Deconstructing the Film Sinister through the Lens of Psychiatry

Films have long entertained people and affected their attitudes regarding a multitude of issues including mental illness. Over the decades, movies have depicted various aspects of psychiatry ranging from acculturation to the patient-therapist relationship. This paper summarizes a case formulation of the film, Sinister, and demonstrates how introducing a trivial modification to the plot could transform the film into a teaching didactic on the Dissociative Disorders


REDRUM (Reviewing [Mental] Disorders with a Reverent
Understanding of the Macabre) is a curriculum we developed for PGY-1 and -2 residents at Rutgers Robert Wood Johnson Medical School that teaches psychopathology set to the horror genre [1]. The main objective of REDRUM is to enhance learning through creative discussion of examples of psychiatric disorders that come from film and literature (Table 1). Due to its popularity, medical students rotating through their core clerkship in Psychiatry participate in selective didactics of REDRUM. This paper reviews one of the movies, Sinister, and summarizes students' case formulation of Dissociative Amnesia, with Dissociative Fugue.
Sinister is a 2012 supernatural horror film chronicling the existential crisis of Ellison Oswalt, a fictional crime author who is trying to resurrect his fledgling career. Following an opening scene that shows an unnamed family being hanged from a tree, we meet the Oswalts who are moving into their new Pennsylvania home. On moving day, they are met by the town sheriff, who after admonishing his deputy for soliciting an autograph, tries to convince Ellison to load his boxes back onto the moving truck and leave. The sheriff 's warning, a harbinger, serves as foreshadowing of the Oswalts' fate, as it is ultimately learned that the house they are moving into is the former "Stevenson home;" a Pennsylvania house that's become an urban legend because it was the site of the horrific hanging depicted in the movie's opening scene.
Upon the discovery of a box containing "Super 8 mm films" in his attic, Ellison begins to watch movies capturing several heinous murders. The tapes show the murders of five families, and become the foundation of Ellison's new novel. While working on his new manuscript, Ellison begins to experience a feeling of unreality and detachment from the world. A visual distortion in which he sees himself in one of the films leads him to the conclusion that his family is the next in line to be murdered. He discloses his experience to the town deputy, an unnamed character (Deputy So and So), who agrees to help him while eluding the scrutiny of the sheriff.
Unfortunately, things grow more horrifying in the Oswalt home. When the boogeyman (Bughuul) suddenly appears before him, Ellison takes the films to the backyard and burns them, then immediately moves his family back to their old house. Following the move, Deputy So and So warns Ellison that by moving back to his former home, his family is in imminent danger, "The problem is that you moved. You just…put yourself in the timeline. " The pattern presented by Deputy so and so ( Figure 1) suggests that one is murdered after moving out of their newly purchased house (where the previous murder took place).

Illness Film Summary
The

Methods
The REDRUM Psychopathology course at Rutgers Robert Wood Johnson Medical School is held weekly for 1 hour over one semester (about 15 weeks). The 1-hour didactic is supplemented by weekly readings and film viewings that take approximately 1-2 hours per week outside of the classroom. All our residents in their first two years of training are encouraged to read selected chapters from the required textbook, Kaplan and Sadock's Synopsis of Psychiatry [2], before the instructor-led didactic presentation. The salient feature of the course is that we supplement traditional classroom didactic with a discussion of selected movies such as Sinister.
Approximately 90 minutes into the film, Deputy So and So contacts Ellison to inform him that he's discovered the pattern of the murders. In a poll taken in our course, 69.7% (n=69) of participating medical students (n=99) reported that they were unable to follow the deputy's logic. As a result, course directors at Rutgers Robert Wood Johnson Medical School proposed an alternative pattern of the Sinister murders. This alternative scenario is for pedagogical purposes only and not to allege that there are inconsistencies in the movie per se. Our proposed pattern changes the plot and thus creates a situation that allows for a diagnostic formulation that promotes Sinister as a movie depicting mental illness. The pattern presented by Deputy So and So suggests that one can only be murdered after moving out of the house in which the previous murder took place. We believe our proposed pattern is a simplified version of Deputy So and So's theory that doesn't require the family to move out of their newly purchased home in order to be killed. Specifically, a family sells their house, moves into a newly purchased home, and then meets their untimely demise (Figure 2). Upon extension of this pattern, we know that whoever sold their house to the Stevenson family (the family murdered before the Oswalts) should be the next in line to be murdered. However, [spoiler alert] the movie's climax reveals that the Oswalts are the next victims. The class is then posed the hypothetical question, "If the deputy's explanation is amended in lieu of our alternate view, how can these two seemingly opposing conditions be explained?" Specifically, how can the family that sold their house to the Stevensons be the next in line to be murdered when we know that it's the Ellison family that in fact is slaughtered?
The only way these two facts could be reconciled is if Ellison Oswalt was the seller of the Pennsylvania home (to the Stevenson family). Participants are then asked to formulate the most likely diagnosis that would explain Ellison's behavior. One explanation of how Ellison

Results
Prior to and following their core clerkships, medical students routinely completed surveys through the Office of Education. Survey data are disseminated to the clerkship directors to share with teaching faculty. The results provide information on the strengths and weaknesses of the curriculum and help identify areas of potential quality improvement. Students who participated in the REDRUM didactic (n=99) reported that the teaching sessions are of high quality, enjoyable, and preferable to more traditional approaches (Figure 3).

