from one’s mind.

Another important neuropsychological concept demonstrated in the film is the relationship between sleep and memory. When Riley sleeps, her memories are processed into her long-term memory. This scene of sleep and memory storage has elements of truth. Brain research supports the ideas that that sleep is a vital component in forming and shaping memories (Stickgold, 2005). In the movie, Riley is in REM sleep (i.e., Rapid Eye Movement sleep which is usually associated with dreaming) while her memories are being stored.  However, most brain research suggests that memories of this type are most often encoded into long-term memory during non-dreaming (i.e., non-REM) slow wave sleep (i.e., stages 3 and 4) (Stickgold, 2005).

An important scene about dreams occurs when Joy, Bing Bong, and Sadness stumble upon “Dream Productions,”  which are events from Riley’s day at school. These events are combined with abstract images to create a dream. This portrayal is consistent with research that demonstrates that dreams are abstract representations of events that occur in daily life are not typically representations of specific autobiographical memories (Stickgold, 2005). As noted above, the scene when Joy tries to play a  verbatim “core memory” to prevent Riley's bad dream is not accurate. Memories are changed every time they are brought to consciousness and, therefore, do not have the ability to be played verbatim.  Memories that are called forth within our dreams  are more likely to be merged to create visual scenes (Llewellyn, 2013).

"Inside Out" also highlights the critical role of emotions for the perception of social cues, interpersonal interactions, and behavioral responses. When Riley loses Joy and Sadness (i.e., they are literally lost in her mind), she responds to her parents with angry outbursts and responses. The movie flashes to the parents’ minds and shows how their emotions are used to pick up on the social cue that Riley is upset. Research indicates that social information processing as well as emotional regulation are key for social competence, especially among children (Lemerise & Arsenio, 2000). Children with poor regulatory behaviors or negative experiences with peers may have more social information processing deficits (Lemerise & Arsenio, 2000). In the movie, when Riley has high negative emotionality and is unable to inhibit these extreme emotions, she argues and fights with her father. In contrast, when she is in a good mood and is asked by her mother to stay positive for her father, she is able to regulate her negative emotions. Notably, sadness facilitates a sense of empathy in others, which is a key point in this film. The development of emotions and the increase of complex emotions (as indicated by mixed emotional memory at the end of the film) reveals Riley’s character development and suggests that, as she gets older, her emotional experiences become more complex. These scenes provide valuable information about the importance of all emotions to understand other people, facilitate social interaction, and regulate behaviors.

Inside Out is an excellent and creative film that deserves 5/5 stars for entertainment, 3.5/5 for accuracy, and 5/5 for education. The movie includes witty language, puns, engaging graphics and animation, and an entertaining plot line that offers deep messages about growing up, family, and brain processes that influence human behavior. The film addresses many neuropsychological and psychosocial constructs relevant to understanding human cognition, emotion, and behavior through the metaphor of the brain. Because these concepts are greatly simplified for the audience and entertainment, 3.5 stars are given for scientific accuracy. However, this film provides valuable information and can be effective to educate children about emotions and memory. The film appeals to all ages, especially children, and does not include any inappropriate language or images.

Craik, F. I., Govoni, R., Naveh-Benjamin, M., & Anderson, N. D. (1996). The effects of divided attention on encoding and retrieval processes in human memory. Journal of Experimental Psychology: General, 125(2), 159.
 
Ekman, P. (1992). An argument for basic emotions. Cognition & emotion, 6(3-4), 169-200.
 
LaBar, K. S., & Cabeza, R. (2006). Cognitive neuroscience of emotional memory. Nature reviews. Neuroscience, 7(1), 54.
 
Lemerise, E. A., & Arsenio, W. F. (2000). An integrated model of emotion processes and cognition in social information processing. Child development, 71(1), 107-118.
 
Llewellyn, S. (2013). Such stuff as REM and NREM dreams are made on? An elaboration. Behavioral and Brain Sciences, 36(6), 634-659.
 
Loftus, E. F. (1995). Memory malleability: Constructivist and fuzzy-trace explanations. Learning and Individual Differences, 7(2), 133-137.
 
Stickgold, R. (2005). Sleep-dependent memory consolidation. Nature, 437(7063), 1272.
 
Tulving, E., & Kroll, N. (1995). Novelty assessment in the brain and long-term memory encoding. Psychonomic Bulletin & Review, 2(3), 387-390.
 
Wilson, A., & Ross, M. (2003). The identity function of autobiographical memory: Time is on our side. Memory, 11(2), 137-149. 

Neuropsychological Review
Trapped in my Mind
Justin W. White

Cognitively alert, you can think, you can see, but you can’t move a thing, and as a result, you are unable to communicate through verbal or motor means, effectively placing a human being in a tomb of flesh (Kobert, 2008). This unimaginable experience is the stark reality for patients who experience a condition known as ‘locked-in syndrome.’ In The Diving Bell and the Butterfly (based on the book The Diving Bell and the Butterfly: A Memoir of Life in Death by Jean Dominique Bauby), Mathieu Amalric plays the role of Jean-Dominique Bauby, the editor of a trendy French magazine who suddenly experiences a stroke (cerebrovascular accident, CVA)​.

Once a charismatic, artistic and athletic person, Jean adapts to life restricted within the confines of a coastal rehabilitation center. Because of a brainstem injury he is paralyzed from the neck down, unable to speak and with only his left eye functioning.  The movie depicts Jean’s new life through a first-person view.
 
Although a rare condition, which leaves patients’ ability to communicate in a primitive fashion, ‘locked-in syndrome’ affects nearly 500,000 people in the world (Kobert, 2008). Even though the condition is most frequently observed in patients of Lou Gehrig’s disease, also known as ALS or amyotrophic lateral sclerosis, stroke patients who experience significant damage to the rear portion of the brain, closest to the spinal cord (brainstem), may experience a similar condition. Due to his inability to function at the most basic human levels, Jean is faced with the internal dilemma to succumb to the powerful grasp of his condition or fight through hope. Through his monologue, this struggle is most apparent as Jean lay’s in the bed of his coastal treatment facility, unable to escape the reality life has placed before him, “Today, my life feels like a string of near-misses. Women I was unable to love, opportunities I failed to seize, moments of happiness I let drift away. A race whose result I knew beforehand but failed to pick the winner. Had been blind or deaf or did the harsh light of disaster make me find my true nature?” The setting for the film is in the beautiful, northern coastal community of Berck, France, but Jean can no longer experience the simple pleasure of feeling sand between his toes. Still in a state of delirium, at the beginning of the film, medical specialists explain what Jean’s condition is, but provide minimal explanation pertaining to it’s occurrence or go into great detail of the impairments his body now has been afflicted by.
 
Stroke is the clinical syndrome caused by neurological signs and symptoms developing due to rapid onset of brain dysfunction with vascular (blood vessels) cause and lasting more than 24 hours (Aysal et al., 2010). Pre-indicators of stroke, which Jean displayed while he was driving in the French countryside with his son, include: sudden confusion and trouble speaking; sudden numbness or weakness of face; sudden trouble seeing in one or both eyes; and a sudden loss of balance (American, 2017). Contrary to less severe strokes, Jeans condition resulted in quadriplegia (loss of use in all limbs) and anarthria (loss of articulate speech). Although patients are conscious, attention, executive function, intellectual ability, perception, and visual and verbal memory are often affected (Delargy & Smith, 2005). Given this total immobility while still maintaining ones sense of consciousness, Jean is placed in a complete state of distress as the doctor sews his right eye-lid shut. Utterly helpless, Jean lays motionless while screaming for help internally. No one answer’s his cries. Like an infant bird high atop a tree without their mother, there’s nothing he can do.
 
