Anxiety-Belief Misalignment Hypothesis (DABMH): Anxiety Preserved, Cognition Distorted

Background: Some patients present with intense anxiety coupled to irrational or paranoid beliefs without full loss of reality testing. Standard models split "anxiety disorders" (hypervigilance) from "psychosis" (aberrant salience/delusions), obscuring cases where anxious arousal is preserved yet belief formation drifts. Objective: To advance the Anxiety-Belief Misalignment Hypothesis (DABMH), which posits that anxiety remains intact and adaptive while belief updating becomes biased by mis-weighted salience and precision, producing psychotic-like interpretations with fluctuating insight. Approach: Conceptual integration of clinical phenomenology with network and computational neuroscience. We synthesize evidence across HPA-LC noradrenergic drive, CSTC circuitry, large-scale networks (salience, default mode, frontoparietal), predictive-coding accounts of precision-weighting, and reasoning biases (jumpingto-conclusions, BADE). We derive falsifiable behavioral, electrophysiological, and imaging predictions. Model: In DABMH, (i) anxious arousal is sustained by HPA reactivity and LC-NE tone; (ii) CSTC dysbalance and serotonin-modulated prefrontal control increase "stickiness" of intrusive threat representations; (iii) amygdala/BNST and salience nodes over-assign importance, with strengthened coupling to self-referential DMN and weakened top-down control; (iv) elevated priors for threat and increased precision of interoceptive signals bias belief updating. The result is a real emotion attached to an unreal belief: insight is strained, not collapsed. Predictions: DABMH should show (a) preserved/increased ERN with nearnormal MMN/P50; (b) HRV↓, startle/EDA↑ under uncertainty; (c) mild JTC/ BADE, amplified by affective load; (d) fMRI evidence of insula/dACC ↔ amygdala/ BNST hypercoupling with reduced dlPFC/vmPFC control; (e) clinical improvement when worry/IU are targeted, independent of antipsychotic dose. Clinical implications: Management should be affect-first (SSRIs/SNRIs; CBT/MCT/ERP focused on worry, uncertainty, and reasoning biases), reserving antipsychotics for clear psychotic deterioration. Conclusion: DABMH reframes paranoia as a miswired explanatory system: anxiety seeks cause; cognition imposes distorted structure. Recognizing this phenotype may reduce misdiagnosis and guide mechanism-informed care.