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Purpose: Following its introduction in the early 1990s, cognitive behavioural therapy for psychosis (CBTp) has been evaluated in a large number of clinical trials and is now established as a recommended treatment in the UK National Health Service and elsewhere in the world. Meta‐analyses, however, indicate modest effects compared to treatment as usual or comparison therapies such as supportive counselling. Here, we seek to identify factors impacting the effectiveness of CBTp, and avenues for future psychotherapy research that may improve outcomes. Method: We outline two recent umbrella reviews and discuss factors likely to impact the effectiveness of CBTp. Results: Modest effect sizes from meta‐analyses mask heterogeneous outcomes, with some people benefiting and others possibly being harmed by therapy. Common factors such as the therapeutic alliance play an important role in determining outcomes but have been largely neglected by CBTp researchers. There is also the promise of improving outcomes by identifying and targeting the psychological mechanisms that either maintain psychotic symptoms (e.g. worry) or are causally implicated (e.g. trauma). Conclusions: It is unlikely that everyone with psychosis will be equally responsive to the same therapeutic protocols. We need a new, personalised psychotherapy approach to CBTp research and practice, and can learn from research for anxiety and depression examining predictors of therapeutic response to inform treatment decisions. Precision psychological therapies informed by a combination of individual characteristics, common factors and a focus on specific mechanisms will require new research strategies and are likely to lead to improved outcomes for people with psychosis. [ABSTRACT FROM AUTHOR]

An editorial is presented discussing the current state of cognitive and behavioral therapies for psychosis, including CBT, third-wave therapies, and the challenges in implementing evidence-based interventions. Topics include the effectiveness of various therapies, the importance of addressing trauma, and the need for personalized and technology-assisted interventions to improve global mental health provision.

Objectives: Paranoia is known to be associated with insecure attachment, with negative self‐esteem as a mediator, but this pathway is insufficient to explain the paranoid individual's beliefs about malevolent others. Mistrust is a likely additional factor as it is a core feature of paranoid thinking also associated with insecure attachment styles. In this study, we tested whether mistrust – operationalized as judgements about the trustworthiness of unfamiliar faces – constitutes a second pathway from insecure attachment to paranoia. Design: The design of the study was cross‐sectional. Methods: A nationally representative British sample of 1,508 participants aged 18–86, 50.8% female, recruited through the survey company Qualtrics, completed measurements of attachment style, negative self‐esteem, and paranoid beliefs. Usable data were obtained from 1,121 participants. Participants were asked to make trustworthiness judgements about computer‐generated faces, and their outcomes were analysed by conducting signal detection analysis, which provided measures of bias (the tendency to assume untrustworthiness in conditions of uncertainty) and sensitivity (accuracy in distinguish between trustworthy and untrustworthy faces). Results: Results using structural equation modelling revealed a good model fit (RMSEA =.071, 95% CI: 0.067–0.075, SRMR =.045, CFI =.93, TLI =.92). We observed indirect effects through bias towards mistrust both for the relationship between attachment anxiety and avoidance (β =.003, 95% CI: 0.001–0.005,p <.001) and attachment anxiety and paranoia (β =.003, 95% CI 0.002–0.006, p <.001). We observed an indirect effect through negative self‐esteem only for the relationship between attachment anxiety and paranoia (β =.064, 95% CI: 0.053–0.077, p <.001). Trust judgements and negative self‐esteem were not associated with each other. Conclusions: We find that a bias towards mistrust is associated with greater paranoia. We also find indirect effects through bias towards mistrust between attachment styles and paranoia. Finally, we reaffirm the strong indirect effect through negative self‐esteem between attachment anxiety and paranoia. Limitations of the study are discussed. Practitioner points: When working with individuals suffering from paranoia, clinicians should consider not only explicit, deliberative cognitive processes of the kind addressed in cognitive behaviour therapy (e.g. cognitive restructuring) but also the way in which their patients make perceptual judgements (e.g., their immediate reactions on encountering new people) and consider interventions targeted at these judgements, for example, bias modification training.Assessment and clinical interventions for people should consider the role of trust judgements and the way in which they combine with low self‐esteem to provoke paranoid beliefs.Psychological interventions targeting paranoid beliefs should focus on both attachment anxiety and attachment avoidance. [ABSTRACT FROM AUTHOR]

