Medicine:Delusion

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A delusion[lower-alpha 1] is a fixed belief that is not amenable to change in light of conflicting evidence.[2] As a pathology, it is distinct from a belief based on false or incomplete information, confabulation, dogma, illusion, hallucination, or some other misleading effects of perception, as individuals with those beliefs are able to change or readjust their beliefs upon reviewing the evidence. However:

"The distinction between a delusion and a strongly held idea is sometimes difficult to make and depends in part on the degree of conviction with which the belief is held despite clear or reasonable contradictory evidence regarding its veracity."[2]

Delusions occur in the context of many pathological states (both general physical and mental) and are of particular diagnostic importance in psychotic disorders including schizophrenia, paraphrenia, manic episodes of bipolar disorder,[3][4] and psychotic depression.

Types

Delusions are categorized into four different groups:

  • Bizarre delusion: Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences.[5] An example named by the DSM-5 is a belief that someone replaced all of one's internal organs with someone else's without leaving a scar, depending on the organ in question.
  • Non-bizarre delusion: A delusion that, though false, reflects real–life situations and is at least technically possible; it may include feelings of being followed, poisoned, infected etc.[6] e.g., the affected person mistakenly believes that they are under constant police surveillance.
  • Mood-congruent delusion: Any delusion with content consistent with either a depressive or manic state, e.g., a depressed person believes that news anchors on television highly disapprove of them, or a person in a manic state might believe they are a powerful deity.
  • Mood-neutral delusion: A delusion that does not relate to the patient's emotional state; for example, a belief that an extra limb is growing out of the back of one's head is neutral to either depression or mania.[7]

French psychiatry (which is influenced by psychoanalysis), however, also establishes a difference between "paranoid" (paranoïde) and "paranoiac" (paranoïaque) delusion.[8][9] The paranoid delusion, observed in schizophrenia, is non-systematized and is characterized by a disorganized structure and confused speech and thoughts.[10] The paranoiac delusion, observed in paraphrenia, is highly systematized (which means it is very organized and clear) and focuses on a single theme.

Themes

In addition to these categories, delusions often manifest according to a consistent theme. Although delusions can have any theme, certain themes are more common. Some of the more common delusion themes are:

  • Delusion of control: False belief that another person, group of people, or external force controls one's general thoughts, feelings, impulses, or behaviors.[7]
  • Delusional jealousy: False belief that a spouse or lover is having an affair, with no proof to back up the claim.[7]
  • Delusion of guilt or sin (or delusion of self-accusation): Ungrounded feeling of remorse or guilt of delusional intensity.[7]
  • Thought broadcasting: False belief that other people can know one's thoughts.[7]
  • Delusion of thought insertion: Belief that another thinks through the mind of the person.[7]
  • Persecutory delusions: False belief that one is being persecuted.
  • Delusion of reference: False belief that insignificant remarks, events, or objects in one's environment have personal meaning or significance. "Usually the meaning assigned to these events is negative, but the 'messages' can also have a grandiose quality."[7]
  • Erotomania: False belief that another person is in love with them.[7]
  • Religious delusion: Belief that the affected person is a god or chosen to act as a god.[11][12]
  • Somatic delusion: Delusion whose content pertains to bodily functioning, bodily sensations or physical appearance. Usually the false belief is that the body is somehow diseased, abnormal or changed.[7] A specific example of this delusion is delusional parasitosis: Delusion in which one feels infested with insects, bacteria, mites, spiders, lice, fleas, worms, or other organisms.
  • Delusion of poverty: Person strongly believes they are financially incapacitated. Although this type of delusion is less common now, it was particularly widespread in the days preceding state support.[13]

Grandiose delusions

Grandiose delusions or delusions of grandeur are principally a subtype of delusional disorder but could possibly feature as a symptom of schizophrenia and manic episodes of bipolar disorder.[14] Grandiose delusions are characterized by fantastical beliefs that one is famous, omnipotent or otherwise very powerful. The delusions are generally fantastical, often with a supernatural, science-fictional, or religious bent. In colloquial usage, one who overestimates one's own abilities, talents, stature or situation is sometimes said to have "delusions of grandeur". This is generally due to excessive pride, rather than any actual delusions. Grandiose delusions or delusions of grandeur can also be associated with megalomania.[15]

