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Virtual reality (VR) is increasingly used in the study and treatment of paranoia. This is based on the finding that people who mistakenly perceive hostile intent from other people also perceive similar threat from virtual characters. However, there has been no study of the programming characteristics of virtual characters that may influence their interpretation. We set out to investigate how the animation and expressions of virtual humans may affect paranoia. In a two-by-two factor, between-groups, randomized design, 122 individuals with elevated paranoia rated their perceptions of virtual humans, set in an eye-tracking enabled VR lift scenario, that varied in facial animation (static or animated) and expression (neutral or positive). Both facial animation (group difference = 102.328 [51.783, 152.872], p < 0.001, η p 2 = 0.125) and positive expressions (group difference = 53.016 [0.054, 105.979], p = 0.049, η p 2 = 0.033) led to less triggering of paranoid thoughts about the virtual humans. Facial animation (group difference = 2.442 [- 4.161, - 0.724], p = 0.006, η p 2 = 0.063) but not positive expressions (group difference = 0.344 [- 1.429, 2.110], p = 0.681, η p 2 = 0.001) significantly increased the likelihood of neutral thoughts about the characters. Our study shows that the detailed programming of virtual humans can impact the occurrence of paranoid thoughts in VR. The programming of virtual humans needs careful consideration depending on the purpose of their use., (© 2024. The Author(s).)

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., (Copyright © 2023 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Background: Paranoia-incorrectly thinking that others are deliberating trying to harm you-causes distress, undermines social interactions and leads to withdrawal. It presents across multiple psychiatric diagnoses., Objective: The primary aim was to determine the extent that cognitive and social processes may explain paranoia. The secondary aim was to identify explanatory factors that distinguished paranoia and social anxiety., Methods: 10 382 UK adults, quota sampled to match the population for age, gender, ethnicity, income and region, participated in a non-probability survey. All participants completed a paranoia measure and assessments of cognitive and social processes. Structural equation modelling was conducted., Findings: 2586 (24.9%) participants described being mistrustful of other people. 1756 (16.9%) participants wanted help to trust more. 66.7% of variance in paranoia was explained by a model comprising (in descending order of importance): within-situation defence behaviours, negative images, negative self-beliefs, discrimination, dissociation, aberrant salience, anxiety sensitivity, agoraphobic distress, worry, less social support, agoraphobic avoidance, less analytical reasoning and alcohol use. All explanatory factors were associated with paranoia and social anxiety. Ten factors were more closely associated with paranoia than social anxiety, including discrimination, hallucinations, negative images, aberrant salience and alcohol use. Nine factors were more closely associated with social anxiety, including less positive self-belief, an external locus of control, worry and less analytical reasoning., Conclusions: Multiple causes are likely to be involved in paranoia. Cognitive and social processes may explain a high degree of paranoia., Clinical Implications: Multiple clear targets for intervention to reduce paranoia are identified., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. Published by BMJ.)

Objectives: Paranoia is most likely to emerge in adolescence. In adolescents with mental health disorders, the disruptive effect of paranoia on social relationships could worsen outcomes. However, little is known about clinical presentations of paranoia at this age. We therefore explored the development, experience, and impact of paranoia in adolescent patients., Design: A qualitative interview design with interpretative phenomenological analysis was used., Method: Twelve adolescents (11-17 years) with paranoia attending child and adolescent mental health services were interviewed., Results: Adolescents described a journey starting with their awareness of paranoia beginning to a paranoid experience of mistrust and fear of others, and, subsequently, their adjustment to paranoia in daily life. Paranoia onset was rooted in the discovery of interpersonal threat and personal vulnerability, shaped by challenging peer interactions, becoming aware of danger in the world, and personal adverse experiences. The paranoia experience included a struggle to trust friends, anticipating threat with intense fear, and using defensive strategies to keep safe. Adolescents described how the paranoia experience was confusing, negatively impacted self-concept, held them back from teenage life, and caused disconnection from friends. Longer-term responses to paranoia reflected a tension between reluctantly resigning to the experience and trying to resist the impact., Conclusions: The journey of paranoia in adolescence involves navigating multiple tensions, with young people balancing independence with vulnerability, trust with mistrust, and the desire to socialise with a fear of danger and deception. Decisions about how to respond to paranoia are likely to determine the next stage of their journey., (© 2022 The Authors. Psychology and Psychotherapy: Theory, Research and Practice published by John Wiley & Sons Ltd on behalf of The British Psychological Society.)

Objectives: SlowMo therapy is a pioneering blended digital therapy for paranoia, augmenting face-to-face therapy with an interactive 'webapp' and a mobile app. A recent large-scale trial demonstrated small-moderate effects on paranoia alongside improvements in self-esteem, worry, well-being and quality of life. This paper provides a comprehensive account of therapy personalisation within this targeted approach., Design: Case examples illustrate therapy delivery and descriptive data are presented on personalised thought content., Method: Thought content was extracted from the webapp (n = 140 participants) and coded using newly devised categories: Worries: (1) Persecutory, (2) Negative social evaluation, (3) Negative self-concept, (4) Loss/life stresses, (5) Sensory-perceptual experiences and (6) Health anxieties. Safer thoughts: (1) Safer alternative (specific alternatives to worries), (2) Second-wave (generalised) coping, (3) Positive self-concept, (4) Positive activities and (5) Third-wave (mindfulness-based) coping. Data on therapy fidelity are also presented., Results: Worries: 'Persecutory' (92.9% of people) and 'Negative social evaluation' (74.3%) were most common. 'General worries/ life stresses' (31.4%) and 'Negative self-concept' (22.1%) were present in a significant minority; 'Health anxieties' (10%) and 'Sensory-perceptual' (10%) were less common. Safer thoughts: 'Second-wave (general) coping' (85%), 'Safer alternatives' (76.4%), 'Positive self-concept' (65.7%) and 'Positive activities' (64.3%) were common with 'Third-wave' (mindfulness) coping observed for 30%. Fidelity: Only three therapy withdrawals were therapy related. Session adherence was excellent (mean = 15.2/16; SD = 0.9). Behavioural work was conducted with 71% of people (119/168)., Conclusion: SlowMo therapy delivers a targeted yet personalised approach. Potential mechanisms of action extend beyond reasoning. Implications for cognitive models of paranoia and causal interventionist approaches are discussed., (© 2021 The Authors. Psychology and Psychotherapy: Theory, Research and Practice published by John Wiley & Sons Ltd on behalf of The British Psychological Society.)

Paranoia and belief in conspiracy theories both involve suspiciousness about the intentions of others but have rarely been studied together. In three studies, one with a mainly student sample (N = 496) and two with more representative UK population samples (N = 1,519, N = 638) we compared single and two-factor models of paranoia and conspiracy theories as well as associations between both belief systems and other psychological constructs. A model with two correlated factors was the best fit in all studies. Both belief systems were associated with poor locus of control (belief in powerful others and chance) and loneliness. Paranoid beliefs were specifically associated with negative self-esteem and, in two studies, insecure attachment; conspiracy theories were associated with positive self-esteem in the two larger studies and narcissistic personality traits in the final study. Conspiracist thinking but not paranoia was associated with poor performance on the Cognitive Reflection Task (poor analytical thinking). The findings suggest that paranoia and belief in conspiracy theories are distinct but correlated belief systems with both common and specific psychological components., Competing Interests: The authors have declared that no competing interests exist.

