The Girl with the Dragon Tattoo - a review for healthcare staff

(See what the International Movie Database says about The Girl with the Dragon Tattoo)

Please note: This article may spoil your spontaneous enjoyment of the film. A number of significant events are revealed, so if you want to watch the film without preconceptions, we advise you to read the article after watching the film.

SUBJECT:
Coping with the unbearable
– how a functional disorder can be a salvation

By Lars Häggström, Specialist in psychiatry, Affecta Psychiatric Clinic, Halmstad, Sweden

Travelling to Arlanda Airport in a taxi, I am accompanied by an Italian psychiatrist. We talk about Sweden and Italy. He has opinions about Zlatan Ibrahimovic's temperament, at least during his time in Italy: how Zlatan was probably not particularly popular with his teammates because he was too selfish with the ball (and still is, according to my Italian colleague), but that he was occasionally dazzling on the pitch, perhaps precisely because of his often impetuous temperament.

My colleague then brings up another public example, with no other comparisons with to Zlatan: Diego Maradona, and his heyday as a football player. The fact that Maradona used cocaine during his playing days is no secret. His television interviews were occasionally pretty spectacular, and it was easy to imagine – without any particular psychiatric training – that the star was close to a manic outburst.

Maradona was subsequently treated with a neuroleptic medication that caused him to put on so much weight that it almost cost him his life. A Cuban psychiatrist halted this treatment and gave him the ADHD medication that he needed. Maradona lost most of the weight he had put on, and ended up becoming coach of Argentina's national team. But nobody thought quicker than him on the field. Many defenders have ended up despairingly sprawling on the grass simply because they were not able to keep up, either with their thoughts or their legs.

Then we started talking about literature. My Italian colleague observes that Stieg Larsson's books are selling like never before in Italy and then there are the films, of course. Why is that so? Why is this particular criminal psychology series breaking records when it comes to capturing the attention of so many Italians as well as Swedes, Germans, French and Spaniards, as and their mental time and energy. What is it that attracts us? Who attracts us? We have now arrived at Terminal 2 at Arlanda. My Italian colleague climbs out of the taxi, leaving a misty November Stockholm with a certain amount of relief. He closes the door just as a question travels through the taxi cab.

"Diego Maradona and Lisbeth Salander: what do they have in common?"

I do not think this thought. It is just suddenly there in the car.

""We can always be surprised at a person's apparent complete inability fundamentally to understand and empathise with his victims' emotions"

The film "The Girl with the Dragon Tattoo", and the two sequels, are well-made psychological thrillers about a reality that could be feasible. There is probably nobody who doubts that a Swedish financial family, with or without a shipping company, might have had a past with Nazi sympathisers during the war and a hidden family secret. This was the case in many Swedish families, even those far below the richest classes, in the years just before and during the Second World War.

Martin Vranger himself is not a particularly surprising figure either. His personal disorder – as a psychopathic serial murderer with bizarre and violent sexual inclinations – is described in forensic psychiatry literature, in criminal history and in numerous films. We can always be surprised by a person's fundamentally apparent complete inability to understand and empathise with his/her victims' emotions, or at least to be touched by some of their feelings.

His level of intelligence may be normal, or even above average, but almost completely lacks empathy. This personality type can not only be explained by previous traumas and learned behaviour from an equally disturbed father. A natural – genetic – inability intuitively to feel the feelings of others, in combination with a lack of love and role models, must form the basis for compulsive and destructive sexual habits being realised in such a macabre way.

The idea of a lawyer sexually exploiting a young woman for whom he is the guardian is not impossible either. You only have to look in the daily press to have that confirmed. Not so long ago this was carried out by a chain of men in Stockholm, several of whom had good professions and were "respected" in society, who systematically exploited young women.

There are probably several psychiatric diagnoses among these men, as well as more normal psychological traumas at an early age, resulting in a culture where sex – via the media, television or the Internet – is often not synonymous with, but rather the opposite to, closeness and understanding.

