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Research Article                                                                                                                                        Open Access

## Continuity between Stressful Experiences and Delusion Content in Adolescents with Psychotic Disorders - A Pilot Study

Gennaro Catone 1,2* , Simone Pisano 1 , Matthew Broome 2 , Juliana Fortes Lindau 2.3 , Antonio Pascotto 2 and Antonella Gritti 4

1 Dept. of Mental and Physical Health and Preventive Medicine, Child and Adolescent Psychiatry Division, Second University of Naples, Italy 2 Dept. of Psychiatry, Warnerford Hospital, University of Oxford, UK 3 NESMOS Dept. (Neurosciences, Mental Health and Sensory Functions, Sapienza University, Rome, Italy 4 Faculty of Education Sciences, Suor Orsola Benincasa University, Naples, Italy

*Corresponding author: Gennaro Catone: catoge@libero.it

## Abstract

Background: Delusions are usually considered core symptoms of schizophrenia, but they are in fact associated with a wide range of psychiatric disorders. The content of a delusion is often related to stressful life experiences that preceded the delusion. Objective: The aim of this study is to detect whether there is a link-specifically, a thematic link-between past experiences and delusion content that connects the two events via thematic analogy.

Method: The sample population evaluated for this study consisted of 16 consecutive patients with delusions between the ages of 9.9 and 16.5 years. All patients were experiencing their first psychotic episodes and were not taking any medications. Data were obtained from transcribed clinical sessions.

Results: The data suggested the presence of a thematic link between previous experiences and the contents of delusions for 15 patients (93%). Humiliating events, including bullying, are more likely to be linked to persecutory delusions ( p = .004).

Conclusions: If a thematic link between past experiences and delusion content does exist, this may provide a means of greater psychotherapeutic understanding.

Keywords: Psychosis; delusion; children and adolescents; bullying; paranoia

## Introduction

Delusions are 'fixed beliefs that are not amenable to change in light of conflicting evidence' (1), and they are  a  feature  of  schizophrenia  and  other  psychotic disorders.  In  addition,  delusions  can  be  found  in patients  with  mood  disorders  and  in  those  with certain  organic  disorders  (2,  3).  Delusions  were considered the hallmark of mental illness for a long time,  and  they  have  always  been  the  subject  of psychopathological debates. To define true delusions from  the phenomenological  perspective, Jaspers emphasized three fundamental criteria that are still considered  milestones  in  the  psychopathology  of psychosis: certainty, incorrigibility, and impossibility of content (4). An essential problem of the psychopathology of delusions was Jaspers' notion of the understandability of the condition resulting from particular events or emotional conditions, how this could be characterized, and how such a distinction could be used to demarcate primary or true delusions from secondary or delusion-like ideas. In this regard, the  third  criterion  of  impossibility  of  content  only becomes  applicable in the event of a primary delusion (and thus not for secondary delusions).

The concept of understandability arises from Dilthey's hermeneutic method and the wider idea of verstehen in the German social sciences of the late nineteenth and early twentieth century, which means 'interpretative understanding'  and  refers  to  experiencing  another person's thoughts and emotions from the inside and being able to follow the psychic connections between mental events (5). In the field of clinical psychiatry in the  last  century,  Kretschemer  contributed  to  this debate by arguing for a continuum  that links personality  structure,  experiences,  and  emotions to delusion onset, emphasizing that each delusion may be  understandable  if  psychopathological  analysis  is investigated thoroughly enough (6). Bleuler delineated the thematic report of a delusion with the affected  person's  wishes  and  fears  and  the  formal report with the nuclear phenomenon of dissociation (7). Schneider introduced the term delusional perception as a first-rank symptom of schizophrenia (8).

From the psychodynamically informed perspective,  Freud  formulated  the  hypothesis  that,  in psychosis,  the  libidinal  drives  are  withdrawn  from object representations, and they converge regressively around fixation points. The delusion is formed  through  the  work  of  the  mechanisms  of projection and denial. For Freud, the construction of the delusion responds to specific defensive goals; the formation of the delusion is an attempt to reconstruct  a  new  reality  that  makes  sense  to  the patient and that allows him or her to control a world that  has  become  fragmented.  The  delusion  would thus be organized around a fragment of reality that involves the patient's childhood experiences. When explaining  paranoia,  Freud  outlined  the  role  of humiliation and social defeat (9, 10). Jung suggested that impulses from the unconscious mind speak to individuals as visions or voices, and this interpretation led to a better understanding of what psychotic  symptoms  may  be  trying  to  tell  us  (11). More recently, Lucas highlighted the importance of the meaning of psychotic symptoms in the process of psychoanalytic treatment (12).

