Review 31 (2011) 684–696

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Clinical Psychology Review

Grandiose : A review and theoretical integration of cognitive and affective perspectives

Rebecca Knowles ⁎, Simon McCarthy-Jones, Georgina Rowse

University of Sheffield, UK article info abstract

Article history: (GDs) are found across a wide range of psychiatric conditions, including in around two- Received 24 August 2010 thirds of patients diagnosed with , half of patients diagnosed with , as well as in Accepted 23 February 2011 a substantial proportion of patients with disorders. In addition, over 10% of the healthy Available online 5 March 2011 general population experience grandiose thoughts that do not meet full delusional criteria. Yet in contrast to other psychotic phenomena, such as auditory and persecutory delusions, GDs have received Keywords: little attention from researchers. This paper offers a comprehensive examination of the existing cognitive and Grandiose ‘ ’ Grandeur affective literature on GDs, including consideration of the evidence in support of -as-defence and ’ Delusion emotion-consistent models. We then propose a tentative model of GDs informed by a synthesis of the Bipolar available evidence designed to be a stimulus to future research in this area. As GDs are considered to be relatively resistant to traditional cognitive behavioural techniques, we then discuss the implications of our Schizophrenia model for how CBT may be modified to address these beliefs. Directions for future research are also highlighted. © 2011 Elsevier Ltd. All rights reserved.

Contents

1. Introduction ...... 685 2. What are grandiose delusions? ...... 685 3. The epidemiology of grandiose delusions and beliefs ...... 685 3.1. Prevalence of clinically relevant grandiose delusions ...... 685 3.2. Demographic variables, culture and grandiose delusions ...... 686 3.4. Prevalence of grandiose delusion-like beliefs...... 686 3.5. Diagnostic specificity of grandiose delusions ...... 687 4. Grandiose delusions, persecutory delusions and ...... 687 5. Affect and grandiose delusions ...... 687 5.1. Affect in “delusion as defence” models of GDs ...... 688 5.2. Affect in emotion-consistent models of grandiose delusions ...... 688 6. Anomalous experiences, their appraisal, and GDs ...... 689 7. Cognitive styles and grandiose delusions ...... 690 7.1. Jumping to conclusions bias ...... 690 7.2. Attributional style ...... 690 7.3. Modality of thought ...... 690 7.4. Thinking about thinking ...... 691 8. The dynamic nature of grandiose delusions ...... 691 9. Developing a model of grandiose delusions ...... 691 10. Implications for treatment ...... 693 11. Future research...... 693 References ...... 694

⁎ Corresponding author at: Clinical Psychology Unit, Sheffield University, Western Bank, Sheffield S10 2TN, UK. Tel.: +44 114 2226577; fax: +44 114 2226610. E-mail address: r.knowles@sheffield.ac.uk (R. Knowles).

0272-7358/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2011.02.009 R. Knowles et al. / Clinical Psychology Review 31 (2011) 684–696 685

1. Introduction Table 1 Examples of grandiose delusions.

Recent approaches to have shifted away from a Example Source diagnostically driven approach towards a focus on transdiagnostic efforts “I was spitting on a light bulb, thinking if I watched the Goodwin and Jamison to understand individual symptoms and processes (Bentall, 2006). saliva burn, the different colours and shapes, I could find (1990, p. 26) Dedicated cognitive models have been developed for many of the the key to the cure to cancer” experiences typically associated with psychosis, such as auditory “I would write books on psychiatric theory… on theology. I Goodwin and Jamison hallucinations (e.g., Beck & Rector, 2005; Bentall, 1990; Horowitz, would write novels. I had the libretto of an opera in (1990, p. 29) mind. Nothing was beyond me… The major work which 1975) and persecutory delusions (e.g., Bentall, Corcoran, Howard, would be based on this material would be accurate, Blackwood, & Kinderman, 2001; Freeman, Garety, Kuipers, Fowler, & provocative, and of profound significance.” Bebbington, 2002), including integrative frameworks that seek to account I can communicate and have a special relationship with Smith et al. (2005) for the positive symptoms of psychosis together (e.g., Garety, Kuipers, God. I am also the cousin of Tony Blair and I can fly. I am a special athlete and I run a national charity. Smith et al. (2005) Fowler, Freeman & Bebbington, 2001; Morrison, 2001). Grandiose I am God; I created the universe and I am son of Prince Smith et al. (2005) delusions (GDs), by contrast, have received relatively little theoretical Phillip. I am also a famous DJ. I have superman-type or empirical attention. Indeed, one of the few recent studies to have powers. addressed these experiences directly concluded that “much remains to be I have special luck and have won the lottery four times and Smith et al. (2005) determined in understanding the formation and maintenance of am owed £126 million. “ ” ” I am Roger Taylor from the rock group Queen . Smith et al. (2005) grandiose delusions (Smith, Freeman, & Kuipers, 2005, p. 486). I am the gang leader of drug dealers in Los Angeles. I have Smith et al. (2005) Achieving a better understanding of the onset and maintenance of great wealth. GDs is likely to be beneficial for a number of reasons. Models of Believed he possessed the recording of a song he had Lake (2008) persecutory delusions have informed the development of focused composed and performed that was “worth millions of cognitive behavioural interventions (Freeman & Garety, 2006), and dollars. Belief he had developed a “Star Wars” intercontinental Lake (2008) similarly tailored interventions for GDs are likely to be useful. It has ballistic missile interceptor system, and had tried to also been suggested that GDs may play a role in the development of phone Ronald Reagan to tell him. persecutory delusions (Lake, 2008) and a better understanding of GDs may thus contribute to the development of more effective interven- tions for persecutory delusions. The present paper aims to review the less likely to motivate individuals to act than other types of delusions. existing literature on the psychological mechanisms underpinning This finding is somewhat counterintuitive in the light of clinical GDs and to propose an integrated conceptualization of this phenom- observations of patients engaging in risky and impulsive behaviour enon that is amenable to empirical testing. In particular, we aim to fuelled by grandiose delusional beliefs. Appelbaum et al.'s (1999) summarise epidemiological findings, to evaluate the evidence for finding may be a measurement artefact, since the ‘action’ dimension delusion-as-defense and emotion-consistent accounts, and to consid- of the MacArthur-Maudsley Delusions Assessment Schedule is biased er the role of cognitive biases in the development and maintenance of towards the assessment of aggressive acts, meaning that respondents GDs. The present review is hence restricted to a consideration of would achieve low scores for not acting on their beliefs in an cognitive and affective factors. Whilst there is a clear need for a review aggressive or violent manner regardless of other behavioural con- of genetic, neurobiological and neurocognitive perspectives on GDs, sequences. Because of their nature and content, we would not expect this is beyond the scope of the present review. the behaviours motivated by GDs to be of an aggressive or violent This review is informed by a systematic search of MEDLINE (1950– nature, and so this assessment tool may be inadequate for the purposes May 2010), PsychInfo (1967–2010) and Scopus (1823–May 2010) of establishing links between GDs and any associated behaviour. databases for peer-reviewed articles on grandiose delusions published in English. The search string employed was “(grandeur* OR grandi*) 3. The epidemiology of grandiose delusions and beliefs AND (delus* OR belief)”. Each result was examined first by inspection of the title, and then, as required, the abstract and the full text. Studies 3.1. Prevalence of clinically relevant grandiose delusions were excluded if they focused exclusively on in the context of personality disorders (e.g., Narcissistic ). The GDs are among the most commonly encountered delusional beliefs. reference sections and citation reports of papers identified by this In a study of 1,136 consecutively admitted psychiatric patients, search were examined to identify further relevant papers. The Appelbaum et al. (1999) found that 43% of the 328 patients who criterion for the inclusion of studies for the purposes of prevalence presented with delusional beliefs reported GDs. Only persecutory estimates of GDs was a sample size in excess of 50 participants, and for delusions (78%) and delusions of body/mind control (60%) were more studies of psychiatric patients, that they be published after the commonly observed. Table 2 lists the studies that have reported on the publication of DSM-III-R in 1994 in order to achieve some measure prevalence of GDs in large (NN50) psychiatric samples since the of diagnostic comparability. publication of DSM-III-R in 1994. Clear prevalence estimates are hard to establish since a wide range of self-report and clinician-rated 2. What are grandiose delusions? instruments with differing thresholds and cut-offs have been employed. Prevalence comparisons are also made harder by the use GDs are defined as false beliefs about having inflated worth, of both lifetime prevalence and point prevalence figures (usually at power, knowledge or a special identity which are firmly sustained hospital admission), with some studies failing to report which of these despite undeniable evidence to the contrary (APA, 2000). Some two methods was used. examples are given in Table 1. GDs, like other delusional beliefs, are The issue of whether patients are able to reliably report on their multidimensional (Garety & Hemsley, 1994), varying with regard to own delusional beliefs is a further consideration. The absence of an the degree of conviction and preoccupation, and the levels of distress objective marker of delusional beliefs means that we are reliant on and dysfunction caused. GDs (alongside religious delusions) seem to patients' descriptions and clinicians' interpretations of these phe- be held with the greatest conviction and tend to be associated with nomena, and a recent article by Lincoln, Ziegler, Lüllmann, Müller, and less negative affect than other delusions (Appelbaum, Robbins, & Rief (2010) suggests that patients with schizophrenia spectrum Roth, 1999). However, an apparent paradox given this increased disorders are reliably able to provide information about the presence degree of conviction is Appelbaum and colleagues' report that GDs are and type of their delusional beliefs. 686 R. Knowles et al. / Clinical Psychology Review 31 (2011) 684–696

