THE PSYCHOLOGY OF PERSECUTORY Freeman2007 PDF

Clinical Psychology Review 27 (2007) 425 457
Suspicious minds: The psychology of persecutory delusions

Daniel Freeman
Department of Psychology, PO Box 77, Institute of Psychiatry, Kings College London, Denmark Hill, London, SE5 8AF, UK
Received 6 July 2006; accepted 10 October 2006
Abstract
At least 1015% of the general population regularly experience paranoid thoughts and persecutory delusions are a frequent
symptom of psychosis. Persecutory ideation is a key topic for study. In this article the empirical literature on psychological
processes associated with persecutory thinking in clinical and non-clinical populations is comprehensively reviewed. There is a
large direct affective contribution to the experience. In particular, anxiety affects the content, distress and persistence of paranoia. In
the majority of cases paranoia does not serve a defensive function, but instead builds on interpersonal concerns conscious to the
person. However, affect alone is not sufficient to produce paranoid experiences. There is also evidence that anomalous internal
experiences may be important in leading to odd thought content and that a jumping to conclusions reasoning bias is present in
individuals with persecutory delusions. Theory of mind functioning has received particular research attention recently but the
findings do not support a specific association with paranoia. The threat anticipation cognitive model of persecutory delusions is
presented, in which persecutory delusions are hypothesised to arise from an interaction of emotional processes, anomalous
experiences and reasoning biases. Ten key future research questions are identified, including the need for researchers to consider
factors important to the different dimensions of delusional experience.
2006 Elsevier Ltd. All rights reserved.
Keywords: Delusions; Paranoia; Cognitive; Schizophrenia; Psychosis
1. Introduction
We are living in paranoid times, with fears of others attaining a new intensity. Nonetheless, being overly wary of the
intentions of others has long been recognised as a problem. In the seventeenth century Francis Bacon (1612), often
credited as the founder of the scientific method, commented on the corrosive nature of the experience: Suspicions
amongst thoughts are like bats amongst birds, they ever fly by twilight. Certainly they are to be repressed, or, at the
least, well guarded. For they cloud the mind, they lose friends, and they check with business, whereby business cannot
go on currently and constantly. They dispose kings to tyranny, husbands to jealousy, wise men to irresolution and
melancholy.
Yet in the last 10 years there has been a rapid development in the understanding of persecutory thinking, assisted by
the focus on it as a phenomenon of interest in its own right rather than simply as a symptom of severe mental illness
(Bentall, 1990). The argument that will be put forward in this review is that there is now an excellent opportunity to
E-mail address: D.Freeman@iop.kcl.ac.uk.
0272-7358/$ - see front matter 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2006.10.004
426 D. Freeman / Clinical Psychology Review 27 (2007) 425457
take the starting point of this work of the last 10 years and make dramatic increases in the understanding of persecutory
thinking. Explanatory models can become as powerful as those for emotional disorders and lead to more effective
psychological interventions for paranoia. But also emphasised are the significant conceptual and methodological
limitations of previous work.
2. The definition of persecutory delusions
There have, of course, been many commentaries on the limitations of definitions of delusional beliefs in general, in
that most criteria do not apply to all delusions, which partly results from epistemological difficulties in determining the
referent of a name by a single set of necessary or sufficient characteristics (see Kripke, 1980). This has all too often
been a rarefied academic debate without consideration of the implications for research or clinical practice.
The most sustainable position is that of Oltmanns (1988). Assessing the presence of a delusion may best be
accomplished by considering a list of characteristics or dimensions, none of which is necessary or sufficient, that with
increasing endorsement produces greater agreement on the presence of a delusion. For instance, the more a belief is
implausible, unfounded, strongly held, not shared by others, distressing and preoccupying then the more likely it is to
be considered a delusion. The practical importance of the debate about defining delusions is that it informs us that there
is individual variability in the characteristics of delusional experience (see Table 1). Delusions are definitely not
discrete discontinuous entities. They are complex, multi-dimensional phenomena (Garety & Hemsley, 1994). The
implication is that there can be no simple answer to the question What causes a delusion? Instead, an understanding of
each dimension of delusional experience is needed: what causes the content of a delusion? What causes the degree of
belief conviction? What causes resistance to change? What causes the distress? It is plausible that different factors are
involved in different dimensions of delusional experience. Research on the causes of different dimensions of delusional
experience is rare; a few studies consider delusional conviction (Freeman et al., 2004; Garety et al., 2005) and
delusional distress (Freeman & Garety, 1999; Freeman, Garety, & Kuipers, 2001; Startup, Freeman, & Garety, in
press). The implication for clinical practice is that clinicians need to think with clients about the aspect of delusional
experience they are hoping will change during the course of an intervention (see Birchwood & Trower, 2006) and
formulate accordingly.
In contrast to the debates about defining delusions, diagnostic criteria for sub-types of delusional beliefs based upon
content have not been a topic of comment. Many reports of studies are unclear about the definition of persecutory
delusions used. This is perhaps because the issue is thought to be self-evident, but it is more complex than might be
Table 1
The multi-dimensional nature of delusions
Characteristic of Variability in characteristic
delusions
Unfounded For some individuals the delusions reflect a kernel of truth that has been exaggerated (e.g. the person had a dispute with the
neighbour but now believes that the whole neighbourhood is monitoring them and will harm them). It can be difficult to
determine whether the person is actually delusional. For others the ideas are fantastic, impossible and clearly unfounded (e.g.
the person believes that s/he was present at the time of the Big Bang and is involved in battles across the universe and
heavens).
Firmly held Beliefs can vary from being held with 100% conviction to only occasionally being believed when the person is in a particular
stressful situation.
Resistant to change An individual may be certain that they could not be mistaken and will not countenance any alternative explanation for their
experiences. Others feel very confused and uncertain about their ideas and readily want to think about alternative accounts of
their experiences.
Preoccupying Some people report that they can do nothing but think about their delusional concerns. For other people, although they firmly
believe the delusion, such thoughts rarely come into their mind.
Distressing Many beliefs, especially those seen in clinical practice, are very distressing (e.g. persecutory delusions) but others (e.g.
grandiose delusions) can actually be experienced positively. Even some persecutory delusions can be associated with low
levels of distress (e.g. the individual believes that the persecutor hasn't the power to harm them).
Interferes with Delusions can stop people interacting with others and lead to great isolation and abandonment of activities. Other people can
social functioning have a delusion and still function at a high level including maintaining relationships and employment.
Involves personal In many instances the patient is at the centre of the delusional system (e.g. I have been singled out for persecution). However
reference friends and relatives can be involved (e.g. They are targeting my whole family) and some people believe that everybody is
affected equally (e.g. Everybody is being experimented upon).
D. Freeman / Clinical Psychology Review 27 (2007) 425457 427
Table 2
Criteria for a delusion to be classified as persecutory (Freeman & Garety, 2000)
Criteria A and B must be met:
A. The individual believes that harm is occurring, or is going to occur, to him or her.
B. 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 leads to the individual experiencing 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 upon the
individual.
The individual must believe that the persecutor at present or in the future will attempt to harm him or her.
Delusions of reference do not count within the category of persecutory beliefs.
considered at first sight. There is great variety in the content of persecutory thoughts, 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 inter-
changeably and to refer to different concepts. Freeman and Garety (2000) clarify the definition of persecutory ideation:
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 (see Table 2). The second element of the definition distinguishes persecutory from anxious
thoughts. Use of clear criteria such as these, coupled with descriptions of the levels of conviction and distress in
participant groups, will enable both a focus on pure phenomena and comparisons across research studies.
3. The epidemiology of paranoid thinking
Surprisingly, the epidemiology of persecutory ideation has not been systematically reviewed. Basic information on
the prevalence and distribution of paranoid thoughts is key in determining the importance of the experience and the
most appropriate research strategy. This neglected area will therefore be given some consideration.
Persecutory delusions, as most people are aware, are taken as a key sign of severe mental illnesses such as
schizophrenia. Sartorius et al. (1986) present findings from a World Health Organisation prospective study in ten
countries of individuals with signs of schizophrenia making first contact with services (N = 1379). Persecutory
delusions were the second most common symptom of psychosis, after delusions of reference, occurring in almost 50%
of cases. However, there are many other diagnoses in which persecutory delusions occur in a substantial minority. The
presence of delusions and hallucinations in unipolar depression is approximately 15% (Johnson, Horwath, &
Weissman, 1991). Again, persecutory beliefs are a common presentation of these delusions: a case-note review by
Frangos, Athanassenas, Tsitourides, Psilolignos, and Katsanou (1983) found that 44% of patients with unipolar
depressive psychosis (N = 136) had persecutory delusions. In a review of bipolar disorder, Goodwin and Jamison
(1990) suggest that persecutory delusions (28%) are frequent in manic episodes. There is evidence from small-scale
clinical studies that psychotic symptoms occur in approximately 30% of cases of combat-related PTSD (Butler,
Mueser, Sprock, & Braff, 1996; Hamner, Freuch, Ulmer, & Arana, 1999). Hallucinations are the most common
psychotic symptom associated with PTSD, but delusions also occur, particularly with a persecutory theme. Persecutory
ideation is of course likely to be common in paranoid personality disorder, the main criterion for which is that the
person has a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent
(DSM-IV; APA, 1994). It is also of note that people with anxiety or depression have elevated scores on measures of
persecutory ideation (Van Os et al., 1999). Finally, persecutory delusions occur in neurological disorders, such as
dementia (Flint, 1991) and epilepsy (Trimble, 1992). For instance, Rubin, Drevets, and Burke (1988) report that 31% of
110 individuals with dementia of the Alzheimer type had paranoid delusions.
Many have argued that psychotic symptoms such as delusions might be better understood on a continuum with
normal experience (Chapman & Chapman, 1980; Claridge, 1997; Johns, 2005; Peters, Joseph, & Garety, 1999; Van Os
& Verdoux, 2003; Strauss, 1969). Delusions in psychosis would represent the severe end of a continuum, but such
experiences would be present, often to a lesser degree, in the general population, and this would be related to milder
attenuated forms of the experience. For example, a clinical persecutory delusion about government attempts to kill the
person would be considered related to non-clinical delusions about neighbours trying to get at the person that would in
turn be considered as related to everyday suspicions about the intentions of others. However, it should be emphasised
that there are different forms of the continuum view (Claridge, 1994) and the distribution of symptoms may well be
Table 3
Studies of paranoid thinking in non-clinical populations
Study N Assessment Time period Prevalence
Representative general population studies
Epidemiologic 810 adults in Baltimore, Diagnostic Interview Past Symptom endorsement is reported first
Catchment Area United States (weighted Schedule (Robins et al., month followed by clinical symptom level in brackets
(EPA) program for larger population of 1981). This schedule People spying on you 12% (1%)
Eaton et al. (1991) 3481 from which this was not administered by People following you 8% (1%)
sub-sample was drawn) a mental health professional. Trying to hurt you 5% (1%)
Reading your mind 2% (1%)
Others control you 2% (2%)
Steal thoughts 2% (1%)
Epidemiologic Catchment
Area (EPA) program
prospective study
Tien and Anthony 4994 adults (aged 18 to Diagnostic Interview New New symptom onset:
(1990) 49 years) were selected Schedule (Robins et al., occurrence Believed people were watching you
from the US survey who 1981). This schedule of or spying on you? 2.6%
had not reported any was not administered by symptoms Believed people were following you? 1.6%
psychotic symptoms at a mental health professional. in the past Believed someone was plotting against
the baseline assessment. year. you or trying to hurt you or poison
They were then assessed you? 0.5%
1 year later. Believed someone was reading your
mind? 0.6%
Believed others were controlling how you
moved or what you thought against your
will? 0.3%
Felt that someone or something could put
strange thoughts directly into your mind of could
take or steal thoughts out of your mind? 0.2%
2000 British National 8580 adults in the Psychosis Screening Past year Paranoia
Survey of Psychiatric United Kingdom Questionnaire (Bebbington Over the past year, have there been times
Morbidity Johns et al. (aged 1674) (60 & Nayani, 1995). Not when you felt that people were against you?
(2004) individuals with administered by 21.2%
psychosis were then mental health professional. Have there been times when you felt that
excluded) people were deliberately acting to harm you
or your interests? 9.1%
Have there been times when you felt that
a group of people were plotting to cause you
serious harm or injury? 1.5%
Thought insertion
Over the past year, have you ever felt that
your thoughts were directly interfered with
or controlled by some outside force or
person? 9.0%
Did this come about in a way that many
people would find hard to believe, for
instance, through telepathy? 0.9%
Representative older adult general population studies

Older American 997 adults (aged 65+) Mini-Mult For total group generalised persecutory
Resources and in Durham County, (Kincannon, 1968) ideation 4%
Services (OARS) N.C., USA For group without cognitive impairment
Durham survey (N = 781)
Christenson and Generalised persecutory ideation 2%
Blazer (1984)
Kungsholmen project 1420 adults (aged 75+) Comprehensive 6.3% had paranoid symptom.
Forsell and in Stockholm, Sweden. Psychopathological Rating For individuals without cognitive
Henderson (1998) People living in all types Scale (CPRS) (sberg et al., impairment the prevalence was 2.6%
of institutions were also 1978). Assessment by mental
included. health professional.
Table 3 (continued )
Study N Assessment Time period Prevalence
Representative older adult general population studies
Longitudinal 347 adults (aged 85) Comprehensive Last Belief of being persecuted, harassed, or
Gerontological and without dementia Psychopathological Rating month unfairly treated that did not reach delusional
Geriatric Population representative of a Scale (sberg et al., proportions was classified as paranoid
Study stling and birth cohort in Gteborg, 1978). Administered ideation 6.9%
Skoog (2002) Sweden. by a mental Persecutory delusion 3.5%
health professional. Plus
informant interview and
inspection of medical records.
King's County, 1027 adults (aged 55+) Paranoid sub-scale of the Past week Paranoid ideation present in 13%
Brooklyn study. without cognitive SCL-90 (Derogatis, Lipman, Paranoid ideation was considered present
Cohen et al. (2004) impairment in Brooklyn, & Covi, 1973). if the respondent endorsed three or more
N.Y., USA. Four ethnic Self-report questionnaire. items. The items in the scale are:
groups sampled. Feeling that you are watched or talked
about by others.
Having ideas or beliefs that others do
not share
Others not giving you proper credit for
your achievements
Feeling that people will take advantage of
you if you let them
Feeling others are to blame for most of
your troubles
Feeling that most people cannot be trusted
Studies of selected non-clinical samples

