Fear of madness and persecutory delusions: Preliminary investigation of a new scale

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1 Psychosis Vol. 1, No. 1, February 2009, Fear of madness and persecutory delusions: Preliminary investigation of a new scale Michael Bassett a, David Sperlinger b and Daniel Freeman c * a Psychological Therapies, Kent & Medway NHS & Social Care Partnership Trust, Tunbridge Wells, Kent, UK; b Salomons, Canterbury Christ Church University, Southborough, Kent, UK; c Department of Psychology, Institute of Psychiatry, King s College London, London, UK Taylor RPSY_A_ sgm and Francis (Received 11 September 2008; final version received 7 October 2008) / Psychosis Original Taylor Dr. d.freeman@iop.kcl.ac.uk DanielFreeman & Article Francis (print)/ (online) There are anecdotal clinical reports of fear of madness occurring in individuals with psychosis, but the topic has not been a focus of empirical scrutiny. The first aim of the study was to investigate whether fear of madness is present in individuals with persecutory delusions. The second aim was to investigate whether fear of madness is linked to paranoia: it was hypothesised that fear of madness is an anxious worry associated with more distressing persecutory experience. Twenty-five individuals with persecutory delusions were compared with 25 nonclinical individuals. The participants completed the newly developed Worries About Mental Health questionnaire and assessments of paranoia, anxiety and worry. It was found that the individuals with delusions reported significantly higher levels of anxiety, worry and fear of madness than the non-clinical control group. Importantly, in the clinical group higher levels of fear of madness were associated with higher levels of anxiety, worry and persecutory delusion distress. In summary, fear of madness may be a common concern in people with persecutory delusions that is a contributory cause of paranoia distress. Sensitively addressing the content of ideas about madness during interventions may therefore help reduce patient distress about persecutory delusions. Keywords: anxiety; delusions; paranoia Introduction In the study of anxiety disorders, the notion that patients might have fears of madness is common. For example, Beck et al. (1985) notes that one attribution for physical symptoms in panic disorder is the thought of going crazy. Consequently, assessment measures such as the Agoraphobic Cognitions Questionnaire contain items asking about fear of going crazy (Chambless, Caputo, Bright, & Gallagher, 1984). Attention to fear of madness is a routine consideration in anxiety disorders. In marked contrast, fear of madness has received very limited investigation in psychotic disorders such as schizophrenia, despite the likelihood that for individuals with severe mental illness it is a pertinent concern. Fear of madness and psychosis A number of researchers of psychodynamic theory have focused on disintegration anxiety as central to the experience of people with schizophrenia. The work of Arieti *Corresponding author. D.Freeman@iop.kcl.ac.uk ISSN print/issn online 2009 Taylor & Francis DOI: /

2 40 M. Bassett et al. (1974) is referred to by McGorry et al. (1991), who state that the central fear is of a sense of dissolution or annihilation of the self. Similarly, Frosch (1983) discusses an underlying fear of self-disintegration and dissolution in people with psychosis. Cognitive therapists have also noted the importance of considering fear of madness during the treatment of schizophrenia. For instance, Gumley and Schwannauer (2006) emphasise how such fears can accelerate the onset of psychotic symptoms. Nelson (1997) provides an example of fear of madness in helping an individual develop a non-psychotic explanation of auditory hallucinations: I realised he was horrified at the thought that the voices might come from within himself because this would mean he was mad. From a traditional view of schizophrenia, it is intriguing that patients can have strong conviction in delusional ideas but still have fears of madness. However, recent studies indicate that almost half of individuals with delusions can consider the possibility that they might be mistaken about their belief (e.g. Freeman et al., 2004), and that insight in psychosis is complex, with multiple separate aspects (Amador & David, 2004; Sparrowhawk, 2009). In a recent theoretical model the role of anxiety and worry in persecutory experience is highlighted (Freeman, 2007; Freeman & Freeman, 2008; Freeman, Garety, Kuipers, Fowler, & Bebbington, 2002). Distressing fears of madness are noted as often being the only alternative explanation available for delusional experience. In studies undertaken to evaluate the model, it has been found that levels of anxiety and worry are raised in individuals with persecutory delusions and, moreover, that the presence of worry is associated with higher levels of delusion distress (Freeman & Garety 1999; Morrison & Wells, 2007; Startup, Freeman, & Garetty, 2007). Given this work, it is timely to consider fear of madness as a specific form of worry that may contribute to the distress of persecutory thoughts. There are a small number of directly relevant empirical studies. Freeman et al. (2004) asked 100 individuals whether there were alternative explanations for the events cited as evidence for their delusions: less than a quarter reported any alternative explanation. Fears of madness were not spontaneously reported, and it was noted that the assessment may need to explicitly ask about alternatives that patients find unthinkable, such as that I m mad. The only explicit assessment of fear of madness in psychosis has been concerned with the identification of prodromes. Herz (1985) developed the Early Signs Questionnaire (ESQ), an interviewer-administered questionnaire designed to assess prodromal features (reported in Birchwood, MacMillan, & Smith, 1994). The measure contains a single item enquiring about a fear of going crazy. Herz and Melville (1980) studied two groups of patients with psychosis using the ESQ. In the first sample (n = 46), 28.3% of patients reported a fear of going crazy. In the second sample (n = 99), 44.5% of patients reported the fear. In a UK study of 44 patients, Hirsch and Jolley (1989) found that 70% reported a fear of going crazy. Therefore it seems possible that fear of madness is reasonably common in people with psychosis. However, there has been no systematic study of its presence or investigation as to whether it affects psychotic experience. The current study In the current study, fear of madness is investigated in individuals with persecutory delusions. However, there was no existing measure of fear of madness. Therefore the self-report Worries About Mental Health questionnaire was developed to assess a wide range of threatening ideas about madness (e.g. from fears about being in a

