Emotions, self-esteem, and paranoid episodes: an experience sampling study

Daily Parent-Teen Conflict and Parent and Adolescent Well-Being: The Moderating Role of Daily and Person-Level Warmth

In early-mid adolescence, parent-teen conflicts become more intense and parents' displays of warmth tend to decline temporarily. Daily increases of parent-teen conflict have been linked to concurrent increases in adolescent emotional distress, yet greater average levels of parental warmth are known to buffer adolescents' response to daily stressors such as interpersonal conflict. It is unclear whether daily increases in parental warmth may also function as a protective buffer that attenuates the daily association between parent-teen conflict and individuals' well-being. The present study aimed to fill an important gap in the literature by examining daily (within-person) fluctuations, and average between-person differences, in parental warmth as potential moderators of the daily association between parent-teen conflict intensity (defined here by the degree of negative emotions in parent-teen interactions) and well-being (distress, positive affect, and self-esteem) of both parents and adolescents. Data are based on daily reports from 120 parents-adolescents dyads recruited from a primary care practice in the Northeastern U.S. Almost all parents were mothers (M_age = 44.55, SD = 6.36), 61% of adolescents were female (M_age = 14.36, SD = 0.88), and 66% of dyads were African American. Multilevel modeling was used to assess the daily association between parent-teen conflict and well-being and examine daily and person-level (across-days) warmth as moderators of that association. Examining daily parental warmth as a moderator addressed whether the daily association between conflict and well-being varied as a function of when parental warmth increased or decreased within individuals (relative to individuals' own daily average). In contrast, examining person-level mean warmth as a moderator addressed whether the daily association between conflict and well-being varied as a function of who, on average, reported higher vs. lower levels of parental warmth. As expected, both parents and adolescents reported significantly lower well-being on days they experienced more conflict than usual. Daily fluctuations in parental warmth did not moderate the daily associations between conflict and well-being in parents or adolescents, indicating that the daily association did not change when parents were warmer than usual. In adolescents, the daily associations between conflict and distress, as well as conflict and positive affect, were moderated by person-mean levels of parental warmth, such that daily increases in conflict were associated with higher distress and lower positive affect (on the same day) primarily among adolescents with average or below average levels of parental warmth. Daily conflict was not associated with lower well-being among adolescents with higher-than-average levels of parental warmth. In parents, neither daily nor person-level warmth moderated the daily association between conflict and well-being, suggesting that the negative, daily association between conflict and well-being did not change as a function of parents' daily or average perceptions of warmth. These findings suggest that isolated, day-specific increases in warmth may be less protective than high, stable levels of parental warmth in mitigating the daily association between parent-teen conflict and adolescent well-being.

Activation in bed nucleus of the stria terminalis (BNST) corresponds to everyday helping

Everyday prosociality includes helping behaviors such as holding doors or giving directions that are spontaneous and low-cost and are performed frequently by the average person. Such behaviors promote a wide array of positive outcomes that include increased well-being, trust, and social capital, but the cognitive and neural mechanisms that support these behaviors are not yet well understood. Whereas costly altruistic responding to others' distress is associated with elevated reactivity in the amygdala, we hypothesized that everyday prosociality would be more closely associated with activation in the bed nucleus of the stria terminalis (BNST), a region of the extended amygdala known for its roles in maintaining vigilance for relevant socio-affective environmental cues and in supporting parental care. One previous study of the neural correlates of everyday prosociality highlighted a functional cluster identified as the septal area but which overlapped with established coordinates of BNST. We used an anatomical mask of BNST (Torrisi et al., 2015) to evaluate the association of BNST activation and daily helping in a sample of 25 adults recruited from the community as well as 23 adults who had engaged in acts of extraordinary altruism. Results found that activation in left BNST during an empathy task predicted everyday helping over a subsequent 14-day period in both samples. BNST activation most strongly predicted helping strangers and proactive helping. We conclude that beyond facilitating care for offspring, activation in BNST may provide a basis for the motivation to engage in a broad array of everyday helping behaviors.

Awareness and rumination moderate the affective pathway to paranoia in daily life

Numerous cross-sectional studies found psychosis to be associated with less awareness of emotions, a decreased use of adaptive (e.g. reappraisal) and an increased use of maladaptive emotion regulation (ER) strategies (e.g. suppression). In this study, we tested whether state levels of emotion awareness and momentary use of specific ER strategies moderate the link between negative affect at one timepoint (t-1) and paranoia at the next timepoint (t) in a six-day experience sampling study. Individuals with psychotic disorders (n = 71) reported on the presence of paranoia, negative affect, emotion awareness and the use of six ER strategies (reappraisal, acceptance, social sharing, distraction, suppression and rumination) ten times per day. Multilevel regression analysis revealed that higher awareness at t-1 reduced the association of negative affect at t-1 and paranoia at t, whereas rumination had an opposite, amplifying moderation effect. Our results provide novel insight into the conditions under which negative affect translates into delusional beliefs. The finding that emotion awareness and rumination have a relevant role corresponds with current psychological conceptualisations of psychosis and with the attempt to treat delusions by focusing on reducing ruminative thoughts. To investigate the causal effect, treatment trials with a focus on enhancing these components of emotion regulation are needed.

A time-series network approach to auditory verbal hallucinations: Examining dynamic interactions using experience sampling methodology

BACKGROUND

Identifying variables that influence daily-life fluctuations in auditory verbal hallucinations (AVHs) provides insight into potential mechanisms and targets for intervention. Network analysis, that uses time-series data collected by Experience Sampling Method (ESM), could be used to examine relations between multiple variables over time.

METHODS

95 daily voice-hearing individuals filled in a short questionnaire ten times a day for six consecutive days at pseudo-random moments. Using multilevel vector auto-regression, relations between voice-hearing and negative affect, positive affect, uncontrollable thoughts, dissociation, and paranoia were analysed in three types of networks: between-subjects (between persons, undirected), contemporaneous (within persons, undirected), and temporal (within persons, directed) networks. Strength centrality was measured to identify the most interconnected variables in the models.

RESULTS

Voice-hearing co-occurred with all variables, while on a 6-day period voice-hearing was only related to uncontrollable thoughts. Voice-hearing was not predicted by any of the factors, but it did predict uncontrollable thoughts and paranoia. All variables showed large autoregressions, i.e. mainly predicted themselves in this severe voice-hearing sample. Uncontrollable thoughts was the most interconnected factor, though relatively uninfluential.

DISCUSSION

Severe voice-hearing might be mainly related to mental state factors on the short-term. Once activated, voice-hearing appears to maintain itself. It is important to assess possible reactivity of AVH to triggers at the start of therapy; if reactive, therapy should focus on the triggering factor. If not reactive, Cognitive Behavioural interventions could be used first to reduce the negative effects of the voices. Limitations are discussed.

Lifetime and Momentary Psychotic Experiences in Adult Males and Females With an Autism Spectrum Disorder

BACKGROUND

Existing research shows that adults with an autism spectrum disorder (ASD) are more vulnerable to develop overt psychosis. However, studies investigating (subclinical) psychotic experiences (PE) in ASD are scarce, and it is unknown if PE are accompanied with more distress in adults with ASD compared to the general population. This study examined lifetime PE and accompanying distress, momentary PE levels, and the impact of daily life stress and negative affect (NA) on momentary PE in males and females with ASD compared to controls.

METHODS

In 50 adults with ASD (males N= 26, females N= 24) and 51 adults without ASD (males N= 26, females N= 25), the Community Assessment of Psychic Experiences (CAPE) was used to analyze group differences in frequency and distress of lifetime subclinical positive, negative, and depressive symptoms. The Experience Sampling Method (ESM) was used to measure momentary PE, NA, and stress (activity-related, event-related, and social stress) for 10 days. Multilevel analyses were conducted to test whether stress and NA were associated with momentary PE and whether these associations were modified by group or sex.

RESULTS

Adults with ASD reported more lifetime CAPE negative and depressive symptoms, but similar levels of PE, than controls. Higher levels of accompanying distress were found in participants with ASD for each subscale. With respect to ESM momentary PE, higher levels were reported by adults with ASD and a stronger association between event-related stress and momentary PE was found compared to controls. This was not the case for NA, activity-related, and social stress. Overall, no significant differences between male and female outcomes were found.

