Psychosis as a failure of reality testing

Beginning of a new month, which means a flurry of lovely new journal issues. I’ve been busy preparing an ethics application for my research though, so haven’t had too much time to get stuck in, maybe next week. I did finish this month’s British Journal of Psychiatry (  though. One article jumped out at me – a review on the nature of delusional belief and development of delusional symptoms (Garety PA, Freeman D. The past and future of delusions research: from the inexplicable to the treatable. The British Journal of Psychiatry 2013).

I enjoyed this article and on first read through thought it was pretty comprehensive – it even had a section on delusion as defence, one of my pet projects and not often covered in the BJP. I thought it would make a good article to discuss on this blog so re-read this morning, along with a couple of other papers on nature of delusion. As I read, I found myself getting more frustrated with the article though. In the end I spent the entire day reading around the literature on the topic which unfortunately at one point lead to Wittgenstein who, I believe, writes in a deliberately opaque manner.

I’ve submitted a letter to the BJP after my reading. I’ve included this below:

Psychosis as a failure of reality testing?

Garety and Freeman present a timely review on the nature of delusional experience.1 Their conclusion regarding the need to focus on individual features of psychosis seems apt. The presented overview of cognitive and affective mechanisms influencing delusion development seems, however, to overlook an essential component of delusional experience; that psychotic symptoms, including delusions, at their heart represent a failure of reality testing.

The description of jumping to conclusions, together with the probabilistic reasoning task methodology, appears to rely on a logical chain of thought progression and conclusion. What Campbell has referred to as an empiricist understanding.2 This approach however does not take into account the nature of conclusions reached in delusional belief: – Conclusions reached on seeing two or less coloured counters seem quite distinct from classical examples of delusional perception; “I saw the traffic lights turn green and realised that the world would end”. Campbell’s alternative rationalist approach presents the delusional subject as having experienced a complete rearrangement of their framework propositions, or underlying background world beliefs. Such a fundamental shift in world view model can go some way to explaining the fantastical nature of conclusions reached, or the failure of reality testing present in psychosis. 

Campbell’s arguments have not gone unchallenged.3 However what they do highlight is a need for careful consideration as to the manner in which delusional beliefs are formed. Garety and Freeman describe the psychoanalytic thinking in relation to defence mechanisms in the development of persecutory delusional belief. Psychotic defence concepts, wherein the subject denies or distorts reality to defend against trauma, provide one possible lens through which psychotic experiences can be viewed.4,5

Garety and Freeman’s conclusion relating to the infancy of research into the nature of delusion, and its having been overshadowed by focus on the larger concept of Schizophrenia, highlights the need for further research. Future research will need to provide some account for the distortion of reality that seems central to the experience of psychosis. 

1 Garety PA, Freeman D. The past and future of delusions research: from the inexplicable to the treatable. The British Journal of Psychiatry 2013.

2 Campbell J. Rationality, Meaning, and the Analysis of Delusion. Philosophy, Psychiatry,  Psychology 2001; 8: 89–100.

3 Bayne T, Pacherie E. Bottom-Up or Top-Down: Campbell’s Rationalist Account of Monothematic Delusions. Philosophy, Psychiatry, Psychology 2004; 11: 1–11.

4 Hingley SM. Psychodynamic perspectives on psychosis and psychotherapy. I: Theory. Br J Med Psychol 1997; 70 ( Pt 4): 301–12.

5 Martindale B, Summers A. The psychodynamics of psychosis. Advances in Psychiatric Treatment 2013; 19: 124–31.


The nature of psychotic symptoms

Reading around this also made me think of several people I have met in clinic in the past who described an experience I seem to hear quite often.

“I hear a man’s voice when I’m angry, it’s outside my head and sounds like yours [i.e. analogous to real percept]. When I’m not angry I hear a voice as well, but this one is inside my head and feels closer to my own thoughts. The voice tells me to do things, like hit the person I’m angry with, but I don’t feel as if I have to obey it, I used to, but not anymore. I find the experience distressing and want it to stop completely”.

This is paraphrased based on a couple of prompting questions from myself, and also represents quotes from different people. We seem to have two phenomena being described here, let’s break them down:

The first is a male voice, qualitatively distinct from the client’s own thoughts and experienced in external space at times of affective arousal. The voice is commanding in nature, but not accompanied by any impulse override experiences. The quality of the voice has changed over time (also, possibly, with antipsychotic medication initiated by another doctor).

The second voice is quieter, experienced in internal space and although still somewhat alien is more egosyntonic.

These experiences – what I think of as affect related hallucinations are very common. I’ve heard other doctors call them pseudo-hallucinations, but I don’t agree with this term. It seems to me we attach the work pseudo when we either don’t believe the person, or want to diminish their experience in some way. I believe that these experiences can be very distressing and are difficult to control. I’m reluctant to prescribe antipsychotic medicine for them usually as I feel this is a little over invasive and, almost always, side-effects out way benefits for individuals.

I’d be interested in hearing other people’s thoughts on this, and how it ties in with the nature of delusions, or psychotic experience in general, as described above.

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