Requiem is a German film directed by Hans-Christian Schmid, starring Sandra Hüller as the main character, Michaela Klinger. This film is based on the life and death of Anneliese Michel, a 23-year-old German woman diagnosed with epilepsy. Anneliese and her family were convinced that her seizures and hallucinations were due to demonic possession and she eventually died from starvation due to not eating as atonement during repeated exorcisms.

Requiem is set in the 1970s and tells the story of Michaela, a 21-year-old young woman with epilepsy who is accepted to her first year at the university. Michaela is elated to go to the university but her family is apprehensive and worried. Michaela is hopeful because her new medication has kept her seizure free for six months.

Michaela experiences college life, a big juxtaposition from her conservative upbringing. After her first return home, Michaela goes on a pilgrimage to San Carlo with her family. In the early morning, we see Michaela's first seizure. She drops the rosary her mother had given her the night before and when she tries to reach for it, her hand contorts. Michaela sits upright and appears disoriented with slightly jerking movements. She stands up and walks with an abnormal gait, then falls to the floor and begins crying out. Her father finds her asleep on the floor sometime later.

The next seizure Michaela has is after a late night out with friends. We don't see Michaela's seizure, but a friend finds her the next morning, sprawled out on the floor under her desk. When roused, Michaela yells at her friend Hanna and curls up like she is afraid. Michaela later tells Hanna that she is suffering from epilepsy. Michaela is upset because medications seem unable to control her seizures.

Rather than see her physician, Michaela goes to the church to talk to a priest. She describes how she was unable to hold the rosary at Saint Carlo and how there are voices and faces (visual and auditory hallucinations) that call her a “filthy slut” and yell at her. She does not mention anything about her epilepsy. This priest tells her that she should be talking to a psychologist about this and not him. However, he tells another priest, Father Borchert, about her story. Father Borchert seems more open to her story, but rather than feeding into her ideas that she is being haunted by some demonic force, he prays with her and tells her to stay strong. Before she meets with Father Borchert, Michaela goes to the doctor and receives a new medication to control her epilepsy, which has been diagnosed as “grand mal epilepsy.” When Michaela's father comes to visit, he shows her that the insurance company sent a letter also recommending that she be evaluated for “psychogenic psychosis.”

Michaela progresses through her semester at college experiencing more new things, finding a relationship with a young man, studying hard for school, and enduring her mother's harsh comments about her new appearance. She also experiences more convulsions with auditory and visual hallucinations. It appears that the stress of new experiences contributes to the frequency and severity of her epileptic and possibly psychotic episodes. Eventually Michaela is convinced that she has been abandoned by God and she stops taking her medication.

During her holiday break, Michaela begins a school project and has difficulty focusing and taking care of herself. She stops eating and sleeping regularly. Her boyfriend, Stefan eventually takes Michaela home. Michaela's parents try to care for her, but she screams and curses at them, closing herself in the kitchen and breaking things. At this point, the family and the priests are now convinced that Michaela is possessed by some demonic entity and needs to be spiritually cleansed. The family and the priests perform a series of exorcisms on Michaela who becomes visibly weakened as time passes. Hanna comes to visit Michaela to talk her into getting medical attention, but she refuses. The end titles tell the audience that Michaela dies in her parents' house from exhaustion after dozens of exorcisms.

This film gives us insight into how neurological diseases and psychiatric disorders can be misinterpreted by people with the best intentions. Michaela's seizures are accompanied by symptoms of visual and auditory hallucinations, combined with affective changes – agitation and fear. This combination gives the impression that she is experiencing ictal psychosis. Also, since Michaela has been experiencing seizures for several years, she may be experiencing chronic, interictal psychosis (CIP) where a long history of uncontrolled seizures can lead to a psychotic state. In CIP, persecutory auditory hallucinations and religiosity may occur. When patients are refractory to treatment or if a diagnosis is mistaken for something supernatural rather than a medical disorder, there can be serious consequences. It also seems that a patient's background and upbringing can dramatically affect his or her attitudes toward a diagnosis or treatment. We see this in the differing attitudes of Michaela, her family and her friends. It is important to keep patient perspectives in mind and have clear and regular communication with patients and their families to ensure optimal treatment and hopefully prevent negative consequences or even tragedy, like what was presented in this film.