Importance: Persistent paranoia is common among patients with psychosis. Cognitive-behavioral therapy for psychosis can be effective. However, challenges in engagement and effectiveness remain., Objective: To investigate the effects on paranoia and mechanisms of action of SlowMo, a digitally supported reasoning intervention, plus usual care compared with usual care only., Design, Setting, and Participants: This parallel-arm, assessor-blinded, randomized clinical trial recruited participants at UK community health services from May 1, 2017, to May 14, 2019. Eligible participants consisted of a referral sample with schizophrenia-spectrum psychosis and distressing, persistent (≥3 months) paranoia., Interventions: Individuals were randomized 1:1 to SlowMo, consisting of 8 digitally supported face-to-face sessions and a mobile app, plus usual care (n = 181) and usual care only (n = 181)., Main Outcomes and Measures: The primary outcome was paranoia, measured by the Green et al Paranoid Thoughts Scale (GPTS) total score at 24 weeks. Secondary outcomes included GPTS total score at 12 weeks and GPTS Part A (reference) and Part B (persecutory) scores, the Psychotic Symptom Rating Scales (PSYRATS Delusion subscale), reasoning (belief flexibility, possibility of being mistaken [Maudsley Assessment of Delusions, rated 0%-100%]), and jumping to conclusions (Beads Task)., Results: A total of 361 participants were included in intention-to-treat analysis, of whom 252 (69.8%) were male and 249 (69.0%) were White; the mean (SD) age was 42.6 (11.6) years. At 24 weeks, 332 participants (92.0%) provided primary outcome data. Of 181 participants in the SlowMo group, 145 (80.1%) completed therapy. SlowMo plus usual care was not associated with greater reductions than usual care in GPTS total score at 24 weeks (Cohen d, 0.20; 95% CI, -0.02 to 0.40; P = .06). There were significant effects on secondary paranoia outcomes at 12 weeks, including GPTS total score (Cohen d, 0.30; 95% CI, 0.09-0.51; P = .005), Part A score (Cohen d, 0.22; 95% CI, 0.06-0.39; P = .009), and Part B score (Cohen d, 0.32; 95% CI, 0.08-0.56; P = .009), and at 24 weeks, including Part B score (Cohen d, 0.25; 95% CI, 0.01-0.49; P = .04) but not Part A score (Cohen d, 0.12; 95% CI, -0.05 to 0.28; P = .18). Improvements were observed in an observer-rated measure of persecutory delusions (PSYRATS delusion) at 12 weeks (Cohen d, 0.47; 95% CI, 0.17-0.78; P = .002) and 24 weeks (Cohen d, 0.50; 95% CI, 0.20-0.80; P = .001) and belief flexibility at 12 weeks (Cohen d, 0.29; 95% CI, 0.09-0.49; P = .004) and 24 weeks (Cohen d, 0.28; 95% CI, 0.08-0.49; P = .005). There were no significant effects on jumping to conclusions. Improved belief flexibility and worry mediated paranoia change (range mediated, 36%-56%)., Conclusions and Relevance: SlowMo did not demonstrate significant improvements in the primary measure of paranoia at 24 weeks; however, a beneficial effect of SlowMo on paranoia was indicated by the results on the primary measure at an earlier point and on observer-rated paranoia and self-reported persecution at 12 and 24 weeks. Further work to optimize SlowMo's effects is warranted., Trial Registration: isrctn.org Identifier: ISRCTN 32448671.

Purpose: Parenting behaviours-including the extent to which parents are protective, hostile, or caring-likely impacts whether a child develops a sense of vulnerability that carries forward into adulthood. Ideas of vulnerability are a contributory factor to the occurrence of paranoia. Our aim was to assess whether there is an association between specific parenting behaviours and paranoia., Method: We examined cross-sectional associations of parenting and paranoia in an epidemiologically representative cohort of 10,148 adolescents (National Comorbidity Survey-Adolescents; NCS-A) and a second dataset of 1286 adults in Oxfordshire. Further, a network analysis was conducted with paranoia, parenting behaviours, and cognitive-affective variables (compassion, self-esteem, anxiety, and depression). Overprotectiveness, verbal abuse, physical abuse, and amount of care were assessed in mothers and fathers separately., Results: Nearly all parenting variables were significantly associated with paranoia, with parental verbal and physical abuse showing the largest associations. For example, the odds of reporting paranoia was over four times higher for those in the adult sample reporting a lot of paternal verbal abuse, compared to those reporting none (OR = 4.12, p < 0.001, CI 2.47-6.85). Network analyses revealed high interconnectivity between paranoia, parenting behaviours, and cognitive-affective variables. Of the parenting variables, paranoia most strongly interacted with paternal abuse and maternal lack of care., Conclusion: There are associations between participants' self-reported experiences of parental behaviours and paranoia. Despite being associated with paranoia, cognitive-affective variables did not appear to mediate the relationship between parenting and paranoia, which is surprising. What might explain the link therefore remains to be determined.

Anticipation of pleasure - a key aspect of hedonic experience - is a motivating factor for engaging in activities. Low levels of anticipatory pleasure and activity are found in individuals with psychosis. Cognitive factors (e.g., working memory and IQ) have been a focus of explanation for anticipation of pleasure in psychosis. However, cognitive factors do not fully account for such difficulties. It is plausible that emotional factors (e.g., depression, self-beliefs) also contribute. We examined anticipatory pleasure in relation to cognitive and emotional processes in patients with current psychosis. 128 patients with persecutory delusions in the context of non-affective psychosis completed assessments of anticipatory pleasure, cognitive functioning, emotional processes, and activity. Lower anticipatory pleasure was significantly associated with depression, insomnia, negative-self beliefs, suicidal ideation, poorer psychological wellbeing, and paranoia-related avoidance. There were no significant associations with working memory, physical activity, or meaningful activity.  Emotional factors may play a more significant role than cognitive difficulties in the experience of anhedonia in psychosis. However, the cross-sectional design precludes causal inferences. Future research should examine whether, for example, improving self-concept or reducing paranoia-related avoidance leads to improvement in anticipatory pleasure in patients with psychosis., (Copyright © 2020. Published by Elsevier B.V.)

Background: The Green et al., Paranoid Thoughts Scale (GPTS) - comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) - was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation., Methods: In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted., Results: The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09-3.67) and Persecution (a = 2.37-4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0-9; Persecution: 0-4); elevated (Reference: 10-15; Persecution: 5-10); moderately severe (Reference: 16-20; Persecution:11-17); severe (Reference: 21-24; Persecution: 18-27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion., Conclusions: The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.

Objective: Persecutory delusions typically build on feelings of inter-personal vulnerability linked to negative views of the self. Negative body image is an overlooked aspect of this link between the self-concept and paranoia., Design: This study explores body image from the first-person perspective of patients with persecutory delusions., Method: Semi-structured interviews, analysed using interpretative phenomenological analysis, were conducted with twelve patients with persecutory delusions in the context of psychotic disorders., Results: Four super-ordinate themes emerged. First, appearance as a source of threat accounted for how negative body image increased feelings of vulnerability and fed into the content of paranoia and voices (e.g., 'I feel that everybody is noticing that I'm getting bigger and bigger and laughing at me'). Second, there was the negative impact of uncontrollable and unwanted weight gain, especially following antipsychotic medication (e.g., 'I ballooned up to 23 stone'). Third, feeling stuck captured the hopelessness and resignation in relation to appearance (e.g., 'I've become so accustomed to being overweight that I've accepted it as my lot'). Finally, looking well symbolises feeling well represented the importance of appearance in determining mental well-being (e.g., 'If I've got clean clothes and I put makeup on, at least I feel that I'm looking after myself')., Conclusions: Patients with persecutory delusions described appearance-related concerns making them feel negative towards themselves, inferior to other people, and vulnerable to harm. Appearance-related distress was broader than weight gain, including dissatisfaction with skin, clothing, and attractiveness. Negative body image may be a contributory factor in the occurrence of paranoia., Practitioner Points: Body image concerns may be of particular relevance in patients with persecutory delusions due to weight gain, inactivity, and medication side effects. Body image concerns include weight gain and broader aspects of appearance. Negative body image contributes to feelings of vulnerability, potentially worsening paranoid fears. It may be helpful for practitioners to explore the psychological impact of weight gain and body image concerns in patients with psychosis., (© 2019 The Authors. Psychology and Psychotherapy: Theory, Research and Practice published by John Wiley & Sons Ltd on behalf of British Psychological Society.)