These initial  observations  introduced  the  distinction  between primary delusions (those that are not understandable) and secondary delusions (those that are more related to an affective state, external events, or  other  psychopathological  symptoms),  but  this discussion is still ongoing. The problem of understandability  is  more  complex.  Indeed,  a  link between delusion content and previous experiences or emotional conditions may often be noticed, but the  nature  of  this  link  is  hard  to  understand.  This complexity  arises  from  the  meaning  of  the  term understandability. Is the application of this term related to the patient's psychological history or to his or her life history? In phenomenological research, the concept of understandability is often considered, but the  term  has  a  twofold  interpretation,  particularly with  regard  to  delusions.  Understanding  can  be defined in terms of psychological history and the idea of attempting to grasp the change from the previous non-delusional  state  to  the  present  delusional  one. Alternatively, it can be defined more biographically in  terms  of  the  patient's  life  history  and  how  the content of the delusion may be included in the frame of the patient's history. The concept of understandability remains difficult to interpret (precisely  because  mental  illness  drags  the  affected individual into an unusual experience) and therefore difficult  to  grasp.  However,  it  is  definitively  the phenomenological  approach  that  marks  a  turning point in this discussion through its inquiry into the understanding  of  forms  of  experience.  Ratcliffe suggested that the phenomenological stance creates a  kind  of  empathy-properly, a  radical  empathythat allows for the interpretation of several changes in the structure of experience. This radical empathy is  a  mode  of  understanding  via  accepting  different types  of  'finding  oneself  in  the  world,'  whereas other forms of empathy are accomplished through the presence of a shared backdrop of similar experience (13).

The issue of understandability is still debated, and it  has  been  investigated  in  recent  psychopathology research.  For  example,  the Diagnostic  and  Statistical Manual  of  Mental  Disorders,  Fifth  Edition, recognizes delusions  as  not  being  bizarre  if  they  are  derived from life experiences and linked by the presence of an epistemological criterion to the culture of belonging (1). The first observations of the association  between  previous  experiences  and  the contents of psychotic symptoms have emerged in the fields  of  cognitive  and  social  psychiatry,  especially with respect to childhood sexual abuse and maltreatment.

In the context of social psychiatry, Read stated that studies have found that the content of hallucinations and  delusions  is  frequently  linked  to  abuse  (14). Patients with a history of childhood abuse are more likely  to  experience  positive  psychotic  symptoms, and the content of those symptoms could be linked at least 50% of the time with the associated traumatic experiences. In particular, it was found that hallucinations were most often associated with sexual abuse and that delusions were associated with physical abuse (15). Romme and Escher carried out important  research  in  this  field,  and  they  have demonstrated that the hearing of voices is frequently correlated with traumatic experiences. In their sample  of  children  who  were  hearing  voices,  they found one or more traumatic events to have occurred around the time of the onset of the voices. These traumas concerned confrontation with death, problems at home or at school, physical conditions that interfered with development, and trauma related to sexuality (including sexual abuse) (16). Escher and colleagues were also interested in delusions and in the factors that determined delusion formation in children who were hearing voices. They found that baseline stressful life events and several characteristics of voices were all related to the onset of the delusions (17).

The  origins  of  delusions  have  been  debated  and can be summarized by two main hypotheses. According to Kraepelin, the first of these-the basic reasoning  deficit  hypothesis-states  that  a  basic defect in the reasoning of deluded individuals exists and that, without this defect, no delusion would have been created. The second hypothesis-the anomalous  experience  hypothesis-states  that  the delusion arises in an attempt to explain anomalous conscious experiences (18). A third model from the field  of  cognitive  psychology  has  been  recently reviewed by Garety and Freeman (19). The potential merit of this new approach is related to the study of delusions  as  a  symptom  transdiagnostically  rather than  as  part  of  a  particular  disorder.  A  literature review demonstrated that the theories that underlie delusion  are  different  but  that  detailed  cognitive models highlight the contribution of both emotional and reasoning processes (19, 20).

