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Understanding delusions

IndPsychiatryJ.2009JanJun18(1):318.

PMCID:PMC3016695

doi:10.4103/09726748.57851

Understandingdelusions
ChandraKiranandSuprakashChaudhury
DepartmentofPsychiatry,RanchiInstituteofNeuropsychiatryandAlliedSciences,Kanke,Ranchi834006,Jharkhand,India
Addressforcorrespondence:Dr.SuprakashChaudhury,DepartmentofPsychiatry,RanchiInstituteofNeuropsychiatryandAllied
Sciences,Kanke,Ranchi834006,Jharkhand,India.Email:suprakashch@gmail.com
CopyrightIndustrialPsychiatryJournal
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
Delusionhasalwaysbeenacentraltopicforpsychiatricresearchwithregardtoetiology,pathogenesis,
diagnosis,treatment,andforensicrelevance.Thevarioustheoriesandexplanationsfordelusionformation
arereviewed.Theetiology,classificationandmanagementofdelusionsarebrieflydiscussed.Recent
advancesinthefieldarereviewed.
Keywords:Delusions,Etiology,Psychopathology,Phenomenology

Thereisnodelusionalideaheldbythementallyillwhichcannotbeexceededinitsabsurditybythe
convictionoffanatics,eitherindividuallyorenmasseHoche
Adelusionisabeliefthatisclearlyfalseandthatindicatesanabnormalityintheaffectedpersonscontent
ofthought.Thefalsebeliefisnotaccountedforbythepersonsculturalorreligiousbackgroundorhisor
herlevelofintelligence.Thekeyfeatureofadelusionisthedegreetowhichthepersonisconvincedthat
thebeliefistrue.Apersonwithadelusionwillholdfirmlytothebeliefregardlessofevidencetothe
contrary.Delusionscanbedifficulttodistinguishfromovervaluedideas,whichareunreasonableideasthat
apersonholds,buttheaffectedpersonhasatleastsomelevelofdoubtastoitstruthfulness.Apersonwith
adelusionisabsolutelyconvincedthatthedelusionisreal.Delusionsareasymptomofeitheramedical,
neurological,ormentaldisorder.Delusionsmaybepresentinanyofthefollowingmentaldisorders:(1)
Psychoticdisorders,ordisordersinwhichtheaffectedpersonhasadiminishedordistortedsenseofreality
andcannotdistinguishtherealfromtheunreal,includingschizophrenia,schizoaffectivedisorder,
delusionaldisorder,schizophreniformdisorder,sharedpsychoticdisorder,briefpsychoticdisorder,and
substanceinducedpsychoticdisorder,(2)Bipolardisorder,(3)Majordepressivedisorderwithpsychotic
features(4)Delirium,and(5)Dementia.
HISTORY
TheEnglishworddeludecomesfromLatinandimpliesplayingormocking,defraudingorcheating.The
GermanequivalentWahnisawhim,falseopinionorfancyandmakesnomorecommentthantheEnglish
uponthesubjectiveexperience.TheFrenchequivalent,delireismoreempathicitimpliestheploughshare
jumpingoutofthefurrow(lira),perhapsasimilarmetaphortotheironicalunhinged.Sincetime
immemorial,delusionhasbeentakenasthebasiccharacteristicofmadness.Tobemadwastobedeluded.

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Whatisdelusionisindeedoneofthebasicquestionsofpsychopathology.Itwouldbeasuperficialand
wronganswertothisquestionjusttocalladelusionafalsebeliefwhichisheldwithincorrigiblecertainty.
Wemaynothopetoresolvethisissuequicklywithadefinition.Delusionisabasicphenomenon.Itisthe
primarytasktogetthisintoview.Thesubjectivedimensionwithinwhichdelusionexistsistoexperience
andthinkourreality(Jaspers,1973).Whetherwelikeitornot,thisistheunavoidablefieldoftensionin
whichresearchondelusionsissituated:Atight,objectivityorientedconceptualizationontheonehandand
thebasicanthropologicaldimensionsofsubjectivityandinterpersonality(i.e.humaninterdependenceor
universalfraternity)ontheotherhand.Evenifoneisskepticalaboutthesebasicaspects,Jaspers
centralideashouldbekeptinmind:Delusionisneveramereobjectwhichcanbeobjectivelydetectedand
described,becauseitevolvesandexistswithinsubjectiveandinterpersonaldimensionsonly,however
pathologicalthesedimensionsmaybe.Thisremindsusofacentraltopicofpsychiatricresearch:There
aretwofundamentallydifferentapproachestoresearchoncomplexmentalphenomena,betheynormalor
pathological.
Thefirstapproachthenaturalisticoneregardsthecomplexityandheterogeneityofscientific
meanstostudydelusionasatemporaryphenomenon,asthesecondbestsolution.Thissolution,
accordingtothenaturalisticperspective,willonlybeuseduntilastrictlyempiricalneuroscientific
approachhasprogressedfarenoughtoreplacementalisticvocabularywithaneurobiologicalone.In
thisviewmentalphenomenaareidenticalwiththeirneurobiologicalbasis.Inotherwords,mental
eventsarenotregardedasadistinctclassofphenomena,eithergraduallyorprincipally.Eliminative
materialismisthemostradicalpositioninthiscontext,whichdeclarestermssuchasintention,
willfulaction,individualvalues,personalityorautonomytobepartoffolkpsychology.According
tothisapproach,thesetermsmaywellbeusefulsociallyandonaneverydaylifebasis,butnot
scientifically,andtheywillbereplaced,eliminated,bythelanguageofneurobiologyinthenottoo
distantfuture.
ThesecondapproachthephenomenologicalpointofviewinJasperstermsdepartsfroma
personssubjectiveexperiencesasthecoreissueofscientificstudiesonpsychopathology.Thisdoes
not,ofcourse,excludeneurobiologicalresearchstrategiesatall,butitdoesinsistonthescientific
significanceofthesubjectivedimension.Researchintodelusionsisoneofthemostinteresting
examplesoftheimportanceofthismethodologicaldichotomy.Wewillbrieflyreviewsomeofthe
majorconceptsofdelusionalthinkingastheyappearedfromthe19thcenturyuntiltoday.
DESCRIPTIVEPHENOMENOLOGICALAPPROACH
Thisapproachtounderstandingdelusionsisaveryinfluentialoneforpsychiatrists.JaspersbookGeneral
Psychopathologymarkedamajorstepforwardsinestablishingpsychopathologyasascientificdiscipline.
Experiencingmentalstatesbythepatientandtheunderstandingofthisexperiencebythephysician
definedthecentralframework.However,incontrasttobiologicalphenomena,mentaleventsinJaspers
viewcanneverbeaccesseddirectly,butonlyviatheexpressionsofthepersonwhoexperiencesthem.
Phenomenologyisthestudyofsubjectiveexperience.Itisonesempathicaccessorunderstandingofthe
patientsexperience.Oneentersintotheotherpersonsexperiencesusingtheanalogyofonesown
experience.Jaspersdistinguishesbetweenstaticunderstandingwhichgraspsparticularpsychicqualities
andstatesasindividuallyexperiencedandgeneticunderstandingwhichgraspstheemergenceofone
psychiceventfromanother.Phenomenologyisstaticunderstanding.Phenomenologyisonesrecreation
ofthepatientsexperiencesthroughtransferringinto,empathizingwithorliterallyfeelingintoor
livingwiththepatientsexperiences.Inthiswayonearrivesatanactualization,representationor
bringingtomindofthepatientsexperience.Phenomenologyactualizesorrepresentsthepatientsinner
subjectiveexperiences.Wecanonlymakearepresentationofthemthroughanactofempathyor
understanding(Jaspers,1963).
THECONCEPTOFFORMANDCONTENT

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FollowingthetheoryofknowledgeofthephilosopherImmanuelKant,Jaspersacceptsthatallexperience
orknowledgeentailsbothanincomingsensationandanorganizingconcept.Theformerismatteror
content,thelatterisform.Theempiricists(Locke,Berkeley&Hume)emphasizedincomingsensation
exclusivelytherationalists(DescartesandLeibniz)emphasizedtheorganizingconceptexclusively.Kant
tookacarefullyconsideredmiddlecourse.Allexperienceandknowledgeentailsthetwostemsof
conceptualformandintuitivecontent.ThiswillbecrucialforJaspersconceptofdelusion.InKants
wordsfromhisCritiqueofPureReason:ThatintheappearancewhichcorrespondstosensationItermits
matter(orcontent)butthatwhichsodeterminesthemanifoldofappearancethatitallowsofbeingordered
incertainrelations,Itermtheformoftheappearance.Thisisthephilosophicaloriginoftheconceptof
formandcontentwithinJasperspsychopathology.Thedifferingformsofpsychopathologicalexperience
arethetopicforphenomenology.Inhisearlypaper,ThePhenomenologicalApproachtoPsychopathology,
Jaspersspellsitoutthatphenomenologicaldefinitions"relatetothedifferentformsofexperience:
Fromitsbeginnings,psychiatryhashadtoconcernitselfwithdelimitingandnamingthesedifferent
formsofexperiencetherecould,ofcourse,havebeennoadvanceatallwithoutsuchphenomenological
definitions.ThisisthecrucialpointthatJaspersisatpainstomakethatphenomenologyisprimarily
concernedwithformandthatcontentislargelyirrelevant:Phenomenologyonlymakesknowntousthe
differentformsinwhichallourexperiences,allpsychicreality,takesplaceitdoesnotteachusanything
aboutthecontents.Then,inGeneralPsychopathology,Jaspersbecomesmoreexplicitabouttheconcept
ofform.Formisthemodeorthemannerinwhichweexperiencecontent:Perceptions,ideas,judgments,
feelings,drives,selfawareness,areallformsofpsychicphenomenatheydenotetheparticularmodeof
existenceinwhichcontentispresentedtous.Thesamecontentcanbepresentedindifferentforms.The
twoKantianstemsarethoughtofbyJaspersassubjectandobject.Thesubjectivestemistheconceptual
formimposedbythemindandtheobjectivestemistheincomingcontentofintuitionorsensation.Asa
contentpresentingindifferentforms,Jaspersgivestheexampleofhypochondriasis:Inallpsychiclife
thereissubjectandobject.Thisobjectiveelementconceivedinitswidestsensewecallpsychiccontent
andthemode(Art)inwhichthesubjectispresentedwiththeobject(beitaperception,amentalimageor
thought)wecalltheform.Thus,hypochondriacalcontents,whetherprovidedbyvoices,compulsiveideas,
overvaluedideasordelusionalideas,remainidentifiableascontent(Jaspers,1963).
THEFORMSOFBELIEF
Jaspersdistinguishesfourformsofbeliefs,i.e.fourdistinctmodesorwaysinwhichbeliefscanbe
presentedtoconsciousness.Thesearenormalbelief,overvaluedidea,delusionlikeideaandprimary
delusion.IntheEnglishliterature,thedelusionlikeideaisusuallyknownasthesecondarydelusionbut
Jaspershimselfdoesnotusethisterm.TheEnglishliteraturetendseithertosplitthesefourformsintotwo
pairsonthebasisthatnormalbeliefandovervaluedideabothoccurinnormalpsychiclifewhile
delusionlikeideaandprimarydelusionalwaysreflectanabnormalmentalstate,ortosplitoffthe
primarydelusiononthegroundsthattheotherthreeareunderstandablewhiletheprimarydelusionisnot.
BothCuttingandSimsrefertothefirstdistinctionwhileonlySimsnotesthesecond(Cutting,1985Sims,
1988).Thisfirstdistinctionemphasizeswhetherthebeliefisdelusionalinnatureormerelyovervalued.
Sims(1988),inSymptomsintheMind,appealstoJaspersandgivesthefollowingcriteriafordelusion:(a)
Theyareheldwithunusualconviction.(b)Theyarenotamenabletologic.(c)Theabsurdityor
erroneousnessoftheircontentismanifesttootherpeople.Cutting(1985),inhisThePsychologyof
Schizophrenia,givesanalmostidenticaldefinition,againwithanappealtoJaspers.Thesethreefeatures
(extraordinaryconvictionandcertainty,imperviousnessorincorrigibilityandimpossiblecontent)arethe
onesusuallytakentodistinguishdelusionfromotherbeliefs.SimsandCuttingarecorrectthatJaspers
doessayexactlythatofdelusions:(a)Theyareheldwithanextraordinaryconviction,withan
incomparablesubjectivecertainty.(b)Thereisimperviousnesstootherexperiencesandtocompelling
counterargument.(c)Theircontentisimpossible.WhatSimsandCuttingmissisthatJasperssaysthat
thesearemerelytheexternalcharacteristicsofdelusion.Theyarecharacteristicofdelusionbuttheyfail
toaccountfortheessentialdifferencesbetweendelusionandotherformsofbelief.Infact,Jaspers

