Living In Metaphor: Why Psychiatry Should Treat Delusions As Whole-Body Experiences, Not "Just Faulty Beliefs"

But while delusions are extremely challenging for people who experience them, they also pose a number of issues for mental health professionals too. As Dr Rosa Ritunnano explained to IFLScience, “In clinical practice, I’ve seen how psychotic experiences can deeply affect people’s lives – and how mental health services often struggle to make sense of them in a way that resonates with the person’s own experience.”

“Psychiatry often defines delusions simply as false beliefs, focusing on whether they seem strange or unsupported by evidence. But that tells us very little about why that belief makes sense to the person having it.”

For example, someone may believe they’re being watched by those around them or by something unseen (known as a persecution delusion) because they feel as though they are constantly observed or threatened. This may not be true, but simply dismissing these often intense experiences can alienate people. As Ritunnano says, it leaves patients feeling “unheard” and clinicians “with only a partial understanding” of what’s going on.

This presents a significant challenge then, not just for patients, but also for those who seek to understand, study and ultimately treat psychosis. However, Ritunnano and colleagues have developed a new way of approaching delusions, one that steps away from seeing them simply as mental errors in need of correction. Instead, the team have devised a radically different perspective that regards episodes of psychosis as being a kind of embodied metaphor shaped by both language and emotions.

Psychosis – what we normally understand

Although it is not easy to know how many people experience psychosis, it is estimated that around 3 percent of people will have a psychotic episode during their lifetime. Most people will make a full recovery, and it is treatable. As with many things, though, it is widely accepted that the earlier people seek help, the better the outcome will be.

Generally speaking, people will experience their first psychotic episode between the ages of 16 and 30 years old, but 25 percent of those who develop psychosis will never have another episode.

In addition to delusional symptoms, such episodes can be accompanied by hallucinations that are not based in belief, but rather sensory stimuli that have no external source. For instance, someone may see things that are not there or hear voices.

Both these experiences disrupt a person’s perception of reality, but they are distinct symptoms of psychosis. Although most research has tended to study delusions and hallucinations once they are fully formed, a recent study has shown that delusions appear before hallucinations do, and both unfold gradually across over time. 

Delusions may begin subtly, with a growing sense of suspicion or unease. Similarly, hallucinations may gradually develop from an initially heightened sensation or vague sound – like static or gentle murmurs – before turning into clearly perceived voices.

This slow progression eventually culminates in the onset of psychosis in around 20 percent of those experiencing these early symptoms.

But how do we explain these experiences, especially delusions? As Ritunnano explained above, clinicians and psychiatrists have traditionally described delusions as either reasoning or cognitive deficits (known as the “deficit model”). But this approach, which is principally a quantitative one, tells us very little about what it means to experience these episodes and makes them inaccessible to other people, and especially medical professionals treating them. At the same time, popular culture often presents psychosis as incomprehensible, bizarre, and even potentially dangerous.

However, it should be noted that this negative portrayal is changing. A 2024 study showed that, over a 10-year period, characters in American TV shows who were depicted with psychosis were progressively less likely to be depicted as having been formerly incarcerated, engaged in criminal activity, or simply as villains. Instead, they are more likely to be portrayed as victims or even the protagonist, while also being attractive and contributing positively to society.

In order to overcome the clinical limitations of the deficit model, Ritunnano and colleagues from the University of Birmingham, University of Melbourne, and the University of York – in collaboration with the Australian youth mental health research institute Orygen – devised their new method that takes the subjectivity seriously.

The work was conducted with young adults receiving care from Early Intervention in Psychosis services in the UK, and combined clinical assessment with both phenomenological interviews and life-story narratives. This allowed the team to explore how people’s sense of self and their perception of reality changes during psychosis.

The results showed that delusions are not isolated ideas that come from glitching brains. Instead, it seems they reflect distinct patterns of the body reacting to strong emotions or experiences of dissociation.

When we focus only on brain mechanisms and ignore people’s bodily, emotional, and mental experiences, we risk losing sight of what those experiences mean to the person.

 Dr Rosa Ritunnano

Participants described alternating states of intense emotional embodiment - like feeling exposed, powerful or connected to God – and disembodiment – such as feeling unreal or detached from one’s body, or even other people or the world. Before these delusions set in, however, participants often seemed to go through some upsetting or traumatic experiences that triggered the intense feeling that would eventually manifest in their delusions, especially those associated with shame.

So, in a circumstance where someone is being repeatedly mocked or shamed by bullies, they may then experience the bodily perception of being surveilled by others when no one is present (what are called “reference delusions”). These turn into persecutory beliefs that others are out to get them or that some seen/unseen audience can literally see what they are doing or hear their thoughts – this eventually deprives them of any sense of privacy (delusions of “thought broadcasting”).

