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Fluctuations in Self-Esteem and Paranoia in the Context of Daily Life
Viviane Thewissen
Open University of the Netherlands and Maastricht University
Richard P. Bentall
University of Manchester
Tania Lecomte
University of British Columbia
Jim van Os
Maastricht University and Institute of Psychiatry
Inez Myin-Germeys
Maastricht University and University of Manchester
Studies investigating the relationship between self-esteem and paranoia have specifically focused on
self-esteem level, but have neglected the dynamic aspects of self-esteem. In the present article, the
authors investigated the relationship between self-esteem and paranoia in two different ways. First, 154
individuals ranging across the continuum in level of paranoia were studied with the Experience Sampling
Method (a structured self-assessment diary technique) to assess the association between trait paranoia and
level and fluctuation of self-esteem in daily life. Results showed that trait paranoia was associated with
both lower levels and higher instability of self-esteem. Second, the temporal relationship between
momentary (state) paranoia and self-esteem was investigated in the daily life of these individuals. Results
showed that a decrease in self-esteem was associated with an immediate increase in paranoia. The
findings indicate that paranoid individuals are not only characterized by a lower level of self-esteem but
also by more fluctuations in their self-esteem and that fluctuations in self-esteem predict the degree of
subsequent paranoia. These results are consistent with the hypothesis that paranoia is associated with
dysfunctional strategies of self-esteem regulation.
Keywords: experience sampling method, paranoia, self-esteem
Persecutory delusions are the most common abnormal beliefs
found in patients with psychosis, both in Western countries (Ga-
rety & Hemsley, 1987; Jorgensen & Jensen, 1994) and in other
parts of the world (Ndetei & Vadher, 1984). They are often highly
distressing and also the most likely delusions to be acted upon
(Wessely et al., 1993). There is therefore a need for an explanatory
account of this symptom, which identifies causal factors and which
can guide the development of novel therapeutic interventions
(Blackwood, Howard, Bentall, & Murray, 2001). It has long been
argued that self-esteem is implicated in the formation of paranoid
beliefs (Colby, 1975, 1977; Meissner, 1981; D. A. Schwartz,
1963). According to a recent psychological model (Bentall, Cor-
coran, Howard, Blackwood, & Kinderman, 2001), persecutory
delusions are the consequence of a coherent set of cognitive biases
that develop in individuals with low self-esteem and that serve the
function of protecting the individual from negative thoughts and
feelings about the self. Because the attempts to avoid negative
thoughts are often dysfunctional, it is predicted by the model that
self-esteem will be highly unstable (fluctuating) in paranoid pa-
tients.
Studies investigating the relationship between paranoia and self-
esteem have mainly focused on level of self-esteem and have
yielded inconsistent results. In a large sample of individuals with
drug-resistant psychosis taking part in a cognitive-behavior ther-
apy trial, low self-esteem was found to be a prominent feature in
the majority of patients with persecutory delusions (Freeman et al.,
1998). Low levels of self-esteem have also been found in non-
clinical samples reporting paranoid beliefs (Combs & Penn, 2004;
Ellett, Lopes, & Chadwick, 2003; Martin & Penn, 2001). Combs
and Penn (2004) compared a sample of students who scored high
and low on a questionnaire that measures subclinical levels of
paranoia. They found that persons high in subclinical paranoia had
lower self-esteem relative to persons low in subclinical paranoia.
Other studies, however, have reported relatively high or normal
Viviane Thewissen, Faculty of Psychology, Open University of the
Netherlands, Heerlen, the Netherlands; and Department of Psychiatry and
Neuropsychology, South Limburg Mental Health Research and Teaching
Network, EURON, Maastricht University, Maastricht, the Netherlands.
Richard P. Bentall, School of Psychological Sciences, University of
Manchester, Manchester, England. Tania Lecomte, Department of Psychi-
atry, University of British Columbia, Vancouver, BC, Canada. Jim van Os,
Department of Psychiatry and Neuropsychology, South Limburg Mental
Health Research and Teaching Network, EURON, Maastricht University;
and Division of Psychological Medicine, Institute of Psychiatry, London,
England. Inez Myin-Germeys, Department of Psychiatry and Neuropsy-
chology, South Limburg Mental Health Research and Teaching Network,
EURON, Maastricht University; and School of Psychological Sciences,
University of Manchester.
Inez Myin-Germeys was supported by a 2006 NARSAD Young Inves-
tigator Award and by the Dutch Medical Research Council (VIDI Grant).
Correspondence concerning this article should be addressed to Inez
Myin-Germeys, Department of Psychiatry and Neuropsychology, Maas-
tricht, University, PO Box 616 (VIJV), 6200 MD Maastricht, the Nether-
lands. E-mail: i.germeys@sp.unimaas.nl
Journal of Abnormal Psychology Copyright 2008 by the American Psychological Association
2008, Vol. 117, No. 1, 143–153 0021-843X/08/$12.00 DOI: 10.1037/0021-843X.117.1.143
143
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self-esteem in paranoid patients (Candido & Romney, 1990;
Krstev, Jackson, & Maude, 1999; Lyon, Kaney, & Bentall, 1994).
For example, Candido and Romney (1990) assessed global self-
esteem in paranoid patients, depressed patients, and patients who
were both paranoid and depressed. They demonstrated high self-
esteem in the paranoid patients, low self-esteem in the depressed
patients, and intermediate scores in patients who were both para-
noid and depressed.
A number of studies, mainly by Kernis and colleagues (Kernis,
2005; Kernis, Cornell, Sun, Berry, & Harlow, 1993; Kernis &
Goldman, 2003), have indicated that, besides self-esteem level, it
is important to take into account the dynamic aspects of self-
esteem when investigating psychological mechanisms. In a recent
large-scale epidemiological study (Thewissen et al., 2007), we
have demonstrated that individuals with paranoid symptoms had a
significantly lower mean self-esteem level compared with individ-
uals with other positive psychotic symptoms. More important, the
study showed a specific association between long-term fluctua-
tions in self-esteem and paranoia. However, because it is known
that fluctuations in self-esteem may result from a variety of con-
textual factors, such as evaluative feedback (Kernis & Johnson,
1990; Markus & Kunda, 1986), it is useful to investigate self-
esteem instability in the context of daily life.
