Diagnostic: Lars and the Real Girl

Abstract

This paper explores the film Lars and the Real Girl (Gillespie, 2007) and the psychological conditions present for the main character. The first part of this paper is written from a clinical perspective, as though the character had been in the clinic with this writer. The subsequent sections address DSM IV diagnoses on all 5 axes and describe the differences between DSM IV and DSM V. Finally, the diagnosis given in the film is analyzed. All history written about the character and diagnoses made is based solely on information given in the film. In Lars and the Real Girl, a 27-year-old male, Lars Lindstrom, orders a sex doll from the Internet and introduces the doll as his girlfriend, “Bianca.” Though Lars demonstrates delusional thinking, his family and the larger community decide together to support Lars and to treat the doll as his actual girlfriend. Rather than insist that Lars face the reality of his situation, they encourage him to get medical help for Bianca and use that to get Lars the treatment he needs for his delusions and other issues. Through an analysis of his personality, relationships, community, home environment, and health history as presented in the film, this paper will discuss the major psychological health issues present in the main character, provide diagnoses on all 5 axes of the DSM IV and analyze the diagnosis given in the film. Appropriate literature will be used to support links to social, biological and other factors that have influenced the diagnoses given.

Character Discussion

Lars Lindstrom is a 27-year-old male in good physical health. He dresses conservatively, is clean kept and very polite. Mr. Lindstrom has a steady office job and is self-sufficient. He lives very simply and enjoys routines. He reports having few friends and limited social supports, stating that he does not need much. Mr. Lindstrom attends church on a weekly basis. He resides in a converted garage behind the home he grew up in. His older brother, Gus Lindstrom, and sister in law, Karin Lindstrom, live in the home. His father died several years ago, and his mother died giving birth to Mr. Lindstrom. Mr. Lindstrom does not have any other family members, though he has discussed the impending birth of a niece or nephew, as Karin Lindstrom is pregnant.

Mr. Lindstrom's brother and sister in law report that they have been concerned for some time about his lack of socializing and disinterest in interpersonal interaction and were initially excited to learn that Mr. Lindstrom had begun dating. Mr. Lindstrom told his family that he had met a woman on-line. However, Gus Lindstrom reports that he was very upset after meeting Mr. Lindstrom's girlfriend, who is a life-like, anatomically correct sex doll bought from an Internet site. Gus Lindstrom's primary concern is that Mr. Lindstrom does not seem aware that his new girlfriend is not actually human, as he introduced the doll to the family over dinner. Gus Lindstrom reports that during the meal, Mr. Lindstrom would whisper to the doll and answer questions for the doll as though the doll were an actual woman. Mr. Lindstrom reports that his new girlfriend is named Bianca and that she is half Danish and half Brazilian. Bianca is a missionary, and is “an orphan, just like me” (Gillespie, 2007). She is wheelchair-bound. Mr. Lindstrom reports that Bianca's Christian values are very important to her, so he asked his brother if she could sleep in the guest room of the main house. Though Bianca is a doll, Mr. Lindstrom interacts with her as though she were a living person. He takes Bianca on dates, brings her to church and has introduced her to many community members. Mr. Lindstrom appears to carry on conversations with Bianca. The community, including Mr. Lindstrom's family, church and co-workers are very supportive of Mr. Lindstrom's relationship with Bianca, welcoming her at different events and treating her as though she is alive. Gus and Karin Lindstrom report that they, along with other friends in the community, have collaborated on a schedule for Bianca that includes dressing and bathing the doll, taking her to volunteer at the hospital and church, and bringing her to different activities while Mr. Lindstrom is at work. Mr. Lindstrom has expressed some frustration about the schedule, worrying that she will not be able to spend enough time with him when he is off work.

