Nigel Blackwood

The Cognitive and Affective Structure of Paranoid Delusions: A Transdiagnostic Investigation of Patients With Schizophrenia Spectrum Disorders and Depression

CONTEXT Paranoid delusions are a common symptom of a range of psychotic disorders. A variety of psychological mechanisms have been implicated in their cause, including a tendency to jump to conclusions, an impairment in the ability to understand the mental states of other people (theory of mind), an abnormal anticipation of threat, and an abnormal explanatory style coupled with low self-esteem. OBJECTIVE To determine the structure of the relationships among psychological mechanisms contributing to paranoia in a transdiagnostic sample. DESIGN Cross-sectional design, with relationships between predictor variables and paranoia examined by structural equation models with latent variables. SETTING Publicly funded psychiatric services in London and the North West of England. PARTICIPANTS One hundred seventy-three patients with schizophrenia spectrum disorders, major depression, or late-onset schizophrenia-like psychosis, subdivided according to whether they were currently experiencing paranoid delusions. Sixty-four healthy control participants matched for appropriate demographic variables were included. MAIN OUTCOME MEASURES Assessments of theory of mind, jumping to conclusions bias, and general intellectual functioning, with measures of threat anticipation, emotion, self-esteem, and explanatory style. RESULTS The best fitting (chi(2)(96) = 131.69, P = .01; comparative fit index = 0.95; Tucker-Lewis Index = 0.96; root-mean-square error of approximation = 0.04) and most parsimonious model of the data indicated that paranoid delusions are associated with a combination of pessimistic thinking style (low self-esteem, pessimistic explanatory style, and negative emotion) and impaired cognitive performance (executive functioning, tendency to jump to conclusions, and ability to reason about the mental states of others). Pessimistic thinking correlated highly with paranoia even when controlling for cognitive performance (r = 0.65, P < .001), and cognitive performance correlated with paranoia when controlling for pessimism (r = -0.34, P < .001). CONCLUSIONS Both cognitive and emotion-related processes are involved in paranoid delusions. Treatment for paranoid patients should address both types of processes.

Persecutory delusions and the determination of self-relevance: an fMRI investigation.

BACKGROUND People with persecutory delusions regard ambiguous data in the social domain as self-relevant and selectively attend to threatening information. This study aimed to characterize these social cognitive biases in functional neuroanatomical terms. METHOD Eight schizophrenic patients with active persecutory delusions and eight matched normal controls underwent functional magnetic resonance imaging while determining the self-relevance of ambiguous self-relevant or unambiguous other-relevant neutral and threatening statements. RESULTS In determining self-relevance, the deluded subjects showed a marked absence of rostral-ventral anterior cingulate activation together with increased posterior cingulate gyrus activation in comparison to the normal subjects. The influence of threat on self-relevance determination did not yield statistically significant differences between deluded and normal subjects. CONCLUSIONS Abnormalities of cingulate gyrus activation while determining self-relevance suggest impaired self-reflection in the persecutory deluded state. This may contribute to persecutory belief formation and maintenance.

Paranoid delusions in schizophrenia spectrum disorders and depression: the transdiagnostic role of expectations of negative events and negative self-esteem.

We aimed to identify transdiagnostic psychological processes associated with persecutory delusions. Sixty-eight schizophrenia patients, 47 depressed patients, and 33 controls were assessed for paranoia, positive and negative self-esteem, estimations of the frequency of negative, neutral, and positive events occurring to the self in the past and in the future and similar estimates for events affecting others in the future. Negative self-esteem and expectations of negative events were strongly associated with paranoia in all groups. Currently deluded patients were asked to rate whether their persecution was deserved on an analogue scale. Mean deservedness scores were higher in deluded-depressed patients than deluded-schizophrenia patients, but patients in both groups used the full range of scores. The findings indicate that negative self-esteem and negative expectations independently contribute to paranoia, but do not support a simple categorical distinction between poor-me (persecution undeserved) and bad-me (persecution deserved) patients.

