Sleep disruption in adolescent inpatients: prevalence, associations with clinical outcomes, and clinician perspectives.

Sleep problems are common for adolescents with psychiatric disorders, and sleep treatment may aid mental health recovery. Inpatient admissions are likely a particularly challenging time for sleep. Despite this little is known about the nature of sleep problems, and how sleep treatments could be optimised for this setting. This mixed-methods study set out to better understand sleep disturbances in adolescent inpatients. Study 1 examined the prevalence of Sleep Condition Indicator-assessed insomnia at admission and associations with psychiatric symptoms and admission length in 100 inpatients (aged 11-17 years) on one unit in Oxford. Data were gathered from admission routine measures and medical records. Associations were analysed using linear regressions. Half of the inpatients (n = 50) screened positive for insomnia at admission. Moderate-large significant associations were observed between more severe insomnia and more severe depression (ß = -0.56), anxiety (ß = -0.51), self-harm (ß = -0.49), psychotic experiences (ß = -0.32), and conduct problems (ß = -0.30), but not admission length. Study 2 gained 12 clinicians' perspectives on sleep problems on the unit via a focus group and semi-structured interviews, analysed using thematic analysis. Ward staff observed insomnia and excessive daytime sleepiness in adolescent inpatients and a reciprocal relationship with mental health symptoms. Ward processes were barriers (e.g., night-time observations) and facilitators (e.g., regular routines) of sleep. Cognitive behavioural therapy for insomnia was not routinely offered but viewed as potentially helpful. Insomnia may be a common problem for adolescent inpatients, associated with greater psychopathology, but not admission length. The possible benefits of psychological sleep interventions for adolescents admitted to psychiatric units now require testing.

The Oxford Agoraphobic Avoidance Scale.

BACKGROUND: Agoraphobic avoidance of everyday situations is a common feature in many mental health disorders. Avoidance can be due to a variety of fears, including concerns about negative social evaluation, panicking, and harm from others. The result is inactivity and isolation. Behavioural avoidance tasks (BATs) provide an objective assessment of avoidance and in situ anxiety but are challenging to administer and lack standardisation. Our aim was to draw on the principles of BATs to develop a self-report measure of agoraphobia symptoms. METHOD: The scale was developed with 194 patients with agoraphobia in the context of psychosis, 427 individuals in the general population with high levels of agoraphobia, and 1094 individuals with low levels of agoraphobia. Factor analysis, item response theory, and receiver operating characteristic analyses were used. Validity was assessed against a BAT, actigraphy data, and an existing agoraphobia measure. Test-retest reliability was assessed with 264 participants. RESULTS: An eight-item questionnaire with avoidance and distress response scales was developed. The avoidance and distress scales each had an excellent model fit and reliably assessed agoraphobic symptoms across the severity spectrum. All items were highly discriminative (avoidance: a = 1.24-5.43; distress: a = 1.60-5.48), indicating that small increases in agoraphobic symptoms led to a high probability of item endorsement. The scale demonstrated good internal reliability, test-retest reliability, and validity. CONCLUSIONS: The Oxford Agoraphobic Avoidance Scale has excellent psychometric properties. Clinical cut-offs and score ranges are provided. This precise assessment tool may help focus attention on the clinically important problem of agoraphobic avoidance.

The meaning in grandiose delusions: measure development and cohort studies in clinical psychosis and non-clinical general population groups in the UK and Ireland.