Persecutory delusions

Main article: Philosophy:Persecutory delusion

Persecutory delusions are the most common type of delusions and involve the theme of being followed, harassed, cheated, poisoned or drugged, conspired against, spied on, attacked, or otherwise obstructed in the pursuit of goals. The person affected by a persecutory delusion wrongly believes that they are being persecuted. Specifically, for a person's delusion to be defined as persecutory, they must believe the following two central elements:[16] * harm is occurring, or is going to occur

  • the persecutors have the intention to cause harm

According to the DSM-IV-TR, persecutory delusions are the most common form of delusions in schizophrenia, where the person believes they are "being tormented, followed, sabotaged, tricked, spied on, or ridiculed".[17] The DSM-IV-TR also identifies persecutory delusions as the main feature of the persecutory type of delusional disorder. When the focus is remedying some injustice by legal action, they are sometimes called "querulous paranoia".[18]

Causes

While explaining the causes of delusions remains a challenge, researchers have developed several theories.[19][20] The genetic or biological theory holds that close relatives of people with delusional disorder are at increased risk of developing delusional traits. Another theory is dysfunctional cognitive processing, according to which delusions arise from distorted ways in which individuals view themselves. A third theory is motivated or defensive delusions, according to which individuals who are predisposed to delusional disorder may develop it at times when they are struggling to cope with life and maintaining high self-esteem. In this case, the person views others as the cause of their personal difficulties in order to preserve a positive self-concept.[21]

Delusional thinking is more common among people who have poor hearing or sight. The probability of developing delusions is also higher where there are ongoing stressors, such as immigration, low socioeconomic status, and possibly the accumulation of smaller daily struggles.[22]

Specific delusions

The two largest factors in the formation of delusions are disorders of brain functioning and background influences of temperament and personality.[23]

Higher levels of dopamine are a sign of disorders of brain functioning. A preliminary 2002 study on delusional disorder (a psychotic syndrome) examined the role of elevated dopamine levels in sustaining certain delusions, in order to establish whether schizophrenia was linked to dopamine abnormalities.[24] The results confirmed the theory, showing that individuals with delusions of jealousy and persecution had different levels of dopamine metabolite HVA and homovanillyl alcohol; the cause of this may in turn be genetic. The authors cautioned that the results were preliminary and called for future research with a larger population. Also, factors beyond dopamine impact the development of a specific delusion; studies show age[25][26] and gender are influential and HVA levels likely change during the life course of some syndromes.[27]

On the influence of personality, Andrew Sims wrote: "Jaspers considered there is a subtle change in personality due to the illness itself; and this creates the condition for the development of the delusional atmosphere in which the delusional intuition arises."[28]

Cultural factors have "a decisive influence in shaping delusions".[29] For example, delusions of guilt and punishment are frequent in Austria (a Western, Christian country), but not in Pakistan, where delusions are more often about persecution.[30] Similarly, in a series of case studies, delusions of guilt and punishment were found in Austrian patients with Parkinson's disease being treated with l-dopa, a dopamine agonist.[31]

Pathophysiology

Abnormalities in specific regions have been associated with specific types of delusions. The volume of the hippocampus and parahippocampus is related to paranoid delusions in Alzheimer's disease, and has been reported to be abnormal post mortem in one person with delusions. Capgras delusions have been associated with occipito-temporal damage and may be related to failure to elicit normal emotions or memories in response to faces.[32]

Definition and diagnosis

James Tilly Matthews illustrated this picture of a machine called an "air loom", which he believed was being used to torture him and others for political purposes.

Although non-specific concepts of madness have been around for several thousand years, the psychiatrist and philosopher Karl Jaspers was the first to define the four main criteria for a belief to be considered delusional in his 1913 book General Psychopathology.[33] These criteria are:

  1. certainty (held with absolute conviction)
  2. incorrigibility (not changeable by compelling counterargument or proof to the contrary)
  3. impossibility or falsity of content (implausible, bizarre, or patently untrue)[34]
  4. not amenable to understanding (i.e., belief cannot be explained psychologically)[35]

Furthermore, when beliefs involve value judgments, only those which cannot be proven true are considered delusions. For example: a man claiming that he flew into the Sun and flew back home. This would be considered a delusion,[36] unless he were speaking figuratively, or if the belief had a cultural or religious source. Only the first three criteria remain cornerstones of the current definition of a delusion in the DSM-5.

