How Delusions in the Real World Disappointed My Expectations

Delusions have long been of interest to me and they're fascinating for many people. Why do people see the same thing as everyone else, but arrive a very different conclusion, and become unable to change their mind about it? I've been fortunate to be able to do basic research into this phenomenon, and in my daily practice I see and treat them frequently.

(You should note that delusions represent a small, pathologic subset of false beliefs, really a disturbed belief process distorted by different anatomy. We all have false beliefs, but hopefully we can update them when we get new information. Even when people don't update their beliefs based on relevant information - they're usually identity-forming or socially important beliefs - and frustrating though that is, that is still different than a delusion. So, no, your most un-favorite religion or political party adherents are not delusional, even if they're wrong.)

There are a number of misconceptions, or more accurately, misexpectations, that I had about delusions when I went into this business, which will be glaringly basic and obvious to any psychiatrist, but will probably not be so obvious to other people. In no particular order:

• If and when delusions resolve, there is only rarely a "eureka" moment where the patient realizes the belief is false, or has even a significant enough increase in insight to gradually look back and sheepishly say "Yeah, I guess that wasn't true." Rather than updating the belief, people just stop being so motivated by it. That is to say, in the large majority of people, rather than the belief changing, the centrality of the belief changes. I find this very unsatisfying. "Yeah, I still think drones are probably following me everywhere but I don't worry about it that much." This isn't all that much different from belief in health - confirmation bias is all-pervasive, and recall that science advances one funeral at a time.
• Related: you can't talk someone out of a delusion. Ever. (As the rationalist proverb goes, you can't reason someone out of a position that they didn't reason themselves into.) At best, you will waste your and their time, and at worst, you will anger them and damage your therapeutic alliance. And if the psychiatrist who gives into this urge is completely honest, it's partly informed by a need to "win" the discussion. Even if you know this intellectually, early in your career it's very difficult to avoid engaging a delusional patient in this way (partly because the patient will not infrequently challenge you to do exactly that.) At this point I'm proud to say I can mostly resist the temptation.
• Though delusions sometimes do appear in isolation, they rarely occur without other neuropsychiatric symptoms. Even delusional disorder (where the patient has ONLY delusions) is often a misdiagnosis that evolves to something else - like dementia, especially when appearing in middle age or later, with the delusion merely as the earliest symptom. So very often, the person with a delusion is quite psychiatrically ill in many ways that make having a coherent discussion about the delusion (to hear a coherent set of delusional beliefs) very unlikely; e.g., severe paranoia that keeps them from talking to you about the details of the delusion, and/or constant hallucinations which distract them and to which they respond, or merely an inability to speak in a way that makes sense at all.
• This one was most disappointing to me: delusions are rarely coherent, in contrast to how they are often presented in the lay media - for example, K-PAX, or the analysand in the essay The Jet-Propelled Couch (who supposedly was in reality the science fiction writer Cordwainer Smith.) They are sometimes completely bizarre and incomprehensible, and even after giving the patient a chance to explain, you still have no idea what they mean. (This is one subtle feature of thought and speech in psychosis: though the sentences might be grammatical and seem to be meaningful, strung together, you can't make sense of what they're saying or even clearly remember it ten minutes later - much like, I think not coincidentally, we struggle to remember an early morning dream even until lunchtime.) Even when delusions are "about" something comprehensive, they are only peripherally about discrete objective facts, delusions are based on affect and "primitive" themes of the sort that color nightmares[1] - pursuit, certain people being morally bad, looming organizations with sinister intent, an overwhelming sense of contamination, etc.
• It is often striking how incurious delusional people are about their predicament - after years of, say, harassment by a sinister government agency, when one asks "Do you know why they're doing this? And where they get all these resources? And how their technology operates?" people often do little more than shrug.[2] They are also usually obviously and badly internally inconsistent, again unlike the cleverly constructed delusions in fiction. If the psychiatrist in the Terminator thought the future-warrior's tale was a delusion, he was right to be impressed by it. People will tell you (for example) that they were victimized for many years by their persecutors, until they developed their special powers at age 23 that made them immune; then in the next sentence, tell you how they were victimized at 26. Rather than becoming upset when such continuity problems are pointed out, they generally just wave it off as irrelevant and keep going.

Delusions are hard to treat; even so, medications can and do help people. But if you get into this business to hear fully elaborated, articulate, consistent delusions about time travel, space empires, or sinister (but interesting) experiments that shadowy government agencies are doing on us - you're going to be disappointed.


[1] Even in delusional "shadow syndromes" like physics crackpots or various denialists that do seem to be focused on external objective cold facts, invariably there is ranting against the Establishment and paranoia about people stealing their work, and this takes up much of the time that might otherwise in a more rational person be devoted to research or making their case.

[2] Regarding this incuriosity: delusions are not the only neuropsychiatric symptom where this feature appears. I'm agnostic as to whether this incuriosity is actually part of these diseases, or is just (unfortunately) the natural state of most humans. For example, hemi-neglect is a symptom usually seen after strokes, where the patient loses one half of space. I don't mean that they can't sense what's going on one side of them; they literally can't understand that that side of the universe exists, exactly like you or I can't perceive the fourth dimension.

To illustrate: these people lose not only the use of one half of their bodies, but the awareness that they exist. So they will deny that they have a left arm. And if you hold their (genuinely paralyzed) left arm up in front of them, they often confabulate ridiculously: "That's my sister's arm. She's hiding under the table." Now, if my doctor told me I had four arms, I would tell her she was a goof. But if she could consistently could keep holding two extra arms up in front of me that had roughly the shape and skin tone of my other arms and in the middle of a room where there was no chance of a trick, I would eventually have to concede that I was having perceptual difficulties and that I indeed had four arms, even if I couldn't tell how they attached to me. Probably a more common situation is that a hospitalized patient will demand to speak to the doctor at dinner, and as the doc enters their room, says angrily "They keep telling me this is a full-sized dinner, but look at this thing!" And they gesture to their plate, exactly one half of which is eaten. So, you turn the plate 180 degrees, and they grunt, and finish the other half of their dinner, now that it exists. Now, if tonight I complain to my wife that she only gave me half a serving of dinner, and she glared at me and reached over and did something I didn't understand and suddenly my plate was full again as if it had passed partway through my dimension like a sphere in Flatland, I think I would say "Whoa! You just magically produced food out of the fourth dimension! I don't understand how you did it, but could you do it again?" But that's not how people usually react, which implies there's a loss of insight or ability to update associated with this condition. It should not be missed that most neglect is left neglect (meaning, a right-sided lesion), and that one theory of delusion holds that somatic delusions can be caused by right frontal lesions, and that some sort of functional right hypofrontality is required for the lack of insight inherent to all delusions, somatic or otherwise.

The Least Surprising Thing Ever

"Although we also ran the learning task with high-dose ketamine, performance was inadequate and we will not report this part of the study further."

Yeah, I bet it did!

- From Corlett, et al, Frontal Responses During Learning Predict Vulnerability to the Psychotogenic Effects of Ketamine: Linking Cognition, Brain Activity, and Psychosis. Archives of General Psychiatry. 2006;63:611-621.

Hints That You're Living in a Simulation; Plus, What Is a Simulation?

See Bostrom's simulation argument for background. From a practical standpoint, you might be suspicious that you live in a simulation if you inhabit a world with the following characteristics:

Hint #1) Limited resolution. A simulation would be computation intensive. It would be useful to have tricks that increase the economy of operations, but in ways that do no compromise the consistency of the simulation to the players. One such trick would be to set an absolute upper limit to resolution (or a lower limit to the size of the elements that make up the "picture") that is below the sensory threshold of the players. These elements could variously be called pixels or quarks. Similarly, it would behoove the simulators to set a maximum time resolution, i.e. maximum frames-per-second, also called Planck times. Furthermore, the simulation's computing power is spared by a statistical method of calculating relationships between entities in the simulation (i.e quantum mechanics) even though it may look, at the scale of the game players or simulated entities, as if the universe maintained quantitative relationships in terms of integers calculated to arbitrary precision. (Related question: is it possible in principle given the physics of our universe for something the size of a bacterium or virus to "be conscious of" this gap in the behavior of the Newtonian and quantum realms, at a very basic sensory level? If not, isn't it interesting that our universe is such that there can be no consciousness operating on scales that would expose the twitching gears behind the scenes?)

Hint #2) There are limitations in what spaces within the game can be occupied by players or sims. In the old Atari 2600 Pole Position game, you couldn't just randomly go off driving off the track and through the crowd even if you didn't care about losing points; the game just wouldn't let you. Similarly, the total space in our apparent universe that we occupy, or directly interact with, or for that matter even get any significant amount of information from, is an infinitesimally small part of the whole. Unless you're in a submarine or in orbit, you don't go more than 200 meters below sea level or 13,000 m above it. (That's a volume of 2.1 x 10^18 m^3 that for all practical purposes the entirety of human history has occurred in; double that figure, and that's the volume that all of evolutionary history has occurred in.)

Hint #3) Beyond the "active game volume" as described above, dab a few pixels here and there in an otherwise almost entirely dark and empty volume. Make them so far away that sims can't possibly interact with them. Reveal additional detail as necessary whenever someone happens to look more closely at them. (And there's another trick: objects in this simulation are only loosely
defined until one of the players interacts with them, "collapsing the wave function". Yeah, that's what the programmers will call it, that's the ticket.)