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dismissesthesecriteriainthefirstparagraphofhisaccount:Tosaysimplythatadelusionisamistaken
ideawhichisfirmlyheldbythepatientandwhichcannotbecorrectedgivesonlyasuperficialand
incorrectanswertotheproblem(Jaspers,1963).
Itiseasytodemonstratetheinadequacyofthesecriteria.Imaginetwopoliticianswithopposingbeliefs.
Bothholdviewswithanextraordinaryconvictionandanincomparablesubjectivecertainty.Bothshow
averydefiniteimperviousnesstootherexperiencesandtocompellingcounterargument.Foreach,the
judgmentsoftheotherarefalse,andthecontentimpossible.Obviously,neitherisdeluded.Bothare
expoundingviewswhicharehighlyvalued,orperhapsovervalued,butwhichfulfilltheaboveexternal
characteristicsofdelusionalbelief.SimsandCuttingscriteriamustbedeemedinadequatetodistinguish
delusionsfromotherfirmlyheldbeliefsandtheexpressionheldwithdelusionlikeintensityasan
essentialcriterionfordelusionisthereforenonsense.Plentyofotherbeliefsbesidesdelusionsareheld
withdelusionlikeintensity.Eventhetruthorfalsehoodofthecontentofabeliefisinadequateto
distinguishadelusion.Jaspersisquicktopointoutthatthecontentofsomedelusionsistrue,e.g.in
pathologicaljealousy,wherethewifeishavinganaffairbutthepatientisrightforthewrongreasonsand
isthereforestilldeluded(Jaspers,1963).Withsomeawarenessoftheaboveproblems,Simsaddsthe
seconddistinctionbasedonunderstanding.Adelusion,unlikeanovervaluedidea,isnotunderstandable
intermsofthepatientsculturalandeducationalbackgroundalthoughthesecondarydelusion(or
delusionlikeidea)isunderstandablewiththeadditionofsomeotherpsychopathologicaleventsuchas
hallucinationorabnormalmood.Thestandardpreoccupationremainswhetheranybeliefisdelusionalor
merelyovervalued.
DELUSIONLIKEOROVERVALUEDIDEAS
Thisstandardviewhasdifficultieswithawidevarietyofstrangebeliefs,someofwhichareexamined
below.Aretheydelusionalormerelyovervalued?Ontheabovethreeexternalcharacteristicsplus
understandability,theycancertainlylookverymuchlikedelusionlikeideasbutthelogicalimplication
thatthismeansadiagnosisofpsychosisisunacceptableandrequiressomeverydeftintellectual
footworktoavoid.Arenotthedisorderedbeliefsofbodyimageinanorexiaderivedfrom(understandable
intermsof)thefearofgainingweightandthepreoccupationwithfoodand,ifso,whydowenotconsider
themtobedelusionlikeratherthanovervalued?Whydowenotconsiderthecatastrophebeliefsinsevere
obsessionalstatestobedelusionlike?Catastrophebeliefsarecloselylinkedtotheunderlyingcompulsions
andsuchpatientsdooftenbelievethatafailuretocarryouttheritualwillresultinsomedreadful
catastrophe.Beckandhisassociateshavedescribedarangeofabnormalcognitionsconsequenton
depressiveandanxietystates(Becketal,1979).Wewouldregardmanyofthesedepressedpatientsas
neuroticratherthanpsychoticdepressivesbutneverthelesstheyhaveverycompellingautomaticthoughts
andnegativeschemataoffailure,hopelessness,andhelplessness,clearlylinkedto(understandableinterms
of)theirmooddisorders.Canthebeliefsofmiscastgenderintranssexualismbepassedoffgliblyas
overvaluedideawhenpersonalitytraitmakesthebeliefunderstandable?
Afurtherexamplecanbefoundinpathologicalgambling.Althoughtheexperiencedgamblerknowsthat
thecasinogameisriggedagainsthimandthatinthelongtermthehousemustwin,hecontinuestobelieve
inhisownluck.Wagenaar(1988)foundawebofillogicalcognitionsincompulsivegamblers.Manywere
magicalinqualityandsomeactuallymadeitmorelikelythatthegamblerwouldlose.Atroulette,agame
ofchanceentirely,playershadastrongtendencytoleavetheirchipsonawinningnumberonthegrounds
thatitwaslucky.Whentheylosttheytendedtoputtheirchipsonnumbersthathavenotyetwon.Backing
anumberadjacentto,orarithmeticallyrelatedto,thewinnermeanttheirluckwasreturning.Wagenaar
pointsoutthatfewnumbersarenotrelatedeitherbyproximityorbyarithmeticsothatthegamblercan
alwaysdeludehimselfthathisluckisrisingandthatawinisimminent.Somegamblershadanelaborate
system,provokingtheoldtelegramSystemperfected,sendmoremoney.Manygamblersbelievedthat
chanceandluckwerenotjustabstractideasbutwerecausalforceswhichwereopentomanipulation.
RouletteistheclosestthingtorandomnumbersoutsideacomputerbutmanyofWagenaarsgamblershad

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developedbeliefswhichweremagicalinnature,defiedthelawsofmathematicsand,insomecases,were
actuallyhelpingthemtolose.Thesemagicalbeliefsarederivedfrom(areunderstandableintermsof)the
compulsion,thearousalandtheexcitementofpathologicalgambling.
Walker(1991)hasproposedthat:(1)Anumberofideasbothinsideandoutsidepsychopathologyhaveat
leastaprimafaciecasetobeconsidereddelusionlike(theyfulfillthethreeexternalcharacteristicsand
theyareunderstandableintermsofunusual,ifnotpsychopathological,experiences).(2)anintellectual
sleightofhandisofteninoperationinthedistinctionofovervaluedanddelusionlike.Ifweintendtomake
apsychoticdiagnosis,thenthebeliefisdelusionlikeifweintendtomakeanonpsychoticdiagnosis,
thenthebeliefisovervalued.Thephenomenologyismoldedtofit.(3)Thethirdaimistosuggest,with
Jaspers,that,asbothanovervaluedideaandadelusionlikeideaareunderstandable(theovervaluedidea
intermsofthepersonalityandlifeexperiencesandthedelusionlikeideaintermsofthesameplussome
otherpsychopathologicalevent)thereislittletobegainedbytheirdistinction.Jasperssolvesthisproblem
neatlybyshiftingthewholeemphasis.Forhim,theimportantdistinctionisnotbetweenovervaluedidea
anddelusionlikeideabutratherbetweendelusionlikeideaandprimarydelusion.Jaspersterminology
hasimportanceforhisaccount.Onlytheprimarydelusionisadelusionalideaproperforhimandthe
delusionlikeideais,asitsnamesuggests,notatruedelusionbutmerelydelusionlike.Jaspers,therefore,
makesnorealdistinctionbetweentheovervaluedideaandthedelusionlikeidea.Thereareseveral
occasionswhenhesimplyequatesthetwo.Forexample,inJaspers(1963):Exhaustionmayhelpto
developalongprepareddelusionofreference(anovervaluedidea).Melancholia.Inthisstatethe
overvaluedorcompulsivedepressiveideasbecomedelusionlike.Moodstates,wishesanddrivesgive
risetodelusionlikeideas(overvaluedideas)whichariseinmoreorlessunderstandablefashionfrom
them.
THEESSENTIALCHARACTERISTICSOFDELUSION
Jasperssolutiontotheproblemofdelusionisasfollows:Ifwewanttogetbehindthesemereexternal
characteristicsofdelusionintothepsychologicalnatureofdelusion,wemustdistinguishtheoriginal
experiencefromthejudgmentbasedonit,i.e.thedelusionalcontentsaspresenteddatafromthefixed
judgmentwhichisthenmerelyreproduced,disputed,dissimulatedasoccasiondemands.Theessential
criteriondistinguishingthedifferentformsofbeliefliesnotintheirconvictionandcertainty,notintheir
incorrigibilityandnotintheirimpossiblecontentbutintheiroriginswithinthepatientsexperience.
Jaspersgoeson:Wecanthendistinguishtwolargegroupsofdelusionaccordingtotheirorigin:onegroup
emergesunderstandablyfromprecedingaffects,fromshattering,mortifying,guiltprovokingorother
experiences,fromfalseperceptionorfromtheexperienceofderealisationinstatesofaltered
consciousness,etc.Theothergroupisforuspsychologicallyirreduciblephenomenologicallyitis
somethingfinal.Wegivethetermdelusionliketothefirstgroupthelatterwetermdelusionsproper.
Thus,theessentialdistinguishingfactorwithinthefourformsofbeliefistheconceptofunderstanding.
Onecanunderstandtheevolutionordevelopmentofthenormalbeliefandtheovervaluedideafromthe
personalityanditslifeevents.Onecanunderstandthedelusionlikeideafrompersonality,lifeeventsand
fromsomeotherpsychopathologicalexperiencebuttheprimarydelusionissomethingnew,irreducible
andnonunderstandable.TheprimarydelusionisofparamountimportanceforJaspers.Includingthe
abovedistinctionofalackofunderstandability,theprimarydelusiondiffersinthreewaysfromtheother
threeformsofbelief:(a)Theprimarydelusionisunmediatedbythought.(b)Theprimarydelusionis
ununderstandable.(c)Theprimarydelusionimpliesachangeinthetotalityofunderstandable
connectionswhichispersonality.
PRIMARYDELUSIONASANUNMITTELBARPHENOMENON
Cuttingacrossthewholeofphenomenologyisthedistinctionbetweendirectorimmediate
(unmittelbarliterallyunmediated)experiencesandexperienceswhicharetheresultofreflectionor
thoughtandwhichareindirect(gedanklichvermitteltes:Literallymediatedbythought).This

