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Rebecca H. Campbell, PharmD Candidate
University of Pittsburgh School of Pharmacy

G. Lucy Wilkening, PharmD
Assistant Professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy

Student Perspective

Black Swan depicts a young woman’s tragic journey through her first episode of psychosis. Nina is a talented ballerina whose stress intensifies as she works to perfect the role of the Swan Queen in her professional ballet company’s production of Swan Lake. Nina epitomizes the qualities of the White Swan but struggles to achieve the loss of self-control needed to perform the Black Swan. While striving to embody this role, Nina loses touch with reality.

Nina is pushed beyond her limit from all angles of her life. She is shown engaging in a co-dependent relationship with her smothering mother, who still treats Nina like a young girl. Nina’s mother appears to be living vicariously through her daughter’s accomplishments, reminding Nina that if it were not for her, she would not be successful. Genetic link is an established risk factor for the development of schizophrenia. While viewers are uncertain of her mother’s mental illness status, the genetic factor may be present. This magnitude of stress is a precipitating factor of Nina’s symptoms. Nina is in her early twenties and is socially withdrawn, two common elements in patients experiencing their first psychotic episode.

Throughout the film, Nina and the viewer find it difficult to distinguish reality from psychosis. The symptoms begin as visual hallucinations in which she sees an eerie version of herself in various situations; she even sees her stuffed animals and her mother’s paintings mocking her. Hallucinations often present as auditory as opposed to visual; however, visual hallucinations provide a more profound experience for the viewer. Nina also displays a paranoid delusion that her colleague, Lily, is after her lead role. In one scene, Nina engages in uncharacteristic reckless behavior with Lily, in which they go to a club and take ecstasy. It is unknown whether this drug use is linked to her psychotic symptoms, but this incident leads to further visual hallucinations involving Lily and defiant behavior against her mother. As the film progresses, Nina completes her transformation into the Swan Queen. She continuously scratches a specific spot on her back, which viewers are told she has done in the past. This behavior develops into the visual and tactile hallucination of Nina sprouting wings. Furthermore, at her final performance, her feet become webbed and her neck elongated. Throughout the film, the progressive disorganization of Nina’s behaviors and thoughts is evident.

Nina also exhibits symptoms of other mental illnesses. Characteristics of an eating disorder are shown in Nina’s behavior. In one scene, she is repulsed by the sugary cake her mother brought home as a celebratory treat. The movie also alludes to her purging habits. Additionally, Nina’s constant fixation on achieving perfection displays elements of an obsessive-compulsive personality disorder.

The movie provides no explanation of Nina’s diagnosis, nor does it show her receiving treatment, which left interpretation of her mental illness to the audience. The film does an excellent job of depicting the symptoms of psychosis, giving the viewer a feel for the fear and uncertainty experienced by the individual. However, the film dramatized a few elements of mental illness in order to deliver a more impactful viewing experience. Overall, this movie provided insight into the severity of psychotic disorders, as Nina’s illness ultimately progressed untreated.

Faculty Perspective

The motion picture Black Swan is a psychological thriller set in New York City that tells the story of a professional ballerina struggling with the pressures of competitive dancing. The film was directed by Darren Aronofsky and includes themes and sequences from Tchaikovsky’s ballet Swan Lake. Natalie Portman received an Academy Award and Golden Globe Award for Best Actress for her performance as the film’s protagonist, Nina Sayers. Although intentionally ambiguous, the movie centers on the manifestation of Nina's first psychotic break.

Nina is a young woman in her twenties who is presented as a dedicated, perfectionistic dancer. From the very opening scene, the film relates the fragility of her psychological state, evidenced by unsteady camera angles, turbulent music, and rapidly changing choreography. The film begins by defining Nina’s struggles and rise through the ranks of her competitive dancing company, and her interactions with her domineering director and mother. After several implied failures to make lead in the past, Nina finally achieves the lead role in her company’s reproduction of Swan Lake. The viewer learns early on that Nina struggles with several issues, including obsessions with dancing and perfectionism, as well as an eating disorder. Additionally, Nina lives with her mother who also displays elements of mental illness, including narcissistic personality and depressive features. The film progresses as Nina becomes increasingly engrossed in her role as the Swan Queen. Nina’s struggles peak when her free-spirited dancing counterpart, Lily (played by Mila Kunis), begins competing for the lead position.

While the film dramatizes the unveiling of Nina’s illness, it presents some reasonably accurate elements of first-break psychosis. Black Swan clearly highlights the first-hand perspective of individuals with psychosis and their interpretation of reality. Although these perceptions may deviate significantly from the real world, the film portrays the extent to which individuals with psychosis believe their delusions and hallucinations, and also shows how this misinterpretation becomes increasingly confusing, alarming, and dangerous to the individual. Similar to most real-life presentations, Nina’s psychotic symptoms gradually worsen over time. Nina’s disturbance in perception is evidenced by hallucinations, which evolve from shadows and seeing her face on others, to Nina’s belief that she is physically transforming into a swan. As Nina becomes increasingly paranoid that Lily is trying to steal her role and sabotage her, her behavior becomes progressively unstable and erratic. Nina experiments with drugs and alcohol, different sexual partners, and becomes increasingly agitated. The film concludes when Nina has fatally wounded herself with a shard of mirror, believing that she had stabbed Lily while fighting over who would dance the last act of Swan Lake.

Black Swan does an exceptional job relaying elements of psychosis and the psychosocial implications of untreated mental illness. For example, Nina’s demographics and social circumstances present actual risk factors for first-break psychosis, including, an individual in their twenties, the presence of other psychiatric comorbidities, intense external stress, and a primary family member with mental illness. Additionally, Nina’s experimentation with drugs, alcohol, and risky sexual behavior present very clearly her inability to safely care for herself while untreated. However, the film relays a few details inaccurately, largely for dramatic effect and viewer experience. Namely, Nina’s preponderance of visual hallucinations is not frequently encountered in actual patient presentations, whereas auditory hallucinations are much more frequently reported. Lastly, Nina’s inclination towards violent behavior as she becomes increasingly psychiatrically ill is a social stigma and misrepresentation of psychotic illness that has not been substantiated by the literature. Overall, this film serves as a great tool for illustrating the debilitating nature of psychosis, and highlights the need for treatment of mental illness in order to preserve patients’ quality of life.

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