CONCLUSION

Adults with ASD are more prone to encounter lifetime subclinical negative and depressive symptoms and accompanying distress compared to adults without ASD. Similar levels of lifetime PE in both groups were still accompanied with more distress in the ASD group. Furthermore, higher levels of ESM momentary PE were found in participants with ASD. Additionally, event-related stress may act as a risk factor for PE in both females and males with ASD, with a stronger risk-increasing effect than in their control counterparts.

Emotion regulation as a moderator of the interplay between self-reported and physiological stress and paranoia

Experience sampling method (ESM) studies have found an association between daily stress and paranoid symptoms, but it is uncertain whether these findings generalize to physiological indicators of stress. Moreover, the temporality of the association and its moderating factors require further research. Here, we investigate whether physiological and self-rated daily stress predict subsequent paranoid symptoms and analyze the role of emotion regulation as a putative moderator. We applied ESM during 24 h to repeatedly assess heart rate, self-rated stress, and subclinical paranoia in a sample of 67 psychosis-prone individuals as measured with Community Assessment for Psychotic Experiences (CAPE). Adaptive and maladaptive emotion regulation was assessed at baseline with the Emotion Regulation Skills Questionnaire (ERSQ-ES) and the Cognitive Emotion Regulation Questionnaire (CERQ). Linear mixed models were used to analyze the data. Heart rate (b = 0.004, p < 0.05) and self-rated stress (b = 0.238, p < 0.001) predicted subsequent paranoia. The reverse effect, paranoia as a predictor of subsequent heart rate (b = 0.230, p = 0.615) or self-rated stress (b = –0.009, p = 0.751) was non-significant. Maladaptive emotion regulation was a significant predictor of paranoia (b = 0.740, p < 0.01) and moderated the path from self-rated stress to paranoia (b = 0.188, p < 0.05) but not the path from heart rate to paranoia (b = 0.005, p = 0.09). Our findings suggest a one-way temporal link between daily stress and paranoia and highlight the importance of emotion regulation as a vulnerability factor relevant to this process.

Double-blind placebo controlled trial of the anxiolytic effects of a standardized Echinacea extract

Earlier studies suggested that specific Echinacea preparations might decrease anxiety. To further study the issue, we performed a double blind, placebo controlled trial with a standardized Echinacea angustifolia root extract. Participants were volunteers scoring above 45 points on the state or on the trait subscale of the State Trait Anxiety Inventory (STAI). They were treated with 40 mg Echinacea or with placebo tablets twice daily for 7 days followed by a 3 week-long washout period. Participants were also administered the Beck Depression Inventory (BDI) and the Perceived Stress Scale (PSS). In the Echinacea group, state anxiety scores decreased by approximately 11 points by the end of the treatment period, whereas the decrease was around 3-points in the placebo group (p< 0.01). The effect maintained over the washout period. The difference from placebo was significant from the 7th day of treatment throughout. Changes were less robust with trait anxiety scores, but the preparation performed better than placebo in patients with high baseline anxiety. Neither BDI nor PSS scores were affected by the treatments. Adverse effects were rare and mild, and all were observed in the placebo group. These findings suggest that particular Echinacea preparations have significant beneficial effects on anxiety in humans.

Immediate and short term effects of values-based interventions on paranoia

BACKGROUND AND OBJECTIVES

Paranoia is a common, distressing, and persistent experience that can negatively impact on health, wellbeing, and functioning. This study examined the immediate and short term (2-weeks) effects of two values-based interventions, versus a non-values control, on paranoia, as well as the moderating effect of self-esteem.

METHODS

171 non-clinical adults were randomised to a value-affirmation and goals task (VAG: clarifying and reflecting on core values and setting value-based goals) (n = 57), a value-affirmation task (VA: clarifying and reflecting on core values without setting value-based goals) (n = 57), or a non-affirmation control task (NAC) (n = 57). Paranoia was assessed at baseline (T1), post-intervention (T2), and two weeks post-intervention (T3). Self-esteem was measured at baseline.

RESULTS

VAG participants had significantly lower state paranoia scores at T3 than VA (d = .34) and NAC (d = .31) participants. This effect was moderated by trait self-esteem: At follow-up, the differential effect of condition on state paranoia was greatest amongst those with low self-esteem, with the VAG condition being most beneficial for participants with low self-esteem and the VA condition being least beneficial.

LIMITATIONS

Without a goals only control group it is possible that the benefits of VAG over VA were attributable to setting and achieving goals. Use of a nonclinical sample limits generalisability to clinical groups.

CONCLUSIONS

The findings suggest that focusing on a deeply held value and setting goals in line with that value reduced paranoia. This intervention may be most beneficial for individuals with low self-esteem.

Dynamic relationships between emotional distress, persecutory ideation, and metacognition in schizophrenia

OBJECTIVE

Determine whether metacognitive capacity (i.e., a range of abilities that involve recognition, reflection, and integration of mental states) influences the relationships between emotional distress and persecutory ideation (PI).

METHODS

The present study examined emotional distress, metacognition and PI in a sample (n = 337) of individuals with schizophrenia or schizoaffective disorder and clinician-rated PI. Pearson and partial correlations were used to examine relationships between variables, as well as between-subjects analysis of variances to compare groups characterized based on emotional distress and persecutory ideation scores.

RESULTS

While emotional distress and PI are associated with one another, metacognition is negatively associated with PI and positively associated with emotional distress. Subgroup comparisons demonstrated that individuals with high emotional distress and low PI had significantly higher metacognitive capacity than those elevated in PI or reduced in both emotional distress and PI.

CONCLUSIONS

Findings suggest metacognitive capacity may relate to improved awareness of distress and reduced PI.

Worry and metacognitions as predictors of the development of anxiety and paranoia

Recent studies have shown that worry and related negative metacognitions are characteristic in generalized anxiety and paranoia respectively. However, most of these studies did not take into account common co-occurrence of anxiety and paranoia, and longitudinal modelling of the role of worry and metacognitions on the development of anxiety and paranoia is rare. The current study aimed at examining the bidirectional longitudinal relationship between anxiety and paranoia, as well as the importance of worry and metacognitions in the development of these symptoms. Our validated sample consisted of 2291 participants recruited from universities, among whom 1746 participants (76.21%) completed online questionnaires at baseline and at one year, reporting levels of anxiety, paranoia, worry, and negative metacognitions. Structural equation modeling analyses, followed by path comparisons, revealed that anxiety and paranoia mutually reinforced each other over time. Negative metacognitions, rather than worry itself, were contributive to the development of both symptoms over time. Negative metacognitions showed bi-directional relationships with anxiety over the time period assessed and showed uni-directional relationships with paranoia. Clinical implications of our findings are discussed.

Autonomic arousal during psychosis spectrum experiences: Results from a high resolution ambulatory assessment study over the course of symptom on- and offset

INTRODUCTION

Ecological momentary assessment (EMA) studies show that stressors trigger the onset or increase of psychotic symptoms. These studies, however, predominantly rely on large sampling intervals and self-report assessment. This study aims to identify the autonomic stress-response to psychosis-spectrum experiences by using a one-day high-resolution EMA with continuous skin conductance and heart rate monitoring in a sample with attenuated positive symptoms.

METHODS

Sixty-two participants were equipped with a smartphone and wearable sensors to monitor skin conductance level (SCL) and heart rate variability (HRV) for 24 h. Every 20 min, participants answered questions on current stress, hallucination spectrum experiences (HSE), and paranoia. Sampling intervals were categorized into no event, pre-onset, event, pre-offset, and post-offset phases. We contrasted stress, SCL, and HRV between phases using multilevel regression models of sampling intervals nested in participants.

RESULTS

For paranoia, we found alterations in the autonomic and self-reported stress response prior to the onset that persisted until the episodes had ended. For HSE, we found no effects. Exploratory separate analyses of the different items aggregated into HSE yielded diverging results for intrusive thoughts, perceptual sensitivity, and hallucinations.

CONCLUSION

Physiological parameters are sensitive indicators of the onset of paranoia, which holds implications for preventive mobile interventions. To further explore the autonomic stress-response associated with HSE, further studies of the different HSE are needed.