3 Psychosis 41 trance-like inactive state to fears about running around out of control). We tested the following hypotheses. (1) Individuals with persecutory delusions will report higher levels of fear of madness relative to a non-clinical control group. In particular, individuals with delusions will report higher levels of distress associated with fear of madness relative to a control group. (2) Fear of madness will be associated with higher levels of worry and anxiety. (3) Fear of madness will be associated with more distressing persecutory experience (i.e. fear of madness and delusional experience are connected). Method A cross-sectional within and between groups design was used to test the hypotheses. Approval to undertake the study was obtained from the local NHS research ethics committee. Participants Twenty-five individuals with persecutory delusions were recruited from adult mental health services. Persecutory beliefs were defined by the criteria of Freeman and Garety (2000). Inclusion criteria were a current persecutory delusion and a case note diagnosis of schizophrenia, schizoaffective disorder, delusional disorder, bipolar affective disorder or depression with psychotic features. The delusion also had to be held with conviction, defined as a score of 2 or greater (at least fairly sure ) on the Psychotic Symptoms Rating Scale delusion conviction item (Haddock, McCarron, Tarrier, & Faragher, 1999). Exclusion criteria were a diagnosis of primary substance misuse, learning disability or organic syndrome, and inability to read or write. Fifty-three individuals were initially approached and 25 (47%) completed the research interview (see Figure 1). The non-clinical group comprised volunteers from a participant panel and non-clinical staff from a hospital. Figure 1. Flow diagram for clinical participant recruitment. The development of the Worries About Mental Health (WAMH) questionnaire The five content areas of the questionnaire were derived from the clinical experience of the authors and references in the literature to fear of madness (see Table 1). Early versions of the questionnaire were also discussed with colleagues with relevant research and clinical experience. The main content area concerned lay conceptions of the word madness. The other content areas represented cognitive, behavioural and social correlates of fears of madness: loss of self-control in relation to the mind (cognitive), loss of self-control of one s own actions (behavioural), inner/outer boundary loss and confusion, and negative reactions from other people. In short, some people simply fear going mad, others fear acting crazy, others fear being unable to function at all, while others fear being locked up. The questionnaire captures these different manifestations of fear of madness. Each item is rated for associated preoccupation, conviction and distress. Each of these three dimensions is rated on a five-point scale (0 to 4), with higher scores indicating greater endorsement. The study built in psychometric testing of the WAMH. Internal consistency was assessed by Cronbach s alpha, test retest reliability was assessed by having 12 clinical participants repeat the questionnaire within one week, and convergent validity was assessed by correlations with a measure of worry.

