The phrase “alternative facts” has recently made the news in a political context, but psychiatrists like me are already intimately acquainted with the concept – indeed, we hear various forms of alternate reality expressed almost every day.
All of us need to parse perceived from actual reality every day, in nearly every aspect of our lives. So how can we sort out claims and beliefs that strike most people as odd, unfounded, fantastical or just plain delusional?
Untruths aren’t always lies
First, we need to make a distinction often emphasized by ethicists and philosophers: that between a lie and a falsehood. Thus, someone who deliberately misrepresents what he or she knows to be true is lying – typically, to secure some personal advantage. In contrast, someone who voices a mistaken claim without any intent to deceive is not lying. That person may simply be unaware of the facts, or may refuse to believe the best available evidence. Rather than lying, he’s stating a falsehood.
Some people who voice falsehoods appear incapable of distinguishing real from unreal, or truth from fiction, yet are sincerely convinced their worldview is absolutely correct. And this is our entree into the psychiatric literature.
In clinical psychiatry, we see patients with a broad spectrum of ideas that many people would find eccentric, exaggerated or blatantly at odds with reality. The clinician’s job is, first, to listen empathically and try to understand these beliefs from the patient’s point of view, carefully taking into account the person’s cultural, ethnic and religious background.
Sometimes, clinicians can be wildly mistaken in their first impressions. A colleague of mine once described a severely agitated patient who was hospitalized because he insisted he was being stalked and harassed by the FBI. A few days into his hospitalization, FBI agents showed up on the unit to arrest the patient. As the old joke goes, just because you’re paranoid doesn’t mean they aren’t after you!
When what you believe is wrong
We can think of distortions of reality as falling along a continuum, ranging from mild to severe, based on how rigidly the belief is held and how impervious it is to factual information. On the milder end, we have what psychiatrists call over-valued ideas. These are very strongly held convictions that are at odds with what most people in the person’s culture believe, but which are not bizarre, incomprehensible or patently impossible. A passionately held belief that vaccinations cause autism might qualify as an over-valued idea: it’s not scientifically correct, but it’s not utterly beyond the realm of possibility.