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(p. 175) Social cognition in paranoia 

(p. 175) Social cognition in paranoia
(p. 175) Social cognition in paranoia

Dennis R. Combs

and David L. Penn

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Subscriber: null; date: 16 January 2019


Paranoia can be generally defined as the perception or belief that others have current or future malevolent or harmful intentions towards another person (Bentall et al. 2001; Freeman and Garety 2000). Although paranoia can be approached from a variety of perspectives (cognitive, neuropsychological, neural/imaging), it is the hostile perceptions of others and their intentions that places paranoia clearly in the domain of social cognition. For example, when a person with persecutory delusions engages in an ambiguous social interaction (e.g. person walks by without speaking) there are a host of perceptual and inferential processes that are actively processing the encounter, which may ultimately lead to a paranoid interpretation of the event. Thus, there seems to be some impairment in the way the person perceives the event and the conclusions drawn from those interactions. In a sense, paranoia is the ideal disorder to study from a social cognitive perspective.

In this chapter, first we will define what comprises the study of social cognition and why it is important to study this area. Second, we discuss whether paranoia exists on a continuum and specifically whether social cognitive biases are present in individuals with varying levels of paranoid ideation. Third, we will review the extant literature on paranoia and social cognition and focus on the domains of ‘theory of mind’ (ToM), attributional style, and social/emotion perception. Within this section, we will also comment on methodological issues that are important in social cognitive research. Finally we will provide a social cognitive model of paranoia and discuss a new group-based intervention (Social Cognition and Interaction Training; SCIT) that attempts to remediate the social cognitive biases present in paranoia.

Social cognition: definitions, domains, and importance

Before we proceed with a review of the research on paranoia and social cognition, we need to define what constitutes social cognition and why is it important to study this area. Social cognition can be generally defined as the (p. 176) ‘mental operations underlying social interactions, which include the human ability and capacity to perceive the intentions and dispositions of others’ (Brothers 1990, p. 28). Similarly, Adolphs (2001) identified social cognition as ‘the ability to construct representations of the relation between oneself and others and to use those representations flexibly to guide social behavior’ (p. 231). These definitions share the idea that social cognition is a set of related neurocognitive processes applied to the recognition, understanding, accurate processing, and effective use of social cues and information in real-world situations (Penn et al. 1997).

The construct of social cognition is vast and there are many methods to study these processes. However, in terms of schizophrenia and paranoia, there appear to be three primary social cognitive processes of interest (Penn et al. 1997, 2006). These domains include ToM, attributional style, and social and emotion perception (Table 9.1).

Table 9.1 Major domains of social cognition



Representative measures

Theory of mind

Ability to represent the mental states of others or make inferences about others’ intentions. This includes understanding hints, false beliefs, intentions, irony, metaphor, and faux pas.

  • Hinting Task

  • Sally-Anne Test

  • Brüne Cartoons

Attributional style

Assigning causality to positive and negative events

  • Internal Personal, and Situational Attributions Questionnaire (IPSAQ)

  • Ambiguous Intentions Hostility Questionnaire (AIHQ)

Social/emotion perception

  1. 1. Perception or scanning of social details and scenes.

  2. 2. Identification or discrimination of emotional expressions. emotional expressions usually reflect both positive (happy and surprise) and negative emotional states (anger, fear, sadness, ashamed, disgust).

  • Social Perception Scale

  • Face Emotion Identification Test (FEIT)

  • Bell–Lysaker Emotion Recognition Test (BLERT)

Once we have a working definition of social cognition and its major domains, it is imperative to ask why it is important to study this area. First, performance on neurocognitive (memory, language, etc.) and social cognitive tasks is dissociable. In some studies, participants can complete non-social (p. 177) tasks quite well and perform poorly on social cognition tasks. At the clinical level, individuals with frontal lobe damage (Anderson et al. 1999; Blair and Cipolotti 2000; Fine et al. 2001) or prosopagnosia (inability to recognize faces; Kanwisher 2000) show significantly impaired performance in varying areas of social cognition such as ToM and facial processing, but have intact discrimination of non-social stimuli (e.g. geometric designs). In contrast, individuals with Williams syndrome tend to show a relative strength in social cognitive abilities, such as the detection of basic emotions from faces and normal performance on some ToM tasks, but tend to have below-normal intelligence and have deficits in other aspects of neurocognition (Tager-Flusberg et al. 1998; Jones et al. 2000). Second, there is evidence in support of the presence of a ‘social cognitive neural circuit’, incorporating the amygdala, fusiform gyrus, superior temporal sulcus, and prefrontal cortices (Phillips et al. 2000b, 2003; Blackwood et al. 2001; Adolphs 2003; Pinkham et al. 2003; Blakemore and Frith, 2004; Lee et al. 2004). Finally, performance on social cognitive tasks tends to be only moderately associated with neurocognitive performance (e.g. Penn et al. 1993). In general, the correlations between affect recognition and attention, memory, and executive processing range from 0.20 to 0.60 (Schneider et al. 1995; Bryson et al. 1997; Kee et al. 1998; Kohler et al. 2000; Silver and Shlomo 2001; Sergi and Green 2002; Bozikas et al. 2004; Combs and Gouvier, 2004; Sachs et al. 2004; Sergi et al. 2006). Therefore, neurocognition and social cognition appear to represent related, but non-redundant constructs.

The study of social cognition, albeit interesting by itself, must relate to real-world functioning. Both emotion perception and ToM have a consistent relationship with functional outcomes (Appelo et al. 1992; Mueser et al. 1996; Toomey et al. 1997; Hooker and Park, 2002; Penn et al. 2002; Kee et al. 2003; Brüne 2005a; Schenkel et al. 2005; Pinkham and Penn 2006; reviewed in Couture et al. 2006). In fact, some studies have shown that social cognition has a stronger relationship with functional outcome than neurocognition (Penn et al. 1996; Roncone et al. 2002; Vauth et al. 2004; Pinkham and Penn 2006). As we discuss later, by improving social cognition perhaps the social functioning of persons with paranoia can also be enhanced.

