Grandiose delusions

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Grandiose delusions
Other namesExpansive delusions, delusions of grandeur
Cat and lion in mirror illustration.svg
A cartoon illustrating the phenomenon. People with grandiose delusions wrongly hold themselves at an extraordinarily high status in their mind.
Specialty Psychiatry

Grandiose delusions (GDs), also known as delusions of grandeur or expansive delusions, [1] are a subtype of delusion characterized by the extraordinary belief that one is famous, omnipotent, wealthy, or otherwise very powerful or of a high status. Grandiose delusions often have a religious, science fictional, or supernatural theme. Examples include the extraordinary belief that one is a deity or celebrity, or that one possesses fantastical talents, accomplishments, or superpowers. [2]

Contents

While non-delusional grandiose beliefs are somewhat common—occurring in at least 10% of the general population [3] —and often[ vague ] positively influence a person's self-esteem, in some cases they may cause a person distress, in which case such beliefs may be clinically evaluated and diagnosed as a psychiatric disorder.

When studied as a psychiatric disorder in clinical settings, grandiose delusions have been found to commonly occur with other disorders, including in two-thirds of patients in a manic state of bipolar disorder, half of those with schizophrenia, patients with the grandiose subtype of delusional disorder, frequently as a comorbid condition in narcissistic personality disorder, and a substantial portion of those with substance abuse disorders.[ vague ] [3] [4]

The term grandiose delusion overlaps with, but is distinct from, grandiosity. Grandiosity is an attitude of extraordinary self-regard (feelings of superiority, uniqueness, importance or invulnerability), while grandiose delusion concerns specific extraordinary factual beliefs about one's fame, wealth, powers, or religious and historical relevance.

Signs and symptoms

According to the DSM-IV-TR diagnostic criteria for delusional disorders, grandiose-type symptoms include exaggerated beliefs of:

For example, someone who has extraordinary beliefs about their power or authority may believe themselves to be a ruling monarch who deserves to be treated like royalty. [6] There are substantial differences in the degree of grandiosity linked with grandiose delusions in different people. Some patients believe they are God, the Queen of the United Kingdom, a president's son, a famous rock star, and some other examples. Others are not as expansive and think they are skilled athletes or great inventors. [7]

Expansive delusions may be maintained by auditory hallucinations, which advise the patient that they are significant, or confabulations, when, for example, the patient gives a thorough description of their coronation or marriage to the king. Grandiose and expansive delusions may also be part of fantastic hallucinosis in which all forms of hallucinations occur. [7]

Positive functions

Grandiose delusions frequently serve a very positive function by sustaining or increasing a person's self-esteem. As a result, it is essential to consider the consequences of removing the grandiose delusion on self-esteem when trying to modify the grandiose delusion in therapy. [5] In many instances of grandiosity, it is suitable to go for a fractional rather than a total modification, which permits those elements of the delusion that are central for self-esteem to be preserved. For example, a person who believes they are a senior secret service agent gains a great sense of self-esteem and purpose from this belief, thus until this sense of self-esteem can be provided from elsewhere, it is best not to attempt modification. [5]

In a case study of more than 13,000 non-clinical and almost 3,000 clinical participants, Isham et al. [8] found that the primary sources of meaning derived from grandiose delusions were: [8]

Comorbidity

Schizophrenia

Schizophrenia is a mental disorder distinguished by a loss of contact with reality and the occurrence of psychotic behaviors, including hallucinations and delusions (unreal beliefs which endure even when there is contrary evidence). [9] Delusions may include the false and constant idea that the person is being followed or poisoned, or that the person's thoughts are being broadcast for others to listen to. Delusions in schizophrenia often develop as a response to the individual attempting to explain their hallucinations. [9] Patients who experience recurrent auditory hallucinations can develop the delusion that other people are scheming against them and are dishonest when they say they do not hear the voices that the delusional person believes that he or she hears. [9]

Specifically, grandiose delusions are frequently found in paranoid schizophrenia, in which a person has an extremely exaggerated sense of their significance, personality, knowledge, or authority. For example, the person may declare to be the owner of a major corporation and kindly offer to write a hospital staff member a check for $5 million if they only help them escape from the hospital. [10] Other common grandiose delusions in schizophrenia include religious delusions such as the belief that one is Jesus Christ, [11] or the Mahdi of the end times in Muslim societies. [12]

