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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by alexandra_k on December 19, 2004, at 17:40:40
Defining Delusion and Kinds of Delusional Utterance.
What is a delusion? The clinicians handbook The Diagnostic and Statistical Manual of Mental Disorders defines delusion as
>[A] False belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture…’ (American Psychiatric Association, (2000) pp. 821-822).
There is much controversy surrounding this definition and whether delusions must be: False, beliefs, incorrect inferences, regarding external reality, firmly sustained, and so forth. In short we may question this definition on every substantial point that it makes. Despite this controversy the DSM would seem to provide the best definition that we have at present, though there is ongoing research into devising a definition that may more accurately capture what is distinctive about delusion.
While there is ongoing debate about the definition of delusion, there is general agreement as to which kinds of utterance are appropriately classified as expressing delusions. The following are fairly standard examples, and the first two types will be the focus of this paper.
Capgras
‘My wife has been replaced by an impostor’.
Frégoli
‘People I know are disguising themselves and are following me around’.
Thought Insertion
‘Someone else’s thoughts are being inserted into my mind’.
Alien Control
‘Someone else is controlling my actions’.
Posted by smokeymadison on December 20, 2004, at 0:20:21
In reply to 1.1, posted by alexandra_k on December 19, 2004, at 17:40:40
i believe that i have been borderline delusional at times. once i thought my boyfriend was going to stab me. we were arguing, but he hadn't even raised his voice. i moved out for a week and called the police twice b/c i was sure that he was going to kill me. i considered taking out a restraining order. would you consider this delusional? or perhaps just obsessional? everything my senses took in told me that i was in no harm, but in my head i was sure that i was going to die. he wasn't loud or threatening in any way, looking back on it, of course. i "snapped" out of it after a week. it just hit me how ridiculous i was being.
sometimes i feel like i am being watched. i try to act normal, but i act as if someone is watching. it is just a feeling i can't shake.
i have read the DSM's definition of "delusion" many times. the problem i have with it is that at times i have have acted out delusions while some small part of me knows the belief is false. it is like my consciousness is fragmented into uneven chunks. antipsychotics keep the rational chunks large, but doesn't really get rid of the small, irrational ones. the meds keep the small, irrational ones from taking over.
so, is someone delusional if their BEHAVIOR is governed by a false belief while some small part of them, far in the back of their mind, knows that the belief that drives the behavior is false? i am starting from the premise that thoughts drive behavior. what is more important in diagnosing psychosis, the delusional behavior or the tiny thought that contradicts it?
SM
Posted by alexandra_k on December 20, 2004, at 1:23:07
In reply to DSM version sound, but,,,, posted by smokeymadison on December 20, 2004, at 0:20:21
I think I remember you contributing to the BPD thread - right? It is part of the criteria for that one that you can get a little bit psychotic (delusions included) in times of severe stress. I do this too - paranoia mostly, but sometimes grandiose.
>Would you consider this delusional? or perhaps just obsessional?
Welllll I am not a Dr. and one isnt' supposed to try to use DSM to diagnose without all that training... but my guess would be that it would probably be considered delusional in virtue of the BPD diagnosis and the provision there of the brief psychotic episodes. If you have been clearly obsessional about other things then maybe they might be more inclined to consider it obsessional - kind of in keeping with what they had already observed / noted. I think there is a great deal of controversy over the distinction (and indeed whether there is a hard and fast one) between over-valued ideas, obsessions, and delusions. I don't know too much about it really. I guess that because there are so many problems with definiton it may be best to consider utterances and how close they stand to some fairly typical exemplars. Considering someone is trying to kill you when they aren't seems fairly text-book paranoid, so my guess would be that delusional it is.
>everything my senses took in told me that i was in no harm, but in my head i was sure that i was going to die. he wasn't loud or threatening in any way, looking back on it, of course. i "snapped" out of it after a week. it just hit me how ridiculous i was being.
It is of considerable interest to me (and others) whether delusions are 'rationalisations' offered for certain kinds of anomalous experiences (e.g., strong feeling that someone wishes you harm); or whether the belief kind of occurs to one with a strong sense of conviction attached to it and that this results in the experience of a strong feeling that someone wishes you harm. The first is an 'empirical' or 'bottom-up' model, whereas the second is a 'rationalist' or 'top-down' model.
> sometimes i feel like i am being watched. i try to act normal, but i act as if someone is watching. it is just a feeling i can't shake.Does it seem to be a feeling, or a belief (firstly). Maybe these two things are impossible to disentangle though...
> is someone delusional if their BEHAVIOR is governed by a false belief while some small part of them, far in the back of their mind, knows that the belief that drives the behavior is false? i am starting from the premise that thoughts drive behavior. what is more important in diagnosing psychosis, the delusional behavior or the tiny thought that contradicts it?Some people act on their delusions, whereas others do not. Someone had the delusion that they were napolean, yet they did not attempt to order their troops around in the hospital. Closer to what I am talking about, some people with the Capgras delusion act on their delusion (e.g., one man decapitated his stepfather after becoming convinced he was a robot. He said that he did this in order to look for the batteries and microfilm in his head). While others do not seem to act in ways one would expect. Most people with the Capgras delusion show a suprising lack of concern as to where their loved one might have gotten to, and they do not report their disappearance to the relevant authorities.
