MDMA-assisted psychotherapy for post-traumatic stress disorder: The devil is in the detail.

Recent years have seen escalating media, public and scientific interest in psychedelic medicine. Australia and New Zealand have been late to this research; however, in the past 2 years, rapid developments suggest that this is changing. Here, we argue for the need to critically review existing evidence in this field to guide future directions. We focus on (±)3,4-methylenedioxymethamphetamine-assisted psychotherapy for post-traumatic stress disorder, currently the most advanced area of clinical psychedelic research. Food and Drug Administration approval of this approach is likely in 2023, based on a series of promising findings. We provide a detailed overview of Phase 2 and 3 studies published to date. We identify several concerns related to this body of evidence, including methodological/design limitations and broader factors - such as robust involvement of advocacy groups in research and reliance on non-government financing leading to simplistic public messaging - that compound the methodological issues identified. We propose steps for future improvement, including the need for large, high-quality, independent efficacy trials with design enhancements, effectiveness trials and for researchers to consider their own engagement with media and public messaging around these modalities. We argue that, notwithstanding promising findings to date, rigorous and dispassionate science is needed to move the field forward and safeguard the welfare of participants.

A Comparison of Adolescent versus Young Adult Outpatients with First-Presentation Borderline Personality Disorder: Findings from the MOBY Randomized Controlled Trial.

OBJECTIVE: The increasing focus on adolescent personality disorder has tended to ignore evidence of the developmental continuity of the period from puberty to young adulthood. This study aims to: (1) describe the characteristics of a sample of young people with borderline personality disorder (BPD) who had no previous history of evidence-based treatment for the disorder and (2) compare their characteristics by participant age group. METHODS: One hundred and thirty-nine young people (15 to 25 years) with BPD, newly enrolled in the Monitoring Outcomes of BPD in Youth randomized controlled trial, completed semi-structured interview and self-report measures assessing demographic, clinical, and functional characteristics. Younger (aged 15 to 17 years; n = 64) and older (aged 18 to 25 years; n = 75) participants were compared on these same variables using t-tests, chi-square tests, and logistic regression. RESULTS: Young outpatients with BPD had extensive and severe psychopathology and were functioning poorly. Adolescents and young adults with BPD showed substantial similarities on 20 key aspects of their presentation. Significant between-groups differences were observed in household makeup, treatment history, antisocial personality disorder, emotion dysregulation, substance use, age of commencement and extent of self-harm, and achievement of age-appropriate educational milestones. Adolescent BPD group membership was predicted by family composition and self-harm, whereas young adult BPD group membership was predicted by not achieving age-appropriate milestones, vocational disengagement, and emotion dysregulation. The final model explained 54% of the variance and correctly classified 80.2% of the sample by age. CONCLUSIONS: Both adolescents and young adults with early stage BPD present with severe and often similar problems to one another, supporting developmental continuity across this age range. However, there are also meaningful differences in presentation, suggesting that pathways to care might differ by age and/or developmental stage. Detection and intervention for personality disorder should not be delayed until individuals reach 18 years of age.

Ill-defined: Concepts of mental health and illness are becoming broader, looser, and more benign.

OBJECTIVES: We argue that mental health-related concepts have become degraded within professional circles and in the wider community. We identify three trends: concept creep, the rise of broad umbrella concepts (e.g. distress and trauma), and the conflation of mental health with well-being, which marginalises serious mental illness. We speculate on the causes of these trends, including cultural shifts towards greater sensitivity to harm and the rise of wellness industries. Contributing factors within psychiatry include overdiagnosis, dimensional models and transdiagnostic perspectives. CONCLUSIONS: These trends may lead to inflated demands on services from those at the milder end of the psychopathological spectrum. We set out seven measures that mental health professionals can take to resist trends towards broad concepts of mental illness and limit some of their adverse consequences.

Enhancing the contribution of clinical psychology: an under-utilised workforce in public mental health services.

