Flesh start: A beginner’s guide to Windigo Psychosis

In previous blogs I have examined various culture bound syndromes (i.e., a combination of psychiatric and/or somatic symptoms viewed as a recognizable disease within specific cultures or societies). Arguably, one of the most interesting culture bound syndromes is (the much disputed) ‘Windigo psychosis’ that was said to have been reported among Algonquian native tribes (which are among the biggest and most widespread of North American natives and who lived around the Great Lakes of Canada and America). The disorder allegedly comprised individuals who intensely craved human flesh and who believed they would turn into cannibals.

The windigo was a cannibalistic spirit forest creature that appeared in Algonquian legends, and was known by lots of other names and variants (including – among 37 others identified by John Columbo in his 1982 book Windigo – wendigo, weendigo, windiga, waindigo, windago, wihtikow, and witiko). For instance, the Ojibwa tribe (a Native American people originally located north of Lake Huron before moving westward in the 17th and 18th centuries into Michigan, Wisconsin, Minnesota, western Ontario, and Manitoba) believed the windigo was a ferocious ogre that took children away if they did not behave themselves.  More generally, it was believed that the windigo could possess and infect human beings and transform them into cannibalistic creatures. Such cannibalistic practices were said to have begun in times of extreme winter famine when families were isolated and confined to their cabins because of heavy snowfall. Legend also has it that the infected sufferer would have their heart turned to ice.

However, windigo is a disorder that has been continually challenged across many decades as a myth (for instance, Dr. R.H. Prince in a 1992 issue of Transcultural Psychiatric Research Review; Dr. R.C. Simons and Dr. C. Hughes in a 1993 book chapter on culture bound syndrome; Dr. P.M. Yap in a 1967 issue of the Australia New Zealand Journal of Psychiatry). Whether the condition genuinely existed or not, no-one disputes that the number of cases reported over the last hundred years are minimal.

According to John Columbo, the first derivation of the word ‘windigo’ (i.e., the word ‘onaouientagos’ meaning both ‘cannibal’ and ‘evil spirit’) first appeared in print as long ago as 1722 in an account by Bacqueville de la Potherie, a French traveler. Windigo psychosis was said to occur when an individual became highly anxious that they were transforming into a windigo and believed that other humans that they lived among them were edible. Symptoms of the psychosis were said to include nausea, vomiting, poor appetite and anti-social behaviour. In extreme cases, the psychosis was said to produce suicidal tendencies (as a way of preventing possession by the windigo) and/or homicidal tendencies (to eat the human flesh of others). A book (The Lost Valley and Other Stories) written by Algernon Blackwood in 1910 featured a horror story (called ‘The Wendigo’), and was widely believed to be based on the Algonquian windigo legends.

In the 1982 book Windigo: An Anthology of Facts and Fantastic Fiction edited by John Columbo, he noted that:

“Windigo has been described as the phantom of hunger which stalks the forests of the north in search of lone Indians, halfbreeds, or white men to consume. It may take the form of a cannibalistic Indian who breathes flames. Or it may assume the guise of a supernatural spirit with a heart of ice that flies through the night skies in search of a victim to satisfy its craving for human flesh. Like the vampire, it feasts on flesh and blood. Like the werewolf, it shape-changes at will”.

In an online article about ‘culture specific diseases’, Denis O’Neil claims that modern medical diagnoses might label windigo as a form of paranoia because “of the irrational perceptions of being persecuted”. Here, O’Neil argues that it is the windigo monsters who are the persecutors (i.e., the windigo monsters are trying to turn people into monsters like themselves).  O’Neil also argues that in contemporary North American culture “the perceived persecutors of paranoids are more likely to be other people or, perhaps, extra terrestrial visitors”. 

Writing in a 2006 issue of the journal Transcultural Psychiatry, Dr. Wen-Shing Tseng said that it’s important to re-examine the sources of knowledge for each culture-related specific syndrome (including windigo which she also examined). She acknowledged that literature relating to windigo dated back to the 17th century, she made a lot of reference to the work of J.E. Saindon and the Reverend J.M. Cooper who both worked among an Algonquian community in the 1930s. She argued that the reports of both Saindon and Cooper “were based on second-hand information provided by non-clinical observers”. She then noted that the pioneering cultural psychiatrists of the 1950s and 1960s dealt with these early accounts “as though they were well-defined clinical entities with the diagnostic term witiko psychosis”.

