Background: Current psychological theories of persecutory delusions appear limited in being able to explain their interpersonal nature. Unanswered questions include why the content of delusions mostly involves persecution by other people. Research into rejection including rejection sensitivity may provide a rational for delusion personalisation and also may indicate how rejection may be implicated in the maintenance of delusions. The aim of this study was to investigate responses to rejection for individuals with a psychosis that includes persecutory delusions compared with controls. Methodology: Participants (22 with psychosis with persecutory delusions, 18 with an anxiety disorder and 19 healthy individuals) played a computerised game of catch (Cyberball). Half of each group was either included or excluded, inducing a mood change in those rejected. Questionnaires were completed to measure mood change, indicating rejection sensitivity. A second task was completed enabling participants to react either antisocially or neutrally towards the game characters. Measures of psychological and demographic variables were also collected. Results: There was a large effect between the excluded and included participants. There was a null finding for the hypothesis that the psychotic group would have higher levels of rejection sensitivity than the anxious and healthy groups. There was also a null finding for the hypothesis that the psychosis group will be more likely to respond antisocially after rejection and make more negative attributions about the game character’s personalities. However, there was a trend for a the psychotic group to be more antisocial after inclusion. Conclusions: The results obtained in the study were contrary to those expected. Rejection appears to be a similarly negative experience for all participants, but differences may be observed behavioural responses with those with psychosis appearing ambivalent to inclusion or exclusion.

A growing body of research demonstrates that paranoia is common in the general population. Four studies are presented that investigate factors associated with paranoia and naturalistic change in non-clinical groups. First, two experimental studies examine paranoia in the context of the Prisoner's Dilemma Game (PDG), an interpersonal research paradigm, where two players have the choice to cooperate or compete with each other. The dominant and rational choice for both players is to compete, however each players' individual reward would be greater if they both played cooperatively. Study 1 found that higher state paranoia was associated with the choice to compete. However the competitive choice can be selected due to distrust of the other player, or in order to maximise personal gain. The second experimental study employs a Three-Choice version of the PDG (PDG-Alt) that includes the option to withdraw, the rational choice when distrust of the other player is high. Higher state paranoia was associated with the withdrawal choice. These studies conclude that the withdrawal choice in the PDG –Alt provides a potential behavioral marker of state paranoia. Second, two studies examine naturalistic change in nonclinical paranoia. Idiosyncratic accounts of a single past paranoid experience are elicited and variations in dimensions known to be important in clinical paranoia are examined. Results show that levels of preoccupation, distress, impact on well being and conviction that harm was intentional significantly reduce over time. However the amount of time passed since the experience occurred is not significantly associated with level of change. Finally, in Study 4 a qualitative investigation is presented that identifies themes associated with change in nonclinical experiences of paranoia. The thesis concludes with a discussion of the theoretical, clinical and research implications of the findings.

Purpose: A systematic review and meta-analysis was conducted to test key predictions of the widely-studied ‘paranoia as defence’ model (more formally known as the ‘attribution–self-representation cycle’) proposed by Bentall, Corcoran, Howard, Blackwood, and Kinderman (2001), as applied to people with psychosis with persecutory delusions. A novel case series was also conducted to examine the feasibility and acceptability of collaborative psychological assessment and formulation of impaired treatment decision-making capacity (TDMC) among patients with psychosis, and produce preliminary data on safety and efficacy. Methods: With regard to the systematic review and meta-analysis, people with psychosis with persecutory delusions were compared to healthy controls, people with depression and people with psychosis without persecutory delusions (and, if specified, grandiose delusions) on a number of outcomes: externalising attributional bias, explicit self-esteem, implicit self-esteem and discrepancy between implicit and explicit self-esteem. Correlations between paranoia severity and each of these outcomes and self-esteem instability were also examined. In regards to the case series, a formulation of impaired TDMC for 5 patient participants was developed and shared with 13 clinician participants. Acceptability, utility, working alliance