Technology and Delusions

[NOTE: This paper was written in Spring 2020 in collaboration with Drs. Devin Gibbs, MD, Tolulope Omojokun, MD, and Audrey Wang, MD. It has not been updated and may no longer accurately reflect an up-to-date understanding of the interplay between technology and delusions. It may hopefully prove interesting anyway.]

Introduction

Contemporary psychiatric care providers have been forced to contend with the role modern technology plays in the lives of our patients. The effect can be especially striking when it comes to psychotic patients, whose interpolation of technological themes into their delusions can have far-reaching consequences on their ability to work and stay connected in a world of ever-elaborating technological complexity. As the contours of psychiatric diagnosis remain hotly contested, so too do questions remain as to the most precise or helpful ways to define a delusion (Freeman, 2000). These challenges notwithstanding, working to understand the role of technology within delusions can enrich our appreciation of psychiatry's past and provide key context as we and our patients move forward together into a more technologically complex future.

Technology and Delusions

Developing an understanding of the evolution of humanity's delusional contents over time presents a significant challenge. Descriptions of pathology consistent with psychosis do survive dating to antiquity. Jeste et al. (1985) describe accounts of preoccupation with "mischief makers" in ancient Mesopotamia, grandiose delusions reported by Alexander of Tralles of ancient Greece, and scattered accounts from ensuing centuries, including Christoph Haizmann, the Bavarian painter whose psychosis inspired Freud's "Seventeenth-Century Demonological Neurosis." In general, though, early accounts of delusions--and the psychiatric disorders accompanying them--are rare. Jeste et al. attribute this historiographical deficiency to several factors, including the absence of a syndrome-based approach to medicine, the failure of physicians to attempt to treat conditions considered incurable, and perhaps most significantly, the attribution of mental health symptoms to religious or magical causes, rather than medical ones. The dearth of surviving descriptions limits the conclusions which can be drawn on the nature of delusional content before the 18th century. Though it would appear clear that persecutory, grandiose, erotomanic, somatic, and other delusions have persisted for millennia, the finer details have unfortunately been lost to time.

As we approach the modern era of medicine, some broad trends in delusional content are described relatively consistently. Kraeplin's 1904 interviews in Java included an early consideration of the differences in expression of delusion between cultures (Steinberg, 2015). Ahmed's (1978) examination of delusional content among Pakistani patients with schizophrenia suggests that delusional content is more strongly influenced by general cultural norms than by a patient's immediate surroundings (e.g., family beliefs and practices). Kim et al. (1993) elaborate on differences in delusional content between cultures by comparing symptomatology between delusional patients of Chinese, Korean, and Chinese-Korean extraction, all living in Yanbien, China. One notable example are delusions of romantic partners engaging in extra-marital affairs, which was found to be prevalent among Korean patients, rare in Chinese patients, and intermediate in Chinese-Korean patients. The authors attribute this finding to differences in sexual mores between the two macrocultures. They also cite diminished family-centered delusions in Chinese patients following institution of the One Child Policy to suggest that culturally-informed delusions can vary over time with political changes. Several other authors have similarly explored the connection between delusional presentations and sociopolitical changes, from changes in societal religiosity (Stompe, 2003; Krzystanek, 2012) to political destabilization (Bohlken, 1991) and nuclear armament (Sher, 2000).

Individual reports of modern technology influencing delusional content are preserved from the early days of industrialization onwards. One famous early account concerns the Welsh tea merchant James Tilly Matthews, described in an 1810 book by John Haslam, an apothecary at Bethlem Hospital in London. Matthews described a device he called an "air loom," which he believed, among other things, was used by a "gang of villains profoundly skilled in Pneumatic Chemistry" to influence his thoughts and trigger an 1800 assassination attempt against King George III (Carpenter, 1989). More than a century later, in 1919, Freudian colleague Victor Tausk described a "schizophrenic influencing machine" consisting of then-modern parts including "boxes, cranks, levers, wheels, buttons, wires, [and] batteries." The idea of such a machine was said to be common to several of Tausk's patients, who employed "all the forces known to technology" (elsewhere listed to include "air-currents, electricity, magnetism, or X-rays") to explain its functioning.

A small number of longitudinal retrospective surveys have attempted to explore the changes seen in delusional content over time in more detail. One such study by Cannon and Kramer (2011) surveyed psychiatric records from a Pennsylvania state psychiatric hospital dating between 1913 and 1999. They describe a majority (76%) of delusional content as persecutory, followed in frequency by religious and somatic content. Technologically-themed delusional content is also specifically enumerated, with the authors reporting, in decreasing order of frequency, delusions centered around radio, television, telephone, dictaphone, airplanes, lasers, radar, and trains. It is noted that delusional content appears to evolve in response to contemporary culture, with higher incidence of delusions regarding syphilis in the early 1900s and Germans during World War II. In this same vein, changes in technology (along with the advent of the Cold War) are cited as likely explanations for an observed increase in concern about being spied upon starting in the 1950s.