In a paper by Dr. Lou Marano in a 1982 issue of Current Anthropology, it was noted that aspects of the Windigo belief complex may have had components in some individual’s psychological dysfunction. However, he concluded that after (i) five years’ field experience among Northern Algonquians, (ii) extensive archival research, and (iii) a critical examination of the literature:

“There probably never were any windigo psychotics in an etic/behavioral sense. When the windigo phenomenon is considered from the point of view of group sociodynamics rather than from that of individual psychodynamics, the crucial question is not what causes a person to become a cannibalistic maniac, but under what circumstances a Northern Algonquian is likely to be accused of having become a cannibalistic maniac and thus run the risk of being executed as such”.

In essence, Marano’s conclusion was that windigo psychosis was simply an artifact of research that was conducted without sufficient knowledge of the indigenous experience.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Colombo, J.R. (1982). Windigo: An Anthology of Facts and Fantastic Fiction. Lincoln: University of Nebraska Press.

Marano, Lou (1982). Windigo psychosis: The anatomy of an emic-etic Confusion. Current Anthropology, 23, 385-412.

O’Neil, D. (2010). Culture specific diseases. October 7. Located at: http://anthro.palomar.edu/medical/med_4.htm

Prince, R. H. (1992). Koro and the Fox Spirit on Hainan Island (China). Transcultural Psychiatric Research Review, 29(2), 119-132.

Simons, R. C., & Hughes, C. (1993). The culture bound syndrome. In A. Gaw (Ed.). Culture, Ethnicity and Mental Illness (pp. 75–99). Washington, DC: APA.

Tseng, W-S. (2006). From peculiar psychiatric disorders through culture-bound syndromes to culture-related specific syndromes. Transcultural Psychiatry, 43; 554-576.

Wikipedia (2012). Wendigo. Located at: http://en.wikipedia.org/wiki/Wendigo

Yap P. M. (1967). Classification of the culture-bound reactive syndromes. Australia New Zealand Journal of Psychiatry, 1, 172-179.

Yap, P. M. (1969). The culture bound syndromes. In W. Cahil., & T. Y. Lin. (Eds.). Mental Health Research in Asia and the Pacific (pp. 33-53). Honolulu: East West Centre Press.

“I see dead people”: Are hallucinations always bad?

I have to admit that I know relatively little about the neuropsychology of hallucinations. The only time I have written about them in scientific journals is in the context of excessive video gaming where there are case studies of people who appear to display auditory and/or visual game-related hallucinations, and may be part of a wider repertoire of sensory consequences of video game playing that we have coined ‘game transfer phenomena’ (and which I outlined in a previous blog).

However, in a completely different context, I recently came across a really interesting 2011 case study by Dr. Amin Gadit who published a short paper in BMJ Case Reports entitled ‘Insightful hallucination: psychopathology or paranormal phenomenon?’ Dr. Gadit noted that hallucinations are usually indicative of a serious psychiatric problem (i.e., typically some kind of psychosis) and typically require treatment. However, Dr. Gadit described the case of a 26-year old successful Pakistani businessman who was suffering hallucinations but experienced a dilemma as to whether to treat him or not because his hallucinations appeared to be providing some therapeutic benefit to his patient.

The man was married to his first cousin (also from Pakistan) and was described as being “extremely close” to his mother. Dr. Gadit reported that his patient’s wife sometimes got extremely upset (which I interpreted as being jealous) about her husband’s attachment to his mother. Following the mother’s diagnosis of a terminal illness with only a few months left to live, the man (understandably given the relationship with his mother) experienced deep emotional turmoil and upset. Dr. Gadit wrote that according to his patient that:

“[His] mother told him before dying that she would remain in contact with him after death. The patient went through a complicated bereavement period when she died. However, 6 months later, he regained his cheerful mood and started taking an interest in business again. His wife noticed that he was talking to himself for at least an hour each day. When asked, he said that his mother visits him every day and he talks to her. This was his firm belief. There was no deterioration in his personality and no other features worthy of note”.

