Stephanie Mehl

The jumping to conclusions bias in delusions: specificity and changeability.

There are indications that a jumping to conclusions bias (JTC) plays a role in the formation and maintenance of delusions and should be targeted in therapy. However, it is unclear whether (a) JTC is uniquely associated with delusions or simply an epiphenomenon of schizophrenia or impaired intellectual functioning and (b) it can be changed by varying task demands, motivational factors, or feedback. Seventy-one patients with schizophrenia spectrum disorders and either acute or remitted delusions and 68 healthy controls were included. Patients were assessed with self- and observer-rated symptom measures. All participants were assessed for intellectual ability and performed the classic beads task with a ratio of 80:20. They were then presented with task variations that involved increasing the difficulty of the ratio to 60:40, introducing a rule for which correct decisions were rewarded by monetary gains and false decisions led to financial losses, and providing feedback on the accuracy of the previous decisions. Participants with current delusional symptoms took fewer draws to decision (DTD) than did those in remission and healthy controls. DTD were associated with observer-rated delusions, but controlling for negative symptoms or intelligence rendered this association insignificant. DTD increased after the difficulty of the task increased and after feedback. The study demonstrated that JTC is linked to delusions but that this association is not unique. Patients with delusions are principally able to adapt their decisions to altered conditions but still decide relatively quickly even when decisions have negative consequences. These difficulties might stem in part from impaired intellectual functioning.

Negative Symptoms and Social Cognition: Identifying Targets for Psychological Interventions

BACKGROUND How to improve treatment for negative symptoms is a continuing topic of debate. Suggestions have been made to advance psychological understanding of negative symptoms by focusing on the social cognitive processes involved in symptom formation and maintenance. METHODS Following the recommendations by the National Institute of Mental Health workshop on social cognition in schizophrenia, this study investigated associations between negative symptoms and various aspects of social cognition including Theory of Mind (ToM), attribution, empathy, self-esteem, and interpersonal self-concepts in 75 patients with schizophrenia spectrum disorders and 75 healthy controls. RESULTS Negative symptoms were significantly associated with difficulties in ToM, less readiness to be empathic, lower self-esteem, less self-serving bias, negative self-concepts related to interpersonal abilities, and dysfunctional acceptance beliefs. Different aspects of social cognition were mildly to moderately correlated and interacted in their impact on negative symptoms: Difficulties in ToM were associated with negative symptoms in persons with low but not in persons with medium or high levels of self-esteem. Taken together, the social cognition variables and their hypothesized interaction explained 39% of the variance in negative symptoms after controlling for neurocognition and depression. CONCLUSIONS The results highlight the relevance of self-concepts related to social abilities, dysfunctional beliefs, and global self-worth alone and in interaction with ToM deficits for negative symptoms and thereby provide a helpful basis for advancing psychosocial interventions.

Moving from Efficacy to Effectiveness in Cognitive Behavioral Therapy for Psychosis: A Randomized Clinical Practice Trial.

OBJECTIVE Randomized controlled trials have attested the efficacy of cognitive behavioral therapy (CBT) in reducing psychotic symptoms. Now, studies are needed to investigate its effectiveness in routine clinical practice settings. METHOD Eighty patients with schizophrenia spectrum disorders who were seeking outpatient treatment were randomized to a specialized cognitive behavioral intervention for psychosis (CBTp; n = 40) or a wait list (n = 40). The CBTp group was assessed at baseline, posttreatment, and 1-year follow-up. The wait list group was assessed at baseline, after a 4-month waiting period, at posttreatment, and after 1 year. The primary outcome measure was the Positive and Negative Syndrome Scale (PANSS). RESULTS The CBTp group showed significant improvement over the wait list group for the total PANSS score at posttreatment-postwaiting. CBTp was also superior to the wait list group in regard to the secondary outcomes positive symptoms, general psychopathology, depression, and functioning, but not in regard to negative symptoms. The number of dropouts during the treatment phases was low (11.3%). Participants perceived the treatment as helpful (98%) and considered themselves improved (92%). Significant pre- and posttreatment effect sizes varied between 0.77 for general psychopathology and 0.38 for delusional conviction. The positive effects of treatment could be maintained at 1-year follow-up, although the number of patients who had deteriorated was higher than at postassessment. CONCLUSIONS Large proportions of patients in clinical practice settings benefit from CBTp. The efficacy of CBTp can be generalized to clinical practice despite the differences in patients, therapists, and deliverance.

The precuneus and the insula in self-attributional processes

Attributions are constantly assigned in everyday life. A well-known phenomenon is the self-serving bias: that is, people’s tendency to attribute positive events to internal causes (themselves) and negative events to external causes (other persons/circumstances). Here, we investigated the neural correlates of the cognitive processes implicated in self-serving attributions using social situations that differed in their emotional saliences. We administered an attributional bias task during fMRI scanning in a large sample of healthy subjects (n = 71). Eighty sentences describing positive or negative social situations were presented, and subjects decided via buttonpress whether the situation had been caused by themselves or by the other person involved. Comparing positive with negative sentences revealed activations of the bilateral posterior cingulate cortex (PCC). Self-attribution correlated with activation of the posterior portion of the precuneus. However, self-attributed positive versus negative sentences showed activation of the anterior portion of the precuneus, and self-attributed negative versus positive sentences demonstrated activation of the bilateral insular cortex. All significant activations were reported with a statistical threshold of p ≤ .001, uncorrected. In addition, a comparison of our fMRI task with data from the Internal, Personal and Situational Attributions Questionnaire, Revised German Version, demonstrated convergent validity. Our findings suggest that the precuneus and the PCC are involved in the evaluation of social events with particular regional specificities: The PCC is activated during emotional evaluation, the posterior precuneus during attributional evaluation, and the anterior precuneus during self-serving processes. Furthermore, we assume that insula activation is a correlate of awareness of personal agency in negative situations.

Is fear of others linked to an uncertain sense of self? The relevance of self-worth, interpersonal self-concepts, and dysfunctional beliefs to paranoia.

The assumption that a low sense of self-worth can give rise to paranoid delusions is relevant from a therapeutic perspective, but research has been inconsistent. The present study sought to investigate how interpersonal self-concepts and global self-worth relate to psychotic and depressive psychopathology in persons with psychosis. Participants with psychosis (n=83) and healthy controls (n=33) were assessed for global self-worth, interpersonal self-concepts, and dysfunctional beliefs using the Frankfurt Self-Concept Scale and the Dysfunctional Attitude Scale. Symptoms were assessed with the Positive and Negative Syndrome Scale, the Peters et al. Delusions Inventory, the Paranoia Checklist, and the Beck Depression Inventory. We hypothesized that perceived threat to self-worth, as expressed in dysfunctional acceptance beliefs and negative interpersonal self-concepts, would be uniquely associated with persecutory delusions. In contrast, low global self-worth would be strongly associated with symptoms of depression. Multiple regression analyses were used to investigate the association between symptoms and self-concepts. As expected, low global self-worth was associated with depression, whereas the more specific perception of not being accepted by relevant others was most clearly related to psychotic symptoms. Almost half of the variance in paranoia scores was explained by negative interpersonal self-concepts and the interaction between negative interpersonal self-concepts and dysfunctional acceptance beliefs. Thus, cognitive interventions for delusions might be improved by focusing more on interpersonal self-concepts.

Are theory of mind deficits in understanding intentions of others associated with persecutory delusions

The purpose of this study was to investigate the association of the Theory of Mind ability to infer intentions of others and delusions in patients with schizophrenia-spectrum disorders. In a cross-sectional design, patients with acute persecutory delusions (PD) (n = 33), patients with remitted persecutory delusions (PD-rem) (n = 25), and non-clinical controls (n = 58) completed a movie task, in which they had to infer the characters’ intentions and emotions and a false-belief task. Delusions were rated by observers and by the patients. Patients with PD were specifically impaired in the ability to infer intentions compared with patients with remitted delusions and controls. The ability to infer intentions predicted a significant amount of variance in delusions, even when executive functioning was controlled. Implications for models explaining the development and maintenance of delusions are discussed.

Hasty decision-making in a variety of tasks: Does it contribute to the development of delusions?

OBJECTIVES The finding that persons with delusions tend to jump-to-conclusions ( JTC) in the beads task has often been replicated. This study investigates whether hasty decision-making in the beads task is associated with hasty decisions in tasks with more relevance for everyday decision-making. Furthermore, it is hypothesized that hasty decisions in these tasks will be associated with subclinical delusional beliefs. DESIGN A correlational study. METHODS A sample of students (N=85) completed the beads task and three additional non-probabilistic decision-tasks. Subclinical delusional beliefs were assessed using the Peters et al. delusions inventory (PDI; Peters, Joseph, & Garety, 1999). RESULTS In support of the hypothesis, participants with hasty decisions in the beads task also made hasty decisions in two of the other tasks. Hasty decisions were only associated with higher subclinical delusional beliefs in one of the tasks (a letter recognition task). CONCLUSIONS Decision-making in the beads task can be generalized to decisions in other contexts. Other decision-making tasks may be more closely related to delusions than the beads task.