            With the help of a caring and devoted speech therapist, Henriette, played by Marie-Josee Croze, Jean learns the ability to communicate through a modified alphabetical system, solely using his left eye. Through his internal debate of whether to let go from his perceived dreary and dark state, Jeans focus shifts. He releases thoughts of defeatism and realizes he still maintains one key aspect indicative of human consciousness, the ability to imagine, “I’ve decided to stop pitying myself. Other than my eye, two things aren’t paralyzed. My imagination and my memory. They’re the only two things I can escape my diving bell”.
 
            Through contact with a publisher he previously had been contracted to complete a revised version of The Count of Monte Cristo, with the help of a tenderhearted writer, Claude, played by Anne Consigny, Jean begins work on his personal memoir. Even though his speech is impaired, his humor is not. At first glance, Jean knows his face may appear ghastly to the unfamiliar eye. “Don’t panic”, he tells Claude, and from this point on, their bond is solidified during hours of translation and dictation. Decisively obtaining a sense of purpose in his once believed dreadful state, Jean finds elation through work on his personal memoir, “My whole body is encased in a kind of diving suit. My task now is to write the motionless travel notes from a castaway on the shores of loneliness.” With his newfound positive outlook on the future, Jean’s condition throws him yet another curve ball. While visiting with a friend, and displaying his new ability to sing song through tone, he begins to choke and pneumonia sets in. In the bed of an intensive care unit, Jean passes away two days after the French publication of his personal memoir. The film eloquently depicts the ultimate dichotomy between an exuberant and jovial lifestyle, with immobility and losing ones ‘sense of self.’  
 
           
Taking into consideration accuracy of the portrayed disorder in the film, I rate the work 5 out of 5. By employing a first-person perspective throughout the film, the viewer is thrust into the world of a patient with ‘locked-in syndrome.’ Struggle, sorrow, joy and internal conflict all become surreal through this representation. Pertaining to an educational value, both in a collegiate environment and for persons who may have minimal understanding of complex neurological terminology and disorders, I also rate the film 5 out of 5. The directors ability to depict an entire spectrum of the condition, from onset to termination, complete with symptoms associated with the illness, along with psychological turmoil experienced by the patient, make the film an excellent teaching supplement. Comparing to other dramas, this film is a smidgen slow and takes sometime for the plot to truly develop, 3 out of 5 for entertainment value. The movie was highly interesting, thought provoking, and at times, emotional, but my interests in the realm of film and theatre are highly eclectic. Given brief scenes of nudity, the film would not be recommended for ages under 12. In just shy of two hours, The Diving Bell and the Butterfly enables the viewer to transport themselves into a world of stark colors and vivid imagination. After this journey, the viewer will have a genuine appreciation of the dichotomy between life and death. 

​References
 
American Stroke Association. (2017). Stroke warning signs and symptoms. Retrieved from http://www.strokeassociation.org/STROKEORG/WarningSigns/Stroke-Warning-Signs-and-Symptoms_UCM_308528_SubHomePage.jsp
 
Aysal, F., Bakac, G., Baybas, S., Dayan, C., Demirci, S. & Yalciner, B. (2010). Risk factors that affect recurrence in strokes. Paris, FR: Dusunen Adam. Retrieved from http://www.library.drexel.edu/cgi-bin/r.cgi/login?url=http://search.proquest.com/docview/755429654?accountid=10559
 
Delargy, M. & Smith, E. (2005). Locked-in syndrome. London, UK: British Medical Journal. Retrieved from http://dx.doi.org/10.1136/bmj.330.7488.406 
 
Kobert, L. J. (2008). Unlocking locked-in syndrome: University of Virginia researcher helps patients with complete paralysis, or locked-in syndrome, communicate. Washington, D.C: US Federal News Service. Retrieved from http://www.library.drexel.edu/cgi-bin/r.cgi/login?url=http://search.proquest.com/docview/468439943?accountid=10559
 
Schnabel, J. (2007). The Diving Bell and the Butterfly. France.

Neuropsychological Review
CTE: The brain disease that is changing the NFL
Timothy J. Grillo

​Concussion depicts Dr. Bennett Omalu’s efforts to identify what was causing former NFL players to exhibit signs of psychosis and dementia. Omalu, a neuropathologist is staggered when he analyzes a former player’s brain. He was expecting to see an ugly degraded brain, like the brain of someone suffering Alzheimer’s disease, but to his surprise the brain of former Pittsburg Steeler Mike Webster looked different (Kirk, 2013). 

Doctor Omalu meticulously examines the effects of repeated blows that are customarily delved out during NFL.  He hypothesizes that the effect, in the longer term, is on cognitive functioning. Omalu enters the fight of his life against the NFL as he attempts to bring to light the dangers of playing America’s most beloved game.
Concussion is defined as a traumatic brain injury that alters the way the brain functions. Effects of mild concussions are usually temporary but can include headaches and problems with concentration, memory, balance and coordination (Mayo clinic, 2014). In the film, it is said that it takes about 60 g force to cause a concussion. The average hit in an NFL game is 100 g force. Players are at risk for suffering multiple concussions per game.  Dr. Omalu named a condition that had not been identified, Chronic Traumatic Encephalopathy or CTE. He believed many of those who experienced recurring brain trauma in the NFL had CTE. CTE is a progressive degenerative brain disease that persists and may build over a period of years as the result of traumatic impacts to the head (BRRI, 2016).

Concussion does not go into detail about what is happening neuropsychologically to those afflicted with CTE. It is only described in neuopathological terms;  killer proteins are  unleashed, which strangle the brain from the inside out. The film proclaims that neuro imaging techniques will not pick up any early signs of CTE. For the time period of the film this is correct.  However, today, with finer detailed imaging there may be some warning signs of CTE that become apparent via 3T MRI. The bodies of NFL players examined post mortem revealed higher rates of Cavum Septi Pellucci. A study conducted by Korete et al. (2016) found that football players exhibiting signs of behavioral and cognitive distress had a “higher rate of CSP, a greater length of CSP, as well as a greater ratio of CSP length to septum length was found in symptomatic former professional football players compared with athlete controls. CSP may serve as a potential early in vivo imaging marker to identify those at high risk for CTE”.

The movie’s characters, former NFL players Mike Webster, Terry Long and Andre Waters are  portrayed as plagued by CTE. They are depicted as broken men, tormented by memory loss, mood swings, depression and violent outbursts. Mike Webster is destitute living in his van. He suffers from memory loss and has taken to ripping out his own teeth and super gluing them back. Terry Long has violent outbursts that terrify his family. Andre Waters deals with memory loss and chronic headaches. For Waters and Long the suffering is too much to endure, they both commit suicide.

The depiction in the movie of those suffering from CTE is an accurate portrayal of how the symptoms of the disease manifest themselves in actuality. Omalu, Hamilton, Kamboh, DeKosky and Bailes (2010) conducted an autopsy of a 44 year old former NFL player who had been displaying almost identical behaviors as those portrayed in the film including committing suicide. The autopsy confirmed the man had CTE. Dr. Omalu, the man on whom film is based, was involved in this study. Once Omalu was certain that more NFL players were suffering from CTE, he tried to inform the public about the dangers of football. However, he is met with scorn and ridicule. The NFL refuses to recognize his research and denounces Omalu as a quack.  The NFL refuses to admit that there is any link between playing football and chronic brain injury. Omalu is ultimately forced to stop investigating any further cases of CTE. Years later, at the request of former Steelers doctor Julian Bailes, Omalu reopens his investigations on CTE. By this time many more players have fallen victims to CTE, the NFL begrudgingly admits the validity of Omalu’s research in the process taking precautions to try and limit brain injury in the NFL. 
    