Paranoia across the continuum

In this chapter, we will approach paranoia and social cognition from a continuum approach. It has been argued that clinical researchers begin to focus more on the study of symptoms instead of traditional diagnostic syndromes (Bentall et al. 1988; Costello 1994). A number of studies have found that delusions and hallucinations are present in normal individuals (Peters et al. 1999; van Os et al. 2000; Johns and van Os 2001; Verdoux and van Os 2002; Johns 2004). (p. 178) Paranoia also appears to exist on a continuum ranging from sub-clinical to clinical levels. At the lower end of the paranoia continuum, sub-clinical paranoia is found in normal persons often in response to everyday situations or contexts that evoke suspicion or self-focused attention (i.e. self as the target of others; Fenigstein and Vanable 1992). In fact, paranoia appears to be relatively common among non-clinical samples. Recently, Ellett et al. (2003) reported that a sizeable number of adults (n = 153 out of 324) reported beliefs or experiences in which others were out to harm them intentionally (see also Freeman et al. 2005b). The origin of this type of sub-clinical paranoia may reflect environmental events such as racism, poverty, immigration, incarceration, or a diathesis (predisposition) towards paranoia (Newhill 1990; Bentall et al. 2001; Whaley 2001; Combs et al. 2006b). Little is known, however, about how to distinguish between these ‘contextual’ or ‘cultural’ forms of paranoia from the unfounded paranoia found in psychosis (Freeman et al. 2005b). At the more severe end of the paranoia continuum are clinical forms of paranoia such as persecutory delusions or paranoid personality disorder which are more extreme, based on less external evidence, and which have more functional and social impairment (e.g. behavioural avoidance).

Based on the continuum view of paranoia, we would expect that many of the same cognitive, social cognitive, and symptom characteristics of persons with persecutory delusions would also be present in analogue samples. A few illustrations from recent research studies will reflect the underlying similarity across the continuum. First, the theoretical relationships between paranoia and other symptoms such as anxiety, depression, abnormal sensory experiences, self-esteem, and self-monitoring are also found in sub-clinical samples (Martin and Penn 2001; Freeman et al. 2005a,c; Combs et al. 2007a). Second, there are similarities in social behaviours between sub-clinical and clinical participants. In two separate studies, we demonstrated that as the level of paranoia increased (from sub-clinical to clinical) so did social distance from the examiner and there was also a greater tendency to perceive others more negatively (Combs and Penn 2004; Gay and Combs 2005). In addition, persons high in sub-clinical paranoia show biases to threatening stimuli based on slower read times for paranoid words using the Emotional Stroop Task and poorer recognition of negative emotional expressions (Combs et al. 2003; Green et al. 2003a,b). Finally, we found evidence for Trower and Chadwick’s two types of paranoia (‘poor me’ and ‘bad me’; Trower and Chadwick 1995) in a sub-clinical sample of 114 college students who scored 1 standard deviation on the Paranoia Scale (Combs et al. 2007b). All of these studies support the idea that paranoia is present on a continuum and, more importantly, that the (p. 179) construct can be approached at any point on the continuum. Given the cost and difficulty in identifying persons with persecutory delusions, the use of analogue samples may lead to an explosion of research on social cognition and paranoia.

The continuum approach to the study of paranoia is not without its critics (e.g. few measures are available to measure the paranoia continuum) and encounters resistance from those who remain committed to the traditional approach to the study of schizophrenia and its clinical subtypes (e.g. paranoid and disorganized schizophrenia). However, the use of diagnostic categories such as paranoid schizophrenia is relatively heterogeneous (delusions and/or hallucinations) in terms of symptom patterns and may not contain individuals who have persecutory delusions (Corcoran 2001; Combs et al., 2006a). Also, the use of paranoid schizophrenia as a diagnostic entity usually leads to the formation of a non-paranoid group, which contains persons with more severe symptoms and greater cognitive impairment, thus hindering comparisons. One of the major challenges in symptom-focused research is to demonstrate that the participants are actually paranoid, which necessitates a careful assessment of the level of paranoia. The use of a combination of self-report and interviewer-rated measures, which provide convergent data as to the presence of paranoia, is an especially strong methodology. Also, there appears to be emerging evidence that the persecutory ideation component of paranoia is the most valid aspect of the construct to measure (Freeman and Garety 2000; McKay et al. 2006). The impact of ethnicity on paranoia suggests that culturally validated measures be developed to provide a more sensitive examination of mistrust. Thus, a continuum approach would bring much-needed specificity to the study of paranoia and allow researchers to examine the impact of a single symptom on social cognition. We propose that a symptom-focused approach which spans the paranoia continuum provides the strongest evidence for the presence of social cognitive deficits in paranoia.

Paranoia and social cognition: research evidence

As we review the research literature on paranoia and social cognition, we pose several questions to consider as we proceed. To reflect the paranoia continuum, we will draw conclusions from studies using both clinical and sub-clinical participants.

  1. 1 What conclusions can we draw from research about social cognition and paranoia? For example, are the deficits specific to paranoia and are these deficits stable over time?

  2. (p. 180) 2 Is there evidence that these deficits are present across the paranoia continuum? For example, do persons with sub-clinical paranoia show similar deficits in social cognition to those with persecutory delusions?

  3. 3 What are the important methodological issues in research on social cognition and paranoia?