Another significant finding suggests that not all delusional experiences are negative. Some participants reported powerful feelings of awe, love, and spiritual connection, which produced a positive sense of identity and a renewed sense of hope for the future.

Embodied metaphor

One of the most important outcomes of this research was the frequent use of figurative and metonymic language (expressions that link bodily sensations with abstract ideas or emotions) participants used. This, the team believes, helps explain why delusional content often appears bizarre or unusual to other people. For example, feeling “exposed” or “tainted” can manifest as the belief that the person is being watched by cameras or being contaminated in some way (known as delusions of parasitosis).

In this sense, people who experience psychotic delusions are living in metaphor.

“Metaphors can operate on different levels,” Jeannette Littlemore, Professor of Linguistics and Communication at the University of Birmingham, told IFLScience. “Sometimes they're simply expressions whereas other times they can be more experienced through the body.”

For example, someone who doesn’t experience psychosis may see someone as being “cold”, which means they’re unfriendly. In some situations, this can lead people to actually feel colder in that person’s presence.

“This can happen to all of us and there is a good body of research showing that the linguistic and bodily based meanings of metaphor are very closely related,” Littlemore explained.

“However, when a person is in psychosis and is experiencing the metaphor as part of their reality, they are more likely to be experiencing it in a bodily way most of the time and perhaps taking it to extremes. They might then create a narrative around the metaphor in order to explain it.”

Treatment is more than biology

This discovery adds new dimensions to how we understand psychosis and how we can approach people who experience it. In particular, the insights can be used to create new care options that take the narrative core of patient’s experiences more seriously.  

“When we focus only on brain mechanisms and ignore people’s bodily, emotional, and mental experiences”, Ritunnano said, “we risk losing sight of what those experiences mean to the person. In that sense, research can start to miss something essential about being human. This is particularly important for delusions.”

There appears to be a common near universal basis for many metaphors but there are small variations across languages that may indeed shape the ways in which speakers of different languages experience psychosis.

Professor Jeannette Littlemore

“Delusions are not just faulty beliefs; they are embedded in emotions, bodily sensations, and personal histories that unfold over time. When we skip over these layers of meaning – moving straight from lived experience to abstract scientific categories – we lose important information and risk distorting the very phenomenon we are trying to understand. Our work argues that to understand delusions properly, we need to take their narrative and emotional structure seriously, alongside biological explanations.”

One approach could be for psychiatrists to attend more carefully to how emotions are felt in the body, as well as the life situations that brought them into being. By approaching them narratively within a “life-as-a-whole context”, Ritunnano says, there is a space for patients to make sense of their delusions without reinforcing their literal content.

“Our findings also point to the potential value of bodily-oriented and movement-based approaches, alongside talking therapies and medication. If delusions are grounded in states of emotional hyper-arousal or, conversely, emotional detachment, then interventions that help regulate bodily arousal or promote emotional attunement may be particularly helpful,” she explained.

There are several ways to do this. It could include approaches that focus on movement – such as rhythm and posture, or interpersonal synchrony (a non-verbal form of attunement between psychiatrist and patient) – as well as therapeutic environments that reduce stress and offer a sense of safety.

“This kind of work – whether through conversation, embodied interventions, or the therapeutic environment itself – can potentially reduce shame, improve trust, and make treatment more responsive to what patients themselves find meaningful.”

At present, it is unclear to what extent these embodied metaphors are universal experiences for people across the world. As Littlemore noted, there are “variations in terms of the ways in which [...] metaphors manifest in language and some of the more body focused metaphors vary in terms of the organs” they refer to.

For instance, we may think about love being associated with the heart, but in Malay, that emotion is located in the liver. The seat of the emotions is therefore a cultural and historical point, which changes across time and geography. However, Littlemore says that many metaphors are likely universal.

“There appears to be a common near universal basis for many metaphors but there are small variations across languages that may indeed shape the ways in which speakers of different languages experience psychosis.”

The team suggest future research could explore more creative methods to reach a wider range of participants and to explore their lived experiences in more detail. But for now, it the study clearly shows that delusions are not just false beliefs that need to be corrected. In contrast, they are sources of meaning for those who experience them.

“Taking this perspective seriously doesn’t replace biological explanations or treatments,” Ritunnano concluded, “but it complements them. It opens up more humane, personalised ways of listening to patients and thinking about care – ways that recognise people not just as carriers of symptoms, but as individuals trying to make sense of their world.”

The study is published in The Lancet.