August 2014

James Orbesen


An Interview with Dr. Joel Gold

Dr. Joel Gold is one half of the creative team behind Suspicious Minds: How Culture Shapes Madness (the other is professor and brother, Ian). While the book goes on to explore dozens of different factors that can feed into mental illness and delusion, the book returns, again and again, to the "Truman Show Delusion," a recent phenomenon whereby sufferers believe not only that they're under constant surveillance but they are starring in their own reality TV show. Starting with this delusion, I spoke with Joel to elaborate on the book, to go further in-depth on how culture molds mental illness, and where the line between madness and sanity is drawn.

The first time I heard about the "Truman Show Delusion," was in The New Yorker. Andrew Marantz wrote about a college student suffering from this particular delusion. I even think you, Joel, were quoted. When I first read this, I just couldn't believe it was true since it seemed so surreal. I remember seeing the movie in theaters and really enjoying it, and I think about it not infrequently. With that said, could you elaborate more on your gut reaction when you had that first viewing of The Truman Show and saw how it mirrored your patients' delusions so precisely?

Yes, I spent quite a lot of time talking with Andrew during his writing of the piece, and put him in touch with Nick Lotz, the student you describe, after assessing him to make sure he was no longer psychotic.

Like you, I enjoyed the film very much but to be honest, at first viewing, I didn't see any clinical significance. Even after the first "Truman" patient I treated compared his experience to the movie, I didn't make much of it; after all, I was working at Bellevue where incredible delusions were commonplace.

It was only after I treated the third or fourth patient who described his life as something akin to a reality TV show -- one in which even I was an actor reading from a script -- that I realized the cultural and psychiatric significance of what I began calling the "Truman Show delusion."

When I returned to the film with this new perspective, I could appreciate how the beliefs (and attendant feelings) that Truman develops over the course of the story so accurately portray the persecutory, grandiose, and referential delusions (a trio of beliefs that, in this context, I described as "controlled unreality") patients with schizophrenia and other psychotic disorders often suffer. In short, I was blown away.

That sort of rings to me like a chicken-or-the-egg quandary. I think you addressed this well in the book when you talked about how the form of the delusion is more important than the content (being followed by a non-existent KGB agent fifty years ago isn't functionally different than thinking you're followed by a phantom film crew today). Still, I just kept thinking how porous the boundaries between delusions and culture can be. For instance, you mentioned a patient started incorporating material about the NSA into her delusions days after the Edward Snowden story broke. But what really interested me was your thoughts on why only certain trends or technologies become prevalent in delusions. When you write about how Friedrich Krauss was convinced a cabal was using magnetism to influence his mind or James Tilly Matthew's "air loom" that controlled him via pneumatic chemistry, it seems that these delusions repeat and repeat in other patients. A lot of delusions seem centered around key technologies (like cameras or microphones or television) but not so much others (zippers, nylon, or highlighters). What do you make of that?

That's an important observation: not all technological advances are created equal (at least when it comes to delusions). While we initially thought of TSD as a combination of delusions of persecution, grandiosity and reference, we came to understand it as a delusion of control in form.

As control delusions have been recognized as long as madness has been recognized, the content has changed. We think of TSD as the heir to the influencing machine.

In our era, control is largely asserted by the controller having knowledge about the controlled, and hence power over the controlled. You needn't be delusional to shudder at the idea of corporations knowing your buying habits and key-strokes, or the government reading your email and (essentially) tapping your phone.

It is for this reason that surveillance and entertainment technologies like cameras and mics, ever smaller, have largely replaced the influencing machine's mesmerism and magnetism as the tools of control. When it comes to influencing machines, The NSA and Hollywood have the Air Loom gang beat.

This is why advances like the highlighter and the ShamWow don't show up in patients' delusions; they are not tools of watching, of listening, of knowing. They are not tools of control.