Hint #4) Even in that limited location, make the active game volume wrap around. That way the simulators get rid of edge-distortion problems, as in Conway's Life. A sphere is the best way to do this. Therefore, work out the physics rules of the simulation to favor spheres.

Hint #5) Make each state of the simulation dependent on previous states of the simulation, but simplify by dramatically limiting the number of inputs with any causal weight. The simulators can limiting computations by having only mass, charge, space and their change over time determine subsequent frames.

Hint #6) If for some reason it is important for the entities in the simulation to remain ignorant to their existence as part of a simulation, the simulators could make sure the entities are accustomed to not only these kinds of stark informational discontinuities but to profound differences in the quality of awareness, both within themselves and each other. That is, the sims will accept not just that the vast majority of the universe (as seen in the sky at night) is interactively off-limits to them, but they'll also accept that their own awareness thereof and ability to connect the dots will dramatically vary over time. That way, if there is any need to interfere and make adjustments (to stop someone from figuring out the game) it won't strike the sims as strange. (Forgetfulness, deja vu, mental illness, drugs, varying intelligence or ability to concentrate on math, death of player-characters before they can learn too much?)

#6 does raise a very important question: why would the simulators give a damn if we knew we were in a simulation. So what? What would we do about it, sue them? If Pac-Man woke up and deduced that he were a video game character, if he still experienced suffering and mortality the same way, why would it matter? By this same view, there's an easy answer to whether we should behave differently if we're actually in a simulation: no. Whether our universe is in reality just World of Warcraft from the sixth dimension, if we simulated beings can suffer (and I know I can), then the moral rules are exactly the same as before.

It's also worth asking for some humility, and asking why we humans always assume that we would be the purpose of any such simulation. We could be merely incidental consciousnesses that are necessary for harboring the populations of simulated bacteria that the simulators are really studying. Or, the simulators could be cryonicists who preserve pets, and the most popular pets in their dimension look like what we call raccoons, and our universe is actually the raccoon heaven in which their beloved masked companions await a cure for the disease that forced the owners to put them on ice. In fact the raccoon-heaven simulation would contain a whole suite of ecosystem, all of them purely simulated (with the exception of raccoons) to keep up the appearance of a full biosphere. So the point of such a simulation would be to fool raccoons - or maybe even mice (again, why would they care about fooling everyone! If the simulators are reading this, just give me more juicy steaks and I won't make problems. It doesn't cost you anything!)

While the raccoon thought experiment is meant to be whimsical, a healthy respect for our own ignorance is always in order for these kinds of speculations. After all, assuming what we have guessed about the rest of (for the sake of argument simulated) universe is accurate, then there might be "aliens" (other non-human intelligences within the simulation) who may very well be much brighter than us. So even if the simulation is somehow arranged around the most intelligent entities within it (as we assume), those entities need not be human. Even if we're simulated, and we have a real brain and body in the "real" universe that's similar to our form in this one, this simulated universe might be designed for Martians (who are brighter than us) and be much less pleasant than our home dimension.

Finally, the very idea of a simulation is poorly defined. Mostly we think of something like almost completely controlled full-world simulation in the Matrix, but let's explore boundary cases. If I wear rose-colored glasses, is that a simulation (or a red world)? What about LSD that causes me to see unidentified animals scurrying past in my peripheral vision? What about DMT that causes a complete dissociation of external stimuli from subjective experience? What if I have some chip implanted that displays blueprints of machinery in my visual field a la the Terminator, is that a simulation? What about a chip that makes me see a tiger following me around that isn't there? (Hypothetical given current limitations.) What if I hear voices telling me to do things that are produced by tissue inside my own skull, by no conscious intent of anyone? (Not at all hypothetical.)

One of the interesting points in the popular movie Inception is the way that external stimuli appear in dreams. This gives us a hint as to what we mean by simulation, and why we care. Most of us have had experiences where the outside world "intruded" into a dream, with the stimulus obvious after we awoke. I once dreamed that a dimensional portal slid open in front of me with an ominous metallic resonance, and I stepped through it, suddenly speeding over the red, rocky surface of Mars. Then I realized it was my father opening his metal closet door in the next room, and I was looking into that room at the red-orange carpeting. Before I was fully awake I had received the sound stimulus but I had built a world out of it that most of us would not regard as real. (The experience of speeding over Mars was quite real, even if most humans would have a more accurate representation of that auditory stimulus.) So, a better way of saying "how do I know 'this' is reality, rather than another dream, or a simulation?" is to ask "how do I know I am perceiving "true" stimuli, without mapping them unnecessarily onto internal stimuli, giving me as accurate and un-contorted a view of the world as possible?"

