Delusion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

A delusion is commonly defined as a fixed false belief and is used in everyday language to describe a belief that is either false, fanciful or derived from deception. In psychiatry, the definition is necessarily more precise and implies that the belief is pathological (the result of an illness or illness process). As a pathology it is distinct from a belief based on false or incomplete information or certain effects of perception which would more properly be termed an apperception or illusion.

Delusions typically occur in the context of neurological or mental illness, although they are not tied to any particular disease and have been found to occur in the context of many pathological states (both physical and mental). However, they are of particular diagnostic importance in psychotic disorders and particularly in schizophrenia.

Psychiatric definition

Although non-specific concepts of madness have been around for several thousand years, the psychiatrist and philosopher Karl Jaspers was the first to define the three main criteria for a belief to be considered delusional in his book General Psychopathology. These criteria are:

  • certainty (held with absolute conviction)
  • incorrigibility (not changeable by compelling counterargument or proof to the contrary)
  • impossibility or falsity of content (implausible, bizarre or patently untrue)

These criteria still live on in modern psychiatric diagnosis. In the most recent Diagnostic and Statistical Manual of Mental Disorders, a delusion is defined as:

A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's culture or subculture (e.g., it is not an article of religious faith).

Example: Nebraska Head Coach Bill Callahan [[2]]

Causes

Common Causes

Causes by Organ System

Cardiovascular No underlying causes
Chemical / poisoning Cathinone, Heavy metal poisoning
Dermatologic No underlying causes
Drug Side Effect Cathinone, Clobazam, 5,-Methoxy-N,N-Diisopropyltryptamine, Cocaine, Crystal meth, Ecstasy, Lysergic acid diethylamide, Marijuana, Methylphenidate, Opium, Oxcarbazepine, Pergolide, Phencyclidine, Sleeping pills, Steroid abuse , Amphetamine abuse
Ear Nose Throat No underlying causes
Endocrine Cushing's disease, Hyperthyroidism, Myxedema madness
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic Cerebrotendinous xanthomatosus , DiGeorge syndrome
Hematologic Porphyria
Iatrogenic No underlying causes
Infectious Disease African trypanosomiasis, Cerebral abscess
Musculoskeletal / Ortho No underlying causes
Neurologic Alzheimer's disease, Bing-Neel syndrome, Cerebral tumour, Creutzfeldt-Jakob disease, Dementia with lewy bodies, HIV encephalopathy, Huntington disease, Multi-infarct dementia, Multiple sclerosis, Myxedema madness, Neurosyphilis, Parkinson disease, Seizure disorders, Stroke, Cerebrotendinous xanthomatosus , Uremic encephalopathy
Nutritional / Metabolic B12 deficiency, Thiamine deficiency
Obstetric/Gynecologic No underlying causes
Oncologic Cerebral tumor
Opthalmologic No underlying causes
Overdose / Toxicity Cathinone, 5,-Methoxy-N,N-Diisopropyltryptamine, Cocaine, Crystal meth, Ecstasy, Lysergic acid diethylamide, Marijuana, Methylphenidate, Opium, Phencyclidine, Sleeping pills, Steroid abuse , Excess of cortisol, Amphetamine abuse
Psychiatric Bell mania, Bipolar affective disorder, Bipolar disorder , Brief psychotic disorder , Capgras syndrome, Delusional disorder , Dissociative identity disorder , Functional disorders, Hoigne's syndrome , Kandinsky syndrome, Major depressive disorder, Panic attack , Parasitophobia, Postpartum psychosis, Primary affective disorder, Pseudocyesis, Schizoaffective disorder, Schizophrenia, Schizotypal personality disorder, Shared psychotic disorder, Social phobia
Pulmonary No underlying causes
Renal / Electrolyte Hypomagnesemia, Uremic encephalopathy
Rheum / Immune / Allergy Systemic lupus erythematosus
Sexual No underlying causes
Trauma Head injury
Urologic No underlying causes
Dental No underlying causes
Miscellaneous Alcohol abuse, Alcohol withdrawal, Amphetamine abuse, Cannabis abuse, Water intoxication

Causes in Alphabetical Order


Diagnostic issues

The modern definition and Jaspers' original criteria have been criticised, as counter-examples can be shown for every defining feature.