Theory of mind

A comprehensive review of ToM is presented by Corcoran in Chapter 10. However, since ToM falls under the construct of social cognition, we would like briefly to comment on this area of research as it pertains to paranoia. First, superficially it makes sense that individuals with paranoia have impairments in understanding the mental states, motives, or intentions of others. The belief that someone harbours ill will or malevolent intentions can be viewed as a type of ‘mentalizing’ deficit in which a false belief or motive about some other person or group is inferred. In his cognitive theory of schizophrenia, Frith (1992) argued that ToM deficits should be present in persons with disorders involving impaired willed action (e.g. negative and disorganized symptoms), self-monitoring (e.g. delusions of passivity and control), and others’ beliefs and intentions (e.g. delusions of persecution). According to Frith (1992), persons with paranoia show a normal development of ToM, but these abilities become impaired during the acute paranoia. The ToM literature is complex and fraught with different methodologies, samples, and ToM tasks, which makes drawing conclusions difficult. However, there is consistent evidence that (i) persons with schizophrenia show impaired ToM performance compared to normal controls, and (ii) the most severe deficits in ToM are found in persons with negative symptoms and disorganization (see Brüne 2005b for a review). Also, it appears that persons in the acute phase of illness show more ToM impairment than those in remission, who show relatively intact ToM and perform similar to normal controls (Drury et al. 1998; Corcoran 2001). Thus, many consider ToM deficits a ‘state’ instead of a ‘trait’ deficit (Penn et al. 2006).

So, what can we conclude about the ToM abilities of persons with paranoia? Several recent reviews have concluded that the empirical link between paranoia and ToM is relatively weak, and that ToM deficits are not specific to paranoia, but found in a number of other disorders such as autism, Asperger syndrome, and even other subtypes of schizophrenia (Pilowsky et al. 2000; Craig et al. 2004; Brüne 2005b).

Studies supporting the presence of ToM deficits in paranoia are primarily found in early research conducted by Corcoran, Frith and colleagues (see Corcoran 2001 for a review). More recently, Harrington et al. (2005a) examined a sample of 25 persons classified as paranoid and non-paranoid and (p. 181) found that those with persecutory delusions showed ToM deficits for first-and second-order verbal tasks, but not non-verbal tasks. On average, ToM deficits in persons with paranoia appear to be less severe than in persons with negative symptoms and disorganization, but greater than those in remission, with passivity symptoms, and normal controls. In fact, some have asserted that only three studies have found clear evidence to support the ToM–paranoia link (Blackwood et al. 2001; Harrington et al. 2005b). In contrast, other studies are inconclusive (Brüne 2005b) or do not support a relationship between paranoia and ToM deficits (see Mazza et al. 2001). For example, Drury et al. (1998) did not find differences in ToM between persecutory deluded versus non-deluded participants on ToM tasks, but persons with schizophrenia showed significantly lower scores than psychiatric controls. Thus, the consensus is that paranoia has not been consistently linked to ToM deficits and largely depends on the comparison groups used in the study (Brüne 2005b; Penn et al. 2006).

There are several methodological issues that are important to note in this area of research. First, the method of symptom classification may be partially responsible for the mixed results. Studies have used a variety of classification schemes such as positive versus negative symptom dimensions, factor analytic classification systems (positive, negative, thought disorder) and paranoid versus non-paranoid schizophrenia (Harrington et al. 2005b). These symptom groupings do not allow clear conclusions about whether ToM is present or absent as it pertains to paranoia (Corcoran 2001). As we stated earlier, using clearly defined groups whose primary symptom is persecutory delusions can lead to clarification of whether ToM deficits are present (Walston 2000). Clearly, more attention is needed to symptom measurement and classification in this type of research.

Second, the types of tasks used in research needs to be addressed. Measurement considerations include the use of both first-order (false belief) and second-order (false belief about another person’s belief; more difficult) tasks and whether to use control tasks that do not contain the mentalizing aspect such as physical, non-verbal, or mechanical-type tasks. It is important to match these tasks psychometrically or at least report the psychometric properties since verbal or social ToM tasks may be inherently more difficult (differential deficit model; see Penn et al. 1997 for a review). In many cases, ToM deficits are found for the verbal, but not the non-verbal, tasks and it needs to be demonstrated that this is not an artefact of the measurement.

Finally, the successful completion of ToM tasks can be affected by cognitive factors such as intellectual, abstraction/reasoning, memory, or language-processing deficits (Frith and Corcoran 1996; Pickup and Frith 2001; (p. 182) Roncone et al. 2002; Brüne 2003, 2005b; Greig et al. 2004), but this is an issue for all psychological testing. For example, the most severe deficits in ToM are found in persons with autism due to the pervasive cognitive deficits found in this population. In schizophrenia, ToM appears partially influenced by cognitive factors. Thus, it is important to account for these characteristics in this area of research either by matching participants on IQ or cognitive ability or by measuring these areas with neuropsychological tests which can later be examined (account for variance). For paranoia, it has been suggested that paranoid individuals can pass first-order ToM tasks which are relatively easy and tend to fail the harder second-order tasks due to intact cognitive functioning (Pickup and Frith 2001). It is possible that when under greater cognitive load, such as during natural or in-vivo social interactions, these persons may show the expected ToM deficit, but this remains to be demonstrated (see Walston 2000).

