Excerpt from The Truman Show: Good morning! (Good morning!) Oh, and in case I don't see ya, good afternoon, good evening, and goodnight. Hahaha, yup.

Lynne Malcolm: Hi, it's All in the Mind on RN, I'm Lynne Malcolm. Today we look at the impact that popular culture can have on our mental health, by casting our minds back to Peter Weir's 1998 film The Truman Show. The film tells the story of Truman Burbank, the first person to be adopted by a corporation; in his case, a television network.

Truman is brought up on the set of a reality TV show, the most popular on the planet. Everyone in his life is an actor, and for 30 years, Truman has remained completely unaware of his situation.

In this program we hear that for some people, like Scott, the concept of this film is disturbingly real.

Scott: And so as the sun's coming up, and I'm looking around and I'm starting to feel like, wait a second, there are cameras everywhere. I am the centre. And I've just discovered that I have been being watched for probably my whole life.

 

Lynne Malcolm: Scott suffers from Truman Show Delusion, a delusion where people think they are the star of a reality TV show, or movie, even though they're not.

Joel Werner reports from Manhattan, New York, the city where this delusion was first identified.

Joel Gold: My name is Dr Joel Gold, I'm a psychiatrist here in New York City. I wrote a book called Suspicious Minds: How Culture Shapes Madness.

Joel Werner: Today we're in the offices of Joel Gold's private practice in downtown Manhattan. But it was about 40 blocks uptown from here that Gold got his start in psychiatry.

Joel Gold: Bellevue Hospital in the general consciousness, it's sort of like the Bedlam of New York. We see every form of psychosis, and that would include the kinds of symptoms like delusions; the strange, odd thoughts that people with psychosis have that are immutable to change despite the fact that they may be presented with evidence to the contrary.

Joel Werner: Gold would go on to serve as the director of Bellevue's Psychiatric Emergency Room. And it was here, about ten years ago, that he first saw a patient present with what would become known as The Truman Show Delusion.

Joel Gold: Albert came in, I remember vividly, it was Halloween. I was with my resident at the time on the inpatient training unit, and Albert had come from the United Nations where he had taken a swing at a guard. He believed that his life was a reality television show. He believed everyone in his life was an actor reading from scripts, including his family. Everyone he passed in the street, everything about his life was inauthentic, much like in The Truman Show, the Jim Carrey character Truman Burbank whose life actually is a reality television show. He ended up in front of the United Nations, decided to seek asylum from his own show, and that's when he, unfortunately, got into a scuffle and was brought to Bellevue.

Joel Werner: Working somewhere like Bellevue, where you have patients suffering mental health crises of every shape, was Albert's presentation particularly unique? At the time did it stand out from the general noise of Bellevue?

Joel Gold: Not at all. We see so many fascinating and at times bizarre kinds of delusions, that at the time, it was interesting but not particularly more so than a patient who thought that they were a vampire, or that their neighbour was a vampire. Things of that nature happened every day. So, when he first came in, I didn't make much of it. But over the course of the next months I saw a second, then third, and ultimately over the course of a couple of years five people. And they all believed the same thing. They would say, 'Dr Gold, did you see the film?' And I had, and they said, 'Yes, that's my life, just like that movie.' And at that point, you know, three, four, five patients, I thought this is something worth looking into.

Joel Werner: By the time people turn up somewhere like Bellevue, it's usually end game Truman Show Delusion, their delusional belief is so strong that they need the specialist care only a psychiatric hospital can provide. But, what about the other end of the delusional experience? How does The Truman Show Delusion take hold in the first place?

Scott: So my name is Scott, and I'm 33 years old. I live in Chicago, I've lived here for about nine years.

Joel Werner: Scott isn't his real name, we've changed it to protect his identity. But everything else about his story is true.

Scott: So I guess it was the summer of 2002, so it was the summer after my sophomore year of college when the madness set in. I guess you could say things were speeding up in my mind, and in the way that I was feeling about myself in general. By the time, say, mid-summer came around, I can't even remember really laying down and going to sleep much. I would basically sit up under a porch light, hatching ideas and just writing endlessly, whether it was something poetic, or whether it was about some business plan that would never come to fruition.

