Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022.

CHAPTER 4

DELUSIONS AND DELUSIONAL DISORDER

Delusions are false beliefs which continue to be held in spite evidence to the contrary
(they are not held by the general public, or any sub-group of the community).

Delusions occur in various mental disorders - schizophrenia, bipolar disorder (manic or

depressed phases), major depressive disorder, substance abuse and major neurocognitive
disorders. In these disorders, delusions are accompanied by other signs and symptoms –
and the combination provides the diagnosis.

Delusional disorder is the exception - in this disorder, delusions are the only symptoms
present.

Until recently, delusions were thought to be absolutes – like pregnancy - the individual
either had a delusion or did not. However, categories such as “sub-threshold delusions”
have been suggested (DeVylder, 2018, 2019). These categories have not entered clinical
practice and are mentioned for interest/entertainment.

Anorexia nervosa - There is a strange reluctance to use the term ‘delusion’ in connection
to anorexia nervosa. Instead the words used (about beliefs about being fat and gaining
weight) have been termed “beliefs of delusional proportions” (Steinglass et al, 2007) and
“beliefs of delusional intensity” (de Young et al, 2021). This is semantic nonsense – if
beliefs satisfy the definition of delusions, they should be identified as such. Steinglass et
al (2007) found delusions in 20% and De Young found delusion in 18% (and “poor
insight” in another 34%) of people with anorexia nervosa.

Body dysmorphic disorder (BDD) is another disorder in which there has been
reluctance to apply the term delusion. Body dysmorphic disorder is marked by
preoccupation with “one or more perceived defects in physical appearance”, which are
non-existent or mild. ‘Corrective surgery’ and other medical treatments may be pursued
(James et al, 2019). In DSM5 this condition is listed under Obsessive-Compulsive and
Related Disorders – When the belief is held with delusional intensity the qualification
“without insight” is added to the diagnosis (Rossell, et al, 2019).

Rautio et al (2022) studied a large group of children and adolescents and reported that
more than 50% displayed “absent insight/delusional beliefs”.
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 2

Disorders which feature delusions include the following

Mental Disorder Comment

Delusional Disorder Delusions only. No other prominent additional symptoms.
Usually involve some form of persecution.
Schizophrenia Delusions may take many forms – including persecutory
and bizarre. Are accompanied by at least some other
symptoms such as hallucinations, problems with logical
thought or self-neglect.
Bipolar Disorder (mania) Delusions associated with undue confidence, elation and
overactivity, rapid speech. Often grandiose plans to make a
fortune or establish world peace.
“depression” Uncommon. Delusions consistent with low mood.
(Major Depressive Disorder Contents may include terminal illness, loss of assets or
Bipolar depressed phase) unfounded guilt.
Substance Abuse Disorder Particularly amphetamines. 13.2% of methamphetamine
dependent individuals (Salo, et al, 2011). Usually
persecutory.
Organic Mental Disorder Variable presentations depending on the pathology. 10%
of people with Parkinson disease (Mack et al. 2011). Half
of all patients with Dementia with Lewy Bodies have
delusions (Tzeng et al, 2018).
Table. Delusions can occur in a range of mental disorders. A diagnosis is only possible
after consideration of the complete clinical picture.

Categories of delusions

Delusions are categorized in various ways. The following are not mutually exclusive
categories; for example, a delusion may be both bizarre and systematized.

Bizarre delusions are absurd and factually not possible. They may involve newly
discovered gods or supernatural/space creatures.
Grandiose delusions are beliefs that the individual has exceptional beauty, intelligence
or influence.
Persecutory (or paranoid) delusions include that the individual is being harassed,
threatened, watched or bugged. They often involve spies, bikies, God, Satan or
neighbours.
Delusions of reference are the belief that the everyday actions of others are premeditated
and made with special reference to the patient. Commonly patients complain about being
talked about on television or the radio. Patients may believe that music played, or words
spoken on television have been specifically chosen to identify or annoy them. People
crossing the street or coughing may be interpreted as making purposeful actions,
performed to indicate something to, or about, the patient.
Delusions of control involve the belief that others are controlling the patient’s thoughts,
feelings or actions.
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 3

