Delusions in First-Episode Psychosis: Principal Component

Analysis of Twelve Types of Delusions and Demographic and

Clinical Correlates of Resulting Domains

a,b c b,d
Enrico Paolini , Patrizia Moretti , and Michael T. Compton

aSchool of Psychiatry, University of Perugia, Perugia, PG, Italy

bLenox Hill Hospital, Department of Psychiatry, New York, NY, USA

cDepartment of Medicine, Division of Psychiatry, Clinical Psychology and Psychiatric

Rehabilitation, University of Perugia, Perugia, PG, Italy

dHofstra Northwell School of Medicine, Department of Psychiatry, Hempstead, NY, USA

Abstract
Although delusions represent one of the core symptoms of psychotic disorders, it is
remarkable that few studies have investigated distinct delusional themes. We analyzed
data from a large sample of first-episode psychosis patients (n=245) to understand
relations between delusion types and demographic and clinical correlates. First, we
conducted a principal component analysis (PCA) of the 12 delusion items within the
Scale for the Assessment of Positive Symptoms (SAPS). Then, using the domains
derived via PCA, we tested a priori and exploratory hypotheses related to delusional
content. PCA revealed five distinct components: Delusions of Influence,
Grandiose/Religious Delusions, Paranoid Delusions, Negative Affect Delusions
(jealousy, and sin or guilt), and Somatic Delusions. The most prevalent type of delusion
was Paranoid Delusions, and such delusions were more common at older ages at onset
of psychosis. The level of Delusions of Influence was correlated with the severity of
hallucinations and negative symptoms. We ascertained a general relationship between
different childhood adversities and delusional themes, and a specific relationship
between Somatic Delusions and childhood neglect. Moreover, we found higher scores
on Delusions of Influence and Negative Affect Delusions among cannabis and
stimulant users. Our results support considering delusions as varied experiences with
varying prevalences and correlates.

Keywords

Childhood adversities; Delusions; Depression; Drugs of abuse; Hallucinations;

Paranoia; Persecutory delusions
 *Corresponding author: Enrico Paolini, M.D., School of Psychiatry, University of Perugia, Piazzale Lucio Severi 1, 06132,

S. Andrea delle Fratte (Pg), Italy. Tel. (+39) 075/5783194. [email protected]. Publisher's Disclaimer: This is
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Psychiatry Res. Author manuscript; available in PMC 2017
September 30.

Published in final edited form

as:
Psychiatry Res. 2016 September 30; 243: 5–13.
doi:10.1016/j.psychres.2016.06.002.
Paolini et al. Page 2

1. Introduction

Despite the growing interest in first-episode psychosis, a paucity of research on

delusions is noticeable in this area of study (Compton et al., 2012; Rajapakse et
al., 2011). It is remarkable how, at the present time, although delusions represent
one of the core symptoms of schizophrenia and related psychotic disorders, it
remains unclear as to whether or not these phenomena should be considered
unitary or diversified (Sass and Byrom, 2015), and few studies have investigated
distinct delusional themes, in particular in first-episode psychosis samples.

Moreover, very few studies have focused on possible underlying dimensions of

different delusional themes. There has been some interest in detecting the factor
structure of psychotic symptoms generally (Emsley et al., 2003; Peralta et al.,
2013), and one of the advantages of this analytic approach (i.e., factor analysis) is
that it allows for the reduction of heterogeneity in data from a measurement
instrument by identifying a group of coherent dimensions. Across different types of
available tools measuring delusions, the Scale for the Assessment of Positive
Symptoms (SAPS; Andreasen, 1984) has been extensively utilized, and several
studies have performed factor analyses in order to identify the latent dimensions
amongst its items (e.g., John et al., 2003; Minas et al., 1994; Peralta and Cuesta,
1999; Toomey et al., 1997). Those studies conducted an item-level factor analysis
of SAPS items, and they included both delusions and non-delusion items.
Conversely, only three studies (Ellersgaard et al., 2014; Kimhy et al., 2005;
Vázquez-Barquero et al., 1996) conducted a factor analysis specifically using only
the 12 SAPS delusion items. They found three different solutions, respectively
composed of five, three, and four factors, meaning that their findings concurred
only partially, which could be related to the characteristics of the study samples.
 Vázquez-Barquero et al. (1996) studied first-episode schizophrenia patients
(without severe psychotic symptoms) from a rural community in Cantabria, Spain
(n=86; range = 15–54 years). Participants (n=411; range = 18–45 years) included
in the study of Ellersgaard et al. (2014) were inpatients and outpatients affected by
schizophrenia-spectrum disorders (i.e., not only schizophrenia) coming from the
two most populous cities in Denmark (i.e., Copenhagen and Aarhus). Lastly, the
study of Kimhy et al. (2005) enrolled antipsychotic-free (for at least 14 days)
inpatients (n=83; range = 18–60 years) with diagnoses of
schizophrenia/schizoaffective disorder (i.e., not a first-episode psychosis sample)
in New York.

