Curtis (Michael Shannon) is an Ohio construction worker whose mother, Sarah (Kathy Baker), is a paranoid schizophrenic who had to leave the family when Curtis was still a child. Now Curtis begins to develop a series of nightmares about a pending storm (often multiple tornadoes), his dog attacking him and being a victim of a serious car accident. On several occasions, the sensations of the dreams carry over to his daytime life. He sees a therapist. Though Curtis is concerned about his family history, he tells the therapist he thinks he may just be suffering from a brief psychosis, since, despite his nightmares, delusions and visual and auditory hallucinations, he lacks the disorganized speech, behavior and other negative symptoms that also characterize schizophrenia. Curtis builds a tornado fallout shelter complete with gas masks (he is concerned about a nearby chlorine spill) and other emergency supplies. He brings his family down there during one of his perceived storms (this one may be real initially — it's unclear), and his wife, Samantha (Jessica Chastain), finds it very difficult to persuade him to leave the shelter the following day. Curtis then sees a psychiatrist (Jeffrey Grover), who says Curtis has schizophrenia. He wants to put Curtis on antipsychotic medication and admit him to an inpatient facility. But Curtis is reluctant to be admitted and chooses to go first with his family on their annual vacation to Myrtle Beach, S.C.
Does schizophrenia run in families, and can it be diagnosed based on extended nightmares, recurrent delusions and visual hallucinations? Is acting on a delusion to the extent that Curtis does — building and occupying a storm shelter — a way of relieving mental pressure, or does it contribute to a worsening of the condition over time? Can such a patient be treated as an outpatient with the help of a supportive family?
Schizophrenia is the most serious of all mental disorders, says schizophrenia expert Dr. Peter F. Buckley, dean of the Medical College of Georgia in Augusta. It affects thinking, perception and behavior, as the movie shows. People often have fixed false ideas (delusions), such as being persecuted, and they often hear or see things when there is nothing there (hallucinations).
According to Dr. Dolores Malaspina, professor of psychiatry at New York University Langone Medical Center, schizophrenia is diagnosed when a disturbance that includes delusions leading to declining function has been present for six months. Bizarre behavior and negative symptoms (decreased emotional expression or social interest) may be present or absent. "It is important to treat symptoms as soon as possible in hope of preventing deterioration," she says.
Schizophrenia typically begins in early adulthood and is a lifelong illness for most affected individuals, says Dr. Daniel R. Weinberger, director and chief executive of the Lieber Institute for Brain Development at Johns Hopkins University in Baltimore, Md.
Twenty percent of schizophrenia cases have a family history, Malaspina says, and the risk in a schizophrenia patient's offspring is 10%. Genetics contributes to the considerable variability in the way the disease looks in different patients.
Curtis' overall pattern of behavior seems to fit with a schizophrenia diagnosis, the experts agree, though auditory hallucinations are more common than the visual ones shown in the film. Nightmares can occur, but they are not really part of the diagnosis, Buckley says.
Acting out on one's delusions (for example, by building a storm shelter based on a growing belief that one's dreams of storms are real) usually makes a patient sicker and does not help the delusions go away, Malaspina says. In fact, the more the delusions are reinforced, the more they tend to persist.
A schizophrenia patient can be helped by seeing a psychiatrist regularly, and, importantly, by taking antipsychotic medications to dampen the visions, voices and irrational ideas. Families can be immensely helpful and supportive in many ways, Buckley says, including persuading the person to remain in treatment. There is value to initially starting medication in an inpatient setting in order to stabilize the patient while watching for side effects.
Weinberger maintains that mandatory inpatient treatment is necessary only when patients are found to be a danger to themselves or others. Curtis is certainly close to that point in the film. Weinberger concludes that decisions on treatment for a case as complex as this "have to be made by thoughtful professionals."
Siegel is an associate professor of medicine at New York University Langone Medical Center. His latest book is "The Inner Pulse: Unlocking the Secret Code of Sickness and Health."
Grove Hill Productions
U.S. release: Oct. 2