The role of perseverative thinking
processes in paranoia
Dr. Kate Cavanagh
University of Sussex, UK
kate.cavanagh@sussex.ac.uk
It’s not what you think it’s
the way that you think it
• In cognitive psychopathology research focuses
on both the content of automatic thoughts,
attributions and beliefs
• But also on the way we respond to these
thoughts (cognitive or ‘thinking’ processes)
and the implications of this for further
thoughts, feelings and behaviour
– For example: if the idea ‘I look foolish’ crosses my
mind – how I respond to that thought (focus on it,
evaluate it, dismiss it or distract from it, argue
with it etc) will have an effect on future thought
content, how I feel and my behaviour over time.
Outline
• Repetitive thought and repetitive negative thinking
• Role of repetitive negative thinking processes in
psychopathology
• Hypothesised role of repetitive negative thinking
processes in paranoia
• Research programme exploring the role of rumination
in paranoia
– Questionnaire based study (correlation)
– Lab based studies testing the causal relationship between
rumination and the maintenance of suspicious and
mistrustful beliefs in student sample
• Conclusions, questions and future directions
Colleagues and collaborators
• Newcastle University, UK:
– Rob Dudley, Jennifer Simpson, Bryony McGregor
• University of Sussex, UK:
– Cheontell Barnes, Stacey Hemmings, Deidre
Robertson, Cristina Martinelli and Moitree
Banerjee.
Repetitive thought
• The “process of thinking attentively,
repetitively or frequently about one’s self and
one’s world”
– Segerstrom et al. (2003, p.909)
e.g. planning, reflection, emotional processing,
problem solving, working through, worry,
rumination, post-event processing
Repetitive thought
• May be ‘adaptive’ or ‘maladaptive’
• Vary on three dimensions (Watkins, 2008)
– Valence of the thought content (positive vs negative
– Intrapersonal and situational context (positive vs
negative)
– Level of construal adopted (abstract vs concrete)
+
– Level of volition/control (Ehring & Watkins, 2008)
Repetitive thought
• With ‘constructive’ or ‘unconstructive’
consequences for mental and physical health
(Watkins, 2008)
Constructive consequences
Unconstructive consequences
e.g. recovery from upsetting
and traumatic events, adaptive
preparation and planning,
recovery from depression,
uptake of health promoting
behaviours
e.g. Depression, anxiety,
difficulties in physical health
Repetitive negative thought
Transdiagnostic process (Harvey et al., 2004)
• “same process across disorders, which is
applied to disorder specific content’ (p. 192;
Ehring & Watkins, 2008
• Repetitive
• Passive / Relatively uncontrollable
• Focused on negative content
Repetitive negative thought
• Growing evidence of repetitive negative
thinking processes in various types of
psychopathology
Worry
• Worry
– repetitive thought about “future potential threat,
catastrophes, uncertainty and risks” (Watkins,
2008, p. 164)
– Cardinal feature of GAD (DSM-IV APA, 1994),
– Also associated with OCD, PTSD, depression,
insomnia, bipolar disorder (and psychosis)
Rumination
• Rumination
– A “mode of responding to distress that involves
repetitively and passively focusing on symptoms of distress
and the possible causes and consequences of these
symptoms” (Nolen-Hoeksema, Wisco & Lyubomirsjy, 2008,
p. 400)
Cardinal feature of depression (Nolen-Hoeksema, 2008)
– but also evident in social phobia (Brozovich & Heimberg,
2008), PTSD, GAD and panic (Smith & Alloy, 2008) and
associated with binge eating and alcohol abuse (NolenHoeksema et al., 2008) and negative symptoms of
psychosis (emotional withdrawal, stereotyped thinking,
Halari et al., 2009).