Bipolar disorder

Bipolar 1 disorder can lead to severe affective dysregulation, or mood states that sway from exceedingly low (depression) to exceptionally high (mania). [13] In hypomania or mania, some bipolar patients can have grandiose delusions. In its most severe manifestation, days without sleep, auditory and other hallucinations, or uncontrollable racing thoughts can reinforce these delusions. In mania, this illness affects emotions and can also lead to impulsivity and disorganized thinking, which can be harnessed to increase their sense of grandiosity. Protecting this delusion can also lead to extreme irritability, paranoia, and fear. Sometimes their anxiety can be so over-blown that they believe others are jealous of them and, thus, undermine their "extraordinary abilities," persecuting them or even scheming to seize what they already have. [14]

The vast majority of bipolar patients rarely experience delusions. Typically, when experiencing or displaying a stage of heightened excitability called mania, they can experience joy, rage, and other intense emotions that can cycle out of control, along with thoughts or beliefs that are grandiose. Some of these grandiose thoughts can be expressed as strong beliefs that the patient is very rich or famous or has super-human abilities, or can even lead to severe suicidal ideations. [15] In the most severe form, in what was formerly labeled as megalomania, the bipolar patient may hear voices that support these grandiose beliefs. In their delusions, they can believe that they are, for example, a monarch, a creative genius, or even someone who can exterminate the world's poverty because of their extreme generosity. [16]

Theories and mechanisms

Psychologists and psychiatrists have proposed multiple theoretical accounts of GDs: [17]

Empirical evidence largely supports emotion-consistent models, but also suggests additional factors like reasoning biases. [18] Grandiose delusions are usually associated with high self-esteem and self-serving attributional style and low levels of depression, anxiety and negative self-evaluation. [8] [17] [19] [20] Moreover, there is evidence from neurotypical persons that repetitive positive self-thinking can confer temporary increases in (non-delusional) grandiose ideas of own superiority, importance or uniqueness. [21] A functional magnetic resonance imaging (fMRI) study of patients with bipolar disorder found that such thinking is associated with exaggerated connectivity between the medial prefrontal cortex and anterior cingulate cortex (brain regions involved in self-relevant information-processing). [22]

Qualitative research likewise indicates that grandiose delusions, far from occurring against a backdrop of negative self-evaluation, conferred a sense of uniqueness, purpose, and belonging, and added meaning to adverse events. [23]

The defensive hypothesis bears a strong similarity to the psychodynamic mask model of non-delusional narcissistic grandiosity, [24] which is also unsupported by the evidence. [25] [26]

Neurobiology

Grandiose delusions may be related to lesions of the frontal lobe. [27] Temporal lobe lesions have been mainly reported in patients with delusions of persecution and of guilt, while frontal and frontotemporal involvement have been described in patients with grandiose delusions, Cotard's syndrome, and delusional misidentification syndrome. [28]

Some studies indicate that GDs are associated with abnormalities in dopaminergic reward pathways and other limbic structures associated with reward and emotion processing. [29] [30] GDs seem to be related to impaired connectivity between the left middle temporal gyrus and more dorsal regions of the left temporal lobe, regions forming a central hub of the default mode network and mediating a variety of cognitive functions (namely social and linguistic ones). [31]

Diagnosis

Patients with a wide range of mental disorders which disturb brain function experience different kinds of delusions, including grandiose delusions. [32] Grandiose delusions usually occur in patients with syndromes associated with secondary mania, such as Huntington's disease, [33] Parkinson's disease, [34] and Wilson's disease. [35] Secondary mania has also been caused by substances such as L-DOPA and isoniazid which modify the monoaminergic neurotransmitter function. [36] Vitamin B12 deficiency, [37] uremia, [38] hyperthyroidism [39] as well as the carcinoid syndrome [40] have been found to cause secondary mania, and thus grandiose delusions.

In diagnosing delusions, the MacArthur-Maudsley Assessment of Delusions Schedule is used to assess the patient. [41]

Treatment

In patients with schizophrenia, grandiose and religious delusions are found to be the least susceptible to cognitive behavioral interventions. [41] Cognitive behavioral intervention is a form of psychological therapy, initially used for depression, [42] but currently used for a variety of different mental disorders, in hope of providing relief from distress and disability. [43] During therapy, grandiose delusions were linked to patients' underlying beliefs by using inference chaining.[ jargon ] [42] [44] Some examples of interventions performed to improve the patient's state were focus on specific themes, clarification of patient's neologisms, and thought linkage. [44] During thought linkage, the patient is asked repeatedly by the therapist to explain his/her jumps in thought from one subject to a completely different one. [44]

Patients with mental disorders that experience grandiose delusions have been found to have a lower risk of having suicidal thoughts and attempts. [45]