Columbia University 1005 adults (aged Mini International Currently Belief that others were spying on or
Study Olfson et al. 1870) attending Neuropsychiatric present following them 10.6%
(2002) a general medicine Interview (Sheehan et al., Belief that people were plotting or trying
practice in northern 1998). Not administered to poison them 6.9%
Manhattan, N.Y., USA. by a mental health Delusion of reference 4.7%
professional. Belief that people were secretly testing
or experimenting on them 4.6%
Aquitaine Sentinel 462 adults (18+ years) Peters et al. Delusions Lifetime Do you ever feel as if you are being
Network study without psychiatric Inventory (PDI) (Peters persecuted in some way? 25.5%
Verdoux et al. (1998) disorder attending et al., 1999). Self-report Do you ever feel there is a conspiracy
general medicine questionnaire. against you? 10.4%
practices in
Southwest France
Paranoia survey 1202 university Paranoia Checklist. Last Percentages of sample experiencing
Freeman, Garety, students (ages 1661) Self-report questionnaire. month paranoid thoughts at least weekly:
Bebbington, Smith in Southeast There might be negative comments
et al. (2005) England, UK being circulated about me 42%
Bad things are being said about me behind
my back 30%
People deliberately try to irritate me 27%
I might be being observed or followed 19%
People are trying to make me upset 12%
Someone I know has bad intentions towards
me 12%
I am under threat from others 10%
I have a suspicion that someone has it in for
me 8%
Someone I don't know has bad intentions
towards me 8%
People would harm me if given the
opportunity 8%
There is a possibility of a conspiracy against
me 5%
quasicontinuous, lying between dichotomous and continuous (Van Os & Verdoux, 2003). An important implication if
the continuum perspective is correct is that researching non-clinical delusional ideation can inform the understanding of
clinical phenomena, just as studying anxious or depressive states can inform the understanding of emotional disorders.
On the basis of a review of 15 studies, Freeman (2006) concludes that there is clear evidence that the rate of
delusional beliefs in the general population is higher than that of psychotic disorders (i.e. that delusions occur in
individuals with experiences that have not been diagnosed as psychosis). 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). Approximately 13% of the non-clinical population have delusions
of a level of severity comparable to clinical cases of psychosis. A further 56% of the non-clinical population have a
delusion of less severity. Although less severe, these beliefs are still associated with a range of social and emotional
difficulties. A further 1015% of the non-clinical population have fairly regular delusional ideation. For example, Jim
van Os and colleagues 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 had
endorsed a delusion item but these beliefs were considered plausible or founded (3.8%).
Many studies do not differentiate between delusion sub-types, and therefore it is harder to estimate the prevalence of
persecutory thinking in particular. In Table 3 studies that include details of the occurrence of paranoid thinking are
displayed. A conservative estimate is that 1015% of the general population regularly experience paranoid thoughts,
though such figures hide marked differences in content and severity. It is also likely that the studies underestimate the
true frequency of paranoid thoughts because 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 eight thousand people. Individuals with probable psychosis were removed from the study results.
The assessment of delusions was fairly rudimentary: there was no assessment of conviction, differentiation between
real or unfounded events, or consideration of clinical severity. However the results are still striking. 20% had thought in
the past year that people were against them at times, and 10% felt 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. So although this study
does not provide robust data on the presence of delusional beliefs, it does indicate that thoughts of a paranoid nature are
common in the non-clinical population. Interestingly, there is evidence from more elaborate epidemiological research
that the distribution of paranoid thinking in the general population is continuous and that odder, less plausible paranoid
thoughts build upon commoner, more plausible ones, indicating a hierarchical structure to paranoia (Freeman, Garety,
Bebbington, Smith et al., 2005) (see Fig. 1). It is clinically noteworthy that a number of studies have found delusions in
the general population to be associated with distress and significant impairment in work, family and social functioning
(e.g. Olfson et al., 2002).
The prevalence figures indicate that there is a need for literature on paranoid thinking that is aimed at the general
population and is not focussed on severe mental illness (Freeman, Freeman & Garety, 2006). They are also consistent
with the idea of paranoid thoughts being an appropriate strategy that can, in particular circumstances, become
excessive, just like anxious thoughts. Consideration of the potentially hostile intentions of others can be a highly
intelligent and appropriate strategy to adopt. Walking down certain streets can feel threatening. Friends are not always
good friends. As Francis Bacon (1612) noted: What would men have? Do they think that those they employ and deal
with are Saints? Do they not think they will have their own ends, and be truer to themselves than to them? Whether to
trust or mistrust is a judgement that lies at the heart of social interactions and one that is prone to errors.
It has been seen that studies using traditional psychiatric assessments find that non-clinical populations experience
delusions. Therefore it is reasonable to assume that they are indeed the same phenomena as seen in clinical
populations. There is also other evidence consistent with the idea that clinical and non-clinical experiences are linked.
Non-clinical symptoms are associated with an increased likelihood of being diagnosed with a psychotic disorder
(Eaton, Romanoski, Anthony, & Nestadt, 1991; Van Os, Hanssen, Bijl, & Ravelli, 2000). In particular, Van Os et al.
(2000) found that plausible symptoms, secondary symptoms and non-clinically relevant symptoms were all very
strongly associated with the presence of clinical symptoms. Moreover, non-clinical and clinical experiences were
associated with the same demographic and clinical risk factors (e.g. urban dwelling, living alone, depression). The
authors view this as evidence of aetiological continuity (see Myin-Germeys, Krabbendam, & van Os, 2003). There is
also important evidence that non-clinical symptoms are predictive of the later development of psychosis (Chapman,
Fig. 1. The paranoia hierarchy.
Chapman, Kwapil, Eckbald, & Zinser, 1994; Poulton et al., 2000). The evidence is substantial enough to conclude that
studying non-clinical paranoid experiences will inform the understanding of clinically severe persecutory delusions.
Finally, it should be highlighted that, while it has been established that paranoid thinking is a significant topic, there is
considerable work to be done on its epidemiological study. Consideration needs to be given to the multi-dimensional
nature of the experiences, using assessments that separate the occurrence of such thinking from levels of belief conviction
in the thought and associated distress. Just as importantly, greater consideration needs to be given to the content of the
thoughts assessed. Persecutory thinking differs greatly in the nature of the threat and the identity of the persecutors. It has
also been shown that specific aspects of the content of paranoid thinking (e.g. the power of the persecutor, the awfulness
of the threat) are associated with distress (Boyd & Gumley, in press; Chisholm, Freeman, & Cooke, 2006; Birchwood,
Meaden, Trower, Gilbert, & Plaistow, 2000; Freeman et al., 2001; Green et al., 2006). Prevalence by content will differ
and there could be important differences in the detailed content of delusional ideation between clinical and non-clinical
groups. This level of epidemiological scrutiny of paranoid thinking has not been carried out.
4. Psychological processes and persecutory thinking
Can the widespread experience of unfounded paranoid thoughts be explained psychologically? The focus will be on
psychological processes that have been empirically investigated in relation to persecutory ideation. Some of the
psychological processes (e.g. jumping to conclusions) have more often been investigated in relation to delusions in
general, which is a clear weakness for the review. Principal components analysis indicates that sub-types such as
paranoia and grandiosity/fantastic delusions may have a degree of independence (Vzquez-Barquero, lastra, Nuez,
Castanedo, & Dunn, 1996) suggesting that there may be non-shared causes, although research on differential causes of
delusion sub-types is yet to be carried out. A related methodological point is that most studies do not control for the
common co-occurrence of symptoms found in clinical settings (Maric et al., 2004) so that spurious associations with
paranoia might be found.
5. Anomalous experiences
the delusional belief is not being held in the face of evidence normally sufficient to destroy it, but is being held
because of evidence powerful enough to support it (Maher, 1974)
The American psychologist Brendan Maher (1974, 1988, 2003) emphasises that delusional ideas spring from
unusual internal experiences. The argument, simply put, is that odd experiences lead to odd ideas. This is consistent
with findings that many people with psychosis have clear anomalous experiences such as hallucinations, thought
insertion, and replacement of will, and also a range of more subtle perceptual and attentional alterations in experience
(e.g. McGhie & Chapman, 1961) and, often, periods of arousal (e.g. Docherty, Van Kammen, Siris, & Marder, 1978;
Hemsley, 1994). For instance, Bunney et al. (1999) found that 67 people with schizophrenia reported significantly
more perceptual anomalies, particularly in the auditory and visual modalities, than non-clinical controls. Patient reports
included: Things are louder than normal: the TV is louder; other peoples' conversations seem louder, Sometimes it
seems like everything is coming in, like my brain is a radar for sounds, Things in the corner of my eyes often catch my
attention. I feel like I see everything at once. Kapur (2003) has highlighted the importance of aberrant feelings of
salience in delusion formation, which is particularly of note since in this account the abnormal experience itself
concerns processes of meaning ascription.
Odd internal experiences are clearly present in psychosis, but are they connected with delusions? There are a
number of strands of evidence from patient reports, investigation of delusions and hallucinations over time, and
examination of the anomalous experiences of hearing impairment and illicit drug use concerning this question.
Asking individuals with delusions directly about their experiences using a structured interview finds, in two out of three
studies, that internal feelings and experiences are more often cited as evidence for the beliefs than external events
(Buchanan et al., 1993; Freeman et al., 2004; Garety & Hemsley, 1994). In a study of 100 people with delusions, over
half of whom had persecutory beliefs, it was found that non-delusional alternative explanations for the evidence taken
for the beliefs were uncommon (Freeman et al., 2004). Internal anomalous experiences were least likely to have an
alternative explanation, consistent with the anomalous experiences account; in part, individuals may explain puzzling
and confusing anomalous experiences delusionally because they have no alternative explanations to turn to.
Individuals in the non-clinical population also have anomalies of experience, such as hallucinations, and these have
been found to be associated with delusional ideas (Bell, Halligan, & Ellis, 2006; Freeman et al., 2005a; Van Os et al., 2000).
Krabbendam et al. (2004) used longitudinal data from the NEMESIS general population study to show a link between
hallucinations and delusions. They found that the risk of developing psychosis is significantly increased if delusional
ideation develops after hallucinatory experience, but not if hallucinatory experience occurs after delusional ideation. The
authors conclude that their data are consistent with Maher's account in that delusional appraisal of anomalous experiences
is important in the development of clinical experiences.
Maher highlights how hearing impairments, conceived as an anomalous experience, can lead to paranoid thoughts.
In older adults there is some evidence of associations of paranoia and hearing difficulties (Christenson & Blazer, 1984;
Cooper & Curry, 1976), although this is not always found (Cohen, Magai, Yaffee, & Walcott-Brown, 2004; stling &
Skoog, 2002). In the NEMESIS general population study, hearing impairment was predictive of the presence of
positive symptoms of psychosis 3 years later (Thewissen et al., 2005). Most intriguing perhaps is evidence from the
first experimental manipulation study of paranoia. Zimbardo et al. (1981) studied 18 highly hypnotisable students. All
were hypnotised; twelve had partial hearing impairment induced, with half being made aware of the source of the
impairment, and the remainder had an unrelated posthypnotic suggestion. Individuals who were unaware of their
hearing impairment had higher levels of paranoid ideation in a later social interaction compared with the other two
groups. This is clearly supportive of the anomalous experiences account of delusions.
Receiving more contemporary interest has been the role of illicit drugs and psychosis (e.g. Murray, Grech, Phillips, &
Johnsons, 2003). Two studies indicate that anomalies of experience caused by street drugs may be associated with
delusional ideas. D'Souza et al. (2004) showed in a double-blind randomised placebo controlled study involving 22 non-
clinical individuals that the principal active ingredient in cannabis can cause transient increases in positive symptoms of
psychosis and perceptual alterations (distorted time perception, external perception, feelings of unreality, and altered
body perception). Participant experiences in this study included I thought you were all trying to trick me by changing
the rules of the tests to make me fail, I thought you could read my mind, that's why I didn't answer, My thoughts were
fragmentedthe past present and future all seemed to be happening at once, I thought I could hear the dripping of the
i.v. and it was louder than your voice. Using experience sampling methodology (repeated self-report assessment of
patient experiences during the day) (Delespaul, 1995), Verdoux, Gindre, Sorbara, Tournier, and Swendsen (2003)
showed that individuals with raised levels of non-clinical delusional or hallucinatory experience were more likely to
have unusual sensorial or perceptual experiences after smoking cannabis (i.e. there is an interaction between psychosis
vulnerability and cannabis use). However these studies do not test whether drug-induced anomalies of experience lead to
delusional ideas.
The anomalous experiences account is a difficult and under-researched area of study. Clearly, anomalies of
experience are frequently found in individuals with delusions but the nature of their relationship remains to be tested
convincingly. It is the least researched of the areas covered in this review and the literature is somewhat fragmented and
lacking in replicated findings. This is surprising since it is a very plausible route to delusional ideas, because
individuals often rely on feelings to guide judgements. However the lack of sustained attention is also understandable.
Internal anomalous experiences are difficult to detect since it is partly the nature of the problem that they go
unrecognised by the experiencer who forms delusional ideas. And an absence of good experimental measures of the
processes underlying the anomalies means that self-report remains the main research strategy. There are also conceptual
and methodological problems in trying to disentangle perceptions from interpretations. And as has been pointed out by
many authors, the anomalous experiences account cannot provide a complete answer to delusion formation. Many
people have unusual experiences and do not get delusions. But this argument should not detract from the idea that the
nature of some internal experiences may particularly lead to unlikely explanations.
6. Affective processes
it is perhaps worthy of notice that the various directions, which the delusions take in paranoia, correspond in
general to the common fears and hopes of the normal human being. They, therefore, appear in a certain manner as
the morbidly transformed expression of the natural emotions of the human heart. Kraepelin (1921)
The distinguishing of psychotic and affective disorders is one of the main boundaries in diagnostic classification
systems. It is therefore intriguing that psychosis researchers have started to pay attention to the role of affective
processes in delusional experience (Birchwood, 2003; Freeman & Garety, 2003). Some researchers have focussed on
anxiety, others on depression, schemas and self-esteem, though clearly there is overlap between all these concepts. All
the main studies of relevance concern persecutory ideation directly.
6.1. Anxiety
Paranoia concerns fear. A number of studies by Freeman and colleagues in both clinical and non-clinical
populations have stemmed from their observation that persecutory and anxious thoughts both concern the anticipation
of threat; fears of physical, social or psychological harm are apparent both in anxious thoughts (e.g. Eysenck & van
Berkum, 1992; Wells, 1994) and in persecutory thoughts (Freeman & Garety, 2000; Freeman et al., 2001). It is argued
that anxiety helps create thoughts of a paranoid content, and that anxiety-related processes contribute to the
maintenance and distress associated with the experience.
At present the evidence for a link between anxiety and paranoia is reasonably strong. Anxiety has repeatedly been found to
be associated with paranoid thoughts (Freeman et al., 2005a; Fowler et al., 2006; Johns et al., 2004; Martin & Penn, 2001) and
persecutory delusions (Freeman & Garety, 1999; Huppert & Smith, 2005; Naeem, Kingdon, & Turkington, 2006; Startup,
Freeman, Garety, in press). Better evidence for the role of anxiety in the development of paranoid thoughts is that anxiety is
predictive of the occurrence of paranoid thoughts (Freeman et al., 2003, 2005b) and of the persistence of persecutory
delusions (Startup et al., in press). Moreover, it has been shown in non-clinical groups that paranoid thoughts build upon
common interpersonal anxieties and worries (Freeman, Garety, Bebbington, Slater et al., 2005; Freeman, Slater, et al., 2003;
Freeman, Garety, Bebbington, & Smith et al., 2005c). The most common type of suspiciousness is that of a social anxiety or
interpersonal worry theme; ideas of reference build upon these sensitivities; persecutory thoughts are closely associated with
the attributions of significance; and as the severity of the threatened harm increases, the less common is the thought. The
implication is that severe paranoia may build upon common emotional concerns. More broadly, the hypotheses are consistent
with innovative work showing greater stress sensitivity in people with psychosis (Myin-Germeys, Delespaul, & van Os,
2005). Intriguingly, Schulze et al. (2005) report a similar genetic marker for persecutory delusions and anxiety.
Paranoid thinking and anxiety-related processes have been linked. Initial evidence indicates that almost two-thirds
of individuals with persecutory delusions have a worry thinking style (even about matters unrelated to paranoia)
(Freeman & Garety, 1999; Startup et al., in press). Worry in individuals with persecutory delusions is associated with
higher levels of distress and with delusion persistence. Other anxiety-related processes are also apparent in people with
persecutory delusions. An example is safety behaviours (Freeman et al., 2001, 2007). Individuals who feel threatened
often carry out actions designed to prevent their feared catastrophe from occurring; this has been termed safety
behaviour (Salkovskis, 1991). When the perceived threat is a misperception, such as in anxiety disorders and paranoia,
there are important consequences. Individuals fail to attribute the absence of catastrophe to the incorrectness of their
threat beliefs. Rather, they believe that the threat was averted only by their safety behaviours (e.g. The reason I wasn't
attacked was because I left the street in time and made it back home). Threat beliefs are likely to persist partly due to
this failure to obtain and process disconfirmatory evidence. Freeman et al. (2007) found that 96 out of 100 patients with
persecutory delusions had used safety behaviours in the past month.
In the course of their work, Freeman and colleagues have collaborated with computer scientists to develop, using
virtual reality (VR), the first method to study persecutory ideation in the laboratory (Freeman et al., 2003, 2005b). With
virtual reality the environment is controlled; individuals can therefore enter an identical situation, and so appraisals for
the same event can be assessed and psychological factors associated with particular appraisals identified. In applying this
method to the study of persecutory ideation, virtual characters (avatars) in a virtual environment can be programmed to
exhibit only behaviour that most people would assess as neutral. Individuals' appraisals of the avatars can then be
assessed, and the psychological factors that lead some individuals to have (clearly unfounded) persecutory thoughts
determined. In the studies, most people found that the virtual library environment used neutral or even positive. However
about a third had persecutory thoughts about the avatars. In both published studies, anxiety and interpersonal sensitivity
were predictors of unfounded persecutory ideation in virtual reality. However, these authors also note the important task
of identifying differential predictors of anxiety and paranoia. They carried out the first study investigating this issue by
not only measuring persecutory thoughts in VR but by also assessing social anxiety thoughts about the avatars.
Interestingly, the prediction of persecutory ideation and social anxiety in virtual reality shared many of the same factors
and this is unsurprising given the similarities in their threat content but what sets apart the prediction of persecutory
ideation from that of social anxiety was the presence of predisposition to hallucinatory experience. The findings support the
view that emotional disturbance can lead to social anxiety but that the addition of anomalous experiences such as
hallucinations makes persecutory ideation more likely.
6.2. Depression, self-esteem and schemas
The issue of the relationship between paranoia and emotion is more controversial when it concerns depression and
self-esteem. Richard Bentall, a leading pioneer of the research field, argues that persecutory delusions are a defense
against negative affective processes (Bentall et al., 1994; Bentall et al., 2001). In contrast, Freeman and colleagues put
forward the view that persecutory delusions are a direct reflection of emotional concerns (Freeman et al., 2002;
Freeman et al., 2004; Freeman et al., 2005c). Trower and Chadwick (1995) argue that there are two quite distinct forms
of paranoia, one of which is a defense (Poor Me paranoia) and the other of which is a direct reflection of extreme
negative emotion (Bad Me paranoia). It is worth noting that some delusion-as-defense theories focus on the avoidance
of negative self-esteem and some focus on the avoidance of depression, but, nonetheless, negative self-esteem and
depression are typically found to correlate in studies of persecutory delusions (Chadwick, Trower, Juusti-Butler, &
Maguire, 2005; Drake et al., 2004; Freeman et al., 1998, 2001; Lyon, Kaney, & Bentall, 1994).
A simplified view would be that if delusions are a defense then self-esteem should be normal but if paranoia builds
on negative views of the self then self-esteem should be low. Bentall et al. (2001) consider the self-esteem data and
argue that there are very mixed findings concerning levels of self-esteem in paranoia, with some studies finding low
self-esteem and some preserved self-esteem. Their explanation for this is that there is instability in self-esteem in people
with paranoia, and that these individuals are locked into a struggle to defend against negative emotion, sometimes
winning, sometimes losing (which clearly makes the theory harder to test). There is, however, perhaps a clearer, less
complicated picture apparent in the self-esteem and paranoia data, which will now be described.
There are actually few studies that simply look at current levels of self-esteem in individuals with current
persecutory delusions compared with a matched non-clinical control group. And the number of patients in these
studies is small and most likely comprises unrepresentative samples. Studies of paranoia in the non-clinical
population provide much better information on the issue because they include a much larger number of participants,
have a greater range in paranoia scores compared to clinical groups because of the dimensional approach adopted,
and avoid the complications of the effects of being a patient with psychosis on self-esteem and depression (e.g.
receiving a diagnosis, compulsory treatment, medication, unemployment, stigma). The findings in non-clinical
populations are clear: paranoia is repeatedly found to correlate with lower self-esteem and higher depression (Ellett,
Lopes, & Chadwick, 2003; Freeman et al., 2005a; Fowler et al., 2006; Johns et al., 2004; Martin & Penn, 2001;
McKay, Langdon, & Colheart, 2005). For instance, in a representative population survey of over eight thousand
people in the UK, Johns et al. (2004) found that paranoid thinking was associated with symptoms of anxiety and
depression, victimisation experiences, and recent stressful life events. The finding of an association of lowered self-
esteem and paranoia is not unique to non-clinical groups. Drake et al. (2004) in a study of approximately two
hundred first episode patients found paranoia to be associated with depression and lower self-esteem at several time
points over 18 months. Furthermore, this study fits within a larger literature indicating an association of affective
problems with the positive symptoms of psychosis (e.g. Freeman, 2006; Guillem et al., 2005; Norman & Malla,
1994; Sax et al., 1996) and evidence that low self-esteem and anxiety predict the later development of positive
symptoms of psychosis (Krabbendam et al., 2002).
So what do these findings indicate? Unless self-esteem is considered as the only cause of paranoia then there is
no reason to expect everyone with paranoia to have the same level of self-esteem (it might even be considered an
odd finding). But what is clear from the self-esteem data is that there is in general an association of paranoia with
lowered self-esteem and depression. The distribution of self-esteem and mood is skewed towards the negative in
paranoia, which would not be expected if persecutory thoughts serve as a defense. Many individuals with paranoia
have lowered self-esteem but some do not. But of course there is the difficulty of determining the causal direction of
the association. It is entirely plausible that having paranoid thoughts would lower mood and self-esteem.
Experimental studies examining causal issues are needed. It is most likely that there is a circular relationship, with
low self-esteem and depression being one of a number of vulnerability factors for paranoia, which then decreases
self-esteem and increases depression further.
But the debate about global self-esteem and paranoia may obscure the important point. Self-esteem may not be
the key concept when considering paranoia; rather it is specific negative beliefs about the self and others that are
important (Chadwick et al., 2005; Freeman et al., 2002; Fowler, 2000; Fowler et al., 2006; Garety et al., 2001). In
both non-clinical (Freeman et al., 2003, 2005b) and clinical studies (Fowler et al., 2006; Smith et al., 2006),
paranoia has been found to be associated with negative self-beliefs and sensitivities. In what is likely to prove a key
paper in the area, David Fowler et al. (2006) found that in a non-clinical population of over seven hundred students
paranoia was associated with negative beliefs about the self, negative beliefs about others, less positive beliefs
about others, and anxiety. Self-esteem as traditionally measured was not as good a predictor of paranoia and, unlike
schematic beliefs, did not discriminate between the non-clinical group and a group of two hundred and fifty patients
with psychosis.
Of course, negative schematic beliefs are related to self-esteem, but they are not exactly the same (Fowler et al.,
2006). When specific negative beliefs are considered, and the exact content may vary in the individual case, then
links with paranoia are more likely to be found. This fits with Christine Barrowclough et al. (2003) arguing that
self-esteem needs to be assessed in a very detailed interview to find links with symptoms of psychosis. However,
just as with depression and schema, there is a clear problem in establishing the direction of causal effects in the
relationship between paranoia and schematic beliefs. It is likely to be a circular effect.
The parsimonious explanation of associations of negative self beliefs, lowered self-esteem and depression with
clinical and non-clinical paranoia is that they are directly associated, without the need to evoke defensive processes.
But a stricter test of defense theories of paranoia would be whether covert self-concept is lower than overt presentations
(i.e. there is discrepancy between core beliefs about the self and those in conscious awareness). Clearly it is a
methodological difficulty to penetrate hypothesised defenses and a negative finding could always be interpreted as a
failure of methodology rather than theory. It has been argued that the emotional Stroop task is currently the most
plausible defense-penetrating task (Garety & Freeman, 1999; Smith, Freeman, & Kuipers, 2005). The delusion-as-
defense model would predict biases towards negative self-concept words using the Stroop but for overt self-esteem to
be comparable to controls. However, even the first step of showing biases towards depressive words has not been
shown in some studies (Bentall & Kaney, 1989; Fear, Sharp, & Healy, 1996), and discrepancy with overt self-esteem
using this method has not been demonstrated. Evidence for a discrepancy has rested on one particular method using
two different measures of attributions (Lyon et al., 1994) but there have been failures to replicate with this particular
methodology (Kristev, Jackson, & Maude, 1999; Martin & Penn, 2002; McKay et al., 2005; Peters & Garety, 2006).
Moreover, it is of methodological note that in none of the attribution studies has the crucial test of discrepancy between
attribution measures at an individual level been tested statistically. Instead the studies have simply looked at patterns of
results at a group level for each measure. Even in grandiose delusions, where the delusion might be more likely to
protect the self, evidence of discrepancy between overt and covert self-esteem is lacking (Smith et al., 2005).
Can it simply be that there are two distinct sub-groups of paranoia as suggested by Trower and Chadwick
(1995)? No systematic empirical tests have been made of this interesting theoretical account; most obviously, there
has been no comparison of overt and covert self-esteem in Poor Me and Bad Me paranoia groups. There are only
two empirical lines of evidence directly related to the theory. Unsurprisingly, Bad Me paranoia is associated with
greater depression and negative self-esteem than Poor Me paranoia (Chadwick et al., 2005; Freeman et al., 2001).
But it also seems that cases of Poor Me paranoia may be uncommon; Fornells-Ambrojo and Garety (2005) found
only three cases of Bad Me paranoia in 40 individuals with early episode psychosis and paranoia. An alternative
account of the current evidence is that the concept of deservedness is an important (dimensional) aspect of the
content of paranoia associated with distress, but not an indicator of discrete categories with opposite causes.
In summary, when understanding paranoia it may be better to think in terms of specific schematic beliefs rather than
global self-esteem. Paranoia may well often build on negative ideas about the self, others and the world. If the measure
is appropriate then paranoia is often associated with self-concept concerns, which are in general apparent in people with
paranoid thoughts. Schematic concerns may provide content to paranoid thoughts but perhaps not affect conviction in
the thoughts to a large degree. If negative self-esteem is present then it may be particularly associated with the distress
of paranoid experience. Overall there is now considerable evidence of affect and related processes having a direct, non-
defensive, role in the development of paranoid thoughts. Anxiety may be especially important in paranoid thoughts.
However, causal tests of hypothesised factors are now needed. It is also of note that psychological factors such as social
rank, power differentials and submissive behaviours have been studied in pioneering studies of the distress of auditory
hallucinations but are yet to be fully applied to paranoia and may be another important element in understanding the
experience (Freeman et al., 2005c; Gilbert, Boxall, Cheung, & Irons, 2005).
7. Reasoning
The degree of paranoia stifled my ability to live and think freely. False suspicions impeded my progress in going
forward. Once I began to question, my suspicions could not be verified. Once I acknowledged that there were holes of
uncertainty, I began to think that some of my thoughts might be delusional even though they had the appearance of
truth and believability. As each day passed and I wasn't killed, I dug deeper at my own scared pace. Chapman (2002).
Robert Chapman (2002) describes his determined recovery from delusions using a self-devised four-step strategy of
doubting paranoid beliefs, recognising and identifying delusional thoughts, processing disconfirmatory evidence, and
considering alternative explanations. His approach is based upon testing delusional beliefs using reasoning strategies.
If delusions are incorrect or perhaps, more importantly, uncorrected beliefs, then judgemental or reasoning
processes are inherently implicated in their cause. A number of researchers have therefore tried to identify biases or
deficits in reasoning in individuals with paranoia.
7.1. Jumping to conclusions
Reasoning had long been assumed to be awry in people with delusions, but empirical evidence for this view had not
been forthcoming. In innovative work from the late 1980s onwards, Philippa Garety and colleagues provide empirical
evidence that individuals with delusions jump to conclusions (JTC). In an experimental probabilistic reasoning task
individuals are required to decide from which of two hidden jars coloured beads are being drawn. The jars both contain
beads of two different colours but the proportion of beads of each colour in the jars is reversed. Typically, one jar will
contain 85 black beads and 15 yellow beads and the other jar will contain 85 yellow beads and 15 black beads. It has
been found that individuals with delusions request fewer pieces of information (i.e. to see fewer beads drawn from the
jar) before making a decision compared with non-clinical controls (see review by Garety and Freeman, 1999). Such a
bias in data gathering is hypothesised to lead to the rapid acceptance of beliefs even if there is limited evidence to
support them, and hence be a factor in delusion development and maintenance. Probabilistic reasoning has rarely been
studied in relation to delusion sub-type. In Table 4 studies of probabilistic reasoning are summarised but with an
emphasis on the presence of persecutory delusions in the samples. Only studies that allow the participants to gather data
freely are reported.
Remarkably, in all ten clinical studies where individuals with delusions are compared with non-clinical controls on
the number of draws to decision in probabilistic reasoning tasks, data gathering is hastier in the delusion group. Such
replication of a finding is rare in psychosis research and is firm evidence for the presence of a JTC bias in individuals
with delusions. One half to two-thirds of individuals with delusions jump to conclusions (defined as making a decision
after two or fewer beads). A study of one hundred individuals with delusions indicates that JTC may be particularly
associated with delusional conviction (Garety et al., 2005). But is the bias apparent in people with persecutory
delusions? This is much less clearly shown by the studies. In only seven studies is information on the presence of
persecutory delusions available. Individuals with persecutory delusions were the focus of only one study (Startup,
2004) and were present in at least half the participants in the other six studies. The limited conclusion that can be made
at present on this information is that JTC is often present in people with persecutory delusions. However, there have
been no tests of specific associations with delusion sub-types. In most cases individuals with persecutory delusions
would have had other delusion beliefs and therefore whether JTC is more strongly associated with another delusion
sub-type such as grandiose delusions remains to be investigated.
The evidence base on JTC concerns individuals with current delusions. However, there are two intriguing recent
studies of JTC in groups that are not currently deluded. Broome et al. (in press; pers. com.) found evidence that hasty
data gathering is present in a group identified as at risk of developing psychosis, indicating that the bias may be present
before delusions occur, although it was only in the more difficult versions of the reasoning task that JTC was apparent.
JTC may be a cause of delusions. In an important study, Van Dael et al. (2006) studied JTC in individuals with
psychosis and their relatives, and individuals in the general population high or low in non-clinical psychotic symptoms
(i.e four groups differing in levels of delusional ideation and vulnerability to psychosis). Hasty data gathering was
associated with both delusional ideation and psychosis liability. As the authors argue, JTC may be both partly a trait
factor reflecting liability for psychosis and partly a state factor as it covaries with level of delusional ideation. In other
words, JTC could contribute to both delusion formation and maintenance. Consistent with this work, two studies have
found JTC in individuals whose delusions have remitted (Mortimer et al., 1996; Moritz and Woodward, 2005),
although one study did not (Peters & Garety, 2006). Colbert and Peters (2002) found evidence of JTC in non-clinical
individuals with high delusional ideation compared with individuals with low clinical delusional ideation, but this was
not replicated by Van Dael et al. (2006). Furthermore, in the only non-clinical study to examine an association of JTC
and paranoid thinking, there was no evidence for such a link (Freeman et al., 2005b). Biases in reasoning may be much
more subtle outside of acute delusional states.
In addition to the exact relationship of JTC to the development of delusions, the cause of hasty data gathering itself
remains to be determined. There have been a number of speculations: Dudley and Over (2003) note the need to
consider the goal of reasoning; Moritz and Woodward (2004) raise the issue of the level of the threshold at which an
explanation is accepted; the belief confirmation bias (Freeman, Garety, McGuire, & Kuipers, 2005) or a bias against
disconfirmatory evidence (Moritz & Woodward, 2006b) may be related to JTC; and data gathering is likely to be
influenced by the availability of alternative explanations for experiences (Freeman et al., 2004). Previous suggestions
that JTC reflects a generalised need for closure have been discounted however (Freeman, Garety, Kuipers, Colbert,
Jolley et al., 2006).
Biases in data gathering will plausibly affect belief formation and maintenance, enabling the rapid acceptance of
implausible explanations. However, it should also be noted that a JTC bias might distort the evidence. For example,
Moritz and Woodward (2006a) suggest that JTC may lead to acceptance of false memories or knowledge corruption,
while misattribution biases hypothesised to be important in the occurrence of hallucinations have been found to be
associated with delusional ideation (e.g. Johns et al., 2006; Allen, Freeman, Johns, & McGuire, 2006). The complexity
is that reasoning biases may contribute to the anomalies of experiences that are taken as the evidence for delusional
beliefs.
Future studies will benefit from not considering data gathering in isolation. More detailed experimental work is
needed on the interaction of the production of potential explanations, data gathering, the processing of confirmatory
and disconfirmatory reasoning, the acceptance of explanations, and how beliefs change. Furthermore, how these are
modified by current goals, emotional state, and interactions with others needs to be examined. Causal studies of
438
Table 4
Jumping to conclusions (as assessed by the probabilistic reasoning task)
Study Groups of participants Proportion delusion group Task Jumping to conclusions Comments
with persecutory beliefs as assessed by draws to
decision (in delusion
groups compared with
non-clinical controls)
Delusion studies
Huq, Garety, and 15 delusions ? 85:15 beads ratio
Hemsley (1989) 10 psychiatric control
D. Freeman / Clinical Psychology Review 27 (2007) 425457

