Jumping to conclusions and persecutory delusions

It is unknown whether a 'jumping to conclusions' (JTC) data-gathering bias is apparent in specific delusion sub-types. A group with persecutory delusions is compared with a sample of non-clinical controls on a probabilistic reasoning task. Results suggest JTC is apparent in individuals with the persecutory sub-type of delusions.     

Cognitive neuropsychiatric models of persecutory delusions

OBJECTIVE: The major cognitive theories of persecutory delusion formation and maintenance are critically examined in this article. METHOD: The authors present a comprehensive review of the literature, citing results of relevant functional neuroimaging and neural network studies. RESULTS: People with persecutory delusions selectively attend to threatening information, jump to conclusions on the basis of insufficient information, attribute negative events to external personal causes, and have difficulty in envisaging others' intentions, motivations, or states of mind. Presence of the "reality distortion" cluster of psychotic symptoms correlates with cerebral blood flow in the left lateral prefrontal cortex, ventral striatum, superior temporal gyrus, and parahippocampal region. Social cognitive processing (selective attention to threat, attribution of causation or mental states) in normal subjects involves similar areas. Neural network models of persecutory delusions highlight the importance of disordered neuromodulation in their formation and of disordered neuroplasticity in their maintenance. CONCLUSIONS: Further studies examining the interaction of these cognitive processes, cross-sectionally and longitudinally, at cognitive psychological, neural network, and functional neuroanatomical levels are warranted to establish a comprehensive cognitive neuropsychiatric model of the persecutory delusion.     

Attentional and memory bias in persecutory delusions and depression

BACKGROUND: Previous research has indicated that persecutory delusions and depression may share similar cognitive biases at implicit levels of processing, but differentiate at explicit levels, supporting the theory that paranoia may have a protective function against underlying negative schemata. The study aimed to investigate attentional bias and both implicit and explicit memory biases for personally salient and standardised emotional stimuli in persecutory delusions and depression. SAMPLING: 36 participants, with 12 in each group, were interviewed in order to generate personally salient stimuli to be employed within the cognitive tests. Standardised emotional stimuli were additionally employed as a control. Participants completed two probe detection tasks, one including personally salient stimuli and one including standard emotional stimuli. Memory for the stimuli presented in this task was assessed by a free recall task (explicit memory) followed by a word completion task (implicit memory). RESULTS: On an implicit memory task, both the deluded and depressed groups displayed comparable retrieval of positive and negative words. However, on the explicit memory task, the depressed group demonstrated a bias for negative stimuli, whereas the deluded group demonstrated a bias for positive stimuli. The groups did not demonstrate an attentional bias for personally salient information. However, an attentional bias for standardised emotional stimuli was found in the depressed group, although this was not specific to either negative or positive stimuli. CONCLUSION: The results indicate that depression and persecutory delusions may share similar patterns of processing at an implicit level but differentiate at the explicit level, which may be indicative of cognitive avoidance of threatening stimuli in psychosis. However, this does not seem to be a feature of automatic attentional processes in people with persecutory delusions. Implications for further research are discussed.     

Virtual reality and persecutory delusions: safety and feasibility

OBJECTIVE: Virtual reality (VR) has begun to be used to research the key psychotic symptom of paranoia. The initial studies have been with non-clinical individuals and individuals at high risk of psychosis. The next step is to develop the technology for the understanding and treatment of clinical delusions. Therefore the present study investigated the acceptability and safety of using VR with individuals with current persecutory delusions. Further, it set out to determine whether patients feel immersed in a VR social environment and, consequently, experience paranoid thoughts. METHOD: Twenty individuals with persecutory delusions and twenty non-clinical individuals spent 4 min in a VR underground train containing neutral characters. Levels of simulator sickness, distress, sense of presence, and persecutory ideation about the computer characters were measured. A one-week follow-up was conducted to check longer-term side effects. RESULTS: The VR experience did not raise levels of anxiety or symptoms of simulator sickness. No side effects were reported at the follow-up. There was a considerable degree of presence in the VR scenario for all participants. A high proportion of the persecutory delusions group (65%) had persecutory thinking about the computer characters, although this rate was not significantly higher than the non-clinical group. CONCLUSIONS: The study indicates that brief experiences in VR are safe and acceptable to people with psychosis. Further, patients with paranoia can feel engaged in VR scenes and experience persecutory thoughts. Exposure to social situations using VR has the potential to be incorporated into cognitive behavioural interventions for paranoia.     

