There has been growing interest in how core beliefs (deep fundamental thoughts we have about ourselves and others), may influence psychosis and serious mental health problems. These sorts of beliefs are sometimes described as the mental glasses through which we see and filter everything that happens to us.
What if the deep-seated beliefs we hold about ourselves and others could actually shape our mental health in powerful ways? New research is revealing just how powerful our core beliefs can be.
We know people with first episode psychosis are more likely to have experienced negative or aversive childhood experiences (see recent Elf blog by Jennifer Murphy). These individuals are three times more likely to develop psychosis, than those who do not experience adversity.
Core beliefs are a bit like mental templates that shape how we see the world and understand ourselves and others and everything that happens to us. These beliefs are usually formed in early life, influenced by relationships with care givers and further built upon in adulthood. The terms used in the literature include negative schematic beliefs or early maladaptive schemas. Recently, there have been some studies examining positive beliefs about the self and early adaptive schemas. When people experience adversity, in particular children, they often develop negative core beliefs such as:
- Beliefs about themselves: “I’m worthless,” “I’m weak,” “I’m unlovable”
- Beliefs about others: “People can’t be trusted,” “No one cares about me,” “People will reject me”
- Beliefs about the world: “The world is dangerous,” “Life is unpredictable,” “I’m all alone”
These negative core beliefs are strongly connected to particular symptoms of psychosis:
- Hearing voices: people with negative beliefs about themselves and others are more likely to hear distressing voices – the content of the negative belief can be reinforced by the negative voice.
- Paranoid thoughts: Negative beliefs about others means individuals can be more likely to mistrust others and develop paranoid delusions (unfounded fears that others mean them harm).
- Grandiose Delusions: Individuals with very strongly held positive beliefs about the self may be more likely to develop grandiose delusions (unfounded beliefs about have special powers or special abilities).
Research on these beliefs matters for treatment for a number of reasons:
- Firstly, understanding how core beliefs may influence the development of psychosis, could suggest possible targets in the at-risk mental state (ARMS) group of people at ultra-high risk of developing psychosis.
- Secondly, psychological therapies can be targeted to reduce symptoms.
- Thirdly, enhancing particular positive beliefs may help with a recovery focused approach to therapy and treatment.
A new systematic review has examined a range of studies about core beliefs and psychosis (Jorovat et al. 2025). It was published in the Nature journal Schizophrenia.
What if the deep-seated beliefs we hold about ourselves and others could actually shape our mental health in powerful ways? New research is revealing just how powerful our core beliefs can be.
Methods
The authors used four databases (MEDLINE (including PubMed), EMBASE, Global Health and APA PsycINFO) to search for studies investigating core beliefs/ schemas in psychosis that were published up to June 2024. Studies were considered regardless of their design; eligibility criteria included:
- Peer-reviewed publications written in English
- Studies that explore the role of core beliefs/schemas or
- Studies that consider interventions that target core beliefs/schemas
- Samples of people diagnosed with psychosis, individuals who were deemed “Clinically High Risk” (also known as “At-Risk Mental State”) and non-clinical populations with Psychotic-Like Experiences.
They excluded studies if participants had drug-induced psychosis or psychosis due to organic causes. The review does not specifically state that affective psychosis (i.e. Bipolar affective disorder, which can sometimes include psychotic experiences) was excluded; however, relevant terms or truncations (e.g., Schizo*) of terms appear not to have been considered in the search strategy, and only one study was included where individuals had diagnoses of Schizoaffective Disorder.
The authors pre-registered the review on PROSPERO and provided a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram, providing clear descriptions of where studies were excluded after retrieval. Due to the mixed designs of the included studies, two tools were required to evaluate methodological quality of the studies retrieved. These results were summarised in the text with the ratings provided in the appendix.
The review aimed to determine what role core beliefs play in psychosis, how they differ between groups, and what the potential clinical implications are by proposing cognitive models.
Results
A total of 79 studies were included in the review, with 18 suitable for inclusion in a meta-analysis. The overarching finding was that more negative beliefs about themselves (e.g., “I’m worthless” or “I’m vulnerable”) and about others (e.g., “others can’t be trusted” or “others are dangerous”) are associated with psychotic experiences. These patterns were evident in cohorts where individuals had established diagnoses of psychosis, were at clinically high risk of developing psychosis, or were from non-clinical populations who had psychotic-like experiences. These results were supported by the meta-analytic findings.
Trauma
The review also reflected on the high prevalence of childhood trauma in psychosis and how this may link to core belief development; they noted that negative beliefs about others tended to mediate the relationship between trauma and paranoia / persecutory delusions.
Psychosis experiences
There were significant associations between negative-self and negative-other beliefs with expressions of auditory hallucinations and persecutory beliefs (delusions).