Fluctuations in self-esteem over the short-term can be measured
by asking participants to rate themselves on a self-esteem ques-
tionnaire several times a day for a number of days (Greenier et al.,
1999; Kernis et al., 1993), preferably at random moments (Deles-
paul, 1995; deVries, 1992; Oosterwegel, Field, Hart, & Anderson,
2001). In the present article, the Experience Sampling Method
(ESM) was used to investigate self-esteem and paranoid ideation
in the context of daily life. ESM (Csikszentmihalyi & Larson,
1987) is a random time-sampling self-assessment diary technique
for assessing mental state and the context in which it is embedded
in the natural flow of daily life. The feasibility, validity, and
reliability of ESM has been demonstrated in a wide range of
populations (e.g., Jacobs et al., 2005), including in individuals with
schizophrenia (Delespaul, 1995; Myin-Germeys, Delespaul, & van
Os, 2005; Myin-Germeys, van Os, Schwartz, Stone, & Delespaul,
2001) and other psychiatric disorders (deVries, 1992). For exam-
ple, Myin-Germeys, Delespaul, and deVries (2000) have demon-
strated that this time-sampling technique is a suitable method for
investigating the variability and intensity of affective experiences
in individuals with schizophrenia.
Paranoia may exist as a continuous trait or phenotype in nature
and is thought to be expressed also at levels well below psychotic
illness (Combs, Michael, & Penn, 2006; Freeman et al., 2005), in
which case it is usually referred to as psychosis proneness, schizo-
typy, or at-risk mental state (Hanssen, Krabbendam, Vollema,
Delespaul, & van Os, 2006; Johns & van Os, 2001; van Os,
Hanssen, Bijl, & Vollebergh, 2001). Psychological mechanisms
associated with paranoid symptoms are also likely to operate in
individuals who have an at-risk mental state. In the current study,
subjects ranging across the paranoia continuum were investigated.
The goal of the current article was twofold. First, we sought to
study the level and instability of self-esteem as trait characteristics
in individuals who ranged across the paranoia continuum. Level of
self-esteem was assessed with a self-esteem questionnaire (the
Self-Esteem Rating Scale; Nugent & Thomas, 1993), and, in
addition, ESM was used to assess the global level of self-esteem in
daily life. Experience sampling data were used to define instability
of self-esteem. The rationale for this was that by definition, mul-
tiple measurement points are necessary to define instability. Insta-
bility was thus defined as (a) standard deviation of self-esteem
over 60 experience sampling reports for each person, and (b)
average moment-to-moment change in self-esteem. It was hypoth-
esized, in accordance with previous findings (Thewissen et al.,
2007), that individuals at higher positions on the paranoia contin-
uum—thus reporting higher levels of trait paranoia—would show
a lower general level of self-esteem. In addition, guided by previ-
ous findings (Thewissen et al., 2007) and predictions by the
aforementioned psychological model (Bentall et al., 2001), it was
hypothesized that individuals with higher levels of trait paranoia
would show more fluctuations in self-esteem compared with indi-
viduals at lower positions on the continuum.
A second purpose of this study was to examine the temporal
relationship between changes in self-esteem and momentary para-
noid experiences in individuals who ranged across the paranoia
continuum. Previously, it was shown that delusional experiences
may fluctuate within days and hours (Myin-Germeys, Nicolson, &
Delespaul, 2001). This study will investigate whether momentary
or state paranoia is preceded by changes in momentary self-
esteem. It was hypothesized, as predicted by the aforementioned
model (Bentall et al., 2001), that a decrease in state self-esteem
would lead to an increase in state paranoia.
Method
Sample
In order to obtain a sample that ranged across the continuum of
paranoia, we included the following individuals who differed in
level of current paranoid symptomatology: (a) patients diagnosed
with a psychotic disorder who currently present paranoid psychotic
symptoms, defined as having a score of ⬎ 3 on Item P6 (suspi-
ciousness) of the Positive and Negative Syndrome Scale (PANSS;
see Instruments section); (b) patients diagnosed with a psychotic
disorder who currently have other positive psychotic symptoms,
defined as having a score of ⬍ 4 on the PANSS Items P6 (suspi-
ciousness) and having a score of ⬎ 3 on at least one of the PANSS
Items P1 (delusions), P3 (hallucinatory behavior), P5 (grandios-
ity), and G9 (unusual thought content); (c) patients diagnosed with
a psychotic disorder who currently report remitted psychotic
symptoms, defined as having a score of ⬍ 4 on all the aforemen-
tioned PANSS items; (d) individuals with no diagnosis of psy-
chotic disorder who present a psychometric at-risk mental state for
paranoid psychosis (hereafter “high schizotypy participants”), de-
fined operationally as scoring high (⬎ 90th percentile) on the
paranoid items of a questionnaire measuring psychosis-proneness
(Community Assessment of Psychic Experiences, CAPE; see In-
struments section); and (e) “healthy” control participants defined
in terms of scoring in the average range (between the 45th and 55th
percentile) on all three symptom dimensions of the CAPE and not
scoring high (⬎ 90th percentile) on the paranoid items.
The inclusion criteria for all participants were signed informed
consent, age 18–65 years, and sufficient command of the Dutch
language to understand and fill out the questionnaires. Patients
were recruited from clinical and ambulatory mental health facili-
ties in the cities of Heerlen and Maastricht, the Netherlands. They
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THEWISSEN ET AL.
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were extensively screened for psychiatric symptoms using diag-
nostic interviews including the PANSS (Kay, Fiszbein, & Opler,
1987) and the Life Chart (Susser et al., 2000). Interview data and,
when necessary, clinical record data were used to yield ICD-10
diagnoses by the OPCRIT computer program (McGuffin, Farmer,
& Harvey, 1991). High schizotypy participants and healthy con-
trols were recruited from an earlier longitudinal family study in the
general population conducted in the city of Sittard, the Netherlands
(Continuum of Mental Disorders study; Hanssen et al., 2003).