Selecting a journalist as the main investigator instead of a police officer is a clever, less predictable narrative device. It is suddenly easier for the viewer to imagine Mikael Blomqvist's way of thinking and acting. Mikael Blomqvist is a kind of innocent Jan Guillou, without the hunting rifle on his back and without the need continually to emphasise cultural male attributes. He is more openly vulnerable, less easily offended and at the same time honourable. He is well-chosen as a lead character and not impossible to imagine as a real person.

However, it is hardly these roles, though well portrayed they are in the film, that have made Stieg Larsson's books, or the films, into the public success they have become. There has to be another factor – and that factor is called Lisbeth Salander.

Lisbeth Salander exists in a world that is believable. She is vulnerable and damaged from an early age by an almost total absence of care and role models. Her father displayed clear psychopathic elements, which are clearly described in the second film, and her mother was unable to defend both herself and her daughter. Her brother has a severe autistic disorder, which is clearly evident in the later films.

In this world, Lisbeth Salander is alone and different, with clear difficulties in behaving "correctly" in social contexts. She is bisexual and finds it difficult to trust men, apart from the obese computer hacker friend in the dark cellar and gradually the innocent Mikael Blomqvist.

With her background, Lisbeth Salander ought to be an outcast, anxiety-riddled, depressed and with social phobic tendencies, perhaps with an ongoing addiction. She ought to be cognitively disturbed, with difficulties in seeing connections in the adult world that failed her from an early age.

If, in psychiatric terminology, she had only had the more difficult to grasp diagnosis of "Personality disorder", that would have been the case. She would have been in the intermediate group between psychiatry and social care, about which governmental studies are continually being carried out while one person after another founders.

But that is not where she is. She has a disorder, but she is smart. She has difficulties in interacting, but is razor-sharp in her contacts when necessary. She is calculating, ice-cold, a genius when it comes to computers and tangible. And it is these characteristics that save her.

"She would have been in the intermediate group between psychiatry and social care, about which governmental studies are continually being carried out"

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Asperger's syndrome

In the middle of the 1940s, at the same time as Dr Leo Kanner at John Hopkins University in the USA was describing the concept of autism for the first time after studies of eleven children, Dr Hans Asperger in Austria described a syndrome in higher functioning individuals with autistic characteristics.

The syndrome became little known outside of Germany, partially due to the war and the limits placed on scientific exchange during the post-war years. The debate on the concept of autism may also have contributed, as the more prominent psychoanalytical interpretation via Bruno Bettelheim had considerable influence during the 1950s, 1960s and 1970s. According to this theory, autism was a form of child psychosis that was best cured with psychoanalytically-oriented therapy.

It was not until the start of the 1980s that Dr Loma Wing published various case studies where she referred to as Asperger's syndrome. This was described as a type of high-functioning form of autism and diagnosis was included in ICD-10 in 1992 and in DSM-IV in 1994.

The diagnostic criteria were summarised in brief in accordance with points 1-6:

The cause of Asperger's syndrome has been sought in several areas. There is probably now no dispute that the condition, like other forms of autism, has hereditary components. French researchers have identified chromosome 22 as a possible reason. Others have looked more specifically at brain function and structural differences in the cerebral cortex, the amygdala and the hippocampus, as well as at the serotonin synapses in the cerebellum and differences in the turnover of several neuropeptides.

Simon Baron-Cohen has proposed a theory about a disruption in the empathising-systemising process. According to this theory, the "female" brain would be better connected for empathy, while the "male" brain would be better connected for understanding and building systems. Asperger’s syndrome would then be a more extreme form of the male brain.

There are also some who consider that Asperger's syndrome should not necessarily be viewed as a disorder, and definitely not an illness. One of the reasons for this is that a "disorder", like most personality traits, has its advantages and its disadvantages. Those who are mentioned as possibly having had Asperger's syndrome include Albert Einstein, Isaac Newton, the philosopher Ludwig Wittgenstein and several Nobel Prize winners, as well as the singer Michael Jackson and Satoshi Tajiri, the creator of the Pokémon series.

The treatment of Asperger's syndrome has to be governed by the degree of reduced functional capacity and the suffering of the individual.

