Uncovering the Realities of Delusional Experience: A Qualitative Phenomenological Study

Background: Delusions in schizophrenia are commonly approached as empirical false beliefs about everyday reality. Phenomenological accounts, by contrast, have suggested that delusions are more adequately understood as pertaining to different kind of reality-experience. To date, however, the specific nature of delusional reality-experience has not been subject to systematic empirical study. It is also unclear how this alteration of reality-experience should be characterized, which dimensions of experiential life are involved and whether delusional reality may differ from standard reality in various ways. Furthermore, little is known about how delusional patients value and relate to these experiential alterations. This study aimed to investigate the nature of delusional reality-experience, and its subjective apprehension, in individuals with lived experience of delusions and a schizophrenia-spectrum diagnosis.  Methods: In this study, individuals with lived experience of delusions and a schizophrenia-spectrum diagnosis formed a purposeful sample. Phenomenologically driven semi-structured interviews were conducted to explore the nature of delusional reality-experience and participants’ subjective valuation of these experiences. Interpretative Phenomenological Analysis (IPA), a qualitative method tailored to the in-depth exploration of participants’ first-person perspective, was used to analyze participants’ accounts.  Findings: Between Mar 2, 2020 and Sep 30, 2020, 18 adults with a clinical schizophrenia-spectrum diagnosis and lived experience of delusions participated in the interview-study. The findings suggest that delusions are often embedded in wide-ranging alterations of basic reality-experience, involving quasi-ineffable atmospheric and ontological qualities that undermine participants’ sense of the world as unambiguously real, fully present, and shared with others. We also found that delusional reality-experience can differ from standard reality in various way (i.e., in a hypo –and hyper-real form), across multiple dimensions (e.g., meaningfulness, necessity/contingency, detachment/engagement), and that participants are often implicitly or explicitly aware of the distinction between delusional and standard reality. Finally, delusional experience can have an enduring value and meaning that is not fully captured by a strictly medical perspective.     Interpretation: Increased awareness and recognition of the distinctive nature of delusional reality-experience, in both clinical and research settings, can improve diagnostic accuracy, explanatory models, and therapeutic support for delusional individuals whose lived realities are not always evident from an everyday perspective. Funding Statement: FWO Flanders - 12Q3319N Declaration of Interests: We declare no competing interests. Ethics Approval Statement: Ethical approval for the study was obtained from Ghent University Hospital Ethics Committee (EC/2019/0042). All participants gave written informed consent, including for use of anonymized quotes.