‘Truman’ signs and vulnerability to psychosis
Paolo Fusar-Poli, Oliver Howes, Lucia Valmaggia, Philip McGuire

Prospective studies indicate that individuals meeting a range of clinical criteria such as attenuated psychotic symptoms, brief psychotic episodes or functional decline and family history of schizophrenia have a high risk of being in the prodromal phase of a psychotic disorder.1 However, these studies do not differentiate between different symptom characteristics. Understanding the phenomenology of attenuated psychotic symptoms may aid the discrimination of truly prodromal from low-risk individuals.

Mr M.A., a 26-year-old postman, presented with the feeling there was something subtle going on around him that others knew about but he didn’t. He had a vague sense that people around him were ‘ acting’, he was the focus of their interest and they knew a secret that was being kept from him. Furthermore he felt ‘detached from the environment’ and had a sense the world was slightly unreal, as if he was the eponymous hero in the film The Truman Show. He was preoccupied with the belief that he was the focus of something that he couldn’t quite understand. At no point did his conviction reach delusional intensity. There was no evidence of hallucinations, thought disorder, odd behaviour or other features of psychosis. The symptoms met the criteria for an ‘at risk mental state’, which is associated with a 25–45% risk of developing psychosis in the next 12 months. Over the ensuing 9 months these preoccupations became more pronounced; he developed grandiose and persecutory delusions, and marked thought disorder. He was diagnosed with DSM–IV schizophrenia. Following treatment with quetiapine 150 mg twice daily these delusions and the thought disorder have resolved, although he continues to experience occupational impairment and has not been able to return to work.

In this case Mr M.A. had a preoccupying belief that the world had changed in some way that other people were aware of, which he interpreted as indicating he was the subject of a film and living in a film set (a ‘ fabricated world’). This cluster of symptoms, which we have termed the ‘Truman syndrome’, is a common presenting complaint in individuals attending the OASIS clinic for people who may be in the prodromal phase of schizophrenia. Underlying the phenomenology of these symptoms are several features that are consistent with theories of delusion formation resulting from a process of aberrant salience.2 First, there is the sense that the ordinary is changed or different, and that there is particular significance in this. This is coupled with a searching for meaning, which, in this case, results in the ‘Truman explanation’. The third feature is a profound alteration of subjective experience and of self-awareness, resulting in an unstable first-person perspective with varieties of depersonalisation and derealisation, disturbed sense of ownership, fluidity of the basic sense of identity, distortions of the stream of consciousness and experiences of disembodiment.3 We suggest that these experiences characterise the earliest clinical manifestation of aberrant salience leading to delusion formation. The qualitative phenomenology of the prodrome has not been widely studied, but may, as in this case, be a useful indicator of impending psychosis.