Connecting Dots That Don't Connect: Aberrant Salience

Psychosis is among the most fascinating experiences I have come across. Seeking to understand the complex perceptual changes in the condition in order to partner with clients is an immense privilege. The creativity I have seen in individuals who have experienced psychosis is unmatched. I don't believe this is a coincidence: Some of the cognitive patterns that lend to psychosis seem also to supplement creativity. Among these is aberrant salience.

One of the most intriguing aspects of psychosis is how it changes a person's relations to patterns. While experiencing psychosis, many share a sense of things being significant, such as a sign on the highway being a sign from God directed just at them, or a signal that they have special powers. Seemingly benign things like a bird can be interpreted as a neighbor spying on them or a menacing message from the government referring to their middle name of "Jay," for example.

Such conclusions would all be considered aberrant salience — creating meaning in loosely connected things. In other words, it's a process that connects dots that aren't meant to be connected.

Aberrant Salience and Psychosis

Aberrant salience is so common in psychosis that some have suggested that instruments such as the Aberrant Salience Inventory may hold screening capabilities for these conditions (Merola et al., 2023). fMRI studies suggest neural changes demarking the experience (Kowalski et al., 2021) with altered patterns of activity involving several brain regions. These changes can contribute to altered perceptions.

Perhaps this gives credence to the rebranding of schizophrenia as an "integration disorder" as has already been adopted in Japan through the term "Togo Shitcho Sho" (Sago, 2006). Rather than implying a "split mind," which is not actually present in schizophrenia, the term integration disorder shows an appreciation for the sensory and perception shape-shifting that accompanies the condition

With psychosis, aberrant salience also is highly difficult to question. Likely because of its neurological underpinnings, delusions are fixed. In a sense, you don't think the connection is there, you just know. Reality checking by asking another person if they also see the connection or looking for objective evidence is often taught in therapy. This might take the form, for example, of if someone sees spiders on their car, believes their roommate is mad at them, and infers that the roommate must have put the spiders there of looking for alternative explanations, asking a friend, or even taking a picture to see if the spiders show up (visual hallucinations often only exist in real space).

Aberrant Salience and OCD

While no condition is more closely linked to aberrant salience than psychotic disorders, certain other mental health conditions share some aspects of the phenomena — most notably, obsessive-compulsive disorder. In OCD, aberrant salience may lead a person to draw relations between rituals like stepping on a crack and unrelated tragedies like someone being harmed. More subtly, people with OCD often adopt this pattern of reasoning during obsessive spirals — for example, when they notice that germs exist, sometimes people get sick, and their friend got the flu, only to conclude that they may get the flu if they don't wash right now.

The difference between aberrant salience in psychosis and in OCD is that in OCD, the person is usually aware that their thinking is irrational. This is not, however, common in psychosis.

With OCD, there is an almost opposite difficulty of doubt, something that inference-based CBT calls "inferential confusion." While someone might be 99% sure of something, that one percent chance of the feared scenario creates a sort of uncertainty that blurs sense of reality.

Even though the person typically uses effective reasoning, when it comes to their OCD theme they often struggle to trust their own inferences and instead utilize strategies like seeking reassurance compulsively. Reality-checking would not typically be a therapeutic intervention in OCD. Rather, therapy, such as, inference-based cognitive therapy may work on building self-trust and other interventions like exposure ritual prevention can utilize specific exercises to build tolerance of uncertainty targeted at the person's obsession.

Support

Psychotherapies such as cognitive behavioral therapy for psychosis and acceptance and commitment therapy (ACT) can help address the effects of aberrant salience. For individuals diagnosed with OCD, a newer therapy — inference-based cognitive behavioral therapy — addresses the underlying reasoning processes of OCD to build self-trust. Aberrant salience is often troubling, yet help is available.

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