4 42 M. Bassett et al. Agreed to be approached by investigator n=53 Declined interview n=18 Agreed to interview n=35 Eligible for interview n=27 Not eligible = 8 (No delusion elicited = 6) (Unable to cooperate = 2) Did not complete interview n=2 Completed interview n=25 Figure 1. Flow diagram for clinical participant recruitment. Additional measures The Psychotic Symptom Rating Scale Delusions Scale (PSYRATS-DS) (Haddock et al., 1999). The PSYRATS structured interview was used to assess the current persecutory delusion. The scale rates the severity of the belief multi-dimensionally (i.e. there are separate items assessing delusion conviction, amount and duration of preoccupation, and amount and intensity of distress). Symptom severity dimensions are rated from 0 (low) to 4 (high). The subscale has good inter-rater reliability (ranging from.88 to in excess of.90). The measure is increasingly being used, including in a large randomised control trial of cognitive therapy for psychosis (Lewis et al., 2002). The Beck Anxiety Inventory (BAI) (Beck, Epstein, Brown, & Steer, 1988). The BAI is a questionnaire measure of anxiety symptoms. Participants rate the severity of symptoms on a scale of 0 to 3 (symptom not present to severe ). Higher scores indicate higher levels of anxiety. The Penn State Worry Questionnaire (PSWQ) (Meyer, Miller, Mezger, & Borkovec, 1990). The PSWQ assesses tendency to worry. Items are rated on a five-point scale with higher scores indicating the presence of greater levels of worry. The scale has good internal reliability and test retest reliability (Cronbach =.93, r =.92). The PSWQ has been used to identify individuals whose level of worry is equivalent to that of individuals with Generalized Anxiety Disorder (GAD). Behar, Alcaine, Zuellig, and Borkoven (2003) state a PSWQ score of at least 45 discriminated treatmentseeking GAD patients from non-anxious controls. Startup and Erikson (2005) also suggest a higher PSWQ score of at least 67.2 to reliably identify individuals with worry equivalent to clinical GAD.

5 Psychosis 43 Table 1. The item statements and five content areas for the Worries About Mental Health questionnaire. Worries About Mental Health questionnaire item statements Content area 1. I fear my thoughts are racing out of control 1 2. I worry other people will see me as being mad 5 3. I fear I will stop thinking altogether and my mind become empty 1 4. I worry my mind is falling apart 4 5. I fear I will somehow dissolve or disappear 3 6. I worry I will be locked up forever 5 7. I worry I will run around out of control because of my condition 2 8. I fear I will go mad 4 9. I am frightened that I cannot tell the difference between reality and my 3 imagination 10. I worry others see me as strange and reject me I worry about how others react to things I think or do I worry I will stop doing anything at all and become like someone in a 2 daze or trance 13. I fear I cannot trust my own thoughts I worry that feeling I have special powers means I am mentally 4 unbalanced 15. I fear I have a mental health problem I fear I will lose control and hurt someone else I worry that unusual experiences I have mean I am going crazy I worry about a feeling of being scattered all over the place I worry I will lose control and harm myself I am frightened my mind will not focus on things I need to think about 1 NB. Item statements shown in order of questionnaire presentation. Content area key: 1. Loss of self-control (cognitive). 2. Loss of self-control (behavioural). 3. Inner/outer boundary loss. 4. Madness. 5. Reactions of others. Analysis Analyses were conducted using SPSS 13.0 (2004). t-tests were used to examine differences between groups for Hypothesis 1. Spearman correlation coefficients were used to test Hypotheses 2 and 3 (very similar results were obtained with Pearson s r test). All tests of probability are reported as two-tailed. Results Demographic and clinical characteristics Fifty participants were recruited, comprising two groups: a clinical group with persecutory delusions and a non-clinical control group. The delusions of the clinical group are summarised in Table 2. Details of key demographic and clinical variables are presented in Table 3. It can be seen that the groups were matched for age, ethnicity

