Acad Psychiatry DOI 10.1007/s40596-017-0682-8

COLUMN: MEDIA

DSM-5 Post-Traumatic Stress Disorder Criteria in “Precious” (2009): Media Content Analysis for Educational Purposes Laura Dip Ramos 1 & Fernanda Severo Guimarães 1 & Antonio Ventriglio 2 & Arthur Guerra de Andrade 3 & Dinesh Bhugra 4 & Francisco Lotufo-Neto 3 & João Maurício Castaldelli-Maia 1

Received: 5 May 2016 / Accepted: 9 February 2017 # Academic Psychiatry 2017

Some folks has a lot of things around them that shines for other peoples. I think that maybe some of them was in tunnels. And in that tunnel, the only light they had, was inside of them. And then long after they escape that tunnel, they still be shining for everybody else. Claireece Precious Jones [1] Films and other audio-visual materials are excellent sources for teaching psychopathology and depicting psychiatric interventions. Documentaries and institutional films are commonly used as auxiliary tools in education, whereas feature films are still gaining more recognition [2–6]. When utilized as psycho-pedagogic tools, movies endorse a broad comprehension of human interactions, individuals displaying signs of a psychiatric disorder or negative responses to certain stimuli and ultimately the capacity to feel empathy toward the characters and situations presented, that can intimately resemble real life in many ways [2–6]. It is well know that “art imitates life, as life imitates art” [2–6] and, thus, many of the films that fascinate audiences around the world and win prizes for their cinematographic quality are important depictions of what our culture is experiencing on a given era [2–6]. When a

* João Maurício Castaldelli-Maia [email protected] 1

Fundação do ABC, Santo André, SP, Brazil

2

University of Foggia, Foggia, Italy

3

University of São Paulo, São Paulo, SP, Brazil

4

Institute of Psychiatry, King’s College, London, UK

motion picture comes as a result of excellent screenplay, direction, acting—better if all together—it becomes an even more effective tool for teaching, helping audiences, and health professionals alike to comprehend psychopathology and the portrayal of the responses of others to these disorders [3–6]. Cinema is a useful pedagogic medium in many fields of medicine [2–4] and psychiatry is certainly one of the pioneering and most engaged areas in endorsing movies as teaching/learning instruments, at both undergraduate and graduate levels [2–6]. We studied the depiction of mental health issues in mainstream movies [3–5, 7, 8] released between years 2008 and 2013. To narrow our selections, due to time and financial constraints, we looked at films that contained one (or more) scenes featuring psychiatric and/or substance abuse disorders and that had received at least one Academy Award® nomination (in any category). Since 1929, the Academy Awards have had a major role to play in the success of films internationally. We were chiefly interested in whether or not the celebrated films depicted psychiatric and/or drug abuse disorders in a manner that met the current Diagnostic and Statistical Manual of Mental Disorders—5th Edition (DSM5) [2–6, 9]. Movies such as “There Will Be Blood” (2007), “Rachel Getting Married” (2008), and “Crazy Heart” (2009) comprised the list obtained by our research group. Among the selection, the film “Precious: Based On The Novel Push, by Sapphire” (2009), whose director Lee Daniels has other stunning pieces in his curriculum, like “Monster’s Ball” (2001) and “The Butler” (2013), stands out for its vivid and realistic portrayal of post-traumatic stress disorder (PTSD). The film is about a 16-year-old, morbidly obese girl that suffers, early in life, severe parental mistreatment and sexual abuse, followed by subsequent educational and relational difficulties.

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While signs and symptoms meeting criteria for PTSD [9] are prominent in her experience during the film, some other important aspects of the narrative were decisive when outlining the purposes of the study. Besides our initial intention of comparing DSM-5 PTSD [9] criteria with the actual depiction of signs and symptoms presented by the main character, “Precious” is a movie that carries a powerful message [10–14], which goes far beyond the objectivity of psychiatric criteria. Education appears as a propellant force of transformation [14] and a teacher committed with her students as the lifeline of a girl that, against all odds, manages to overcome herself and regain hope.

critics and audiences, “Precious” is definitely a startling film, whose cinematographic strength also relies on its’ outstanding original soundtrack, “I Can See in Color,” sang by hip-hop artist Mary J. Blige [16] and, above all, the unforeseen protagonist Gabourey Sidibe, a girl with no professional acting experience, who “doesn’t portray a character as much as embody her (…) it’s amazing for precisely giving the impression that she isn’t acting at all [10],” as written in Dissent Magazine.

