Advances in understanding and treating persecutory delusions: a review
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PURPOSE: Persecutory delusions are a central psychotic experience, at the severe end of a paranoia spectrum in the general population. The aim of the review is to provide an introduction to the understanding of persecutory delusions, highlight key putative causal factors that have the potential to be translated into efficacious treatment, and indicate future research directions. METHODS: A narrative literature review was undertaken to highlight the main recent areas of empirical study concerning non-clinical and clinical paranoia. RESULTS: Six main proximal causal factors are identified: a worry thinking style, negative beliefs about the self, interpersonal sensitivity, sleep disturbance, anomalous internal experience, and reasoning biases. Each has plausible mechanistic links to the occurrence of paranoia. These causal factors may be influenced by a number of social circumstances, including adverse events, illicit drug use, and urban environments. CONCLUSIONS: There have been numerous replicated empirical findings leading to a significant advance in the understanding of persecutory delusions, now beginning to be translated into cognitive treatments. The first trials specifically focussed on patients who have persecutory delusions in the context of psychotic diagnoses are occurring. Initial evidence of efficacy is very promising.
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Cognitive models of psychosis emphasise the role of emotional processes, particularly anxiety, in the onset and maintenance cycle of psychotic symptoms.
“Likewise, cognitive models of psychosis [23] emphasise the role of emotional processes, particularly anxiety, in the onset and maintenance cycle of psychotic symptoms [5, 24].”
From A brief CBT intervention for depersonalisation/derealisation in psychosis: Study protocol for a feasibility randomised controlled trial (2016) · cites this paper as [5]
The sections “A worry thinking style” and “Negative thoughts about the self” link worry and anxiety-related processes to the emergence and persistence of paranoia and persecutory delusions. The review also notes a broader association between negative emotion and positive psychotic symptoms, but its evidence for onset and maintenance concerns paranoia specifically, not psychotic symptoms generally. The indexed passages have no page numbers. (LLM, conf=0.85)
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Hearing impairment and psychosis revisited
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Morrison, A., & Wells, A. (2007) · Behaviour Research and Therapy · doi:10.1016/j.brat.2006.11.010 · Cited by 90 · see citing works
Taylor, M. J., Gregory, A. M., Freeman, D., & Ronald, A. (2015) · Journal of Abnormal Psychology · doi:10.1037/abn0000057 · Cited by 85 · see citing works
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Self-citationImagery and psychotic symptoms: a preliminary investigation
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Phenomenological Evidence for Two Types of Paranoia
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Improving cognitive treatments for delusions
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Self-citationSuspicious young minds: paranoia and mistrust in 8- to 14-year-olds in the UK and Hong Kong
Wong, K. K., Freeman, D. H., & Hughes, C. H. (2014) · The British Journal of Psychiatry · doi:10.1192/bjp.bp.113.135467 · Cited by 78 · see citing works
Self-citationInterpersonal sensitivity in the at-risk mental state for psychosis
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Patterns of positive and negative symptoms in first episode schizophrenia
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Grandiose Delusions: An Experimental Investigation of the Delusion as Defense
Smith, N., Freeman, D., & Kuipers, E. (2005) · Journal of Nervous and Mental Disease · doi:10.1097/01.nmd.0000168235.60469.cc · Cited by 72 · see citing works
Self-citationFreeman, D., Startup, H., Dunn, G., Černis, E., Wingham, G., Pugh, K., Cordwell, J., & Kingdon, D. (2013) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2013.06.016 · Cited by 71 · cited 2× · see citing works
“In clinical groups the presence of the bias does not seem to be affected by anxiety manipulations [68, 98].”
