Intersections of paranoia and the body in the general population

Abstract

Negative body image may be associated with heightened feelings of paranoia. The current study aimed to conduct multidimensional assessments of body image and psychosis facets in the general population. Respondents were 407 individuals, who provided basic sociodemographic information, and completed online questionnaires evaluating dysmorphic concerns, body consciousness, paranoia, persecutory and magical ideation and perceptual aberration. Correlation analysis and a series of regressions onto various body image facets (i.e. dysmorphic concerns, private body consciousness, public body consciousness and body competence) were conducted. Distinct patterns of significant associations were uncovered across the range of body image and psychosis facets examined. Paranoia significantly contributed to the severity of dysmorphic concerns, and magical ideation significantly contributed to private and public body consciousness, though effect sizes were modest. Our findings corroborate the relationship between paranoia and dysmorphic concerns, and tentatively suggest that challenging paranoid beliefs could be a useful strategy for managing negative body image.

Keywords

body image dysmorphic concerns magical ideation online survey paranoia

Introduction

Body image concerns exist on a continuum in the general population, and are continually re-evaluated over the lifetime (Quittkat et al., 2019; Tiggemann, 2004). 87% of a community sample reported some dissatisfaction with their physical appearance, with 39% endorsing moderate to marked severity of concerns (Mond et al., 2013). Such concerns may be exacerbated in certain age groups, for instance involving tertiary (or younger) students (Bartsch, 2007). Existing studies have delved into potential sources of these body image concerns, such as bullying (Day et al., 2022), peer culture (Dohnt and Tiggemann, 2006), social media influences (Perloff, 2014); but it is equally important to examine underlying mechanisms. One such mechanism relates to paranoia, which may be defined as an unrealistic distrust of others, often manifested as a persistent and irrational feeling that others are ‘out to get you’ (Lemert, 1962). The current study therefore aimed to investigate the intersections between paranoia and body image concerns in the general population.

Paranoia and body image concerns

Links between paranoia and body image concerns have been called out as a priority research area that has hitherto been overlooked (Waite and Freeman, 2017). These authors hypothesised that paranoia may build upon feelings of vulnerability arising from body image concerns. Using two epidemiological datasets (N = 5515 and N = 10,113), Waite and Freeman (2017) provided preliminary empirical evidence that body image concerns were significantly associated with levels of paranoia ranging from mild to severe in adults and adolescents from the general population. Body image was assessed by a single item, ‘Was there ever a time in your life when you had a great deal of concern about/worried a great deal or strongly feared being too fat or overweight?’ (yes, no or don’t know response options). Paranoia was evaluated by two items respectively reflecting mild and severe paranoia, ‘People often make fun of me behind my back’ (true, false or don’t know response options), and ‘Did you ever believe that there was an unjust plot going on to harm you or to have people follow you that your family and friends did not believe was true?’ (yes, no or don’t know response options). Study strengths included verifying a novel association between these previously unlinked constructs across large representative cohorts. Yet methodological limitations pertaining to secondary analysis of pre-collected data meant that assessment of the primary outcome measures, which mainly relied on unvalidated single-item questions, was not comprehensive or targeted. Robust replication and extended study of these multifaceted constructs is thus needed. A follow-up qualitative study of the nature of body image concerns in a small sample (N = 12) diagnosed with a psychotic disorder revealed that their appearance-related distress extended beyond weight, and for instance, could involve the skin or general attractiveness (Marshall et al., 2020). Such negative body image was theorised to lower self-esteem and increase vulnerability to perceived threats, thereby exacerbating feelings of paranoia.

Paranoia and other psychosis facets

Paranoia can typically be broken down into two conceptually distinct, but slightly overlapping, facets, involving self-referential (e.g. others are talking about, looking or laughing at oneself) and persecutory (e.g. others are plotting against or trying to hurt oneself) components. This classification somewhat maps onto what Waite and Freeman (2017) have termed as mild and severe paranoia, but can be thought of as theoretically distinct. In clinical disorders involving psychosis (e.g. schizophrenia) or body image concerns (e.g. body dysmorphic disorder or anorexia nervosa), paranoia can reach delusion proportions (Kumari et al., 2013; Phillipou et al., 2017; Toh et al., 2017), and may include bizarre themes (e.g. parts of one’s body not belonging to the self).

Other facets of psychosis can include anomalous perceptual experiences (e.g. hallucinations) and magical ideation. Hallucinations can be described as unusual sensory events that occur in the absence of corresponding external stimuli (Bentall, 1990), whereas magical ideation refers to thinking styles where unrelated events may be causally associated via superstitious or supernatural beliefs (Eckblad and Chapman, 1983). In schizophrenia, hallucinatory experiences are known to co-exist with and mutually reinforce paranoia and other delusions (Shinn et al., 2013). A recent investigation involving individuals with a psychotic disorder (N = 115) demonstrated that body image concerns were significantly positively associated with paranoia, involving self-referential and persecutory aspects, as well as anomalous perceptual experiences (Waite et al., 2022). Unusual sensory experiences and magical thinking are also shared by a segment of the general population (e.g. Khaled et al., 2020; Maijer et al., 2018). Given that paranoia exists on a spectrum (Bebbington et al., 2013), it would be worthwhile to investigate how its self-referential and persecutory components as well as other psychosis facets may contribute to body image concerns.

