Persecutory delusions and catastrophic worry in psychosis: developing the understanding of delusion distress and persistence

In a recent theoretical account of persecutory delusions, it is suggested that anxiety and worry are important factors in paranoid experience [Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., & Bebbington, P. E. (2002). A cognitive model of persecutory delusions. British Journal of Clinical Psychology, 41(4), 331-347]. In emotional disorders worry has been understood in terms of catastrophising. In the current study, the concept of catastrophising is applied for the first time with persecutory delusions. Thirty individuals with current persecutory delusions and 30 non-clinical controls participated in a cross-sectional study. The group with persecutory delusions was also followed up at 3 months to assess predictors of delusion persistence. At its most severe, 21% of individuals with persecutory delusions had clinical worry, 68% had levels of worry comparable with treatment seeking GAD patients. Further, high levels of anxiety, worry and catastrophising were associated with high levels of persecutory delusion distress and with the persistence of delusions over 3 months. If future research replicates these findings, worry reduction interventions for individuals with persecutory delusions may be warranted.     

Acting on persecutory delusions: the importance of safety seeking

OBJECTIVE: Acting on delusions is a significant clinical issue. The concept of safety behaviours--actions carried out with the intention of reducing perceived threat--provides a new way of understanding acting on delusions. A study was conducted with the aim of examining the prevalence and correlates of safety behaviours related to persecutory delusions. METHOD: One hundred patients with persecutory delusions were assessed for safety behaviours, acting on delusions, anxiety, depression, and psychotic symptoms. Case note data were collected on instances of serious violence or suicide attempts. RESULTS: Ninety-six patients had used safety behaviours in the last month. Greater use of safety behaviours was associated with higher levels of distress. A history of violence or suicide attempts was associated with greater use of safety behaviours. Safety behaviours were significantly associated with acting on delusions, but not with the negative symptoms of psychosis. CONCLUSION: Safety behaviours are a common form of acting on persecutory delusions. These behaviours have the consequence that they are likely to prevent the processing of disconfirmatory evidence and will therefore contribute to delusion persistence.     

A comparison of metacognitions in patients with hallucinations,delusions, panic disorder,and non-patient controls

This study tested the hypothesis that metacognitions are a general vulnerability factor for psychological disorder. It was predicted that patients with psychosis (hallucinations or delusions), and patients with panic disorder would score higher than non-patients on measures of metacognition. Moreover, it was hypothesised that patients showing most dysregulation of thinking (voice-hearers) would endorse significantly higher metacognition scores than individuals in the other groups. The Meta-Cognitions Questionnaire (MCQ: ) was administered to patients who met DSM-IV criteria for schizophrenia spectrum disorders with auditory hallucinations, patients who met DSM-IV criteria for schizophrenia spectrum disorders with persecutory delusions, patients who met DSM-IV criteria for panic disorder and non-patients. The results showed that psychotic patients who experience auditory hallucinations tended to exhibit higher levels of dysfunctional metacognitive beliefs than other patient groups, scoring significantly higher than at least two of the three control groups on positive beliefs about worry, negative beliefs about uncontrollability and danger, cognitive confidence and negative beliefs including superstition, punishment and responsibility. It was also found that the metacognitive beliefs of patients with persecutory delusions and panic patients were often similar to each other, and elevated in comparison to non-patients, suggesting that such beliefs are generic vulnerability factors. The theoretical and clinical implications of these findings are discussed.     

