Department of Psychology, Institute of Psychiatry, Kings College London
Department of Mental Health Sciences, Royal Free and University College Medical School, London
School of Medicine, Health Policy and Practice, University of East Anglia, Norwich
Department of Psychology
Department of Biostatistics and Computing, Institute of Psychiatry, Kings College London
Biostatistics Group, Division of Epidemiology and Health Sciences, University of Manchester, Manchester, UK
Correspondence: Dr Daniel Freeman, Department of Psychology, PO Box 77, Institute of Psychiatry, Denmark Hill, London SE5 8AF, UK. E-mail: D.Freeman{at}iop.kcl.ac.uk
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To assess a wide range of paranoid thoughts multidimensionally and examine their distribution, to identify the associated coping strategies and to examine socialcognitive processes and paranoia.
Method Six questionnaire assessments were completed by 1202 individuals using the internet.
Results Paranoid thoughts occurred regularly in approximately a third of the group.Increasing endorsement of paranoid thoughts was characterised by the recruitment of rarer and odder ideas. Higher levels of paranoia were associated with emotional and avoidantcoping, less use of rational and detached coping, negative attitudes to emotional expression, submissive behaviours and lower social rank.
Conclusions Suspiciousnessis common and there may be a hierarchical arrangement of such thoughts that builds on common emotional concerns.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
This study provides information on the frequency in a non-clinical sample of paranoid ideation, and the associated levels of conviction and distress. Such information can be useful to present to patients in the clinical setting, but no comparable research examining a wide range of paranoid thoughts, or considering such thoughts from a multidimensional perspective, has hitherto been published. There is no published evidence on, for example, the weekly frequency of paranoia in the general population. We predicted that the distribution of suspicious thoughts would be similar to that of affective symptoms, with many people having a few suspicious thoughts and a few people having many (Melzer et al, 2002). Moreover, as with affective symptoms, increasing symptom counts will be characterised by the recruitment of rarer and odder ideas (Sturt, 1981). There may be a hierarchy of paranoid thoughts. The study also had the aim of identifying how individuals in the general population cope with paranoid thoughts. We wished to identify the coping strategies that were associated with the most and the least distress. Finally, we examined potential connections between paranoia and three socialcognitive processes: attitudes to emotional expression, social comparison and submissive behaviours.
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Questionnaires
Paranoia Scale
The 20-item, self-report Paranoia Scale
(Fenigstein & Vanable,
1992) was developed to measure paranoia in college students. Each
item is rated on a five-point scale (1 not at all applicable, 5 extremely
applicable). Scores can range from 20 to 100, with the higher scores
indicating greater paranoid ideation. It is the most widely used dimensional
measure of paranoia. However, the scale contains many items that are not
clearly persecutory (e.g. My parents and family find more fault with me
than they should) and does not provide an estimate of the frequency or
distress of paranoid thoughts. The Paranoia Checklist was therefore developed
specifically for this study.
Paranoia Checklist
The Paranoia Checklist was devised to investigate paranoid thoughts of a
more clinical nature than those assessed in the Paranoia Scale and to provide
a multi-dimensional assessment of paranoid ideation. The checklist has 18
items, each rated on a five-point scale for frequency, degree of conviction,
and distress. We report the convergent validity of the Paranoia Checklist in
relation to the Paranoia Scale in the results section.
Coping Styles Questionnaire
The Coping Styles Questionnaire (CSQ;
Roger et al, 1993)
builds upon the Ways of Coping Checklist
(Folkman & Lazarus, 1980),
and was validated with a UK student sample. The questionnaire comprises 60
coping strategies rated on a four-point frequency scale. Participants were
asked to complete the questionnaire for how they typically react to the
worries assessed in the Paranoia Checklist. There are four factors: rational
coping, detached coping, emotional coping and avoidance coping. The former two
factors are considered by the questionnaire developers as adaptive and the
latter two as maladaptive.
Attitudes to Emotional Expression Questionnaire
On the Attitudes to Emotional Expression Questionnaire
(Joseph et al, 1994) respondents were asked to rate how much they agree on a five-point scale (1
agree very much, 2 agree slightly, 3 neutral, 4 disagree slightly, 5 disagree
very much) with four attitudes to emotional expression (e.g. I think
you should always keep your feelings under control). Higher scores
indicate more positive attitudes to emotional expression.