Repetitive negative thought
• Not just ‘associated’ to a range of disorders
• But playing a causal role
The role of rumination in depression
• Evidence of higher levels of rumination in people with depression
(and predicts future episodes of depression)
• Causal role is supported by evidence of the effects of rumination
induction in depressed individuals* (versus distraction), which leads
to
– worsened mood (Donaldson & Lam, 2004)
– Increased retrieval of negative memories (Lyubomirsky, Caldwell &
Nolen-Hoeksema, 1998)
– Distorted interpretation of events and negative expectancies of the
future (Lyubomirky & Nolen-Hoeksema, 1995)
– Indesciveness (Randenborg et al., 2010)
– Withdrawal and inactivity (Martell et al., 2001)
• All factors that may play a role in maintaining depression
Repetitive Negative Thinking
• Evidence of RNT in 13 disorders
– Depression, PTSD, Social Anxiety Disorder, OCD, Insomnia, eating
disorders, pain disorder, hypochondriasis, alcohol use disorder,
psychosis and bipolar disorder
– Including psychosis, where high levels of RNT,
described as worry, have been measured in groups
with persecutory delusions (Freeman & Garety,
1999; Startup, Freeman & Garety, 2007) and other
presentations of psychosis (Morrison & Wells, 2007)
Harvey et al., 2004; Erhing & Watkins, 2008
Perseverative cognition
• “The repeated or chronic activation of the
cognitive representation of one or more
psychological stressors” (Brosschot et al.,
2006)
• Description of repetitive negative thinking
adopted in research relating to stress-related
physiological activation and its health
consequences
Summary
• Significant evidence of a transdiagnostic role
for repetitive negative thought (RNT)
• RNT associated with many Axis 1 disorders
• Evidence of a causal role for RNT in onset and
maintenance of transdiagnostic distress
• Is RNT relevant to psychosis / paranoia and
persecutory delusions?
Repetitive negative thinking processes
in persecutory delusions, paranoia and
psychosis
• ‘Preoccupation’ as a cardinal feature of delusional
beliefs
– e.g. Chadwick & Lowe (1990; belief conviction, belief
preoccupation)
– E.g. Peters et al. (1999; distress, preoccupation,
conviction)
Repetitive thinking processes in
psychosis underpins delusional distress
• “…further
appraisal of the
experience (e.g.
worry and
rumination)”
Freeman (2007),p451
Repetative thought in psychosis
• Limited research available
• High levels of worry found in
– Individuals with current persecutory delusions (Freeman &
Garety, 1998; Startup, Freeman & Garety, 2008)
– And, other presentations of psychoses (Morrison & Wells, 2007)
• Association between rumination and negative
symptoms
– A relationship between rumination and measures of emotional
withdrawal and stereotyped thinking, in participants with
diagnosis of schizophrenia (Harari et al., 2009)
Rumination and psychosis
• Idea of ‘rumination’ or ‘brooding’ as playing a
role in paranoia has clinical face validity
– Repetitive thinking about the meaning, causes and
consequences of activated threat beliefs and
anxious mood
• But, little research has explored the role of
rumination in persecutory or paranoid beliefs
Does rumination play a role in paranoia?
• A questionnaire study investigating the
relationship between rumination and paranoid
ideation in a student sample*
• Two lab-based studies investigating the effect of
rumination (versus distraction) on a personal
threat belief
– 1. autobiographical memory of suspicious or
mistrustful event (within subjects design)
– 2. in vivo exposure to a ‘paranoia prime’ (between
subjects design)
Relevance of non-clinical studies
• There is a continuum of severity of paranoia in
the general population (Os & Verdoux, 2003)
– 15-20% regularly engage in paranoid thinking
• Non-clinical and clinical paranoia are associated
with the same risk factors (Freeman, 2007)
• Presence of non-clinical paranoia increases
likelyhood for a subsequent diagnosis of
psychosis
• Non-clinical paranoia is of interest in its own
right, but may also inform our understanding of
clinical paranoia and persecutory delusions
Is rumination associated with paranoid
ideation? Questionnaire Study
Simpson, Dudley, McGregor & Cavanagh (under review)
• 133 student participants from Newcastle
University, UK
• 40 males and 92 females (data missing for one
participant)
• Mean age = 20 (SD=3.9)
• Ethnicity 91% white British, 7% white other,
2% Asian.
• Measures
– Fenigstein Paranoia Scale (Fenigstein & Vanable,
1992)
• ‘I’m sure I have been talked about behind my back’
• ‘some people have tried to steal my ideas and take
credit for them’
– Rumination Response Scale (Nolen-Hoeksema &
Marrow, 1991)
• ‘think about your shortcomings, faults and mistakes’
• ‘write down what you are thinking and analyse it’
– Positive and Negative Affect Schedule (Watson,
Clark & Tellegen, 1988)
– (plus other measures not reported here)
Result of Pearson’s Correlation and Significance
Values between variables (n=129)
Paranoia
Scale
PANAS
negative
PANAS,negative
0.31**
PANAS,positive
-0.01
-0.16
Ruminative
Response Scale
0.46**
0.52**
PANAS
positive
-0.10
• Regression analysis indicated that rumination predicts significant additional
variance in paranoia when negative mood is accounted for.
