dance like the dead

a blood-spattered tour of cinematic psychomotor pathology

warning: there are a lot of pretty gruesome clips and links below

My friend and colleague Dr Tim Nicholson says we don't spend enough time thinking about gait in psychiatry. And he's right. For years we've been planning a review together on the relevance of gait in psychiatric diagnosis. It's such a rich subject, I think. You can tell so much from someone's gait: it transmits information about emotional state, intention, level of disorganisation. The neurologists spend a lot more time thinking about gait than we do, and you might be forgiven for thinking that they had the gait analysis market cornered: I mean, you've got the festinant gait of Parkinson's, the scissoring gait of spasticity, the myopathic waddling gait, the many remarkable gaits one sees in functional neurological disorders, and a million other kinds. But you'd be wrong. I think in psychiatry we have all kinds of amazing gaits; it's just that we don't spend much time talking about them.

There's the edgy, jerky gait of somebody experiencing acute paranoia, perhaps as part of a psychotic illness. There's the subtly dyspraxic, even in some cases clumsy gait that one sees in a proportion of people with certain neurodevelopmental disorders. And then you have the pharmacological gaits: the tardive gait (or as it used to be called the largactyl shuffle) or perhaps the addiction-related gaits. I've met clinicians who swear they can tell you if somebody is addicted to heroin or to crack cocaine simply by the way that they walk.

Some beautiful work by the group of Mats Lekander in Sweden (who I consider something of a visionary) has shown that you can even perceive health status from gait. In one study, his team gave individuals an inflammatory challenge using a substance which is meant to mimic a bacterial infection called LPS, and it turned out that healthy volunteers were able to spot which people had been given LPS and which had been given placebo simply by looking at the way that they walked. So we even have an infected/inflamed gait. From their paper: “During inflammation, compared to placebo, participants exhibited shorter, slower, and wider strides, less arm extension, less knee flexion, and a more downward-tilting head while walking. They were also slower and took a shorter first step in the timed-up-and-go test. Higher interleukin-6 concentrations, stronger sickness symptoms, and lower body temperature predicted the inflammation-related alterations in biological motion. These findings show that biological motion contains clear information about the inflammatory status of an individual, and may be used by peers or artificial intelligence to recognize that someone is sick or contagious.”

This was all very much on my mind on Thursday night when I went to watch 28 Years Later. I wasn't mad about the first two films but to my genuine surprise I really loved this one. It had a kind of anarchic folk horror vibe that I very much enjoyed, and it tapped into some of that magickal, eerie English supernatural strain of feeling that around this time of the Summer Solstice I tend to feel so vividly (along with a few other films this year [Sinners, Freaky Tales, The Surfer] it felt to me like another amazing recent example of cinema embracing a long-ignored kind of emotionally affecting, OTT maximalism, a kind of psychedelic without the psychedelia vibe).

Sure, 28 Years Later is a lot of things, but ultimately it’s still a zombie film. And as most people will know, there's something very special about the zombies in 28 Days/Weeks/Years Later trilogy. In fact, this third instalment introduces a new class of zombies, equally terrifying. But I won't spoil anything here.

The zombie, for all its apparent simplicity as a monster, has proven to be an extraordinarily rich canvas for exploring the most complex human anxieties. From its folkloric Haitian origins to its current ubiquity in popular culture, the “zombie gait” has shifted in ways that say a lot about what’s on our minds. What began as a metaphor for mindless servitude has evolved into something far more chilling: a physical embodiment of neurological, neuropsychiatric, and ultimately cultural and societal breakdown. The plague-ridden reanimated corpse is the body politic.

