Delusions

Alex Chen-MacLean, M.D., Anne E. Ruble, M.D., M.P.H.

DEFINITION

  • A delusion is a fixed, false, and idiosyncratic belief and is one of the trilogy of psychotic symptoms: hallucinations, delusions, and thought disorder.
    • "Fixed" refers to the strength of the patient’s belief. The patient is certain, and not persuaded by any arguments to the contrary.
    • "False" relates to the veracity of the patient’s belief.
      • Beliefs about which the truth cannot be known with reasonable certainty, such as cultural or religious beliefs, should not be classified as delusions without careful consideration.
    • "Idiosyncratic" means the belief is characteristic of the individual patient.
      • This criterion becomes important when considering the prevalence of fixed, false beliefs in the general population.
      • Beliefs shared by a group of people (for instance, a belief in UFOs) are generally not delusions.
  • Several of Schneider’s first rank symptoms (FRS) of schizophrenia are delusions. These include:
    • Delusions of control or being controlled
    • Thought withdrawal
    • Thought insertion
    • Mind reading
    • Delusional perception (ordinary perception given a bizarre interpretation)
  • Delusions can be divided by theme (e.g. persecutor, grandiose), plausibility (bizarre, non-bizarre), relationship to mood (congruent or non-congruent), or along other dimensions. Themes described by the DSM 5 TR include:
    • Erotomanic - where the individual is convinced that another person (often of fame or higher status) is in love with them
    • Grandiose - where the individual believes they have a substantial, though unrecognized, talent, power, knowledge, discovery, or relationship with a divine or famous entity
    • Jealous - where the individual believes their romantic partner is unfaithful
    • Persecutory - where the individual believes they are systematically being conspired against, harassed, attacked, or otherwise obstructed from achieving their long-term goals
    • Somatic - related to bodily function or sensation
    • Mixed - for delusions where no single theme is dominant
    • Unspecified - for delusions that fall outside the above themes or are unclear
  • Most patients with delusions have more than one.
  • Delusions and hallucinations frequently co-occur.
  • The time course of delusions is highly variable and depends on the underlying diagnosis.
  • An "overvalued idea" is a belief which narrowly fails to satisfy the definition of a delusion. One example would be an anorexic patient’s belief that he or she is fat.
  • "... madmen put wrong ideas together, and so make wrong propositions, but argue and reason right from them; but idiots make very few or no propositions, and reason scarce at all." John Locke[1]

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Last updated: April 12, 2025