BACKGROUND: The content of grandiose delusions-inaccurate beliefs that one has special powers, wealth, mission, or identity-is likely to be highly meaningful. The meaning, for example providing a sense of purpose, could prove to be a key factor in the delusion taking hold. We aimed to empirically define and develop measures of the experience of meaning in grandiose delusions and the sources of this meaning, and to test whether severity of grandiosity in clinical and non-clinical populations is associated with level of meaning. METHODS: We did a cross-sectional self-report questionnaire study in two cohorts: non-clinical participants aged 18 years and older, with UK or Irish nationality or residence; and patients with affective or non-affective psychosis diagnoses, aged 16 years and older, and accessing secondary care mental health services in 39 National Health Service providers in England and Wales. Participants with high grandiosity completed two large item pools: one assessing the experience of meaning in grandiose delusions (Grandiosity Meaning Measure [termed gram]) and one assessing the sources of meaning (Grandiosity Meaning Measure-Sources [termed grams]). The Grandiosity Meaning Measure and Grandiosity Meaning Measure-Sources were developed using exploratory factor analysis and confirmatory factor analysis. Structural equation modelling was used to test the associations of meaning with the severity of grandiosity. The primary outcome measure for grandiosity was the Specific Psychotic Experiences Questionnaire (grandiosity subscale) and associations were tested with the Grandiosity Meaning Measure and the Grandiosity Meaning Measure-Sources. FINDINGS: From Aug 30, 2019, to Nov 21, 2020, 13 323 non-clinical participants were enrolled. 2821 (21%) were men and 10 134 (76%) were women, 11 974 (90%) were White, and the mean age was 39·5 years (SD 18·6 [range 18-93]). From March 22, 2021, to March 3, 2022, 798 patients with psychosis were enrolled. 475 (60%) were men and 313 (39%) were women, 614 (77%) were White, and the mean age was 43·4 years (SD 13·8 [range 16-81]). The experience of meaning in relation to grandiose delusions had three components: coherence, purpose, and significance. The sources of meaning had seven components: positive social perceptions, spirituality, overcoming adversity, confidence in self among others, greater good, supporting loved ones, and happiness. The measurement of meaning was invariant across clinical and non-clinical populations. In the clinical population, each person typically endorsed multiple meanings and sources of meaning for the grandiose delusion. Meaning in grandiose delusions was strongly associated with severity of grandiosity, explaining 53·5% of variance, and with grandiose delusion conviction explaining 27·4% of variance. Grandiosity was especially associated with sense of purpose, and grandiose delusion conviction with coherence. Similar findings were found for the non-clinical population. INTERPRETATION: Meaning is inherently tied to grandiose delusions. This study provides a framework for research and clinical practice to understand the different types of meaning of grandiosity. The framework is likely to have clinical use in psychological therapy to help guide patients to find sources of equivalent meaning from other areas of their lives and thereby reduce the extent to which the grandiose delusion is needed. FUNDING: Health Education England and National Institute for Health and Care Research.

The journey of adolescent paranoia: A qualitative study with patients attending child and adolescent mental health services.

OBJECTIVES: Paranoia is most likely to emerge in adolescence. In adolescents with mental health disorders, the disruptive effect of paranoia on social relationships could worsen outcomes. However, little is known about clinical presentations of paranoia at this age. We therefore explored the development, experience, and impact of paranoia in adolescent patients. DESIGN: A qualitative interview design with interpretative phenomenological analysis was used. METHOD: Twelve adolescents (11-17 years) with paranoia attending child and adolescent mental health services were interviewed. RESULTS: Adolescents described a journey starting with their awareness of paranoia beginning to a paranoid experience of mistrust and fear of others, and, subsequently, their adjustment to paranoia in daily life. Paranoia onset was rooted in the discovery of interpersonal threat and personal vulnerability, shaped by challenging peer interactions, becoming aware of danger in the world, and personal adverse experiences. The paranoia experience included a struggle to trust friends, anticipating threat with intense fear, and using defensive strategies to keep safe. Adolescents described how the paranoia experience was confusing, negatively impacted self-concept, held them back from teenage life, and caused disconnection from friends. Longer-term responses to paranoia reflected a tension between reluctantly resigning to the experience and trying to resist the impact. CONCLUSIONS: The journey of paranoia in adolescence involves navigating multiple tensions, with young people balancing independence with vulnerability, trust with mistrust, and the desire to socialise with a fear of danger and deception. Decisions about how to respond to paranoia are likely to determine the next stage of their journey.

Comparison of a theoretically driven cognitive therapy (the Feeling Safe Programme) with befriending for the treatment of persistent persecutory delusions: a parallel, single-blind, randomised controlled trial.