Why “Precious”?

The lifetime prevalence of PTSD in the USA, in general population, ranges between 7.3 and 9.1% [17]. Low-income countries, countries at war or mass violence zones, show rates considerably higher (15.8% in Ethiopia, 17.8% in Gaza Strip, 28.4% in Cambodia, and 35.4% in Algeria) [18], while, among North American war veterans, the life prevalence of PTSD varies between 1.4 and 60% [19], emphasizing the importance of protective environmental factors, personal resilience strategies [20], and demonstrating how differently people respond to similar traumatic stimuli. Moreover, studies show high rates of co-morbidity in youth populations exposed to a variety of traumas [21]. In 2006, the National Institute of Justice (NIJ) elaborated a special report about violence that shows a lifetime prevalence of sexual abuse among women (ages 18 years or older) of 17.6% [22]; 14.5% of the women between 19 and 29 years were raped before the age of 19 years old [22]. In 67.8% of cases in which women were raped for the first time at age 12 or less, the perpetrators of the act were members of their family [22]. According to a 2007 national study [23] concerning sexual abuse in the USA, mental health issues such as depression, drug abuse, and PTSD were the most prevalent among rape victims; criteria correspondence with PTSD, within the past year, ranged from 9 to 12%, subject to sample [23].

Adapted from the 1996 novel “Push,” by Sapphire, poet Ramona Lofton’s pen name [1], written in the first person, the book accounts for the author’s experience working among young women in the New York suburbs, during the 1980s [14]. The film portrays a teenage girl, Claireece Precious Jones (Gabourey Sidibe), raised in New York City’s Harlem, who finds herself abused and twice impregnated by her father Carl Kenwood Jones (Rodney Bear Jackson), who abandons the family after the incident. Subsequently, relationship between daughter and mother, Mary Johnston (played by comedian Mo’Nique) becomes tense and violent, as Mary despises and blames Precious for the abuses and for Carl’s departure. Precious shows dissociation symptoms when exposed to situations reminiscent of the trauma and develops significant difficulties in learning, nurturing relationships and expressing emotions [9]. After the intervention of a concerned counselor (Mariah Carey), Precious reaches a turning point, leaves public school, and starts attending “alternative school” (Each One/ Teach One program), where she bonds with English teacher Ms. Blu Rain (Paula Patton). When “Precious” premiered in 2009—relying on influential partnership with executive producers Tyler Perry and Oprah Winfrey [13]—it got into the spotlight immediately, being provocative, full of taboos and human right issues [10–15]. The movie won three awards at the Sundance Festival, [15] and when screened in Cannes, it received standing ovations [12]; later in 2010, it was nominated for six Academy Awards and won two, including best adapted screen play [15]. While many critics wrote wonders about the film, it was definitely contentious, referred to as a “sociological horror show” [13] and accused of stereotyping the AfricanAmerican community, pushing audiences to think about how dangerous racial portrayals can be if accepted with no criticism when living in a “white-dominant” culture [14]. Although reactions to the movie were extreme, divvying

PTSD and Sexual Abuse: Epidemiological Importance

Invite Precious to Class: Media Content Analysis and Teaching In this study, we use media content analysis [24] to identify DSM-5 PTSD criteria [9] as seen in the protagonist of the movie Claireece Precious Jones. We analyze her behaviors and attitudes within the context of the film structure and storyline. Media content analysis has been widely used as a research tool for studying portrayals of violence, racism, and women, studying transcripts of interviews and discussions in clinical and social research related to films, TV programs, and the editorial and advertising content of newspapers and magazines [24].

