Schizophrenic De~u~iuna~ Pheuo~~na Melvin R. Lansky
c
LEAR ~N~E~STAN~~NG OF CLINICAL PICTURES that may be called delusional has been hindered by the use of the same word for a number of quite different phenomena. “Delusion’ may refer not only to relatively consistent beliefs about reality but also to fragmented ideational utterances that are not really beliefs; to accusatory outbursts accompanying labile projective phenomena; and to some distinctly paranoid Iifestyles that involve beliefs but do not endow the believer with a psychotic specialness that sets him apart from everyone else as do typically grandiose and persecutory delusions. An appreciation of the complexity of delusional phenomena is not easily gleaned from classical writings about delusions. Delusions have usually been discussed from the point of view of a particular theory or a single method of inquiry, say, psychoanalytic or phenomenologic with understandable constraints against going beyond the theory or particular method of inquiry. Bleuler’s distinction between primary symptoms of schizophrenia (intruding ‘fragmented’ delusions as associative disturbances~ and secondary symptoms (including fixed delusions) as restitutive does not fully cover the spectrum of delusional experience.’ Freud’s best known, but by no means his only contribution to the study of delusions is his analysis of the Schreber case in which he argues for underlying homosexual conflict as basic to delusions and describes the mechanism of projection5 His psychoanalytic successors have dealt with many aspects of delusional thinking: Cameron has studied early socialization experiences? Waelder has theorized about the defense mechanisms involved;” and Federn has studied the psychotic ego from a more experiential point of view.’ Surprisingly, Federn seems to exempt psychotic states from dynamic considerations and he rather consistently fails to see delusions as defensive structures, perhaps because he tends to stress different psyehothera~eut~c techniques with psychoses than for neuroses. The Heidelberg School, and Karl Jaspers in particular, drew attention to experiential reports of an affect-laden sense that things have special meaning.’ Jaspers felt that these experiences were unexpiai~ab~e in terms of conflict or any other experience and called them primary delusions. His reluctance to go beyond phenomenologic methods was not shared by his colleagues, Mayer-Gross@ and Schneider,‘O who extended investigations based on subjective reports to a descriptive phenomenology that greatly aided study of prognosis in reIation to observable findings irrespective of explanatory considerations of any kind. JR general there has been a tendency for those concerned with dynamics and psychotherapeutic treatment to emphasize the mechanism of projection and the role of underlying conflict and to ignore detailed description and prognostic imFmrn xhe UCLA Medici School and rhe ~re~zw~d VA ~ospifu~, Los Angeles, Caf$ Mdvin R. Lansky, M.D.: Assistanr Professor, UCLA Medical School. Sra~Pschyejairisf, wood VA Hospital, Los Angeles. Cali& Reprint requests skotdd be addressed CalijT 91436. Z. 1977 by Grme & Stratton, Inc.
to Melvin R. Lansky,
M.D.,
3940 Sapphire
Brenr-
Drive, Encino,
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plications of the presenting phenomenology. Descriptive thinkers, building on the work of earlier phenomenologists, concern themselves with features prognostically significant for response to the somatotherapies, usually to the extent of ignoring dynamics and psychotherapeutic possibilities. Neither dynamic nor descriptive approaches emphasize the significance of belief in the clinical picture. In consequence, neither distinguish states in which belief is present from those in which it is not, much to the detriment of a fuller understanding of what the clinician faces. Belief is ideational. Projections, wishes, and affects, may underlie beliefs, but belief is not reducible to its constituent ideas, affects, and processes. Beliefs serve as supports for cognitive activity in areas of uncertainty. They are not facts, and they are not held in the same way as are empirical generalizations or scientific hypotheses. Beliefs bind anxiety, justify social interaction, and give support to defensive concerns. Beliefs are not falsifiable, and the fixity, incorrigibility, and elaboration traditionally ascribed to delusional beliefs are probably characteristic of any challenged belief, delusional or not, that supports self-esteem. The relationship between belief and action is not a simple one. Verbal behavior is usually consistent with the belief, but nonverbal forms of action usually are not. With persecutory delusional beliefs, for example, the patient’s verbal behavior may be appropriate to the content of the belief, but his actions are, typically, not like those of someone who is the object of a plot. What distinguishes delusional beliefs from other beliefs is the sense of specialness that the delusion confers on its holder that is not grounded in any way to the holder’s actual circumstances or activities. Considering persecutory, grandiose, erotic, or jealous delusions, one is always tempted to ask: why you? It is precisely by conferring a groundless sense of specialness that the delusion is restitutive not only of object relationships, but also of self-esteem. How this restitution takes place, that is, the delusional reality posited such that object relationships may take place with preservation of selfesteem, is evident from the manifest content of the delusional belief. The delusion may confer a special status on its holder (grandiose or erotic); justify expression of affect and uncovering activities addressed to the problem of being taken advantage of (persecutory or jealous) or explain frightening morbid experiences (secondary delusions). The clinical phenomena considered ‘delusional’ by prevailing convention in which belief is not the basis of defensive organization pose entirely different clinical problems from those in which belief is present. The present study considers the spectrum of schizophrenic delusional phenomena sticking closely to observed behavior and reported experience without inferences about underlying conflict or the past. The typology is not intended to be complete. The attempt has been to illustrate states of disruption, the patient’s response to the disruption, and the significance of this response in terms of the patient’s view of himself in relation to others (that is, his self-esteem) as these factors coexist in different clinical situations. I shall first discuss states unaccompanied by beliefifragmented delusions and accusatory outbursts accompanying labile projective phenomena. Then I will describe a number of clinical entities probably on a continuum in the development of true delusional beliefs including secondary delusional beliefs. And finally, I will mention states in which delusional
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beliefs appear to have attained dary autonomy.6 FRAGMENTED
some degree
of what Hartmann
BIZARRE IDEAS WITH METAPHORICAL
has called secon-
MEANING
Such utterances are common in acutely disorganized schizophrenic states. Their appearance in speech is the basis for inferring looseness of association and primary process thought connections. They usually emerge in a communicative setting where they disrupt and confound the prevailing interpersonal expectations, and, for that reason, they may be considered a type of negativism. (Studies of schizophrenic thought that involve performances by patients frequently fail to realize the significance of negativism.) These fragmented ideas are not true delusions; neither are they beliefs, interpretive distortions, or assertions about reality. There is little sense of conviction conveyed and the ideas may change rapidly. Factual support or elaboration is unusual and projection is not involved. It is usually impossible to get the patient to reflect on the ideas either immediately or at a later time. Patients manifesting such ideas are in an intense, almost adhesive state of dependency and vulnerability to domination from which the bizarre ideas often protect them by confounding the prevailing interpersonal process. It is in this sense that self-esteem is preserved, albeit at the cost of intensifying the patient’s isolation. Self-esteem is not related in any obvious way to the content of the ideas as is the case with true delusions, nor do the ideas justify transactions with other people. The ideas can frequently be understood as metaphorical comments on interpersonal process, and commenting on the interpersonal issues (frequently aggression or domination) may abruptly decrease anxiety and reduce bizarre ideation. Case I A 47 yr old man with many prior admissions for schizophrenic decompensation was seen on admission by a ward staff team. Despite a hostile, teasing, and obvious psychotic quality to his relating, he was able to give a consistent and reliable history. When the interview changed to formal mental status examination he claimed that he could not hear and commented repeatedly that the interviewer’s voice was either too loud or too soft. When the examiner ventured, “You’re testing me, too?,” the patient agreed. The interview (but not the formal mental status exam) continued without disruption. Gas e 2 A 30 yr old separated Caucasian male was taken to the hospital by friends after showing through disorganization, bizarre behavior, and agitation. He had been hospitalized several times in the preceding 5 yr. He was provocative on the ward, antagonizing staff and other patients by claims of artistic superiority and displays of his art work all over the ward. Patients reacted with threats of violence to his provocativeness, his disruption of meetings and conversation, and his general demanding of attention. During one missed psychotherapy session he was found quarreling with a group of patients. Before he left their company, he made several
