Interview with Dr. Jan Kalbitzer, author of the "Twitter Psychosis" article

Today I'm chatting with Dr. Jan Kabitzer, a Physician and Leader of the Neurochemistry Research Group at Charité - Universitätsmedizin Berlin.

Dr. Kabitzer is first author of the “Twitter Psychosis” article that made international news and took social media by storm on August 6, 2014. His provocatively titled paper, “Twitter Psychosis: A Rare Variation or a Distinct Syndrome?” (Kalbitzer et al., 2014), appeared online a week earlier in The Journal of Nervous and Mental Disease. I was struck by the title, of course, and an abstract claiming that “Twitter may have a high potential to induce psychosis in predisposed users.”

I wrote a critical blog post on July 31, 2014 (Twitter Psychosis as a Cultural Artifact) arguing that Twitter resembles other technologies and cultural artifacts that can potentially influence the phenomenology of delusions, citing the work of Vaughan Bell and colleagues (Bell et al., 2005).

It is now August 10, and the media huff has died down a bit. The overarching narrative of this story is very meta —  social media about social media. It is in this spirit that I present the interview. ¹

Q: Could you tell me a little about your clinical work and your research?

Since my Ph.D. in Copenhagen at the Neurobiology Research Unit from 2007 to 2009 I have been working clinically at the psychiatric department of the Charité Berlin to specialize in psychiatry. Most of the time I worked on an acute psychiatric ward. We do have some time for research but I did mainly see patients. We are responsible for larger Berlin-Mitte which includes Berlin-Tiergarten and Berlin-Wedding so we see a lot of patients with severe mental disorders who are often in a precarious social situation. My research was initially with PET (positron emission tomography) but over the last year I have changed direction because I became very interested in recovery concepts and right now we are planning a project where we want to study which effect it has to abstain from using diagnostic classifications systems on different measures of mental health and well being. But since February my time as a resident is over and I am actually on paternity leave since then. The reviewing process of this case just took some time.


Q: The first question on everyone's mind is, why did you choose to include the term “Twitter Psychosis” in the title?

We observed the symptoms that we describe only in a few cases but it really disturbed us how these spam bots [Twitter bots] messed with our patients’ perception. We had the impression that abbreviations were intentionally used to create confusion and curiosity to follow the link in the tweet. We saw that this method that was used for commercial purposes can have a destructive effect. So we wanted to spark a discussion about what Twitter does to our minds and chose a provocative title to bring this subject up. But I see now that the main effect was that some news sites, like the Daily Dot, profited insanely from repetitively tweeting their exaggerated headlines. So I would not choose to be that provocative again outside of a closed scientific context. That is sad because I hate ivory towers - but being provocative as a researcher just doesn’t work well with the mass media.


Q: How do you compare the coverage you've seen on blogs vs. mass media?

I have seen both horrible blogs and great blogs. My impression is that in the case of blogs there is more often someone who feels responsible for it which is not always the case with the media (even though there are of course also great journalists).

You would have thought that I was a coveted interviewee during the last week. But I was only contacted by three journalists from NBCNews, betanews and Wired (UK). The NBC guy was great, I told him that I want the article to put things into perspective and he was fine with that. He quoted me exactly how I wrote it and I particularly insisted that he put in the sentence that this is not “real”, what he did. Just the headline wasn't that great. betanews I had never heard of, I just saw all these ads on their page, but I thought I’d rather reply to influence what they write and I think they covered it ok. And I asked them to take down the unbearable picture of a “crazy man” which they used first and they did. And, finally, Wired UK where Liat Clark offered to write against the panic. She interviewed me, but the article isn’t out yet and I am wondering if they will still cover it because the main wave on Twitter and in the news seems to have passed and the interview was Friday evening.

But I did contact some of the newspapers/magazines with the worst headlines myself. The funny thing is that none of them were really interested in an interview with the first author of the study they were writing about. After a while I realized that this is not about me and our article.

Bloggers like you and “Dr. Shock” warned early on and in this case we contacted you and you felt responsible for following up on the story.


Q: The tone of the article was confusing to many people. It wasn't clear if you were being completely serious, somewhat sensationalistic, partially joking, or if it was a joke paper. Your comment gave a brief answer, but could you elaborate here?

The case study had a small political flavor by citing Ben Goldacre (as a homage because I like his critical work about the pharmaceutical industry) but besides that it was completely serious. It would be preposterous to say that we aren’t sensationalistic at all. Every researcher who likes to publish also likes to be read and to be mentioned. But the fact is that our department is strongly influenced by the ideas of the recovery movement. So we focus on treating our patients according to their individual needs and not according to their diagnoses. So, yes, a ‘Morbus Kalbitzer’ [Kalbitzer's Syndrome] and being famous would be great. But would I get to use it? No. And even if ‘Twitter Psychosis’ entered Wikipedia with us describing it first, it would not have been worth it that all these people all over the world became even more insecure about how they should feel about modern media.

Besides that I think there are two things that contributed to the fact that the paper had such a provocative tone:

1. I love Paul Feyerabend² [a philosopher of science] and I believe that you should always challenge existing research theories with new, provocative hypotheses. I learned during the last week that this holds true if you are among reasonable people but in the context of globalized digital mass media you probably can’t do that with scientific publications.

2. Although we do often complain about the quality of our media in Germany, we are actually quite spoiled, so I was naive. News channels went mad in the US and the UK but it didn’t cross over to Germany. Even though I am sure that German journalists do follow these news channels, nothing went viral here. People in Germany are always a bit intimidated by the intensity of North American News.

