Seminar Presentation on the above-mentioned topic held at JNMCH, AMU, ALIGARH, UP, INDIA on 09 September 2017.

1. PHENOMENOLOGY
OF DELUSION
MODERATOR - PROF. R.K. GAUR
PRESENTER - DR FAISAL SHAAN
09 SEPTEMBER 2017

2. DEFINITIONOF DELUSION
KARL JASPERS (psychiatrist and philosopher) was the first to define the 3 main
criteria for a belief to be considered delusional in his book (General
psychopathology, 1913) as follows:
1. Certainty (Held with absolute conviction)
2. Incorrigibility (Not changeable by compelling counterargument or proof to
the contrary)
3. Impossibility or falsity of content (implausible, bizarre or patently untrue)

3. DEFINITIONOF DELUSION
(HAMILTON, 1978) A DELUSION IS A FALSE UNSHAKEABLE BELIEF WHICH
ARISES FROM INTERNAL MORBID PROCESS. It is easily recognizable when it is not
keeping with the person’s educational & cultural background.
(SIMS, 2003) A DELUSIONAL IS A FALSE, UNSHAKABLE IDEA OR BELIEF, which
is out of keeping with the patient’s educational, cultural and social background; it is
held with extraordinary conviction and subjective certainty.
(FISH) A DELUSION IS A FALSE UNSHAKEABLE BELIEF, which is out of keeping
with the patient’s social, culture, religious background or his/her level of intelligence
and it is due to internal morbid process (the fact it is false makes it easy to recognize
but this is not its essential quality).

4. DEFINITIONOF DELUSION
(CTP 9th Edition) DELUSION IS DEFINED AS A:
1. False belief based on incorrect inference about external reality
2. Firmly held despite objective & obvious contradictory proof or evidence
3. Despite the fact that other members of the culture don't share the belief

5. PATHOPHYSIOLOGY OF DELUSIONS

6. PATHPOPHYSIOLOGY OF DELUSION
 Uncertain and may differ from one disorder to another
 Dysfunction of prefrontal and temporal lobes (Leposavic et al,2009) and the
basal ganglia(Morrison and Murray, 2009)has been suggested
 Dysregulation of Dopamine
 Endocannabinoid and adenosine systems may be involved (Morrison and
Murray, 2009)
 Cascella et al, (2011) suggested that the insula/claustrum may be “critical to
the experience of delusions” in schizophrenia.

8. ORIGINSOF DELUSION
Jaspers considered that our concrete perception of reality is a primary event not
determined by sense organs.
Reality lies in the interpretation of or the significance attached to the event.
From a review of the nineteenth-century literature Berrios (1991) has concluded that
these authors regarded the pre-delusional state as far more informative from the
neurobiological point of view than detailed study of already formed delusion.

9. FACTORS CONCERNEDWITH GENERATION OF DELUSIONS
The factors involved in delusion formation have been summarized by Brockington (1991) as
follows:
1. Disorders of Brain Functioning
2. Background Influences of Temperament & Personality
3. Maintenance of Self-esteem
4. Role of Affect
5. As a Response to Perceptual Disturbances
6. As a Response to Depersonalisation
7. Associated with Cognitive Overload

10. FACTORS CONCERNED WITHMAINTENANCEOFDELUSIONS
1. The inertia of changing ideas and the need for consistency.
2. Poverty of interpersonal communication.
3. Aggressive behaviour resulting from persecutory delusions.
4. Delusions impair respect for and competence of the sufferer & promote compensatory
delusional interpretation.

11. STAGES INTHEDEVELOPMENT OF DELUSION (FISH,CONRAD)
Conrad proposed five stages in the development of delusional psychosis.
1. Trema – delusional mood representing a total change in perception of the world
2. Apophany – a search for a new meaning for psychological events
3. Anastrophy – heightening of psychosis
4. Consolidation – formation of new world or psychological set based on new
meanings
5. Residuum – eventual autistic state

12. THEORIES OF DELUSION FORMATION
PSYCHODYNAMIC THEORY
Freud (1911) proposed that delusion formation involved denial, contradiction and
projection of repressed homosexual impulses that break out from unconscious.
DELUSIONS AS EXPLANATIONS OF EXPERIENCE
1. Binswanger & Minkowski (1930) proposed disordered experiences of space and
time leading to imprisoned and controlled feelings.
2. De Clerembault (1942) put forth the view that chronic delusions resulted from
abnormal neurological events( infections, intoxications, lesions).

