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http://hpy.sagepub.com/History of Psychiatry

http://hpy.sagepub.com/content/11/41/003The online version of this article can be foundat:

DOI: 10.1177/0957154X0001104101

2000 11: 003History of PsychiatryRamin Mojtabai

Delusion as error: the history of a metaphor

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003

Delusion as error: the history of a metaphor

RAMIN MOJTABAI*

Address for correspondence: Ramin Mojtabai, MD, PhD, 200 HavenAve.,Apt. # 6P, NewYork, NY 10033, USA. E-mail: [email protected]

Error has been the major metaphor for understanding delusions through the pastthree centuries. Modern definition of delusion as erroneous opinion or belief isevidence of the continuing role of this metaphor to this day. However, throughlong habituation the metaphorical nature of the association between delusionand error is no longer recognized. In other words, the metaphor has becomeliteral and all but invisible. This paper seeks to shed light on this metaphor bytracing its development from inception in the seventeenth century to the presenttime.

Also,the

impact ofthe

metaphoron modern research and

therapeuticapproaches is briefly discussed. Finally, to put the metaphor of error in

perspective, some other metaphors applied to delusion over the years are reviewed.

Delusion is the morbid manifestation of knowledge and error in regard to

empirical reality, as it is of faith and superstition in regard to metaphysical reality.(:108)1

Delusions are often defined as false or erroneous beliefs, strongly held andunshakeable.At the core of this definition are the two

metaphorsof belief

and error, as reflected in the above quote from Jaspers. BerrioS2 criticized thetraditional view that delusion is belief on the basis of structural differences

between delusion and belief. Little attention, however, has been paid to the

metaphor of error. Perhaps the reason for this neglect is that the use of this

metaphor for delusion has become so ingrained in the minds of cliniciansand researchers that it has become, so to speak, literal.

In this paper I will first review the history of the metaphor of error as

applied to delusion. Next, the impact of this metaphor on the currentresearch and therapeutic approaches to delusion will be discussed. Finally, to

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put this metaphor in perspective, some of the other metaphors proposed fordelusion throughout the years will be briefly reviewed. Before delving into

our discussion of delusion and the metaphor of error, however, a brief noteon the place of metaphors in the history of psychopathology is in order.

Metaphors in psychopathology

We see the world through language, and metaphors are among the most

powerful tools of language, widely applied in both everyday conversationsand the language of science. Broadly defined, a metaphor is the transfer of a

concept from one (usually better known) domain, to another (usually less

known) domain based on some similarity. This definition is close toGrubers3 who also classifies, under the general term of metaphor, analogyand model as comparison processes by which we use some part of our

knowledge to illuminate others (:122) .All knowledge is deeply rooted in the

metaphorical modes of perception and thought.~cut

Metaphors are commonly used in sciences including psychology and

psychopathology and are a rich source of devices for understanding and

expressing elusive concepts such as mind, emotion, thought, and theirdisorders (to use a metaphor). Platos metaphor of reflections on a cave wall

for human knowledge is well known, as are the modern metaphors ofmachine or computer for mind. Leary and his collaborators have presenteda comprehensive review of the influential metaphors in the history of

psychology.A large number of such psychological and psychopathologicalmetaphors have become ingrained in our everyday language. For instance,we talk of the stream of consciousness, outbursts of anger, anxietyattacks, psychotic episodes, etc. Sometimes the underlying metaphors are,so to speak, implicit, and appear only in the vocabulary used to define the

phenomena. Because of common usage, the metaphorical nature of these

expressions is no longer noticeable. In Learys4 words, these metaphors havebecome literal, or myths and all but invisible through long habituation.

Leary defined myth in this sense as,

... the taking of an analogy or metaphor as an identity - and, by extension,the taking of its elaboration as a completely true story.Another way of

saying this is that myths (in the negative sense) arise when people forgetto say like or as if when proposing a metaphorical comparison ... (:47)4

The use of the metaphor of error (i.e., erroneous judgement or opinion)for delusion is a case in

point.

Insanity and the metaphor of error

The concept of mental symptoms independent of mental illness evolved inthe nineteenth century. Before that time, in words of Berrios, Madness had

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been a molar category..., mad behaviour was viewed &dquo;in toto&dquo; and not as an

array of individual &dquo;signs&dquo; (:29).6 The vestiges of this unity between

symptom and illness are still found in the French and German terms fordelusion, ddlire and Wahn respectively, which have a much broader definitionthan the English delusion, encompassing psychosis in general. Therefore, inorder to trace the history of the metaphor of error as applied to delusionbefore the nineteenth century we need to trace this metaphor as applied toinsanity in general.