Table 2 Prevalence of clinically relevant grandiose delusions (studies published post 1994, NN50).

Diagnosis Study Sample Diagnostic tool Delusion categorisation

Bipolar 59% Appelbaum et al. (1999) 73 adults DSM-III-R DSM-III-R: Point prevalence 55% Geller, Williams, Zimerman, Frazier, 60 children DSM-IV WASH-U-KSADS: Unspecified Beringer and Warner (1998) (7–16 yrs) 9% Baethge et al. (2005) 549 adults ICD-10 AMDP: Point prevalence 68% Tillman, Geller, Klages, Corrigan, 257 children, DSM-IV WASH-U-KSADS: Lifetime prevalence Bolhofner and Zimerman, 2008 (6–16 yrs) 62% Canuso, Bossie, Zhu, Youssef and 515 adult patients DSM-IV PANSS score≥4 at time of study Dunner (2008) 88% Conus, Abdel-Baki, Harrigan, 87 adult patients DSM-III-R RPMIP: point prevalence Lambert and McGorry (2004) 47% Goodwin and Jamison (1990)* 3801 manic patients various various Schizophrenia 49% Appelbaum et al. (1999) 138 patients DSM-IV DSM-III-R: Point prevalence 9% Breier and Berg (1999) 1665 patients DSM-IV PANSS score≥5 at time of study 40% Azhar, Varma and Hakim (1995) 270 patients ICD-9 Present State Examination: unspecified Depression 21% Appelbaum et al. (1999) 56 patients DSM-III-R DSM-III-R: Point prevalence Alcohol or drug 30% Appelbaum et al. (1999) 30 patients DSM-III-R DSM-III-R: Point prevalence disorders Alzheimer's N1% Hirono, Mori, Yasuda, Ikejiri, Imamura, 228 patients DSM-IV DSM-IV: Point prevalence Shimomura et al. (1998) 6% Migliorelli, Petraccam, Tesón, Sabe, 103 patients DSM-III-R DSM-III-R: Point prevalence Leiguarda and Starkstein (1995)

Note: * This study was a review of 26 studies (published between 1922 and 1989) studies of manic patients, and is just included for reference as it is hard to make direct comparison with present studies due to the range of diagnostic criteria and assessment tools these studies would have used.

In the only study to have examined the transdiagnostic prevalence So GDs are evident across cultures, but there appears to be some cross- of GDs, Appelbaum et al. (1999) found that they were more frequent cultural variation in the specificpresentation(Suhail & Cochrane, 2002). in bipolar disorder (59%) than in schizophrenia (49%), substance Several studies have compared GDs between European and Asian misuse disorders (30%) or depression (21%), although the statistical patients. Stompe, Bauer, Karakula, Rudaleviciene, Okribelashvili, status of these differences was not reported. Consistent with this Chaudhry et al. (2007) reported significantly higher frequencies of GDs pattern, an earlier study by Junginger, Barker, and Coe (1992) found in patients with schizophrenia in Austria than in Pakistan, and they also significantly fewer patients with schizophrenia (19%) than with found that delusional grandiosity with a religious theme was especially affective disorders (37%) presenting with GDs, although the failure to rare in Pakistan (2007). In contrast, when Suhail (2003) compared the apply a Bonferroni correction to the correlational analysis may have delusional beliefs of three groups of patients diagnosed with schizo- yielded a false positive result. The findings of the other studies in phrenia – a White British group living in Britain, a group of Pakistani Table 2 are broadly in line with Appelbaum et al. (1999), with people living in Britain, and a third group of Pakistani people resident in approximately two-thirds of patients with a diagnosis of bipolar Pakistan – they found that the groups did not differ in the frequencies of disorder and around half of patients with a diagnosis of schizophrenia GDs. In fact, in this study, Pakistani people living in Pakistan were more reporting GDs. Two studies, however, report much lower prevalence likely to have a delusion about being a star/hero/famous person (32%) rates. Baethge, Baldessarini, Freudenthal, Streeruwitz, Bauer and compared to the other cultural/ethnic groups (b 10%). The authors Bschor (2005) observed GDs in just 9% of patients diagnosed with speculate that the large socio-economic disparities in Pakistan and the bipolar disorder, perhaps due to the use of point prevalence in a study difficulty in achieving upward social mobility may fuel delusional beliefs in which only 26% of patients presented with any form of delusion. about self-worth and achievements — a sort of self-defensive strategy. Breier and Berg (1999) also found a GD prevalence of only 9% in a There are also variations in the occurrence of GDs between ethnic schizophrenia sample, which appears to result from the conservative groups living in the same country. Yamada et al. (2006) studied patients diagnostic criteria employed. with psychotic disorders in the USA and found a greater prevalence of grandiose content in the delusions of European-American patients 3.2. Demographic variables, culture and grandiose delusions (45%) compared to African-American (35%) and Latino (25%) patients. Yamada and colleagues attempted to explain this pattern of findings as There is some preliminary evidence of a relationship between age being due to the “individualistic orientation associated with an of onset of bipolar disorder and the occurrence of GDs. Carlson, Bromet, emphasis on uniqueness often associated with the Euro-American and Sievers (2000) identified GDs in 74% of patients with early-onset culture”, whereas grandiosity might be “culturally dystonic with the (b21 years) bipolar disorder, but in just 40% of those who were aged socio-centric values of the Latino culture” (p. 165). It therefore appears 30 years or over at the time of their first episode, representing a that cultural factors may influence the prevalence and manifestation of statistically significant difference. There is no evidence that rates of GDs, although precise causal mechanisms are unclear. GDs differ between men and women (de Portugal, González, Haro, Usall, & Cervilla, 2010), although it is interesting to note that the 3.4. Prevalence of grandiose delusion-like beliefs particular content of GDs may vary according to gender (Rudalevičienė, Stompe, Narbekovas, Raškauskienė, & Bunevičius, 2008). Grandiose beliefs which fail to meet full delusional criteria are found In a study of over 1000 individuals with a diagnosis of schizophrenia in the general population. Indeed, as is the case for several other from socioculturally diverse countries, grandiosity was found to be the psychotic phenomena (e.g., Johns & van Os, 2001), grandiose ideation second most common delusional theme behind persecutory delusions appears to exist on a continuum ranging from full-blown delusions (Stompe, Karakula, Rudalevičiene, Okribelashvili, Chaudhry, Idemudia et (held with conviction, resistant to change and causing significant social al., 2006). Stompe and colleagues also found that the prevalence of GDs and occupational impairment) to more transient grandiose thoughts at had remained broadly similar (38–44%) in Austrian patients over the the other end of the spectrum. The most commonly used tool to assess past 145 years despite the extensive societal changes during this period. the presence of grandiose beliefs is the short-form version of the Peters R. Knowles et al. / Clinical Psychology Review 31 (2011) 684–696 687