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allusions to Switzerland. As he entered the office, he said, “This is Switzerland.” After Switzerland was mentioned several more times, the therapist ventured, “Switzerland is a neutral country. It doesn’t get involved in wars.” The patient grinned broadly, and his agitation decreased markedly. For the time that he was calm, he could discuss his provocativeness, others’ responses to him, and his relief that he had not provoked his therapist. ACCUSATORY
OUTBURSTS PROJECTIVE
ACCOMPANYING
LABILE
STATES
Projective components are present in fixed delusional beliefs, but in such cases, the delusion does more than simply attribute the patients’ impulses to others. The elaborated delusion usually has an explanatory force that diminishes anxiety and, to some extent, calms the patient and inhibits his acting on the delusion in an impulsive way. This is not the case with much more labile ego states in which an unacceptable impulse must be externalized immediately in the form of an accusation imputing to someone else an impulse, sexual (often homosexual) or aggressive, felt to be blameworthy. Self-esteem is protected by the transfer of blame. The patient may suddenly become agitated in response to feeling blamed, accuses someone else, and often acts on his belief with violent behavior. Argument may accompany the accusation, but tightly reasoned elaboration using factual support and the sense of figuring something out are seldom, if ever, present. It is noteworthy that such patients, even when calm, can rarely acknowledge sexual or aggressive feelings. Case 3
A 39 year old chronic paranoid schizophrenic with many prior hospitalizations was admitted after presenting with an account of erratic behavior. The patient appeared calm and without obvious evidence of decompensation or fixed delusion. He was medicated with phenothiazines at his own request for feelings of inner tension, and his behavior reflected calmness except for outbursts that appeared related to projected impulses. He tried to frighten a female attendant and at that time had an erection. When the incident was discussed in agroup, he excitedly singled out another patient and said that this person was masturbating and trying to arouse him. At the insistence of patients and staff, he quieted down, but with no awareness of the role that his own sexual arousal had played in the episode. Case 4
A patient in his early twenties was admitted for bizarrely contentious complaints and repeated calls to persons in authority for unsubstantiated claims of various injustices. Except for his excitable states, he was calm, passive, and quite compliant. In large meetings he frequently became furious and threatened to attack others to defend himself from alleged aggressive and homosexual attacks. There was no persistent belief evident at any time and he never adduced facts to support his feeling. He could be calmed by pointing to the prevailing affects of anger and fear, but he was totally unable, during or after one of his excited episodes, to reflect on what had happened.
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DELUSIONS
PROPER
These often take the form of fixed notions, ideas, or beliefs, but even if they do not, the patient is usually able to reflect on his constructions of or premonitions about reality as such whether or not these are currently held. This capacity is not present with regard to fragmented bizarre ideas or with projective experiences unaccompanied by fixed belief. Delusions are secondary process ascriptions about reality, and it is not frequent to find them in a clinical picture dominated by looseness of association or the intrusion of primary process material. Phenomenologically, fixed delusions are beliefs. They are not necessarily false, and, as noted above, the fixity, incorrigibility, and elaboration with factual arguments is probably applicable to all beliefs supporting self-esteem, not just to delusional beliefs. The manifest content of a delusion relates in an obvious way to selfesteem by endowing its holder with special status in relation to others. The activities of others are often in the forefront of the patient’s concern, but his status has little to do with his own activities and does not derive from them. In this sense, projection is ubiquitous, but it is rarely a simple impulse that is projected. Special status may take the form of being the object of a plot, of erotic attention, of divine choice, of royal birth, or special deception. The responsibility for the choice is projected, but ultimately the question, ‘Why you?’ remains unanswered. Blameworthy intent or impulse, if present, is projected. Delusions bind anxiety by the conferral of special status, transfer of blame, and justification for anxieties and for defensive operations that had been disallowed by the patient’s previous construction of reality. Even the most adamantly delusional schizophrenic patient can usually give a cogent and complete history of his ideas about reality, so long as this is discussed without confirming or challenging the belief. His reconstruction of reality usually dates from an acute disruptive experience, and he may pass through a continuum of experiences before belief becomes fixed, especially if his concern is about external reality and not about coexistent morbid phenomena within himself. Delusional mood and ideas of reference may be on that continuum and delusional experience may remit short of the formation of fixed belief. Secondary delusions explain other morbid phenomena, usually hallucination or feelings that thoughts are known or controlled by outside forces.
Delusional Mood
Delusional mood or primary delusion is characterized by the exquisite, affectladen sense that things have special meaning for the patient. There is no sense of firm conviction, and the patient is perplexed and terrified by what is happening to him. He can generally discuss what has been happening, and at such times, affect is appropriate to the related experience. Jaspers and others of the Heidelberg school felt that such experiences cannot be reduced to anything more basic that explains them as, for example, the content of a fixed delusion may be explained in terms of an underlying conflict. This fundamental irreducibility is the basis for calling such phenomena primary delusions. Anxiety is not bound in the same way that it is with fixed delusions, and disruptive states and restitutive measures coexist. The sense that things have a special
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meaning, even if this be a premonition that the patient may be the object of a plot, is supportive of self-esteem by defining the patient’s importance in relation to certain others. Facts are adduced in a perplexing and unconvincing way, as small pieces in a large puzzle, and the patient’s reasoning has neither the conviction nor the tightness that marks elaboration of a fixed delusion. Primary delusions may be the initial stage of a process of delusion formation that may be crystallized into ideas of reference and further into delusional belief. The delusional experience may remit at any point along this continuum or persist as a fixed delusion. Rapid remission is common if medication with major tranquilizer or hospitalization intervene, or if the patient is removed from stressful circumstances. Case 5
A 21 year old single, Negro female in military service was admitted 9 days after a therapeutic abortion. She had been returned to duty a week after the operation and did not sleep on the 2 following nights. She reported fearfulness, crying, feeling that things were unreal and that reality was shattering. She had a sense that everyone except her close friends were after her. She experienced this, not as a conviction about reality, but as a fear and as a sign that she was going crazy. She was admitted a day after that experience with a clear sensorium and diminished anxiety. She related her experiences and described the previous days’ events and their impact on her with no sense of having believed people were after her. Later, there was anxiety and tears when she discussed her fears of heterosexual ties and her conflicted relationship with her mother. Case 6
An enlisted man in his early twenties was admitted to the hospital for his second disruptive episode, the first having occurred in Southeast Asia under great stress. His return to the United States did not go smoothly, and he soon became isolated and disorganized. On the day of admission he paced up and down and said that he felt suspicious. He felt that things were going on that had to do with him in inexplicable ways. There was no sense of certainty to the feeling and he regarded it as abnormal. With phenothiazine medication, he returned very rapidly to his premorbid condition. He was an overly dependent, naive individual with markedly inadequate social skills, but without signs of overt psychosis. Ideas of Reference
Though referential thinking is a component of persecutory and grandiose fixed delusions, isolated episodes of referential thinking may be an intermediate stage between primary delusional experiences and fixed delusional beliefs. There is less an explicit fear of going mad than is the case with primary delusion, but persecutory anxieties may be high and defensive operations concerned with specific fears, suspiciousness, uncovering activities, and caution-taking activities may occupy the patient’s attention. Delusional elaboration is an indication that the delusion has become fixed. The relationship of evidence to the referential ideas is even more bizarre than it is to primary delusional experiences.
