Am I Being Followed? Dealing with the Dilemma of Patients with Paranoid Schizophrenia in the Age of Digital Marketing

To the editor,

Smartphones have grown exponentially; greater connectivity through Social Network Services (SNS) has opened up an arena for digital marketing. Smartphone users, who are potential consumers, are engaged through automatic notifications or pop-up messages with precisely chosen content based on an analysis of their browsing behavior. ¹ Though the use of smartphones is associated with mental health^2–4 little is known about the impact of personalized notifications or content on the psychopathology of a patient with schizophrenia. Here we discuss two cases of paranoid schizophrenia whose psychopathology was deeply influenced by such pop-up notifications and managed by a behavioural experiment.

A young graduate male presented with delusions of persecution, reference, and thought broadcasting for five years. He believed that notifications and contents on his YouTube and Facebook apps are the same as what he thought. He attributed it to his thoughts being known by others.

Similarly, in another case, a middle-aged unemployed graduate with delusions of grandiosity and reference for eight years firmly believed that Shreya Ghoshal (a famous Indian playback singer) likes him and prime minister Narendra Modi wishes to recruit him on a special mission. He attributed repeated notifications of related content being messages from them.

We ruled out internet addiction, examined apps’ browser history, and correlated them with both cases’ current psychopathology. Both patients were getting notifications and suggestions, reinforcing their morbid self-referential beliefs. The first case was treated with oral risperidone 6 mg per day, while the second was on oral olanzapine 20 mg daily. Despite adequate pharmacotherapy, there was a persistent illness and no change in the patient’s morbid beliefs.

We planned a behavior experiment based on empirical hypothesis testing (Figure 1). ⁵ First, the treating team discussed the behavioral investigation with the patients, reached a mutual agreement, and chose a trusted attendee (nominated by the patient). Secondly, a formal experiment design was prepared with the involvement of the patients. The patient’s predictions were recorded, that is, his beliefs are accurate and the suggested content of pop-up notifications is not affected by the mobile setting and search pattern. Thirdly, the patient’s mobile location service was turned off, the search history was deleted, and the profile was logged off. He was allowed to use his smartphone for limited hours (3 hours/day). After one week of smartphone use, the results were evaluated. The patient was asked to assess and validate his previously recorded prediction.

Figure 1.

Behavioral Experiment Design Based on Hypothesis Testing Method.

Finally, the patient was educated about personalized web delivery systems. The patient recognized that the content of pop-up notifications is determined by his inputs on the browser and not due to his thoughts being known to others or any prominent personality having a particular interest in him. There was a significant improvement in the patients’ insight and functioning, which remained sustained for six months of follow-up after discharge.

Companies try to engage smartphone users by using push or pull notifications and pop-up messages on browsers. ¹ Personalized web content delivery is the new norm for Internet-based service agencies that provide web services to millions of users worldwide and make revenue by showing relevant ads to each user. Many websites have constantly been trying to model a near-perfect cognitive model (automatic cognitive style identification) ⁶ for each user to predict their likes and dislikes, catering to preferred interests and extending the overall use time and ad revenue in turn.

For an average person, personalized web content is an expected outcome. Still, for patients with multiple cognitive distortions and morbid thought processes, such an encounter is a reinforcing agent for pre-existing morbid beliefs loaded with strong confirmatory bias, ⁷ such as referential ideas, thought broadcast, and persecutory delusion.

One plausible reason for this facilitation is the inadequate understanding of the rapidly advancing technology among the general population, which provides a fertile ground for cognitive distortions and makes information technology a suitable explanation for various morbid experiences. Another role the Internet can play in the psychopathology of patients with paranoid schizophrenia is the facilitation of conviction, extension, and maintenance of delusions, by providing web content personalized to everyone, giving reinforcing evidence to a patient’s morbid assumptions (e.g., thoughts are being read and manipulated).

We conclude that an automatic notification system is the upcoming sophisticated digital marketing tool that potentially intrudes into the personal space of patients with paranoid schizophrenia. As psychiatrists, we should be aware of cutting-edge technology and the need to innovate treatment strategies accordingly.