QAnon: A Modern Conspiracy Theory and the Assessment of Its Believers

https://jaapl.org/content/early/2022/01/25/JAAPL.210053-21 Skip to main content Main menuUser menuSearch Journal of the American Academy of Psychiatry and the Law Article CommentaryAnalysis and Commentary QAnon: A Modern Conspiracy Theory and the Assessment of Its Believers Brian J. Holoyda Journal of the American Academy of Psychiatry and the Law Online January 2022, JAAPL.210053-21; DOI: https://doi.org/10.29158/JAAPL.210053-21 ArticleFigures & DataInfo & Metrics PDF Abstract Pizzagate and its progeny QAnon are two conspiracy theories with a growing number of believers worldwide. QAnon has entered mainstream conservative politics, with followers identifying themselves with posters and t-shirts at rallies for former President Trump beginning in 2018. With growing numbers of QAnon theorists the world over, psychiatrists will begin to encounter such individuals with increasing frequency. Because some individuals are motivated to engage in criminal behavior on the basis of their beliefs, forensic psychiatrists may also encounter QAnon more commonly in the future. It is therefore important that psychiatrists understand the QAnon conspiracy theory, as well as how it is consistent with and different from other conspiracy theories. Particularly noteworthy is the rapid and global spread of QAnon via social media. Clinically, it is important for psychiatrists to be able to differentiate QAnon beliefs from other types of beliefs, including delusions and other delusion-like beliefs. For forensic psychiatrists, understanding the role that conspiracy theories may play in individuals’ legal proceedings is particularly important. QAnonconspiracy theorydelusion-like beliefsforensic evaluationdelusion Pizzagate was a conspiracy theory that high-ranking Democratic officials in the United States government were involved in a child sex trafficking ring located in the basement of a pizza parlor in Washington, D.C.1 The theory developed following WikiLeaks’ release of e-mails originally hacked by Russians from the e-mail account of John Podesta, Hillary Clinton’s campaign chairman, one month before the 2016 United States presidential election.2 Right-wing, alt-right, and Russian trolls on forum sites including 4chan and Reddit posted that the use of the phrase “cheese pizza” in e-mails about dinner plans was code for child pornography. The association between pizza and child sexual abuse led forum users to target Comet Ping Pong, a Washington, D.C. pizza parlor from which Mr. Podesta had ordered. Believers began spreading the Pizzagate meme, which expanded via stories containing disinformation on conservative forums and websites. The conspiracy theory became progressively stranger, ultimately invoking the existence of an elite, Satanic, cannibalistic, child sex trafficking ring operating out of Comet Ping Pong’s basement.3 Motivated by his belief that alleged child abuse was occurring at the pizzeria, 26-year-old Edgar Welch drove from North Carolina to Washington, D.C., carrying three loaded firearms on December 4, 2016.4 He marched into the store armed with an AR-15 assault rifle and a revolver. As customers and employees fled the building, Mr. Welch reportedly attempted to open a locked door with a butter knife and, when unsuccessful, his AR-15. Unable to find the alleged sex ring’s kill rooms, he departed the pizzeria unarmed after about 20 minutes and was arrested. In an interview from jail with The New York Times, Mr. Welch expressed regret over how he “handled the situation.”5 Regarding the absence of children at the pizzeria, he said, “The intel on this wasn’t 100 percent.”5 He was subsequently sentenced to four years in prison for interstate transportation of a firearm and ammunition and assault with a deadly weapon. On October 28, 2017, the birth of the QAnon conspiracy theory picked up where Pizzagate left off.6 On that day the now mythic Q created a post entitled “Calm Before the Storm” on the forum site 4chan in which he claimed to be a government official with connections to the Trump administration and Q clearance. Releasing alleged intelligence in the form of breadcrumbs or Qdrops, Q built on the Pizzagate conspiracy theory, asserting that then-President Trump would initiate The Storm, an attack against the deep-state actors responsible for the global pedophile cabal. Since then, a community of online followers has expanded the belief system of QAnon, often in response to political and societal happenings or to the tweets of former President Trump. For example, the group identified Q’s influence when Alabama’s football team presented Trump with a jersey bearing the number 17, which also happens to be the position of letter Q in the alphabet.7 The conspiracy theory rapidly worked its way into the mainstream, in part due to the amplification of QAnon material by celebrities like Roseanne Barr, who tweeted supportive comments about the Trump administration’s role in breaking up pedophile rings in March 2018,8 and Trump himself, who is estimated to have promoted the conspiracy theory at least 265 times via retweets of QAnon-associated accounts between October 2017 and October 2019.9 QAnon has been associated with various criminal acts. For example, on June 15, 2018, Matthew Phillip Wright blocked traffic on a bridge over the Hoover Dam with an armored truck containing two assault rifles, two handguns, and 900 rounds of ammunition.10 He held a sign next to the vehicle that stated, “Release the OIG report,” and claimed that he was on a mission for QAnon to obtain a report on the conduct of Federal Bureau of Investigation (FBI) agents during their investigation of Hillary Clinton’s use of a private e-mail server for official public communications. He