Episode 261: Understanding Delusions Leading to Violence: Types, Assessment, AI Risks & Treatment in Forensic Psychiatry

David Puder, MD; Blaire Heath, DO; Michael Cummings, MD

None of the presenters have any conflicts of interest.

Corresponding author: David Puder, MD

By listening to this episode, you can earn 1.5 Psychiatry CME Credits.

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Delusions as Psychological "Death Ground": How Fixed False Beliefs Trigger Violence (00:00)

Puder:

All right. Welcome back to the podcast. I am going to introduce this podcast before we get started. We're going to have a great conversation on delusions, which are fixed false beliefs that sometimes lead to aggression and violence. I have two guests who will be helping me articulate and deepen our understanding of this, both working with patients who acted upon their paranoid delusions or different types of delusions, which led to an arrest. Dr. Cummings has spent his whole life working in the largest forensic state hospital in the world. He is a known expert who has been on multiple episodes prior. It'll be great to have him back. And Blaire Heath, a child psychiatrist who has a unique background as both a pharmacist and a nutritionist, who was mentored by Dr. Cummings for the last eight years, will also be with us. She was a former resident of mine, a true lifelong learner, and deeply invested in understanding and how to help this population.

Understanding “Death Ground” in The Art of War

Puder:

I have an idea, I have a new idea I would like to propose, which I don't think I've ever heard, in line with this type of conversation. It came to me last night, as I was lying in bed, and before posting this episode. I thought I might record this and it might help us understand, and how to make sense of delusions and psychosis and how they lead to violence. The idea actually came from a book of mine. It's called The Art of War by Sun Tzu. And he wrote about this idea of “death ground”. So there were nine different types of geographic environments that he described, nine varieties of ground, and he talked about death, ground and in death ground, also called in other translations, “desperate ground”, “fatal ground”, “ground of death”. It's the most extreme terrain

Puder:

that armies can find. No escape, and therefore, the army survives only if it fights with the courage of desperation, the courage that comes from desperation. And he wrote, “Throw the troops into a position from which there is no escape. And even when faced with death, they will not flee for if prepared to die. What can they not achieve then? Officers and men together put forth their utmost efforts and a desperate situation. They fear nothing when there is no way out. They stand firm deep and hostile land. They're bound together, and there is no alternative. They will engage the enemy in hand to hand combat” (Sun Tzu, 1910/2005, ch. 11).

No Escape = Desperate Courage & Ferocity

Puder:

And so, death ground is a place where, when your army is either deep in enemy territory or it is surrounded on all sides, soldiers will ignite with a new courage that they may not have access to without being on death ground. And so, Sun Tzo explicitly advised his people who followed him to put their own troops in death ground, for example, with their backs to a river or deep in enemy territory without the ability to psychologically retreat. And if you can connect this to delusions already, you might be thinking like I am. But if not, I will further explain.

Puder:

He also wrote to not force the enemy into death ground, like to not fully encircle an army that you're fighting against, leave a path out for people to retreat. So the basic idea of death ground is when you remove all paths of safety, humans’ survival capacity overrides any hesitation of fear and creates superhuman efforts. 

Historical Examples: Cortés, Spartans, D-Day

Puder:

Leaders have subsequently used this. Hernán Cortéz burned his ships in Mexico to eliminate any possible retreat for his men, forcing his men to continue their conquest into Aztec, into the Aztec Empire. Geographically, this has been imposed in some of the most famous battles, like the 300 Spartans, Thermopylae 480 BC. They were able to hold a narrow pass. There was no escape. Right? Because of the geography of it. Also, you could think of allied forces during D-Day, 1944.

Puder:

There was no ability to escape because the sea was at their backs. They had to fight with life or death ferocity. So I also was thinking, this will be a small tangent, I promise, but you can imagine Iran, currently being considered in a death ground. And news articles actually, I looked up, have even highlighted this. One news article pointed out that Iran is now on a death ground amid existential threat from the U.S. attacks and could go big in retaliation. I also wonder if China, with 20% of their oil supply coming from Venezuela and Iran, is in some way in its own death ground, or maybe the pressure is increasing. I also think about how Epstein's emails have put some of his prior clients on a sort of death ground, publicly. And if further emails are released, maybe more incriminating emails that they don't want to release, or maybe emails that they have blacked out for various reasons, it could put many very, very wealthy people, who did horrific things, on a sort of psychological death ground. 

Delusions That Simulate Death Ground

Persecutory: Omnipresent Threat, No Place to Hide

Now, shifting to delusions and the link to death ground, think about persecutory delusions. Okay, here you have an imminent threat, a threat of an omnipresent, invisible threat. Maybe they're being spied on, from all sorts of ways. Maybe the CIA  is following them. There is no place to run, no place to hide. Do you see how that could be kind of a death ground of sorts and violence could become the only survival option to defend themself, their family, the world? They feel completely psychologically cornered.

Capgras & Cotard: Identity Annihilation, Nothing Left to Lose

Puder:

Likewise, you could think about Capgras delusion, where your family is replaced by identical looking imposters, doubles, maybe even demons. Maybe, also if you mix that with some paranoia, they're these demon, imposter, lookalikes conspiring against you. And, we're going to be talking about this in the podcast, but imagine if the only way to get the real one's back was by taking out the replacements. You could see how this kind of becomes a sort of a death ground internally, psychologically in their mind. We will talk about the Cotard’s delusion. This is where a person believes they're dead, and therefore, there may be nothing to lose. 

Erotomanic & Jealous: “Without This Love, I Am on Death Ground”

Puder:

We're going to talk about erotomania, or jealous delusions, maybe without love of a particular person. If the person puts up some sort of restraining order, it becomes the erotomania turns to anger. Maybe they turn into a sort of a death ground with this fear of annihilation if they don't receive the love from a particular object.

Modern Amplifiers: AI as Death-Ground Reinforcers

Puder:

We'll also mention AI, modern AI chatbots and algorithms. How they could be death ground amplifiers. We won't say death ground to the podcast. This is something I've thought about since. But imagine them as death ground amplifiers as sycophant amplifying delusions, giving confirmatory bias or increasing confirmatory evidence, increasing bias. And therefore, this feeling of not being able to escape is amplified. I remember watching a man on YouTube. I talked about this in our episode on AI psychosis. Where he was interacting with the chatbot. And the chatbot was confirming his delusions. The garbage truck could be, very much be, some government agency. Right? Or some hostile intruder. So in death ground, there is no safe retreat. And likewise, in the danger that delusions, the fixed false beliefs give a person, there can be this feeling of no safe retreat.

And there, preemptive strikes can be a way of survival, and that's where violence can happen. Right? Treatment, therefore, can be framed with the thought that we need to not create death ground situations for patients that are struggling with this, we need to create psychological outs. Right? Just like Sun Tzu said, “Leave an outlet for the enemy to retreat” (Sun Tzu, 1910/2005, ch. 7). We, as clinicians give an opportunity for a pathway to a door. Right? We  don't want to have them feel cornered in a room. We may give them an antipsychotic to reduce preoccupation, compulsion, and likelihood of violence. We know that clozapine decreases risk of violence, as well. Cognitive behavioral therapy can create cognitive space for treating beliefs as testable hypotheses.

Puder:

You know, we want to create some room to consider if some of the things that are deeply entrenched, believed, are true. And so, cognitive behavioral therapy can do that. So hopefully, you enjoyed this linkage to ancient literature SunTzu, The Art of War, and this idea of death ground. And hopefully, this can kind of give you a way, a perspective, of looking at this episode. And I hope that you enjoy this. And with no further ado, let the episode begin.

Introduction to Delusions, Violence & AI Chatbot Risks in Teens (Psychiatry Podcast with Dr. Cummings & Dr. Heath) (10:31)

Puder:

Welcome back to the podcast. I am joined today with Blaire Heath and Dr. Michael Cummings. Blaire Heath is a prior psychiatry resident that I had the joy of helping. How many years have you been in practice?

