Delusi 6

Clinical Psychology Review 31 (2011) 684696
Contents lists available at ScienceDirect
Clinical Psychology Review
Grandiose delusions: A review and theoretical integration of cognitive and

affective perspectives
Rebecca Knowles , Simon McCarthy-Jones, Georgina Rowse
University of Shefeld, UK
a r t i c l e
i n f o
Article history:
Received 24 August 2010
Accepted 23 February 2011
Available online 5 March 2011
Keywords:
Grandiose
Grandeur
Delusion
Bipolar
Mania
Schizophrenia
Psychosis
a b s t r a c t
Grandiose delusions (GDs) are found across a wide range of psychiatric conditions, including in around twothirds of patients diagnosed with bipolar disorder, half of patients diagnosed with schizophrenia, as well as in
a substantial proportion of patients with substance abuse disorders. In addition, over 10% of the healthy
general population experience grandiose thoughts that do not meet full delusional criteria. Yet in contrast to
other psychotic phenomena, such as auditory hallucinations and persecutory delusions, GDs have received
little attention from researchers. This paper offers a comprehensive examination of the existing cognitive and
affective literature on GDs, including consideration of the evidence in support of delusion-as-defence and
emotion-consistent models. We then propose a tentative model of GDs informed by a synthesis of the
available evidence designed to be a stimulus to future research in this area. As GDs are considered to be
relatively resistant to traditional cognitive behavioural techniques, we then discuss the implications of our
model for how CBT may be modied to address these beliefs. Directions for future research are also
highlighted.
2011 Elsevier Ltd. All rights reserved.
Contents
1.
2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . .
What are grandiose delusions? . . . . . . . . . . . . . . . . .
The epidemiology of grandiose delusions and beliefs . . . . . . .
3.1.
Prevalence of clinically relevant grandiose delusions . . . .
3.2.
Demographic variables, culture and grandiose delusions . .
3.4.
Prevalence of grandiose delusion-like beliefs. . . . . . . .
3.5.
Diagnostic specicity of grandiose delusions . . . . . . . .
4.
Grandiose delusions, persecutory delusions and depression . . . .
5.
Affect and grandiose delusions . . . . . . . . . . . . . . . . .
5.1.
Affect in delusion as defence models of GDs . . . . . . .
5.2.
Affect in emotion-consistent models of grandiose delusions
6.
Anomalous experiences, their appraisal, and GDs . . . . . . . . .
7.
Cognitive styles and grandiose delusions . . . . . . . . . . . . .
7.1.
Jumping to conclusions bias . . . . . . . . . . . . . . .
7.2.
Attributional style . . . . . . . . . . . . . . . . . . . .
7.3.
Modality of thought . . . . . . . . . . . . . . . . . . .
7.4.
Thinking about thinking . . . . . . . . . . . . . . . . .
8.
The dynamic nature of grandiose delusions . . . . . . . . . . .
9.
Developing a model of grandiose delusions . . . . . . . . . . .
10.
Implications for treatment . . . . . . . . . . . . . . . . . . .
11.
Future research . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Corresponding author at: Clinical Psychology Unit, Shefeld University, Western Bank, Shefeld S10 2TN, UK. Tel.: + 44 114 2226577; fax: + 44 114 2226610.
E-mail address: r.knowles@shefeld.ac.uk (R. Knowles).
0272-7358/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2011.02.009
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R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696
1. Introduction
Recent approaches to psychopathology have shifted away from a
diagnostically driven approach towards a focus on transdiagnostic efforts
to understand individual symptoms and processes (Bentall, 2006).
Dedicated cognitive models have been developed for many of the
experiences typically associated with psychosis, such as auditory
hallucinations (e.g., Beck & Rector, 2005; Bentall, 1990; Horowitz,
1975) and persecutory delusions (e.g., Bentall, Corcoran, Howard,
Blackwood, & Kinderman, 2001; Freeman, Garety, Kuipers, Fowler, &
Bebbington, 2002), including integrative frameworks that seek to account
for the positive symptoms of psychosis together (e.g., Garety, Kuipers,
Fowler, Freeman & Bebbington, 2001; Morrison, 2001). Grandiose
delusions (GDs), by contrast, have received relatively little theoretical
or empirical attention. Indeed, one of the few recent studies to have
addressed these experiences directly concluded that much remains to be
determined in understanding the formation and maintenance of
grandiose delusions (Smith, Freeman, & Kuipers, 2005, p. 486).
Achieving a better understanding of the onset and maintenance of
GDs is likely to be benecial for a number of reasons. Models of
persecutory delusions have informed the development of focused
cognitive behavioural interventions (Freeman & Garety, 2006), and
similarly tailored interventions for GDs are likely to be useful. It has
also been suggested that GDs may play a role in the development of
persecutory delusions (Lake, 2008) and a better understanding of GDs
may thus contribute to the development of more effective interventions for persecutory delusions. The present paper aims to review the
existing literature on the psychological mechanisms underpinning
GDs and to propose an integrated conceptualization of this phenomenon that is amenable to empirical testing. In particular, we aim to
summarise epidemiological ndings, to evaluate the evidence for
delusion-as-defense and emotion-consistent accounts, and to consider the role of cognitive biases in the development and maintenance of
GDs. The present review is hence restricted to a consideration of
cognitive and affective factors. Whilst there is a clear need for a review
of genetic, neurobiological and neurocognitive perspectives on GDs,
this is beyond the scope of the present review.
This review is informed by a systematic search of MEDLINE (1950
May 2010), PsychInfo (19672010) and Scopus (1823May 2010)
databases for peer-reviewed articles on grandiose delusions published
in English. The search string employed was (grandeur* OR grandi*)
AND (delus* OR belief). Each result was examined rst by inspection
of the title, and then, as required, the abstract and the full text. Studies
were excluded if they focused exclusively on grandiosity in the context
of personality disorders (e.g., Narcissistic Personality Disorder). The
reference sections and citation reports of papers identied by this
search were examined to identify further relevant papers. The
criterion for the inclusion of studies for the purposes of prevalence
estimates of GDs was a sample size in excess of 50 participants, and for
studies of psychiatric patients, that they be published after the
publication of DSM-III-R in 1994 in order to achieve some measure
of diagnostic comparability.
2. What are grandiose delusions?
GDs are dened as false beliefs about having inated worth,
power, knowledge or a special identity which are rmly sustained
despite undeniable evidence to the contrary (APA, 2000). Some
examples are given in Table 1. GDs, like other delusional beliefs, are
multidimensional (Garety & Hemsley, 1994), varying with regard to
the degree of conviction and preoccupation, and the levels of distress
and dysfunction caused. GDs (alongside religious delusions) seem to
be held with the greatest conviction and tend to be associated with
less negative affect than other delusions (Appelbaum, Robbins, &
Roth, 1999). However, an apparent paradox given this increased
degree of conviction is Appelbaum and colleagues' report that GDs are
685
Table 1
Examples of grandiose delusions.
Example
Source
I was spitting on a light bulb, thinking if I watched the

saliva burn, the different colours and shapes, I could nd
the key to the cure to cancer
I would write books on psychiatric theory on theology. I
would write novels. I had the libretto of an opera in
mind. Nothing was beyond me The major work which
would be based on this material would be accurate,
provocative, and of profound signicance.
I can communicate and have a special relationship with
God. I am also the cousin of Tony Blair and I can y.
I am a special athlete and I run a national charity.
I am God; I created the universe and I am son of Prince
Phillip. I am also a famous DJ. I have superman-type
powers.
I have special luck and have won the lottery four times and
am owed 126 million.
I am Roger Taylor from the rock group Queen.
I am the gang leader of drug dealers in Los Angeles. I have
great wealth.
Believed he possessed the recording of a song he had
composed and performed that was worth millions of
dollars.
Belief he had developed a Star Wars intercontinental
ballistic missile interceptor system, and had tried to
phone Ronald Reagan to tell him.
Goodwin and Jamison

(1990, p. 26)
Goodwin and Jamison
(1990, p. 29)
Smith et al. (2005)

Smith et al. (2005)
Smith et al. (2005)
Smith et al. (2005)

Smith et al. (2005)
Smith et al. (2005)
Lake (2008)
Lake (2008)
less likely to motivate individuals to act than other types of delusions.

