“Help! I am being held hostage in a reality show!”

The Suspicion System: How the social world shapes delusions

Not so long ago, any decent-sized psychiatric hospital had at least two or three Jesus Christs in residence, and plenty of other patients serving as conduits for the CIA or the KGB.

Nowadays, Jesus Christ is harder to find. You are far more likely to encounter reality TV stars: patients whose every move is choreographed by hidden directors, videotaped by hidden camera crews, and broadcast without consent to an audience of millions. “We see many, many young people who have had the sensation of being filmed,” a psychiatrist at a public clinic in London told the New Yorker. His estimate: One or two out of every 10 patients he sees. 

This so-called Truman Show Delusion is not so irrational in our modern surveillance state, where we (and our cars) are photographed and videotaped whenever we venture into the public space, microphones capable of recording our conversations and instantly beaming them to authorities are hidden in street lighting, and – as exposed by Edward Snowden – the NSA is intercepting vast swaths of our communications and storing them in a massive, top-secret vault in the Utah desert. Soon, our homes will afford no privacy; the CIA is cheering the advent of the “smart home” as a bonanza for clandestine eavesdropping. If you scoff at the notion that They are watching you, revisit the chilling scene in the Bourne Ultimatum (2007) in which Matt Damon tries to avoid the cameras in London’s Waterloo Station.   

The solipsist premise of Peter Weir’s 1998 Truman Show, starring Jim Carrey as an insurance adjuster who realizes that his entire life is actually a TV show, was not original. The psychiatric patient in Robert Heinlein’s 1941 short story, “They—,” was convinced that he was an actor on a stage; the troubled protagonist of Philip K. Dick’s 1959 novel, Time Out of Joint, also starred in his own self-constructed reality. But in an innocent era before the entrenchment of the panoptical gaze or reality TV – in which any random person, it seems, can wake up to find him- or herself an instant social media celebrity – these stories were fantastical, and thus incapable of producing mass contagion. 

But the cultural environment influences more than just the superficial content of persecutory or grandiose delusions. Far more profoundly, it impacts who will catch psychosis, and why. This blog’s readers may know that early use of cannabis significantly increases the risk of psychosis, as does experiencing childhood adversity such as severe abuse or parental loss. You may also be aware that merely growing up in a city puts one at heightened risk of mental breakdown; there is a near-linear correlation between population density and psychosis. But consider these further research findings:

• The greater a nation’s income inequality, the higher its per capita rate of psychosis. 

• Immigration is a major risk factor for psychosis – and not just for the immigrants themselves, but for their first-generation offspring. Nor is this risk equally distributed: It is highest for darker-skinned people relocating to whiter countries, especially if they settle outside of ethnic enclaves.

The burden of social defeat

In Suspicious Minds: How Culture Shapes Madness, psychiatrist Joel Gold and his philosopher brother Ian identify social fragmentation as the construct tying these seemingly disparate strands together. More precisely, the experience of social defeat, in which a person who is persistently demeaned, humiliated, or subordinated ultimately comes to see himself as a second-class citizen.

I have long found delusional beliefs fascinating. In particular, I enjoy talking with delusional people, and trying to understand the meaning of their beliefs. In this, I’ve gained a lot from the theories of luminaries in the field such as Brendan Maher, Richard Bentall and John Read. But Suspicious Minds is brilliant in pulling together all of the extant research to create a single unified theory, one that foregrounds and humanizes the delusional person’s experience.

The theory developed out of Joel Gold’s experiences as attending psychiatrist at New York City’s notorious Bellevue Hospital. After treating several patients with Truman Show delusions, he – in partnership with his brother Ian, a philosophy professor at McGill University in Canada – published a 2012 article on the phenomenon in Cognitive Neuropsychiatry. That, in turn, generated a deluge of emails from people all around the world who were relieved to realize they were not the only one who thought their lives were being secretly filmed and broadcast to the masses.

The Gold brothers’ theory of delusions as a social phenomenon goes against the grain in this era of pharmaceutical industry domination and biological reductionism, especially here in the United States, where the social context of mental illness has been systematically suppressed in favor of simplistic theories of genetic or chemical imbalances.

But things have a way of circling back around. Almost 50 years ago, against the backdrop of the assassination of Martin Luther King and the ensuing inner-city rebellions, African American psychiatrists William Grier and Price Cobbs dissected the psychic burden of prejudice. To survive, they wrote in their influential 1968 book Black Rage, oppressed people must maintain a delicate balancing act of being ever-vigilant and suspicious, yet without succumbing to frank paranoia:

“[S]urvival in America depends in large measure on the development of a ‘healthy’ cultural paranoia. [The black man] must maintain a high degree of suspicion toward the motives of every white man and at the same time never allow this suspicion to impair his grasp of reality. It is a demanding requirement and not everyone can manage it with grace…. Of all the varieties of functional psychosis, those that include paranoid symptoms are by far the most prevalent among black people.”

