Assessment the construct of paranoia in a non-clinical sample: validation of the paranoia scale based on two-factor model

doi:10.21203/rs.3.rs-3938258/v1

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Assessment the construct of paranoia in a non-clinical sample: validation of the paranoia scale based on two-factor model

https://doi.org/10.21203/rs.3.rs-3938258/v1

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Objectives

This study aimed to investigate the psychometric properties of the Persian form of the paranoia scale in a sample of Iranian students.

Methods

A total of 471 university students were selected using an available sampling method over a six-month period. Participants completed the Paranoia Scale, Depression, Anxiety, and Stress Scale − 21 Items, Rosenberg Self-Esteem Scale, Self-Consciousness Questionnaire, and Symptom Checklist-90-Revised. Data analysis comprised descriptive statistics, correlation coefficients, as well as exploratory and confirmatory factor analysis.

Results

The data analysis revealed a two-factor structure. To further corroborate the two-factor arrangement of the paranoia scale, a second-order confirmatory factor analysis method was employed. The findings indicated that the second-order two-factor structure exhibited an acceptable fit.

Conclusions

Paranoia emerges as a common human experience, supporting the notion of continuity between ordinary and pathological experiences.

Paranoia continuum

and Paranoia Scale

The term paranoia is defined as a disordered thinking style that is characterized by illogical content and a permanent lack of trust to others. Also, the leading to the interpretation of others' actions as threatening and the undermining of their accomplishments (1). Paranoia is defined as beliefs of persecution, conspiracy, and threat in the absence of supporting evidence (2). This phenomenon spans both nonclinical and clinical populations, ranging from mild suspiciousness to severe delusions (3). Fenigstein and Vanable have also distinguished subclinical and clinical forms of paranoia. The first occurs in daily behaviors and is characterized by self-reference, mistrust, grudges, resentment towards others, and beliefs of external influence and control, and the latter encompasses persecutory ideations of more clinical nature (4). Freeman suggest that paranoid beliefs reflect a defensive mechanism related to social comparisons, dominance, and similar behaviors within a social context, and notes that the intensity of paranoid beliefs heightens during perceived social threats (5). In general, the distinction between clinical and subclinical paranoia underscores that the latter is more susceptible to the influence of social context, emerging during interactions with unfamiliar individuals and periods of stress, whereas clinical paranoia is relatively independent of these factors (6). Freeman's hierarchical model posits a spectrum of paranoid beliefs, ranging from ordinary suspicions of acquaintances to exaggerated notions of malevolence and persecution by others (3). In one study were compared paranoid beliefs using the Portuguese versions of the General Paranoia Scale and the Paranoia Checklist, in 187 individuals (in four different groups). The results revealed, paranoia was reported in the general population on a continuum from non-clinical forms to more severe clinical examples (7). In instances, paranoia thoughts are erroneously diagnosed by clinicians as manifestations of anxiety or depression within normal adult populations (8). Freeman and Garety assert that there is a close relationship between the persecutory beliefs and emotions. According to them, depression is related to persecutory beliefs about punishment, while anxiety is related to a person's perception of other people who are talking about him (9). Long-term anxiety, as proposed by Freeman and colleagues, forms the backdrop for the development of paranoia (10). Notably, studies suggest that self-esteem, depression, and anxiety are interconnected with paranoia in both clinical and non-clinical populations (11). Aligned with the concept of a continuum of psychotic symptoms (12), low self-esteem exhibits a strong association with paranoid thoughts in the general population (13) and increases the susceptibility to its development (14). It appears that low self-esteem plays a critical role in both the vulnerability and maintenance of paranoid beliefs (15). The stress-vulnerability model posits that stressful life events trigger psychotic episodes in individuals at risk (16). In an exploratory model, was introduced social rejection and public discredit as social stressors that provoke negative emotions and precede the formation of delusions (17). Poon and colleagues also discuss social rejection and conspiracy theories in their study (18). Considering the close relationship between paranoid thinking and concerns regarding social evaluation, Fenigstein and Vanable propose self-consciousness as a potential factor contributing to increased paranoid ideation. They highlight the association between public self-consciousness and paranoia, in which the excessive self-focus manifests as a belief of being targeted (4). Public self-consciousness, reflects an individual's perception of others' actions and aligns with the principle of self-reference beliefs inherent in paranoid ideation (19). In this context, Fenigstein and Vanable developed the Paranoia Scale, a self-report instrument designed to assess paranoid ideation in non-clinical populations. The scale includes dimensions such as resentment and mistrust toward others, perceived rejection, and persecutory beliefs. Following the pilot study conducted on 144 college students, the selected items were refined, resulting in a 20-item scale for the Paranoia Scale. They found strong evidence in support of a general factor for the paranoia scale. In this research, the total Cronbach's alpha was 0.84 and the test-retest reliability was 0.70, and the validity of the tool was relatively high (4). In one study involving 1218 normal adolescents from Portugal, the initial single-factor model was supplanted by a three-factor model highlighting thoughts of mistrust, persecution, and depreciation. The study exhibited high psychometric properties, with a total Cronbach's alpha coefficient of 0.90 (20). Similarly, a study in Portugal involving 906 participants from the general population and 91 subjects from the patient population compared two conceptual models, revealing the superiority of the three-factor model (mistrust thoughts, persecutory ideas, and depreciation) over the original single-factor model. The results affirmed the Paranoia Scale as a valuable tool boasting high internal consistency and sound psychometric properties (21). Another study encompassing 175 students in Pakistan demonstrated the reliability of the scale with coefficients of 0.83, 0.91, and 0.73 using the Cronbach's alpha method, test-retest, and split-half methods, respectively (22).

