One of my interests has been how institutional psychiatry and psychology constructs its categories in texts. I have written about constructions of diagnostic criteria and psychological instruments particularly with reference to depression. But for some time I have wanted to go back to psychosis (I have written an article on insight) and to write something about delusions.
And so, when I was reading the Imperfect cognitions blog, I came across a very interesting blog by Lisa Bortolotti, who compares the definition of delusions in DSM-IV and the latest one in DSM-V. This is exactly, what I am interested in! The problem was that in broad humanities delusions are really spoken for by philosophers (e.g. like Lisa Bortolotti) or philosophising psychiatrists (e.g. like Matthew Broome), and there is really not much left for a linguist, apart from the text itself. Because they tend not to touch upon, how it is all written. And so, I can spread my wings (not exactly Summertime, still, I do).
Bortolotti quotes these two extracts, starting with the DSM-IV definition.
Delusion. A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture (e.g., it is not an article of religious faith). When a false belief involves a value judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility.
And then delusions according the DSM-V
Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence. Their content may include a variety of themes (e.g. persecutory, referential, somatic, religious, grandiose).[…] Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences. […] The distinction between a delusion and a strongly held idea is sometimes difficult to make and depends in part on the degree of conviction with which the belief is held despite clear or reasonable contradictory evidence regarding its veracity.
I think the difference is quite interesting and significant, so let me tell you about it. In a nutshell, APA seems to extend the cateogry of delusions and does it by changing their statements by making them weaker.
Let me first consider the first text. This is a text written by a very certain author who wants to make very clear and tough criteria for delusions which cannot easily be undermined. APA is speaking as if trying to show us a narrow and well defined category, all the time reinforcing their statements. reinforcing. Consider:
- A false belief based
- (almost) everyone
- firmly sustained
- incontrovertible and obvious
- is not one accepted by other members
The first example should really have ‘is’, without it, it’s more difficult to challenge it. This is actually more interesting that might appear. The speaker normally indicates their certainty by using the grammatical third person. Here, however, the speaker doesn’t even use a clause. Deleting the verb, you delete the possibility of a challenge, situating the claim in the presupposition of the sentence. In other words, the claim that delusion is
a false belief (which) is based on incorrect inference
is simply put into the assumptions of what is said. APA doesn’t even need to argue it. You will have noticed, of course, that the rest of the fragment is in the 3rd person, without any qualifications.
Moreover, ‘everyone’ (just like ‘not accepted by other members’) is a bit of an exaggeration – what’s the evidence, even with ‘almost’? What does ‘firmly’ mean, apart from strengthening and making the group narrower, however fuzzy it might be? Exactly the same comment applies to ‘incontrovertible’ and ‘obvious’. Needless to say, this is not much more than rhetorical devices, but this is rhetoric which ‘goes narrow’, even though it is constructed as if there was a clear reality to which it referred. It also contructs the one perspective from which ‘obviousness’ is seen, but that’s beside the point here. The statements are strong, and even though the strength is only rhetorical, APA pulls no punches. Boundaries of delusions are constructed not only as extreme, but also commonly accepted and objective – they are between everybody and obvious.
Interestingly, DSM-V is different. So, let’s compare the ‘certain’ bits of DSM-IV with their equivalents in DSM-V:
- Delusions are fixed beliefs that are not amenable to
- conflicting evidence.
- are deemed bizarre if they are clearly implausible and not understandable
Can you see? They’re going weaker on certainty; there is no longer a presupposition which doesn’t need to be argued. They also actually introduce the modal verb ‘may’. Does it mean that delusions ‘may’ include other things? APA makes the boundaries fuzzier and considerably less extreme! The definition by negation, no references to everyone, it’s no longer ‘incontrovertible’… Where has APA gone? Why have ‘obvious’ and ‘incontrovertible’ been replaced only by ‘conflicting’ and merely ‘bizarre’? Yes, we have ‘clearly’, yet but in a conditional sentence!