Various models have implications for both theoretical  and  practical  approaches,  such  as  early intervention  and  psychotherapy  (21).  The  roles  of emotions and life experiences are strictly conceived as  explanations  for  delusion  psychopathology,  and our study is part of this discussion. We started with the assumption that there is a statistically significant association between past experiences and psychotic symptom content, and we are interested in the nature of this association and in whether it is meaningful. This interest is supported by previous observations from  the  field of cognitive behavioral therapy, specifically that 'many symptoms of psychosis have a  content  that  can  be  meaningfully  related  to  past personally significant experience' (16). Furthermore, previous work by Hardy and colleagues explored this topic in adults with hallucinations (22), and our intent is to continue on the path laid out by this and other research (17, 23-25).

We explored the hypothesis that this connection may be considered a thematic link (TL) in addition to reflecting causal or temporal aspects. A TL connects the two events via analogy and develops a biographical  continuity  between  the  two  events; hence, certain elements of the content of the delusion may  be  influenced by the themes  of previous  life  experiences.  We  used  a  mixed  study method that was derived from both phenomenological and empirical inquiry, that emphasized  the  hermeneutic  tradition, and  that incorporated  Jaspers'  view  of  phenomenological psychopathology and his method of studying subjective  experiences  (26).  This  mixed  method involves a qualitative and quantitative design that was developed to extrapolate conclusions regarding the association between life experiences and the content of a delusion. In other words, the interviewer would be able to identify similar themes when listening to narrations describing both previous experiences and the delusion itself. We studied a sample of children and adolescents to address the lack of studies of the contents of delusions in this population.

## Methods

Study Design

The  study  design  consisted  of  a  cross-sectional evaluation  of  the  clinical  and  psychopathological features of a cohort of psychotic delusional adolescent patients and focused on the content of the patients'  delusions.  The  assessment  of  delusional content  was  made  contemporaneously,  and  past experiences were then assessed retrospectively. Patients were enrolled at the Child and Adolescent Psychiatry Unit of the Second University of Naples from 2009 to 2012. They were consecutive patients who were experiencing their first episodes of psychosis.  All  subjects  were  referred  for  psychotic symptoms  and  diagnosed  with  psychotic  disorders (schizophrenia/schizoaffective, psychosis not otherwise specified, delusional disorder, or affective psychosis) according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text  Revision (1).  Patients  were  assessed  with  the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version (27), which was administered by a child and adolescent  psychiatrist  who  had  experience  with psychosis. All subjects were medication-free during the  research  period.  The  exclusion  criteria  were  as follows: intelligence quotient of less than 70; concomitant major neurological disease; current or previous diagnosis of pervasive developmental disorder; current or previous diagnosis of substance abuse disorder; and acute suicidality. To corroborate the  presence  of  a  formal  thought  disorder  in  each patient,  an  Italian  version  of  the  Child  Behavior Checklist (28) was obtained from parents or caregivers.  The  Child  Behavior  Checklist  is  a  118item standardized questionnaire that allows for the recording  of  behavioral  problems  among  children who are 6 to 18 years old, and it is widely used in clinical  and  research  practice.  We  considered  the Thought Problems subscale in particular.

## Data Collection

Data collection occurred via three unstructured 45minute sessions with a trained child psychiatrist for each participant. The clinicians who performed these sessions  were  blinded  to  the  study  design,  the research  aims,  and  the  hypotheses.  To  enable  the patients to be free to convey their spontaneous flow of  thoughts,  clinicians  were  asked  not  to  interfere with the sessions. However, during the last session and for research purposes, clinicians were asked to directly address the patients to try to obtain information about the patients' previous experiences. The clinicians were allowed to use neutral sentences that  could  allow  the  patients  to  think  about  their pasts without invoking specific events (e.g., 'Tell me something more,' 'What can you remember about...?'). The sessions were performed every day and  transcribed  soon  after  they  were  performed. Each  session  was  performed  in  the  same  room, which was furnished as neutrally as possible, and at the same time on each day. The sessions were not tape-recorded: a recorder could be viewed as highly persecutory  by  some  patients,  and  the  clinicians needed  to  be  actively  and  empathically  listening during the interviews.

## Data Coding and Analysis

We  differentiated  the  methodology  of  the  data analysis as being either qualitative or quantitative; this mixed  model  seemed  the  best  method  to  use  to address the purpose of the study. With regard to the qualitative  aspect  of  the  analysis,  two  investigators (GC  and  SP)  examined  the  recorded  sessions  but were blinded to each other's analyses.

