Yoda: Teaching Differential Diagnosis, I Be Good For

Assuming that Yoda’s speech pattern is not just a peculiarity of his species, one has to wonder if it is occurring for a medical or psychodynamic reason. This makes Yoda a great “blank slate” upon which the process of psychiatric formulation can be applied and taught considering biologic explanations, as well as psychogenic factors or motivation.

To start with, certain forms of dyslexia or expressive aphasia can occur if there is damage to the brain’s language centers (Broca’s or Brodmann’s area). However, these types of aphasias usually result in either word salad or halting speech patterns. In addition, there are not physical indications that Yoda is suffering from deep or significant brain damage—such as scars, facial asymmetry, neglect, general cognitive limitations, or partial paralysis.

Some forms of dyslexia such as “surface dyslexia” (a disorder characterized by the inability to read words with irregular or exceptional print-to-sound correspondence) can be acquired from head injury affecting the left parietal or temporal lobe and can also present with spoken language difficulties [12,13]. Although this form of dyslexia can affect an individual’s ability to properly phonate words, it usually does not result in the speech pattern Yoda displays.

There is the possibility that Yoda may suffer from a genetic condition such as Williams syndrome, which occurs due to deletion of parts of chromosome 7. Humans with Williams syndrome are hyper-verbal with potentially unusual speech patterns, very friendly, elfish in facial appearance, and small in stature. Individuals with Williams syndrome usually have language abilities higher than what would be expected for their IQs, which average in the 60s. Yoda’s intelligence is the obvious reason that he cannot have Williams syndrome (besides potentially not even having chromosome 7). However, in the context of teaching and forming a differential diagnosis, this is an example of a classic “Zebra” diagnosis (“when you hear hoof beats, think horses not zebras”), which needs acknowledgement even if it is not probable.

Cultural factors should also be discussed, such as whether Yoda is simply a non-native speaker of Basic Galactic Standard language. Many people who learn a new language later in life (and Yoda is 900 years old) retain syntactic structures from their native language, rather than fully adjusting to the new one. However, Yoda never seems to have word-finding difficulties, word-meaning errors, or trouble with idioms—which are often encountered in people who learn a new language later in life.

This then raises the question of whether there is an intentional or unintentional psychogenic explanation. Yoda either suffers from a consistent syntax error or may be intentionally using a literary technique known as Hyperbaton, the inversion of normal word order for effect. If it is intentional, then why does Yoda do it? Does Yoda feel a need to play intellectual games even if he is the only one playing? Does this come from some deeper unseen self-confidence problem such as his short stature, waning ability to use the Force in the context of a re-emerging Sith threat, or advancing age? These hypotheses can be used to highlight many points about psychodynamics—such as the need to know the life story, actively listen to look for patterns or topics repeatedly brought up, and to be cautious about over-interpretation and jumping at obvious explanations.

Last but not least, a startling possibility that also bears consideration is that Yoda may be malingering. Yoda’s speech pattern is that of a literary technique which he is bright enough to intentionally use in everyday encounters. There are also examples in the movies of Yoda intentionally engaging in deception for secondary gain in order to have others underestimate him. One example is when he meets Luke Skywalker for the first time in the swamps of Dagobah and plays the part of a simple but friendly native. The second is when he engages Count Dooku in a lightsaber duel inAttack of the Clones where he initially appears decrepit, walking with a cane, only to be found to be quite nimble. Given the old adage that past behavior is the best predictor for future behavior, one must wonder if Yoda is intentionally speaking in this unusual manner for secondary gain. The training questions then center around what is the secondary gain, the context in which it is done (e.g., lying as a prisoner of war is considered adaptive, not malingering), and whether the behavior is to such an extreme or grossly exaggerated state to qualify as malingering.

