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Emotion Review
Vol. 4, No. 2 (April 2012) 187191
The Author(s) 2012
ISSN 1754-0739
DOI: 10.1177/1754073911430115
er.sagepub.com
Lisa Bortolotti
Matthew R. Broome
Warwick Medical School, University of Warwick, UK
Abstract
It has been argued that schizophrenic delusions are behaviourally inert. This is evidence for the phenomenon of double
bookkeeping, according to which people are not consistent in their commitment to the content of their delusions. The traditional
explanation for the phenomenon is that people do not genuinely believe the content of their delusions. In the article, we resist
the traditional explanation and offer an alternative hypothesis: people with delusions often fail to acquire or to maintain the
motivation to act on their delusional beliefs. This may be due to avolition, to emotional disturbances, or to the fact that, given the
peculiar content of some delusions, the surrounding environment does not support the agents motivation to act.
Keywords
avolition, delusions, double bookkeeping, emotional disturbances, motivation, schizophrenia
People with delusions may believe that they are dead (Cotard
delusion), that a celebrity is secretly in love with them
(erotomania), or that some of their thoughts are being inserted
into their heads by an ill-meaning third person (thoughtinsertion). According to the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV 2000, p. 765), delusions are
false beliefs that resist counterevidence. However, there is a
lively debate on whether delusions should be characterized as
beliefs at all (Bayne & Pacherie, 2005; Bortolotti, 2009). As
Campbell elegantly puts the problem,
You might propose that what we have here is not, strictly speaking,
belief at all, but empty speech masquerading as belief. The trouble
with this diagnosis is that these are perfectly sincere assertions made by
people who seem to understand what they are saying, who may indeed
act on the basis of what they are saying. (Campbell, 2001, p. 91)
The thesis that delusions are not beliefs is often justified on the
basis of the view that beliefs have core features which delusions
do not share. Possibly the most powerful of these arguments is
that delusions are not beliefs because people with delusions fail
Corresponding author: Lisa Bortolotti, School of Philosophy, Theology and Religion, University of Birmingham, Edgbaston B15 2TT, UK. Email: l.bortolotti@bham.ac.uk
Table 1. Possible reasons for inaction or inconsistency between attitudes and behaviour
(1) Failure to generate intentions or
access goals due to representational or
meta-representational factors
to act, if she has attitudes that conflict with her finding the goal
desirable. A third hypothesis is that the social and contextual factors lead the agent to see herself as incompetent in performing
the relevant action (Ryan & Deci, 2000). This is the case when
the agent lacks a sense of autonomy (intended as the belief that
the action is actually caused by her) and a sense of relatedness
(intended as support from her close personal relationships). It
may not be a coincidence that some of the conditions responsible for lack of motivation are also among the causal factors
contributing to psychopathology (Ryan & Deci, 2000, p. 76),
such as the impression that there is excessive external control
over ones thoughts and actions, which compromises the agents
sense of autonomy, and the absence of supportive personal relationships, which negatively affects the sense of relatedness.
Foussias and Remington (2008) suggest that people with
schizophrenia are not necessarily unable to represent their goals
as desirable. Rather, they find it harder than participants in control conditions to act in such a way as to enjoy the pleasant emotions associated with the pursuit and achievement of their goals
and to channel them into action. Studies presented and reviewed
by Gard, Kring, Germans Gard, Horan, and Green (2007) and
Kring and Germans (2004) seem to confirm this hypothesis. If
people with schizophrenia are asked to predict how much pleasure they will derive from a potentially pleasurable experience,
they predict that they will derive less pleasure from it than participants in control conditions. Similarly, when asked to report
after the experience how pleasant the experience was, people
with schizophrenia report that they felt less pleasure than participants in control conditions. The hypothesis is that there are
several emotional components to the enjoyment of pleasant
experiences. The anticipatory component concerns the pleasure
derived from the imagination or the expectation of a rewarding
experience. The consummatory component concerns the pleasure
derived from the actual pursuit of and engagement in the desired
activity. Finally, there is also the issue of whether pleasurable
experiences are successfully encoded and can be recalled as
pleasurable at a later time. Judging from self-reports, people
with schizophrenia seem to experience less pleasure than
participants in control conditions, but this may not be the case.
Neurobiological data suggest that people with schizophrenia are
able to enjoy pleasurable actions as much as participants in
control conditions. A possible explanation for their self-reports
is that differences between people with schizophrenia and
participants in control conditions emerge at the stage of anticipation and encoding, and do not affect the actual experience.
What are the implications of the avolition literature for
double bookkeeping? Avolition is often characterized as a form
of weakness of will and distinguished from absence of hedonic
reward. But one hypothesis is that people are less motivated to
act in a way that is consistent with the content of their delusions
because they find it harder to imagine the future outcomes of
their actions and to anticipate the pleasure they may derive from
the achievement of their goals. This hypothesis predicts that
failures of imagination and anticipation would affect ones
motivation to act in general, and not just the motivation to act in
accordance with delusional beliefs.
Another reason why people might fail to commit behaviourally to their delusions may be found in emotional disturbances.
These phenomena may contribute to a failure of motivation
which results in an agent ceasing to pursue her initial goal.
Bleuler (1950, p. 70), who identifies schizophrenia with a
breakdown of the emotions, notices that people with schizophrenia often appear indifferent in the sense that they do not
express the emotions they feel. Such indifference would now be
considered as a negative symptom of schizophrenia.
