Peter Kinderman

Persecutory delusions: a review and theoretical integration.

Persecutory (paranoid) delusions are a frequently observed clinical phenomenon. In recent years, an increasing volume of research has attempted to explain these types of beliefs in terms of psychological mechanisms. Theories have emphasized early experience, perceptual abnormalities, motivational factors, and information-processing deficits. In this article we review relevant findings, including our own studies of the role of causal attributions and theory of mind deficits. We propose a new integrative model that builds on this work. The core of the model is an account of the way that causal attributions influence self-representations, which in turn influence future attributions: the attribution--self-representation cycle. We argue that biases in this cycle cause negative events to be attributed to external agents and hence contribute to the building of a paranoid world view. These abnormalities are amenable to investigation by functional neuroimaging, and recent studies have implicated specific areas of neuroactivation. However, these findings do not necessarily suggest that paranoid delusions are entirely biological in origin, and there is evidence that adverse early experience may play a role in determining the development of a cognitive vulnerability to paranoid thinking.

The self, attributional processes and abnormal beliefs: Towards a model of persecutory delusions

In this paper we review a series of recent investigations into cognitive abnormalities associated with persecutory delusions. Studies indicate that persecutory delusions are associated with abnormal attention to threat-related stimuli, an explanatory bias towards attributing negative outcomes to external causes and biases in information processing relating to the self-concept. We propose an integrative model to account for these findings in which it is hypothesized that, in deluded patients, activation of self/ideal discrepancies by threat-related information triggers defensive explanatory biases, which have the function of reducing the self/ideal discrepancies but result in persecutory ideation. We conclude by discussing the implications of this model for the cognitive-behavioural treatment of paranoid delusions.

Causal attributions in paranoia and depression: Internal, personal, and situational attributions for negative events.

Causal attributions for positive and negative hypothetical social events made by paranoid patients, depressed patients, and nonpatient participants were examined via a novel measure of causal locus, the Internal, Personal and Situational Attributions Questionnaire. Depressed patients tended to attribute negative social events to internal (self-blaming) causes. Nonpatient participants and patients with delusions of persecution tended to avoid such self-blame. However, whereas nonpatient participants tended to choose situational or circumstantial external attributions, paranoid patients tended to choose external attributions that located blame in other individuals. These findings support R. P. Bentall, P. Kinderman, and S. Kaneys (1994) defensive attributional model of persecutory delusions, suggest some modifications to that model, and have implications for the understanding of the relationship between causal attributions and social and self-perception.

The Cognitive and Affective Structure of Paranoid Delusions: A Transdiagnostic Investigation of Patients With Schizophrenia Spectrum Disorders and Depression

CONTEXT Paranoid delusions are a common symptom of a range of psychotic disorders. A variety of psychological mechanisms have been implicated in their cause, including a tendency to jump to conclusions, an impairment in the ability to understand the mental states of other people (theory of mind), an abnormal anticipation of threat, and an abnormal explanatory style coupled with low self-esteem. OBJECTIVE To determine the structure of the relationships among psychological mechanisms contributing to paranoia in a transdiagnostic sample. DESIGN Cross-sectional design, with relationships between predictor variables and paranoia examined by structural equation models with latent variables. SETTING Publicly funded psychiatric services in London and the North West of England. PARTICIPANTS One hundred seventy-three patients with schizophrenia spectrum disorders, major depression, or late-onset schizophrenia-like psychosis, subdivided according to whether they were currently experiencing paranoid delusions. Sixty-four healthy control participants matched for appropriate demographic variables were included. MAIN OUTCOME MEASURES Assessments of theory of mind, jumping to conclusions bias, and general intellectual functioning, with measures of threat anticipation, emotion, self-esteem, and explanatory style. RESULTS The best fitting (chi(2)(96) = 131.69, P = .01; comparative fit index = 0.95; Tucker-Lewis Index = 0.96; root-mean-square error of approximation = 0.04) and most parsimonious model of the data indicated that paranoid delusions are associated with a combination of pessimistic thinking style (low self-esteem, pessimistic explanatory style, and negative emotion) and impaired cognitive performance (executive functioning, tendency to jump to conclusions, and ability to reason about the mental states of others). Pessimistic thinking correlated highly with paranoia even when controlling for cognitive performance (r = 0.65, P < .001), and cognitive performance correlated with paranoia when controlling for pessimism (r = -0.34, P < .001). CONCLUSIONS Both cognitive and emotion-related processes are involved in paranoid delusions. Treatment for paranoid patients should address both types of processes.

A new measure of causal locus: the internal, personal and situational attributions questionnaire

Abstract Attributional style is commonly assessed using Peterson, Semmel, Von Baeyer, Abramson, Metalsky and Seligmans ( Cognitive Therapy and Research , 1982) Attributional Style Questionnaire (ASQ). The ASQ has been criticized for its low internal reliability, particularly with regard to the internality subscales. However, recent research has indicated that judgements of causal locus may be implicated in severe psychiatric disorders, particularly paranoia, and has pointed to the potential utility of taxonomies of causal locus not included in the ASQ. This report describes the development of a new method of assessing causal locus, the Internal, Personal and Situational Attributions Questionnaire (IPSAQ). For positive and negative events two measures of internality are derived from responses on the questionnaire, a measure of self-blame and a measure of the extent to which external attributions implicate other persons as opposed to situations. In a group of normal subjects the IPSAQ subscales were found to be adequately reliable. Self-blame was significantly associated with ASQ internality scores and with depressed mood. Scores representing the proportion of personal as opposed to situational external attributions were significantly associated with an analogue measure of paranoia.