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The case depicted in the motion picture helps promote discussion about signs and symptoms that meet diagnostic criteria proposed by the DSM-5 for PTSD [9], as well as other important themes such as resilience, family cohesion, incest, social iniquity, prejudice, education, and coping strategies [10, 14], all significantly relevant for psychiatric clinical practice. The overall objective of watching and discussing this film is having a practical activity concerning PTSD and its signs and symptoms, according to DSM-5. Considering the educational purposes of this paper and others that reinforce the use of cinema as a teaching tool [2–6], we advise the reader to become a viewer and watch the film, using our study as a “guide.” For medical students, interns, first year residents in psychiatry, and health professional in general interested in the subject, this motion picture is highly suitable for learning and teaching PTSD DSM-5 criteria [9], either in a group viewing (classroom/nursery) and open questions/talk scenario, or in an individual viewing (home essay) and post-film talk juncture [2, 25, 26]. Because medical students are usually busy with daily obligatory chores, media activities should be acknowledged as something pleasurable, but at the same time taken seriously, just as though the situation depicted corresponds to something that can happen to a real-life patient who needs to be diagnosed and treated. For best educational use, the ideal settings and procedures are described in the next section of this paper (“How to approach the film: DSM-5 guided and facilitated discussion”), but it is important to notice that the aim of the study is not to prompt readers to replicate our methods, but create their own means of teaching/learning with “Precious.”

How to Approach the Film: DSM-5 Criteria and Facilitated Discussion In this paper, we utilize diagnostic criteria from DSM-5 (APA, 2013) to analyze symptoms presented by the films characters and use tentative diagnosis of PTSD. DSM-5 includes PTSD among other similar disorders (reactive attachment disorder, adaptation disorder, etc.) in a new chapter: Trauma and Stress Related Disorders [9] and proposes a new four-cluster model for PTSD [22]: intrusion (criteria B), avoidance (criteria C), negative alterations in cognitions and mood (criteria D), and alterations in arousal and reactivity (criteria E) [9]. Initially, two authors (LDR and JMCM) watched the film independently, and each selected the scenes (lasting a minimum of 30 s) considered relevant for PTSD portrayal. A minimum of ten scenes in common was reached between them and the film was chosen for analysis. No other films were watched for portrayal of PTSD. Both authors then reassessed the film together and found 17 scenes that met the DSM-5 PTSD criteria. Finally, all authors watched the movie

individually, so that the scenes selected could be reviewed for any of the 24 DSM-5 PTSD criteria [9]. The inclusion criteria assessment was carried out in a structured manner using methods validated in previous studies [3–5, 7]. Consensus was reached among authors about all scenes and their corresponding criteria. All results from media analysis are descriptive, as summarized in Table 1 and unraveled through the “Scene Guide” section. In Table 1, scenes are numbered from 1 to 17, beginning and ending identified (time-lapse/HH:MI:SS) according to the DVD format of the film (duration, 110 min), described in a factual point of view and the ones containing traits of violence/abuse are pointed out. Corresponding DSM-5 criteria and disorder are listed in the last columns (Table 1). Before watching the movie, we recommend reading all the 24 DSM-5 PTSD criteria [9], and also the DSM-5 Pre-, Periand Post-traumatic Risk and Prognostic Factors for PTSD [9]. While watching the film, pay close attention and take note of the time-lapse of each scene that may meet criteria. Pausing the film more than once may be needed if the student has never seen the movie to have an overall idea of what it is about, it can be of great use to watch it once entirely before promptly assessing the scenes (though not a requirement). Additionally, the “Scene Guide” section and Table 1 should be assessed together and only after watching the movie, for best educational use. As a cautionary note, according to the Motion Picture Association of America (MPAA) [25], the film is Restricted/ rated R (people less than 17 years old need to be accompanied by parent or adult guardian), because of depictions of emotional and physical violence, including child sexual abuse. After the viewing, either on the same day or later on, depending on the format chosen for the screening, dialogue about the film should be oriented, preferably by a psychiatrist (or doctor, health professional, teacher) that is already familiar with the motion picture and this article’s general proposal [2–6]. Material gathered from discussion guides [26, 27] that focus on better understanding the film and built around the metaphor “we are all Precious” (www.weareallprecious.com), can be of great use. Suggested questions elaborated upon those guides [25, 26] and acknowledging important reflections that arose from the interaction between authors of this study during analysis of the movie are listed below: & & &

Both the writing in the novel and the opening credits in the film are unique. How did the style in which these were written impact you? Does knowing that the story is based on the author Sapphire’s experience teaching in Harlem and the students she met impact your appreciation of the story? How? Though this story is set in Harlem in 1987, what about the film is true to today? What has changed?

