Murphy Philip, Bentall Richard P, Freeman Daniel, O'Rourke Suzanne, Hutton Paul
School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK; Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, UK.
Department of Psychology, University of Sheffield, Sheffield, UK.
Lancet Psychiatry. 2018 Nov;5(11):913-929. doi: 10.1016/S2215-0366(18)30339-0. Epub 2018 Oct 9.
An influential psychological model of persecutory delusions proposed that they are caused by a bias towards holding others responsible for negative events (an externalising attributional bias), preventing the individual from becoming aware of underlying low self-esteem. An early version of the model predicted self-esteem would, therefore, be preserved in people with these delusions, but a later version suggested it would be unstable, and that there would be a discrepancy between explicit and implicit self-esteem, with the latter being lower. We did a comprehensive meta-analytical test of the key predictions of this model and assessed the quality of evidence.
We searched PubMed from Jan 1, 1994, to July 31, 2018, and collated systematic reviews of the defensive model's predictions in relation to persecutory delusions. We also searched PsycINFO, MEDLINE, Embase, and Web of Science for articles published from Jan 1, 2012, to Sept 10, 2016. Cross-sectional data from case-control, longitudinal, or experimental studies that examined self-esteem or the externalising attributional bias in individuals diagnosed as having schizophrenia-spectrum disorder were eligible for meta-analyses of group differences if at least 50% of participants with psychosis also had current persecutory delusions. Uncontrolled and longitudinal studies were included in meta-analyses of correlations and self-esteem instability, respectively. Study and outcome quality were assessed with the Agency for Healthcare Research and Quality assessment tool, and a modified version of Grading of Recommendations Assessment, Development and Evaluation, respectively. The study protocol is registered with PROSPERO, number CRD42016032782.
We screened 3053 records, examined 104 full-text reports, and included 64 eligible studies. Consistent with the predictions of both versions of the model, paranoia severity in psychosis was positively correlated with the degree of externalising attributional bias (21 studies involving 1128 individuals; r=0·18, 95% CI 0·08 to 0·27, with moderate quality evidence). People with persecutory delusions also had a greater externalising attributional bias than non-clinical individuals (27 studies involving 1442 individuals; g=0·48, 95% CI 0·23 to 0·73) and depressed individuals (ten studies involving 421 individuals; g=1·06, 0·48 to 1·63), and people with psychosis without persecutory delusions (11 studies involving 480 individuals; g=0·40, 0·12 to 0·68), all based on moderate quality evidence. Contrary to the predictions in the early version of the model, paranoia severity in psychosis was negatively correlated with explicit self-esteem (23 studies involving 1866 individuals; r=-0·26, 95% CI -0·34 to -0·17, with high quality evidence). People with persecutory delusions also had lower explicit self-esteem than non-clinical individuals (22 studies involving 1256 individuals; g=-0·88, 95% CI -1·10 to -0·66, with high quality evidence) and explicit self-esteem similarly low to that in people with psychosis without persecutory delusions (11 studies involving 644 individuals; g=-0·26, -0·54 to 0·02, with moderate quality evidence). Consistent with the predictions in the later version of the model, self-esteem instability was positively correlated with paranoia severity in psychosis (four studies involving 508 individuals; r=0·23, 95% CI 0·11-0·34, with high quality evidence), and people with persecutory delusions had a greater discrepancy between their implicit and explicit self-esteem than depressed individuals (seven studies involving 398 individuals; g=0·61, 95% CI 0·37 to 0·85, with moderate quality evidence). They had higher explicit self-esteem than depressed individuals (13 studies involving 647 individuals; g=0·89, 95% CI 0·51 to 1·28, with moderate quality evidence), but similarly low implicit self-esteem (seven studies involving 398 individuals; g=-0·19, -0·45 to 0·07, with low quality evidence). In contrast to the later predictions, people with persecutory delusions did not have a greater self-esteem discrepancy than non-clinical individuals (ten studies involving 592 individuals; g=-0·17, 95% CI -0·45 to 0·12), although the evidence was very low quality. People with psychosis with or without persecutory delusions did not differ for implicit self-esteem (four studies involving 167 individuals; g=-0·24, 95% CI -0·77 to 0·30, with low quality evidence) or self-esteem discrepancies (four studies involving 165 individuals; g=0·17, -0·19 to 0·53, with moderate quality evidence).