OBJECTIVE: Clinical psychologists are practitioners with expertise in mental health, who apply advanced psychological theory and knowledge to their practice in order to assess and treat complex psychological disorders. Given their robust specialised mental health training, clinical psychology is an integral component of the Australian mental health workforce, but is under-utilised. Recent reviews have identified significant problems with Australia's mental health system, including unequal access to clinical psychology services and fragmentation of service delivery, including convoluted pathways to care. CONCLUSIONS: Clinical psychology is well placed to contribute meaningfully to public mental health services (PMHS). We describe what clinical psychologists currently contribute to team-based care in PMHS, how we could further contribute and the barriers to making more extensive contributions. We identify significant historical and organisational factors that have limited the contribution made by clinical psychologists and provide suggestions for cultural change to PMHS.

Personality disorder increases risk of low quality of life among women with mental state disorders.

BACKGROUND: Limited data are available examining the relationship between mental state disorders (mood, anxiety, substance use, eating disorders), their co-occurrence with personality disorder (PD), and quality of life among women. We aimed to investigate these relationships in a sample of women from the community. METHOD: Women from the Geelong Osteoporosis Study (n = 717) were administered the Structured Clinical Interview for DSM-IV (SCID-I/NP and SCID-II) and the World Health Organisation Quality of Life scale (WHOQOL-BREF). Weight and height were measured and lifestyle and demographic factors were self-reported. Logistic regression models (odds ratios with 95% confidence intervals) were undertaken to investigate associations among groups (mental state disorders, co-occurring mental state disorders with PD, and controls) and the WHOQOL-BREF domains (physical, psychological, social, and environmental health) while testing for potential confounding. RESULTS: Results indicated that mental state disorders were associated with increased risk of low quality of life in physical, psychological, social, but not environmental domains, compared to controls. This risk was increased among women with co-occurring PD across all domains compared to both controls and those with mental state disorders. CONCLUSION: These findings add evidence suggesting poor quality of life is experienced by those with mental state disorders, and that this is worsened by the experience of co-occurring PD.

Testing the Interpersonal-Cognitive Model of Auditory Verbal Hallucinations in Youths with Either Early-Stage Borderline Personality Disorder or First-Episode Schizophrenia Spectrum Disorder.

This is the first study to explore interpersonal schemata in outpatient youths (age 15-25 years) with early-stage borderline personality disorder (BPD) and auditory verbal hallucinations (AVH). It also aimed to replicate, in a transdiagnostic youth sample, the finding from studies of adults with AVH that negative beliefs about the self and others lead to negative appraisals of voices, which in turn elicits depression. The following 3 groups were compared: youth with BPD+AVH (n = 23), youth with schizophrenia spectrum disorder (SZ) with AVH (SZ+AVH, n = 20), and youths with BPD who did not experience AVH (BPD no AVH, n = 23). The BPD+AVH group reported more negative and fewer positive self schemata than the SZ+AVH group. They also saw themselves as being more socially inferior to others than did the SZ+AVH group, but they did not differ in appraisals of self or others, compared with the BPD no AVH group. In youths with AVH (BPD+AVH, SZ+AVH combined), the indirect effect of beliefs about self or others, via negative appraisals of voices on depression, was not significant. Instead, a significant indirect effect of negative appraisals of voices on depression, via negative beliefs about self, was found. The experience of AVH during adolescence and young adulthood, when the identity is still being formed, might have a more profound effect on the developing self than during later adulthood, when the self is more stable and resilient. Negative self-appraisals might constitute a treatment target for early intervention for youths with distressing voices, including those with BPD.

Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial.

BACKGROUND: High unemployment is a hallmark of psychotic illness. Individual placement and support (IPS) may be effective at assisting the vocational recoveries of young people with first-episode psychosis (FEP).AimsTo examine the effectiveness of IPS at assisting young people with FEP to gain employment (Australian and Clinical Trials Registry ACTRN12608000094370). METHOD: Young people with FEP (n = 146) who were interested in vocational recovery were randomised using computer-generated random permuted blocks on a 1:1 ratio to: (a) 6 months of IPS in addition to treatment as usual (TAU) or (b) TAU alone. Assessments were conducted at baseline, 6 months (end of intervention), 12 months and 18 months post-baseline by research assistants who were masked to the treatment allocations. RESULTS: At the end of the intervention the IPS group had a significantly higher rate of having been employed (71.2%) than the TAU group (48.0%), odds ratio 3.40 (95% CI 1.17-9.91, z = 2.25, P = 0.025). However, this difference was not seen at 12- and 18-month follow-up points. There was no difference at any time point on educational outcomes. CONCLUSIONS: This is the largest trial to our knowledge on the effectiveness of IPS in FEP. The IPS group achieved a very high employment rate during the 6 months of the intervention. However, the advantage of IPS was not maintained in the long term. This seems to be related more to an unusually high rate of employment being achieved in the control group rather than a gross reduction in employment among the IPS group.Declaration of interestNone.