Capturing behavioral indicators of persecutory ideation using mobile technology

Most existing measures of persecutory ideation (PI) rely on infrequent in-person visits, and this limits their ability to assess rapid changes or real-world functioning. Mobile health (mHealth) technology may address these limitations. Little is known about passively sensed behavioral indicators associated with PI. In the current study, sixty-two participants with schizophrenia spectrum disorders completed momentary assessments of PI on a smartphone that also passively collected behavioral data for one year. Results suggested that PI was prevalent (n = 50, 82% of sample) but had infrequent incidence (25.2% of EMA responses). PI was also associated with changes in several passively sensed variables, including decreases in distance traveled (M_kilometers = -1.20, SD = 18.88), time spent in a vehicle (M_minutes = -4.15, SD = 49.59), length of outgoing phone calls (M_minutes = -0.79, SD = 13.13), time spent proximal to human speech (M_minutes = -6.26, SD = 153.03), and an increase in time sitting still (M_minutes = 4.04, SD = 94.69). The present study suggests changes associated with PI may be detectable by passive sensors, including reductions in moving or traveling, and time spent around others or in self-initiated phone conversations. These constructs might constitute risk for PI.

The intra-day dynamics of affect, self-esteem, tiredness, and suicidality in Major Depression

Despite growing interest in the temporal dynamics of Major Depressive Disorder (MDD), we know little about the intra-day fluctuations of key symptom constructs. In a study of momentary experience, the Experience Sampling Method captured the within-day dynamics of negative affect, positive affect, self-esteem, passive suicidality, and tiredness across clinical MDD (N= 31) and healthy control groups (N= 33). Ten symptom measures were taken per day over 6 days (N= 2231 observations). Daily dynamics were modeled via intra-day time-trends, variability, and instability in symptoms. MDD participants showed significantly increased variability and instability in negative affect, positive affect, self-esteem, and suicidality. Significantly different time-trends were found in positive affect (increased diurnal variation and an inverted U-shaped pattern in MDD, compared to a positive linear trend in controls) and tiredness (decreased diurnal variation in MDD). In the MDD group only, passive suicidality displayed a negative linear trend and self-esteem displayed a quadratic inverted U trend. MDD and control participants thus showed distinct dynamic profiles in all symptoms measured. As well as the overall severity of symptoms, intra-day dynamics appear to define the experience of MDD symptoms.

Associations between affect and alcohol consumption in adults: an ecological momentary assessment study

Background: Consuming alcohol for coping with negative affect (NA) or enhancing positive affect (PA) may lead to risky drinking patterns. Previous research has yielded mixed findings regarding these affective drinking associations.Objectives: To examine support for the self-medication and expectancy models of alcohol use in an adult community sample, by examining reciprocal associations between alcohol consumption and NA and PA within and between persons.Methods: During seven consecutive days, 162 adults from the community (109 female) reported their affective experiences and alcohol consumption, following a signal contingent ecological momentary assessment protocol on their smartphones.Results: Within-person daily NA preceding the first drinking event was associated with increased likelihood of same-day alcohol consumption. Within-person momentary NA was associated with a decrease in the amount of next-moment alcohol consumption. Within-person momentary PA was positively associated with likelihood of next-moment alcohol consumption. Between persons, levels of daily and momentary NA and PA were not associated with any index of alcohol consumption. The intercepts and slopes of NA were not significantly different before and after alcohol consumption. The intercept of PA was higher after alcohol consumption, whereas the slope of PA decreased after alcohol consumption.Conclusion: In the current sample affective drinking was a within-person process (i.e. persons were sensitive to their varying levels of affect). Some support was found for the self-medication and expectancy models. People may drink for coping with NA, but may also be at risk for developing affective drinking patterns in response to PA.

Cognitive reappraisal capacity mediates the relationship between prefrontal recruitment during reappraisal of anger-eliciting events and paranoia-proneness

Difficulties in emotion regulation, particularly in using adaptive regulation strategies such as cognitive reappraisal, are a commonly observed correlate of paranoia. While it has been suggested that poor implementation of cognitive reappraisal in dealing with aversive events precedes the onset of subclinical paranoid thinking, there is little empirical research on neural activation patterns during cognitive reappraisal efforts that might indicate vulnerability towards paranoid thinking. Prefrontal EEG alpha asymmetry changes were recorded while n = 57 participants were generating alternative appraisals of anger-eliciting events, and were linked to a behavioral measure of basic cognitive reappraisal capacity and self-reported paranoia proneness (assessed by personality facets of hostility and suspiciousness; Personality Inventory for DSM-5). Mediation analysis revealed that less left-lateralized activation at ventrolateral prefrontal sites during reappraisal efforts predicted a higher degree of paranoia proneness. This relationship was mediated through poorer cognitive reappraisal capacity. Matching previous evidence, findings suggest that inappropriate brain activation during reappraisal efforts impairs individuals' capacity to come up with effective alternative interpretations for anger-evoking situations, which may accentuate personality features related to increased paranoid thinking. The findings add to our understanding of neurally underpinned impairments in the capacity to generate cognitive reappraisals and their link to maladaptive personality and behavior.

Factor mixture analysis of paranoia in young people

BACKGROUND

Paranoid thoughts are relatively common in the general population and can increase the risk of developing mental health conditions. In this study, we investigate the latent structure of paranoia in a sample of young people.

METHODS

Cross-sectional survey; 243 undergraduate students (males: 44.9%) aged 24.3 years (SD 3.5). The participants completed the Green et al. Paranoid Thought Scales GPTS, a 32-item scale assessing ideas of social reference and persecution; the 12-item General Health Questionnaire (GHQ-12), and the 74-item Schizotypal Personality Questionnaire (SPQ). Confirmatory factor analysis (CFA) was used to confirm the two-factor structure of the GPTS. Factor mixture modeling analysis (FMMA) was applied to map the best combination of factors and latent classes of paranoia.

RESULTS

The GPTS showed excellent internal reliability and test-retest stability. Convergent validity was good, with stronger links with measures of ideas of reference and of suspiciousness than with other measures of psychosis-proneness. CFA showed excellent fit for the two-factor solution. FMMA retrieved a three-class solution with 176 subjects (72.5%) assigned to a baseline class, 54 (22.2%) to a "suspicious and mistrustful" class, and 13 (5.3%) to a "paranoid thinking" class. Compared to the baseline class, the other two classes had a higher risk of psychological distress and psychosis-proneness.

CONCLUSIONS

The latent structure of paranoid thinking in young people appears dimensional. Although caution is advised when generalizing from studies on college students, screening for paranoid ideation in young people who complain about psychological distress might prove useful to prevent the development of severe and potentially debilitating conditions.

Links between psychotic and neurotic symptoms in the general population: an analysis of longitudinal British National Survey data using Directed Acyclic Graphs

BACKGROUND

Non-psychotic affective symptoms are important components of psychotic syndromes. They are frequent and are now thought to influence the emergence of paranoia and hallucinations. Evidence supporting this model of psychosis comes from recent cross-fertilising epidemiological and intervention studies. Epidemiological studies identify plausible targets for intervention but must be interpreted cautiously. Nevertheless, causal inference can be strengthened substantially using modern statistical methods.

METHODS

Directed Acyclic Graphs were used in a dynamic Bayesian network approach to learn the overall dependence structure of chosen variables. DAG-based inference identifies the most likely directional links between multiple variables, thereby locating them in a putative causal cascade. We used initial and 18-month follow-up data from the 2000 British National Psychiatric Morbidity survey (N = 8580 and N = 2406).

RESULTS

We analysed persecutory ideation, hallucinations, a range of affective symptoms and the effects of cannabis and problematic alcohol use. Worry was central to the links between symptoms, with plausible direct effects on insomnia, depressed mood and generalised anxiety, and recent cannabis use. Worry linked the other affective phenomena with paranoia. Hallucinations were connected only to worry and persecutory ideation. General anxiety, worry, sleep problems, and persecutory ideation were strongly self-predicting. Worry and persecutory ideation were connected over the 18-month interval in an apparent feedback loop.

CONCLUSIONS

These results have implications for understanding dynamic processes in psychosis and for targeting psychological interventions. The reciprocal influence of worry and paranoia implies that treating either symptom is likely to ameliorate the other.

Self-esteem moderates affective and psychotic responses to social stress in psychosis: A virtual reality study

BACKGROUND

Higher liability to psychosis is associated with low self-esteem and increased sensitivity to social stress. Recently, we reported a positive relation between liability to psychosis and affective and psychotic responses to social stress. This study investigated how self-esteem moderates paranoia, peak subjective distress and stress reactivity of people with different psychosis liability in response to social stressors in virtual reality.

