On Delusion Formation (2024)

Controversy surrounds the birth of delusions. Most theorists agree on the first step, that delusions arise in the context of a delusional mood, an emotionally aroused state that makes the person hyperalert to threat.¹ After that, some assume perception goes awry—something misheard or misperceived giving rise to increasing emotional upheaval and misinterpretation. Others believe that cognitive processes are disrupted first, setting in motion various interpersonal behaviours that reinforce originally tenuous mistaken beliefs.^2,3 The nature of the original stimulus that sets the misperceptions or misconstruals going has not been given much attention. It has been seen as unimportant. In this Perspective, I make the assumption that the original stimulus has to be one that inherently lends itself to numerous possible interpretations. In the case example, it is the colour red. Psychiatrists are not present when a delusion is first born, thus we have to reconstruct the series of events that lead to delusion as best we can, working backwards, relying on what patients choose to tell us. The example that I use as illustration is loosely based on my experience with a former patient, now deceased. Identifying information has been changed. The purpose of this communication is to identify the stages of delusion formation: the emotional matrix, the provocative stimulus, the perception, the interpretation, the reinforcement, and the full-blown delusion.

On her first visit, a patient said to me: “You can’t wear red. If you wear red, I won’t come back.” She was 45, lived alone, and had been diagnosed with schizophrenia at age 28. She was firmly against taking medication because, she said, she needed to have her wits about her: “they” were trying to force her into sexual relations. They whispered orders of this nature outside her window and left various related ciphers and signs around her bedroom. The identity of the “they” was unclear to me, but was associated in a peripheral way with a boyfriend of long ago. Based on her earlier excellence in academic work, this patient had received tenure in the Department of History at a local college, which meant a regular income. However, she was not allowed to teach because of the disruptions she caused among staff and students whenever she came on campus. As a result, she worked on her own research from home, and published in scholarly journals; her academic area was the mythology of ancient Egypt.

I asked her to elaborate on her aversion to red. Because of the nature of her delusion, I suspected that red clothes were associated in her mind with red-light districts and that, by wearing red, I was crossing over to the “theys” who plotted to turn her into a sexual degenerate. I mentioned this to her. She responded, “I don’t want to talk about it”; thus the subject was closed. One day, I inadvertently wore a red blouse and she walked out of the office. I never saw her again, although we stayed in touch for many years over email because she repeatedly asked for help to find new psychiatrists. She needed a psychiatrist to sign her forms so that she could continue receiving her university pension. Very recently, I heard that she had died, which made me think again about the colour red as a trigger, a delusional stimulus.

Red as the Trigger

As the patient was either offended or frightened or angered by the colour red, was it possible that, in her 20s, when emotionally upset as a result, perhaps, of a relationship gone wrong, the sight of the colour red had jump-started her delusion? Red is fertile ground for the growing of a delusion. It is generally acknowledged to be a stimulating colour, heightening any underlying aroused state. Kurt Goldstein noticed nearly 75 years ago that patients prone to psychosis were especially sensitive to the effects in their surroundings of stimulating colours, such as red.⁴

Is there something about red that is inherently stimulating? In about 10% of primate species, females call attention to their fertile periods by bright red sexual swellings around their buttocks and vulva. In the human female, elevated levels of sex hormones lead to increased skin vascularity and vasodilatation, making the skin rosy during fertile periods⁵ and, interestingly, Beall and Tracy⁶ have shown that women are 3 times more likely to wear red at the time of ovulation than they are at any other time, as if in imitation of nature.

In a series of related experiments, Guéguen (see Guéguen⁷ and Guéguen and Jacob⁸) has shown that wearing red brings with it unexpected advantages. For instance, waitresses who wear red uniforms or bright red lipstick get higher tips than their colleagues. Women hitchhikers have a greater chance of being offered a ride when they wear red clothes. In photographs on personal Internet sites, women wearing red receive more attention than those wearing other colours. Red appears to be an attention-getter. People notice it, and it is understandable that extrasensitive people, such as my patient, would notice it more.

There is a seeming universality to the many emotional connotations of the colour red (passion, lust, guilt, danger, and anger) shown by the similarity of colour metaphors in use in many parts of the world.^9–12 However, the universality is challenged by recent work¹³ that emphasizes cultural differences in colour associations. For instance, whereas, in English, being in the red means danger—being in debt— for Chinese stockbrokers, red marks happiness—a rise in stock price.¹⁴ This may be because feng shui, a Chinese philosophical system intended to harmonize human beings with their environment, connects the colour red with warmth, wealth, and luck.¹⁵ The delusional potential of a stimulus will likely differ depending on culture, personality,¹⁶ and life experience. Introverts, for instance, as well as people whose predominant mood is negative or depressed, seem to be most affected by strong colours.¹⁷ Age is also an important determinant of response to colour,^18,19 as are sex and gender.²⁰ In most studies, women show a colour preference for red, while men prefer other colours. This difference between men and women, according to the literature, overshadows differences based on culture and context,^21,22 and on life experience.²³

Disorganized Perception

Some theorists argue that delusions arise from everyday stimuli being misperceived. As a result of a psychosis-related perceptual defect, is it possible that my patient saw the colour red in a distorted way? Matussek²⁴ is credited with being the first to attribute delusions to perceptual distortions. Although schizophrenia is known to be associated with visual hallucinations,²⁵ there is relatively little appreciation in the literature of visual misperceptions, which also occur.²⁶ The colour red may have looked extraluminous to my patient or have flared or sparkled or flickered in an apparently threatening way or, for that matter, have been synesthetically associated for her with nasty odours or terrifying sounds.²⁷ Of course, these are all conjectures.

