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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
Author’s Accepted Manuscript Negative Cognitions about the Self in Patients with Persecutory Delusions: An empirical study of selfcompassion, self-stigma, schematic beliefs, selfesteem, fear of madness, and suicidal ideation Authors Nicola Collett, Katherine Pugh, Felicity Waite, Daniel Freeman
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To appear in: Psychiatry Research Received date: 21 April 2015 Revised date: 25 January 2016 Accepted date: 17 February 2016 Cite this article as: Nicola Collett, Katherine Pugh, Felicity Waite and Daniel Freeman, 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 Authors, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2016.02.043 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: 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 Authors: Nicola Collettᵃ, Katherine Pughᵇ, Felicity Waiteᵇ, Daniel Freemanᵇ 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.
*Corresponding Author. Telephone: 07912 074629. Email: [email protected]
Abstract There has been growing awareness of the high prevalence of negative cognitions about the self in patients with persecutory delusions, and it has been proposed that paranoid fears build upon these perceived vulnerabilities. This study aimed to investigate for the first time a wide range of different conceptualisations of the negative self, and to examine associations with suicidal ideation, in patients with persecutory delusions. Twenty-one patients with persecutory delusions and twentyone non-clinical individuals completed measures relating to negative self cognitions. The delusions group also completed a measure of suicidal ideation. It was found that the patients with persecutory delusions had low self-compassion, low self-esteem, increased fears of being mad, beliefs of inferiority to others, negative self-schemas, and low positive self-schemas when compared to the non-clinical control group. The effect sizes (Cohen’s d) were large, and the different conceptualisations of negative self cognitions were highly associated with one another. Self-stigma did not differ between the two groups. Furthermore, suicidal ideation was highly associated with low self-compassion, low self-esteem, fears of madness, and negative self-schema but not selfstigma. 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. Keywords: psychosis, schizophrenia, suicidal ideation, negative self-concept, self-compassion, selfesteem
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1. Introduction Three recent literature reviews have all confirmed a connection of paranoia to negative cognitions about the self (Garety and Freeman, 2013; Kesting and Lincoln, 2013; Tiernan et al., 2014). It has been hypothesised that paranoia builds upon the sense of vulnerability that low self-worth triggers (Freeman et al., 2005). Consistent with this, a longitudinal study with 301 patients with psychosis indicated that negative self beliefs predict the later severity of persecutory delusions (Fowler et al., 2012). Furthermore, two experimental studies by our group show that in individuals with paranoid ideation the induction of negative self cognitions leads to an increase in paranoia (Freeman et al., 2014; Atherton et al., 2014). This has led to a clinical test of targeting negative self beliefs in patients with persecutory delusions (Freeman et al., 2014). Although there are multiple ways that negative self cognitions can be conceptualised, studies have mainly focussed upon negative self beliefs and low self esteem. In this paper we examine five concepts together in patients with persecutory delusions: 1). self-compassion, 2). schema, 3). self-stigma, 4). fears of madness and 5). self-esteem. Further, we examine their links to the clinically important problem of suicidal ideation in patients with psychosis.
1.1. Five conceptualisations of negative self cognitions Self-compassion has been defined by Neff (2003a) as comprising three components: self-kindness versus self-judgement in our responses to pain or failure, common humanity versus isolation when understanding one’s own suffering, and being mindful versus over-identification when paying attention to our own suffering (Neff, 2003a). Self-compassion involves an open, non-judgemental stance to our own pain and suffering, which is viewed as part of the human condition and promotes self-kindness (Neff, 2003b). Two recent meta-analyses have found that self-compassion is an important explanatory variable in understanding psychopathology and wellbeing (MacBeth and Gumley, 2012; Zessin et al., 2015). Eicher et al. (2013) found in a study of 88 participants with either schizophrenia or schizoaffective disorder that higher scores on the self-compassion scale were negatively associated with positive symptoms of psychosis. Qualitative accounts from patients with psychosis highlight the potential role of self-compassion in facilitating recovery in psychosis (Waite et al., 2015). Current research studies have found positive outcomes for compassion focussed therapy for psychosis (Mayhew and Gilbert, 2008; Brahler et al., 2013). However, these studies have not focussed on reducing symptoms of psychosis, and they do not focus specifically on persecutory delusions. Mills et al. (2007) found in a study of 131 students that paranoia was significantly negatively correlated with scores on the selfcompassion scale (Neff, 2003), indicating in particular the presence of self-judgement, isolation, and over-identification in those with higher paranoia scores. Hutton and colleagues (2013) found that a group of 15 patients with persecutory delusions were significantly less likely to self-reassure compared to non-clinical controls. These authors propose that a decreased capacity to self-reassure may activate perceptions of threat. Lincoln et al. (2013) found in an experimental study that a brief compassion focused manipulation decreased paranoid thoughts in a non-clinical population. However, no studies have yet specifically explored levels of self-compassion in a clinical group of people with persecutory delusions, although specific elements have been examined in one study (Hutton et al. 2013). Negative self-schema, defined as stable negative self evaluations which influence the individual’s interpretation of situations (Beck et al., 1979), is a concept well-established in depression research (Beck et al., 1967). In contrast to self-compassion, their potential role in paranoia has been tested in cross-sectional (e.g. Gracie et al., 2007; Smith et al., 2006), longitudinal (e.g. Fowler et al., 2011; Oliver et al., 2012; Freeman et al., 2013) and experimental studies (e.g. Freeman et al., 2008), using 2
the Brief Core Schema Scale (Fowler et al., 2006). In a recent pilot randomised controlled trial with patients with persecutory delusions, there was evidence that targeting negative self cognitions may lead to reductions in paranoia (Freeman et al., 2014). To date negative self beliefs have been most strongly connected to paranoia, compared to, for example, self esteem (Fowler et al., 2006). The experience of mental health problems often leads to further difficulties for how people view themselves. Self stigma is the internalisation of harmful stereotypes, which results in a reduction in self esteem (Link and Phelan, 2001; Corrigan and Watson, 2002; Corrigan et al., 2011). Corrigan et al. (2011) propose that internalising stereotypes about mental illness, for example concerning dangerousness and poor recovery rates, decreases self-esteem in individuals with serious mental health difficulties. In a study of 49 people with schizophrenia, self-stigma was associated with low self-esteem (Rodrigues et al., 2013). No studies to date have explored self-stigma and persecutory delusions specifically. A specific type of self-stigma in relation to mental health problems is the fear that one is ‘mad’, and in a cross-sectional study higher levels of fears of madness have been associated with greater distress associated with persecutory delusions (Bassett et al., 2009). Typical fears of madness are concerns that one is unable to tell the difference between reality and imagination, worrying that the mind is falling apart, and a fear of being locked up forever. Fear of recurrence of psychosis is a predictor of the development of psychosis-related post-traumatic stress disorder (White and Gumley, 2009). Gumley et al. (2015) found that fear of recurrence of psychosis was associated with increased risk of relapse and increased emotional distress, suggesting that individual’s idiosyncratic appraisals may influence relapse (Gumley et al., 2015). Finally, self-esteem has been considered as a central factor in the occurrence of persecutory delusions, with differing views on whether paranoia reflects a defence against low self-esteem (Bentall et al., 2001) or is a direct reflection of low self-esteem (Freeman et al., 2002). Multiple studies, but not all, demonstrate that low self-esteem is present in patients with persecutory delusions (e.g. Combs et al., 2009; Freeman et al., 1998). For instance, in a study of 154 participants who ranged across the continuum of paranoia, paranoia was found to be associated with lower selfesteem, and fluctuations in self-esteem were predictive of paranoia (Thewissen et al., 2008). Findings from studies on self-esteem interventions for people with psychosis have demonstrated improvements in positive symptoms (Lecomte et al., 1999; Hall and Tarrier, 2003) which may also lend support for a connection between self-esteem and positive symptoms of psychosis. 1.2. Persecutory delusions and suicide It is estimated that approximately 5% of patients with psychosis commit suicide (Hor and Taylor, 2010). Paranoid ideation in the general population too is associated with suicidal ideation (Freeman et al., 2011). To our knowledge there are no psychological studies of specific psychological constructs that are associated with suicide specifically in patients with persecutory delusions. But an association has been established between suicidal ideation and hopelessness as predictors for attempted and completed suicide in psychosis (Klonsky et al., 2012; King et al., 2001). Turner et al. (2012) found an association between internal and external shame associated with psychosis, and symptoms of trauma in fifty patients with psychosis, who were not acutely psychotic at the time. Internal shame was also associated with depression (Turner et al., 2012), suggesting that shame may be a key emotion in depression in psychosis. Filako et al. (2006) found that suicidal ideation in people with psychosis was associated with depressed mood, low self-esteem, and negative beliefs about the self and others, pointing towards negative self-cognitions as an important link to suicidal ideation. Overall, these findings highlight the importance of considering suicidal ideation in relation to negative self-cognition in individuals with persecutory delusions.