The prevalence, age distribution and comorbidity of personality disorders in Australian women.

OBJECTIVE: We aimed to describe the prevalence and age distribution of personality disorders and their comorbidity with other psychiatric disorders in an age-stratified sample of Australian women aged ⩾25 years. METHODS: Individual personality disorders (paranoid, schizoid, schizotypal, histrionic, narcissistic, borderline, antisocial, avoidant, dependent, obsessive-compulsive), lifetime mood, anxiety, eating and substance misuse disorders were diagnosed utilising validated semi-structured clinical interviews (Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition and Structured Clinical Interview for DSM-IV Axis II Personality Disorders). The prevalence of personality disorders and Clusters were determined from the study population ( n = 768), and standardised to the Australian population using the 2011 Australian Bureau of Statistics census data. Prevalence by age and the association with mood, anxiety, eating and substance misuse disorders was also examined. RESULTS: The overall prevalence of personality disorders in women was 21.8% (95% confidence interval [CI]: 18.7, 24.9). Cluster C personality disorders (17.5%, 95% CI: 16.0, 18.9) were more common than Cluster A (5.3%, 95% CI: 3.5, 7.0) and Cluster B personality disorders (3.2%, 95% CI: 1.8, 4.6). Of the individual personality disorders, obsessive-compulsive (10.3%, 95% CI: 8.0, 12.6), avoidant (9.3%, 95% CI: 7.1, 11.5), paranoid (3.9%, 95% CI: 3.1, 4.7) and borderline (2.7%, 95% CI: 1.4, 4.0) were among the most prevalent. The prevalence of other personality disorders was low (⩽1.7%). Being younger (25-34 years) was predictive of having any personality disorder (odds ratio: 2.36, 95% CI: 1.18, 4.74), as was being middle-aged (odds ratio: 2.41, 95% CI: 1.23, 4.72). Among the strongest predictors of having any personality disorder was having a lifetime history of psychiatric disorders (odds ratio: 4.29, 95% CI: 2.90, 6.33). Mood and anxiety disorders were the most common comorbid lifetime psychiatric disorders. CONCLUSIONS: Approximately one in five women was identified with a personality disorder, emphasising that personality disorders are relatively common in the population. A more thorough understanding of the distribution of personality disorders and psychiatric comorbidity in the general population is crucial to assist allocation of health care resources to individuals living with these disorders.

The Maintaining Factors of Social Anxiety: A Three-Group Comparison of a Clinical Sample with Highly Socially Anxious Students and Non-Anxious Students.

BACKGROUND: Clark and Wells' (1995) cognitive model of social anxiety (CWM) explains the maintenance of social anxiety and has been used as a guide for treatment of Social Anxiety Disorder (SAD). Few studies have examined the components of the model together across different samples. AIMS: This study had two distinct aims: to test the components of CWM and to examine how the variables of CWM may differ between clinical and non-clinical samples with varying levels of social anxiety. METHOD: Hypothesized relationships between three groups (i.e. a clinical sample of individuals diagnosed with SAD (ClinS), n = 40; socially anxious students (HSA), n = 40; and, non-anxious students (LSA), n = 40) were investigated. RESULTS: Four out of five CWM variables tested were able to distinguish between highly socially anxious and non-anxious groups after controlling for age and depression. CONCLUSIONS: CWM variables are able to distinguish between high and low levels of social anxiety and are uniquely related to social anxiety over depression.

Delusional infestation: the case for improved mental state testing.

OBJECTIVES: Delusional infestation may present as a primary disorder or secondary to another disorder (e.g. schizophrenia). In this report we focus on the issue of inadequacies in mental state examinations leading to diagnostic uncertainty. METHODS: Case studies were identified for this review through searching the academic databases MedLine, PSYCInfo and PubMed. We developed a template that contained 36 headings and independently examined each case study report. Our percentage agreement for the first 42 case studies we reviewed was 91%. RESULTS: We identified diagnostic uncertainty due to inadequacies in the reporting of mental state examinations. CONCLUSIONS: Clinicians need to provide mental state information to an adequate standard that would allow confirmation of a diagnosis of delusions of infestation or exclude other possibilities.

