Madness Explained

by Richard P. Bental

  It is possible that the ability of deluded patients to evaluate their hypotheses may be limited, not only by their inability to weigh evidence appropriately, but also by their avoidance of disconfirmatory information.

  A few years ago, my colleague Tony Morrison noticed an interesting parallel between the behaviour of paranoid patients and the behaviour of patients suffering from phobias or anxiety disorders.113 Patients suffering from these conditions often fail to notice that the object of their fear cannot harm them, because they avoid situations in which this would be obvious. Instead, they perform safety behaviours, which keep them in situations in which their fears never have to be confronted. For example, a man who is very seriously frightened of dogs may stay at home all of the time, thereby preventing himself from discovering that most dogs are friendly.

  The concept of safety behaviours exemplifies, yet again, the reaction-maintenance principle (see p. 262). It is easy to see why persecutory beliefs in particular may lead to these kinds of behaviours, and why these behaviours in turn may help to keep the beliefs alive. It is fairly commonplace to find that patients who fear that secret organizations are conspiring to hurt them stay away from places where they believe that they may be vulnerable to attack, or that those who mistrust people living nearby avoid talking to their neighbours. An extreme example of this kind of behaviour studied by Tony Morrison concerned a woman who believed that she was being followed by the IRA, and who attempted to lose her trackers by wearing disguises, varying her routes to local shops, and by hiding behind cars at intervals while out walking. In a survey of a small group of paranoid patients recently carried out by Daniel Freeman at the Institute of Psychiatry in London it was found that the majority reported safety behaviours.114

  Whether or not this concept can be extended to other types of delusions remains to be seen. There is evidence, for example, that dismorphobic patients (who believe that they are disfigured or ugly, despite being completely normal in appearance) avoid social situations in which they may be able to judge how other people look at them,115 but it is difficult to see how, say, grandiose or somatic delusions could be maintained in this way.

  An Embarrassment of Riches

  By now, the reader will have appreciated that research on delusions has moved forward dramatically over the last decade. Whereas ten years ago there was hardly any evidence to discuss, we now have the opposite problem of trying to make sense of a wide range of research findings which can be interpreted in a variety of ways. The comparison between deluded patients and scientists that I have taken as my theme in this chapter seems to make some kind of sense (at least as a framework for organizing this information) but obviously leaves a lot of questions unanswered. For example, we can ask which of the many processes we have considered is most important in the causation of delusional beliefs. Of course it is possible that all play an important role but to different degrees in different people. (It is easy to imagine that somatic delusions arise primarily as an attempt to explain unusual bodily sensations, whereas what may be termed the social delusions– of persecution, grandiosity and jealousy – seem to involve the mental mechanisms responsible for generating causal explanations and understanding others’ mental states.)

  This idea raises the interesting possibility that it may one day be possible to construct a typology of delusions based on different psychological processes, rather than merely on content. However, it is equally possible that, in the case of some delusional systems, we will be able to construct a unifying theory that shows how these different processes interact. In the next chapter, I will try and construct such a theory to explain delusions of persecution.

  13

  On the Paranoid World View

  When I was coming up, it was a dangerous world, and you knew exactly who they were. It was us vs. them, and it was clear who them was. Today, we are not so sure who they are, but we know they’re there.

  George W. Bush1

  Only the paranoid survive.

  Andrew Grove2

  In this chapter I will attempt to bring together some of the ideas covered in the last three chapters and, at the same time, make good my promise to outline a detailed theory of paranoid (persecutory) delusions. The theory3 that I will describe has evolved over more than a decade, during which time earlier versions4 have been proposed and modified as they have confronted new data.* Of course, it is likely that further modifications will be required as new research findings become available.

  I will begin with two assumptions. First, given that paranoid ideas involve worries about relationships with other people, they surely must have something to do with social cognition. Second, most people who have thought seriously about delusions in general have assumed that they arise from attempts to explain unusual or troubling experiences. This assumption seems to lie behind nearly every study that we considered in the last chapter.5

  Together, these assumptions suggest that attributions must play a central role in paranoid ideas. And, indeed, we have already seen evidence that this is the case. In the last chapter, we saw that paranoid patients show an exaggeration of the self-serving bias (the normal tendency to attribute positive events to the self and negative events to external causes) and that, when they make external attributions for negative events, their explanations usually implicate the intentions of others (they make external-personal attributions) rather than circumstantial factors (external-situational attributions). It is not difficult to see how complex conspiracy theories might arise from repeatedly explaining unpleasant experiences in this way.