Self-Structure in Persecutory Delusions

There is currently limited research examining self-structure in clinical groups and no current data on the extent to which self-structure is amendable to change following psychological therapy. We address this important gap by examining self-structure in individuals with persecutory delusions using the card sort task, an established paradigm measuring key self-structure indices, including the degree to which self-structure is compartmentalized (characterized by primarily positive or negative attributes, as opposed to a mix of both), and the proportion and importance of negative attributes.In Study 1, individuals with a schizophrenia spectrum diagnosis with current persecutory delusions (clinical group, n = 27) and a healthy control group (n = 47) were compared on self-structure indices. In Study 2 (n = 27), the clinical group also completed the card sort task before and after randomization to either a 12-week mindfulness-based psychological therapy or treatment-as-usual control.In Study 1, self-structure differed significantly between the clinical and control groups. The clinical group had a greater proportion of negative attributes, assigned more importance to negative self-aspects, and had more compartmentalized self-structures compared with controls. In Study 2 there were no associations between delusion severity and self-structure. Large effect sizes for reductions in compartmentalization and proportion of negative attributes across self-aspects were found following mindfulness therapy. The findings highlight key differences in self-structure between individuals with persecutory delusions and healthy controls, and suggest that it might be possible to change self-structure following psychological therapy. These data support the central role of the self in theoretical models of paranoid thinking.     

Implicit and explicit self-esteem discrepancies in paranoia and depression

The main purpose of the present study was to examine implicit and explicit self-esteem (SE) in patients with persecutory delusions. In samples of paranoid patients, depressed patients, and healthy controls, implicit SE was assessed using the experimental go/no-go association task, whereas explicit SE was measured using 2 self-reporting questionnaires: the self-worth subscale of the World Assumption Scale (Janoff-Bulman, 1989) and the self-acceptance subscale of the Scales of Psychological Well-Being (Ryff & Keyes, 1995). Our analysis revealed that depressed patients showed lower explicit SE than did paranoid and healthy control participants. However, participants with persecutory delusions had significantly lower implicit SE scores than did healthy controls. We interpret the discrepancies observed between overt and covert measures in the paranoid group as psychological defense mechanisms. The present study stresses the clinical and theoretical importance of the use of implicit measures in psychopathology.     

Attributional style in psychosis--the role of affect and belief type

People holding persecutory beliefs have been hypothesised to show a self-serving attributional style, which functions to protect self-esteem Bentall, Corcoran, Howard, Blackwood, and Kinderman (2001). Experimental support for this has been mixed. Freeman et al. (1998) suggested depressed and grandiose subgroups of those with persecutory beliefs might explain events differently. In this study, 71 participants completed measures of delusional beliefs, depression and attributional style. We hypothesised that those with persecutory beliefs would form grandiose and depressed subgroups, and that a self-serving attributional style would characterise only the grandiose subgroup. Hypotheses were partially confirmed. Clear subgroups were evident and only those with both persecutory and grandiose beliefs showed an externalising attributional style for negative events. Depression, irrespective of co-occurring persecutory beliefs, was related to a reduced self-serving bias and an externalising attributional style for positive events. On their own, persecutory beliefs were not related to any particular attributional style. Depressed and grandiose subgroups of those with persecutory beliefs might account for some of the inconsistencies in the attribution literature. Even within a single symptom group, care should be taken in both research and therapy to consider individual symptom patterns.     

Psychometric evaluation of the Dutch Persecutory Ideation Questionnaire (PIQ) and its relation to aggression

Patients with schizophrenia and a violent past more often have persecutory delusions than other types of delusions. The main aim of the present study was to examine the relation between persecutory ideation and self-reported aggression in a community based and clinical population. A second aim was to evaluate the psychometric properties of the Dutch version of the Persecutory Ideation Questionnaire (PIQ; McKay, Langdon, & Coltheart, 2006). From the general population, 269 persons were included as well as 79 inpatients from different psychiatric facilities. In the community based sample, the PIQ appeared to be a reliable and valid instrument to measure persecutory ideation. Evaluation of the PIQ in a sample with patients with a psychotic disorder showed that the PIQ had good criterion validity. In addition, results showed that persecutory ideation was significantly related to self-reported aggression in the community based, and in the clinical sample. Moreover, in the community based sample, this association was higher than that between positive psychopathological experiences in general and aggression in the community based sample. In sum, persecutory ideation can be measured reliably with the PIQ, and there seems a robust relation between persecutory ideation in particular and aggression in both clinical and community based samples.     