First, the investigators were asked to judge whether they  felt  a  TL  existed  between  the  patient's  past experiences and the contents of his or her delusions. They were then asked to label each patient's experiences.  Past  events  were  evaluated  from  a dimensional point of view regarding their meaning for patients, and they were grouped according to four themes.  Three  of  these  themes  were  based  on adapted definitions for the patient's developmental age at the time of the stressful event based on the Life Events and Difficulties Schedule (29): humiliating experiences, which included social devaluation (e.g., bullying, hypercriticism, marginalization); loss experiences, which mainly referred to the loss of a person who was important to the patient (e.g., mourning, neglect); and intrusive experiences,  which  involved  intention  to  harm  by others (e.g., sexual abuse, physical aggression). The last theme  included  was  biological  events  (e.g., illness, pubertal changes); we included this category because pubertal development during adolescence is a complex  task  that is related to socialization, concerns  about body  image, and  the onset of adjustment problems (30). For these first two tasks, we  calculated  Cohen's  kappa  to  assess  inter-rater reliability.

Finally, we asked the investigators to describe each patient's delusion content and type according to the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version (27). All information acquired for research purposes was then corroborated through semistructured  interviews  with  the  patients'  parents  or caregivers and their teachers. (31). The quantitative analysis  was  performed  post  hoc  to  assess  the relationship between experiences and delusions. Only  humiliating  events  and  persecutory  delusions were frequent enough to allow for statistical analysis, so previous experiences were dichotomized as humiliating/other, and delusions were dichotomized as persecutory/other. Any correlation between binary  variables  was  ruled  out  with  the  use  of Pearson's chi-squared test and the phi coefficient as determined by SPSS 18 software. Written informed consent  was  obtained  from  the  parents  or  legal guardians of each patient. The study was approved by the ethical committee of the Second University of Naples and performed  in accordance with the Declaration of Helsinki.

## Results

## Demographic Data

The final sample was composed of 16 patients (mean age,  13.4  years;  standard  deviation,  ±  1.49  years; range,  9.9  to  16.5  years),  7  of  whom  were  female (43%). Their diagnoses were as follows: 5, psychosis not  otherwise  specified  (33%);  5,  schizoaffective disorder  (33%);  3,  schizophrenia  (18%);  and  3, delusional disorder (18%). Seven patients (43%) had at least  one  comorbidity (e.g., multiple anxiety disorder,  obsessive-compulsive  disorder).  For  the Thought Problems subscale of the Child Behavior Checklist, the mean T-score was 79 ± 4.3, with all patients  having  scores  that  were  higher  than  the clinical cutoff.

## Characterization of Delusions and Life Experiences

Two patients demonstrated more than one type of delusion. The total number of delusions analyzed was 18, and they were distributed as follows: 8, persecutory (42%); 4, somatoform (21%); 2, grandeur (including sexual) (10%); 2, nihilistic (10%); 1, guilt (5%); and 1, control (5%). The total number of  experiences  analyzed  was  18,  and  they  were distributed as follows: 9, humiliating (52.9%); 4, loss (23.5%); 4, biological (23.5%); and  1, intrusive (5.8%).  There  was  only  one  case  in  which  neither investigator  was  able  to  link  the  patient's  previous experiences to  his  or  her  delusion  content:  Patient no. 1, who had a persecutory delusion but no history of humiliating experiences. For all other cases, both investigators  agreed  about  the  presence  of  TLs. However,  there  was  one  case  for  which  the  two investigators  did  not  agree  about  how  to  label  the experience: Patient no. 8, who had an experience that GC  labeled  as  humiliating  and  that  SP  labeled  as biological.  Inter-rater  reliability  between  the  two researchers  was  very  good  (Cohen's  kappa,  0.893; 95% confidence interval, 0.687 to 1.098). Persecutory delusions  were  found to  be  significantly  associated with humiliating experiences (phi coefficient, 0.7; p = .004), but no other statistically significant relationships were demonstrated.

