REVIEW ARTICLE

PARANOID : A REVIEW OF THEORETICAL EXPLANATIONS

Dr. Fahmi Hassan, F. S. Psychology Department, Faculty of Arts, P.O.Box: 3114, Hodeidah University, Yemen.

Abstract Objective: There are two general theoretical explanations for delusions, the deficit and the motivational. In the deficit approach, scientists have argued that delusions are the consequences of fundamental perceptual or reasoning deficits which cause the individual to misunderstand what is happening in the world. The second approach views delusions as serving a defensive, palliative function, as representing an attempt to relieve pain, tension and distress. Methods: The present review article is based on literature review about Paranoid theories. Results and Conclusion: This article reviews the most important theories in the above mentioned approaches and it has found that we need more studies to verify the results of these approaches. The deficits in reasoning ability for example, need more explanations to show how and why these deficits occur and cause persecutory delusions. In this article I suggest that there are basic cognitive impairments that lead to disturbances in the mental imagination. These disturbances result on the two cognitive deficits (two losses) and force a person to have delusional beliefs. This study is a qualitative study based on judgments of some cases which the researcher has had the opportunity to study. ASEAN Journal of Psychiatry, Vol.12(1), Jan – June 2011: XX XX.

Keywords : Persecutory delusion, paranoid delusion, mental imagination, problem solving method.

Introduction

Delusions are defined as fixed false Definitions of this sort have been beliefs which are unfounded, unrealistic, criticized because it is not obvious, but and idiosyncratic [1]. These false beliefs what constitutes an ‘‘incorrect are held despite the presence of evidence inference’’ or “incontrovertible and to the contrary [2]. It is "based on obvious proof or evidence” [4]. incorrect inference about external reality However, these definitions of delusions that is firmly sustained in spite of what have a qualitative difference from almost everyone else believes and in normal beliefs. The delusional beliefs spite of what usually constitutes are false in that they are not justified by incontrovertible and obvious proof or the evidence [5] and are held with evidence to the contrary. The belief is unusual conviction, whose absurdity is not one ordinarily accepted by other manifested to others and which are not members of the person’s culture or amenable to logic. These monolithic subculture (e.g., it is not an article of definitions also have been modified in religious faith)" [3]. the light of so many recent

