Content
Introduction
Referral letter
Theoretical perspectives * Formation of paranoia
Assessment
* Assessment tools and baseline measures * Individual belief ratings * Management of risk
Case Formulation
Treatment Plan & Interventions
Evaluation
Critical review
References
Appendix 1 – Assessment Summary (diagrammatic)
Appendix 2 – Formation of paranoia
Appendix 3 – Risk assessment and management
Appendix 4 – Letters
Appendix 5 – Judging by appearances a behavioural experiment
Confidentiality statement
The name and other identifiable information relating to this patient have been changed to maintain confidentiality.
Introduction
This case study describes the CBT assessment, formulation and treatment of delusions of persecution and associated paranoid beliefs.
Referral Letter
Roger, a 29 year old single man was referred to the Psychological Therapies Department. The letter noted that he had had one inpatient admission three years previously due to paranoia and risk of suicide. He was currently being supported by community mental health services.
A differential diagnosis of Delusional Disorder – Paranoid Type, (ICD 10- F22.0) and Paranoid Personality Disorder (ICD 10 – F60.0) as defined by the ICD 10 manual (World Health Organisation, 1992) was indicated.
Theoretical perspectives
Delusions are irrational beliefs, held with a high level of conviction, that are resistant to change even when the delusional person is exposed to forms of proof that contradict the belief. Paranoia is driven by the anticipation of danger (Freeman, 2007), and the condition involves excessive vigilance for danger, misinterpretation of threat and attentional and memory biases for threat-related material (Bentall, Kinderman, Corcoran, Howard & Blackwood, 2001). Anxiety is suspected to hold a central role by maintaining the cognitive component ‘anticipation of danger’.
Formation of paranoia
As early as 1974, Maher suggested that delusional ideas are related to unusual internal experiences, a principle captured by, whereby odd experiences lead to odd ideas and that delusions are explanations of experiences. Individuals attempt to make sense of such experiences when trying to resolve anxiety. External events such as ambiguous social information (facial expression, eye contact, hand gestures, laughing or smiling) or verbal information (overheard conversation or shouting) may form an anomalous experience and cause anxiety. In keeping with established CBT models, a person experiencing anxiety is more likely to detect threat and respond with avoidant behaviours.
Reasoning biases influence the way threat information is collected and processed and the threat detection bias is implicated in the maintenance of paranoia. The impact of selectively attending to an event or stimulus is noted in information processing, recall and memory or perceived threat.
Negative views of self and others are thought to provide poor defence for an individual. It is hypothesised these factors are involved in developing anxiety and that this anxiety provides the threat theme that maintains paranoia (Ellett, Freeman & Garety, 2008).
The ‘Threat Anticipation Model of Paranoia’ (Freeman, Garety & Kuipers, 2001) coherently uses these factors within a cognitive model.
Assessment
At the first meeting Roger identified the following problems: 1. People spread rumours about him and whole sections of the community intend him harm. 2. He is unable to leave the house and do things that he wants to do.
He described currently believing people to be a threat to him, believing that young people locally had heard rumours about him. He worried about being found, picked on and at worse being tortured. Due to these beliefs he found himself devoting significant personal resources to detecting danger and was often in highly anxious states anticipating imminent harm. As a result he had now become isolated from others and increasingly withdrawn, only leaving the house to obtain food and keep appointments with mental health workers. He reported feeling very low in mood and living with continual anticipation of threat.
Modulating factors that he had noticed were divided into two groups, those that increased his distressing experience and those that lessened it. Worsening factors included physical distance from home and the proximity to identified geographical locations. He had also noticed that being in busy settings such as a public house or cafe increased his distress and that he would report noticing people ‘looking him over’. Using alcohol in this situation evoked a fear of losing control and he anticipated that it would result in him confronting others. Roger had also noticed that he responded negatively to unexpected noises (such as loud revving cars or people shouting) which he personalised as intentional acts aimed at him.
