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Frequency and correlates of maladaptive responses to paranoid thoughts in patients with psychosis compared to a population sample a

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Tania M. Lincoln , Carolin Möbius , Martin T. Huber , Matthias Nagel

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& Steffen Moritz

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Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Hamburg, Hamburg, Germany b

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Department of Psychiatry, Psychotherapy and Psychosomatics, Elbe Klinikum Stade, Bremervörder Strasse 111, 21682 Stade, Germany c

Department of Psychiatry and Psychotherapy, University of Marburg, Rudolf Bultmann Strasse 8, 35033 Marburg, Germany d

Department of Psychiatry and Psychotherapy, University Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany e

Clinic for Psychiatry and Psychotherapy, Asklepios Clinic Nord Wandsbek, Jüthornstraße 71, 22043 Hamburg, Germany f

Department for Psychiatry and Psychotherapy, Clinical Neuropsychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Published online: 25 Jul 2014.

To cite this article: Tania M. Lincoln, Carolin Möbius, Martin T. Huber, Matthias Nagel & Steffen Moritz (2014) Frequency and correlates of maladaptive responses to paranoid thoughts in patients with psychosis compared to a population sample, Cognitive Neuropsychiatry, 19:6, 509-526, DOI: 10.1080/13546805.2014.931220 To link to this article: http://dx.doi.org/10.1080/13546805.2014.931220

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Cognitive Neuropsychiatry, 2014 Vol. 19, No. 6, 509–526, http://dx.doi.org/10.1080/13546805.2014.931220

Frequency and correlates of maladaptive responses to paranoid thoughts in patients with psychosis compared to a population sample

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Tania M. Lincolna*, Carolin Möbiusa, Martin T. Huberb,c, Matthias Nageld,e and Steffen Moritzf a Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Hamburg, Hamburg, Germany; bDepartment of Psychiatry, Psychotherapy and Psychosomatics, Elbe Klinikum Stade, Bremervörder Strasse 111, 21682 Stade, Germany; cDepartment of Psychiatry and Psychotherapy, University of Marburg, Rudolf Bultmann Strasse 8, 35033 Marburg, Germany; d Department of Psychiatry and Psychotherapy, University Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany; eClinic for Psychiatry and Psychotherapy, Asklepios Clinic Nord Wandsbek, Jüthornstraße 71, 22043 Hamburg, Germany; fDepartment for Psychiatry and Psychotherapy, Clinical Neuropsychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

(Received 7 April 2013; accepted 30 May 2014) Introduction. The aims of this study were to identify whether responses to paranoid thoughts distinguish patients with psychotic disorders from people in the population who have paranoid thoughts occasionally and to identify factors that are associated with and might explain the different ways of responding. Methods. Paranoid thoughts were assessed in patients diagnosed with a psychotic disorder (n = 32) and a population control sample (n = 34) with the Paranoia Checklist. Responses to paranoid thoughts were assessed with the Reactions to Paranoid Thoughts Scale (RePT) and social support, self-efficacy and cognitive insight were assessed as potential correlates of the responses to paranoid thoughts. Results. The patients showed significantly more depressed, physical and devaluating responses to paranoid thoughts and employed less normalising responses than the controls. The differences in normalising responses were explained by perceived social integration, whereas the differences in depressive responses were explained by the overall levels of depression and partly explained by externality and social integration. Conclusions. Maladaptive responses to paranoid thoughts could be relevant to the pathogenesis and maintenance of persecutory delusions. Interventions aimed at reducing paranoia could benefit from targeting dysfunctional responses to paranoid thoughts and by placing a stronger emphasis on treating depression and improving social integration. Keywords: paranoid delusions; psychosis; depression; maintenance; coping

Persecutory delusions are one of the core symptoms of psychosis (Andreasen & Flaum, 1991; Sartorius et al., 1986). Paranoid thoughts are also a common experience. Most people admit to have been unfoundedly suspicious at least occasionally, such as blaming the cleaner to have taken something that one has accidently misplaced or worrying that others are gossiping behind one’s back. According to empirical studies, at least 10–15% in the general population regularly experience more clear-cut paranoid thoughts such as

