Delusions are deeply evidence-resistant. Patients with delusions are unmoved by evidence that is in direct conflict with the delusion, often responding to such evidence by offering obvious, and strange, confabulations. As a consequence, the standard view is that delusions are not evidence-responsive. This claim has been used as a key argumentative wedge in debates on the nature of delusions. Some have taken delusions to be beliefs and argued that this implies that belief is not constitutively evidence-responsive. Others hold fixed the evidence-responsiveness of belief and take this to show that delusions cannot be beliefs. Against this common assumption, I appeal to a large range of empirical evidence to argue that delusions are evidence-responsive in the sense that subjects have the capacity to respond to evidence on their delusion in rationally permissible ways. The extreme evidence-resistance of delusions is a consequence of powerful masking factors on these capacities, such as strange perceptual experiences, motivational factors, and cognitive biases. This view makes room for holding both that belief is constitutively evidence-responsive and that delusions are beliefs, and it has important implications for the study and treatment of delusions.
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Wang mostly discusses her experiences with the Capgras and Cotard delusion, which are fairly unusual delusions. These delusions arose, in her case, in the context of schizoaffective disorder, which is a diagnosis often accompanied by a wide range of (common and unusual) delusions.
The DSM’s definition of delusion has been subject to vigorous criticism, both for failing to distinguish delusions from non-delusional beliefs and for wrongly excluding some delusions from the category (Bortolotti 2018; Coltheart 2007). But few contest the claim that deep evidence-resistance is at least present in the vast majority of delusions.
I owe the term “intractable” to Reimer (2010).
Bortolotti and Miyazono (2015) helpfully center this argument in discussing the philosophical literature on belief.
See Helton (forthcoming) for illuminating discussion.
Note that one can accept doxasticism without holding that a full theory of delusions will be limited to studying delusional beliefs. As phenomenological approaches note, a full understanding of delusions involves understanding the subjective experience of delusions, which in turn may require studying more pervasive changes in the patient’s experience of, and perspective on, the world. See Bovet and Parnas (1993), Sass (1994), Sass et al. (2011), Sass (2013) for more on such approaches.
There are parallel debates about other candidate constitutive features of belief, such as inferential integration, action guidance, and reason-giving. On one side, doxasticists use delusions to argue that these are not constitutive features of belief; on the other side, defenders of traditional conceptions of belief appeal to these features to argue that delusions are not beliefs. Discussing these debates is beyond the scope of this paper. See Bortolotti and Miyazono (2015) and Bortolotti (2018) for overviews.
Gerrans (2001) argues for the related view that delusions are performance failures of the subject’s capacity for pragmatic rationality, i.e. the ability to apply rules of rationality in context. In his view, subjects with delusions have a capacity for pragmatic rationality, and just fail to apply it in a wide range of circumstances. Though this is similar to my view, we are concerned with different capacities: the capacity to respond to evidence, in my case, and the capacity to apply rules of reasoning in context, in his. Further, I am not equating delusions with failures to exercise such capacities, as Gerrans does. Instead, I explain why delusions are evidence-resistant in terms of masking factors on the subject’s capacities.
Thanks to an anonymous referee for pressing me to clarify the scope of my claim.
My discussion here draws heavily on Schellenberg (2018)’s discussion of capacities.
This is, of course, just one case. I do not here present data on what fraction of patients with delusions inferentially integrate the evidence in relevantly similar ways. The role of presenting case studies is to make vivid why certain kinds of behavior are indicative of the capacity to respond to counter-evidence. The pervasiveness of those kinds of behavior is a different matter. Thanks to an anonymous referee for pressing me to articulate the role of case studies in the argument.
Thanks to an anonymous referee for pressing me to clarify this point.
Though it is hard to get statistics on just how common evidence-avoidance is in delusion patients, empirically well-supported models (e.g. Freeman et al. (2001)’s model, which focuses on persecutory delusions) ascribe evidence-avoidance a significant role in delusion maintenance. This suggests that it is a pervasive feature of delusions.
Note two complications. First, there is an alternative explanation that is compatible with full evidence-insensitivity: perhaps subjects avoid gathering evidence because they don’t want to receive evidence of their own evidence-insensitivity (thanks to Andy Egan for suggesting this alternative explanation). But this explanation is inferior to the one I propose. It imputes to subjects beliefs about the degree of evidence-sensitivity of their own beliefs. And it does not match the phenomenology of confirmation bias, which is one of wanting to avoid being forced into a view one dislikes, or first-personal descriptions like the ones above. Second, this does not establish that patients have the capacity to respond to evidence to a rationally permissible extent; perhaps they have the capacity to respond by adjusting to some extent in the right direction, but not to a rationally permissible extent (thanks to an anonymous referee for pointing this out). However, it does indicate that counter-evidence can have some substantial effects on patients, which sits poorly with the intractability assumption. I will shortly discuss some reasons why patients with delusions may fail to respond to evidence to a sufficient extent, while still adjusting in the right direction.
Thanks for an anonymous referee for bringing these studies to my attention.
