Delusions Of Reference, Schizophrenia, And The Boundaries Of The Self
The psychotic symptoms of schizophrenia can take many forms, but certain kinds seem to occur more frequently than others. Delusions of reference, in which an individual believes that chance events in the world carry hidden meanings directed at them, tend to be particularly common in schizophrenia and related forms of mental illness. Distorted beliefs of this kind may offer clues to the neurological and cognitive underpinnings of psychotic disorders.
A delusion of reference tends to be resistant to evidence against the belief and may be reinforced by a person’s other hallucinations or delusions. Neurological research suggests these symptoms may result partly from deficits in the brain systems responsible for self-related cognition. Some theories suggest that such distortions of personal identity could be central features of schizophrenia. Delusions and other schizophrenia symptoms can usually be managed with therapy and medication.
What are delusions of reference?
A delusion can be defined as an inaccurate or bizarre belief that an individual holds strongly, even when presented with evidence that contradicts the belief. Along with hallucinations, delusions can be considered one of the core symptoms of psychosis, a type of psychological dysfunction involving severe deficits in a person’s ability to understand what is and is not real.
Delusions typically form part of the core diagnostic criteria for schizophrenia, which can be a severely debilitating mental health condition. Delusions, along with hallucinations and disorganized thinking, are considered positive symptoms of schizophrenia, as opposed to negative symptoms, in which ordinary mental functions are suppressed or diminished. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), schizophrenia can’t be diagnosed without at least one positive symptom.
- The people they see on television are speaking to them in code
- The pattern of shadows on the wall spells out a warning about their future
- World events are conveying symbolic instructions to them
- The people sitting next to them on the plane are spies observing their movements
- A stranger browsing in a supermarket is trying to tell them something based on which products they look at
- Laughter heard in the distance is mocking them
- A new street sign on their block contains a surveillance device that’s monitoring them
- The weather patterns are shifting in response to their thoughts
- They can foresee their destiny by paying attention to the stories that come up on their social media feed
These are far from the only possible examples, but they may convey the general pattern of this symptom. For someone experiencing delusions of reference, events that others interpret as random or coincidental seem deeply meaningful.
Delusions of reference, ideas of reference, and magical thinking
A closely related concept to the delusion of reference is the idea of reference (IR). An idea of reference can be very similar to a delusion of reference, but in general, the person is not certain about their interpretation of events, and they’re open to being convinced that they’re wrong. They may be able to recognize that what they think they’re experiencing is unusual and improbable. In contrast, individuals with acute schizophrenia often lack insight and have trouble identifying delusions as indicators that they’re mentally ill.
Ideas of reference can occur even in healthy individuals, and by themselves, they’re not necessarily a sign of pathology. However, some studies suggest that a high frequency of IRs may indicate a higher susceptibility to psychosis.
Delusions of reference in schizophrenia
Delusions can occur in many mental health disorders, from bipolar disorder to depression, and their content can be highly variable. Some research suggests that delusions of reference may be especially prevalent in schizophrenia spectrum disorders (SSDs) compared to other types of psychotic disorders.
These delusions may overlap with or reinforce other kinds of delusional thinking common in schizophrenia, such as the following:
- Persecutory delusions: Some people with schizophrenia may believe that others are conspiring to harm or control them (a phenomenon formerly referred to as “paranoid schizophrenia”). Their delusions of reference might include perceptions of hostile, threatening, or deceptive intent in ordinary occurrences.
- Erotomanic delusions: A person convinced that a famous individual is secretly in love with them might believe that the object of their delusion is sending them romantic messages during their public appearances.
- Grandiose delusions: Someone who believes they’re divine or destined for greatness might interpret everyday events as omens of their future greatness or as messages of approval from God.
Some researchers have suggested that delusions of reference can be divided into two distinct categories associated with different types of psychopathology, although updated evidence may be needed.