Robert Trivers writes that delusion is a discrepancy in relation to objective reality, but with a firm conviction in reality of delusional ideas, which is manifested in the "affective basis of delusion".[37]

Debate over definitions

The modern definition and Jaspers' original criteria have been criticised, as counter-examples can be shown for every defining feature.

Studies on psychiatric patients show that delusions vary in intensity and conviction over time, which suggests that certainty and incorrigibility are not necessary components of a delusional belief.[38]

Delusions do not necessarily have to be false or "incorrect inferences about external reality".[39] Some religious or spiritual beliefs by their nature may not be falsifiable, and hence cannot be described as false or incorrect, no matter whether the person holding these beliefs was diagnosed as delusional or not.[40] In other situations the delusion may turn out to be true belief.[41] For example, in delusional jealousy, where a person believes that their partner is being unfaithful (and may even follow them into the bathroom believing them to be seeing their lover even during the briefest of partings), it may actually be true that the partner is having sexual relations with another person. In this case, the delusion does not cease to be a delusion because the content later turns out to be verified as true or the partner actually chose to engage in the behavior of which they were being accused.[citation needed]

In other cases, the belief may be mistakenly assumed to be false by a doctor or psychiatrist assessing it, just because it seems to be unlikely, bizarre or held with excessive conviction. Psychiatrists rarely have the time or resources to check the validity of a person's claims leading to some true beliefs to be erroneously classified as delusional.[42] This is known as the Martha Mitchell effect, after the wife of the attorney general who alleged that illegal activity was taking place in the White House. At the time, her claims were thought to be signs of mental illness, and only after the Watergate scandal broke was she proved right (and hence sane).[43]

Similar factors have led to criticisms of Jaspers' definition of true delusions as being ultimately "un-understandable". Critics (such as R. D. Laing) have argued that this leads to the diagnosis of delusions being based on the subjective understanding of a particular psychiatrist, who may not have access to all the information that might make a belief otherwise interpretable. R. D. Laing's hypothesis has been applied to some forms of projective therapy to "fix" a delusional system so that it cannot be altered by the patient. Psychiatric researchers at Yale University, Ohio State University and the Community Mental Health Center of Middle Georgia have used novels and motion picture films as the focus. Texts, plots and cinematography are discussed and the delusions approached tangentially.[44] This use of fiction to decrease the malleability of a delusion was employed in a joint project by science-fiction author Philip José Farmer and Yale psychiatrist A. James Giannini. They wrote the novel Red Orc's Rage, which, recursively, deals with delusional adolescents who are treated with a form of projective therapy. In this novel's fictional setting other novels written by Farmer are discussed and the characters are symbolically integrated into the delusions of fictional patients. This particular novel was then applied to real-life clinical settings.[45]

Another difficulty with the diagnosis of delusions is that almost all of these features can be found in "normal" beliefs. Many religious beliefs hold exactly the same features, yet are not universally considered delusional. For instance, if a person was holding a true belief then they will of course persist with it. This can cause the disorder to be misdiagnosed by psychiatrists. These factors have led the psychiatrist Anthony David to note that "there is no acceptable (rather than accepted) definition of a delusion."[46] In practice, psychiatrists tend to diagnose a belief as delusional if it is either patently bizarre, causing significant distress, or excessively pre-occupying the patient, especially if the person is subsequently unswayed in belief by counter-evidence or reasonable arguments.[citation needed]

Psychiatrist Joseph Pierre states that one factor that helps differentiate delusions from other kinds of beliefs is that anomalous subjective experiences are often used to justify delusional beliefs. While idiosyncratic and self-referential content often make delusions impossible to share with others,[47] Pierre suggests that it may be more helpful to emphasize the level of conviction, preoccupation, and extension of a belief rather than the content of the belief when considering whether a belief is delusional.[48]

It is important to distinguish true delusions from other symptoms such as anxiety, fear, or paranoia. To diagnose delusions a mental state examination may be used. This test includes appearance, mood, affect, behavior, rate and continuity of speech, evidence of hallucinations or abnormal beliefs, thought content, orientation to time, place and person, attention and concentration, insight and judgment, as well as short-term memory.[49]