Delusion Inventory (PDI-21: Peters, Joseph, Day, & Garety, 2004). Scores domains” (Rhodes, Jakes, & Robinson, 2005, p.383) and GDs appear on these items from non-clinical populations are shown in Table 3. unlikely to exist in a pure and isolated form. They tend to occur most It can be seen from Table 3 that rates of endorsement of grandiose frequently alongside persecutory delusions (PDs), although large- beliefs are higher in student samples than in the general population. scale studies are lacking. Raune, Bebbington, Dunn, and Kuipers Given that general population samples have a significantly higher mean (2006) found that of 39 psychiatric patients who presented with age than student samples, this difference may be explained by the delusions, 54% reported PDs only, 10% reported GDs in , and finding of Verdoux, van Os, Maurice-Tison, Gay, Salamon and Bourgeois 33% reported having both PDs and GDs. Another recent study found (1998) who reported a negative correlation between age and scores on that of 14 patients diagnosed with non-affective psychosis, 68% had the grandiose subscale of the PDI-21. This would also be consistent with just PDs, 16% had just GDs, and 16% had both PDs and GDs (Jolley, Carlson et al.'s (2000) finding of a greater prevalence of GDs in early- Garety, Bebbington, Dunn, Freeman, Kuipers et al., 2006). The high onset bipolar disorder. This pattern may be driven by the feelings of comorbidity between GDs and persecutory delusions might lead to uniqueness and indestructibility (Elkind, 1967)thathavebeenfoundto the assumption that GDs in patients with schizophrenia diagnoses are peak in adolescence (Enright, Shukla, & Lapsley, 1980). -incongruent (see Section 4). Lake (2008) suggests that the potential of a GD to contribute to the development of persecutory 3.5. Diagnostic specificity of grandiose delusions ideation and thus to low mood may disguise the fact that it was originally associated with positive affect. He argues that the strength of There have been no direct attempts to establish whether GDs in people's beliefs in their extraordinary possessions, powers or talents as bipolar disorder and schizophrenia share a common aetiology and reflected in typical GDs, in conjunction with the broader effects of other phenomenology. One factor that may distinguish between GDs in the unusual attentional and reasoning processes, means that individuals psychotic and in the affective disorders is the widely-held but poorly- worry that others will wish them ill or try to steal their ‘gifts’ from them, evidenced assumption that GDs are mood-incongruent in the former, which then leads to the development of persecutory ideation. Such an and mood-congruent in the latter. If true, this could be taken to account is consistent with the co-occurrence of GDs with both suggest that GDs occurring in patients diagnosed with bipolar persecutory delusions and depression and highlights the need for disorder and schizophrenia, respectively, may have different phe- longitudinal studies of the course and emergence of delusional beliefs. nomenologies, aetiologies, and affective/cognitive/behavioural ante- In the absence of larger-scale clinical studies, information about the cedents, and thus require separate maintenance models. Junginger relationship between GDs and PDs can be obtained from analogue and et al. (1992) reported a strong positive correlation between mood and factor analytic studies. Fowler, Freeman, Smith, Kuipers, Bashforth, the presence of GDs in a mixed sample of psychiatric patients with Coker et al. (2006) found that levels of grandiose beliefs were predicted manic mood states being associated with GDs. However, the authors by levels of in a non-clinical student sample. However, this did not specify whether this correlation was significant in both patient correlational study was unable to establish whether this reflected an groups or just those with affective disorder diagnoses. individual's tendency to experience delusion-like thoughts per se, or Current psychiatric nomenclature retains Kraepelin's original dis- whether there was a causal relationship between the two types of tinction between the diagnostic categories of schizophrenia and bipolar beliefs. Several factor analytic studies also show an association between disorder (APA, 2000), but the clinical reality suggests that there is PDs and GDs. Bedford & Deary's (2006) analysis of 713 participants' extensive symptomatic overlap and comorbidity between the two delusional symptoms found that grandiosity formed a distinct factor presentations (e.g., Laursen, Agerbo, & Pedersen, 2009) which means which correlated significantly with a separate persecutory beliefs factor. that it may not be meaningful to talk in terms of diagnostic distinctness. Other factor analyses have concluded that GDs and PDs are at least Indeed, the diagnostic category of (APA, 2000) partially independent from one another (e.g., Kitamura, Okazaki, captures those individuals who meet criteria for both schizophrenia and Fujinawa, Takayanagi, & Kasahara, 1998) and that PDs and GDs have bipolar disorder. We have no reason to suspect that the origins and some non-shared causes (Freeman, 2007), although what these might maintenance of GDs will differ between individuals with different be remains poorly understood. psychiatric diagnoses, and so for the purposes of this review it will be assumed that the same underlying psychological processes are of 5. Affect and grandiose delusions interest independent of diagnostic classification. Contemporary psychological models of GDs reject Berrios's (1991) 4. Grandiose delusions, persecutory delusions and depression claim that delusions are meaningless speech acts and propose instead that GDs are related to past/current emotional concerns. One family of Qualitative studies of delusions have noted “a complex set of models suggests that GDs arise from an individual's attempt to defend interconnected themes drawing uniquely from several possible themselves against negative affective states, which Freeman, Garety,

Table 3 Grandiose beliefs in general population.

Study Sample Mean age % endorsing PDI-21 item “Do you % endorsing PDI-21 item “Do you ever (SD, range) ever feel that you are a very special feel as if you are, or destined to be or unusual person?” someone very important

Verdoux et al. (1998) 462 attendees of a GP with no 52 years (18, 18–95) 12% 8% psychiatric disorder Peters, Joseph and Garety (1999) 272 general population 37 years (10, 19–75) 43% data not reported Armando, Nelson, Yung, Ross, 1,777 high school and university 18 years (4, 15–26) 75% 65% Birchwood, Girardi et al. (2010) students Jones and Fernyhough 493 university students 19 years (2, 18–54) 44% 36% (2007, unpublished data) Scott, Chant, et al. (2006) 10,641 general population not reported 3.4% of people answered the question [which the authors aimed to address the presence of grandiose delusions] “Do you have any special powers that most people lack?” in the affirmative. 688 R. Knowles et al. / Clinical Psychology Review 31 (2011) 684–696

