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Research Paper on the movie
“One Flew over the Cuckoo’s Nest”
By Matt Littlefield
HSC-505 Clinical Assessment & Diagnosis
National Louis University, Lisle Campus

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Abstract
The author explores the mental illness dimensions of the movie “One Flew Over the Cuckoo’s
Nest” (Forman, 1975). This movie was highly acclaimed at the time it was released and its
impact on American society has proven to be enduring. The author inspects the main character
of the movie, R.P. McMurphy, through the lens of the Diagnostic & Statistical Manual of Mental
Disorders, fifth edition, [DSM-5], published nearly forty years later (American Psychiatric
Association, 2014). The film is described, McMurphy’s behavior is analyzed, and other possible
differential diagnoses are considered within this document.

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Research Paper on the movie
“One Flew over the Cuckoo’s Nest”
The movie “One Flew Over the Cuckoo’s Nest” is one of the top 100 films of all-time,
according to the American Film Institute, which rated it at #33 in 2007 (American Film Institute,
2016). It also swept the ‘Big Five’ categories at the 48th Annual Academy Awards: Best Picture,
Best Director, Best Actor, Best Actress, & Adapted Screenplay (The Academy of Motion Picture
Arts & Sciences, 2016).
This movie was produced in 1975, in a period of time, when the American public was
increasingly more aware of and concerned about the treatment of the mentally ill in our country.
This came to be known as the process of deinstitutionalization. In general, this major reform
happened due to the development of new medications, which lessened the time required for
hospitalization, reports of abuses within the asylum setting, which led to much-needed hospital
reforms, and cost-control measures, which focused on treating the mentally ill in smaller,
community-based settings.
Nearly two years after the release of the film, Gerald L. Klerman, who was a former
professor of Psychiatry at the Harvard Medical School, identified a number of other reasons for
this seismic change in the care for the mentally ill: “avoidance of seclusion and restraint,
development of large group techniques, upgrading of the education of nonprofessionals,
conscious efforts at early discharge, and involvement of the family in therapy” (Klerman, 1977,
p. 618).
Disorder Description, Analysis, & Diagnostic Criteria
The main character is Randall Patrick (R.P.) McMurphy, who is a man convicted of
raping a 15-year old girl. He was serving his time on an Oregon prison farm, before deciding to

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fake being crazy, so he could spend the rest of his time in the mental institution. He did not
realize that his time spent in the psych ward did not count towards the remaining balance of his
criminal sentence. Since he was faking his mental illness to receive a secondary gain, which was
to leave the prison farm, he qualifies for the DSM-5 diagnosis of [Z76.5] Malingering. “The
essential feature of malingering is the intentional production of false or grossly exaggerated
physical or psychological symptoms, motivated by external incentives such as avoiding military
duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or
obtaining drugs” (American Psychiatric Association, 2014, p. 726).
He also fits the diagnosis of [Z69.021], which is due to an encounter for mental health
services for perpetrator of nonparental child sexual abuse due to conviction and admission of
raping a 15-year old girl. Of course, this is not the reason for his confinement in the mental
institution, but it is more of a side note due to his known criminal past. However, we are not
given any more information about his childhood, adolescence, or young adulthood prior to the
time of his arrest and incarceration.
He can also be strongly suspected of having a diagnosis of [F60.2], which is Antisocial
Personality Disorder, even though there is a lack of detailed background information available.
He meets the following criteria in the DSM-5 (American Psychiatric Association, 2014, p. 659):
 Criteria A. A pervasive pattern of disregard for and violation of the rights of
others, occurring since age 15 years, as indicated by three (or more) of the
following:
o 1. Failure to conform to social norms with respect to lawful behaviors, as
indicated by repeatedly performing acts that are grounds for arrest.

