The experience of body image concerns in patients with persecutory delusions: ‘People don't want to sit next to me’

OBJECTIVE: Persecutory delusions typically build on feelings of inter‐personal vulnerability linked to negative views of the self. Negative body image is an overlooked aspect of this link between the self‐concept and paranoia. DESIGN: This study explores body image from the first‐person perspective of patients with persecutory delusions. METHOD: Semi‐structured interviews, analysed using interpretative phenomenological analysis, were conducted with twelve patients with persecutory delusions in the context of psychotic disorders. RESULTS: Four super‐ordinate themes emerged. First, appearance as a source of threat accounted for how negative body image increased feelings of vulnerability and fed into the content of paranoia and voices (e.g., ‘I feel that everybody is noticing that I'm getting bigger and bigger and laughing at me’). Second, there was the negative impact of uncontrollable and unwanted weight gain, especially following antipsychotic medication (e.g., ‘I ballooned up to 23 stone’). Third, feeling stuck captured the hopelessness and resignation in relation to appearance (e.g., ‘I've become so accustomed to being overweight that I've accepted it as my lot’). Finally, looking well symbolises feeling well represented the importance of appearance in determining mental well‐being (e.g., ‘If I've got clean clothes and I put makeup on, at least I feel that I'm looking after myself’). CONCLUSIONS: Patients with persecutory delusions described appearance‐related concerns making them feel negative towards themselves, inferior to other people, and vulnerable to harm. Appearance‐related distress was broader than weight gain, including dissatisfaction with skin, clothing, and attractiveness. Negative body image may be a contributory factor in the occurrence of paranoia. PRACTITIONER POINTS: Body image concerns may be of particular relevance in patients with persecutory delusions due to weight gain, inactivity, and medication side effects. Body image concerns include weight gain and broader aspects of appearance. Negative body image contributes to feelings of vulnerability, potentially worsening paranoid fears. It may be helpful for practitioners to explore the psychological impact of weight gain and body image concerns in patients with psychosis.