Heath:

I have been in practice 4 years after completing my General Psychiatry Residency at Loma Linda and Child Psychiatry Fellowship at Kaiser Fontana. 

Puder:

And then you went through residency at Loma Linda, and you've graduated, and now you're at the California Department of Corrections. Yeah. Great. Okay. And Dr. Michael Cummings is at Patton State Hospital and today we're going to be talking about delusions. Specifically, when they can lead to violence and different types of delusions. Blaire, how would you like to introduce the topic?

Why Delusions Cause Violence in Forensic Settings

Heath:

Well, I worked at Patton a long time ago, and I think some of the really interesting cases of Capgras syndrome and then, more recently, at the Department of Corrections, seeing risks for assault, seeing  how much delusions, paranoia play into that. It seemed like an interesting, important topic. And I know I've talked with Dr. Cummings, I definitely want him to chime in, but it seemed like a bigger topic now that I'm seeing it more on a day-to-day basis and the real risk it poses.

Heath:

There were some issues recently, but I think Dr. Cummings can also say to this, even working at Patton, a lot of our patients are actually incarcerated because of delusions, paranoia, and hallucinations too, that they had acted out of those experiences. So, I mean, there's been some recent stuff, issues with staff, but also a lot of their family members. They, Dr. Cummings again, can jump in. Even at Patton, in a patient receiving Clozapine with extensive intervention and monitoring, they still are having certain types of delusions of their family being aliens or clones that they actually may have killed, waiting for the real family members to come back. And so, you have really severe delusions of family members, but even, we'll see it transferred to staff delusions, which you may not even realize because they're quiet. People don't always talk when they're paranoid, and then they may act out of their belief [that] they're being poisoned with their food or this person is trying to control them. And so, it's something that has really been coming more since I've come back to the department of corrections, and has really, I think, made an impact. Dr. Cummings, do you want to speak to that?

Cummings:

Yes. Basically, Blaire is exactly right. In forensic settings, there is a very strong bias for people to wind up in either state hospitals or prisons due to positive psychotic symptoms. And certainly one of the most common scenarios in that regard is that people are experiencing persecutory ideation, believing that others are harming them in some way, and they therefore feel justified in acting violently toward the person. That's in contrast to more general functioning in the community, where actually negative symptoms and cognitive deficits are more impaired with respect to function. But in forensic settings it's more often the positive persecutory delusional systems that get people in trouble with the law.

How to Assess and Rate Delusions — Key Scales for Clinicians (SDSS, BABS) (13:12)

Puder:

Okay. So maybe we should back up a little bit and just talk about how we rate delusions, how we think about it. I know, Blaire, you had written down some notes on some ways of instruments asking about this. Do you want to take us through that briefly? And then Cummings can kind of deepen it.

Heath:

Okay. So, adelusion is a fixed, false belief, a mistaken belief. The psychopathology, I didn't know how much you wanted to go into it, but I know at least that the neurotransmitters look like, at least with delusional disorders, look to be more dopamine based. But when you look at something like schizophrenia, dopamine's one of multiple neurotransmitters in a broader way that's related to it. I mean, this isn't just focused on delusional disorder because that's kind of rare, but it really can be a part of a lot of different conditions like mania and schizophrenia, of course is one of the main things that we think of. But Dr. Cummings provided some good, I think you probably received them, some articles, and there were a few that I really liked that were talking about scales (Forgácová, 2008). One, is the Simple Delusional Syndrome Scale (SDSS), and it kind of helps look at delusions in, I feel, like a more of a dimension. [Assessing] is it logical?

Characteristics of Delusional Experience & Response to Antipsychotics

Heath:

How is it organized? How strongly the person believes that delusion, the influence on their actions, their stability, extension, because also sometimes it's just an isolated delusion about one thing, but the rest of their reality is normal, reality based. That's kind of like a delusional story can be isolated versus something like schizophrenia where it may be very extensive, with different parts of the reality. A lot of times it may not just be one delusion, they talk about a theme, but there may be a mixture of different parts of the theme. And, also talking about the characteristic of delusional experience for the person. Do they try to resist it? How preoccupied? And, at least in my experience, with antipsychotics, the person will still believe that thing. They will still have some inclination towards it, but they're able to dismiss it more.

Heath:

They're able to question it more and they're becoming more reality based, but they still may stick with them to some extent, but not as strong of conviction. So there's another one, the Characteristics of Delusional Experience that talks about some of those and the self-evidence and reassurance, happiness (Garety & Hemsley, 1987). But also, I think one of the things I like is that it talked about the distress, belief, strength, intrusiveness and concerns. So how distressed the person is by the delusions, at least in my experience, lessens over time and that allows them to be more open to maybe psychotherapy, to question and look at their reality. Dr. Cummings, did you want to….

Using Rating Scales to Track Delusion Preoccupation Over Time

Cummings:

I think David and I have talked many times about the utility of rating scales in clinical practice. And something certainly I tend to encourage people to do is find simple scales where they can actually track the person's condition over time. It's often difficult when you're seeing people intermittently to have a clear memory of, “Well, just how were they doing the last time I saw them?” It can be very helpful to have a nice numeric anchor as to, is my treatment working? Is it getting them better? Are they not getting better? It can help answer those questions. So, rating scales can be very important in this area, just as they can be in many other areas of psychiatry.

Puder:

One thing I like about some of these rating scales is sometimes you kind of  blur your eyes a little bit and kind of get some of the big themes, the preoccupation. Right? Like, is this something that they're thinking about one hour a day, 10 minutes a day, six hours a day? Right? This can make a big difference if they're preoccupied and then they're thinking about it and the delusion is shaping every action that they do, or it's just a kind of a passing thought, a couple times a day. Right? This is a big difference.

Cummings:

Yes, indeed. And, as Blaire pointed out, often the improvement we see with antipsychotics is not so much that the delusional thought vanishes entirely, but it loses the degree of preoccupation it had initially, and the person is less compelled by the delusional content. And those are both very important clinical goals in terms of preventing harm to the person as well as preventing harm to other people.

Cummings:

You know, Karl Jaspers, in 1913, originally defined delusions as a fixed false belief. His second description was that it was incorrigible, meaning you could not use logic to alter the delusional belief (Jaspers, 1963). Well, it turns out neither of those things is true. The strength of delusions varies over time (Hayashi et al., 2021). And indeed there's now an entire psychotherapy CBT for schizophrenia that is focused on getting people with delusional beliefs to begin to treat those beliefs as hypotheses that they can test. Which is a major advance for people, once their more flagrant psychotic symptoms are under control.

Puder:

Yes. And I've done that psychotherapy, somewhat. It can be a mixture of success initially. I think the most important part of psychotherapy initially, is of course, getting them to come back to psychotherapy. And if you push too quickly, too hard, sometimes they just do not come back, is my experience.

Cummings:

Yes. My experience has been you have to get the positive symptoms under better control, and you need to get the preoccupation with, and being compelled by the delusions down to a more manageable level so that essentially, the person has the cognitive space to begin to question the delusional content. It's at that point that they're ready for psychotherapy. I think if it's introduced too early, often the person will flee from it.

Puder:

Yes. And this is where I think that you have to be very calm. People want to be with a person that is very calm, and if anything, that we can provide to the audience is to reduce their anxiety of someone else's fixed, false beliefs today. Maybe a little bit, so that they can sit calmly with them in the midst of [the delusions].

Puder:

Blaire,  let's go through some of the different ones. Let's talk about them.

Delusions in OCD, Mania, Body Dysmorphic Disorder & Beyond Schizophrenia (20:43)

Heath:

Oh, yeah. And one other thing I did want to  bring up, that Dr. Cummings had brought up previously, there was one other scale, the Brown Assessment of Beliefs Scale (BABS). That one of the things you mentioned was talking about delusions associated with OCD, or maybe body dysmorphia, as far as looking at delusions based on different conditions like that or trying to distinguish it?