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The current study set-out to examine these five different conceptualisations of negative self cognitions specifically in patients with persecutory delusions. It was hypothesised that patients with persecutory delusions, compared to non-clinical controls, would demonstrate negative self-schema, self-stigma, fears of madness, low self-compassion and low self-esteem. Of these constructs, associations with self-esteem were expected to be the smallest, since it has been argued that some studies have not shown associations between clinical paranoia and low self-esteem (Bentall et al., 2001). We did expect the different constructs to be highly correlated. Finally, we hypothesised that negative self cognitions in participants with persecutory delusions will be associated with suicidal ideation.
2. Method A cross-sectional, between-groups comparison was conducted. 2.1. Participants Twenty-one participants with persecutory delusions were recruited from clinical teams in Oxford Health NHS Foundation Trust. Inclusion criteria were: experience of a current persecutory delusion as defined by Freeman and Garety (2000); a clinical diagnosis of non-affective psychosis; and aged eighteen years or over. Participants were excluded if English was not their first language, or if they were unable to complete questionnaire measures. The clinical group completed measures in an assessment session with the first author. The non-clinical control group was matched by age and gender. Twenty one control participants were recruited from a participant pool. The participant pool was developed from respondents to a previous advert for participation in studies (Freeman et al. 2013). The non-clinical control participants had no self-reported history of a mental health problem. They completed measures online using Qualtrics (Smith et al., 2011).
2.2. Measures 2.2.1 Measures of psychotic experiences Psychotic Symptom Rating Scale - Delusions (PSYRATS; Haddock et al., 1999) The PSYRATS is a 6 item assessment of preoccupation, conviction, distress and disruption associated with the delusion over the previous fortnight. Higher scores indicate greater delusional severity. The PSYRATS has good reliability and validity for the assessment of delusions in participants with psychosis (e.g. Drake et al., 2007). The Positive and Negative Syndrome Scales (PANSS) (Kay et al., 1987) The PANSS is a 30 item interviewer-rated tool to assess psychiatric symptom severity present in the previous 72 hours. Ratings are delivered using a 7 point scale (1-7). Higher scores are indicative of increased symptom severity. Kay et al. (1991) found good reliability and validity for the PANSS in a cohort of 101 participants with schizophrenia. Persecution and Deservedness Scale (PaDS) (Melo et al., 2009) This is a 10 item self-report measure of the severity of paranoid thinking and the level of perceived deservedness for the persecution. Only the section on persecution was employed in this study. Higher scores represent greater levels of persecutory ideation. The PaDS demonstrates high validity and reliability and is validated for use in clinical samples (Melo et al., 2009). The scoring for this measure uses a percentage as described by Melo and Bentall (2010).
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2.2.2 Measures of negative self cognitions The Self-Compassion Scale (SCS) (Neff, 2003a) The SCS is a 26 item self-report scale comprising statements (e.g. “I try to be loving towards myself when I am feeling emotional pain”) for which responses can range from 1 (Almost Never) to 5 (Almost Always). An overall self-compassion score is provided, as well as scores for sub-scales including self-judgement, isolation, over-identification, self-kindness, common humanity, and mindfulness. Scores for total self compassion were calculated by reverse scoring negative subscale items (self-judgement, isolation and over identification) before calculating subscale means for all six subscales. An overall mean of all six subscale means was then computed, as suggested by Neff (2003). Higher total self-compassion scores indicate greater self-compassion in times of distress. The SCS demonstrates good construct validity. The Brief Core Schema Scale (BCSS) (Fowler et al., 2006) The BCSS is a 24 item self-report measure which assesses beliefs about self and others. Items are rated using a 0-4 scale, and comprises four factors (negative self, positive self, negative others and positive others) with a score given for each factor. Only the items related to self were included in this study. For the six items on negative self (e.g. “I am worthless”), the greater the total on this subscale, the greater the negative beliefs about the self. For the positive subscale (e.g. “I am respected”), the larger the total, the more positive beliefs a person holds. Addington and Tran (2009) concluded that the psychometric properties of the BCSS make it appropriate for use in this population. Self-Stigma of Mental Illness Scale (SSMIS) (Corrigan et al., 2006) This 40 item measure comprises four subscales. Only the agreement subscale, which denotes the level to which people agree with stereotypes of mental illness, was employed in this study (e.g. “I think most persons with mental illness are to blame for their problems”). This was to investigate stigma about mental illness amongst people with and without persecutory delusions. Good internal consistency and concurrent validity for the measure has been established (Corrigan et al., 2006). Responses are given on a 9 point scale (9 = strongly agree). Higher total scores indicate greater endorsement of self-stigma (Corrigan et al., 2011). Mental Health Worries Questionnaire (MHWC)( Bassett et al., 2009) This is a 20 item self-report measure of fears of madness and associated distress in the previous week (e.g. “I worry my mind is falling apart”). Responses relate to levels of distress associated with fears ranging from 0 (not at all) to 5 (extremely distressing) for each statement item. Initial findings have shown good reliability and validity for the scale (Bassett et al., 2009). Higher total scores represent greater levels of distressing fears about madness. Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965) The RSES is the most used self-esteem measure and comprises ten items (e.g. “I feel that I'm a person of worth, at least on an equal plane with others.”). The higher the RSES score the lower selfesteem. A four point Likert scale of agreement (4- “strongly disagree”) is used for scoring. Items are totalled into an overall scale which has been shown to have good internal consistency in individuals with serious mental health problems (Corrigan et al., 2011; Corrigan et al., 2006). Social Comparison Scale (SCS) (Allan and Gilbert, 1995) Participants’ beliefs about how they compare to others were measured using an adapted version of the Social Comparison Scale. This 19 item self-report scale asks participants to rate how they have felt in relation to others during the previous week, on items including inferior/superior and incompetent/competent. Eleven items were from the original scale (e.g. inferior versus superior)
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and eight items (e.g. failure versus success) were newly added. 2.2.3 Measures of depression and suicidal ideation Beck Depression Inventory (BDI) (Beck, 1967) The BDI is a 21-item self-report measure of symptoms of depression over the past fortnight. Each item involves selecting one of four statements, with scores for each varying between 0 and 3. Higher total scores indicate higher levels of depression. Items tap cognitive distortions, hopelessness, suicidal ideation and physiological symptoms including fatigue. The BDI demonstrates good construct validity and reliability (Beck et al., 1988). Beck Scale for Suicidal Ideation (BSS) (Beck and Steer, 1991) This is a 21-item self-report measure of thoughts, attitudes, and intentions about suicide. Items are rated on a three point scale (0 to 2), with a total possible score of 38. Higher total scores indicate higher levels of suicidal thinking. The measure has good internal reliability (.96), and one study showed that the BSI had a test re-test reliability of 0.88 (p<0.001) (Pinninti et al., 2002). In addition, Pinninti et al. (2002) found that the BSI was positively correlated with past suicide attempts (r=0.46, p<0.001) and recommended it for use with participants with psychosis.
