References Br J Clin Psychol. 2002 Nov;41(Pt 4):331-47. A cognitive model of persecutory delusions.

Freeman D, Garety PA, Kuipers E, Fowler D, Bebbington PE. Department of Psychology, Institute of Psychiatry, King's College London, UK. D.Freeman@iop.kcl.ac.uk A multifactorial model of the formation and maintenance of persecutory delusions is presented. Persecutory delusions are conceptualized as threat beliefs. The beliefs are hypothesized to arise from a search for meaning for internal or external experiences that are unusual, anomalous, or emotionally significant for the individual. The persecutory explanations formed reflect an interaction between psychotic processes, pre-existing beliefs and personality (particularly emotion), and the environment. It is proposed that the delusions are maintained by processes that lead to the receipt of confirmatory evidence and processes that prevent the processing of disconfirmatory evidence. Novel features of the model include the (non-defended) direct roles given to emotion in delusion formation, the detailed consideration of both the content and form of delusions, and the hypotheses concerning the associated emotional distress. The clinical and research implications of the model are outlined. Schizophr Bull. 2008 Jul 11. [Epub ahead of print] Reasoning Anomalies Associated With Delusions in Schizophrenia. Langdon R, Ward PB, Coltheart M. 2Macquarie Centre for Cognitive Science, Macquarie University, NSW, Australia. Deluded people differ from nondeluded controls on attributional style questionnaires and probabilistic-reasoning and theory-of-mind (ToM) tasks. No study to date has examined the relations between these 3 reasoning anomalies in the same individuals so as to evaluate their functional independence and potentially inform theories of delusion formation. We did so in 35 schizophrenic patients with a history of delusions, 30 of whom were currently deluded, and 34 healthy controls. Compared with healthy controls, patients showed (a) a jumping-to-conclusions bias and a bias to overadjust when confronted with a change of evidence on probabilistic-reasoning tasks, (b) an excessive externalizing attributional bias, and (c) performance deficits on 3 ToM tasks. Probabilistic-reasoning and ToM measures correlated, while attributional-bias scores were independent of other task measures. A general proneness to delusional ideation correlated with probabilistic-reasoning and ToM measures, while externalizing bias was unrelated to the study measures of delusional ideation. Personalizing bias associated specifically with paranoia across the clinical and nonclinical participants. Findings are consistent with a common underlying mechanism in schizophrenia which contributes to the anomalies on probabilistic-reasoning and ToM tasks associated with delusions. We speculate that this mechanism is impairment of the normal capacity to inhibit "perceived reality" (the evidence of our senses), a capacity that evolved as part of the "social brain" to facilitate intersubjective communication within a shared reality. Cogn Neuropsychiatry. 2008 Mar;13(2):148-65. Erratum in: Cognit Neuropsychiatry. 2008 May;13(3):278. Delusions and reasoning: a study involving cognitive behavioural therapy. Brakoulias V, Langdon R, Sloss G, Coltheart M, Meares R, Harris A. Nepean Clinical School, University of Sydney and Nepean Hospital, Penrith, NSW, Australia. vbrakoulias@bigpond.com INTRODUCTION: Anomalies on probabilistic reasoning, theory of mind (ToM) tasks,

and attributional biases have been found in delusional people. Delusions are also effectively modified by cognitive behavioural therapy (CBT). We sought to examine whether CBT reduces delusional conviction by changing such general reasoning anomalies. METHOD: Sixteen patients commenced an 8-11 week CBT programme that targeted their delusions. Probabilistic reasoning, attributional biases, and ToM were assessed pre- and post-treatment. Delusional conviction, preoccupation, and distress were rated at each session. Pretreatment task performances were compared to norms. Repeated measures analyses compared pre- and posttreatment task performances and ratings of delusions. Correlational analyses were used to identify factors associated with reduced delusional conviction. RESULTS: At baseline, 11 patients showed some form of abnormal probabilistic reasoning, 13 excessive attributional biases, and 13 defective ToM compared to norms. Fourteen patients completed the CBT programme and showed significant reductions in delusional conviction and preoccupation. Despite some inconsistent evidence of improvement in verbal ToM tasks, reasoning styles in these 14 patients were largely unchanged by CBT. CONCLUSION: Reasoning anomalies associated with delusions in this sample mark a vulnerability that persists and is independent of the effectiveness of CBT. 1: Br J Clin Psychol. 