Acad Psychiatry Table 1 Scenes that represented any DSM-5 criteria for post-traumatic stress disorder (APA, 2013) in the movie’s main character Claireece Precious Jones (2009), according to media content analysis Scene no.

Time-lapse (HH:MI:SS)

Scene description

Violence/Abuse

DSM-5 PTSD criteria

1

1′45′′–2′35′′

–

2

2′41′′–2′51′′

D. 2, 5, 6 E. 5 E. 1

3

4′41′′–6′11′′

Absent-minded during class, thinks about life and whishes for changes (voice in off) Physically assaults a classroom mate that was disturbing the teacher and is called to the dean’s office Talks to the dean about her 2nd pregnancy; receives a suspension

4

6′34′′–6′41′′

5

8′22′′–10′39′′

Mary throws an object toward her daughter’s head. Incestuous rape scenes appear as flashback (vivid memories) –

6

10′56′′–13′35′′

Precious’s mother throws an object on the daughter’s head, she falls on the ground and enters a flashback (vivid memories) state involving sexual abuse Agrees with her mother that “only idiots ring the bell at their house” and mistreats the school dean through the intercom Mary hits her daughter’ s head with a pan, says innumerous insulting words and throws objects in her direction

7

18′48′′–19′56′′

8

20′15′′–21′31′′

9

22′44′′–23′30′′

10

31′17′′–32′45′′

11

34′48′′–35′24′′

12

35′57′′–38′17′′

13

39′58′′–40′43′′

14

49′23′′–51′22′′

She becomes tense, has cold sweats, taps her feet nervously and feels incapable of reading the task proposed at the “alternative school”. Voice in off implies feelings of inferiority, sadness and defenselessness Boys assault her verbally and physically while strolling on the streets, and knock her on the floor. Precious enters a dissociative (depersonalization), “dream like” state, in which she is desired and loved by a handsome young man Mary is in bed, masturbating. She yells her daughter’s name, asking for Precious to go and “take care” of her. It stays implicit that the girl is abused sexually, in some way, by her mother When introducing herself to her colleagues, at the “alternative school,” Precious acts in a depreciative way saying “she can’t do anything well” Assaults physically a classroom mate after being called fat, in a facetious way, during an activity at the each one/teach one, “alternative school” Shows physical symptoms and has flashbacks (related to the incest and daily aggressions perpetrated by father and mother) when she fails to read a children’s book, while in front of the teacher who proposed the task Precious’s mother devaluates her interest in “each one/teach one” school, and judges her as incapable of learning anything, emphasizing the necessity of continuous financial support from Welfare aid Talking to the social assistant delicate themes, such as her problematic relationship with her mother, the incest and the children she had from her father, are brought to surface

She slaps a boy’s head in a classroom, at school –

Precious is violently hit on the head, verbally insulted and objects are thrown at her; Mary diminishes her, blaming Precious for suffering sexual abuse –

B. 4 C. 1 E. 1, 2, 4 B. 1, 3

D. 2 E. 3 A. 4 Post-traumatic factors

D. 2, 4

She is insulted by a group of younglings, on the street, listening to music. They use coarse words and one of the, motivated by peer pressure, knocks her down; they all go away laughing and leave her on the floor Precious is abused sexually by her mother, while Mary masturbates

B. 3 Post-traumatic factors

–

D. 2, 4

Slaps a school colleague on the head with twice, for calling her fat

E. 1, 4

Flashes/vivid memories of the incestuous rape, fights and physical aggression involving her parents

B. 1, 3, 5 D. 2 Post traumatic factors

Verbal assault from her mother, that reiterates the erroneous notion that Precious has no learning capability, whatsoever, and must be submissive to Mary’s wishes –

Post-traumatic factors

B. 4 Post-traumatic factors

C. 1 B. 5 D. 3, 5, 6 E. 1

Acad Psychiatry Table 1 (continued) Scene no.