Though, many studies have highlighted the social nature of paranoid beliefs, but few researchers have used tools to measure these social processes in normal populations. Therefore, the importance of validating this tool is justified for use in both clinical and research areas and its applicability to normal populations.

The current research is a cross-sectional design. The studied tool was first translated and then its content validity was confirmed by two experienced professors. The subjects of this research were all the students of Shahid Beheshti University of Medical Sciences, who were selected by available sampling method and online in a certain period of 6 months. Among the 470 subjects, 256 were women (54.46%) and 214 were men (45.53%). Most of the subjects were between the ages of 18 and 25 (62.1%). Participation in this study was voluntary, and information on the study goals and confidentiality was provided to all participants. In this study, SPPS version 23 software was used for exploratory factor analysis and Mplus 8.3 was used for drawing parallel analysis and confirmatory factor analysis diagrams. Data analysis showed the representation of two factors (mistrust thoughts and persecutory ideas). Then, to obtain more evidence for the two-factor structure of the paranoia scale, the second-order confirmatory factor analysis method was used.

Instrument

Paranoia scale

The PS scale comprises 20 items answered in a Likert scale ranging from 1 (never) to 5 (always). Total scores is ranging from 20 to 100, indicating higher levels of paranoid beliefs related to higher scores. In the original study, the Cronbach’s alpha and the test-retest reliability was .84 and 0.70, respectively. Convergent validity was established through an examination of its relationship with the MMPI questionnaire items. Factor analysis results supported the presence of a general factor (4).

Depression, Anxiety and Stress Scale − 21 Items

This questionnaire is conceptualized with three subscales of depression, anxiety and stress based on the dimensional model. In the initial study, Cronbach's alpha values of the three subscales were reported as 0.91, 0.81, and 0.89 for depression, anxiety, and stress, respectively (23). Subsequently, in an Iranian context, the confirmation of the three-factor structure of DASS was accompanied by Cronbach's alpha values exceeding 0.70 for each subscale and test-retest coefficients of 0.84, 0.89, and 0.91 for depression, anxiety, and stress, respectively (24).