2.3 Analysis Data were analysed using the Statistics Package for Social Sciences (SPSS version 20) (IBM, 2011). For the first hypothesis, t-tests and Mann Whitney U tests were employed to test group differences on the self-concept measures, depending on whether assumptions for the use of parametric tests were met. A Cohen’s d calculation was used to determine effect sizes, in order to establish which negative self-concepts showed the largest group differences. For the second main hypothesis, associations with suicidal ideation for the self-concept measures within the clinical group were tested using Pearson’s r. Correlation coefficients were similarly used to examine associations between the individual self-concept measures. Power calculations to establish the required sample size were based on the Mental Health Worries Questionnaire (MHWQ) data from Bassett et al. (2009), which was the most similar study. It showed effect sizes (d) of 0.80. 80% power to detect such an effect size at the conventional significance level of 0.05 requires a sample size of 26 (G Power; Faul et al., 2007). All hypothesis testing was two-tailed.
3. Results 3.1 Participant Characteristics For the clinical group (n=21) the mean age was 45.6 years (SD=12.1; range: 21-66), compared to a mean age of 41.9 years (SD=12.2; range: 22-61) in the control group (n=21). The gender balance was the same in both groups (males n=10; 48% and females n=11; 52%). More participants in the clinical group were unemployed (n=18; 86%), compared with the control group (n=5; 24%). No significant difference was found between participants with persecutory delusions and control participants for age (t= .885, df= 30.06, p=.383) or gender ( ²=0.00, df=1, p=0.74). However, there was a significant difference between the groups for employment status, with significantly fewer employed participants in the delusion group ( ²= 14.40, df=1, p<0.001).
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Table 1- Means, standard deviations, and ranges for the clinical group on the symptom measures Measure Psychotic Symptoms Rating Scale (PSYRATS)
Mean 16.86
SD 3.14
Range 9-22
Persecution and Deservedness Scale (PaDS)
76.62
19.03
17.5-100
Positive and Negative Syndrome ScalePANSS (Positive Scale)
20.38
3.78
14-29
Positive and Negative Syndrome ScalePANSS (Negative Scale)
14.95
6.03
8-29
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
Positive and Negative Syndrome ScalePANSS (Total Score)
Table 1 summarises the clinical characteristics of the persecutory delusions group. For the PSYRATS, the clinical group scored comparably to other studies with patients selected for current persecutory delusions (e.g. Freeman et al, 2014). The scores on the PaDS for levels of persecutory ideation in this group were similar to those in a recent study by Melo and Bentall (2013), which found that the mean persecution score in a similar group was 70.23% (SD=17.37). The Beck Depression Inventory (BDI) was completed by both the group with persecutory delusions (mean= 22.81; SD= 11.43) and the control group (mean= 6.43; SD= 6.96) and a significant group difference was clearly apparent, U=47.00, p<0.001. 3.2 The self-concept in patients with persecutory delusions Tables 2 and 3 summarise the group scores on the measures of self-concept. It can be seen that there were significant and clear group differences for all measures, apart from self-stigma. The persecutory delusion had much more negative self-cognitions and fewer positive self-cognitions. The effect size differences were all large.
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Table 2- Means, standard deviations, t values, confidence intervals, p values, and effect sizes for measures of negative self-cognition. Measure Mean (SD) t Value Confidence p Value Effect Size (df) interval (d) (95%) Clinical NonClinical Self Compassion 2.40 3.64 -5.34 -1.72 to -0.77 <0.001 d= 1.60 Scale (SCS) (0.53) (0.92) (40)
Brief Core Schema Scale Positive self (BCSS-P)
6.60 (4.71)
14.95 (4.73)
-5.65 (39)
-11.34 to -5.37
<0.001
d= 1.76
Social Comparison Scales (SCS)
608.37 (323.84)
1147.48 (337.40)
-5.14 (38)
-751.30 to 326.91
<0.001
d=1.78
Rosenberg Self Esteem Scale (RSES)
11.95 (5.63)
21.10 (4.49)
-5.81 (40)
-12.32 to -5.96
<0.001
d= 1.79
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Table 3-Mean ranks, mean scores, U scores, p values, and effect sizes for measures of negative self. Measure Mean Rank Mean Scores U Score p Value Effect Size (Standard Deviation) (d) Clinical
NonClinical
Clinical
NonClinical
Brief Core Schema Scale Negative self (BCSS-N)
28.50
13.86
9.45 (5.02)
3.05 (4.98)
30.00
p< 0.001
1.28 (Large)
Self-Stigma of Mental Illness Scale (SSMIS)
23.58
17.71
31.21 (14.52)
25.19 (13.56)
141.00
p= 0.11
0.43 (Medium)
Mental Health Worries Questionnaire (MHWQ)
25.88
16.36
34.40 (16.41)
23.57 (6.17)
112.50
p= 0.01
0.88 (Large)
3.3 Suicidal Ideation and negative self Correlational analyses were conducted in order to investigate potential associations between suicidal ideation and the measures of self-cognitions (see Table 4). Suicidal ideation was highly associated with low self-compassion, low self-esteem, negative self-schema, and negative selfcomparisons to others. Fears of madness and depression were also significantly related to suicidal ideation. Self-stigma was not related to current levels of suicidal ideation. It can also be seen in Table 4 that all the self-concept assessments, apart from self-stigma, were highly correlated with each other. Table 4- Correlations of suicide with negative self-constructs and depression 1 _
2
Self Compassion Scale (SCS)
-0.64 p=0.002
_
3.
Fear of Madness (MHWQ)
0.48 p= 0.03
4.
Rosenberg SelfEsteem Scale (RSES)
-0.77 p< 0.001
-0.64 p< 0.001 0.80 p< 0.001
-0.67 p< 0.001
_
5.
Self-Stigma of Mental Illness Scale (SSMIS)
-0.19 p= 0.42
-0.27 p= 0.09
0.41 p= 0.009
-0.22 p= 0.17
_
6.
Social Comparison Scale (SCS)
-0.67 p= 0.002
0.85 p< 0.001
-0.52 p< 0.001
0.79 p< 0.001
-0.12 p= 0.45
_
7.
Brief Core
0.56
-0.82
0.73
-0.75
0.39
-0.76
1.
Beck Suicide Scale (BSS)
2.
3
4
5
6
7
8
9
_
_
9
8.