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PHENOMENA
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Case 7
A 20 year old, Puerto Rican born enlisted man was hospitalized for suicidal thoughts and drug abuse. In psychotherapy sessions, his fears of homosexuality emerged, and he told of his seduction by a male relative, his worries about the size of his penis, and his fears that he was feminine. Nearing the time of his transfer to a civilian hospital, he requested that his ward privileges be cancelled and spoke with great alarm about his feeling that things were directed at him and that people’s conversations were about him. “Everyone scratching himself did that to tell me that he knew I was a homosexual.” He experienced this sense as frightening, overwhelming, and crazy. Major tranquilizers restored his equilibrium overnight. Case 8
A 26 year old sergeant was admitted with a fixed delusion that his wife was an imposter. He gave an account of his condition that was verified in detail by his wife. After a course designed to prepare him for computerization of his field, he felt that he would be unable to meet the new demands on him and would be asked to leave; he became suspicious, fearful, and withdrawn. He had depersonalized and derealized episodes, felt reality was shattering, and then wondered if a group of people were after him. This was a primary delusional experience. As time progressed, he felt certain that he was the center of a plot of some sort. This referential idea progressed to a fixed belief that there was a plot against him headed by one of his superiors, because the patient knew of the former’s dishonest methods. Fixed Delusion
Fixed delusions are beliefs, and belief has a defensive function that differs markedly from that in other types of delusional experience. Projection may be involved and wish and fear components may be obvious, but belief cannot be reduced to these more simple components. Thinking is seldom disorganized, and there is seldom looseness of association or primary process thought connection. Factual material is adduced to support the challenged delusion, and the patient often presents a tightly reasoned elaboration. Assertions about reality need not be false. Fixity, incorrigibility, and elaboration may be found in response to challenging the belief, but, contrary to prevailing opinion, the patient may speak of fluctuating doubts about his belief if it is not challenged. Fixed delusions are relatively permanent interpretive changes that follow, explain, and justify intuitive changes (changes in personality). Such a personality change frequently follows a disruption in which previously unacknowledged anxieties about interpersonal events erupt. The delusion is restitutive, ameliorating such anxieties by altering the construction of reality. Anxieties concern ego weakness in interpersonal situations. The specifics of these anxieties are usually evident from consideration of the manifest content of the belief. A grandiose (or erotic) construction removes the need for discernment in interpersonal situations by conferring a special status on the patient that is not grounded in his own activities or his own interpersonal adroitness. Persecutory (or jealous) constructions bring to the forefront of the patient’s attention vigilance about clandestine
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motives, dissembling, plotting, and, in general, justify defensive operations that had been previously disallowed. Protection of the patient’s self-esteem is a prominent feature, often obvious from the content of the delusion. Delusional talk often appears in the forefront of the patient’s interactions. The patient’s actions are usually not entirely appropriate to the belief if it were true, and patients with fixed beliefs are less likely to act impulsively on the basis of these beliefs than are patients who project without formed beliefs. Indeed, concern with the belief itself may prevent the patient’s taking one action or another in an untenable situation. Patients can often discuss their beliefs as such, and, as is the case with other defenses, anxiety appears when the defensive function becomes apparent. At these times the defense may strengthen. Case8 (continued)
The same patient presented with the beliefs that his wife had been impersonated by a series of doubles (Capgras’ Syndrome).’ This delusion had replaced the persecutory delusion around the time that hospitalization was imminent. In group meetings, in public, and in meetings involving his wife, the belief was fixed and incorrigible. He adduced minute details that distinguished the original from the imposter when his belief was challenged. At times he behaved as though the belief were quite literally true; he refused to support the imposter and he feared he would be charged with adultery with the imposter. But in individual sessions, he often wondered if he was crazy and protested that he could not rid himself of the crazy belief. The defensive function of the belief became clear as he began to doubt that his wife was a double. He realized that the undesirable qualities he had imputed to the double were things he disliked about the (previously idealized) original all along, and he neared a decision to divorce. At this time the belief became adamant. Case 9
A man in his mid thirties was hospitalized for evaluation after repeated religious proselytizing and appending the date of his religious rebirth to his official signature despite repeated orders to the contrary. His behavior, all justified by his religious convictions, was provocative and brought forth criticism to which his rebuttal was invariably facile and ingenious. His views of his religious mission had justified subverting the plans of his superiors, and, on the ward, a similar situation emerged when he advised other patients not to take medication because “Jesus did not take sorceries.” In patient group meetings, his superior intelligence and skill at arguing made him more than a match for the staff with whom he was embroiled. In individual sessions he recounted the development of his belief in rebirth. It was near the time of his divorce some years before. He was overwhelmed with mortifying anxiety, fears of death and homosexuality, and impulses to kill his wife and children. The rebirth occurred suddenly; he had not previously been religious. “All the demons left.” He meant by these impulses: fears of sexual excesses, homosexuality, and murder. There was no evidence of psychotic disorganization at the time of the evaluation, and the patient was socially facile and free from anxiety. As the defensive function of his belief neared his awareness in therapy, he became anxious and angry and refused to attend sessions.
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Secondary Delusions
Secondary delusions are fixed beliefs that explain other morbid phenomena, particularly hallucinations, depersonalized episodes, and feelings that thoughts are known or controlled. The morbid phenomena which they explain frequently occur in situations that are strange for the patient or represent some sort of social assertiveness which he fears, and these phenomena often remit when the patient is out of the situation. The delusional explanation, however, may persist indefinitely. Patients are terrified by the experiences which the delusion explains. Selfesteem is supported by the delusion which allows psychotic disruption to coexist with a restitutive explanation of it in terms of the patient’s specialness. As with other delusions, this specialness may take a grandiose or a persecutory form or both. Compared to other patients with fixed delusions, such patients are less willing to reflect on their beliefs, but may be quite willing to admit that they may be crazy. Secondary delusions do not often form the basis for action. Case 10
A 19 year old male was admitted in a fearful state after being immobilized at his parents’ home for months after his release from military service. He felt his thoughts were controlled and his anxiety diminished as he discussed this feeling. He explained that a group of warlocks and one witch controlled his thoughts when he was stationed in Germany. He said he heard voices as signals from this group. Later he said that Martians sent him messages. When asked why it was he that was selected, he replied that he was chaste and innocent. He went on to say that he had never had intercourse but that he had frequent wet dreams which worried him greatly. Case 11
A 58 year old divorced man was admitted with a three week history of sleeplessness, agitation, hallucinations, and a delusional explanation of his difficulties. He claimed that a young couple who had just moved next door to him had very frequent sexual relations that were audible. Voices told him that they were after him, and he realized that a plot had been formed to murder him because he knew of the widespread prostitution ring moving into the building. He fled to a hotel, but heard the same couple next door and the same threatening voices. He moved from hotel to hotel, but the same thing occurred repeatedly. He confessed he did not know whether the plot included the ward staff. After a short while on phenothiazines, the voices stopped, and he believed the prostitution ring was no longer after him. He remained convinced that there had been a plot against him. Case 12
A 26 year old man with repeated hospitalizations had feelings of thought control, hallucinations, and was convinced his thoughts were audible. These experiences recurred, despite medication with major tranquilizers, when he went to dances and on weekend passes. “There’s a transmitter in my head and they send messages from outer space.” “ The Martians don’t want me mixing with strangers.”