13. THEORIES OF DELUSION FORMATION
VON DOMARUS RULE
Hepostulated that delusions inSchizophrenia result fromfaulty logical reasoning.
Thedefect apparently consists ofthe assumption ofthe identity of two subjects onthe
ground ofidentical predicates.
(Example – Lord Rama was a Hindu, I am a Hindu, and therefore I am Lord Rama)
LEARNINGTHEORY
Thisexplains delusions interms of avoidance response, arisingspecially fromfearof
Interpersonal encounter.

14. GENERAL MODEL OF DELUSION FORMATION

15. TYPES OF DELUSIONS

16. TYPES OF DELUSION
 PRIMARY DELUSION - True delusions, result of primary delusional experience
and not occurring in response to another psychopathological form such as mood
disorder.
According to Jaspers, the core of Primary delusion is that it is ultimately un-
understandable.
 SECONDARY DELUSION - Delusion-like ideas which can be understandably
derived from some other morbid psychological phenomena( perceptual
disturbances, patient’s mood state & personality disorder).
Secondary delusions are understandable when a detailed psychiatric history
and examination is available.
For example, a person becomes depressed, suffers very low mood and self-
esteem, and subsequently believes they are responsible for some terrible
crime which they did not commit.

17. Jaspers describes four types of primary delusion:
1. DELUSIONAL INTUITION - where delusions arrive 'out of the blue', without external
cause.
2. DELUSIONAL PERCEPTION (APOPHANOUS) - where a normal percept is
interpreted with delusional meaning. For example, a person sees a red car and knows
that this means their food is being poisoned by the police.
3. DELUSIONAL ATMOSPHERE - where the world seems subtly altered, uncanny or
sinister. This resolves into a delusion, usually in a revelatory fashion, which seems to
explain the unusual feeling of anticipation.
4. DELUSIONAL MEMORY - where a delusional belief is based upon the recall of
memory or false memory for a past experience. For example, a man recalls seeing a
woman laughing at the bus stop several weeks ago and now realizes that this person
was laughing because the man has animals living inside him.
PRIMARYDELUSION

18. SECONDARY DELUSION
Can be understood as arising from some other morbid experience:
1. Projection - occurs in the non-psychotic. Some other explanation is necessary to
account for the excessive projection which occurs in delusions, particularly those of
persecution
2. Latent homosexuality (Freud) - the different ways in which this is denied gave rise
to delusions of persecution, erotomania, jealousy and grandeur
3. Depressive moods
4. Hallucinations
5. Psychogenic Reaction
 Secondary delusions are understandable when a detailed psychiatric history and
examination is available.

19. It is an idea which is an isolated preoccupying belief neither delusional nor
obsessional in nature which comes to dominate a persons life for many years & may
affect his actions.
Is Ego-syntonic
The preoccupying belief may be understandable when the person background is
known.
It was described by Werneke in 1900 as an acceptable comprehensible idea pursued
by the patient beyond the bounds of reason
OVERVALUED IDEAS

20. SYSTEMATIZATION
1. Elaboration of Delusions & their integration into some sort of system (Delusional
Work); i.e. delusions are built logically on one basic delusion.
2. They are usually highly detailed and may remain unchanged for years.
3. They are commonly seen in older schizophrenics.
4. Systematization appears to be related to the retention of integrity of the
personality.
5. When schizophrenia occurs in young person it has a devastating effect on the
integrity of their personality therefore young schizophrenics have non-systematized
delusions.
6. Non-Systematized delusions change in content and level of concern.

