Safety behaviors maintain persecutory ideation in individuals with psychotic disorders: evidence from an ecological momentary assessment study

Background Safety behaviors are a common response to persecutory ideation in psychosis. They potentially contribute to the maintenance and exacerbation of symptoms and emotional distress and are therefore a promising treatment target. However, empirical evidence for this hypothesized maintenance role is scarce. We therefore examined cross-sectional and micro-longitudinal associations between safety behaviors, negative affect, and persecutory ideation in the daily lives of individuals with psychotic disorders. Methods We assessed safety behaviors, persecutory ideation, and negative affect at baseline and 10 times/day during one week of Ecological Momentary Assessment (EMA) in N = 64 participants with persecutory ideation and a psychotic disorder. Results At baseline, safety behaviors were positively correlated with persecutory ideation ( r = .47), depression ( r = .67), and anxiety ( r = .69). Safety behaviors assessed at baseline and safety behaviors assessed in daily life showed a moderate correlation ( r = .56). Multilevel analyses of the longitudinal EMA data revealed persecutory ideation ( β = .16) and negative affect ( β = .11) to predict subsequent use of safety behaviors. Momentary use of safety behaviors predicted subsequent persecutory ideation ( β = .13) and negative affect ( β = .18). Conclusions Our results provide evidence for a vicious cycle of maintenance involving persecutory ideation, negative affect, and safety behaviors. Targeting safety behaviors with ecological momentary interventions in daily life could be a promising approach to interrupt this cycle.