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distinctionofphenomenawhichareunmediatedandthosewhicharemediatedbythoughtoverlapsall
otherdivisions.Jaspersdoestrytoclarifywhathehasinmindbythisdistinction.Immediate,director
unmediatedexperienceshedescribesasexperienceswhichareelementaryandirreducible.Incontrast,
experienceswhicharemediatedbythoughthedescribesasdeveloped,evolved,basedonthinkingand
workingthroughthatistheyaretheproductofreflection.Thedistinctioniscrucial:Wehaveto
distinguishbetweenimmediatecertaintyofrealityandrealityjudgment.Realityjudgmentistheresultofa
thoughtfuldigestionofdirectexperiences(Jaspers,1963).Theprimarydelusionisadirect,unmediated
phenomenonthedelusionlikeideaisreflectiveormediatedbythought:Theprimarydelusional
experienceisthedirect,unmediatedintrusiveknowledgeofmeaning.notconsideredinterpretationsbut
meaningdirectlyexperienced.Ontheotherhand:Delusionlikeideas.emergeunderstandablyfromother
psychiceventsandcanbetracedbackpsychologicallytocertainaffects,drives,desiresandfears.Jaspers
givessomefurtherexamplesofthedistinction[Table1].Theprimarydelusionisadirect,immediateor
unmediatedphenomenonwhiletheotherthreeformsofbeliefareallmediatedbythought.Thatis,normal
beliefs,overvaluedideasanddelusionlikeideasareallreflective,consideredinterpretations.Infact,the
primarydelusionisessentiallynotabelieforjudgmentatallbutratheranexperience.Jasperswrites
exactlythatPhenomenologicallyitisanexperience.TheGermanisprimareWahnerlebnisprimary
delusionalexperience.
Primarydelusionistheexperienceofdelusionalmeaning.Theexperienceofmeaning(Bedeutung)is
implicitinallperceptionanditisthedistortionofthisimplicitmeaningwhichistheprimarydelusional
experience.Jaspersbeginswithexamplesfrommundaneperceptions:Allthinkingisthinkingabout
meanings.Perceptionsarenevermechanicalresponsestosensestimulithereisalwaysatthesametimea
perceptionofmeaning.Ahouseisthereforpeopletoinhabit.IfIseeaknife,Iseedirectly,immediatelya
toolforcutting.Wemaynotbeexplicitlyconsciousofthemeaningswemakewhenweperceivebut
neverthelesstheyarealwayspresent.Jaspersgoeson:Now,theprimarydelusionalexperienceis
analogoustothisseeingofmeanings.Theawarenessofmeaningundergoesaradicaltransformation.The
directorimmediate,intrusiveknowledgeofmeaningistheprimarydelusionalexperience.Thesearenot
consideredinterpretationsbutdirectexperiencesofmeaningwhileperceptionitselfremainsnormaland
unchanged.Allprimarydelusionalexperienceisanexperienceofmeanings.
Themeaningforpeopletoinhabitisimplicitintheperceptionofahouse.Themeaningforcuttingis
implicitintheperceptionofatool.Inexactlythesameway,thedelusionalmeaningisimplicitinthe
primarydelusionalexperience.ExamplesofprimarydelusionswillhelpclarifyJaspersmeaning:
Suddenlythingsseemtomeansomethingquitedifferent.Thepatientseespeopleinuniforminthestreet
theyareSpanishsoldiers.ThereareotheruniformstheyareTurkishsoldiers.Thenamaninabrown
jacketisseenafewstepsaway.HeisthedeadArchdukewhohasresurrected.Twopeopleinraincoatsare
SchillerandGoethe.[andfromanotherpatient]:InthemorningIranawayasIwentacrossthesquarethe
clockwassuddenlyupsidedownithadstoppedupsidedown.Ithoughtitwasworkingontheotherside
justthenIthoughttheworldwasgoingtoendonthelastdayeverythingstopsthenIsawalotofsoldiers
onthestreetwhenIcameclose,onemovedawayah,Ithought,theyaregoingtomakeareportthey
knowwhenyouareawantedpersontheykeptlookingatmeIreallythoughttheworldwasturning
roundme.Intheafternoonthesundidnotseemtobeshiningwhenmythoughtswerebadbutcameback
whentheyweregood.ThenIthoughtcarsweregoingthewrongwaywhenacarpassedmeIdidnothear
it.IthoughttheremustberubberunderneathlargeLorriesdidnotrattlealonganymoreassoonasacar
approached,Iseemedtosendoutsomethingthatbroughtittoahalt.Ireferredeverythingtomyselfasifit
weremadeformepeopledidnotlookatme,asthoughtheywantedtosayIwasaltogethertooawfulto
lookat.ForJaspers,thesetwopatients,andespeciallythesecond,arefacingashowerofnewprimary
delusionalmeanings.
KurtSchneidersimpetusfromabout1925onwardswastoreformulateclinicalpsychopathologyona
descriptivebasis,avoidinginterpretationandspeculationwhereverpossible.Itremainedinaccordance

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withJaspersideasofpsychopathologyhowever,Schneiderconsidereditimportantnottoreturntothe
elementaryconceptofassociationpsychology,buttokeeptheclinicalandbiographicalcontextinmind
(Schneider,1980).Schneidermainlydealtwithdelusionsthroughtheirformalstructure.He,too,wasin
searchofacriterionthatcoulddifferentiatereliablybetweendelusionproperanddelusionlike
phenomena,andsuchacriterion,inhisview,wasdelusionalexperience(Wahnwahrnehmung),which
wasdefinedasatwostepprocess:Thesensoryinputiscorrect,whereasitsinterpretationisdelusional.
Thepatient,forexample,seesadarkcloudinthesky,which,forhim,isproof,beyonddoubt,thathewill
diethedayafter.This,inKurtSchneidersview,isdelusionalinanarrowsense.Unlessanorganiclesion
ofthecentralnervoussystemcanbeidentified,heregardedsuchanexperienceasafirstranksymptom
ofschizophrenia.
STRUCTURALDYNAMICAPPROACH
TheGermanpsychiatristandpsychopathologistWernerJanzarikdevelopedhistheoryofstructural
dynamicsbeginninginthe1950s.Itisaninterestingandunderestimatedapproachtotheunderstandingof
psychoticdisorders,beyondmereoperationalismandbeyondpsychoanalyticalinterpretation.Inmental
life,healthyordisordered,Janzarikdifferentiatedbetweenstructuralcomponentsthatareratherfirmand
longstanding,suchasbasicideasandvalues,fromtheirdynamicqualities,whichmainlyaddressthe
affectivefield.Inhealthypersons,thedynamicaspectislinkedtocertainstructuralcomponents,which
mayhavegeneticorpsychologicaloriginsormayjustresultfromalearningprocess.Inpsychosis,
includingmanydelusionalstates,however,thesedynamicforces,notbeingsufficientlyintegratedintothe
structuralcomponents,willshowaderailment,clinicallypresentingasrestrictionthedepressivepole,
expansionthemanicpole,orinstability(Unstetigkeit)theacutepsychoticpole.Inthelattercase,there
willoftenappearwhatiscalledanincreasinglyimpressivewayofexperiencing.Thismeansthatinthe
patientsperspectivemany,ifnotallperceptions,eventhoseofminorornoimportanceforthatperson,
gainhighandembarrassingpersonalsignificance,albeitinanodd,vague(impressive)manner.Klaus
Conrad(1958)gaveamasterfuldescriptionofthispsychopathologicalphenomenoninhisbookon
BeginningSchizophrenia.Hearguedthatsensoryinputwillbesubjectivelyalteredandwillbecome
symbolical,frightening,oreventhreatening.Thepsychoticpersonwilloftenhavetheimpressionofideas
orexperiencesbeingforceduponhimorherbyanexternalpower.Thiswillclinicallybedescribedasa
delusionalsyndrome.
ANTHROPOLOGICALANDDASEINSANALYTICALAPPROACH
Binswangersaysthatonemustdealwithhumanexistenceasawholeinordertounderstanditsparticular
abnormalities.DelusionforBinswangerisapathologicaltypeofworlddesign.Worlddesignisaterm
whichreflectstheorganizationofalltheconsciousandunconsciousattitudesofahumanbeingtowardsall
thatissensible.Minkowskiattemptstocharacterizementaldisorderassomesinglefundamental
disturbance(troublegenerator)andhethinksthatallsuchdisturbancesarespatiotemporalinnatureby
thishemeansthatthepatientwithadelusionofpersecutionisnolongerabletoperceivethechancenature
ofallthathappensaroundhimowingtoafeelingofrestrictionoffreedomandmovement(the
spatiotemporaldisturbance),andsorefersitalltohimselfthusinthedelusionofpersecutionwhatthe
patientwantsisnotafeelingofbenevolencetowardshimbutafeelingofeaseandfreedom.Rumke
maintainsthatdelusionisaproductofanill,notanormalperson.Heoffersasproofthataftertheir
recoverypatientsclaimtheydidnotmeanexactlywhattheysaid.Healsobelievesthatdelusionisa
secondaryandlessimportantphenomenon,andthatwhatisofrealinteresttothepsychiatrististheinner
attitudeofthepatient,hisworlddesignandhiswayofthinking,eventhough,ashestates,phenomenology
ofthiskindwillneverteachustoexplaintheillness,itonlyputsusinapositiontounderstandit.
Kronfeldsviewcanbestbesummarizedasfollows:Adelusionistheresultofthefailureofthe
objectifyingactbecauseofthestrengthoftheintentionalact.Byobjectifyingactismeantthe
exerciseofmansabilitytobeawareofhisownintentionandaction,andbyintentionalactismeantthe

