BackgroundPersecutory fears build on feelings of vulnerability that arise from negative views of the self. Body image concerns have the potential to be a powerful driver of feelings of vulnerability. Body image concerns are likely raised in patients with psychosis given the frequent weight gain. We examined for the first-time body esteem – the self-evaluation of appearance – in relation to symptom and psychological correlates in patients with current persecutory delusions.MethodsOne-hundred and fifteen patients with persecutory delusions in the context of non-affective psychosis completed assessments of body image, self-esteem, body mass index (BMI), psychiatric symptoms and well-being. Body esteem was also assessed in 200 individuals from the general population.ResultsLevels of body esteem were much lower in patients with psychosis than non-clinical controls (d= 1.2,p< 0.001). In patients, body esteem was lower in women than men, and in the overweight or obese BMI categories than the normal weight range. Body image concerns were associated with higher levels of depression (r=−0.55,p< 0.001), negative self-beliefs (r =−0.52,p< 0.001), paranoia (r =−0.25,p= 0.006) and hallucinations (r =−0.21,p= 0.025). Body image concerns were associated with lower levels of psychological wellbeing (r =0.41,p< 0.001), positive self-beliefs (r =0.40,p< 0.001), quality of life (r =0.23,p= 0.015) and overall health (r =0.31,p= 0.001).ConclusionsPatients with current persecutory delusions have low body esteem. Body image concerns are associated with poorer physical and mental health, including more severe psychotic experiences. Improving body image for patients with psychosis is a plausible target of intervention, with the potential to result in a wide range of benefits.