Dec. 20, 2010 -- Black Swan, a new psycho-drama anchored in the competitive world of ballet, is getting as much analysis on the psychiatrist's couch as it is Oscar buzz.
The Golden-Globe nominated film takes viewers deep into a ballerina's descent into madness in a frightening portrait of psychosis that doctors say resonates realism.
Nina Sayers, a fragile and repressed ballerina, played by Natalie Portman, strives for the lead in Tchaikovsky's "Swan Lake," a role that will require her to play both the gentle white and the seductive black swans.
But in the process, she will have to shed her "sweet girl" persona and embrace her darker side to fully embrace the role and to please her demanding and sexually aggressive director.
Her metamorphosis is so complete, that Nina eventually develops webbed feet, bird-like legs and sprouts feathers and wings to actually become the black swan.
"It was intense and disturbing and fascinating and mysterious," said Nadine Kaslow, vice-chair of the department of psychiatry at Emory University and psychologist to the Atlanta Ballet. "What was a hallucination and what was real? When people are psychotic, it's difficult, even as a therapist, to know what's real and what's not."
Nina, who constantly strives for perfection, lives with her controlling mother Erica, played by Barbara Hershey, who gave up dance to have her daughter. They live in a tiny New York City apartment, cluttered with her mother's narcissistic paintings.
When the ballet's artistic director decides to replace the aging prima ballerina for the new season production of "Swan Lake," Nina is his first choice. But she has competition in new sexually open dancer Lily, played by Mila Kunis.
After securing the role, Nina is asked to "lose herself" to play the black swan, and so she does.
In visual hallucinations, she sees a black-clad version of herself across the subway platform and again in the maze of hallways at Lincoln Center. Even the pink stuffed animals that adorn the bedroom she shares with her neurotic mother seem to come alive and mock her.
She conjures up an array of fantasies and delusions, including a lesbian love scene with Lily.
"As a movie fan, it held my attention," said Dr. Steve Lamberti, professor of psychiatry at University of Rochester Medical Center. "It was poetic in a way, showing this transformation gone wrong."
But speaking as a psychiatrist, Lamberti said the film did not accurately depict schizophrenia, as has been widely speculated, but "does present a reasonable portrait of psychosis."
"People tend to be scared of things they don't understand," he said. "If you have never treated or observed a person with psychosis, it's upsetting."
Psychosis is a loss of contact with reality that usually includes false beliefs or delusions, and seeing or hearing things that are not there.
Like a fever, psychosis is a symptom rather than a disease, and can be caused by a variety of triggers: exposure to mercury (the hats of the Mad Hatter were impregnated with the heavy metal), drugs like amphetamines, epilepsy, a brain tumor, dementia or psychiatric disorders like schizophrenia.
Psychosis Usually Involves Auditory Hallucinations
But unless psychosis is due to neurological causes, patients normally have auditory, rather than visual hallucinations.
"In terms of cinematography, it's much easier to portray the visual," he said. "Whispers are not nearly as dramatic as seeing something."
Several risk factors may have made the fictional Nina susceptible to psychosis if she had a genetic vulnerability, said Lamberti.
"Natalie Portman's character was involved in a highly stressful competition, she had conflicted relationships with her mother and with her understudy, and she was the object of sexual advances by her director," he said. "Any one of these issues alone would be stressful, but experiencing all of them at once could be emotionally devastating, particularly for a young woman who is somewhat naïve and sheltered."
Ecstasy, a powerful hallucinogen that Nina and Lily take in one libidinous scene, can also trigger a psychotic event.
Lamberti also suggests that the repeated vomiting and weight loss in the days leading up to her final performance may have caused an electrolyte disturbance that could have contributed to the psychosis.
The film took liberties with a host of anxiety disorders: anorexia, bulimia, cutting and obsessive compulsive disorder (OCD) -- most of which would not all appear together, say psychiatrists.
Nina is meticulous about preparing her slippers, lining up the make-up in the dressing room and washing her hands at each turn. Viewers see hints of anorexia as she stares at a simple pink grapefruit for breakfast and turns away the fatty cake her mother buys to celebrate getting the coveted role.
Nina also makes frequent bulimic trips to the bathroom to throw-up. Her scratching and cutting is hardest to watch - blood oozes from her fingers as she rips off old scabs.
Director Darren Aronofsky has a "wild imagination, according to Jonathan Abramowitz, associate chair of psychology at the University of North Carolina at Chapel Hill, who specializes in obsessive compulsive and anxiety disorders.
"It would be fairly rare to have a psychosis and an eating disorder," he said. "People in psychosis are not in touch with reality. With eating disorders and OCD, they are too in touch with reality."
Psychosis Usually Involves Auditory Hallucinations
Psychosis, particularly in schizophrenia, involves negative symptoms, as patients start "slipping away from contact with reality," said Abramowitz. "They don't care about social interactions and what they look like and speech starts to deteriorate. It's the polar opposite with anxiety disorders and OCD."
Those disorders abound in the dance profession, according to ballet psychologist Nadine Kaslow, who continues to perform and teach.
"The world of ballet is intensely competitive," she said. "They over-exercise and eat very little. Anorexia and bulimia are extremely common. It's not as rampant as it was 20 years ago when we saw people get sick and die. But there is still a lot of controversy over how thin you should be."
Cutting is occasionally seen and substance abuse, particularly with drugs that help the dancer lose weight or keep up energy, is widespread.
"It's all about perfection and you can never be perfect," said Kaslow. "But the demand for it is off the charts."
The exploration of bisexuality was also on point in the ballet world, where men are often gay and where women's physiques are more childlike.
"The ballet world gives you such a message to look like a child," she said. "They are pretty flat-chested and they look like kids. The notion of being sexual or being a woman -- it's not uncommon to struggle with that.
But could Natalie Portman's character have carried off the demanding ballet performance in a psychotic state? Doctors say it would have been "unlikely."
"Psychosis usually interferes with a person's ability to function," said psychiatrist Lamberti. "However, artists and musicians have been known to perform despite the presence of psychosis. For a dancer who is trained to cope with pain and other distractions, it might be possible to perform in a psychotic state depending on the severity of the psychosis.".
"It may be possible for them to cope to an extent at a pretty high level, but it's not typical," he said. "Still, human resilience is remarkable."