Background
Delusions are a common transdiagnostic feature of psychotic disorders and their treatment remains suboptimal. Despite the urgent need to better understand the nature, meaning and course of these symptoms, research on the lived experience of delusional phenomena in psychosis is scarce.
Therefore, we aimed to explore the lived experience and subjective apprehension of delusions in help-seeking people with psychosis, regardless of the diagnosis and thematic content of the delusion.
Methods
In our systematic review and qualitative evidence synthesis, we searched MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science for qualitative studies published in English since the database’s inception, with the last search on September 9, 2021. Search Gray literature and hand searching of relevant journals were also performed.
Studies were eligible if they provided an analysis of the lived experience of delusions or predelusional phenomena presented from the perspective of individuals (aged 14 to 65 years) who had developed a high-risk clinical stage of psychosis, or an affective or psychotic disorder. non-diagnosable affective. Studies with only a subset of relevant participants were eligible only if data on the population of interest were reported separately. Studies that did not discriminate between the experience of delirium and other positive symptoms (e.g., hallucinations) were included only if delusion data were reported separately or could be extracted.
First-person accounts (and author interpretations) analyzing changes in sense of self, lived world, and meaning in relation to delusions were extracted and synthesized using a novel thematic synthesis approach informed by a critical realist stance and a phenomenological theoretical framework.
The analytical themes were developed in a new general framework for understanding the emergence of delusional phenomena. The study was registered with PROSPERO, CRD42020222104. First-person accounts (and author interpretations) analyzing changes in sense of self, lived world, and meaning in relation to delusions were extracted and synthesized using a novel thematic synthesis approach informed by a critical realist stance and a phenomenological theoretical framework.
Results
Of the 3265 records examined, 2115 were identified after duplicate removal. Of these, 1,982 were excluded after screening of titles and abstracts and 106 after screening for full-text eligibility. Of the 27 studies that entered the quality assessment, 24 eligible studies were included in the qualitative evidence synthesis, representing the perspectives of 373 people seeking help with lived experiences of delusions in the context of psychosis.
Gender was reported as male (n=210), female (n=110) , transgender (n=1), or not reported (n=52). Only 13 studies reported ethnicity, with white being predominant. The age of most participants ranged between 15 and 65 years.
No eligible studies were found that investigated subclinical or predelusional experiences in at-risk mental status populations using qualitative methods. Most studies were conducted in Western, educated, wealthy, industrialized, democratic (WEIRD) societies, and the majority of included participants had received or self-reported a diagnosis within the schizophrenia spectrum. Studies differed regarding whether they focused on one type or theme of delusion or delusional phenomena in general as a unified category.
Three overarching themes related to experiential changes and meanings in delirium were identified : (1) a radical reorganization of the lived world dominated by intense emotions; (2) doubt, get lost and find oneself again within delirious realities; and (3) search for meaning, belonging, and coherence beyond mere dysfunction.
Interpretation
Delusions are best understood as strongly individualized and inherently complex phenomena that arise from a dynamic interaction between interdependent subpersonal, personal, interpersonal, and sociocultural processes. Integrative approaches to delirium research, considering its potential adaptive capacity and favoring explanatory pluralism, could be advantageous.
Effective clinical care for people with psychosis may need to be tailored to more closely match and take into account the subjective experience and meaning of delusions as they are experienced, which could also help to redress power imbalances. and enduring epistemic injustices in mental health.
Added value of this study
By gathering evidence on the views of 373 people with psychosis, this study provides valuable data on the lived experience of a wide range of delusional phenomena and allows for the identification of similarities and differences between delusional and transdiagnostic themes.
Our new interpretive model, the emergent model of delusion , adds depth, nuance, and complexity to previous cognitive and phenomenological theories of delusion by providing an empirically robust, multi-layered explanation of how delusions emerge and how they are shaped by social, relational contexts. and emotional. It also highlights the role of communicative dynamics and trust in the clinical encounter with people with delusions, underscoring the epistemic value of first-person accounts as crucial sources of knowledge that can inform therapeutic interventions.
Implications of all available evidence
A deeper understanding of what people with delusions experience and might find meaningful can help guide clinical practice and improve communication within the clinical encounter. Better communication is likely to improve the quality of the therapeutic relationship and trust in individual clinicians and services, contributing to better clinical outcomes and benefiting service users and clinicians.
Our findings can inform future theoretical and causal research, and potentially contribute to the refinement of existing psychological interventions and the development of new ones for people with psychosis.
Funding : Priestley Scholars, Wellcome Trust.