What evidence can we draw from studies that use individuals at risk or at the lower end of the paranoia continuum in terms of ToM and paranoia? Unfortunately, no studies have assessed the ToM abilities of subjects with persecutory delusions compared with sub-clinical paranoid people. However, we can draw some inferences from studies using high-risk individuals (family history) and those with schizotypal symptoms. We found seven studies that have examined this issue and most involve whether ToM represents a ‘state’ or ‘trait’ deficit. Pickup and Frith (2001) showed that remitted participants performed as well as normal controls, while Herold et al. (2002) showed that the ToM deficits were persistent, trait-like, and found in remitted clients. In a study on non-clinical participants, Langdon and Coltheart (1999) showed that individuals who reported schizotypal symptoms performed more poorly on ToM tasks than low-schizotypal persons and the scores were related to the degree of positive symptoms reported by participants (Brüne 2005b). This link to specific symptoms at the time of testing, which is consistent with Frith’s idea of a loss of ToM during acute illness, has been supported by Marjoram et al.’s (2006) study in which high-risk relatives with current transient positive symptoms were more impaired on a self-monitoring-type task than those who reported symptoms in the past. Pickup (2006) found that level of positive symptoms on a measure of schizotypy significantly predicted ToM scores, but there was no difference between high and low scorers on ToM tasks. Studies by Janssen et al. (2003) and Wykes et al. (2001) found evidence for ToM deficits in unaffected relatives with a family risk of schizophrenia. Janssen et al. (2003) suggested that there is a dose–response relationship between ToM impairment and schizophrenia risk.

(p. 183) Overall, it appears that deficits in ToM are found in persons at risk for schizophrenia such as family members and persons reporting schizotypal symptoms at the time of testing. The level of impairment is lower than in schizophrenia but is related to current level of positive symptoms. For nonclinical samples, there is little support for the role of negative symptoms in ToM and the impact of negative symptoms may only be relevant for persons with psychosis (Pickup 2006). However, ToM has not been examined across the paranoia continuum and the use of high-risk groups can only be considered a proxy for a direct examination of paranoia.

Attributional style

Attributions are generally defined as the manner in which one explains and assigns causality to positive (e.g. receiving a pay raise) and negative (e.g. getting fired) events. For example, if a friend does not show up for a movie, the person generates a reason as to why this occurred. Attributions usually assign causes to internal (something about me), personal (something about the other person), or situational factors (something about the situation or context). Historically, the work on attributional style has been largely centred on persons with depression, and it was found that depressed persons have a greater tendency to blame themselves for negative events while attributing positive events/success to others or external factors (Bentall et al. 2001). Most of the research on attributional style and paranoia has come from the work of Bentall and colleagues in the UK. There is consistent evidence that persons with paranoia and persecutory delusions show attributional abnormalities. Most commonly, these persons exhibit a type of ‘personalizing’ bias in which they blame others for negative events rather than themselves (Bentall and Kinderman 1997; Garety and Freeman 1999; Bentall et al. 2001). However, there is mixed evidence as to whether this personalizing bias is specific to paranoia as it may be found in persons with delusions in general (Fear et al. 1996; Martin and Penn 2002). This presence of a personalizing bias is found across the majority of studies, but the reason why this occurs remains unclear and hotly debated.

Theoretically, Bentall and colleagues have proposed several inter-related models to explain the attributional style of persons with persecutory delusions. The most current version of this theory is called the Attribution Self-Representation Cycle (ASRC). Bentall et al. (1994) in their original theory proposed that paranoia may be a defence that prevents negative information from reducing self-esteem (see Zigler and Glick 1988). Thus, by blaming others self-esteem is protected. More recently, it has been suggested that personalizing or external–personal attributions prevent self-discrepancies between (p. 184) the actual and ideal parts of the self (which maintain self-esteem) while opening up discrepancies between the self and others (Kinderman and Bentall 1996b, 1997). Evidence for the ‘paranoia as a defence’ model was initially derived from studies showing that persons with paranoia demonstrate an exaggerated self-serving bias (tendency to blame others for negative events and to take credit for positive events) compared to both normal controls and persons with depression (Kaney and Bentall 1989; Candido and Romey 1990). Several reviews (Garety and Freeman 1999; Bentall et al. 2001; Penn et al. 2006) have suggested that there is greater support for the presence of an external–personalizing bias for negative events, but less support for the internalization for positive events (Fear et al. 1996; Won and Lee 1997; Kristev et al. 1999; Martin and Penn 2002; Humphreys and Barrowclough 2006). Furthermore, if the defence theory of paranoia is correct, then persons with persecutory delusions should show a depressive attributional style on covert or opaque attributional tasks (e.g. Pragmatic Inference Test) and show evidence of a discrepancy between overt and covert self-esteem. However, the research on self-esteem levels is inconsistent, with some studies showing high or normal levels of self-esteem and some showing low self-esteem (Kinderman 1994; Kinderman and Bentall 1996b; Peters et al. 1997; Humphreys and Barrowclough 2006; Moritz and Woodward 2005). In fact, only two studies have found a discrepancy between overt and covert self-esteem (Lyon et al. 1994; McKay et al. 2007). It is currently believed that the relationship between paranoia and self-esteem seems to be related to whether the sample contains persons with elevated levels of depression (Freeman et al. 1998; Peters and Garety 2006).

The finding that persons with paranoia make personalizing attributions poses the question as to why situational or contextual information is not used. According to Gilbert et al. (1988), most persons make automatic personal or dispositional attributions and subsequently correct these explanations for situational factors, but this seems to be absent in persons with paranoia. For example, we may blame our friend for not showing up to the movie, but we correct that attribution if we learn that she had a flat tyre en route. The failure to incorporate situational information may stem from impairments in ToM (Kinderman et al. 1998; Taylor and Kinderman 2002; Randall et al. 2003), which provides additional contextual information about the intentions or minds of others, or a greater need for closure (Colbert and Peters 2002; Bentall and Swarbrick 2003), which prematurely closes the search for situational information.