Factors that were noticed to lessen distress included being in the company of a friend or family member. During these times he had already spotted that if the conversation was ‘good’ he would spend less time scanning for danger. However at assessment, he explained this as an unwanted effect as he thought his lack of observation for dangers left him vulnerable. He had also noticed that his fear tended to be at a lower intensity if he was familiar with a venue. He was able to give the example of how local shops were less threatening because he knew the staff.
The assessment identified both avoidant and excess behaviours that Roger was employing. Avoidance behaviours included physically restricting own geographical movements which resulted in whole swaths of the community being ‘out of bounds’. He described avoiding schools and bus stops as these were places young people gathered and they represented a threat to him. Interpersonally he described his way of scanning for information and shared his belief that he could tell what someone was morally like just by looking at them. He said he gained this information by constantly looking around, always avoiding eye contact and if eye contact was established he would drop his eyes immediately. This behaviour included both an avoidant and an excess component. Further excess behaviours were identified to also include dressing in black. He explained that by doing so he had a point of reference to judge if others were talking about him as all he had to do was listen for words such as ‘the one dressed all in black’.
Strengths identified included his ongoing contact with his sister and that he had one social friendship that he had maintained over the past two years. He also had maintained an interest in nature conservation. This was identified as an interest he wished to pursue further. Roger was also able to describe a network of support that included his supported accommodation, his key worker and his CPN. Currently he was prescribed 200mg quetiapine daily and was receiving consult review every three months.
Roger was able to isolate two events which he believed represented the onset and then establishment of his problem. At 20 years he described his first period of homelessness and that he had been living on a local beach. He reported that he had got into an argument after being accused of taking a photograph of a topless bather. Later that day he overheard a group of youths saying ‘he’s the one’ and ‘stab him’.
In a second incident he described being accused of stealing personal property. After this event he became aware of people staring at him on the streets and over a person say ‘I’ve heard he is hidden. He is quick this one, we will get him one day’.
Roger shared his personal theory that he had come to the attention of the local youth. He believed that rumours about him were openly shared across youth gangs. This resulted in all young people being considered as a threat.
From the psychosocial history the following events were considered to be significant. Roger is one of three siblings and is the middle aged child. His parents split up when he was 8 years old, which he thinks was due to his mother’s drinking. He told me that his mother drank because her first two children died. His father provided further details in that the first child, a son, had died of cot death and the second, a daughter, had drowned in their garden pond. Mother died two years after the divorce.
Roger reported that primary school was alright, and that he was a ‘day dreamer’ who did not have many friends - saying that ‘I don’t need others’. Roger went on to a local college which he described as ‘ok’, achieving one GCSE at grade ‘D’ with the remainder at E’s, F’s, and U’s. He initially joined the sixth form to take an I.T. course but left after a few months. He then started a kitchen porter job at the age of 18 and from then on held short term employments in shops, kitchens and for one day in a factory.
As an 18 year old he moved out from the family home and shortly after this his father remarried. Since this time he has either lived with friends or has been homeless.
Assessment Tools and Baseline Measures
Tools were selected to specifically target Roger’s reported problems. These measures would also monitor progress during therapy. Each measure chosen was considered to have both reliability and validity.
Standardised Measures
Beck Depression Inventory – 2nd Edition – BDI-ii (Beck, Steer & Brown, 1996)
Beck Anxiety Inventory – BAI (Beck, Epstein, Brown & Steer, 1988)
Beck Hopelessness Scale – BHS (Beck & Steer, 1988)
Rosenberg Self-Esteem Scale – RSES (Rosenberg, 1965)
Psychotic Symptom Rating Scale – PSYRATS (Haddock, McCarron, Tarrier & Faragher, 1999)
Scores at session 6 BDI-ii | BAI | BHS | RSES | PSYRATS | 17 | 25 | 18 | 17 | 19* |
*PSYRATS delusional rating scale (DRS) structured assessment interview applied.
