Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
6/8/2016 Paranoia 101 Paranoia 201: Understanding the Nature of Excessive Suspiciousness David J. LaPorte, Ph.D. Department of Psychology Clinical Psychology Doctoral Program Author Paranoia Word Count Comer (Fundamentals of Abnormal Psychology) 650 Butcher, Hooley & Mineka 653 Barlow & Durand (Abnormal Psychology: An Integrative Approach) 1,714 Oltmanns & Emery 2,066 Paranoid Personality Disorder Paranoid Schizophrenia Delusional Disorder Persecutory Type Posttraumatic Stress Disorder Follie á Deux Delirium Mis‐ Identification Disorders (Capgras Syndrome) Depression Nolen‐Hoeskema 987 Whitbourne & Halgin 464 Barlow & Durand (Essentials of Abnormal Psychology) 1,626 Comer (Abnormal Psychology) 858 Sue, Sue, Sue & Sue (The Essentials of Understanding Abnormal Behavior) 187 Kring, Johnson, Davison, Neale 120 Kearney & Trull 180 Sue, Sue, Sue & Sue (Understanding Abnormal Beheavior) 291 Paranoid Schizophrenia Bipolar Disorder Paranoid Personality Disorder Social Anxiety Disorder Substance Use (Amphetamines, cocaine, bath salts, designer drugs) Delusional Disorder Persecutory Type Schizotypal Personality Disorder Dementia Alcohol Dependence Brief Psychotic Disorder Temporal Lobe Epilepsy Schizoid Personality Disorder Clarification • Paranoia is a broad term – Lycanthropy – Parasitosis – Fregoli syndrome – Capgras Syndrome • Paranoia= undue, elevated suspiciousness Paranoia: Essential Features • Undue suspiciousness • Belief in mal-intent of others 1 6/8/2016 Posttraumatic Stress Disorder Problems with the Research Literature Paranoid Schizophrenia • Under-studied • Embedded phenomenon Substance Use cocaine, bath salts, designer drugs) Delusional Disorder Persecutory Type Schizotypal Personality Disorder Problems with the Research Literature • “People are spying on me” • “People are following me” • 10% Social Anxiety Disorder Paranoid Personality Disorder (Amphetamines, Dementia Alcohol Dependence Epidemiology Mis‐ Identification Disorders (Capgras Syndrome) Depression Bipolar Disorder • Under-studied • Embedded phenomenon • Anosognosia Follie á Deux Delirium Brief Psychotic Disorder Temporal Lobe Epilepsy Schizoid Personality Disorder Epidemiology • • • • • Community surveys: “Are people talking behind your back” “Do you feel someone is out to get you” “Do you feel persecuted in some way” 20-30% admit to this Epidemiology • “People are trying to poison me” • “I am being plotted against” • 5-10% 2 6/8/2016 Epidemiology • NYC survey* • 11% felt being followed or spied on • 7% felt being poisoned or plotted against • 5% felt being experimented on Epidemiology • Patients admitted to hospital for psychiatric problems: • 40% experience paranoia *Olfson et al. (2002) Am. J. Psychiatry. 159: 1412‐19 Epidemiology • • • • Swiss study* 4-9% had paranoid thoughts Followed for next 20 years Numbers remained the same *Rössler, W., Riecher‐ Rössler, A., Angst, J., Murray, R., Gamma, A., Eich, D., van Os, J., & Gross, V.A. (2007). Psychotic experiences in the general population. Schizophrenia Research, 92, 1‐14. Epidemiology • Medical patients >65 yo: • 23-30% develop delirium • Almost all develop paranoia S.K. Inouye, “Delirium in Older Persons,” New England Journal of Medicine 354 (2006). Epidemiology • Currently 4-6 million suffer from dementia • Likely double in next decade • 35-50% of demented individuals develop paranoia M.M. Bassiony and C.G. Lyketsos, “Delusions and Hallucinations in Alzheimer’s Disease,” Psychosomatics 44 (2003). Epidemiology • Conclusions: • Between 10-30% of non-patients experience varying levels of paranoia • Occurs regularly in 15-20% of general population • Similar rates across industrialized countries 3 6/8/2016 Posttraumatic Stress Disorder Epidemiology • Conclusions: • Among older individuals who develop delirium or dementia: 20-50% will become paranoid • Are rates of paranoia increasing? Paranoid Personality Disorder • mistrust or suspicion of • bears grudges and seeks other’s motives revenge* • Hostility • constant mobilization and on the lookout for • Jealousy perceived threats • susceptibility to slights (intended or unintended) • belief that one is being talked about, referred to, by others followed, stared at, or watched Follie á Deux Delirium Mis‐ Identification Disorders (Capgras