Advances in understanding and treating persecutory delusions: a review

Modelling the longitudinal dynamics of paranoia in psychosis: A temporal network analysis over 20 years

BACKGROUND

Paranoia is a key feature of psychosis that can be highly debilitating. Theories of paranoia mostly interface with short-scale or cross-sectional data models, leaving the longitudinal course of paranoia underspecified.

METHODS

We develop an empirical characterisation of two aspects of paranoia - persecutory and referential delusions - in individuals with psychosis over 20 years. We examine delusional dynamics by applying a Graphical Vector Autoregression Model to data collected from the Chicago Follow-up Study (n = 135 with a range of psychosis-spectrum diagnoses). We adjusted for age, sex, IQ, and antipsychotic use.

RESULTS

We found that referential and persecutory delusions are central themes, supported by other primary delusions, and are strongly autoregressive - the presence of referential and persecutory delusions is predictive of their future occurrence. In a second analysis we demonstrate that social factors influence the severity of referential, but not persecutory, delusions.

IMPLICATIONS

We suggest that persecutory delusions represent central, resistant states in the cognitive landscape, whereas referential beliefs are more flexible, offering an important window of opportunity for intervention. Our data models can be collated with prior biological, computational, and social work to contribute toward a more complete theory of paranoia and provide more time-dependent evidence for optimal treatment targets.

Interpersonal consequences of paranoid ideation, negative symptoms and sleep problems in a transdiagnostic sample of individuals with psychosis

Paranoid ideation is a transdiagnostic construct that is associated with social impairment and often occurs in psychotic spectrum disorders. Little research has examined how paranoid ideation is related to social behaviors that underlie social impairment and may ultimately lead to social rejection. It is important to consider that negative symptoms and sleep problems also contribute to social impairment. No research has assessed the unique and combined influence of paranoid ideation, negative symptoms, and sleep problems on social impairment. Therefore, the current study examined how paranoid ideation, negative symptoms, and sleep problems contribute to poorer social skills and social rejection in a transdiagnostic sample of persons with psychosis and community members (N = 112). Assessments included diagnostic and symptom interviews, questionnaires, behavioral ratings of social skill and facial displays of affect, and naive observer reactions utilizing thin-slice methodology. Greater paranoid ideation, negative symptoms, and sleep problems were each related to poorer social skill and more negative reactions from observers. When considered in path analyses, negative symptoms were associated with observer reports of less willingness to interact with participants through poorer social skill. These findings demonstrate the symptom correlates of social rejection and how interpersonal behavior may contribute to social exclusion.

Immersive virtual reality as a novel approach to investigate the association between adverse events and adolescent paranoid ideation

PURPOSE

Paranoid ideation is common among adolescents, yet little is known about the precursors. Using a novel immersive virtual reality (VR) paradigm, we tested whether experiences of bullying, and other interpersonal/threatening events, are associated with paranoid ideation to a greater degree than other types of (i) non-interpersonal events or (ii) adverse childhood experiences.

METHODS

Self-reported exposure to adverse life events and bullying was collected on 481 adolescents, aged 11-15. We used mixed effects (multilevel) linear regression to estimate the magnitude of associations between risk factors and paranoid ideation, assessed by means of adolescents' reactions to ambiguously behaving avatars in a VR school canteen, adjusting for putative confounders (gender, year group, ethnicity, free school meal status, place of birth, family mental health problems).

RESULTS

Lifetime exposure to interpersonal/threatening events, but not non-interpersonal events or adverse circumstances, was associated with higher levels of state paranoid ideation, with further evidence that the effect was cumulative (1 type: ϐadj 0.07, 95% CI -0.01-0.14; 2 types: ϐadj 0.14, 95% CI 0.05-0.24; 3 + types: ϐadj 0.24, 95% CI 0.12-0.36). More tentatively, for girls, but not boys, recent bullying was associated with heightened paranoid ideation with effect estimates ranging from ϐadj 0.06 (95% CI -0.02-0.15) for physical bullying to ϐadj 0.21 (95% CI 0.10-0.32) for cyber bullying.

CONCLUSIONS

Our data suggest a degree of specificity for adversities involving interpersonal threat or hostility, i.e. those that involve unwanted interference and/or attempted control of an individual's personal boundaries being associated with heightened levels of state paranoid ideation among adolescents.

Further Validation of the Persecutory Ideation Questionnaire in the Italian Context: Results From Classical and Modern Test Theory

The Persecutory Ideation Questionnaire (PIQ) is a valuable instrument to measure persecutory ideation. The aim of this study is to validate the scale in the Italian context and to extend the study of its psychometric properties using approaches from both classical and modern test theories. The results of the study, involving 700 individuals, confirmed the one-factor structure and the good validity and reliability of the scale. Full metric invariance and partial scalar and strict invariance were also supported across gender, age, and education level groups. Rasch analysis indicated that the 5-point response scale is well-functioning and that the PIQ is most appropriate to measure high levels of persecutory ideation. The results contribute to a better understanding of the measurement properties of the PIQ. The paper discusses the advantages and contributions of each method used to explore the measurement properties of the scale.

Emotion regulation flexibility and psychosis: A longitudinal study disentangling components of flexibility in psychosis-proneness

OBJECTIVES

Flexibility in self-regulation has emerged as an important component of mental health. Previous findings found that deficits in two components of regulatory flexibility were linked cross-sectionally to psychosis-proneness. We aimed to replicate and extend these findings longitudinally.

METHODS

We measured psychosis-proneness and components of emotion regulation flexibility (i.e. context sensitivity, repertoire and feedback) at two time points with three months in between.

RESULTS

Two flexibility components predicted psychotic-like experiences. The ability to detect the absence of contextual cues was implicated in both positive and negative dimensions but through opposite pathways. Expressive suppression ability-a subcomponent of repertoire-predicted positive symptoms. None of the flexibility components predicted distress related to the symptoms.

CONCLUSIONS

The current study provides further evidence on the implication of emotion regulation flexibility in the longer-term maintenance of psychotic-like experiences. Future studies can advance this work further by evaluating possible bidirectional relationships between psychotic-like experiences and deficits in emotion regulation flexibility.

Altered Perception of Environmental Volatility During Social Learning in Emerging Psychosis

Paranoid delusions or unfounded beliefs that others intend to deliberately cause harm are a frequent and burdensome symptom in early psychosis, but their emergence and consolidation still remains opaque. Recent theories suggest that overly precise prediction errors lead to an unstable model of the world providing a breeding ground for delusions. Here, we employ a Bayesian approach to test for such an unstable model of the world and investigate the computational mechanisms underlying emerging paranoia. We modelled behaviour of 18 first-episode psychosis patients (FEP), 19 individuals at clinical high risk for psychosis (CHR-P), and 19 healthy controls (HC) during an advice-taking task designed to probe learning about others' changing intentions. We formulated competing hypotheses comparing the standard Hierarchical Gaussian Filter (HGF), a Bayesian belief updating scheme, with a mean-reverting HGF to model an altered perception of volatility. There was a significant group-by-volatility interaction on advice-taking suggesting that CHR-P and FEP displayed reduced adaptability to environmental volatility. Model comparison favored the standard HGF in HC, but the mean-reverting HGF in CHR-P and FEP in line with perceiving increased volatility, although model attributions in CHR-P were heterogeneous. We observed correlations between perceiving increased volatility and positive symptoms generally as well as with frequency of paranoid delusions specifically. Our results suggest that FEP are characterised by a different computational mechanism - perceiving the environment as increasingly volatile - in line with Bayesian accounts of psychosis. This approach may prove useful to investigate heterogeneity in CHR-P and identify vulnerability for transition to psychosis.

Validation of the French COVID-Related Thoughts and Behavioral Symptoms Questionnaire (Cov-Tabs): A self-report assessment

OBJECTIVES

The COVID-Related Thoughts and Behavioral Symptoms (Cov-Tabs) is a self-reported questionnaire developed to identify the presence of psychological distress and anxiety-related behavior associated with COVID-19. This scale has been used since the first episodes of mass contamination of COVID-19 disease in the USA without psychometric validation analysis. The objective of this paper is to validate the French version of the Cov-TaBS.