Misunderstanding the Intentions of Others: An Exploratory Study of the Cognitive Etiology of Persecutory Delusions in Very Late-Onset Schizophrenia-Like Psychosis

OBJECTIVE The objective of this study was to explore the cognitive etiology of persecutory delusion formation and maintenance in very late-onset schizophrenia-like psychosis (SLP). METHOD Probabilistic reasoning, causal attributional style, and mentalizing ability were examined in 29 patients with SLP, 30 with onset of depression after the age of 60 years and 30 healthy comparison subjects. RESULTS Patients with SLP made significantly more errors than the healthy comparison group in deception, but not false belief, mentalizing tasks. There were no significant performance differences between groups on the probabilistic reasoning task or the attributional style task. CONCLUSIONS Mentalizing errors may contribute to the development and maintenance of persecutory delusions in SLP. These patients do not appear to show the wider range of cognitive biases described in deluded patients with schizophrenia with onset in younger adult life.

Cool and Hot Executive Function Impairments in Violent Offenders with Antisocial Personality Disorder with and without Psychopathy

Background Impairments in executive function characterize offenders with antisocial personality disorder (ASPD) and offenders with psychopathy. However, the extent to which those impairments are associated with ASPD, psychopathy, or both is unknown. Methods The present study examined 17 violent offenders with ASPD and psychopathy (ASPD+P), 28 violent offenders with ASPD without psychopathy (ASPD−P), and 21 healthy non-offenders on tasks assessing cool (verbal working memory and alteration of motor responses to spatial locations) and hot (reversal learning, decision-making under risk, and stimulus-reinforcement-based decision-making) executive function. Results In comparison to healthy non-offenders, violent offenders with ASPD+P and those with ASPD−P showed similar impairments in verbal working memory and adaptive decision-making. They failed to learn from punishment cues, to change their behaviour in the face of changing contingencies, and made poorer quality decisions despite longer periods of deliberation. Intriguingly, the two groups of offenders did not differ significantly from the non-offenders in terms of their alteration of motor responses to spatial locations and their levels of risk-taking, indicated by betting, and impulsivity, measured as delay aversion. The performance of the two groups of offenders on the measures of cool and hot executive function did not differ, indicating shared deficits. Conclusions These documented impairments may help to explain the persistence of antisocial behaviours despite the known risks of the negative consequences of such behaviours.

A transdiagnostic investigation of 'theory of mind' and 'jumping to conclusions' in patients with persecutory delusions.

BACKGROUND A tendency to make hasty decisions on probabilistic reasoning tasks and a difficulty attributing mental states to others are key cognitive features of persecutory delusions (PDs) in the context of schizophrenia. This study examines whether these same psychological anomalies characterize PDs when they present in the context of psychotic depression. METHOD Performance on measures of probabilistic reasoning and theory of mind (ToM) was examined in five subgroups differing in diagnostic category and current illness status. RESULTS The tendency to draw hasty decisions in probabilistic settings and poor ToM tested using story format feature in PDs irrespective of diagnosis. Furthermore, performance on the ToM story task correlated with the degree of distress caused by and preoccupation with the current PDs in the currently deluded groups. By contrast, performance on the non-verbal ToM task appears to be more sensitive to diagnosis, as patients with schizophrenia spectrum disorders perform worse on this task than those with depression irrespective of the presence of PDs. CONCLUSIONS The psychological anomalies associated with PDs examined here are transdiagnostic but different measures of ToM may be more or less sensitive to indices of severity of the PDs, diagnosis and trait- or state-related cognitive effects.

Reasoning under uncertainty: heuristic judgments in patients with persecutory delusions or depression

OBJECTIVE The substantial literature examining social reasoning in people with delusions has, to date, neglected the commonest form of decision making in daily life. We address this imbalance by reporting here the findings of the first study to explore heuristic reasoning in people with persecutory delusions. METHOD People with active or remitted paranoid delusions, depressed and healthy adults performed two novel heuristic reasoning tasks that varied in emotional valence. RESULTS The findings indicated that people with persecutory delusions displayed biases during heuristic reasoning that were most obvious when reasoning about threatening and positive material. Clear similarities existed between the currently paranoid group and the depressed group in terms of their reasoning about the likelihood of events happening to them, with both groups tending to believe that pleasant things would not happen to them. However, only the currently paranoid group showed an increased tendency to view other people as threatening. CONCLUSION This study has initiated the exploration of heuristic reasoning in paranoia and depression. The findings have therapeutic utility and future work could focus on the differentiation of paranoia and depression at a cognitive level.