Error became a dominant metaphor for insanity in mid seventeenthcentury, although this concept was not unfamiliar to earlier authors. Forinstance, as early as 1586, the British physician Timothy Bright had defined

madness as the false report of senses to the mind.&dquo; The French historian,Michel Foucault has dramatically traced the transition in our understandingof insanity from the medieval times, when the alchemical metaphor ofimbalance in humors was dominant, to the seventeenth century when

insanity came to be equated with lack of reason:

We call madmen, Sauvages was to say, those who are actually deprivedof reason or who persist in some notable error; it is this constant errorof the soul manifest in its imagination, in its judgments, and in its desires,which constitutes the characteristic of this category. (:104, italics original)8

The seventeenth-century British empiricist, John Locke9 most succinctlydescribed this new way of looking at insanity in general and delusions in

particular:

... they [madmen] do not appear to me to have lost the faculty ofreasoning, but having joined together some ideas very wrongly, theymistake them for truths; and they err as men do that argue right from

wrong principles. For by violence of their imaginations, having taken theirfancies for realities, they make right deductions from them. Thus youshall find a distracted man

fancyinghimself a

king,with a

rightinference

require suitable attendance, respect and obedience: others who have

thought themselves made of glass, have used the caution necessary to

preserve such brittle bodies. (:209)9

British empiricism, and along with it this view of insanity, predominated in

Europe throughout the seventeenth and eighteenth centuries. This new wayof seeing insanity and delusion did not only affect the formal definitions, butalso the terminology and the therapeutic approaches to patients. It was

during this period that the German terms irre and Irrsinn - from the same

root as the English error - becamecommon

terms for mentally ill patient anddelusion respectively. 10The impact on treatment of patients materialized somewhat later.

Confinement, purging, blood-letting and other forms of physical therapyremained the mainstay of treatment for insanity throughout the seventeenthand eighteenth centuries. It was only at the end of the eighteenth and the

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beginning of the nineteenth century that behavioural and psychologicaltreatments became popular. Either reasoning with the patients or imposing

their own opinions through coercive methods, the nineteenth-centuryphysicians tried to correct the errors of their patients.

IThis change in

therapeutic approach was in part due to a change in the perception of mentalillness.According to the nineteenth-century British asylum owner, ThomasBakewell:

The disease, in its mildest state, simply consists in the prevalence oferroneous or visionary conceptions, with which reason has nothing to do:Induce, by means of new and strong impressions upon the senses, a newtrain of thoughts, and the patient shall reason as well as others. (:708)7

The set of behavioural and psychological interventions introduced at the

beginning of nineteenth century, generally known as Moral Treatment, was

partly based on this assumption about the nature of insanity and the propertreatment for it. Thus, application of the metaphor of error perhapscontributed to the asylum reforms of the early nineteenth century.

Delusion and the metaphor of error

As early as 1754 the influential French Encyclopdie had defined delusion(delire) as an error of judgement by the spirit, during wakefulness, of thingsknown to all (:85). 12 However, delusion, along with other symptoms, cameinto its own as a distinct symptom in the nineteenth century. The earlynineteenth-century German psychiatrist, Wilhelm Griesinger, was one of themost influential figures in the separation of symptoms from diseases. Hediscussed symptoms as separate elementary disorders which, when groupedtogether, constitute the various forms of insanity (:60).&dquo; Griesinger alsodistinguished between delusions and the erroneous views of normal

individuals by a number of characteristics, among them their tenacity andimperviousness to contrary evidence - the two criteria that are used to definedelusions in our time.

As early as 1798 Crichton had criticized the term erroneous inreference to delusions and hallucinations:

The expression diseased perceptions or notions is here to be preferred tothat of false or erroneous perceptions which is employed by other authors,first because the ideas in all kinds of delirium whatever, arise from adiseased state of the brain, or nerves, or both ... and

secondlybecause

the word erroneous does not describe anything peculiar to delirium; for

every man, however sane or wise he may be, has some erroneous notionsin which he firmly believes.... (:92, italics in original) 12

-)

On the other hand, the association with error was evident to GriesingersBritish contemporaries Tuke and Bucknill who defined delusion as including

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all the various errors to which reference has been made, whenever thoseerrors are not corrected by the understanding (:104) .