There are several methodological issues to consider in this area of research. First, most studies on attributions use paper-and-pencil self-report (p. 185) questionnaires such as the Attributional Style Questionnaire (ASQ; Peterson et al. 1982), and the Internal, Personal and Situational Attributions Questionnaire (IPSAQ; Kinderman and Bentall 1996a, 1997), which present a variety of hypothetical positive and negative situations. The ASQ, in particular, has been criticized for having poor internal consistency values for the internality index and has been supplanted by the IPSAQ. Second, it has been argued that coding natural social interactions may be a more valid method of studying attributions. A recent study by Lee et al. (2004) found that more external–personal attributions were identified from the speech samples of 24 persons classified as paranoid versus non-paranoid. Third, it is open to debate as to the best method to study attributions in terms of using self-ratings or having independent raters’ code responses (Bentall et al. 2001). Some studies have found that comparing self versus independent ratings leads to different findings (Kinderman et al. 1998; Martin and Penn 2002; Randall et al. 2003). Fourth, current measures of attributional style do not address situations that differ in intentionality. Research by Crick and Dodge (1994) suggest that conduct-disordered children have a hostile attribution bias for ambiguous situations. Theoretical models of persecutory delusions posit that ambiguous situations are difficult to interpret and may be misperceived as hostile and threatening (Turkat et al. 1995; Freeman et al. 2002, 2005a; Freeman and Garety 2003; Green and Phillips 2004). That may be one reason why persons with persecutory delusions (or persecutory ideation) spend extra time looking at ambiguous scenes (Phillips et al. 2000a), and why they perceive neutral experimenter behaviour in a negative manner (Combs and Penn 2004).

To address this limitation in current attributional style measures, we developed a new measure of attributional style called the Ambiguous Intentions Hostility Questionnaire (AIHQ) which includes situations that are ambiguous, accidental, and intentional (Combs et al. 2007c). In a sample of 322 college students reflective of the paranoia continuum, there were significant correlations between several measures of paranoia [Paranoia Scale (PS) and the Structured Clinical Interview for DSM-IV (SCID-I) paranoia items] and AIHQ self-rated blame and hostility scores for ambiguous situations. More importantly, the AIHQ blame and hostility scores for ambiguous situations accounted for significant incremental variance in the prediction of paranoia scores as compared to the IPSAQ, which supports the usefulness of the scale in paranoia research. Finally, there are few studies on attributional style that involve longitudinal measurement, and, given the instability of attributions (Bentall et al. 2001; Bentall and Kaney 2005), this area needs additional research.

(p. 186) In terms of data from sub-clinical studies, there does not appear to be clear evidence for the presence of personalizing attributional biases when college student samples are used. Combs and Penn (2004) identified 29 persons with elevated scores on the PS (>1 SD on the PS) and compared them with 31 persons with low PS (<1 SD on the PS) scores on a variety of social cognition measures. There was no difference between the groups on the externalizing or personalizing bias scores from the IPSAQ. In addition, several studies have found that sub-clinical paranoia scores are not correlated with attributional style (Martin and Penn 2001; McKay et al. 2005); a finding which is supported in studies on clinical samples (Garety and Freeman 1999; Martin and Penn 2002). Despite the lack of findings in attributions style, there is some support for a relationship between ToM errors and a greater tendency to make personalizing attributions for negative events (Kinderman et al. 1998; Taylor and Kinderman 2002). Also several studies have found relationships between sub-clinical paranoia, self-discrepancies and self-concept (Chung and Lee 1998; Lee and Won 1998) and negative perceptions of others (Lee, 1999). Thus, it appears that some aspects of attributional style such as the presence of ToM impairments, self-discrepancies and lower self-concept are present in analogue studies, but it appears that personalizing attributions only appear when paranoia reaches delusional levels (McKay et al. 2005).

Social and emotion perception

It is believed that perceptions and other cognitive processes (attention, memory, learning) are affected by information-processing biases (i.e. schema) found in paranoia (Rector, 2004). These biases appear to be especially sensitive to threatening stimuli, such as negative emotional expressions (Locascio and Synder 1975; Brennan and Hemsley 1984; Miller and Karoni 1996; Freeman et al. 2002; Green et al. 2003c; Phillips et al. 2000b; Green and Phillips 2004). Information-processing biases are considered important factors in the both the development and maintenance of persecutory delusions (Freeman et al. 2002). These biases can affect what the individual attends to and also how this information is interpreted and recalled (Fiske and Taylor 1991; Wyer and Carlston 1979 as discussed in Fenigstein 1997; Pinkham et al. 2003). In the following sections, we review some of the constructs that may underlie impaired social and emotion perception such as an increased sensitivity for threat and the presence of visual scanning deficits for facial stimuli. This will be followed by a review of studies examining emotion perception and person perception.

Persons with elevated levels of paranoia seem to be more sensitive to threat, based on research using the Emotional Stroop Test, which measures pre-attentive or early visual processing. These individuals have greater interference (p. 187) (slower read times) for paranoid content words as compared to neutral and depressed words (Bentall and Kaney 1989; Kinderman 1994; Fear et al. 1996; Combs et al. 2003; Combs and Penn 2004). Also, paranoia has been shown to be associated with an increased recall for threatening words/stories and a higher tendency to form illusory correlations to threatening words, which reflects the involvement of deeper encoding or controlled processes (Brennan and Hemsley 1984; Kaney et al. 1992; Bentall et al. 1995; Fenigstein 1997). Finally, persons with elevated paranoia levels exhibit improved implicit learning for negative subtle co-variations among facial features and negative personality traits such as unfairness (Combs et al. 2003).