For the last few days, I've gone down a bit of a rabbit hole. I've convinced myself that maybe I can find parallels between predominant cinematic zombie depictions of an age and the societal anxieties of that time, and that this might best be viewed through a neuropsychiatric lens. From the slow, stumbling somnambulists of early horror to the hyperkinetic, rage-driven infected of contemporary cinema, I reckon the zombie gait stands as a frankly terrifying symbol of disintegrating agency, disordered volition, and the evils that lurk within society.

from haitian folklore to early cinema: sleepwalking slaves

Long before the relentless hordes of The Walking Dead began their endless shamble across our screens (full confession: I’ve not watched it), the zombie archetype emerged from the rich spiritual landscape of Haitian Vodou culture. The “zombi” (Haitian Creole zonbi) isn’t quite a reanimated corpse in our Western understanding, but something perhaps more terrifying: a living person stripped of their ti bon anj, a phrase that refers to that vital aspect of the soul that encompasses agency, memory and self-awareness. This leaves behind only a passive, obedient body under the control of a sorcerer, or bokor. The real-world accounts are genuinely haunting. Consider Clairvius Narcisse, reportedly discovered wandering fields in 1980, years after his supposed burial, moving with that characteristic slow, aimless shuffle, eyes vacant, shoulders slumped, like someone trapped in a profound neurological stupor.

This is reportedly the first known photograph of a zombie, taken by anthropologist Zora Neale Hurston and reproduced in her 1938 book Voodoo Gods where it notes that the subject was photographed in a psychiatric hospital (many thanks to Vaughan Bell for this photo)

When anthropologists Roland Littlewood and Chavannes Douyon investigated such cases for The Lancet, they found plausible medical explanations lurking beneath the folklore: catatonic schizophrenia, anoxic brain injury and severe learning disabilities. These individuals, with their profound apathy, vacant stares, and aimless movements, embodied the folkloric concept of zonbi with unsettling precision – people who had lost what we recognise as volition and memory. The folkloric understanding had captured, with remarkable accuracy, the presentation of severe neuropsychiatric states.

And in fact, this didn't all begin in Haiti. Vodou can be traced to the small African nation of Benin where it is known as Vodún. However, Benin does not have a clear analogue of the zonbi, despite trance and possession states having a major role in religious practice and ceremony. It might be that the zombie, as it emerged in Haiti, is not a pure cultural inheritance from Beninese Vodún, but is a creature that was born at a violent intersection of African cosmology and plantation slavery. At the height of its colonial exploitation in the 18th century, Saint-Domingue (modern-day Haiti) was the most profitable colony in the world. Its wealth was extracted through a brutal system of plantation slavery under French rule. Enslaved Africans, largely from West and Central Africa, were worked to death in conditions so extreme that the average life expectancy on a sugar plantation was less than 10 years.

So rather than representing a fear of the other, the Haitian zombie was fundamentally a victim, above all representing the horror of being owned. In his controversial ethnobotanical account "The Serpent and the Rainbow," the anthropologist Wade Davis claimed to have uncovered the secret biochemical mechanisms of zombification in Haiti. He argued that certain bokors used a combination of tetrodotoxins from pufferfish and deliriant plant substances, including Datura, which is a substance still reportedly used by Colombian drug gangs today to induce a state of death-like paralysis followed by a revivification and an increased suggestibility and susceptibility to external control (check out this wild Vice video on the topic).

Fascinatingly, we are straying here onto the territory of the neurochemistry of suggestibility, a topic that has been beautifully reviewed by Devin Terhune and his team (although Datura/scopolamine is notably absent from this excellent review).

The foundational concept of the zombie as a being without will, and bent to the will of its master, shaped its earliest cinematic incarnations. Bela Lugosi's White Zombie (1932), the first feature-length zombie film, drew directly from these Haitian roots. Here we find mind-controlled labourers, hollow-cheeked slaves shuffling silently under the sinister commands of a voodoo master. Their movement was stiff, trance-like and profoundly slowed. Arms held awkwardly for balance, feet dragging as if each step required enormous effort. In White Zombie, the undead never speak, their blank faces and lurching, deliberate steps conjuring images of profound psychomotor retardation: movement slowed to an agonising crawl by an entrapped, entranced mind. It's as if their frontal lobes had been switched off. These zombies demonstrate no inherent drive or spark; only external will, that of Lugosi's malevolent character, animates them.

This notion of a walking being devoid of internal mental presence was particularly eerie in the early 20th century, when neurological conditions like encephalitis lethargica, the sleeping sickness that left hundreds of thousands in parkinsonian stupors during the 1920s, remained poorly understood mysteries. Such real-world conditions could readily inspire fictional horrors, tapping into deep anxieties about the fragility of consciousness and the terrifying possibility of a body without a soul.

