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Self-Reported Cognitive Functions Predict the Trajectory of Paranoid Ideation Over a 15-Year Prospective Follow-Up

Self-Reported Cognitive Functions Predict the Trajectory of Paranoid Ideation Over a 15-Year... Background This study investigated whether self-reported cognitive functions (i.e. task orientation, distractibility, per- sistence, flexibility, and perseverance) predict the trajectory of paranoid ideation over a 15-year prospective follow-up in adulthood. Methods The participants came from the population-based Young Finns study (N = 1210‒1213). Paranoid ideation was assessed with the Paranoid Ideation Scale of the Symptom Checklist-90 Revised (SCL-90R) in 1997, 2001, 2007, and 2012. Self-reported cognitive functions were evaluated in 1997 with the Task orientation, Distractibility, Persistence, and Flex- ibility scales of the DOTS-R (the Revised Dimensions of Temperament Survey) and the Perseverance scale of the FCB-TI (the Formal Characteristics of Behaviour – Temperament Inventory). The data was analyzed using growth curve models that were adjusted for age, sex, and socioeconomic factors in childhood and adulthood. Results Low self-reported task orientation, low persistence, high distractibility, low flexibility, and high perseverance pre- dicted higher level of paranoid ideation over the 15-year follow-up. Conclusions Self-reported cognitive functions seem to predict paranoid ideation over a long-term follow-up. Promoting cognitive functions in early interventions may have long-term protective influences against the development of paranoid ideation in non-clinical populations. Keywords Paranoid ideation · Subclinical · Cognition · Cognitive functions · Every-day functioning · Longitudinal Introduction Paranoid ideation refers to an unjustified suspiciousness towards others so that others’ motives are supposed to be malevolent (APA 2013). Paranoid ideation can be regarded Electronic supplementary material The online version of this as a continuum, from mild and subclinical levels to severe article (https ://doi.org/10.1007/s1060 8-020-10142 -z) contains paranoid ideation (e.g. Freeman et  al. 2005; Freeman supplementary material, which is available to authorized users. and Garety 2014; Van Os 2003). Mild paranoia includes, * Aino I. L. Saarinen for example, transient and uncertain ideas about negative aino.i.saarinen@helsinki.fi rumors circulating around the self (Freeman and Garety 2014). More severe paranoia, in turn, may refer to paranoid Research Unit of Psychology, University of Oulu, Oulu, personality disorder that includes stable and convincing Finland beliefs that others are deliberately trying to cause significant Department of Psychology and Logopedics, Faculty harm to the self (Freeman and Garety 2014). Most severe of Medicine, University of Helsinki, Haartmaninkatu 3, P.O. Box 21, 00014 Helsinki, Finland paranoid ideation may be manifested as persecutory delu- sions and, thus, reach the level of psychosis (Van Os 2003). Department of Adolescent Psychiatry, Helsinki University Hospital, Helsinki, Finland Paranoid ideation has aroused significant interest because of its relatively high prevalence and societal disadvantages. Department of Clinical Chemistry, Fimlab Laboratories and Finnish Cardiovascular Research Center-Tampere, Specifically, the prevalence of mild paranoid ideas is about Faculty of Medicine and Health Technology, Tampere 10% in China (Chan et al. 2011) and even in 40% in the UK University, Tampere, Finland Vol.:(0123456789) 1 3 334 Cognitive Therapy and Research (2021) 45:333–342 (Freeman et al. 2005). The lifetime prevalence of psychotic- some external events to the self in a biased way), and an level persecutory delusions is estimated to be approximately elevated sensitivity to direct attention to threat-related infor- 5‒8% (Freeman and Freeman 2008; Mohr et al. 2008; Rut- mation (Bentall et al. 2001; Freeman 2014). Furthermore, ten et al. 2008). Additionally, paranoid ideation is related it has been suggested that deficits in cognitive inhibition to substantial psychiatric comorbidity with, for example, may lower one’s ability to control unjustified interpretations depression, anxiety, post-traumatic stress disorder, substance about others’ behavior and, in that way, to increase the risk abuse, and even suicidality (Alsawy et al. 2015; Chen et al. for paranoid beliefs (Freeman et al. 2002). 2003; Freeman et al. 2011). Previous intervention studies have mostly evaluated Importantly, paranoid ideation is noted to be linked to the level of cognitive functions using neuropsychological stigmatization and low symptom awareness that, in turn, test patterns or observations by health care professionals, may hinder from seeking help and also disturb with the for- while evidence is lacking whether self-experienced cogni- mation of psychotherapeutic alliance (Świtaj et al. 2009; tive functions might be associated with paranoid ideation. Wright et al. 2012). Traditionally, individuals with paranoid There is, however, evidence that impairments in executive ideation have been provided with heterogeneous interven- functioning commonly result in a variety of self-reported tions, including psychodynamic therapy, cognitive analytic challenges in social and every-day functioning that result therapy, day program interventions, or self-dialogical meth- in lower quality of life (Addington et al. 2008; Niendam ods (Bartak et al. 2011; Bornstein 2005; Dimaggio et al. et al. 2007). On the other hand, it has been reported that 2006; Kellett and Hardy 2014). However, even though these psychiatric patients may compensate their neurophysiologi- psychotherapeutically oriented treatments typically require cal deficits in some brain regions by hyperactivating adjacent a long time span with number of sessions, the results about brain regions (Cooper et al. 2014). There is also evidence their effectiveness have been inconclusive (Bartak et  al. for compensatory cognitive capacities in healthy individuals 2011; Karterud et al. 2003). during test situation (Strobach et al. 2012) and in schizophre- Consequently, there has been an urgent need for novel nia patients (Holthausen et al. 2002). Hence, all cognitive interventions for paranoid ideation. Generally, recent empha- deficits may not necessarily be detected in neuropsychologi- sis has been directed on early interventions for subclinical cal tests. Along with this, previous studies have found that symptoms (McGorry 2010; Scott et al. 2013). Moreover, the correlation of neurocognitive tests with every-day level there has been increasing interest in maladaptive cognitive of functioning is only moderate (Chaytor and Schmitter- functions of paranoid ideation and cognitive remediation Edgecombe 2003; Odhuba et al. 2005). Hence, it has been interventions. In a variety of psychiatric populations, the emphasized that cognitive functions should be investigated most significant deficits seem to occur in executive func- also with self-reports in order to gain insights into practical tioning, working memory, and inhibitory control (Brewer every-day functioning (Løvstad et al. 2012). et al. 2006; Koutsouleris et al. 2011; Rock et al. 2014). For Previously, it has been found that there is a decline in the example, longitudinal studies in high-risk populations have level of paranoid ideation over age (Saarinen et al. 2018b). demonstrated that high levels of cognitive functioning (i.e. This study investigated whether different levels of self- attention, vigilance, working memory) predict a lower risk reported cognitive functioning predict different trajectories for psychosis over a 6-month follow-up (Barbato et al. 2013), of paranoid ideation over a 15-year prospective follow-up. over a 1-year follow-up (Keefe et al. 2006), over a follow-up We used the population-based Young Finns data that pro- of a few years (Seidman et al. 2016), and even over a 7-year vided exceptional possibilities to investigate the trajectories follow-up (Lin et al. 2011). Taken together, executive func- of paranoid ideation in a population-based and non-clinical tioning seems to play a critical role in the transition from sample. Cognitive functions were evaluated with partici- subclinical stage to more severe symptomatology. pants’ self-reported levels of task orientation, distractibility, However, to the best of our knowledge, there have been persistence, flexibility, and perseverance that have essential no longitudinal studies investigating whether cognitive func- roles for every-day functioning. tions predict the course of paranoid ideation. To date, there exist cross-sectional studies suggesting that frequent perse- veration correlated with higher paranoid ideation in high- Methods risk individuals (Berry et al. 2015; Valmaggia et al. 2007) and in clinical patients (Peer et al. 2004). Additionally, an Participants impulsive cognitive style is found