I think this film was accurate in portraying the symptoms that are associated with CTE. The audience really got a sense of the pain and suffering people go through living with CTE. In terms of a neurological perspective, I don’t think nearly enough information was presented with regard to what areas of the brain are effected by CTE, this could be because information was not available during the time the movie was reflecting. Accuracy-4/5.
 
I think Concussion can be an extremely valuable educational tool. Everyone who has thought about putting a pair of cleats should watch this film. Concussion exposes the dangers and ramifications playing contact football on any level can have. Omalu’s research is having tangible effects, in the last few years numerous NFL players have retired early citing concerns about developing CTE as the reason. Educational value- 5/5
 
As a whole I did not think this movie was anything special, however, I thought Will Smith did a phenomenal job depicting Doctor Bennett Omalu. Smith delivered an Oscar worthy performance. I thought there was not enough focus on the neurological effect. I thought CTE should have been explained in much more detail. I thought the supporting acting was decent, the casting could have been better. For example, Luke Wilson does not resemble Roger Goodell in the slightest.  Entertainment- 2/5
 
                                                            Reference List
Bagger, A. (Producer), & Landesman, P. (Director). (2015). Concussion [Motion Picture]. United States: Columbia Pictures.
 
 
Kirk, M. (2013, March 25). League of denial: The NFL’s concussion crisis. Retrieved from http://www.pbs.org/wgbh/pages/frontline/sports/league-of-denial/the-frontline-interview-dr-bennet-omalu/
 
Mayo Clinic Staff. (20014, April 4). Diseases and conditions, concussion. Retrieved fromhttp://www.mayoclinic.org/diseases-conditions/concussion/basics/definition/con-20019272
 
Brain Injury Research Institute. (NA). Protect the brain. Retrieved fromhttp://www.protectthebrain.org/     
                            
Koerte, I. K., Hutschmindt, J., Muehlmann, M., Tripodis, Y., Stamm, J. M., Pasternak, O.…Shenton, M. E. (2016). Cavum septi pellucidi in symptomatic former professional football players. Journal of Neurotrauma, 33 (4), 346-353.

Omalu, B. I., Hamilton, R. L., Kamboh, I. M., DeKosky, S. T., & Bailes, J. (2010). Chronic traumatic encephalopathy (CTE) in a National Football League player: Case report and emerging medicolegal practice questions. Journal of forensic Nursing, 6, (1). 40-46.

An Autistic boy finds himself at the butt of most jokes in his school until he utilizes his online gaming skills in order to seek courage and revenge.

Ben is a young high school student who falls on the Autism Spectrum Scale. Because he is different, many students find it acceptable to pick and bully Ben. Consequently, he finds himself disassociating during these traumatic experiences and honing in on his online video game persona. Through his process of gaming, Ben builds a relationship with a girl coined his “helper”. His      helper assists him in building not only courage in standing up for his rights but revenge on the bullies.

Neuropsychological Review
Behind the Eyes of a Boy With Autism
Lisa Vallone

BenX is a heart-wrenching tale regarding an Autistic boy who has Asperger’s Syndrome, a form of Autism Spectrum Disorder (ASD). While Ben is known as somewhat of a social pariah, he excels in learning, his store of knowledge, and most importantly, video gaming.  Due to his social differences, Ben finds himself the victim of many merciless pranks at the hands of school bullies. At school Ben is different, but online he is just as good, if not better, than any other player.
​

He is a highly respected online video gamer reaching an almost impossible level of 80. Through his high status on his video game, he builds a close relationship with a girl named Starlite, his “helper” in his online voyages. Starlite helps Ben stand up to those who hate his differences in the most courageous and impressive fashion of staging his own funeral. Only through the act of faking his own suicide was Ben able to show his schoolmates that they’re actions towards him are not only unacceptable but also able-ist and inhumane.
 
While Ben is on the Autism Spectrum, he is high functioning and able of to perform the required daily functions for living (i.e. able to dress, use bathroom, eat, navigate on his own). For the most part, the film greatly portrayed not only the symptoms of Autism but also gave the audience an Autism perspective straight from Ben’s mind. The general criteria for Autism according to the DSM V is: persistent difficulties in the social use of verbal and nonverbal communication, functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, and onset of symptoms are present in an early developmental period. Ben is close to a textbook example of a person with moderate Autism (with several exceptions). Specifically, he did have functional limitations such as: difficulties in the social use of verbal and nonverbal communication (i.e. not being able to communicate that he did not want be bullied nor was he able to physically stop it), limitations in social participation and social relationships (i.e. not feeling comfortable in crowds of people or just the presence of people) and lastly he was diagnosed at an early age which was addressed in the film.
 
A couple of Autistic symptoms in the movie  may not be commonly noticed by the public.  These include Ben’s difficulties in  speech, hearing, and seeing. Often times, certain social functions of people with Autism get “traded-off” for other cognitive functions unrelated to social ability. Research done by Broderick and Kasa-Hendrickson does not only touch on  the compromised hearing and seeing functions of Autistic people, but also found that speech is one of the most commonly compromised assets due to the misunderstanding of certain social cues (2001). Another symptom portrayed in BenX was his irritability and agitation when there is a stimulus overload of any kind. The movie showed that Ben had more outbursts as a child but then learned to control such reactions’ as he got older. Research conducted by Mikita, Hollocks, Papadopoulos. Aslani, et. al. (2015), found that irritability in people with ASD, especially men, is often a result of extreme stress that is built up over a period of time. BenX coincides with this research due to the fact that Ben was generally able to control his outbursts as an older adolescent, until a build up of stress related to bullying resulted in a fit of irritability and material destruction.
 
One aspect of the movie related to ASD was a bit far off from the general known symptoms of the disorder. BenX is seen as having an on-going hallucination of Starlite for several known days. During these hallucinations Starlite stopped him from committing suicide, gave his confidence and courage in order to stand up to his peers, and ultimately helped him execute his fake funeral set-up. While these hallucinations gave a great twist to the movie, these symptoms are otherwise unrelated to ASD. In fact, researcher Gadow (2013) founded that people with ASD who experience hallucinations are often times experiencing that due to another underlying mental disorder, mainly schizophrenia . Therefore, this aspect of the movie wasn’t an accurate depiction of a person with Autism only. On the flipside, it could be considered that Ben may be diagnosed both Autistic and Schizophrenia to a certain degree.
 
Overall, I would rate this movie as a 4/5 for accuracy, only because of the false depiction of hallucinations in people with ASD. I would rate a 5/5 for educational value considering this movie not only presented many of the ASD symptoms but also gave insight on how Autistic people experience such symptoms. And I would rate a 5/5 for entertainment due to the fact that the movie was unique in its nature, did not drag on, had a surprise ending, and addressed certain social justice issues concerning people with mental disabilities. I would recommend this movie to ages 12 and older for a couple of reasons. One, there were very explicit depictions of bullying that could trigger children who have experienced extreme bullying in the past. Two, the subject matter is mature and a bit complex, I would imagine that someone who is 8 would not developmentally be able to understand the underlying premise of the movie the way a cognitively more developed 12 year old would. 

References
 
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental       disorders: DSM-5. Washington, D.C: American Psychiatric Association.