1999 Jun;38 ( Pt 2):113-54. Comment in: Br J Clin Psychol. 1999 Sep;38 ( Pt 3):315-8. Br J Clin Psychol. 1999 Sep;38 ( Pt 3):319-21. Clin Psychol. 1999 Sep;38 ( Pt 3):323-7. Cognitive approaches to delusions: a critical review of theories and evidence. Garety PA, Freeman D. Department of Clinical Psychology, GKT, University of London, St Thomas' Hospital, UK. PURPOSE: To review critically the evidence for three contemporary theories of delusions. METHODS: The theoretical approaches to delusions proposed by Frith and colleagues ('theory of mind' deficits), Garety and colleagues (multi-factorial, but involving probabilistic reasoning biases) and Bentall and colleagues (attributional style and self-discrepancies) are summarised. The findings of empirical papers directly relevant to these proposals are critically reviewed. These papers were identified by computerised literature searches (for the years 1987-1997) and a hand search. RESULTS: The evidence does not unequivocally support any of the approaches as proposed. However, strong evidence is found to support modifications of Garety and colleagues' and Bentall and colleagues' theories. Studies have replicated a 'jumping to conclusions' data-gathering bias and an externalising attributional bias in people with delusions. There is preliminary evidence for a 'theory of mind' deficit, as proposed by Frith, although possibly related to a more general reasoning bias. Evidence for an underlying discrepancy between ideal and actual self-representations is weaker. CONCLUSIONS: A multi-factorial model of delusion formation and maintenance incorporating a data-gathering bias and attributional style, together with other factors (e.g. perceptual processing, meta-representation) is consistent with the current evidence. It is recommended that these findings be incorporated into cognitive therapy approaches. However, there are limitations to existing research. Future studies should incorporate longitudinal designs and first episode studies, and should not neglect the co-morbidity of delusions, including affective processes, or the multi-dimensional nature of delusions. Harv Rev Psychiatry. 2000 Jul-Aug;8(2):73-83. Logical processing, affect, and delusional thought in schizophrenia. Mujica-Parodi LR, Malaspina D, Sackeim HA. Department of Medical Genetics, New York State Psychiatric Institute, NY 10032, USA.

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Deficits of logical reasoning have long been considered a hallmark of schizophrenia and delusional disorders. We provide a more precise characterization of "logic" and, by extension, of "deficits in logical reasoning." A model is offered to categorize different forms of logical deficits. This model acknowledges not only problems with making inferences, which is how logic deficits are usually conceived, but also problems in the acquisition and evaluation of premises (i.e., filtering of "input"). Early (1940-1969) and modern (1970-present) literature on logical reasoning and schizophrenia is evaluated within the context of the presented model. We argue that, despite a substantial history of interest in the topic, research to date has been inconclusive on the fundamental question of whether patients with delusional ideation show abnormalities in logical reasoning. This may be due to heterogeneous definitions of "logic," variability in the composition of patient samples, and floor effects among the healthy controls. In spite of these difficulties, the available evidence suggests that deficits in logical reasoning are more likely to occur due to faulty assessment of premises than to a defect in the structure of inferences. Such deficits seem to be provoked (in healthy individuals) or