Background: Precise assessment tools for psychotic experiences in young people may help identify symptoms early and facilitate advances in treatment. In this study we provide an exemplar - with a paranoia scale for youth - for improving measurement precision for psychotic experiences using item response theory (IRT). We evaluate the psychometric properties of the new measure, test for measurement invariance, and assess its potential for computerised adaptive testing (CAT)., Method: The 18-item Bird Checklist of Adolescent Paranoia (B-CAP) was completed by 1102 adolescents including 301 patients with mental health problems and 801 from the general population. After excluding outliers (n = 10), IRT was used to examine item properties, test reliability, and measurement invariance. The properties of an adaptive B-CAP were assessed using a simulation of 10,000 responses., Results: All B-CAP items were highly discriminative (a = 1.14-2.77), whereby small shifts in paranoia led to a higher probability of item endorsement. Test reliability was high (a > 0.90) across a wide range of paranoia severity (θ = -0.45-3.36), with the greatest precision at elevated levels. All items were invariant for gender, age, and population groups. The simulated adaptive B-CAP performed with high accuracy and required only 5-6 items at higher levels of paranoia severity., Conclusions: The B-CAP is a reliable assessment tool with excellent psychometric properties to assess both non-clinical and clinical levels of paranoia in young people, with potential as an efficient adaptive test. In future, these approaches could be used to develop a multidimensional CAT to assess the full range of psychotic experiences in youth., Competing Interests: Declaration of competing interest All authors declare that they have no conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Paranoia may build on negative beliefs held both about the self and others. Compassionate imagery may be one way of reducing such negative beliefs, and hence paranoia. Two studies tested this idea, one targeting compassion for the self and one targeting compassion for others. Two-hundred individuals from the general population scoring highly for paranoia were recruited. The studies used a randomised controlled experimental design, with embedded tests for mediation. Study one targeted self-compassion via creation of a compassionate coach (CC) image. Study two targeted compassion for others via loving kindness meditation (LKM). Individuals repeatedly entered neutral virtual reality social environments. Changes in compassion and paranoia were assessed. Compared to controls, the CC group increased in self-compassion (group difference = 2.12, C.I. = 1.57;2.67, p = <0.0001, d = 1.4) and decreased in paranoia (group difference = -1.73, C.I. = -2.48; -0.98, p = <0.0001, d = 0.8). Change in self-compassion explained 57% of change in paranoia. Compared to controls, the LKM group increased their compassion for others (group difference = 3.26, C.I. = 2.72;3.80, p = <0.0001, d = 1.7), and decreased in paranoia (group difference = -1.70, C.I. = -2.50; -0.89, p = <0.0001, d = 0.8). Change in compassion for others explained 67% of change in paranoia. Targeting negative beliefs about the self and others using compassionate imagery causes reductions in paranoia. Tests in clinical populations are indicated.

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.

Background: Adolescence can be a challenging time, characterized by self-consciousness, heightened regard for peer acceptance, and fear of rejection. Interpersonal concerns are amplified by unpredictable social interactions, both online and offline. This developmental and social context is potentially conducive to the emergence of paranoia. However, research on paranoia during adolescence is scarce., Method: Our aim was to examine the prevalence, structure, and probabilistic causal mechanisms of adolescent paranoia. A representative school cohort of 801 adolescents (11-15 y) completed measures of paranoia and a range of affective, cognitive, and social factors. A Bayesian approach with Directed Acyclic Graphs (DAGs) was used to assess the causal interactions with paranoia., Results: Paranoid thoughts were very common, followed a continuous distribution, and were hierarchically structured. There was an overall paranoia factor, with sub-factors of social fears, physical threat fears, and conspiracy concerns. With all other variables controlled, DAG analysis identified paranoia had dependent relationships with negative affect, peer difficulties, bullying, and cognitive-affective responses to social media. The causal directions could not be fully determined, but it was more likely that negative affect contributed to paranoia and paranoia impacted peer relationships. Problematic social media use did not causally influence paranoia., Conclusions: There is a continuum of paranoia in adolescence and occasional suspicions are common at this age. Anxiety and depression are closely connected with paranoia and may causally contribute to its development. Paranoia may negatively impact adolescent peer relationships. The clinical significance of paranoia in adolescents accessing mental health services must now be established., (© The Author(s) 2018. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Background: Treatment approaches for patients with psychosis need major improvement. Our approach to improvement is twofold: target putative causal mechanisms for psychotic experiences that are treatable and also that patients wish treated. This leads to greater treatment engagement and clinical benefit. To inform mental health service provision we assessed the presence of treatable causal mechanisms and patient treatment preferences., Methods: Patients with non-affective psychosis attending NHS mental health services completed assessments of paranoia, hallucinations, anxious avoidance, worry, self-esteem, insomnia, analytic reasoning, psychological well-being, and treatment preferences., Results: 1809 patients participated. Severe paranoia was present in 53.4% and frequent voices in 48.2%. Of the causal mechanisms, severe worry was present in 67.7%, avoidance at agoraphobic levels in 64.5%, analytic reasoning difficulties in 55.9%, insomnia in 50.1%, poor psychological well-being in 44.3%, strongly negative self-beliefs in 36.6%, and weak positive self-beliefs in 19.2%. Treatment target preferences were: feeling happier (63.2%), worrying less (63.1%), increasing self-confidence (62.1%), increasing activities (59.6%), improving decision-making (56.5%), feeling safer (53.0%), sleeping better (52.3%), and coping with voices (45.3%). Patients with current paranoia and/or hallucinations had higher levels of the causal factors and of wanting these difficulties treated., Conclusions: Patients with non-affective psychosis have high levels of treatable problems such as agoraphobic avoidance, worry, low self-esteem, and insomnia and they would like these difficulties treated. Successful treatment of these difficulties is also likely to decrease psychotic experiences such as paranoia., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: An influential psychological model of persecutory delusions proposed that they are caused by a bias towards holding others responsible for negative events (an externalising attributional bias), preventing the individual from becoming aware of underlying low self-esteem. An early version of the model predicted self-esteem would, therefore, be preserved in people with these delusions, but a later version suggested it would be unstable, and that there would be a discrepancy between explicit and implicit self-esteem, with the latter being lower. We did a comprehensive meta-analytical test of the key predictions of this model and assessed the quality of evidence., Methods: We searched PubMed from Jan 1, 1994, to July 31, 2018, and collated systematic reviews of the defensive model's predictions in relation to persecutory delusions. We also searched PsycINFO, MEDLINE, Embase, and Web of Science for articles published from Jan 1, 2012, to Sept 10, 2016. Cross-sectional data from case-control, longitudinal, or experimental studies that examined self-esteem or the externalising attributional bias in individuals diagnosed as having schizophrenia-spectrum disorder were eligible for meta-analyses of group differences if at least 50% of participants with psychosis also had current persecutory delusions. Uncontrolled and longitudinal studies were included in meta-analyses of correlations and self-esteem instability, respectively. Study and outcome quality were assessed with the Agency for Healthcare Research and Quality assessment tool, and a modified version of Grading of Recommendations Assessment, Development and Evaluation, respectively. The study protocol is registered with PROSPERO, number CRD42016032782., Findings: We screened 3053 records, examined 104 full-text reports, and included 64 eligible studies. Consistent with the predictions of both versions of the model, paranoia severity in psychosis was positively correlated with the degree of externalising attributional bias (21 studies involving 1128 individuals; r=0·18, 95% CI 0·08 to 0·27, with moderate quality evidence). People with persecutory delusions also had a greater externalising attributional bias than non-clinical individuals (27 studies involving 1442 individuals; g=0·48, 95% CI 0·23 to 0·73) and depressed individuals (ten studies involving 421 individuals; g=1·06, 0·48 to 1·63), and people with psychosis without persecutory delusions (11 studies involving 480 individuals; g=0·40, 0·12 to 0·68), all based on moderate quality evidence. Contrary to the predictions in the early version of the model, paranoia severity in psychosis was negatively correlated with explicit self-esteem (23 studies involving 1866 individuals; r=-0·26, 95% CI -0·34 to -0·17, with high quality evidence). People with persecutory delusions also had lower explicit self-esteem than non-clinical individuals (22 studies involving 1256 individuals; g=-0·88, 95% CI -1·10 to -0·66, with high quality evidence) and explicit self-esteem similarly low to that in people with psychosis without persecutory delusions (11 studies involving 644 individuals; g=-0·26, -0·54 to 0·02, with moderate quality evidence). Consistent with the predictions in the later version of the model, self-esteem instability was positively correlated with paranoia severity in psychosis (four studies involving 508 individuals; r=0·23, 95% CI 0·11-0·34, with high quality evidence), and people with persecutory delusions had a greater discrepancy between their implicit and explicit self-esteem than depressed individuals (seven studies involving 398 individuals; g=0·61, 95% CI 0·37 to 0·85, with moderate quality evidence). They had higher explicit self-esteem than depressed individuals (13 studies involving 647 individuals; g=0·89, 95% CI 0·51 to 1·28, with moderate quality evidence), but similarly low implicit self-esteem (seven studies involving 398 individuals; g=-0·19, -0·45 to 0·07, with low quality evidence). In contrast to the later predictions, people with persecutory delusions did not have a greater self-esteem discrepancy than non-clinical individuals (ten studies involving 592 individuals; g=-0·17, 95% CI -0·45 to 0·12), although the evidence was very low quality. People with psychosis with or without persecutory delusions did not differ for implicit self-esteem (four studies involving 167 individuals; g=-0·24, 95% CI -0·77 to 0·30, with low quality evidence) or self-esteem discrepancies (four studies involving 165 individuals; g=0·17, -0·19 to 0·53, with moderate quality evidence)., Interpretation: The predictions that self-esteem would be preserved in people with persecutory delusions in the early version of the paranoia as defence model and that implicit-explicit self-esteem discrepancy would be greater in people with persecutory delusions than in non-clinical individuals and people with psychosis without persecutory delusions in the later version of the model were not supported. By contrast, the later version correctly predicted that people with persecutory delusions have a greater self-esteem discrepancy than people with depression and a greater externalising attributional bias than all control groups, and that both this bias and self-esteem instability are associated with increased paranoia severity. Nevertheless, the reviewed data had limitations. Experimental studies, which might include interventionist-causal trials, are needed., Funding: None., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Childhood emotional and behaviour problems are antecedents for later psychopathology. This study investigated genetic and environmental influences shaping the longitudinal association between childhood emotional and behaviour problems and specific PEs., Method: In a community-based twin sample, parents reported on emotional and behaviour problems when twins were ages 7 and 12 years. At age 16 years, specific PEs were measured using self-reports and parent reports. Structural equation model-fitting was conducted., Results: Childhood emotional and behaviour problems were significantly associated with paranoia, cognitive disorganisation and parent-rated negative symptoms in adolescence (mean r = .15-.38), and to a lesser extent with hallucinations, grandiosity and anhedonia (mean r = .04-.12). Genetic influences on childhood emotional and behaviour problems explained significant proportions of variance in adolescent paranoia (4%), cognitive disorganisation (8%) and parent-rated negative symptoms (3%). Unique environmental influences on childhood emotional and behaviour problems explained ≤1% of variance in PEs. Common environmental influences were only relevant for the relationship between childhood emotional and behaviour problems and parent-rated negative symptoms (explaining 28% of variance) and are partly due to correlated rater effects., Conclusions: Childhood emotional and behaviour problems are significantly, if weakly, associated with adolescent PEs. These associations are driven in part by common genetic influences underlying both emotional and behaviour problems and PEs. However, psychotic experiences in adolescence are largely influenced by genetic and environmental factors that are independent of general childhood emotional and behaviour problems, suggesting they are not merely an extension of childhood emotional and behaviour problems., (© 2017 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.)

