خود حمله و خود اطمینان در هذیان های گزند: مقایسه افراد سالم، افسرده و پارانوئید

Previous research has found that reduced self-reassurance and heightened verbal ‘self-attacking’ of a sadistic and persecutory nature are both associated with greater subclinical paranoia. Whether these processes are also linked to clinical paranoia remains unclear. To investigate this further, we asked 15 people with persecutory delusions, 15 people with depression and 19 non-psychiatric controls to complete several self-report questionnaires assessing their forms and functions of self-attacking. We found that people with persecutory delusions engaged in more self-attacking of a hateful nature and less self-reassurance than non-psychiatric controls, but not people with depression. Participants with persecutory delusions were also less likely than both healthy and depressed participants to report criticising themselves for self-corrective reasons. Hateful self-attacking, reduced self-reassurance and reduced self-corrective self-criticism may be involved in the development or maintenance of persecutory delusions. Limitations, clinical implications and directions for future research are discussed.

A considerable number of studies have examined the role of self-esteem and attributional style in persecutory delusions, beginning with the seminal work of Richard Bentall and colleagues (Kaney and Bentall, 1989 and Bentall et al., 1994). These authors, inspired in part by an earlier hypothesis that paranoia was a form of camouflaged depression (Zigler and Glick, 1988), proposed that paranoia could develop out of an increased tendency to hold others responsible for negative events (Bentall et al., 2001). This externalising attributional style was thought to help reduce discrepancies between one's ‘ideal self’ and one's ‘actual self’ (Bentall et al., 2001), thereby easing the sense of internal threat which might otherwise occur. This has been termed the Attribution-Self-Representation cycle (ASR) and has been conceptualised as a more extreme version of the self-serving bias frequently observed in the general population (Campbell and Sedikides, 1999). Bentall's model has inspired much empirical work and debate, largely centred on whether people with paranoia actually do have an external attributional style, whether they have low or high ‘explicit’ self-esteem (i.e., what people say they think about themselves), and whether there is a discrepancy between this and their ‘implicit’ self-esteem (i.e., what people really think about themselves) (e.g., Moritz et al., 2006, Freeman, 2007, McKay et al., 2007, Bentall et al., 2008, Vazquez et al., 2008, Mehl et al., 2010, Kesting et al., 2011, MacKinnon et al., 2011 and Valiente et al., 2011). The argument goes that having low implicit self-esteem but high explicit self-esteem might be good evidence for the presence of maladaptive defensive processes (Bentall et al., 2001). However, several studies suggest people with clinical paranoia tend to hold quite negative beliefs about themselves (e.g., Fowler et al., 2006, Smith et al., 2006 and Fowler et al., 2011) and relatively low levels of self-esteem, whether explicit (e.g., Bentall et al., 2009) or implicit (e.g., Vazquez et al., 2008). Such findings are in line with another influential account of persecutory delusions proposed by Freeman et al. (2002), who argue that self-esteem has a direct role in influencing the content of paranoid beliefs. Results are inconsistent, however, and a number of studies provide support for some of the predictions of the ASR model (e.g., Janssen et al., 2006, Jolley et al., 2006, Aakre et al., 2009 and Valiente et al., 2011). This inconsistency might arise because studies have not distinguished between those who believe they deserve their persecution and those who do not (Trower and Chadwick, 1995). Consistent with the ASR model, the latter have been shown to have better self-esteem (Chadwick et al., 2005a), an externalising attributional style (Fornells-Ambrojo and Garety, 2009) and less shame (Morris et al., 2011). Moreover, one particular strength of the ASR model is that it predicts a reciprocal link between self-esteem instability and extreme attributions ( Kernis et al., 1993), of which persecutory delusions might be considered a paradigmatic example. The results of recent cross-sectional, longitudinal and experience-sampling research support this prediction, in that paranoia has been linked to both low self-esteem and fluctuations in self-esteem ( Thewissen et al., 2007, Thewissen et al., 2008a, Raes and Van Gucht, 2009 and Thewissen et al., 2011), although a recent analysis of an older dataset did not replicate this ( Palmier-Claus et al., 2011). Other work has demonstrated that perceived deservedness of persecution is also highly variable in persecutory delusions, a finding that is again consistent with a dynamic conceptualisation of self-esteem in paranoia ( Melo et al., 2006). Cognitive behavioural therapy (CBT) for persecutory delusions, influenced by these and other cognitive models (e.g., Morrison, 2001), often involves improving self-esteem (Fowler et al., 1995 and Morrison et al., 2003), on the assumption that doing so will reduce distress and increase well-being. However recent authors have criticised the self-esteem concept, highlighting the differences between it and self-compassion and discussing the implications of these differences for understanding and promoting well-being. Neff and Vonk (2009) in particular discuss the negative consequences of making efforts to maintain self-worth, which may include engaging in dysfunctional behaviour and avoiding personal responsibility ( Neff and Vonk, 2009). They also highlight how judgements of self-worth are very often contingent on achievement in certain domains. They argue that understanding self-esteem may not help us understand concepts such as self-kindness and self-acceptance, which other studies suggest may be more important in accounting for well-being and resilience ( Leary et al., 2007). They discuss how high self-esteem can involve high levels of self-criticism, alertness and preoccupation with social rank and competitiveness, whereas self-compassion involves caring, acceptance and kindness to self and others. The authors also present data suggesting self-compassion is associated with a more stable sense of self-worth than global judgements of self-esteem. Another difficulty with the concept of low self-esteem is that it does not seem to adequately capture the sense of hatred and disgust that some people seem to hold for themselves (Gilbert et al., 2004). Furthermore, concepts of self-esteem (and negative self-schemata) do not help us fully understand why people feel they need to treat themselves in this way. Understanding these variables may have important clinical implications, as outlined elsewhere ( Gilbert, 2010 and Gumley et al., 2010). Although self-esteem and self-criticism are related constructs, self-criticism (and its antithesis self-compassion) is much less about self-evaluation and judgement and much more about an interaction one has with oneself ( Gilbert et al., 2004). Conceptualising self-criticism and self-compassion in this way allows us to consider how these might be linked to the relationships we have with other people. If people are looked at this way, we might better understand their purpose, as well as gain insights into the function of the emotional responses they elicit.

