Measurement invariance of the Revised-Green Paranoid Thought Scale across Black and White Americans

Given the culturally diverse landscape of mental healthcare and research, ensuring that our psychological constructs are measured equivalently across diverse populations is critical. One construct for which there is significant potential for inequitable assessment is paranoia, a prominent feature in psychotic disorders that can also be driven by culture and racial marginalization. This study examined measurement invariance-an analytic technique to rigorously investigate whether a given construct is being measured similarly across groups-of the Revised-Green Paranoid Thought Scale (R-GPTS; Freeman et al., 2021) across Black and White Americans in the general population. Racial group differences in self-reported paranoia were also examined. The analytic sample consisted of 480 non-Hispanic White and 459 non-Hispanic Black Americans. Analyses demonstrated full invariance (i.e., configural, metric, and scalar invariance) of the R-GPTS across groups, indicating that the R-GPTS appropriately captures self-reported paranoia between Black and White Americans. Accordingly, it is reasonable to compare group endorsement: Black participants endorsed significantly higher scores on both the ideas of reference and ideas of persecution subscales of the R-GPTS (Mean ± SD = 10.91 ± 7.12 versus 8.21 ± 7.17 and Mean ± SD = 10.18 ± 10.03 versus 6.35 ± 8.35, for these subscales respectively). Generalized linear modeling revealed that race remained a large and statistically significant predictor of R-GPTS total score (β = -0.38756, p < 0.001) after controlling for relevant demographic factors (e.g., sex, age). This study addresses a critical gap within the existing literature as it establishes that elevations in paranoia exhibited by Black Americans in the R-GPTS reflect actual differences between groups rather than measurement artifacts.

[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.

Rethinking paranoid ideation and reasoning: A pilot study based on the argumentative theory of reasoning

BACKGROUND AND OBJECTIVES

Cognitive theories assume an imbalance of intuitive and analytical reasoning in paranoid ideation. The argumentative theory of reasoning offers an approach on the primary function of reasoning and its flaws. It assumes social exchange as main purpose of reasoning. We applied this theory to delusion research and tested experimentally whether social exchange in the form of production and evaluation of arguments influences subsequent reflective reasoning. Additionally, we examined whether the social network and the frequency/preference for discussions are associated with distorted reflective reasoning and paranoid ideation.

METHODS

327 participants completed the Social Network Index (SNI), the Paranoia Checklist (PCL), and the Cognitive Reflection Test-2 (CRT2). Moreover, preference and frequency of discussions were assessed. In the discussion group (N = 165), participants produced arguments and evaluated counterarguments on two socially relevant topics. The control group (N = 162) watched a nature video instead.

RESULTS

The discussion group showed lower distorted reflective reasoning than the control group. Discussion preference and/or frequency was associated with frequency and disturbance of paranoid thoughts, as well as overall paranoid ideation.

LIMITATIONS

Due to the online format environmental factors could not be held constant and no intrasubject comparison of the CRT2 could be computed in the trial. Furthermore, the sample mainly consisted of psychology students.

CONCLUSION

The results contribute to the understanding of distorted reflective reasoning and provides preliminary evidence that the argumentative theory of reasoning may offer a promising perspective for delusion research.

Sexual abuse and psychotic phenomena: a directed acyclic graph analysis of affective symptoms using English national psychiatric survey data

BACKGROUND

Sexual abuse and bullying are associated with poor mental health in adulthood. We previously established a clear relationship between bullying and symptoms of psychosis. Similarly, we would expect sexual abuse to be linked to the emergence of psychotic symptoms, through effects on negative affect.

METHOD

We analysed English data from the Adult Psychiatric Morbidity Surveys, carried out in 2007 (N = 5954) and 2014 (N = 5946), based on representative national samples living in private households. We used probabilistic graphical models represented by directed acyclic graphs (DAGs). We obtained measures of persecutory ideation and auditory hallucinosis from the Psychosis Screening Questionnaire, and identified affective symptoms using the Clinical Interview Schedule. We included cannabis consumption and sex as they may determine the relationship between symptoms. We constrained incoming edges to sexual abuse and bullying to respect temporality.

RESULTS

In the DAG analyses, contrary to our expectations, paranoia appeared early in the cascade of relationships, close to the abuse variables, and generally lying upstream of affective symptoms. Paranoia was consistently directly antecedent to hallucinations, but also indirectly so, via non-psychotic symptoms. Hallucinosis was also the endpoint of pathways involving non-psychotic symptoms.

CONCLUSIONS

Via worry, sexual abuse and bullying appear to drive a range of affective symptoms, and in some people, these may encourage the emergence of hallucinations. The link between adverse experiences and paranoia is much more direct. These findings have implications for managing distressing outcomes. In particular, worry may be a salient target for intervention in psychosis.

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.

Conspiracy mentality, subclinical paranoia, and political conservatism are associated with perceived status threat

Status threat (i.e., concern that one's dominant social group will be undermined by outsiders) is a significant factor in current United States politics. While demographic factors such as race (e.g., Whiteness) and political affiliation (e.g., conservatism) tend to be associated with heightened levels of status threat, its psychological facets have yet to be fully characterized. Informed by a "paranoid" model of American politics, we explored a suite of possible psychological and demographic associates of perceived status threat, including race/ethnicity, political conservatism, analytic thinking, magical ideation, subclinical paranoia, and conspiracy mentality. In a small, quota sample drawn from the United States (N = 300), we found that conspiracy mentality, subclinical paranoia, conservatism, and age were each positively (and uniquely) associated with status threat. In addition to replicating past work linking conservatism to status threat, this study identifies subclinical paranoia and conspiracy mentality as novel psychological associates of status threat. These findings pave the way for future research regarding how and why status threat concerns may become exaggerated in certain individuals, possibly to the detriment of personal and societal wellbeing.

Experimental studies of paranoid thinking in clinical and nonclinical populations: a systematic review and meta-analysis

Paranoia is common in clinical and nonclinical populations, consistent with continuum models of psychosis. A number of experimental studies have been conducted that attempt to induce, manipulate or measure paranoid thinking in both clinical and nonclinical populations, which is important to understand causal mechanisms and advance psychological interventions. Our aim was to conduct a systematic review and meta-analysis of experimental studies (non-sleep, non-drug paradigms) on psychometrically assessed paranoia in clinical and nonclinical populations. The review was conducted using PRISMA guidelines. Six databases (PsycINFO, PubMed, EMBASE, Web of Science, Medline and AMED) were searched for peer-reviewed experimental studies using within and between-subject designs to investigate paranoia in clinical and nonclinical populations. Effect sizes for each study were calculated using Hedge's g and were integrated using a random effect meta-analysis model. Thirty studies were included in the review (total n = 3898), which used 13 experimental paradigms to induce paranoia; 10 studies set out to explicitly induce paranoia, and 20 studies induced a range of other states. Effect sizes for individual studies ranged from 0.03 to 1.55. Meta-analysis found a significant summary effect of 0.51 [95% confidence interval 0.37-0.66, p < 0.001], indicating a medium effect of experimental paradigms on paranoia. Paranoia can be induced and investigated using a wide range of experimental paradigms, which can inform decision-making about which paradigms to use in future studies, and is consistent with cognitive, continuum and evolutionary models of paranoia.

Temporal pathways from attachment insecurity to paranoia in a heterogeneous clinical sample: An experience sampling study

INTRODUCTION

There has been growing interest in the role of attachment mechanisms in the onset and maintenance of paranoia. The latest systematic reviews of mixed samples of healthy individuals and psychiatric patients have revealed that increased trait attachment anxiety and avoidance are associated with experiencing paranoia, with trait attachment anxiety showing a stronger association. Few studies have examined attachment and paranoia in naturalistic conditions via the Experience Sampling Method.