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exerciseofmansabilitytowish,desireandimaginesomeparticularaction.Thestrengthofthis
intentionalactmaybecomesogreatthattheegofailstoobjectifyit,i.e.,toidentifyitcorrectlyasawish,
andthusadelusionisestablished.Putsimply,Kronfeldsaysthatthedelusionalpatientcannotdistinguish
betweenphantasyandrealitythishassomeconceptualsimilaritytothenotionofprojection:Onedoesnot
recognizeonesownideasasonesownandattributesthemtotheexternalandobjectiveenvironment.The
anthropologicalapproachandthatofDaseinsanalyseconsiderstheproblemofdelusionswithregardto
theirspecificrelevanceforthewholelifeofthedeludedperson.Thecentralideahereisthatwithinan
existentialcrisisofthedeludedpersonadelusioncanserveasakindofcopingorproblemsolvingalbeit
apathologicalonefromtheperspectiveofothers.Ofcourse,thiswayofresolvingthecrisisitselfcreates
moreproblems,andisevenharmful,especiallytocommunicationwithothers.Thisisneverthelessalesser
evilforthesufferer,becauseitcanallowanewstabilityofmentalstate,eventhoughpathological.Here,a
delusion(andpsychosisingeneral)isunderstoodasaveryspecifichumanwayofbeingintheworld,
therootsofwhichlieinabasicdisturbanceofinterpersonalcommunication.
BIOGRAPHICALAPPROACH
Theperiodofromanticpsychiatry,whichhadasignificantinfluenceonthedevelopmentofEuropean
psychiatryatleastinthefirstdecadesofthe19thcentury,focusedoncomplexbiographicalandemotional
aspectsofhumanlifemorethanontherationalisticperspective,which,inturn,hadbeenthecentralpoint
ofreferenceduringtheperiodofenlightenmentinthe18thcentury(Steinberg,2004).Thisframeworkof
romanticismwasnearlysweptawayaround1850byanaturalisticattitude,whichwasalliedtothenatural
sciencesandbiologicallyorientedgeneralmedicineandpsychiatry,whichbecamemoreandmore
successful.Ratherthangoingintodetailonthisspecificissue,Iwanttoaddresstherediscoveryofthe
biographicalapproachtodelusionsintheearly20thcentury.Earlyinthe20thcenturytwoinfluential
psychiatrists,RobertGauppandErnstKretschmer,focusedonthecorrelationbetweenbiographyand
personalitytraitsofpeoplelaterdiagnosedasdeluded.Kretschmercoinedthetermsensitivedelusionof
reference(sensitiverBeziehungswahn).Themainhypothesiswasthatvulnerableandanancastic
personalitytraitsincombinationwithrealandrepeatedinsultswillfirstleadtoadysphoricandsuspicious
attitude,andthen,ifnosolutionisfound,todelusionlikeideasand,finally,toadelusionproper.In
contrasttotheideasofearlypsychoanalysis,thisapproachdidnotclaimtoexplainthegenesisofa
delusioninthesenseofcausality,buttoidentifytypicalpatternsofsituationsandconditionsthatleadto
delusionalstates.Thisexplicitlyincludedbiologicalfactors,atthattimeoftencalledconstitutional.
Kretschmerspokeoftheneedforamultidimensionalpsychiatryaverymodernconceptindeed.The
casethatrepresentsthisapproachmostprominentlyisthatofErnstWagner(18741938).Hewasateacher,
livingwithhisfamily(hiswifeandfourchildren)inDegerlochnexttoStuttgartinsouthernGermany.In
thenightfrom3to4September1913,hekilledallfivemembersofhisfamilywhiletheyweresleeping
andlatershotorwoundedatleast20otherpersonsandsetfiretoseveralhouses.Hewasexaminedfor
forensicpurposesbyRobertGaupp,whofoundhimnotresponsibleforhisdeedsbecauseofthechronic
developmentofadelusionaldisorder,withthebackgroundofhavingbothsensitivepersonalitytraitsand
distressinglifeevents.Wagnerwasnotsenttojail,butremainedinseveralpsychiatrichospitalsfor
decades,wherehebegantowritedramasandnovels.
PSYCHOANALYTICALAPPROACH
ForFreudandmanyofhisearlypupils,delusionslikethemajorityofpsychopathologicalsymptoms
weretheresultofaconflictbetweenpsychologicalagencies,theid,ego,andsuperego.Delusion,briefly
stated,isseenasapersonalunconsciousinnerstateorconflictwhichisturnedoutwardsandattributedto
theexternalworld.Heconsideredthatlatenthomosexualtendenciesespeciallyformedthebasisof
paranoiddelusions.Later,psychoanalyticalauthorsgaveupthisverynarrowhypothesisandsuggestedthat
delusionsmightbeacompensationforanyi.e.notnecessarilysexualityrelatedkindofmental
weakness,e.g.lackofselfconfidence,chronicanxietyoridentitydisturbances.Thisconceptinaway

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resemblesAlfredAdlerstheoryofindividualpsychology,inwhichtheconsequencesofpersonalfailures
orshortcomingsplayamajorroleintheetiologyandpathogenesisof(neurotic)mentaldisorders(Adler,
1997).Thebestknownexamplefortheapplicationoftheabovementionedpsychoanalyticalargumentsin
thedebateondelusionisFreudspaperontheSchrebercase.
NEUROBIOLOGICALAPPROACH
Therestillisnocomprehensiveneurobiologicaltheoryofdelusionformationormaintenance,although
variousempirical,conceptualandspeculativeargumentshavebeenproposed,oftenresultingfromthe
discussionofpsychoticstatesoccurringduringneurologicaldisorders(Munro,1994).Inrecentdecades
therehasbeensignificantprogressinpsychopharmacology,psychiatricgeneticsandfunctional
neuroimaginginthestudyofpsychoticandaffectivedisorders.Theproblemremains,however,thatmost
neurobiologicalstudieshavenotaddresseddelusionsperse,nordelusionaldisorder/paranoia,duetoits
rarity.Rather,theytendtobeaboutschizophrenicor,worse,psychoticdisordersinalltheir
heterogeneity.Thesepsychosesmayormaynothavehaddelusionalfeatures.So,alltheneurobiological
hypothesesthatweresuggestedinconnectionwithdelusionalsyndromesmustbereadwiththecaveatthat
theymightatleastpartlyrelatemoretopsychosisthantodelusion,e.g.thehypothesesof
hyperdopaminergicactivity,functionaldisconnectionoffrontalandtemporalbrainareas,ordisturbed
basalinformationprocessing,asdetectablebyevokedpotentialtechniques.Theclinicalefficacyof
antipsychoticsinacutelypsychoticpatientswithdelusionalandhallucinatorysyndromesisanargumentin
favorofthehypothesisofdopaminergichyperactivityinmesolimbicandmesocorticalcircuits,sincethese
agentshaveincommontheirdopamineantagonisticproperties.Asfordelusions,however,thisefficacyis
typicallylimitedtoacuteorsubacutestates,whereaschronicdelusions,andespeciallytherareconditionof
paranoia,often,althoughnotinvariably,proveresistanttoantipsychotic(andotherbiologicaland
psychotherapeutic)treatments.AhypothesisproposedbySpitzer(1995)combinestheaspectofdisturbed
dopaminergicneurotransmissionindeludedpatientswiththeconceptofneuralnetworksderivedfrom
computationalscience.Onthebasisofreplicatedfindingsfromwordassociationstudies(semantic
primingparadigm),hesuggeststhatelevateddopaminergictransmissionwillresultinanincreasedsignal
noisedifferenceintheneuralnetwork.Incomputersimulationmodels,theartificialnetwillshow
propertiesthatinafarreachingconclusionbySpitzerresembleclinicalfeaturesofdeludedpatients,
e.g.thetendencytorelateanyexperience,howeverirrelevantitmayobjectivelybe,tothepatients
personalsituation,ofteninanegativeoreventhreateningway.
ANALYTICALPHILOSOPHYOFMIND/LINGUISTICAPPROACH
Inrecentphilosophicalliterature,thereisaninterestinglineofthoughtconcerningthequalitativestatusof
subjectiveexperiencesthatisimportantforthepsychiatrist.Themeaningofqualitativehereisthe
specificqualityofacertainexperience,forexampletheexperienceofcolororpain.Thisisusuallycalled
thequaliaproblem.Thequestioniswhatpreciselymakesthedifferencebetweenastatementofinternal
experience(e.g.,Ilikethatrichredcolor)andastatementabouttheouterworld(e.g.,Itisraining).An
importantdifferenceisthatutterancesaboutonesownmentalstatesarenotsubjecttoexternalvalidation
andthereislittleexpectationoftestingthem,whereasstatementsabouttheouterworldarealways
verifiableandsubjecttocorrections,whetherbyobservationorsuperiorrationalargumentsbyanother
person.Tomakethiscentralissuemoreconcrete,thestatements,Ihaveaheadache,Iamsad,and,I
amangry,cannotbecorrectedbyanyargumentbyanotherperson.Thepropertyincorrigibilityat
leastsinceJasperswritingsalsoconstituteaprominentcriterionofdelusionalstates.Spitzer(1990)
appliedthisformalargumenttodelusionalstatementsandcametotheconclusionthatweshouldidentify
delusionwheneverapersonspeaksabouttheouterworldwiththesamehighdegreeofsubjectivecertainty
thatisusuallyonlyobservedinutterancesaboutonesinnerexperiencesi.e.withthequalityof
incorrigibility.Forexample,ifaparanoidpersonsaysthatheorsheisbeingobservedbythesecret
serviceallday,thisstatement,ifdelusional,wouldhavethesameincorrigibledegreeofsubjective

