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Psychiatric Times
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Conspiracy theories can lead individuals to engage in criminal and violent behaviors. It is necessary for psychiatrists treating or forensically evaluating individuals with conspiracy theories to be able to correctly identify different forms of belief.
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SPECIAL REPORT: FORENSIC PSYCHIATRY
Case Vignette
“Mr Parker” is a 20-year-old man with no psychiatric history. He was arrested for trespassing on the grounds of a local Social Security Administration facility. He was caught while attempting to break in via the front entrance in the middle of the night. When questioned by law enforcement, he stated that he was there to find documents that list the names of local government officials who are engaged in the sexual abuse of children. He went on to state that these officials have been harvesting adrenochrome from the blood of a group of children, who they are consuming to maintain their vitality. He reported that he learned the documents implicating the local government officials were stored at the local Social Security Administration building after reading about it on a Facebook group for “local child advocates.”
Upon evaluation at the county jail, Mr Parker spoke at length about his engagement with online groups that ascribe child sexual abuse and occult practices to local elected politicians. Concerned by the recent onset of a firm belief in outlandish, persecutory themes, the psychiatrist at the jail felt that Mr Parker may be experiencing first-episode psychosis and recommended initiation of an antipsychotic medication. Mr Parker staunchly declined any treatment. After refusing to engage with his court-appointed counsel, Mr Parker’s defense attorney raised doubt regarding Mr Parker’s competency to stand trial. You, an independent psychiatrist, are appointed to evaluate his mental condition, his understanding of the legal process, and his capacity to work with an attorney.
Introduction
Conspiracy theories are a common phenomenon. More than half of adults in the US espouse belief in some form of political conspiracy.1 In the age of social media, it is easier than ever for like-minded individuals to congregate online to discuss and share conspiracy theories. As with other forms of mass shared belief, conspiracy theories can spill over into violent action. Psychiatrists, including forensic psychiatrists, may be called on to evaluate and treat individuals who espouse conspiracy theories; therefore, it is necessary to understand conspiracy theories and how they differ from delusions. This article defines the concept of the conspiracy theory, differentiates it from psychosis and other types of delusion-like beliefs, and offers recommendations regarding how to explore an individual’s beliefs.
The Basics
A conspiracy theory is a set of propositions regarding the alleged collusion of various individuals to achieve a malevolent aim. Conspiracy theories are inherently unverified and unverifiable, as they are typically based on spurious or fantastically embellished facts. Conspiracy theories rebut practical and coherent explanations for happenings in the world in favor of a more bombastic and secretive narrative.2 Common elements of conspiracy theories include the following3,4:
Conspiracy theories are common and develop around phenomena ranging from the banal to the salacious. An online survey of more than 1000 Americans regarding medical conspiracy theories found that 37% believe that the US Food and Drug Administration deliberately prevents the public from accessing natural cures for cancer and other diseases due to the influence of drug companies. Additionally, 20% believe that physicians and the US government want to vaccinate children despite knowing that vaccines cause autism and other psychological disorders.5 In a telephone poll of more than 1000 randomly selected American adults, more than 36% stated that it was at least “somewhat likely” that the federal government assisted in the September 11, 2001, terrorist attacks or took no action to prevent them in order to force the United States to go to war in the Middle East.6
Who believes in conspiracy theories? Data are limited, but their widespread acceptance suggests that most individuals are susceptible to adopting conspiracy theories.7,8 It is also probable that conspiracy theories that dovetail with individuals’ preexisting biases, political leanings, or cultural backgrounds may be more appealing. Individuals were more likely to report a belief in 9/11 conspiracy theories if they were racial minorities, younger, female, and less educated, and if they read blogs.6 The phenomenon of conspiracy theories is not unique to specific political parties, ideologies, or movements, though political figures and groups may co-opt and spread conspiracy theories for their own ends. For example, QAnon is a conspiracy theory group associated with former US president Donald Trump’s brand of right-wing populism, in no small part because he promoted QAnon content at least 265 times on X (formerly Twitter) between October 2017 and October 2019.9 Alternatively, left-leaning media pushed the conspiracy theory that Trump and his staff colluded with Russia in the 2016 presidential election on the basis of the Steele dossier, a collection of opposition research commissioned by Hillary Clinton’s campaign that consisted of falsehoods.10
The Differential Diagnosis
Table 1. Differential Diagnosis of Belief in Conspiracy Theories
Table 1 offers a differential diagnosis for individuals presenting with false beliefs. Depending on the content of a conspiracy theory and the degree to which an individual claims to believe it, one may mistakenly identify the individual as delusional. Individuals who believe in conspiracy theories are not delusional, however. The DSM-5-TR notes that “[t]he distinction between a delusion and [a] strongly held idea is sometimes difficult to determine and depends in part on the degree of conviction with which the belief is held despite clear or reasonable contradictory evidence regarding its veracity,” and it indicates that “[s]ome religious and supernatural beliefs…may be viewed as bizarre and possibly delusional in some cultural contexts but [may] be generally accepted in others.”11 The same is true of conspiracy theories. Belief in conspiracy theories is not delusional because their existence depends on a community or subculture of individuals who share the belief and because individuals may alter their beliefs when presented with evidence to the contrary.