OBJECTIVES

The present study examined whether experiences of attachment anxiety and avoidance fluctuate in the flow of daily life, and whether a within-person change in both attachment states precedes the experience of momentary paranoia, and negative and positive emotions.

METHODS

Thirty-seven clinical participants and twenty-six healthy controls were studied over six consecutive days using the Experience Sampling Method (ESM). An experience-in-close-relationships questionnaire (ECR-R 16 SF) was used to capture trait attachment dimensions. Several ESM items were used to capture momentary negative and positive affect, paranoia and attachment insecurity states.

RESULTS

The findings revealed that fluctuations in both attachment insecurity states were significantly higher in the clinical group. A prior elevated attachment anxiety and avoidance was followed by an increase in negative affect in the next moment and elevated attachment avoidance was additionally followed by a decrease in positive affect and an increase in paranoia.

CONCLUSION

Our findings reveal the specific temporal associations between momentary attachment insecurity states as predictors of change in emotions/affects and paranoia, along with evidence that state attachment avoidance has a superior impact on momentary affect and paranoia compared to state attachment anxiety. These results contrast with those of recent cross-sectional studies.

Are paranoid ideation and hallucination spectrum experiences differently associated with affect dynamics? A continuous-time modeling approach

Psychotic experiences have been associated with distortions in affective functioning, including aberrancies in affect dynamics. However, it remains unclear whether the two principal symptom dimensions of psychosis, namely paranoid ideation and hallucination spectrum experiences, are differently associated with affect dynamics, and whether associations hold after statistically controlling for depressive symptoms. We investigate this by using a novel statistical approach, the hierarchical Ornstein-Uhlenbeck (OU) process model. This is a continuous-time stochastic differential equations model in a Bayesian framework that describes dynamics in affective valence and arousal via three core parameters: attractor point, variability, and attractor strength. In a community sample with varying levels of psychotic experiences (n = 116), we measured affective valence and arousal 10 times per day for 7 days, using the experience-sampling method. We found-while statistically controlling for depressive symptoms-credible between-subjects associations between paranoid ideation and attractor points of negative valence and high arousal. We also found a credible positive association between hallucination spectrum experiences and arousal variability. Limited evidence emerged for small associations between paranoid ideation and high valence variability as well as between paranoid ideation and high attractor strengths of valence and arousal. Hallucination spectrum experiences showed some evidence for a small association with high arousal attractor points. The detailed picture of affect dynamics provided by the OU model reveals different cross-sectional affective profiles associated with paranoid ideation versus hallucination spectrum experiences that suggest different affective mechanisms of their formation and maintenance. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Cognitive flexibility and emotion regulation: Dual layers of resilience against the emergence of paranoia

Cognitive inflexibility has been linked to difficulties in revising paranoid beliefs, whereas cognitive flexibility may protect against the development and maintenance of paranoid beliefs by allowing for troubleshooting in light of available evidence. While less discussed in the context of paranoia research, better regulation of affective states may reduce the likelihood of biased beliefs developing in the first place, reducing the burden on belief updating mechanisms. The present study hypothesized that high cognitive flexibility and strong emotion regulation ability may act as a reciprocal protective shield against the risk associated with lower ability in the other domain. Participants were recruited from the general population (N = 221) to complete the Ambiguous Interpretation Inflexibility Task, as well as self-report measures for paranoia and emotion regulation ability. The results show an interaction between cognitive flexibility and emotion regulation ability as related to less severe paranoia. Better emotion regulation ability is associated with lower paranoia in individuals with lower cognitive flexibility, whereas higher cognitive flexibility is associated with less severe paranoia in individuals with greater emotion regulation difficulties. These findings highlight the importance of emotion regulation in early interventions of paranoia, especially how emotion regulation relates to known cognitive vulnerabilities such as inflexibility.

Cognitive bias modification for paranoia (CBM-pa): a randomised controlled feasibility study in patients with distressing paranoid beliefs

BACKGROUND

Cognitive Bias Modification for paranoia (CBM-pa) is a novel, theory-driven psychological intervention targeting the biased interpretation of emotional ambiguity associated with paranoia. Study objectives were (i) test the intervention's feasibility, (ii) provide effect size estimates, (iii) assess dose-response and (iv) select primary outcomes for future trials.

METHODS

In a double-blind randomised controlled trial, sixty-three outpatients with clinically significant paranoia were randomised to either CBM-pa or an active control (text reading) between April 2016 and September 2017. Patients received one 40 min session per week for 6 weeks. Assessments were given at baseline, after each interim session, post-treatment, and at 1- and 3-months post-treatment.

RESULTS

A total of 122 patients were screened and 63 were randomised. The recruitment rate was 51.2%, with few dropouts (four out of 63) and follow-up rates were 90.5% (1-month) and 93.7% (3-months). Each session took 30-40 min to complete. There was no statistical evidence of harmful effects of the intervention. Preliminary data were consistent with efficacy of CBM-pa over text-reading control: patients randomised to the intervention, compared to control patients, reported reduced interpretation bias (d = -0.48 to -0.76), improved symptoms of paranoia (d = -0.19 to -0.38), and lower depressed and anxious mood (d = -0.03 to -0.29). The intervention effect was evident after the third session.

CONCLUSIONS

CBM-pa is feasible for patients with paranoia. A fully powered randomised control trial is warranted.

Body image concerns in patients with persecutory delusions

BACKGROUND

Persecutory fears build on feelings of vulnerability that arise from negative views of the self. Body image concerns have the potential to be a powerful driver of feelings of vulnerability. Body image concerns are likely raised in patients with psychosis given the frequent weight gain. We examined for the first-time body esteem - the self-evaluation of appearance - in relation to symptom and psychological correlates in patients with current persecutory delusions.

METHODS

One-hundred and fifteen patients with persecutory delusions in the context of non-affective psychosis completed assessments of body image, self-esteem, body mass index (BMI), psychiatric symptoms and well-being. Body esteem was also assessed in 200 individuals from the general population.

RESULTS

Levels of body esteem were much lower in patients with psychosis than non-clinical controls (d = 1.2, p < 0.001). In patients, body esteem was lower in women than men, and in the overweight or obese BMI categories than the normal weight range. Body image concerns were associated with higher levels of depression (r = -0.55, p < 0.001), negative self-beliefs (r = -0.52, p < 0.001), paranoia (r = -0.25, p = 0.006) and hallucinations (r = -0.21, p = 0.025). Body image concerns were associated with lower levels of psychological wellbeing (r = 0.41, p < 0.001), positive self-beliefs (r = 0.40, p < 0.001), quality of life (r = 0.23, p = 0.015) and overall health (r = 0.31, p = 0.001).

CONCLUSIONS

Patients with current persecutory delusions have low body esteem. Body image concerns are associated with poorer physical and mental health, including more severe psychotic experiences. Improving body image for patients with psychosis is a plausible target of intervention, with the potential to result in a wide range of benefits.

"Green et al. Paranoid Thoughts Scale-revised": Structural invariance and clinical utility of a brief version in schizophrenia

OBJECTIVE

Persecutory ideas are highly frequent in psychotic disorders and particularly in schizophrenia. Although several measures exist to assess persecutory ideas in both clinical and non-clinical samples, there is a need for brief and psychometrically sound measures to capture the multidimensional aspects of paranoia in people diagnosed with schizophrenia. Our aim was to validate a brief version of the revised Green et al., Paranoid Thoughts Scale (R-GPTS) in schizophrenia in order to minimize time-consuming assessment.

METHODS

100 individuals with schizophrenia and 72 non-clinical controls were recruited. We used the GPTS-8, a brief 8-item version of the R-GPTS recently developed and validated in the French general population. Psychometric properties of the scale were investigated including its factor structure, internal consistency, and convergent/divergent validities.