METHOD

In this study, we assessed a French translation of Cov-Tabs in 300 subjects from the general population. Moreover, we assessed convergent and discriminant validities using an anxiety and depression scale and a paranoid ideation scale. Statistical analyses consisted of evaluating internal consistency, test-retest reliability, and construct validity as well.

RESULTS

The French translation of the Cov-Tabs demonstrated high internal consistency and reliability, as well as good temporal stability over a period of less than 2 weeks. It also showed strong convergent validity with anxiety and depression traits and divergent validity with paranoid ideation.

CONCLUSION

Our study indicates that the French version of the Cov-Tabs has robust psychometric properties and is a valid tool for evaluating behavioral symptomatology and thoughts related to COVID-19 disease. Therefore, the French version of the Cov-Tabs is a valid tool that can be used in French-speaking individuals.

[Recent developments in the modeling and psychological management of persecutory ideation]

Persecutory ideas are a major clinical problem and are associated with impaired functioning, reduced compliance with medication and increased risk of hospitalization. Persecutory ideation is defined as the false conviction that others are threatening or conspiring against one. Although persecutory delusions are mainly described and experienced in schizophrenia spectrum disorders, they also occur in other neurological and psychiatric diagnoses including Alzheimer disease, epilepsy, depression, mania, dementia and post-traumatic stress disorder. Moreover, epidemiological data from general and clinical populations indicated that paranoid beliefs occur on a hierarchy of severity and are present to a lesser degree in the general population, with paranoid delusions representing the severe end of a continuum. In this review we focus on the important advances following a decade of research from psychological sciences, and more particularly the work of Daniel Freeman and Philippa Garety in England. Their work has demonstrated that a range of causal factors are involved in the development and maintenance of delusions beyond the traditional cognitive and behavioural models. Indeed, there is now well-validated evidence that sleep disturbances, worry proneness, reasoning biases, such as failure to consider alternative explanations or belief confirmation bias, abnormal experiences such as hallucinations, negative self-beliefs, and safety behaviours, are central factors that contribute to the paranoid phenomenon. In this review, we describe each of these causal factors in detail as well as the clinical interventions developed by Freeman and his collaborators, including the integrative and modular "Feeling Safe" intervention. Broadly speaking, the aim of this psychological intervention is for patients to relearn safety by exposing them to situations they consider as potentially dangerous after reduction of the influence of the maintenance factors described above. A recent publication showed that the Feeling Safe program led to recovery in persecutory delusions for 50% of patients having poor response to antipsychotic medication, making the intervention as the most effective psychological treatment for persecutory delusions. Finally, we will critically discuss the efficacy data from the numerous clinical studies validating its effectiveness. Prospects for the implementation of the Feeling Safe program in France also is discussed.

Differentiating paranoia and conspiracy mentality using a network approach

Although mostly considered distinct, conspiracy mentality and paranoia share conceptual similarities (e.g., persecutory content, resistance to disconfirming evidence). Using self-report data from a large and multinational online sample (N = 2510; from the UK, the US, Hong Kong, Germany, and Australia), we examined whether paranoia and conspiracy mentality represent distinct latent constructs in exploratory and confirmatory factor analyses. Utilising network analysis, we then explored common and unique correlates of paranoia and conspiracy mentality while accounting for their shared variance. Across sites, paranoia and conspiracy mentality presented distinct, yet weakly correlated (r = 0.26), constructs. Both were associated with past traumatic experiences, holding negative beliefs about the self and other people, sleep problems, and a tendency to worry. However, paranoia was related to increased negative affect (i.e., anxiety) and decreased social support, whereas the opposite pattern was observed for conspiracy mentality (i.e., decreased anxiety and depression, increased social support). Paranoia and conspiracy mentality are related but not the same constructs. Their similar and distinct correlates point to common and unique risk factors and underlying mechanisms.

Predictors of paranoia in the daily lives of people with non-affective psychosis and non-clinical controls: A systematic review of intensive longitudinal studies

BACKGROUND AND OBJECTIVES

Worrying, self-esteem, sleep problems, anomalous internal experiences, reasoning biases, and interpersonal sensitivity are associated with paranoia. However, no review has examined whether these variables function as predictors of paranoia in everyday life. The present systematic review of intensive longitudinal studies (e.g., experience sampling) examined contemporaneous and time-lagged associations between paranoia and each candidate mechanism in individuals with non-affective psychosis and controls (pre-registration: https://osf.io/uwr9d).

METHODS

We searched electronic databases, PsyArXiv, and reference lists for studies published since 1994.

RESULTS

Of n = 5,918 results, n = 54 fulfilled inclusion criteria (n = 43 datasets). Most studies examined individuals with non-affective psychosis (n = 34). Strong evidence emerged for negative affect (subsumed under 'anomalous internal experiences') and sleep problems. For self-esteem, results suggest contemporaneous and lagged effects on paranoia but associations are likely driven by between-person variance. The low number of studies (n = 2 studies each) allowed no conclusions regarding worrying and reasoning biases. Findings on interpersonal sensitivity, which should be interpreted with caution because of the predictor's conceptual overlap with paranoia, indicate contemporaneous effects whereas time-lagged and within-person associations could not be judged due to insufficient data.

LIMITATIONS

The present review used a narrative data-synthetization and it did not cover outcomes such as hallucinations.

CONCLUSIONS

Despite convincing evidence for affect and sleep problems, it remains unclear whether affective states are precursors or also consequences of paranoia (vicious circle), and which of the actigraphy measures (sleep time, -efficiency, -fragmentation, etc.) best predicts paranoia.

A Child-Parent Dyad Study on Adolescent Paranoia and the Influence of Adverse Life Events, Bullying, Parenting Stress, and Family Support

BACKGROUND

Paranoid beliefs commonly occur in the general adolescent population. Exposure to adverse life events (ALEs) and/or bullying are important environmental risk factors. The extent to which others, especially parents, are available to help a young person cope with stressful situations may offset this risk.

STUDY DESIGN

A cross-sectional adolescent-parent dyad design (n = 142 pairs) was used to test whether an adolescent's perception of being supported by their family, and/or the parent's perception of stress and burden in their parenting role, moderated the association between environmental risk and adolescent paranoid beliefs.

STUDY RESULTS

Moderation analysis indicated that ALEs were significantly associated with adolescent paranoid beliefs when parents reported high stress and burden in their parenting role. Conversely, at low and moderate levels of parental stress, ALEs were unrelated to paranoid beliefs. Bullying was strongly associated with paranoia, with no moderation effects. The adolescent's perception of support within their family had no moderating effects.

CONCLUSIONS

Findings indicate that the focus of prevention should be shifted beyond just families of adolescents who are experiencing psychosis and/or have high "at-risk" profiles, to families of adolescents exposed to ALEs. Targeted support for parents to help reduce parental stress and burden, and help foster protective family environments even in the face of ALEs, is an important avenue for reducing the risk of paranoid beliefs in adolescents. Further research is required to better understand how to offset the deleterious effect of bullying on paranoid beliefs in adolescents.

At-risk mental states and personality traits: A cluster analysis approach on a group of help-seeking young adults

INTRODUCTION

Research on the relationship between personality and psychosis onset is growing, with the goal of preventing or intervening early in patients' vulnerability. The identification of individuals with at-risk mental states has enabled the development of early intervention strategies, such as Programma 2000, a youth mental health service that was implemented in Milan (Italy).

AIMS

Focusing on the 18-25 age range-the time window with the highest incidence of psychotic onset-this study aims to identify the personality traits that may characterize the at-risk mental states and the social functioning of a group of help-seeking young adults.

METHODS

The sample includes 169 people (48.5% males and 51.5% females). Data were collected during an initial assessment that comprised the Social and Occupational Functioning Assessment Scale, the Personality Inventory for DSM-5, the Checklist ERIraos and a clinical session.

RESULTS

Results identified a three-cluster solution based on the Checklist scores: Cluster 1 'Not at psychotic risk'; Cluster 2 'At intermediate risk'; Cluster 3 'With psychotic onset'. The multivariate analysis of the variance of personality traits shows significant differences among the clusters in negative affect, detachment and disinhibition. Higher scores in these traits may distinguish individuals, not at psychotic risk from those at intermediate risk or with psychotic onset. Moreover, social functioning was found to be negatively associated with clusters of psychotic risk.

