Ritunnano Rosa, Kleinman Joshua, Whyte Oshodi Danniella, Michail Maria, Nelson Barnaby, Humpston Clara S, Broome Matthew R
Institute for Mental Health, School of Psychology, University of Birmingham, Birmingham, UK; Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia; Early Intervention in Psychosis Service, Coventry and Warwickshire Partnership NHS Trust, Coventry, UK.
The Ohio State University College of Medicine, Columbus, Ohio, USA.
Lancet Psychiatry. 2022 Jun;9(6):458-476. doi: 10.1016/S2215-0366(22)00104-3. Epub 2022 May 4.
Delusions are a common transdiagnostic feature of psychotic disorders, and their treatment remains suboptimal. Despite the pressing need to better understand the nature, meaning, and course of these symptoms, research into the lived experience of delusional phenomena in psychosis is scarce. Thus, we aimed to explore the lived experience and subjective apprehension of delusions in help-seeking individuals with psychosis, regardless of diagnosis and thematic content of the delusion.
In our systematic review and qualitative evidence synthesis, we searched MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science for qualitative studies published in English from database inception, with the last search on Sept 9, 2021. Grey literature search and hand-searching of relevant journals were also done. Studies were eligible if they provided an analysis of lived experience of delusions or predelusional phenomena presented from the perspective of individuals (age 14-65 years) who had developed a clinical high-risk stage of psychosis, or a diagnosable affective or non-affective psychotic disorder (as clinically defined, self-reported, or assessed within the primary study). Studies with only a subset of relevant participants were eligible only if data for the population of interest were reported separately. Studies that did not discriminate between the experience of delusion and other positive symptoms (eg, hallucinations) were included only if data for delusions were reported separately or could be extracted. First-person accounts (and author interpretations) discussing changes in the sense of self, lived world, and meaning in relation to delusions were extracted and synthesised using a novel thematic synthesis approach informed by a critical realist stance and a phenomenological theoretical framework. Analytic themes were developed into a new overarching framework for understanding the emergence of delusional phenomena. The study was registered with PROSPERO, CRD42020222104.
Of the 3265 records screened, 2115 were identified after duplicate removal. Of these, 1982 were excluded after title and abstract screening and 106 after full-text eligibility assessment. Of the 27 studies entering quality assessment, 24 eligible studies were included in the qualitative evidence synthesis, representing the perspectives of 373 help-seeking individuals with lived experience of delusions in the context of psychosis. Gender was reported as male (n=210), female (n=110), transgender (n=1), or not reported (n=52). Only 13 studies reported ethnicity, with White being predominant. The age of most participants ranged from 15 to 65 years. We found no eligible studies investigating subclinical or predelusional experiences in at-risk mental state populations through qualitative methods. Most studies were undertaken in western, educated, industrialised, rich, and democratic (WEIRD) societies, and most included participants had received or self-reported a diagnosis within the schizophrenia spectrum. Studies differed in relation to whether they focused on one kind or theme of delusion or delusional phenomena more generally as a unified category. Three superordinate themes relating to experiential changes and meanings in delusion were identified: (1) a radical rearrangement of the lived world dominated by intense emotions; (2) doubting, losing, and finding oneself again within delusional realities; and (3) searching for meaning, belonging, and coherence beyond mere dysfunction. Based on the review findings and thematic synthesis, we propose the Emergence Model of Delusion to advance understanding of delusional phenomena in psychosis.
Delusions are best understood as strongly individualised and inherently complex phenomena emerging from a dynamic interplay between interdependent subpersonal, personal, interpersonal, and sociocultural processes. Integrative approaches to research on delusion, which consider their potential adaptiveness and favour explanatory pluralism, might be advantageous. Effective clinical care for individuals with psychosis might need adapting to match more closely, and take account of, the subjective experience and meaning of delusions as they are lived through, which might also help redress power imbalances and enduring epistemic injustices in mental health.
Priestley Scholars, Wellcome Trust.
妄想是精神障碍常见的跨诊断特征，其治疗效果仍不尽人意。尽管迫切需要更好地理解这些症状的本质、意义和病程，但关于精神病中妄想现象的生活体验的研究却很少。因此，我们旨在探讨有精神病症状且寻求帮助的个体对妄想的生活体验和主观认知，无论其诊断结果和妄想的主题内容如何。
在我们的系统评价和定性证据综合分析中，我们检索了MEDLINE、Embase、PsycINFO、CINAHL和Web of Science数据库，以查找自数据库创建以来发表的英文定性研究，最后一次检索时间为2021年9月9日。我们还进行了灰色文献检索和相关期刊的手工检索。如果研究提供了对妄想或妄想前现象的生活体验的分析，且这些分析是从已发展到精神病临床高危阶段、或可诊断的情感性或非情感性精神障碍（如临床定义、自我报告或在主要研究中评估）的14至65岁个体的角度呈现的，则这些研究符合要求。只有当相关人群的数据被单独报告时，仅包含部分相关参与者的研究才符合要求。只有当妄想的数据被单独报告或可以提取时，未区分妄想体验与其他阳性症状（如幻觉）的研究才被纳入。使用一种新的主题综合方法，提取并综合了关于自我意识、生活世界和与妄想相关意义变化的第一人称叙述（以及作者解读），该方法以批判实在论立场和现象学理论框架为指导。分析主题被发展成一个新的总体框架，用于理解妄想现象的出现。该研究已在PROSPERO注册，注册号为CRD42020222104。
在筛选的3265条记录中，去除重复记录后有2115条被识别。其中，经过标题和摘要筛选后排除了1982条，经过全文合格性评估后排除了106条。在进入质量评估的27项研究中，24项符合要求的研究被纳入定性证据综合分析，代表了373名有精神病症状且寻求帮助的个体对妄想的生活体验的观点。报告的性别为男性（n = 210）、女性（n = 110）、跨性别者（n = 1）或未报告（n = 52）。只有13项研究报告了种族，其中白人占主导。大多数参与者的年龄在15至65岁之间。我们没有找到通过定性方法研究处于高危精神状态人群的亚临床或妄想前体验的合格研究。大多数研究是在西方、受过教育、工业化、富裕和民主（WEIRD）的社会中进行的，大多数纳入的参与者在精神分裂症谱系内接受过诊断或自我报告有诊断。研究在是关注一种类型或主题的妄想，还是更普遍地将妄想现象作为一个统一类别上存在差异。确定了与妄想中的体验变化和意义相关的三个上级主题：（1）由强烈情感主导的生活世界的彻底重新排列；（2）在妄想现实中怀疑、迷失和重新找到自我；（3）在单纯功能障碍之外寻找意义、归属感和连贯性。基于综述结果和主题综合分析，我们提出了妄想出现模型，以促进对精神病中妄想现象的理解。
妄想最好被理解为从相互依存的亚个人、个人、人际和社会文化过程之间的动态相互作用中产生的高度个体化且本质上复杂的现象。综合研究妄想的方法，考虑到它们的潜在适应性并支持解释多元主义，可能是有益的。对患有精神病个体的有效临床护理可能需要更紧密地适应并考虑妄想的主观体验和意义，因为它们是实际经历的，这也可能有助于纠正心理健康中的权力不平衡和长期存在的认知不公正。
普里斯特利学者奖、惠康信托基金会
