Persecutory delusions and catastrophic worry in psychosis: developing the understanding of delusion distress and persistence

In a recent theoretical account of persecutory delusions, it is suggested that anxiety and worry are important factors in paranoid experience [Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., & Bebbington, P. E. (2002). A cognitive model of persecutory delusions. British Journal of Clinical Psychology, 41(4), 331-347]. In emotional disorders worry has been understood in terms of catastrophising. In the current study, the concept of catastrophising is applied for the first time with persecutory delusions. Thirty individuals with current persecutory delusions and 30 non-clinical controls participated in a cross-sectional study. The group with persecutory delusions was also followed up at 3 months to assess predictors of delusion persistence. At its most severe, 21% of individuals with persecutory delusions had clinical worry, 68% had levels of worry comparable with treatment seeking GAD patients. Further, high levels of anxiety, worry and catastrophising were associated with high levels of persecutory delusion distress and with the persistence of delusions over 3 months. If future research replicates these findings, worry reduction interventions for individuals with persecutory delusions may be warranted.     

The logic of delusion

Piagetian concepts explaining normal mental development are applied to delusion, a major psychiatric disorder of thought which can result in bizarre conduct. Piaget constructed problems in which the errors of six to eight year old children fit the standard textbook definition of delusion surprisingly well. When we examined cases of delusional individuals, we concluded that their apparent irrational and bizarre conduct could be explained as problem-solving errors like those of Piaget's young children. In contradistinction to existing theories, we define delusion as a regression under stress to the logic of children of a particular age range, and that what appears bizarre and irrational is the result of an adult attempting to filter experience through a child's logic.Under a different title this paper was presented at the Biennial Congress of the World Federation for Mental Health in Mexico City in August, 1991.     

The phenomenological role of affect in the Capgras delusion

This paper draws on studies of the Capgras delusion in order to illuminate the phenomenological role of affect in interpersonal recognition. People with this delusion maintain that familiars, such as spouses, have been replaced by impostors. It is generally agreed that the delusion involves an anomalous experience, arising due to loss of affect. However, quite what this experience consists of remains unclear. I argue that recent accounts of the Capgras delusion incorporate an impoverished conception of experience, which fails to accommodate the role played by ‘affective relatedness’ in constituting (a) a sense of who a particular person is and (b) a sense of others as people rather than impersonal objects. I draw on the phenomenological concept of horizon to offer an interpretation of the Capgras experience that shows how the content ‘this entity is not my spouse but an impostor’ can be part of the experience, rather than something that is inferred from a strange experience.

Acting on persecutory delusions: the importance of safety seeking

OBJECTIVE: Acting on delusions is a significant clinical issue. The concept of safety behaviours--actions carried out with the intention of reducing perceived threat--provides a new way of understanding acting on delusions. A study was conducted with the aim of examining the prevalence and correlates of safety behaviours related to persecutory delusions. METHOD: One hundred patients with persecutory delusions were assessed for safety behaviours, acting on delusions, anxiety, depression, and psychotic symptoms. Case note data were collected on instances of serious violence or suicide attempts. RESULTS: Ninety-six patients had used safety behaviours in the last month. Greater use of safety behaviours was associated with higher levels of distress. A history of violence or suicide attempts was associated with greater use of safety behaviours. Safety behaviours were significantly associated with acting on delusions, but not with the negative symptoms of psychosis. CONCLUSION: Safety behaviours are a common form of acting on persecutory delusions. These behaviours have the consequence that they are likely to prevent the processing of disconfirmatory evidence and will therefore contribute to delusion persistence.     

Capgras delusion: a window on face recognition

Capgras delusion is the belief that significant others have been replaced by impostors, robots or aliens. Although it usually occurs within a psychiatric illness, it can also be the result of brain injury or other obviously organic disorder. In contrast to patients with prosopagnosia, who cannot consciously recognize previously familiar faces but display autonomic or covert recognition (measured by skin conductance responses), people with Capgras delusion do not show differential autonomic activity to familiar compared with unknown faces. This challenges traditional models of the way faces are identified and presents some epistemological questions concerning identity. New data also indicate that, contrary to previous evidence, covert recognition can be fractionated into autonomic and behavioural/cognitive types, which is consistent with a recently proposed modification of the modal face recognition model.     

Attributional style in a case of Cotard delusion

Young and colleagues (e.g. Young, A. W., & Leafhead, K. M. (1996). Betwixt life and death: case studies of the Cotard delusion. In P. W. Halligan & J. C. Marshall (Eds.), Method in madness: Case studies in cognitive neuropsychiatry. Mahway, NJ: Lawrence Erlbaum Associates.) have suggested that cases of the Cotard delusion (the belief that one is dead) result when a particular perceptual anomaly (caused by a disruption to the affective component of visual recognition) occurs in the context of an internalising attributional style. This hypothesis has not previously been tested directly. We report here an investigation of attributional style in a 24-year-old woman with Cotard delusion ("LU"). LU's attributional style (and that of ten healthy control participants) was assessed using the Internal, Personal and Situational Attributions Questionnaire (Kinderman, P., & Bentall, R. P. (1996). A new measure of causal locus: the internal, personal and situational attributions questionnaire. Personality and Individual Differences, 20(2), 261-264.). LU showed a significantly greater proportion of internalising attributions than the control group, both overall and for negative events specifically. The results obtained thus support an association of Cotard delusion with an internalising attributional style, and are therefore consistent with the account of Young and colleagues. The potential brain basis of Cotard delusion is discussed.     