One might worry that this just pushes intractability one step back, to the intractability of these alternative views: why do they accept views that common sense would immediately dismiss? But liberal acceptance does not require failing to respond to counter-evidence to these implausible alternatives. More plausibly, patients simply fail to gather such evidence, in that they may fail to retrieve it from memory and are likely not to receive such counter-evidence from their environment at the moment of acceptance.
These findings cohere with phenomenological descriptions of delusion in schizophrenia, which highlight disturbances in background or bedrock certainties Rhodes and Gipps (2008), “a change in the totality of understandable connections” (Jaspers 1963, p. 97), or “a mutation of the ontological framework of experience itself” (Sass 2013, p. 633) as factors in the formation and maintenance of delusions. One would expect such disturbances to be reflected in accepting options that common sense dismisses.
This study considers only patients with schizophrenia.
As seen in our discussion of the bias against disconfirming evidence, they are typically swayed to a lesser extent than people without schizophrenia. But, as discussed there, this is no objection to the claim that they have and exercise the capacity to rationally respond to evidence in such cases.
The alternative is that they acquire this capacity in therapy, but lacked it beforehand. This alternative implies deep changes to the patient’s cognitive architecture over the course of a small number of therapy sessions, which is implausible.
This result should not be over-stated. CBT is relatively effective as a treatment for delusions, but this is in part because delusions are still poorly understood, and, as a result, we lack highly effective treatments. Indeed, most of the effect sizes found are in the small-to-medium range (Gaag et al. 2014), and there are many cases of delusions where this treatment does not work at all. That said, when it works, it is in part because the delusion is evidence-responsive. When it does not, this is likely due to the kinds of factors I will outline in §3.3.
This explanation paradigmatically applies to cases of Capgras that occur without a schizophrenia diagnosis, but Coltheart et al. (2007) argue that it also extends to such delusions in the context of schizophrenia. Similar explanations in terms of localized brain damage causing perceptual distortions have also been explored for other monothematic delusions.
This brief explanation omits many points of disagreement about Capgras formation. For example, some accounts hold that the first step in delusion formation is not a conscious experience but the mere lack of an autonomic response (Coltheart 2005). And some hold that the patient endorses the experience of seeing their partner as an impostor (Bayne and Pacherie 2004), instead of adopting it as an explanation for the experience that something is off in the interaction (Maher 1999; Stone and Young 1997). Others still think that the perceptual effects we find in Capgras are the result of a top-down disturbance (Campbell 2001: the experience is the result of the delusion, and not the other way around. Which of these views is correct is an interesting question, but it does not affect the point that delusion formation involves a strange experience, which is the key point for my purposes.
Most theorists agree that there are other factors involved in the formation of the delusion, such as a deficit in hypothesis evaluation (Coltheart 2007), reasoning biases such as the tendency to jump to conclusions (Garety and Freeman 1999), a liberal acceptance bias (Moritz and Woodward 2004, Moritz and Woodward 2005), or a bias toward privilege explanatory adequacy (i.e. privileging how well the experience is explained by the hypothesis over how probable the hypothesis antecedently is (McKay 2012)).
See Corlett et al. (2009) for an account of delusion maintenance that emphasizes the role of such reinforcement.
See the essays in Bayne (2010) for discussion of the relationship between delusion and self-deception.
Freeman and Garety (2004) argue that this is an important factor in the maintenance of persecutory delusions.
Thanks to Christopher Willard-Kyle for pressing me on this point.
See Mandelbaum (2019) for compelling defense of this claim.
Indeed, sometimes they explicitly consider other versions of the idea. See Bortolotti (2009), pp. 18–21.
My argument in this paper suggests a novel argumentative strategy for dealing with these debates. Instead of asking whether subjects with delusions act, infer, and feel in belief-characteristic ways most of the time, we should investigate whether subjects with delusions have the relevant capacities (e.g. for acting on a belief, drawing inferences from it, and experiencing corresponding emotional reactions). Focusing on capacities is a promising strategy for accommodating pervasive irrationality on the one hand, and theoretical and practical roles that belief is called upon to play on the other. Exploring this possibility is beyond the scope of this paper.
There is substantial unclarity about what normality consists in: is it the statistically normal case (here, of belief maintenance)? The case where the systems involved in belief maintenance meet their function, whatever that may be? The case that satisfies norms of rationality? This is an important unresolved methodological question in cognitive neuropsychiatry. I am here just assuming that there is some thin (non-moral) notion of normality that allows us to study the functioning and malfunctioning of cognitive mechanisms. Thanks to August Gorman for discussion.
Thanks to Sofia Jeppsson for bringing the nurturing stance to my attention.
Thanks to August Gorman for helpful discussion of the ethical implications of the view.
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Thanks to Elisabeth Camp, Andy Egan, August Gorman, Sofia Jeppsson, Hannah Read, Susanna Schellenberg, Ernest Sosa, Christopher Willard-Kyle, and three anonymous referees for helpful comments on previous versions of this paper. Thanks to Anita Avramides for first spurring my interest in this topic. Thanks also to participants in the Rutgers Epistemology Seminar and the Rutgers Junior Seminar for helpful discussion.
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Flores, C. Delusional evidence-responsiveness. Synthese (2021). https://doi.org/10.1007/s11229-021-03070-2