Several studies have investigated the prevalence of distinct delusional themes and
their correlations with demographic or clinical variables (e.g., Freeman's extensive
work on persecutory delusions (e.g., Freeman, 2007; Freeman and Garety, 2014),
Startup's work on delusions of reference (e.g., Startup et al., 2009; Startup and
Startup, 2005), Langdon and Coltheart's work on bizarre delusions (e.g., Langdon
and Coltheart, 2000)). As reported in first-episode psychosis studies by Kim et al.
(2011) and Rajapakse et al. (2011), persecutory delusions are the most prevalent
type of delusions in this patient population. With respect to sociodemographic
variables, first-episode psychosis studies have reported evidence showing a
relationship between persecutory delusions and older age at onset (Galdos and
van Os, 1995; Häfner et al., 1993), while there is not strong evidence for a
relationship between persecutory delusions and sex. According to first-episode
psychosis studies by Birchwood et

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al., 2005 and Drake et al., 2004, as well as findings among chronic patients
described by Hartley et al., 2013, persecutory delusions are positively correlated
with depression. On the other hand, such delusions are negatively associated with
grandiose delusions, as reported by Garety et al., 2013 (though this study also did
not involve first-episode psychosis patients in particular). Furthermore, persecutory
delusions have been proven to be related to cannabis use in the general population
(Freeman et al., 2011; Freeman et al., 2013).

In this study, we made use of in-depth clinical research data from a large sample of
hospitalized first-episode psychosis patients to test hypotheses related to
delusional thought content. We had three objectives. The first was to conduct a
principal component analysis (PCA) of the 12 delusion items of the SAPS. Second,
we tested three a priori hypotheses. Third, we examined three exploratory
research questions. In testing a priori and exploratory hypotheses, we planned to
use the extracted domains from the PCA.

With regard to PCA, given differences in the socio-demographic characteristics of

prior studies (Ellersgaard et al., 2014; Kimhy et al., 2005; Vázquez-Barquero et al.,
 1996) and the limited literature available, such a factor analysis was warranted in
our sample. Specifically, factor analysis of the 12 delusion items has never been
performed among a hospitalized, predominantly African American, male, low
income, and socially disadvantaged sample. Thus, rather than relying on results
from different first-episode samples from other countries and settings, we first
wanted to examine the factor structure in our unique sample.

Similar purposes guided our first a priori hypothesis; we investigated the prevalence
of delusions, and in particular the prevalence of different delusional themes. We
hypothesized that persecutory delusions would be the most prevalent type.
Although the finding of persecutory delusions as the most prevalent type of
delusions has been replicated, we wanted to prove this finding in our unique
sample. Based on the limited prior literature, we second hypothesized that patients
with persecutory delusions would be older in age at onset, but that there would be
no particular relationships with sex. Finally, we also had the a priori hypothesis that
depression would be linked positively with persecutory delusions and negatively
with grandiose delusions.

After testing our hypotheses, we carried out exploratory analyses again based on
limited previous research not specifically involving first-episode psychosis patients.
First, we explored the relationship between the total scores on the extracted
delusion domains and the SAPS hallucinations total score, as well as the Scale for
the Assessment of Negative Symptoms (SANS; Andreasen, 1983) total score.
Second, we explored whether greater childhood adversity would be associated
with a greater severity of one or more of the various types of delusional thought
content. Third, based on the aforementioned Freeman et al. studies (2011 (2013),
we explored how cannabis use is related to delusional content (i.e., persecutory
delusions, as well as the other types of delusions included in our sample), and also
how the use of other drugs is associated with delusional content.

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2. Method

2.1. Participants and Procedure

Patients were selected using a preexisting database of 247 consecutively admitted

patients with first-episode psychosis (see Birnbaun et al., 2015; Fresan et al., 2015;
Kelley et al., 2015 for detailed information regarding recruitment sites, eligibility
criteria, and assessment procedures). All patients met the following inclusion
criteria: (1) were English-speaking, (2) were within the age range of 18–40 years,
 (3) did not have known or suspected mental retardation, (4) had a Mini-Mental
State Examination (Folstein et al., 1975, Cockrell and Folstein, 1988) score of ≥24,
(5) did not have a significant medical condition compromising ability to participate,
and (6) were able to provide informed consent. All patients were considered
“first-episode” in that they had never been hospitalized for psychosis prior to three
months before their index hospitalization (for most, this was the very first
hospitalization) and they had received less than three months of treatment with an
antipsychotic (for most, they had never been treated with an antipsychotic prior to
index hospitalization). Having full data on the SAPS was the criterion for extraction
from the previous database and inclusion in the present one; only two patients
were excluded for missing values (resulting in n=245).

