https://wires.onlinelibrary.wiley.com/doi/10.1002/wcs.70023

The self and its disorders in schizophrenia have been studied extensively over recent decades. Much of this literature is grounded in a bipartite understanding of the self, distinguishing the pre-reflective, minimal self from the reflective, narrative self. However, few studies have systematically examined the links between disturbances at these two levels of self. This integrative review addresses this gap by analyzing both theoretical and empirical contributions. Three theoretical models are described. The Structural model posits that minimal self-disorders hierarchically give rise to narrative self-disturbances and the schizophrenia phenotype, with a primarily pathogenic focus. The Dialectical model emphasizes reciprocal interactions between minimal and narrative self-disturbances, generating the schizophrenia phenotype with both pathogenic and salutogenic implications. The Contextual model highlights social, territorial, and biological dimensions of the self and its disorders in context. Empirical studies specifically addressing the mechanistic links between minimal and narrative self-disturbances remain scarce and preliminary. Overall, the literature appears preliminary and occasionally speculative, yet it suggests several promising avenues for future research and clinically relevant applications.

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(25)00341-4/fulltext

Background

Delusions in psychosis involve complex and dynamic experiential, affective, cognitive, behavioural, and interpersonal alterations. Their pattern of emergence during the early stages of illness remains poorly understood and the origin of their thematic content unclear. Phenomenological accounts have emphasised alterations of selfhood and reality experience in delusion formation but have not considered the role of life events and other contextual factors in the development of these disturbances. This study aimed to investigate the relationship between self-experience and the lived world in first-episode psychosis by situating the phenomenological analysis of delusions in the context of the person's life narrative.

Methods

In this qualitatively driven study, we recruited individuals with lived experience of delusions receiving care from three Early Intervention in Psychosis (EIP) teams in the UK. People with lived experience were involved in the development of the study design and protocol. Inclusion criteria were that the individual was being treated within an EIP service; past or current experience of clinically significant delusions, assessed by the attending psychiatrist to be at least of moderate severity; aged between 18 and 65 years; and willing and able to give informed consent and able to undertake interviews in English. Exclusion criteria included presence of a psychotic disorder solely related to substance intoxication or withdrawal. We used a novel multi-perspectival design to investigate delusions across three analytical standpoints: standard clinical psychopathology (third person), phenomenological psychopathology (a top-down approach to eliciting first-person data), and narrative inquiry (a bottom-up approach to eliciting first-person data). Delusion content was classified based on the definitions provided by the Scale for the Assessment of Positive Symptoms. Participants completed standardised psychometric scales, a narrative interview (ad-hoc Life Story Interview), and a phenomenological (Examination of Anomalous World Experience [EAWE]) interview. Findings were integrated through meta-inference across analytical frameworks.

Findings

Between Jan 4, 2023, and June 14, 2023, 33 interview sessions were completed with ten adults with first-episode psychosis and lived experience of delusions (three men, six women, and one person who was non-binary; median age 24·5 years [IQR 14·8]; eight White, two White and Black Caribbean). The three most common delusion themes were: persecutory (ten [100%]), reference (nine [90%]), and grandiose or religious (nine [90%]). No theme occurred in isolation. The phenomenological component of the analysis revealed a global, qualitative shift in the subjective experience of the lived world, with total EAWE scores ranging from 13 to 48 (mean 26·5 [SD 10·85]). The first narrative theme highlighted the role of early and repeated negative interpersonal emotions (especially shame) and subsequent experiential avoidance or immersion and absorption to understand the embodied phenomenology of delusions emerging in later life: (1) recurrent shame, anger, fear, and feelings of being controlled; and (2) “it really turned my whole life upside down”: coping with emotional upheavals before the onset of delusions. The second narrative theme revealed three main patterns of emotional transformation of the world and the self: (1) being under the spotlight: from embodied shame to almighty invincibility; (2) being part of something bigger: from meaninglessness and absence to embodied love, awe, and hope; and (3) being in a simulation: life without a body, cut off from others.