BackgroundSelf-citationPoor me versus bad me paranoia and the instability of persecutory ideation
Melo, S. S., Taylor, J. L., & Bentall, R. P. (2006) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1348/147608305x52856 · Cited by 71 · see citing works
The Near Babylonian Speech Confusion in Early Detection of Psychosis
Schultze‐Lutter, F., SCHIMMELMANN, B. G., & Ruhrmann, S. (2011) · Schizophrenia Bulletin · doi:10.1093/schbul/sbr039 · Cited by 69 · see citing works
Paranoia and self-concepts in psychosis: A systematic review of the literature
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Persecutory delusions and psychological well-being
Freeman, D. H., Startup, H. M., Dunn, G., Wingham, G., Černis, E., Evans, N., Lister, R., Pugh, K., Cordwell, J., & Kingdon, D. (2013) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-013-0803-y · Cited by 60 · see citing works
Self-citationElucidating the Black Box From Stress To Paranoia
Moritz, S., Burnette, P., Sperber, S. H., Köther, U., Hagemann-Goebel, M., Hartmann, M. M., & Lincoln, T. M. (2010) · Schizophrenia Bulletin · doi:10.1093/schbul/sbq055 · Cited by 60 · see citing works
Freeman, D. H., Startup, H. M., Dunn, G., Černis, E., Wingham, G., Pugh, K., Cordwell, J., Mander, H., & Kingdon, D. (2014) · Psychological Medicine · doi:10.1017/s0033291714000592 · Cited by 59 · see citing works
Self-citationMorrison, A. P., Gumley, A. I., Schwannauer, M., Campbell, M., Gleeson, A., Griffin, E., & Gillan, K. (2004) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465804001900 · Cited by 58 · see citing works
Emotion regulation difficulties are relevant to persecutory ideation
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Mehl, S., Landsberg, M. W., Schmidt, A.-C., Cabanis, M., Bechdolf, A., Herrlich, J., Loos-Jankowiak, S., Kircher, T. T. J., Kiszkenow-Bäker, S., Klingberg, S., et al. (2014) · Schizophrenia Bulletin · doi:10.1093/schbul/sbu040 · Cited by 53 · see citing works
Jacobsen, P. C., Freeman, D. H., & Salkovskis, P. M. (2011) · British Journal of Clinical Psychology · doi:10.1111/j.2044-8260.2011.02014.x · Cited by 49 · see citing works
Self-citationFreeman, D. H., Evans, N., & Lister, R. (2012) · Psychiatry Research · doi:10.1016/j.psychres.2011.12.031 · Cited by 49 · see citing works
Self-citationThe use of intuitive and analytic reasoning styles by patients with persecutory delusions
Freeman, D., Lister, R., & Evans, N. (2014) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2014.06.005 · Cited by 48 · see citing works
Self-citationFreeman, D. H., & Freeman, J. (2008) · Oxford University Press eBooks · doi:10.1093/oso/9780199237500.001.0001 · Cited by 48 · see citing works
Self-citationThe Impact of Rumination on State Paranoid Ideation in a Nonclinical Sample
Martinelli, C., Cavanagh, K., & Dudley, R. E. J. (2013) · Behavior Therapy · doi:10.1016/j.beth.2013.02.002 · Cited by 47 · see citing works
What Do People with Psychosis Think Caused their Psychosis? A Q Methodology Study
Dudley, R. E. J., Siitarinen, J., James, I. A., & Dodgson, G. (2008) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465808004955 · Cited by 47 · see citing works
Developing Treatments of Persistent Persecutory Delusions
Hepworth, C., Startup, H. M., & Freeman, D. H. (2011) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0b013e318229cfa8 · Cited by 46 · see citing works
Self-citationHutton, P., KELLY, J. A., Lowens, I., Taylor, P. J., & Tai, S. (2012) · Psychiatry Research · doi:10.1016/j.psychres.2012.08.010 · Cited by 45 · see citing works
Intrusive mental imagery in patients with persecutory delusions
Schulze, K., Freeman, D. H., Green, C., & Kuipers, E. (2012) · Behaviour Research and Therapy · doi:10.1016/j.brat.2012.10.002 · Cited by 44 · see citing works
Self-citationSocial cognition and social functioning in nonclinical paranoia
Combs, D. R., Finn, J. A., Wohlfahrt, W., Penn, D. L., & Basso, M. R. (2013) · Cognitive Neuropsychiatry · doi:10.1080/13546805.2013.766595 · Cited by 44 · see citing works
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An experiential perspective on persecutory paranoia: A grounded theory construction
Boyd, T., & Gumley, A. I. (2006) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1348/147608306x100536 · Cited by 43 · see citing works
Overcoming Paranoid and Suspicious Thoughts
Freeman, D. H., Freeman, J., & Garety, P. A. (2006) · Cited by 43 · see citing works
Self-citationParanoid thinking, suspicion, and risk for aggression: A neurodevelopmental perspective