Cummings:

Yes. Frankly, since both Blaire and I work in settings that are very selective for people with serious mental illness, usually schizophrenia spectrum disorders, it's very easy to forget that delusional or false beliefs occur in a whole variety of both psychiatric and neurological conditions, including things like body dysmorphic disorder (BDD) and obsessive compulsive disorder (OCD), where the person may have varying degrees of insight that the belief may or may not be true. But it's important to recognize that delusion is not limited to a single psychiatric disorder. This is a symptom or mental state that can cross diagnostic boundaries.

Body Dysmorphic Disorder vs Somatic Delusions

Puder:

Really, really important. Yes. Like body dysmorphic disorder. I've actually done an episode on that [see episode 191]. You know, interestingly, we don't treat that with the dopamine.

Cummings:

Medication.

Puder:

Often, it's SSRI.

Cummings:

Yes. The pathophysiology seems to differ by condition, although I think the end areas of the brain involved are often the same. Certainly in the schizophrenia spectrum disorders, ventral segmental increased dopamine plays a role, but regardless of whether it's a primary dysregulation of dopaminergic signaling or physical damage to the non-dominant dorsal lateral prefrontal cortex by stroke, both of those conditions can give rise to delusion. One, by influencing the functioning of that part of the brain and the other, by causing direct damage to it. You know, the two characteristics of delusions that seem to hold across categories of illness and types of delusions is that there's a failure of reality testing. I've always been impressed that in the healthy population, surveys indicate that up to a third to a half of people may experience occasional psychotic symptoms, like hearing their name when there's no one there, or having the eerie feeling that they're being followed or watched, but they're able to dismiss those things because they're dorsal lateral prefrontal cortex basically evaluates how likely is this and says “It's not, ignore it.” The other element that appears to occur in almost all delusions is an inappropriate assignment of salience or importance. The people who are delusional are assigning importance to things that, in truth, are often innocuous or unimportant in the environment, which may have to do with the reward pathway being abnormally activated by dopamine.

Puder:

Also, OCD can have with and without delusions. And one, sometimes patients with schizophrenia can have coexisting OCD, which I've treated some of this recently, and it's very difficult. With OCD, the insight into the obsessions can start out as very low. And so this is almost like a delusion, the OCD thoughts can sound like a demon. Right? So this is where it gets tricky, and I'm curious what your thoughts are on this. When is it…?

Cummings:

I think it's actually a mistake when we say people with OCD, the obsessions are not delusional, and some people they are delusional….

Puder:

Well, I think it can start out delusional until they gain a level of insight. 

Cummings:

…until they get better. Yes. Just as in schizophrenia, and people can be very delusional. And then over time, the delusions can become much less compelling and they may indeed reach the point where they can begin to question the content of their delusions.

Puder:

Right. So, let me make this more real for the audience so we're not lost. So specifically, you could have a delusion, or it could be an obsession. Right? And the obsession could be, “Don't go through the door. If you go through the door, something bad is going to happen.” It can take on a delusional character when they believe that it is true. Is that the way you see it? 

Cummings:

Yes. Yes, indeed.

Puder:

But then it can become just an OCD thing when it's like, “I know that this is my OCD, this is not a rational thought. I'm going to be okay if I go through the door, I'm just going to struggle with my compulsions if I go through the door. I'm having a compulsion to not go through the door, I'm going to resist and not do the compulsion. Because that's going to help the OCD get better over time.”

Cummings:

Yes, indeed.

Puder:

Okay. So yeah, thanks for bringing this up, Blaire. I think delusions can happen outside of schizophrenia. They can happen in mania. I've seen them in mania, multiple times. Where people get manic, they'll develop a new delusion. They'll come out of mania, maybe on lithium, maybe on olanzapine, and then the delusion is still there. Right?

Cummings:

Yes.

Puder:

It lingers. They have a new belief about reality. It can be very difficult.

Cummings:

Yes. I think that's one of the things that attracts psychiatry to delusions is they're one of the toughest symptom categories for our field to deal with. We really struggle to get people past delusional beliefs.

Puder:

One of my early mistakes, I was a resident, this is so far gone, and so vague of a patient. But I had this patient who had a belief that his parents had tortured him, and he was in a psychiatric hospital, and I believed him for the first two weeks. And I really believed that his parents were the worst people in the world until I didn't. Until I realized, “Oh, this is part of his schizophrenia.” You know? And this is the first year in residency. Right? Where you just do not know what you don't know. Right? But I imagine there's some people out there who are hearing patients' delusions, and it's like, is this real? Does this person have severe trauma, or is this a delusion? And it's very hard to differentiate, and I would never want to tell a patient right off the bat, like this is the delusion.

Cummings:

Yes. Well you know, the DSM divides delusions into four types. There's bizarre, which is usually fairly easy to spot for that reason that they're bizarre, not likely to occur in any form of reality. The non- bizarre, which is what you're talking about though, are things that are possible but don't seem likely. And then there are  the mood congruent and mood incongruent delusions. You know, I've seen it go both ways. When I worked at the VA, we had a patient who was manic. He was admitted. He claimed that he worked in the Senate and that he was friends with a number of very powerful people, senators, and of course, the staff all thought, “Oh, the guy's grandiose, he's delusional.” Until he started getting “get well” cards two days later from D.C.

Puder:

Yes, that's a good example. In my example, it started out as a non-bizarre delusion, but then, as I heard his story more, it became more and more bizarre. And so then I was challenged to either believe that this guy was the most abused person I'd ever met in the world, right? Or that some of his stuff was so over the top that it was impossible to happen. And then yes, it got so over the top that it was truly unbelievable. 

Cummings:

Yes. Blaire, why don't you talk about some of the specific subtypes of delusions. Some of those are very fascinating and have gotten named simply because they are so unusual.

Most Dangerous Delusion Types — Persecutory Delusions and Violence Risk (28:54)

Heath:

I would say the persecutory are probably the ones that I think, even early on, working at Patton, a lot of the paranoias associated… I know in one of the articles that you put that the anger is often what drives the violence, and of course, that's our biggest concern. But one of the biggest ones, really, that was a main theme for ones that were at risk for violence, being spied on, conspiracy (Coid et al., 2013). I mean, often, they're mixed themes. There may be other ones; grandiose, and they may have bizarre ones. But I think that is a key one that I feel really can go under the surface and it can be like general mistrust. This is just more my experience, that general mistrust, which it actually can be a much deeper, very complex delusion going on. And like you said, all innocuous things in their environment reinforce it.

Heath:

And it's hard to know how that tip of the iceberg we talk about, how deep it is. And so, at any time, when they can know for months, years, and then suddenly they act out even on a family member, on, you know, a person that may be trusted. So I think that one is a really big one to me. That, especially in a forensic setting, where there's already a level of trust, there's already a level of violence potential when you add that. That seems to me, probably one of the biggest risk factors that really stood out to me. Is there anything you would want to add to that?

Capgras, Cotard’s and Other Delusions Leading to Harm

Cummings:

Well, I was going to say there are also some very unique delusions that crop up in settings where you treat a lot of psychosis. Things like capgras delusion, where people believe that people they know have been replaced by imposters. Indeed, we have a number of patients who have harmed family members because they misidentified the family member as a demon, or the devil, or as someone else who was an enemy who had taken away their family member and had replaced them. Probably one of the most unusual named delusions I've come across, and I've only had a couple of these, but was Cotard's delusion. I had a VA patient who believed in all sincerity that he was dead. He was not, he was alive walking, talking, breathing. During his neurological exam, he told me when I tested his strength, however, “Doc, that's not strength. It's just rigor mortis.” You know, he was firmly convinced that he was dead. There are other culture bound delusions that are fairly unique to some cultures like Koro [syndrome] believing that the genitals are being withdrawn into the body, and that when that process is complete the person fears that they will die. You know, there are a number of these kind of encapsulated, very unusual delusional beliefs. Did you want to comment further on those?

