Delusion (Corsini Encyclopedia Entry)

Dr Richard G T Gipps & Professor K. W. M. (Bill) Fulford

1. What is Delusion?

Delusions are often described as ‘defined since Karl Jaspers as false,

subculturally atypical beliefs, strongly maintained in the face of
counterargument’. Whilst such attempted definitions are not entirely false, they
are nevertheless in danger of satisfying their own criteria, and we profit more by
understanding their several shortfallings than we do by acquiescing in them.
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’ (ibid, 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 unintelligible way in our contact with
reality itself – and secondary delusions, which are intelligible attempts to
understand baffling experiences. Whilst Jaspers’ doctrine of the
‘ununderstandability’ 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

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 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

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 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

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 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. (1913/1997). General psychopathology. Johns Hopkins.
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.