Fitz is Crazy, Y'all

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A paper I wrote for my cognitive psychology class. Read it, learn something, better yourself. Or not. Whatever. I thought it was interesting when I was writing. Anyway, here it is!

Traumatic Brain Injury on Marvel’s Agents of S.H.I.E.L.D.: Symptoms of a Psychotic Disorder in Agent Fitz

In season two of Marvel’s Agents of S.H.I.E.L.D. the character Leopold Fitz exhibits multiple signs of impaired cognitive and psychological functioning following a narrow escape from death in the previous season’s final episode. The other characters on the show witness this only in the form of trouble with verbalization, similar to conductive aphasia. As viewers we are witness to further symptoms, such as complex hallucinations, and, when compared to his season one behavior and personality, mood swings, occupational and relationship impairment, and reckless/aggressive behavior—symptoms of a psychotic disorder. Specifically, he seems to have developed schizophrenia, which is a realistic possibility following a traumatic brain injury.

In the penultimate episode of the first season of Marvel’s Agents of S.H.I.E.L.D., agents Fitz and Simmons are trapped in a life-pod by a traitor working for the terrorist organization Hydra. The life-pod was jettisoned from the S.H.I.E.L.D. aircraft (“The Bus”), and they are stranded at the bottom of the Pacific Ocean with no way of contacting anyone for help and a rapidly diminishing air supply.

After being stranded, Fitz notes that they are deep enough that there is no sunlight. It is here that the first of several problems with Agents of S.H.I.E.L.D.’s portrayal of his condition arises. Under normal circumstances, sunlight penetrates to a depth of about 656 feet, well below the depth at which special equipment is needed to prevent divers from developing nitrogen narcosis, oxygen toxicity, decompression sickness (the bends), or hypercapnia<fn>Officially, divers should not exceed depths of 130 feet without special equipment; anecdotally, depths of 165 to 200 feet have been achieved with no ill effects by highly experienced divers.</fn>. Simmons, however, shows no ill effects at the time of their escape upon reaching the surface, nor when she returns to the show in season 2. Further, at that depth the temperature of the water would be between, on average, 46 and 53 degrees Fahrenheit. In water below 70 degrees, the mammalian diving reflex automatically kicks in, slowing the heart rate and limiting blood flow to the extremities in order to preserve the vital organs and brain; the colder the water is, the quicker this reaction occurs.

Simmons is not exhibiting any symptoms that could fairly be expected from a rapid ascension from the depth given by the show’s writers. If the given depth is accepted, and the correlating water temperature, the mammalian diving reflex would be triggered at the moment of immersion<fn>They escape by breaking the pod’s window, which equalizes the pressure in the pod and allows the door to be opened; Simmons drags Fitz to the surface while using the pod’s one breathing device.</fn> and prevent Fitz from suffering brain damage. If they were shallow enough to allow Simmons to swim to the surface without detriment, then Fitz wouldn’t be without air long enough—four minutes—to cause TBI.

The only symptoms of his brain injury the show focuses on are his speech disruptions and hallucinations. Psychological impairment following TBI is more common than neurophysical symptoms, so this fits with reality. He specifically has issues accessing technical words related to his work as the team’s tech guru, and has developed a tendency to repeat portions of his sentences as he struggles to find the word he is needing.

Aphasia is usually caused by damage to the language centers of the brain; for the type of language disruptions Fitz is experiencing, likely conductive aphasia, damage to Broca’s area and surrounding tissues. Aphasia generally causes disruption to the patient’s speech patterns and comprehension, including associated acts like gesturing while speaking and reading comprehension; conductive aphasia further causes the patient to exhibit halting speech and self-correction, with deficits in the retrieval of substantive content words. Sufferers will also repeat phrases and may replace their target word with one phonetically similar. It is typical to have the most trouble with words acquired later in life, words not typical of most languages, multi-syllabic words, and with non-words—for example, highly technical or unique words such as those found in scientific subjects. Aphasia also typically has no effect on working memory, intelligence, expert-level skills, or semantic and auto-biographical memory. Fitz exhibits all of these symptoms on a regular basis.

Yeah, um…no. Actually, no. I’m just having a bit of trouble identifying the… A bit of trouble… I’m having a bit of trouble identifying the…material…. Yeah, well, I may not seem like the genius I used to be, but I still have ideas. I’m just having a hard time… I’m just having…expressing them.

Typically, though, aphasics are literally unable to access the lexicon, not just slow to do so, which is what the show portrays<fn>The hallucinatory Simmons provides him the word he is seeking, which he then verbalizes.</fn>. Further, while auditory hallucinations may be comorbid with aphasia, this is rare, nor are visual hallucinations associated with the condition.

Hallucinations can be a result of TBI. Damage to Brodmann’s areas 18 and 19 has been found to cause complex hallucinations—which Fitz’s imaginary Simmons certainly is, going beyond speaking to him to making physical contact on several occasions, even striking him. Auditory hallucinations can also be the result of damage to the superior temporal gyrus and its surrounding areas, which include Broca and Wernicke’s respective areas.

Aphasia-like symptoms and hallucinations are also symptoms of schizophrenia, along with symptoms that match other changes in behavior Fitz has displayed in the second season of the show. He displays hallucinations, disorganized speech, and negative symptoms such as social withdrawal and affective responsiveness, meeting area A of the diagnosis criteria. His function in his work and interpersonal relationships are markedly impaired, satisfying area B.

Area C requires that signs of disturbed function be exhibited for at least six months, with at least one month of continuous symptomatic behavior. This is where this diagnosis becomes questionable, as the show does not provide a concrete timeline of its events. Context clues within the show suggest that it has been acceptably close to six months since the events of the season one finale.

As shown in the series thus far, there is no evidence of Fitz having depressive or schizoaffective symptoms, using any substances that could cause his condition (or at all), and no history of autistic symptoms or diagnosis. Thus, criteria D, E, and F are satisfied.

Schizophrenia is linked to brief mood instability and anxiety, which have been shown, and cognitive deficits, particularly in vocational impairment and processing speed. Fitz has also displayed uncharacteristic aggressive behavior, which, while not usual, is more likely in young males.

Even without TBI, Fitz is a likely candidate for developing a schizophrenia. He is in the prime male age range of early to mid-twenties to develop schizophrenia; and he both leads a stressful life and experienced traumatic events. Beyond that, approximately 46% of those with no history of psychological disturbance prior to suffering a traumatic brain injury develop one after their injury. Ten percent of those who have suffered a TBI develop a psychotic disorder, displaying irritability and aggression, a diminished capacity for mental and recreation activities, and impairment in relationships, increasing their social isolation. A separate study found not only is there an increased risk of “schizophrenia-like psychoses” in those who have suffered a brain injury, males who have are nearly twice as likely to develop schizophrenia as the general population.

If we accept the show’s premise of a near-drowning causing a traumatic brain injury, it is within the realm of possibility that Fitz would develop his symptoms due to this injury. It is not likely, though, given the in-fiction state of S.H.I.E.L.D. and his related outlaw status, legally, that he received a proper diagnosis or is receiving proper continuing treatment. Schizophrenia requires both pharmacological and psychosocial treatments, which he is not receiving.

Within the guidelines of the show’s in-fiction science, Fitz will almost certainly eventually make a full recovery. Applying real-world science and reasoning, Fitz will only get worse without an immediate change in his situation and treatment.

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