Heath:

I think one of the things that when I was looking more into this, that I didn't realize, was how they can be mixed. I didn't really think of, you know, there could be the grandiose with hyperreligious, versus there's also a level of the persecutory. Like you can have a mixture, so they may have the Capgras, but believing this person you care about has been replaced, isn't there an aspect of paranoia? Or is it, you know, this person's conspiring against me? It's a mixture, almost that might make someone act out. Would you agree with that?

Cummings:

Yes. Well, I think the hypothesis I've read in the literature as well as my own hypothesis about why people become delusional, is that if we lose the ability to test reality we're then faced with having to explain these unusual psychotic experiences. As a species, we love stories. And I think what happens, albeit via different mechanisms, is that if the person cannot reject an unlikely experience, they then have to explain it. And the explanation can become a  very elaborate story. Well, you know, “This happened to me because the CIA is following, or that happened because the demons are after me.”

Heath:

You're talking to me, and then I believe that this thing I saw, the voices said this, so then this thing happened. So it must mean the delusion, I believe, is being reinforced by the voices and kind of believe that. What about grandiose? What would you say as far as, I don't know that I always think that as being as risky, but I mean, grandiose is a really interesting one. I feel like I don't always see it, you think more of maybe mania, but I, there were times, you know, one of my favorite patients at the state hospital had bazillions of dollars and servants and mansions and….

Cummings:

Often, those seem to be, in some ways, often a counter response to exactly the opposite, very difficult circumstances where the person may indeed, rather than being incredibly wealthy, they may have lost wealth. We had one banker who, because of his mental illness, had suffered truly impressive losses of wealth, but his response to that was to believe that he essentially owned everything.

Heath:

Well, interesting. It's interesting.

Puder:

I was thinking about the Capgras and the Jim Carrey thing. I don't know if you guys heard about that. But after he gave a speech there were pictures of him before and after, and it looked a little bit different. His eye color looked different. And so all these people on the internet were saying like, “Oh, Jim Carrey's gone. Jim Carrey's dead. Jim Carrey's been replaced.” but it was like a mass Capgras experience, right now.

Cummings:

Well, certainly trust has become more difficult now that we have things like deep fakes and so forth, so…

Puder:

Yeah, absolutely. Yes.

Cummings:

…I don't know. I don't know if that will doom all of us to some extent, to become somewhat delusional, but I hope not.

Puder:

I remember before the Epstein files came out, I was, you know, a fan of conspiracy theory, and I had some theories, and they actually came true with the Epstein files. And so, it's like, were my delusions well-placed? When are they poorly placed? How do we know for sure? Right?

Cummings:

Well, I think, in many cases, as your story with your patient illustrates, for the psychiatrist working with an individual patient, I think it's always very important to check out as many collateral sources of information as you can. Now, in the case, for example, of the man who actually did work in the Senate, it became very obvious when you started getting get well cards from senators that his was a reality-based statement that was not delusional on his part. You know, so it's worthwhile to always do a bit of investigating and figure out is the person actually delusional or is what the person is saying actually true. Because, that is a possibility, at least for the nonbizarre delusions.

Puder:

Or, I remember I had this mother who was like, “My son is really going off the deep end. He believes that microplastics are in the foods and they're getting into his brain,” And then I was like, “Have you read the study about how we have about a spoonful of microplastics on average in our brain, on autopsy?”

Puder:

And you know, maybe he was ahead of his time. Right? 

Cummings:

Yea, Could be. Could be. 

Puder:

So, on a side note, with that, people are listening, if you're worried about microplastics, I think the key is just not to heat your food in plastics. Don't microwave your food in plastics, don't use plastic tea bags. That's my big takeaway [see . 

Cummings:

Yes. The other good news, of late, is they have discovered that we, as a species, actually do eliminate microplastics over time. So we're not going to fill up to the point that we are nothing but microplastic.

Puder:

Right. Our body is constantly getting rid of them. Maybe a high fiber diet will help. Right? Maybe it…

Heath:

Could move everything along

Puder:

For the very small particles. They'll come out in sweat, you know, a good salt. Once a day, we'll take care of a lot of heavy metals, a lot of bad things in our environment. Yes. Okay. But getting back to different types of delusions, let's make sure we cover all the ones. Erotomanic ones….

Erotomanic Delusions — Stalking and Celebrity Cases (John Hinckley)

Heath:

Interesting one. I was thinking, John Hinkley Jr., with Jodie Foster. Wasn't that a famous one, Dr. Cummings?

Cummings:

Yes. Yes.

Heath:

So, if someone is like, “Oh, when I get out, this famous person is going to take care of me.” What is your plan? “Well, this famous person is going to have a relationship and they're going to take care of me.” Or, as far as I know, that's more than maybe this forensic setting, but, it looks like it can be a cause of violence. Do you have any thoughts about how we approach that or get a larger view of….

Cummings:

Well, yes. Erotomania is a type of delusion, and it does intersect with forensics in the sense that you know, the person who believes that often stalks the person they believe is in love with them and will show up in their home. For example, when the person rejects them or gets a restraining order, that feeling can turn to anger. And there have been a number of celebrities either harmed or killed as a result of people with erotomanic delusions. So, certainly, nothing to take lightly. Same thing, similar in delusional disorder. When people have a jealous subtype, where they believe that their spouse or significant other is cheating on them, even though there's no evidence to support that those people can become quite dangerous if they feel they're being abandoned or rejected. 

Puder:

Yes. So, the classic John Hinkley Jr. versus Jodi Foster, he had watched Taxi Driver, 15 times. This 25-year-old male developed this erotic  fixation, where he believed that she was in love with him. He moved to New Haven, stalked her at Yale, subsequently sent letters, poems, declaring his love. She rejects him. He has this unshakable belief, “She loves me back. She can't say it publicly yet.” To win her heart, to create a legendary romantic bond, he plans this very traumatic act of assassinating President Ronald Reagan on March 30th, 1981. He left her a letter, in his hotel room, addressed to Jodi Foster, “I would abandon this idea of getting Reagan, in a second, if I could win your heart and live out the rest of my life with you.” So think about it as also like this, despite overwhelming evidence that the person is not in love with you, you continue to believe that the person is in love with you.

Puder:

That's the erotomanic delusion.

Jealous Delusions (Othello Syndrome) and Relationship Violence

Heath:

I thought it was interesting. It's called the Othello subtype. That was kind of interesting. Dr. Cummings, if anyone would know…. I know that's a talk about infidelity. I think, in the Shakespearean play, but that was kind of an interesting association. Do you have any thoughts about how those two go together?

Cummings:

Yes. You know, Shakespeare was ahead of his time in terms of talking about human nature and indeed rejection by someone who is the loved object, of course, can quickly become angry at that object, that person, or can be displaced onto another. In this case, Mr. Hinkley, since he had been rejected by Jodi Foster, essentially decided that if he did something famous enough and important enough, maybe he could overcome her rejection. But there was also an element of self-defeat there. I think he was fully aware that he might be killed in the process of attempting to assassinate a president.

Puder:

So, the Othello type is really a jealous delusion. Right? Where you have Othello is convinced that his wife is cheating on him with Cassio and in delusional rage, he murders her [Shakespeare, 1604/2005].

Cummings:

Yes.

Puder:

It's like a delusion of this, and I've actually seen this. I've actually seen it be as fixed as can fixed be, initially. I've worked to make it unfixed, but it's this complete delusion of the unfaithfulness of your partner, despite no evidence that they're unfaithful.

Puder:

I've also seen one patient who really believed this about their partner, and then found out their partner was unfaithful. They had the intuition before they had the evidence. Right? So, this is where it's complicated as a psychiatrist or a therapist, you're coming into a situation not fully knowing what's true or not true. Trying to not make assumptions too early. Right?