2.2. Assessments

Patients were administered an extensive battery to evaluate diverse clinical

variables, psychopathology, and diagnosis. The SAPS was used to assess
hallucinations, delusions, bizarre behavior, and positive formal thought disorder
(Andreasen, 1984). The SANS was used to assess affective flattening or blunting,
alogia, avolition-apathy, anhedonia-asociality, and attention (Andreasen, 1983). The
SAPS has 34 items, including the 12 types of delusions, while the SANS includes
25 items. Items on both scales are rated 0–5 (“none,” “questionable,” “mild,”
“moderate,” “marked,” “severe”). Test-retest reliability and construct validity have
been demonstrated for both instruments previously (Rogers, 2001) and in the
current sample (see Birnbaum et al., 2015). Moreover, the Positive and Negative
Syndrome Scale (PANSS) was used as global symptom severity measure (Kay et
al., 1987). The PANSS depression item was used as a measure of depression
severity, as it has been shown to give a valid approximation of depression in
patients with schizophrenia (El Yazaji et al., 2002). Diagnoses of psychotic
disorders and substance-related disorders were assessed using the Structured
Clinical Interview for DSM-IV Axis I Disorders (SCID; First et al., 1998).

Childhood adversity was assessed using seven instruments: the Childhood

Trauma Questionnaire–Short Form (CTQ-SF; Bernstein et al., 2003), Trauma
Experiences Checklist (TEC; Cristofaro et al., 2013), Parental Nurturance
(Barnes and Windle, 1987), Parental Harsh Discipline (Ge et al., 1994; Mrug et al.,
2008), Violence Exposure (Mrug et al., 2008), Friends' Delinquent Behavior
(Mrug et al., 2012), and School Connectedness Scale (Sieving et al., 2001). In the
present analysis, in order to reduce the subscales of these measures of childhood
adversity to their latent constructs, we relied on factors derived from a previously
conducted factor analysis in this sample (McGuire et al., in progress). The factors
from the resulting model were named Environmental Violence (which included
Violence Exposure at

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 school, Violence Exposure in the neighborhood, Friends' Delinquent Behavior,
TEC – Violence, Death, and Legal Involvement; i.e., scales pertaining to extreme
risk, danger, and violence exposure), Interpersonal Abuse (including CTQ –
physical abuse, CTQ – emotional abuse, CTQ – sexual abuse, TEC –
Interpersonal Abuse and Family Stress, Parental Harsh Discipline, Violence
Exposure at home; i.e., scales tapping abuse and harsh conditions in the family or
at home), and Neglect (which included CTQ – emotional neglect, Parental
Nurturance, School Connectedness, CTQ – physical neglect; i.e., scales referring
to physical/emotional neglect and lack of connectedness or support at home and
school).

2.3. Data Analysis

Descriptive statistics and distributional properties of all variables of interest were

first examined. Thereafter, the 12 delusion items of the SAPS were subjected to a
Principal Component Analysis (PCA) in order to identify any latent or underlying
dimensions within the items. The analysis had exploratory (rather than
confirmatory) objectives.

Prior to performing PCA, we verified the applicability of the data for the analysis.
The case- to-variable ratio was 20.4 (which well exceeds the recommended
minimum of 10; Nunnally, 1978), indicating adequacy of the sample size. The
Kaiser-Meyer-Olkin sampling adequacy measure was 0.709 (the recommended
value being ≥0.6), and the Bartlett's Test of Sphericity was significant, both of which
supported the factorability of the correlation matrix. Eigenvalues >1.0 were chosen
as the criterion for factor extraction. Components were rotated using Varimax
rotation. A minimum factor loading of 0.3 was deemed to indicate a meaningful
loading and for including each item on the respective component.

Then, in reference to the hypotheses and exploratory analyses previously

described, we analyzed the relationship between each extracted delusion domain
identified via PCA and sociodemographic and clinical variables. Notably, in stating
our hypotheses above, we referred to a specific type of delusions (e.g., persecutory
delusions), though in testing the hypothesis we used the PCA-derived domain
containing that specific type of delusions (i.e., even if it is not the only type of
delusion loading on that domain). All hypothesis tests and exploratory analyses
were carried out using chi-square tests, Mann-Whitney U tests, analysis of variance
(ANOVA), and Pearson or Spearman correlations, as appropriate, using IBM SPSS
Statistics version 21.0.

3. Results

3.1. Sociodemographic Analysis

Sociodemographic features, as well as diagnoses of psychotic disorders and

substance use disorders, are summarized in Table 1. Of the 245 subjects, 182
 were men and 63 were women. The mean age was 23.9±4.7 years (range =
18–39 years). Regarding race, the majority of patients were African American
(86.1%). Schizophrenia was the most common SCID-based diagnosis (57.6%). In
Table 2, we report the frequency of each SAPS delusion item. A score of ≥2 (mild)
was chosen as requisite for including a patient in the respective delusional theme
category. Remarkably, a total of 235 patients (95.9%) manifested at least one type
of delusion. The three most common delusion items with a ≥2 (mild) score were:

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persecutory (182, 74.3%), reference (165, 67.4%), and grandiose (113, 46.2%).
The three least common were somatic (44, 18.0%), sin or guilt (32, 13.0%), and
jealousy (25, 10.2%).