PSYRATS – DRS Score sheet Item | Score | Amount of preoccupation | 2 | Duration of preoccupation | 4 | Conviction | 4 | Amount of distress | 4 | Intensity of distress | 3 | Disruption | 2 | 19 |
BDI-ii – Score indicates moderate depression (score range 17 – 29). Subjective evidence of depression noted at interview.
BAI – Indicating moderate levels of anxiety.
BHS – measures hopelessness based on feelings about the future, loss of motivation and expectations. The high score is indicative of severe problems in this area. This measure was selected because of a past history of suicide attempts.
RSES – A score of 17 is generally regarded as being indicative of falling within the ‘normal’ range for self-esteem. Self-esteem is a positive or negative orientation toward oneself and is an overall evaluation of one's worth or value.
PSYRATS – this total assessment score is useful in providing a baseline measure of Roger’s experience of delusional beliefs. The multi-dimensional broken down scores are of great value in measuring the detailed impact of therapy.
Individual belief ratings 1. ‘I can tell that a person is dangerous just by looking at them’ – conviction rating 90%. 2. ‘If I don’t monitor threat bad will happen’ – conviction rating 98%. 3. ‘People know rumours about me and talk about me’ – conviction rating 95%.
Management of risk
Roger has made a number of suicide attempts in the past. The first incident, recorded in 2009, was an attempt to jump from a high cliff. The second in 2010 was an overdose of Olanzapine, and the third was a period of self-enforced dehydration. He maintained that he would rather kill himself than be tortured and he did not have hope that this situation would resolve. He considers that his family and his fear of dying are buffers against suicide, but maintained that if he was facing imminent torture he would kill himself. Further reasons buffers were described as having not yet found a painless way to kill self, fear of hurting self, thoughts of impact on family and thoughts that his deceased mother would have been shocked and disapproved of him talking like this.
Monitoring of risk was incorporated into each therapy session through the use of an agreed standing agenda item. Risk management was further supported by regular contact with the community care coordinator and the Community Mental Health Team. Risk management plans were recorded within care plans (see appendix 4).
Case Formulation
The initial formulation(s) provided a way of engaging and familiarising Roger with the cognitive model using both the ‘Hot Cross Bun’ (Padesky & Greenberger, 1995) and the ABC cognitive model (Ellis, 1962).
Roger’s cross-sectional formulations captured recent experiences. Content was collected through thought diaries and these formulations were developed in session.
In this case it was evident to both client and therapist that the paranoid belief was creating unpleasant social isolation and causing emotional distress through anxiety and fear. It also allowed the separation of activating events, beliefs and consequences. This approach helped Roger understand that paranoia increased when exposed to a social situation and that once activated the use of threat detection accelerated.
Cross-sectional formulation diagram - ABC
Example of a more developed ABC formulation of a social encounter
People out there think they know things about me.
I could tell he was a dark seedy character – had a look in his eyes.
I can tell what a person is like by the way they look.
He could mean me trouble.
I am in danger
I check out everyone
Turn on scan – detect danger
Drop out of conversation
Heart rate increases
Threat level increases
Prepare self for a fight
Leave quickly
Went to pub and noticed person staring approximately 2 m away.
In my line of sight
Noticed people staring.
Heard one of them say ‘I wish that guy would f**k off’. A B C
The formulation demonstrated that threat detection was a core part of paranoia. Roger noticed that once it was active all his attention switched to the monitoring of threat. This initial work allowed him to think about what triggers activated this detection.
Views about others were accessed and the operation of the belief ‘I can tell if a person is a threat just by looking at them’ was isolated. Roger made the interesting discovery in that sometimes the feeling of discomfort (felt sense of anxiety) alone activated his threat detection. Importantly Roger was able to spot how this tended to happen when in social situations and how he felt when in the company of others. This discovery formed the bridge into the next stage of therapy which looked at the formation and maintenance of paranoid belief.
