PI Brief Update

Where do delusions come from? - Dr Mark Burgin

24/03/25. Dr Mark Burgin explains how to recognise that a client may require a disability report to comply with SRA codes of conduct and the Equality Act 2010.

Delusions are false beliefs that are firmly held despite evidence to the contrary. They can be a symptom of several mental health conditions, including schizophrenia, delusional disorder and bipolar disorder. However, many people hold delusional type beliefs without mental illness. Understanding where these beliefs come from may help explain why we have delusions.

There are three basic types of delusion based upon clinical presentation. They share a feeling of urgency that is often inconsistent with the belief. Even if they are true the response is disproportionate to the apparent threat. The person will usually describe and manifest agitation. Reassurance will have no effect or will worsen their agitation.

Overvalued thoughts have similar features but the person can accept that they might be wrong. Delusions are not just irrational they are held irrationally, the person cannot accept that they could be wrong. Delusions have become part of the person’s identity and any attempt to explore the delusion is treated as an attack of the person themselves.

Classical Delusion

The first is a classical delusion which shares similarities with fake news as the ideas are often bizarre. The person has a single core belief that other thoughts are based upon. The interconnected nature of the belief can be difficult to follow but generally is superficially believable. To understand the classic delusion the therapist must consider how it helps the person’s identity.

It may give them a sense of importance or grandiosity if they are the only person to have found the truth. They may give them a purpose in life to share the message or to investigate the problem. This may be as part of a legal process or collections of evidence that they study for hours each day. The focus on the belief can be obsessional in nature and they are often agitated when they are not investigating the belief.

Human Rights

The second is an emotional reaction with a word salad of catch phrases which give the impression that some right has been injured or an injustice has occurred. Their reasoning is confused and internally inconsistent and lacks coherence. They will ask for help to fight whoever they blame but make personal attacks and are intolerant if asked questions.

The key sign is that there is a strong assertion but it is not supported by evidence. This focus on how the person feels and their opinions can be initially engaging. To the person listening the description makes complete sense but a transcript shows logical gaps. The fluency of speech is inconsistent with the lack of rational flow of ideas. They often involve complex and convoluted narratives with emotional outbursts. There are also internal inconsistencies which mean that any points that are made are lost.

Persecutory

The third is persecutory where they believe other people are actively trying to do them harm. This paranoia is usually associated with agitation and they may focus on an individual. It often starts when the person has lost their sense of self due to a crisis and had difficult interactions with authorities. They may be reluctant to share their difficulties unless asked directly.

Their behaviour is often defensive, they may live in their bedroom and use a mask when they are outside. Some will create a fortress in their house with traps or heavy duty doors to make entry difficult. As it can be difficult to recognise that they are becoming agitated there is a risk that they will react in an inappropriate way and get into trouble. Some will have weapons and feel that they must attack if they feel threatened.

Conclusions

Delusions are a defence response to identity breakdown and become part of the person’s identity. The belief is unshakable and this can be tested by asking whether they could possibly be wrong. As anyone can make a mistake it is abnormal to have no doubt. The greater the proportion of the day that the person spends on the belief the more likely that it is a problem.

Where there is a strong family history, drug misuse or brain injuries then a psychiatric diagnosis is more likely. A prompt response to antipsychotics, Lithium and mood stabilisers makes an illness more likely as the cause. Other patterns such as associated depression or anxiety do not predict whether there is a disease present.

A common error is to see all delusions as psychosis however most people with delusions are not psychotic. It is common to have beliefs that are defended because they are part of the person’s identity. As the disability does not reduce with antipsychotics it is better to focus on the underlying identity issues.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is a Disability Analyst and is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 01226 761937 websites drmarkburgin.co.uk and gecko-alligator-babx.squarespace.com

Disability Analysis: A Practical Guide by Mark Burgin | 18 Oct 2024

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

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