This article was downloaded by: [Griffith University]On: 18 June 2014, At: 06:46Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UKCognitive NeuropsychiatryPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/pcnp20The Truman Show delusion:Psychosis in the global villageJoel Gold a & Ian Gold ba Department of Psychiatry , New York University School ofMedicine , New York , NY , USAb Departments of Philosophy and Psychiatry , McGill University ,Montreal , Quebec , CanadaPublished online: 29 May 2012.To cite this article: Joel Gold & Ian Gold (2012) The Truman Show delusion: Psychosis in theglobal village, Cognitive Neuropsychiatry, 17:6, 455-472, DOI: 10.1080/13546805.2012.666113To link to this article:http://dx.doi.org/10.1080/13546805.2012.666113PLEASE SCROLL DOWN FOR ARTICLETaylor & Francis makes every effort to ensure the accuracy of all the information (theContent) contained in the publications on our platform. 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Terms& Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditionsTheTrumanShow delusion:PsychosisintheglobalvillageJoelGold1andIanGold21DepartmentofPsychiatry,NewYorkUniversity SchoolofMedicine,NewYork,NY,USA2DepartmentsofPhilosophyandPsychiatry,McGillUniversity,Montreal,Quebec,CanadaIntroduction. Wereportanovel delusion, primarilypersecutoryinform, inwhichthepatientbelievesthatheisbeingfilmed,andthatthefilmsarebeingbroadcastfortheentertainmentofothers.Methods. Wedescribeaseriesofpatientswhopresentedwithadelusional systemaccordingto whichtheywerethesubjectsofsomethingakintoarealitytelevisionshow that was broadcasting their daily life for the entertainment of others. We thenaddressthreequestions,thefirstconcerninghowtocharacterisethedelusion,thesecondconcerningtheroleof cultureindelusion, andthethirdconcerningtheimplicationsofculturalstudiesofdelusionforthecognitivetheoryofdelusion.Results. Delusions are bothvariable andstable: Particular delusional ideas aresensitive to culture, but the broad categories of delusion are stable both across timeandculture. This stability has implications for the forma cognitive theoryofdelusioncantake.Conclusions.Culturalstudiesofdelusionhaveimportantcontributionstomaketothecognitivetheoryofdelusion.Keywords: Culture; Delusion; Grandiosity; Ideas of reference; Persecution;Realitytelevision.Inthefuture,everyonewillbeworld-famousfor15minutes.(AndyWarhol)INTRODUCTIONWiththeadvent of theInternet andothernovel formsof communicationandsocial interaction, oursocietyisundergoingashift inculturegreaterCorrespondence should be addressed to Joel Gold, MD, 225 Broadway, Suite 3400, New York,NY10007,USA.E-mail:joel.gold@nyumc.orgWe are grateful to Leah Katzman and Elizabeth Scott for research assistance. The paper has beengreatly improved by comments from Adam Karpati, MD, Lauren Olin and two anonymous referees.COGNITIVENEUROPSYCHIATRY2012,17(6),455472#2012PsychologyPress,animprintoftheTaylor&FrancisGroup,anInforma businesshttp://www.psypress.com/cogneuropsychiatry http://dx.doi.org/10.1080/13546805.2012.666113Downloaded by [Griffith University] at 06:46 18 June 2014 thananythingwehave witnessedindecades.Whatimpactmightsignificantchangesinculturehaveontheprocessesofmentalillness?Hereweexploreone aspect of this cultural change. Internet sites suchas YouTube, andanothernewcultural presence*realitytelevision*reveal twonewculturalphenomena. First, theydemonstratethatpeoplewithoutostensibleskillortalentcanbecomecelebritiesinanagewhencelebrityholdsgreatcurrency.Second,theseformsofentertainmentmakeitpossibletobecomeknowntotens of millions of people overnight. They have the powerful effect of makingtheworldfeel at onceverysmall andpossiblyoverwhelming. Wepresentfivepatientsinwhomtheideasofcelebrityandexposuretakecentrestageinthepresentationoftheirpsychosis. Theydevelopedthedelusional beliefthattheywerethestar ofarealitytelevisionshowsecretlybroadcastingtheir daily life, much like the main character in Peter Weirs filmTheTrumanShow.ThefilmTheTrumanShowwas releasedin1998andpresagedthewaveof realitytelevision shows that succeeded it. It follows the story of Truman Burbank, a30-year-oldmanwhoseentirelife*frominuterotothetimeofthemoviespresent*is broadcast around the world, without his knowledge, as a form ofsoap opera. The city he inhabits is, in fact, a domed sound studio, and all thepeopleinhislife, includinghiswife, parents, best friend, co-workers, andstrangers,are allactors andextras.Eventhe weatheriscontrolled.TheplotcentresonTrumansdawningawarenessofhisconditionandhisescapetothereal world, whereheis reunitedwithhis formergirlfriend, previouslybanishedbytheshowscreator.Givenhis realisationthat theworldhelives inis counterfeit, Trumanbegins tosoundlike apatient withmental illness. He has the idea ofreference that [t]he radio starts following me along, talking abouteverything Imdoing. He expresses the paranoid ideas that he isdefinitelybeingfollowed andthat he is beingset upfor something;hehasthegrandiosenotionthatthewholeworldrevolvesaround[him]somehow.Inordertokeeptheshowgoingatallcosts,theactorstellhimthatheisimaginingthesethings*thatheis,ineffect,mentallyill.Thefivepatients described later,1all treated at different times but