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The past and future of delusions research: from the inexplicable to the treatable
<jats:sec><jats:title>Background</jats:title><jats:p>Problems with the diagnosis and treatment of schizophrenia have led for a call to change strategy and focus on individual psychotic experiences. In recent years, research on delusions has led the way.</jats:p></jats:sec><jats:sec><jats:title>Aims</jats:title><jats:p>To update our 1999 review of almost 40 studies on delusions.</jats:p></jats:sec><jats:sec><jats:title>Method</jats:title><jats:p>A systematic literature search was conducted of reasoning and affective processes related to delusions.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Over 200 studies were identified. The presence of jumping to conclusions' in individuals with delusions has been substantiated, the theory of mind account has not stood up to subsequent testing, and there is a promising new focus on the ways that affective processes contribute to delusional experience.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Theoretical work rendering delusions understandable can be translated into treatment; future clinical trials should focus on individual psychotic experiences as outcomes.</jats:p></jats:sec>
Neuropsychological functioning and jumping to conclusions in delusions.
BACKGROUND: It has been consistently demonstrated that delusions are related to jumping to conclusions (JTC), a data-gathering bias and potential candidate endophenotype of psychosis. Recent research suggests that JTC may be a marker of treatment response. However, we know little about the factors contributing to the occurrence of this reasoning bias. This study investigated the relationship between JTC and hypothesised deficits in working memory, employing standard well-validated neuropsychological tests, in people with current delusions. METHOD: One hundred and twenty six people with schizophrenia spectrum psychosis and current delusions were assessed for current symptoms, and tested for JTC. We compared performance on tests of working memory in those with the reasoning bias and those without. RESULTS: As expected, 30-40% of this sample of people with current delusions showed the JTC bias. There were no differences in premorbid IQ between those with and without the JTC reasoning bias. However, the performance of the JTC group was significantly worse on tests of working memory. CONCLUSIONS: The JTC data-gathering bias is associated with impairments in working memory. New non-pharmacological interventions for people with delusions, designed to improve data gathering, may benefit from incorporating strategies to overcome deficits in working memory.
London–East Anglia randomised controlled trial of cognitive–behavioural therapy for psychosis
<jats:sec><jats:title>Background</jats:title><jats:p>Despite growing evidence of the effectiveness of cognitive–behavioural therapy (CBT) for psychosis, typically only about 50% of patients show a positive response to treatment. This paper reports the first comprehensive investigation of factors which predict treatment outcome.</jats:p></jats:sec><jats:sec><jats:title>Method</jats:title><jats:p>In a randomised controlled trial of CBT for medication-resistant psychosis (see Part I) measures were taken at baseline of demographic, clinical and cognitive variables. Changes over time were assessed on the Brief Psychiatric Rating Scale and the relationship between potential predictor variables and outcome was investigated using analysis of variance and covariance.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>A number of baseline variables were identified as predictors of good outcome in the CBT group. Key predictors were a response indicating cognitive flexibility concerning delusions (<jats:italic>P</jats:italic>=0.005) and the number of recent admissions (<jats:italic>P</jats:italic>=0.002). Outcome was less predictable in the control group and was not predicted by any cognitive variable.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Good outcome is strongly predicted in patients with persistent delusions by a cognitive measure, while this was not the case in controls. Thus we argue that positive outcome in CBT is due in part to specific effects on delusional thinking.</jats:p></jats:sec>
Understanding jumping to conclusions in patients with persecutory delusions: working memory and intolerance of uncertainty
<jats:sec id="S0033291714000592_sec_a1"><jats:title>Background</jats:title><jats:p>Persecutory delusions are a key psychotic experience. A reasoning style known as ‘jumping to conclusions’ (JTC) – limited information gathering before reaching certainty in decision making – has been identified as a contributory factor in the occurrence of delusions. The cognitive processes that underpin JTC need to be determined in order to develop effective interventions for delusions. In the current study two alternative perspectives were tested: that JTC partially results from impairment in information-processing capabilities and that JTC is a motivated strategy to avoid uncertainty.</jats:p></jats:sec><jats:sec id="S0033291714000592_sec_a2" sec-type="methods"><jats:title>Method</jats:title><jats:p>A group of 123 patients with persistent persecutory delusions completed assessments of JTC (the 60:40 beads task), IQ, working memory, intolerance of uncertainty, and psychiatric symptoms. Patients showing JTC were compared with patients not showing JTC.</jats:p></jats:sec><jats:sec id="S0033291714000592_sec_a3" sec-type="results"><jats:title>Results</jats:title><jats:p>A total of 30 (24%) patients with delusions showed JTC. There were no differences between patients who did and did not jump to conclusions in overall psychopathology. Patients who jumped to conclusions had poorer working memory performance, lower IQ, lower intolerance of uncertainty and lower levels of worry. Working memory and worry independently predicted the presence of JTC.</jats:p></jats:sec><jats:sec id="S0033291714000592_sec_a4" sec-type="conclusion"><jats:title>Conclusions</jats:title><jats:p>Hasty decision making in patients with delusions may partly arise from difficulties in keeping information in mind. Interventions for JTC are likely to benefit from addressing working memory performance, while <jats:italic>in vivo</jats:italic> techniques for patients with delusions will benefit from limiting the demands on working memory. The study provides little evidence for a contribution to JTC from top-down motivational beliefs about uncertainty.</jats:p></jats:sec>
Implications for neurobiological research of cognitive models of psychosis: a theoretical paper
<jats:title>ABSTRACT</jats:title><jats:sec id="S003329170700013X_sec_a001"><jats:title>Background</jats:title><jats:p>Cognitive models of the positive symptoms of psychosis specify the cognitive, social and emotional processes hypothesized to contribute to their occurrence and persistence, and propose that vulnerable individuals make characteristic appraisals that result in specific positive symptoms.</jats:p></jats:sec><jats:sec id="S003329170700013X_sec_a002"><jats:title>Method</jats:title><jats:p>We describe cognitive models of positive psychotic symptoms and use this as the basis of discussing recent relevant empirical investigations and reviews that integrate cognitive approaches into neurobiological frameworks.</jats:p></jats:sec><jats:sec id="S003329170700013X_sec_a003" sec-type="results"><jats:title>Results</jats:title><jats:p>Evidence increasingly supports a number of the hypotheses proposed by cognitive models. These are that: psychosis is on a continuum; specific cognitive processes are risk factors for the transition from subclinical experiences to clinical disorder; social adversity and trauma are associated with psychosis and with negative emotional processes; and these emotional processes contribute to the occurrence and persistence of psychotic symptoms. There is also evidence that reasoning biases contribute to the occurrence of delusions.</jats:p></jats:sec><jats:sec id="S003329170700013X_sec_a004" sec-type="conclusion"><jats:title>Conclusions</jats:title><jats:p>The benefits of incorporating cognitive processes into neurobiological research include more sophisticated, bidirectional and interactive causal models, the amplification of phenotypes in neurobiological investigations by including emotional processes, and the adoption of more specific clinical phenotypes. For example, there is potential value in studying gene×environment×cognition/emotion interactions. Cognitive models and their derived phenotypes constitute the missing link in the chain between genetic or acquired biological vulnerability, the social environment and the expression of individual positive symptoms.</jats:p></jats:sec>