This nding is somewhat counterintuitive in the light of clinical
observations of patients engaging in risky and impulsive behaviour
fuelled by grandiose delusional beliefs. Appelbaum et al.'s (1999)
nding may be a measurement artefact, since the action dimension
of the MacArthur-Maudsley Delusions Assessment Schedule is biased
towards the assessment of aggressive acts, meaning that respondents
would achieve low scores for not acting on their beliefs in an
aggressive or violent manner regardless of other behavioural consequences. Because of their nature and content, we would not expect
the behaviours motivated by GDs to be of an aggressive or violent
nature, and so this assessment tool may be inadequate for the purposes
of establishing links between GDs and any associated behaviour.
3. The epidemiology of grandiose delusions and beliefs
3.1. Prevalence of clinically relevant grandiose delusions
GDs are among the most commonly encountered delusional beliefs.
In a study of 1,136 consecutively admitted psychiatric patients,
Appelbaum et al. (1999) found that 43% of the 328 patients who
presented with delusional beliefs reported GDs. Only persecutory
delusions (78%) and delusions of body/mind control (60%) were more
commonly observed. Table 2 lists the studies that have reported on the
prevalence of GDs in large (N N 50) psychiatric samples since the
publication of DSM-III-R in 1994. Clear prevalence estimates are hard
to establish since a wide range of self-report and clinician-rated
instruments with differing thresholds and cut-offs have been
employed. Prevalence comparisons are also made harder by the use
of both lifetime prevalence and point prevalence gures (usually at
hospital admission), with some studies failing to report which of these
two methods was used.
The issue of whether patients are able to reliably report on their
own delusional beliefs is a further consideration. The absence of an
objective marker of delusional beliefs means that we are reliant on
patients' descriptions and clinicians' interpretations of these phenomena, and a recent article by Lincoln, Ziegler, Lllmann, Mller, and
Rief (2010) suggests that patients with schizophrenia spectrum
disorders are reliably able to provide information about the presence
and type of their delusional beliefs.
686
Table 2
Prevalence of clinically relevant grandiose delusions (studies published post 1994, N N 50).
Diagnosis
Bipolar
59%
55%
9%
68%
62%
88%
Schizophrenia
Depression
Alcohol or drug
disorders
Alzheimer's
47%
49%
9%
40%
21%
30%
N 1%
6%
Study
Sample
Diagnostic tool
Delusion categorisation
Appelbaum et al. (1999)

Geller, Williams, Zimerman, Frazier,
Beringer and Warner (1998)
Baethge et al. (2005)
Tillman, Geller, Klages, Corrigan,
Bolhofner and Zimerman, 2008
Canuso, Bossie, Zhu, Youssef and
Dunner (2008)
Conus, Abdel-Baki, Harrigan,
Lambert and McGorry (2004)
Goodwin and Jamison (1990)*
Breier and Berg (1999)
Azhar, Varma and Hakim (1995)
73 adults
60 children
(716 yrs)
549 adults
257 children,
(616 yrs)
515 adult patients
DSM-III-R
DSM-IV
DSM-III-R: Point prevalence

WASH-U-KSADS: Unspecied
ICD-10
DSM-IV
AMDP: Point prevalence

WASH-U-KSADS: Lifetime prevalence
DSM-IV
PANSS score 4 at time of study
87 adult patients
DSM-III-R
RPMIP: point prevalence
3801 manic patients

138 patients
1665 patients
270 patients
56 patients
30 patients
various
DSM-IV
DSM-IV
ICD-9
DSM-III-R
DSM-III-R
various
PANSS score 5 at time of study
Present State Examination: unspecied
228 patients
DSM-IV
DSM-IV: Point prevalence
103 patients
DSM-III-R
Hirono, Mori, Yasuda, Ikejiri, Imamura,

Shimomura et al. (1998)
Migliorelli, Petraccam, Tesn, Sabe,
Leiguarda and Starkstein (1995)
Note: * This study was a review of 26 studies (published between 1922 and 1989) studies of manic patients, and is just included for reference as it is hard to make direct comparison
with present studies due to the range of diagnostic criteria and assessment tools these studies would have used.
In the only study to have examined the transdiagnostic prevalence

