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Advances in understanding and treating persecutory delusions: a review
Open accessAbstract
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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![Fig. 1 The distribution of total paranoia scores in the general population [15]](/paper-figures/87ad0b497ded46b4bfb6778576ff43c1/advances-in-understanding-and-treating-persecutory-delusions-a-review-figure-1.jpg)
![Fig. 2 The paranoia hierarchy [14]](/paper-figures/c80ae724d67c458d97361c81d531b206/advances-in-understanding-and-treating-persecutory-delusions-a-review-figure-2.jpg)
![Fig. 3 Outline of factors involved in delusion formation [31]](/paper-figures/4f71774d34e849a7ac745e505fdbf7d4/advances-in-understanding-and-treating-persecutory-delusions-a-review-figure-3.jpg)
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“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]
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Freeman, 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 90
Self-citationTaylor, M. J., Gregory, A. M., Freeman, D., & Ronald, A. (2015) · Journal of Abnormal Psychology · doi:10.1037/abn0000057 · Cited by 85
Suspicious 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 82
Self-citationImagery and psychotic symptoms: a preliminary investigation
Morrison, A. P., Beck, A. T., Glentworth, D., Dunn, H., Reid, G. S., Larkin, W., & Williams, S. (2002) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(01)00128-0 · Cited by 81
Phenomenological Evidence for Two Types of Paranoia
Chadwick, P., Trower, P., Juusti-Butler, T.-M., & Maguire, N. (2005) · Psychopathology · doi:10.1159/000089453 · Cited by 81
Paranoia and self-concepts in psychosis: A systematic review of the literature
Tiernan, B., Tracey, R., & Shannon, C. (2014) · Psychiatry Research · doi:10.1016/j.psychres.2014.02.003 · Cited by 81
Improving cognitive treatments for delusions
Freeman, D. H. (2011) · Schizophrenia Research · doi:10.1016/j.schres.2011.08.012 · Cited by 80
Self-citationFreeman, D., Thompson, C., Vorontsova, N., Dunn, G., Carter, L.-A., Garety, P., Kuipers, E., Slater, M., Antley, A., Glucksman, E., et al. (2013) · Psychological Medicine · doi:10.1017/s003329171300038x · Cited by 79
Self-citationInterpersonal sensitivity in the at-risk mental state for psychosis
Masillo, A., Day, F., Laing, J., Howes, O. D., Fusar‐Poli, P., Byrne, M., Bhattacharyya, S., Nastro, P. F., Girardi, P., McGuire, P. K., et al. (2012) · Psychological Medicine · doi:10.1017/s0033291711002996 · Cited by 79
van Oosterhout, B., Krabbendam, L., de Boer, K., Ferwerda, J., van der Helm, M., Stant, A. D., & van der Gaag, M. (2014) · Psychological Medicine · doi:10.1017/s0033291714000555 · Cited by 75
Patterns of positive and negative symptoms in first episode schizophrenia
Vázquez-Barquero, J. L., Lastra, I., Nuñez, M. J. C., Castanedo, S. H., & Dunn, G. (1996) · British Journal of Psychiatry · doi:10.1192/bjp.168.6.693 · Cited by 73 · cited 1×
“The empirical research indicates that within these diagnoses are multiple independent experiences, such as paranoia, hallucinations, grandiosity, thought disorder, and anhedonia [13, 20–22].”