Belief in conspiracy theories is more accurately described as a form of delusion-like beliefs (DLBs). In one article, Joseph M. Pierre, MD, describes DLBs as beliefs that “slip through the cracks of symptom definitions and drift into the gray area between pathological and normal beliefs.”12 Other examples of DLBs include religious beliefs, cult beliefs, and the beliefs of sovereign citizen groups that consist of political extremists who reject governmental authority. The conflation of QAnon with a cult in popular media outlets highlights the poor definitional boundaries of DLBs and the confusion with which the lay press addresses such phenomena.
Assessing Conspiracy Theories
When assessing a patient or forensic evaluee who presents with false beliefs, it is necessary to understand the etiology of the beliefs so you can develop an appropriate treatment plan or inform the attorney or court about the impact of the individual’s beliefs on the relevant legal matter. To correctly identify the etiology of the person’s beliefs, you should conduct a belief history, as summarized in Table 2.2 Individuals espousing belief in a conspiracy theory should be able to identify when and where they first learned of it. In the case of QAnon and other political conspiracy theories, you should expect the person to identify media sources, online forums, or discussion boards as the source of their knowledge. This contrasts with religions, cults, and sovereign citizen groups where belief is transmitted primarily via in-person encounters with other members. Once you have established the origin of the person’s beliefs, you should ask about the process by which they came to view the conspiracy theory’s propositions as true, engaged further with like-minded individuals, and, if relevant, began to act in response to their beliefs.
Table 2. The Belief History2
Evidence of psychopathology can also aid in understanding a person’s false beliefs. Individuals with schizophrenia, mania, and psychotic depression should demonstrate additional evidence of illness that clarifies the etiology of their beliefs. In cases of suspected delusional disorder, collateral information from family members or friends may assist in clarifying the individual’s belief history. Evidence that the individual viewed fringe political news outlets and online forums before developing their belief would suggest against a delusional disorder. A community of like-minded individuals supports the finding of a DLB rather than a delusion. The evaluator should be aware that individuals with genuine mental illness may also believe in conspiracy theories or hold DLBs, in which case an understanding of the basic tenets of current conspiracy theories, fringe political ideologies, and creeds of religious sects may help to clarify what aspects of the person’s belief system are pathological.
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Esther Schoenfeld, MD; Raina Aggarwal, MD; and Danielle B. Kushner, MD
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Seena Fazel, MBChB, MD, FRCPsych; and Giulio Scola
Armed with a wealth of knowledge regarding QAnon, you meet with Mr Parker and realize that his beliefs stem from this broad-ranging conspiracy theory. He maintained that high-level government officials were part of a pedophilic cabal. However, he demonstrated no evidence of a psychotic disorder, such as negative symptoms, hallucinations, disorganized thinking, or mood disturbance. His mother confirmed that he had no history of treatment for mental illness. Collateral information from his mother indicates that Mr Parker only began espousing belief in these propositions within the past 2 months and that he has not demonstrated any functional impairments in his employment or relationships with family members. You rightly realize that Mr Parker does not have a mental illness and therefore has the capacity to understand his legal proceedings and to work with his attorney in his defense, whether he chooses to do so or not.
Concluding Thoughts
Conspiracy theories are a common cognitive phenomenon. Similar to religious faith, cult beliefs, and extremist political ideologies, the propositions of conspiracy theories appeal to human minds seeking special knowledge and a unique understanding of events in the world. Like all forms of belief—true, delusion-like, or pathological—conspiracy theories can lead individuals to engage in criminal and violent behaviors. It is necessary for psychiatrists treating or forensically evaluating individuals with conspiracy theories to be able to correctly identify different forms of belief. By doing so, one can clarify the individual’s treatment needs and the relevance of their beliefs to the legal question posed.
Dr Holoyda is a forensic psychiatrist in Denver, Colorado. He is also chief psychiatrist at Contra Costa County Detention Health Services in Martinez, California, and an adjunct assistant professor at the Medical College of Wisconsin in the Department of Psychiatry & Behavioral Sciences in Milwaukee.
References
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9. Kaplan A. Trump has repeatedly amplified QAnon Twitter accounts. The FBI has linked the conspiracy theory to domestic terror. Media Matters for America. Published August 1, 2019. Updated January 11, 2021. Accessed October 2, 2024. https://www.mediamatters.org/twitter/fbi-calls-qanon-domestic-terror-threat-trump-has-amplified-qanon-supporters-twitter-more-20
10. Lake E. Framed and guilty. Commentary. January 2021. Accessed October 2, 2024. https://www.commentary.org/articles/eli-lake/donald-trump-russia-framed-and-guilty/
11. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. American Psychiatric Association; 2013.
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