Syndrome) Depression Paranoid Schizophrenia Bipolar Disorder Social Anxiety Disorder Paranoid Personality Disorder Substance Use (Amphetamines, cocaine, bath salts, designer drugs) Delusional Disorder Persecutory Type Schizotypal Personality Disorder Dementia Alcohol Dependence Brief Psychotic Disorder Temporal Lobe Epilepsy Schizoid Personality Disorder Paranoid Personality Disorder • rigidity • excessive sense of selfimportance • feeling “wronged” by others • hypersensitivity Posttraumatic Stress Disorder • high levels of anger* • Hypervigilance • overly concerned with “evidence” • everything “means” something; no chance occurrences Follie á Deux Delirium Mis‐ Identification Disorders (Capgras Syndrome) Depression Paranoid Personality Disorder • malevolent others, known or unknown, who abuse, torment, harass, threaten, wrong, vilify, accuse disparage, mistreat, persecute and taunt them • mountains out of molehills • an edgy, irritable, quarrelsome, and querulous demeanor Bipolar Disorder Social Anxiety Disorder Paranoid Personality Disorder Paranoid Schizophrenia Substance Use Insomnia (Amphetamines, cocaine, bath salts, designer drugs) Delusional Disorder Persecutory Type Schizoid Personality Disorder Schizotypal Personality Disorder Alcohol Dependence Dementia Brief Psychotic Disorder Temporal Lobe Epilepsy 4 6/8/2016 Delusional Disorder • • • • • Delusions are non-bizarre (plausible) Stable, logically constructed Monomania Logical processes and mood preserved Delusion is central to person’s life Delusional Disorder Delusional Disorder • Paranoia querulans (aka: litigious paranoia) • 1-3/ 100,000 • Chronic disorder Robert Lewis Dear, Jr • Killed 3 at Planned Parenthood clinic • Believed he was targeted by federal government for surveillance • FBI is trying to kill him • People with delusions: –90% act on them in some way –90% believe the delusions are completely true Paranoid Schizophrenia • Bazaar paranoid delusions • Embedded within schizophrenia syndrome What is going on? • Cognitive: – Not different from normal – Confirmatory bias – Limited data gathering • Quick to form conclusions • Confidence in their judgment • Illusory correlations 5 6/8/2016 What is going on? Paranoid and Violence • Biologically: • Dopamine –Increase environmental salience Authors & Date Authors & Date Sample Methodology Results Combs et al., 2009 Individuals with Persecutory Delusions (PD) (N= 32), without PD (N= 28) and healthy participants (N=50) Completed Ambiguous Intentions Hostility Questionnaire and questions about paranoia Individuals with PD showed greater hostility, blame, and aggression when faced with ambiguous situations; hostility bias was associated with paranoid ideation Douglas, Guy, & Hart (2009) 204 studies investigating the association between psychosis and violence Meta‐analysis Psychosis significantly associated with a 49%‐68% increase in the risk of violence Cold et al., 2013 Patients with first‐episode psychosis, age 18‐64 (N= 458) Population‐based survey of first‐episode psychosis and informal interview 38% engaged in violence (minor and serious) in the past year; delusions of persecution, being spied on, and conspiracy linked with minor violence Fazel et al., 2009 Individuals with schizophrenia and other psychoses (N= 18,423) Systematic review of studies (N= 20) investigating associations between violence and schizophrenia and other psychoses Schizophrenia and other psychoses are associated with violence, particularly homicide; this is highly comorbid with substance abuse Junginger, Parks‐Levy, & McGuire (1998) Psychiatric inpatients with delusions (N= 54) Formal interviews about history of delusions and concurrent violence 40% inpatients reported at least one violent incident that was “probably or definitely” motivated by a concurrent delusion Kinoshita et al., 2011 Japanese adolescents (N= 18,104) Self‐report questionnaire Psychotic‐like experiences associated with interpersonal violence and violence towards objects; positive correlation between number of psychotic experiences and risk of violence; “spied upon” and “voice hearing” psychotic‐like experiences highly associated with interpersonal violence Link, Stueve, & Phelan (1998) Israeli‐born Jewish young adults (N= 2741) Fixed‐format self‐report questions and interviews using the Schedule for