Interpretation

The emergence and evolution of delusions reflected a temporally extended, embodied, and cognitive–linguistic process characterised by an emotional transformation of the self and the world​ as a unified conscious experience. Metonymic thinking and language linked to contiguous bodily experiences appeared to explain some of the apparently incomprehensible or extreme delusional appraisals of self and world, such as being a bad person or being connected to God. Prevention and intervention models for psychosis should consider the role of the lived body for the regulation of emotions, and the effect of the surrounding material and social environments as central affective–regulatory mechanisms, and potential targets for intervention and support.

https://muse.jhu.edu/article/937765

Hermeneutical injustice as a concept has evolved since its original formulation by Miranda Fricker (2007). The concept has been taken up in psychiatry, with its moral, epistemic and clinical premium on the interpretation of extremely complex and difficult experiences (Kidd et al., 2022). There are many varieties of hermeneutical injustice with different forms, sources, degrees, effects, and interpersonal and socio-structural aspects (Medina, 2017). José Eduardo Porcher has proposed the addition of a new form of ‘radical’ hermeneutical injustice, with a case study of psychotic symptoms involving religious content.

He offers different characterizations of this injustice:

a particularly radical form of injustice, namely, having their own interpretation of their experiences unjustifiably undermined.

a form of hermeneutical injustice that occurs when a patient diagnosed with psychosis is denied the opportunity of interpreting their own experiences within their own religious framework.

These are different things. Denying someone the opportunity to interpret their experiences in their own, preferred framework is one way of undermining their interpretations. Another is forcing someone to use your own preferred framework and then belittling their own, which seems doubly wrong. Misusing some preferred interpretive framework can be as unjust as not using it. The two definitions could be combined, but then much will depend on what it means to undermine someone’s interpretation of an experience. We think there is a form of radical hermeneutical injustice—different to the one described by Porcher. Some interpretations of kinds of experience with religious content can be undermined if one is committed to a metaphysical naturalism. In these cases, one person cannot regard someone’s interpretive framework as coherent or intelligible (one that involves supernatural entities, for instance).

https://www.taylorfrancis.com/chapters/edit/10.4324/9781003296386-4/delusion-meaning-rosa-ritunnano-jeannette-littlemore?context=ubx

The territory of meaning in delusions can be carved up in many ways, depending on the different senses of the word ‘meaning’. In this chapter, we address three main philosophical questions arising from three distinct regions of meaning: psychological meaningfulness, felt meaning, and metaphorical meaning. There are many ways in which delusions are harmful or can lead to harm, but there is also increasing evidence that they can be lived through at certain times, and in certain contexts, as meaningful. To solve this apparent tension, we adopt a dynamical perspective on delusions as complex, performative, and situated phenomena arising through multiple layers of meaning-making across embodied, psychological, linguistic, and social levels of analysis. Within this framework, we consider the felt dimension of experiencing as a generative locus of meaning, particularly for those delusions referred to as ‘primary’ and described by Jaspers as analogous to the seeing of meaning. However, meaning is not only felt but also articulated in delusions through linguistic and cognitive acts of meaning-making which operate at the boundaries between the literal and metaphorical. Here, we encounter both a blurring of these boundaries and the boundaries between ‘novel’ or unconventional uses of metaphors. Guided by these insights, we suggest that our ability to genuinely engage with delusional discourse may improve once we understand delusions as expressive attempts at articulating felt meaning and understanding, rather than unshakeable assertions of truth.

https://doi.org/10.1016/S2215-0366(22)00104-3

Background

Delusions are a common transdiagnostic feature of psychotic disorders, and their treatment remains suboptimal. Despite the pressing need to better understand the nature, meaning, and course of these symptoms, research into the lived experience of delusional phenomena in psychosis is scarce. Thus, we aimed to explore the lived experience and subjective apprehension of delusions in help-seeking individuals with psychosis, regardless of diagnosis and thematic content of the delusion.