I'm not going to get stuck on the neuropsychiatric parallels here. One reason for that is that they're too neat. A more powerful reason is that I think there is good evidence that these neuropsychiatric conditions themselves evolve over time. It's not at all clear that someone experiencing an acute episode of catatonic schizophrenia today, for example, would exhibit the same psychomotor manifestations as somebody 100 years ago.

But suffice it to say that in these early zombies we had bradykinesia, we had akinetic mutism and the nods to catatonia were hard to ignore.

the living dead as degenerating body-minds

Historians of film would probably demand I hang my head in shame for jumping forward another 34 years. But jump forward we will, to George A. Romero's Night of the Living Dead (1968), the film that that etched the “zombie gait” into global consciousness. They’re never actually explicitly called “zombies” in the film,  but gone is the puppetmaster or sorceror who controls them. These are reanimated corpses, driven by a singular drove to feed. They stumbled with a grotesque, actually rather pathetic, parody of human locomotion. There is something profoundly neurodegenerative about these zombies.

Neurologists and psychiatrists have found compelling parallels between Romero's classic zombies and patients with specific movement disorders. Steven Schlozman, a Harvard psychiatrist and horror enthusiast, identified three primary characteristics in Romero's undead: they're slow, they move awkwardly, and their only goal-oriented behaviour is insatiable hunger. He speculated about dysfunction in the basal ganglia. And perhaps the trademark tottering gait does bear a resemblance to the extrapyramidal shuffle seen in Parkinson's disease (a disorder affecting the basal ganglia).

In Parkinson's disease, patients adopt a stooped posture, walk with short, shuffling steps, and frequently experience “freezing of gait” when they suddenly become rooted to the spot without obvious trigger. Conversely, someone with spinocerebellar ataxia walks with a wide-legged, unsteady lurch, taking large, clumsy steps and swaying profoundly as their cerebellum fails to fine-tune balance and coordination.

But Romero zombies don’t freeze: they're persistently moving, relentlessly lurching toward victims, showing no discernible hesitation. Their stance is wide; they don't shuffle with the tiny, hurried steps of parkinsonism, but stagger with a drunken, lumbering gait, often extending arms for balance. These observations led neurologists Timothy Verstynen and Bradley Voytek to conclude that the typical slow zombie's presentation “reflects a pattern of cerebellar degeneration.”

Maybe we should pause here. I appreciate the silliness in what I'm trying to do, but this exercise illuminates why zombies feel so viscerally unsettling. They trigger our innate understanding of normal human movement and signal that there is something profoundly wrong. We (perhaps subconsciously) recognise in the zombie’s stagger the same signals we perceive in someone with brain damage attempting to walk. I would go one step further and argue that our threat detection mechanisms make such extensive use of gait as a data source that the inaccurate and frankly dangerous-seeming movements of Romero zombies trigger within us the same impulse we might feel were a belligerent drunkard to stumble towards us on the street, their cerebellum bathed in alcohol, gagging for a bit of Friday night violence.

the velocity of violence and disinhibited rage

In 2002, Danny Boyle's 28 Days Later changed everything. Fresh from upending the narrative with two culturally defining films, Trainspotting and The Beach (both, in fact, alluding to other variants of cultural apocalypse), he now delivered an electrifying shock with an image few had witnessed: zombies that could run.

Were these actually zombies? The “infected” in this movie were technically still living humans, driven to crazed a frenzy by a virulent “Rage” virus. The zombie as manifestation of plague was not new, but this brought a pandemic totality to the phenomenon. I still can't forget how in the early days of the COVID pandemic, coming back from a hospital shift I drove through central London across Waterloo Bridge through entirely empty streets, without passing another human on the street, and barring a few empty busses rolling past I couldn't help shake the uncanny feeling that I had landed directly into the same situation that Cillian Murphy found himself at the beginning of Boyle's film.

A May 2020 drive I took through Central London, mid-pandemic (first wave), on my way home from the hospital

After this, fast zombies were everything. Cinema screens were flooded with sprinters: the hyper-aggressive runners of Zack Snyder's Dawn of the Dead remake (2004), the insect-like swarms of World War Z (2013), Train to Busan (2016) and countless video-game-inspired hybrids. These guys emerged in an era of viral panic and collapsing attention spans. Like the newly ascendant algorithms, they pursue you: their speed amplifying our fears of uncontrollable spread, hyperarousal and social acceleration.