RESULTS

Confirmatory factor analysis supported the original two-factor structure (social reference and persecution subscales) of the GPTS-8. The GPTS-8 was positively and moderately correlated with the Positive and Negative Syndrome Scale (PANSS) suspiciousness item indicating good internal consistency. Concerning divergent validity, no correlations were found between the GPTS-8 and the Montreal cognitive assessment (MoCA). Importantly patients with schizophrenia reported higher scores on the GTPS-8 than controls demonstrating its clinical validity.

CONCLUSIONS

The French GPTS 8-item brief scale-8 retains the psychometric strengths of the R-GPTS in schizophrenia with relevant clinical validity. The GPTS-8 can consequently be used as a short and quick measure of paranoid ideations in individuals with a diagnosis of schizophrenia.

A preliminary study examining terminology used by individuals with lived experience describing beliefs about being targeted or harmed by others

While recent studies have prompted re-evaluation of the term "schizophrenia," few have examined the use of terms to describe persecutory ideation (PI) or paranoia. This study examines the preferences and terms used by a cross-diagnostic population of individuals (N = 184) with lived experience using an online survey. Participants most commonly described their PI in terms of the perceived source of threat, followed by clinical language, most commonly variants of "paranoia" and "anxiety." Of five selected terms assessed quantitatively - "anxiety," "paranoia," "persecutory thoughts," "suspiciousness," and "threat thoughts" - participants were more likely to report that "anxiety" aligned with their experience of PI, followed by "suspiciousness." Endorsement of terms more specific to PI was associated with self-report PI severity, while a preference for "anxiety" over other terms was both associated with less severe PI and lower scores on a measure of stigma. These results suggest that the heterogeneity of terms used by individuals with lived experience support a person-centered approach to language describing such experiences.

Aberrant adapting of beliefs under stress: a mechanism relevant to the formation of paranoia?

BACKGROUND

Difficulties in the ability to adapt beliefs in the face of new information are associated with psychosis and its central symptom - paranoia. As cognitive processes and psychotic symptoms are both known to be sensitive to stress, the present study investigated the exact associations between stress, adapting of beliefs [reversal learning (RL), bias against disconfirmatory evidence (BADE), and jumping to conclusions (JTC)] and paranoia. We hypothesized that paranoia would increase under stress and that difficulties in adapting of beliefs would mediate or moderate the link between stress and paranoia. Furthermore, we hypothesized that the investigated effects would be strongest in the group of individuals diagnosed with a psychotic disorder.

METHODS

We exposed 155 participants (38 diagnosed with a psychotic disorder, 40 individuals with attenuated psychotic symptoms, 39 clinical controls diagnosed with an obsessive-compulsive disorder, and 38 healthy controls) to a control condition and a stress condition, in which we assessed their levels of paranoia and their ability to adapt beliefs. We applied multilevel models to analyze the data.

RESULTS

Paranoia was higher in the stress condition than in the control condition, b = 1.142, s.e. = 0.338, t(150) = 3.381, p < 0.001. RL, BADE, and JTC did not differ between conditions and did not mediate or moderate the association between stress and paranoia (all p_s > 0.05).

CONCLUSIONS

The results support the assumption that stress triggers paranoia. However, the link between stress and paranoia does not seem to be affected by the ability to adapt beliefs.

Genetic and Geographical Associations With Six Dimensions of Psychotic Experiences in Adolesence

BACKGROUND AND HYPOTHESIS

Large-scale epidemiological and genetic research have shown that psychotic experiences in the community are risk factors for adverse physical and psychiatric outcomes. We investigated the associations of six types of specific psychotic experiences and negative symptoms assessed in mid-adolescence with well-established environmental and genetic risk factors for psychosis.

STUDY DESIGN

Fourteen polygenic risk scores (PRS) and nine geographical environmental variables from 3590 participants of the Twins Early Development Study (mean age 16) were associated with paranoia, hallucinations, cognitive disorganization, grandiosity, anhedonia, and negative symptoms scales. The predictors were modeled using LASSO regularization separately (Genetic and Environmental models) and jointly (GE model).

STUDY RESULTS

In joint GE models, we found significant genetic associations of negative symptoms with educational attainment PRS (β = -.07; 95% CI = -0.12 to -0.04); cognitive disorganization with neuroticism PRS (β = .05; 95% CI = 0.03-0.08); paranoia with MDD (β = .07; 95% CI = 0.04-0.1), BMI (β = .05; 95% CI = 0.02-0.08), and neuroticism PRS (β = .05; 95% CI = 0.02-0.08). From the environmental measures only family SES (β = -.07, 95% CI = -0.10 to -0.03) and regional education levels (β = -.06; 95% CI = -0.09 to -0.02) were associated with negative symptoms.

CONCLUSIONS

Our findings advance understanding of how genetic propensity for psychiatric, cognitive, and anthropometric traits, as well as environmental factors, together play a role in creating vulnerability for specific psychotic experiences and negative symptoms in mid-adolescence.

Childhood trauma and real-world social experiences in psychosis

BACKGROUND

Childhood trauma is associated with a variety of negative outcomes in psychosis, but it is unclear clear if childhood trauma affects day-to-day social experiences. We aimed to examine the association between childhood trauma and functional and structural characteristics of real-world social relationships in psychosis.

METHODS

Participants with psychotic disorders or affective disorders with psychosis completed ecological momentary assessments (EMAs) over ten days (N = 209). Childhood trauma was assessed retrospectively using the Childhood Trauma Questionnaire. Associations between childhood trauma and EMA-assessed social behavior and perceptions were examined using linear mixed models. Analyses were adjusted for sociodemographic characteristics and psychotic and depressive symptom severity.

RESULTS

Higher levels of childhood trauma were associated with more perceived threat (B = -0.19, 95 % CI [-0.33, -0.04]) and negative self-perception (B = -0.18, 95 % CI [-0.34, -0.01]) during recent social interactions, as well as reduced social motivation (B = -0.29, 95 % CI [-0.47, -0.10]), higher desire for social avoidance (B = 0.34, 95 % CI [0.14, 0.55]), and lower sense of belongingness (B = -0.24, 95 % CI [-0.42, -0.06]). These negative social perceptions were mainly linked with emotional abuse and emotional neglect. In addition, paranoia was more strongly associated with negative social perceptions in individuals with high versus low levels of trauma. Childhood trauma was not associated with frequency (i.e., time spent alone) or type of social interactions.

CONCLUSION

Childhood trauma - particularly emotional abuse and neglect - is associated with negative social perceptions but not frequency of real-world social interactions. Our findings suggest that childhood trauma may affect day-to-day social experiences beyond its association with psychosis.

Belief Updating and Paranoia in Individuals With Schizophrenia

BACKGROUND

Persecutory delusions are among the most common delusions in schizophrenia and represent the extreme end of the paranoia continuum. Paranoia is accompanied by significant worry and distress. Identifying cognitive mechanisms underlying paranoia is critical for advancing treatment. We hypothesized that aberrant belief updating, which is related to paranoia in human and animal models, would also contribute to persecutory beliefs in individuals with schizophrenia.

METHODS

Belief updating was assessed in 42 participants with schizophrenia and 44 healthy control participants using a 3-option probabilistic reversal learning task. Hierarchical Gaussian Filter was used to estimate computational parameters of belief updating. Paranoia was measured using the Positive and Negative Syndrome Scale and the revised Green et al. Paranoid Thoughts Scale. Unusual thought content was measured with the Psychosis Symptom Rating Scale and the Peters et al. Delusions Inventory. Worry was measured using the Dunn Worry Questionnaire.

RESULTS

Paranoia was significantly associated with elevated win-switch rate and prior beliefs about volatility both in schizophrenia and across the whole sample. These relationships were specific to paranoia and did not extend to unusual thought content or measures of anxiety. We observed a significant indirect effect of paranoia on the relationship between prior beliefs about volatility and worry.

CONCLUSIONS

This work provides evidence that relationships between belief updating parameters and paranoia extend to schizophrenia, may be specific to persecutory beliefs, and contribute to theoretical models implicating worry in the maintenance of persecutory delusions.