Time-lapse (HH:MI:SS)

Scene description

Violence/Abuse

DSM-5 PTSD criteria

15

1 h 03′50′′–1 h 08′27′′

Mary throws the newborn negligently on the sofa and, afterwards, tosses a glass at Precious. Several physical and verbal aggressions follow against the daughter, which tries to protect her child, culminating with Mary attacking them with the TV

A. 4 B. 3 C. 2 Post-traumatic factors

16

1 h 23′53′′–1 h 26′00′′

–

D. 3, 4, 6 E. 1

17

1 h 32′40′′–1 h 41′23′′

Carrying her second baby (result of sexual intercourse with her father), Precious returns to her mother’s house, after a few days in the hospital. Mary reacts coldly, asks to hold the baby, while smokes a cigarette and asks Precious for something to drink. As the girl turns to the kitchen, she throws the newborn on the sofa and starts yelling and reassumes her usually abusive pattern: says her daughter ruined her life, stole “her man,” had more children with him than her, calling her depreciative names. Precious takes the baby on her arms and escapes, after she’s injured on the head by a ceramic vase. Runs down the stairs and falls; Mary throws a television trying to hit Precious on the ground floor, but she misses. Alone in the apartment, Mary goes up to her daughter’s room and rips all the posters from the walls, crying and struggling in despair Precious tells she is HIV positive to her friends and teacher, at each “one/teach one” and when stimulated to write about her story, starts crying, becomes angry, uses coarse words and undertakes a defeatist and sorrowful attitude, as well manifests outright disenchantment toward life Mary tells the social assistant details of the sexual abuse suffered by Precious, since she was 3 years old, how it happened many times in the couple’s bed and how she felt awkward, but incapable of stopping him. She witnessed and acted somewhat indulgently and many of the situations, perpetrating the abuse pattern. She reiterates that Precious can be blamed for the incestuous rapes she suffered, because she would let herself be abused by her father and would not say anything, “wouldn’t shout or struggle”. Mary shows a manipulative and persecutory personality, and possibly (?) moments of dissension with reality. After listening to her mother’s statement, Precious reacts in astonishment, yet very sad and also a bit relieved to finally know more about her past

The sexual abuse/incest themes become patent in Mary Johnson’s speech, the purport is violent and vulgar; although there is no flashback depicting the memories

B. 5 D. 1, 3 Post-traumatic factors

& &

& & &

What themes and issues do you believe Precious’ story intends to shed light upon? Why? Precious is a very powerful film depicting intense situations—including graphic language, images, and situations—what feelings and/or reactions did you have while viewing it? Can you relate to Precious or her life? In what way? Is “Precious” a movie about what we all can overcome or is it merely an examination of one girl’s life and circumstances? Why? Precious’ reading teacher, Blue Rain, takes a serious and consistent interest in her well being and success. Think of a teacher who made a difference in your life. What key

& &

characteristics made this teacher so pivotal? Is she similar to Blue Rain in any way? How did this change or influence your choices later in life? What does this story tell us about the ability or preparedness of ordinary schools to deal with students’ learning difficulties? “Precious” is ultimately a story of hope; the girl has a core of hope, though she does feel hopeless at times. She goes to the GED program as an alternative to her current situation and puts her faith in her teacher, in the process of writing and learning, even in the face of difficult circumstances. How does her optimism change her daily life? How did writing help her to heal?

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&

Only for health professionals, such as doctors and psychiatrists: consider Precious a patient of the Primary Health Care System. Her initial complaint has no direct correlation to domestic/sexual violence (i.e., recurrent headaches, anxiety, and lack of interest in daily activities, for more than 6 months). But, the social assistant bound to that health unit gathers important information about the case and mentions that Precious has a son with Down syndrome, to whom she gave birth in her early teen years, lives alone with her problematic mother since her father became completely absent, and the overall family relationship has characteristics that strongly suggest abusive parents and sexual violence.

–

How would you manage this situation, working as a “General Practitioner”? Which questions would be adequate to complete the anamnesis? Consider another scenario in which you are the Psychiatrist called upon evaluating Precious’ complex situation. What might be the best therapeutics for her? Finally, what is the importance of having productive interaction between different sectors (medic, psychology, social assistance) that interweave in the Primary Health Care field? What do you think is necessary for that to happen?