TABLE 1.

|   Patient No. | Gender   | Experience                                                                                                                                                                | Label                      | Content of Delusion    | Description of Delusion                                                                                              |
|---------------|----------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------|------------------------|----------------------------------------------------------------------------------------------------------------------|
|             1 | M        | None                                                                                                                                                                      | None                       | Persecutory            | Believed that he was being observed and followed                                                                     |
|             2 | F        | She reported a high level of criticism about her body aspect and that she was being bullied at school                                                                     | Humiliating                | Persecutory            | Believed that she was being observed when taking a shower and being marginalized because she was too thin            |
|             3 | F        | She reported recurring episodes in which she was constrained and forced to watch horror films at an early age and that she was teased by friends                          | Humiliating                | Persecutory            | Believed that she was being persecuted by a murderous woman in black                                                 |
|             4 | F        | She saw relatives secretly administer prescribed psychotropic drugs to an ill relative She experienced the severe health conditions and deaths of several close relatives | Humiliating Loss           | Persecutory Somatoform | Believed that she was being given food that had been poisoned Believed that she had cancer and other deadly diseases |
|             5 | M        | He reported marginalization, recurrent criticism, and bullying at school                                                                                                  | Humiliating                | Persecutory            | Believed that he was being persecuted by unknown individuals                                                         |
|             6 | M        | He experienced the severe health conditions and deaths of several close relatives                                                                                         | Loss                       | Somatoform             | Believed himself to be at risk for cardiovascular and metabolic disease                                              |
|             7 | M        | He experienced the first bodily changes of puberty                                                                                                                        | Biological                 | Somatoform             | Had a severe growth and developmental refusal, with the strong intention to keep his body infantile                  |
|             8 | M        | He reported criticism of his smell by classmates and he experienced the first bodily changes of puberty                                                                   | Humiliating and biological | Somatoform             | Believed that he continuously issued an unpleasant smell                                                             |
|             9 | M        | He experienced the suicide of a neighbor of the same age                                                                                                                  | Loss                       | Nihilistic             | Had recurrent thoughts of death and believed his own death would be violent                                          |
|            10 | M        | He experienced the sudden and contentious divorce of his parents                                                                                                          | Humiliating                | Guilt                  | Had recurrent thoughts of neglect and a strong belief that there were monsters in his house                          |
|            11 | F        | She reported recurrent criticism and bullying at school                                                                                                                   | Humiliating                | Persecutory            | Believed that she was being persecuted by unknown individuals                                                        |
|            12 | M        | He suffered from severe alopecia during childhood                                                                                                                         | Biological                 | Control                | Believed he had loose body integrity if he was not able to collect and hang up hair that he found                    |
|               |          | He experienced the sudden death of his father                                                                                                                             | Loss                       | Nihilistic             | Believed he was connected with the souls of the dead and that he had to help them                                    |
|            13 | F        | She reported a high level of criticism about her body aspect and that she was being bullied at school                                                                     | Humiliating                | Persecutory            | Believed that she was being persecuted by unknown individuals                                                        |
|            14 | M        | He reported marginalization, recurrent criticism, and bullying at school                                                                                                  | Humiliating                | Persecutory            | Believed that he was in a dangerous environment in which his identity could be stolen and his will influenced        |
|            15 | F        | She experienced the first bodily changes of puberty                                                                                                                       | Biological                 | Grandeur               | Believed herself to be sexually attractive to everyone                                                               |
|            16 | F        | She experienced sexual abuse                                                                                                                                              | Intrusiveness              | Grandeur               | Believed herself to be sexually attractive to everyone                                                               |

## The Thematic Link: The Elements of the Narration in the Contents of the Delusion

Demographic features of the sample population and qualitative  data  regarding  the  association  between experiences and delusions, as corroborated by family members and teachers, are summarized in Table 1. Here  we  will  describe  four  cases  (one  for  each category of event) to illustrate our research on TLs.

1. A girl with schizophrenia with a complicated delusional system characterized by the extreme  conviction  that  she  was  suffering from cancer also presented with a persecutory delusion,  which  was  expressed in her absolute certainty that her meals were being poisoned. The girl had greatly reduced her food intake. One  of this patient's relatives had been diagnosed with schizophrenia as a child. The girl's caregiver told  us  how  the  family  had  secretly  given psychotropic drugs to the ill relative in meals

and drinks due to the relative's poor adherence to treatment. The patient remembered these instances and described these  episodes  during  her  clinical  sessions. We  labeled  her  experience  as  humiliating and her delusion as persecutory.