Interactions between attributions and beliefs at trial-by-trial level: Evidence from a novel computer game task

Inferring causes of the good and bad events that we experience is part of the process of building models of our own capabilities and of the world around us. Making such inferences can be difficult because of complex reciprocal relationships between attributions of the causes of particular events, and beliefs about the capabilities and skills that influence our role in bringing them about. Abnormal causal attributions have long been studied in connection with psychiatric disorders, notably depression and paranoia; however, the mechanisms behind attributional inferences and the way they can go awry are not fully understood. We administered a novel, challenging, game of skill to a substantial population of healthy online participants, and collected trial-by-trial time series of both their beliefs about skill and attributions about the causes of the success and failure of real experienced outcomes. We found reciprocal relationships that provide empirical confirmation of the attribution-self representation cycle theory. This highlights the dynamic nature of the processes involved in attribution, and validates a framework for developing and testing computational accounts of attribution-belief interactions.

As part of interpreting our experiences, we spontaneously make causal attributions and use them to update our beliefs about the world, ourselves and others. This has long been a topic of interest, particularly within psychiatry. Some theories assume that people have stable “attributional styles”, others focus on the changing nature of attribution-making and on the relationships between attributions and one’s beliefs about the self, suggesting that the two are mutually connected. In this area of research, people have traditionally been asked to imagine themselves experiencing various significant life events and report on how they would interpret those, or have been exposed to artificial and highly simplified situations in the lab. In this work, we introduce a new task to study relationships between causal attributions and beliefs: repeatedly playing an engaging and relatively complex game of skill. We show that we can detect mutual influences between attributions and beliefs at the level of individual wins and losses. This has implications for how everyday successes and failures impact our beliefs about ourselves and our well-being. It also could help understand how our interpretations of negative experiences can spiral out of control, affecting our mental health.

The computational relationship between reinforcement learning, social inference, and paranoia

Theoretical accounts suggest heightened uncertainty about the state of the world underpin aberrant belief updates, which in turn increase the risk of developing a persecutory delusion. However, this raises the question as to how an agent’s uncertainty may relate to the precise phenomenology of paranoia, as opposed to other qualitatively different forms of belief. We tested whether the same population (n = 693) responded similarly to non-social and social contingency changes in a probabilistic reversal learning task and a modified repeated reversal Dictator game, and the impact of paranoia on both. We fitted computational models that included closely related parameters that quantified the rigidity across contingency reversals and the uncertainty about the environment/partner. Consistent with prior work we show that paranoia was associated with uncertainty around a partner’s behavioural policy and rigidity in harmful intent attributions in the social task. In the non-social task we found that pre-existing paranoia was associated with larger decision temperatures and commitment to suboptimal cards. We show relationships between decision temperature in the non-social task and priors over harmful intent attributions and uncertainty over beliefs about partners in the social task. Our results converge across both classes of model, suggesting paranoia is associated with a general uncertainty over the state of the world (and agents within it) that takes longer to resolve, although we demonstrate that this uncertainty is expressed asymmetrically in social contexts. Our model and data allow the representation of sociocognitive mechanisms that explain persecutory delusions and provide testable, phenomenologically relevant predictions for causal experiments.

Paranoia, self-deception and overconfidence

Self-deception, paranoia, and overconfidence involve misbeliefs about the self, others, and world. They are often considered mistaken. Here we explore whether they might be adaptive, and further, whether they might be explicable in Bayesian terms. We administered a difficult perceptual judgment task with and without social influence (suggestions from a cooperating or competing partner). Crucially, the social influence was uninformative. We found that participants heeded the suggestions most under the most uncertain conditions and that they did so with high confidence, particularly if they were more paranoid. Model fitting to participant behavior revealed that their prior beliefs changed depending on whether the partner was a collaborator or competitor, however, those beliefs did not differ as a function of paranoia. Instead, paranoia, self-deception, and overconfidence were associated with participants' perceived instability of their own performance. These data are consistent with the idea that self-deception, paranoia, and overconfidence flourish under uncertainty, and have their roots in low self-esteem, rather than excessive social concern. The model suggests that spurious beliefs can have value-self-deception is irrational yet can facilitate optimal behavior. This occurs even at the expense of monetary rewards, perhaps explaining why self-deception and paranoia contribute to costly decisions which can spark financial crashes and devastating wars.

The relationship between psychological symptom ratings and crime in juvenile justice system involved young people

RATIONALE

Prior research has not adequately examined the relationship between psychological state and offending. Limitations include over-reliance on criminal convictions as the dependent variable, failure to examine a comprehensive set of psychological states, the limited nature of measures and the frequent use of cross-sectional data that cannot ensure temporal ordering.

AIMS

To explore the relationship between five self-reported psychological states-anxiety, depression, hostility, paranoia and psychoticism-and three types of offending-violent, non-violent and marijuana use-reported 6 months later in a sample of justice system involved young people.

METHODS

Data were acquired from the publicly available Pathways to Desistance dataset, a longitudinal study of 1262 young people (86% male) involved in the criminal justice system. Measures of psychological state were self-reported using the Brief Symptom Inventory at project entry and self-report offending measures 6 months later.

RESULTS

No psychological states were significantly associated with reports of marijuana use and depression was not related to offending. Anger and paranoia each predicted an increased variety of violent and non-violent offending, while anxiety and psychoticism each increased the variety of violent but not non-violent offending. Clinically significant states on one or more sub-scales were related to variety of both violent and non-violent offending.

IMPLICATIONS

These results suggest that early screening of psychological state may help identify young people at risk for offending. Further research might be directed at clarifying the extent of actual disorder and the nature of interventions that would best help not only those with a diagnosable disorder, but also those with aspects of their psychological state which trouble them, but which may not actually amount to disorder.

Reduction in social learning and increased policy uncertainty about harmful intent is associated with pre-existing paranoid beliefs: Evidence from modelling a modified serial dictator game

Current computational models suggest that paranoia may be explained by stronger higher-order beliefs about others and increased sensitivity to environments. However, it is unclear whether this applies to social contexts, and whether it is specific to harmful intent attributions, the live expression of paranoia. We sought to fill this gap by fitting a computational model to data (n = 1754) from a modified serial dictator game, to explore whether pre-existing paranoia could be accounted by specific alterations to cognitive parameters characterising harmful intent attributions. We constructed a ‘Bayesian brain’ model of others’ intent, which we fitted to harmful intent and self-interest attributions made over 18 trials, across three different partners. We found that pre-existing paranoia was associated with greater uncertainty about other’s actions. It moderated the relationship between learning rates and harmful intent attributions, making harmful intent attributions less reliant on prior interactions. Overall, the magnitude of harmful intent attributions was directly related to their uncertainty, and importantly, the opposite was true for self-interest attributions. Our results explain how pre-existing paranoia may be the result of an increased need to attend to immediate experiences in determining intentional threat, at the expense of what is already known, and more broadly, they suggest that environments that induce greater probabilities of harmful intent attributions may also induce states of uncertainty, potentially as an adaptive mechanism to better detect threatening others. Importantly, we suggest that if paranoia were able to be explained exclusively by core domain-general alterations we would not observe differential parameter estimates underlying harmful-intent and self-interest attributions.

A great deal of work has tried to explain paranoia through general cognitive principles, although relatively little has tried to understand whether paranoia may be explained by specific changes to social learning processes. This question is crucial, as paranoia is inherently a social phenomenon, and requires mechanistic explanations to match with its dynamic phenomenology. In this paper we wanted to test whether pre-existing and live paranoid beliefs about others specifically altered how an individual attributed harmful intent–the live expression of paranoia–to partners over a series of live interactions. To do this we applied a novel computational model and network analysis to behavioural data from a large sample of participants in the general population that had played a modified Dictator game online, and required them to attribute whether the behaviour of their partner was due to their intent to harm, or their self-interest, on two mutually exclusive scales. Pre-existing paranoid beliefs about others reduced the value of new partner behaviours on evolving attributions of harmful intent. We suggest that both pre-existing paranoid beliefs and momentary paranoia may incur an adaptive cognitive state to better track potentially threatening others, and demonstrate phenomenological specificity associated with mechanisms of live paranoia.