– –

How to Approach Precious: Real-Life Practice and Therapeutic Options Even though it is not this article’s purpose to point out or compare remedial options for PTSD cases, considering that similar situations occur in a psychiatrist’s or doctor’s daily practice— maybe not as complex or multifaceted, but certainly equally challenging to handle—it is important to notice that in such intricate cases, all means available should be at hand for optimal patient management. Firstly, utilizing the Child and Adolescent Needs and Strengths (CANS) assessments provides a comprehensive measurement of the type and severity of clinical and psychosocial factors that may impact treatment decisions and outcomes [28]. According to a recent study concerning CANS assessment in California-based mental health treatment agencies [29], the vulnerabilities of high-need populations can be best associated to the following four predictors: child’s frustration management problems, recreation and leisure time activity challenges, poor response to consequences for aggressive behavior, and lack of optimism [29]. The CANS can be used either as a prospective assessment tool during treatment planning or as a retrospective assessment tool [28, 29]. Secondly, cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) appear to be the

most effective tools for treating PTSD patients [30, 31]. CBT can be held individually or in groups and often combined with several other exercises, such as writing therapy and stress management (the latter, recommended only for adults) [30, 31]. According to World Health Organization’s (WHO, 2009) evidence-based guidelines and intervention strategies [30], antidepressants (SSRIs and TCAs) should not be used as the first line of treatment for adults (standard recommendation) and should not be used at all for treating children and adolescents (strong recommendation) [30]. Much research has been done in the last decade—propelled inclusively by former experiences utilizing psychotropic substances in clinical/experimental contexts—toward proving the efficacy of MDMA-assisted psychotherapy in treating chronic and refractory cases of PTSD [31], showing until now, some promising results. Lastly, but most importantly, health professionals, in order to communicate effectively with patients who may be in situations analogous to Precious’, must be able to handle such complex individuals with the necessary care, empathy, and provide them with non-judgmental listening space.

Scene Guide We found 17 scenes that meet the DSM-5 PTSD criteria [9]. Among those, some are particularly relevant for the depiction of PTSD and deserve the reader’s attention. In the first sequence of scenes 1, 2, and 3, Precious is in the classroom where she suddenly assaults a classmate (criteria E. 1) and gets called to the dean’s office. She illustrates a set of personality traits all within the opening scene that meet criterion D. 2, 5, and 6, related to her sense of alienation and excessive selfconsciousness expressed as self-depreciative feelings and anhedonia. Her lack of concentration (criteria E. 5) becomes recognizable during the classroom scene, as well as her lack of interest; the character’s internal dialogue refers to subjects that do not seem to fit in the external reality. In scene number 3, Precious shows negative emotions and avoidance when required to recall the reasons for her second pregnancy and talk about it with the school dean (criteria B. 4 and C. 1). Her subsequent reactions of feistiness, aggressiveness, and imprudence when facing authority refer to criteria E. 1, 2, and 4. In the next scene, Precious is at home and the first part of the sequence shows an argument between mother and daughter. Precious falls on the floor after being assaulted by her mother; the character shows intrusive symptoms related to the traumatic event (criteria B. 1 and 3). In scene 7, in which Precious takes the placement test at the “alternative school,” and in scene 10, in which she presents herself to her school colleagues, symptoms are presented as described in criteria D. 2 and 4 (persistently negative emotional state, profound feelings of abandonment, exaggerated negative beliefs, and expectations about herself). The possibility of a

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differential diagnosis or a co-morbid disorder such as depression, as suggested by the traits presented in these scenes, is discussed in the “Final Remarks” section. In scene 12, Precious shows physiological symptoms related to the intrusive memories of the traumatic experience. As portrayed, Precious is unable to read a sentence from a book, when asked by her teacher. She experiences flashbacks (B. 1 and 3) focusing on her experience of the rapes and her mother’s verbal assaults. This is followed by physiological symptoms such as cold sweating, blurred vision, voices in “echo,” and a short period of absence (B. 5), leading the teacher to call a nurse. The girl resumes the reading task but unsuccessfully. She is not able to read a children’s book at the age of 16, and appears to be functionally illiterate. This indicates the character’s severe learning difficulties as well as a possible neuro-cognitive deficit due to trauma experienced during childhood and adolescence [32–36]. In scene 14, Precious shows alienation and lack of interest when interviewed again by the social worker (D. 5 and 6) and experiences great difficulty talking about the abuse and her troubles with Mary. She avoids elaborating on the incest and shows nervousness and anxiety, as well as peevishness and anger, on being asked insistently about it (B. 5 and E. 1). She can talk a little about her mother, criticizing her, but cannot talk about their troubles as the causes and consequences of the traumatic event (D. 3).

