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Negative Cognitions About the Self in Patients with Persecutory Psychiatry Research 239 (2016) 79–84 Contents lists available at ScienceDirect Psychiatry Research journal homepage: www.elsevier.com/locate/psychres Negative cognitions about the self in patients with persecutory delusions: An empirical study of self-compassion, self-stigma, schematic beliefs, self-esteem, fear of madness, and suicidal ideation Nicola Collett a,n, Katherine Pugh b, Felicity Waite b, Daniel Freeman b a The Oxford Institute of Clinical Psychology Training, University of Oxford, Isis Education Centre, Roosevelt Drive, Warneford Hospital, Oxford, OX3 7JX, UK b Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK article info abstract Article history: There has been growing awareness of the high prevalence of negative cognitions about the self in pa- Received 21 April 2015 tients with persecutory delusions, and it has been proposed that paranoid fears build upon these per- Received in revised form ceived vulnerabilities. This study aimed to investigate for the first time a wide range of different con- 25 January 2016 ceptualisations of the negative self, and to examine associations with suicidal ideation, in patients with Accepted 17 February 2016 persecutory delusions. Twenty-one patients with persecutory delusions and twenty-one non-clinical Available online 18 February 2016 individuals completed measures relating to negative self cognitions. The delusions group also completed Keywords: a measure of suicidal ideation. It was found that the patients with persecutory delusions had low self- Psychosis compassion, low self-esteem, increased fears of being mad, beliefs of inferiority to others, negative self- Schizophrenia schemas, and low positive self-schemas when compared to the non-clinical control group. The effect Suicidal ideation sizes (Cohen's d) were large, and the different conceptualisations of negative self cognitions were highly Negative self-concept Self-compassion associated with one another. Self-stigma did not differ between the two groups. Furthermore, suicidal Self-esteem ideation was highly associated with low self-compassion, low self-esteem, fears of madness, and negative self-schema but not self-stigma. This study shows marked negative self cognitions in patients with persecutory delusions. These are likely to prove targets of clinical interventions, with patient preference most likely determining the best conceptualisation of negative self cognitions for clinicians to use. & 2016 Elsevier Ireland Ltd. All rights reserved. 1. Introduction five concepts together in patients with persecutory delusions: 1). self-compassion, 2). schema, 3). self-stigma, 4). fears of madness Three recent literature reviews have all confirmed a connection and 5). self-esteem. Further, we examine their links to the clini- of paranoia to negative cognitions about the self (Garety and cally important problem of suicidal ideation in patients with Freeman, 2013; Kesting and Lincoln, 2013; Tiernan et al., 2014). It psychosis. has been hypothesised that paranoia builds upon the sense of vulnerability that low self-worth triggers (Freeman et al., 2005). 1.1. Five conceptualisations of negative self cognitions Consistent with this, a longitudinal study with 301 patients with fi psychosis indicated that negative self beliefs predict the later se- Self-compassion has been de ned by Neff (2003a) as com- verity of persecutory delusions (Fowler et al., 2012). Furthermore, prising three components: self-kindness versus self-judgement in two experimental studies by our group show that in individuals our responses to pain or failure, common humanity versus isola- tion when understanding one's own suffering, and being mindful with paranoid ideation the induction of negative self cognitions versus over-identification when paying attention to our own suf- leads to an increase in paranoia (Freeman et al., 2014a; Atherton fering (Neff, 2003a). Self-compassion involves an open, non-jud- et al., 2016). This has led to a clinical test of targeting negative self gemental stance to our own pain and suffering, which is viewed as beliefs in patients with persecutory delusions (Freeman et al., part of the human condition and promotes self-kindness (Neff, 2014b). Although there are multiple ways that negative self cog- 2003b). Two recent meta-analyses have found that self-compas- nitions can be conceptualised, studies have mainly focussed upon sion is an important explanatory variable in understanding psy- negative self beliefs and low self-esteem. In this paper we examine chopathology and wellbeing (MacBeth and Gumley, 2012; Zessin et al., 2015). n Corresponding author. Eicher et al. (2013) found in a study of 88 participants with E-mail address: [email protected] (N. Collett). either