phenomenological studies, which lead to almost 50% of cases. Zolotova and now conceptualizations as "dimensional Brune [13] compared between two entities rather than categorical ones, samples of German and Russian patients lying at the extreme end of a “belief with delusions of , and they continuum” " [6]. found (57.1%) from German patients and (53.44%) from Russian patients On the other hand, "delusion is a key were classified correctly on the basis of clinical manifestation of " [7] the model for " identity of persecutors." and with hallucination it constitutes first- Jorgensen and Jensen (14) found that 37 rank symptoms in disorders of of 88 deluded patients had persecutory such as schizophrenia, beliefs. These findings show that the , and delusional persecutory delusions have high disorder [8,9]. Although, the DSM- IV A prevalence rates among patients of criteria for schizophrenia may be met in schizophrenia, and it shows the the absence of delusional ideas [3] importance of studying this "delusions also occur in dementia, phenomenon. temporal lobe epilepsy, Huntington’s disease, Parkinson’s disease, multiple Theories of Paranoid Delusions sclerosis, and traumatic brain injury" [9]. So delusions have been referred to as We can distinguish between two general “the sine qua non of psychosis” in classes of theoretical explanation for general [10] and for schizophrenia in delusion: the deficit and the motivational particular [8]. [11,15,16]. In the deficit approaches, scientists have argued that "abnormal According to the primary themes, beliefs are the consequences of delusions also can vary ranging from the fundamental perceptual or reasoning bizarre to the moderate humdrum [9] and deficits which cause the individual to divided into more subsymptoms such as misunderstand what is happening in the delusions of control, persecutory world, whereas, others have held that beliefs that ــــ delusion, , and they are motivated beliefs delusions of reference. Grandiose and despite their apparent bizarreness serve Persecutory (Paranoid) delusions have some intra-psychic function for the received more attention than other kinds individual" [11]. of abnormal beliefs because they are very commonly observed in clinical The deficits theories involve the notion practice [11]. of deficits or defects, which view delusions as the consequence of These observations probably have some fundamental cognitive or perceptual cross-cultural validity, for example abnormalities, ranging from wholesale Sartorius, and colleagues [12] present failures in certain crucial elements of findings from a World Health cognitive-perceptual machinery, to Organization prospective study in ten milder dysfunctions involving the countries of individuals with signs of distorted operation of particular schizophrenia making first contact with processes. services (N=1379) show that the persecutory delusions are the second Maher [17] has proposed that “delusions most common symptom of psychosis, arise from the application of normal after delusions of reference, occurring in reasoning processes to abnormal experiences” [18]. And the delusions development of delusions. Coltheart and reflect rational attempts to explain his colleagues thus claim that Maher’s anomalous experiences. According to account is incomplete, and invoke a a deficit in ــــ this view delusions arise when a patient second explanatory factor applies normal logic to abnormal the machinery of belief revision". And it experience or perception; thus, someone is "hypothesized that the individuals who is hearing voices may deduce that a with this second deficit are unable to group of scientists have invented a reject implausible candidates for belief, special machine that ”broadcasts” these once they are suggested by first-factor voices [19]. Maher [20] thus emphasizes perceptual anomalies" [9]. that delusional ideas spring from unusual internal experiences. He maintains that In the other deficit theory, David delusions do not arise via defective Hemsley and his colleagues have various reasoning, but rather constitute rational hypotheses about logical reasoning. responses to unusual perceptual They suggest that "delusions are more experiences, which are, in turn, caused than statements of experience, and by a spectrum of neuropsychological involve an abnormal evaluative abnormalities. judgment arising from reasoning biases" [18]. And it is probable, delusions may Maher highlights how hearing arise through defective Bayesian impairment, conceived as an anomalous reasoning [28]. experience, can lead to paranoid thoughts. Some studies found evidences Brennan and Hemsley [29] observed that about associations of and paranoid patients perceived illusory hearing difficulties in older adults [21], correlations between pairs of words that although this result is not always found had only appeared together at random, [22,23]. In the recent study Freeman [24] particularly when these words are related concludes that "the anomalous to their delusion. Hemsley and Garety experiences account is a difficult and [28] have suggested that "some under- researched area of study and it is delusions result from deficits in the frequently found in individuals with ability to weigh new evidence and adjust delusions but the nature of their beliefs accordingly" [19]. relationship remains to be tested convincingly". Both of these last accounts [17, 20, 15] suggest that deluded patients reach The current model of delusion formation conclusions about the world in much the and maintenance is known as the “two same way that scientists reach about deficits” or “two factors” models, theoretical beliefs, but assume that the [25,26]. These models incorporate an processes leading from evidence to empiricist perspective on delusion deduction are somehow dysfunctional in formation [27]. the psychotic patient [11], although evidence for reasoning ability impaired In addition to Maher's theory, Coltheart in deluded patients is far from and colleagues [9] "identify perceptual convincing. Simpson & Done [16] anomalies that may potentially be found the performance by the deluded involved in a series of other delusions. group was certainly impaired when They note that such first deficit compared with the depressed and non- experiences are not sufficient for the psychiatric control groups though less convincingly so when compared with the likely to revise their hypothesis in the non-deluded schizophrenia group. The light of disconfirmatory evidence. These impairment shown by the deluded results suggest that "limited amount of schizophrenia group seemed to occur at information represent sufficient evidence the initial stage of the reasoning task. for a hypothesis to be accepted, thereby increasing the likelihood of inaccurate However, comparisons between beliefs being formed hastily" [18]. paranoid and non-paranoid subgroups, while finding no evidence of gross The second type of delusional theories reasoning impairment on the part of the view delusions as serving a defensive, paranoid subjects, have indicated palliative function, as representing an specific cognitive styles. Nicholson and attempt to relieve pain, tension, and Neufeld [30] found impairments in distress. Such theories regard delusions specific reasoning ability in paranoid as providing a kind of psychological patients who have particular difficulty in refuge or spiritual salve, and consider extracting from their environment the delusions explicable in terms of the stimulus properties necessary for emotional benefits they confer. "This informed responses. Interestingly, approach to theorizing about delusions McKenna [31] found problems in has been prominently exemplified by the semantic memory could lead to delusion psychodynamic tradition with its formation. Studies, also, found deficits concept of defense, and by the in semantic memory in deluded patients philosophical notion of self-deception. [32]. From a motivational