The Dunn Worry Questionnaire and the Paranoia Worries Questionnaire: new assessments of worry

BACKGROUND

The cognitive process of worry, which keeps negative thoughts in mind and elaborates the content, contributes to the occurrence of many mental health disorders. Our principal aim was to develop a straightforward measure of general problematic worry suitable for research and clinical treatment. Our secondary aim was to develop a measure of problematic worry specifically concerning paranoid fears.

METHODS

An item pool concerning worry in the past month was evaluated in 250 non-clinical individuals and 50 patients with psychosis in a worry treatment trial. Exploratory factor analysis and item response theory (IRT) informed the selection of scale items. IRT analyses were repeated with the scales administered to 273 non-clinical individuals, 79 patients with psychosis and 93 patients with social anxiety disorder. Other clinical measures were administered to assess concurrent validity. Test-retest reliability was assessed with 75 participants. Sensitivity to change was assessed with 43 patients with psychosis.

RESULTS

A 10-item general worry scale (Dunn Worry Questionnaire; DWQ) and a five-item paranoia worry scale (Paranoia Worries Questionnaire; PWQ) were developed. All items were highly discriminative (DWQ a = 1.98-5.03; PWQ a = 4.10-10.7), indicating small increases in latent worry lead to a high probability of item endorsement. The DWQ was highly informative across a wide range of the worry distribution, whilst the PWQ had greatest precision at clinical levels of paranoia worry. The scales demonstrated excellent internal reliability, test-retest reliability, concurrent validity and sensitivity to change.

CONCLUSIONS

The new measures of general problematic worry and worry about paranoid fears have excellent psychometric properties.

Does hallucination perceptual modality impact psychosis risk?

OBJECTIVE

Subthreshold perceptual abnormalities are commonly used to identify individuals at clinical high risk (CHR) for developing a psychotic disorder. Predictive validity for modality-specific perceptual abnormality severity on psychosis risk is unknown.

METHODS

We examined prospectively collected data from 164 individuals age 12-35 meeting criteria for CHR followed for 6-24 months or until conversion to psychosis. Using intake interview notes, baseline perceptual abnormality scores were split into auditory, visual, somatic/tactile, and olfactory/gustatory components, and auditory scores were further split into those for verbal vs non-verbal content. Relationships between perceptual abnormality characteristics and conversion were assessed with Cox proportional hazards regression and logistic regression.

RESULTS

Unusual thought content and paranoia were predictive of conversion, but no modality-specific perceptual abnormality score predicted conversion status or days to conversion. However, when auditory perceptual abnormalities were further categorized as verbal vs non-verbal, the severity of verbal experiences was predictive of conversion to psychosis (P = 0.007).

CONCLUSIONS

Perceptual abnormality scores failed to meaningfully predict conversion to psychosis in either direction in this CHR sample. However, verbal auditory experiences may identify a group of CHR individuals at elevated risk of conversion. Further exploration of the relationship between phenomenological aspects of perceptual abnormalities and conversion risk is warranted.

Cultural differences in positive psychotic experiences assessed with the Community Assessment of Psychic Experiences-42 (CAPE-42): a comparison of student populations in the Netherlands, Nigeria and Norway

BACKGROUND

Previous studies have suggested that culture impacts the experience of psychosis. The current study set out to extend these findings by examining cultural variation in subclinical positive psychotic experiences in students from The Netherlands, Nigeria, and Norway. Positive psychotic experiences were hypothesized to (i) be more frequently endorsed by, and (ii) cause less distress in Nigerian vs. Dutch and Norwegian students.

METHODS

Psychology students, aged 18 to 30 years, from universities in the Netherlands (n = 245), Nigeria (n = 478), and Norway (n = 162) were assessed cross-sectionally with regard to the frequency of subclinical positive psychotic experiences and related distress, using the Community Assessment of Psychic Experiences (CAPE-42). Multi-group confirmatory factor analysis and multivariate analysis of covariance were performed to assess measurement invariance of the positive symptom dimension (CAPE-Pos) and compare mean frequency and associated distress of positive psychotic experiences across study samples.

RESULTS

Only CAPE-Pos items pertaining to the dimensions 'strange experiences' and 'paranoia' met assumptions for (partial) measurement invariance. Frequencies of these experiences were higher in the Nigerian sample, compared to both the Dutch and Norwegian samples, which were similar. In addition, levels of experience-related distress were similar or higher in the Nigerian sample compared to respectively the Dutch and Norwegian samples.

CONCLUSION

Although positive psychotic experiences may be more commonly endorsed in non-Western societies, our findings do not support the notion that they represent a more benign, and hence less distressing aspect of human experience. Rather, the experience of psychotic phenomena may be just as, if not more, distressing in African than in European culture. However, observed differences in CAPE-Pos frequency and distress between samples from different cultural settings may partly reflect differences in the measure rather than in the latent trait. Future studies may therefore consider further cross-cultural adaptation of CAPE-42, in addition to explicitly examining cultural acceptance of psychotic phenomena, and environmental and other known risk factors for psychosis, when comparing and interpreting subclinical psychotic phenomena across cultural groups.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Impulse control disorders in patients with prolactinoma receiving dopamine agonist therapy: a prospective study with 1 year follow-up

OBJECTIVE

To assess prospectively the prevalence of impulse control disorders (ICD), psychiatric symptoms, and their clinical correlates in patients with prolactinoma receiving dopamine agonists (DA) in comparison to those with non-functioning pituitary adenomas (NFA) and healthy controls (HC).

METHODS

A total of 25 patients with prolactinoma, 31 with NFA, and 32 HCs were included in the study. All patients and controls were screened for the presence of ICDs and other psychiatric disorders using revised version of Minnesota Impulsive Disorders Interview (MIDI-R), Barratt Impulsiveness Scale (BIS-11), Symptom Check List (SCL-90-R) questionnaire and Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI).

RESULTS

We detected two new cases (8%) of ICD associated with DAs. Both cases presented with hypersexuality, which reversed totally or decreased upon discontinuation of the drug. The re-challenge of the DA in a smaller dose has led to either no symptoms or weaker symptoms than before. There was an increase in the number of patients who screened positive on obsession, interpersonal sensitivity, paranoid ideation, and additional items subscales of SCL-90-R in comparison to HCs at the end of the study period (p < 0.05 for all). Likewise, cumulative DA dose was positively correlated to obsession, interpersonal sensitivity, paranoid ideation, hostility, phobic anxiety subscales, and GSI scores of SCL-90-R (p < 0.05 for all).

CONCLUSIONS

DAs are associated with a small but substantial short-term risk of ICD development and a broad range of psychiatric symptoms in patients with prolactinoma receiving DAs.

Preliminary study of effects on paranoia ideation and jumping to conclusions in the context of group treatment of anxiety disorders in young people

BACKGROUND

People with anxiety disorders tend to focus on unpleasant and threatening stimuli. Our aims were to evaluate: (1) the presence of paranoid ideation, and the jumping to conclusions (JTC) bias in young suffering from an anxiety disorder and (2) the effectiveness of a cognitive-behavioural intervention (CBT) to manage anxiety combined with 2 modules to reduce the JTC bias.

METHODS

Psychopathology, social functioning, metacognition and the JTC bias were investigated in 60 subjects, randomly assigned to the experimental CBT group + treatment-as-usual (TAU) (n = 35) or to a wait-list group (n = 25) receiving only TAU. Each group was divided into 2 subgroups based on the score of the SCL-90 subscale paranoid ideation (high paranoid ideation, HP; low paranoid ideation, LP). The experimental group received a weekly session of a CBT for a 3-month period.