Linking theory of mind and central coherence bias in autism and in the general population

Three experiments investigated whether 2 characteristic aspects of the psychological profile of autism, theory-of-mind deficits and weak central coherence, might be functionally related. Experiment 1 showed that in the general population, performance on a proposed test of theory of mind was inversely related to speed on the Embedded Figures Test, a measure of central coherence bias. Experiments 2 and 3 confirmed that poor theory-of-mind performance was linked to weak central coherence among typically developing children and among children with autism; however, the correlations between these measures were reliable only after accounting for differences in individuals' verbal mental ages. This pattern of results is interpreted in terms of a relationship between individual differences in theory of mind and central coherence bias, a relationship that is separate from any developmental differences in these domains.     

Psychotic symptoms and violence toward others — a literature review of some preliminary findings: Part 1. Delusions

The main scope of this paper is to delineate some findings from a review of the literature concerning the possible impact of delusions on violence toward others by psychiatric patients. According to this review, studies on a possible association between delusions and increased risk of violence are scarce, but steadily growing, and have shown some interesting results. However, since delusions are also common in nonviolent psychiatric patients, there is emerging evidence that our attention should be directed to specific hallmarks of delusions that indicate an increased risk of violence. Among the main findings of the present review are: the number of empirical studies were surprisingly low; about 80% of the studies were conducted during the last 8 years; and less than one third of the studies used a prospective design. Further findings were that persecutory delusions appear to increase risk of violence in some patients; co-occurence of persecutory delusions and emotional distress may increase risk of violence; and there is limited but tentative support to the existence of an association between symptoms of perceived threat and internal control override (TCO) and violence.     

The relationship of borderline personality disorder, life events and functioning in an Australian psychiatric sample

Studies have documented poor functioning and higher rates of negative life events in association with personality disorders (PDs), in particular with borderline personality disorder (BPD). The current study investigated the impact of recent life events, daily hassles and uplifts on psychosocial functioning in patients with PDs, while extending previous research by examining the role of perceived coping effectiveness and perceived stress of recent life events. Ninety-seven participants (Axis I group, N = 30; BPD group, N = 23; Other PD group, N = 44) completed measures of functioning, recent life events, daily hassles and uplifts. Results indicated that the BPD group reported the poorest levels of functioning, especially interpersonal functioning. The BPD group also reported more negative life events, particularly in the interpersonal relationships, personal health, crime, and financial domains. The BPD group experienced less uplifts, more hassles and found employment circumstances particularly stressful and difficult to cope with. Intensity of hassles was a predictor of functioning independent of a BPD diagnosis. A greater frequency of life events was closely associated with a non-BPD diagnosis in predicting a decrease in psychosocial functioning.     

Is Fear of Others Linked to an Uncertain Sense of Self? The Relevance of Self-Worth, Interpersonal Self-Concepts, and Dysfunctional Beliefs to Paranoia

The assumption that a low sense of self-worth can give rise to paranoid delusions is relevant from a therapeutic perspective, but research has been inconsistent. The present study sought to investigate how interpersonal self-concepts and global self-worth relate to psychotic and depressive psychopathology in persons with psychosis. Participants with psychosis (n = 83) and healthy controls (n = 33) were assessed for global self-worth, interpersonal self-concepts, and dysfunctional beliefs using the Frankfurt Self-Concept Scale and the Dysfunctional Attitude Scale. Symptoms were assessed with the Positive and Negative Syndrome Scale, the Peters et al. Delusions Inventory, the Paranoia Checklist, and the Beck Depression Inventory. We hypothesized that perceived threat to self-worth, as expressed in dysfunctional acceptance beliefs and negative interpersonal self-concepts, would be uniquely associated with persecutory delusions. In contrast, low global self-worth would be strongly associated with symptoms of depression. Multiple regression analyses were used to investigate the association between symptoms and self-concepts. As expected, low global self-worth was associated with depression, whereas the more specific perception of not being accepted by relevant others was most clearly related to psychotic symptoms. Almost half of the variance in paranoia scores was explained by negative interpersonal self-concepts and the interaction between negative interpersonal self-concepts and dysfunctional acceptance beliefs. Thus, cognitive interventions for delusions might be improved by focusing more on interpersonal self-concepts.     