Therapy contamination as a measure of therapist treatment adherence in a trial of cognitive behaviour therapy versus befriending for psychosis.

BACKGROUND: High quality randomized controlled trials (RCT) of psychotherapeutic interventions should ensure that the therapy being tested is what is actually delivered. However, contamination of one therapy into the other, a critical component of treatment adherence, is seldom measured in psychotherapy trials of psychosis. AIMS: The aim of the study was to determine whether a purpose-designed measure, the ACE Treatment Integrity Measure (ATIM) could detect therapy contaminations within a controlled trial of cognitive behavioural therapy (CBT) versus Befriending for first-episode psychosis and to compare the ATIM to a more traditional adherence measure, the Cognitive Therapy Scale (CTS). METHOD: Therapy sessions were audio-recorded and at least one therapy session from 53 of the 62 participants in the RCT was rated by an independent rater using the CTS and ATIM. RESULTS: Ninety-nine therapy sessions were rated. All Befriending sessions and all but three CBT sessions were correctly identified. The ATIM showed that 29 of the 99 (29%) sessions were contaminated by techniques from the other therapy. Within the CBT sessions, 19 of the 51 sessions (37%) were contaminated by one or more Befriending techniques. Of the Befriending sessions, 10 of 48 (21%) were contaminated by ACE techniques. The mean CTS score was higher in the CBT than the Befriending group. CONCLUSIONS: The ATIM was able to detect contaminations and revealed more meaningful, fine-grained analysis of what therapy techniques were being delivered and what contaminations occurred. The study highlights the benefit of employing purpose-designed measures that include contamination when assessing treatment adherence.

Social relationships and quality of life moderate distress associated with delusional ideation.

PURPOSE: In a previous study, individuals who followed a particular new religious movement (NRM) reported significantly less distress even though they reported similar levels of delusional ideation when compared with individuals diagnosed with psychotic disorders. Protective factors such as social relationship quality and quality of life (QOL) were hypothesized to explain attenuated distress associated with delusional ideation. METHODS: NRM individuals (n = 29), individuals diagnosed with psychotic disorders (n = 25), and control individuals (n = 63) were recruited. Psychotic symptoms, delusion-proneness, and facets of social relationships quality and QOL were examined across group. Potential moderators of the relationship between group membership and distress were further examined in multiple regression models. RESULTS: NRM participants reported more social relationships that were of higher quality (as demonstrated by more crisis supports, unique and overlap supports, more helpful supports and more reciprocated supports) than individuals with psychotic disorders. NRM participants also reported significantly higher QOL than individuals with psychotic disorders. Furthermore, NRM participants reported more distinct and less reciprocated supports, and significantly higher psychological, environmental, and total QOL, when compared with control participants. The relationship between group membership, delusional ideation, and distress was moderated by relationship reciprocity as well as by total QOL. CONCLUSIONS: Findings highlight the importance of establishing healthy reciprocal social relationships and improving QOL in people diagnosed with psychotic disorders, as these factors may act as a buffer against distress associated with delusional beliefs.

Mineral content in commercially branded and local salt in selected villages from Bahi, Iramba, Manyoni, and Singida urban districts, Tanzania.

