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BritishJournal of Clinical Psychology (2002), 41, 331– 347 2002The BritishPsychological Society www.bps.org.uk

Acognitivemodel of persecutory

Daniel Freeman 1*,Philippa A.Garety 1 ,2 ,Elizabeth Kuipers 1 , David Fowler 3 and Paul E.Bebbington 4 1Department ofPsychology, Instituteof Psychiatry, King’s College London,UK 2Division ofPsychological Medicine, GKTMedical School King’s College London, UK 3Clinical Psychology Doctoral Programme, School ofHealth Policy andPractice, University ofEastAnglia, UK 4Department ofPsychiatry andBehavioural Sciences, Royal Free andUniversity College Medical School, University College London,UK

Amultifactorialmodel ofthe formation and maintenance of persecutory delusions is presented.Persecutory delusions are conceptualizedas threat beliefs. The beliefs are hypothesizedto arise from asearchfor meaning forinternal or externalexperiences thatare unusual,anomalous, or emotionally significant for the individual. The persecutoryexplanations formed reflect aninteraction between psychotic processes, pre-existingbeliefs and personality (particularly emotion), and the environment. It is proposedthat the delusions are maintainedby processes that lead tothe receipt of confirmatoryevidence and processes that prevent the processing of disconfirmatory evidence.Novel features of themodel includethe (non-defended) direct rolesgiven to emotionin formation, the detailed considerationof both the content and form ofdelusions, and the hypotheses concerning the associated emotional distress. Theclinical and research implicationsof the model are outlined.

Garety,Kuipers,F owler,F reeman,and Bebbington (2001)have proposed anewmodel of the positivesy mptoms of .I nthis paperthe modelis applie dto one specific symptom: persecutory delusions.G iventhe complexnature of psychosis,such specificationmay be clinicallyand theoreticallyuseful. The positivesy mptoms of psychosis frequently co-occur,but symptom-specificmodels can fac ilitatetheory and treatment development, ashas been found for anxiety disorders (see Clark& Fairburn, 1997).The model was deve lopedwith the aimof beinghelpful for cliniciansusing psychologicalapproaches for the problems of individualswith persecutory delusions.

*Requestsfor reprints should be addressed to Dr DanielFreeman, Department of Psychology, Instituteof Psychiatry, DenmarkHill, London SE5 8AF, UK(e-mail:[email protected]). 332 DanielFreeman et al. Themode liscomplex ,despite the focus on asinglesy mptom. Thisis be cause multiplefac tors areinc orporated.H owever,we argue that only amultifactorial understanding of symptom development and maintenanceadequatelyre flects the phenomenon (Garety &Freeman,1999; G arety &Hemsley,1994). I nshort, the causes of delusions,even of the samecontent -type,arelikely to varybetwe enindividuals.Why then focus upon persecutory delusions?T hereare two mainre asons. Thefirst isthat persecutory delusionsare like lyto havecommon maintainingfac tors. Thisis be cause they havea common theme of the ‘anticipationof danger’: theyarethreat beliefs. Similarly,the psychologicalconceptualization of anxiety disorders isthat theyarethreat beliefs.T herefore, many of the processesimplicatedin the maintenanceof anxiety disorders (Clark,19 99)should be implicatedinthe maintenanceof persecutory delusions(F reeman& Garety,1999, 2002). The sec ond reason for focusingon persecutory delusionsis be causeof their clinicalrele vance.T hey areone of the most frequently occurringdelusions (C utting,1997) and symptoms of psychosis(World HealthO rganization,1973). T hey arealso associated with distress—more so, for example,than grandiosedelusions. F inally,possession of apersecutory beliefoften has clearramifications for the individualconcerne d.F or example,We ssely et al. (1993) report that persecutory beliefsare the most likelyty pe of delusionto be acted upon, and Castle,Phelan, Wesse ly,and Murray (1994)found that the presenceof a persecutory delusionis a predictor of admissionto hospital. Thediscussion willc oncern delusionsassociated with diagnosesof non-affective functionalpsy chosissinc ethese arethe disorders inwhich sy stematicresearch has occurred,but the modelwill have re levancefor the understanding of delusionsin other disorders.The model builds upon the work of other authors, notably Maher, Birchwood, Chadwick,and Bentall,and the researchteam’ s own clinicaland theoretical studies. The differencesfrom the moregeneral framework of Garety et al. (2001) are those of emphasis.The model of persecutory delusionshas greateremphasis on processesthat arety picallyassociated with anxiety.Maintenancefactors aregrouped differently.The hypothesesconcern both delusionalc onviction and accompanying distress (delusionaldistress, anx iety,and depression). Aspects of the content of persecutory beliefsare inc orporated. Whenthe modeliscompared with that proposed by Bentalland colleagues(B entall, 1994;B entall,K inderman,& Kaney,1994)the differencesaregre ater.I nessence,these researchers suggest that persecutory delusionsre flectan attributional defence against lowself -esteemthoughts reachingconsciousness. Byblaming others for negative events,rather than the selfor the situation, itis argue dthat negativethoughts about the selfare prevented from reachingawarene ss.T hisis summarized by Bentalland Kaney (1996):

Buildingon previousaccounts that implicate defences against self-esteem (Colby et al., 1979;Zigler &Glick,1988), we haveargued thatparanoid patients have latent negative self-representationsor schemata similar tothe more accessiblenegative self- representationsobserved in depressed patients(Bentall et al.,1994).When these negativeself-representations are primed bythreateningevents, leading todiscrepancies betweenthe self-representations and self-ideals, external (other-blaming) attributions forthe threatening events are elicited.These attributions are self-protectivein the sensethat they reduce thepatient’ s awareness ofdiscrepancies between the self and self-ideals,but carry thepenalty of activating schemata that represent threats from others. Acognitivemodel of persecutorydelusions 333 Thedegreeto whichevidencehas been found to support the hypothesized discrepancy betweenimplicitand explicitself -concepts inindividuals with persecutory delusionsis atopic of debate.I nanumberof studies Bentalland colleagueshave sought evidenceof such discrepancy(Bentall& Kaney,1996;K inderman,1 994;L yon, Kaney,&Bentall, 1994).They c oncludethat: ‘Thehy pothesisthat deluded patients havean implicit,but explicitlyde nied,negative self -concept has been morediffic ult to test but has been supported by anumber of studies’(Bentall & Kinderman,19 98).These re searchersalso interpretthe evidencefrom their attributional studiesassupportive of such a discrepancy(B entall,1994; B entall et al.,1994;B entall& Kinderman,1999). H owever ina recent reviewG arety and Freeman(1999 )suggestthat the defencehy pothesis may only apply to aminority of individualswith persecutory delusions.They argue that there isevidence of an associationof persecutory delusionswith an externalizing attributional bias,but that the evidenceis muc hweakerfor the existenceof a discrepancybe tween implicitand explicitself -schemas.E videnceof implicitand explicitself -concept discrepancy isnot compellingwhen allthe relevantstudie sare considered and the valueof the variousex perimentalme thodologiesscrutinized.T he attributional biasmay not servethe function of preventinglow self -esteemthoughts from reachingconsc iousness. Consistent with the viewthat persecutory delusionsare not adefence,there is evidencethat depression does not increase,or self-esteemlower, whe npersecutory delusionsimprove ove rtimeor with apsychologicalinterve ntion (Chadwick &Lowe, 1994;F reeman et al.,1998).M oreover,Bowins and Shugar(1998) re port that delusions arege nerallyrated asself -diminishing.T hey found that delusionsof and referenceare the most self-diminishingty pe of delusion.I ntheirstudy there was consistency between self-esteemand the content of delusions:the lowerthe self- esteem,the moreself -diminishingthe delusion.The refore, the new modelincorporate s the attributional biase lement of Bentall et al.’stheory,but itis argue dthat persecutory delusionsare a directreflectionof the emotions of the individualand not adefence. That is,the delusionsare c onsistent with existingideas about the self,others, and the world.