Luke Skywalker, as an Example of Adolescent Mental Health Concerns

As the movies progress, Luke grows into the role of a Jedi Knight. However, if justA New Hope is taken in isolation and the cultural and religious value of the Force is ignored, then Luke may be used for teaching points about mental health evaluation in an angst-ridden teen. Issues that can be discussed are the potential diagnosis if any (e.g., prodromal schizophrenia vs. adolescent depression), effects of losing his parents at an early age, difficulty in finding an identity versus having one forced on him by his uncle, and being left behind by his peer group. InA New Hope, Luke is an 18-year-old male, who is having conflicts with his “adopted” family; is not meeting obligations such as chores; acquires a new peer group, which puts him into conflict with authority; starts expressing new strange religious beliefs; starts hanging out in bars; and is engaging in reckless behavior (e.g., spying on sand people), not to mention potential animal cruelty with “bullseye[ing] womp rats in [his] T-16 back home.” All this culminates in him having auditory hallucinations and grandiose beliefs that he is saving the galaxy. When all this is taken into account, one may start to lean towards a diagnosis of prodromal schizophrenia. The problem with this formulation is that he does actually have Force powers and did actually save the galaxy. But the abstract teaching point— regarding considering the possibility of prodromal schizophrenia and how it is often not recognizable until after a full-blown psychotic event—remains. A teaching point can also be made about his comforting and encouraging hallucinations of Obi-wan Kenobi being a culturally appropriate part of grieving the loss of his mentor.

Also of note are the differences between Luke’s and his father Anakin’s paths. Both were tempted by the Dark Side, but Luke did not succumb. Though father and son share genetic traits like intellect and Force powers, the difference lies in their resilience [14]. Luke was raised by a caring if dreary aunt and uncle until he was a young adult, while Anakin lost his mother early and was subsequently raised in what might be described as a cult that forbade members from engaging in romantic relationships. Luke also did not have to cope with the destructive treacherous Palpatine who had tricked both of his parents during their adolescent struggles for independence [14].

Princess Leia Organa, Not Your Typical Storybook Princess, Especially Regarding Her Choice in Men

To some, Leia is a feminist warrior princess who is a strong female role model skilled in politics; however, debate can be had about Leia demonstrating histrionic traits common to many “operatic” heroines. Drama seems to follow this princess everywhere she goes. There is no doubt that she is highly functioning and intelligent, but Leia is always getting herself into trouble. She is dramatic in her speech (e.g., “Help me Obi-wan Kenobi, you are my only hope.” which is what we hear multiple times in isolation before hearing the “entire message.”) She is vivacious, enthusiastic, needs to be the center of attention, and demonstrates strong emotions. In the midst of being chased by enemy storm-troopers, she suddenly kisses Luke “for luck.” Is this because she believes relationships are more intimate than they actually are, or an understandable reaction of a scared person trying to be close to someone while facing a deadly situation? She is in need of rescue on more than one occasion, and is always rescued by a man (though to be fair, she is one of the few women in the first Star Wars trilogy so odds are good that any rescuer will be male). InA New Hope, she blamed her disappointments on her rescuers: “You’ve managed to cut off our only escape route” (to which Han aptly replied “perhaps [she] would rather be back in [her] cell.”). While one may argue that she dresses provocatively to call attention to herself, it should be noted that Jabba is the one who put her in the iconic bikini. She is seductive and uses sexual behavior to try to control others, such as intentionally kissing Luke Skywalker in the beginning ofEmpire Strikes Back to upset Han Solo. Although for most of the original trilogy she is involved in a love triangle with her own brother, the sibling relations part of the triangle should not be considered diagnostically, since she didn’t yet know that Luke was her twin brother.

Histrionic personality disorder, like borderline PD, is often borne out of abandonment issues. Though raised by a prominent family, Leia’s mother (Queen Amidala) died in childbirth and her adopted mother is presumed to have died when she was young (e.g., Leia claims to remember only images and that she was beautiful). This, in combination with the associated personality features, may be why she sets herself up for future abandonment by falling for a “scoundrel” (“Your friend is quite the mercenary. I wonder if he really cares about anything. Or anybody.”). Discussion can be held with trainees about the utility of noting personality traits in assessments, even if full PD diagnoses are not met. Traits such as those noted in this case can profoundly impact on people’s lives and patterns of behaviors, i.e., who they are attracted to or situations in which they end up.