Following these episodes of speaking to his dead mother almost every night at different times in the evening, the man’s wife persuaded him to seek psychiatric help. Dr. Gadit claimed that his patient resented being in treatment and argued that the regular “contact” with his dead mother was a positive experience and made the man happy and helped bring normality to his day-to-day life. Following initial psychiatric assessment, Dr. Gadit noted that:

“There was no significant medical history or family history indicative of any mental disorder. A thorough clinical history revealed nothing except this hallucination. The patient had retained insight as he believed that this would not happen normally but in his case was a special occurrence. He attributed this to his Muslim belief of God’s blessing in sending his mother back to him in this way. His physical examination was unremarkable and all laboratory results were normal. MRI did not reveal any pathology. His mental state examination revealed normothymic mood, delusion, visual hallucination, psychosis (with no supporting evidence), intact cognitive function and reasonable insight into his problem”.

The man’s mother appeared most evenings wearing different dresses (ones that she used to wear when she was alive) but he said his mother would not allow him to touch her when she appeared. The man was adamant that his mother appeared before him in the real world and refused any medical treatment. Organ pathology (often associated with auditory hallucinations) was ruled out as a cause, and there was insufficient evidence for a diagnosis of schizophrenia (often associated with auditory hallucinations). Ultimately, Dr. Gadit did not reach a psychiatric diagnosis and he sought a second opinion (which also failed to produce a diagnosis). The lack of formal diagnosis posed a dilemma in terms managing the presenting condition. The man had monthly appointments for over half a year with Dr. Gadit but the condition remained constant. In discussing the case, Dr. Gadit wrote that:

“The patient recognises the hallucination (perception without the presence of an external stimulus) as happening in the real world. It is important to differentiate true hallucination from ‘pseudo-hallucination’ and ‘imagery’. A pseudo-hallucination is an involuntary sensory experience vivid enough to be regarded as a hallucination but recognised by the patient as not the result of external stimuli; it would not be considered by the person to be ‘real’. Imagery is a collection of images used to create a sensory experience and is the element in a literary work used to evoke mental images and stimulate an emotional response. In the current case report, the patient believes that he can see and talk to his mother in the real world and that he is not imagining it”.

In discussing the case in relation to previous literature, Gadit made reference to a 2009 paper by H. Haween in the Dartmouth Undergraduate Journal of Science (DJUS) that reported hallucinations following bereavement typically resolve over time. Such hallucinations are most commonly in reported during the grieving process in males aged 25 to 30 years. Other similar non-psychiatric illnesses include Charles Bonnet’s Syndrome (typical sufferers being the elderly) that comprises clear hallucinations experienced among visually impaired individuals. A study dating back to 1971 by Dr. W.D. Rees and published in the British Medical Journal reported ‘widowhood hallucinations’ in 14% of Welsh widows and widowers (n=293). A more recent study in a 2002 issue of the British Journal of Psychiatry, a team led by Dr. L.C. Johns reported a 4% prevalence of hallucinations in white and ethnic minority populations and suggested that hallucinations are not always associated with psychotic disorders.

Gadit claimed that his male case study was “unique” as the persistent hallucinations resulted in no noticeable psychopathology, and appeared beneficial to his patient. He also speculated that the visions might be a paranormal experience or “a case of hallucinosis with a secondary delusional explanation”. Gadit claimed that paranormal phenomena are fairly common in both the developed and the developing world (and typically associated with rituals and myths).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Gadit, A.A.M. (2011). Insightful hallucination: psychopathology or paranormal phenomenon? BMJ Case Reports 2011; doi:10.1136/bcr.10.2010.3456

Heewan K. (2009). Hallucination: a normal phenomenon? Dartmouth Journal of Undergraduate Science, November 21. Located at: http://dujs.dartmouth.edu/fall-2009/hallucination-a-normal-phenomenon

Johns, L.C., Nazroo, J.Y., Bebbington, P., et al. (2002). Occurrence of hallucinatory experiences in a community sample and ethnic variations. British Journal of Psychiatry, 180, 174-178.

Menon, G.J., Rahman, I. & Menon, SJ, et al. (2003) Complex visual hallucinations in the visually impaired: the Charles Bonnet Syndrome. Survey of Ophthalmology, 48, 58-72.

Ortiz de Gotari, A., Aronnson, K. & Griffiths, M.D. (2011). Game Transfer Phenomena in video game playing: A qualitative interview study. International Journal of Cyber Behavior, Psychology and Learning, 1(3), 15-33.
Rees, W.D. (1971). The hallucinations of widowhood. British Medical Journal, 4, 37-41.

