Delusion(s)

Delusions typically occur in the context of neurological or mental illness, although they are not tied
to any particular disease 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 and particularly in schizophrenia, paraphrenia, manic episodes of bipolar disorder, and
psychotic depression. Delusions can be fixed or transient.
Psychiatric 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 1917 book General Psychopathology. 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)
These criteria still continue in modern psychiatric diagnosis. The most recent Diagnostic and
Statistical Manual of Mental Disorders defines a delusion as:
A false belief based on incorrect inference about external reality that is firmly sustained despite what
almost everybody else believes and despite what constitutes incontrovertible and obvious proof or
evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's
culture or subculture.
There is controversy over this definition, as 'despite what almost everybody else believes' implies
that a person who believes something most others do not is a candidate for delusional thought.
Furthermore, it is ironic that, while the above three criteria are usually attributed to Jaspers, he
himself described them as only 'vague' and merely 'external'.[1] He also wrote that, since the
genuine or 'internal' 'criteria for delusion proper lie in the primary experience of delusion and in the
change of the personality [and not in the above three loosely descriptive criteria], we can see that a
delusion may be correct in content without ceasing to be a delusion, for instance - that there is a
world-war.'.[2]
Types
Delusions are categorized as either bizarre or non-bizarre and as either mood-congruent or mood-
neutral. A bizarre delusion is a delusion that is very strange and completely implausible; an example
of a bizarre delusion would be that aliens have removed the affected person's brain. A non-bizarre
delusion is one whose content is definitely mistaken, but is at least possible; an example may be that
the affected person mistakenly believes he or she is under constant police surveillance. A mood-
congruent delusion is any delusion whose content is consistent with either a depressive or manic
state; for example, a depressed person may believe that news anchors on the television highly
disapprove of him or her, or a person in a manic state might believe that he or she is a powerful
deity. A mood-neutral delusion 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.[3]
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 [3]:
.
Delusion of control: This is a false belief that another person, group of people, or external
force controls one's thoughts, feelings, impulses, or behavior. A person may describe, for
instance, the experience that aliens actually make him or her move in certain ways and that
the person affected has no control over the bodily movements. Thought broadcasting (the
false belief that the affected person's thoughts are heard aloud), thought insertion, and
thought withdrawal (the belief that an outside force, person, or group of people is removing
or extracting a person's thoughts) are also examples of delusions of control.
Nihilistic delusion: A delusion whose theme centers on the nonexistence of self or parts of
self, others, or the world. A person with this type of delusion may have the false belief that
the world is ending. They may also believe that they are dead (figuratively or literally).
Delusional jealousy (or delusion of infidelity): A person with this delusion falsely believes
their spouse or lover is having an affair. This delusion stems from pathological jealousy, and
the person often gathers "evidence" and confronts the spouse about the nonexistent affair.
Delusion of guilt or sin (or delusion of self-accusation): This is a false feeling of remorse
or guilt of delusional intensity. A person may, for example, believe he has committed some
horrible crime and should be punished severely. Another example is a person who is
convinced he is responsible for some disaster (such as fire, flood, or earthquake) with which
there can be no possible connection.
Delusion of mind being read: The false belief that other people can know one's thoughts.
This is different from thought broadcasting in that the person does not believe their thoughts
are heard aloud.
Delusion of reference: The person falsely believes that insignificant remarks, events, or
objects in one's environment have personal meaning or significance. For instance, a person
may believe they are receiving special messages from newspaper headlines; they are being
talked about on the radio/tv.
Erotomania is a delusion in which one believes that another person is in love with him or
her. They believe that this other person was the first to declare his or her affection, often by
special glances, signals, telepathy, or messages through the media.
Grandiose delusion: An individual is convinced they have special powers, talents, or
abilities. Sometimes, the individual may actually believe they are a famous person or
character (for example, a rock star). More commonly, a person with this delusion may
believe they have accomplished some great achievement for which they have not received
sufficient recognition (for example, the discovery of a new scientific theory).
Persecutory delusion: These 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 obstructed in the pursuit of goals. Sometimes the delusion is isolated and
fragmented (such as the false belief that co-workers are harassing), but sometimes are well-
organized belief systems involving a complex set of delusions ("systematized delusions").
People with a set of persecutory delusions may believe, for example, they are being followed
by government organizations because the "persecuted" person has been falsely identified as a
spy. These systems of beliefs can be so broad and complex that they can explain everything
that happens to the person.
Paranoid: believing that people are "out to get" you, or the thought that people are doing
things when there is no external evidence that such things are taking place.