Nihilistic delusions are the belief that part of the individual or the external world does
not exist, or that the individual is dead (Cotard syndrome). Financially comfortable
individuals may believe they are destitute, in spite of bank statements to the contrary.
Patients who believe they have no head or are dead, are unable to explain how that could
be possible, but still hold the belief.
Somatic delusions are false beliefs about the body. These may be bizarre or non-bizarre.
A bizarre example is when the individual believes his nose is made of gold. A non-
bizarre example is when the individual believes he has cancer of the rectum, in spite of
negative reports from a competent doctor who has examined the rectum.
Somatoparaphrenia is a delusion that a limb or side of the body does not belong to the
person to the person to whom it is attached – it is frequently argued that it belongs to
another person (Neven & Blom, 2021). (This is different to anosognosia – which is
usually associated with neurological disorder – and has a disability, but is unable to
recognize that fact.)
Delusions of infestation/parasitosis are not uncommon in dermatological clinics (Reich
et al, 2019; Ansari & Bragg, 2021).
Delusions of guilt - that the individual is guilty of purposefully or non-purposefully
damaging themselves, other individuals or important property. Individuals may believe
they are guilty of causing the cancer of the lady next door, or a drought in Africa.
Delusional jealousy - the belief that the partner is being unfaithful - this may involve
checking the partner’s underclothes for stains or foreign pubic hairs.
Erotic delusions (erotomania) - the patient holds the belief that another person is in love
with him/her (de Clerambault syndrome, see later). This (among others) may be a
motivation for stalking, and lead to contact with the unwelcoming central figure of the
delusion.

Systematized delusions are united by a single theme. They are often highly detailed and
may remain unchanged for years.
Non-systematized delusions may change in content and level of concern, from day to
day or even from minute to minute.
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 4

Chain Letter PUBLIC NOTICE Time For True Colours

By Order of the King
Please note: If I was crazy I would have been locked up by now
WARNING: YOU ARE GOING TO LIVE FOREVER (Z provides absolute proof)
There is a hell of a lot to the saga but some of the more interesting points
of the WAR so far include my entire body verging on combustion, my brain being
physically altered to the point where it is in tune with the entire universe (but it’s
still me) including God, Satan and all living things, and flying fully conscious in
the flesh (100% link).
Be Aware: You are all in the hands of the gods. Magic is compulsory. Have a
magic day.
‘Tis a fantastic tale vouched for by the fact that Bad Bill and is army of
darkness are too scared to touch or even talk to me when I’ve told the whole
world that they’ve done and where they’re going is no fun but my hands are
clean. The entire planet is coated with agents of Satan, they hate me just
because I’ve told them the truth. Hotspur himself still tried it on occasionally but
he knows he’s lost. (God and Tom incorporated)…
Illustration. The above “public notice” was part of a one-page document widely
distributed throughout an Australian capital city by its writer. The full document is not
presented because the second half made accusations against named people. The writer
believed the owners of a coffee lounge were persecuting him. One night he burned the
business down. He was jailed and died in prison, by suicide, days later. Prominent
pathological features were the bizarre and persecutory delusional material, and that while
disorder of the form of thought (loss of logical connections) made the delusion difficult to
follow, message remain relatively unchanged throughout.

14.
After about six months off the injecti ons the belief t hat
some tragedy was imminent and pressure from other people
had overtaken me. I was worried. I believed Ellen and
Kerry had been backbiting. This hurt me. I went to
Ellen's y outh group where the Minister, Rev. Anonymous,
po l itely called me Peter (the Apostle) and said tha t I
belonged in prison.

Illustration. This is a passage from a “biography” written by a man who subsequently

drowned himself. The injections referred to are injections of long-lasting antipsychotic
medication. These “depot” medications help prevent relapse in psychotic disorders and
can be given once every few weeks. After this man had ceased his injections for six
months and his body was completely free of antipsychotic medication, he began to
misinterpret the environment in a persecutory manner. He believed his friends had been
“backbiting” and that a church leader (whose name has been replaced with
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 5

“Anonymous”) said that he should be in prison. The writer’s name was not Peter, but
another biblical name. It is reasonable to conclude that the clergyman used the name
‘Peter’ by mistake, the patient failed to recognize the mistake, and concluded instead, that
this misuse was purposeful. Another possibility is that the patient was hallucinating when
he heard the name ‘Peter’ and the comment that he (the patient) should be in prison.