Broderick, A.A., & Kasa-Henrickson, C. (2001). ‘SAY JUST ONE WORD AT FIRST:    ‘The emergence of reliable speech in a student labeled with autism. Journal Of      The Association For Persons With Severe Handicaps, 26(1), 13-24.            Doi:10.2511/rpsd.26.1.13

Gadow, K.D. (2013). Association of schizophrenia spectrum and autism spectrum            disorder (ASD) symptoms in children with ASD and clinic controls. Research In Developmental Disabilities, 34(4), 1289-1299. Doi:10.1016/j.ridd.2013.01.011

Mikita, N., Hollocks, M.J., Papadopoulos, A.S., Aslani, A., Harrison, S., Leibenluft, E.,   & … Stringaris, A. (2015). Irritability in boys with autism spectrum disorders: An          investigations of physiological reactivity. Journal Of Child Psychology And                        Psychiatry, 56(10), 1118-1126, doi:10.1111/jcpp.12382

Neuropsychological Review
The Changing Self in Alzheimer’s Disease: a Personal Perspective Through “Still Alice”
Daniel G. Smith, M. S. (Contact )

Alzheimer’s Disease (AD) can be called the “ultimate thief” insofar as we define ourselves as “the sum of our combined experiences” (Wolfson, 2008). In Still Alice (based on the fictional book I’m Still Alice by neuroscientist Lisa Genova), Julianne Moore gives a stellar portrayal of Alice, a strong woman who must face a life with early-onset (familial) Alzheimer’s Disease (AD). A woman who defines herself by her intellect and strong facility with language must adapt to the many existential dilemmas and at the center, a fundamental loss of self that arises with this chronic, progressive, and at present, incurable condition.

Although Alice’s problems begin with seemingly small slips of memory that are passed off by her husband as normal aging, she quickly shows problems that point to deeper, more serious symptoms of dementia. Throughout the movie, we see Alice’s past, her autobiographical memory, stripped away from her. This is poignantly represented by the super 8 cuts from her childhood, and the contrast is emphasized by the final scene of the movie, showing a super 8 cut of her younger self waving goodbye to the camera, suggesting that the last of Alice’s childhood has left her. Alice’s progressive loss of autobiographical memory tends to match the presentation for individuals with AD, with the progression of impairments in autobiographical memory recall following a temporal gradient, such that most recent memories are the first to go and oldest memories from childhood the last (Leyhe et al., 2009).

Although AD frequently begins with problems of encoding and remembering new information there is usually an increasing loss of memory for personal events as the disease progresses (Holtzman, Morris, & Goate, 2011). Autobiographical-knowledge is a fundamental component of self-knowledge (Buckner,2007), with self-knowledge typically defining conceptions of self (Dore et al., 2014). Autobiographical memory and memories about relationships with others, both rely upon a constant tracking of events with respect to the self (Buckner, 2007). Theory of mind, the ability to place oneself mentally in the perspective of another, appears to rely in part on intact self-knowledge, and also tends to be impaired in AD throughout the progression of the disease (Moreau et al., 2013).

Language dysfunction, which can also be a symptom of AD (Holtzman, Morris, & Goate, 2011), is particularly damaging to Alice’s sense of self. Along with autobiographical memory, language appears intimately tied to self-knowledge. Alice, a well-respected linguistics professor at a prestigious university, has defined her life through her command of language.  It is her difficulties finding words that first reveal that something is wrong. In an early scene as a guest speaker, Alice is able to pass off her difficulties with word finding as  “too much wine”. As the movie and  stages of the disease progress, Alice’s language problems worsen. In the early stages, Alice’s deficits are characterized by word finding errors in conversation and in an online word game with her daughter. In the moderate stages, we observe greater difficulties in Alice’s comprehension and disorientation during conversations. By the end of the movie, seemingly the severe to advanced stages, Alice becomes almost non-verbal, having difficulties in comprehension, and grunts her initial responses, revealing the potential onset of muteness.

As a final affront to Alice’s self, self-control, personality and mood change and inability to live independently are a part of AD’s progression. For Alice in the moderate stage of the disease, obvious memory problems and difficulty with language are accompanied by what many family members would perceive as personality changes, or reactions to the disease, but can also be related to brain changes that affect the frontal lobes. As the movie and the disease progresses, Alice’s well kempt appearance slowly fades. Alice’s smart suits, straightened hair, and hint of makeup, disappear in favor of more comfortable clothing and less focus on appearance. The way in which she interacts with others similarly changes, as she is frustrated far more easily by slights and suggestions that she is remembering things incorrectly. In the moderate stage, people begin to experience loss of independent function in most activities of daily living and during the severe and advanced stages, are unable to live independently (Holtzman, Morris, & Goate, 2011). For a fiercely ambitious woman like Alice, this loss of independence combines with worsening memory and language changes from the early stage of the disease to the later stages. Together, each stage of the disease and each decline is a particularly egregious offense to Alice’s sense of self.

Not only is Alice’s past lost, so too is her future. Beyond the perception of the self and how we come to relate to others, AD tends to result in a loss of future self and the ability to think about and plan for the future (Klein, 2014; Shacter, 2012). Given Alice’s knowledge of the progressive symptoms of the disease and her fear of losing herself, early on she plans suicide for the time she can no longer answer the memory questions she has made up for herself. Her plan mimics real world considerations for end of life decisions and advanced directives in the US and abroad (de Boer et al., 2011). For Alice, however, her personal directive fails. The later mentally impaired Alice that stumbles upon the message - and the plan for euthanasia - is not sure of the goal of the butterfly folder, and is unable to keep track of its instructions.

Following the botched suicide plan, we are left wondering what’s next for Alice? What defines Alice after much has been taken away and her family begins to separate from her? On a grander scale, what is the purpose of life for an individual robbed of both past and future? In the final moments we are given the possibility that the acknowledgement of love, and the continued ability for connection is what gives Alice’s new life hope and meaning.

This brings us to the overall goal and hope for the movie. Throughout, the purpose and quality of Alice’s life is fundamentally called into question. We are given a close look at Alice and her progression through this devastating disease. We are provided a glimpse into the need for adaption by the individual as well as the family, and by the end of the movie, we are left to question the essential qualities of life apart from our memories and experiences.

From a neuropsychological perspective, while the movie excellently portrays the heart-wrenching loss of self that may come with a diagnosis of AD, it at times inaccurately represents several components of the progression, as well as the manner in which that progression is tracked. For the purpose of time constraints and dramatic movement in the movie we see more immediate progression in memory loss and an overall quick timeline of the disease. However, even in early-onset AD, the progression tends to take place over the course of 10 years, with the early stage lasting 2 – 5 years, the moderate from 2 – 4 years, and the severe and advanced stages characterizing the remainder of life through death (Holtzman, Morris, & Goate, 2011). Given the timing of events in the movie, it appears that Alice progresses from the early to severe stage within a much more constrained time frame, likely 2 to 2.5 years.

Also, possibly due to a need to combine the professional characters of a neuropsychologist and neurologist, the movie takes liberties with the book’s excellent portrayal of the in-depth neuropsychological assessments that take place as a fundamental aspect of the Alzheimer’s Disease diagnosis and progression. Rather than the exhaustive battery of tests required to carefully tease the symptoms of AD apart from other dementias, as well as the in-depth interviewing of family members that are typically part and parcel to this diagnosis of exclusion, these roles are seemingly replaced by simplistic indices of cognitive function administered by her neurologist, and similarly an insufficient tracking of progression by way of self-imposed and simplistic memory testing.

