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Positive Symptoms of Schizophrenia: The Psychotic Dimension

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D.

Positive Symptoms: The Psychotic Dimension

Hallucinations are sensory perceptions that occur in the absence of anything causing those sensations. Whatever stimulation causes them occurs within the ill person's brain, and not outside in the world. Hallucinations may occur within any sensory realm (including sight, sound, taste, smell and touch) with convincing reality. However, the most commonly reported form of hallucination is auditory; involving hearing people's voices when those people are not there. Auditory hallucinations such as voices occur during full consciousness and appear to originate from one or more third parties. They are not like the common odd 'hypnogogic' sensations that many people experience during transitions from waking to sleep or vice versa (e.g., during periods of semi-consciousness). Schizophrenic patients describe the voices as providing a running commentary of their behaviors and intentions in their heads, or as commanding presences telling them to do or not do certain things. Frequently, the voices are highly negative and critical in tone and attempt to humiliate patients.

Unlike hallucinations, which are sensory in nature, delusions are false fixed beliefs that misinterpret events and relationships. They may originate based on hallucinations, or from faulty suppositions and interpretations of events that either happened or were believed to have happened but which have no basis in reality. Delusions vary widely in their themes; they may be persecutory, referential (about oneself), somatic (involving the body), religious, erotomanic (involving sexuality), or grandiose in nature.

  • A persecutory delusion involves the belief that the sufferer is being stalked, tricked, framed, or hunted in some fashion. A common persecutory delusion many patients share is that the FBI or other police or spy institutions are after them.
  • Referential delusions involve the belief that certain public communications in fact contain specific hidden messages meant for the schizophrenic patient alone. A patient may believe that a television host's gesture has personal meaning for them, for example, or that song lyrics contain a special personal message. When patients can demonstrate some insight that their referential delusions are possibly not true, the delusions can be called "ideas of reference". When they take on the force of delusions, they are termed "delusions of reference".
  • Somatic delusions typically revolve around patients expressing 'knowledge' that they have a terrible illness (of a physical and possibly bizarre variety; not schizophrenia). For example, patients may complain that they have worms under their skin, that they have a tumor, or that they are being damaged by cosmic rays (of supernatural origin).
  • Religious delusions involve patients' belief that they have a special relationship with God normally reserved for bible or mythic figures, or with the spiritual world. Patients may state that they are the incarnation of the archangel Michael, for instance. They may complain of demon possession, of being able to speak to God directly and hear replies, or to be in communication with a spirit from another dimension. Patients may believe that they are God, or God's chosen messenger.
  • Erotomanic delusions are social delusions involving false ideas and feelings about relationships that may not actually exist. Patients may believe that a famous actor or actress is in love with them, for example. They may believe that their actual spouse or partner has cheated on them when this has not actually occurred. Patients may also believe that people they don't want anything to do with desire to have sexual contact with them. In bizarre cases, patients may hallucinate that people have sexual organs in wrong places (such as penises in the place of a nose or ears).
  • Patient's grandiose delusions consist of them believing that they are a significant figure in the world, such as a movie star, political leader, or someone incredibly wealthy and powerful.

Many times, delusions will involve more than one of these categories at once. For instance, patients who think they are Jesus Christ, are expressing a delusion that is simultaneously religious, grandiose and persecutory, for example. This sort of mixing is normal, although there is usually one theme that is dominant above the others. For example, the religious element of believing you are Christ may be more prominent than grandiose or persecutory elements.

Hallucinations and delusions generally can be described as being either plausible or bizarre. Plausible delusions are those that might possibly be consistent with reality if reality were slightly different than it actually is, while bizarre delusions are completely inconsistent with reality and highly unlikely to ever actually occur. For example, it is plausible for someone to think that their lover has cheated on them with another person. It is implausible and bizarre for them to think that their lover has cheated on them with the entire crew of an alien space craft. It would also be bizarre for someone to complain about their intestines spilling out of their body when simple observation by an objective third party shows that this is not the case.

Frequently, the combination of hallucinations and delusions go hand in hand. This is to say, delusion of persecution may be supported by 'evidence' derived from hallucinated voices, or a belief that one is the archangel Gabriel may be supported by evidence from "God's" voice. The two symptoms interact, creating mental chaos and an atmosphere for psychosis and the loss of reality.