Psychosis patients ‘living in metaphor’ -- new study radically shifts ideas about delusions

People experiencing delusions during an episode of psychosis may be ‘living out’ a deeply held emotion, according to new research that provides a ‘radically different perspective’ on one of the most puzzling elements of psychosis.

About 2–3% of the UK and Australian population will experience psychosis at some point in their lives, with people commonly experiencing their first psychotic episode between the ages of 16 and 30 years old. Delusions are often described as fixed or false beliefs, understood to be reasoning or cognitive deficits and usually portrayed as incomprehensible and bizarre in popular culture.

New research by the University of Birmingham, University of Melbourne, and the University of York, in collaboration with the Australian youth mental health research institute Orygen, offers the first-known study of how delusions in psychosis are shaped by emotions and language, leading those experiencing delusions to ‘live in metaphor.’

The study has been published in The Lancet Psychiatry.

Conducted with young adults receiving care from Early Intervention in Psychosis services, the research combines clinical assessment, phenomenological interviews, and life-story narratives to explore how people’s sense of self and their perception of reality change during psychosis.

Dr Rosa Ritunnano, from the Institute for Mental Health at the University of Birmingham, consultant psychiatrist and author of the study, said: “Our research provides a radically different perspective on psychotic delusions, demonstrating how they emerge from the emotional, bodily, and linguistic fabric of people’s lives.

“For a long time, clinicians have struggled to understand where delusions come from and how they take shape. Our research offers new insight by showing how delusions are grounded in emotional experiences that involve great bodily turmoil.”

Strong emotions

The findings reveal that delusions are not isolated ideas produced by ‘glitches in the brain,’ but they reflect distinctive patterns of the body reacting to strong emotions or experiences of dissociation.

Participants described alternating states of intense emotional embodiment, such as feeling exposed, powerful, or connected to God, and disembodiment, such as feeling unreal or detached from one’s body, other people, and the world.

Before the delusions started, people often went through upsetting or traumatic experiences that triggered the same intense feelings they later felt during the delusions, especially being shamed.

Repeated negative experiences such as being publicly mocked and shamed by bullies could induce the bodily perception of being surveilled by others when no one is present (so-called ‘reference delusions’). These turn into persecutory beliefs that others are out to get them, and that an audience can literally see what they are doing or hear what they are thinking at all times — leaving no space for privacy (delusions of ‘thought broadcasting’).

Importantly, delusional experiences were not always negative. For some participants, they involved powerful feelings of awe, love, and spiritual connection, fostering a positive sense of identity and a renewed sense of hope about the future.

Figurative language

A striking feature of participants’ accounts was their use of figurative and metonymic language (expressions linking bodily sensations with complex emotions or abstract ideas). This helps explain why delusional content can appear unusual or bizarre. For instance, feeling ‘exposed’ or ‘tainted’ might be expressed through the beliefs of being watched by cameras or being contaminated (as in delusions of parasitosis).

The language reflects how emotion concepts take shape in bodily experiences, establishing fundamental cognitive links between, for instance, the emotion of parental love and the physical sensation of warmth, or the emotion of shame and the physical sensation of being 'seen' by others.

Jeannette Littlemore, Professor of Linguistics and Communication at the University of Birmingham and co-author of the paper, said: “We all use metaphors and narratives to understand our experiences and make sense of our lives. But psychosis patients do so more intensely. As a result of having endured strong (often negative) emotional experiences, which are then responded to by the body, and shaped by everyday language use, people experiencing psychotic delusions really are living in metaphor. People may feel delighted and say they are so happy they can ‘touch the sky’; this could lead them to experience the delusion of thinking they can fly.”

The study argues that better insight into how delusions come about can be used to create more effective care for people experiencing psychosis. Participants felt that there was no space to talk about the meaning of their delusions in the context of their treatment and recovery from psychosis, which led to more shame and increased the sense of being dismissed and marginalised.

The researchers highlight the importance of attending to people’s bodily and emotional worlds, and how they express them, when developing compassionate and effective approaches to psychosis care.

The paper concludes that delusions are not simply beliefs gone wrong, but embodied attempts to restore meaning and emotional balance when life becomes overwhelming. The metaphors and narratives people use are keys to understanding their suffering and are not signs of irrationality.

Reference:

Ritunnano, Rosa et al., Delusion as embodied emotion: a qualitatively driven, multimethod study of first-episode psychosis in the UK, The Lancet Psychiatry, DOI:,10.1016/S2215-0366(25)00341-4