15 non-clinical controls
Garety et al. (1991) 27 delusions ? 85:15 beads ration 55% of the delusion group jumped to conclusions (two
14 anxious beads or fewer). 11% of the non-delusion participants
13 non-clinical control showed JTC.
Mortimer et al. (1996) 43 patients with ? 85:15 beads ratio The study did not include a control group and therefore
schizophrenia it is unknown whether the clinical group shows hasty
data gathering in relation to non-clinical controls.
It is not known how many of the participants had
delusions.
42% of the sample were reported as jumping to
conclusions defined as deciding after one bead has been
drawn.
Dudley et al. (1997a) 15 delusions 73% (Dudley, pers. com). 85:15 and 60:40 beads The delusion group requested fewer beads in both
15 depression ratios versions of the beads task.
Dudley et al. (1997b) 15 delusions of 73% (Dudley, pers. com) 60:40 neutral word stimuli The delusion group requested fewer words in both
persecution or grandeur ratio versions of the task. Emotionally salient stimuli reduced
16 depression 60:40 emotionally data gathering in all three groups.
15 non-clinical controls salient word stimuli
ratio
Fear and Healy (1997) 30 delusions ? 85:15 beads ratio 73% of the delusion group showed jumping to
16 obsessional and conclusions as defined by deciding after one bead. 20%
delusional features of the non-clinical control group jumped to conclusions.
29 obsessive-compulsive
disorder
Conway et al. (2002) 10 delusions 50% 85:15 beads ratio The beads task was administered four times and average
10 non-clinical controls scores used. 70% of the delusion group and 10% of the
control group jumped to conclusions defined as a
decision after two beads or fewer.
Startup (2004) 28 Persecutory delusions 100% 60:40 beads ratio 50% of the delusion group showed jumping to
30 Non-clinical conclusions defined as deciding after two beads or
participants fewer. 10% of the control group showed JTC.
Moritz and Woodward 17 delusions 100% 90:10 beads ratio Defining JTC as making a decision after two or fewer
(2005) 14 schizophrenia and no All participants had beads, 65% of the delusion group, 43% of the no
current delusions at least mild paranoid current delusions schizophrenia group, 21% of the
28 psychiatric controls ideation/suspiciousness psychiatric controls and 6% of the non-clinical
17 non-clinical as assessed with the controls showed JTC.
controls Brief Psychiatric
Rating Scale item 11
(Moritz, pers. Comm.).
Garety et al. (2005) 100 delusions 70% (SAPS N2) 85:15, 60:40 beads A non-clinical control group was not included in this
ratios. 60:40 study. With JTC defined as making a decision after
emotionally salient two beads or fewer:
word stimuli task 53% showed JTC on the 85:15 tasks
also used 41% showed JTC on the 60:40 task