Risk and Prognostic Factors The pre-, peri-, and post-traumatic risk and prognostic factors related to the development of PTSD, as indexed in the DSM-5 [9], all show important influence upon the character and the development of the story. The temperamental pre-traumatic factors are significant since the protagonist has been abused before the age of six (meaning “prior” traumatic exposition). The environmental pre-traumatic factors are equally important, as she comes from a low socio-economic status, has low level of education and she has been exposed to trauma and adversity during childhood (economic, social, and emotional factors). She also demonstrates reduced coping skills (until she starts at the “alternative school”). In addition, she is black and obese and presents a psychiatric familial history (Mary shows traits of an antisocial personality and a possible concomitant mood disorder [9], scenes: 4–6, 9, 12–15, and finally scene 17). Genetic and physiological factors such as being young and female also play a role. The environmental peri-traumatic factors, in this case, refer to the interpersonal violence (as the abuse has been perpetrated by her father) and the dissociation, which occurs during the trauma and persists subsequently [9].

The quality of the mother/daughter relationship represents potential post-traumatic factor. Temperamental factors influence the acute stress reactions in response to the complex relationship between them. Precious has very unproductive coping skills, low self-esteem, and negative evaluation of herself. Her mother shows great influence on her, especially during the first two-thirds of the movie. The environmental post-traumatic factors are evident in her being repeatedly exposed to reminiscences of the trauma (on a daily basis, when living with Mary). She also presents inconspicuous feelings of loss related to the abuse (such as the disappointment she expresses in scene 16—see Table 1—for having had her first sexual experience with her father and not ever having a boyfriend.). Almost all scenes that contain post-traumatic factors involve Precious’ mother. Scene 6 depicts an extremely violent fight between mother and daughter, in which Precious gets in touch which several aversive details of the traumatic event (criteria A. 1) as a result of Mary’s aggressive and unreasonable manner, verbal and physical attacks. Nevertheless, scene 8 is an example of other sources of post-traumatic distress: Precious is walking down the street and a group of young boys hassle and jostle her, calling her fat. They push her to the floor and she undergoes a dissociative experience (criteria B. 3) in which she appears to be happy, accompanied by a handsome and loving young man. Scene 9 implies that Precious may have been sexually abused by Mary too, as reflected in her obvious distress, shame, and vulnerability. In scene 12, Precious shows dissociative reactions, has a flashback regarding the sexual abuses, and her mother’s voice please a role in the background, as an amalgam of traumatic experiences. Subsequently, scene 13, in which Precious is exceptionally excited by the “alternative school,” Mary’s negative and pessimistic evaluations about Precious’ choices, behaviors, or conduct become very clear, especially when she announces that the girl “is good for nothing.” Mary is critical when talking about the money received from the Welfare (on Precious’ account) while ignoring Claireece’s happiness in discovering new coping and overcoming strategies. Scene 15 shows very clearly how the relationship between Mary and Precious itself is an acute stress factor (post-traumatic temperamental factor). The adolescent goes back to her mother’s house, after having been away for months, with baby Abdul in her arms. She is welcomed with great cynicism and violence. Mary, at first, appears to have accepted the grandson, but promptly shows her dissimulation and dissatisfaction, especially concerning the paternity of the boy. Furthermore, she blames Precious for her father’s incestuous acts (criteria A. 4) showing no degree of empathy or love toward the girl, throws objects in her direction in a kind of rampage.

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Finally, in scene 17, Mary makes several revelations most notably that she herself had witnessed sexual abuse perpetrated by father, Carl. These act as a major post-traumatic environmental factor.