Body image facets

Body image is a multifaceted construct that can include appraisals of physical attractiveness, dysmorphic concerns (including body image dissatisfaction and/or disturbances), general body consciousness, as well as overvaluation of or preoccupation with weight/shape or other social evaluative concerns (Slade, 1994). In Waite and Freeman (2017), their conceptualisation hinged on weight concerns. Though not unique to the disorder, a predominant focus on weight concerns is found in anorexia nervosa, characterised by intense fears of weight gain alongside body weight/shape disturbances (American Psychiatric Association, 2013). Yet given its multifaceted nature, other body image facets are equally deserving of exploration in relation to paranoia.

Akin to this, dysmorphic concerns may be clearly linked to body dysmorphic disorder, where individuals typically endorse preoccupation with one or more perceived flaws in physical appearance (American Psychiatric Association, 2013). In both disorders, significant proportions of patients have endorsed referential and/or persecutory delusions, which could be related to disorder-specific beliefs, or general social scenarios (Mountjoy et al., 2014; Rossell et al., 2020; Toh et al., 2017). Should paranoia significantly contribute to dysmorphic concerns, this may yield important therapeutic implications in terms of paranoia possibly serving as a novel but viable therapeutic target.

Whilst dysmorphic concerns may be present in the general population to some extent (Bartsch, 2007), body consciousness is a concept most individuals can identify with. Body consciousness can be subdivided into three factors (Miller et al., 1981) – private body consciousness (i.e. awareness of internal bodily sensations), public body consciousness (i.e. awareness of the observable aspects of the physical body) and body competence (i.e. judgements regarding bodily strength and abilities). There is a strong case for its investigation in relation to paranoia, given tentative links between paranoia and general self-consciousness (Baker, 2015; von Gemmingen et al., 2003); paranoia has been noted to significantly correlate with public, but not private, self-consciousness (Fenigstein and Vanable, 1992).

Aims and hypotheses of the current study

Given how paranoia and body image concerns exist on a continuum, ranging from negligible to pathological with significant variability in between, a clear understanding of how these constructs intersect along this spectrum is important. It has been theorised that negative body image may contribute to heightened paranoia (Waite and Freeman, 2017; Waite et al., 2022), yet it is equally plausible these relationships are bidirectional. Another possible mechanism could be that those prone to paranoid thoughts in their daily interactions, may generalise these to their own bodily experiences, especially in the presence of other unusual thinking styles or anomalous perceptual events, exacerbated by negative emotional states. Beyond dysmorphic concerns, these could also impact other aspects of bodily experience. We thus sought to examine these relationships, with body image as the outcome, and paranoia and other psychosis facets as potential predictors. The inclusion of body consciousness was appropriate, given the population under study, where body image concerns on the clinical spectrum may not be as prominent. The current study therefore aimed to extend on Waite et al. (2022) and Waite and Freeman (2017) by: (i) employing validated, comprehensive assessments of multidimensional body image, beyond weight concerns, and (ii) incorporating added psychosis dimensions, involving perceptual aberration and magical ideation. With regards to dysmorphic concerns, we specifically sought to corroborate a significant association with paranoia as well as delineate the contributions of paranoia versus persecutory ideation (see 2.2.6), given notable endorsement of persecutory (and self-referential) delusions in body dysmorphic disorder (Rossell et al., 2020; Toh et al., 2017).

Hypothesis 1: Paranoia, persecutory ideation and perceptual aberration would be significantly positively correlated with dysmorphic concerns. Whether magical ideation and other body image facets would also be significantly correlated was exploratory.

Hypothesis 2: Paranoia would significantly contribute to the severity of dysmorphic concerns, beyond that offered by extraneous sociodemographic factors (i.e. age, sex, education, negative emotional states). The potential influence of other psychosis facets, including perceptual aberration, as well as magical and persecutory ideation remained exploratory.

Hypothesis 3: Paranoia would significantly contribute to levels of public, but not private, body consciousness, beyond that offered by extraneous sociodemographic factors (i.e. age, sex, education, negative emotional states). Again, the potential influence of other psychosis facets, as well as their impact on body competence, remained exploratory.