Relationships Among Self,Others, and Persecutors in Individuals With Persecutory Delusions: A Repertory Grid Analysis

The purpose of the current study was to examine the way individuals with persecutory delusions construe the self, others, and their main persecutor with reference to the constructs of malevolence and omnipotence, and examine the extent to which these interpersonal beliefs link to distress, self-esteem, and delusion conviction. Repertory grid methodology was used to explore interpersonal beliefs about malevolence and omnipotence in a sample (N = 30) of individuals with current persecutory delusions (mean age 36.4 years; 62% male and 53% White). Participants also completed measures of emotional distress (depression and anxiety) and self-esteem. The findings suggested that persecutors were construed as more omnipotent and malevolent than both the self and others; others in turn were construed as more omnipotent and malevolent than the self. Beliefs about self as powerful were associated with lower anxiety, depression, and higher self-esteem, and beliefs about persecutors’ omnipotence predicted delusion conviction. As with voices, the concepts of power/omnipotence and malevolence/benevolence appear to be important constructs when seeking to understand the relationship between individuals and their perceived persecutors. These findings support working therapeutically with negative schematic beliefs about self, others, and persecutors, which is consistent with a person-based cognitive therapy model of distressing psychosis.     

Learning to be possessed as a form of pathogenic relating and a cause of certain delusions

A form of pathogenic relating observed frequently by the author in family interviews is described in which it is communicated that a member has acted as if possessed by evil forces. This form of pathogenic relating is termed learning to be possessed. A number of illustrations are provided of the way this learning takes place beginning in childhood; how the so-called victim can gain insight into the process so that he or she is spared the worst penalties for impulsive, aggressive, or irrational behavior; but how the insight may be a cause of delusions, particularly persecutory or paranoid delusions, that become fixed. A comparison is made with the psychoanalytic theory of paranoid delusion, because that appears to be the only extant theory with which a comparison can be made.     

Theory of Mind in schizophrenia: first person vs third person perspective

Patients suffering from schizophrenia have an impaired meta-representation also known as Theory of Mind (ToM). Moreover, the presence of delusions or other positive symptoms of schizophrenia has been correlated to poor ToM performances. Lack of insight is a common symptom of schizophrenia and can be considered a critical manifestation of impaired ToM abilities. In particular, the present study addresses the role of perspective ToM ability in schizophrenic patients. Thirty severely delusional schizophrenic patients completely lack insight when interviewed about their delusions. Seven subsequently gain insight about their mental state when perspective is shifted from the first person to third person. These data suggest that in some delusional schizophrenic patients, it may be possible to gain access to and modify their mental states.     

The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications

The Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000) was developed to fill gaps in our understanding of the nature, course, and impact of personality disorders (PDs). Here, we review published findings to date, discuss their implications for current conceptualizations of PDs, and raise questions that warrant future consideration. We have found that PDs are more stable than major depressive disorder, but that meaningful improvements are possible and not uncommon. We have confirmed also that PDs constitute a significant public health problem, with respect to associated functional impairment, extensive treatment utilization, negative prognostic impact on major depressive disorder, and suicide risk. At the same time, we have demonstrated that dimensional models of PDs have clinical validity that categories do not, especially greater temporal stability. Furthermore, dimensional personality traits appear to be the foundation of behaviors described by many PD criteria. Taken together, our results lead us to hypothesize that PDs may be reconceptualized as hybrids of stable personality traits and intermittently expressed symptomatic behaviors.     