The model The modelis summarized in F igs1 and 2.Thelines repre sent majorlinks, and arenot exhaustive.

The formation ofthe delusion Underlyingthe modelisa stress-vulnerabilityframe work: the emergenceof symptoms isassume dto depend upon an interaction between vulnerability(from genetic, biological,psy chological,and socialfac tors) and stress (which mayalso be biological, psychological,or social).There fore,the formation of the delusionwill be ginwith a precipitator,such asa life-eventor otherstressful occurrenceor drugmisuse. A rousal willbe caused,and this islikely to be exacerbatedby disturbancesinsle ep. Furthermore,this mayoften occur againstthe backdrop of long-term anxiety and depression (seebelow). For individualswith avulnerabilityto psychosis,the arousal willinitiate inner -outerconfusion (Fowler,2000), causing anomalous ex periences(e.g. thoughts beingex perienced asvoices, actions experienced asunintended, or more 334 DanielFreeman et al.

Figure 1. Summary ofthe formation of a persecutorydelusion. subtle cognitiveex periencessuch asperc eptual anomalies), whichwillin turn drivea searchfor meaning(M aher,1988 ).The inner-outer confusion and the anomalous experiencesmay result from the types of psychologicaldy sfunction describedby Frith (1992)and Hemsley(1987).The reis e videnceof subtle anomalousperc eptual experiencesin individuals with (B unney et al.,1999;E belG ross, Klosterkotter,& Huber, 1989;F reedman& Chapman,1973; M cGhie& Chapman,1961 ) and of individualswith delusionsreporting that their beliefswere caused by anunusual internalstate such asthe experienceof hallucinations (Garety &Hemsley,1994).T he generationof anomalousex periencesby the precipitatinge ventmay oc cur viathree routes (indicated by the three arrows from the precipitantin F igure1): the precipitant maytrigger anomalies directly ;emotionaldisturbance maybe triggered leadingto anomalies;or cognitivebiase sassociatedwith psychosis maybe triggeredleadingto anomalies.T he heightenedstate of the individualmay lead to externalevents that are unusual, ambiguous,ne gative,or neutral (though often with socialsignificance ),also becomingincorporated into the searchfor meaning.I nasmallerproportion of cases (e.g.ofte ninde lusionaldisorde r), the precipitatingeve nt itselfwill le ad directlyto a searchfor meaning(i.e. there areno internalanomalous e xperiences).The pe rson will be searchingfor an explanationof the triggeringe ventor of recent events relatedto the Acognitivemodel of persecutorydelusions 335 schemaac tivatedby the triggeringevent. I nsum,individuals will be searchingfor explanations of internalanomalous e xperiences,or recent externaleve nts, or arousal. Inthe searchfor meaning,pre- existingbeliefs about the self,others, and the world aredrawn upon. Apersecutory beliefis likely to be formedifindividuals already believe that theyarevulnerable, ‘ asoft-target’(F reeman et al,1998),or considerthat they deserveto be harmedbecauseof their own previousbehaviour (Trower &Chadwick, 1995),or becausethe yviewothe rpeopleand the world ashostileand threateningon the basisof earlierexperiences(e.g.trauma). Thesebeliefs will be closelyassociated with premorbid levelsof anxietyand depression.I nthe contextof these typesof beliefs,anx ietyand depression caninflue ncethe formation of persecutory delusions. Highlevels of pre-existinganx ietywill be particularlysignificant; the cognitive component of anxiety centresupon concern about impendingdange r,and such thoughts willbe reflectedinperse cutory delusions.The most strikingelement of anxiety isthe ‘anticipationof danger’(D SM-IV;AmericanPsychiatric A ssociation,1994). Thisis e vident inworry ,whichcan be viewedas‘ the persistent awarenessof possible future danger,which isre peatedly rehearsedwithout beingre solved’(M athews, 1990). The content of worry isphy sical,social, or psychologicalthreat (Wells,1994). Persecutory delusionstoo, by definition,conce rn anticipationof dangerand havea content of physical,social, or psychologicalthreat (Freeman& Garety,2000).T he thematicc ontent of persecutory delusionsand anxiety arethe same,which is consistent with the hypothesis that anxiety isdirectly ex pressed inpe rsecutory delusions.A nxiety ishy pothesizedto be the key emotion with regardto the formation of persecutory delusions,although otheremotions (depression, anger,e lation) mayadd furtherto the contents of the delusion.I nshort, inmost casesthe content of the delusionis consistent with the emotionalstate of the individual. The explanations considered inthe searchfor meaningwill also be influencedby cognitivebiase sassociatedwith psychosis(see Garety &Freeman(1999) for areviewof the empiricalliterature ).The‘ jumpingto conclusions’bias de scribedby Garety, Hemsley,&Wessely(1991) may limit the amount of data gathered to support an explanation.The attributional biasproposed by Kindermanand Bentall(1997) may causea tendencyto blameothe rs for the events.T heTheory of Mind (ToM)dysfunction proposed by Frith (1992)may lead to errors inreading the intentions of other people. From the internalor externalevents, pre- existingbeliefs, and cognitivebiase s, explanations willbe formed, though the threecontributing factors willnot, of course, be independent of eachother. Thus,for instance,negativevie ws about the selfwill oftenbe reflected inderogatory voices,whic hinturn shape viewsabout the self.T he explanation chosen willbe mediatedby at leastthre eother factors. Thefirst mediatoris beliefsabout mentalillness and ‘madness’(B irchwood, 1995).Simply put, many patients havehad to makea choicebetwee nsomethingbe ingwrong with themand somethingbeing wrong inthe world.B elievingthat somethingis wrong with them(for instance,that theyarebecoming mad) maybe amoredistressing be liefthenthat they arebeing pe rsecuted, and henceapersecutory beliefismore like lyto be chosen insuch circumstances.I nthis respect,the reis an externalattribution that limitsthe distress causedto individualsin terms of cost to self-esteem;this could be viewedasa defensive attribution. However,unlike B entall(1994) it is not proposed that there isdiscrepancy betweenovertand covertse lf-esteem,and itis not proposedthat such achoice betweenexplanationsoc curs inall c asessinc esomeindividuals consider no alternative to the delusion.The sec ond mediator issocial fac tors. Ifthe person isisolated, unable to revisehis or herthoughts on the basisof interactions with supportive others, then ideas 336 DanielFreeman et al. of threat aremore likely to flourish.A similarprocess willoccur ifthe person is reluctant to talkto others—he or she maybe secretiveor mistrustful (Cameron, 1959), or believethat personal matters should not bediscussed with others. Thefinalmediator isthat ifa person has littlebe liefflex ibility(a poor capacity for consideringalte rnatives) (Garety et al.,1997),or has aneed for closurebecause of adifficulty intolerating ambiguity,thentheyaremore likely to accept the initialex planation:the anxious, persecutory belief. Insummary,persecutory delusionswill arise from asearchfor meaningthat reflects aninteraction betweenpsychotic processes,the pre-existingbeliefs and personality of the individual,and the (often adverse)environment.C learlya persecutory delusionis an attribution (i.e.acausale xplanationfor events). But, again,the reare difference s from the modelof Bentalland colleagues.The attribution tradition, developedin researchon depression,has concerned causalex planations for good or bad events (Abramson, Seligman,& Teasdale,1978). C onsequently,Bentalland colleaguesargue that: ‘the deludedindividualmake sexternal,global and stableattributions for negative eventsto minimisethe extent to whichdiscrepanciesbetwee nself-representations and self-guidesare acc essibleto consciousness’. Attributions for negativeevents are c entral to the paranoiamodel proposed by Bentalland colleagues.I ncontrast itis observe din clinicalpractice that neutralevents (e.g. a glancein the street), or evenpositive events (e.g.a smile),can be taken asthreatening by individualswith persecutory delusions (e.g.the glanceis a signof plotting,the smileis a nasty one). Theattribution canalsobe for an unusual or discrepant event—that is,an eventthat maynot necessarilybe threateningbut that requirese xplanation(e.g. perceptual abnormalitie sor arousal). Afurthercomplexity should be highlighted:two levelsof attributions maybe involvedinde lusionformation. The delusioncan be an attribution for other attributions. Theindividual with apersecutory delusionmay make attributions for events(e.g. seeing a person inthe street glancingleads to the attribution ‘the person is watchingme’ or ‘the look was anasty one’), and the delusionmay be anattribution for anumberof these attributions (e.g.‘ that person waswatching me’ , ‘Iwasgiven a nasty look’leads to the attribution ‘there must be aconspiracy,they areout to getme ’).This raisesthe interestingissue of the linksbetwe endelusionsof referenceand delusionsof persecution. Thereis also a timedimension to the attributional process.Bentall and colleagues’theory has the implicationthat arapidattribution ismade in orde rto prevent implicitnegative sche mabecoming c onscious.H owever,the formation of somedelusions re sults from alengthysearch or investigatoryproce ss by the person (especiallyin cases prec eded by delusionalmood). Therecan a period of puzzlement, confusion, and surprise,whichMaherdescribesin his writing. Why use the term ‘searchfor meaning’? Theterm isbroad and caninclude within itattributions for negativeevents, neutral events and unusual events.I tcaninc orporate the possibilities that the delusionis an attribution for severalattributions and that the explanation processmay take time.Searchfor meaningdoes not havesuc haclosetie to self-esteem (it istheoretic allymore neutral). Theterm works wellin clinical settings as it is e asily understood. Anxietyis given a central rolein the model.Postulating a directrole for anxiety,in combination with psychotic processes,is novel in conte mporary theories (but see Bleuler,1911/ 1950).I tisconsistent with evidencethat levelsof anxiety arehigh many yearsbefore the development of psychosis,during the prodrome, and subsequently. Jones,R odgers,M urray,&Marmot (1994)ex amineddata gatheredfrom acohort of 5000people all born inthe sameweek in1946 who werefollowed from birth. Children Acognitivemodel of persecutorydelusions 337 who went on to developschizophrenia we resignificantly more soc iallyanx ious at13 yearsof agethan those childrenwho did not. Krabbendam Janssen,B ije,V ollebergh,& vanO s(2002)report data from a3-yearpopulation samplestudy of 4000individuals. Highne uroticismand lowself -esteempredic ted first everonset of psychotic symptoms. Tienand Eaton (1992)presente dresults from the NIMHEpidemiologicC atchment Area Program:the presenceof anxiety1 yearbefore onset wasa riskfactor for development of delusionsor hallucinations.Prospec tive,re trospective,and clinicalstudies find that ina majorityof cases(60 –80%)symptoms of anxiety,depression, and irritability precedeby 2to 4weeks the appearanceof positivesy mptoms, often accompaniedby subtle cognitivec hangesand, later, by low-levelpsy chotic phenomena (see reviewsby Birchwood, Macmillan,& Smith,1992 ;Docherty,VanKammen,Siris, & Marder,1978; Yung& McGorry,1996).The presence of anxietyhas been studied inindividuals who havepositive sy mptoms (i.e.are sy mptomatic atthe time).A nxietyhas beenfound to be frequently comorbid with schizophrenia(A rgyle,1990; C osoff &Hafner,1998; Foulds &Bedford, 1975;M oorey&Soni,19 94;se ereviewby Turnbull& Bebbington (2001)).F or instance,Cosoff and Hafner (1998)report 43%of 60c onsecutivein - patients with schizophreniahaving an anxiety disorder.I nalongitudinalstudy ,Norman and Malla(1994) showed that anxiety and depression aremore strongly relatedto positivesy mptoms than to negativesy mptoms. Theauthors report afurther study in whichanxiety was found to be morestrongly relatedthan depression to delusionsand hallucinations (Norman,M alla,C ortese,&Diaz,1998). F inally,arolefor anxiety in delusionformation isconsiste nt with findingsof highrate sof trauma and PTSDin individualswith severemental illne ss (Mueser et al.,1998),and with earlyabuse being reflected inthe content of delusions(R ead &Argyle,1999). Suchc onsistent findingsof highle velsof emotionaldistress throughout the course of delusionsand hallucinationssupports the hypothesis that emotion has adirect contributory roleto positivesy mptom development.H owever,it c ould equallybe arguedthat emotion issimply a consequenceof psychotic symptoms. For example, someauthors suggest(most famously Chapman,19 66)that the emotionaldisturbanc e that occurs inthe prodromal phase of illness isa consequence of subtle (attentional and perceptual) changesassociated with psychosis.H oweverit is the ubiquitous presence of emotionaldisturbance prior to fullsy mptoms that isthe key findingwith regardto its potentialinfluence on delusions:eve nifanx iety isa consequenceof another psychologicaldy sfunction, inprec edingthe frank occurrenceof positivesy mptoms, itmay still have a rolein sy mptom formation. Inaddition,as Y ungand McGorry (1996) propose, itis plausible to suggestthat thereare inte ractions between anxietyand more specificdy sfunction (suchasperce ptual changes)prior to the appearanceof positive symptoms. Thisargume nt alsofollows for emotion causedby the formedpsychotic symptom. Anyanxiety generatedby adelusionis like lyto alterthe processingof the individualand therefore mayplay a part inthe maintenanceof the belief.