Fowler, Kuipers, Dunn, Bebbington et al. (1998) call “delusion-as- these studies did not report specifically on GDs, the findings further defense” (DAD) accounts. A second group of models termed “emotion- undermine the plausibility of a DAD model of GDs. consistent” proposes that GDs emerge out of current positive affective However, these investigations are open to criticism. As the authors states (Smith et al., 2005, p. 486). themselves concede, Smith et al. (2005) only tested a defense against verbally mediated thoughts, but a defense against negative feelings 5.1. Affect in “delusion as defence” models of GDs might take a different form from the traditionally conceived verbal delusional belief. In our view (see Section 7.3), there are important Beck and Rector (2005) have argued that GDs “may develop as a reasons to believe that a defense may need to counteract visual compensation for an underlying sense of loneliness, unworthiness, or thoughts or mental images which are commonly found in patients powerlessness” (p. 588) and note from their clinical experience that with bipolar disorder — the clinical population in whom GDs are most many patients with GDs “have experienced prior life crises charac- common (Tzemou & Birchwood, 2007). terized by a sense of failure or worthlessness” (p. 588). There is some Empirical tests may also have failed to find support for the DAD preliminary evidence that early traumatic life-events may be model of GDs because of the stipulation that the defense operates associated with GDs (Read, Agar, Argyle, & Aderhold, 2003) but in a specifically to protect self-esteem. Self-esteem is non-relational sample of patients with psychosis, Mason, Brett, Collinge, Curr, and concept, defined as an individual's of themselves. Rhodes (2009) only detected a trend towards an association between However, delusional beliefs are typically interpersonal and embedded grandiose beliefs and a composite measure of childhood trauma. in a social context. Hence, a more appropriate candidate for what is Neale's (1998) manic defense hypothesis – by which grandiose beliefs being defended by the emergence of GDs may be “social self-esteem” (with other symptoms of mania) serve the function of keeping (Heatherton & Polivy, 1991) or social rank (Gilbert, 1992). Smith, distressing thoughts out of consciousness – is similar to Beck and Fowler, Freeman, Bebbington, Bashforth, Garety et al. (2006) argue Rector's (2005) argument. Some preliminary evidence in support of that negative beliefs about others held by individuals with GDs may the hypothesis that GDs may be understood to compensate for failure/ serve to increase social rank. It has been suggested that grandiosity dissatisfaction with life can be found in qualitative study of delusional could increase the social status of the individual who expresses it by patients, which concluded that “a link can be made between generating an impression of enhanced access to resources which delusional themes and themes from personal goals” (Rhodes & favors social success (McGuire & Troisi, 1998). That is, GDs may Jakes, 2000, p.221). represent the of an adaptive coping mechanism. The While the qualitative evidence is limited by the small number of qualitative work of Rhodes and Jakes (2000), who found that an studies, there is a greater volume of quantitative research in this area. individual's GD was related to a real-life theme of failure might be This body of work arose from the success of a paradigm for testing a usefully interpreted in this light. Birchwood, Trower, Brunet, Gilbert, defensive account of persecutory delusions (PDs). Bentall (1994) Iqbal and Jackson (2006) argue that when individuals without the proposed that PDs were a means of protecting against low self-esteem social power to protect themselves are alerted to their low relative and depression by preventing awareness of discrepancies between rank they may activate internal defensive emotions and strategies, of actual and ideal self-concepts. This leads to the prediction that there which GDs are an example. If this is the case then we would expect will be a measurable discrepancy between overt (explicit) and covert individuals with GDs to display a of negative evaluation by others, (implicit) self-esteem in individuals with current PDs, a hypothesis which may also be linked to the development of persecutory which has received some empirical support (e.g., Lyon, Kaney, & delusions. Furthermore, since social rank theory predicts that Bentall, 1994) although results are mixed (e.g., Martin & Penn, 2002). and outsider status is associated with social (Gilbert & Trower, A similar paradigm has been applied to the evaluation of a defensive 2001) we might also expect these features to be associated with GDs. account of GDs. As Smith et al. (2005) note, a DAD model makes more Given that only one study has directly examined the relationship intuitive sense in the context of GDs which appear to be better between GDs and implicit/explicit self-esteem discrepancies, it is candidates for protecting positive self-esteem than PDs. As they put it, important to consider other potential sources of evidence. Explicit “believing yourself to be, for example, a famous talented individual is self-esteem has been found to exceed implicit self-esteem in currently more likely to reduce low self-esteem than thinking that the manic and remitted patients (Lyon et al., 1999) and in an analogue neighbors are spreading distressing rumors about you and are study of (Bentall & Thompson, 1990). Bentall, Kinderman, plotting to have you evicted” (p. 480). and Manson (2005) examined self-discrepancies in manic, depressed To date only Smith et al. (2005) have attempted to test the DAD and remitted bipolar patients as well as a group of healthy controls. theory of GDs by comparing explicit and implicit self-esteem in a They found that manic patients rated their actual self as being closer mixed group of 21 patients. Explicit self-esteem was measured by to their ideal self than any of the other groups, why they interpreted self-report questionnaire, while implicit self-esteem was assessed as being consistent with the proposal that a defense was operational using an emotional Stroop task and the Self-Referent Incidental Recall in the manic state to prevent the negative affective consequences of Task (Lyon, Startup, & Bentall, 1999). No evidence of low implicit self- actual-ideal self-discrepancies. esteem in the patients with GDs was found. Raune, Bebbington, Dunn, and Kuipers (2005) have also reported evidence that appears 5.2. Affect in emotion-consistent models of grandiose delusions inconsistent with a DAD model. If the DAD account is correct, then events that threaten the individual's self-esteem would be expected An alternative to the DAD pathway is the suggestion that delusional to be associated with the development of GDs which would arise as a beliefs arise from current concerns (Freeman et al., 2002), referred to psychological defense. However, the authors found that GDs in a first- as an “emotion-consistent” account (Smith et al., 2005, p. 486). This episode psychosis sample were actually negatively associated with model suggests that grandiose beliefs are built on “existing or loss events and they also failed to find a relationship between the preserved raised areas of self-esteem” (Smith et al., 2005, p. 481). onset of GDs and recent humiliating events. It is worth noting that key These positive beliefs about the self may become exaggerated against prospective studies have reported an increase in manic symptoms the backdrop of the positive affective state, and may be uncritically after routine-disrupting and goal-attainment events, while negative accepted due to cognitive and information processing biases (see life events precede depressive episodes but do not appear to predict Section 7.1). The positive affective state may also be amplified by other symptoms of mania (Johnson, 2005a,b; Johnson, Sandrow, Meyer, processes such as the occurrence of mood-congruent mental imagery Winters, Miller, Keitner et al., 2000; Johnson, Cuellar, Ruggero, (see Section 7.3). Smith et al. (2006) have further proposed that a Winnett-Perlman, Goodnick, White and Miller, 2008). Although combination of elevated mood and positive views of the self alongside R. Knowles et al. / Clinical Psychology Review 31 (2011) 684–696 689 negative evaluations of others may promote a social position that for the initial anomalous trigger