Škodlar et al. (2008) surveyed psychiatric records from a psychiatric hospital in Ljubljana, Slovenia for delusional content, with cases dating between the hospital's foundation in 1881 to 2000. These authors helpfully identify the 1920s and 1950s, respectively, as the periods of introduction and stepwise adoption of radio and television in Slovenia. Their analysis uses both of these periods as a landmark for exploration of the changes in delusional content associated with these arrivals. A statistically significant increase in delusions of influence and control was noted surrounding the arrival of both radio and television. Specifically with respect to "delusions with technical themes," an increase in frequency was noted following the arrival of both broadcast media, though only with the introduction of television was this increased frequency noted to reach statistical significance.

Subsequent technological advancements have since manifested themselves in delusional content, as well. Kidd et al. and Ryder (1992) separately describe cases in Ireland and Oklahoma of paranoid and erotomanic delusions centered on satellite dishes, emerging in both cases shortly after the introduction of these technologies to the patients' neighborhoods. Spence (1993) and Forsyth et al. (2001) describe delusional content related to video games, respectively describing cases in which the patient believed they were receiving messages from the game and participating in the game directly. A 1999 case series by Catalano et al. describes two cases of Internet-centered delusions but describes both patients as having limited access to--or even specific interest in--computers and the Internet. Duggal et al. (2002) add a case report of a 31-year-old male developing Internet-centered delusions approximately 10 years into his course of treatment-refractory paranoid schizophrenia, in spite of a general lack of computer literacy. Stompe et al. (2003) describe a first psychotic break in which their patient's pre-delusional sense of heightened perception became concretized to delusions surrounding technology after purchasing a new computer. In this patient's case, the delusion gradually elaborated from one seemingly restricted to his computer to a broader scheme in which the computer was communicating locally with the patient's microwave and remotely with satellites.

In common with the above descriptions of computer- and Internet-based delusions, Kobayashi et al. (2001) describe another woman who developed ideas of reference related to the Internet in spite of minimal prior computer use. These authors even suggest that "the more that patients are acquainted with the Internet, the less it is incorporated into their delusional systems." However, in a subsequent case series by Compton (2003), cases of two patients developing Internet delusions in the absence of technological literacy are accompanied by a third who was a computer science major at the time of her likely first psychotic break. Likewise, Lerner et al. (2006) describe Internet-based delusions not only in a woman with poor technological literacy, but in a man with more than 10 years of passion for computing prior to the onset of his symptoms. It would seem intuitive that patients to whom technology was important in their premorbid state could develop technology-centered delusions, and these studies suggest that this is likely true, despite early underrepresentation in case reports.

Surveys of delusional content specific to the most recent of technological developments, such as the increasing ubiquity of geolocation-enabled smartphones and Internet access, are as yet limited in number and scope.

Discussion

Compton uses the work of Catalano et al., and others, as a launching point for consideration of the basis of technology-based delusions. It is noted that delusions can be informed by cultural norms or may represent projections of internal conflict. Technological delusions may therefore be understood as displacement of psychotically-informed fears of persecution. The resultant fear of technology can exist in (or perhaps even be amplified by) the absence of technological literacy. This suggests that in order to incorporate technology into delusional thinking, it is necessary merely to recognize that said technology exists, rather than to understand how it works. As noted above, however, it also appears true that facility with a given technology might not be protective against incorporating it into delusional thinking. In both cases, these delusions might be expected to increase as such technologies as smartphones and the Internet become ever-more widely available and prominent.

The findings of Škodlar et al. would appear consistent with this uptrending prevalence of delusions related to technology and its ability to exert control over human beings. Though the increase in "delusions with technical themes" achieved statistical significance only after the introduction of television, it is safe to assume that the introduction of television to a world already familiar with radio would naturally have a summative effect on the prominence of technologies in society, and therefore, in delusions. Additionally, the nature of television as a multisensory modality compared to radio may have increased the perceived threat with which it was associated (with imagined persecutors perhaps newly able to watch, in addition to hear, patients in their own homes through the visual medium of the television screen). Both of the above arguments are echoed by Škodlar et al. themselves. In their words, though "epistemological dilemmas prevent us from jumping too quickly to conclusions" regarding causality, these arguments would seem both to conform to common sense and to fit the clinical observations which have continued to emerge regarding the Internet and smartphones since the publication of their study.

A perfectly informed understanding of how and why emerging technologies become incorporated into delusions is likely to remain elusive. However, it appears certain that the prevalence of delusional concerns related to technology will remain elevated compared with the early days of broadcasting 100 years ago, and may even continue to increase. What remains as yet unmentioned here is that patients and providers alike now carry devices outfitted with GPS and high-resolution cameras, through which unseen others have in reality been shown to watch us and track our locations. Historically, the ever-changing psychiatric conception of delusions and their role in mental illness challenged providers to properly understand their patients in order to optimally treat them. It is clear that if anything, the delicacy and nuance required of mental health providers in understanding and treating delusional disorders will only increase as these technologies continue to evolve.

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