Do you feel that these tools that populate this type of delusion are central because they can be solely seen as methods of control or is there a fear of the unknown in there too? Although this isn't a delusion but I remember thinking, as a kid, that if I stood too close to a microwave oven I'd get superpowers or cancer. Of course, I was a kid and didn't understand how microwaves worked, but that's what made me leery. So it seems that lack of knowledge of how invisible forces (radio waves, microwaves, magnetism) work, at least in my understanding, would also contribute to these delusions. It's like the Panopticon. That fear of not knowing if/when you're being watched can be more powerful than direct, overt surveillance. Do you see that contributing to your patients' delusions or is control still the key factor?

The unknown is frightening to most of us. People with delusions can certainly incorporate almost any technology into their belief system. You mention your childhood wondering about the effects of microwaves. Aaron Alexis, the Washington Navy Yard shooter, believed he was being controlled by microwaves (though it's important to note that the majority of people with delusions are not violent).

I would bet that there are many people whose delusions now include the electromagnetic radiation associated with cellphones. The fact that the jury is still out on the long-term safety of cellphones increases the likelihood that both psychotic and non-psychotic people will worry more about their use. However, I am confident that even if cellphone use is found to be completely safe -- I'm not sure if this ever can be incontrovertibly the case -- people who have cellphone use incorporated in their delusion will not give it up, and still more people will incorporate them going forward. Even perfect information, an impossibility, would not likely encourage those who have such delusions to give them up. So, yes, I believe that unseen forces are more likely than, say, a piece of furniture or a car are to be found in certain delusions (persecutory thought translate to control). But think for a moment about your computer on which you are reading this. Many patients have expressed the belief that their computer has been hacked, exposing them to malevolent others, or that the camera on their laptop is filming them.

This is to say nothing of things we understand and know are dangerous, like cigarettes, yet rarely appear in delusions, other than, perhaps, in those of psychotic people who believe that their cigarettes have been laced.

As for overt-versus-covert surveillance, I think the line has been so blurred as to be almost meaningless when it comes to delusion. The CCTV cameras, observable to all, and the unseen cameras that do exist both in reality and in the minds of our deluded patients, both contribute to an environment where privacy is a shrinking concept. In either case, we contend that this culture of continual watching and being watched contributes to the feeling that we are being controlled. In those with psychosis, this feeling might take on delusional proportions. And while I'm no conspiracy theorist, mightn't the knowledge that we (or our emails, or our phone records) are being watched in some fashion, a fact that is beyond dispute, impact our behavior, if only slightly? Is this not a form of control? As for those who are on the cusp of psychosis...

I think that tips over into my next question. There is a reasonable (I guess that's the best word for it) level of paranoia for people who are not deemed delusional to have about daily life. History seems to prove certain variants of paranoia correct. When you hear stories about how the FBI actually performed surveillance on suspected radicals, like Martin Luther King, Jr., what was once thought to be just wild speculation is now an established fact. The same might apply to how findings about the dangers of cigarettes were smoothed over, or how lead toxicity was downplayed by powerful forces. What people fear about cell phone use or GMOs today might turn out to be true. But, and this is the question I was really centered on reading your book, what is the line in our culture that separates healthy skepticism from unhealthy paranoia? You touch on it briefly when you mention how arbitrary the line can be. However, you cite, early on, the example of President Obama "birthers," that their numbers actually increased once he released his birth certificate and gave them the proof they'd been asking for. It goes from something like thirty percent of Tea Party adherents believe he is foreign born to, if I recall, forty-five percent. That's a huge jump. And considering the size of the movement, that's a very large chunk of people. So, what separates their, arguably, delusional belief, though they might say skepticism, from a person who is convinced Obama is the reincarnation of Hitler, a truly delusional belief, that they might also say is just healthy skepticism?

This answer is a little longer.

The question of what is and what is not a delusion is difficult to answer, and not just for me. Psychiatric diagnosis (at least in the DSM world of psychiatry) is ever shifting.