12

These apparently opposite views echoed throughout the nineteenthcentury. The similarity or dissimilarity of delusions and common errors, wasa constant preoccupation of the authors of the numerous psychiatrictextbooks written throughout that century. The views of Krafft-Ebingl4 andKirchhoff, both authors of popular late nineteenth-century textbooks, arerepresentative. Krafft-Ebing repeated Griesingers criteria with some modifi-cations, distinguishing delusions from common errors, whereas Kirchhoffsaw these two phenomena as continuous:

Delusions are falsejudgments,

and henceclosely

allied to errors in their

development and contents. Superstition shows a transition betweendelusions and error. Common to all of them is a weakness of judgment.(:72)~

However, underlying these apparent disagreements a common theme is

recognizable. If criteria are needed to distinguish delusion from common

error, it is because in the minds of these psychiatrists the two were closelyassociated. Error, once introduced as a new metaphor for understandingdelusion, had now become literal. While for Locke and other originators of

the metaphor it retained its as if quality (e.g., ... they [madmen] err asmen do that argue right from wrong principles... (:209, italics added)9), forthe later users this quality was lost.The twentieth century, as Berrios notes,2 contributed little to our

understanding of delusion. The current formulation of delusion in English-speaking psychiatry is almost totally based on the teachings of the Heidelbergpsychopathologists, and most importantly, Karl Jaspers. Drawing on thework of Griesinger and other German-speaking psychiatrists, Jaspers introducedthe three defining characteristics of delusion in modern psychiatry (i.e.,

erroneousness, firm conviction and imperviousness to contrary evidence).Although Jasperss treatment of delusions in General Psychopathology is

multifaceted and subject to different interpretations,6 from a re-reading ofhis work with an eye towards the metaphors it appears that he was strugglingto disentangle the conception of delusion from the metaphor of error byintroducing a new metaphor.

1

Before his ideas are discussed, it should be noted that Jaspers had

distinguished between two groups of delusions: one arising understandablyfrom other experiences (i.e., delusion-like ideas), and another group that

arises from an un-understandable morbid process, (i.e., delusion proper).His discussion of delusions focused almost totally on delusion proper as hesaw it as the genuine or true (echte) form of the delusional experience.

Jaspers argued that it is only in external characteristics (:96)I

that

delusions appeared as erroneous ideas, firmly held and incorrigible.An

everyday error or mistaken idea is an individual experience that may be

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correctable against a non-confirming context of experience. The totalcontext of experience, however, is stable and cannot be changed. In

delusion proper, it is this context of experience that is altered. So, whilethe deluded patients faculties of perception and judgement are intact, the

perceptions convey different meanings. These new meanings are notunderstandable to us because we do not share the patients context of

experience or meaning, in other words, we cannot enter the patients world:

Delusion proper shows itself as a whole primarily in the fact that it creates anew world for the deluded person ... In psychopathology, therefore, wemust be careful not to put all incorrigible mistakes under the heading ofdelusion proper. But when faced with actual delusional worlds, we need

to think afresh about the meaning of truth.... (: 196-7, italics in original)1

Thus to disentangle delusions from the metaphor of error, Jaspers used the

metaphor of a different world, a world with its own rules of meaning andnot understandable to normal individuals. In using this metaphor, Jasperswas influenced by phenomenologist philosophers. However, the use of this

metaphor remained limited to the work of existential psychiatrists and didnot replace the metaphor of error which continues to dominate themainstream psychiatric thought to our day. Jasperss external charac-

teristics,on the other

hand,were

adopted bymodem

psychiatryas

definingcharacteristics of delusion.The definition of delusion in the fourth edition of the Diagnostic and

Statistical Manual of Mental Disorders (DSM-IV),&dquo; is typical of the modemdefinitions and clear evidence of the dominance of the error metaphor.DSM-IV defines delusion as,

A false belief based on incorrect inference about external reality that is

firmly sustained despite what almost everyone else believes and despitewhat constitutes incontrovertible and obvious proof or evidence to the

contrary. (:765)&dquo;The falseness characteristic in this definition has been subject to criticism

by several modern authors. 18,19Their criticisms are curiously similar to the

nineteenth-century attempts to distinguish between delusions and commonerrors as discussed earlier. Those early attempts and these modern criticismscan be understood as reactions to the restricting nature of a metaphor turnedliteral.