experience is an individual's internal sustains positive self-beliefs and a rejection of social cues, which could state. Mansell, Morrison, Reid, Lowens, and Tai (2007) have argued in turn maintain GDs. that a range of mental disorders may be characterized by intrusions The limited available evidence is broadly in support of this into awareness of information (in the form of body state information, emotion-consistent model. Two separate clinical studies have affect, thoughts and images or external sensory input, for example) reported that levels of grandiose beliefs were correlated with higher which is appraised in an unusual manner. Mansell et al. (2007) further explicit self-esteem and lower depression scores (Moritz et al., 2010; note that the particular appraisal made about an intrusion is Smith et al., 2006). Smith and colleagues suggested that individuals influenced by existing beliefs resulting from individual life experi- with GDs tend to make negative evaluations of others in order to ences. Mansell and colleagues have applied this idea primarily to the “foster a social position that maintains positive self-evaluations” (p. emergence of manic mood states, but it may also be relevant to the 183). Although there was no correlation between negative evalua- development of GDs. tions of others and levels of GDs, a logistic regression showed that An example of the problematic appraisal in action may look some- both low depression scores and negative beliefs about others were thing like this. An initial event (e.g., an exciting life event, or stimulant independently associated with GDs (Smith et al., 2006). An analogue use) leads to a more positive mood, greater physiological arousal, or study also found that levels of grandiose beliefs were predicted by altered cognition. This experience is interpreted by an attribution of positive (but not negative) views of the self (Fowler et al., 2006). None extreme personal meaning, rather than an external or situational of these studies is able to establish the potential direction of causation attribution (Mansell et al., 2007). For example, experiencing one's rate in the relationship between explicit self-esteem and grandiose beliefs: of thinking as being increased might be interpreted as a sign of great higher explicit self-esteem may facilitate the development of mood- intelligence, wit and intuition (a personal attribution), or it could be congruent grandiose beliefs, but a DAD interpretation of these interpreted as a consequence of managing too many competing tasks findings could be that grandiose beliefs arise as a defense against (a situational attribution) (Mansell et al., 2007; Jones, Mansell, & low self-esteem, resulting in increased positive self-esteem. Raune Waller, 2006). Similarly, an individual who suddenly feels alert, active et al.'s (2005) study which found fewer negative loss events in the and finds they have a reduced need for sleep may make sense of this recent history of those individuals with GDs offers some basis for sensation by assuming that it is due to dispositional characteristics favouring the emotion-consistent interpretation of the results, such as their underlying dynamism or ability as opposed to being the although the (limited) evidence discussed in Section 5.1 linking result of excessive stimulation from the environment (Jones et al., trauma and GDs leaves this question open. We note that at least one of 2006). The tendency to make extreme personal attributions has been the predictions of an emotion-consistent account appears to be borne found to be more common in patients with bipolar disorder (who are out by empirical research. Given that feelings of uniqueness, vulnerable to hypo/mania and grandiose ideation) than in healthy indestructibility and heroicness peak in adolescence, the emotion- controls (Jones et al., 2006). consistent model would predict a higher incidence of GDs in younger An individual may reach for an internal personal appraisal of their adults than in older people — a pattern that has been observed. Lake unusual experience because of an image they hold of an aspirational (2008) has argued for a key role of positive mood in the aetiology of “imminent possible self” (Mansell et al., 2007, p. 523). For example, GDs, and interestingly, the clinical vignettes in his study appear to individuals who are vulnerable to mania exhibit higher levels of support a relatively underdeveloped facet of the emotion-consistent aspirations for fame, wealth and political influence (Johnson & Carver, account of GDs. Freeman and Garety (2003) suggest that GDs may 2006), and the greater the extent to which patients with bipolar build on “pre-existing inflated, or accurate, of the self” (p. disorder value and perceive themselves as dynamic, creative and 938, italics added), and Smith et al. (2005, p.481) note that GDs may successful, the more likely they are to relapse into hypomania or build on “existing or preserved raised areas of self-esteem”. This is mania (Lam, Wright, & Sham, 2005). Similarly, hypomania scores in consistent with Lake's examples of the chemistry graduate who students have been found to predict their expectations of academic believed that he possessed a formula to make synthetic narcotics, and and career success (Meyer & Krumm-Merabet, 2003). Drawing on the patient with a background in rocket engineering who believed studies of clinical mania (e.g., Meyer, Johnson & Carver, 1999) these that he had a Star Wars missile design. Lake describes these beliefs as findings may be interpreted as evidence of heightened responsiveness building on a “thread of truth” (p. 1153). of the behavioural activation systems in individuals. Additionally, GDs can be very specific beliefs related to particular areas of thinking in terms of the DAD model discussed earlier, if an individual positive self-esteem expertise or achievement. However, as is clear has a strongly positive ideal self, then any attempt to reduce the from Table 1, they may also be much broader and less grounded in discrepancies between this and the actual self should lead to the reality, and the differences between the two types of beliefs is unclear. adoption of positive self-representations. Hence, a positive imminent It may be that if an individual does not have a clear current/past or ideal self may act as a risk factor for GDs. strength on which to draw, then a GD may involve global self-esteem Mansell et al.'s (2007) ascent behaviour construct helps to explain being elevated. Alternatively, it may be that broad GDs start off as how these initial ideas may escalate into full-blown GDs. Ascent more specific beliefs that escalate and expand due to the effects of behaviours aim to either enhance or control anomalous internal states, various cognitive mechanisms as discussed in Section 7. such as feeling unusually alert or active. Mansell and colleagues list a In conclusion, the current empirical evidence appears to offer more number of possible ascent behaviours including “extended wakeful- support for an emotion–consistent account of GDs than for a DAD ness; increased rate of activity; generating multiple ideas and goals, model, although a series of clinical vignettes and the one qualitative the seeking of social stimulation; and the dismissing of others’ study in this area suggest the DAD model may also be applicable, attempts to moderate behavioural changes” (p. 523). They give an highlighting the need for further longitudinal research into the onset example of the latter behaviour in the case of individual who appraises and development of GDs. his as a manifestation of his superior intelligence, and who subsequently dominates social interactions and ignores negative 6. Anomalous experiences, their appraisal, and GDs feedback from others. This particular ascent behavior, ignoring negative feedback from others, has been further examined in relation Psychological models of delusional ideation typically argue that to bipolar disorder by Mansell and Lam (2006) who reported that the search for meaning following an initial anomalous experience individuals with current symptoms of bipolar disorder were less likely leads to the emergence of a delusional explanation (Maher, 1988), than remitted participants to use advice from others to inform their and an account of this type may be applicable to GDs. One candidate decisions after having undergone an experimental mood elevation. 690 R. Knowles et al. / Clinical Psychology Review 31 (2011) 684–696