Residents of the municipality of Sittard, age 36–65 years, were
randomly selected and sent a letter in which they were asked to
participate. The mailing frame comprised 4,589 participants (2,287
females and 2,302 males). Additionally, a snowball sampling
procedure was used: Participants who had responded to the mail
survey were asked to invite their family members to participate in
the study. The total general population sample comprised 768
individuals, age 17–77 years, from 116 families. All participants
filled in the extended, 42-item CAPE. Participants with a high
score (⬎90th percentile) on the paranoid items of the CAPE (see
Instruments section) and those with an overall CAPE score close to
the mean (i.e., scores between the 45th and 55th percentile) were
invited to take part in the current study.
Instruments
The Community Assessment of Psychic Experiences
(CAPE)
CAPE (Hanssen et al., 2003; Konings, Bak, Hanssen, van Os, &
Krabbendam, 2006; Stefanis et al., 2002) is a self-report instru-
ment that measures frequency of attenuated psychotic experiences
in the affective and nonaffective domains, as well as distress
associated with these experiences. The extended, 42-item instru-
ment is mainly based on the 21-item Peters et al. Delusions
Inventory (PDI–21; Peters, Joseph, & Garety, 1999). The fre-
quency score is measured on a 4-point scale in which 0 ⫽ never,
1 ⫽ sometimes,2⫽ often, and 3 ⫽ nearly always. The degree of
distress is measured on a 4-point scale in which 0 ⫽ not distressed,
1 ⫽ a bit distressed,2⫽ quite distressed, and 3 ⫽ very distressed.
As mentioned above, the CAPE was used to select individuals with
an at-risk mental state for paranoid psychosis. The frequency
scores of the following two paranoia items were used: “Do you
ever feel as if you are being persecuted in some way?” (Item 7) and
“Do you ever feel as if there is a conspiracy against you?” (Item
10). The CAPE has demonstrated good test–retest reliability and
cross-validity in a general population sample (Konings et al.,
2006) and discriminative validity between individuals from the
general population and patients with schizophrenia and affective
and anxiety disorders (Hanssen et al., 2003).
Positive and Negative Syndromes Scale (PANSS)
Within a week after the sampling period, a trained research
assistant assessed all participants (including the control partici-
pants) with the PANSS (Kay et al., 1987), a semistructured inter-
view for rating positive, negative, and other symptom dimensions
in schizophrenia. The PANSS consists of 30 items: 7 items relating
to the positive dimension, 7 items relating to the negative dimen-
sion, and 16 items relating to general psychopathology. Each item
is assessed over the past fortnight and scored on a 7-point scale,
ranging from 1 (absent)to7(extreme). The item G6 “depression”
was used in the analyses as a covariate. The PANSS has demon-
strated good evidence of reliability, criterion-related validity, and
construct validity (Kay, Opler, & Lindenmayer, 1988).
Paranoia Scale (PS)
In order to assess trait paranoia, participants were asked to
complete the PS (Fenigstein & Vanable, 1992). The PS was
designed specifically to measure the incidence of paranoia in a
college population (Fenigstein & Vanable, 1992), but has also
been validated as a measure of current paranoid ideation in indi-
viduals with schizophrenia (Sma´ri, Stefa´nsson, & Thorgilsson,
1994). The scale consists of 20 items, which can be scored on a
5-point scale, ranging from 1 (not at all applicable to me)to5
(extremely applicable to me). The scale is derived from the Min-
nesota Multiphasic Personality Inventory, which was intended
primarily for a clinical population (Dahlstrom, Welsh, & Dahl-
strom, 1975). The following aspects of paranoia are measured on
the scale: (a) the belief that other people or forces are trying to
influence one’s behavior or control one’s thinking; (b) the belief
that other people are against the person; (c) the belief of being
watched or talked about; (d) suspicion or mistrust of others’
motives; and (e) feelings of resentment, bitterness, or ill will
(Fenigstein & Vanable, 1992). The PS is the most widely used
dimensional measure of paranoia (Freeman et al., 2005) and has
been found to have a substantial degree of internal consistency
(␣⫽.84), good test–retest reliability, and good construct validity
(Fenigstein & Vanable, 1992).
Self-Esteem Rating Scale (SERS)
In order to obtain a global measure of trait self-esteem, partic-
ipants were asked to complete the SERS (Nugent & Thomas,
1993). The SERS is a clinical measure designed to measure not
only problematic aspects of self-esteem but also positive nonprob-
lematic aspects of self-esteem. The SERS is partially based on
Hudson’s Index of Self-Esteem (Hudson, 1982) and taps into a
variety of areas of self-evaluation, including overall self-worth,
social competence, problem-solving ability, intellectual ability,
self-competence, and worth relative to others. It consists of 40
items, which can be scored on a 7-point Likert scale, ranging from
1(never)to7(always). Twenty of the items are scored negatively
and the remaining items are scored positively. The items are
summed to produce a total score that can range from ⫺120 to
⫹120. Positive scores indicate higher levels of self-esteem,
whereas negative scores indicate lower levels of self-esteem. The
SERS has a high internal consistency (␣⫽.98) and good construct
validity (Nugent & Thomas, 1993).
Experience Sampling Method (ESM) Procedure
The ESM (Csikszentmihalyi & Larson, 1987) is a structured
self-assessment technique. Participants received a preprogrammed
digital wristwatch and 10 identical pocket-size assessment forms
collated in a booklet for each day. Ten times a day on 6 consec-
utive days, the watch emitted a signal at unpredictable moments
between 7.30 a.m. and 10.30 p.m. After every “beep,” reports of
145
SELF-ESTEEM AND PARANOIA
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current context, mood, and self-esteem were collected. All self-
assessments were rated on 7-point Likert scales.
The ESM procedure was explained to the participants during an
initial briefing session, and a practice form was completed to
confirm that they were able to understand the 7-point Likert scale
format. Participants were instructed to complete their reports im-
mediately after the beep to minimize memory distortions. They
were also instructed to register the time at which they completed
the questionnaire. During the actual sampling period, research staff
contacted participants frequently by phone or, when necessary,
visited them to assess whether they were complying with the
instructions. During a debriefing session, the participants were
interviewed extensively to be sure that they had complied with the
instructions. On the basis of the times participants indicated they
had completed the reports, we excluded from the analyses all
reports that had been completed more than 15 min after the signal.
Previous work (Delespaul, 1995) has shown that reports completed
after this time interval are less reliable and consequently less valid.
Participants with less than 20 valid reports were excluded from the
analyses.