Affective Disorders and Schizophrenia Fighting and weapon use significantly associated with persecutory delusions and delusions of thought control/mind being dominated by outside forces Mojtabai, 2006 Adult participants from United States (N= 38,132) National household survey Individuals with psychotic‐like experiences were 5.72 times more likely to attack with intent of hurting another person Nederlof, Muris, & Hovens (2011) Individuals with a diagnosis of schizophrenia, delusional disorder, psychotic disorder NOS, or a hi ff i di d (N 124) Informal interview and self‐report questionnaires Perceived threat and feeling of losing control to an external force significantly related to aggressive behavior in h i i di id l Sample Methodology Results Cold et al., 2006 Community household sample in (N= 8,000) Cross‐sectional survey 12% engaged in violence, exacerbated alcohol and drug dependence. Risk of violence in people with severe mental illness is low. Bjorkly, 2001 26 studies investigating link between mental illness and violence Literature review Persecutory delusions increase risk of violence, further increased when co‐ occurs with emotional distress Darrell‐Berry, Berry, & Bucci (2016) 15 studies investigating link between paranoia and aggression Literature Review Positive association between paranoia and aggression (66% significantly positively correlated) McKetin et al., 2016 Non‐psychotic methamphetamine users (N= 164) Administered Brief Psychiatric Rating Scale after use of methamphetamine for one year Methamphetamine use caused positiv psychotic and affective symptoms Coid et al., 2016 General population surveys (n= 23,444) Metanalysis Paranoid ideation and psychotic disor were associated with violence Van Dorn, Volavka, Johnson (2011) Adult civilian noninstitutionalized population (N= 34,653) Two‐wave analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions Individuals with serious mental illness Schizophrenia) have higher risk of violence than those with no mental ill Appelbaum, Robbins, & Monahan (2000) Recently discharged patients from acute psychiatric hospitalization (N= 1,136) Data analysis from MacArthur Violence Risk Assessment Study Delusions not associated with a higher of violence in mentally ill individuals, although they may provoke violence in individual cases Arseneault et al., 2000 Young adults in New Zealand in a birth cohort (N= 961) Measured past year prevalence of mental disorders and violence using self‐reports of criminal offenses and search of conviction records Individuals with schizophrenia‐spectru disorder 2.5 times more likely to be violent; best explained by excessive perceptions of threat Rossler et al., 2007 Community cohort of young adults, over 20 years (N= 591) Longitudinal assessment of semi‐ structured interviews and examination of paranoid ideation and psychoticism Subclinical psychosis is characterized b schizophrenia nuclear symptoms and schizotypal signs; these individuals experience deficiencies in social functioning Author & Date Sample Methodology Results Stueve & Link, 1997 Young adults in Israel (N= 2,678) Self‐reports and the Psychiatric Epidemiology Research Interview Recent fighting and weapon use higher among those diagnosed with a psychotic or bipolar disorder Swanson et al., 1996 Data from the Epidemiologic Catchment Area survey; community household samples (N= 10,000) Collective data analysis Perceived threat and feeling of losing control to an external force five times more likely to engage in violent behavior than those with no mental disorder Large, 2014 Recently released prisoners incarcerated for sexual or violent offense (N= 967) Follow‐up surveys and interviews for approximately 40 weeks after release Prisoners with untreated schizophrenia were four times more likely to be violent than those treated or no psychosis; persecutory delusions can partially explain this Ulrich, Keers, & Coid (2013) Male and female psychiatric inpatients post‐discharge Measured delusions, affect due to delusions, and violence at baseline and in 5‐month follow‐up assessments Delusions of being spied upon, followed, plotted against, being under control of person or force, thought insertion, and having special gifts/powers were associated with angry affect Tamburello, Bajgier, & Reeves (2015) Electronic medical