Understanding, treating, and renaming grandiose delusions: A qualitative study

Abstract

Background Grandiose delusions are arguably the most neglected psychotic experience in research. Objectives We aimed to discover from patients: whether grandiose delusions have harmful consequences; the psychological mechanisms that maintain them; and what help patients may want from clinical services. Design A qualitative interview design was used to explore patients’ experiences of grandiose delusions. Method Fifteen patients with past or present experiences of grandiose delusions who were attending psychiatric services were interviewed. Thematic analysis and grounded theory were used to analyse the data. Results Participants reported physical, sexual, social, occupational, and emotional harms from grandiose delusions. All patients described the grandiose belief as highly meaningful: it provided a sense of purpose, belonging, or self‐identity, or it made sense of unusual or difficult events. The meaning from the belief was not synonymous with extreme superiority or arrogance. The meaning obtained appeared to be a key driver of the persistence of the beliefs. Other maintenance factors were subjectively anomalous experiences (e.g., voices), symptoms of mania, fantasy elaboration, reasoning biases, and immersive behaviours. Participants described insufficient opportunities to talk about their grandiose beliefs and related experiences and were generally positive about the possibility of a psychological therapy. Conclusions We conclude that grandiosity is a psychologically rich experience, with a number of maintenance factors that may be amenable to a targeted psychological intervention. Importantly, the term ‘grandiose delusion’ is an imprecise description of the experience; we suggest ‘delusions of exceptionality’ may be a credible alternative. Practitioner points Harm from grandiose delusions can occur across multiple domains (including physical, sexual, social, occupational, and emotional) and practitioners should assess accordingly. However, grandiose delusions are experienced by patients as highly meaningful: they provide a sense of purpose, belonging, or self‐identity, or make sense of unusual or difficult events. Possible psychological maintenance mechanisms that could be a target for intervention include the meaning of the belief, anomalous experiences, mania, fantasy elaboration, reasoning biases, and immersive behaviours. Patients are keen to have the opportunity to access talking therapies for this experience. Taking extra time to talk at times of distress, ‘going the extra mile’, and listening carefully can help to facilitate trust.

Paranoia and Grandiosity in the General Population: Differential Associations With Putative Causal Factors

“…These findings are also interesting in light of a recent qualitative study of grandiose delusions, which identified a number of potential maintenance factors in the experience of grandiosity: meaning-making, anomalous experiences, mania, fantasy elaboration, reasoning biases, and immersive behaviors (28). We note some overlap with maintenance factors of paranoia-for instance sleep disturbances are characteristic of mania, and negative self-beliefs may motivate meaningmaking-which are in line with our findings of significant (but relatively less robust) associations between grandiosity, sleep and negative self-beliefs in the current sample; yet the cognitive-behavioral model is relatively distinct from that of paranoia.…”

“…Although seemingly counter-intuitive, the "delusion as defense" model suggests that grandiose beliefs serve to protect feelings of worthlessness and vulnerability (27). Furthermore, insomnia is commonly reported as a precursor to the development of grandiose beliefs (28). While theoretically compelling, the contribution of worry, negative self-beliefs, and sleep quality to grandiosity requires continued study (22).…”

Understanding young peoples’ and family members’ views of treatment for first episode psychosis in a randomised controlled trial (MAPS)

“…This might be achieved by ordering the delivery of interventions in line with individual outcome priorities and preferences. Researchers are increasingly exploring the value of targeting treatments to specific difficulties based on patient preference [ 26 , 27 ], and future qualitative research can enhance this approach by exploring and informing treatment for specific aspects of psychosis [28] .…”

Derationalizing Delusions

“…That delusions commonly involve a belief of having a radically altered social status (e.g., C. Green et al, 2006 ; Isham et al, 2019 ) and that, independently, social exclusion and social distance are risk factors for psychosis ( Jongsma et al, 2020 ) suggest that cognitive mechanisms involved in the perception and processing of social status may be an important site of pathology. Processes involved in perceiving and managing social status are common across a range of social species, including humans; have an evolutionarily important social function ( Chiao, 2010 ); and do not seem to be explainable solely in terms of mentalization ( Rushworth et al, 2013 ).…”