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certaintyasthesentence,Iamsad.
HALLUCINATIONS
Adelusionmightbeanattemptatexplainingahallucinatoryexperience.Wernickecalledsuchadelusion,
delusionofexplanation.However,eventheearlydescriptionbyLaseguein1852ofdelusionsof
persecutionandoftheircommonassociationwithauditoryhallucinationsneverfirmlystatedthetemporal
relationshipbetweendelusionsandhallucinations.Wecannotcalluponanyestablishedknowledgeinthe
fieldofstudyofhallucinationstohelpanswerthequestion.Frenchpsychiatrydoesdistinguishtwotypes
ofhallucinations,oneofwhichis,onemighthold,morelikeadelusionthanhallucination.Thetwotypes
arethetruehallucinationwithfullimpressionoftheexternalnatureofthesensationandthesocalled
mentalhallucinationwherethereisnoimpressionoftheexternalnatureofthesensation,onlyabeliefthat
onehasseensomething,orverycommonly,thatonehasheardvoicesornoisesorpersonstalkingtoone.
Thephenomenonofmentalhallucinationprobablydeservesaplaceamongsttheotherphenomenaof
delusionandhallucination.
DECLERAMBAULTSAUTOMATISMS
Theroleofthehallucinatorytypesofexperienceisbetterdiscussedtogetherwithalltheothersocalled
automatisms.DeClerambaultholdsthatdelusionsarethereactionsofanabnormalpersonalityto
automatisms.Briefly,histheoryisananatomicalhypothesisthatsystematizedchronichallucinatory
psychosisisbasedonanatomicalprocessesinthebrainduetoinfections,lesions,toxins,traumataor
sclerosis.Theseanatomicalinsultsproducementalautomatismswhichmarkthebeginningofthe
psychosis.ContrarytoprevalentbeliefsdeClerambaultmaintainedthatatthebeginningthese
automatismswereneutralinfeelingtone.Thepatienttendedtobepuzzledbythembuttheywereneither
pleasantnorunpleasant.DeClerambaultalsodescribedtheseautomatismsasnonsensoryincharacter,to
distinguishthemfromhallucinations[Table2].Apatientassailedbysuchautomatismsmayattemptto
explainthemasintentionalandproducedelusionssuchasdelusionsofinfluence,possession,persecution
andsoon.DeClerambaultstheoreticalnotionsregardingthecausationofchronichallucinatorypsychosis
havebeensubjectedtocriticism.Intheabsenceofpublishedstudiesofthefrequencyandnatureofthe
relationshipbetweentheautomatismsanddelusionalstates,theautomatismsremainashypotheticalcauses
ofdelusions.
PERCEPTIONALAPPROACH
AsMaher(1974)suggested,adelusioniscontrarytotheclassicalpositionnotacognitivedisturbance,
especiallyleadingtoflawedconclusionsfromcorrectlyperceivedsensoryinput,butanormalcognitive
reactiontounexpected,strangementalevents,especiallyperceptions.Inearlystagesofdelusionalor,more
generally,psychoticdisordersthepatientmayregisterdistressingalterationsinsensoryqualitiese.g.,
thingsseembiggerorsmallerthanusual,orlook,feelorsmelldifferent.Suchdeeplyworryingstrangeness
ofexperiencesisregardedasthestartingpointofadevelopmentleadingfromsuspiciousnesstovague
paranoidideationand,finally,tosystematizeddelusions.Theseexperiencesmaybepartlyexplainedorat
leastmadelessfrighteningbytheconstructionofatheoreticalbackgroundofsomeonewhodoesallthis
deliberatelyonthegroundsofcertainmotives,betheyknowntothepatientornot.Thisposition,of
course,marksasharpcontrasttoKurtSchneidersviewofdelusionalexperience.
ATTRIBUTIONALANDCOGNITIVEPSYCHOLOGYAPPROACH
Sincethe1990stherehasbeenanincreaseinpsychologicalresearchoncognitiveprocessesindeluded
patients.Inthislineofthought,thetraditionalassumptionofundisturbedcognitivefunctionsindelusional
disorder,i.e.pathologicalcontentonthebasisofnormalformofthought,wasquestioned.Inordertocome
closertodelusionrelatedphenomenathemselvesascomparedtothemuchbroaderpsychosisrelated
phenomenaanumberofstudiescomparedpatientswithandwithoutdelusionalideation.Suchaprocess

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alsoledtoanumberofinterestingtherapeuticimplications.Threeapproachesareworthyofmention.
Decisionmakingparadigm:Severalgroupsfoundthatinsimple,affectivelyneutraldecisionmaking
paradigms,adeludedpersonneedslessinformationtoarriveatadefinitedecisionthanpersons
withoutadelusionorpeoplewithadepressivedisorder.Thelatterneededsignificantlymore
information.Withregardtodelusions,thisphenomenonwascalledjumpingtoconclusionsand
wasinterpretedasanargumentfordisturbedcognitiveprocessesinthecaseof(persecutory)
delusion(Garety&Freeman,1999).
Attributionpsychology:Anumberofresearchgroupsconfirmedthefindingthat,incomparisonto
healthypersons,deludedpatientstendtoattributenegativeeventsorsituationsmoreoftentoother
peopleortoexternalcircumstancesandnottothemselves.Thisisalsotruefortopicsthathave
nothingtodowiththeactualdelusionaltheme.Forclinicianshavinghadexperiencewithparanoid
patients,thisisnotasurprisingfinding,butitbecomesinterestingwhenregardedasanargumentin
favorofstablepathologicalpatternsinthesocialcognitionofdeludedpersons.Recently,thispath
hasreachedbeyondtheattributionalperspectiveitselfandencompassescognitivemodelsof
delusionalthinkingingeneral,sometimeswithastrongneurobiologicalimpact(Blackwoodetal.,
2001).
Theoryofmind:AccordingtoFrith&Frith(1999),patientswithparanoidschizophreniasufferfrom
adeficitinunderstandingcorrectlywhatothersthinkaboutthepatientandwhattheirfutureattitudes
oractionstowardsthepatientmightbe.Thisphenomenoniswellknownfromautismresearch,and
isoftencalledtheoryofminddeficit.Itisthereducedabilitytoformavalidhypothesisabout
anotherpersonsstateofmindwithregardtooneself.Paranoidor,moregenerallyspeaking,
delusionalideationinthisviewisaresultofdisturbedcognitiveandsocialmetarepresentation.
DEFINITIONOFDELUSION
Therecanbenophenomenologicaldefinitionofdelusion,becausethepatientislikelytoholdthisbelief
withthesameconvictionandintensityasheholdsothernondelusionalbeliefsabouthimselforasanyone
elseholdsintenselypersonalnondelusionalbeliefs.Subjectively,adelusionissimplyabelief,notionor
idea.
KraepelininthenintheditionofhisTextbookdefineddelusionalideasaspathologicallyderived
errors,notamenabletocorrectionbylogicalprooftothecontrary.
AsperStoddart,adelusionisajudgmentwhichcannotbeacceptedbypeopleofthesameclass,
education,raceandperiodoflifeasthepersonwhoexperiencesit.
Jaspers(1959)regardedadelusionasapervertedviewofreality,incorrigiblyheld,havingthree
components:
1.Theyareheldwithunusualconviction
2.Theyarenotamenabletologic
3.Theabsurdityorerroneousnessoftheircontentismanifesttootherpeople.
Hamilton(1978)defineddelusionasAfalse,unshakeablebeliefwhicharisesfrominternalmorbid
processes.Itiseasilyrecognizablewhenitisoutofkeepingwiththepersonseducationaland
culturalbackground.
AccordingtoSims(2003),adelusionisafalse,unshakeableideaorbeliefwhichisoutofkeeping
withthepatientseducational,culturalandsocialbackgrounditisheldwithextraordinary
convictionandsubjectivecertainty.
IntheDiagnosticandStatisticalManualofMentalDisorders,adelusionisdefinedas:Afalsebelief
basedonincorrectinferenceaboutexternalrealitythatisfirmlysustaineddespitewhatalmost
everybodyelsebelievesanddespitewhatconstitutesincontrovertibleandobviousprooforevidence
tothecontrary.Thebeliefisnotoneordinarilyacceptedbyothermembersofthepersonscultureor
subculture(e.g.itisnotanarticleofreligiousfaith).

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Thefactthatadelusionisfalsemakesiteasytorecognizebutthisisnotitsessentialquality.Avery
commondelusionamongmarriedpersonsisthattheirspousesareunfaithfultothem.Inthenatureof
things,someofthesespouseswillindeedhavebeenunfaithfulthedelusionwillthereforebetrue,butonly
bycoincidence(Casey&Kelly,2008).
Kendleretal.,(1983)haveproposedseveralpoorlycorrelatedvectorsofdelusionalseverity:
1.Conviction:Thedegreetowhichthepatientisconvincedoftherealityofthedelusionalbeliefs.
2.Extension:Thedegreetowhichthedelusionalbeliefinvolvesareasofthepatientslife.
3.Bizarreness:Thedegreetowhichthedelusionalbeliefdepartsfromculturallydetermined
consensualreality.
4.Disorganization:Thedegreetowhichthedelusionalbeliefsareinternallyconsistent,logicaland
systematized.
5.Pressure:Thedegreetowhichthepatientispreoccupiedandconcernedwiththeexpressed
delusionalbeliefs.
6.Affectiveresponse:Thedegreetowhichthepatientsemotionsareinvolvedwithsuchbeliefs.
7.Deviantbehaviorresultingfromdelusions:Patientssometimes,butnotalways,actupontheir
delusions.
CLASSIFICATION
Thereisnorecognizedwayofclassifyingdelusionsaccordingtoanyphenomenologicalprinciples.Tables
3and4givestheclassificationgivenbyCutting(1997).
Primaryandsecondarydelusions

Thetermprimaryimpliesthatdelusionisnotoccurringinresponsetoanotherpsychopathologicalform
suchasmooddisorder.AccordingtoJaspersthecoreofprimarydelusionisthatitisultimatelyun
understandable.Secondarydelusionsareunderstandablewhenadetailedpsychiatrichistoryand
examinationisavailable.Thatis,theyareunderstandableintermsofthepatientsmoodstate,tothe
circumstancesofhislife,tothebeliefsofhispeergroupandtohispersonality.Adelusion,whether
primaryorsecondaryinnature,isbasedondelusionalevidence:thereasonthepatientgivesforholding
hisbeliefislikethebeliefitself,false,unacceptableandincorrigible.Gruhle(1915)consideredthata
primarydelusionwasadisturbanceofsymbolicmeaning,notanalterationinsensoryperception,
apperceptionorintelligence.Wernicke(1906)formulatedtheconceptofanautochthonousideaanidea
whichisnativetothesoil,aboriginal,arisingwithoutexternalcause.Thetroublewithfindingsupposed
autochthonousorprimarydelusionsisthatitcanbedisputedwhethertheyaretrulyautochthonous.For
thisreasontheyarenotconsideredoffirstrankinSchneiders(1957)classificationofsymptoms.
Typesofprimarydelusions

Delusionalmood/atmosphereDelusionalperceptionDelusionalmemoryDelusionalideasDelusional
awareness.
Delusionalmood Itisusuallyastrange,uncannymoodinwhichtheenvironmentappearstobechangedin

athreateningwaybutthesignificanceofthechangecannotbeunderstoodbythepatientwhoistense,
anxiousandbewildered.Finally,adelusionmaycrystallizeoutofthismoodandwithitsappearancethere
isoftenasenseofrelief.
Delusionalperception Inthisanabnormalsignificance,usuallyinthesenseofselfreference,despitethe

absenceofanyemotionalorlogicalreason,isattributedtonormalperception.Jaspersdelineatedthe
conceptofdelusionalperceptandGruhle(1915)usedthisdescriptiontocoveralmostalldelusions.
Schneider(1949)consideredtheessenceofdelusionalperceptiontobetheabnormalsignificanceattached
toarealperceptwithoutanycausethatisunderstandableinrationaloremotionaltermsitisselfreferent,