The maintenance ofthe delusion Persecutory delusionsare conce ptualizedasthre at beliefs.They are reinforced by the reliefthat comeswith anexplanation(M aher,1988), the knowledgethat the person is not ‘losingtheir mind’, and the confirmation of pre-existingideas and beliefs. Maintainingfactors canthen be dividedinto two types:those that result inthe obtainingof confirmatory evidenceand those that leadto disconfirmatory evidence 338 DanielFreeman et al.

Figure 2. Summary ofthe maintenance of a persecutorydelusion. beingdisc arded.The more maintenance factors that arepresent, the morelike lythat the delusionwill persist. Thereare a number of waysinwhic hconfirmatory evidenceis obtained. Thenormal beliefc onfirmation biaswill operate :individualswill look for evidenceconsistent with their beliefs(M aher,1988). A ttentionalbiases will come on- line,as is found in emotionaldisorde rs:thre at willbe preferentiallyproce ssed(Bentall& Kaney,1989); threateninginterpretations of ambiguouse ventswill be made; and suchbiasesare likely to be enhanced by aself-focused cognitivesty le(F reeman,G arety,&Phillips,2 000). Memory biases,which may be associatedwith emotionaldisorder (e.g.intrusive trauma memories),will le ad to frequent presentations inthe mindof the individualof the evidencefor the delusion.C ontinuing anomalousex periences(often triggered by anxiety),and the cognitivebiases assoc iatedwith psychosis,will also provide evidence consistent with the threat belief.F inally,the person’s interactions with others may becomedisturbe d.T heperson mayact upon their delusionin a waythat elicitshostility or isolation(e.g. by beingaggressive ,or treatingothe rs suspiciously),and they may suffer stigma(Wahl, 1999). I nessence,others mayact diffe rently around the person, or break contact with them,thus confirmingpersec utory ideas. But why does the persecutory beliefremain for such alengthof timewhe nthe predicted harmhas not actuallyhappe ned? Someindividuals live in fear that their persecutors areabout to ringtheir doorbell,but the persecutors havenever calle d. Acognitivemodel of persecutorydelusions 339 Someare convinced that governmentalorganizations are going to killthem, yettheyare stillalive. I tisargue dthat potentiallydisconfirming e videnceisdiscarded in two main ways. The first mainway isby the use of safety behaviours.Safety behavioursis an important conceptdeveloped by Salkovskis(1991, 1 996)to explainthe maintenanceof threat beliefs inanx ietydisorders, and has sincehas been appliedto persecutory delusions(F reeman,1 998;F reeman,G arety,&Kuipers,2001 ;Morrison, 1998).I tis hypothesizedthat individualswith persecutory delusionstake actions designedto reducethe threat, but whichactually prevent disconfirmatory evidencebeing rece ived or fullyprocessed. Toe xplainthe absenceof the fearedoutcome ,individualscan reason that theirsafe ty behaviourshave pre ventedharm, rathe rthan that the harmwas not goingto occur inany case.Potentiallydisconfirming evidence is re ndered ineffectiveby turning the situation into a‘nearmiss’ (‘ Thepersec ution would have occurredifI hadn’t ...’).The use of avoidancebe haviourswill have the additional effectof limitingthe amount and detailof potentiallydisconfirming evidence rec eived. Types of safety behavioursre portedby individualswith persecutory delusionsinclude avoidance,escape, within- situation behaviours,c ompliance,and aggression(F reeman et al.,2001).H igherlevels of anxietyassociated with the delusionwill le ad to greater use of safety behaviours,consistent with the literaturec oncerningacting upon delusions(B uchanan et al., 1993). The second way inwhich disconfirmatory evidencemay be discarded isby incorporatingthe failureof predictedharmevents into the delusionalsy stem.O nly Melgesand Freeman(1975 )makepassing re ferenceto this issuewhen they setout their cyberneticmodel of persecutory delusions: Theruminative vicious cycle common to thisstage canbe paraphrasedas follows: ‘ IfI dothis, they will dothat; and if they don’ t dothat, it’ s becausethey are pretending (muchlike Iam) inorder tocatch me offguard later on.’In this way, hispredictions appear confirmedno matter whathappens, and his seemingly correctpredictions ensnarehim further in what seems tobe apreordained web ofeventsdetermined by others. Inother words, disconfirmatory evidenceis dismissed because individuals view it as instancesof the deviousnessof the persecutors. They maysay ,‘Ican’t be sure of the exactplans of my tormentors, but inthe end they’llge tme’.Orindividualsmay believe that theyhavebe enlucky,or that other powers areacting in their favour.Some patie nts haveattributed bad eventsthat do happen (e.g.loss of ajob,illness, mugging) to the persecutors, take this asan indication that worse willfollow, and can therefore disregardinc onsistent evidence.

The emotion associatedwith the delusion The modelinc ludeshy potheses concerningthe emotionaldistre ss associatedwith the delusion(delusional distress, anx iety,and depression), based upon the findingsof Freeman et al. (2001).I tishy pothesizedthat emotionaldistress arisesin two ways: from the content of the delusionand from furtherappraisalof the delusionand associatedex periences. Atthe simplestlevel, e motionalex periencesare directly assoc iatedwith the content of delusionalbe liefs.T hecognitivec ontent of emotions willhave be enexpressedinthe delusionsand, in turn, the content of the delusionswill contribute to the maintenance 340 DanielFreeman et al. and exacerbation of the emotion.N egativebe liefsabout the self,others, and the world, which areassoc iatedwith emotionaldistre ss,influe nce,and arereflected in, the contents of delusions.O ncethe delusionis formed, itis likely to feedback and confirm affect-relatedbeliefs, leadingto the persistenceand enhancement of emotionaldistress. Anxietywill dire ctlyre sult from the threat belief. Inparticular,beliefs about the pervasivenessof threat and the presenceof rescuefactors willinfluenc elevelsof anxiety.The threat beliefwillreaffirm and exacerbate previouslyhe ldide asabout vulnerabilityor hostility.Levelsof delusionaldistre ss willbe higherfor individualswho believethat the harmwill be extremelyawful and that itis very like lyto occur. Depression willbe associatedwith beliefsabout the power of the persecutors (Chadwick &Birchwood, 1994)and about whether the persecution isdese rved punishment (Trower &Chadwick,1995). I fpersecutors arebe lievedto be extremely powerful,this willreinforce and increasede pression.Similarly ,ifindividuals had been depressed, and believedthat theydeservedto be harmed,the nthe threat beliefwill confirm their depressivethoughts and henceincreasedepression. Thelink betwe en delusionsand depression isconsistent with observationsthat depression isfreque ntly comorbid with the acute symptoms of psychosisbut remitswith recovery(B irchwood, Iqbal,C hadwick,& Trower,2000 ;House,Bostock, &Cooper 1987;K oreen et al., 1993). Thesec ond way inwhich emotion isge neratedconcerns further appraisal,in relationto the self,of the contents of the delusionalbelie fand of the actualdelusional experienceitself, the importanceof whichwill vary from individualto individual.T he further appraisalmay inc reasethe negativee motionalreaction to the delusionalbelie f, and lead to the person becoming‘ stuckinpsy chosis’(F owler,2000). D epression will result from negativeappraisals of the delusionor delusionalthoughts inre lationto the self:e.g., that the persecution or persecutory thoughts area signof failureor badness. For someindividuals, the negativebe liefsabout the selfare long term, prec ededelusion formation, and werealre ady reflected inthe contents of the delusion.H owever,for otherindividuals,appraisal of the delusionc an triggerideasof failureor badness. Depression willalso oc cur ifindividuals believe upon reflectionthat they haveno control overthe persecutory situation, and that this seemsto be true of many areasof their lives.A dditionalanx ietymay result from appraisalsc oncerningvulne rability, hostility,and danger.D elusionaldistress willbe associatedwith appraisalsof the experienceof delusionalthoughts (Freeman& Garety,1999).Higherlevels of delusionaldistress willbe associatedwith worriesabout alackof control of persecutory thoughts, particularlyin individuals with alongerillness history. Contributing to these feelingsof uncontrollabilitywill be the counterproductive use of thought control strategies. Theimportance of eachof the two paths to emotionaldistre ss willvary from individualto individual.F urther appraisalmay be elaborateand negativefor some individuals,while in othe rcasesit may be fleetingand not asource of concern. Negativevie ws of the selfmay already be incorporatedinto the contents of delusions, and hencethe contribution of further appraisalin these casesisminimal; negative viewsof the selfmay be contained within the contents of the delusionsif appraisals had occurredat an earlystage of delusionformation, or lowself -esteemhad driventhe delusions,such asin B ad-Meparanoia(Trower &Chadwick,1995). Acognitivemodel of persecutorydelusions 341

