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.     

Group Cognitive Behavioral Therapy for Delusions: Helping Patients Improve Reality Testing

Group Cognitive Behavior Therapy (CBT) was used to treat residual delusions in patients with schizophrenia. Initially all patients (N = 6) reported delusions of various types, such as persecution, body/mind control, grandiosity, and religious themes. The group format allowed patients to share their experiences and beliefs, thereby eliminating shame and providing support and coping strategies; as well as allowing for peer–peer discussion of irrationalities and inconsistencies in each other's beliefs. After 13 sessions there was a statistically significant reduction in delusional conviction, unhappiness associated with thinking about a delusion, intensity of distress associated with delusion, and an increased ability to dismiss a delusional thought.     

Some comments on masochism and the delusion of omnipotence from a developmental perspective.

This paper explores the relation of the delusion of omnipotence to masochism and suggests that this fantasy constitutes a major component of the resistance so prominent in work with masochistic patients. The connections among masochism, omnipotence, negative therapeutic reaction, and clinging to pain are discussed. The classical view has been that the failure of infantile omnipotence forces the child to turn to reality. Our experience with masochistic patients suggests that it is the real failure to achieve competent interactions with others that forces the child to turn to omnipotent solutions. The distinction is made between fantasies that enhance the real capacities of the self and those aimed at denying and transforming the pain and inadequacy of the mother-child relationship. The epigenetic transformations of omnipotent fantasies through all levels of development are described. The patient's need to protect the omnipotent fantasy is discussed in relation to resistance at each phase of analysis.     

The epistemic innocence of motivated delusions

Delusions are defined as irrational beliefs that compromise good functioning. However, in the empirical literature, delusions have been found to have some psychological benefits. One proposal is that some delusions defuse negative emotions and protect one from low self-esteem by allowing motivational influences on belief formation. In this paper I focus on delusions that have been construed as playing a defensive function (motivated delusions) and argue that some of their psychological benefits can convert into epistemic ones. Notwithstanding their epistemic costs, motivated delusions also have potential epistemic benefits for agents who have faced adversities, undergone physical or psychological trauma, or are subject to negative emotions and low self-esteem. To account for the epistemic status of motivated delusions, costly and beneficial at the same time, I introduce the notion of epistemic innocence. A delusion is epistemically innocent when adopting it delivers a significant epistemic benefit, and the benefit could not be attained if the delusion were not adopted. The analysis leads to a novel account of the status of delusions by inviting a reflection on the relationship between psychological and epistemic benefits.     

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.     

Proneness to hallucinations and delusions in a non‐clinical sample: Exploring associations with metacognition and negative affect

Commonly, individuals prone to hallucinations and delusions hold dysfunctional metacognitive beliefs and report higher levels of negative affect, yet, these associations have not been clearly investigated in non‐clinical samples due to the failure to control for high intercorrelations between variables. The aim of the current study was to investigate how hallucination and delusion proneness are associated with dysfunctional metacognitions and negative affect. A cross‐sectional sample of 715 students free from psychiatric diagnoses (M_age = 28.1 years, SD = 10.9, range 18–65) completed the Launay‐Slade Hallucination Scale (LSHS‐R); Peters et al. Delusion Inventory (PDI‐21); Depression, Anxiety, and Stress Scale (DASS‐21); and the Metacognition Questionnaire (MCQ‐30). Findings that participants who were prone to both hallucinations and delusions reported elevated levels of negative affect support the need for targeted mental health treatment for individuals who experience psychological distress related to their hallucinatory and delusional experiences. While metacognition beliefs of need to control thoughts and cognitive self‐consciousness, along with the anxiety and stress DASS‐21 subscales appeared as significant cross‐sectional predictors of proneness to hallucinations and delusions, only metacognitions demonstrated any notable predictive value for delusion proneness. This finding questions the role of metacognitions in determining hallucination and delusion proneness in non‐clinical samples.     

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.     

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.     

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.     

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.     

Loving, hating, vacillating: Agreeableness, implicit self-esteem, and neurotic conflict

An implicit preference for the self over others may be beneficial when pursuing one's own desires but costly when adjusting the self to the desires of others. On the basis of this reasoning, the authors hypothesized that Agreeableness and implicit self-esteem would interact in predicting measures of neurotic distress. Three studies and one meta-analysis, involving 235 undergraduate participants, confirmed that high levels of implicit self-esteem were beneficial (i.e., less neurotic distress) within the context of low levels of Agreeableness but costly (i.e., more neurotic distress) within the context of high levels of Agreeableness. Because findings were robust across various measures of Agreeableness, implicit self-esteem, and neurotic distress, the interpersonal principles examined here appear to have broad relevance for understanding this particular form of intrapsychic conflict and its manifestation in neurotic distress. Results therefore support Horney's (1945) theory concerning the consequences of intrapsychic conflicts related to interpersonal motivation and cognition.     

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.     

Jumping to conclusions and the continuum of delusional beliefs

The present study examined the jumping to conclusions reasoning bias across the continuum of delusional ideation by investigating individuals with active delusions, delusion prone individuals, and non-delusion prone individuals. Neutral and highly self-referent probabilistic reasoning tasks were employed. Results indicated that individuals with delusions gathered significantly less information than delusion prone and non-delusion prone participants on both the neutral and self-referent tasks, (p<.001). Individuals with delusions made less accurate decisions than the delusion prone and non-delusion prone participants on both tasks (p<.001), yet were more confident about their decisions than were delusion prone and non-delusion prone participants on the self-referent task (p=.002). Those with delusions and those who were delusion prone reported higher confidence in their performance on the self-referent task than they did the neutral task (p=.02), indicating that high self-reference impacted information processing for individuals in both of these groups. The results are discussed in relation to previous research in the area of probabilistic reasoning and delusions.     