METHODS

Ninety-four individuals with lower (41 siblings and 53 controls) and 75 persons with higher psychosis liability (55 with recent onset psychotic disorder and 20 at ultra-high risk for psychosis) explored five times a virtual café with various social stressors (crowdedness, ethnic minority status, and hostility). They rated momentary paranoia (State Social Paranoia Scale) after each experiment and subjective distress on a visual analogue scale before and after the experiments. Positive and negative self-esteem were assessed with the Self-Esteem Rating Scale.

RESULTS

Momentary paranoia, peak subjective distress, and reactivity to social stressors were associated with negative self-esteem, but not positive self-esteem. Effects of both positive and negative self-esteem on psychotic and affective stress responses, but not stress reactivity, became significantly stronger when individuals were exposed to more stressful environments. Effects of self-esteem on momentary paranoia and peak subjective distress did not differ between the high liability and low liability group. Persons with lower psychosis liability had a stronger effect of negative self-esteem on stress reactivity than persons with higher liability.

CONCLUSIONS

Positive and negative self-esteem may play an important role in affective and psychotic responses to social stress.

Social media and its relationship with mood, self-esteem and paranoia in psychosis

OBJECTIVE

An evidence-base is emerging indicating detrimental and beneficial effects of social media. Little is known about the impact of social media use on people who experience psychosis.

METHOD

Forty-four participants with and without psychosis completed 1084 assessments of social media use, perceived social rank, mood, self-esteem and paranoia over a 6-day period using an experience sampling method (ESM).

RESULTS

Social media use predicted low mood, but did not predict self-esteem and paranoia. Posting about feelings and venting on social media predicted low mood and self-esteem and high paranoia, whilst posting about daily activities predicted increases in positive affect and self-esteem and viewing social media newsfeeds predicted reductions in negative affect and paranoia. Perceptions of low social rank when using social media predicted low mood and self-esteem and high paranoia. The impact of social media use did not differ between participants with and without psychosis; although, experiencing psychosis moderated the relationship between venting and negative affect. Social media use frequency was lower in people with psychosis.

CONCLUSION

Findings show the potential detrimental impact of social media use for people with and without psychosis. Despite few between-group differences, overall negative psychological consequences highlight the need to consider use in clinical practice.

An experience sampling study on the nature of the interaction between traumatic experiences, negative affect in everyday life, and threat beliefs

Research suggests that trauma is associated with the development of psychotic experiences, such as paranoia, via affective processes. However, the empirical evidence on the exact mechanism is limited and it is unclear which aspects of trauma are relevant. Here we tested whether self-reported frequency of trauma, recurring trauma, age, and type of trauma are predictive of later threat beliefs in daily life and which role affective processes (self-reported negative affect and autonomic arousal) play in this association. We tested two often postulated mechanisms: mediation, with affective processes in everyday life explaining the association between trauma and threat beliefs; and moderation, with trauma strengthening the association between affective processes and threat beliefs in everyday life. Trauma was assessed at baseline with the Trauma-History-Questionnaire in 67 individuals with attenuated symptoms of psychosis. We then applied the experience-sampling-method during 24 h to assess negative affect, heart rate and threat beliefs. Multilevel analysis showed that negative affect (p < 0.001) and heart rate (p < 0.05) were predictive of subsequent threat beliefs. There was no significant mediation effect from any trauma characteristic to threat beliefs via negative affect and heart rate. Trauma frequency (p < 0.001), age at first trauma (p < 0.001), as well as the presence of physical trauma (p < 0.001) moderated the path from negative affect to subsequent threat beliefs. Our findings indicate that more frequent trauma, trauma at young age and physical trauma strengthen the association from negative affect to threat beliefs and could be relevant to determining the extent of vulnerability to psychosis.

Association of Residential Mobility Over the Life Course With Nonaffective Psychosis in 1.4 Million Young People in Sweden

IMPORTANCE

Residential mobility (changing residence) during childhood and early adolescence is a possible risk factor for several adverse health outcomes, including psychotic disorders. However, it is unclear whether sensitive periods to residential mobility exist over the life course, including in adulthood, or if greater moving distances, which might disrupt social networks, are associated with a greater psychosis risk.

OBJECTIVE

To examine the association between residential mobility over the life course and the risk of nonaffective psychosis.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included all people born in Sweden between January 1, 1982, and December 31, 1995, who were alive and resided in Sweden on their 16th birthday who were followed up until up to age 29 years (ending December 2011). Participants were followed until receiving a first diagnosis of an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) nonaffective psychotic disorder (F20-29), emigration, death, or the end of 2011, whichever was sooner. National register linkage provided exposure, outcome, and covariate data (complete data were available for 1 440 383 participants [97.8%]).

EXPOSURES

The exposures to distance moved and the number of residential moves were examined for participants at the following periods over the life course: 0 to 6 years, 7 to 15 years, 16 to 19 years, and 20 years and older.

RESULTS

This study included 1 440 383 participants, of whom 4537 (0.31%) had nonaffective psychotic disorder (median age, 20.9 [interquartile range, 19.0-23.3]). More frequent moves during childhood and adolescence were associated with an increased risk of nonaffective psychosis that showed dose-response associations independent of covariates. The most sensitive period of risk occurred during late adolescence; those who moved during each year between age 16 to 19 years had an increased adjusted hazard ratio (HR) of 1.99 (95% CI, 1.30-3.05) compared with those who never moved. One move during adulthood was not associated with psychosis risk (adjusted HR, 1.04; 95% CI, 0.94-1.14), but moving 4 or more times during adulthood was associated with increased risk (adjusted hazard ratio, 1.82; 95% CI, 1.51-2.23). Independently, moving greater distances before age 16 years was associated with an increased risk (adjusted HR, 1.11; 95% CI, 1.05-1.19), with evidence of a nonlinear threshold effect for moves longer than 30 km. The distance moved after age 20 years was associated with a decreased risk (adjusted HR, 0.67; 95% CI, 0.63-0.71).

CONCLUSIONS AND RELEVANCE

Children and adolescents with less disruption in their residential environments are less likely to experience psychotic disorders in early adulthood. Moves that may necessitate changes in school and social networks were most strongly associated with future risk.

Reduced scanning of salient facial features mediates the association between paranoia and emotion recognition

The vigilance-avoidance hypothesis of paranoia states that in paranoia visual attention is shifted away from threat-related stimuli. This may be an explanation for reduced scanning of salient facial features in psychosis and subsequently impaired emotion recognition. Here, we explored whether higher levels of paranoia would predict reduced visual attention to salient facial features and impaired emotion recognition and whether reduced visual attention to salient facial features mediates the association between paranoia and errors in emotion recognition. Participants with schizophrenia (SZ, n = 22) and healthy controls (HC, n = 19) completed questionnaire assessments of paranoia and negative symptoms and conducted an emotion recognition task comprised of dynamic facial stimuli. Additionally, visual attention (number of fixations) to salient facial features was assessed using eye-tracking. SZ made more errors in affect recognition than HC. Visual attention to salient facial features did not differ between SZ and HC but significantly mediated the significant association between paranoia and errors in the emotion recognition task in the complete sample. Negative symptoms also predicted errors in emotion recognition but this association was not mediated by visual attention. Our findings are in line with the avoidance-assumption of a vigilance-avoidance hypothesis of paranoia, in which correct facial emotion recognition is prevented due to an avoidance of salient facial features.

Shifts in positive and negative psychotic symptoms and anger: effects on violence

BACKGROUND

Changes in positive and negative symptom profiles during acute psychotic episodes may be key drivers in the pathway to violence. Acute episodes are often preceded by fluctuations in affect before psychotic symptoms appear and affective symptoms may play a more important role in the pathway than previously recognised.

METHODS

We carried out a prospective cohort study of 409 male and female patients discharged from medium secure services in England and Wales to the community. Measures were taken at baseline (pre-discharge), 6 and 12 months post-discharge using the Positive and Negative Syndrome Scale. Information on violence was obtained using the McArthur Community Violence Instrument and Police National Computer.

RESULTS

The larger the shift in positive symptoms the more likely violence occurred in each 6-month period. However, shifts in angry affect were the main driving factor for positive symptom shifts associated with violence. Shifts in negative symptoms co-occurred with positive and conveyed protective effects, but these were overcome by co-occurring shifts in anger. Severe but stable delusions were independently associated with violence.

CONCLUSIONS

Intensification of angry affect during acute episodes of psychosis indicates the need for interventions to prevent violence and is a key driver of associated positive symptoms in the pathway to violence. Protective effects against violence exerted by negative symptoms are not clinically observable during symptom shifts because they are overcome by co-occurring anger.

