Who is Joker?
The explanatory paragraph via Wikipedia:
Image: Joker (source DC)
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1. Does the situation meet the FDA Blackbox warning rule: ‘BEHAVIOUR THAT IS UNUSUAL?’
What caught my attention (*spoiler): In the first comic that Joker featured in, Batman #1, Joker features twice.
In the first part Joker manages to commit the following crimes:
Hijacking
Threaten to Kill (1x count)
Break & Enter (3x counts)
Theft (2x counts)
Assault – 1st Responders (2x counts); Batman (2x counts); Robin (1x count); Civilians (2x counts during toxin testing on random civilians)
Murder (Henry Claridge d. 1940, poison)
Murder (Jay Wilde d. 1940, poison)
Murder (Brute Nelson, Mob Boss d. 1940, poison)
Murder (Judge Drake d. 1940, poison)
He then gets caught by Batman trying to steal the Cleopatra Necklace but escapes two days later. He then commits the following crimes:
Prison Escape
Threaten to Kill (1x count)
Theft (2x counts)
Assault – 1st Responders (4x counts); Batman (1x count); Robin (1x count)
Murder (Police Chief Chalmers d. 1940, poison)
Murder (John Doe d. 1940, not disclosed, most likely poison)
Murder (Edgar Martin, Political Reformer d. 1940, poison)
This comic was penned in 1940. In 1998 a US federal law defined serial killings as:
The term ‘serial killings’ means a series of three or more killings, not less than one of which was committed within the United States, having common characteristics such as to suggest the reasonable possibility that the crimes were committed by the same actor or actors.
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2. Was the person(s) exposed to antimalarials. If YES… what type, duration and were there multiple exposures?
It was technically possible in 1940 and his alternate back story featured a vat of anti-psychotics in 2007
In most of his back stories, Joker falls into a chemical vat or swims through toxic waters. One chemical being developed during that time period was Mepacrine. Otherwise known by its brand name Atabrine it was developed in the early 1930s and used during World War II to combat malaria. It had awful side effects including toxic psychosis and was replaced by chloroquine after the war. He might have fallen in that.
Fast forward to the new Millennium and in the 2007 Batman Confidential retelling, Joker gets kidnapped by a mob crew, tortured and thrown into a vat of anti-psychotics. Page 6:
Image: ‘Jack’ getting tortured prior to ending up in a vat of anti-psychotics and becoming Joker (source: Batman Confidential, Dec-07)
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3. How was the person(s) mental health?
AWFUL
Valentin Yurievich Skryabin wrote the piece that Google quotes when you ask it what mental health issue Joker suffers from. In his 2021 paper ‘Analysing Joker: an attempt to establish diagnosis for a film icon’ he diagnoses Joker with pseudobulbar affect (often caused by a TBI), personality disorder and antisocial disorder. An excerpt:
Although Arthur's disease remains unspecified throughout the film, we can make some conclusions if we take a look at Joker's symptoms and mental condition throughout the film. During the therapy sessions, Arthur describes his complaints as loneliness, isolation and ‘constant negative thoughts’. An entry in his notebook states that ‘the worst part of having a mental illness is that people expect you to behave as if you don't’. We know that the character attends therapy sessions for a long time and that he is prescribed several psychotropic medications. He even had sufficient insight to say, ‘I need my medication to be increased’. Unfortunately, we have very little information on his family history since he was abandoned as a child. His foster mother has delusional disorder and probably a personality disorder and she underwent in-patient therapy. Arthur was brought up by a foster mother and did not have a father figure. The foster mother herself describes him growing up as a fun and kind boy, but later he was abused and beaten by his adoptive parents and even had a severe head injury. Thus, we can find a number of risk factors for mental disorders in our fictional patient's case history.
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4. Were there any confounding variables?
YES (just the 2019 Todd Phillips Joker/Arthur Fleck version)
Mother/Father issues: We all have them.
Mental Health stigma: Everyone talks about RUOK but the scene on the bus sums up with what life is like is you suffer from severe mental health issues, and you live in poverty.
Complex PTSD: Arthur has an extremely traumatic childhood including torture and sexual assault.
Possible amnesia? The older Arthur also has few memories of his childhood. Most likely blocking traumatic events but does he have amnesia?
Long periods on pharmaceuticals: In the 2019 movie Arthur requests to ‘up his meds’ to which his case worker responds in surprise as he already is on ‘seven meds already’.
