Reconceiving delusion

Delusions are critical components in a number of mental disorders, schizophrenia foremost. What are they? The standard view is that they are a type of belief--a pathological belief. Unfortunately, the standard view does not consistently correspond to clinical practice, where the term 'delusion' often applies to non-beliefs. We review the case for saying that non-beliefs can count as delusions. We argue that delusions are complexes of higher and lower order attitudes. They constitute a distinctive type of failure of self-knowledge and self-management. We describe the relevant type. One of the conceptual implications of our view is that beliefs need not be central to delusions.     

Reconceiving delusion

Delusions are critical components in a number of mental disorders, schizophrenia foremost. What are they? The standard view is that they are a type of belief—a pathological belief. Unfortunately, the standard view does not consistently correspond to clinical practice, where the term ‘delusion’ often applies to non-beliefs. We review the case for saying that non-beliefs can count as delusions. We argue that delusions are complexes of higher and lower order attitudes. They constitute a distinctive type of failure of self-knowledge and self-management. We describe the relevant type. One of the conceptual implications of our view is that beliefs need not be central to delusions.     

The meanings of delusions in dementia: a preliminary study

One of the common symptoms of dementia is delusions. Due to a biological conceptualization of the behaviors represented as delusions, these are classified as psychotic symptoms. This is a qualitative and quantitative study aiming to describe the delusions experienced by older persons with dementia and the context of occurrence, and to elucidate their etiology. Participants were 74 nursing home residents aged 65 and over, diagnosed with dementia, from nine nursing homes in Israel. Participants with delusions were found to have significantly more difficulties in performing ADLs, and poorer vision and hearing. Based on assessment using the BEHAVE-AD, six categories of delusions were examined: 1. One's house is not one's home, 2. Theft, 3. Danger, 4. Abandonment, 5. Misidentification, and 6. Other non-paranoid. Common themes appeared across delusions including reality, disorientation, re-experience of past events, loneliness and insecurity, boredom, and trigger. Current results suggest that delusions may not represent psychotic symptoms for most participants, because they sometimes represented reality, or were neither firm nor incontrovertible. Thus, utilizing the term delusion relegates the person's behavior to the domain of severe psychiatric phenomena and precludes understanding its true meaning.     

The incubus syndrome. A variant of erotomania.

The term "incubus syndrome" is proposed to describe patients suffering from the delusion that they have been sexually approached at night by an unseen lover. Two cases characterized by co-existence of erotomania and schizophrenic sexual delusions are described. The patient's behaviour secondary to the defusion is discussed from the point of view of social significance as well as potential dangerousness.     

Delusions in individuals with schizophrenia: factor structure, clinical correlates, and putative neurobiology

BACKGROUND: Delusions are a central feature of schizophrenia, yet our understanding of their neurobiology is limited. Attempt to link dimensions of psychopathology to putative neurobiological mechanisms depends on careful delineation of symptoms. Previous factor analytic studies of delusions in schizophrenia were limited by several methodological problems, including the use of patients medicated with antipsychotics, inclusion of nondelusion symptoms in the analyses, and/or inclusion of patients with psychotic disorders other than schizophrenia. These problems may have possibly biased the resulting factor structure and contributed to the inconclusive findings regarding the neurobiology of positive symptoms. Our goal is to examine the factor structure of delusions in antipsychotic-free individuals with diagnoses of schizophrenia/schizoaffective disorder. SAMPLING AND METHODS: We assessed 83 antipsychotic-free individuals with DSM-IV diagnoses of schizophrenia/schizoaffective disorder. A principal component analysis was conducted on the delusions symptoms of the SAPS. RESULTS: The principal component analysis resulted in three distinct and interpretable factors explaining 58.3% of the variance. The Delusions of Influence factor was comprised by delusions of being controlled, thought withdrawal, thought broadcasting, thought insertion, and mind reading. The Self-Significance Delusions factor was comprised by delusions of grandeur, reference, religious, and delusions of guilt/sin. The Delusions of Persecution factor was comprised solely by persecutory delusions. The three factors displayed distinct associations with hallucinations, bizarre behavior, attention, positive formal thought disorder, and avolition/apathy. CONCLUSIONS: The results indicate that delusions are best described by three distinct subtypes. The authors propose a novel model linking the three delusion subtypes, attributions to self/other, and putative neurobiological mechanisms. Implications for future research are discussed, as well as links to cognitive-behavioral conceptualizations of delusions.     