Clinicalimplications The modelidentifies a number of processesthat mayform and maintainpe rsecutory delusions.C arefulassessment willbe neededto determinethose that operate inthe individualc ase.A lso,given the conceptualizationof persecutory delusionsas thre at beliefs,and the highlevels of anxietyfound inthis group,the clinicianne eds to be especiallyattentive to issuesof rapport (seeChadwick,B irchwood, &Trower,1996; Fowler,G arety,&Kuipers,1995; K ingdon& Turkington,1994 ).Furthermore,the modelsuggests that individualswill be e speciallysensitive to cliniciansviewing them as mador mentallyill. E mphasisis placed in the modelon beliefsabout illness;it is hypothesizedthat individualswho developperse cutory delusionsdo not haveany alternativee xplanations that arepalatable in c omparison with the delusional explanation.The refore, akey aimof therapy must be to construct with clients alternativenon- delusionalmode lsof experiencesthat areacc eptableto themand not stigmatizing.The therapist willnee dto explorethe meaningfor individualsof different explanations for their experiences(including the delusionalex planations). Normalizing ishe lpful(K ingdon& Turkington,1994), but aplausible,biases -in-psychological- processingex planationis partic ularlyvaluable (F owler et al.,1995;F reeman& Garety, 2002).A nindividualizedex planationis ne ededof how psychologicalprocesses may leadto specificsubje ctivee xperiences;this isce ntral to cognitivetherapy for all disorders.H owever,the emphasisof an explanationwill clearly depend primarilyon what isac ceptableand helpfulto clients. Conceptualizingpersec utory delusionsas threat beliefsle ads to the idealobjective of therapy beingthe reduction of emotionaldistress viachange in the degreeof conviction inthe threat beliefs.E valuatingdelusional beliefs and alternativee xplanations isa key technique.The mode lindicatesthat somecoping strategies c ould act assafety behavioursthat prevent delusionalbe liefchange and maintaine motionaldistress. However,the use of copingstrate gieswith peoplewith psychosiswill nee dto be pragmatic,and basedupon carefulindividualize dformulation to identify the potential advantagesand disadvantagesof eachc opingstrate gy.C opingstrate giescanbe used earlyin therapy to buildtrust inthe relationship,or to dealwith highle velsof emotionaldistress before goingon to evaluatebe liefs(F owler et al.,1995),when the use of such strategieswould be discouraged.Some individuals are unwilling to evaluate their delusionalbelie fs, and copingstrategies can be ahelpful technique inreduc ing emotionaldistress. C opingstrategies that reducefocus upon delusions,that allow distancing,but that do not deliberatelysuppress delusionalthoughts, aremore favourablethan copingstrate giesthat havethe opposite consequences.Those strategiesthat helpthe person to dealwith distress whileengage dinactivity (and henceprovide an opportunity for the person to be less self-focused) willon the whole be better than ones that try to dealwith distress simplyby withdrawal.Strategies that contribute to the person beingloc kedinto the delusionalsy stem,providing little opportunity for himor her to receivedisc onfirmatory evidence,should preferablynot be used. The therapist should consider the copingstrategy inre lationto the individual formulation, and,ideally ,discuss with the person how the strategy works, or does not work, from this perspective. The individualizedmodelcan guide the intervention. Inparticular,altering the identifiedmaintenancefactors (e.g.reasoning and attentionalbiases) will be central to a good outcome. Ideally,this should be carriedout with the goalin mind of evaluating the delusionalversus the psychologicalex planations of experiences.Aclinicallyuse ful 342 DanielFreeman et al. manoeuvreis to address safety behaviours(F reeman& Garety,2002).A clientgiving up asafety behaviouris a test of the function of the behaviour;but itis also a test of the threat belief, albeita less directone than the beliefchallengingmore routinely used in cognitivetherapy for psychosis(se eChadwick &Lowe,1994 ).Afurther benefit isthat by reducingthe constrictions imposedon the person’s lifeby the safety behaviours there maybe associatedinc reasesinfee lingsof control and therefore reductions in depression. Themodel highlights the importanceof addressingthe emotionaldistre ss associated with adelusion,and this ispartic ularlythe casewhe nan individualis unwilling to consideralternativeex planations to the delusionalbelief. D iscussingthe linksbetwe en the content of adelusionand how the person isfeeling c an be empathicand normalizing,and cansuggest beliefs that canbe targetedto causechange sinemotional experiences.F or instance,beliefs about the powerof the persecutor can be evaluated, asin the innovativework on cognitivethe rapy for voices(Chadwick et al., 1996). Changesinsuc hbeliefsmay reduc edepression and be agentlechalle ngeto central parts of the persecutory delusions.I tisalso useful inthe earlystage sof therapy simply to think through the detailsof the threat with the client.F or instance,itmay be helpful to ask the person whenthe threat ismost likelyto occur.This may prompt the person to considerwhy the harmhas not actuallymaterialized (i.e .to process disconfirmatory evidence)—itmay make them lessanx ious and itmay provide insights into how the beliefcan be evaluated.O verall,then, targetingaspe cts of the content of adelusionmay leadto emotionalc hangesand maybe ginto weaken the conviction inthe delusion. Sucha process maysoc ializethe person into the cognitiveapproac hand leadto greater success whenmoredire cttestingof the delusionis attempte d. Individuals’appraisals of their delusionalbeliefs and associatede xperiencesmay havele dto emotionaldistre ss.The refore, the use of thought chainingfrom the delusion,and checkingfor the presenceof meta-worry,maybe helpfulin the assessment stage.Beliefsabout the self,others, and the world,may ne edre-evaluating. Insomecase s(e.g.if it is belie vedthat the persecution isdese rved)addre ssingthese beliefswill be amaingoal of therapy.However,in many othercases,it will be alater target,with particularregard to relapseprevention. Finally,the modelalsohighlights the socialworld’ s importancein the formation and maintenanceof the delusion.Soc ialfac tors aresometime soverlooked incognitive interventions with their emphasisupon internalproc esses.H owever,relationships with others,leve lsof expressed emotion,and beliefsabout talkingwith others, mayalso be valuabletopic sfor discussion intherapy .