- Delusions of communication, in which the individual thinks that chance occurrences are conveying information to them
- Delusions of observation, in which the individual believes that some person, agency, or entity is covertly surveilling them
This paradigm suggests that delusions of observation may be a subset of paranoid delusions, while delusions of communication could emerge from a distinct mental process.
What causes delusions of reference?
The exact causes of schizophrenia and its various symptoms are complex and not yet fully understood. However, the existing evidence may point to some partial explanations for the phenomenon of referential delusions.
Self-concept and self-reference in schizophrenia
Self-referential delusions might be only one manifestation of a broader phenomenon common in schizophrenia: a diminished sense of self.
People with this disorder often report believing that they have no coherent personal identity, or that the boundaries between themselves and the world outside them seem to have dissolved. Certain observers have argued that this loss of felt identity may be at the heart of the pathology of schizophrenia.
Studies show that patients at high risk for psychosis seem to be more likely to develop schizophrenia if they report disturbances in their sense of self. This could explain why people with this condition frequently believe they’re being controlled by outside forces or hearing external commands — they may lack a stable idea of their own identity, preventing them from recognizing that their thoughts and impulses are internally generated.
In this model of schizophrenia, delusions of reference could result from the inability to distinguish between the inner self and the outer world. Because the individual is confused about what separates their mind from the situations and people around them, their own desires, fears, or idiosyncratic ideas may be projected onto real-world events.
Delusions of reference and meaning-making
Delusions of reference may also represent attempts to make sense of the world despite the mental distortions resulting from schizophrenia. Evidence suggests that referential delusions tend to be more common in patients with more frequent hallucinations. Delusions could be attempts to make rational sense of the seemingly inexplicable and bizarre sensory data resulting from these psychotic symptoms.
This process could be further distorted by cognitive impairments, which also tend to be prevalent in psychotic disorders. Such symptoms might make it harder for individuals to come to accurate conclusions about the causes of their unusual perceptions.
Brain correlates of delusions of reference
Neurological research may also offer some insight into the biological mechanisms underlying delusions of reference. A 2017 paper reported that people with a higher incidence of delusions of reference usually showed atypical activity in the brain’s cortical midline structures (CMS). Hyperactivity in the frontal portion of the CMS was seen to be directly correlated with referential delusions.
This collection of brain structures has previously been linked to self-referential thinking tasks — for example, thinking about one’s own strengths and weaknesses. Dysfunctional activity in this area could indicate a distorted capability to judge whether something is related to the self.
Another brain region that may be involved in delusions of reference is the caudate nucleus, which may play a role in associative learning, including the ability to predict stimulus-response relationships. A 2015 neuroimaging study found evidence that this region was typically smaller in people who exhibited delusions of reference. This could indicate that people with schizophrenia may have an impaired ability to understand cause-and-effect relationships, potentially making it easier to believe that random events in the outside world could be influenced by their thoughts or actions.
How can delusions of reference in schizophrenia be treated?
According to the American Psychiatric Association, effective treatment for the acute psychotic symptoms of schizophrenia — including delusions — typically involves antipsychotic medication. Taking an antipsychotic prescription as prescribed by a doctor or psychiatrist may diminish the frequency and strength of delusions of reference while reducing the likelihood of relapse.
Receiving psychotherapy alongside medication may also help. Numerous studies have found positive effects of cognitive behavioral therapy for psychosis (CBTp), and some evidence suggests that newer developments in this technique may have increased CBT’s effectiveness at treating delusions in particular.
Some people may have difficulty finding a mental health care provider whose availability aligns with their own. If you’re looking for psychotherapy to help with schizophrenia delusions, online care could be a helpful option. Internet therapy platforms often have large pools of providers across many time zones, which can make it easier to find a time to meet that works for you. However, in-person care may be necessary in some cases of acute psychosis.
Emerging research generally supports the idea that online psychotherapy can be an effective treatment for schizophrenia, especially as a complement to medication. Some studies have demonstrated online therapy’s potential effectiveness in reducing psychotic symptoms.
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