3.2. Principal Component Analysis

PCA revealed five distinct components with eigenvalues >1, explaining 62.4% of
the total variance. As shown in Table 2, the delusions of being controlled, mind
reading, thought broadcasting, thought insertion, and thought withdrawal loaded
significantly on factor 1, hereafter referred to as Delusions of Influence, in line with
Kimhy et al. (2005). Grandiose and religious delusions comprised factor 2,
hereafter called Grandiose/Religious Delusions. Persecutory delusion as well as
delusions of reference made up factor 3; Startup and Startup (2005) already
showed an association between persecutory delusions and one of the two form of
delusions of reference they recognize (i.e., referential delusions of observation).
This factor is subsequently referred to as Paranoid Delusions. Delusions of
jealousy and of sin or guilt loaded onto factor 4, subsequently named Negative
Affect Delusions. Only the somatic delusion item loaded significantly as factor 5
and we consequently referred to it as Somatic Delusions. Notably, delusions of
mind reading loaded on factor 2 (0.51) in addition to factor 1 (0.48). However, in
considering the previous study of Ellersgaard et al. (2014), and taking into
consideration the clinical overlap between delusions of mind reading and delusions
of being controlled, thought broadcasting, thought insertion, and thought
withdrawal, (which all loaded onto factor 1), we decided to include delusions of
mind reading in factor 1 rather than factor 2. The SAPS scores composing the five
extracted delusion factors are summarized in Table 3. A visual comparison of our
derived domains, in relation to the results of Ellersgaard et al. (2014), Kimhy et al.
(2005) and Vázquez- Barquero et al. (1996) is given in Figure 1.

By categorizing patients on the basis of the highest standardized domain scores

(minimum score value ≥2), it was possible to identify a predominant delusional
theme for 181 participants (73.9%): 129 (71.3%) presented with Paranoid
Delusions as the predominant theme, 21 (11.6%) with Somatic Delusions, 20
(11.0%) with Grandiose/Religious Delusions, and 11 (6.1%) with Delusions of
 Influence. None of them presented Negative Affect Delusions as predominant
theme. Otherwise, for 64 patients (26.1%), it was not possible to identify a
predominant delusional theme (i.e., no scores ≥2 in any of the domains or equal
scores in two or more domains).

3.3. Testing of A Priori Hypotheses

As hypothesized, we found a significant difference between the percentages of

2
different types of delusions (χ =208.02; df=3; p<0.001). Also as hypothesized,
no significant relationship was found between gender and the presence of
Paranoid Delusions (131 (72.0%) of males and 46 (73.0%) of females;
2
χ =0.03; df=1; p=0.874).

With regard to our hypothesis pertaining to age, our data supported the expectation
that patients with persecutory delusions would be older in age at onset: 22.1±5.2
(median of 21.6) among the 167 patients with Paranoid Delusions, compared to
20.4±4.0 (median of 20.6) among the 55 patients without Paranoid Delusions
(Mann-Whitney U-test p=0.010). When age by sex was checked, no significant
interaction was found with respect to Paranoid

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Delusions (F=0.138; df=1, 217; p=0.711). Moreover, the severity of Paranoid

Delusions was correlated, though modestly, with age at onset (ρ=0.136; p=0.043).
Interestingly, when we performed the same correlation with age at hospitalization
instead of age at onset (as another approach to the above Mann-Whitney U test),
the magnitude was higher (ρ=0.211; p=0.001). Redoing this Spearman correlation
in two subsamples based on a median split by age (to determine whether the
correlation was more apparent among younger or older patients), revealed a
correlation of ρ=0.046 (p=0.617) in those 18–22 years of age (n=119), and ρ=0.104
(p=0.244) in those 23–40 years of age (n=128).

With regard to our hypothesis pertaining to the correlations—positive and

negative, respectively—between depression and persecutory delusions and
grandiose delusions, our results did not confirm our expectations: no significant
correlation was observed between depression and Paranoid Delusions
(ρ=0.042; p=0.516) or between depression and Grandiose/Religious Delusions
(ρ= -0.121; p=0.059).

3.4. Exploratory Analyses

Results of correlation analyses pertaining to the delusion domains and SAPS

hallucinations scale, SANS total score, and the three childhood adversity factors
 are summarized in Table 4. The magnitude of correlations between hallucinations
and Delusions of Influence (ρ=0.485; p <0.001) was more than double the
magnitude of correlation showed by any other delusion domain. Delusions of
Influence was the only domain correlated with negative symptoms (ρ=0.214;
p=0.001). Environmental Violence and Interpersonal Abuse correlated significantly
with all delusional themes revealed by the PCA (except for the nonsignificant
relationship between Environmental Violence and Somatic Delusions); though the
degree of correlations was overall modest. Somatic Delusions was the only
domain showing a correlation with Neglect.

