Persecutory Delusions: A Clinical Study and Related Therapy
Garety (2014) defined persecutory delusions to be a central psychotic experience at the extreme continuum of paranoia. To clarify, Freeman (2016) expanded that they may be considered false, firm threat beliefs that are usually developed due to several genetic and environmental risks. Likewise, there is a substantial and irrefutable need to bring persecutory delusions and associated clinical experience into the limelight.
These sorts of delusions are conspicuous and upsetting, and can lead to severe violent misconduct (Amminger et al. 2011). Occasionally, afflicted patients may experience a persecutory delusion without exploring the suspect. The instigating agent can be animate or inanimate. (Chaudary and Kiran, 2009). This condition then co-relates with other psychotic disorders such as schizophrenia, making it more severe.
A 33-year-old female is admitted in Karachi Psychiatric Hospital with paranoid delusions following a mental illness called schizophrenia; she claims that her brother-in-law has attempted to harm her by hitting her on the head with a chair. Furthermore, she believes that her in-laws are not happy with her and hence want her husband to divorce her. She even stated that her husband had several pre- and extramarital affairs. She is also afraid for her children and claims that her in-laws will turn them against her.
Upon further unfolding her history, I came to know that she had a positive history of self-harm in 2007 and, during the same year, had a bike accident and was admitted in the hospital for a longer duration. She was born prematurely into a low socioeconomic family, wherein her father was a cart painter and her mother was a housewife. Throughout the interview, she was restless and extremely conscious about environmental stimuli, such that my therapeutic interventions made her uncomfortable. Her wide, swollen eyes turned into a red signal for me.
Upon exploring her history and evaluating literature about schizophrenic patients, we can say that a whole paradigm of hallucinations and delusions is influenced by cultural and environmental stimuli from a low socioeconomic status (Anderson and Freeman, 2013). In eastern culture, mental illness and its consequences are often perceived as superstitious i.e. as an outcome of the ‘evil eye’ after which patients are referred to ‘pirs’ (spiritual healers) rather than mental healthcare settings (Gong et al., 2015). In contrast, western cultures often isolate such patients, considering them to be violent and a source of threat for the society. Ultimately, on basis of rationales, I decided to work with such clients for better prognosis of disease and to explore newly-learned theories in practice.
Looking into the etiological basis of mental illness, Freeman (2002) formulated a cognitive theory of persecutory delusion. This theory is divided into two parts; one part deals with formation of persecutory delusions while the other refers to the maintenance of this delusion (refer appendices, figures 1 and 2). It suggests that such a delusion has a root-precipitating factor, such as a stressful life event which is later exaggerated in the form of hysteria that may manifest as sleep disturbances or loss of appetite. Even long-term anxiety or depression can add fuel to fire by influencing overall mental well-being.
In clients more vulnerable to psychosis, (such as my own patient), anomalous experiences start to form as ideas of reference. This is apparent in the above-mentioned case; according to her, the in-laws conspired against her as she has often heard them ‘murmuring’, after which she became certain that these conversations were against her.
Abnormal perceptions are evident in individuals with schizophrenia (Frith, 2014). Precipitating factors will lead to development of an explanation of itself in any of the three forms — cognitive, abnormal perception or emotions. A person will select an explanation on the basis of preexisting beliefs — for example, in the above-mentioned patient, the precipitating factor was an act of being hit by a chair which exaggerated ideas of reference and disturbed the patient’s sleep pattern. The aftermath of such experiences led to an account which centered around considering her in-laws a threat.
Here, the preexisting belief was herself being the soft target as she considers herself to be naive. Her history of self-harm further made her an easy target to kill and label murder as suicide, and thus she experienced ‘poor-me’ paranoia. Patient will rationalize such explanations and form either confirmatory evidence or dis-confirmatory evidence.
Reflecting on the patient I encountered, she used to have frequent thoughts related to persecution following her mental illness. Eventually, her delusion elicited hostility i.e. she treated her in-laws suspiciously and suffered stigma. In such essence, her in-laws started behaving differently in her presence. According to the patient, her cousins-in-law broke contact with her, and thus her persecutory delusion was confirmed.
