Helping patients with paranoid and suspicious thoughts: a cognitive–behavioural approach

Daniel Freeman is a Wellcome Trust Fellow and a senior lecturer in clinical psychology at the Institute of Psychiatry, King’s College London (Department of Psychology, PO Box 77, Institute of Psychiatry, King’s College London, Denmark Hill, London SE5 8AF, UK. Email: D.Freeman{at}iop.kcl.ac.uk). He is also an honorary consultant clinical psychologist with the South London and Maudsley NHS Trust. Philippa Garety is Professor of Clinical Psychology at King’s College London, Head of Psychology in the South London and Maudsley NHS Trust, and a Fellow of the British Psychological Society.

Abstract

TOP Abstract What is paranoia? How common is persecutory... How is paranoia understood... The cognitive-behavioural way of... The techniques of cognitive... Conclusions Declaration of interest MCQs References and related articles

‘Although it is a waste of time to argue with a paranoid patient about his delusions, he may still be persuaded to keep them to himself, to repress them as far as possible and to forgo the aggressive action they might suggest, in general to conduct his life as if they did not exist’ (Mayer-Gross et al, 1954: p. 280)

Such ideas were not confined to psychiatry. A number of psychologists applied reinforcement techniques to try to reduce the time that patients spoke about delusions (e.g. Wincze et al, 1972; Liberman et al, 1973). However, there has been a remarkable transformation in how delusions are viewed. Together with medication, recommended treatment now encourages clinicians to give most patients time to talk about their experiences and to use particular cognitive–behavioural therapeutic techniques to reduce distress (National Institute for Clinical Excellence, 2002; Lehman et al, 2004).

But how should the content of delusional ideas be discussed? There are clearly lingering uncertainties in the mental health professions about this, as illustrated by a study of psychiatrist–patient routine consultations (McCabe et al, 2002). It was found that patients repeatedly tried to talk about the content of their psychotic symptoms and in response doctors hesitated, responded with a question rather than an answer and, when a carer was present, even smiled and laughed.

In this article we focus on paranoid and suspicious thoughts, drawing on developments in the cognitive understanding and treatment of such experiences to describe how best to talk with patients about them.

What is paranoia?

TOP Abstract What is paranoia? How common is persecutory... How is paranoia understood... The cognitive-behavioural way of... The techniques of cognitive... Conclusions Declaration of interest MCQs References and related articles

View this table: [in this window] [in a new window]

Table 1 The multidimensional nature of delusions

In contrast to the debates about defining delusions, diagnostic criteria for subtypes of delusional beliefs based on content have not been a topic of comment. This is perhaps because the issue is thought to be self-evident, but it is more complex than might be considered at first sight. There is great variety in the content of thoughts of a persecutory nature, for instance, in the type and timing of threat, the target of the harm, and the identity and intention of the persecutor (Freeman et al, 2001). Furthermore, terms such as paranoia, delusions of persecution and delusions of reference have been used interchangeably and to refer to different concepts. Freeman & Garety (2000) clarify the definition of persecutory delusions: the individual believes that harm is occurring, or is going to occur, to him or her, and that the persecutor has the intention to cause harm (Box 1). The second element of this definition distinguishes persecutory from anxious thoughts.

Box 1 Criteria for a delusion to be classified as persecutory (Freeman & Garety, 2000) Criteria A and B must be met: the individual believes that harm is occurring, or is going to occur, to him or her the individual believes that the persecutor has the intention to cause harm There are a number of points of clarification: harm concerns any action that causes the individual to experience distress harm only to friends or relatives does not count as a persecutory belief, unless the persecutor also intends this to have a negative effect on the individual the individual must believe that the persecutor at present or in the future will attempt to harm him or her lusions of reference do not count within the category of persecutory beliefs

 

How common is persecutory thinking?

TOP Abstract What is paranoia? How common is persecutory... How is paranoia understood... The cognitive-behavioural way of... The techniques of cognitive... Conclusions Declaration of interest MCQs References and related articles

There are many other psychiatric and neurological diagnoses in which persecutory delusions occur in a substantial minority of patients. These include depression, mania, post-traumatic stress disorder, dementia and epilepsy (Manschreck & Petri, 1978).

Increasingly, however, paranoid thoughts are considered not just as a symptom of a disorder but as an experience of interest in its own right, which occurs outside clinical groups and is frequently a cause of distress. The focus is on understanding and treating the distressing experience rather than on the diagnosis. Many have argued that psychotic symptoms such as delusions might be better understood on a continuum with normal experience (e.g. Strauss, 1969). Delusions in psychosis represent the severe end of a continuum, although such experiences are present, often to a lesser degree, in the general population. Thus, a relationship of degree is suggested between, for example, a clinical persecutory delusion about government attempts to kill the person, non-clinical delusions about neighbours trying to get at the person and everyday suspicions about the intentions of others. However, it should be emphasised that there are different forms of the continuum view (Claridge, 1994). The distribution of symptoms may well be quasi-continuous, lying between dichotomous (i.e. most people have no paranoid thoughts and a small proportion have many) and continuous (i.e. there is a normal distribution of paranoid thoughts in the general population similar to, for example, blood pressure), which will depend on the number, prevalence and interaction of causal factors (van Os & Verdoux, 2003).