Key: PS=Paranoia Scale, PANAS=Positive and Negative Affect Scale, SBQ=Safety Behaviour Questionnaire, RRS=Rumination Response Scale.
*p<0.05
**p<0.01
• Correlational analysis supports the idea that
rumination may be associated with paranoid
ideation
• This effect is over and above the processes
intrinsic to negative mood
• Next step, to test hypothesis that this is a
causal relationship in the lab…
Does rumination on paranoid ideation increase
conviction in paranoid ideas and feelings of paranoia?
Simpson, McGregor, Dudley, Cavanagh (under review)
• 25 University Students
– 22 females, mean age 20 (SD=3), 96% white
• Autobiographical memory procedure
– “Bring to mind a time when you felt suspicious or mistrustful of another
persons intentions…”
– “focus on the events that made you feel suspicious or mistrustful”
• Within subjects design
– With that memory held in mind think about…(counterbalanced)
• Rumination (e.g. ‘Why people treat you the way they do’?)
• Distraction (e.g. ‘the layout of your local supermarket aisles’)
• Based on Rusting & Nolen-Hoeksema (1998)
• Measures of procedure fidelity and adherence, conviction in threat
beliefs, self-reported distress etc
Design
Baseline Measures
Paranoia Induction:
Autobiographical
memory
Rumination /
Distraction
Tasks
(counterbalanced)
Outcome measures
Fidelity checks: memory procedure
Prior to Rumination
Task
Prior to Distraction
Task
How clearly can you remember the
73.1(21.0)
incident?
76.8 (21.5)
To what extent did you feel
mistrustful or suspicious of the
other person/people?
60.6 (19.3)
67.3 (21.5)
To what extent did you feel that
you were at threat of physical
harm or psychological harm
47.4 (28.3)
49.0 (29.9)
To what extent did you feel that the
34.9 (27.5)
person(s) meant to cause harm?
34.4 (27.7)
Thinking tasks
• Rumination induction
– 15 rumination items and asked to spend 8 minutes thinking
sequentially about the meaning of the items.
– e.g. “Think about why people treat you the way they do” and “Think
about how you react to other people
• Distraction induction
– 15 externally-focused distraction items
– e.g. “Think about the layout of the local post office” and “Think about
a double-decker bus driving down the street”
• All items were taken from Rusting and Nolen-Hoeksema, (1998)
rumination procedure.
• Matched for instructions and length of task
Adherence checks: thinking tasks
Rumination Task
Distraction Task
Percentage of time you managed to
stay focused on the task
76.0 (12.1)
75.3 (15.2)
Extent you were able to follow the
instructions of the task
87.2 (13.5)
89.4 (10.6)
Proportion of the time you spent
thinking about yourself or other
people?
87.4 (8.6)
43.0 (31.1)
Proportion of the time you spent trying
to understand or make sense of things? 70.0 (19.5)
45.8 (30.8)
Outcomes (nb. baseline = post-prime)
140
20
18
120
16
100
14
80
12
Baseline
Rumination
60
Distraction
40
Baseline
10
Rumination
8
Distraction
6
4
20
2
0
0
Threat belief
VAS paranoia
Rumination vs distraction, p<0.05
Baseline vs distraction, p<0.05
Baseline vs rumination, ns
Rumination vs distraction, p<0.05
Baseline vs distraction, p<0.05
Baseline vs rumination, ns
Conclusions
• Rumination appears to be associated with the
maintenance of threat beliefs and paranoid
feelings following recall of an autobiographical
memory characterised by suspicion/mistrust
• Distraction appears to remediate threat
beliefs and paranoid feelings
• Next step – does rumination have a similar
effect on paranoid threat beliefs in vivo?
Martinelli & Cavanagh (in prep)
• 37 students
– 30 females, mean age = 24.5 (SD = 3.9),
• In vivo paranoia induction – concern about potential harm from an
other person
• Between subjects design
– With these events held in mind think about…
• Rumination (e.g. ‘Why people treat you the way they do’?)
