By David Joel Miller.
What exactly is a delusion and why are they so hard to recognize beforehand?
One particular delusion has been implicated as a leading cause of homicides. Related delusions may also play a major role in other violent acts even though professionals have such a hard time recognizing them.
Delusions are one of those things like art or pornography we have a great difficulty in defining but we all think we will recognize it when we see it. Unfortunately, it often goes unrecognized until way too late.
While not necessarily a particular mental illness, Delusions are a symptom of a number of mental illnesses. In practice professionals rarely seem to pick out the delusion first. The person gets diagnosed with a particular mental illness and then the descriptor with delusions gets tossed in later like that tells us much about what is going on.
Some mental status exam forms and assessment forms include checkboxes to mark off delusions. Since deciding if someone is delusional is such an extreme judgment call, this decision often comes after the diagnosis not before. Also, note that the one delusion that results in many homicides is not usually included in the list of delusions that we are presented to check off.
The commonly considered delusions are, Paranoid, Grandiose, Religious, and Persecutory. Let’s look at these one at a time and see why they can be problematic. Some of these examples are slightly exaggerated and embroidered for effect. Can you tell which are which?
When paranoia is not a delusion.
A client told me that he was being followed; that the police were out to get him and that it was not safe to walk the streets. Clearly, he was sounding paranoid. On Monday I learned that he had been arrested after the police responded to a shooting at his house. The police were quick to respond as they were only a couple of blocks down. They had been watching his house. He was found in possession of a large quantity of drugs.
Was he paranoid? As I tell students in the substance abuse counseling program, if the client thinks people are watching him and he has a kilo of dope in the trunk of his car this is not paranoia, it is common sense.
How Grandiose is Grandiose.
If I told you that an African-American though he could run for president and have a chance of winning in this the 21 century that would sound Grandiose wouldn’t it? And if that Black man was a first-term Senator from the mid-west – any psychiatrist worth his salt would know right off that this person was Grandiose.
Thank goodness no one told President Obama those things. Or if they did, it is a good thing that he did not listen. Whatever your political affiliation, it is clear that President Obama ought not to be diagnosed as Grandiose, not since he won anyway.
So it is not grandiosity if you are actually able to do something. This makes me nervous when I put down that someone is having grandiose delusions. How do I know for a fact that they are delusional? In my mind, any doubt goes to the client.
Your religion is delusional mine is doing what God wants.
All religions are based on Beliefs. They customarily urge you to act on faith and have belief. Unfortunately, they all seem to have a different group of these essential beliefs.
In mental health, if something occurs to you and most of the other people in your community think this is correct, we do not diagnose this as a mental illness.
If a Catholic believes that they see the Virgin Mary we let that go.
Where this becomes a problem is if you move to a country where no one believes in the Virgin Mary and now if you keep seeing her they can lock you up as delusional. That whole community values thing is a rabbit hole down which the truth can disappear in an instant.
If you are now thinking of sending me a nasty comment or e-mail about how far off I am about your religious beliefs please read the next section before hitting send.
It is not persecutory if people are after you. Like paranoid this one is a matter of degree and judgment.
If you think that people are out to get you and then you start getting written death threats, that is probably not a persecution delusion.
This like all the others is a matter of fact and judgment.
Which major delusion is not on a lot of forms?
We don’t like to look for and may miss jealousy delusions. People who believe that their partner is cheating on them can and do frequently get violent. Sometimes after they shot or kill someone they discover that their partner was not in fact cheating on them but at the time the evidence looked to them like that partner was clearly cheating.
One article I read recently reported that someone killed a man he believed was cheating with the client’s wife. He was arrested. The victim now dead was clearly not having an affair with the client’s wife. This belief was called a delusion.
Later it came out that the wife was, in fact, having an affair, the client just got the identity of the man she was cheating with wrong.
Was he delusional? I let you decide that.
Certain groups are far more likely than others to be described as delusional. I worry that if you do not agree with the assessor you will get called delusional.
Say you are sent for an evaluation and the assessor is a member of the Church of the Religious Egg. They teach that you should cover yourself with plastic and surround yourself with plastic objects three times a day to meditate. You report that this whole idea is crazy. The assessor reports that you are having religious delusions because you believe in some other deity.
At this point who are we thinking is delusional?
Please do not misunderstand here. I do believe that people, with or without mental illness, can and do have delusions, some more bizarre than others. My point is that we need to be careful about what we call a delusion and what we let go.
So in some future posts, we will need to talk about the research on delusions and why certain groups get that label more often than other groups.
Until next time, stay happy.
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