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momentous,urgent,ofoverwhelmingpersonalsignificanceandofcoursefalse.
Delusionalmemory Thisisthesymptomwhenthepatientrecallsasrememberedaneventorideathatis

clearlydelusionalinnature,thatis,delusionisretrojectedintime.Thesearesometimescalled
retrospectivedelusions.
Delusionalideas Theyappearabruptlyinthepatientsmind,arefullyelaborated,andunheraldedbyany

relatedthoughts.
Delusionalawarenessisanexperiencewhichisnotsensoryinnature,inwhichideas
oreventstakeonanextremevividnessasiftheyhadadditionalreality.Delusionalsignificanceisthe
secondstageoftheoccurrenceofdelusionalperception.Objectsandpersonsareperceivednormally,but
takeonaspecialsignificancewhichcannotberationallyexplainedbythepatient.Finedistinctionsare
sometimesimposedupontheclassificationofprimarydelusions,butaremorecollectorsitemsthan
featuresofusefulclinicalsignificance.
Delusionalawareness

CONTENTOFDELUSIONS
Delusionsareinfinitelyvariableintheircontentbutcertaingeneralcharacteristicscommonlyoccur.Itis
determinedbytheemotional,socialandculturalbackgroundofthepatient.Commongeneralthemes
includepersecution,jealousy,love,grandiose,religious,nihilistic,hypochondriacalandseveralothers.
Delusionofpersecution

Itisthemostfrequentcontentofdelusion.Itwasdistinguishedfromothertypesofdelusionandother
formsofmelancholiabyLasegue(1852).Theinterferingagentmaybeanimateorinanimate,otherpeople
ormachinesmaybesystem,organizationsorinstitutionsratherthanindividuals.Sometimesthepatient
experiencespersecutionasavagueinfluencewithoutknowingwhoisresponsible.Mayoccurin
conditionslike:Schizophrenia,Affectivepsychosis:Manic,Depressivetype,andOrganicstates:Acute,
chronic.Persecutoryovervaluedideasareaprominentfacetofthelitiginoustypeofparanoidpersonality
disorder.
Delusionofinfidelity

DescribedbyEy(1950)maybemanifestedasdelusion,overvaluedidea,depressiveaffectoranxietystate.
Varioustermshavebeenusedtodescribeabnormal,morbidormalignantjealousy.Kraeplinusedtheterm
sexualjealousy.EnochandTrethowan(1979)haveconsideredthedemonstrationofdelusionofinfidelity
indistinguishingpsychoticfromothertypes.
Mullen(1997)hasclassifiedmorbidjealousywithdisordersofpassioninwhichthereisanoverwhelming
senseofentitlementandaconvictionthatothersareabrogatingtheirrights.Theothertwoarethe
querulantwhoareindignantatinfringementsofrightsandtheerotomanicwhoaredriventoasserttheir
rightsoflove.Delusionofinfidelitymayoccurwithoutotherpsychoticsymptoms.Suchdelusionsare
resistanttotreatmentanddonotchangewithtime.Delusionsofjealousyarecommonwithalcoholabuse,
theymayalsooccurinsomeorganicstates,andareoftenassociatedwithimpotence,e.g.thepunchdrunk
syndromeofboxersfollowingmultiplecontracoupcontusion.Morbidjealousyariseswiththebeliefthat
thereisathreattotheexclusivepossessionofhiswife,butthisisjustaslikelytooccurfromconflicts
insidehimself,hisowninabilitytoloveorhissexualinterestdirectedtowardssomeoneelse,asfrom
changingcircumstancesinhisenvironmentorhiswifesbehavior.Husbandsorwivesmayshowsexual
jealousy,asmaysexualcohabiteesandhomosexualpairs.Morbidjealousymakesamajorcontributionto
thefrequencyofwifebatteringandisoneofthecommonestmotivationsforhomicide.
Delusionsoflove

ErotomaniawasdescribedbySirAlexanderMorrison(1848)asbeing:Characterizedbydelusionsthe

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patientsloveisofsentimentalkind,heiswhollyoccupiedbytheobjectofhisadoration,whomifhe
approachitiswithrespect.Therespectthefixedandpermanentdelusionsattendingerotomaniasometimes
promptthoselaboringunderittodestroythemselvesorothers,forthoughingeneraltranquilandpeaceful,
thepatientsometimesbecomesirritable,passionateandjealous.Erotomaniaiscommonerinwomenthan
menandavarietyhasbeencalledoldmaidsinsanitybyHart(1921),inwhichpersecutorydelusions
oftendevelop.Thesehavesometimesbeenclassifiedasparanoia,ratherthanparanoidschizophreniathese
delusionalsymptomssometimesoccurinthecontextofmanicdepressivepsychosis.Trethowan(1967)
demonstratedthesocialcharacteristicsoferotomania,relatingthepatientspreviousdifficultiesinparental
relationshipstothepresenterotomania.Avariationoferotomaniawasdescribedbyandretainsthename
ofdeClerambault(1942).Typically,awomanbelievesaman,whoisolderandofhighersocialstatusthan
she,isinlovewithher.
Grandiosedelusions

Inthisthepatientmaybelievehimselftobeafamouscelebrityortohavesupernaturalpowers.Expansive
orgrandiosedelusionalbeliefsmayextendtoobjects,soleadingtodelusionofinvention.Grandioseand
expansivedelusionsmayalsobepartoffantastichallucinosis,inwhichallformsofhallucinationsoccur.
Religiousdelusions

Thereligiousnatureofthedelusionisseenasadisorderofcontentdependentonthepatientssocial
background,interestsandpeergroup.Theformofthedelusionisdictatedbythenatureoftheillness.So
religiousdelusionsarenotcausedbyexcessivereligiousbelief,norbythewrongdoingwhichthepatient
attributesascause,buttheysimplyaccentuatethatwhenapersonbecomesmentallyillhisdelusions
reflect,intheircontent,hispredominantinterestsandconcerns.Althoughcommon,theyformedahigher
proportioninthenineteenthcenturythaninthetwentiethcenturyandarestillprevalentindeveloping
countries.
Delusionsofguiltandunworthiness

Initiallythepatientmaybeselfreproachfulandselfcriticalwhichmayultimatelyleadtodelusionsof
guiltandunworthiness,whenthepatientsbelievethattheyarebadorevilpersonsandhaveruinedtheir
family.Theymayclaimtohavecommittedanunpardonablesinandinsistthattheywillrotinhellforthis.
Thesearecommonindepressiveillness,andmayleadtosuicideorhomicide.
Delusionsofnegation/nihilisticdelusions

Thesearethereverseofgrandiosedelusionswhereoneself,objectsorsituationsareexpansiveand
enrichedthereisalsoaperversegrandiosityaboutthenihilisticdelusionsthemselves.Feelingsofguilt
andhypochondriacalideasaredevelopedtotheirmostextreme,depressiveforminnihilisticdelusions.
Factorsconcernedinthegerminationofdelusions:
1.Disorderofbrainfunctioning
2.Backgroundinfluencesoftemperamentandpersonality
3.Maintenanceofselfesteem
4.Theroleofaffect
5.Asaresponsetoperceptualdisturbance
6.Asaresponsetodepersonalization
7.Associatedwithcognitiveoverload.
Factorsconcernedinthemaintenanceofdelusions:
1.Theinertiaofchangingideasandtheneedforconsistency

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2.Povertyofinterpersonalcommunication
3.Aggressivebehaviorresultingfrompersecutorydelusionsprovokeshostility
4.Delusionsimpairrespectforandcompetenceofthesuffererandpromotecompensatorydelusional
interpretation.
Noneofthesefactorsareabsolutebutanyorallmayactsynergisticallytoinitiateandmaintaindelusion.
STAGESOFDELUSIONFORMATION
Conradproposedfivestagesofwhichareinvolvedintheformationofdelusions:
1.Trema:Delusionalmoodrepresentingatotalchangeintheperceptionoftheworld
2.Apophany:Asearchfor,andthefindingofnewmeaningforpsychologicalevents
3.Anastrophy:Heighteningofthepsychosis
4.Consolidation:Formingofanewworldorpsychologicalsetbasedonnewmeaning
5.Residuum:Eventualautisticstate.
THEORIESOFDELUSIONFORMATION
Psychodynamictheory

Freud(1911)proposedthatdelusionformationinvolvingdenial,contradictionandprojectionofrepressed
homosexualimpulsesthatbreakoutfromunconscious.
Delusionsasexplanationsofexperience

Binswanger&Minkowski(1930)proposeddisorderedexperiencesofspaceandtimeleadingtoimprisoned
andcontrolledfeelings.Laterin1942deClerambault,putforththeviewthatchronicdelusionsresulted
fromabnormalneurologicalevents(infections,intoxications,lesions).Maherofferedacognitiveaccount
ofdelusionswhichemphasizeddisturbancesofperception.Heproposedthatadelusionalindividual
suffersfromprimaryperceptualabnormalities,seeksanexplanationwhichisthendevelopedthrough
normalcognitivemechanism,theexplanation(i.e.thedelusion)isderivedbyaprocessofreasoningthatis
entirelynormal.Also,delusionismaintainedinthesamewayasanyotherstrongbelief.Thesearefurther
reinforcedbyanxietyreductionduetodevelopingexplanationfordisturbingorpuzzlingexperiences.
vonDomarusrule

Hepostulatedthatdelusionsinschizophreniaarisefromfaultylogicalreasoning.Thedefectapparently
consistsoftheassumptionoftheidentityoftwosubjectsonthegroundofidenticalpredicates(e.g.Lord
RamawasaHindu,IamaHindu,andthereforeIamLordRama).
Learningtheory

Learningtheoristshavetriedtoexplaindelusionsintermsofavoidanceresponse,arisingspeciallyfrom
fearofinterpersonalencounter.
Luhmannssystemtheory

Luhmanndefinesthatinformation,messageandunderstandingconnectsthesocialsystemswiththe
psychicones.Ifthepsychicsystemfailstorecognizethemessageofinformationcorrectlyorisunableto
negotiatebetweenunderstandingandmisunderstandingmessage,itdetachesitselffromthesocialsystem
towhichitisnormallycloselyconnected.Thisdetachmentreleasesthepossibilityofunhinderedautistic
fulfillmentofdesiresanduncontrolledfearmayappearasdelusions.
Neurocomputationalmodel