on the samepsychiatric inpatient unit at BellevueHospital CentreinNewYorkCity,believed themselves to be in the same position as Truman Burbank; three ofthemreferredtothefilmbyname.1ThesepatientswerefirstpresentedatGrandRoundsintheDepartmentofPsychiatry,NewYorkUniversity,21September2006.456 GOLDANDGOLDDownloaded by [Griffith University] at 06:46 18 June 2014 CasesPatient 1. Mr A. was admitted after he scuffled with security at a federalbuilding. HesaidthathislifewaslikeTheTrumanShowandthathehadcometo ask for asylum. Hehad heldthisbelief for five years,andalthoughhelived withfamily,theywerenotawareofhisdelusionsuntilseveraldaysprior toadmission; he hadonlytoldafriendabout it 2weeks prior toadmission. He believed that the attacks of 9/11 were fabricated as part of hisnarrative. Hehadtravelledfromout-of-stateinordertoseeif theWorldTrade Centre had in fact been destroyed; if the towers were standing,hewouldhaveproof that he was onthe show. Onfirst presentation, hedemandedtospeaktothedirector. Hesaidthat sincehehadseenTheTrumanShow,he believedthat alltheindividualsinhislife werepartoftheconspiracy. Healsobelievedhehadcamerasinhiseyes. Despitethislong-standingdelusion, MrA. hadhadnopreviouspsychiatrictreatment. Itisnoteworthy, however, thatthepatienthadbeenusingover-the-counterfat-loss supplements and had lost 40 pounds over the previous 2 months in ordertobeabletojointhemilitary. Initial DSM-IVdifferential diagnosiswasschizophrenia, chronic paranoidtype versus substance-inducedpsychoticdisorder. Thepatient wasstartedonrisperidone1mgtwicedaily. Withindays,hewastransferredtoahospitalinhishomestate.Patient 2. Mr B. was admitted after he told psychiatric outreach that hebelieved he was being taped continuously for national broadcast. As a result,he had formulated a plan to come to NYC and meet an unknown woman atthetopof thestatueof liberty. Heexpected[her] toreleasehimfromthecontrol of an extended networkof individuals who are . . . taping himcontinually . . . and broadcasting the tapes nationally for viewers enjoymentaspartofascenariosimilarto. . .TheTrumanShow.Hesaid:Irealizedthat I was and am the centre, the focus of attention by millions and millionsof people . . . my [family] and everyone I knew were and are actors in a script,acharade whose entire purpose is tomake me the focus of the worldsattention. The patient had a history of three suicide attempts in the contextofdysphoria, hopelessness, andpersecutorydelusions. However, hedeniedever being in psychiatric treatment. He had a significant substance usehistory, includingfrequent crackcocaineuseof upto$150per day, andregularmarijuana use.On exam, Mr B.was dysphoric and irritable. He wasalsodiagnosedwithchronic hepatitis Bviral infection. He was initiallytreated withrisperidone,whichrequireddiscontinuationduetotransamini-tis. He was thengivenhaloperidol, titratedto15mgdailyandlithium,titrated to 300 mg tid, with therapeutic blood levels. Mr B. became akatheticon haloperidol, which was cross-tapered with quetiapine, advanced to300mgatbed. Bythistimethepatienthadbeenhospitalisedfor7weeksTHETRUMANSHOWDELUSION 457Downloaded by [Griffith University] at 06:46 18 June 2014 withlittleimprovement; heremainedpsychotic, withlabilemood. Hewasthereforetransferredtostatehospitalforcontinuedtreatment.Ontransfer,Mr Bs DSM-IV diagnoses were schizoaffective disorder, bipolar type; crackcocainedependenceandmarijuanadependence.Patient3. MrC. workedasawriterforalocal newspaper. Hisfamilybrought him to Bellevue Hospital Centres psychiatric emergency room afterthey received a disorganised letter intimating that the patient might besuicidal. He hadahistoryof outpatient treatment for depressionbut nohistory of hospitalisation. In fact, on admission, the patient was not suicidalbut was found to be manic and psychotic, with racing thoughts, loosening ofassociationsandpressuredspeech. MrC. believedthatnewsstoriesinthenewspaper, on television, and on the Internet were created for his amusementby his associates in the media. He claimed to knowthis because hiscolleagueswereusinghis styleof reporting. Hesaidthat his privacywasbeinginvaded andthathisfriendshadhadhimhospitalisedasa prank.Hebelievedthathisdoctor, thestaff, andeverypatientontheunitwerewell-paidactors, that everythingwas fake, andthat all myassociates areinvolved. Mr C. believed that he had won a prize for his journalism and thatthe hospitalisation was a build-up to his being awarded a large sum of moneybothfor his writingas well as for playingalongwiththe conspiracy.Duringhishospitalisation,thepatientattemptedtoescapeostensiblytoseethe disparities between the news he was receiving on the ward and what wasreallyhappeningoutside. Mr C. hadapositive familyhistoryof bipolardisorder onbothsides. UsingDSM-IVcriteria, as well as psychologicaltesting, the patient was given a diagnosis of bipolar disorder, current episodemanic, withpsychoticfeatures. Thepatientwastreatedwitholanzapine30mgatbed, valproicacid500mginthemorningand1000mgatbed, andlithium450mgtwicedaily,thelattertwototherapeuticbloodlevels.MrC.improved to the point where he could say that there is an 80% chance that Iwill treat the hospitalization as if it is for real and that he