Persecutory delusion
Other namesParanoid delusion[1]
SpecialtyPsychiatry, clinical psychology Edit this on Wikidata
SymptomsFalse beliefs that one will be harmed, violent behaviour, theory of mind deficits, safety behaviours, low self-esteem, rumination
ComplicationsPremature death, heart disease, diabetes, high blood pressure, anxiety, depression, sleep disturbance
CausesMental illness (schizophrenia, delusional disorder, schizoaffective disorder), emotional abuse, drugs and alcohol use, family history
Differential diagnosisDelusions of guilt or sin[1] and paranoid personality disorder
TreatmentAntipsychotics, cognitive behavioral therapy, vitamin B12 supplements

A persecutory delusion is a type of delusional condition in which the affected person believes that harm is going to occur to oneself by a persecutor, despite a clear lack of evidence. The person may believe that they are being targeted by an individual or a group of people. Persecution delusions are very diverse in terms of content and vary from the possible, although improbable, to the completely bizarre. The delusion can be found in various disorders, being more usual in psychotic disorders.

Persecutory delusion is at the more severe side of the paranoia spectrum and it induces multiple complications, from anxiety to suicidal ideation. Persecutory delusion have a high percentage to be acted upon, such as not leaving the house due to fear or acting violently. The persecutory type is a common delusion and is more prevalent in males.

The causality of persecutory delusions are a combination of genetic (family history) and environmental (drug and alcohol use, emotional abuse) factors. This type of delusion is treatment-resistant. The most common methods of treatment are cognitive behavioral therapy, medications, namely first and second generation antipsychotics, and in severe cases, hospitalization. The diagnosis of the condition can be made using the DSM-5 or the ICD-11.

James Tilly Matthews' illustration of a gang of spies using an "air loom" to torment him at a distance

Signs and symptoms

Persecutory delusions are persistent, distressing beliefs that one is being or will be harmed, that continue even when evidence of the contrary is presented. This condition is often seen in disorders like schizophrenia, schizoaffective disorder, delusional disorder, manic episodes of bipolar disorder, psychotic depression, and some personality disorders.[2][3] Alongside delusional jealousy, persecutory delusion is the most common type of delusion in males and is a frequent symptom of psychosis.[4][5] More than 70% of individuals with a first episode of psychosis reported persecutory delusions.[6] Persecutory delusion is often paired with anxiety, depression, disturbed sleep, low self-esteem, rumination and suicidal ideation.[3][7][8] High rates of worry, similar to those in generalized anxiety disorder, are present in individuals with the delusion, moreover the level of worry has been linked to the persistence of the delusion.[3] People with persecutory delusion have an increased difficulty in attributing mental states to others and oftentimes misread others' intentions as a result.[9][5]

People who present with this form of delusion are often in the bottom 2% in terms of psychological well-being.[3] A correlation has been found between the imagined power the persecutor has and the control the sufferer has over the delusion. Those with a stronger correlation between the two factors have a higher rate of depression and anxiety.[8] In urban environments, going outside leads people with this delusion to have a major increases in levels of paranoia, anxiety, depression and lower self-esteem.[3] People with this delusion often live a more inactive life and are at a higher risk of developing high blood pressure, diabetes and heart disease, having a lifespan 14.5 years less than the average as a result.[10][11]

Those with persecutory delusion have the highest risk of acting upon those thoughts compared to other type of delusions, such acts include refusing to leave their house out of the fear of being harmed, or acting violently due to a perceived threat.[12][13] Safety behaviors are also frequently found — individuals who feel threatened perform actions in order to avert their feared delusion from occurring. Avoidance is commonly observed: individuals may avoid entering areas where they believe they might be harmed. Some may also try to lessen the threat, such as only leaving the house with a trusted person, reducing their visibility by taking alternative routes, increasing their vigilance by looking up and down the street, or acting as if they would resist attack by being prepared to strike out.[14]

Causes

A study assessing schizophrenia patients with persecutory delusion found significantly higher levels of childhood emotional abuse within those people but found no differences of trauma, physical abuse, physical neglect and sexual abuse.[15] Because individuals with the disorder tend to respond to the delusion with worry instead of challenging the content of the delusion, worry is responsible in developing and maintaining the persecutory thoughts on the individuals' minds.[3][16] Biological elements, such as chemical imbalances in the brain and alcohol and drug use are a contributing factor to persecutory delusion. Genetic elements are also thought to influence, family members with schizophrenia and delusional disorder are at a higher risk of developing persecutory delusion.[17]

Persecutory delusions are thought to be linked with problems in self-other control, that is, when an individual adjusts the representation of oneself and others in social interactions.[note 1] Because of this shortcoming, the person might misattribute one's negative thoughts and emotions onto others.[18] Another theory is that the delusional belief arises due to low self-esteem. When a threat appear the person protect itself from negative feelings by blaming others.[19]

The development of these delusional beliefs can be influenced by a past history of persecutory experiences — being stalked, drugged or harassed.[1] Certain factors further contribute to this, including having a low socioeconomic status, lacking access to education, experiencing discrimination, humiliation, and threats during early life, and being an immigrant.[1][20][21]