Materials and methods

Participants and procedure

Respondents comprised 682 individuals recruited from three primary sources, namely, Prolific (n = 472), advertising via websites and social media apps (e.g. Gumtree and Facebook; n = 75) and first-year Psychology students enrolled in the Research Experience Program (REP) at Swinburne University of Technology (n = 135). Prolific is a dedicated research platform, comprising >100 K global participants of varying demographics. Across all sources, we sought to recruit participants from the general population residing in a range of developed nations (see footnotes in Table 1), where English is widely used. Participant eligibility was: Aged 18 years or above, with adequate English language abilities as well as access to a computer, tablet or mobile device with internet connectivity. Participation involved completing a 1-hour survey via Qualtrics. Data cleaning was performed, where respondents who: (i) completed less than 50% of the total survey (n = 130), or (ii) failed two or more of the three embedded attention check questions (Peer et al., 2014; n = 145) were excluded from further analyses to minimise random, spurious responding. No duplicate responses based on Internet Protocol (IP) address were identified. These stringent data cleaning procedures were necessary to ensure data integrity, given the online nature of the study. The final dataset comprised of 407 individuals. The study was approved by the Swinburne University of Technology Human Research Ethics Committee (#20200949-4152), and procedures conformed to the Declaration of Helsinki (World Medical Association, 2013). Respondents provided written informed consent.

Table 1.

Respondent sociodemographic and clinical information (N = 407).

	Mean ± standard deviation or percentage
Sociodemographic
Age (years)	29.1 ± 9.6
Sex (% male, female, prefer not to say)	55.5, 44.0, 0.5
Education (% tertiary or above)	60.0
Employment (% employed, students, unemployed)	56.8, 26.3, 17.0
Marital status (% partnered)	36.4
Region of residence (%)^a	11.5 Oceania, 28.7 North America, 15.7 Central/South America, 42.8 Europe, 1.2 Others
Clinical
Lifetime psychiatric diagnosis (% yes)	22.2
Bipolar disorders	0.7
Body dysmorphic disorder	1.0
Borderline personality disorder	0.7
Depressive disorders (e.g. major depression, post-natal depression)	4.4
Eating disorders (e.g. anorexia or bulimia nervosa)	3.2
General anxiety and related disorders (e.g. agoraphobia, panic disorder, generalised anxiety disorder)	4.7
Obsessive-compulsive disorder	1.0
Post-traumatic stress disorder	1.2
Lifetime psychological treatment (% yes)	17.9
Negative emotional states (DASS-21)	36.6 ± 27.6
Depression	16.0 ± 12.3
Anxiety	10.9 ± 9.6
Stress	15.3 ± 10.5
Dysmorphic concerns (DCQ)	6.2 ± 4.4
Body consciousness (BCQ)	36.3 ± 7.9
Private body	11.9 ± 3.4
Public body	15.7 ± 4.3
Body competence	8.7 ± 3.4
Perceptual aberration (CS-PA)	6.6 ± 6.2
Magical ideation (CS-MI)	8.5 ± 5.3
Paranoia (PS)	63.0 ± 26.5
Persecutory ideation (PIQ)	8.4 ± 8.7

For specific psychiatric diagnoses, respondents were asked to endorse as many as applicable. Despite this, percentage of lifetime diagnoses exceeded cumulative percentage of specific psychiatric diagnoses owing to missing data (i.e. not everyone who said yes to a lifetime psychiatric diagnosis was willing/able to specify their diagnoses. Categorical ratings for the DASS-21 denote: normal (0–9 depression, 0–7 anxiety, 0–14 stress); mild (10–13 depression, 8–9 anxiety, 15–18 stress); moderate (14–20 depression, 10–14 anxiety, 19–25 stress); severe (21–27 depression, 15–19 anxiety, 26–33 stress); and extremely severe (⩾28 depression, ⩾20 anxiety, ⩾34 stress).

DASS-21: Depression Anxiety and Stress Scale; DCQ: Dysmorphic Concerns Questionnaire (0–21); BCQ: Body Consciousness Questionnaire (0–60); CS-PA: Chapman Scales-Perceptual Aberration (0–35); CS-MI: Chapman Scales-Magical Ideation (0–30); PS: Paranoid Scale (20–100); PIQ: Persecutory Ideation Questionnaire (0–40).

Region of residence can be further broken down into: Oceania (Australia and New Zealand), North America (USA and Canada), Central/South America (Mexico and Chile), Europe (Eastern and Western, including the UK) and Others (Japan, South Korea and Israel).

Measures

The current study formed part of a larger investigation of perceptual anomalies in relation to body image. Only materials relevant for this study are described here. Basic sociodemographic information, including age, sex, education, employment and marital status as well as presence of any mental health conditions and whether psychological treatment had been sought, was collected. The following measures were employed to characterise our variables of interest, including negative emotional states, dysmorphic concerns and body consciousness as well as unusual perceptual experiences or thinking styles. It is noted that paranoia and persecutory ideation were assessed using separate measures owing to their distinct but overlapping nature (see 1.2). The timeframe under consideration for all measures was over the lifetime, except for negative emotional states, which was assessed currently.

