Frameworks: The Price of Delusion

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In this article we aimed to analyse the dimensions of both hallucinations and delusions in a sample of patients with schizophrenia and schizoaffective disorder. We also intend to find the determinants of the main dimensions of hallucinations. In this study we designed an empirical based model by means of bivariate Spearman's rank correlation coefficient, and multivariate statistics linear regression and multiple multivariate linear regression , where the main dimensions of hallucinations are determined by the central dimensions of delusions.


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Nowadays, hallucinations are classified according to their sensory modality: auditory, visual, tactile, cenesthetic, olfactory, gustatory, etc. Telles-Correia et al. Hallucinations may occur not only in functional psychotic states schizophrenia, psychotic mania, psychotic depression , but also in organic situations or in cases of sensory deprivation Telles-Correia et al. In the current psychiatric classifications, hallucinations are one of the fundamental criteria for establishing a schizophrenia diagnosis or any of the related psychotic disorder's diagnoses brief psychotic disorder, schizophreniform disorder, schizoaffective disorder.

They may also be present in other psychiatric disorders, such as affective disorders in depressive or manic episodes Telles-Correia et al. Another symptom linked to the genesis of schizophrenia and other related psychotic disorders is delusion. Throughout the history of Psychiatry the conceptual proximity between delusions and hallucinations in the psychiatric patient was maintained until the end of the XIX century, with several supporters during the XX century such as Ey , Ey et al.

This means that their frontier was not yet definitely defined in terms of Descriptive Psychopathology, and much less so in terms of biochemical and anatomical models Telles-Correia et al. Contrary to former practice in which psychopathological description of symptoms was considered a priority, quantitative studies became a prime concern in the end of XX century.

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Nevertheless, in the last few years, with the re-emerging of Descriptive Psychopathology, several authors attempt to include again in their studies the more descriptive component of Psychopathology. Among these, the investigation of the several dimensions of delusions and hallucinations are highlighted Chen and Berrios, ; Haddock et al.

In this article we aimed at analysing the dimensions of both hallucinations and delusions in an adult sample of patients with schizophrenia and schizoaffective disorder. We also intend to find the correlates of the main dimensions of hallucinations. This non-randomized but non-intentional convenience sample included all patients fulfilling the inclusion criteria and was collected by six medical doctors three psychiatry residents and three psychiatrists of both hospitals from July to July We first selected patients, but 10 of them rejected to enter in the study and 8 to continue in the study.

This group of dropouts didn't differ from the group investigated. The inclusion criteria were the following: psychiatric patients with 18 years old or older, hospitalized or in ambulatory care; a schizophrenia or schizoaffective disorder diagnosis according to DSM-5; accepting to participate in the study and signing the informed consent.

Exclusion criteria include: psychomotor agitation and compulsory treatment. The study was approved by the Ethics Committee of both centers. Informed consent was obtained from all individual participants included in the study. The term dimension is used by the author of the scale meaning the characteristics of hallucinations and delusions Haddock et al.

They are composed by two subscales: one to evaluate the dimensions of hallucinations and another to evaluate the dimensions of delusions Haddock et al. The Psyrats-hallucinations are composed by 11 items and each one is rated in an ordinal scale from 0 to 5 , varying from less to more severe. The subscale of delusions is composed by six items, each rated in the same way as the subscale of hallucinations. These six items correspond to the following dimensions: preoccupation, duration, conviction, amount of distress, intensity of distress, and disruption.

Cronbach's alpha in our sample for the hallucinations' subscale was 0. This scale was validated by our study group for the Portuguese population. We performed a spearman correlation coefficient bivariate analysis to evaluate the association of the dimensions of hallucinations within themselves and between them and the dimensions of delusions.

We also performed a stepwise linear regression to determine the determinants of the dimensions of hallucinations considered conceptually and clinically more important by the authors as dependent variables. These were the ones that we considered more relevant from a theoretical point of view according to the definitions that have been given throughout history of psychiatry : the location in space and the beliefs re-origin that were the characteristics that more persistently have differentiated them from pseudohallucinations. From a clinical point of view it is the disruption that measures the global impact that the hallucinations have in the functioning of the patient.

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We used as independent variables the dimensions of hallucinations and of delusions that proved to be correlated to the former ones in the bivariate analysis. We took in consideration in the interpretation of the results the Bonferroni Correction. Therefore the alpha accepted was 0. We used a multivariate multiple linear regression with AMEE analysis of the model of structural equations and the significance of indirect effects with the Sobel test to check for the presence of mediator variables to statistically find a theoretical model among the dimensions of hallucination and delusion.

The bivariate statistics and the regression models were exploratory but the AMME was directed to the findings of the former statistical analysis. Since this is a cross sectional study no causal or explanatory relations are established. Informed consent: Informed consent was obtained from all individual participants included in the study.

The main clinical and sociodemographic variables are described in Table 1 Considering these variables, no statistically significant differences were found between the group of patients diagnosed with schizophrenia and the one diagnosed with schizoaffective disorder.

