Belief Updating and Paranoia in Individuals with Schizophrenia

Background and Hypothesis: Persecutory delusions are among the most common delusions in schizophrenia and represent the extreme end of the paranoia continuum. Paranoia is accompanied by significant worry and distress. Identifying cognitive mechanisms underlying paranoia is critical for advancing treatment. We hypothesized that aberrant belief updating, which is related to paranoia in human and animal models, would also contribute to persecutory beliefs in individuals with schizophrenia. Study Design: Belief updating was assessed in 42 schizophrenia and 44 healthy participants, using a 3-option probabilistic reversal learning (3-PRL) task. Hierarchical Gaussian filter (HGF) was used to estimate computational parameters of belief updating. Paranoia was measured using the Positive and Negative Syndrome Scale (PANSS) and the revised Green et al. Paranoid Thoughts Scale (R-GPTS). Unusual thought content was measured with the Psychosis Symptom Rating Scale (PSYRATS) and the Peters et al. Delusions Inventory (PDI-21). Worry was measured using the Dunn Worry Questionnaire. Results: Consistent with prior work, paranoia was significantly associated with elevated win-switch rate, prior on volatility and sensitivity to volatility in both schizophrenia and across the whole sample. These relationships were specific to paranoia and did not extend to unusual thought content or measures of anxiety. We did, however, find a significant indirect effect of paranoia on the relationship between prior beliefs about volatility and worry. Conclusions: This work provides evidence that relationships between belief updating parameters and paranoia extend to schizophrenia, may be specific to persecutory beliefs, and contribute to theoretical models implicating worry in the maintenance of persecutory delusions.

Digitally supported CBT to reduce paranoia and improve reasoning for people with schizophrenia-spectrum psychosis: the SlowMo RCT

Background Reasoning may play a causal role in paranoid delusions in psychosis. SlowMo, a new digitally supported cognitive–behavioural therapy, targets reasoning to reduce paranoia. Objectives To examine the effectiveness of SlowMo therapy in reducing paranoia and in improving reasoning, quality of life and well-being, and to examine its mechanisms of action, moderators of effects and acceptability. Design A parallel-arm, assessor-blind, randomised controlled trial comparing SlowMo plus treatment as usual with treatment as usual alone. An online independent system randomised eligible participants (1 : 1) using randomly varying permuted blocks, stratified by site and paranoia severity. Setting Community mental health services in three NHS mental health trusts in England, plus patient identification centres. Participants A total of 362 participants with schizophrenia-spectrum psychosis. Eligibility criteria comprised distressing and persistent (≥ 3 months) paranoia. Interventions Eight face-to-face SlowMo sessions over 12 weeks plus treatment as usual, or treatment as usual alone (control group). Main outcome measures The primary outcome measure was paranoia measured by the Green Paranoid Thoughts Scale and its revised version, together with observer-rated measures of persecutory delusions (The Psychotic Symptom Rating Scales delusion scale and delusion items from the Scale for the Assessment of Positive Symptoms). The secondary outcome measures were reasoning (measures of belief flexibility, jumping to conclusions, and fast and slow thinking), well-being, quality of life, schemas, service use and worry. Results A total of 362 participants were recruited between 1 May 2017 and 14 May 2019: 181 in the SlowMo intervention group and 181 in the treatment-as-usual (control) group. One control participant subsequently withdrew. In total, 325 (90%) participants provided primary Green Paranoid Thoughts Scale outcome data at 12 weeks (SlowMo, n = 162; treatment as usual, n = 163). A total of 145 (80%) participants in the SlowMo group completed all eight therapy sessions. SlowMo was superior to treatment as usual in reducing paranoia on all three measures used: Green Paranoid Thoughts Scale total at 12 weeks (Cohen’s d = 0.30, 95% confidence interval 0.09 to 0.51; p = 0.005) and 24 weeks (Cohen’s d = 0.20, 95% confidence interval –0.02 to 0.40; p = 0.063); Psychotic Symptom Rating Scales delusions at 12 weeks (Cohen’s d = 0.47, 95% confidence interval 0.17 to 0.78; p = 0.002) and 24 weeks (Cohen’s d = 0.50, 95% confidence interval 0.20 to 0.80; p = 0.001); and Scale for the Assessment of Positive Symptoms persecutory delusions at 12 weeks (Cohen’s d = 0.43, 95% confidence interval 0.03 to 0.84; p = 0.035) and 24 weeks (Cohen’s d = 0.54, 95% confidence interval 0.14 to 0.94; p = 0.009). Reasoning (belief flexibility, possibility of being mistaken and Fast and Slow Thinking Questionnaire measure) improved, but jumping to conclusions did not improve. Worry, quality of life, well-being and self-concept also improved, improving most strongly at 24 weeks. Baseline characteristics did not moderate treatment effects. Changes in belief flexibility and worry mediated changes in paranoia. Peer researcher-led qualitative interviews confirmed positive experiences of the therapy and technology. Nineteen participants in the SlowMo group and 21 participants in the treatment-as-usual group reported 54 adverse events (51 serious events, no deaths). Limitations The trial included treatment as usual as the comparator and, thus, the trial design did not control for the effects of time with a therapist. Conclusions To the best of our knowledge, this is the largest trial of a psychological therapy for paranoia in people with psychosis and the first trial using a brief targeted digitally supported therapy. High rates of therapy uptake demonstrated acceptability. It was effective for paranoia, comparable to longer therapy, and equally effective for people with different levels of negative symptoms and working memory. Mediators were improvements in belief flexibility and worry. Our results suggest that targeting reasoning helps paranoia. Future work Further examination of SlowMo mechanisms of action and implementation. Trial registration Current Controlled Trials ISRCTN32448671. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a MRC and National Institute for Health Research (NIHR) partnership. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 11. See the NIHR Journals Library website for further project information.