Depression Anxiety and Stress Scale (DASS-21)

This abbreviated 21-item version aims to assess negative emotional states over the past week, including depression (e.g. ‘I felt down-hearted and blue’), anxiety (e.g. ‘I felt scared without any good reason’) and stress (e.g. ‘I found it difficult to relax’), rated on four-point Likert scales (0 = Did not apply to me at all to 3 = Applied to me very much, or most of the time). Scores within the three subscales are summed and then doubled to align with original norms (0–42), with higher scores denoting increased negative emotional states; a total score can also be obtained by summing subscale scores (0–126). Categorical ratings denote: normal (0–9 depression, 0–7 anxiety, 0–14 stress); mild (10–13 depression, 8–9 anxiety, 15–18 stress); moderate (14–20 depression, 10–14 anxiety, 19–25 stress); severe (21–27 depression, 15–19 anxiety, 26–33 stress); and extremely severe (⩾28 depression, ⩾20 anxiety, ⩾34 stress). Internal consistencies were excellent (Cronbach’s α = 0.92–0.95; Lovibond and Lovibond, 1995).

Dysmorphic Concerns Questionnaire (DCQ)

This seven-item measure aims to assess level of appearance-related concerns (e.g. ‘Have you ever been very concerned about some aspect of your physical appearance?’), rated on four-point Likert scales (0 = Not at all to 3 = Much more than most people). These are summed to yield a total score (0–21), with higher scores denoting increased dysmorphic concerns. The DCQ has acceptable internal consistency, and good convergent and discriminant validity (Mancuso et al., 2010). Internal consistency was excellent (Cronbach’s α = 0.85; Oosthuizen et al., 1998).

Body Consciousness Questionnaire (BCQ)

This 15-item measure aims to assess self-awareness of the body and comprises three subscales, rated on five-point Likert scales ranging from 0 = extremely uncharacteristic to 4 = extremely characteristic. Private body (PB1) evaluates the tendency to focus on internal bodily sensations (e.g. ‘I am sensitive to internal bodily tensions’.); public body (PB2) gauges awareness of the body as perceived by others (e.g. ‘When with others, I want my hands to be clean and look nice’.); and body competence (BC) rates a sense of perceived ability of one’s own body (e.g. ‘For my size, I’m pretty strong’.). Higher scores indicate enhanced body awareness/competence (0–60). Internal consistencies ranged from low to acceptable (Cronbach’s α = 0.57–0.74), likely owing the small number of items (Miller et al., 1981).

Chapman Scales (CS)

The perceptual aberration (PA; Chapman et al., 1978) and magical ideation (MI; Eckblad and Chapman, 1983) subscales were employed. PA comprises 35 items that gauge anomalous perceptions, such as bodily discontinuities or other unusual corporeal experiences (e.g. ‘I sometimes have had the feeling that some parts of my body are not attached to the same person’.); and MI comprises 30 items that evaluate erroneous thinking styles based on superstitious or supernatural beliefs (e.g. ‘I have occasionally had the silly feeling that a TV or radio broadcaster knew I was listening to him’.). Responses are rated as true/false, and higher scores indicate heightened anomalous perceptual experiences (0–35) or magical thinking (0–30). Internal consistencies ranged from acceptable to excellent (Cronbach’s α = 0.61–0.90; Chapman et al., 1976).

Paranoia Scale (PS)

This 20-item measure aims to assess the level of paranoid ideation across a range of scenarios, rated on a five-point Likert scale ranging from 1 = Not at all applicable to 5 = Extremely applicable (e.g. ‘Someone has it in for me’.). Higher scores indicate greater paranoid beliefs (20–100). Internal consistency was excellent (Cronbach’s α = 0.93; Fenigstein and Vanable, 1992).

Persecutory Ideation Questionnaire

This 10-item measure aims to assess the level of paranoid ideation across a range of scenarios, rated on five-point Likert scales ranging from 0 = Very untrue to 4 = Very true (e.g. ‘I sometimes feel as if there is a conspiracy against me’.). Higher scores indicate greater persecutory beliefs (0–40). The PIQ has excellent internal consistency as well as good convergent and criterion validity, distinguishing specific persecutory ideation from more general paranoia (McKay et al., 2006). Internal consistency was excellent (Cronbach’s α = 0.94).

Statistical analyses

Data analysis was performed with IBM SPSS, v.27. Descriptive statistics, in the form of means and standard deviations for continuous variables or percentages for categorical variables, were used to characterise our participants. To test hypothesis 1, Pearson’s correlation analysis was performed. To test hypothesis 2, two parallel hierarchical regressions were conducted to compare the relative contribution of paranoia versus persecutory ideation to predicting dysmorphic concerns. To control for the influence of extraneous sociodemographic variables, age, sex, education and negative emotional states (DASS-21 total) were entered at Step 1, perceptual aberration (CS-PA), magical ideation (CS-MI) and either paranoia (PS) or persecutory ideation (PIQ) in turn, were entered at Step 2, with DCQ as the dependent variable.