Childhood Maltreatment and Aggressive Behaviour in Violent Offenders with Psychopathy

Objective: To document experiences of childhood maltreatment among violent offenders with antisocial personality disorder (ASPD) distinguishing between those with and without the syndrome of psychopathy (+P and –P), and to determine whether maltreatment is associated with proactive and reactive aggression. Method: The sample included 10 violent offenders with ASPD+P, 15 violent offenders with ASPD-P, and 15 nonoffenders. All participants completed interviews with the same forensic psychiatrist focusing on physical, sexual, and emotional abuse prior to age 18 using the Early Trauma Inventory. Aggression was assessed using the Reactive-Proactive Questionnaire. Results: Violent offenders with ASPD+P reported significantly more severe childhood physical abuse, but not more sexual or emotional abuse, than violent offenders with ASPD-P and nonoffenders. Psychopathy Checklist—Revised (PCL-R) scores, but not childhood physical abuse, were associated with proactive aggression. Childhood physical abuse was associated with reactive aggression, as was an interaction term indicating that when both PCL-R scores and childhood physical abuse were high, so was reactive aggression. Conclusions: Among violent offenders, PCL-R scores were positively associated with proactive aggression, while experiences of childhood maltreatment were not. This finding concurs with previous studies of children and adults and suggests that proactive aggression may be a behavioural marker of psychopathic traits. By contrast, childhood physical abuse was associated with reactive aggression, even among violent offenders with high PCL-R scores. This latter finding suggests a strong influence of childhood physical abuse on the development of reactive aggression that persists over the lifespan.

Punishment and psychopathy: a case-control functional MRI investigation of reinforcement learning in violent antisocial personality disordered men

BACKGROUND Men with antisocial personality disorder show lifelong abnormalities in adaptive decision making guided by the weighing up of reward and punishment information. Among men with antisocial personality disorder, modification of the behaviour of those with additional diagnoses of psychopathy seems particularly resistant to punishment. METHODS We did a case-control functional MRI (fMRI) study in 50 men, of whom 12 were violent offenders with antisocial personality disorder and psychopathy, 20 were violent offenders with antisocial personality disorder but not psychopathy, and 18 were healthy non-offenders. We used fMRI to measure brain activation associated with the representation of punishment or reward information during an event-related probabilistic response-reversal task, assessed with standard general linear-model-based analysis. FINDINGS Offenders with antisocial personality disorder and psychopathy displayed discrete regions of increased activation in the posterior cingulate cortex and anterior insula in response to punished errors during the task reversal phase, and decreased activation to all correct rewarded responses in the superior temporal cortex. This finding was in contrast to results for offenders without psychopathy and healthy non-offenders. INTERPRETATION Punishment prediction error signalling in offenders with antisocial personality disorder and psychopathy was highly atypical. This finding challenges the widely held view that such men are simply characterised by diminished neural sensitivity to punishment. Instead, this finding indicates altered organisation of the information-processing system responsible for reinforcement learning and appropriate decision making. This difference between violent offenders with antisocial personality disorder with and without psychopathy has implications for the causes of these disorders and for treatment approaches. FUNDING National Forensic Mental Health Research and Development Programme, UK Ministry of Justice, Psychiatry Research Trust, NIHR Biomedical Research Centre.

Deception and false belief in paranoia: Modelling Theory of Mind stories

Background. This study used Item Response Theory (IRT) to model the psychometric properties of a Theory of Mind (ToM) stories task. The study also aimed to determine whether the ability to understand states of false belief in others and the ability to understand anothers intention to deceive are separable skills, and to establish which is more sensitive to the presence of paranoia. Method. A large and diverse clinical and nonclinical sample differing in levels of depression and paranoid ideation performed a ToM stories task measuring false belief and deception at first and second order. Results. A three-factor IRT model was found to best fit the data, consisting of first- and second-order deception factors and a single false-belief factor. The first-order deception and false-belief factors had good measurement properties at low trait levels, appropriate for samples with reduced ToM ability. First-order deception and false beliefs were both sensitive to paranoid ideation with IQ predicting performance on false belief items. Conclusions. Separable abilities were found to underlie performance on verbal ToM tasks. However, paranoia was associated with impaired performance on both false belief and deception understanding with clear impairment at the simplest level of mental state attribution.