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Thecerebralcortexcanbeviewedasacomputationalsurfacethatcreatesandmaintainsdynamicmapsof
importantsensorimotorandhigherlevelaspectsoftheorganismanditsenvironment,reflectingthe
organismsexperience.Acutedelusionsaretheresultofanincreasedactivityoftheeuromodulators
dopamineandnorepinephrine.Thisnotonlyleadstoastateofanxiety,increasedarousalandsuspicion,
butalsotoanincreasedsignaltonoiseratiointheactivationofneuralnetworksinvolvedinhigherorder
cognitivefunctions,leadingtoformationofacutedelusions.Alterationintheneuromodulatorystatenot
onlycausestheoccurrenceofunusualexperiencesbutalsomodifyneruroplasicitywhichinfluencesthe
mechanismoflongtermchanges.Sochronicdelusionsmaybemaintainedbyapermanentlyincreased
neuromodulatorystate,orbyanextremelydecreasednoradrenergicneuromodulatorystate(Blackwoodet
al.,2001).
THEORIESOFNEUROCOGNITIVEANDEMOTIONALDYSFUNCTION
Theoryofmind

Itreferstothecapacityofattributingmentalstatessuchasintentions,knowledge,beliefs,thinkingand
willingtooneselfaswellastoothers.Amongstotherthingsthiscapacityallowsustopredictthebehavior
ofothers.FrithpostulatedthatparanoidsyndromesexhibitaspecificToMdeficit,e.g.,delusionsof
referencecanbeexplained,atleastingoodpart,bythepatientsinabilitytoputthemselvesinanother
personsplaceandthuscorrectlyassesstheirbehaviorandintentions.Thoughtinsertionandideationsof
controlbyotherscanbetracedbacktodysfunctionalmonitoringofonesownintentionsandactions.
Hence,thoughtsenterthepatientsconsciousnesswithouthisorherawarenessofanyintentiontoinitiate
thesethoughts.Sincedeludedpatientsinsymptomaticremissionperformedaswellasnormalcontrolsat
ToMtasks,ToMdeficitsseemtobeastateratherthanatraitvariable.
Theroleofemotions

Delusionsdrivenbyunderlyingaffect(moodcongruent)maydifferneurocognitivelyfromthosewhich
havenosuchconnection(moodincongruent).Thus,specificdelusionrelatedautobiographicalmemory
contentsmayberesistanttonormalforgettingprocesses,andsocanescalateintocontinuousbiasedrecall
ofmoodcongruentmemoriesandbeliefs.Regardingthreatandaversiveresponse,identificationof
emotionallyweightedstimulirelevanttodelusionsofpersecutionhasbeenseen.
Probabilisticreasoningbias

Itassumesthattheprobabilitybaseddecisionmakingprocessindelusionalindividualsrequiresless
informationthanthatofhealthyindividuals,causingthemtojumptoconclusions,whichisneithera
functionofimpulsivedecisionmakingnoraconsequenceofmemorydeficit.Kempetal.,pointedoutthat
deludedpatientsarenotdeludedabouteverythingandthattheremaybenoglobaldeficitinreasoning
abilities.Thefindingsinreasoningabilitiesindelusionalpatientsareonlysubtleandonemightquestion
thestrengthoftheircausalityindelusionalthinking.
Theoryofattributionalbias

Bentallandothersproposedthatnegativeeventsthatcouldpotentiallythreatentheselfesteemare
attributedtoothers(externalizedcausalattribution)soastoavoidadiscrepancybetweentheidealselfand
theselfthatisasitisexperienced.Anextremeformofaselfservingattributionalstyleshouldexplainthe
formationofdelusionalbeliefs,atleastincaseswherethedelusionalnetworkisbasedonideasof
persecution,withoutanycooccurringperceptualorexperientialanomaly.Duringthecourseofillness,the
preferentialencodingandrecallofdelusionsensitivematerialcanbeassumedtocontinuallyreinforceand
propagatethedelusionalbelief.
Multifactorialmodel

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Theemergenceofsymptomsassumedtodependuponaninteractionbetweenvulnerabilityandstress.
Thereforetheformationofdelusionbeginswithaprecipitatorsuchaslifeevent,stressfulsituations,drug
useleadingtoarousalandsleepdisturbance.Thisoftenoccursagainstthebackdropoflongtermanxiety
anddepression.Thearousalwillinitiateinnerouterconfusioncausinganomalousexperiencesasvoices,
actionsasunintendedorperceptualanomalieswhichwillturnonadriveforasearchformeaning,leading
toselectionofexplanationintheformofdelusionalbelief[Figure1].
Neurobiologicaltheories

TheearlierworkslikeHartley(1834)suggestedthatvibrationcausedbybrainlesionmaymatchwith
vibrationsassociatedwithrealperception.Ey(1952)believeddelusiontobeasignofcerebral
dysfunctionsandMorsellilistedthemetabolicstatesfordelusionalpathogenesis.Jackson(1894)
suggestedpathogenesisofdelusionsduetocombinationoflossoffunctionsofdamagedpartofbrain.
Cummings(1985)foundthatawidevarietyofconditionscaninducepsychosis,particularlythosethat
affectthelimbicsystem,temporallobe,caudatenucleus.Healsonotedthatdopaminergicexcessor
reducedcholinergicactivityalsopredisposetopsychosis.Hesuggestedthatthecommonlocusislimbic
dysfunctionsleadingtoinappropriateperceptionandparanoiddelusionformation.
Septohippocampaldysfunctionmodel:Thedysfunctionleadstoerroneousidentificationofneutral
stimuliasimportantandjudgeexpectedasactual.Storageoferroneousinformationleadsto
delusionformation.
Semanticmemorydysfunctionmodel:Delusionsformduetoinappropriatelyingdownofsemantic
memoryandtheirrecollections.
RegionalcorrelationwithAlzheimers:Revealedasignificantrelationshipbetweenseverityof
delusionalthoughtandthemetabolicratesinthreefrontalregions.Thestudyindicatedthatseverity
ofdelusionswasassociatedwithhypometabolisminadditionalprefrontalandanteriorcingulate
regions.
Delusionofaliencontrolhasbeenlinkedwithhyperactivationoftherightinferiorparietallobule
andcingulategyrus,brainregionimportantforvisuospatialfunctions.
Organicdelusionaldisordersaremorelikelytobenotedinextrapyramidaldisordersinvolvingthe
basalgangliaandthalamusandinlimbicsystemdisease.Alexanderetal.,(1986)proposedfive
structuralfunctionalloops.Anylesions,dysfunctionsorderangementsthataffectanypartofthis
loopcanbeexpectedtoalterbeliefsandemotionalbehavior[Figure2].
THEPERSISTENCEANDELASTICITYOFDELUSIONS
Predictionerrortheoriesofdelusionformationsuggestthatundertheinfluenceofinappropriateprediction
errorsignal,possiblyasaconsequenceofdopaminedysregulation,eventsthatareinsignificantandmerely
coincidentseemtodemandattention,feelimportantandrelatetoeachotherinmeaningfulways.
Delusionsultimatelyariseasameansofexplainingtheseoddexperiences(Kapur,2003Maher,1974).
Theinsightreliefgainedbyarrivingatanexplanatoryschemeleadstostrongconsolidationofthescheme
inmemory.Insupportofthisview,aberrantpredictionerrorsignalsduringlearninginpatientswithfirst
episodepsychosishavebeenconfirmedexperimentally.Furthermore,themagnitudeofaberrantprediction
errorsignalcorrelatedwithdelusionseverityacrossagroupofpatientswithfirstepisodepsychosis.
However,thereareimportantcharacteristicsofdelusionsthatstilldemandexplanation:Notablytheir
persistence.Normalassociationscanextinguishiftheyproveerroneous,normalbeliefscanbechallenged
andmodified.Butdelusionsarenoteworthyforthefactthattheyremainevenintheabsenceofsupport
andinthefaceofstrongcontradictoryevidence.Webelievethatthisstrikingclinicalphenomenoncanbe
explainedwithinthesameframeworkbyconsideringkeyfindingsfromtheanimallearningliterature,a
literaturethathasbeenformerlyinvokedtoexplainchronicrelapsetodrugabuseextinctionand
reconsolidation.Ifdelusionformationmaybeexplainedintermsofassociativelearningthenperhaps
extinctionmayrepresenttheprocessthroughwhichdelusionsareresolved.Extinctioninvolvesadecline

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inrespondingtoastimulusthathaspreviouslybeenaconsistentpredictorofasalientoutcome.Prediction
errorisalsocentraltoextinction.Ithasbeensuggestedthatnegativepredictionerror(areductionin
baselinefiringrateofpredictionerrorcodingneurons)leadstheorganismtocategorizetheextinction
situationasdifferentfromtheoriginal,reinforced,situationanditnowlearnsnottoexpectthesalient
eventinthatsituation.Thislearningfocusesoncontextualcues,allowingtheanimaltodistinguishthe
newlynonreinforcedcontextfromtheold,reinforcedone.Extinctiondoesnotinvolveunlearningofthe
originalassociation,butrathertheformationofanewassociationbetweentheabsenceofreinforcement
andtheextinctionsituation.Extinctionexperiences(theabsenceofexpectedreinforcement)invokean
inhibitorylearningprocesswhicheventuallyoverridestheoriginalcueresponseinmidbraindopamine
neurons.Individualswithpsychosisdonotlearnwellfromtheseabsentbutexpectedevents,nordothey
consolidatethelearningthatdoesoccur.Butthereismoretodelusionmaintenancethanpersistenceinthe
absenceofsupportiveevidence:delusionspersistevenwhenthereisevidencethatdirectlycontradicts
them.Whenconfrontedwithcounterfactualevidence,deludedindividualsdonotsimplydisregardthe
information.Rather,theymaymakefurthererroneousextrapolationsandevenincorporatethe
contradictoryinformationintotheirbelief.So,whiledelusionsarefixed,theyarealsoelasticandmay
incorporatenewinformationwithoutshiftingtheirfundamentalperspective.
RESOLUTIONOFDELUSION
Onceasimpledelusionalbeliefisadoptedwithconviction,thesubsequentcourseisveryvariable.
Somepatientshavefleetingorbriefdelusionalstates,spontaneouslyremittingandreturningto
normal.
Othersrespondwelltostandardtreatment.
Otherselaborateanddeveloptheirbeliefintoacomprehensivesystemwhichmayremainunaltered
evenwithregularmedication.
Themultidimensionalityofdelusionalexperiencealsohasimplicationsfortheconceptualizationofthe
temporalcourseofpsychoticdecompensationandresolution.Individualdimensionsofdelusional
experienceoftenchangeindependentlyofoneanotherduringthecourseofapsychoticepisode,sothat
recoverycanbedeterminedbychangesinoneoftheseveraldimensions(GaretyandFreeman,1999).
PATTERNOFRESOLUTION
Encapsulation:Patientsvaryverymuchinthedegreetowhichtheycanmaintaintheiroriginal
personalityandadapttoanormallife.Itisfrequentlyseeninresidualstates.
Insomecasesoneseesalongitudinalsplittingasitwereinthecurrentoflife,boththereality
adaptedandthedelusionallifegoonalongsideeachother.
Oncertainoccasions(e.g.Meetingcertainpeople,returntofamiliarlocations,meetingthedoctor
whohadtreatedthepatient)thedelusionalcomplexcomestothesurfaceandfloridsymptoms
reappear.
Jorgensen(1995)foundthreetypesofrecovery,onewithfullandtheothertwowithpartialrecoveryof
delusionalbeliefs.Inpatientswithpartialrecovery,decreaseinpressureprecede,decreaseinother
dimensions.Fortwothirdstherewasnochangeinthedegreeorinsightduringrecovery.
CONCLUSION
Delusionsareakeyclinicalmanifestationofpsychosisandhaveparticularsignificanceforthediagnosis
ofschizophrenia.Althoughcommoninseveralpsychiatricconditions,theyalsooccurinadiverserangeof
otherdisorders(includingbraininjury,intoxicationandsomaticillness).Delusionsaresignificant
preciselybecausetheymakesenseforthebelieverandareheldtobeevidentiallytrue,oftenmakingthem
resistanttochange.Althoughanimportantelementofpsychiatricdiagnosis,delusionshaveyettobe