Our view is that insomnia may be a causal factor in the occurrence of psychotic experiences such as paranoia and hallucinations. However, the causal relationship is not established. The aim of the study was to investigate the causal role of insomnia in psychotic experiences via a sleep restriction manipulation. The study was a within-subjects crossover design that included a planned mediation analysis. Sixty-eight nonclinical volunteers underwent a sleep loss condition (restricted to 4 h sleep for 3 nights) and a control condition (standard sleep) in randomized order in 2 consecutive weeks, with a weekend washout period. Psychotic experiences (paranoia, hallucinations, grandiosity, and cognitive disorganization) and candidate mediating variables (negative affect and related processes, working memory, decision making, and perceptual processing) were assessed before and after each condition. Actigraphy verified an average sleep duration of 5 h 15 min in the sleep loss condition, vs 6 h 58 min in the control condition. After the sleep loss condition, relative to the control condition, participants reported significant increases in paranoia, hallucinations, and cognitive disorganization, with no significant changes in grandiosity. The sleep loss condition was also associated with significant increases in negative affect, negative self and other cognitions, worry, and working memory impairment. Mediation analyses indicated that changes in psychotic experiences were mediated by changes in negative affect and related processes, but not memory impairment. The overall conclusion is that insomnia has a causal role in the occurrence of certain psychotic experiences, and that a key route is via negative affect.

Background: Previous studies have suggested that cannabidiol has anxiolytic and antipsychotic properties, raising hopes that cannabidiol will translate to the psychiatric clinic. Cannabidiol may be particularly useful for anxiety and paranoia in those at-risk of major mental illness., Methods: Immersion in a controlled 3D virtual-reality scenario was used to assay persecutory ideation and anxiety in a sample of non-clinical volunteers ( n=32) pre-selected for high paranoid traits. Participants were randomised to receive oral cannabidiol (600 mg) or placebo 130 min prior to entering virtual-reality. Well-validated rating scales were used to assay persecutory thinking and anxiety. Salivary cortisol concentration, heart rate and blood pressure were measured over the course of the experimental session., Results: Immersion in the virtual-reality session elicited anxiety as indexed by the Beck's anxiety inventory ( p<0.005), and increased cortisol concentration ( p=0.05), heart rate ( p<0.05) and systolic blood pressure ( p<0.05). However, cannabidiol had no impact upon any of these effects, except for a strong trend to increase anxiety ( p=0.09). Cannabidiol had no effect on persecutory ideation as assayed by the Community Assessment of Psychic Experiences questionnaire or the State Social Paranoia Scale., Conclusions: In contrast to previous studies, there was no evidence of any benefits of cannabidiol on anxiety or persecutory ideation in healthy volunteers with high trait paranoia. However, a larger sample will be required for a definitive study.

Paranoia builds upon feelings of vulnerability. Our clinical experience indicates that negative body image, including concerns regarding weight, may be one source of feeling vulnerable and hence raise the risk of paranoia. There has been no empirical test of an association between body image and paranoia. Our aim was to provide the first test of this issue by examining in epidemiologically representative cohorts the cross-sectional associations between paranoia and a proxy measure of body image. This was an initial exploration of a potentially important but overlooked issue. Data were used from 5515 participants in the US National Comorbidity Survey-Replication (NCS-R). To validate the findings, the analyses were replicated with 10,113 participants in the US National Comorbidity Survey-Adolescents (NCS-A). Concerns about weight were associated with paranoia in the NCS-R (OR = 1.48, p = 0.006, CI = 1.123, 1.955) and NCS-A (OR = 1.67, p < 0.001, CI = 1.490, 1.873). The associations remained significant after controlling for gender and body mass index. The results show that negative body image and paranoia are associated in the general population, consistent with the idea that paranoia may build upon feelings of vulnerability arising from body image concerns. Studies are needed to examine whether there is a causal relationship., (Copyright © 2017. Published by Elsevier B.V.)

Background: Paranoia is one of the most common symptoms of schizophrenia-spectrum disorders, and is associated with significant distress and disruption to the person's life. Developing more effective and accessible psychological interventions for paranoia is a clinical priority. Our research team has approached this challenge in two main ways: firstly, by adopting an interventionist causal approach to increase effectiveness and secondly, by incorporating user-centred inclusive design methods to enhance accessibility and usability. Our resultant new digital intervention, SlowMo, intensively targets a reasoning style associated with paranoia, fast thinking, characterised by jumping to conclusions and belief inflexibility. It consists of an easy-to-use, enjoyable and memorable digital interface. An interactive web-based app facilitates delivery of face-to-face meetings which is then synchronised with an innovative mobile app for use in daily life., Methods/design: We aim to test the clinical efficacy of SlowMo over 24 weeks to determine the mechanisms through which it reduces paranoia, and to identify participant characteristics that moderate its effectiveness. In a parallel-group randomised controlled trial, with 1:1 allocation, 360 participants with distressing persecutory beliefs will be independently randomised to receive either the SlowMo intervention added to treatment as usual (TAU) or TAU, using randomly varying permuted blocks, stratified by paranoia severity and site. Research workers will be blind to therapy allocation. The primary outcome is paranoia severity over 24 weeks; our hypothesised mechanism of change is reasoning; moderators include negative symptoms and working memory; and secondary outcomes include wellbeing, quality of life, and service use. The accessibility, usability and acceptability of the digital platform will be assessed., Discussion: SlowMo has been developed as the first blended digital therapy to target fears of harm from others through an inclusive design approach. In addition to testing its efficacy, this trial will add to our understanding of psychological mechanisms in paranoia. The study will examine the usability and adherence of a novel digital therapy, including an app for self-management, in a large sample of people affected by severe mental health difficulties., Trial Registration: ISRCTN registry, ID: ISRCTN32448671 . Registered prospectively on 30 January 2017. Date assigned 2 February 2017.

