Models of Madness Neglect the Role of the Social World in Delusions

Cognitive models of psychosis commonly ignore ample evidence for the role of social processes in delusions.

Emaline Friedman, PhD

Delusions are typically characterized by irrationality and described as impairments to all-purpose inferential reasoning. In a theoretical piece in the Clinical Psychological Science journal, researchers led by Vaughan Bell at University College London argue that the cognitive models used to explain delusions neglect the substantial evidence for the social influences on delusions. Citing alterations in coalitional cognition (e.g., processes involved in affiliation, group perception, and strategic management of relationships), the researchers lay out the advantages of changing cognitive models to reflect delusions’ social form and content.

Alongside hallucinations, delusions are key to dominant characterizations of ‘serious mental illnesses,’ psychosis, and schizophrenia. Revolutionary grassroots organizations like the Hearing Voices Network have moved the needle on understanding hallucinations, creating a non-stigmatizing space in which those who hear voices have the opportunity to really listen to them. Delusions have not received as much attention and mostly remain consigned to stereotypes in the “black box” of irrational thinking.

A small groundswell of research suggests that delusions center on social beliefs and generally constitute adaptive, albeit very firmly held, strategies generated from past experiences. A few efforts take a humanistic tack, recognizing that the beliefs that some understand as delusions have a protective function and pointing to contexts in which highly unusual beliefs serve important social purposes. Some of this thinking is even reflected in cognitive-behavioral approaches to psychosis that aim to deflate exaggerations about the cognitive impairments leading to delusions and explain how commonplace distortions of thinking can amount to the appearance of delusions.

Bell and her coauthors argue that the inclusion of specific impairments to coalitional cognition in delusion-formation models would better explain the form and content of delusions. It would also account for the established role of mesolimbic dopamine in delusions, belief, and social organization.

First, the authors describe the predominant models of delusions. Some approaches explain delusions in terms of perceptual or linguistic impairments; most default to the age-old understanding that implies rationality impairment. Research attempting to prove impairments in domain-general rationality in patients with delusions has shown only minimal effects. This suggests a “validity gap” in the rationality-impairment approach to understanding delusions.

This approach has seemed viable only by failing to consider that healthy and adaptive social processes can form and maintain delusion-like beliefs by ignoring the most striking phenomenological characteristics of delusions—that they are overwhelmingly socially and relationally themed—and by disregarding the fact that delusions show reduced sensitivity to social context both in terms of how they are shaped and how they are communicated.

Moreover, this approach pins “irrationality” to current scientific knowledge about the natural world (e.g., humans’ thoughts do not control the weather), rather than context-specific demands on belief. The need to fit in creates a host of “functionally rational” irrational beliefs, as is evident in episodes of mass delusion, cults, and highly dogmatic religions that reflect relatively inaccurate models of the natural world.

In this light, many delusions are socially adaptive, and their content often involves key themes of adaptive social processes shaped by evolution. Common themes like “persecution, reference, guilt or sin, grandiosity, erotomania, jealousy, somatic changes, religion, mind-reading, external control, thought broadcast, insertion, and withdrawal” all involve social dangers, changes to social position, stigma, or affiliation. None of this common thematic content is taken into account in general cognitive impairment models of delusion.

The communication of delusions also shows individuals’ reduced sensitivity to social context by definition, as criteria for delusions preclude adherence to beliefs accepted by other members of a person’s culture or subculture. This strongly suggests the involvement of the mesolimbic dopamine system, which affects coalitional cognition and is found to increase dopamine turnover in patients with delusions.

“Converging evidence from multiple sources, including observational and experimental studies of delusion, models of normal belief, the social responsiveness of delusional beliefs, and the functions of mesolimbic dopamine, suggests that coalitional cognition is likely an important but currently overlooked component of explanatory models of delusional belief.”

The authors hypothesize that dysfunction to coalitional cognition processes like a reduced ability to strategically communicate delusion-related beliefs during group decision-making, inaccurate perception of group boundaries, and inaccurate perception of social status are good candidates for inclusion in models of delusion.

Adopting a new model specifying impairments to coalitional cognition has the advantages of better accounting for the form and content of delusional beliefs and distinguishing delusional from non-delusional but epistemically irrational beliefs. It would also better reflect the known function of the mesolimbic dopamine system that plays a large role in forming beliefs and managing social coordination.



Bell, V., Raihani, N., & Wilkinson, S. (2020). Derationalizing Delusions. Clinical Psychological Science. (Link)


  1. Someone is forcibly jailed in an institution. They are forcibly drugged and told the drugs will fix them. They continue to get worse because the drugs actually worsen all outcomes and the additional stigma and discrimination caused by being medically labeled “crazy, dangerous and mentally defective”. The mental health industry gets their family to spy on them and make sure they are taking the drugs.

    Paranoia in this case isn’t a delusion. It is manufactured by the mental health industry constantly lying, using force and hurting people. A common phrase is, “It’s not paranoia if they are really out to get you.” Everyone who has been through the the mental healthy system can one up that with, “It’s not paranoia when they already got me and a hundred million other people.”

    • To a psychiatrist any belief you could have, that’s wrong in their eyes, can qualify as a delusion. That includes obviously true believes about facts outside the psychiatrists knowledge.

      When I was locked up, I was allegedly psychotic. At no point in the documentation is there even a hint of what was supposed to be my psychotic belief. In a later court revision one of the psychiatrists explained it by me stating that I heard voices in the hallway before cops entered my appartement. Well, there were cops in the hallway who tried to annouce themselves. I just didn’t understand them as I was taking a shower. Reality is a delusion to those idiots.

      One of the doctors (not a psychiatrist) asked me if I thought I was being locked up just for the money. I did neither hold nor express that belief. At least not until I was asked. Fucking psychiatrists confusing their own thoughts for my delusions.

      • Right, in the PANSS scale (which is used to measure psychotic symptoms in drug studies) someone is labeled psychotic if they are hostile and suspicious in disagreeing with psychiatry.

        In studies testing drugs for depression someone saying they are mentally defective is considered a 2 point improvement on a 54 point scale. The average drug has a 1.5 point improvement in the short term biases flawed corporate studies.

      • If you are ever in the position again, perhaps tell them to write what they want. It really makes no difference to them what you say.
        Most ‘therapy’ really cannot refrain from diagnosing either.

        In fact, pretty much we can all diagnose each other, and boy oh boy, opinions about others flow freely. It’s just most of us don’t make a buck from doing so.

  2. Few have subscribed to the notion that delusions are attempts to understand the meaning of altered perceptions and that you might have the same or similar delusions were your perceptions altered in the same way. This is why you need to understand people’s experiential worlds before you pontificate about their “delusions”.