Studies on psychiatric patients have shown that delusions can be seen to vary in intensity and conviction over time which suggests that certainty and incorrigibility are not necessary components of a delusional belief.[1]

Delusions do not necessarily have to be false or 'incorrect inferences about external reality'.[2] Some religious or spiritual beliefs (such as 'I believe in the existence of God') by their nature may not be falsifiable, and hence cannot be described as false or incorrect, no matter whether the person holding these beliefs was diagnosed as delusional or not. [3]

In other situations the delusion may turn out to be true belief.[4] For example, delusional jealousy, where a person believes that their partner is being unfaithful (and may even follow them into the bathroom believing them to be seeing their lover even during the briefest of partings) may result in the faithful partner being driven to infidelity by the constant and unreasonable strain put on them by their delusional spouse. In this case the delusion does not cease to be a delusion because the content later turns out to be true.

In other cases, the delusion may be assumed to be false by a doctor or psychiatrist assessing the belief, because it seems to be unlikely, bizarre or held with excessive conviction. Psychiatrists rarely have the time or resources to check the validity of a person’s claims leading to some true beliefs to be erroneously classified as delusional.[5] This is known as the Martha Mitchell effect, after the wife of the attorney general who alleged that illegal activity was taking place in the White House. At the time her claims were thought to be signs of mental illness, and only after the Watergate scandal broke was she proved right (and hence sane).

Similar factors have led to criticisms of Jaspers' definition of true delusions as being ultimately 'un-understandable'. Critics (such as R. D. Laing) have argued that this leads to the diagnosis of delusions being based on the subjective understanding of a particular psychiatrist, who may not have access to all the information which might make a belief otherwise interpretable.

Another difficulty with the diagnosis of delusions is that almost all of these features can be found in "normal" beliefs. Many religious beliefs hold exactly the same features, yet are not universally considered delusional. Similarly, Thomas Kuhn argued in The Structure of Scientific Revolutions that scientists can hold strong beliefs in scientific theories despite considerable apparent discrepancies with experimental evidence.[6]

These factors have led the psychiatrist Anthony David to note that "there is no acceptable (rather than accepted) definition of a delusion".[7] In practice psychiatrists tend to diagnose a belief as delusional if it is either patently bizarre, causing significant distress, or excessively pre-occupies the patient, especially if the person is subsequently unswayed in belief by counter-evidence or reasonable arguments.

Related Chapters

Further reading

  • Bell, V., Halligan, P.W. & Ellis, H. (2003) Beliefs about delusions. The Psychologist, 16(8), 418-423. Full text
  • Blackwood NJ, Howard RJ, Bentall RP, Murray RM. (2001) Cognitive neuropsychiatric models of persecutory delusions. American Journal of Psychiatry, 158 (4), 527-39. Full text
  • Coltheart, M. & Davies, M. (2000) (Eds.) Pathologies of belief. Oxford: Blackwell. ISBN 0-631-22136-0
  • Persaud, R. (2003) From the Edge of the Couch: Bizarre Psychiatric Cases and What They Teach Us About Ourselves. Bantam. ISBN 0-553-81346-3.

References

  1. Myin-Germeys, I., Nicolson, N.A. & Delespaul, P.A.E.G. (2001) The context of delusional experiences in the daily life of patients with schizophrenia. Psychological Medicine, 31, 489-498.
  2. Spitzer, M. (1990) On defining delusions. Comprehensive Psychiatry, 31 (5), 377-97
  3. Young, A.W. (2000).Wondrous strange: The neuropsychology of abnormal beliefs. In M. Coltheart & M. Davis (Eds.) Pathologies of belief (pp.47-74). Oxford: Blackwell. ISBN 0-631-22136-0
  4. Jones, E. (1999) The phenomenology of abnormal belief. Philosophy, Psychiatry and Psychology, 6, 1-16.
  5. Maher, B.A. (1988) Anomalous experience and delusional thinking: The logic of explanations. In T. Oltmanns and B. Maher (eds) Delusional Beliefs. New York: Wiley Interscience. ISBN 0-471-83635-4
  6. Kuhn, T. (1962) The Structure of Scientific Revolutions. University of Chicago Press. ISBN 0-226-45808-3
  7. David, A.S. (1999) On the impossibility of defining delusions. Philosophy, Psychiatry and Psychology, 6 (1), 17-20

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