21. DELUSIONS ONTHE BASISOF CONTENT OF DELUSIONS
1. Delusions of Persecution
2. Grandiose Delusions
3. Delusions of Jealousy
4. Delusions of Love
5. Delusions of Ill Health
6. Delusions of Guilt
7. Nihilistic Delusions
8. Delusions of Poverty

22. Result of apophanous experiences, auditory hallucinations, bodily hallucinations and experiences of passivity;
can take many forms:
 Delusions of reference: Pt. knows that people are talking about him, slandering him or spying on
him.
 Belief that they or their loved ones are about to be killed.
 Being robbed or deprived of their just inheritance.
 Have special knowledge which the persecutors want to take.
 Being poisoned – these are often explanatory delusions or based on hallucinations of smell and
taste.
 Delusions of influence: are logical results of experiences of passivity, which are diagnostic of
schizophrenia.
DELUSION OFPERSECUTION

23. DELUSION OFPERSECUTION
Delusions of persecution
are seen in :
 Schizophrenia
 Depressive
Illnesses
 Psychogenic
Reactions
PEOPLE ARE TALKING ABOUT ME- PEOPLE ARE TRYING
TO HARM ME

24. GRANDIOSE DELUSION
 Beliefs that the individual has exceptional beauty, intelligence or influence.
 They are an important person who is able to help others, or may report hearing the
voice of God and the saints, confirming their elevated status.
 The expansive delusions may be supported by hallucinatory voices (voices telling
the patient that he is important).
 They may be supported by confabulations when, the patient gives a detailed
account of his coronation or of her marriage to king.
 It may be a part of fantastic hallucinosis in which all forms of hallucination occur.

25. GRANDIOSE DELUSION
I AM GREAT-I AM GOD-I LOVE ONLY MYSELF-I CAN DO ANYTHING-I
HAVE SPECIAL POWERS
Grandiose Delusion are
seen in :
 Organic brain
disease
 Drug
dependence
 Schizophrenia

26. DELUSION OFJEALOUSY
 The term is a misnomer
 “Delusion of marital infidelity”
 Belief that the partner is being unfaithful
 Often the patient has been suspicious, sensitive and mildly jealous before the onset
of the illness or psychogenic reaction
 The severity of the condition fluctuates in the course of time, so that sometimes it
seems to be a series of psychogenic reactions

27. DELUSION OFJEALOUSY
I LOVE HIM-I DO NOT LOVE HIM-SHE LOVES HIM
Delusions of jealousy
are seen in :
 Alcohol
addiction
 Schizophrenia

28. DELUSION OFLOVE
I LOVE HIM-I DO NOT LOVE HIM-I LOVE HER
Also called as “the
fantasy lover” &
“erotomania”
Patients are convinced
that some person is in
love with them although
the alleged lover may
never have spoken to
them or met them.
Delusions of love are
seen in :
 Personality
disorders
 Schizophrenia

29. DELUSIONS OFILL HEALTH
Characteristic picture of DEPRESSIVE ILLNESS - result of an uncovering of the
patients worries.
DEPRESSIVE DELUSIONS of ill-health may involve the patient’s spouse & children
(post-partum psychosis).
Moderately depressed patient believe that they are becoming incurably insane
(therefore, hesitate to take medical help)

30. DELUSIONS OFILL HEALTH
Delusions of Ill-Health
may also be seen in :
 Schizophrenia -
early stages
secondary to
depression;
chronic cases
due to somatic
hallucination
 Personality
Development

31. DELUSION OFGUILT
Belief that individuals are guilty of purposefully or non purposefully damaging
themselves, other individuals or property.
Mainly seen in DEPRESSIVE ILLNESSES.
MILD DEPRESSION - patient is self-critical & self-reproachful (this differentiates true
depression from reactive depression).
SEVERE DEPRESSION - (delusion of guilt) patient believes he is wicked sinner who
has ruined his family - this may take on a somewhat grandiose character-“wickedest
man in the world will be punished for eternity”.
DELUSIONS OF GUILT CAN GIVE RISE TO DELUSIONS OF PERSECUTION.