Redefining delusion based on studies of subjective paranormal ideation

The DSM-IV definition of delusion is argued to be unsatisfactory because it does not explain the mechanism for delusion formation and maintenance, it implies that such beliefs are necessarily dysfunctional (pathological), it underestimates the social component to some delusions, and it is inconsistent with research indicating that delusions can be modified through techniques such as contradiction, confrontation, and cognitive-behavioral therapy. However, a well-replicated mathematical model of magical/delusional thinking based on a study of paranormal beliefs and experiences is consistent with the hypothesis that attributional processes play a central role in delusion formation and maintenance. The model suggests attributional processes serve the adaptive function of reducing fear associated with ambiguous stimuli and delusional thinking is on a continuum with nonpathological forms. Based on this collective research an amendment to the definition of delusion is proposed and its clinical implications are addressed.     

Construct representation and definitions in psychopathology: the case of delusion

Background  

Delusion is one of the most intriguing psychopathological phenomena and its conceptualization remains the subject of genuine debate. Claims that it is ill-defined, however, are typically grounded on essentialist expectations that a given definition should capture the core of every instance acknowledged as delusion in the clinical setting.     

Metacognitions in proneness towards hallucinations and delusions

The objectives of the present study were to examine the degree of co-existence of hallucinations and delusions in the nonclinical population. In addition, we wished to investigate the role of metacognitions in hallucinations and delusions. Finally, we explored the relative roles of positive and negative metacognitive beliefs in proneness to hallucinations and delusions. Three hundred and thirty-one nonclinical participants completed instruments assessing: hallucination-proneness (Launay-Slade Hallucinations Scale; LSHS), delusion-proneness (21-item version of the Peters et al. Delusions Inventory; PDI-21) and metacognitive beliefs (Meta-Cognitions Questionnaire; MCQ). Participants were successively grouped according to their scores on the LSHS and the PDI-21. Results revealed that hallucination-proneness was positively and significantly associated with delusion-proneness. Furthermore, hallucination-prone and delusion-prone participants scored significantly higher on some sub-scales of the MCQ compared to non-prone participants. Finally, multiple regression analysis revealed that positive and negative beliefs were good predictors of proneness towards hallucinations and delusions.     

The epistemic innocence of motivated delusions

Delusions are defined as irrational beliefs that compromise good functioning. However, in the empirical literature, delusions have been found to have some psychological benefits. One proposal is that some delusions defuse negative emotions and protect one from low self-esteem by allowing motivational influences on belief formation. In this paper I focus on delusions that have been construed as playing a defensive function (motivated delusions) and argue that some of their psychological benefits can convert into epistemic ones. Notwithstanding their epistemic costs, motivated delusions also have potential epistemic benefits for agents who have faced adversities, undergone physical or psychological trauma, or are subject to negative emotions and low self-esteem. To account for the epistemic status of motivated delusions, costly and beneficial at the same time, I introduce the notion of epistemic innocence. A delusion is epistemically innocent when adopting it delivers a significant epistemic benefit, and the benefit could not be attained if the delusion were not adopted. The analysis leads to a novel account of the status of delusions by inviting a reflection on the relationship between psychological and epistemic benefits.     

Freud's theory of paranoid delusion based on the Schreber case contrasted with related theories

The historic importance of Freud's analysis of the Schreber case is acknowledged, even though the theory it expounds is largely disavowed. The theory ascribes the cause of paranoid delusion to homosexual impulses unresolved in infancy or early childhood. This paper summarizes Freud's monograph on Schreber and contrasts his theory with the views of various revisionists. The writers focus on the Freudian concept of projection, which is intended to explain how much meaning can become reversed under the impetus of stress, and the reversal lead to delusional thinking. Based on their work in family therapy, where they observed one form of pathogenic relating termed learning to be possessed, the writers concluded that this form was also based on a type of projection which could culminate in delusional ideation. A relationship between learning to be possessed and H. S. Sullivan's theory of paranoid transformation is described. A learning factor is present in several of the psychological theories advanced to explain delusion, and the factor is akin to if not identical with Freud's concept of projection.Gerald Zuk, PhD, is in private practice at 25316 Pacy Street, Santa Clarita, California 91321-3343. Carmen Zuk, MD, is a child psychiatrist-partner affiliated with the Southern California Permanente Medical Group at its psychiatric clinic in Van Nuys, California. Both may be reached by telephone at (805) 252-7702.