To Understand Delusions, We Need To Listen To People With Delusional Beliefs

The worst thing that Sophie* remembers about her delusion is sitting on the sofa—stuck and waiting. She felt cold deep down into her body, “the sort of cold when you’ve been outside and you shrink away from your skin." She felt like she’d been sitting on her sofa for a thousand years.

"One of the things that’s most frightening about delusions is that time completely stops,” she says. She could see the clock, and that time was passing, but it didn’t register. That, along with the fact that she believed she was dead, meant she all but stopped eating or drinking.

Sophie had Cotard’s Syndrome, which is a rare delusion that causes a person to think they're dead, even when they’re very much alive. Delusions are strongly held, preoccupying false beliefs and they can range from Cotard's to believing you’re being followed and that strangers want to attack you, to thinking you are the second coming of the messiah.

In a new ten-part series on BBC Radio 4 called A History of Delusions, University of Oxford clinical psychologist Daniel Freeman interviews people with delusions of all kinds, including Sophie, and discovers what the experience is like to feel something so intensely that isn’t true. Freeman also tells stories of historical cases of delusions. I spoke to Freeman about what delusions are, how our understanding of them is changing, and why delusional stories need to be told.

What is a delusion? How do you define it?

People argue about this because it can be hard to define anything. In essence, a delusion is a fixed false belief. The three main criteria are that it's false, impossible, or incredible; that it's held with a high degree of conviction, and thirdly, that it tends to remain despite evidence current to the contrary.

When I went to university, you were taught that delusions were a sign of schizophrenia, but I always remember thinking that seems unlikely that it's as simple as this. Once you talk to someone that's had a delusion experience, I think your perspective shifts. When you take time to listen to people and you start to put yourself in someone else's shoes and start to understand how they arrived at those conclusions, and what sort of function the delusion serves. As soon as I talked to people that have delusions, it all became something I wanted to study and I wanted to make much more psychologically understandable, and most importantly, develop better psychological treatment.

To be defined as a delusion, does it need to interfere with someone’s life in a negative way?

With any mental health problem, the key criteria is that it has a significant impairment on your social relationships, on your day-to-day functioning, and it causes impairment. With delusions, that can be complicated, because in some—for example, delusions of grandiosity—the person might actually like the belief.

Of course, it still impacts on their relationships because other people don't necessarily believe them, and it can isolate people. So the effect of the impairment can vary. In paranoia persecution delusions, often the person is really distressed, and quietly withdraws from life because of the delusion.

In the radio show, you’ve split up the time between interviewing people today who have had delusions and talking about historical cases of delusion. What’s the benefit of going back in time and examining these delusional occurrences from hundreds of years ago?

I think what the series does nicely is highlight some of the similarities in the basic themes of delusions. You can see that across the centuries. Often they're the same sorts of concerns, but also you can see how the concerns are shaped by the current social and political climate. There's a nice example of when the telephone was beginning to emerge and that starts to feature in someone's delusional beliefs. Or in Revolutionary France, the guillotine was featuring in delusions, which of course, it doesn't really these days.

I think about that with Truman Show delusions, which are when a person thinks they’re being secretly filmed, or that they’re the center of some staged reality. That specific delusion couldn’t exist before television, and somehow that technological development has been co-opted and brought into delusional thinking.

We have a person who believes that on the show, who describes their experience as believing they're on a reality TV show. What you've got going on there is two things: You've got delusions of reference, that you're being monitored and observed and of course that's a very common type of fear that's been around for a long time. And also, potentially, you've got more of a grandiose flavor to it as well. So the Truman Show delusion might have a bit of reference and grandiosity in it. Certain delusion types have always been there.

I want to go back to what you said about delusions and schizophrenia. I think a lot of people associate the two and find them inseparable from each other—if you're hearing voices or you're seeing things, then that must mean that you have schizophrenia, that's the only time that happens. When did we start to understand that they can be distinct and how does that help us understand delusions more generally?

Historically, delusions in the past were often considered a symptom of melancholy, of depression. But then at the end of the 19th century, we came to associate it with what became called schizophrenia.

What's really interesting is that psychiatry has become more of a science. People developed diagnostic systems that were much more reliable and everyone could start diagnosing the same way. And that's why with the systems, epidemiologists start to say, 'Well we can find out how common these problems are in the general population.' And they focused on depression, anxiety, but also included diagnostic interviews of schizophrenia.

What you then have, for the first time ever, is diagnostic interviews of schizophrenia done with random people in the general population, not just those in psychiatric hospitals. The more people did that, they were really puzzled to find much higher rates of delusions than would be expected on the premise of schizophrenia. And that helped shift views.

I think there's a convincing case that schizophrenia itself isn't the most scientific diagnosis. It's really an umbrella term of a whole range of different sorts of experiences. And there's good data showing that hearing voices is different from grandiosity, which is different from paranoia, which is different from a thought disorder—so you've got a whole breaking up of these sorts of diagnosis.

The model that these symptoms all reflect some other underlying disorder doesn't really work so well anymore. There's clearly a disorder, there's clearly a problem, but you don't necessarily have to group it into those clusters. There’s probably something like eight different problems, and each of those are on continuum in the general population. There's no clear dividing line on any of them.

Let's say I develop paranoid delusions, but my friend develop grandiosity delusions. Why would I become paranoid and somebody else would go in a different direction?