later pleaded guilty to charges of making a terrorist threat, aggravated assault, and unlawful flight from a pursuing law enforcement vehicle. On May 30, 2019, the FBI released a report classifying Pizzagate and QAnon as “fringe political” conspiracy theories and noted that they likely motivate domestic extremists to commit violent and other criminal behavior.1 It is therefore not surprising that many of those arrested for their participation in the January 6, 2021 insurrection at the United States Capitol building have been found to be loyal QAnon believers.11 Like any other type of belief, a conspiracy theory can motivate the believer to act, including in ways that are violent or otherwise unlawful. QAnon has managed to invade mainstream political discourse and spread to other nations.12 Given its wide uptake, general psychiatrists, correctional psychiatrists, and forensic psychiatrists may encounter individuals espousing belief in the conspiracy theory more frequently. It is therefore important for practitioners to understand the underlying tenets of this theory, as well as how QAnon compares to other types of atypical belief systems. Psychiatrists charged with evaluating or treating QAnon theorists should also be aware of how conspiracy theories spread, a process that has become more rapid and virulent with the rise of social media. Finally, forensic examiners require a framework by which to evaluate the role of QAnon and other conspiracy theories in the context of forensic assessment. The Anatomy of a Conspiracy Theory A conspiracy theory is a set of ideas describing the collusion of various individuals or entities for a malevolent purpose. The claims encompassed in conspiracy theories are unverified, unverifiable, and sensationalistic, and they rebut more coherent and logical explanations for the topic at hand.13,–,15 Central elements of a conspiracy theory include a pattern or causal connection between various people, objects, or events; agency or intentionality among alleged conspirators; a coalition of actors; threatening or malevolent goals; and secrecy among those involved.16 There is evidence that conspiracy theories about a broad range of topics are widely held in the general population. For example, in a telephone poll of 1,010 randomly selected adults in the United States, 16.1 percent and 20.0 percent reported that it was “very likely” or “somewhat likely,” respectively, that people in the federal government assisted in the September 11 terrorist attacks or took no action to prevent the attacks because they wanted the United States to go to war in the Middle East.17 Such beliefs were more likely to be held by racial minorities, younger people, women, those with less education, and those who read blogs. Similarly, an online survey of 1,351 Americans regarding medical conspiracies found that 37 percent agreed that the Food and Drug Administration is deliberately preventing the public from getting natural cures for cancer and other diseases because of pressure from drug companies, while 20 percent agreed that doctors and the government wish to vaccinate children despite knowing that vaccines cause autism and psychological disorders.18 Analyzing data from four nationally representative surveys conducted in 2006, 2010, and 2011, the same authors reported that more than half of American adults believe in common conspiracy theories and concluded that “both the willingness to agree with conspiracy theories or see them as valid explanations for political phenomena are quite commonplace in the American public” (Ref. 19, p 963). Not surprisingly, conspiracy theorizing leads individuals to engage in behaviors consistent with their beliefs. Individuals who expressed agreement with an increasing number of medical conspiracy theories reported greater use of alternative medicine and herbal supplements and less utilization of annual check-ups and sunscreen.18 Similarly, a recent online survey of more than 5,000 UK residents identified a negative relationship between COVID-19 conspiracy beliefs and COVID-19 health-protective behaviors, and a positive relationship between conspiracy beliefs and the use of social media as a source of information about COVID-19.20 QAnon clearly demonstrates the defining characteristics of a conspiracy theory. Theorists identify patterns and causal relationships among individuals, events, and places, attributed to the work of a cabal of cannibalistic pedophiles. The cabal is alleged to act in coalition to satisfy a malevolent goal, namely the commission of child sexual abuse and sacrifice. Despite the purported involvement of high-profile politicians and Hollywood celebrities, the cannibalistic sect has managed to conduct its affairs in secrecy. Some have hypothesized that conspiracy theorizing may be an evolutionary by-product of adaptive psychological mechanisms including pattern perception, agency detection, and threat management.16 Indeed, the processes of pattern perception and agency detection are well on display in the interpretation of banal events by QAnon theorists. For example, when Donald Trump was on a trip to Asia, Q posted photographs of islands that conspiracists interpreted as evidence that Q was on Air Force One.21 The content of the conspiracy theory has crept across various thematic areas over time, incorporating both well-worn conspiracy tropes and current world events. The theory has been linked with antisemitism due to its fixation on Jewish elites, including accusations of malevolence targeting George Soros and the Rothschilds.22 Following the onset of the COVID-19 pandemic, QAnon theorists spread the idea that drinking an industrial bleach known as Miracle Mineral Solution was a cure for the illness.23,24 With the spread of wildfires across the West Coast in