Impact on research

Metaphors not only shape our definition and understanding of phenomena,but also guide the way for acquiring further knowledge about these

phenomena, in other words, they act as heuristics. As Lear -y4 argues,acquisition of new knowledge is always based on the forward reach of

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metaphorical or analogical perception and thought (:26). The impactof the metaphor of error on research into the cognitive foundations of

delusion is a clear example of the influence of metaphoron the acquisition of

new knowledge.A syllogistic model for common errors in judgement would attribute these

errors either to mistaken premises or to mistaken conclusions from correct

premises, i.e., defective reasoning. Modern research into the cognitiveprocesses of delusion formation has followed the same two general lines. One

group of researchers attributes delusions to abnormal perceptions or

premises,20 and another group to defects in reasoning or reaching incorrectconclusions from correct premises. 21, 22

Followers of the abnormal perception view argue that delusion arises asan explanation for anomalous experiences such as undiagnosed sensorydefects. However, the thinking is not aberrant. These same anomalous

perceptions can cause delusions in normals as well as in the mentally ill. 20This view is very similar to John Lockes in the seventeenth century as

quoted earlier.Followers of the defective reasoning view argue that delusions arise

because of defects in inferential thinking,&dquo; cognitive systems23 or internalmonitors .2Although not completely denying the possible role of aberrant

perceptions in some cases of delusion, 22 these authors generally hold thaterrors in thinking (or an equivalent higher cognitive function) are the

necessary and sufficient cause for delusion formation. This is very similar to

the views of some classical physicians who saw insanity as the corruption ofreason. This view was revived in modern times by von Domarus5 whoattributed delusional ideas to errors in syllogistic reasoning.

Impact on treatment

The development of Moral Treatment in late eighteenth and early nineteenthcenturies was partly based on the view that delusions are errors limited toonly a part of the patients mental life. Capitalizing on the remaining normalfaculties, the adherents to this form of treatment sought to correct the errors.The emergence of cognitive models for delusion in modern times has

similarly led to a renewed interest in treatment of delusions by psychologicaland behavioural measures. Beginning with the pioneering work of Beck etal., 26 several groups of therapists have made attempts to correct thedelusional beliefs of patients by confrontation, reasoning, or discussing other

possible interpretations for events. 27,28Earlier psychoanalytic therapists who had dealt with psychotic patients had

regarded delusion as motivated self-deception and, therefore, sought touncover the motives rather than remove the symptom. For the cognitivetherapists, on the other hand, delusion can be a focus of treatment by itself asit is the principle of correcting an error that guides their practices.

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Other

metaphorsSo far we have discussed the metaphor of error as if it was the uncontested

single metaphor guiding the understanding of delusion through the past twoor three centuries. This simply is not the case. Other metaphors such as

belief, dream and self-deception have dominated the discourse of delusion inthe work of some authors or in certain periods either alone or in conjunctionwith the metaphor of error.A brief discussion of these alternative metaphorsmay help to put the error metaphor in perspective.The view that delusions are beliefs was first formulated during the

nineteenth century. and was a consequence of what Berrios has called aconceptual divorce between knowledge and belief:

... during the nineteenth century, knowledge and belief followed

diverging paths. Knowledge became entrained to scientific certainty, andhence required redefinition in terms of newly found evidential canons;belief, on the other hand, became subjectivised, and redefined in terms of

probabilistic knowledge and mental attitudes. (:10)

This duality is prominent in Kraepelins29 view of delusion which is

completelybased on the

metaphorof belief. He

arguedthat there are two

sources of knowledge for humans: experience and faith. The common errorsof daily life are in the domain of experiential knowledge and, therefore, are

easily corrected by experience and rational reflection. On the other hand,delusions do not arise from experience or reflection, but from faith because

they are impervious to correction by arguments (:116).9However, for other psychiatrists the metaphor of belief was used in

conjunction with the metaphor of error, putting delusions in the order of

superstitious beliefs. Jasperss statement quoted at the beginning of this paper

is a clear example of this particular combination of metaphors.

1

The metaphor of dream as applied to delusion in particular and to insanityin general has a long history going back at least to ancient Greece and to

Aristotle who saw a common origin for dreams and symptoms of madness. 30This metaphor again reappeared during the seventeenth century. Foucaultnotes that the quasi-oneiric character of madness is one of the constantthemes in the classical [i.e., seventeenth century] period (:101). Foucaultalso describes in some detail the correspondence drawn between the different

stages of sleep and the different forms of madness by the seventeenth-century

physician Zacchias. In modem times this idea was forcefully advocated byCarl Jung3 who stated that insanity was a dream that had replacednormal consciousness, and emphasized that this statement was no metaphorand had to be taken literally. In this view, Jung was influenced by the psycho-analytic teachings that saw, in both dreams and delusions, forms of

self-deception.