Spence, S. A. (1993). Nintendo hallucinations: A new phenomenological entity. Irish Journal of Psychological Medicine, 10, 98–99.

Lovestruck: A brief look at de Clérambault’s Syndrome

In previous blogs I have looked at both love addiction and obsessional love. Since writing my blog on obsessional love and noting that it is also known as erotomania, I have received a couple of emails from clinicians saying that obsessional love is not necessarily erotomania by definition. The problem with the wider area of obsessions, compulsions and addiction more generally is that academics and clinicians have different definitions of what it is to be obsessed or addicted to something.

In clinical circles, erotomania is known as de Clérambault’s syndrome (DCS), and was named after a paper published in 1921 (Les Psychoses Passionelles) by the French psychiatrist Gaëtan de Clérambault. Those with DCS typically have a delusional belief that another person (typically someone famous, high status and/or a stranger) is in love with them. Some of the scientific literature suggests that DCS sufferers may have experienced loss of people that were emotionally close to them, and that therefore they may feel emotionally and psychologically safer by attaching themselves to people who are unattainable. Such actions prevent any further losses. In a 1983 issue of Psychological Medicine, Dr. P. Taylor and colleagues described the main components of DCS:

• The presence of a delusion that the individual (usually described as a female) is loved by a specific man;
• The woman has had little or no contact with the man;
• The man is unattainable in some way, because he is already married or because he has no personal interest in her;
• The man is perceived as watching over, protecting or following the woman;
• Despite the erotic delusion, the woman remains chaste.

One of the reasons I am personally interested in DCS is that back in the early 1990s, my then girlfriend (who was – and still is – a clinical psychologist) was the object of affection by a DCS sufferer. The man who fell in love with my girlfriend was slightly brain damaged following a bad motorcycling accident. The accident had also left him paralyzed and had to use a wheelchair. As part of her job, my girlfriend worked with the charity Headway (a brain injury association), and it was when she was caring for this head injured and paralyzed man that he fell in love with her and believed that the feelings were reciprocal. The condition was so intense that he even booked a wedding date, sent out wedding invitations, and told all his family and friends that he was marrying my girlfriend. I even started to question my girlfriend’s fidelity because I couldn’t comprehend that someone could organize a whole wedding if nothing had ever happened between them. (Even though I was a psychologist when this happened I had never come across DCS).

The research literature on DCS suggests that the delusional behaviour is usually part of psychotic behaviour (typically schizophrenia, bipolar disorder, or borderline personality disorder) and can therefore be treated using atypical anti-psychotics (however, most DCS sufferers do not ask for help or seek treatment as they don’t believe they are doing anything wrong). According to the Wikipedia entry on DCS (and based on a paper published in a 1998 issue of the Journal of Neuropsychiatry and Clinical Neuroscience by Dr. C. Anderson and colleagues):

“During an erotomanic episode, the patient believes that a ‘secret admirer’ is declaring his or her affection to the patient, often by special glances, signals, telepathy, or messages through the media. Usually the patient then returns the perceived affection by means of letters, phone calls, gifts, and visits to the unwitting recipient. Even though these advances are unexpected and unwanted, any denial of affection by the object of this delusional love is dismissed by the patient as a ploy to conceal the forbidden love from the rest of the world”.

In a 2002 issue of the journal History of Psychiatry, Dr. German Berrios and Dr. N. Kennedy describe four convergences in the history of erotomania.

• Convergence 1: From classical times to the early eighteenth century, erotomania was viewed as a ‘general disease caused by unrequited love’.
• Convergence 2: During the nineteenth century, erotomania was viewed as a disease of ‘excessive physical love (nymphomania)’
• Convergence 3: During the twentieth century, erotomania was viewed as a form of ‘mental disorder’
• Convergence 4: Currently, erotomania is viewed as a ‘delusional belief of being loved by someone else’.

Berrios and Kennedy also note that there are differences between Anglo-Saxon and French views surrounding the meaning or coherence of “the much-abused English eponym ‘de Clérambault syndrome’. Erotomania is a construct, a mirror reflecting Western views on spiritual and physical love, sex, and gender inequality and abuse. On account of this, it is unlikely that there will ever be a final, ‘scientific’ definition rendering erotomania into a ‘natural kind’ and making it susceptible to brain localization and biological treatment”.