Freeman and Garety’s (2002) multi-factorial model was used to underpin an explanation for the formation and the maintenance of the paranoid delusional belief. As a homework task Roger agreed to spend time thinking about the model and sort which aspects of his experience fitted with this theoretical explanation of the formation of paranoia. In session these ideas were presented in diagrammatic form and referenced back to the assessment summary.
This approach allowed for the generation in session of an individualised theory of formation (appendix 2) and in turn a maintenance cycle. The maintenance formulation was collaboratively generated and draws out the relationships between triggering events, initial threat detection, the cognition, emotional response and the resulting behaviour. Having detected a potential threat, Roger describes an adrenaline response which he understood to indicate that his threat detection system had found a real and imminent danger. This response typically cued the cognitions ‘I am being watched’, ‘I am in danger’, ‘they know the rumours about me’. The cognition of ‘I stand out because people know the rumours about me’ cues the metacognition ‘paranoia keeps me safe’ which primes behaviours and emotional responses. Each of these cognitions carried the meaning that others were viewing him badly and that this was likely to lead them to at best shout at him, and at worst assault him. This meaning meant Rogers invested greater efforts into trying to understand his immediate world and maintain his safety. As concentration on threat detection increases a reciprocal process of selecting for danger and escalating emotional response (fear) occurs. In keeping with a fear driven response, Roger selects a flight response. As distance from the threat increases the emotional arousal decreases. This process results in Roger confirming his belief ‘I am only safe because I detect danger early and I choose to leave situation’.
Perceived vulnerability was worsened by beliefs about self as being shy, weak and about others as being cruel, uncaring and revengeful and of the world as being dangerous and hostile. The felt sense of anxiety and fear increases the level of personal resources devoted to threat detection. Roger described the process of the wider world fading out of focus as all resources became devoted to threat monitoring. Cognitive biases then operate to pay attention to threat consistent information, whilst information that disconfirms threat is ignored. The ‘evidence’ collected is used to further enhance held beliefs about others. In this case it would confirm that loud young people were indeed dangerous and should be avoided. Due to this process Roger reported ever increasing anxiety levels and at the point where he anticipated confrontation was inevitable he described leaving the situation. The formulation predicts that the use of this safety behaviour means that Roger never collects information to disprove his assessment of threat.
Maintenance formulation diagram
Treatment Plan
The formulations were considered to be part of the treatment plan and their generation was an intervention that targeted collaborative understanding, education, validation and provided a shared rationale for further interventions.
Within the cross-sectional formulations the following areas are identified for possible intervention: * Manipulating the use of the ‘scan’ – using behavioural experiments * Raising awareness of its operation – using thought diaries, self-rating scales.
Within the maintenance formulation the following areas are identified as targets for possible intervention: * Cognitive biases – especially jumping to conclusion biases (JTC). Possible interventions - guided discovery, education and behavioural experiments. * Use of safety behaviours and avoidance of anxiety provoking situations. Possible interventions - graded exposure tasks. * Thinking errors – black and white thinking, over-generalisation. Possible interventions - ABC formulations, thought diaries, verbally generating alternatives. * Belief modification – views of self, others and world. Possible interventions – schema work using a ‘Two Chair approach’. * Meta-cognitive belief ‘paranoia keeps me safe’. Possible interventions – positive/negative evidence review, behavioural experiments. * Isolation and reduced activity. Possible interventions - behavioural activation and activity scheduling.
The treatment plan was informed by the hypothesis that the maintenance cycle can be disrupted by targeting the operation of threat detection processes, by improving tolerance of perceived social threat and reducing the use of escape behaviours.
Goals
The following behavioural goals were collaboratively agreed following assessment and formulation review during session six. 1. To join local conservation group and take part in outside activity on weekly basis. 2. To re-establish contact with friends and go to local pub with them. 3. To be able to eat meal and finish it before leaving.