Schema Scale (Negative)
p= 0.009
p< 0.001
p< 0.001
p< 0.001
p= 0.01
p< 0.001
Beck Depression Inventory (BDI)
0.54 p= 0.01
-0.73 p< 0.001
0.72 p< 0.001
-0.79 p< 0.001
0.46 p= 0.002
-0.66 p< 0.001
-0.66 p< 0.001
_
4. Discussion The current study investigated a number of different conceptualisations of the negative self in patients with persecutory delusions, and also examined associations with the clinically important problem of suicidal ideation in this population. Findings suggested that negative self-cognitions in those with persecutory delusions are marked and globally low, however they are conceptualised. The findings in the delusions group are in line with previous studies (e.g. Fowler et al., 2012; Hutton et al., 2013). Patients with persecutory delusions experience severe feelings of being inferior to others, worry that they are mad, and have lower self-compassion. They have increased negative beliefs about themselves, decreased positive beliefs about themselves, low self-esteem, and low mood. The only construct which did not significantly differ between the two groups was self-stigma, which was an unexpected finding, although the relatively small sample size limited the power of the study to the detection of large effect size differences only. We conclude that negative self-concept in patients with persecutory delusions are a clear treatment target, and may well lead to consequent improvement in the paranoia. The levels of suicidal ideation in the group with persecutory delusions were high, even compared to other studies of people with psychosis (e.g. Beck and Steer, 1991). Suicidal ideation was highly associated with low self-esteem, negative self-schema, fears of madness, and lower levels of selfcompassion. The evidence of links between suicidal ideation and a range of negative self views is entirely plausible, and consistent with previous research that has utilised fewer self-concept assessments (e.g. Fialko et al., 2006). Several important limitations must be considered in this study. The cross-sectional design means that it is not possible to determine cause and effect, and it may be argued by some that the findings related to negative self-cognitions in this study are simply a result of the high levels of depression and/or paranoia in the persecutory delusions group (i.e. the cognitions themselves are secondary to affect). One consideration was whether to conduct an analysis controlling for level of depression, but it has been argued that this would be highly likely to remove genuine variance of interest (see Miller and Chapman, 2001). The sample size also was insufficient to detect anything other than large differences between the measures. Further, although the groups were well matched for age and gender, the groups were clearly biased in terms of employment status, which would affect the scores. Future research would benefit from longitudinal studies in larger sample sizes. Although we believe that the pressing issue now is how best to treat negative self-cognitions in patients with psychosis (Freeman et al., 2014). A number of small studies have investigated treatment of negative self-cognitions, including self-compassion (Mayhew and Gilbert, 2008; Braehler et al., 2013) and selfesteem (Hall and Tarrier, 2003). However, these studies have not tested improvements in persecutory delusions specifically. The current findings suggest that there are several different ways in which negative self-cognitions associated with persecutory delusions may be framed. No single construct was identified as the key treatment direction, however, negative self-schema, selfcompassion, self-esteem and negative self-comparisons to others were found to be most important. All constructs were highly inter-correlated, with the exception of self-stigma, which did not correlate with negative self-comparisons to others. Therefore, a flexible, individually tailored approach to improving self confidence in this patient group may be possible. We suspect that at this stage of knowledge, the language and concepts that best resonate with an individual patient may prove best
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to use in treatment.
Acknowledgements DF is supported by a National Institute for Health Research (NIHR) Research Professorship.
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Drake, R., Haddock, G., Tarrier, N., Bentall, R., Lewis, S., 2007. The psychotic symptoms rating scales (PSYRATS): their usefulness and properties in first episode psychosis. Schizophr. Res. 89 119122. Eicher, A. C., Davis, L. W., Lysaker, P. H., 2013. Self-compassion: a novel link with symptoms in schizophrenia? J. Nerv. Ment. Dis. 201, (5), 1-5. Faul, F., Erdfelder, E., Lang, A.G., Buchner, A., 2007. G* Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav. Res. Meth. 39, (2), 175191. Fowler, D., Freeman, D., Smith, B., Kuipers, E., Bebbington, P., Bashforth, H., Coker, S., Hodgekins, J., Gracie, A., Dunn, G., Garety, P., 2006. The brief core schema scale (BCSS): psychometric properties and associations with paranoia and grandiosity in non-clinical and psychosis samples. Psychol. Med. 36, 749-759. Fowler, D., Hodgekins, J., Garety, P., Freeman, D., Kuipers, E., Dunn, G., Smith, B., Bebbington, P.E., 2012. Negative cognition, depressed mood, and paranoia: a longitudinal pathway analysis using structural equation modelling. Schizophr. Bull. 38, 1063-1073.
Freeman, D., Evans, N., Lister, A., Antley, A., Dunn, G., Slater, M., 2014. Height, social comparison and paranoia: an immersive virtual reality experimental study. Psychiatry Res. 218, 37, 348362. Freeman, D., Garety, P.A. 2000. Comments on the content of persecutory delusions: Does the definition need clarification? Br. J. Clin. Psychol. 39, 407−414. Freeman, D., Garety, P.A., Bebbington, P.E., Smith, B., Rollinson, R., Fowler, D., Kuipers, E., Ray, K., Dunn, G., 2005. Psychological investigation of the structure of paranoia in a non-clinical population. Br. J. Psychiatry. 186, (5), 427-435. Freeman, D., Garety, P. A., Fowler, D., Kuipers, E., Dunn, G., Bebbington, P., Hadley, C., 1998. The London-East Anglia randomised controlled trial of cognitive-behaviour therapy for psychosis IV: self-esteem and persecutory delusions. Br. J. Clin. Psychol. 37, (4), 415-430. Freeman, D., Garety, P.A., Kuipers, E., Fowler, D., Bebbington, P.E., 2002. A cognitive model of persecutory delusions. Br. J. Clin. Psychol. 41, 331-347. Freeman, D., McManus, S., Brugha, T., Meltzer, H., Jenkins, R., Bebbington, P., 2011. Concomitants of paranoia in the general population. Psychol. Med. 41, 923-936.
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Freeman, D., Morrison, P.D., Murray, R.M., Evans, N., Lister, R., Dunn, G., 2013. Persecutory ideation and a history of cannabis use. Schizophr. Res. 148, 122-125 Freeman, D., Pugh, K., Dunn, G., Evans, N., Sheaves, B., Waite, F., Cernis, E., Lister, R., Fowler, D., 2014. An early phase II randomised controlled trial testing the effect on persecutory delusions of using CBT to reduce negative cognitions about the self: the potential benefits of enhancing self confidence. Schizophrenia Res. 160, (1-3), 186-192. Freeman, D., Stratup, H., Dunn, G., Wingham, G., Cernis, E., Evans, N., Lister, R., Pugh, K., Cordwell, J & Kingdon, D. 2014. Persecutory delusions and psychological well-being. Soc. Psychiatry Psychiatr. Epidemiol. 49 (7), 1045-1050. Freeman, D., Stahl, D., McManus, S., Meltzer, H., Brugha, T., Wiles, N., 2012. Insomnia, worry, anxiety and depression as predictors of the occurrence and the persistence of persecutory ideation. Soc. Psychiatry Psychiatric Epidemiol. 47, 1195–203. Freeman, D., Thompson, C., Vorontsova, N., Dunn, G., Carter, L. A., Garety, P., Kuipers, E., Slater, M., Antley, A., Glucksman, E., Ehlers, A., 2013. Paranoia and post-traumatic stress disorder in the months after a physical assault: a longitudinal study examining shared and differential predictors. Psychol. Med. 43 (12), 2673-2684. Garety, P.A., Freeman, D., 2013. The past and future of delusions research: from the inexplicable to the treatable. Br. J. Psychiatry. 203, (5), 327-333. Gracie, A., Freeman, D., Green, S., Garety, P. A., Kuipers, E., Hardy, A., Ray, K., Dunn, G., Bebbington, P., Fowler, D., 2007. Acta Psychiatrica Scandinavia, 116, (4), 280-289. Gumley, A. I., MacBeth, A., Reilly, J. D., O’Grady, M., White, R. G., McLeod, H., Schwannauer, M., Power, K. G., 2015. Fear of recurrence: results of a randomized trial of relapse detection in schizophrenia. Br. J Clin. Psychol. 54, 49-62. Haddock, G., McCarron, J., Tarrier, N., Faragher, E.B., 1999. Scales to measure dimensions of hallucinations and delusions: The psychotic symptom rating scales (PSYRATS). Psychol. Med. 29, 879-889. Hall, P., Tarrier, N. (2003). The cognitive-behavioural treatment of low self-esteem in psychotic patients: a pilot study. Behav. Res. Ther. 41, 317-332. Hutton, P., Kelly, J., Lowens, I., Taylor, P., Tai, S., 2013. Self-attacking and self-reassurance in persecutory delusions: a comparison of healthy, depressed and paranoid individuals. Psychiatry Res. 205, 127-136. IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Kay, S.R., Flszbein, A., Opfer, L.A., 1987. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr. Bull. 13, (2), 261. Kay, S.R., 1991. Positive and negative syndromes in schizophrenia: assessment and research (No. 5). Psychology Press.
