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Though the genre of the movie Lars and the real girl released by Metro-Goldwyn-Mayer in 2007 can be defined as comedy-drama, the plot of the picture is based on real life psychological concepts. But for the enormously sympathetic attitude of the inhabitants of the town towards Lars and his delusions, the plot of the film seems plausible.
Even though it produces comic effect upon the audience, the non-pharmacological intervention strategy implemented for treating delusional disorder in Lars, the main character of the film, is effective and corresponds to the results of the real life empirical research.
The development of the events in Lars and the real girl is based upon the delusional disorder of the main character Lars Lindstrom. Living in a garage and having difficulties with communicating with his relatives, co-workers and especially representatives of the opposite sex, Lars orders a lifelike doll Bianca from the online store and persists that she is a real girl (Lars and the real girl).
It is significant that Lars actually has difficulties even in communicating with his doll as he refuses any kind of intimacy with her, making Bianca sleep in a separate room.
Lars’ delusions were so strong that even at the end of the film he announces that Bianca dies instead of obtaining a more sensible view of the surrounding reality. On the one hand, Dagmar as the family doctor chooses the most appropriate intervention strategy for treating the main character by establishing confidential relationships with him.
On the other hand, the community creates favorable conditions for Lars’ recovery by treating Bianca as a real person and even involving the doll into volunteer programs and employing her as a model in a clothing store. The sympathy of the inhabitants of the town is touching as they even attend Bianca’s funeral (Lars and the real girl).
The community’s attitude and feelings of Margo, Lars’ co-worker who is interested in Lars disregarding his obvious disorder, are the only details of the plot of the film which lack feasibility. As a rule, the individuals with delusional disorders are not met with open arms by the community. The sympathetic attitude of the inhabitants of the town not only creates plenty of comic situations, but also contributes to the atmosphere which was favorable for enhancing the effectiveness of Lars’ treatment.
Lars’ case of delusional disorder with analysis of its main causes, symptoms and intervention strategies are central to the movie Lars and the real girl. Combining plausible data on psychological disorder and the enormously sympathetic attitude of the community to Lars’ delusions, the author achieves the comic and dramatic affects at the same time.
History of the concept of delusional disorder
The concepts of paranoia and delusional disorders have been evolved over time and underwent a number of changes through continuing research and practical application of the findings.
The term ‘paranoia’ was coined by ancient Greek and was combined of two stems which can be translated as ‘besides’ and ‘self’ or ‘mind’ (Grover et al, 2006, p. 62). This term was used for defining the conditions in which primarily cognition but not perception was disturbed. Kraepelin is known for making a significant contribution to the definition of the concept and distinguishing paranoia from other disorders.
According to Kraepelin theories, the only behavioral changes in patients with delusional disorder were associated with their delusional beliefs, while the personality could be preserved even if the illnesses lasted for several decades (Grover et al, 2006, p. 62). Kruger (1917) as one of Kraepelin’s followers claimed that the system of delusions does not go beyond the realms of possibility and can be logically assumed.
Bleuler (1920) broadened the definition of the concept, discussing the occurrence of hallucinations and emphasizing the appearance of paranoid symptoms in other conditions (Grover et al, 2006, p. 62). In 1987, however, this condition was renamed as delusional disorder due, while the term ‘paranoia’ was recognized as vague and inappropriately applied (Manschreck and Kahn 2006).
In general, as it can be seen from the above mentioned historical overview, the cases of delusional disorders have been known since ancient times. Disregarding the chosen terminology and theoretical framework, the definition of this illness is based upon the disturbance of the patient’s cognition while perception and the rest of personal characteristics are preserved undisturbed.
This definition is applicable to Lars’ case depicted in the movie under consideration, taking into account that the main character seems to be relatively normal but for the perception of the doll as a real girl.