could distinguishreality from unreality. The patient was discharged with residual delusionalideationaftera10-weekhospitalisation.Patient4. MrD.was workingonarealitytelevisionshowwhenhe washospitalised after causing a public disturbance. While working on theproductionof theshow, hecametobelievethat hewastheonewhowasactuallybeingbroadcast: IthoughtIwasasecretcontestantonarealityshow.IthoughtIwasbeingfilmed.IwasconvincedIwasacontestantandlatertheTVshowwouldreveal me. Hebelievedhisthoughtswerebeingcontrolled by a film crew paid for by his family. During the 2 weeks prior toadmission, he experienced decreased sleep, pressured speech, irritability,paranoia, andhyperreligiosity. The patient carriedadiagnosis of bipolar458 GOLDANDGOLDDownloaded by [Griffith University] at 06:46 18 June 2014 disorderandhadhadtwoprevioushospitalisationsformanicepisodes.Hehadsmokedmarijuanaintermittentlysincehewasincollegeandhadlastsmokedmarijuanaoneweekprior toadmission. Mr D. was treatedwithquetiapine titrated to 500 mg daily and valproic acid 750 mg twice daily, withtherapeuticbloodlevel,andherespondedtothistreatmentregimen.Ashismaniasubsided,hisdelusionremitted,andhewasdischargedafter4weeksof treatment with DSM-IVdiagnoses of bipolar disorder, most recentepisodemanic,withpsychoticfeatures,andmarijuanaabuse.Patient5. MrE. washospitalisedafterhewasfoundinalibraryafterhours. Heclaimedthat theSecret Servicewas followinghiminorder toprotect himbecausehehadbrokenthecode. Hehadbeentreatedwithmethylphenidatefor attentiondeficit hyperactivitydisorder andacknowl-edged using more than was prescribed at times. He had seen a psychiatrist inthemonthpriortoadmission, ashehadbeenfeelingdepressed, andwasprescribedparoxetineandolanzapinebutdidnottakethemedication. Hehad no history of hospitalisation. Mr E. described a scheme, which he saidwassimilartoTheTrumanShow.Hebelievedthathewasthemaster ofthescheme,thatitinvolvedeveryoneinhislifeincludingthehospitalstaff,andthat all these people were actors. He thought that he might be recorded whilein hospital.He believed that the news was fabricatedand that the radio wasrecorded for him. Mr E. said that he wanted to get back to my real life andwanted to find out whats really going on in the outside world. He believedthat the scheme would end on Christmas Day and that he would be releasedthen. He was prescribedrisperidone 5mgdaily, whichhe acceptedonlybecause he believed that it was actually the methylphenidate required to treathis attention deficit hyperactivity disorder. Propranolol was added forakathisiaandwastitratedto30mgtwicedaily. Hewasinitiallyprescribedfluoxetinefordepressedmood, but giventheakathisia, hisantidepressantwas switched to escitalopram10 mg daily. Mr E.s insight graduallyimproved. He continued to question the veracity of the news but alsoexpressedconcernthathemightbedevelopingschizophrenia.ThepatientsDSM-IV differential diagnosis was schizophreniform disorder versusmethylphenidate-inducedpsychoticdisorder.After8weeksatBellevue,thepatientwasdischargedtoapartialhospitalisationprogramme.OthercasesWe knowof noother scientific reports of patients withdelusions of theTruman Show type, but Fusar-Poli, Howes, Valmaggia, and McGuire (2008,p. 168) report on a patient who had a sense the world was slightly unreal, asTHETRUMANSHOWDELUSION 459Downloaded by [Griffith University] at 06:46 18 June 2014 ifhewastheeponymousherointhefilmTheTrumanShow. However,atnopointdidhisconvictionreachdelusionalintensity.Therehavebeenatleasttwonewsreportsofindividualswhoappeartohave suffered from the Truman Show delusion. In 2007, William Johns III, apsychiatrist fromFlorida, attempted to abscond with a child, ThorinNovenski, andsubsequentlyattackedthechildsmother. Anewsreportontheincidentclaimsthatafriendofthepsychiatristreportedlytoldajudgethat Johns saidhe hadtogotoNewYorktoget out of TheTrumanShow.2In 2009, Antony Waterlow, a Sydney man, murdered his father and sisterwhile in a psychotic state.A news report statedthat Mr Waterlow believedhisfamilywasbehindaworldwidegametomurderhimorforcehimtocommit suicide. A doctor who interviewed the man is reported to have saidthatMrWaterlowtoldherinaconsultationinFebruarythathebelievedcomputerswereaccessinghis brainthroughbrainwaves andsatellites. HesaidhisfamilywasscreeninghislifeontheInternetfortheworldto watch,akintothefilmTheTrumanShow.3We have heard anumber of anecdotesfromcolleagues whohave,or havehad, patients expressing the same delusion. We have had numerousinteractions, bothbyemail andtelephone, withindividualswhoclaimtohavesuffered, orbesuffering, fromthisdelusion. WehavealsospokentopeoplewhobelievedtheirfamilymembersweresufferingfromTSD.Whilethesehistoriesseemtousauthentic, wehavenotconductedformalclinicalinterviewstosubstantiatethispossibility.These patients raise three general questions of interest. First, howpreciselyshouldtheir delusions be characterised? Second, what does thedelusion contribute to our understanding of the role of culture in psychosis?And, third, what, if anything, does the influence of culture ondelusionsuggest about the cognitive processes underlying delusional belief ? Weaddressthesequestionsinthenextthreesections.CHARACTERISINGTHETRUMANSHOWDELUSIONIt