to be related to paranoid symptoms (Freeman et al. 2002). In particular, paranoid We used data from the prospective Young Finns Study. The ideation is related to specic fi cognitive biases such as “jump - participants were selected randomly from six age cohorts ing to conclusions” (i.e. an impulsive style to draw conclu- (born between 1962 and 1977) from the population regis- sions), an external-personal attribution style (i.e. attributing ter of the Social Insurance Institution. The Social Insurance 1 3 Cognitive Therapy and Research (2021) 45:333–342 335 Institution covers the whole population of Finland. The orig- e.g. “I usually continue working until I have completed inal sample included 3596 participants in the baseline meas- the task”). The scale of flexibility included 6 items (e.g. urement in 1980 (when participants were aged 3‒18 years). “Changes in my plans make me nervous”). All the items The participants have been followed since then so that the were responded with a 5-point scale (1 = totally disagree; latest follow-up measurement was in 2012 (participants were 5 = totally agree). In this study, the internal consistencies aged 35‒50 years). The study was carried out in accordance of the scales were adequate for the scales of task orienta- with the Declaration of Helsinki. Furthermore, the design tion (Cronbach’s α = 0.79), distractibility (α = 0.79), and of the Young Finns Study was approved by all the Finn- flexibility (α = 0.69). Internal consistency of persistence ish universities with medical schools. Before participation, was lower (α = 0.59) that may partly result from the low all the participants or their parents (for participants aged number of items. Furthermore, the stability of the scales is below 12 years) provided informed consent after the nature shown to be adequate (Windle and Windle 2006). of the procedures had been fully explained. The design of the Perseverance was measured with the FCB-TI (the For- Young Finns Study is described with more detail elsewhere mal Characteristics of Behaviour—Temperament Inven- (see Raitakari et al. 2008). tory) (Strelau and Zawadzki 1993). The scale of perse- For this study, paranoid ideation was evaluated in 1997, verance consists of 20 items (e.g. “After completing a 2001, 2007, and 2012; cognitive functions in 1997; partici- time-taking task, I shortly stop thinking about it” or “Usu- pants’ socioeconomic factors in 2011; and parents’ socio- ally I do not start rethinking about the decisions that I have economic factors in 1980. In the analyses, we included all made previously” [reversed]) that were responded with no the participants with data available on the study variables (score 0) or yes (score 1). The internal consistency of the (i.e. full data available on age, gender, and socioeconomic scale was adequate (Cronbach’s α = 0.70). Furthermore, factors; data available on paranoid ideation in at least one of previous studies have confirmed the validity, stability, the measurement points; and data available on each cogni- and internal reliability of the scale (e.g. De Pascalis et al. tive function in 1997). Other participants (e.g. participants 2000; Strelau and Zawadzki 1993, 1995). who did not have data available on cognitive functions in We calculated the mean scores of flexibility, task ori- 1997) were excluded. The n fi al sample included 1210 ‒1213 entation, persistence, distractibility, and perseverance for participants in the analyses. all the participants who had responded to at least 50% of the items. Measures Self‑Reported Cognitive Functions Paranoid Ideation Self-reported cognitive functions included flexibility, task Paranoid ideation was evaluated with the Paranoid Idea- orientation, persistence, distractibility, and perseverance. tion Scale of the Symptom Checklist-90 Revised (SCL- Flexibility refers to the ability to adapt one’s behavior to 90R; Derogatis 1986). It includes 6 items (e.g. “I think that unexpected changes of the situation or circumstances. Task other people would take advantage of me if I let them to do orientation is defined as the disposition to work in a goal- that”) that are responded with a 5-point scale (1 = totally oriented way and to self-regulate one’s behavior to achieve disagree; 5 = totally agree). The internal reliability of the the goals. Persistence refers to the disposition to continue scale was good (Cronbach’s α = 0.74‒0.80 in 1997, 2001, working toward the goals despite temporary frustration or 2007, and 2012). We calculated the mean score of the challenges. Distractibility refers to disposition to become items for each measurement year if the participant had interrupted by irrelevant internal and external stimuli and responded to at least 50% of the items. The scores for para- to easily direct attention away from the task along with noid ideation were standardized with the mean and stand- other stimuli. Perseverance is defined as the disposition to ard deviation of year 1997 scores, in order to stabilize the response repetition or the inability to undertake set shifting growth curve trajectories between different measurement in line with the circumstances (e.g. rethink previous deci- years. The scale of paranoid ideation has been used also sions or get stuck into a working phase). previously (e.g. Saarinen et al. 2018a, b). Previous studies Flexibility, task orientation, persistence, and distract- have confirmed good reliability and discriminant validity ibility were evaluated with the DOTS-R (the Revised for the SCL-90R and for the subscale of paranoid ideation Dimensions of Temperament Survey) (Windle and Lerner (e.g. Olsen et al. 2004; Schmitz et al. 2000; Starcevic et al. 1986). The scale of task orientation includes 9 items and 2000). Higher scores for paranoid ideation are found to two subscales, namely distractibility (4 items, e.g. “When discriminate between patients with paranoid conditions I’m concentrating on a task, any environmental stimuli and controls and to predict less mature character traits cannot catch my attention”) and persistence (3 items, (Bjørkly 2002; Saarinen et al. 2018b). 1 3 336 Cognitive Therapy and Research (2021) 45:333–342 Covariates analyses, we predicted the course of paranoid ideation over the 15-year follow-up time (in 1997‒2012) by self-reported Socioeconomic factors included participants’ and their par- cognitive functions. Each indicator of cognitive functions ents’ level of income and educational level. Participants’ and (flexibility, task orientation, persistence, distractibility, and their parents’ educational level was categorized into three perseverance) was included separately in the analysis as categories (1 = comprehensive school; 2 = high school or time-invariant predictor. All the models were adjusted for occupational school; 3 = academic level, i.e. university or follow-up time, follow-up time squared, age, sex, and par- college). If mother’s and father’s educational levels differed ticipants’ and their parents’ socioeconomic factors. Further, from each other, we selected the higher level of education. we investigated whether the associations of self-reported Level of parents’ income included 8 categories (1 = less than cognitive functions with paranoid ideation change over the 15 000 Finnish mark per year; 8 = more than 100 000 Finn- follow-up. For this purpose, we included the interactions of ish mark per year). Participants’ level of income was evalu- follow-up time with cognitive functions in the models. ated with a 13-point scale (1 = less than 5 000€ per year; 13 = more than 60 000€ per year). Statistical Analyses Results Statistical analyses were conducted with STATA SE (ver- The descriptive statistics of the study variables are shown sion 13.0). The association of self-reported cognitive func- in Table 1. The correlation coefficients between the study tions with paranoid ideation was investigated using multi- variables are presented in Supplementary Table 1. Briefly, level models for longitudinal design (growth curve models). the inter-correlations between the cognitive functions were Growth curve models estimate two types of effects: i) “fixed as follows: r(correlation of flexibility with other cognitive effects” that refer to classic regression coefficients, and ii) functions) = [−  0.283; 0.166]; r(correlation of persever- “random effects” that refer to the individual-level variance ance with other cognitive functions) = [−  0.283; 0.166]; in the intercept, slopes, and residual variance (i.e. within- r(correlation of task orientation with flexibility or perse- individual variance over the follow-up time). In all the verance) = [− 0.163; 0.134]. The strongest correlation was Table 1 The means, standard Mean SD Measurement Frequency (%) deviations (SD), frequencies, range and ranges of the study variables Age (1997) 27.479 4.983 20–35 Sex (female) 737 (60.76) Parents’ educational level Comprehensive school 377 (31.08) High school or occupational