Paranoia may be a significant concern during adolescence, but there has been little research on excessive mistrust in young people. In this longitudinal study we set out to test the predictive ability of a number of cognitive, affective, and social factors in the early development of paranoia in a clinical adolescent population. Thirty four help-seeking adolescents, aged 11-16 years, reporting paranoid thoughts and attending mental health services were recruited. Self-report and interview assessments of paranoia were conducted at baseline. Measures relating to a cognitive model of persecutory delusions were completed. Paranoia was reassessed after three months with thirty three participants. Significant predictors of paranoia persistence were anxiety, depression, worry, negative self-beliefs, perceptual anomalies, insomnia, affective reactivity, bullying, and cyber victimization. No effect was found for reasoning bias or negative perceptions of academic ability, social competence, and physical appearance. In conclusion, many of the maintenance factors implicated in adult paranoia are likely to prove important in the early development of paranoia in young people. Further experimental and treatment studies are now needed to examine the causal role of these factors in the occurrence of paranoia in adolescents., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Sleep difficulties might be a contributory causal factor in the occurrence of mental health problems. If this is true, improving sleep should benefit psychological health. We aimed to determine whether treating insomnia leads to a reduction in paranoia and hallucinations., Methods: We did this single-blind, randomised controlled trial (OASIS) at 26 UK universities. University students with insomnia were randomly assigned (1:1) with simple randomisation to receive digital cognitive behavioural therapy (CBT) for insomnia or usual care, and the research team were masked to the treatment. Online assessments took place at weeks 0, 3, 10 (end of therapy), and 22. The primary outcome measures were for insomnia, paranoia, and hallucinatory experiences. We did intention-to-treat analyses. The trial is registered with the ISRCTN registry, number ISRCTN61272251., Findings: Between March 5, 2015, and Feb 17, 2016, we randomly assigned 3755 participants to receive digital CBT for insomnia (n=1891) or usual practice (n=1864). Compared with usual practice, the sleep intervention at 10 weeks reduced insomnia (adjusted difference 4·78, 95% CI 4·29 to 5·26, Cohen's d=1·11; p<0·0001), paranoia (-2·22, -2·98 to -1·45, Cohen's d=0·19; p<0·0001), and hallucinations (-1·58, -1·98 to -1·18, Cohen's d=0·24; p<0·0001). Insomnia was a mediator of change in paranoia and hallucinations. No adverse events were reported., Interpretation: To our knowledge, this is the largest randomised controlled trial of a psychological intervention for a mental health problem. It provides strong evidence that insomnia is a causal factor in the occurrence of psychotic experiences and other mental health problems. Whether the results generalise beyond a student population requires testing. The treatment of disrupted sleep might require a higher priority in mental health provision., Funding: Wellcome Trust., (Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Worry may be common in patients with paranoia and a contributory causal factor in the occurrence of the delusions. A number of psychological mechanisms have been linked to the occurrence of worry in emotional disorders but these are yet to be investigated in psychosis. The primary aim of the study was to test the links between five main worry mechanisms - perseverative thinking, catastrophizing, stop rules, metacognitive beliefs, and intolerance of uncertainty - and the cognitive style of worry in patients with persecutory delusions., Method: One hundred and fifty patients with persecutory delusions completed assessments of paranoia, worry, and worry mechanisms., Results: Worry in patients with psychosis was associated with the following: a perseverative thinking style, an 'as many as can' stop rule, a range of metacognitive beliefs (cognitive confidence, worry as uncontrollable and the need to control thoughts), and intolerance of uncertainty. Higher levels of worry were associated with higher levels of paranoia. There was also evidence that intolerance of uncertainty and the metacognitive belief concerning the need to control thoughts were independently associated with paranoia., Conclusions: Worry in patients with persecutory delusions may well be understood by similar underlying mechanisms as worry in emotional disorders. This supports the use of interventions targeting worry, suitably modified, for patients with psychosis., Practitioner Points: Worry is a significant concern for patients with paranoia Worry in paranoia is likely to be caused by similar mechanisms as worry in emotional disorders The results support the recent trial findings that standard techniques for treating worry in anxiety, suitably modified, are applicable for patients with paranoia LIMITATIONS: The findings are limited by the self-report nature of measures and by the study design which precludes any assumptions about the direction of causality between the psychological mechanisms and worry., (© 2016 The British Psychological Society.)

Background: Many patients do not respond adequately to current pharmacological or psychological treatments for psychosis. Persistent persecutory delusions are common in clinical services, and cause considerable patient distress and impairment. Our aim has been to build a new translational personalized treatment, with the potential for wide use, that leads to high rates of recovery in persistent persecutory delusions. We have been developing, and evaluating individually, brief modular interventions, each targeting a key causal factor identified from our cognitive model. These modules are now combined in "The Feeling Safe Programme"., Aims: To test the feasibility of a new translational modular treatment for persistent persecutory delusions and provide initial efficacy data., Method: 12 patients with persistent persecutory delusions in the context of non-affective psychosis were offered the 6-month Feeling Safe Programme. After assessment, patients chose from a personalized menu of treatment options. Four weekly baseline assessments were carried out, followed by monthly assessments. Recovery in the delusion was defined as conviction falling below 50% (greater doubt than certainty)., Results: 11 patients completed the intervention. One patient withdrew before the first monthly assessment due to physical health problems. An average of 20 sessions (SD = 4.4) were received. Posttreatment, 7 out of 11 (64%) patients had recovery in their persistent delusions. Satisfaction ratings were high., Conclusions: The Feeling Safe Programme is feasible to use and was associated with large clinical benefits. To our knowledge this is the first treatment report focused on delusion recovery. The treatment will be tested in a randomized controlled trial.

Psychotic disorders and major depression, both typically adult-onset conditions, often co-occur. At younger ages psychotic experiences and depressive symptoms are often reported in the community. We used a genetically sensitive longitudinal design to investigate the relationship between psychotic experiences and depressive symptoms in adolescence. A representative community sample of twins from England and Wales was employed. Self-rated depressive symptoms, paranoia, hallucinations, cognitive disorganization, grandiosity, anhedonia, and parent-rated negative symptoms were collected when the twins were age 16 (N = 9618) and again on a representative subsample 9 months later (N = 2873). Direction and aetiology of associations were assessed using genetically informative cross-lagged models. Depressive symptoms were moderately correlated with paranoia, hallucinations, and cognitive disorganization. Lower correlations were observed between depression and anhedonia, and depression and parent-rated negative symptoms. Nonsignificant correlations were observed between depression and grandiosity. Largely the same genetic effects influenced depression and paranoia, depression and hallucinations, and depression and cognitive disorganization. Modest overlap in environmental influences also played a role in the associations. Significant bi-directional longitudinal associations were observed between depression and paranoia. Hallucinations and cognitive disorganization during adolescence were found to impact later depression, even after controlling for earlier levels of depression. Our study shows that psychotic experiences and depression, as traits in the community, have a high genetic overlap in mid-adolescence. Future research should test the prediction stemming from our longitudinal results, namely that reducing or ameliorating positive and cognitive psychotic experiences in adolescence would decrease later depressive symptoms., (© The Author 2016. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Background: Persecutory delusions may be unfounded threat beliefs maintained by safety-seeking behaviours that prevent disconfirmatory evidence being successfully processed. Use of virtual reality could facilitate new learning., Aims: To test the hypothesis that enabling patients to test the threat predictions of persecutory delusions in virtual reality social environments with the dropping of safety-seeking behaviours (virtual reality cognitive therapy) would lead to greater delusion reduction than exposure alone (virtual reality exposure)., Method: Conviction in delusions and distress in a real-world situation were assessed in 30 patients with persecutory delusions. Patients were then randomised to virtual reality cognitive therapy or virtual reality exposure, both with 30 min in graded virtual reality social environments. Delusion conviction and real-world distress were then reassessed., Results: In comparison with exposure, virtual reality cognitive therapy led to large reductions in delusional conviction (reduction 22.0%, P = 0.024, Cohen's d = 1.3) and real-world distress (reduction 19.6%, P = 0.020, Cohen's d = 0.8)., Conclusion: Cognitive therapy using virtual reality could prove highly effective in treating delusions., (© The Royal College of Psychiatrists 2016.)

