By Sara Millspaugh, Ph.D.
Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence, and the belief must not be ordinarily accepted by members of a group with which the individual identifies. For example, the sovereign citizen belief that the U.S. government does not have legal and constitutional jurisdiction over them may appear delusional as there is conflicting evidence this is not true. But, the belief is commonly held by individuals who identify as sovereign citizens, and thus, is not, in and of itself, a delusion. On the other hand, conspiracy theories have been defined as “narratives about hidden, malevolent groups secretly perpetuating political plots and social calamities to further their own nefarious goals” (Oliver & Wood, 2014, p. 952). One study estimated that at least 50% of the U.S. population believes at least one conspiracy theory (Oliver & Wood, 2014). Thus, when conducting forensic evaluations, it is important to distinguish whether the client is experiencing true delusions or extreme, overvalued beliefs, such as a conspiracy theory.
Mark Cunningham published a seminal article in 2018 about how to differentiate delusional disorder from radicalized extreme beliefs that can be utilized by an evaluator when faced with a case that involves making this distinction. In this article, he laid out a 17-Factor Model that guides the evaluator when attempting to differentiate between delusions and extreme, overvalued beliefs. In the model, seven criteria of analysis are laid out: the cognitive content of the belief, the cognitive style of the belief, distress and social dysfunction associated with the belief, social influences, social inclusion, prodromal symptomology, and behavioral and action factors. Therefore, in order to distinguish whether an individual’s beliefs are delusions rather than extreme beliefs, an evaluator must consider: what the belief is (e.g., whether the belief is idiosyncratic or aligned with a group’s ideology) and how it is believed (e.g., “rigid adherence” or “suspension of critical judgment”; p. 144) and whether the belief causes distress and functional impairment for the individual, there are social influences that play a role in the belief (e.g., “social motivators”; p. 146), holding the belief leads to inclusion in a social group, there are symptoms of emerging psychosis, and there are behaviors connected to the beliefs. Cunningham indicated that an individual is more likely experiencing delusions if their beliefs are idiosyncratic, improbable, and/or grandiose and they rigidly hold the beliefs despite conflicting evidence, are preoccupied with and have difficulty engaging in critical judgment of their beliefs, are experiencing significant distress and/or functional impairment due to the beliefs, do not have social support for their beliefs, are not included in a group based on these beliefs, are experiencing other emerging symptoms/signs of psychosis (e.g., bizarre behavior, changes in hygiene and grooming, and inappropriate affect), and feel compelled to act on their beliefs.
References
Cunningham, M. D. (2018). Differentiating delusional disorder from the radicalization of extreme beliefs: A 17-factor model. Journal of Threat Assessment and Management, 5(3), 137-154. http://dx.doi.org/10.1037/tam0000106
American Psychiatric Association (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Oliver, J. E., & Wood, T. J. (2014). Conspiracy theories and the paranoid style(s) of mass opinion. American Journal of Political Science, 58(4), 952-966. https://dx.doi.org/10.1111/ajps.12084
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