The DSM-IV definition of delusion is "A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary..."

DSM 5, has it that "[d]elusions are fixed beliefs that are not amenable to change in light of conflicting evidence... Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences... The distinction between a delusion and a strongly held idea is sometimes difficult to make and depends in part on the degree of conviction with which the belief is held despite clear or reasonable contradictory evidence regarding its veracity."

These changes are not insignificant. First, it is now recognized that delusions need not be false. For example, a person may have a delusion that his partner is cheating on him because she regularly says "thank you" to men who hold a door open for her or who say "gesundheit" when she sneezes. Still, the partner might, in fact, be cheating on him.

Now, even DSM acknowledges that it is hard to strictly separate delusions from strongly held ideas. Superstitions are a good example. Many of us are familiar with wearing a lucky piece of clothing, or sitting in the same chair when watching a sports game, as if that will help our team win. Yet, nobody will claim that is a delusion.

As for the "birthers," I think there are a couple of factors at play. First, as will come as a surprise to no one, people who hold beliefs rooted in already personal and meaningful worldviews (religion, politics, nationalism) will see things very differently. A strike to a Yankees fan is often a ball to a Red Sox fan. So the (primarily conservative) birthers have a predilection to have more negative or even suspicious attitudes toward more liberal politicians. Once the idea was floated that President Obama was born in Kenya, it stuck with some people who already had doubts about his politics, personality, race (perhaps), or what have you. The fact that his father was Kenyan was taken as some evidence that this might be the case. And his birth certificate was determined not to be either "incontrovertible and obvious proof" or "clear or reasonable contradictory evidence regarding its veracity" by many. "It's the short form. It's been doctored." It's hard to prove a negative.

Culture has much to do with delusion, as well. The idea that Obama is the reincarnation of Hitler is delusional on its face, to us. But what about in a society that believes wholeheartedly in reincarnation? One could then argue that even in such a culture, the lineage from Hitler to Obama would be considered arbitrary and bizarre. But what of the Dalai Lama whose reincarnated bodhisattva is unquestioningly accepted by Tibetan Buddhists (and by others)?

This brings us to a final factor: "same-culture peers." If enough people believe something, it's rarely considered a delusion. As you point out, there were many birthers. I was more familiar with the posters of the mustachioed Obama and less so with the reincarnation belief. After a quick Google, I see that, while many of the posts were figurative or mixed in with "X is the reincarnation of Hitler's" and "Obama is the reincarnation of Y's," a number are genuinely held beliefs. In this sense, it comes down to the question of how many people make up a "culture." As Nathaniel Lee put it, "They called me mad, and I called them mad, and damn them, they outvoted me."

That's a solid explanation there. And I love that quote. Somehow it reminds me of Planet of the Apes, when no one believes Charlton Heston. The apes think him mad but he, and we, know better. Another related issue in our conversation and the book seems to be how great humans are at self-deception. Some of the cases you present show how patients can really fall down this rabbit hole of reasoning that, although technically logical, is highly improbable and unsound. But you don't need to be delusional to do that. So how do factors like confirmation bias fit into your understanding of delusions? Is our ability to highlight facts that support our worldview and reject those that challenge it something to consider when evaluating what makes a delusion?

Defense mechanisms are necessary for psychological survival. Defenses lie on a spectrum from less to more mature. An immature defense can be normative when used by a child, but pathological when employed by an adult. For example, healthy children commonly deny aspects of reality, whereas adult denial can reach delusional proportions. In the face of trauma, an adult might be in denial for a time, like Kübler-Ross's first stage of grief, without being deemed ill. Overt and ongoing denial of reality, however, yields delusion.