There has been growing awareness of the high prevalence of negative cognitions about the self in patients with persecutory delusions, and it has been proposed that paranoid fears build upon these perceived vulnerabilities. This study aimed to investigate for the first time a wide range of different conceptualisations of the negative self, and to examine associations with suicidal ideation, in patients with persecutory delusions. Twenty-one patients with persecutory delusions and twenty-one non-clinical individuals completed measures relating to negative self cognitions. The delusions group also completed a measure of suicidal ideation. It was found that the patients with persecutory delusions had low self-compassion, low self-esteem, increased fears of being mad, beliefs of inferiority to others, negative self-schemas, and low positive self-schemas when compared to the non-clinical control group. The effect sizes (Cohen's d) were large, and the different conceptualisations of negative self cognitions were highly associated with one another. Self-stigma did not differ between the two groups. Furthermore, suicidal ideation was highly associated with low self-compassion, low self-esteem, fears of madness, and negative self-schema but not self-stigma. This study shows marked negative self cognitions in patients with persecutory delusions. These are likely to prove targets of clinical interventions, with patient preference most likely determining the best conceptualisation of negative self cognitions for clinicians to use., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Persecutory delusions (strong unfounded fears that others intend harm to the person) occur in more than 70 % of the patients diagnosed with schizophrenia. This major psychotic experience is a key clinical target, for which substantial improvement in treatment is needed. Our aim is to use advances in theoretical understanding to develop a much more efficacious treatment that leads to recovery in at least 50 % of people with persistent persecutory delusions. Our cognitive conceptualisation is that persecutory delusions are threat beliefs, developed in the context of genetic and environmental risk, maintained by a number of psychological processes including excessive worry, low self-confidence, intolerance of anxious affect and other internal anomalous experiences, reasoning biases, and safety-seeking strategies. The clinical implication is that safety has to be relearned, by entering the feared situations after reduction of the influence of the maintenance factors. We have been individually evaluating modules targeting causal factors. These will now be tested together as a full treatment, called The Feeling Safe Programme. The treatment is modular, personalised, and includes patient preference. We will test whether the new treatment leads to greater recovery in persistent persecutory delusions, psychological well-being, and activity levels compared to befriending (that is, controlling for therapist attention)., Methods/design: The Feeling Safe Study is a parallel group randomised controlled trial for 150 patients who have persecutory delusions despite previous treatment in mental health services. Patients will be randomised (1:1 ratio) to The Feeling Safe Programme or befriending (both provided in 20 sessions over 6 months). Standard care will continue as usual. Online randomisation will use a permuted blocks algorithm, with randomly varying block size, stratified by therapist. Assessments, by a rater blind to allocation, will be conducted at 0, 6 (post treatment), and 12 months. The primary outcome is the level of delusional conviction at 6 months. Secondary outcomes include levels of psychological well-being, suicidal ideation, and activity. All main analyses will be intention-to-treat. The trial is funded by the NHS National Institute for Health Research., Discussion: The Feeling Safe study will provide a Phase II evaluation of a new targeted translational psychological treatment for persecutory delusions., Trial Registration: Current Controlled Trials ISRCTN18705064 (registered 11 November 2015).

Background: Paranoia may build directly upon negative thoughts about the self. There have been few direct experimental tests of this hypothesis., Aims: The aim of the study was to test the immediate effects of manipulating self-esteem in individuals vulnerable to paranoia., Method: A two condition cross-over experimental test was conducted. The participants were 26 males reporting paranoid ideation in the past month. Each participant experienced a neutral immersive virtual reality (VR) social environment twice. Before VR participants received a low self-confidence manipulation or a high self-confidence manipulation. The order of manipulation type was randomized. Paranoia about the VR avatars was assessed., Results: The low self-confidence manipulation, relative to the high self-confidence manipulation, led to significantly more negative social comparison in virtual reality and higher levels of paranoia., Conclusions: Level of self-confidence affects the occurrence of paranoia in vulnerable individuals. The clinical implication is that interventions designed to improve self-confidence may reduce persecutory ideation.