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o 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning
others for personal profit or pleasure
o 4. Irritability and aggressiveness, as indicated by repeated physical fights
or assaults.
o 5. Reckless disregard for safety of self or others
o 7. Lack of remorse, as indicated by being indifferent to or rationalizing
having hurt, mistreated, or stolen from another.
 Criteria B. The individual is at least age 18 years
 Criteria D. The occurrence of antisocial behavior is not exclusively during the
course of schizophrenia or bipolar disorder.
McMurphy consistently displays the destructive behavior listed above throughout the
movie. He breaks-out of the institution and steals a bus, in order to meet a woman friend and to
take the whole group on a fishing trip. He showed little to no concern for the safety of the
patients on the boat. He also showed no regard for the rules of the institution or of the local,
state, or federal laws related to stealing the boat. Later in the movie, he even snuck two women
and alcohol into the unit for a Christmas party, after bribing the night watchman.
Throughout his entire stay in the institution, he blatantly disobeys and fights against the
wishes of the staff as much as possible. He appears to find it a real challenge and pleasure to
manipulate everyone into getting his way. He cheats his fellow patients out of money and
cigarettes, before betting them that he could torment and irritate Nurse Ratched. She made him
really angry, when she would not change the daily schedule, so he and the boys could watch the
World Series. She was the main target of his attention, until he realized that she could literally
keep him involuntarily committed as long as she wanted, and his prison sentence was not

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lessening by even a single day. After that moment of clarity and understanding, his sole focus
became to escape with Chief Bromden, before making a run to Canada.
Case Study & Differential Diagnoses
The Psychiatric Times presented a list of symptoms that are commonly presented by
malingerers: “dissociative identity disorder, psychosis, suicidality/mood disorder, post-traumatic
stress disorder, acute dystonia, amnesia, cognitive deficit, dementia, seizure, and sleep disorder”
(Malingering: Key Points in Assessment, p. 1).
The DSM-5 states that malingering should be “strongly suspected if any combination of
the following is noted:
1. Medicolegal context of presentation (e.g., the individual is referred by an attorney
to the clinician for examination, or the individual self-refers while litigation or
criminal charges are pending).
2. Marked discrepancy between the individual’s claimed stress or disability and the
objective findings and observations.
3. Lack of cooperation during the diagnostic evaluation and in complying with the
prescribed treatment regimen.
4. The presence of antisocial personality disorder.” (p. 727)
In the Cunnien’s threshold model for consideration of malingering, “clinicians should be
cautious in how they frame questions, avoid leading questions that might give evaluees clues
about how a genuine syndrome manifests itself. Rather, clinicians should rely at first on open-
ended questions. After evaluees have been given a chance to report symptoms in their own
words, clinicians can ask specific, detailed questions that help to characterize symptoms as
typical or atypical” (Psychiatric Times, 2007, p. 2).

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The clinician also has the ability to help identify malingering with the use of fundamental
interviewing techniques and skilled use of questioning. “Clinicians should be aware that
malingering often takes great effort on the part of the evaluee; therefore, some malingerers will
tire the longer the interview lasts” (Psychiatric Times, 2007, p. 5).
Clinicians can also utilize psychological testing tools to help them identify real signs of
real problems from those that are inconsistent or imagined. For example, “The Test of Memory
Malingering [TOMM] is useful in assessing malingered memory deficits. This instrument can
help determine whether a subject is intentionally responding in a manner to appear memory
impaired” (Psychiatric Times, 2007, p. 6).
Clinicians must first rule-out legitimate psychiatric disorders, before settling on a
diagnosis of malingering. Interestingly, it is quite possible for malingering to be present in a
patient, who is also suffering from some serious and legitimate symptoms. “While there are
batteries of neuropsychological instruments specific enough to make a diagnosis of malingering,
clinicians must not forget that malingering could coexist with genuine psychiatric illnesses.
Based on this, when a patient malingers suicidality, they should be given the benefit of the doubt
pending clinical observations” (Adetunji, et al., 2006, p. 68).
A patient with these symptoms could also be considered for Factitious disorder, imposed
on self [F68.10]. The main difference between malingering and factitious disorder is in the
motivation of the patient. Malingerers, as mentioned previously, are looking to gain something
by faking symptoms. “Definite evidence of feigning would suggest a diagnosis of factitious
disorder if the individual’s apparent aim is to assume the sick role, or malingering if it is to
obtain an incentive, such as money” (American Psychiatric Association, 2014, p. 727).