CONCLUSION

Findings from this study highlighted the need to evaluate personalized interventions targeting such personality traits that could prevent psychotic transition and promote psychological well-being.

Do loneliness and social exclusion breed paranoia? An experience sampling investigation across the psychosis continuum

Background

The role of loneliness and social exclusion in the development of paranoia is largely unexplored. Negative affect may mediate potential associations between these factors. We investigated the temporal relationships of daily-life loneliness, felt social exclusion, negative affect, and paranoia across the psychosis continuum.

Method

Seventy-five participants, including 29 individuals with a diagnosis of non-affective psychosis, 20 first-degree relatives, and 26 controls used an Experience Sampling Method (ESM) app to capture the fluctuations in loneliness, feelings of social exclusion, paranoia, and negative affect across a 1-week period. Data were analysed with multilevel regression analyses.

Results

In all groups, loneliness and feelings of social exclusion were independent predictors of paranoia over time (b = 0.05, p < .001 and b = 0.04, p < .05, respectively). Negative affect predicted paranoia (b = 0.17, p < .001) and partially mediated the associations between loneliness, social exclusion, and paranoia. It also predicted loneliness (b = 0.15, p < .0001), but not social exclusion (b = 0.04, p = .21) over time. Paranoia predicted social exclusion over time, with more pronounced effects in controls (b = 0.43) than patients (b = 0.19; relatives: b = 0.17); but not loneliness (b = 0.08, p = .16).

Conclusion

Paranoia and negative affect worsen in all groups following feelings of loneliness and social exclusion. This highlights the importance of a sense of belonging and being included for mental well-being. Loneliness, feeling socially excluded, and negative affect were independent predictors of paranoid thinking, suggesting they represent useful targets in its treatment.

Paranoid Thinking as a Function of Minority Group Status and Intersectionality: An International Examination of the Role of Negative Beliefs

BACKGROUND

Paranoia is higher in minority group individuals, especially those reporting intersecting aspects of difference. High negative and low positive self and other beliefs, and low social rank, are predictive of paranoia overtime; however, data are typically from majority group participants. This study examined whether social defeat or healthy cultural mistrust best characterizes paranoia in minority groups.

STUDY DESIGN

Using cross-sectional, survey design, with a large (n = 2510) international sample, moderation analyses (PROCESS) examined whether self and other beliefs, and perceived social rank, operate similarly or differently in minority vs majority group participants. Specifically, we tested whether beliefs moderated the influence of minority group, and intersecting aspects of difference, on paranoia.

STUDY RESULTS

Paranoia was consistently higher in participants from minority vs majority groups and level of paranoid thinking was significantly higher at each level of the intersectionality index. Negative self/other beliefs were associated with elevated paranoia in all participants. However, in support of the notion of healthy cultural mistrust, low social rank, and low positive self/other beliefs were significantly associated with paranoia in majority group participants but unrelated to paranoia in respective minority group members.

CONCLUSIONS

Although mixed, our findings signal the need to consider healthy cultural mistrust when examining paranoia in minority groups and bring into question whether "paranoia" accurately describes the experiences of marginalized individuals, at least at low levels of severity. Further research on paranoia in minority groups is crucial to developing culturally appropriate ways of understanding people's experiences in the context of victimization, discrimination, and difference.

The moderating effect of cognitive impairment on the relationship between inner speech and auditory verbal hallucinations among chronic patients with schizophrenia

BACKGROUND

Even though there is an increasing amount of evidence from behavioral and neuroimaging studies to suggest that pathological inner speech plays a role in the emergence of auditory verbal hallucinations (AVH), studies investigating the mechanisms underlying this relationship are rather scarce. Examining moderators might inform the development of new treatment options for AVH. We sought to extend the existing knowledge by testing the moderating role of cognitive impairment in the association between inner speech and hallucinations in a sample of Lebanese patients with schizophrenia.

METHODS

A cross-sectional study was conducted from May till August 2022, enrolling 189 chronic patients.

RESULTS

Moderation analysis revealed that, after controlling for delusions, the interaction of experiencing voices of other people in inner speech by cognitive performance was significantly associated with AVH. In people having low (Beta = 0.69; t = 5.048; p < .001) and moderate (Beta = 0.45; t = 4.096; p < .001) cognitive performance, the presence of voices of other people in inner speech was significantly associated with more hallucinations. This association was not significant in patients with high cognitive function (Beta = 0.21; t = 1.417; p = .158).

CONCLUSION

This preliminarily study suggests that interventions aiming at improving cognitive performance may also have a beneficial effect in reducing hallucinations in schizophrenia.

Attachment Style and Self-Experience: The Association Between Attachment Style and Self-Reported Altered Self-Experience in Patients With Psychotic Disorders, Unaffected Siblings, and Healthy Controls

ABSTRACT

The present study aimed to examine the cross-sectional association between attachment style and self-reported disturbed self-awareness (disturbed sense of mineness of experiences) and depersonalization (disturbed sense of first-person perspective) in patients with psychotic disorders, unaffected siblings, and healthy controls. Data pertain to a subsample of the GROUP (Genetic Risk and Outcome of Psychosis) study. We found positive associations between anxious attachment and disturbed self-awareness and depersonalization across participants with different psychosis vulnerability. We also found a positive association between avoidant attachment and depersonalization, although on a trend level. Findings indicate that attachment style is associated with self-reported disturbed self-awareness and depersonalization over and above the influence of psychotic or depressive experiences in people across the vulnerability spectrum of psychosis. This supports the importance of attachment style, self-awareness, and depersonalization as potential targets in prevention and treatment interventions in patients with psychotic disorders or those with increased vulnerability.

Components of emotion regulation flexibility and psychosis: The association between psychosis-proneness and context sensitivity

OBJECTIVES

Emotion regulation flexibility has been conceptualized as a multi-componential construct involving context sensitivity, repertoire and feedback responsiveness. Psychosis research has yet to incorporate these new developments in the study of emotion regulation. Thus, we sought to advance even further the knowledge on emotion regulation in psychosis by adopting the emotion regulation flexibility approach as proposed by Bonanno and Burton (Perspectives on Psychological Science, 2013, 8, 591).

METHOD

In total, 401 participants completed 4 scales assessing the multi-components of emotion regulation flexibility and psychosis-proneness.

RESULTS

Our results indicated that Context Sensitivity (i.e., Cue Absence) and Feedback Responsiveness (i.e., Evaluation) were associated with psychosis-proneness. Cue absence was specifically associated with the positive dimension, while both Cue Absence and Enhancement ability were associated with the negative dimension.

CONCLUSIONS

Overall, our results suggest that emotional context insensitivity is the most relevant component of regulatory flexibility in the case of psychosis-proneness. Thus, the disruption in this first step of flexible emotion regulation might be already present in those prone to psychosis. Difficulties in decoding appropriately the contextual cues might further disrupt the other steps of emotion regulation contributing to the psychotic (-like) experiences. This study needs replication in clinical and non-clinical samples.

Hostile attribution bias in schizophrenia-spectrum disorders: narrative review of the literature and persisting questions

BACKGROUND

Social cognition is often aberrant or impaired in psychotic disorders and related to functional outcomes. In particular, one core social cognitive bias - hostile attribution bias - is proposed to be implicated in paranoia, anxiety, mood disturbances and interpersonal conflict outcomes. However, questions remain about this domain's specificity to psychosis and its relationship to general functional outcomes.

AIMS

The present paper offers a descriptive and critical review of the literature on hostile attribution bias in psychotic disorders, in order to examine (1) its impact on persecutory symptoms in schizophrenia-spectrum disorders, (2) impact on other related psychopathology among those experiencing psychosis and (3) relationship to functioning.

METHODS

Twenty-eight studies included in this review after parallel literature searches of PsycINFO and PubMed.

RESULTS

Evidence from these studies highlighted that hostile attribution bias is elevated in schizophrenia, and that it is related to anxiety, depression and interpersonal conflict outcomes.

CONCLUSION

While results suggest that hostile attributions are elevated in schizophrenia and associated with symptoms and functioning, there exist numerous persisting questions in the study of this area, including identifying which measures are most effective and determining how it presents: as a state or trait-like characteristic, via dual processes, and its situational variation.