*Corresponding author. Email: [email protected] © 2014 Taylor & Francis

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the unfounded suspicion that other people are trying to cause one harm (Freeman, 2007). Several studies have demonstrated that these types of attenuated psychotic symptoms are risk factors, emerging before the onset of schizophrenia or preceding relapse (Møller & Husby, 2000; van Os, Jones, Sham, Bebbington, & Murray, 1998). As a rule though, paranoid thoughts are transient and the majority of people experiencing them do not develop clinically relevant persecutory delusions (McGorry, Yung, & Phillips, 2003). There has been abundant research on cognitive and emotional processes that contribute to the development of delusions, resulting in and corroborating a number of explanatory models (e.g. Bentall, Corcoran, Howard, Blackwood, & Kinderman, 2001; Freeman, 2007). Comparatively less research has focused on the processes that maintain paranoid ideas once they have arisen. This research, however, indicates that maladaptive cognitive, emotional and behavioural responses to paranoid thoughts play a role in their maintenance. For example, Campbell and Morrison (2007) directly compared patients and healthy individuals who had experienced paranoid thoughts. The most striking difference found was that the patient groups felt more controlled by their paranoia. Laroi and Van der Linden (2005) found higher levels of paranoia in healthy individuals to be associated with more negative beliefs about the uncontrollability of thoughts. In studies by Morrison et al. (2005) and Moritz, Peters, Larøi, and Lincoln (2010), positive beliefs about paranoia were associated with more paranoid thoughts. Finally, Freeman et al. (2005) found people with higher levels of paranoia to be characterised by more emotional and avoidant coping styles and less detached coping. These studies suggest that less paranoia is associated with more functional cognitive, emotional and behavioural responses. People with lower levels of paranoia tend to appraise paranoid thoughts as having less power over them, consider them to be less meaningful or helpful and are more able to cognitively distance themselves from them. Furthermore, lower levels of paranoia are associated with less negative emotions, in particular depression and with less avoidance and social isolation. However, previous research focused on trait or general responses to paranoid thoughts rather than situation-specific responses. Also, previous studies investigated specific aspects, such as appraisal or coping, and, to our knowledge, no study assessed the full range of cognitive, emotional and behavioural responses. In order to advance this area of research, Lincoln, Reumann and Moritz (2010c) developed the Reactions to Paranoid Thoughts questionnaire (RePT) which assesses a range of cognitive, emotional and behavioural responses that people have in response to clinical and subclinical paranoid thoughts, including depressed, composed, communicating, rational, positive coping and normalising responses. The most frequently employed responses in a healthy population were found to be normalising, rational and composed responses (Lincoln et al., 2010c). For example, upon experiencing a paranoid thought such as “Colleagues could be gossiping behind my back” a healthy person was likely to remind himself or herself that having such a thought sometimes is fairly natural, that it is just a thought and not necessarily a fact and was not likely to pay too much attention to the thought. Within the healthy sample, people who reported paranoid thoughts frequently were characterised by more depressive responses, or by believing and concealing thoughts more frequently than people with less frequent paranoid thoughts. The first aim of the present study is therefore to replicate these and the previous findings in people with clinically relevant delusions. The second aim is to identify factors that are associated with and might help to explain maladaptive responses to paranoid thoughts. One, patients with psychosis have higher levels of depression (Fenton, 2001). It seems intuitive to assume that depressed