Paranoia, persecutory delusions and attributional biases

An influential model of persecutory delusions put forward by Bentall and colleagues hypothesizes that persecutory-deluded patients avoid the activation of negative self-beliefs by making externalising, personalising attributions for negative events. The first study reported here used a new instrument for the measurement of persecutory ideation, the Paranoid, Persecutory and Delusion-Proneness Questionnaire, to investigate whether attributional biases are associated with subclinical persecutory ideation. The second study extended this investigation by re-examining associations between attributional biases and persecutory delusions. Both studies used the Internal, Personal and Situational Attributions Questionnaire to measure attributional style. No evidence was found for a connection between attributional biases and subclinical persecutory ideation. Furthermore, there was no support for an association between persecutory delusions and an externalising bias, and only marginal support for the hypothesized relationship between persecutory delusions and a personalising bias. These results suggest that the putative link between persecutory ideation and attributional biases only manifests (if at all) when persecutory ideation is of delusional intensity, and that it is confined to a personalising bias.     

Regional brain atrophy in patients with mild Alzheimer's disease and delusions

BACKGROUND AND OBJECTIVE: The pathophysiology and the neurobiology of the behavioral disturbances in Alzheimer's disease (AD) are far from understood. The aim of the study was to assess whether delusional AD patients have a specific pattern of regional brain atrophy. METHODS: The setting of the study was the outpatient facility of a memory clinic. Subjects were 41 AD patients with mild dementia severity (Mini-Mental State Exam score of 22 +/- 3, range 18 to 27). Delusions were assessed with the pertinent subscale of the UCLA Neuropsychiatric Inventory (NPI). Nondelusional (n = 22) AD and delusional (n = 19) AD were defined on the basis of absence (NPI delusions subscale = 0) or presence (NPI delusions subscale = 1 or higher) of delusions. Thirteen (68%) of the delusional patients had isolated theft delusions, and 6 (32%) had theft associated with another paranoid delusion (of jealousy or persecution). None of the patients had misidentifications or other delusions of nonparanoid content. Temporal lobe and frontal lobe atrophy were assessed with linear measures (radial width of the temporal horn, rWTH, and frontal index, FI) taken from computed tomographic films. Temporal and frontal asymmetries were computed as right/left ratio of the rWTH and FI. RESULTS: AD patients without delusions had symmetrical enlargement of both temporal (8.1 +/- 3.9 vs. 8.5 +/- 4.5) and frontal horns (35.8 +/- 4.8 vs. 35.9 +/- 4.6). On the contrary, AD with delusions showed temporal horns larger to the right (9.1 +/- 3.3 vs. 7.7 +/- 3.1, p = .06) and the frontal horn to the left (35.7 +/- 4.3 vs. 37.5 +/- 4.2, p = .02). This different pattern was confirmed with a gender-adjusted repeated measures analysis of variance model interaction term between asymmetry and group: F1,38 = 5.5, p = .03). DISCUSSION: AD patients with delusions are characterized by a specific pattern of frontal and temporal asymmetry of brain atrophy, whereas nondelusional patients are symmetric. Because the asymmetry pattern of the delusional patients is similar to the physiological pattern of asymmetry of individuals without dementia, the data indicate that the absence of theft delusions in the mild stage of AD rather than their presence is associated with an abnormal asymmetry pattern.     

Socially naïve self-appraisal moderates the relationship between cognitive insight and positive symptoms in schizophrenia

Cognitive insight refers to awareness of one's own thinking. Research has found deficits in cognitive insight in schizophrenia but studies of its links with positive symptoms and delusions have been equivocal. One possibility is that the association of cognitive insight with positive symptoms and delusions is moderated by other factors. To explore this issue this study examined whether level of socially naive self-appraisal moderated the relationship of two forms of cognitive insight, self-reflectivity and self-certainty with delusions and positive symptoms. Participants were 92 adults, with diagnoses of schizophrenia or schizoaffective disorder, who were administered the Positive and Negative Syndrome Scale, self-deceptive subscale from the Marlowe–Crowne Social Desirability Scale and the Beck Cognitive Insight Scale. Stepwise multiple regressions with the interaction term of the predictive and moderator variables suggested that social naiveté moderates the relationship between self-reflectivity and self-certainty with positive symptoms in general. Moreover, association between self-certainty and delusions was also moderated by social naiveté self-appraisal. All models were significant after controlling for willful impression management as well as a measure of executive function. Results suggest that higher levels of self-certainty are a risk factor for having greater positive symptoms including more severe levels of delusions, when one has a view of oneself that is not tempered by the perceptions of others. Concerning lower levels of self-reflectivity it may be that this combined with a socially naïve view of oneself leaves persons less inhibited when they are tempted to accept unusual thoughts and perceptions as accurate. Implications for treatment are discussed.     

