When paranoia fails to enhance self-esteem: explicit and implicit self-esteem and its discrepancy in patients with persecutory delusions compared to depressed and healthy controls

The hypothesis that persecutory delusions function to enhance self-esteem implies that patients will show normal explicit, but low implicit self-esteem. As evidence for this has been inconsistent, our study assessed delusional state, explicit and implicit self-esteem and depression in a large sample (n=139) of schizophrenia patients with acute persecutory delusions (n=28), patients with remitted persecutory delusions (n=31), healthy controls (n=59), and depressed controls (n=21). Patients with delusions and patients with depression both showed decreased levels of explicit, but normal levels of implicit self-esteem when compared to healthy controls. The direct comparison of levels of explicit and implicit self-esteem within each group revealed that healthy controls had higher explicit than implicit self-esteem, while the converse pattern was found for depressed controls. No discrepancy between explicit and implicit self-esteem was found for acute deluded or remitted patients with schizophrenia. Although these findings do not support the hypothesis that delusions serve to enhance self-esteem, they underline the relevance of low self-esteem in patients with persecutory delusions and point to the necessity of enhancing self-esteem in therapy.     

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.     

Emotion and psychosis: links between depression, self-esteem, negative schematic beliefs and delusions and hallucinations

BACKGROUND: The role of emotion in psychosis is being increasingly recognised. Cognitive conceptualisations of psychosis (e.g. [Garety, P.A., Kuipers, E.K., Fowler, D., Freeman, D., Bebbington, P.E., 2001. A cognitive model of the positive symptoms of psychosis. Psychological Medicine, 31, 189-195]) emphasise a central, normal, direct and non-defensive role for negative emotion in the development and maintenance of psychosis. This study tests specific predictions made by Garety et al. [Garety, P.A., Kuipers, E.K., Fowler, D., Freeman, D., Bebbington, P.E., 2001. A cognitive model of the positive symptoms of psychosis. Psychological Medicine, 31, 189-195] about the role of emotion and negative evaluative beliefs in psychosis. METHODS: 100 participants who had suffered a recent relapse in psychosis were recruited at baseline for the Prevention of Relapse in Psychosis (PRP) trial. In a cross-sectional analysis, we examined the role of depression, self-esteem and negative evaluative beliefs in relation to specific positive symptoms (persecutory delusions, auditory hallucinations and grandiose delusions) and symptom dimensions (e.g. distress, negative content, pre-occupation and conviction). RESULTS: Analysis indicated that individuals with more depression and lower self-esteem had auditory hallucinations of greater severity and more intensely negative content, and were more distressed by them. In addition, individuals with more depression, lower self-esteem and more negative evaluations about themselves and others had persecutory delusions of greater severity and were more pre-occupied and distressed by them. The severity of grandiose delusions was related inversely to depression scores and negative evaluations about self, and directly to higher self-esteem. CONCLUSIONS: This study provides evidence for the role of emotion in schizophrenia spectrum-disorders. Mood, self-esteem and negative evaluative beliefs should be considered when conceptualising psychosis and designing interventions.     

Implicit and explicit self-schema in active deluded, remitted deluded, and depressed patients

The main objective of this study was to analyze the hypothesis that patients with persecutory delusions would show a depressive-type self-concept when assessed with implicit measures of self-schema (i.e., a free recall test of self-relevant adjectives) but would show a normal self-concept when assessed with explicit measures (i.e., a self-concept questionnaire and a task requiring endorsement of self-relevant adjectives). The sample consisted of 136 participants (40 acute deluded participants, 25 remitted deluded participants, 35 depressed patients and 36 normal controls). Our results revealed that both groups of deluded participants showed no significant discrepancy between explicit and implicit measures of self-concept. These findings do not support the hypothesis of an implicit negative cognitive schema in persecutory deluded participants.     

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.     

