Schizophrenia Bulletin https://doi.org/10.1093/schbul/sbac071 Psychological Pathways to Paranoia and Psychotic-Like Experiences in Daily-Life: The Mediating Role of Distinct Affective Disturbances Manel Monsonet1, , Nicholas J. Rockwood2, Thomas R. Kwapil3, and Neus Barrantes-Vidal*,1,4,5, 1 Departament de Psicologia Clínica i de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain; 2School of Behavioral Health, Loma Linda University, Loma Linda, CA, USA; 3Department of Psychology, University of Illinois at Urbana-Champaign, Champaign, IL, USA; 4Sant Pere Claver—Fundació Sanitària, Barcelona, Spain; 5Centre for Biomedical Research Network on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain *To whom correspondence should be addressed; Departament de Psicologia Clínica i de la Salut, Facultat de Psicologia, Edifici B, Universitat Autònoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Barcelona, Spain; tel: 34-93-581-38-64, fax: 34-93-581-21- 25, e-mail: neus.barrantes@uab.cat Background and Hypothesis: Influential models of psychosis Introduction indicate that the impact of putative causal factors on positive Unraveling the psychological mechanisms that lead to symptoms might be explained partly through affective dis- psychosis is essential for reducing the suffering of people turbances. We aimed to investigate whether pathways from who are impacted by psychotic disorders. Stress has been stress and self-esteem to positive symptoms, as well as reversal historically implicated and accepted as a risk factor for pathways from symptoms to stress and self-esteem, were me- psychotic disorders,1,2 but influential models of psychosis diated through specific affective disturbances across the ex- argue that different complex pathways could be acting be- tended psychosis phenotype. Study Design: Using experience tween stress and psychotic symptoms.3–8 One pathway to sampling methodology, 178 participants (65 high-schizotypy, psychosis may involve the interplay of affective disturb- 74 at-risk mental state, and 39 first-episode psychosis) were ances with stress. Myin-Germeys and van Os8 argued that assessed on levels of momentary stress, self-esteem, anxiety, stress triggered by daily hassles was related to an increase sadness, psychotic-like experiences (PLE), and paranoia. in negative affect, suggesting that increased emotional re- Multilevel mediation models were fit to examine indirect ef- activity to stress may act as a vulnerability factor for pos- fects of each of these pathways. Considering evidence of me- itive symptoms of psychosis. However, a range of specific diation, each indirect pathway will be combined in a single negative mental states falls under the umbrella of nega- model to explore their relative contributions. Study Results: tive affect that could be differently interacting with stress Anxiety, sadness, and self-esteem mediated the pathways in the onset and exacerbation of positive symptoms. from stress to PLE and paranoia in daily-life. In the pathway Specifically, anxiety, depression, and low self-esteem have to paranoia, sadness, and self-esteem showed larger contri- been postulated as possible factors that could mediate butions than anxiety. Pathways from self-esteem to PLE and the path from stress to psychosis.4,9,10 Studies using exper- paranoia were mediated by anxiety and sadness, the later imental designs with nonclinical participants found that showing a larger contribution. Pathways from symptoms to anxiety11 and self-esteem12 mediated the association of stress, but not from symptoms to self-esteem, were differently stress and paranoia. Further, Freeman et al13 showed in explained by emotional states; sadness lost its mediating ef- patients with persecutory delusions that anxiety and de- fect and anxiety was the most important mediator. Few dif- pression partially mediated the association of the “stress ferences across groups were found. Conclusions: This study of the street” and paranoia. Therefore, it seems critical to lends support to psychological models of psychosis that high- disentangle how stress could be interplaying with these light the relevance of affective disturbances in the risk and specific negative mental states in the pathway to positive expression of psychosis. Furthermore, specific influences of symptoms. different negative emotional states were identified, which In recent years, a significant proportion of research has could enhance psychological treatments. used the “single symptom” approach.14,15 This strategy tries to understand the etiology and development of Keywords: psychosis/stress/self-esteem/experience specific core symptoms to minimize the large heteroge- sampling/first-episode psychosis/at-risk mental states neity present in the psychosis phenotype. Following this © The Author(s) 2022. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.comPage 1053 of 1065 M. Monsonet et al approach, relevant models of persecutory delusions have study has explored the mediation effects of emotional been proposed.9,16,17 Emotions and low self-esteem have and cognitive factors in the association between stress been implicated as casual factors in the development and psychotic experiences.42 Using an early psychosis and maintenance of paranoia.16,18–23 However, the precise sample, they found that negative affect mediated the link mechanisms that explain the link between self-esteem, between stress and psychotic experiences, and that the emotions, and paranoia are still not well understood. relative contribution of this indirect path was larger com- Freeman et al9 proposed that in individuals with per- pared to other indirect paths involving cognitive factors sistent negative beliefs about the self, low self-esteem (threat anticipation and aberrant salience). Given that could impact the formation and expression of persecu- negative affect may have a key role in the association be- tory delusions through negative emotional states such tween stress and psychosis, it would be highly relevant to as anxiety and depression. Some evidence for this indi- explore whether specific aspects of affective disturbance rect path from negative beliefs about the self to para- (anxiety, depression, and low self-esteem) mediate the noia has been reported. Using path analyses, Galbraith path from stress to psychosis, examining the possible dif- et al24 found in undergraduate students that self-esteem ferences between them, as well as whether similar path- lead to paranoia depending on levels of anxiety and de- ways are acting across individuals with different levels of pression. They showed that depression was the strongest expression along the psychosis continuum. mediator, concluding that the effect of anxiety depended The present study used ESM to test different theory- on the presence of depression. In contrast, Oliver et al25 driven models of the association of stress, affective dis- found that anxiety, but not depression, mediated the as- turbances, and symptoms in real life and whether these sociation between negative schemas and delusional ide- associations held across different levels of expression of ation in sample of undergraduate students. Finally, in a the psychosis