Rosenberg Self-Esteem Scale

The Self-Esteem Scale developed to measure a general factor of personal self-worth. Each statement of this scale is arranged on a 4-point Likert from 10 to 40. Test-retest reliability over a two-week period exhibited correlations of 0.85 and 0.88. The validity of the scale indicated its relationship with self-esteem, depression and anxiety questionnaires (25). In an Iranian sample, the scale displayed high internal consistency with Cronbach's alpha values of 0.84 overall, 0.80 for girls, and 0.87 for boys. Divergent validity was confirmed through the use of the death obsession scale, yielding correlations of -0.34, -0.44, and − 0.27 for the entire sample, girls, and boys, respectively (26).

Self-Consciousness questionnaire: The self-consciousness scale consists of 23 statements and the results of the factor analysis of the initial version showed three subscales: private, public and social anxiety. In original study, the test-retest reliability for the three subscales and the total scale were 0.79, 0.84, 0.73, and 0.80, respectively. Moreover, the validity of the tool was deemed high, with results showing a moderate relationship between public self-consciousness and both private self-consciousness and social anxiety. While the relationship between private self- consciousness and social anxiety fluctuated around zero (19). In the present study, Cronbach's alpha coefficients were 0.79 for the total scale and 0.71, 0.58, and 0.72 for the private, public, and social anxiety subscales, respectively.

Symptom Check List − 90 - Revised

A comprehensive self-report tool designed for quick evaluation of the type and severity of client symptoms. The SCL-90-R checklist is applicable to both clinical and non-clinical populations. Initial study findings demonstrated varying internal consistency, ranging from 0.90 for depression to 0.77 for psychosis. Test-retest reliability, within a one-week interval, was reported between 0.80 and 0.90. Its validity was established through correlations with the Minnesota Personality Questionnaire across all subscales (27). In an Iranian sample, the test's reliability was reported to be over 0.8 in all subscales, except for the subscales of hostility, morbid fear and paranoia thoughts. Construct validity also indicated that this test can be used as a screening and diagnosis tool for mental illness (28).

In the present study, SPPS software version 23 was used for exploratory factor analysis and Mplus 8.3 was used for drawing parallel analysis graphs and confirmatory factor analysis Convergent validity was assessed through the use of the Depression, Anxiety, and Stress Questionnaire, Self-Consciousness Scale, and the Revised 90 Disease Symptoms Checklist, focusing on hostility, paranoid ideation, and psychotic symptoms. Divergent validity was evaluated using the Self-Esteem Scale.

Initially, confirmatory factor analysis was conducted to evaluate the factor structure of paranoia scale. For this purpose, the fit indices of one-factor model were evaluated, in which all items were loaded onto a latent construct (4). For parameter estimation of the model, we utilized the Weighted Least Squares Mean and Variance Adjusted correction (WLSMV) method. This approach is particularly suitable for analyzing ordinal data and is robust against deviation from the assumption of normality. Various fit indices were employed to assess the model fit. A chi-square to degree of freedom ratio lower than 3 is indicative of a good model fit (29). According to Hu & Bentler, an RMSEA index lower than 0.08, as well as CFI and TLI indices higher than 0.90, signify acceptable fit, while values exceeding 0.95 indicate a good fit (30). In the present study, results of fit indices χ2 = 806.93, p = 0.001, χ2/df = 4.75, CFI = 0.894, TLI = 0.882, RMSEA = 0.089, [0.083–0.096], SRMR = 0.068, showed that the single-factor model is not fall within the acceptance range. Consequently, we employed exploratory factor analysis utilizing principal component analysis and varimax rotation for factor extraction. Suitability in exploratory factor analysis was assessed through the Kaiser-Meyer-Olkin test, yielding an index value of 0.918, indicating high sample adequacy. Bartlett's Test of Sphericity was also significant (p < 0.001, Chi-Square = 3076.05), confirming the data's suitability for factor extraction. We used the cut-off point suggested by Comeri and Lee for factor loadings, in which the minimum acceptable value equal to 0.32 and values higher than 0.45 are considered suitable (31). It should be noted that before conducting the exploratory factor analysis, we first used the parallel analysis method to decide how many factors to retain, which is the best criterion for choosing the number of factors. Based on the parallel analysis line graphs (Fig. 1), were kept two factors, and the two-factor structure contributed 42.48% of the variance.