There is also evidence that persons with delusions show abnormalities in visual scanning for faces and emotional expressions. On face and emotion perception tasks, persons with deluded schizophrenia tend to focus on nonessential areas of the face or even peripheral stimuli (Gordon et al. 1992; Phillips and David 1997; Streit et al. 1997). There is also a reduction in the amount of time they view relevant facial features such as the eyes, nose, and mouth (Gordon et al. 1992; Swartz et al. 1999; Green et al. 2005). There also appear to be differences in the visual scanning for negative and positive emotions (Loughland et al. 2002). When viewing threatening expressions, normal persons show more extensive and longer fixations to facial features and these expressions are identified more rapidly, which is considered evolutionarily adaptive in the detection of threat (Green et al. 2003c). Similarly, both deluded and delusion-prone persons also show this extensive scanning for threat. However, there is a reduction in attention to facial features and these emotions tend to be recognized more slowly, and it is speculated that these scanning deficits may be a reason for the poorer accuracy scores found in research (Green et al. 2001, 2003a,b).

In terms of emotion perception, there is consistent evidence that persons with schizophrenia perform worse on emotion identification and discrimination tasks than both psychiatric (depressed and bipolar) and non-psychiatric controls (see reviews by Mandal et al. 1998; Edwards et al. 2002; Penn et al. 2006, 2000). These deficits appear to be relatively stable over time based on several longitudinal studies using follow-up periods between three months and one year (Addington and Addington 1998; Kee et al. 2003). The performance of persons with paranoia on emotion perception tasks is interesting in that contradictory predictions are possible. On one hand, the presence of an information-processing bias for social and threatening stimuli suggests that persons with persecutory delusions should show enhanced emotion perception abilities (Kline et al. 1992; Penn et al. 1997; Green and Phillips 2004; Combs et al. 2006a). In contrast, it is possible that there are deficits (p. 188) (i.e. visual scanning, etc.) in this ability since many persons with persecutory delusions also have schizophrenia. Research in this area is still developing, although several previous studies found that persons with paranoid schizophrenia are better at emotion perception than persons with non-paranoid schizophrenia (Kline et al. 1992; Lewis and Garver 1995), with this strength being particularly evident for naturalistic rather than posed emotions (Davis and Gibson 2000; Peer et al. 2004).

In terms of accuracy, there is generally no difference for positive emotions between persons with paranoid schizophrenia and normal controls (Kline et al. 1992; Davis and Gibson, 2000), which is a pattern consistent with the general schizophrenia literature (Dougherty et al. 1974; Edwards et al. 2002). For negative emotions, the findings largely depend on the type of comparison group used in the study. Persons with paranoid schizophrenia typically perform better than persons with non-paranoid schizophrenia (disorganized, negative/deficit type), but worse (not better) than normal controls in the recognition of negative emotions such as fear, anger, sadness, shame, and disgust (LaRusso 1978; Kline et al. 1992; Lewis and Garver 1995; Davis and Gibson 2000; Green et al. 2001). The fact that persons with non-paranoid schizophrenia show the poorest scores suggests that cognitive abilities play a major role in emotion recognition (Combs and Gouvier 2004). Thus, it should be emphasized that any improvement in recognizing negative emotions is relative to other types of schizophrenia only.

To further illustrate the relationship between paranoia and emotion perception, we present findings from a recently published study on emotion perception across the paranoia continuum (Combs et al. 2006a). In this study, we used four groups of participants that differed on level of paranoia. The sample was comprised of thirty clinical participants who had documented persecutory delusions based on the BPRS and three groups of sub-clinical participants (n = 88 college students) who showed low, medium, and high levels of sub-clinical paranoia based on the PS. We administered two measures of emotion perception: the Face Emotion Identification Test (FEIT) and the Bell–Lysaker Emotion Recognition Test (BLERT). As evident in Table 9.2, as paranoia increased in severity, emotion perception scores (composite mean score) decreased. Clinical participants with persecutory delusions had the poorest emotion perception abilities and the low paranoia group had the best. Consistent with the research findings, there was a significant difference between the groups for negative emotions, but not for positive emotions. The recognition of positive emotions was relatively unimpaired with the differences mainly arising from the negative emotions such as anger, fear, disgust, and sadness, which may be more difficult to distinguish (Phillips et al. 2000a; (p. 189) Horley et al. 2001; Edwards et al. 2002; Green et al., 2003a; Kohler et al. 2003; Peer et al. 2004).

Table 9.2 Affect perception scores by group membership

Variable (range)

Sub-clinical groups





Mean affect score (0–20)

12.3 (3.3)

14.6 (1.6)

15.7 (1.6)

16.2 (1.4)

Mean positive score (0–5)

3.6 (1.0)

4.3 (0.58)

4.3 (0.58)

4.5 (0.41)

Mean negative score (0–11)

7.0 (1.4)

7.5 (1.1)

8.2 (1.0)

8.5 (1.1)

Note. Higher scores indicate better emotion recognition

Table reproduced with permission from Combs abilities. et al. (2006a), © 2006 British Psychological Society.

A more complex construct is social perception which consists of how persons perceive and attend to social scenes and other persons in their environment. There is not as much literature on social perception to draw upon, but there are four studies of note (Freeman et al. 2000, 2005b; Phillips et al. 2000a; Combs and Penn 2004). Similar to research on attributional style, person perception research tends to use ambiguous interactions or neutral-behaving examiners, which are believed to elicit the cognitive biases associated with paranoia. Combs and Penn (2004) examined a group of high (n = 29) and low (n = 31) participants based on scores from the PS. To assess immediate perceptions, each participant was allowed to sit as close or as far away from the examiner as possible. Persons with high paranoia scores sat significantly (almost 1 foot) father from the examiner. Also, these persons took almost twice as long to read the consent form and both of these behaviours reflect the suspiciousness of others found in paranoia. In fact, similar behaviours were found in a recent replication of this study with inpatients with persecutory delusions (Gay and Combs 2005). At the end of the study, the participants were asked to rate the examiner (who left the room), and who was trained to remain neutral during the study, on five ‘in-vivo’ perception items. To enhance the validity of the perceptions, the participants returned the rating form to a secure box and were assured that only the lead experimenter would review the results. As predicted, persons with high paranoia viewed the examiner as less trustworthy and more likely to be analysing their performance and influencing their performance during the study even though the examiner remained neutral. Ratings of hostility and friendliness were in the expected direction, but were not statistically significant.