exacerbated (in patients with schizophrenia) by emotional content. The hypothesis is offered that delusional ideation is primarily affect-driven, and that a mechanism present in healthy individuals when they are emotionally challenged may be inappropriately activated in patients who are delusional. Behav Res Ther. 2007 Jun;45(6):1255-69. Epub 2006 Oct 18. Jumping to conclusions and the continuum of delusional beliefs. Warman DM, Lysaker PH, Martin JM, Davis L, Haudenschield SL. School of Psychological Sciences, University of Indianapolis, 1400 East Hanna Avenue, Indianapolis, IN 46227, USA. dwarman@unidy.edu The present study examined the jumping to conclusions reasoning bias across the continuum of delusional ideation by investigating individuals with active delusions, delusion prone individuals, and non-delusion prone individuals. Neutral and highly self-referent probabilistic reasoning tasks were employed. Results indicated that individuals with delusions gathered significantly less information than delusion prone and non-delusion prone participants on both the neutral and self-referent tasks, (p<.001). Individuals with delusions made less accurate decisions than the delusion prone and non-delusion prone participants on both tasks (p<.001), yet were more confident about their decisions than were delusion prone and non-delusion prone participants on the self-referent task (p=.002). Those with delusions and those who were delusion prone reported higher confidence in their performance on the self-referent task than they did the neutral task (p=.02), indicating that high self-reference impacted information processing for individuals in both of these groups. The results are discussed in relation to previous research in the area of probabilistic reasoning and delusions. Clin Psychol Rev. 2007 May;27(4):425-57. Epub 2007 Jan 26. Suspicious minds: the psychology of persecutory delusions. Freeman D. Department of Psychology, Institute of Psychiatry, King's College London, Denmark Hill, London, UK. D.Freeman@iop.kcl.ac.uk At least 10-15% of the general population regularly experience paranoid thoughts and persecutory delusions are a frequent symptom of psychosis. Persecutory ideation is a key topic for study. In this article the empirical literature on psychological processes associated with persecutory thinking in clinical and non-clinical populations is comprehensively reviewed. There is a large direct

affective contribution to the experience. In particular, anxiety affects the content, distress and persistence of paranoia. In the majority of cases paranoia does not serve a defensive function, but instead builds on interpersonal concerns conscious to the person. However, affect alone is not sufficient to produce paranoid experiences. There is also evidence that anomalous internal experiences may be important in leading to odd thought content and that a jumping to conclusions reasoning bias is present in individuals with persecutory delusions. Theory of mind functioning has received particular research attention recently but the findings do not support a specific association with paranoia. The threat anticipation cognitive model of persecutory delusions is presented, in which persecutory delusions are hypothesised to arise from an interaction of emotional processes, anomalous experiences and reasoning biases. Ten key future research questions are identified, including the need for researchers to consider factors important to the different dimensions of delusional experience. Clin Psychol Rev. 2001 Nov;21(8):1143-92. Persecutory delusions: a review and theoretical integration. Bentall RP, Corcoran R, Howard R, Blackwood N, Kinderman P. Department of Psychology, University of Manchester, Coupland 1 Building, Oxford Rd., Manchester M13 9PL, UK. Persecutory (paranoid) delusions are a frequently observed clinical phenomenon. In recent years, an increasing volume of research has attempted to explain these types of beliefs in terms of psychological mechanisms. Theories have emphasized early experience, perceptual abnormalities, motivational factors, and information-processing deficits. In this article we review relevant findings, including our own studies of the role of causal attributions and theory of mind deficits. We propose a new integrative model