Delusions are among the most curious facets of psychosis. They can be as frustrating for clinicians treating them as it is for patients trying to make sense of them. Delusions almost always crop without the benefit of any context. Where do they come from? Why do they appear the way they do? And maybe, most importantly, how do they feel from the inside?
A new study in The Lancet Psychiatry makes the case that this misses the point. Drawing on in-depth interviews with people experiencing first-episode psychosis in the United Kingdom, researchers found that delusions emerge not as isolated beliefs but as emotionally grounded, embodied experiences. Early life events, interpersonal relationships, and the ways people cope with overwhelming feelings shape these experiences.
Led by psychiatrist Rosa Ritunnano of the University of Birmingham, the study integrates three distinct lenses:
- Standard clinical assessment of delusional themes,
- Phenomenological analysis of how patients experience the world, and
- Narrative interviews that organize those experiences within a person’s life story.
What the team uncovered appears to be one of the most detailed portraits yet of how delusions form, evolve, and latch on in the earliest stages of psychosis.
Delusions Don’t Fly Solo
The authors conducted nearly three dozen interview sessions with 10 adults receiving care from Early Intervention in Psychosis services. All of them confessed to clinically significant delusions, either active or in remission. None of them included a single, standalone delusional theme.
Instead, persecutory, referential, and grandiose or religious ideas clustered together. Every participant reported persecutory delusions. And nearly all of them also experienced beliefs involving special messages, heightened significance, or divine purpose.
The authors argue that these overlapping themes reflect deeper shifts in how individuals experience themselves and other people. They also point to changes in how people experience reality itself, as opposed to distinct diagnostic categories.
Using the Examination of Anomalous World Experience, the researchers discovered that all of the participants described broad changes in how the world felt. Space, time, social interactions, mood, and existential meaning all shifted (to varying degrees) creating what the authors explain as a “global transformation” of lived experience.
Delusion’s Long Shadow
One of the study’s central findings is the role of early emotional experiences – shame, in particular – in shaping delusions. Many of the participants recounted childhood or adolescent experiences marred by bullying, rejection, abuse, or incessant notions of being watched, judged, or controlled.
And those emotions didn’t go away. Rather, they appeared to coalesce into enduring emotional patterns that came roaring back years later during times of stress or upheaval, whether it’s a breakdown in a relationship, a lost job, or social isolation. When those old feelings resurface without a clear cause, participants were desperate for an explanation.
Delusions, the authors suggest, can arise as a way to pin down the source of overwhelming bodily and emotional sensations. In this view, a belief that you’re under surveillance (or being persecuted) isn’t a logical fallacy. It’s an emotionally coherent response to a perceived threat.
“We all use metaphors and narratives to understand our experiences and make sense of our lives. But psychosis patients do so more intensely,” Birmingham Professor of Linguistics and Communication and co-author Jeannette Littlemore said in a statement. “As a result of having endured strong (often negative) emotional experiences, which are then responded to by the body, and shaped by everyday language use, people experiencing psychotic delusions really are living in metaphor. People may feel delighted and say they are so happy they can ‘touch the sky’; this could lead them to experience the delusion of thinking they can fly.”
Three Emotional Worlds
Regardless of the narrative, the researchers identified three recurring experiential patterns.
In the first, driven by shame, the self feels exposed and vulnerable. Others appear hostile, critical, or intrusive. The body itself might feel “transparent,” as if thoughts and intentions are visible to everyone. Participants reported delusions of persecution, mind-reading, or guilt in this emotional landscape.
In the second scenario, participants described a swing toward meaning, connection, and purpose. Feelings of emptiness or despair yielded to intense emotions such as love, awe, and hope. Spiritual narratives sometimes fueled these. Here, delusions took the form of divine missions, special status, or cosmic significance. These experiences can feel uplifting – at first.
The final pattern involved a disconnect. Some participants discussed feeling numb, or detached from their bodies and other people. They talked as if life were a simulation or even a staged performance. It was during these moments when the world appeared to them as hollow and artificial. And their relationships felt distant or fake.
But the researchers also noted that the participants usually shifted between states. Substance use, sleep disruption, and social stress could intensify or dampen different emotional modes, reshaping delusional content in the process.
Reconsidering Treatment
The study challenges the prevalent cognitive models that describe delusions as a fractured reality that clinicians must put back together. Instead, the authors argue that these delusions remain anchored in emotional and bodily experiences that can persist even when the belief itself is questioned or weakened.
That insight offers practical implications. Effective assessment and treatment, the authors argue, should pay closer attention to patients’ emotional histories, bodily sensations, and the language they use to describe their experiences. Therapeutic approaches that help regulate emotion, rebuild a sense of safety, and address long-standing shame or disconnection might be just as critical as challenging the beliefs themselves.
As it turns out, delusions might not be about losing touch with reality after all. They might just be our mind’s way of trying to make some sense of it.
Further Reading
Somatic Delusions: An Approach to Diagnosis and Treatment