2. A boy with psychosis not otherwise specified was referred for his eating restriction. The psychiatric examination revealed that this symptom was the result of a  delusion rather than anorexic cognitions. The patient had a tenacious conviction that involved certainty and incorrigibility that he was at risk for cardiovascular and metabolic disease.  His  thoughts  were  not  definitively disorganized, and  he  told us about  his experiences  involving  the  severe  chronic illnesses and deaths of several close relatives from cancer or heart attacks. This drove him

- to exclude  practically all types  of  food because he believed them to be unhealthy. We labeled the patient's experience as loss and his delusion as persecutory.
3. A girl with psychosis not otherwise specified with  a  history  of  neglect  and  sexual  abuse perpetrated by a relative developed a grandeur delusion (with an erotomanic background) of being courted by a mysterious man who called her at night. The girl would often sneak out of her house. We labeled her experience as intrusive and her delusion as grandeur.
4. A boy with schizophrenia also had delusions, hallucinations, thought disorganization, and bizarre behaviors. He was observed by doctors and nurses to collect his hair from any surface on which it may have fallen.  He  believed  that  it  was  his  duty  to preserve  this  hair.  The  patient's  personal history was characterized by severe alopecia during  childhood  that  had  caused  him  to lose his hair in large quantities and repeatedly. In this case, the delusion emerged as a result of psychotic anxiety surrounding  the  loss  of  boundaries  and  the fragility of the psychotic self. We labeled this patient's  experience  as  biological  and  his delusion as control.

## Discussion

This study stimulates a discussion about the nature of  delusions,  and  it  promotes  psychopathological studies in child and adolescent psychiatric populations. Studying a pediatric population could be highly effective, because these individuals are more likely  to  be  experiencing  their  first  episodes  of psychosis and to be drug naïve. Multiple informants (e.g., parents, teachers) could also be crucial to reduce recall  bias.  Our  data  corroborate  findings  from previous studies that have found positive associations between early adverse experiences and the  onset  of  psychotic  symptoms  (32-38).  In  our sample, researchers  were  able  to  identify  traumatic events that occurred before the onset of psychosis in 15 patients (93.7%). These events are quite heterogeneous, but they are similar in that they were socially  or  emotionally  threatening.  Our  emphasis was on the identification of TLs, and the connections found were thematic as well as causal or temporal. The  causal  relationship  between  previous  stressful life experiences and delusions has been well established  (14,  22,  36,  39).  TLs  are  intended  to connect an experience with a delusion via a thematic analogy.

The concept of TLs fits well into the understood structure of the positive symptoms of psychosis, and Hardy has previously described a thematic association between trauma and hallucinations (22). Authors have described a 'content rating' for direct association that is based on a literal correspondence between the content of the trauma and the content of  the  hallucination;  they  have  also  discussed  a 'thematic rating' for indirect association, where the effect of the experience on the emotions and beliefs shapes the content of the hallucination (22). According to our hypothesis, when psychosis begins, patients are inclined to extend the feelings associated with certain previous experiences into their current interpretations of themselves and the world. Delusion  content  is  not  derived  from  unknown themes;  rather,  it  is  shaped  through  a  progressive revision and re-signification of specific life experiences that have emotional and cognitive impact.

These  assertions  are  supported  by  research  that, over time, has led to a greater understanding of how the  environment  affects  the  onset  of  psychosis. Raune  and  colleagues  demonstrated  a  relationship between  either  intrusive  events  and  persecutory delusions or danger events and depressive delusions (40). Furthermore, stressful events may be considered to be non-specific triggers of delusions (39), and empirical studies have shown that certain events  may  specifically  influence  the  themes  of  a patient's delusions (41). Other authors have proposed that psychotic symptoms have meaning for patients and that they facilitate a 'making of sense' of complex feelings related to stressful experiences. Freeman  and  colleagues  affirmed  that  people  who underwent chronic stressful experiences could develop an hostile and dangerous interpretation of the  world  that  in  turn  may  lead  to  the  onset  of psychotic symptoms(42).  These  researchers also showed that emotions like anxiety, depression, and anger can influence psychotic symptoms, as they may represent  the  emotional  terrain  in  which  psychotic symptoms proliferate (43, 44).

In addition, cognitive and emotional models have been  developed.  Garety  and  colleagues  conceptualized delusions as attempts to provide meaning to internal and external events; they proposed that the main  features  of  delusions  reflect  internal  beliefs about the self, the world, and others (45). According to  this  theory,  depression  and  low  self-esteem  that have resulted from social exclusion may generate an individual's belief that he or she is the target of others (46). In our sample, persecutory delusions were the most common (42%). Although our sample size was small,  we  noted  a  positive  association  between humiliating events and persecutory delusions, which is consistent with data obtained by other studies of adults (42, 47, 48). In our sample, bullying was the humiliating element that was most frequently described  (see  Table  1).  More  specifically,  bullying was a specific event that occurred during childhood and adolescence and that could be linked to various psychopathological  phenomena  (49-56),  psychosis onset (57-63), and paranoid beliefs (32, 64).