The panoptical gaze in The Bourne Ultimatum

Suspicion, then, is necessary and adaptive, especially for those most vulnerable to exploitation. But when chronic stressors overwhelm the brain’s capacity to cope, delusions are kindled. This is the essence of the Golds’ theory of delusions as the product of an overtaxed “Suspicion System.”

Drawing on recent research in neuroscience and evolutionary psychiatry, the Golds locate the Suspicion System in the amygdala – evolved to anticipate threat by interpreting ambiguous signs of potential social danger – and connected brain regions. Delusions take hold, they posit, with a breakdown in communication between this early-warning Suspicion System and the more rational, slower-thinking (“System 2” in Daniel Kahneman’s formulation) cognitive network that should be dampening the amygdala’s over-enthusiasm.

A solid theory should not only be logical, elegant, and empirically supportable, but should also explain diverse manifestations of a phenomenon. The Golds’ theory explains not just persecutory delusions, but each of the other 11 major delusional themes (e.g., grandiose, religious, erotomanic) as well. For example, grandiosity  – which we see in the Truman Delusion  – can be interpreted as a way of deflecting threat, much like a puffer fish blows itself up or a cat arches it back when faced with danger:

“Flexing your social muscles makes you less vulnerable to exploitation by others, and putting your high status front and center in a potential exploiter’s mind might make them think twice about victimizing you…. Grandiosity is thus a symptom of a Suspicion System on overdrive, a caricature of the normal adaptive strategies we employ every day…. Paranoia and grandiosity … are functionally connected: paranoia is a broken form of threat detection, and grandiosity is a broken threat response.”

With ever-growing income disparity and economic stress, social network disintegration, loss of privacy,  and social media's increasingly panoptical reach, we may expect more and more alienated people with trouble psyches to succumb to Truman Show delusions. Let us hope that, in treating them, we do not lose sight of their humanity, for they really are  not so different from us. As the Golds put it, “mental illness is just a frayed, weakened version of mental health.”

Indeed, if we listen, these frantic souls may even have something to teach.

Garrido to undergo competency evaluation

The attorney for Phillip Garrido, the man who gained worldwide infamy last year in the alleged abduction of Jaycee Dugard, has raised a doubt as to whether Garrido is competent to stand trial.

"This is a fundamental fairness issue," his attorney, Susan Gellman, a deputy public defender in El Dorado County, told a reporter for the San Francisco Chronicle. "What we're talking about here is whether or not a citizen is able to make a decision about his case. When someone wants to go to trial for crazy reasons, or not go to trial for crazy reasons, that person is not competent." She noted persistent trouble communicating with Garrido during her more than 20 meetings with him at the jail.

As I explained in my analysis of the case in the Guardian of UK last August, psychiatric issues -- including competency and perhaps insanity -- are sure to be prominent in this case due to Garrido's history of religious delusions. Through the wonders of the Internet, I wrote at the time, we can "travel back in time and enter his mind, via rambling blog posts about voices in his head, mind control, and religious delusions of himself as the savior." (Amazingly, his contemporaneous "Voices Revealed" blog is still online, for those of you who want to take a gander.)

At Friday's court hearing in El Dorado County, Judge Douglas Phimister commented that he had spotted strange behavior during his limited observations of the defendant in court. At times, he noted, "Garrido aggressively scribbled notes in a pad even though little was going on in court."

Demian Bulwa's San Francisco Chronicle account is HERE. My August 2009 analysis in the Guardian of UK, "Jaycee Dugard, transfixed by a monster," is HERE. My Sept. 3, 2009 followup post on the case, "Sex-Registry Flaws Stand Out," has more background and links.

Photo credit: Rich Pedroncelli, AP

Elizabeth Smart testifies at competency hearing

Kidnap victim Elizabeth Smart provided dramatic testimony today in David Mitchell's long-anticipated competency-to-stand-trial hearing.

But Mitchell wasn't in the room to hear her. He was removed from the courtroom when he refused to stop singing a Mormon hymn, as he does whenever he comes to court.

Smart's testimony was ostensibly intended to establish that Mitchell was acting rationally in order to further his criminal conduct, rather than being motivated by religious delusions as the defense has maintained.

A "calm, poised, articulate" Smart testified that Mitchell was obsessed with sex and used religion to further his predatory goals. She described Mitchell as "evil, wicked, manipulative, sneaky, slimy, selfish, greedy."