A review of 15 studies shows clear evidence that the rate of delusional beliefs in the general population is higher than that of psychotic disorders and that delusions occur in individuals without psychosis (Freeman, 2006). The frequency of delusional beliefs in non-clinical populations varies according to the content of the delusion studied and the characteristics of the sample population (e.g. age structure, level of urbanicity). About 1–3% of the non-clinical population have delusions of a level of severity comparable to clinical psychosis. A further 5–6% have a delusion but not of such a severity. Although less severe, these beliefs are still associated with a range of social and emotional difficulties. A further 10–15% of the non-clinical population have fairly regular delusional ideation. For example, Jim van Os and colleagues (2000) studied delusions in the large epidemiological Netherlands Mental Health Survey and Incidence Study (NEMESIS). In the sample, 2.1% received a DSM–III–R diagnosis of non-affective psychosis. However, a greater proportion had a ‘true’ psychiatrist-rated delusion (3.3%) or had a ‘clinically not relevant delusion’ (8.7%), defined as the person not being bothered by the belief and not seeking help for it. A separate group of people (3.8%) had endorsed a delusion item, but these beliefs were considered plausible or founded.

Many studies do not differentiate between delusion subtypes, and therefore it is harder to estimate the prevalence of persecutory thinking in particular. A conservative estimate is that 10–15% of the general population regularly experience paranoid thoughts, although such figures hide marked differences in content and severity (Table 2). It is also likely that the studies underestimate the true frequency of paranoid thoughts since large epidemiological studies from a psychiatric perspective are unlikely to record more plausible fleeting everyday instances of paranoid thinking. Johns et al(2004) report findings from a British survey of over 8000 people. The results of individuals with probable psychosis were removed from the analysis. The assessment of delusions was fairly rudimentary but the results are still striking: 20% had thought in the preceding year that people were against them at times, and 10% felt that people had deliberately acted to harm them. The least plausible paranoid item, fears of a plot, was endorsed by 1.5% of this non-clinical population. Interestingly, there is evidence from more elaborate epidemiological research that odder, less plausible paranoid thoughts build on commoner, more plausible ones, indicating a hierarchical structure to paranoia (Fig. 1).

View this table: [in this window] [in a new window]

Table 2 Frequency of paranoid thoughts in a student sample (n = 1202)

View larger version (23K): [in this window] [in a new window]

Fig. 1 The paranoia hierarchy (Freeman et al, 2005).

How is paranoia understood psychologically?

TOP Abstract What is paranoia? How common is persecutory... How is paranoia understood... The cognitive-behavioural way of... The techniques of cognitive... Conclusions Declaration of interest MCQs References and related articles

Persecutory delusions are explicable in terms of normal psychological processes. However, there is an important caveat: no single factor is likely to account for paranoia. With colleagues, we have detailed a multi-factorial account of the formation and maintenance of persecutory delusions that addresses the complexity of the causal picture (Fig. 2) (Garety et al, 2001; Freeman & Garety, 2004).

View larger version (27K): [in this window] [in a new window]

Fig. 2 Outline of factors involved in the development of delusions.

Making sense of events
The key opening for the psychological understanding of paranoia is that such thoughts are individuals’ attempts to explain their experiences, that is, to make sense of events (Maher, 1988). The sorts of experiences that are the proximal source of evidence for persecutory delusions are external events and internal feelings.

Clinical experience indicates that ambiguous social information is a particularly important external factor. Such information is likely to be both non-verbal (e.g. facial expressions, people’s eyes, hand gestures, laughter/smiling) and verbal (e.g. snatches of conversation, shouting). Coincidences and negative or irritating events also feature in persecutory ideation.

Unusual or anomalous internal feelings often lead to delusional ideation. For example, the individual might be in a heightened state or aroused; feel that certain events are significant; experience perceptual anomalies (e.g. things may seem vivid or bright or piercing, sounds may feel very intrusive); feel that they are not really ‘there’ (depersonalisation); and might have illusions and hallucinations (e.g. hear voices). Experiences of this sort can also be caused by use of illicit drugs or sleep deprivation.