Insufficiencies in diagnostic testing as well as the gradual decline along a prolonged timeframe compressed into a matter of several years, may be forgivable as artistic license taken by the directors. As is their intent, the take home message is rather aptly, what is the definition of self, and the meaning of life, in the context of AD? The meaning of life in the context of AD is a question that resonates with the public, and as demonstrated by Still Alice, is not easily addressed . The movie’s message further speaks to the need for greater awareness of the impact of AD, as well as the need for funding of research seeking early diagnosis and treatment of AD. Alice, as excellently portrayed by Julianne Moore, may well serve as a symbol for the need for progress toward the treatment of Alzheimer’s Disease, as well as a model of the possibility for continued relationship for family’s suffering from the disease. 

 
References:

Buckner, R. L., & Carroll, D. C. (2007). Self-projection and the brain. Trends in cognitive sciences, 11(2), 49-57.

de Boer, M. E., Dröes, R. M., Jonker, C., Eefsting, J. A., & Hertogh, C. M. (2011). Advance directives for euthanasia in dementia: how do they affect resident care in Dutch nursing homes? Experiences of physicians and relatives.Journal of the American Geriatrics Society, 59(6), 989-996.

Doré, B.P., et al., Social cognitive neuroscience: A review of core systems, in APA Handbook of Personality and Social Psychology, Mikulincer, M., et al., (Eds). 2014, American Psychological Association: Washington, DC. p. 693-720.

Holtzman, D. M., Morris, J. C., & Goate, A. M. (2011). Alzheimer’s disease: the challenge of the second century. Science translational medicine, 3(77), 77sr1-77sr1.

Klein, S. B. (2015). What memory is. Wiley Interdisciplinary Reviews: Cognitive Science, 6(1), 1-38.

Leyhe, T., Müller, S., Milian, M., Eschweiler, G. W., & Saur, R. (2009). Impairment of episodic and semantic autobiographical memory in patients with mild cognitive impairment and early Alzheimer's disease. Neuropsychologia,47(12), 2464-2469.

Moreau, N., Rauzy, S., Bonnefoi, B., Renié, L., Martinez-Almoyna, L., Viallet, F., & Champagne-Lavau, M. (in press). Different Patterns of Theory of Mind Impairment in Mild Cognitive Impairment. Journal of Alzheimer's Disease.

Schacter, D. L. (2012). Adaptive constructive processes and the future of memory. American Psychologist, 67(8), 603.

Wolfson, W. (2008). Unraveling the tangled brain of Alzheimer's. Chemistry & biology, 15(2), 89-90.

In real life, Dr. Temple Grandin became a professor of animal science, a field in which she is renown for revolutionizing the slaughterhouse industry by inventing various humane cattle handling mechanisms used worldwide. Additionally, Dr. Grandin has published multiple best-selling books, and publicly speaks as an authority on both the topics of autism and livestock handling. 

The beef and potatoes of this film takes place during the cumbersome and painful early chapters of Grandin’s life with autism, before the days where the back-sides of minivans were adorned with puzzle-piece ribbon magnets. Dane’s physical and prosody-perfect transformation into the youthful Temple featured here is nothing short of uncanny.

This film aims to tell a tale of what it takes to overcome the plethora of adversity associated with an autism diagnosis. It takes the viewer through the frustration faced by both mother and child during Temple’s speechless pre-school years, educational ostracism, peer rejection, and abundant sexism in the male dominated cattle handling industry suffered by Temple during the 60’s and 70’s.  Over the course of one hundred, forty nine minutes, the film highlights how a comprehensive support network of dedicated family members and educators insistent on early intervention and innovative teaching methods centered around her “visual thinking”, contribute Temple’s extraordinary outcome. 


Grandin describes the concept of visual thinking in her novel Thinking in Pictures and Other Reports From my Life with Autism (1995).  She describes  her ability to “translate both spoken and written words into full-color movies, complete with sound, which run like a VCR tape in my head.” In the cinematographically impressive “shoe” scene,  in which Temple’s science teacher Dr. Harlock, carefully uncovers her unusual thinking style, the film’s director gives us a dead-on visualization of Temple’s somewhat abstracted description. The notion of “thinking in pictures”, or visual thinking is common among autistic persons, as is thinking in patterns or word details (Grandin, 1995). Interestingly, this propensity for specialized thinking among autists is thought to be a compensatory adaptation to the suspected underconnectivity in various cortical brain regions (Kana et al., 2006; Courschsne et al., 2001).

Once Dr. Carlock uncovers how Temple thinks, he is able to understand how she learns, a puzzle often faced by many professionals or family members working with autists. In the scene where Dr. Carlock invites Temple to re-create the classic “Ames Room” optical illusion using horses for extra-credit, we see very clearly that by developing Temple’s strengths as a visually and spatially oriented thinker through challenging her with an innovative design-oriented task, she is able to exceed and thereby express her truly unique talents. 

This is also the first time during the film where her peers seem to begin to appreciate her as different, not less. In her novel, Thinking in Pictures and Other Reports From my Life with Autism (1995), Dr. Grandin addresses the awesome importance of educators, such as we see here in the realization of her grade school mentor's  willingness to explore and emphasize the strengths of autistic students instead of merely focusing on deficits.  Throughout many scenes, the film hammers home the social and cultural significance of not only appreciating, but also valuing the specialized thinking and strengths of autistic persons.

During a haunting flashback into Grandin’s childhood of a strained teaching session, we see Eustacia, Temple’s mother, trying desperately to elicit speech from her daughter by repetitively showing her flashcards while simultaneously enunciating words. Temple, instead of paying attention to her mother, let alone verbally responding to her, stares blankly at a light fixture with hanging crystals while experiencing a spell of sensory overload from the slight sound emitted by the light. 

One common feature of disordered communication presented in autistic persons is a lack of expressive speech. Emerging on the scene in the early 1980’s, various behaviorist treatment methods geared towards not only modifying behavior but also teaching language (a notion that will make any cognitive psychologist or psycholinguist cringe) were developed to address this deficit. A majority of early intervention techniques in the field seem to be centered around an autistic person’s aptitude for visual thinking, including as picture communication exchange (PECs) and TEACCH method, which uses visual organization to teach language (Kana et al., 2006). In her book, Temple credits her mother with helping her learn to effectively communicate through consistently using flashcards which paired 100’s of pictures with words, an intervention she started with her daughter during her second year. While some may view this as merely an anecdotal account of success, evidence does suggest that early intervention methods in the treatment of symptoms of autism do produce positive outcomes, particularly in the domains of IQ score and modifying behavior (Rogers and Vismara, 2008).  

The movie’s portrayal of Temple Grandin’s early life with autism is as successful and as inspiring as it gets. At the end of the day and at the end of the film it is important to remember that individuals with autism are just that, individuals. Everyone’s journey with overcoming and embracing the ups and downs of autism is different, and this movie is careful to show that Temple was lucky that things seem to fall in place for her. 

Her story shows us that with the right cocktail of a strong support network , early intervention, innovative educational accommodations, personal perseverance, and self sufficiency, a remarkable outcome is entirely possible for a person with an autism spectrum disorder. We see how the influential people in Temple’s early life encouraged developing her strengths instead of merely focusing on modifying her weaknesses, a very simple and entirely realistic thought. 

It is also important to note that this film strongly captures Temple’s anti-cure perspective, which is central to acceptance of neurodiversity and the autism rights movement. For Dr. Grandin and many others, autism should not be conceptualized as a disease to be cured, but instead, as a natural variation in functioning. In spite of her struggles through life, we see here how Temple has an incredible ability to think differently than the rest of us; and that is nothing short of a true gift. This film gets a giant, red, A+.