Cummings:

Yes. That's why we always need to be on the lookout for more evidence, as well as collateral sources of information, you know, some delusions are obviously false. Others, not quite so much.

Puder:

Yes. Or they'll make evidence up out of things that are not evidence. Like, “Oh, my partner was 10 minutes late, they're cheating on me.”

Cummings:

Yes. That gets back to the salience issue before they assign importance to things that are not important. 

AI Chatbots Reinforcing Delusions — The Rise of AI Psychosis (43:10)

Puder:

I don't know if either of you listened to my episode on ChatGPT psychosis, but we talked a lot about how often ChatGPT would actually strengthen the character of the delusion [see episode 253]. 

Puder:

By the sycophantic nature of it. By the agreeableness of it. And they would actually find new potential reasons for delusions, or new paranoia. It would almost strengthen the paranoia.

Cummings:

Yes. Well, certainly current large language model chatbots essentially are designed to agree with and support what the person says. And indeed, they will do that often to the person's detriment. Hopefully, as AI moves forward, they'll get some guardrails around that because it can be very dangerous.

Heath:

Yes. It can get to God and people think they're God, where it's the only relationship they have. I've talked with Dr. Cummings before. I mean, it's pretty scary, and I'm sure you know that it definitely can get more and more problematic to try and address. And again, is it silent? The person, just that their whole world and their whole social interaction is with these AI.

Puder:

Right. Normally a friend will start to try to question some of the delusions that don't make sense. Right? And then, in the case of AI, can sometimes just agree, because  they're often trained by other people. AI will say, “Do you like response A or B better?” And the more agreeable one gets voted up, and so the AI gets trained over time to be more agreeable.

Teens Using AI Companions: Pew Survey & Mental Health Dangers (2025)

Cummings:

Yes. Which is of concern. Now, this is kind of off topic, but I read a survey recently, I think it was by the Pew Research Corporation (2026), where they found that roughly 40% of junior high school students say that their best friend is a chatbot [see also Chatterjee, 2025; Common Sense Media, 2025].

Puder:

That seems very high, but scary.

Cummings:

It seems very high to me too, but also very scary. Although, I can see it because as you know, junior high school can be a kind of hypercritical, very stressful time; and here, you have this thing that will talk to you and it's never critical.

Heath:

Of course. Yes. As a child psychiatrist, I did a fellowship in child psychiatry, a lot of them are socially awkward, you know, and their parents may not…they're not involved in extracurriculars, they have online friends. But we wonder if the online friend AI? Is the online friend real? Is the online friend someone that just got out of the Department of Corrections that might be targeting this person. They send inappropriate pictures. I mean, there's a lot of pressure that they're sending pictures of themselves. They get distributed to other kids in the school, where a lot of the depression or, you know, like you mentioned, the deep fakes. I mean, they are so susceptible, and not only, I would say to the AI part, but just they're so susceptible in so many different aspects of social media and being preyed upon and the impact that can have, I think, mentally and not understanding what they're doing and the impact. 

Cummings:

Well, I think we've now reached the point where we're talking about in some ways, delusional beliefs that go beyond the individual and begin to resonate in kind of a sound chamber provided by the internet.

How Algorithms and Sycophantic AI Strengthen Paranoia & Delusions

Cummings:

So, I do wonder sometimes, does that mean that we're becoming more potentially delusional as a society?

Puder:

I have found that it's with the algorithm, you know, like when I got on the Jim Carrey kick, it all of a sudden started to show me video after video of this. And it's like you're getting, this is a great example of you could get pulled too far into it, you know, and then you could start to think like, “Oh, man. Is he really Jim Carrey? Is he not Jim Carrey?” It's kind of, for me, it's kind of like, I'm like holding this loosely, but you can imagine if someone had more of a paranoid personality, if someone has a little bit less of a, I don't know, different types of personality structures, they may be more likely to start just believing something early on or in a fixed way.

Cummings:

I think what my big concern is, for indeed, as Blaire is pointing out, for the awkward, socially limited adolescent who's growing up. If you have real friends, they will say, “Wait, that's dumb. That's not real.” The internet sources are not going to say that. In fact, the AI will go, “Oh, yeah, well, that's a possibility. Here, let me tell you 500 stories about this.”

Puder:

Exactly. Oh, I get questions as well, [about] some of these dating apps. Because male patients of mine will meet females; And I'm like, “I don't think that's a real person.” And they're not. They're catfished. Actually, some of my patients, pretty much every girl he matches with is catfish. Now, if you saw his profile, you would understand why he might be overly catfished. But this is real. Is he talking to an AI bot? It's more and more likely he's talking to a sophisticated AI bot.

Cummings:

Yes. Oh, indeed. There have been people who've lost huge amounts of money because their  “girlfriend”, who just happens to be in another country, says, “Oh, I really have this need and that need, and could you send me some money? Maybe I'll come visit you.” Of course, the visit never happens because the girlfriend is an AI bot.

Puder:

Right. And this is the world we face. We need to prepare our patients for it. We need to ask the right questions to see what are the influences bringing them further into a delusion. Right? Because it's like, for a lot of these patients of mine, it's a very nice delusion to have that there's a very attractive female that's very interested in them, that's in another country, that they're going to spend their future with. Right? You could see how that starts to….

Cummings:

Yes. I think as this worsens, we may get into a state where we have essentially internet induced delusions, which we have now in the appendices of the DSM: Internet addiction disorder. Well, we may eventually have internet delusional disorder.

Puder:

Well, I think it's probably here. It just hasn't been codified in the DSM. Right?

Cummings:

Yes. Well, that's because the DSM committee lags behind just a bit. 

Heath:

I know there were some other ones, we'll go back to the referential ideas of reference. There's the thought insertion, but I was going to say, I think another big one is somatic. Because, in medicine, we have a lot of patients that can be convinced. I remember, Dr. Puder, even in residency, Dr. Puder having a patient, there was a clinic and people wanted to find a reason, they'll want to find a medical reason for what's going on with them. And so, a lot of times, I think somatic. I think one of the things is it's not just believing, not just hypochondriasis illness, anxiety disorder, which that's kind of, I don't know, if we put that completely, but people believing they have a microchip in their brain or having parasites. I thought somatic is really interesting. Did you both want to expand on that, at all?

Cummings:

Yes. I mean, there's an entire literature on Morgellons disease, which is essentially delusional parasitosis, where people will go to extreme lengths to try to prove that they are infested by parasites. Even though, when people finally look at samples that they've dug out from under their skin, there are no parasites. This can be a very damaging delusion, especially when it's a parent who essentially is engaging in Munchausen by proxy where they're taking the child from place to place to place and saying, “Oh, the child has parasites.” And the poor kid winds up with all sorts of tests, all of which, of course, are negative. Somatic delusions are one of the toughest categories of delusion to overcome.

Puder:

I've seen the parasite syndrome. Another word for it is Ekbom syndrome or delusional parasitosis. The crawling under the skin. I remember one patient, I figured out it was because he was using some meth, and once he cut the meth, it went away. And he had seen a couple different people for that. You know, some people do have Lyme Disease, acute Lyme Disease. But there's a lot of people who, despite real infectious disease specialists saying, “No, you don't have Lyme Disease,” they'll find some expert that they pay cash, by the way, and it's very expensive, that believes that they have Lyme Disease, and they'll put them on years of antibiotics, and they'll have huge side effects. They'll get C. difficile [Clostridioides difficile] and they'll end up in the hospital.

Puder:

I had a very good friend of mine, an infectious disease doctor at UCSF, across from one of the big Lyme Disease places in San Francisco. He said he would get these cases of people having awful side effects of being on chronic antibiotic treatment from these patients for years. And, you know, people are looking for an answer for their suffering. Right? And it's very hard to discern the cause of the suffering. Sometimes it's psychological. It's easier to believe it's actually physical. If you have a psychological problem, you may not get the empathy from your spouse. If you have a physical issue, you may get empathy, you may get kindness from your spouse. 