is clear that the broad themes of the Truman Show delusion arepersecutory and grandiose, with ideas of reference, but some unusualfeatures manifest intheparticular contents of thepatients beliefs totheeffect that they are living in an artificial environment populated with peoplewhoaremerelyplayingarole.2http://abcnews.go.com/TheLaw/story?id3416296&page1(accessed11May2011).3http://www.smh.com.au/nsw/waterlow-shattered-by-the-reality-of-killings-20110412-1dcpz.html(accessed11May2011).460 GOLDANDGOLDDownloaded by [Griffith University] at 06:46 18 June 2014 Onehypothesisconcerningthecorebeliefof thepatientsisthat it isaformofmisidentificationdelusion, suchastheCapgrasdelusion, inwhichthe patient typically believes a loved one to have been replaced by a duplicateor fake (Enoch &Ball, 2001). In Capgras, the object of the delusionappears like the loved one, but is not in fact the loved one. Silva, Leong, andOReilly(1990, p. 45)reportonapatientofwhomtheysaythefollowing:Mr D. recognized several of the patients, whom he had met during previoushospitalizations onthis wardandexplainedthat they hadbeengenuinepsychiatric patients inthe past, but hadsincebeenreplacedbyidenticaldoubles whowere well paidactors. Because this patient believes thosearoundhimtobeduplicates,Capgrasseemstobethecorrectdiagnosis.Incontrast, the present patients delusions do not involve duplication. They donot believe that the identity of the people around them are at odds with theirappearance, nor is their environment a copy of a genuine hospital that existselsewhere(amanifestationofthedelusionofreduplicativeparamnesia; seeForstl, Almeida, Owen, Burns, &Howard, 1991). It is rather that thefunctions of thepersonnel andthehospital arebeingmisrepresented. Wesuspect,therefore,thatthepatientsdescribeddonotsufferfromdelusionalmisidentification but rather from a culturally shaped combination ofpersecutoryandgrandiosedelusions,aswellasideasofreference.Parallels tothepresent casemight alsobesought intheexperienceofunreality that may be brought about by stress such as that caused byhospitalisation (e.g., Granberg, Engberg, &Lundberg, 1999) and, to agreater extent,bythephenomenonofdepersonalisationwhichissometimesexpressedastheexperiencethat everythingfeelsfakeorunreal (Young&Leafhead, 1996). Patientssufferingfromdepersonalisationhavealsobeenreportedtosay that their doctors are actors andthe like. Suchclaims,however, seembestunderstoodasexpressionsofthegeneral experienceofunrealitycharacteristic of depersonalisation, rather thanthe belief inanorganiseddeception.A third parallel may be found in the sense of unreality that ischaracteristicof theonset of schizophrenia. Sass(1988, p. 224) representsthe prodromal phase of schizophreniaas characterisedby a sense thateverythinghas undergone somesubtle, all-encompassingchange. Subse-quently, thephenomenologyofschizophreniamaycontinuetoincludethesenseof aworldthat is radicallyalien. Althoughthis phenomenology,which Sass refers to as Stimmung (i.e., mood), does not amount to delusionalbelief, itdoesresonatewiththeTrumanShowideathattheentireworldisunreal, rather than some particular person or thing in it. The all-encompassingnature of this experience is thus similar towhat might becalledthecontrolledunrealityoftheTrumanShowworld.THETRUMANSHOWDELUSION 461Downloaded by [Griffith University] at 06:46 18 June 2014 THETRUMANSHOWDELUSIONANDREALITYTELEVISIONHowevertheTrumanShowdelusionoughttobeclassified,itiswellworthconsidering which cultural phenomena, if any, might be relevant to itsmanifestation. Ofcourse, thepatients referencetothefilmmightbequitecoincidental. Itmay,incontrast,beaproductinpartofthecontemporarypopularityinourcultureofrealitytelevision. Canacasebemadethatthephenomenon of reality television might interact with the expression ofpsychoticsymptoms?There is less in the way of psychological research on reality television thanonemightexpectgivenitspopularity.Inonestudy,ReissandWiltz(2004)investigatedthecorrelationbetweentheviewingofrealitytelevisionandalarge number of personality traits. They foundthe strongest correlationbetween reality television viewing and a trait they refer to as social status,which entails an above-average trait motivation to feel self-important(p.363).Theyalsofoundadoseeffect;themorerealitytelevisionwatched,thegreatertheconcern.This is perhaps not altogether surprising, but it suggests that realitytelevision resonates with a common anxiety about ones position in the socialhierarchy. Asnotedearlier, realitytelevisionmakesitconceivablethatonecouldcometotheattentionofacommunity ofpeopleordersofmagnitudelarger thanwas possibleonlyafewyears ago. Onemight speculate thatbecause our worldreallyis aglobal village now, the threats fromothermembers of ones community(see Buss &Duntley, 2008), as well as thepromiseofthestatusthatmightachievedbybeingknowntostrangers, isalsosignificantly greaterthanithaseverbeen.Someonewhoisparticularlyanxious about their social status, therefore, might experience realitytelevision as presenting a significant social threat, or a tantalising possibilityof success, or both. In the life of such a person, reality television might act asa significant stress, the effects