The therapeutic goals underpinning these behavioural goals were (i) to reduce how suspicious he felt about others, (ii) to be able to work out accurately if others were a real risk (iii) to feel more comfortable and less anxious whilst out and (iv) to stop leaving difficult situations.
Implementation of Treatment Plan
Reducing suspiciousness of others and working out ‘real’ risk
Verbal re-attribution strategies were used to address jumping to conclusion bias. It proved useful to share the research material that highlighted this JTC bias as being implicated in the formation and maintenance of paranoia. This process allowed Roger to consider the importance of collecting full information in any given situation. This principle was compatible with Roger’s held beliefs about the importance of monitoring threat, but needed tuning to ensure that additional non-threat information was also collected. A number of interventions targeted this objective.
Firstly ABC analysis was used to examine episodes of distress. The analysis of an incident where Roger observed a car and concluded that the police were following him proved useful to discover the way he observed and detected threat in his immediate environment. In sessions, work focused on identifying the relationship between anxious thoughts and paranoia and the operation of selective attention biases. Using the maintenance formulation as a point of reference Roger discovered that when a threat is detected, the way he collects additional information changes. In this case he made a number of threat biased interpretations based on dress of the driver, presence of sunglasses, speed of vehicle, and brief broken eye contact with the passenger. We were able to consider the possibility that interpretation of ambiguous material (Renton, 2002), was being used to enforce the paranoid belief.
Verbal reattribution methods, supported by using thought diaries within homework tasks, proved useful for collecting further examples of this cognitive bias function. Content was then used to generate viable non-threatening alternative explanations for the observed behaviour of others.
Feeling more comfortable and less anxious when outside Spending time outside of the flat was anxiety provoking. At these times Roger reported intrusive thoughts such as ‘people are looking at me’, ‘I am standing out and being noticed’ and that those around him, based on looks, were dangerous. An exposure approach was used in an attempt to habituate the anxiety response and a hierarchy of anxiety provoking situations was developed based on distance from the flat. Roger experienced difficulty in this task because of his 95% certainty that people knew and believed rumours about him and that he stood out. Whilst out Roger continued to invest heavily in his use of scanning for threat. Further progression through the hierarchy remains dependant on reduction of the strength of conviction in the belief ‘people know rumours about me’. Hopefully anxiety reduction will continue to occur in association with reduced levels of conviction in the beliefs connected with dangerousness, threat monitoring and rumours. Awareness of the operation of cognitive bias was developed through exposure to avoided situations through activity scheduling, thought diaries and behavioural experiments. Being able to work out accurately if others were a real risk
Roger believed he had enhanced abilities to detect threat and could accurately tell how dangerous people were by looking at them. This belief was tested by looking at images of people, taken from the internet, and trying to sort them into ‘safe’ or ‘dangerous’ categories based on appearance (sample page appendix 4). Once sorted, written statements about each person were disclosed which could be verified on the internet. On analysis of results Roger discovered his sorting skills were no better than chance. Further data collecting was completed using an observation task completed discreetly at the local library. Observations were made of the library readers against a pre-prepared checklist of features, actions and behaviours usually interpreted as threatening. This list included eye contact, voice volume and hand gestures. This data was used to consider alternative explanations for observed behaviours. Roger reported consistent reductions in his belief that he could predict people’s dangerousness by looking at them. Beliefs about young people Roger believed that he was unable to walk in certain areas of town because he would come to the attention of groups of young people and he would expose himself to the risk of violent assault. He believed that single individuals within the general teenage grouping had heard rumours about him and would have told everyone else within that group about him. Roger reported this as a fact, based on observation he had made of the conduct of local youths. Further evidence was collected from media and internet sources leading to active avoidance of contact with others. This was formulated as a vicious circle being maintained by cognitive biases, avoidance and safety behaviours. Flexibility in this belief was generated by looking for exceptions from personal experiences of young people. This approach led to the awareness of an over-generalisation thinking error. As therapy progressed Roger was encouraged to notice his use of this thinking error and to self-generate more balanced thoughts in response.
