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Extreme Overvalued Beliefs REGULAR ARTICLE Extreme Overvalued Beliefs Tahir Rahman, MD, Sarah M. Hartz, MD, Willa Xiong, MD, J. Reid Meloy, PhD, Jeffrey Janofsky, MD, Bruce Harry, MD, and Phillip J. Resnick, MD An extreme overvalued belief is shared by others in a person’s cultural, religious, or subcultural group. The belief is often relished, amplified, and defended by the possessor of the belief and should be differentiated from a delusion or obsession. Over time, the belief grows more dominant, more refined, and more resistant to challenge. The individual has an intense emotional commitment to the belief and may carry out violent behavior in its service. Study participants (n 5 109 forensic psy- chiatrists) were asked to select among three definitions (i.e., obsession, delusion, and extreme over- valued belief) as the motive for the criminal behavior seen in 12 randomized fictional vignettes. Strong interrater agreement (kappa 5 0.91 [95% CI 0.830.98]) was seen for vignettes representing extreme overvalued belief. Vignettes representing delusion and obsession also had strong reliability (kappa 5 0.99 for delusion and 0.98 for obsession). This preliminary report suggests that forensic psychiatrists, given proper definitions, possess a substantial ability to identify delusion, obsession, and extreme overvalued belief. The rich historical foundation of extreme overvalued belief and this small survey study highlight the benefit of inclusion of extreme overvalued belief in future glossaries of the Diagnostic and Statistical Manual. J Am Acad Psychiatry Law 48(3) online, 2020. DOI:10.29158/JAAPL.200001-20 Forensic psychiatrists face the challenging problem definition in the Diagnostic and Statistical Manual of evaluating odd or unusual beliefs while conduct- of Mental Disorders, Fifth Edition (DSM-5), is strik- ing threat assessments and forensic evaluations. ingly different from Wernicke’s original conceptuali- Psychotic beliefs can be confused with shared ideol- zation from 1892 and many subsequent textbook ogies as motives for terrorism and mass shootings. definitions.1,4 The DSM-5 describes overvalued idea In an effort to provide forensic psychiatry with a as a belief held with “less than delusional intensity” concise definition for such shared beliefs, the term and “not shared by others” intheirculturalorsubcul- “extreme overvalued belief” was derived from ear- tural group (Ref. 4, p 826). The proper definition of lier, less concise definitions. It was adapted from delusion affects several important diagnostic terms the term “overvalued idea” (Ueberwertige Idee), often seen in forensic criminal cases, including schiz- first coined by Carl Wernicke, the German neuro- ophrenia, delusional disorder, folie à deux,anderoto- psychiatrist who is well known for his work with – mania. To provide a framework based on historically aphasias and Wernicke-Korsakoff syndrome.1 3 validated phenomenology in describing disorders, we The main problem we uncovered is that the reviewed an extensive body of psychiatric literature to describe extreme overvalued belief, which we defined in a previous article as follows: Published online June 29, 2020, with several corrections to the ver- sion published online May 14, 2020. An extreme overvalued belief is one that is shared by others Dr. Rahman and Dr. Hartz are Associate Professors, Washington in a person’s cultural, religious, or subcultural group. The University in St. Louis, Missouri. Dr. Xiong is Assistant Professor, belief is often relished, amplified, and defended by the University of Maryland, College Park, Maryland. Dr. Meloy is possessor of the belief and should be differentiated from Clinical Professor, University of California, San Diego. Dr. Janofsky is Associate Professor, Johns Hopkins Hospital, Baltimore, an obsession or a delusion. The belief grows more domi- Maryland. Dr. Harry is Associate Professor, University of Missouri- nant over time, more refined, and more resistant to Columbia. Dr. Resnick is Professor, Case Western Reserve challenge. The individual has an intense emotional com- University, Cleveland, Ohio. Address correspondence to: Tahir mitment to the belief and may carry out violent behavior Rahman, MD, Department of Psychiatry, Washington University in in its service (Ref. 3, p 2). St. Louis, 660 S. Euclid, Campus Box 8134, St. Louis, MO 63110. E-mail: [email protected]. The definition of extreme overvalued belief was Disclosures of financial or other potential conflicts of interest: None. first described in a prior article in the Journal in Volume 48, Number 3, 2020 1 Copyright 2020 by American Academy of Psychiatry and the Law. Extreme Overvalued Beliefs – response to an analysis of the insanity trial of Anders definition).11 16 These definitions are summarized in