Treatment

Persecutory delusion is difficult to treat and is therapy resistant.[22] Medications for schizophrenia are often used, especially when positive symptoms are present. Both first-generation antipsychotics and second-generation antipsychotics may be useful.[23] Since these delusions are often accompanied with worry, using cognitive behavioral therapy to tackle this thought has shown to reduce the frequency of the delusions itself, improvement of well-being and less rumination.[24] When vitamin B12 deficiency is present, supplements have shown positive results in treating those patients with persecutory delusion.[25] Virtual reality cognitive therapy as a way to treat persecutory delusion, has shown a reduction in paranoid thinking and distress. Virtual reality permits patients to be immersed in a world that replicates real life but with a decreased amount of fear. Patients are then proposed to fully explore the environment without engaging in safety behaviors, thus challenging their perceived threat as unfounded.[26]

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) enumerates eleven types of delusions. The International Classification of Diseases (ICD-11) defines fifteen types of delusions; both include persecutory delusion. They state that persecutory type is a common delusion that includes the belief that the person or someone close to the person is being maliciously treated. This encompasses thoughts that oneself has been drugged, spied upon, harmed, mocked, cheated, conspired against, persecuted, harassed and so on and may procure justice by making reports, taking action or responding violently.[27]

In an effort to have a more detailed criteria for the disorder, a diagnostic table has been advanced by Daniel Freeman and Philippa Garety. It is divided in two criteria that must be met: the individual believes that harm is going to occur to oneself at the present or future, and that the harm is made by a persecutor. There are also points of clarification: the delusion has to cause distress to the individual; only harm to someone close to the person doesn't count as a persecutory delusion; the individual must believe that the persecutor will attempt to harm them and delusions of reference do not count within the category of persecutory beliefs.[20]

See also

Notes

  1. ^ For example, when empathizing with others, one's own mental and emotional state are temporarily put aside.