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All patients with AVHs had also delusions. Considering these variables, no statistically significant differences were found between the group of patients diagnosed with schizophrenia and those diagnosed with schizoaffective disorder. Table 2. Table 3. To find statistical models of correlation and with an adjustment of confounding variables we used a linear regression analysis using the stepwise method. As independent variables we used the dimensions of hallucinations and delusions for which we obtained a statistically significant correlation in the bivariate analysis with the dependent variable Tables 4 , 5.

Table 5. Correlation bettween hallucinations' dimensions and delusions' dimensions. Table 6. Determinants of the main dimensions of the hallucination—linear regression. Considering the dimension disruption, we obtained a regression model with an R 2 of 0. Considering the results of the previous regression models, an integrated model was proposed between the main dimensions of the hallucination and the conviction of the delusion. In this model, all trajectories were confirmed as statistically significant, except the direct connection between the conviction and the disruption.

We infer from this model that the beliefs re-origin could then be an intermediary variable between the conviction and the location and disruption of the hallucination. The significance of the indirect effects was evaluated with the Sobel test.

Thus, we confirm this intermediary. As we have referred above, these conclusions do not allow us to infer a causal or explanatory model. Although the search for the significance of indirect effects with the Sobel test to check for the presence of mediator variables does allow us to infer about the direction of the statistical relations showed in the Figure 1.

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Based on these data we have drawn a Model of the determinants of the main dimensions of the auditory verbal hallucinations Figure 2. Figure 2. Model of the determinants of the main dimensions of the auditory verbal hallucinations in patients with schizophrenia and schizoaffective disorder. Based on our findings in the explorative multiple regression models we considered a hypothesis of interaction among the main dimensions of the hallucination and the delusion. Within this framework a model was proposed recurring to a multiple multivariate linear regression with AMEE, and the significance of the indirect effects was evaluated with the Sobel test, to know the presence of intermediary variables, which allowed us to infer about the direction of the statistical relations Figure 1.

Through this correlational model there seems to be a strategic determination of the conviction of the delusion about the belief re-origin that determines, in its turn, the most important dimensions of the hallucination. The conclusions of our study empirically corroborate the conceptual references that have always approximated both concepts: hallucinations and delusions.

Persecution is usually a polythematic and elaborated delusion, that is, it extends to more than one theme where the themes can be interrelated, and it is well integrated in the person's belief system, often driving action that is consistent with the person believing the content of the delusion.

For instance, a young woman who believes that she is surrounded by alien forces that control her own actions and are slowly taking over people's bodies might decide to run away to protect her loved ones from danger Payne, That means that, apart from the content of the delusion itself, the person may not make any other implausible claim and the delusion may not be supported by, or support, the person's other beliefs. Other examples of monothematic delusions are Capgras and Cotard. In Capgras the person claims that a dear one a close relative or the spouse has been replaced by an impostor.

In Cotard the person reports being disembodied or dead. In most cases such beliefs are not interacting with the person's other beliefs, although they may be defended with reasons when challenged. So, the person with Capgras may not go looking for the loved one who is believed to be missing although some people with Capgras are hostile and even violent towards the alleged impostor and the person with Cotard may not act dead although some people with Cotard may stop routine behavior such as bathing.

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One might wonder what the difference is between delusion and other false or irrational behaviors we find in the clinical and nonclinical population. In delusion, motivational factors may have a role, but need not.

The content of delusional beliefs is not always something we find desirable. In some delusions, we might conjure a positive image of ourselves, for instance, as people who were chosen by God to accomplish an important mission in delusions of reference; as the only people able to understand a complex conspiracy in delusions of grandeur; or as attractive sexual partners pursued by famous people in erotomania.

In other delusions, though, we see ourselves as overwhelmed by guilt delusions of guilt , or manipulated by external forces who can control our actions or even insert thoughts in our heads delusions of passivity and thought insertion. Bad events in our lives are explained by the evil intentions of the persecutors and not by our own failings. Another distinction that is not made consistently in the literature is between delusion and confabulation. It is key to confabulation that the belief or narrative is genuinely endorsed and presented with no intention to deceive.

So, there is a substantial overlap with delusion.


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The main difference between delusion and confabulation is that, as a clinical phenomenon narrow confabulation , confabulation concerns the distortion or fabrication of a memory, and thus it most often emerges in psychiatric disorders that feature serious memory impairments such as amnesia and dementia. Delusion does not need to involve memory distortions or fabrications.

That said, some differences can be found also between delusion and broad confabulation. Whereas a delusion is usually an implausible belief that can be further elaborated but does not need to, a confabulation can be very plausible and often takes the shape of an explanation or a narrative, thus exhibiting a high level of elaboration and integration with the person's other beliefs. The adaptiveness of delusions has been briefly explored in the recent literature, and we shall review some of the identified costs and benefits of adopting or maintaining delusional beliefs in Sections 4 , 5 , and 6.

Here we explain why we distinguish such costs and benefits in biological and psychological, and consider some hypotheses about what the relationship between the two categories may be. The goal of adaptive traits is to support the reproductive success and survival of the biological organism they belong to. Crucially, adaptiveness is not a timeless process but rather a historical one, and an adaptive trait is closely connected to the environment in which it develops.

Thus, some traits can be adaptive in one environment without being adaptive in other environments, or they can lose their adaptiveness as a consequence of environmental changes. By analogy with biological adaptiveness, some authors speak of psychological adaptiveness when a belief, state of mind.