Social Comparison Scale
On the Social Comparison Scale (Gilbert
& Allan, 1994) participants rate, by selecting a number
between 1 and 10, whether they generally feel in relation to others:
inferiorsuperior; less competentmore competent; less
likeablelikeable; more reservedless reserved; left
outaccepted. Higher scores indicate higher perceived social rank.
Submissive Behaviours Scale
The Submissive Behaviours Scale (Allan
& Gilbert, 1997) is a 16-item scale assessing a number of
behaviours considered as submissiveness (e.g. I agree that I am wrong,
even though I know Im not). Each behaviour is rated on a
five-point scale (0 never, 4 always). Higher scores indicate greater use of
submissive behaviours.
Analysis
Analyses were conducted using the Statistical Package for the Social
Sciences, SPSS for Windows, version 11.0
(SPSS, 2001). Significance
test results are quoted as two-tailed probabilities.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Reliability and validity of the Paranoia Checklist
Cronbachs a for each of the three dimensions of the Paranoia
Checklist was 0.9 or above, indicating excellent internal reliability. As
would be expected, time taken to complete the Paranoia Checklist had a small
positive correlation with a total score for frequency, conviction and distress
(r=0.10, P<0.001). The Paranoia Scale was completed by
1016 of the Paranoia Checklist respondents. The mean Paranoia Scale score of
the total group was 42.7 (s.d.=14.3), which is comparable with that reported
by Fenigstein & Vanable
(1992). There was convergent
validity of the checklist with the Paranoia Scale: higher Paranoia Scale
scores correlated with Paranoia Checklist frequency (r=0.71,
P<0.001), conviction (r=0.62, P<0.001) and
distress scores (r=0.58, P<0.001).
Prevalence of thoughts with a paranoid content
The frequencies, conviction and distress associated with the suspicious
thoughts assessed in the Paranoia Checklist are displayed in Tables
1,
2,
3. There was appreciable
endorsement of the checklist items. The 1-week prevalence of the individual
thoughts ranged from 3% (I can detect messages about me in the
press/TV/radio) to 52% (I need to be on my guard against
others) (Table 1). The
mean frequency score was 11.9 (s.d.=10.5, range 064; 25th percentile
4.0, 50th percentile 9.0, 75th percentile 16.0). Between 2% and 7% of
participants adhered to individual thoughts with a level of absolute
conviction (Table 2). If we
consider levels of belief of somewhat or greater, there is more
variation between the individual items (456%). The mean conviction
score was 16.7 (s.d.=12.1, range 072; 25th percentile 8.0, 50th
percentile 14.0, 75th percentile 22.0). Between 1% and 7% of participants
found individual thoughts very distressing
(Table 3). Again, there was
more variation between the thoughts if distress was taken as at least
somewhat distressing or greater (342%). The mean distress score
was 14.6 (s.d.=12.2, range 070; 25th percentile 5.0, 50th percentile
12.0, 75th percentile 21.0).
|
|
|
The different dimensions of the Paranoia Checklist were positively correlated. Frequency scores were correlated with conviction (r=0.75, P<0.001) and distress (r=0.66, P<0.001), and conviction and distress scores were also positively correlated (r=0.65, P<0.001). There were no differences between men and women in the frequency (t=0.66, d.f.=1190, P=0.51) or conviction (t=1.03, d.f.=1190, P=0.30) with which paranoid thoughts were experienced. Females did report a significantly higher level of distress associated with the thoughts (t=2.72, d.f.=1190, P=0.007, mean difference 2.07, 95% CI 3.60 to 0.58), although it can be seen that this difference is very small.
