In Joker (2019), Todd Phillips offers a portrait of mental illness that is raw, uncomfortable, and fiercely debated [1,2]. Beneath the makeup we meet a man unravelling; not just because of what’s within him, but because of what surrounds him. So, what if we stopped seeing Arthur as a villain and instead, looked at him as a patient?
This article adopts a clinical gaze; not to simply reduce Arthur to a diagnosis, but to explore how trauma, poverty, and neglect manifest as psychiatric symptoms.
Through psychiatric frameworks and diagnostic criteria, we examine Arthur’s symptoms, history, and risk profile. But more importantly, we interrogate the care structures that fail him, drawing uncomfortable parallels with real-world mental health gaps, exploring how fragmented services, chronic underfunding, and stigma create the perfect storm for tragedy.
Clinical Portrait of Arthur Fleck: A Case Presentation
Presenting Complaint
Arthur presents with episodes of uncontrollable, socially inappropriate laughter. He reports increasing isolation, delusional thoughts, and low mood. He also demonstrates signs of thought disorder and poor emotional regulation, with a clear deterioration in function across social, occupational, and psychological functioning.
History of Present Illness
Arthur’s symptoms appear chronic, with longstanding difficulties in emotional regulation and social interaction. He displays persecutory ideation, marked anhedonia, and feelings of worthlessness.
He also exhibits psychotic symptoms, including fixed false beliefs and likely hallucinations. A notable example is an entirely fabricated romantic relationship with a neighbour, which he later realises was a delusion. He also demonstrates delusional ideation and displays grandiose behaviour when appearing on live TV.
There are multiple episodes of reactive and escalating violence. He brings a firearm into a children’s hospital, stalks individuals, and ultimately commits homicide. These acts often appear dissociative, with reduced emotional response or awareness of consequence.
Past Psychiatric History
Arthur is prescribed psychotropic medication but is unaware of what he’s taking. He is under the care of a state-assigned social worker and appears to have received limited, poorly coordinated mental health support. His clinical records are sparse, and no definitive diagnosis is documented.
Social / Childhood / Forensic History
Arthur’s upbringing was marked by profound trauma. Abandoned as an infant, he was adopted by a woman later diagnosed with delusional psychosis and narcissistic personality disorder. She was institutionalised in Arkham State Hospital and found guilty of endangering Arthur as a child.
Arthur was subjected to prolonged abuse and neglect by his mother’s ex-partner, with documented malnutrition, physical trauma, and a severe head injury sustained during early childhood
He currently has no support network, is chronically unemployed, and lives in poverty. He serves as the sole carer for his mother, adding to his emotional burden.
His forensic history includes possession of a weapon, stalking, and multiple episodes of violence—often reactive or dissociative in nature.
Risk Assessment
Arthur poses escalating risk to both himself and others. He has poor insight, reports suicidal ideation, and demonstrates a delusional framework. His past trauma, social instability, and lack of support amplify this risk.
His laughter further ostracises him, feeding into a vicious cycle of shame and alienation. His belief that, “the worst part of having a mental illness is people expect you to behave as if you don’t”, reflects both internal distress and the systemic invalidation he experiences.
Impression
Arthur Fleck is a vulnerable individual with probable chronic psychotic illness, complex developmental trauma, and significant psychosocial deprivation. His high-risk profile is exacerbated by inconsistent engagement with services, neurological comorbidity, limited insight, and severe social instability.
Differential Diagnosis & Clinical Discussion
Arthur Fleck is a vulnerable individual with probable chronic psychotic illness, complex developmental trauma, and significant psychosocial deprivation. His high-risk profile is exacerbated by inconsistent engagement with services, neurological comorbidity, limited insight, and severe social instability.
Pseudobulbar Affect
Pseudobulbar Affect (PBA) is a neurological condition characterised by involuntary, sudden and inappropriate episodes of laughing or crying that are incongruent with the underlying emotional state [4]. This is due to disruption in corticobulbar pathways regulating emotional expression, often secondary to neurological injury or neurodegenerative disease [5].
From the film’s outset, Arthur displays frequent jarring paroxysms of laughter often at socially inappropriate moments. Crucially, these laughing fits are incongruent with his internal state; his face contorts, his breathing becomes erratic, and his laughter is often followed by visible distress or tears. This suggests that these behaviours are physiologically intrusive, not voluntary.