the fall of 2020, Q posted comments from a former U.S. Senate candidate in Oregon that six Antifa members had been arrested for intentionally starting wildfires.25 Conspiracy theories can grow to incorporate current events and topics with relative ease, propagating some claims that may not individually appear false or unusual. The Spread of QAnon Perhaps one of the most distinctive aspects of the QAnon conspiracy theory is the speed and ease with which it has propagated around the world. Prior to the advent of blogs and social media platforms, people obtained the news from traditional media outlets, including newspapers and television. People’s beliefs about the world were shaped by the news and the communities to which they belonged, which were commonly local neighborhoods, professional networks, religious organizations, and other civic institutions. The rise of social media, however, has enabled conspiracy theories like QAnon to spread rapidly and globally. Social media platforms allow all comers instant access to communication with people around the world and facilitate the linkage of those susceptible to conspiracy thinking with a community of like-minded individuals. It has also enabled the immediate, global sharing of disinformation, including the ideas of celebrity conspiracy theorists like Alex Jones, host of the popular show InfoWars. The problems associated with disinformation on social media platforms are becoming increasingly apparent and include the loss of a shared sense of reality, political polarization,26 and a risk to public health.20,27 An information landscape that enables the development of siloed communities of individuals who are prone to reject traditional news provides fertile soil for the growth of conspiracy thinking. Indeed, QAnon’s spread and representation on social media platforms have been extensive and persistent. The Institute for Strategic Dialogue (ISD), a global think tank that seeks to address extremism and disinformation, published a report outlining the presence of QAnon-related posts on Facebook, Instagram, Twitter, and YouTube.12 From October 27, 2017 to June 17, 2020, ISD identified 69,475,451 tweets, 487,310 Facebook posts, and 281,554 Instagram posts that mentioned QAnon-related phrases or hashtags. They noted that the number of posts and unique users discussing QAnon tends to increase in response to certain events, such as when Q followers were first spotted at Trump rallies in Florida in August 2018 and after the arrest and death of Jeffrey Epstein in July and August 2019. ISD also reported that the highest volume of QAnon-related posts on all platforms occurred between March 2020 and June 2020 with the imposition of stay-at-home orders in response to the COVID pandemic. The number of unique users discussing QAnon on Facebook grew 161 percent from 344 per day in the first week of March 2020 to 898 per day in the last week; similarly, the average number of Twitter users grew from 37,302 in the first week to 89,338 in the last week. Despite Facebook’s efforts to eliminate QAnon content from the platform beginning in October 2020, many personal profiles have remained active, including that of Larry Cook, an anti-vaccination activist who shares videos in which he explains QAnon to beginners and how the U.S. government runs secret detention camps.28 Later that month, YouTube stated that it would begin “removing more conspiracy theory content used to justify real-world violence.”29 It remains unclear whether these platforms’ efforts will be able to curb the spread of QAnon-related content in the future. Perhaps most revealing of the effect of social media’s ability to spread the QAnon conspiracy theory is how it has taken root abroad. According to the ISD, from November 2019 to June 2020, 2.8 percent of QAnon-related tweets came from the United Kingdom, 2.7 percent from Canada, 1.7 percent from Australia, and 0.5 percent from Germany.12 An online survey of 2,000 adults in the United Kingdom found that 19 percent had heard of QAnon, and, of those, 5.7 percent reported supporting it.30 In addition, in August 2020 there were street protests in 10 cities across the UK, including one in London involving 500 protestors, organized by Freedom for the Children UK, a group promulgating the QAnon conspiracy theory online under the hashtag #SaveOurChildren.31 QAnon’s growth in Germany has resulted in theorists demonstrating in the streets as well, along with anti-COVID lockdown and far-right Reichsburgers nationalist protestors.32 In countries around the world, QAnon themes have been picked up and adapted by local groups to promote conspiracy theorizing and to foment grievance. The Differential Diagnosis of Belief in QAnon Because individuals espousing belief in the QAnon conspiracy theory are engaging in criminal behavior, they are more likely to encounter correctional and forensic psychiatrists in the future. Psychiatrists therefore require a framework with which to understand and assess conspiracy theorists. It is necessary to be able to identify conspiracy theories as such because the differential diagnosis of atypical beliefs is vast. QAnon and Delusion-Like Beliefs Belief in conspiracy theories is not delusional. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines a delusion as 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” (Ref. 33, p 819). Furthermore, the text indicates that delusions are “not ordinarily accepted” by an individual’s culture or subculture and, when they involve a value judgment, are “so extreme as to defy credibility” (Ref. 33, p 819). Belief in QAnon and other conspiracy theories fails to meet the DSM-5 definition of a delusion because their existence depends on a community or subculture of individuals that share the belief. In addition, there are degrees to which theorists adhere to their beliefs that may change depending on evidence presented to them. Even those committed to act on behalf of QAnon, such as Edgar Welch, may find that their “intel [is not] 100 percent”5 or that their belief is shaken by evidence to the contrary. Finally, the fact that conspiracy theories are widely held within the general population17,–,19 indicates that they are not delusions, lest most of the population be considered to have a delusional disorder. Belief in conspiracy theories may be described more appropriately as one form of delusion-like belief (DLB). Pierre recently published a review of DLBs in The Journal in which he described them as beliefs that “slip through the cracks of symptom definitions and drift into the gray area between pathological and normal beliefs” (Ref. 34, p 327). Indeed, because of their prevalence, cultural sanction, shared nature, and content ranging from the mundane to the extreme, conspiracy theories uncomfortably straddle the line between the pathological and the normal. In his review, Pierre argues that a failure to look beyond typical psychiatric classifications may result in misunderstanding and misidentification of DLBs. In either a clinical or forensic context an uninformed psychiatrist could certainly mistake belief in a conspiracy theory for a delusion and misidentify a theorist as experiencing psychosis. Pierre advocates for careful consideration of the conviction, preoccupation, self-reference, grandiosity, and distress associated with the belief, rather than its content or the degree to which it is shared, as the former factors may suggest a delusional belief rather than a DLB.34–35 Though being able to distinguish between a delusion and belief in a conspiracy theory is undoubtedly helpful, particularly for a treatment provider, it may be less useful for a jury or other legal decision-maker. In forensic considerations of dangerousness or criminal responsibility, it is necessary for the expert to be able to explain how individuals developed their beliefs and how these beliefs contributed to their behavior. Pierre advocates the use of a cognitive perspective in the evaluation and diagnostic formulation of individuals with DLBs.36 An expert must understand individual belief acquisition and maintenance and the impact of dyads, closed groups, and the Internet in such processes. Pierre recommends that experts understand models of the adoption of unconventional beliefs. Relevant examples include the two-deficit model that involves the cognitive misinterpretation of an anomalous experience37 and the socio-epistemic model that involves epistemic mistrust (i.e., lack of belief in the authority of traditional institutions), as well as information-processing biases that make an individual vulnerable to misinformation.38 QAnon and Extreme Overvalued Beliefs Recently, Rahman and colleagues put forth the concept of the extreme overvalued belief.39,40 Based on Carl Wernicke’s concept of overvalued idea, extreme overvalued belief is meant to assist psychiatrists in distinguishing between delusions, obsessions, and DLBs to which someone may firmly adhere. Differentiating elements of the definition of extreme overvalued belief include that it “is shared by others in a person’s cultural, religious, or subcultural group,” that the “individual has an intense emotional commitment to the belief and may carry out violent behavior in its service,” and that it “is usually associated with an abnormal personality” (Ref. 39, p 33). In theory, a conspiracy theory to which a believer closely adheres could constitute a single extreme overvalued belief or multiple extreme overvalued beliefs. Indeed, various vignettes that Rahman and colleagues presented to conference attendees to assess the concept’s interrater reliability were consistent with conspiracy theories.41 Though a conspiracy theory could be considered an extreme overvalued belief, problems with the concept belie its utility. First, there are no published data indicating that the various elements of the definition cohere to validate the concept of an extreme overvalued belief. Second, Rahman and colleagues suggest that the extreme overvalued belief assists by “classifying beliefs by putative causation,” which would “promote progress in forensic psychiatry” (Ref. 41, p 325). Yet the definition itself does not posit any mechanism of causation, apart from noting that belief may contribute to an individual’s violent behavior. This conclusion is both obvious and unhelpful. Furthermore, the definition indicates that an individual may, but does not necessarily, act on the belief. As previously noted, in considerations of dangerousness or criminal responsibility involving DLBs, it is the link between belief and action that matters. The concept of extreme overvalued belief does not help in understanding this link. Finally, the definition of extreme overvalued belief is so broad that it potentially can include conspiracy theories, religious or cult beliefs, or other DLBs of sociocultural or political sects. These different DLBs have their own historical, social, political, and psychological underpinnings. Placing them all under one umbrella term does not help to further their study; rather, it further blurs the lines distinguishing them. QAnon and Cult Considerations QAnon’s casual and inaccurate conflation with a cult by various news outlets42,43 highlights the difficulty in distinguishing between various types of DLBs and offers an example as to how one might do so. Whether the community of conspiracists who believe in and promote QAnon’s tenets represents a cult depends on how closely it adheres to the characteristics of a cult. Galanter identified some of the essential traits of a cult, including a consensual