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Kesting, M.L., Lincoln, T.M., 2013. The relevance of self-esteem and self-schemas to persecutory delusions: a systematic review. Comp. Psychiatry. 54 (7), 766-789. King, E.A., Baldwin, D.S., Sinclair, J. M., 2001. The wessex recent in-patient suicide study, I. Case— control study of 234 recently discharged psychiatric patient suicides. Br. J. Psychiatry. 178, 531 -536. Klonsky, D.E., Kotov, R., Bakst, S., Rabinowitz, J., Bromet, E.J., 2012. Hopelesness as a predictor of attempted suicide among first admission patients with psychosis: a 10 year cohort study. Suicide Life Threat. Behav. 42, 1-10. Lecomte, T., Cyr, M., Lesage, A., Wilde, J., Leclere, C., Ricard, N., 1999. Efficacy of a self-esteem module in the empowerment of individuals with chronic schizophrenia. J. Nerv. Ment. Dis. 187, 406–413. Lincoln, T. M., Hohenhaus, F., Hartmann, M., (2013). Can paranoid thoughts be reduced by targeting negative emotions and self-esteem? An experimental investigation of a brief compassionfocused intervention. Cogn. Ther. Res. 37, (2), 390-402. MacBeth, A., Gumley, A. (2012). Exploring compassion: a meta-analysisof the association between self-compassion and psychopathology. Clin. Psychol. Rev. 32, (6), 545-552. Mayhew, S. L., Gilbert, P. (2008). Compassionate mind training with people who hear malevolent voices: A case series report. Clin. Psychol. Psychother.11, 113-138. Melo, S., Corcoran, R., Shryane, N., Bentall, R.P., 2009. The persecution and deservedness scale. Psychol. Psychother. Theory. Res. Prac. 82, (3), 247-260. Melo. S., Bentall, R.P., 2010. Coping in subclinical paranoia: a two nations study. Psychol. Psychotherapy. Theo. Res. Prac. 83, 407-420. Mills, A., Gilbert, P., Bellew, R., McEwan, K., Gale, C., 2007. Paranoid beliefs and self criticism in students. Clin. Psychol. Psychother. 14, 358-364. Neff, K., (2003a). Development and validation of a scale to measure self-compassion. Self Identity, 2 223-250. Neff, K. 2003b. Self-compassion: an alternative conceptualisation of a healthy attitude towards oneself. Self Identity. 2, 85-191. Oliver, J.E., O’Connor, J.A., Jose, P.E., McLachlan, K., Peters, E., 2012. The impact of negative schemas, mood and psychological flexibility on delusional ideation- mediating and moderating effects. Psychosis: Psychological, Social and Integrative Approaches. 4, 6-18. Pinninti, N., Steer, R.A., Rissmiller, D.J., Nelson, S., Beck, A.T., 2002. Use of the Beck scale for suicide ideation with psychiatric inpatients diagnosed with schizophrenia, schizoaffective or bipolar disorders. Behav. Res. Ther. 40, (9), 1071-1079. Rodrigues, S., Serper, M., Novak, S., Corrigan, P., Hobart, M., Ziedonis, M., Smelson, D., 2013. SelfStigma, Self-Esteem, and Co-occurring Disorders. J. Dual Diagnosis, 9, (2), 129-133.
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Ronald, A., Sieradzka, D., Cardno, A.G., Haworth, C.M., McGuire, P., Freeman, D., 2014. Characterisation of psychotic experiences in adolescents using the specific psychotic experiences questionnaire: findings from a study of over 5000 16 year-old twins. Schizophr. Bull. 40 (4), 868-877. Rosenberg, M., 1965. Rosenberg self-esteem scale (RSES). Acceptance and Commitment Therapy. Measures Package, 61. Smith, B., Fowler, D.G., Freeman, D., Bebbington, P., Bashforth, H., Garety, P., Dunn, G., Kuipers, E., 2006. Emotion and psychosis: links between depression, self esteem, negative schematic beliefs and delusions and hallucinations. Schizophr. Res. 86 (1-3), 181-188. Smith, S., Smith, R., Smith, J., Orgill, J., 2011. Qualtrics. Provo, Utah, USA. www.qualtrics.com Thewissen, V., Bentall, R.P., Lecomte, T., van Os, J., Myin-Germeys, I., 2008. Fluctuations in selfesteem and paranoia in the context of daily life. J. Ab. Psych. 117, 143-153. Tiernan, B., Tracey, R., Ciaran, S., 2014. Paranoia and self-concepts in psychosis: a systematic review of the literature. Psychiatry Res. 216 (3), 303-313. Turner, M. H., Bernard, M., Birchwood, M., Jackson, C., Jones, C., 2012. The contribution of shame to post-psychotic trauma. Br. J. Clin. Psychol. 52, (2), 162-182. Waite, F., Knight, M.T.D., Lee, D. 2015. Self-compassion and self-criticism in recovery in psychosis: An Interpretative Phenomenological Analysis Study. Br. J. Clin. Psychol. 71, (12), 1201-1217. White, R. G., Gumley, A. I., 2009. Post-psychotic PTSD: associations with fear of recurrence and intolerance of uncertainty. J. Nerv. Ment. Dis. 197, 841-849. Zessin, U., Dickhauser, O., Garbade, O. (2015). The relationship between self-compassion and wellbeing: a meta-analysis. Appl. Psychol. Health Well Being, 7, (3), 340-364. Highlights Patients with persecutory delusions had marked negative self cognitions. Low self-compassion, low self-esteem and increased fears of madness were found. Also beliefs of inferiority, negative self-schemas, and low positive self-schemas. Suicidal ideation was highly associated with several negative self constructs.
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S0165-1781(16)30303-1 http://dx.doi.org/10.1016/j.psychres.2016.02.043 PSY9480
To appear in: Psychiatry Research Received date: 21 April 2015 Revised date: 25 January 2016 Accepted date: 17 February 2016 Cite this article as: Nicola Collett, Katherine Pugh, Felicity Waite and Daniel Freeman, 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 Authors, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2016.02.043 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: 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 Authors: Nicola Collettᵃ, Katherine Pughᵇ, Felicity Waiteᵇ, Daniel Freemanᵇ 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.
*Corresponding Author. Telephone: 07912 074629. Email: [email protected]
Abstract There has been growing awareness of the high prevalence of negative cognitions about the self in patients with persecutory delusions, and it has been proposed that paranoid fears build upon these perceived vulnerabilities. This study aimed to investigate for the first time a wide range of different conceptualisations of the negative self, and to examine associations with suicidal ideation, in patients with persecutory delusions. Twenty-one patients with persecutory delusions and twentyone non-clinical individuals completed measures relating to negative self cognitions. The delusions group also completed a measure of suicidal ideation. It was found that the patients with persecutory delusions had low self-compassion, low self-esteem, increased fears of being mad, beliefs of inferiority to others, negative self-schemas, and low positive self-schemas when compared to the non-clinical control group. The effect sizes (Cohen’s d) were large, and the different conceptualisations of negative self cognitions were highly associated with one another. Self-stigma did not differ between the two groups. Furthermore, suicidal ideation was highly associated with low self-compassion, low self-esteem, fears of madness, and negative self-schema but not selfstigma. 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. Keywords: psychosis, schizophrenia, suicidal ideation, negative self-concept, self-compassion, selfesteem
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1. Introduction Three recent literature reviews have all confirmed a connection of paranoia to negative cognitions about the self (Garety and Freeman, 2013; Kesting and Lincoln, 2013; Tiernan et al., 2014). It has been hypothesised that paranoia builds upon the sense of vulnerability that low self-worth triggers (Freeman et al., 2005). Consistent with this, a longitudinal study with 301 patients with psychosis indicated that negative self beliefs predict the later severity of persecutory delusions (Fowler et al., 2012). Furthermore, two experimental studies by our group show that in individuals with paranoid ideation the induction of negative self cognitions leads to an increase in paranoia (Freeman et al., 2014; Atherton et al., 2014). This has led to a clinical test of targeting negative self beliefs in patients with persecutory delusions (Freeman et al., 2014). Although there are multiple ways that negative self cognitions can be conceptualised, studies have mainly focussed upon negative self beliefs and low self esteem. In this paper we examine five concepts together in patients with persecutory delusions: 1). self-compassion, 2). schema, 3). self-stigma, 4). fears of madness and 5). self-esteem. Further, we examine their links to the clinically important problem of suicidal ideation in patients with psychosis.
