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A Cognitive Model of Persecutory Delusions

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A Cognitive Model of Persecutory Delusions 331 BritishJournal of Clinical Psychology (2002), 41, 331– 347 2002The BritishPsychological Society www.bps.org.uk Acognitivemodel of persecutory delusions 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, GKT Medical 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 delusion 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 psychosis.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 developedwith 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 delusions isbe 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 delusions has 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 delusions reflectan 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. Inanumberof 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 explicit self-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 delusions arenot 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 persecution 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
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