Johnson-Laird suggests that delusions may be viewed as the natural consequence of failure to distinguish conceptual relevance. That is, irrelevant information would be framed as disconnected experiences, then it is taken to be relevant in a manner that suggests false causal connections. Furthermore, relevant information would be ignored as counterexamples.[50]

Treatment

Delusions and other positive symptoms of psychosis are often treated with antipsychotic medication, which reduce symptoms with a medium effect size according to a meta-analysis.[51] Cognitive behavioral therapy (CBT) improves delusions relative to control conditions according to a meta-analysis.[52] A meta-analysis of 43 studies reported that metacognitive training (MCT) reduces delusions at a medium to large effect size relative to control conditions.[53]

Criticism

Some psychiatrists criticize the practice of defining one and the same belief as normal in one culture and pathological in another culture, arguing that it is based in cultural essentialism. They argue that it is not justified to assume that culture can be simplified to a few traceable, distinguishable and statistically quantifiable factors and that everything outside those factors must be biological; rather, cultural influences are mixed, including not only parents and teachers but also peers, friends, and media, and the same cultural influence can have different effects depending on earlier cultural influences. Other critical psychiatrists argue that just because a person's belief is unshaken by one influence does not prove that it would remain unshaken by another. For example, a person whose beliefs are not changed by verbal correction from a psychiatrist, which is how delusion is usually diagnosed, may still change his or her mind when observing empirical evidence; the critics state that psychiatrists rarely, if ever, present patients with such evidence.[54][55]

See also

Footnotes

  1. ↑ From Latin delusio lit. deceiving, from deludere 'to mock, to deceive'[1]