that builds on this work. The core of the model is an account of the way that causal attributions influence self-representations, which in turn influence future attributions: the attribution--self-representation cycle. We argue that biases in this cycle cause negative events to be attributed to external agents and hence contribute to the building of a paranoid world view. These abnormalities are amenable to investigation by functional neuroimaging, and recent studies have implicated specific areas of neuroactivation. However, these findings do not necessarily suggest that paranoid delusions are entirely biological in origin, and there is evidence that adverse early experience may play a role in determining the development of a cognitive vulnerability to paranoid thinking. Psychol Med. 2006 Aug;36(8):1109-18. Epub 2006 May 31. Reasoning under uncertainty: heuristic judgments in patients with persecutory delusions or depression. Corcoran R, Cummins S, Rowse G, Moore R, Blackwood N, Howard R, Kinderman P, Bentall RP. Division of Psychology, School of Psychological Sciences, University of Manchester, Manchester, UK. rhiannon.corcoran@manchester.ac.uk 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. Cogn Neuropsychiatry. 2007 Nov;12(6):495-510. Persecutory delusions and the conditioned avoidance paradigm: towards an integration of the psychology and biology of paranoia. Moutoussis M, Williams J, Dayan P, Bentall RP. Tolworth Hospital, Red Lion Road, Surbiton, UK. michael.moutoussis@swlstg-tr.nhs.uk INTRODUCTION: Theories of delusions often underplay the role of their content. With respect to persecutory delusions, taking threat as fundamental suggests that models of threat-related, aversive learning, such as the Conditioned Avoidance Response (CAR) task, might offer valid insights into the underlying normal and abnormal processes. In this study, we reappraise the psychological significance of the CAR model of antipsychotic drug action; and we relate this to contemporary psychological theories of paranoia. METHODS: Review and synthesis of literature. RESULTS: Anticipation and recall of aversive events are abnormally accentuated in paranoia. Safety (avoidance) behaviours may help perpetuate and fix persecutory ideas by preventing their disconfirmation. In addition, patients may explain negative events in a paranoid way instead of making negative self-attributions (i.e., in an attempt to maintain self-esteem). This defensive function only predominates in the overtly psychotic patients. The "safety behaviours" of paranoid patients, their avoidance of negative self-attributions, and the antiparanoid effect of antipsychotic medication all resonate with aspects of the CAR. CONCLUSIONS: The CAR appears to activate some normal psychological and biological processes that are pathologically activated in paranoid psychosis. Paranoid psychological defences may be a result of basic aversive learning mechanisms, which are accentuated during acute psychosis. Behav Res Ther. 1994 Mar;32(3):331-41. The self, attributional processes and abnormal beliefs: towards a model of persecutory delusions. Bentall RP, Kinderman P, Kaney S. Department of Clinical Psychology, University of Liverpool, England. In this paper we review a series of recent investigations into cognitive abnormalities associated with persecutory delusions. Studies indicate that persecutory delusions are associated with abnormal attention to threat-related stimuli, an explanatory bias towards attributing negative outcomes to external causes and biases in information processing relating to the self-concept. We propose an integrative model to account for these findings in which it is hypothesized that, in deluded patients, activation of self/ideal discrepancies by threat-related information triggers defensive explanatory biases, which have the function of reducing the self/ideal discrepancies but result in persecutory ideation. We conclude by discussing the implications of this model for the cognitive-behavioural treatment of paranoid delusions. Br J Clin Psychol. 1998 Nov;37 ( Pt 4):415-30. The London-East Anglia randomized controlled trial of cognitive-behaviour therapy for psychosis. IV: Self-esteem and persecutory delusions. Freeman D, Garety P, Fowler D, Kuipers E, Dunn G, Bebbington P, Hadley C.