BACKGROUND: There is a large clinical need for improved treatments for patients with persecutory delusions. We aimed to test whether a new theoretically driven cognitive therapy (the Feeling Safe Programme) would lead to large reductions in persecutory delusions, above non-specific effects of therapy. We also aimed to test treatment effect mechanisms. METHODS: We did a parallel, single-blind, randomised controlled trial to test the Feeling Safe Programme against befriending with the same therapists for patients with persistent persecutory delusions in the context of non-affective psychosis diagnoses. Usual care continued throughout the duration of the trial. The trial took place in community mental health services in three UK National Health Service trusts. Participants were included if they were 16 years or older, had persecutory delusions (as defined by Freeman and Garety) for at least 3 months and held with at least 60% conviction, and had a primary diagnosis of non-affective psychosis from the referring clinical team. Patients were randomly assigned to either the Feeling Safe Programme or the befriending programme, using a permuted blocks algorithm with randomly varying block size, stratified by therapist. Trial assessors were masked to group allocation. If an allocation was unmasked then the unmasked assessor was replaced with a new masked assessor. Outcomes were assessed at 0 months, 6 months (primary endpoint), and 12 months. The primary outcome was persecutory delusion conviction, assessed within the Psychotic Symptoms Rating Scale (PSYRATS; rated 0-100%). Outcome analyses were done in the intention-to-treat population. Each intervention was provided individually over 6 months. This trial is registered with the ISRCTN registry, ISRCTN18705064. FINDINGS: From Feb 8, 2016, to July 26, 2019, 130 patients with persecutory delusions (78 [60%] men; 52 [40%] women, mean age 42 years [SD 12·1, range 17-71]; 86% White, 9% Black, 2% Indian; 2·3% Pakistani; 2% other) were recruited. 64 patients were randomly allocated to the Feeling Safe Programme and 66 patients to befriending. Compared with befriending, the Feeling Safe Programme led to significant end of treatment reductions in delusional conviction (-10·69 [95% CI -19·75 to -1·63], p=0·021, Cohen's d=-0·86) and delusion severity (PSYRATS, -2·94 [-4·58 to -1·31], p<0·0001, Cohen's d=-1·20). More adverse events occurred in the befriending group (68 unrelated adverse events reported in 20 [30%] participants) compared with the Feeling Safe group (53 unrelated adverse events reported in 16 [25%] participants). INTERPRETATION: The Feeling Safe Programme led to a significant reduction in persistent persecutory delusions compared with befriending. To our knowledge, these are the largest treatment effects seen for patients with persistent delusions. The principal limitation of our trial was the relatively small sample size when comparing two active treatments, meaning less precision in effect size estimates and lower power to detect moderate treatment differences in secondary outcomes. Further research could be done to determine whether greater effects could be possible by reducing the hypothesised delusion maintenance mechanisms further. The Feeling Safe Programme could become the recommended psychological treatment in clinical services for persecutory delusions. FUNDING: NIHR Research Professorship and NIHR Oxford Health Biomedical Research Centre.

Does raising heart rate prior to a behavioural test enhance learning in cognitive therapy for anxiety? An experimental test for the treatment of fear of heights using virtual reality.

BACKGROUND: A key clinical issue is how to maximise the belief change central to cognitive therapy. Physiological arousal is a key internal cue confirming threat beliefs in anxiety disorders. Deeper extinction of anxiety may occur if catastrophizing responses to physiological arousal are inhibited prior to joint exposure with external phobic stimuli. The aim of the study was to test whether increasing physiological arousal using exercise increases the benefits of behavioural tests. METHODS: Sixty individuals with a fear of heights had one session of VR cognitive treatment. They were randomised to have the treatment either with periods of intense physical exercise (cycling at 80% of maximum heart rate) prior to exposures or without. Linear mixed effects models were used to check the manipulation and test the primary hypothesis of a group difference in degree of conviction in the phobic threat belief. RESULTS: Heart rate was significantly higher in the exercise group throughout compared with the control group. Both groups showed significant reductions in threat beliefs after the VR treatment (d = 1.0, p < 0.001) but there was no significant group difference (d = 0.1, p = 0.56). DISCUSSION: An increase in physiological arousal achieved via exercise did not enhance cognitive change in beliefs about feared stimuli.

Paranoia in patients attending child and adolescent mental health services.

OBJECTIVE: Paranoia may be particularly prevalent during adolescence, building on the heightened social vulnerabilities at this age. Excessive mistrust may be corrosive for adolescent social relationships, especially in the context of mental health disorders. We set out to examine the prevalence, symptom associations, and persistence of paranoia in a cohort of young people attending child and adolescent mental health services. METHOD: A total of 301 patients (11-17 years old) completed measures of paranoia, affect, peer difficulties and behavioural problems. Clinicians also rated each participant's psychiatric symptoms. Patterns of association were examined using linear regressions and network analyses. In total, 105 patients repeated the measures several months later. RESULTS: Most of the adolescents had affective disorders (n = 195), self-harm/suicidality (n = 82), or neurodevelopmental conditions (n = 125). Few had suspected psychosis (n = 7). Rates of paranoia were approximately double compared with previous reports from the general population. In this patient sample, 35% had at least elevated paranoia, 15% had at least moderate paranoia, and 6% had high paranoia. Paranoia had moderate associations with clinician-rated peer difficulties, self-harm, and trauma, and small associations with clinician-rated social anxiety, depression, generalised anxiety, and educational problems. Network analyses showed paranoia had the strongest unique relationship with peer difficulties. Paths from peer difficulties to anxiety, self-harm, post-traumatic stress disorder symptoms, and behavioural problems were all via paranoia. Both self-harm and post-traumatic stress disorder were solely associated with paranoia in the network. Paranoia remained persistent for three-quarters and was associated with greater psychological problems over time. CONCLUSION: Paranoia is relatively common and persistent across a range of clinical presentations in youth. When paranoia occurs alongside emotional problems, important peer interactions may be adversely affected. Wider consideration of paranoia in adolescent patients is needed.

