Delusion Formation Research Articles

The relationship between cognitive insight and quality of life in schizophrenia spectrum disorders: Symptom severity as potential moderator

Cognitive insight is implicated in the formation and maintenance of hallucinations and delusions. However, it is not yet known whether cognitive insight relates to broader outcome measures like quality of life. In the current study, we investigated whether the component elements of cognitive insight—self-certainty and self-reflectiveness—were related to quality of life for 43 outpatients with schizophrenia or schizoaffective disorder. Cognitive insight was assessed using the Beck Cognitive Insight Scale (BCIS) while quality of life was assessed with Quality of Life Scale (QLS). We tested whether this relationship was moderated by clinical insight and symptom severity using the Scale to Assess Unawareness of Mental Disorder (SUMD) and the Positive and Negative Syndrome Scale (PANSS). We found that self- reflectiveness had an unmoderated positive relationship with quality of life. Self-certainty was associated with better quality of life for people with more severe symptoms. Theoretical and clinical implications of these findings are discussed and areas of future research are proposed.

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; = 0.27). However, the comparison between CBTp and TAU after an average follow-up period of 47 weeks was not statistically significant (k = 12, = 0.16). When compared with other interventions, there was no significant effect of CBTp at end-of-therapy (k = 8; = 0.16) and after a follow-up period (k = 5; = −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.

Cognitive impairments may mimic delusions

Delusions are often recognized as key to the concept of psychosis. What is delusion is one of the basic questions of psychopathology. The common denominator of definitions of delusions is the divergence between the strong conviction in the delusional belief and superior evidences to the contrary which are continually ignored. An implicit, sustainably unspoken assumption is that the person with delusional belief has cognitive capacities to process the (counter-)arguments relevant to their delusion. However, individual’s cognitive capacities are not being emphasized when delusions are evaluated. Moreover, the impact of cognitive decline on formation of delusions is neglected, both in theory and practice. We elaborate that cognitive deficits may facilitate, oppose, or mimic delusions. We focus on the last, which can lead to diagnosing as delusion what could be explained by cognitive decline and better called pseudo-delusion. The risk is significant when cognition is impaired, as in demented people; an issue which has not yet been debated. True delusions are incompatible with person’s cognitive capacities, i.e., if we take into account person’s cognitive status, we still cannot understand how the person holds the strange belief with an extraordinary conviction. Pseudo-delusions would be beliefs, thoughts or judgments that at first seem delusional (they are false, subculturally atypical beliefs that are strongly maintained in the face of counterargument), but lose the essence of delusions after we take cognitive impairment into account. Pseudo-delusions could actually be explained or understood by person’s cognitive impairments, they “fit into” them. The reported reality-based contents of delusions in the elderly, poor response to antipsychotics and lack of association with early or family history of psychiatric disorders could in part be accounted for by the bias of misdiagnosing the cognitive impairment as the delusion. Not recognizing that the cognitive impairment underlies formation of pseudo-delusions and misdiagnosing it as delusions may lead to focusing on antipsychotic treatment, instead on treatment of the underlying cognitive deficit.

Recent Work on the Nature and Development of Delusions.

In this paper we review two debates in the current literature on clinical delusions. One debate is about what delusions are. If delusions are beliefs, why are they described as failing to play the causal roles that characterise beliefs, such as being responsive to evidence and guiding action? The other debate is about how delusions develop. What processes lead people to form delusions and maintain them in the face of challenges and counter‐evidence? Do the formation and maintenance of delusions require abnormal experience alone, or also reasoning biases or deficits? We hope to show that the focus on delusions has made a substantial contribution to the philosophy of the mind and continues to raise issues that are central to defining the concept of belief and gaining a better understanding of how people process information and learn about the world.

Hallucinations and related concepts-their conceptual background.

Prior to the seventeenth century, the experiences we now name hallucinations were valued within a cultural context, they could bring meaning to the subject or the world. From mid-seventeenth to eighteenth centuries, they acquire a medical quality in mental and organic illnesses. However, the term was only fully integrated in psychiatry by Esquirol in the eighteenth–nineteenth centuries. By then, a controversy begins on whether hallucinations have a perceptual or intellectual origin. Esquirol favors the intellectual origin, describing them as an involuntary exercise of memory and imagination. By the twentieth century, some authors maintain that hallucinations are a form of delusion (Ey), while others describe them as a change in perception (Jaspers, Fish). More integrated perspectives like those proposed by Alonso Fernandez and Luque, highlights the heterogeneity of hallucinations and the multiplicity of their types and causes. The terms pseudohallucination, illusion, and hallucinosis are grafted into the concept of hallucination. Since its introduction the term pseudohallucination has been used with different meanings. The major characteristics that we found associated with pseudohallucinations were “lack of objectivity” and “presence of insight” (differing from hallucinations). Illusions are unanimously taken as distortions of real objects. Hallucinosis, first described in the context of alcohol consumption, is generally considered egodystonic, in which insight is preserved. These and other controversial aspects regarding the evolution of the term hallucination and all its derivative concepts are discussed in this paper.