32. DELUSION OFGUILT
The patient believe that
they are bad or evil and
have ruined their family.
Seen in case of severe
depression.

33. NIHILISTICDELUSION
A delusion in which one imagines that the world and all that relates to it have ceased
to exist.
Also known as DELUSION OF NEGATION (as patient denies the existence of his body,
his mind, his loved ones & the world around him).
Financially comfortable individuals may believe they are destitute, inspite bank
statements to the contrary.
A person believes he/she is dead or dying, doesn’t exist, is putrefying or has lost
his/her internal organs “My Intestines have rotten from inside”

34. NIHILISTICDELUSION
THIS IS A FALSE BELIEF THAT ONE DOES NOT EXIST OR HAS BECOME DECEASED
Nihilistic Delusion are
seen in :
 Severe
agitated
depression
(Involutional
melancholia)
 Subacute
delirious state
 Schizophrenia

35. Somatic delusions are false
beliefs about the body.
These may be bizarre or non-
bizarre.
A bizarre example is when the
individual believes his nose is made of
gold.
A non-bizarre example is when the
individual believes he has cancer of
the rectum, in spite of negative
reports from a competent doctor who
has examined the rectum.
SOMATIC DELUSION

36. DELUSIONAL PARASITOSIS
 Also known as EKBOM SYNDROME.
 Delusional Parasitosis is a mistaken belief
that one is being infested by parasites such
as mites, lice, fleas, spiders, worms, bacteria,
or other organisms.
 Affected individuals may report being
repeatedly bitten & sometimes physical
manifestations may occur including skin
lesions.

37. NAMED DELUSIONS

38. NAMED DELUSIONS
CAPGRAS SYNDROME
It is the delusion that a person
(usually a family member or
someone close to the patient)
has been replaced by an
impostor of nearly identical
appearance.
This most commonly occurs in:
•Schizophrenia
•Organic Brain disease

39. DE FREGOLI SYNDROME
It is the delusion that a person
(usually a suspected tormentor)
can change into different people
and many of the people the
patient meets are misidentified
as transformed version of the
suspected person.
NAMED DELUSIONS

40. NAMED DELUSIONS
FOLIE A DEUX
(Shared Psychotic Disorder)
It is diagnosed when two persons
share the same delusion (Shimizu
et al, 2007)
Usually one of these people is
psychotic and the other is non
psychotic; but the non-psychotic
person has come to accept
what the psychotic person believes.

41. NAMED DELUSIONS
COTARD SYNDROME
It is nihilistic (denying the existence
syndrome).
Also known as the “Walking Corpse
Syndrome”
The patient believes that they are
dead or don’t exist.

42. NAMED DELUSIONS
DE CLEREMBAULT SYNDROME
It is the delusion that a person
(usually an important person) is in
love with the patient. The love
object is usually unknown to the
patient.
The syndrome may lead to phone
calls, unwanted letters and other
attention.
Usually held by middle aged single
women towards person belonging
to higher Socioeconomic status.

43. DELUSIONS IN VARIOUS TYPES OF
MENTAL DISORDERS

45. DELUSIONAL SEVERITY

46. KENDLER’S VECTORS – FOR DELUSIONAL SEVERITY
Kendler etal.(1983)have proposed several poorly correlated vectors ofdelusional severity.
1. Conviction : The degree to which the patient is convinced of the reality of Delusional beliefs.
2. Extension : The degree to which the Delusional belief involves areas of patient’s life.
3. Bizarreness : The degree to which the Delusional belief departs from culturally determined
consensual reality.
4. Disorganization : The degree to which the Delusional beliefs are internally consistent, logical and
systematized.
5. Pressure : The degree to which the patient is preoccupied and concerned with the expressed
delusional beliefs.
6. Affective Response : The degree to which the patient’s emotions are involved with such beliefs.
7. Deviant Behavior resulting from delusions : Patients sometimes, but not always, act upon their
delusions.