Dear Sir,
I have sent you a data CD containing information regarding the use of implant
technology by the agencies of the CIA and the SIS. Both these agencies are involved
in the theft of millions of dollars from the international banking system. The implants
can also be used to make there host commit suicide and have been used in the murders
of many Prominent public figures, including Princess of Wales Diana Spencer, Dr
David Kelly and many others. In the case of Dr David Kelly the implant was used to
murder the host itself, but in the case of the Princess of Wales, Bali bombings,
September 11 and the Egyptian Airlines crash the implants were used to indirectly
murder people by being placed into the heads and mouths of the pilots and driver and
in tum make them commit suicide.
I was implanted in Dallas Texas in 1999 and have since survived a suicide and many
murder attempts. Please read the CD, it is not well set out as I have poor grammar
skills but with a little perseverance you will obtain the knowledge to protect yourself
and others from what l can only describe as a horror almost beyond imagination. I
have set out a list of the files and it is of some importance to read them in this order to
best comprehend the information.

OPERATIONS MOOITORING CENTRE

GPO 80>:: 485G ~ VIC 3001

Te6eph0ne 03 96077303 F,e:siml o 03 '96077390
Email [email protected]
~81'rJ':·~-~
Our Ref: 3417034

IDENT ITY R E MOVED

OLD

Matters vital to Internal Se curity

I refer to your correspondence received by the Melboume Office on 29 May 2006. regarding lhe
above-mentioned mauer.

The Australian Federal Police (AFP) has the primary law enforcement responsibility for
investigating criminal offences against Commonwealth laws.

An evaluation of the information you have provided to the AFP indicates that no Commonwealth
offence has occurred. The AFP is unable to assist you with your complaint.

Your correspondence has been placed on file,

IDE NT ITY REMOVED

COORDINATOR
OPERATIONS MONITORING CENTRE
MELBOURNE OFFICE
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 6

Illustration. The two documents above, along with a CD of other documents, were mailed
to many neurosurgeons and psychiatrists at leading hospitals around Australia. The writer
provided full contact details and welcomed any response. He believed that an implant
was placed in his head by the CIA in 1999 and it had caused him to attempt suicide. He
attributed various events over the years (Deaths of Princess Diana, Dr David Kelly, and
others) to the same process. These beliefs have the hallmarks of a detailed delusional
system which may have been present for some years. The second letter is a response to
this individual from the Australian Federal Police. He had written to them regarding his
beliefs, and they responded stating they were unable to help with his complaint.

Named delusions

This section is added for completeness. Mention is made of some delusions which get
quite a bit of attention in some books, because they are exotic and interesting. However,
they are rare and are managed in the same as other delusion. Thus, they do not warrant
much space or time. They do provide a fascinating window into psychosis.

Capgras syndrome is the delusion that a person (usually a family member or someone
close to the patient) has been replaced by an impostor of nearly identical appearance.
This most commonly occurs in schizophrenia and organic brain disease (Jain & Wadhwa,
2022).

de Fregoli syndrome is the delusion that a person (usually a suspected tormentor) can
change into different people, and many of the people the patient meets are misidentified
as transformed version of the suspected person.

Capgras and De Fregoli syndromes may be related. The issue may be whether the person
who is misidentified is known or unknown to the patient.

Folie a deux (shared psychotic disorder) is diagnosed when two people share the same
delusion (Bhutani & Huremovic, 2021). Usually one of these people is psychotic and the
second is not psychotic - but the non-psychotic person has come to accept what the
psychotic person believes. It is common for the psychotic person to have been of high
intelligence and authoritative, and for the non-psychotic individual to be somewhat
dependant. The psychotic person should be managed in the normal manner. When
removed from the influence of the psychotic person, the non-psychotic individual rapidly
gains “insight”.

Cotard syndrome is the nihilistic (denying the existence) syndrome. It is rare in some
forms, such as, when a psychotic person believes their head has been removed. The most
common form may be when a person with psychotic depression believe they are dead (a
way of non- existence).
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 7

de Clerambault syndrome is the delusion (usually held by a middle-aged single women,

but not exclusively so) that another person (usually an important person) is in love with
the them. The ‘victim’ is usually unknown to the patient. The syndrome may lead to
phone calls, unwanted letters, and other attention (Sampogna et al, 2020).

A leading, charismatic surgeon [now deceased] of Hobart, Australia, was a ‘victim’. On

more than one occasion the patient presented at his offices without an appointment, and
disrobed in the waiting-room.

Difference between the delusions of delusional disorder and the delusions of other
disorders

For interest – not to be learned for exams. The person with delusional disorder may
believe the Tax-man (not bizarre) is after him and the story may fit together pretty well
(systematized) – while the person with schizophrenia may believe a metal horse (bizarre)
is after him and the story does not hang together (non-systematized)
Delusional disorder Other disorders

not bizarre Bizarre

Systematized Not systematized

Charlton and McClelland (1999) observed that in delusional disorder there is

fundamental mistake about the motives of others, but that thereafter, the thinking
processes are logical (and will therefore be non-bizarre and systematized), while in other
disorders with delusions, there is evidence of many breaks in logic.

Delusions and evolution?

The argument can be made that delusions may provide the sufferer with some advantages
(DeVylder, 2018).

For evolution and the survival of the species, the genes need to be passed on – this will be
more likely if the individual lives a long life and has sexual partners.

Some delusions (particularly noted in delusional disorder) – can be theoretically linked to

threats to the passing on of genes.

1) belief of threat from gangs or organizations

- Homicide by gangs (other tribes) can shorten life.

2) belief (particularly by the male) of infidelity of the spouse

 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 8

- Infidelity by the female spouse means the supportive male contributes energy to
the welfare of the genes of another male.

3) belief (particularly females) that a high-status individual is in love with him/her

- Erotomania will increase chances of passing on genes (and increasing their
chances through combination with genes from a highly successful organism)

4) belief the individual suffers a life-threatening disease

- Great concern as presence of disease will reduce chances of passing on genes

5) belief of a the presence of a bodily/facial deformity

- Deformity would reduce attractiveness to members of the other gender and
reduce the chances of passing on genes.

Sub-threshold delusions

Until recently delusions were considered to be absolutes – they were present or absent.

However, DeVylder (2019) has described “fixity of thinking” (or sub-threshold

delusional thinking) – examples include political affiliations which are highly resistant to
change. He postulates fixity of thinking has evolutionary advantage - allowing the
individual to belong to a group, which will then provide emotional and instrumental
support.

To the current author – the notion of sub-threshold delusional thinking fits well with the
current climate change debate. Two groups of people look at the same evidence and come
to different, passionately held conclusions (climate is or is not changing - man is or is not
responsible).

Unknown prevalence of delusional disorder

The prevalence of Delusional disorder is uncertain. People with this disorder often
function reasonably well in the community. They do not believe they have a mental
disorder and do not go to the doctor for help (so, they are difficult to count). They avoid
contact with others and attract as little attention as possible. In large blocks of flats there
are always people who have many locks on their doors, and believe the neighbours come
into their residences and move or steal things during the night. Some people with
delusional disorder are well known to the police as they make frequent calls about being
persecuted. People are occasionally encountered who have suffered greatly as a
consequence of their delusions for decades.
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 9

Psychology

Delusions are poorly understood and difficult to manage. Medication is helpful but does
not routinely provide a certain, satisfactory result. Not surprisingly, there has been great
interest in psychological factors in aetiology and treatment.

People with delusions have been found to have ‘jumping-to-conclusion’ (JTC) bias in
their thinking processes – that is, they are pathologically quick to make conclusions on
the basis of limited information (Andreou et al, 2018).

A number of psychological therapies based on the theory of JTC and other supposed
problems with thinking have emerged for the treatment of delusions. The most prominent
is “Metacognitive therapy” (MCT) – where “metacognition refers to thoughts about one’s
own thoughts” (Dunlosky and Metcalf, 2009). MCT has been found effective in some
(Balzan et al 2018) but not all studies (Mehl et al, 2015).

Recently, the argument has been made that there is no reason why people who JTC could
not be dissuaded from the belief. It has been suggested the problem is that once patients
reach conclusions, they stick to them irrespective of new evidence (Schmack & Sterzer,
2019).

Pathophysiology of delusions

The pathophysiology of delusions remains uncertain. Observation include the following.

Joyce (2018) suggests that damage to the right lateral prefrontal cortex may lead to
delusions. This region is part of a network which includes the limbic system and basal
ganglia.

Wolthusen et al (2018) studied people with “subclinical delusions” and people with
schizophrenia and found both demonstrated elevated perfusion of limbic structures.

Gurok et al (2019) report that people with delusions have significantly smaller pituitaries.

Jung et al (2019) have shown delusions to be associated with reduced size of the planum
temporale (a triangular region which forms the heart of Wernicke's area).

Bracht et al (2019) reported increased structural connectivity of the medial forebrain

bundle (a collection of fibers that connect the hypothalamus with the brainstem and basal
forebrain) in people suffering delusions.
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 10

Falk et al (2021) studied the autoantibodies of people with psychosis and report that high
levels of anti-AP3B2 are associated with persecutory delusions – we wait and hope.