Han Solo, Lovable “Scoundrel” and the Need for Clinical Objectivity

Han Solo matures over the course of the films into a reluctant hero. There is a reason the viewer cheers for Han to win Leia, a reason other than merely that Luke is her brother. Early on, in Star Wars, the viewer learns that Han has been unable to pay his debts and is in trouble with a crime lord after he dropped a shipment he was smuggling (“You think I had a choice? Even I get boarded sometimes”)—which could make some trainees think of antisocial personality disorder. Likewise, inEmpire Strikes Back, he repeats “it’s not my fault!,” apparently externalizing blame. However, he’s just a guy from the wrong side of the galaxy trying to get by in difficult circumstances. In a galaxy made of black and white, he is the only main character in the films who is ambivalent about the rebellion and the empire [15]. When Princess Leia accuses him of only loving money, she is wrong: he wants the money to pay back the aforementioned debts and tries throughout the series to do so. Whether this is from a desire to meet obligations or due to a sense of self-preservation is debatable.

Han defies categorization not only due to his character growth, but also the digital magic re-editing of the cantina shooting scene with Greedo [10] (Star Wars Universe fans would also know that Han washed out of the Imperial Academy because he violated an order to kill Chewbacca.) However, Han could be a high-functioning antisocial whose charms have blinded the authors of this paper to his true nature. One of the key learning points from this character is not to take an isolated incident in a person’s history (e.g., owing money, washing out of school for not following orders, or frying poor Greedo) and let that blind the evaluator to potential growth and change with time. With that being said, evaluators must also use care to detect and appreciate rationalizations—such as the hypothetical “Greedo made me shoot him; it was self-defense.” In addition, Han may be the best character to teach the difference between traditional Personality Disorder diagnostic criteria with stricter cutoffs and the alternative DSM-5 model for personality disorder which takes into account factors such as pervasiveness and stability of traits.

Chewbacca, the Emotional Wookiee?

Chewie is the intensely loyal sidekick of Han Solo; the two have a “bromance” pre-dating the term “bromance”. Wookiees understand basic language, but aren’t able to speak it themselves. Thus, they communicate with growls and grunts and often let their behaviors and emotions speak for them. From his specific grunts and behavior, the viewer notices that Chewie has anger management issues. He has been described as an “alien lion-like male whose emotions are his controls” ([16], p393). Chewie, the “walking carpet,” acts rashly and uses violence to solve his problems. He even uses violence when it is contraindicated for his own safety, such as strangling Lando Calrissian when Lando is trying to save Chewie and his friends. He gets the group of rebels stuck in a trap set for wild animals after eating bait; Han confirms “Great, Chewie, always thinking with your stomach.” In humans, orbito-frontal cortex lesions lead to emotional lability and impulsivity, consistent with Chewbacca’s actions. Thankfully, Chewie does not demonstrate other characteristics of those with orbito-frontal lesions though, like sexual disinhibition, sociopathy, or memory problems.

Han Solo implies that it is not merely Chewie who gets violent quickly, but others in his wookiee culture as well: “[Wookiees] pull people’s arms out of their sockets when they lose.” This again brings up the issue for trainees about the importance of knowledge of norms in a patient’s culture prior to making a diagnosis.

Lando Calrissian, Pathological Gambler?

Viewers learn that the reason Han Solo owns his own spaceship is because Lando lost the Millennium Falcon to him “fair and square.” This dapper rogue continues to gamble throughout the films, accepting bad deals with high potential payoffs which are unlikely to be kept, despite the negative personal consequences. For example, he gambles and makes a “deal with the Empire,” betraying his friends Han and Chewie. As everyone but Lando expects, the evil Darth Vader changes the “deal” and Lando is a sucker yet again (“I have altered the deal. Pray I don’t alter it any further,” says an all-powerful Vader to Lando). He takes high-risk shady business deals as well, such as the Bespin gas mine that he “conned somebody out of” and the pie-in-the-sky idea of Cloud City, which he runs. Lando gambles with the lives of other rebels, albeit successfully, by demanding that the spaceship not abort their mission when Admiral Ackbar orders everyone to retreat from the unexpectedly operational Death Star (he was gambling on Han Solo to have the deflector shield down, though this was not what the more seasoned Admiral would advise). Lando goes in closer, instead of retreating. Even Han Solo calls the mission Lando has agreed to lead “crazy.” Using Lando as an example, trainees can discuss the recent DSM changes, and debate can be held regarding whether pathological gambling is more appropriately considered an addiction or an impulse-control disorder (Table 1 describes how the DSM changes affect the various characters).