Indicationsfor furtherresearch Themode lindicatesmany researchpaths. What arethe newer directions ithighlights? Exploration of the varietyand typesof explanations that clientshave available for the experiencesthe irpe rsecutory beliefsare intended to explainwill cle arlybe of interest. Thety pes of internaland externalevents that contribute to delusiondevelopment remainto be determinedempirically.Themodel allows for eventsthat maybe negative, neutral,or evenpositive to be incorporated into the delusion.I nvestigationof direct rolesfor emotion inde lusiondevelopment is needed, bringing the study of neurosis and psychosiscloser toge ther(see Freeman& Garety,inpress). Detailedstudy of how disconfirmatory evidenceis disc ardedwould be valuable.F urtherstudy of the content Acognitivemodel of persecutorydelusions 343 of delusionalsy stemswould be greatlybeneficial; this canbe investigatedin relation to emotionalex periencesand key beliefs about the self,othe rs,and the world.A ttention needs to be givento the patients’relationships with theirpersecutors and the identity of the persecutors, asB irchwood, Meaden,Trowe r,G ilbert,& Plaistow(2000) have considered for voices.I ndividuals’appraisals of their delusionalbelie fs and associated experiencesre quirefurthe rinvestigation.These topic areasare underde velopedand need basicwork interms of questionnaire development, cross-sectionalstudies assessingthe presenceof the cognitivefactors, and longitudinalstudies assessingtheir influence. Itremainsto be determinedwhetherthe cognitivebiase sassociatedwith persecutory delusionsare state or trait variablesor whether adifferentialactivation relationshipex ists such asin depre ssion (Teasdale,1988).M anipulationof the key variablesin individuals with persecutory delusionswill be an important stepin determiningcausal role s.Study of cognitiveproc essesassociatedwith delusionsacross disorders isalso likely to be avaluablestrate gy.Delusionshave been studied from a cognitivepe rspectivein non- affectivefunctional psychosisbut theyoccur inmany other disorders (Manschreck&Petri,1978 ;Coryell& Tsuang,1982; C ummings,1992; Cutting,198 7;Trimble,1992).A strength of sucharesearchstrategy isthat itfacilitates investigationas to whetherthereare psy chologicalproce sses that arespecific to the occurrenceof delusionsin each disorde r.I norderto study delusion-specificfactors a closelymatched control group of individualswithout delusionsis ne eded;it is diffic ult to recruit acontrol group of individualswith schizophreniawho havenever had delusionsbut the task issimpler for individualswith depression and individualswith neurologicaldisorde r.F urthermore,itis significant for the newmodelof persecutory delusionsthat delusionsin mood disorders such asbipolardisorde rand depression are associatedwith emotion (by diagnosticdefinition). Thisis a clearindication of direct rolesfor emotion indelusion formation and maintenance. Finally,the modelhighlightsthe interaction between psychotic processes,non- psychotic processes,and the environment; cognitiveinvestigation into how each affects the otherwillbe of great interest.

Acknowledgements Thiswork wassupporte dby aprogrammegrant from the We llcomeT rust.