References

  1. ↑ Harper, Douglas. "delusion". Online Etymology Dictionary. https://www.etymonline.com/?term=delusion. 
  2. ↑ 2.0 2.1 "Delusions in the DSM 5". 7 June 2013. http://imperfectcognitions.blogspot.com/2013/06/delusions-in-dsm-5.html. 
  3. ↑ Dunayevich, Eduardo; Keck, Paul E. (2000). "Prevalence and description of psychotic features in bipolar mania". Current Psychiatry Reports 2 (4): 286–290. doi:10.1007/s11920-000-0069-4. ISSN 1523-3812. 
  4. ↑ Bergen, Annet H. van; Verkooijen, Sanne; Vreeker, Annabel; Abramovic, Lucija; Hillegers, Manon H.; Spijker, Annet T.; Hoencamp, Erik; Regeer, Eline J. et al. (2019). "The characteristics of psychotic features in bipolar disorder" (in en). Psychological Medicine 49 (12): 2036–2048. doi:10.1017/S0033291718002854. ISSN 0033-2917. https://www.cambridge.org/core/journals/psychological-medicine/article/abs/characteristics-of-psychotic-features-in-bipolar-disorder/0B66A67B9F8629FCDD65420A389A3C37. 
  5. ↑ Diagnostic and statistical manual of mental disorders: DSM-5. American Psychiatric Association. 2013. 
  6. ↑ Chowdhury, Arabinda N. (2019) (in en). Bedside Psychiatry. Jaypee Brothers Medical Publishers. pp. 102. ISBN 978-93-5270-985-4. https://books.google.com/books?id=kXKSDwAAQBAJ. 
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 "Delusions". Encyclopedia of Mental Disorders. Advameg.com. http://www.minddisorders.com/Br-Del/Delusions.html. Retrieved 2018-04-22. 
  8. ↑ "Paranoïa (histoire du concept)" (in French). Universalis. https://www.universalis.fr/encyclopedie/paranoia-histoire-du-concept/2-la-structure-paranoiaque-des-delires/. 
  9. ↑ Pirlot, Gérard; Cupa, Dominique (2019). "Chapitre 22. Psychoses passionnelles et délires paranoïaques". Approche psychanalytique des troubles psychiques. Dunod. pp. 218–243. https://www.cairn.info/approche-psychanalytique-des-troubles-psychiques--9782100785421-page-218.htm. 
  10. ↑ "Paranoïde". Larousse. https://www.larousse.fr/encyclopedie/divers/parano%c3%afde/76810. 
  11. ↑ "Religious delusions are common symptoms of schizophrenia.". http://www.sciforums.com/showthread.php?t=51361. 
  12. ↑ "Religious delusion". http://www.sanp.ch/pdf/2000/2000-01/2000-01-058.PDF. 
  13. ↑ Barker, p.. 1997. Assessment in Psychiatric and Mental Health Nursing in Search of the Whole Person. UK: Nelson Thornes Ltd. p. 241.
  14. ↑ Diagnostic and Statistical Manual of Mental Disorders Fourth edition Text Revision (DSM-IV-TR) American Psychiatric Association (2000)
  15. ↑ "Theories of delusional disorders. An update and review". Psychopathology 40 (3): 191–202. March 2007. doi:10.1159/000100367. PMID 17337940. 
  16. ↑ Paranoia: The Psychology of Persecutory Delusions.. Hove: PsychoIogy Press. 2004. ISBN 1-84169-522-X. 
  17. ↑ Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association. 2000. p. 299. ISBN 0-89042-025-4. 
  18. ↑ Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association. 2000. p. 325. ISBN 0-89042-025-4. 
  19. ↑ "Understanding delusions". Industrial Psychiatry Journal 18 (1): 3–18. January 2009. doi:10.4103/0972-6748.57851. PMID 21234155. 
  20. ↑ McKenna, Peter (2017-07-25). Delusions: Understanding the Un-understandable (1 ed.). Cambridge University Press. doi:10.1017/9781139871785. ISBN 978-1-139-87178-5. https://www.cambridge.org/core/product/identifier/9781139871785/type/book. 
  21. ↑ "Delusional Disorder". http://www.minddisorders.com/Br-Del/Delusional-disorder.html. 
  22. ↑ "Life hassles and delusional ideation: Scoping the potential role of cognitive and affective mediators". Psychology and Psychotherapy 89 (4): 445–463. December 2016. doi:10.1111/papt.12089. PMID 26846698. 
  23. ↑ Symptoms in the mind: an introduction to descriptive psychopathology. Philadelphia: W. B. Saunders. 2002. pp. 127. ISBN 0-7020-2627-1. 
  24. ↑ "Delusional disorder: molecular genetic evidence for dopamine psychosis". Neuropsychopharmacology 26 (6): 794–801. June 2002. doi:10.1016/S0893-133X(01)00421-3. PMID 12007750. 
  25. ↑ "Pretreatment plasma HVA predicts neuroleptic response in manic psychosis". Journal of Affective Disorders 48 (1): 83–86. February 1998. doi:10.1016/S0165-0327(97)00159-6. PMID 9495606. 
  26. ↑ "Age at onset of delusional disorder is dependent on the delusional theme". Acta Psychiatrica Scandinavica 97 (2): 122–124. February 1998. doi:10.1111/j.1600-0447.1998.tb09973.x. PMID 9517905. 
  27. ↑ "Family functioning and parent general health in families of adolescents with major depressive disorder". Journal of Affective Disorders 48 (1): 1–13. February 1998. doi:10.1016/S0165-0327(97)00105-5. PMID 9495597. 