I was interpreting that shift in momentum as…it didn't even feel like a shift in a way, it felt natural, it felt like any other change that had happened in my life, where it wasn't even really noticeable to me. It was noticeable to people outside of me I think more than it was to me. When it started to sort of furrow brows, and people started to ask me if I was okay was when some friends of mine from my hometown asked me if I wanted to head out to Colorado with them, and of course I agreed and hopped in a car with these guys and hit the road for Colorado.

I can't keep my mouth shut, I'm going on tangent after tangent of explaining one thing, but then that sparks an idea of another thing that I thought about, and so now I've got to explain that. And so they have some concern, but at the same time excitement is mutual, and we're cruising across the country together, and so despite a few, 'What the hell are you talking about', 'Shut up, let's listen to the music', 'Let's just drive', there wasn't too much of an issue at this point.

So we arrived, and I think it was probably three or four AM or something when we pulled in. And of course everyone else is exhausted and goes to bed, but why would I need to go to bed? I guess I was probably out there for two or so weeks before I really turned a corner. I was writing just as much but also I'm surrounded by my peers and I want to include them in my numerous epiphanies. And more increasingly they're sort of asking me, 'Dude, are you sure you're all right?' And each time I'm explaining, with a more eloquent than before reason of how I've never been better, cause that's exactly how I felt.

Joel Werner: As you might've picked up, Scott is bipolar, and at the time was in the early stages of a manic episode. And this is probably a good time to make an important distinction: like Scott's mania, the delusions that would come aren't mental health issues in their own right, they're symptoms of one. Here's Joel Gold again:

Joel Gold: Delusions are ideas, beliefs that people hold that are false, for the most part, though not always. And despite overwhelming evidence to the contrary, they hold onto these beliefs tenaciously. If I were to tell you something that was contrary to what you believed you might have a second thought and come over to my side of thinking. People who have delusions, that's not the case. We reckon there are about a dozen forms of delusion; the most common are persecutory, or paranoid, and grandiose. 

Excerpt from The Truman Show: (Truman, what are you doing here?) I got to talk to you. (It's a bad time, okay? I'm way behind…) I'm onto something Marlon, something big! (Are you okay? You look like shit.) I think I'm mixed up in something. (Mixed up in what?) There's no point trying to explain it, but a lot of strange things have been happening. I'm definitely being followed. (Who?) It's hard to tell, they look just like regular people.

Joel Gold: In persecutory delusions, people feel that they are being targeted, that there are people who mean them harm. They may feel as though they have a lot of important information, and this is where it often connects to the grandiosity, because of course if you feel that you're important enough to be followed by the FBI or the CIA, you must be a pretty important person, so the two do overlap.

Excerpt from The Truman Show: Maybe I'm being set up for something. You ever think about that, Marlon? Like your whole life has been building toward something? (Mmm, no.)

Joel Gold: And grandiose delusions, as the name suggests, people feel they have quite a bit of power. It can be religious in nature. Someone might feel that they have incredible talent. I've treated a number of people when I was at Bellevue who believed that they were going to leave and have a multi-million dollar record deal waiting for them, even though they clearly had no ostensible talent. 

And so initially I believed that The Truman Show Delusion was a combination of both grandiose delusion, persecutory delusion, and the delusions of reference, when benign stimuli in the environment are believed to be significant to the individual. It might be a news reader who would report something that doesn't actually refer to the viewer, but that person might think, 'No, the interviewer is talking to me directly.' Or, 'He's wearing a red tie, and he's trying to signal me in some fashion.'

Scott: So it was after any normal night of us hanging out and…yeah, we had definitely done a small bit of mushrooms. And so I guess I consider the mushrooms like a straw that broke the camel's back. But I do feel like it was inevitably going to break.

Joel Werner: After a few weeks hanging out in Colorado, Scott and his friends had a night on magic mushrooms. As he was coming down from that hallucinogenic experience, Scott's already manic episode transformed into full-blown Truman Show Delusion.

Scott: A couple of hours before the sun came up, I was still very much awake and decided to climb up on the roof, and was just sitting up there, and sort of listening and looking at everything that was happening around me. As the sun started to come up, the way that I experienced it was I stood up, and I think all it really was was that I waved, say, my right hand in a certain way. And I guess I could describe the way as somewhat like a conductor in a symphony might. And I felt that when I did that, something far off to the right, say a car siren, or a dog barked. And I very much felt like I had caused that. So in order to test this theory, I then tried a similar thing with my left arm, and of course, at least in my interpretation, something happened in that general direction that I believed I had caused.