Padme Amidala, a Sensible Queen but a Doomed Mother

Viewers learn that Queen Amidala of Naboo is actually a heavily made-up young ruler named Padme. Later, as Senator Amidala, she falls in love with and secretly marries Anakin Skywalker, which is unfortunate since his destiny is to become Darth Vader. Throughout the films, Padme appears level-headed, but naïve. However, Padme’s end provides an entrée to teaching about perinatal psychiatric disorders and consultation-liaison psychiatry (Table 2 describes how various characters provide an entrée to subspecialties).

Padme tells us “something wonderful has happened; Annie, I’m pregnant.” Later though, quite pregnant with Anakin’s twins, she “has lost the will to live.” These symptoms occur right before delivery (and lead to her immediate dramatic demise). Time frame is not terribly clear; we see her crying when she is worried about the safety of the Jedi and her man, and tormented when she discovers that Obi-wan plans to kill Anakin because he has turned to the Dark Side. She tells Anakin that he is breaking her heart, when he talks to her about ruling the galaxy together.

The medical droid reassures us that “medically she is completely healthy.” One must bear in mind however that this is the same medical system that treated Anakin’s life-threatening lava burns by putting him in a Darth Vader costume. Padme’s onset of symptoms could have been caused by a perinatal hypoactive delirium, depression, or grief—only one of which could lead to such a quick death. Discussion might include whether the droid checked all the labs that the resident on a CL psychiatry rotation would check, and what these labs would be. A further discussion of risk factors for perinatal depression which Padme possessed might include the following: stressful life events and relationship issues (e.g., finding out that her loving secret husband was actually the big bad guy who had slaughtered the young Jedis, and finding out that the other Jedis were planning to kill him because he had turned to the Dark Side), her partner violence victimization (being force-choked by Anakin), and even her pregnancy’s multiplicity [17,18].

Obi-wan (Ben) Kenobi, is the Force Growing Weak with This One?

Similar to Luke Skywalker highlighting issues in adolescent mental health, Obi-wan Kenobi can be used to discuss geriatric psychiatric formulation. Obi-wan’s differential diagnosis for teaching purposes should include major depressive disorder and pseudo-dementia. When he is first seen inA New Hope, he is disheveled, thin, and appears to have aged more than would be expected since his last appearance inRevenge of the Sith roughly 18 years earlier, suggesting poor self-care and appetite. One must also take into account collateral statements, such as Luke’s Uncle Owen referring to Obi-wan as “that crazy old wizard.” By all accounts, Obi-wan had withdrawn from the universe, with Luke noting that “old Ben lives out beyond the Dune Sea; he’s kind of a strange old hermit”—indicating social isolation, potential lack of motivation, anhedonia, and poor energy for a once vibrant and worldly Jedi master. His reaction to the destruction of Alderaan—quiet numbness— is consistent with the depressive who sees misery everywhere. All of Ben’s lies inA New Hope (such as the identity of Luke’s father, not telling Luke about Leia being his sister, and the amount of money he could pay Han Solo) could be indicative of pathological guilt over not preventing Anakin Skywalker from becoming Darth Vader. Granted some may argue about the meaning of his final actions, but it does appear that Obi-wan committed suicide-by-Vader when he intentionally did not continue in the lightsaber duel. In addition, if one does accept that Obi-wan is suffering from depression, it may answer one of the greatest mysteries ofStar Wars—which is why Obi-wan does not seem to “remember owning any droids” (e.g., R2D2 and C3PO). The reason for the memory difficulties could be explained by depression affecting his concentration and memory. Given his other cognitive faculties, he is not the best example of pseudo-dementia, but, as an avenue to raise a teaching point, Obi-wan Kenobi fromA New Hope does serve as a good springboard for discussing depression in the golden years.