Schizophrenia has been associated with dysfunction in the connection between visual pathways in the brain and emotion processing regions, and this is, interestingly, especially marked when visual targets are seen against a red background.²⁸ In the presence of schizophrenia, a red background increases errors so that neutral facial expressions, for instance, are perceived as hostile. This is known as the visual masking effect.²⁹

Cognitive Distortions

Approaching 30 and childless at the time her delusion started, my patient may have been particularly sensitive to the association between red and fertility, described above. Seeing people wear red could make her erroneously jump to the conclusion³⁰ that they were laughing at her, mocking her childless state.

Because of her belief that the colour red was of vast importance, there are many other seemingly illogical interpretations she could have made on seeing the colour red.³¹ Elliot and Maier³² have recently reviewed links between red and 2 psychological constructs: interpersonal attraction and competitiveness. They conclude that human beings show sexual attraction to members of the opposite sex who are dressed in red, that women use red clothing as deliberate sexual enticement,³² and that men perceive it as such.⁷ In line with subscribing only to that which confirms her delusional belief,³³ my patient could have interpreted my wearing red to mean I was enticing her into sexual activity, that I was part of the “they.”

In competition (sports, games, battle), an adversary in red is said to usually have the upper hand,³⁴ with male dominance boosted by a red accessory, such as a red shirt.^35,36 Across a range of sports, wearing red is consistently associated with a higher than average probability of winning, partly (it is thought) because the opponent is intimidated by seeing red and partly because red in the wearer is associated with greater muscle strength, a quicker heart rate, and a stronger will to win.³⁷ Perhaps fertility and sex were not at all in my patient’s mind. Perhaps, instead, the red blouse meant I was wearing red, contrary to her explicit wishes, to start a fight. She operated, perhaps, under an illusion of control,³⁸ assuming that her stated wishes would always be uppermost in other people’s minds, unless they were her enemies.

I knew little about my patient’s personal history but, with her academic field being the history of ancient Egypt, the colour red may have had other prominent meanings for her. Red was associated with heat, destruction, and evil in ancient Egypt. There is a prayer to the Egyptian goddess Isis that has survived: “Oh Isis, protect me from all things evil and red.”³⁹, ^p45 For my patient, by a process of illusory correlation,⁴⁰ a common reasoning bias, red (spilled blood) may have been inextricably linked with evil.

Possible misinterpretations of a stimulus based on faulty reasoning are essentially limitless.

Conclusion

To recapitulate, we must presume the patient was psychosis-prone from early on for reasons of heredity and development. In a chaotic emotional state in her middle 20s, in unknown circ*mstances, she observed the colour red. Her perception of the colour may have been distorted or it may have been intact. In either case, the way she interpreted what it signified was idiosyncratic.⁴¹ According to Kurt Schneider, the bizarre meanings that constitute delusions always tend toward self-reference and are “momentous, urgent, somehow filled with personal significance as, for example, a particular sign or a message from another world.”⁴², ^p33 This was true for my patient; red took on momentous meaning for her, even though what that meaning was remained unclear.

Subsequently, seeing red triggered an aha experience that repeatedly confirmed her delusional belief.⁴³ When she saw me wearing red, she might have thought, “Aha, she is going to make me have sex,” or “Aha, she is taunting me,” or “Aha, she is evil,” or other mistaken ahas that the colour red evoked—self-referential, tyrannical,⁴⁴ with an aura of the metaphysical.⁴⁵

Apophany

The experience of seeing patterns or connections in random or essentially meaningless coincidence and attributing special meaningfulness to these patterns is called apophany, a term originally coined by Klaus Conrad in his 3-stage account of progression to full-blown delusion: trema (or delusional mood), apophany, apocalypse.⁴⁶

These steps apply to my patient, and do so in many delusions: the colour red came to the patient’s attention at a juncture of her life when she was anxious, alert to trouble; it was a stimulus that lent itself intrinsically, metaphorically, and idiosyncratically to various potential meanings. The perception of the colour was perhaps distorted (extraluminous or extraconspicuous). Self-referential interpretation of the distorted stimulus followed, aided by reasoning biases that led to the delusional belief that a pattern existed and that it was of extraspecial significance. The pattern seemed to repeat itself and to confirm its truth. Importantly, the belief in the pattern served a function.⁴⁷ Ascribing momentous meaning to events in which one plays a key role can brighten an otherwise colourless life.

Though sexually themed delusions, such as this patient expressed, are not uncommon, delusions about colours are rarer. The example was chosen because of the rich psychological literature on the varied meanings of the colour red in ordinary life. It makes the point that when susceptible people are emotionally aroused, certain phenomena, especially those that lend themselves to metaphor-making,⁴⁸ are perceived in a special way, reasoned about in a special way, and conclusions are drawn, wrong conclusions, but ones that coincidence, synchronicity, and the reactions of others seem to confirm. Ultimately, delusions—from that first all-important perception of the provocative stimulus— give life meaning.

Acknowledgments

Dr Seeman is the Medical Consultant to Clera Inc; however, this financial relationship is not connected to this manuscript.

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