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PARANOIA
On occasion a case reaches clinical attention in which it seems very likely that once delusional defenses serve functions other than postulating a purely private construction of reality. Such delusional defenses may have achieved a degree of secondary autonomy and serve the patient in some socially accepted function. Beliefs involved may be paranoid and persecutory, but they are shared by others and do not convey a groundless sense of specialness. Activities involving masquerade, uncovering, proving, and investigating are in the forefront. The patient’s self-esteem may be enhanced by being in a role where he is more than what he seems to be. The patient discussed below had several decompensations to overt psychosis and so came to psychiatric attention. It is not possible to estimate the prevalence of such nonautistic ‘sublimated’ paranoid patterns which shade unperceptibly into eccentricities and accepted lifestyles. Case 13
A 19 year old female was seen in consultation at the request of her resident physician. The patient related easily and did not appear disorganized. She had had several prior disorganized episodes and was hospitalized for schizophrenic symptomatology. She spoke at length of her work for secret agencies to break narcotic rings, her patriotism and her fear of foreign invaders, and her involvement in investigative work. Her father, recently deceased, had been involved in such investigations. Discussion of her family and other relationships revealed bizarre patterns. The family was dominated by religious and patriotic ideals, suspiciousness, secrecy, and prohibitions to socialization outside of the family. Investigation was a way of life, and, for father and daughter, an occupation. The patient had friends, but none knew of her secret identity as a narcotics agent. She said her fiance had been killed in Vietnam, but she discussed that relationship as though she had known him only slightly. She had difficulty acknowledging sexual feelings and told of having intercourse twice, once with someone under the influence of a witch and another time during allegedly innocent circumstances when she lost consciousness. When similarities were pointed out between her undercover activities and the aura of secrecy in her family, she showed awareness that her way of life was bizarre. She said that the recently televised Watergate investigations had upset her too much to talk about. She eagerly accepted the suggestion that she continue therapy and consider living away from home. DISCUSSION
AND
IMPLICATIONS
A meaningful classification has meaningful consequences, and the focus on disruption, restitution, self-esteem and the presence or absence of belief should provide the clinician with a clearer picture of what is going on in delusional phenomena in such a way that he can respond appropriately. States unaccompanied by belief are termed delusional by virtue of the ideational content expressed during disruptive states. In my opinion, the rationale for calling them delusional is weak. They are transient states and the expressed ideas
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do not serve the defensive functions of delusional belief and do not pose the same clinical problems. In decompensated patients with fragmented metaphorical utterances (“fragmented delusion” is an unhappy term for these statements), disruption is global and vulnerability to interpersonal processes is high. Metaphorical ideas support self-esteem by a negativistic revolt from domination by interpersonal processes, but, by so doing, they intensify the disruption. Medication with major tranquilizers is indicated. Demands for competent ego functioning and meaningful discussion of difficulties in groups or milieu activities is best deferred until the patient has less need to push himself away from involvement. It requires a skilled therapist to grasp the significance of metaphorical ideas in the context of current interpersonal process, but when these ideas are so understood, the patient’s avoidance of devastating process issues (often aggression, domination, or loss) will also be seen. In accusatory outbursts accompanying labile projective states, the patient’s agitation is.in striking contrast to his passivity and naivete when he is calm. Excitation can often be reduced by pointing to the prevailing terror which is usually contagious, and it may be particularly helpful for the therapist to admit his own fears at such times. The patient’s proneness to distort situations into ones in which he is accused and the rapidity of his accusatory projective response pose extremely difficult management problems. The patient is quite likely to act impulsively and violently. What is more, satisfactory remission is hard to estimate because absence of agitation and reality distortion are not indications that the patient is less labile. States on a continuum in the crystallization of delusional belief may progress to fixed delusions, may remit spontaneously or after intervention, and may recur at times of stress. Intervention by reducing the stress. avoiding the situation or facing it with more support, or medication with major tranquilizers is indicated and rapid remission is the rule if the intervention deals successfully with the stress. The immediate circumstances point to areas of vulnerability and areas in need of environmental support or psychotherapeutic attention are usually obvious. Fixed delusional beliefs, unlike primary delusions and ideas of reference, often persist after acutely disruptive states remit. This may indicate either chronicity in the schizophrenic episode or localization of the disruption. In the latter case, then, paranoid schizophrenia remits into paranoia. In either case, major tranquilizers may not affect the delusional belief. The thought content in usually related in an obvious way to the patient’s self-esteem either by justifying fears of being taken advantage of, giving the patient special status or preserving an idealized relationship. The suggestion that tricyclic antidepressants may ameliorate fixed delusional states,” is an interesting, though untested proposal which may point to the role of fixed delusions in defending against depressive phenomena. The important relationship between fixed delusions and premeditated acts of violence to self or others goes beyond the material available for the present study. Patients apparently in remission and on medication may have transient reappearance of morbid phenomena with secondary delusional interpretation. Such phenomena can usually be shown to arise as responses to specific stresses which threaten the patient’s adaptive capacities: getting a job, leaving the hospital, exposure to sexual situations, or loss of a relationship. Thus, a perspicacious view of
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the whole delusional experience will point to specific areas in which the patient requires support, protection, or reconstructive work. Sublimated paranoid states may or may not be the aftermath of actual psychotic episodes. In the illustrative case cited above, the patient did have several psychotic decompensations, but at least some of the formerly psychotic defenses attained enough secondary autonomy to serve as socially useful defenses. The case underscores the function of delusional beliefs as defenses, a function commonly neglected because in delusional states the disruption is so evident and the content so groundless. The fact that delusional beliefs, like other defenses, may assume functions not immediately connected with their original defensive function, i.e., that they may become secondarily autonomous, points to the intriguing possibility that the psychotherapy of delusional patients might profitably include following the restitutive pathway indicated by the delusion instead of avoiding it as has often been advocated. Considered in its complexity, the manifest content of delusional belief points to quite specific anxieties about ego weakness in interpersonal situations. There is every reason to use this information without affirming or attacking the belief per se. Approaches like Federn’s which emphasize reality testing as though the delusion were simply an error misconstrue the delusional phenomena as indicative of cognitive weakness. Quite the reverse is true. In the presence of damaged self-esteem and overwhelming psychotic anxiety, delusional phenomena (beliefs, their elaboration, and undercovering and justifying activities), indicate considerable cognitive mobilization. Failure to grasp the significance of the specific restitutive response for the patient’s self-esteem, his fears of being taken advantage of, of being unimportant, or of losing an idealized relationship, and failure to recognize the strengths mobilized in the restitution may seriously impede the reconstructive work that can begin when the acute disruption is in remission. REFERENCES I. Bleuler E: Dementia Praecox or The Group of Schizophrenias, New York, International Universities, 1950, pp 13-227 2. Cameron N: Paranoid Reactions, in Freedman, Kaplan (eds), Comprehensive Textbook of Psychiatry, Baltimore, Williams & Wilkins, 1967, pp. 665-675 3. Detre T, Jarecki H: Modern Psychiatric Treatment, Lippincott, 1971, p 211 4. Federn P: Paranoid certainty, in Ego Psychology and The Psychoses. Imago, London, 1953, pp 207-209 5. Freud, S. Notes on an autobiographical account of paranoia (Dementia Paranoides), Collected Papers, Vol III, London, Hogarth, 1957 6. Hartmann H: Ego Psychology and the
Problem of Adaptation, New York, International Universities, 1958, p 93 7. Jaspers K: General Psychopathology, (7th ed), Hoenig J, Hamilton M (trans), Chicago, University of Chicago, 1963 8. Lansky MR: Delusions in a patient Capgras’ syndrome, Bull Men Cl 38:360, (This case has been published in detail.) 9. Mayer-Gross W: Psychopathology sions, Rapports (Congres International chiatrie-Paris), vol I, pp 59-87, 1950 10. Schneider (trans Hamilton ton, 1959
