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A Transdiagnostic Investigation of Patients With Schizophrenia Spectrum Disorders and Depression

Richard P. Bentall, PhD; Georgina Rowse, ClinPsyD; Nick Shryane, PhD; Peter Kinderman, PhD; Robert Howard, MD, MRCPsych; Nigel Blackwood, MD; Rosie Moore, MSc; Rhiannon Corcoran, PhD

Arch Gen Psychiatry. 2009;66(3):236-247.

Context  Paranoid delusions are a common symptom of a range of psychotic disorders. A variety of psychological mechanisms have been implicated in their cause, including a tendency to jump to conclusions, an impairment in the ability to understand the mental states of other people (theory of mind), an abnormal anticipation of threat, and an abnormal explanatory style coupled with low self-esteem.

Objective  To determine the structure of the relationships among psychological mechanisms contributing to paranoia in a transdiagnostic sample.

Design  Cross-sectional design, with relationships between predictor variables and paranoia examined by structural equation models with latent variables.

Setting  Publicly funded psychiatric services in London and the North West of England.

Participants  One hundred seventy-three patients with schizophrenia spectrum disorders, major depression, or late-onset schizophrenia-like psychosis, subdivided according to whether they were currently experiencing paranoid delusions. Sixty-four healthy control participants matched for appropriate demographic variables were included.

Main Outcome Measures  Assessments of theory of mind, jumping to conclusions bias, and general intellectual functioning, with measures of threat anticipation, emotion, self-esteem, and explanatory style.

Results  The best fitting (²₉₆ = 131.69, P = .01; comparative fit index = 0.95; Tucker-Lewis Index = 0.96; root-mean-square error of approximation = 0.04) and most parsimonious model of the data indicated that paranoid delusions are associated with a combination of pessimistic thinking style (low self-esteem, pessimistic explanatory style, and negative emotion) and impaired cognitive performance (executive functioning, tendency to jump to conclusions, and ability to reason about the mental states of others). Pessimistic thinking correlated highly with paranoia even when controlling for cognitive performance (r = 0.65, P < .001), and cognitive performance correlated with paranoia when controlling for pessimism (r = –0.34, P < .001).

Conclusions  Both cognitive and emotion-related processes are involved in paranoid delusions. Treatment for paranoid patients should address both types of processes.

Author Affiliations: The School of Psychology, University of Bangor, Bangor, Wales (Dr Bentall); Department of Psychology, University of Sheffield, Sheffield, England (Dr Rowse); Institute for Social Change, University of Manchester, Manchester, England (Dr Shryane); The Department of Clinical Psychology, University of Liverpool, Liverpool, England (Dr Kinderman); The Institute of Psychiatry, Kings College London, London, England (Drs Howard and Blackwood and Ms Moore); and Division of Psychiatry, School of Community Health Sciences, University of Nottingham, Nottingham, England (Dr Corcoran).

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