Exploitation of Individuals With Psychosis

TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From The Clinic: The Art of Psychiatry, the team tackles exploitation of individuals with psychosis. While this is clinically recognized facet and sequelae of being vulnerable, there is surprisingly little literature, evidence base, or policy to guide clinicians when they encounter such cases.

Case 1

“Monica,” a 30-year-old woman with schizophrenia and suspected intellectual developmental disability (IDD), was hospitalized for acute psychosis after several weeks of increased distress and perceptual disturbances. Her decompensation was preceded by frequent online communication with a medium, through whom she sought guidance about persistent delusional guilt related to a boyfriend who had died several years earlier. Monica reported hearing spirits and was utilizing the medium to communicate with them. On discussion with the family, it was determined that this medium had been in touch with Monica for years, had pressured her to maintain their relationship, and had solicited money from her. Shortly before hospitalization the family encouraged her to cut ties with this medium, but Monica became resentful towards them and perceived them as dismissive and controlling.

During hospitalization, when clinicians raised concern about fraud, she became angry and mistrustful. The rupture of contact, combined with family conflict and pressure from the medium, was a trigger for worsening psychosis.

Case 2

“Collin,”a 43-year-old man with schizophrenia, presented with a persistent preoccupation with money-making schemes. He expressed strong desire for financial independence and described recurrent conflict with family members who restricted his spending due to concerns about alcohol and cannabis use. During outpatient visits, he received assistance applying for employment; however, he remained focused on multiple “get rich quick” and crypto-related scams accessed via smartphone apps and messaging platforms. As a result, he missed opportunities for actual employment.

Collin repeatedly complained that he had spent hours completing “work” through apps without receiving pay, and he sometimes stepped out of therapy sessions to check accounts or take calls related to these schemes. Over time, scam-related content was incorporated into his delusions (such as beliefs that he was being intentionally blocked from payment, or that he was now wealthy).

Discussion

According to the World Health Organization (WHO), about 0.29% of the world’s population—or 1 in 345 individuals—live with schizophrenia.¹ They, like other vulnerable populations, face an increased risk of exploitation and victimization—up to 4 to 6 times greater risk than the general population. These crimes include those of violent, sexual, and nonviolent/property offense natures.² A systematic review and meta-analysis of 35 studies done in 2018 showed that approximately 1 in 5 adults with a psychotic disorder were victimized in a 1-year period.³

Thus far, literature around the financial exploitation of individuals with schizophrenia has centered around discussions around financial capacity, as they often inappropriately manage spending and are prone to fraud.⁴ There are also case reports of erotomanic symptoms elicited by romantic deception.^5-7

Individuals with schizophrenia are vulnerable for several reasons. Their condition includes social/cognitive deficits, cognitive impairment, and issues with emotional perception.^8,9 Studies have demonstrated deficits with processing speed, attention, working memory, episodic memory, language, and executive functions.¹⁰

The rapid evolution of technology in recent decades and the dependence on internet has lead to significant sophistication in the methods utilized for fraud and deception. Internet dependence can be characterized by society largely relying on the internet for socialization, commerce, employment, and hobby engagement.¹¹ It is well known that internet addiction is also pervasive, built on mechanisms that capture human attention and engagement.¹² The US Federal Trade Commission reported a significant increase in consumer fraud losses in 2023, averaging around $12.5 billion. Romance and investment scams, including crypto-based scams, were the most costly contributors to this number. With the pervasiveness of artificial intelligence (AI) in recent years, deepfake-impersonations have also become a new threat in convincingly scamming others.

There is limited evidence that examines victimization in individuals with schizophrenia in today’s technological and digitized society. Exploring the available evidence will help clinicians to understand patient risk, ways to intervene or prevent scams, and find opportunities to advocate for policy changes to protect the vulnerable.

