Psychiatry in the Age of Justifiable Paranoia

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Photo: Paramount Pictures

About a decade ago, Joel Gold started seeing a small but steady stream of patients who were each complaining of a similar problem: They believed they were the subject of a reality television show. Everything that happened around them, from their friendships to global news events, wasn’t real, they insisted; it was all orchestrated by unseen producers and directors. 

Gold, a psychiatrist at NYU Langone Medical Center, dubbed the phenomenon the Truman Show Delusion, after the 1998 Jim Carrey film. He and his brother, McGill University psychiatrist Ian Gold, wrote a case study on the subject, arguing that it wasn’t that reality TV had caused these delusions; rather, these were people who were genetically predisposed to psychosis, and the culture they lived in simply helped shape its symptoms. (In the 1950s or 1960s, for instance, people with similar risk factors might become convinced that the CIA was watching them.)

But what happens when already-paranoid people live in an age in which their fears of being watched are at least somewhat justified? The Golds recently wrote a book on the way environment affects delusions — it’s called Suspicious Minds: How Culture Shapes Madness, and it’s out tomorrow. The Golds believe that mental health research focuses too much on the genetic causes of psychosis; culture, they argue, is just as important. Science of Us recently spoke with Joel Gold about paranoid delusions in the era of Facebook emotional manipulations and government surveillance.

What is the 2014 version of this kind of delusion?
The form of delusion that you’re talking about is the persecutory or paranoid delusion. And so you might say that the surveillance culture that we live in is certainly going to be incorporated in people’s delusions. In the book, I talk about some people who work at Bellevue who have already seen people come in with these delusions. And, very weirdly, I’ve seen a patient who, before the Snowden story broke, believed that what he called the NIA, the National Intelligence Agency, was hacking his computer. And within a couple of weeks, the story broke.

So how do you talk to someone who is delusional but at the same time, isn’t wholly wrong? If this happened ten years ago, and my patients were saying, “There are cameras everywhere, the government is watching me, they’re listening to my phone calls,” we’d believe they were paranoid. Today, we can’t really automatically say that, because it’s true — the government might be listening to this conversation right now.

So what is the treatment approach when their delusions have at least a little bit of truth to them?
You look at the full picture. The patient with the NIA delusion had other symptoms of psychosis, I felt comfortable stating to myself and to him. He was talking a mile a minute and he had not slept for five days. Once he was in the hospital he believed the other patients were working for Microsoft, and that they were following him. So at a certain point it stretches the bounds of belief, and you feel pretty comfortable saying he’s in the midst of a manic episode.

What’s the line between psychosis and a more general feeling of being creeped out by news stories about surveillance?
On some level, it comes down to how much anxiety someone has, and often it’s family members, friends, or colleagues who can best judge that. If you’re putting masking tape over every crack on your wall for fear that cameras are watching you, if you can’t sleep at night because you feel that your every word is being monitored by the powers that be — that might be a sign that you could benefit from an evaluation by a mental health professional.

If everyone in a room is sitting around saying, Can you believe what Facebook has done? — well, okay, there’s a dozen people who don’t have to go to a psychiatric ER. But if 1 of those 12 behaves in a way that is concerning to them and their loved ones, if they’re responding to this information above and beyond what’s considered average, then that’s cause for concern. And just because someone has concerns — and a lot of it may be well-placed — that is not necessarily a diagnosis of mental disorder. Any number of mental health issues might be at play.

But what about people who aren't quite at the delusional level, but who are a little more paranoid than the average person ± how do mental health professionals calm these people down when many of their fears may very well be justified?
That is an open question. But I think it’s something we really do need to look at much more closely. For people who are thoroughly grounded in the reality of the stories of Facebook and NSA and Prism and the like — those stories are upsetting for sure, but they’re unlikely to make you psychotic if you are otherwise well. And people who are already experiencing psychotic delusions will likely incorporate these kinds of material into their delusional belief symptoms.

But what about the people who are teetering on the edge, who may be developing early onset psychosis, which could go either way? We don’t know for sure, but we want to look at this further. I don’t believe watching reality TV is going to make someone psychotic. But this more corrosive kind of information about surveillance and the like really could have an impact on someone who is on the brink, perhaps, and might otherwise, if they were living in some lush fields hundreds of years ago, not become psychotic.

We know a few factors that raise the risk of psychosis for those who are genetically predisposed to it — if they live in an urban setting, if they’re an immigrant, if they’re a child abuse victim. So does the surveillance age actually belong in the same category as a risk factor for a certain segment of the population that may be genetically at risk? Maybe. It’s an important open question.