Personality traits and transition to psychosis one year after the first assessment

Introduction

Several studies have identified ultra-high-risk criteria that may characterize an at-risk mental state and predict the transition of psychotic evolution. Personality traits may play a crucial role in this process.

Aims

The current study aims to: (a) explore the evolution of an initial diagnosis over 12 months; (b) assess differences in social and occupational functioning; (c) identify common (trans-diagnostic) personality traits of psychotic risk.

Methods

The sample includes 97 (44 males and 53 females) young adults. They completed an assessment that consists of socio-demographic data, the Social and Occupational Functioning Scale, the Early Recognition Inventory-retrospective assessment onset of schizophrenia, and the Personality Inventory for DSM-5 (PID-5). According to the tests' assessment, the sample was divided into three different groups: Ultra-High Risk (UHR), At-Risk, and Not at risk. One year after the first evaluation, psychiatrists administered the QuickSCID-5 to verify the diagnostic trajectories of the sample.

Results

Overall, the most prevalent category diagnoses were anxiety/depression, personality disorders, and psychosis. Specifically, the most common diagnosis in the UHR group was psychosis. Moreover, in the UHR group, the social and occupational functioning score was the lowest. In terms of differences in PID-5 personality traits, the At-risk and UHR groups scored highest in detachment and disinhibition. No statistically significant differences were found between the groups for negative affectivity, antagonism, and psychoticism traits.

Conclusion

Results obtained by the current study should be considered an attempt to better understand the diagnostic trajectories and trans-diagnostic personality traits in a group of young help-seekers, specifically in UHR. Findings highlight both the importance of diagnosis and personality traits evaluation to customize a specific intervention based on the level of psychotic risk. Clinical suggestions are reported.

Using Smartphones to Identify Momentary Characteristics of Persecutory Ideation Associated With Functional Disability

Objectives

Though often a feature of schizophrenia-spectrum disorders, persecutory ideation (PI) is also common in other psychiatric disorders as well as among individuals who are otherwise healthy. Emerging technologies allow for a more thorough understanding of the momentary phenomenological characteristics that determine whether PI leads to significant distress and dysfunction. This study aims to identify the momentary phenomenological features of PI associated with distress, dysfunction, and need for clinical care.

Methods

A total of 231 individuals with at least moderate PI from 43 US states participated in a study involving 30 days of data collection using a smartphone data collection system combining ecological momentary assessment and passive sensors, wherein they reported on occurrence of PI as well as related appraisals, responses, and cooccurring states. Most (N = 120, 51.9%) participants reported never having received treatment for their PI, while 50 participants had received inpatient treatment (21.6%), and 60 (26.4%) had received outpatient care only.

Results

Individuals with greater functional disability did not differ in PI frequency but were more likely at the moment to describe threats as important to them, to ruminate about those threats, to experience distress related to them, and to change their behavior in response. Groups based on treatment-seeking patterns largely did not differ in baseline measures or momentary phenomenology of PI as assessed by self-report or passive sensors.

Conclusions

Smartphone data collection allows for granular assessment of PI-related phenomena. Functional disability is associated with differences in appraisals of and responses to PI at the moment.

Investigating Specific Associations Between Childhood Victimization Profiles and Positive Psychosis Symptoms: The Mediating Roles of Anxiety, Depression, and Schema

Background

Childhood trauma is a risk factor for psychosis. It is proposed this is due to traumatic events giving rise to psychological mechanisms that are implicated in the development and maintenance of symptoms. Investigation of the psychological mechanisms accounting for relationships between trauma and psychosis will be assisted by focusing on specific trauma profiles, hallucination modalities, and delusion subtypes.

Study Design

In 171 adults with schizophrenia-spectrum diagnoses and high-conviction delusions, associations between childhood trauma classes, and hallucination and delusion factors, were tested using structural equation models (SEMs). Anxiety, depression, and negative schema were examined as potential mediators of trauma class-psychosis symptom factor links.

Study Results

Significant associations were found between the emotional abuse/neglect and poly-victimization classes with persecutory delusions and delusions of influence, that were all mediated through anxiety (β = 1.24-0.23, P = < .05). There was an association between the physical abuse class and grandiose/religious delusions that was not explained by the mediators (β = 1.86, P = < .05). Trauma class was not significantly associated with any hallucination modality (β = 0.004-1.46, P = > .05).

Conclusions

In a sample of people with strongly held delusions, this study demonstrates that childhood victimization is associated with delusions of influence and grandiose beliefs, as well as with persecutory delusions in psychosis. Consistent with previous findings, the potent, mediating role of anxiety supports affective pathway theories and the utility of targeting threat-related processes when treating trauma effects in psychosis.

Fluctuations in proximity seeking and paranoia

OBJECTIVES

This study aimed to investigate associations between proximity seeking, stress and paranoia in the context of daily life, and whether these relationships are moderated by trait attachment styles.

METHODS

Sixty non-clinical participants completed 3423 assessments of state stress, proximity seeking and paranoia over a 6-day period using an experience sampling method. Multilevel linear regression was performed to evaluate relationships between variables.

RESULTS

The post-hoc analysis showed antecedent events subjectively appraised as very unpleasant or very pleasant predicted greater levels of momentary proximity seeking at the subsequent timepoint. Greater stress predicted greater subsequent shifts or variability in proximity seeking. Changes in proximity seeking were not associated with momentary paranoia. However, for individuals with an avoidant attachment style, greater shifts in proximity seeking resulted in greater subsequent reports of paranoia.

CONCLUSIONS

These findings suggest that, in daily life, the attachment system may become active in response to stress. For those with an avoidant attachment style, an active attachment system may exacerbate paranoid thoughts possibly due to the activation of attachment-related beliefs that one should be fearful of unavailable others and instead rely on one's autonomy to regulate affect. These findings highlight the need to consider attachment in the assessment and formulation of paranoia.

Modelling the temporal interplay between stress and affective disturbances in pathways to psychosis: an experience sampling study

BACKGROUND

One putative psychological mechanism through which momentary stress impacts on psychosis in individuals with increased liability to the disorder is via affective disturbance. However, to date, this has not been systematically tested. We aimed to investigate whether (i) cross-sectional and temporal effects of momentary stress on psychotic experiences via affective disturbance, and (ii) the reverse pathway of psychotic experiences on stress via affective disturbance were modified by familial liability to psychosis.

METHODS

The Experience Sampling Method was used in a pooled data set of six studies with three groups of 245 individuals with psychotic disorder, 165 unaffected first-degree relatives, and 244 healthy control individuals to index familial liability. Multilevel moderated mediation models were fitted to investigate indirect effects across groups cross-sectionally and multilevel cross-lagged panel models to investigate temporal effects in the proposed pathways across two measurement occasions.

RESULTS

Evidence on indirect effects from cross-sectional models indicated that, in all three groups, effects of stress on psychotic experiences were mediated by negative affect and, vice versa, effects of psychotic experiences on stress were mediated by negative affect, with all indirect effects being weakest in relatives. Longitudinal modelling of data provided no evidence of temporal priority of stress in exerting its indirect effects on psychotic experiences via affective disturbance or, vice versa.

CONCLUSIONS

Our findings tentatively suggest a rapid vicious cycle of stress impacting psychotic experiences via affective disturbances, which does, however, not seem to be consistently modified by familial liability to psychosis.

Depression, reduced education, and bias perceptions as risk factors of beliefs in misinformation

The spread of misinformation and conspiracy theories related to COVID‐19 has represented one of the several undesirable effects of the current pandemic. In understanding why people can be more or less at risk to believe in misinformation, emotional distress and education could play a crucial role. The present study aims to analyze the relationship among depressive symptoms, education, and beliefs in misinformation about COVID-19 during the early phase of the pandemic. We do this through a cross-sectional study carried out on a random and representative sample of the Italian population that allows us to go and verify the co-evolution of many factors: i.e., beliefs in misinformation, symptoms of depression, perceptions about COVID-19, ways in which citizens got informed about the pandemic, and sociodemographic characteristics (e.g., age, gender, education). The results show that the relationship between depression and beliefs in misinformation exists and is more complex than hypothesized because it is mediated by individual perceptions. In particular, the most at-risk people to believe in misinformation show higher bias perceptions, higher depression, and lower education. Practical implications are discussed suggesting a supportive intervention at both individual and social levels.