With regard to the relationship between delusional themes and substances of

abuse, we grouped the abuse/dependence of each substance into three categories:
no abuse/dependence, current or lifetime abuse, and current or lifetime
dependence. Moreover, we combined the two groups of cocaine abuse/dependence
and other substance (e.g., ecstasy, methamphetamine, PCP) abuse/dependence.
No statistically significant difference was found in scores on each delusion domain
between subjects with no abuse/dependence (n=164), alcohol abuse (n=23), and
alcohol dependence (n=45); all five F values were <1.50, all p>0.22). With regard to
cannabis use (no abuse/dependence n=84, abuse n=43, dependence n=104), a
statistically significant difference was found in scores on Delusions of Influence (no
abuse/dependence: 0.8±0.9, current or lifetime abuse: 1.2±1.0, current or lifetime
dependence: 1.4±1.1; F=8.505, df=2, 228, p<0.001) and on Negative Affect
Delusions (no abuse/dependence: 0.3±0.6, current or lifetime abuse: 0.4±0.7,
current or lifetime dependence: 0.5±0.7; F=3.333, df=2, 228, p=0.037). On the other
hand, cannabis use category was not associated with severity of
Grandiose/Religious Delusions (F=2.066, df=2, 228, p=0.129), Paranoid
Delusions (F=1.820, df=2, 228, p=0.164) or Somatic Delusions (F=1.929, df=2,
228, p=0.148). Similarly, regarding cocaine/other substance use (no abuse/
dependence n=191, abuse n=16, dependence n=27), a statistically significant
difference was found in scores on Delusions of Influence (no abuse/dependence:
1.0±1.0, current or lifetime

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abuse: 1.7±1.1, current or lifetime dependence: 1.3±1.1; F=3.262, df=2, 231,

p=0.040) and on Negative Affect Delusions (no abuse/dependence: 0.3±0.5,
current or lifetime abuse: 0.4±0.6, current or lifetime dependence: 0.7±0.9;
F=3.404, df=2, 231, p=0.035). The cocaine/other drug use category was not
significantly related to severity of Grandiose/ Religious Delusions (F=0.497,
df=2, 231, p=0.609), Paranoid Delusions (F=0.168, df=2, 231, p=0.846), or
Somatic Delusions (F=0.668, df=2, 231, p=0.514).
4. Discussion

To the best of our knowledge, only two studies have investigated dimensions
underling the 12 SAPS delusion items by conducting an item-level PCA in a
first-episode psychosis sample (Ellersgaard et al., 2014; Vázquez-Barquero et al.,
1996). Our PCA findings replicate in toto the result of Ellersgaard et al. (2014): the
same items grouped into the same five factors. In Vázquez-Barquero et al. (1996),
a PCA of SAPS delusion items revealed four factors. Delusions of being controlled,
thought broadcasting, thought insertion, and thought withdrawal loaded on the first
factor; grandiose delusions, religious delusions, and delusions of sin or guilt loaded
on the second; delusions of mind reading and delusions of reference loaded on the
third; and delusions of jealousy loaded alone on the fourth factor. One additional
PCA has been conducted, though not in a first-episode psychosis sample (Kimhy et
al., 2005), revealing three factors. Factor 1 (Delusions of Influence) consisted of the
same delusion items as our Delusions of Influence. Factor 2 (Delusions of
Self-Significance) consisted of delusions of grandeur, reference, guilt/sin, and
religious delusions. Factor 3 (Delusions of Persecution) consisted only of
persecutory delusions. Referring to the abovementioned studies, delusion of being
controlled, mind reading, thought insertion, thought broadcasting, and thought
withdrawal consistently load on a recognizable factor (Ellersgaard et al., 2014;
Kimhy et al., 2005), with the exception of Vázquez-Barquero et al., 1996, in which
delusions of mind reading loaded on a distinct factor. Similarly, grandiose and
religious delusions load together on a distinct factor (Ellersgaard et al., 2014) or
along with delusions of sin or guilt (Vázquez-Barquero et al., 1996), or along with
delusions of sin or guilt and reference (Kimhy et al., 2005). Somatic delusions load
alone (Ellersgaard et al., 2014) or do not load on any factors (Kimhy et al., 2005;
Vázquez-Barquero et al., 1996). It is remarkable that the only two studies
conducting a factor analysis of SAPS delusion items in an adequately large
first-episode psychosis sample (n=245, our study; n=411, Ellersgaard et al., 2014)
revealed exactly the same results. The non-first-episode sample (Kimhy et al.,
2005), the small samples (n=83, Kimhy et al., 2005; n=86 Vázquez-Barquero et al.,
1996), as well as the different sociodemographic features (see the Introduction),
could account for the discrepancies between these factor analytic studies and our
results. These findings mean that the relationships among the SAPS delusion items
that we found are overall consistent with previous studies (see Figure 1). Of note,
one other study (Shtasel et al., 1992) conducted an item-level factor analysis in a
first-episode sample, but included items of the SAPS, SANS, and Brief Psychiatric
Rating Scale, and other studies have done factor analyses of SAPS items but
included items other than delusions in a non-first-episode sample (e.g., Arora et al.,
1999; John et al., 2003; Minas et al., 1994; Lin et al., 1998; Peralta and Cuesta,
1999; Toomey et al., 1997).