with 1974
of Delude Psy-
K: Clinical Psychopathology M) New York, Grune & Strat-
Il. Waelder R: The structure of paranoid ideas, Int J Psychoanal 32:167, 1951
c
LEAR ~N~E~STAN~~NG OF CLINICAL PICTURES that may be called delusional has been hindered by the use of the same word for a number of quite different phenomena. “Delusion’ may refer not only to relatively consistent beliefs about reality but also to fragmented ideational utterances that are not really beliefs; to accusatory outbursts accompanying labile projective phenomena; and to some distinctly paranoid Iifestyles that involve beliefs but do not endow the believer with a psychotic specialness that sets him apart from everyone else as do typically grandiose and persecutory delusions. An appreciation of the complexity of delusional phenomena is not easily gleaned from classical writings about delusions. Delusions have usually been discussed from the point of view of a particular theory or a single method of inquiry, say, psychoanalytic or phenomenologic with understandable constraints against going beyond the theory or particular method of inquiry. Bleuler’s distinction between primary symptoms of schizophrenia (intruding ‘fragmented’ delusions as associative disturbances~ and secondary symptoms (including fixed delusions) as restitutive does not fully cover the spectrum of delusional experience.’ Freud’s best known, but by no means his only contribution to the study of delusions is his analysis of the Schreber case in which he argues for underlying homosexual conflict as basic to delusions and describes the mechanism of projection5 His psychoanalytic successors have dealt with many aspects of delusional thinking: Cameron has studied early socialization experiences? Waelder has theorized about the defense mechanisms involved;” and Federn has studied the psychotic ego from a more experiential point of view.’ Surprisingly, Federn seems to exempt psychotic states from dynamic considerations and he rather consistently fails to see delusions as defensive structures, perhaps because he tends to stress different psyehothera~eut~c techniques with psychoses than for neuroses. The Heidelberg School, and Karl Jaspers in particular, drew attention to experiential reports of an affect-laden sense that things have special meaning.’ Jaspers felt that these experiences were unexpiai~ab~e in terms of conflict or any other experience and called them primary delusions. His reluctance to go beyond phenomenologic methods was not shared by his colleagues, Mayer-Gross@ and Schneider,‘O who extended investigations based on subjective reports to a descriptive phenomenology that greatly aided study of prognosis in reIation to observable findings irrespective of explanatory considerations of any kind. JR general there has been a tendency for those concerned with dynamics and psychotherapeutic treatment to emphasize the mechanism of projection and the role of underlying conflict and to ignore detailed description and prognostic imFmrn xhe UCLA Medici School and rhe ~re~zw~d VA ~ospifu~, Los Angeles, Caf$ Mdvin R. Lansky, M.D.: Assistanr Professor, UCLA Medical School. Sra~Pschyejairisf, wood VA Hospital, Los Angeles. Cali& Reprint requests skotdd be addressed CalijT 91436. Z. 1977 by Grme & Stratton, Inc.
to Melvin R. Lansky,
M.D.,
3940 Sapphire
Brenr-
Drive, Encino,
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plications of the presenting phenomenology. Descriptive thinkers, building on the work of earlier phenomenologists, concern themselves with features prognostically significant for response to the somatotherapies, usually to the extent of ignoring dynamics and psychotherapeutic possibilities. Neither dynamic nor descriptive approaches emphasize the significance of belief in the clinical picture. In consequence, neither distinguish states in which belief is present from those in which it is not, much to the detriment of a fuller understanding of what the clinician faces. Belief is ideational. Projections, wishes, and affects, may underlie beliefs, but belief is not reducible to its constituent ideas, affects, and processes. Beliefs serve as supports for cognitive activity in areas of uncertainty. They are not facts, and they are not held in the same way as are empirical generalizations or scientific hypotheses. Beliefs bind anxiety, justify social interaction, and give support to defensive concerns. Beliefs are not falsifiable, and the fixity, incorrigibility, and elaboration traditionally ascribed to delusional beliefs are probably characteristic of any challenged belief, delusional or not, that supports self-esteem. The relationship between belief and action is not a simple one. Verbal behavior is usually consistent with the belief, but nonverbal forms of action usually are not. With persecutory delusional beliefs, for example, the patient’s verbal behavior may be appropriate to the content of the belief, but his actions are, typically, not like those of someone who is the object of a plot. What distinguishes delusional beliefs from other beliefs is the sense of specialness that the delusion confers on its holder that is not grounded in any way to the holder’s actual circumstances or activities. Considering persecutory, grandiose, erotic, or jealous delusions, one is always tempted to ask: why you? It is precisely by conferring a groundless sense of specialness that the delusion is restitutive not only of object relationships, but also of self-esteem. How this restitution takes place, that is, the delusional reality posited such that object relationships may take place with preservation of selfesteem, is evident from the manifest content of the delusional belief. The delusion may confer a special status on its holder (grandiose or erotic); justify expression of affect and uncovering activities addressed to the problem of being taken advantage of (persecutory or jealous) or explain frightening morbid experiences (secondary delusions). The clinical phenomena considered ‘delusional’ by prevailing convention in which belief is not the basis of defensive organization pose entirely different clinical problems from those in which belief is present. The present study considers the spectrum of schizophrenic delusional phenomena sticking closely to observed behavior and reported experience without inferences about underlying conflict or the past. The typology is not intended to be complete. The attempt has been to illustrate states of disruption, the patient’s response to the disruption, and the significance of this response in terms of the patient’s view of himself in relation to others (that is, his self-esteem) as these factors coexist in different clinical situations. I shall first discuss states unaccompanied by beliefifragmented delusions and accusatory outbursts accompanying labile projective phenomena. Then I will describe a number of clinical entities probably on a continuum in the development of true delusional beliefs including secondary delusional beliefs. And finally, I will mention states in which delusional
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beliefs appear to have attained dary autonomy.6 FRAGMENTED
some degree
of what Hartmann
BIZARRE IDEAS WITH METAPHORICAL
has called secon-
MEANING
Such utterances are common in acutely disorganized schizophrenic states. Their appearance in speech is the basis for inferring looseness of association and primary process thought connections. They usually emerge in a communicative setting where they disrupt and confound the prevailing interpersonal expectations, and, for that reason, they may be considered a type of negativism. (Studies of schizophrenic thought that involve performances by patients frequently fail to realize the significance of negativism.) These fragmented ideas are not true delusions; neither are they beliefs, interpretive distortions, or assertions about reality. There is little sense of conviction conveyed and the ideas may change rapidly. Factual support or elaboration is unusual and projection is not involved. It is usually impossible to get the patient to reflect on the ideas either immediately or at a later time. Patients manifesting such ideas are in an intense, almost adhesive state of dependency and vulnerability to domination from which the bizarre ideas often protect them by confounding the prevailing interpersonal process. It is in this sense that self-esteem is preserved, albeit at the cost of intensifying the patient’s isolation. Self-esteem is not related in any obvious way to the content of the ideas as is the case with true delusions, nor do the ideas justify transactions with other people. The ideas can frequently be understood as metaphorical comments on interpersonal process, and commenting on the interpersonal issues (frequently aggression or domination) may abruptly decrease anxiety and reduce bizarre ideation. Case I A 47 yr old man with many prior admissions for schizophrenic decompensation was seen on admission by a ward staff team. Despite a hostile, teasing, and obvious psychotic quality to his relating, he was able to give a consistent and reliable history. When the interview changed to formal mental status examination he claimed that he could not hear and commented repeatedly that the interviewer’s voice was either too loud or too soft. When the examiner ventured, “You’re testing me, too?,” the patient agreed. The interview (but not the formal mental status exam) continued without disruption. Gas e 2 A 30 yr old separated Caucasian male was taken to the hospital by friends after showing through disorganization, bizarre behavior, and agitation. He had been hospitalized several times in the preceding 5 yr. He was provocative on the ward, antagonizing staff and other patients by claims of artistic superiority and displays of his art work all over the ward. Patients reacted with threats of violence to his provocativeness, his disruption of meetings and conversation, and his general demanding of attention. During one missed psychotherapy session he was found quarreling with a group of patients. Before he left their company, he made several