Moment-to-moment associations between negative affect, aberrant salience, and paranoia

INTRODUCTION

There is an ongoing debate about whether negative affect are consequences or triggers of paranoid thinking. It has also been suggested that aberrant salience is central to the development of delusions. This study modelled the moment-to-moment relationships between negative affect, aberrant salience, and paranoia in acute inpatients with psychosis.

METHODS

Participants with active paranoid delusions were assessed using clinical rating scales and experience sampling method (ESM) over 14 days. ESM data were analysed using time-lagged multilevel regression modelling.

RESULTS

Both negative affect and aberrant salience predicted an increase in paranoia at the next time point. Conversely, the level of paranoia did not predict subsequent changes in negative affect or aberrant salience. Negative affect predicted an increase in aberrant salience at the next time point, and vice versa.

CONCLUSIONS

Negative affect and aberrant salience appear to drive and exacerbate paranoia, rather than being merely the sequelae of the symptom. Our results suggest both direct and indirect (via aberrant salience) pathways from negative affect to paranoia.

Remission of depression in patients with schizophrenia and comorbid major depressive disorder: results from the FACE-SZ cohort

BACKGROUND

Major depressive disorder (MDD) is underdiagnosed and undertreated in schizophrenia, and has been strongly associated with impaired quality of life.AimsTo determine the prevalence and associated factors of MDD and unremitted MDD in schizophrenia, to compare treated and non-treated MDD.

METHOD

Participants were included in the FondaMental Expert Centers for Schizophrenia and received a thorough clinical assessment. MDD was defined by a Calgary score ≥6. Non-remitted MDD was defined by current antidepressant treatment (unchanged for >8 weeks) and current Calgary score ≥6.

RESULTS

613 patients were included and 175 (28.5%) were identified with current MDD. MDD has been significantly associated with respectively paranoid delusion (odds ratio 1.8; P = 0.01), avolition (odds ratio 1.8; P = 0.02), blunted affect (odds ratio 1.7; P = 0.04) and benzodiazepine consumption (odds ratio 1.8; P = 0.02). Antidepressants were associated with lower depressive symptoms score (5.4 v. 9.5; P < 0.0001); however, 44.1% of treated patients remained in non-remittance MDD. Nonremitters were found to have more paranoid delusion (odds ratio 2.3; P = 0.009) and more current alcohol misuse disorder (odds ratio 4.8; P = 0.04). No antidepressant class or specific antipsychotic were associated with higher or lower response to antidepressant treatment. MDD was associated with Metabolic syndrome (31.4 v. 20.2%; P = 0.006) but not with increased C-reactive protein.

CONCLUSIONS

Antidepressant administration is associated with lower depressive symptom level in patients with schizophrenia and MDD. Paranoid delusions and alcohol misuse disorder should be specifically explored and treated in cases of non-remission under treatment. MetS may play a role in MDD onset and/or maintenance in patients with schizophrenia.Declaration of interestNone.

Paranoia and anxiety: A cluster analysis in a non-clinical sample and the relationship with worry processes

BACKGROUND

Worry processes are implicated in paranoia and anxiety. However, clinical studies focused on patients with co-occurring paranoia and anxiety. As both paranoia and anxiety are distributed across clinical and non-clinical groups, an investigation on worry processes among non-clinical individuals will allow us to delineate the specific worry mechanisms in paranoia and anxiety respectively.

AIMS

To identify clusters of non-clinical individuals who report varied levels of paranoia and anxiety, and to compare worry processes across clusters.

METHOD

An online survey, consisting of self-report questionnaires on generalized anxiety, paranoia, and worry processes, was completed by 2796 undergraduate students. A multiple-step validity check procedure resulted in a subsample of 2291 students, upon which cluster analyses and multivariate analyses of variance were conducted.

RESULTS

Four clusters of individuals were identified: (1) high paranoia/moderate anxiety, (2) average paranoia/high anxiety, (3) average paranoia/average anxiety, and (4) low paranoia/low anxiety. A unique cluster of individuals with high paranoia but low/average level of anxiety was not found. Cluster 1 reported a significantly higher intensity of day-to-day worries, a higher level of meta-worry, and more extreme meta-cognitive beliefs about worry than other clusters.

CONCLUSIONS

Individuals with high paranoia tended to report anxiety as well, but not vice versa. Our findings supported a hierarchical structure of anxiety and paranoia. All worry processes were exacerbated in individuals with paranoia and anxiety than those with anxiety alone.

Maintaining Delusional Beliefs to Satisfy and Protect Psychological Needs

Abstract. Affiliation, control, and self-esteem are psychological needs that human beings attempt to satisfy and protect ( Epstein, 2003 ; Grawe, 2004 ). From a motivational perspective, behaviors, attentional and cognitive biases as well as symptoms can have an instrumental function for need satisfaction and protection ( Caspar, 2011 ). In this opinion paper, we elaborate the idea that the maintenance of delusions could be a motivated process. This approach helps to view the maintenance of delusional beliefs as a purposeful, yet mostly nonconscious, and not completely adaptive attempt to satisfy and protect psychological needs. Conclusions for case formulations, therapy planning, and therapeutic relationship building are drawn within the framework of cognitive-behavioral therapy for psychosis. In addition, limitations of the approach and future research avenues are discussed.

Does CBT for Psychosis Have an Impact on Delusions by Improving Reasoning Biases and Negative Self-Schemas?

Abstract. Cognitive-behavioral therapy for psychosis (CBTp) builds on theoretical models that postulate reasoning biases and negative self-schemas to be involved in the formation and maintenance of delusions. However, it is unclear whether CBTp induces change in delusions by improving these proposed causal mechanisms. This study reports on a mediation analysis of a CBTp effectiveness trial in which delusions were a secondary outcome. Patients with psychosis were randomized to individualized CBTp (n = 36) or a waiting list condition (WL; n = 34). Reasoning biases (jumping to conclusions, theory of mind, attribution biases) and self-schemas (implicit and explicit self-esteem; self-schemas related to different domains) were assessed pre- and post-therapy/WL. The results reveal an intervention effect on two of four measures of delusions and on implicit self-esteem. Nevertheless, the intervention effect on delusions was not mediated by implicit self-esteem. Changes in explicit self-schemas and reasoning biases did also not mediate the intervention effects on delusions. More focused interventions may be required to produce change in reasoning and self-schemas that have the potential to carry over to delusions.

The network structure of paranoia in the general population

PURPOSE

Bebbington and colleagues' influential study on 'the structure of paranoia in the general population' used data from the British National Psychiatric Morbidity Survey and latent variable analysis methods. Network analysis is a relatively new approach in psychopathology research that considers mental disorders to be emergent phenomena from causal interactions among symptoms. This study re-analysed the British National Psychiatric Morbidity Survey data using network analysis to examine the network structure of paranoia in the general population.

METHODS

We used a Graphical Least Absolute Shrinkage and Selection Operator (glasso) method that estimated an optimal network structure based on the Extended Bayesian Information Criterion. Network sub-communities were identified by spinglass and EGA algorithms and centrality metrics were calculated per item and per sub-community.

RESULTS

We replicated Bebbington's four component structure of paranoia, identifying 'interpersonal sensitivities', 'mistrust', 'ideas of reference' and 'ideas of persecution' as sub-communities in the network. In line with previous experimental findings, worry was the most central item in the network. However, 'mistrust' and 'ideas of reference' were the most central sub-communities.

CONCLUSIONS

Rather than a strict hierarchy, we argue that the structure of paranoia is best thought of as a heterarchy, where the activation of high-centrality nodes and communities is most likely to lead to steady state paranoia. We also highlight the novel methodological approach used by this study: namely, using network analysis to re-examine a population structure of psychopathology previously identified by latent variable approaches.

A Systematic Review of Trials Targeting Depression and Anxiety in Patients With Delusions

Abstract. Negative affect and impaired emotion regulation skills are prevalent in patients with delusions and contribute to delusion formation and maintenance. This review evaluates existing research on interventions targeting negative affect and emotional processes as a causal mechanism on the pathway to delusions. A MEDLINE and PsycINFO search identified 7,909 articles. Five studies with randomized-controlled designs and three with uncontrolled designs met the inclusion criteria. Interventions comprised cognitive-behavioral and compassion-focused techniques. Overall, the review studies found positive intervention effects on negative affect and delusions. Where significant, controlled effect sizes ranged from small to large for negative affect and from moderate to large for delusions. Thus, existing research indicates that negative affect in patients with delusions can be modified by psychological therapy and points toward a carryover effect from the reduction of negative affect to a reduction of delusions. More large-scale randomized-controlled studies are needed to be able to draw valid conclusions on which types of interventions are most beneficial.