Jumping to conclusions in schizophrenia.

Schizophrenia is a mental disorder associated with a variety of symptoms, including hallucinations, delusions, social withdrawal, and cognitive dysfunction. Impairments on decision-making tasks are routinely reported: evidence points to a particular deficit in learning from and revising behavior following feedback. In addition, patients tend to make hasty decisions when probabilistic judgments are required. This is known as “jumping to conclusions” (JTC) and has typically been demonstrated by presenting participants with colored beads drawn from one of two “urns” until they claim to be sure which urn the beads are being drawn from (the proportions of colors vary in each urn). Patients tend to make early decisions on this task, and there is evidence to suggest that a hasty decision-making style might be linked to delusion formation and thus be of clinical relevance. Various accounts have been proposed regarding what underlies this behavior. In this review, we briefly introduce the disorder and the decision-making deficits associated with it. We then explore the evidence for each account of JTC in the context of a wider decision-making deficit and then go on to summarize work exploring JTC in healthy controls using pharmacological manipulations and functional imaging. Finally, we assess whether JTC might have a role in therapy.

Visual Attention to Threat-Related Faces and Delusion-Proneness: An Eye Tracking Study Using Dynamic Stimuli

Visual attention to threat-related facial expressions possibly contributes to delusion formation and maintenance and may serve as a vulnerability marker. The aim of the present study was to examine visual attention to threat-related facial expressions using dynamic stimuli in people with differing levels of delusion-proneness. We expected that threat-relevant facial expressions would attract more foveal attention compared to neutral faces. Additionally, we hypothesized that more delusion-prone individuals would show foveal avoidance and that this avoidance would occur particularly in the visual processing of threat-related faces. In a quasi-experimental design we categorized our sample by the paranoia checklist (PCL) into a high-PCL (n = 25) and low-PCL (n = 30) group. The participants’ task was to view emotional facial expressions in validated film sequences while eye movements were measured. A mixed ANOVA for the number of fixations and equivalent non-parametric tests for fixation time were conducted. Both groups spent significantly more time viewing relevant features in threat-related faces compared to neutral faces. A significant main effect for group indicated fewer fixations in the high-PCL group compared to the low-PCL group for all faces. A significant Group × Affect interaction indicated that the number of fixations differed between the high-PCL group and the low-PCL group depending on whether the faces displayed neutral or threat-related expressions. The findings suggest that higher delusion-proneness is already associated with a deviant style of visually attending to facial expressions even in people who do not have a clinical diagnosis of schizophrenia. This style may thus be a vulnerability marker for psychosis.

Phenomenological and neurocognitive perspectives on delusions: A critical overview.

There is considerable overlap between phenomenological and neurocognitive perspectives on delusions. In this paper, we first review major phenomenological accounts of delusions, beginning with Jaspers' ideas regarding incomprehensibility, delusional mood, and disturbed "cogito" (basic, minimal, or core self-experience) in what he termed "delusion proper" in schizophrenia. Then we discuss later studies of decontextualization and delusional mood by Matussek, changes in self and world in delusion formation according to Conrad's notions of "apophany" and "anastrophe", and the implications of ontological transformations in the felt sense of reality in some delusions. Next we consider consistencies between: a) phenomenological models stressing minimal-self (ipseity) disturbance and hyperreflexivity in schizophrenia, and b) recent neurocognitive models of delusions emphasizing salience dysregulation and prediction error. We voice reservations about homogenizing tendencies in neurocognitive explanations of delusions (the "paranoia paradigm"), given experiential variations in states of delusion. In particular we consider shortcomings of assuming that delusions necessarily or always involve "mistaken beliefs" concerning objective facts about the world. Finally, we offer some suggestions regarding possible neurocognitive factors. Current models that stress hypersalience (banal stimuli experienced as strange) might benefit from considering the potential role of hyposalience in delusion formation. Hyposalience - associated with experiencing the strange as if it were banal, and perhaps with activation of the default mode network - may underlie a kind of delusional derealization and an "anything goes" attitude. Such an attitude would be conducive to delusion formation, yet differs significantly from the hypersalience emphasized in current neurocognitive theories.