Personal Constructs of Mind-Body Identity in People Who Experience Medically Unexplained Symptoms

“Medically unexplained symptoms” (MUS) refers to chronic physical symptoms without a clear medical cause, which produce significant levels of distress and functional impairment. This project modified the repertory grid technique to explore how twenty participants experiencing MUS construed self and others in bodily and psychological ways. Findings suggested that symptoms are well integrated within participants' wider mind–body construct systems. Increased distance between how self in general is construed compared to self when symptoms are worst was associated with reduced anxiety. Measuring intrapersonal and interpersonal implicative dilemmas suggested that moral and relational construing of identity is affected by MUS.     

The cognitive and affective dimensions of moral conviction: implications for attitudinal and behavioral measures of interpersonal tolerance

The present studies investigate the role of both cognitive and affective dimensions of moral conviction in contributing to negative interpersonal responses. After demonstrating that the cognitive and affective dimensions of moral conviction are distinct constructs, the studies show that the cognitive dimension is sufficient to produce many forms of interpersonal intolerance. Simply believing an issue to be moral (i.e., objectively grounded, non-negotiable) results in greater intolerance for (Study 1), less sharing with (Study 2), and greater distancing from (Study 3) people with divergent attitudes. The emotional intensity with which beliefs are experienced is not alone explanatory. Nonetheless, it interacts with moral beliefs to produce the highest levels of interpersonal intolerance, distancing from dissimilar others, and context insensitivity. This interaction pattern between moral beliefs and affect was specific to emotional intensity and not other measures of attitude strength (Study 3).     

The relationship between interpersonal perception and post-traumatic stress disorder-related functional impairment: a social relations model analysis

This study used Kenny's social relations model to examine the relationship between Post-Traumatic Stress Disorder-related impairment and interpersonal perceptions. Participants were 124 students who had previously completed the Post-traumatic Stress Diagnostic Scale as part of a larger study. After engaging in brief dyadic conversations with 3 other students, participants recorded perceptions of personality traits for themselves, their interaction partners and how they believed their partners saw them (metaperceptions). Results indicated that those with more severe post-traumatic stress disorder-related impairment saw themselves negatively and believed their interaction partners also viewed them negatively. However, these individuals were not seen differently by others, except that they were rated as less dependable. Our findings suggest that post-traumatic stress disorder is associated with negative beliefs about the self that may influence self-esteem and interpersonal relationships.     

Jumping to conclusions, a lack of belief flexibility and delusional conviction in psychosis: a longitudinal investigation of the structure, frequency, and relatedness of reasoning biases

Two reasoning biases, jumping to conclusions (JTC) and belief inflexibility, have been found to be associated with delusions. We examined these biases and their relationship with delusional conviction in a longitudinal cohort of people with schizophrenia-spectrum psychosis. We hypothesized that JTC, lack of belief flexibility, and delusional conviction would form distinct factors, and that JTC and lack of belief flexibility would predict less change in delusional conviction over time. Two hundred seventy-three patients with delusions were assessed over twelve months of a treatment trial (Garety et al., 2008). Forty-one percent of the sample had 100% conviction in their delusions, 50% showed a JTC bias, and 50%-75% showed a lack of belief flexibility. Delusional conviction, JTC, and belief flexibility formed distinct factors although conviction was negatively correlated with belief flexibility. Conviction declined slightly over the year in this established psychosis group, whereas the reasoning biases were stable. There was little evidence that reasoning predicted the slight decline in conviction. The degree to which people believe their delusions, their ability to think that they may be mistaken and to consider alternative explanations, and their hastiness in decision making are three distinct processes although belief flexibility and conviction are related. In this established psychosis sample, reasoning biases changed little in response to medication or psychological therapy. Required now is examination of these processes in psychosis groups where there is greater change in delusion conviction, as well as tests of the effects on delusions when these reasoning biases are specifically targeted.     

The emergence of narcissism and self-esteem: A social-cognitive approach*

Abstract

What separates narcissism from self-esteem, and what sparks their development? This article proposes that narcissism and self-esteem are underpinned by distinct core beliefs – beliefs about the nature of the self, of others, and of the relationship between the self and others. These beliefs (1) arise early in development, (2) are cultivated by distinct socialization experiences, and (3) can be targeted through precise interventions so as to simultaneously curb narcissism and raise self-esteem. Recognizing the distinction between narcissism and self-esteem will help parents, teachers, and practitioners nurture healthy feelings of self-worth in children from an early age.     

Unemployment,Self-Esteem,and Depression: A Social Comparison Theory Approach

A social comparison theory approach to the relation between unemployment, self-esteem, and depression was tested using a cross-sectional questionnaire design (N = 88). Personal attributes were used as the domain of comparison, and four types of comparisons-intrapersonal, interpersonal, intragroup, and intergroup-were operationalized. Employment status affected the salience of intrapersonal comparisons. Comparisons with the past self were highly predictive of psychological distress among unemployed respondents, whereas comparisons with the ideal self predicted distress among the employed. Individual-level and group-level social comparisons had different associations with the dependent measures for unemployed respondents. Intrapersonal and interpersonal comparisons were significantly related to depression and self-esteem scores, whereas intragroup and intergroup comparisons were related only to self-esteem. Social comparisons with unemployed people were related to reduced depression levels among employed respondents. Results also showed that unemployed people had more negative social comparison scores relative to their employed counterparts. Results are discussed in terms of recent developments in social comparison theory. Suggestions for future research are outlined.