Breivik, a Norwegian terrorist responsible for the Table 1. Karl Jaspers was also a key figure in bringing massacre of 77 people, mostly youth, in Oslo and rigorous definitions to abnormal psychic phenom- toya, Norway, in July 2011.2 Mental health profes- ena. He defined delusion as qualitatively different sionals disagreed as to whether he held delusions due from normal belief, with a radical transformation to schizophrenia or shared beliefs with other right- from the meaning attached to events and incorrigible wing extremists. Prior to his attacks, Breivik released to an extent unlike normal belief. Jaspers also con- a bizarre manifesto and proclaimed that he was a trasted delusion from overvalued idea; he described “Knight Templar” on a mission to cleanse Norway the latter as an isolated notion associated with strong of immigrants. He believed that he would become affect and an abnormal personality, similar in quality the New Regent in Norway following a coup d’état to passionate political, religious, or ethics convictions and that he would acquire the name “Sigurd the that are strongly toned by affect and best understood Crusader” as a pioneer in an impending European in terms of an individual’s personality and unique civil war. Both forensic teams agreed that he did not biography. Thus, Jaspers emphasized that overvalued have hallucinations, nor did he exhibit grossly disor- ideas are isolated notions that develop comprehensi- ganized speech or behavior. This left his unusual bly out of a given personality and situation.15 beliefs as the main source of disagreement during his Frank Fish also brought the German tradition forensic evaluations. The Norwegian court declared (including Wernicke) of descriptive psychopathology that he held extremist beliefs shared by other right- to English-speaking psychiatrists. His classic British wing groups in Norway and not idiosyncratic, fixed, clinical guide continues to influence students of the and false beliefs from delusions, thus rejecting the Royal College of Physicians.17 He observed that there insanity defense.2,5 was frequently a discrepancy between the degree of Similar controversies regarding the source of fix- conviction in overvalued ideas and the extent to ated beliefs erupted in the cases of John Hinckley, Jr. which the beliefs directed abnormal behavior. He (i.e., fixation on Jodi Foster), and other cases of lone- also argued that patients with overvalued ideas acted actor terrorism (such as Theodore Kaczynski’sfixa- on them, determinedly and repeatedly, and com- tion on protecting the environment of the Earth).6 pared them to the drive of an instinct, like nest Moreover, in the past two decades, online interaction building.15,17 has been of increasing concern to counterterrorism experts. Reports of violent attacks by lone-actor Fixated Beliefs and Psychopathology offenders has increased dramatically.3,7 For example, The classic descriptions of overvalued idea (Table in a recent case, an individual sent package bombs to 1) from various international texts are similar; how- political leaders and former U.S. President Barack ever, they all are clearly different from the definitions 11–16 Obama after viewing online extremist conspiracy in the DSM-5 and the DSM-IV, Text Revision. theories. In a sentencing memorandum, his attorneys To further confuse matters, several British texts argued that he developed “delusions” and “obses- categorize the following conditions as disorders 8 with overvalued ideas: anorexia nervosa; paranoid sions” from online interaction. In a separate inci- state, querulous or litigious type; morbid jealousy; dent, called “Pizzagate,” a man fired shots into a “ ” hypochondriasis; dysmorphophobia; and parasito- pizza restaurant after he was self-investigating an phobia (Ekbom’ssyndrome).12,15,17 Some of these online conspiracy theory that the restaurant was disorders are seen as the product of delusions in “ ” harboring child sex slaves linked to the Democratic U.S. texts.6,17 9–10 Party. Mass shootings and acts of terrorism Wernicke’s 1892 description of overvalued idea,1 are well known to be inspired by online interaction which was recently published in English translation,6 and social media.2 does not mention these disorders. Instead, he described In our review of the literature, we discovered overvalued ideas in the context of criminality and that the term “overvalued idea” varies in its exact insanity.1,6 Although Wernicke did not explicitly – wording.11 17 It is usually described as being different define delusion, obsession, and overvalued idea, from a delusion or obsession and as having shared he gave case examples and stated that these three ideologies (in keeping with Wernicke’s seminal cognitive drivers of fixations can be easily 2 The Journal
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