On the surface, Requiem (subtitled in German) is a movie about a college-aged woman with epilepsy and a mental health disorder. The film is based loosely on the story of Anneliese Michel and is set in Germany. At a deeper level, the film touches on the complex interplay of cultural, neurologic, psychiatric, social, and spiritual aspects of epilepsy and mental health. As the storyline unfolds, we learn that the main character, named Michaela Klinger, has had epilepsy since childhood with associated hospitalizations. She is no stranger to the medical system. Also, it soon becomes apparent that she also suffers from a mental health disorder. This is particularly evident as she moves away from home and begins acclimating to college life. It is unclear if she has a prior history of mental health issues; although this is subtly implied. Important non-medical elements include her familial relations and religiosity. Both parents exhibit their love by different behaviors. Her father in a supportive and encouraging manner; while her mother in a judgmental and overprotective manner. She and her family are devoted Roman Catholics and pastoral intervention is prominent in this film. It is clear that Michaela is intelligent and socially adept. However, her medical condition adversely affects her self-image. Early in the film, the script gives us clues that Michaela feels stigmatized by her epilepsy. Private-life scenes in the film give us a hint that mental health issues are involved. However, the public-life scenes in the film show that Michaela is able to make friends and socialize with skill once in college. It is not until later in the film that her psychopathology becomes the focus.

Prior to entering college, Michaela had been seizure free for six months; however during her first semester, she experiences recurrent seizures which are accompanied by auditory and visual hallucinations. It is apparent that, due to past experiences, she does not have much faith in the medical system. However, she reluctantly seeks medical follow-up and is prescribed a new medication, carbamazepine, for monotherapy. The importance of medication adherence is a highlighted in the film (she utilizes a daily pill box, her father encourages her to take medications daily). We learn she has “grand mal epilepsy” and that she has been on several antiepileptic medications in the past which were either ineffective or associated with intolerable side effects. At first, she is adherent to her medications but as her mental health deteriorates, she abandons her medications. We learn that her doctors suspect “psychogenic psychosis.” It is at this point, that the film transitions into a focus on her psychopathology and meta-physical intervention. At first, she seeks pastoral counseling and prayer, but ultimately, she becomes averse and intolerant to this form of intercession. As the film progresses, we see her refuse both pharmacologic and non-pharmacologic interventions. As her psychopathology worsens, she becomes more isolated and at risk for inanition. Her family, friends, and pastors take drastic steps to intervene by performing an excorcism. As the movie wraps up, there are moments in which Michaela is overtly hysterical followed by periods of lucidity. After the first excorcism, Michaela is lucid and talking about her future. The movie ends on this note with a caption that she eventually undergoes many excorcisms and succumbs to exhaustion.

The movie can be used for educational purposes to discuss various aspects of epilepsy and psychiatric disorders. The epilepsy and mental health issues remained primary; and the film director, Hans-Christian Schmid, did not portray the meta-physical (e.g., possession) aspects in a spooky, horror movie manner.

The film is categorized under the drama genre and I think it retained a “clinical” feel. From a psychosocial and academic perspective, the main character has strong family, social and pastoral support; and access to medical care. She appears to be prepared for college life. It has been demonstrated that mentoring, parent relationship quality, school connectedness, and religious attendance are associated with college level success in epilepsy.3 She is intent on being a good student. There is one point in the film, in which she goes without much sleep for two days and two nights in preparation for an essay deadline. Personally, I was waiting to see if this period of sleep deprivation would provoke a seizure episode (especially since she was off medications); but it did not. From a clinical perspective, she appears to suffer from mixed seizures, perhaps partial complex epilepsy with secondary generalizations. Pre-ictal and aura symptoms include dissociative and hallucinatory (auditory and visual) components and she displays post-ictal confusion. Although she is 21 years old, we never see her driving a motor vehicle. Clinically, she likely has refractory epilepsy due to her history of failed antiepileptic trials. Interestingly, after abruptly discontinuing her medications, the film does not portray her experiencing more frequent seizures or status epilepticus; perhaps at this point in the film, the shifts to her psychopathology (e.g., psychosis), which becomes the dominant focus. She comes to believe that her epilepsy and dissociative feelings are a punishment from God. She is convinced that supernatural (demonic) forces actively restrain her from participating in religious activities (e.g., prohibiting her to pray or touch the cross). In one scene, she extends her arm in an attempt to touch a cross but is unable. The physical exertion makes her arm and hand tremble with effort; it is as if an unseen force grips her hand and restrains her. This is a nice cinematic analogy for epilepsy “seizing” the body. As her mental state spirals downward, she loses self-perspective and associates her epilepsy and symptoms (e.g., pre-and interictal) with the supernatural. As her psychopathology begins to severely interfere with her health (risk of inanation), drastic steps are taken. The film ends with Michaela in a moment of lucidity with a suggestion that her psychosis has remitted; but the ending credits inform us of the tragic outcome.

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