Background: Grandiose delusions are arguably the most neglected psychotic experience in research. Objectives: We aimed to discover from patients: whether grandiose delusions have harmful consequences; the psychological mechanisms that maintain them; and what help patients may want from clinical services. Design: A qualitative interview design was used to explore patients' experiences of grandiose delusions. Method: Fifteen patients with past or present experiences of grandiose delusions who were attending psychiatric services were interviewed. Thematic analysis and grounded theory were used to analyse the data. Results: Participants reported physical, sexual, social, occupational, and emotional harms from grandiose delusions. All patients described the grandiose belief as highly meaningful: it provided a sense of purpose, belonging, or self‐identity, or it made sense of unusual or difficult events. The meaning from the belief was not synonymous with extreme superiority or arrogance. The meaning obtained appeared to be a key driver of the persistence of the beliefs. Other maintenance factors were subjectively anomalous experiences (e.g., voices), symptoms of mania, fantasy elaboration, reasoning biases, and immersive behaviours. Participants described insufficient opportunities to talk about their grandiose beliefs and related experiences and were generally positive about the possibility of a psychological therapy. Conclusions: We conclude that grandiosity is a psychologically rich experience, with a number of maintenance factors that may be amenable to a targeted psychological intervention. Importantly, the term 'grandiose delusion' is an imprecise description of the experience; we suggest 'delusions of exceptionality' may be a credible alternative. Practitioner points: Harm from grandiose delusions can occur across multiple domains (including physical, sexual, social, occupational, and emotional) and practitioners should assess accordingly.However, grandiose delusions are experienced by patients as highly meaningful: they provide a sense of purpose, belonging, or self‐identity, or make sense of unusual or difficult events.Possible psychological maintenance mechanisms that could be a target for intervention include the meaning of the belief, anomalous experiences, mania, fantasy elaboration, reasoning biases, and immersive behaviours.Patients are keen to have the opportunity to access talking therapies for this experience. Taking extra time to talk at times of distress, 'going the extra mile', and listening carefully can help to facilitate trust. [ABSTRACT FROM AUTHOR]

Objectives: People from ethnic minority groups experience higher rates of paranoid delusions compared with people from ethnic majority groups. Identifying with social groups has been shown to protect against mental health symptoms; however, no studies have investigated the relationship between social identification and paranoia in ethnic minority populations. Here, we investigated the association between British identification and paranoia in a sample of people from African and African Caribbean backgrounds living in the United Kingdom. We also assessed the role of potential mediating (self‐esteem and locus of control) and moderating (contact with White British people) factors. Design: Cross‐sectional quantitative survey design. Methods: We recruited 335 people from African and African Caribbean backgrounds who completed online self‐report measures of identification with Great Britain, self‐esteem, locus of control, positive and negative contact with White British people, and paranoia. Results: A parallel moderated mediation model indicated that British identification was associated with lower paranoia when participants experienced primarily positive contact with White British people. British identification was associated with higher paranoia when participants had primarily negative contact with White British people. Both effects were mediated by changes in locus of control, but self‐esteem was not implicated in either pathway. Conclusions: Identification with the majority culture is associated both positively and negatively with paranoid beliefs depending on the types of social interactions people experience. The findings have implications for preventative social prescribing initiatives and for understanding the causes of the high rates of psychosis in ethnic minority populations. Practitioner points: People from African and African Caribbean backgrounds experience high rates of paranoia, which may stem from social causes such as lack of belonging and negative social experiences.Among people from African backgrounds living in the UK, British identification is associated with lower paranoia when people's social experiences with White British people are positive and higher paranoia when their social experiences with White British people are negative.It is recommended that social interventions designed to reduce paranoia in vulnerable groups foster positive social contact and community belonging, which should enhance feelings of personal control.Understanding the complex interplay between social identity and social contact in the development of paranoia may help therapists and researchers better understand the phenomenology and risk factors of paranoid symptomology. [ABSTRACT FROM AUTHOR]