school 510 (42.04) Academic level 326 (26.88) Parents’ level of income 4.986 1.889 1–8 Participants’ educational level Comprehensive school 22 (1.81) High school or occupational school 632 (52.10) Academic level 559 (46.08) Participants’ level of income 7.350 3.003 1–13 Flexibility 3.925 0.608 1–5 Task orientation 3.249 0.599 1–5 Persistence 3.698 0.645 1–5 Distractibility 2.980 0.732 1–5 Perseverance 0.576 0.186 0–1 Paranoid ideation 1997 2.424 0.648 1–5 2001 2.277 0.630 1–5 2007 2.124 0.641 1–5 2011 2.134 0.669 1–5 1 3 Cognitive Therapy and Research (2021) 45:333–342 337 found between task orientation and its subscale persistence but these interactions were not significant after Bonferroni (r = 0.719). correction for multiple testing. That is, between participants Attrition analyses showed that women were more likely with high vs. low level of cognitive functions, there were to participate than men (40.2% vs. 27.0%, p < 0.001). There no significant differences in the course of paranoid idea- was no attrition bias in age, flexibility, task orientation, dis- tion over the follow-up. Taken together, the results showed tractibility, persistence, or perseverance between included that there was a decline in the level of paranoid ideation and excluded participants. Included participants had slightly over the follow-up, independently of the level of cognitive lower level of paranoid ideation in 1997 (2.424 vs. 2.546, functions at the baseline measurement point. Moreover, the p < 0.001), in 2001 (2.277 vs. 2.385, p < 0.001), in 2007 results indicated that high flexibility, high task orientation, (2.124 vs. 2.194, p < 0.05), and in 2012 (2.134 vs. 2.212, high persistence, low distractibility, and low perseverance p < 0.05). There was no attrition bias in participants’ level predicted lower level of paranoid ideation over the 15-year of income. Furthermore, included participants’ parents had prospective follow-up. The findings are illustrated in Fig.  1. slightly higher level of income (4.986 vs. 4.691, p < 0.001) We further investigated whether participants’ age might and were less likely to have low educational level (31.1% vs. modify the associations of cognitive functions with para- 36.6%, p < 0.01) than excluded participants’ parents. Pre- noid ideation. That is, whether participants in different viously, values of the psychosocial variables of the Young age periods and with different cognitive functions could Finns data are found to be missing at random (Pulkki- have different developmental trajectories of paranoid idea - Råback et al. 2015). tion. There were no significant 2-way interactions between The results of the growth curve models are shown in age (p > 0.05) and cognitive functions or 3-way interac- Table  2. Regarding cognitive functions, the main effects tions between age, cognitive functions, and follow-up time showed that low flexibility (B = − 0.509, p < 0.001), task (p > 0.05). Consequently, the associations of cognitive func- or ient ation (B = −  0.291, p < 0.001), and persistence tions with paranoid ideation seemed to be evident regardless (B = − 0.252, p < 0.001) predicted higher course of para- of participants’ age. noid ideation. Additionally, high distractibility (B = 0.116, p < 0.001) and perseverance (B = 1.427, p < 0.001) predicted higher course of paranoid ideation. When predicting para- Discussion noid ideation, there were no significant interaction effects of follow-up time/follow-up time-squared with task orienta- To the best of our knowledge, this study was the first to tion, persistence, or distractibility. That is, a difference in the longitudinally investigate the relationship of self-reported cognitive functions at the baseline measurement (in 1997) cognitive functions with paranoid ideation. The findings predicted a stable difference in paranoid ideation over the showed clear associations of all the single cognitive func- 15-year follow-up (from 1997 to 2012). We obtained follow- tions with paranoid ideation. That is, the results demon- up-interactions with flexibility (p < 0.05) and perseverance strated that low flexibility, low task orientation, low persis- (p < 0.05), when predicting the course of paranoid ideation, tence, high distractibility, and high perseverance predicted Table 2 Results of the growth curve models. Estimates (B) with p-values (within brackets) of task orientation, distractibility, persistence, perse- verance, flexibility and follow-up time, when predicting the growth curve of paranoid ideation in adulthood Fixed effects Random effects Predictor Time Time Predictor* Predictor* Variance of Variance of Residual vari- Time time intercept time ance Task orienta- − 0.219 − 0.068 0.003 (0.157) 0.000 (0.970) 0.000 (0.925) 0.724 (< 0.05) 0.034 (< 0.05) 0.537 (< 0.05) tion (< 0.001) (0.027) Distractibility 0.116 (0.001) − 0.084 0.003 (0.048) 0.005 (0.534) 0.000 (0.804) 0.730 (< 0.05) 0.034 (< 0.05) 0.537 (< 0.05) (< 0.001) Persistence − 0.252 − 0.104 0.004 (0.053) 0.009 (0.280) 0.000 (0.495) 0.718 (< 0.05) 0.034 (< 0.05) 0.537 (< 0.05) (< 0.001) (0.001) Perseverance 1.427 − 0.026 0.000 (0.743) − 0.075 0.004 (0.041) 0.696 (< 0.05) 0.034 (< 0.05) 0.537 (< 0.05) (< 0.001) (0.149) (0.012) Flexibility − 0.509 − 0.149 0.007 (0.003) 0.020 (0.025) − 0.001 0.675 (< 0.05) 0.034 (< 0.05) 0.537 (< 0.05) (< 0.001) (< .001) (0.065) N = 1210–1213 Adjusted for age, sex, and participants’ and their parents’ socioeconomic factors STATA does not report the exact p-values for random effects 1 3 338 Cognitive Therapy and Research (2021) 45:333–342 (a) (d) (b) (e) (c) Fig. 1 The trajectories of paranoid ideation in adulthood separately sistence (b), flexibility (c), perseverance (d), and distractibility (e). for participants with low (lowest 25% in the sample), average, and Estimated means with 95% confidence intervals. Note: adjusted for high (highest 25% in the sample) scores of task orientation (a), per- age, sex, and participants’ and their parents’ socioeconomic factors higher level of paranoid ideation. These associations were individuals with lower self-reported cognitive functioning systematically evident over a 15-year prospective follow- are more prone to paranoid ideation. up in adulthood. All the findings remained after con- The findings are highly in accordance with previous liter - trolling for age, sex, and participants’ and their parents’ ature. Firstly, high perseverance is linked to higher levels of socioeconomic factors. Overall, the results indicate that somatic anxiety, sensory sensitivity, and emotional reactivity 1 3 Cognitive Therapy and Research (2021) 45:333–342 339 (Fruehstorfer et al. 2012; Jankowski and Zajenkowski 2012) the interaction between cognitive functions and paranoid and also more frequent beliefs about uncontrollability and ideation. Previous evidence suggests that there may likely danger of upcoming situations (Dragan and Dragan 2014) exist also indirect pathways from high paranoid ideation to that, in turn, are reported to increase risk for higher paranoid cognitive functions. For example, severe paranoid ideation ideation (Freeman et al. 2002; Freeman 2007). Secondly, may increase stress, anxiety, and social isolation (APA 2013; low vigilance (high task distractibility, conversely) predicts Freeman 2007; Morse and Lynch 2004) that, in turn, may lower level of social functioning (Meyer et al. 2014). Low- increase risk for deficits in cognitive functions (Cacioppo ered social activity and staying away from interpersonal and Hawkley 2009; Derakshan and Eysenck 2009). Recent contacts, in turn, may result in fewer possibilities to receive meta-analyses in clinical populations, however, have con- contradictory evidence for one’s paranoid beliefs (Morse cluded that in most cases cognitive deficits are evident and Lynch 2004). Finally, intervention studies suggest that before the onset of symptomatology and that there appears lower level of inhibitory control is related to more frequent to be no cognitive decline thereafter (Bora and Murray 2013; intrusive thoughts (Bomyea and Amir 2011). Intrusive men- Rock et al. 2014). In this light, impairments in cognitive tal imagery, in turn, is related to higher paranoid ideation functions may be rather a predisposing factor than a conse- (Schulze et al. 2013). Taken together, cognitive impairments quency of paranoid ideation. may predict an array of alterations in socioemotional pro- Secondly, as we used population-based data, our findings cesses and every-day behavioral activities that, in turn, may may not be generalized to clinical populations where para- increase risk for the emergence of paranoid ideation. noid ideation is clinically significant and reaches the level Previous evidence suggests that besides of the psycho- of paranoid personality disorder or psychosis. However, the social associations between cognitive functions and para- current emphasis in interventions has been directed towards noid ideation, there