Tone, E. B., & Davis, J. S. (2012) · Development and Psychopathology · doi:10.1017/s0954579412000521 · Cited by 42 · see citing works
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Paranoia the 21st Century Fear
(2009) · The Journal of Nervous and Mental Disease · doi:10.1097/01.nmd.0000356995.62898.86 · Cited by 40 · see citing works
Implicit and explicit self-schema in active deluded, remitted deluded, and depressed patients
Vázquez, C., Diez-Alegría, C., Hernández-Lloreda, M. J., & Nieto‐Moreno, M. (2008) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2008.01.006 · Cited by 39 · see citing works
Impact of State Anxiety on the Jumping to Conclusions Delusion Bias
So, S. H., Freeman, D. H., & Garety, P. A. (2008) · Australian & New Zealand Journal of Psychiatry · doi:10.1080/00048670802345466 · Cited by 39 · see citing works
Self-citationBell, V., & Freeman, D. H. (2014) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2014.06.001 · Cited by 39 · see citing works
Self-citationWard, T. A., Gaynor, K. J., Hunter, M. D., Woodruff, P. W. R., Garety, P. A., & Peters, E. R. (2014) · Schizophrenia Bulletin · doi:10.1093/schbul/sbt094 · Cited by 38 · see citing works
Self-citationFear of madness and persecutory delusions: Preliminary investigation of a new scale
Bassett, M., Sperlinger, D., & Freeman, D. (2009) · Psychosis · doi:10.1080/17522430802535031 · Cited by 31 · see citing works
Self-citationThe emerging biology of delusions
Murray, G. (2010) · Psychological Medicine · doi:10.1017/s0033291710000413 · Cited by 29 · see citing works
The Development and Validation of the Beliefs about Paranoia Scale (Short Form)
Gumley, A. I., Gillan, K., Morrison, A. P., & Schwannauer, M. (2010) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s135246581000055x · Cited by 29 · see citing works
First Person Account: Living With the Delusions and Effects of Schizophrenia
Weiner, S. K. (2003) · Schizophrenia Bulletin · doi:10.1093/oxfordjournals.schbul.a007054 · Cited by 25 · see citing works
Freeman, D. H., Startup, H. M., Myers, E., Harvey, A. G., Geddes, J. R., Yu, L., Zaiwalla, Z., Luengo-Fernández, R., Foster, F., & Lister, R. (2013) · Trials · doi:10.1186/1745-6215-14-214 · Cited by 25 · see citing works
Self-citationBad me paranoia in early psychosis: A relatively rare phenomenon
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Self-citationFreeman, D. H., Waller, H., Harpur, R. A., Moore, R., Garety, P. A., Bebbington, P., Kuipers, E., Emsley, R., Dunn, G., Fowler, D. G., et al. (2013) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465813000660 · Cited by 17 · see citing works
Self-citationDepersonalization in Patients With Persecutory Delusions
Černis, E., Dunn, G., Startup, H., Kingdon, D., Wingham, G., Pugh, K., Cordwell, J., Mander, H., & Freeman, D. (2014) · Journal of Nervous & Mental Disease · doi:10.1097/nmd.0000000000000185 · Cited by 14 · see citing works
Self-citationStartup, H. M., Pugh, K., Cordwell, J., Kingdon, D., & Freeman, D. H. (2014) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465813001136 · Cited by 10 · see citing works
Self-citationInduced hearing deficit generates experimental paranoia
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Experiencing Suspicious Thoughts and Paranoia: An Account
Adam (2010) · Schizophrenia Bulletin · doi:10.1093/schbul/sbq123 · Cited by 9 · see citing works
Clinical presentation and early care relationships in ‘poor‐me’ and ‘bad‐me’ paranoia
Morris, E., Milner, P., Trower, P., & PETERS, E. R. (2010) · British Journal of Clinical Psychology · doi:10.1348/014466510x525498 · Cited by 7 · see citing works
Freeman, D. H., Dunn, G., Startup, H. M., & Kingdon, D. (2015) · Efficacy and Mechanism Evaluation · doi:10.3310/eme02010 · Cited by 6 · see citing works
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Dudley, R., Taylor, P., Wickham, S., & Hutton, P. (2016) · Schizophrenia Bulletin · doi:10.1093/schbul/sbv150 · Cited by 353 · see citing works
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Self-citationThe role of sleep dysfunction in the occurrence of delusions and hallucinations: A systematic review
Reeve, S., Sheaves, B., & Freeman, D. (2015) · Clinical Psychology Review · doi:10.1016/j.cpr.2015.09.001 · Cited by 273 · see citing works
“A focus on individual psychotic experiences has allowed development of detailed theoretical models, for example for paranoia (Freeman, Garety, Kuipers, Fowler, & Bebbington, 2002) accompanied by corresponding innovations in treatment (Freeman & Garety, 2014).”
