Overvalued Ideas or Underappreciated Values?

alien grinSo this CNN article about newly declassified documents regarding Area 51 in the Nevada desert caught my interest recently, Area 51 officially acknowledged by CIA – CNN.com. Area 51 is an area northwest of Las Vegas which has provided fuel for conspiracy theorists and UFO enthusiasts for decades.

Naturally, because I’m a psychiatrist, I thought of overvalued ideas. I think of overvalued ideas when I consider psychiatric disorders in which we think they might commonly appear, such as in obsessive compulsive disorder and eating disorders. I sometimes wonder if the main issue is overvalued ideas or underappreciated values. Anyway, I did a PubMed search and guess how many results it returned? Exactly 51!

Tell me there’s not something going on there, huh?

The earliest article I could find was one I think I looked at years ago by McKenna, in which the abstract contains what sounds like a provocative definition [1]:

The overvalued idea, first described by Wernicke, refers to a solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is preoccupying to the extent of dominating the sufferer’s life. Disorders conforming to his definition are well documented, though their recognition as such has been variable, and they may not be as rare as is often thought. As well as sharing a distinctive phenomenology, the conditions develop in similar settings and carry a uniformly poor prognosis. Their pathogenesis is obscure and difficult to account for in conventional terms.

You can see where I’m going with this. Read the CNN article, but also be sure to scan through some of the comments which follow it. Despite the debunking nature of the story, which tends to cast doubt on the idea (overvalued?) that there is a murky, men-in-black conspiracy surrounding the goings-on at Area 51, there are many “true believers” out there who manage to read hidden meanings into it. Even the term “true believer” sparks an internal debate about what a delusion is. Psychiatrists are taught that a delusion is a fixed, false belief not amenable to reality testing.

So if a belief that Area 51 shenanigans is a good example of an overvalued idea, does that make Area 51 “true believers” mentally ill?

Not necessarily, although the concept comes to mind whenever I chance across popular TV  shows as I’m flipping channels (OK, OK, I watch them sometimes!). They’re the one about ancient aliens (you don’t know about the hair dude?), Bigfoot, Chupacabra, , ghost hunts, and UFOs.

The most recent article I could find was published in 2011 and the authors sought to nail down a clearer definition of it [2]. I’ll admit I had more than a bit of trouble understanding the authors’ point partly because there seemed to be difficulties translating the text from Spanish to English. However, they seem to prefer conceptualizing the overvalued idea as a continuous rather than a dichotomous variable. They doubt it could be measured in a conventional sense and even used the word “metaphor” when attempting to differentiate overvalued ideas from delusions on the basis of how intensely the idea is held. They note that “…the role of the metaphors in the formation of the concept of the mental helps us to consider the mistakes that language may introduce when we speak of the intensity of an idea, as if it were dealing with a quantitatively measurable physical magnitude. Our opinion is that speaking of the intensity of an idea is a metaphoric concept…”

I think they also don’t want to leave out the “value” concept of the overvalued idea. It’s important to examine what quality is being overvalued, such as beauty in the overvalued idea of symmetry thought to be held by some with Body Dysmorphic Disorder.

So what is the quality that is overvalued by those with an intensely held belief by those interested in Area 51? Could it be trustworthiness, especially if we take into account the readiness of true believers to focus on conspiracy theories?

How do you overvalue trustworthiness? For example, if the belief that the government or non-profit boards (say the American Board of Medical Specialties, ABMS) are misusing concepts like lifelong learning, twisting it into things like Maintenance of Certification (MOC) leading to the American Association of Physicians and Surgeons (AAPS) to file a lawsuit about MOC against the ABMS in Federal court–does that mean that thousands of doctors and lawyers are afflicted with an overvalued idea based on the quality of trustworthiness?

On the other hand, is there a chance the ABMS and the Federation of State Medical Boards (FSMB), the latter of which is trying to promote the Maintenance of Licensure (MOL) both share an overvalued idea? What would be the quality with which it might be associated? Say it’s improvement or maybe perfection rather than greed. How do you overvalue improvement? Does the United States Senate Committee on Finance hold an overvalued idea about trustworthiness as well because that body is conducting an ongoing investigation into the FSMB regarding its financial relationships with pharmaceutical companies which make and market opioid analgesics?

The next most recent article was published in 2010 [3]. As you can see from the abstract below in the reference list, the authors were less inclined to think conviction and insight separated delusions from overvalued ideas. Rather, the difference seemed to turn on plausibility and not caring a fig what others think, which tended to be associated with delusions. In other words, those with overvalued ideas tend to care about the opinions of others regarding their ideas.

Somehow this reminds me of the concept of alexithymia (literally, no words for feelings). The psychiatrists who promoted this idea cautioned us against the reification of alexithymia. However, this didn’t stop them from creating the Toronto Alexithymia Scale. There’s even a rating scale called the Overvalued Ideas Scale described by Neziroglu and colleagues [4]. I wonder if Santin and colleagues would warn us about the reification of overvalued ideas?

In other words, do we just underappreciate certain values?

