In order to get the correct psychiatric diagnosis psychoanalysis can't be of any help in some cases. Many patients don't have the capacity for psychoanalysis cause the presence of morphological, organic substrate in the brain (brain lesions of any kind or neurodegeneration) and subsequent dysfunction. When you deal with these kind of patients, you need to take (neuro)biological approach in the assessment of their condition.
There will be blood by Paul Thomas Anderson is easily one of my all time top ten movies. Loosely based on Upton Sinclair's novel Oil! has received eight Oscar nominations and met with a fanfare of critical acclaim. Even if we put aside marvelous directing, original score, cinematography and all other more technical elements of the movie which are so finely merged into a strong, harmonic whole, the Oscar winning performance of Daniel Day Lewis will knock you of your feet. Apparently Daniel Day Lewis rent a cabin, isolated from the world in period of several months preparing for the role. He was doing all sorts of physically demanding tasks, fulfilling his muscle memory with movements and gags of a strong physical worked. His rivetingly physical rendering made this character so imaginable in every day psychiatric practice (if we'd forget about the parts with blood maybe) and therefore a case to describe a typical clinical features of organic brain damage.
ROUGH ANALYSIS OF DANIEL PLAINVIEW'S PSYCHIC STATUS (I've pin pointed few features, not the whole status)
In this epic portrayal of slowly progressive evolution of „madness“ we can see every step of the process as time in the movie goes by. I'll approach to this case as if he had came to a psychiatric examination right after the ending scene. Spoiler alert to all of you who haven't seen the movie yet, but the final scene of the movie is crucial in the diagnostics of this character as we get to see how seriously mentally ill Daniel Plainview really is.
APPEARENCE, PSYCHOMOTORICS
Physically strong, kind of asthenic. He's dressed and groomed unobtrusively, at least until the last sequence of the movie where we meet him sort of scruffy the morning after heavy drinking. I can imagine the vapor of alcohol and sweat all over the place. His movement is rigid and hard, modeled by the decades of heavy physical work as a gold digger and later on during his works on the oil well. Strong mustaches are just a cherry on top of the whole macho figure that Daniel presents.
THOUGHT PROCESS
No psychopathological verbal production until the last scene. Until that point he was mostly silent, with occasional moments of anger bursts. We can't say that he is delusional, but he certainly is in sort of schizo –paranoid state of mind the whole movie. He is a loner. Unaffectionate toward his son and others, kinda distrustful and suspicious. Surely doesn't hide his misanthropy. But the catch of the diagnosis (in final third of the movie) lays in a phenomena of PERSEVERATION.
Perseveration
Perseveration is a phenomena of repetition particular content in verbal production (such as a word, phrase, or gesture). It is usually caused by a brain injury or other organic disorder. In the final third of the movie during the argument with his son he ends up his little monologue repeating the phrase directed to his son:
„You're not my son. You're just a little piece of competition. Bastard from a basket. Bastard from a basket! You're a bastard from a basket! A bastard from a basket! A bastard from a basket!...“
...Or in the scene with his "archenemy" reverent Paul Sunday when he yells during the fight:
„Did you think your song and dance and your superstition would help you, Eli?! I am the Third Revelation! I am who the Lord has chosen! And because I’m not a false prophet, you sniveling boy. I am the Third Revelation! I am the Third Revelation! I told you I would eat you! I told you I would eat you up!“
AFFECT
Throught the movie his mimics is kinda reduced, but he certainly can put a proper smile when it comes to business agrements. Later on we can se alot of emotinal labilty, if not even moments of emotional incontinence wich is specific for some kind of brain damages.
MOOD
He is usually dysphoric and angry. Doesn't seem depressed, he doesn't cry, isn't sad or gloomy. Later on, while chasing and bullying Paul we can see a specific mood state, in psychiatry known as MORIA.
Moria
Moria is the condition characterized by euphoric behavior, such as frivolity and the inability to act seriously. In addition, there is a lack of foresight and a general indifference. It is found in frontal lobe lesions, often along with Witzelsucht, particularly when the orbital surface is damaged. Recent research has shown its presence in frontotemporal dementia.
source: https://en.wikipedia.org/wiki/Glossary_of_psychiatry
COGNITIVE FUNCTIONING AND MOTIVATION
I'd say his IQ above average. The guy has a nose for business and in combination with extreme will to win in this money making competition it made it possible to excel. Later on he had certainly developed more severe cognitive deficiencies which could be detected with Mini Mental State Examination, a useful tool for rough analysis of cognitive functions. Neurocognitive testing should be conducted by the neurologist.