Typically, individuals who exhibit paranoid thinking are trying to make sense of their internal unusual experiences, often by drawing in negative, discrepant or ambiguous external information (e.g. others’ facial expressions). For example, a person may go outside feeling in an unusual state and rather than thinking ‘I’m feeling a little odd and anxious, probably because I’ve not been sleeping well’, interprets their feelings, together with the facial expressions of strangers in the street, as evidence of a threat (e.g. ‘People don’t like me and may harm me’). But why a persecutory interpretation? We interpret internal and external events in line with our previous experiences, knowledge, emotional state, memories, personality and decision-making processes and therefore the origin of persecutory explanations lies in such psychological processes.

Emotions
Suspicious thoughts often occur in the context of emotional distress. They are often preceded by stressful events such as difficult interpersonal relationships, bullying and isolation. Further, the stresses may happen against a background of previous experiences that have led to beliefs about the self (e.g. as vulnerable), others (e.g. as potentially dangerous) and the world (e.g. as bad) that make suspicious thoughts more likely (Fowler et al, 2006).

Anxiety may be especially important in the generation of persecutory ideation. This is because anxiety and suspiciousness have the same cognitive theme of the anticipation of danger. In our model we hypothesise that anxiety is central in the interpretation of internal and external events and provides the threat theme of paranoia. Hence, we argue that emotion has a direct role in delusion formation (for a review see Freeman & Garety, 2003); this is in contrast to a popular view that delusions conceal emotional distress or low self-esteem (e.g. Colby, 1975; Bentall et al, 1994). Typically, therefore, in paranoid thinking a person having unusual experiences that they find it hard to identify and correctly label interprets them in line with their emotional state. If they are anxious it is more likely that the interpretation will be of threat.

Anxious thoughts are truly persecutory when they contain the idea that harm is actually intended by the perpetrator. The cause of this idea of intent is underresearched. We think that most often ideas of threat contain an implicit attribution of intent. Irritation, resentment or anger – often not expressed because of fears of others’ reactions (‘timidity’) – may perhaps contribute to this idea of hostile intent, since judgements of blame and attributions of intent are central to anger. A lack of trust in others, an unwillingness to discuss emotions, or social isolation mean that the feelings of threat and intent are not shared with others but are ruminated on alone, preventing disconfirmation of their persecutory nature.

Reasoning
The final piece of the puzzle is reasoning. It needs to be remembered that persecutory delusions are inherently a judgement and therefore reasoning processes are of central importance. Persecutory ideas are more likely to reach a delusional intensity if there are accompanying biases in reasoning such as reduced data gathering (jumping to conclusions) (Garety & Freeman, 1999), failure to consider alternative explanations (Freeman et al, 2004) and a strong belief confirmation bias (Wason, 1960). When reasoning biases are present, suspicions become near certainties; ideas of threat are held with a conviction unwarranted by the evidence and may then be considered delusional.

Our model contains further hypotheses concerning the maintenance and emotional reaction associated with persecutory delusions. For example, since the explanations contain threat beliefs, the fears will be maintained by processes similar to those outlined in the anxiety disorders literature, such as the use of safety behaviours (e.g. avoiding other people) which prevent the processing of disconfirmatory evidence (Clark, 1999). Furthermore, the individual’s relationship with the persecutor may be important in determining emotional reactions; the belief that the persecutor is powerful has been associated with higher levels of depression (Birchwood et al, 2000b; Freeman et al, 2001). Thus, we conceptualise paranoia as resulting from individuals’ attempts to understand their experiences, particularly unusual internal states, while under the influence of emotional states such as anxiety and biases of reasoning. Careful assessment is needed to determine the relevant factors in each individual case.

The cognitive–behavioural way of talking to people with paranoid thoughts

TOP Abstract What is paranoia? How common is persecutory... How is paranoia understood... The cognitive-behavioural way of... The techniques of cognitive... Conclusions Declaration of interest MCQs References and related articles

This ‘voyage of discovery’ attitude will be more helpful in engaging the patient than any simple implementation of a set of techniques. The exploratory approach must be combined with an empathic, collaborative style. The patient needs to feel that their problems are being taken seriously. The therapist should listen empathically and regularly give brief summaries of what the patient has been saying. This will ensure that the clinician has understood and will help structure the discussion. The therapist should comment on the distress caused by the experiences, but without agreeing that the perceived threat is real, for example ‘It must make you very anxious’ or ‘Believing that the neighbours are trying to harm you must feel very intrusive and be upsetting’. The clinician should be collaborative, drawing up a list of goals with the patient, discussing what will happen in the meetings and regularly asking the patient for both positive and negative feedback on the meetings. Providing written information on paranoid thoughts can be helpful (Freeman et al, 2006). Any immediate concerns (e.g. thoughts of suicide, difficulties getting to therapy sessions) should be dealt with before a full assessment is carried out. The clinician needs to be flexible in both the length of sessions and the degree to which key material is focused on. They must also keep a close eye on whether there are aspects of the sessions that the patient finds upsetting. In the early sessions, the therapist should not start challenging delusions, but perform the more difficult task of listening and trying to understand the patient’s perspective: challenging delusions in an inexpert way is equivalent to not listening to the patient’s experiences. It can also be extremely helpful not always to focus on problems but to find out about the positive aspects and achievements of the individual and show that you have noticed them. Patients with suspicious thoughts often present with low self-esteem, difficulties with trust and fears that others think they are ‘mad’. A clinician who shows positive regard can help circumvent these negative self-views, which sometimes hinder engagement.