The revised Green et al., Paranoid Thoughts Scale (R-GPTS): psychometric properties, severity ranges, and clinical cut-offs.

BACKGROUND: The Green et al., Paranoid Thoughts Scale (GPTS) - comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) - was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation. METHODS: In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted. RESULTS: The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09-3.67) and Persecution (a = 2.37-4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0-9; Persecution: 0-4); elevated (Reference: 10-15; Persecution: 5-10); moderately severe (Reference: 16-20; Persecution:11-17); severe (Reference: 21-24; Persecution: 18-27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion. CONCLUSIONS: The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.

The assessment of paranoia in young people: Item and test properties of the Bird Checklist of Adolescent Paranoia.

BACKGROUND: Precise assessment tools for psychotic experiences in young people may help identify symptoms early and facilitate advances in treatment. In this study we provide an exemplar - with a paranoia scale for youth - for improving measurement precision for psychotic experiences using item response theory (IRT). We evaluate the psychometric properties of the new measure, test for measurement invariance, and assess its potential for computerised adaptive testing (CAT). METHOD: The 18-item Bird Checklist of Adolescent Paranoia (B-CAP) was completed by 1102 adolescents including 301 patients with mental health problems and 801 from the general population. After excluding outliers (n = 10), IRT was used to examine item properties, test reliability, and measurement invariance. The properties of an adaptive B-CAP were assessed using a simulation of 10,000 responses. RESULTS: All B-CAP items were highly discriminative (a = 1.14-2.77), whereby small shifts in paranoia led to a higher probability of item endorsement. Test reliability was high (a > 0.90) across a wide range of paranoia severity (θ = -0.45-3.36), with the greatest precision at elevated levels. All items were invariant for gender, age, and population groups. The simulated adaptive B-CAP performed with high accuracy and required only 5-6 items at higher levels of paranoia severity. CONCLUSIONS: The B-CAP is a reliable assessment tool with excellent psychometric properties to assess both non-clinical and clinical levels of paranoia in young people, with potential as an efficient adaptive test. In future, these approaches could be used to develop a multidimensional CAT to assess the full range of psychotic experiences in youth.

Cognitive appraisals of dissociation in psychosis: a new brief measure.

BACKGROUND: Catastrophic cognitive appraisals, similar to those in anxiety disorders, are implicated in depersonalisation, a form of dissociation. No scales exist to measure appraisals of dissociative experiences. Dissociation is common in psychosis. Misinterpretations of dissociative experiences may maintain psychotic symptoms. Therefore, assessing appraisals in this context may be valuable. AIMS: The primary aim was to develop a measure of key appraisals of dissociation in psychosis. Secondary aims were to test the relationship between appraisals and psychotic experiences (paranoia and hallucinations), and determine whether appraisals explain additional variance in psychotic symptoms above dissociative symptoms. METHOD: Fifty items were generated from transcripts of interviews with patients. The measure was developed and psychometrically validated via factor analysis of data from 9902 general population participants and 1026 patients with psychosis. Convergent validity, test-re-test reliability, and internal reliability were assessed. Regression analyses tested relationships with psychotic symptoms. RESULTS: A 13-item single-factor measure was developed. Factor analysis indicated good model fit [χ2(65) = 247.173, comparative fit index (CFI) = 0.960, root mean square error of approximation (RMSEA) = 0.052]. The scale had good convergent validity with a rumination (non-clinical: r = 0.71; clinical: r = 0.73) and dissociation measure (r = 0.81; r = 0.80), high internal consistency (α = 0.93; α = 0.93), and excellent 1-week test-re-test reliability [intraclass correlation (ICC) = 0.90]. It explained variance in psychotic symptoms (paranoia: 36.4%; hallucinations: 35.0%), including additional variance compared with dissociation alone (paranoia: 5.3%; hallucinations: 2.3%). CONCLUSIONS: The Cognitive Appraisals of Dissociation in Psychosis (CAD-P) measure is a psychometrically robust scale identifying appraisals of dissociative experiences in psychosis and is associated with the presence of psychotic experiences. It is likely to prove useful for clinical assessment and research.