There was no main group effect for gender differences, as shown in Table 1 (χ2 (2, N=49)=4.32, p=0.115). Kruskal–Wallis analyses found significant group differences in age (H(2)=10.095, p=0.006), years of education (H(2)=16.89, p<0.001) and current mood according to HADS-D scores (H(2)=33.96, p<0.001). One-way ANOVA found significant group differences in current anxiety according to HADS-A scores (F(2,45)=39.03, p<0.001). Post-hoc tests (Mann–Whitney and Scheffé) found that, compared to members of the two clinical groups, the healthy control group were younger (versus depression U=62.5, p=0.01, d=−0.95; versus persecutory delusions U=62.5, p=0.005, d=−0.91), reported fewer symptoms of depression (versus depression U=0, p<0.001, d=−2.71; versus persecutory delusions U=0, p<0.001, d=−3.74) and were less anxious (versus depression p<0.001, d=−2.73; versus persecutory delusions p<0.001, d=−2.72). They had more years of education than the persecutory delusions group (U=24, p<0.001, d=1.89) but not the depression group. No significant differences were found between the depression group and the persecutory delusions group with respect to age, HADS depression and HADS anxiety scores. The depression group were found to have spent significantly longer in full-time education than the persecutory delusions group (U=55, p=0.025, d=0.89). The group differences in age and years of education meant they could not be incorporated as covariates in any subsequent three-group ANCOVAs, as doing so would violate the assumption of independence of the covariate and treatment effect (Miller and Chapman, 2001 and Field, 2005).