may also exist a neurophysiological early preventive interventions for subclinical symptoms pathway from cognitive functions to paranoid ideation. (McGorry 2010; Scott et al. 2013). This study responds to Specifically, neurophysiological alterations in the frontal the need of early interventions, by providing new evidence cortex may likely explain a major part of the associations for developing cognitive training interventions for individu- of cognitive functions with paranoid ideation. For exam- als with subclinical paranoid ideation. ple, studies among patients with neurosurgical lesions or To the best of our knowledge, this is the longest follow-up delusions have shown that deficits in the prefrontal cortex study of the relationships of cognitive functions with para- are linked to biases in cognitive processing, such as “jump- noid ideation so far. Our findings provide several valuable ing to conclusions” and deficits in prediction-error process- implications for clinical practice. Previously, individuals ing (i.e. difficulties to expect rewards in different situations with paranoid ideation have been treated with psychothera- on the basis of one’s previous experiences) (Corlett et al. peutically oriented interventions, such as psychodynamic 2007; Lunt et al. 2012). These cognitive biases, in turn, are therapy, cognitive analytic therapy, or self-dialogical meth- strongly related to paranoia and other delusions (Corlett ods (Bornstein 2005; Dimaggio et  al. 2006; Kellett and et al. 2007; Freeman et al. 2008). The neurophysiological Hardy 2014). However, even though those interventions deficits in the frontal lobe may partly derive from altera- commonly consist of a long-term set of meetings, their effec- tions in dopamine-related neurotransmission. That is, several tiveness has remained uncertain (e.g. Dixon-Gordon et al. studies have shown that cognitive impairments are related to 2011; Karterud et al. 2003; Schneider and Klauer 2001). Our dopamine-mediated dysfunctions in the frontal lobes (Abi- findings suggest that promoting every-day cognitive func- Dargham et al. 2002; Goldman-Rakic et al. 2004) that are tioning might have long-term protective effects against para- suggested to predispose to the emergence of delusional idea- noid ideation in adulthood. Importantly, cognitive training tion (Pankow et al. 2012). is found to improve cognitive skills even within 2–3 months Overall, it is necessary to consider that, besides of cogni- (Pisculic et al. 2015; Twamley et al. 2012), probably provid- tive functions, there are a variety of other factors affecting ing a cost-effective intervention for high-risk groups. Fur - the development of paranoid ideation: for example, early ther, cognitive training may be particularly effective in sub- life experiences, sleep disturbances, reasoning biases, attri- clinical populations (Rauchensteiner et al. 2011), so that it butional styles, temperament traits related to anxiety-prone- could be provided at the early stages of paranoid ideation. In ness, and depressive symptoms (Bentall et al. 2001; Freeman addition to direct cognitive training, the interventions could 2014; Saarinen et al. 2018a,b). Hence, training cognitive be directed to providing beneficial preconditions for effec- functions can be a part of treatment programs for paranoid tive cognitive functioning e.g. through stress reduction and ideation but also other types of interventions are needed. promoting healthy lifestyle like sufficient sleep. This study had some limitations that are necessary to To date, psychotherapeutic interventions for para- be taken into consideration. Firstly, despite the appropri- noid ideation have typically aimed to promote symptom ate temporal design of this study, we could not investigate 1 3 340 Cognitive Therapy and Research (2021) 45:333–342 Animal Rights No animal studies were carried out by the authors for awareness and insight into one’s deeper mental processes. this article. Symptom awareness itself, however, may not necessarily improve treatment outcome. Instead, there is evidence that Open Access This article is licensed under a Creative Commons Attri- among paranoid patients, high insight may be linked to bution 4.0 International License, which permits use, sharing, adapta- lower levels of self-acceptance, sense of autonomy, and tion, distribution and reproduction in any medium or format, as long personal growth (Valiente et  al. 2011). With regard to as you give appropriate credit to the original author(s) and the source, treatment outcome, the crucial factor appears to be stig- provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are matization. That is, when high symptom awareness occurs included in the article’s Creative Commons licence, unless indicated together with low stigmatization, the treatment outcomes otherwise in a credit line to the material. If material is not included in seem to be substantially enhanced (Lysaker et al. 2006; the article’s Creative Commons licence and your intended use is not Staring et  al. 2009; Valiente et  al. 2011). Our findings permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a suggest that paranoid ideation is linked to self-experi- copy of this licence, visit http://creativ ecommons .or g/licenses/b y/4.0/. enced and self-recognized challenges in daily cognitive functioning. Moreover, challenges in every-day cognitive functioning do not fulfill any diagnosis that might increase stigmatization. Consequently, interventions focusing on References self-experienced impairments in every-day cognitive functioning might provide a possible pathway to increase Abi-Dargham, A., Mawlawi, O., Lombardo, I., Gil, R., Martinez, D., symptom awareness without resulting in stigmatization. Huang, Y., et al. (2002). Prefrontal dopamine D1 receptors and This, in turn, might reduce treatment resistance and working memory in schizophrenia. Journal of Neuroscience, 22, 3708–3719. enhance the development of confidential relationships with Addington, J., Penn, D., Woods, S. W., Addington, D., & Perkins, D. health care professionals. O. (2008). Social functioning in individuals at clinical high risk for psychosis. Schizophrenia Research, 99, 119–124. Acknowledgements The Young Finns Study has been financially sup- Alsawy, S., Wood, L., Taylor, P. J., & Morrison, A. P. (2015). Psychotic ported by the Academy of Finland: Grants 322098, 286284, 134309 experiences and PTSD: exploring associations in a population (Eye), 126925, 121584, 124282, 129378 (Salve), 117797 (Gendi), and survey. Psychological Medicine, 45, 2849–2859. 41071 (Skidi); the Social Insurance Institution of Finland; Competitive American Psychiatric Association (APA), 2013. Diagnostic and Sta- State Research Financing of the Expert Responsibility area of Kuopio, tistical Manual of Mental Disorders (DSM-5®). American Psy- Tampere and Turku University Hospitals (grant X51001); the Juho chiatric Pub. Vainio Foundation; the Sigrid Juselius Foundation; the Yrjö Jahnsson Barbato, M., Colijn, M. A., Keefe, R. S., Perkins, D. O., Woods, S. W., Foundation; the Paavo Nurmi Foundation; the Finnish Foundation of Hawkins, K. A., et al. (2013). The course of cognitive functioning Cardiovascular Research and Finnish Cultural Foundation; the Tampere over six months in individuals at clinical high risk for psychosis. Tuberculosis Foundation; the Emil Aaltonen Foundation; and Diabetes Psychiatry Research, 206, 195–199. Research Foundation of Finnish Diabetes Association. Bartak, A., Andrea, H., Spreeuwenberg, M. D., Thunnissen, M., Ziegler, U. M., Dekker, J., et al. (2011). Patients with cluster A Author Contributions A.S. designed the study, analyzed the data, and personality disorders in psychotherapy: an effectiveness study. prepared the original draft of the manuscript. N.G. and T.L. contrib- Psychotherapy and Psychosomatics, 80, 88–99. uted to interpretation of the results and collaborated with writing the Bentall, R. P., Corcoran, R., Howard, R., Blackwood, N., & Kinder- manuscript. man, P. (2001). Persecutory delusions: a review and theoretical integration. Clin Psychol Rev, 21, 1143–1192. Berry, K., Bucci, S., Kinderman, P., Emsley, R., & Corcoran, R. (2015). Funding Open access funding provided by University of Oulu includ- An investigation of attributional style, theory of mind and execu- ing Oulu University Hospital. The funding source had no role in the tive functioning in acute paranoia and remission. Psychiatry design, analysis, interpretation, or publication of this study. Research, 226, 84–90. Bjørkly, S. (2002). SCL-90-R profiles in a sample of severely violent Compliance with Ethical Standards psychiatric inpatients. Aggressive Behavior, 28, 446–457. Bomyea, J., & Amir, N. (2011). The effect of an executive function- Conflict of Interest Aino I. L. Saarinen, Niklas Granö, and Terho ing training program on working memory capacity and intrusive Lehtimäki declare that they have no conflict of interest. thoughts. Cognitive Therapy and Research, 35, 529–535. Brewer, W. J., Wood, S. J., Phillips, L. J., Francey, S. M., Pantelis, Ethical Approval The study was carried out in accordance with the C., Yung, A. R., et al. (2006). Generalized and specific cognitive Declaration of Helsinki. Furthermore, the design of the Young Finns performance in clinical high-risk cohorts: a review highlighting Study was approved by all the Finnish universities with medical potential vulnerability markers for psychosis. Schizophrenia Bull, schools. 