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adequatelydefined.Thelastdecadehaswitnessedaparticularintensificationofresearchondelusions,
withcognitiveneurosciencebasedapproachesprovidingincreasinglyusefulandtestableframeworksfrom
whichtoconstructabetterunderstandingofhowcognitiveandneuralsystemsareinvolved.Thereisnow
considerableevidenceforreasoning,attention,metacognitionandattributionbiasesindelusionalpatients.
Recently,thesefindingshavebeenincorporatedintoanumberofcognitivemodelsthataimtoexplain
delusionformation,maintenanceandcontent.Althoughdelusionsarecommonlyconceptualizedasbeliefs,
notallmodelsmakereferencetomodelsofnormalbeliefformation.Ithasbeenarguedthataberrant
predictionerrorsignalsmaybeimportantnotonlyfordelusionformationbutalsofordelusion
maintenancesincetheydrivetheretrievalandreconsolidationbasedstrengtheningofdelusionalbeliefs,
eveninsituationswhenextinctionlearningoughttodominate.Giventheproposedfunctionof
reconsolidation,indrivingautomaticityofbehavioritisarguedthatinanaberrantpredictionerrorsystem,
delusionalbeliefsrapidlybecomeinflexiblehabits.Takingthistranslationalapproachwillenhanceour
understandingofpsychoticsymptomsandmaymoveusclosertotheconsiliencebetweenthebiologyand
phenomenologyofdelusions.
Footnotes
SourceofSupport:Nil
ConflictofInterest:Nonedeclared

REFERENCES
1.AdlerA.UberdennervosenCharakter:GrundzugeeinervergleichendenIndividualpsychologieund
Psychotherapie.In:WitteK.H,editor.KommentiertetextkritischeAusgabe.Goettingen:Vandenhoeckand
Ruprecht1997.
2.BlackwoodN.J,HowardR.J,BentallR.P,MurrayR.M.Cognitiveneuropsychiatricmodelsof
persecutorydelusions.AmericanJournalofPsychiatry.2001158:527539.[PubMed:11282685]
3.BlankenburgW.AnalysenderVerselbstandigungeinesThemaszumWahn.In:KaschkaW.P,
LungershausenE,editors.ParanoideStorungen.Berlin:Springer1991.pp.1732.
4.ChurchlandP.M.Theontologicalstatusofintentionalstates:Nailingfolkpsychologytoitsperch.
BehavioralBrainScience.198811:507,508.
5.ConradK.VersucheinerGestaltanalysedesWahns.Stuttgart:Thieme1958.Diebeginnende
Schizophrenie.
6.EstesW.K.Processesofmemoryloss,recovery,anddistortion.PsycholRev.1997104:148169.
[PubMed:9009883]
7.FrithC.D,FrithU.Interactingmindsabiologicalbasis.Science.1999286:16921695.
[PubMed:10576727]
8.ErkwohR,SabriO,SteinmeyerM.E,RodonA,BuellU,SassH.DelusionsandcorrelatingrCBF
findings.NeurologyPsychiatryBrainResearch.19986:8796.
9.GaretyP.A,FreemanD.Cognitiveapproachestodelusions:Acriticalreviewoftheoriesandevidence.
BritishJournalofClinicalPsychology.199938:113154.[PubMed:10389596]
10.HoffP.DelusioninGeneralandForensicPsychiatryHistoricalandContemporaryAspects.BehavSci
Law.200624:241255.[PubMed:16773628]
11.JakesS,RhodesJ,TurnerT.Effectivenessofcognitivetherapyfordelusioninroutineclinicalpractice.
BritishJournalofPsychiatry.1999175:331335.[PubMed:10789299]
12.JanzarikW.StrukturdynamischeGrundlagenderPsychiatrie.Stuttgart:Enke1998.

8/13/2016

Understanding delusions

13.KapurS.Psychosisasastateofaberrantsalience:aframeworklinkingbiology,phenomenology,and
pharmacologyinschizophrenia.AmJPsychiatry.2003160:1323.[PubMed:12505794]
14.MaherB.A.Delusionalthinkingandperceptualdisorder.JournalofIndividualPsychology.
197430:98113.[PubMed:4857199]
15.MoorheadS,TurkingtonD.TheCBTofdelusionaldisorder:Therelationshipbetweenschema
vulnerabilityandpsychoticcontent.BritishJournalofMedicalPsychology.200174:419430.
[PubMed:11780791]
16.MunroA.DelusionaldisordersareanaturallyoccurringexperimentalpsychosisPsychopathology.
199427:247250.[PubMed:7846245]
17.SchneiderK.12.,unveranderteAuflage.Stuttgart:Thieme1980.KlinischePsychopathologie.
18.SpitzerM.Aneurocomputationalapproachtodelusions.ComprehensivePsychiatry.199536:83105.
[PubMed:7758303]
19.SpitzerM.Ondefiningdelusions.ComprehensivePsychiatry.199031:377397.[PubMed:2225797]
20.SteinbergH.ThesinintheaetiologicalconceptofJohannChristianAugustHeinroth(17731843).Part
1:Betweentheologyandpsychiatry.Heinrothsconceptsofwholebeing,freedom,reasonand
disturbanceofthesoul.HistoryofPsychiatry,15,329344.Part2:Selfguiltasturningawayfrom
reasonintheframeworkofHeinrothsconceptoftheinterrelationshipsbetweenbodyandsoul.Historyof
Psychiatry.200415:437454.[PubMed:15628028]
21.ZalewskiC,JohnsonSelfridgeM.T,OhrinerS,ZarellaK,SeltzerJ.C.Areviewofneuropsychological
differencesbetweenparanoidandnonparanoidschizophrenicpatients.SchizophreniaBulletin.
199824:127145.[PubMed:9502551]
FiguresandTables
Table1

Jaspersdistinctionbetweenunmediatedordirectandmediatedorreflectivephenomena
Unmediated,directexperience

Thoughtmediatedexperience

Delusionalideaproper

Ordinarymistake

Concreteawareness(thesenseofpresence) Theasifexperience
Truehallucination

Afantasticimageprojectingitselfillusivelyinspace

Amelancholicstate

Neuroticdepressionasaresultofanunpleasantevent

Theexperienceofonesowndouble

Thefeelingasiftherearetwopsychesinmybreast

Aninstinctualdrive

Asimplewish

Theurgetomove

Understandablemotordischargeoffeelings

Table2

DeClerambaultsautomatisms(DerivedfromBaruk,1959)
Mental

Sensory

Motor

Mentalhallucinations

Bizarre

Kinesthetic

Constantparadeofmemories

Sensations

Sensations

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ldeorrhea.gushingoutofrandomideas Pricks

Understanding delusions
Involutionary

Strangenessofthings

Currents

Gestures

Feelingsoffamiliarity

Pulverizedcorpuscles Levitation

Falserecognition
Disappearanceofthought
Forgettingofthought
Emptinessofthought
Arrestofthought
Feelingsofperplexity
Feelingsofdoubt
Substitutionofthoughts
Disturbancesofattention
Affective,emotional,volitionalautomatisms
Lossofvisualmemories

Table3

Phenomenologicalclassificationofdelusions
Inexplicability

Primary/pure/trueSecondarydelusionlikeidea
Overvaluedidea

Subvertedmental

Delusionalperception

function
Delusionalnotion
Delusionalmemory
Delusionalawareness
Delusionalmood/atmosphere
Allegedpsychological

MisinterpretativedelusionalstateConfabulatorydelusionalstate

antecedent
Hallucinatorydelusionalstate
Delusionalmisidentification(e.g.Capgrassyndrome)Sensitivedelusionsofreference
Folieadeux
Nosologicalstatus

Paranoia/delusionaldisorder/monodelusionaldisorder
Delusionalloving/erotomania/deClerambaultssyndrome
Monosymptomatichypochondriacalpsychosis
Cotardssyndrome/nihilisticdelusionalstate
Delusionaldepression
Schizophrenialikepsychosis

Thematiccontent

Persecutory,reference,influence/control,jealousy,sin,poisoning,theft,pregnancy,grandiose,
infestation,lycanthropy,etc.

Modeofmisconstruing
world

Misidentification

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Understanding delusions

Misclassification
Misattribution
Missubstantiation

Table4

Classificationofdelusionsaccordingtocause(Cutting1997)
Diagnostic Dementia,delirium,
link

schizophrenia,depressive
psychosis,mania

Purported

Antecedent

mechanism phenomenological
condition
(a)Forprimarydelusions

EndoftheworldexperienceTremafrightAnomalousexperienceFeelingof
conviction

(b)Forsecondarydelusions DepressedmoodElatedmoodHallucinationsIllogicalthinking
Impasseinlifewith
personalitypredisposition
(a)Forprimarydelusions

InnerconflictOntologicalmeaningsearch

(b)Forsecondarydelusions PersonalitydisorderInnerconflictExternalconflictExistentialdilemma
Exaggeratedcognitivebias
Psychologicaldeficit
(a)Forprimarydelusions

ThoughtdisorderBreakdowninGestalt

(b)Forsecondarydelusions AnxietyStimulusovergeneralizationBreakdowninresponsehierarchies
ImpairedattentionPerceptualdeficitHeightenedconsciousnessIllogicalthinking
Generalcognitiveintegrationfailure
Extramentalevents
Applicabletoprimaryand
secondarydelusions

Figure1

BraindiseaseSensorydeprivationDeafness

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Understanding delusions

RobertsG.(1992)reviewedallconceptsandgavethefollowinggeneralmodelofdelusionformation
Figure2

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Understanding delusions
Alexanderetal.s(1986)proposedfivestructuralfunctionalloops

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