perspective, delusions constitute psychologically This field of theory has been supported dexterous (sleights of mind)" [39] deft from a number of resources, for example mental maneuvers executed for the "there is a large body of evidence maintenance of psychic integrity and the documenting the disruption of reduction of anxiety [9]. The important information processing in psychotic theory in this field is Firth’s theory [19]. individuals leading to a variety of He suggested the “Inability to perceptual disturbances" [18]. Delusions monitor the beliefs and intentions of also occur in a large number of medical others leads to delusions of reference, and psychological conditions [33]. And paranoid delusions, certain kinds of those irrational beliefs can be induced in incoherence, and third person the general population under anomalous hallucinations (p.115)”. environmental conditions [18]. He thinks the paranoid delusions and However, there is a growing body of delusions of reference both occur evidence demonstrating reasoning and because the patient has made incorrect attribution biases in people with inferences about the intentions of other delusions [34, 35]. This attempt presents people. Patients, with delusions of challenges for Maher’s position. "Garety reference incorrectly, believe that other and her colleagues demonstrated that people are intending to communicate deluded people have a 'jump-to- with them; this means a person with conclusions' (JTC) reasoning style on a schizophrenia mistakenly labels an probabilistic reasoning task (the ‘beads’ action as having an intention behind it. task). They require less information "Will patients with paranoid delusions before making a decision, and are more unlike autistic individual, know that other people have minds, but have lost In the other hand, I do not think that the the full capacity to make appropriate failure in the monitor of beliefs and inferences concerning the contents of intentions of others can lead to delusions other people’s minds" [36]. And they of reference or paranoid delusions. The believe that other people are intending disturbing question here is how this them harm, so other peoples' actions process leads to forming fixed false have become opaque and surmises that a beliefs. The paranoid beliefs are more conspiracy exists [24]. fixed beliefs, and some paranoid beliefs are more false compared with social Frith [19, 37] proposes that symptoms of culture. So to get this type of delusions it schizophrenia develop from newly is necessary to find an interaction acquired difficulties in a person's ‘theory between three etiological groups of of mind’ skills (ToM), and refers to the factors. The first group contains the poor ability to understand mental states circumstances (this means: adverse life (beliefs, desires, feelings, and intentions) events, non-equality in educational in the self or others. But he notes the opportunities, low economic level), (ToM) findings for paranoia may be upbringing dependent on suspicion, more equivocal [37]. This is because lower social support, repeated failure, ToM difficulties have been hypothesized low self-esteem, and anxiety. These to explain several symptoms of variables lead to a cognitive –intellectual psychosis, the majority of studies have structure basics depend on suspicious tested a group of people with thought or mind (second group). But all schizophrenia and examined associations these variables in the first and second between symptoms of psychosis and groups cannot be the causes factors of ToM performance, but the majority paranoid delusions until it has negitive results of these studies did not support effects on the mental imagination in the ToM theory [24]. way related to delusional thinking style –type paranoid. And the contents of Discussion and New Suggestions mental imagination conforms with patient’s needs, motives, hopes, and In this review the author focuses on two fears. The mental imagination continue general classes of delusional theories, over and over in the person’s thoughts. the deficit and the motivational, These cognitive processes lead to especially the theories of Maher, occupy his thought because he uses Hemsley, and Frith. According to imagination as a method of problem Maher’s theory [15,20] delusions arise solving and as an instrument to when the individual applies normal extenuate the painful daily events, such logic to abnormal perception (Reasoning as with Bentall and colleagues [11] who Deficits). But this view is not clear, so understand persecutory delusions to be the author need more studies to verify it. the result of a psychological defense We do not know how or why the against underlying negative emotion and reasoning deficits occur, thus the deficits low self-esteem. in reasoning ability need more explanations about the primary causes of The disturbances in this cognitive this deficit, thus I suggest that there are functions (Mental imagination, Thinking other basic cognitive impairments lead Style –paranoid type- and the problem to reasoning deficits in deluded patients. solving method) will affect in the other cognitive processes, and the impairment will be found with different conditions in the other cognitive operations such as: References 1- confusion in the attention, concentration, and perception. 2- slow 1. Kay , S.R., Opler, L.A. & information processing and encoding, Fiszbein, A. (1992). which delay of information processing Posative and negative for the new information and ignore or syndrome scale: Manual. delete some of this information. So, Multi-Health Systems, Inc. depending on little information causes 2. Meyers, B., English, J., the insufficiency of ideas (information Gabriele, G., Peasley- possessing deficits) which lead to the Miklus, C., Heo, M., Flint, impairment in the reasoning processes A. J., Mulsant, B. H., (abnormal logic) and perception ( false Rothschild, A .J., & STOP- interpretation). PD Study Group, (2006). A delusion assessment scale In order to solve her/ his daily problems, for psychotic major a deluded person will find the depression: Reliability, imagination as an easy way to have good validity, and utility. feelings, to escape from the psychosocial Biological Psychiatry, 60, problems, and to overcome the feeling of (12), 1336-1342. frustration, or to satisfy the hidden 3. American Psychiatric wishes [38]. This makes him return to Association (1994). imagination mostly so that he becomes Diagnostic and statistical preoccupied with mental imagination. manual of mental disorders. Because of this preoccupation an (4th ed.).Washington DC: individual may have two losses: the first Author. is the loss of healthy interaction style 4. Harper, D. J. (1992). with other people, especially with Defining delusions and the persons who criticize the patient’s serving of professional behavior. The Second loss is more interests: The case of important, because it’s related to the ‘paranoia’. British Journal ability of distinguishing between reality of Medical Psychology, 65, and imaginary ideas. This state occurs 357– 369. because he/she daily depends on the 5. Frith, C. D. (2005). The delusional thinking style which is used self in action: Lessons from as problem solving method and because delusions of control. she/ he is daily suffering from Consciousness and preoccupation with mental imagination. Cognition, 14, 752-770. Then, the patient will think that the 6. Blackwood, N. J., Howard, imaginary (delusional) ideas are real, R. J., Bentall, R. P., & and will try to show to his friends and Murray, R. M. other people. (2001).Cognitive neuropsychiatric models of Finally, the logical conclusion is that persecutory delusions. interaction between the three groups of American Journal of cognitive factors results on the two Psychiatry, 158, 527–539. cognitive deficits (two losses) and force 7. Bell, V., Halliga, P. W. & a person to have delusional beliefs. Ellis, H. D. (2006).

