Introduction Cognitive biases are associated with psychosis liability and paranoid ideation. This study investigated the moderating relationship between pre-existing self-reported cognitive biases and the occurrence of paranoid ideation in response to different levels of social stress in a virtual reality environment. Methods This study included 170 participants with different levels of psychosis liability (55 recent onset psychosis, 20 ultrahigh risk for psychosis, 42 siblings of psychotic patients, and 53 controls). All participants were exposed to virtual environments with different levels of social stress. The level of experienced paranoia in the virtual environments was measured with the State Social Paranoia Scale. Cognitive biases were assessed with a self-report continuous measure. Also, cumulative number of cognitive biases was calculated using dichotomous measures of the separate biases, based on general population norm scores. Results Higher belief inflexibility bias (Z = 2.83, P <.001), attention to threat bias (Z = 3.40, P <.001), external attribution bias (Z = 2.60, P <.001), and data-gathering bias (Z = 2.07, P <.05) were all positively associated with reported paranoid ideation in the social virtual environments. Level of paranoid response increased with number of cognitive biases present (B = 1.73, P <.001). The effect of environmental stressors on paranoid ideation was moderated by attention to threat bias (Z = 2.78, P <.01) and external attribution bias (Z = 2.75, P <.01), whereas data-gathering bias and belief inflexibility did not moderate the relationship. Conclusion There is an additive effect of separate cognitive biases on paranoid response to social stress. The effect of social environmental stressors on paranoid ideation is further enhanced by attention to threat bias and external attribution bias.
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