The Brief History of Fraud and Exploitation

Before widespread internet access, fraud was primarily offline and could follow predictable patterns, such as deception in interpersonal relationships, theft, and exploitation tied to disability benefits. People with severe mental illness are disproportionately affected given higher rates of poverty, unemployment, substance use, and social isolation, as well as cognitive deficits.² Deinstitutionalization beginning in the mid-20th century further reduced support for vulnerable people.

The internet became more accessible around 2010, and was dominated by social media and romance baiting, including within dating apps and catfishing. Catfishing is a scam in which someone presents as someone they are not, often using stolen photos or a stolen identity. Initially, scams were closer to phishing or fake auctions. Later on, cybercrime became more sophisticated, using social media to create trusting relationships that eventually lead to the transfer of money.¹¹

Around 2023, AI and crypto exploded onto the technological scene. Scams include “pig-butchering” (fraud that combines romance, investment fraud, and social engineering to exploit victims), deep-fake or voice cloning, instant-payment push rails (where recovery of money is nearly impossible due to the speed at which scammers move), and long-term grooming via social media platforms.¹³ Deepfake or AI voice cloning is particularly troublesome as it can use seconds of audio to mimic a family member, creating a “relative in distress” situation. It can also superimpose words on videos of others speaking. Another fraud is that of fake remote jobs, such as crypto-mining, refund processing or wallet verification. In these jobs, a victim is required to pay fees or provide personal information to get “employed.” These jobs attract vulnerable populations, including those with schizophrenia, who are trying to find anything that gives them a sense of financial security or autonomy.¹⁴

Sophisticated algorithms or spam messaging used by websites and apps further exploit those that interact with their systems through repeating the person’s exposure to said scams through “digital reinforcement,” especially once a person interacts with it. These scams can be difficult for the average person to identify, as they are quite targeted in their exploitation of cognitive vulnerabilities and social engineering. They can give off a sense of urgency and promise money fast, creating a high-risk environment that can draw in someone struggling with impulse, not unlike how other addictive habits, such as gambling.¹² They are significantly more difficult for a person with psychosis to identify, particularly if they are in an isolated or decompensated (delusions, grandiosity, paranoia) position or are struggling with impulsive or executive dysfunction.¹² Digital reinforcement further makes it difficult for them to protect themselves.

Another important consideration is the after-effects of a vulnerable person falling victim to a scam. If they can recognize the scam, which is not always the case, they will often experience associated shame, guilt, distress and anxiety, compounded by family which may also put pressure on them. If the person does not recognize the scam, confrontation by family or staff can feel invalidating, controlling, or persecutory, especially in the context of paranoid ideation. Family pressure around restricting devices or finances may further intensify conflict, particularly when autonomy is already a sensitive topic.⁴ Collectively, these dynamics can precipitate decompensation, reduce engagement in treatment, and increase risk of hospitalization.

A Clinical Lens

As previously mentioned, cognitive deficits in attention, working memory, and executive functioning may reduce the ability of people with schizophrenia or psychosis to evaluate claims, ignore urgency, track inconsistencies or assess intent.^8-10

The case studies listed above demonstrate how online exploitation can become clinically correlated with psychosis. In case 1, a “medium” validated delusions and delusional guilt, and increased dependence for the patient. Reality testing became a point of conflict. In case 2, scam engagement competed with treatment and further validated delusions and disorganized thought patterns. Scam narratives were incorporated into the patients’ thought processes, furthering impairment.

A recurring and unfortunate theme in psychotic disorders is loneliness and the desire for reintegration. When a person remains chronically undertreated for prolonged periods of time with intermittent decompensation, they tend to lose social connections and further find it difficult to return to a baseline where they can re-engage in safe, meaningful relationships, until they receive appropriate treatment. A meta-analysis from this year highlights the loneliness epidemic within this population.¹⁵ People with schizophrenia are often exploited by strangers or acquaintances. The apparent benefit of engaging in questionable relationships can appear more appealing to them than to someone without a psychosis. Scammers offer consistent contact, validation and compete with real-world supports and people are susceptible to attempts to form relationships or gain status through the acquisition or of money.^4,15 Unfortunately, these interactions move them further from their goals of forming social connections.