Stopping leaving difficult situations
Roger held a number of positive beliefs about paranoia and how it contributed to keeping him safe. In session the impact of this safety belief was explored by looking at its advantages and disadvantages. Using a pros and cons table we discovered that it had a high impact on his experience of being able to trust or be around others. A memory bias was identified at this point and recall of how observation of others whilst at school had kept Roger safe from experiencing repeated bullying. This was explored and accepted as being a memory of a strategy that had worked in the past but might not be all that useful in the present.
The analogy of using an alarm set at different sensitivities was introduced and Roger was encouraged to consider how having a detection alarm always set on high affected him. As a result Roger was able to construct a behavioural experiment to test his safety behaviour that arose from the beliefs ‘paranoia keeps me safe’ and specifically ‘If I don’t monitor threat bad will happen’. Experiment design relied on the removal of safety behaviours by sitting at a coffee shop and not engaging in scanning or listening for danger (book and earphones interrupted usual safety behaviours). Prior to the experiment belief was held at 98% certainty and post experiment this had dropped to 80% certainty.
Evaluation
Behavioural goals were achieved in part. This included Roger joining a local conservation project. Out of ten sessions he managed to attend four meetings. Non attendance was related to high levels of anxiety prior to leaving his flat.
Roger established contact with an old friend and went out and spent an evening in a local pub. After the event he expressed high levels of anxiety and worry whilst out, but discovered by keeping his attention on his friend he was much less focused on others in the pub. However he does not feel ready to repeat this activity at the end of therapy.
Roger has not been able to eat in public place as yet.
Outcome scores: session 14 (baseline scores bracketed). BDI-ii | BAI | BHS | RSES | PSYRATS | (17) 18 | (25) 18 | (18) 12 | (17) 18 | (19) 15 |
PSYRATS – DRS score sheet: session 14 (baseline scores bracketed). Item | Score | Amount of preoccupation | (2) 2 | Duration of preoccupation | (4) 3 | Conviction | (4) 3 | Amount of distress | (4) 2 | Intensity of distress | (3) 3 | Disruption | (2) 2 | (19) 15 |
Individual belief ratings Belief | Baseline | Session 14 | 1. ‘I can tell that a person is dangerous just by looking at them’. | 90% certainty | 60% certainty | 2. ‘If I don’t monitor threat bad will happen’. | 98% certainty | 80% certainty | 3. ‘People know rumours about me and talk about me’. | 95% certainty | 95% certainty |
Interpretation of outcome measures
BDI-ii - results indicate no change in this measure of depression, remaining indicative of moderate depression.
BAI - results indicate a numerical lowering of score, however remains indicative of a moderate anxiety experience.
BHS - results indicate a shift from severe to moderate on this scale.
RSES - results indicate no change.
DRS - results indicate a reduction in the overall impact of the delusional belief.
Analysis of the scoring identifies reduction in the amount of preoccupation, a reduction in conviction and the amount of distress.
These objective measures offer tentative support to the subjective appraisal of change over the course of therapy. Subjective reports of improvements in sleeping, reduced anxiety and increased activity are consistent with the indicative trend within the objective data. The mechanism of change appears to be related to the robustness of formulation and the acceptance of the role of cognitive biases and his willingness to explore how they operate for him. A change in conviction on the selected held beliefs appears to have resulted from Roger identifying some of his paranoid beliefs as in fact being paranoid thoughts. On occasions this has allowed alternative explanations to be generated in the presence of the trigger, and has resulted in normalisation taking place.
Roger continues to resist exploring the belief ‘people know rumours about me’. His avoidance remains a limiting factor and requires ongoing attention over the course of therapy.
Critical review
The efficacy of CBT in the treatment of delusions and hallucinations has been well demonstrated (Zimmermann et al, 2005). The evidence base is strongest concerning CBT for persistent positive symptoms such as delusions and in about 20% of patients with persistent symptoms strong treatment gains are reported and in a further 40% of patients important improvements are shown (Kuipers et al, 1997). Results indicate that Roger falls into the latter category.