Mr. Lindstrom reports that he does not touch people and does not like to be touched. He reports experiencing physical pain when touched and attempts to avoid any contact with others through maintaining a large area of personal space and wears layers of clothing in order to prevent feeling if he is touched. Mr. Lindstrom appears anxious and jumpy. His hands shake when he is talking and his eyes dart around the room. Gus and Karin Lindstrom have reported concerns that Mr. Lindstrom may be depressed, citing the time he spends alone in his room in the garage, and his history of social isolation. Mr. Lindstrom does not self-identify as depressed or anxious. He does report that he prefers solitude. He reports feeling concerned about the physical health and well-being of his family members and is quite fearful of death. Mr. Lindstrom is especially fearful that Karin Lindstrom will experience complications during childbirth, specifically that she will die during labor. Mr. Lindstrom stated several times that his own mother died during labor. He expresses a great deal of concern regarding the dangers of childbirth.

Though Mr. Lindstrom lives on the same property as his brother, Gus Lindstrom, and sister-in-law, Karin Lindstrom, Mr. Lindstrom reports that he does not have a close relationship with the couple. Mr. Lindstrom notes that Gus Lindstrom left the family home when he was still a child and describes feeling abandoned by his brother. Left with his father, whom Mr. Lindstrom felt held him responsible for his mother's death, Mr. Lindstrom learned to fend for himself. Mr. Lindstrom reports that his father was “an unhappy man” and that he did not engage in conversation or any activities with him. Mr. Lindstrom stated that his father would not talk about his mother, so he has limited information regarding his mother's personality. Mr. Lindstrom states that he feels responsible for his mother's death because she died while giving birth to him. He reports that he struggles to get close to others and is glad to have Bianca with whom he has a “good” relationship. When asked to discuss how he communicates with Bianca, Mr. Lindstrom reports that they communicate “well” and that they understand one another. Mr. Lindstrom shows no sign that he understands that Bianca is a doll and not a human being. Mr. Lindstrom also appears unaware of the great lengths that his community goes to in order to make him feel comfortable and accepted. He appears to have high expectations for both his family and the community to help him take care of Bianca but will become upset or anxious if Bianca is “too busy” with the community-created activities.

Despite Mr. Lindstrom's delusional belief that Bianca is an actual person, he does not show signs of any other delusional thinking. He does not hear voices or hallucinate. He has no noted history of drug use or substance abuse. Mr. Lindstrom has not been treated for a mental health disorder in the past. Mr. Lindstrom has not reported a history of any other psychological issues. The family reports no psychological issues, though after the death of his mother, Mr. Lindstrom notes that his father was depressed.

Character Diagnosis

Mr. Lindstrom appears to be highly interested in the social behaviors of others but seems uncertain about how to engage socially. He expresses a high level of self-consciousness and anxiety in social situations. Mr. Lindstrom seems unaware of the ways in which his anxiety impacts his life and relates to his decision-making processes, though he appears to use his relationship with Bianca to act out typical relationship patterns he has witnessed. His lack of insight seems to be a defense mechanism, allowing him to live in denial about his limited interpersonal relationships, including the reality of his relationship with Bianca. Mr. Lindstrom demonstrates empathy for others, discussing concern for a co-worker who is being picked on at work, worry for his sister in-law's health and for Bianca's well-being. He seems especially to use Bianca and her “illness” to develop greater empathy and understanding of those around him. Though he struggles to express himself emotionally, he is able to use the Bianca narrative as a means to connect with his community. Mr. Lindstrom appears to want connection but does not seem sure of how to establish the connection he wants. Intimacy is an uncomfortable subject for Mr. Lindstrom, and when discussed he often deflects by changing the subject or ignoring questions.

Mr. Lindstrom expresses interest in having a family and in building relationships with his brother and sister-in-law. He respects and admires his brother for “being a man” and running the household. He is aware that his sister-in-law would like a relationship with him and struggles with how to make the relationship happen.

Mr. Lindstrom's discomfort with physical contact is perhaps related to his feelings of fear around intimacy, and possibly due to the guilt he feels for his mother's death. He also expresses guilt that his father had to go on without his mother, holding himself responsible for the loss of his father's primary relationship. Though Mr. Lindstrom lacks insight into the necessity for interpersonal relationships, he seems to be aware on some level that these relationships are important. His purchase of Bianca demonstrates a desire for a close personal relationship and a deeper connection with people in his community. His social anxiety has limited his ability to participate in events and get to know people, however, he does pay attention to how his brother and sister-in-law interact, both as a couple and in town. Mr. Lindstrom has been more willing to attend social events when he is able to bring Bianca as his date.