Explaining delusions: a ancestral hostile threats. cognitive perspective. Evolution and Human Trends in Cognitive Behavior, 27, (3), 185-192. Sciences, 10, (5), 221-226. 14. Jorgensen, P., & Jensen, J. 8. American Psychiatric (1994). Delusional beliefs Association (2000). in first admitters. Diagnostic and statistical Psychopathology, 27, 100– manual of mental disorders. 112. (4th ed.). Washington, DC, 15. Hemsley, D. R. (1993). A Text Revision. simple (or simplistic?) 9. McKay, R., Langdon, R., & cognitive model for Coltheart, M. (2007). schizophrenia. Behavior Models of misbelieve: Research and Therapy, 31, Integrating motivational 633–645. and deficit theories of 16. Simpson, J., & Done D. J. delusions. Consciousness (2004). Analogical and Cognition, 16, (4), 932- reasoning in schizophrenic 941. delusions. European 10. Peters, E. (2001). Are Psychiatry, 19, (6), 344- delusions on a continuum? 348. The case of religious and 17. Maher, B. A. (1992). delusional beliefs. In I. Models and methods for the Clarke, (Ed.), Psychosis study of reasoning in and spirituality: Exploring delusions. Revue the new frontier (pp. 191– Europeenne de Psychologie 207). London, England: Appliqee, 42, 97– 102. Whurr Publishers, Ltd. 18. Peters, E., & Garety, P., 11. Bentall, R. B., Corcoran, (2006). Cognitive R., Howard, R., functioning in delusions: A Blackwood, M., & longitudinal analysis. Kinderman, P. (2001). Behavior Research and Persecutory Delusions: A Therapy, 44, 481–514. review and theoretical 19. Frith, C. D. (1992). The integration. Clinical cognitive neuropsychology Psychology Review, 21, of schizophrenia. Hove, (8), 143 -1192. UK, Lawrence Erlbaum 12. Sartorius, N., Jablensky, Association. A., Korten, A., Ernberg, G., 20. Maher, B. A. (2003). Anker, M., Cooper, J. E., et Psychopathology and al. (1986). Early delusions: Reflections on manifestations and first- methods and models. In M. contact incidence of F. Lenzenweger & J. M. schizophrenia in different Hooley (Eds.), Principles of cultures. Psychological experimental Medicine, 16, 909−928. psychopathology: Essays in 13. Zolotova, J., & Brüne, M.. honor of Brendan A. Maher (2006). Persecutory (pp. 9−28).Washington: delusions: reminiscence of