Time invested in therapeutic engagement and the adoption of a ‘voyage of discovery attitude’ (Freeman & Garety, 2006) have been well rewarded. The considerable time invested in assessment and the collaborative development of formulation was key to underpinning treatment intervention. The process provided a structured approach to understanding the evidence on which Roger was basing his paranoia and the formulation also allowed investigation of how beliefs relate to past experience and events.
The formulation itself provided a framework to identify which processes and factors were involved in the formation and maintenance of the paranoia. In turn this allowed for a ‘therapeutic path’ for intervention to be collaboratively designed.
The chosen model provided guidance in this case and the role of JTC biases, selective attention, thinking errors and memory biases were relevant in maintenance of the problem.
The interventions offered have not made best use of the longitudinal assessment information collected and although beliefs about others and the world have been addressed, the most important area, beliefs about self, received very little attention. Further gains may have been achievable if increased emphasis on the social anxiety aspect of the paranoia experience had been pursued. Roger had clearly indicated that his detection of threat escalated in the presence of others and that he considered himself from childhood as being shy. A formulation underpinned with a social anxiety model may have guided interventions differently.
On reflection, the inclusion of an outcome measure more sensitive to self-esteem changes may have been more useful as the measure chosen failed to record subjective reports of self-esteem improvement (activity, diet improvements & tidiness of home).
This case has shown that distress, preoccupation and the impact of paranoid beliefs can be addressed in a relatively short period of time.
References
Beck, A. T., Epstein, N. Brown, G., Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties, Journal of Consulting and
Clinical Psychology, 56, 893- 897.
Beck, A.T., Brown, G., Berchick, R.J., Steward, B.L., & Steer, R.A. (1990). Relationship between hopelessness and ultimate suicide: a replication of psychiatric outpatients. American Journal of Psychiatry, 147, 190-195
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897
Beck, A.T., Steer R.A., Brown G.K., (1996). Manual for the Beck Depression Inventory–ii. San Antonio, TX: Psychological Corporation.
Bentall R.P., Rouse, G., Kinderman, P., Blackwood, N., Howard, R., Moore, R., Cummins, S., Corcoran, R., (2008). Paranoid delusions in schizophrenia and depression: The transdiagnostic role of expectations of negative events and negative self-esteem. Journal of Nervous and Mental Disease. 196, 375-8
Chadwick, P. (2006). Person-based cognitive therapy for distressing psychosis. Chichester, England ; Hoboken, NJ: John Wiley & Sons.
Chadwick, P. D., Birchwood, M. H. J., & Trower, P. (1996). Cognitive therapy for delusions,voices and paranoia. Chichester, UK: Wiley.
Ellett, L., Freeman, D., & Garety, P.A. (2008). The psychological effect of an urban environment on individuals with persecutory delusions: The Camberwell Walk Study. Schizophrenia Research, 99: 77-84.
Freeman, D., Garety, P., Kuipers, E., Fowler, D., Bebbington, P.E., and Dunn, G. (2007). Acting on persecutory delusions: the importance of safety seeking. Behaviour Research and Therapy, 45, 89-99.
Freeman, D., and Freeman, J. (2008). Paranoia: The 21st Century Fear. Oxford: Oxford University Press.
Freeman, D., & Garety, P.A. (2006). Delusions. In Practitioners’ Guide to Evidence-Based Psychotherapy (Eds. J.E.Fisher & W.O’Donohue). New York: Springer Academic.
Freeman, D., Garety, P.A., and Kuipers, E. (2001). Persecutory delusions: Developing the understanding of belief maintenance and emotional distress. Psychological Medicine, 31, 1293-1306.
Haddock, G., McCarron, J., Tarrier, N., & Faragher, E. B. (1999). Scales to measure dimensions of hallucinations and delusions: The Psychotic Symptom Rating Scales (PSYRATS). Psychological Medicine, 29, 879–889.