of GDs, Appelbaum et al. (1999) found that they were more frequent
in bipolar disorder (59%) than in schizophrenia (49%), substance
misuse disorders (30%) or depression (21%), although the statistical
status of these differences was not reported. Consistent with this
pattern, an earlier study by Junginger, Barker, and Coe (1992) found
signicantly fewer patients with schizophrenia (19%) than with
affective disorders (37%) presenting with GDs, although the failure to
apply a Bonferroni correction to the correlational analysis may have
yielded a false positive result. The ndings of the other studies in
Table 2 are broadly in line with Appelbaum et al. (1999), with
approximately two-thirds of patients with a diagnosis of bipolar
disorder and around half of patients with a diagnosis of schizophrenia
reporting GDs. Two studies, however, report much lower prevalence
rates. Baethge, Baldessarini, Freudenthal, Streeruwitz, Bauer and
Bschor (2005) observed GDs in just 9% of patients diagnosed with
bipolar disorder, perhaps due to the use of point prevalence in a study
in which only 26% of patients presented with any form of delusion.
Breier and Berg (1999) also found a GD prevalence of only 9% in a
schizophrenia sample, which appears to result from the conservative
diagnostic criteria employed.
3.2. Demographic variables, culture and grandiose delusions
There is some preliminary evidence of a relationship between age
of onset of bipolar disorder and the occurrence of GDs. Carlson, Bromet,
and Sievers (2000) identied GDs in 74% of patients with early-onset
(b21 years) bipolar disorder, but in just 40% of those who were aged
30 years or over at the time of their rst episode, representing a
statistically signicant difference. There is no evidence that rates of
GDs differ between men and women (de Portugal, Gonzlez, Haro,
Usall, & Cervilla, 2010), although it is interesting to note that the
particular content of GDs may vary according to gender (Rudaleviien,
Stompe, Narbekovas, Rakauskien, & Buneviius, 2008).
In a study of over 1000 individuals with a diagnosis of schizophrenia
from socioculturally diverse countries, grandiosity was found to be the
second most common delusional theme behind persecutory delusions
(Stompe, Karakula, Rudaleviiene, Okribelashvili, Chaudhry, Idemudia et
al., 2006). Stompe and colleagues also found that the prevalence of GDs
had remained broadly similar (3844%) in Austrian patients over the
past 145 years despite the extensive societal changes during this period.
So GDs are evident across cultures, but there appears to be some crosscultural variation in the specic presentation (Suhail & Cochrane, 2002).
Several studies have compared GDs between European and Asian
patients. Stompe, Bauer, Karakula, Rudaleviciene, Okribelashvili,
Chaudhry et al. (2007) reported signicantly higher frequencies of GDs
in patients with schizophrenia in Austria than in Pakistan, and they also
found that delusional grandiosity with a religious theme was especially
rare in Pakistan (2007). In contrast, when Suhail (2003) compared the
delusional beliefs of three groups of patients diagnosed with schizophrenia a White British group living in Britain, a group of Pakistani
people living in Britain, and a third group of Pakistani people resident in
Pakistan they found that the groups did not differ in the frequencies of
GDs. In fact, in this study, Pakistani people living in Pakistan were more
likely to have a delusion about being a star/hero/famous person (32%)
compared to the other cultural/ethnic groups (b 10%). The authors
speculate that the large socio-economic disparities in Pakistan and the
difculty in achieving upward social mobility may fuel delusional beliefs
about self-worth and achievements a sort of self-defensive strategy.
There are also variations in the occurrence of GDs between ethnic
groups living in the same country. Yamada et al. (2006) studied patients
with psychotic disorders in the USA and found a greater prevalence of
grandiose content in the delusions of European-American patients
(45%) compared to African-American (35%) and Latino (25%) patients.
Yamada and colleagues attempted to explain this pattern of ndings as
being due to the individualistic orientation associated with an
emphasis on uniqueness often associated with the Euro-American
culture, whereas grandiosity might be culturally dystonic with the
socio-centric values of the Latino culture (p. 165). It therefore appears
that cultural factors may inuence the prevalence and manifestation of
GDs, although precise causal mechanisms are unclear.
3.4. Prevalence of grandiose delusion-like beliefs
Grandiose beliefs which fail to meet full delusional criteria are found
in the general population. Indeed, as is the case for several other
psychotic phenomena (e.g., Johns & van Os, 2001), grandiose ideation
appears to exist on a continuum ranging from full-blown delusions
(held with conviction, resistant to change and causing signicant social
and occupational impairment) to more transient grandiose thoughts at
the other end of the spectrum. The most commonly used tool to assess
the presence of grandiose beliefs is the short-form version of the Peters
Delusion Inventory (PDI-21: Peters, Joseph, Day, & Garety, 2004). Scores
on these items from non-clinical populations are shown in Table 3.
It can be seen from Table 3 that rates of endorsement of grandiose
beliefs are higher in student samples than in the general population.
Given that general population samples have a signicantly higher mean
age than student samples, this difference may be explained by the
nding of Verdoux, van Os, Maurice-Tison, Gay, Salamon and Bourgeois
(1998) who reported a negative correlation between age and scores on
the grandiose subscale of the PDI-21. This would also be consistent with
Carlson et al.'s (2000) nding of a greater prevalence of GDs in earlyonset bipolar disorder. This pattern may be driven by the feelings of
uniqueness and indestructibility (Elkind, 1967) that have been found to
peak in adolescence (Enright, Shukla, & Lapsley, 1980).
3.5. Diagnostic specicity of grandiose delusions
There have been no direct attempts to establish whether GDs in
bipolar disorder and schizophrenia share a common aetiology and
phenomenology. One factor that may distinguish between GDs in the
psychotic and in the affective disorders is the widely-held but poorlyevidenced assumption that GDs are mood-incongruent in the former,
and mood-congruent in the latter. If true, this could be taken to
suggest that GDs occurring in patients diagnosed with bipolar
disorder and schizophrenia, respectively, may have different phenomenologies, aetiologies, and affective/cognitive/behavioural antecedents, and thus require separate maintenance models. Junginger
et al. (1992) reported a strong positive correlation between mood and
the presence of GDs in a mixed sample of psychiatric patients with
manic mood states being associated with GDs. However, the authors
did not specify whether this correlation was signicant in both patient
groups or just those with affective disorder diagnoses.
Current psychiatric nomenclature retains Kraepelin's original distinction between the diagnostic categories of schizophrenia and bipolar
disorder (APA, 2000), but the clinical reality suggests that there is
extensive symptomatic overlap and comorbidity between the two
presentations (e.g., Laursen, Agerbo, & Pedersen, 2009) which means
that it may not be meaningful to talk in terms of diagnostic distinctness.
Indeed, the diagnostic category of schizoaffective disorder (APA, 2000)
captures those individuals who meet criteria for both schizophrenia and
bipolar disorder. We have no reason to suspect that the origins and
maintenance of GDs will differ between individuals with different
psychiatric diagnoses, and so for the purposes of this review it will be
assumed that the same underlying psychological processes are of
interest independent of diagnostic classication.
4. Grandiose delusions, persecutory delusions and depression
Qualitative studies of delusions have noted a complex set of
interconnected themes drawing uniquely from several possible
687
domains (Rhodes, Jakes, & Robinson, 2005, p.383) and GDs appear
unlikely to exist in a pure and isolated form. They tend to occur most
frequently alongside persecutory delusions (PDs), although largescale studies are lacking. Raune, Bebbington, Dunn, and Kuipers
(2006) found that of 39 psychiatric patients who presented with
delusions, 54% reported PDs only, 10% reported GDs in isolation, and
33% reported having both PDs and GDs. Another recent study found
that of 14 patients diagnosed with non-affective psychosis, 68% had
just PDs, 16% had just GDs, and 16% had both PDs and GDs (Jolley,
Garety, Bebbington, Dunn, Freeman, Kuipers et al., 2006). The high
comorbidity between GDs and persecutory delusions might lead to
the assumption that GDs in patients with schizophrenia diagnoses are
mood-incongruent (see Section 4). Lake (2008) suggests that the
potential of a GD to contribute to the development of persecutory
ideation and thus to low mood may disguise the fact that it was
originally associated with positive affect. He argues that the strength of
people's beliefs in their extraordinary possessions, powers or talents as
reected in typical GDs, in conjunction with the broader effects of other
unusual attentional and reasoning processes, means that individuals
worry that others will wish them ill or try to steal their gifts from them,
which then leads to the development of persecutory ideation. Such an
account is consistent with the co-occurrence of GDs with both
persecutory delusions and depression and highlights the need for
longitudinal studies of the course and emergence of delusional beliefs.
In the absence of larger-scale clinical studies, information about the
relationship between GDs and PDs can be obtained from analogue and
factor analytic studies. Fowler, Freeman, Smith, Kuipers, Bashforth,
Coker et al. (2006) found that levels of grandiose beliefs were predicted
by levels of paranoia in a non-clinical student sample. However, this
correlational study was unable to establish whether this reected an
individual's tendency to experience delusion-like thoughts per se, or
whether there was a causal relationship between the two types of
beliefs. Several factor analytic studies also show an association between
PDs and GDs. Bedford & Deary's (2006) analysis of 713 participants'
delusional symptoms found that grandiosity formed a distinct factor
which correlated signicantly with a separate persecutory beliefs factor.
Other factor analyses have concluded that GDs and PDs are at least
partially independent from one another (e.g., Kitamura, Okazaki,
Fujinawa, Takayanagi, & Kasahara, 1998) and that PDs and GDs have
some non-shared causes (Freeman, 2007), although what these might
be remains poorly understood.
5. Affect and grandiose delusions
Contemporary psychological models of GDs reject Berrios's (1991)
claim that delusions are meaningless speech acts and propose instead
that GDs are related to past/current emotional concerns. One family of
models suggests that GDs arise from an individual's attempt to defend
themselves against negative affective states, which Freeman, Garety,
Table 3
Grandiose beliefs in general population.
Study
Verdoux et al. (1998)
Sample
462 attendees of a GP with no

psychiatric disorder
Peters, Joseph and Garety (1999) 272 general population
Armando, Nelson, Yung, Ross,
1,777 high school and university
Birchwood, Girardi et al. (2010) students
Jones and Fernyhough
493 university students
(2007, unpublished data)
Scott, Chant, et al. (2006)
10,641 general population
Mean age
(SD, range)
% endorsing PDI-21 item Do you ever

% endorsing PDI-21 item Do you
ever feel that you are a very special feel as if you are, or destined to be
someone very important
or unusual person?
52 years (18, 1895) 12%
8%
37 years (10, 1975) 43%

