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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.

Background Persecutory fears build on feelings of vulnerability that arise from negative views of the self. Body image concerns have the potential to be a powerful driver of feelings of vulnerability. Body image concerns are likely raised in patients with psychosis given the frequent weight gain. We examined for the first-time body esteem – the self-evaluation of appearance – in relation to symptom and psychological correlates in patients with current persecutory delusions. Methods One-hundred and fifteen patients with persecutory delusions in the context of non-affective psychosis completed assessments of body image, self-esteem, body mass index (BMI), psychiatric symptoms and well-being. Body esteem was also assessed in 200 individuals from the general population. Results Levels of body esteem were much lower in patients with psychosis than non-clinical controls (d = 1.2, p < 0.001). In patients, body esteem was lower in women than men, and in the overweight or obese BMI categories than the normal weight range. Body image concerns were associated with higher levels of depression (r = −0.55, p < 0.001), negative self-beliefs (r = −0.52, p < 0.001), paranoia (r = −0.25, p = 0.006) and hallucinations (r = −0.21, p = 0.025). Body image concerns were associated with lower levels of psychological wellbeing (r = 0.41, p < 0.001), positive self-beliefs (r = 0.40, p < 0.001), quality of life (r = 0.23, p = 0.015) and overall health (r = 0.31, p = 0.001). Conclusions Patients with current persecutory delusions have low body esteem. Body image concerns are associated with poorer physical and mental health, including more severe psychotic experiences. Improving body image for patients with psychosis is a plausible target of intervention, with the potential to result in a wide range of benefits.

Background\ud The SlowMo study demonstrated the effects of SlowMo, an eight-session digitally supported reasoning intervention, on paranoia in a large-scale randomized-controlled trial with 362 participants with schizophrenia-spectrum psychosis.\ud \ud Aim\ud The current evaluation aimed to investigate the impact of Patient and Public Involvement (PPI) in the SlowMo study.\ud \ud Method\ud PPI members were six women and three men from Sussex, Oxford and London with experience of using mental health services for psychosis. They received training and met at least 3-monthly throughout the project. The impact of PPI was captured quantitatively and qualitatively through (i) a PPI log of recommendations and implementation; (ii) written subjective experiences of PPI members; (iii) meeting minutes; and (iv) outputs produced.\ud \ud Results\ud The PPI log revealed 107 recommendations arising from PPI meetings, of which 87 (81%) were implemented. Implementation was greater for recruitment-, data collection- and organization-related actions than for dissemination and emergent innovations. Qualitative feedback revealed impacts on study recruitment, data collection, PPI participants' confidence, knowledge, career aspirations and society more widely. Outputs produced included a film about psychosis that aired on BBC primetime television, novel webpages and journal articles. Barriers to PPI impact included geography, travel, funding, co-ordination and well-being.\ud \ud Discussion\ud A future challenge for PPI impact will be the extent to which peer innovation (innovative PPI-led ideas) can be supported within research study delivery.\ud \ud Patient and Public Contribution\ud Planned Patient and Public Contribution in SlowMo comprised consultation and collaboration in (i) design, (ii) recruitment, (iii) qualitative interviews and analysis of service users' experiences of SlowMo therapy and (iv) dissemination.

Key Points Question Can a brief blended digital therapy targeting reasoning (SlowMo) improve paranoia for adults with psychosis when added to usual care? Findings This randomized clinical trial of 361 individuals with clinical paranoia did not demonstrate that SlowMo therapy reduced the primary outcome of self-reported paranoia at 24 weeks compared with usual care only, although secondary beneficial effects were found on this measure at 12 weeks. Self-reported persecution and observer-rated paranoia were improved at both points. Meaning SlowMo, a digitally supported reasoning intervention, indicated a beneficial effect on paranoia; further work to optimize the effects of SlowMo is warranted., This randomized clinical trial investigates the effects and mechanisms of action of SlowMo, a digitally supported reasoning intervention, plus usual care compared with usual care only among individuals with clinical paranoia., 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

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.