The study examines the mineral content of table salts used by households in villages adjacent to the production areas. A total of 210 samples from commercial and local salts were collected, and analyzed using iodometry titration, spectrophotometry, colorimetry, and atomic absorption spectroscopy (AAS) techniques, followed by a household interview for salt type preference. The lowest detectable concentration LOD, lowest quantifiable concentration LOQ and, recovery of methods ranged (0.32-2.155 µg/kg), (0.117-6.387 µg/kg) and, (94.2-103.6 %), respectively. Significant differences in mineral contents were observed within and between local and commercially branded salts (p < 0.001). The mean iodine in the local salt samples from Kitangiri (SA), Singidani (SB), Kindai (SC), Chibumagwa (SD), and Sulunga (SE) ranged from 10.5 ± 0,02 to 16.9 ± 0.01 mg/Kg, with only SA and SC in the World Health Organization (WHO) limits, while commercially branded salt samples SF (Malindi), and SG (Dar es salaam) ranged from 23.4 ± 0.01 to 35.9 ± 0,02 mg/kg that were in the Tanzania Bureau of Standards (TBS) and WHO agreed range. Other ions recorded were nitrate (3.3-4.4 mg/kg, 5.45-7.40 mg/kg), phosphate (0.02-0.48 mg/kg, 0.03 mg/kg), sulphate (0.31-0.42 mg/kg, 0.03-0.07 mg/kg), ammonia (0.5 mg/kg, 0.5 mg/kg to 0.6 mg/kg), copper (1.0-2.0 mg/kg, 0.9-2.0 mg/kg), iron (0.5-1.8 mg/kg, 0.9 mg/kg), and manganese (0.5-1.8 mg/kg, 0.9 mg/kg) for local and commercially branded salt, respectively. Households preferred local to commercial-branded salts: Nkonkilangi 163 (69.9, 32.1 %), Mangwanjuki 96 (17.2, 82.8 %), Unyanga 54 (26.7, 73.3 %), Chibumagwa 106 (63.0, 37.0 %), and Chali Igongo 51 (74.6, 25.4 %), respectively. Public health interventions are recommended to promote the consumption of adequately iodized salt for informed dietary choices.

An analysis of real-time suicidal ideation and its relationship with retrospective reports among young people with borderline personality disorder.

INTRODUCTION: This study aimed to analyze the real-time variability of suicidal ideation intensity and the relationship between real-time and retrospective reports of suicidal ideation made on the Beck Scale for Suicidal Ideation (BSS), among young people with borderline personality disorder (BPD). METHODS: Young people (15-25-year olds) with BPD (N = 46), recruited from two government-funded mental health services, rated the intensity of their suicidal ideation six times per day for 7 days before completing the BSS. RESULTS: For 70% of participants, suicidal ideation changed in intensity approximately five times across the week, both within and between days. BSS ratings were most highly correlated with the highest real-time ratings of suicidal ideation. However, this was not significantly different from the relationship between the BSS and both the average and most recent ratings. Median ratings of suicidal ideation intensity were higher on the BSS compared with an equivalent question asked in real time. CONCLUSION: Findings suggest that young people with BPD experience high levels of fluctuation in their intensity of suicidal ideation across a week and that retrospective reports of suicidal ideation might be more reflective of the most intense experience of suicidal ideation across the week.

Tobacco smoking predicts depression and poorer quality of life in heart disease.

BACKGROUND: We report on the prospective association between smoking and depression and health-related quality of life (HRQOL) in patients with coronary artery disease (CAD). METHODS: Prospective study of 193 patients with assessment of depression occurring 3-, 6- and 9- months (T1, 2, and 3, respectively) following discharge from hospital for a cardiac event. HRQOL was assessed at T3. T1 depression was assessed by clinical interview; T2 and T3 depression was assessed by self-report. Smoking at time of cardiac event was assessed by self-report. Multivariate analyses controlled for known demographic, psychosocial and clinical correlates of depression. RESULTS: Smoking at the time of index cardiac event increased the likelihood of being diagnosed with Major Depressive Disorder (MDD) at T1 by 4.30 [95% CI, 1.12-16.46; p < .05]. The likelihood of receiving a diagnosis of minor depression, dysthymia or MDD as a combined group was increased by 8.03 [95% CI, 2.35-27.46; p < .01]. Smoking did not reliably predict depression at T2 or T3 and did not reliably predict persistent depression. Smoking increased the likelihood of being classified as depressed according to study criteria at least once during the study period by 5.19 [95% CI, 1.51-17.82; p < .01]. Smoking independently predicted worse mental HRQOL. CONCLUSIONS: The findings support a role for smoking as an independent predictor of depression in CAD patients, particularly in the first 3 months post-cardiac event. The well-established imperative to encourage smoking cessation in these patients is augmented and the findings may add to the evidence for smoking cessation campaigns in the primary prevention of depression.

Testing a model of the relationship between childhood sexual abuse and psychosis in a first-episode psychosis group: the role of hallucinations and delusions, posttraumatic intrusions, and selective attention.