belief system, social cohesiveness, behavioral mores, a charismatic leader, and a transcendental goal.44 QAnon, however, lacks defined behavioral mores and belief in a transcendental goal. In terms of behavioral mores, QAnon theorists are spread internationally and rely on social media to communicate. The widespread network of believers, each with the ability to contribute to or interact with QAnon messaging at his or her frequency of choice, makes it difficult to establish coherent behavioral norms. Even if there were a set of behavioral mores, there would be no way for a central authority to enforce it. QAnon theorists differ from a cult also in terms of transcendent experiences and belief in a transcendental goal. Galanter noted that cults are “more specifically religious” (Ref. 45, p 543) than other charismatic groups with atypical beliefs. He indicated that transcendent experiences, including hallucinatory experiences in psychotic and nonpsychotic cult members, are instrumental in cult activities such as recruitment, conversion, and conflict resolution. Participation in QAnon, however, largely occurs via social media and does not involve such experiences. For example, joining QAnon entails opening a web browser and searching social media sites for relevant posts and like-minded individuals. There is no evidence that QAnon theorists seek to bring about transcendent experiences in believers. In addition, the QAnon conspiracy theory does not entail belief in a transcendental goal. Rather, the theory is fixated on comparatively banal topics related to human life on Earth, including the tweets of Donald Trump, Hillary Clinton’s e-mail history, wildfires, the COVID-19 pandemic, alleged child sexual abuse, and the 2020 United States presidential election.3,7,11,21,23,–,25 Though QAnon and its adherents are not a cult, its conspiracy theories have begun to merge with the preexisting DLBs of the sovereign citizen movement. Sovereign citizen beliefs have morphed since their inception in England in the 19th century, but common tenets include the United States’ rule via admiralty law; the creation of a corporate trust in a child’s name coinciding with the assignment of a social security number; and redemption by freeing oneself from the jurisdiction of the U.S. government. Because of their beliefs, sovereign citizens attempt to combat government interference in their lives by refusing to pay taxes and filing excessive pseudolegal documents in court.46 Recently some QAnon supporters used sovereign rhetoric to explain why Donald Trump will be President of the United States again.47 Specifically, QAnon adherents claimed in January 2021 that Joe Biden was inaugurated President of the corporation of the United States, but that Donald Trump would be inaugurated as President of the original republic on March 4, 2021.48 This crossover of sovereign beliefs into QAnon further demonstrates the malleability of the conspiracy theory and the difficulty of distinguishing between different DLBs, including similar types of DLBs. QAnon in Forensic Assessment The forensic evaluation of conspiracy theorists requires careful consideration of the differential diagnosis, the individual’s belief history, and cognitive and affective domains relating to his or her beliefs. These elements are summarized in Table 1, along with example questions. View inline Table 1. Important Considerations in Forensic Evaluation of QAnon and Other Conspiracy Theorists General Assessment Considerations The forensic psychiatrist should be aware of the broad range of etiologies of atypical beliefs, which may represent delusions, DLBs, or the product of pathological or subclinical personality traits. Formulating a proper psychiatric diagnosis is necessary to inform attorneys or the court regarding the presence or absence of mental illness, the potential impact of individuals’ beliefs on their engagement with the legal process, and their amenability to treatment. There are numerous practical recommendations that will assist the forensic psychiatrist in clarifying the diagnosis. An evaluator must obtain a belief history and identify the origin of an individual’s belief system. Depending on the mode of dissemination of conspiracy theories, believers should be able to describe their source. In the case of QAnon, adherents may identify social media platforms or outlets of disinformation as the origin of their knowledge. This is in contrast to other types of DLBs, such as those seen among cultists and the religious, who are likely to identify a community from which they obtained their faith.49 Individuals with delusions, on the other hand, may not be able to express the origin of their beliefs or describe evidentiary bases that are patently false or illogical.50 The forensic psychiatrist, then, should inquire as to how the evaluee first encountered content related to the conspiracy theory. Specifically, the evaluator should ask about forum sites, official and unofficial news sources, podcasts, YouTube channels, and chat groups to which the evaluee may belong. This information can help trace the origins of the person’s belief in conspiracy theories and the factors that led to an individual’s increased participation in them over time. After determining the origin of an evaluee’s beliefs, one can assess the individual’s continued interaction with the conspiracy theory. The evaluator should ask about the individual’s eventual acceptance of the conspiracy theory’s content and the frequency and intensity of interactions that the individual has had with relevant online or physical communities. This may involve meeting like-minded individuals, engaging in protests, or perpetrating criminal offenses. Behaviors may include posting online about conspiracy theories, sharing