An Experimental Investigation into the Effect of State-Anxiety on State-Paranoia in People Experiencing Psychosis

BACKGROUND

There is strong evidence to suggest that anxiety is associated with paranoia in clinical and non-clinical samples. However, no research to date has directly manipulated anxiety to investigate if state-anxiety has a causal role in state-paranoia in clinical populations.

AIMS

To investigate whether an anxious-mood induction leads to greater paranoia than a neutral-mood induction in people experiencing psychosis and paranoia and, if so, whether this is predicted by anxiety over and above other variables.

METHOD

22 participants with a psychosis-spectrum diagnosis took part in a two condition cross-over experimental design. Participants underwent a neutral-mood and an anxious-mood induction with levels of state-anxiety, state-affect and state-paranoia being measured before and after each condition.

RESULTS

State-paranoia was significantly higher after the anxious condition compared with the neutral condition. State-anxiety and negative-affect were significant predictors of levels of state-paranoia after the anxious condition. When both predictors were included in a regression model, only negative-affect was a significant predictor of state-paranoia after the anxious condition. There were a number of methodological limitations.

CONCLUSIONS

State-anxiety and negative-affect may both be involved in the maintenance of paranoia in clinical populations, as predicted by cognitive models. Negative-affect may be the strongest predictor of state-paranoia in clinical populations. Reasons for this are discussed, as well as the implications. Interventions that seek to reduce negative state-affect may be beneficial in managing state-paranoia. Further research is warranted to explore the suggested clinical and theoretical implications of these findings.

A longitudinal mediation analysis of the effect of negative-self-schemas on positive symptoms via negative affect

BACKGROUND

Cognitive models postulate that negative-self-schemas (NSS) cause and maintain positive symptoms and that negative affect mediates this link. However, only few studies have tested the temporal mediation claim systematically using an appropriate design.

METHODS

A longitudinal cohort design in an online community sample (N = 962) from Germany, Indonesia, and the USA was used. NSS, negative affect and positive symptoms were measured at four time-points (T0-T3) over a 1-year period. Cross-lagged panel and longitudinal mediation analyses with structural equation modeling were used to test the temporal mediation.

RESULTS

Independent cross-lagged panel models showed a significant unidirectional longitudinal path from NSS to positive symptoms (T2-T3, β = 0.18, p < 0.01) and bidirectional longitudinal associations from NSS to negative affect (T0-T1, γ = 0.14, p < 0.01) and vice versa (T0-T1, γ = 0.19, p < 0.01). There was also a significant indirect pathway from NSS at baseline via negative affect at T1 and T2 to positive symptoms at T3 (unstandardized indirect effect coefficient = 0.020, p < 0.05, BCa CI 0.004-0.035), indicating mediation.

CONCLUSIONS

Our findings support the postulated affective pathway from NSS to positive symptoms via negative affect. Specifically, our data indicate that NSS and negative affect influence each other and build up over the course of several months before leading on to positive symptoms. We conclude that interrupting this process by targeting NSS and negative affect early in the process could be a promising strategy to prevent the exacerbation of positive symptoms.

Experience sampling methodology in mental health research: new insights and technical developments

In the mental health field, there is a growing awareness that the study of psychiatric symptoms in the context of everyday life, using experience sampling methodology (ESM), may provide a powerful and necessary addition to more conventional research approaches. ESM, a structured self-report diary technique, allows the investigation of experiences within, and in interaction with, the real-world context. This paper provides an overview of how zooming in on the micro-level of experience and behaviour using ESM adds new insights and additional perspectives to standard approaches. More specifically, it discusses how ESM: a) contributes to a deeper understanding of psychopathological phenomena, b) allows to capture variability over time, c) aids in identifying internal and situational determinants of variability in symptomatology, and d) enables a thorough investigation of the interaction between the person and his/her environment and of real-life social interactions. Next to improving assessment of psychopathology and its underlying mechanisms, ESM contributes to advancing and changing clinical practice by allowing a more fine-grained evaluation of treatment effects as well as by providing the opportunity for extending treatment beyond the clinical setting into real life with the development of ecological momentary interventions. Furthermore, this paper provides an overview of the technical details of setting up an ESM study in terms of design, questionnaire development and statistical approaches. Overall, although a number of considerations and challenges remain, ESM offers one of the best opportunities for personalized medicine in psychiatry, from both a research and a clinical perspective.

The Relevance of Emotion Regulation in Explaining Why Social Exclusion Triggers Paranoia in Individuals at Clinical High Risk of Psychosis

BACKGROUND

Vulnerability-stress models postulate that social stress triggers psychotic episodes in vulnerable individuals. However, experimental evidence for the proposed causal pathway is scarce and the translating mechanisms are insufficiently understood. The study assessed the impact of social exclusion on paranoid beliefs in a quasi-experimental design and investigated the role of emotion regulation (ER) as a vulnerability indicator and emotional responses as a putative translating mechanism.

METHODS

Participants fulfilling criteria for clinical high risk of psychosis (CHR, n = 25), controls with anxiety disorders (AC, n = 40), and healthy controls (HC, n = 40) were assessed for dysfunctional (eg, rumination, catastrophizing, blaming) and functional ER-strategies (eg, reappraising, accepting, refocusing). They were then exposed to social exclusion during a virtual ball game (Cyberball) and assessed for changes in self-reported emotions and paranoid beliefs.

RESULTS

The CHR sample showed a significantly stronger increase in paranoid beliefs from before to after the social exclusion than both control groups. This was accounted for by lower levels of functional and higher levels of dysfunctional ER (compared to HC) and by a stronger increase in self-reported negative emotion in the CHR group (compared to AC and HC).

CONCLUSIONS

The results confirm the role of negative emotion on the pathway from social stressors to psychotic symptoms and indicate that both the use of dysfunctional ER strategies and difficulties in employing functional strategies add to explaining why people at risk of psychosis respond to a social stressor with increased paranoia.

Beck Self-Esteem Scale-Short Form: Development and psychometric evaluation of a scale for the assessment of self-concept in schizophrenia

A requisite step for testing cognitive theories regarding the role of self-concept in schizophrenia is the development of measures that follow a cognitive conceptualization and better capture the multifaceted nature of this construct. The purpose of this study was to examine the psychometric properties a new self-concept measure, the Beck Self-Esteem Scale-Short Form (BSES-SF), based on a sample of 204 individuals with schizophrenia or schizoaffective disorder. We evaluated the BSES-SF's dimensionality, internal consistency reliability, and construct and divergent validity using confirmatory factor analysis, Cronbach's alpha, Pearson correlations, independent samples t-tests, and one-way analysis of variance. Findings indicate that the 10-item BSES-SF is a reliable and valid measure of self-concept that is appropriate for a broad group of individuals with schizophrenia spectrum disorders. Following cognitive theory, the scale demonstrated significant relationships with delusion severity, motivation, and depression, further signifying its utility for research and practice efforts that are designed to address psychopathology in schizophrenia.

Negative affective stress reactivity: The dampening effect of snacking

The present study sets out to further elucidate the complex relationship between daily hassles, snacking, and negative affect (NA). The aim of the present study was to examine whether or not moment-to-moment energy intake from snacks moderates the association between momentary stress and NA. And, if so, can this moderating effect be replicated by using the amount of macronutrient intake (i.e., carbohydrates, fat, and protein) as moderator on the association between momentary stress and NA? Adults (N = 269), aged 20-50 years, participated in this study. Stress, NA, and snack intake were assessed 10 times a day for 7 consecutive days in daily life with an experience sampling smartphone application. Multilevel regression analyses were performed to assess the hypothesized associations. Our study revealed a dampening effect of snacking on negative affective stress reactivity. However, this dampening effect could not be replicated by the amount of macronutrient intake from snacks. On the contrary, the amount of carbohydrates has an enhancing effect on negative affective stress reactivity. In the end, our study suggests that the critical question is which mechanisms are decisive in the dampening role of snacking on stress reactivity. A multidisciplinary approach may provide a full perspective.