The evolution of insight, paranoia and depression during early schizophrenia

BACKGROUND How insight, paranoia and depression evolve in relation to each other during and after the first episode of schizophrenia is poorly understood but of clinical importance. METHOD Serial assessments over 18 months were made using multiple instruments in a consecutive sample of 257 patients with first episode DSM-IV non-affective psychosis. Repeated measures of paranoia, insight, depression and self-esteem were analysed using structural equation modelling, to examine the direction of relationships over time after controlling for confounds. RESULTS Depression was predicted directly by greater insight, particularly at baseline, and by greater paranoia at every stage of follow-up. Neither relationship was mediated by self-esteem, although there was a weak association of lower self-esteem with greater depression and better insight. Paranoia was not strongly associated with insight. Duration of untreated psychosis and substance use at baseline predicted depression at 18 months. CONCLUSIONS In first-episode psychosis, good insight predicts depression. Subsequently, paranoia is the strongest predictor. Neither effect is mediated by low self-esteem. Effective treatment of positive symptoms is important in preventing and treating low mood in early schizophrenia.

AN INVESTIGATION INTO THE PSYCHOMETRIC PROPERTIES OF THE COGNITIVE THERAPY SCALE FOR PSYCHOSIS (CTS-Psy)

Recent research suggests that cognitive-behaviour therapy (CBT) can significantly improve outcomes for patients with severe mental health problems. However, there are no tools specifically designed to assess competence in delivering CBT to psychotic patients. This study investigates the psychometric properties of the Cognitive Therapy Scale for Psychosis (the CTS-Psy) for assessing the quality of CBT with psychotic patients. Inter-rater reliability of trained raters using the CTS-Psy was investigated using taped therapy of trainees engaged in a CBT oriented psychosis training course. Validity was investigated in relation to examining the degree to which the scale could be used to assess a range of therapist ability and patient severity and by assessing the degree to which the CTS-Psy could pick up changes in skill acquisition during the training course over a 9-month period. The CTS-Psy demonstrated excellent inter-rater reliability and good validity in relation to it being able to rate all standards of therapy and all types of patient sessions in the sample studied. In addition, the scale was sensitive to changes in clinical skills during a training course and could discriminate between those who had received training and those who had not.

Theory of Mind, Causal Attribution and Paranoia in Asperger Syndrome

Theory of mind (ToM) deficits are central to autistic spectrum disorders, including Asperger syndrome. Research in psychotic disorders has developed a cognitive model of paranoid delusions involving abnormal causal attributions for negative events. Possible aetiologies of these include deficits in social reasoning, specifically ToM. The present study investigated this attributional model of paranoia in Asperger syndrome. Participants diagnosed with Asperger syndrome scored significantly higher on a measure of paranoia and lower on a measure of ToM, compared with the control group. They did not differ in self-concept and causal attributions, contrary to the attributional model of paranoia. A regression analysis highlighted private self-consciousness as the only predictor of paranoia. The theoretical and clinical implications of these findings are discussed.

Psychological processes in bipolar affective disorder: negative cognitive style and reward processing

BACKGROUND Psychological processes in bipolar disorder are of both clinical and theoretical importance. AIMS To examine depressogenic psychological processes and reward responsivity in relation to different mood episodes (mania, depression, remission) and bipolar symptomatology. METHOD One hundred and seven individuals with bipolar disorder (34 in a manic/hypomanic or mixed affective state; 30 in a depressed state and 43 who were euthymic) and 41 healthy controls were interviewed with Structured Clinical Interview for DSM-IV and completed a battery of self-rated and experimental measures assessing negative cognitive styles, coping response to negative affect, self-esteem stability and reward responsiveness. RESULTS Individuals in all episodes differed from controls on most depression-related and reward responsivity measures. However, correlational analyses revealed clear relationships between negative cognitive styles and depressive symptoms, and reward responsivity and manic symptoms. CONCLUSIONS Separate psychological processes are implicated in depression and mania, but cognitive vulnerability to depression is evident even in patients who are euthymic.

Self-discrepancy in body dysmorphic disorder

OBJECTIVES According to self-discrepancy theory (SDT), depression, social anxiety, eating disorders and paranoia result from different types of conflicting self-beliefs. Body dysmorphic disorder (BDD) consists of a preoccupation with imagined or slight defects in ones appearance, which is often associated with a depressed mood and social anxiety. SDT was therefore applied to BDD patients to further understand their beliefs about their appearance. DESIGN Using a comparative group design, BDD patients were compared against a non-patient control group. METHOD A sample of 149 participants, consisting of three groups - BDD (72), BDD preoccupied with their weight and shape (35), and controls (42) - completed a modified version of the Selves Questionnaire (Higgins, Bond, Klein, & Strauman, 1986) requiring them to list and rate physical characteristics according to the following standpoints: (a) self-actual; (b) self-ideal; (c) self-should; (d) other-actual; and (e) other-ideal. RESULTS BDD patients displayed significant discrepancies between their self-actual and both their self-ideal and self-should. However, there were no significant discrepancies in BDD patients between their self-actual and other-actual or other-ideal domains. Analysis of variance using depression and social anxiety scores as covariates revealed a significant difference for both the self-ideal and self-should discrepancy. CONCLUSION The results suggest that BDD patients have an unrealistic ideal or demand as to how they should look. BDD patients are more like depressed patients (rather than social phobics or bulimics), being more concerned with a failure to achieve their own aesthetic standard than with the perceived ideals of others.