BackgroundSelf-citationChildhood adversities and psychosis: evidence, challenges, implications
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Mehl, S., Werner, D., & Lincoln, T. M. (2015) · Frontiers in Psychology · doi:10.3389/fpsyg.2015.01450 · Cited by 129 · see citing works
Freeman, D. H., Pugh, K., Dunn, G., Evans, N., Sheaves, B., Waite, F., Černis, E., Lister, R., & Fowler, D. G. (2014) · Schizophrenia Research · doi:10.1016/j.schres.2014.10.038 · Cited by 127 · see citing works
Self-citationWilliams, J., Bucci, S., Berry, K., & Varese, F. (2018) · Clinical Psychology Review · doi:10.1016/j.cpr.2018.05.009 · Cited by 127 · see citing works
A systematic review on mediators between adversity and psychosis: potential targets for treatment
Alameda, L., Rodríguez, V., Carr, E., Aas, M., Trotta, G., Marino, P., Vorontsova, N., Herane-Vives, A., Gadelrab, R., Spinazzola, E., et al. (2020) · Psychological Medicine · doi:10.1017/s0033291720002421 · Cited by 125 · see citing works
Childhood adversity and psychosis: a systematic review of bio-psycho-social mediators and moderators
Sideli, L., Murray, R. M., Schimmenti, A., Corso, M., Barbera, D. L., Trotta, A., & Fisher, H. L. (2020) · Psychological Medicine · doi:10.1017/s0033291720002172 · Cited by 104 · see citing works
Reininghaus, U., Depp, C. A., & Myin‐Germeys, I. (2015) · Schizophrenia Bulletin · doi:10.1093/schbul/sbv193 · Cited by 102 · see citing works
Moritz, S., Pfuhl, G., Lüdtke, T., Menon, M., Balzan, R. P., & Andreou, C. (2016) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2016.07.004 · Cited by 99 · see citing works
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Self-citationThe network structure of paranoia in the general population
Bell, V., & O’Driscoll, C. (2018) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-018-1487-0 · Cited by 83 · see citing works
The paranoia as defence model of persecutory delusions: a systematic review and meta-analysis
Murphy, P., Bentall, R. P., Freeman, D. H., O’Rourke, S. J., & Hutton, P. (2018) · The Lancet Psychiatry · doi:10.1016/s2215-0366(18)30339-0 · Cited by 84 · see citing works
Self-citationFreeman, D. H., Emsley, R., Dunn, G., Fowler, D. G., Bebbington, P., Kuipers, E., Jolley, S., Waller, H., Hardy, A., & Garety, P. A. (2014) · Schizophrenia Bulletin · doi:10.1093/schbul/sbu173 · Cited by 84 · see citing works
Self-citationBell, V., Raihani, N., & Wilkinson, S. (2021) · Clinical Psychological Science · doi:10.1177/2167702620951553 · Cited by 78 · see citing works
Lavin, R., Bucci, S., Varese, F., & Berry, K. (2019) · British Journal of Clinical Psychology · doi:10.1111/bjc.12231 · Cited by 80 · see citing works
Transdiagnostic Extension of Delusions: Schizophrenia and Beyond
Bebbington, P., & Freeman, D. H. (2017) · Schizophrenia Bulletin · doi:10.1093/schbul/sbw191 · Cited by 80 · see citing works
Self-citationWaller, H., Emsley, R., Freeman, D., Bebbington, P., Dunn, G., Fowler, D., Hardy, A., Kuipers, E., & Garety, P. (2015) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2015.02.007 · Cited by 77 · see citing works
Self-citationFurther evidence of a cumulative effect of social disadvantage on risk of psychosis
Stilo, S. A., Gayer-Anderson, C. E., Beards, S., Hubbard, K., Onyejiaka, A. N., Keraite, A., Borges, S., Mondelli, V., Dazzan, P., Pariante, C. M., et al. (2016) · Psychological Medicine · doi:10.1017/s0033291716002993 · Cited by 75 · see citing works