To test hypothesis 3, three parallel hierarchical regressions were conducted to compare the contribution of our variables of interest to predicting various aspects of body consciousness. Once again, to control for the influence of extraneous sociodemographic variables, age, sex, education and negative emotional states (DASS-21 total) were entered at Step 1, perceptual aberration (CS-PA), magical ideation (CS-MI) and paranoia (PS) were entered at Step 2, with private body (BCQ-PB1), public body (BCQ-PB2) and body competence (BCQ-BC) in turn, serving as the dependent variable. For all regressions, the number of predictors was within recommended guidelines for minimum sample size requirements (Tabachnick and Fidell, 2007), and assumptions of normality and homoscedasticity were supported. Effect sizes for regressions were interpreted as adjusted R², where small ⩽0.02, medium 0.03–0.13 and large ⩾0.014 (Cohen, 1988). Across all analyses, a statistical significance level of 0.05 was employed, except for correlations, where a more stringent level of 0.01 was applied to limit Type I error owing to multiple comparisons. The relevant data has been shared in the form of a statistical dataset, with de-identified participant data comprising basic sociodemographic information as well as body image and psychosis variables of interest.

Results

Basic sociodemographic information as well as mental health history, and performance on the range of measures employed are shown in Table 1. Respondents were relatively young, well-educated and balanced across the sexes. Most were engaged in some form of paid employment, or current students. In terms of mental health, our participants may be described as moderately depressed, moderately anxious and mildly stressed (Lovibond and Lovibond, 1995).

Correlation analysis amongst body image and psychosis facets

Pearson’s correlation analysis amongst various body image and psychosis facets is shown in Table 2. Dysmorphic concerns was significantly positively correlated with perceptual aberration, magical ideation, paranoia and persecutory ideation. Private body consciousness was significantly positively correlated with magical and persecutory ideation, whereas public body consciousness was significantly positively correlated with magical ideation and paranoia. No other significant correlations were found.

Table 2.

Pearson’s correlations amongst variables of interest.

	Perceptual aberration (CS-PA)	Magical ideation (CS-MI)	Paranoia (PS)	Persecutory ideation (PIQ)
Dysmorphic concerns (DCQ)	0.350**	0.235**	0.480**	0.362**
Private body (BCQ-PB1)	0.114*	0.208**	0.118*	0.131**
Public body (BCQ-PB2)	0.109*	0.177**	0.155**	0.075
Body competence (BCQ-BC)	0.042	0.066	−0.031	0.040

DCQ: Dysmorphic Concerns Questionnaire; BCQ: Body Consciousness Questionnaire; PB1: private body; PB2: public body; BC: body competence; CS-PA: Chapman Scales-Perceptual Aberration; CS-MI: Chapman Scales-Magical Ideation; PS: Paranoid Scale; PIQ: Persecutory Ideation Scale.

p < 0.05. **p < 0.01. Owing to multiple comparisons, only **p < 0.01 (in bold) considered statistically significant.

Paranoid versus persecutory ideation in the prediction of dysmorphic concerns

Two parallel hierarchical regressions comparing the relative contribution of paranoia versus persecutory ideation to predicting dysmorphic concerns are shown in Table 3. In Step 1 of both models, age, sex and negative emotional states were significant predictors. Only sex and negative emotional states remained significant in Step 2, where paranoia emerged as a significant predictor in the first model, F(7, 406) = 36.3, p < 0.001, adjusted R² = 0.378, and perceptual aberration emerged as a significant predictor in the second model, F(7, 406) = 34.0, p < 0.001, adjusted R² = 0.363. Both overall models were significant, with large effect sizes. Paranoia explained 1.9% of the variance in dysmorphic concerns in the first model, and perceptual aberration explained 0.7% of the variance in dysmorphic concerns in the second model.

Table 3.

Hierarchical regressions comparing paranoia versus persecutory ideation as potential predictors of dysmorphic concerns.

	Dysmorphic concerns (DCQ)
	R² change, p	β	t	p	Part correlation
Step 1	0.360, <0.001
Age		−0.084	−2.07	0.039	−0.075
Sex		0.085	2.12	0.035	0.085
Education		−0.017	−0.44	0.664	−0.017
Negative emotional states (DASS-21)		0.566	13.90	<0.001	0.554
Step 2	0.029, <0.001
Age		−0.071	−1.77	0.077	−0.069
Sex		0.102	2.57	0.011	0.100
Education		−0.002	−0.05	0.957	−0.002
Negative emotional states (DASS-21)		0.425	8.26	<0.001	0.323
Perceptual aberration (CS-PA)		0.101	1.90	0.058	0.074
Magical ideation (CS-MI)		−0.056	−1.09	0.277	−0.043
Paranoia (PS)		0.189	3.51	0.001	0.137
Step 2	0.014, 0.032
Age		−0.074	−1.81	0.072	−0.071
Sex		0.095	2.34	0.020	0.093
Education		−0.010	−0.26	0.795	−0.010
Negative emotional states (DASS-21)		0.491	10.08	<0.001	0.399
Perceptual aberration (CS-PA)		0.115	2.14	0.033	0.085
Magical ideation (CS-MI)		−0.038	−0.72	0.472	−0.029
Persecutory ideation (PIQ)		0.076	1.46	0.145	0.058