Nearly all Early Maladaptive Schemas (EMS) showed positive correlations with suicidal thoughts (except Self-Sacrifice and Unrelenting Standards). The Emotional Deprivation schema specifically increased lifetime suicide attempt risk by 1.56 times and was linked to positive symptoms, negative symptoms, and depression. Generally, more negative views of self and others correlated with increased suicidal ideation.
Models
Three models were developed from the results in the article:
- Cognitive model of core beliefs in auditory hallucinations and persecutory delusions
- Cognitive model of core beliefs in clinical high risk
- Mediation model for non-clinical samples
The two cognitive models follow a typical longitudinal formulation structure of early experiences leading to core belief development. The first model then leads to cognitive (thinking biases), behavioural and affective (increased arousal) elements, in turn leading to the psychotic symptoms, where these then provide feedback into core beliefs. The second model for clinically high-risk (“at risk mental state”) individuals follows a similar structure, but considers beliefs rather than cognitions, accompanied by affective and behavioural components feeding into attenuated psychotic symptoms. Interestingly, there is not a feedback loop from these symptoms back to core beliefs. Both models acknowledge psychosocial stressors as triggers for core belief reactivation.
The key finding was that negative self beliefs were associated with psychosis experiences.
Conclusions
The authors conclude:
Core beliefs were found to play a significant role in the development and maintenance of positive symptoms of psychosis. The development of psychosocial interventions that explicitly target negative self and other-beliefs, whilst also enhancing positive self-beliefs are warranted and would innovate CBTp practices.
Strengths and limitations
The strengths of this review include the broad search exploring core beliefs in non-clinical, clinically high risk and clinical populations, and the inclusion of both qualitative and quantitative data. The restriction of articles to English language-only is likely to have led to omissions of relevant data, although it must be acknowledged that the review includes a considerable sample of literature. Utilising two raters for screening, data extraction and methodological quality ratings and reporting a kappa value for inter-rater reliability would have increased the rigour of this review. A PRISMA checklist would have been a useful addition in the online supplementary materials to demonstrate adherence to the reporting guidelines.
The development of models formed from peer-reviewed publications enhances the scientific grounding of psychological formulation. However, aside from the clear relation of early life experiences influencing core belief and schema development, the other details of these formulation models likely need more research to substantiate them before they are used clinically.
While the basic structure of these models is not dissimilar to cognitive models in general and links between the data and these models can be seen, it is unclear where the examples of these category headings are derived and whether this is also data-driven. For example, it is unclear why “hypervigilance to threat” is listed under Persecutory Delusions in the model as opposed to under Behaviour, where this may be a functional behaviour driven by core beliefs and early experiences that leads to the experience of persecutory delusions.
It is unclear whether the three models identified are data driven.
Implications for practice
This review further evidences the relationship between early experiences and core belief development, particularly the influence of negative-self and negative-other beliefs in individuals with psychosis or who are at high risk of developing it. Moreover, it demonstrates how these core beliefs can link to psychotic experiences, symptoms and suicidality. Therefore, a comprehensive assessment of these factors when undertaking psychological intervention is essential. Indeed, the Young Schema Questionnaire for in-depth assessment may be useful, or for a shorter measure, the Brief Core Schema Scales (Fowler et al. 2006) Questionnaire as an adjunct to psychosocial assessment.
Consideration must also be given to whether these negative-other and negative-self beliefs would benefit from specific targeting in psychological interventions. For example, a recently published book has outlined adaptations to Schema Therapy for Psychosis (Rhodes & Voronstosva, 2024), building on an approach that was first developed for complex emotional and relational needs within a broad cognitive behavioural therapy framework. The therapy model is more integrative, drawing on object relations, attachment theory, gestalt therapy approaches. It utilises cognitive and behavioural approaches, but also emotion focused techniques such as imagery rescripting, chair work and has more focus on therapeutic relationship (sometimes called limited reparenting). However, case studies, case series and feasibility trials are yet to be conducted.
Overall, the review highlights the evidence underpinning the importance of core beliefs and their relationship with psychotic symptoms and experiences of psychosis, pointing to future directions for research, therapy and care.
A comprehensive assessment of core beliefs is essential to psychological formulation.
Statement of interests
NA and CT contributed a chapter to the Rhodes and Voronstosva book referenced in the article. CT has published studies on core beliefs and schemas in psychosis.
Links
Primary Paper
Jorovat, A., Twumasi, R., Mechelli, A., & Georgiades, A. (2025). Core beliefs in psychosis: a systematic review and meta-analysis (PDF). Schizophrenia, 11(1), 38.
Other references
Rhodes, J. & Voronstosva, N. (2024). Schema Therapy Adapted for Psychosis and Bipolarity. Routledge.
Fowler, D. et al. (2006). The Brief Core Schema Scales (BCSS): psychometric properties and associations with paranoia and grandiosity in non-clinical and psychosis samples. Psychological Medicine, 36, 749-759. https://pubmed.ncbi.nlm.nih.gov/16563204/