The intersubjectivity of delusions.

The intersubjectivity of delusions.

Current Treatments for Delusional Disorder

Delusional disorders form part of the spectrum of psychotic disorders in psychiatry. They are poorly understood in practically every aspect of their nature, including cause, phenomenology, prevalence, comorbidity, course, treatment, and prognosis. The key symptom in delusional disorders is one or more delusions. A cardinal characteristic of delusional disorder, conviction that one is not mentally ill, contributes complexity to the treatment challenges and profoundly affects the therapeutic relationship. Diagnosis and differential diagnosis are critical tasks. Delusional conditions may arise from many sources and, only when the case conforms to the criteria and is clearly idiopathic—is a primary delusional disorder—can we feel confident that the patient suffers from delusional disorder rather than a secondary delusional condition. Adequate treatment follows principles for the treatment of delusions. First line pharmacological treatment for delusional disorder is antipsychotic medication, both first and second-generation agents, and some evidence suggests that clozapine may be effective in certain cases. The assumption in such a formulation is that the delusion(s) encountered in delusional disorders respond as a class of symptoms found in different disorders. Hence, the approach for failed interventions with these agents may be similar to that proposed for the treatment of schizophrenia or other psychotic disorders. Namely, searching for evidence of failure to take medication, inadequate dosing, a missed diagnosis of a substance disorder, medical condition, or even another psychiatric disorder should be considered. For individuals with delusional disorders who are also experiencing comorbid depression or anxiety, the addition of appropriate agents for those symptoms may provide a synergistic strategy for overall effectiveness. Psychotherapy is another important clinical tool. Cognitive behavioral therapy focusing on different aspects of delusions (i.e., anxiety, reasoning biases, faulty logic, etc.) has demonstrated some value for at least short-term improvement. Various techniques may be useful in allying with the patient and supplying means to assist in managing their thinking and approach to circumstances and factors that promote delusion formation and encourage actions taken to respond. A significant problem in applying what we know about delusional disorders to treatment is the limited available evidence. Lack of randomized controlled trials, which form the standard in most clinical disorders, is a major shortcoming. Recent observations of compromised cognitive functioning in working memory, attention, and executive function should be replicated with similar standards. Systematic case studies and large series are useful, and a growing effort to be more rigorous methodologically in all contributions including case registries and longer follow-up studies is promising. Nevertheless, our knowledge remains less than optimal. These comments apply not only to pharmacological observations but also to those of neuropsychological and psychotherapeutic studies.

Perceptual instability in schizophrenia: Probing predictive coding accounts of delusions with ambiguous stimuli

BackgroundDelusions, a core symptom of schizophrenia, are thought to arise from an alteration in predictive coding mechanisms that underlie perceptual inference. Here, we aimed to empirically test the hypothesized link between delusions and perceptual inference. Method28 patients with schizophrenia and 32 healthy controls matched for age and gender took part in a behavioral experiment that assessed the influence of stabilizing predictions on perception of an ambiguous visual stimulus. ResultsParticipants with schizophrenia exhibited a weaker tendency towards percept stabilization during intermittent viewing of the ambiguous stimulus compared to healthy controls. The tendency towards percept stabilization in participants with schizophrenia correlated negatively with delusional ideation as measured with a validated questionnaire. ConclusionOur results indicate an association between a weakened effect of sensory predictions in perceptual inference and delusions in schizophrenia. We suggest that attenuated predictive signaling during perceptual inference in schizophrenia may yield the experience of aberrant salience, thereby providing the starting point for the formation of delusions.

Phenomenology Of Delirium: A Cross-Sectional Study Among Referred Cases Of Delirium

Introduction: Studies from developing countries are few, on phenomenology of Delirium, even though it is a common diagnosis among psychiatric referrals. We studied the phenomenology of delirium in a teaching hospital in western region of Nepal by using standard assessment methods. Aim: The aim of the study was to assess the phenomenological characteristics of delirium based on Delirium Rating Scale-Revised-98 (DRS–R98). Methods: All consecutive patients of delirium who were referred to department of psychiatry for assessment were enrolled over a period of 12 months. Socio-demographic variables and other medical information were collected by using standardized data-collection forms developed by the department of Psychiatry. Assessments were based on all available information obtained from the patients, caregivers, medical staff, and medical records. Results and conclusions: A total of 62 cases were studied out of which 83.9% were male. Mean age of the subjects was 47 years. Mean delirium severity was 21.35 (SD=3.54). Orientation, attention and short term memory was impaired in all of the cases. Long term memory impairment was noted in 98.4% of cases. Sleep wake cycle disturbance was present in 60 (96.8%) cases, perceptual abnormalities in 49 (79%) cases, some form of delusion was present in 19 (30.6%), lability of affect could be appreciated in 27(43.5%). Language, thought process abnormalities and impaired visuo-spatial ability was present in 19 (30.6%), 3 (4.8%) and 13 (21%) cases respectively.J Psychiatric Association of Nepal Vol .3, No.2, 2014, pp: 43-47DOI: http://dx.doi.org/10.3126/jpan.v3i2.12394

