Delusions and Meaning

Today’s post is by Rosa Ritunnano, consultant psychiatrist and PhD candidate at the Institute for Mental Health University of Birmingham. Here she talks about a recent paper she co-authored with Clara Humpston and Matthew Broome, “Finding order within the disorder: a case study exploring the meaningfulness of delusions”, published in the British Journal of Psychiatry Bulletin.

In this paper, we ask questions relating to delusions and meaning, as prompted by the clinical encounter with Harry who is, in his own words, “the happiest man in the world”. Harry was referred to Early Intervention for Psychosis (EIP) services for a suspected first episode of psychosis, after telling his doctor that he had been the target of a worldwide conspiracy for more than 5 years. Harry believes that people are being told lies since the day they are born, and that we all live in a sort of “Truman Show” where the government and the NASA are using fake imagery to fool people into believing that what they see on TV is real. 

Rosa Ritunnano

Harry also believes that there is a hierarchy of people who are taunting him and this hierarchy goes up to Illuminati and the Queen. He thinks that there are lizard people in charge of the earth that have made people believe that the earth is round, when in fact it is flat. Harry is also constantly followed by people in the streets who make gestures as an indication to him that they know about him and about his past deeds. They can interfere with his thoughts, but he is now able to communicate back, putting the right thoughts into people’s minds.

One day, when talking about his current situation with me, Harry said: 

“If I went out one day and I realised that people weren’t expecting me to be there, it would be a real shock again…I would be...I don't know...?! I got so used to people expecting me to be there and lash out with them…I would feel alone again, which is what everyone else feels, like alone. So people are like a family for me, it's like a safety blanket, they make me feel so comfortable now…If I found out that they are not watching me and reading my mind, I would feel alone and crazy like everyone else. To feel like I have everyone following me around, whether it’s negative or positive, that alone is a force of power…knowing that you can influence people’s minds in the right way, I feel like Jesus (of course I’m not) but why not believe?”

While Harry’s case induced a sharp divide between clinicians in relation to issues of diagnosis, bizarreness and need for treatment, I found myself grappling with an ethical dilemma. I was called, in some ways, to make an ethically loaded decision about whether this person’s reality was too “disordered” or “dysfunctional” to be allowed within the limits of “normality”. As a clinician with ten years’ experience in psychiatry, I knew very well the DSM/ICD diagnostic criteria for psychotic disorders and I had been trained to assess risk and functioning, yet I felt unsure as to how we should best understand the sense of meaningfulness that Harry was describing.

Were Harry’s delusions the source of the problem or a response to the problem? What specifically was “dysfunctional” about them? In some ways, they seemed to be enhancing his sense of purpose, meaningfulness and belonging in his life (even if only subjectively). On the other hand, his “usual” life as socially construed (for example, holding a stable job) had been significantly impacted and he was no longer able to work.

Very limited research has investigated the relationship between delusions and the sense of meaning in life. This is in spite of empirical observations that elaborated delusions can enhance a person’s experience of meaning and purpose in life (Roberts, 1991), contribute positively to their “sense of coherence” (Bergstein et al., 2008) and also provide a sense of purpose, belonging and self-identity (Isham et al., 2019). 

In addition to their explanatory value, considerations of meaning could have major implications for clinical practice, for example in relation to 1) patient-clinician communication: how should psychiatrists address delusions? (e.g., Zangrilli et al., 2014), 2) nosology: what makes a belief delusional and what makes delusions pathological? (e.g., Bortolotti et al., 2016; Petrolini 2017) and 3) treatment and medical ethics: is there a risk of iatrogenically inducing loss of meaning and subsequent depression if we eliminate self-enhancing delusions without addressing other issues?

Although we might not have all the answers yet, I believe that a phenomenological and value-based approach, along with interdisciplinary efforts from phil- and psy-disciplines, are needed to aid clinicians who often face the seemingly paradoxical coexistence of harmfulness and meaningfulness in individuals with delusions.