Objective: Sexual minorities have an increased risk of psychosis, potentially explained by experiences of social adversity. Sexual minorities may also have a specific risk of paranoid symptoms. The current study aimed to determine whether sexual minorities have increased risk of psychosis, whether they have a specific increased risk of paranoia when compared to auditory verbal hallucinations (AVHs), and whether social adversity such as bullying, recent discrimination, lack of social support, and drug use can explain this risk. Methods: The study used data from the Adult Psychiatric Morbidity Survey 2007 (n = 7,403), exploring both sexual identity and past sexual behaviour. Associations between sexual minority status and probable psychosis, paranoia, and AVH were analysed using logistic regression. Mediation analysis was also conducted using the Karlson–Holm–Breen method, with bullying, recent discrimination, social support, and drug use as mediators assessing pathways between sexual minority status and paranoia/AVH. Socio‐demographic confounders were included in analyses. Results: Sexual minority status did not significantly predict probable psychosis. Findings generally indicated a specific association between sexual minority status and paranoia when contrasted with AVH. However, sexual behaviour remained significantly associated with AVH in logistic regression models. Bullying, lack of social support, and drug use partially mediated the association between sexual minority status and paranoia. Conclusions: Sexual minority status appears to have a specific association with paranoia symptoms, which may be partially explained by experiences of social adversity. However, the cross‐sectional nature of the study limits direct inference about causality of such symptoms. Practitioner points: Sexual minority groups may be more likely to experience symptoms of paranoia.It may be important to consider experiences of social adversity such as bullying, lack of social support, and also history of drug use in the context of paranoia within these groups. [ABSTRACT FROM AUTHOR]

Objectives: Psychological models of voice‐hearing propose that auditory‐verbal hallucinations occur when inner speech is attributed to a source external to the self. Approximately half of the world's population is multilingual, and the extent to which they use a second language for inner speech depends on their experience and competency in it. Bilingualism therefore provides a natural window into the processes operating in auditory‐verbal hallucinations, but no systematic study of voice‐hearing in bilinguals has hitherto been conducted. Design: A mixed‐methods observational study of psychiatric service users who hear voices and who are Welsh–English bilingual. Methods: Thirty‐seven participants were interviewed about their history and use of Welsh and English and divided into three groups: those who learnt Welsh first (L1 Welsh), those who learnt English first (L1 English), and those who learnt the two languages simultaneously. Detailed phenomenological data were collected using The Mental Health Research Institute Unusual Perceptions Schedule. Results: Both qualitative and quantitative data indicated very considerable variation in the extent to which voices were in Welsh, English, or both, with some voice‐hearers reporting that the predominant language of their voices had changed with time. There were modest but statistically significant associations between the predominant language of voices and age of language acquisition (late Welsh learners did not hear voices in Welsh), frequency of language use (more frequent use of Welsh was associated with more Welsh voices), and subjective language proficiency (proficiency in English was associated with a tendency to hear English voices). Conclusions: Although this was a small study, it was the first of its kind. There is a need for more research on the implications of bilingualism for psychosis in particular and mental illness more generally. The results are broadly consistent with the hypothesis that hallucinated voices are misattributed inner speech. Practitioner points: Assessments of people with mental health difficulties should routinely inquire whether they are multilingual and, if so, which language they prefer to use.People with mental health difficulties may have difficulty expressing complex issues and emotions in a second language, despite apparent fluency.When working with bilingual people who hear voices, mental health professionals should consider the language used by the voices when conducting assessments and proposing formulations. [ABSTRACT FROM AUTHOR]

Objectives Self-esteem is a key feature of bipolar symptomatology. However, so far no study has examined the interaction between explicit and implicit self-esteem in individuals vulnerable to bipolar disorder. Design Cross-sectional design was employed. Methods Thirty children of parents with bipolar disorder and 30 offspring of control parents completed Hamilton Rating Scale for Depression, the Bech-Rafaelson Mania Scale, the Self-esteem Rating Scale and the Implicit Association Test. Results No differences between groups were revealed in levels of explicit or implicit self-esteem. However, bipolar offspring showed increased levels of symptoms of depression and mania. Furthermore, depressive symptoms were associated with low explicit self-esteem, whilst symptoms of mania were associated with low implicit self-esteem. When self-esteem discrepancies were examined, damaged self-esteem (i.e., low explicit but high implicit self-esteem) was associated with depression, whilst no associations between mania and self-esteem discrepancies were found. Conclusions Not only explicit, but also implicit self-esteem, and the interactions between the two are of relevance in bipolar symptoms. Clinical implications and future research directions are discussed. Practitioner points Explicit as well as implicit SE, and particularly their relationship, are relevant for mental health., Fluctuations in implicit SE may serve as an early indicator for risk of bipolarity., Psychotherapeutic approaches may be more suitable for one kind of SE challenge than the other. [ABSTRACT FROM AUTHOR]