Obstacles to good engagement
There are, of course, obstacles to forming a good collaborative relationship with an individual who has paranoid thoughts. Elements of the role of a psychiatrist bring problems. Two key issues are hospitalisation and medication. An individual with paranoid thoughts may be worried about revealing these and being admitted compulsorily to hospital (or not discharged, if already an in-patient). The psychiatrist will often be keen to prescribe medication, which the patient may take as an indication that the clinician’s mind is already made up or which might conflict with the wishes of the patient. Such difficulties need to be acknowledged, discussed openly and resolved by negotiation. Specific techniques for developing appropriate medication adherence, including forming a collaborative relationship, using motivational interviewing, provision of information, and monitoring symptoms and side-effects, are described elsewhere (e.g. Randall et al, 2002).

There is also the issue of the use of language. Mental health professionals may use diagnostic terms such as schizophrenia and give only biological explanations for experiences. Illness accounts of experiences can be helpful to some patients but there are two main difficulties with them. The first is that they contain within them a number of potential further or other meanings. For example, for some patients ‘schizophrenia’ carries connotations of madness and violence, they believe it to be an uncontrollable organic condition that will not improve and they fear that they will be shunned by others. There is an emerging and important literature indicating that careful attention should be given to appraisals of illness – concerning, for example, cause, course, outcome, loss, entrapment and humiliation – because they can lead to distress (Birchwood et al, 2000a; Lobban et al, 2003).

The second difficulty with illness models is that they mostly provide a poor causal description of a person’s subjective experiences. For example, telling Mr Smith that he is ‘ill’ does not necessarily provide a compelling account of why, when he goes outside, he feels very anxious, senses that something odd is going on and notices that people in the street are looking at him. A delusional explanation that people seem to recognise and know about him, are aware of bad things about his past and, as a consequence, are hostile may provide a richer account for Mr Smith of his subjective experience and draws on his own knowledge. Patients may favour the delusional account, being richer, over the illness account.

In psychological therapies, as shall be seen, an elaborated alternative account that draws on both the patient’s and the therapist’s knowledge is made: for example, that the patient has had previous adverse experiences with others (e.g. has been bullied) and therefore expects threat, may be more prone to notice it in ambiguous social information and to jump to the conclusion that they are to be harmed whenever there is any sign of danger. The therapist also tries to ensure that there is a simple, non-stigmatising label for such an account (e.g. that the person is ‘alert’ or ‘sensitive’ to threat). These accounts developed in therapy, similar in explanatory power to the delusional accounts, may make a more plausible alternative than either the ‘illness’ or the ‘delusional’ accounts.

Another obstacle to engagement can be that the clinician becomes incorporated into the delusional system. If the clinician’s approach is empathic and based on understanding, this happens less often than they fear it might. However, the clinician should anticipate the problem by checking at the end of initial meetings whether the patient has any concerns about them (e.g. ‘You have described mistrusting people. I therefore wondered whether you’ve had any such worries about me?’). If the patient does have such concerns the clinician should first explain their role very clearly. If the patient does not respond to simple reassurance the clinician should use problem-solving techniques to address the difficulty in the therapeutic relationship. For example, the clinician might suggest that the patient does not talk about the most private aspects of their experiences until they feel greater trust or may ask whether there is anything that they could do to ease the patient’s worries about them. It can be helpful for the clinician to show the patient the notes being taken in the meeting. It can bring down the emotional impact of paranoid thoughts in meetings if the clinician points out that it is not surprising that the patient is suspicious about the clinician, given the delusional system, and that it is simply a problem that can be discussed like any other and compromises and solutions can be found.

The techniques of cognitive–behavioural therapy for paranoia

TOP Abstract What is paranoia? How common is persecutory... How is paranoia understood... The cognitive-behavioural way of... The techniques of cognitive... Conclusions Declaration of interest MCQs References and related articles

It is important to note that at this stage of development CBT for delusions is not a brief treatment; typically, it needs to be provided weekly for at least 6 months. Although similar to CBT for other disorders, clinicians should be aware that modifications to the approach are needed for delusions. Therapists using CBT for psychosis are often working with people who have complex disorders and need a good understanding of the psychology of psychosis, cognitive therapy skills, and regular supervision and support. It is also important to be aware that CBT is provided as part of a multi-modal treatment that includes antipsychotic medication and, for example, assertive community treatment, rehabilitation, supported employment and family intervention.