1.1. Five conceptualisations of negative self cognitions Self-compassion has been defined by Neff (2003a) as comprising three components: self-kindness versus self-judgement in our responses to pain or failure, common humanity versus isolation when understanding one’s own suffering, and being mindful versus over-identification when paying attention to our own suffering (Neff, 2003a). Self-compassion involves an open, non-judgemental stance to our own pain and suffering, which is viewed as part of the human condition and promotes self-kindness (Neff, 2003b). Two recent meta-analyses have found that self-compassion is an important explanatory variable in understanding psychopathology and wellbeing (MacBeth and Gumley, 2012; Zessin et al., 2015). Eicher et al. (2013) found in a study of 88 participants with either schizophrenia or schizoaffective disorder that higher scores on the self-compassion scale were negatively associated with positive symptoms of psychosis. Qualitative accounts from patients with psychosis highlight the potential role of self-compassion in facilitating recovery in psychosis (Waite et al., 2015). Current research studies have found positive outcomes for compassion focussed therapy for psychosis (Mayhew and Gilbert, 2008; Brahler et al., 2013). However, these studies have not focussed on reducing symptoms of psychosis, and they do not focus specifically on persecutory delusions. Mills et al. (2007) found in a study of 131 students that paranoia was significantly negatively correlated with scores on the selfcompassion scale (Neff, 2003), indicating in particular the presence of self-judgement, isolation, and over-identification in those with higher paranoia scores. Hutton and colleagues (2013) found that a group of 15 patients with persecutory delusions were significantly less likely to self-reassure compared to non-clinical controls. These authors propose that a decreased capacity to self-reassure may activate perceptions of threat. Lincoln et al. (2013) found in an experimental study that a brief compassion focused manipulation decreased paranoid thoughts in a non-clinical population. However, no studies have yet specifically explored levels of self-compassion in a clinical group of people with persecutory delusions, although specific elements have been examined in one study (Hutton et al. 2013). Negative self-schema, defined as stable negative self evaluations which influence the individual’s interpretation of situations (Beck et al., 1979), is a concept well-established in depression research (Beck et al., 1967). In contrast to self-compassion, their potential role in paranoia has been tested in cross-sectional (e.g. Gracie et al., 2007; Smith et al., 2006), longitudinal (e.g. Fowler et al., 2011; Oliver et al., 2012; Freeman et al., 2013) and experimental studies (e.g. Freeman et al., 2008), using 2
the Brief Core Schema Scale (Fowler et al., 2006). In a recent pilot randomised controlled trial with patients with persecutory delusions, there was evidence that targeting negative self cognitions may lead to reductions in paranoia (Freeman et al., 2014). To date negative self beliefs have been most strongly connected to paranoia, compared to, for example, self esteem (Fowler et al., 2006). The experience of mental health problems often leads to further difficulties for how people view themselves. Self stigma is the internalisation of harmful stereotypes, which results in a reduction in self esteem (Link and Phelan, 2001; Corrigan and Watson, 2002; Corrigan et al., 2011). Corrigan et al. (2011) propose that internalising stereotypes about mental illness, for example concerning dangerousness and poor recovery rates, decreases self-esteem in individuals with serious mental health difficulties. In a study of 49 people with schizophrenia, self-stigma was associated with low self-esteem (Rodrigues et al., 2013). No studies to date have explored self-stigma and persecutory delusions specifically. A specific type of self-stigma in relation to mental health problems is the fear that one is ‘mad’, and in a cross-sectional study higher levels of fears of madness have been associated with greater distress associated with persecutory delusions (Bassett et al., 2009). Typical fears of madness are concerns that one is unable to tell the difference between reality and imagination, worrying that the mind is falling apart, and a fear of being locked up forever. Fear of recurrence of psychosis is a predictor of the development of psychosis-related post-traumatic stress disorder (White and Gumley, 2009). Gumley et al. (2015) found that fear of recurrence of psychosis was associated with increased risk of relapse and increased emotional distress, suggesting that individual’s idiosyncratic appraisals may influence relapse (Gumley et al., 2015). Finally, self-esteem has been considered as a central factor in the occurrence of persecutory delusions, with differing views on whether paranoia reflects a defence against low self-esteem (Bentall et al., 2001) or is a direct reflection of low self-esteem (Freeman et al., 2002). Multiple studies, but not all, demonstrate that low self-esteem is present in patients with persecutory delusions (e.g. Combs et al., 2009; Freeman et al., 1998). For instance, in a study of 154 participants who ranged across the continuum of paranoia, paranoia was found to be associated with lower selfesteem, and fluctuations in self-esteem were predictive of paranoia (Thewissen et al., 2008). Findings from studies on self-esteem interventions for people with psychosis have demonstrated improvements in positive symptoms (Lecomte et al., 1999; Hall and Tarrier, 2003) which may also lend support for a connection between self-esteem and positive symptoms of psychosis. 1.2. Persecutory delusions and suicide It is estimated that approximately 5% of patients with psychosis commit suicide (Hor and Taylor, 2010). Paranoid ideation in the general population too is associated with suicidal ideation (Freeman et al., 2011). To our knowledge there are no psychological studies of specific psychological constructs that are associated with suicide specifically in patients with persecutory delusions. But an association has been established between suicidal ideation and hopelessness as predictors for attempted and completed suicide in psychosis (Klonsky et al., 2012; King et al., 2001). Turner et al. (2012) found an association between internal and external shame associated with psychosis, and symptoms of trauma in fifty patients with psychosis, who were not acutely psychotic at the time. Internal shame was also associated with depression (Turner et al., 2012), suggesting that shame may be a key emotion in depression in psychosis. Filako et al. (2006) found that suicidal ideation in people with psychosis was associated with depressed mood, low self-esteem, and negative beliefs about the self and others, pointing towards negative self-cognitions as an important link to suicidal ideation. Overall, these findings highlight the importance of considering suicidal ideation in relation to negative self-cognition in individuals with persecutory delusions.
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The current study set-out to examine these five different conceptualisations of negative self cognitions specifically in patients with persecutory delusions. It was hypothesised that patients with persecutory delusions, compared to non-clinical controls, would demonstrate negative self-schema, self-stigma, fears of madness, low self-compassion and low self-esteem. Of these constructs, associations with self-esteem were expected to be the smallest, since it has been argued that some studies have not shown associations between clinical paranoia and low self-esteem (Bentall et al., 2001). We did expect the different constructs to be highly correlated. Finally, we hypothesised that negative self cognitions in participants with persecutory delusions will be associated with suicidal ideation.
2. Method A cross-sectional, between-groups comparison was conducted. 2.1. Participants Twenty-one participants with persecutory delusions were recruited from clinical teams in Oxford Health NHS Foundation Trust. Inclusion criteria were: experience of a current persecutory delusion as defined by Freeman and Garety (2000); a clinical diagnosis of non-affective psychosis; and aged eighteen years or over. Participants were excluded if English was not their first language, or if they were unable to complete questionnaire measures. The clinical group completed measures in an assessment session with the first author. The non-clinical control group was matched by age and gender. Twenty one control participants were recruited from a participant pool. The participant pool was developed from respondents to a previous advert for participation in studies (Freeman et al. 2013). The non-clinical control participants had no self-reported history of a mental health problem. They completed measures online using Qualtrics (Smith et al., 2011).