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allusions to Switzerland. As he entered the office, he said, “This is Switzerland.” After Switzerland was mentioned several more times, the therapist ventured, “Switzerland is a neutral country. It doesn’t get involved in wars.” The patient grinned broadly, and his agitation decreased markedly. For the time that he was calm, he could discuss his provocativeness, others’ responses to him, and his relief that he had not provoked his therapist. ACCUSATORY
OUTBURSTS PROJECTIVE
ACCOMPANYING
LABILE
STATES
Projective components are present in fixed delusional beliefs, but in such cases, the delusion does more than simply attribute the patients’ impulses to others. The elaborated delusion usually has an explanatory force that diminishes anxiety and, to some extent, calms the patient and inhibits his acting on the delusion in an impulsive way. This is not the case with much more labile ego states in which an unacceptable impulse must be externalized immediately in the form of an accusation imputing to someone else an impulse, sexual (often homosexual) or aggressive, felt to be blameworthy. Self-esteem is protected by the transfer of blame. The patient may suddenly become agitated in response to feeling blamed, accuses someone else, and often acts on his belief with violent behavior. Argument may accompany the accusation, but tightly reasoned elaboration using factual support and the sense of figuring something out are seldom, if ever, present. It is noteworthy that such patients, even when calm, can rarely acknowledge sexual or aggressive feelings. Case 3
A 39 year old chronic paranoid schizophrenic with many prior hospitalizations was admitted after presenting with an account of erratic behavior. The patient appeared calm and without obvious evidence of decompensation or fixed delusion. He was medicated with phenothiazines at his own request for feelings of inner tension, and his behavior reflected calmness except for outbursts that appeared related to projected impulses. He tried to frighten a female attendant and at that time had an erection. When the incident was discussed in agroup, he excitedly singled out another patient and said that this person was masturbating and trying to arouse him. At the insistence of patients and staff, he quieted down, but with no awareness of the role that his own sexual arousal had played in the episode. Case 4
A patient in his early twenties was admitted for bizarrely contentious complaints and repeated calls to persons in authority for unsubstantiated claims of various injustices. Except for his excitable states, he was calm, passive, and quite compliant. In large meetings he frequently became furious and threatened to attack others to defend himself from alleged aggressive and homosexual attacks. There was no persistent belief evident at any time and he never adduced facts to support his feeling. He could be calmed by pointing to the prevailing affects of anger and fear, but he was totally unable, during or after one of his excited episodes, to reflect on what had happened.
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DELUSIONS
PROPER
These often take the form of fixed notions, ideas, or beliefs, but even if they do not, the patient is usually able to reflect on his constructions of or premonitions about reality as such whether or not these are currently held. This capacity is not present with regard to fragmented bizarre ideas or with projective experiences unaccompanied by fixed belief. Delusions are secondary process ascriptions about reality, and it is not frequent to find them in a clinical picture dominated by looseness of association or the intrusion of primary process material. Phenomenologically, fixed delusions are beliefs. They are not necessarily false, and, as noted above, the fixity, incorrigibility, and elaboration with factual arguments is probably applicable to all beliefs supporting self-esteem, not just to delusional beliefs. The manifest content of a delusion relates in an obvious way to selfesteem by endowing its holder with special status in relation to others. The activities of others are often in the forefront of the patient’s concern, but his status has little to do with his own activities and does not derive from them. In this sense, projection is ubiquitous, but it is rarely a simple impulse that is projected. Special status may take the form of being the object of a plot, of erotic attention, of divine choice, of royal birth, or special deception. The responsibility for the choice is projected, but ultimately the question, ‘Why you?’ remains unanswered. Blameworthy intent or impulse, if present, is projected. Delusions bind anxiety by the conferral of special status, transfer of blame, and justification for anxieties and for defensive operations that had been disallowed by the patient’s previous construction of reality. Even the most adamantly delusional schizophrenic patient can usually give a cogent and complete history of his ideas about reality, so long as this is discussed without confirming or challenging the belief. His reconstruction of reality usually dates from an acute disruptive experience, and he may pass through a continuum of experiences before belief becomes fixed, especially if his concern is about external reality and not about coexistent morbid phenomena within himself. Delusional mood and ideas of reference may be on that continuum and delusional experience may remit short of the formation of fixed belief. Secondary delusions explain other morbid phenomena, usually hallucination or feelings that thoughts are known or controlled by outside forces.
Delusional Mood
Delusional mood or primary delusion is characterized by the exquisite, affectladen sense that things have special meaning for the patient. There is no sense of firm conviction, and the patient is perplexed and terrified by what is happening to him. He can generally discuss what has been happening, and at such times, affect is appropriate to the related experience. Jaspers and others of the Heidelberg school felt that such experiences cannot be reduced to anything more basic that explains them as, for example, the content of a fixed delusion may be explained in terms of an underlying conflict. This fundamental irreducibility is the basis for calling such phenomena primary delusions. Anxiety is not bound in the same way that it is with fixed delusions, and disruptive states and restitutive measures coexist. The sense that things have a special
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meaning, even if this be a premonition that the patient may be the object of a plot, is supportive of self-esteem by defining the patient’s importance in relation to certain others. Facts are adduced in a perplexing and unconvincing way, as small pieces in a large puzzle, and the patient’s reasoning has neither the conviction nor the tightness that marks elaboration of a fixed delusion. Primary delusions may be the initial stage of a process of delusion formation that may be crystallized into ideas of reference and further into delusional belief. The delusional experience may remit at any point along this continuum or persist as a fixed delusion. Rapid remission is common if medication with major tranquilizer or hospitalization intervene, or if the patient is removed from stressful circumstances. Case 5
A 21 year old single, Negro female in military service was admitted 9 days after a therapeutic abortion. She had been returned to duty a week after the operation and did not sleep on the 2 following nights. She reported fearfulness, crying, feeling that things were unreal and that reality was shattering. She had a sense that everyone except her close friends were after her. She experienced this, not as a conviction about reality, but as a fear and as a sign that she was going crazy. She was admitted a day after that experience with a clear sensorium and diminished anxiety. She related her experiences and described the previous days’ events and their impact on her with no sense of having believed people were after her. Later, there was anxiety and tears when she discussed her fears of heterosexual ties and her conflicted relationship with her mother. Case 6
An enlisted man in his early twenties was admitted to the hospital for his second disruptive episode, the first having occurred in Southeast Asia under great stress. His return to the United States did not go smoothly, and he soon became isolated and disorganized. On the day of admission he paced up and down and said that he felt suspicious. He felt that things were going on that had to do with him in inexplicable ways. There was no sense of certainty to the feeling and he regarded it as abnormal. With phenothiazine medication, he returned very rapidly to his premorbid condition. He was an overly dependent, naive individual with markedly inadequate social skills, but without signs of overt psychosis. Ideas of Reference
Though referential thinking is a component of persecutory and grandiose fixed delusions, isolated episodes of referential thinking may be an intermediate stage between primary delusional experiences and fixed delusional beliefs. There is less an explicit fear of going mad than is the case with primary delusion, but persecutory anxieties may be high and defensive operations concerned with specific fears, suspiciousness, uncovering activities, and caution-taking activities may occupy the patient’s attention. Delusional elaboration is an indication that the delusion has become fixed. The relationship of evidence to the referential ideas is even more bizarre than it is to primary delusional experiences.