records from the New Jersey Department of Corrections inmates (N= 1,154) Systematic chart review Prevalence of delusional disorder in prison is eight times higher than that in the community Taylor, 1998 Inmates in a high security hospital and a general psychiatric hospital Systematic review from three studies investigating the epidemiology of violence and mental disorder 30% of delusional prisoners were violent; 58% of them were driven by their delusions Wessley et al., 1993 Adults with a diagnosis of schizophrenia, paranoia, or paranoid psychosis (N= 83) Self and observer reports 50% reported acting on least one delusion, 20% reported acting on three or more delusions; 25% of these actions were violent in nature 6 6/8/2016 Paranoia & Violence: Conclusions • Between 10-50% of paranoia individuals will become violent • Most paranoid individuals are not violent • Paranoid individuals are more violent than other types of mental disorders Paranoia & Violence • Anger as key variable Treatment: CBT Treatment • No controlled studies • Therefore, no empirically supported treatments • Most research on psychotic levels of paranoia • Targeting delusions: • Targeting reasoning: • Targeting worry**: Freeman et al. An explanatory randomized controlled trial testing the effects of targeting worry in patients with persistent persecutory delusions: The Worry Intervention Trial (WIT). Efficacy Mech Eval 2015; 2(1). Treatment: CBT Treatment • Targeting interpersonal sensitivity (rejection & vulnerability: • Mindfulness: • Family interventions: ?? • Insomnia: 7 6/8/2016 Medications • Most studies are done in schizophrenia • Modest improvements in paranoid delusions • No studies looking at non-delusional Are Rates of Paranoia Increasing? • General increase in severe mental illnesses over the past 2 centuries paranoia Are Rates Increasing? • Recent increases • >50% will have a mental illness of some type R.C. Kessler, et al., “Lifetime Prevalence and Age‐of‐onset Distributions of DSM‐IV Disorders in the National Comorbidity Survey Replication,” Archives of General Psychiatry 62 (2005). 8 6/8/2016 Are Rates Increasing? • Urbanization • 2.4 time higher rate of psychosis Are Rates Increasing?: Threats to Sense of Security/Safety and Privacy • Computer hacks • Electronic surveillance Do we have evidence that social/cultural factors in our environment can influence rates of mental illness? Cannabis • 3-fold increased risk for development of psychosis Semple, D.M., et al., “Cannabis as a Risk Factor for Psychosis: Systematic Review,” 9 6/8/2016 Indomethacin Contact Strokes Actifed Klinefelter’s syndrome Cortisone Subarachnoid hemorrhage Acute intermittent porphyria Leukoencephalopathy Creutzfeld‐Jakob disease Subdural hematoma Addison’s disease ACTH Levodopa Cushing’s syndrome Syphilis AIDS Lidocaine Delirium Systemic lupus erythematosus Albuterol Liver failure DDAVP Thallium Alcohol intoxication Niacin deficiency Diphenylhydantoin Thiamine deficiency Alcohol withdrawal Nitrous oxide Disulfiram (Antabuse) Alcohol hallucinosis Normal Pressure Hydrocephalus Encephalitis lethargica Alpha‐methyldopa Pancreatic encephalopathy LSD Traumatic Brain Injury Alzheimer’s type dementia Amphetamines Parathyriod disorders Parkinson’s Disease Malaria Malnutrition Trypanosomiasis Tuberothalamic artery infarction Anticholinergic drugs PCP Manganese Tumors (pituitary; temporal lobe) Antimalarial drugs Thyrotoxicosis Toxic shock syndrome Pellagra Marchiafava‐Bignami disease Turner’s syndrome Antitubercular drugs Niacin deficiency Marijuana Typhus Arsenic Nitrous oxide Menzel‐type ataxia Uremia Atropine toxicity Bipolar Disorder Mephentermine Trypanosomiasis Barabiturates Brain tumors Methylphenidate (Ritilin) Tuberothalamic artery infarction Hypoparathyroidism Bromide intoxication Mercury Tumors (pituitary; temporal lobe) Hypopituitarism Bromocriptine LSD Turner’s syndrome Hypothyroidism Buproprion Mescaline Typhus Ibuprofen Carbon monoxide poisoning Pentazocine Uremia Ideopathic basal ganglia calcification Cerebrovascular disease Imipramine Cimetidine Pernicious anemia Tuberothalamic artery infarction Hypoparathyroidism Cocaine Pick’s dementia Tumors (pituitary; temporal lobe) Phenylketonuria Hepatic encephalopathy Migraine headaches Turner’s syndrome Phenylpropanolamine Herpes simplex encephalitis Motor