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Source Definition Freudenreich12 [Overvalued ideas are] a passionate attitude, also known as ‘fanatic’ in lay terms. One important aspect of overvalued ideas is that they are shared with other people, making them potentially destructive. Remember that delusions, by contrast, are uniquely false ideas held by individuals and identified by others as erroneous. While most people would not jeopardize their careers or lives for overvalued ideas, some will (and are secretly regarded as heroes by those less inclined to fight for an idea) (Ref. 12, p 6). Gelder, Gath, Mayou, Cohen13 An overvalued idea is an isolated preoccupying belief, neither delusional nor obsessional in nature, which comes to dominate a person's life for many years and may affect his actions. The preoccupying belief may be understandable when the person's background is known (Ref. 13, p 10). McHugh14 An overvalued idea is a thought shared by others in a society or culture but in the patient held with an intense emotional commitment capable of provoking dominating behavior in its service. An overvalued idea differs from a delusion in that delusions are false ideas unique to the possessor, whereas overvalued ideas develop from assumptions and beliefs shared by many others. An overvalued idea differs, too, from an obsession in that, although it dominates the mind as an obsession does, the subject does not fight an overvalued idea but instead relishes, amplifies, and defends it. Indeed, the idea fulminates in the mind of the subject, growing more dominant and more resistant to challenge (Ref. 14, p 243). Winokur and Clayton15 [The definitive test of a delusion is] whether an unusual belief is shared by members of the patient's subculture. Delusions must also be differentiated from overvalued ideas, which are fanatically maintained notions, such as the superiority of one sex, nation, or race over others … (Ref. 15, p 376). Sims16 The background on which an overvalued idea is held is not necessarily unreasonable or false. It becomes so dominant that all other ideas are secondary and relate to it: the patient's whole life comes to dominate around this one idea. It is usually associated with a very strong affect that the person because of his temperament has great difficulty in expressing … (Ref. 16, p 147). American Psychiatric Association4 An unreasonable and sustained belief that is maintained with less than delusional intensity (i.e., the person is able to acknowledge the possibility that the belief may not be true). The belief is not one that is ordinarily accepted by the other members of the person's culture or subculture (Ref. 4, p 826). 1 A 35-year-old man with no prior psychiatric disorder plants bombs at a factory that builds computers. He is arrested before anyone is harmed. After his arrest, he tells the police that he believes that computers are ruining the planet and the ecosystem. He is an avid environmentalist and belongs to a group that advocates for the protection of the environment. He regularly attends meetings that advocate violence to “save planet Earth” from total destruction. He believes that others in his group will follow his lead and that he is a hero for doing this. No past psychiatric history or current symptoms are found, and the exam is notable only for increased speech volume when explaining the reasoning for his actions. (Extreme Overvalued Belief) 2 A 27-year-old male graduate student is questioned by police after he tells a new friend that he struggled with “weird thoughts of shooting a lot of people.” On exam, he is anxious and stated that he never wants to harm anyone. He hates guns and has never owned one. If he sees a knife or a gun, he is “afraid of what might happen.” Since his late teenage years, he has had repeated, intrusive images of people getting shot or killed and unwanted thoughts that weapons could hurt him as well. These images and thoughts cause him severe anxiety and distress, and he avoids crowds because it makes these thoughts worse. He has panic attacks at times and was treated in an emergency room for them five years ago. (Obsession) 3 A 40-year-old man with unclear past psychiatric history is arrested after stabbing his neighbor to death. He tells police that his neighbor was a space alien and that the “world is now safe” because he stopped the alien. On exam, he is disheveled and has disorganized speech. His home is found to be unkempt, littered with cigarette butts, with all the windows and vents covered with plastic trash bags and duct tape. (Delusion) 4 A 38-year-old man is detained and questioned by airport security after he is seen with religious books on an airplane that frightened another passenger. Security discovers many prayer books in his luggage. He appears anxious and states that he cannot refrain from praying because he has recurrent thoughts of the plane crashing and believes that reciting his prayers 15 times every time the clock lands on the hour will keep him safe. He states, “This probably sounds ridiculous to you, but I can't help it.” These thoughts have bothered him for many years, and he is only able to stop them with the prayer routine. As a child, he always had to look under his bed three times before he went to bed. (Obsession) 5 A 42-year-old male is arrested after violent behavior during an anti-government protest. During and after his arrest, he challenges the legitimacy of the U.S. government and the entire criminal justice system. During his arraignment, he shouts out odd and what appear to be nonsensical statements to the court. After the courtroom proceedings, he exhibits organized, rational, sequential, and coherent thought processes. Further collateral information is obtained. He is neatly dressed, has no hallucinations, no prior psychiatric treatment, and no grossly disorganized behavior. He belongs to a group called “Freedom Rights” who refuse to pay income taxes and believe that they are free of any legal constraints because they don't recognize the legitimacy of the U.S. government. He has also delivered speeches to crowds espousing such beliefs. (Extreme Overvalued Belief) 6 A 40-year-old man is arrested after carrying Sarin nerve agent on a subway in a