Persecutory ideation (PI) describes “unfounded ideas that harm is going to occur and that the persecutor has deliberate intention” (p. 686; Freeman, 2016). These experiences comprise a continuum, ranging from more common and passing worries about threats to highly distressing and disruptive delusions (Bebbington et al., 2013). Most individuals experiencing a first episode of psychosis experience persecutory delusions (Rajapakse et al., 2011) and across presentations, PI is associated with loneliness (Contreras et al., 2022), poor functioning (Freeman et al., 2011) poor well-being (Contreras et al., 2022), anxiety (Freeman et al., 2012), depression (Hartley et al., 2013), and suicidality (Carrillo de Albornoz et al., 2022). While the most severe forms of PI are often associated with schizophrenia-spectrum diagnoses, they also occur in other mental health conditions—for example, bipolar disorder (Smith et al., 2017) or post-traumatic stress disorder (Alsawy et al., 2015)—as well as 2 to 19 % of the general population (Freeman et al., 2011). Given its potentially devastating outcomes, conceptual models of PI which lend themselves to empirical testing, are necessary in order to advance our understanding and development of treatment and prevention strategies.

One leading model—the cognitive model of persecutory delusions (Freeman, 2007, 2016; Freeman et al., 2002)—argues that PI is best conceptualized as a “threat belief” that emerges when an individual makes maladaptive interpretations of ambiguous, confusing, or threatening stimuli. Threat beliefs are maintained (i.e. continue to be salient moment-to-moment) when negative affective states reduce cognitive resources required to revise initial interpretations. Negative affect comprises internal states associated with both non-reward and anticipatory concerns (American Psychological Association, 2018) and often emerges in the context of symptoms of depression, anxiety or distress. According to the cognitive model, threat beliefs are furthered when individuals avoid situations that would challenge such beliefs (e.g., by staying inside to avoid a believed conspiracy, the individual receives no information that would contradict the initial belief), a phenomenon referred to as safety seeking. This model has been supported by early studies demonstrating cross-sectional relationships of a number of factors to PI, including worry or rumination (Hartley et al., 2014; O'Driscoll et al., 2014), negative self-beliefs (Kesting and Lincoln, 2013), and safety-seeking behaviors (Freeman et al., 2007).

Early studies examining predictors of PI primarily relied upon cross-sectional or experimental laboratory research designs and retrospective measures. In addition to being susceptible to memory errors, biases in reporting, or demand characteristics, retrospective measures do not provide granular information about the real-time antecedents and consequences of PI. More recently, technology-assisted approaches—e.g. ecological momentary assessments (EMA) or experience sampling methodology (ESM)—have provided new opportunities to address these limitations. Studies using PDAs (Ben-Zeev et al., 2011), pagers (with accompanying journals; Thewissen et al., 2008, 2011) and later smartphones (Kramer et al., 2014) have provided support for components of the cognitive model of PI. Lüdtke et al. (2023) summarized this literature in a recent systematic review finding strong evidence supporting two predictors: negative affect and sleep problems. Their review also identified a number of limitations. First, though PI ranges in severity cross diagnostically, most longitudinal studies have examined PI in either individuals diagnosed with schizophrenia-spectrum disorders or amongst non-clinical controls. This underrepresents individuals with mild or moderate PI and could impede identifying attributes that lead to significant distress and disruption across the continuum (McGrath et al., 2015; Van Os and Reininghaus, 2016). Second, a minority of studies have modeled within-participant effects (i.e. controlling for participant mean values), which are the standard of evidence for identifying each factor as a precursor to PI. In Ludtke's review (2023), authors could not judge whether time-lagged and within-person associations existed for these factors given insufficient data. Most studies have examined affective or behavioral characteristics that increase the likelihood of PI; fewer studies have examined the impact of responses to PI once it emerges.

Cognitive approaches to persecutory ideation are designed to challenge the certainty one feels about a particular threat (Freeman, 2013); for example, challenging the veracity of intrusive worries that one is being spied on by a neighbor. Approaches built on the principles of acceptance and commitment therapy (ACT) work toward intentional action consistent with one's values in place of preoccupation with one's threat beliefs; for example, persisting in meaningful or required daily activity even while being distressed. While several studies (Bloy et al., 2011; Garety et al., 2021a,b; Johns et al., 2016) have provided evidence to support these approaches, few studies have examined changes in theory-derived intervention targets on a moment-to-moment time scale. Understanding momentary predictors can help identify targets for momentary interventions, for example, just-in-time adaptive interventions provided through digital platforms.

Our team has developed and deployed a smartphone data collection system designed for longitudinal studies and deployed that system in samples of individuals with schizophrenia (Ben-Zeev et al., 2017; Buck et al., 2019; Wang et al., 2016) and cross-diagnostic auditory verbal hallucinations or voices (Ben-Zeev et al., 2020). More recently, we recruited a sample of over 200 individuals with cross-diagnostic PI to carry and respond to ecological momentary assessment (EMA) questionnaires over a 30-day period (Buck et al., 2023). The present study involves an examination of four factors proposed to maintain (i.e. sustain or worsen once emerged) persecutory ideation once it emerges: appraisals of certainty about the threat, appraisals of its importance, rumination, and changing one's behavior in response. Specifically, we aimed to determine the extent to which each of these factors are associated with negative affect both between-participants (i.e. at the mean level) and in time-lagged within-participants analyses, and whether each predicts whether PI will be maintained over time within-participants (i.e. on the day-to-day level). In order to assess the impact of these factors on a more sustained and clinically meaningful time scale, we assessed changes that occurred on a day-to-day level. Based on the cognitive model (Freeman et al., 2002), we propose that all four proposed factors—attributing threats as certain and important, ruminating about them, and changing one's behavior in response—will both be associated with increases in previous negative affect and serve as precursors to worsening negative affect and persecutory ideation. This would support their role as key links in cycles that maintain paranoia over time and support momentary interventions to address them.