of whichmight include a persecutoryorgrandiosedelusionoftheTrumanShowtype.THETRUMANSHOWDELUSIONANDCULTUREContentandformindelusionNovel delusionsthat makereferencetopopularcultureortechnologyarestriking in part because they seem to provide evidence of the capacity of thecultural environmenttointeractwithpsychoticillness. Cultural psychiatrydoesindeedmakereferencetoa widevariety ofexoticdelusionalideasthatdepend on the local culture. For example, one can find patients in China whobelieve that they are the chief disciple of the Buddha (Yip, 2003), but such a462 GOLDANDGOLDDownloaded by [Griffith University] at 06:46 18 June 2014 delusionisunlikelytooccurinWesterncultures; sufferersfromdelusionalturabosis*thebeliefthatoneisbeingcoveredbysand*canbefoundinSaudi Arabia but probably not Finland (Qureshi, Al-Babeeb, & Al-Ghamdy,2004); andonecanbelievethat oneis pregnant withpuppies after beingbittenbyadoginWest Bengal but probablynot Australia(Chowdhury,Mukherjee,Ghosh,&Chowdhury,2003).In addition,delusional beliefsaresufficiently sensitive to culture that both current events (Sher, 2000) culturalinnovationssuchasmicrochips(Eytan,Liberek,Graf,&Golaz,2002),andtheInternet(Bell, Grech, Maiden, Halligan, &Ellis, 2005)canbeusedasdelusionalvehicles,ascangeneralscientificknowledge(see,e.g.,Stefanidis,2006).Nonetheless, the variety of delusions across cultures obscures theimportant fact that the basic motifs of delusionare bothuniversal andrathersmallinnumber.Delusions,asJaspers(1959/1997,p.411)putit,are of striking variety, imaginativeness and eccentricity. The initial folly wascommittedof consideringeverysingledelusional content asaspecial illnessandgiving it a name . . . without noticing that nomenclature of this sort has no end. Butthe contents do have a number of general, common characteristics that recurrepeatedly and give a peculiarly uniformcharacter to the multiplicity of thecontents.Following Jaspers, we will refer to a particular delusional idea as adelusional content, and the type or category of the delusion as the delusionalform. Thus, abelief withthedelusional content that onesphoneisbeingtappedbytheCIAisadelusionwithapersecutoryform; abeliefwiththedelusional content that one is the star of a reality televisionshowis adelusionwithagrandioseform;andsoon.The distinctionbetween content and form in delusionis vague but not inanywaythat threatens its coherence(seeSorensen, 2001). Onemight beuncertain, for example, whether the delusion of thought insertion is a specieswhose genus also includes thought broadcast, mind-reading, and the like, ordeservestobecountedagenusall itsown. Issuessuchasthiscanonlyberesolvedbycomprehensiveepidemiological researchintothefrequencyofoccurrence of particular delusions and an adequate theory of delusion whichmotivatesonetaxonomyratherthananother.Neithertheepidemiologynorthetheoryisasyetavailabletomakesuchdecisions. Nonetheless, itseemsvery plausible that an Americans belief that his phone is being tapped by theCIA and a Chinese persons belief that his post is being read by the GeneralSecretaryoftheCommunistPartydeservetobeclassifiedtogether. Onlyadeveloped theory will be able to confirm the validity of this classification andofthecontentformdistinctionmoregenerally.THETRUMANSHOWDELUSION 463Downloaded by [Griffith University] at 06:46 18 June 2014 VariabilityandstabilityindelusionIn addition to the cultural plasticity of delusional contents, the frequency ofdelusionalformsalso appears to exhibit some variability over time.Stompe,Ortwein-Swoboda, Ritter, &Schanda (2003, p. 9) surveyed studies ofchanges in the frequency of delusional forms in schizophrenia in fourcountries (Austria, Germany, Italy, and Switzerland) between 1856 and 1975.They found evidence of both increases and decreases in these forms; religiousdelusions, for example, have increased, whereas delusions of guilt havedecreased.Thedistributionofdelusionalformsalsovarieswithculture.Delusionaljealousy is more common in Tu bingen, for example, than Tokyo (Tateyama,Asai, Hashimoto, Bartels, &Kasper, 1998). Gender and class are alsorelevant. Awealthy male Pakistani is more likely toexhibit grandiosity,whereasapoorfemaleismorelikelytoexhibiterotomaniaordelusionsofcontrol (Suhail, 2003). Adislocation fromone culture to another alsochanges the manifestationof delusions. Pakistanis whohave migratedtoBritain exhibit a pattern of delusional forms that is more like that of the localpopulation than the population in the country of origin (Suhail & Cochrane,2002). Finally, differencesintheoccurrenceofdelusional formshaveevenbeenreportedacross different regions of thesamecountry(Gecici et al.,2010).Itremainsunclearwhethertheprevalenceofdelusionsingeneral variesacross time or culture. One would like to know, for example, whetherparticular culturesor historical periods aremoreconducivetodelusionalideationof anykind, rather thantoother psychotic symptoms, suchashallucinations. Thisquestionisparticularlyacutewhenasocietyisunder-going rapid cultural change. Under such conditions, it is conceivable that thestresses of this change could produce a greater number of delusions in thosewhoaresufferingfrompsychoticdisorders. Inaddition, onewouldliketoknow