Decoding the Madness: Joker's Diagnosis and Mental Health in Film

Todd Phillips’s 2019 film Joker sparked intense debate surrounding its portrayal of the protagonist’s unspecified mental illness. As a psychological thriller, the movie invites viewers to consider the depths of Arthur Fleck’s psyche, prompting questions about the accuracy and impact of depicting mental disorders in popular media. Using the DSM-5 criteria, this analysis delves into the psychopathology of the Joker, aiming to understand the complexities of his condition and its implications for how mental illness is perceived. While a definitive diagnosis remains elusive, the film presents a disturbing yet compelling mix of personality traits and neurological symptoms, potentially misleading audiences about the nature of mental health.

The Ever-Evolving Joker: An Icon of Chaos

The Joker stands as a monumental figure in popular culture, a villain of unparalleled recognition and influence.1 From comic books to television and film, his iterations are countless. Like any enduring fictional creation, the Joker has consistently transformed, adapting his persona and motivations to resonate with evolving societal trends.1 He has served as Batman’s nemesis across various media, from Cesar Romero’s campy portrayal in the 1960s Batman TV series and film, to Jack Nicholson’s sinister gangster in Batman (1989), Heath Ledger’s anarchic mastermind in The Dark Knight (2008), Jared Leto’s flamboyant gangster in Suicide Squad (2016), and Joaquin Phoenix’s deeply disturbed individual in Joker (2019). Over eight decades, the Joker’s character has oscillated between comical buffoonery and terrifying malevolence.

While Cesar Romero’s Joker was known for slapstick antics, Joaquin Phoenix’s portrayal, visually reminiscent of Romero, is a stark contrast, embodying a chilling realism.2 Jack Nicholson’s Joker shares a similar origin to Phoenix’s, depicting ordinary men, Jack Napier and Arthur Fleck respectively, transformed into the Joker persona by traumatic events. Nicholson’s Joker was a criminal physically and mentally altered by a chemical accident. Heath Ledger’s rendition redefined the character for a new generation, injecting profound angst into the clown prince of crime. Ledger famously described his Joker as a ‘psychopathic, mass-murdering, schizophrenic clown with zero empathy.’3 Phoenix’s Joker appears to draw inspiration from Ledger’s, portraying a social outcast whose actions inadvertently ignite a protest movement.2 Jared Leto’s interpretation, though widely criticized for its aesthetic choices, captured a core element of the Joker’s psychology: his ‘super-sanity.’ This concept, articulated by Grant Morrison, suggests the Joker possesses a heightened, albeit twisted, form of intellect, blurring the lines between rationality and madness. Despite the diverse portrayals, the essence of the Joker remains consistent: a trickster figure who thrives on subverting expectations, occupying a disturbing and captivating space beyond easy categorization.1

Joker (2019): A Dive into Neuropsychology

Todd Phillips’s Joker, starring Joaquin Phoenix, diverges significantly from previous interpretations, igniting intense discussions about its depiction of mental illness.4–6 Phillips transforms a comic book icon into a character study exploring societal neglect and the consequences of untreated mental health issues. Some critics argue that Joker risks glorifying the actions of a disturbed loner, potentially heroizing a violent archetype.7 Andrew A. Nierenberg cautioned that, ‘Sadly, the movie will increase stigma for those with psychiatric disorders and make people afraid. It will take great efforts to combat this setback in the battle against stigma.’8 Similarly, doctors Annabel Driscoll and Mina Husain in The Guardian noted, ‘Severe mental health conditions, such as psychotic illnesses, remain shrouded in stigma and are consistently misrepresented and misunderstood […] Portrayals of mental illness in film can perpetuate unfounded stereotypes and spread misinformation.’9 Conversely, neurocriminologist Adrian Raine praised the film’s accurate portrayal of a murderer’s psychology, deeming it ‘a great educational tool’ and intending to use clips in his lectures.10

Joker leans towards art-house cinema, prioritizing social commentary over typical superhero action. Unlike previous Jokers, Arthur Fleck is presented as a timid, isolated, and unremarkable man. The narrative centers on Arthur, a struggling party clown and aspiring comedian living in impoverished, crime-ridden Gotham City with his ailing mother, Penny. Arthur is depicted as underweight and pale, suffering from a condition causing uncontrollable laughter at inappropriate times, reliant on social services for medication. His social skills are deficient; he avoids eye contact, displays unusual facial expressions, and misinterprets social cues, causing discomfort in others. Arthur fixates on the TV show hosted by Murray Franklin, fantasizing about appearing on it and gaining recognition. He develops a romantic infatuation with his neighbor, Sophie, which is later revealed to be a delusion. A series of traumatic events pushes Arthur to his breaking point: he murders three men on the subway after being harassed; his therapy is discontinued; he loses access to medication; and he discovers Penny is his adoptive mother with a history of mental illness and abuse, including a head injury inflicted upon Arthur. His fantasy becomes reality when he’s invited on Murray Franklin’s show, requesting to be introduced as Joker. Initially appearing suicidal, he instead murders Franklin live on air. The film concludes with Joker in a mental health facility, running through the corridors, leaving bloody footprints, implying the death of his psychiatrist.