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mood impacts on the way patients respond to paranoid thoughts and thereby contributes to the maintenance of paranoia. Closely related to depression, people with psychosis have been found to have a reduced sense of self-efficacy and power (e.g. Bentall et al., 2010) and a tendency to attribute problems to external factors (Kinderman & Bentall, 1997) which closely resemble Levenson’s (1981) concept of externality. Reduced self-efficacy is also relevant to the way a person will respond to paranoid thoughts. Responding in a depressed manner is more likely in individuals who feel out of control and tend to blame external factors. Furthermore, patients with psychosis tend to be more withdrawn and less socially integrated (Häfner, Löffler, Maurer, Hambrecht, & an der Heiden, 1999; Wiersma et al., 2000) and a study by Riggio (2011) indicated that paranoid thinking is associated with loneliness and social isolation. As a consequence, people with paranoid symptoms are probably less likely to exchange thoughts and feelings with other people and gain a sense of which types of thoughts are normal, which is an important precondition for adopting normalising strategies. Finally, patients with psychotic disorders have been found to show both the lower levels of cognitive reflectivity and the higher self-certainty or overconfidence in several studies (Beck, Baruch, Balter, Steer, & Warman, 2004; Bora, Erkan, Kayahan, & Veznedaroglu, 2007; Engh et al., 2010; Moritz & Woodward, 2006). Both a reduced ability to self-reflect on the interpretations of one’s experiences and overconfidence in one’s beliefs make it less likely to distance oneself from a paranoid thought, for example, by encountering it rationally. In the present study, we hypothesised that people who experience paranoid thoughts at least occasionally that do not, however, result in a diagnosis of psychosis will differ from patients with psychotic disorders in their responses to the paranoid thoughts. We predict that the population sample will show more adaptive responses in terms of composed, communicative, rational, positive distracting and normalising responses and less maladaptive ones, such as responding in a depressed manner, believing the thought, devaluating or concealing it. We expect the responses to paranoid thoughts to be associated with the levels of depression, self-efficacy, emotional support, social integration and cognitive insight in both patients and controls. Furthermore, we expect differences between the patients’ and the controls’ responses to be partly explicable by these factors. Specifically, the differences in concealing, communicative and normalising responses are expected to be explained by the differences in social integration. Differences in depressed responses are expected to be explained by the overall depression, social integration and externality and differences in rational responses by self-reflectiveness.

Methods Recruiting and assessment procedure Patients were recruited from two collaborating clinics in the Hamburg (Germany) Metropolitan Area (Elbe Kliniken Stade-Buxtehude and Asklepios Klinik Nord Wandsbek) and one outpatient setting (Birkenhof Steinmetz-Haus, Himmelpforten). Collaborating mental health professionals informed patients with psychotic disorders and positive symptoms. Eligible patients were then contacted by the experimenters. The population control sample was recruited via advertisement leaflets pinned to boards at, for example, local supermarkets and by advertising on part of the experimenters within the circle of their acquaintances. About half of the sample was recruited within the university.

