Previous research suggests that CBT focusing on worry in those with persecutory delusions reduces paranoia, severity of delusions and associated distress. This preliminary case series aimed to see whether it is feasible and acceptable to deliver worry-focused CBT in a group setting to those with psychosis. A secondary aim was to examine possible clinical changes. Two groups totalling 11 participants were run for seven sessions using the Worry Intervention Trial manual. Qualitative and quantitative data about the experience of being in the group was also collected via questionnaires, as was data on number of sessions attended. Measures were delivered pre- and post-group and at 3-month follow-up. These included a worry scale, a measure of delusional belief and associated distress and quality of life measures. Of the 11 participants who started the group, nine completed the group. Qualitative and quantitative feedback indicated that most of the participants found it acceptable and helpful, and that discussing these issues in a group setting was not only tolerable but often beneficial. Reliable Change Index indicated that 6/7 of the group members showed reliable reductions in their levels of worry post-group and 5/7 at follow-up. There were positive changes on other measures, which appeared to be more pronounced at follow-up. Delivering a worry intervention in a group format appears to be acceptable and feasible. Further research with a larger sample and control group is indicated to test the clinical effectiveness of this intervention.

Background: A one-to-one cognitive behavioural therapy intervention targeting worry significantly reduces both worry and persecutory delusions (Freeman et al., 2015). Aim: To adapt this intervention for group delivery and conduct a feasibility trial within routine clinical practice. Method: Thirteen participants were randomized to a weekly 8-session worry intervention group (n = 7) or wait-list control (n = 6). Results: All but one participant completed measures at all time points. Participants attended an average of six therapy sessions. Conclusions: Recruitment, retention and therapy uptake were feasible. Observed treatment effects were in the expected direction, but may be diluted compared with one-to-one interventions.

Attachment theory may develop understanding of the occurrence and maintenance of persecutory delusions. This study investigates the role of dispositional attachment and contextually primed secure base attachment representations in the occurrence of paranoid thinking. Sixty participants were randomly allocated to one of three conditions: a secure attachment priming condition, a positive affect condition, or a neutral control condition. Following priming, all participants were exposed to a paranoia induction. State paranoia was measured at baseline and following the paranoia induction. Dispositional insecure attachment was associated with both trait and state paranoid thinking. Contrary to predictions, the secure attachment prime did not appear to buffer paranoid thinking and had a negative impact for participants with high levels of attachment anxiety, highlighting the potentially aversive effects of exposure to secure attachment material in those with existing insecure attachment styles.

Background: Ruminative negative thinking has typically been considered as a factor maintaining common emotional disorders and has recently been shown to maintain persecutory delusions in psychosis. The Perseverative Thinking Questionnaire (PTQ) (Ehring et al., 2011) is a transdiagnostic measure of ruminative negative thinking that shows promise as a “content-free” measure of ruminative negative thinking. Aims: The PTQ has not previously been studied in a psychosis patient group. In this study we report for the first time on the psychometric properties of Ehring et al.'s PTQ in such a group. Method: The PTQ was completed by 142 patients with current persecutory delusions and 273 non-clinical participants. Participants also completed measures of worry and paranoia. A confirmatory factor analysis was performed on the clinical group's PTQ responses to assess the factor structure of the measure. Differences between groups were used to assess criterion reliability. Results: A three lower-order factor structure of the PTQ (core characteristics of ruminative negative thinking, perceived unproductiveness, and capturing mental capacity) was replicated in the clinical sample. Patients with persecutory delusions were shown to experience significantly higher levels of ruminative negative thinking on the PTQ than the general population sample. The PTQ demonstrated high internal reliability. Conclusions: This study did not include test-retest data, and did not compare the PTQ against a measure of depressive rumination but, nevertheless, lends support for the validity of the PTQ as a measure of negative ruminative thinking in patients with psychosis.

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: Worry is a significant problem for individuals with paranoia, leading to delusion persistence and greater levels of distress. There are established theories concerning processes that maintain worry but little has been documented regarding what brings worry to a close. Aims: The aim was to find out what patients with persecutory delusions report are the factors that bring a worry episode to an end. Method: Eight patients with persecutory delusions who reported high levels of worry participated. An open-ended semi-structured interview technique and IPA qualitative analysis was employed to encourage a broad elaboration of relevant constructs. Results: Analyses revealed one theme that captured participants’ detailed descriptions of their experience of worry and five themes that identified factors important for bringing worry episodes to a close: natural drift, distraction, interpersonal support, feeling better, and reality testing. Conclusions: Patients with persecutory delusions report worry being uncontrollable and distressing but are able to identify ways that a period of worry can stop. The present study suggests that building on individuals’ distraction techniques, reality testing ability and their social support network could be of benefit. Research is needed to identify the most effective means of bringing paranoid worries to an end.