The Dunn Worry Questionnaire and the Paranoia Worries Questionnaire: new assessments of worry.

BACKGROUND: The cognitive process of worry, which keeps negative thoughts in mind and elaborates the content, contributes to the occurrence of many mental health disorders. Our principal aim was to develop a straightforward measure of general problematic worry suitable for research and clinical treatment. Our secondary aim was to develop a measure of problematic worry specifically concerning paranoid fears. METHODS: An item pool concerning worry in the past month was evaluated in 250 non-clinical individuals and 50 patients with psychosis in a worry treatment trial. Exploratory factor analysis and item response theory (IRT) informed the selection of scale items. IRT analyses were repeated with the scales administered to 273 non-clinical individuals, 79 patients with psychosis and 93 patients with social anxiety disorder. Other clinical measures were administered to assess concurrent validity. Test-retest reliability was assessed with 75 participants. Sensitivity to change was assessed with 43 patients with psychosis. RESULTS: A 10-item general worry scale (Dunn Worry Questionnaire; DWQ) and a five-item paranoia worry scale (Paranoia Worries Questionnaire; PWQ) were developed. All items were highly discriminative (DWQ a = 1.98-5.03; PWQ a = 4.10-10.7), indicating small increases in latent worry lead to a high probability of item endorsement. The DWQ was highly informative across a wide range of the worry distribution, whilst the PWQ had greatest precision at clinical levels of paranoia worry. The scales demonstrated excellent internal reliability, test-retest reliability, concurrent validity and sensitivity to change. CONCLUSIONS: The new measures of general problematic worry and worry about paranoid fears have excellent psychometric properties.

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

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.

The comments of voices on the appearance of patients with psychosis: 'the voices tell me that I am ugly'.

BACKGROUND: There are high rates of obesity and low self-esteem in patients with psychosis. The occurrence of negative voice content directly about appearance is therefore plausible. Derogatory comments about appearance are likely to be distressing, increase depression and contribute to social withdrawal. AIMS: To systematically assess the occurrence of voice content regarding appearance and identify correlates. METHOD: Sixty patients experiencing verbal auditory hallucinations at least once a week in the context of non-affective psychosis completed a measure assessing positive and negative voice content about appearance. They also completed assessments about body image, self-esteem, psychiatric symptoms and well-being. RESULTS: Fifty-five (91.7%) participants reported hearing voices comment on their appearance. A total of 54 (90%) patients reported negative voice content about their appearance with 30 (50%) patients experienced negative appearance comments on a daily basis. The most common negative comment was 'the voices tell me that I am ugly' (n = 48, 80%). There were 39 (65%) patients who reported positive voice content on appearance. The most frequent positive comment was 'I look as nice as other people' (n = 26, 43.3%). Negative voice content about appearance was associated with body image concerns, paranoia, voice hearing severity, depression, worry, negative self-beliefs and safety-seeking behaviours. Positive appearance voice content was associated with greater body esteem and well-being and lower levels of depression and insomnia. CONCLUSIONS: Voice content about appearance is very common for patients seen in clinical services. Negative voice content may reflect - and subsequently reinforce - negative beliefs about one's appearance, low self-esteem, worry and paranoia. DECLARATION OF INTEREST: None.

Suicidal ideation and behaviour in patients with persecutory delusions: Prevalence, symptom associations, and psychological correlates.

