Delusional Thinking: A Thought or Affective Disorder? A Paradigm for Working through Delusional Thinking in Psychotherapy

Article excerpt

A paradigm for treating delusional beliefs is offered here. Certain delusional beliefs are analyzed as the result of an underlying affective disorder that masquerades as a thought problem. Through clinical illustration the author demonstrates that the psychotherapist can access the very heart of a delusion and restructure it by focusing on the affective origins of the delusion.

Delusions are among the most intransigent symptoms of psychosis. They are generally resistant to medications and are very difficult to work through in psychotherapy. Many psychotherapists are resigned to just mitigate the virulence of the delusions and suppress their influence in the everyday life of the patient. Independent of the naivete or sophistication of the delusion, it is hardly changed by rational argumentation, or persuasion. A systematic and entrenched delusional structure is even harder to modify by normal human interaction and feedback.

A review of literature essentially reveals that three intertwining trends of theories-cognitive, psychophysiological, and psychodynamic-were proposed in varied forms regarding the development, maintenance and content of delusional beliefs. The most obvious and easily understood theory is that delusions arise out of a cognitive deficit, a distortion of thinking, and logical deduction. The second theoretical position is that delusions emerge out of normal cognitive processes that follow abnormal perceptual experiences, such as those resulting from anomalous sensations or psychophysiological mechanisms. The third approach is based on motivational and psychodynamic theories. Clinically, it can be safely asserted that these approaches are not mutually exclusive; a combination of factors could influence the formation and maintenance of delusions.

In 1863 Karl Kahlbaum called a chronic delusional disorder paranoia and observed that the delusional system per se did not cause deterioration in intellectual functioning. Emil Kraepelin essentially agreed with this position further distinguishing paranoia from dementia praecox, observing that a delusional disorder did not have some of the characteristic symptoms of dementia praecox, such as hallucinations. Eugene Bleuler, who renamed dementia praecox as schizophrenia, proposed that powerful affective experiences influenced the formation of delusions. Karl Jaspers (1), following a phenomenological methodology, wrote elaborately on the formation and maintenance of delusions. He stated that delusions are judgments that arise in the process of thinking and judging. They are held with an extraordinary conviction supported by an incomparable subjective certainty; are impervious to other experiences and to compelling counter-arguments. Their contents are "impossible." However, Jaspers carefully distinguished the "original experience" from the "judgment" based on it, thereby deducing that there are two kinds of delusions. Delusion proper is a "psychologically irreducible phenomenon," while a derived delusion arises out of a judgment. This phenomenological analysis is very close to many a clinical experience and is different from the psychoanalytic view of delusional formation. The famous Schreber case discussed by Freud (2) gave rise to the classic psychoanalytic view that all delusions are a protection against homosexual urges. Fenichel (3) compared the structure of delusions with those of hallucinations: "Delusions have a structure similar to that of hallucinations. They are misjudgments of reality based on projection." This certainly confuses sensory perceptions with judgments based on those perceptions. Harry Stack Sullivan used a psychodynamic view of delusional formation suggesting that hallucinations are disguised symbolic expressions of unconscious or dissociated impulses and emotional patterns, carried over from some earlier period in a person's life (4). The proposition that delusions are a result of abnormal neurological mechanisms is not new. …