Title: Harmful grandiose delusions: developing a translational treatment.
Funder: Health Education England

Abstract: Harmful grandiose delusions: developing a translational treatment Background: Grandiose delusions are unfounded beliefs held by patients that they have exceptional abilities, wealth or fame. They become harmful when detrimental actions ensue, such as believing one is invincible and therefore stepping into traffic or attacking a perceived assailant. Social isolation is a common consequence. Grandiose delusions occur in 25-50% of people with schizophrenia and in 35- 60% of bipolar manic episodes. They are an important treatment target but have not been subject to a systematic programme of research and there is no specific targeted treatment. This is because researchers have traditionally adopted a diagnostic approach (focusing broadly on schizophrenia'), but this has yielded medical and psychological treatments with only modest effects. This is a major problem. The human costs are high (increased suicidality, isolation, physical morbidity and hospital admissions), and the annual cost to the public sector of schizophrenia alone is 7.2 billion in England. Factor analytic studies indicate that grandiose delusions are an independent psychotic experience and the adoption of a precision-medicine paradigm to develop a targeted psychological treatment is warranted. This fits with the priority for evidence-based psychological treatments demonstrated by major NHS developments: the Improving Access to Psychological Treatments Severe Mental Illness programme, and the access and waiting time standards for Early Intervention in Psychosis services. The applicant has developed a theoretical maintenance model of grandiose delusions. This proposes that such beliefs are developed in the context of genetic and environmental risk, and maintained by factors including: repetitive thinking; disregard of feedback from others; attentional, memory, and reasoning biases; anomalous experiences (such as hearing voices); and dysregulated affect. This model needs to be refined, tested, and translated into an evidence-based, effective psychological treatment. Research aims: The primary aim is to develop the first, evidence-based, translational, psychological treatment specifically for harmful grandiose delusions. A secondary aim is to increase understanding of harmful outcomes associated with grandiose delusions. Research questions: 1) What and how often do harmful outcomes occur in association with grandiose delusions? 2) What factors predict maintenance of grandiose delusions? 3) Is it feasible to deliver the manualised treatment, based on the maintenance model, to patients with grandiose delusions? Plan of investigation: Five studies will be undertaken. A systematic literature review will investigate harm associated with grandiose delusions, and review psychological processes implicated in their maintenance. A secondary analysis of existing large longitudinal databases , using multilevel and structural equation modelling, will test the association between grandiose delusions and harmful outcomes, and the extent to which hypothesised maintenance factors, predict persistence of grandiose delusions. A qualitative study, using thematic analysis methodology, will provide a valuable patient perspective on the experience and treatment of grandiose delusions. A longitudinal, observational study will test the ability of factors identified in the model to predict the temporal maintenance of grandiose delusions. Finally, based on these data, the model will be refined, a translational treatment protocol developed, and a feasibility study conducted. The applicant will work within the Oxford Cognitive Approaches to Psychosis (O-CAP) research team, adopting their general approach which has already significantly improved treatments for persecutory delusions. Potential benefits to patients and the NHS: This research will be a key step towards substantially improving treatments and outcomes for people with psychotic illness. It will deliver the first evidence-based, psychological treatment specifically for grandiose delusions. The intervention will be highly manualised so that mental health professionals can incorporate it within routine clinical care. After efficacy is demonstrated, the applicant's part-time role as a CBT trainer and supervisor will provide an appropriate platform for dissemination.CHAR(13) + CHAR(10)

Lay abstract: Harmful grandiose delusions: developing an evidence-based treatmentThe problem I believed I had special powers......I knew when the end of the world was coming due to toxic substances and felt that I was the only one who could stop it. - Jaime I believed that my friends were deserting me because they envied my ability to see colours they couldn't. - LindsayGrandiose delusions are when people develop false beliefs that they have exceptional abilities, wealth or fame. These beliefs can be harmful: someone who believes that they have super powers and can't be injured might step out into traffic; or someone who believes they are desirable to all others might mistakenly think a person is attracted to them and therefore sexually assault them. Dangerous outcomes occur, but most commonly harm is in the form of social isolation (losing friends, family, and employment). This might be because the person gets so caught up in acting on their beliefs that they withdraw from others, or because others avoid them, finding them difficult to be around. This can be a serious problem for the person themselves, their loved ones, and wider society. Grandiose delusions are a key difficulty for people with severe mental health illnesses such as schizophrenia and bipolar disorder. There has, however, been very little research carried out that focuses specifically on this symptom. This is because, in the past, research has focused broadly on schizophrenia' or bipolar disorder' as a whole rather than looking at individual psychotic experiences. This approach hasn't worked well, and traditional treatments are not very effective. This is a serious concern because these types of difficulty are linked to isolation, suicide, physical health problems, and hospital admissions. The annual cost to the public sector of schizophrenia alone is estimated 7.2 billion in England. Clearly there is a need to improve treatments and the importance of psychological (i.e. talking therapy) treatments is a current priority for the NHS and the UK government. The maintenance model After studying existing research I hypothesise that grandiose beliefs persist because of several key 'maintenance factors'. These include: (i) thinking about the belief repeatedly (because it feels good) which then increases the person's level of certainty in the delusion; (ii) disregard of feedback from others, so being less able to consider alternative views to the grandiose belief; (iii) a tendency to jump to conclusions' rather than weighing up different ways of seeing a situation; (iv) thinking biases, whereby the person tends to notice information that fits with their grandiose belief, and ignore information that might disprove it; (v) unusual experiences, such as hearing voices, which might tell the person their belief is correct; and (vi) disrupted emotions which might cause someone to cope in ways that makes the belief worse (e.g. using drugs and alcohol, or changing their sleep pattern). This is a 'maintenance model' of grandiose beliefs. The next steps This model needs to be developed further and tested to see if it has predictive power. It can then be used to develop a psychological treatment aimed at reducing harmful grandiose delusions by targeting the maintenance factors. The proposed research aims to do this using five studies: 1)a thorough review of all existing research on grandiose delusions; 2)analysing existing large databases to see what types of harm occur when people experience grandiose delusions, and why they persist over time; 3)interviewing patients who have grandiose delusions to ask them what their experience is like; 4)monitoring patients with grandiose delusions over six months to see what factors are related to the belief persisting or going away; 5)developing a talking therapy treatment and testing its feasibility by offering it to four people with grandiose delusions and getting their feedback. At a later point I will conduct a clinical trial to establish whether the therapy is helpful. Potential benefits to patients and the NHS This research will be a key step towards significantly improving treatments and outcomes for people with grandiose beliefs. It will deliver the first evidence-based specific psychological treatment for grandiose delusions. A treatment manual will be developed so that, once it has been shown to work, other mental health professionals can offer the treatment.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH