Exposure and Delusion

[romanticscience]

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In a patient who the quality of their cognitions are closer to delusional (v. overvalued or distorted), how does one conceptualize the value of exposure-based interventions?

Patients that come to mind are those that have obsessions without insight and patients whose “trauma” may actually be a delusion (or delusional perception of a real event). I’ve found that “brining up exposure” will invalidate the patient and in the former case, increase suspiciousness—paranoia or even elicit dissociation.

I remember reading someplace that a treatment for one with grandiose delusions is to accept the cognitions UNTIL that person has another area to leverage their self-esteem (also, the risk of suicide if confronted).

Is there evidence that PE works in psychosis + PTSD? What about PTSD based on a delusion or OCD without insight? I’m mentioning OCD here because the OCD without insight always confused me as it compares to delusional disorder; I suppose the recurrence and intrusiveness of the cognitions is more consistent with OCD?

I’d appreciate your help! With some patients, the therapy seemingly “goes better” when the focus is here—now and almost always blows up the alliance when the focus turns back to exposure. I want to be vigilant in doing the hard and difficult work by not colluding with avoidance, but I don’t want to hurt my patient either.

I believe this is a debate in the dissociative disorders regarding exposure (phased based treatment v. PE).

 

[tr]

It always comes back to motivation.

Personally I would consider it fruitless to try to impose cognitive -behavioral strategies on someone whose insight was poor enough that they didn't desire change.

I'd just back up to motivational interviewing/agenda setting and see if there is something they would like to work on in therapy. If not their delusions/obsessions, then something else. Find a goal they can feel good about working toward. Working on something *they* want to work on will at least help you build rapport and credibility.

Unlike medication, therapy requires a pretty significant commitment and investment of time and energy from the patient. If they don't want to be there, they are unlikely to benefit.

Getting into a power struggle with a patient where you insist on having them work on what *you* want to work on is always a losing proposition.

 

[G Sheb]

Are you seeking to address PTSD-like symptoms or the actual delusion?
Is PTSD based on a delusion a real thing?
Just curious here. Haven't seen it and would be quite a thing if someone presents with bona fide PTSD symptoms because of a delusional belief of a trauma incident rather than actual exposure.
It also seems counterproductive to do exposure for an actual delusion. Seems like all you're doing is actually reinforcing the delusion, which one shouldn't do.

 

[splik]

I think there are 2 different aspects to this. The first is, can patients on the more delusional end of the obsessional spectrum benefit from exposure based interventions. The second is can patients who have PTSD symptoms based on delusions/psychosis benefit.

For 1, the answer is yes, if the delusions do not prevent engagement in the first place. I believe delusional parasitosis is best conceptualized an an OCD with poor insight. Many pts won't engage in psychotherapies because they are too fixated on whether you believe them. But if they are open to engaging in treatment (and some of them are), they can benefit. This also includes patients with morbid jealousy and erotomania (though they often have underlying personality disorders).

For 2, the answer is also yes with caveats. I have definitely had PTSD symptoms due to their psychosis/delusions of what happened to them. Technically they don't have PTSD since a delusion does count as a criterion A event, but if they really believed it happened, then they can develop all the same symptoms. The problem is you don't want to reinforce memories of something that didn't happened so exposure based treatments are out of the question. However, they might still benefit from CPT-C or interpersonal therapy.

In terms of patients with grandiose delusions, they have a very poor prognosis. Since their delusions tend to be egosyntonic, they do not want to engage in treatment for their beliefs though may seek treatment for other reasons. They are often highly defended against psychic reality and their delusions are essentially fantasies that provide them with meaning of which their lives are otherwise bereft. These patients are often quite miserable, alone, immature, and they can be quite child like in some ways which can often make them quite vulnerable to exploitation and harm from others.

Patients w/ dissociative reactions are often a different flavor than the psychotic ones. Those patients seems to do better receiving therapy initially in a residential treatment setting with more structure and without exposure to the things in their life that so often trigger such reactions.

 

[G Sheb]

I have definitely had PTSD symptoms due to their psychosis/delusions of what happened to them.

My guess is that an actual traumatic event happened leading to PTSD symptoms, but someone with a more psychotic organization would formulate it in delusional terms. Hallucinations can definitely be traumatic though.
Would be interesting though if there is any literature on that.

 

[Psych Person]

In a patient who the quality of their cognitions are closer to delusional (v. overvalued or distorted), how does one conceptualize the value of exposure-based interventions?

Patients that come to mind are those that have obsessions without insight and patients whose “trauma” may actually be a delusion (or delusional perception of a real event). I’ve found that “brining up exposure” will invalidate the patient and in the former case, increase suspiciousness—paranoia or even elicit dissociation.

I remember reading someplace that a treatment for one with grandiose delusions is to accept the cognitions UNTIL that person has another area to leverage their self-esteem (also, the risk of suicide if confronted).