continuum, that is, high-schizotypy (or psy- large sample of people with schizophrenia, both anxiety chometric risk for psychosis), at-risk mental states for and depressive symptoms mediated the path between psychosis (ARMS; clinical risk for psychosis), and first- self-esteem and paranoia,26 although depression showed episode psychosis (FEP). First, we examined whether a greater mediational effect than anxiety. Thus, the pre- stress in the moment was associated with positive cise role of anxiety and depression in the pathway from psychotic-like experiences (PLE) through specific neg- self-esteem to paranoia remains to be elucidated. To date, ative mental states of sadness, anxiety, and low self-es- no studies have explored this possible mechanism in sam- teem. To assess the specificity of these different pathways, ples comprising different stages of the psychosis con- we tested these models with both paranoia and PLE tinuum, nor in the realm of daily-life. other than paranoia as separate outcomes (figure 1, dia- Experience sampling methodology (ESM) is a struc- gram 1). A significant indirect effect of stress to PLE and tured diary technique that repeatedly assesses experiences, paranoia was expected through all negative mental states. such as cognition, affect, symptoms, and contextual fac- Second, based on claims that self-esteem has a specific tors, in daily-life,27–29 offering relevant advantages over causal role in the development of paranoia, we investi- traditional laboratory assessments.30–32 For example, ESM gated whether low self-esteem would be associated with allows examination of the interaction of the individual paranoia through anxiety and sadness (figure 1, diagram with the environment through repeated assessments of 2). We hypothesized that both anxiety and sadness would mental experiences in their natural context, offers a fine- mediate the pathway from self-esteem to paranoia, al- grained repeated assessment of psychological experi- though, following the literature reviewed above, a larger ences, and increases ecological validity.33–35 ESM studies effect was expected for sadness. As self-esteem has been have made significant contributions to the investigation also implicated in the development of PLE other than of putative psychological mechanisms underlying the de- paranoia,21,47,48 we also tested whether self-esteem was re- velopment of psychotic disorders,36–41 expanding previous lated to PLE through anxiety and sadness. Third, as it findings of traditional laboratory research.30 However, has been postulated that the connection between self-es- only a few ESM studies have examined the causal psy- teem and psychopathology may be bidirectional, with chological mechanisms that could be interacting in the self-esteem affecting symptoms and symptoms affecting development of psychosis37,42–45; therefore, there is a need self-esteem,49–52 competitive models explored whether the to replicate these findings and to explore other relevant associations of PLE and paranoia with self-esteem were putative causal mechanisms, especially in early psychosis also mediated by sadness and anxiety (figure 1, diagram samples.30 Looking at etiological factors of psychosis 4). Similarly, the same bidirectional link between stress in at-risk and early stages of the illness should provide and PLE could be hypothesized. Indeed, Barrantes-Vidal both additional and more precise information than that et al53 found that both PLE and paranoia predicted sub- obtained at more developed stages by avoiding many sequent stress in nonclinical participants. Thus, we also of the confounding effects of illness chronicity, such as investigated whether the associations of PLE and para- stigma, long-term medication effects, and comorbidity noia with stress were mediated by sadness, anxiety, and with other conditions.46 To our knowledge, only 1 ESM self-esteem (figure 1, diagram 3). Finally, we examined Page 1054 of 1065 Pathways to Psychotic-Like Experiences Fig. 1. Diagrams of hypothesized pathways examined in the study. Group variable was only included in the final models examined. Note: PLE, psychotic-like experiences. whether these potential combined indirect pathways The ARMS and FEP participants were drawn from varied across samples with high-schizotypy, ARMS, and a longitudinal study at 4 Mental Health Centres of FEP individuals. Barcelona belonging to the Sant Pere Claver Early Psychosis Program.59,60 The inclusion criteria were ages Methods 14–40 years old and IQ ≥ 75, whereas exclusion criterion was evidence of organically based psychotic symptoms. Participants and Procedure ARMS specific criteria were based on the Comprehensive The sample comprised 178 participants, with 65 high- Assessment of At-Risk Mental States.61 FEP patients schizotypy, 74 ARMS, and 39 FEP participants (mean met DSM-IV-TR62 criteria for any psychotic disorder age = 22.0 years, SD = 3.90 years; 53.4% males). The high- or affective disorder with psychotic symptoms assessed schizotypy participants were drawn from the Barcelona by the SCID-I. FEP patients who experienced their first Longitudinal Investigation of Schizotypy (BLISS).53 An psychotic episode more than 2 years before the assess- initial unselected sample comprised 547 undergraduates ment were not included. Participants provided written from the Universitat Autonòma de Barcelona (UAB) informed consent, conforming to local ethics committee and 261 students from technical training schools in guidelines. The project was developed following the Code Barcelona. A subsample (214 and 39, respectively) was of Ethics of the World Medical Association (Declaration selected to conduct an in-depth assessment. A detailed of Helsinki). description of the sample selection procedure has been Experience sampling data were collected on personal provided elsewhere.54 From this subsample, we selected digital assistants (n = 137) or smartphones (n = 41) that 65 high-schizotypy participants (49 from UAB and 16 signaled participants semi-randomly 8 times daily (be- from technical schools) who had standard scores based tween 11 am and 10 pm) for 7 days to complete brief upon sample norms of at least 1.5 on the positive dimen- questionnaires. The average number of completed ESM sion of the Wisconsin Schizotypy Scales (WSS),55 the questionnaires did not differ between PDA and smart- suspiciousness subscale of the Schizotypal Personality phones (t = .931, P = .353) and these methods generate Questionnaire (SPQ),56 or the positive symptom subscale comparable data in terms of quantity and quality.63,64 of the Community Assessment of Psychic Experiences Participants had up to 15 min after the signal to complete (CAPE).57 None of the university or technical school the ESM questionnaires and participants who completed participants had a psychotic disorder as assessed by the less than a third (<18) of the total questionnaires (56) Structured Clinical Interview for DSM-IV (SCID-I).58 were excluded from the analyses.65 Page 1055 of 1065 M. Monsonet et al Measures stress and self-esteem was also mediated by sadness, anx- ESM items were rated on a 7-point Likert scale that iety, and self-esteem. Similar to previous models, separate ranges from “not at all” to “very much.” The complete multilevel mediation models were conducted to examine list of ESM items can be found in Barrantes-Vidal et al.53 the within-person indirect effects of each pathway inde- Several studies have employed ESM across the psy- pendently, and then, subsequent combined multilevel me- chosis continuum demonstrating its validity and relia- diation models were fitted with all statistically significant bility.41,44,53,66 Within and between-person reliabilities for mediating variables included in the same model. Finally, ESM indices were computed following Geldhof et al.67 multilevel moderated mediation models were employed Momentary stress was assessed with the item “My cur- to examine whether within-person indirect effects varied rent situation is stressful.” Momentary self-esteem was between the high-schizotypy, ARMS, and FEP groups measured with the mean of 3 ESM items (“Right now (level 2 variables). I feel good about myself,” “Right now I can cope,” and “Right now I feel guilty or ashamed,” reversed; within Results alpha = .53, between alpha = .84). To assess momentary PLE the mean of 8 ESM items were used (eg, “Right now From the initial sample, 10 participants (5 high- I feel weird,” “Since the last beep, I have heard or seen schizotypy, 1 ARMS, and 4 FEP) refused to participate things others could not”; within alpha = .65, between in the ESM assessment or were omitted due to equip- alpha = .88). Momentary paranoia was assessed with ment malfunctions. Nine participants (3 high-schizotypy, the mean of 2 ESM items (“Right now I feel suspicious,” 2 ARMS, and 4 FEP) completed less than 18 question- “Right now I feel mistreated”; within alpha = .52, between naires and were excluded from the analyses, resulting in alpha = .81). Finally, anxiety and depressive experiences a final sample of 178 participants (65 high-schizotypy, 74 were measured with the items “Right now I feel anxious ARMS, and 39 FEP). Basic sample characteristics and (nervous)” and “Right now I feel sad,” respectively. group comparisons of all variables employed in this study are presented in table 1. Multilevel correlations between all variables employed in this study showed small to mod- Data Analyses erate magnitudes, except for the correlation between ESM data have a hierarchical structure in which re- stress and anxiety that was large (supplementary table 1). peated daily-life ratings (level-1 units) are nested within All subsequent effects reported correspond to effects at subjects (level-2 units). Therefore, multilevel structural the within-person level, which were of primary relevance equation models were employed using Mplus Version 8.68 to the hypotheses. Following the recommendation of the Mplus developers, Results of multilevel mediation analyses examining the we fit the models using Bayesian estimation.69 Posterior within-person indirect effects of pathways from stress to credible intervals (comparable to frequentist-based CIs) PLE and paranoia through anxiety, sadness, or self-es- for the parameter estimates were used to determine sta- teem indicated that all the indirect effects were statisti- tistical significance. Supplementary Methods contain a cally significant when they were examined separately. detailed description of these models. Similarly, indirect effects of self-esteem on PLE and par- The present study examines 2 types of multilevel medi- anoia through anxiety or sadness were significant when ation analyses to test the independent and simultaneous they were examined separately (table 2). within-person mediating effects of anxiety, sadness, and Subsequent multilevel mediational analyses com- self-esteem. First, separate multilevel mediation models bining the significant within-person indirect effects of were conducted to examine the within-person indirect ef- each pathway in a single model were performed (table 3). fects of each pathway independently: (1) with stress as Indirect effects of stress on PLE through anxiety, sad- predictor variable, 1 mediator variable for anxiety, sad- ness, and self-esteem all remained statistically significant ness, or self-esteem, and 1 criterion variable of PLE or and the relative contribution of each indirect effect to paranoia; and (2) with self-esteem as predictor variable, the model was similar. No differences in the magnitude 1 mediator variable for anxiety or sadness, and 1 crite- of indirect effects across groups were found except for rion variable of PLE or paranoia. Second, in order to the indirect effect through sadness, which was greater in evaluate the relative contribution of each mediator si- ARMS than in high-schizotypy participants. Likewise, multaneously, and based on evidence of mediation in the indirect effects of stress on paranoia through anxiety, the previous models, subsequent combined multilevel sadness, and self-esteem remained statistically signifi- mediation models were fitted with all statistically signif- cant. However, the relative contribution of sadness and icant mediating variables included in the same model.70 self-esteem was larger than the contribution of anxiety. These models also performed a statistical comparison The specific indirect effect through sadness was greater of the indirect effects through the different mediators. in ARMS than in FEP and high-schizotypy participants. Competitive models were also performed to examine In terms of pathways from self-esteem to PLE and para- whether the association between PLE and paranoia with noia, both anxiety and sadness mediated these associations, Page 1056 of 1065 Table 1. Descriptive Data and Comparison of High-Schizotypy, ARMS, and FEP Groups on Study Variables High-Schizotypy ARMS FEP Test Statistics n = 65 n = 74 n = 39 df = 2 P Scheffé/Games-Howella Demographic variables Age, mean (SD) 20.83 (1.96) 21.56 (4.02) 24.59 (4.88) F = 13.7 <.001 3 > 1***, 2** Sex, n (%)   Female 47 (72.3) 24 (32.4) 12 (30.8) Χ2 = 27.2 <.001   Male 18 (27.7) 50 (67.6) 27 (69.2) Immigrant, n (%)   No 53 (81.5) 63 (85.1) 27 (69.2) Χ2 = 4.2 .123   Yes 12 (18.5) 11 (14.9) 12 (30.8) Clinical variables DSM-IV-TR psychotic disorder diagnosis, n (%)    Schizophrenia and other psychotic disorders 0 (0.0) 0 (0.0) 29 (74.4) — —    Depressive disorder with psychotic features 0 (0.0) 0 (0.0) 1 (2.6)    Bipolar disorder with psychotic features 0 (0.0) 0 (0.0) 9 (23.0) DSM-IV-TR current mood episode/disorderb, n (%)    Major depressive episode 0 (0.0) 28 (37.8) 15 (38.5) Χ2 = 33.0 <.001   Manic episode 0 (0.0) 0 (0.0) 2 (5.1) Χ2 = 7.2 .028   Mixed episode 0 (0.0) 0 (0.0) 0 (0.0) — —   Hypomanic episode 1 (1.5) 5 (6.8) 2 (5.1) Χ2 = 2.3 .318   Dysthymia 3 (4.6) 0 (0.0) 0 (0.0) Χ2 = 5.3 .072 Current psychopharmacological treatmentb, n (%)   Yes 2 (3.1) 52 (70.3) 39 (100) Χ2 = <.001   No 63 (96.9) 21 (28.4) 0 (0.0) 109.2 Momentary variablesc, mean (SD) ESM usable questionnaires 39.5 (9.87) 35.8 (11.12) 34.6 (10.87) F = 2.9 .060 ESM psychotic-like experiences 1.26 (0.32) 1.59 (0.84) 1.35 (0.48) F = 5.5 .005 2 > 1** ESM paranoia 1.46 (0.53) 1.92 (1.10) 1.44 (0.63) F = 6.7 .002 2 > 1**, 3* ESM sadness 1.70 (0.67) 2.05 (1.05) 1.83 (0.87) F = 2.7 .067 ESM anxiety 2.26 (0.81) 2.29 (1.16) 2.20 (1.20) F = 1.0 .910 ESM self-esteem 5.42 (0.75) 4.83 (1.02) 5.21 (1.11) F = 6.8 .001 2 < 1** ESM situational stress 2.46 (1.03) 2.44 (1.22) 2.15 (1.21) F = 1.1 .350 Note: ARMS, At-Risk Mental State for Psychosis; ESM, experience sampling method; FEP, first-episode psychosis. Missing values: b1. a 1. High-schizotypy; 2. ARMS; 3. FEP. c Mean ESM scores for each participant were used. * P < .05. ** P < .01. *** P < .001. Page 1057 of 1065 Pathways to Psychotic-Like Experiences M. Monsonet et al Table 2. Within-Person Direct and Indirect Effects of Separate Pathways From Stress and Self-esteem to PLE and Paranoia via Anxiety, Sadness, or Self-esteem Estimates (SD) 95% CI Pathways from stress to PLE Via anxiety    Direct effect (stress → PLE) 0.062 (0.004) 0.052 to 0.069    Indirect effect (stress → anxiety → PLE) 0.028 (0.005) 0.017 to 0.038 Via sadness    Direct effect (stress → PLE) 0.056 (0.003) 0.049 to 0.062    Indirect effect (stress → sadness → PLE) 0.027 (0.004) 0.020 to 0.035 Via self-esteem    Direct effect (stress → PLE) 0.054 (0.003) 0.047 to 0.061    Indirect effect (stress → self-esteem → PLE) 0.030 (0.004) 0.022 to 0.038 Pathways from stress to paranoia Via anxiety    Direct effect (stress → paranoia) 0.147 (0.007) 0.133 to 0.160    Indirect effect (stress → anxiety → paranoia) 0.032 (0.008) 0.018 to 0.047 Via sadness    Direct effect (stress → paranoia) 0.120 (0.006) 0.107 to 0.133    Indirect effect (stress → sadness → paranoia) 0.051 (0.007) 0.037 to 0.066 Via self-esteem    Direct effect (stress → paranoia) 0.112 (0.006) 0.099 to 0.125    Indirect effect (stress → self-esteem → paranoia) 0.058 (0.007) 0.045 to 0.073 Pathways from self-esteem to PLE Via anxiety    Direct effect (self-esteem → PLE) −0.148 (0.005) −0.159 to −0.138    Indirect effect (self-esteem → anxiety → PLE) −0.026 (0.006) −0.040 to −0.017 Via sadness    Direct effect (self-esteem → PLE) −0.112 (0.007) −0.122 to -0.098    Indirect effect (self-esteem → sadness → PLE) −0.049 (0.007) −0.063 to −0.038 Pathways from self-esteem to paranoia Via anxiety    Direct effect (self-esteem → paranoia) −0.303 (0.011) −0.324 to −0.281    Indirect effect (self-esteem → anxiety → paranoia) −0.043 (0.007) −0.056 to −0.027 Via sadness    Direct effect (self-esteem → paranoia) −0.227 (0.011) −0.246 to −0.207    Indirect effect (self-esteem → sadness → paranoia) −0.110 (0.012) −0.132 to −0.089 Note: PLE, psychotic-like experiences; SD, posterior standard deviations; significant indirect paths (CI does not include zero) are pre- sented in bold. but the relative contribution of sadness was larger than the self-esteem, but not via sadness. The relative contribution contribution of anxiety in both models. In the pathway to of anxiety was larger than the contribution of self-esteem. PLE the indirect effect via sadness was of greater magnitude In both pathways, the indirect effect via anxiety was of in ARMS than in high-schizotypy, whereas in the pathway greater magnitude in high-schizotypy than in ARMS and to paranoia the indirect effect via sadness was greater in FEP participants, whereas the indirect effect via self-es- ARMS than in FEP and high-schizotypy participants. teem was of greater magnitude in high-schizotypy than in Results of competitive reversal models examining the FEP. In pathways from PLE and paranoia to self-esteem within-person indirect effects of pathways from PLE and both anxiety and sadness mediated these routes, showing paranoia to stress through anxiety, sadness, or self-esteem sadness a larger relative contribution to the models than indicated that all the indirect effects were statistically signif- anxiety. Differences across groups were found only in the icant when they were examined separately (supplementary indirect effect of PLE through sadness, which was greater in table 2). Similarly, indirect effects of PLE and paranoia high-schizotypy than in FEP participants. Supplementary on self-esteem through anxiety or sadness were significant figure 1 displays a schematic representation of the main when they were examined separately. Finally, subsequent findings of the study. multilevel mediational analyses combining the significant Discussion within-person indirect effects of each pathway in a single model were performed (table 4). Indirect effects of PLE The present study examined the interplay between theory- and paranoia on stress were significant via anxiety and driven, putative etiological factors of paranoia and Page 1058 of 1065 Pathways to Psychotic-Like Experiences Table 3. Within-Person Direct and Indirect Effects of Combined Pathways From Stress and Self-esteem to PLE and Paranoia via Anxiety, Sadness, and Self-esteem Estimates (SD) 95% CI Pathway from stress to PLE Direct effect (stress → PLE)a 0.029 (0.004) 0.024 to 0.037 Specific indirect effects   Stress → anxiety → PLEa 0.019 (0.004) 0.012 to 0.027    ARMS vs FEPb 0.007 (0.008) −0.008 to 0.024    ARMS vs high-schizotypyb 0.016 (0.008) −0.001 to 0.031    FEP vs high-schizotypyb 0.008 (0.009 −0.009 to 0.032 Stress → sadness → PLEa 0.016 (0.004) 0.010 to 0.024    ARMS vs FEPb 0.003 (0.007) −0.012 to 0.017    ARMS vs high-schizotypyb 0.011 (0.005) 0.002 to 0.024    FEP vs high-schizotypyb 0.009 (0.007) −0.006 to 0.024   Stress → self-esteem → PLEa 0.020 (0.003) 0.014 to 0.027    ARMS vs FEPb 0.001 (0.007) −0.014 to 0.013    ARMS vs high-schizotypyb −0.001 (0.005) −0.012 to 0.008    FEP vs high-schizotypyb −0.002 (0.007) −0.015 to 0.013 Contrasts of indirect effectsa    Anxiety vs sadness 0.002 (0.005) −0.008 to 0.011    Anxiety vs self-esteem −0.001 (0.004) −0.010 to 0.007    Sadness vs self-esteem −0.004 (0.005) −0.012 to 0.006 Pathway from stress to paranoia Direct effect (stress → paranoia)a 0.082 (0.007) 0.066 to 0.093 Specific indirect effects   Stress → anxiety → paranoiaa 0.015 (0.006) 0.004 to 0.029    ARMS vs FEPb 0.015 (0.012) −0.006 to 0.041    ARMS vs high-schizotypyb 0.004 (0.011) −0.019 to 0.028    FEP vs high-schizotypyb −0.011 (0.012) −0.035 to 0.010   Stress → sadness → paranoiaa 0.034 (0.006) 0.023 to 0.048    ARMS vs FEPb 0.027 (0.013) 0.001 to 0.058    ARMS vs high-schizotypyb 0.021 (0.010) 0.002 to 0.045    FEP vs high-schizotypyb −0.006 (0.011) −0.026 to 0.017   Stress → self-esteem → paranoiaa 0.040 (0.006) 0.027 to 0.054    ARMS vs FEPb 0.024 (0.014) −0.005 to 0.046    ARMS vs high-schizotypyb 0.013 (0.012) −0.009 to 0.037    FEP vs high-schizotypyb −0.009 (0.013) −0.037 to 0.017 Contrasts of indirect effectsa    Anxiety vs sadness −0.019 (0.010) −0.039 to −0.001    Anxiety vs self-esteem −0.025 (0.009) −0.045 to −0.008    Sadness vs self-esteem −0.006 (0.010) −0.025 to 0.014 Pathway from self-esteem to PLE Direct effect (self-esteem → PLE)a −0.099 (0.007) −0.112 to −0.086 Specific indirect effects   Self-esteem → anxiety → PLEa −0.021 (0.005) −0.030 to −0.012    ARMS vs FEPb −0.010 (0.009) −0.026 to 0.009    ARMS vs high-schizotypyb −0.014 (0.008) −0.027 to 0.001    FEP vs high-schizotypyb −0.004 (0.009) −0.021 to 0.011   Self-esteem → sadness → PLEa −0.042 (0.007) −0.057 to −0.029    ARMS vs FEPb −0.021 (0.015) −0.047 to 0.010    ARMS vs high-schizotypyb −0.030 (0.014) −0.055 to −0.003    FEP vs high-schizotypyb −0.010 (0.015) −0.043 to 0.015 Contrasts of indirect effectsa    Anxiety vs sadness 0.022 (0.008) 0.006 to 0.039 Pathway from self-esteem to paranoia Direct effect (self-esteem → paranoia)a −0.209 (0.013) −0.231 to −0.184 Specific indirect effects   Self-esteem → anxiety → paranoiaa −0.032 (0.008) −0.044 to −0.017    ARMS vs FEPb −0.023 (0.012) −0.046 to 0.002    ARMS vs high-schizotypyb 0.001 (0.012) −0.021 to 0.024    FEP vs high-schizotypyb 0.024 (0.012) −0.005 to 0.046   Self-esteem → sadness → paranoiaa −0.101 (0.012)) −0.123 to −0.075    ARMS vs FEPb −0.100 (0.025) −0.148 to −0.050    ARMS vs high-schizotypyb −0.058 (0.025) −0.109 to −0.013 Page 1059 of 1065 M. Monsonet et al Table 3. Continued Estimates (SD) 95% CI    FEP vs high-schizotypy b 0.040 (0.023) −0.006 to 0.082 Contrasts of indirect effectsa    Anxiety vs sadness 0.068 (0.015) 0.039 to 0.097 Note: ARMS, At-Risk Mental State for Psychosis; FEP, first-episode psychosis; PLE, psychotic-like experiences; SD, posterior standard deviations; significant indirect paths, differences across groups and contrast of indirect effects (CI does not include zero) are presented in bold. a Effects estimated without group variable included into the model. b Group variable included as a moderator of both a and b indirect pathways. positive symptoms (stress and self-esteem) with different validity and across a psychosis continuum sample. The negative emotional states in a comprehensive psychosis results that self-esteem and sadness were stronger pre- continuum sample. The results support the existence of dictors than anxiety in the indirect pathway from stress mediating pathways from stress to PLE and paranoia to paranoia seems to contradict Freeman et al9 model of through negative mental states of anxiety, sadness, and persecutory delusions that postulated anxiety as the key self-esteem. In contrast, competitive reverse models from emotion in the development of paranoia. We tentatively symptoms to stress were differently mediated by negative speculate that the relative similarities between stress and emotions; whereas anxiety had a particularly relevant anxiety could lessen the mediating effect of anxiety, al- contribution, sadness lost its mediating effect. We also though it must be noted that anxiety had a similar con- found consistent evidence of mediating pathways from tribution to sadness and self-esteem in the pathway from self-esteem to PLE and paranoia, and from symptoms stress to PLE. to self-esteem, through anxiety and sadness, but sadness This study also revealed possible pathways in the was the key emotion in accounting for these associations. well-established relationship of low self-esteem with par- Finally, findings indicate that these mechanistic path- anoia and psychosis. Findings replicate previous studies ways work similarly across high-schizotypy, ARMS, and employing path analysis in nonclinical24 and chronic schiz- FEP participants, which seems to suggest an etiological ophrenia samples,26 indicating that anxiety and sadness and phenomenological continuity across the psychosis mediated the association between self-esteem and para- continuum. noia, and suggesting that sadness is an essential emotion A key recent ESM study found that negative affect me- in the mechanistic pathway from low self-esteem to par- diates the link between different types of daily-life stress anoia. Furthermore, we replicated findings for positive and PLE, underscoring that the effect of this indirect PLE other than paranoia, which seems to indicate that path was superior to indirect paths via threat anticipa- some theoretical assumptions that Freeman et al made tion and aberrant salience.42 Our findings in the pathways in their model of persecutory delusions9,73 apply at least from stress to PLE through anxiety, sadness, and self-es- in part to positive symptoms broadly. In fact, Freeman’s teem replicate and broaden this study by disentangling model of persecutory delusions is based on Garety’s cog- the roles of specific emotions, and add support to pre- nitive model of positive symptoms,4 and both authors put vious models of psychosis that posited the existence of forth that neurotic processes contribute to the develop- an affective pathway to psychosis.4,6–8 It is worth noting ment of positive symptoms of psychosis.74 Finally, this that the mediating effect of self-esteem is in line with the study yields novel evidence about putative mechanisms self-esteem buffering hypothesis for depression,71,72 which of paranoia in natural contexts across different levels of suggests that high self-esteem buffers the effects of stress psychosis expression. on symptoms, whereas low self-esteem boosts the vulner- Overall, there were few significant differences across ability to stress.52 Further studies need to replicate and ex- psychosis continuum groups in their indirect effects. This pand these findings in order to disentangle the specificity suggests that the affective mechanisms underlying psy- of a possible self-esteem buffering hypothesis for psychosis, chotic and paranoid traits, experiences, and symptoms are which could be relevant in devising therapeutic strategies at least partly overlapping, supporting claims of etiolog- integrating both the reduction of risk mechanisms as well ical and phenomenological continuity across nonclinical as building resilience through, for instance, personal em- and clinical manifestations of the schizotypy-psychosis powerment. Regarding the specific pathway from stress extended phenotype—even if they differ in terms of need to paranoia, findings also support experimental studies for care, severity, comorbidity, etc.46,75 Differences were showing the mediating role of anxiety, depression, and found only in the pathways that included sadness, with self-esteem in this pathway.11–13 We expand on these greater indirect effects in ARMS than in other groups, studies by showing evidence in daily-life with ecological which seems to indicate that sadness may have a critical Page 1060 of 1065 Pathways to Psychotic-Like Experiences Table 4. Within-Person Direct and Indirect Effects of Combined Pathways From PLE and Paranoia to Stress and Self-esteem via Anxiety, Sadness, and Self-esteem Estimates (SD) 95% CI Pathway from PLE to stress Direct effect (PLE → stress)a 0.324 (0.040) 0.255 to 0.407 Specific indirect effects   PLE → anxiety → stressa 0.475 (0.059) 0.379 to 0.602    ARMS vs FEPb 0.163 (0.093) −0.049 to 0.334    ARMS vs high-schizotypyb −0.270 (0.108) −0.498 to −0.068    FEP vs high-schizotypyb −0.432 (0.109) −0.624 to −0.209   PLE → sadness → stressa 0.037 (0.030) −0.019 to 0.097   PLE → self-esteem → stressa 0.220 (0.033) 0.158 to 0.283    ARMS vs FEPb 0.105 (0.066) −0.025 to 0.225    ARMS vs high-schizotypyb −0.122 (0.073) −0.258 to 0.013    FEP vs high-schizotypyb −0.224 (0.086) −0.393 to −0.057 Contrasts of indirect effectsa    Anxiety vs self-esteem 0.256 (0.059) 0.155 to 0.372 Pathway from paranoia to stress Direct effect (paranoia → stress)a 0.257 (0.022) 0.215 to 0.298 Specific indirect effects   Paranoia → anxiety → stressa 0.173 (0.028) 0.123 to 0.241    ARMS vs FEPb 0.027 (0.041) −0.065 to 0.099    ARMS vs high-schizotypyb −0.149 (0.046) −0.244 to −0.059    FEP vs high-schizotypyb −0.176 (0.053) −0.278 to −0.069   Paranoia → sadness → stressa 0.020 (0.015) −0.011 to 0.050   Paranoia → self-esteem → stressa 0.098 (0.017) 0.062 to 0.0128    ARMS vs FEPb 0.043 (0.034) −0.021 to 0.109    ARMS vs high-schizotypyb −0.039 (0.034) −0.104 to 0.029    FEP vs high-schizotypyb −0.081 (0.036) −0.157 to −0.016 Contrasts of indirect effectsa    Anxiety vs self-esteem 0.074 (0.032) 0.028 to 0.152 Pathway from PLE to self-esteem Direct effect (PLE → self-esteem)a −0.381 (0.025) −0.436 to −0.337 Specific indirect effects   PLE → anxiety → self-esteema −0.097 (0.018) −0.132 to −0.066    ARMS vs FEPb 0.001 (0.031) −0.056 to 0.076    ARMS vs high-schizotypyb 0.032 (0.034) −0.031 to 0.105    FEP vs high-schizotypyb 0.032 (0.041) −0.051 to 0.112   PLE → sadness → self-esteema −0.295 (0.030) −0.358 to −0.235    ARMS vs FEPb −0.085 (0.063) −0.196 to 0.064    ARMS vs high-schizotypyb 0.088 (0.071) −0.052 to 0.225    FEP vs high-schizotypyb 0.179 (0.083) 0.021 to 0.325 Contrasts of indirect effectsa    Anxiety vs sadness 0.196 (0.034) 0.131 to 0.266 Pathway from paranoia to self-esteem Direct effect (paranoia → self-esteem)a −0.237 (0.012) −0.262 to −0.215 Specific indirect effects   Paranoia → anxiety → self-esteema −0.038 (0.007) −0.052 to −0.026    ARMS vs FEPb 0.012 (0.015) −0.019 to 0.042    ARMS vs high-schizotypyb 0.017 (0.012) −0.009 to 0.044    FEP vs high-schizotypyb 0.006 (0.017) −0.024 to 0.036   Paranoia → sadness → self-esteema −0.149 (0.018) −0.186 to −0.119    ARMS vs FEPb −0.023 (0.038) −0.093 to 0.060    ARMS vs high-schizotypyb 0.044 (0.036) −0.031 to 0.107    FEP vs high-schizotypyb 0.069 (0.044) −0.022 to 0.147 Contrasts of indirect effectsa    Anxiety vs sadness 0.110 (0.020) 0.074 to 0.148 Note: ARMS, At-Risk Mental State for Psychosis; FEP, first-episode psychosis; PLE, psychotic-like experiences; SD, posterior standard deviations; significant indirect paths, differences across groups and contrast of indirect effects (CI does not include zero) are presented in bold. a Effects estimated without group variable included into the model. b Group variable included as a moderator of both a and b indirect pathways. Page 1061 of 1065 M. Monsonet et al role in the clinical high-risk stages for psychosis and that (anxiety, sadness, and self-esteem) as well as predictors it could be a key emotion in the putative prodrome of (stress and self-esteem) variables employed in this study psychosis. are core processes of emotional disturbance and they are Models from symptoms to stress indicated that anxiety closely related, potential interactions between them not had a particularly relevant contribution, whereas sadness examined in this study might have influenced the results lost its mediating effect, highlighting that these pathways obtained. were differently mediated by negative emotions than the reversed pathways. Indeed, symptoms are disturbing ex- Conclusions periences that become themselves stressors and, as our findings suggest, this link would be mainly explained This study contributes to the understanding of the mech- through the effect of anxiety. This seems to support a anistic pathways underlying psychosis symptom forma- bidirectional model between stress and positive-like tion, expression, and maintenance in real-life experience. symptoms, although not exactly a mirror image as the Findings indicate that the links between putative etiolog- different effects of the mediators implicated in these ical factors such as stress and self-esteem with paranoia pathways indicate. Self-esteem stands as a significant me- and other PLE are explained in part by the effects of anx- diator as well, which seems to indicate that experiencing iety, sadness, and self-esteem, thus supporting psycho- symptoms also boost negative affective and cognitive logical models of psychosis that highlight the relevance self-perceptions. It is important to note that the study of affective disturbances in the onset and expression of design does not allow us to easily determine the within- psychotic symptoms. Furthermore, these emotions also day direction of the effects and therefore no causal infer- interact with symptoms in the pathways from symptoms ences can be established regarding the reciprocal impact to stress and self-esteem, suggesting a complex vicious of stress or self-esteem on symptoms. However, previous cycle between putative etiological factors and symptoms, ESM studies have shown that positive-like symptoms although differently mediated by the indirect pathways. predicted subsequent levels of stress,53 self-esteem,76 and Finally, as these mechanistic pathways work relatively negative emotions,77 suggesting a vicious cycle between similarly across groups, findings support claims of eti- stress, self-esteem, negative emotions, and positive symp- ological continuity across nonclinical, subclinical, and toms. Therefore, further longitudinal studies are needed clinical manifestations of the psychosis extended phe- to examine the similarities and differences of causal notype.78 These findings should enhance psychological mechanisms implicated on the putative vulnerability and treatments by identifying emotional processes that give scar pathways of positive symptoms, as the differences rise to or exacerbate positive symptoms as targets for in- found between competitive models tested in the present tervention. Specifically, real-world interventions using study seem indicate. ESM could monitor these experiences and provide inter- Regarding differences across groups in pathways from ventions to minimize negative emotions and enhance symptoms to stress and self-esteem, and in contrast to the self-esteem in real-world situations. reversed routes, some indirect effects were greater in high- schizotypy than ARMS and FEP participants, whereas Supplementary Material no differences between ARMS and FEP were found. This seems to suggest that the experience of PLE and para- Supplementary material is available at Schizophrenia noid experiences in nonclinical participants with high- Bulletin online. schizotypy is associated to higher levels of disturbing emotions and creates a greater cognitive dissonance as Acknowledgments compared to clinical participants. The present study is not without limitations. ESM is an The authors wish to express their gratitude to Drs. intensive protocol assessment based on self-reported re- Hinojosa-Marqués and Cristóbal-Narváez for their work peated measures in which some of the questionnaires are in data collection and to the participants that took part expected to be missed because participants did not hear in the study. the beeping signal, or they could not attend the question- naire at that particular time, which might affect the re- Funding sults obtained in this study. A quarter of the sample of FEP participants included individuals with a diagnosis of This work was supported by the Spanish Ministry of affective disorder with psychotic symptoms, which might Economy and Competitiveness (Plan Nacional: PSI2017- affect the direct generalization of the findings to popu- 87512-C2-1-R) and the Government of Catalonia lations restricted to schizophrenia spectrum diagnoses. (2017SGR1612). Manel Monsonet has a postdoctoral Furthermore, gender differences in the composition of fellowship (Margarita Salas Grants) supported by the nonclinical and clinical samples may also limit the gen- Spanish Ministry of Universities and the European eralizability of findings. Finally, since putative mediators Union-NextGenerationEU. Page 1062 of 1065 Pathways to Psychotic-Like Experiences Conflicts of Interest 18. Bentall RP, Kinderman P, Kaney S. The self, attributional processes and abnormal beliefs: towards a model of persecu- The authors have declared that there are no conflicts of tory delusions. Behav Res Ther. 1994;32(3):331–341. interest in relation to the subject of this study. 19. Fowler D, Freeman D, Smith B, et al. The Brief Core Schema Scales (BCSS): psychometric properties and associations with paranoia and grandiosity in non-clinical and psychosis sam- References ples. Psychol Med. 2006;36(6):749–759. 20. Freeman D. Suspicious minds: the psychology of persecutory 1. Nuechterlein KH, Dawson ME. A heuristic vulnerability/ delusions. Clin Psychol Rev. 2007;27(4):425–457. stress model of schizophrenic episodes. Schizophr Bull. 21. Smith B, Fowler DG, Freeman D, et al. Emotion and psych- 1984;10(2):300–312. osis: links between depression, self-esteem, negative sche- 2. Zubin J, Spring B. Vulnerability—a new view of schizo- matic beliefs and delusions and hallucinations. Schizophr Res. phrenia. J Abnorm Psychol. 1977;86(2):103–126. 2006;86(1–3):181–188. 3. Garety PA, Freeman D. The past and future of delusions re- 22. Thewissen V, Bentall RP, Lecomte T, Van Os J, Myin- search: from the inexplicable to the treatable. Br J Psychiatry. Germeys I. Fluctuations in self-esteem and paranoia in the 2013;203(5):327–333. context of daily life. J Abnorm Psychol. 2008;117(1):143–153. 4. Garety PA, Kuipers E, Fowler D, Freeman D, Bebbington BE. 23. Udachina A, Varese F, Myin-Germeys I, Bentall RP. The role A cognitive model of the positive symptoms of psychosis. of experiential avoidance in paranoid delusions: an experi- Psychol Med. 2001;31(2):189–195. ence sampling study. Br J Clin Psychol. 2014;53(4):422–432. 5. Gibson LE, Reeves LE, Cooper S, Olino TM, Ellman LM. 24. Galbraith ND, Morgan CJ, Jones CL, Ormerod DR, Traumatic life event exposure and psychotic-like experiences: Galbraith VE, Manktelow KI. The mediating effect of affect: a multiple mediation model of cognitive-based mechanisms. different pathways from self and other schemas to persecu- Schizophr Res. 2019;205:15–22. tory ideation. Can J Behav Sci. 2014;46(4):497–505. 6. Howes OD, Murray RM. Schizophrenia: an inte- 25. Oliver JE, O’Connor JA, Jose PE, McLachlan K, Peters E. grated sociodevelopmental-cognitive model. Lancet. The impact of negative schemas, mood and psychological 2014;383(9929):1677–1687. flexibility on delusional ideation—mediating and moderating 7. Morgan C, Charalambides M, Hutchinson G, effects. Psychosis. 2012;4(1):6–18. Murray RM. Migration, ethnicity, and psychosis: to- 26. Ben-Zeev D, Granholm E, Cafri G. Symptoms of depression ward a sociodevelopmental model. Schizophr Bull. and anxiety mediate the relationship between self-esteem and 2010;36(4):655–664. paranoia. Schizophr Res. 2009;115(2–3):377–378. 8. Myin-Germeys I, van Os J. Stress-reactivity in psychosis: evi- 27. Conner TS, Tennen H, Fleeson W, Barrett LF. Experience dence for an affective pathway to psychosis. Clin Psychol Rev. sampling methods: a modern idiographic approach to 2007;27(4):409–424. personality research. Soc Personal Psychol Compass. 9. Freeman D, Garety PA, Kupiers E, Fowler D, Bebbington P. 2009;3(4):292–313. A cognitive model of persecutory delusions. Br J Clin Psychol. 28. Csikszentmihalyi M, Larson R. Validity and reliability 2002;41(Pt 4):331–347. of the experience sampling method. In: Devries MW, ed. 10. Kuipers E, Garety P, Fowler D, Freeman D, Dunn G, The Experience of Psychopathology: Investigating Mental Bebbington P. Cognitive, emotional, and social processes Disorders in Their Natural Settings. New York, NY: in psychosis: refining cognitive behavioural therapy for per- Cambridge University Press; 1992:34–57. sistent positive symptoms. Schizophr Bull. 2006;32(Suppl. 29. Palmier-Claus JE, Myin-Germeys I, Barkus E, et al. 1):S24–S31. Experience sampling research in individuals with mental 11. Lincoln TM, Peter N, Schäfer M, Moritz S. Impact of stress illness: reflections and guidance. Acta Psychiatr Scand. on paranoia: an experimental investigation of moderators 2011;123(1):12–20. and mediators. Psychol Med. 2009;39(7):1129–1139. 30. Reininghaus U, Depp CA, Myin-Germeys I. Ecological 12. Kesting ML, Bredenpohl M, Klenke J, Westermann S, interventionist causal models in psychosis: targeting Lincoln TM. The impact of social stress on self-esteem psychological mechanisms in daily life. Schizophr Bull. and paranoid ideation. J Behav Ther Exp Psychiatry. 2016;42(2):264–269. 2013;44(1):122–128. 31. Conner TS, Barret LS. Trends in ambulatory self-report: the 13. Freeman D, Emsley R, Dunn G, et al. The stress of the street role of momentary experience in psychosomatic medicine. for patients with persecutory delusions: a test of the symp- Psychosom Med. 2012;74(4):327–337. tomatic and psychological effects of going outside into a busy 32. Myin-Germeys I, Delespaul P, van Os J. The experience sam- urban area. Schizophr Bull. 2015;41(4):971–979. pling method in psychosis research. Curr Opin Psychiatry. 14. Bentall RP, Jackson HF, Pilgrim D. Abandoning the concept 2003;16(Suppl. 2):33–38. of ‘schizophrenia’: some implications of validity arguments 33. Mehl MR, Conner TS. Handbook of Research Methods for for psychological research into psychotic phenomena. Br J Studying Daily Life. New York, NY: Guilford Press; 2012. Clin Psychol. 1988;27(Pt. 4):303–324. 34. Myin-Germeys I, Oorschot M, Collip D, Lataster J, 15. Boyle M. Schizophrenia: A Scientific Delusion. London, UK: Delespaul P, van Os J. Experience sampling research in psy- Routledge; 2002. chopathology: opening the black box of daily life. Psychol 16. Bentall RP, Corcoran R, Howard R, Blackwood N, Med. 2009;39(9):1533–1547. Kinderman P. Persecutory delusions: a review and theoretical 35. Oorschot M, Kwapil T, Delespaul P, Myin-Germeys I. integration. Clin Psychol Rev. 2001;21(8):1143–1192. Momentary assessment research in psychosis. Psychol Assess. 17. Kesting ML, Lincoln TM. The relevance of self-esteem and 2009;21(4):498–505. self-schemas to persecutory delusions: a systematic review. 36. Ben-Zeev D, Ellington K, Swendsen J, Granholm E. Compr Psychiatry. 2013;54(7):766–789. Examining a cognitive model of persecutory ideation in the Page 1063 of 1065 M. Monsonet et al daily life of people with schizophrenia: a computerized experi- 54. Cristóbal-Narváez P, Sheinbaum T, Myin-Germeys I, et al. ence sampling study. Schizophr Bull. 2011;37(6):1248–1256. The role of stress-regulation genes in moderating the asso- 37. Kramer I, Simons CJ, Wigman JT, et al. Time-lagged ciation of stress and daily-life psychotic experiences. Acta moment-to-moment interplay between negative affect and Psychiatr Scand. 2017;13(4):389–399. paranoia: new insights in the affective pathway to psychosis. 