Empirical research suggests that women are more likely than men to suffer from DCS, and that DCS sufferers tend to have social and intimacy difficulties, and are therefore typically loners. Developmentally, they are likely to have a poor sense of self and may have suffered abuse during childhood and/or adolescence. Much of the published theorizing about erotomania is from a psychodynamic perspective or genetic/neurochemical presispositions. I’m far more eclectic in my approach to understanding human behaviour and believe that environmental, psychological, pharmacological and physiological factors most likely trigger a predisposed person into developing DCS. It’s also been speculated that learning through the media (television, radio, books, etc.) has influenced the development of DCS.

Dr. Louis Schlesinger in his 2004 book Sexual Murder: Catathymic and Compulsive Homicides writes about DCS sufferers in relation to possible stalking behaviour. He notes that: “some stalkers are unable to give up a prior intimate relationship (Zona, Sharma, and Lane, 1993). Some develop delusional beliefs about the target (Goldstein, 1987), while others develop strong obsessional thoughts about virtual strangers (Spitzberg and Cupach, 1994). Meloy (1992) and Kienlen (1998) believe that a disturbance of attachment begins in the offender’s early childhood and stalking starts when some type of loss in adulthood resurrects these early conflicts”

In some individuals, DCS can remain with the person for a long time. For instance, Dr. Harold Jordan and colleagues published a paper in a 2006 issue of the Journal of the National Medical Association. They reviewed two cases of DCS that they had followed for over 30 years “making these some of the longest, single-case longitudinal studies yet reported”. They noted that DCS remains a “ubiquitous nosological psychiatric entity with uncertain prognosis”. De Clerambault’s original paper presented the case of a woman whose chronic, erotic delusion remained with her for 37 years, and the cases reported by Dr. Jordan and his colleagues also demonstrated that the delusion can remain unchanged for decades. I have yet to come across any research that estimates the prevalence of DCS among the general population but given most published papers are clinical case reports, it suggests the disorder is relatively rare.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Anderson CA, Camp J, Filley CM (1998). Erotomania after aneurismal subarachnoid hemorrhage: Case report and literature review. Journal of Neuropsychiatry and Clinical Neuroscience, 10, 330-337.

Berrios G.E. & Kennedy, N. (2002). Erotomania: a conceptual history. History of Psychiatry, 13, 381-400.

Jordan, H.W., Lockert, E.W., Johnson-Warren, M., Cabell, C., Cooke, T., Greer, W. & Howe, G. (2006). Erotomania revisited: Thirty-four years later. Journal of the National Medical Association, 98, 487-793.

Schlesinger, L.B. (2004). Sexual murder: Catathymic and compulsive homicides. London: CRC Press.

Taylor, P., Mahendra, B. & Gunn J. (1983). Erotomania in males. Psychological Medicine, 13, 645-650.

Zona, M., Sharma, K., and Lane, J. (1993). A comparative study of erotomania and obsessional subjects in a forensic sample. Journal of Forensic Sciences, 38, 894–903.

Wholly holy: A beginner’s guide to Jerusalem syndrome

In a previous blog I examined Stendhal Syndrome where some people when exposed to the concentrated works of art, experience a wide range of symptoms including physical and emotional anxiety (rapid heart rate and intense dizziness, that often results in panic attacks and/or fainting), feelings of confusion and disorientation, nausea, dissociative episodes, temporary amnesia, paranoia, and – in extreme cases – hallucinations and temporary ‘madness’. While researching that article, I also came across another condition that would appear to be related to Stendhal Syndrome, namely ‘Jerusalem Syndrome’ – a condition that I have some empathy with.

One of the things I love about my job is all the wonderful places I have been able to travel to and visit as part of my work. Back in 2010, I did some consultancy on social responsibility practices for the online gambling company 888 and was flown to Tel Aviv to speak to various departments about my work. Once my talks and meeting were over, I experienced one of the best days of my life when I given a personal guide around the whole of Jerusalem. I am not religious but I found myself totally overcome with emotion as I visited one tourist attraction after another.

I say all this by way of introduction to what has been reported in the psychological literature as the aforementioned ‘Jerusalem Syndrome’ where visitors to the holy city are totally overcome by the weight of its history. The condition was first described (perhaps unsurprisingly) by an Israeli psychiatrist – Haim Herman – in the 1930s. However, psychiatrists did not begin keeping comprehensive clinical and statistical information on these cases until the late 1970s. One of the most infamous cases often cited in relation to Jerusalem Syndrome occurred in 1969, when a male Australian tourist (Denis Michael Rohan) set alight the al-Asqa Mosque following an overwhelming feeling of divine mission.