Mr. Lindstrom presents as shy and depressed. His family reports that prior to purchasing the doll, he spent much of his free time before and after work alone in the converted garage where he lives. He attempts to interact with coworkers while at work, but often will end conversations somewhat abruptly. Mr. Lindstrom has introduced Bianca to coworkers and that has allowed him to feel more comfortable interacting with them socially and attending group functions.

When looking at Mr. Lindstrom's ego functioning, it is apparent that though he is able to identify the reality of his environment, he struggles to find a way to balance his internal reality with his external reality (Berzoff, Flanagan & Hertz, 2011 p.65). He wishes for a romantic relationship and intimacy, but unable to communicate his desires to others, he must create a situation that allows him to have the experiences he wants. Mr. Lindstrom is in many ways able to live in reality through his job, home life, church attendance, and other community interactions.

Due to his fear of intimacy, Mr. Lindstrom seems to have developed defense mechanisms as protection from the situations he is uncomfortable with (Berzoff, Flanagan & Hertz, 2011 p.72). Wearing several layers of clothing is a mechanism he's developed to protect him from physical contact with others because he is not prepared for that level of intimacy. Likewise, his avoidance of interaction with family and co-workers is a defense mechanism developed to protect him from close relationships that could end in painful loss.

Though Mr. Lindstrom has developed these mechanisms to protect him from experiencing the pain of loss, he has effectively shut himself off from the things that make him most human. His purchase of the doll and the introduction of her as his girlfriend allow him to practice intimacy in a way that is safe for him. As he scripts the relationship, he is able to prepare himself and plan for the eventual end of the romance, even though he is not fully aware that he is involved in the relationship to help him to develop these skills (Berzoff, Flanagan & Hertz, 2011 p.73).

Analysis of Diagnosis

In order to diagnose the character based on his personality, only information presented in the film was used in conjunction with information presented in the DSM IV. Therefore, for the diagnosis of Delusional Disorder, Unspecified, the romantic relationship that Lars believes he has with a life-like doll is the key factor. The conversations the character has with the doll that includes him translating her side of the dialogue for others is especially important. However, the delusion he has related to the relationship with the doll does not appear in any other area of his life.

Major Depressive Episode was diagnosed because of scenes in the movie with Lars spending a good deal of time alone and often depicted showing little to no affect. For example, he is shown sitting alone fully dressed apparently waiting for it to be time to leave for work. He is also shown several times as longing for the ability to connect with others; wanting connection but feeling fearful and alone and not knowing how to reach out. This is evidenced through scenes in which he is observing the interactions of other characters, seemingly trying to figure out how to have intimate relationships. In diagnosing depression, some of the conversations with Karin and Gus Lindstrom's characters were also used. Several scenes depict Karin attempting to engage Lars in conversation or to entice him into having dinner with the family. Lars always appears uncomfortable and sad and seems interested but unsure of how to proceed. The characters also discussed Lars's depressed state in more than one scene. Lars discusses experiences of long-term sadness and depression growing up with his father after his brother left home. The character also seems very depressed by his role in his mother's death. A further diagnosis including some form of PTSD may have been appropriate, however, there was too little information presented in the film, and Major Depressive Episode arguably made the most sense.

To diagnose Social Phobia, the scenes depicting Lars at work and at church were especially helpful. He is shown sitting in the back and looking uncomfortable at church. When others are smiling and singing along with hymns, he is depicted looking down and fidgeting. When greeted outside of the church, he attempts to get out of the conversation as quickly as possible and leaves right away. The character's interactions with co-workers are awkward and he appears almost fearful. At work, he makes minimal conversation with his cube-mate and though he appears interested in a co-worker, he avoids conversation with her. His interactions with the characters of Gus and Karin Lindstrom also show some signs of social anxiety or social phobia, as he hides from them when he arrives home, and avoids their invitations for meals and activities together. Generalized Anxiety Disorder was diagnosed to address some of the other signs of fear and anxiety, including his discomfort with physical contact.

