Still Alice

April 23, 2015

This film is a must-see for psychiatrists, not because it adds new information about the course of Alzheimer disease or its impact on families, but because it forces us to rethink issues that can affect our clinical practice.

[[{"type":"media","view_mode":"media_crop","fid":"34192","attributes":{"alt":"Still Alice","class":"media-image media-image-right","height":"186","id":"media_crop_5658580840045","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3633","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image","width":"124"}}]]Her speech was rambling and filled with circumlocutions, yet her warm smile remained unchanged. When this pleasant-looking 50-year-old woman first walked into my office, she apologized for being late, pausing a moment before saying that there was a problem with “the place she keeps her car.” I realized that Ms A was referring to the “garage,” but I also suspected that she had word-finding problems. I was relieved to learn that she took a taxi, out of necessity.

As she continued, she drifted off into tangents, but not in a pressured, manic way. When she made the appointment, she said that the problem was depression-because that’s what the drug company commercials said. Concentration was bad, planning was poor, and now her job was in jeopardy. No alcohol, no drugs, no marital or medical problems that could contribute to her symptoms-except for one thing: her family history. Her mother died of early-onset dementia 25 years ago, at age 55.

Ms A had mentioned migraine meds, so I asked about her neurologist-and dodged expressing concerns about her cognition just then. Looking a bit embarrassed, she said that her primary care physician renewed her meds, usually by phone, to save her travel time and avoid bigger copays for specialists. I wondered how long those word-finding problems were present, but had gone unnoticed by the receptionist who answered the phone and called in refills, sight unseen. When I offered to call her neurologist myself, she looked relieved. I, too, was relieved, knowing that neurology could address awkward issues about cognition.

The next day, I saw Still Alice (2014) at the Angelika, 2 blocks from my office. The film was still on limited release, even though rumors predicted that Julianne Moore would win an Oscar for Best Actress. Those rumors proved right; Moore subsequently won an Academy Award.

No disrespect intended, but whenever I hear her name, I picture Moore seated near Ray Liotta, whose racist and sexist character was lobotomized by Hannibal Lecter (Anthony Hopkins), at a dinner party. The Hannibal series made an indelible impression, probably because Dr Hannibal Lecter is a psychiatrist.1

In Hannibal (2001), Moore’s Agent Starling paled in comparison to Jodie Foster’s rendition of the same character in Silence of the Lambs (1991). In Still Alice, Julianne Moore shines. Curiously (and perhaps not accidentally, given the insights of casting directors), Moore’s Alice runs a parallel course as Liotta’s FBI agent. Alice’s brain is also consumed, not by cannibal Hannibal, but by early-onset Alzheimer disease (AD).

Alice is a professor, an author, and a world-renowned authority in her field. At age 50, she gropes for words as she stands at the podium and lectures. Students complain. Her department chair cannot comprehend the transformation. Outside of the university, she has a husband, 2 daughters, and a son. She lives a storybook life until the disease strikes-suddenly and swiftly. As Alice’s neurologist explains, persons of high intelligence and high education decline more quickly-perhaps because they were able to push past their early deficits better than less educated peers, who cannot conceal earlier symptoms.

Alice plans for the future while she still possesses the ability to plan, but she doesn’t plan well enough. She sees AD as a memory-robber that interferes with language abilities and memory (which is mostly true). She sets up memory tests on her computer to show when her illness has run its course and when it is time to suicide. Early on, she plants pills in a safe place with the intent to overdose. However, she does not foresee the effects of dyspraxia; she appears unaware that “muscle memory” also disappears in dementia. Her hand function falters as she attempts to open the bottle. Pills spill out and roll onto the floor. She is still alive (and still Alice) before the film ends. Eerily, the words “Alice” and “alive” are easy to interchange when typing, because “c” is next to “v” on the keyboard, making me curious if the author of the book that inspired the film had made such substitutions herself.

The plot is straightforward, without frills or curlycues or unexpected detours. Even the botched suicide attempt fails to add suspense-but no matter, because the film holds our attention. The plot can be called, “parsimonious,” to borrow neurologists’ favorite term. Neurologists practice “parsimony” when they explain the most symptoms with the shortest answer. They get to the point and so does Still Alice.

We learn that 2 of her 3 children opt for genetic tests to show whether they are or are not carriers of the mutation implicated in Alice’s early-onset AD. Earlier, we heard the neurologist dig into Alice’s own family history, unearthing details and reconstructing events, to hypothesize that Alice’s estranged alcoholic father showed strange symptoms well before he succumbed to cirrhosis.

There is a lesson to be learned here: alcohol abuse and liver failure can coexist with a gene for early-onset AD, even though alcohol abuse and liver failure can cause neurological deficits on their own. The movie does not spell this out, but readers of Psychiatric Times will read between the lines.

We watch the older daughter cope with the news and see her make the best of this horrific situation, without showing sentiment or resentment. We understand why the younger daughter, the drama major, continues her usual course and avoids confronting reality. She refuses testing, just as she refused her parents’ recommendations to choose a more “realistic” college major. We know that most persons at risk for Huntington disease did not opt for genetic testing once it became available, and so we are not shocked that one of Alice’s children refuses testing. Rather, we are surprised that only one refuses.

The neurologist (Stephen Kunken) interested me as much as Alice. I studied his every word, his every movement, his crooked half-smile, his nice but not-too-neat haircut, and his nice-enough but not-too-nice tweed jacket. I wondered whether the actor rode up and down the med center’s elevators or attended Grand Rounds, observing neurologists in their “natural habitat” and mimicking their appearance, their speech, and their interpersonal styles. The fact that Lisa Genova, the author of the book Still Alice, is a PhD in neurophysiology undoubtedly added authenticity.

The neurologist seems slightly shy, but not shy enough to hinder his ability to deliver a straightforward diagnosis without stammering or stuttering. It amazed me that he could speak so coherently and so directly when delivering such dire news. Is this how neurologists do it? When the neurologist facilitates a speaking engagement for Alice at an Alzheimer’s Association conference, it made me rethink an APA-sponsored course about “creative boundary breaking.” How would a psychiatrist approach this situation? For someone who seems standoffish in his office, the neurologist makes a point of attending Alice’s lecture, applauding Alice on a job well done. He appears to be genuinely impressed.

This film is a must-see for psychiatrists, not because it adds new information about the course of AD or its impact on families, but because it forces us to rethink issues that can affect our clinical practice. Cutting-edge questions about medical ethics simmer under the surface. Most (non-geriatric) psychiatrists are accustomed to reassuring depressed patients that their perceived deficits are not so bad or are even nonexistent and are expected to pass-but there are times when someone like Ms A walks into our office. A movie like this helps us mentally rehearse our responses and prepare for the challenges of ethical as well as clinical decision making and for delivering not-nice news to a very nice person.

Disclosures:

Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine in the Bronx, NY. She is the author of several books, including, Cinema’s Sinister Psychiatrists: From Caligari to Hannibal (McFarland, 2012) and Neuroscience in Science Fiction Films (McFarland, 2015). She is in private practice in New York City. She reports that she receives royalties from Neuroscience in Science Fiction Films; A History of Evil in Popular Culture: What Hannibal Lecter, Stephen King, and Vampires Reveal About America (ABC-CLIO, 2014); Cinema’s Sinister Psychiatrists, Movies and the Modern Psyche (Praeger, 2007); and other books that do not relate to the topic at hand.

References:

1. Packer S. Cinema’s Sinister Psychiatrists: From Caligari to Hannibal. Jefferson, NC: McFarland & Company, Inc, Publishers; 2012.