schizophrenia or schizoaffective disorder that higher scores http://dx.doi.org/10.1016/j.psychres.2016.02.043 0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved. 80 N. Collett et al. / Psychiatry Research 239 (2016) 79–84 Table 1 Means, standard deviations, and ranges for the clinical group on the symptom measures. Measure Mean SD Range Psychotic Symptoms Rating Scale (PSYRATS) 16.86 3.14 9–22 Persecution and Deservedness Scale (PaDS) 76.62 19.03 17.5–100 Positive and Negative Syndrome Scale- PANSS (positive scale) 20.38 3.78 14–29 Positive and Negative Syndrome Scale- PANSS (negative scale) 14.95 6.03 8–29 Positive and Negative Syndrome Scale- PANSS (Total Score) 75.29 13.46 52–100 Beck Depression Inventory (BDI) 22.81 11.43 0–44 Beck Scale for Suicidal Ideation 12.76 9.51 0–34 on the self-compassion scale were negatively associated with po- unable to tell the difference between reality and imagination, sitive symptoms of psychosis. Qualitative accounts from patients worrying that the mind is falling apart, and a fear of being locked with psychosis highlight the potential role of self-compassion in up forever. Fear of recurrence of psychosis is a predictor of the facilitating recovery in psychosis (Waite et al., 2015). Current re- development of psychosis-related post-traumatic stress disorder search studies have found positive outcomes for compassion fo- (White and Gumley, 2009). Gumley et al. (2015) found that fear of cussed therapy for psychosis (Mayhew and Gilbert, 2008; Braehler recurrence of psychosis was associated with increased risk of re- et al., 2013). However, these studies have not focussed on reducing lapse and increased emotional distress, suggesting that in- symptoms of psychosis, and they do not focus specifically on dividual’s idiosyncratic appraisals may influence relapse. persecutory delusions. Mills et al. (2007) found in a study of 131 Finally, self-esteem has been considered as a central factor in students that paranoia was significantly negatively correlated with the occurrence of persecutory delusions, with differing views on scores on the self-compassion sc (Neff, 2003a), indicating in par- whether paranoia reflects a defence against low self-esteem ticular the presence of self-judgement, isolation, and over-identi- (Bentall et al., 2001) or is a direct reflection of low self-esteem fication in those with higher paranoia scores. Hutton et al. (2013) (Freeman et al., 2002). Multiple studies, but not all, demonstrate found that a group of 15 patients with persecutory delusions were that low self-esteem is present in patients with persecutory de- significantly less likely to self-reassure compared to non-clinical lusions (e.g. Combs et al., 2009; Freeman et al., 1998). For instance, controls. These authors propose that a decreased capacity to self- in a study of 154 participants who ranged across the continuum of reassure may activate perceptions of threat. Lincoln et al. (2013) paranoia, paranoia was found to be associated with lower self- found in an experimental study that a brief compassion focused esteem, and fluctuations in self-esteem were predictive of para- manipulation decreased paranoid thoughts in a non-clinical po- noia (Thewissen et al., 2008). Findings from studies on self-esteem pulation. However, no studies have yet specifically explored levels interventions for people with psychosis have demonstrated im- of self-compassion in a clinical group of people with persecutory provements in positive symptoms (Lecomte et al., 1999; Hall and delusions, although specific elements have been examined in one Tarrier, 2003) which may also lend support for a connection be- study (Hutton et al., 2013). tween self-esteem and positive symptoms of psychosis. Negative self-schema, defined as stable negative self evalua- tions which influence the individual’s interpretation of situations 1.2. Persecutory delusions and suicide (Beck et al., 1979), is a concept well-established in depression re- search (Beck, 1967). In contrast to self-compassion, their potential It is estimated that approximately 5% of patients with psychosis role in paranoia has been tested in cross-sectional (e.g. Gracie commit suicide (Hor and Taylor, 2010). Paranoid ideation in the et al., 2007; Smith et al., 2006), longitudinal (e.g. Fowler et al., general population too is associated with suicidal ideation (Free- 2011; Oliver et al., 2012; Freeman et al., 2013b) and experimental man et al., 2011). To our knowledge there are no psychological studies (e.g. Freeman et al., 2008), using the Brief Core Schema studies of specific psychological constructs that are associated Scale (Fowler et al., 2006). In a recent pilot randomised controlled with suicide specifically in patients with persecutory delusions. trial with patients with persecutory
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