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

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.

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 twenty-one 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 self-stigma. 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.

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., 2014a; Atherton et al., 2016). This has led to a clinical test of targeting negative self beliefs in patients with persecutory delusions (Freeman et al., 2014a, Freeman et al., 2014b, Freeman et al., 2014c). 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.

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; Braehler 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 self-compassion sc (Neff, 2003a), indicating in particular the presence of self-judgement, isolation, and over-identification in those with higher paranoia scores. Hutton et al. (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, 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; Freeman et al., 2013a, Freeman et al., 2013b, Oliver et al., 2012) and experimental studies (e.g. Freeman et al., 2008), using 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., 2014b). 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.

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 self-esteem, 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.

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. Fialko 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-cognitions in individuals with persecutory delusions.

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.