Interpersonal attributional biases in hallucinatory-prone individuals

Research in the area of auditory hallucinations has found that the occurrence of a hallucinatory experience is mediated, in part, by a bias towards making an external attribution for private events and experiences. The current study examined whether external attributional biases in hallucinators extend to their interpretation of social-cognitive interpersonal events. University students scoring high and low on the Launay-Slade Hallucination Scale (LSHS) were compared on self-report measures of locus-of-control (LOC) orientation, psychosis proneness and on the Phares [Journal of Abnormal and Social Psychology 54 (1957) 339-342] "betting task" designed to encourage internal locus-of-control attributions. We predicted that high LSHS scorers would be less susceptible to a reinforcement paradigm designed to encourage internal locus-of-control judgments compared to low LSHS scorers. Consistent with our hypothesis, results revealed that hallucinatory predisposed individuals were less likely to show increased success expectancy following reinforcement and to decrease success expectancy following failure than were non-hallucinatory predisposed subjects. These findings suggest that hallucinatory-prone individuals not only make external attributions for private events and experiences, but are more likely to make external attributions to social-interpersonal events as well. We also found that subjects' severity of hallucinatory predisposition was significantly associated with their Chapman Magical Ideation and Perceptual Aberration scale scores. These results are consistent with past studies that suggest that hallucinatory subjects are more vulnerable to suggestion and support the notion that external loci of control over interpersonal experiences are associated with increased psychosis vulnerability.     

Advances in understanding and treating persecutory delusions: a review

Purpose

Persecutory delusions are a central psychotic experience, at the severe end of a paranoia spectrum in the general population. The aim of the review is to provide an introduction to the understanding of persecutory delusions, highlight key putative causal factors that have the potential to be translated into efficacious treatment, and indicate future research directions.

Methods

A narrative literature review was undertaken to highlight the main recent areas of empirical study concerning non-clinical and clinical paranoia.

Results

Six main proximal causal factors are identified: a worry thinking style, negative beliefs about the self, interpersonal sensitivity, sleep disturbance, anomalous internal experience, and reasoning biases. Each has plausible mechanistic links to the occurrence of paranoia. These causal factors may be influenced by a number of social circumstances, including adverse events, illicit drug use, and urban environments.

Conclusions

There have been numerous replicated empirical findings leading to a significant advance in the understanding of persecutory delusions, now beginning to be translated into cognitive treatments. The first trials specifically focussed on patients who have persecutory delusions in the context of psychotic diagnoses are occurring. Initial evidence of efficacy is very promising.     

Self-attacking and self-reassurance in persecutory delusions: A comparison of healthy,depressed and paranoid individuals

Previous research has found that reduced self-reassurance and heightened verbal ‘self-attacking’ of a sadistic and persecutory nature are both associated with greater subclinical paranoia. Whether these processes are also linked to clinical paranoia remains unclear. To investigate this further, we asked 15 people with persecutory delusions, 15 people with depression and 19 non-psychiatric controls to complete several self-report questionnaires assessing their forms and functions of self-attacking. We found that people with persecutory delusions engaged in more self-attacking of a hateful nature and less self-reassurance than non-psychiatric controls, but not people with depression. Participants with persecutory delusions were also less likely than both healthy and depressed participants to report criticising themselves for self-corrective reasons. Hateful self-attacking, reduced self-reassurance and reduced self-corrective self-criticism may be involved in the development or maintenance of persecutory delusions. Limitations, clinical implications and directions for future research are discussed.     

The relevance of self-esteem and self-schemas to persecutory delusions: A systematic review

Background

Self-esteem is frequently targeted in psychological approaches to persecutory delusions (PD). However, its precise role in the formation and maintenance of PD is unclear and has been subject to a number of theories: It has been hypothesized that PD function to enhance self-esteem, that they directly reflect negative conceptualizations of the self, that self-esteem follows from the perceived deservedness of the persecution (poor-me versus bad-me-paranoia) and that the temporal instability of self-esteem is relevant to PD. In order to increase our understanding of the relevance of self-esteem to PD, this article systematically reviews the existing research on self-esteem in PD in the light of the existing theories.

Methods

We performed a literature search on studies that investigated self-esteem in PD. We included studies that either investigated self-esteem a) within patients with PD or compared to controls or b) along the continuum of subclinical paranoia in the general population. We used a broad concept of self-esteem and included paradigms that assessed implicit self-esteem, specific self-schemas and dynamic aspects of self-esteem.

Results

The literature search identified 317 studies of which 52 met the inclusion criteria. The reviewed studies consistently found low global explicit self-esteem and negative self-schemas in persons with PD. The studies therefore do not support the theory that PD serve to enhance self-esteem but underline the theory that they directly reflect specific negative self-schemas. There is evidence that low self-esteem is associated with higher perceived deservedness of the persecution and that PD are associated with instable self-esteem. Only few studies investigated implicit self-esteem and the results of these studies were inconsistent.