• Distraction (e.g. ‘the layout of your local supermarket aisles’)
• Based on Rusting & Nolen-Hoeksema (1998)
• Measures of state paranoia scale (adapted from Freeman et al),
time on task, distress etc
Association between trait paranoia
and RNT
• Trait paranoia and trait perseveration were
highly correlated, r = 0.54, p<0.001.
• Supporting the idea that RNT and paranoia are
related
Martinelli & Cavanagh (in prep)
Procedure
Rumination
Baseline
Measures
Paranoia
Induction:
In vivo
Outcome
measures
Distraction
Induction of paranoia
• Previous studies have used different protocols to initiate in
situ paranoia
• Prevost et al (2010) – participants told there was a hidden
goal to the study, their cerebral activity would be
manipulated via electrical currents during the experiment,
and were given the impression they were being observed
from behind a one-way mirror (paranoia not measured)
• Ellet et al.(2008) exposure to deprived urban environment
(increased paranoia)
• Ellett & Chadwick (2007) video camera observation during
task (increased paranoia – but artifact of self-focus/social
anxiety?)
Our paranoia induction procedure
– Sit in a dark room for 5 minutes, facing a wall with
back to door, after some time someone might
come in and might interact with you in a mildly
unpleasant way – e.g. pinch you, tickle you, say
something unpleasant to you…
– Demonstrated to elevate state paranoia in pilot
studies.
Measuring state paranoia
Freeman et al (2007) State Social Paranoia Scale –
designed to capture participants responses to a ‘social’
situation
•
•
•
•
“someone was hostile towards me”
“someone had it in for me”
“I felt safe…”
“everyone was pleasant”
etc
Freeman et al have found that
more than 1/3rd people report
paranoid thoughts even when
the social environment is neutral
(2008)
Was the paranoia induction effective?
30
25
Post-paranoia
20
Neutral situation
15
Freeman nonclinical
10
Freeman clinical
5
0
Mean State Paranoia Scale
• Suggests our induction procedure was effective in
eliciting ‘paranoia’ in our participants
State paranoia scale
• No difference between
groups after paranoia
induction
– t(35) = 0.6, ns
• Time x Condition interaction
effect for thought process
– F (1,35) = 7.1, p = 0.01
• Post-test differences
• Distraction v Rumination
– t(35) = 2.3, p = 0.03
No differences between groups in following instructions, concentration, time on task etc
Findings of Martinelli & Cavanagh
study
• Paranoia induction appeared to raise state paranoia
(needs validation/replication)
• Rumination on this ‘dark-room’ experience was
associated with maintenance of feelings of paranoia
• Distraction was associated with reductions in feelings
of paranoia
• Baseline paranoia was associated with baseline
perseverative style, and response to the paranoia
induction.
• Other methodological factors did not account for the
effects of rumination on final level of paranoid ideation
Conclusions
• Rumination appears to be associated with maintenance
(elevation?) of threat beliefs and feelings of paranoia
associated with exposure to ambiguous/threatening
interpersonal situations
• Distraction appears to remediate paranoid ideas and
mood (at least in the short term)
• This replicates and extends a significant body of research
supporting the transdiagnostic role of repetitive negative
thinking processes
• Limitations to these studies in terms of small sample
sizes, use of non-clinical examples of suspicious threat
beliefs etc
Questions
• Does this have any implications for our understanding
of clinical paranoia/persecutory delusions?
• How can we reconcile evidence of both repetitive
negative thinking and ‘jumping to conclusions’
reasoning biases in relation to paranoia and
persecutory delusions?
• How might we extend our knowledge of paranoia
processes in non-clinical samples?
• How similar are these measured effects to those found
in ‘post-event processessing’ in social anxiety?
• Other questions….
Future research should explore…
• Bio-psycho-social mechanisms underlying the
relationship between rumination and suspicious and
mistrustful thinking in non-clinical populations
• The role of repetitive thought in paranoid ideation in
clinical populations
• The impact of keeping rumination and other types of
perseveration in mind when working therapeutically
with suspicious and mistrustful thinking and paranoia
in clinical settings
– E.g. can RNT therapies offer benefit in this domain?
Thank-you
Kate Cavanagh DPhil DClinPsych
Senior Lecturer in Clinical Psychology
Director of the Interactive Wellbeing Lab
University of Sussex, UK.
kate.cavanagh@sussex.ac.uk