18 years (4, 1526)
75%
data not reported

65%
19 years (2, 1854)
44%
36%
not reported
3.4% of people answered the question [which the authors aimed to

address the presence of grandiose delusions] Do you have any special
powers that most people lack? in the afrmative.
688
Fowler, Kuipers, Dunn, Bebbington et al. (1998) call delusion-asdefense (DAD) accounts. A second group of models termed emotionconsistent proposes that GDs emerge out of current positive affective
states (Smith et al., 2005, p. 486).
5.1. Affect in delusion as defence models of GDs
Beck and Rector (2005) have argued that GDs may develop as a
compensation for an underlying sense of loneliness, unworthiness, or
powerlessness (p. 588) and note from their clinical experience that
many patients with GDs have experienced prior life crises characterized by a sense of failure or worthlessness (p. 588). There is some
preliminary evidence that early traumatic life-events may be
associated with GDs (Read, Agar, Argyle, & Aderhold, 2003) but in a
sample of patients with psychosis, Mason, Brett, Collinge, Curr, and
Rhodes (2009) only detected a trend towards an association between
grandiose beliefs and a composite measure of childhood trauma.
Neale's (1998) manic defense hypothesis by which grandiose beliefs
(with other symptoms of mania) serve the function of keeping
distressing thoughts out of consciousness is similar to Beck and
Rector's (2005) argument. Some preliminary evidence in support of
the hypothesis that GDs may be understood to compensate for failure/
dissatisfaction with life can be found in qualitative study of delusional
patients, which concluded that a link can be made between
delusional themes and themes from personal goals (Rhodes &
Jakes, 2000, p.221).
While the qualitative evidence is limited by the small number of
studies, there is a greater volume of quantitative research in this area.
This body of work arose from the success of a paradigm for testing a
defensive account of persecutory delusions (PDs). Bentall (1994)
proposed that PDs were a means of protecting against low self-esteem
and depression by preventing awareness of discrepancies between
actual and ideal self-concepts. This leads to the prediction that there
will be a measurable discrepancy between overt (explicit) and covert
(implicit) self-esteem in individuals with current PDs, a hypothesis
which has received some empirical support (e.g., Lyon, Kaney, &
Bentall, 1994) although results are mixed (e.g., Martin & Penn, 2002).
A similar paradigm has been applied to the evaluation of a defensive
account of GDs. As Smith et al. (2005) note, a DAD model makes more
intuitive sense in the context of GDs which appear to be better
candidates for protecting positive self-esteem than PDs. As they put it,
believing yourself to be, for example, a famous talented individual is
more likely to reduce low self-esteem than thinking that the
neighbors are spreading distressing rumors about you and are
plotting to have you evicted (p. 480).
To date only Smith et al. (2005) have attempted to test the DAD
theory of GDs by comparing explicit and implicit self-esteem in a
mixed group of 21 patients. Explicit self-esteem was measured by
self-report questionnaire, while implicit self-esteem was assessed
using an emotional Stroop task and the Self-Referent Incidental Recall
Task (Lyon, Startup, & Bentall, 1999). No evidence of low implicit selfesteem in the patients with GDs was found. Raune, Bebbington, Dunn,
and Kuipers (2005) have also reported evidence that appears
inconsistent with a DAD model. If the DAD account is correct, then
events that threaten the individual's self-esteem would be expected
to be associated with the development of GDs which would arise as a
psychological defense. However, the authors found that GDs in a rstepisode psychosis sample were actually negatively associated with
loss events and they also failed to nd a relationship between the
onset of GDs and recent humiliating events. It is worth noting that key
prospective studies have reported an increase in manic symptoms
after routine-disrupting and goal-attainment events, while negative
life events precede depressive episodes but do not appear to predict
symptoms of mania (Johnson, 2005a,b; Johnson, Sandrow, Meyer,
Winters, Miller, Keitner et al., 2000; Johnson, Cuellar, Ruggero,
Winnett-Perlman, Goodnick, White and Miller, 2008). Although
these studies did not report specically on GDs, the ndings further
undermine the plausibility of a DAD model of GDs.
However, these investigations are open to criticism. As the authors
themselves concede, Smith et al. (2005) only tested a defense against
verbally mediated thoughts, but a defense against negative feelings
might take a different form from the traditionally conceived verbal
delusional belief. In our view (see Section 7.3), there are important
reasons to believe that a defense may need to counteract visual
thoughts or mental images which are commonly found in patients
with bipolar disorder the clinical population in whom GDs are most
common (Tzemou & Birchwood, 2007).
Empirical tests may also have failed to nd support for the DAD
model of GDs because of the stipulation that the defense operates
specically to protect self-esteem. Self-esteem is non-relational
concept, dened as an individual's perception of themselves.
However, delusional beliefs are typically interpersonal and embedded
in a social context. Hence, a more appropriate candidate for what is
being defended by the emergence of GDs may be social self-esteem
(Heatherton & Polivy, 1991) or social rank (Gilbert, 1992). Smith,
Fowler, Freeman, Bebbington, Bashforth, Garety et al. (2006) argue
that negative beliefs about others held by individuals with GDs may
serve to increase social rank. It has been suggested that grandiosity
could increase the social status of the individual who expresses it by
generating an impression of enhanced access to resources which
favors social success (McGuire & Troisi, 1998). That is, GDs may
represent the exaggeration of an adaptive coping mechanism. The
qualitative work of Rhodes and Jakes (2000), who found that an
individual's GD was related to a real-life theme of failure might be
usefully interpreted in this light. Birchwood, Trower, Brunet, Gilbert,
Iqbal and Jackson (2006) argue that when individuals without the
social power to protect themselves are alerted to their low relative
rank they may activate internal defensive emotions and strategies, of
which GDs are an example. If this is the case then we would expect
individuals with GDs to display a fear of negative evaluation by others,
which may also be linked to the development of persecutory
delusions. Furthermore, since social rank theory predicts that shame
and outsider status is associated with social anxiety (Gilbert & Trower,
2001) we might also expect these features to be associated with GDs.
Given that only one study has directly examined the relationship
between GDs and implicit/explicit self-esteem discrepancies, it is
important to consider other potential sources of evidence. Explicit
self-esteem has been found to exceed implicit self-esteem in currently
manic and remitted patients (Lyon et al., 1999) and in an analogue
study of hypomania (Bentall & Thompson, 1990). Bentall, Kinderman,
and Manson (2005) examined self-discrepancies in manic, depressed
and remitted bipolar patients as well as a group of healthy controls.
They found that manic patients rated their actual self as being closer
to their ideal self than any of the other groups, why they interpreted
as being consistent with the proposal that a defense was operational
in the manic state to prevent the negative affective consequences of
actual-ideal self-discrepancies.
5.2. Affect in emotion-consistent models of grandiose delusions
An alternative to the DAD pathway is the suggestion that delusional
beliefs arise from current concerns (Freeman et al., 2002), referred to
as an emotion-consistent account (Smith et al., 2005, p. 486). This
model suggests that grandiose beliefs are built on existing or
preserved raised areas of self-esteem (Smith et al., 2005, p. 481).
These positive beliefs about the self may become exaggerated against
the backdrop of the positive affective state, and may be uncritically
accepted due to cognitive and information processing biases (see
Section 7.1). The positive affective state may also be amplied by other
processes such as the occurrence of mood-congruent mental imagery
(see Section 7.3). Smith et al. (2006) have further proposed that a
combination of elevated mood and positive views of the self alongside
negative evaluations of others may promote a social position that