RESULTS

At baseline, 46.7% of our sample showed a HP and 38% showed a JTC biasAt the end of the intervention, greater effectiveness in improving anxious symptoms, paranoid ideation, interpersonal sensitivity and interpersonal relationship was reported in the experimental CBT + TAU group, with a statistically significant reduction of the JTC bias, displayed by 14.3% of the experimental group versus the 36% of the TAU group. In the same variables, greater benefits were reported for the HP experimental subgroup.

CONCLUSIONS

Our study suggests the gains to integrate an anxiety CBT with modules to reduce the JTC bias in subjects with paranoid ideation, which may negatively impact the course of the disease.

The network structure of paranoia in the general population

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Conflict and cooperation in paranoia: a large-scale behavioural experiment

BACKGROUND

Paranoia involves thoughts and beliefs about the harmful intent of others but the social consequences have been much less studied. We investigated whether paranoia predicts maladaptive social behaviour in terms of cooperative and punitive behaviour using experimental game theory paradigms, and examined whether reduced cooperation is best explained in terms of distrust as previous studies have claimed.

METHODS

We recruited a large population sample (N = 2132) online. All participants completed the Green et al. Paranoid Thoughts Scale and (i) a Dictator Game and (ii) an Ultimatum Game, the former with an option for costly punishment. Following distrust-based accounts, we predicted highly paranoid people would make higher offers when the outcome depended on receiving a positive response from their partner (Ultimatum Game) but no difference when the partner's response was irrelevant (Dictator Game). We also predicted paranoia would increase punitive responses. Predictions were pre-registered in advance of data collection. Data and materials are open access.

RESULTS

Highly paranoid participants actually made lower offers than non-paranoid participants both in the Dictator Game and in the Ultimatum Game. Paranoia positively predicted punitive responses.

CONCLUSIONS

These findings suggest that distrust is not the best explanation for reduced cooperation in paranoia and alternative explanations, such as increased self-interest, may apply. However, the tendency to attribute harmful intent to partners was important in motivating punitive responses. These results highlight differing motivations underlying adverse social behaviour in paranoia and suggest that accounts based solely on the presenting features of paranoia may need to be rethought.

Association between perceived level of stress, clinical characteristics and psychopathological symptoms in women with systemic lupus erythematosus

OBJECTIVES

To evaluate psychopathological status and stress level from a sample with SLE; compare mental functioning and stress levels between women with SLE and healthy women; determine whether disease duration, disease activity, cumulative organ damage and stress have an influence on psychopathological symptoms in SLE patients; and evaluate whether perception of stress is related to SLE severity.

METHODS

We conducted a cross-sectional study of 425 participants; 202 women with SLE, with an average age (SD) of 36.61 (10.15), and 223 healthy women, with age-matched controls. The assessment included the clinical characteristics (disease duration, SLE activity, cumulative organ damage, pharmacotherapy), the Symptom Checklist-90-Revised (SCL-90-R) and the Perceived Stress Scale. Descriptive, comparative, univariate and multivariate analysis were performed.

RESULTS

SLE patients showed psychopathological alterations in the somatisation, obsessive-compulsive and positive discomfort subscales of SCL-90-R. Women with SLE reported significantly higher scores on the psychopathological dimensions and perceived stress compared to healthy women, except for paranoid ideation. Disease duration, SLE activity, cumulative organ damage, and perceived stress were shown to be significant predictors of psychopathological manifestations, explaining a range, between 20 and 43%, of variance across SCL-90-R dimensions. Moreover, perceived stress was related to SLE activity, after controlling for psychopathological dimensions.

CONCLUSIONS

The psychopathological manifestations in SLE appeared to be influenced by perceived stress, disease duration, disease activity and cumulative organ damage. In turn, perceived stress was associated with disease severity. This knowledge may contribute to a more comprehensive perspective of these manifestations in the SLE population in the clinical setting.

Social Identity and Psychosis: Associations and Psychological Mechanisms

Humans possess a basic need to belong and will join groups even when they provide no practical benefit. Paranoid symptoms imply a disruption of the processes involved in belonging and social trust. Past research suggests that joining social groups and incorporating those groups into one's identity (social identification) promotes positive self-views and better physical and mental health. However, no research has investigated whether social identity is associated with paranoia, nor the mechanisms by which this effect may emerge. Here, we examined the relationship between social identity and mental health (paranoia, auditory verbal hallucinations [AVHs], and depression), and tested the mediating role of self-esteem. In study 1, we analyzed data collected from 4319 UK residents as part of the NIHR CLAHRC NWC Household Health Survey. Study 2 comprised data collected from 1167 students attending a large UK university. The studies provided convergent evidence that social identification reduces symptoms of paranoia and depression by furnishing people with self-esteem. There was no consistent effect of social identification on AVHs. People developing mental health assessments, treatments, and policies are encouraged to consider the notion that joining and identifying with social groups may reduce people's risk of paranoia and depression.

Incorporation of an invasive object

The author discusses the experience of 'being invaded' that is sometimes communicated by certain severely disturbed patients. The complaint can sometimes be couched in terms of bodily suffering and such patients may state that they have the experience of a 'foreign body' inside. It is suggested that these patients have suffered severe early failure of containment of their projections, while at the same time they have incorporated primitive characteristics of the object that have been powerfully projected into them. An object that invades in this way, it is suggested, experiences a compulsive need to expel unbearable states of mind using others as a repository. The infant incorporates these violent projections as part of his own mental representational system, and normal identification processes are disrupted. There follows impairment of the development of the sense of self. Clinical examples of how the invasive experience manifests itself in the analytic setting and in the transference and countertransference are presented. It is argued that this highly complex form of early subject-object interaction (prior to the differentiation of psyche-soma) is more likely to be found in severely narcissistically disturbed individuals. Some reflections on the origins of invasive phenomena are given.

Substance Use and Self-Harm: Case Studies From Patients Admitted to an Urban Hospital Following Medically Serious Self-Harm

Few qualitative studies have explored the relationship between substance use and self-harm. We employed a multiple-case study research design to analyze data from 80 patients who were admitted to a hospital in South Africa following self-harm. Our analysis revealed, from the perspective of patients, a number of distinct ways in which substance use is implicated in self-harm. Some patients reported that substance intoxication resulted in poor decision making and impulsivity, which led to self-harm. Others said substance use facilitated their self-harm. Some participants detailed how in the past their chronic substance use had served an adaptive function helping them to cope with distress, but more recently, this coping mechanism had failed which precipitated their self-harm. Some participants reported that substance use by someone else triggered their self-harm. Findings suggest that there are multiple pathways and a host of variables which mediate the relationship between substance use and self-harm.

Cognitive Bias Modification for paranoia (CBM-pa): study protocol for a randomised controlled trial

BACKGROUND

Persecutory delusions are the most common type of delusions in psychosis and present in around 10-15% of the general population. Persecutory delusions are thought to be sustained by biased cognitive and emotional processes. Recent advances favour targeted interventions, focussing on specific symptoms or mechanisms. Our aim is to test the clinical feasibility of a novel psychological intervention, which manipulates biased interpretations toward more adaptive processing, in order to reduce paranoia in patients.

METHODS

The 'Cognitive Bias Modification for paranoia' (CBM-pa) study is a feasibility, double-blind, randomised controlled trial (RCT) for 60 stabilised outpatients with persistent, distressing paranoid symptoms. Patients will be randomised at a 50:50 ratio, to computerised CBM-pa or a text-reading control intervention, receiving one 40-min session per week, for 6 weeks. CBM-pa involves participants reading stories on a computer screen, completing missing words and answering questions about each story in a way that encourages more helpful beliefs about themselves and others. Treatment as Usual will continue for patients in both groups. Patients will be assessed by a researcher blind to allocation, at baseline, each interim session, post treatment and 1- and 3-month follow-up post treatment. The primary outcome is the feasibility parameters (trial design, recruitment rate and acceptability) of the intervention. The secondary outcomes are clinical symptoms (including severity of paranoia) as assessed by a clinical psychologist, and 'on-line' measurement of interpretation bias and stress/distress. The trial is funded by the NHS National Institute for Health Research.