For Axes II, III and IV, no diagnoses were made because those issues were not directly addressed in the film. A GAF of 42 was given because of Lars's delusions regarding Bianca, the depictions of Lars as depressed and the character's discomfort with social interaction, which appeared to cause anxiety for the character as well as his family and co-workers. Despite the delusions and other issues, the character was able to maintain a job, complete daily tasks regarding personal hygiene, and kept a schedule. He did not use drugs or other substances and was generally depicted as physically healthy.

Further influencing diagnosis decisions were the character's age and gender. Initially, given that he is 27 years old and male, schizophrenia seemed like a plausible diagnosis. However, Lars did not experience hallucinations at all, and only experienced delusion as applied to his relationship with the doll. Another key component when diagnosing schizophrenia can be a tendency towards violent actions or thoughts, including hearing violent voices (Luhrmann, 2013). Lars did not demonstrate any violent behaviors. His delusion did not include any element of violence, in fact, his idea of Bianca included her role as a missionary, specifically describing her as loving and kind.

If diagnosed using the DSM V, the character of Lars would still have the same diagnoses. However, there would not be a multi-axial diagnosis as the DSM V no longer uses a multi-axial system. The first three axes would be combined, and all ICD coding would be the same (American Psychiatric Association, 2013). Due to the revision of the DSM V, the character may fit into more diagnosis categories, as the diagnoses in the DSM V are not as stringent as they have been in previous editions. The DSM V has more flexible definitions and requirements for diagnoses that demonstrate how multiple diagnoses fit together (Grohol, 2013).

Conclusion

In the film Lars and the Real Girl (Gillespie, 2007), Lars Lindstrom is diagnosed with a delusion that is explained as “a symptom or manifestation of an underlying problem.” To address the issue, Lars is tricked into meeting weekly with a psychologist by convincing him that his girlfriend needs medical treatment for her blood pressure. Through conversations with the psychologist, Lars is able to start addressing his fear of intimacy. The psychologist helps Lars to become comfortable with touch by touching him on the arm for varying periods of time. The films emphasize the importance of patience and an open-minded approach to care. Mental health disorders are portrayed as issues that can be treated successfully not only with the help of medical professionals but with support and care from the larger community. The idea that delusions can be discussed with others allows the person experiencing the delusion to find the space they need to work through their issues (Sacks, 2012). The film depicts a highly stigmatized mental illness as an issue that is not only manageable but even healthy through its depiction as a path to healing deeply ingrained fears of intimacy. Lars and the Real Girl offers a refreshing perspective on how the treatment of those with mental health disorders can be improved and de-stigmatized through acceptance, support and understanding.

References

Berzoff, J., Flanagan, L. M., & Hertz, P. (2011). Inside out and outside in: Psychodynamic clinical theory and psychopathology in contemporary multicultural contexts (3rd ed.). Lanham, Md.: Jason Aronson.

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

Diagnostic and statistical manual of mental disorders: DSM-IV-TR. (4th ed.). (2000). Washington, DC: American Psychiatric Association.s

Grohol, J. (2013, May 18). DSM-5 released: The big changes | world of psychology. Psych Central.com. Retrieved from http://psychcentral.com/blog/archives/2013/05/18/dsm-5-released-the-big-changes/

Gillespie, C. (Director). (2007). Lars and the real girl [Motion picture]. USA: MGM.

Luhrmann, T. (2013, September 19). The violence in our heads. The New York Times. Retrieved from http://www.nytimes.com/2013/09/20/opinion/luhrmann-the-violence-in-our-heads.html?emc=edit_tnt_20130920&tntemail0=y&_r=3&

Sacks, O. (2012, November 3). Seeing things? Hearing things? Many of us do. The New York Times. Retrieved from http://www.nytimes.com/2012/11/04/opinion/sunday/seeing-things-hearing-things-many-of-us-do.html?partner=rss&emc=rs