32, 538–555. Bora, E., & Murray, R. M. (2013). Meta-analysis of cognitive deficits Informed Consent Before participation, all the participants or their par- in ultra-high risk to psychosis and first-episode psychosis: do the ents (for participants aged below 12 years) provided informed consent cognitive deficits progress over, or after, the onset of psychosis. after the nature of the procedures had been fully explained. Schizophrenia Bull, 40, 744–755. 1 3 Cognitive Therapy and Research (2021) 45:333–342 341 Bornstein, R. F. 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Clinical staging in psychiatry: a cross-cutting model Publisher’s Note Springer Nature remains neutral with regard to of diagnosis with heuristic and practical value. British Journal of jurisdictional claims in published maps and institutional affiliations. Psychiatry, 20, 243–245. Seidman, L. J., Shapiro, D. I., Stone, W. S., Woodberry, K. A., Ronzio, A., Cornblatt, B. A., et al. (2016). Association of neurocognition with transition to psychosis: baseline functioning in the second 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Cognitive Therapy and Research Springer Journals

Self-Reported Cognitive Functions Predict the Trajectory of Paranoid Ideation Over a 15-Year Prospective Follow-Up

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0147-5916
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10.1007/s10608-020-10142-z
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Abstract

Background This study investigated whether self-reported cognitive functions (i.e. task orientation, distractibility, per- sistence, flexibility, and perseverance) predict the trajectory of paranoid ideation over a 15-year prospective follow-up in adulthood. Methods The participants came from the population-based Young Finns study (N = 1210‒1213). Paranoid ideation was assessed with the Paranoid Ideation Scale of the Symptom Checklist-90 Revised (SCL-90R) in 1997, 2001, 2007, and 2012. Self-reported cognitive functions were evaluated in 1997 with the Task orientation, Distractibility, Persistence, and Flex- ibility scales of the DOTS-R (the Revised Dimensions of Temperament Survey) and the Perseverance scale of the FCB-TI (the Formal Characteristics of Behaviour – Temperament Inventory). The data was analyzed using growth curve models that were adjusted for age, sex, and socioeconomic factors in childhood and adulthood. Results Low self-reported task orientation, low persistence, high distractibility, low flexibility, and high perseverance pre- dicted higher level of paranoid ideation over the 15-year follow-up. Conclusions Self-reported cognitive functions seem to predict paranoid ideation over a long-term follow-up. Promoting cognitive functions in early interventions may have long-term protective influences against the development of paranoid ideation in non-clinical populations. Keywords Paranoid ideation · Subclinical · Cognition · Cognitive functions · Every-day functioning · Longitudinal Introduction Paranoid ideation refers to an unjustified suspiciousness towards others so that others’ motives are supposed to be malevolent (APA 2013). Paranoid ideation can be regarded Electronic supplementary material The online version of this as a continuum, from mild and subclinical levels to severe article (https ://doi.org/10.1007/s1060 8-020-10142 -z) contains paranoid ideation (e.g. Freeman et  al. 2005; Freeman supplementary material, which is available to authorized users. and Garety 2014; Van Os 2003). Mild paranoia includes, * Aino I. L. Saarinen for example, transient and uncertain ideas about negative aino.i.saarinen@helsinki.fi rumors circulating around the self (Freeman and Garety 2014). More severe paranoia, in turn, may refer to paranoid Research Unit of Psychology, University of Oulu, Oulu, personality disorder that includes stable and convincing Finland beliefs that others are deliberately trying to cause significant Department of Psychology and Logopedics, Faculty harm to the self (Freeman and Garety 2014). Most severe of Medicine, University of Helsinki, Haartmaninkatu 3, P.O. Box 21, 00014 Helsinki, Finland paranoid ideation may be manifested as persecutory delu- sions and, thus, reach the level of psychosis (Van Os 2003). Department of Adolescent Psychiatry, Helsinki University Hospital, Helsinki, Finland Paranoid ideation has aroused significant interest because of its relatively high prevalence and societal disadvantages. Department of Clinical Chemistry, Fimlab Laboratories and Finnish Cardiovascular Research Center-Tampere, Specifically, the prevalence of mild paranoid ideas is about Faculty of Medicine and Health Technology, Tampere 10% in China (Chan et al. 2011) and even in 40% in the UK University, Tampere, Finland Vol.:(0123456789) 1 3 334 Cognitive Therapy and Research (2021) 45:333–342 (Freeman et al. 2005). The lifetime prevalence of psychotic- some external events to the self in a biased way), and an level persecutory delusions is estimated to be approximately elevated sensitivity to direct attention to threat-related infor- 5‒8% (Freeman and Freeman 2008; Mohr et al. 2008; Rut- mation (Bentall et al. 2001; Freeman 2014). Furthermore, ten et al. 2008). Additionally, paranoid ideation is related it has been suggested that deficits in cognitive inhibition to substantial psychiatric comorbidity with, for example, may lower one’s ability to control unjustified interpretations depression, anxiety, post-traumatic stress disorder, substance about others’ behavior and, in that way, to increase the risk abuse, and even suicidality (Alsawy et al. 2015; Chen et al. for paranoid beliefs (Freeman et al. 2002). 2003; Freeman et al. 2011). Previous intervention studies have mostly evaluated Importantly, paranoid ideation is noted to be linked to the level of cognitive functions using neuropsychological stigmatization and low symptom awareness that, in turn, test patterns or observations by health care professionals, may hinder from seeking help and also disturb with the for- while evidence is lacking whether self-experienced cogni- mation of psychotherapeutic alliance (Świtaj et al. 2009; tive functions might be associated with paranoid ideation. Wright et al. 2012). Traditionally, individuals with paranoid There is, however, evidence that impairments in executive ideation have been provided with heterogeneous interven- functioning commonly result in a variety of self-reported tions, including psychodynamic therapy, cognitive analytic challenges in social and every-day functioning that result therapy, day program interventions, or self-dialogical meth- in lower quality of life (Addington et al. 2008; Niendam ods (Bartak et al. 2011; Bornstein 2005; Dimaggio et al. et al. 2007). On the other hand, it has been reported that 2006; Kellett and Hardy 2014). However, even though these psychiatric patients may compensate their neurophysiologi- psychotherapeutically oriented treatments typically require cal deficits in some brain regions by hyperactivating adjacent a long time span with number of sessions, the results about brain regions (Cooper et al. 2014). There is also evidence their effectiveness have been inconclusive (Bartak et  al. for compensatory cognitive capacities in healthy individuals 2011; Karterud et al. 2003). during test situation (Strobach et al. 2012) and in schizophre- Consequently, there has been an urgent need for novel nia patients (Holthausen et al. 2002). Hence, all cognitive interventions for paranoid ideation. Generally, recent empha- deficits may not necessarily be detected in neuropsychologi- sis has been directed on early interventions for subclinical cal tests. Along with this, previous studies have found that symptoms (McGorry 2010; Scott et al. 2013). Moreover, the correlation of neurocognitive tests with every-day level there has been increasing interest in maladaptive cognitive of functioning is only moderate (Chaytor and Schmitter- functions of paranoid ideation and cognitive remediation Edgecombe 2003; Odhuba et al. 2005). Hence, it has been interventions. In a variety of psychiatric populations, the emphasized that cognitive functions should be investigated most significant deficits seem to occur in executive func- also with self-reports in order to gain insights into practical tioning, working memory, and inhibitory control (Brewer every-day functioning (Løvstad et al. 