The internal state may also be amplified resulting in a GD through reasoning biases such as ‘jumping to conclusions’ (JTC) is well docu- the process of goal-setting and the impact of goal-attainment. Again, mented in association with delusional beliefs in general (see Garety & there are at present no studies that pertain directly to GDs, but a Freeman, 1999), although to date, no studies have investigated this number of suggestive findings come from studies of bipolar mania. bias in relation to GDs in particular. Previous research has tended to Individuals with a history of mania have a tendency to set themselves combine patients with GDs and patients with persecutory delusions higher goals than control participants (Johnson, 2005a,b), and current (PDs) into a mixed delusional group for comparison with a non- levels of hypomania have been found to predict a greater positive delusional control group (e.g., Dudley, John, Young, & Over, 1997) and affective response to achieving a goal as well as the subsequent setting analysis by type of delusion is unfortunately often prevented by the of more extreme goals (Johnson, Ruggero, & Carver, 2005). These small sample sizes. However, the majority of research into decision- findings are consistent with evidence that it is goal-achievement life making processes and delusions has explored purely cognitive events rather than positive events more generally that are associated mechanisms without considering the impact of emotion. Mansell with increased manic symptoms (Johnson et al., 2000). This is and Lam (2006) found that individuals with bipolar disorder showed interesting in the light of Lake's (2008) case examples which describe impaired decision-making (characterized by failure to utilize social the emergence of grandiose beliefs about achievements in particular feedback) in an induced elevated mood state, but there has been fields of personal expertise. almost no research into how positive affect might influence cognitive Another candidate for the initial anomalous triggering experience biases and decision-making. might be the perception of unexpected, unsolicited or undue attention from others. If other people are experienced as paying more attention to 7.2. Attributional style the individual than usual (perhaps leading to comorbid delusions of reference), impaired theory of mind (ToM) may lead an individual to In addition to the reasoning processes discussed above, it has been explain this behaviour by inferring that it must be because s/he is special suggested that GDs may be associated with a self-serving attributional and worthy of this additional attention. ToM performance in the context style, according to which individuals tend to make more internal of persecutory delusions has been the subject of extensive empirical attributions for positive events (Freeman et al., 1998). However, research (see Freeman, 2007,forareview),butGDshavenotbeen research on the specific relationship between attributional style and considered in the same way. ToM has, however, been studied in the GDs in isolation from other types of delusional belief is very limited. context of bipolar mania. Kerr, Dunbar, and Bentall (2003) found that ToM This may be partly due to the significant comorbidity between GDs wasimpairedincurrentlymanicpatientsaswellasbipolardepressed and PDs and the tendency for researchers to recruit mixed groups of patients, but not in a remitted group. It remains unclear whether ToM patients for comparison with a healthy control group (e.g., Fear, becomes impaired as a result of a manic mood state, or whether ToM Sharp, & Healy, 1996; Sharp, Fear, & Healey, 1997). Jolley et al. (2006) deficits are a risk factor for mania and hence perhaps for GDs. have come closest to a specific investigation of attributional style in Not only may individuals with GDs misinterpret the interest and GDs in their study of 71 patients with a diagnosis of non-affective attention of others, but they may also react more strongly to such psychoses. They predicted that patients with persecutory beliefs perceived attention. Evidence from studies of patients with bipolar would form grandiose and depressed subgroups displaying self- affective disorder reveals increased neural activity in response to human serving and depressive attributional styles, respectively. Jolley and smiles in brain areas associated with positive affect and reward (Rolls, colleagues found that higher levels of grandiose beliefs were 2000). Chen, Lennox, Jacob, Calder, Lupson, Bisbrown-Chippendale et al. associated with a greater self-serving attributional bias, but they (2006) report evidence of abnormal brain activation in patients in manic failed to apply a Bonferroni correction for the number of correlations and depressed states of bipolar disorder in response to mood calculated. The only other specific association with grandiose beliefs incongruent affective stimuli. Manic patients were found to have was detected in a small subsample of patients (N=16) who showed abnormal neural activation in response to images of sad faces, and an externalizing bias for negative events. In this group, there was a interestingly they showed a differentiated pattern of neural activation to correlation between the extent to which people made external implicit and explicit presentations of sad face, unlike the unipolar and attributions of negative events and the severity of their grandiose bipolar depressed patients. Specifically, Chen et al. found that a number beliefs. of areas were underactivated by explicit processing of sad faces but There has also been a lack of research into how elevated mood overactivated by implicit processing of these faces in the currently affects attributional style, and whether elation enhances the self- manic patients. These were the amygdala, insula, and superior and serving bias. However, one study has examined how goal attainment middle temporal gyri (involved in emotional arousal and perception), affects attributional style (Stern & Berrenberg, 1979). Students who and the hippocampus, dorsal anterior cingulate and medial superior scored highly on a measure of hypomania were more likely to attribute frontal gyrus (involved in emotional regulation and sensitivity to their apparent success to internal factors. After an initial success, affective incongruency). This pattern is consistent with the finding that students also exaggerated their likelihood of correctly guessing the bipolar patients in a manic episode are worse at identifying negative outcome of a coin toss. Attributional style may be therefore be affected facial affect (Lembke & Ketter, 2002). This may be one way in which GDs by goal attainment in the context of GDs. are maintained, through the failure to consciously process incongruent emotional states in others. Given the apparent failure of individuals with 7.3. Modality of thought mania to attend to negative social feedback, it would be particularly interesting to replicate this study to examine whether there are Given the key role of positive affect in GDs, factors that amplify differences in the implicit and explicit processing of disapproving positive emotion are likely to play a role in the escalation of mood and faces in individuals with GDs. grandiosity as well as in the maintenance of GDs. The role of ascent behaviors has already been discussed, and one further factor is the 7. Cognitive styles and grandiose delusions modality of thought used. Holmes and Mathews (2005) have argued that emotional processing in the brain is particularly sensitive to 7.1. Jumping to conclusions bias visual mental imagery — more so than to verbal thought. They suggest that imagery susceptibility (the tendency to be a “visualizer” rather Freeman (2007) asserts that if delusions are incorrect/uncorrected than a “verbalizer”) may be a neglected risk factor for psychiatric beliefs, then we must understand the reasoning processes involved in disorders due to the amplifying effect of imagery on emotion and the formation and maintenance of these false beliefs. The presence of several authors have shown that visual mental imagery has a greater R. Knowles et al. / Clinical Psychology Review 31 (2011) 684–696 691 amplifying effect on positive affect than verbal thought (e.g., Holmes, Interestingly, other forms of metacognitive beliefs were the best Lang, & Shah, 2009). predictors for proneness to all other types of delusion-like beliefs. The Although no empirical studies have examined the role of mental authors concluded that this could be interpreted to mean that “the imagery in GDs, its potential for a role in hypomania is suggestive. For presence of such intrusive thoughts and beliefs (i.e. having grandiose example, intrusive images of positive future events are commonly ideas) may not be incompatible with the subject's metacognitive observed in hypomania (Gregory, Brewin, Mansell & Donaldson, beliefs (therefore not creating an aversive state of arousal). Indeed, 2010), many of which involve “goal-oriented events that were the presence of such experiences may even lead to a state of positive interpersonal in nature, for example ‘being in charge of a project, in affectivity” (p. 1437). In this way, people experiencing GDs may not an all-powerful situation with people underneath me’ or 'self as a only appraise internal state changes by inferring extreme personal great business man, people looking up to me’. Interestingly, depressed meaning (Mansell et al., 2007), but they may do so by thinking in a patients in the same study reported intrusive goal-orientated mental modality that amplifies affect (imagery), in a manner that amplifies images of a negative emotional valence. This suggests that GDs might affect (1st person rumination), with more positive content (future- arise from depressive mood states if self-esteem shifts and the content orientated goal-directed thoughts), and they may also be more of mental