ESM Variables
The ESM assessment forms contained questions regarding mo-
mentary self-esteem and momentary paranoia.
State paranoia. State paranoia was defined as the mean score
of the following four items: “I feel that others dislike me,” “I feel
that others might hurt me,” “I feel suspicious,” and “I feel safe”
(reversed scale). Factor (principal component) analysis on the raw
within-participants scores identified one factor according to the
Kaiser criterion (eigenvalue ⬎ 1), explaining 75% of the total
variance. The items had a strong loading on the factor (negative
statements ⬍⫺.84; positive statement ⬎ .80) and high internal
consistency (Cronbach’s ␣⫽.89). State paranoia is significantly
correlated with total score on the PS (Pearson bivariate correlation,
r ⫽ .42, p ⬍ .001) and the PANSS Item P6 paranoia/persecution
(Pearson bivariate correlation, r ⫽ .58, p ⬍ .001).
State self-esteem. The ESM assessment forms contained four
self-esteem items: “I am a failure,” “I am ashamed of myself,” “I
like myself,” and “I am a good person.” The items were rated on
7-point Likert scales, ranging from 1 (not at all)to7(very). Factor
(principal component) analysis on the raw within-participant
scores identified one factor according to the Kaiser criterion (eig-
envalue ⬎ 1), accounting for 68% of the total variance. The four
items had a strong loading on the factor (negative statements ⬍
⫺0.76; positive statements ⬎ 0.80) and high internal consistency
(Cronbach’s ␣⫽.84). State self-esteem was defined as the mean
score of the four items (scales of the two negative statements were
reversed).
Change in state self-esteem. Change in state self-esteem was
defined as the difference in self-esteem between two succeeding
reports: the self-esteem score on the previous moment (t ⫺ 1,
roughly 90 min earlier) minus the self-esteem score on the target
moment (t). The difference score ranges from ⫺6to⫹6 and high
scores reflect decreases (see Figure 1).
Data analyses
Is Self-Esteem Level and Variability Associated With Trait
Paranoia?
The first set of analyses aimed to investigate the association
between level and instability of self-esteem as person characteris-
tics and trait paranoia. Trait paranoia was defined as the mean
score on the PS. Level of self-esteem was defined as (a) the sum
score of the SERS questionnaire and (b) the mean of the ESM
momentary self-esteem reports for each individual (mean over 60
reports). In order to examine the association between self-esteem
... t-2 t-1
ESM timeline
t+1 ... t
troper tnerructroper suoiverp
self-esteem
self-esteem
change in
self-esteem
paranoia
A
Figure 1. Longitudinal association between changes in self-esteem and paranoia. A: Multilevel regression
analysis to investigate whether a change in self-esteem (self-esteem t ⫺ 1 minus self-esteem t; independent
variable) longitudinally influences paranoia (t; dependent variable), with sex, depressive mood (t), and paranoia
(t ⫺ 1) as confounding factors. ESM ⫽ Experience Sampling Method.
146
THEWISSEN ET AL.
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level and paranoia, two separate linear regression models were
estimated with the two self-esteem levels as the dependent variable
and trait paranoia as the independent variable.
Self-esteem instability was defined as (a) the standard deviation
of the ESM momentary self-esteem reports over 60 beeps per
subject and (b) the mean absolute ESM momentary self-esteem
change score for each individual over 60 reports (indicating the
mean change in self-esteem from moment to moment). Again, two
separate linear regression models were estimated with the two SE
instability measures as dependent variable and trait paranoia as the
independent variable. Data were analyzed with the REG module in
STATA/SE version 9.2 (StataCorp, 2006).
Each abovementioned analysis was repeated to investigate a
dose-response relationship between trait paranoia and self-esteem
level or self-esteem instability. Participants were therefore divided
into tertiles based on their total score on the PS (Time 1 ⫽ low
paranoia, Time 2 ⫽ medium paranoia, Time 3 ⫽ high paranoia).
Trait self-esteem level or self-esteem instability was treated as
dependent variables and paranoia (divided into tertiles) as the
independent variable.
The following a priori selected confounders were included in the
regression models: depression (PANSS Item G6) and sex. Depres-
sion was included as a confounder in the model as self-esteem is
highly correlated with depression (Barrowclough et al., 2003;
Rosenberg, Schoenbach, Schooler, & Rosenberg, 1995).
Is Trait SE Instability More Strongely Associated With
Trait Paranoia Than With SE Level?
First, it was investigated whether SE instability (defined as
standard deviation of all momentary self-esteem scores of a per-
son) was associated with SE level (defined as the average of the
momentary self-esteem scores for each person) using linear regres-
sion analyses. If they are indeed associated, self-esteem level will
be added as a confounder to the models predicting self-esteem
instability, and self-esteem instability will be added as a con-
founder to the models predicting self-esteem level.
Are Momentary Changes in SE Associated With State
Paranoia?
In order to examine the temporal relationship between changes
in self-esteem and state paranoid experiences, multilevel linear
random regression models were estimated. Multilevel or hierar-
chical linear modeling techniques are a variant of the more often
used unilevel linear regression analyses and are ideally suited for
the analysis of hierarchical or clustered data (J. E. Schwartz &
Stone, 1998). ESM data have a hierarchical structure in which
repeated momentary observations are clustered within participants
(beeps within participants). Because ESM observations from the
same participants are more similar than observations from differ-
ent participants, the residuals are not independent. Conventional
regression techniques do not take into account the variance com-
ponents at two levels. Data were analyzed with the XTREG
module in STATA/SE version 9.2 (StataCorp, 2006). The B is the
fixed regression coefficient of the predictor and can be interpreted
identically to the estimate in a unilevel linear regression model.
The individual intercepts (␣) of the multilevel model are treated as
a random factor.
In order to examine the relationship between momentary
changes in self-esteem and state paranoid experiences, a multilevel
linear random regression model was estimated with change in
momentary self-esteem between the previous moment and the
target moment as the independent variable and state paranoia at the
target moment as the dependent variable. The multilevel model
was corrected for the a priori selected confounders sex and de-
pressive mood. Depressive mood was assessed using the momen-
tary mood item, “I feel down,” at the target moment. In addition,
the model was adjusted for paranoia at previous moments (t ⫺ 1).