37% showed JTC on the emotionally salient
words task.
Peters and Garety 23 delusions 61% 85:15 beads ratio It is also of note that in this study the groups were
(2006) 22 psychiatric controls followed up over time. Individuals with delusions
36 non-clinical controls that had remitted did not differ from non-clinical
controls in data gathering.
Van Dael et al. 40 individuals with ? 85:15 Jumping to conclusions (defined as deciding after one
(2006) schizophrenia bead) was found in 32.5% of the individuals with
40 first degree schizophrenia; 25% of the relative group; 14.6% of the
nonpsychotic relatives non-clinical high symptom group; and 11.3% of the
41 non-clinical individuals control group.
with psychotic
experiences
53 non-clinical controls JTC was associated with delusional ideation and
psychosis liability across the groups.
Broome et al. (in press; 31 at risk of psychosis 85:15, 60:40 and The at risk group showed hasty data gathering on the
pers. com.) 23 non-clinical controls 44:28:28 beads ratios two more difficult beads ratio tasks
(but not the 85:15 task).
Draws to decision were correlated with delusional
conviction in all participants.
Non-clinical studies
Colbert and Peters 17 non-clinical individuals 85:15 beads ratio
(2002) high in delusional ideation
17 non-clinical individuals
low in delusional ideation
Freeman, Garety, 30 non-clinical individuals Scorers across the full range of 85:15 beads ratio X There was no evidence of jumping to conclusions being
Bebbington, Slater non-clinical paranoia associated with paranoid thoughts in an
et al. (2005) experimental situation.
439
reasoning and delusional ideation are clearly indicated now. This work has relevance for the study of delusional beliefs
but also more generally for cognitive therapy approaches to problems where changes in beliefs are targeted.
7.2. Attributional style
The literature on attributional style developed by Richard Bentall and colleagues has been closely linked to the
delusion-as-defense theory, but attributional style need not be tied to such a theoretical framework; if a person tends to
explain events in terms of other people then this would be a plausible factor in the creation of paranoid thoughts,
without evoking the further hypothesis that the explanation serves to defend the self-concept. This means that the key
issue is not whether individuals with delusions have a self-serving bias (i.e. differences in the types of attributions given
for positive and negative events) but, given the negative content of paranoid thoughts, whether external attributions for
negative events are made. Snyder's (2006) account of his paranoid episode illustrates a strong bias to explain events in
a particular way: My concept of THEM grew and began to colour every experience I had. After a few months,
everything that happened to me was somehow related to THEM, or was caused by THEM. When I started experiencing
problems with my home computer, I blamed THEM. When I got a parking ticket, it was THEIR influence with the
police that got me into trouble. Every thought that I had was somehow associated with THEM.
Most attribution studies have used either the Attributional Style Questionnaire (ASQ) (Peterson et al., 1982) or the
Internal, Personal and Situational Attributions Questionnaire (IPSAQ) (Kinderman & Bentall, 1996a). The basic design
of these questionnaires is similar. A hypothetical event is described (e.g. You go on a date and it goes badly) and the
participant is asked to note a cause and then rate it for how much the cause is due to something about them or to
something about other people or circumstances. The results of these studies are summarised in Table 5.
Three ASQ studies (Fear et al., 1996; Krstev et al., 1999; Lyon et al., 1994) show clear evidence of an externalising bias
for negative events in people with persecutory delusions compared with non-clinical controls and two ASQ studies find no
differences between persecutory delusion and non-clinical control groups (Kinderman, Kaney, Morley, & Bentall, 1992;
Martin & Penn, 2002). None of the four IPSAQ studies finds evidence of an externalising bias for negative events in
persecutory delusion groups compared with non-clinical controls (Kinderman & Bentall, 1996b; Martin & Penn, 2002;
Randall, Corcoran, Day, & Bentall, 2003; McKay et al., 2005). In the first clinical study using the IPSAQ, Kinderman and
Bentall (1996b) found that, when external attributions were made, individuals with persecutory delusions were more likely to
make externalpersonal attributions compared to non-clinical controls (who were more likely to make externalsituational
attributions). However, this has not been replicated in three further clinical studies (Martin & Penn, 2002; McKay et al.,
2005; Randall et al., 2003). In studies of non-clinical paranoid ideation in student groups only one of three studies finds an
association of paranoia and a personalising bias (Kinderman & Bentall, 1996a).
Overall, four out of nine studies using the two attribution measures indicate that there are differences between
individuals with persecutory delusions and non-clinical controls in attributions for negative events. Therefore, the
empirical case for persecutory delusions being associated with an excessive externalising style for negative events is
unconvincing at present. A large-scale study is needed, but it will be important to control for both grandiosity and
depression since there is evidence for their association with attributional style (e.g. Jolley et al., 2006). However, it
should be noted that the questionnaire assessments of attributional style used may limit the chances of finding evidence
of an externalising style. There are concerns over the psychometric properties of questionnaires such as the ASQ (e.g.
Krstev et al., 1999) and anecdotal reports indicate that participants have difficulties completing the attribution
questionnaires. Perhaps most importantly, clinical experience indicates that the questionnaires do not assess the types
of events that delusional attributions concern. Delusions often concern ambiguous social events (e.g. the look on a face,
the gesture of a person) and, as discussed earlier, confusing internal experiences. The ASQ was designed for depression
research and does not assess these sorts of experiences.
7.3. Theory of mind
Individuals with persecutory ideation are by definition sometimes misreading the intentions of other people.
Therefore a candidate cause is the mechanism of determining others' mental states. Drawing upon established research
into children's understanding of folk psychology, and drawing a close analogy with autism, Frith (1992, 2004)
proposes that symptoms of schizophrenia develop from newly acquired difficulties in a person's theory of mind skills
(ToM) (Premack & Woodruff, 1978). ToM refers to the ability to understand mental states (beliefs, desires, feelings,
Table 5
Attributional style for negative events (assessed by the ASQ or IPSAQ)
Study Groups of participants Attributional measure Externalising bias for Comments
negative events (in
delusion group compared
with non-clinical controls).
Clinical psychosis studies
Kinderman et al. (1992) 23 persecutory delusions ASQ X From graphed data it appears from visual inspection that the
21 psychiatric control delusion group score comparably to the non-clinical group on
28 non-clinical control attributions for negative events. The depressed group, however,
makes more internal ratings for negative events.

Candido and Romney (1990) 15 persecutory delusions ASQ ? This study did not include a non-clinical control group and
15 persecutory delusions therefore the presence of an externalising bias in individuals with
and depression persecutory delusions cannot be tested. In comparison with
depressed patients, individuals with persecutory delusions made
more externalising attributions for negative events, but this could
be due to people with depression showing an internalising bias.
15 depression Attributions were associated with levels of depression and paranoia.
Higher depression was associated with more internalising. Higher
paranoia was associated with more externalising.
Lyon et al. (1994) 14 persecutory delusions ASQpf In this study a new parallel version of the ASQ was used.
14 depression control group
14 non-clinical control
Fear et al. (1996) 20 persecutory delusions ASQ The externalising style was present in both individuals with
9 non-persecutory delusions persecutory delusions and individuals with non-persecutory
20 non-clinical controls delusions (mainly grandiose).
Sharp et al. (1997) 19 persecutory and/or grandiose ASQ Externalising specific to persecutory/grandiose group and not to
delusions (14 persecutory, other delusion sub-types.
5 grandiose)
12 somatic or jealousy delusions
Krstev et al. (1999) 62 individuals with first episode ASQpf X The parallel version of the ASQ developed
psychosis, but none held a by Lyon et al. (1994) was used.
persecutory delusion at the The authors did not include a non-clinical
time of testing control group. They compared their results with
other studies to argue that an excessive
externalising bias for negative events is not apparent.
Higher levels of depression were associated with more
internalising, while
higher levels of suspiciousness were associated
with less internalising for negative events.
(continued on next page)
441
442

Study Groups of participants Attributional measure Externalising bias for Comments
negative events (in
delusion group compared
with non-clinical controls).
Clinical psychosis studies
Jolley et al. (2006) 7 persecutory delusions ASQ ? The absence of a non-clinical control group prevents determination
23 persecutory delusions of whether an externalising bias was present. However there were
and depression group differences in externalising for negative events. Individuals
7 persecutory and with persecutory and grandiose delusions were more likely to
grandiose delusions externalise negative events than the persecutory delusions and
depression group and the non-persecutory delusions group. In the
34 non-persecutory whole sample, the presence of both grandiosity and persecutory
delusions psychosis delusions was associated with externalising attributions for
negative events and not persecutory delusions or grandiose
delusions on their own.
Martin and Penn (2002) 15 persecutory delusions ASQ X Using two measures of attributions there was no evidence of
15 non-persecutory delusions IPSAQ X either excessive externalising or personalising attributions
schizophrenia group in individuals with persecutory delusions based
(9 had no delusions) upon their self-report.
Kinderman and Bentall 20 persecutory delusions IPSAQ X The persecutory delusion group scored comparably to the
(1996b) non-clinical group for whether an external attribution was made
for a negative event.
20 psychiatric control However, when an external attribution was made, the persecutory
delusion group was more likely to make a personalising attribution
than the non-clinical control group. The non-clinical control
group was more likely to make situational external attributions
than the persecutory delusions group.
20 non-clinical Paranoia scale scores were not correlated with the tendency to
personalise external attributions.
Depression scores were associated with internal but not
personalising attributions.
Randall et al. (2003) 19 persecutory delusions IPSAQ X There were no differences in internal, personal, or situational
14 persecutory delusions attributions for negative events for the three groups as self-rated.
in remission
McKay et al. (2005) Study 2 IPSAQ X The persecutory delusion group made more internal attributions
13 persecutory delusions for negative events than the control group (accounted for
by levels of depression).
12 remitted persecutory All groups had comparable scores for level of personalising
delusions group attributions for negative events.
19 non-clinical controls The control group made more situational attributions for negative
events than the persecutory delusion group (accounted for
by levels of depression).