information with friends, attending rallies, threatening targets of conspiracy theories, or planning violence against perceived enemies. For all evaluees, but especially for those who are hesitant to disclose current belief in conspiracy theories, the evaluator should carefully review police reports and interviews conducted around the time of alleged offenses. For example, individuals may attribute their behaviors to conspiracy theorizing as a response to perceived persecution or wrongdoing.1 The use of collateral sources, including family members or friends, may also assist in clarifying individuals’ history of contact with conspiracy theory-related content and their degree of commitment to the theory. Conducting an evaluation of an individual who may believe in conspiracy theories and being able to discern conspiracy beliefs from delusion and other DLBs may require advanced preparation. The forensic psychiatrist should have a basic understanding of current conspiracy theories, fringe political ideologies, and common elements of the creeds of religious sects. Having a complete knowledge of such wide-ranging beliefs may be an unreasonable expectation, but evaluators should attempt to educate themselves as thoroughly as possible to enable facile communication with evaluees. Being able to recognize the individual’s statements as a component of a conspiracy theory (e.g., “Joe Biden molests and eats children.”) can prevent one from inaccurately identifying a subject as delusional. Evidence of psychopathology may also assist in differentiating between conspiracy theories, other DLBs, and mental illness. Of course, individuals with schizophrenia, mania, psychotic depression, Alzheimer’s disease, and other disorders in which delusions are present should demonstrate additional evidence of illness that clarifies the etiology of their beliefs. There are situations in which the distinction may be less clear, however, such as when one must discern between a conspiracy theory and a delusional disorder. In such cases, obtaining collateral information from family members or friends may assist in clarifying the history of the development of the individual’s belief system. For example, reports that subjects used social media and disinformation outlets or participated in online communities before developing their beliefs would argue against the presence of a delusional disorder. Identifying a community of like-minded individuals would also support the assessment that an individual is a conspiracy theorist rather than delusional. Of course, the evaluator should be aware that individuals with genuine mental illness may also believe in conspiracy theories, which may make distinguishing conspiracy theorizing from psychosis more complicated. The role of personality functioning and personality disorders is another area of consideration in the assessment of conspiracy theorists. Perhaps not surprisingly, paranoid ideation and schizotypy have been found to be related to individuals’ belief in conspiracy theories,51,52 though the relationship may simply be tautological as opposed to causal. Numerous studies have attempted to identify a relationship between belief in conspiracy theories and the “big five” personality factors of openness, conscientiousness, extraversion, agreeableness, and neuroticism. Initial reports suggested that theorists tend toward negative agreeableness (i.e., associated with antagonism and suspicion toward others) and positive openness to experience (i.e., associated with intellectual curiosity, active imagination, and amenability to new ideas).53,–,55 A recent meta-analytic study reported no significant relationship, however, when 74 effect sizes from 13 studies assessing such associations were aggregated.56 The distinction between DLBs and paranoid personality disorder, in particular, may pose a diagnostic challenge. Individuals with paranoid personality disorder, however, should demonstrate suspiciousness throughout adulthood in most interpersonal facets of life, as opposed to within circumscribed areas of belief, as one might expect with a QAnon theorist. One might expect an individual with paranoid personality disorder to be particularly susceptible to conspiracy theories. Indeed, conspiracy theories may co-present with genuine psychosis and personality disturbance. Evaluators should also consider the cognitive and affective functioning of the subject. As described further below, states of anger and paranoia are associated with individuals’ willingness to engage in destructive behavior in response to conspiracy theories.57 Additional research suggests that trait aggression may be associated with violent protest.58 Cognitive domains that warrant assessment include an individual’s conviction or degree of certainty regarding the conspiracy theory, preoccupation with the theory, the degree of self-reference experienced when thinking about the theory, and flexibility or willingness to revise beliefs in response to new information. One should also determine the extent to which evaluees experience justification of their behavior, including criminal and violent acts, due to their belief in the conspiracy theory. Competency to Stand Trial Evaluations QAnon theorists may claim that they are not beholden to the U.S. government or decry their criminal proceedings proceedings as falsified or a sham. Similarly, they may refuse to meet with an attorney or a consulting forensic expert for any number of seemingly strange reasons. As a result, the person’s fitness to stand trial may be questioned. In such cases the forensic psychiatrist will need to assess for the presence of any underlying mental illness and determine whether the disorder affects the individual’s ability to understand the criminal proceedings or to work with an