References:

1. McKenna, P. J. (1984). “Disorders with overvalued ideas.” Br J Psychiatry 145: 579-585.

The overvalued idea, first described by Wernicke, refers to a solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is preoccupying to the extent of dominating the sufferer’s life. Disorders conforming to his definition are well documented, though their recognition as such has been variable, and they may not be as rare as is often thought. As well as sharing a distinctive phenomenology, the conditions develop in similar settings and carry a uniformly poor prognosis. Their pathogenesis is obscure and difficult to account for in conventional terms.

2. Santin, J. M. and F. M. Galvez (2011). “Overvalued ideas: psychopathologic issues.” Actas Esp Psiquiatr 39(1): 70-74.

The position attributed in recent years to overvalued ideas between delusion and obsession and that are derived from the reduction of the construct per se to one of its characteristics, that is, insight, has undergone a critical review. Using a case with dysmorphophobic ideas, the difficulties to define it and differentiate it from delusion are proposed and different psychopathological approaches are outlined that make it possible to reconstruct the case differently.

3. Mullen, R. and R. J. Linscott (2010). “A comparison of delusions and overvalued ideas.” J Nerv Ment Dis 198(1): 35-38.

The relationship between delusions and overvalued ideas is uncertain, and has clinical as well as conceptual implications. This study aims to compare delusions and overvalued ideas on several characteristics that might further describe and distinguish them. A total of 24 individuals with delusions and 27 with overvalued ideas were recruited from a psychiatric service and assessed using a semistructured interview. Deluded individuals were less likely to identify what might modify their belief, less preoccupied, and less concerned about others’ reactions than those with overvalued ideas. Delusions were less plausible and their onset less likely to appear reasonable. Delusions were more likely to have abrupt onset and overvalued ideas a gradual onset. Conviction and insight were similar in the 2 groups. Belief conviction and insight may be an inadequate basis for separating delusions from overvalued ideas. Abrupt onset, implausible content, and relative indifference to the opinions of others may be better distinguishing features.

4. Neziroglu, F., D. McKay, et al. (1999). “The overvalued ideas scale: development, reliability and validity in obsessive–compulsive disorder.” Behaviour Research and Therapy 37(9): 881-902.

The presence of overvalued ideas in obsessive–compulsive disorder (OCD) has been theoretically linked to poorer treatment outcome [Kozak, M. J. & Foa, E. B. (1994). Obsessions, overvalued ideas and delusions in obsessive–compulsive disorder. Behaviour Research and Therapy, 32, 343–353]. To date, no measures have been developed which quantitatively assess levels of overvalued ideas in obsessive–compulsives. The present studies examined the psychometric properties of a scale developed to measure this form of psychopathology, the Overvalued Ideas Scale (OVIS). In study 1, 102 patients diagnosed with OCD were administered a battery of instruments including the OVIS at baseline and two weeks later, prior to initiating treatment. Results indicate that the OVIS has adequate internal consistency reliability (coefficient α=0.88 at baseline), test–retest reliability (r=0.86) and interrater reliability (r=0.88). Moderate to high levels of convergent validity was found with measures of obsessive–compulsive symptoms, a single item assessment of overvalued ideas and psychotic symptoms. Medium levels of discriminant validity with measures of anxiety and depression was obtained in this study. Individuals determined to have high OVI showed greater stability of this pathology than those with lower OVI, suggesting that overvalued ideas are stable for extreme scorers. In study 2 a total of 40 patients participated who were diagnosed with OCD. The same battery of instruments was administered as in study 1, as well as the Beck Depression Inventory and Beck Anxiety Inventories. Results were similar to that obtained in study 1, including a relative lack of discriminant validity with self-report measures of depression and anxiety. It is suggested that further research with the OVIS may show predictive value in treatment outcome studies of OCD.

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Comments

  1. Jim – Great post. When I think of overvalued ideas and delusions or even speculative hypotheses – I come back to the definition of a delusion that I use when doing cognitive behavioral therapy for overvalued ideas or psychotic disorders. I define a delusion as a low probability explanation of an event and usually discuss how that is context dependent. For example – it occurs during a time of extreme anxiety or distress and offers an explanation for what is going on. I would differentiate the conspiracy theorists and survivalists as being more speculative or as some cognitive psychologists have conceptualized it as decisions made under uncertainty. The delusional and those with overvalued ideas are generally much less uncertain.

    The interesting aspect of the CNN article is the overall tone that there was never anything of big interest in Area 51. The logical question is if that were true, why was all of this information suppressed for half a century? You don’t have to be paranoid to realize that doesn’t pass the smell test.

    Like we learned from the “X-Files” the truth is out there. You are just not very likely to hear it from the government. At least until all of those involved are long gone.

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    • Hi George-I really like your cognitive behavioral therapy (CBT) framework in this context. I also think your comment is super in allowing readers to see that psychiatrists still do psychotherapy. And there’s an evidence base for CBT in patients with schizophrenia.

      We used to watch X-Files. Heck, I am an X-File.

      Cheers!

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