Paranoid delusions in schizophrenia spectrum disorders and depression: the transdiagnostic role of expectations of negative events and negative self-esteem

We aimed to identify transdiagnostic psychological processes associated with persecutory delusions. Sixty-eight schizophrenia patients, 47 depressed patients, and 33 controls were assessed for paranoia, positive and negative self-esteem, estimations of the frequency of negative, neutral, and positive events occurring to the self in the past and in the future and similar estimates for events affecting others in the future. Negative self-esteem and expectations of negative events were strongly associated with paranoia in all groups. Currently deluded patients were asked to rate whether their persecution was deserved on an analogue scale. Mean deservedness scores were higher in deluded-depressed patients than deluded-schizophrenia patients, but patients in both groups used the full range of scores. The findings indicate that negative self-esteem and negative expectations independently contribute to paranoia, but do not support a simple categorical distinction between poor-me (persecution undeserved) and bad-me (persecution deserved) patients.     

Persecutory delusions: a cybernetic model.

The authors propose a cybernetic model for the formation and maintenance of persecutory delusions. During the formation of persecutory ideation, the threat of loss of control over the self or others interacts with predictions of control from others. This interaction may result in feelings of alien control followed by persecutory explanations. Since the persecutory explanations provide the individual with a new goal of resisting others' influence in order to prevent being controlled, they reduce the threat of loss of self-control. This is how persecutory delusions are maintained.     

Persecutory delusions and the self-serving bias. Evidence from a contingency judgment task.

The self-serving attributional bias was studied in matched groups of patients with persecutory delusions, patients with major affective disorder, and normal controls, (N = 14 in each group). On a preprogrammed computer task, subjects mainly won points in one condition and mainly lost points in the other. Subjects were asked to estimate the degree of control they thought they had over winning or losing in the two conditions. In comparison with the normal subjects and the psychiatric controls, the deluded subjects showed a greater self-serving bias, as evidenced by their perceived greater control over outcomes in the win condition. These findings are interpreted as consistent with the hypothesis that persecutory delusions function as a defense against low self-esteem.     

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.     

Attributional style in delusional patients: a comparison of remitted paranoid, remitted nonparanoid, and current paranoid patients with nonpsychiatric controls

Many studies have found that people experiencing persecutory delusions have a marked tendency to use external-personal attributions when establishing the causes of negative events. Although nonclinical populations also tend to attribute negative events to external causes, those causes are typically believed to be universal in nature, rather than personal. The central goal of the present study was to investigate whether individuals with remitted persecutory delusions would display this external-personal bias regarding negative events, in comparison to remitted patients whose delusions were not paranoid in nature and to nonpsychiatric controls. Results indicate that currently paranoid patients were significantly more likely than all other groups, including the remitted paranoid group, to use external-personal attributions in negative events. Interestingly, all patient groups also were found to be significantly more likely than the controls to use internal-personal and internal-universal attributions when explaining negative events.     

Psychological processes underlying delusional thinking in late-onset psychosis: a preliminary investigation

BACKGROUND AND AIMS: It has been suggested that delusions may serve as a defence against negative self-representations. The present study investigated general psychological well-being and evidence for defensive emotional processes among people with late-onset psychosis. METHOD: The performance and responses of older people with late-onset psychosis (n = 13), older people with depression (n = 15), and age-matched healthy controls (n = 15) were compared in a cross-sectional design. Participants rated their own levels of depression and self-esteem, and completed an emotional Stroop task to establish whether there was evidence of implicit depression in the absence of explicit acknowledgement. Participants rated themselves on a number of personal attributes in relation to two life stages to generate discrepancies in 'actual', 'ideal' and 'other' self-concepts, and completed measures of their perceptions of current and past psychological well-being. RESULTS: People with late-onset psychosis showed no evidence of overt depression or low-self esteem. All three groups showed an attentional bias to depression-related and age-related words, although response times overall were faster for controls. The psychosis group showed no discrepancies between either their past or their current 'actual' and 'other' self-concepts, suggesting that they do not have more negative views about how others see them. CONCLUSIONS: Evidence from this study does not support the application of the 'delusion-as-defence' model to late-onset psychosis, but methodological constraints must be borne in mind when interpreting the findings.     