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Participants were paid for the participation, or – in the case of psychology students – could complete the requirements of their curriculum. Inclusion criteria for all the participants were that they had to report at least one paranoid thought to occur at least once a month. This was assessed with the Paranoia Checklist (Freeman et al, 2005). Furthermore, participants were required to be between 18 and 70 years of age and able to read and understand written instructions in the German language. Inclusion criteria for the patient sample were a DSM-IV diagnosis of schizophrenia, schizoaffective or delusional disorder. Exclusion criteria for the patient sample were substance abuse in the last two weeks, severe acute impairment, such as strong sedation due to medication, suicidal ideation or intent or inability to provide informed consent. Exclusion criteria for control participants were a DSM-IV bipolar or psychotic disorder or a neurological disorder. All participants were informed about the aims of the study and signed an informed consent before the participation. In the next step, socio-demographic and clinical characteristics (previous mental and physical disorders, treatment for mental health problems) were assessed. To verify diagnoses patients were assessed with the Structured Clinical Interview for DSM-IV (Wittchen, Zaudig, & Fydrich, 1997) sections B and C, which was followed by the questionnaire assessments described below. The experimenter read out the questions for patients with difficulties in understanding them. The study was approved by the local Ethical Committee (Psychotherapeutenkammer Hamburg). Measures The Paranoia Checklist (Freeman et al., 2005) is an 18-item self-report scale that assesses ideas of persecution (e.g. “I need to be on my guard against others”) and reference (e.g. “There might be negative comments being circulated about me”). It has excellent internal consistency (Cronbach’s alpha >.90) and good convergent validity. The German version has demonstrated high internal consistency and convergent validity in patients and healthy samples (Lincoln, Ziegler, Lüllmann, Müller, & Rief, 2010d; Moritz, van Quaquebeke, & Lincoln, 2012). Following recommendations derived from our previous work (Lincoln et al., 2010c), we used a short version including nine items that are frequently endorsed. Participants were asked to rate the frequency with which they experience each of the nine thoughts ranging from 1 (rarely) to 5 (at least once a day) on 5-point Likert scales and were given the opportunity to add similar thoughts that were not listed. The RePT (Lincoln et al., 2010c) builds on the responses provided in the Paranoia Checklist and asks participants to indicate to which extent the following responses to these types of thoughts apply to them (e.g. “When I have these thoughts I tell myself to calm down”) on a 5-point frequency rating scale from 1 (never) to 5 (always). The RePT was developed based on the interviews with healthy participants and patients with psychotic disorders about how they respond on a cognitive, emotional, physical and behavioural level to paranoid thoughts. It consists of 69 items for which a principal components analysis revealed a 10-factor solution. The factors include depressive, composed, communicative, rational, believing, devaluating, physical, positive distracting, normalising and concealing reactions to paranoid thoughts. The convergent and divergent validity of the RePT factors has been confirmed (Lincoln et al., 2010c). Cronbach’s alphas for the factors in this study ranged from .77 (believing reaction) to .97 (depressive reaction). They are provided in the appendix along with the specific items.

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Potential mediators We used the Community Assessment of Psychic Experiences (CAPE; Stefanis et al., 2002) to measure the depression. The CAPE is a 42-item self-report instrument developed to rate lifetime psychotic experiences in the positive, negative and depressive symptom domain. A three-factor structure of positive, negative and depressive dimensions has been demonstrated (Stefanis et al., 2002), and previous studies have confirmed good discriminative validity of the CAPE across groups of individuals with schizophrenia, affective and anxiety disorders and individuals from the general population (Hanssen, Bijl, Vollebergh, & van Os, 2003) and reliability over a mean period of 7.7 months (Konings, Bak, Hanssen, van Os, & Krabbendam, 2006). The German version of the CAPE has good to excellent internal consistency and validity (Moritz & Laroi, 2008). In the present study, we used the depression subscale of the CAPE as an indicator of depression, and the positive and negative subscale to assess the baseline differences in the samples. Cognitive insight was assessed with the German version (Mass, Wolf, & Lincoln, 2012) of the Beck Cognitive Insight Scale (BCIS; Beck et al., 2004). The 15 items of this self-report scale are rated on 4-point Likert scales and constitute two subscales “selfcertainty” assessing a participants’ certainty or overconfidence about his or her own beliefs or judgments (e.g. “My interpretations of my experiences are definitely right”) and “self-reflectiveness”, the ability to acknowledge own expression of introspection and willingness to acknowledge fallibility (e.g. “If somebody points out that my beliefs are wrong, I am willing to consider it”). The internal consistency of the original version was α = .68 for “self-reflectiveness” and .60 for “self-certainty” in a schizophrenia sample in a study by Beck et al. (2004) and comparable in non-clinical samples (Warman, Dunahue, Martin, & Beck, 2004). The internal consistency of the two scales was has been shown to be acceptable for the German version in a schizophrenia sample (α = .56 and .60, respectively) and slightly higher in a healthy sample (α of the total scale = .72; Mass et al., 2012). Social support was assessed with a social support questionnaire [Fragebogen zur Sozialen Unterstützung] (Fydrich, Geyer, Hessel, Sommer, & Brähler, 1999) that consists of 54 items divided into four subscales ‘emotional support’ (e.g. being liked and accepted by others, sharing feelings), ‘practical support’ (e.g. receiving practical help from others), ‘social integration’ (e.g. being part of a circle of friends) and ‘social stress’ (e.g. feeling rejected, criticised). Items are endorsed on a 5-point Likert scale. For this study, we used the subscales ‘emotional support’ and ‘social integration’. Sufficient validity and reliability data have been provided (Fydrich et al., 1999). Self-efficacy was assessed with a German Competence and Control Questionnaire [Fragebogen zu Kompetenz und Kontrollüberzeugungen, FKK] (Krampen, 1991) which is based on Levenson’s ‘internality’, ‘powerful others’ and ‘chance’ scales (Levenson, 1981). The FKK assesses the self-concept of being able and expecting to have the ability to gain control. It consists of the four 8-item primary scales internality (the subjective perception of being in control of important events in one’s life), powerful others control orientation (the perception that other people have power over one’s life), chance control orientation (the belief that events are generally due to fate, luck or chance) and the selfconcept of own ability (the expectation to be able to deal with important events in life). The items are rated on a 6-point Likert scale from 1 (not at all true) to 6 (very true). The subscores for internality and self-concept of one’s own ability are summed up to a total