and safety were assessed through pre and post self-report and interview measures. Results: Sixty-three studies were included in the meta-analysis and systematic review, of which 33, 36, 10, 10 and 4 were used to test hypotheses on externalising attributional bias, explicit self-esteem, implicit self-esteem, implicit-explicit self-esteem discrepancy and selfesteem instability, respectively. Key model-consistent findings included the following: people with psychosis with persecutory delusions had a greater externalising attributional bias compared to all the other groups and a greater implicit-explicit self-esteem discrepancy than people with depression, and paranoia severity was positively correlated with externalising attributional bias and self-esteem instability. Key model-inconsistent findings included the following: people with psychosis with persecutory delusions had lower explicit self-esteem than healthy controls, and paranoia severity was negatively correlated with explicit self-esteem. There were also some model-inconclusive findings. Regarding the case series, 3 of the patient participants collaborated in the development of their formulation. They found the intervention safe and acceptable, following which they provided a much richer understanding of the factors that may impair their TDMC (Cohen’s d = 2.16). Two patient participants only partially adhered to the intervention protocol, but a psychological formulation was still feasible to produce and no adverse effects were reported. Clinician participants provided a much richer understanding of the factors that may impair the patient participants’ TDMC (Cohen’s d = 1.36; 95% CI = 0.63 to 2.07) after the presentation of the case formulations. Increases in knowledge, confidence and positive attitudes regarding supporting the TDMC of patients were observed. They strongly believed that the formulations cohered with their knowledge of the patient participants and were comprehensive and accurate. Conclusions: The findings of the systematic review and meta-analysis support a ‘weak’ version of the paranoia as defence model, which suggests persecutory delusions are only partially effective at protecting low implicit self-esteem from reaching awareness. The findings of the case series suggest that patients with psychosis, and their clinicians, can be engaged in a collaborative psychological assessment and formulation of factors that may impair their TDMC. Initial data from the case series also suggests this process is acceptable, safe and helpful.

Cette thèse propose une modélisation de la dynamique psychique à l’œuvre dans les contextes d’anorexie. A partir d’une approche processuelle, elle explore la continuité psychodynamique entre les anorexies du bébé-dans-sa-famille et les anorexies mentales de l’adulte. La première partie est consacrée à une revue de la littérature psychanalytique considérant les travaux portant sur l’anorexie mentale de l’adolescente et de l’adulte, les travaux consacrés aux anorexies du bébé et les travaux traitant des anorexies aux différents âges de la vie. La seconde partie présente les fondements épistémologiques de cette recherche. Elle ouvre une réflexion sur la recherche en psychologie clinique et sur ses liens avec la pratique et l’enseignement. Elle précise ma filiation théorique et praticienne. La troisième partie est consacrée à la méthodologie de la recherche clinique, et principalement aux spécificités de l’observation clinique psychanalytique. Elle présente la méthode E. Bick d’observation du bébé dans sa famille, ses apports à la recherche et à la pratique cliniques ainsi que l’adaptation réalisée auprès des patients souffrant d’anorexies. La quatrième partie propose une réflexion sur les enjeux psychiques de la « relation de nourrissage ». Cette relation est envisagée comme une relation commensale (W.R. Bion, 1962), paradigme de la rencontre intersubjective, de la croissance psychique de la subjectivité du bébé et de l’essor de la parentalité, mais aussi terrain privilégié de la transmission psychique inconsciente. La cinquième partie est consacrée à la mise en dialogue entre le bébé-dans-sa-famille et les aspects bébés du self de l’adulte dans les contextes d’anorexie. Les anorexies sont envisagées en terme de refus-impossibilité alimentaire témoignant d’une tentative d’organisation de modalités de survie psychique. Deux angoisses communes apparaissent au centre de la dynamique psychique : une angoisse catastrophique et une angoisse de persécution. L’angoisse catastrophique prend la forme d’une « chute sans fin désintégrante », signe d’une dépression primaire. Elle est surchargée par une angoisse de vampirisation-dévoration qui est notamment envisagée comme une forme d’objectalisation de l’angoisse de « chute sans fin désintégrante ». Les modalités de défenses adhésives ont pour fonction de lutter contre la chute sans fin désintégrante. Elles sont accompagnées d’une inhibition de la vie pulsionnelle —plus particulièrement de l’avidité secondaire— ainsi que de son clivage, son déni et sa projection. Le contact avec la vie émotionnelle du bébé réactive la dépression primaire contre laquelle les aspects bébés du self parental se sont organisés dans une économie