How does paranoia develop

Along with hallucinations, delusion is one of the cardinal symptoms of schizophrenic disorders. Paranoia, in particular, is one of the most common delusional experiences both in patients (Sartorius et al., 1986) and in the general population (Freeman et al., 2011). Through the scientific examination of the phenomenon of paranoia, the previously existing definition of paranoid madness has been realigned over the past twenty years. The dichotomous either-or category of pathological symptoms could be abandoned in favor of a continuum of paranoid experiences, which extends from subclinical delusional ideas to pronounced bizarre paranoid delusional systems (T. Lincoln, 2007; Nuevo et al., 2012; van Os, Linscott, Myin-Germeys, Delespaul, & Krabbendam, 2009). In accordance with bio-psycho-social disorder models of schizophrenia (Nuechterlein & Dawson, 1984; Yank, Bentley, & Hargrove, 1993), emotional-cognitive models of the delusional experience could be developed (Freeman, Garety, Kuipers, Fowler, & Bebbington, 2002; Freeman & Garety, 2014; Kuipers et al., 2006). With these, the nimbus of an uncorrectable delusional experience (Jaspers, 1913) was finally discarded and those affected and the practitioners were shown starting points for the changeability of stressful paranoid symptoms on a scientific basis. On the basis of these findings, the present dissertation examines the etiological role of loneliness and examines the extent to which this construct can be integrated into existing models of the development and maintenance of delusion. Various studies show the high prevalence of loneliness among those affected by schizophrenic disorders (Meltzer et al., 2013; Sündermann, Onwumere, Kane, Morgan, & Kuipers, 2014), who often experience or experience rejection, social exclusion or stigmatization (Gras et al., 2014; Switaj, Grygiel, Anczewska, & Wciórka, 2013; Yang et al., 2013). Loneliness is closely linked to the subjective experience of social interactions and integration into a social structure and includes various emotional and cognitive facets that could lead to paranoid experiences (Mikulincer & Segal, 1990; Schwab, 1997). In the first study of this dissertation, the causality in the relationship between loneliness and paranoia was investigated and examined which moderating role the risk of developing a schizophrenic disorder has on the connection between loneliness and paranoia. The second study looked at mechanisms related to loneliness and paranoia in a clinical sample. This included the mediating influence of negative external patterns as well as possible causes of loneliness such as perceived social support and the frequency of social contacts. Experimentally induced or reduced loneliness causally affected paranoia in Study I. This relationship was greater in high-risk persons (study I) and was completely mediated by negative external patterns in the clinical sample (study II). In the third study of this dissertation, the effectiveness of a mood-stabilizing cognitive-behavioral therapeutic concept for the treatment of delusional symptoms as well as its feasibility was investigated. Depressiveness and other stressful emotions were shown to be closely linked to the development of delusional symptoms (Freeman et al., 2002; Fusar-Poli, Nelson, Valmaggia, Yung, & McGuire, 2014; Garety & Freeman, 2013; Smith et al., 2006) . The first British studies in an inpatient context demonstrated the effectiveness of cognitive behavioral therapy (Durrant, Clarke, Tolland, & Wilson, 2007; Haddock et al., 1999), which is recommended in the guidelines for all phases of the disorder (Gaebel, Falkai, Weinmann, & Wobrock, 2006; National Collaborating Center for Mental Health, 2014), but is only inadequately implemented across national borders (Bechdolf & Klingberg, 2014; Haddock et al., 2014). Against the background of existing cognitive disorder models for delusional experiences, a manualized inpatient treatment concept (Mehl, 2013) in pre-post design was examined in terms of its effectiveness and feasibility. Delusional and positive symptoms were significantly reduced with large effect sizes and in the majority of cases to a clinically relevant degree. In particular, the delusional facets of stress and occupation were reduced with large effect sizes. In addition, the depressive symptoms could be reduced and the psychotherapeutic approach was well integrated into the regular operation of the ward for schizophrenia. In future studies, the findings of this pre-post comparison should also be checked against a control group in a randomized procedure. The results of the first and second studies confirm the important role of loneliness in connection with the development of paranoid symptoms and shed light on other interpersonal cognitive processes involved. The connections and the causal classification as well as implications for research and psychotherapy are discussed against the background of the findings of the first two studies. The findings of the pilot study on mood-stabilizing cognitive behavioral therapy in the focus area of ​​schizophrenia are discussed against the background of the processes involved and a possible adaptation of the concept.

Delusions are part of the core symptoms of psychosis. Paranoia in particular is one of the most predominant among delusional symptoms in clinical samples (Sartorius et al., 1986) and also highly prevalent in non-clinical individuals (Freeman et al., 2011). Over the past two decades researchers developed a multidimensional definition of paranoia that is based on a continuum between sub-clinical paranoid ideation and severe and bizarre paranoid delusions (T. Lincoln, 2007; Nuevo et al., 2012; van Os et al., 2009). On this basis and in line with bio-psycho-social models of schizophrenia (Nuechterlein & Dawson, 1984; Yank et al., 1993) emotion and cognitive based models of paranoia were developed (Freeman et al., 2002; Freeman & Garety, 2014; Kuipers et al., 2006). The statute that delusions were unalterable with methods of psychotherapy (Jaspers, 1913) could be rejected in favor of scientific proof for psychological predictors of paranoia and thus create a basis for cognitive-behavioral therapy and its interventions. Several studies showed a high prevalence of loneliness in individuals with psychosis (Meltzer et al., 2013; Sündermann et al., 2014), but a causal influence could not be proven. Individuals with psychosis often perceive rejection or stigma (Gras et al., 2014; Switaj et al., 2013; Yang et al., 2013) that could trigger loneliness and thus paranoia. Based on the cognitive models of paranoia (Freeman et al., 2002; Garety & Freeman, 2013) and the conceptualizations of loneliness (Mikulincer & Segal, 1990; Schwab, 1997) the present dissertation investigated loneliness as a possible additional etiological factor in the formation of paranoia. To proof causality, the first study of this dissertation experimentally manipulated loneliness and assessed the impact on paranoia. This study was a first causal proof for the impact of experimentally induced or reduced loneliness on paranoia. Additionally a moderator effect of proneness to psychosis on the relation between loneliness and paranoia was assessed. In individuals more prone towards paranoia a reduction of loneliness had a larger effect on a decrease in paranoia than in low prone individuals. Study II focused on the mechanisms involved in the relation between loneliness and paranoia in a clinical sample. The hypothesized mediator effect of negative schemata on other persons could be proven and showed a fully mediation on the relation between loneliness and paranoia. As an evidence based intervention cognitive behavioral therapy for psychosis was included in national therapy guidelines for schizophrenia spectrum disorders (Gaebel et al., 2006; National Collaborating Center for Mental Health, 2014), however the implementation of cognitive behavioral therapy concepts seems to be insufficient (Bechdolf & Klingberg, 2014; Haddock et al., 2014), although British pilot-studies showed promising effectiveness of cognitive behavioral interventions on psychiatric acute wards (Durrant et al., 2007; Haddock et al., 1999). Negative affect showed to be strongly associated with paranoia and was included as a mediator in the cognitive models on paranoia (Freeman et al., 2002; Fusar-Poli et al., 2014; Garety & Freeman, 2013; Smith et al., 2006 ). With regard to the cognitive model of paranoia and findings of earlier intervention studies a manualized mood-stabilizing cognitive behavioral therapy concept (Mehl, 2013) was tested in a pre-post design in study III. This study had a focus on the implementation of the concept in an acute ward of a local psychiatry under normal conditions and on testing the effectiveness of mood stabilizing interventions on delusions. Positive symptoms and delusions reduced significantly with large effect sizes and with clinical relevance in a majority of the cases. With regard to the subscales, delusional distress and preoccupation decreased with the largest effect sizes. Furthermore, depressive symptoms reduced significantly with large effect sizes. Additionally, the concept of the present pre-post study could be implemented in the into the therapeutic standard procedure of the acute ward, to further test effectiveness in randomized controlled studies. The findings support the important role of loneliness in the formation of paranoid ideation and enlighten the relevance of interpersonal cognitive processes involved in this relation. Furthermore, mechanisms and implications for future research and therapy are discussed. The results of the mood stabilizing intervention further emphasize the relevance of a better implementation of effective cognitive behavioral interventions for patients with psychosis on acute wards. Implications for research, clinical practice and possible adaptations of the program are derived on the basis of the findings.

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