Stephanie Reiter, M.A., LPCC
Primary Therapist
Resilience Treatment Center

Delusions are an often-misunderstood cornerstone of schizophrenia spectrum and other psychotic disorders. Delusions are fixed beliefs that persist in the midst of concrete, conflicting evidence that the beliefs are not true or logical. An individual with delusions often has an unshakeable certainty in the truth of these beliefs. Delusions are common in individuals suffering from schizophrenia spectrum disorders, a manic episode of bipolar disorder, or in individuals with medical conditions such as epilepsy, dementia, and brain injury. This article will outline several types of delusions, which are categorized based on the predominant theme and nature of the false belief:

Persecutory delusions are the most common; individuals with persecutory delusions have a strong conviction that they will be, or have been, harmed, harassed, conspired against, spied on, poisoned or drugged, or followed by an individual or organization (i.e. the government or FBI). Individuals with persecutory delusions frequently believe they are being videotaped or that their phone lines have been tapped as part of an ongoing investigation. I worked with a client once who believed the Nazi Party had poisoned her water and food; therefore, she had turned off her water supply and hadn’t eaten for over two weeks out of fear.

Individuals with grandiose delusions believe they have exceptional and special abilities, powers, talents, or wealth. Often this manifests as believing they are deities, significant figures from history (“I am Gandhi”), celebrities (“I am famous and should be recognized by TMZ and the paparazzi!”) or professional sports players. One time I had a client in the midst of a psychotic episode with grandiose and religious delusions who screamed at me, “I’m Jesus! I died for your sins! My back hurts from being nailed to the cross!”

An erotomanic delusion is the belief that another individual is in love with him or her. This individual is usually of higher status, often a celebrity, but can be a complete stranger. I once worked with a client who had an erotomanic delusion that Johnny Depp was in love with her and his tattoos corresponded with her significant life events (i.e. she stated Johnny Depp got his “Betty Sue” tattoo the same day she had been in a car accident with her friend named Betty Sue). It is common for someone with an erotomanic delusion to attempt to contact the individual through emails, phone calls, written letters, sent gifts, and, in extreme cases, can manifest into house visits and/or stalking.

Ideas of reference are that normal, insignificant events have significant meaning. For example, an individual with ideas of reference may believe they receive messages from the weatherman on television or interpret that a famous singer’s song lyrics are directed at them. Somatic delusions are a fixed preoccupation with physical health, organ function, and/or bodily sensations. An individual with somatic delusions may believe they emit a foul odor, their body parts are not functioning properly, they are carrying a rare virus, or that there is an infestation of insects on or under their skin. There is also a type of delusion classified as mixed, which includes one or more themes. For example, one of my former clients had a mixed delusion of somatic, ideas of reference, and grandiose natures. He believed his pacemaker could transmit signals and communicate to inanimate objects such as the radio or television.

A jealous delusion holds the central theme that one’s spouse or partner has been unfaithful and/or is currently having an affair. An individual with a jealous delusion will frequently collect evidence in an attempt to justify their delusional belief. Individuals with a jealous delusion may go to great lengths to obtain evidence confirming their belief, such as hiring a private investigator or having their spouse followed.

A delusion is classified as bizarre if the beliefs are clearly implausible, not understandable to others within the same cultural context, and do not derive from ordinary life experiences. A delusion would be bizarre if an individual is stating that an alien abducted him and removed his brain, replaced it with a foreign object, and did not leave any wounds or scars from the surgery.

Delusions of control are of the nature that one’s body or actions are being manipulated by an outside, and usually unknown, force. Examples of delusions of control include thought broadcasting (that one’s thoughts are constantly heard aloud by others), thought insertion (that others are inserting thoughts into one’s head; i.e. think of the movie Inception), and thought withdrawal (an individual’s thoughts have been “stolen” or removed by an outside force). An internet delusion is an individual being controlled by the internet, or, more specifically, Google is controlling his or her brain and actions.

The following delusions are characterized as monothematic, meaning the individual’s delusional state concerns only one particular theme or topic:

Someone with a capgras delusion believes that their family member, spouse, or friend has been replaced by an imposter with an identical appearance. These individuals may state, “that’s not my father! This duplicate is just pretending to be!” with strong conviction. This type of delusion is commonly seen in those with paranoid schizophrenia, but also in populations of Alzheimer’s dementia and traumatic brain injuries. One of the most rare types of delusions is lycanthropy, the belief that an individual has the superhuman ability to morph into an animal. Individuals may believe they can transform, have transformed in the past, or are currently an animal, most commonly a wolf. These individuals may exhibit animal-like behavior such as growling, scratching, or howling given their strongly held delusional belief. This may also be associated with visual/tactile hallucinations of seeing fangs or feeling fur on their skin.

Cotard’s syndrome is a delusion in which the individual believes they are already dead or do not exist. Individuals with Cotard’s syndrome may experience olfactory hallucinations (i.e. smelling their flesh rotting) or tactile hallucinations (as if maggots are crawling on their skin) which align with the belief that they are already “deceased.” An associated feature of Cotard’s syndrome is a delusion of immortality, that the individual is immortal and will never die.

The last type of rare delusions outlined in this article is the fregoli delusion, which is the belief that different people are all one single person capable of morphing his or her appearance with disguises. The first recorded case of a fregoli delusion involved a woman who believed two actors in the theater were secretly pursuing her by disguising themselves as others, including old coworkers, friends, doctors, and strangers on the street.

Apart from the presence of delusions, there are additional criteria that impact the diagnostics of a delusional disorder and other schizophrenia spectrum disorders, including the duration of symptoms, presence of hallucinations, level of impairment in psychosocial functioning, and whether the symptoms are due to a substance or medical condition. Future Keys of Unlocking Psychosis articles may include types of hallucinations, diagnostics of psychotic disorders, causes of psychosis, and how to clinically treat clients with hallucinations and/or delusions; stay tuned!

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

Appelbaum, P.S., Robbins, P.C., Roth, L.H. (1999). Dimensional approach to delusions: Comparison across types and diagnoses. American Journal of Psychiatry, 156(12), 1938-1943.

Chadwick, P., Lowe, C.F., Horne, P.J., & Higson, P.J. (1994). Modifying delusions: The role of empirical testing. Behavior Therapy, 25, 35-49.

National Institute of Mental Health (2017). Schizophrenia. Retrieved from https://www.nimh.nih.gov/health/publications/schizophrenia-booklet/index.shtml

Smith, J.L. (2016, March 6). Shape-shifters and psycho-killers: how a bizarre psychological delusion inspired Anomalisa. Retrieved from http://www.telegraph.co.uk/film/anomalisa/what-is-fregoli-delusion-charlie-kaufman/

Smith, L., Nathan, P., Juniper, U., Kingsep, P., & Louella, L. (2003). Cognitive Behavioural Therapy for Psychotic Symptoms: A Therapist’s Manual. Perth, Australia: Centre for Clinical Interventions.