Consistent with the results from Combs and Penn (2004), Freeman et al. (2005b) examined paranoia among 30 non-clinical participants across five (p. 190) virtual reality interactions with neutral-behaving computer-generated characters. Using a modified measure of persecutory ideation developed for the study, it was found that paranoid ideation was generated during these interactions. In fact, 23 out of the 30 participants reported some degree of persecutory ideation. The reporting of paranoia in virtual reality settings was also related to other external indicators, such as interview ratings, visual analogue ratings and self-report measures of paranoia, which provide validity to the reported symptoms. Using a regression analysis, predictors of paranoia ratings in the virtual reality setting were sub-clinical paranoia, hallucinatory experiences, timidity, anxiety, and sense of being in the simulated environment (viewed scene as more realistic).

Finally, two studies have examined visual appraisal of social scenes using eye tracking methodology. Freeman et al. (2000) found that persons with persecutory delusions showed a restricted scanning for happy scenes and a more extensive scanning of directly threatening and ambiguous scenes. Phillips et al. (2000a) examined the visual scanning patterns of 19 persons with persecutory delusions, eight persons without persecutory delusions and 18 normal controls while viewing ambiguous, threatening, and neutral social scenes. The social scenes were black-and-white images from magazines, which were rated as ambiguous, threatening, and neutral by normal controls prior to the study. Using an eye-tracking technology, each participant viewed each scene twice. The first time was a free-viewing condition and during the second time the person was instructed to look for threat. Initially, all groups showed equivalent scanning patterns to the various scenes. On the second viewing, the study found that when viewing the ambiguous scene, persons with persecutory delusions showed less scanning of overtly threatening areas, but greater scanning of non-threatening areas. Thus, this may reflect the sensitivity to threat and more specifically the tendency to look for threat in inappropriate places. Also this viewing of non-threatening areas instead of the threatening ones may suggest problems with context appreciation or ambiguity (which would be consistent with research on attributions). The lack of reappraisal may reflect a jumping-to-conclusions bias (seeking less information before making a decision; Huq et al. 1988; Garety et al. 1991) or impaired cognitive flexibility (Freeman et al., 2004; Garety et al., 2005) associated with delusions and paranoia (see Green and Phillips 2004 for a discussion).

Methodologically, emotion perception studies rely mainly on static, posed images and may not be ecologically valid given the brevity of expressions. In fact, persons with paranoia may over-analyse these types of expressions (Davis and Gibson, 2000). Sadly, there are no measures of emotion perception that present emotions embedded in natural social interactions, but one recent (p. 191) study used moving emotional expressions and found better recognition for moving versus static expressions (Tomlinson et al. 2006). Also, positive expressions may be easier to identify, thus hindering direct comparisons with negative emotions. The same issue is relevant for person perception studies which often use researchers playing a simulated role, which may not reflect natural interactions. Using more natural, ecologically valid stimuli would help to determine whether the findings are related to the test and measures (measurement artefact) or reflect a deficit across situations and contexts.

Drawing together the studies on emotion and social perception, it appears that paranoia affects both pre-attentive and controlled processing. When threat is identified, persons with paranoia tend to process this information more slowly and deliberately. Research on eye tracking suggests that they may actually avoid looking at threatening areas and instead examine areas of ambiguity (Green and Phillips 2004). These visual scanning deficits in paranoids when viewing threatening emotions may reflect a reduced neural response compared with normals (Phillips et al. 2000b). The reduced reappraisal and visual fixation to facial features may reflect the jumping-to-conclusions bias when attempting to recognize the emotional states of others. Furthermore, problems attending to the subtle facial cues important in recognizing emotions may exacerbate this deficit. It is possible that sufficient information would be obtained if subjects were instructed on how to scan emotions or social scenes (see Combs et al. 2006c for an example of this methodology).

Remediating social cognition: social cognition and interaction training (SCIT)

Given the number of impairments in social cognition and the consequent impact of paranoia on social functioning, attention is now turned to developing interventions that address the deficits in ToM, attributional style, and social/emotion perception (Couture et al. 2006). In Figure 9.1, we present a social cognitive model of paranoia, which attempts to integrate the various domains discussed in this review and their relationships.

Fig. 9.1 Social cognitive model of paranoia. Adapted from Couture et al. (2006), with permission from Oxford University Press.

Fig. 9.1
Social cognitive model of paranoia. Adapted from Couture et al. (2006), with permission from Oxford University Press.

The primary treatment of paranoia is cognitive-behavioural therapy, which is used to reduce paranoia, delusional ideation, and emotional distress through challenging evidence for those beliefs and behavioural testing (Rector 2004). In contrast, there are a number of interventions that attempt to remediate social cognition. These social cognitive interventions can be classified as either ‘targeted’ or ‘broad-based’ (see Combs et al. in press a; Couture et al. 2006 for a review; Penn and Combs 2000). Targeted interventions focus on a specific social cognitive domain (e.g. ToM or emotion perception; Kayser et al. 2006; (p. 192) Russell et al. 2006), whereas broad-based interventions combine a variety of psychosocial approaches, including cognitive remediation and social skills training (Spaulding et al. 1999; van der Gaag et al. 2002; Hogarty et al. 2004). Although both approaches improve social cognition, several key issues remain unaddressed. First, can we expect the narrow focus of targeted interventions to yield improvements across social cognitive domains or to generalize to social functioning? Second, if targeted interventions are too narrow, are broad-based interventions too burdensome? That is, is it necessary to stack social cognitive training atop intensive cognitive remediation and social skills training, or might social cognitive training alone be sufficient to improve social functioning? Third, these interventions have not been empirically examined or developed to address the social cognitive biases found in paranoia.