The co-occurrence between depressive symptoms and paranoid ideation: A population-based longitudinal study

BACKGROUND

The aim of this study was to examine longitudinally in the general population (a) whether depressive symptoms co-occur with paranoid ideation from late adolescence to middle age (b) whether depressive subsymptoms are differently linked with paranoid ideation (c) whether depressive symptoms are associated with state-level or trait-level paranoid ideation.

METHODS

Altogether 2109 subjects of the Young Finns study completed the Paranoid Ideation Scale of the Symptom Checklist-90 Revised and a modified version of the Beck Depression Inventory in 1992, 1997, 2001, 2007, and 2012, and the Beck Depression Inventory-II in 2007, 2011, and 2012.

RESULTS

Higher self-rated depressive symptoms were associated with the course of more severe paranoid ideation over age, especially in late adolescence and early adulthood. Regarding depressive subsymptoms, the associations of negative attitude and performance difficulties with paranoid ideation were evident over age, whereas the influence of somatic symptoms (such as changes in sleep and appetite) was not significant until after early adulthood. Additionally, depressive symptoms were more evidently associated with the development of trait- than state-level paranoid ideation.

LIMITATIONS

Our study mostly captured mild depressive and paranoid symptoms. The results cannot be directly generalized to clinical populations.

CONCLUSIONS

Depressive symptoms were associated with the course of paranoid ideation from late adolescence to middle age. Patients with paranoid ideation might merit from evaluation of potential depressive symptoms, especially in late adolescence and early adulthood. Among patients with co-occurring depressive symptoms and paranoid ideation, there may be a substantial need for neurocognitive rehabilitation and community-based treatments.

Monocausal attribution and its relationship with reasoning biases in schizophrenia

BACKGROUND

Aberrant attributional styles are counted to a set of circumscribed cognitive biases that are implicated in the pathogenesis of (paranoid) psychosis. However, evidence for a specific profile (e.g., an exaggerated self-serving bias, other-blaming bias) has become equivocal over the years. More recently, one-sided (monocausal) attributions have been reported in patients with psychosis.

METHODS

We compared a large sample of patients with diagnosed schizophrenia (n=145) to nonclinical controls (n=30) on a revised version of the Internal, Personal and Situational Attributions Questionnaire (IPSAQ-R). In this task, participants have to assign probability estimates to each of three potential causes (i.e., myself, others, circumstances) for a specific (negative or positive) event.

RESULTS

Participants with schizophrenia displayed an abolished self-serving bias and showed a significant preference for one-sided/monocausal attributions, which was neither correlated with jumping to conclusions nor overconfidence in errors. School education correlated with less monocausal attributions. We did not find any congruence between attributional styles with core delusional ideas.

CONCLUSIONS

Our study corroborates earlier investigations showing that monocausal attributions may play a role in the pathogenesis of psychosis; this bias unlikely represents an epiphenomenon of established biases. Unexpectedly, attributional styles (e.g., external-blaming) did not shape delusional contents. The true prevalence of monocausal attributions in psychosis is perhaps underestimated in the study, as groups were equated on school education, which was correlated with monocausal attributions.

Symptom fluctuations, self-esteem, and cohesion during group cognitive behaviour therapy for early psychosis

Group cohesion has been linked to positive changes in self-esteem and in symptoms during group psychotherapy in people with psychosis. These changes may be linked to changes in symptoms as fluctuations in self-esteem have been linked to symptom fluctuations.

OBJECTIVE

We aimed to determine the relationship between these three factors - group cohesion, self-esteem, and symptoms - during group cognitive behaviour therapy for psychosis (GCBTp). We hypothesized that group cohesion would precede changes in symptoms and self-esteem and that improvements in self-esteem would precede improvements in symptoms.

DESIGN

This is an uncontrolled longitudinal study recruiting from a convenience sample within two early psychosis clinics.

METHODS

Sixty-six individuals from first episode of psychosis treatment programmes participated in this study and received 24 sessions of a validated GCBTp protocol. Participants answered a brief questionnaire at the end of each session, measuring their group cohesion, self-esteem, and perception of their symptoms as worse, same, or better than usual.

RESULTS

Orthogonal polynomial contrasts for time effects were estimated with a mixed model for repeated measures with a random cluster effect and revealed a quartic trend regarding changes in symptoms over the 24 sessions. Self-esteem, symptoms, and group cohesion were strongly linked during a given session. Also, self-esteem changes predicted changes in symptoms up to two sessions later, and symptoms changes predicted self-esteem changes at the next session. Group cohesion preceded improvements in both self-esteem and symptoms; self-esteem also predicted improvements in group cohesion.

CONCLUSION

These results suggest that self-esteem and symptoms influence each other during therapy, with improvements in one leading to improvements in the other. Group cohesion also appears to be an essential prerequisite to positive changes in self-esteem and symptoms during GCBTp.

PRACTITIONER POINTS

This study emphasizes the interrelation between self-esteem improvements and symptom improvements, with improvements in one leading to improvements in the other, during group CBT for psychosis. Group cohesion, in this study, is a predictor of self-esteem and symptom improvements, suggesting that a special attention should be given to developing a strong alliance and group cohesion early on during CBT for psychosis.

Expressive suppression is associated with state paranoia in psychosis: An experience sampling study on the association between adaptive and maladaptive emotion regulation strategies and paranoia

OBJECTIVES

Although emotional instability and problems in emotion regulation (ER) are known to be linked to the formation and maintenance of psychosis and paranoia, it remains unclear whether the use of specific ER strategies is associated with it. The first aim of the study was to explore the association between emotional instability and paranoia. The second and third aims were to investigate whether the use of maladaptive ER strategies leads to paranoia in patients with psychosis in daily life and whether the use of more adaptive ER strategies reduces paranoia.

DESIGN

A prospective momentary assessment study over the course of 6 days was performed.

METHOD

Participants with psychosis (n = 32) reported repeatedly over six consecutive days on the presence and instability of positive and negative emotions, their use of adaptive (reappraisal, acceptance, distraction, social sharing, reflection) and maladaptive ER strategies (rumination, expressive suppression) and momentary paranoia in their daily life.

RESULTS

Hierarchical linear regression analysis revealed that patients with psychosis who presented pronounced instability of negative emotions showed more severe levels of state paranoia. In addition, patients with psychosis who used expressive suppression when confronted with negative emotions at one point in time presented more pronounced levels of state paranoia at the following point in time.

CONCLUSION

The results presented here suggest that both emotional instability and the use of expressive suppression might cause state paranoia and thus add to our understanding of causal mechanisms related to paranoia such as instability of negative emotions and the use of less adaptive ER strategies.

PRACTITIONER POINTS

Maladaptive emotion regulation strategies and more pronounced instability of negative emotions are relevant to paranoia in patients with psychosis and should be a special focus of CBTp interventions. Future interventions designed for patients suffering from paranoia should promote coping with unstable negative emotions and replacing or reducing maladaptive emotion regulation strategies with adaptive ones.

The Cascade of Stress: A Network Approach to Explore Differential Dynamics in Populations Varying in Risk for Psychosis

Stress plays a central role in the development and persistence of psychosis. Network analysis may help to reveal mechanisms at the level of the micro-dynamic effects between stress, other daily experiences and symptomatology. This is the first study to examine time-lagged networks of the relations between minor daily stress, momentary affect/thoughts, psychotic experiences, and other potentially relevant daily life contexts in individuals varying in risk for psychosis. Intensive longitudinal data were obtained through 6 studies. The combined sample consisted of 654 individuals varying in risk for psychosis: healthy control subjects (n = 244), first-degree relatives of psychotic patients (n = 165), and psychotic patients (n = 245). Using multilevel models combined with permutation testing, group-specific time-lagged network connections between daily experiences were compared between groups. Specifically, the role of stress was examined. Risk for psychosis was related to a higher number of significant network connections. In all populations, stress had a central position in the network and showed direct and significant connections with subsequent psychotic experiences. Furthermore, the higher the risk for psychosis, the more variables "loss of control" and "suspicious" were susceptible to influences by other network nodes. These findings support the idea that minor daily stress may play an important role in inducing a cascade of effects that may lead to psychotic experiences.

The Effect of Cognitive Behavioral Interventions on Depression and Anxiety Symptoms in Patients with Schizophrenia Spectrum Disorders: A Systematic Review

Depression and anxiety are prominent comorbid disorders in psychosis and relevant to psychotic symptom formation and maintenance. This poses the question of whether psychological interventions are effective in improving symptoms of depression and anxiety in patients with psychosis. A systematic review of the literature identified 14 studies evaluating a broad range of interventions targeting depression, anxiety, and posttraumatic stress disorder in patients with psychosis. The reviewed studies support the effectiveness of cognitive-behavioral interventions in improving the target symptoms. Further research is needed to examine whether the effects carry over to psychotic symptoms in the long term.