attorney. If the individual will not meet for an assessment, collateral accounts of the individual’s beliefs, behaviors, and general functioning obtained from correctional mental health providers, the patient’s attorney, and collateral contacts from the community will likely clarify the presence or absence of a psychiatric disorder. If the concerns raised by the attorney or judge are found to be secondary to conspiracy theorizing, then any refusal to participate in legal proceedings would likely be considered volitional and fail to render the conspiracist incompetent to stand trial. Though there are no published studies on competency assessment in QAnon believers, Parker reviewed nine competency evaluations of sovereign citizens from the period of 2001 to 2012.59 One third of the evaluees refused to participate in a clinical interview. Two of the six who underwent assessment received diagnoses of psychiatric disorders, one of recurrent depression and one of delusional disorder. Only in the case of the evaluee with delusional disorder did Parker opine that a sovereign citizen was incompetent to stand trial. As he noted, “In retrospect, it is quite likely that this defendant did not truly meet criteria for a diagnosis of delusional disorder, in that his beliefs were not as unique as they appeared to be on first impression” (Ref. 59, p 346). This finding highlights the importance of forensic psychiatrists’ educating themselves about conspiracy theories and other DLBs, as failure to do so is likely to result in misdiagnosis and potential improper forensic determinations. Criminal Responsibility Evaluations Because QAnon and other conspiracy theories may appear strange or the product of a mental illness, attorneys may raise concern regarding the responsibility of defendants who commit criminal acts in service of their beliefs. Studies have demonstrated that efforts to claim insanity for behavior committed on the basis of DLBs are rarely successful, even when individuals involved receive schizophrenia spectrum diagnoses.49,60,61 QAnon conspiracy theorists should not expect their beliefs to assist in efforts to evade criminal responsibility for their actions. As described above, forensic psychiatrists charged with evaluating QAnon believers should exercise care to distinguish between an evaluee’s DLBs and the presence of a primary psychotic or mood disorder that may affect the evaluee’s legal and moral capacities, as defined in insanity statutes. It is in the assessment of criminal responsibility that concepts such as the extreme overvalued belief could generate confusion. Codifying extreme, violent behavior stemming from a delusion-like belief as a psychiatric symptom, as Rahman and colleagues propose,39,41 increases the risk of evaluators and the courts inappropriately labeling individuals without mental illness as insane. In contrast, some have advocated for the utility of dimensional approaches in the forensic assessment of criminal behavior perpetrated in the service of DLBs because defendants who hold DLBs are “often far from mentally healthy” (Ref. 34, p 331) and act on their beliefs in a manner similar to how psychotic individuals act on delusions.62 Though perhaps not as practical in determinations of sanity, which are binary decisions rendered by the court, evidence of conspiracy theorizing as a motivation could be presented as mitigating evidence. This raises the question of whether information related to an individual’s belief in conspiracy theories would cause a judge or jury to render harsher or lighter punishment against a defendant. Though determinations of guilt are ultimately the role of the court, defense attorneys may be more likely to request the services of a psychiatrist willing to state that an evaluee’s violent behavior occurred as a result of a purported psychiatric symptom such as an extreme overvalued belief, as opposed to an expert who can identify disturbances in an individual’s cognitive, affective, and personality functioning that may have contributed to the illegal behavior. Criminal Recidivism and Violence Risk Assessment The forensic evaluator may be asked to comment on a QAnon theorist’s risk for criminal recidivism or violence if released to the community. In its May 2019 report, the FBI specifically addressed the concern that conspiracy theorizing may directly motivate violent behavior. It noted:The FBI considered the alternative hypothesis that domestic extremists likely turn to violence only as a result of an underlying extremist ideology (such as militia extremism or white racially motivated violent extremism), whereas conspiracy beliefs held by such extremists do not play a role in their mobilization to violence. The FBI deemed this alternative to be less likely because these conspiracy beliefs have motivated, at least in part, several high profile violent acts, or have influenced the perpetrators—to the extent that they attributed their actions to their conspiratorial beliefs before or after their arrests (Ref. 1, p 5). In addition to the cases of Edgar Welch and Matthew Wright described earlier, there have been other notable cases of QAnon-related violent behavior. On March 13, 2019, Anthony Comello, a 24-year-old from Staten Island, allegedly shot and killed Mafia leader Francesco Cali.63 Mr. Comello’s lawyer stated that the defendant did not drive to Mr. Cali’s house intending to kill him, but to perform a citizen’s arrest because he believed Mr. Cali was a member of the deep state. Mr. Comello reportedly shot Mr. Cali for resisting the arrest and believed that he was Trump’s chosen vigilante. Similarly, Jessica Prim, a 37-year-old from Peoria, Illinois, was arrested on April 29, 2020, in New York City after driving onto a pier with a car full of knives after livestreaming