Results
Of the 183 participants who entered the study, some individuals
were recruited from clinical or ambulatory mental health facilities
and others were recruited from the general population. Of these
183 participants, 29 (15.8%) individuals were excluded from the
analyses. Twenty-two participants terminated the study before the
end of the 6-day sampling period, due to severity of psychotic
symptoms (n ⫽ 11), cognitive incapability (n ⫽ 5), or lack of
cooperation (n ⫽ 6). Although they finished the study, 3 individ-
uals were excluded because of an insufficient number (⬍ 20) of
valid ESM observations, 1 individual because of missing data on
the PS, 1 individual because of missing data on the PANSS, and 2
individuals because of missing data on both the PS and the
PANSS. Of the 29 individuals who were excluded from the anal-
yses, 24 were patients, 3 were high-schizotypy participants, and 2
were healthy controls. The final study sample therefore comprised
154 participants. These participants had each completed an aver-
age of 44 valid ESM reports (SD ⫽ 10). Additional information
regarding number of valid reports and sociodemographic and
clinical characteristics of the participants are summarized in Table
1. In the patient group with current paranoid psychotic symptoms,
9 patients had a score of 4 on the PANSS, 10 patients had a score
of 5, 5 patients had a score of 6, and 6 patients had a score of 7.
In the current study, trait paranoia is included as a continuous
variable based on the mean score on the PS. However, in order to
investigate dose–response relationships, the participants were di-
vided in three tertiles. The composition of the paranoia tertile
groups is presented in Table 2. Mean scores of the independent and
dependent variables by tertile group are presented in Table 3.
Depression, as measured with the PANSS, was significantly
associated with trait paranoia, B ⫽ 0.30, SE ⫽ 0.01, p ⬍ .001.
Depression was also correlated with self-esteem level (e.g., ESM
self-esteem level, B ⫽⫺0.24, SE ⫽ 0.05, p ⬍ .001), and with
self-esteem variability (e.g., self-esteem standard deviation, B ⫽
0.09, SE ⫽ 0.02, p ⬍ .001). It is therefore likely that depression
confounds the association between paranoia and the self-esteem
variables. In order to assess the associations that are specific for
paranoia, depression was added as a confounder in the models.
Is Self-Esteem Level and Variability Associated With Trait
Paranoia?
Trait paranoia was significantly associated with a lower level of
trait self-esteem, as consistently shown by lower sum scores on the
SERS questionnaire and by lower mean levels of momentary
self-esteem assessed in daily life (Table 4). High paranoid indi-
viduals (highest tertile) showed a significantly lower self-esteem
147
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level compared with low paranoid participants (lowest tertile;
Table 4). After controlling for the possible confounding effects of
sex and depression, paranoia was still significantly associated with
a lower level of self-esteem. After subsequently controlling for the
constraining effect of self-esteem instability, the effect disappeared
at momentary level (Table 4).
In addition, trait paranoia was significantly associated
with higher fluctuations in self-esteem. Both larger standard
deviations and a larger mean change from moment to mo-
ment measured in daily life were associated with more trait
paranoia, even after controlling for the possible confounding
effects of sex and depression (Table 5). High paranoid individ-
uals (highest tertile) showed significantly more self-esteem
fluctuations compared with low paranoid individuals (lowest
tertile), even after controlling for all possible confounding
effects (Table 5).
Table 1
Descriptive Characteristics of the Participants
Variable
Current paranoid
patients
(n ⫽ 30)
Current
nonparanoid
patients
(n ⫽ 34)
Remitted patients
(n ⫽ 15)
High schizotypy
participants
(n ⫽ 38)
Healthy controls
(n ⫽ 37)
Number of valid reports (SD) 37 (10) 38 (10) 42 (9) 49 (6) 49 (6)
Range 20–59 21–58 20–55 32–59 37–59
Sociodemographic
Mean age (SD) 38.1 (10.7) 36.0 (11.6) 32.5 (12.3) 47.3 (10.3) 48.7 (9.2)
Range in years 19–57 18–63 18–59 23–60 23–59
Sex, male/female ratio 26/4 26/8 14/1 13/25 14/23
No. (%) 87 (13) 76 (24) 93 (7) 34 (66) 38 (62)
Education, No. (%)
Elementary school 3 (10) 6 (18) 1 (7) 2 (5) 1 (3)
Secondary school 25 (83) 22 (65) 14 (93) 23 (61) 14 (38)
Higher education 2 (7) 6 (18) 0 (0) 13 (34) 22 (59)
Marital status, No. (%)
Married or living together 3 (10) 2 (6) 1 (7) 29 (76) 32 (86)
Divorced 6 (20) 5 (15) 1 (7) 4 (11) 4 (11)
Widowed 0 (0) 1 (3) 0 (0) 0 (0) 0 (0)
Never married 21 (70) 26 (76) 13 (87) 5 (13) 1 (3)
Work situation, No. (%)
Working/fulltime household/studying 1 (3) 2 (6) 2 (13) 24 (63) 33 (89)
Protected work 0 (0) 2 (6) 1 (7) 0 (0) 0 (0)
Incapable of work 24 (80) 26 (76) 9 (60) 6 (16) 2 (5)
Unemployed 5 (17) 4 (12) 3 (20) 7 (18) 1 (3)
Retired 0 (0) 0 (0) 0 (0) 1 (3) 1 (3)
Clinical
OPCRIT (McGuffin et al., 1991) lifetime
ICD-10 diagnosis, No. (%)
Schizophrenia/psychotic disorder 28 (93) 28 (82) 14 (93) 0 (0) 0 (0)
Schizoaffective disorder 2 (7) 6 (18) 1 (7) 0 (0) 0 (0)
Mild/moderate depression 0 (0) 0 (0) 0 (0) 4 (11) 6 (16)
PANSS score
a
(SD)
71.4 (13.7) 60.5 (9.7) 44.3 (8.5) 36 (4.5) 33.7 (2.9)
Range 47–103 41–79 32–60 31–50 30–44
PANSS suspiciousness/persecution
b
(SD)
5.3 (1.1) 2.3 (0.9) 1.7 (0.9) 1.6 (0.7) 1.2 (0.4)
Range 4–7 1–3 1–3 1–3 1–2
ESM momentary paranoia (SD) 3.0 (1.6) 2.1 (1.1) 1.7 (0.8) 1.6 (0.7) 1.3 (0.4)
Range 1–7 1–7 1–4.8 1–5.5 1–4.5
Mean age of first psychotic episode (SD) 22.8 (8.2) 23.1 (7.3) 22.1 (6.3) — —
Range in years
c
13–45 13–43 12–35 — —
Mean age of first contact with psychiatric
service due to psychotic symptoms (SD)
26.9 (8.8) 24.5 (7.7) 22.5 (6.0) — —
Range in years
d
16–49 15–44 12–35 — —
Usual symptom severity last 2 years (Life
Chart), No. (%)
e
Severe 3 (10) 1 (3) 0 (0) — —
Moderate 14 (48) 14 (45) 6 (46) — —
Mild 11 (38) 15 (48) 5 (38) — —
Recovered 1 (3) 1 (3) 2 (15) — —
Note. Due to rounding, percentages may not add exactly to 100%. PANSS ⫽ Positive and Negative Syndromes Scale; ESM ⫽ Experience Sampling
Method.
a
Total score on the PANSS.
b
Mean score on item P6 of the Positive and Negative Syndromes Scale, scale ranges from 1 to 7.
c
Because of missing
values, data were only calculated for 26 current paranoid patients, 28 current non-paranoid patients, and 14 remitted patients.
d
Because of missing values,
data were only calculated for 28 current paranoid patients and 32 current non-paranoid patients.
e
Because of missing values, data were only calculated
for 29 current paranoid patients, 31 current nonparanoid patients, and 13 remitted patients.
148
THEWISSEN ET AL.
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Is Trait Self-Esteem Instability More Strongly Associated
With Trait Paranoia Than With Self-Esteem Level?
Self-esteem level was significantly and linearly associated with
self-esteem instability, B ⫽⫺0.20, SE ⫽ 0.03, p ⬍ .001. There-
fore, self-esteem instability was controlled for in the model pre-
dicting self-esteem level. As presented in Table 4, the effect of trait
paranoia on self-esteem level disappeared after controlling for the
constraining effects of self-esteem instability. In the model pre-
dicting self-esteem instability on the other hand, the effect of trait
paranoia remained significant after controlling for self-esteem
level (see Table 5). Therefore, it seems safe to suggest that self-
esteem instability is more strongly related to paranoia than to
self-esteem level.
Are Momentary Changes in State SE Associated With
State Paranoia?
Multilevel linear regression analysis showed a temporal associ-
ation between changes in self-esteem and state paranoia. A de-
crease in self-esteem between two succeeding reports was signif-
icantly associated with an increase in subsequent momentary
paranoia, B ⫽ 0.17, SE ⫽ 0.01, p ⬍ .001. This association
remained strong and significant after controlling for sex, current
depressive mood, and paranoia at the previous beep moment, B ⫽
0.17, SE ⫽ 0.01, p ⬍ .001.
Examining Robustness of the Results
Additional analyses were performed to investigate whether the
individuals who were excluded from the analyses were comparable
to the study group in terms of their scores on ESM momentary
self-esteem. The analyses were performed on the data of 27 indi-
viduals, because 2 individuals did not comply with the protocol
(one filled out all the booklets on the first day, the other did not
report the time on any of the beeps). Factor (principal component)
analysis on the raw within-participants ESM self-esteem scores
identified one factor, accounting for 68% of the total variance. The
four self-esteem items had a strong loading on the factor (negative
statements, ⫺0.78 and ⫺0.90, respectively; positive statements,
0.90 and 0.69, respectively) and good internal consistency (Cron-
bach’s ␣⫽.84), which is comparable to that of the study group.
The mean ESM momentary self-esteem level of the excluded
individuals was 5.1 (SD ⫽ 1.1), which was substantially lower
than the mean ESM momentary self-esteem level of high paranoid
individuals in the highest tertile (Table 3). The mean ESM mo-
Table 2
Composition of the Paranoia Tertiles
Study sample (n ⫽ 144)
Tertile 1
low
paranoia
(n ⫽ 47)
Tertile 2
medium
paranoia
(n ⫽ 51)
Tertile 3
high
paranoia
(n ⫽ 56)
% n % n % n
Current paranoid patients 0 0 23 7 77 23
Current nonparanoid patients 15 5 26 9 59 20
Remitted patients 20 3 33 5 47 7
High schizotypy participants 32 12 53 20 16 6
Healthy controls 73 27 27 10 0 0
Note. Due to rounding, percentages may not add exactly to 100%.
Table 3
Independent and Dependent Variables by Tertile Group
Variable
Tertile 1
low
paranoia
(n ⫽ 47)
Tertile 2
medium
paranoia
(n ⫽ 51)
Tertile 3
high
paranoia
(n ⫽ 56)
Total sample
(n ⫽ 154)
PS
a
(SD)
1.5 (0.2) 2.2 (0.2) 3.3 (0.5) 2.4 (0.8)
Range 1–1.8 1.9–2.6 2.6–4.5 1–4.5
PANSS depression
b
(SD)
1.5 (1.0) 1.9 (1.1) 2.8 (1.3) 2.1 (1.3)
Range 1–5 1–5 1–6 1–6
Measures of SE level
Momentary level
c
(SD)
6.3 (0.5) 6.0 (0.8) 5.6 (1.0) 6.0 (0.8)
Range 3.9–7 3.5–7 2.7–7 2.7–7
Participant level
d
(SD)
56.4 (25.1) 41.8 (27.7) 18.8 (34.0) 37.9 (33.2)
Range ⫺33–102 ⫺9–93 ⫺53–92 ⫺53–102
Measures of SE instability
Momentary level
e
(SD)
0.2 (0.2) 0.3 (0.3) 0.4 (0.3) 0.3 (0.3)
Range 0–0.8 0–1.7 0–1.5 0–1.7
Participant level
f
(SD)
0.3 (0.2) 0.4 (0.3) 0.6 (0.4) 0.4 (0.3)
Range 0–1.0 0–1.6 0–1.8 0–1.8
ESM momentary paranoia
g
(SD)
1.3 (0.5) 1.7 (1.0) 2.6 (1.3) 1.9 (1.1)
Range 1–6.3 1–7 1–7 1–7
Note. Separate means were calculated for each participant and subsequently aggregated to obtain group means.
a
PS indicates mean score on the Paranoia Scale, scale ranges from 1 to 5.
b
PANSS depression indicates mean score on the depression item of the Positive
and Negative Syndromes Scale, scale ranges from 1 to 7.
c
ESM (Experience Sampling Method) momentary self-esteem assessment, scale ranges from
1to7.
d
Total score on the Self-Esteem Rating Scale, scale ranges from ⫺120 to ⫹120.
e
Absolute difference score in self-esteem between two
concurrent ESM assessments, minimum possible difference score is 0 and maximum possible difference score is 6.
f
Standard deviation of all ESM
momentary self-esteem assessments.
g
ESM momentary paranoia assessment, scale ranges from 1 to 7.
149
SELF-ESTEEM AND PARANOIA
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mentary fluctuation, based on only 23 individuals, was 0.7 (SD ⫽
0.5), which was substantially higher than the mean ESM momen-
tary fluctuation of high paranoid individuals in the highest tertile
(Table 3). These differences will be addressed in the discussion.
Discussion
The findings support the hypothesis that instability in self-
esteem is associated with paranoia, both trait and state paranoia.
The results of the first two analyses confirm the hypothesis that
individuals at higher positions on the paranoia continuum not only
show a lower general self-esteem level but also more fluctuations
in their self-esteem. These results are consistent with previous
findings of an association between paranoia and low levels of
self-esteem, both found in patients with psychosis (Freeman et al.,
1998) and in nonclinical samples (Combs & Penn, 2004; Ellett et
al., 2003; Martin & Penn, 2001). The results are also in line with
findings of a specific association between paranoia and fluctua-
tions of self-esteem in a general population sample (Thewissen et
al., 2007) and extend these findings to the context of daily life in
individuals ranging from nonpathological to pathological levels of
paranoia. Furthermore, these data suggest that instability of self-
esteem plays a more important role in the association with para-
noia than level of self-esteem. The second set of analyses aimed to
investigate the temporal relationship between momentary self-
esteem and state paranoia in the daily life of psychotic patients.
The results are in line with the hypothesis that decreases in
self-esteem may result in increases in paranoid thinking (Bentall et
al., 2001) thus providing evidence for a causal relationship be-
tween self-esteem and paranoia.
The relationship between self-esteem and psychosis has been
investigated thoroughly (Barrowclough et al., 2003; Bowins &
Shugar, 1998; Freeman et al., 1998; Krabbendam et al., 2002;
Lecomte et al., 1999; Nickols, 1966; Silverstone, 1991; Silverstone
& Salsali, 2003). There is a growing consensus that psychotic
individuals present with low levels of self-esteem at different
phases of the illness (Hall & Tarrier, 2003), even after symptom-
atic recovery (Gureje, Harvey, & Herrman, 2004). Negative eval-
uations of the self are specifically associated with positive psy-
chotic symptoms in general (Barrowclough et al., 2003), although
premorbid feelings of inferiority have been found to be more
frequent in paranoid patients than in a comparison group of indi-
viduals with schizophrenia (Kendler & Hays, 1981).
The more specific relationship between self-esteem and para-
noia has also been the focus of study for many years (Bentall,
Table 4
Regression Estimates (B) for the Effect of Paranoia on Self-Esteem (SE) Level
SE level and confounders nB(SE) p linear trend p (T2 vs. T1)
a
p (T3 vs. T1)
a
Mean ESM self—esteem level
— 154 ⫺0.32 (0.08) ⬍.001 ⬍.001
Sex 154 ⫺0.32 (0.08) ⬍.001 ⬍.001
Sex, depression 154 ⫺0.20 (0.09) ⫽.03 ⬍.05
Sex, depression, SE instability 154 ⫺0.09 (0.01) ns
SERS self-esteem level
— 154 ⫺18.93 (2.89) ⬍.001 ⬍.05 ⬍.001
Sex 154 ⫺20.33 (3.09) ⬍.001 ⬍.01 ⬍.001
Sex, depression 154 ⫺16.10 (3.30) ⬍.001 ⬍.05 ⬍.001
Sex, depression, SE instability 154 ⫺13.04 (3.30) ⬍.001 ⬍.001
Note. Paranoia, defined as the mean score on the Paranoia Scale, yielded approximately similar results. The association disappeared, however, after
controlling for sex, depression and SE instability. T1 ⫽ Tertile 1 low paranoia; T2 ⫽ Tertile 2 medium paranoia; T3 ⫽ Tertile 3 high paranoia; ESM ⫽
Experience Sampling Method; SERS ⫽ Self-Esteem Rating Scale.
a
Positive and Negative Syndromes Scale tertile scores.
Table 5
Regression Estimates (B) for the Effect of Paranoia on Self-Esteem (SE) Instability
SE instability and confounders nB(SE) p linear trend p (T2 vs. T1)
a
p (T3 vs. T1)
a
Self-esteem instability defined as mean moment-to-moment change
— 154 0.11 (0.03) ⬍.001 ⬍.001
Sex 154 0.14 (0.03) ⬍.001 ⬍.05 ⬍.001
Sex, depression 154 0.09 (0.03) ⫽.002 ⬍.01
Sex, depression, SE level 154 0.06 (0.03) ⫽.02 ⬍.05
Self-esteem instability defined as SD
— 154 0.13 (0.03) ⬍.001 ⬍.001
Sex 154 0.16 (0.03) ⬍.001 ⬍.05 ⬍.001
Sex, depression 154 0.11 (0.03) ⫽.001 ⬍.001
Sex, depression, SE level 154 0.08 (0.03) ⫽.01 ⬍.01
Note. Paranoia, defined as the mean score on the Paranoia Scale, yielded approximately similar results, before and after controlling for sex, depression
and SE level. T1 ⫽ Tertile 1 low paranoia; T2 ⫽ Tertile 2 medium paranoia; T3 ⫽ Tertile 3 high paranoia.
a
Paranoia Scale tertile scores.
150
THEWISSEN ET AL.
