Attribution style
What is the evidence to date that transient paranoid ideation contributes to risk of violence? In current research, transient paranoid ideation has been most precisely studied by way of the construct of attribution style, which has been examined to a limited extent in relation to violence.
Attribution style is a concept of cognitive processing used to characterize the extent to which an individual attributes causation for positive events to his own abilities while attributing negative events to chance or external factors and vice versa.18 This general concept, however, is related to one of the main psychopathological mechanisms present in paranoid states, described by Freud as projection. In projection, an internal state that is otherwise unbearable is experienced by the person as a property of the external environment. In 1922, Freud remarked that:
"[S]ufferers from persecutory paranoia . . . cannot regard anything in other people as indifferent, and they . . . take up minute indications with which these other, unknown people present them, and use them in their delusions of reference. The meaning of their delusion of reference is that they expect from all strangers something like love . . . the paranoic is not so far wrong in regarding this indifference as hate, in contrast to his claim for love. . . . They let themselves be guided by their knowledge of the unconscious, and displace to the unconscious minds of others the attention which they have withdrawn from their own."19
Current conceptualizations of attribution style diverge from this psychoanalytic formulation of projection, and divide the phenomenon into 4 classes of explanations for paranoid behavior in the context of persecutory delusions:20,21
1. Heightened perception of threat from the content of delusions, particularly TCO delusions
2. Theory of mind abnormalities, which involve the ability to envision the minds of others but without empathy
3. Attributional bias, which is characterized by a hostile and threatening outlook regarding others and external stimuli
4. Early adverse experience
Also described as a paranoid cognitive personality style, attribution bias involves distortions in the interpretation of innocuous events.
Bentall and Taylor20 emphasize that because these constructs have been studied separately, their combination or convergence in risk for violence has yet to be elucidated, since many persons with such traits do not commit acts of violence. Recent efforts to examine the interrelations of different reasoning abnormalities in schizophrenic delusions may allow further study of these dimensions as contributors to violence risk.22
In a comprehensive review of persecutory delusions, Bentall and colleagues18 propose a heuristic model of persecutory thought processes, proceeding from data to attention and perception, to inference, belief, and the search for further data regarding the belief. This progressive feedback loop leads the authors to posit an attribution–self-representation cycle that can account for the evolution of the paranoid individual’s self-concept and behavior over time, in relation to biological as well as experiential and environmental factors. They remark that the distinction between persecutory delusions and delusional guilt, as found in psychotic depression, is difficult to make because of the perception of imminent harm in both concepts that may be viewed as either intentional malevolence or deserved punishment. They note alternative definitions that include defining delusions that would properly be classified as persecutory by attributing the experience of intent to a perpetrator.
The difficulty in arriving at clear definitions speaks to the wide range of paranoid delusions that may be found in conditions other than schizophrenia or delusional disorder. A study of acute, remitted (nonacute) paranoid, and remitted nonparanoid patients with schizophrenia or schizoaffective disorder indicates that acutely paranoid patients are more likely to demonstrate external-personal attributions when confronted with negative events, and that remitted patients are more likely to do so than controls.23 This suggests that there is a stable, chronic component to attribution style that is associated with specific disorders. Another component of attribution may be state-dependent and augmented during psychiatric decompensation, either of a primary psychotic disorder or an affective disorder, such as depression.
Attributional style has been operationalized outside the realm of delusions per se in a study by McNiel and colleagues24 on violence in an inpatient sample. These investigators found that “an aggressive attributional style is associated with increased rates of violent behavior by psychiatric patients” in the 2 months before admission. Impulsiveness was also associated with violence but did not independently contribute to violence once attributional style was taken into account. The findings indicate that aggressive attributions predict violence beyond demographic variables and diagnoses, as well as beyond other established predictors of violence.24
Nestor25 presents 4 key dimensions of personality that were each hypothesized to be predictive of violence risk in patients with a particular mental disorder. In addition to impulse control, affect regulation, and narcissism, paranoid cognitive personality style was examined in schizophrenia and chronic psychotic disorders using the construct of attribution bias. Nestor proposes that personality traits associated with specific disorders, such as substance abuse, personality disorders, and schizophrenia, may be useful to study in a transdiagnostic manner as refined predictors of a propensity for violence.