From a psychodynamic perspective, Obi-wan Kenobi also allows for a discussion of some ego defense mechanisms such as splitting (e.g., seeing things as all good or all bad), intellectualization (cold reason and facts used to overcome conflict, emotional stress, or ambiguity), and rationalization (justifying actions with acceptable rationales even though they were committed for other reasons). In his final confrontation scene with Anakin Skywalker, Obi-wan Kenobi identifies Anakin’s tendency to use splitting when he states “Only a Sith deals in Absolutes.” Obi-wan’s need to identify Anakin’s defense mechanism, as well as statements such as “in my experience there is no such thing as luck,” demonstrate how he uses intellectualization as a defense to deal with uncertainty or extreme emotion in his own life. In addition, he uses rationalization to justify lies he has told such as “A young Jedi named Darth Vader, who was a pupil of mine… betrayed and murdered your father” to protect Luke from being hurt or refusing to fight if he learned Vader’s true identity. Since we have learned that Jedi do not deal in absolutes, but Jedi will use the force to cloud people’s minds and overcome their free will with no apparent moral dilemma, it is not a stretch for him to use rationalization to justify lying when it suits his purposes, especially when it is the truth “from a certain point of view.”

OCPD in C3PO, or Is it Just Programming?

C3PO demonstrates traits of obsessive-compulsive personality disorder wrapped up in a shiny, whiny gold protocol droid. C3PO frequently misses the forest for the trees, which was quite literally demonstrated on the forest moon of Endor when he chastised R2D2 for thinking it was pretty. C3PO annoys other characters with his rigidity; R2D2 aptly calls him a “mindless philosopher.” In the asteroid scene inEmpire Strikes Back, Han Solo has to briskly remind him “Never tell me the odds” while Leia has to tell him to “shut up.” This occurs after C3PO has chosen a high-stress moment, when Han and Chewie have been doing their best to save the group’s lives, to announce the statistical odds of survival–even though there are no other viable alternatives. In the midst of a romantic moment, he interrupts Han and Leia’s kiss: “Sir! I’ve isolated the reverse power flux coupling.” When Han sarcastically thanks him, he does not understand Han’s tone. In a game between R2D2 and Chewbacca, after Chewie lets out an angry scream because R2D2 was winning, C3PO is so preoccupied with the rules of the game that he needs to be told by Han that “it’s not wise to upset a Wookiee.” This occurs after C3PO had informed Chewie that “screaming about it can’t help you,” and before pointing out the obvious “But sir, nobody worries about upsetting a droid.” C3PO is repeatedly so preoccupied with rules and protocol that dysfunction often ensues—even to the point that he would let his friends be eaten by ewoks, rather than to impersonate the deity that they mistook him for (“It’s against my programming to impersonate a deity.”). Even for a protocol droid, he seems a bit much.

C3PO also provides excellent examples for trainees of both “catastrophizing” and “externalizing” blame (usually to R2D2, though Chewbacca doesn’t escape blame either). A variety of scenes and quotes can be used to demonstrate. After Chewie has worked hard to reassemble C3PO who was in many pieces, C3PO misses the fact that he is at least now put together and thanks him by saying “Oh my! What have you done? I’m backwards. You flea-bitten fur-ball! Only an overgrown mop-head like you would be stupid enough to…” (others include the following: “Help, I think I’m melting. This is all your fault.” (to R2D2); “We seem to be made to suffer. It’s our lot in life.”; “They’ve shut down the main reactor. We’ll be destroyed for sure. This is madness.”; and “There’ll be no escape for the princess this time.”)

An alternative argument can be advanced that C3PO has traits of dependent personality disorder. R2D2 (co-dependent) keeps getting him into trouble, yet C3PO is unable to separate himself from R2. Other people might call this loyalty to a friend though.

Star Wars is well-known across generations, and the heroes present an excellent venue for psychiatrists to teach concepts ranging from personality traits to pathological gambling, malingering, pseudo-dementia, perinatal psychiatry, and prodromal schizophrenia. No matter if one wants to focus on biological psychiatry or more psychodynamic aspects, teaching points are found in the six films, often with memorable scenes and dialogue to help demonstrate the concepts.