The network structure of paranoia dimensions and its mental health correlates in the general population: The core role of loneliness

Paranoid ideas are the most common abnormal beliefs in the schizophrenia spectrum, are also prevalent in non-clinical populations, and are highly correlated with other mental health problems such as anxiety, depression and low levels of well-being. Two previous studies with the same British population sample used confirmatory factor analysis and network analysis to show that the spectrum of paranoid beliefs is made up of four factors or dimensions (i.e., interpersonal sensitivity, mistrust, ideas of reference and ideas of persecution). The aims of this study are: 1) to explore the distribution and the structure of paranoid beliefs in a Spanish general population by applying the network approach and 2) to use network analysis to explore for the first time whether specific domains of paranoid ideation (i.e., dimensions) are specifically associated with mental health correlates such as depression, anxiety, loneliness, and well-being. We found a continuous distribution of paranoid beliefs among the 1328 individuals constituting the sample (e.g., 29,2 % did not endorse any items, 4.6 % endorsed half of the items, while 0.8 % endorsed all paranoid items). Paranoid ideas form three dimensions; interpersonal sensitivity, mistrust, and ideas of persecution (ideas of reference did not form a separate factor). The network model showed that loneliness has a pivotal role in connecting paranoid ideation with general psychopathology measures (i.e., depression, anxiety, loneliness and well-being). Research and clinical implications derived from our findings are also discussed.

Six-year changes of posttraumatic stress symptoms and depressive symptoms among Chinese earthquake survivors: A network analysis

BACKGROUND

The risk factors of Posttraumatic Stress Symptoms (PTSS) and depressive symptoms have been well-established, but whether the network structure of their symptoms changes over time remains unclear. This study aims to examine the six-year changes of network structure of PTSS and depressive symptoms among Wenchuan earthquake adult survivors in China.

METHODS

In this pooled cross-sectional study, respondents were sampled from the same population at each of the five waves (N = 1343, 1205, 1177, 1376, and 1339). The network structure of them was investigated using network analyses.

RESULTS

The study shows network connections stable across waves were the positive connections between hyperarousal and intrusions, hyperarousal and somatic symptoms, and two dimensions of positive effects. Stable negative connections were those between depressed affects and positive effects, avoidance and depressed affects, avoidance with interpersonal symptoms and avoidance with somatic symptoms. Across waves, fearful emotion consistently was the strongest bridge symptom connecting with PTSS symptoms. However, for PTSS the strongest bridge symptom varied across time as it was avoidance in wave 1 but were hyperarousal in other four waves.

LIMITATIONS

This study was based on a pooled cross-sectional survey, which inhibits conclusions regarding causal influences between symptoms at the individual patient level.

CONCLUSIONS

The network structure of PTSS and depressive symptoms was partly stable, yet also varied across survey waves. Core symptom clusters for PTSS and depressive symptoms were avoidance and depressed affect, respectively. The central role of these clusters in PTSS and depressive symptoms has important implications to future psychiatric programs.

Jumping to Conclusions and Its Associations With Psychotic Experiences in Preadolescent Children at Familial High Risk of Schizophrenia or Bipolar Disorder-The Danish High Risk and Resilience Study, VIA 11

BACKGROUND

The jumping to conclusions (JTC) bias, ie, making decisions based on inadequate evidence, is associated with psychosis in adults and is believed to underlie the formation of delusions. Knowledge on the early manifestations of JTC and its associations with psychotic experiences (PE) in children and adolescents is lacking.

DESIGN

Preadolescent children (mean age 11.9 y, SD 0.2) at familial high risk of schizophrenia (FHR-SZ, n = 169) or bipolar disorder (FHR-BP, n = 101), and controls (n = 173) were assessed with the Beads Task to examine JTC. The number of beads drawn before making a decision, "draws to decision" (DTD) was used as a primary outcome. PE were ascertained in face-to-face interviews. General intelligence was measured with Reynolds Intellectual Screening Test.

RESULTS

Children at FHR-SZ took fewer DTD than controls (4.9 vs 5.9, Cohen's d = 0.31, P = .004). Differences were attenuated when adjusting for IQ (Cohen's d = 0.24, P = .02). Higher IQ was associated with a higher number of DTD (B = 0.073, P < .001). Current subclinical delusions compared with no PE were associated with fewer DTD in children at FHR-SZ (P = .04) and controls (P < .05). Associations between delusions and DTD were nullified when accounting for IQ.

CONCLUSIONS

JTC marks familial risk of psychosis in preadolescence, not reducible to general intelligence. JTC is associated with subclinical delusions, but this may be an expression of intellectual impairment. Future studies should establish temporality between JTC and delusion formation and examine JTC as a target for early intervention.

A replication study of JTC bias, genetic liability for psychosis and delusional ideation

BACKGROUND

This study attempted to replicate whether a bias in probabilistic reasoning, or 'jumping to conclusions'(JTC) bias is associated with being a sibling of a patient with schizophrenia spectrum disorder; and if so, whether this association is contingent on subthreshold delusional ideation.

METHODS

Data were derived from the EUGEI project, a 25-centre, 15-country effort to study psychosis spectrum disorder. The current analyses included 1261 patients with schizophrenia spectrum disorder, 1282 siblings of patients and 1525 healthy comparison subjects, recruited in Spain (five centres), Turkey (three centres) and Serbia (one centre). The beads task was used to assess JTC bias. Lifetime experience of delusional ideation and hallucinatory experiences was assessed using the Community Assessment of Psychic Experiences. General cognitive abilities were taken into account in the analyses.

RESULTS

JTC bias was positively associated not only with patient status but also with sibling status [adjusted relative risk (aRR) ratio : 4.23 CI 95% 3.46-5.17 for siblings and aRR: 5.07 CI 95% 4.13-6.23 for patients]. The association between JTC bias and sibling status was stronger in those with higher levels of delusional ideation (aRR interaction in siblings: 3.77 CI 95% 1.67-8.51, and in patients: 2.15 CI 95% 0.94-4.92). The association between JTC bias and sibling status was not stronger in those with higher levels of hallucinatory experiences.

CONCLUSIONS

These findings replicate earlier findings that JTC bias is associated with familial liability for psychosis and that this is contingent on the degree of delusional ideation but not hallucinations.

Psychological Pathways to Paranoia and Psychotic-Like Experiences in Daily-Life: The Mediating Role of Distinct Affective Disturbances

BACKGROUND AND HYPOTHESIS

Influential models of psychosis indicate that the impact of putative causal factors on positive symptoms might be explained partly through affective disturbances. We aimed to investigate whether pathways from stress and self-esteem to positive symptoms, as well as reversal pathways from symptoms to stress and self-esteem, were mediated through specific affective disturbances across the extended psychosis phenotype.

STUDY DESIGN

Using experience sampling methodology, 178 participants (65 high-schizotypy, 74 at-risk mental state, and 39 first-episode psychosis) were assessed on levels of momentary stress, self-esteem, anxiety, sadness, psychotic-like experiences (PLE), and paranoia. Multilevel mediation models were fit to examine indirect effects of each of these pathways. Considering evidence of mediation, each indirect pathway will be combined in a single model to explore their relative contributions.

STUDY RESULTS

Anxiety, sadness, and self-esteem mediated the pathways from stress to PLE and paranoia in daily-life. In the pathway to paranoia, sadness, and self-esteem showed larger contributions than anxiety. Pathways from self-esteem to PLE and paranoia were mediated by anxiety and sadness, the later showing a larger contribution. Pathways from symptoms to stress, but not from symptoms to self-esteem, were differently explained by emotional states; sadness lost its mediating effect and anxiety was the most important mediator. Few differences across groups were found.

CONCLUSIONS

This study lends support to psychological models of psychosis that highlight the relevance of affective disturbances in the risk and expression of psychosis. Furthermore, specific influences of different negative emotional states were identified, which could enhance psychological treatments.

SlowMo therapy, a new digital blended therapy for fear of harm from others: An account of therapy personalisation within a targeted intervention

OBJECTIVES

SlowMo therapy is a pioneering blended digital therapy for paranoia, augmenting face-to-face therapy with an interactive 'webapp' and a mobile app. A recent large-scale trial demonstrated small-moderate effects on paranoia alongside improvements in self-esteem, worry, well-being and quality of life. This paper provides a comprehensive account of therapy personalisation within this targeted approach.

