External Shame as a Mediator between Paranoia and Social Safeness in Psychosis

Experiencing Psychosis and Shame: A Systematic Review and Meta-analysis of the Strength and Patterns of Association

BACKGROUND AND HYPOTHESIS

Shame has been linked to the experience of psychosis, with implications for clinical outcomes, however, a meta-analysis of the relationship has not yet been conducted. This systematic review and meta-analysis aimed to examine the strength of the association between shame and psychosis, and any variations between clinical and non-clinical populations and shame type (internal vs external shame).

STUDY DESIGN

Searches were conducted in CINAHL, EMBASE, PsycInfo, PubMed, Scopus, and Web of Science from the inception of the e-databases until July 2023. For inclusion, studies reported a quantitative association between psychosis and shame, or data that could be used to identify a relationship. From 11 372 unique retrieved records, 40 articles met the inclusion criteria and 38 were included in the meta-analyses.

STUDY RESULTS

A significant large pooled estimate of the psychosis-shame association was identified (Zr = 0.36, [95% CI: 0.28, 0.44], P < .001), indicating that higher levels of shame were associated with greater severity of psychotic symptoms. The strength of the association was similar across clinical and non-clinical populations, however, differed by type of shame and psychosis symptom measured. External shame was strongly associated with paranoia suggesting possible confounding. Only a minority of studies met the highest quality criteria.

CONCLUSIONS

Shame is strongly associated with the severity of psychotic symptoms in clinical and non-clinical populations. Given the overlap with paranoia, measurement of external shame alone is not advised. Larger studies in clinical populations, with measures of a range of psychosis symptoms, are needed to better understand the relationship between shame and specific symptoms.

Racism and psychosis: an umbrella review and qualitative analysis of the mental health consequences of racism

Black people and People of Color are disproportionately affected by racism and show increased rates of psychosis. To examine whether racialized migrant groups are particularly exposed to racism and therefore have higher risks for psychosis, this paper (1) systematically assesses rates of psychosis among racialized migrant groups concerning the country of origin, and (2) analyzes interviews regarding the association of racism experiences with psychosis-related symptoms in racialized Black people and People of Color populations in Germany. We present an umbrella review of meta-analyses that report the incidence of positive symptoms (e.g., hallucinations and delusions) and negative symptoms (e.g., apathy and incoherent speech) of diagnosed schizophrenia, other non-affective psychotic disorders (e.g., schizoaffective disorder) or first-episode psychosis among migrants by country of origin. We also report 20 interviews with first- and second-generation migrants racialized as Black and of Color in Germany to capture and classify their experiences of racism as well as racism-associated mental health challenges. In the umbrella review, psychosis risk was greatest when migration occurred from developing countries. Effect size estimates were even larger among Caribbean and African migrants. In the qualitative study, the application of the constant comparative method yielded four subordinate themes that form a subclinical psychosis symptomatology profile related to experiences of racism: (1) a sense of differentness, (2) negative self-awareness, (3) paranoid ideation regarding general persecution, and (4) self-questioning and self-esteem instability. We here provide converging evidence from a quantitative and qualitative analysis that the risk of poor mental health and psychotic experiences is related to racism associated with minority status and migration.

Moral Emotions and Social Economic Games in Paranoia

Impaired social cognitive processes are putative psychological mechanisms implicated in the formation and maintenance of paranoid beliefs. Paranoia denotes unfounded fears about the hostile intentions of others and is prevalent in a significant proportion of the general population. We investigated social cognition in healthy participants selectively recruited to have a broad occurrence of paranoid thinking (n = 89). Participants completed a novel computerized task of moral emotions and two social economic exchange games (Prisoner's Dilemma, Ultimatum Game) from the EMOTICOM neuropsychological test battery. Regression analyses revealed that delusional ideation predicted shameful feelings when the victim of deliberate harm by another person. Cooperative behavior on the Prisoner's Dilemma was greatest when the participant and opponent contributed equally to joint earnings. Participants demonstrated significantly more punishment behavior when contributions were unequal and stole more from the opponent using a suspicious strategy of gameplay. In addition, paranoid thinking was positively associated with more stealing from the cooperative opponent. On the Ultimatum Game, participants accepted significantly more unequal offers when the opponent contributed more and sensitivity to fairness was greatest when the participant contributed more. These data demonstrate that delusional ideation predicts a maladaptive emotional response to interpersonal harm and that paranoid thinking may lead to reduced cooperation toward mutual reward. The effects of paranoia on moral emotions and pro-social behavior at more severe levels of persecutory thinking warrant further investigation.

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.