In 1999, Dr. Eliezer Witzum and Dr. Moshe Kalian wrote the first paper on Jerusalem Syndrome in an issue of the Israelian Journal of Psychiatry and Related Sciences. The condition became more widely known in 2000, when Dr. Yair Bar-El and colleagues published a paper in it in the British Journal of Psychiatry (BJP). Since 1980, Dr. Bar-El and his colleagues reported that Jerusalem’s psychiatric services had encountered over 1000 tourists with Jerusalem Syndrome (approximately 100 a year and overwhelmingly evangelical Christians). All cases were sent to one central facility (the Kfar Shaul Mental Health Centre [KSMHC]) for psychological counselling, psychiatric intervention, and/or admission to hospital. Between 1980 and 1993 approximately 1200 tourists with severe, Jerusalem-generated mental problems were referred to the KSMHC (with 470 being admitted to hospital). Based on those requiring treatment, the 2000 BJP paper outlined what the authors believed were the three main categories of the syndrome.

• Type I: Comprises individuals that have already been diagnosed as having a psychosis (e.g., schizophrenia, bipolar illness) prior to visiting Israel. They usually travel alone and come to Israel for psychiatric religious ideation.
• Type II: Comprises individuals with mental disorders (e.g., personality disorders, obsessions) but don’t have a clear mental illness and whose strange thoughts would not be classified as delusional or psychotic. They usually travel in groups (but sometimes alone) and come to Israel for curiosity reasons.
• Type III: Comprises individuals that have no previous history of mental illness, but who become victim to a psychotic episode while in Israel (particularly Jerusalem). Type III individuals are said to recover spontaneously, and enjoy normality on their return to their home country. They usually travel with friends or family (often as part of an organized tour) and come to Israel as regular tourists (and have a religious home background).

The authors reported that the third type was the most was “perhaps the most fascinating” because it included individuals with no prior history of mental illness and whose symptoms were context-specific and recover spontaneously with little psychological intervention. Therefore, the authors noted that Type III Jerusalem Syndrome is not associated with other psychopathologies, and is this is a “pure” or “unconfounded” form of the syndrome. Of the 1200 or so cases, only 42 were classified as Type III.

Despite the many reported case of Jerusalem Syndrome, in subsequent responses to the BJP paper, Kalian and Witzum then disputed its existence and claimed it is just a variant of schizophrenic illness. They wrote in a letter that:

“Our accumulated data indicate that Jerusalem should not be regarded as a pathogenic factor, because the morbid ideation of the affected travelers started elsewhere. Jerusalem syndrome should be viewed as an aggravation of a chronic mental illness and not a transient psychotic episode. The eccentric conduct and bizarre behavior of these colorful but mainly psychotic travelers become dramatically overt once they reach the Holy City – a geographical locus containing the axis mundi of their religious beliefs”.

The authors of the original paper then responded with yet another letter and pointed out that:

“Our initial account of Jerusalem syndrome clearly distinguished between patients with Jerusalem syndrome who also have a history of psychotic illness – Jerusalem syndrome superimposed on a previous psychotic illness – and those with no previous psychopathology, whom we referred to as having the discrete form of the syndrome. In either case, the symptoms of the syndrome appear on arrival in Jerusalem and exposure to the holy places”.

There have been a number of explanations as to why Jerusalem Syndrome occurs. Some authors suggest that mental state changes can occur as a result of a significant change in routine and circumstances  (e.g., culture clash, geographical isolation, unfamiliar surroundings, proximity to strangers and/or foreigners). These factors compounded with the religious significance to many different faiths (Christians, Jews and Muslims), may be the stimuli that to trigger acute psychotic episodes. Such ‘spiritual’ travel may represent a modern-day version of a pilgrimage. There are of course limitations of the work by Bar-El and colleagues that the authors duly acknowledge including the fact that the study (i) was based on a phenomenological description and was not a research study, (jj) lacked follow-up information, and (iii) did not taken into account changes in circumstances associated with the expected influx of tourists in the millennial year.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bar-El, Y., Durst, R., Katz, G., Zislin, J., Strauss, Z. & Knobler, H.Y. (2000) Jerusalem syndrome. British Journal of Psychiatry, 176, 86-90.