sustains positive self-beliefs and a rejection of social cues, which could
in turn maintain GDs.
The limited available evidence is broadly in support of this
emotion-consistent model. Two separate clinical studies have
reported that levels of grandiose beliefs were correlated with higher
explicit self-esteem and lower depression scores (Moritz et al., 2010;
Smith et al., 2006). Smith and colleagues suggested that individuals
with GDs tend to make negative evaluations of others in order to
foster a social position that maintains positive self-evaluations (p.
183). Although there was no correlation between negative evaluations of others and levels of GDs, a logistic regression showed that
both low depression scores and negative beliefs about others were
independently associated with GDs (Smith et al., 2006). An analogue
study also found that levels of grandiose beliefs were predicted by
positive (but not negative) views of the self (Fowler et al., 2006). None
of these studies is able to establish the potential direction of causation
in the relationship between explicit self-esteem and grandiose beliefs:
higher explicit self-esteem may facilitate the development of moodcongruent grandiose beliefs, but a DAD interpretation of these
ndings could be that grandiose beliefs arise as a defense against
low self-esteem, resulting in increased positive self-esteem. Raune
et al.'s (2005) study which found fewer negative loss events in the
recent history of those individuals with GDs offers some basis for
favouring the emotion-consistent interpretation of the results,
although the (limited) evidence discussed in Section 5.1 linking
trauma and GDs leaves this question open. We note that at least one of
the predictions of an emotion-consistent account appears to be borne
out by empirical research. Given that feelings of uniqueness,
indestructibility and heroicness peak in adolescence, the emotionconsistent model would predict a higher incidence of GDs in younger
adults than in older people a pattern that has been observed. Lake
(2008) has argued for a key role of positive mood in the aetiology of
GDs, and interestingly, the clinical vignettes in his study appear to
support a relatively underdeveloped facet of the emotion-consistent
account of GDs. Freeman and Garety (2003) suggest that GDs may
build on pre-existing inated, or accurate, perceptions of the self (p.
938, italics added), and Smith et al. (2005, p.481) note that GDs may
build on existing or preserved raised areas of self-esteem. This is
consistent with Lake's examples of the chemistry graduate who
believed that he possessed a formula to make synthetic narcotics, and
the patient with a background in rocket engineering who believed
that he had a Star Wars missile design. Lake describes these beliefs as
building on a thread of truth (p. 1153).
GDs can be very specic beliefs related to particular areas of
positive self-esteem expertise or achievement. However, as is clear
from Table 1, they may also be much broader and less grounded in
reality, and the differences between the two types of beliefs is unclear.
It may be that if an individual does not have a clear current/past
strength on which to draw, then a GD may involve global self-esteem
being elevated. Alternatively, it may be that broad GDs start off as
more specic beliefs that escalate and expand due to the effects of
various cognitive mechanisms as discussed in Section 7.
In conclusion, the current empirical evidence appears to offer more
support for an emotionconsistent account of GDs than for a DAD
model, although a series of clinical vignettes and the one qualitative
study in this area suggest the DAD model may also be applicable,
highlighting the need for further longitudinal research into the onset
and development of GDs.
6. Anomalous experiences, their appraisal, and GDs
Psychological models of delusional ideation typically argue that
the search for meaning following an initial anomalous experience
leads to the emergence of a delusional explanation (Maher, 1988),
and an account of this type may be applicable to GDs. One candidate
689
for the initial anomalous trigger experience is an individual's internal

state. Mansell, Morrison, Reid, Lowens, and Tai (2007) have argued
that a range of mental disorders may be characterized by intrusions
into awareness of information (in the form of body state information,
affect, thoughts and images or external sensory input, for example)
which is appraised in an unusual manner. Mansell et al. (2007) further
note that the particular appraisal made about an intrusion is
inuenced by existing beliefs resulting from individual life experiences. Mansell and colleagues have applied this idea primarily to the
emergence of manic mood states, but it may also be relevant to the
development of GDs.
An example of the problematic appraisal in action may look something like this. An initial event (e.g., an exciting life event, or stimulant
use) leads to a more positive mood, greater physiological arousal, or
altered cognition. This experience is interpreted by an attribution of
extreme personal meaning, rather than an external or situational
attribution (Mansell et al., 2007). For example, experiencing one's rate
of thinking as being increased might be interpreted as a sign of great
intelligence, wit and intuition (a personal attribution), or it could be
interpreted as a consequence of managing too many competing tasks
(a situational attribution) (Mansell et al., 2007; Jones, Mansell, &
Waller, 2006). Similarly, an individual who suddenly feels alert, active
and nds they have a reduced need for sleep may make sense of this
sensation by assuming that it is due to dispositional characteristics
such as their underlying dynamism or ability as opposed to being the
result of excessive stimulation from the environment (Jones et al.,
2006). The tendency to make extreme personal attributions has been
found to be more common in patients with bipolar disorder (who are
vulnerable to hypo/mania and grandiose ideation) than in healthy
controls (Jones et al., 2006).
An individual may reach for an internal personal appraisal of their
unusual experience because of an image they hold of an aspirational
imminent possible self (Mansell et al., 2007, p. 523). For example,
individuals who are vulnerable to mania exhibit higher levels of
aspirations for fame, wealth and political inuence (Johnson & Carver,
2006), and the greater the extent to which patients with bipolar
disorder value and perceive themselves as dynamic, creative and
successful, the more likely they are to relapse into hypomania or
mania (Lam, Wright, & Sham, 2005). Similarly, hypomania scores in
students have been found to predict their expectations of academic
and career success (Meyer & Krumm-Merabet, 2003). Drawing on
studies of clinical mania (e.g., Meyer, Johnson & Carver, 1999) these
ndings may be interpreted as evidence of heightened responsiveness
of the behavioural activation systems in individuals. Additionally,
thinking in terms of the DAD model discussed earlier, if an individual
has a strongly positive ideal self, then any attempt to reduce the
discrepancies between this and the actual self should lead to the
adoption of positive self-representations. Hence, a positive imminent
or ideal self may act as a risk factor for GDs.
Mansell et al.'s (2007) ascent behaviour construct helps to explain
how these initial ideas may escalate into full-blown GDs. Ascent
behaviours aim to either enhance or control anomalous internal states,
such as feeling unusually alert or active. Mansell and colleagues list a
number of possible ascent behaviours including extended wakefulness; increased rate of activity; generating multiple ideas and goals,
the seeking of social stimulation; and the dismissing of others
attempts to moderate behavioural changes (p. 523). They give an
example of the latter behaviour in the case of individual who appraises
his racing thoughts as a manifestation of his superior intelligence, and
who subsequently dominates social interactions and ignores negative
feedback from others. This particular ascent behavior, ignoring
negative feedback from others, has been further examined in relation
to bipolar disorder by Mansell and Lam (2006) who reported that
individuals with current symptoms of bipolar disorder were less likely
than remitted participants to use advice from others to inform their
decisions after having undergone an experimental mood elevation.
690
The internal state may also be amplied resulting in a GD through