Final Remarks DSM-5 criteria were used to analyze character Claireece Precious Jones and discuss parameters for PTSD, currently and broadly accepted among the psychiatrists worldwide [2–6], adding educational material to exemplify a theme poignantly discussed by the medical community [37–39]. However, when using films for educational purposes, one should be aware that commercial films are primarily made for entertainment and not education [2]. In this particular case, on the contrary, we found that signs and symptoms related to PTSD, as described by DSM-5 criteria, were not distorted or exaggerated by their cinematographic depiction, especially how the director chose to display the dissociative symptoms (as flashbacks and vivid dreams), which added cinematographic quality without losing conceivability. The film manages to show “inside the young girl’s vivid inner world”—her memories of sexual abuse, her fights at home, and her growing self-awareness [10]—as we listen to Precious’ thoughts as a voice-over, during many scenes. Language, either spoken or written, is a visceral sign tracing Precious’ limitations and, likewise, tracing her capability to overcome trauma, endorsing the association between PTSD and learning impairments, extensively confirmed through previous researches [32–36]. Nevertheless, differential diagnosis for PTSD must be considered with major depressive disorder, dissociative disorder, traumatic cerebral lesion, and psychotic disorders (see DSM5, Differential Diagnosis section, for all possible differentials) [9]. During the film and the 17 selected scenes, particularly in scene 7 and scene 10 (Table 1), Precious shows symptoms of anxiety, fear, anhedonia, and low self-esteem. That said, major depressive disorder is the most important differential diagnosis for PTSD, in this case, but authors agree that it appears most likely to be a co-morbid disorder—the character meets symptoms from clusters B, C, D, and E (depression does not enclose those symptoms [9])—suggesting that while PTSD is flagrant, major depressive disorder could be an overlapping diagnosis. Individuals with PTSD are 80% more likely than the general population to have symptoms that meet criteria for at least one other psychiatric disorder [9]. Other differential diagnosis for PTSD (DSM-5 criteria), regarding the protagonist Claireece Precious Jones, are dissociative disorders, traumatic brain injury, and psychotic disorders [9]. Even though dissociative amnesia and other conditions alike may or may not be preceded by a traumatic event, when PTSD criteria are fulfilled, subtype “with dissociative symptoms” should be considered firstly [9]. Likewise,

analyzing scenes 4, 6, and 15—see Table 1—in which Mary acts violently and hits Precious in the head, traumatic brain injury (TBI) concurrent to PTSD should also be considered, as post-concussive symptoms (irritability, concentration deficit, and headaches) may be acutely present, but neuro-cognitive symptoms such as confusion and disorientation [9] cannot be detected, supporting, nevertheless, a main background diagnosis of PTSD. Dissociative reactions and flashbacks/dream states (scenes 4, 6, 8, and 12—see Table 1) also suggest differential diagnosis with symptoms such as hallucinations and deliriums, typical of psychotic disorders, which could also be concomitant ailments to PTSD [9]. In summary, the film “Precious” cannot be seen with an unbiased approach, because it involves so many puzzling issues such as racial stereotypes, poverty, and the images of poverty, sexism, sexual abuse, incest, and the usual silence of the victims [10, 11, 14]. Screening the movie for larger audiences, study groups, psychiatry trainees, and such [2, 3] will be the next step perhaps leading to new results and broader conclusions. The analysis of the movie “Precious” according to DSM-5 PTSD criteria represents a high-quality material for teaching psychopathology and contributes to the study of “mainstream” cinema, used as a psycho-pedagogic tool. It may help readers, students, and teachers to create their own approach toward the theme presented. This material, in fact, can help in the discussion of the current diagnostic criteria for PTSD, including co-morbid disorders and developing potential therapeutic interventions. Acknowledgements If possible, to the reviewers. Compliance with Ethical Standards Ethical Considerations Non applicable. Disclosures Dr. Castaldelli-Maia receives Pfizer Independent Grant for Learning and Change (IGLC) managed by Global Bridges (Healthcare Alliance for Tobacco Dependence Treatment) hosted at Mayo Clinic, to support free smoking cessation treatment training in addiction/mental health care units in Brazil (grant IGLC 13513957), which had no relationship with the present study. Dr. Andrade is Executive President of the Center for Information on Health and Alcohol (CISA), which had no funding relationship with this project. All other authors have no conflicts of interest.

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