47. HOW TO CONFIRM DELUSIONS?

48. Present State Examination PSE (Ninth Edition, 1974 by WING et al.) provides sets of questions to
be asked.
Delusions are rated as (1= Partial Delusions) and (2= Full Delusions)
(Hindi adaptation of PSE, 1978) to challenge delusions is mentioned below:
1. Iske baare me chahe apko poora yakeen ho phir bhi kabhi aisa lagta hai ki shayad ye sach nhi hai ya
man ka wahem hai?
2. Kya aisa mahsoos hota hai ki apko kisi bahar ki taaqat ya shakti ne apne vash me kar rakha hai?
3. Kya aisa lagta hai ki log apki or ishara karke baate karte hain ya logo ki baato ke dohre matlab hain
ya log aisa kaam karte hain jinka apke liye khaas matlab ho?
4. Kya aisa lagta hai ki sabhi log apke baare me baat karte hain?
5. Kya apko koi jaanboojh kar nuksaan pahuchaane ki koshish kar raha hai? Jaise apko zaher dene ya
maar dene ki koshish kar raha ho?
HOWTO CONFIRM DELUSIONS ?

49. 6. Kya aisa lagta hai ki log apki madad karne ke liye khaas taur se intejam kar rahe
hain?
7. Kya aap me koi khaas baat hai?Ap me koi khaas taqat ya shakti aa gyi hai?
8. Kya aap bahut dharmik vicharo ke hain?
9. Kya aisa lagta hai ki koi jadoo tona ho raha hai,upari kasar ya bhoot preto ka asar
hai? Ye sab kaise hota hai?
10. Kya aisa lagta hai ki bijli,xray,machines ka ap par asar ho raha hai?
11. Apko kaise pata laga ki yahi wajah hai?
12. Kya in dino apko koi khaas anubhav hua hai ya koi ajeeb baat hui hai?
13. Apko aisa mehsoos hota hai ki apne koi bada paap ya apraadh kiya hai jiske liye
apko saza milni chahiye

50. SCALES FOR ASSESSMENT OF
DELUSIONS

51. SCALES TO ASSESS DELUSIONS
 Developed by Eisen et al.
 The BABS© scale has been developed to rate the degree of conviction and insight patients have
concerning their beliefs.
 The BABS© rates a number of dimensions that underlie delusional and non-delusional beliefs.
 RATING: The BABS© consists of 7 items: the first 6 items are added to obtain the total BABS©
score. An additional item (ideas of reference) is not included in the total score. Each item
corresponds to one of the dimensions listed above. Each item is rated from 0 to 4 (from least to
most severe). The instrument is semi-structured.
 SCORING: All items should be rated. The total score is the sum of items 1 through 6. Item 7
should be rated but not included in the total score.
1. BROWN ASSESSMENT OF BELIEFS SCALE(BABS ©).

52. This questionnaire is
designed to measure
beliefs and vivid mental
experiences.
RATING: Done on the
basis of:
(a) how distressing these
beliefs or experiences are;
(b) how often you think
about them; and
(c) how true you believe
them to be.
2. THE 21-ITEM PETERS et al. DELUSIONS INVENTORY (PDI-21):

54. REFERENCES
1. Max Hamilton; Disorders of Thought and Speech; Fish’s Clinical Psychopathology
(Signs and Symptoms in Psychiatry);Varghese publishing house; Second edition; 43-
53.
2. Chandra Kiran & Suprakash Chaudhary; Understanding Delusions; Industrial
Psychiatry Journal 2009 Jan-Jun; 18(1);3-18.
3. Femi Oyebode; Delusions and other erroneous ideas; SIMS’symptoms in the mind;
Reed Elsevier India Pvt limited; Fifth edition;111-134.
4. Jane L. Eisen, M.D.1 Katharine A. Phillips, M.D.1 Douglas Beer, M.D.1 Katherine D.
Atala, M.D.2 Steven A. Rasmussen, M.D.1 LEE BAER, Ph.D. BABS©
5. Schizophr Bull. 2004;30(4):1005-22. Measuring delusional ideation: the 21-item Peters
et al. Delusions Inventory (PDI).

55. THANKYOU