the process of goal-setting and the impact of goal-attainment. Again,
there are at present no studies that pertain directly to GDs, but a
number of suggestive ndings come from studies of bipolar mania.
Individuals with a history of mania have a tendency to set themselves
higher goals than control participants (Johnson, 2005a,b), and current
levels of hypomania have been found to predict a greater positive
affective response to achieving a goal as well as the subsequent setting
of more extreme goals (Johnson, Ruggero, & Carver, 2005). These
ndings are consistent with evidence that it is goal-achievement life
events rather than positive events more generally that are associated
with increased manic symptoms (Johnson et al., 2000). This is
interesting in the light of Lake's (2008) case examples which describe
the emergence of grandiose beliefs about achievements in particular
elds of personal expertise.
Another candidate for the initial anomalous triggering experience
might be the perception of unexpected, unsolicited or undue attention
from others. If other people are experienced as paying more attention to
the individual than usual (perhaps leading to comorbid delusions of
reference), impaired theory of mind (ToM) may lead an individual to
explain this behaviour by inferring that it must be because s/he is special
and worthy of this additional attention. ToM performance in the context
of persecutory delusions has been the subject of extensive empirical
research (see Freeman, 2007, for a review), but GDs have not been
considered in the same way. ToM has, however, been studied in the
context of bipolar mania. Kerr, Dunbar, and Bentall (2003) found that ToM
was impaired in currently manic patients as well as bipolar depressed
patients, but not in a remitted group. It remains unclear whether ToM
becomes impaired as a result of a manic mood state, or whether ToM
decits are a risk factor for mania and hence perhaps for GDs.
Not only may individuals with GDs misinterpret the interest and
attention of others, but they may also react more strongly to such
perceived attention. Evidence from studies of patients with bipolar
affective disorder reveals increased neural activity in response to human
smiles in brain areas associated with positive affect and reward (Rolls,
2000). Chen, Lennox, Jacob, Calder, Lupson, Bisbrown-Chippendale et al.
(2006) report evidence of abnormal brain activation in patients in manic
and depressed states of bipolar disorder in response to mood
incongruent affective stimuli. Manic patients were found to have
abnormal neural activation in response to images of sad faces, and
interestingly they showed a differentiated pattern of neural activation to
implicit and explicit presentations of sad face, unlike the unipolar and
bipolar depressed patients. Specically, Chen et al. found that a number
of areas were underactivated by explicit processing of sad faces but
overactivated by implicit processing of these faces in the currently
manic patients. These were the amygdala, insula, and superior and
middle temporal gyri (involved in emotional arousal and perception),
and the hippocampus, dorsal anterior cingulate and medial superior
frontal gyrus (involved in emotional regulation and sensitivity to
affective incongruency). This pattern is consistent with the nding that
bipolar patients in a manic episode are worse at identifying negative
facial affect (Lembke & Ketter, 2002). This may be one way in which GDs
are maintained, through the failure to consciously process incongruent
emotional states in others. Given the apparent failure of individuals with
mania to attend to negative social feedback, it would be particularly
interesting to replicate this study to examine whether there are
differences in the implicit and explicit processing of disapproving
faces in individuals with GDs.
7. Cognitive styles and grandiose delusions
7.1. Jumping to conclusions bias
Freeman (2007) asserts that if delusions are incorrect/uncorrected
beliefs, then we must understand the reasoning processes involved in
the formation and maintenance of these false beliefs. The presence of
reasoning biases such as jumping to conclusions (JTC) is well documented in association with delusional beliefs in general (see Garety &
Freeman, 1999), although to date, no studies have investigated this
bias in relation to GDs in particular. Previous research has tended to
combine patients with GDs and patients with persecutory delusions
(PDs) into a mixed delusional group for comparison with a nondelusional control group (e.g., Dudley, John, Young, & Over, 1997) and
analysis by type of delusion is unfortunately often prevented by the
small sample sizes. However, the majority of research into decisionmaking processes and delusions has explored purely cognitive
mechanisms without considering the impact of emotion. Mansell
and Lam (2006) found that individuals with bipolar disorder showed
impaired decision-making (characterized by failure to utilize social
feedback) in an induced elevated mood state, but there has been
almost no research into how positive affect might inuence cognitive
biases and decision-making.
7.2. Attributional style
In addition to the reasoning processes discussed above, it has been
suggested that GDs may be associated with a self-serving attributional
style, according to which individuals tend to make more internal
attributions for positive events (Freeman et al., 1998). However,
research on the specic relationship between attributional style and
GDs in isolation from other types of delusional belief is very limited.
This may be partly due to the signicant comorbidity between GDs
and PDs and the tendency for researchers to recruit mixed groups of
patients for comparison with a healthy control group (e.g., Fear,
Sharp, & Healy, 1996; Sharp, Fear, & Healey, 1997). Jolley et al. (2006)
have come closest to a specic investigation of attributional style in
GDs in their study of 71 patients with a diagnosis of non-affective
psychoses. They predicted that patients with persecutory beliefs
would form grandiose and depressed subgroups displaying selfserving and depressive attributional styles, respectively. Jolley and
colleagues found that higher levels of grandiose beliefs were
associated with a greater self-serving attributional bias, but they
failed to apply a Bonferroni correction for the number of correlations
calculated. The only other specic association with grandiose beliefs
was detected in a small subsample of patients (N = 16) who showed
an externalizing bias for negative events. In this group, there was a
correlation between the extent to which people made external
attributions of negative events and the severity of their grandiose
beliefs.
There has also been a lack of research into how elevated mood
affects attributional style, and whether elation enhances the selfserving bias. However, one study has examined how goal attainment
affects attributional style (Stern & Berrenberg, 1979). Students who
scored highly on a measure of hypomania were more likely to attribute
their apparent success to internal factors. After an initial success,
students also exaggerated their likelihood of correctly guessing the
outcome of a coin toss. Attributional style may be therefore be affected
by goal attainment in the context of GDs.
7.3. Modality of thought
Given the key role of positive affect in GDs, factors that amplify
positive emotion are likely to play a role in the escalation of mood and
grandiosity as well as in the maintenance of GDs. The role of ascent
behaviors has already been discussed, and one further factor is the
modality of thought used. Holmes and Mathews (2005) have argued
that emotional processing in the brain is particularly sensitive to
visual mental imagery more so than to verbal thought. They suggest
that imagery susceptibility (the tendency to be a visualizer rather
than a verbalizer) may be a neglected risk factor for psychiatric
disorders due to the amplifying effect of imagery on emotion and
several authors have shown that visual mental imagery has a greater
amplifying effect on positive affect than verbal thought (e.g., Holmes,

Lang, & Shah, 2009).
Although no empirical studies have examined the role of mental
imagery in GDs, its potential for a role in hypomania is suggestive. For
example, intrusive images of positive future events are commonly
observed in hypomania (Gregory, Brewin, Mansell & Donaldson,
2010), many of which involve goal-oriented events that were
interpersonal in nature, for example being in charge of a project, in
an all-powerful situation with people underneath me or 'self as a
great business man, people looking up to me. Interestingly, depressed
patients in the same study reported intrusive goal-orientated mental
images of a negative emotional valence. This suggests that GDs might
arise from depressive mood states if self-esteem shifts and the content
of mental imagery changes. This proposal is consistent with the
nding that self-esteem in bipolar patients is unstable compared to
healthy controls and patients with unipolar depression (Knowles, Tai,
Jones, Higheld, Morriss and Bentall, 2007).
The tendency to use mental imagery may interact with the goalsetting and achievement patterns characteristic of individuals who
are susceptible to mania and which may play a role in the
development of GDs. If goals are simulated as mental images then
this could stimulate mood elevation according to the imagery-asamplier hypothesis (Holmes & Mathews, 2010). The pre-experiencing of the future via imagining positive goal attainment could
amplify mood and contribute to the development of GDs. This
tendency to pre-experience goals or behaviours may help to explain
the high level of conviction with which GDs are typically held
(Appelbaum et al., 1999): given the commonalities in neural
activation between perception and mental imagery, the representation of GDs in imagery may enhance people's judgments of their truth
value.
7.4. Thinking about thinking
The apparent role of mental imagery in the amplication of
emotion means that it is important to consider the role of both the
modality and method of thinking in relation to GDs. A distinction is
made between rumination and reection as cognitive processing
strategies. Rumination describes a repetitive focus on the content,
causes and consequences of events (Gruber et al., 2009). It often
involves taking a rst-person perspective, resulting in the experience
of being immersed in mental events (Kross, Ayduk, & Mischel, 2005).
In contrast, reection has a cognitive distancing effect as events are
viewed more objectively from a third-person perspective. In PTSD,
rst-person perspective memories are associated with greater levels
of affect than are third-person memories (McIsaac & Eich, 2004), and
when asked to recall a happy autobiographical memory, both patients
with bipolar disorder and healthy controls show greater positive
affect, positive thoughts and faster heart rates when they are
instructed to think about the memory in a ruminative manner as
opposed to a reective manner (Gruber et al., 2009). Although
rumination is more commonly associated with verbal thought than
with mental imagery (McLaughlin, Borkovec, & Sibrava, 2007),
individuals who have a tendency to think ruminatively using rstperson imagery may be at greater risk for the development of GDs.
Furthermore, the nding that ruminating about past events often
leads to rumination about future events (McLaughlin et al., 2007) may
be linked to the future- and goal-orientated thinking often found in
mania.
In addition to cognitive style, meta-cognitive style may also play a
role in the development and maintenance of GDs. Although studies of
meta-cognition and grandiosity have not been conducted in clinical
samples, one analogue study has examined grandiose ideation in the
general population. Lari and Van der Linden (2005) found that
cognitive self-consciousness (the tendency to focus attention on and
monitor one's own thinking) predicted levels of grandiose ideation.
691
Interestingly, other forms of metacognitive beliefs were the best