References

Courchesne, E., Karns, C.M., Davis, H.R., Ziccardi, R., Carper, R.A., and Tigue, Z.D.     (2001).Unusual brain growth patterns in early life in patients with autistic disorder.an     MRI study. Neurology, 57, 245–254.

Grandin, T. (1995). Thinking in pictures and other reports from my life with autism. New York, NY: Vintage.

Just, M.A., Cherkassky, V.L., Keller, T.A., Minshew, N.J.(2004).Cortical activation and synchronization during sentence comprehension in high-functioning autism: evidence of underconnectivity.  Brain,127,1811-1821.

Kana, R. A., Keller, T., Cherkassy, V. L., Minshew, N. J, and M. A. Just. (2006). Sentence comprehension in autism: thinking in pictures with decreased functional connectivity. Brain, 129, 2484-2493. 

Rogers, S. J. and Vismara, L. A. (2008). Evidence based intervention treatments for early autism.     Journal of Clinical Child and Adolescent Psychology, 37, 8-38.

In the United States one-quarter of the population report occasionally not getting enough sleep and about ten percent experience chronic insomnia (Center for Disease Control and Prevention [CDC], 2013), a disorder that is characterized by difficulty initiating sleep, maintaining sleep, and early morning awakening with the inability to return to sleep; and is often due to increased anxiety and an overabundance of light. (American Psychiatric Association, 2013).

Throughout Insomnia detective Dormer shows many signs of sleep deprivation. He appears drowsy, inattentive, confused, and he encounters numerous scenarios that appear to be visual hallucinations, a possible symptom of extreme sleep deprivation (West, Janszen, Lester, & Cornelisoon, 1962). But just as Dormer begins his murder investigation, a second murder occurs and the anxiety surrounding this crime begins to take an extreme toll on his sleep and overall wellbeing.

In addition to the midnight sun of Alaska, in true Christopher Nolan fashion, the director has added another element to Dormer’s decay: extreme anxiety. By creating this traumatic event in Dormer’s life, Nolan creates a scenario in which the audience sees both anxiety and lack of sleep contributing to Dormer’s decay.

Throughout Dormer’s time in Alaska, he endures one night in which he struggles to sleep before he witnesses a second crime. It should also be noted that despite having no apparent sleep this one night, the following day he does not suffer many adverse effects despite being tired. It is only after he is exposed to the trauma of second crime that the majority of his symptoms begin to manifest.

Due to this timing, from a psychological point of view, we can begin to examine differential diagnoses. One diagnosis that captures Dormer’s experience alarmingly well is Acute Stress Disorder. The symptoms of Acute Stress Disorder typically occur with 3 days to 1 month after a trauma but can manifest immediately (American Psychiatric Association, 2013). These symptoms include recurrent, intrusive and distressing memories, distressing dreams, flashbacks, an altered sense of self or surroundings, effort to avoid the memory, negative mood, and sleep disturbance (American Psychiatric Association, 2013). Keeping these symptoms in mind, it becomes increasingly clear that while Dormer does seem to be bothered by the never setting sun and his inability to sleep, his experience is better explained by Acute Stress Disorder. This would likely be his primary diagnosis because of how well his experience is captured by this disorder. It is not likely he would receive a primary diagnosis of insomnia from this snapshot of his behavior because sleep difficulty must persist for 3 months before meeting diagnostic criteria (American Psychiatric Association, 2013).    

Since sleep disturbance is a significant part of the Acute Stress Disorder diagnosis, how would his disturbed sleep be accounting for many of the symptoms we see during the movie? Detective Dormer is very sleep deprived and it appears that he has not slept once during the entire movie. Due to this extreme sleep deprivation, we would suspect that Dormer would begin to have hallucinations (Sheldon, Kryger, Ferber, & Gozal, 2014). In Insomnia though, Dormer begins to have hallucinations early on which is atypical for short durations of sleep deprivation. 

Typically, hallucinations, as experienced in Schizophrenia, are auditory in nature and are often described as hearing voices that are not present (American Psychiatric Association, 2013). However, Dormer’s hallucinations are strictly visual and he exhibits no other signs of Schizophrenia. One way to explain these apparent visual hallucinations that Dormer experiences is with a phenomenon known as micro-sleep. Micro-sleep is common in those with insomnia and is defined as a brief unintended episode of loss of attention; and often co-occurs with head snapping, a blank stare, and prolonged eye closure (Innes, Poudel, & Jones, 2013; BBC, 2014).  Because Dormer is not sleeping at night, it is likely that his brain is attempting to rest whenever possible and slips into brief micro-sleep episodes during the day. With this in mind, when analyzing Dormer’s hallucinations, while it was not likely the intent of the director,  it can be reasoned that he is in fact experiencing episodes of micro-sleep and therefore is experiencing hypnagogic hallucinations that can occur in the transition from wakefulness to sleep.

Since we have noted that Insomnia is a more accurate portrayal of Acute Stress Disorder, we should also note that some of the representations about insomnia as a disorder are indeed accurate and capture “what it feels like” to have insomnia. For example, late in the movie (time stamp: 1:44:27) detective Dormer is driving down a long stretch of straight Alaskan highway and begins to nod off while attempting to fight his body’s urge to sleep. This is not only an accurate portrayal of what insomnia's side effects could look like but it is also accurate because 37% of Americans have admitted to falling asleep behind the wheel in the past year (National Sleep Foundation, 2014). Overall, Insomnia captures the feeling of the insomnia diagnosis by utilizing a variety of imagery as demonstrated by a scene in which Dormer “spaces out” and experiences a distortion of his environment (time stamp: 1:11:38).

Insomnia is a movie I would recommend because it is not only an enjoyable film but it also does an excellent job of conveying “what it feels like” to have insomnia. Including the extreme cognitive and behavioral difficulties that may occur with insomnia. While this film can be used to demonstrate the idea of “what it feels like” to have insomnia, it should also be noted that this film is not strictly about insomnia alone. Insomnia is also about anxiety, trauma and more accurately Acute Stress Disorder. While the film does not clearly differentiate between what symptoms are due to Dormer’s anxiety versus insomnia, this effectively makes this movie very useful for teaching and discussing the topics of insomnia, anxiety, and trauma. Besides, leaving “gray areas” up to the interpretation of the viewer is a hallmark of Christopher Nolan and of good discussion.


References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

BBC. (2014, January 8). Who, what, why: What is a micro-sleep?. Retrieved from http://www.bbc.com/news/blogs-magazine-monitor-25593327

Center for Disease Control and Prevention. (2013, July 1). Sleep and Sleep Disorder. Retrieved from http://www.cdc.gov/sleep/

Innes, C. R., Poudel, G. R., & Jones, R. D. (2013). Efficient and regular patterns of nighttime sleep are related to increased vulnerability to microsleeps following a single night of sleep restriction. Chronobiology international, 30(9), 1187-1196.

National Sleep Foundation. (2014). Drowsy Driving. Retrieved from http://sleepfoundation.org/sleep-topics/drowsy-driving

Sheldon, S. H., Kryger, M. H., Ferber, R., & Gozal, D. (2014). Principles and practice of pediatric sleep medicine. Elsevier Health Sciences.

West, L. J., Janszen, H. H., Lester, B. K., & Cornelisoon, F. S. (1962). The psychosis of sleep deprivation. Annals of the New York Academy of Sciences, 96(1), 66-70.

 

An 8 year old girl from Australia becomes a pen friend to to a middle aged man in New York City with Asperger's Syndrome.