But defense attorney Robert Steele said Smart's testimony hinted that Mitchell is delusional, according to coverage in the Salt Lake Tribune. Last week, he argued unsuccessfully that Smart should not be allowed to offer opinions about Mitchell's state of mind or motivations.

Mitchell has refused to submit to any psychological evaluations or diagnostic tests.

His wife and co-defendant, Wanda Barzee, has twice been found incompetent for trial and is undergoing forced treatment with antipsychotic medications. Her next competency hearing is scheduled for Oct. 23.

A transcript of Smart’s 100-minute testimony is online HERE.

My Guardian commentary on Jaycee Dugard saga

The Guardian of UK asked me to write a comment on the extraordinary saga of Jaycee Lee Dugard. I'm posting the first few paragraphs here, with a link to the Guardian website for the full article and the comments, many of which are quite interesting. (I posted a couple of my own comments to the comments.)

In these harsh economic times, the saga of Jaycee Lee Dugard is especially riveting to the public imagination. Our horror and revulsion unite us. Who can we blame? How could this monster hide amongst us while committing unspeakable acts against innocent children?

Our collective furor and thirst for vengeance run counter to the principles of our justice system, under which a criminal defendant is presumed innocent until proven guilty. Psychiatric issues will make justice especially slow for Phillip Garrido, the registered sex offender who is accused of holding Dugard hostage for 18 years, after kidnapping her in June 1991 when she was just 11. (Garrido and his wife Nancy have both denied the charges.)

Initial evidence points toward a psychosis. In an interview from jail, Garrido called Dugard's story "heartwarming" and referenced secret documents and "hundreds and hundreds of thousands" of lawsuits. And that is just the tip of the iceberg. The wonders of the internet allow us to travel back in time and enter his mind, via rambling blog posts about voices in his head, mind control, and religious delusions of himself as the savior.

Ironically, more than a year ago Garrido referenced the potential for psychotic symptoms to cause violence against children. A woman who drowned her three children in the San Francisco Bay was, he wrote, "led by a powerful internal and external (hearing) process that places the human mind under a hypnotic siege that in time leads a person to build a delusional belief system that drives them to whatever course of action they take."

My Guardian (UK) commentary continues HERE. Please feel free to add your comments and opinions at either the Guardian website or here.

Excerpt from Garrido's Voices Revealed blog

Crazy but sane, Texas court rules

Remember Andre Thomas, the eye-plucking Texas prisoner I blogged about back in January? The delusional schizophrenic guy who killed his wife and two children, ripped out their hearts, and then walked into a police station and confessed? The fellow who plucked out one eye shortly after the crime, and the other eye just a couple of months ago?

Yesterday, in rejecting an appeal of his death sentence, a Texas appellate court ruled that Thomas "is clearly 'crazy,' but he is also 'sane' under Texas law."

At Thomas' trial, the defense argued that the killings were the result of insane delusions caused solely by Thomas' mental disease. Prosecutors countered that his psychosis was caused or aggravated by his voluntary use of alcohol, drugs and prescription drugs.

The court also rejected an appeal argument that Thomas was not competent to stand trial at the time of his 2005 trial:

"Although reasonable people might well differ on the questions of whether (Thomas) was sane at the time he committed these murders or competent at the time he was tried, those issues were appropriately addressed by the defense, the prosecution, trial judge, and the jury during the trial," wrote Judge Cathy Cochran of the Texas Court of Criminal Appeals in a concurring opinion.

Scott Henson over at Grits for Breakfast found the ruling ludicrous:

It's just ridiculous to send somebody who's so obviously nuts to death row - what's the moral point of killing a guy who'd mutilate himself to death if you let him? What's the insanity defense for if not cases like this one? … How can the court just assume Thomas' substance abuse wasn't a symptom of his mental illness - a form of self-medication, perhaps? Which came first, the chicken or the egg?

Psychiatrist Lucy Puryear, writing at Women and Crime Ink, agreed:

Non-mentally ill people do not pluck their own eyes out for some secondary gain…. To those of you who would suggest that I am soft on crime, consider this novel idea. How about we make mental health treatment available in the community to those who need it. Had Mr. Thomas been adequately treated and monitored he never would have killed his family or plucked out his eye. Three people would be alive today and an enormous amount of money would be saved keeping him out of the prison system. That's not soft on crime, that's preventing crime.

As one solution, Dr. Puryear advocates specialized mental health courts, which are popping up quite regularly in courts around the United States these days:

Instead of the revolving door from prison to back on the streets where psychiatric care is lacking, then back in prison when another crime is committed, these persons can be put into a system where follow-up is mandatory and resources are available.

Tragically, Thomas had twice sought psychiatric help at local hospitals shortly before the crime, but had not stuck around voluntarily and could not be detained against his will.

Competent and sane, you betcha.