The effects of cannabidiol on persecutory ideation and anxiety in a high trait paranoid group
Hundal, H., Lister, R., Evans, N., Antley, A., Englund, A., Murray, R. M., Freeman, D. H., & Morrison, P. D. (2017) · Journal of Psychopharmacology · doi:10.1177/0269881117737400 · Cited by 70 · see citing works
Self-citationSocial Adversity and Psychosis: The Mediating Role of Cognitive Vulnerability
Jaya, E. S., Ascone, L., & Lincoln, T. M. (2016) · Schizophrenia Bulletin · doi:10.1093/schbul/sbw104 · Cited by 68 · see citing works
Lopes, B., Bortolon, C., & Jaspal, R. (2020) · Psychiatry Research · doi:10.1016/j.psychres.2020.113455 · Cited by 68 · see citing works
The lonely road to paranoia. A path-analytic investigation of loneliness and paranoia.
Lamster, F., Lincoln, T., Nittel, C., Rief, W., & Mehl, S. (2017) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2016.12.007 · Cited by 64 · see citing works
Garety, P. A., Ward, T., Freeman, D. H., Fowler, D. G., Emsley, R., Dunn, G., Kuipers, E., Bebbington, P., Waller, H., Greenwood, K., et al. (2017) · Trials · doi:10.1186/s13063-017-2242-7 · Cited by 65 · see citing works
Self-citationParanoia and the social representation of others: a large-scale game theory approach
Raihani, N., & Bell, V. (2017) · Scientific Reports · doi:10.1038/s41598-017-04805-3 · Cited by 65 · see citing works
Valmaggia, L., Day, F., & Rus‐Calafell, M. (2016) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-016-1245-0 · Cited by 62 · see citing works
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- Authors
- Freeman, D., & Garety, P.
- Affiliations
- Warneford Hospital (GB)
- King's College London (GB)
- Corresponding author
- Freeman, Daniel
- Venue
- Social Psychiatry and Psychiatric Epidemiology
- Published
- 2014-07-09
- Volume
- 49
- Issue
- 8
- Pages
- 1179-1189
- ISSN
- 0933-7954 (ISSN-L)
- 1433-9285
- PMC
- PMC4108844
- OpenAlex
- W2013939918
- Cited by
- 348
- References
- 157
- Citations by year
- 2026: 14 · 2025: 23 · 2024: 24 · 2023: 22 · 2022: 18 · 2021: 22 · 2020: 36 · 2019: 41 · 2018: 37 · 2017: 43 · 2016: 35 · 2015: 29 · 2014: 4
- FWCI
- 5.09
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Social Psychiatry and Psychiatric Epidemiology (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Portal (King's College London) (submittedVersion, other-oa)
- Funders
- South London and Maudsley NHS Foundation Trust
- National Institute for Health and Care Research (NF-SI-0510-10121)
- King's College London
- Medical Research Council (G0902308)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Life Sciences › Neuroscience › Cognitive Neuroscience › Hallucinations in medical conditions
- Keywords
- persecutory delusions, paranoia, negative self-beliefs, interpersonal sensitivity, sleep disorders, reasoning biases, cognitive intervention, psychosis, illicit drug use, urban environment, life events
- MeSH terms
- Adult, Aged, Anxiety, Culture, Delusions, Female, Humans, Internal-External Control, Male, Middle Aged, Paranoid Disorders, Psychotic Disorders, Risk Factors, Schizophrenia, Paranoid, Severity of Illness Index, Thinking, Cognitive Behavioral Therapy
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