Assessment and formulation: ‘making sense of psychosis’
The initial task is to develop an individualised formulation that accounts for the patient’s paranoid thoughts and the associated distress. This occurs through detailed descriptions of paranoid experiences and their development. The formulation is a personalised account of the development of paranoid thoughts based on the cognitive model and is not simply ‘education about illness’. The clinician should be thinking about the following sorts of questions:

• On what evidence is the person basing their thoughts?
  
• How do paranoid thoughts build on the patient’s ideas about the self and others and ordinary worries?
  
• How do the thoughts make sense given previous life events?
  
• Is the person reacting to puzzling and confusing experiences?
  
• How is the person reasoning about their experiences?
  
• What behaviours are keeping the thoughts going?
  

The answers to these questions are then fed back to the patient for their opinion (e.g. ‘I may have this wrong, but could it be that, given the things that have happened in the past, your first reaction now is to think that others will be bad to you?’ or ‘From what you’ve said, you seem to rely on your instinct to know that there is threat, rather than think of many different explanations for others’ behaviour and weigh up the evidence – do I have that right, do you think?’). Gradually the therapist will develop a formulation – a multifactorial account of the development of the paranoid thoughts. Sometimes all, sometimes parts, of the formulation are shared with the patient.

There are a number of benefits to good formulation: a full description of the patient’s subjective experiences is made, which is empathic, normalising, makes the experiences understandable and does not treat the patient as if they were ‘mad’; it enables patients to revisit their decision-making processes with the benefit of time and new information; it can provide an alternative non-delusional account of experiences; and it identifies targets of therapy. One of the most important elements in the therapy is that the clinician slows down and ‘unpacks’ the decision-making processes that lead to paranoid thoughts. This enables patients to gain distance from their thoughts so that they are more likely to review (often implicit) interpretations at any or all of the different steps in the development of their paranoid accounts. It also allows the clinician and the patient to introduce fresh information and other ideas that enable a different sense to be made of experiences. Given this renewed attempt at making sense, patients can consider how they might proceed differently in thought or behaviour.

Cognitive therapies were developed in a tradition that interventions should be assessed for their efficacy, and therefore formal measures of symptoms are routinely taken by therapists in individual cases to monitor treatment effectiveness (using, for example, PSYRATS; Haddock et al, 1999).

Interventions after formulation
Making sense of persecutory experiences illuminates many potential therapeutic paths. Thus, if anomalous experiences are assessed as central to delusion formation – for instance, the paranoid thoughts are provoked by feelings of depersonalisation, a sense of reference, perceptual disturbances or hallucinations – therapy may aim to reduce the frequency of such experiences using a functional analysis (examining the triggers and reactions), to change the interpretation of the anomalous experiences, or simply to enhance coping strategies. Where anxiety and worry contribute to the persistence of paranoid ideas, other ways of dealing with thinking about fears can be introduced and worry-reduction strategies used (Wells, 1997). In some cases it is possible to review with patients the evidence for and against different explanations for their experiences and to conduct behavioural experiments (i.e. to test out the persecutory thoughts). In other cases, the therapist and patient will be ‘working within’ persecutory delusions, and distress may be reduced by, for example, focusing on the interpretations associated with the most distressing aspects of the delusion (e.g. the degree to which the person is powerless, whether the threat is as widespread as thought), or Ed. by developing alternative ways of reacting to the threat. In our self-help book on overcoming paranoid and suspicious thoughts (Freeman et al, 2006), intervention for paranoid thoughts is crystallised into six key steps (Box 2). These encourage the reader to:

Box 2 Six key self-help steps in overcoming paranoid thoughts Become a detached observer of your fears. Readers are shown how to monitor and learn about their paranoid thoughts using diaries and writing exercises Develop a detailed understanding of the causes of suspicious thoughts. Substantial information is provided on the causes of paranoid thoughts, and readers are shown in a structured way how to formulate their own experiences Review paranoid interpretations rather than just accepting them. The rules of good decision-making are introduced and readers are shown how to review their paranoid thoughts and alternative explanations for their experiences Test out suspicious thoughts. It is explained how to test out paranoid fears in behavioural experiments. Hierarchies of tests are constructed, predictions made and the results of tests considered Let go of a suspicious thought when it comes. Readers are encouraged not to fight suspicious thoughts when they occur but instead to let them go and focus on what they are doing, not what they are thinking Spend less time worrying about paranoid thoughts. Reduction in worry is attempted by showing how worrying makes things worse, introducing ‘worry periods’ and substituting problems (Freeman et al, 2006)

 

1. become a detached observer of their fears;
   
2. develop a detailed understanding of the causes of suspicious thoughts
   
3. review paranoid interpretations rather than just accepting them;
   
4. test out suspicious thoughts;
   
5. ‘let go’ of a suspicious thought if it comes;
   
6. reduce the time spent worrying about paranoid thoughts.
   

