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C H A P T E R 1 4 The Perils of Belief Psychosis The term delusion is vaguely applied to all false judgments that share the following characteristics. . . . (1) they are held with an extraordinary conviction , with an incomparable, subjective certainty; (2) there is an imperviousness to other experiences and to compelling counter-argument; (3) their content is impossible. —KARL JASPERS, 1913 1. The definition of psychosis is tendentious. This can be disheartening: if, after all, we cannot agree on what psychosis means, how can we claim to diagnose it, much less treat it? Superficially, one would expect psychosis to be the simplest thing to diagnose. Even the unversed, when faced with the “crazy” person who talks to himself on a street corner, seem to be able to recognize the psychotic symptom of probable hallucinations. Psychosis appears utterly at odds with “normal” psychological experience, and thus it should be easy to recognize as different from normal experience. All this is not the case with mood, since depression and happiness are part of normal human experience. Yet psychosis remains controversial. Part of this controversy may reflect the penchant of psychiatrists to argue. Part of it may reflect some real problems. The standard view is that psychosis is defined by the presence of delusions or hallucinations. Hallucinations are described as the experience of sensory phenomena in the absence of an appropriate stimulus. Delusions are said to be fixed false beliefs. Hallucinations are not purely sensory experiences, however, because the individual experiencing them needs to believe, according to the classic definition, that they are true, when they are not. If someone hears a voice, for instance, and knows that the voice is not “real,” this is not technically a true hallucination, according to standard accounts in psychopathology texts. This experience, when the person has insight into a hallucination, is sometimes referred to as a pseudo-hallucination. Although these terms are somewhat arbitrary, the general concept holds that there is a cognitive component to a hallucination. One experiences something sensory and believes it to be real, when it is not real. This leads to the conclusion that delusions, the psychotic symptom expressed in thought, are necessary for hallucinations and that therefore all psychosis at bottom rests on the presence of delusion. 2. So let me now turn to delusion. I said that the standard current view is that a delusion is a fixed false belief. Sometimes it is added that this fixed false belief is held against incontrovertible evidence to the contrary, and sometimes that it also lies outside of the bounds of beliefs that are accepted as true within the culture of the individual involved. So it appears that the standard view of delusion has at least four properties: it is fixed, false, held against incontrovertible evidence, and culturally atypical. But all of these properties are subject to doubt. First, are delusions fixed? Not always. Obviously, they can resolve with medications , and sometimes they are amenable to some psychotherapeutic techniques (such as the counterprojective techniques of Harry Stack Sullivan). Also, the same individual can be seen to hold a delusion with varying intensity over the course of a number of days. Second, are delusions false? Not always. The classic example is the Othello Syndrome, in which a person has the delusion that her spouse is cheating on her, based, say, on the constellation of the stars that day; suppose that, for reasons totally unknown to that person, her spouse in fact is cheating on her. We still might say she has a delusion. The conclusion is not false, but we sense that her thinking is not right because it is illogical , or it follows from false premises. Third, are delusions always held against incontrovertible evidence to the contrary? Usually, a clinician does not possess incontrovertible evidence, and yet delusions are diagnosed. Much evidence might be available to show that someone’s delusion is false, but rarely is that evidence incontrovertible. I am reminded of the manic patient admitted to the hospital who told us on her arrival that if the Cardinal of Boston called, we should please transfer him to her room. She had delusions regarding many subjects , and we felt that this was one more. The Cardinal called later that night. Fourth, are delusions culturally atypical? This would seem to water down the concept of delusion almost beyond recognition. It is frequently difficult to Psychosis 205 [18.118.32.213] Project MUSE (2024-04-25...

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