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[F44.7] Conversion Disorder and [F45.1] Somatic Symptom Disorder are also possible
differential diagnoses for malingering. The DSM states that “malingering is differentiated from
conversion disorder and somatic symptom-related mental disorders by the intentional production
of symptoms and by the obvious external incentives associated with it” (American Psychiatric
Association, 2014, p. 727).
Treatment Possibilities
Treatment for malingering is not relevant, but it is still important to rule out some real
symptoms and illnesses, as mentioned previously.
Discussion of Cultural, Gender, & Social Considerations
It is very difficult to prove that someone is malingering. One could become a victim of
all sorts of false allegations about discrimination and possible threats by the malingerer. “The
statement ‘Remember your ABC’s’ may be useful to clinicians who decide to seek clarification
from evaluees:
 Avoid accusations of lying
 Beware of countertransference
 Clarification, not ‘confrontation’
 Security measures
The latter is included because some malingerers may respond by escalating their behavior
in an attempt to justify their self-reports; in extreme cases, this may take the form of physical
aggression or self-injury” (Psychiatric Times, 2007, p. 6).
The Texas Coalition to Abolish the Death Penalty presents the significant case of Monty
Delk. He was convicted of murder at age 19 and was put on death row. Over nearly four years,
13 clinicians diagnosed him with either bi-polar or schizophrenia disorder. Unfortunately, he

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was found to have an allergic reaction to anti-psychotic drugs and often would not allow his
blood to be drawn. He basically refused to take medication. His behavior reportedly
deteriorated with disorganized speech, delusions, and impulse control issues. One prison staff
member allegedly overheard Delk tell another inmate that he was basically faking his symptoms.
Even though he was found to be suffering from a severe mental illness and therefore incompetent
to stand trial, the supposed incidence of malingering some three years prior persuaded the judge
to proceed with the trial anyway. Delk was executed on February 28th, 2002. “Another
examination by Dr. Dickenson in December 2001 revealed Delk likely suffered from
schizophrenia and was not competent to be executed” (Texas Coalition to Abolish the Death
Penalty, 2010, p. 2).
In conclusion, there are no specific treatment plans for someone believed to be faking
symptoms. It is very difficult to investigate and prove malingering. Since it is possible for
someone to have another real disorder while in the act of malingering, clinicians must tread
carefully and attempt to rule out all other serious possible options first. This historic and
powerful movie left an indelible mark on many within an entire generation. Even now, after over
40 years, it is still a very relevant and moving example of our nation’s history in treating the
mentally ill.

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References
Adetunji, B. A., Basil, B., Mathews, M., Williams, A., Osinowo, T., & Oladinni, O. (2006).
Detection and Management of Malingering in a Clinical Setting. Primary Psychiatry, 61-
69.
American Film Institute. (2016). American Film Institute. Retrieved from AFI's 100 Greatest
American Movies of All-Time: http://www.afi.com/100years/movies10.aspx
American Psychiatric Association. (2014). Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association.
Forman, M. (Director). (1975). One Flew Over the Cuckoo's Nest [Motion Picture].
Klerman, G. L. (1977). better but not well: social and ethical issues in the deinstitutionalization
of the mentall ill. Schizophrenia Bulletin, 617-631.
Psychiatric Times. (2007, April 15). Malingering: Key Points in Assessment. Retrieved from
Psychiatric Times: http://www.psychiatrictimes.com/forensic-psychiatry/malingering-
key-points-assessment
Texas Coalition to Abolish the Death Penalty. (2010, June). Case Study: Monty Delk. Retrieved
from Texas Coalition to Abolish the Death Penalty: tcadp.org/wp-
content/uploads/2010/06/monty-delk-case-study2.pdf
The Academy of Motion Picture Arts & Sciences. (2016). Oscars. Retrieved from The 48th
Academy Awards | 1975: https://www.oscars.org/oscars/ceremonies/1976