2012). et al. 2006; Koutsouleris et al. 2011; Rock et al. 2014). For Previously, it has been found that there is a decline in the example, longitudinal studies in high-risk populations have level of paranoid ideation over age (Saarinen et al. 2018b). demonstrated that high levels of cognitive functioning (i.e. This study investigated whether different levels of self- attention, vigilance, working memory) predict a lower risk reported cognitive functioning predict different trajectories for psychosis over a 6-month follow-up (Barbato et al. 2013), of paranoid ideation over a 15-year prospective follow-up. over a 1-year follow-up (Keefe et al. 2006), over a follow-up We used the population-based Young Finns data that pro- of a few years (Seidman et al. 2016), and even over a 7-year vided exceptional possibilities to investigate the trajectories follow-up (Lin et al. 2011). Taken together, executive func- of paranoid ideation in a population-based and non-clinical tioning seems to play a critical role in the transition from sample. Cognitive functions were evaluated with partici- subclinical stage to more severe symptomatology. pants’ self-reported levels of task orientation, distractibility, However, to the best of our knowledge, there have been persistence, flexibility, and perseverance that have essential no longitudinal studies investigating whether cognitive func- roles for every-day functioning. tions predict the course of paranoid ideation. To date, there exist cross-sectional studies suggesting that frequent perse- veration correlated with higher paranoid ideation in high- Methods risk individuals (Berry et al. 2015; Valmaggia et al. 2007) and in clinical patients (Peer et al. 2004). Additionally, an Participants impulsive cognitive style is found to be related to paranoid symptoms (Freeman et al. 2002). In particular, paranoid We used data from the prospective Young Finns Study. The ideation is related to specic fi cognitive biases such as “jump - participants were selected randomly from six age cohorts ing to conclusions” (i.e. an impulsive style to draw conclu- (born between 1962 and 1977) from the population regis- sions), an external-personal attribution style (i.e. attributing ter of the Social Insurance Institution. The Social Insurance 1 3 Cognitive Therapy and Research (2021) 45:333–342 335 Institution covers the whole population of Finland. The orig- e.g. “I usually continue working until I have completed inal sample included 3596 participants in the baseline meas- the task”). The scale of flexibility included 6 items (e.g. urement in 1980 (when participants were aged 3‒18 years). “Changes in my plans make me nervous”). All the items The participants have been followed since then so that the were responded with a 5-point scale (1 = totally disagree; latest follow-up measurement was in 2012 (participants were 5 = totally agree). In this study, the internal consistencies aged 35‒50 years). The study was carried out in accordance of the scales were adequate for the scales of task orienta- with the Declaration of Helsinki. Furthermore, the design tion (Cronbach’s α = 0.79), distractibility (α = 0.79), and of the Young Finns Study was approved by all the Finn- flexibility (α = 0.69). Internal consistency of persistence ish universities with medical schools. Before participation, was lower (α = 0.59) that may partly result from the low all the participants or their parents (for participants aged number of items. Furthermore, the stability of the scales is below 12 years) provided informed consent after the nature shown to be adequate (Windle and Windle 2006). of the procedures had been fully explained. The design of the Perseverance was measured with the FCB-TI (the For- Young Finns Study is described with more detail elsewhere mal Characteristics of Behaviour—Temperament Inven- (see Raitakari et al. 2008). tory) (Strelau and Zawadzki 1993). The scale of perse- For this study, paranoid ideation was evaluated in 1997, verance consists of 20 items (e.g. “After completing a 2001, 2007, and 2012; cognitive functions in 1997; partici- time-taking task, I shortly stop thinking about it” or “Usu- pants’ socioeconomic factors in 2011; and parents’ socio- ally I do not start rethinking about the decisions that I have economic factors in 1980. In the analyses, we included all made previously” [reversed]) that were responded with no the participants with data available on the study variables (score 0) or yes (score 1). The internal consistency of the (i.e. full data available on age, gender, and socioeconomic scale was adequate (Cronbach’s α = 0.70). Furthermore, factors; data available on paranoid ideation in at least one of previous studies have confirmed the validity, stability, the measurement points; and data available on each cogni- and internal reliability of the scale (e.g. De Pascalis et al. tive function in 1997). Other participants (e.g. participants 2000; Strelau and Zawadzki 1993, 1995). who did not have data available on cognitive functions in We calculated the mean scores of flexibility, task ori- 1997) were excluded. The n fi al sample included 1210 ‒1213 entation, persistence, distractibility, and perseverance for participants in the analyses. all the participants who had responded to at least 50% of the items. Measures Self‑Reported Cognitive Functions Paranoid Ideation Self-reported cognitive functions included flexibility, task Paranoid ideation was evaluated with the Paranoid Idea- orientation, persistence, distractibility, and perseverance. tion Scale of the Symptom Checklist-90 Revised (SCL- Flexibility refers to the ability to adapt one’s behavior to 90R; Derogatis 1986). It includes 6 items (e.g. “I think that unexpected changes of the situation or circumstances. Task other people would take advantage of me if I let them to do orientation is defined as the disposition to work in a goal- that”) that are responded with a 5-point scale (1 = totally oriented way and to self-regulate one’s behavior to achieve disagree; 5 = totally agree). The internal reliability of the the goals. Persistence refers to the disposition to continue scale was good (Cronbach’s α = 0.74‒0.80 in 1997, 2001, working toward the goals despite temporary frustration or 2007, and 2012). We calculated the mean score of the challenges. Distractibility refers to disposition to become items for each measurement year if the participant had interrupted by irrelevant internal and external stimuli and responded to at least 50% of the items. The scores for para- to easily direct attention away from the task along with noid ideation were standardized with the mean and stand- other stimuli. Perseverance is defined as the disposition to ard deviation of year 1997 scores, in order to stabilize the response repetition or the inability to undertake set shifting growth curve trajectories between different measurement in line with the circumstances (e.g. rethink previous deci- years. The scale of paranoid ideation has been used also sions or get stuck into a working phase). previously (e.g. Saarinen et al. 2018a, b). Previous studies Flexibility, task orientation, persistence, and distract- have confirmed good reliability and discriminant validity ibility were evaluated with the DOTS-R (the Revised for the SCL-90R and for the subscale of paranoid ideation Dimensions of Temperament Survey) (Windle and Lerner (e.g. Olsen et al. 2004; Schmitz et al. 2000; Starcevic et al. 1986). The scale of task orientation includes 9 items and 2000). Higher scores for paranoid ideation are found to two subscales, namely distractibility (4 items, e.g. “When discriminate between patients with paranoid conditions I’m concentrating on a task, any environmental stimuli and controls and to predict less mature character traits cannot catch my attention”) and persistence (3 items, (Bjørkly 2002; Saarinen et al. 2018b). 1 3 336 Cognitive Therapy and Research (2021) 45:333–342 Covariates analyses, we predicted the course of paranoid ideation over the 15-year follow-up time (in 1997‒2012) by self-reported Socioeconomic factors included participants’ and their par- cognitive functions. Each indicator of cognitive functions ents’ level of income and educational level. Participants’ and (flexibility, task orientation, persistence, distractibility, and their parents’ educational level was categorized into three perseverance) was included separately in the analysis as categories (1 = comprehensive school; 2 = high school or time-invariant predictor. All the models were adjusted for occupational school; 3 = academic level, i.e. university or follow-up time, follow-up time squared, age, sex, and par- college). If mother’s and father’s educational levels differed ticipants’ and their parents’ socioeconomic factors. Further, from each other, we selected the higher level of education. we investigated whether the associations of self-reported Level of parents’ income included 8 categories (1 = less than cognitive functions with paranoid ideation change over the 15 000 Finnish mark per year; 8 = more than 100 000 Finn- follow-up. For this purpose, we included the interactions of ish mark per year). Participants’ level of income was evalu- follow-up time with cognitive functions in the models. ated with a 13-point scale (1 = less than 5 000€ per year; 13 = more than 60 000€ per year). Statistical Analyses Results Statistical analyses were conducted with STATA SE (ver- The descriptive statistics of the study variables are shown sion 13.0). The association of self-reported cognitive func- in Table 1. The correlation coefficients between the study tions with paranoid ideation was investigated using multi- variables are presented in Supplementary Table 1. Briefly, level models for longitudinal design (growth curve models). the inter-correlations between the cognitive functions were Growth curve models estimate two types of effects: i) “fixed as follows: r(correlation of flexibility with other cognitive effects” that refer to classic regression coefficients, and ii) functions) = [−  0.283; 0.166]; r(correlation of persever- “random effects” that refer to the individual-level variance ance with other cognitive functions) = [−  0.283; 0.166]; in the intercept, slopes, and residual variance (i.e. within- r(correlation of task orientation with flexibility or perse- individual variance over the follow-up time). In all the verance) = [− 0.163; 0.134]. The strongest correlation was Table 1 The means, standard Mean SD Measurement Frequency (%) deviations (SD), frequencies, range and ranges of the study variables Age (1997) 27.479 4.983 20–35 Sex (female) 737 (60.76) Parents’ educational level Comprehensive school 377 (31.08) High school or occupational school 510 (42.04) Academic level 326 (26.88) Parents’ level of income 4.986 1.889 1–8 Participants’ educational level Comprehensive school 22 (1.81) High school or occupational school 632 (52.10) Academic level 559 (46.08) Participants’ level of income 7.350 3.003 1–13 Flexibility 3.925 0.608 1–5 Task orientation 3.249 0.599 1–5 Persistence 3.698 0.645 1–5 Distractibility 2.980 0.732 1–5 Perseverance 0.576 0.186 0–1 Paranoid ideation 1997 2.424 0.648 1–5 2001 2.277 0.630 1–5 2007 2.124 0.641 1–5 2011 2.134 0.669 1–5 1 3 Cognitive Therapy and Research (2021) 45:333–342 337 found between task orientation and its subscale persistence but these interactions were not significant after Bonferroni (r = 0.719). correction for multiple testing. That is, between participants Attrition analyses showed that women were more likely with high vs. low level of cognitive functions, there were to participate than men (40.2% vs. 27.0%, p < 0.001). There no significant differences in the course of paranoid idea- was no attrition bias in age, flexibility, task orientation, dis- tion over the follow-up. Taken together, the results showed tractibility, persistence, or perseverance between included that there was a decline in the level of paranoid ideation and excluded participants. Included participants had slightly over the follow-up, independently of the level of cognitive lower level of paranoid ideation in 1997 (2.424 vs. 2.546, functions at the baseline measurement point. Moreover, the p < 0.001), in 2001 (2.277 vs. 2.385, p < 0.001), in 2007 results indicated that high flexibility, high task orientation, (2.124 vs. 2.194, p < 0.05), and in 2012 (2.134 vs. 2.212, high persistence, low distractibility, and low perseverance p < 0.05). There was no attrition bias in participants’ level predicted lower level of paranoid ideation over the 15-year of income. Furthermore, included participants’ parents had prospective follow-up. The findings are illustrated in Fig.  1. slightly higher level of income (4.986 vs. 4.691, p < 0.001) We further investigated whether participants’ age might and were less likely to have low educational level (31.1% vs. modify the associations of cognitive functions with para- 36.6%, p < 0.01) than excluded participants’ parents. Pre- noid ideation. That is, whether participants in different viously, values of the psychosocial variables of the Young age periods and with different cognitive functions could Finns data are found to be missing at random (Pulkki- have different developmental trajectories of paranoid idea - Råback et al. 2015). tion. There were no significant 2-way interactions between The results of the growth curve models are shown in age (p > 0.05) and cognitive functions or 3-way interac- Table  2. Regarding cognitive functions, the main effects tions between age, cognitive functions, and follow-up time showed that low flexibility (B = − 0.509, p < 0.001), task (p > 0.05). Consequently, the associations of cognitive func- or ient ation (B = −  0.291, p < 0.001), and persistence tions with paranoid ideation seemed to be evident regardless (B = − 0.252, p < 0.001) predicted higher course of para- of participants’ age. noid ideation. Additionally, high distractibility (B = 0.116, p < 0.001) and perseverance (B = 1.427, p < 0.001) predicted higher course of paranoid ideation. When predicting para- Discussion noid ideation, there were no significant interaction effects of follow-up time/follow-up time-squared with task orienta- To the best of our knowledge, this study was the first to tion, persistence, or distractibility. That is, a difference in the longitudinally investigate the relationship of self-reported cognitive functions at the baseline measurement (in 1997) cognitive functions with paranoid ideation. The findings predicted a stable difference in paranoid ideation over the showed clear associations of all the single cognitive func- 15-year follow-up (from 1997 to 2012). We obtained follow- tions with paranoid ideation. That is, the results demon- up-interactions with flexibility (p < 0.05) and perseverance strated that low flexibility, low task orientation, low persis- (p < 0.05), when predicting the course of paranoid ideation, tence, high distractibility, and high perseverance predicted Table 2 Results of the growth curve models. Estimates (B) with p-values (within brackets) of task orientation, distractibility, persistence, perse- verance, flexibility and follow-up time, when predicting the growth curve of paranoid ideation in adulthood Fixed effects Random effects Predictor Time Time Predictor* Predictor* Variance of Variance of Residual vari- Time time intercept time ance Task orienta- − 0.219 − 0.068 0.003 (0.157) 0.000 (0.970) 0.000 (0.925) 0.724 (< 0.05) 0.034 (< 0.05) 0.537 (< 0.05) tion (< 0.001) (0.027) Distractibility 0.116 (0.001) − 0.084 0.003 (0.048) 0.005 (0.534) 0.000 (0.804) 0.730 (< 0.05) 0.034 (< 0.05) 0.537 (< 0.05) (< 0.001) Persistence − 0.252 − 0.104 0.004 (0.053) 0.009 (0.280) 0.000 (0.495) 0.718 (< 0.05) 0.034 (< 0.05) 0.537 (< 0.05) (< 0.001) (0.001) Perseverance 1.427 − 0.026 0.000 (0.743) − 0.075 0.004 (0.041) 0.696 (< 0.05) 0.034 (< 0.05) 0.537 (< 0.05) (< 0.001) (0.149) (0.012) Flexibility − 0.509 − 0.149 0.007 (0.003) 0.020 (0.025) − 0.001 0.675 (< 0.05) 0.034 (< 0.05) 0.537 (< 0.05) (< 0.001) (< .001) (0.065) N = 1210–1213 Adjusted for age, sex, and participants’ and their parents’ socioeconomic factors STATA does not report the exact p-values for random effects 1 3 338 Cognitive Therapy and Research (2021) 45:333–342 (a) (d) (b) (e) (c) Fig. 1 The trajectories of paranoid ideation in adulthood separately sistence (b), flexibility (c), perseverance (d), and distractibility (e). for participants with low (lowest 25% in the sample), average, and Estimated means with 95% confidence intervals. Note: adjusted for high (highest 25% in the sample) scores of task orientation (a), per- age, sex, and participants’ and their parents’ socioeconomic factors higher level of paranoid ideation. These associations were individuals with lower self-reported cognitive functioning systematically evident over a 15-year prospective follow- are more prone to paranoid ideation. up in adulthood. All the findings remained after con- The findings are highly in accordance with previous liter - trolling for age, sex, and participants’ and their parents’ ature. Firstly, high perseverance is linked to higher levels of socioeconomic factors. Overall, the results indicate that somatic anxiety, sensory sensitivity, and emotional reactivity 1 3 Cognitive Therapy and Research (2021) 45:333–342 339 (Fruehstorfer et al. 2012; Jankowski and Zajenkowski 2012) the interaction between cognitive functions and paranoid and also more frequent beliefs about uncontrollability and ideation. Previous evidence suggests that there may likely danger of upcoming situations (Dragan and Dragan 2014) exist also indirect pathways from high paranoid ideation to that, in turn, are reported to increase risk for higher paranoid cognitive functions. For example, severe paranoid ideation ideation (Freeman et al. 2002; Freeman 2007). Secondly, may increase stress, anxiety, and social isolation (APA 2013; low vigilance (high task distractibility, conversely) predicts Freeman 2007; Morse and Lynch 2004) that, in turn, may lower level of social functioning (Meyer et al. 2014). Low- increase risk for deficits in cognitive functions (Cacioppo ered social activity and staying away from interpersonal and Hawkley 2009; Derakshan and Eysenck 2009). Recent contacts, in turn, may result in fewer possibilities to receive meta-analyses in clinical populations, however, have con- contradictory evidence for one’s paranoid beliefs (Morse cluded that in most cases cognitive deficits are evident and Lynch 2004). Finally, intervention studies suggest that before the onset of symptomatology and that there appears lower level of inhibitory control is related to more frequent to be no cognitive decline thereafter (Bora and Murray 2013; intrusive thoughts (Bomyea and Amir 2011). Intrusive men- Rock et al. 2014). In this light, impairments in cognitive tal imagery, in turn, is related to higher paranoid ideation functions may be rather a predisposing factor than a conse- (Schulze et al. 2013). Taken together, cognitive impairments quency of paranoid ideation. may predict an array of alterations in socioemotional pro- Secondly, as we used population-based data, our findings cesses and every-day behavioral activities that, in turn, may may not be generalized to clinical populations where para- increase risk for the emergence of paranoid ideation. noid ideation is clinically significant and reaches the level Previous evidence suggests that besides of the psycho- of paranoid personality disorder or psychosis. However, the social associations between cognitive functions and para- current emphasis in interventions has been directed towards noid ideation, there may also exist a neurophysiological early preventive interventions for subclinical symptoms pathway from cognitive functions to paranoid ideation. (McGorry 2010; Scott et al. 2013). This study responds to Specifically, neurophysiological alterations in the frontal the need of early interventions, by providing new evidence cortex may likely explain a major part of the associations for developing cognitive training interventions for individu- of cognitive functions with paranoid ideation. For exam- als with subclinical paranoid ideation. ple, studies among patients with neurosurgical lesions or To the best of our knowledge, this is the longest follow-up delusions have shown that deficits in the prefrontal cortex study of the relationships of cognitive functions with para- are linked to biases in cognitive processing, such as “jump- noid ideation so far. Our findings provide several valuable ing to conclusions” and deficits in prediction-error process- implications for clinical practice. Previously, individuals ing (i.e. difficulties to expect rewards in different situations with paranoid ideation have been treated with psychothera- on the basis of one’s previous experiences) (Corlett et al. peutically oriented interventions, such as psychodynamic 2007; Lunt et al. 2012). These cognitive biases, in turn, are therapy, cognitive analytic therapy, or self-dialogical meth- strongly related to paranoia and other delusions (Corlett ods (Bornstein 2005; Dimaggio et  al. 2006; Kellett and et al. 2007; Freeman et al. 2008). The neurophysiological Hardy 2014). However, even though those interventions deficits in the frontal lobe may partly derive from altera- commonly consist of a long-term set of meetings, their effec- tions in dopamine-related neurotransmission. That is, several tiveness has remained uncertain (e.g. Dixon-Gordon et al. studies have shown that cognitive impairments are related to 2011; Karterud et al. 2003; Schneider and Klauer 2001). Our dopamine-mediated dysfunctions in the frontal lobes (Abi- findings suggest that promoting every-day cognitive func- Dargham et al. 2002; Goldman-Rakic et al. 2004) that are tioning might have long-term protective effects against para- suggested to predispose to the emergence of delusional idea- noid ideation in adulthood. Importantly, cognitive training tion (Pankow et al. 2012). is found to improve cognitive skills even within 2–3 months Overall, it is necessary to consider that, besides of cogni- (Pisculic et al. 2015; Twamley et al. 2012), probably provid- tive functions, there are a variety of other factors affecting ing a cost-effective intervention for high-risk groups. Fur - the development of paranoid ideation: for example, early ther, cognitive training may be particularly effective in sub- life experiences, sleep disturbances, reasoning biases, attri- clinical populations (Rauchensteiner et al. 2011), so that it butional styles, temperament traits related to anxiety-prone- could be provided at the early stages of paranoid ideation. In ness, and depressive symptoms (Bentall et al. 2001; Freeman addition to direct cognitive training, the interventions could 2014; Saarinen et al. 2018a,b). Hence, training cognitive be directed to providing beneficial preconditions for effec- functions can be a part of treatment programs for paranoid tive cognitive functioning e.g. through stress reduction and ideation but also other types of interventions are needed. promoting healthy lifestyle like sufficient sleep. This study had some limitations that are necessary to To date, psychotherapeutic interventions for para- be taken into consideration. Firstly, despite the appropri- noid ideation have typically aimed to promote symptom ate temporal design of this study, we could not investigate 1 3 340 Cognitive Therapy and Research (2021) 45:333–342 Animal Rights No animal studies were carried out by the authors for awareness and insight into one’s deeper mental processes. this article. Symptom awareness itself, however, may not necessarily improve treatment outcome. Instead, there is evidence that Open Access This article is licensed under a Creative Commons Attri- among paranoid patients, high insight may be linked to bution 4.0 International License, which permits use, sharing, adapta- lower levels of self-acceptance, sense of autonomy, and tion, distribution and reproduction in any medium or format, as long personal growth (Valiente et  al. 2011). With regard to as you give appropriate credit to the original author(s) and the source, treatment outcome, the crucial factor appears to be stig- provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are matization. That is, when high symptom awareness occurs included in the article’s Creative Commons licence, unless indicated together with low stigmatization, the treatment outcomes otherwise in a credit line to the material. If material is not included in seem to be substantially enhanced (Lysaker et al. 2006; the article’s Creative Commons licence and your intended use is not Staring et  al. 2009; Valiente et  al. 2011). Our findings permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a suggest that paranoid ideation is linked to self-experi- copy of this licence, visit http://creativ ecommons .or g/licenses/b y/4.0/. enced and self-recognized challenges in daily cognitive functioning. Moreover, challenges in every-day cognitive functioning do not fulfill any diagnosis that might increase stigmatization. Consequently, interventions focusing on References self-experienced impairments in every-day cognitive functioning might provide a possible pathway to increase Abi-Dargham, A., Mawlawi, O., Lombardo, I., Gil, R., Martinez, D., symptom awareness without resulting in stigmatization. Huang, Y., et al. (2002). Prefrontal dopamine D1 receptors and This, in turn, might reduce treatment resistance and working memory in schizophrenia. Journal of Neuroscience, 22, 3708–3719. enhance the development of confidential relationships with Addington, J., Penn, D., Woods, S. W., Addington, D., & Perkins, D. health care professionals. O. (2008). 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W., Foundation; the Paavo Nurmi Foundation; the Finnish Foundation of Hawkins, K. A., et al. (2013). The course of cognitive functioning Cardiovascular Research and Finnish Cultural Foundation; the Tampere over six months in individuals at clinical high risk for psychosis. Tuberculosis Foundation; the Emil Aaltonen Foundation; and Diabetes Psychiatry Research, 206, 195–199. Research Foundation of Finnish Diabetes Association. Bartak, A., Andrea, H., Spreeuwenberg, M. D., Thunnissen, M., Ziegler, U. M., Dekker, J., et al. (2011). Patients with cluster A Author Contributions A.S. designed the study, analyzed the data, and personality disorders in psychotherapy: an effectiveness study. prepared the original draft of the manuscript. N.G. and T.L. contrib- Psychotherapy and Psychosomatics, 80, 88–99. uted to interpretation of the results and collaborated with writing the Bentall, R. P., Corcoran, R., Howard, R., Blackwood, N., & Kinder- manuscript. man, P. (2001). 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