The Dallas News story is HERE.

Eye-plucking prisoner competent and sane

Andre Thomas plucked out his right eye in 2004. Now, he has plucked out his left.

The Texas death row inmate with a history of mental problems killed his wife and their two children and ripped out their hearts. He then walked into a police station and confessed.

None of that sounds all that sane. Indeed, Thomas has been diagnosed with schizophrenia and suffers from psychotic delusions and a preoccupation with death, religion, and suicide, sources say.

Nonetheless, he was found competent to stand trial, convicted, and sentenced to die for the death of his 13-month-old daughter.

The self-mutilation is unlikely to have any effect on his appeals, but at least they got him transferred to a psychiatric hospital for treatment.

The story is here.

Statements during insanity evaluation: Admissible?

Can the state introduce at trial incriminating statements made by a defendant during a court-ordered insanity evaluation?

That is one of several intriguing evidentiary issues in the case of Naveed Haq, whose trial gets underway today in a Seattle courtroom.

Haq has pleaded not guilty by reason of insanity (NGI) to multiple charges stemming from a shooting rampage last year at the Jewish Federation of Greater Seattle that left one woman dead and five other people wounded.

Defense attorneys argue that any self-incriminating statements made by Haq to psychologists and psychiatrists should be excluded from evidence, because the evaluations were court-ordered and Haq could not invoke his Fifth Amendment right to silence.

Senior Deputy Prosecuting Attorney Don Raz retorted that "to slice and dice" what information his expert witness can rely on goes against "proper methodology" and is "an affront to good forensic psychology."

This is a thorny issue and one worthy of contemplation by forensic psychologists and psychiatrists. The reigning text in our field, Gary Melton and colleagues' Psychological Evaluations for the Courts, suggests that experts should be "circumspect" in relying upon statements of defendants, especially defendants' statements to police, and should initially refuse to even consider third-party information that is known to be inadmissible so as not to contaminate our opinions. Parsing out specific statements made during a clinical evaluation is probably trickier, but certainly not impossible.

Judge Paris Kallas deferred ruling on the matter pending further contemplation. It will be interesting to see how she decides to balance Haq's rights against self-incrimination with the state’s right to challenge the insanity defense.

Haq's lengthy history of bipolar disorder is not disputed; indeed, it was a basis of the prosecution's decision to drop the death penalty. What is at issue is the severity of his illness, and whether his mental state at the time of the crime met Washington's legal standard for insanity, the M'Naghten test, which requires that a defendant be unable to tell the difference between right and wrong. (For more detail on the standard in Washington, see the 2003 appellate opinion in Washington v. Applin.)

Defense lawyers say Haq was delusional at the time of the murders. The prosecution contends that his careful planning belies psychosis. Insanity verdicts are notoriously difficult to obtain, in part because many people driven by persecutory delusions appear superficially rational and are capable of carrying out complex plans in furtherance of their delusionally based goals.

The judge denied a motion by defense attorneys to place the burden on the prosecution to prove that Haq was sane at the time of the rampage. Although the judge observed that Washington's higher courts had "not squarely resolved" this issue, prosecutors argued that a century of state law established that the burden was on the defense to prove insanity. (States handle this issue differently, with about one-third of states putting the burden on the prosecution to prove sanity beyond a reasonable doubt.)

In another evidentiary issue, the judge ruled last week that Haq's videotaped statement to police could not be introduced at his trial, because police ignored not just one but at least six requests for an attorney.

The Seattle Times has ongoing coverage; Wikipedia has additional background on the case.

"I've always been crazy . . .

. . . but it's kept me from going insane"

Those Waylon Jennings lyrics echoed in my head upon seeing today's article in the New York Times differentiating craziness from legal insanity.

The article, "Actions Considered Insane Often Don't Meet the Standards of New York's Legal System," highlights the case of David Tarloff, a chronic schizophrenic awaiting trial in the slashing death of a Manhattan therapist. But it is relevant across the board to the insanity defense, which is widely misunderstood by the general public and even many in the mental health professions.

The defense, which varies by jurisdiction but generally requires that the defendant did not know the difference between right and wrong, is rarely employed and is even more rarely successful.

As Ronald Kuby, a criminal defense lawyer, put it in the article, "You can be extremely crazy without being legally insane. You can hear voices, you can operate under intermittent delusions, you can see rabbits in the road that aren't there and still be legally sane."

Another public misconception is that successful use of the insanity defense allows people to "get off" for the crime. In reality, most insanity acquittees are sent to locked state hospitals that look very much like prisons. They often spend more time locked up than if they had been convicted of their crime.

The New York Times article is temporarily available here. A previous blog post of mine on high-profile insanity cases is here. Wikipedia has more information on the insanity defense.