Management

The management of people with delusions can be difficult. Particularly, where there are
no other symptoms such as depressed mood or hallucinations. Where there are other
symptoms the patient may present and accept treatment for these and the delusions may
be helped simultaneously. In delusional disorder where the patient has a single
symptom/delusion (that he is the subject of a plot, for example), it may be very difficult
or impossible to form a trusting patient-doctor relationship, and medication is likely to be
refused.

Some form of patient-doctor relationship is essential for successful treatment.

Many delusions respond to adequate doses of antipsychotic medication when these can be
sustained for a sufficient period (3 weeks at least; Manschreck & Khan, 2006). A trial of
Metacognitive therapy may prove helpful (Balzan et al 2018). ECT is effective in treating
the delusions of schizophrenia, and a combination of antipsychotic medication plus ECT
is more effective than either alone (Zervas et al, 2012).

Unfortunately, scholars report: “There is currently insufficient evidence to make

evidence-based recommendations for treatment of any type for people with delusional
disorder” (Skelton, et al, 2015).

[Some success has very recently been claimed for bilateral sub-caudate tractotomy plus
bilateral anterior cingulotomy plus bilateral amygdalotomy (Vilela-Filho O, et al, 2021).
This seems to be a surprisingly invasive form of treatment.]

Unfortunately, symptoms of delusional disorder often reappear when therapy is ceased,

and permanent medication may be required.

The prognosis for delusions becomes less favourable the longer they have been present.
This is consistent with the theory that psychosis is “toxic” to the brain.

APPENDIX

This chapter ends with the word “brain”, above. A case history follows.

John Miller was 31 years of age and lived with his wife, Helen, and their five-year-old
daughter, Julia, in a limestone brick house in the Adelaide foothills. John was a clerk at
the Taxation Department in the city centre, and Helen worked part time as a hairdresser
in a salon near their home.
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 11

John’s father, now deceased, had been a motor mechanic and his mother was a registered
nurse; she still worked in a nursing home. John had one sibling, Kevin, who was one year
younger. They were always close companions. As boys, they kicked the football in the
street every night, until it was too dark to see. At school they had plenty of friends and
had good relationships with their teachers, except that kicking the football left little time
for homework.

In high school, John, who was already nearly six-foot tall, joined the Glenelg Surf
Lifesaving Club and Kevin, who was clever with electrical gadgets, started building
model airplanes and yachts.

Helen had always played excellent tennis. Her parents owned a take-away food shop and
she left school to take up an apprenticeship in hairdressing.

John met Helen at the beach when he was “on duty” for the Surf Club. He was nineteen
and she was seventeen years of age. He was in the first year of an Arts degree and she
was halfway through her apprenticeship. John was not enthusiastic about his studies and
left before the end of year exams, opting for a clerical job which would leave his
evenings and weekends free of work commitments.

The couple spent time together at the beach and on the tennis court. They lived together
for six months before they married. This union was precipitated by Helen becoming
pregnant with Julia. They had one brief separation, but that was in the long forgotten past.
Julia was not planned, but the couple was not taking preventive measures. They were
pleased when marriage became “necessary”.

John achieved little promotion at work, his prospects were limited by his lack of tertiary
education and ambition. He was a fitness trainer at the local football club, he kept himself
fit and was an instructor in Surf Club. Julia was a healthy, articulate child. Helen had
returned to work half-time when breast-feeding finished and planned to return to full-time
work when the girl was well established at school.

The living grandparents were healthy, except that John’s mother was worried about her
heart, perhaps because her husband had died from a sudden heart attack.

John travelled to work each day by train. Conveniently, the Taxation Department was
close to an inner-city railway station. He had accepted that staff with greater ambition
would gain more promotion. He shared an office with a married woman, Penny Hope,
who was a few years and one public-service level senior to him. He had a good
knowledge of his area of work; he had learned what he needed to know about computers
and felt secure in his position.

One day Penny came back after lunch and found that John had moved his desk. Their
desks had been against opposite walls. He had moved his so that it was now against a
wall adjacent to hers. This wasn’t really a problem for her, but it wasn’t a good use of the
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 12

space; they were now both cramped up in one half, while the other half of the room was
relatively empty.

While this rearrangement didn’t particularly annoy Penny – it did happen without any
discussion. But then, she had no authority or responsibility regarding the positioning of
fellow workers’ desks. When she asked John about it, he was evasive and said that it was
“for the best”.