Epidemiology

In a study of over 1000 individuals of a vast range of backgrounds, Stompe and colleagues (2006) found that grandiosity remains the second most common delusion after persecutory delusions. [3] The prevalence of grandiosity delusions in schizophrenic patients has also been observed to vary cross-culturally. [46] [47] In research done by Appelbaum et al. it has been found that GDs appeared more commonly in patients with bipolar disorder (59%) than in patients with schizophrenia (49%), followed by presence in substance misuse disorder patients (30%) and depressed patients (21%). [48]

A relationship has been claimed between the age of onset of bipolar disorder and the occurrence of GDs. According to Carlson et al. (2000), grandiose delusions appeared in 74% of the patients who were 21 or younger at the time of the onset, while they occurred only in 40% of individuals 30 years or older at the time of the onset. [49]

Prevalence

Research suggests that the severity of the delusions of grandeur is directly related to higher self-esteem and inversely related to severity of depression and negative self-evaluations. [50] Lucas et al. found, in 1962, that there is no significant gender difference in the establishment of grandiose delusion. [51] However, the particular content of religious Grandiose delusions is variable across genders, with men more likely to consider themselves to be God, whereas women are more likely to consider themselves to be saints. [52] Lucas et al also noted that grandiose delusions are more prevalent in people with greater education. Similarly, the presence of grandiose delusions in individuals who are the eldest is greater than in individuals who are the youngest of their siblings. [51]

See also

Related Research Articles

Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes. Typically, these manic episodes can last at least 7 days for most of each day to the extent that the individual may need medical attention, while the depressive episodes last at least 2 weeks.

Psychosis is a condition of the mind or psyche that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are disorganized thinking and incoherent speech and behavior that is inappropriate for a given situation. There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities. Psychosis can have serious adverse outcomes.

<span class="mw-page-title-main">Schizophrenia</span> Mental disorder with psychotic symptoms

Schizophrenia is a mental disorder characterized variously by hallucinations, delusions, disorganized thinking and behavior, and flat or inappropriate affect. Symptoms develop gradually and typically begin during young adulthood and are never resolved. There is no objective diagnostic test; diagnosis is based on observed behavior, a psychiatric history that includes the person's reported experiences, and reports of others familiar with the person. For a diagnosis of schizophrenia, the described symptoms need to have been present for at least six months or one month. Many people with schizophrenia have other mental disorders, especially mood disorders, anxiety disorders, and obsessive–compulsive disorder.

A delusion is a false fixed belief that is not amenable to change in light of conflicting evidence. As a pathology, it is distinct from a belief based on false or incomplete information, confabulation, dogma, illusion, hallucination, or some other misleading effects of perception, as individuals with those beliefs are able to change or readjust their beliefs upon reviewing the evidence. However:

Schizoaffective disorder is a mental disorder characterized by symptoms of both schizophrenia (psychosis) and a mood disorder - either bipolar disorder or depression. The main diagnostic criterion is the presence of psychotic symptoms for at least two weeks without prominent mood symptoms. Common symptoms include hallucinations, delusions, disorganized speech and thinking, as well as mood episodes. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses. Many people with schizoaffective disorder have other mental disorders including anxiety disorders.

<span class="mw-page-title-main">Delusional disorder</span> Mental illness featuring beliefs with inadequate grounding

Delusional disorder, traditionally synonymous with paranoia, is a mental illness in which a person has delusions, but with no accompanying prominent hallucinations, thought disorder, mood disorder, or significant flattening of affect. Delusions are a specific symptom of psychosis. Delusions can be bizarre or non-bizarre in content; non-bizarre delusions are fixed false beliefs that involve situations that could occur in real life, such as being harmed or poisoned. Apart from their delusion or delusions, people with delusional disorder may continue to socialize and function in a normal manner and their behavior does not necessarily seem odd. However, the preoccupation with delusional ideas can be disruptive to their overall lives.

Richard Bentall is a Professor of Clinical Psychology at the University of Sheffield in the UK.

<span class="mw-page-title-main">Thought disorder</span> Disorder of thought form, content or stream

A thought disorder (TD) is a disturbance in cognition which affects language, thought and communication. Psychiatric and psychological glossaries in 2015 and 2017 identified thought disorders as encompassing poverty of ideas, neologisms, paralogia, word salad, and delusions—all disturbances of thought content and form. Two specific terms have been suggested—content thought disorder (CTD) and formal thought disorder (FTD). CTD has been defined as a thought disturbance characterized by multiple fragmented delusions, and the term thought disorder is often used to refer to an FTD: a disruption of the form of thought. Also known as disorganized thinking, FTD results in disorganized speech and is recognized as a major feature of schizophrenia and other psychoses. Disorganized speech leads to an inference of disorganized thought. Thought disorders include derailment, pressured speech, poverty of speech, tangentiality, verbigeration, and thought blocking. One of the first known cases of thought disorders, or specifically OCD as it is known today, was in 1691. John Moore, who was a bishop, had a speech in front of Queen Mary II, about "religious melancholy."

