Delusion as embodied emotion: a qualitatively-driven, multimethod study in first-episode psychosis in the UK

Background: Delusions in psychosis involve complex and dynamic experiential, affective, cognitive, behavioural and interpersonal alterations. Their pattern of emergence during the early stages of illness remains poorly understood, and the origin of their thematic content unclear. Phenomenological accounts have emphasised alterations of selfhood and reality experience in delusion formation but have failed to attend to the role of life events and other contextual factors in the development of these disturbances. This study aimed to investigate the relationship between self-experience and the lived world in first-episode psychosis (FEP) by situating the phenomenological analysis of delusional experiences in the context of the person’s life narrative. <br/><br/>Methods: In this qualitatively driven study, we recruited individuals with lived experience of delusions receiving care from three Early Intervention in Psychosis (EIP) teams in the UK. A diverse group of young lived experience experts was involved in the development of the study design and protocol. Inclusion criteria were: being treated within an EIP service; either past or current experience of clinically significant delusions assessed by the attending psychiatrist to be at least of moderate severity; aged between 18 years and 65 years; willing and able to give informed consent and able to undertake interviews in English. Exclusion criteria were: psychotic disorder solely related to substance intoxication or withdrawal; any known neurological or neurodegenerative disorders or intellectual disability interfering with the capacity for consent. We used a novel multi-perspectival design to investigate delusions across three analytical standpoints: standard clinical psychopathology (3rd-person), phenomenological psychopathology (a top-down approach to eliciting 1st-person data) and narrative enquiry (a bottom-up approach to eliciting 1st-person data). Delusion content was classified based on the definitions provided by the Scale for the Assessment of Positive Symptoms (SAPS). Participants completed standardised psychometric scales, and a series of narrative (ad-hoc Life Story Interview, LSI) and phenomenological interviews (Examination of Anomalous World Experience, EAWE). The integration of findings proceeded through meta-inference across analytical frameworks. <br/><br/>Findings: Between January 4, 2023, and June 14, 2023, 33 interview sessions in total were completed with 10 adults with FEP and lived experience of delusions (3 men, 6 women, 1 non-binary, aged 19-33). The 3 most common delusion themes were: persecutory (100%), reference (90%), grandiose and/or religious (90%). No theme occurred in isolation. The phenomenological component of the analysis revealed a global, qualitative, shift in the subjective experience of the lived world, with total EAWE scores ranging from 13 to 48 (average of items endorsed=26.5 ± 10.85). Especially common EAWE items included: Disturbances involving veridicality of auditory perceptions (100%), Sense of inferiority, criticism or mistrust in relation to others (100%), Feeling of being special or superior (90%). The first narrative theme highlighted the role of early and repeated negative interpersonal emotions (especially shame) and subsequent experiential avoidance or immersion and absorption, for understanding the embodied phenomenology of delusions emerging in later life. The second narrative theme revealed three main patterns of emotional transformation of the world and the self: 1) Being under the spotlight: from embodied shame to almighty invincibility; 2) Being part of something bigger: from meaninglessness and absence to embodied love, awe and hope; 3) Being in a simulation: life without a body, cut off from others. <br/><br/>Interpretation: Situated In the context of the person’s life, the emergence and evolution of delusions reflected a temporally-extended, embodied and cognitive-linguistic process characterised by an emotional transformation of the self and the world as a unified conscious experience. Metonymic thinking and language linked to contiguous bodily experiences appeared to explain some of the apparently un-understandable or extreme delusional appraisals of self and world — for example, the idea of being a “paedophile” or “bad person” in shame (to be “caught” or “killed” by hostile others), or of being “connected to God” in love and awe. Prevention and intervention models for psychosis should consider the significant role of the lived body for the regulation of emotions, as well as the effect of the surrounding material and social environment as central affective-regulatory mechanisms, and potential targets for intervention and support. <br/>