6 44 M. Bassett et al. Table 2. Participant Summary of the clinical participants persecutory delusions. Persecutory belief 1 People follow him in the street and plan to beat him up or murder him. 2 Other patients are trying to kill him. They are working through spirits to do this. 3 Cars and vans draw up outside his house. There are people who plan to take him away and torture or kill him. 4 Everyone is against her because of her boyfriend. They mouth hurtful things about her. 5 A stage hypnotist and a spirit are hypnotising him to cause him problems. 6 There is an ultra-sonic computer controlling his thoughts. It makes him angry and frustrated. 7 A demon sends radio signals to his neighbours to make them noisy and drive him out of the neighbourhood. 8 People at work set him up to have a mental breakdown and get him out of the job. 9 People he had an argument with put him in hospital by making him mentally ill to get revenge. 10 People put him in hospital for faking being mentally ill and put him on Sky TV to embarrass him. 11 People in the street say hurtful, unsettling things. He is a target. 12 He is threatened telepathically by people who do not recognise his leadership qualities. 13 His neighbours are trying to overthrow him. They say things that have caused physical damage to him. 14 She revealed her father-in-law is a spy so she has been sectioned and things could get dangerous now. 15 The management and union at his place of work taped him in his marital bedroom and made him paranoid and mentally ill. 16 People follow her in cars and helicopters to cause her stress. 17 His neighbours are paid to be against him. They make noise to keep him awake all night. 18 Her neighbours are against her. They insult her and threaten to run her over. 19 Her dead grandfather talks to her and says people want to kill her. She is frightened in public places. 20 A guy he used to work with has a group of people who plan to kill him. 21 He was used by a policeman who locked him into a telepathic state. It was mental torture. 22 Aliens from outer space are trying to poison him because he does not believe in the antichrist. 23 Gangsters are out to have him shot. They could pay a million pounds to locate him. 24 When he walks along the street people plan to punch him and think about killing him. It is worse at night. 25 An evil person is sticking pins in a voodoo doll of her. She can feel the pin pricks.

7 Table 3. Variable Clinical and demographic information for the participants. Delusion group n = 25 Psychosis 45 Control group n = 25 Gender: Male Female 6 6 Mean age (SD) (13.57) (12.28) Ethnicity: White Indian 1 0 Other 1 3 Clinical diagnosis: Schizophrenia 20 (80%) Schizoaffective disorder 1 (4%) Bipolar affective disorder 4 (16%) Patient status: Inpatient 14 (56%) Outpatient 11 (44%) Mean (SD) PSYRATS: Conviction 3.04 (0.84) Preoccupation with delusion 2.04 (0.98) Duration of preoccupation 2.48 (1.00) Amount of distress 2.69 (1.07) Intensity of distress 2.64 (1.04) Disruption to life 2.36 (1.08) and gender. The PSYRATS scores indicate that the delusions were held with high conviction, preoccupation and distress. Reliability of the Worries About Mental Health questionnaire The internal consistency of the WAMH questionnaire was excellent for all the dimensions. For the clinical group the Cronbach alphas for the preoccupation, conviction and distress scales were.94,.93 and.94, respectively. For the non-clinical participants the Cronbach alphas for the scales were.88,.82, and.96, respectively. In order to assess the test retest reliability of the WAMH questionnaire 12 clinical participants repeated the measure. Test retest reliability was assessed using Pearson s r and was very good (Clark-Carter 1999). The correlations between the two time points were high for the preoccupation scale, r =.91, p <.001, for the conviction scale, r =.80, p <.001, and for the distress scale r =.91, p <.001. The three dimensions showed very high levels of inter-correlations within both groups. Tests of the hypotheses Hypothesis 1 was that individuals with persecutory delusions will report higher levels of fear of madness relative to a non-clinical control group. It can be seen in Table 4