Is there evidence that PE works in psychosis + PTSD? What about PTSD based on a delusion or OCD without insight? I’m mentioning OCD here because the OCD without insight always confused me as it compares to delusional disorder; I suppose the recurrence and intrusiveness of the cognitions is more consistent with OCD?

I’d appreciate your help! With some patients, the therapy seemingly “goes better” when the focus is here—now and almost always blows up the alliance when the focus turns back to exposure. I want to be vigilant in doing the hard and difficult work by not colluding with avoidance, but I don’t want to hurt my patient either.

I believe this is a debate in the dissociative disorders regarding exposure (phased based treatment v. PE).

I don’t have enough professional expertise to effectively prescribe clinical guidance to your specific inquiry, but all you have said, I believe, is in the right direction. Your curiosity and passion will lead you to do the most optimal ideas, actions, outcomes. The responses provided by other posters thus far are very insightful, and I hope provide you with the kind of guidance that empowers you to take further steps to doing what you believe is best.

The fact that you are even thinking this way and making effort to try to understand so that you can provide treatments that are maximally helpful while minimizing harm is a testament to your extraordinary commitment to your patients, ethics, and sound scientific thinking. You are asking brilliant questions that get at the difficult to articulate nuances between these various conditions which often approximate one another but can require significantly different approaches for treatment to have a chance to succeed.

Because you are asking these questions, and because you are capable of evening formulating these questions with your own original thought, I assure you that your patients will be in far better hands with you than they would with the vast majority of available psychiatrists and psychiatric providers. Many of these questions in clinical psychiatry, when dealing with the most obscure disorders and situations, have no concrete answer because they thrust the thinker into realms of thought more akin to philosophy and meta-psychology. You are on the right path with what you are bringing up, which is “good enough” fundamentally in my opinion, but by all means, continue to seek the answers, understanding, and specificity that you crave to the extent that you hunger for them. Just don’t drive yourself too mad in the process of going deeper into these things, as the boxes of reality that we classify things in with such confidence will likely start to feel more fluid, arbitrary, and even unreliable at times. Absolute precision in the extremes of scientific domains is impossible and becomes more of a philosophical and linguistic exercise in the end. It is my belief that all roads in science lead to this point for the individual capable of wringing the sponge of logic to its limit, hence why the Sagans, Einsteins, Jungs, etc. start to sound very similar at some point in their careers. A philosopher I like once said that “The weak mind requires precision.” He said this in the context of exploring logic to its limit, when logic runs out of the required material to remain “logical”, when the metaphysical and existential are what is left and bewilderment, awe, and wonder are what we are often left with. It doesn’t mean that we don’t strive for precision in our vocational pursuits, but the “strong mind” is able to recognize and tolerate when the degree of precision being sought is perhaps not available within the limits of reality at the present time, and may not ever be.

Your patients are uniquely fortunate to have someone like you involved in and overseeing their care. Thank you for posting.

 

[clausewitz2]

I think there are 2 different aspects to this. The first is, can patients on the more delusional end of the obsessional spectrum benefit from exposure based interventions. The second is can patients who have PTSD symptoms based on delusions/psychosis benefit.

For 1, the answer is yes, if the delusions do not prevent engagement in the first place. I believe delusional parasitosis is best conceptualized an an OCD with poor insight. Many pts won't engage in psychotherapies because they are too fixated on whether you believe them. But if they are open to engaging in treatment (and some of them are), they can benefit. This also includes patients with morbid jealousy and erotomania (though they often have underlying personality disorders).

ACT for psychosis is in many ways getting people to tolerate the idea of letting their fears and unusual experiences be without trying to struggle with them, suppress them, or engage with them; not so different from what exposure-based interventions ask you to do. You don't need to change anyone's mind about how "real" their ideas are if the focus is on helping them continue to live life and do what matters to them regardless of what might be happening. If they buy into learning to respond differently to the thoughts (e.g. acknowledging that panicking about the cartel assassins that are stalking them probably doesn't make them any safer and definitely gets in the way of holding on to their job) no reason you can't do exposure-based interventions.

For 2, the answer is also yes with caveats. I have definitely had PTSD symptoms due to their psychosis/delusions of what happened to them. Technically they don't have PTSD since a delusion does count as a criterion A event, but if they really believed it happened, then they can develop all the same symptoms. The problem is you don't want to reinforce memories of something that didn't happened so exposure based treatments are out of the question. However, they might still benefit from CPT-C or interpersonal therapy.

I would chime in for an ACT-y kind of approach here. Identify and develop values and explore the extent to which repetitively returning to the memory of the event does or does not move them in the direction of those values.

In terms of patients with grandiose delusions, they have a very poor prognosis. Since their delusions tend to be egosyntonic, they do not want to engage in treatment for their beliefs though may seek treatment for other reasons. They are often highly defended against psychic reality and their delusions are essentially fantasies that provide them with meaning of which their lives are otherwise bereft. These patients are often quite miserable, alone, immature, and they can be quite child like in some ways which can often make them quite vulnerable to exploitation and harm from others.

Hard to let someone strip away your narcissistic defenses if what you are left with is a bleak and barren existence.