Note: Todd Phillips Joker is a great educational tool, even if it starts a discussion. A quote from Dr Skryabin’s paper:
Furthermore, doctors Annabel Driscoll and Mina Husain wrote in an opinion piece for The Guardian soon after the film's release, ‘Severe mental health conditions, such as psychotic illnesses, remain shrouded in stigma and are consistently misrepresented and misunderstood […] Portrayals of mental illness in film can perpetuate unfounded stereotypes and spread misinformation’. Meanwhile, British neuro-criminologist Adrian Raine was impressed by how accurate the film's depiction of the psychology of a murderer was. In an interview with Vanity Fair, he described it as ‘a great educational tool’ and stated that he planned to present film clips during his classes.
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5. Was there a specific trigger?
YES. In every iteration of Joker, there is always a trigger
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6. Other considerations?
YES
Antimalarials can also make you turn funny colours including blue and yellow
DermNet states the following about drug-induced pigmentation. Excerpt:
Drug-induced pigmentation is a change in skin pigmentation due to a change in melanin synthesis, or the accumulation of drugs or their metabolites in the skin.
Common causes include chemotherapy, antimalarials, and nonsteroidal anti-inflammatory drugs. Hyperpigmentation is more common and results from the deposition of melanin or the implicated drug in an uneven manner, while hypopigmentation develops from melanin deficiency.
Drugs are responsible for 10–20% of acquired hyperpigmentation. Other causes include sun damage, hormonal changes, or inflammation.
Image: Pigmentation of the tongue from hydroxychloroquine administration (source: DermNet, 2023)
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ASSESSMENT
The Joker remains UNCLASSIFIABLE but… POSSIBLE (as likely as pseudobulbar affect)
I’ll leave the last line for the man himself…
Image: Joker (source DC)
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REFERENCES
Batman Fandom (2024) Batman (1940-2011) #1 [https://batman.fandom.com/wiki/Batman_Issue_1] Page accessed 3.06.2024
DC (01.12.2007) Laughing Matters! The Joker: Day One! [https://www.dcuniverseinfinite.com/] Batman Confidential. Burbank, California, USA
DermNet (01.06.2023) Drug-induced pigmentation [https://dermnetnz.org/topics/drug-induced-pigmentation] Page accessed 3.06.2024
Grand Comics Database (2024) Batman #1 [Cover Number with Period] [https://www.comics.org/issue/724/] Page accessed 3.06.2024
Joker (2019) Warner Bros. Pictures. Burbank, California, USA
Manness, D (19.10.2018) Which Version of The Joker Is the Most Psychotic? [https://www.cbr.com/psychotic-versions-of-the-joker/] CBR. Page accessed 3.06.2024
Mithaiwala, M (11.07.2016) The Complete History of The Joker [https://screenrant.com/complete-history-of-the-joker/] Screenrant. Page accessed 3.06.2024
National Center for the Analysis of Violent Crime (2.09.2005) Serial Murder [https://www.fbi.gov/stats-services/publications/serial-murder] FBI. Page accessed 3.06.2024
Sager, J (22.05.2023) 150 Joker Quotes To Make You Appreciate the Madness and Put a Smile on That Face [https://parade.com/1231125/jessicasager/joker-quotes/] Parade. Page accessed 3.06.2024
Skryabin V (1.12.2021) Analysing Joker: an attempt to establish diagnosis for a film icon [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8727382/] BJPsych Bull. DOI: 10.1192/bjb.2020.146. PMID: 33407973; PMCID: PMC8727382.
The Dark Knight (2008) Warner Bros. Pictures. Burbank, California, USA
Tickell-Painter M, Saunders R, Maayan N, Lutje V, Mateo-Urdiales A, Garner P (2017) Deaths and parasuicides associated with mefloquine chemoprophylaxis: A systemic review. Travel Medicine and Infectious Diseases. DOI: 10.1016/j.tmaid.2017.10.011
Wikipedia (2024) Joker (character) [https://en.wikipedia.org/wiki/Joker_(character)] Page accessed 3.06.2024
Wikipedia (2024) Mepacrine [https://en.wikipedia.org/wiki/Mepacrine] Page accessed 3.06.2024
Wikipedia (2024) Quinism [https://en.wikipedia.org/wiki/Quinism] Page accessed 19.01.2024