A compassionate imagery intervention for patients with persecutory delusions

Background: Negative beliefs about the self, including low self-compassion, have been identified as a putative causal factor in the occurrence of paranoia. Therefore, improving self-compassion may be one route to reduce paranoia. Aims: To assess the feasibility, acceptability, and potential clinical effects of a brief compassionate imagery intervention for patients with persecutory delusions. Method: Twelve patients with persecutory delusions received an individual four-session compassionate imagery intervention. Assessments of self-concept and paranoia were completed before treatment, immediately after treatment, and at 1-month follow-up. A qualitative study exploring participants’ experiences of the treatment was also completed. Results: Twelve out of 14 eligible patients referred to the study agreed to take part. All participants completed all therapy sessions and assessments. Post-treatment, there were improvements in self-compassion (change score –0.64, 95% CI –1.04, –0.24, d = –1.78), negative beliefs about the self (change score 2.42, 95% CI –0.37, 5.20, d = 0.51), and paranoia (change score 10.08, 95% CI 3.47, 16.69, d = 0.61). There were no serious adverse events. Three themes emerged from the qualitative analysis: ‘effortful learning’, ‘seeing change’ and ‘taking it forward’. Participants described a process of active and effortful engagement in therapy which was rewarded with positive changes, including feeling calmer, gaining clarity, and developing acceptance. Conclusion: This uncontrolled feasibility study indicates that a brief compassionate imagery intervention for patients with persecutory delusions is feasible, acceptable, and may lead to clinical benefits.

High-dose olanzapine in treatment resistant schizophrenia. A case report and literature review

ObjectiveWe report a case of a 58-year-old gentleman who was hospitalised intermittently for one year due to treatment resistant schizophrenia. Prior to hospitalisation he had been prescribed standard antipsychotics for decades without full resolution of positive psychotic symptoms. During his final admission lasting six months he was guarded, suspicious, irritable, constantly paced the corridor and displayed thought block and paranoid persecutory delusions. He would not enter the assessment room or allow any blood or ECG monitoring, however, he was compliant with oral medication. He was successfully treated with high dose olanzapine (40mg/day) and was discharged to the community. The aim of this study is to bring awareness and add to the body of evidence for the use of high-dose olanzapine in patients with treatment resistant schizophrenia in whom a trial of clozapine is not possible.Case reportThe patient gave written consent for this case report to be written and presented. An extensive literature review was performed and key papers were identified. Discussion focuses on the key areas in the literature.DiscussionThis case demonstrates that high-dose olanzapine can be used effectively as an alternative to clozapine in treatment resistant schizophrenia.ConclusionThis case highlights the need for further evaluation of high-dose olanzapine as an alternative to clozapine in patients with treatment-resistant schizophrenia.

Michael Kohlhaas Syndrome – Taking the court to court

ObjectiveTo explore Michael Kohlhaas syndrome and development of litigious paranoia.Case reportA 50-year-old Swiss woman spent a number of weeks travelling around the UK, reporting to police that her family in Switzerland were working with their police, doctors and the mafia to kill her. She was therefore running away for her own safety, and trying to seek legal help to investigate. She had been in close contact with a woman in London who claimed to be able to give her legal aid in exchange for payment. On admission to the ward, it was felt that the legal aid was actually feeding her persecutory delusions.DiscussionWe discovered that she had in fact been detained in Switzerland prior to coming to the UK, and the discharge report was obtained which diagnosed her with Michael Kohlhaas syndrome and Folie a deux.ConclusionThis poster will further explore Michael Kohlhaas syndrome and litigious paranoia, with connection to this case.

‘Things are not what they seem to be’: A proposal for the spectrum approach to conspiracy beliefs

Objective: Conspiracy beliefs (also known as conspiracy theories) become more prominent at times of heightened uncertainty and inconsistent or conflicting explanations provided by the authorities for events like terrorist attacks or pandemics, such as COVID-19. This article aims to examine the relevance of conspiracy beliefs for psychiatry in the context of the dynamics of trust and mistrust. Conclusions: Conspiracy beliefs may be situated on a spectrum of mistrust-related phenomena, which extends from healthy scepticism to persecutory delusions. They can be conceptualised as unfounded and fixed beliefs held with strong conviction about harm inflicted by powerful groups on the community or another group of people, usually with preserved insight that these beliefs differ from those that most people have and with reasons for having such beliefs not necessarily being implausible. It is important for conspiracy beliefs to be distinguished from persecutory delusions.