Discussion
Undergraduate [3,4] and postgraduate [5,6] course directors often reference film to depict aspects of human behavior including the role of the psychiatrist, issues in medical ethics, and the stigma toward people with mental illness. Furthermore, courses designed to teach psychopathology to trainees have traditionally used examples from art and literature to emphasize major teaching points. The use of film may have advantages over traditional didactics as they are efficient, presenting a controlled patient scenario that can be used repeatedly from year to year. For example, Sinister is highlighted by introducing a change in the movie's narrative. The consideration of an alternate pattern allows for the movie to be presented as a case study to teach and review the differential diagnoses within the Dissociative Disorders. Our pattern suggests that Ellison Oswalt sold a Pennsylvania home he was living in, and then repurchased the house once the new occupants were murdered there. One way Ellison could accomplish this is if he had traveled away from his family and established a separate residence for some time during which he assumed a new identity (pseudonym). Moving his family back into his previous residence was enabled by his inability to recall important information about his time in Pennsylvania. Taken together, Ellison is most likely afflicted with a Dissociative Disorder. The Dissociative Disorders section of the DSM-5 is comprised of a group of disorders that include disruptions in the integrated functions of memory and identity as a prominent aspect of their presentation. Both Dissociative Identity Disorder (DID) and Dissociative Amnesia are characterized by an inability to recall important information that is inconsistent with ordinary forgetting. DID is differentiated from Dissociative Amnesia by the presence of two or more distinct personality states that recurrently take control of the individual's behavior. Since we have no evidence that Ellison has a distinct "alter identity, " DID is unlikely, making Dissociative Amnesia our provisional diagnosis. Given that Ellison would have purposefully traveled away from his family and assumed a new identity (albeit not a distinct alter) in Pennsylvania makes Dissociative Amnesia, with Dissociative Fugue the most likely diagnosis.
One limitation of our use of Sinister is that it is difficult to follow (especially for people who are not familiar with the movie). Students are strongly encouraged to watch the recommended films, and have reported no barriers accessing the media. They are also reminded that the plot may be confusing and that our didactic serves to simplify the timeline while transforming the movie into a teaching didactic.
A second limitation of our adjusted version is that by replacing Deputy So and So's explanation of the pattern of murders, it creates the scenario of the deputy being deceitful with no explicit explanation of his motive. If he proposed the wrong pattern to Ellison, was it intentionally misleading? If so, the secondary gain would suggest Deputy So and So is a character of much greater complexity than "a small town deputy that's starstruck" [7]. Despite his obsessive research of the Super 8 mm films, Ellison never begins the manuscript of his next great work. Despite this, Sinister debuted in theaters in October 2012. The audience is then left with the question of 'who wrote the story?' The answer becomes obvious when one recognizes the lengths Deputy So and So would go to become an author. This is introduced early in the movie when he's the object of the sheriff 's ire upon asking for Ellison's autograph on moving day. The deputy's motivation is later reinforced when he asks for a signed copy of Kentucky Blood during an investigation of a possible breaking and entering (at the Oswalt's home). Soon after, the deputy asks for a book acknowledgment. Until this time, the deputy is nameless. When he references a "fictional" helper who assists in co-authorship, he is given the name of "Deputy So and So. " The deputy's identity is established, and motivation revealed, once he becomes an active participant in the authorship of Ellison's work. Deputy So and So wrote Sinister.
Implications for future research include the integration and evaluation of innovative teaching methods as course directors are met with the challenge of captivating trainees with increasing demands on time and resources. At Rutgers Robert Wood Johnson Medical School, we've created a curriculum that teaches psychopathology through creative discussion of examples of psychiatric disorders that come from film.
The sequel to Sinister premiered in August, 2015. It remains to be seen if Sinister 2 will be medically accurate with our formulation of Ellison Oswalt as being afflicted with Dissociative Amnesia, with Dissociative Fugue.

Financial Disclosures
Dr. Dobkin has research support from the Patterson Trust Awards Program in Clinical Research and the Michael J. Fox Foundation.

Implications for Educators
Educators may reference this paper to introduce small group exercises that promote problem-based learning for a medical student curriculum.
By referencing this paper, educators may create a presentation to teach the Dissociative Disorders to medical students and other trainees.
Educators may use media sources like film to introduce salient points of psychopathology, thus overcoming time constraints often encountered in clinical practice.