The weeks before 100 persecutory delusions: the presence of many potential contributory causal factors

Abstract

Background The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding. Aims To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors – identified from a cognitive model – before delusion onset. Method A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed. Results Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types. Conclusions Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality. Declaration of interest None.

Premature commitment to uncertain decisions during human NMDA receptor hypofunction

“…This early stage of the disease is extremely difficult to study because patients are typically not receiving health care before developing a full-blown psychosis. The two effects of ketamine observed in our task could potentially reconcile these two stages in a unified account: an initial state of high uncertainty 46 and premature commitments 47 which progressively results in overconfidence and a weaker relation between confidence and decision accuracy-both of which being characteristic of psychosis 48 . Confirming this speculative hypothesis will require testing patients diagnosed with schizophrenia in our task at different stages of their illness.…”

The Role of Dissociative Compartmentalization in Difficult-to-Treat Psychotic Phenomena

“…Dissociation has a well-established presence in psychosis populations (Ross and Keyes, 2004;Moskowitz, 2011;Vogel et al, 2013;Renard et al, 2017;Sun et al, 2018a), and may have a pivotal role in the formation and maintenance of psychotic symptoms (Schäefer et al, 2012;Sun et al, 2018a;Freeman et al, 2019;Treise et al, 2019;Longden et al, 2020). Dissociative symptoms have been found in both longer-term psychotic illness (Ross and Keyes, 2004) and in first episode of psychosis (Sun et al, 2018b), and are mostly associated with positive symptoms, specifically delusions and hallucinations (Spitzer et al, 1997;Ross and Keyes, 2004;Kilcommons and Morrison, 2005;Lysaker and LaRocco, 2008;Schäefer et al, 2012;Vogel et al, 2013;Schroeder et al, 2016;Sun et al, 2018b;Longden et al, 2020;Varese et al, 2020).…”

“…Moreover, the severity of dissociative phenomena may fluctuate in step with psychotic symptoms, with higher levels of dissociation in the acute illness phase compared to stabilization (Schäefer et al, 2012). Despite evidence supporting a relationship between dissociative and psychosis phenomena, evidence supporting dissociation as a treatment focus for positive symptoms of psychosis (Longden et al, 2020;Varese et al, 2020), and proposals that some psychotic symptoms may be better conceptualized as forms of dissociation (Moskowitz et al, 2009;Longden et al, 2020), the nature of this connection has remained elusive (Sun et al, 2018b;Freeman et al, 2019;Treise et al, 2019). This uncertainty may have contributed to the fact that treatment guidelines [National Institute of Health and Care Excellence (NICE), 2014] have not yet included dissociative processes as targets for routine psychological treatment in populations with psychosis (Newman-Taylor and Sambrook, 2013; Treise et al, 2019).…”

Sleep Interventions in the Treatment of Schizophrenia and Bipolar Disorder

“…Clinical studies examining the relationship between sleep and psychotic disorder report that sleep problems are common in patients with delusions and that delusions decrease with improvement of sleep problems ( 19 – 21 ). However, most patients with schizophrenia experience sleep problems before delusions appear ( 22 ), almost 80% of patients in the first episode psychosis have sleep disorders ( 23 ), and sleep and circadian rhythm disorders are associated with poor prognosis in high-risk groups for psychosis ( 24 ). Besides, it is known that sleep deprivation in healthy individuals can cause paranoia and hallucinations ( 25 ).…”