imagery changes. This proposal is consistent with the consciously aware of such thoughts when they occur. finding that self-esteem in bipolar patients is unstable compared to healthy controls and patients with unipolar depression (Knowles, Tai, 8. The dynamic nature of grandiose delusions Jones, Highfield, Morriss and Bentall, 2007). The tendency to use mental imagery may interact with the goal- One factor that has been overlooked in much of the research into setting and achievement patterns characteristic of individuals who delusional beliefs is their dynamic nature. Appelbaum, Robbins, and are susceptible to mania and which may play a role in the Vesselinov (2004) studied the stability of patients’ delusions over the development of GDs. If goals are simulated as mental images then course of a year in a mixed group of 405 delusional patients by this could stimulate mood elevation according to the imagery-as- interviewing them every 10 weeks. Although they did not report data amplifier hypothesis (Holmes & Mathews, 2010). The “pre-experi- on GDs in particular, a number of findings are of interest. They encing” of the future via imagining positive goal attainment could reported that only 15% of patients were delusional at every follow-up amplify mood and contribute to the development of GDs. This interview. Furthermore, there was only a 61% chance that a patient's tendency to pre-experience goals or behaviours may help to explain primary delusion type would remain the same between any two the high level of conviction with which GDs are typically held interviews. Appelbaum et al. concluded that “[d]elusions appear to be (Appelbaum et al., 1999): given the commonalities in neural more dynamic and fluid over relatively short periods of time than has activation between perception and mental imagery, the representa- been suggested by many classic descriptions and contemporary tion of GDs in imagery may enhance people's judgments of their truth formulations” (p. 323). One underlying cause for both the primary value. type of delusion and whether an individual endorses a delusion at all might be the instability of a number of cognitive and affective states, 7.4. Thinking about thinking such as the fluctuation in paranoia that results from fluctuations in self-esteem for example (e.g., Thewissen, Myin-Germeys, Bentall, de The apparent role of mental imagery in the amplification of Graaf, Vollebergh and Van Os, 2007; Thewissen, Bentall, Lecomte, van emotion means that it is important to consider the role of both the Os, & Myin-Germeys, 2008). modality and method of thinking in relation to GDs. A distinction is Integrating the instability of delusional beliefs and the association made between rumination and reflection as cognitive processing of unstable self-esteem with paranoia, we might hypothesize that not strategies. Rumination describes a repetitive focus on the content, only are GDs unstable, but they are so due to instability in self-esteem causes and consequences of events (Gruber et al., 2009). It often or social rank. There is already evidence that patients with bipolar involves taking a first-person perspective, resulting in the experience disorder (diagnostic category most strongly associated with GDs) of being immersed in mental events (Kross, Ayduk, & Mischel, 2005). have greater day-to-day fluctuations in self-esteem than both healthy In contrast, reflection has a cognitive distancing effect as events are controls and patients with unipolar depression (Knowles et al., 2007). viewed more objectively from a third-person perspective. In PTSD, This hypothesis remains in need of testing more specifically in groups first-person perspective are associated with greater levels of patients with GDs, and we suggest that ESM would be an of affect than are third-person memories (McIsaac & Eich, 2004), and appropriate methodology. We would expect GDs to be associated when asked to recall a happy autobiographical , both patients with momentary positive fluctuations in self-esteem and social rank. with bipolar disorder and healthy controls show greater positive As discussed above, these may not be global fluctuations in self- affect, positive thoughts and faster heart rates when they are esteem but may instead be specific to a particular “island” of self- instructed to think about the memory in a ruminative manner as worth, such as one's skill as a entrepreneur or prowess at football for opposed to a reflective manner (Gruber et al., 2009). Although instance. These fluctuations in self-esteem may also influence rumination is more commonly associated with verbal thought than cognitive processes like the JTC bias. We would predict that negative with mental imagery (McLaughlin, Borkovec, & Sibrava, 2007), fluctuations in mood and/or self-esteem would be associated firstly individuals who have a tendency to think ruminatively using first- with a reduction in the degree of conviction in the GDs, and that person imagery may be at greater risk for the development of GDs. further falls in mood/self-esteem might be associated with the Furthermore, the finding that ruminating about past events often development of persecutory delusions. leads to rumination about future events (McLaughlin et al., 2007) may be linked to the future- and goal-orientated thinking often found in 9. Developing a model of grandiose delusions mania. In addition to cognitive style, meta-cognitive style may also play a The factors discussed above may be configured into a tentative role in the development and maintenance of GDs. Although studies of model of the development and maintenance of GDs. Various empirical meta-cognition and grandiosity have not been conducted in clinical findings have indicated that persecutory and grandiose delusions are samples, one analogue study has examined grandiose ideation in the the result of distinct yet related psychological processes but at the general population. Larøi and Van der Linden (2005) found that moment there is insufficient evidence to determine whether GDs cognitive self-consciousness (the tendency to focus attention on and differ from other types of delusional beliefs with respect to key monitor one's own thinking) predicted levels of grandiose ideation. aetiological and maintaining factors and processes. And so, while this 692 R. Knowles et al. / Clinical Psychology Review 31 (2011) 684–696 tentative model may be adaptable to other classes of delusional primed to detect any sign or evidence of change/improvement. They beliefs, it has been configured specifically with GDs in mind. We may detect an externally generated ‘chink of light’ in the form of a would expect the content, direction and valence of attributional positive event or an internal state change (e.g., achieving a goal, biases, mental images, life events, internal state changes and self- physiological/ cognitive changes due to drug use or fatigue) which they esteem fluctuations to vary between different types of delusion, seek to make sense of in dispositional terms, their internal positive although the over-arching framework might still apply. It is clear from attributions being influenced by earlier life events or cultural factors, or the evidence discussed above that discrepancies between implicit and perhaps by their desire to feel better and motivation to seize explicit psychological states are common, and contemporary theories opportunities to modify their negative mood. In this way, the process of affect (e.g., Cacioppo & Bernston, 1994; Watson & Tellegen, 1985) might be both emotion-consistent (the initial grandiose thought is allow for the simultaneous occurrence of contrasting emotional congruent with an initial positive change in mood) and defensive experiences. The proposed model is principally concerned with the (occurring within a broader context of negative affect and self-esteem explicit versions of affect and cognition that are overtly accessible and that the individual is motivated to change). The initial grandiose amenable to self-report. thought might then develop into a full-blown GD by the operation of The balance of the current evidence is slanted in favour of an cognitive biases, the failure to process social feedback, and possible ToM emotion-consistent account of GDs, although there is some evidence impairments. Throughout this phase, a number of factors are likely to consistent with a DAD model (Beck & Rector, 2005; Rhodes & Jakes, play a role in the further amplification of positive affect and the internal 2000), and both routes are therefore reflected in the model. We state change, including the use of ruminative first-person mental propose that the research to-date has been overly focused on trying to imagery relating to future goal attainment. determine whether either an emotion-consistent or a delusion-as- From a DAD perspective, grandiose thoughts are proposed to arise defense account of delusional beliefs is ‘true’. In fact, these may not be as a deliberate defense against a perceived decrease in mood, self- mutually exclusive mechanisms or pathways, and indeed they might esteem or social rank. The precise mechanisms underlying such a each imply the other's internal logic. What we present in Fig. 1 is an process remain unclear, but may involve ruminating on past attempt to integrate the two theoretical accounts of the development achievements or on autobiographical memories of episodes when of GDs in such a way as to illustrate the potential interplay between self-esteem or social rank were more positive (perhaps again using a the routes as well as being amenable to empirical testing. mental imagery modality), leading to small improvements in mood A person who is experiencing low mood, low self-esteem/social rank and self-esteem and internal state changes which may then be is likely to be motivated to modify these feelings and may therefore be appraised in positive dispositional terms, initiating the same mood-