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The psychoanalytic view of delusion is heavily based on Freudsinterpretation of delusions of one patient: Daniel Paul Schreber.32 Freudviewed Schrebers delusions as homosexual wishes that had been distortedand projected in order not to be owned.Along the same lines, Feniche133viewed delusions as warded-off instinctual wishes as well as threats from the

superego (:436). Sullivan,34 Cameron35 and in recent years Benta1l36 haveused similar concepts in their formulations of delusion. Common to the

views of these theoreticians is the metaphor of self-deception, which implies acertain wilfulness, motive or intention. Like everyday self-deception,delusions serve a function for the patient - they are restitutional processes.They also contain a meaning which reveals, in analysis, an historical

kernel.33 No such purposefulness and meaning was implied in the metaphorerror.

Belief, dream and self-deception have been some of the most popular metaphorsfor delusion through the years; however, they are not the only ones. Otherdisciplines of human knowledge have contributed new metaphors for delusionin the more recent years. For instance, Manfred Spitzer37 has used a neuralnetworks metaphor to explain acute and chronic delusions.According tohim, acute delusions result from a change in the signal-to-noise ratio in theactivation of cognitive neural networks. This, in turn, results in the tendencyto attach significance and meaning to an ordinary, insignificant event. In theabsence of self-critical judgement, the meaning attached to this insignificantevent becomes the focus around which the acute delusion establishes itself.

The persistence of these acute delusions leads to the enlargement of thefunctional area in the cortex (representational map) coding for the delusional

system and, hence, to the development of chronic delusions.&dquo;As another example, Sass38, 39 found the concept of solipsism as expounded

in the work of theAustrian philosopher Ludwig Wittgenstein an enlighteningmetaphor for delusion:

Wittgensteins likening of traditional, metaphysical philosophy to madnessis more than just a striking metaphor: many of the pathological tendenciesof mind, the diseases of intellect, which he diagnoses in his favorite

examples of philosophical illusion turn out to correspond with uncannyprecision to the experiences of such insane persons ... Not only do I

dispute the notion that schizophrenic delusions manifest poor reality-testing, I also argue that the mode of consciousness in which thesedelusions are typically embedded is not, in its essence, truly primitive. In

my view, the experience of many schizophrenic patients involves not an

overwhelming by, but a detachment from, normal forms of emotion anddesire, not a loss but an exacerbation of various forms of self-consciousawareness. (:9-12)38

Elsewhere, Sass39 has invoked modernism and the artistic, literary and

philosophical attitudes associated with it as metaphors for insanity in generaland delusion in particular.

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Conclusion

Metaphors are means of perceiving, comprehending and accordingly dealingwith the world. In this respect metaphors are like conceptual lenses or filters.Insofar as they provide a window for perceiving a new phenomenon inaccustomed ways they are like lenses, but insofar as they restrict our view tothe accustomed, they are like filters. In this sense metaphors both reveal andhide: reveal those aspects of the new phenomenon which are similar to thoseof the vehicle of the metaphor (e.g. error) and hide those aspects which arenot similar. In words of Danziger, et

A metaphorical depiction of a particular subject matter is necessarily a

partial depiction ... Out of the infinity of the possible ways of construingthe subject matter, one is picked out and given a privileged status. (:350)

For instance the metaphor of error highlights the discordance between theobjective or consensual reality and the personal knowledge of the deluded

patient. When the content of delusion is subject to objective or consensualvalidation, such as in most cases of persecutory delusion, the metaphor fitswell. But when the content of delusion is not subject to such validation, for

example such as in the use of delusions of thought insertion or thoughtwithdrawal, it does poorly. 18 Similarly, in the case of delusions that

apparently serve a defensive or wish-fulfilling function, the error metaphortends to hide more than reveal.

My aim in this paper was not to advocate the use of one metaphor overanother or to criticize the use of metaphors in the study of delusions in

general. It is unlikely that our understanding of such an uncannyphenomenon as delusion would ever be free from metaphors of one sort oranother. Rather, my aim was to examine one of these metaphors, the

metaphor of error, which has dominated our understanding of delusion forsuch a long time; to investigate its impact on our current research andtreatment attempts; and to recognize its strengths as well as its limitations.

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