And so as the sun's coming up, and I'm looking around and I'm starting to feel like, wait a second, I'm pretty certain that there are cameras everywhere. I am the centre. And I've just discovered that I have been being watched for probably my whole life. I guess eventually it occurred to me that everyone around me—my friends, my family, my co-workers, my colleagues, my teachers—were imposters. I didn't feel like someone was out to get me. I definitely felt important. Well, obviously if every single person in the world around me is acting for my benefit or to experiment on me, that could be interpreted as important.

Excerpt from The Truman Show: I don't know what to think, Marlon. Maybe I'm losing my mind, but it feels like the whole world revolves around me somehow. (That's a lot of world for one man, Truman.)

Joel Gold: Ultimately, my brother and I came to believe that The Truman Show Delusion was in fact a delusion of control, which is one of the 12 forms where one feels that perhaps their thoughts are being controlled. And we feel that, in this age of surveillance, and in instant fame, where everyone is being watched, and everyone is watching, that in watching and in having information about someone, you have in a sense control over them.

Scott: Yes, The Truman Show was a big part of it, but I'm not sure if you've ever seen a movie, I think Michael Douglas is the star, and it's called The Game. And in that movie he's sort of given clues or hints or has to decode various things in order to get to the next step of the game and/or solve the game. I'm realising that there is some sort of Wizard of Oz like character behind a curtain somewhere, and I need to find this curtain and pull it back.

So I've hopped down off the roof and at this point I decide to start meandering around the neighbourhood. Every single thing that I'm looking at, every sign, every grouping of numbers, every license plate on a parked car is some sort of clue. This was a set put here by the team in charge of laying things out for me to decode. And so now I'm walking around the neighbourhood, I'm not wearing shoes, I'm not wearing a shirt, and I've got very red eyes most likely, and it's fairly early, but there are people, say, walking their dog. And as they pass by, and maybe nod good morning or look a little bit nervous, I'm now giving them a wink and a grin, basically saying, 'I know what's going on, I know what you're up to!' And so everyone I would sort of encounter I would say, 'Oh that's the same actor that played my teacher in fourth grade,' or something like that.

And so at one point as I'm walking around the neighbourhood, I notice a house, there was a For Sale sign in front of it, so I decide to go investigate further. So I hop a fence, I'm looking through windows, looking for additional clues. I think I was getting frustrated that they're taking so long to reveal the final game to me, I think I hop back over the fence, and there's a couple of cop cars there. And this is just hysterical to me. I'm like, 'That's good, that's good! I didn't see that coming!' And so I just walk out to them just laughing and laughing and at this point, yeah, I'm no longer winking and grinning, I'm actually complimenting them on their ability to stay in character. In my mind I think at this time this was like I was going to be led off to the big show where the big reveal was going to happen. So they say, 'Do you want to come with us?' And I say, 'Yes, sure, let's go. Let's go.'

Lynne Malcolm: Scott, recalling his experience of Truman Show Delusion. You're with All in the Mind on RN, Radio Australia and online, I'm Lynne Malcolm and we're exploring what's known as The Truman Show Delusion with Joel Werner in New York. Scott's delusional experience wasn't only shaped by The Truman Show, there were other cultural influences as well. 

The concept of The Truman Show Delusion has been criticised for being nothing new. For as long as people have experienced delusions, they've integrated culture and their environment into the delusional content. So is The Truman Show Delusion a new form of delusion, or is it just an old delusion updated with content for a modern age? 

Joel Gold: It's very hard to know, frankly, if it is a new delusion all together, or if it's something that has just replaced something else in terms of content. Over the course of time there have been forms of delusion that have not changed.

Joel Werner: These forms are the 12 types of delusions we mentioned earlier; broad categories like grandiose, persecutory, or ideas of reference. These types, or forms of delusion are thought to be set in stone.

Joel Gold: But the content of those delusions can change. And so people will often say, 'Well, this is not particularly interesting.' You know, people used to think that they were Napoleon, and then as times changed they thought they were a Kennedy. If they thought they were being pursued by the KGB, now it may be Al-Qaeda, something of that nature.

Joel Werner: So The Truman Show Delusion is just the same old egocentric/paranoid delusion, but with content updated for the 21st century, right?

