The psychological effect of an urban environment on individuals with persecutory delusions: The Camberwell walk study

doi:10.1016/j.schres.2007.10.027

Schizophrenia Research

Volume 99, Issues 1–3, February 2008, Pages 77-84

https://doi.org/10.1016/j.schres.2007.10.027 Get rights and content

Abstract

Background

Epidemiological studies have found that individuals who live in urban areas are at increased risk of developing psychosis. However it is unknown whether exposure to urban environments exacerbates psychotic symptoms in people who have a diagnosed psychotic disorder. The aim of the study was to examine the psychological and clinical effects of exposure to one specific deprived urban environment on individuals with persecutory delusions. It was predicted that the urban environment would affect emotional and reasoning processes highlighted in a cognitive model of persecutory delusions and would increase paranoia.

Method

Thirty patients with persecutory delusions were randomised to exposure to a deprived urban environment or to a brief mindfulness relaxation task. After exposure, assessments of symptoms, reasoning, and affective processes were taken. Thirty matched non-clinical participants also completed the study measures to enable interpretation of the test scores.

Results

In individuals with persecutory delusions, exposure to the urban environment, rather than participation in a mindfulness task, increased levels of anxiety, negative beliefs about others and jumping to conclusions. It also increased paranoia. The individuals with persecutory delusions scored significantly differently from the non-clinical group on all measures.

Conclusions

For individuals with psychosis, spending time in an urban environment makes them think more negatively about other people and increases anxiety and the jumping to conclusions reasoning bias. Their paranoia is also increased. A number of processes hypothesised in cognitive models to lead to paranoid thoughts are exacerbated by a deprived urban environment. Further research is needed to clarify which aspects of urban environments cause the negative effects. Methodological challenges in the research area are raised.

Introduction

An impressively consistent literature now shows that the occurrence of psychosis is increased in urban environments (eg. Van Os, 2004, Sundquist et al., 2004, Marcelis et al., 1998, Kirkbride et al., 2006). For example, in a longitudinal study of 4.4 million people in Sweden those people living in the most densely populated areas had 68–77% greater risk of developing psychosis than those in the least populated areas (Sundquist et al., 2004). However, less is known about whether exposure to urban environments increases psychotic symptoms in people who are already diagnosed with a psychotic illness. In examining this question, it is also possible to investigate the effects on cognitive and emotional processes resulting from environmental exposure, which might be involved in developing or exacerbating symptoms (Freeman, 2007, Garety et al., 2007).

The aim of the study was, therefore, to investigate, for the first time, the effects of brief exposure to a specific urban environment on psychotic processes and symptoms. We hypothesised that entering an urban environment would lead to exacerbation of psychological processes implicated in a cognitive model of persecutory delusions (Freeman et al., 2002, Freeman, 2007, Garety et al., 2001). That is, we predicted that spending time in a busy inner London high street would make an individual with current persecutory delusions more anxious, more negative about the self and others and increase the jumping to conclusions reasoning bias. Feeling more threatened, pessimistic and quick to make decisions would, in turn, be likely to increase paranoid thinking in a circular relationship. In this study, we did not set out to investigate which aspects, if any, of an urban environment, would be responsible for observed effects. The emphasis was on testing the effects of exposure to a real-life situation, routinely encountered by patients. This study of going into a busy street converges both with the traditional stress-vulnerability perspective on psychosis (eg. Zubin and Spring, 1977) and with recent research indicating that people with psychosis are especially emotionally reactive to everyday stress (see review by Myin-Germeys and van Os, 2007).

Section snippets

Participants

The main group comprised thirty individuals with current persecutory delusions (see Table 1). The inclusion criteria were: a current persecutory delusion as defined by Freeman and Garety (2000); a diagnosis of non-affective psychosis (schizophrenia, delusional disorder, schizo-affective psychosis); and aged 18–65 years. The exclusion criteria were: primary diagnosis of alcohol or substance dependency, organic syndrome or learning disability. Age and IQ matched non-clinical control individuals (n

Results

The clinical group predominantly contained individuals with a diagnosis of schizophrenia and an illness history of approximately ten years (see Table 2). On the PSYRATS, all clinical participants scored either 3 or 4 for delusion conviction and for delusion distress. These are the highest scores on the scale. For example, Category 3 is defined as conviction in the delusional belief as between 50–99% and Category 4 is defined as ‘conviction is 100%’. The participants were therefore experiencing

Discussion

McGrath (2007) has highlighted ‘the surprisingly rich contours of schizophrenia epidemiology’ and the robust evidence that those born and raised in cities have an increased risk of developing schizophrenia compared with those raised in rural areas. We have tried to map these contours more closely by examining the effects of brief exposure to an urban environment in a group already experiencing delusions, on factors implicated in the development of persecutory delusions. We have discussed

Role of the funding source

Funding for this study was provided by a programme grant from the Wellcome Trust (No. 062452) and by a grant from the Central Research Fund, University of London; the Wellcome Trust and Central Research Fund had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Contributors

Daniel Freeman, Philippa Garety and Lynn Ellett designed the study and contributed to the final manuscript. Daniel Freeman and Lynn Ellett wrote the manuscript. Lynn Ellett carried out the data collection as part of a Doctorate in Clinical Psychology.

Conflict of interest

All three authors have no conflicts of interest.

Acknowledgment

The work was supported by a programme grant from the Wellcome Trust (No. 062452) and by a grant from the Central Research Fund, University of London.

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^☆: Daniel Freeman is supported by a Wellcome Trust Fellowship.

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The psychological effect of an urban environment on individuals with persecutory delusions: The Camberwell walk study☆

Abstract

Background

Method

Results

Conclusions

Introduction

Section snippets

Participants

Results

Discussion

Role of the funding source

Contributors

Conflict of interest

Acknowledgment

Schizophrenia Research

Clinical Psychology Review,

Clinical Psychology Review,

The Brief Core Schema Scales (BCSS): psychometric properties and associations with paranoia and grandiosity in non-clinical and psychosis samples

Psychological Medicine

Comments on the contents of persecutory delusions: does the definition need clarification?

British Journal of Clinical Psychology

A cognitive model of persecutory delusions

British Journal of Clinical Psychology

Overcoming Paranoid and Suspicious Thoughts

A measure of state persecutory ideation for experimental studies

Journal of Nervous and Mental Disease

Cognitive approaches to delusions: a critical review of theories and evidence

British Journal of Clinical Psychology

Reasoning in deluded schizophrenic and paranoid patients: biases in performance on a probabilistic inference task

Journal of Nervous and Mental Disorder

A cognitive model of the positive symptoms of psychosis

Psychological Medicine

Reasoning, emotions and delusional conviction in psychosis

Journal of Abnormal Psychology

Implications for neurobiological research of cognitive models of psychosis

Psychological Medicine,

Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS)

Psychological Medicine