DCQ: Dysmorphic Concerns Questionnaire; DASS-21: Depression Anxiety and Stress Scale; CS-PA: Chapman Scales-Perceptual Aberration; CS-MI: Chapman Scales-Magical Ideation; PS: Paranoid Scale; PIQ: Persecutory Ideation Questionnaire; β: standardised regression coefficient.Statistically significant findings shown in bold.

Paranoid ideation in the prediction of various aspects of body consciousness

Three parallel hierarchical regressions examining potential predictors of various facets of body consciousness are shown in Table 4. For private body consciousness, negative emotional states was the only significant predictor in Step 1 and remained significant in Step 2. Magical ideation emerged as a significant predictor, explaining 2.9% of the variance in private body consciousness. The overall model was significant, F(7, 406) = 3.5, p = 0.001, adjusted R² = 0.042. For public body consciousness, age and negative emotional states were significant predictors in Step 1. Education (but not age or negative emotional states) became significant in Step 2, where magical ideation also emerged as a significant predictor, explaining 1.3% of the variance in public body consciousness. The overall model was significant, F(7, 406) = 4.0, p < 0.001, adjusted R² = 0.049. For body competence, sex and negative emotional states were significant predictors in Step 1, and remained the only significant predictors in the final model, which was significant, F(7, 406) = 5.4, p < 0.001, adjusted R² = 0.071. Magical ideation did not emerge as a significant predictor in the third model. Paranoia and perceptual aberration were not significant predictors in any of the three regressions.

Table 4.

Hierarchical regressions examining potential predictors of facets of body consciousness.

	Private body (BCQ)					Public body (BCQ)					Body competence (BCQ)
	R² change, p	β	t	p	Part	R² change, p	β	t	p	Part	R² change, p	β	t	p	Part
Step 1	0.024, 0.042					0.047, 0.001					0.064, <0.001
Age		0.025	0.50	0.615	0.025		−0.102	−2.07	0.039	−0.101		−0.016	−0.33	0.743	−0.016
Sex		−0.019	−0.38	0.701	−0.019		0.005	0.11	0.914	0.005		−0.171	−3.51	<0.001	−0.169
Education		0.050	1.02	0.208	0.050		0.096	1.97	0.050	0.098		0.030	0.61	0.542	0.029
Negative emotional states (DASS-21)		0.154	3.06	0.002	0.151		0.160	3.22	0.001	0.158		−0.167	−3.38	0.001	−0.163
Step 2	0.034, 0.003					0.018, 0.055					0.023, 0.020
Age		0.048	0.96	0.337	0.047		−0.089	−1.78	0.076	−0.086		0.008	0.08	0.877	0.007
Sex		−0.021	−0.42	0.675	−0.020		0.010	0.21	0.833	0.010		−.167	−3.43	0.001	−0.164
Education		0.051	1.05	0.294	0.051		0.101	2.06	0.040	0.100		0.037	0.77	0.443	0.037
Negative emotional states (DASS-21)		0.126	1.97	0.049	0.096		0.114	1.79	0.075	0.086		−0.256	−4.07	<0.001	−0.195
Perceptual aberration (CS-PA)		−0.056	−0.85	0.395	−0.041		−0.066	−1.01	0.314	−0.049		0.092	1.42	0.155	0.068
Magical ideation (CS-MI)		0.226	3.52	<0.001	0.171		0.150	2.35	0.019	0.114		0.069	1.09	0.278	0.052
Paranoia (PS)		−0.022	−0.32	0.746	−0.016		0.049	0.74	0.460	0.036		0.055	0.83	0.407	0.040

BCQ: Body Consciousness Questionnaire; DASS-21: Depression Anxiety and Stress Scale; CS-PA: Chapman Scales-Perceptual Aberration; CS-MI: Chapman Scales-Magical Ideation; PS: Paranoid Scale; β: standardised regression coefficient; part: part correlation.Statistically significant findings shown in bold.