Department of Psychology, Institute of Psychiatry, Denmark Hill, London, UK. OBJECTIVES: There has been a resurgence of interest in the view that persecutory delusions serve a function of defending self-esteem. An alternative account of levels of self-esteem in individuals with persecutory delusions is that they result from processes similar to those studied in people with depression (i.e. from the occurrence of a range of life experiences and how the individual interprets and copes with them). This study aimed to examine both hypotheses together for the first time, and, as the literature indicates that delusions may not share a common cause, attention was given to the possibility of the presence of subgroups. DESIGN: Data were examined cross-sectionally and longitudinally from a randomized controlled trial of cognitive behaviour therapy for 60 people with drug-resistant psychosis. METHOD: The study is based on the initial assessment of all participants on self-esteem, delusional conviction and a large number of demographic, clinical and cognitive measures. Longitudinal analyses were also carried out, and are reported separately for those who received the therapy intervention and those in the control group. RESULTS: Almost three-quarters of participants with persecutory delusions reported low self-esteem. Changes over time in total self-esteem correlated with changes in measures of mood and social functioning, but not conviction in persecutory delusions. The individuals who initially had normal levels of self-esteem displayed a different pattern of results from the majority of participants. CONCLUSION: Low self-esteem in people with drug-resistant persecutory delusions is common and, in most cases, can best be understood in terms of normal emotional processes. There was evidence that the majority of persecutory delusions do not fit either strong or weak formulations of the delusion-as-defence explanation and that there may be subgroups with differing aetiologies. These results need to be replicated, and extended to groups in which symptoms are not resistant to medication. Br J Clin Psychol. 2006 Jun;45(Pt 2):231-46. Attributional style, defensive functioning and persecutory delusions: symptom-specific or general coping strategy? Humphreys L, Barrowclough C. Psychology Services, Bolton, Salford and Trafford Mental Health NHS Trust, Manchester, UK. lloyd.humphreys@bstmht.nhs.uk OBJECTIVE: Previous research has suggested that individuals with persecutory delusions use an exaggerated self-serving bias to protect themselves from real or delusional threats to their underlying self-concept. However, the research to date has been inconsistent thereby limiting the conclusion that can be inferred. A possible explanation for these discrepant findings may be due to the use of measures with questionable validity and reliability such as the Attributional Style Questionnaire and the Rosenberg Self-Esteem Inventory. The present study aims to re-examine this theory using an improved methodology to determine whether defensive functioning is a defining feature of persecutory delusions. DESIGN AND METHODS: Thirty-five participants suffering from recent onset psychosis were assessed in a cross-sectional design. Three tests of attributional style were used, two overt measures (Attributional Style Questionnaire, ASQ; and the Internal Personal and Situational Attributions Questionnaire, IPSAQ) and one covert measure (Pragmatic Inference Test). Self-esteem was measured using the Rosenberg Self-Esteem Inventory (SEI) and a semi-structured interview (Self-Evaluation and Social Support interview - schizophrenia version). RESULTS: A self-serving bias (SSB) was found in the total sample using the ASQ but not specifically in participants with persecutory delusions. In addition, the SSB was unrelated to levels of paranoia on any measure of attributional style. An underlying depressive attributional style was found in both subjects with and without persecutory delusions, but was not associated with levels of paranoia. Lower positive and higher negative self-esteem was associated with increased

paranoia and was associated with a SSB. CONCLUSION: The results indicate that the attributional biases observed in individuals with persecutory delusions are not symptom-specific as previously suggested. The presence of an attributional, SSB was associated with lower psychotic experiences. The theoretical implications of the results will be discussed. Br J Psychiatry Suppl. 2007 Dec;51:s38-42. Delusion formation and reasoning biases in those at clinical high risk for psychosis. Broome MR, Johns LC, Valli I, Woolley JB, Tabraham P, Brett C, Valmaggia L, Peters E, Garety PA, McGuire PK. Section of Neuroimaging, Division of Psychological Medicine, Institute of Psychiatry, London, UK. m.broome@iop.kcl.ac.uk BACKGROUND: Cognitive models propose that faulty appraisal of anomalous experiences is critical in developing psychosis, particularly delusions. A data gathering bias may be fundamental to abnormal appraisal. AIMS: To examine whether there is a data gathering bias in people at high risk of developing psychosis. METHOD: Individuals with an at-risk mental state (n=35) were compared with a matched group of healthy volunteers (n=23). Participants were tested using a modified version of the 'beads' reasoning task with different levels of task difficulty. RESULTS: When task demands were high, the at-risk group made judgements on the basis of less information than the control group (P<0.05). Within both groups, jumping to conclusions was directly correlated with the severity of abnormal beliefs and intolerance of uncertainty (P<0.05). In the at-risk group it was also associated with impaired working memory (P<0.05), whereas in the control group poor working memory was associated with a more conservative response style (P<0.05). CONCLUSIONS: People with an at-risk mental state display a jumping to conclusions reasoning style, associated with impaired working memory and intolerance of uncertainty. This may underlie a tendency to develop abnormal beliefs and a vulnerability to psychosis.