Langdon et al. (2006) 19 persecutory delusions IPSAQ ? The groups were not compared on the numbers of internal
15 non-persecutory delusion attributions for negative events. However, there were no
schizophrenia group significant differences in
(nine had no delusions) levels of personalising of negative events between the three groups.
Non-psychosis studies
Kinderman and Bentall 85 non-clinical students IPSAQ Higher levels of non-clinical paranoid ideation were associated with
(1996a) making personalising external attributions.
Depression was associated with making internal attributions.
Martin and Penn (2001) 193 non-clinical students IPSAQ Higher levels of non-clinical paranoid ideation were not associated
with a personalising bias for negative events.
McKay et al. (2005) Study 1: 40 non-clinical IPSAQ No association of persecutory ideation and attributional style was found.
students A drawback for interpretation of this study is that the authors use an
unpublished novel measure of persecutory ideation.
Blackshaw et al. (2001) 25 individuals with IPSAQ Individuals with Asperger syndrome had higher levels
Asperger syndrome of paranoia than the control group but did not differ
18 non-clinical control group significantly in the presence of a personalising
bias for negative events.
443
and intentions) in the self or others. Previously, Cameron (1959) observed that people vulnerable to paranoia are
unable to understand adequately the motivations, attitudes, and intentions of others. Frith argues that delusions of
persecution and reference arise from the person with schizophrenia knowing that people have mental states that cannot
be directly viewed, but making invalid attempts at inferring them. According to Frith, delusions of reference occur
because a person with schizophrenia mistakenly labels an action as having an intention behind it. Persecutory delusions
arise because the person notices that other peoples' actions have become opaque and surmises that a conspiracy exists.
Frith's innovative research has led to a large literature in which tasks assessing different levels of ToM abilities have
been used with people with schizophrenia. Indeed this is now the most researched psychological process and psychosis,
and it could be argued that an association of ToM performance and paranoia has been more stringently tested than the
other psychological factors reviewed. There is a consensus that ToM difficulties are apparent in people with a diagnosis
of schizophrenia, and may be most severely present in individuals with negative symptoms and incoherent speech
(Brne, 2005; Garety & Freeman, 1999; Harrington, Langdon, Seigert, & McClure, 2005; Harrington, Siegert, &
McClure, 2005; Sarfati, Hardy-Bayl, Besche, & Widlcher, 1997). Indeed, this association with negative symptoms
may be expected from the neuropsychological literature; ToM tasks and executive functioning have been found to be
linked in the developmental psychology literature (e.g. Hughes, 2002) and executive functioning difficulties have been
found to be associated with negative symptoms and thought disorder but not the positive symptoms of psychosis (e.g.
O'Leary et al., 2000). Difficulties with ToM may be a trait factor associated with liability to psychosis (Janssen,
Krabbendam, Jolles, & van Os, 2003).
As Frith (2004) notes, however, the ToM findings for paranoia may be more equivocal. In Table 6 ToM studies are
listed that include a comparison of individuals with predominately paranoid symptoms and non-clinical controls, or
that examine correlations between positive symptoms and ToM performance.
It is clear that ToM problems do occur in people with predominately paranoid symptoms. In eight studies ToM
performance in people with paranoid symptoms is poorer relative to controls (Corcoran, Cahill, & Frith, 1997; Corcoran,
Mercer, & Frith, 1995; Craig, Hatton, Craig, & Bentall, 2004; Frith & Corcoran, 1996; Harrington, Langdon, Siegert, &
McClure, 2005; Langdon, Corner, McLaren, Ward, & Coltheart, 2006; Randall et al., 2003; Russell, Reynaud, Herba,
Morris, & Corcoran, 2006). There is only one failure to replicate (Pickup & Frith, 2001). However, ToM problems are not
necessary for paranoid experiences. Walston, Blennerhassett, and Charlton (2000) set out to deliberately recruit a highly
selected pure persecutory delusion group from psychiatric services. Four individuals with persecutory delusions but with
an absence of other psychopathology, intellectual impairment, overtly illogical or incoherent reasoning, or diagnoses such
as depression, mania or schizophrenia were assessed. All four cases showed intact theory of mind performance.
Because ToM difficulties have been hypothesised to explain several symptoms of psychosis, the majority of studies
have tested a group of people with schizophrenia and examined associations between symptoms of psychosis and ToM
performance. It is important to note that this provides a more stringent test than the group division studies because
paranoid symptoms in clinical groups are rarely the only symptom present (Maric et al., 2004). Even in the studies that
group individuals with paranoid symptoms separately from people with negative symptoms, there may still be low
levels of negative symptoms in the paranoid group. The possibility remains that the findings of ToM difficulties in
people with paranoid symptoms are actually due to the presence of other symptoms.
Most studies do not find an association of positive symptoms of psychosis and ToM performance. In six studies,
negative symptoms and/or thought disorder, but not delusions and hallucinations, are associated with ToM difficulties
(Kelemen et al., 2005; Langdon et al., 1997; Langdon, Coltheart, Ward, & Catts, 2001; Mitchley, Barber, Gray, Brooks,
& Livingstone, 1998; Mazza, De Risio, Surian, Roncone, & Casacchia, 2001; Pickup & Frith, 2001). Roncone et al.
(2002) and Russell et al. (2006) found no association of positive or negative symptoms with ToM performance in their
sample, although in the Roncone et al. (2002) study a sub-sample was examined controlling for IQ and an association
with positive symptoms was found. In two studies positive symptoms were associated with poorer ToM performance
(Doody, Gtz, Johnstone, Frith, & Cunningham Owens, 1998; Marjoram et al., 2005).
Six studies have examined associations with paranoid symptoms in particular. Four found no association of paranoia and
ToM abilities (Blackshaw, Kinderman, Hare, & Hatton, 2001; Greig, Bryson, & Bell, 2004; Langdon et al., 1997, 2001) and
two studies did find an association (Craig et al., 2004; Harrington et al., 2006). The study of Greig et al. (2004) is the largest
study of ToM in schizophrenia and best addresses the question of ToM and psychotic symptoms. 128 outpatients with
schizophrenia were assessed on the ability to understand hints. Theory of mind performance was most strongly associated
with thought disorder. There was an association of ToM performance with delusions but not the level of persecutory
delusions. In a regression analysis it was thought disorder, and not delusions, that predicted ToM performance.
Table 6
Theory of mind and paranoid symptoms
Study Persecutory and Task ToM difficulty Correlation of Comments
control groups (in paranoid ToM performance
group compared with paranoia or
with non-clinical positive symptoms
controls) of psychosis
within whole
psychosis group
Corcoran et al. 23 paranoid symptoms Hinting task
(1995) (delusions of reference or
persecution or auditory
hallucinations)

14 psychiatric controls
Frith and Corcoran 24 paranoid (delusions or First and The paranoid group performance was lower than the
(1996) reference, misidentification, second order control group for both first order and second order
and persecution with or without ToM tasks ToM tasks. However when tests were made for
auditory hallucinations) matched IQ sub-groups the group difference was
22 non-clinical controls only significant for the second order tasks. It is also
13 psychiatric control of note that the paranoid patients were finding the
tasks simply more difficult as assessed by a
memory question.
Corcoran et al. (1997) 16 paranoid (delusions of Cartoon jokes The paranoid group was poorer than the control
reference, misidentification requiring group for explaining jokes containing understanding
and/or persecution) understanding of of others' mental states, but did not statistically differ
40 non-clinical controls mental state in explaining jokes with no theory of mind component.
Langdon et al. (1997) 20 individuals with Picture X Poorer mentalising ability associated with negative
schizophrenia sequencing task symptoms. There was no association with
20 non-clinical controls paranoid symptoms.
Doody et al. (1998) 28 schizophrenia First and Performance on the second order ToM task was
12 affective disorder second order associated with the presence of positive and
19 mild learning disability ToM tasks negative symptoms of psychosis.
18 schizophrenia and
learning disability
Drury et al. (1998) 21 persecutory delusions A battery of This study did not include a non-clinical control
12 depressed ToM tasks group and therefore it cannot be determined whether
psychiatric control including the persecutory delusion group had ToM difficulties.
second order However the individuals with persecutory delusions
false belief did not differ from the non-deluded depressed
tasks controls on any of the tasks. At a repeat assessment
after symptom recovery the remitted delusion group
had worse performance than the recovered depressed
group on the second order false belief tasks.
Mitchley et al.(1998) 18 individuals with Irony task X Poorer performance associated with negative and not
schizophrenia positive symptoms of psychosis.
13 psychiatric controls
(continued on next page)
445
446
Study Persecutory and Task ToM difficulty Correlation of Comments
control groups (in paranoid ToM performance

group compared with paranoia or
with non-clinical positive symptoms
controls) of psychosis
within whole
psychosis group
Pickup and Frith (2001) 16 paranoid First and second X X There were no differences for the first order tasks. On the
35 non-clinical controls order false belief second order task a statistical trend for the paranoid group
tasks. to score lower than the controls was reported (p b .1) but
this test was one-tailed, and since results in the opposite
direction would not have been ignored, a two-tailed test
would have been better to have reported and would
have weakened the finding further. This trend disappeared
with matching for IQ. In regression analyses negative
symptoms and thought disorder were predictors of
ToM performance.
Mazza et al. (2001) 35 individuals with First and second order X ToM performance was associated with negative symptoms
schizophrenia false beliefs tasks and not positive symptoms of psychosis.
Blackshaw et al. (2001) 25 Asperger syndrome Projective X Individuals with Asperger syndrome performed more
imagination test poorly on the ToM task than the controls.
18 non-clinical controls Paranoia in the study participants was not associated
with ToM scores.
Langdon et al. (2001) 32 individuals with psychosis ToM picture X Paranoia was not associated with ToM performance.
24 non-clinical controls sequencing task. ToM performance was associated with the presence of
negative symptoms (although this link was not
significant when other neuropsychological task results
were controlled for).
Roncone et al. (2002) 44 individuals with First and second order X ToM performance not associated with positive, negative,
schizophrenia ToM tasks or disorganised symptoms, but with social functioning.
In 22 individuals IQ was also assessed. When IQ was
co-varied for in this sub-sample then poorer ToM
performance was associated with the presence
of positive symptoms.
Randall et al. (2003) 15 persecutory delusions First and second order The delusion group performed poorer than the
15 remitted persecutory false belief tasks. non-clinical controls on both tasks.
delusions group
Mazza, De Risio, 42 people with schizophrenia First and second order false belief tasks X From data presented, individuals with negative
Surian, Roncone, and (divided into a positive symptoms and individuals with positive symptoms
Casacchia (2001) symptom group and a perform poorer than the controls on the ToM
negative symptom group) tasks. Individuals with negative symptoms
20 non-clinical controls scored significantly lower than individuals with
positive symptoms of psychosis.
Greig et al. (2004) 128 individuals with schizophrenia Hinting task X A non-clinical control group was not included in
or schizo-affective disorder this study.
Theory of mind performance was related to thought
disorder in particular.
ToM performance was also related to level
of delusions, but not persecutory delusions.
Craig et al. (2004) 16 persecutory delusions Hinting task and the Both the delusions group and the Asperger group
17 Asperger syndrome Reading the Mind in the performed more poorly than the controls on the tasks.
16 non-clinical control Eyes task Higher levels of paranoia were associated with poorer