Kuipers, E., Garety, P., Fowler, D., et al (1997) London—East Anglia randomised controlled trial of cognitive behavioural therapy for psychosis- Effects of the treatment phase. British Journal of Psychiatry, 171, 319-327.
Kuyken,W., Padesky, A., & Dudley, R., (2008). Collaborative Case Conceptualization: Working Effectively with Clients in Cognitive Behavioral Therapy.
New York: Guilford Press.
Maher, B. A. (1974). Delusional thinking and perceptual disorder. Journal of individual psychology, 30, 98-113. cited in Freeman, D. (2007). Suspicious Minds: The psychology of persecutory delusions. Clinical Psychology Review, 27, 425-457.
Padesky, C.A., & Greenberger, D., (1995). Clinicians guide to mind over mood. New York: Guilford Press.
Rosenberg, M., (1965). Society and the adolescent self-image. Princeton, NJ:
Princeton University Press.
Trower, P., & Chadwick, P., (1995). Pathways to defence of the self: A theory of two types of paranoia. Clinical psychology: Science and Practice, 2, 263–278.
Wells, A., (1995). Meta-cognition and worry: a cognitive model of generalised anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301–320.
World Health Organisation (1992). ICD-10 Classifications of Mental and Behavioural Disorder: Clinical Descriptions and Diagnostic Guidelines. Geneva. World Health Organisation.
Zimmermann, G., Favrod, J., Trieu, V. H., et al (2005). The effect of cognitive behavioural treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research, 77, 1–9.
Appendix 1
Assessment Summary
“This is unfair”
“Poor me”
Onset event - Wrongly blamed for events
Individual people believe rumours about me
People share rumours amongst groups – so any
Group member will know and be part of torment
Get away
Avoid contact
Stay alert
Shamed
Anxious
Fearful
Unsafe
Dread
Local town is small so everyone knows each other
I stand out and am noticeable
I am under threat of torture and they mean to kill me
Heart beating fast
Stomach turning
I have ability to sense and detect danger
Protect myself by monitoring threat & avoiding others
Within the ‘high risk groups’
Appendix 2 – Formation of paranoia
TRIGGER
Being in public place, being alone, becoming homeless, and being blamed for something I did not do, hearing people talk about me.
THREAT BELIEF
People believe rumours about me, they have shared these rumours widely, and certain sections of the population wish to punish me for what they believe I have done. If they get me they will torture and kill me.
SELECTION OF EXPLANATION
Individual people believe rumours about me, people share rumours amongst groups, so everyone in that group will know about me. I stand out and am noticeable.
INTERPRETATION/SEARCH FOR MEANING
I have enhanced abilities to detect threat. Without these skills I am unsafe.
EMOTION
Shame, anxiety, fear and dread.
REASONING STYLE
External explanations –not about me but others.
Jumping to conclusions
INTERNAL FEELING
Heart speeds up, stomach turns, on edge, ready to fight.
Appendix 2 – Risk Plan
Appendix 3– Letters
Appendix 4 – Judging by appearances
1
4
5
2
3
8
6
7
0 Key - Go
Photo 1, Martti Ahtisaari, Photo 2, Roger Tsien
Photo 3, Jamie Bristow-Diamond, Photo 4, Kal Penn
Photo 5, Robert English, Photo 6, Charlie Stokes,
Photo 7, John Robinson, Photo 8, Zdzierak.
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[ 1 ]. Beck, Brown, Berchick, Steward, & Steer, (1990) identified a strong association between scores greater than 11 and completed suicide in outpatient groups.
[ 2 ]. Trower and Chadwick (1995) identify two types of paranoia, ‘poor me’ persecution paranoia, and ‘bad me’ or punishment paranoia. Within assessment it is important to identify whether the client has a belief about punishment or persecution. This distinction is used to guide therapy.