The internal consistency was evaluated using Cronbach's alpha. Total Cronbach's alpha as well as the subscales of mistrust, and persecutory ideas were obtained as 0.893, 0.853, and 0.819, respectively.

Table 1 illustrates the grouping of items based on the rotated matrix, highlighting a distinct factor structure. We named the two extracted factors Mistrust and Persecutory Ideas, align with existing literature. The Mistrust factor includes items 10, 18, 15, 8, 16, 9, 12, 7, 11, 19, 6 and the Persecutory Ideas factor includes items 1, 13, 4, 2, 3, 17, 5, It was 20, 14. Notably, all questionnaire items were retained in this study.

Table 1

Paranoia Scale factor loadings and bivariate correlations for the two-factor solution
Item	Components
Item	Mistrust	Persecutory Ideas
10. It is safer to trust no one	.763
18. People often disappoint me	.678
15. Most people inwardly dislike putting themselves out to help other people	.670
8. Most people will use somewhat unfair means to gain profit or an advantage, rather than lose it	.650
16. I tend to be on my guard with people who are somewhat more friendly than I expected	.632
9. I often wonder what hidden reason another person may have for doing something nice for you	.624
12. Most people make friends because friends are likely to be useful to them	.619
7. I am sure I get a raw deal from life	.497	.339
11. I have often felt that strangers were looking at me critically	.493	.410
19. I am bothered by people outside, in cars, in stores, etc. watching me	.481
6. No one really cares much what happens to you	.466
1. Someone has it in for me		.693
13. Someone has been trying to influence my mind		.683
4. Some people have tried to steal my ideas and take credit for them		.633
2. I sometimes feel as if I'm being followed		.604
3. I believe that I have often been punished without cause		.594
17. People have said insulting and unkind things about me	.422	.573
5. My parents and family find more fault with me than they should		.531
20. I have often found people jealous of my good ideas just because they had not thought of them first	.356	.516
14. I am sure I have been talked about behind my back	.458	.490
Eigen values	4.71	3.78
% of Variance	23.57	18.90
Mistrust Thoughts	1
Persecutory Ideas	.623^**	1
** p < 0.01

In order to substantiate the presence of a two-factor structure within the paranoia scale, the researchers applied the second-order confirmatory factor analysis. The findings indicated that in contrast to the one-factor model, the second-order two-factor structure has an acceptable fit (χ2 = 601.26, p = 0.001, χ2/df = 3.55, SRMR = 0.058, RMSEA = 0.074 [0.067–0.080], TLI = 0.919, CFI = 0.928). The graphical representation in Fig. 2 illustrates the two-factor structure of the paranoia scale. Specifically, the depicted model denotes the first-order factors of mistrust and persecutory ideas, which subsequently contribute to the second-order factor of paranoia thoughts. Importantly, all factor loadings are significant at the p < 0.01 level.

The correlation between the total score of the paranoia scale and the subscales of mistrust and persecutory ideas with other related constructs is reported in Table 2. Findings revealed a significant positive correlation between the scale of paranoia and its subscales with depression, anxiety, stress, self-consciousness (subscales of general self- consciousness and social anxiety) and the 90 revised disease symptoms checklist (subscales of hostility, psychotic paranoia and paranoid ideation). But no significant relationship was observed between the subscale of private self-consciousness and the subscales of paranoia. Also, a significant negative correlation was found with self-esteem.

Table 2

bivariate correlations between DASS, Self-consciousness, Self-esteem and SCL-90 with the Paranoia scale
Model	Mistrust	Persecutory Ideas	Paranoia Total Score
DASS-Depression	.554^**	.405^**	.543^**
DASS-Anxiety	.493^**	.497^**	.548^**
DASS-Stress	.573^**	.484^**	.593^**
Self-conscious	.343^**	.285^**	.352^**
Private Self-consciousness	.077	.087	.090
Public Self-consciousness	.314^**	.298^**	.340^**
Social anxiety	.416^**	.288^**	.400^**
Self-esteem	− .330^**	− .276^**	− .340^**
SCL-90-Hostility	.492^**	.475^**	.537^**
SCL-90-Paranoia Ideation	.674^**	.606^**	.714^**
SCL-90-Psychoticism	.490^**	.467^**	.532^**
** p < 0.01

As it was mentioned in the introduction of the study, Fenigstein and Vanable have distinguished subclinical and clinical forms of paranoia. They defined subclinical paranoia as a mental state characterized by exaggerated self-referential attributions that occur in normal everyday behavior. This mode of thinking is linked to relatively persistent tendencies toward suspicion, resentment, mistrust, and belief in external control or influence. In contrast, clinical paranoia involves persecutory delusions and intense distrust. To examine such phenomena, they a new instrument designed to assess paranoid thought in college students. The scale's items encompass a range of experiences, from resentment and mistrust towards others to feelings of humiliation, rejection, and harassment, all of which may commonly occur in everyday life. Their original study identified a one-factor model in a sample of college students (4).

The present study aimed to examine the psychometric properties of the Persian version of the paranoia scale within a student sample. Following exploratory factor analysis, two distinct factors, namely mistrust in others and persecutory thoughts, were extracted and subsequently validated through confirmatory factor analysis. This outcome corresponded with Fenigstein and Vanable theory, which distinguished subclinical and clinical forms of paranoia (4). However, it contradicted the results of their original research, which indicated a one-factor structure for the scale. Furthermore, our findings were inconsistent with the outcomes of Carvalho and colleagues exploratory factor analysis, which revealed a three-factor model (thoughts of mistrust, persecutory beliefs, and depreciation) in an adolescent sample (20). The emergence of distinct factors reflects varying types of paranoia ideas, aligning with the hierarchical model (3).

In the study's introduction, it was elucidated that the foundational framework of the model posits that the emergence of extreme and unconventional paranoid thoughts, often revolving around persecution, may stem from prevalent social distrust commonly observed in individuals. This sense of mistrust can be seen as a continuum of interpersonal sensitivity and suspicion, wherein self-attributed thoughts contribute to the development of distressing cognitions. Aligned to the hierarchical model, the current study reveals two dimensions of mistrust and persecutory thoughts, manifesting as a pervasive personality trait at one end of the continuum and organized delusional disorder at the other. According to Freeman et al.'s model, mistrust with the highest frequency in the lowest order, while thoughts of sting and harm with the lowest frequency in the highest order exist among the normal population. This operational aspect of paranoia seems to be a normative phenomenon. The prevalent nature of paranoia prompts the question: Why is paranoia so prevalent in the general population? Theorists posit that a certain level of mistrust is an adaptive and normative feature, serving a protective function, particularly in situations involving unknown individuals outside one's social group (3). Paranoia has an evolutionary value and provides the possibility of recognizing the threat of a person by others. Clinically diagnosed patients see the main benefit of paranoia as keeping themselves safe from danger in the social world. The evolutionary principle of "better safe than sorry" may help explain why trait paranoia persists even in a normal population. In fact, a perspective on paranoia that sees it as a normal cognitive process with adaptive value is potentially therapeutic for patients as well. This is a normalization framework to reduce social stigma (32).

In the present study, convergent validity was reported to be significant through the examination of the relationship between the paranoia and stress, anxiety, depression and self-consciousness (subscales of public self-consciousness and social anxiety). Furthermore, the paranoia scale exhibited negative divergent validity with self-esteem. These findings are consistent with previous research outcomes (13; 19; 4; 9; 12; 15; 14; 16; 18; 17; 8; 11).

Our findings align with the conclusions of Poon and colleagues who posited a correlation between social rejection and conspiracy theory (18). The perception of being subjected to such distressing social stressors, such as repeated feelings of neglect, can potentially heighten vulnerability and promote a tendency for hypervigilance in identifying potential threats within the environment. Additionally, according to the stress-disease model, it is theorized that stress induces paranoid ideation in susceptible individuals by exacerbating negative emotions, including low self-esteem (16). But, the mediating role of self-esteem reduction in the ideation of paranoia cannot be discussed without referring to the psychodynamic situation in which persecutory delusions may be used to defend against low self-esteem (15). Some researchers suggest that delusions serve as a defensive strategy against low self-esteem, protecting individuals from feeling threatened by social comparisons (4, 5). Bentall, Kinderman, and Kaney, also proposed that persecutory delusions function to minimize the discrepancy between the actual self and the ideal self, particularly in situations linked to social threat. According to them, self-esteem decreases in response to social stress, while paranoia thoughts increase, and it is consistent with the notion that delusions can act to protect oneself against the activation of negative schemas related to childhood trauma (33).

Freeman and colleagues suggested, the cognitive component of anxiety concentrate on upon concern about impending danger, and such thoughts will be reflected in persecutory delusions (10). Anxiety is hypothesized to be the key emotion in the formation of persecutory delusions, although other emotions (depression, anger, elation) may add further to the contents of the delusion. Essentially, in the majority of cases, the content of the delusion corresponds with the individual's emotional state.

As previously stated in the introduction, self-consciousness may be associated with paranoia (4). Individuals who experience self-consciousness may tend to overemphasize the degree of being seen by others, which can explain the relationship between paranoia beliefs and social anxiety. Since such self-referential perceptions of others' behavior are one of the signs of paranoia thinking, it is argued that people with higher general self-consciousness tend to think in paranoia ways. According to Fenigstein and colleagues people with high general self-consciousness are especially sensitive to rejection and interpret the behavior of others according to their personal desires or intentions (19). Such These interpretations can foster suspicion, mistrust, heightened sensitivity to rejection, and increased hostility in response to potential threats, all of which are linked to paranoia.

The findings of this study align with previous similar research, indicating that paranoid beliefs are a prevalent phenomenon extending beyond clinical populations. Although paranoia is usually considered a form of psychopathology, there are at least certain characteristics of paranoia that are common in normal university students. Moreover, normalizing the continuum of paranoid thoughts can potentially mitigate self-stigmatization. Considering the hierarchical model of paranoid thoughts, interventions can be tailored to address each stage of their emergence.

Arguably, the most critical strength of the current study was the theoretical validation of the two-factor structure of the paranoia scale. This discovery was in line with the conceptual framework proposed by Fenigstein and Vanable, which had not been established in their original empirical study, and subsequent investigations (4). The most important limitation of the study was the non-representation of the studied population in order to generalize its results, which is suggested to be taken into consideration by researchers in future studies.

Acknowledgments and disclosures

The authors thank those who participated in this study and thank Dr. Katherine Berry and Dr. Mohammad Kazem Atef Vahid for helpful comments on the initial draft of the manuscript.

Ethics approval and consent to participate

This study has been approved by the Student Research and Technology Committee of Shahid Beheshti University of Medical Sciences with an ethical charter (IR.SBMU.RETECH.REC.1400.828). Informed consent was obtained from all subjects.

Consent for publication

Not Applicable

Availability of data and materials

There is no Data Availability Statement provided on the system. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare no competing interests.

Funding

This research received no external funding.

Authors' contributions

Amini, M., Title of research and preparation of tools and translation and author. Masjedi, A., Supervisor. Fatollahzadeh, S., Data collection. Mohajerin, B., Statistics consultant. Mazaheri, M., Article edition. Shahi, A., Data collection

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No competing interests reported.

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Assessment the construct of paranoia in a non-clinical sample: validation of the paranoia scale based on two-factor model

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