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1994; Bentall, Kinderman, & Kaney, 1994; Colby, 1975; Garety,
Kuipers, Fowler, Freeman, & Bebbington, 2001; Meissner, 1981;
D. A. Schwartz, 1963). Up to now, most studies have specifically
focused on the relationship between levels of self-esteem and
paranoia. However, the results of these studies are equivocal,
particularly compared with the results of studies investigating the
relationship between self-esteem and psychosis in general. Para-
noia has been found to be associated with low levels of self-
esteem, both in patients (Freeman et al., 1998) and in nonclinical
samples (Combs & Penn, 2004; Ellett et al., 2003; Martin & Penn,
2001), as well as with relatively high or even normal levels of
self-esteem in paranoid patients (Candido & Romney, 1990;
Krstev et al., 1999; Lyon et al., 1994). One explanation for these
inconsistent findings is that the dynamic aspects of self-esteem
were not taken into account.
The importance of fluctuations in self-esteem has been stressed
by a recent explanatory model of paranoia in which the formation
of persecutory delusions is suggested to be a complex and dynamic
process (Bentall et al., 2001). According to the model, paranoid
patients attempt to avoid negative beliefs about the self by assum-
ing that their disappointments in life are caused by intentional
actions of other people. These attempts to maintain self-esteem
have the unfortunate consequence of obtaining a negative world
view. However, as the attempts to avoid negative beliefs are not
always effective, it is predicted that self-esteem will be highly
unstable in paranoid patients rather than being a stable trait. The
present findings of a strong association between paranoia and
higher fluctuations of self-esteem are therefore well in line with
this theory and additionally show that self-esteem may fluctuate
within a very short period.
The strength of the findings in the first two analyses is that
fluctuations in self-esteem were consistently demonstrated using
two different approaches to measure instability of self-esteem:
first, at a momentary level, in which fluctuations were identified
from moment to moment, and second, as a participant character-
istic, in which the fluctuations reflected the variance in self-esteem
over the study period. There was evidence for a dose–response
relationship, in that the results showed significantly more self-
esteem fluctuations in high paranoid individuals compared with
low paranoid individuals at all three levels.
These findings also provide evidence for a strong association
between paranoia and a lower self-esteem level using two different
approaches to measure self-esteem level: global level of self-
esteem over the days, and level of self-esteem assessed with a
questionnaire. After controlling for self-esteem instability, the
association disappeared at momentary level. This may indicate that
self-esteem level is strongly constrained by self-esteem instability.
On the other hand, self-esteem instability was not found to be
confounded by level of self-esteem. This suggests that in the
context of daily life, instability of self-esteem plays a more im-
portant role in the relationship with paranoia than level of self-
esteem, as the latter is reducible to the first but not the other way
around.
In the first two analyses, it was not possible to infer the direction
of causality between paranoia and level and fluctuations in self-
esteem. Level and fluctuations in self-esteem could merely be
interpreted as an expression of psychosis liability. The results of
the third analysis, however, yield evidence of a temporal associ-
ation between self-esteem and paranoia by showing that a decrease
in self-esteem is associated with an immediate increase in para-
noia. Although these findings demonstrate that the fluctuation
magnitude of self-esteem influences the degree of paranoia, it is
most likely that a low self-esteem level and a high self-esteem
instability both act as a vulnerability, maintaining, and consequen-
tial factor of paranoia (Bentall et al., 2001; Freeman et al., 1998;
Krabbendam et al., 2002; Roe, 2003).
The current results should be interpreted in the context of some
limitations. First, comparison analyses in the first set of analyses
demonstrated that the individuals who had been excluded from the
main analyses were different from the study group in terms of
mean momentary self-esteem level and fluctuations. The excluded
group showed a lower self-esteem level and considerably higher
self-esteem fluctuations. However, as most of the excluded indi-
viduals were patients who were not able to participate in the study
due to severity of their illness, the lower self-esteem level and
higher self-esteem fluctuations can be interpreted as expressions of
the degree of their illness. Moreover, this observation suggests
that, if anything, the current findings may underestimate the asso-
ciation between paranoia and level and fluctuations of self-esteem.
Second, it has been argued that the PS might contain some affec-
tively laden or depression items. Therefore, one could argue that
current findings of a relationship between self-esteem and paranoia
are ambiguous. However, controlling for depression did not
change the results, suggesting that it is more the paranoid rather
than the depressive content of the PS that is associated with
self-esteem. Third, self-esteem was measured in both studies as
one single concept. According to some researchers (Barrowclough
et al., 2003), it is important to make a distinction between positive
and negative components of self-esteem, since individuals may
hold both positive and negative views about the self, which may
act independently. However, because the current results are con-
sistently found using two different definitions, the results are
expected to be reliable. Besides, factor analysis on the positive and
negative momentary self-esteem items demonstrated that the items
were representative of one single substantive construct. Fourth, no
distinction was made on the basis of content of the paranoid
beliefs. It has been argued that there may be two separate types of
paranoia that represent beliefs about the deservedness of the per-
secution. One type is persecution or “poor me” paranoia and the
other type is punishment or “bad me” paranoia (Chadwick,
Trower, Juusti-Butler, & Maguire, 2005). “Bad me” paranoia, in
which the malevolence of others is conceived as justifiably de-
served, is typically characterized by lower self-esteem. Recent
evidence shows that these beliefs on deservedness may change or
alternate within a person over time, representing separate phases of
an unstable phenomenon (Melo, Taylor, & Bentall, 2006). There-
fore, it would be valuable for future studies on momentary para-
noia to investigate these two types of paranoia separately. Finally,
it could be argued that the key issue is not variability in self-esteem
but rather a more general emotional vulnerability. Self-esteem
variability possibly is a marker for this more general emotional
vulnerability. This possibility cannot be ruled out in the current
article.
The current findings have several implications. The finding that
not only low self-esteem level but also self-esteem fluctuations are
a main feature of paranoid patients has an important implication
for treatment. Besides targeting improvement of self-esteem (Hall
& Tarrier, 2003; Lecomte et al., 1999), psychological treatments
151
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should also focus on regulation of self-esteem. Future explanatory
models of paranoia should also take into account the dynamic
structure of self-esteem. Other factors, such as mood, which are
involved in the complex relationship between self-esteem and
paranoia, merit further investigation.
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Received October 5, 2006
Revision received July 5, 2007
Accepted July 17, 2007 䡲
153
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