whether particular cultures or historical periods are more conducive tothedevelopmentofpsychosisatall.Thatis,aretheretimesorplaces wherepeoplewhowouldotherwisenotsufferfrompsychosisdoso?Despite the variability in the frequency of delusional forms over time, theavailable evidence supports the claim that the absolute number of delusionalforms is relatively small. Stompe et al. (2003) list sevenmotifs that arecentral todelusion: persecution, grandiosity, guilt, religion, hypochondria,jealousy, and love. To these we would add: reference, control, thought,nihilism, and misidentification. Table 1 summarises three studies of thefrequencyofthesedelusional formsindifferentlocalesorcultural groups.Although the taxonomy of the delusional forms differs somewhat across thestudies, all three support the claimthat the number of forms is small,particularlythosethatarehighinfrequency.464 GOLDANDGOLDDownloaded by [Griffith University] at 06:46 18 June 2014 TABLE1Thefrequencyofdelusionalformsin11localesorculturalgroups(a) Form Seoul Shanghai TaipeiPersecutory 72.3 78.9 79.1Reference 66.0 54.2 59.0Grandiose 48.2 27.5 38.8Control 35.5 23.9 30.9Somatic 23.4 14.1 24.5Guilt 31.2 4.9 5.8Jealousy 17.0 8.5 3.6Poverty 2.1 4.2 5.0Nihilism 0.7 2.1 3.6(b) Form Tokyo Vienna Tu bingenInjury(includingpersecution)78.4 71.3 77.3Grandeur 25.3 25.7 26.7Belittlement 13.3 37.6 24.0Unclassifiable 3.4 1.0 2.7(c) Form White BritishPakistani PakistaniPersecution 48 60 62Control 50 26 13Reference 48 43 11Grandioseability 26 19 28Grandioseidentity 14 23 42Religious 14 21 11Sexual 18 13 16Depersonalisation 12 11 2Hypochondriacal 8 17 5Misinterpretation 8 6 8(d) Form WesternTurkey CentralTurkeyPersecutory 74.6 83.7Reference 57.7 70.9Poisoning 9.5 26.2Religious 10.9 20.9Grandiosity 10.0 19.8Beingcontrolled 6.0 19.8Mindreading 4.5 17.4Jealousy 3.5 14.0Guilt/sin 0.5 13.4Hypochondria 1.0 12.2Erotomania 2.5 9.3Thoughtbroadcasting 0.5 11.1Thoughtinsertion 1.0 9.3Nihilistic 4.0 5.2Thoughtwithdrawal 0.5 5.2THETRUMANSHOWDELUSION 465Downloaded by [Griffith University] at 06:46 18 June 2014 Incontrast,thereislittleevidencetosuggestthatnoveldelusionalformsarise in response to cultural change. When new delusions arise, the novelty istypically rather minor. Schmid-Siegel, Stompe, and Ortwein-Swoboda(2004), forexample, report onapatient whobelievedthat herperceptualexperienceswerebeingtransmittedtoothersviatheInternet. Perceptionbroadcast, as the authors refer toit, differs intwoways fromthoughtbroadcast. It involves the transmission of perceptual experience, ratherthanthought,anddoesso viatheintermediaryoftheInternet,ratherthandirectly. Despite the novel features of this delusion, however, perceptionbroadcast seems much more like a variation on thought broadcast than like anewdelusional category. Thesameis trueof theTrumanShowdelusion.Although the feature of controlled unreality is novel, the delusion remains avariantonpersecution,grandiosityandreference.The same can be said of the so-called culture-bound syndromes (Simons&Hughes, 1985), psychopathological phenomena that are believed by some tobe culture specific. There is reason to be sceptical about the coherence of thistheoretical construct(Kirmayer, 2007). Inanycase, fewofthephenomenalistedinthe DSM-IVare clearlypsychotic innature, makingthemonlymarginally relevant to the present discussion. Those that are include bouffeedelirante, abriefpsychoticepisodeoccurringinWestAfricaandHaiti, qi-gong psychotic reaction, a psychotic episode associated with qi-gong practice,andlocura, aformof chronicpsychosis foundinLatinAmericaandtheUnited States. Crucially, however, these psychotic states do not involve uniquedelusional forms. Other cases of delusion that look to be culture specific*thedelusionof puppy-pregnancy, for example, or theJerusalemsyndrome, areligiousdelusionthatdevelopsinsomevisitorstoJerusalem(Bar-Eletal.,2000)*nonetheless fall into one of the familiar delusional forms.We are in agreement, therefore, with Stompe et al. (2003), who argue thatputatively newdelusions are never more than novel manifestations ofTABLE1(Continued)(d) Form WesternTurkey CentralTurkeyNobility 0 3.5Inferiority 0 3.5Homosexual 0 3.5Parasitosis 0 1.2Worldcatastrophe 0 1.2Resurrection 0 1.2Others 4.5 0.6Sources: (a) Kimet al. (2001); (b) Tateyamaet al. (1998); (c) Suhail andCochrane(2002);(d)Gecicietal.(2010).466 GOLDANDGOLDDownloaded by [Griffith University] at 06:46 18 June 2014 delusional formsthat areunchangingacrosstimeandculture. Changesindelusional content, astheauthorsputit, arenevermorethanoldwineinnew bottles. Culture is thus pathoplastic with respect to delusions*it canshapedelusional contents*butitisnotpathogenic; itdoesnotcreatenewformsofdelusion(Tseng,2001,p.178ff.).CULTUREANDCOGNITIVETHEORIESOFDELUSIONCognitive neuropsychiatrictheoriesofdelusionhave not,todate,takenanyaccount of the role of culture inthe genesis andshaping of delusionalideation. There are at present three general approaches to cognitive accountsof delusion (Garety & Freeman, 1999), all of which are concerned primarilywiththequestionof howdelusionsareformed, ratherthanwhytheyareretained in the face of conflicting evidence: (1) the theory of