To control for the possibility that relationships explored may have been driven by the presence of psychiatric diagnosis, the regressions were rerun under different conditions. Patterns of findings remained largely unchanged, with minor exceptions (see Supplemental Material for detailed explanations). In brief, Supplemental Tables A and B respectively show regressions for dysmorphic concerns and body consciousness when individuals who had endorsed one or more lifetime psychiatric diagnoses (n = 93) were excluded. In these revised models, age was now a significant predictor, with perceptual aberration no longer a significant predictor for dysmorphic concerns. Similarly, negative emotional states and magical ideation were no longer significant predictors for private and public body respectively. Likewise, Supplemental Tables C and D respectively show regressions for dysmorphic concerns and body consciousness with presence of psychiatric diagnosis as a covariate. No change in findings was observed for dysmorphic concerns, with education and age becoming significant predictors for private and public body respectively. Most of these differences were minor, and related to the sociodemographic variables controlled for.

Discussion

The current study aimed to investigate associations between body image and paranoia in the general population by employing multidimensional assessments of body image and added psychosis facets. Hypothesis 1 was supported; paranoia, persecutory ideation and perceptual aberration were all significantly positively correlated with dysmorphic concerns. This finding represents an extension of Waite et al. (2022) and Waite and Freeman (2017) in that the impact of various psychosis facets was shown to encompass dysmorphic concerns, beyond weight. Further positive correlations between dysmorphic concerns with magical ideation as well as private body consciousness with magical and persecutory ideation, and public body consciousness with magical ideation and paranoia, denote that other psychosis facets exerted selective influences on multidimensional body image. We speculate that the emergence of several specific associations with magical ideation may be attributed to the self-referential nature of some items on this scale (e.g. ‘I have sometimes had the passing thought that strangers are in love with me’.), suggesting that further exploration of self-referential ideas is warranted.

Hypothesis 2 was also supported in that paranoia, but not persecutory ideation, significantly contributed to the prediction of dysmorphic concerns, alongside sex and negative emotional states. In light of previous theorisations that negative body image contributes to heightened paranoia (Waite and Freeman, 2017; Waite et al., 2022), our current findings have demonstrated bidirectional links in showing that the converse is also true. This represents a novel alternate mechanism by which paranoid thoughts may be generalised to one’s bodily experiences, and highlights a possible aetiological pathway deserving of clinical attention and future enquiry. Magical ideation was not a significant predictor in either model, though perceptual aberration (in the absence of persecutory ideation) did emerge as a significant predictor in the second model. We theorise that anomalies in perception could partially underlie misidentifications of physical flaws, thereby contributing to heightened dysmorphic concerns. Given perceptual aberration was not a significant predictor in the first model, this likely suggests the predominant influence of paranoia in predicting dysmorphic concerns. As age was a significant predictor in Step 1, but not in Step 2 when paranoia emerged as a significant predictor, paranoia (at least in part) mediated the influence of age. Simply put, younger age was associated with greater paranoia, which in turn contributed to the severity of dysmorphic concerns. It is noted that though large effect sizes were yielded for both overall models, the proportion of variance explained by paranoia in the first model was limited; caution should be exercised in drawing further conclusions.

Evident dissociation between the involvement of paranoia versus persecutory ideation is noteworthy, and conveys several implications. First, when the non-significant contribution of persecutory ideation is distilled from paranoia, what largely remains is the self-referential component. From this, we can deduce that it is likely this self-referential component which drives the association with dysmorphic concerns (akin to our findings for Hypothesis 1). Though this interpretation is tentative, it fits in with clinical conceptualisations of body dysmorphic disorder, where ideas of reference are known to predominate (Rossell et al., 2020; Toh et al., 2017). Second, it remains unknown if this pattern of dissociation also applies to the relationship between paranoia and weight concerns, and concomitantly, anorexia nervosa on the clinical end of the spectrum. Whether it is the persecutory and/or self-referential components that underpin paranoia deserves future enquiry.

Hypothesis 3 was not supported in that paranoia did not significantly contribute to the prediction of public or private body consciousness nor body competence. This was in opposition to early research suggesting a link between paranoia and general self-consciousness (Fenigstein and Vanable, 1992). Instead, magical ideation significantly contributed to private and public body consciousness. For private and public body consciousness, negative emotional states and education were respectively also significant predictors in the final model. For body competence, sex and negative emotional states were the only two significant predictors throughout. Paranoia and perceptual aberration were not significant predictors in any of the three models, which were all significant. Magical ideation often expresses as heightened awareness of the surrounding environment underlying the formation of unusual connections or ideas. Such attention may then manifest as greater sensitivity to events within a person’s internal and external worlds. This could be a possible explanation for the specific contribution of magical ideation to private and public body consciousness, but further studies are essential. Again, it is noted that medium effect sizes were yielded for the three overall models, though the proportion of variance explained by each individual significant predictor was small in magnitude.