Difficulties associated with this change emerged. They now had to share one pair of
power points, while the power points on John’s vacated wall stood unused. Next day, to
bring electricity to his computer and printer, John produced long extension cords which
tangled around under Penny’s desk and then his own.

Penny thought this was an unsightly and unnecessary mess, but again, she said nothing.
She had recently found John to be tense and serious. She soon found him to be quick to
take offence and prepared to argue over minor details.

Any discussion they had about the taxation of multinational companies ended in an
argument – even when Penny was careful.
“I know you’re not one of their people, but you help them, by defending them so much,”
he once said, angrily.

Penny noticed that John was not working effectively. He began spending too much time
checking his calculations, and was not getting through the required volume of work. Then
he began doing his calculations with a pencil and paper. Because their tasks were inter-
related, his slowness was reducing her output. For months, she tried to carry him. She
hinted, she would be prepared to take over some of his tasks.
“What are you saying?” he snapped, “So, you want to get me sacked, do you?”
“Don’t be silly,” she replied and dropped the topic.

Partly out of concern for him, and partly out of concern for herself, Penny went to her
superior.
“He seems to be unhappy or something. Perhaps it’s that he doesn’t like working in an
office with a woman. But things have always been fine between us.…I don’t like to be
disloyal, but he’s not getting through his work the same.…I’m afraid it’s making me look
bad…. I need his figures before I can do my estimates…”
“He’s not the man he used to be,” she was told. She was surprised, saddened and relieved
to hear that others had noticed a change over the last year.

As long as anyone could remember, John had bought his lunch at a sandwich shop and
eaten it with the same group of men in the staff room. In the summer he had talked about
cricket, and in the winter, football. During both seasons, he had tried to recruit the sons of
all new employees for the Surf Club. That had changed. Now, he brought his lunch from
home and ate it alone in a park.
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 13

People in other sections had begun to complain about him. In the past, when he detected
inaccuracies or oversights in the work which came to him he had done the usual thing,
called the authors, teased them and passed on. But, then, uncharacteristically he took one
of these errors to his section head; it seemed that he could not accept an honest mistake
had been made. Eventually, he said to a colleague,
“Well, if you don’t want to make waves, you must be happy with what’s going on,”
walked out and left the building for an hour. It wasn’t clear what he meant. It was taken
as an insult; it was an awkward situation and the section head let the matter drop.

Over the next few months things did not improve. John continued to be tense, snappy and
slow. Penny didn’t want anything said to him while they were sharing an office. She
finally left Taxation and went to Customs. Still, John had not acted illegally, improperly
or contrary to the Public Service Act, and there were no grounds to discipline him. But
they now all knew they had a problem. The Divisional Director called John to his office.
“Mr. Miller. You’ve been here for twelve years. You have been a valuable employee. But
over the last couple of years, you’ve slowed down quite a bit. I understand that you don’t
mix with the other staff much. I just asked you to come up to have a chat, to see if you
like it here, and whether there is anything we can do to help you work things out,” he
said, in a kindly manner.
“You’d better talk to my Union Representative…and my Lawyer,” said John, terminating
the interview by walking out.

Thus commenced a union, legal and medical wrangle which lasted for two years. John
contacted his Union Representative and stated he had been threatened with the sack,
without warning or reason. This was believed and repeated by the Union Representative.
John’s lawyer got involved, demanding copies of the “charges” and the “evidence”. Then
John went on sick leave, his doctor claiming that he was suffering from “nervous
exhaustion”, due to “industrial harassment”.

After months of discussions and letters, denials that there had been harassment and
agreement that there was no hard evidence, John (possibly agitated by this turmoil) made
an unexpected visit to the Consumer Protection Authority. He claimed that multinational
companies were colluding to reduce their taxes. His “proof” was that, because he knew
had “discovered this illegal activities”, he was being victimized and threatened with the
sack. This information, which strongly suggested a delusion, was conveyed to the Union,
the lawyer and his general practitioner. They all protested that a person under this much
“strain” could sensibly conclude that he was being victimized. Nevertheless, they all soon
agreed that it would be appropriate for John to be examined by the Government Medical
Officer.