Perhaps confirmation bias could be thought of as moving along a similar spectrum of health. At one end, the bias might affect opinions, but not beliefs for which there is contradictory evidence. We would invoke the Suspicion System's override of the Reflective System in describing how conformation bias shifts to the delusional end of the spectrum. As we hypothesize in the book, once the dysfunctional Suspicion System is calling the shots, the Reflective System accepts its assessments rather than keeping it in check. When the Suspicion System's judgment has become the default, the Reflective System continues to fact-check the environment, but the "facts" have now changed. The adoption of the Suspicion System's hastily developed and erroneous beliefs explains why delusions are hung onto so tenaciously; the Reflective System is the ultimate arbiter of truth. In short, the Suspicion System denies input from the Reflective System.

I think an important question to address is something you touch on in the book. Since delusions are such a subjective experience, it can be hard, as objective witnesses, such as doctors, to diagnose. Yet, you mention the importance of sympathetic and empathic clinicians. Can you go into that? What have your experiences been treating patients while attempting to relate to them? What sort of successes have you encountered? Or failures?

I think the right approach is to connect with people's experiences, more so than with their beliefs. I will not confront the patient's delusion (at least not at first). I will simply listen: listen to the beliefs and listen for the responses to those beliefs. And I will then respond to the expression of a delusion in much the same way as I would respond to expressions of anger, sadness, or elation. I just left a patient who is suffering greatly from the feelings accompanying his delusions.  When listening to patients, I want to understand what they are going through. This is as true when talking to a delusional patient as it is when talking to a depressed or anxious patient. And these states are not mutually exclusive. It doesn't take much to imagine the fear that comes with the belief that others are out to harm you. The belief may be delusional, but the fear is very real.

I think that's a commendable approach and I also like how that sort of insulates you from indulging the patient's delusion. How can one know if you're experiencing a delusion? We've talked a lot from the perspective of the outside looking in. But, as a thought experiment of being on the inside, is it possible to recognize, on one's own, if you are experiencing a delusion? Do you ever fear that your mind is playing tricks?

By definition, one cannot know he is experiencing a delusion; if she does, she is not delusional. At times, early on in an illness, some people (like the first "Truman" patient, Albert) maintain some insight that, while things feel strange, their experience might be a product of their mind. That tends to fade pretty quickly, however. The same could be said for those in treatment, those whose delusions fade gradually. They may begin to question their beliefs. Some ultimately give up their delusions altogether. Many do not.

There are experiences that might approximate delusional feeling. In the book I give an example of seeing a state trooper's patrol car, when you are speeding on a highway, and believing he's coming for you. You just know it. You feel afraid and angry. And then he drives right past you.

There is also a difference between a delusion and an illusion. We've all had the frightening experience of waking up in the middle of the night and seeing someone sitting in our room, only to realize a moment later that it's just a shirt tossed over a chair.

And finally, there's a part in the book where you list cures for mental illness from the eighteenth century. One of them was marriage. I love that part. Do you feel culture, as much as it shapes our thinking, can also unfairly victimize people? Like a few centuries ago a woman who felt she didn't need to get married was deemed delusional but, today, that's a perfectly acceptable thought to hold. So, essentially, what do you think about people who are deemed delusional today but might be totally "normal" tomorrow?

As for the unmarried, there certainly was a time when "spinsters" were thought to be mentally ill, though in our book we reference the suggestion that marriage might be a cure for depression. (To be fair, the 1621 book also suggests exercise, which we now know to be therapeutic.)

There are countless ways in which culture can demonize. The DSM deemed homosexuality a mental illness until 1980! There is however a difference between bigotry and delusion. For the bulk of American history, African and Caribbean Americans were thought of as inferior to whites. This odious idea is obviously incorrect, but as many people believed at one time that it was perfectly acceptable to own other human beings, they would not be considered delusional.

There will certainly be parallels in the future. There will come a day when we could not have imagined the time when people accepted the fact that women were paid less than men for the same job done. Still, though you and I might find this reality absurd today, a large enough swath of society carries the belief that this state of affairs is okay. And so we don't call it a delusion, we just call it wrong.