To combat persecutory delusions, one needs to overcome the sufficient component cause, for which cognitive behavioral therapy for worry can play an integral role (Freeman et al, 2015). A newly-proposed model of meta-cognitive training (MCT) has been proven to exert a mild to moderate effect on patients with delusional disorders (Eichner, & Berna, 2016). On an individual level, we can orient them to reality by providing individualized teaching of safety behaviors according to the situation and by indulging them in CBT worry-reduction intervention (Eichner, & Berna, 2016). Talent identification along with its promoting techniques can also work well (Freeman and Garety, 2013).
It should be noted that these interventions were applied in the above-mentioned scenario individually. On a community level, we can make use of group therapy to allow patients to overcome the ‘poor-me’ paranoia by creating awareness about disease and disproving the associated myths respectively. On a government level in the near future, nurse instructors can spread awareness about newly-researched, effective practices such as MCT and CBT worry reduction techniques in different hospitals of Pakistan, and teach to identify potential risks and eradicate them from behavior at an early age by promoting healthy practices.
In a nut shell, persecutory delusions are false firm beliefs that steer patient to consider external stimuli as harm and enable them to develop violent and self-harming behaviors. Preexisting beliefs play a vital role in the etiology of such delusions, potentially leading to severe consequences of persecutory delusion. To overcome the severity, we can execute different approaches such as CBT and MCT on all three levels of implementation.
Gong, Q., Dazzan, P., Scarpazza, C., Kasai, K., Hu, X., Marques, T. R., & David, A. S. (2015). A neuroanatomical signature for schizophrenia across different ethnic groups. Schizophrenia bulletin, 41(6), 1266-1275.
Amminger, G. P., Schäfer, M. R., Papageorgiou, K., Klier, C. M., Schlögelhofer, M., Mossaheb, N.,&McGorry, P. D. (2012). Emotion recognition in individuals at clinical high-risk for schizophrenia.Schizophrenia bulletin, 38(5), 1030-1039.
Frith, C. D. (2014). The cognitive neuropsychology of schizophrenia. Psychology Press.
Anderson, F., & Freeman, D. (2013). Socioeconomic status and paranoia: the role of life hassles, self-mastery, and striving to avoid inferiority. The Journal of nervous and mental disease, 201(8), 698-702.
Freeman, D., Dunn, G., Startup, H., Pugh, K., Cordwell, J., Mander, H., … &Kingdon, D. (2015). Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): a parallel, single-blind, randomised controlled trial with a mediation analysis. The Lancet Psychiatry, 2(4), 305-313
Eichner, C., & Berna, F. (2016). Acceptance and efficacy of metacognitive training (MCT) on positive symptoms and delusions in patients with schizophrenia: a meta-analysis taking into account important moderators.Schizophrenia bulletin, 42(4), 952-962.
Freeman, D. (2016). Persecutory delusions: a cognitive perspective on understanding and treatment. The Lancet Psychiatry, 3(7), 685-692. http://dx.doi.org/10.1016/s2215-0366(16)00066-3
Chaudhury, S. & Kiran, C. (2009). Understanding delusions. Industrial Psychiatry Journal, 18(1), 3. http://dx.doi.org/10.4103/0972-6748.57851
Freeman, D. &Garety, P. (2014). Advances in understanding and treating persecutory delusions: a review. Social Psychiatry And Psychiatric Epidemiology, 49(8), 1179-1189. http://dx.doi.org/10.1007/s00127-014-0928-7
Garety, P. A., & Freeman, D. (2013). The past and future of delusions research: from the inexplicable to the treatable. The British Journal of Psychiatry, 203(5), 327-333.
Join JPMS Medical Blogs Team as Editor or Contributor, email your cover letter and resume to [email protected]
We welcome Guest posts. Submit online via: http://blogs.jpmsonline.com/submit/
Disclaimer: JPMS Medical Blogs are published by the publisher of Journal of Pioneering Medical Sciences (JPMS). This article does not reflect the policies of JPMS or its Staff or Editorial nor does it intend to provide legal, financial or medical advice. Refer to Disclaimer and Policies section for more details.
Advertisement: Call for Papers for Journal of Pioneering Medical Sciences (www.jpmsonline.com): Submit Original Article, Review Article, Case Report, Letter to the Editor, News Article, Clinical Images, Perspectives or Elective Report to JPMS. We also publish Conference Proceedings and Conference Abstracts as Supplement. No paper submission or publication charges. Submit your articles online (click here) or send them as an Email to: [email protected]