Untangling the complex relationships between symptoms of schizophrenia and emotion dynamics in daily life: Findings from an experience sampling pilot study

The unfolding of emotions over time (i.e., emotion dynamics) has been characterized by baseline, intraindividual variability and regulatory tendency (return time to baseline after deflection). Mounting evidence suggests that compared to healthy individuals, individuals with schizophrenia are characterized by a more negatively valenced baseline and a higher intraindividual variability. However, the regulatory tendency has not been investigated in schizophrenia so far. We hypothesize that the severity of positive symptoms is linked to increased emotional variability and that the severity of negative symptoms is associated with an increased regulatory tendency. Fifteen individuals diagnosed with schizophrenia took part in this pilot experience sampling study and reported their emotional state ten times a day. The dynamics of valence and arousal and their relationship with symptomatology were estimated with the DynAffect model. Regulatory tendency in valence and arousal was positively associated with negative symptom severity and negatively associated with positive symptom severity. However, the severity of positive symptoms was not credibly associated with the variability of valence. The study only partly corroborates findings on increased stress reactivity in schizophrenia, which might be due to the small sample size. However, results suggest that negative symptoms could stem from over-regulated emotion dynamics, which may impede goal-directed behavior.

A structural equation model of the relationship between insomnia, negative affect, and paranoid thinking

Background

A growing body of evidence points to relationships between insomnia, negative affect, and paranoid thinking. However, studies are needed to examine (i) whether negative affect mediates the relation between insomnia and paranoid thinking, (ii) whether different types of insomnia exert different effects on paranoia, and (iii) to compare the impact of objective and self-reported sleeping difficulties.

Method

Structural equation modelling was therefore used to test competing models of the relationships between self-reported insomnia, negative affect, and paranoia. n = 348 participants completed measures of insomnia, negative affect and paranoia. A subset of these participants (n = 91) went on to monitor their sleep objectively (using a portable sleep monitor made by Zeo) for seven consecutive nights. Associations between objectively recorded sleep, negative affect, and paranoia were explored using linear regression.

Results

The findings supported a fully mediated model where self-reported delayed sleep onset, but not self-reported problems with sleep maintenance or objective measures of sleep, was directly associated with negative affect that, in turn, was associated with paranoia. There was no evidence of a direct association between delayed sleep onset or sleep maintenance problems and paranoia.

Conclusions

Taken together, the findings point to an association between perceived (but not objective) difficulties initially falling asleep (but not maintaining sleep) and paranoid thinking; a relationship that is fully mediated by negative affect. Future research should seek to disentangle the causal relationships between sleep, negative affect, and paranoia (e.g., by examining the effect of an intervention using prospective designs that incorporate experience sampling). Indeed, interventions might profitably target (i) perceived sleep quality, (ii) sleep onset, and / or (iii) emotion regulation as a route to reducing negative affect and, thus, paranoid thinking.

Affect and between-meal snacking in daily life: the moderating role of gender and age

OBJECTIVE

Affect-related energy intake from snacks remains relatively unexplored in daily life. This study examines the associations between momentary positive affect (PA) and momentary negative affect (NA) and subsequent energy intake from snacks. In addition, the moderating role of BMI, gender, age and level of education is investigated.

DESIGN

Adults (N = 269), aged 20-50, participated in this study. Demographics were assessed in an online composite questionnaire. An experience sampling smartphone application was used to map momentary NA/PA and energy intake (kilocalories) from snacks in the context of daily life.

MAIN OUTCOME MEASURES

Energy intake from moment-to-moment self-reported snacks in real-life settings.

RESULTS

A significant negative main effect of momentary NA on moment-to-moment energy intake was found. The higher the momentary NA, the lower the subsequent amount of kilocalories consumed. There was no main effect with regard to PA. Interaction analyses showed that men decreased their energy intake after experiencing NA, and increased their intake after experiencing PA. No associations were found in women. Additionally, young adults (20-30) increased their energy intake after experiencing PA. No associations were found in the other age groups.

CONCLUSION

Interventions aiming at reducing energy intake might also address PA-related snacking in young adults and men.

The effect of unfavourable and favourable social comparisons on paranoid ideation: An experimental study

BACKGROUND AND OBJECTIVES

Low social rank is associated with paranoia, but there is a lack of evidence for causality. We tested the effects of social comparisons on negative affect and paranoia with an online social rank paradigm, and whether striving to avoid inferiority or fears of social rejection moderated paranoid reactions.

METHOD

Female students (N = 172) were randomly exposed to one of two validated online profiles depicting a same-aged, high (unfavourable comparison) vs. low rank (favourable comparison) female student. Moderators were assessed at baseline. Social rank, anxiety, sadness and paranoia were assessed pre and post profile-exposure.

RESULTS

There was a large effect of the experimental manipulation on social rank (p < 0.001, η²_partial = 0.191). The manipulations had no effects on anxiety and paranoia (p > 0.38). Sadness was significantly altered (p = 0.016, η²_partial = 0.033). There were significant moderation effects between the experimental conditions and insecure striving (trend-level) as well as fears of rejection.

LIMITATIONS

Our findings may be biased (overestimation of effects) as students are likely to be more competitive compared to the general population.

CONCLUSION

Our rank manipulations did not alter paranoia. This suggests that changes in the cognitive representation of social rank alone - without triggering a strong emotional response - do not suffice to evoke paranoia. Although our results do not support the notion that threats to social rank cause paranoid symptoms, they suggest that threats to social rank are more likely to trigger paranoid states in those who are insecure in regard to their social position.

A two-stage cognitive theory of the positive symptoms of psychosis. Highlighting the role of lowered decision thresholds

OBJECTIVES

We outline a two-stage heuristic account for the pathogenesis of the positive symptoms of psychosis.

METHODS

A narrative review on the empirical evidence of the liberal acceptance (LA) account of positive symptoms is presented.

HYPOTHESIS

At the heart of our theory is the idea that psychosis is characterized by a lowered decision threshold, which results in the premature acceptance of hypotheses that a nonpsychotic individual would reject. Once the hypothesis is judged as valid, counterevidence is not sought anymore due to a bias against disconfirmatory evidence as well as confirmation biases, consolidating the false hypothesis. As a result of LA, confidence in errors is enhanced relative to controls. Subjective probabilities are initially low for hypotheses in individuals with delusions, and delusional ideas at stage 1 (belief formation) are often fragile. In the course of the second stage (belief maintenance), fleeting delusional ideas evolve into fixed false beliefs, particularly if the delusional idea is congruent with the emotional state and provides "meaning". LA may also contribute to hallucinations through a misattribution of (partially) normal sensory phenomena. Interventions such as metacognitive training that aim to "plant the seeds of doubt" decrease positive symptoms by encouraging individuals to seek more information and to attenuate confidence. The effect of antipsychotic medication is explained by its doubt-inducing properties.

LIMITATIONS

The model needs to be confirmed by longitudinal designs that allow an examination of causal relationships. Evidence is currently weak for hallucinations.

CONCLUSIONS

The theory may account for positive symptoms in a subgroup of patients. Future directions are outlined.

Exploring the feasibility and usability of the experience sampling method to examine the daily lives of patients with acquired brain injury

The experience sampling method (ESM) is a structured diary method with high ecological validity, in that it accurately captures the everyday context of individuals through repeated measurements in naturalistic environments. Our main objective was to investigate the feasibility of using ESM in individuals with acquired brain injury (ABI). A second goal was to explore the usability of ESM data on a clinical level, by illustrating the interactions between person, environment, and affect. The PsyMate device provided ABI patients (N = 17) with ten signals (beeps) per day during six consecutive days. Each beep was followed by a digital questionnaire assessing mood, location, activities, social context, and physical well-being. Results demonstrated high feasibility with a 71% response rate and a 99% completion rate of the questionnaires. There were no dropouts and the method was experienced as user-friendly. Time-lagged multilevel analysis showed that higher levels of physical activity and fatigue predicted higher levels of negative affect at the same point in time, but not at later time points. This study illustrates the potential of ESM to identify complex person-environment dynamics after ABI, while generating understandable and easy to use graphical feedback.