Religious delusion: Any delusion with a religious or spiritual content. These may be
combined with other delusions, such as grandiose delusions (the belief that the affected
person was chosen by God, for example), delusions of control, or delusions of guilt. Beliefs
that would be considered normal for an individual's religious or cultural background are also
often called delusions by some.
Somatic delusion: A 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 changedfor example, infested with parasites.
Delusional parasitosis: also known as Ekbom's syndrome,
[39]
is a form of psychosis
whose victims acquire a strong delusional belief that they are infested with parasites, whereas
in reality no such parasites are present.
[40]
Very often the imaginary parasites are reported as
being "bugs" or insects crawling on or under the skin; in these cases the experience of the
sensation known as formication may provide the basis for this belief.
The alternative name of Ekbom's syndrome derives from Swedish neurologist Karl Axel
Ekbom,
[41]
who published seminal accounts of the disease in 1937 and 1938. This term is
also used interchangeably with Wittmaack-Ekbom syndrome, another name for restless legs
syndrome (RLS). Although delusional parasitosis and RLS were both researched by Ekbom,
and RLS sufferers sometimes describe some of their symptoms as if they have, for example,
"ants in my veins", they are distinctly different disorders. RLS is a physical condition with
physical causes, whereas delusional parasitosis is a false belief.
The false belief of delusional parasitosis stands in contrast to actual cases of parasitosis, such
as scabies.
People with delusional parasitosis are likely to ask for help not from psychiatrists but from
dermatologists, veterinarians, pest control specialists, or entomologists. Because delusional
parasitosis is not at all well known to non-specialists, under those circumstances the
condition often goes undiagnosed, or may be incorrectly diagnosed.
In primary delusional parasitosis, the delusions comprise the entire disease entity, there is no
additional deterioration of basic mental functioning or idiosyncratic thought processes. The
parasitic delusions consist of a single delusional belief regarding some aspect of health. This
is also referred to as "monosymptomatic hypochondriacal psychosis",
[5]
and sometimes as
:389
"true" delusional parasitosis. In the DSM-IV, this corresponds with "delusional disorder,
somatic type".
Secondary functional delusional parasitosis occurs when the delusions are associated with a
psychiatric condition such as schizophrenia or depression.
Mixed: People with this type of delusion have two or more of the delusions listed above.
Diagnostic issues
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 criticized, as counter-examples can be
shown for every defining feature.
Studies on psychiatric patients have shown that delusions can be seen to vary in intensity and
conviction over time which suggests that certainty and incorrigibility are not necessary components
of a delusional belief.[4]
Delusions do not necessarily have to be false or 'incorrect inferences about external reality'.[5] 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. [6]
In other situations, the delusion may turn out to be true belief.[7] For example, 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) may result in
the faithful partner being driven to infidelity by the constant and unreasonable strain put on them by
their delusional spouse. In this case, the delusion does not cease to be a delusion because the content
later turns out to be true.
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 persons claims leading to some true beliefs to
be erroneously classified as delusional.[8] 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
'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 which 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.[9]. 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. [10]
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."[11] In practice psychiatrists tend to
diagnose a belief as delusional if it is either patently bizarre, causing significant distress, or
excessively pre-occupies the patient, especially if the person is subsequently unswayed in belief by
counter-evidence or reasonable arguments.
Development of 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[12].
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) which was instigated to clarify if schizophrenia had a dopamine psychosis [13]
There were positive results - delusions of jealousy and persecution had different levels of dopamine
metabolite HVA (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 [14][15] and gender to be influential and it is most likely that HVA levels change
during the life course of some syndromes [16]
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" [17]
Cultural factors have "a decisive influence in shaping delusions". [18] 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. It says cultural factors have a decisive influence in shaping
delusions. [19] . In a series of case studies, delusions of guilt and punishment were shown in Austria
as well and this is with Parkinson's patients treated with l-dopa - a dopamine agonist.[20]
Further reading
1. Bell V, Halligan PW, Ellis H (2003). "Beliefs about delusions" (PDF). The Psychologist
16 (8): 418423.
http://mindfull.spc.org/vaughan/Bell_et_al_2003_BeliefsAboutDelusions.pdf.
2. 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): 527539. doi:10.1176/appi.ajp.158.4.527. PMID 11282685.
http://ajp.psychiatryonline.org/cgi/content/abstract/158/4/527.
3. Coltheart M., Davies M., ed. (2000). Pathologies of belief. Oxford: Blackwell. ISBN 0-
631-22136-0.
4. 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.
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Cited text

Jaspers, Karl (1997). General Psychopathology. 1. Baltimore: Johns Hopkins University