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‘self-efficacy’ score; the subscores powerful others and chance control orientation are summed up to a total ‘externality’ score. The FKK has been normed in a large sample of adults and has been shown to be reliable in several studies (Krampen, 1991).

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Analyses The analyses were carried out using SPSS Version 17. All variables used for the analyses were normally distributed (skewness < ∣2∣, kurtoses < ∣7∣, guidelines by Curran, West, & Finch, 1996). In a first step, we tested for the baseline differences in age, gender and education between the two samples. After checking for equality of co-variance matrices, we used MANOVA and post-hoc ANOVAs to assess the differences between patients and controls in the RePT and on the proposed mediators (cognitive insight, social support, depression and self-efficacy). To assess the association of the mediators with the responses to paranoid thoughts, we analysed the magnitude of the bivariate associations between the RePT scales that discriminated between the groups and the mediators controlling for group membership. Finally, we conducted mediation analyses in order to assess whether specific differences in patients’ and the controls’ responses can be explained by the proposed mediators.

Results Participants Informed consent was signed by 32 participants with psychotic disorders and 34 controls drawn from the population who were eligible for the study. Socio-demographic characteristics: patients and population controls differed in age (patients: 43.2 (SD = 13.9); controls: 31.8 (SD = 11.4); t(64) = 3.6; p < .01). However, using Pearson correlations, we found age to be uncorrelated with any of the RePT scales within the patient or control group (all ps > .05). Chi-square tests revealed the differences in regard to the highest school degree attained, with 4 patients having no school degree, 9 the lowest degree within the German educational system (Hauptschule, 9th grade), 8 a medium one (Realschule, 10th grade) and 11 the highest school degree (Abitur = equivalent to A level or 13th grade) compared to 0, 1, 10 and 23, respectively, in the population sample, χ2(3) = 14.8; p < .01. Using MANOVA to compare the RePT scores in the groups with no, low, medium or high education, we found no significant association between the RePT scales and education status, neither within the patient sample (Λ = 0.53, F(20, 46) = 0.83, p = .66) nor in the controls (Λ = 1.16, F(30, 60) = 1.26, p = .22). There were no differences in gender (ratio male/female: patients 19/13; controls 17/17, χ2(1) = 0.6; p = .45) or nationality (ratio German/other: patients 31/1; controls 31/3, χ2(1) = 0.9; p = .33). Clinical characteristics: in the patient sample, 25 were diagnosed with schizophrenia, 4 with schizoaffective disorder and 3 with brief psychotic disorder. The majority of the patients were currently taking anti-psychotic medication (65.6% atypical anti-psychotics, 6.2% benzodiazepines, 3.1% anticonvulsant drugs, 18.8% unspecified medication and 6.3% no medication). The mean duration of disorder was 14.7 years (SD = 14.7); the mean number of hospitalisations was 7.0 (SD = 6.3). The majority of the patients (62%) were permanently or temporarily on sick leave. In the population sample, 21 reported to have been in mental health treatment or counselling at some time in their life for anxiety problems (n = 3), obsessive compulsive disorder (n = 3), depression (n = 3) or other