2.2. Measures 2.2.1 Measures of psychotic experiences Psychotic Symptom Rating Scale - Delusions (PSYRATS; Haddock et al., 1999) The PSYRATS is a 6 item assessment of preoccupation, conviction, distress and disruption associated with the delusion over the previous fortnight. Higher scores indicate greater delusional severity. The PSYRATS has good reliability and validity for the assessment of delusions in participants with psychosis (e.g. Drake et al., 2007). The Positive and Negative Syndrome Scales (PANSS) (Kay et al., 1987) The PANSS is a 30 item interviewer-rated tool to assess psychiatric symptom severity present in the previous 72 hours. Ratings are delivered using a 7 point scale (1-7). Higher scores are indicative of increased symptom severity. Kay et al. (1991) found good reliability and validity for the PANSS in a cohort of 101 participants with schizophrenia. Persecution and Deservedness Scale (PaDS) (Melo et al., 2009) This is a 10 item self-report measure of the severity of paranoid thinking and the level of perceived deservedness for the persecution. Only the section on persecution was employed in this study. Higher scores represent greater levels of persecutory ideation. The PaDS demonstrates high validity and reliability and is validated for use in clinical samples (Melo et al., 2009). The scoring for this measure uses a percentage as described by Melo and Bentall (2010).
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2.2.2 Measures of negative self cognitions The Self-Compassion Scale (SCS) (Neff, 2003a) The SCS is a 26 item self-report scale comprising statements (e.g. “I try to be loving towards myself when I am feeling emotional pain”) for which responses can range from 1 (Almost Never) to 5 (Almost Always). An overall self-compassion score is provided, as well as scores for sub-scales including self-judgement, isolation, over-identification, self-kindness, common humanity, and mindfulness. Scores for total self compassion were calculated by reverse scoring negative subscale items (self-judgement, isolation and over identification) before calculating subscale means for all six subscales. An overall mean of all six subscale means was then computed, as suggested by Neff (2003). Higher total self-compassion scores indicate greater self-compassion in times of distress. The SCS demonstrates good construct validity. The Brief Core Schema Scale (BCSS) (Fowler et al., 2006) The BCSS is a 24 item self-report measure which assesses beliefs about self and others. Items are rated using a 0-4 scale, and comprises four factors (negative self, positive self, negative others and positive others) with a score given for each factor. Only the items related to self were included in this study. For the six items on negative self (e.g. “I am worthless”), the greater the total on this subscale, the greater the negative beliefs about the self. For the positive subscale (e.g. “I am respected”), the larger the total, the more positive beliefs a person holds. Addington and Tran (2009) concluded that the psychometric properties of the BCSS make it appropriate for use in this population. Self-Stigma of Mental Illness Scale (SSMIS) (Corrigan et al., 2006) This 40 item measure comprises four subscales. Only the agreement subscale, which denotes the level to which people agree with stereotypes of mental illness, was employed in this study (e.g. “I think most persons with mental illness are to blame for their problems”). This was to investigate stigma about mental illness amongst people with and without persecutory delusions. Good internal consistency and concurrent validity for the measure has been established (Corrigan et al., 2006). Responses are given on a 9 point scale (9 = strongly agree). Higher total scores indicate greater endorsement of self-stigma (Corrigan et al., 2011). Mental Health Worries Questionnaire (MHWC)( Bassett et al., 2009) This is a 20 item self-report measure of fears of madness and associated distress in the previous week (e.g. “I worry my mind is falling apart”). Responses relate to levels of distress associated with fears ranging from 0 (not at all) to 5 (extremely distressing) for each statement item. Initial findings have shown good reliability and validity for the scale (Bassett et al., 2009). Higher total scores represent greater levels of distressing fears about madness. Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965) The RSES is the most used self-esteem measure and comprises ten items (e.g. “I feel that I'm a person of worth, at least on an equal plane with others.”). The higher the RSES score the lower selfesteem. A four point Likert scale of agreement (4- “strongly disagree”) is used for scoring. Items are totalled into an overall scale which has been shown to have good internal consistency in individuals with serious mental health problems (Corrigan et al., 2011; Corrigan et al., 2006). Social Comparison Scale (SCS) (Allan and Gilbert, 1995) Participants’ beliefs about how they compare to others were measured using an adapted version of the Social Comparison Scale. This 19 item self-report scale asks participants to rate how they have felt in relation to others during the previous week, on items including inferior/superior and incompetent/competent. Eleven items were from the original scale (e.g. inferior versus superior)
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and eight items (e.g. failure versus success) were newly added. 2.2.3 Measures of depression and suicidal ideation Beck Depression Inventory (BDI) (Beck, 1967) The BDI is a 21-item self-report measure of symptoms of depression over the past fortnight. Each item involves selecting one of four statements, with scores for each varying between 0 and 3. Higher total scores indicate higher levels of depression. Items tap cognitive distortions, hopelessness, suicidal ideation and physiological symptoms including fatigue. The BDI demonstrates good construct validity and reliability (Beck et al., 1988). Beck Scale for Suicidal Ideation (BSS) (Beck and Steer, 1991) This is a 21-item self-report measure of thoughts, attitudes, and intentions about suicide. Items are rated on a three point scale (0 to 2), with a total possible score of 38. Higher total scores indicate higher levels of suicidal thinking. The measure has good internal reliability (.96), and one study showed that the BSI had a test re-test reliability of 0.88 (p<0.001) (Pinninti et al., 2002). In addition, Pinninti et al. (2002) found that the BSI was positively correlated with past suicide attempts (r=0.46, p<0.001) and recommended it for use with participants with psychosis.
2.3 Analysis Data were analysed using the Statistics Package for Social Sciences (SPSS version 20) (IBM, 2011). For the first hypothesis, t-tests and Mann Whitney U tests were employed to test group differences on the self-concept measures, depending on whether assumptions for the use of parametric tests were met. A Cohen’s d calculation was used to determine effect sizes, in order to establish which negative self-concepts showed the largest group differences. For the second main hypothesis, associations with suicidal ideation for the self-concept measures within the clinical group were tested using Pearson’s r. Correlation coefficients were similarly used to examine associations between the individual self-concept measures. Power calculations to establish the required sample size were based on the Mental Health Worries Questionnaire (MHWQ) data from Bassett et al. (2009), which was the most similar study. It showed effect sizes (d) of 0.80. 80% power to detect such an effect size at the conventional significance level of 0.05 requires a sample size of 26 (G Power; Faul et al., 2007). All hypothesis testing was two-tailed.
3. Results 3.1 Participant Characteristics For the clinical group (n=21) the mean age was 45.6 years (SD=12.1; range: 21-66), compared to a mean age of 41.9 years (SD=12.2; range: 22-61) in the control group (n=21). The gender balance was the same in both groups (males n=10; 48% and females n=11; 52%). More participants in the clinical group were unemployed (n=18; 86%), compared with the control group (n=5; 24%). No significant difference was found between participants with persecutory delusions and control participants for age (t= .885, df= 30.06, p=.383) or gender ( ²=0.00, df=1, p=0.74). However, there was a significant difference between the groups for employment status, with significantly fewer employed participants in the delusion group ( ²= 14.40, df=1, p<0.001).