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With regards to our a priori hypotheses, first, we confirmed that the persecutory
delusions domain is the most prevalent, which is in line with all prior studies using
the SAPS (Kim et al., 2001) or other instruments (e.g., Jørgensen and Jensen,
1994; Rajapakse et al., 2011; Raune et al., 2006) in first-episode psychosis. The
majority of previous studies focused on putative underlying factors leading to the
genesis and maintenance of persecutory delusions (e.g., reviews of Bentall et al.,
2001 and Freeman, 2007), and they generally agree with a multidimensional model
involving both external precipitating events and reasoning biases. Yet, the exact
reasons why Paranoid Delusions are the most common type of delusions,
irrespective of socio-cultural context (Stompe et al., 1999; Skodlar et al., 2008), are
unclear. In Stompe et al. (1999), despite the fact that cultural factors substantially
influence delusional content—as shown by the different prevalence of specific
delusional themes in Austrian and Pakistani samples—persecutory delusions were
the most prevalent type of delusions in both countries and their prevalences were
not significantly different. Similarly, in Skodlar et al. (2008), persecutory delusions,
along with delusions of reference (i.e., our Paranoid Delusions domain), are the
most frequent type of delusions from 1881 to 2000. Moreover, the prevalence of
Paranoid Delusion, according to that report, increased over time, but the impact of
social-cultural changes affect this type of delusions less than other types.
Therefore, despite the influence of socio-cultural events, paranoid delusions seem
to be less susceptible to such influence, and the most constant and prevalent
across time and culture, which may mean that they are linked to basic brain
responses to environmental stress. We hypothesize that paranoid thinking is a
defense mechanism in response to chronic mental stress, leading to paranoid
delusions in individuals showing a certain vulnerability. Further research is needed
to address whether paranoid delusions could be innately and evolutionarily linked
to response to stressors.

Second, the presence and the severity of Paranoid Delusions was modestly
associated with older age, but was not associated with sex. Our results seem to be
similar to first-episode psychosis findings reported by Häfner et al. (1993), who
found persecutory delusions to be more frequent at older ages regardless of sex,
and by Galdos and van Os (1995) who found an increased likelihood of displaying
persecutory delusions with age in both sexes. They suggest (Galdos and van Os,
1995), in keeping with Frith (1994), that the distinction between accidental and
intentional behavior is part of a maturational process; therefore, persecutory
delusions cannot be displayed unless the ability of inferring intentions of others is
completely developed. Such interpretation agrees with the findings of Häfner et al.
(1993), who reported the tendency toward undifferentiated delusions in
adolescence compared to systematized persecutory delusions in adulthood.
Freeman (2007) described a multifactorial cognitive model of persecutory delusions
in which developing delusions requires biases in reasoning involving the ability to
correctly interpret mental states of others, so that it seems to be feasible that the
relationship between persecutory delusions and older age is linked with the altered
maturation of that process (i.e., the acquisition of the ability of inferring others'
 mental states accompanied by deficits in correctly interpreting such states). Said
hypothesis seems to agree with the correlation we found between severity of
Paranoid Delusions and both age of onset and with age in general. However,
within our sample with a restricted age range, the correlation was not observed
among only the younger participants (18–22 years), but rather across the entire age
range (18–40 years).

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Third, our results do not confirm a significant relationship between depression and
delusional themes; neither positively with Paranoid Delusions, nor negatively with
Grandiose/Religious Delusions. The review of Hartley et al. (2013), and both
first-episode (Birchwood et al., 2005; Drake et al., 2004) and non-first-episode
(e.g., Bentall et al., 2009; Chadwick et al., 2005; Green et al., 2006) studies, have
previously reported a relationship between depression and persecutory ideation.
However, all cited studies included in their samples persecutory deluded patients
or provided a measure exclusively of persecutory delusions or paranoid ideation
and no other delusional themes. Only the studies of Garety et al. (2013) and Smith
et al. (2006) measured grandiose delusions in addition to persecutory delusions
(but no other delusional themes) and found a positive relationship between
persecutory delusions and depression and a negative one between grandiose
delusions and depression. On account of the limited research exploring different
delusional themes, our results comply with Hartley et al. (2013)—conclusions
cannot yet be drawn about the relationship between specific types of delusions and
depression, particularly in a first- episode sample.