Joel Gold: I think it's not solely the content. In this case it may actually be not a new form, but increasing the likelihood of that form or those forms coming into play. Thirty, 40 years ago, these delusions would been considered bizarre. A bizarre delusion would be something like, 'I went to Mars this morning and I'm back now.' As opposed to, 'My wife is having an affair.' That might be a delusion, but it's certainly not bizarre, and frankly, she could be having an affair. Albert, the first Truman patient, he believed he had cameras in his eyes, which is kind of a bizarre idea, but when you think about Google Glass and things of this nature, you know, what impact might that have on people? So the fact that ideas that would've been considered bizarre are now not is very significant.

Joel Werner: And I mean, how long until the idea of taking a day trip to Mars isn't considered bizarre either? And that's kind of the point; if you're already prone to delusion, someone with a tendency to fixate on ideas of being watched, or having information that others might want, what happens when the gap between reality and the unreality of delusional belief starts to narrow? As Gold points out in Suspicious Minds, 'The Truman Show Delusion is a delusion of control in the age of surveillance.'

Over time, Gold realised that the way we'd traditionally thought about psychosis and delusion ignored a big piece of the puzzle. 

Joel Gold: Historically we've thought of all delusions through a neurobiological lens; a broken brain, essentially. And that's not just delusions, that's mental illness more globally. And we felt that there was a lot being left out of the picture with respect to delusion and psychosis. Things like the size of the city; the larger one's urban environment, the more likely someone may develop schizophrenia. Being a survivor of child abuse will increase someone's likelihood of having psychosis. So if there are other environmental factors that can actually increase the likelihood of becoming psychotic, how can we see psychosis solely through the lens of the brain, solely through the lens of neuroscience and biology? The notion that it's solely neurons misfiring is looking at it through a keyhole.

Joel Werner: Stepping back from the keyhole, Gold and his brother, philosopher Ian Gold, developed a new theory that explains how delusions are formed. And at the heart of their idea are two interconnected systems that link brain, mind, and the environment.

Joel Gold: We call it the Suspicion System, hence the title of the book, Suspicious Minds. And the Reflective System.

Joel Werner: So the Suspicion System is a reflex, or an instinct, it's the fast thought that identifies a threat. The Reflective System is a conscious response to a triggering of the Suspicion System, it's the slow thought that weighs up whether or not the threat you detected is for real. These systems are thought to have evolved:

Joel Gold: ...as a way of essentially detecting social threat. There are many people in the world who may mean us harm, maybe in our village, in our city et cetera. And it's much more useful to see the bulge in the jacket that's a gun than wait until the gun is pointed at your head, then it's too late. So it's very important that we all have an intact suspicion system. However, in some people this system goes awry and we believe that when it does, delusions can arise.

If you were to wake up and your wife seemed a little bit odd, you might think any number of things; she might be in a bit of an off mood, and her facial expressions might be a bit different. But, if you had some very bizarre idea, that she had been removed and replaced with a dummy or a robot, you would dismiss that as a crazy thought that popped into your mind, and you would go back to the much more likely explanations. That would be the quick, and the slow. The slow would be the Reflective, you reflect on your initial thought, however strange or not it might be, and then you're able to edit.

If however your Reflective System was not able to override your Suspicion System, you might stay with that thought and believe that in fact your wife was a robot or alien of some kind. And no matter what anyone would say, this Suspicion System would keep firing, and the Reflective System, though it may be firing, would not be able to override it.

Joel Werner: The rate at which culture has changed over the past couple of decades, and the nature of that change, has greatly increased the strain that these systems are under. Especially in people whose systems are already malfunctioning.

Joel Gold: Given the current state of instant fame, the internet, cameras everywhere, there are far more unknown others in the world. Before, if I knew everyone in my village, I would have a pretty good sense of who the bad actors might be. Now everyone is watching everyone else, and if I feel that hundreds of thousands, millions, billions perhaps of people are watching me, then that might push me over that edge when the Suspicion System gets overheated, so to speak, and delusions follow.

Joel Werner: Back in Colorado, Scott's Suspicion System was running hot. He had been taken into custody by local police, and wound up in a jail cell, not the big reveal that he'd hoped for. As his frustration with 'The Game' continued to mount, Scott's Truman Show Delusion held fast, and the authorities decided to call in his family.

Scott: So essentially my dad comes out. He approaches me very calmly and asks if I'd like to go talk to some doctors and go to a hospital. And I think this is a great idea, because all these dummies at the prison place, and all my friends just don't quite get it, and I'm sure this doctor person will understand a little bit better.

We go and sit down with doctors and they explain that they're diagnosing me with bipolar, you know, we've got a tall stack of prescription slips and plenty of pills. Obviously this is absurd to me because I'm certain that my mind has never been better and I'm understanding the world more clearly than I ever have. I still believe I'm being recorded. I still believe that there's a camera arguably in the squirrel running by, or every tree trunk, or everything around me is still a set. And I'm still wholly believing that everyone is an imposter or an actor and asking me questions to see what my answers might be.

Joel Gold: Sadly, The Truman Show Delusion is not amenable to treatment in any particular way that other forms of psychosis are or are not treatable. Not trying to be flip, there's no Truman Show Delusion pill. It's a symptom, it's not an illness in and of itself, it's a delusional symptom. It's a symptom of what? Psychosis. And people can be psychotic because they have a medical condition, like dementia. They can be psychotic if they have schizophrenia, bipolar disorder, substance abuse, and the like. So, at core, how would you treat those illnesses? If you would treat bipolar disorder with, say, a mood stabiliser and an antipsychotic, then that's what you ought to do for Truman Show Delusion as well.

One aspect of the book that we touch on is the lack of talk therapies, psychotherapeutic techniques for psychosis. You can actually treat people with delusions, even though it seems counter-intuitive, the whole point of a delusion is that you can't talk someone out of it, but in the course of developing a relationship with a patient, over the course of time and using very specific clinical techniques there have been great successes with some people with delusions.

I think that delusions have meaning. I think there is a lot of information in people's delusions about their lives, about who they are and at the very least that can help us form therapeutic bonds with patients. Once you've done that you have a much higher success rate than if you have a poor connection to your patient. We take our own thoughts very seriously, so why should we not take our patients' thoughts seriously?

Joel Werner: Scott returned to his family home in the Midwest and took a semester off college to recuperate. Over time, his Truman Show Delusion started to fade away.

Scott: And maybe in a not so gradual way over the course of a couple of weeks my obsession at least with these things were diminishing. And then I kind of remember one day just waking up and knowing for sure that it had all been in my head. Maybe there was this brief amount of relief offered by that, of like, 'Oh wait, no, that's not…oh no!' Because, yeah, essentially then it's just a very quick slide back down the last couple of months remembering all the very bizarre things I've said to either strangers or people that are very close to me, and it's a quick realisation that the next time I saw that person, and they said, 'What were you talking about that last time I saw you?' That I would have to explain that I was crazy. The prospect of having to do that to pretty much everyone I've seen over the past four or five months was about as terrifying as anything I could imagine. Basically then it turned incredibly dark. 

Joel Werner: Our understanding of The Truman Show Delusion, and the impact of culture on mental illness is still in its infancy. But Joel Gold hopes that improving our understanding of experiences like Scott's might one day lead to the development of more advanced clinical tools.

Joel Gold: It's very interesting that since we've been describing this Truman Show Delusion, a number of colleagues have told me that people very early on in their illness, often schizophrenia, have these Truman-like symptoms. And I am curious as to whether or not it can be useful to determine who might go on to full blown schizophrenia. So, my hope is to develop some research wherein we might be able to find a way to use these Truman symptoms, ask patients if they're experiencing them, and see if that actually does correlate with their later becoming schizophrenic.

Joel Werner: Over a decade later, Scott's fully recovered, living a happy and successful life in Chicago. His Truman Show Delusion is now just another memory.

Scott: I'm no more the person that climbed a roof and scared my friends than I am the idiot seven-year-old who broke an antique at my grandma's house. This was a thing that happened and…fuck it. [laughs]

Lynne Malcolm: Scott, who shared his experiences with Truman Show Delusion. You also heard from Joel Gold, psychiatrist and author of Suspicious Minds: How Culture Shapes Madness. And Joel Werner produced this report for All in the Mind from New York.

Head to the All in the Mind website for more information related to today, abc.net.au/rn, and select All in the Mind in the list. If you've been distressed by anything you've heard today you can call Lifeline on 13 11 14, and you'll find other helpful links on our website. While you're there leave a comment, we'd love to hear your thoughts.

I'm Lynne Malcolm, see you next time, bye for now

Excerpt from The Truman Show: You want another slice? (Nah, I'm okay.) What else in on? (Yeah, what else is on?) Where's the TV Guide?