  The Paranoid Self

  As the self-serving bias is a homeostatic mechanism that most of us use to regulate our self-esteem, the obvious inference from these findings is that paranoid patients are struggling excessively to protect themselves from negative beliefs about themselves. This idea is consistent with the account of paranoia proposed by psycho analyst and computer scientist Kenneth Colby, which I discussed at the beginning of the last chapter, and seems to lead to the prediction that paranoid patients should score normally on self-esteem measures.6

  In fact, the available evidence on self-esteem in paranoia is inconsistent and overall not favourable to this prediction. Daniel Freeman at the Institute of Psychiatry in London administered a questionnaire to a group of schizophrenia patients taking part in a treatment study and reported that many of the patients who had paranoid delusions had quite low self-esteem, although they also identified a small group in which self-esteem appeared to be normal.7 B. Bowins and G. Shugar, two psychiatrists in Canada, also used a questionnaire to measure self-esteem in psychotic patients, reporting that deluded patients in general (although not necessarily patients suffering from persecutory delusions) had low self-esteem.8 Most recently, Christine Barrow-clough and Nick Tarrier in my own university used a detailed interview to assess separately positive and negative self-esteem in a large group of schizophrenia patients, finding that paranoia was associated with high levels of negative self-esteem. This association remained even when the effects of depression and other symptoms were taken into account.9

  Against these studies, several others have reported that self-esteem is relatively normal or even high in paranoid patients. For example, Carmie Candido and David Romney in Canada assessed global self-esteem in paranoid, depressed-paranoid and depressed patients. They reported high self-esteem in the paranoid group, low self-esteem in the depressed group, and intermediate scores in the depressed-paranoid group.10 In one of my own studies, paranoid patients scored normally on a simple self-esteem questionnaire.11 Perhaps the most interesting study to provide evidence of high self-esteem in paranoid patients was conducted by Thomas Oxman, Stanley Rosenberg and Paula Schnurr at the University of Washington in Seattle, who, instead of administering a questionnaire, simply asked paranoid patients and several other groups of patients to speak about anything they wished for five minutes. They then used a computer to analyse the frequency with which different concepts were expressed in the speech sa
mples. The concepts expressed by the paranoid patients were judged to indicate ‘an artificially positive, grandiose self-image, and a defensive abstractness’.12

  When data are as inconsistent as this it is a fair bet that researchers have been asking the wrong question, or at least asking the right question in the wrong sort of way. In this case, a stumbling block seems to be the concept of self-esteem, which, as we saw in Chapter 10, fails to capture adequately the psychological processes involved in self-representation and can be measured in many different ways. Clearly, we need to turn to methods of assessing the self that more accurately reflect its dynamic nature.

  Borrowing the ideas of American social psychologists E. Tory Higgins and Tim Strauman, Peter Kinderman and I asked paranoid patients, depressed patients and ordinary people to describe themselves as they actually were (the actual self), how they would like to be (the ideal self, a self-standard) and how they believed their parents saw them (the parent-actual self). (We began by asking our participants to describe how they thought their friends saw them. However, this strategy foundered because many of the paranoid patients reported that they had no friends!) We then examined the discrepancies between these different descriptions.13 (Higgins and Strauman, it will be recalled from Chapter 10, showed that discrepancies between the actual self and ideals are associated with depressed mood.)

  As other researchers had reported previously, we found that these descriptions were fairly concordant in our normal control group, who believed that they were more or less the sort of people they would like to be, and that their parents shared their positive self-perceptions. Like depressed patients in previous studies (see Chapter 10), our depressed group showed marked discrepancies between how they saw themselves and how they said they would like to be. In contrast, our paranoid patients showed very little discrepancy between their self-actual and self-ideal concepts but very marked discrepancies between their self-actual concepts and their beliefs about how their parents saw them. In general, they seemed to believe that their parents had extremely hostile attitudes towards them.

  The observation that paranoia is associated with the belief that other people harbour negative attitudes towards the self might be regarded as a statement of the obvious. However, it is an observation that is consistent with the attributional data we considered in the last chapter. If paranoid patients consistently blame their misfortunes on the intentional actions of other people, it is not surprising that they believe that other people hate them.

  Implicit beliefs about the self

  So far we have considered immediate, conscious judgements about the self. However, many of our judgements about ourselves, for example when we make remarks that reflect our feelings without carefully thinking about what we are saying, are more implicit. These implicit judgements echo relatively enduring stored knowledge and beliefs about the self, rather than what we consider to be our virtues and deficits at the present moment in time. They may well be different from the kinds of opinions expressed when we actively reflect about the self, but (because they are ephemeral) can be difficult to capture.

  Peter Kinderman devised an approach to this problem that exploited the Stroop effect, which I first described in Chapter 11 (pp. 281–2). He reasoned that people who are uncomfortable about themselves should be slow to colour-name self-descriptive words. He therefore showed paranoid patients, depressed patients and ordinary people a questionnaire consisting of high self-esteem words (for example, ‘capable’, ‘wise’) and low self-esteem words (for example, ‘childish’, ‘lazy’). They were asked to indicate with a tick which of the words described themselves. As expected, ordinary people endorsed most of the positive words and very few of the negative words. The depressed patients, on the other hand, ticked about equal numbers of positive and negative words. The paranoid patients ticked mostly positive words but also slightly more of the negative words than the normal controls. In the second stage of the study, the participants completed a Stroop task in which they were asked to colour-name the same words. Peter Kinderman found that the normal people had little difficulty with this task and colour-named both the high self-esteem and the low self-esteem words about as fast as they colour-named a list of emotionally neutral words. However, the depressed patients showed slowed colour-naming for the high self-esteem words and especially for the low self-esteem words. This effect was even more pronounced for the paranoid patients, indicating that the words had special emotional significance for them (see Figure 13.1).14 These findings were recently repeated in two studies carried out by Hon Lee in South Korea, one comparing students who scored high and low on a paranoia questionnaire, and one comparing clinically paranoid, clinically depressed and normal participants. In the first study, the paranoid students showed slow colour-naming only for low self-esteem words. In the second, paranoid patients showed slowed colour-naming for both positive and negative trait words.15

