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Acting up: A brief look at the ‘Hollywood Phenomenon’ delusion

In a previous blog I briefly examined Delusional Misidentification Syndromes (DMSs). These are arguably some of the strangest mental and neurological syndromes that exist. All DMSs involve a belief by the affected individual that the identity of something (i.e., a person, place, object, etc.) has altered or changed in some way. There are many variants of DMS, and in most cases the delusion is monothematic (i.e., it only concerns one particular topic). The DMSs that are most written about are:

  • The Fregoli delusion (individuals who have the belief that more than one person that they have met is the same person in more than one disguise).
  • The Capgras delusion (individuals who have the belief that someone (typically a spouse or close relative) has been replaced by an identical-looking imposter.
  • Subjective doubles (aka Christodoulou syndrome) (individuals who have the belief that there are (one or more) doubles of themselves [i.e., doppelgangers] that carry out actions and behaviours independently and lead a life of their own.
  • Intermetamorphosis: (individuals who have the belief that people in their immediate vicinity change identities with each other but keep the same appearance.

According to Dr. K.W. De Pauw and Dr. T.K. Szulecka in a 1988 issue of the British Journal of Psychiatry, those with DMSs are “more likely to commit violent crimes against persons than those with chronic, undifferentiated psychoses”. In their paper, De Pauw and Szulecka reviewed the literature concerning violence associated with DMSs and reported four case studies of individuals that were “either perpetrators or victims of assaults as a consequence of the syndromes of Fragoli, Intermetamorphosis, Subjective Doubles and Capgras”. After this paper was published, Dr. A.P. Shubsachs and Dr. A. Young responded to the paper (also in the British Journal of Psychiatry) with a short account of two case studies with a variant of delusional misidentification environment”.

The two cases had a delusion that was described as the ‘Hollywood Phenomenon’ and comprised the belief “that the patient’s environment has been changed to a film or theatre set peopled by actors and in which the patient has a role to play”. (This also appears to be similar to the ‘Truman Show’ Delusion that I described in a previous blog and is “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”).

Shubsachs and Young asserted that the ‘Hollywood Phenomenon’ (HP) was a symptom rather than a syndrome. They also reported that based on their tow case studies, HP can occur along with atypical Capgras phenomenon, and may result in violence, verbal hostility, and non co-operation. Here are the two case studies in the authors’ own words (taken verbatim from the British Journal of Psychiatry):

  • Case 1: “Mr. A, a 22-year-old single Australian man with a history of two admissions for bipolar affective disorder, left Australia in the early stages of a manic episode. On arrival in the UK his condition deteriorated, with elevated mood, decreased sleep, excess energy, and accelerated thoughts. He recognised that he was relapsing and consulted a GP, who arranged an urgent out-patient appointment. Before that appointment he became convinced he was ‘an actor and that everything that was going on was a film’ in which he was the main player. He stole a car which he deliberately crashed because ‘it was a stunt car and I was a stunt man who was supposed to crash it…it was rigged so I wouldn’t get hurt’. He was arrested and later assaulted the police surgeon with what he erroneously believed was a bottle of ‘harmless sugar glass’ causing severe injuries. Mr A. claimed that he, the surgeon, and the police were all play actors and that his actions would have ‘no real consequence’. Remanded in prison for psychiatric reports, he was intermittently violent in response to similar misidentifications until he became euthymic following medication. He was transferred Hospital Order, and on admission had insight into his previous delusions”.
  • Case 2: “Miss B. exhibited both a Capgras phenomenon and a ‘Hollywood phenomenon’. She was a single retired midwife in late middle age, living alone. She had had several admissions with a diagnosis of depressive psychosis or schizophrenia. On this occasion she was depressed with early morning wakening, psychomotor retardation, appetite and weight loss, and felt hopeless and worthless. She believed relatives were impostors and was verbally aggressive towards them. She believed that the hospital was a film set peopled by actors, the admitting doctor a film director, and that the purpose of the interview was to obtain a script for the film. While she struggled and was verbally hostile at attempts to detain her, there was no serious violence. She recovered fully after ECT”.

Shubsachs and Young claimed that the HP delusion was both uncommon and under-reported, and that both of the cases that they described involved “affective illness without organic impairment”. They then went on to claim that they didn’t think that the ‘Hollywood Phenomenon’ was “specific for affective disorders” (and asked if other psychiatrists reading their case studies could provide other examples). They concluded that the HP “differs from the superficially similar transient experience in derealisation in that it has a real, not an ‘as if’ quality, is enduring, and has all the features of a delusion including the tendency to be acted upon”.

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

Further reading

Christodoulou G.N. (1986). Delusional Misidentification Syndromes. Basel: Karger.

De Pauw, K. W., & Szulecka, T. K. (1988). Dangerous delusions. Violence and the misidentification syndromes. British Journal of Psychiatry, 152(1), 91-96.

Ellis, H.D., Luauté, J.P. & Retterstøl, N. (1994). Delusional misidentification syndromes. Psychopathology, 27(3-5), 117-120.

Enoch, M.D. & Trethowan, W. (1979). Uncommon Psychiatric Syndromes. Oxford: Butterworth-Heinemann; 1979.

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, 17, 455.

Shubsachs, A.P., & Young, A. (1988). Dangerous delusions: The ‘Hollywood phenomenon’. British Journal of Psychiatry, 152(5), 722-722.

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