We therefore developed a comprehensive, ‘stand-alone’ manual-based intervention called Social Cognition and Interaction Training (SCIT; D.L. Roberts et al. unpublished manual) that targets the three core social cognitive deficits in schizophrenia: emotion perception, ToM, and attributional style. SCIT is comprised of three phases: (1) emotion training, (2) figuring-out situations, and (3) integration, which are delivered by one or two therapists over 20–24 weekly sessions, with each session lasting 50 min. SCIT involves the use of didactic instruction, videotape and computerized learning tools, and role-play methods to improve social cognition. We will briefly describe the goals and (p. 193) techniques associated with each phase of treatment. Pilot testing of SCIT in a small sample of inpatients showed improvements in ToM and attributional hostility but not emotion perception (Penn et al. 2005).

The primary goals of phase 1 (emotion training) are to provide information about emotions and their relationship to thoughts and situations, define the basic emotions, improve emotion perception with computerized facial expression training tools, and teach clients to distinguish between justified and unjustified suspiciousness.

The primary goals of phase 2 (figuring-out situations) are to teach clients about the potential pitfalls of jumping to conclusions, to improve cognitive flexibility in social situations, and to help clients distinguish between personal and situational attributions, and between social ‘facts’ and social ‘guesses’. Techniques include a variety of guessing games (20 question game) and fact-finding exercises (doing detecting work), and generating attributions for events in the client’s lives with an emphasis on possible situational factors that should be considered.

The primary goals of phase 3 (integration) are to assess the certainty of facts and guesses surrounding events in clients’ personal lives, recognize that it is sometimes necessary to obtain more information about social situations, and to teach effective social skills for checking out guesses. The purpose of the final phase is to put into practice what clients have learned in SCIT. One can view the phases of SCIT as moving from ‘cold’ social cognition in phase 1 (i.e. social cognition for non-personal events) to ‘hot’ social cognition in phase 3 (i.e. application of social cognitive skills to personally relevant situations) (Brenner et al. 1992). We have done this intentionally, so as to allow clients to learn social cognitive skills without become over-aroused or defensive.

To illustrate the effect of SCIT on paranoia and social cognition, we have provided some data from a recently completed outcome study on SCIT using forensic inpatients (Combs et al. 2007a). We present data for 13 persons with persecutory delusions as defined by scores on the Positive and Negative Syndrome Scale (PANSS) suspiciousness item of 5 (see Humphreys and Barrowclough, 2006). All of the participants were diagnosed with schizophrenia using the SCID.

Outcome measures included measures of social and emotion perception, ToM, and attributional style for ambiguous situations. We also examined scores from the engagement sub-scale for the Social Functioning Scale to reflect functioning on the treatment ward. As evident in Table 9.3, SCIT was associated with a significant reduction in level of paranoia (as measured by the PANSS), but also significant improvements across the social cognition and functioning measures. Thus, SCIT can be considered an emerging treatment (p. 194) for social cognitive deficits (Penn et al. 2007) and several randomized trials are being planned.

Table 9.3 Social Cognition and Interaction Training (SCIT) for inpatients with persecutory delusions (n = 13)





PANSS Suspiciousness Item

5.3 (0.48)

4.0 (1.1)*

Face Emotion Identification Test

11.3 (3.0)

15.5 (1.7)*

Social Perception Scale

12.1 (2.9)

24.5 (5.7)*

Hinting Task

13.9 (2.2)

19.0 (0.12)*

AIHQ Hostility Bias for Ambiguous Situations

1.9 (0.38)

1.2 (0.06)*

Social Functioning Scale: social engagement subscale

10.3 (1.7)

13.5 (1.0)*

Values are mean (SD).

Persecutory delusions defined by Positive and Negative Syndrome Scale (PANSS) suspiciousness scores of ≥5.

*P < 0.01 (dependent t-tests).

AIHQ, Ambiguous Intentions Hostility Questionnaire.

Conclusions and summary

We would like to emphasize several important points about social cognition in paranoia. First, the study of social cognition illuminates the manner in which these persons attend, process, and interpret their place in the social world, which is important in its own right. As discussed, there are three main types of social cognitive deficits (ToM, attributional style, and social/emotion perception) and a number of potential underlying causes (jumping to conclusions, need for closure, visual scanning deficits for faces). In addition, some of the biases are found in clinical samples, but not in sub-clinical ones (attributional style), while others are found across the continuum (ToM in high-risk samples and social/emotion perception in sub-clinical samples). It is possible that some of these deficits emerge at clinical levels of paranoia, but this remains to be consistently demonstrated. Thus, the pattern of social cognitive impairment may become more pervasive as symptoms become more severe, which is akin to the way an ordinary belief becomes delusional. Longitudinal studies of sub-clinical and clinical samples would help answer this question. Second, once an understanding of these processes is obtained, work can continue on remediating these deficits with the ultimate goal of improving social functioning (p. 195) and community outcome. It would be wise for treatment outcome studies to include measures of social cognition in addition to symptom measures.

Paranoia has both clinical and research implications and can be approached from a number of perspectives, We feel that a continued emphasis on social cognition is a key component in understanding this debilitating condition.


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