Implicit self-esteem in bulimia nervosa

Implicit and explicit self-esteem were compared in a group of female participants with bulimia nervosa or binge eating disorder (n = 20) and a healthy control group (n = 20). Lower explicit and a less positive implicit self-esteem bias in the clinical group was predicted. Participants completed a self-esteem implicit association test and two explicit self-esteem measures. The eating disordered group had lower explicit self-esteem, but a more positive implicit self-esteem bias than controls. The results are discussed in relation to the idea that discrepancies between implicit and explicit self-esteem reflect fragile self-esteem and are related to high levels of perfectionism, which is associated with eating disorders.     

Implicit cognitive processes in binge-eating disorder and obesity

ObjectivesBinge-eating disorder (BED) is characterized by recurrent binge eating episodes, associated eating disorder and general psychopathology, and commonly occurs in obese individuals. Explicit self-esteem and explicit weight bias have been linked to BED, while little is known about implicit cognitive processes such as implicit self-esteem and implicit weight bias.MethodsObese participants with BED and an individually matched obese only group (OB) and normal weight control group (CG; each N = 26) were recruited from the community to examine group differences and associations in explicit and implicit self-esteem and weight bias, as well as the impact of implicit cognitive processes on global eating disorder psychopathology. Implicit cognitive processes were assessed using the Implicit Association Test.ResultsSignificantly lower explicit self-esteem, as well as higher exposure to explicit weight bias, compared to CG and OB was found in the BED group. All groups showed positive implicit self-esteem, however, it was significantly lower in BED when compared to CG. BED and CG demonstrated equally high implicit weight bias whereas OB did not. Explicit and implicit measures were not significantly correlated. Global eating disorder psychopathology was predicted by explicit and implicit self-esteem.ConclusionsThe results of the present study add to the importance of implicit self-esteem and implicit weight bias beyond explicit measures in BED, while both were previously shown to be associated with onset and maintenance of BED. In conclusion, implicit cognitive processes should be focused on in interventions for BED to investigate their impact on psychological treatments.     

Implicit self-esteem in recurrently depressed patients

Negative self-esteem is suggested to play an important role in the recurrence of depressive episodes. This study investigated whether repeated experiences of a negative view of the self within a recurrent course of depression might cause implicit self-esteem to be impaired and negative self-attributes to even be chronically activated beyond remission. We measured implicit self-esteem using an Implicit Association Test. The sample consisted of N = 24 currently depressed patients with first-onset depressive episode, N = 28 currently depressed patients with recurrent depressive episodes, N = 33 currently remitted patients with recurrent depressive episodes, and N = 34 controls with no history of depression. In line with cognitive theories, results revealed significantly lower implicit self-esteem in current depressive patients than in healthy controls but no significant differences in implicit self-esteem between remitted recurrent depressive patients and healthy controls. However, remitted depressive patients with three or more depressive episodes showed a significantly lower implicit self-esteem than those with less than three depressive episodes. The current findings underline the necessity of relapse prevention treatments which not only enhance self-esteem at an explicit but also at an implicit level as well as emphasizing the need for evaluations of treatment efficacy to focus upon both implicit and explicit levels of self-esteem.     

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.     

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.     

Grandiose delusions: an experimental investigation of the delusion as defense

Two distinct roles for emotion in the development of delusions have been outlined. Some authors argue that delusions defend against low self-esteem and negative emotion (the delusion-as-defense account). Other authors hypothesize that delusions are not a defense but are a direct reflection of emotion and associated processes (the emotion-consistent account). An empirical investigation was conducted of the delusion-as-defense account with reference to grandiose delusions. Twenty individuals with grandiose delusions and 21 individuals without mental illness were compared on overt and covert measures of self-esteem. No evidence for a discrepancy between overt and covert self-esteem in individuals with grandiose delusions was found. One potential interpretation of the results is that the tasks were not able to penetrate defensive processes. However, we argue that in this group, the grandiose delusions do not currently defend against low self-esteem. Instead, grandiose delusions may in part be direct exaggerations of the emotional state of individuals.     