Frequently, clinicians also work with patients on improving low self-esteem (Hall & Tarrier, 2003), reducing depression, increasing activities and structuring time. Our theoretical model clearly indicates that reducing emotional difficulties should also lead to lessening of suspiciousness.

Finally, the therapist and patient may try to prevent relapse by identifying vulnerabilities and early warning signs and rehearsing compensatory strategies.

Conclusions

TOP Abstract What is paranoia? How common is persecutory... How is paranoia understood... The cognitive-behavioural way of... The techniques of cognitive... Conclusions Declaration of interest MCQs References and related articles

Declaration of interest

TOP Abstract What is paranoia? How common is persecutory... How is paranoia understood... The cognitive-behavioural way of... The techniques of cognitive... Conclusions Declaration of interest MCQs References and related articles

MCQs

TOP Abstract What is paranoia? How common is persecutory... How is paranoia understood... The cognitive-behavioural way of... The techniques of cognitive... Conclusions Declaration of interest MCQs References and related articles

1. 1The approximate proportion of the general population (excluding those diagnosed) that regularly have paranoid thoughts is:
   1. 0–10%
      
   2. 10–20%
      
   3. 20–30%
      
   4. 30–40%
      
   5. Over 40%.
      
   
   
2. Persecutory thoughts are distinguished from anxious thoughts by:
   1. the fact that their content is incorrect
      
   2. the anticipation of danger
      
   3. the belief that harm is intended
      
   4. the level of distress
      
   5. the person acting on the thought.
      
   
   
3. In CBT the following is not considered as a potential cause of persecutory delusions:
   1. reasoning
      
   2. anomalous experiences
      
   3. anxiety
      
   4. diet
      
   5. ideas about self and others.
      
   
   
4. Persecutory ideas are considered as:
   1. fears partly caused by past experiences
      
   2. arising from random firing of neurons
      
   3. individuals’ attempts to make sense of events
      
   4. a product of thought disorder
      
   5. empty speech acts without meaning.
      
   
   
5. CBT for delusions is contraindicated if the patient:
   1. has poor insight
      
   2. has cognitive deficits
      
   3. is taking antipsychotic medication
      
   4. has persistent symptoms
      
   5. is not distressed by their paranoia.
      
   
   

MCQ answers

1 2 3 4 5 a F a F a F a T a F b T b F b F b F b F c F c T c F c T c F d F d F d T d F d F e F e F e F e F e T

Footnotes

References and related articles

TOP Abstract What is paranoia? How common is persecutory... How is paranoia understood... The cognitive-behavioural way of... The techniques of cognitive... Conclusions Declaration of interest MCQs References and related articles