Paranoid thoughts are common across the psychosis continuum. It is well established that reasoning biases (conceived as an overreliance on fast thinking and lack of willingness and/or ability to engage in slow thinking) contribute to paranoia. Targeted therapies have shown promise in improving reasoning in order to reduce paranoia. Psychometrically robust and easy-to-use measures of these thinking styles will assist research and clinical practice. Existing assessments include experimental tasks that are complex to administer or self-report measures that have limitations in comprehensively assessing cognitive biases in paranoia. We have developed the first questionnaire to assess fast and slow thinking biases related to paranoid thoughts, and here report on its evaluation. In study 1, we generated, evaluated, and extracted items reflecting reasoning, and assessed their reliability and validity in a non-clinical sample (n = 209). In study 2, we replicated the factor analysis and psychometric evaluation in a clinical sample (n = 265). The resultant Fast and Slow Thinking (FaST) questionnaire consists of two 5-item scales reflecting fast and slow thinking and is therefore brief and suitable for use in both research and clinical practice. The fast thinking scale is reliable and valid. Reliability and criterion validity of the slow scale shows promise. It had limited construct validity with objective reasoning assessments in the clinical group, possibly due to impaired meta-cognitive awareness of slow thinking. We recommend the FaST questionnaire as a new tool for improving understanding of reasoning biases in paranoia and supporting targeted psychological therapies.

Background There are high rates of obesity and low self-esteem in patients with psychosis. The occurrence of negative voice content directly about appearance is therefore plausible. Derogatory comments about appearance are likely to be distressing, increase depression and contribute to social withdrawal. Aims To systematically assess the occurrence of voice content regarding appearance and identify correlates. Method Sixty patients experiencing verbal auditory hallucinations at least once a week in the context of non-affective psychosis completed a measure assessing positive and negative voice content about appearance. They also completed assessments about body image, self-esteem, psychiatric symptoms and well-being. Results Fifty-five (91.7%) participants reported hearing voices comment on their appearance. A total of 54 (90%) patients reported negative voice content about their appearance with 30 (50%) patients experienced negative appearance comments on a daily basis. The most common negative comment was ‘the voices tell me that I am ugly’ (n = 48, 80%). There were 39 (65%) patients who reported positive voice content on appearance. The most frequent positive comment was ‘I look as nice as other people’ (n = 26, 43.3%). Negative voice content about appearance was associated with body image concerns, paranoia, voice hearing severity, depression, worry, negative self-beliefs and safety-seeking behaviours. Positive appearance voice content was associated with greater body esteem and well-being and lower levels of depression and insomnia. Conclusions Voice content about appearance is very common for patients seen in clinical services. Negative voice content may reflect – and subsequently reinforce – negative beliefs about one's appearance, low self-esteem, worry and paranoia. Declaration of interest None.

Background The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding. Aims To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors – identified from a cognitive model – before delusion onset. Method A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed. Results Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types. Conclusions Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality. Declaration of interest None.

Background To determine the prevalence of suicidal ideation and behaviour - and their correlates - in patients with persecutory delusions. Methods 110 patients with persecutory delusions in the context of non-affective psychosis were assessed for suicidal thoughts and behaviours over the past month. Symptom and psychological assessments were also completed. Results The severity of suicidal ideation was: no suicidal ideation (n = 26, 23.6%); wish to be dead (n = 21, 19.1%); nonspecific active suicidal thoughts (n = 14, 12.7%); suicidal thoughts with methods but no intent (n = 29, 26.4%); suicidal thoughts with intent but no specific plan (n = 13, 11.8%); and suicidal intent with plan (n = 7, 6.4%). In the past month, five patients (4.5%) had made an actual, interrupted, or aborted suicide attempt. The severity of suicidal ideation was associated with higher levels of depression, paranoia, hallucinations, anger, insomnia, negative beliefs about the self and others, pessimism, worry, and delusion safety-seeking behaviours and lower levels of psychological well-being and reward responsiveness. Severity of ideation was not associated with cannabis or alcohol use, working memory, pain, or meaningful activity levels. Conclusions Patients with persecutory delusions are typically in a severe state of psychological stress, and at risk of suicide, as indicated by very high levels of suicidal ideation. This exploratory study also identifies correlates of suicidal ideation that could be investigated in causal research designs.

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.