Naturally, there was intense debate among genre purists. George Romero, naturally a defender of the classic shuffler, famously said: “They can't run - their ankles would snap. What did they do, wake from the dead and immediately join a health club?” The objection points to a critical neurological point: if we assume corpses undergo significant rigor mortis and muscle (and brain?) decay, fluid movement should be impossible, right? However, the fast zombie concept typically presumes fresher or still-living bodies with largely intact musculoskeletal function and coordination. From a neuroscientific standpoint, these fast zombies represent an entirely distinct subtype. Voytek and Verstynen categorize them as “Subtype II (fast-moving) zombism: distinguished from Subtype I by healthy motor coordination.”

So if fast zombies aren't afflicted by ataxia or parkinsonism, what neurological disorder defines them? Now we're getting into proper neuropsychiatry: they embody pure aggression, unbridled impulsivity, and a profound loss of higher-order cognition. A fast zombie essentially behaves like someone consumed by acute mania or florid delirium, but with a terrifyingly singular, violent obsession. I can't get into the topic of excited delirium here because it's so fascinating and controversial and merits its own full post, but if ever there was a cinematic description of the sheer power and aggression of this most feared variant of neuropsychiatric delirium, it's this. Excited delirium as a diagnosis is notorious for embodying some of the worst excesses of psychiatric overreach, in which minoritised individuals have been subject to coercive control on the basis of a diagnosis that most feel is entirely spurious. To me, this appears to be a perfect example of the othering function that can be imposed upon people by the strategic use of particular neuropsychiatric lenses. And unlike the Haitian originals, cinematic zombies exist to perform that othering, at an individual psychological and a societal level.

Sure, the frontal lobes of these infected individuals might as well be completely offline, but it’s really their amygdalae which are the stars of the show, locked into extreme overdrive. The resulting mental state bears a resemblance to advanced rabies infection or certain drug-induced psychoses. Virologists and neurologists have frequently used rabies as a real-world model for plausible “zombie virus” scenarios: it can cause intense agitation, biting, hyperactivity, and delirium, though in reality it ultimately leads to paralysis and death, whereas fictional zombie pathogens conveniently spare the motor neurons and/or cortices (as an aside, it's worth considering that there is a plausible argument for rabies also being the source of the vampire myth, emerging from the bat-infested woodlands of the Transylvanian forests of Romania).

Before coming to the end of this chapter in my journey of neuropsychiatric carnage, I want to spare a moment for consideration of a striking neuropsychiatric zombie outlier. Uniquely, Pontypool (2008) displaces the locus of horror from the body to the mouth: the infection spreads through language itself. Certain terms in English become fatally “infected,” triggering a breakdown in meaning that leads to repetition, disintegration and ultimately self-destructive violence. It is a pandemic of comprehension in which to understand is to succumb. The horror crystallises when a French-language emergency broadcast cuts through the static, calmly instructing listeners not to translate the message, not to speak English, not to use terms of endearment. The result - I think uniquely in zombie cinema - is a contagion that bypasses the immune system and attacks the semantic layers of the mind. These zombies leave in their wake a trail of lost sense-making and cognitive disorientation. Released at the dawn of the so-called post-truth era, Pontypool captured a moment when postmodern doubt was no longer a fashionable academic lens but had gone mainstream, as the internet blurred fact and fiction and words no longer reliably pointed to the world. Its horror lies in the recognition that our greatest vulnerability is not what we say, but what we understand. Perhaps the internet had not yet fully eroded our bedrocks of truth but there was an emerging sense that we might be on the cusp of a crisis of meaning itself.

the ultimate neuropsychiatric zombie: MadS

Clearly, cinematic depictions of the undead have long served as allegories for societal anxieties and neurological dysfunctions for nearly a century. But there's one zombie movie I saw earlier this year that blew me away and was to my mind the apotheosis of the genre artistically, culturally, and, if it isn’t weird to say, medically. David Moreau's MadS (2023) is the most neuropsychiatrically complex, perhaps even accomplished, zombie film to date. Moreau deliberately deviates from established zombie tropes by portraying the infected as likeable human beings consumed by wildly erratic emotional and behavioural swings.