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Table 1- Means, standard deviations, and ranges for the clinical group on the symptom measures Measure Psychotic Symptoms Rating Scale (PSYRATS)
Mean 16.86
SD 3.14
Range 9-22
Persecution and Deservedness Scale (PaDS)
76.62
19.03
17.5-100
Positive and Negative Syndrome ScalePANSS (Positive Scale)
20.38
3.78
14-29
Positive and Negative Syndrome ScalePANSS (Negative Scale)
14.95
6.03
8-29
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
Positive and Negative Syndrome ScalePANSS (Total Score)
Table 1 summarises the clinical characteristics of the persecutory delusions group. For the PSYRATS, the clinical group scored comparably to other studies with patients selected for current persecutory delusions (e.g. Freeman et al, 2014). The scores on the PaDS for levels of persecutory ideation in this group were similar to those in a recent study by Melo and Bentall (2013), which found that the mean persecution score in a similar group was 70.23% (SD=17.37). The Beck Depression Inventory (BDI) was completed by both the group with persecutory delusions (mean= 22.81; SD= 11.43) and the control group (mean= 6.43; SD= 6.96) and a significant group difference was clearly apparent, U=47.00, p<0.001. 3.2 The self-concept in patients with persecutory delusions Tables 2 and 3 summarise the group scores on the measures of self-concept. It can be seen that there were significant and clear group differences for all measures, apart from self-stigma. The persecutory delusion had much more negative self-cognitions and fewer positive self-cognitions. The effect size differences were all large.
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Table 2- Means, standard deviations, t values, confidence intervals, p values, and effect sizes for measures of negative self-cognition. Measure Mean (SD) t Value Confidence p Value Effect Size (df) interval (d) (95%) Clinical NonClinical Self Compassion 2.40 3.64 -5.34 -1.72 to -0.77 <0.001 d= 1.60 Scale (SCS) (0.53) (0.92) (40)
Brief Core Schema Scale Positive self (BCSS-P)
6.60 (4.71)
14.95 (4.73)
-5.65 (39)
-11.34 to -5.37
<0.001
d= 1.76
Social Comparison Scales (SCS)
608.37 (323.84)
1147.48 (337.40)
-5.14 (38)
-751.30 to 326.91
<0.001
d=1.78
Rosenberg Self Esteem Scale (RSES)
11.95 (5.63)
21.10 (4.49)
-5.81 (40)
-12.32 to -5.96
<0.001
d= 1.79
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Table 3-Mean ranks, mean scores, U scores, p values, and effect sizes for measures of negative self. Measure Mean Rank Mean Scores U Score p Value Effect Size (Standard Deviation) (d) Clinical
NonClinical
Clinical
NonClinical
Brief Core Schema Scale Negative self (BCSS-N)
28.50
13.86
9.45 (5.02)
3.05 (4.98)
30.00
p< 0.001
1.28 (Large)
Self-Stigma of Mental Illness Scale (SSMIS)
23.58
17.71
31.21 (14.52)
25.19 (13.56)
141.00
p= 0.11
0.43 (Medium)
Mental Health Worries Questionnaire (MHWQ)
25.88
16.36
34.40 (16.41)
23.57 (6.17)
112.50
p= 0.01
0.88 (Large)
3.3 Suicidal Ideation and negative self Correlational analyses were conducted in order to investigate potential associations between suicidal ideation and the measures of self-cognitions (see Table 4). Suicidal ideation was highly associated with low self-compassion, low self-esteem, negative self-schema, and negative selfcomparisons to others. Fears of madness and depression were also significantly related to suicidal ideation. Self-stigma was not related to current levels of suicidal ideation. It can also be seen in Table 4 that all the self-concept assessments, apart from self-stigma, were highly correlated with each other. Table 4- Correlations of suicide with negative self-constructs and depression 1 _
2
Self Compassion Scale (SCS)
-0.64 p=0.002
_
3.
Fear of Madness (MHWQ)
0.48 p= 0.03
4.
Rosenberg SelfEsteem Scale (RSES)
-0.77 p< 0.001
-0.64 p< 0.001 0.80 p< 0.001
-0.67 p< 0.001
_
5.
Self-Stigma of Mental Illness Scale (SSMIS)
-0.19 p= 0.42
-0.27 p= 0.09
0.41 p= 0.009
-0.22 p= 0.17
_
6.
Social Comparison Scale (SCS)
-0.67 p= 0.002
0.85 p< 0.001
-0.52 p< 0.001
0.79 p< 0.001
-0.12 p= 0.45
_
7.
Brief Core
0.56
-0.82
0.73
-0.75
0.39
-0.76
1.
Beck Suicide Scale (BSS)
2.
3
4
5
6
7
8
9
_
_
9
8.
Schema Scale (Negative)
p= 0.009
p< 0.001
p< 0.001
p< 0.001
p= 0.01
p< 0.001
Beck Depression Inventory (BDI)
0.54 p= 0.01
-0.73 p< 0.001
0.72 p< 0.001
-0.79 p< 0.001
0.46 p= 0.002
-0.66 p< 0.001
-0.66 p< 0.001
_
4. Discussion The current study investigated a number of different conceptualisations of the negative self in patients with persecutory delusions, and also examined associations with the clinically important problem of suicidal ideation in this population. Findings suggested that negative self-cognitions in those with persecutory delusions are marked and globally low, however they are conceptualised. The findings in the delusions group are in line with previous studies (e.g. Fowler et al., 2012; Hutton et al., 2013). Patients with persecutory delusions experience severe feelings of being inferior to others, worry that they are mad, and have lower self-compassion. They have increased negative beliefs about themselves, decreased positive beliefs about themselves, low self-esteem, and low mood. The only construct which did not significantly differ between the two groups was self-stigma, which was an unexpected finding, although the relatively small sample size limited the power of the study to the detection of large effect size differences only. We conclude that negative self-concept in patients with persecutory delusions are a clear treatment target, and may well lead to consequent improvement in the paranoia. The levels of suicidal ideation in the group with persecutory delusions were high, even compared to other studies of people with psychosis (e.g. Beck and Steer, 1991). Suicidal ideation was highly associated with low self-esteem, negative self-schema, fears of madness, and lower levels of selfcompassion. The evidence of links between suicidal ideation and a range of negative self views is entirely plausible, and consistent with previous research that has utilised fewer self-concept assessments (e.g. Fialko et al., 2006). Several important limitations must be considered in this study. The cross-sectional design means that it is not possible to determine cause and effect, and it may be argued by some that the findings related to negative self-cognitions in this study are simply a result of the high levels of depression and/or paranoia in the persecutory delusions group (i.e. the cognitions themselves are secondary to affect). One consideration was whether to conduct an analysis controlling for level of depression, but it has been argued that this would be highly likely to remove genuine variance of interest (see Miller and Chapman, 2001). The sample size also was insufficient to detect anything other than large differences between the measures. Further, although the groups were well matched for age and gender, the groups were clearly biased in terms of employment status, which would affect the scores. Future research would benefit from longitudinal studies in larger sample sizes. Although we believe that the pressing issue now is how best to treat negative self-cognitions in patients with psychosis (Freeman et al., 2014). A number of small studies have investigated treatment of negative self-cognitions, including self-compassion (Mayhew and Gilbert, 2008; Braehler et al., 2013) and selfesteem (Hall and Tarrier, 2003). However, these studies have not tested improvements in persecutory delusions specifically. The current findings suggest that there are several different ways in which negative self-cognitions associated with persecutory delusions may be framed. No single construct was identified as the key treatment direction, however, negative self-schema, selfcompassion, self-esteem and negative self-comparisons to others were found to be most important. All constructs were highly inter-correlated, with the exception of self-stigma, which did not correlate with negative self-comparisons to others. Therefore, a flexible, individually tailored approach to improving self confidence in this patient group may be possible. We suspect that at this stage of knowledge, the language and concepts that best resonate with an individual patient may prove best
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to use in treatment.
Acknowledgements DF is supported by a National Institute for Health Research (NIHR) Research Professorship.
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