Diagnosing Arthur Fleck: Unpacking the Joker’s Mental State

While Joker deliberately avoids a specific diagnosis for Arthur, we can analyze his symptoms and behaviors throughout the film to infer potential conditions. In therapy, Arthur expresses feelings of loneliness, isolation, and ‘constant negative thoughts.’ His notebook poignantly states, ‘The worst part of having a mental illness is that people expect you to behave as if you don’t.’ He is shown attending therapy and taking multiple psychotropic medications, even expressing a need for increased dosage. Information about his family history is limited due to his abandonment as a child. His adoptive mother, Penny, suffered from delusional disorder and likely a personality disorder, with a history of inpatient treatment. Arthur’s upbringing lacked a father figure, and while Penny initially described him as kind and happy, he later endured abuse and a severe head injury at her hands and those of her boyfriend. These factors collectively indicate a significant number of risk factors for mental disorders in Arthur’s life.

Pseudobulbar Affect: The Uncontrollable Laughter

Furthermore, Arthur likely exhibits pseudobulbar affect (PBA), also known as emotional incontinence. PBA is a neurological condition characterized by involuntary and uncontrollable episodes of crying, laughing, or both, disproportionate to the situation or underlying mood.11, 12 In Arthur’s case, PBA is likely a consequence of his traumatic brain injury (TBI). Research consistently links TBI to increased risks of mood disorders, personality changes, and substance abuse.13–15 A study by Tateno et al. found that pathological laughing and crying (PLC) occurred in 10.9% of TBI patients within the first year, and these patients exhibited higher rates of depression, anxiety, aggression, and poorer social functioning compared to those without PLC.16 This aligns with a recent analysis suggesting Arthur’s condition involves neuropsychiatric sequelae from childhood TBI affecting frontotemporal regions, particularly the left frontal lobe.17

Personality Disorders: Narcissism and Psychopathy

Arthur displays a complex blend of personality traits, notably narcissism (seeking attention at any cost) and psychopathy (lack of empathy). While exhibiting depressive traits, he also demonstrates considerable self-control. He shows no clear thought disorder; Arthur is a lucid and driven individual. His romanticized relationship with Sophie seems to be conscious fantasy, not delusion or hallucination. This diagnostic ambiguity makes a definitive diagnosis of psychotic disorder or schizophrenia difficult, despite the Joker’s stereotypical portrayal of ‘insanity.’ Evidence for major depressive disorder or bipolar disorder is also lacking.

Narcissistic Personality Disorder: The Need for Admiration

The DSM-5 criteria for Narcissistic Personality Disorder (NPD) (301.81) include ‘a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy,’ evident by early adulthood and indicated by at least five of nine specific criteria.18

Criterion 1 describes individuals with NPD as routinely exaggerating their abilities and achievements, often appearing boastful. Arthur’s life revolves around his stand-up comedy aspirations, driven by a craving for public recognition and fantasies of TV show appearances. Criterion 2 notes preoccupation with fantasies of success, power, brilliance, beauty, or ideal love. Arthur’s infatuation with Sophie, later revealed as fantasy, exemplifies this. Criterion 4 highlights the need for excessive admiration. Individuals with NPD have fragile self-esteem, constantly seeking attention and praise. Arthur’s actions throughout the film demonstrate this need. Criterion 5 describes a sense of entitlement and unreasonable expectations of favorable treatment. Arthur’s expectation of charming the TV audience contrasts sharply with his disastrous joke and violent outburst when challenged. Finally, Criterion 7 points to a lack of empathy and difficulty recognizing others’ feelings. Arthur’s remorselessness towards his victims aligns with this. Arthur meets at least five NPD criteria, sufficient for a diagnosis of 301.81 Narcissistic Personality Disorder.

Antisocial Personality Disorder: Psychopathic Traits

Arthur also presents symptoms of psychopathy, a recognized variant of Antisocial Personality Disorder (ASPD) (301.7 in DSM-5), though not formally listed as a separate disorder. He fulfills some Criterion A symptoms for ASPD: disregard for lawful behavior (repeatedly engaging in arrestable acts), irritability, aggression, disregard for safety, and lack of remorse. However, ASPD diagnosis requires the individual to be at least 18 years old (Criterion B) and to have exhibited conduct disorder symptoms before age 15 (Criterion C). While Arthur is over 18, his childhood history before age 15 is unclear, preventing a definitive ASPD diagnosis based on DSM-5 criteria.

From Flawed Individual to Supervillain Caricature

While Joker incorporates elements of real mental disorders, Arthur’s overall psychopathology remains ambiguous, and his symptom combination is atypical. This vagueness allows for a more relatable character, reflecting the broad struggles of mental illness, but can be confusing for mental health professionals, potentially conflating neurological and mental disorders. The narrative shifts from a portrayal of an individual grappling with mental illness to a supervillain archetype. The film uses Arthur’s childhood trauma and mental health struggles to elicit audience sympathy, rather than disgust at his violence, tapping into the cliché of a character lacking love. Arthur’s appeal stems from the human tendency towards self-pity. His mental illness becomes a catalyst connecting various stressors that lead to his Joker transformation. Reducing Arthur’s actions solely to his mental health issues is overly simplistic.

In conclusion, as Arthur states after his joke bombs on the Murray Franklin Show, ‘humor is subjective.’ Similarly, interpreting Arthur Fleck’s diagnosis requires acknowledging the subjectivity inherent in clinical assessment.

About the author

Valentin Yurievich Skryabin, MD, is chair of Department no. 2 at the Moscow Research and Practical Centre for Narcology of the Moscow Department of Public Health, Russia.

Funding

This work received no external funding.

Declaration of interest

None.

Supplementary material

For supplementary material accompanying this paper visit http://doi.org/10.1192/bjb.2020.146.

S2056469420001461sup001.pdf (1.2MB, pdf) click here to view supplementary material

References

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