The Government Medical Officer, after two lengthy interviews, recommended that John
be assessed by a psychiatrist. Initially John refused to see a psychiatrist, apparently taking
the suggestion as an insult. A month later he agreed, “just to prove” there was “nothing
wrong” with him. By the time the appointment arrived, John was doubting the wisdom of
his “co-operation”. After the exchange of names and hand shaking, he made an
apprehensive, but angry statement,
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 14

“Everybody knows that it’s easy to silence people by saying they’re mad. They do it in
Russia all the time. I’m not here for that. I won’t agree to being hypnotized or anything
like that. My lawyer knows I’m here. I’m here to get a clean bill of health.”

The psychiatrist was calm and respectful.

“OK, sure,” she said. “My role is simply to find out what the difficulties are.”
“Who pays for this?” John challenged, looking from the power points to the telephone
and around the walls.
“The Commonwealth Government. This meeting was requested by the Government
Medical Officer. But, Mr. Miller, can you tell me what you think the purpose of this
meeting is, and what has led up to it?”
They sat silently looking at each other. She said nothing. He started.

He said that, three years ago people in the train had started holding newspapers up in
front of their faces. He realized they were giving him the message that he was being
watched. He didn’t know them, but they knew him. Sometimes he would be sitting in a
carriage and find himself surrounded by them. Changing carriages didn’t help, there was
always at least one in every carriage. He was afraid at first but then he realized they
weren’t going to do anything violent. They always had the business pages pointing
toward him, showing rows and rows of stock market figures. They were from the
multinationals. Their message was, don’t rock the boat, don’t increase the taxes on the
multinationals.

“But with respect, you don’t have much to do with government policy or deciding which
companies will be prosecuted. What could you do that could hurt the multinationals?”,
she asked.
He explained that if he started getting tough on them, like a snowball, it would get bigger
an bigger, as it went from him to others, like compound interest, and it would hurt them.
Make no mistake. The proof was that they had people watching him. They had already
silenced half the people in the Tax Department. Once friendly work-mates “made
remarks” and he had to start keeping to himself. That led to the multinationals watching
him with fibre-optic devices through power points. They also bugged his office and his
computer so that he had to do most of his work with pencil and paper and shred each
page as he went along.

This had led to the multinationals, through mining company subsidiaries, to drill tunnels
under the building, and line them with bullet-proof glass. John didn’t say precisely how
the tunnels fitted in with the surveillance activities. The psychiatrist didn’t push him on
the point. That was unnecessary, John was clearly out of touch with reality.

John had a delusional system. He believed that multinational companies believed that he
was a threat to their prosperity, as his actions may force them to pay higher taxes.
Supporting this central delusion were other delusions including that the multinationals
were having people give him messages in the train by holding up the financial pages of
the newspaper and having him watched in a variety of ways, including via fibre optic
devices hidden in the power points. He also had the delusion that the multinationals had
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 15

dug tunnels under his place of work. These are persecutory delusions. Such delusions
often have a grandiose flavour – in this case a clerk, with relatively little influence,
believed that powerful multinational companies were concerned that he could hurt them.
He believed he was so important that they employed dozens of people to watch him and
even went to the enormous expense of digging tunnels under the building where he
worked.

This case illustrates the interesting point that people with complex delusional systems
can, sometimes for years, function reasonably effectively in the community. This is
possible when the delusional system is the only psychotic symptom and the delusions are
limited to certain areas of life. In the case of John Miller, symptoms were most
distressing when he was travelling to and from, and when he was at work. It is possible
for a person with a delusional system to work through to retirement without serious work
problems, particularly when the delusions do not involve the workplace. Usually, fellow
workers find such people to be tense, secretive and isolative, but also, precise (because
they are cautious to protect themselves) and determined. Generally, the better the
individual is able to function, the slower they come to the attention others and the later
they receive offers of help.

It may be very difficult to obtain a clear understanding of the beliefs of people with
persecutory delusions and to commence treatment. The nature of the condition means all
attempts to discuss matters with them are interpreted as a threat or as “evidence” of a
conspiracy. Believing they are being persecuted rather than sick, they “sensibly” reject
the initial, and sometimes all, offers of treatment.

Helen had noticed her husband had changed. He laughed less and was often angry about
the events of the day at the office. She saw this as a reaction to the additional
responsibilities of fatherhood. She married John “for richer or for poorer”, and ever since
they met, had known he chose to avoided stressful situations. She was glad he still had
the Surf Club and the local football team to take his mind off his stress.

Helen knew nothing of John’s delusional system until after he went onto sick leave.
Spending more time at home and more than usually worried, he started to talk to her
about being watched at work. She thought this was a terrible way to treat an employee,
and that she should go and complain to the Federal Minister for Taxation. Eventually she
had contact with the family doctor, the union officials and the psychiatrist, and came to
know the full story. She continued to support her husband and protested that,
“He wouldn’t be like this if they didn’t keep cutting the public service work force and
putting more and more stress on the few who’re left”.