Stimulant psychosis is a mental disorder characterized by psychotic symptoms. It involves and typically occurs following an overdose or several day binge on psychostimulants, though one study reported occurrences at regularly prescribed doses in approximately 0.1% of individuals within the first several weeks after starting amphetamine or methylphenidate therapy. Methamphetamine psychosis, or long-term effects of stimulant use in the brain, depend upon genetics and may persist for some time.

The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains.

The syndrome of subjective doubles is a rare delusional misidentification syndrome in which a person experiences the delusion that they have a double or Doppelgänger with the same appearance, but usually with different character traits, that is leading a life of its own. The syndrome is also called the syndrome of doubles of the self, delusion of subjective doubles, or simply subjective doubles. Sometimes, the patient is under the impression that there is more than one double. A double may be projected onto any person, from a stranger to a family member.

Thought broadcasting is a type of delusional condition in which the affected person believes that others can hear their inner thoughts, despite a clear lack of evidence. The person may believe that either those nearby can perceive their thoughts or that they are being transmitted via mediums such as television, radio or the internet. Different people can experience thought broadcasting in different ways. Thought broadcasting is most commonly found among people who have a psychotic disorder, specifically schizophrenia.

An auditory hallucination, or paracusia, is a form of hallucination that involves perceiving sounds without auditory stimulus. While experiencing an auditory hallucination, the affected person hears a sound or sounds that did not come from the natural environment.

Brief psychotic disorder—according to the classifications of mental disorders DSM-IV-TR and DSM-5—is a psychotic condition involving the sudden onset of at least one psychotic symptom lasting 1 day to 1 month, often accompanied by emotional turmoil. Remission of all symptoms is complete with patients returning to the previous level of functioning. It may follow a period of extreme stress including the loss of a loved one. Most patients with this condition under DSM-5 would be classified as having acute and transient psychotic disorders under ICD-10. Prior to DSM-IV, this condition was called "brief reactive psychosis." This condition may or may not be recurrent, and it should not be caused by another condition.

<span class="mw-page-title-main">Postpartum psychosis</span> Rare psychiatric emergency beginning suddenly in the first two weeks after childbirth

Postpartum psychosis (PPP), also known as puerperal psychosis or peripartum psychosis, involves the abrupt onset of psychotic symptoms shortly following childbirth, typically within two weeks of delivery but less than 4 weeks postpartum. PPP is a condition currently represented under "Brief Psychotic Disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Volume V (DSM-V). Symptoms may include delusions, hallucinations, disorganized speech, and/or abnormal motor behavior. Other symptoms frequently associated with PPP include confusion, disorganized thought, severe difficulty sleeping, variations of mood disorders, as well as cognitive features such as consciousness that comes and goes or disorientation.

<span class="mw-page-title-main">Persecutory delusion</span> Delusion involving perception of persecution

A persecutory delusion is a type of delusional condition in which the affected person believes that harm is going to occur to oneself by a persecutor, despite a clear lack of evidence. The person may believe that they are being targeted by an individual or a group of people. Persecution delusions are very diverse in terms of content and vary from the possible, although improbable, to the completely bizarre. The delusion can be found in various disorders, being more usual in psychotic disorders.

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

The diagnosis of schizophrenia, a psychotic disorder, is based on criteria in either the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, or the World Health Organization's International Classification of Diseases (ICD). Clinical assessment of schizophrenia is carried out by a mental health professional based on observed behavior, reported experiences, and reports of others familiar with the person. Diagnosis is usually made by a psychiatrist. Associated symptoms occur along a continuum in the population and must reach a certain severity and level of impairment before a diagnosis is made. Schizophrenia has a prevalence rate of 0.3-0.7% in the United States.

The relationship between religion and schizophrenia is of particular interest to psychiatrists because of the similarities between religious experiences and psychotic episodes. Religious experiences often involve reports of auditory and/or visual phenomena, which sounds seemingly similar to those with schizophrenia who also commonly report hallucinations and delusions. These symptoms may resemble the events found within a religious experience. However, the people who report these religious visual and audio hallucinations also claim to have not perceived them with their five senses, rather, they conclude these hallucinations were an entirely internal process.

Schizophrenia is a primary psychotic disorder, whereas, bipolar disorder is a primary mood disorder which can also involve psychosis. Both schizophrenia and bipolar disorder are characterized as critical psychiatric disorders in the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5). However, because of some similar symptoms, differentiating between the two can sometimes be difficult; indeed, there is an intermediate diagnosis termed schizoaffective disorder.

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