  A second method of assessing implicit beliefs about the self involves studying implicit attributions. The ASQ asks people to make deliberate and thoughtful judgements about the causes of events, and it is therefore unsurprising that paranoid patients’ responses on it are defensive. If patients could be led to make more implicit or thoughtless judgements, perhaps their responses would be more concordant with any underlying negative beliefs about the self. As we saw in Chapter 11 (pp. 279–80), a suitable measure – the Pragmatic Inference Task (PIT) – has been developed by researchers investigating bipolar patients.

  Helen Lyon, Sue Kaney and I administered the PIT and a conventional attributional style questionnaire to paranoid patients, depressed patients and ordinary people. As we expected, the ordinary people showed a self-serving bias on both measures. In contrast, both the deluded and the depressed patients made more internal attributions

  Figure 13.1 The upper panel shows the number of positive and negative trait words endorsed as true by paranoid, depressed and normal control participants on a questionnaire (PPQ). The lower panel shows the interference index (extra time taken in comparison with emotionally neutral words) for the same words in a Stroop colour-naming task administered to the same participants (from Kinderman, 1994).

  for negative than for positive events on the PIT (see Figure 13.2). In the case of the depressed patients, this pattern corresponded with their scores on the conventional questionnaire, and is consistent with the research we considered earlier in this book. However, on the explicit measure the paranoid patients made more external attributions for

  Figure 13.2 Internality scores for paranoid, depressed and normal participants on the PIT (from Lyon, Kaney and Bentall, 1994).

  negative than for positive events, an attributional style that was consistent with our previous findings but completely different from their pattern of responding on the PIT.16

  A final indirect method of assessing beliefs about the self that we will consider here concerns the enduring standards by which we judge ourselves. In order to measure these standards, Sue Kaney and I used the Dysfunctional Attitudes Scale (DAS), a widely used questionnaire, which I described in Chapter 10 (p. 253). Because paranoid patients often complain of being depressed, and because depressed patients typically score highly on the DAS, we wanted to ensure that any highly perfectionistic attitudes we detected could not be a mere consequence of negative mood. We therefore struggled hard to identify two groups of deluded patients, one with concurrent depression and a smaller group who were not depressed at the time of testing. As it turned out, both groups scored similarly to a group of depressed patients who were not suffering from delusions, and showed very high scores on the questionnaire.17 Similar findings were obtained in a study by Chris Fear, Helen Sharp and David Healy, which was published at about the same time.18 As perfectionistic self-standards presumably make individuals vulnerable to negative self-evaluations, these findings are consistent with the hypothesis that paranoid patients are strongly motivated to avoid threats to the self.

  The dynamic nature of the paranoid defence


  It is clear that paranoid patients do not consistently maintain a high level of self-esteem. Indeed, the findings obtained from the indirect measures that we have just considered seem more consistent with the opposite conclusion – that paranoid patients have low self-esteem. However, even this would be an over-simplification. The picture that emerges suggests a much more complex and dynamic relationship between attributions, different kinds of self-representations, mood and paranoid delusions, as if the paranoid patient is constantly fighting to maintain a positive view of the self, sometimes winning and but more often losing.

  This picture is, of course, consistent with the idea of the attribution– self-representation cycle, which we arrived at a few chapters back (see Figure 10.6, p. 260). Remember that, according to this idea, attributions and self-representations are coupled in a cyclical relationship. Current beliefs about the self influence attributions, but attributions have the power to bring about changes in beliefs about the self (a psychological chicken-or-egg phenomenon).

  To see how paranoid beliefs fit into this general model, let us look at the results of two experiments that Peter Kinderman and I carried out. The relatively minor differences between the experiments need not detain us here; suffice it to say that, in both, ordinary people described themselves, their ideals and their beliefs about other people’s attitudes towards them before and after making a series of attributions for negative events. As we had expected from our existing understanding of depression (see Chapter 10) those who initially showed substantial discrepancies between their beliefs about themselves and their ideals tended to make internal attributions for the negative events, whereas those who had relatively few discrepancies tended to make external attributions. However, the most interesting finding emerged when we measured the changes in beliefs about the self that had occurred by the end of the experiments (see Figure 13.3). Again, as we had expected on the basis of previous research, those who made internal attributions tended to show even more substantial discrepancies between their beliefs about themselves and their ideals. However, the effects of external attributions depended on the precise nature of the attributions. External-situational attributions (the essence of