In Tables 4 and 5 the levels of conviction and distress associated with each suspicious thought are reported for the individuals experiencing such ideas at least weekly. Here it can be seen that the rarer and more implausible paranoid items (e.g. There is a possibility of a conspiracy against me) are held with the strongest levels of conviction and associated with the most distress. This is confirmed by high negative correlations between the frequency of (at least weekly) endorsement of questionnaire items and the percentage of people who believed the thought absolutely (n=18; r=-0.74, P<0.001) and with the percentage of people who found the thought very distressing (n=18; r=0.75, P<0.001). In other words, the less frequently experienced thoughts were held with proportionately more conviction and distress.
|
|
To examine whether people who endorsed the rarer items also endorsed the more common suspicious thoughts with higher conviction and distress, we split the sample into those who endorsed at least one rare item (items with frequency less than 10%) (n=277) and those who did not endorse a rare item (n=925). The two groups were then compared on levels of conviction and distress for the eight most common items (endorsement rates of over 20%). Each one of these comparisons was made only for the individuals in the two groups who had endorsed the item (i.e. experienced the thought at least weekly). The rarer item group had significantly higher conviction rates for seven of the eight common suspicious thoughts and significantly higher distress levels for five of the eight common suspicious thoughts (P<0.05). It seems that individuals with the rarer thoughts were also experiencing the commoner thoughts more strongly.
We predicted that suspiciousness in the general population would have a profile similar to that of affective symptoms. First, there would be a single population distribution rather than evidence of a bimodal distribution (i.e between clinical paranoia and non-clinical paranoia). Second, the rarer ideas would be associated with the presence of many other suspicions; put another way, the relationship between rare symptoms and common symptoms would be non-reflexive, in that the former would be more predictive of the latter than vice versa. The total number of checklist items endorsed by each person was first calculated (endorsement referring to weekly occurrence or above). The count of suspicious thoughts could therefore range from 0 to 18. The distribution of the count is displayed in Fig. 1. It can be seen that the suspicious thought count follows a single continuous model (Melzer et al, 2002). The distribution closely fits an exponential curve. To examine whether the rarer thoughts were associated with a higher rate of endorsement of other checklist items, the mean difference for the suspicious thought count was calculated between those with and those without each suspicious thought (correcting for the contribution due to that item; Sturt, 1981). The mean difference (i.e. the excess of endorsement associated with each item) was significantly associated with the frequency of item endorsement (n=18; r=-0.75, P<0.001). Thus, the rarer checklist items were associated with a higher total score than were the more common ones. For example, endorsing the item There might be negative comments being circulated about me (frequency 42%) was associated with endorsing 3.9 other checklist items in comparison with not endorsing the item. Endorsing the item There is a possibility of a conspiracy against me (frequency 5%) was associated with endorsing 7.0 other checklist items in comparison with not endorsing the item.
|
Coping with paranoid thoughts
A total of 1046 participants also completed the CSQ. Higher levels of
emotional and avoidant coping were associated with higher levels of paranoia
(Table 6). In contrast, higher
levels of detached coping were associated with lower levels of paranoia.
Higher levels of rational coping were associated with lower levels of paranoia
frequency and distress, but not significantly with paranoia conviction. In
Table 7 we highlight the coping
strategies most strongly correlated with paranoia frequency.
|
|
Socialcognitive processes and paranoid thoughts
There were significant but generally modest associations between the
socialcognitive processes and the dimensions of paranoia. Negative
attitudes to emotional expression, lower social comparison (particularly
feeling left out) and greater use of submissive behaviours were significantly
associated with greater paranoia (Table
8).
|
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Hierarchy of paranoia
Our survey clearly indicates that suspicious thoughts are a weekly
occurrence for many people: 3040% of the respondents had ideas that
negative comments were being circulated about them and 1030% had
persecutory thoughts, with thoughts of mild threat (e.g. People
deliberately try to irritate me) being more common than severe threat
(e.g. Someone has it in for me). In contrast, only a small
proportion (approximately 5%) of respondents endorsed the checklist items that
were the most improbable (e.g. that there was a conspiracy). Nevertheless, the
rarer and odder suspicions characteristic of clinical presentations
occurred in tandem with the more common and plausible experiences. The
rarer the thought, then the higher the total score indicated by its presence.
There has been no previous examination of paranoia in this way.