  28. ↑ Symptoms in the mind: an introduction to descriptive psychopathology. Philadelphia: W. B. Saunders. 2002. pp. 128. ISBN 0-7020-2627-1. 
  29. ↑ "Assessment of psychopathology across and within cultures: issues and findings". Behaviour Research and Therapy 41 (7): 755–776. July 2003. doi:10.1016/S0005-7967(02)00190-0. PMID 12781244. 
  30. ↑ "Comparison of delusions among schizophrenics in Austria and in Pakistan". Psychopathology 32 (5): 225–234. 1999. doi:10.1159/000029094. PMID 10494061. 
  31. ↑ "The balance of biogenic amines as condition for normal behaviour". Journal of Neural Transmission 33 (2): 163–178. 1972. doi:10.1007/BF01260902. PMID 4643007. 
  32. ↑ "The Anatomy of Delusions". Genomics, Circuits, and Pathways in Clinical Neuropsychiatry. Elsevier Science. pp. 366–369. 
  33. ↑ Allgemeine Psychopathologie: Ein Leitfaden für Studierende, Ärzte und Psychologen. Berlin: J. Springer. 1913. 
  34. ↑ Jaspers 1997, p. 106
  35. ↑ "Delusion: what did Jaspers really say?". The British Journal of Psychiatry. Supplement 159 (14): 94–103. November 1991. doi:10.1192/S0007125000296566. PMID 1840789. 
  36. ↑ "Terms in the Field of Psychiatry and Neurology". http://www.abess.com/glossary.html#D. 
  37. ↑ Natural Selection and Social Theory: Selected Papers of Robert Trivers.. Oxford University Press. 2002. ISBN 978-0-19-513062-1. 
  38. ↑ "The context of delusional experiences in the daily life of patients with schizophrenia". Psychological Medicine 31 (3): 489–498. April 2001. doi:10.1017/s0033291701003646. PMID 11305857. 
  39. ↑ "On defining delusions". Comprehensive Psychiatry 31 (5): 377–397. 1990. doi:10.1016/0010-440X(90)90023-L. PMID 2225797. 
  40. ↑ "Wondrous strange: The neuropsychology of abnormal beliefs". Pathologies of belief. Oxford: Blackwell. 2000. pp. 47–74. ISBN 0-631-22136-0. 
  41. ↑ "The phenomenology of abnormal belief". Philosophy, Psychiatry, & Psychology 6: 1–16. 1999. http://muse.jhu.edu/journals/philosophy_psychiatry_and_psychology/toc/ppp6.1.html. 
  42. ↑ "Anomalous experience and delusional thinking: The logic of explanations". Delusional Beliefs. New York: Wiley Interscience. 1988. ISBN 0-471-83635-4. 
  43. ↑ Colman, Andrew M. (2015). A dictionary of psychology. Oxford quick reference (4th ed.). Oxford: Oxford University Press. pp. 441. ISBN 978-0-19-965768-1. https://books.google.com/books?id=UDnvBQAAQBAJ&pg=PA441. 
  44. ↑ "Use of fiction in therapy". Psychiatric Times 18 (7): 56. 2001. 
  45. ↑ "Afterword". Red Orc's Rage. NY: Tor Books. 1991. pp. 279–282. 
  46. ↑ "On the impossibility of defining delusions". Philosophy, Psychiatry, & Psychology 6 (1): 17–20. 1999. 
  47. ↑ "There and Back Again: Joseph Pierre, M.D.". Psychiatric Times 38 (1). 2021. https://www.psychiatrictimes.com/view/there-back-joseph-pierre. 
  48. ↑ "Faith or delusion? At the crossroads of religion and psychosis". Journal of Psychiatric Practice 7 (3): 163–172. May 2001. doi:10.1097/00131746-200105000-00004. PMID 15990520. 
  49. ↑ "Diagnostic Test List for Delusions". http://www.wrongdiagnosis.com/symptoms/delusions/tests.htm. 
  50. ↑ Mujica-Parodi, L.R.; Sackeim, Harold A. (2001). "Cultural Invariance and the Diagnosis of Delusions". The Journal of Neuropsychiatry and Clinical Neurosciences (American Psychiatric Association Publishing) 13 (3): 403–409. doi:10.1176/jnp.13.3.403-a. ISSN 0895-0172.  See section "A New Definition of Delusional Ideation in Terms of Model Restriction".
  51. ↑ "Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis" (in English). Lancet 394 (10202): 939–951. September 2019. doi:10.1016/S0140-6736(19)31135-3. PMID 31303314. 
  52. ↑ "Corrigendum: Does Cognitive Behavior Therapy for psychosis (CBTp) show a sustainable effect on delusions? A meta-analysis". Frontiers in Psychology 10: 1868. 2019-08-28. doi:10.3389/fpsyg.2019.01868. PMID 31555162. 
  53. ↑ "Immediate and Sustained Outcomes and Moderators Associated With Metacognitive Training for Psychosis: A Systematic Review and Meta-analysis". JAMA Psychiatry 79 (5): 417–429. March 2022. doi:10.1001/jamapsychiatry.2022.0277. PMID 35320347. 
  54. ↑ Critical Psychiatry: The Limits of Madness. Springer. 2006. ISBN 978-0-230-59919-2. 
  55. ↑ Models of mental health. Macmillan International Higher Education. December 2015. ISBN 978-1-137-36591-0. 
Cited text
  • General Psychopathology. 1. Baltimore: Johns Hopkins University Press. 1997. ISBN 0-8018-5775-9. 

Further reading

Classification

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