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Notes -
Thank you for this, very insightful.
To add specificity, I'm interested in that demarcation point related to neurosis and delusion. Where does perception end and earnest (and non-reality based) belief begin?
To illustrate, image there's someone who has a unshakeable belief that they're going to get fired from their job. They believe it's just a matter of time. Maybe they can point to a causal chain that gets them there ("My last project didn't go well with a customer" / "I know that this other team similar to mine got downsized" etc.). What matters it that their belief in the inevitability of being fired is as strong as "the sky is blue." It's essentially self-evident to them. They catastrophize over it, definitely are neurotic in the fixation on it, perhaps rising to the level of obsession in the OCD context. They begin to see adverse impacts on all areas of their life; diet and exercise suffer, they stop attending social engagements, become withdrawn, and, as a perverse self-fulfilling prophecy, their work performance suffers.
It's my understanding that that would NOT be characterized as schizophrenia regardless of the intensity of the beliefs or their adverse impacts. They aren't erroneous and any objective factual issue (like the "neighbors from Mars" illustration you provided) they simply have an extreme perceptional bias they can't be worked out of. But, at that level of extreme, are we talking about something that qualifies as delusion?
Or, is this more in the territory of mood disorders a la MDD or Bipolar? Maybe this is somewhere in those weird border-borderline diagnoses like schizoaffective?
As you stated, schizophrenia is a progressive illness. People don't go from waking up one day without symptoms to tearing out their walls looking for the listening devices the next. It starts and grows with a little more subtlty. In my (admittedly amateur) epistemology reading, this seems to mirror the perception-to-belief continuum I see debated so often.
None of this is easy.
Some thoughts.
-One offered definition of delusion is: "a delusion is a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary." Not mentioned here is the importance of cultural context. One of the reasons why it's not appropriate to label a Democrat or Republican, or a woke activist, or a ghost believer, or a religious person delusional is because their is some element of shared cultural support for the beliefs. This is important to keep in mind.
-Level of fixation and ignoring evidence to the contrary is variable. Delusions are some of the hardest symptoms to treat with medication but they can be treated, at times very successfully. Patient when less sick (and sickness can be caused by stress, sleep deprivation, medical sickness) may find that they still believe the thing but have the insight to lie about it to someone else (which they may not when fully decompensated), may be willing to say something like "I guess it's possible that this isn't true" or many have it resolve in totality.
-With schizophrenia it is more common to have a prodrome and/or progression of symptoms but it's not universal, especially with complicated factors like medical illness, severe stress, drugs, and other psychotic disorders like bipolar with psychotic features. Schizophrenia specifically involves a combination of factors and you'll generally see the negative symptoms, gross disorganization and other things that give you the whole "this guy is crazy" vibes. Disease like "delusional disorder" exist (patient believes one thing or a category of things without the other symptoms like hallucination and functional decline. Example: husband absolutely convinced his wife is cheating on him and seemingly nothing else is wrong. These patients can be very "safe" but are extremely terrifying to me on an existential level lol.
-As above mental illness is often defined as deviation from cultural norms and functional impairment. This gets hairy. Homosexuality was at one point a mental illness, does not appear appropriate now....but by this definition is that only because it's now culturally acceptable? Woke people with woke anxiety appear to be deviating from cultural norms and often have severe functional impairment, but they are social support for the beliefs. Shit's complicated.
-In the case of the more traditional disease like schizophrenia we can look at brain imaging, see things improve with antipsychotics but our understanding of what's going on is incomplete and the philosophical questions have tension with the medical ones.
-Often we are just saved by the fact that most people who are sick and present themselves for psychiatric care are obvious. Their are other types of mental illness that are more often seen by non-psychiatric doctors for general medical care because they stay out of trouble and function well (ex: schizoid personality disorder). This complicates matters.
-Other types of psychiatric disease like OCD, Autism, and Anxiety can appear psychotic and push into psychosis territory (maybe even become psychosis?).
-Leaning on formal diagnostic criteria helps greatly for reducing ambiguity but again most cases are obvious. It is possible that not obvious cases exist in large numbers and healthcare just doesn't see them because they don't need it.
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