The Embodied Nature of Autistic Learning: Implications for Physical Education

Abstract Autism spectrum disorder (ASD) and learning difficulties are difficult to separate in clinic manifestations and diagnoses. By taking learning as being-in-the-world, this article considers the embodied nature of autistic learning and urges its importance for understanding the phenomenological core of ASD. We begin by arguing that three mainstream contemporary ASD theories are inherently limited in offering an adequate account of autistic learning due to the disembodied ontology inscribed within them. Then, we provide an understanding of learning guided by the subjective dynamics of experience. Instead of having a disembodied and individualistic point of view, we suggest that autistic learning has an embodied nature. The “inappropriate” or “abnormal” affections and behaviors in the autistic experience of learning may actually be inherently meaningful for individuals with ASD. They strive to make sense of some basic disturbances and re-establish some form of coherence with the world, though this may only be possible in the form of delusions or autistic withdrawals. Finally, we explore the relationship between autistic learning and physical education and suggest in particular how spontaneous imitation can boost the development of children with ASD. We conclude that the application of implicit learning strategies in playful settings and the reduction of explicit strategies based upon intellectual reasoning rather than bodily reciprocity should be encouraged in the process of autistic learning.

Screen Memories and Screening Functions: Recollection, Personal Histories, and Post-Traumatic Dreams

The earliest psychoanalytic theoretical formulations viewed external, usually sexual, trauma as the basic pathogenic instigator of repression and of formation of obsessions, compulsions, conversions, delusions, and phobias. Recollection with affect of that trauma was presumed to result in cure. Only in 1899 did Freud realize that that memory itself was not bedrock but itself material for further analysis. Clinical examples illustrate the notion of screen memory per se: of idealized personal myth serving to screen out upsetting features of the patient’s history, and, in the analytic understanding of post-traumatic nightmares, the adult trauma represented in the dream serving to screen predisposing childhood trauma. This pivotal turn in 1899, pointing to memory itself as something to be analyzed and abandoning the notion of bedrock memory, points to the necessity of expanding the notion of trauma beyond a single childhood sexual episode or adult trauma to a sustained cumulative trauma with the potential for exerting a continuous impact.

Memories reactivated under ketamine are subsequently stronger: A potential pre-clinical behavioral model of psychosis

BackgroundSub-anesthetic doses of the NMDA antagonist ketamine have been shown to model the formation and stability of delusion in human subjects. The latter has been predicted to be due to aberrant prediction error resulting in enhanced destabilization of beliefs. To extend the scope of this model, we investigated the effect of administration of low dose systemic ketamine on memory in a rodent model of memory reconsolidation. MethodsSystemic ketamine was administered either prior to or immediately following auditory fear memory reactivation in rats. Memory strength was assessed by measuring freezing behavior 24h later. Follow up experiments were designed to investigate an effect of pre-reactivation ketamine on short-term memory (STM), closely related memories, and basolateral amygdala (BLA) specific destabilization mechanisms. ResultsRats given pre-reactivation, but not post-reactivation, ketamine showed larger freezing responses 24h later compared to vehicle. This enhancement was not observed 3h after the memory reactivation, nor was it seen in a closely related contextual memory. Prior inhibition of a known destabilization mechanism in the BLA blocked the effect of pre-reactivation ketamine. ConclusionsPre- but not post-reactivation ketamine enhances fear memory. These data together with recent data in human subjects supports a model of delusion fixity that proposes that aberrant prediction errors result in enhanced destabilization and strengthening of delusional belief.

Jumping to Conclusions About the Beads Task? A Meta-analysis of Delusional Ideation and Data-Gathering.