mindhypothesis,duetoChristopherFrith,holdsthatdelusionsariseinpartasaresult of a disorder in the processes involved in making inferences about thementalstatesof others;(2)thejumpingto conclusionshypothesis,duetoPhillipaGarety, holds that delusionsariseinpart asaresult of abiasinprobabilisticreasoning; and(3)theattributional bias hypothesis, duetoRichardBentall,holdsthatdelusionsariseinpartasaresultofadistortedexplanatory style in which blame for negative events is located in the externalworldratherthaninthesubject. Wedescribeeachinturnandthenbrieflydiscusstherelevanceofcultureforthecognitivetheoryofdelusion.TheoryofminddisorderThetheory of mind(ToM)capacity referstoa family of abilitiesto makeinferences about the mental states of others (see Baron-Cohen, Leslie, &Frith, 1985). An example of this capacity is the ability to knowwhatsomeoneinaparticularsocialsituationis,ormightbe,feelingorthinking.The ToMcapacity is thought to be disordered in autismwhich wouldaccount forthesocial impairmentsthat arecharacteristicof thedisorder.Frith(1992)hypothesisesthataToMdisordermayalsobeimplicatedinatleastsomedelusions.In order to be able to think about the mental states of others, one must beable to keep track of thoughts that are self-generated and those that originatewithothers. Self-monitoring of ananalogous kindis present inotherdomains of mental life. Eye movements, to use Friths analogy, do not lead totheimpressionthat theworldismoving, eventhoughtheretinal imageisshifting. An efference copy of the motor command alerts the visual systemthat the change in the retinal image is caused by motor behaviour and not bya change in the external world. The efference copy enables the visual systemTHETRUMANSHOWDELUSION 467Downloaded by [Griffith University] at 06:46 18 June 2014 tocompensate for the movement of the retinal image andgenerate theappearanceof astableenvironment inwhichonlythedirectionof gazeischanging.Frithhypothesisesthatsomethinglikeanefferencecopymustbepresent in thought as well so as to tag ones thoughts as self-generated ratherthanoriginatingfromsomeoneelse.Anintentiontothinkathought,sotospeak, is preceded by a copy of the intention, which serves as an indicator oftheoriginofthethought.Suppose, however, that thisprocessof self-monitoringweredisordered.One would then encounter thoughts that were not tagged as havingoriginatedinonesownmind. Anexplanationofthisanomalousphenom-enonmight bethat someoneelsehadplacedthethought there. Suchanexplanationwouldamount toadelusionof thought insertion. Asimilaraccount canbegivenof delusions of control. If anefferencecopyof theintentionto carry out an action werenot made, thentheaction would seemtooccur without the agents intention. One possible explanationfor thisoccurrence is that the intention to carry out the action in fact lies in someoneelsesmind.JumpingtoconclusionsPhillipa Garety (e.g., Garety et al., 2005) has proposed that one contributortothe development of delusions is a disorder of probabilistic reasoningknownasthejumpingtoconclusions(JTC)bias.Thebasicphenomenonis as follows (see Fine, Gardner, Craigie, & Gold, 2007). A subject is told thathewill beshownasequenceofcolouredbeadsdrawneitherfromajarinwhich 85% of the beads are red and 15% of the beads are black or from a jarinwhich85%of thebeads areblackand15%of thebeads arered. Thesubjectisshownonebeadata timeandaskedtostoptheexperimentwhenhe is confident he knows whichjar is beingused. People withdelusionsrequiresignificantlyfewerbeadsbeforereachingadecision; theyjumptoprobabilistic conclusions onthebasis of less evidencethat nondelusionalsubjects.Garetyandher colleagues believe that delusionformationis amulti-factorial process only part of which requires the presence of a JTC bias. Onepossibleroleof thebias indelusiondevelopment is as follows. It is verywidely believed that delusions begin with a strange or anomalousexperience. Theanomalous experience seems tocall for explanation, andthe hypothesised explanation is the delusion. For the experience to lead to adelusional belief, however, many theorists believe that some cognitive processhas to be disordered as well. The strongest evidence for this claim is that theanomalous experiences hypothesised to be present in some delusions are alsofound without the presence of delusions in other psychological or468 GOLDANDGOLDDownloaded by [Griffith University] at 06:46 18 June 2014 neurological disorders (see Davies, Coltheart, Langdon, &Breen, 2001).Intuitively, a cognitive disorder*sometimes referred to as a secondfactor*seems implicated in delusion formation because delusions areimprobable or bizarre. If one were to have the anomalous experience that onewere being watched, for example, the Truman Show delusion is surely not themost plausible explanation of that feeling.In order for the delusionto seemplausible, the reasoning goes, one must have a second disorder of some kindwhichblindsonetotheimplausibilityoftheproposedexplanationfortheanomalous experience. TheJTCbiasis apossiblecandidateforasecondfactor in delusion formation. If one were to entertain the hypothesis that oneis being filmed as an explanation for the anomalous feeling that one is beingwatched, that hypothesis couldonlybeacceptedif