Does Cognitive Behavior Therapy for psychosis (CBTp) show a sustainable effect on delusions? A meta-analysis

Cognitive Behavior Therapy for psychosis (CBTp) is an effective treatment resulting in small to medium effect sizes with regard to changes in positive symptoms and psychopathology. As a consequence, CBTp is recommended by national guidelines for all patients with schizophrenia. However, although CBTp was originally developed as a means to improve delusions, meta-analyses have generally integrated effects for positive symptoms rather than for delusions. Thus, it is still an open question whether CBTp is more effective with regard to change in delusions compared to treatment as usual (TAU) and to other interventions, and whether this effect remains stable over a follow-up period. Moreover, it would be interesting to explore whether newer studies that focus on specific factors involved in the formation and maintenance of delusions (causal-interventionist approach) are more effective than the first generation of CBTp studies. A systematic search of the trial literature identified 19 RCTs that compared CBTp with TAU and/or other interventions and reported delusions as an outcome measure. Meta-analytic integration resulted in a significant small to medium effect size for CBTp in comparison to TAU at end-of-therapy (k = 13; d¯ = 0.27). However, the comparison between CBTp and TAU after an average follow-up period of 47 weeks was not statistically significant (k = 12, d¯ = 0.16). When compared with other interventions, there was no significant effect of CBTp at end-of-therapy (k = 8; d¯ = 0.16) and after a follow-up period (k = 5; d¯ = −0.04). Comparison between newer studies taking a causal-interventionist approach (k = 4) and first-generation studies showed a difference of 0.33 in mean effect sizes in favor of newer studies at end-of-therapy. The findings suggest that CBTp is superior to TAU post-therapy in bringing about a change in delusions, but that this change may not be maintained over the follow-up period. Moreover, interventions that focus on causal factors of delusions seem to be a promising approach to improving interventions for delusions.

When paranoia fails to enhance self-esteem: Explicit and implicit self-esteem and its discrepancy in patients with persecutory delusions compared to depressed and healthy controls

The hypothesis that persecutory delusions function to enhance self-esteem implies that patients will show normal explicit, but low implicit self-esteem. As evidence for this has been inconsistent, our study assessed delusional state, explicit and implicit self-esteem and depression in a large sample (n=139) of schizophrenia patients with acute persecutory delusions (n=28), patients with remitted persecutory delusions (n=31), healthy controls (n=59), and depressed controls (n=21). Patients with delusions and patients with depression both showed decreased levels of explicit, but normal levels of implicit self-esteem when compared to healthy controls. The direct comparison of levels of explicit and implicit self-esteem within each group revealed that healthy controls had higher explicit than implicit self-esteem, while the converse pattern was found for depressed controls. No discrepancy between explicit and implicit self-esteem was found for acute deluded or remitted patients with schizophrenia. Although these findings do not support the hypothesis that delusions serve to enhance self-esteem, they underline the relevance of low self-esteem in patients with persecutory delusions and point to the necessity of enhancing self-esteem in therapy.

Smart Transparency for Illustrative Visualization of Complex Flow Surfaces

The perception of transparency and the underlying neural mechanisms have been subject to extensive research in the cognitive sciences. However, we have yet to develop visualization techniques that optimally convey the inner structure of complex transparent shapes. In this paper, we apply the findings of perception research to develop a novel illustrative rendering method that enhances surface transparency nonlocally. Rendering of transparent geometry is computationally expensive since many optimizations, such as visibility culling, are not applicable and fragments have to be sorted by depth for correct blending. In order to overcome these difficulties efficiently, we propose the illustration buffer. This novel data structure combines the ideas of the A and G-buffers to store a list of all surface layers for each pixel. A set of local and nonlocal operators is then used to process these depth-lists to generate the final image. Our technique is interactive on current graphics hardware and is only limited by the available graphics memory. Based on this framework, we present an efficient algorithm for a nonlocal transparency enhancement that creates expressive renderings of transparent surfaces. A controlled quantitative double blind user study shows that the presented approach improves the understanding of complex transparent surfaces significantly.