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The Intrasubjectivity of Self, Voices, and Delusions


This post is by Cherise Rosen (pictured above). Cherise is an Assistant Professor in the Departments of Psychiatry and Public Health at the University of Illinois at Chicago. She has conducted extensive research on issues involving the symptoms and longitudinal course of psychosis. 

 Her research has focused on the phenomenological aspects of psychosis, hallucinations, delusions, metacognition, and self-disturbances. Much of her research follows mixed-methods research designs to elucidate findings that include the subjective experience. 

 Additionally, her research investigates the underlying epigenetic mechanisms of psychosis. In this post, Cherise summarises her recent paper (co-authored with Nev Jones, Kayla A. Chase, Hannah Gin, Linda S. Grossman, and Rajiv P. Sharma) 'The Intrasubjectivity of Self, Voices, and Delusions: A Phenomenological Analysis', published in Psychosis. 

In our recent study, we focused on the phenomenologically complex and nuanced interrelatedness of self, voices, and delusions. We investigated the prevalence of co-occurring Auditory Verbal Hallucinations (AVHs) and delusions in schizophrenia compared to bipolar disorder with psychosis; the correlations between AVHs and forms of delusions; and if there are sub-categories/clusters of AVHs and forms of delusions that are distinct and identifiable and what is the symptom presentation of these sub-categories/clusters?

Our study found two distinct clusters of AVHs and forms of delusions: AVHs paired with thought delusions (Cluster One) and AVHs paired with thematic delusions (Cluster Two). These clusters begin to disentangle the intrasubjectivity of voices and delusion by characterizing Cluster One: AVH and Thought Delusions as a structure that centres on alterations of self and internal/external boundaries, while Cluster Two: AVH and Thematic Delusions centres on exaggerated processes of social internalization (guilt) or externalization (jealousy/delusions of infidelity).

As phenomenological psychopathologists have long contended, we found that participants with schizophrenia spectrum disorder were more likely to fall into Cluster One: AVH and Thought Delusions and those with bipolar psychosis into Cluster Two: AVH and Thematic Delusions. Nevertheless, neither group was diagnostically pathognomonic. Cluster One: AVH and Thought Delusions participants also showed elevated disorganized, cognitive and depressive symptoms, but not negative symptoms or excitement. Future research would be needed to further unpack whether these differences in severity are tied to diagnosis (schizophrenia versus bipolar) or more strongly to predominant pattern of delusions.

While both clusters implicate alternations of self-other experience, they do so in distinct ways: the former involving Schneiderian symptoms of passivity or confusion over ownership and internal versus external genesis of thoughts and the latter exaggerated projection and introjection. This study underscores the need for expanded clinical and phenomenological research into the intersection of AVHs and delusions, including work that seeks to deconstruct conventional divisions between ostensible symptoms of perception (hallucinations) and belief (delusions).

Clinically, study findings underscore the need for greater attention to the nuances of experiences conventionally divided up into AVHs and delusions, particularly when this distinction is framed as a difference between symptoms of perception versus belief. Potential problems with mono-symptom approaches are further highlighted by the high prevalence of co-occurring AVHs and delusions. 

Going one-step further, we might also conjecture that in cases where a common underlying alteration (such as attenuated ego boundaries) drives both AVHs and delusions, this underlying problem may represent a more valid clinical target. Thus, a detailed assessment of the phenomenology of self, voices, and thought or thematic delusions may help to provide information needed to develop a tailored, multipronged clinical intervention that addresses the complexities and interrelatedness.

In summary, this novel phenomenological study of self, voices, and delusions suggests a significant relationship between voices and delusions of reference, persecution, control, thought insertion, thought withdrawal, and thought broadcasting. The overwhelming majority of our participants reported both AVHs and delusions. We also provide preliminary support for differentiation of patients into subgroups characterized by the intersection of Voices and Thought Delusions versus Voices and Thematic Delusions.

Acknowledgement: The authors would like to thank all the subjects who participated in this study. This work was supported in part by PHS grant (NIH) R01MH094358 (R.P.S.)
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