But at the core of our paper is clearly a scientific question: is that what we observe on Twitter a new, unique feature that has a distinct effect on the development and course of delusions? While you and Vaughan seem to disagree with this, I believe that it makes a difference whether you are watching TV and believe the talk show host is talking to you or watching something that actually does react to what you do like the stream on Twitter. For example, you watch a morning show and still run around naked and suddenly the guy on TV says that running around naked in the morning can cause athlete's foot. That is what spam bots do on Twitter. This is what we meant by “Twitter communication responds to changes in communication style.” When you don’t use Twitter for a while you get emails that you are missed. And then you log in again and might see a spam tweet that links to a book about loneliness by some social guru. Isn’t that different to seeing a telephone post?

Q: One of the most puzzling things to me was the Twitter “experiment”. The purpose was unclear, the details were sparse, and it was difficult to follow what happened. Can you explain?

This partially got messed up by being reviewed for more than one journal. This one-page case study had probably more reviewers contributing to it than authors. We created several experimental accounts which are all deleted now and wrote tweets to more or less famous people on Twitter to see what kind of spam tweets we get in response to our tweets. We tried out different concepts but it was quite difficult for us to simulate what our patients described. So in the end we just used an example for the features of Twitter we described.

But it doesn’t say anywhere that we did a ‘Twitter experiment’ or a ‘Ben Goldacre experiment’, we just say that we used an experimental account. Instead of writing that we ‘test’ something we could have written something like: here is an example of such a tweet to illustrate the features we are talking about. It was more like psychiatrists who treat a patient who took a new designer drug and then, for the case study, the authors take the drug themselves and describe what they’ve experienced. The funny thing is, though, that we had a hard time simulating what most patients described as losing control, in this case that “it would not stop”. Today I know exactly what they are talking about. I surely had a Twitter overdose. Sometimes I used the live search function and watched the stream of tweets on ‘twitter’ and ‘psychosis’. It was a bit like the 'Listening Post' in the Science Museum in London,  just much more disturbing. And after this experience, when thousands of people on Twitter just oafishly retweeted the “news” without looking up the source, and some of these people were psychologists and doctors, I can say that “to twitter” is the right term for what they do. It’s not my cup of tea.


Q: Usually journal articles have a formal Methods section where the authors describe the procedures (hopefully in enough detail so others can try to replicate). In retrospect, would you change the word “Experiment” to something else, like “Demonstration”?

As I said, we presented an example of a tweet that we received when we used an experimental Twitter account. I think what added to the confusion is that this was published as a 'Brief Report'. The Journal of Mental and Nervous Disease doesn’t have a section for case studies so we first submitted the case study as a letter to the editor but were asked to re-submit it as a 'Brief report'. But it is still a regular case report with no experiment, just an experimental Twitter account that we created in order to receive spam messages to, well, yes: demonstrate the features we are talking about.


Q: How do you think scientific articles should be communicated to the public?

I believe that most researchers in social neuroscience are to some degree lay people. Both the PET people who talk about ’the mind’ and the philosophers who want to find the voxel of morality. So I think experiments should be as simple as possible and then be published with absolute transparency and open access (even though I am a bit disturbed by the commercial approach of some open access journals). Then many other 'lay' people will understand what is going on.

I do also believe that you should use scientific data to provoke. In my Ph.D. I wrote in a small paragraph that the whole serotonin - depression story may just be based on mis-interpreting changes in motor activity and vigilance. George Ashcroft already questioned the serotonin story in a similar way. But I guess nobody except my opponents ever read my Ph.D. and they didn’t seem so provoked. It is difficult to find the golden mean.


Now I would like to ask you something! Q: Neurocritic, in your posts you can be fun and ironic but being in contact with you over the last week I realized that you are very serious about your work on this blog. You have been writing extensive and well researched posts for eight years. What is your motivation to do this? Is fighting sensationalistic research your 'Raison d’être‘? And why?

Although it may not be obvious, I am a serious person in real life. I started this blog out of sheer frustration with peer review, during a time when I was facing many rejections. When deeply flawed papers were routinely appearing in top journals, I wondered why all my hard work did not pay off. ³ Since I wanted to critique outrageous claims published in high-profile journals and discussed in the popular press, fighting sensationalistic research is largely my 'Raison d’être.

I saw this as cathartic at the time (since I never expected many readers), but my reasons over the years have evolved to include educating the public and providing a service to the field. I've remained anonymous because the vast majority of peer review is anonymous, which allows reviewers to be rude and insulting. I never want to do that.

However, the humorous and sometimes snarky nature of the blog may have unintended consequences on occasion, and I think that was true in the case of your paper. I try to think about the potential impact of my posts on the authors involved, and in this case I did not anticipate such a media circus. In fact, one of my parting thoughts was, "Hopefully we will not see “Twitter causes psychosis” headlines any time soon."  

So overall I'm sorry about this whole ordeal.



And thank you, Jan, for taking the time to answer these questions.


ADDENDUM (August 11 2014) - This new article at Wired UK has the clearest coverage: Twitter spam may 'aggravate psychosis' in the vulnerable


Footnotes

¹ Jan's answers were very lightly edited by me for English language smoothness and formatting.

² Paul Feyerabend was an Austrian philosopher of science who...

...became famous for his purportedly anarchistic view of science and his rejection of the existence of universal methodological rules. He is an influential figure in the philosophy of science, and also in the sociology of scientific knowledge. ... His major works include Against Method (published in 1975).

According to the Stanford Encyclopedia of Philosophy, Feyerabend:

made a name for himself both as an expositor and (later) as a critic of Karl Popper's “critical rationalism”, and went on to become one of the twentieth century's most famous philosophers of science. An imaginative maverick, he became a critic of philosophy of science itself, particularly of “rationalist” attempts to lay down or discover rules of scientific method.

³ This was in stark opposition to the "All your hard work will soon pay off" fortune taped to my monitor.