Delusions and delusional reasoning

In 2 studies, delusional participants assigned higher probabilities to narratives of actual delusions than participants with no history of delusions; previously delusional participants did not differ significantly from delusional participants or participants with no history of delusions. In Study 2, the authors found that this reasoning bias was specific to delusions and did not generalize to "neutral" text. Familiarity with the content of the delusion narratives played a mediating role in the estimation of their probability, but delusional status also had a significant, independent effect. These findings are consistent with the Bayesian model of delusion formation proposed by D. R. Hemsley and P. A. Garety (1986), and with R. P. Bentall, P. Kinderman, and S. Kaney's (1994) concept of "emotional saliency." A productive area of future research might be to further determine the elements of "emotional saliency" and their impact on the individual steps of the Bayesian model.     

Difficulties in interpersonal relationships associated with personality disorders and axis I disorders: a community-based longitudinal investigation

A longitudinal study was conducted to investigate the association between Axis I and Axis II psychiatric disorders, interpersonal relationships, and global functioning among men in the community. Structured clinical interviews assessing Axis I and Axis II psychiatric disorders, global assessments of functioning, and questionnaires assessing social support, social conflict, and loneliness were administered to a community sample of 95 HIV+ and 45 HIV- men. The questionnaires were readministered 1 year later. Results indicated that (a) Personality disorders (PDs) and unipolar depressive disorders were associated with loneliness, social conflict, and low levels of social support after HIV status was controlled statistically; (b) PDs were associated with interpersonal and global impairment after HIV status and co-occurring Axis I disorders were controlled statistically; (c) Axis I disorders were associated with global impairment, but were not associated with interpersonal difficulties after HIV status and PDs were controlled statistically; (d) PDs, but not Axis I disorders, predicted increases in social conflict and global impairment after HIV status was controlled statistically; (e) PDs continued to predict increases in global impairment after both Axis I disorders and HIV status were controlled statistically; and (f) HIV+ men reported more loneliness, less social support, and had a higher prevalence of substance use disorders than HIV- men. The present findings are of particular interest because they suggest that PDs are associated with loneliness, social conflict, and a lack of social support among men in the community, whether or not Axis I disorders are present.     

An examination of hypervigilance for external threat in individuals with generalized anxiety disorder and individuals with persecutory delusions using visual scan paths

One account of generalized anxiety disorder (GAD) is that it results from hypervigilance, manifest as excessive scanning of the external environment and preferential attention to threat. However, for individuals with GAD, there has been no direct study of scanning, and evidence for preferential attention to threat has only been found for threat-words. We therefore devised a new measure of hypervigilance. Visual scan paths were recorded of individuals with GAD (N=12) and people without a psychiatric illness (N=12) viewing complex pictures that varied in threat content. People with persecutory beliefs (N=11) also participated in the study to test the hypothesis that anxiety, via such hypervigilant cognitive processes, may contribute to the maintenance of delusions. Compared with the control group, the anxious individuals were not found either to scan excessively for or to look at threat. The anxiety group was therefore not hypervigilant for external threat, which is inconsistent with the hypervigilance model. As a consequence, the hypothesis that anxiety maintains delusions was not tested. However, additional support was found for the hypothesis that people with delusions form rapid judgements on the basis of less data-gathering than control groups who are either anxious or have no psychiatric illness.     

The use of imagery in cognitive therapy for psychosis: a case example

There has been a long tradition of studying imagery in relation to psychotic symptoms. Recent studies have suggested that imagery may be involved in the development and maintenance of psychotic symptoms (hallucinations and delusions in particular). Following a review of this literature, including work conducted by the author and colleagues, a case study is used to illustrate the clinical applications of this work. Working with images that were associated with persecutory delusions appeared to contribute to a reduction in distress, preoccupation, and conviction in relation to these beliefs, which were assessed using a standardised measure (PSYRATS). The implications for theory, practice, and future research are considered.