Bar-El, Y., Kalian, M. & Eisenberg, B. (1991) Tourists and psychiatric hospitalization with reference to ethical aspects concerning management and treatment. Psychiatry, 10, 487 -492.

Bar-El, I., Witztum, E., Kalian, M., et al (1991) Psychiatric hospitalization of tourists in Jerusalem. Comprehensive Psychiatry, 32, 238 -244.

Fastovsky N, Teitelbaum A, Zislin J, et al (2000). The Jerusalem syndrome. Psychiatric Services, 5, 1052.

Gordon, H., Kingham, M. & Goodwin, T. (2004). Air travel by passengers with mental disorder. The Psychiatrist, 28, 295-297.

Halim, N. (2009). Mad tourists: The “vectors” and meanings of city-syndromes. In K. White (Ed.), Configuring Madness. Oxford: Inter-Disciplinary Press.

Kalian, M. & Witzum, E. (2000) Comments on Jerusalem syndrome. British Journal of Psychiatry, 176, 492.

Kalian M. & Witzum, E. (2002) Jerusalem syndrome as reflected in the pilgrimage and biographies of four extraordinary women from the 14th century to the end of the second millennium. Mental Health, Religion and Culture, 5, 1-16.

Monden, C. (2005). Development of psychopathology in international tourists. In van Tilburg, M. & Vingerhoets, A. (Eds.), Psychological Aspects of Geographical Moves: Homesickness and Acculturation Stress (pp. 213-226). Amsterdam: Amsterdam Academic Archive.

Witztum, E., & Kalian, M. (1999). The “Jerusalem syndrome” – fantasy and reality. A survey of accounts from the 19th century to the end of the second millennium. Israelian Journal of Psychiatry and Related Sciences, 36, 260-271.

Here’s looking at you: The Truman Show Delusion

Reality television shows have now became a staple of modern life. However, little is known about the effect they have on day-to-day living. Earlier this year, Joel Gold and Ian Gold published a paper in the journal Cognitive Neuropsychiatry about a new phenomenon that they coined the ‘Truman Show Delusion’ (TSD) based on (director) Peter Weir’s 1998 film that told the (fictional) story of Truman Burbank (played by Jim Carrey) whose whole life had been filmed and broadcast as real life a soap opera around the world (without his knowledge) from the day he was born. All the people around Truman were paid actors and extras.

The plot of The Truman Show revolved around Truman’s gradual awareness that there was something wrong about his life (i.e., that the world appears to revolve around him) and of his of his desire to escape the town in which he is living. Because of the high audience ratings, the show’s producers attempt to keep the show even when Truman begins to suspect there is something amiss in his life. The actors are then instructed by the show’s producers and writers to tell Truman that he is imagining these things and that he is (to all intents and purposes) mentally ill (i.e., a persecutory delusion). In their paper, Gold and Gold described the conditions as:

“…a novel delusion, primarily persecutory in form, in which the patient believes that he is being filmed, and that the films are being broadcast for the entertainment of others. We describe a series of patients who presented with a delusional system according to which they were the subjects of something akin to a reality television show that was broadcasting their daily life for the entertainment of others”

Gold and Gold highlighted five short case studies of patients who had presented for treatment in their psychiatric practices. The cases ‘diagnosed’ as having the TSD are the reverse of what occurred in the film as their reported symptoms recall that of Truman, without the knowledge and awareness that their attempts to understand their situation will lead to a [Hollywood] happy ending. Interestingly, three of the cases highlighted by the authors referred to The Truman Show by name. Here is a brief summary of the five reported cases.