onewerepreparedtoaccepthypothesesonrelativelylittleevidence.AttributionalbiasRichard Bentall incorporates Garetys jumping to conclusions theory as wellasFrithsToMdeficitaccountintoamodel ofparanoia(see, e.g., Bentall,2009).AccordingtoBentall,however,theengineofparanoiaisprimarilytheexternalisingof attributionin theface of negative lifeeventsas a way ofmaintaining self-esteem.In the face of the disappointments of life, paranoidindividuals maintain self-esteemby blaming their misfortune on othersratherthanonthemselves. Someonewhodoesnotreceiveapromotionatworkandconcludesthatherbossisoutto gether,ratherthanthatshehasnotdonea very goodjob,maintainsherself-esteem;thecostisparanoia.Buffering against narcissistic injury alone, however, does not lead todelusion. The goal of preserving self-esteemis near universal innonde-pressed people, but delusions are not. In Bentalls model, people withparanoiddelusionsaremorelikelytohaveahistory ofinsecureattachmentto parents in childhoodor to have experiencedpowerlessnessand victimisa-tion.Theseadverselifeeventsresultinlowself-esteemand,inconjunctionwithToMdeficits, yieldtheexternalisingattributional bias. Thesecircum-stancesthensensitisethedopaminesystem,raisingtheassessmentofthreatand ultimately produce paranoia. Finally, the JTC bias inhibits the paranoidpatientfromquestioningthedelusiononceitisinplace.CultureanddelusionalcognitionThe models of Frith and Bentall differ fromthat of Garety in generalapproach. FrithandBentall posit disorders that are tailoredtoexplainindividual delusional forms*thoughtinsertionanddelusionsofcontrol inFriths account, and persecutory delusions in Bentalls. In contrast, GaretysTHETRUMANSHOWDELUSION 469Downloaded by [Griffith University] at 06:46 18 June 2014 account isglobal, insofarasit positsacognitivebiasthat isputativelyimplicated in the formation of any delusion. The fact that culture appears tobepathoplasticwithrespecttodelusionsratherthanpathogenic, however,suggests that aglobal account of this kindcannot standonits own(asGaretyacknowledges).AJTCbiasisneutralwithrespecttothecontentofbeliefs. Any belief evaluated against evidence should be more quicklyadoptedbysomeonewithaJTCbiaswithoutregardtothecontentofthebelief. Thus, thepresenceofaJTCbias, onitsown, wouldbeexpectedtolead to the adoption of all manner of delusional belief. In particular, as novelideas appear in the local culture, someone with the bias would be as likely toadopt that ideaas part of their psychoticideationas anyof thefamiliardelusional forms. By itself, a JTC bias directed at the phenomenon of realitytelevision,forexample,isnotmorelikelytoleadtoapersecutorydelusionthantothe bizarre ideathat humanbeings are beingtransformedfromcreatures of flesh and blood into electromagnetic radiation. And yet no suchdelusional formexists. The stabilityof the categories of delusionacrossculture supports the idea, therefore, that delusions arise as a result ofdisorders of relatively narrow cognitive mechanisms such as those subservingaToMcapacityorattributionalstyle.The cross-cultural stability of delusional forms thus represents asignificantconstraintontheconstructionofcognitivetheoriesofdelusion.A salient aspect of cultural change in general is precisely the changing beliefsheldby the members of the culture. These changes are reflectedinthechanging contents of delusion in those suffering frompsychotic illness.Persecutory beliefs, for example, can and do make reference to realitytelevisiononce the ideais available inthe local culture. However, realitytelevisioncanonlyappearinoneof thefamiliarformsof delusionwhichremain stable across culture and history. The delusional forms are conceptualplaceholders whichculture canfillina variety ofways,but culturedoes notappear to be able to create or abolish the delusional categories themselves.CONCLUDINGREMARKSThe Truman Show delusion represents a new addition to the many particulardelusional ideas that arise bymeans of apathological transformationofculturallyavailableconcepts. Althoughrelativelylittleisknownabout theinteractions betweencultureandtheprocesses of delusionformationandretention, the available evidence points tocognitive mechanisms that areboth universal and specific. The universality of the mechanisms is supportedbythefact that the same handful of motifs recurs indifferent historicalperiods and cultures.At leastsome aspects of delusional thought,therefore,are rooted in features of cognition that seemto be shared by people470 GOLDANDGOLDDownloaded by [Griffith University] at 06:46 18 June 2014 regardless of culture. Whether this universalityis the result of biologicalcommonalities, or aspects of humanexistence that are shared(or both)remains an open question. The processes of delusional cognition are specificinthesensethatdespitethevarietyofhumanexperience, delusional formsare highly restricted insubject matter. Once again, the reasons for thisspecificityremaintobeclarified.The universality and specificity of the forms of delusion representsignificant constraints on a cognitive theory of delusion, and furtherattention should be given to these facets of cognition in psychosis. 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