Third-year medical students have an opportunity to rotate through the Division of Psychosomatic Medicine for 4 weeks during their core Psychiatry clerkship. As part of the Consultation-Liaison curriculum, clerks participate in morning Psy-feld rounds. Participating students are encouraged to watch the syndicated series and be prepared to discuss the plot/theme at the next morning’s teaching rounds. At 08:30, students convene in a conference room with teaching faculty and describe the psychopathology highlighted in the selected episode. Students’ comments initiate a discussion facilitated by teaching faculty. The goal of the discussion is to reach specific teaching objectives provided in the clerkship syllabus (Table 1). Faculty discussants are provided a manual that details how to reach the stated objectives from subplots of individual episodes. Sometimes, students enrich the dialogue with discovery of novel interpretations of the characters’ behaviors. The course director continually updates a database and the course manual for future rotations.

Psy-feld is introduced at the orientation to the clerkship. Our orientation PowerPoint slide is titled, “While the sitcom is funny, mental illness is not.” It is specifically clarified that the characters’ behavioral and emotional expressions depicted in the sitcom were created for comedic value and are therefore not meant to illustrate psychiatric symptoms or psychopathology. Instead, they form subplots which may be related to themes of mental illness such as Delusional Disorder. The role of teaching faculty is then clarified with the bullet point, “Supervise and facilitate discussion to bring about teaching points recorded in the database.” Our primary goal is to discuss aspects of character development that allow for the review of the mental illness. It’s the discussion itself that lends to active participation and achieving course goals. Each Psy-feld session begins with an inquiry of who was able to watch the assigned episode. Students are then asked to give their impressions of the psychopathology depicted in the episode. Since the discussion is facilitated by teaching faculty, all students are able to participate in the didactic regardless if they were able to view the episode or not.

Although we discuss characters portrayed in a situational comedy, measures are taken not to perpetuate the stigma often associated with mental illness. References are made for teaching and transformative purposes only. Therefore, our didactic is considered “fair use” of material from Castle Rock Entertainment. Students are encouraged to complete anonymous course evaluations that address feelings of being offended. They are specifically asked to share their impressions of all didactic experiences at the mid-rotation meetings with the clerkship director and are reminded they can meet with the course director at any time to discuss their concerns.

Specific episodes, and their associated teaching points related to Delusional Disorder, are illustrated further below.

Episode 49 (1992): The Opera & Jealous Type

The jealous type of Delusional Disorder is characterized by unfound beliefs based on incorrect inferences. When limited to the delusion that one’s spouse has been unfaithful, the term conjugal paranoia has been used [7]. The theme that one’s partner is unfaithful is portrayed by “Crazy” Joe Davola. While significant effort is made to avoid insensitive labels that often promote the stigma of mental illness, we choose to leave the prefix (crazy) in our course syllabus. Our point is to parallel the wrongful use of such judgmental language with Davola’s inconsistent history. Davola’s past psychiatric history is established in “The Ticket” (Episode 44, 1992) when Elaine dates her psychiatrist, and the two take a trip to Europe. On vacation, Elaine’s boyfriend, Dr. Reston, becomes concerned he did not leave an extra prescription for Davola for the time he’s away. Since the jealous type usually afflicts those with no prior psychiatric history, Davola’s inconsistent history is a focus of discussion. Despite this discrepancy, Reston’s concern, “…you don’t understand. He could be dangerous” (http://www.seinfeldscripts.com/) is well-founded when Davola becomes violent and renders his victim with hemispatial neglect.

After she breaks up with Reston, Elaine inadvertently dates Davola in “The Watch” (Episode 46, 1992), and their relationship continues into Episode 49 (“The Opera”). In this episode, Leoncavallo’s Pagliacci is juxtaposed with Davola’s conjugal paranoia that Elaine is being unfaithful.

Episodes 75, 144, 162, & Somatic Type

In somatic type, the central theme of one’s delusions involves bodily functions and sensations. The prevalence of somatic type is less than 0.2 %, but may be underestimated. Affected individuals more commonly present to dermatologists, infectious disease specialists or plastic surgeons. Although there is no single character who portrays monosymptomatic hypochondriacal psychosis, several of Elaine’s acquaintances are referenced to introduce the three main subtypes of delusions seen in this disorder; (a) infestation, (b) dysmorphophobia, and (c) foul body odor or halitosis.

Delusions of Infestation

Delusions of infestation are characterized by the belief of infection on or in the skin. In “The Conversion” (Episode 75, 1993), the theme of delusional parasitosis is presented when the sitcom’s central character, Jerry Seinfeld, peeks in his girlfriend’s medicine cabinet and finds a tube of fungicide. Jerry’s obsession with the cream compels him to slip the tube into Elaine’s purse, and urge her to consult with her podiatrist-boyfriend. Elaine’s role in the episode is central to the discussion of disease prevalence. Specifically, the 0.2 % prevalence is likely an underestimate; similar to Elaine, affected individuals are more likely to present to their dermatologist than a psychiatrist.

Delusions of Dysmorphophobia

The theme of misshapenness, personal ugliness or exaggerated size of body parts is central to “The Andria Doria” (Episode 144, 1996). In this episode, Elaine is on a date with her new boyfriend, Alan, when she discovers he’s a “bad breaker-upper.” Having little respect for someone who “doesn’t break up nicely” (http://www.seinfeldscripts.com/), Elaine terminates their relationship. Alan’s response to Elaine, “…see ya around.. big head” (http://www.seinfeldscripts.com/) leads to several occurrences that reinforce Elaine’s belief of exaggerated head size. In one of the scenes, a bird flies right into Elaine’s head prompting a bystander to marvel, “He flew right into your head. Like he couldn’t avoid it” (http://www.seinfeldscripts.com/). While Elaine’s head injury clearly takes place after the onset of dysmorphophobia, the scene is highlighted to remind students that younger patients with this subtype frequently have a previous history of head injury [7].

Delusions of Foul Body Odor or Halitosis

Individuals with this subtype suffer delusions of having foul body odor or halitosis. “The Merv Griffin Show” (Episode 162, 1997) introduces Lou Filerman, a new co-worker of Elaine’s, who comes to believe he has bad breath. Lou characterizes this disorder in that he’s male, single, without past psychiatric treatment, and young (mean age of 25 years helps differentiate from other forms of somatic delusions) [7]. Elaine identifies Lou as “a sidler” because he silently sneaks up on people. Given several misunderstandings occurring at work that result from sidling, Elaine experiences significant distress in occupational functioning. She is overcome with the belief that Lou is trying to take her job, “…he’s getting credit for work I did! He’s gonna sidle me right out of a job” (http://www.seinfeldscripts.com/). Elaine’s persecutory beliefs serve as a reminder that while olfactory reference syndrome possesses some distinguishing features, subtypes of Delusional Disorder may overlap (mixed).

Episode 113 (1995): The Maestro & Grandiose Type

In his 1921 book Manic Depressive Insanity and Paranoia, Emil Kraepelin described megalomania (delusions of grandeur), a major theme of this subtype of Delusional Disorder. The theme of inflated worth and identity is portrayed by Bob Cobb. Elaine’s new boyfriend demands to be referred to as “Maestro” given his status as a conductor of the Policeman’s Benevolent Association orchestra. Cobb’s conviction that he has a great talent is reinforced when he compares himself to Leonard Bernstein.

In addition to his grandiosity, the Maestro also displays obsessive-compulsive personality traits in “The Doll” (Episode 127, 1996) when he removes his pants prior to performances so he does not lose the crease when he sits. Maestro’s preoccupation with details and perfectionism demonstrates convergence between obsessive-compulsive personality disorder and obsessive-compulsive disorder [8]. This reference reinforces the teaching point that obsessive-compulsive and related disorders may be comorbid with psychotic disorders such as Delusional Disorder [9].

Episode 120 (1995): The Gum & Erotomanic Type

Individuals afflicted with erotomanic type suffer from the delusional belief that another individual is in love with them. Afflicted individuals are usually female, but males are also susceptible [7] as evidenced by Lloyd Braun. This condition is also referred to as de Clerambault’s syndrome to emphasize its occurrence in different disorders such as major depressive disorder, a diagnosis established in Braun in “The Non-Fat Yogurt” (Episode 71, 1993).

Following hospital discharge, Lloyd helps the Alex Theatre gain historical status in “The Gum.” At this time, Braun’s presentation is characteristic; he has a low-level job, is socially withdrawn, and single with few sexual contacts [7]. Braun meets Elaine, and proceeds to interpret her neutral actions as evidence that she is still in love with him, “She was practically undressing in front of me at the theatre” (http://www.seinfeldscripts.com/). His interactions with Elaine also demonstrate paradoxical conduct when he interprets her persistent rebuffs as secret affirmations of her love.

Episode 153 (1997): The Yada Yada & Persecutory Type

Along with jealousy-type, persecutory delusions are frequently encountered by psychiatrists. The persecutory theme that an individual is being mistreated in some way is portrayed by Dr. Tim Whatley, “dentist to the stars.” Before he dates Elaine in “The Label Maker” (Episode 98, 1995), Whatley irks Jerry Seinfeld by converting to Judaism “just for the jokes” in “The Yada Yada.” Jerry’s indignation causes Whatley to complain that Jerry has it in for him because he’s a dentist. Whatley’s ideas of persecution (Jerry is accused of being an “anti-dentite”) are systematically elaborated on. This is consistent with patients afflicted with Delusional Disorder, Persecutory type who characteristically demonstrate remarkable logic and clarity [7].