Cummings:

Yes. And physical illness doesn't come with typically the same degree of stigma as psychological or mental illness.

Heath:

Dr. Cummings, would you speak to body dysmorphia versus maybe a somatic delusion?

Cummings:

I think that body dysmorphia [body dysmorphic disorder (BDD)], that is the feeling that something is wrong or irregular even though it is not, is a form of somatic delusion, frankly. It leads to a lot of unnecessary plastic surgery. Now I think that that's something if you're a plastic surgeon, you need to be on the lookout for, and if somebody is wanting, you know, multiple revisions of a perfectly healthy, well shaped nose or ears or anything else, they're taking a lot of risk by having multiple, these people usually have multiple surgeries. I think the onus is on the plastic surgery community to say, “No, this is not reasonable.” You know, having rhinoplasty because you don't like the shape of your nose is perfectly fine. Having 15 rhinoplasties is not.

Puder:

Well, it's 15 going on 30. Right? There's no end to it. And that's the problem with delusional body defects, is that they could believe, “My nose is massively deformed. It's rotting from the inside.” They could say something like, “My penis is shrinking and disappearing into my body. It's an odd shape. It's hideous.” You know, Koro-like delusion, where it's shrinking inside of my body. “My face is asymmetrical. Everyone's noticing it, everyone's looking at it. I could never date because of it.” I had a patient like that, and I tried to help him through just realizing that this wasn't going to be the thing that kept him from success in dating. Right? So we have to use cognitive behavioral therapy on these things, otherwise the delusion doesn't just go away. You know, it's not like you get 15 plastic surgeries and the delusion is gone. It's always one more. Right? And that's the problem with this type of patient, is that then, if you're the plastic surgeon, you're going to get sued maybe, or they're going to go from idealization, “Oh, you're the best plastic surgeon ever! You're going to be able to fix this thing that no one else has been able to fix.” To, “I hate you! You're evil! You're the worst doctor ever!” You know? 

Cummings:

Yes. Well, it becomes the same goal that covers all of the delusions we've been talking about. Our goal in mental health is to try to help the person achieve the delusion becoming less compelling of behavior. We may or may not be able to make the delusional thought go away completely, but as a first goal, we should try to make the delusional belief less dangerous for them and less dangerous for other people, as well.

Heath:

I think that's just one of the few things that we are talking about. Plastic surgery can intervene, so different than just this belief. We give an antipsychotic, hopefully it lessens, but is it enough that they won't keep pursuing the surgery?

Cummings:

Well, I think Dr. Puder is right. I think it takes a combination, in many cases, of both medication and, in terms of body dysmorphic disorder, the SSRIs seem to do better than the antipsychotics. But with that, cognitive behavioral therapy. I think it's key to get the person to question the validity of their delusional thought. If they can begin to treat it, not as a firm, “This is truth,” but as a hypothesis, “Could this be truth? Is it true or isn't it? What's the evidence for and against?” If they can reach that point, they're regaining some of that reality testing.

Heath:

Another one I really like, that you pointed out, Dr. Cummings, the nihilistic. I mean, with depression or certain ones that can be more key, based on the disorder, the mood issue. Like you're trying mood congruent versus incongruent. Do you want to discuss that all?

Cummings:

Yes. People who are severely depressed often suffer from extreme guilt. Delusional guilt, meaning they believe they're responsible for things they are not responsible for. You know, “Oh, I caused all of the deaths of the world, or all of the wars in the world.” Well, that's it. It's both grandiose and nihilistic. Or, “My organs are turning to dust,” is the classic nihilistic delusion.

Puder:

“My organs are rotting away. I'm already dead.”

Puder:

“Nothing exists anymore, including me.” Right?

Cummings:

Yes. And of course, the key for that is you're usually at that point of dealing with a psychotic mood disorder, which from a pharmacologic standpoint, the key is to treat them with both an antidepressant and an antipsychotic. The response rate to an antipsychotic alone, in those cases, is somewhere between 20 and 30%. But if you add an antipsychotic to an antidepressant, you can get the response rate up into the 60 to 70% range, which gets the person usually better enough that you can then begin to again, support them with, in this case, psychotherapy treating both their depression and their delusional beliefs. 

Heath:

And, you were talking about the guilt, the sin, poverty, fear of being ruined. There's a kind of overall, maybe a negativity, like a negative delusion maybe that you would say depression or,

Cummings:

Yes. Well, it comes down to if the person believes they are delusively guilty of something, and therefore they need to be punished. And often, they delusionally believe that they either have been or are being punished in some way.

Heath:

And would they maybe not seek treatment because they feel like they're being punished?

Cummings:

That is a possibility. Most of the delusionally depressed people that I've treated in my career were brought by family members. They did not bring themselves into treatment.

Heath:

And I think one of the things, I did want to go back, that we didn't talk as much, is that ideas of reference. Belief that neutral events, I've had patients, “Oh, the TV is talking to me, or it has a special message for me.” It's good they have enough insight where they say, “Okay, I turned off the TV because I realize I read into it. Or certain stories mean something to me.” Do you have any thoughts about that one specifically?

Cummings:

Well, I think that's also an example of deranged or abnormal salience assignment. People see something that is ordinary, mundane, routine. You know, people talking down the hallway, the TV's on, and they begin to make assumptions that, “Oh, that's important. Somehow it's related to me. They're talking about me, or the TV's talking to me, or people are able to read my mind or people are inserting thoughts in my head.” In fact, we have one patient, here at Patton, who committed homicide because he believed that his victim was stealing his thoughts.

Puder:

Or, it could be, a patient could be watching two people laugh across the street, and then, “They're talking about me. They're laughing about me.”

Cummings:

Yes.

Cummings:

It's that inappropriate assignment of what they're doing is referential to me. Right? Which can have both persecutory and grandiose elements. Well, you know, if you believe that everyone on the street is talking about you, well, you must be pretty important. On the other hand, there's often a persecutory element of, “Well, they're talking about me because they don't like me. They're plotting against me in some way.”

Puder:

“Every lyric of Taylor Swift is talking really about me.”

Heath:

Yes. I think that goes along with the thought insertion, withdrawal, broadcasting. Basically, the thoughts either being other people being privy to their thoughts coming or going. And I think, I feel like a lot of times, it's mixed with one of the other ones. I could be wrong, but kind of like there's a bit of a paranoia associated with it.

Cummings:

Well, I think in many of these, as you look at all of the different, specific named delusions, in many respects, they all share a lot of common characteristics in terms of having elements of persecution, elements of grandiosity. You know, in terms of….

Puder:

Or like the envious one. Have you ever heard of the delusions of envy? 

Cummings:

Yes. Oh, yes.

Puder:

So, “This person stole my success.” Right? The envy of the person next to me, next to my cell, next to me  is stealing something from me.” Right? And it's like, “They're stealing my thoughts.”

Cummings:

Yes.

Puder:

But maybe that's different. Stealing thoughts is different, but it's “stealing my success” would be envy of the thing. So it's like there's a level of anger in there. Do you have any other examples of that one?

Cummings:

Yes. The person who delusively believes that in some way, everyone else has secretly cheated them out of their success. They're never quite clear about how that happened. But I have met people ranging from paranoid personality disorder up to primary psychosis who, the rest of society was in some way cheating them, basically. Which I think, again, we get back down to the two main elements of a failure of reality testing and this abnormality in salience assignment that given those two things together, you can create all sorts of stories, basically.

Puder:

And say something about salience assignment. Can you describe that again?

