The Insight Paradox

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A recurrent theme in popular Hollywood films is that delusions help us in powerful ways. Films like Shutter Island, A Beautiful Mind, and Memento depict characters who have a momentary, painful insight into their delusions. Rather than leading to health and wholeness, their insights nearly destroy them.

Is this anything more than a Hollywood trope? Can delusions provide a protective buffer against a world that’s too painful to bear? If so, what happens when we return to reality?

I've written in this venue (here and here) on the surprising ways delusions can help us. Here I want to address a relatively new body of evidence for this claim. The “insight paradox” refers to a phenomenon in which the very thing that’s supposed to help – seeing our delusions for what they are – actually hurts.

“Insight” is a complex, multidimensional measure of one’s awareness of one’s mental illness. Put simply, it’s what fictional Hollywood characters gain in the moment of truth when they grasp the nature of their delusions.

Discovering that one has been in a delusional world can give rise to depression, hopelessness, low self-esteem, and even suicidal thoughts and feelings. But if the step that’s supposed to heal ends up hurting, that suggests some delusions, far from being mere byproducts of a disordered mind, are designed to protect us. What does that mean for treatment?

The Insight Paradox

Delusions are seemingly bizarre beliefs that are firmly held, even in the face of strong counterevidence. They don’t generally have widespread cultural support. That’s why religious ideas, even those that seem strange, don’t count as delusions.

Delusions are a common feature of schizophrenia, but they can also accompany depression and bipolar disorder. The belief that I’m the second coming of Christ, that a secret government organization is communicating with me through the radio, or that a celebrity is in love with me, are examples of delusions.

If delusions are a symptom of a brain disorder, one might expect people to be relieved to get rid of them. But psychiatrists have observed for decades that patients recovering from delusions can feel deep sadness, shame, and hopelessness.

In the last several years, this observation has been substantiated on a large, international scale. A 2016 study that included nearly 90 schizophrenic patients, carried out by Martino Belvederi Murri at the University of Ferrara, Italy, and colleagues confirmed a striking correlation between insight into symptoms and depression. A 2018 study with over 100 patients, by Winnie Mak and colleagues at the Chinese University of Hong Kong, corroborated this and demonstrated a link to self-stigma. A 2020 meta-analysis confirmed that insight can negatively impact one’s quality of life.

This raises a crucial question: What causes the low mood that often follows the loss of delusions?

Losing one’s delusions

One cause is stigma. Sadly, schizophrenia is still associated with stigma. In fact, despite decades of biomedical explanations that were supposed to fight stigma, it's getting worse.

Discovering that one has been in the grips of a delusion can stir up all of the negative connotations of having a serious mental disorder ("I’m crazy”) and the social anxieties it provokes (“How will others see me now?”).

But those Hollywood films have suggested a second cause—that delusions can give people a profound sense of purpose, meaning, and significance in life. The belief that a celebrity is in love with me and is communicating with me through their albums, or that the government has given me a mission of profound geopolitical significance, can be exhilarating. To lose one’s delusion may be to lose a potent sense of meaning, too.

A recent paper by Louise Isham, consultant clinical psychologist and NIHR Clinical Doctoral Research Fellow at Oxford, has shown that grandiose delusions—those that center around an exceptional calling or ability—are connected to a powerful sense of meaning in life. Similarly, Rosa Ritunnano, a psychiatrist and philosopher at Birmingham University’s Institute for Mental Health, has recently shown that there’s a whole category of delusions that are best seen as the mind’s attempt to come to grips with a life crisis.

As philosopher Lisa Bortolotti emphasizes in a forthcoming book, the fact that delusions can give us a sense of meaning, or protect us from a difficult circumstance, might help us understand why losing one’s delusions can be so painful. For example, Isham describes the “sense of loss” that some feel after losing their delusions. As one participant puts it, “You slip into quite a deep depression after you realise…it’s not like you go from a feeling of being really important back to where you were before; you go from really important to really unimportant.”

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Implications for treatment

What does the insight paradox mean for therapy? In the 1980s and 90s, one of the leading biological theories of schizophrenia was the dopamine hypothesis. It held that schizophrenia was due to excessive dopamine levels. The solution? Drugs that block your dopamine receptor. Such treatment is suboptimal for many because it can produce serious movement disorders, but a more subtle effect is that it might rob you of the very anchor that gave your life a sense that it was worth holding onto. Understanding that delusions might be purposeful rather than pathological suggests that we need to think about how to put alternative meaning structures in place for recovering patients.

As Bortolotti points out, the insight paradox might have wide-ranging social consequences. Even though conspiracy theories aren’t generally considered to be delusions, it’s likely that they have similar psychological benefits. Conspiracy theories like the famous “Pizzagate” theory can give people a sense of identity, belonging, and purpose. When such conspiracies are debunked, true believers face severe disappointment. It might be psychologically easier to elaborate the delusion rather than drop it entirely. Perhaps this is one reason conspiracy theories are so hard to topple.