1. Bentall, R. P., Kinderman, P. & Kaney, S. (1994) The self, attributional processes and abnormal beliefs: towards a model of persecutory delusions. Behaviour Research and Therapy, 32, 331–341.[CrossRef][Medline]
2. Birchwood, M., Iqbal, Z., Chadwick, P., et al (2000a) Cognitive approach to depression and suicidal thinking in psychosis. 2. Testing the validity of a social ranking model. British Journal of Psychiatry, 177, 522–528.[Abstract/Free Full Text]
3. Birchwood, M., Meaden, A., Trower, P., et al (2000b) The power and omnipotence of voices: subordination and entrapment by voices and significant others. Psychological Medicine, 30, 337–344.[CrossRef][Medline]
4. Castle, D. J., Phelan, M., Wessely, S., et al (1994) Which patients with non-affective functional psychosis are not admitted at first psychiatric contact? British Journal of Psychiatry, 165, 101–106.[Abstract/Free Full Text]
5. Claridge, G. (1994) Single indicators of risk for schizophrenia. Probable fact or likely myth? Schizophrenia Bulletin, 20, 151–168.[Abstract/Free Full Text]
6. Clark, D. M. (1999) Anxiety disorders: why they persist and how to treat them. Behaviour Research and Therapy, 37, S5–S27.
7. Colby, K. M. (1975) Artificial Paranoia: A Computer Simulation of Paranoid Processes. Toronto: Pergamon Press.
8. Day, J. C., Bentall, R. P., Roberts, C., et al (2005) Attitudes toward antipsychotic medication. Archives of General Psychiatry, 62, 717–724.[Abstract/Free Full Text]
9. Drury, V., Birchwood, M., Cochrane, R., et al (1996) Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms. British Journal of Psychiatry, 169, 593–601.[Abstract/Free Full Text]
10. Fowler, D., Freeman, D., Smith, B., et al (2006) The Brief Core Schema Scales (BCSS). Psychometric properties and associations with paranoia and grandiosity in non-clinical and psychosis samples. Psychological Medicine, 36, 749–759.[CrossRef][Medline]
11. Freeman, D. (2006) Delusions in the non-clinical population. Current Psychiatry Reports, 8, 191–204.[Medline]
12. Freeman, D. & Garety, P. A. (2000) Comments on the content of persecutory delusions. Does the definition need clarification? British Journal of Clinical Psychology, 39, 407–414.
13. Freeman, D. & Garety, P. A. (2003) Connecting neurosis and psychosis: the direct influence of emotion on delusions and hallucinations. Behaviour Research and Therapy, 41, 923–947.[CrossRef][Medline]
14. Freeman, D. & Garety, P. A. (2004) Paranoia: The Psychology of Persecutory Delusions. Hove: Psychology Press.
15. Freeman, D., Garety, P. A. & Kuipers, E. (2001) Persecutory delusions: developing the understanding of belief maintenance and emotional distress. Psychological Medicine, 31, 1293–1306.[CrossRef][Medline]
16. Freeman, D., Garety, P. A. Fowler, D., et al (2004) Why do people with delusions fail to choose more realistic explanations for their experiences? An empirical investigation. Journal of Consulting and Clinical Psychology, 72, 671–680.[CrossRef][Medline]
17. Freeman, D., Garety, P. A., Bebbington, P. E., et al (2005) Psychological investigation of the structure of paranoia in a non-clinical population. British Journal of Psychiatry, 186, 427–435.[Abstract/Free Full Text]
18. Freeman, D., Freeman, J. & Garety, P. (2006) Overcoming Paranoid and Suspicious Thoughts. London: Robinson Constable.
19. Garety, P. A. & Freeman, D. (1999) Cognitive approaches to delusions: a critical review of theories and evidence. British Journal of Clinical Psychology, 38, 113–154.
20. Garety, P. A. & Hemsley, D. R. (1994) Delusions: Investigations into the Psychology of Delusional Reasoning. Oxford: Oxford University Press.
21. Garety, P. A., Kuipers, E., Fowler, D., et al (2001) A cognitive model of the positive symptoms of psychosis. Psychological Medicine, 31, 189–195.[CrossRef][Medline]
22. Gumley, A., O’Grady, M., McNay, L., et al (2003) Early intervention for relapse in schizophrenia: results of a 12-month randomised controlled trial of cognitive behavioural therapy. Psychological Medicine, 33, 419–431.[CrossRef][Medline]
23. Haddock, G., McCarron, J., Tarrier, N., et al (1999) Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychological Medicine, 29, 879–889.[CrossRef][Medline]
24. Hall, P. L. & Tarrier, N. (2003) The cognitive–behavioural treatment of low self-esteem in psychotic patients: a pilot study. Behaviour Research and Therapy, 41, 317–332.[CrossRef][Medline]
25. Johns, L. C., Cannon, M., Singleton, N., et al (2004) The prevalence and correlates of self-reported psychotic symptoms in the British population. British Journal of Psychiatry, 185, 298–305.[Abstract/Free Full Text]
26. Kingdon, D. & Turkington, D. (2002) The Case Study Guide to Cognitive Behaviour Therapy of Psychosis. Chichester: J. Wiley & Sons.
27. Kuipers, E., Garety, P. A., Fowler, D., et al (1997). London–East Anglia randomised controlled trial of cognitive–behavioural therapy for psychosis. I: effects of the treatment phase. British Journal of Psychiatry, 171, 319–327.[Abstract/Free Full Text]