Conclusions

We conclude by proposing an explanatory model of how self-esteem and PD interact from which we derive clinical implications.     

Suicidal ideation and behaviour in patients with persecutory delusions: Prevalence,symptom associations,and psychological correlates

BackgroundTo determine the prevalence of suicidal ideation and behaviour - and their correlates - in patients with persecutory delusions.Methods110 patients with persecutory delusions in the context of non-affective psychosis were assessed for suicidal thoughts and behaviours over the past month. Symptom and psychological assessments were also completed.ResultsThe severity of suicidal ideation was: no suicidal ideation (n = 26, 23.6%); wish to be dead (n = 21, 19.1%); nonspecific active suicidal thoughts (n = 14, 12.7%); suicidal thoughts with methods but no intent (n = 29, 26.4%); suicidal thoughts with intent but no specific plan (n = 13, 11.8%); and suicidal intent with plan (n = 7, 6.4%). In the past month, five patients (4.5%) had made an actual, interrupted, or aborted suicide attempt. The severity of suicidal ideation was associated with higher levels of depression, paranoia, hallucinations, anger, insomnia, negative beliefs about the self and others, pessimism, worry, and delusion safety-seeking behaviours and lower levels of psychological well-being and reward responsiveness. Severity of ideation was not associated with cannabis or alcohol use, working memory, pain, or meaningful activity levels.ConclusionsPatients with persecutory delusions are typically in a severe state of psychological stress, and at risk of suicide, as indicated by very high levels of suicidal ideation. This exploratory study also identifies correlates of suicidal ideation that could be investigated in causal research designs.     

The use of intuitive and analytic reasoning styles by patients with persecutory delusions

Background and objectivesA previous study has shown an association of paranoid thinking with a reliance on rapid intuitive (‘experiential’) reasoning and less use of slower effortful analytic (‘rational’) reasoning. The objectives of the new study were to replicate the test of paranoia and reasoning styles in a large general population sample and to assess the use of these reasoning styles in patients with persecutory delusions.Method30 Patients with persecutory delusions in the context of a non-affective psychotic disorder and 1000 non-clinical individuals completed self-report assessments of paranoia and reasoning styles.ResultsThe patients with delusions reported lower levels of both experiential and analytic reasoning than the non-clinical individuals (effect sizes small to moderate). Both self-rated ability and engagement with the reasoning styles were lower in the clinical group. Within the non-clinical group, greater levels of paranoia were associated with lower levels of analytic reasoning, but there was no association with experiential reasoning.LimitationsThe study is cross-sectional and cannot determine whether the reasoning styles contribute to the occurrence of paranoia. It also cannot be determined whether the patient group's lower reasoning scores are specifically associated with the delusions.ConclusionsClinical paranoia is associated with less reported use of analytic and experiential reasoning. This may reflect patients with current delusions being unconfident in their reasoning abilities or less aware of decision-making processes and hence less able to re-evaluate fearful cognitions. The dual process theory of reasoning may provide a helpful framework in which to discuss with patients decision-making styles.     

伴有被害妄想的精神分裂症患者症状归因风格研究

目的:探讨伴有被害妄想的精神分裂症患者症状归因风格及其相关影响因素。方法:采用精神分裂症症状归因问卷(SAQS)和简明精神病评定量表评估136例伴有被害妄想的精神分裂症患者(病例组),并与132名正常人(正常对照组)进行分析比较。结果:两组SAQS问卷中内在-外在、局部-整体和可控-不可控归因维度的组别效应显著(F=49.14,F=49.01,F=36.88;P均=0.00)。多元回归分析显示,患者内在-外在维度得分受首发年龄、病程、敌对性因子和宗教因素的影响(β=-0.205、-0.189、-0.556、-0.170;P0.001或P0.05);暂时-持久维度得分受住院次数、焦虑忧郁因子分和迟滞因子分的影响明显(β=0.313、0.342、-0.266;P0.05);局部-整体维度得分受敌对性因子分影响较大(β=0.227,P0.05)。结论:与正常人相比,伴有被害妄想的精神分裂症患者症状归因特点趋于外在的、整体的和不可控的归因风格,且可能会随某些因素的变化而发生改变。     

Examining cognitive biases in patients with delusions of reference

Cognitive biases may not be seen in all subtypes of delusions, and might be more involved in the etiology of some delusional subtypes than others. A sample of patients with delusions of reference did not show the jumping to conclusions (JTC) bias. JTC appears to be more closely related to paranoia than referential delusions.     