It is hard to figure why some people act on their delusions whereas others do not. It is also of considerable clinical interest (with respect to protecting innocent people). So, anyway, I figure that diagnoses of delusions are made on the basis of comparing the UTTERANCES of subjects with some fairly standard exemplars of typical types of delusions within the context of the subjects overall presentation. Go with UTTERANCES rather than behaviour because many delusional people do not act out.
Hey, thanks for your thoughts :-)
Posted by alexandra_k on December 20, 2004, at 1:25:54
In reply to Re: DSM version sound, but,,, » smokeymadison, posted by alexandra_k on December 20, 2004, at 1:23:07
Oh, there is also evidence that degree of conviction (in delusions) may vary over time. As one would expect as the medication and / or therapy starts to do its thing... Or just as people start to get a bit better.
Posted by smokeymadison on December 20, 2004, at 1:58:46
In reply to Re: DSM version sound, but,,,, posted by alexandra_k on December 20, 2004, at 1:25:54
i have thought about it and i think that the paranoia stems from a feeling of unease. i feel uneasy and tend to want to attribute the feeling to something. i then attribute it to being scrutinized by some unseen source. the feeling comes first in this case, then the thought.
i am interested in the relationship between feelings, thoughts, and actions (behaviors). i know that there are a lot of cognitive behavioral theories out there that would propose that thoughts cause or give rise to feelings. but i can't believe tha this is ALWAYS the case. there have been so many times when i just feel something and have no thought related to it that i know of.
Posted by alexandra_k on December 20, 2004, at 12:45:08
In reply to Re: about being watched, posted by smokeymadison on December 20, 2004, at 1:58:46
> i have thought about it and i think that the paranoia stems from a feeling of unease. i feel uneasy and tend to want to attribute the feeling to something. i then attribute it to being scrutinized by some unseen source. the feeling comes first in this case, then the thought.
Yay! Phenomenological support for the empiricist model (sorry). Yeah, thats my intuition too...
> i am interested in the relationship between feelings, thoughts, and actions (behaviors). i know that there are a lot of cognitive behavioral theories out there that would propose that thoughts cause or give rise to feelings. but i can't believe tha this is ALWAYS the case. there have been so many times when i just feel something and have no thought related to it that i know of.Yes, yes, yes. I am interested in the relationship and causation between thoughts, feelings, and behaviours too. Even got permission to attend a graduate paper 'theory and issues in cognitive behaviour therapy'. I have lots of issues with the notion that thoughts cause feelings cause behaviours. Sometimes the feelings come first, as you say, and the thoughts are adopted as justifications or rationalisations - especially when the therapist requires you to rationalise or justify or you are being 'resistant'. Thats why I don't like cognitive restructuring. When you are required to JUSTIFY an intense / extreme state of emotional arousal you invariably envoke a cognitive error in your justification. If you are then told that you can change your feeling by changing your thinking then I think that they have the matter backwards. I learned nothing in the class except that cognitive behavioural therapy is so eclectic that it doesn't even deserve to be called a theory. I am not at all convinced that there is a coherent theory that could support or make sense of the little homework tasks and activities. But then I have a bone of contention there I suppose (too invalidating and superficial IMHO).
Linehan allows for feelings to come first. In fact, on her model the feelings typically do come first and she acknowledges that it is the intense emotions that produce the cognitive errors. But she still thinks that the way into the dysfunctional thought / feeling / behaviour cycle is usefully thoughts. Though I guess she tries to come in everywhere really...
Posted by smokeymadison on December 21, 2004, at 21:13:20
In reply to Re: about being watched » smokeymadison, posted by alexandra_k on December 20, 2004, at 12:45:08
is she the one who came up with DBT? because i am starting DBT w/ my new therapist and would like to know more about the theories behind the therapy.
Posted by alexandra_k on December 22, 2004, at 16:12:32
In reply to Re: about Linehan, posted by smokeymadison on December 21, 2004, at 21:13:20
> is she the one who came up with DBT? because i am starting DBT w/ my new therapist and would like to know more about the theories behind the therapy.
Yes, she's the one. Here is a link to her books (both the treatment manuel and the skills training manuel).
http://faculty.washington.edu/linehan/MML'sd%20Books.htm
They are expensive (at least the treatment manuel is). I think the best way into her theory is probably to read what she has to say. You should be able to get them from your uni library (even if you have to interloan). I would reccomend having a read of both of them if you are interested in the theory. Especially the treatment manuel.
I'll admit I haven't really read it very critically. After wading through oh so much psycho-dynamic judgemental crap I was just so wrapped to have found it that I haven't had the heart to attempt to dissect it yet (most unlike me).
Kernberg springs to mind. I do believe that his theory (and treatment) counted as the 'treatment as usual' control group that DBT was compared with. He now practices DBT would you believe!!! He hasn't recanted his theory (to the best of my knowledge) however, so I suppose he either manages to divorce his theory from her practice, and has just decided to pipe down (ha!) - or he is a convert as well.
If you have sympathy with buddhist spiritual principles you should find the mindfullness stuff easier to grasp, though this is not necessary.
I particularly like her model of emotions.
I think DBT and the theory behind it is really the very best there is for BPD at the moment. While viewing BPD as being at the borderline between psychosis and neurosis is somewhat out of date I think I like this to the extent that I think her theory (and techniques) could be adapted to use with psychotic patients. Instead of cognitive restructuring delusional beliefs one might attempt to at least build up a good rapport and working relationship by validating the 'inherent grain of wisdom in the patients utterances' ie - the EXPERIENCE that they are attempting to express.
This is the end of the thread.
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