The epidemiology of psychosis in dementia.

OBJECTIVE: Authors compared delusions, hallucinations, and misidentification delusions in Alzheimer disease (AD) and vascular dementia (VaD) patients. METHODS: The authors report data on the prevalence, severity, clinical, and demographic associations of these symptoms in a population sample of 260 persons with dementia, examined with the Neuropsychiatric Inventory. RESULTS: The primary finding was that there was no difference in psychosis as a whole, or in delusions and hallucinations, between AD and VaD. Also, in AD, female gender appeared to be a risk factor for delusions; subjects in an earlier stage of dementia showed fewer delusions. CONCLUSION: The profile of delusions and hallucinations seen is different from that seen in schizophrenia, further supporting the hypothesis that AD-associated psychosis is a distinct phenomenological syndrome.     

Neuroimaging of delusions in Alzheimer's disease

MEDLINE, Embase and PsycINFO were searched using the keywords "imaging", "neuroimaging", "CT", "MRI", "PET", "SPECT", "Alzheimer's", "dementia", "delusions" and "psychosis" to find studies specifically assessing or reporting on neuroimaging of delusions in Alzheimer's Dementia (AD), separate from hallucinations or psychosis in general in AD. Twenty-five studies were found meeting criteria and are included in this review which reports on structural, regional perfusion, metabolic and receptor binding imaging modalities assessing delusions as a whole, as well as persecutory and misidentification delusional subtypes. The majority of studies implicate right-sided pathology, primarily frontal lobe. Left-frontal predominance and release, secondary to right-sided pathology, may create a hyperinferential state resulting in the formation of delusions. This perturbation and imbalance of normal networks is associated with delusional phenomenology. Temporal lobe structures are also important in misidentification syndromes, which have a different natural history than paranoid delusions. Consistent with the neuropathological and genetic literature, neuroimaging has shown that paranoid versus misidentification delusions are associated with different phenomenology and different neural substrates. Delusional subtype is an important factor in understanding the neurobiological underpinnings of delusions in dementia. We also discuss methodological issues related to neuroimaging of delusions in AD.     

Referential delusions of communication and interpretations of gestures

Gestures are an important aspect of non-verbal communication, but people with schizophrenia have poor comprehension of them. However, the tests of gesture comprehension that have been used present only scenes in which interpersonal meaning is communicated, though there is evidence that people with psychotic disorders tend to perceive communications where none were intended. Such mistakes about non-verbal behaviour are the hallmark of a subtype of delusions of reference identified as delusions of communication. Thus we hypothesised that patients with delusions of communication would tend to misinterpret incidental movements as gestures and, since delusions are often derogatory to the self, they would also tend to misinterpret gestures as insulting. Patients with acute psychotic symptoms (n=64) were recruited according to a 2 x 2 design (presence vs. absence of delusions of communication by presence vs. absence of auditory hallucinations). They, and 57 healthy controls, were presented with 20 brief video clips in which an actor either made a well-known gesture or an incidental movement. After each clip, they selected one of four interpretations: a correct interpretation if a gesture had been presented; the interpretation of a different gesture; an insulting interpretation; no gesture intended (correct for incidental movements). The patients made significantly more errors of all kinds than the controls, perceived significantly more of the incidental movements as gestures, and selected significantly more insulting interpretations of the clips. These differences between patients and controls were almost wholly due to patients with delusions of communication. These results suggest that the difficulties that people with delusions of communication experience in understanding gestures can be explained, at least in part, by the misattribution of self-generated internal events to external sources.     

Psychopathology of schizophrenia in Ljubljana (Slovenia) from 1881 to 2000: changes in the content of delusions in schizophrenia patients related to various sociopolitical, technical and scientific changes

BACKGROUND: Clinical observations and research have found the content of delusions in schizophrenia to be sensitive to sociopolitical and cultural factors. AIMS: The aim of this retrospective case-note study was to determine changes in the frequencies of various contents of delusions in schizophrenia patients over time. METHODS: A total of 120 records of first-time admission schizophrenia patient at Ljubljana's psychiatric hospital in the period from 1881 to 2000 were randomly selected. Information was taken from each record to fill out a form specially created for this study. The frequencies of delusions with regard to their content in various time spans were compared. RESULTS: A marked increase in two delusional themes--persecution and self-reference--was found after the change of political regime (1941-2000) in Slovenia. After the spread of radio in the 1920s and television in the 1950s in Slovenia, there was an obvious increase in delusions of outside influence and control as well as delusions with technical themes. A striking increase in the percentage of Schneiderian first-rank symptoms was found after the spread of Schneider's ideas in the 1950s. CONCLUSIONS: Sociopolitical changes and scientific and technical developments have a marked influence on the delusional content in schizophrenia.     