This quirky animated black comedy explores the friendship of two social misfits through their letters.  Among Max's  mental health issues, including anxiety and depression, he is also diagnosed with Asperger's syndrome. He calls himself an Aspie and goes on to describe the traits he has which fit what others call his "disability". Max stands firm in his self-assessment that he doesn't feel defective or need to be cured. He simply doesn't understand how humans can be so illogical.  When Mary writes a book about his disorder, their friendship is sorely tested. This film doesn't hold back on black humor nor the effects of not being accepted.  A movie about friendship.

We learn in the movie that Vincent first started to experience vocal and motor tics in the third grade (1:14:30) which is fairly typical (Leckman 2009). No one is really sure what causes tourette's syndrome (TS),  but  there appears to be a disruption in the motor functioning of the basal ganglia, which causes the tics and possibly other neurochemical abnormalities (Kurlan 2013).  

After the funeral we learn that Vincent’s father will place Vincent in a mental institution so that he can continue on with his political career. The use of a mental institution appears to be a mis-portrayal of placement and treatment for people with TS. TS, by itself is not a reason to place someone in a mental institution in the United States, and presumably, in Europe. Vincent’s father also states that his son is "retarded" (29:26). In reality, TS is not a form of intellectual disability or delay and people who have TS are expected to have normal IQ levels (Munson 2005).  In the movie Vincent does appear naïve but does appear to be able to learn as others do.
 
Mr. Galler also expects that Vincent will become "cured" of TS and seems disappointed when he learns that the tics and vocalizations are something Vincent needs to learn to live with and manage. We learn during the intake process that the institution focuses on habit reversal training where the tics are replaced with another behavior. This type of therapy, based on an actual treatment (Kurlan 2013), involves self-monitoring of tics and learning to substitute a behavior that is physically incompatible with the tic. Studies have suggested that this type of therapy can be effective in children, but it remains to be seen how effective this type of therapy is with adults (Piacentini et al 2010). We also learn during this time that Vincent would like to finish high school and maybe go on to college, but most of all it seems that Vincent would like to be accepted by his father.  


At the institution, Vincent meets two other patients Alex, a patient who experiences OCD and Marie, an anorexic. The rest of the film centers around Vincent, Marie and Alex escaping the institution and traveling to Italy while Mr. Galler and Dr. Rose, the institution’s physician, desperately try to catch them to make sure that nothing happens to them and to help make sure that this stays out of the public's eye so that Mr. Galler's reelection campaign continues on unharmed.  

As the trio continues on their trip to Italy, they begin to form a bond and Vincent begins to share what it is like to live with TS.  When Marie asks if he can tell when the tics are coming Vincent compares the tics to something similar to a sneeze. "It just kind of crawls up" (45:58) he states. Often times many people with TS feel that the tics they experience help relieve uncomfortable sensations. They can be suppressed for a period of time, but the sensation continues to build until the impulse becomes so great that releasing the tic is the only source of relief (Kurlan 2010).  The types of tics that Vincent displayed throughout the movie were pretty typical. Common tics include eye twitching, tensing of the abdominal muscles, facial grimacing, throat clearing and sniffing.  Throughout the movie, Vincent displayed another behavior called coprolalia, which is defined as obscene or insulting utterances. This type of tic is what many people identify as a typical of TS. However in reality, coprolalia occurs in less than fifteen percent of patients diagnosed with TS (Munson 2005). 

Another realistic view of TS is captured when Vincent's tics get worse when he is under periods of high stress, anxiety or anger.  When told to calm down Vincent replies with "It forces me to do what I don't want to. Calming down is about the last thing that I can do" (49:39). The tics have the tendency to come more often during periods of stressful life events or during periods of high excitement (Leckman 2002) and there are times in the movie that Vincent experiences no tics, which is also the case with TS.  While in search of the trio, Vincent’s father finally begins to accept Vincent for who he is. At the end of the film, there is a newfound respect between Mr. Galler and Vincent and the movie ends with Vincent starting a new life in Italy.

 
In conclusion, Vincent Wants to Sea portrays a mostly accurate account about the symptoms of TS but is not accurate about people with TS needing to be cared for in Mental Institutions. The main character Vincent experiences the everyday struggles of living with TS.


I would have liked to see another type of vocal tic used besides coprolalia since the majority of patients with TS do not suffer from this type of tic. I also feel that if another type of vocal tic was used this movie could be used in middle school settings. I really liked this film. It also showed that people with TS can lead normal lives. I think the best audience for this film would for teenagers above the age of 16. If parental permission is granted, this film may be used in the middle school setting from perhaps eighth grade on up. The scene between Marie and Vincent in the woods may be considered inappropriate for younger audiences, and I feel that if a teacher decided to show this movie as part of a lesson, they would have to stress the fact that coprolalia is not a common tic in TS. Teachers would also have to stress the importance that people with TS can manage their tics effectively, lead normal lives and function very well in society.

References
Jäger V., Kügler H. (Producers) & Huettner, R. (Director). (2010). Vincent Wants to Sea [Motion picture]. Germany: Corinth Films

Kurlan, R. (2010). Tourette's syndrome. The New England Journal of Medicine. 363(24), 2332-2338

Kurlan, R. (2013) Treatments of tourette syndrome. NeuroTherapeutics. 11(1), 161-165

Leckman, J. (2002) Tourette's syndrome. The Lancet. 360(9345), 1577-1586

Munson, B. (2005). Myths & Facts....About tourette's syndrome. Nursing. 35(8), 29.

Piacentini, J., Woods, D., Scahill, L., Wilhelm, S.,  Peterson, A., Chang, S., ...Walker, J. (2010). Behavior therapy for children with tourette disorder. A randomized controlled trial. The Journal of the American Medical Association. 303(19) 1929-1937

Zillmer, E., Spiers, M., Culbertson, W. (2008) Principles of neuropsychology. Cengage Learning

A young woman miraculously survives a serial killer's attack only to be stricken with prosopagnosia, a disorder that prevents her from recognizing faces.

A young woman named Anna sees her world turned upside down when she becomes the sole witness to a murder and also suffers an injury that leaves her unable to recognize people by their faces, including the killer. Struggling with prosopagnosia, also known as "face blindness", Anna must learn how to navigate a world full of friends who look like strangers, and strangers who could be killers.  Can she see people for who they really are before the killer comes for her? 

Neuropsychological Review 
Face Blindness: Losing Others, Losing Yourself
Caitlin Potter


There is nothing so comforting as recognizing the face of a loved one amongst a veritable sea of strangers.  Imagine what life would be like if you lost the ability to recognize a friend, family member, and even yourself! ...    

This is the effect of prosopagnosia, or "face blindness", which is a distinct impairment in the ability to recognize faces (Ellis & Florence, 1990).  To those affected with face blindness, it is emotionally taxing and can cause a complete upheaval in sense of self and connection to others (Sacks, 1985).  In "Faces in the Crowd", Anna Merchant, played by Milla Jovovich, is a gifted teacher.  She's socially adept, having a close relationship with her two best friends, as well as a promising new relationship with her boyfriend, Bryce.  Anna's world is upended when she becomes an inadvertent witness to a sadistic murder.  The serial killer, known as Tearjerk Jack, attacks the witness Anna, and a brutal struggle ensues.  Anna ends up tumbling over the side of a bridge and violently hitting the back of her head on scaffolding before plummeting into the river below.  Upon waking up in the hospital, Anna cannot recognize Bryce or her best friends, Nina and Francine.  As a result of the head trauma, Anna is stricken with acquired prosopagnosia.  In addition to the harrowing difficulties of her new disorder, Tearjerk Jack is fixated on Anna, as only she has seen his face and lived.  As the killer closes in on her, Anna attempts to help Detective Kerrest track down a man whose face she cannot remember or recognize.  She must learn new methods to identify people and make sense of her new life, all while surviving murderous intent of Tearjerk Jack.

