In 2003, at New York’s Bellevue Hospital, Dr. Joel Gold met his first patient suffering from what is now called the Truman Show delusion: the belief that he was being stalked by reality television, and that almost everyone was in on the gag but him. Gold’s current book, written with his brother Ian, a philosopher, is an attempt to explain the cultural roots of madness, with Truman Show patients and others as case studies.
The Truman Show delusion takes its name from the 1998 film The Truman Show, about a man who discovers that his life has been stage-managed from birth on an enormous set and broadcast to a fascinated and devoted worldwide TV audience. It may seem odd, even darkly comic, that mental illness could take inspiration from a film starring the putty-faced actor Jim Carrey, but the patients’ suffering is often severe, and the Golds report, anecdotally, that a large number of people present Trumanesque symptoms. One mental-health clinic in London, they say, reports that one in four patients has Truman syndrome, a condition in which a person shows early signs of the illness but not yet full psychosis. (About 1.1 percent of the adult population has schizophrenia, one of the more common diagnoses given to Trumans.)
To an incredible extent, certain manifestations of mental disease occur only or primarily in specific cultural contexts.
At least one Truman patient has committed suicide. In many cases the patients live in a state of constant tension and insecurity, as one might upon learning that a billion people are watching you, even as you sleep. One sufferer, named Albert, hid in New York’s U.N. building, in the belief that it would offer sanctuary from the show’s hidden camera crews. Another patient (a staffer at a reality show, oddly enough) believed his parents were impostors, and that his real family had hired a crew to film him. Albert “believed that when people made a thumbs-up sign, they were giving him a secret hand signal that they were ‘in’ on the show.”
All this constitutes unequivocally pathological behavior. If symptoms appear, seek help. But it also reveals the aspect of mental illness that is the main topic of the Golds’ book, which is the ways culture gives madness its form. With just about any non-psychiatric medical condition you can name, culture is at best a secondary consideration when establishing the nature of the problem. Conditions result from predictable interactions between physiology, pathogens, and the environment. Hang around someone coughing up tuberculosis bacilli, and you stand a good chance of getting TB too—no matter whether you live in modern Bombay or in ancient Rome. Okinawans eating their native diets may get fewer heart attacks than Americans, but if you feed them burgers, their arteries will clog.
But the necessary condition of falling under the Truman Show delusion is cultural. If you have never seen The Truman Show or experienced reality television or ubiquitous surveillance cameras, you are effectively immunized against Truman Syndrome. You may have other psychoses and paranoia, but to an incredible extent, certain manifestations of mental disease occur only or primarily in specific cultural contexts. Seemingly neutral cultural shifts, such as migration from Norway to the United States, increase markedly the prevalence of schizophrenia among the immigrants. The Golds propose that psychiatrists who treat the mind as a chunk of diseased flesh, reparable with material interventions like Prozac or lithium, have missed out on an important aspect of their practice. That weird interplay of culture and illness establishes psychiatry as one of the most slippery of the medical arts, far less easily understood than, say, a plumbing-based field like heart surgery.
To diagnose a delusionary schizophrenic, one needs to have a concept not merely of what is “normal” behavior, but of what is reasonable—not a quality that any laboratory can test for. Indeed, the very definition of “delusional” belief remains a complete mess, the Golds say (in a series of chapters that would make Michel Foucault smile). The same beliefs, stated in different ways or in different contexts, receive radically different diagnoses. If someone thinks he is living not in the real world but in a computer simulation, he might get admitted to a psych ward on that basis alone. But the philosopher Nick Bostrom has written papers arguing that all of us may live in such a simulation, and instead of anti-psychotic medication he has received a professorship at Oxford University. Similarly, the Golds say, the belief that the U.S. military kidnaps civilians for mind-control experiments would strike most as wacky, though not clinically so. But anyone who says he has personally been subject to these experiments goes to the shrink.
The Golds entertain a few theories that at least attempt to suggest what is happening when someone goes mad with something like the Truman Show delusion. They consider a theory proposed by the cognitive scientist Max Coltheart and colleagues, who suggest delusional patients are people who have had strange experiences and suffer from an inability to reason about them, and reach insane conclusions about what has happened. Ultimately, the Golds offer a theory of their own. They suggest that a standard-issue part of our mental toolkit is a “Suspicion System,” which helps us figure out when other people have malign intentions toward us. Psychological data does suggest that detecting the intentions of others, through brief glances at their faces, is a basic skill, and one that our brains do exceptionally well. If that system lost its calibration and became too sensitive, it might detect threats and plots when none exist, like a smoke detector that goes off when you’re harmlessly frying an egg.
This theory of a busted Suspicion System has the merit of making sense, or at least slightly more sense than the myriad other theories that are proposed. But one’s general impression, from the authors’ tentative tone, is that the Suspicion System still barely begins to capture the whole diversity of experience of mental illness, which (the authors remind us) may be as diverse as the experience of mental health. The territory is, after all, still so uncharted that, as the Golds say, we “don’t have anything like a theory of mental illness that is good enough even to be wrong.” Many of the Truman Syndrome patients, it seems, have made full recoveries, and nothing seems to explain why some snap back to reality and others persist in madness—performing for an audience that never tires of persecuting them, and waiting for a season finale that never comes.
This post originally appeared in the July/August 2014 print issue ofPacific Standardas “Caught in a Trap.” Subscribe to our bimonthly magazine for more coverage of the science of society.