In Arthur’s case, it is possible that PBA may have occurred secondary to traumatic brain injury experienced in his childhood. Trauma to areas such as the prefrontal cortex or brainstem can impair emotional regulation pathways, resulting in disinhibited affect [6]. Several studies have shown that traumatic brain injury elevates the risk of developing mood disorders and personality changes [7,8] thereby supporting this potential diagnosis. Furthermore, patients exhibiting pathological laughing and crying have been shown to display significantly poorer social functioning and aggressive behaviours [9].
While PBA alone does not explain his complex psychopathology, it illustrates the interplay between brain injury and psychiatric vulnerability. His laughter is not comedic but tragic; a visceral reminder of how neurological dysfunction can distort emotional communication and amplify isolation. In Arthur’s world, laughter becomes a kind of scream—a symptom no one hears, until it’s too late.
Schizoaffective Disorder
Schizoaffective disorder is defined by the presence of both psychotic symptoms (e.g., delusions, hallucinations, disorganised thinking) alongside mood episodes, either depressive, manic, or mixed. These must occur simultaneously or in close succession with psychotic symptoms, as well as independently of mood episodes [10,11]. It occupies a diagnostic space between schizophrenia and mood disorders and is consequently often misclassified [12].
Arthur exhibits persistent psychotic features throughout the film. He experiences grandiose delusions, imagining himself as a beloved comedian, and believing he has been personally invited onto The Murray Franklin Show [3]. These beliefs are not fleeting fantasies and rather guide his actions and shape his sense of identity. Additionally, Arthur shows signs of thought broadcasting; he sees himself being applauded on live television, blurring the line between fantasy and perception. These moments reflect a collapse of ego boundaries, a hallmark of psychosis [13].
Arthur’s relationship with his mother adds further diagnostic nuance. Their shared delusion that Thomas Wayne is Arthur’s father borders on folie à deux—a rare but documented condition where delusional beliefs are transmitted within a close relationship [14]. Studies show that such shared psychoses often occur in such highly enmeshed and co-dependent relationship [15] and could possibly indicate that such a dynamic fuelled Arthur’s identity confusion.
In addition to psychosis, Arthur exhibits severe depressive symptoms, including persistent low mood, anhedonia, hopelessness, and suicidal ideation. Notably, his psychotic features persist during periods when his mood appears stable, suggesting that the two symptoms are not entirely mood congruent. This temporal separation between affective and psychotic symptoms is a defining characteristic of schizoaffective disorder and helps distinguish it from major depressive disorder with psychotic features or bipolar disorder [10].
This separation of mood and psychosis, their coexistence and relative independence, make schizoaffective disorder a compelling diagnostic possibility. While the film resists psychiatric labels, Arthur’s narrative aligns disturbingly well with the lived reality of those who suffer from this severe and isolating condition. He is, in a sense, a man torn between delusion and despair—his mind unravelling in parallel with a world that refuses to see him clearly.
The System is Broken: Mental Health in Gotham and Beyond
Arthur Fleck’s deterioration wasn’t the result of a few bad days. It was the slow bleed of structural abandonment; the weight of generational trauma pressing down on someone no longer able to carry it. So where were the systems that were meant to keep him safe? Arthur is not just a case study in psychosis. He’s a case study in neglect — of healthcare, of social care, of society.
Overmedicated, Under-Supported: The Cost of Quick Fixes in Mental Health
Arthur Fleck’s treatment consists of multiple psychotropic medications, prescribed with little explanation and no visible review. He even requests for an increased dose; a plea accentuating both his desperation and the system’s one-size-fits-all approach to suffering. While Arthur attends therapy sessions, they are perfunctory at best. His pathological laughter, history of childhood abuse, and emotional volatility go completely unaddressed.
This is not care. It is symptom control.
In underfunded services, masking distress often takes precedence over understanding it. Psychopharmacology becomes the fastest and cheapest solution. Arthur’s experience mirrors a growing trend in the NHS; overmedication in the absence of holistic or trauma-informed care.
In 2023/24, 89 million antidepressant items were prescribed to 8.7 million patients, a 34.8% increase from 2015/16 [16]. Meanwhile, only 63.1% of adults discharged from psychiatric inpatient care in April 2024 received a follow-up within 72 hours, down from 71.3% the previous month (Figure 1) [17]. This is despite NICE guidelines recommending contact within 48 hours [18]. These trends reflect growing pressures on community mental health services and potential risks for early relapse and readmission.