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.

Background: Emerging evidence suggests that mindfulness can be beneficial for people with distressing psychosis. This study examined the hypothesis that for people with persecutory delusions in the absence of voices, mindfulness training would lead to reductions in conviction, distress, preoccupation and impact of paranoid beliefs, as well as anxiety and depression. Method: Two case studies are presented. Participants completed measures of mindfulness, anxiety and depression at baseline, end of therapy and 1 month follow-up, and bi-weekly ratings of their paranoid belief on the dimensions of conviction, preoccupation, distress and impact. Results: Ratings of conviction, distress, impact and preoccupation, and measures of anxiety and depression, reduced for both participants from baseline to end of intervention. Improvements in mindfulness of distressing thoughts and images occurred for both participants. These gains were maintained at 1 month follow-up. Conclusions: Findings suggest that mindfulness training can impact on cognition and affect specifically associated with paranoid beliefs, and is potentially relevant to both Poor Me and Bad Me paranoia.

Background: Paranoia is a common experience in the non-clinical population. We use a novel experimental methodology to investigate paranoid ideas in individuals without a history of mental illness. Aims: We aimed to determine whether this paradigm could elicit unfounded paranoid thoughts and whether these thoughts could be predicted by factors from a cognitive model. Method: Fifty-eight individuals took part and completed measures assessing trait paranoia, mood, self and other schema and attributional style. They were exposed to two experimental events: 1) an interruption to the testing session by a stooge, and 2) a recording of laughter played outside the testing room and subsequently asked about their explanations for these events. Results: 15.5% (n = 9) of the sample gave a paranoid explanation for at least one of the experimental events. The remainder reported generally neutral explanations. Individuals with a paranoid explanation reported significantly higher levels of trait paranoia. Factors predictive of a paranoid interpretation were interpersonal sensitivity and attributional style. Conclusions: The results show that spontaneous paranoid explanations can be elicited in non-clinical individuals, even for quite neutral events. In line with current theories, the findings suggest that emotional processes contribute to paranoid interpretations of events, although, as a novel study with a modest sample, it requires replication.

This paper provides an overview of perceptual control theory (PCT) in relation to understanding severe and enduring mental health problems. The core principles of control and conflict are reviewed in relation to understanding the experiences associated with psychotic disorders. The therapeutic application of PCT known as the Method of Levels (MOL) is described and an overview of how this might be a useful approach to use with people experiencing psychosis is provided. The benefits and difficulties of using MOL to work with people experiencing psychosis are described including case illustrations of preliminary work based on the application of MOL in clinical practice. It is concluded that PCT is a useful framework for understanding severe and enduring mental health problems and there are potential benefits in using MOL as a therapeutic intervention. Further research examining the effectiveness and feasibility of MOL as a specific treatment for psychosis is recommended.

This study investigated whether reasoning biases are specific to people with delusions and the role of emotional material on “jumping to conclusions”. Associations between reasoning and cognitive factors as well as other top-down factors such as metacognition were also explored. A comparative design was used to investigate group differences between people with persecutory delusions, people with panic disorder and non-patient controls. A probabilistic reasoning task involving three types of material was utilized to investigate the effect of emotional content on reasoning. Participants also completed questionnaire measures to explore whether hasty decision making was associated with measures of mood or cognitive processes. The results of the reasoning task showed that there was no main effect of group. However, all participants requested significantly less information on the two types of emotional material. None of the questionnaire measures were associated with performance on the reasoning task. Aspects of metacognition were found to be associated with ratings of delusions. This study suggested that between group differences in reasoning were small but that emotional content increases haste of decision making across all groups.

This study reports the development of a self-report measure to assess metacognitive beliefs about paranoia in non-patients. We aimed to test the specific hypotheses that positive beliefs about paranoia would predict frequency of paranoia, and that negative beliefs about paranoia would predict distress associated with delusional ideation. Three-hundred and seventeen non-patient participants were asked to complete questionnaires assessing beliefs about paranoia, paranoia, dimensions of delusional ideation and trait anxiety. The results showed that four empirically distinct subscales were measured by the beliefs about paranoia scale (negative beliefs about paranoia, beliefs about paranoia as a survival strategy, general positive beliefs and normalising beliefs). The scales possessed acceptable internal consistency and were associated with the measures of paranoia, delusional ideation and anxiety. Consistent with predictions, it was found that beliefs about paranoia as a survival strategy were associated with frequency of paranoia, and negative beliefs were associated with distress associated with delusional ideation. These findings suggest that a metacognitive approach to the conceptualization of paranoia as a strategy for managing interpersonal threat may have some utility. The clinical implications of the findings are also discussed.