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Definition and classifications of delusional disorder
Currently, the concept of delusional disorder is defined as the condition “characterized by the presence of one or more nonbizarre delusions and the relative absence of associated psychopathology” (O’Conor et al, 2007, p. 183).
Depending upon the content of the delusions and the corresponding patients’ behavior, the delusions are subdivided into several main types. The first type which is defined as persecutory comprises individuals who believe that they are malevolently treated. The second type is called somatic and includes patients who believe that they have a certain physical disorder. The third type of delusional disorder is defined as erotomanic and is associated with belief in love at a distance.
The patients with the third type may persist that they are in relationship with celebrities. The fourth type is jealous and is associated with belief in an unfaithful partner. The fifth type is called a grandiose one and is associated with belief in enormous power or knowledge (O’Conor et al, 2007, p. 184).
Implementing the above-mentioned classification for Lars’ case, it can be stated that the main character of the movie under consideration can be diagnosed as a peculiar modification of erotomanic type.
As opposed to the primary definition, there is no distance between Lars and Bianca as the object of his dreams, but he intentionally creates it by refusing any kind of intimacy and making the doll live in a separate room. It might seem that the doll is intended to solve Lars’ problems with communication and isolation, but experiencing difficulties even with Bianca, the main character demonstrates the level of his communicative problems and the strength of his belief that Bianca is a real girl.
Main causes and symptoms of delusional disorder
The main theories meant to explain the causes of delusional disorder can be subdivided into three main groups, including those of cognitive, psychophysiological and psychodynamic theories on occurrence, development, maintenance and content of delusional beliefs.
Cognitive theories as the first subgroup explain the occurrence of delusions with cognitive deficit, inability to draw logical conclusions from the available information and the distorted thinking. The second subgroup focuses on abnormal perceptual experiences following the normal cognitive processes, explaining the occurrence of delusions with anomalous psychophysiological mechanisms involved into the perceptual process and responsible for interpreting the information retrieved from the surrounding world.
The third subgroup of psychodynamic theories places special emphasis upon motivational factors. It should be noted that all these theories are rather complementary than mutually exclusive. Malancharuvil (2004) noted that “a combination of factors could influence the formation and maintenance of delusions” (p. 163).
Apart from theoretical research concerning the origin and explanation of delusional disorder in general, when treating a certain patient, practitioners have to answer two main questions concerning the roots of disorder in every particular case and the reasons for the formation of the peculiar type of delusions in every single patient.
Proper diagnosis and a comprehensive understanding of the underlying causes of the symptoms would allow selecting the most appropriate and effective intervention strategies. In the course of time, the formation of delusions in patients has been explained with genetic predisposition, cultural and personal experience.
Regarding the genetic predispositions, reviewing the results of the latest studies of the issue, it is possible to find the evidence supporting the contradicting hypotheses on the role of genetics in the occurrence of delusions in individuals. For example, according to the results of the study by Morimoto et al (2002), “polymorphism of the DRD2, DRD3 and/or TH gene was part of the genetic basis underlying the hyperdopaminergic state that produced paranoid symptoms” (Grover et al, 2006, p. 69).
On the other hand, the findings of Cardno and McGuffin (2006) prove that there is no sufficient evidence for proving the links between the genetic predispositions and formation of delusional disorders and further research along with wider samples are required for establishing these relationships.
Regarding Lars’ case, it is hard to define whether the disorder of the main character has got the genetic roots. However, taking into account the subnormal behavior of his father who blames Lars in his mother’s death and turns the lives of his sons to hell, it can be hypothesized that Lars’ father also had certain disorder which just was not diagnosed and investigated.
Concerning the cultural background, empirical studies have proven that this factor does not have any significant impact upon the formation and maintenance of delusions. Grover et al (2007) noted that “the sociodemographic profile of delusional disorder is consistent across various cultures” (p. 462).