The findings indicate a hierarchy of paranoia (Fig. 2): the most common type of suspiciousness is that of a social anxiety or interpersonal worry theme; ideas of reference build upon these sensitivities; persecutory thoughts are closely associated with the attributions of significance; as the severity of the threatened harm increases, the less common the thought; and suspiciousness involving severe harm and organisations and conspiracy is at the top of the hierarchy. The implication is that severe paranoia may build upon common emotional concerns, consistent with a recent cognitive model of persecutory delusions (Freeman et al, 2002; Freeman & Garety, 2004). The interesting questions therefore concern the identification of the additional factors that contribute to the development of severe paranoia and whether there are qualitative shifts in experience at the top end of the hierarchy (note that individuals at the higher end of the hierarchy tended to endorse all their suspicious thoughts with high levels of conviction and distress). The survey findings also indicate that there is a continuous (exponential) distribution of total number of suspicious thoughts in the general population, although the thoughts appear in a hierarchical arrangement. No distinct subpopulation was identified. This therefore demonstrates correspondence to common mental health disorders such as depression and anxiety.
|
Interestingly, the ideation captured in this survey did not seem to be restricted to passing thoughts that were dismissed almost in the same instant that they occurred. Approximately 1020% of the survey respondents held paranoid ideation with strong conviction and significant distress. It is likely that the survey identified a significant group of people who were having distressing experiences that they managed on their own. We believe that there is a reticence in the general population about discussing the occurrence of suspicious thoughts, partly arising from the negative connotations associated with the term paranoia and a lack of recognition of how common these experiences actually are. The provision of the type of information obtained in this survey may help to normalise paranoia and set the stage for making the experience understandable. This is an important element in the development of alternative explanations of experiences (Freeman et al, 2004).
Coping with paranoid thoughts
If paranoia is an everyday phenomenon, which many people manage well, then
it provides an opportunity to gain clinically useful information on optimal
ways of coping. More frequent and distressing paranoia was associated with
becoming isolated, giving up activities, and feelings of powerlessness and
depression. Conversely, less frequent paranoia was associated with not
catastrophising and by gaining sufficient (metacognitive) distance to consider
the situation dispassionately. More broadly, coping with paranoia may resemble
coping with other stressful or negative events: rational (or task-oriented)
coping and detachment from the situation are more helpful than emotional or
avoidant coping. It is not clear to what extent poor coping encourages
paranoia, and to what extent strong paranoia interferes with effective
coping.
Socialcognitive factors
There has been a re-emergence of the study of the influence of social
factors on psychosis by examining their impact at the cognitive level of
explanation (Garety et al,
2001). In our survey associations were found between paranoia and
socialcognitive processes that could plausibly exacerbate
suspiciousness. Thus, we found evidence that not expressing feelings to others
may increase suspiciousness. This follows early research on the psychological
consequences of the Herald of Free Enterprise ferry disaster, which
indicated that negative attitudes to emotional expression in survivors were
associated with higher levels of anxiety
(Joseph et al,
1997).
There was a significant association of paranoia with submissive behaviours. As Allan & Gilbert (1997) note, people who have difficulties in asserting themself which these authors conceptualise within an evolutionary framework as having low dominance and inferior social rank can be vulnerable to a number of psychological problems. Further, these authors report that submissiveness is associated with paranoid thoughts and with angry thoughts and feelings. Attributions that others have negative intentions underlie feelings of anger. We think that in some cases anger may contribute to the attribution of intent in persecutory ideation. However, rather than expressing anger or resentment towards others, individuals may instead ruminate and feel aggrieved owing to timidity or submissiveness. This will maintain a state in which external attributions and anomalous experiences are more likely, thus leading to the persistence of persecutory ideation.
We also found that respondents who felt left out, inferior or less competent in relation to others displayed higher levels of suspiciousness. Birchwood et al (2000) reported a connection between social comparison and the experience of hearing voices. We suggest that a lack of social self-confidence might make people feel vulnerable to attack and hence contribute to the occurrence of paranoia. This is consistent with experimental evidence that interpersonal sensitivity predicts persecutory ideation (Freeman et al, 2003). It is of note, however, that in our study the associations of paranoia with many of the variables were of small to medium effect size. This is unsurprising, and is consistent with the view that paranoia is a complex phenomenon likely to arise from a number of social, cognitive and biological factors.
Interventions for paranoid thoughts
Our study has practical implications for clinical interventions in
paranoia. Interventions may be more effective if they include recognition of
the ubiquity of suspiciousness; encourage talking about such experiences with
others; improve self-esteem; help people in negotiating relationships with
others; and encourage detachment and feelings of control over the situation.
These are all central components of cognitivebehavioural interventions
for psychosis (e.g. Fowler et al,
1995; Chadwick et al,
1996).