Clinical Implications

Online exploitation of people with psychosis is related to the interaction of several factors, including individualized, specific factors, the digital environment that they are exposed to, and the specific scam they are victim to. Amplified harm, clinical sequelae and intervention points, and the ultimate results can be seen in the Figure.

Practical Tips for Clinicians

There are several ways that clinicians can intervene to protect patients with psychotic disorders from online fraud. The simplest method is to include questions related to fraud as a part of a patient’s initial intake interview, and periodically throughout follow-up visits. Basic screening questions include asking if anyone has asked the patient for money, crypto, gift cards, or fees for jobs. It is also helpful to ask if the patient is in a relationship, the nature of said relationship, and whether the patient has been requested to keep the relationship secret or not. An important follow-up question is to inquire regarding whether the patient has ever met the individual in person or not.

Identifying reliable and safe contacts for a patient to seek counsel from, or have additional monitoring from, can also be useful. It is important to work carefully with family, so that patients do not feel they are losing autonomy. In the case of a scam, patients and their trusted family/friends can assist with trying to minimize financial losses, and involve adult protective services, if appropriate. They can also assist the patient in enrolling in financial education classes, which are often offered at local community centers/colleges, as well as online.

As online fraud can become part of a delusion, it is important to address involvement in fraudulent schemes in a compassionate manner, such as validating patient distress without direct or abrasive confrontation.

Concluding Thoughts

Technology-facilitated exploitation is increasingly sophisticated and can intersect with psychosis in clinically meaningful ways. The 2 cases presented here illustrate how online scams may validate delusional content, capture attention through reinforcement, disrupt treatment, provoke family conflict around autonomy, and contribute to acute decompensation. A structured clinical approach with screening, psychoeducation, collaborative safety planning, autonomy-preserving family involvement, and coordinated support, may reduce harm. Greater research is needed to characterize prevalence, risk factors, and effective interventions for digital victimization among individuals with psychotic disorders in recent online environments.

Dr Isa is a 4th year psychiatry resident at Baylor College of Medicine.

Dr Moukaddam is a professor of psychiatry in the Department of Psychiatry at Baylor College of Medicine and the director of outpatient psychiatry at Harris Health. She also serves on the Psychiatric Times Editorial Board.

Dr Wojcik is an assistant professor of psychology at Baylor College of Medicine, an associate training director for BCM Psychology Internship, and program director for the Support, Treatment, and Rehabilitation (S.T.A.R.) Program at Harris Health.

References

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11. Nurse JRC. Cybercrime and you: how criminals attack and the human factors that they seek to exploit. arXiv preprint. 2018. Accessed August 17, 2026. https://arxiv.org/abs/1811.06624

12. Consumer Reports’ assessment of AI voice-cloning products. Consumer Reports. March 10, 2025. Accessed August 17, 2026. https://www.consumerreports.org/media-room/press-releases/2025/03/consumer-reports-assessment-of-ai-voice-cloning-products/

13. Oak R, Shafiq Z. “Hello, is this Anna?”: a first look at pig-butchering scams. arXiv preprint. 2025. Accessed August 17, 2026. https://arxiv.org/html/2503.20821v1

14. Holkar M, Lees C. Caught in the web: financial scams, mental health and vulnerability. Money and Mental Health Policy Institute. 2020. Accessed August 17, 2026. https://www.moneyandmentalhealth.org/wp-content/uploads/2020/12/Caught-in-the-web-full-report.pdf

15. Hajek A, Gyasi RM, Pengpid S, et al. Prevalence of loneliness and social isolation amongst individuals with severe mental disorders: a systematic review and meta-analysis. Epidemiol Psychiatr Sci. 2025;34:e25.