Regarding the remaining factor of personal background, Maher (2005) noted that “The patient presents his particular delusion with content that is drawn from his past history or present circumstances because that is the kind of explanatory material available to him” (p. 141). Taking into account the results of the above-mentioned studies, it can be stated that the personal experience can be regarded as the most influential factor in development of delusional disorder in particular individuals.
Taking into account the existing theories on the causes and content of delusions, it can be concluded that the unhealthy family atmosphere is the main cause of Lars’ delusions. His mother died during his birth and it preconditioned his fear of not only having children, but also having relationships with the opposite sex at all. Thus, though Lars’ genetic predisposition cannot be taken into consideration, his personal background has become the major cause of his delusional disorder.
Pharmacological and non-pharmacological treatment
The existing treatment strategies are divided into pharmacological and non-pharmacological interventions which are both applied by modern psychotherapists.
The pharmacological approach which has been regarded is ineffective previously, has become popular among contemporary doctors and theoreticians. For instance, as it was cited in Grover et al (2006), Srinivasan et al (1994) found “good response to antipsychotic treatment using trifluperazine, haloperidol, chlorpromazine, and electroconvulsive therapy” (p. 70).
As opposed to the past belief that delusional disorder cannot be treated through pharmacological interventions, the results of the recent studies have demonstrated the effectiveness of this method. Manschreck and Khan (2006) concluded that “delusional disorder should not be considered a treatment-resistant condition; medication can be effective if the patient adheres to the treatment regimen” (p. 118).
Disregarding the available evidence on the effectiveness of pharmacological interventions, Dagmar as the family doctor decides on non-pharmacological treatment which appears to be sufficient for treating Lars. Recognizing the peculiarities of the patient’s condition, the doctor in a movie not only does not reassure the patient in his delusions, but also supports his ideas and even offers the treatment for the doll, playing according to the rules of the patient’s game.
Though this approach may seem extraordinary and even comic to certain extent, this treatment corresponds to the results of the recent research. Taking into account the fact, that most patients with delusional disorder do not recognize their illness and refuse any treatment, it can be stated that supporting Lars in his delusions was the best way out for avoiding his confrontation. O’Connor et al (2007) noted that “It seems crucial to initially adopt an accommodating and non-confrontational approach” (p. 187).
This goal is successfully achieved by Dagmar who is supported by altruistic inhabitants of the town. Emphasizing the effectiveness of non-pharmacological approach, Malancharuvil (2004) noted that “Instead of considering the delusional thought as a thought problem, it should be examined as an affective problem that is intellectually defended” (p. 167). The small detail that Lars always carries a baby blanket with him proves that the character looks for protection and tries to hide from the surrounding.
Detailing the treatment strategies, Malancharuvil (2004) defined the main stages of working through delusional thinking, namely establishing therapeutic alliance with the patient, modifying defensiveness, connecting to core experience, restructuring and consolidation. All these stages were passed by Dagmar in treating Lars, though some of them were completed in a rather untraditional way by involving the community into the process of treatment.
On the one hand, the fact of Lars’ recovery may seem doubtful, because he returns to reality by announcing that Bianca dies. Still, the facts that the patient gets rid of his delusions and has a love affair with his co-worker, a real girl prove that Dagmar’s treatment is effective. The community’s attitude to Lars’ delusions and his love affair with Margo can be regarded as an important component of the intervention strategy which was significant for Lars’ recovery.
In general, it can be concluded that disregarding the peculiarities of the genre of drama-comedy, the plot of the movie Lars and the real girl has sufficient theoretical basis on treating the patients with delusional disorder and can be regarded as plausible. Dagmar’s non-pharmacological approach in establishing the non-confrontational relationship with the patient, defining the causes of the delusions and restructuring them may produce a comic effect, but were effective for modifying Lars’ defensiveness and returning him to reality.
Aubrey, S., Cameron, J., Kimmel, S. (Producers) and Gillespie, C. (Director). (2007). Lars and the real girl [Motion picture]. United States: Metro-Goldwyn-Mayer.
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