DISCUSSION

This pilot study will test whether CBM-pa has the potential to be a cost-effective, accessible and flexible treatment. If the trial proves feasible and demonstrates preliminary evidence of efficacy, a fully powered RCT will be warranted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN: 90749868 . Retrospectively registered on 12 May 2016.

I'll See You in Court…Again: Psychopathology and Hyperlitigious Litigants

Persistent litigation is a problem in many legal jurisdictions and is costly at individual and systemic levels. This phenomenon is referred to as "querulous" behavior in psychiatric literature, whereas legal discourse refers to it as "vexatious litigation." We refer to this phenomenon as "hyperlitigious behavior" and those who engage in these actions as "hyperlitigious litigants." Hyperlitigious litigants and hyperlitigious behavior were once the focus of a considerable amount of psychiatric literature, but research devoted to these topics has declined over the past half century. A review of the published literature on hyperlitigious behavior in European and English-speaking countries highlights geographic differences in the conceptualization and management of this behavior. We provide an alternative framework to consider the motivation to engage in hyperlitigious behavior and suggest three strategies for mental health professionals who interact with these individuals. Finally, we call for a revival of discussions and research within the English-speaking psychiatric community to facilitate more informed decisions regarding the management and treatment of hyperlitigious behavior.

Emotional, Cognitive and Behavioral Reactions to Paranoid Symptoms in Clinical and Nonclinical Populations

BACKGROUND

Paranoia is a disruptive belief that can vary across a continuum, ranging from persecutory delusions presented in clinical settings to paranoid cognitions that are highly prevalent in the general population. The literature suggests that paranoid thoughts derive from the activation of a paranoid schema or information processing biases that can be sensitive to socially ambiguous stimuli and influence the processing of threatening situations.

METHODS

Four groups (schizophrenic participants in active psychotic phases, n=61; stable participants in remission, n=30; participants' relatives, n=32; and, healthy controls, n=64) were assessed with self-report questionnaires to determine how the reactions to paranoia of clinical patients differ from healthy individuals. Cognitive, emotional and behavioral dimensions of their reactions to these paranoid thoughts were examined.

RESULTS

Paranoid individuals were present in all groups. Most participants referred to the rejection by others as an important trigger of paranoid ideations, while active psychotics were unable to identify triggering situations to their thoughts and reactions. This may be a determinant to the different reactions and the different degree of invalidation caused by paranoid thoughts observed across groups.

CONCLUSIONS

Clinical and nonclinical expressions of paranoid ideations differ in terms of their cognitive, emotional and behavioral components. It is suggested that, in socially ambiguous situations, paranoid participants (presenting lower thresholds of paranoid schema activation) lose the opportunity to disconfirm their paranoid beliefs by resourcing to more maladaptive coping strategies. Consequently, by dwelling on these thoughts, the amount of time spent thinking about their condition and the disability related to the disease increases.

Childhood trauma, psychosis liability and social stress reactivity: a virtual reality study

BACKGROUND

Childhood trauma is associated with higher risk for mental disorders, including psychosis. Heightened sensitivity to social stress may be a mechanism. This virtual reality study tested the effect of childhood trauma on level of paranoid ideations and distress in response to social stress, in interaction with psychosis liability and level of social stress exposure.

METHOD

Seventy-five individuals with higher psychosis liability (55 with recent onset psychotic disorder and 20 at ultra-high risk for psychosis) and 95 individuals with lower psychosis liability (42 siblings and 53 controls) were exposed to a virtual café in five experiments with 0-3 social stressors (crowded, other ethnicity and hostility). Paranoid ideation was measured after each experiment. Subjective distress was self-rated before and after experiments. Multilevel random regression analyses were used to test main effects of childhood trauma and interaction effects.

RESULTS

Childhood trauma was more prevalent in individuals with higher psychosis liability, and was associated with higher level of (subclinical) psychotic and affective symptoms. Individuals with a history of childhood trauma responded with more subjective distress to virtual social stress exposures. The effects of childhood trauma on paranoia and subjective distress were significantly stronger when the number of virtual environmental stressors increased. Higher psychosis liability increased the effect of childhood trauma on peak subjective distress and stress reactivity during experiments.

CONCLUSIONS

Childhood trauma is associated with heightened social stress sensitivity and may contribute to psychotic and affective dysregulation later in life, through a sensitized paranoid and stress response to social stressors.

Differences in Connection Strength between Mental Symptoms Might Be Explained by Differences in Variance: Reanalysis of Network Data Did Not Confirm Staging

Background

The network approach to psychopathology conceives mental disorders as sets of symptoms causally impacting on each other. The strengths of the connections between symptoms are key elements in the description of those symptom networks. Typically, the connections are analysed as linear associations (i.e., correlations or regression coefficients). However, there is insufficient awareness of the fact that differences in variance may account for differences in connection strength. Differences in variance frequently occur when subgroups are based on skewed data. An illustrative example is a study published in PLoS One (2013;8(3):e59559) that aimed to test the hypothesis that the development of psychopathology through “staging” was characterized by increasing connection strength between mental states. Three mental states (negative affect, positive affect, and paranoia) were studied in severity subgroups of a general population sample. The connection strength was found to increase with increasing severity in six of nine models. However, the method used (linear mixed modelling) is not suitable for skewed data.

Methods

We reanalysed the data using inverse Gaussian generalized linear mixed modelling, a method suited for positively skewed data (such as symptoms in the general population).

Results

The distribution of positive affect was normal, but the distributions of negative affect and paranoia were heavily skewed. The variance of the skewed variables increased with increasing severity. Reanalysis of the data did not confirm increasing connection strength, except for one of nine models.

Conclusions

Reanalysis of the data did not provide convincing evidence in support of staging as characterized by increasing connection strength between mental states. Network researchers should be aware that differences in connection strength between symptoms may be caused by differences in variances, in which case they should not be interpreted as differences in impact of one symptom on another symptom.

The Interaction between Childhood Bullying and the FKBP5 Gene on Psychotic-Like Experiences and Stress Reactivity in Real Life

AIM

The present study employed Experience Sampling Methodology to examine whether the interaction between childhood bullying and FKBP5 variability (i) is associated with the expression of psychotic-like experiences, paranoia, and negative affect, and (ii) moderates psychotic-like, paranoid, and affective reactivity to different forms of momentary stress (situational and social) in daily life.

METHODS

A total of 206 nonclinical young adults were interviewed for bullying with the Childhood Experience of Care and Abuse and were prompted randomly eight times daily for one week to complete assessments of their current experiences, affect, and stress appraisals. Participants were genotyped for three FKBP5 single nucleotide polymorphisms (SNPs) (rs3800373, rs9296158, and rs1360780) that have been linked to hypothalamus-pituitary-adrenal axis reactivity. Multilevel analyses were conducted to examine the effect of the interaction between childhood bullying and the FKBP5 haplotype derived from these three SNPs.

RESULTS

The interaction between bullying and the FKBP5 haplotype was associated with positive, but not negative, psychotic-like experiences, paranoia, and negative affect. The bullying x FKBP5 interaction also moderated the association of a social stress appraisal (specifically, being alone because people do not want to be with you) with psychotic-like experiences and negative affect in daily life. Simple slopes analyses indicated that, in all cases, the associations were significantly increased by exposure to bullying in participants with the risk haplotype, but not for those with the non-risk haplotype.