References Abramson, L.Y.,Seligman, M .E.P.,&Teasdale,J. D.(1978).L earnedhe lplessnessin humans: Critiqueand reformulation. JournalofAbnormalPsychology,8 7 , 49–74. AmericanPsy chiatricA ssociation(1994). Diagnostica ndstatisticalmanualofmentaldisorders (4the d.).Washington, D C:American PsychiatricA ssociation. Argyle,N .(1990).P anicattac ks in chronicsc hizophrenia. BritishJournalofPs ychiatry,1 57 , 430–433. Bentall,R .P.(1994).C ognitivebiases and abnormalbeliefs: T owardsa modelof persecutory delusions.In A.S.D avid& J. Cutting(E ds.), Theneuropsychologyof schizophrenia (pp. 337– 360).L ondon: Erlbaum. Bentall,R .P.,& Kaney,S.(1989). C ontent specificproce ssingand persecutorydelusions: A n investigationusing the emotional Stroop test. BritishJournalofMedicalPsychology,6 2 , 355– 364. 344 DanielFreeman et al. Bentall,R .P.,& Kaney,S.(1996). A bnormalitiesof self-representationand persecutorydelusions: Atestof acognitivemodel of . PsychologicalMedicine,2 6 ,1231–1237. Bentall,R .P.,& Kinderman,P .(1998).Psychologicalproc essesand delusionalbe liefs: Implicationsfor the treatment of paranoid states.I nT.Wykes,N .Tarrier,& S.Lewis(E ds.), Outcomea nd innovationin psychologicaltreatmento fschizophrenia (pp. 119–144). Chichester:Wiley . Bentall,R .P.,& Kinderman,P .(1999).Self -regulation,affect and psychosis:T he roleof social cognitionin paranoiaand .In T.Dalgleish& M.Power(Eds.), Handbook ofcognition and emotion (pp. 353–382). C hichester:Wiley . Bentall,R .P.,K inderman,P., & Kaney,S.(1994). T he self,attributional proce ssesand abnormal beliefs:T owardsa model of persecutorydelusions. BehaviourR esearcha nd Therapy,3 2 , 331–341. Birchwood, M.(1995).E arlyinterve ntion in psychoticrelapse: cognitive approache sto detection and management.In G.Haddock &P. Slade(E ds.), Cognitivebeha viouralinterventionswith psychoticdis orders (pp. 171–211). L ondon: Routledge. Birchwood, M.,Iqbal,Z .,Chadwick, P.,& Trower,P .(2000).C ognitiveapproach to depression and suicidalthinking in psychosisI :Ontogeny of post-psychoticdepression. BritishJourna lof Psychiatry,1 77 , 516–521. Birchwood, M.,Macmillan,F .,&Smith,J. (1992).E arlyintervention. In M.Birchwood &N.Tarrier (Eds.), Innovationsin thepsycho logicalmanagementof s chizophrenia .(pp. 115–145). Chichester:Wiley . Birchwood, M.,Meaden,A .,Trower,P .,Gilbert,P., & Plaistow,J. (2000).T he power and omnipotence of voices:Subordination and entrapmentby voicesand significantothers. PsychologicalMedicine,3 0 , 337–344. Bleuler,E .(1911/1950). Dementiapra ecoxorthegro upofschizophrenias .(E.Zinkin, Trans.). NewYork: InternationalU niversitiesPress. Bowins, B.,&Shugar,G .(1998).D elusionsand self-esteem. CanadianJournalofPsychiatry,4 3 , 154–158. Buchanan, A.,Reed, A.,Wessely,S.,G arety,P.,Tay lor,P .,Grubin, D.,&Dunn, G.(1993).A cting on delusionsI I:T he phenomenological correlatesof actingon delusions. BritishJo urnalof Psychiatry,1 63 , 77–81. Bunney,W.E .,Hetrick, W.P .,Bunney,B.G.,Patterson,J. V.,Jin, Y.,Potkin, S.G.,&Sandman,C . A.(1999).Structured intervie wforasse ssingperc eptualanomalies (SIA PA). Schizophrenia Bulletin,2 5 , 577–592. Cameron,N .(1959).The paranoid pseudo-community revisited. AmericanJournalofSociology, 65, 52–58. Castle,D.J.,Phelan, M .,Wessely,S.,& Murray,R.M.(1994).Whic hpatientswith non-affective functionalpsy chosisare not admittedat first psy chiatriccontact? BritishJourna lof Psychiatry,1 65 , 101–106. Chadwick, P. D.J. &Birchwood, M.J. (1994).The omnipotenceof voices:A cognitiveapproach to hallucinations. BritishJournalofPsychiatry,1 64 , 190–201. Chadwick, P.D.J.,B irchwood, M.J.,& Trower,P .(1996). Cognitivethera pyfordelus ions, voicesa nd paranoia .Chichester:Wiley . Chadwick, P.D.J.,& Lowe,C .F.(1994).A cognitiveapproac hto measuringde lusions. Behaviour Researcha ndTherapy,3 2 , 355-367. Chapman, J. (1966).The earlysy mptoms of schizophrenia. BritishJourna lofPsychiatry,1 12 , 225–251. Clark,D .M.(1999).A nxietydisorders: Why they persistand how to treatthe m. Behaviour Researcha ndTherapy,3 7 , S5–S27. Clark,D .M.&Fairburn,C .G.(1997). Sciencea nd practiceof cognitive beha viourthera py . Oxford:O xford UniversityP ress. Coryell,W., & Tsuang,M .T. (1982).P rimaryunipolar depressionand theprognostic importance of delusions. Archivesof GeneralPsychiatry,3 9 ,1181–1184. Acognitivemodel of persecutorydelusions 345 Cosoff,S. J., & Hafner,R .J. (1998).The prevalenceof comorbid anxietyin schizophrenia, schizoaffectivedisorder and bipolardisorder. Australianand NewZea land Journalof Psychiatry,3 2 , 67–72. Cummings,J. L.(1992).P sychosisin neurologicdisease: N eurobiology and pathogenesis. Neuropsychiatry,N europsychologya nd BehaviouralNeurology,5 , 126–131. Cutting,J. (1987).T he phenomenology of acuteorganic psy chosis. BritishJourna lofPsychiatry, 151, 324–332. Cutting,J. (1997). Principlesofpsychop athology:T woworlds-two minds- twohemisp heres . Oxford:O xfordU niversityP ress. Docherty,J. P.,V an Kammen,D .P.,Siris, S. G .,&Marder,S. R .(1978).Stages of onsetof schizophrenicpsy chosis. AmericanJournalofPsychiatry,1 35 , 420–426. Ebel,H .,Gross,G .,Klosterkotter,J., & Huber,G .(1989).B asicsy mptoms in schizophrenicand affectivepsy choses. Psychopathology,2 2 , 224–232. Foulds, G.A.,&Bedford, A.(1975).H ierarchy of classesof personalillne ss. Psychological Medicine, 5, 181–192. Fowler,D .(2000).P sychologicalformulation of earlyepisodes of psychosis:a cognitivemodel. In M.Birchwood, D.Fowler,& C.Jackson (Eds.), Earlyintervention in psychosis:Aguideto concepts,evidencea nd interventions (pp. 101–127). C hichester:Wile y. Fowler,D .,Garety,P. A.,&Kuipers,L .(1995). Cognitivebeha viourthera pyfor ps ychosis: Theorya nd practice .Chichester:Wile y. Freedman, B.,&Chapman, L.J. (1973).E arlysubjec tiveexperienc ein schizophrenicepisodes. JournalofAbnormalPsychology,8 2 , 46–54. Freeman,D .(1998). Neurosisandpsychosis .UnpublishedPh.D.thesis,U niversityof London. Freeman,D .,&Garety,P. A.(1999).Worry ,worry processesand dimensions of delusions:A n exploratoryinve stigationof arolefor anxiety proce ssesin themaintenance of delusional distress. BehaviouralandCognitivePs ychotherapy,2 7 , 47–62. Freeman,D .,&Garety,P. A.(2000).C omments on theconte nt of persecutory delusions:D oesthe definitionneed clarification? BritishJourna lofClinicalPsychology,3 9 , 407–414. Freeman,D .,&Garety,P.A.(2002).C ognitivethe rapy foran individualwith along-standing persecutory delusion: Incorporatinge motional processesinto amulti-factorialperspe ctiveon delusionalbe liefs.In T.Morrison(E d.), Fromtheoryto pra ctice:A casebookof cognitive therapyforps ychosis (pp. 173–196). Wiley :Chichester. Freeman,D .&Garety,P.A.(inpress). C onnectingneurosis and psychosis:T he directinfluenc eof emotion on delusionsand hallucinations. Behaviour,R esearch& Therapy . Freeman,D .,Garety,P.A.,&Kuipers,E .