Background: The experience of social defeat may increase the risk of developing psychotic symptoms and psychotic disorders. We studied the relationship between social defeat and paranoid appraisal in people at high risk for psychosis in an experimental social environment created using Virtual Reality (VR)., Method: We recruited UHR (N=64) participants and healthy volunteers (N=43). Regression analysis was used to investigate which baseline measures predicted paranoid appraisals during the VR experience., Results: At baseline, UHR subjects reported significantly higher levels of social defeat than controls (OR=.957, (CI) .941-.973, p<.000). Following exposure to the VR social environment, the UHR group reported significantly more paranoid appraisals than the controls (p<.000). Within the UHR sample, paranoid appraisals were predicted by the level of social defeat at baseline, as well as by the severity of positive psychotic and disorganised symptoms., Conclusion: In people who are at high risk of psychosis, a history of social defeat is associated with an increased likelihood of making paranoid appraisals of social interactions. This is consistent with the notion that social defeat increases the risk of developing psychosis., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background and Objectives: Delusional beliefs with persecutory content are common in psychosis, but difficult to treat. Interventions targeting hypothesised causal and maintaining factors have been proposed as a way of improving therapy. The current study is a feasibility randomised controlled trial of the 'Thinking Well (TW)' intervention: This novel approach combines the recently developed Maudsley Review Training Programme (MRTP), with additional, focussed cognitive-behavioural therapy sessions., Methods: 31 participants with distressing persecutory delusions and schizophrenia spectrum disorders were randomised to TW or to treatment as usual in a 2:1 ratio. Participants completed outcome assessments at 0 (baseline), 1 (post-MRTP), 6 (post-TW) and 8 (follow-up) weeks. Key outcomes included belief flexibility, paranoia, and delusional conviction and distress. Participants allocated to TW completed the MRTP package and four CBT sessions with a clinical psychologist., Results: Recruitment proved feasible. Participants reported the intervention was relevant and had resulted in positive changes in thinking and mood, which they could use in everyday life. Treatment effects were moderate-large for key outcomes including belief flexibility, paranoia conviction and distress. The additional TW sessions appeared to confer benefits over MRTP alone., Limitations: Assessments were not carried out blind to treatment condition. Recruitment was opportunistic, from an identified pool of research participants. Finally, a few participants had already completed the MRTP as part of a previous study., Conclusions: The TW intervention appears to be feasible and acceptable to participants, and the effects of treatment are promising. A fully powered randomised controlled trial of the intervention is warranted., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: For many patients with persecutory delusions, leaving home and going into crowded streets is a key clinical problem. In this study we aimed to inform treatment development by determining the psychological mechanisms whereby busy urban environments increase paranoia. In a randomized design with prespecified mediation analysis, we compared the effects on patients of going outside into a busy social environment with staying inside., Methods: Fifty-nine patients with current persecutory delusions, in the context of nonaffective psychosis, reporting fears when going outside were assessed on factors from a cognitive model of paranoia. They were then randomized either to enter a busy local shopping street or to complete a neutral task indoors. They were then reassessed on the measures., Results: Compared with staying inside, the street exposure condition resulted in significant increases in paranoia, voices, anxiety, negative beliefs about the self, and negative beliefs about others. There was also a decrease in positive thoughts about the self. There was no alteration in reasoning processes. There were indications that the increase in paranoia was partially mediated by increases in anxiety (45%), depression (38%), and negative beliefs about others (45%)., Conclusions: We found that increases in negative affect may form an important route by which social exposure in urban environments triggers paranoid thoughts. The study provides an illustration of how an experimental approach can be applied to help understand a specific difficulty for patients with psychosis. In future studies the effects of specific elements of the social environment could be tested., (© The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Background: Bullying is a risk factor for developing psychotic experiences (PEs). Whether bullying is associated with particular PEs, and the extent to which genes and environments influence the association, are unknown. This study investigated which specific PEs in adolescence are associated with earlier bullying victimization and the genetic and environmental contributions underlying their association., Method: Participants were 4826 twin pairs from a longitudinal community-based twin study in England and Wales who reported on their bullying victimization at the age of 12 years. Measures of specific PEs (self-rated Paranoia, Hallucinations, Cognitive disorganization, Grandiosity, Anhedonia, and parent-rated Negative Symptoms) were recorded at age of 16 years., Results: Childhood bullying victimization was most strongly associated with Paranoia in adolescence (r = .26; P < .01), with weaker associations with Hallucinations, Cognitive Disorganization, parent-rated Negative Symptoms (r = .12-.20; P < .01), Grandiosity (r = .04; P < .05), and Anhedonia (r = .00, n.s.). Bivariate twin model-fitting demonstrated that bullying victimization and Paranoia were both heritable (35% and 52%, respectively) with unique environmental influences (39% and 48%, respectively), and bullying victimization showed common environmental influences (26%). The association between bullying victimization and Paranoia operated almost entirely via genetic influences (bivariate heritability = 93%), with considerable genetic overlap (genetic correlation = .55)., Conclusion: In contrast to the assumed role of bullying victimization as an environmental trigger, these data suggest that bullying victimization in late childhood is particularly linked to self-rated Paranoia in adolescence via a shared genetic propensity. Clinically, individuals with a history of bullying victimization are predicted to be particularly susceptible to paranoid symptoms., (© The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Background: Given the evidence that reasoning biases contribute to delusional persistence and change, several research groups have made systematic efforts to modify them. The current experiment tested the hypothesis that targeting reasoning biases would result in change in delusions., Methods: One hundred and one participants with current delusions and schizophrenia spectrum psychosis were randomly allocated to a brief computerized reasoning training intervention or to a control condition involving computer-based activities of similar duration. The primary hypotheses tested were that the reasoning training intervention, would improve (1) data gathering and belief flexibility and (2) delusional thinking, specifically paranoia. We then tested whether the changes in paranoia were mediated by changes in data gathering and flexibility, and whether working memory and negative symptoms moderated any intervention effects., Results: On an intention-to-treat analysis, there were significant improvements in state paranoia and reasoning in the experimental compared with the control condition. There was evidence that changes in reasoning mediated changes in paranoia, although this effect fell just outside the conventional level of significance after adjustment for baseline confounders. Working memory and negative symptoms significantly moderated the effects of the intervention on reasoning., Conclusion: The study demonstrated the effectiveness of a brief reasoning intervention in improving both reasoning processes and paranoia. It thereby provides proof-of-concept evidence that reasoning is a promising intermediary target in interventions to ameliorate delusions, and thus supports the value of developing this approach as a longer therapeutic intervention., (© The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Paranoia is receiving increasing attention in its own right, since it is a central experience of psychotic disorders and a marker of the health of a society. Paranoia is associated with use of the most commonly taken illicit drug, cannabis. The objective was to determine whether the principal psychoactive ingredient of cannabis-∆(9)-tetrahydrocannabinol (THC)-causes paranoia and to use the drug as a probe to identify key cognitive mechanisms underlying paranoia. A randomized, placebo-controlled, between-groups test of the effects of intravenous THC was conducted. A total of 121 individuals with paranoid ideation were randomized to receive placebo, THC, or THC preceded by a cognitive awareness condition. Paranoia was assessed extensively via a real social situation, an immersive virtual reality experiment, and standard self-report and interviewer measures. Putative causal factors were assessed. Principal components analysis was used to create a composite paranoia score and composite causal variables to be tested in a mediation analysis. THC significantly increased paranoia, negative affect (anxiety, worry, depression, negative thoughts about the self), and a range of anomalous experiences, and reduced working memory capacity. The increase in negative affect and in anomalous experiences fully accounted for the increase in paranoia. Working memory changes did not lead to paranoia. Making participants aware of the effects of THC had little impact. In this largest study of intravenous THC, it was definitively demonstrated that the drug triggers paranoid thoughts in vulnerable individuals. The most likely mechanism of action causing paranoia was the generation of negative affect and anomalous experiences., (© The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Background: Environmental factors have been associated with psychosis but there is little qualitative research looking at how the ongoing interaction between individual and environment maintains psychotic symptoms., Aims: The current study investigates how people with persecutory delusions interpret events in a virtual neutral social environment using qualitative methodology., Method: 20 participants with persecutory delusions and 20 controls entered a virtual underground train containing neutral characters. Under these circumstances, people with persecutory delusions reported similar levels of paranoia as non-clinical participants. The transcripts of a post-virtual reality interview of the first 10 participants in each group were analysed., Results: Thematic analyses of interviews focusing on the decision making process associated with attributing intentions of computer-generated characters revealed 11 themes grouped in 3 main categories (evidence in favour of paranoid appraisals, evidence against paranoid appraisals, other behaviour)., Conclusions: People with current persecutory delusions are able to use a range of similar strategies to healthy volunteers when making judgements about potential threat in a neutral environment that does not elicit anxiety, but they are less likely than controls to engage in active hypothesis-testing and instead favour experiencing "affect" as evidence of persecutory intention.

Objective: Social psychological research has indicated that intentional harm may be perceived as causing greater damage than unintentional harm. It has been proposed that this harm magnification is a consequence of a need to blame, condemn and punish ("blame motivation"). The objective of the current study was to replicate these findings and to test whether such judgements about harmful events are associated with the level of an individual's paranoia., Method: Three hundred adults read a scenario in which a head of a company causes a reduction in employees' pay. Participants were randomly allocated to versions in which the outcome of the executive's action was intended or unintended. Ratings were made of intent, harm caused and blame motivation. Participants also completed assessments of paranoia and anxiety., Results: Intentional harm was judged as causing worse outcomes than unintentional harm, explaining a small amount of variance in harm scores. Paranoia moderated judgements of intent and blame motivation but not the degree of harm caused; high paranoia, relative to low paranoia, was associated with the unintentional scenario generating higher attributions of intent and blame and the intentional scenario generating lower attributions of intent and blame. Anxiety levels did not affect judgements., Conclusions: The study supports the theory that there is a reasoning bias that magnifies the consequences of intentional harm relative to unintentional harm. In the initial judgement about intent, people with paranoia are less accurate in their use of contextual information.

Information in the environment is frequently ambiguous in meaning. Emotional ambiguity, such as the stare of a stranger, or the scream of a child, encompasses possible good or bad emotional consequences. Those with elevated vulnerability to affective disorders tend to interpret such material more negatively than those without, a phenomenon known as "negative interpretation bias." In this study we examined the relationship between vulnerability to psychosis, measured by trait paranoia, and interpretation bias. One set of material permitted broadly positive/negative (valenced) interpretations, while another allowed more or less paranoid interpretations, allowing us to also investigate the content specificity of interpretation biases associated with paranoia. Regression analyses (n=70) revealed that trait paranoia, trait anxiety, and cognitive inflexibility predicted paranoid interpretation bias, whereas trait anxiety and cognitive inflexibility predicted negative interpretation bias. In a group comparison those with high levels of trait paranoia were negatively biased in their interpretations of ambiguous information relative to those with low trait paranoia, and this effect was most pronounced for material directly related to paranoid concerns. Together these data suggest that a negative interpretation bias occurs in those with elevated vulnerability to paranoia, and that this bias may be strongest for material matching paranoid beliefs. We conclude that content-specific biases may be important in the cause and maintenance of paranoid symptoms., (Copyright © 2014. Published by Elsevier Ltd.)