Cummings:

Ah, well, salience assignment is being able to distinguish what is important in the environment versus what is not. And many of the delusions that we've been talking about have, at their core, two elements. One, the person is unable to accurately assess reality. In other words, they're not able to weigh how likely it is that what I just thought is true. But coupled with that, they have an inability to distinguish what in the environment is important and what isn't. A good example is two people laughing across the street, as you pointed out, not an important event relative to, you know, they don't know you, they're not laughing at you, they're just laughing. But for the person with a defect in that area, that somehow is important, it's related to them. And then we're, again, we're a species that loves stories, so it's very easy to move from that to then trying to create a whole narrative about, “Well, why are they laughing at me? Is it part of some conspiracy? Is there some giant joke or conspiracy going on that I don't know about?”

Puder:

And then if they have a somatic delusion of their nose being off, they can then intertwine that. They're laughing really, because of my nose.

Cummings:

Yes. So you can weave all sorts of things into this, which is why some of the delusional stories become incredibly complex and organized. And for the truly organized ones, they would make a great piece of fiction in some cases. 

Cultural Influences on Delusion Content Over Time (01:05:35)

Heath:

Well, one of the things I really liked that you mentioned before, Dr. Cummings, was how different times and, we mentioned cultures, but in general, the society someone lives in influences their delusions and what it looks like in maybe someone from…Do you want to speak to that?

Cummings:

Yes. I mean, what you and I, Blaire, have talked about the fact that the content of delusions, even if the process is the same, the content is very much history and culture dependent. And I think the example we've talked about is there were no alien abduction, UFO delusions, before about the 1950s. Those began to occur after the launch of Sputnik and with the introduction of all of those RKO [RKO Radio Pictures], grade B sci-fi movies, things like, It Came from Outer Space, et cetera. That caught the public imagination. And then people prone to delusions started to incorporate the content into their delusional beliefs.

Puder:

One of my favorite stories of a delusional thing, a jealousy delusion, is The Kreutzer Sonata, by [Leo] Tolstoy. I don't know if you've heard of this, but Pozdnyshev, I think, the protagonist, believes that his wife is having a sexual affair with the violinist. And despite no evidence, and he's come to this based on them playing a sonata together, and so, then he stabs his wife to death (Tolstoy, 1889/2021).

Puder:

This is rich in the literature. I think it's very interesting what you said that alien delusions increased after the cultural increase. In talking about things through movies, I've seen the same thing with The Matrix. Post-Matrix, there's more delusions about, “We're part of the matrix. We're part of a simulation.” Right? And so, as the culture and what kind of … what are people consuming, right?

Cummings:

Yes. Exactly. I mean, I can't tell you know at one point when I was a psychiatry resident, because of course we're talking about ancient history, there was a re-release in theaters of an updated version of The Exorcist, which I didn't see, but by reputation, it was even scarier than the first one. I can't tell you how many people I saw in the ER the week after that movie aired, who believed they were demon possessed. That became the complaint of the day in terms of psychiatric cases in the emergency room. 

Puder:

Which speaks to the emotive effect of film. Right? 

Cummings:

Yes, it does.

Puder:

And stories and how we have to remain reflective on how these things are influencing us.

Cummings:

Yes.

Heath:

And the cultural view of the person, if they're from a different culture, a different country, a different, you know…. what they present with. If I'm not as aware or understanding, is it based on where they came from? You know, sometimes it's hard to judge, I would say, if I'm not as familiar with what their life is like or where they came from for me, to be accurate perhaps. I mean, I had some patients that I was seeing that came from the Middle East and they really were tortured by terrorists. They were kidnapped, their houses were burned, there were horrible atrocities. But understanding, you know, they really were around this versus someone that has never had any exposure, that maybe watches something on TV. You know, trying to understand the actual context of this person, what they've experienced, versus this person living on the streets.

Heath:

I think that was something I feel like working with a lot of different populations from homeless people, skid row, kids, adults, and different cultures has been really insightful to be like, “I really don't know, to some extent, that growing up in downtown LA or Oakland, you just get shot walking down the street. You might see a dead body just walking on your way to school. Your family is the gang that runs the city.” And, it's very different. And what is delusional? I think it can be very interesting.

Cummings:

Well, I think that's why it's very important to help our patients, that we try as much as we can to understand their background. And that means sometimes going and doing some research and finding out about the culture they came from or the area they came from so that you can understand what they're trying to tell you.

Puder:

Yes. What I appreciate, we have to be culturally sensitive, especially to where people are coming from. Because if they come from very different cultures than ourselves, maybe their delusions actually make sense, you know? 

Cummings:

Yes.

Puder:

I'm curious. Oh, go ahead.

Cummings:

Yes. I was just going to say, they may still be delusions, but it makes much more sense if you understand the cultural context those delusions arose in.

Puder:

Yes. Like the delusion of being pregnant could come in the context of a person that really does want to get pregnant. Right? They really do want to have a child. I've seen a couple of these in the ER, and been called for consults on these patients, when they come in and they're very convinced that they're pregnant and they're not. They don't have a baby in them, at all.

Heath:

My favorite pregnant man was from Patton. One of my first patients, years ago, and he was probably [in his] sixties. Back then I was a dietitian and at least wanted to eat healthy for his baby. So we focused on that, trying to make healthy choices. Because he was very convinced. It's the only pregnant man I've met, so far. But you know, what I was like, if this will help you be healthier, I'm not here to treat that part of it. But, you know, it can even be a man. 

Cummings:

Yes. In some ways delusions don't know a lot in the way of boundaries.

Puder:

Yes. Let's talk about when should we, as providers, let's say, outpatient providers, be a little bit more concerned when patients come in regarding their delusions. When does it cross the line? Because I know you both deal with the sickest of the sick population. Right? But I'm curious, like what kind of input you would have for outpatient professionals?

Risk Assessment — When Delusions Become Dangerous for Clinicians & Patients (01:11:54)

Cummings:

I think for me, the elements I always look for are: does this person's delusion include elements of paranoia or persecution that are coupled with being angry? Because that's a very potent combination for being at risk of harming someone else.Or, are there delusional beliefs such that it's a great risk to them? I'm thinking here of things like delusional guilt where the person may indeed be saying, “Well, you know, I'm sure I'm responsible for all these horrible things. I really should die.” You know, that person's going to be up on the urgency scale for me. 

Puder:

Yes. The degree of anger. How do you determine the degree of anger?

Cummings:

In part, indirectly starting by asking, “You say these people are plotting against you. They're persecuting you. How dangerous are they to you? Are they going to physically harm you or kidnap you? Are they going to harm members of your family?” And if they say yes to any of those things, my next question is, “Doesn't that make you angry that they're going to harm you or your family members?” And that usually leads into a discussion of, “If you're angry, how angry are you?” And, “Would you think about harming them first?”

Heath:

One thing I would probably throw in there, because I worked outpatient for a few years. I know you guys, both of you have a lot more experience than I do. But I think one of the things, it's like, when do you kind of poke? When do you poke what's going on? And a lot of it, at least for me personally, was occupational and relational. If it's really causing an impact on their ability to have relationships. I had someone that kept losing jobs because they got paranoid or they had delusions about people being against them. They lost their housing. It was, you know, “How much are they going to even believe me?” But trying to focus on, look at their unstable housing, look at the instability of their life. I think for me, that was something I tried to go into. Okay, let's really treat the fact that they're having problems even maintaining regular occupational social relationships. Because they’re constantly mistrustful. This is a problem where they believe these people are against them. I don't know if that's helpful, but I think, with me, that was where I might get away with a milder anti-psychotic onto their antidepressant, or like trying to frame it in a way. 

Cummings:

I think this brings us back to something we touched on very early on. Those rating scales that we mentioned can be very useful in trying to evaluate how likely it is that the delusion is going to lead to dangerous behavior. Because you're asked to… and these scales all have anchors. You're asked to rate, how intense is this? How much is the person preoccupied with it? And basically, the more intense it is, the more they're preoccupied, the more likely they're going to act on these thoughts.