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reasons (n = 9). As expected, the samples differed significantly in their mean CAPE positive (patients: 38.0, SD = 13.0 versus controls: 26.8, SD = 3.3; t = 4.6, df = 32.3, p < .001) and negative symptom scores (patients: 29.1, SD = 7.5 versus controls: 25.7, SD = 4.4; t = 2.3, df = 62.3, p = .03). Differences between patients and controls in responses to paranoid thoughts Patients and controls did not differ in the number of endorsed paranoid thoughts that they indicated to occur at least once a month (rating ≥ 1; patients: 7.4, SD = 2.3; controls: 7.5, SD = 2.5; t = 0.24, df = 63, p = .89). However, patients obtained significantly higher overall frequency scores (18.3, SD = 12.0) than controls (11.4, SD = 6.0; t = 2.9, df = 45.1, p < .01). Both patients and controls endorsed “There might be negative comments being circulated about me” as the most frequently occurring paranoid thought. Table 1 depicts the mean scores in the RePT subscales for the patients and controls as well as the significance level of group differences in the MANOVA. Using Pillai’s trace, we found a significant effect of group on the RePT subscale scores, V = 0.44, F(10/54) = 4.26, p < .01, η2partial =.44. Separate univariate ANOVAs on the subscale scores revealed significant group differences for the depressed, physical, devaluating and normalising reactions to paranoid thoughts. To assess the combined value of these RePT factors in discriminating between the groups, we followed up the MANOVA with a discriminant analysis. The standardised discriminant function coefficients were .75 for depressive, .22 for devaluating, .03 for physical and −.64 for normalising reactions, indicating the presence of two independent differentiating factors (depression and normalising). The function significantly differentiated between the groups (Δ = .72, χ2(4) = 20.1, p < .001) and was successful in classifying 79% of the control participants and 71% of the patients to their correct group. Group differences in cognitive insight, social support, depression and self-efficacy The mean scores in cognitive insight, social support, depression and self-efficacy by group are depicted in Table 2. MANOVA revealed patients and controls to differ significantly in the proposed mediating variables, V = 0.55, F(7/56) = 9.9, p < .01, η2 = .55). The patients reported to receive significantly less emotional support (F = 22.4, p < .001) and to be less Table 1.

Responses to paranoid thoughts in patients with psychotic disorders and healthy controls.

Normalising Rational Composed Concealing Positive distracting Believing Communicative Depressed Devaluating Physical

Patients

Controls

Statistics

Mean (SD)

Mean (SD)

F (df), p

2.9 3.1 2.8 3.0 2.9 2.9 2.8 3.1 2.4 2.6

3.3 3.2 2.9 2.8 2.8 2.7 2.9 2.3 2.0 2.0

(0.78) (0.81) (0.74) (0.90) (0.72) (0.93) (0.93) (0.88) (0.75) (0.86)

(0.69) (0.67) (0.58) (0.85) (0.68) (0.80) (0.83) (0.61) (0.57) (0.57)

5.0 0.6 0.2 0.8 0.9 0.9 0.2 15.5 2.0 7.2

(1,63), (1,63), (1,63), (1,63), (1/63), (1,63), (1,63), (1,63), (1,63), (1,63),

Frequency and correlates of maladaptive responses to paranoid thoughts in patients with psychosis compared to a population sample.

The aims of this study were to identify whether responses to paranoid thoughts distinguish patients with psychotic disorders from people in the popula...
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