FUNCTIONALITY
Except his obsessive urge to succeed and to be the strongest and wealthiest oil man in the business, he fails as a father end besides his son, doesn't have any other significant interpersonal relation. Alcohol abuse comes from the emptiness and the gap that endless amount of oil wouldn't fill up. At the endpoint of this slowly building madness precipitated with excessive alcohol abuse he doesn't seem to have a capacity to function properly in any field in life. Few years ahead from the point where movie ends, if untreated, we could see the full clinical picture of dementia with hallucinations, delusions and even delirium.
INSIGHT
He's basically person with severe structural deficits manifesting antisocial and narcissistic features. Doesn't show any empathy and was brutal in the way he treated others. Later on as he starts to mentally deteriorate due to alcohol abuse and finally he loses it completely. We usually perceive that as the determinant factor while defining the term „ madness“.
DIFFERENTIAL DIAGNOSIS
source: http://pmj.bmj.com/content/80/941/125
According to his psychic mental state and anamnestic data I'd conclude that Daniel is suffering from some sort of chronic brain degeneration. From my past experience, I'm pretty sure he wouldn't be capable of giving credible information about his former functioning and would most probably be extremely negativistic about his mental problems, possibly even agressive or hostile during the examination. Heteroanamnestic data (taken from a person that knows the patient very well, or has any significant data about the patient) would be needed to get the whole picture. MRi or MSCT scan should be needed to see what kind of visible pathomorphological substrate is present. I assume we could see neuroatrophy (reduced brain tissue) in cortical gray matter, and possibly in basal ganglia. Damage is done by the effect of alcohol abuse and subsequent cerebrovascular incidents that usually occur over time. We'd also need to take the blood tests to see if there are some signs of infection, or metabolic disorder that could cause such a severe decompensation in his psychic status.
Notable deficiencies primarily occur when the most fragile parts of the brain get exposed to effect of noxious (harmful) factors. Cognitive processing, memory and attention are functions that are primarily affected. Later on with the progression of degeneration other functions will get impaired as well.
PFC (prefrontal cortex)
Area of the brain know as prefrontal cortex is responsible for planning complex cognitive behavior, personality expression, decision making, and moderating social behavior. It is in direct relation to the amygdala, having an inhibitory effect on it, modulating it's function.
Amygdala
Corpus amygdaloideum is a basal ganglion located in the heart of the limbic system in temporal lobe. The amygdala is the reason we are afraid of things outside our control. It also controls the way we react to certain stimuli, or an event that causes an emotion, that we see as potentially threatening or dangerous. When PFC is damaged, amygdala gets hyper-reactive. This is where the trouble begins.
source: http://brainmadesimple.com/amygdala.html
source: www.psypost.org
DIAGNOSIS
Diagnosis according to ICD (International Statistical Classification of Diseases ) - 10th revision
F07.9 Unspecified organic personality and behavioral disorder due to brain disease, damage and dysfunction (Organic psychosyndrome)
F10.2 Alcohol dependance
F60.2 Antisocial personality disorder
TREATMENT
He'd have to be treated in the psychiatric department of closed type, where he could be monitored intensively. During his first few days we'd have to cope his alcohol withdrawal symptoms with high doses of diazepam, probably to the extent of 60 – 80 mg (usual daily doses rarely exceeds 30 mg a day), maybe even lower in a case of serious liver damage. During his first week the dose would be reduced to approximately 30 mg a day (20-40). He'd have to be hydrated properly so he'd get intravenous sollutions of 0.9% sodium chloride enriched with vitamin B1, B6 and vitamin C, as well as intramuscular aplications of vitamin B12. Electrolyte status should be checked every day and supplemented according to the laboratory results. Patients with brain damage can be very impulsive, unable to control their emotions and behavior, exposing others (and themselves) to a great danger, as was the case of Daniel. To cope these symptoms I'd treat him with combination of antipsychotics (probably promazine and haloperidol). We'd also have to open the question of legal capacity, as his state is progressive and irreversible, and with the premise that he isn't capable of taking basic care of himself. It would also be interesting to see how would forensic psychiatric expertise asses this case, weather he'd end up in department of forensic psychiatry or in prison.