In cognitive neuro-psychological approaches to schizophrenia the relationship between emotions and psychotic symptoms
is an object of controversy. The accepted view is that emotional
disturbances (e.g., emotional excesses and deficits or lack of
regulation) are not a direct cause of psychotic symptoms, but
contribute to their maintenance and severity. For instance, in
people with schizophrenia, negative self-evaluation is correlated
with more severe positive symptoms (Barrowclough et al.,
2003). In people with delusions, distress is correlated with the
severity of the delusions (Lysaker, Lancaster, Nees, & Davis,
2003) and high levels of anger are often recorded (Cullari, 1994;
Siris, 1995). More recently, Freeman and Garety (2003) have
challenged the accepted view and suggested that emotions
directly cause delusions. This is because anxiety contributes to
delusional conviction, in a way that is quite independent of reasoning. It is proposed that delusional explanations are a direct
reflection of pre-existing beliefs about the self, world and others,
and that these beliefs are intimately linked to emotion (Freeman
& Garety, 2003, p. 931). Broome et al. (2005), who investigated the developmental and epidemiological factors influencing prodromal symptoms (i.e., the symptoms immediately
prior to the onset of a disease), observed how people at high
risk of psychosis experience distress, decreased motivation,
and poor socialization from an early age. Those in the highrisk sample who make the transition to psychotic are
often depressed and anxious before suffering from positive
symptoms.
Evidence that seems to support a positive correlation
between emotion and motivation emerges from the observation that, when there are strong emotional reactions relevant to
a persons delusions, such as anger, the person is more likely
to act on her delusions. If the emotions typically associated
with the content of the delusions are not manifested, as with
emotional disturbances, then the motivation is undermined as
a result.
action that she can take, or the only appropriate action would
have unpleasant or dangerous consequences.
A woman believes that the world is ending and she is the
only one who can save the world by deciphering signs that God
sends her in her dreams. Although the womans verbal behaviour
may be a testimony of her commitment to the delusion, it is
difficult to identify desirable goals that she could achieve if she
decided to act on her delusions. The woman is well aware that
other people are unlikely to believe her, so she may not even
warn others about the end of the world.
When a man with Capgras delusion says that he cant go to
the police to report the disappearance of his wife because the
police wouldnt believe that aliens abducted her and replaced
her with an impostor, it is obvious to him as well as to others
that his social environment would not be supportive of his
action. Action may be inhibited as a result.
In both the cases above, people fail to act on their delusions
because they retain an awareness of how odd their beliefs and
behaviour may appear to others. In more radical cases, the delusion conflicts with our current understanding of the physical
world. One case discussed by Campbell (2009) and by Broome,
Bortolotti, and Mameli (2010) is that of a man who believed
that a lizard was inside his body due to the scaly appearance
of his skin. As a result, he tried to remove the lizard with a
knife, harming himself as a result (Browning & Jones, 1988).
Arguably it is not unreasonable to try and remove a source of
danger from oneself if one believes that the danger is real. If the
man believed that the doctor could not help him, and that there
were no professional lizard killers around, then the prospect of
removing the lizard himself with a knife may have seemed to
him the only rational thing to do. By comparison, one can think
about the case of a person stranded on Mount Everest who
rationally decides to remove a gangrenous or frostbitten arm to
save her life. The rational agent balances perceived risks in
order to maximize her chances of survival: in this case, the relevant risks are (a) the risk incurred in cutting oneself with a
knife and (b) the risk of being eaten from the inside by a poisonous lizard (compare the latter with the risk of gangrene leading
to certain death).
A similar riskbenefit analysis can result in inaction rather
than action for the person with delusions. If the outcome of the
riskbenefit analysis had been different, then the person afflicted
by the delusion of lizard infestation would have refrained from
acting. He could have concluded that it was less dangerous to
have his body colonized by reptiles than to attempt to remove the
reptiles with a knife. This would have led the man to do nothing
about the infestation, or maybe search for other ways to stop it.
The point we are attempting to make is that, in the case of
some delusional beliefs that are held with absolute conviction,
the very strangeness of the belief seems to inhibit action altogether, or to lead to undesirable or dangerous actions for which
motivation is likely to falter. Examples encountered in clinical
practice by one of us (MB) tend to be beliefs that conflict with
the basic laws of physics and biology:
Conclusions
The phenomenon of double bookkeeping in delusions is of great
interest: Why do people seem to lack commitment to the content
of their delusional beliefs? The standard approach is to reject
the view that delusions are beliefs and emphasize the disanalogy
between delusions and beliefs: The latter are manifested
behaviourally, whereas the former are behaviourally inert.
In this article, we suggested that there is an alternative
explanation that hasnt been sufficiently explored in the philosophical literature: People may fail to commit behaviourally
to the content of their delusions when they fail to acquire or
sustain the motivation to act on their delusions. In attempting
to make this alternative explanation plausible, we stressed the
analogy between delusions and beliefs: Both may fail to
be acted upon when certain conditions obtain, such as the
relevant goals appearing either unattainable or undesirable to
the agent.
We explored different routes to undermining motivation in
psychopathology and briefly examined the role of avolition and
emotional disturbances in the explanation of double bookkeeping. Then, we considered the contribution of the surrounding
environment to the agents appreciation of the desirability or
attainability of the goals that are relevant to her delusions.
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