Figure 1.Proportion of patients followed up within 72 hours of discharge from psychiatric inpatient care in England (June 2020 – April 2024) [17]. This graph shows the percentage of psychiatric inpatients who were followed up within 72 hours of discharge, as monitored against the national operating standard target of 80% (red dashed line). While performance remained relatively stable between 2020 and early 2023, a sharp decline is observed from late 2023 onwards, with follow-up rates falling below 65% by April 2024.
When systems are overstretched, therapy is sidelined. Review is delayed. Continuity vanishes. The result? Patients are stabilised temporarily, discharged prematurely, and returned to crisis again and again. Arthur’s decline reflects the real-world “revolving door” of modern psychiatry: short bursts of intervention with no long-term support [19]. Without consistent person-centred care, the system fails to heal — it merely postpones collapse.
A Perfect Storm: How Underfunding Breaks Mental Health Systems
Gotham’s mental health infrastructure is collapsing; disappearing social work programmes, bureaucratic indifference, and abrupt funding cuts create a perfect storm of neglect. Arthur loses access to his medication overnight. No referrals, no follow-up, no safety net. His descent into delusion and violence accelerates soon after.
In the UK, Community Mental Health Teams are buckling under pressure. Demand has surged, but resources have not kept pace. As of June 2024, vacancy rates in mental health nursing stand at 14.3%, and consultant psychiatrist vacancies at 15.1%—more than double the average NHS vacancy rate [20]. These gaps aren’t just numbers; they translate to longer waits, fewer follow-ups, and overworked staff unable to provide consistent care.
Furthermore, mental health’s share of the NHS budget is projected to fall from 8.87% in 2022/23 to a projected 8.71% by 2025/26, amounting to a shortfall of £300 million [21]. This comes at a time when over 1.6 million people are on waiting lists for mental health services [21].
Despite accounting for over 20% of the UK’s disease burden, mental health receives less than half the funding it would need to achieve parity with physical health [21]. The result is a system that can’t offer early intervention, can’t guarantee continuity, and too often can’t respond until crisis hits.
Arthur’s descent is not the result of a single decision. It is the end point of chronic underinvestment. His story is a reminder that untreated mental illness is not just a personal tragedy. It’s a policy failure with human consequences.
Childhood Trauma Isn’t Left Behind
Arthur’s suffering began in childhood. His history of physical abuse, neglect, and life with a mother suffering from untreated delusions isn’t just tragic; it’s a textbook representation of Adverse Childhood Experiences (ACEs), which are among the strongest predictors of long-term mental illness [22].
Research shows that individuals with four or more ACEs are over ten times more likely to experience serious psychological distress [22]. But trauma doesn’t just haunt memory; it reshapes development. It rewires brain circuitry, setting the stage for long-term emotional volatility, mistrust, and hypervigilance.
According to Maslow’s hierarchy of needs, human flourishing depends on foundational experiences of safety, stability, and love (Figure 2) [23,24]. Arthur had none. With his most basic physical and emotional needs unmet, the psychological scaffolding for trust, self-worth, and belonging was never built.
Figure 2. Maslow’s Hierarchy of Needs. This model outlines the layered structure of human psychological development, from basic physiological needs to higher growth states. It highlights how early deprivation of safety, love, and stability undermines the foundation for mental well-being [24].
The tragedy isn’t simply that Arthur was traumatised. It’s that no one intervened, not in his childhood nor in his adult life. His collapse may not be a personal failure. Rather, the result of lifelong neglect, compounded by a world that looked away.
Arthur Fleck may be fictional, but his suffering is not.
He is a man failed by almost every system—childhood abuse, social neglect, fractured care. Joker dares us to look beyond violence and see the vulnerable. In medicine, it’s easy to define patients by what they do. But sometimes, those we label as dangerous were first victims themselves.
Diagnosing Arthur is not about condoning his actions but about understanding the deep fractures beneath them. His story is an uncomfortable reminder of the devastating consequences of social deprivation, unprocessed trauma, and disintegrating care.
In the end, Arthur Fleck is not merely a tragic figure. He is a mirror reflecting the consequences of when trauma meets indifference, and when systems designed to care forget to listen.
References
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