DISCUSSION

The present study provides the first evidence of the interplay between childhood bullying and FKBP5 variability in the real-world expression of psychosis proneness and social stress reactivity. The findings underscore the importance of investigating how gene-environment interactions are involved in mechanistic pathways to the extended psychosis phenotype and lend further support to the increasing relevance given to socially defeating appraisals in the experience of reality distortion.

What can the study of first impressions tell us about attitudinal ambivalence and paranoia in schizophrenia?

Although social cognition deficits have been associated with schizophrenia, social trait judgments - or first impressions - have rarely been studied. These first impressions, formed immediately after looking at a person's face, have significant social consequences. Eighty-one individuals with schizophrenia or schizoaffective disorder and 62 control subjects rated 30 neutral faces on 10 positive or negative traits: attractive, mean, trustworthy, intelligent, dominant, fun, sociable, aggressive, emotionally stable and weird. Compared to controls, patients gave higher ratings for positive traits as well as for negative traits. Patients also demonstrated more ambivalence in their ratings. Patients who were exhibiting paranoid symptoms assigned higher intensity ratings for positive social traits than non-paranoid patients. Social trait ratings were negatively correlated with everyday problem solving skills in patients. Although patients appeared to form impressions of others in a manner similar to controls, they tended to assign higher scores for both positive and negative traits. This may help explain the social deficits observed in schizophrenia: first impressions of higher degree are harder to correct, and ambivalent attitudes may impair the motivation to interact with others. Consistent with research on paranoia and self-esteem, actively-paranoid patients' positive social traits judgments were of higher intensity than non-paranoid patients'.

Switch Function and Pathological Dissociation in Acute Psychiatric Inpatients

Swift switching, along with atypical ability on updating and inhibition, has been found in non-clinical dissociators. However, whether swift switching is a cognitive endophenotype that intertwines with traumatisation and pathological dissociation remains unknown. Unspecified acute psychiatric patients were recruited to verify a hypothesis that pathological dissociation is associated with swift switching and traumatisation may explain this relationship. Behavioural measures of intellectual function and three executive functions including updating, switching and inhibition were administered, together with standardised scales to evaluate pathological dissociation and traumatisation. Our results showed superior control ability on switching and updating in inpatients who displayed more symptoms of pathological dissociation. When all three executive functions were entered as predictors, in addition to intellectual quotient and demographic variables to regress upon pathological dissociation, switching rather than updating remained the significant predictor. Importantly, the relationship between pathological dissociation and switching became non-significant when the effect of childhood trauma were controlled. The results support a trauma-related switching hypothesis which postulates swift switching as a cognitive endophenotype of pathological dissociation; traumatisation in childhood may explain the importance of swift switching.

The relationship between paranoia and aggression in psychosis: A systematic review

Aggression in the context of schizophrenia has significant detrimental personal, clinical and societal implications. Whilst understanding the precise pathways to aggression in people with a diagnosis of schizophrenia is critical for risk management and treatment, these pathways remain unclear. A paranoid belief that others intend harm is one psychotic symptom that might contribute to aggressive behaviours. This is the first review to investigate the relationship between paranoia and aggression in psychosis. A systematic review of published literature pertinent to the relationship between paranoia and aggression was conducted. A search of online databases from inception to November 2014 was performed with keywords related to 'schizophrenia', 'paranoia' and 'aggression'. Fifteen studies, primarily cross-sectional in design (n=9), met eligibility criteria. Studies reviewed showed mixed support for an association between paranoia and aggression in both inpatients and community settings. However, when study quality was taken into account, more methodologically rigorous studies tended to show a positive association between factors. Mixed findings are most likely due to important methodological shortcomings, including heterogeneous samples and studies using a diverse range of aggression/violence measures. In light of methodological limitations of individual studies reviewed, further investigation of the relationship between paranoia and aggression in psychosis using robust methodology is needed before definitive clinical recommendations regarding the hypothesised relationship between paranoia and aggression can be made. This paper sets out key recommendations for future studies, including operationalizing the specific components of aggression and paranoia under investigation and methods to delineate important mediators in the paranoia and aggression relationship.

Brief Symptom Inventory symptom profiles of outpatients with borderline intellectual functioning and major depressive disorder or posttraumatic stress disorder: Comparison with patients from regular mental health care and patients with Mild Intellectual Disabilities

INTRODUCTION

In most countries, people with borderline intellectual functioning (BIF) are not considered a separate group in mental health care. There is little to no research on the impact of BIF on the presentation, nature and severity of mental health problems. The aim of the present exploratory study was to compare, in a naturalistic setting of patients referred to secondary care, symptom profiles of patients with BIF diagnosed with either major depressive disorder (MDD) or posttraumatic stress disorder (PTSD) to patients from regular mental health care (RMHC) and patients with Mild ID diagnosed with the same disorders.

METHODS

We used a cohort of adolescent and adult outpatients (aged 16-88) with or without BIF diagnosed with a primary diagnosis MDD or PTSD. Primary outcome was the nature and severity of psychopathological symptoms assessed at baseline using the Brief Symptom Inventory. All outcomes were adjusted for gender and age.

RESULTS

Results showed that BIF patients with a primary diagnosis MDD reported less severe symptoms on BSI Total and the subscales Depression, Obsession-Compulsion and Psychoticism than patients from regular mental health care (RMHC). There were no statistically significant differences in reported symptom severity on BSI Total and the different BSI subscales between BIF patients with PTSD and either patients from RMHC or patients with Mild ID. Patients Mild ID, did report significantly less severe symptoms on the subscale Depression and on the subscale Psychoticism than patients from RMHC.

DISCUSSION

Since there were no other published studies into symptom profiles in patients with BIF compared to either patients with higher or lower levels of cognitive functioning, the study was mainly exploratory in nature, providing direction for future research. Results indicate that symptom profiles did not widely differ, but that there might be some characteristics unique to patients BIF separating them as a group from both patients from RMHC and patients with Mild ID.

[Prisoners in units for difficult patients]

Prisoners, on remand or convicted, can be placed for a variable amount of time in a unit for difficult patients if their pathological mental state so requires. For the most part, their therapeutic care does not depend on their status as prisoner. The treatments provided are those indicated for their psychological pathologies and their potential or known dangerousness. However, some administrative measures make a distinction between their treatment and that of non-prisoner patients placed in these secure psychiatric units.

Impact of childhood adversities on specific symptom dimensions in first-episode psychosis

BACKGROUND

The relationship between childhood adversity (CA) and psychotic disorder is well documented. As the adequacy of the current categorical diagnosis of psychosis is being increasingly questioned, we explored independent associations between different types of CA and specific psychotic symptom dimensions in a well-characterized sample of first-episode psychosis (FEP) patients.

METHOD

This study involved 236 FEP cases aged 18-65 years who presented for the first time to psychiatric services in South London, UK. Psychopathology was assessed with the Positive and Negative Syndrome Scale and confirmatory factor analysis was used to evaluate the statistical fit of the Wallwork/Fortgang five-factor model of psychosis. CA prior to 17 years of age (physical abuse, sexual abuse, parental separation, parental death, and being taken into care) was retrospectively assessed using the Childhood Experience of Care and Abuse Questionnaire.

RESULTS

Childhood sexual abuse [β = 0.96, 95% confidence interval (CI) 0.40-1.52], childhood physical abuse (β = 0.48, 95% CI 0.03-0.93) and parental separation (β = 0.60, 95% CI 0.10-1.11) showed significant associations with the positive dimension; while being taken into care was associated with the excited dimension (β = 0.36, 95% CI 0.08-0.65), independent of the other types of CA. No significant associations were found between parental death and any of the symptom dimensions.

CONCLUSIONS

A degree of specificity was found in the relationships between different types of CA and psychosis symptom dimensions in adulthood, suggesting that distinct pathways may be involved in the CA-psychosis association. These potentially different routes to developing psychosis merit further empirical and theoretical exploration.