55. Kwapil TR, Barrantes-Vidal N, Silva PJ. The dimen- Schizophr Bull. 2014;40(2):278–286. sional structure of the Wisconsin Schizotypy Scales: 38. Kwapil TR, Brown LH, Silvia PJ, Myin-Germeys I, Barrantes- factor identification and construct validity. Schizophr Bull. Vidal N. The expression of positive and negative schizotypy 2008;34(3):444–457. in daily-life: an experience sampling study. Psychol Med. 56. Raine A. The SPQ: a scale for the assessment of schizotypal 2012;42(12):2555–2566. personality based on DSM-III-R criteria. Schizophr Res. 39. Palmier-Claus JE, Dunn G, Lewis SW. Emotional and symp- 1991;17(4):555–564. tomatic reactivity to stress in individuals at ultra-high risk of 57. Stefanis NC, Hanssen M, Smirnis NK, et al. Evidence that developing psychosis. Psychol Med. 2012;42(5):1003–1012. three dimensions of psychosis have a distribution in the 40. Reininghaus U, Gayer-Anderson C, Valmaggia L, et al. general population. Psychol Med. 2002;32(2):347–358. Psychological processes underlying the association between 58. First MB, Spitzer RL, Gibbon M, Williams JB. Structured childhood trauma and psychosis in daily life: an experience Clinical Interview for DSM-IV Axis I Disorders-Patient ed. sampling study. Psychol Med. 2016;46(13):2799–2813. (SCID-I/P, Version 2.0). New York, NY: Biometrics Research 41. Thewissen V, Bentall RP, Oorschot MA, et al. Emotions, Department; 1995. self-esteem, and paranoid episodes: an experience sampling 59. Domínguez-Martínez T, Medina-Pradas C, Kwapil TR, study. Br J Clin Psychol. 2011;50(2):178–195. Barrantes-Vidal N. Relatives’ illness attributions mediate the 42. Klippel A, Myin-Germeys I, Chavez-Baldini U, et al. association of expressed emotion with early psychosis symp- Modeling the interplay between psychological processes toms and functioning. Psychiatry Res. 2014;218(1–2):48–53. and adverse, stressful contexts and experiences in pathways 60. Domínguez-Martínez T, Vainer E, Massanet MA, Torices I, to psychosis: an experience sampling study. Schizophr Bull. Jané M, Barrantes-Vidal N. The need-adapted integrated 2017;43(2):302–315. treatment in Sant Pere Claver-Early Psychosis Program (SPC- 43. Krkovic K, Krink S, Lincoln TM. Emotion regulation as a EPP) in Barcelona, Spain. Salud Ment. 2011;34(6):517–524. moderator of the interplay between self-reported and physio- 61. Yung AR, Yuen H, McGorry PD, et al. Mapping the onset logical stress and paranoia. Eur Psychiatry. 2018;49:43–49. of psychosis: the comprehensive assessment of at-risk mental 44. Reininghaus U, Kempton MJ, Valmaggia L, et al. Stress sen- states. Aust N Z J Psychiatry. 2005;39(11–12):964–971. sitivity, aberrant salience, and threat anticipation in early 62. American Psychiatric Association. Diagnostic and Statistical psychosis: an experience sampling study. Schizophr Bull. Manual of Mental Disorders, 4th edn.—Text Revision (DSM- 2016;42(3):712–722. IV-TR). Washington, DC: American Psychiatric Association; 45. van der Steen Y, Gimpel-Drees J, Lataster T, et al. Clinical 2000. high risk for psychosis: the association between momentary 63. Burgin CJ, Silvia PJ, Eddington KM, Kwapil TR. Palm or stress, affective and psychotic symptoms. Acta Psychiatr cell? Comparing personal digital assistants and cell phones Scan. 2017;136(1):63–73. for experience sampling research. Soc Sci Comput Rev. 46. Kwapil TR, Barrantes-Vidal N. Schizotypy: looking back 2013;31(2):244–251. and moving forward. Schizophr Bull. 2015;41(Suppl. 64. Kimhy D, Myin-Germeys I, Palmier-Claus J, Swendsen J. 2):S366–S373. Mobile assessment guide for research in schizophrenia and 47. Barrowclough C, Tarrier N, Humphreys L, Ward J, Gregg L, severe mental disorders. Schizophr Bull. 2012;38(3):386–395. Andrews B. Self-esteem in schizophrenia: relationships be- 65. Delespaul PAEG. Assessing Schizophrenia in Daily Life— tween self-evaluation, family attitudes, and symptomatology. The Experience Sampling Method. Maastricht, Holland: J Abnorm Psychol. 2003;112(1):92–99. Maastricht University Press; 1995. 48. Krabbendam L, Janssen I, Bak M, Bijl RV, de Graff R, 66. Kwapil TR, Kemp KC, Mielock A, et al. Association of van Os J. Neuroticism and low self-esteem as risk fac- multidimensional schizotypy with psychotic-like experi- tors for psychosis. Soc Psychiatry Psychiatr Epidemiol. ences, affect, and social functioning in daily life: comparable 2002;37(1):1–6. findings across samples and schizotypy measures. J Abnorm 49. Greenberg J, Solomon S, Pyszczynski T, et al. Why do people Psychol. 2020;129(5):492–504. need self-esteem? Converging evidence that self- esteem 67. Geldhof GJ, Preacher KJ, Zyphur MJ. Reliability estima- serves an anxiety-buffering function. J Pers Soc Psychol. tion in a multilevel confirmatory factor analysis framework. 1992;63(6):913–922. Psychol Methods. 2014;19(1):72–91. 50. Karatzias T, Gumley A, Power K, O’Grady M. Illness ap- praisals and self-esteem as correlates of anxiety and affective 68. Muthén LK, Muthén BO. Mplus User’s Guide. 6th ed. Los comorbid disorders in schizophrenia. Compr Psychiatry. Angeles, CA: Muthén & Muthén;1998–2010. 2007;48(4):371–375. 69. Asparouhov T, Muthén B. Latent variable centering of pre- 51. Klein DN, Kotov R, Bufferd SJ. Personality and depression: dictors and mediators in multilevel and time-series models. explanatory models and review of the evidence. Annu Rev Struct Equ Modeling. 2019;26(1):119–142. Clin Psychol. 2011;7:269–295. 70. Preacher KJ. Advances in mediation analysis: a survey 52. Zeigler-Hill V. The connections between self-esteem and psy- and synthesis of new developments. Annu Rev Psychol. chopathology. J Contemp Psychother. 2011;41(3):157–164. 2015;66:825–852. 53. Barrantes-Vidal N, Chun CA, Myin-Germeys I, Kwapil TR. 71. Hammen C. Stress and depression. Annu Rev Clin Psychol. Psychometric schizotypy predicts psychotic-like, paranoid, 2005;1:293–319. and negative symptoms in daily life. J Abnorm Psychol. 72. Metalsky GI, Joiner TE, Hardin TS, Abramson LY. 2013;122(4):1077–1087. Depressive reactions to failure in a naturalistic setting: a test Page 1064 of 1065 Pathways to Psychotic-Like Experiences of the hopelessness and self-esteem theories of depression. J 76. Udachina A, Varese F, Oorschot M, Myin-Germeys I, Abnorm Psychol. 1993;102(1):101–109. Bentall R. Dynamics of self-esteem in “Poor-Me” and 73. Freeman D, Garety P. Advances in understanding and “Bad-Me” paranoia. J Nerv Ment Dis. 2012;200(9):777–783. treating persecutory delusions: a review. Sol Psychiatry 77. Krkovic K, Clamor A, Schlier B, Lincoln TM. Emotions Psychiatr Epidemiol. 2014;49(8):1179–1189. and persecutory ideation in daily life: on the trail of 74. Freeman D, Garety PA. Connecting neurosis and psychosis: the “chicken and egg” problem. J Abnorm Psychol. the direct influence of emotion on delusions and hallucin- 2020;129(2):215–223. ations. Behav Res Ther. 2003;41(8):923–947. 78. van Os J, Linscott RJ. Introduction: the extended psych- 75. van Os J, Reininghaus U. Psychosis as a transdiagnostic osis phenotype—relationship with schizophrenia and and extended phenotype in the general population. World with ultrahigh risk status for psychosis. Schizophr Bull. Psychiatry. 2016;15(2):118–124. 2012;38(2):227–230. Page 1065 of 1065