Precipitating event (e.g., goal achievement, substance use)

Ruminative, Positive internal state change 1st person (e.g., positive mood change, increase visual mental self-esteem or social rank, change in imagery cognitions, such as speeded up thoughts) amplification

Search for meaning

Earlier life events Appraisal Range of possible Positive internal attribution future selves

Cultural factors Emotion-consistent route Negative life events involving Seeds initial grandiose thought Delusion as threatened defence self-esteem route Cognitive biases, or social ToM impairment, rank and ascent behaviours Grandiose delusion

Unstable self- Unstable self- esteem: esteem: Positive Negative fluctuation fluctuation Previously documented routes to persecutory delusion formation (see Bentall et al., 2001; Freeman 2007)

Fig. 1. A preliminary model of grandiose delusions. R. Knowles et al. / Clinical Psychology Review 31 (2011) 684–696 693 congruent process as described above. In this way, the two supposedly engaging the patient in certain behavioural strategies such as reality contrasting pathways into grandiosity may in fact operate alongside testing may be limited. Early collaboration and working towards a each other, feeding into each other rather than being mutually ex- shared understanding are crucial to successful therapeutic outcomes clusive. Clearly, not everyone who makes internal attributions for in CBT (Gilbert & Leahy, 2007) and such therapeutic factors are thus their positive internal state changes develops GDs so this is a nec- perhaps even more salient when working with GDs, as is the essary but not sufficient part of the process of onset, and a complex consideration of the emotional valence of these beliefs. GDs are interplay of situational, cognitive and affective factors contributes to typically associated with positive explicit affect and positive self- the emergence of GDs in a vulnerable individual. beliefs (e.g., Smith et al., 2006) which may hinder the development of The model allows for two ways in which persecutory ideation may a shared rationale for a therapeutic intervention. relate to GDs, centring around unstable self-esteem and social rank. As Based on the model proposed in Fig. 1 we might expect a number a result of negative fluctuations in self-esteem and/or social rank, of cognitive and behavioural strategies to be of use in addressing the individuals may believe that a facet of their (grandiose) worth is difficulties associated with GDs. The proposed role for adverse early coveted by others, resulting in secondary persecutory delusions (PDs). life events in the evolution of GDs suggests that trauma-focused Conversely, GDs may also emerge from existing PDs, since positive interventions should be considered. This therapeutic approach would fluctuations in self-esteem or social rank may encourage the appraisal also be expected to have an impact on self-esteem, mood and coping that the negative intentions of others towards them are due to the fact styles which may also moderate the role played by GDs in an that they have a special talent/value/wealth that others wish to steal. individual's presentation. These therapeutic targets need not just be It is clear that at present, due to a lack of empirical studies in this area, addressed as part of trauma-focused work, but may also constitute this model is tentative and in need of extensive empirical testing. individually tailored, discrete interventions. If there is a role for ToM However, we believe that it offers a fruitful range of hypotheses that impairments to lead to mistaken attributions of others' intentions, researchers may wish to explore. A number of hypotheses can be then we might expect patients to benefit from interventions which derived from this model, but just three specific examples are given specifically target this domain, as used successfully in other popula- here. First, this model would predict that internal state changes tions (e.g., Ashcroft, Jervis, & Roberts, 1999). Although current precede the onset of GDs. This could be tested using Experience evidence is limited, other cognitive biases that may be implicated in Sampling Methodologies (ESM: Hurlburt & Heavey, 2006) to examine GDs (such as attributional style and the JTC bias) might be amenable the affective and cognitive precursors to grandiose beliefs, as well as to the application of CBT techniques. the role of appraisals and attributional style. The model also predicts According to the model, attributional patterns to account for internal that the relationship between GDs and persecutory delusions may be state changes may be involved in the development of GDs which may mediated by unstable self-esteem. ESM could be used to examine emerge as overly positive and personal explanations for these affective, whether fluctuations in self-esteem precede the transition between cognitive and physiological experiences. Therefore by applying cogni- GDs and persecutory delusions. A third hypothesis derived from the tive restructuring approaches to these unhelpful appraisals of mood- model is that the development and maintenance of GDs would be related phenomena, we might expect patients to be able to work associated with impaired ToM, which could be tested by comparing towards the ability to generate more balanced explanations for these the performance of GD, non-GD delusional and control groups on experiences. This in turn should lead to a reduction in the striving and standard ToM measures. excessively goal-oriented ascent behaviours that are typically associated with manic episodes. The identification and recognition of early warning 10. Implications for treatment signs has been shown to be a valuable component of psychological interventions aimed at preventing the onset and relapse of both GDs present a particular problem for psychological intervention, psychosis (Spencer, Birchwood, & McGovern, 2001) and bipolar predicting poor clinical outcome up to ten years later (Thara & Eaton, disorder (Perry, Tarrier, Morriss, McCarthy, & Limb, 1999). We would 1996) as well as being negatively associated with medication compli- therefore anticipate that similar approaches to the identification of early ance (Appelbaum & Gutheil, 1980). Cognitive Behavioural Therapy warning signs or relapse signatures alongside the development of (CBT) has been found to be effective in ameliorating the difficulties ‘staying well plans’ (Gumley & Schwannauer, 2006) might also be associated with schizophrenia-spectrum disorders (Turkington, Dudley, effective in managing the impact of GDs. Warman, & Beck, 2004), but the results for bipolar disorder are less The importance of social feedback and reinforcement in regulating encouraging (Scott, Paykel, Morriss, Bentall, Kinderman, Johnson et al., beliefs is acknowledged (Bandura, 1986) but if people are socially 2006; Lam, 2006). A number of factors have been suggested to account isolated or purposefully withdraw from others then they are less able for the somewhat disappointing evidence for the effectiveness of CBT for to benefit from the moderating effects of these interactions. Inter- bipolar disorder (such as the number of previous episodes, Scott, Chant, ventions which enhance people's access to a social network might et al., 2006; Scott, Paykel, et al., 2006), but the prevalence of GDs may be therefore be expected to be useful as an adjunct to augment the effects an additional consideration. Although CBT is effective for treating the of individual therapy. Recent conceptualizations of mental imagery as positive symptoms of psychosis (Zimmerman, Favrod, Trieu, & Pomini, an emotional amplifier (Holmes, Geddes, Colom, & Goodwin, 2008) 2005), little work has focused on specific psychotic experiences. In one of suggest that harnessing that modality of thought as an additional the few such studies, persecutory delusions and unusual thought content strategy for affect regulation might also be of use. This could involve but not grandiosity were highlighted as being most reduced following rescripting existing images or promoting the development of CBT interventions (Kuipers et al., 1997). Indeed, little is known about the alternative images to initiate more adaptive cognitive and behavioural specific application of CBT to GDs. responses. CBT appears to be less effective at preventing manic episodes than at preventing depressive relapse in bipolar disorder (Lam, Hayward, 11. Future research Watkins, Wright, & Sham, 2005), and the sense of a “hyperpositive self”–the belief that one is creative, dynamic or entertaining for This review and the proposed model have generated a number of example – predicts a worse response to cognitive therapy in patients questions and hypotheses which need to be addressed by future diagnosed with bipolar disorder (Lam, Wright, & Sham, 2005). empirical work. The need for longitudinal investigations of GDs has Furthermore, given that GDs are associated with greater conviction clearly emerged. This type of research would enable a better than many other forms of delusions (Appelbaum et al., 1999), the understanding of the onset, development and stability of GDs over initial success of cognitive approaches to modifying the belief and time, as well as how their presentation and impact on functioning is 694 R. Knowles et al. / Clinical Psychology Review 31 (2011) 684–696 influenced by changes in self-esteem, mood and social rank. Breier, A., & Berg, P. H. (1999). The psychosis of schizophrenia: Prevalence, response to atypical , and prediction of outcome. Biological , 46, Longitudinal research designs would also lend themselves to answer- 361−364. ing questions about whether a delusion-as-defence or an emotion- Cacioppo, J. T., & Bernston, G. G. (1994). Relationship between attitudes and evaluative consistent paradigm (or a combination of both) best accounts for the space: A critical review, with emphasis on the separability of positive and negative substrates. Psychological Bulletin, 115, 401−423. development and maintenance of GDs, as well as clarifying the factors Canuso, C. M., Bossie, C. A., Zhu, Y., Youssef, E., & Dunner, D. L. (2008). Psychotic governing the hypothesised relationship between persecutory and symptoms in patients with bipolar mania. Journal of Affective Disorders, 164−169. grandiose delusions. Carlson, G. A., Bromet, E. J., & Sievers, S. (2000). Phenomenology and outcome of There are also a number of important questions to be addressed subjects with early- and adult-onset psychotic mania. American Journal of Psychiatry, 157, 213−219. using cross-sectional designs, such as whether or not there are Chen, C. -H., Lennox, B., Jacob, R., Calder, A., Lupson, V., Bisbrown-Chippendale, R., et al. meaningful ways of classifying or subdividing GDs, whether/when (2006). Explicit and implicit facial affect recognition in manic and depressed states GDs tend to occur in conjunction with or in isolation from PDs, and of bipolar disorder: A functional magnetic resonance imaging study. Biological Psychiatry, 59,31−39. whether the phenomenology of GDs allows clinicians and researchers Conus, P., Abdel-Baki, A., Harrigan, S., Lambert, M., & McGorry, P. D. (2004). to differentiate between diagnostic categories such as bipolar disorder Schneiderian first rank symptoms predict poor outcome within first episode and schizophrenia. Much work remains to be done to understand the manic psychosis. Journal of Affective Disorders, 81, 259−268. fi de Portugal, E., González, M., Haro, J. 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