I wrote this for the student BMJ (Sorry about the dreadful photo above)
Identifying mental illness in historical figures is a favourite hobby of psychiatric sleuths. Particular scrutiny has been paid to the lives of painter Vincent van Gogh and composer Robert Schumann. Both spent time in asylums, but their correct diagnoses remain in dispute. Similarly, descriptions of symptoms of mental disorder have been identified in creative works dating as far back as Shakespeare in the 16th and 17th centuries and the playwright Sophocles in ancient Greece.
Until recently depiction of mental disorders in comics (also known as graphic novels) has attracted less interest. This may be because of their historic association with younger readers, but comics are now read by people of all ages and are gaining more attention, particularly in healthcare. Long running series such as Batman have multiple characters who display symptoms of mental disorder, and works such as Couch Fiction and Psychiatric Tales have storylines specifically about mental health issues.
Looking at the psychopathology of comic book characters is an interesting diagnostic challenge and also a newly used approach to medical education. A comic book convention earlier this year was held to educate the public about psychiatric conditions. Various comics were studied, with Batman being heavily scrutinised.
Mental illness is ubiquitous in Batman’s Gotham city. “Over the years, the stories of the Batman comics have been intensely psychological,” says psychologist, writer, and visiting senior research fellow at the Institute of Psychiatry, Vaughan Bell.
The longevity and popularity of Batman comics and films make it one of the best known representations of mental illness. Arkham Asylum, Gotham’s sanatorium for the “criminally insane,” towers both literally and metaphorically over the city. Many of Batman’s adversaries have either escaped from there, or are destined to return there.
In Batman, “the fictional explanations of what causes madness tend to be particularly detailed,” says Dr Bell. The disorders often bear little relation to those seen in clinical practice, however. In Batman comics “two main themes are used to explain the development of madness,” says Dr Bell. “The influence of trauma and the pursuit of forbidden knowledge.”
The personas of Batman and his arch enemy the Joker are both trauma-induced. Batman’s crusade against crime begins with witnessing the death of his parents. The Joker becomes a villain when, as told in The Killing Joke, he falls into a toxic river shortly after the death of his wife.
Batman’s response to his traumatic experience is to become a masked vigilante. Objectively this is unusual behaviour, but not in Gotham city, where spandex-clad criminals are the norm. In contrast, the Joker is unable to show such a “mature” response and turns to crime. Both can be considered madness owing to trauma.
On the other hand, it is those who seek to know who also suffer. For example, being a psychiatrist in Gotham city’s Arkham Asylum is a particular “risk factor” for mental ill health. “A remarkable number of Arkham inmates are former psychiatrists who have been driven to madness as a result of their work as investigators of the human mind,” says Dr Bell. “Rarely are psychiatrists, psychologists, or neuroscientists portrayed as anything except figures of fear.”
Harley Quinn is an example of a disturbed psychiatrist, although her presentation has little resemblance to an established psychiatric disorder.
Quinn, originally Dr Harleen Quinzel, is an Arkham psychiatric intern who becomes fascinated with the Joker and offers to psychoanalyse him. During treatment, the Joker’s influence causes her to abandon her previous life and personality. She falls in love with him and helps him escape on several occasions.
The portrayals of mental disorder in the Batman characters such as the Joker and Harley Quinn are often highly inaccurate. This has been of interest to American psychiatrists Eric Bender, Praveen Kambam, and Vasilis Pozios.
“In the real world we don’t necessarily see someone either becoming a hero or a villain following a single traumatic event,” says Dr Bender, questioning the verisimilitude of the back stories of Batman and the Joker.
Dr Bender also says that the term “criminally insane,” although liberally used in the Batman stories, is not a term that is used either legally or in psychiatry.
Batman storylines often combine syndromes, and sometimes the use of terminology is just plain incorrect.
“The Joker is the character who is most commonly referred to as ‘psychotic’,” says Dr Kambam, “but in over 70 years of stories you’d be hard pressed to find evidence of actual psychosis depicted.” Classically, the definition of psychosis is a mental state seen in serious mental disorders such as schizophrenia, when a patient has disorganised behaviour and thinking.
“What the Joker actually displays more of is psychopathic traits,” says Dr Kambam. Psychopathic traits include manipulativeness and a lack of empathy.
Drs Bender, Kambam and Pozios are using the depictions of mental states in Batman as a way to talk to the general public about psychiatric disorders. The histories of comic book characters are well known and, unlike other public figures, can be discussed without fear of impropriety.
Pioneering this form of medical education, they held a seminar at Comic Con, a large comic convention held in San Diego in July 2011.
“We looked at whether the character of Bruce Wayne [Batman] displays any symptoms of post-traumatic stress disorder (PTSD) in the film Batman Begins,” says Dr Pozios. During the seminar they explored the nature of PTSD and the challenges in making a diagnosis. They felt that Batman had symptoms of PTSD but does not meet the full diagnostic criteria.
Audience questions also provided an opportunity to correct misperceptions. One audience question was, “If Batman doesn’t have PTSD then is it better to say that he has schizophrenia?” This refers to the common misunderstanding that schizophrenia means split personality.
“That’s not correct,” says Dr Bender, “schizophrenia is a psychotic illness.” PTSD is an anxiety disorder.
Beyond the bat cave
Many other comic book characters are amenable to psychiatric scrutiny. Could we diagnose the Hulk with an impulse control disorder? And how has Superman been affected by being the last survivor of his planet?
Mental disorder is also depicted in characters who are not superheroes. “The examination of mental illness in comic form goes well beyond that seen in genre comics,” says Ian Williams, a general practitioner and comics artist. “Batman comics primarily aim to entertain, and their interest in mental disorder is second to this. Other more thoughtful works address the subtleties of mental disorder directly, and aim for a more realistic depiction,” says Dr Williams. “Comics are able to convey an immediate visceral understanding in a way that conventional texts cannot.”
“The handling of mental disorder is particularly effective in The Long Road Home by G B Trudeau,” says Dr Williams.
G B Trudeau draws the well known newspaper comic strip Doonesbury. In The Long Road Home he examines the life of a Doonesbury character following active duty in Iraq.
“The comic documents how the character’s life changes after he loses a limb traumatically,” says Dr Williams. “The author spent time in rehabilitation centres in order to make the approach more realistic.” The character develops PTSD, becomes withdrawn, and has constant flashbacks.
Another comic, Depresso, by Brick, examines depression. “The visual metaphors in Depresso are very powerful,” says Dr Williams. “Especially when he likens depression to being entombed in wet shrinking concrete.”
Brick’s approach to doctors is interesting. “Brick takes a deliberately provocative point of view to his medical care,” says Dr Williams. “He is by nature suspicious, and this influences his view of the psychiatrists who treat him.”
Dr Williams also recommends Psychiatric Tales. This is a collection of 11 strips about psychiatric illness, which was published to acclaim in 2010. Its author, Darryl Cunningham, worked as a healthcare assistant on psychiatric wards and also had his own problems with mental illness.
“Psychiatric Tales is patient centred and humane as Cunningham has experienced mental illness from both sides,” says Dr Williams. “Despite the seriousness of the subject he has a light touch and the book is funny and informative.”
Comics are very accessible as they are quick and easy to read. Their ability to juxtapose image and text means that they are a rich medium for both storytelling and documenting.
Established comics such as Batman have featured mental disorder for many years. Although the characters’ disorders in Batman often display a high degree of artistic licence, they can still be used as a teaching aid and may engage an audience who would otherwise lack interest.
Non-fiction comics such as Psychiatric Tales are often more realistic and can provide us with valuable insights into the lives of psychiatric patients.