28. Lehman, A. F., Kreyenbuhl, J., Buchanan, R. W., et al (2004) The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophrenia Bulletin, 30, 193–217.[Abstract/Free Full Text]
29. Lewis, S., Tarrier, N., Haddock, G., et al (2002) Randomised controlled trial of cognitive–behavioural therapy in early schizophrenia: acute-phase outcomes. British Journal of Psychiatry, 181 (suppl. 43), s91–s97.[Abstract/Free Full Text]
30. Liberman, R. P., Teigen,J., Patterson, R., et al (1973) Reducing delusional speech in chronic paranoid schizophrenics. Journal of Applied Behavior Analysis, 6, 57–64.[Medline]
31. Lobban, F., Barrowclough, C. & Jones, S. (2003) A review of the role of illness models in severe mental illness. Clinical Psychology Review, 23, 171–196.[CrossRef][Medline]
32. Lucas, R. (2006) Over-formalising the formulation? Invited commentary on: Teaching psychodynamic formulation to psychiatric trainees. Advances in Psychiatric Treatment, 12, 265–267.[Abstract/Free Full Text]
33. Mace, C. & Binyon, S. (2005a) Teaching psychodynamic formulation to psychiatric trainees. Part 1: Basics of formulation. Advances in Psychiatric Treatment, 11, 416–423.[Abstract/Free Full Text]
34. Mace, C. & Binyon, S. (2005b) Teaching psychodynamic formulation to psychiatric trainees. Part 2: Teaching methods. Advances in Psychiatric Treatment, 12, 92–99.
35. Maher, B. A. (1974) Delusional thinking and perceptual disorder. Journal of Individual Psychology, 30, 98–113.[Medline]
36. Maher, B. A. (1988) Anomalous experience and delusional thinking: the logic of explanations. In Delusional Beliefs (eds T. F. Oltmanns & B. A. Maher), pp. 15–33. New York: John Wiley & Sons.
37. Manschreck, T. C. & Petri, M. (1978) The paranoid syndrome. Lancet, 2, 251–253.[CrossRef][Medline]
38. Mayer-Gross, W., Slater, E. & Roth, M. (1954) Clinical Psychiatry. London: Cassell.
39. McCabe, R., Heath, C., Burns, T., et al (2002) Engagement of patients with psychosis in the consultation: conversation analytic study. BMJ, 325, 1148–1151.[Abstract/Free Full Text]
40. National Institute for Clinical Excellence (2002) Clinical Guideline 1. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. London: NICE.
41. Oltmanns, T. F. (1988) Approaches to the definition and study of delusions. In Delusional Beliefs (eds T. F. Oltmanns & B. A. Maher), pp. 3–12. New York: John Wiley & Sons.
42. Randall, F., Wood, P., Day, J., et al (2002) Enhancing appropriate adherence with neuroleptic medication. In A Casebook of Cognitive Therapy for Psychosis (ed. A. T. Morrison), pp. 281–297. Hove: Brunner-Routledge.
43. Sartorius, N., Jablensky, A., Korten, A., et al (1986) Early manifestations and first-contact incidence of schizophrenia in different cultures. Psychological Medicine, 16, 909–928.[Medline]
44. Strauss, J. S. (1969) Hallucinations and delusions as points on continua function. Archives of General Psychiatry, 20, 581–586.
45. Tarrier, N., Yusupoff, L., Kinney, C., et al (1998) Randomised controlled trial of intensive cognitive behavioural therapy for patients with chronic schizophrenia. BMJ, 317, 303–307.[Abstract/Free Full Text]
46. Van Dael, F., Versmissen, D., Janssen, I., et al (2006) Data gathering: biased in psychosis? Schizophrenia Bulletin, 32, 341–351.[Abstract/Free Full Text]
47. Van Os, J. & Verdoux, H. (2003) Diagnosis and classification of schizophrenia: categories versus dimensions, distributions versus disease. In The Epidemiology of Schizophrenia (eds R. M. Murray, P. B. Jones, E. Susser, et al), pp. 364–410. Cambridge: Cambridge University Press.
48. Van Os, J., Hanssen, M., Bijl, R.V., et al (2000) Strauss (1969) revisited: a psychosis continuum in the general population. Schizophrenia Research, 45, 11–20.[CrossRef][Medline]
49. Wason, P. C. (1960) On the failure to eliminate hypotheses in a conceptual task. Quarterly Journal of Experimental Psychology, 12, 129–140.[CrossRef]
50. Wells, A. (1997) Cognitive Therapy of Anxiety Disorders. Chichester: John Wiley & Sons.
51. Wessely, S., Buchanan, A., Reed, A., et al (1993) Acting on delusions. I: prevalence. British Journal of Psychiatry, 163, 69–76.[Abstract/Free Full Text]
52. Wincze, J. P., Leitenberg, H. & Agras, W. S. (1972) The effects of token reinforcement and feedback on the delusional verbal behavior of chronic paranoid schizophrenics. Journal of Applied Behavior Analysis, 5, 247–262.[CrossRef][Medline]
53. Zimmermann, G., Favrod, J., Trieu, V. H., et al (2005) The effect of cognitive behavioural treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research, 77, 1–9.[CrossRef][Medline]

This article has been cited by other articles:

				R. Lucas Balancing the cognitive-behavioural approach with an analytic perspective Adv. Psychiatr. Treat., March 1, 2007; 13(2): 155 - 155. [Full Text] [PDF]

				G. Khandpur and S. P. Singh CBT for psychosis Adv. Psychiatr. Treat., March 1, 2007; 13(2): 155 - 156. [Full Text] [PDF]

eLetters:

This Article Abstract Full Text (PDF) Submit an eLetter View responses Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Freeman, D. Articles by Garety, P. Search for Related Content PubMed Articles by Freeman, D. Articles by Garety, P.