As a new challenger approaches, how will modern psychiatry cope with ’shifting realities’?

From culture to subculture

Psychiatry has long relied on defining delusions as deviations from shared cultural and societal beliefs (Gaines, 1995). From a standpoint, this is becoming increasingly complicated for modern psychiatry with the growing interconnectedness of the Internet and smart devices. These have allowed for large-scale sharing of specific persecutory belief systems, such as ‘gangstalking’, which contradicts the traditional definitions of a delusion by being simultaneously held by thousands of people as a shared worldview. Online forums with discussions and guidance in evading mental health services further complicate clinical practice (Lustig et al., 2021). The growth of social media networks has also been associated with a rapid increase in more specific mental health diagnoses, such as Dissociative Identity Disorder (Giedinghagen, 2022).

A new challenger

Internet subcultures group people who share a major interest or belief through the medium of the Internet. A less-researched Internet subculture is ‘reality shifting’ (RS). Since the practice of RS or ‘DimensionalJumping’ first appeared on the subreddit ‘/r/DimensionalJumping’ in 2014, the community has spread to other platforms like YouTube, TikTok and Amino. Though official definitions are lacking, reality shifting involves people altering their subjective experience of reality (see Table 1 for key concepts). This is often described as being able to ‘travel to’ or ‘visit’ alternative (often fictional) realities and dimensions while simultaneously remaining physically present in the real world (Somer et al., 2021).

Table 1. Overview of terminology frequently used by people describing reality shifting

The topic of reality shifting has amassed over 40,000 members on Reddit and 1.8 billion video views across the TikTok hashtag, largely among teenagers and young adults. Described to involve quantum mechanics and astral projection, the experiences and induction methods closely resemble self-hypnosis and dissociation, where the latter can be inducted using technology like virtual reality (Aardema et al., 2010; Somer et al., 2021). It remains unclear whether RS might signal a mental health concern. Depending on the experience and belief, there might be a potential overlap with the DSM-5 diagnosis of other specified dissociative disorder where the subcategory of dissociative trance involves a loss of awareness of one’s surroundings. However, this diagnosis cannot be made when the trance is part of a collective cultural experience (APA, 2013). The ability to utilise this diagnosis, therefore, depends on the wider recognition of reality shifting as a cultural phenomenon. There is also an overlap with other emerging research areas such as maladaptive daydreaming (MD), which has been linked to attention-deficit/hyperactivity disorder, obsessive-compulsive disorder and dissociative symptoms. MD typically focuses on fictional characters and plots that are difficult to control and affect daily functioning (Bigelsen et al., 2016). This means that reality shifting could equally be a phenomenon associated with other established disorders (Table 1).

An important challenge to face

While psychiatry has previously focused on cultural disorders, we now need to understand Internet subcultures. This is challenging because, by nature, they are much more fluid, variable and rapidly growing. Despite this, Internet subcultures also conform to traditional cultural transmission biases where people copy prestigious individuals or a majority group (Acerbi, 2016). Previous work has shown how misinformation and new trends can spread through social media faster and wider than services can keep up (Norman et al., 2022). This could escalate as technology companies change strategies towards large aspects of your life being lived within virtual environments.

Despite this, videos and concepts are likely to be presented to some of the youngest and most vulnerable patient groups with limited access to and ability of mental health services to detect or influence exposure. Though shifting realities is unlikely to be a frequent presenting complaint, it is likely to increasingly come up during mental health assessments. Considering the minimal coverage of such concerns in the psychiatric literature, it is possible that an unaware psychiatrist could, understandably, identify the concept as a delusion. It would be a concern if this led to the unnecessary prescribing of antipsychotic medications or even hospital admissions.

A possible redemption for digital psychiatry

It has previously been highlighted that digital psychiatry, which still lacks a clear definition in the literature, has had limited impact on clinical practice beyond the uptake of telehealth (Lundin and Menkes, 2021). However, identifying and understanding new subcultures of the Internet will allow a better understanding of what should be considered a psychiatric concern within an increasingly online-based society and how psychiatry can stay relevant in the rapidly evolving social culture that technology brings.

To achieve this, we propose a thematic analysis of RS groups online, focusing on identifying key terminology and phenomenology using strategies such as corpus linguistics (Havey, 2012). Social media platforms contain rich amounts of data to perform psychological classification tasks. Similar approaches need to be extended to other subcultures to identify which represent typical behaviour, requiring awareness only, and which are likely to represent a primary or co-occurring psychiatric disorder. Application of big data or machine learning approaches in monitoring Internet subcultures would allow for the classification of key themes, track developments and identify established mental health symptoms like the relative presence of formal thought disorder (Bayer et al., 2023).

Collaboration between mental health clinicians, particularly with youth/young adult experience, and computer science experts with significant technical knowledge associated with online monitoring and analysis will be key to achieving a rigorous analysis. Involving private technology companies and investors will also be crucial to understanding the impact these subcultures have on the brain capital of traditional societies (Smith et al., 2021).

Establishing ongoing identification and monitoring of emerging subcultures should reach beyond those that impact established mood, anxiety and eating disorders. The goal is not to label subcultures as mental health problems. Rather, to improve clinical outcomes, there may even be avenues to turn RS into tangible therapeutic interventions for defined clinical problems such as isolation, loneliness or lack of emotional or cognitive engagement. Still, if our disorders are defined as different from the norm, then it is more important than ever to have an overview of the ever-shifting norms so we can avoid misuse of power and understand the subjective experiences of the patients we see. It is possible that psychiatry needs to shift its focus from the content to the function of a delusion. Finally, there is a need for psychiatry-led discussions around these issues and alternative ways to assess the validity of delusions, which should be accessible and welcome responses of all opinions.