Background. Trower and Chadwick argued that there are two types of paranoia: 'poor me', in which persecution is seen as undeserved, and 'bad me', in which it is perceived to be deserved. These authors outlined a theory which accounts for both types of paranoia and makes predictions regarding their stability. Aims and objectives. To examine whether different degrees of persecutory ideation and deservedness are associated with different coping strategies in non-clinical populations. Methodology. Six hundred and eight university students from two European countries (UK and Portugal) took part via the Internet, and were assessed in terms of the severity of persecution and deservedness (Persecution and Deservedness Scale), mood (Beck Depression Inventory), and coping strategies (Response Styles to Depression Questionnaire and COPE Questionnaire). Results. Deservedness was associated with acceptance and with engaging in dangerous activities. Conclusions. 'Poor me' and 'bad me' paranoia may represent separate phases of the same unstable defensive phenomenon. The effectiveness of the existing psychological interventions in prodromal psychosis could be increased by addressing the negative impact of safety behaviours and of substance misuse and by encouraging the practice of more adaptive ways of dealing with everyday problems. [ABSTRACT FROM AUTHOR]

Objective. The present study uses an indirect measure to explore whether dysfunctional attitudes are characteristic of all phases of bipolar disorder. Previous studies with bipolar patients using indirect measurements have uncovered depression-like responses that were otherwise undetected. Design. A cross-sectional study design was adopted to explore the presence of dysfunctional attitudes within each phase of the illness. Method. Manic patients, depressed bipolar patients, remitted bipolar patients, and healthy controls were compared on a sentence stem completion task designed to implicitly assess dysfunctional attitudes. Results. The manic, depressed, and remitted patients all exceeded the controls on implicit measures of dysfunctional attitudes. Conclusions. The findings are consistent with the hypothesis that all phases of bipolar disorder are associated with depressogenic dysfunctional attitudes. [ABSTRACT FROM AUTHOR]

Objectives. To determine how security of adult attachment style is related to the mania, major depression and euthymic mood states in bipolar 1 (BP1) disorder. Design. An observational cross-sectional study. Method. One hundred and seven BP1 patients (34 in a manic type episode, 30 in major depressive episode, and 43 in remission) and 41 healthy controls similar in age, gender, reading age, and education were recruited. The groups were compared on self-reported mean and preferred attachment style controlling for psychiatric comorbidity. Results. Preferred attachment style was insecure in 84 (78%) BP1 patients but only 13 (32%) healthy controls (χ² = 34.3, df = 3, and p < .001). Healthy controls reported higher secure attachment, lower anxious, and lower preoccupied attachment scores than all groups of patients with bipolar disorder, although the scores for secure attachment in mania and preoccupied attachment in euthymic patients were not significantly different from healthy controls. Overall, within the bipolar groups, anxious attachment style varied little with mood but mania was associated with higher secure and preoccupied attachment style, and depression with higher preoccupied and lower dismissing attachment style scores. Conclusions. Insecure attachment is found in most patients with BP1 disorder. Attachment style is affected by mood episodes so it should be assessed when a patient with bipolar disorder is in remission with minimal residual depressive or manic symptoms. [ABSTRACT FROM AUTHOR]

Objectives. To design a brief measure to assess both the severity of paranoid thinking and the perceived deservedness of persecution, which can be employed in clinical and non-clinical populations. Background. No existing measure is adequate for these purposes. Methods. In Study 1, we selected 10 items for a persecution and deservedness scale (PaDS) using data from 318 UK and 290 Portuguese undergraduate students, who also completed the Beck Depression Inventory and the Fenigstein's Paranoia Scale. In Study 2, we made comparisons between 45 clinical participants with a diagnosis of schizophrenia, schizoaffective disorder or delusional disorder and the UK students from Study 1. The psychometric properties of the PaDS were analysed for separate persecution (P) and deservedness (D) subscales. Results. The 10-item PaDS subscales were internally reliable for both clinical and student samples. Correlations with other measures of depressive mood and paranoid thinking indicate that the P subscale has concurrent validity. Higher P and D scores were observed in UK students compared to Portuguese students. The clinical participants' P scores subscale were significantly higher than the students' scores but their D scores were lower. Conclusions. The PaDS is a reliable and valid measure of paranoid thinking and perceived deservedness of persecution, which is sensitive for use in clinical and non-clinical populations. Paranoid thinking appears to be mainly bad-me in non-clinical groups but poor-me in psychotic psychiatric patients. [ABSTRACT FROM AUTHOR]

