Religion and Spirituality in Psychiatry

Delusions and Hallucinations 87fundamental cognitive abnormalities. A set oftheories emphasize the cognitive biases and cognitivedeficits that have been found in deludedpeople, such as the jumping to conclusions, anexternal attribution style, an attention bias forthreatening stimuli, source monitoring deficits,and deficits in theory of mind. Thus, delusionsconstitute disorders of beliefs. For example, theformation of the delusion of persecution has beenexplained by a motivational factor (to preserveself-esteem) and a cognitive factor (attributingnegative events to external causes). The delusionof persecution is then upheld by a selective attentionfor threatening stimuli and a recall bias ofthreatening stimuli. (45)A third type of theoretical model is basedon the interpretation of abnormal perceptionsor experiences. Delusions are viewed as normaland rational explanations of such phenomena.(46) This model postulates that the mechanismsof formation of delusional beliefs are the same asthose of nondelusional beliefs.Like any other beliefs, delusional beliefs aimat giving meaning to events, they are personaltheories. Those personal theories are needed inthe face of unexpected events. The data not fittingwith the theory then will be either ignoredor reinterpreted. So, unusual beliefs are understandablein the personal and cultural context ofthe individual and his or her way to give meaningto his or her experiences.For Freeman et al., (47) the formation andthe maintenance of the delusion of persecutiongoes as follows. The delusion emerges after aprecipitating event that occurs often in a contextof anxiety and depression. For individualsprone to psychosis, stress induces confusionbetween internal and external events, whichleads to abnormal experiences (for example, hallucinationsand imposed thoughts and actions).The individual needs to explain those abnormalexperiences. In this search for meaning, previousbeliefs about self, others, and the world will beactivated. Those explanations are also influencedby the cognitive bias associated with psychosis.Th e conservation of the delusion is explainedby the reduction of the cognitive dissonance(selective bias for data confirming the delusionand avoidance of other data) and the disturbedaffect associated with delusion (anxiety anddepression). In summary, three componentshave been found in the formation and the conservationof delusion: cognitive deficits and bias,abnormal experiences, and emotions. However,there is no consensual model that explains therole of those dimensions in delusion, even if theyare all necessary. Indeed, some authors consideronly abnormal perceptual experiences as indispensablefor the formation of delusion.(48) Forother authors, although cognitive bias and deficitsare essential for the formation of delusions,this is not the case for abnormal perceptualexperiences.(45)The role of emotion in the formation of delusionis conceptualized either as a defense to preserveself-esteem (45) or as an emotional stateof anxiety and depression that contributes todelusion by a cognitive bias (for example, by theanticipation of the threat) and behavioral reinforcement(for example, by safety behaviors). (47)For Morrison, (49) delusions and hallucinationsresult from intrusions into consciousness ofthoughts, perceptions, and bodily sensationsthat are misattributed to an external source, dueto such thoughts being inconsistent with theperson’s beliefs about his or her own mental processes(metacognitive beliefs). This is the interpretationthat causes despair and dysfunction.The root of negative metacognitive beliefs aboutself and others often lies in childhood traumaticevents. Indeed, a robust association has beenfound between childhood negligence and abusesand the onset of psychosis.(50)2.4. Hallucinations and the Role ofAbnormal Perceptual Experience sTh e debate about the necessary or contingentcharacter of abnormal perceptual experience indelusion is still open. However, abnormal perceptualexperiences, like delusional beliefs, arenot restricted to psychiatric patients. For example,in an epidemiological study conducted inthe United States with 15,000 adults, 4.6 percent