References

  1. ^ a b c d Bentall RP, Corcoran R, Howard R, Blackwood N, Kinderman P (2001-11-01). "Persecutory Delusions: A Review and Theoretical Integration". Clinical Psychology Review. PSYCHOSIS. 21 (8): 1143–1192. doi:10.1016/S0272-7358(01)00106-4. ISSN 0272-7358. PMID 11702511.
  2. ^ Startup H, Freeman D, Garety PA (19 June 2006). "Persecutory delusions and catastrophic worry in psychosis: developing the understanding of delusion distress and persistence". Behaviour Research and Therapy. 45 (3): 523–537. doi:10.1016/j.brat.2006.04.006. PMID 16782048.
  3. ^ a b c d e f Freeman D, Garety P (9 July 2014). "Advances in understanding and treating persecutory delusions: a review". Social Psychiatry and Psychiatric Epidemiology. 49 (8): 1179–1189. doi:10.1007/s00127-014-0928-7. PMC 4108844. PMID 25005465.
  4. ^ American Psychiatric Association (2022). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. doi:10.1176/appi.books.9780890425787. ISBN 978-0-89042-575-6. S2CID 249488050.
  5. ^ a b Freeman D (May 2007). "Suspicious minds: the psychology of persecutory delusions". Clinical Psychology Review. PSYCHOSIS. 27 (4): 425–457. doi:10.1016/j.cpr.2006.10.004. PMID 17258852.
  6. ^ Freeman D, Bebbington P (1 March 2017). "Transdiagnostic Extension of Delusions: Schizophrenia and Beyond". Schizophrenia Bulletin. pp. 273–282. doi:10.1093/schbul/sbw191. PMC 5605249. PMID 28399309. Retrieved 2023-07-26.
  7. ^ Bergstein M, Weizman A, Solomon Z (2008). "Sense of coherence among delusional patients: prediction of remission and risk of relapse". Comprehensive Psychiatry. 49 (3): 288–296. doi:10.1016/j.comppsych.2007.06.011. ISSN 0010-440X. PMID 18396189.
  8. ^ a b Hartley S, Barrowclough C, Haddock G (November 2013). "Anxiety and depression in psychosis: a systematic review of associations with positive psychotic symptoms". Acta Psychiatrica Scandinavica. 128 (5): 327–346. doi:10.1111/acps.12080. PMID 23379898. S2CID 27880108.
  9. ^ Craig JS, Hatton C, Craig FB, Bentall RP (July 2004). "Persecutory beliefs, attributions and theory of mind: comparison of patients with paranoid delusions, Asperger's syndrome and healthy controls". Schizophrenia Research. 69 (1): 29–33. doi:10.1016/S0920-9964(03)00154-3. PMID 15145468. S2CID 7219952.
  10. ^ "Ground-breaking Treatment Offers New Hope for Patients with Persecutory Delusions". Oxford University Department of Psychiatry. 9 July 2021. Retrieved 28 October 2022.
  11. ^ Diamond R, Bird JC, Waite F, Bold E, Chadwick E, Collett N, Freeman D (1 August 2022). "The physical activity profiles of patients with persecutory delusions". Mental Health and Physical Activity. 23: 100462. doi:10.1016/j.mhpa.2022.100462. ISSN 1755-2966. S2CID 250250997.
  12. ^ Wessely S, Buchanan A, Reed A, Cutting J, Everitt B, Garety P, Taylor PJ (July 1993). "Acting on delusions. I: Prevalence". The British Journal of Psychiatry. 163 (1): 69–76. doi:10.1192/bjp.163.1.69. PMID 8353703. S2CID 45346403.
  13. ^ Keers R, Ullrich S, Destavola BL, Coid JW (March 2014). "Association of violence with emergence of persecutory delusions in untreated schizophrenia". The American Journal of Psychiatry. 171 (3): 332–339. doi:10.1176/appi.ajp.2013.13010134. PMID 24220644.
  14. ^ Freeman D, Garety PA, Kuipers E, Fowler D, Bebbington PE, Dunn G (January 2007). "Acting on persecutory delusions: the importance of safety seeking". Behaviour Research and Therapy. 45 (1): 89–99. doi:10.1016/j.brat.2006.01.014. PMID 16530161. S2CID 23653063.
  15. ^ Ashcroft K, Kingdon DG, Chadwick P (June 2012). "Persecutory delusions and childhood emotional abuse in people with a diagnosis of schizophrenia". Psychosis. 4 (2): 168–171. doi:10.1080/17522439.2011.619012. ISSN 1752-2439. S2CID 143518253.
  16. ^ Freeman D, Dunn G, Startup H, Pugh K, Cordwell J, Mander H, Černis E, Wingham G, Shirvell K, Kingdon D (31 March 2015). "Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): a parallel, single-blind, randomised controlled trial with a mediation analysis". The Lancet Psychiatry. 2 (4): 305–313. doi:10.1016/S2215-0366(15)00039-5. PMC 4698664. PMID 26360083.
  17. ^ "Delusional Disorder: Causes, Symptoms, Types & Treatment". Cleveland Clinic. Retrieved 17 July 2023.
  18. ^ Simonsen A, Mahnkeke MI, Fusaroli R, Wolf T, Roepstorff A, Michael J, Frith CD, Bliksted V (2020-01-01). "Distinguishing Oneself From Others: Spontaneous Perspective-Taking in First-Episode Schizophrenia and its relation to Mentalizing and Psychotic Symptoms". Schizophrenia Bulletin Open. 1 (1). doi:10.1093/schizbullopen/sgaa053. hdl:1893/31882. ISSN 2632-7899.
  19. ^ Bentall RP, Corcoran R, Howard R, Blackwood N, Kinderman P (November 2001). "Persecutory Delusions: A Review and Theoretical Integration". Clinical Psychology Review. 21 (8): 1143–1192. doi:10.1016/S0272-7358(01)00106-4. PMID 11702511.
  20. ^ a b Freeman D, Garety PA (November 2000). "Comments on the content of persecutory delusions: Does the definition need clarification?". British Journal of Clinical Psychology. 39 (4): 407–414. doi:10.1348/014466500163400. PMID 11107494.
  21. ^ Fuchs T (1999). "Life Events in Late Paraphrenia and Depression". Psychopathology. 32 (2): 60–69. doi:10.1159/000029069. ISSN 0254-4962. PMID 10026450. S2CID 28553128.
  22. ^ Fried EI, Koenders MA, Blom JD (August 2021). "Bleuler revisited: on persecutory delusions and their resistance to therapy". The Lancet. Psychiatry. 8 (8): 644–646. doi:10.1016/S2215-0366(21)00240-6. hdl:1887/3447591. PMID 34246325. S2CID 235796615.
  23. ^ Garety PA, Freeman DB, Bentall RP (2008). Persecutory delusions: assessment, theory, and treatment. Oxford [Oxfordshire]: Oxford University Press. p. 313. ISBN 978-0-19-920631-5.
  24. ^ Freeman D, Dunn G, Startup H, Pugh K, Cordwell J, Mander H, et al. (April 2015). "Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): a parallel, single-blind, randomised controlled trial with a mediation analysis". The Lancet. Psychiatry. 2 (4): 305–313. doi:10.1016/S2215-0366(15)00039-5. PMC 4698664. PMID 26360083. S2CID 14328826.
  25. ^ Carvalho AR, Vacas S, Klut C (April 2017). "Vitamin B12 deficiency induced psychosis–a case report". European Psychiatry. 41 (S1): S805. doi:10.1016/j.eurpsy.2017.01.1557. S2CID 79628360.
  26. ^ Freeman D, Bradley J, Antley A, Bourke E, DeWeever N, Evans N, et al. (July 2016). "Virtual reality in the treatment of persecutory delusions: randomised controlled experimental study testing how to reduce delusional conviction". The British Journal of Psychiatry. 209 (1): 62–67. doi:10.1192/bjp.bp.115.176438. PMC 4929408. PMID 27151071.
  27. ^ "MB26.07 Persecutory delusion". ICD-11 for Mortality and Morbidity Statistics. World Health Organization. 1 January 2022. Retrieved 25 October 2022.
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