A pilot trial of cognitive behavioural therapy for interpersonal sensitivity in individuals with persecutory delusions

BackgroundAdvances in understanding delusions may be used to improve clinical interventions. Interpersonal sensitivity – feeling vulnerable in the presence of others due to the expectation of criticism or rejection – has been identified as a potential causal factor in the occurrence of persecutory delusions. The purpose of this study was to examine the potential impact on persecutory delusions of a (newly devised) cognitive behavioural intervention targeting interpersonal sensitivity (CBT-IPS).MethodsCBT-IPS was tested in an uncontrolled pilot study with eleven patients with persistent persecutory delusions in the context of a psychotic disorder. Patients had two baseline assessments over a fortnight period to establish the stability of the delusions, which was followed by six sessions of CBT-IPS, a post-therapy assessment, and a further follow-up assessment one month later.ResultsInterpersonal sensitivity and the persecutory delusions were stable during the baseline period. At the post-therapy assessment there were significant reductions of large effect size for both interpersonal sensitivity and the persecutory delusions. These gains were maintained at follow-up.LimitationsThe main limitation is that in this initial test there was no control group. The intervention may not have caused the reduction in delusions. Further, bias may have been introduced by the outcome data being collected by the therapist.ConclusionsThe findings from this evaluation are consistent with the hypothesised causal role for interpersonal sensitivity in the occurrence of persecutory delusions. CBT-IPS shows promise as a therapeutic intervention but requires a rigorous test of its efficacy.     

Neurobiology of Delusions in Alzheimer’s Disease

Alzheimer’s disease (AD) is associated with cognitive and functional impairment as well as neuropsychiatric sequelae, including psychotic symptoms such as delusions and hallucinations. Strong evidence supports the need to study delusions separate from hallucinations. Integrating the epidemiology, clinical correlates, and neuropathological and genetic literature for delusions in AD allows us to speculate on etiology and mechanisms. Plaque and tangle deposition in individuals with susceptible alleles of serotonergic, muscarinic, nicotinic, or Apoε4 genes appears to result in disruption of cortical circuitry, culminating in delusions. While delusions in AD correspond to a phenotype distinct from AD without delusions, subtypes of delusions may also define further distinct clinical entities. Persecutory delusions may occur earlier in the illness and have a more significant genetic component than misidentification delusions, which are associated with increased cognitive impairment and advanced dementia. Clearly distinguishing between these two syndromes is essential to making progress in the area of delusions in AD.     

Outcomes of child psychiatric treatment

Objective: While hallucinations and delusions are often considered as a single class of ‘positive symptoms’, little is known about their dynamic cooccurrence in relation to clinical outcome in non‐help‐seeking people. Method: The Netherlands Mental Health and Incidence Study (NEMESIS‐1) is a longitudinal study of mental disorders (n = 7075) with three measurements over a 3‐year period. Risk factors, persistence of psychotic experiences, and clinical outcome were analyzed for groups with: i) no psychotic experiences, ii) only delusions, iii) only hallucinations, and iv) both delusions and hallucinations. Results: Hallucinations and delusions occurred together more often (T0, 3.5%; T1, 1.0%; T2, 0.9%) than that predicted by chance (T0, 1.0%; T1, 0.1%; T2, 0.04%). The group with both symptoms showed more ‘first‐rank’‐like delusions compared with the group with only delusions. Having both hallucinations and delusions, compared to isolated symptoms, was associated more strongly with risk factors, comorbid affective symptoms, negative symptoms, and persistence of psychotic experiences. This was not an artifact of having more symptoms in general. Conclusion: Experiencing both delusions and hallucinations is an indicator of greater etiological load resulting in more clinical outcome. A specific ‘hallucinatory‐delusional state’ may represent an early phase of exacerbation of aberrant attribution of salience, increasing risk for clinical outcome.     

