Delusion of being controlled. A case of virtual reality

Delusion of being controlled is a condition where an individual is not capable to control his thoughts, feelings and actions, but instead they are imposed by some external forces or characters. Throughout the history of psychopathology a number of psychiatrists and psychologists addressed this theme through case reports and hypothesis of interpretation. Although this kind of symptoms where included among Schneider’s First Rank Symptoms, pathognomonic of schizophrenia, they are not exclusive of this mental disorder. Currently we can find this kind of delusions among the psychotic disorders on the DSM-5 and on the ICD-11. According to some accounts, in these cases the core of sense of self-agency is disrupted. We’re presenting a case of delusion of body control whose peculiarity is that the patient felt like a character of a virtual game reproducing his life. He was under control of a “master of puppets”, someone who, like a player, had the complete control of his movements, leading him to move in a mechanical way, bumping into walls inside his hospitalization room.

Introduction

The concept of delusion of being controlled has played a noticeable role in the psychopathology of the psychoses. According to Kurt Schneider this is a condition where there is certainty that an action of the person or a feeling is caused not by the subject but by some other individual or external force ¹. Usually listed under the general label of delusions of influence, it’s a symptom considered as a characteristic of schizophrenia, but not exclusive. Starting from the nineteenth century several psychiatrists provided an early description of this kind of delusions in therms of somatic passivity. Esquirol, Prichard, Leidesdorf, Griesinger, Kahlbaum and Fisher explored this condition in their writings ². From the first introduction of the concept of schizophrenia, from the Kraepelinian’s “dementia precox” to Bleuler’s formulation of the fundamental symptoms, the disorders of the self have been considered symptoms of the illness. Kraepelin mainly wrote about thought insertion, but also described contemporary sensations of electricity and similar action at a distance ³. However, neither Kraepelin or Bleuler considered this essential for the diagnosis ⁴, furthermore they didn’t present a systematic description of anomalous self-experience. Karl Jaspers in his “General psychopathology” included the feeling of activity among the four formal characteristics of the self-awareness, qualified by an awareness of unity, awareness of identity and the awareness of self as distinct from the outside world. According to him, the domain of the activity of the self comprehends the alteration in awareness of existence and the alteration in the awareness of one’s own performance; the latter represents a “reduction in one’s awareness of performing one’s own actions” ⁵. Throughout history of psychiatry, lots of authors wrote specifically about this topic trough patients reports. To name a few, Berze in 1914 reported a case of a patient with physical delusions which made him jump in the air: “Sometimes I feel like I have my own will. But then suddenly he is there and transports me through his will. Sometimes he lets me be free, but when he is there, I cannot compel myself to any action. Then I am completely under his will” ⁶. Later Gruhle, in 1932, reported a case of a patient who described a sensation of magnetism: “I sensed something happening in my body. […] I am wrenched away from certain places without any consciousness on my part”. Kurt Schneider, one of Jaspers’ pupils, considered a mineness of experience as prerequisite for diagnosing influence phenomena ⁷. In his “Clinical psychopathology” of 1959 inserted the “feelings or actions experienced as made or influenced by external agents” in his first rank of schizophrenia symptoms and was the first to consider them as pathognomonic of schizophrenia. Despite the fact that the concept of self-disorders always played a major role for the psychopathology of the psychoses, in both DSM and ICD, within their latest editions, they had been regarding among bizarre delusions, although they preserved an important role in the diagnosis of schizophrenia. Recently self-disorders have been investigated, especially by Parnas ⁸ and his research group, as a touch point between schizophrenia spectrum disorders and a more basic symptom level, the level of prodromal. Furthermore, according to Fuchs ⁹ and the latest studies in the field of cognitive science by Gallagher and Frith, a distinction between the “sense of agency” and the “sense of ownership” is needed and represents a challenge for a better comprehension of delusions of body control and their clinical significance. We’re presenting a case of delusion of being controlled with the peculiarity, not reported in the literature before, that the patient felt himself in the middle of a computer game, reproducing his life, controlled by an external player with total control on his body.

Case Report

The patient, that we will call Mario, is a 57-years-old man without any evident psychiatric disorder and any previous drug therapy. He is a person without significant social contacts and a single important emotional relationship which ended when they decided to live together.

