Joel Gold

I was given this book by the GoodReads First Reads program. The review is entirely my own opinion.

Ah, so refreshing to read a really good science book! This is written for a general audience without being oversimplified. The authors manage to make the evidence supporting their theory clear enough for any reader, and provides excellent resources and references for anyone interested in going into the topics even more deeply.

I highly recommend this book to anyone with an interest in psychiatry, or anyone interested in how and why people experience delusions.… (more)

While Dr. Joel Gold was a psychiatrist at Bellevue Hospital in New York City, he began to notice a trend in some of the patients – they thought they were being watched and manipulated, similar to the film, The Truman Show. He mentioned this phenomenon to his brother, a professor of philosophy and psychiatry. Together they began to delve deeper into the current and historical research and thought on delusions. While the current literature in the field focused on neurobiology, the Golds saw more to it. When so many patients all mention The Truman Show, perhaps culture has much more to do with delusions than currently given credit.

Regardless of location, delusions fall into common classifications. While the content of a delusion may vary based on culture, the form of the delusions are remarkably similar worldwide. They looked into the history of the study of delusions and found many theories – disturbed association, dopamine hypothesis, theory of the mind, evolutionary psychology, and more. While each of these explanations have some merit, none fully explain how and why delusions begin to manifest in some people. Perhaps the onset of delusions has more to do with social factors than these other theories give credit.

Looking to studies done with people with mental disorders and those without mental disorders, themes in behavior and perspective of those with mental disorders start to occur. People with schizophrenia, when shown photos of faces, are more likely to see threats and negative emotions in those faces. When measuring where their eyes scan when viewing these photos, people with persecutory delusions show abnormal scanpaths. Studies also show that delusional people over-estimate how long pictures of angry faces displayed to them lasted. Also, delusional people are more likely to remember sentences that contain threats. This all points to delusional people misperceiving things as threats.

Looking further at what people with delusions have in common, they found that three factors highly increase the likelihood of the development of psychosis. First is childhood adversity. This could come in the form of abuse, bullying, and parental separation. The second factor is immigration. While there is no conclusive reasons why immigrants are more prone to psychosis, it may partly be due to race/ethnicity discrimination. The last factor is living in a city. Studies found that this is likely due to population density – the more people there are around you, the more threats you may perceive.

Based on all of these studies, the Golds formed their own theory of psychosis. They find that the Suspicion System is at the root of delusions. Being suspicious is an evolutionary mechanism that helps us pick out threats so that we can defend ourselves against malign intentions. To guard against exploitation, we have to focus on the intentions of others and suspect them of wrong doing. Some ways we do this is by recognizing facial expressions. These recognitions are automatic first and begin in the amygdala, the region of our brains sensitive to fear. People more prone to delusions have Suspicion Systems that are over-active, more likely to interpret social cues as threats.

The authors go on to explain that we have two systems of cognition. System 1 which is more automatic includes the Suspicion System. System 2 requires more slow and deliberate thought and includes the Reflective System. The Suspicion System makes a quick judgments and the Reflective System decides if the Suspicion System is correct. They find that delusions arise when the two systems are not communicating properly. Over time as these two systems become more and more out of sync, the Suspicion System takes precedence, and the Reflective System tries to make sense out of these suspicions. “Human thought is always seeking out patterns and coherence, trying to make sense of the world. When the delusion is taken as true, it becomes the foundation for a new way of seeing the world” (p. 202).

When thinking back on the three factors that increase the likelihood of psychosis, the authors turn to a theory of social defeat. What these three factors have in common is subordination. In turn, being subordinated can change your brain’s thinking over time. Being subordinated also increases feelings of fear which causes a heightened state of internal vigilance.

“The social determinants of psychosis, therefore, may be stressors that increase our need for vigilance and in the long run ‘overload’ the Suspicion System. Childhood abuse and immigrant adversity render malign intentions more tangible, and urban living multiples them. As the amperage being sent through the Suspicion System increases, it overheats; and when social life puts too much current across these already heated circuits, delusions are kindled” (p.206).

The authors conclude the book with a call to action to rethink current psychiatric methods and theories of psychosis and delusion. They see the focus on neurobiology as falling short. Embracing the social environment of patients as well as physiology would provide a clearer view of psychosis and would result in better results for patients.… (more)

What a disappointment. For some crazy reason I thought, given the title, that this was a book about "how culture shapes madness." I took the authors at their word and expected a reasoned discussion of how "madness" is defined from the culture surrounding a person and what is 'mad' in one culture is 'sane' in another. I've been thinking about this ever since I read "The Confessions of St. Patrick," in which Patrick reports the devil came and sat on his chest, something he apparently believed really happened to him--and why not, if the devil is real?

But no. The book doesn't actually have a thing to say about how culture shapes madness, beyond the most superficial observation that delusional people pick up cues from their culture and misinterpret them. Beyond this common sense observation the book is primarily a quick survey of how mental illness has been treated in the past, interspersed with case studies of Gold's patients. Reading this book did make me appreciate Oliver Sachs more, for the way he treats each person he writes about with compassion. I felt a little bit as if Gold was trivializing the suffering of these people or using them for shock value or entertainment of the reader, rather than presenting their stories with dignity and human kindness.… (more)