If we again consider the classic concept of understandability, we agree with the perspective that each delusion may ultimately be understandable if the psychopathological analysis is thorough enough (6). The TL concept is promising because it may provide clinicians  with  a  greater  awareness  of  the  thoughts and emotions of the patient and assist with therapeutic  engagement  and  rapport.  The  patient's history offers an historical understanding, whereas a psychological understanding is difficult to assess in phenomenological terms. Hence, the TL comes close to representing Jaspers' idea of understandability.

We  also  want  to  address  the  limitations  of  this study.  First,  the  nature  of  the  collected  data  is somewhat concerning; the information that we are collecting  is  essentially  descriptive,  but  it  has  been coded so that statistical analysis can take place. To the best of our knowledge, there are only a few prior studies  that  are  comparable  to  ours  (22,  40),  and these  addressed  adult  populations.  Thus,  a  proven methodology for addressing  this  topic  in  the  child and adolescent population does not exist. Narrative data have been used to allow both qualitative analysis (thematic  linkage)  and  quantitative  analysis.  This combined  mixed-method  approach  allows  a  fine grain of data collection to be achieved and adequate attention to be paid to the richness of each participant's  subjective  experience.  Moreover,  the physicians  who  performed the therapeutic sessions were blinded to the purpose of the research to limit any bias with regard to data collection, and they were also blinded to each other's findings.

Second, although each event may have had more than one dimension and thus classifying each such event as having only one attribute may seem artificial, we decided to assign only one main theme to each event given the small sample size to allow for more simplicity of the analysis and linearity of the results. In fact, the small sample size used and the recruitment of patients from a single center limit the generalizability of our findings. This population was chosen to address our aim of studying a child and adolescent population that closely fulfilled the inclusion criteria (i.e., drug-free patients experiencing their first psychotic episodes).

Third, the study may suffer from recall bias due to data  being  collected  by  listening  to  patients  with psychotic disorders. However, these data were corroborated  by  interviews  with  parents,  teachers, and other caregivers. With regard to this topic, Keller and  colleagues  previously  stated  the  following:  'A number  of  studies  indicate  that  individuals  with psychotic disorders are no less likely to be accurate in  recalling  abusive  experiences  than  the  general population' (59). Indeed, it has to be said that the onset of psychosis was relatively recent for all of our patients,  so  our  sample  does  not  suffer  from  the 'long time of disease' confounding variable that can bias data gathered from adult populations.

## Clinical Significance

The TL could be a highly relevant concept in terms of early intervention,  psychosocial  support,  and psychotherapy. It could be quite useful for providing better  tailored  and  targeted  treatments  during  the early stages of disease.

The findings presented here may play an important role in supporting young people who are at risk for psychosis in the area of mental health services and for psychotic patients during psychotherapy. In fact, the  possibility  of  addressing  past  experiences  and linking them to the content of emerging or consolidated delusions may make these experiences less frightening and more understandable. The clinical  analysis  of  these  cases  should  be  oriented toward the issues that are shared between a patient's life  experiences  and  the  content  of  his  or  her delusions; the psychopathologist could identify these themes by listening to descriptions of both previous experiences and the delusions themselves. A thematic continuity between certain past experiences and at least some elements of delusion content could be hypothesized, and our results support this possibility. Further studies are needed to focus on the link  between  past  experiences  and  the  contents  of delusions  in  child  and  adolescent  populations,  and the  role  of  bullying  in  the  content  of  psychotic symptoms needs to be further explored. In fact, this study  serves  to  highlight  the  poor  quality  and  the general lack of information regarding these topics in the child and adolescent populations.

These findings present a new way of interpreting classic psychopathology. In its definition of the term delusion, the recently published Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, included the following: 'Delusions are deemed bizarre if they are clearly implausible and not understandable to some culture  peers  and  do  not  derive  from  ordinary  life experience'  (1).  This  statement  seems  to  explicitly accept the link between personal experience and the content of a delusion, thereby expanding the possibilities  of  understanding  a  patient's  psychotic symptoms.

## Acknowledgements

Gennaro Catone would like to thank the Maudsley Philosophy  Group  for  its  help  in  promoting  his research activity on philosophical and phenomenological aspects of delusions.

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