DESIGN

Case examples illustrate therapy delivery and descriptive data are presented on personalised thought content.

METHOD

Thought content was extracted from the webapp (n = 140 participants) and coded using newly devised categories: Worries: (1) Persecutory, (2) Negative social evaluation, (3) Negative self-concept, (4) Loss/life stresses, (5) Sensory-perceptual experiences and (6) Health anxieties. Safer thoughts: (1) Safer alternative (specific alternatives to worries), (2) Second-wave (generalised) coping, (3) Positive self-concept, (4) Positive activities and (5) Third-wave (mindfulness-based) coping. Data on therapy fidelity are also presented.

RESULTS

Worries: 'Persecutory' (92.9% of people) and 'Negative social evaluation' (74.3%) were most common. 'General worries/ life stresses' (31.4%) and 'Negative self-concept' (22.1%) were present in a significant minority; 'Health anxieties' (10%) and 'Sensory-perceptual' (10%) were less common. Safer thoughts: 'Second-wave (general) coping' (85%), 'Safer alternatives' (76.4%), 'Positive self-concept' (65.7%) and 'Positive activities' (64.3%) were common with 'Third-wave' (mindfulness) coping observed for 30%. Fidelity: Only three therapy withdrawals were therapy related. Session adherence was excellent (mean = 15.2/16; SD = 0.9). Behavioural work was conducted with 71% of people (119/168).

CONCLUSION

SlowMo therapy delivers a targeted yet personalised approach. Potential mechanisms of action extend beyond reasoning. Implications for cognitive models of paranoia and causal interventionist approaches are discussed.

Relationship between Interpersonal Sensitivity Measure score and clinical symptoms in patients with major psychiatric disorders and healthy individuals

Aim

We compared the Interpersonal Sensitivity Measure (IPSM) scores between diagnostic groups and examined the relationship between IPSM scores and clinical variables.

Methods

This study included 166 patients with schizophrenia, 47 patients with bipolar disorder (BD) Ⅰ, 110 patients with BD Ⅱ, 380 patients with major depressive disorder (MDD), and 558 healthy individuals. Symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS), Young Mania Rating Scale, 21-item Hamilton Depression Rating Scale (HAMD-21), and Pittsburgh Sleep Quality Index (PSQI).

Results

The IPSM interpersonal awareness, separation anxiety, timidity, fragile inner self, and total scores were significantly higher in all the patient groups compared with healthy individuals (corrected p < 0.05). The IPSM need for approval score was significantly higher in patients with BD Ⅰ and those with BD Ⅱ than in those with schizophrenia or MDD (corrected p < 0.05). The PSQI total score and PANSS general psychopathology score, HAMD-21 delusion subscale score, HAMD-21 total score, and HAMD-21 core subscale score and PSQI sleep disturbance subscale score were significantly and positively correlated with the IPSM total score in patients with schizophrenia, those with BD Ⅰ, those with BD Ⅱ, and those with MDD, respectively, while the PSQI total score and daytime dysfunction subscale score were significantly and positively correlated with the IPSM total score in healthy individuals (corrected p < 0.05).

Conclusion

Our data suggest that higher interpersonal sensitivity may play a role in the development of major psychiatric disorders and may be involved in some clinical symptom formations.

Increased Belief Instability in Psychotic Disorders Predicts Treatment Response to Metacognitive Training

BACKGROUND AND HYPOTHESIS

In a complex world, gathering information and adjusting our beliefs about the world is of paramount importance. The literature suggests that patients with psychotic disorders display a tendency to draw early conclusions based on limited evidence, referred to as the jumping-to-conclusions bias, but few studies have examined the computational mechanisms underlying this and related belief-updating biases. Here, we employ a computational approach to understand the relationship between jumping-to-conclusions, psychotic disorders, and delusions.

STUDY DESIGN

We modeled probabilistic reasoning of 261 patients with psychotic disorders and 56 healthy controls during an information sampling task-the fish task-with the Hierarchical Gaussian Filter. Subsequently, we examined the clinical utility of this computational approach by testing whether computational parameters, obtained from fitting the model to each individual's behavior, could predict treatment response to Metacognitive Training using machine learning.

STUDY RESULTS

We observed differences in probabilistic reasoning between patients with psychotic disorders and healthy controls, participants with and without jumping-to-conclusions bias, but not between patients with low and high current delusions. The computational analysis suggested that belief instability was increased in patients with psychotic disorders. Jumping-to-conclusions was associated with both increased belief instability and greater prior uncertainty. Lastly, belief instability predicted treatment response to Metacognitive Training at the individual level.

CONCLUSIONS

Our results point towards increased belief instability as a key computational mechanism underlying probabilistic reasoning in psychotic disorders. We provide a proof-of-concept that this computational approach may be useful to help identify suitable treatments for individual patients with psychotic disorders.

Differences between delusional disorder and schizophrenia: A mini narrative review

Psychotic syndromes are divided into affective and non-affective forms. Even among the non-affective forms, substantial differences exist. The aim of this relatively brief review is to synthesize what is known about the differences between two non-affective psychoses, schizophrenia and delusional disorder (DD), with respect to clinical, epidemiological, sociodemographic, and treatment response characteristics. A PubMed literature search revealed the following: in schizophrenia, hallucinations, negative symptoms and cognitive symptoms are prominent. They are rare in DD. Compared to schizophrenia patients, individuals with DD maintain relatively good function, and their delusions are believable; many are beliefs that are widely held in the general population. Treatments are generally similar in these two forms of psychosis, with the exception that antidepressants are used more frequently in DD and, for acute treatment, effective antipsychotic doses are lower in DD than in schizophrenia. It is with the hope that the contrasts between these two conditions will aid in the provision of safe and effective treatment for both that this review has been conducted.

Verschwörungstheorien und paranoider Wahn: Lassen sich Aspekte kognitionspsychologischer Modelle zu Entstehung und Aufrechterhaltung von paranoiden Wahnüberzeugungen auf Verschwörungstheorien übertragen?

Der vorliegende narrative Übersichtsartikel stellt zunächst verschiedene Definitionen von Verschwörungstheorien und Verschwörungsmentalität vor und präsentiert Studien zu Zusammenhängen zwischen Persönlichkeitseigenschaften, Symptomen psychischer Störungen und Verschwörungstheorien. Anschließend werden die Kontinuumshypothese des Wahns sowie neuere Konzeptualisierungen von allgemeinem und paranoiden Wahn diskutiert, des Weiteren werden typische kognitionspsychologische Modelle präsentiert, die die Entstehung und Aufrechterhaltung von Wahnüberzeugungen durch eine Interaktion von biologischen Vulnerabilitätsfaktoren, psychologischen Faktoren und sozialen Faktoren erklären. In diesen Modellen mediieren sowohl kognitive Verarbeitungsstile („cognitive biases“) als auch emotionale Prozesse die Entstehung und Aufrechterhaltung von Wahn, beispielsweise die Tendenz, voreilige Schlussfolgerungen zu treffen („jumping to conclusions bias“), sowie externale Kontrollüberzeugungen und ein externalisierender personalisierender Kausalattributionsstil. Anschließend wird diskutiert, ob Menschen, die Verschwörungstheorien zugeneigt sind, ebenfalls ähnliche kognitive Verarbeitungsstile aufweisen, die auch bei Personen zu finden sind, die paranoiden Wahnüberzeugungen zustimmen und unter psychotischen Störungen leiden. Parallelen bestehen zwischen beiden Personengruppen beispielsweise im Hinblick auf eine Neigung zu externalen Kontrollüberzeugungen und einen external personalisierenden Kausalattributionsstil. Auch bestehen Ähnlichkeiten in der Neigung, voreilige Schlussfolgerungen zu treffen. Fragen nach Gemeinsamkeiten und Unterschieden zwischen beiden Phänomenen sollten in weiteren präregistrierten experimentellen Studien quer- sowie längsschnittlich untersucht werden. Möglicherweise könnten moderne niedrigschwellige Interventionsmethoden der kognitiven Verhaltenstherapie von Psychosen (CBTp) in die Beratung oder Prävention von Verschwörungstheorien implementiert werden.

