Tuesday, 16 February 2021

Delusions Beyond Beliefs

This post is by Jasper Feyaerts, who is discussing a paper he co-authored with Mads G Henriksen, Stijn Vanheule, Inez Myin-Germeys, and Louis A Sass, entitled "Delusions beyond Beliefs", and published in The Lancet Psychiatry. With this link, there will be free access to the article for a few weeks.

Jasper Feyaerts

Delusions are commonly conceived as false beliefs that result from epistemic failures to represent reality correctly. This view has been dominant throughout the history of psychiatry, and continues to inform contemporary research and practice. In explanatory research, it underlies (neuro)cognitive attempts to explain delusions in terms of impairments or biases in cognitive reasoning. In clinical practice, it motivates cognitive-behavioral strategies focusing on the rational evaluation of delusional appraisals.

Yet despite being the standard view of delusion in psychosis research, this conception has not gone entirely unchallenged. Most notably in the tradition of phenomenological psychopathology (Sass & Pienkos, 2013; Stanghellini et al., 2019), less emphasis has been put on the erroneous or belief-like nature of delusions, than on adequately identifying the specific experiential context within which delusions occur, with a particular focus on what ‘sort’ of reality delusional individuals may ascribe to them. 

Karl Jaspers in General Psychopathology, for example, already emphasized how certain types of delusions – i.e., which he called ‘primary’ or ‘true’ delusions, and considered specific for schizophrenia – are not mere ordinary empirical beliefs, but may involve global ontological changes that affect our most basic experience of reality. “Delusion proper”, Jaspers wrote, “implies a transformation in our total awareness of reality” (page 95); “reality [for the patient] does not always carry the same meaning as that of normal reality” (page 105).

In our review paper, we discuss how this phenomenological emphasis on the overall experiential context of delusions can be used to critically revisit and to enhance contemporary diagnosis, explanation and treatments for delusions. In diagnostic research, we show how claims regarding the existence of a so-called ‘continuum’ between ordinary irrational beliefs and delusions may have more to do with the vagueness and selectivity of criteria and measures used in assessing these phenomena, than with the continuous nature of delusional experience itself. 

In explanatory research, we discuss how one/two-factor-accounts and predictive models could benefit from accommodating global ontological transformations in their accounts. This could offer more specificity to the nature of anomalous experience in schizophrenia, while it also challenges the idea that delusion is always a matter of (rational or irrational) belief explaining or endorsing experience. We emphasize in particular that alterations in reality experience also alter the cognitive status of delusions. It is unclear, for example, whether straightforward believing is actually possible in a delusional world that is experienced as entirely unreal or sometimes even as somehow mind-dependent.

In therapeutic research, we suggest that the limited therapeutic benefits of current cognitive-behavioral treatments for delusions (see Jauhar et al., 2014) may be the result of applying an ordinary framework of reality experience in emphasizing rational evaluation of delusional beliefs. We argue that treatments should shift away from narrowly targeting delusions themselves (via attempts, eg., to refute or challenge them) towards altering the experiential conditions that inspire and sustain them. From a phenomenological perspective, effective treatments are most likely those that help to reduce feelings of self-alienation and uncertain embeddedness in everyday reality that are conducive to delusional experience.

Yet we also emphasize that delusions are not always experienced as a simple affliction or deficit. Indeed, for some individual with delusions, the common-sense perspective can look flat, uninspiring, and utterly constrained by conventionality, closed off from what they consider the true sources of originality and truth. As such, delusions are not only a psychopathological or psychiatric issue, they also seem to confront us with the possible contingency or ungroundedness of our ordinary reality experience.

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