de survie psychique. Le refus-impossibilité alimentaire du bébé apparaît en miroir d’un refus-impossibilité d’accueil et de mise en sens de la vie émotionnelle qui caractérise la parentalité anorexique. Le lien entre le bébé et la parentalité, mais aussi entre les aspects bébés du self et la parentalité interne, est caractérisé par une réflexivité opaque et persécutoire intériorisée par le bébé —et les aspects bébés du self— sous la forme d’un cercle pernicieux et involutif. Ce travail se conclut sur la proposition d’un gradient du lien de nourrissage structuré par deux pôles. Le plus intégré, celui de la relation de nourrissage, est caractérisé par une relation d’intimité entre le bébé et la parentalité et l’introjection d’une relation de réflexivité commensale, mutuelle et asymétrique, soutenant l’intégration pulsionnelle, le développement des bases d’un surmoi protecteur et la croissance psychique. Le second est défini comme un lien d’anourrissage, caractérisé par une relation d’ex-timité entre le bébé et la parentalité, l’intériorisation d’un réflexivité opaque et persécutoire sous la forme d’un cercle involutif entraînant la désintrication pulsionnelle et le développement d’un « surmoi sévère et destructeur du moi » (W.R. Bion, 1959). / This dissertation offers a modelisation of the psychological dynamics which are at work in the contexts of anorexia. Process is the cornerstone to the exploration of the ongoing psychodynamic that is at work with the anorexia of the baby-in-its-family and the anorexia nervosa of the adult. The first part reviews the existing psychoanalytical literature and considers the works dealing with the anorexia nervosa of the teenager and of the adult, then the works dedicated to the anorexias of the baby; last but not least, the works offering an approach that considers the anorexias at the different stages of life. The second part deals with the epistemological basis of this work. It explores the research in clinical psychology and the way it is linked to practice and teaching. It looks into the theoretical and practical filiation that operates in our approach to the mental life and to the care relationship. The third part is dedicated to the methodology of the clinical research – mainly the specificities of psychoanalytical observation. It presents E. Bick’s method of infant observation and how this method was adapted for the clinical work with anorexic patients. The fourth part ponders on what is psychologically at stake in the ‘feeding relation’. This relation is seen as commensal (W.R. Bion, 1962), the paradigm of the intersubjective encounter, of the psychological development of the baby’s subjectivity and the emerging parentality, but also the most favored ground of the unconscious psychological transmission. The fifth part creates a dialogue between the baby-in-its-family and the babies aspects of the adult self in the contexts of anorexia. Anorexias are considered in terms of food refusal-impossibility demonstrating an attempt to organise psychological survival. Two common anxieties are at the center of the psychological dynamic : a catastrophic anxiety and a persecution anxiety. The catastrophic anxiety appears as an « endless and disintegrative fall », a sign of a primary depression, which is overloaded with a vampirising and devouring anxiety. The persecution anxiety is also thought as a form of objectalisation of the anxiety of « endless and disintegrative fall ». The adhesive defenses, which are organised to fight against the « endless and disintegrative fall », are accompagnied by an inhibition of the instinctual drives —especially of secondary greed— as well as their splitting, denial and projection. The contact with the baby’s emotional life reactivates the primary depression against which the babies aspects of the parental self are organised in an economy of psychological survival. The food refusal-impossibility of the baby appears as a mirror to the refusal-impossibility to receive and give meaning to the emotionnal life that characterises anorexic parentality. The link between the baby and its parentality, but also between the babies aspects of the self and the internal parentality, presents an opaque and persecutory reflexivity that is interiorized by the baby and the babies aspects of the self, with the form of a pernicious and involutive circle. Finally, this dissertation concludes with the proposition of a range of the feeding relation that is structured by two poles. The first pole is the more integrated one : that of the feeding relation. It is marked by a relation of intimacy between the baby and its parentality and by the introjection of a commensal reflexivity which is both mutual and asymmetrical, and which sustains the integration of instinctual drives, the development of the bases of a protective superego and of the mental growth. The second pole, the un-linked one, is that of the relation of un-feeding characterized by a relation of ex-timity between the baby and its parentality, and the interiorization of a persecutory and opaque reflexivity in the form of a involutive circle leading to the desintegration of the drive and the development of an ego destructive superego (W.R.Bion, 1959).