MadS's zombies terrifyingly oscillate between primal drives and profound human fear. Within mere seconds, an infected character may cower in abject terror, then lunge with feral aggression or ravenous hunger, before shifting into disturbingly sexual or manic behaviour (are these the first cinematic horny zombies? I doubt it, somehow), then snapping back to a frightened, fleetingly lucid state. It's absolutely devastating.

Moreau has discussed his goal of injecting fresh vitality into the zombie genre by depicting infection from the inside-out by unerringly showcasing its volatile progression. The film unfolds with a relentless intensity in one unbroken take, forcing audiences to endure every disorienting mood-swing alongside the characters. Without traditional editing or time jumps, the infection had to be depicted as gradual, agonising mental breakdown rather than sudden physical metamorphosis.

The infected's erratic shifts can be interpreted as a virus systematically attacking different specialised brain regions in sequence. Moments of profound fear suggest intermittent activation of the intact human side, whereas bursts of intense hunger and aggression indicate primitive drives taking over. The unsettling, sudden bursts of hypersexual behaviour could represent disinhibition of normally suppressed urges. From a neuroscientific perspective, MadS presents what could be interpreted as a rapidly shifting, multi-focal encephalopathy or severe, drug-induced psychosis where different brain systems flicker between extreme activity and profound inhibition. The zombies aren't consistently ataxic, parkinsonian, or purely hyper-aggressive. Their pathology resembles conditions where different brain systems malfunction in random sequence, like certain forms of limbic encephalitis or autoimmune disorders that can trigger combinations of violent agitation, profound rage, and abnormal movements. These are film caricatures, of course, but the unpredictability of these zombies is likely to be familiar to anyone who's worked on an acute neurological ward and looked after a strong young person with a fluctuating immune-mediated encephalopathy. These are patients who can be so risky precisely because they shift in their mental state from reassuring lucidity to delirious rage to catatonia and withdrawal.

The final 40 minutes or so of the film is an absolute tour de force. Watching the actors convulse and jerk and moan within a single, reeling, technically mind-blowing take that crosses an entire city is one of the most impressive cinematic experiences I've had in recent years.

a humanistic understanding of the undead

The zombie gait compels us to ask, in gruesomely literal terms, “What if the lights go out upstairs, but the body keeps moving?”. I can remember this question weighing on me when I was a child, long before I saw my first zombie movie. The answers we arrive at can be, I think, profound. If we can recognise that a stumbling, grotesque zombie evokes pity because it resembles someone grappling with devastating illness, might we be less likely to shun or stigmatise the real person afflicted with that illness? Or might the existence of these depictions of zombies move us to even loftier considerations? Like the philosophers who have used the notion in recent years as a thought experiment, zombies can be an intuition pump for our deepest thoughts about the nature of consciousness and its dependence (or not) on the human body and brain.

Culturally, it seems to me that zombies might act as a kind of kinetic barometer of collective dread. The slower the zombie, the more we fear numbing societal apathy; the faster, the more we fear overwhelm. And I really do think that the zombies in MadS are the perfect zombies for our time. Today, the zombie body doesn’t care about braindead stumbling or rage-filled pursuit. It glitches, echoing a moment in our history which the greatest fear might plausibly be the collapse of coherent agency, of stable identity, of continuity of culture, or even of a collective memory that lasts more than a few days or weeks. The real terrors we face now are the brutalising effects of the untold numbers of competing, flickering, momentary narratives that compete for our attention, and for our cognitive and emotional allegiance every day.

A Haitian understanding is that “The zombie is the spirit that dies and the flesh that lives.” In our engagement with the zombie trope, I think both science and art are striving to reunite these seemingly disparate elements. As any neuropsychiatrist hopes to do, the zombie filmmaker invites us to comprehend the spirit (mind, consciousness, agency) through the flesh (the intricate, vulnerable brain and its once-allied body). If a terrifying horde of shambling corpses leads us to more nuanced understanding of how human emotion and motion interact, or of the elusive nature of consciousness itself, maybe the zombie apocalypse will be worth it.