8 46 M. Bassett et al. Table 4. Scale Mean scores (and standard deviations) on the questionnaire scales. Persecutory delusion group Control group t (df) p-value 95% CI BAI (13.56) 6.08 (6.33) 5.29 (34.0) < PSWQ (12.70) (7.34) 2.74 (38.45) WAMH Preoccupation (15.03) 9.24 (6.27) 3.97 (32.1) < WAMH conviction (15.12) 7.96 (5.90) 4.99 (31.1) < WAMH distress (16.96) (16.36) 2.84 (48.0) that the group with persecutory delusions scored significantly higher than the control group on all three WAMH scales. Hypothesis 2 was that fear of madness will be associated with higher levels of worry and anxiety. In both groups higher levels of fear of madness were correlated with higher levels of anxiety and worry (see Tables 5 and 6). This effect was clearly statistically significant for the group with delusions. However, the effect was sometimes a non-significant trend for the control group. Hypothesis 3 was that fear of madness will be associated with more distressing persecutory experience. It can be seen in Table 5 that higher levels of fears of madness were significantly associated with higher levels of persecutory delusion distress. Discussion This is the first systematic study of fear of madness in people with psychosis. Fear of madness was hypothesised to be a particular concern for people with persecutory delusions because of the close connection of anxiety and worry to paranoid experience. Two key questions were asked: Is fear of madness commonly present in individuals with persecutory delusions? Does fear of madness relate to persecutory experience? A new measure had to be developed to study fear of madness. The three scales of the fear of madness measure had very good internal reliability for both the group with delusions and the control group. Test retest reliability was also very good for the measure, indicating that the questionnaire may be a robust measure of fear of madness. Convergent validity was indicated by the positive correlations between the questionnaire and measures of anxiety and general worry. During the course of the study all participants were asked whether the WAMH had missed out related fears, but no additional items were suggested. Importantly, it was found that many individuals with delusions did report fear of madness, showing preoccupation, conviction and distress related to such ideas. This result can be usefully compared to Freeman et al. (2004). This study used a structured interview to ask about alternative (non-delusional) explanations for psychotic experiences. Commenting on the absence of alternative explanations resembling madness concerns, Freeman and colleagues suggest that asking directly about the presence of fear of madness is needed to access such distressing alternative ideas. The current study demonstrated that with direct questioning fear of madness is reported. Moreover, fear of madness may be a form of worry: there were significant associations between the WAMH and worry assessments. In future studies it would be intriguing

9 Psychosis 47 Table 5. Correlations of delusional experience, fear of madness, anxiety and worry in the clinical group. PSYRATS WAMH Preocc. amount Preocc. duration Conviction Distress amount Distress intensity Preocc. Convic. Distress WAMH Preoccupation.143 p =.495 WAMH Conviction.147 p =.484 WAMH Distress.133 p =.526 BAI.226 p =.278 PSWQ.229 p = p = * p = * p = * p = ** p = p = p = p = p = p = ** p = ** p = * p = * p = ** p = * p = p = * p = p =.034*.369 p = ** p < ** p < * p = ** p = ** p < p = ** p = p = ** p =.001 ** Correlation is significant at the 0.01 level; * correlation is significant at the 0.05 level.

10 48 M. Bassett et al. Table 6. Correlations of fear of madness, anxiety and worry in the non-clinical control group. BAI.565** p =.003 PSWQ.408* p =.043 WAMH preocc. WAMH conviction WAMH distress.525** p = p = 139 * Correlation is significant at the 0.05 level; ** correlation is significant at the 0.01 level..363 p = p =.229 to compare the levels of fear of madness in individuals with persecutory delusions both with other delusion subtypes and with other clinical groups such as panic disorder. It would also be worthwhile to investigate the relationship of fear of madness to depression and suicidal ideation. Fears of madness may be present in people with psychosis, but is it related to delusion experience? It was found that higher levels of fear of madness were associated with higher levels of delusion distress. Fear of madness may contribute to the distress of persecutory experience. The study also replicated the association of general measures of worry with delusion distress (Freeman & Garety, 1999; Startup et al., 2007). There is now a growing literature indicating the importance of worry to persecutory experience (Freeman et al., 2008). None the less, there are obvious limitations with the current study. For example, the cross-sectional design meant that causal relationships between fear of madness and persecutory delusions could not be determined. The sample size was also small. However, the study does raise intriguing implications for clinical practice. A primary technique in cognitive therapy for persecutory delusions is to help individuals evaluate their beliefs with a view to considering more adaptive alternatives (Freeman, Freeman, & Garety, 2006). The results of the current study highlight the possibility that if a delusion is challenged too prematurely then a person may only be able to turn to distressing ideas of madness. Evaluating delusional explanations needs to be carried out in the context of an alternative explanation that the patient finds acceptable. Fear of madness may need to be a more explicit treatment focus in cognitive behaviour therapy for persecutory delusions. This may help to reduce distress and provide a better context for the individual to consider adaptive alternative explanations of psychotic experience. Acknowledgements Michael Bassett undertook this study while completing a Doctorate in Clinical Psychology at Salomons, Canterbury Christ Church University, Kent, UK. Daniel Freeman is supported by a Wellcome Trust Fellowship. References Amador, X., & David, A. (Eds.) (2004). Insight and psychosis. Oxford: Oxford University Press. Arieti, S. (1974). Interpretation of schizophrenia (2nd ed.). London: Crosby, Lockwood, Staples. Beck, A.T., Emery, G., & Greenberg, R.L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.

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