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PHENOMENA
163
Case 7
A 20 year old, Puerto Rican born enlisted man was hospitalized for suicidal thoughts and drug abuse. In psychotherapy sessions, his fears of homosexuality emerged, and he told of his seduction by a male relative, his worries about the size of his penis, and his fears that he was feminine. Nearing the time of his transfer to a civilian hospital, he requested that his ward privileges be cancelled and spoke with great alarm about his feeling that things were directed at him and that people’s conversations were about him. “Everyone scratching himself did that to tell me that he knew I was a homosexual.” He experienced this sense as frightening, overwhelming, and crazy. Major tranquilizers restored his equilibrium overnight. Case 8
A 26 year old sergeant was admitted with a fixed delusion that his wife was an imposter. He gave an account of his condition that was verified in detail by his wife. After a course designed to prepare him for computerization of his field, he felt that he would be unable to meet the new demands on him and would be asked to leave; he became suspicious, fearful, and withdrawn. He had depersonalized and derealized episodes, felt reality was shattering, and then wondered if a group of people were after him. This was a primary delusional experience. As time progressed, he felt certain that he was the center of a plot of some sort. This referential idea progressed to a fixed belief that there was a plot against him headed by one of his superiors, because the patient knew of the former’s dishonest methods. Fixed Delusion
Fixed delusions are beliefs, and belief has a defensive function that differs markedly from that in other types of delusional experience. Projection may be involved and wish and fear components may be obvious, but belief cannot be reduced to these more simple components. Thinking is seldom disorganized, and there is seldom looseness of association or primary process thought connection. Factual material is adduced to support the challenged delusion, and the patient often presents a tightly reasoned elaboration. Assertions about reality need not be false. Fixity, incorrigibility, and elaboration may be found in response to challenging the belief, but, contrary to prevailing opinion, the patient may speak of fluctuating doubts about his belief if it is not challenged. Fixed delusions are relatively permanent interpretive changes that follow, explain, and justify intuitive changes (changes in personality). Such a personality change frequently follows a disruption in which previously unacknowledged anxieties about interpersonal events erupt. The delusion is restitutive, ameliorating such anxieties by altering the construction of reality. Anxieties concern ego weakness in interpersonal situations. The specifics of these anxieties are usually evident from consideration of the manifest content of the belief. A grandiose (or erotic) construction removes the need for discernment in interpersonal situations by conferring a special status on the patient that is not grounded in his own activities or his own interpersonal adroitness. Persecutory (or jealous) constructions bring to the forefront of the patient’s attention vigilance about clandestine
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motives, dissembling, plotting, and, in general, justify defensive operations that had been previously disallowed. Protection of the patient’s self-esteem is a prominent feature, often obvious from the content of the delusion. Delusional talk often appears in the forefront of the patient’s interactions. The patient’s actions are usually not entirely appropriate to the belief if it were true, and patients with fixed beliefs are less likely to act impulsively on the basis of these beliefs than are patients who project without formed beliefs. Indeed, concern with the belief itself may prevent the patient’s taking one action or another in an untenable situation. Patients can often discuss their beliefs as such, and, as is the case with other defenses, anxiety appears when the defensive function becomes apparent. At these times the defense may strengthen. Case8 (continued)
The same patient presented with the beliefs that his wife had been impersonated by a series of doubles (Capgras’ Syndrome).’ This delusion had replaced the persecutory delusion around the time that hospitalization was imminent. In group meetings, in public, and in meetings involving his wife, the belief was fixed and incorrigible. He adduced minute details that distinguished the original from the imposter when his belief was challenged. At times he behaved as though the belief were quite literally true; he refused to support the imposter and he feared he would be charged with adultery with the imposter. But in individual sessions, he often wondered if he was crazy and protested that he could not rid himself of the crazy belief. The defensive function of the belief became clear as he began to doubt that his wife was a double. He realized that the undesirable qualities he had imputed to the double were things he disliked about the (previously idealized) original all along, and he neared a decision to divorce. At this time the belief became adamant. Case 9
A man in his mid thirties was hospitalized for evaluation after repeated religious proselytizing and appending the date of his religious rebirth to his official signature despite repeated orders to the contrary. His behavior, all justified by his religious convictions, was provocative and brought forth criticism to which his rebuttal was invariably facile and ingenious. His views of his religious mission had justified subverting the plans of his superiors, and, on the ward, a similar situation emerged when he advised other patients not to take medication because “Jesus did not take sorceries.” In patient group meetings, his superior intelligence and skill at arguing made him more than a match for the staff with whom he was embroiled. In individual sessions he recounted the development of his belief in rebirth. It was near the time of his divorce some years before. He was overwhelmed with mortifying anxiety, fears of death and homosexuality, and impulses to kill his wife and children. The rebirth occurred suddenly; he had not previously been religious. “All the demons left.” He meant by these impulses: fears of sexual excesses, homosexuality, and murder. There was no evidence of psychotic disorganization at the time of the evaluation, and the patient was socially facile and free from anxiety. As the defensive function of his belief neared his awareness in therapy, he became anxious and angry and refused to attend sessions.
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165
Secondary Delusions
Secondary delusions are fixed beliefs that explain other morbid phenomena, particularly hallucinations, depersonalized episodes, and feelings that thoughts are known or controlled. The morbid phenomena which they explain frequently occur in situations that are strange for the patient or represent some sort of social assertiveness which he fears, and these phenomena often remit when the patient is out of the situation. The delusional explanation, however, may persist indefinitely. Patients are terrified by the experiences which the delusion explains. Selfesteem is supported by the delusion which allows psychotic disruption to coexist with a restitutive explanation of it in terms of the patient’s specialness. As with other delusions, this specialness may take a grandiose or a persecutory form or both. Compared to other patients with fixed delusions, such patients are less willing to reflect on their beliefs, but may be quite willing to admit that they may be crazy. Secondary delusions do not often form the basis for action. Case 10
A 19 year old male was admitted in a fearful state after being immobilized at his parents’ home for months after his release from military service. He felt his thoughts were controlled and his anxiety diminished as he discussed this feeling. He explained that a group of warlocks and one witch controlled his thoughts when he was stationed in Germany. He said he heard voices as signals from this group. Later he said that Martians sent him messages. When asked why it was he that was selected, he replied that he was chaste and innocent. He went on to say that he had never had intercourse but that he had frequent wet dreams which worried him greatly. Case 11
A 58 year old divorced man was admitted with a three week history of sleeplessness, agitation, hallucinations, and a delusional explanation of his difficulties. He claimed that a young couple who had just moved next door to him had very frequent sexual relations that were audible. Voices told him that they were after him, and he realized that a plot had been formed to murder him because he knew of the widespread prostitution ring moving into the building. He fled to a hotel, but heard the same couple next door and the same threatening voices. He moved from hotel to hotel, but the same thing occurred repeatedly. He confessed he did not know whether the plot included the ward staff. After a short while on phenothiazines, the voices stopped, and he believed the prostitution ring was no longer after him. He remained convinced that there had been a plot against him. Case 12
A 26 year old man with repeated hospitalizations had feelings of thought control, hallucinations, and was convinced his thoughts were audible. These experiences recurred, despite medication with major tranquilizers, when he went to dances and on weekend passes. “There’s a transmitter in my head and they send messages from outer space.” “ The Martians don’t want me mixing with strangers.”