ToM performance.
Marjoram et al. (2005) 15 schizophrenia Hinting task. Participants with delusions and hallucinations
15 affective performed significantly lower than the control group.
(7 bipolar, 8 depression) However it is unclear whether this is due to the
15 non-clinical controls presence of persecutory delusions. There was also
a trend for negative symptoms to be associated
with poorer
ToM performance.
Kelemen et al. (2005) 52 individuals with schizophrenia Eyes test X ToM performance correlated with negative but not
30 non-clinical controls positive symptoms of psychosis.
Harrington et al. (2006) 25 schizophrenia divided into 1st and 2nd order verbal and non-verbal ToM tasks. Persecutory delusions associated with ToM
persecutory delusions group and performance. Differences on verbal tasks.
non-persecutory delusions group Also an association of ToM performance with
(13 and 12 respectively, formal thought disorder.
McClure and Siegert, pers. com.).
Langdon et al. (2006) 19 persecutory delusions False belief picture Both clinical groups performed more poorly than the
15 non-persecutory delusion sequencing task control group.
schizophrenia group
(nine had no delusions)
Russell et al. (2006) 61 individuals with schizophrenia Animations task X A novel ToM task was used in this study,
(including 15 predominately requiring judges to rate the participants' responses.
paranoid symptoms)
22 non-clinical controls ToM performance was not associated with negative or
positive symptoms of psychosis.
447
Greig et al. (2004) and Harrington et al. (2006) note that mixed findings might relate to the different ToM tasks used
in studies, the different symptom groupings in studies, small sample sizes, and the idea that ToM may not be the only
factor contributing to persecutory experience. These issues do complicate the findings. However, the literature is
beginning to indicate that although ToM problems may be present in people with persecutory delusions they are
certainly not specific or necessary to this experience and their presence in people with paranoid experiences may
actually be due to the presence of negative symptoms and thought disorder (conceptual disorganisation and
psychomotor poverty syndromes). Difficulties with theory of mind abilities may not be central to the development of
persecutory ideation. Walston et al.'s (2000) finding of intact ToM in individuals with pure persecutory delusions is
very much consistent with such a view. Like the attribution work, a large early episode study is required, combining
good ToM assessment and measures of different positive and negative symptoms and controlling for different positive
and negative symptoms, IQ, executive functioning and social functioning. ToM abilities have not been fully examined
in relation to dimensional measures of delusional ideation or paranoia. Such studies seem warranted and could provide
good dimensional tests of symptom associations with ToM performance. Only Langdon and Coltheart (2004a, 2004b)
have taken this approach. In a small student samples higher levels of schizotypy were found to be associated with lower
mentalising abilities, but no consistent pattern with different schizotypy factors and ToM was found.
A very interesting study by McCabe, Heath, Burns, and Priebe (2002) merits note. They argue that if ToM
difficulties are present then they should be detectable in real-life social interactions. These researchers found that
outpatients with positive and negative symptoms of schizophrenia actually showed intact ToM skills in conversations
with mental health professions. The patients represented mental states of others coherently and used them effectively.
Furthermore, some patients knew that others did not share their delusions and viewed their beliefs as odd, and examples
are given of patients understanding implicit messages in therapists' speech. McCabe notes that some problems of
communication were apparent in the conversations but not those expected from ToM accounts.
The theoretical account of how ToM relates to paranoid experiences contains weaknesses. While this work has
developed from the plausible argument that by definition persecutory delusions reflect incorrect judgements of the
intentions of others, the ToM account of schizophrenia is much weaker in explaining exactly why a mentalising
problem should lead to paranoid thoughts. It does not seem inevitable that difficulties in reading others' intentions
would lead to the explanation that people are disguising their intentions and forming a conspiracy. Many paranoid
individuals would say that their persecutors are not disguising their intentions and indeed make their intent all too clear.
Furthermore, Walston et al. (2000) make the point that if everybody's mental states are opaque persecutory delusions
should not be restricted to a single person or group as is often the case. In short, a mentalising difficulty may lead to
incorrect inferences but why errors that are paranoid and often circumscribed?
8. The threat anticipation cognitive model of persecutory delusions
Conceptualising delusions as beliefs has provided the main theoretical opening for psychological research. As
McReynolds (1960) notes: It appears that delusional beliefs are not formally different from non-delusional beliefs.
Maher has highlighted that the beliefs result from trying to make sense of events, especially anomalous experiences that
invite explanation. It is likely that the delusional explanations and their persistence are closely tied to reasoning
processes. For persecutory thinking in particular, consideration of the phenomenology has identified anxiety as a key
contributory factor. These principal findings have been integrated into the threat anticipation model of paranoia
(Freeman & Garety, 2004; Freeman et al., 2002, 2006). The model is explicitly built on the idea that there are multiple
factors responsible for the development and maintenance of paranoia. Furthermore, the model addresses the multi-
dimensional nature of persecutory experience, highlighting specific factors for the development of delusion content,
conviction, persistence, and distress (Figs. 2 and 3).
Following the influential work of Maher (1974), delusional beliefs are considered as explanations of experience.
The sorts of experiences considered as the proximal source of evidence for persecutory delusions are:
Internal feelings. Unusual or anomalous experiences are frequently key to delusional ideation. These include: being in a
heightened state/aroused; having feelings of significance; perceptual anomalies (e.g. things may seem vivid or bright or
piercing, sounds may feel very intrusive); having feelings as if one is not really there (depersonalisation); and illusions
and hallucinations (e.g. hearing voices). These sorts of experiences can be caused by the processes hypothesised by
theorists such as Hemsely (1994) and Frith (1992), by the use of street drugs or by high levels of affect.
Fig. 2. Summary of the formation of a persecutory delusion.
External events. Ambiguous social information is particularly important. This includes both non-verbal information
(e.g. facial expressions, people's eyes, hand gestures, laughter/smiling) and verbal information (e.g. snatches of
conversation, shouting). Coincidences and negative or irritating events also feature in persecutory ideation.
Typically, individuals vulnerable to paranoid thinking try to make sense of internal unusual experiences by drawing
in negative, discrepant, or ambiguous external information. For example, a person may go outside feeling in an unusual
state and, rather than label this experience as such (e.g. I'm feeling a little odd and anxious today, probably because
I've not been sleeping well), the feelings are instead used as a source of evidence, together with the facial expressions
of strangers in the street, that there is a threat (e.g. People don't like me and may harm me). Persecutory delusions are
viewed as explanations that contain threat beliefs about physical, social, or psychological harm.
But why a suspicious interpretation of experiences? The internal and external events are interpreted in line with
previous experiences, knowledge, emotional state, memories, personality, and decision-making processes and therefore
the origin of persecutory explanations lies in such psychological processes. Suspicious thoughts often occur in the context
of emotional distress. They are frequently preceded by stressful events (e.g. difficult interpersonal relationships, bullying,
isolation). Furthermore, the stresses may happen against a background of previous experiences that have led the person to
have 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 to occur. Living in difficult urban areas is likely to increase the accessibility of such
negative views about others. These sorts of negative beliefs about the self and others are associated with anxiety and
depression, but anxiety may be especially important in the generation of persecutory ideation. The theme of anxiety is the
anticipation of danger and it is the origin of the threat content in persecutory ideation. Anxiety may be fleeting in the
Fig. 3. Summary of the maintenance of a persecutory delusion.
generation of a paranoid thought, but paranoid thoughts will be more significant in the context of higher levels of trait
anxiety. Paranoid thoughts are hypothesised to have close links with anxiety processes. Worry may keep the suspicions in
mind and develop the content in a catastrophising manner. Hence in the model emotion is given a direct role in delusion
formation. The anxious thoughts are hypothesised to become truly persecutory when an attribution is made concerning the
intention of the perpetrators. The cause of this idea of intent is under-researched. Most often the threat beliefs contain an
implicit attribution of intent. In other cases anger often not expressed because of fear of others' reactions may
contribute to this attribution of hostile intent, since judgements of blame and attributions of intent are central to anger.
The persecutory ideas are most likely to become of a delusional intensity when there are accompanying biases in reasoning
such as reduced data gathering (jumping to conclusions) (Garety & Freeman, 1999), a failure to generate or consider
alternative explanations for experiences (Freeman et al., 2004), and a strong confirmatory reasoning bias (Freeman, Garety,
Kuipers, & McGuire, 2005). Social isolation may also contribute to a failure to fully review paranoid thoughts. When
reasoning biases are present, the suspicions are more likely to become near certainties; the threat beliefs become held with a
conviction unwarranted by the evidence and may then be considered delusional.
In the model there are further hypotheses concerning the maintenance of persecutory delusions and the associated
emotional reaction. For example, since the explanations are threat beliefs they will be maintained by processes that
maintain anxiety disorders, such as self-focus and safety behaviours (see Clark, 1999). Distress is hypothesised to arise
from two processes: aspects of the content of the delusion (e.g. beliefs about the power of the persecutor, control over the
threat, deservedness of harm) and further appraisal of the experience (e.g. worry and rumination). Beyond the defining
ideas of threat and attribution of intent, the content of paranoia varies in the individual case, particularly important being
affect-laden beliefs that vary dimensionally (Freeman et al., 2001). For example, beliefs about the degree to which harm is
deserved are viewed as one aspect of the content of the delusion important in determining the level of distress, but not
indicating the presence of a discrete type of paranoia. More broadly, it is of interest to note that reactions to delusions, such
as worrying, are not considered the only route to distress and the development of clinical cases specific aspects of the
content of beliefs make distress more likely too. Thus, emphasised in the psychological understanding of persecutory
ideation are: anomalous experiences, such as hallucinations, which may be caused by core cognitive dysfunction and street
drug use; affective processes, especially anxiety, worry, and interpersonal sensitivity; reasoning biases, particularly belief
confirmation, jumping to conclusions, and belief inflexibility; and social factors, such as isolation and trauma.
9. Pitfalls in studying persecutory thinking
Developments in the understanding of paranoia have been heralded, but recognition and discussion of the
methodologies and pitfalls of researching paranoia have been lacking. In this review the tendency to ignore the multi-
dimensional nature of the experience and the failure to define the phenomena of interest in detail have been highlighted.
Two other important issues bear upon research on delusions: the recruitment of participants and the course of illness.
Research on delusions is likely to have been affected by systematic recruitment biases. For instance, individuals
with persecutory delusions that are the most strongly held, preoccupying, and distressing are probably the least likely to
participate. Conversely, it is easier to recruit a patient into a research study as their paranoia diminishes. For purposes of
comparison across studies, it would be helpful if researchers report the levels of belief conviction, preoccupation, and
distress of the participants. In addition, data on levels of emotional disorder are informative. Recruitment of participants
is also often ad hoc and it is often not clear whether all suitable individuals within a referral system have been
approached. Even then it is common for half of patients who meet study criteria to refuse to participate. The demands of
each research study will also affect patient recruitment. How representative a study group is, and the potential influence
on study results of recruitment biases, needs to be given greater attention.
Course of illness (history length and symptom outcome) are also likely to relate to recruitment biases, and may have
importance in the interpretation of results. Individuals at first episode may be more difficult to recruit into research, in
comparison with people with multiple episodes, because they are currently coming to terms with their experiences.
Moreover, individuals who have symptoms that quickly and fully recover often do not attend services, particularly if they do
not relapse, and therefore they seldom participate in research studies. There may be differences in participation rates
depending upon recovery styles such as sealing over or integration (McGlashan, Levy, & Carpenter, 1975). There are
theoretical reasons why it is likely that the course of illness may affect the results of studies. The presentation of individuals
after their initial episode will be affected by this first experience of symptoms and psychiatric services, particularly in relation
to emotion. Depression and self blame may become more prominent and emotions such as anger, which may have been
important at delusion formation, may recede. This may particularly be the case in instances when there has been a long
chronic course in which symptoms have never fully remitted. It is also likely that the factors that trigger relapses may be
different from those at first episode (e.g. the fear of relapse itself). The difficulties in recruiting participants whose symptoms
quickly remit will limit what can be learnt about the factors that promote recovery. Clearly, cross-sectional studies that
include both individuals with symptoms that recover and individuals whose symptoms tend to persist will make it more
difficult to detect maintenance processes if the variable of recovery is not included in the analysis (a failing of previous
studies); however, longitudinal studies are generally preferable, but these are few in number (Startup et al., in press).
10. The next 10 years and beyond
In this review a number of factors have been highlighted as important to the development of persecutory delusions.
However, studies have mainly concerned associations of psychological factors and persecutory thinking. It is now time for
the causal roles of these variables to be investigated, for example in experimental manipulation studies (e.g. examining the
effects of reducing or increasing anxiety). There is a need to have more longitudinal studies of natural recovery.
Furthermore, psychological factors need to be studied together, including testing for interactions between variables (e.g.
anxiety and the presence of anomalous experience). It is important to note that studies of delusional ideation dimensionally
in the general population enable recruitment of a larger number of participants than are possible for studies of clinical
populations and therefore provides a better means of testing complex models. In order for such work, however, to be
considered convincing for the psychosis field, it needs to be carried out in the context of detailed scrutiny of both the
similarities and differences between clinical cases of persecutory delusions, non-clinical cases of persecutory delusions,
and non-clinical paranoid ideation.
Aside from psychological factors, which have been the focus of the review, there is considerable work needed on the
phenomenological examination of persecutory ideation. As distress is often what marks out clinical from non-clinical
cases, an understanding of its causes should be a higher priority, and content of the beliefs is one cause of distress. One
future line of clinically relevant research would be the investigation of change in delusion content. How do the
important emotional content and associated appraisals in delusional systems change with recovery? How do the
internal contents of a delusion change in relation to each other? This type of approach has the potential to form a link
with patient views of recovery. Furthermore, persecutory thinking can be associated with other delusion sub-types,
particularly reference but also sometimes grandiose, and the inter-relationships between symptoms need to be
considered. For example, persecutory thinking often builds upon ideas of reference. But it is also the case that it will be
important to identify the factors that distinguish, for example, paranoid from grandiose thinking or anxious thinking.
From the review, ten research questions for future investigation are apparent:
1. Can psychological models of paranoia be shown to have high accuracy in explaining the occurrence of
persecutory thoughts?
2. How do psychological factors relate to the different dimensions of delusional experience?
3. What are the psychological factors that distinguish clinical from non-clinical paranoia?
4. Can it be shown that psychological factors are causal in paranoid thinking?
5. Do psychological factors interact in the development of paranoia?
6. What factors distinguish the development of persecutory ideation from the development of grandiosity?
7. What distinguishes the development of paranoid from anxious fears?
8. What are the key emotion-associated aspects of paranoid thoughts and how do they change with time?
9. How do psychological processes relate to social and biological factors potentially associated with paranoia?
10. Can the developments in the understanding of paranoia be used to improve treatments?
In the past, paranoia was too often studied only in the context of severe mental illness and, even then, researchers
were trying to explain a diagnosis such as schizophrenia rather than persecutory thinking itself. Researchers over the
last 10 years have begun to free paranoia from this association, and view it as a phenomenon to be explained in its own
right, linking it with suspicious thoughts apparent in many people in the general population. Moreover, analogies with
the study of depressive and anxious thinking are being made. The key questions for the future study of persecutory
thinking are now becoming apparent and over the next 10 years there are likely to be great strides in understanding in
this important clinical area as it receives greater attention. These developments in understanding will then need to be
translated into improvements in the emerging cognitivebehavioural treatments for paranoid thoughts (Freeman et al.,
2006).
Acknowledgement
Daniel Freeman is supported by a Wellcome Trust Fellowship.
References
Allen, P., Freeman, D., Johns, L., & McGuire, P. (2006). Misattribution of self-generated speech in relation to hallucinatory proneness and delusional
ideation in healthy volunteers. Schizophrenia Research, 84, 281288.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, Fourth Ed. Washington, DC: American Psychiatric
Association.
sberg, M., Montgomery, S. A., Perris, C., Schalling, D., & Sedvall, G. (1978). A comprehensive psychopathological rating scale. Acta Psychiatrica
Scandinavica, 271, 527.
Bacon, F. (1612). The essaies of Sr. Francis Bacon Knight, the Kings Solliciter Generall. London: John Beale.
Barrowclough, C., Tarrier, N., Humphreys, L., Ward, J., Gregg, L., & Andrews, B. (2003). Self-esteem in schizophrenia: Relationships between self-
evaluation, family attitudes, and symptomatology. Journal of Abnormal Psychology, 112, 9299.
Bebbington, P. E., & Nayani, T. (1995). The Psychosis Screening Questionnaire. International Journal of Methods in Psychiatric Research, 5, 1119.
Bell, V., Halligan, P. W., & Ellis, H. D. (2006). The Cardiff Anomalous Perceptions Scale (CAPS). Schizophrenia Bulletin, 32, 366377.
Bentall, R. P. (1990). The syndromes and symptoms of psychosis. Or why you can't play twenty questions with the concept of schizophrenia and
hope to win. In R. P. Bentall (Ed.), Reconstructing schizophrenia (pp. 2360). London: Routledge.
Bentall, R. P., Corcoran, R., Howard, R., Blackwood, N., & Kinderman, P. (2001). Persecutory delusions: A review and theoretical interpretation.
Clinical Psychology Review, 21, 11431192.
Bentall, R. P., & Kaney, S. (1989). Content specific processing and persecutory delusions: An investigation using the emotional Stroop test. British
Journal of Medical Psychology, 62, 355364.
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, 331341.
Birchwood, M. (2003). Pathways to emotional dysfunction in first episode psychosis. British Journal of Psychiatry, 182, 373375.
Birchwood, M., Meaden, A., Trower, P., Gilbert, P., & Plaistow, J. (2000). The power and omnipotence of voices: Subordination and entrapment by
voices and significant others. Psychological Medicine, 30, 337344.
Birchwood, M., & Trower, P. (2006). The future of cognitivebehavioural therapy for psychosis: Not a quasi-neuroleptic. British Journal of
Psychiatry, 188, 107108.
Blackshaw, A. J., Kinderman, P., Hare, D. J., & Hatton, C. (2001). Theory of mind, causal attribution and paranoia in Asperger syndrome. Autism, 5, 147163.
Boyd, T., & Gumley, A. (in press). An experiential perspective on persecutory paranoia. Psychology and Psychotherapy.
Broome, M. R., Johns, L. C., Valli, I., Woolley, J. B., Tabraham, P., Brett, C., Valmaggia, L., Peters, E., Garety, P. A., & McGuire, P. K. (in press).
People with an At Risk Mental State jump to conclusions. British Journal of Psychiatry.
Brne, M. (2005). Theory of mind in schizophrenia. Schizophrenia Bulletin, 31, 2142.
Buchanan, A., Reed, A., Wessely, S., Garety, P., Taylor, P., Grubin, D., & Dunn, G. (1993). Acting on delusions. II: The phenomenological correlates
of acting on delusions. British Journal of Psychiatry, 163, 7781.
Bunney, W. E., Hetrick, W. P., Bunney, B. G., Patterson, J. V., Jin, Y., Potkin, S. G., et al. (1999). Structured interview for assessing perceptual
anomalies (SIAPA). Schizophrenia Bulletin, 25, 577592.
Butler, R. W., Mueser, K. T., Sprock, J., & Braff, D. L. (1996). Positive symptoms of psychosis in posttraumatic stress disorder. Biological
Cameron, N. (1959). The paranoid pseudo-community revisited. American Journal of Sociology, 65, 5258.
Candido, C. L., & Romney, D. M. (1990). Attributional style in paranoid versus depressed patients. British Journal of Medical Psychology, 63,
355363.
Chadwick, P. D. J., Trower, P., Juusti-Butler, T. -M., & Maguire, N. (2005). Phenomenological evidence for two types of paranoia. Psychopathology,
38, 327333.
Chapman, L. J., & Chapman, J. P. (1980). Scales for rating psychotic and psychotic-like experiences as continua. Schizophrenia Bulletin, 6,
476489.
Chapman, L. J., Chapman, J. P., Kwapil, T. R., Eckbald, M., & Zinser, M. C. (1994). Putatively psychosis-prone subjects 10 years later. Journal of
Abnormal Psychology, 103, 171183.
Chapman, R. K. (2002). First person account: Eliminating delusions. Schizophrenia Bulletin, 28, 545553.
Chisholm, B., Freeman, D., & Cooke, A. (2006). Identifying potential predictors of PTSD reactions to psychotic episodes. British Journal of Clinical
Psychology, 45, 545559.
Christenson, R., & Blazer, D. (1984). Epidemiology of persecutory ideation in an elderly population in the community. American Journal of
Psychiatry, 141, 10881091.
Claridge, G. (1994). Single indicators of risk for schizophrenia. Probably fact or likely myth? Schizophrenia Bulletin, 20, 151168.
Claridge, G. (1997). Schizotypy: Implications for illness and health. Oxford: Oxford University Press.
Clark, D. M. (1999). Anxiety disorders: Why they persist and how to treat them. Behaviour Research and Therapy, 37, S5S27.
Cohen, C. I., Magai, C., Yaffee, R., & Walcott-Brown, L. (2004). Racial differences in paranoid ideation and psychoses in an older urban population.
American Journal of Psychiatry, 161, 864871.