Pandemic paranoia, general paranoia, and their relationships with worry and beliefs about self/others - A multi-site latent class analysis

BACKGROUND

During the COVID-19 pandemic, an increase in paranoid thinking has been reported internationally. The development of the Pandemic Paranoia Scale (PPS) has provided a reliable assessment of various facets of pandemic paranoia. This study aimed to (i) identify classes of individuals with varying levels of general paranoia and pandemic paranoia, and (ii) examine associations between classification and worry, core beliefs, and pro-health behaviours.

METHODS

An international sample of adults (N = 2510) across five sites completed the Revised-Green Paranoid Thoughts Scale and the PPS. Latent class analysis (LCA) was conducted using these two paranoia variables. Classes were compared on trait worry (Penn State Worry Questionnaire), beliefs about self/others (Brief Core Schema Scales), and pro-health behaviour.

RESULTS

Three latent classes emerged: Class 1 with low R-GPTS and PPS scores, Class 2 with a high R-GPTS score and a moderate PPS score, and Class 3 with high R-GPTS and PPS scores. Compared to Class 1, Classes 2-3 were associated with more worry and negative self- and other-beliefs. Class 3 was further characterised by greater positive-self beliefs and less engagement in pro-health behaviours. Engagement in pro-health behaviours was positively correlated with interpersonal mistrust and negatively correlated with paranoid conspiracy and persecutory threat.

CONCLUSIONS

Individuals with a general paranoia tendency were more likely to respond to the global health threats in a suspicious and distrusting way. Our findings suggested that worry and negative self/other beliefs may contribute to not just general paranoia but also pandemic paranoia. The preliminary finding of a link between pro-health behaviours and interpersonal mistrust warrants further examination.

Pathways from insecure attachment to paranoia: the mediating role of emotion regulation

Background:

Paranoia is common across the clinical and non-clinical spectrum. Cognitive behavioural therapy for psychosis currently yields modest results, warranting research into symptom-specific maintenance factors to improve outcomes. There is strong evidence of a relationship between insecure attachment and increased paranoia, but little is known about the mediating mechanisms. Emotion dysregulation is associated with both insecure attachment and paranoia, and a candidate causal mechanism.

Aims:

This study aimed to determine if emotion dysregulation mediates the association between attachment and paranoia.

Method:

Sixty-two individuals with elevated paranoia were recruited from NHS services and community settings across the South of England. Mediation analyses were conducted on trait attachment, emotion regulation and paranoia variables, which were collected at one time point.

Results:

As predicted, emotion dysregulation mediated the relationship between attachment avoidance and paranoia, and between attachment anxiety and paranoia. Emotion suppression did not mediate the relationship between attachment avoidance and paranoia, possibly due to power. Attachment avoidance correlated with deactivating emotion regulation strategies (e.g. lack of emotional awareness) and attachment anxiety correlated with hyperactivating emotion regulation strategies (e.g. impulse control difficulties). Both deactivating and hyperactivating strategies correlated with paranoia.

Conclusion:

Emotion dysregulation is not routinely targeted in cognitive behavioural therapy for psychosis. This study suggests that incorporating emotion regulation strategies in therapy may improve clinical outcomes. Experimental studies are now required to support a causal argument, and pilot intervention studies should investigate if emotion regulation skills development (aligned with attachment style) is effective in reducing non-clinical and clinical paranoia.

Psychotic experiences among informal caregivers: findings from 48 low- and middle-income countries

PURPOSE

Informal caregivers may be at high risk for psychotic experiences (PE) due to caregiving related stress, sleep issues, or other potential mechanisms, but this has not been previously investigated in the general adult population. Thus, we examined the association between caregiving and PE, and its mediators, in a large sample of adults from 48 low- and middle-income countries (LMICs).

METHODS

Cross-sectional, community-based data from the World Health Organization (WHO) World Health Survey were analyzed. Informal caregivers referred to those who provided help to a relative or friend (adult or child) in the past year, because this person has a long-term physical or mental illness or disability, or is getting old and weak. PE were assessed using the WHO Composite International Diagnostic Interview psychosis screen. Multivariable logistic regression and mediation analyses were conducted.

RESULTS

Data on 224,842 individuals were analyzed. The mean (SD) age was 38.3 (16.0) years (range 18-120 years) and 50.7% were females. After adjustment for age, sex, and country, in the overall sample, caregiving was associated with 1.67 (95%CI = 1.56-1.79) times higher odds for PE. Sleep/energy explained the largest proportion of the association between caregiving and PE (13.9%), followed by pain/discomfort (11.5%), perceived stress (7.6%), depression (6.2%), and cognition (3.5%).

CONCLUSION

Caregivers in LMICs are at higher risk of PE. Future studies are warranted to gain a further understanding of the underlying mechanisms, and to assess whether addressing the identified mediators can lead to lower risk for PE among caregivers.

Are they out to get me? Individual differences in nonclinical paranoia as a function of narcissism and defensive self-protection

OBJECTIVE

Three studies tested a novel model of the narcissism-paranoia link, whereby narcissism (primarily its socially maladaptive facets) is associated with paranoia via over-use of defensive self-protection and/or under-use of self-affirmation.

METHODS

In Study 1, 245 online volunteers (87% female; M_AGE  = 20.92; 44% White-British) completed trait measures of narcissism, self-enhancement/protection strategies and paranoia. In Study 2, 116 students (82% female; M_AGE  = 20.23; 70% White-British) completed baseline measures, then reported state reactions and paranoia following two difficult and two pleasant interpersonal events after 3-10 days. In Study 3, 517 online volunteers (64% female; M_AGE  = 22.76; 77% White/Caucasian) completed baseline measures, experienced a standardized social exclusion (vs. neutral) manipulation (Cyberball), then reported state reactions and paranoia.

RESULTS

In Study 1, narcissism was associated with higher paranoia via defensiveness. In Study 2, this was replicated in difficult but not pleasant events, and was driven by the Entitlement/Exploitativeness facet of narcissism. In Study 3, narcissistic rivalry and vulnerable narcissism, but not admiration, were associated with Cyberball-related paranoia via general defensiveness and denigration of others.

CONCLUSIONS

Individuals high in narcissism-especially its socially maladaptive facets-who over-rely on defensive self-protection strategies in response to threat, are particularly vulnerable to paranoia. Findings help to understand individual differences in paranoia.

Personal and contextual components of resilience mediate risky family environment's effect on psychotic-like experiences

BACKGROUND

Psychotic-like experiences (PLEs) index an increased risk for subsequent psychotic disorders. A risky family environment is a well-established risk factor for PLEs; however, different contextual and personal resiliency factors may differentially mediate its effect on PLEs.

OBJECTIVE

In this study, we propose a two-dimensional model of resilience. Our aim is to address separately the mediational role of personal and contextual resiliency factors between a risky family environment and PLEs in a community sample.

METHODS AND MATERIALS

Five-hundred University students completed an on-line questionnaire, including the Resilience Scale for Adults (RSA), the 16-item version of the Prodromal Questionnaire (iPQ-16) and the Risky Family Questionnaire (RFQ). Mediation was assessed using Structural Equation Modelling with bootstrapping estimation of indirect effect.

RESULTS

The direct effects of personal and contextual resilience on PLEs were respectively -0.69 [-0.97, -0.41] (P < .001) and - 0.19 [-0.58, 0.20] (ns); the indirect effect through personal resilience was 0.03[0.01, 0.04] (P < .001). Personal resilience mediated 27.4% of the total effect of risky family environment on PLEs.

DISCUSSION

Personal resilience, as opposite to contextual resilience, mediates the effect of a risky family environment on PLEs. Low personal resilience may represent an individual risk factor that transmits the effect of risky family environment on PLEs and could represent a central aspect of individualized prevention and treatment strategies.

Evaluating a Values-Based Intervention for Adolescence with High Nonclinical Paranoia: A Schools-Based Randomised Control Trial

Background

Paranoia in adolescents is common, but research on attenuating it is scarce. Focusing on values and enhancing value-based acts is a low intensity method for attenuating paranoia in adults. This randomised trial compared a brief (30-min, self-directed) values-plus-goals intervention to an active control for adolescents with high nonclinical paranoia (Paranoia Scale ≥ 53), delivered in schools. The study also investigated the role of self-esteem.