With regard to our exploratory analyses, Delusions of Influence were much more
correlated with the severity of hallucinations and negative symptoms compared to
the other domains of delusions. There have been remarkably few studies
addressing the relationship between specific delusional themes and other domains
of psychopathology. The only study performing similar analyses (i.e., between
extracted factors among 12 SAPS delusion items and other SAPS/SANS scores)
(Kimhy et al., 2005) similarly found a significant relationship between delusions of
influence (composed of the same five delusion items as our Delusions of
Influence) and hallucinations (a correlation of 0.46, similar to our 0.49) as well as
the SANS subscale of avolition/apathy. Of note, these two associations would seem
to be unique, non-redundant associations because the correlation between
hallucination severity and negative symptom severity was modest (ρ=0.24). Bias
toward attributing self/other- generated experiences have been proposed
respectively for hallucinations (Woodward et al., 2007) and Delusions of Influence
(Woodward et al., 2006). It is conceivable that these source-monitoring biases
share overlapping cognitive operations leading to the associations between
Delusions of Influence and hallucinations.
 Then, we found a widespread relationship between childhood adversities and
delusional themes, in line with a recent meta-analysis reporting an association with
an increased risk of psychosis associated with a wide range of adverse childhood
experiences (Matheson et al., 2013; Varese et al., 2012). There is growing interest
focusing on putative relationships between specific childhood adversities and
specific psychotic symptoms (Bentall et al., 2014). With regards to delusions, a
specific relationship between persecutory delusions and physical abuse has been
suggested (Bentall et al., 2012; Rajkumar, 2015). However, such findings have not
been replicated (Longden et al., 2015; Read et al., 2003; Uçok and Bıkmaz, 2007;
van Nierop et al., 2014), and a more global model of associations, in which no
differential associations between particular adversities and specific delusions
exists, has been proposed (Longden et al., 2015). Whereas Interpersonal Abuse
was modestly correlated with the severity of all five types of delusions,
Environmental Violence was modestly correlated with the severity of four of them
(all but Somatic Delusions). However, we found that Neglect was correlated only
with Somatic Delusions. Therefore, we could

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hypothesize that experiencing violence “outside the house” or serious danger

events (Environmental Violence), as well as experiencing violence “inside the
house” or being abused (Interpersonal Abuse), could generally increase risk for
delusional ideation. On the other hand, Neglect is instead particularly linked with
Somatic Delusions.

Finally, looking at the relationship between delusional themes and substance

abuse/ dependence, remarkably, we found a significant progressive increase of
severity of Delusions of Influence and Negative Affect Delusions in patients who
did not take drugs, who abused, and who were dependent on cannabis and
cocaine/other substances. Few studies have focused on the presence of specific
delusional themes, generally reporting an increased incidence of
persecutory/paranoid ideation among cannabis (Freeman et al., 2011; Freeman et
al., 2013), methamphetamine (Ali et al., 2010; Zweben et al., 2004), or cocaine
(Brady et al., 1991) users, though these studies primarily focused on substance
users and not patients with psychotic disorders. Meanwhile, our results suggest a
linear relationship between the severity of cannabis and cocaine/other drug use (but
not alcohol use) and the severity of specific non-paranoid delusions in first-episode
psychosis patients. Although a clear distinction between substance-induced
psychosis and primary psychotic disorders is still challenged (Hides et al., 2015;
Mathias et al., 2008), we could hypothesize that paranoid ideation relates to
substance-induced psychosis, while Delusions of Influence and Negative Affect
Delusions could be particular correlates of substance use among those with a
primary psychotic disorder. This distinction, if confirmed, could possibly help
clinically in distinguishing the two conditions.
 Our study is subject to a number of limitations. First, our measure of depression
consisted only of the depression item from the PANSS; to truly test that hypothesis,
we would need to measure depression in a much more extensive way. Future
studies should rely on depression scales with greater variability. Second, we chose
an exploratory factor analysis (rather than confirmatory) since the limited literature
available (coming from different samples in different settings/countries) did not
allow us to clearly identify a pre-defined model to confirm; nonetheless, we
replicated a previously reported model (e.g., Ellersgaard et al., 2014). Third, the
varimax rotation used in our exploratory approach assumes that the different factors
are orthogonal, which makes it impossible to test for associations between
covariates (i.e., the different types of delusions). Therefore, our analytic strategy
might have underestimated differential effects of specific types of delusions as
several patients had more than one type of delusions of different severity (e.g.,
patients presenting Paranoid Delusions as a predominant theme likely display also
other types of delusions as a secondary theme). Fourth, all demographic and
clinical variables (e.g., depression severity, experiences of childhood adversity)
were based on the patient's self-report, and delusion items were rated based on
present and past-month symptomatology only. Further work could incorporate
objective measures and longitudinal ratings of delusions.