That's a great question, and I think you're ahead of the times in asking. Most research is basically still on schizophrenia. Over the last 20 years, there has been increasingly more people suffering delusions in particular. Paranoia gets the most attention, grandiosity less, and there's been very few studies that have looked at differences.

One of the studies we've done as a research group just a while ago, indicated that there's a lot of shared overlap, but there might be even greater emotional processing leading to paranoia and there might be a bit more skewing in reasoning processing in grandiosity.

There's a lot of shared causes, but there might be different emphases in different types of problems. It's an excellent question, and I think we need much more research in what separates out depression in paranoia and grandiosity from paranoia, or hallucinations from delusions.

Something that I found really striking from listening to the people with delusions, is I think we think of delusions as a really cognitive thing, but a lot of these people have such physical symptoms too. Sophie with Cotard's Syndrome—she really feels these changes in her body that lead to this delusion. It's this mix of both mental and physical. Is that pretty common with delusions? Is the idea that it's purely cognitive outdated as well?

Delusions aren't purely cognitive because they're an explanation, they're a thinking style, and often they're trying to explain internal experiences. In other people I see who get paranoid, they're getting these great rushes of anxiety that they don't understand where it's coming from. Rather than say it's their own anxiety that's disregulated, they're searching for explanations in terms of the environment. And of course also, your anxiety's more likely to be disregulated if you've had people do bad things to you, and therefore that's an even more obvious reason why you would jump to the conclusion that it's external, rather than just your anxiety system misfiring too much.

In the Cotard's delusion, I think the explanation is often about those feelings of dissociation, numbness, the whole inner physical experience and pain sometimes brought on by depression itself. When you verify that, it makes a lot more sense.

There’s a movement called Healthy Voices Network, which is moving away from defining health as the absence of hearing voices. And letting some people, if it doesn't bother them, just continue to hear voices and as long as they regard them in a positive way. What do you think about that idea, and where's the line between a delusion that's okay to just let a patient continue on with it, and one that needs to be addressed?

My view is that it needs to be the choice of the person in most of these instances. Even hearing voices—I think plenty of people will not want them but plenty of people will also want to accept them and incorporate them in life, and I think that's an individual choice. So in my experience, if you've got a persecution delusion, on the whole, people really don't want that to continue because it's very frightening, terrifying. They'd like to find a world that's safer for them.

Grandiosity's a bit different. And often people actually like their beliefs, because they give meaning to people. And the meaning cannot always be easy: It can often convey responsibility. But grandiosity is certainly one of the delusion types where, as a therapist, you're less likely to want to change the whole structure. You may want to find other ways that people can get meaning, or you just want to reduce the impact of the delusion on their day to day functioning and their relationships for example.

So sometimes it's about reducing the time acting upon or thinking about delusion, not letting them take over your life. We all need balance in our life and delusion shouldn't necessarily take over everything.

What can you tell me about treatments for delusions, and any new options on the horizon? Is medication the answer or are there alternative ways to tackle this?

I think we've made a lot of understanding about some delusion types, particularly persecution delusions, and we need to use that knowledge to develop better psychological treatments. It's very clear there's no single cause of delusion, but often you're dealing with a number of factors that are interacting.

The work I've done shows that excessive worrying, very low self esteem, reasoning biases, sleeplessness, and anxious avoidance of situations can all make delusions a lot worse. The psychological therapy we've been doing, some call it the Feeling Safe Program, is tackling each of those causes one at a time, and we've shown that you can then reduce the delusions. We're doing work here that's a much higher recovery rate in delusions. It's not so much the talking therapy, it's the doing therapy.

We do lots of getting outside into the situations that trouble people, and coaching them. And so people learn directly that their fears may be less founded now than they thought, and that they can treat much better. And we've found that's really helpful. We build up memories of safety, and then the paranoia kind of melts away.

That feeds onto the work we've been doing with virtual reality, because that reality is very much about experiential experiences, and using computer simulations for a situation that's difficult. What's great about that, is that people are much more willing to go into difficult situations in VR because they know it's a simulation, so they have a conscious thought going into it, "Okay I can do this because it's not real." But the learning in these simulations still transfers to the real world, and that's the beauty of VR.

And the other bit of VR that we're doing that's very novel here, is that historically psychological therapy has not really been given to people in delusions in large numbers. Psychological therapy has been more thought to be used for things like anxiety and depression, not people with delusions. And therefore there are very few therapists trained to provide psychological therapy for people with delusions, so we're working on automating a provision of psychological therapy using immersive virtual reality, so we're very excited about that. That's what we're busy working on now. So we're doing two things: One is developing a really intensive, six-month translational treatment that's face to face with a therapist, a lot of it's about going outside, helping the person. And we're also doing a brief, automated version of that using virtual reality.

What do you hope that people who has never experienced delusions gets out of listening to these stories?

I think delusions are probably the most misunderstood mental health issue. I think they're the least discussed. I hope people recognize these experiences are much more common than maybe thought, but also they can see a lot more how people end up having delusional beliefs, and also how they can find other ways to think and relate to them as well. So I'm delighted with the contributors, the people who have been sharing their histories of delusions. I think it's brilliant they're doing that; I have a lot of admiration. I think they're describing experiences that are actually quite common and just not talked about. And I think they're … knocking down some walls with discussions. Some of the conversations in the radio program I just think you don't hear in media, normally.

Sign up for our newsletter to get the best of Tonic delivered to your inbox.