neuron disease Typhus Prednisone Trauma Perbitine Trypanosomiasis HIV infetion Multiple sclerosis Uremia Procaine penicillin Huntington’s chorea Muscular dystrophy Tumors (pituitary; temporal lobe) Prophylhexedrine Hydrocephalus Myxedema Turner’s syndrome Propranolol Hypercalcemia Narcolepsy Typhus Ephedrine Hypertensive encephalopathy Nasal decongestants Uremia Epilepsy (temporal lobe origin) Hyperthyroidism Roussy‐Levy syndrome Tumors (pituitary; temporal lobe) Fahr’s Disease Hypoglycemia Salbutamol Vascular dementia Fat embolism Metachromatic Scleroderma Viral encephalitis Folate deficiency leukodystrophy Sleep apnea Vitamin B12 deficiency Hearing loss Methyltestosterone Spinocerebellar degeneration Hemodialysis Hyperthyroidism Wilson’s Disease 47XYY syndrome Vascular dementia Viral encephalitis Authors & Date Sample Methodology Results Authors & Date Barrigón et al. (2015) 60 patient‐sibling pairs (patients with functional psychosis and a non‐psychotic sibling) in Granada and Spain Semi‐structured interview to assess for childhood trauma and psychotic symptoms Participants who experienced childhood trauma were 7.3 times more likely to suffer from psychosis Krabbendam, Bak, Hanssen, & Graaf (2004) Kelleher et al. (2013) Nationally representative sample of adolescents 13‐16 years old (N= 1,112) Assessed at baseline and 3‐month and 12‐month follow‐up for childhood trauma and psychotic symptoms Trauma was strongly predictive of psychotic experiences; dose‐response relationship between severity of bullying and risk for psychotic experiences Shevlin, Dhrahy, & Adamson (2007) Data from National Comorbidity Survey (using noninstitutionalized individuals between 15 and 54 years of age) (N= 5,877) Dual‐wave analysis using data from the National Comorbidity Survey and administration of the Composite International Diagnostic Interview to assess psychosis Morrison, Frame, & Larkin (2003) Meta‐analysis of research and theoretical literature on association between trauma and psychosis Spauwen et al. (2006) Sample Methodology Results General population sample age 18‐64 years (N= 4045) Composite International Diagnostic Interview and additional interviews used to assess first onset of positive psychotic symptoms at two‐year follow‐up Self‐reported childhood abuse significantly predicted positive psychotic symptoms associated with need for care Catone et al. (2015) Adults from Great Britain (N= 8,000) Assessed potential association of bullying with development of psychosis via analysis of the British Adult Psychiatric Morbidity Survey (2000 and 2007) Bullying significantly associated with diagnosis of probably psychosis; bullying predicted emergence and maintenance of persecutory ideation and hallucinations Childhood physical abuse predicted psychosis; higher number trauma types experienced increased probability of psychotic symptoms Freeman & Fowler (2008) Members of the general public in the United Kingdom (N= 200) Self‐report questionnaires History of traumatic events significantly associated with persecutory ideation and hallucinations; severe sexual abuse in childhood associated with psychotic‐ like experiences Three major issues addressed: causal link between psychosis and PTSD, trauma caused by psychosis, and the conceptualization of PTSD and psychosis on a spectrum of responses to trauma Trauma has been repeatedly found to cause psychosis; both psychosis and PTSD could be part of a spectrum of responses to trauma Evans et al. (2014) Individuals diagnosed with psychosis (N= 29) compared to healthy control group Face‐to‐face questionnaires administered to both groups, including the Childhood Trauma Questionnaire and the Psychosis Screening Questionnaire, among others High rates of childhood maltreatment found in psychosis sample; Childhood physical neglect increased the likelihood of experiencing psychotic symptoms Adolescents age 14‐24 (N= 2524) Self‐reports on psychological trauma and psychosis proneness; follow up interview 42 months later to assess for psychotic symptoms Trauma was significantly associated with psychotic symptoms, particularly following trauma causing intense fear, helplessness, or horror Varese, Barkus, & Bentall (2012) Patients with Schizophrenia spectrum disorders (N= 45) compared to healthy controls without a history of hallucinations (N=20) Questionnaire measuring proneness to hallucinations, dissociative tendencies, and childhood trauma Patients with hallucinations reported significantly higher levels of childhood sexual abuse; link positively mediated by dissociation, particularly in cases of sexual abuse Matheson et al. (2012) Studies investigating link between childhood adversity and schizophrenia, as found in Medline, EMBASE, and PsycINFO databases (N= 25) Meta‐analysis using case‐control, cohort, and cross‐sectional studies. Studies assessed using a systematic checklist and systematic quality evaluation Significantly increased rates of childhood adversity in individuals diagnosed with schizophrenia (p<0.00001) Haahr et al. (2016) Patients in Treatment and Intervention in Psychosis (TIPS) cohort (N= 191) Assessed at five‐year follow‐up interview using Brief Betrayal Trauma Survey Kraan et al. (2014) Studies published on PsychINFO and Embase investigating the prevalence of trauma in patients at an Ultra High Risk (UHR) of developing a psychotic disorder (N= 12) Three random‐effects meta‐analyses assessing prevalence of childhood trauma in patients UHR patients Trauma significantly more prevalent in UHR patients compared to healthy control groups Half of psychotic patients reported experiencing interpersonal trauma; one‐ third reported experiencing close interpersonal trauma before age 18. Significant associations between early interpersonal trauma and duration of untreated psychosis Read, van Os, Morrison, & Ross (2005) Studies investigating link between child abuse and schizophrenia via PsychINFO (N= 28) Literature review of research studies and review papers Psychotic and Schizophrenic symptoms (i.e. hallucinations) strongly related to childhood abuse and neglect; large‐scale l l ti t di t Trauma • Significant increases in psychosis • Childhood trauma increases rate of adult paranoid thoughts 2.5 times 10 6/8/2016 Post 9/11 • NY Times poll: • October 2001: 74% of New Yorkers “very concerned” about another terrorist attack • 2006: 69% were • 60% did trust the government to tell them the truth Drugs of abuse Today • Hackers + electronic surveillance + security cameras + NSA + omnipresent cameras + shredders • Threats to our sense security • Tells us it is an unsafe world Do you find it concerning that the U.S. government is collecting and storing your personal information like phone records, emails, bank statements, and other communications?* • 82% of Americans were “somewhat”, “very” or “extremely” concerned Global Strategy Group poll, May 2015 Insomnia Cannabis Paranoia Elderly Sensory deficits Trauma Immigrants How personally concerned are you that the government accesses any of your personal communications, information, or records you share with a company without a judge’s permission? • 83% of Americans were “somewhat”, “very” or “extremely” concerned 11 6/8/2016 How personally concerned are you that the government uses information collected without a warrant for things other than stopping terrorist attacks • 83% of Americans were “somewhat”, “very” or “extremely” concerned How personally concerned are you that the government performs instant wiretaps on any phone or other telecommunications device located in the U.S. How personally concerned are you that the government allows private companies to use public school technology programs to track the online activities of school children. • 77% of Americans were “somewhat”, “very” or “extremely” concerned “Can People You Encounter Be Trusted?” 60 Percent Responding "Yes" 50 40 • 76% of Americans were “somewhat”, “very” or “extremely” concerned • 20-33% said “extremely” to each of the above questions 30 50 20 30 10 0 1973 2013 Associated Press‐ GfK Poll, October 2013 “Can People You Encounter Be Trusted?” 45 Percent Responding "Yes" “Can People You Encounter Be Trusted?” 40 35 35 30 30 25 25 20 Percent Responding "Yes" 45 40 40 15 20 40 31 15 10 10 5 5 0 0 Baby Boomers GenXers Baby Boomers Associated Press‐ GfK Poll, October 2013 Associated Press‐ GfK Poll, October 2013 12 6/8/2016 “Can People You Encounter Be Trusted?” 45 Percent Responding "Yes" 40 • • • • 35 30 25 20 40 31 15 10 Circumspect Concerned Guarded Suspicious cautious wary mistrustful paranoid 19 5 0 Baby Boomers GenXers Millenials Associated Press‐ GfK Poll, October 2013 13