He was admitted to our psychiatric ward for an acute psychotic episode. Upon admission he was in a state of suspicion, distress and fear. In ED he presented severe psychomotor agitation caused by a delusion of control acted with electronic devices of a computer game, which would influence his movements. He was without any awareness of disease and he wanted to go home. It was required to submit him to a compulsory medical treatment and physical restraint for several hours.

During an interview Mario reported to join a computer game that would take place inside his home. He said that he felt observed by his neighbors, that they were probably play the game, from the windows of his room, from computer screen or hidden cameras. For these reasons he decided, in his home, to walk at distance from windows and turn off the Wi-fi. He told us that he felt controlled by a technical apparatus of the game, manipulating his movements by means of electromagnetics waves which he would he have lived as vibrations throughout his body, pushing him to move, which he perceived as harmful and scary. He described the feeling of being maneuvered from the outside and feeling like a puppet (pawn) in their hands. He said that during the days before his hospitalization, in which he could not sleep, imperative auditory hallucinations appeared that would guide him in his movements and would denigrate, mock him. He said that he followed the orders given to him, to understand what would happen and what the purpose of the game would be.

During the hospitalization, as the medications slowly showed effect, Mario became progressively less wired and itchy, and by the time of the discharge (22 days after the admission) he appeared more critical about the game and no longer feel outside influence, although he remained puzzled.

During the hospitalization, extended laboratory tests did not reveal any significant abnormality. Cranial MRI and EEG were all unremarkable. Clinical internal and neurological examinations were both normal. Results of the MMPI-2 mainly showed: A mental rigidity in his views and choices that make problem solving more complicated, a lack of self-confidence that lead him to avoid responsibility. He is insecure and submissive in interpersonal relationships and tends to be dependent. He perceives the people as selfish, unreliable and threatening; he has no faith in social relationships. A neuropsychological assessment was performed to evaluate global cognitive abilities, short verbal and long-term memory, complex constructive practice, executive functions, simple and divided attention, logical-deductive reasoning, language and visuospatial memory. The tests administered were: Mini Mental State Examination, Rey’s Word Test - immediate and deferred recall, Copy and re-enactment of the complex figure of Rey-Osterrieth, Trial Making A and Trial Making B, Wisconsin Card Sorting Test, Raven’s Progressive Matrices, Phonological and Semantic Fluency. The neuropsychological examination showed only slight difficulties in a test of access to the lexicon on a phonological criterion.

Conclusions

During the permanence in our ward the patient was treated with paliperidone 3 mg/die, first injection of paliperidone 150 mg, (the second scheduled a week later and then one injection every three weeks) and lorazepam 1mg/die. The patient was discharged with diagnosis of acute psychotic episode in NAS personality disorder (where the NAS indicated a combination of structural features of the paranoid and schizoid type). The choice of therapy was motivated by the fact that, after the acute delusional condition, it was necessary to administer an LAI to promote a continuity of therapy even at home, for the persistence of a share of suspiciousness and a relative awareness of the disease.

Discussion

The case presented was of great theoretical-clinical interest for us, as an opportunity to study and to discuss the possible genesis of a delusion. Jaspers has the credit of changing the perspective from a definition of delusion as a judgment disorder to a perceptual disorder. Nowadays, thanks to this Copernican revolution, we can focus on the relation between the individual and his ambience. We believe that delusion is founded on a specific and natural human mechanism characterizing the psychology of the social interactions: the possibility to “see” trough the way of looking or smiling at us, the feelings of a person we met or maybe to feel a physical discomfort because of the presence of someone we don’t like. This kind of perception, in a healthy mind, becomes the premise for re-evaluation of future relationships and crisis that may follow ¹⁰. On the contrary we can suppose that bodily self-disturbances and disturbed mental states (transnosographically understood as pervasive anxiety, conditions of narrowing of the field of consciousness, important fluctuations in mood, abnormal and pervasive emotional states based on the encounter between a certain personological constitution and adverse environmental events) involve interference with the correct construction of the premises ¹¹. Eventually, these conditions may interfere with the subsequent process of restriction of the counterexamples relating to the conclusions, with the result of a position of certainty impermeable to the fluidity of a possible comparison, consistently with what is described by Mujica-Parodi ¹². With these premises, the embodiment of a delusional perception could gradually become something that cannot ever be rejected, possibly resulting in a passive state that we think could be the seed for developing cenestesic hallucinations.

Conflict of interest statement

The authors declare to have no conflicts of interest.