BACKGROUND: To determine the prevalence of suicidal ideation and behaviour - and their correlates - in patients with persecutory delusions. METHODS: 110 patients with persecutory delusions in the context of non-affective psychosis were assessed for suicidal thoughts and behaviours over the past month. Symptom and psychological assessments were also completed. RESULTS: The severity of suicidal ideation was: no suicidal ideation (n = 26, 23.6%); wish to be dead (n = 21, 19.1%); nonspecific active suicidal thoughts (n = 14, 12.7%); suicidal thoughts with methods but no intent (n = 29, 26.4%); suicidal thoughts with intent but no specific plan (n = 13, 11.8%); and suicidal intent with plan (n = 7, 6.4%). In the past month, five patients (4.5%) had made an actual, interrupted, or aborted suicide attempt. The severity of suicidal ideation was associated with higher levels of depression, paranoia, hallucinations, anger, insomnia, negative beliefs about the self and others, pessimism, worry, and delusion safety-seeking behaviours and lower levels of psychological well-being and reward responsiveness. Severity of ideation was not associated with cannabis or alcohol use, working memory, pain, or meaningful activity levels. CONCLUSIONS: Patients with persecutory delusions are typically in a severe state of psychological stress, and at risk of suicide, as indicated by very high levels of suicidal ideation. This exploratory study also identifies correlates of suicidal ideation that could be investigated in causal research designs.

Adolescent Paranoia: Prevalence, Structure, and Causal Mechanisms.

BACKGROUND: Adolescence can be a challenging time, characterized by self-consciousness, heightened regard for peer acceptance, and fear of rejection. Interpersonal concerns are amplified by unpredictable social interactions, both online and offline. This developmental and social context is potentially conducive to the emergence of paranoia. However, research on paranoia during adolescence is scarce. METHOD: Our aim was to examine the prevalence, structure, and probabilistic causal mechanisms of adolescent paranoia. A representative school cohort of 801 adolescents (11-15 y) completed measures of paranoia and a range of affective, cognitive, and social factors. A Bayesian approach with Directed Acyclic Graphs (DAGs) was used to assess the causal interactions with paranoia. RESULTS: Paranoid thoughts were very common, followed a continuous distribution, and were hierarchically structured. There was an overall paranoia factor, with sub-factors of social fears, physical threat fears, and conspiracy concerns. With all other variables controlled, DAG analysis identified paranoia had dependent relationships with negative affect, peer difficulties, bullying, and cognitive-affective responses to social media. The causal directions could not be fully determined, but it was more likely that negative affect contributed to paranoia and paranoia impacted peer relationships. Problematic social media use did not causally influence paranoia. CONCLUSIONS: There is a continuum of paranoia in adolescence and occasional suspicions are common at this age. Anxiety and depression are closely connected with paranoia and may causally contribute to its development. Paranoia may negatively impact adolescent peer relationships. The clinical significance of paranoia in adolescents accessing mental health services must now be established.

The Experience of Sleep Problems and Their Treatment in Young People at Ultra-High Risk of Psychosis: A Thematic Analysis.

We view sleep disruption as a contributory causal factor in the development of psychotic experiences. Clinical trials indicate that psychological interventions targeting insomnia result in improvements in both sleep and psychotic experiences. The aim of this study was to gain the perspective of young people at ultra-high risk of psychosis on their sleep problems and associated psychological treatment. Interviews were conducted with 11 patients, aged 15-22 years, at ultra-high risk of psychosis who had received a psychological sleep intervention. Responses were analyzed using thematic analysis. Disrupted sleep timing and a lack of routine were the characteristic hallmarks of participants' sleep problems. Sleep disturbance, psychological wellbeing, and functioning had a reciprocal relationship. There were negative expectations prior to therapy, however meaningful improvements occurred in sleep, mood, and functioning. The active implementation of therapy techniques was highlighted as important. These findings indicate that the treatment of sleep problems is highly valued and has a meaningful impact on wellbeing in young people at ultra-high risk of psychosis.

Cognitive, affective, and social factors maintaining paranoia in adolescents with mental health problems: A longitudinal study.

Paranoia may be a significant concern during adolescence, but there has been little research on excessive mistrust in young people. In this longitudinal study we set out to test the predictive ability of a number of cognitive, affective, and social factors in the early development of paranoia in a clinical adolescent population. Thirty four help-seeking adolescents, aged 11-16 years, reporting paranoid thoughts and attending mental health services were recruited. Self-report and interview assessments of paranoia were conducted at baseline. Measures relating to a cognitive model of persecutory delusions were completed. Paranoia was reassessed after three months with thirty three participants. Significant predictors of paranoia persistence were anxiety, depression, worry, negative self-beliefs, perceptual anomalies, insomnia, affective reactivity, bullying, and cyber victimization. No effect was found for reasoning bias or negative perceptions of academic ability, social competence, and physical appearance. In conclusion, many of the maintenance factors implicated in adult paranoia are likely to prove important in the early development of paranoia in young people. Further experimental and treatment studies are now needed to examine the causal role of these factors in the occurrence of paranoia in adolescents.