major metropolitan area. Witnesses tell police that a toxin took effect in a matter of seconds, leaving several people dead. The man states to police that “people must die to elevate their souls” and that “their souls would reach the planet Jupiter.” After further investigation, it is determined that he belongs to a “new age church” in which all members believe that their souls will be saved after they die and that the souls will travel to the planet Jupiter to meet a prophet from centuries ago. He smoked marijuana as a teenager but became religiously devout and stopped using all drugs after he joined his church. He has no other psychiatric history. (Extreme Overvalued Belief) 7 A 32-year-old man with a history of prior psychiatric hospitalizations is arrested after a mass shooting in which he opened fire on 12 people attending a multicultural event, resulting in five dead and seven wounded. He has been hearing voices since adolescence. On exam, his speech is found to be grossly disorganized. He believes that he is a “superhero here to do good work,” that all the people he shot are “future devils,” and that he can tell “good people from bad people by looking into their souls.” He has been treated with antipsychotic drugs in the past but stopped taking them two to three years ago. (Delusion) 8 A 24-year-old man with chronic mental health problems is arrested after killing his parents. He stated that his parents are actually “undercover government agents” who are harassing and spying on him. He tells the examiner that he knows that these individuals are not his parents, but rather imposters. He is certain of this because “my real parents walk and talk differently.” He has a previous mental health admission for threatening his parents and assaultive behavior toward them. On exam, he is disheveled and unkempt, and requires repeated questioning because he frequently goes off on tangents. He was seen responding to auditory hallucinations by staff. (Delusion) 9 A 19-year-old woman is seen by police after she tells her neighbor that she has thoughts of stabbing her parents. She is visibly upset when evaluated and states that she loves her parents and would never want them harmed by anyone. She reports images of seeing her parents being stabbed that will not leave her mind. She tries to distract herself by singing or walking around. By the end of the interview, she is calmer and feels her thoughts are “silly” but very intrusive. She has some insomnia but denies all other symptoms and is willing to seek help for this problem. (Obsession) 10 A 43-year-old man shoots and kills a police officer during a routine traffic stop. An investigation reveals that he had formed many odd beliefs after several years of Internet use. It is determined that he and others he interacted with online believe that the U.S. government was originally set up by the founding fathers but was secretly replaced by a new government system based on admiralty law, the law of the sea and international commerce. He believed in the process of “redemption” and began filing multiple complex, legal-sounding documents to tap into a secret U.S. Treasury account that he and others believed had been set up for him at birth to draw on at any time. He was routinely rejected by the courts, his house was foreclosed on, and he was about to be evicted. On forensic evaluation, he spent much time talking about his redemption ideas, had no other symptoms, and said he “snapped” when he was pulled over by a government official. Upon a review of the Internet sites, it is determined that his beliefs match those of many others in videos devoted to this topic. (Extreme Overvalued Belief) 11 A 38-year-old woman is arrested after she stabs and kills her gynecologist. She recently found out that he that also performs abortions. She believes that the doctor is trying to kill her unborn baby by forcibly performing an abortion on her. She is taken to an emergency room after her arrest because the police cannot understand her speech patterns and she is so upset about her “unborn baby being harmed.” A pregnancy test is found to be negative, yet she insists that she is carrying “the first cousin of God” in her body. She can hear voices of many gods and demons telling her she is a bad person who must stop her doctor from killing her unborn baby. On exam she is disheveled and has grossly disorganized speech. A newspaper story the next morning reads, “Abortion doctor killed by crazed fanatic.” (Delusion) 12 An 18-year-old woman is detained by security for trying to jump over a barrier into a secure area. When questioned, she is quite upset and tearful as police are called to investigate. She states that the lotion she uses to keep her hands clean was accidentally left in her luggage and she was trying to get it back. On exam, she has numerous lesions from skin picking all over her body. She washes her hands 50 to 60 times a day. The skin on her hands is cracked and bleeding. She has intrusive, unwanted thoughts of getting “the AIDS virus from someone.” She knows it is not how people get the virus, but she can't seem to control these intrusive thoughts. The lotion she has in her luggage is what she likes to use to prevent getting sick. (Obsession) Delusion A false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not ordinarily accepted by other members of the person's culture or subculture (i.e., it is not an article of religious faith) (Ref. 4, p 819). Extreme Overvalued Belief A belief that 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. The belief grows more dominant over time, 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 (Ref. 3, p 2). Obsession Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted and that in most individuals cause marked anxiety or distress. The individual attempts to ignore or suppress such thoughts, urges, images, or to neutralize them with some other thought or action (i.e., by performing a compulsion) (Ref. 4, p 826). Vignette Estimated kappa (95% CI) 1 0.91 (0.85, 0.98) 2 0.96 (0.91, 1.00) 3 0.99 (0.96, 1.00) 4 0.94 (0.89, 1.00) 5 0.96 (0.91, 1.00) 6 0.73 (0.62, 0.84) 7 0.99 (0.96, 1.00) 8 0.99 (0.96, 1.00) 9 0.99 (0.96, 1.00) 10 0.90 (0.83, 0.97) 11 0.99 (0.96, 1.00) 12 0.99 (0.96, 1.00)
