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Psychotic episodes are a collection of heterogeneous mental states in which patients experience delusions and hallucinations. Delusions are classically defined as “false beliefs based on incorrect inferences about external reality that are firmly sustained despite what almost everyone else believes,” and hallucinations are perceptions without objects. Although psychotic episodes are characterized by several other symptoms (e.g., disordered thinking, disorganized behaviours), delusions and hallucinations are the most salient and puzzling aspects of the psychotic experience. The terms that are often used to define psychosis are philosophically very loaded. What are beliefs and external reality and how we make sound inferences have all been and still are some of the most difficult questions in the history of philosophy and science. For some, reality is out there; it does not need to be defined. The expression “losing touch with reality,” often used to describe psychosis, is grounded in this conception of reality. For others, reality is coextensive to being human and having expectations, desires and fears. Reality in this sense is not a theatre offered to our senses that we watch in the way that we watch a movie; rather, it is a mental construction in which our memories, emotions, intentions, successes, failures, and conceptions of ourselves and of others are blended and experienced. Thus, the psychotic experience is not a loss of contact with reality, it is just a different form of phenomenal reality. Although this debate is centuries old and may seem timeworn, we encounter these issues every day in clinical practice, and we engage ourselves in understanding the delusional (and nondelusional) reality of our patients, negotiating with them the need for reflecting on it, and ultimately helping them to remodel it so that it induces less suffering and dysfunction. It is always impressive and sobering to witness how the psychotic experience can differ from patient to patient and how it is difficult to find unifying traits for all these experiences. Delusions can be very difficult to separate, even by experts, from common religious or other cultural beliefs, overvalued ideas, fertile and highly productive imaginations and selfdeception. Alternatively, delusions can be so “out of this world” that their nature is obvious to a nonprofessional observer. They can torment patients and cause them to feel pain, guilt or persecution. They can also be pleasant or even soothing. Delusions may be emotionally charged and drive the person’s behaviours or they can be associated with emotional indifference and lack of action. Some delusional patients may be focused on a single persistent theme that takes a major place in their lives (e.g., jealousy, invention, grandiosity), whereas others may go between multiple themes that infiltrate every aspect of their lives. These are only a few aspects of the rich phenomenology of delusions. Several accounts of the neuropsychological mechanisms of delusions have been proposed. In 1 account, delusions result from failure(s) of some basic neurocognitive or perceptual competencies. For example, Capgras syndrome, charac terized by the belief that familiar persons are replaced by identical-looking imposters, may be conceived primarily as a result of prosopagnosia, a neurocognitive deficit of face recognition due to neural abnormalities in the inferior tem por al cortex and its connections with the amygdala.

journal of psychiatry and neuroscience

Medium range cognitive impairment (MeRCI) hypothesis for psychosis formation: evidence from epidemiological studies and recent molecular genetic developments