But, that’s not all. This is the last sentence again:
The distinction between a delusion and a strongly held idea is sometimes difficult to make and depends in part on the degree of conviction with which the belief is held despite clear or reasonable contradictory evidence regarding its veracity.
APA tells us that the distinction between a delusion and an acceptable idea is “difficult to make”. But as it acknowledges the difficulty, such an acknowledgement seems at the same time to be a licence to make a judgement. This is actually a significant diffrence between DSM-4 and 5, the former definition tried to be very objective. DSM-5 seems to sympathise with psychiatrists, APA (metaphorically) holds their hand in making the (difficult) judgement. I can hear a clinician asking ‘is it OK to call this a delusion?’, yes, it is, APA knows, how tough your job is….After all, how would you assess “the degree of conviction with which the belief is”. Yes, you are supposed to assess it in your surgery, outside any context, social, cultural, linguistic…Good luck!
Let me give you an example, how tough it might be. Many years ago my 5-year-old son asked me:
Dad, are there aliens?
As I had no idea, I said, I didn’t know. My son, however, was persistent and asked:
But what do you think?
Ha, ha! Gotcha! The linguist in me thought. You really offer me a way out, my son. I can no longer speak of aliens, I can now speak of myself and what I think! So I said:
Yes, I think, there are.
The superordinate clause (‘I think’) offers me the way out. I firmly think, despite lack of evidence, that there are aliens. Is this a delusion? Does a clinician see the difference between ‘I think there are…’ and ‘There are…’? Of course they do….
And finally, to the epitome of fuzziness: “clear and reasonable evidence”. I’m sorry, could you please offer criteria for ‘clear and reasonable’. Might it be more like beauty which apparently is in the eye of the beholder? I really prefer ‘obvious’ and ‘incontrovertible’, they seem so clear in comparison!
I could go on, but I think my point is made. APA gives up on telling us what delusions are, they prefer to defer to your, the shrink’s, judgement. You, the shrink, decide, what clear and reasonable is, supported in the knowledge how difficult it is to make the judgement. Does it offer a little bit of licence to make a mistake? Sure. There is just no telling, of course, which side of delusionality the mistakes might be. Still, there is little doubt, I think, that the new definition of delusions weakens the threshold for beliefs to be delusions. Moreover, as APA used to offer (however unrealistic) criteria for them, in DSM V, they give them up, telling clinicians to make up their own minds.
Now, the linguist in me can offer two interpretations of it all. The first is – congratulations. APA is getting much more realistic in constructing such difficult beliefs as delusions. But that’s reading it outside context. I think, the fuzziness here is more to do with expanding the boundaries of delusions. By shifting the responsibility onto the (difficult) judgement, making the boundaries considerably less extreme, APA seem to cast the delusion net more widely.
Why do I say it? Well, because it’s also consistent with APA’s other attempts to cast the net more widely, for example by trying to introduce the ‘psychosis risk syndrome’, about which Allen Frances wrote:
I knew immediately that the results could be disastrous—misdiagnosis, stigma, and exposure to unnecessary and harmful antipsychotic meds. Most youngsters meeting criteria for “Psychosis Risk Syndrome” would never go on to develop a psychotic disorder. Given this high false-positive rate, the very real risks to the many seemed far to outweigh any theoretical benefits to the few.
But the point of this blog is different, though. I wanted to show the consequences of how the diagnostic criteria are phrased. While preparations for DSM-5 created many controversies (see, again, Allen Frances’ text) regarding extensions of mental illness and shrinking the realm of normal, the definition of delusion did not, I think, attract much attention in this context. And yet, I think, it should have.
Language is important in medicine. But in psychiatry (and in psychology) it is crucial. Linguistics (or discourse analysis) is probably more important in understanding psychiatry and mental illness than might be thought. It might no longer be possible to be ill of ‘not yet being ill’, but we still should probably worry a little about the definition of delusions. And the analysis of language can actually be a useful tool in ‘saving normal’, to borrow the title Allen Frances’ book and blog.