Delusions are a heterogeneous phenomenon. It seems to be unlikely that distinct

delusional themes share exactly the same clinical features; likewise, it is unlikely
that different variables affect delusional thoughts irrespective of their contents. Our
results support considering delusions not as a unitary construct, but rather as
different experiences with varying prevalences and correlates. Further research is
needed in order to more fully unpack

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Paolini et al. Page 12

the heterogeneity of these phenomena. Improved knowledge in this area could

lead to a better understanding of the mechanisms involved in the genesis of
delusions and offer clinical insights in terms of tailoring therapies.

Acknowledgments
Research reported in this publication was supported by National Institute of Mental Health grant R01
MH081011 (“First-Episode Psychosis and Pre-Onset Cannabis Use”) to the last author. The content is
solely the responsibility of the authors and does not necessarily represent the official views of the
National Institutes of Health or National Institute of Mental Health.

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Highlights
• Paranoid Delusions is the most prevalent type of delusion, and such
delusions are more common at older ages at onset of psychosis

• The level of Delusions of Influence is correlated with the severity of

hallucinations and negative symptoms

• Childhood Neglect is correlated with Somatic Delusions, while

Environmental Violence and Interpersonal Abuse showed a correlation with
the majority of our delusion domains

• Cannabis and stimulant users have higher scores on Delusions of

Influence and Negative Affect Delusions (jealousy, and sin or guilt)
 Psychiatry Res. Author manuscript; available in PMC 2017
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Psychiatry Res. Author manuscript; available in PMC 2017
 September 30.
Figure 1. A visual comparison of our derived domains, in relation to the results of
the only previous studies which have investigated dimensions underling the 12
SAPS delusion items by conducting an item-level PCA
Paolini et al. Page 19

Table 1 Sociodemographic Characteristics of the Study

Sample (n=245)

Total M SD

Mean age 23.9 4.7

Years of school completed 11.9 2.2

n%

Male 182 74.3

Admission Legal
status

Voluntary 59 24.1

Rac
e

Asian 4 1.6

African American 211 86.1

White 19 7.8

Other 11 4.5

Marital status (n
=244)

Single, never married 211 86.1

Married or living with a partner 12 4.9

Separated 12 4.9

Divorced 8 3.3

Widowed 1 0.4

Being a parent (n=244) 74 30.2

Living
conditions

Alone 16 6.5

Parents, siblings, other family 160 65.3

Boyfriend or girlfriend 10 4.1

Spouse or partner 7 2.9

Friends 10 5.3

Structured living arrangement 2 0.8

Homeless 24 9.8
 Other 13 5.3

Brought up
with

Mother 110 44.9

Father 15 6.1

Both parents 72 29.4

Other family members 39 15.9

Foster family 4 1.6

Other 5 2.0

Currently employed 76 31.0

Religious
affiliation

Baptist 91 37.1

Other Protestant 61 24.9

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Paolini et al. Page 20

Total M SD

Catholic 12 4.9

Muslim 11 4.5

None or Agnostic 33 13.5

Other 37 15.1

Been incarcerated (n=234) 136 55.5

SCID substance-related disorders

diagnosis

Alcohol abuse/dependence (n=232) 68 27.7

Current abuse 11 4.5

Lifetime abuse (past 5 years) 12 4.9

Current dependence 27 11.0

Lifetime dependence (past 5 years) 18 7.3

Cannabis abuse/dependence (n=231) 147 59.9

Current abuse 25 10.2

Lifetime abuse (past 5 years) 18 7.3

Current dependence 76 31.0

Lifetime dependence (past 5 years) 28 11.4

Cocaine abuse/dependence (n=234) 20 8.1

 Current abuse 2 0.8

Lifetime abuse (past 5 years) 4 1.6

Current dependence 9 3.7

Lifetime dependence (past 5 years) 5 2.0

Other substances abuse/dependence (n=234) 31

12.7

Current abuse 5 2.0

Lifetime abuse (past 5 years) 7 2.9

Current dependence 12 4.9

Lifetime dependence (past 5 years) 7 2.9

SCID
diagnosis

Schizophrenia 141 57.6

Paranoid 95 38.8

Catatonic 2 0.8

Disorganized 11 4.5

Undifferentiated 33 13.5

Schizophreniform Disorder 29 11.8

Psychotic Disorder NOS 38 15.5

Schizoaffective Disorder 31 12.6

Bipolar 5 2.0

Depressive 26 10.6

Brief Psychotic Disorder 2 0.8

Delusional Disorder 4 1.6

Psychiatry Res. Author manuscript; available in PMC 2017

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Psychiatry Res. Author manuscript; available in PMC 2017
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Psychiatry Res. Author manuscript; available in PMC 2017
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Psychiatry Res. Author manuscript; available in PMC 2017
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