Methods

Ninety adolescents were randomly assigned to condition. Paranoia (primary outcome) and self-esteem (potential mediator) were assessed at baseline (T1), and two- (T2) and six-weeks (T3) after baseline.

Results

Results were analysed using intention to treat (ITT) and per protocol (PP) analysis. Using ITT analysis, the Condition*Time interaction was significant (F(2, 168) = 3.98, p = .02), paranoia was significantly lower at T3 following values-plus-goals as compared to control (d = 0.64). Differences were not significant using per protocol analysis (F(2, 106) = 1.61, p = .21). The between group effect size at T3 was (d = 0.61). The Condition*Time interaction for self-esteem was not significant (F(2, 112) = 2.86, p = .06).

Conclusions

Tentatively, findings suggest that a brief values-plus-goals intervention can reduce paranoia in adolescents relative to an active control.

I want to believe: delusion, motivated reasoning, and Bayesian decision theory

Introduction: Several arguments suggest that motivated reasoning (occurring when beliefs are not solely shaped by accuracy, but also by other motives such as promoting self-esteem or self-protection) is important in delusions. However, classical theories of delusion disregard the role of motivated reasoning. Thus, this role remains poorly understood.Methods: To explore the role of motivated reasoning in delusions, here we propose a computational model of delusion based on a Bayesian decision framework. This proposes that beliefs are not only evaluated based on their accuracy (as in classical theories), but also based on the cost (in terms of reward and punishment) of rejecting them.Results: The model proposes that, when the values at stake are high (as often it is the case in the context of delusion), a belief might be endorsed because rejecting it is evaluated as too costly, even if the belief is less accurate. This process might contribute to the genesis of delusions.Conclusions: Our account offers an interpretation of how motivated reasoning might shape delusions. This can inspire research on the affective and motivational processes supporting delusions in clinical conditions such as in psychosis, neurological disorders, and delusional disorder.

Virtual reality cognitive-behavioural therapy versus cognitive-behavioural therapy for paranoid delusions: a study protocol for a single-blind multi-Centre randomised controlled superiority trial

BACKGROUND

Seventy per cent of patients with psychotic disorders has paranoid delusions. Paranoid delusions are associated with significant distress, hospital admission and social isolation. Cognitive-behavioural therapy for psychosis (CBTp) is the primary psychological treatment, but the median effect size is only small to medium. Virtual reality (VR) has a great potential to improve the effectiveness of CBTp. In a previous study, we found that VR based CBT (VRcbt) for paranoid delusions is superior to waiting list. As a next step, a direct comparison with CBTp is needed. The present study aims to investigate whether VRcbt is more effective and cost-effective than regular CBTp in treating paranoid delusions and improving daily life social functioning of patients with psychotic disorders.

METHODS

A total of 106 patients with DSM-5 diagnosis of psychotic disorder and at least moderate level of paranoid ideations will be recruited for this multicentre randomized controlled trial (RCT). Patients will be randomized to either VRcbt or standard CBTp for paranoid delusions. VRcbt consists of maximum 16 sessions in virtual social situations that trigger paranoid ideations and distress, delivered in an 8-12 week time frame. Standard CBTp also consists of maximum 16 sessions including exposure and behavioural experiments, delivered in an 8-12 week time frame. The two groups will be compared at baseline, post-treatment and six months follow-up. Primary outcome is the level of paranoid ideations in daily life social situations, measured with ecological momentary assessments (EMA) at semi-random moments ten times a day during seven days, before and after treatment. Every session, participants and therapists will rate the level of paranoid ideation and global clinical impression.

DISCUSSION

Comparison of VRcbt and CBTp will provide information about the relative (cost-) effectiveness of VRcbt for this population. VRcbt may become a preferred psychological treatment for paranoid delusions and social anxiety in patients with psychotic disorder.

TRIAL REGISTRATION

Netherlands Trial Register, NL7758. Registered on 23 May 2019.

A network analysis of post-traumatic stress and psychosis symptoms

BACKGROUND

Understanding the interplay between trauma-related psychological mechanisms and psychotic symptoms may improve the effectiveness of interventions for post-traumatic stress reactions in psychosis. Network theory assumes that mental health problems persist not because of a common latent variable, but from dynamic feedback loops between symptoms, thereby addressing the heterogeneous and overlapping nature of traumagenic and psychotic diagnoses. This is a proof-of-concept study examining interactions between post-traumatic stress symptoms, which were hypothesized to reflect trauma-related psychological mechanisms, and auditory hallucinations and delusions.

METHOD

Baseline data from two randomised controlled trials (N = 216) of trauma-focused therapy in people with post-traumatic stress symptoms (87.5% met diagnostic criteria for PTSD) and psychotic disorder were analysed. Reexperiencing, hyperarousal, avoidance, trauma-related beliefs, auditory hallucinations and delusional beliefs were used to estimate a Gaussian graphical model along with expected node influence and predictability (proportion of explained variance).

RESULTS

Trauma-related beliefs had the largest direct influence on the network and, together with hypervigilance, were implicated in the shortest paths from flashbacks to delusions and auditory hallucinations.

CONCLUSIONS

These findings are in contrast to previous research suggesting a central role for re-experiencing, emotional numbing and interpersonal avoidance in psychosis. Trauma-related beliefs were the psychological mechanism most associated with psychotic symptoms, although not all relevant mechanisms were measured. This work demonstrates that investigating multiple putative mediators may clarify which processes are most relevant to trauma-related psychosis. Further research should use network modelling to investigate how the spectrum of traumatic stress reactions play a role in psychotic symptoms.

Task-related neural mechanisms of persecutory ideation in schizophrenia and community monozygotic twin-pairs

Perceptions of spiteful behavior are common, distinct from rational fear, and may undergird persecutory ideation. To test this hypothesis and investigate neural mechanisms of persecutory ideation, we employed a novel economic social decision‐making task, the Minnesota Trust Game (MTG), during neuroimaging in patients with schizophrenia (n = 30) and community monozygotic (MZ) twins (n = 38; 19 pairs). We examined distinct forms of mistrust, task‐related brain activation and connectivity, and investigated relationships with persecutory ideation. We tested whether co‐twin discordance on these measurements was correlated to reflect a common source of underlying variance. Across samples persecutory ideation was associated with reduced trust only during the suspiciousness condition, which assessed spite sensitivity given partners had no monetary incentive to betray. Task‐based activation contrasts for specific forms of mistrust were limited and unrelated to persecutory ideation. However, task‐based connectivity contrasts revealed a dorsal cingulate anterior insula network sensitive to suspicious mistrust, a left frontal–parietal (lF‐P) network sensitive to rational mistrust, and a ventral medial/orbital prefrontal (vmPFC/OFC) network that was sensitive to the difference between these forms of mistrust (all p < .005). Higher persecutory ideation was predicted only by reduced connectivity between the vmPFC/OFC and lF‐P networks (p = .005), which was only observed when the intentions of the other player were relevant. Moreover, co‐twin differences in persecutory ideation predicted co‐twin differences in both spite sensitivity and in vmPFC/OFC–lF‐P connectivity. This work found that interconnectivity may be particularly important to the complex neurobiology underlying persecutory ideation, and that unique environmental variance causally linked persecutory ideation, decision‐making, and brain connectivity.

A case study on a severe paranoid personality disorder client treated with metacognitive interpersonal therapy

Paranoid personality disorder (PPD) is a severe condition, lacking specialized and empirically supported treatment. To provide the clinician with insights into how to treat this condition, we present a case study of a 61-year-old man with severe PPD who presented with ideas of persecution, emotionally charged hostility, and comorbid antisocial personality disorder. The client was treated with 6 months of Metacognitive Interpersonal Therapy, which included: creating a shared formulation of his paranoid attitudes; trying to change his inner self-image of self-as-inadequate and his interpersonal schemas where he saw the others as threatening. Guided imagery and rescripting techniques, coupled with behavioral experiments, were used to promote a change. At the end of the therapy the client reported a reliable change in general symptomatology and, specifically, in interpersonal sensitivity, hostility, and paranoid ideation; he could no longer be diagnosed as PPD and only some paranoid and antisocial characteristics remained.