Attributional style in schizophrenia: an investigation in outpatients with and without persecutory delusions

The attributional style of outpatients with schizophrenia with and without persecutory delusions was investigated. Thirty individuals with schizophrenia were divided into persecutory-deluded and non-persecutory-deluded groups based on a score of 5 or higher on the suspiciousness item from the Expanded Brief Psychiatric Rating Scale (BPRS-E). The two resulting groups, and a nonclinical control group, were administered a battery of attributional measures, and their attributional responses were coded by both the subjects themselves and a pair of independent raters. The results showed evidence of a self-serving bias for subjects with persecutory delusions; however, this bias was not unique to those with persecutory delusions, and it disappeared when independent raters evaluated subjects' causal statements on a reliable measure of attributional style. Subjects with persecutory delusions tended to show a stronger bias toward blaming others rather than situations for negative outcomes, and there was a linear association between persecutory ideation and a self-serving attributional style. Finally, there were significant discrepancies between the attributional ratings of the persecutory-deluded subjects and those of independent judges. Implications for future research are discussed.     

A randomised controlled trial of a worry intervention for individuals with persistent persecutory delusions

Recent research has shown that worry is associated with distressing paranoia. Therefore, the aim was to target worry in a therapeutic intervention for individuals with delusions. It was predicted that a worry intervention would reduce levels of worry and paranoia distress. Twenty-four individuals with persistent persecutory delusions and high levels of worry were randomly assigned to receive a four session cognitive-behavioural worry intervention (W-CBT) or treatment as usual (TAU). The worry intervention was specifically designed not to target the content of delusions. In this open-label evaluation, assessments of worry and paranoia were conducted at baseline, at one month (end of treatment) and at two months. The worry intervention achieved a statistically significant reduction in worry which was maintained at two month follow up. A significant reduction in delusional distress was also reported. There was an indication that the worry intervention may also reduce the frequency of paranoid thoughts but this was not statistically significant. In the first trial specifically for persecutory delusions, a brief worry intervention was shown to have benefits. The results support a causal role for worry in paranoid experience.     

The influence of client socioeconomic status on psychotherapists' attributional biases and countertransference reactions

Clinical reaction related to client socioeconomic status has not been adequately researched, yet socioeconomic status can profoundly affect psychotherapist perceptions of a client's presenting concerns, symptom severity, and prognosis. Using an online national survey, this study examined the influence of client socioeconomic status on psychotherapist cognitive attributions and countertransference reactions (N = 141). Results revealed no significant differences in cognitive attributions based on socioeconomic status. However, significantly stronger countertransference reactions of being dominated by the client with a higher socioeconomic status were found. In addition, the clients with higher socioeconomic status were ascribed with mild problems compared with the client of lower socioeconomic status. Psychotherapeutic implications are discussed.     

A pilot trial of cognitive behavioural therapy for interpersonal sensitivity in individuals with persecutory delusions

BackgroundAdvances in understanding delusions may be used to improve clinical interventions. Interpersonal sensitivity – feeling vulnerable in the presence of others due to the expectation of criticism or rejection – has been identified as a potential causal factor in the occurrence of persecutory delusions. The purpose of this study was to examine the potential impact on persecutory delusions of a (newly devised) cognitive behavioural intervention targeting interpersonal sensitivity (CBT-IPS).MethodsCBT-IPS was tested in an uncontrolled pilot study with eleven patients with persistent persecutory delusions in the context of a psychotic disorder. Patients had two baseline assessments over a fortnight period to establish the stability of the delusions, which was followed by six sessions of CBT-IPS, a post-therapy assessment, and a further follow-up assessment one month later.ResultsInterpersonal sensitivity and the persecutory delusions were stable during the baseline period. At the post-therapy assessment there were significant reductions of large effect size for both interpersonal sensitivity and the persecutory delusions. These gains were maintained at follow-up.LimitationsThe main limitation is that in this initial test there was no control group. The intervention may not have caused the reduction in delusions. Further, bias may have been introduced by the outcome data being collected by the therapist.ConclusionsThe findings from this evaluation are consistent with the hypothesised causal role for interpersonal sensitivity in the occurrence of persecutory delusions. CBT-IPS shows promise as a therapeutic intervention but requires a rigorous test of its efficacy.     