(2001).P ersecutory delusions:D eveloping the understandingof beliefmainte nanceand emotional distress. PsychologicalMedicine 31, 1293–1306. Freeman,D .,Garety,P.A.,&Phillips,M .L.(2000).A nexaminationof hypervigilancefor ex ternal threatin individualswith generalisedanx iety disorderand individualswith persecutory delusionsusing visual scan paths. QuarterlyJourna lofExperimentalPsychology,5 3A , 549– 567. Freeman,D .,Garety,P.,F owler,D .,Kuipers,E .,Dunn, G.,Bebbington, P.,&Hadley,C.(1998). The London–E astA ngliarandomised c ontrolled trialof cognitivebehaviour therapy for psychosisI V:Self-esteemand persecutory delusions. BritishJournalofClinicalPsychology, 37, 415–430. Frith,C .D.(1992). The cognitiveneurops ychologyof schizophrenia . Hove: LEA. Garety,P.A.,Fowler,D .,Kuipers,E .,Freeman,D .,Dunn, G.,Bebbington, P. E.,Hadley,C.,& Jones, S.(1997). T he London–E astA ngliarandomise dcontrolledtrial of cognitivebe haviour therapyfor psy chosisII :Predictorsof outcome. BritishJourna lofPsychiatry,1 71 , 420–426. Garety,P. A.,&Freeman,D .(1999).C ognitiveapproaches to delusions:A criticalre viewof theoriesand evidence. BritishJournalofClinicalPsychology,3 8 , 113–154. Garety,P.A.,&Hemsley,D.R.(1994). Delusions:I nvestigationsinto the psycholo gyof delusionalreasoning .Oxford:O xford UniversityPress. 346 DanielFreeman et al. Garety,P.A.,Hemsley,D.R.,&Wessely,S.(1991). R easoningin deluded schizophrenicand paranoid patients:B iasesin performanceon aprobabilisticinference task. JournalofNervous andMentalDisorder,179 , 194–201. Garety,P. A.,Kuipers,E .,Fowler,D .,Freeman,D .,&Bebbington, P.E.(2001).A cognitivemode l of thepositive sy mptoms of psychosis. PsychologicalMedicine,3 1 , 189–195. Hemsley,D.R.(1987).A nexperimentalpsy chologicalmodel forschizophre nia.I nH.Hafner,W. F.Gattaz,& W.Janzarik (E ds.), Searchfor the ca usesof s chizophrenia (pp. 179–188). Heidelberg:Springer. House,A.,Bostock,J., & Cooper, J. (1987).D epressivesy ndromes in they earfollowingonset of a firstschizophrenic illness. BritishJo urnalofPsychiatry,1 51 , 773–779. Jones,P .,Rodgers,B .,Murray,R.,&Marmot,M .(1994).C hild developmentalrisk factors for adult schizophreniain theB ritish1946 birth cohort. Lancet, 344,1398–1402. Kinderman,P. (1994).A ttentionalbias, persecutory de lusionsand theself -concept. British JournalofMedicalPsychology,6 7 , 53–66. Kinderman,P .,&Bentall,R .P. (1997).C ausalattributions in paranoiaand depression:I nternal, personaland situationalattributions for negative events. JournalofA bnormalPsychology, 106, 341–345. Kingdon, D.G.,&Turkington, D.(1994). Cognitivebeha viourthera pyofschizophrenia . Hove: Erlbaum. Koreen,A .R.,Siris,S. G .,Chakos, M.,Alvir,J., M ayerhoff,D .,&Lieberman,J. (1993).D epression in first-episodesc hizophrenia. AmericanJournalofPsychiatry,1 50 ,1643–1648. Krabbendam, L.,Janssen,I .,Bijl,R .V.,Vollebergh,W. A .M.,&vanO s,J. (2002).N euroticismand low self-esteemasrisk factors for psy chosis. SocialPsychiatrya ndPsychiatricE pidemiology, 37, 1–6. Lyon, H.M.,Kaney,S.,& Bentall,R .P.(1994).T he defensivefunction of persecutorydelusions: Evidencefromattribution tasks. BritishJo urnalofPsychiatry,1 64 , 637–646. Maher,B .A.(1988).A nomalous experienceand delusionalthinking: The logicof explanations.I n T.F.Oltmanns& B.A.Maher(Eds.), DelusionalBeliefs (pp. 15–33). N ewYork: Wiley. Manschreck,T .C.&Petri,M .(1978).T he paranoid syndrome. Lancet, 2, 251–253. Mathews,A .(1990).Why worry?The cognitivefunction of anxiety. BehaviourR esearcha nd Therapy, 28, 455–468. McGhie,A .,&Chapman, J. (1961).D isordersof attentionand perceptionin earlyschizophrenia. BritishJournalofMedicalPsychology,3 4 , 103–116. Melges,F .T.,& Freeman,A .M.(1975).Perse cutory delusions:a cyberneticmode l. American JournalofPsychiatry,1 32 ,1038–1044. Moorey,H.,&Soni,S. D .(1994).A nxietysy mptoms in stablechronic schizophre nics. Journal of MentalHealth,3 , 257–262. Morrison,A .P. (1998).C ognitivebe haviourtherapy for psy choticsy mptoms in schizophrenia.I n N.Tarrier,A .Wells,& G.Haddock(Eds.), Treatingco mplexca ses:Thecognitivebeha vioural therapyapproach (pp. 195–216). Wiley :Chichester. Mueser,K .T.,Goodman, L.B.,Trumbetta,S. L .,Rosenberg,S. D .,Osher,F .C.,Vidaver,R ., Auciello,P., & Foy,D.W.(1998). T raumaand posttraumaticstre ssdisorder in severemental illness. JournalofConsultingand ClinicalPsychology,6 6 , 493–499. Norman,R .M.,&Malla,A .K.(1994).C orrelationsover time betwe en dysphoricmood and symptomatology in schizophrenia. ComprehensivePs ychiatry,3 5 , 34–38. Norman,R .M.G.,Malla,A .K.,Cortese,L .,&Diaz,F .(1998).A spectsof dysphoriaand symptoms of schizophrenia. PsychologicalMedicine,2 8 ,1433–1441. Read,J., & Argyle,N .(1999).H allucinations,delusions, and thought disorderamong adult psychiatricinpatie ntswith ahistoryof childabuse . PsychiatricServices, 5 0 ,1467–1472. Salkovskis,P .M.(1991).T he importanceof behaviourin themainte nanceof anxiety and panic:A cognitiveac count. BehaviouralPsychotherapy,1 9 , 6–19. Salkovskis,P .M.(1996).T he cognitiveapproac hto anxiety:Threatbelie fs,safety -seeking Acognitivemodel of persecutorydelusions 347 behaviours,and thespe cialcase of healthanxiety and obsessions.In P.M.Salkvoskis(E d.), Frontierso fcognitivethera py (pp. 48–74). N ewYork: Guilford Press. Teasdale,J. D.(1988).C ognitivevulnerability to persistentdepression. Cognitiona ndEmotion, 2, 247–274. Tien,A .Y.,&Eaton,W. W. (1992). P sychopathologicprecursors and sociodemographicrisk factorsfor the schizophrenia sy ndrome. Archivesof GeneralPsychiatry,4 9 , 37–46. Trimble,M.R.(1992).The schizophrenia-likepsychosis of epilepsy. Neuropsychiatry, Neuropsychologya ndBehaviouralNeurology,5 , 103–107. Trower,P., & Chadwick, P. (1995).Pathway sto defenseof theself: A theory of two typesof paranoia. ClinicalPsychology:Science a ndPractice,2 , 263–278. Turnbull, G.,&Bebbington, P.(2001).A nxiety and thesc hizophrenicprocess: C linicaland epidemiologicale vidence. SocialPsychiatrya ndPsychiatricE pidemiology,3 6 , 235–243. Wahl,O .F.(1999).M entalhe althconsumers’ ex perienceof stigma. SchizophreniaBulletin, 2 5 , 467–478. Wells,A .(1994).A multi-dimensionalme asureof worry:Developmentand preliminaryvalidation of theanx ious thoughts inventory. Anxiety,Stres sand Coping,6 , 289–299. Wessely,S.,B uchanan, A.,Reed,A .,Cutting,J., E veritt,B .,Garety,P.,&Taylor,P. J. (1993).A cting on delusions(1): P revalence. BritishJournalofPsychiatry,1 63 , 69–76. World HealthO rganization(1973). The InternationalPilotStudyof Schizo phrenia . Geneva: World HealthO rganization. Yung, A.R.&McGorry,P. D.(1996).T he prodromal phaseof first-episode psychosis:Past and currentconce ptualizations. SchizophreniaBulletin, 2 2 , 353–370.

Received27 October 2000; revised version received12 October 2001