اتصال اختلال روانی و روان: تأثیر مستقیم از احساسات در هذیان ها و توهم

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.

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 and 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 and 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. 2. 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.

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 commonly) a direct reflection of the emotional state of the individual. However further studies are clearly required. Evidence is needed from studies examining whether delusions are consistent with emotional concerns prior to symptom development. It would be of interest to examine the potential link between emotional processes and psychosis in the context of social and cultural factors such as ethnicity and social marginalisation. An important implication of the review is that delusional beliefs may share common maintenance factors with emotional disorders (e.g. safety behaviours, attentional biases). That the content of delusions directly reflects emotion also supports the idea that the form of delusions is also a direct result of emotion. Anxiety and associated processes are likely to be important in the formation of persecutory delusions. Most obviously, depression is likely to have a key role in the development of depressive delusions (e.g. guilt, catastrophe). Elation may be a factor in the formation of grandiose delusions. While a particular delusion may be linked with a particular emotion (see Table 2), sometimes a combination of emotions may contribute directly to the formation of a delusion. For example, anxiety and depression may directly contribute to the formation and maintenance of delusions of persecution in which individuals believe that they are being punished. Careful consideration of the content of delusions is needed. While the role of anxiety in symptom development has received some experimental attention, potential roles for depression, anger, and mania have received little investigation. It is also clear from Table 2 that other emotions, such as disgust, jealousy, guilt, and shame, may have a central role in the formation and maintenance of particular types of delusions defined by content, but to date these links have not been examined. It should be noted that an account of delusions as directly representing emotion does not of course rule out the possibility that the delusion may have reduced the level of negative emotion, since certainty will have replaced uncertainty. There is an accumulation of evidence supporting the notion that emotion directly triggers auditory hallucinations in individuals with hallucinatory predisposition. An explanation in psychological terms of how emotion can trigger self-monitoring failures remains to be detailed, although self-focus is a likely contributory factor. As Morrison, Chadwick, and Birchwood have suggested, a negative cycle involving a direct role for anxiety in maintaining hallucinations is plausible: hallucinations are interpreted as threatening, leading to anxiety and further hallucinations. More study of this hypothesised relationship is warranted. Emotion may also be directly reflected in the content of auditory hallucinations. However, it is proposed that this relationship is less strong than for delusions. The content of verbal hallucinations often appear to be unrelated to emotional concerns. Such findings regarding hallucinatory content are consistent with explanations of hallucinations that posit failure of self-monitoring processes. This review indicates that delusions and the content of hallucinations may often be a direct representation of the emotional state of the individual. Furthermore, common to both psychotic symptoms may be the importance of emotional processes in the appraisal of delusions and hallucinations, as has been found in the case of panic disorder. The interpretations of the positive symptoms will contribute to the distress produced. This is a neglected but important area of research. It is an important area because it is the distress associated with the symptoms that most often leads to individuals being seen in psychiatric services and receiving a diagnosis. The theme of this paper has been potential connections between neurosis and psychosis but, of course, there is evidence that individuals with psychosis differ from individuals with neurosis. For instance, individuals with psychosis have been found to differ from individuals with neurosis on a number of psychological tasks such as probabilistic reasoning (e.g. Garety, Hemsley, & Wessely, 1991); attributions (e.g. Kaney & Bentall, 1989); theory of mind (e.g. Corcoran, Mercer, & Frith, 1995); and the continuous performance task (e.g. Cornblatt , Lenzenweger, & Erlenmeyer-Kimling, 1989). Symptoms of psychosis will need to be understood within a multi-factorial framework that incorporates (distinctive) psychotic and (shared) neurotic processes. How psychotic and neurotic processes interact in the formation and maintenance of delusions and hallucinations will need to be determined. In particular the study of the influence of emotion and associated processes on basic psychotic cognitive processing disturbance (e.g. Hemsley, 1993 and Frith, 1992) will be important. For both hallucinations and delusions a valuable research method is likely to be the study of the affects of the manipulation of emotion (decreased in clinical groups and increased in non-clinical groups) on psychological processes associated with psychosis. It is plausible that the influence of affect on basic psychotic disturbances produces the distinct psychotic symptoms shown in clinical presentations. It is also likely that psychotic and neurotic disorders share similar maintaining factors. In this work it will be important to study delusions and hallucinations across diagnoses, including mood disorders, personality disorders, and organic conditions; the list of delusions in Table 2 includes beliefs that most commonly occur in conditions such as depression, body dysmorphic disorder, eating disorders, health anxiety, and bipolar disorder. The relative influence of emotion on delusions and hallucinations may be greatest in affective disorders, less in schizophrenia, and least in organic illnesses. If the divide between neurosis and psychosis begins to be bridged, there are implications for the clinician treating delusions and hallucinations. Clinicians are already ahead of the theorists; it has been shown that, suitably modified, cognitive behaviour therapy, devised originally for neurotic disorders, has efficacy in the treatment of 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 and Sensky, Turkington, Kingdon, Scott, Scott, Siddle, O’Carroll and Barnes, 2000). By refining the theoretical understanding of the links between emotion, emotional processes, and delusions and hallucinations, clinical formulations can have greater accuracy and therapeutic efficacy thereby enhanced. It has been highlighted that emotion and associated processes may contribute directly to the formation, maintenance, and appraisal of delusions and hallucinations. By treating the emotion the clinician is likely to reduce the positive symptom. When individual assessment indicates that emotion has a direct role, it may be helpful for clinicians to conceptualise delusions as emotion beliefs, and then to consider the associated neurotic processes that may maintain the beliefs, while not neglecting the role of psychotic processes (Freeman and Garety, 2002 and Freeman, Garety, Kuipers, Fowler and Bebbington, in press). The same will apply for certain beliefs about hallucinations (see Morrison, 1998). Techniques and formulations modified from the treatment for emotional disorders (e.g. Clark & Fairburn, 1997) will be useful in therapy for psychosis. This review indicates that the relationship between emotional processes and delusions and hallucinations is a future area of both clinical practice and research that is likely to provide clinically worthwhile and theoretically important results. Finally, looking at the commonalities and interactions of psychotic and neurotic disorders is likely to alter once again the relationship between the categories. Compared with ‘psychosis’, the term ‘neurosis’ is older, has undergone more changes in meaning, and currently generates more confusion. Uncertainty in defining neurosis has resulted in an alteration in nomenclature: ‘neurosis’ is now a ‘popular rather than medical’ term (Hare, 1991). ‘Neurosis’ is used less in psychiatric writings and instead is replaced by either the individual disorders making up the category or the phrase ‘non-psychotic disorders’. However the divide between psychosis and neurosis still remains in all but name.