It has been claimed that delusional and delusion-prone individuals have a tendency to gather less data before forming beliefs. Most of the evidence for this "jumping to conclusions" (JTC) bias comes from studies using the "beads task" data-gathering paradigm. However, the evidence for the JTC bias is mixed. We conducted a random-effects meta-analysis of individual participant data from 38 clinical and nonclinical samples (n = 2,237) to investigate the relationship between data gathering in the beads task (using the "draws to decision" measure) and delusional ideation (as indexed by the "Peters et al Delusions Inventory"; PDI). We found that delusional ideation is negatively associated with data gathering (r(s) = -0.10, 95% CI [-0.17, -0.03]) and that there is heterogeneity in the estimated effect sizes (Q-stat P = .03, I(2) = 33). Subgroup analysis revealed that the negative association is present when considering the 23 samples (n = 1,754) from the large general population subgroup alone (r(s) = -0.10, 95% CI [-0.18, -0.02]) but not when considering the 8 samples (n = 262) from the small current delusions subgroup alone (r(s) = -0.12, 95% CI [-0.31, 0.07]). These results provide some provisional support for continuum theories of psychosis and cognitive models that implicate the JTC bias in the formation and maintenance of delusions.

Delusions and prediction error: clarifying the roles of behavioural and brain responses

Griffiths and colleagues provided a clear and thoughtful review of the prediction error model of delusion formation [Cognitive Neuropsychiatry, 2014 April 4 (Epub ahead of print)]. As well as reviewing the central ideas and concluding that the existing evidence base is broadly supportive of the model, they provide a detailed critique of some of the experiments that we have performed to study it. Though they conclude that the shortcomings that they identify in these experiments do not fundamentally challenge the prediction error model, we nevertheless respond to these criticisms. We begin by providing a more detailed outline of the model itself as there are certain important aspects of it that were not covered in their review. We then respond to their specific criticisms of the empirical evidence. We defend the neuroimaging contrasts that we used to explore this model of psychosis arguing that, while any single contrast entails some ambiguity, our assumptions have been justified by our extensive background work before and since.

Hope: A Form of Delusion? Buddhist and Christian Perspectives ed. by Elizabeth Harris (review)

Hope: A Form of Delusion? Buddhist and Christian Perspectives ed. by Elizabeth Harris (review)

Prefrontal activity measured by functional near infrared spectroscopy during probabilistic inference in subjects with persecutory delusions

Jumping to conclusions (JTC) is a probabilistic reasoning bias and is thought to contribute to delusion formation. Neurobiological correlates of the JTC bias are not known. We aimed to examine the rostral prefrontal cortex (rPFC) activity with functional near ınfrared spectroscopy during a modified version of the Beads in a Jar Task (BIJT) in subjects with persecutory delusions (N=25). In BIJT participants are presented beads either drawn from one of the two jars with opposite probability ratios (PRs) of colored beads and are required to decide from which jar beads are being drawn. We administered the BIJT with 90/10 and 55/45 PRs. Compared to healthy controls (N=20), patients reached a decision earlier in both conditions. While the medial rPFC regions were more active in the 90/10 condition in controls compared to patients, lateral rPFC activation was higher in the 55/45 condition in patients than controls. Only in the control group, there was a marked decline in the lateral rPFC activation in the 55/45 condition compared to the 90/10 condition. The activity in the lateral rPFC was negatively correlated with the amount of beads drawn in healthy controls but not in subjects with persecutory delusions. Our results suggest that during the BIJT, rPFC does not function as a single unit and rather consists of functional subunits that are organized differently in patients and controls. The failure to deactivate the lateral rPFC may be associated with earlier decisions in subjects with persecutory delusions.

The Painful Analgesia of Cotard’s Syndrome

In the present paper, we look into what is painful psychical analgesia in relation to what 19th century clinicians have named “moral pain” in melancholia, and more particularly in the delusion of negation described by the French psychiatrist Jules Cotard in 1880, a form of delusion that can be seen mostly in cases of chronic anxious melancholia. This condition is characterized by a painful absence of emotions, which occurs when the subject, in the Lacanian sense of the word, ceases to be touched by the signifiers, and consequently ceases to exist as a subject. Hence, these patients often declare themselves to be already dead or incapable of dying. The psychoanalytical approach to this delusion allows an understanding of the ‘’lack of lack’’ concept, as these patients, having lost the lack, affirm that their body’s orifices are clogged, that they have lost their mental vision, that they miss various visceral organs etc. The completeness of their body – the absence of orifices – can sometimes attain universal dimensions and these patients can thus identify themselves to the universe, which contains everything. The delusion of negation teaches us something important concerning the essence of desire, in relation to what has been named by Lacan area-between-two-deaths. This Lacanian concept refers essentially to the tragic hero, but also, more generally, to the lonely condition where anyone’s desire should be able to exist beyond any narcissistic commitment, which means beyond the pleasure principle as well.