Knowledge about the condition through education is of the utmost importance, as are cognitive behavioural therapy training programmes in order to improve the capacity for social interaction, if this is required. If the functional disorder ADHD exists at the same time, it can be treated pharmacologically, as can depressive or anxiety-related symptoms.

1. Qualitatively reduced capacity for social interaction,
2. Limited, repetitive and stereotypical behavioural patterns, interests and activities,
3. Significant reduction in functional capacity in important respects,
4. No significant delay in general language development,
5. No significant delay in cognitive development, such as curiosity about the surroundings, or in the development of age-appropriate everyday proficiencies or adaptive behaviour (apart from social interaction) during the first three years of life.
6. The symptoms cannot be explained better by any other specific, radical developmental disorder, or by schizophreni

continued from above...
So does Lisbeth Salander have Asperger's syndrome? Is it this that saves her from destruction? Is this the actual precondition for her survival and her remarkable talent for keeping her razor-sharp analytical capabilities alive, even in situations where, from a human perspective, she ought to have reacted with anxiety and fear?

Her inability or uncertainty in close relations and in more intimate human interaction is well described and understood by the director. In the scene where she seduces the still rather awkward, innocent Mikael Blomqvist, she quickly leaves the bed after the act. She does not understand his surprised question regarding why she is leaving.

Her sexuality, the most intimate characteristic, is also made tangible, although we can imagine a different type of longing for closeness about which she mostly seems confused.

When at the end of the first film, Martin Vranger drives off the road and is hanging upside-down in his car, at risk of burning to death, she can save him, which she does not. She stands almost coldly and watches his appeals. She lets him die in the explosion, and does not understand the question when Mikael Blomqvist points out that he would never have done that.

"He was a rapist and a murderer," observes Lisbeth.

An eye for an eye - tangible, but not acceptable in a society governed by the rule of law, however great Martin Vranger's guilt is. But she wins our sympathy. Would we have done the same? When Mikael Blomqvist stresses that it would not have been his choice, but that he understands her decision based on her background, this is the first – and the only time in the series – that she is able to show closeness.

"Thank you."

And her hand briefly seeks his. Not even in the last film, when everything is over and she is freed by the court and obtains redress, is she able to say thank you. She goes home to the loneliness she knows best, while the entire editorial team at Millennium celebrate with champagne.

My experience of people with Asperger's syndrome, whether they are considered to have had a "long-term mental disability" or they work and occasionally hold various managerial positions, is that they have often been treated for several different symptoms – depression, tiredness, anxiety, sleep disorders – without great effect.

Over the years they have undergone psychotherapy to look for "early traumas", or they have taken several different types of psychotropic drugs, usually resulting in side-effects. When we give the condition a name and state the symptoms precisely this kind of relief arises, occasionally, in the form of some sort of closeness.

"So that's the way it is. Thank you. Now I understand better."

Lisbeth Salander lives at the margin of what is and is not allowed. She is not afraid to move freely between various legal, ethical or moral boundaries. When she does this, she asks questions: was it right to let Martin Vranger burn to death? Was it right at the end of the series to tip off a motorbike gang about where her autistic brother was to be found, so that they could kill him? Was it right to tie up her rapist guardian and to insert a dildo in his rectum, and then to put a tattoo on his body stating that he was a rapist. Would we have done that? But it is certainly fascinating that she does it. After all, we would also have wanted to, would we not?

Lisbeth Salander stretches the boundaries and at the same time reinforces her position as an outsider. With her mild autistic traits she maintains a vitality and tension throughout the trilogy. She dares to do the things nobody else would dare to do. Her Asperger's-like condition is her salvation. It is her we are fascinated about. She is the queen of the sales figures.

She and Maradona. They became what they became, not despite, but rather because of their disorder. They coped with the deficiencies they were born with and these became preconditions for their lives. That is remarkable.

But my Italian colleague has disappeared into the sea of people. He just had time to say something about Prime Minister Berlusconi's diagnosis, and is perhaps not receptive to theories about the benefits that a functional disorder can provide.