Warning Signs: Paranoia Involving the Provider or Preemptive Violence

Puder:

So number one, persecutory delusions, paranoid type. Right? Are these a little bit more dangerous? I would say, specifically when you, the provider, become part of the conspiracy, right? “You are poisoning me with these meds. You are implanting chips. Dr. Puder, you are spying on me. You're controlling my thoughts. You're in on it with the government.” If they give hints of this, does that raise your concern? 

Cummings:

Yes. You know, there have been a few providers killed over the years because they were, frankly, they were foolishly overconfident, “Oh, this is my patient. They couldn't possibly harm me.” And they would do foolish things like agree to see the patient after hours, alone in the office. That was the last case of this I saw, because I was consulted by the attorney who was investigating the case. 

Puder:

I'm actually building a database on this because of the recent homicide that happened in my city, Winter Park, with Rebecca White. She was murdered by a patient. So I'm building a database of this. It's probably done in a month or so.

Cummings:

Yes. Wow. 

Puder:

It's about one or two per year. So it's not a huge amount, which I think should be a little bit relieving to us as providers. 

Cummings:

Yes. But it's an area that obviously people should pay attention to.

Puder:

Yes.

Puder:

I just don't want to freak every provider out that this is….

Heath:

No, I was gonna say though, also your setting makes a difference, you know, that awareness. 

Puder:

If there's also a delusion, like, “I have to stop you before you kill me.” If that sort of preemptive defensive violence type of narrative comes in, I think the risk goes up.

Cummings:

Yes, very much so. Well, you know, one of the things about persecutory/paranoid delusions is that the person's own inhibitions against being violent are often overcome by the fact that in their mind they're just defending themselves.

Puder:

Yes.

Puder:

They could be defending themselves. They could be saving the world. They could be defending their family. Right? And that's where it gets dangerous. It's like the moral quality in the defensiveness increases the risk. Right? Yes. The moral justification in the delusion.

Cummings:

Well, yes. I mean, the person may have very strong inhibitions against violence or killing, except in this case that can be obviated by the fact that they're saying, “Well, but I'm just defending myself.” You know? I mean, that is actually a societally recognized reason to be violent, is you're permitted to be violent in your own self-defense. And for many of these patients, that's the way they perceive it.

Puder:

I think risk also increases with a history of violence.

Cummings:

Yes. Yes.

Puder:

When they have a history of attacking multiple people in the past that really does increase the risk.  Especially if it's been lethal. Especially if they have a history of going to jail for it.

Heath:

Being in jail.

Puder:

Being in jail, currently in jail.

Cummings:

You know, which is why I think the take home lesson for providers in this regard is, if you have a patient who's making statements like, “Oh, you're poisoning me, you're doing bad things to me.” I don't think you need to abandon that patient immediately. But I do think you need to think about the context and the circumstances under which you interact with the patient.

Cummings:

You know, this may be somebody in whom you only see them in a well-staffed office. Or maybe you only see them via video conference [televisit/telehealth].

Heath:

Be aware of them seeking opportunities. I think that's one of the biggest things. Learning, even at the state hospital, and stuff like that. The people are resourceful and they are looking. If they're looking for opportunities, you can't always be as vigilant as possible because it's so easy to drop your guard.

Puder:

Yes, I think that keeping the frame right and then getting supervision from a good forensic… a forensically trained person. You know,  if you're listening to this and you have a particular patient you're thinking about, and your anxiety is super high and you lose sleep over it, that's a good reason to reach out to an experienced colleague in the community to get a one-time consult. Most psychiatrists will do a one-time consultation. They're more than happy to, especially if you're a little bit less experienced, if you're out in a small city, please reach out. Please. You know, I'm sure Blaire wouldn't mind getting an occasional consult. I don't know if I could put you out there.

Treatment of Delusions: Antipsychotics, Long-Acting Injectables & CBT (01:19:57)

Heath:

No. I'll ask Dr. Cummings. I'm still very much learning, especially in different populations. I mean, especially with parents and kids. I have parents that were scared of their kids. You know, there's so many different situations to be cautious about. I mean, that's all outside this realm. But the truth is, one thing I did want to just kind of close with Dr. Cummings, as far as treatments, I know one of the articles you sent talked about first-generation antipsychotics (Munoz-Negro & Cervilla, 2016). I know we mentioned serotonin for body dysmorphic disorder. But it may be more of an OCD type nature. But one of the articles that I know you had sent me, you said maybe the first generation [antipsychotic] wasn't a lot better. What do you think about treating as far as pharmacologically? I know we talked about the CBT part. 

Best Medications for Delusional Disorder & Psychosis

Cummings:

Certainly the broadest category of medication that's been used to treat delusions, particularly given the evidence that elevated dopamine signal transduction appears to play a role in a large number of delusional contexts are dopamine antagonists. I don't have a strong opinion about whether first or second generation are better. I think that depends on the individual and what they respond best to. But my first choice, given absence of any other guiding data, would be probably a dopamine antagonist with somebody who is delusional.

Puder:

So you start with a dopamine antagonist. When would you think as well about something like clozapine?

Cummings:

If the person has evidence of treatment resistance.

Puder:

Yes.

Puder:

Then when do you think of injection versus not injection?

Cummings:

Oh, I think of injection very early on. You know, it's one of the major faults in the U.S., is we don't use long-acting injectable [LAIs] antipsychotics nearly as often as we should. And that's one of the reasons we have frequently bad outcomes, is that the rate of adherence to oral antipsychotics, universally across all the studies done in that area, is below 40%, often below 30%. Well, these medications don't work if people don't take them.

Puder:

Very good. So starting with an antipsychotic and cognitive therapy, right? Can be some help.

When to Use Cognitive Behavioral Therapy for Delusions

Cummings:

Oh, yes. But, wait for the cognitive therapy until you get the delusional intensity down to the point where the person appears able to begin to entertain the idea that maybe their delusional thought just might not be true. Because, at that point, then you're ready to embark on cognitive behavioral therapy to try to help the person use psychological tools to overcome their delusions.

Heath:

And there could be a serotonin, like you mentioned, for body dysmorphia. If there's more of an OCD, maybe there could be more of a serotonin agent [SSRIs are the main treatment for obsessive delusional beliefs like body dysmorphia]

Puder:

More for the like body dysmorphia OCD. Yes.

Cummings:

Although, even in those, if you have somebody who's on a robust dose of SSRI and they're still, you know, their obsessions are still more in the delusional camp, then addition of a dopamine antagonist may be worth considering. Although, I will say, the other thing thatthe common mistake with the SSRIs and OCD is underdosing. People tend to want to use the antidepressant dose range for more severely OCD patients. That's not going to be sufficient. OCD requires higher doses and longer exposure.

Puder:

Okay. Well, we need to actually wrap this up. This has been a great discussion. Blaire, thank you for reaching out and recommending this topic. Really appreciate connecting with you. Again. It's been some years. Glad you're thriving out there. And Dr. Cumming's, always good to see you. 

Cummings:

Good to see you, too. Thank you.

Puder:

Thank you. Okay guys, take care. Okay. Have a good one.

Cummings:

Bye-Bye.

References

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About Blaire Heath:

Dr. Blaire Heath is a board-certified psychiatrist specializing in child and adolescent psychiatry, with a unique background that integrates expertise in nutrition (B.S. in Nutrition and Dietetics), pharmacy (Doctor of Pharmacy from Loma Linda School of Medicine), and mental health care (DO and subsequent Loma Linda Residency). She finished a fellowship in child and adolescent psychiatry at Kaiser Medical Center in Fontana, California.

Dr. Heath brings a holistic, patient-centered approach to her practice, drawing on her diverse training to address the interplay between physical health, nutrition, and psychiatric conditions. She currently serves as a full-time staff psychiatrist with the California Department of Corrections and Rehabilitation (CDCR), where she provides telepsychiatry evaluations, diagnoses, and medication management for incarcerated individuals.

In addition to her correctional work, she maintains part-time roles providing telepsychiatry and in-person care across various settings, including community health centers and crisis services, treating patients of all ages with a wide range of mental health concerns.