• Case 1 (‘Mr. A’): Mr A. claimed his life was like The Truman Show, a belief that he had held for five years without his family’s knowledge. He believed the 9/11 attacks of 9/11 were fabricated and travelled to New York to see if the Twin Towers were still standing (and if they were, it would prove that he was the star of his own show). He believed that everyone in his life were part of the conspiracy and that he had cameras implanted in his eyes (and when he was admitted to the psychiatry department he asked to speak to the ‘director’). He was diagnosed as having schizophrenia (and more specifically a chronic paranoid type versus substance-induced psychotic disorder).
• Case 2 (‘Mr. B.’): Mr B. believed he was being continuously recorded for national broadcast. He formulated a “plan to come to NYC and meet an unknown woman at the top of the Statue of Liberty. He expected [her] to release him from the control of an extended network of individuals who [were]…taping him continually…and broadcasting the tapes nationally for viewers’ enjoyment as part of a scenario similar to…The Truman Show”. He believed he “was and am the centre, the focus of attention by millions and millions of people…my [family] and everyone I knew were and are actors in a script, a charade whose entire purpose is to make me the focus of the world’s attention”. He had attempted suicide three times due to dysphoria, hopelessness, and persecutory delusions. He was diagnosed with schizoaffective disorder (bipolar type) along with both crack cocaine and marijuana dependence.
• Case 3 (‘Mr. C’): Mr. C. – a journalist – had a history of depression, and was manic and psychotic. He believed that stories – in newspapers, online, and on television – were created by his colleagues in the media for his personal amusement. He believed that those around him were paid actors, and that everything around him was fake, and that “all [his] associates are involved”. During his hospitalization, Mr. C. attempted to escape to confirm whether there were disparities between the news given on the ward and what was happening outside. He was diagnosed as having bipolar disorder with psychotic features.
• Case 4 (‘Mr. D.’): Mr D. actually worked on a reality television show and came to believe that he was the person whose life was actually being broadcast. He thought he was “a secret contestant on a reality show and believed he was being filmed. He also believed all his thoughts were being controlled by a film crew paid for by his family. He was diagnosed with bipolar disorder, had manic episodes, and a marijuana abuser.
• Case 5 (‘Mr. E’): Mr E. believed that the Secret Service was following him. He had attention deficit hyperactivity disorder and had bouts of depression. He described a “scheme” that he claimed was similar to The Truman Show. Gold and Gold reported that Mr. E. “believed that he was the master of the scheme, that it involved everyone in his life including the hospital staff, and that all these people were actors. He thought that he might be recorded while in hospital. He believed that the news was fabricated and that the radio was recorded for him…He believed that the scheme would end on Christmas Day and that he would be released then”. He was diagnosed with schizophreniform disorder versus methylphenidate-induced psychotic disorder.

Gold and Gold searched the academic and clinical literature for other similar scientific reports of patients with delusions of The Truman Show type but said there were none. However, they did cite a 2008 study by Dr. Fusar-Poli and colleagues in the British Journal of Psychiatry. They reported the case of a person who ‘‘had a sense the world was slightly unreal, as if he was the eponymous hero in the film The Truman Show [but] at no point did his conviction reach delusional intensity”. They also made reference to two news reports (one in 2007 and the other in 2009) of men who appear to have suffered from the TSD.

“In 2007, William Johns III, a psychiatrist from Florida, attempted to abscond with a child, Thorin Novenski, and subsequently attacked the child’s mother. A news report on the incident claims that ‘a friend of the psychiatrist reportedly told a judge that Johns said he had to go to New York to ‘get out of The Truman Show’.In 2009, Antony Waterlow, a Sydney man, murdered his father and sister while in a psychotic state. A news report stated that Mr Waterlow believed his family was behind a ‘world wide game’ to murder him or force him to commit suicide. A doctor who interviewed the man is reported to have said that Mr Waterlow told her in a consultation in February that he believed computers were accessing his brain through brainwaves and satellites. He said his family was screening his life on the Internet for the world to watch, akin to the film The Truman Show”.

Gold and Gold noted that their case studies gave rise to three general questions of interest: (1) How precisely should these peoples’ delusions be characterized? (2) What does the delusion contribute to the understanding of the role of culture in psychosis? (3) What does the influence of culture on delusion suggest about the cognitive processes underlying delusional belief? Obviously, watching reality television shows do not cause psychotic or delusional episodes. However, these cases appear to highlight that those with underlying illnesses (e.g., schizophrenia) who watch reality television shows may develop delusions that seem somewhat familiar. Gold and Gold concluded that cultural insights into delusions are an essential part of understanding how these phenomena operate.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Fusar-Poli, P., Howes, O., Valmaggia, L., & McGuire, P. (2008). ’’Truman’’ signs and vulnerability to psychosis. British Journal of Psychiatry, 193, 168.

Gold, J. & Gold, I. (2012). The “Truman Show” delusion: Psychosis in the global village. Cognitive Neuropsychiatry, DOI:10.1080/13546805.2012.666113