predictors for proneness to all other types of delusion-like beliefs. The
authors concluded that this could be interpreted to mean that the
presence of such intrusive thoughts and beliefs (i.e. having grandiose
ideas) may not be incompatible with the subject's metacognitive
beliefs (therefore not creating an aversive state of arousal). Indeed,
the presence of such experiences may even lead to a state of positive
affectivity (p. 1437). In this way, people experiencing GDs may not
only appraise internal state changes by inferring extreme personal
meaning (Mansell et al., 2007), but they may do so by thinking in a
modality that amplies affect (imagery), in a manner that amplies
affect (1st person rumination), with more positive content (futureorientated goal-directed thoughts), and they may also be more
consciously aware of such thoughts when they occur.
8. The dynamic nature of grandiose delusions
One factor that has been overlooked in much of the research into
delusional beliefs is their dynamic nature. Appelbaum, Robbins, and
Vesselinov (2004) studied the stability of patients delusions over the
course of a year in a mixed group of 405 delusional patients by
interviewing them every 10 weeks. Although they did not report data
on GDs in particular, a number of ndings are of interest. They
reported that only 15% of patients were delusional at every follow-up
interview. Furthermore, there was only a 61% chance that a patient's
primary delusion type would remain the same between any two
interviews. Appelbaum et al. concluded that [d]elusions appear to be
more dynamic and uid over relatively short periods of time than has
been suggested by many classic descriptions and contemporary
formulations (p. 323). One underlying cause for both the primary
type of delusion and whether an individual endorses a delusion at all
might be the instability of a number of cognitive and affective states,
such as the uctuation in paranoia that results from uctuations in
self-esteem for example (e.g., Thewissen, Myin-Germeys, Bentall, de
Graaf, Vollebergh and Van Os, 2007; Thewissen, Bentall, Lecomte, van
Os, & Myin-Germeys, 2008).
Integrating the instability of delusional beliefs and the association
of unstable self-esteem with paranoia, we might hypothesize that not
only are GDs unstable, but they are so due to instability in self-esteem
or social rank. There is already evidence that patients with bipolar
disorder (diagnostic category most strongly associated with GDs)
have greater day-to-day uctuations in self-esteem than both healthy
controls and patients with unipolar depression (Knowles et al., 2007).
This hypothesis remains in need of testing more specically in groups
of patients with GDs, and we suggest that ESM would be an
appropriate methodology. We would expect GDs to be associated
with momentary positive uctuations in self-esteem and social rank.
As discussed above, these may not be global uctuations in selfesteem but may instead be specic to a particular island of selfworth, such as one's skill as a entrepreneur or prowess at football for
instance. These uctuations in self-esteem may also inuence
cognitive processes like the JTC bias. We would predict that negative
uctuations in mood and/or self-esteem would be associated rstly
with a reduction in the degree of conviction in the GDs, and that
further falls in mood/self-esteem might be associated with the
development of persecutory delusions.
9. Developing a model of grandiose delusions
The factors discussed above may be congured into a tentative
model of the development and maintenance of GDs. Various empirical
ndings have indicated that persecutory and grandiose delusions are
the result of distinct yet related psychological processes but at the
moment there is insufcient evidence to determine whether GDs
differ from other types of delusional beliefs with respect to key
aetiological and maintaining factors and processes. And so, while this
692
tentative model may be adaptable to other classes of delusional

beliefs, it has been congured specically with GDs in mind. We
would expect the content, direction and valence of attributional
biases, mental images, life events, internal state changes and selfesteem uctuations to vary between different types of delusion,
although the over-arching framework might still apply. It is clear from
the evidence discussed above that discrepancies between implicit and
explicit psychological states are common, and contemporary theories
of affect (e.g., Cacioppo & Bernston, 1994; Watson & Tellegen, 1985)
allow for the simultaneous occurrence of contrasting emotional
experiences. The proposed model is principally concerned with the
explicit versions of affect and cognition that are overtly accessible and
amenable to self-report.
The balance of the current evidence is slanted in favour of an
emotion-consistent account of GDs, although there is some evidence
consistent with a DAD model (Beck & Rector, 2005; Rhodes & Jakes,
2000), and both routes are therefore reected in the model. We
propose that the research to-date has been overly focused on trying to
determine whether either an emotion-consistent or a delusion-asdefense account of delusional beliefs is true. In fact, these may not be
mutually exclusive mechanisms or pathways, and indeed they might
each imply the other's internal logic. What we present in Fig. 1 is an
attempt to integrate the two theoretical accounts of the development
of GDs in such a way as to illustrate the potential interplay between
the routes as well as being amenable to empirical testing.
A person who is experiencing low mood, low self-esteem/social rank
is likely to be motivated to modify these feelings and may therefore be
primed to detect any sign or evidence of change/improvement. They

may detect an externally generated chink of light in the form of a
positive event or an internal state change (e.g., achieving a goal,
physiological/ cognitive changes due to drug use or fatigue) which they
seek to make sense of in dispositional terms, their internal positive
attributions being inuenced by earlier life events or cultural factors, or
perhaps by their desire to feel better and motivation to seize
opportunities to modify their negative mood. In this way, the process
might be both emotion-consistent (the initial grandiose thought is
congruent with an initial positive change in mood) and defensive
(occurring within a broader context of negative affect and self-esteem
that the individual is motivated to change). The initial grandiose
thought might then develop into a full-blown GD by the operation of
cognitive biases, the failure to process social feedback, and possible ToM
impairments. Throughout this phase, a number of factors are likely to
play a role in the further amplication of positive affect and the internal
state change, including the use of ruminative rst-person mental
imagery relating to future goal attainment.
From a DAD perspective, grandiose thoughts are proposed to arise
as a deliberate defense against a perceived decrease in mood, selfesteem or social rank. The precise mechanisms underlying such a
process remain unclear, but may involve ruminating on past
achievements or on autobiographical memories of episodes when
self-esteem or social rank were more positive (perhaps again using a
mental imagery modality), leading to small improvements in mood
and self-esteem and internal state changes which may then be
appraised in positive dispositional terms, initiating the same mood-
Precipitating event
(e.g., goal achievement, substance use)
Ruminative,
1st person
visual mental
imagery
Positive internal state change

(e.g., positive mood change, increase
self-esteem or social rank, change in
cognitions, such as speeded up
thoughts)
amplification
Search for meaning

Earlier life
events
Range of possible
future selves
Appraisal
Positive internal attribution
Cultural
factors
Emotion-consistent route
Seeds initial grandiose thought

Cognitive biases,
ToM impairment,
and ascent
behaviours
Delusion as
defence
route
Negative life
events
involving
threatened
self-esteem
or social
rank
Grandiose delusion
Unstable selfesteem:
Positive
fluctuation
Unstable selfesteem:
Negative
fluctuation
Persecutory delusion
Previously documented routes to

persecutory delusion formation
(see Bentall et al., 2001; Freeman
2007)
Fig. 1. A preliminary model of grandiose delusions.
congruent process as described above. In this way, the two supposedly

contrasting pathways into grandiosity may in fact operate alongside
each other, feeding into each other rather than being mutually exclusive. Clearly, not everyone who makes internal attributions for
their positive internal state changes develops GDs so this is a necessary but not sufcient part of the process of onset, and a complex
interplay of situational, cognitive and affective factors contributes to
the emergence of GDs in a vulnerable individual.
The model allows for two ways in which persecutory ideation may
relate to GDs, centring around unstable self-esteem and social rank. As
a result of negative uctuations in self-esteem and/or social rank,
individuals may believe that a facet of their (grandiose) worth is
coveted by others, resulting in secondary persecutory delusions (PDs).
Conversely, GDs may also emerge from existing PDs, since positive
uctuations in self-esteem or social rank may encourage the appraisal
that the negative intentions of others towards them are due to the fact
that they have a special talent/value/wealth that others wish to steal.
It is clear that at present, due to a lack of empirical studies in this area,
this model is tentative and in need of extensive empirical testing.
However, we believe that it offers a fruitful range of hypotheses that
researchers may wish to explore. A number of hypotheses can be
derived from this model, but just three specic examples are given
here. First, this model would predict that internal state changes
precede the onset of GDs. This could be tested using Experience
Sampling Methodologies (ESM: Hurlburt & Heavey, 2006) to examine
the affective and cognitive precursors to grandiose beliefs, as well as
the role of appraisals and attributional style. The model also predicts
that the relationship between GDs and persecutory delusions may be
mediated by unstable self-esteem. ESM could be used to examine
whether uctuations in self-esteem precede the transition between
GDs and persecutory delusions. A third hypothesis derived from the
model is that the development and maintenance of GDs would be
associated with impaired ToM, which could be tested by comparing
the performance of GD, non-GD delusional and control groups on
standard ToM measures.
10. Implications for treatment
GDs present a particular problem for psychological intervention,
predicting poor clinical outcome up to ten years later (Thara & Eaton,
1996) as well as being negatively associated with medication compliance (Appelbaum & Gutheil, 1980). Cognitive Behavioural Therapy
(CBT) has been found to be effective in ameliorating the difculties
associated with schizophrenia-spectrum disorders (Turkington, Dudley,
Warman, & Beck, 2004), but the results for bipolar disorder are less
encouraging (Scott, Paykel, Morriss, Bentall, Kinderman, Johnson et al.,
2006; Lam, 2006). A number of factors have been suggested to account
for the somewhat disappointing evidence for the effectiveness of CBT for
bipolar disorder (such as the number of previous episodes, Scott, Chant,
et al., 2006; Scott, Paykel, et al., 2006), but the prevalence of GDs may be
an additional consideration. Although CBT is effective for treating the
positive symptoms of psychosis (Zimmerman, Favrod, Trieu, & Pomini,
2005), little work has focused on specic psychotic experiences. In one of
the few such studies, persecutory delusions and unusual thought content
but not grandiosity were highlighted as being most reduced following
CBT interventions (Kuipers et al., 1997). Indeed, little is known about the
specic application of CBT to GDs.
CBT appears to be less effective at preventing manic episodes than
at preventing depressive relapse in bipolar disorder (Lam, Hayward,
Watkins, Wright, & Sham, 2005), and the sense of a hyperpositive
self the belief that one is creative, dynamic or entertaining for
example predicts a worse response to cognitive therapy in patients
diagnosed with bipolar disorder (Lam, Wright, & Sham, 2005).
Furthermore, given that GDs are associated with greater conviction
than many other forms of delusions (Appelbaum et al., 1999), the
initial success of cognitive approaches to modifying the belief and
693
engaging the patient in certain behavioural strategies such as reality

testing may be limited. Early collaboration and working towards a
shared understanding are crucial to successful therapeutic outcomes
in CBT (Gilbert & Leahy, 2007) and such therapeutic factors are thus
perhaps even more salient when working with GDs, as is the
consideration of the emotional valence of these beliefs. GDs are
typically associated with positive explicit affect and positive selfbeliefs (e.g., Smith et al., 2006) which may hinder the development of
a shared rationale for a therapeutic intervention.
Based on the model proposed in Fig. 1 we might expect a number
of cognitive and behavioural strategies to be of use in addressing the
difculties associated with GDs. The proposed role for adverse early
life events in the evolution of GDs suggests that trauma-focused
interventions should be considered. This therapeutic approach would
also be expected to have an impact on self-esteem, mood and coping
styles which may also moderate the role played by GDs in an
individual's presentation. These therapeutic targets need not just be
addressed as part of trauma-focused work, but may also constitute
individually tailored, discrete interventions. If there is a role for ToM
impairments to lead to mistaken attributions of others' intentions,
then we might expect patients to benet from interventions which
specically target this domain, as used successfully in other populations (e.g., Ashcroft, Jervis, & Roberts, 1999). Although current
evidence is limited, other cognitive biases that may be implicated in
GDs (such as attributional style and the JTC bias) might be amenable
to the application of CBT techniques.
According to the model, attributional patterns to account for internal
state changes may be involved in the development of GDs which may
emerge as overly positive and personal explanations for these affective,
cognitive and physiological experiences. Therefore by applying cognitive restructuring approaches to these unhelpful appraisals of moodrelated phenomena, we might expect patients to be able to work
towards the ability to generate more balanced explanations for these
experiences. This in turn should lead to a reduction in the striving and
excessively goal-oriented ascent behaviours that are typically associated
with manic episodes. The identication and recognition of early warning
signs has been shown to be a valuable component of psychological
interventions aimed at preventing the onset and relapse of both
psychosis (Spencer, Birchwood, & McGovern, 2001) and bipolar
disorder (Perry, Tarrier, Morriss, McCarthy, & Limb, 1999). We would
therefore anticipate that similar approaches to the identication of early
warning signs or relapse signatures alongside the development of
staying well plans (Gumley & Schwannauer, 2006) might also be
effective in managing the impact of GDs.
The importance of social feedback and reinforcement in regulating
beliefs is acknowledged (Bandura, 1986) but if people are socially
isolated or purposefully withdraw from others then they are less able
to benet from the moderating effects of these interactions. Interventions which enhance people's access to a social network might
therefore be expected to be useful as an adjunct to augment the effects
of individual therapy. Recent conceptualizations of mental imagery as
an emotional amplier (Holmes, Geddes, Colom, & Goodwin, 2008)
suggest that harnessing that modality of thought as an additional
strategy for affect regulation might also be of use. This could involve
rescripting existing images or promoting the development of
alternative images to initiate more adaptive cognitive and behavioural
responses.
11. Future research
This review and the proposed model have generated a number of
questions and hypotheses which need to be addressed by future
empirical work. The need for longitudinal investigations of GDs has
clearly emerged. This type of research would enable a better
understanding of the onset, development and stability of GDs over
time, as well as how their presentation and impact on functioning is
694
inuenced by changes in self-esteem, mood and social rank.

Longitudinal research designs would also lend themselves to answering questions about whether a delusion-as-defence or an emotionconsistent paradigm (or a combination of both) best accounts for the
development and maintenance of GDs, as well as clarifying the factors
governing the hypothesised relationship between persecutory and
grandiose delusions.
There are also a number of important questions to be addressed
using cross-sectional designs, such as whether or not there are
meaningful ways of classifying or subdividing GDs, whether/when
GDs tend to occur in conjunction with or in isolation from PDs, and
whether the phenomenology of GDs allows clinicians and researchers
to differentiate between diagnostic categories such as bipolar disorder
and schizophrenia. Much work remains to be done to understand the
potential role of specic cognitive biases in the aetiology and
maintenance of GDs and how this might inform targeted cognitive
behavioural interventions .An additional area of interest centres on
the variation of the specicity of GDs, and how they might relate to
real areas of achievement, esteem or ability. There seems, therefore, to
be an important role for qualitative research to explore the
relationship between life events and GDs and how preserved islands
of self-esteem might contribute to the development of these extreme
beliefs. In summary, there remains much to be done in developing our
understanding of GDs, and in turn developing effective psychological
interventions.
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Clinical Psychology Review 31 (2011) 684696

Contents lists available at ScienceDirect

Clinical Psychology Review

Grandiose delusions: A review and theoretical integration of cognitive and

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

I was spitting on a light bulb, thinking if I watched the

Goodwin and Jamison

Smith et al. (2005)

Smith et al. (2005)

less likely to motivate individuals to act than other types of delusions.

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

Appelbaum et al. (1999)

DSM-III-R: Point prevalence

AMDP: Point prevalence

PANSS score 4 at time of study

RPMIP: point prevalence

3801 manic patients

DSM-IV: Point prevalence

DSM-III-R: Point prevalence

Hirono, Mori, Yasuda, Ikejiri, Imamura,

In the only study to have examined the transdiagnostic prevalence

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

Verdoux et al. (1998)

462 attendees of a GP with no

% endorsing PDI-21 item Do you ever

52 years (18, 1895) 12%

37 years (10, 1975) 43%

data not reported

19 years (2, 1854)

3.4% of people answered the question [which the authors aimed to

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

negative evaluations of others may promote a social position that

for the initial anomalous trigger experience is an individual's internal

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

The internal state may also be amplied resulting in a GD through

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

amplifying effect on positive affect than verbal thought (e.g., Holmes,

Interestingly, other forms of metacognitive beliefs were the best

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

tentative model may be adaptable to other classes of delusional

primed to detect any sign or evidence of change/improvement. They

Positive internal state change

Search for meaning

Seeds initial grandiose thought

Previously documented routes to

Fig. 1. A preliminary model of grandiose delusions.

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

congruent process as described above. In this way, the two supposedly

engaging the patient in certain behavioural strategies such as reality

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

inuenced by changes in self-esteem, mood and social rank.

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

R. Knowles et al. / Clinical Psychology Review 31 (2011) 684696

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