When grandiosity and vulnerability collide: Implicit and explicit self-esteem in patients with narcissistic personality disorder

BACKGROUND AND OBJECTIVES: Narcissistic personality disorder (NPD) is characterized by reports of grandiosity including exaggerated illusions of superiority and entitlement (DSM-IV-TR, APA, 2000). Based on clinical theories (e.g., Kernberg, 1975), many researchers argue that high explicit self-esteem in narcissists masks underlying implicit vulnerability (low implicit self-esteem). Conversely, based on social learning theories (i.e., Millon, 1981), people with NPD are characterized by implicit grandiosity (high implicit self-esteem). We test these competing hypotheses in patients diagnosed with NPD. METHODS: The present study examined implicit self-esteem (using an Implicit Association Test) and explicit self-esteem (using a self-report questionnaire) in patients with NPD in comparison to non-clinical and clinical, non-NPD (Borderline Personality Disorder, BPD) control groups. RESULTS: Patients with NPD scored lower on explicit self-esteem than non-clinical controls. In comparison to patients with BPD, NPD patients scored higher on explicit and implicit self-esteem. Moreover, within the group of NPD patients, damaged self-esteem (i.e., low explicit, high implicit) was associated with higher narcissistic psychopathology. LIMITATIONS: In both clinical groups we included participants seeking psychiatric treatment, which might influence explicit self-esteem. Longitudinal studies are needed to further assess self-esteem stability in NPD patients in comparison to the control groups. CONCLUSIONS: Our findings are indicative of vulnerable facets in patients with NPD (i.e., low explicit self-esteem). Furthermore, damaged self-esteem is connected to specific psychopathology within the NPD group. Implications for research on NPD are discussed.     

Current Paranoid Thinking in Patients With Delusions: The Presence of Cognitive-Affective Biases

Background: There has been renewed interest in the influence of affect on psychosis. Psychological research on persecutory delusions ascribes a prominent role to cognitive processes related to negative affect: anxiety leads to the anticipation of threat within paranoia; depressive negative ideas about the self create a sense of vulnerability in which paranoid thoughts flourish; and self-consciousness enhances feelings of the self as a target. The objective of this study was to examine such affective processes in relation to state paranoia in patients with delusions. Methods: 130 patients with delusions in the context of a nonaffective psychosis diagnosis (predominately schizophrenia) were assessed for contemporaneous levels of persecutory ideation on 5 visual analog scales. Measures were taken of anxiety, depression, threat anticipation, interpretation of ambiguity, self-focus, and negative ideas about the self. Results: Of the patients, 85% report paranoid thinking at testing. Symptoms of anxiety and depression were highly prevalent. Current paranoid thinking was associated with anxiety, depression, greater anticipation of threat events, negative interpretations of ambiguous events, a self-focused cognitive style, and negative ideas about the self. Conclusions: The study provides a clear demonstration that a range of emotion-related cognitive biases, each of which could plausibly maintain delusions, are associated with current paranoid thinking in patients with psychosis. We identified biases both in the contents of cognition and in the processing of information. Links between affect and psychosis are central to the understanding of schizophrenia. We conclude that treatment of emotional dysfunction should lead to reductions in current psychotic experiences.Key words: delusions, paranoia, cognition, anxiety, depression, schizophrenia     

Paranoia, persecutory delusions and attributional biases

An influential model of persecutory delusions put forward by Bentall and colleagues hypothesizes that persecutory-deluded patients avoid the activation of negative self-beliefs by making externalising, personalising attributions for negative events. The first study reported here used a new instrument for the measurement of persecutory ideation, the Paranoid, Persecutory and Delusion-Proneness Questionnaire, to investigate whether attributional biases are associated with subclinical persecutory ideation. The second study extended this investigation by re-examining associations between attributional biases and persecutory delusions. Both studies used the Internal, Personal and Situational Attributions Questionnaire to measure attributional style. No evidence was found for a connection between attributional biases and subclinical persecutory ideation. Furthermore, there was no support for an association between persecutory delusions and an externalising bias, and only marginal support for the hypothesized relationship between persecutory delusions and a personalising bias. These results suggest that the putative link between persecutory ideation and attributional biases only manifests (if at all) when persecutory ideation is of delusional intensity, and that it is confined to a personalising bias.