And indeed in certain ways, we certainly are dreaming, in the sense of injecting internal stimuli and filtering external stimuli through them. (Notably, it is possible to view schizophrenics as people who experience dreams even while awake and filter their perceptions accordingly.) First and most obviously, because our sense organs are limited in what they can detect, we're obtaining only a slice of possible data. Second, the world we knit together is the result of binding of sensory attributes into object/events, as well as pattern recognition. The limitations of our nervous systems, and the associations we are able to make, profoundly influence the representation we build of the world we're perceiving.

Third, and most significantly, a large part of our experience is non-representational: emotions, pleasure and pain do not exist outside of nervous systems, or rather the events to which those experiences correspond are almost entirely contained within nervous systems. Yes, to be precise the experience of light does not exist until the triggering of a cascade of electrochemical events by radiation incident on pigments in retinal cells; but light, which is what is represented in our experience, exists traveling across the universe. Pain and happiness do not. These are internal stimuli that add a non-representational layer to reality, even more certainly than my dream of the Mars overflight.

A good working definition of a simulation as it is commonly understood is when the majority of one's external stimuli are supplied deliberately by another intelligence to produce experiences that do not correlate to physical reality external to the nervous system (or computational equivalent). This avoids taking a position on AI; the sims may or may not be entities separate from the computation. I.e., you might be in sensory deprivation tank like Neo, or you might be a computer program. The question of reality versus dreams or simulations is not one of discrete "levels" as we've come to think of it in popular culture. It is rather a question about how we know our experiences correspond in some consistent way with events separate from our nervous systems.

Hemineglect and Delusions

Hemineglect is among the more bizarre neurological conditions (which is also to say, devastating to the patient). In brief, the patient ignores one or the other half of space, right or left, up to and including his or her own body. They won't register stimuli on the neglected side and will even ignore their own bodies on that side, sometimes claiming that their limbs aren't their own: if you hold their arm up in front of them and ask them whose arm it is, they'll often insist it's a family member who's hiding nearby. (Yes, really.) A neurologist related to me that these patients will even sometimes request to be moved to a new bed in the hospital because there's someone else laying in bed with them (as in, the neglected half of their own body. Yes, really.) To these patients, a circle has only 180 degrees. The neglected half of space might as well be the fourth dimension.

Needless to say, natural experiments like these cases are a rich substrate for neurophilosophy. One aspect of neglect syndromes that I find interesting is that some of this behavior apparently amounts to a delusion, in the strict sense of a steadfast false belief. Neglect patients will sometimes complain that the hospital isn't feeding them enough, and of course when the nurse or physician comes into the room, they see a plate of food that's exactly half-eaten. So they turn the plate 180 degrees - and the patient grumbles "Good," and continues eating. See the disconnect here? If I were at dinner and said "Wow that green curry was good but I wish there were more," and my dining companion was able to magically produce more curry out of the fourth dimension before my eyes like some kind of a 3D chef visiting Flatland, of course I would be utterly amazed - but I haven't heard of such a reaction in the anecdotal reports I've heard from neurologists so far (I have not yet interacted with a neglect patient).

I'll do my best to put myself in the neglect patient's place again. Most of us believe that we have exactly 2 arms and 2 legs, and would react incredulously if a researcher told us that no, in fact we had four arms and four legs, but we were only using two of each. The researcher says to me "Fine, I can prove it." In an empty room with just her and me, she holds up an arm in front of me that looks just like me other two arms - skin color, size, etc. - and says it's my arm. I can't feel it or move it, and somehow I'm unable to see what it connects to, and it seemed to appear out of thin air (just like the green curry). But having four arms is ridiculous! Yet I trust this researcher; she seems incredibly earnest, she can reproduce this trick any time I ask with no preparation, and as I soon discover, so can anyone else I ask, including people with no possible connection to the researcher. All of them can hold up in front of me one or two arms that look like my own arms.

In such a position, I would be forced to conclude, as bizarre as it seems, that the evidence points to some kind of a perceptual defect on my part. As strange as it is, and as much as I absolutely cannot understand where this arm is coming from or how it connects to me, I eventually have to accept the incredible truth (after many, many trials) that I and everybody else has four arms, and that there's something strange about my perception that keeps me from seeing them. And even if I remain incredulous, certainly I would at least want to know how they were doing this amazing trick. But severe neglect patients not only avoid curiosity about things that could disturb their limited perception of space, they make up impossible stories about where their limb is coming from if it's presented to them. Clearly the deficit that produces their inability to fully represent space is neurological, rather than psychogenic. But isn't this part of the behavior arguably delusional?