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Voices coming from Facebook

Vol. 12, No. 02 / February 2013

The concept of pathoplasticity—that the presentation of illness varies depending on a patient’s experiences, situation, and background—is not new to psychiatry. Pathoplastic effects of culture on the content manifestation of psychiatric disorders have been documented in the literature.1 We present a patient with schizophrenia whose hallucinations and delusions incorporated the social networking website Facebook to highlight the role internet culture can play in shaping modern psychiatric phenomena.

Ms. P, age 49, presents to the emergency department with increasing psychosis. At age 20 she was diagnosed with schizophrenia in Puerto Rico, where she was born and raised. One month before her current admission, Ms. P began to have auditory hallucinations of her Facebook “friends,” most of whom live in Puerto Rico. She says she secludes herself in her bedroom with the door closed, but can still hear voices “coming from Facebook.” She describes the voices as emanating from outside her head, from her computer. Ms. P states the voices stop when the computer is off and return as soon as she knows it is back on. The voices sometimes talk to each other, do not provide commentary, and always are derogatory, often commenting on her sexual experiences, mental health, and success as a mother.

Social media and psychiatry

Since the public introduction of the internet in 1991, contemporary culture has become increasingly web-based. Facebook launched in 2004 and now has >1 billion active monthly users, or approximately 14% of the global population.2 Previously, patients such as Ms. P would be described as having auditory hallucinations and a dense delusional framework. However, in the setting of Facebook, her story seems less bizarre. Ms. P’s case shows the pathoplastic effect of web-based social media on psychiatric phenomena.

Social media sites could introduce stressful exogenous information and ideas; sudden, intimate relationships with strangers; permeable personal boundaries; and self-exposure to a degree that until recently was unimaginable.3 For psychotic patients, this new form of “real” can multiply the number of imagined enemies and further a perceived conspiracy.

Recognizing pathoplastic changes

As society shifts to an increasingly web-based culture, the role of culturally informed pathoplasticity in psychiatric illness merits renewed focus. The ever-evolving pathoplastic features of mental illness make our work interesting and challenging. Because every patient has a unique life story, no 2 patients will look the same. Taking a history of a patient’s use of web-based technology—including Facebook and other social media—may help explain possible pathoplastic changes in presentation. Ask patients about their use of social networking sites, blogs, and microblogs (eg, Twitter).


The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.


1. Oyebode F. Sims’ symptoms in the mind: an introduction to descriptive psychopathology. Philadelphia, PA: Elsevier Saunders; 2008.

2. Fowler GA. Facebook: one billion and counting. The Wall Street Journal. October 5, 2012:B1. Accessed October 22, 2012.

3. Nitzan U, Shoshan E, Lev-Ran S, et al. Internet-related psychosis-a sign of the times. Isr J Psychiatry Relat Sci. 2011;48(3):207-211.

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