Cognitive behavioural treatment of insomnia in individuals with persistent persecutory delusions: a pilot trial

Background and Objectives

Insomnia is a putative causal factor for persecutory thinking. Recent epidemiological studies show a strong association of insomnia and paranoia. The clinical implication is that reducing insomnia will reduce paranoid delusions. This study, evaluating for the first time the treatment of insomnia in individuals with persecutory delusions, provides a test of this hypothesis. It was predicted that a brief cognitive behavioural intervention for insomnia (CBT-I) for individuals with persistent persecutory delusions and sleep difficulties would not only reduce the insomnia but that it would also reduce the paranoia.

Methods

Fifteen patients with persistent persecutory delusions and insomnia in the context of a psychotic disorder were each individually given a standard-format, four-session CBT-I intervention. Outcome assessments were conducted at pre-treatment, post-treatment and one-month follow-up.

Results

There were no missing data. Following the intervention, significant reductions were found in levels of insomnia and the persecutory delusions. The effect sizes were large, and the changes were maintained at the follow-up. At least two-thirds of participants made substantial improvements in insomnia and approximately half showed substantial reductions in the persecutory delusions. There were also reductions in levels of anomalies of experience, anxiety and depression.

Limitations

The main limitations are the absence of a control group and unblinded assessments. A more methodologically rigorous evaluation of this intervention is now warranted.

Conclusions

These preliminary findings suggest that CBT-I can be used to treat insomnia in individuals with persecutory delusions and that, consistent with the hypothesised causal role, it also lessens the delusions.     

Targeting reasoning biases in delusions: a pilot study of the Maudsley Review Training Programme for individuals with persistent, high conviction delusions

Delusions are often resistant to change, persisting despite successful antipsychotic treatment or Cognitive Behavioural Therapy. This study aimed to target reasoning processes, particularly the ‘Jumping to Conclusions’ (JTC) bias and belief flexibility, which are thought to play a part in maintaining delusional conviction.13 participants with a diagnosis of psychosis and high levels of conviction in their delusions completed a one-off computerised training package, lasting approximately 1.5 h. Outcomes were assessed at baseline, pre-intervention (two weeks later), post-intervention (immediately after completing the training) and at 1 month follow-up.The package was well received by participants. There were improvements in JTC, belief flexibility and delusional conviction between pre- and post-intervention measures. Controlled studies powered to detect changes in key outcomes are warranted in order to evaluate the efficacy of the programme.     

Developing treatments of persistent persecutory delusions: the impact of an emotional processing and metacognitive awareness intervention

Worry has been implicated in increasing the levels of distress associated with persecutory delusions. It may partly cause this distress via the impediment of emotional processing of upsetting experiences. The clinical implication is that enhancing emotional processing of paranoid experiences will reduce distress. We therefore piloted a new brief intervention-the Emotional Processing and Metacognitive Awareness (EPMA)-on 12 patients with persistent persecutory delusions. The intervention was predominately influenced by written emotional disclosure and lasted for three sessions. The delusions were assessed at baseline, preintervention and postintervention and during a one-month follow-up. It was found that EPMA particularly reduced levels of delusion distress, and this was maintained at follow-up. The effect sizes were large but were likely overestimated given the absence of a control group and assessments that were not blind. These preliminary findings suggest that simply encouraging patients to talk, in the right way, about their delusions can be beneficial.     

The psychological effect of an urban environment on individuals with persecutory delusions: the Camberwell walk study

BACKGROUND: Epidemiological studies have found that individuals who live in urban areas are at increased risk of developing psychosis. However it is unknown whether exposure to urban environments exacerbates psychotic symptoms in people who have a diagnosed psychotic disorder. The aim of the study was to examine the psychological and clinical effects of exposure to one specific deprived urban environment on individuals with persecutory delusions. It was predicted that the urban environment would affect emotional and reasoning processes highlighted in a cognitive model of persecutory delusions and would increase paranoia. METHOD: Thirty patients with persecutory delusions were randomised to exposure to a deprived urban environment or to a brief mindfulness relaxation task. After exposure, assessments of symptoms, reasoning, and affective processes were taken. Thirty matched non-clinical participants also completed the study measures to enable interpretation of the test scores. RESULTS: In individuals with persecutory delusions, exposure to the urban environment, rather than participation in a mindfulness task, increased levels of anxiety, negative beliefs about others and jumping to conclusions. It also increased paranoia. The individuals with persecutory delusions scored significantly differently from the non-clinical group on all measures. CONCLUSIONS: For individuals with psychosis, spending time in an urban environment makes them think more negatively about other people and increases anxiety and the jumping to conclusions reasoning bias. Their paranoia is also increased. A number of processes hypothesised in cognitive models to lead to paranoid thoughts are exacerbated by a deprived urban environment. Further research is needed to clarify which aspects of urban environments cause the negative effects. Methodological challenges in the research area are raised.