American Psychological 28. Hemsley, D. R., & Garety, Association. P. A. (1986). The formation 21. Christenson, R., & Blazer, and maintenance of D. (1984). Epidemiology of delusions: A Bayesian persecutory ideation in an analysis. British Journal of elderly population in the Psychiatry, 149, PP. 51– community. American 56. Journal of Psychiatry, 141, 29. Brennan, J. H. & Hemsley, 1088−1091. D. R. (1984). Illusory 22. Cohen, C. I., Magai, C., correlation s in paranoid Yaffee, R., & Walcott- and non paranoid Brown, L. (2004). Racial schizophrenia . British differences in paranoid Journal of Clinical ideation and psychoses in Psychology, 23, 225-226. an older urban population. 30. Nicholson I. R., & Neufeld. American Journal of R. W. J. (1993). Psychiatry, 161, 864−871. Classification of the 23. Ostling, S., & Skoog, I. according to (2002). Psychotic symptomatology: a two symptoms and paranoid factor model. Journal of ideation in a no demented Abnormal Psychology, 102 population-based sample of , 259–70. the very old. Archives of 31. McKenna, P. J. (1991). General Psychiatry, 59, Memory, knowledge and 53−59. delusions. British Journal 24. Freeman, D. of Psychiatry, 159, 36–41. (2007).Suspicious minds: 32. Rossell, S. L., Shapsleke, The psychology of J., and David, A. S. (1998). persecutory delusions. Sentence verification and Clinical Psychology delusions: a content- Review, 27, 425–457. specific deficit. 25. Davies, D., & Coltheart, M. Psychological Medicine, (2000). Introduction: 28, 189–1198. pathologies of belief. In M. 33. Maher, B. A., & Ross, J. S. Coltheart. & M. Davies, (1984). Delusions. In H. E. (Eds.), Pathologies of belief Adams, & P. Sutker (Eds.), (pp. 1–46). Blackwell. Comprehensive handbook 26. Langdon, R., & Coltheart, of psychopathology (pp. M. (2000). The cognitive 383–411). New York: neuropsychology of Plenum. delusions. Mind and 34. Garety, P. A. (1991). Language, 15 (1), 183–216. Reasoning and delusions. 27. Campbell, J. (2001). British Journal of Rationality, meaning, and Psychiatry, 159(Sup, 4), the analysis of delusion. 14-18. Philosophy, Psychiatry, and 35. Garety, P. A. & Freeman, Psychology, 89–100. D. (1999). Cognitive approaches to delusions: A

critical review of theories of mind. Psychological and evidence. British Medicine, 34, 385−389. Journal of Clinical 38. Strickland, B. (Ed.). (2001). Psychology, 38, 113–155. Gale encyclopedia of 36. Langdon, R., Corner, T., psychology. 2nd ed .Gale McLaren, J., Ward, P. B., group. & Coltheart, M. (2006). 39. McKay, R., Langdon, R., & Externalizing and Coltheart, M. (2005). personalizing biases in Sleights of mind: delusions, persecutory delusions. defences and self- Behavior Research and deception. Cognitive Therapy, 44, 699−713. Neuropsychiatry ,10 (4), 37. Frith, C. D. (2004). 305–326. Schizophrenia and theory

Corresponding Author: Dr. Fahmi Hassan, F. S., Lecturer, Psychology Department, Faculty of Arts, P.O.Box: 3114 Hodeidah University, Yemen.

Email: [email protected].

Received: 24 September 2010 Accepted: 7 February 2011