Connecting neurosis and psychosis: the direct influence of emotion on delusions and hallucinations

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Abstract

Diagnostic classification systems contain a core divide between neurosis and psychosis, leading to their separate study and treatment. The basis for the separation of the disorders is outlined and reassessed. It is argued that the empirical evidence does not support such a sharp distinction between neurosis and psychosis. The frequent occurrence of emotional disorder prior to and accompanying psychosis indicates that neurosis contributes to the development of the positive symptoms of psychosis. Psychological theories and experimental evidence concerning the influence of emotion on the content and form of delusions and hallucinations are therefore reviewed. It is argued that in many cases delusions are a direct representation of emotional concerns, and that emotion contributes to delusion formation and maintenance. The content of hallucinations less often directly expresses the emotional concerns of the individual, but emotion can trigger and contribute to the maintenance of hallucinatory phenomena, although how this occurs is not well understood. It is concluded that study needs to be made of the interaction between psychotic and neurotic processes in the development of delusions and hallucinations, and that neurotic and psychotic disorders may have common maintenance processes.

Introduction

The term psychosis was originally conceived in the nineteenth century as a subcategory of neurosis, and the relationship between the two has undergone many changes (Beer, 1996). During the twentieth century a sharp distinction has been drawn between psychosis and neurosis, and this has been embedded in classification systems. Neurotic and psychotic disorders have come to be studied and treated separately. Implicit in the sharp distinction are the assumptions that neurotic disorders have psychological aetiology and psychotic disorders have organic aetiology. In the last ten years, however, there has been an endeavour to understand the symptoms of psychosis in psychological terms (e.g. Bentall, 1994, Chadwick and Birchwood, 1994, Frith, 1992, Garety and Hemsley, 1994), encouraged by clinical evidence that psychological treatment approaches can reduce delusions and hallucinations (e.g. Drury, Birchwood, Cochrane and MacMillan, 1996, Kuipers, Fowler, Garety, Chisholm, Freeman, Dunn, Bebbington and Hadley, 1998, Tarrier, Yusupoff, Kinney, McCarthy, Gledhill, Haddock and Morris, 1998, Sensky, Turkington, Kingdon, Scott, Scott, Siddle, O’Carroll and Barnes, 2000). At the psychological level of explanation there is now the opportunity to connect the study of neurosis and psychosis. The aim in this paper is to review theoretical ideas and summarize the evidence concerning the possible direct roles of emotion (anxiety, depression, anger, and mania) in the formation and maintenance of delusions and hallucinations. It is likely that a greater theoretical understanding of delusions and hallucinations will enhance the efficacy of cognitive interventions for psychosis. The review will mainly concern evidence relating to non-affective functional psychosis, particularly schizophrenia, since delusions and hallucinations have been systematically studied only in these disorders.

Section snippets

The separation of neurosis and psychosis

It is necessary to review the rationale for the sharp separation of neurosis and psychosis before examining connections: the division may have been made on grounds that are still relevant. Important for the separation of neurosis and psychosis have been the hypothesised qualitative differences, trumping rules, and single-cause research strategies for schizophrenia.

Emotional disturbance preceding and accompanying delusions and hallucinations

The study of the influence of emotion on delusions and hallucinations has been neglected for reasons unsupported by the empirical literature. But why should the role of emotion in psychosis be studied? One important reason is evident where emotional disturbance precedes or accompanies symptoms of psychosis. The argument is simple: if emotional disturbance is present then it may influence psychosis.

Psychological accounts of the influence of emotion on delusions and hallucinations

Potential general relationships between neurosis and psychosis in the development of psychotic symptoms are outlined in Table 1. However research on the influence of neurosis on psychosis has been inhibited - it has been assumed that causal and maintaining factors in neurosis and psychosis are separate. Therefore psychological theories have not systematically examined the range of potential alternative relationships. To date the psychological accounts of the influence of emotion on delusions

Delusions: studies of content

The content of delusional beliefs can provide evidence as to whether emotion has a contributory role in their development. If emotion has a direct role, i.e. if delusions express emotional concerns, then it is expected that the content of delusions shares the main themes of emotions.

Table 2 lists the main emotions and their themes. The themes are linked with delusional beliefs, drawing upon the delusions outlined in the Present State Examination-10 (WHO, 1992). It can be seen that all the major

Delusions and hallucinations in disorders other than non-affective functional psychoses

By necessity, this review has concerned evidence relating to delusions and hallucinations in non-affective functional psychosis, particularly schizophrenia. Delusions and hallucinations do occur in many other disorders however (Manschreck and Petri, 1978, Coryell and Tsuang, 1982, Cutting, 1987, Trimble, 1992, Cummings, 1992). Clearly of interest, symptoms of psychosis are not uncommon in mood disorders such as depression and mania. The presence of psychotic symptoms in major depression is

Summary and conclusions

In this paper it has been seen that the original reasons for the sharp separation of neurotic and psychotic disorders are questionable. The raised levels of emotional disorder preceding, and accompanying, psychosis indicates that emotion could contribute to the development of delusions and hallucinations. Therefore psychological theories and research evidence were reviewed.

On the basis of the shared themes of delusions and emotions, it is plausible that the content of delusions are (most

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