After the attack, Anna and Bryce consult Anna's doctor.  He shows her two photos and asks if she sees the same face in each; when she replies affirmatively, he tells her they're actually two different people.  The doctor says she's symptomatic of prosopagnosia, or "face blindness", and mentions that it is caused by a lesion on the temporal lobe.  The doctor doesn't describe Anna's brain damage specifically; he only offers the general cause.  He then points out the region on a lateral (or side-view) MRI scan of (what we must assume to be) Anna's brain.  Even though the doctor seems to point somewhat indiscriminately at the MRI, he does accurately indicate the general region of the temporal lobe.  In fact, the temporal lobe contains the Fusiform Face Area, a region of the brain which is specifically tuned to recognizing faces in particular (Gazzaniga, Ivry, & Mangun, 2009).  However, the doctor implies that the temporal lobe is solely responsible for facial recognition.  While surprisingly sufficient for a "whodunit" thriller, this is too general of an assertion.  In actuality, most cases of acquired prosopagnosia  result from trauma to the temporal, occipital, and even the parietal lobes of the brain and their underlying structures (Gazzinaga, Ivry, & Mangun, 2009). Throughout the movie, Anna remains a high-functioning person with no reported cognitive or health issues other than prosopagnosia.  While prosopagnosics can potentially maintain all other cognitive abilities, someone with a head trauma as severe as Anna's would most certainly have additional brain damage and symptoms in addition to face-blindness (Gazzaniga, Ivry, & Mangun, 2008).  Lastly, the doctor informs Anna and Bryce that confirmed cases of prosopagnosia are "extremely rare".  In reality, the disorder is much more common than originally thought, affecting 2.47% of the general population (Kennerknecht et al., 2006).

Anna is referred to a neuropsychiatrist, Dr. Langenkamp, for a formal diagnosis.  During the first consultation, Dr. Langenkamp comes across as absurdly insensitive.  After observing an MRI scan of Anna's brain for several silent seconds, the doctor asks, "what was I supposed to see, exactly?", and we're left wondering if she's incompetent or just unprofessional.  Frustrated by the doctor's cryptic dialogue and unclear diagnosis, Anna leave the consultation.  Dr. Langenkamp warns Anna that she must get used to people's faces changing and that she shouldn't underestimate the seriousness of her condition.  While technically correct, Dr. Langenkamp seems a stereotypical portrayal of an eccentric, even pseudo-scientific psychiatrist.  As time passes, the stress of Anna's condition weighs on her; she even fails to recognize her own father, mistaking him for Tearjerk Jack.  Anna resigns herself to her new reality and returns to Dr. Langenkamp, who instructs Anna to use distinctive markers like tattoos, gait, or distinctive facial features to identify people.  This is sound advice, as face-blind individuals learn to use individual, distinctive facial features as well as the sound of a voice and even the sense of smell to identify and recognize people (Zillmer, Spiers, & Culbertson, 2008; Sacks, 1985). Therein lies a glaring short-coming plaguing the film: Anna consistently fails to recognize even her closest friends and family by their voices. Even her father and her love interests aren't vocally recognized.   In actuality, the voice is perhaps the most useful and distinctive marker to someone struggling with any blindness; Anna never sufficiently utilizes it.  Dr. Langenkamp offers Anna a bleak but realistically poignant explanation of the life a prosopagnosic should expect, claiming people will call her "rude, forgetful, stupid" and resent her for not recognizing them. This is unfortunately true for many face-blind people, some of whom shun interaction with friends and family to avoid inevitably offending them (Gauthier, Behrman, & Tarr, 1999).

Throughout the film, many allusions are made to faces and the emotional weight they carry.  There are repeated shots of Anna's Facebook profile littered with personal photographs of herself and her friends.  When Anna first awakens after the attack, the viewer is subjected to a similar sense of disorientation, as Bryce, Nina, and Francine are now portrayed by different actors.  Cinematically, this effectively evokes empathy for Anna and justifies her alarm.  The casting trick continues throughout the movie, and although it conveys the disorientation of face blindness, it grows confusing and tiresome.  Anna's different relationships represent the various levels of understanding and compassion fielded by those suffering from prosopagnosia.  Bryce becomes less and less sympathetic to Anna's struggles, ultimately dumping her after finding a journal with detailed descriptions of the ties he wore each day.  Anna's friends Nina and Francine downplay the severity of her condition.  Detective Kerrest is initially callous, yet becomes Anna's advocate and protector.  Eventually, Anna realizes that she has "regained" the ability to recognize only Kerrest's face.  This is used for dramatic effect to enhance the romantic connection, but it's an inaccurate portrayal of the progression of prosopagnosia.  While many face-blind people can exhibit unaffected functioning in all other cognitive areas, there is no aspect of the disorder that allows specific faces to be recognized while precluding others (Gazzaniga, Ivry, & Mangun, 2009; Kennerknect et al., 2006).  The film establishes a connection between Anna and Kerrest based on a very emotional love.  This doesn't mean that love can magically and selectively cure prosopagnosia, but there is evidence that the experience of strong emotion can cause prosopagnosics to subconsciously recognize certain faces (Barton, Cherkasova, & O'Connor, 2001).

Overall, despite the plot holes, the oversight of voice recognition, the hilariously stereotypical characters, and some less-than-stellar performances, this film offers a relatively accurate representation of prosopagnosia as a neurological disorder. While finer details about the cause of prosopagnosia were left out, the general descriptions of the symptoms and methods of coping are surprisingly accurate.  Many of the characters seemed shockingly, almost irritatingly ignorant to the difficulties someone suffering with "face blindness" endures, and Anna fails to use voices - the most telling marker - to identify people she knows.  This hackneyed plot wanes to a predictable conclusion.  Still, "Faces in the Crowd" does a serviceable job educating viewers on the dramatic emotional toll prosopagnosia can take.  (It contains violence and some sexual content.)

References

Barton, J.J.S., Cherkasova, M., & O'Connor, M. (2001). Covert recognition in acquired and developmental prosopagnosia. Neurology, 57, 1161-1168.

Ellis, H.D., & Florence, M. (1990). Bodamer's (1947) paper on prosopagnosia. Cognitive Neuropsychology, 7, 81-105. doi: 10.1080/02643299008253437

Gauthier, I.L., Behrmann, M., & Tarr, M.J. (1999). Can face recognition really be dissociated from object recognition? Journal of Cognitive Neuroscience, 11, 349-370. doi:10.1162/089892999563472

Gazzaniga, M.S., Ivry, R.B., & Mangun, G.R. (2009). Cognitive Neuroscience: the Biology of the Mind. New York: W.W. Norton & Company, Ltd.

Kennerknecht, I., Grueter, T., Welling, B., Wentzek, S., Horst, J., Edwards, S., & Grueter, M. (2006). “First report of prevalence of non-syndromic hereditary prosopagnosia (HPA).” American Journal of Medical Genetics, 140A, 1617-1622.

Sacks, O. (1985). The Man Who Mistook His Wife for a Hat, and Other Clinical Tales. New York: Summit Books.

Zillmer, E.A., Spiers, M.V., & Culbertson, W.C. (2008). Principles of Neuropsychology. California: Wadsworth, Cengage Learning.