her journey across the country.63 In the livestream Ms. Prim threatened to kill Joe Biden for his involvement in deep state sex trafficking. Review of her Facebook account indicated that she likely first came into contact with QAnon content on April 9, 2020, just 20 days prior to her arrest. These cases highlight the importance of assessing a subject’s history of interaction with specific conspiracy theories, including initial contact and subsequent commitment to them. There is limited empirical research on risk factors for criminal and violent behavior in conspiracy theorists, but some evidence supports the FBI’s claim. Surveying 253 participants in the United Kingdom regarding conspiracy thinking, personality traits, and intention to engage in criminal behavior, Jolley and colleagues reported that conspiracy theorizing itself predicts an increased tendency to engage in everyday crime or crimes that everybody is likely to commit at some point in life, such as running a red light or failing to report faults in second-hand items for sale.64 In an experimental condition involving 120 subjects, 60 of whom read a conspiracy-related article, the authors noted that exposure to conspiracy theories increased subjects’ feelings of anomie (i.e., general unrest and dissatisfaction), which in turn increased their intention to engage in everyday crime in the future. In a follow-up survey of 601 individuals in the United Kingdom assessing conspiracy beliefs pertaining to 5G and the spread of COVID-19, Jolley and colleagues found that belief in 5G COVID-19 conspiracy theories was significantly and positively correlated with participants’ justification of and willingness to commit violence.57 Present state anger was a significant mediator between the belief in the 5G COVID-19 conspiracy theory and violence variables and was strongest for those who reported being more paranoid. These findings suggest that conspiracy theorizing, anger, and paranoia all represent independent risk factors for violent behavior in believers of such theories. There are no actuarial or structured professional judgment tools specifically designed to assess violence risk in conspiracy theorists. Recently, however, Challacombe and Lucas conducted a study assessing the ability of the Terrorist Radicalization Assessment Protocol (TRAP-18), a structured professional judgment tool used to understand and potentially predict acts of terrorism, to discriminate between violent and nonviolent criminal acts committed by sovereign citizens.65 Comparing 30 individuals or groups that planned or committed violent or dangerous actions and 28 individuals that committed nonviolent criminal acts, they found that four proximal warning behaviors (having a pathway to violence, self-identification as a fighter, communication to outside party of violent incident, and viewing one’s action as a last resort) and four distal warning behaviors (thwarting of occupational goals, being motivated by an ideology, personal grievance, and past criminal violence) were all associated with violent incidents. They also found that two proximal warning behaviors (novel aggression unrelated to the target and increased frequency or variety of behaviors related to the target leading up to the incident) were negatively associated with violent incidents. More research is needed to determine the utility of this structured instrument in predicting violence by domestic terrorists and conspiracy theorists, though these variables are certainly worth considering in the evaluation of a QAnon believer. Conclusion Since its birth from the Pizzagate conspiracy theory in October 2017, QAnon has rapidly expanded across the United States and beyond. Social media have enabled the formation of online communities of conspiracy theorists, some of whom go on to engage in violent or criminal behavior, resulting in QAnon’s labeling as an extremist organization or cult. A careful assessment of an individual’s belief history and mental status can help to clarify whether an individual is laboring under the belief in conspiracy theories, religious ideology or other DLBs, a mental illness, or some combination thereof. Such distinctions may be relevant when answering forensic questions for the court. Conspiracy theorists’ criminal behavior should not be surprising to psychiatrists, who often work with patients who engage in aggression or violence that may seem rational in the context of delusions. If one truly believes that an elite, global cabal of pedophiles is systematically carrying out child sexual abuse, then traveling across state lines to a pizza parlor to stop the abuse would likely seem virtuous and heroic to the person taking a stand. Though such a scenario may seem preposterous to an outsider, it raises the question of ultimate culpability. Individuals’ differential propensities for conspiracy thinking likely stem from factors beyond their control, such as genetic effects on personality and social milieu. Social media platforms, insouciant politicians and celebrities, and nihilistic online trolls may all play a role in the popularization and perpetuation of conspiracy theories; however, their effects are felt much more acutely in the minds of the susceptible and the growing rents in the social fabric. Footnotes Disclosures of financial or other potential conflicts of interest: None. © 2022 American Academy of Psychiatry and the Law References 1.↵Federal Bureau of Investigation. (U//LES) Anti-government, identity based, and fringe political conspiracy theories very likely motivate some domestic extremists to commit criminal, sometimes violent activity [Internet]. 2019 May 30. Available from: https://publicintelligence.net/fbi-consiracy-theory-domestic-extremism. 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