Colbert, S. M., & Peters, E. R. (2002). Need for closure and jumping-to-conclusions in delusion-prone individuals. Journal of Nervous and Mental
Disease, 170, 2731.
Conway, C. R., Bollini, A. M., Graham, B. G., Keefe, R. S. E., Schiffman, S. S., & McEvoy, J. P. (2002). Sensory acuity and reasoning in delusional
disorder. Comprehensive Psychiatry, 43, 75178.
Cooper, A. F., & Curry, A. R. (1976). The pathology of deafness in the paranoid and affective psychoses of later life. Journal of Psychosomatic
Research, 20, 97105.
Corcoran, R., Cahill, C., & Frith, C. D. (1997). The appreciation of visual jokes in people with schizophrenia. Schizophrenia Research, 24, 319327.
Corcoran, R., Mercer, G., & Frith, C. D. (1995). Schizophrenia, symptomology and social inference. Schizophrenia Research, 17, 513.
Craig, J. S., Hatton, C., Craig, F. B., & Bentall, R. P. (2004). Persecutory beliefs, attributions and theory of mind. Schizophrenia Research, 69, 2933.
Delespaul, P. (1995). Assessing schizophrenia in daily life. Maastricht: Maastricht University Press.
Derogatis, L. R., Lipman, R. S., & Covi, L. (1973). SCL-90: An outpatient psychiatric rating scalepreliminary report. Psychopharmacological
Bulletin, 9, 1328.
Docherty, J. P., Van Kammen, D. P., Siris, S. G., & Marder, S. R. (1978). Stages of onset of schizophrenic psychosis. American Journal of Psychiatry,
135, 420426.
Doody, G. A., Gtz, M., Johnstone, E. C., Frith, C. D., & Cunningham Owens, D. G. (1998). Theory of mind and psychoses. Psychological
Medicine, 28, 397405.
Drake, R. J., Pickles, A., Bentall, R. P., Kinderman, P., Haddock, G., Tarrier, N., et al. (2004). The evolution of insight, paranoia and depression
during early schizophrenia. Psychological Medicine, 34, 285292.
Drury, V. M., Robinson, E. J., & Birchwood, M. (1998). Theory of mind skills during an acute episode of psychosis and following recovery.
Psychological Medicine, 28, 11011112.
D'Souza, D. C., Perry, E., MacDougall, L., Ammerman, Y., Cooper, T., Wu, Y., et al. (2004). The psychotomimetic effects of intravenous delta
9-tetrahydrocannabinol in healthy individuals: Implications for psychosis. Neuropsychopharmacology, 29, 15581572.
Dudley, R. E. J., John, C. H., Young, A. W., & Over, D. E. (1997a). Normal and abnormal reasoning in people with delusions. British Journal of
Clinical Psychology, 36, 243258.
Dudley, R. E. J., John, C. H., Young, A. W., & Over, D. E. (1997b). The effect of self-referent material on the reasoning of people with delusions.
British Journal of Clinical Psychology, 36, 575584.
Dudley, R. E. J., & Over, D. E. (2003). People with delusions jump to conclusions. Clinical Psychology and Psychotherapy, 10, 263274.
Eaton, W. W., Romanoski, A., Anthony, J. C., & Nestadt, G. (1991). Screening for psychosis in the general population with a self-report interview.
Journal of Nervous and Mental Disease, 179, 689693.
Ellett, L., Lopes, B., & Chadwick, P. (2003). Paranoia in a non-clinical population of college students. Journal of Nervous and Mental Disease, 191,
425430.
Eysenck, M. W., & Van Berkum, J. (1992). Trait anxiety, defensiveness, and the structure of worry. Personality and Individual Differences, 13,
12851290.
Fear, C. F., & Healy, D. (1997). Probabilistic reasoning in obsessive-compulsive and delusional disorders. Psychological Medicine, 27, 199208.
Fear, C., Sharp, H., & Healy, D. (1996). Cognitive processes in delusional disorders. British Journal of Psychiatry, 168, 18.
Flint, A. J. (1991). Delusions in dementia: A review. Journal of Neuropsychiatry and Clinical Neurosciences, 3, 121130.
Fornells-Ambrojo, M., & Garety, P. A. (2005). Bad me paranoia in early psychosis: A relatively rare phenomenon. British Journal of Clinical
Forsell, Y., & Henderson, A. S. (1998). Epidemiology of paranoid symptoms in an elderly population. British Journal of Psychiatry, 172, 429432.
Fowler, D. (2000). Psychological formulation of early episodes of psychosis: A cognitive model. In M. Birchwood, D. Fowler, & C. Jackson (Eds.),
Early intervention in psychosis: A guide to concepts, evidence and interventions (pp. 101127). Chichester: Wiley.
Fowler, D., Freeman, D., Smith, B., Kuipers, E., Bebbington, P., Bashforth, H., 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,
749759.
Frangos, E., Athanassenas, G., Tsitourides, S., Psilolignos, P., & Katsanou, N. (1983). Psychotic depressive disorder. A separate entity? Journal of
Affective Disorders, 5, 259265.
Freeman, D. (2006). Delusions in the non-clinical population. Current Psychiatry Reports, 8, 191204.
Freeman, D., Dunn, G., Garety, P. A., Bebbington, P., Slater, M., Kuipers, E., et al. (2005a). The psychology of persecutory ideation I: A questionnaire
study. Journal of Nervous and Mental Disease, 193, 302308.
Freeman, D., Freeman, J., & Garety, P. (2006). Overcoming paranoid and suspicious thoughts. London: Robinson Constable.
Freeman, D., & Garety, P. A. (1999). Worry, worry processes and dimensions of delusions: An exploratory investigation of a role for anxiety
processes in the maintenance of delusional distress. Behavioural and Cognitive Psychotherapy, 27, 4762.
Freeman, D., & Garety, P. A. (2000). Comments on the content of persecutory delusions: Does the definition need clarification? British Journal of
Freeman, D., & Garety, P. A. (2003). Connecting neurosis and psychosis: The direct influence of emotion on delusions and hallucinations. Behaviour
Research and Therapy, 41, 923947.
Freeman, D., & Garety, P. A. (2004). Paranoia: The Psychology of Persecutory Delusions. Hove: Psychology Press.
Freeman, D., Garety, P. A., Bebbington, P., Slater, M., Kuipers, E., Fowler, D., et al. (2005b). The psychology of persecutory ideation II: A virtual
reality experimental study. Journal of Nervous and Mental Disease, 193, 309315.
Freeman, D., Garety, P. A., Bebbington, P. E., Smith, B., Rollinson, R., Fowler, D., et al. (2005c). Psychological investigation of the structure of
paranoia in a non-clinical population. British Journal of Psychiatry, 186, 427435.
Freeman, D., Garety, P. A., Fowler, D., Kuipers, E., Bebbington, P., & Dunn, G. (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, 671680.
Freeman, D., Garety, P., Fowler, D., Kuipers, E., Dunn, G., Bebbington, P., et al. (1998). The LondonEast Anglia randomised controlled trial of
cognitive behaviour therapy for psychosis IV: Self-esteem and persecutory delusions. British Journal of Clinical Psychology, 37, 415430.
Freeman, D., Garety, P. A., & Kuipers, E. (2001). Persecutory delusions: Developing the understanding of belief maintenance and emotional distress.
Freeman, D., Garety, P. A., Kuipers, E., Colbert, S., Jolley, S., Fowler, D., et al. (2006). Delusions and decision-making style: Use of the Need for
Closure Scale. Behaviour Research and Therapy, 44, 11471158.
Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., & Bebbington, P. E. (2002). A cognitive model of persecutory delusions. British Journal of
Freeman, D., Garety, P., Kuipers, E., Fowler, D., Bebbington, P. E., & Dunn, G. (2007). Acting on persecutory delusions: The importance of safety
seeking. Behaviour Research and Therapy, 45, 8999.
Freeman, D., Garety, P. A., McGuire, P., & Kuipers, E. (2005). Developing a theoretical understanding of therapy techniques: Reasoning, therapy and
symptoms. British Journal of Clinical Psychology, 44, 241254.
Freeman, D., Slater, M., Bebbington, P. E., Garety, P. A., Kuipers, E., Fowler, D., et al. (2003). Can virtual reality be used to investigate persecutory
ideation? Journal of Nervous and Mental Disease, 191, 509514.
Frith, C. D. (2004). Schizophrenia and theory of mind. Psychological Medicine, 34, 385389.
Frith, C. D. (1992). The cognitive neuropsychology of schizophrenia. Hove: LEA.
Frith, C. D., & Corcoran, R. (1996). Exploring theory of mind in people with schizophrenia. Psychological Medicine, 26, 521530.
Garety, P. A., & Freeman, D. (1999). Cognitive approaches to delusions: A critical review of theories and evidence. British Journal of Clinical
Garety, P. A., Freeman, D., Jolley, S., Dunn, G., Bebbington, P. E., & Fowler, D. (2005). Reasoning, emotions and delusional conviction in psychosis.
Journal of Abnormal Psychology, 114, 373384.
Garety, P. A., & Hemsley, D. R. (1994). Delusions: Investigations into the psychology of delusional reasoning. Oxford: Oxford University Press.
Garety, P. A., Hemsley, D. R., & Wessely, S. (1991). Reasoning in deluded schizophrenic and paranoid patients: Biases in performance on a
probabilistic inference task. Journal of Nervous and Mental Disorder, 179, 194201.
Garety, P. A., Kuipers, E., Fowler, D., Freeman, D., & Bebbington, P. E. (2001). A cognitive model of the positive symptoms of psychosis.
Gilbert, P., Boxall, M., Cheung, M., & Irons, C. (2005). The relation of paranoid ideation and social anxiety in a mixed clinical population. Clinical
Psychology and Psychotherapy, 12, 124133.
Goodwin, F., & Jamison, K. (1990). Manic-depressive illness. Oxford: Oxford University Press.
Green, C., Garety, P. A., Freeman, D., Fowler, D., Bebbington, P. E., Dunn, G., et al. (2006). Phenomenology and affect in persecutory delusions.
British Journal of Clinical Psychology, 45, 561577.
Greig, T. C., Bryson, G. J., & Bell, M. D. (2004). Theory of mind performance in schizophrenia. Journal of Nervous and Mental Disease, 192, 1218.
Guillem, F., Pampoulova, T., Stip, E., Lalonde, P., & Todorov, C. (2005). The relationships between symptom dimensions and dysphoria in
schizophrenia. Schizophrenia Research, 75, 8396.
Hamner, M. B., Freuch, C. B., Ulmer, H. G., & Arana, G. W. (1999). Psychotic features and illness severity in combat veterans with chronic
posttraumatic stress disorder. Biological Psychiatry, 45, 846852.
Harrington, L., Langdon, R., Seigert, R. J., & McClure, J. (2005). Schizophrenia, theory of mind, and persecutory delusions. Cognitive
Neuropsychiatry, 10, 87104.
Harrington, L., Siegert, R. J., & McClure, J. (2005). Theory of mind in schizophrenia. Cognitive Neuropsychiatry, 10, 249286.
Hemsley, D. R. (1994). Perceptual and cognitive abnormalities as the bases for schizophrenic symptoms. In A. S. David & J.C. Cutting (Eds.), The
neuropsychology of schizophrenia (pp. 97116). Hove: Erlbaum.
Hughes, C. (2002). Executive functions and development: Emerging themes. Infant and Child Psychology, 11, 201209.
Huppert, J. D., & Smith, T. E. (2005). Anxiety and schizophrenia; the interaction of subtypes of anxiety and psychotic symptoms. CNS Spectrums,
10, 72731.
Huq, S. F., Garety, P. A., & Hemsley, D. R. (1988). Probabilistic judgements in deluded and non-deluded subjects. Quarterly Journal of Experimental
Psychology, 40A, 801812.
Janssen, I., Krabbendam, L., Jolles, J., & van Os, J. (2003). Alterations in theory of mind in patients with schizophrenia and non-psychotic relatives.
Acta Psychiatrica Scandinavica, 108, 110117.
Johns, L. C. (2005). Hallucinations in the general population. Current Psychiatry Reports, 7, 162167.
Johns, L. C., Cannon, M., Singleton, N., Murray, R. M., Farrell, M., Brugha, T., et al. (2004). The prevalence and correlates of self-reported psychotic
symptoms in the British population. British Journal of Psychiatry, 185, 298305.
Johns, L. C., Gregg, L., Allen, P., & McGuire, P. K. (2006). Impaired verbal self-monitoring in psychosis. Psychological Medicine, 36, 465474.
Johnson, J., Horwath, E., & Weissman, M. M. (1991). The validity of major depression with psychotic features based on a community sample.
Archives of General Psychiatry, 48, 10751081.
Jolley, S., Garety, P. A., Bebbington, P. E., Dunn, G., Freeman, D., Kuipers, E., et al. (2006). Attributional style in psychosisthe role of affect and
belief type. Behaviour Research and Therapy, 44, 15971607.
Kapur, S. (2003). Psychosis as a state of aberrant salience: A framework linking biology, phenomenology, and pharmacology. American Journal of
Kelemen, O., Erdlyi, R., Pataki, I., Benedek, G., Janka, Z., & Kri, S. (2005). Theory of mind and motion perception in schizophrenia. Neurop-
sychology, 19, 494500.
Kincannon, J. C. (1968). Predictions of the standard MMPI scale scores from 71 items: The Mini-mult. Journal of Consulting and Clinical
Kinderman, P., & Bentall, R. P. (1996a). A new measure of causal locus: The internal, personal and situational attributions questionnaire. Personality
and Individual Differences, 20, 261264.
Kinderman, P., & Bentall, R. P. (1996b). Self-discrepancies and persecutory delusions. Journal of Abnormal Psychology, 105, 106113.
Kinderman, P., Kaney, S., Morley, S., & Bentall, R. P. (1992). Paranoia and the defensive attributional style. British Journal of Medical Psychology,
65, 371383.
Krabbendam, L., Janssen, I., Bijl, R. V., Vollebergh, W. A. M., & van Os, J. (2002). Neuroticism and low self-esteem as risk factors for psychosis.
Social Psychiatry and Psychiatric Epidemiology, 37, 16.
Krabbendam, L., Myin-Germeys, I., Hanssen, M., Bijil, R. V., de Graaf, R., Vollebergh, W., et al. (2004). Hallucinatory experiences and onset of
psychotic disorder: Evidence that the risk is mediated by delusion formation. Acta Psychiatrica Scandinavica, 110, 264272.
Kraepelin, E. (1921). Manic-depressive insanity and paranoia. Edinburgh: Livingstone.
Kripke, S. (1980). Naming and necessity. Oxford: Blackwell.
Krstev, H., Jackson, H., & Maude, D. (1999). An investigation of attributional style in first-episode psychosis. British Journal of Clinical Psychology,
38, 181194.
Langdon, R., & Coltheart, M. (2004). Recognition of metaphor and irony in young adults. Psychiatry Research, 125, 920.
Langdon, R., & Coltheart, M. (2004). Mentalising, schizotypy, and schizophrenia. Cognition, 71, 4371.
Langdon, R., Coltheart, M., Ward, P. B., & Catts, S. V. (2001). Mentalising, executive planning and disengagement in schizophrenia. Cognitive
Langdon, R., Corner, T., McLaren, J., Ward, P. B., & Coltheart, M. (2006). Externalising and personalising biases in persecutory delusions.
Behaviour Research and Therapy, 44, 699713.
Langdon, R., Michie, P. T., Ward, P. B., McConaghy, N., Catts, S. V., & Coltheart, M. (1997). Defective self and/or other mentalising in
schizophrenia. Cognitive Neuropsychiatry, 2, 167193.
Lyon, H. M., Kaney, S., & Bentall, R. P. (1994). The defensive function of persecutory delusions: Evidence from attribution tasks. British Journal of
Maher, B. A. (1974). Delusional thinking and perceptual disorder. Journal of Individual Psychology, 30, 98113.
Maher, B. A. (1988). Anomalous experience and delusional thinking: The logic of explanations. In T. F. Oltmanns & B. A. Maher (Eds.), Delusional
beliefs (pp. 1533). New York: Wiley.
Maher, B. A. (2003). Psychopathology and delusions: Reflections on methods and models. In M. F. Lenzenweger & J. M. Hooley (Eds.), Principles
of experimental psychopathology: Essays in honor of Brendan A. Maher (pp. 928). Washington: American Psychological Association.
Maric, N., Myin-Germeys, I., Delespaul, P., de Graaf, R., Vollebergh, W., & van Os, J. (2004). Is our concept of schizophrenia influenced by
Berkson's bias? Social Psychiatry and Psychiatric Epidemiology, 39, 600605.
Marjoram, D., Gardner, C., Burns, J., Miller, P., Lawrie, S. M., & Johnstone, E. C. (2005). Symptomatology and social inference. Cognitive
Martin, J. A., & Penn, D. L. (2001). Brief report: Social cognition and subclinical paranoid ideation. British Journal of Clinical Psychology, 40,
261265.
Martin, J. A., & Penn, D. L. (2002). Attributional style in schizophrenia. Schizophrenia Bulletin, 28, 131141.
Mazza, M., De Risio, A., Surian, L., Roncone, R., & Casacchia, M. (2001). Selective impairments of theory of mind in people with schizophrenia.
Schizophrenia Research, 47, 299308.
McCabe, R., Heath, C., Burns, T., & Priebe, S. (2002). Engagement of patients with psychosis in the consultation. British Medical Journal, 325,
11481151.
McGhie, A., & Chapman, J. (1961). Disorders of attention and perception in early schizophrenia. British Journal of Medical Psychology, 34,
103116.
McGlashan, T. H., Levy, S. T., & Carpenter, W. T. (1975). Integration and sealing over: Clinically distinct recovery styles. Archives of General
McKay, R., Langdon, R., & Coltheart, M. (2005). Paranoia, persecutory delusions and attributional biases. Psychiatry Research, 136, 233245.
McReynolds, P. (1960). Anxiety, perception and schizophrenia. In D. D. Jackson (Ed.), The etiology of schizophrenia (pp. 248292). New York:
Basic Books.
Mitchley, N. J., Barber, J., Gray, J. M., Brooks, D. N., & Livingstone, M. G. (1998). Comprehension of irony in schizophrenia. Cognitive
Moritz, S., & Woodward, T. S. (2004). Plausibility judgement in schizophrenic patients. German Journal of Psychiatry, 7, 6674.
Moritz, S., & Woodward, T. S. (2005). Jumping to conclusions in delusional and non-delusional schizophrenic patients. British Journal of Clinical
Moritz, S., & Woodward, T. S. (2006a). Metacognitive control over false memories. Current Psychiatry Reports, 8, 184190.
Moritz, S., & Woodward, T. S. (2006b). A generalised bias against disconfirmatory evidence (BADE) in schizophrenia. Psychiatry Research, 142,
157165.
Mortimer, A. M., Bentham, P., McKay, A. P., Quemada, I., Clare, L., Eastwood, N., et al. (1996). Delusions in schizophrenia. Cognitive
Murray, R. M., Grech, A., Phillips, P., & Johnson, S. (2003). What is the relationship between substance abuse and schizophrenia? In R. M. Murray
(Ed.), The epidemiology of schizophrenia (pp. 317342). Cambridge: Cambridge University Press.
Myin-Germeys, I., Delespaul, P., & van Os, J. (2005). Behavioural sensitization to daily life stress in psychosis. Psychological Medicine, 35,
733741.
Myin-Germeys, I., & Krabbendam, L. (2003). Continuity of psychotic symptoms in the community. Current Opinion in Psychiatry, 16, 443449.
Naeem, F., Kingdon, D., & Turkington, D. (2006). Cognitive behaviour therapy for schizophrenia: Relationship between anxiety symptoms and
therapy. Psychology and Psychotherapy, 79, 153164.
Norman, R. M., & Malla, A. K. (1994). Correlations over time between dysphoric mood and symptomatology in schizophrenia. Comprehensive
O'Leary, D. S., Flaum, M., Kesler, M. L., Flashman, L. A., Arndt, S., & Andreasen, N. C. (2000). Cognitive correlates of the negative, disorganized,
and psychotic symptom dimensions of schizophrenia. Journal of Neuropsychiatry and Clinical Neurosciences, 12, 415.
Olfson, M., Lewis-Fernndez, R., Feder, A., Gameroff, M. J., Pilowsky, D., & Fuentes, M. (2002). Psychotic symptoms in an urban general medicine
practice. American Journal of Psychiatry, 159, 14121419.
Oltmanns, T. F. (1988). Approaches to the definition and study of delusions. In T. F. Oltmanns & B. A. Maher (Eds.), Delusional beliefs (pp. 312).
New York: Wiley.
stling, S., & Skoog, I. (2002). Psychotic symptoms and paranoid ideation in a nondemented population-based sample of the very old. Archives of
General Psychiatry, 59, 5359.
Peters, E., & Garety, P. (2006). Cognitive functioning in delusions. Behaviour Research and Therapy, 44, 481514.
Peters, E. R., Joseph, S. A., & Garety, P. A. (1999). The measurement of delusional ideation in the normal population: Introducing the PDI (Peters et al
Delusions Inventory). Schizophrenia Bulletin, 25, 553576.
Peterson, C., Semmel, A., Von Baeyer, C., Abramson, L., Metalsky, G. I., & Seligman, M. E. P. (1982). The attributional style questionnaire.
Cognitive Therapy and Research, 3, 287300.
Pickup, G. J., & Frith, C. D. (2001). Theory of mind impairments in schizophrenia. Psychological Medicine, 31, 207220.
Poulton, R., Caspi, A., Moffitt, T. E., Cannon, M., Murray, R., & Harrington, H. (2000). Children's self-reported psychotic symptoms and adult
schizophreniform disorder. Archives of General Psychiatry, 57, 10531058.
Premack, D., & Woodruff, G. (1978). Does the chimpanzee have a theory of mind? Behavioural and Brain Sciences, 4, 515526.
Randall, F., Corcoran, R., Day, J. C., & Bentall, R. P. (2003). Attention, theory of mind, and causal attributions in people with persecutory delusions.
Cognitive Neuropsychiatry, 8, 287294.
Robins, L. N., Helzer, J. E., Croughan, J., & Ratcliff, K. A. (1981). National Institute of Mental Health Diagnostic Interview Schedule. Archives of
General Psychiatry, 38, 381389.
Roncone, R., Falloon, I. R. H., Mazza, M., De Risio, A., Pollice, R., Necozione, S., et al. (2002). Is theory of mind in schizophrenia more strongly
associated with clinical and social functioning than with neurocognitive deficits? Psychopathology, 35, 280288.
Rubin, E. H., Drevets, W. C., & Burke, W. J. (1988). The nature of psychotic symptoms in senile dementia of the Alzheimer type. Journal of Geriatric
Psychiatry and Neurology, 1, 1620.
Russell, T. A., Reynaud, E., Herba, C., Morris, R., & Corcoran, R. (2006). Do you see what I see? Interpretations of intentional movement in
schizophrenia. Schizophrenia Research, 81, 101111.
Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: A cognitive account. Behavioural Psychotherapy,
19, 619.
Sarfati, Y., Hardy-Bayl, M., Besche, C., & Widlcher, D. (1997). Attribution of intentions to others in people with schizophrenia. Schizophrenia
Research, 25, 199209.
Sartorius, N., Jablensky, A., Korten, A., Ernberg, G., Anker, M., Cooper, J. E., et al. (1986). Early manifestations and first-contact incidence of
schizophrenia in different cultures. Psychological Medicine, 16, 909928.
Sax, K. W., Strakowski, S. M., Keck, P. E., Upadhyaya, V. H., West, S. A., & McElroy, S. L. (1996). Relationships among negative, positive and
depressive symptoms in schizophrenia and psychotic depression. British Journal of Psychiatry, 168, 6971.
Schulze, T. G., Ohlraun, S., Czerski, P. M., et al. (2005). Genotypephenotype studies in bipolar disorder showing association between the DAOA/
G30 locus and persecutory delusions. American Journal of Psychiatry, 162, 21012108.
Sharp, H. M., Fear, C. F., & Healy, D. (1997). Attributional style and delusions: An investigation based on delusional content. European Psychiatry, 12, 17.
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The Mini-International Neuropsychiatric Interview.
Journal of Clinical Psychiatry, 59(s20), 2233.
Snyder, K. (2006). Kurt Snyder's personal experience with schizophrenia. Schizophrenia Bulletin, 32, 209211.
Smith, B., Fowler, D., Freeman, D., Bebbington, P., Bashforth, H., Garety, P., Kuipers, E., & Dunn, G. (2006). Emotion and psychosis: Direct links
between schematic beliefs, emotion and delusions and hallucinations. Schizophrenia Research, 86, 181188.
Smith, N., Freeman, D., & Kuipers, E. (2005). Grandiose delusions: An experimental investigation of the delusion-as-defence hypothesis. Journal of
Nervous and Mental Disease, 193, 480487.
Startup, H. (2004). Persecutory beliefs and catastrophic worry. D. Clin Psy thesis. University of London.
Startup, H., Freeman, D., & Garety, P. A. (in press). Persecutory delusions and catastrophic worry in psychosis: Developing the understanding of
delusion distress and persistence. Behaviour Research and Therapy.
Strauss, J. S. (1969). Hallucinations and delusions as points on continua function. Archives of General Psychiatry, 20, 581586.
Thewissen, V., Myin-Germeys, I., Bentall, R., de Graaf, R., Vollebergh, W., & van Os, J. (2005). Hearing impairment and psychosis revisited.
Schizophrenia Research, 76, 99103.
Tien, A. Y., & Anthony, J. C. (1990). Epidemiological analysis of alcohol and drug use as risk factors for psychotic experiences. Journal of Nervous
and Mental Disease, 178, 473480.
Trimble, M. R. (1992). The schizophrenia-like psychosis of epilepsy. Neuropsychiatry, Neuropsychology, and Behavioural Neurology, 5, 103107.
Trower, P., & Chadwick, P. (1995). Pathways to defense of the self: A theory of two types of paranoia. Clinical Psychology. Science and Practice, 2,
263278.
Van Dael, F., Versmissen, D., Janssen, I., Myin-Germeys, I., van Os, J., & Krabbendam, L. (2006). Data gathering: Biased in psychosis? Schizo-
phrenia Bulletin, 32, 341351.
Van Os, J., Hanssen, M., Bijl, R. V., & Ravelli, A. (2000). Strauss (1969) revisited: A psychosis continuum in the general population. Schizophrenia
Research, 45, 1120.
Van Os, J., & Verdoux, H. (2003). Diagnosis and classification of schizophrenia: Categories versus dimensions, distributions versus disease. In R. M.
Murray, P. B. Jones, J. E.Susser, & M. van Os (Eds.), The epidemiology of schizophrenia (pp. 364410). Cambridge: Cambridge University
Press.
Van Os, J., Verdoux, H., Maurice-Tison, S., Gay, B., Liraud, F., Salamon, R., et al. (1999). Self-reported psychosis-like symptoms and the continuum
of psychosis. Social Psychiatry and Psychiatric Epidemiology, 34, 459462.
Vzquez-Barquero, J. L., lastra, I., Nuez, M. J. C., Castanedo, S. H., & Dunn, G. (1996). Patterns of positive and negative symptoms in first episode
schizophrenia. British Journal of Psychiatry, 168, 693701.
Verdoux, H., Gindre, C., Sorbara, F., Tournier, M., & Swendsen, J. D. (2003). Effects of cannabis and psychosis vulnerability in daily life.
Verdoux, H., Maurice-Tison, S., Gay, B., van Os, J., Salamon, R., & Bourgeois, M. L. (1998). A survey of delusional ideation in primary-care
patients. Psychological Medicine, 28, 127134.
Walston, F., Blennerhassett, R. C., & Charlton, B. G. (2000). Theory of mind, persecutory delusions and the somatic marker mechanism. Cognitive
Wells, A. (1994). A multi-dimensional measure of worry: Development and preliminary validation of the anxious thoughts inventory. Anxiety, Stress,
and Coping, 6, 289299.
Zimbardo, P. G., Andersen, S. M., & Kabat, L. G. (1981). Induced hearing deficit generates experimental paranoia. Science, 212, 15291531.