Background and Objectives: A previous study has shown an association of paranoid thinking with a reliance on rapid intuitive ('experiential') reasoning and less use of slower effortful analytic ('rational') reasoning. The objectives of the new study were to replicate the test of paranoia and reasoning styles in a large general population sample and to assess the use of these reasoning styles in patients with persecutory delusions., Method: 30 Patients with persecutory delusions in the context of a non-affective psychotic disorder and 1000 non-clinical individuals completed self-report assessments of paranoia and reasoning styles., Results: The patients with delusions reported lower levels of both experiential and analytic reasoning than the non-clinical individuals (effect sizes small to moderate). Both self-rated ability and engagement with the reasoning styles were lower in the clinical group. Within the non-clinical group, greater levels of paranoia were associated with lower levels of analytic reasoning, but there was no association with experiential reasoning., Limitations: The study is cross-sectional and cannot determine whether the reasoning styles contribute to the occurrence of paranoia. It also cannot be determined whether the patient group's lower reasoning scores are specifically associated with the delusions., Conclusions: Clinical paranoia is associated with less reported use of analytic and experiential reasoning. This may reflect patients with current delusions being unconfident in their reasoning abilities or less aware of decision-making processes and hence less able to re-evaluate fearful cognitions. The dual process theory of reasoning may provide a helpful framework in which to discuss with patients decision-making styles., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Research has shown that paranoia may directly build on negative ideas about the self. Feeling inferior can lead to ideas of vulnerability. The clinical prediction is that decreasing negative self cognitions will reduce paranoia., Method: Thirty patients with persistent persecutory delusions were randomised to receive brief CBT in addition to standard care or to standard care (ISRCTN06118265). The six session intervention was designed to decrease negative, and increase positive, self cognitions. Assessments at baseline, 8 weeks (posttreatment) and 12 weeks were carried out by a rater blind to allocation. The primary outcomes were posttreatment scores for negative self beliefs and paranoia. Secondary outcomes were psychological well-being, positive beliefs about the self, persecutory delusions, social comparison, self-esteem, anxiety, and depression., Results: Trial recruitment and retention were feasible and the intervention highly acceptable to the patients. All patients provided follow-up data. Posttreatment there was a small reduction in negative self beliefs (Cohen's d=0.24) and a moderate reduction in paranoia (d=0.59), but these were not statistically significant. There were statistically significant improvements in psychological well-being (d=1.16), positive beliefs about the self (d=1.00), negative social comparison (d=0.88), self-esteem (d=0.62), and depression (d=0.68). No improvements were maintained. No adverse events were associated with the intervention., Conclusions: The intervention produced short-term gains consistent with the prediction that improving cognitions about the self will reduce persecutory delusions. The improvement in psychological well-being is important in its own right. We recommend that the different elements of the intervention are tested separately and that the treatment is lengthened., (Copyright © 2014. Published by Elsevier B.V.)

Delusions are, in part, attempts to explain confusing anomalous experience. Depersonalization, a key subset of anomalous experience, has been little studied in relation to persecutory delusions. The aims of this study were to assess the presence of depersonalization in patients with persecutory delusions and to examine associations with levels of paranoia and worry. Fifty patients with a current persecutory delusion completed measures of depersonalization, psychotic symptoms, and worry. Depersonalization experiences were common: 30 patients (60%) each reported at least 10 different depersonalization symptoms occurring often. A greater number of depersonalization experiences were associated with higher levels of paranoia and worry. The positive association of worry and paranoia became nonsignificant when controlling for depersonalization. Overall, depersonalization may be common in patients with persecutory delusions and is associated with the severity of paranoia. The results are consistent with the view that worry may cause depersonalization experiences that contribute to the occurrence of paranoid thoughts.

Background: Research on paranoia in adults suggests a spectrum of severity, but this dimensional approach has yet to be applied to children or to groups from different countries., Aims: To investigate the structure, prevalence and correlates of mistrust in children living in the U.K. and Hong Kong., Method: Children aged 8-14 years from the U.K. (n = 1086) and Hong Kong (n = 1412) completed a newly developed mistrust questionnaire as well as standard questionnaire measures of anxiety, self-esteem, aggression and callous-unemotional traits., Results: Confirmatory factor analysis of the U.K. data supported a three-factor mode--mistrust at home, mistrust at school and eneral mistrust - with a clear positive skew in the data: just 3.4%, 8.5% and 4.1% of the children endorsed at least half of the mistrust items for home, school and general subscales respectively. These findings were replicated in Hong Kong. Moreover, compared with their peers, 'mistrustful' children (in both countries) reported elevated rates of anxiety, low self-esteem, aggression and callous-unemotional traits., Conclusions: Mistrust may exist as a quantitative trait in children, which, as in adults, is associated with elevated risks of internalising and externalising problems., (Royal College of Psychiatrists.)

Presentation of social situations via immersive virtual reality (VR) has the potential to be an ecologically valid way of assessing psychiatric symptoms. In this study we assess the occurrence of paranoid thinking and of symptoms of posttraumatic stress disorder (PTSD) in response to a single neutral VR social environment as predictors of later psychiatric symptoms assessed by standard methods. One hundred six people entered an immersive VR social environment (a train ride), presented via a head-mounted display, 4 weeks after having attended hospital because of a physical assault. Paranoid thinking about the neutral computer-generated characters and the occurrence of PTSD symptoms in VR were assessed. Reactions in VR were then used to predict the occurrence 6 months later of symptoms of paranoia and PTSD, as assessed by standard interviewer and self-report methods. Responses to VR predicted the severity of paranoia and PTSD symptoms as assessed by standard measures 6 months later. The VR assessments also added predictive value to the baseline interviewer methods, especially for paranoia. Brief exposure to environments presented via virtual reality provides a symptom assessment with predictive ability over many months. VR assessment may be of particular benefit for difficult to assess problems, such as paranoia, that have no gold standard assessment method. In the future, VR environments may be used in the clinic to complement standard self-report and clinical interview methods., (PsycINFO Database Record (c) 2014 APA, all rights reserved.)

Mistrust of others may build upon perceptions of the self as vulnerable, consistent with an association of paranoia with perceived lower social rank. Height is a marker of social status and authority. Therefore we tested the effect of manipulating height, as a proxy for social rank, on paranoia. Height was manipulated within an immersive virtual reality simulation. Sixty females who reported paranoia experienced a virtual reality train ride twice: at their normal and reduced height. Paranoia and social comparison were assessed. Reducing a person's height resulted in more negative views of the self in comparison with other people and increased levels of paranoia. The increase in paranoia was fully mediated by changes in social comparison. The study provides the first demonstration that reducing height in a social situation increases the occurrence of paranoia. The findings indicate that negative social comparison is a cause of mistrust., (Copyright © 2013 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Purpose: Persecutory delusions are a central psychotic experience, at the severe end of a paranoia spectrum in the general population. The aim of the review is to provide an introduction to the understanding of persecutory delusions, highlight key putative causal factors that have the potential to be translated into efficacious treatment, and indicate future research directions., Methods: A narrative literature review was undertaken to highlight the main recent areas of empirical study concerning non-clinical and clinical paranoia., Results: Six main proximal causal factors are identified: a worry thinking style, negative beliefs about the self, interpersonal sensitivity, sleep disturbance, anomalous internal experience, and reasoning biases. Each has plausible mechanistic links to the occurrence of paranoia. These causal factors may be influenced by a number of social circumstances, including adverse events, illicit drug use, and urban environments., Conclusions: There have been numerous replicated empirical findings leading to a significant advance in the understanding of persecutory delusions, now beginning to be translated into cognitive treatments. The first trials specifically focussed on patients who have persecutory delusions in the context of psychotic diagnoses are occurring. Initial evidence of efficacy is very promising.

We aimed to characterize multiple psychotic experiences, each assessed on a spectrum of severity (ie, quantitatively), in a general population sample of adolescents. Over five thousand 16-year-old twins and their parents completed the newly devised Specific Psychotic Experiences Questionnaire (SPEQ); a subsample repeated it approximately 9 months later. SPEQ was investigated in terms of factor structure, intersubscale correlations, frequency of endorsement and reported distress, reliability and validity, associations with traits of anxiety, depression and personality, and sex differences. Principal component analysis revealed a 6-component solution: paranoia, hallucinations, cognitive disorganization, grandiosity, anhedonia, and parent-rated negative symptoms. These components formed the basis of 6 subscales. Correlations between different experiences were low to moderate. All SPEQ subscales, except Grandiosity, correlated significantly with traits of anxiety, depression, and neuroticism. Scales showed good internal consistency, test-retest reliability, and convergent validity. Girls endorsed more paranoia, hallucinations, and cognitive disorganization; boys reported more grandiosity and anhedonia and had more parent-rated negative symptoms. As in adults at high risk for psychosis and with psychotic disorders, psychotic experiences in adolescents are characterized by multiple components. The study of psychotic experiences as distinct dimensional quantitative traits is likely to prove an important strategy for future research, and the SPEQ is a self- and parent-report questionnaire battery that embodies this approach., (© The Author 2013. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)