Objectives. To investigate whether there are two stable types of paranoia, 'poor me' and 'bad me', as described by Trower and Chadwick (1995), and whether beliefs about the deservedness of persecution are associated with psychological measures. Methods. In-patients experiencing persecutory delusions were assigned either to 'poor me' (PM) or 'bad me'(BM) groups, according to their rating of a perceived deservedness scale, which was repeated on subsequent assessments. Participants were assessed for depression (BDI); construction of the self (Self-to-Others Scale); autonomy and sociotropy (PSI); perceived parental behaviour (PBI); attributional style (ASQ) and, meaningful daily events (DEI, devised for the study). A healthy control group was also assessed. Results. Many patients' perceived deservedness of persecution varied across time, so that some patients were PM at one point in time but BM at another. BM paranoia was associated with high levels of depression. PM and BM patients groups both scored higher than the controls on the subscales of Self-to-Others Scale and on the PSI. PM patients exhibited a marked self-serving bias on the ASQ, and reported less parental care on the PSI, compared to the BM patients. Both groups reported less PBI mother care than the controls. BM patients reported more failure events than PM patients or controls. PM patients reported more loss of control events than the than BM patients and controls. Conclusions. PM and BM paranoia may represent separate phases of an unstable phenomenon. The findings are consistent with an attributional account of paranoid thinking. [ABSTRACT FROM AUTHOR]

Research into the nature of attributional reasoning in paranoia has for the most part been restricted to questionnaire-based approaches. This fails to address the issue of whether a distinctive attributional style underpins the everyday talk of paranoid individuals. This study aimed to investigate whether attributional models of paranoid delusions applied to spontaneous attributions generated in the discourse of 12 paranoid and 12 non-paranoid speakers. Causal attributions for negative and positive life experiences were extracted from interview transcripts and rated using the Content Analysis of Verbatim Explanations (CAVE) technique. It was found that, as a proportion, paranoids made more attributions for negative events that were of an external-personal, stable and global nature (as attributional models would predict). They also made significantly more external-personal attributions for negative events and, in one of two datasets, showed a more external mean CAVE rating for negative events than the non-paranoid controls. This paper highlights important issues underlying the extraction of attributions from paranoid talk, and discusses the implications for attributional models of paranoia and future discourse-based research in this area. [ABSTRACT FROM AUTHOR]

Some theories implicate abnormal self-schemas in the development of psychosis in general and in paranoid delusions in particular. Patients with delusions may also be highly intolerant of ambiguity. No study has yet compared remitted and currently ill paranoid patients on schema measures, or on tolerance of ambiguity. Currently ill psychotic patients with persecutory delusions, patients whose persecutory delusions had remitted, and normal participants completed the Personal Style Inventory (PSI), a self-schema measure, and the Need for Closure Scale (NCS), a measure of intolerance of ambiguity. Acutely ill patients scored higher than normal participants on the PSI autonomy scale. This difference became nonsignificant when depression was included as a covariate. III and remitted patients scored higher than normal participants on the NCS. This difference could not be explained entirely by comorbid depression. Currently paranoid and remitted paranoid patients are highly intolerant of ambiguity. It is possible that this contributes to their performance on reasoning measures. The role of self-schemas in paranoid thinking needs to be studied further. [ABSTRACT FROM AUTHOR]

Objectives. To investigate whether different self-attributes would be associated with different degrees of deservedness of persecution in a clinical paranoid sample. Background. Some studies have shown differences between the self-esteem (SE) of individuals with 'Poor Me' (PM) and 'Bad Me' (BM) paranoia (Bentall et al., 2009; Chadwick, Trower, Juusti-Butler, & Maguire, 2005). Most studies investigating this relationship have employed a cross-sectional design, precluding the investigation of changes over time. Methods. In the cross-sectional part of the study, 45 clinical participants and 25 controls were assessed in terms of paranoia, deservedness of persecution, SE, self-discrepancies, daily events, and coping strategies. In the longitudinal part of the study, the clinical group was re-assessed over a period of another 2 days, in order to study changes in these variables. Results. At baseline, there were no differences between the SE of the two paranoia presentations, which was significantly lower than the controls'. However, the paired-samples repeated analysis found the SE of individuals when in a PM presentation was higher than when they were BM. Only BM paranoia was found to be associated with higher self-ideal:self-actual self-discrepancies than the other groups. The longitudinal analysis indicated that, having been PM and having low SE at the previous assessment day made it more likely that individuals would be in BM subsequently. No differences in causal attributions made for ecological events were found between the groups. Higher SE was found to be more likely when individuals coped with adversities by using social support. Conclusions. Both deservedness of persecution and self-views appear to be unstable in individuals with paranoia and to change consistently over time, a finding which is in keeping with Bentall et al.'s (2001) dynamic model of paranoia. [ABSTRACT FROM AUTHOR]