These findings across the body image facets demonstrates that there is utility in treating body image, not as a unitary construct, but rather a multidimensional concept. Though the overall magnitudes of variance explained by paranoia, magical ideation and perceptual aberration were not sizeable (0.7%–2.9%), these remain fruitful mechanistic elements worthy of further investigations. In terms of clinical implications, under what conditions these effects may be bidirectional and/or translate to clinical cohorts remain unknown. However, challenging paranoid thought patterns may serve as a fruitful therapeutic avenue to address negative body image, even in non-clinical groups. Should replication in clinical cohorts be evidenced, this strategy may be especially helpful for those with body dysmorphic disorder or anorexia nervosa.

The current study had several limitations. The online nature of the survey meant that there was no face-to-face validation of the collected information. This could be especially pertinent in view of inherent complexities within the constructs assessed. Our stringent data cleaning protocol was however, designed to eliminate unreliable or invalid responses. Possible biases may have been introduced via our recruitment strategy, which relied on Prolific as well as social media advertising. This is likely reflected in the specific demographics of our participants, with relatively younger mean age and higher educational attainment, which in turn, limited the generalisability of our findings. Related to this, our respondents were largely from developed nations. This skew must be taken into consideration when drawing conclusions, in that our findings may not apply to those residing in other regions. We were also unable to consider the perspectives of those younger than 18 years, who did not speak English or with limited access to an appropriate device or the internet. Given race/ethnicity information was not collected, this meant we were unable to assess cultural influences. In addition, our sample was characterised as having slightly elevated levels of anxiety and depression. We accounted for this by including these negative emotional states as a single covariate in subsequent regression analyses. This was coupled with the use of comprehensive assessments of body image and psychosis dimensions based on well-validated measures. Yet we did not directly assess the self-referential component of paranoia, though we were able to offer a delineation with persecutory ideation. A particular strength of our study relates to establishing an overlap in classes of psychiatric symptoms, which though seldom considered together, may have implications for aetiological mechanisms, clinical diagnosis and intervention.

There are three clear avenues for future research. First, nuanced findings across body image and psychosis facets demonstrate that there is utility in added explorations into these multidimensional constructs. For example, the focus on paranoia may be expanded to include broader themes. Current findings demonstrate that self-referential themes may be especially relevant, and should be directly assessed, with the use of specialised tools (e.g. Wong et al., 2012). A clear delineation between general and body image-specific self-referential scenarios would be beneficial, given nascent literature in body dysmorphic disorder supporting this (Buhlmann et al., 2002, 2006). Second, robust replication across other demographic groups, including adolescents and older adults, those residing in less developed regions and segments with limited access to the internet, is essential. Age effects may be of special interest, as existing research has shown that individual perceptions of body image evolve throughout the lifespan (Quittkat et al., 2019; Tiggemann, 2004). Clinical replication within the psychotic and body image disorders will also help uncover similarities and/or differences in how these constructs operate within each condition, where paranoia and body image disturbances respectively serve as core clinical features. The identification of effective therapeutic targets may then differ according to which disorder/symptom predominates. Given the prevalence of body image dissatisfaction, these investigations will facilitate a comprehensive understanding of the complex intersections between multidimensional body image and psychosis. Third, the current study relied solely on cross-sectional data, where causal attributions cannot be ascertained. Longitudinal research tracking how these body image and psychosis facets evolve over time will help to further elucidate causal relations.

Our study has established several significant associations amongst various body image and psychosis facets, particularly in relation to dysmorphic concerns with paranoia as well as private and public body consciousness with magical ideation, though certain effect sizes were modest. Future research should focus on elucidating the specific influence of self-referential themes as well as corroborating if these trends extend to other groups within the general population as well as clinical cohorts and therapeutic implications therein.

Supplemental Material

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Supplemental material, sj-docx-1-hpq-10.1177_13591053221133890 for Intersections of paranoia and the body in the general population by Wei Lin Toh, Andrea Phillipou, Erica Neill and Susan L Rossell in Journal of Health Psychology

Research Data

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Supplemental material, sj-docx-2-hpq-10.1177_13591053221133890 for Intersections of paranoia and the body in the general population by Wei Lin Toh, Andrea Phillipou, Erica Neill and Susan L Rossell in Journal of Health Psychology

Research Data

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Supplemental material, sj-sav-4-hpq-10.1177_13591053221133890 for Intersections of paranoia and the body in the general population by Wei Lin Toh, Andrea Phillipou, Erica Neill and Susan L Rossell in Journal of Health Psychology

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Footnotes

Acknowledgements

The authors would like to thank all the participants who took the time and effort to take part in this study. WLT (GNT1161609) and AP (GNT1159953) are supported by National Health and Medical Research Council (NHMRC) New Investigator Project Grants; SLR holds a NHMRC Senior Fellowship (GNT1154651).

Data sharing statement

The current article is accompanied by the relevant raw data generated during and/or analysed during the study, including files detailing the analyses and either the complete database or other relevant raw data. These files are available in the Figshare repository and accessible as Supplemental Material via the Sage Journals platform. Ethics approval, participant permissions, and all other relevant approvals were granted for this data sharing.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Wei Lin Toh

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