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Clinical Psychology Review 27 (2007) 425 457

Suspicious minds: The psychology of persecutory delusions

Keywords: Delusions; Paranoia; Cognitive; Schizophrenia; Psychosis

E-mail address: D.Freeman@iop.kcl.ac.uk.

2. The definition of persecutory delusions

3. The epidemiology of paranoid thinking

Representative older adult general population studies

Studies of selected non-clinical samples

Fig. 1. The paranoia hierarchy.

4. Psychological processes and persecutory thinking

6.2. Depression, self-esteem and schemas

7.1. Jumping to conclusions

D. Freeman / Clinical Psychology Review 27 (2007) 425457

D. Freeman / Clinical Psychology Review 27 (2007) 425457

7.2. Attributional style

7.3. Theory of mind

D. Freeman / Clinical Psychology Review 27 (2007) 425457

D. Freeman / Clinical Psychology Review 27 (2007) 425457

D. Freeman / Clinical Psychology Review 27 (2007) 425457

D. Freeman / Clinical Psychology Review 27 (2007) 425457

D. Freeman / Clinical Psychology Review 27 (2007) 425457

D. Freeman / Clinical Psychology Review 27 (2007) 425457

8. The threat anticipation cognitive model of persecutory delusions

Fig. 2. Summary of the formation of a persecutory delusion.

Fig. 3. Summary of the maintenance of a persecutory delusion.

9. Pitfalls in studying persecutory thinking

10. The next 10 years and beyond

Daniel Freeman is supported by a Wellcome Trust Fellowship.

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