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Birchwood, M., Meaden, A., Trower, P., et al (2000) The power and omnipotence of voices: subordination and entrapment by voices and significant others. Psychological Medicine, 30, 337 344.[CrossRef][Medline]
Birnbaum, M. H. (2001) Introduction to Behavioural Research on the Internet. Englewood Cliffs, NJ: Prentice-Hall.
Chadwick, P. D. J., Birchwood, M. J. & Trower, P. (1996) Cognitive Therapy for Delusions, Voices and Paranoia.Chichester: Wiley.
Fenigstein, A. & Vanable, P. A. (1992) Paranoia and self-consciousness. Journal of Personality and Social Psychology, 62, 129 138.[CrossRef][Medline]
Folkman, S. & Lazarus, R. S. (1980) An analysis of coping in a middle-aged community sample. Journal of Health and Social Behaviour, 21, 219 239.[Medline]
Fowler, D., Garety, P. A. & Kuipers, L. (1995) Cognitive Behaviour Therapy for Psychosis: Theory and Practice. Chichester: Wiley.
Freeman, D. & Garety, P. A. (2004) Paranoia: The Psychology of Persecutory Delusions.Hove:Psychology Press.
Freeman, D., Garety, P. A., Kuipers, E., et al (2002) A cognitive model of persecutory delusions. British Journal of Clinical Psychology, 41, 331 347.[CrossRef][Medline]
Freeman, D., Slater, M., Bebbington, P. E., et al (2003) Can virtual reality be used to investigate persecutory ideation? Journal of Nervous and Mental Disease, 191, 509 514.[Medline]
Freeman, D., Garety, P. A., Fowler, D., et al (2004) Why do people with delusions fail to choose more realistic explanations for their experiences? An empirical investigation. Journal of Consulting and Clinical Psychology, 72, 671 680.[CrossRef][Medline]
Garety, P. A., Kuipers, E., Fowler, D., et al (2001) A cognitive model of the positive symptoms of psychosis. Psychological Medicine, 31, 189 195.[CrossRef][Medline]
Gilbert, P. & Allan, S. (1994) Assertiveness, submissive behaviour and social comparison. British Journal of Clinical Psychology, 33, 295 306.[Medline]
Johns, L. C., Cannon, M., Singleton, N., et al
(2004) Prevalence and correlates of self-reported psychotic
symptoms in the British population. British Journal of
Psychiatry, 185, 298
305.
Joseph, S., Yule, W., Williams, R., et al (1994) Correlates of post-traumatic stress at 30 months: the Herald of Free Enterprise disaster. Behaviour Research and Therapy, 32, 521 524.[CrossRef][Medline]
Joseph, S., Dalgleish, T., Williams, R., et al (1997) Attitudes towards emotional expression and post-traumatic stress in survivors of the Herald of Free Enterprise disaster. British Journal of Clinical Psychology, 36, 133 138.[Medline]
Melzer, D., Tom, B. D. M., Brugha, T. S., et al (2002) Common mental disorder symptom counts in populations: are there distinct case groups above epidemiological cut-offs? Psychological Medicine, 32, 1195 1201.[CrossRef][Medline]
Rachman, S. & de Silva, P. (1978) Abnormal and normal obsessions. Behaviour Research and Therapy, 16, 233 248.[CrossRef][Medline]
Roger, D., Jarvis, G. & Najarian, B. (1993) Detachment and coping: the construction and validation of a new scale for measuring coping strategies. Personality and Individual Differences, 15, 619 626.[CrossRef]
SPSS (2001) SPSS Base 11.0.1 Users Guide.Chicago, IL: SPSS.
Sturt, E. (1981) Hierarchical patterns in the distribution of psychiatric symptoms. Psychological Medicine, 11, 783 794.[Medline]
Van Os, J. & Verdoux, H. (2003) Diagnosis and classification of schizophrenia: categories versus dimensions, distributions versus disease. InThe Epidemiology of Schizophrenia (eds R. M. Murray, P. B. Jones, E. Susser, et al), pp. 364410. Cambridge: Cambridge University Press.
Received for publication March 23, 2004. Revision received September 9, 2004. Accepted for publication September 10, 2004.
HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |