Saturday, 20 December 2008

what are delusions?

Having been too busy to publish blog posts, I thought I'd cheat and post some draft versions of what I've been working on recently. In this post an encyclopedia entry on 'delusion'.

Delusion

1. Introduction


Delusions are often described in textbooks as being defined, since Karl Jaspers, as false, subculturally atypical beliefs, strongly maintained in the face of counterargument. Yet such definitions fail to capture either the rich diversity or key features of delusion, and would -were it not for their prevalence - be in danger of meeting their own desiderata.

Common delusions include persecution (there is a plot or conspiracy against the subject; these are the most common delusional beliefs); grandiosity (the subject is an important personage); erotomania (the subject delusionally believes someone is deeply in love with them); and control (the belief that one’s actions, thoughts or feelings are being controlled by others). The majority of delusions concern the subject’s position in the social world, or reflect central existential issues in their lives, and they are indeed often false, atypical and strongly maintained.

It is however possible that a delusion (such as that of one’s partner being unfaithful) be accidentally true. Levels of conviction in delusions may also vary with time. Some delusions may be paradoxically true rather than false (e.g. the delusion that one is mental ill), and others may be not beliefs but rather delusional value judgements, thoughts, perceptions, memories, inner experiences and moods (Sims, 2003). The ‘delusionality’ of delusions of control, for example, arises directly from a disturbed experience of one’s own agency, rather than with beliefs about such experiences.

As Jaspers himself reported, to ‘say simply that a delusion is a mistaken idea which is firmly held by the patient and which cannot be corrected gives only a superficial and incorrect answer’ (Jaspers, 1913/1997, p. 93). Delusions rather reflect a fundamental disturbance in our relation to reality and the integrity of the self which is hard to pinpoint in a definition. Jaspers distinguished between primary delusions – which arise in an ultimately 'un-understandable' way in our contact with reality itself – and secondary delusions, which are intelligible attempts to understand baffling experiences. Whilst Jaspers’ doctrine of the un-understandability of primary delusions has often been criticised, it is important to recognise that his point is not to preclude a reflective understanding of what the deluded person says, what psychodynamics underpin it, what symbolism it expresses, etc. It is rather that we always fall short of inhabiting such beliefs or experiences from a first-person perspective.

2. Psychoanalytic Perspectives

Sigmund Freud described delusions as ‘applied like a patch over the place where originally a rent had appeared in the ego’s relation to the external world’ (Freud, 1924/1981, p. 215). He distinguished between neurotic and psychotic conditions as follows. In the neuroses the subject attempts to adapt to an incompatible reality by defending against their own feelings. The symptoms which result are the product of the internal conflicts within the patient when they try to remodel their desire. In the psychoses, by contrast, the subject attempts to solve their conflicts with reality not by altering their feelings, but by withdrawing from or ‘disavowing’ reality and replacing it instead with fantasies which are treated as realities.

In the 1960s the psychiatrist Thomas Freeman extended the psychoanalytic understanding of delusion (Freeman, Cameron & McGhie, 1966). Whilst some delusions can be understood as fantasised replacements for lost relationships, others consist of misinterpretations of experiences with others from whom the subject has not become completely detached. Accordingly the delusional subject attempt to bend or exaggerate reality to make it more tolerable and less threatening of the subject’s sense of himself or herself, rather than completely substitute for it, and the delusions are the outcome of such defensive manoeuvres.

More recent psychoanalytical thinking on psychosis has been organised, not around the concept of delusion, but rather by attempts to understand the nature of omnipotent fantasy, including the mental mechanisms of splitting, projection and projective identification, minus K, attacks on linking, and symbolic condensation. All of these processes may be implicated in the formation of delusion, but none are specific to it.

3. Phenomenological Perspectives

Phenomenology aims to elucidate the lived, non-reflective and immersed experience of being a self in relation to a meaningful environment including other selves. Accordingly, the phenomenological understanding of delusion – in particular of schizophrenic delusion – views what is specific to it as already contained in germ in a specific pre-delusional disturbance of immersed participation. More specifically, most phenomenological psychiatrists track this disturbance back to fragile temporal and corporeal processes which underpin the constitution of the self. Phenomenologists view the delimitation of self from other as arising out of an organism’s non-reflective interactions with its social and physical environment. Disturbances of that process result in disturbances in the boundary between self and world, and delusional beliefs and experiences carry this fundamental disturbance in reality contact inscribed within them.

Most phenomenological accounts take their lead from the first two stages of Klaus Conrad’s (1958) developmental account of delusion in paranoid schizophrenia. In the initial pre-delusional ‘trema’ stage, the subject starts to vaguely feel that all is not well with himself and/or the world. He may complain of an unspecific groundlessness, confusion about or lack of a sense of his own identity, diminished sense of aliveness, and lost automatic connection with reality. The body may become experienced as an object rather than as a living subject, self and other may start to become confused, the objective character of reality may be lost, and the delusional experience of reference – a sense that everything seen has been constructed for the sake of the subject – may begin (Parnas & Sass, 2001).

In Conrad’s second stage – ‘apophany’ – delusions proper arrive. Now the trema is intuitively resolved into one particular revelatory meaning, and the subject takes themselves to now ‘understand’ what had previously only been confusingly signalled. Relief is experienced from the diffuse tension and terror of the trema, and a monothematic reflective grasp of what is happening (e.g. there is a government plot against me) takes the place of the pre-reflective but destabilised grasp (‘something is up’) the subject had on their situation.

4. Cognitive Science Perspectives

Unlike psychoanalytical and phenomenological theories, cognitive psychological theories are driven by a psychological understanding of the human being as constantly and actively attempting to interpret, or make reflective sense of, their personal situation. Thus Brendan Maher (1974) suggested that delusional beliefs represent rational attempts to make sense of abnormal experiences (e.g. hallucinations or passivity experiences). Phillipa Garety by contrast has suggested that abnormal processes of reflective sense-making may be implicated in delusion formation (Garety & Freeman, 1999). She found, for example, that patients with delusions tend to jump to conclusions on the basis of surprisingly little evidence.

Several difficulties confront such cognitive psychological accounts. First, delusions – especially primary delusions – do not present themselves as active interpretative products, but rather as spontaneous and passive revelations in thought, feeling, or perception. Even the delusional ‘explanations’ that patients offer appear to be more post-hoc rationalisation than genuine justification. Second, Garety also found that the hasty reasoning style of delusional patients makes them equally likely to quickly give up their beliefs, which makes it hard to understand the typical intransigence of the delusional subject. It is also important to recognise that the explanatory task, in understanding delusional intransigence, is not merely how unshakeable beliefs arise, but how unshakeable beliefs with the face-value implausibility of delusions could arise. Finally, Maher’s theory does not explain why the patient fails to accept the obvious explanation that they are hallucinating or experiencing passivity experiences.

Cognitive neuropsychological – as opposed to cognitive psychological – perspectives, are typically not governed by an understanding of the individual as an active reflective sense-maker, and so are not restricted to theorising delusion in such terms. Hemsley (2005) provides a good example with his speculative model of schizophrenia as due to a deficiency in the influence of background context on current task performance. The model ties together the neurological (e.g. frontotemporal functional disconnections), the information processing (e.g. sensory and motor program disturbances), and the psychological (a range of symptoms including delusional beliefs and experiences) levels of explanation.

Primary delusions are accordingly theorised by Hemsley as due to a mismatch between tacit and automatically deployed frames of reference and the sensory inputs to which they are applied. Delusional experience in the trema is also understood as due to a breakdown in gestalt or context perception. Decontextualised stimuli, including those normally screened out as irrelevant, may appear equally salient – and secondary delusional beliefs may reflect a search for the meaning of stimuli which would not normally have come to conscious attention. Hemsley speculates, for example, that delusional thinking about causal relationships may result from a failure of context to constrain judgements about the relevance of the co-occurrence of stimuli.

5. Conclusion

Future work on delusion will need to weave together the above approaches. From epistemology we require adequate understandings of what it is that grounds our relation to reality (e.g. reflective thought, or bodily praxis), and what it is to lose that relation. From psychoanalysis we require an updating of the theory of delusion in the light of post-Kleinian understandings of the nature of unconscious fantasy. From phenomenology we require a precise understanding of how delusional distortions to reality contact manifest in the various (linguistic, corporeal, behavioural, intersubjective, and reflective) dimensions of human existence. And from cognitive neuropsychology we require theories aptly constrained by the above psychological domains, but informed by the latest neuro-imaging research.

Key Words

psychosis, paranoia, phenomenology, psychoanalysis, cognitive science

References

Conrad, K. (1958). Die beginnende Schizophrenie. Versuch einer Gestaltanalyse des Wahns. Stuttgart: Thieme.

Freeman, T., Cameron, J. L., & McGhie, A. (1966). Studies on psychosis: Descriptive, psychoanalytic, and psychological aspects. New York: International Universities Press.

Freud, S. (1981). On psychopathology. Harmondsworth: Penguin Books.

Garety, P. & Freeman, D. (1999). Cogitive approaches to delusions: A critical review of theories and evidence. British Journal of Clinical Psychology, 38, 2, 113-154.

Hemsley, D. R. (2005). The development of a cognitive model of schizophrenia: placing it in context. Neuroscience and Biobehavioral Reviews, 29, 977-988.

Jaspers, K., (1913) Allgemeine Psychopathologie. Berlin, Springer-Verlag. (trans. J. Hoenig, and M.W. Hamilton (1963) General Psychopathology. Chicago: University of Chicago Press. New edition (two volumes, paperback), with a Foreword by Paul R McHugh, (1997) Baltimore: The Johns Hopkins University Press.

Maher. B. (1974). Delusional thinking and perceptual disorder. Journal of Individual Psychology, 30, 98-113.

Parnas, J. & Sass, L. (2001). Self, solipsism, and schizophrenic delusions. Philosophy, Psychiatry, & Psychology, 8, 2/3, 101-120.

Sims, A. (2003). Symptoms in the Mind. 3rd edition. London: Elsevier.

Reading Suggestions:

Berrios, G. (1996). Delusions. In G. Berrios, The history of mental symptoms: Descriptive psychopathology since the 19th century (ch. 6). Cambridge: Cambridge University Press.

Munro, A. (2008). Delusional disorder: Paranoia and related illnesses. Cambridge: Cambridge University Press.

Freeman, D., Bentall, R., & Garety, P. (2008). Persecutory delusions: Assessment, theory and treatment. Oxford: Oxford University Press.