The predictions that self-esteem would be preserved in people with persecutory delusions in the early version of the paranoia as defence model and that implicit-explicit self-esteem discrepancy would be greater in people with persecutory delusions than in non-clinical individuals and people with psychosis without persecutory delusions in the later version of the model were not supported. By contrast, the later version correctly predicted that people with persecutory delusions have a greater self-esteem discrepancy than people with depression and a greater externalising attributional bias than all control groups, and that both this bias and self-esteem instability are associated with increased paranoia severity. Nevertheless, the reviewed data had limitations. Experimental studies, which might include interventionist-causal trials, are needed.
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一种有影响力的被害妄想心理模型提出，被害妄想是由倾向于认为他人应对负面事件负责（外化归因偏差）所致，这使个体无法意识到潜在的低自尊。该模型的早期版本预测，因此，有这些妄想的人的自尊会得到维持，但后期版本表明自尊会不稳定，并且外显自尊和内隐自尊之间会存在差异，后者更低。我们对该模型的关键预测进行了全面的荟萃分析检验，并评估了证据质量。
我们检索了1994年1月1日至2018年7月31日的PubMed，并整理了关于防御模型对被害妄想预测的系统评价。我们还检索了PsycINFO、MEDLINE、Embase和科学网，查找2012年1月1日至2016年9月10日发表的文章。如果至少50%的精神病患者同时患有当前的被害妄想，那么来自病例对照、纵向或实验研究的横断面数据，这些研究考察了被诊断为患有精神分裂症谱系障碍的个体的自尊或外化归因偏差，就有资格进行组间差异的荟萃分析。无对照研究和纵向研究分别纳入相关性和自尊稳定性的荟萃分析。研究和结果质量分别使用医疗保健研究与质量局评估工具和推荐分级评估、制定与评价的修改版进行评估。研究方案已在PROSPERO注册，编号为CRD42016032782。
我们筛选了3053条记录，审查了104篇全文报告，并纳入了64项符合条件的研究。与该模型两个版本的预测一致，精神病中的偏执严重程度与外化归因偏差程度呈正相关（21项研究，涉及1128名个体；r = 0·18，95%CI 0·08至0·27，证据质量中等）。有被害妄想的人比非临床个体（27项研究，涉及1442名个体；g = 0·48，95%CI 0·23至0·73）和抑郁症患者（10项研究，涉及421名个体；g = 1·06，0·48至1·63）以及没有被害妄想的精神病患者（11项研究，涉及480名个体；g = 0·40，0·12至0·68）有更大的外化归因偏差，所有这些均基于中等质量证据。与该模型早期版本的预测相反，精神病中的偏执严重程度与外显自尊呈负相关（23项研究，涉及1866名个体；r = -0·26，95%CI -0·34至-0·17，证据质量高）。有被害妄想的人比非临床个体（22项研究，涉及1256名个体；g = -0·88，95%CI -1·10至-0·66，证据质量高）外显自尊更低，且与没有被害妄想的精神病患者的外显自尊同样低（11项研究，涉及644名个体；g = -0·26，-0·54至0·02，证据质量中等）。与该模型后期版本的预测一致，自尊稳定性与精神病中的偏执严重程度呈正相关（4项研究，涉及508名个体；r = 0·23，95%CI 0·11 - 0·34，证据质量高），并且有被害妄想的人内隐自尊与外显自尊之间的差异比抑郁症患者更大（七项研究，涉及398名个体；g = 0·61，95%CI 0·37至0·85，证据质量中等）。他们比抑郁症患者有更高的外显自尊（13项研究，涉及647名个体；g = 0·89，95%CI 0·51至1·28，证据质量中等），但内隐自尊同样低（七项研究，涉及398名个体；g = -0·19，-0·45至0·07，证据质量低）。与后期预测相反，有被害妄想的人比非临床个体的自尊差异没有更大（10项研究，涉及592名个体；g = -0·17，95%CI -0·45至0·12），尽管证据质量非常低。有或没有被害妄想的精神病患者在内隐自尊（4项研究，涉及167名个体；g = -0·24，95%CI -0·77至0·30，证据质量低）或自尊差异（4项研究，涉及165名个体；g = 0·17，-0·19至0·53，证据质量中等）方面没有差异。
偏执作为防御模型早期版本中关于有被害妄想的人的自尊会得到维持，以及该模型后期版本中关于有被害妄想的人比非临床个体和没有被害妄想的精神病患者的内隐 - 外显自尊差异会更大的预测未得到支持。相比之下，后期版本正确预测了有被害妄想的人比抑郁症患者有更大的自尊差异，比所有对照组有更大的外化归因偏差，并且这种偏差和自尊不稳定性都与偏执严重程度增加相关。然而，所审查的数据存在局限性。需要进行实验研究，可能包括干预性因果试验。
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