John lacked insight, which means that he was unaware that what he believed was
incorrect, unaware that he was suffering a mental disorder and unaware that he needed
psychiatric treatment. By definition, if you come to accept that your belief is incorrect,
you can no longer fully believe it, and you can no longer have a delusion. That is how it
works in theory. In practice, interestingly, people can have partial insight, which means
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 16

they may be able to see that their delusion is incorrect in fact, but continue to behave as
though it is at least partly correct.

John’s lack of insight made it illogical for him to accept that he needed medical help. He
went to the Government Medical Officer because he wanted to keep his job in the
Commonwealth Government. He therefore had no alternative but to comply with that
instruction. The same thing applied to the Government Medical Officer’s
recommendation that he see a psychiatrist. John finally agreed to see a psychiatrist “to
prove” that he was well and that his account of events was accurate. While giving such
reasons, patients sometimes also have a small degree of insight, some tiny doubts about
the accuracy of their thinking, and may agree to see psychiatrists to reassure themselves
that they have got things right.

The psychiatrist did not get into whether or not she believed John’s story. She believed he
believed it. She got him to bring his wife along. The three of them talked about “the
problems” John was having at work.
“Well, Mr. Miller, as you know, this is pretty much the first time Mrs Miller and I have
heard about these issues. I’m sure you will understand if we ask you to explain how some
of these things started to happen?”

Helen was distressed to hear the full extent of her husband’s beliefs, but she was
reassured by the psychiatrist’s composure and supportive approach. By this stage the
general practitioner had a better understanding and his name could be used. Toward the
end of the interview, the psychiatrist said,
“All of us want the best for you. Worrying about all these things must be very distressing.
I speak for myself and your general practitioner, Dr Chen, and I’m sure, for Mrs Miller as
well. We all believe you should probably take some medicine which will help you deal
with the stress you are currently under…How about that? Do you think some medicine
might ease some of your distress and help you deal with things?”

The suffering which is secondary to delusions takes many forms. Fear or anxiety and
insomnia are common and are a natural consequence of the belief that one is in dangerous
circumstances. Some individuals waste money on items such as additional locks and
security devices, new televisions sets and telephones, and sometimes a range of
unnecessary medical or scientific tests to check for levels of poisons in their blood or
water tanks, and other hard evidence. Delusions frequently lead to conflict at home and
work (divorce and dismissal) irrespective of whether others are aware of the illness or
not.

Certain medicines reduce delusional thinking. They also directly and immediately ease
fear, anxiety and insomnia. These secondary symptoms are often the first to subside when
medicine is taken, and subsequently the delusions may weaken and resolve.

John refused medication when it was first offered. He remained off work, supported by
his wife and general practitioner. Helen explained the situation to his mother, who
became angry and distressed. However, Helen got good support from John’s brother,
 Pridmore S. Download of Psychiatry, Chapter 4. Last modified: March, 2022. 17

Kevin, and her own parents, who began to visit more often and took their granddaughter
over night, every few nights. John continued to be troubled by his delusion and his
continued absence from work placed a cloud over his employment.

He could not sleep and finally accepted a medication from the psychiatrist. The next day
he felt more relaxed. Two weeks later he was beginning to have doubts about the
multinationals digging tunnels under the Taxation Department building. A month later he
no longer believed that the multinationals had been watching him through the power
points. And two months later he was free of delusions, but he was more suspicious and
aloof than he had been before the disorder started.

John remained on medication. He remained somewhat suspiciousness and aloofness. This

may have been, at least in part, a natural awkwardness, given that he now knew that he
had behaved irrationally and that his fellow workers would also know, via office grape-
vine, that he had been diagnosed with a mental disorder. One option was to apply for a
transfer to another Commonwealth department. But that would bring a new set of
stresses, the need to learn a new job and meet new people.
“I think I would be safer where I am,” he told Helen.
She wasn’t sure what he meant by “safer”, but chose not to ask. John stayed with the
Taxation Department, and bought himself a car so he didn’t have to travel with people
with whom he was never again entirely comfortable. He remained married and continued
as a good and loving father to his daughter.

John Miller suffered a paranoid delusion. Using the DSM-5 the most appropriate
diagnosis was Delusional Disorder.

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