The interaction of affective with psychotic processes: A test of the effects of worrying on working memory,jumping to conclusions,and anomalies of experience in patients with persecutory delusions

Worry has traditionally been considered in the study of common emotional disorders such as anxiety and depression, but recent studies indicate that worry may be a causal factor in the occurrence and persistence of persecutory delusions. The effect of worry on processes traditionally associated with psychosis has not been tested. The aim of the study was to examine the short-term effects of a bout of worry on three cognitive processes typically considered markers of psychosis: working memory, jumping to conclusions, and anomalous internal experience. Sixty-seven patients with persecutory delusions in the context of a non-affective psychotic disorder were randomised to a worry induction, a worry reduction, or a neutral control condition. They completed tests of the cognitive processes before and after the randomisation condition. The worry induction procedure led to a significant increase in worry. The induction of worry did not affect working memory or jumping to conclusions, but it did increase a range of mild anomalous experiences including feelings of unreality, perceptual alterations, and temporal disintegration. Worry did not affect the occurrence of hallucinations. The study shows that a period of worry causes a range of subtle odd perceptual disturbances that are known to increase the likelihood of delusions. It demonstrates an interaction between affective and psychotic processes in patients with delusions.     

Predicting the occurrence, conviction, distress, and disruption of different delusional experiences in the daily life of people with schizophrenia

Recent research has shown that negative emotional states of increased anxiety and sadness prospectively predict the occurrence of persecutory ideation, but it is not known whether these findings extend to other subtypes of delusions. The current study explored whether these negative emotional states, as well as hallucinations, biased reasoning style (ie, jumping to conclusions), and negative self-esteem prospectively predict the occurrence and various dimensions of delusions of control, reference, and grandiosity in real time, as they occur in daily life. One hundred and thirty community-dwelling participants with schizophrenia or schizoaffective disorder completed laboratory measures and momentary self-reports generated by a personal digital assistant multiple times per day, over 7 consecutive days. Analyses were time lagged allowing simultaneous examination of person-level and within-person time-varying relationships among the variables. Approximately, half of the participants reported having at least one delusional experience during the week, and approximately, a quarter of those individuals reported experiencing all 3 delusion subtypes. Hallucinations were a significant predictor of the occurrence of delusions of control and reference over the subsequent hours of the same day, but negative emotional states of anxiety and sadness were not. Negative self-esteem predicted the frequency of all 3 delusion subtypes during the week, and a reasoning style characterized by reduced information gathering was a significant predictor of the frequency of delusions of control. Delusional dimensions of conviction, distress, and disruption had different associations with the variables tested for each delusion subtype.     

Misattribution of external speech in patients with hallucinations and delusions

BACKGROUND: One of the main cognitive models of positive symptoms in schizophrenia proposes that they arise through impaired self-monitoring. This is supported by evidence of behavioural deficits on tasks designed to engage self-monitoring, but these deficits could also result from an externalising response bias. We examined whether patients with hallucinations and delusions would demonstrate an externalising bias on a task that did not involve cognitive self-monitoring. METHOD: Participants passively listened (without speaking) to recordings of single adjectives spoken in their own and another person's voice, and made self/nonself judgements about their source. The acoustic quality of recorded speech was experimentally manipulated by altering the pitch. Fifteen patients with schizophrenia who were currently experiencing hallucinations and delusions, 13 patients with schizophrenia not experiencing current hallucinations and delusions and 15 healthy controls were compared. RESULTS: When listening to distorted words, patients with hallucinations and delusions were more likely than both the group with no hallucinations and delusions and the control group to misidentify their own speech as alien (i.e. spoken by someone else). Across the combined patient groups, the tendency to misidentify self-generated speech as alien was positively correlated with current severity of hallucinations but not with ratings of delusions or positive symptoms in general. CONCLUSIONS: These findings indicate that patients with hallucinations and delusions are prone to misidentifying their own verbal material as alien in a task which does not involve cognitive self-monitoring. This suggests that these symptoms are related to an externalising bias in the processing of sensory material, and not solely a function of defective self-monitoring.     

Permeable walls,floors, ceilings and doors. Partition delusions in late paraphrenia

A partition delusion is the belief that people, objects or radiation can pass through what would normally constitute a barrier to such passage. These delusions have been reported to be common in late paraphrenia and late-onset schizophrenia. Such partition delusions were found in 68% of 50 patients with late paraphrenia, but only in 13% of patients with schizophrenia who had grown old and in 20% of young schizophrenics. Partition delusions, often in association with persecutory beliefs, are common in late paraphrenia and we discuss some possible reasons for this.