Methods

In our systematic review and qualitative evidence synthesis, we searched MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science for qualitative studies published in English from database inception, with the last search on Sept 9, 2021. Grey literature search and hand-searching of relevant journals were also done. Studies were eligible if they provided an analysis of lived experience of delusions or predelusional phenomena presented from the perspective of individuals (age 14–65 years) who had developed a clinical high-risk stage of psychosis, or a diagnosable affective or non-affective psychotic disorder (as clinically defined, self-reported, or assessed within the primary study). Studies with only a subset of relevant participants were eligible only if data for the population of interest were reported separately. Studies that did not discriminate between the experience of delusion and other positive symptoms (eg, hallucinations) were included only if data for delusions were reported separately or could be extracted. First-person accounts (and author interpretations) discussing changes in the sense of self, lived world, and meaning in relation to delusions were extracted and synthesised using a novel thematic synthesis approach informed by a critical realist stance and a phenomenological theoretical framework. Analytic themes were developed into a new overarching framework for understanding the emergence of delusional phenomena. The study was registered with PROSPERO, CRD42020222104.

Findings

Of the 3265 records screened, 2115 were identified after duplicate removal. Of these, 1982 were excluded after title and abstract screening and 106 after full-text eligibility assessment. Of the 27 studies entering quality assessment, 24 eligible studies were included in the qualitative evidence synthesis, representing the perspectives of 373 help-seeking individuals with lived experience of delusions in the context of psychosis. Gender was reported as male (n=210), female (n=110), transgender (n=1), or not reported (n=52). Only 13 studies reported ethnicity, with White being predominant. The age of most participants ranged from 15 to 65 years. We found no eligible studies investigating subclinical or predelusional experiences in at-risk mental state populations through qualitative methods. Most studies were undertaken in western, educated, industrialised, rich, and democratic (WEIRD) societies, and most included participants had received or self-reported a diagnosis within the schizophrenia spectrum. Studies differed in relation to whether they focused on one kind or theme of delusion or delusional phenomena more generally as a unified category. Three superordinate themes relating to experiential changes and meanings in delusion were identified: (1) a radical rearrangement of the lived world dominated by intense emotions; (2) doubting, losing, and finding oneself again within delusional realities; and (3) searching for meaning, belonging, and coherence beyond mere dysfunction. Based on the review findings and thematic synthesis, we propose the Emergence Model of Delusion to advance understanding of delusional phenomena in psychosis.

Interpretation

Delusions are best understood as strongly individualised and inherently complex phenomena emerging from a dynamic interplay between interdependent subpersonal, personal, interpersonal, and sociocultural processes. Integrative approaches to research on delusion, which consider their potential adaptiveness and favour explanatory pluralism, might be advantageous. Effective clinical care for individuals with psychosis might need adapting to match more closely, and take account of, the subjective experience and meaning of delusions as they are lived through, which might also help redress power imbalances and enduring epistemic injustices in mental health.

Funding

Priestley Scholars, Wellcome Trust.

https://doi.org/10.1192/bjb.2020.151

Abstract

Can delusions, in the context of psychosis, enhance a person’s sense of meaningfulness? The case described here suggests that, in some circumstances, they can. This prompts further questions into the complexities of delusion as a lived phenomenon, with important implications for the clinical encounter. While assumptions of meaninglessness are often associated with concepts of ‘disorder’, ‘harm’ and ‘dysfunction’, we suggest that meaning can nonetheless be found within what is commonly taken to be incomprehensible or even meaningless. A phenomenological and value-based approach appears indispensable for clinicians facing the seemingly paradoxical coexistence of harmfulness and meaningfulness.

https://doi.org/10.1007/s11097-021-09764-9

Delusions are often portrayed as paradigmatic instances of incomprehensibility and meaninglessness. Here we investigate the relationship between delusions and meaning from a philosophical perspective, integrating arguments and evidence from cognitive psychology and phenomenological psychopathology. We review some of the empirical and philosophical literature relevant to two claims about delusions and meaning: (1) delusions are meaningful, despite being described as irrational and implausible beliefs; (2) some delusions can also enhance the sense that one's life is meaningful, supporting agency and creativity in some circumstances. Delusions are not incomprehensible representations of reality. Rather, they can help make sense of one's unusual experiences and in some circumstances even support one's endeavours, albeit temporarily and imperfectly. Acknowledging that delusions have meaning and can also give meaning to people's lives has implications for our understanding of psychotic symptoms and for addressing the stigma associated with psychiatric conditions.

Keywords: Cognitive psychology; Creativity; Delusions; Meaning; Meaningfulness; Phenomenology; Sense of coherence.

https://doi.org/10.1002/wps.20878