BackgroundSieradzka, D., Power, R. A., Freeman, D. H., Cardno, A. G., McGuire, P. K., Plomin, R. J., Meaburn, E. L., Dudbridge, F., & Ronald, A. (2014) · PLoS ONE · doi:10.1371/journal.pone.0094398 · Cited by 72
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×
“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
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
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 68
Self-citationKorver‐Nieberg, N., Fett, A.-K. J., Meijer, C. J., Koeter, M. W. J., Shergill, S. S., de Haan, L., & Krabbendam, L. (2013) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/0004867413484370 · Cited by 66
Elucidating 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 62
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
Self-citationEmotion regulation difficulties are relevant to persecutory ideation
Westermann, S., & Lincoln, T. M. (2010) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1348/147608310x523019 · Cited by 58
Morrison, 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
The 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 54
Smith, N., Freeman, D. H., & Kuipers, E. (2005) · The Journal of Nervous and Mental Disease · doi:10.1097/01.nmd.0000168235.60469.cc · Cited by 54
Self-citationMehl, 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
Social 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 51
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 50
Self-citationFreeman, D. H., Evans, N., & Lister, R. (2012) · Psychiatry Research · doi:10.1016/j.psychres.2011.12.031 · Cited by 50
Self-citationJacobsen, 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
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 49
The 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
Self-citationFreeman, D. H., & Freeman, J. (2008) · Oxford University Press eBooks · doi:10.1093/oso/9780199237500.001.0001 · Cited by 48
Self-citationWhat 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
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
Self-citationDiez-Alegría, C., Vázquez, C., Nieto‐Moreno, M., Valiente, C., & Fuentenebro, F. (2006) · British Journal of Clinical Psychology · doi:10.1348/014466505x86681 · Cited by 44
Bell, V., & Freeman, D. H. (2014) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2014.06.001 · Cited by 43
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 43
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
Overcoming Paranoid and Suspicious Thoughts
Freeman, D. H., Freeman, J., & Garety, P. A. (2006) · Cited by 43
Self-citationSoosay, I., Silove, D. M., Bateman-Steel, C. R., Steel, Z., Bebbington, P., Jones, P. B., Chey, T., Ivancic, L., & Marnane, C. L. (2012) · BMC Psychiatry · doi:10.1186/1471-244x-12-229 · Cited by 42
Paranoia the 21st Century Fear
(2009) · The Journal of Nervous and Mental Disease · doi:10.1097/01.nmd.0000356995.62898.86 · Cited by 40
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
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
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
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
Self-citationThe 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 30
The emerging biology of delusions
Murray, G. (2010) · Psychological Medicine · doi:10.1017/s0033291710000413 · Cited by 29
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
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
Self-citationBad me paranoia in early psychosis: A relatively rare phenomenon
Fornells‐Ambrojo, M., & Garety, P. A. (2005) · British Journal of Clinical Psychology · doi:10.1348/014466505x35326 · Cited by 24
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
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
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
Self-citationInduced hearing deficit generates experimental paranoia
Zimbardo, P. G., Anderson, S., & Kabat, L. G. (1982) · The Journal of the Acoustical Society of America · doi:10.1121/1.388416 · Cited by 9
Experiencing Suspicious Thoughts and Paranoia: An Account
Adam (2010) · Schizophrenia Bulletin · doi:10.1093/schbul/sbq123 · Cited by 9
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
Freeman, D. H., Dunn, G., Startup, H. M., & Kingdon, D. (2015) · Efficacy and Mechanism Evaluation · doi:10.3310/eme02010 · Cited by 7
Self-citationFreeman, D. H., Dunn, G., Startup, H. M., Pugh, K., Cordwell, J., Mander, H., Černis, E., Wingham, G., Shirvell, K., & Kingdon, D. (2014) · ePrints Soton (University of Southampton) · Cited by 4
Self-citation
Research works printed but not linked: 2
- Tiernan B, Tracey R, Shannon C (2014) Paranoia and self-concepts in psychosis. Psychiatry Res 30:202–313
- Freeman D, Freeman J (2012) You can be happy: the scientifically proven way to change how you feel. Prentice Hall Life, Harlow
Cited by
Sorted by citations
Dudley, R., Taylor, P., Wickham, S., & Hutton, P. (2016) · Schizophrenia Bulletin · doi:10.1093/schbul/sbv150 · Cited by 353
Reininghaus, U., Kempton, M. J., Valmaggia, L., Craig, T. K. J., Garety, P., Onyejiaka, A., Gayer-Anderson, C., So, S. H., Hubbard, K., Beards, S., et al. (2016) · Schizophrenia Bulletin · doi:10.1093/schbul/sbv190 · Cited by 304
Self-citationFreeman, D., Dunn, G., Startup, H., Pugh, K., Cordwell, J., Mander, H., Černis, E., Wingham, G., Shirvell, K., & Kingdon, D. (2015) · The Lancet Psychiatry · doi:10.1016/s2215-0366(15)00039-5 · Cited by 295
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
“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
Morgan, C., & Gayer-Anderson, C. E. (2016) · World Psychiatry · doi:10.1002/wps.20330 · Cited by 278
Metadata
- 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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