The Stress of the Street for Patients With Persecutory Delusions: A Test of the Symptomatic and Psychological Effects of Going Outside Into a Busy Urban Area

Abstract

Background:For many patients with persecutory delusions, leaving home and going into crowded streets is a key clinical problem. In this study we aimed to inform treatment development by determining the psychological mechanisms whereby busy urban environments increase paranoia. In a randomized design with prespecified mediation analysis, we compared the effects on patients of going outside into a busy social environment with staying inside. Methods:Fifty-nine patients with current persecutory delusions, in the context of nonaffective psychosis, reporting fears when going outside were assessed on factors from a cognitive model of paranoia. They were then randomized either to enter a busy local shopping street or to complete a neutral task indoors. They were then reassessed on the measures. Results:Compared with staying inside, the street exposure condition resulted in significant increases in paranoia, voices, anxiety, negative beliefs about the self, and negative beliefs about others. There was also a decrease in positive thoughts about the self. There was no alteration in reasoning processes. There were indications that the increase in paranoia was partially mediated by increases in anxiety (45%), depression (38%), and negative beliefs about others (45%). Conclusions:We found that increases in negative affect may form an important route by which social exposure in urban environments triggers paranoid thoughts. The study provides an illustration of how an experimental approach can be applied to help understand a specific difficulty for patients with psychosis. In future studies the effects of specific elements of the social environment could be tested.

In the eye of the beholder: Perceptions of neighborhood adversity and psychotic experiences in adolescence

“…From an adolescent’s perspective, residing in and navigating a threatening neighborhood environment could also promote or reinforce maladaptive cognitive styles such as paranoia and threat detection biases. This proposed mechanism is consistent with studies showing that the severity of persecutory delusions, anxiety, paranoia, and hallucinations among adults with schizophrenia is immediately exacerbated after brief exposure to crowded urban environments (Ellett et al, 2008; Freeman et al, 2014). The potential bidirectional relationship between perceptions of adverse neighborhood conditions and adolescent psychotic experiences is also consistent with the phenotypic overlap documented between psychosis and stress-sensitivity and -reactivity (Collip et al, 2011; Myin-Germeys, Delespaul & Van Os, 2005; Myin-Germeys et al, 2001).…”

How environments get to the skin: biosensory ethnography as a method for investigating the relation between psychosis and the city

“…Drawing on a vulnerability-stress model (Zubin and Spring 1977) of the aetiology of psychosis, this strand of research aims to more closely analyse ill/ health-environment relations as observed in situ. One of the first experiments in this direction was a walk in Camberwell, London, looking at symptoms before and after a walk in a busy shopping street for persons with persecutory delusions (Ellett et al 2008; see also : Freeman et al 2015). This type of experimental procedure is important because it initiates a move out of the laboratory and the clinic, as well as away from epidemiological mapping to consider ordinary situations in cities.…”

Travel Risks for Those With Serious Mental Illness

“…Unfamiliar situations are well known for inducing paranoid thinking. 34 An important stressor associated with travel is leaving behind one's emotional support system. [35][36][37][38] For mental health service users, this means not only separation from family and friends but also from trusted care providers and health resources.…”

“…41 It is not unusual for an unfamiliar place to be perceived as hostile and threatening, especially if one is vulnerable to the misinterpretation of sensory perceptions. 34 Marcheschi et al 42 found that, in people with severe mental illness living in supported housing, perceived physical and social factors in their environments determined approximately one third of the variance in the quality of their lives. The loss of a habitual social or occupational role while traveling (even the often stigmatized role of psychiatric patient) can lead to a sense of rootlessness and lost identity, 43 which looms especially large for individuals with personal experience of psychosis.…”