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PARANOIA
On occasion a case reaches clinical attention in which it seems very likely that once delusional defenses serve functions other than postulating a purely private construction of reality. Such delusional defenses may have achieved a degree of secondary autonomy and serve the patient in some socially accepted function. Beliefs involved may be paranoid and persecutory, but they are shared by others and do not convey a groundless sense of specialness. Activities involving masquerade, uncovering, proving, and investigating are in the forefront. The patient’s self-esteem may be enhanced by being in a role where he is more than what he seems to be. The patient discussed below had several decompensations to overt psychosis and so came to psychiatric attention. It is not possible to estimate the prevalence of such nonautistic ‘sublimated’ paranoid patterns which shade unperceptibly into eccentricities and accepted lifestyles. Case 13
A 19 year old female was seen in consultation at the request of her resident physician. The patient related easily and did not appear disorganized. She had had several prior disorganized episodes and was hospitalized for schizophrenic symptomatology. She spoke at length of her work for secret agencies to break narcotic rings, her patriotism and her fear of foreign invaders, and her involvement in investigative work. Her father, recently deceased, had been involved in such investigations. Discussion of her family and other relationships revealed bizarre patterns. The family was dominated by religious and patriotic ideals, suspiciousness, secrecy, and prohibitions to socialization outside of the family. Investigation was a way of life, and, for father and daughter, an occupation. The patient had friends, but none knew of her secret identity as a narcotics agent. She said her fiance had been killed in Vietnam, but she discussed that relationship as though she had known him only slightly. She had difficulty acknowledging sexual feelings and told of having intercourse twice, once with someone under the influence of a witch and another time during allegedly innocent circumstances when she lost consciousness. When similarities were pointed out between her undercover activities and the aura of secrecy in her family, she showed awareness that her way of life was bizarre. She said that the recently televised Watergate investigations had upset her too much to talk about. She eagerly accepted the suggestion that she continue therapy and consider living away from home. DISCUSSION
AND
IMPLICATIONS
A meaningful classification has meaningful consequences, and the focus on disruption, restitution, self-esteem and the presence or absence of belief should provide the clinician with a clearer picture of what is going on in delusional phenomena in such a way that he can respond appropriately. States unaccompanied by belief are termed delusional by virtue of the ideational content expressed during disruptive states. In my opinion, the rationale for calling them delusional is weak. They are transient states and the expressed ideas
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do not serve the defensive functions of delusional belief and do not pose the same clinical problems. In decompensated patients with fragmented metaphorical utterances (“fragmented delusion” is an unhappy term for these statements), disruption is global and vulnerability to interpersonal processes is high. Metaphorical ideas support self-esteem by a negativistic revolt from domination by interpersonal processes, but, by so doing, they intensify the disruption. Medication with major tranquilizers is indicated. Demands for competent ego functioning and meaningful discussion of difficulties in groups or milieu activities is best deferred until the patient has less need to push himself away from involvement. It requires a skilled therapist to grasp the significance of metaphorical ideas in the context of current interpersonal process, but when these ideas are so understood, the patient’s avoidance of devastating process issues (often aggression, domination, or loss) will also be seen. In accusatory outbursts accompanying labile projective states, the patient’s agitation is.in striking contrast to his passivity and naivete when he is calm. Excitation can often be reduced by pointing to the prevailing terror which is usually contagious, and it may be particularly helpful for the therapist to admit his own fears at such times. The patient’s proneness to distort situations into ones in which he is accused and the rapidity of his accusatory projective response pose extremely difficult management problems. The patient is quite likely to act impulsively and violently. What is more, satisfactory remission is hard to estimate because absence of agitation and reality distortion are not indications that the patient is less labile. States on a continuum in the crystallization of delusional belief may progress to fixed delusions, may remit spontaneously or after intervention, and may recur at times of stress. Intervention by reducing the stress. avoiding the situation or facing it with more support, or medication with major tranquilizers is indicated and rapid remission is the rule if the intervention deals successfully with the stress. The immediate circumstances point to areas of vulnerability and areas in need of environmental support or psychotherapeutic attention are usually obvious. Fixed delusional beliefs, unlike primary delusions and ideas of reference, often persist after acutely disruptive states remit. This may indicate either chronicity in the schizophrenic episode or localization of the disruption. In the latter case, then, paranoid schizophrenia remits into paranoia. In either case, major tranquilizers may not affect the delusional belief. The thought content in usually related in an obvious way to the patient’s self-esteem either by justifying fears of being taken advantage of, giving the patient special status or preserving an idealized relationship. The suggestion that tricyclic antidepressants may ameliorate fixed delusional states,” is an interesting, though untested proposal which may point to the role of fixed delusions in defending against depressive phenomena. The important relationship between fixed delusions and premeditated acts of violence to self or others goes beyond the material available for the present study. Patients apparently in remission and on medication may have transient reappearance of morbid phenomena with secondary delusional interpretation. Such phenomena can usually be shown to arise as responses to specific stresses which threaten the patient’s adaptive capacities: getting a job, leaving the hospital, exposure to sexual situations, or loss of a relationship. Thus, a perspicacious view of
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the whole delusional experience will point to specific areas in which the patient requires support, protection, or reconstructive work. Sublimated paranoid states may or may not be the aftermath of actual psychotic episodes. In the illustrative case cited above, the patient did have several psychotic decompensations, but at least some of the formerly psychotic defenses attained enough secondary autonomy to serve as socially useful defenses. The case underscores the function of delusional beliefs as defenses, a function commonly neglected because in delusional states the disruption is so evident and the content so groundless. The fact that delusional beliefs, like other defenses, may assume functions not immediately connected with their original defensive function, i.e., that they may become secondarily autonomous, points to the intriguing possibility that the psychotherapy of delusional patients might profitably include following the restitutive pathway indicated by the delusion instead of avoiding it as has often been advocated. Considered in its complexity, the manifest content of delusional belief points to quite specific anxieties about ego weakness in interpersonal situations. There is every reason to use this information without affirming or attacking the belief per se. Approaches like Federn’s which emphasize reality testing as though the delusion were simply an error misconstrue the delusional phenomena as indicative of cognitive weakness. Quite the reverse is true. In the presence of damaged self-esteem and overwhelming psychotic anxiety, delusional phenomena (beliefs, their elaboration, and undercovering and justifying activities), indicate considerable cognitive mobilization. Failure to grasp the significance of the specific restitutive response for the patient’s self-esteem, his fears of being taken advantage of, of being unimportant, or of losing an idealized relationship, and failure to recognize the strengths mobilized in the restitution may seriously impede the reconstructive work that can begin when the acute disruption is in remission. REFERENCES I. Bleuler E: Dementia Praecox or The Group of Schizophrenias, New York, International Universities, 1950, pp 13-227 2. Cameron N: Paranoid Reactions, in Freedman, Kaplan (eds), Comprehensive Textbook of Psychiatry, Baltimore, Williams & Wilkins, 1967, pp. 665-675 3. Detre T, Jarecki H: Modern Psychiatric Treatment, Lippincott, 1971, p 211 4. Federn P: Paranoid certainty, in Ego Psychology and The Psychoses. Imago, London, 1953, pp 207-209 5. Freud, S. Notes on an autobiographical account of paranoia (Dementia Paranoides), Collected Papers, Vol III, London, Hogarth, 1957 6. Hartmann H: Ego Psychology and the
Problem of Adaptation, New York, International Universities, 1958, p 93 7. Jaspers K: General Psychopathology, (7th ed), Hoenig J, Hamilton M (trans), Chicago, University of Chicago, 1963 8. Lansky MR: Delusions in a patient Capgras’ syndrome, Bull Men Cl 38:360, (This case has been published in detail.) 9. Mayer-Gross W: Psychopathology sions, Rapports (Congres International chiatrie-Paris), vol I, pp 59-87, 1950 10. Schneider (trans Hamilton ton, 1959
with 1974
of Delude Psy-
K: Clinical Psychopathology M) New York, Grune & Strat-
Il. Waelder R: The structure of paranoid ideas, Int J Psychoanal 32:167, 1951
