Delusion

A delusion is a belief that is held with strong conviction despite superior evidence to the contrary. As a pathology, it is distinct from a belief based on false or incomplete information, confabulation, dogma, illusion, or other effects of perception.

Delusions typically occur in the context of neurological or psychiatric disease, although they are not tied to any particular disorder and have been found to occur in the context of many pathological states (both physical and mental). However, they are of particular diagnostic importance in psychotic disorders including schizophrenia, paraphrenia, manic episodes of bipolar disorder, and psychotic depression.

Definition

Although non-specific concepts of madness have been around for several thousand years, the psychiatrist and philosopher Karl Jaspers was the first to define the three main criteria for a belief to be considered delusional in his 1913 book General Psychopathology.^[1] These criteria are:

• certainty (held with absolute conviction)
• incorrigibility (not changeable by compelling counterargument or proof to the contrary)
• impossibility or falsity of content (implausible, bizarre, or patently untrue)^[2]

Furthermore, when a false belief involves a value judgment, it is only considered a delusion if it is so extreme that it cannot be, or never can be proven true. For example: a man claiming that he flew into the sun and flew back home. This would be considered a delusion,^[3] unless he were speaking figuratively, or if the belief had a cultural or religious source.

Causes

Explaining the causes of delusions continues to be challenging and several theories have been developed. One is the genetic or biological theory, which states that close relatives of people with delusional disorder are at increased risk of delusional traits. Another theory is the dysfunctional cognitive processing, which states that delusions may arise from distorted ways people have of explaining life to themselves. A third theory is called motivated or defensive delusions. This one states that some of those persons who are predisposed might suffer the onset of delusional disorder in those moments when coping with life and maintaining high self-esteem becomes a significant challenge. In this case, the person views others as the cause of their personal difficulties in order to preserve a positive self-view.^[4]

This condition is more common among people who have poor hearing or sight. Also, ongoing stressors have been associated with a higher possibility of developing delusions. Examples of such stressors are immigration, low socio-economic status, and even daily hassles.^[5]

Specific delusions

The top two factors mainly concerned in the germination of delusions are: 1. Disorder of brain functioning; and 2. background influences of temperament and personality.^[6]

Higher levels of dopamine qualify as a symptom of disorders of brain function. That they are needed to sustain certain delusions was examined by a preliminary study on delusional disorder (a psychotic syndrome) instigated to clarify if schizophrenia had a dopamine psychosis.^[7] There were positive results - delusions of jealousy and persecution had different levels of dopamine metabolite HVA and homovanillyl alcohol (which may have been genetic). These can be only regarded as tentative results; the study called for future research with a larger population.

It is too simplistic to say that a certain measure of dopamine will bring about a specific delusion. Studies show age^[8][9] and gender to be influential and it is most likely that HVA levels change during the life course of some syndromes.^[10]

On the influence personality, it has been said: "Jaspers considered there is a subtle change in personality due to the illness itself; and this creates the condition for the development of the delusional atmosphere in which the delusional intuition arises."^[11]

Cultural factors have "a decisive influence in shaping delusions".^[12] For example, delusions of guilt and punishment are frequent in a Western, Christian country like Austria, but not in Pakistan - where it is more likely persecution.^[13] Similarly, in a series of case studies, delusions of guilt and punishment were found in Austrian patients with Parkinson's being treated with l-dopa - a dopamine agonist.^[14]

Types

Delusions are categorized into four different groups:

• Bizarre delusion: Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences.^[15] An example named by the DSM-5 is a belief that someone replaced all of one's internal organs with someone else's without leaving a scar.
• Non-bizarre delusion: A delusion that, though false, is at least possible, e.g., the affected person mistakenly believes that he is under constant police surveillance.
• Mood-congruent delusion: Any delusion with content consistent with either a depressive or manic state, e.g., a depressed person believes that news anchors on television highly disapprove of him, or a person in a manic state might believe she is a powerful deity.
• Mood-neutral delusion: A delusion that does not relate to the sufferer's emotional state; for example, a belief that an extra limb is growing out of the back of one's head is neutral to either depression or mania.^[16]

Themes

In addition to these categories, delusions often manifest according to a consistent theme. Although delusions can have any theme, certain themes are more common. Some of the more common delusion themes are:

• Delusion of control: False belief that another person, group of people, or external force controls one's general thoughts, feelings, impulses, or behavior.^[16]
• Cotard delusion: False belief that one does not exist or has died.^[17]
• Delusional jealousy: False belief that a spouse or lover is having an affair, with no proof to back up their claim.^[16]
• Delusion of guilt or sin (or delusion of self-accusation): Ungrounded feeling of remorse or guilt of delusional intensity.^[16]
• Delusion of mind being read: False belief that other people can know one's thoughts.^[16]
• Delusion of thought insertion: Belief that another thinks through the mind of the person.^[16]
• Delusion of reference: False belief that insignificant remarks, events, or objects in one's environment have personal meaning or significance.^[16]
• Erotomania: False belief that another person is in love with them.^[16]
• Grandiose religious delusion: Belief that the affected person is a god or chosen to act as a god.^[18][19]
• Somatic delusion: Delusion whose content pertains to bodily functioning, bodily sensations or physical appearance. Usually the false belief is that the body is somehow diseased, abnormal or changed.^[16] A specific example of this delusion is delusional parasitosis: Delusion in which one feels infested with insects, bacteria, mites, spiders, lice, fleas, worms, or other organisms. Affected individuals may also report being repeatedly bitten. In some cases, entomologists are asked to investigate cases of mysterious bites. Sometimes physical manifestations may occur including skin lesions.^[20]
• Delusion of poverty: Person strongly believes they are financially incapacitated. Although this type of delusion is less common now, it was particularly widespread in the days preceding state support.^[21]

Grandiose delusions or delusions of grandeur are principally a subtype of delusional disorder but could possibly feature as a symptom of schizophrenia and manic episodes of bipolar disorder.^[22] Grandiose delusions are characterized by fantastical beliefs that one is famous, omnipotent or otherwise very powerful. The delusions are generally fantastic, often with a supernatural, science-fictional, or religious bent. In colloquial usage, one who overestimates one's own abilities, talents, stature or situation is sometimes said to have "delusions of grandeur". This is generally due to excessive pride, rather than any actual delusions. Grandiose delusions or delusions of grandeur can also be associated with megalomania.

Persecutory delusions

Persecutory delusions are the most common type of delusions and involve the theme of being followed, harassed, cheated, poisoned or drugged, conspired against, spied on, attacked, or otherwise obstructed in the pursuit of goals. Persecutory delusions are a condition in which the affected person wrongly believes that they are being persecuted. Specifically, they have been defined as containing three central elements:^[23] The individual thinks that:

1. harm is occurring, or is going to occur.
2. the persecutor(s) has(have) the intention to cause harm.
3. they are constantly being prejudged or profiled.

According to the DSM-IV-TR, persecutory delusions are the most common form of delusions in schizophrenia, where the person believes they are "being tormented, followed, sabotaged, tricked, spied on, or ridiculed."^[24] In the DSM-IV-TR, persecutory delusions are the main feature of the persecutory type of delusional disorder. When the focus is to remedy some injustice by legal action, they are sometimes called "querulous paranoia".^[25]

Diagnosis

John Haslam illustrated this picture of a machine described by James Tilly Matthews called an "air loom," which Matthews believed was being used to torture him and others for political purposes.

The modern definition and Jaspers' original criteria have been criticised, as counter-examples can be shown for every defining feature.

Studies on psychiatric patients show that delusions vary in intensity and conviction over time, which suggests that certainty and incorrigibility are not necessary components of a delusional belief.^[26]

Delusions do not necessarily have to be false or 'incorrect inferences about external reality'.^[27] Some religious or spiritual beliefs by their nature may not be falsifiable, and hence cannot be described as false or incorrect, no matter whether the person holding these beliefs was diagnosed as delusional or not.^[28]

In other situations the delusion may turn out to be true belief.^[29] For example, in delusional jealousy, where a person believes that their partner is being unfaithful (and may even follow them into the bathroom believing them to be seeing their lover even during the briefest of partings), it may actually be true that the partner is having sexual relations with another person. In this case, the delusion does not cease to be a delusion because the content later turns out to be verified as true or the partner actually chose to engage in the behavior of which they were being accused.

In other cases, the delusion may be assumed to be false by a doctor or psychiatrist assessing the belief, because it seems to be unlikely, bizarre or held with excessive conviction. Psychiatrists rarely have the time or resources to check the validity of a person’s claims leading to some true beliefs to be erroneously classified as delusional.^[30] This is known as the Martha Mitchell effect, after the wife of the attorney general who alleged that illegal activity was taking place in the White House. At the time, her claims were thought to be signs of mental illness, and only after the Watergate scandal broke was she proved right (and hence sane).

Similar factors have led to criticisms of Jaspers' definition of true delusions as being ultimately 'un-understandable'. Critics (such as R. D. Laing) have argued that this leads to the diagnosis of delusions being based on the subjective understanding of a particular psychiatrist, who may not have access to all the information that might make a belief otherwise interpretable. R. D. Laing's hypothesis has been applied to some forms of projective therapy to "fix" a delusional system so that it cannot be altered by the patient. Psychiatric researchers at Yale University, Ohio State University and the Community Mental Health Center of Middle Georgia have used novels and motion picture films as the focus. Texts, plots and cinematography are discussed and the delusions approached tangentially.^[31] This use of fiction to decrease the malleability of a delusion was employed in a joint project by science-fiction author Philip Jose Farmer and Yale psychiatrist A. James Giannini. They wrote the novel Red Orc's Rage, which, recursively, deals with delusional adolescents who are treated with a form of projective therapy. In this novel's fictional setting other novels written by Farmer are discussed and the characters are symbolically integrated into the delusions of fictional patients. This particular novel was then applied to real-life clinical settings.^[32]

Another difficulty with the diagnosis of delusions is that almost all of these features can be found in "normal" beliefs. Many religious beliefs hold exactly the same features, yet are not universally considered delusional. These factors have led the psychiatrist Anthony David to note that "there is no acceptable (rather than accepted) definition of a delusion."^[33] In practice, psychiatrists tend to diagnose a belief as delusional if it is either patently bizarre, causing significant distress, or excessively pre-occupying the patient, especially if the person is subsequently unswayed in belief by counter-evidence or reasonable arguments.

It is important to distinguish true delusions from other symptoms such as anxiety, fear, or paranoia. To diagnose delusions a mental state examination may be used. This test includes appearance, mood, affect, behavior, rate and continuity of speech, evidence of hallucinations or abnormal beliefs, thought content, orientation to time, place and person, attention and concentration, insight and judgment, as well as short-term memory.^[34]

Johnson-Laird suggests that delusions may be viewed as the natural consequence of failure to distinguish conceptual relevance. That is, the person takes irrelevant information and puts it in the form of disconnected experiences, then it is taken to be relevant in a manner that suggests false causal connections. Furthermore, the person takes the relevant information, in the form of counterexamples, and ignores it.^[35]

Treatment

Psychotherapies that may be helpful in delusional disorder include individual psychotherapy, cognitive-behavioral therapy (CBT) and family therapy.

See also

References

Cited text

• Jaspers, Karl (1997). General Psychopathology. 1. Baltimore: Johns Hopkins University Press. ISBN 0-8018-5775-9. 

Further reading

• Arnold, K.; Vakhrusheva, J. (2015). "Resist the negation reflex: Minimizing reactance in psychotherapy of delusions" (PDF). Psychosis. doi:10.1080/17522439.2015.1095229. 
• Bell V, Halligan PW, Ellis H (2003). "Beliefs about delusions" (PDF). The Psychologist. 16 (8): 418–423. 
• Blackwood, Nigel J.; Howard, Robert J.; Bentall, Richard P.; Murray, Robin M. (April 2001). "Cognitive Neuropsychiatric Models of Persecutory Delusions". American Journal of Psychiatry. 158 (4): 527–539. doi:10.1176/appi.ajp.158.4.527. PMID 11282685. 
• Coltheart M.; Davies M., eds. (2000). Pathologies of belief. Oxford: Blackwell. ISBN 0-631-22136-0. 
• Persaud, R. (2003). From the Edge of the Couch: Bizarre Psychiatric Cases and What They Teach Us About Ourselves. Bantam. ISBN 0-553-81346-3.