Several theories suggest that posttraumatic intrusive symptoms are central to the relationship between childhood trauma (CT) and hallucinations and delusions in psychosis. Biased selective attention has been implicated as a cognitive process underlying posttraumatic intrusions. The current study sought to test theories of the relationship between childhood sexual abuse (CSA), hallucinations and delusions, posttraumatic intrusions, and selective attention in first-episode psychosis (FEP). Twenty-eight people with FEP and 21 nonclinical controls were assessed for CT and psychotic and posttraumatic stress symptoms and completed an emotional Stroop test using CSA-related and other words. Those with FEP and CSA had more severe hallucinations and delusions than those with FEP and without CSA. They also reported posttraumatic intrusions at clinical levels and showed selective attention to CSA-related words. The results are consistent with the posttraumatic intrusions account of hallucinations and delusions in those with CSA and psychosis.

A prospective study of the impact of floods on the mental and physical health of older adults.

OBJECTIVES: With a longitudinal prospective design, we examined the impact of floods on the mental and physical health of older adults and explored risk and protective factors. METHOD: Two hundred and seventy four older adults (age ≥60) completed surveys before and after a flood event. Both the surveys included measures of anxiety, depression, self-reported health, and satisfaction with life; the post-flood survey also included questionnaires on flood experience, symptoms of post-traumatic stress disorder (PTSD), stoicism, and psychological coping with floods. RESULTS: Compared to those not personally affected (78.8%), personally affected individuals (21.2%) reported significantly higher PTSD symptoms, with about one in six reporting PTSD symptoms that might require clinical attention. Personally affected individuals also reported a greater increase in anxiety post-flood, but changes in their depressive symptoms and self-reported health were not significantly different from those not personally affected. Greater flood exposure and the lack of social support were the risk factors for poorer mental and physical health. Higher stoicism was associated with higher post-flood depression and poorer self-reported mental health. The use of maladaptive coping, such as venting and distraction, was associated with greater deterioration in mental health after floods, whilst emotion-focused coping such as acceptance, positive reframing, and humour, was protective against such deterioration. CONCLUSION: Floods had adverse psychological impacts on some older adults who were personally affected. Despite the evidence of resilience, a small proportion of older adults experienced significant difficulties after the floods. The findings in this study help understand older adults' psychological responses to disasters and have practical implications for service planning and delivery.

The relationship between attitudes to aging and physical and mental health in older adults.

BACKGROUND: Attitudes are known to exert a powerful influence on a range of behaviors. The objective of this study was to investigate the contribution of attitudes toward one's own aging to satisfaction with life and physical and mental health measured in a sample of community-dwelling older adults. METHODS: Adults who were part of a larger study of health and well-being in rural and regional Australia aged ≥60 years (N = 421) completed a cross-sectional postal survey comprising the Attitudes to Aging Questionnaire, the 12-Item Short Form Health Survey (SF-12), the Satisfaction with Life Scale, the Geriatric Anxiety Inventory, and the Center for Epidemiological Studies Depression Scale. RESULTS: Overall, attitudes to aging were positive in this sample. More positive attitudes to aging were associated with higher levels of satisfaction with life, better self-report physical and mental health on the SF-12, and lower levels of anxiety and depression, after controlling for confounding variables. Better financial status and being employed were both associated with more positive attitudes to aging and better self-reported physical health. Relationship status was also significantly associated with mental health and satisfaction with life, but not physical health. CONCLUSION: The promotion of successful aging is increasingly becoming important in aging societies. Having positive attitudes to aging may contribute to healthier mental and physical outcomes in older adults. Overcoming negative stereotypes of aging through change at the societal and individual level may help to promote more successful aging.

The jumping-to-conclusions bias in new religious movements.

The jumping-to-conclusions bias has not been examined in a new religious movement (NRM) group. Twenty-seven delusion-prone NRM individuals were compared with 25 individuals with psychotic disorders and 63 non-delusion-prone individuals on four probabilistic inference tasks, together with measures of psychotic symptoms and delusion proneness. The NRM individuals requested significantly less evidence when compared with the control individuals on both meaningful and nonmeaningful tasks. The NRM individuals requested significantly more evidence on a difficult meaningful task when compared with the individuals with psychotic disorders. A specific reasoning style but not a general reasoning style differentiates the NRM individuals from the individuals with psychotic disorders. These findings may be specific to NRM individuals and may not be generalized to other delusion-prone groups.