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A cognitive model of the positive symptoms of psychosis
Open accessAbstract
In the last 10 years a consensus has developed that the symptoms of psychosis may be better understood by linking the steps between the phenomenological experiences and social, psychological and neurobiological levels of explanation. Cognitive models of psychosis are an important link in this chain. They provide a psychological description of the phenomena from which hypotheses concerning causal processes can be derived and tested; social, individual, and neurobiological factors can then be integrated via their impact on these cognitive processes. In this paper, we set out the cognitive processes that we think lead to the formation and maintenance of the positive symptoms of psychosis and we attempt to integrate into our model research in social factors. If this model proves useful, a fuller integration with the findings of biological research will be required (Frith, 1992).
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“Stress-vulnerability and integrated cognitive models 21,22 posit a role for social, environmental and psychological factors in the aetiology of psychosis, in addition to genetic and neurodevelopmental features such as a family history of psychosis and low intelligence quotient (IQ).”
From Clinical, socio‐demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care” (2016) · cites this paper as [21]
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“These results support biopsychosocial models 21,22,37 that emphasize the importance of environmental and psychological factors in the aetiology of psychosis and need for care.”
From Clinical, socio‐demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care” (2016) · cites this paper as [21]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“it is likely that persistent PEs only become problematic in the context of pre-existent vulnerabilities, as suggested by contemporary aetiological models of psychosis 21,22,37”
From Clinical, socio‐demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care” (2016) · cites this paper as [21]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“According to the cognitive model of positive symptoms of psychosis (Garety et al. 2001) and the Bio‐Psychosocial Model of Transition to Psychosis (Georgiades et al. 2023), avoidance and social withdrawal, as well as psychosocial stress and interpersonal sensitivity, contribute to the onset and maintenance of psychosis symptoms.”
From Social Functioning Interventions in Psychosis: A Systematic Review. (2025) · cites this paper as Garety et al. 2001
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“Likewise, cognitive models of psychosis [23] emphasise the role of emotional processes, particularly anxiety, in the onset and maintenance cycle of psychotic symptoms [5, 24].”
From A brief CBT intervention for depersonalisation/derealisation in psychosis: Study protocol for a feasibility randomised controlled trial (2016) · cites this paper as [23]
In the citing paper
“the jumping to conclusions (JTC) bias is invoked as an explanatory mechanism in models of delusions.4”
From Computational psychiatry: a Rosetta Stone linking the brain to mental illness (2014) · cites this paper as [4]
In the citing paper
“When people with schizophrenia (who have or are prone to delusions) make decisions in an uncertain setting, they tend to draw on less information in reaching that decision than does a person without schizophrenia.”
From Computational psychiatry: a Rosetta Stone linking the brain to mental illness (2014) · cites this paper as [4]
In the citing paper
“They might also ignore pieces of evidence that contradict that decision.”
From Computational psychiatry: a Rosetta Stone linking the brain to mental illness (2014) · cites this paper as [4]
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The Psychopathology of Delusion of Control According to Subjective Experience
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“72 SPSS 24 was used for all descriptive and regression analyses and a P value of .05 was considered significant.”
Ahuir, M., Crosas, J. M., Estrada, F., Zabala, W., Pérez-Muñoz, S., González-Fernández, A., Tost, M., Aguayo, R., Montalvo, I., Miñano, M. J., et al. (2020) · Revista de Psiquiatría y Salud Mental · doi:10.1016/j.rpsm.2020.07.005 · Cited by 9
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“Individuals who experience meaningful and emotionally charged hallucinations will then seek explanations for these experiences, leading to the development of delusions (Garety et al., 2001; Mayer 1974, Mayer 2006).”
BackgroundMontagnese, M., Vignando, M., Collerton, D., Ffytche, D. H., Mosimann, U. P., Taylor, J., Morgan, K. D., & Urwyler, P. (2021) · Cognitive Neuropsychiatry · doi:10.1080/13546805.2021.1960812 · Cited by 9
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BackgroundAberrant adapting of beliefs under stress: a mechanism relevant to the formation of paranoia?
Krkovic, K., Nowak, U., Kammerer, M. K., Bott, A., & Lincoln, T. M. (2021) · Psychological Medicine · doi:10.1017/s0033291721003524 · Cited by 9
Navalón, P., Perea, M., Benavent, P., Sierra, P., Domínguez, A., Iranzo, C., Serrano-Lozano, E., Almansa, B., & García‐Blanco, A. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.09.044 · Cited by 11
“As for auditory hallucinations, the threat-related bias may have an etiological role in their onset (Garety et al., 2001), since altered emotional states together with hypervigilance for threatening stimuli interact to increase the likelihood of hallucinations, especially in those with intimidating content (Dodgson an…”
BackgroundWard, T., Hardy, A., Holm, R. L., Collett, N., Rus‐Calafell, M., Sacadura, C., McGourty, A., Vella, C., East, A., Rea, M., et al. (2022) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12377 · Cited by 7
Self-citationGoldstone, E., Farhall, J., & Ong, B. (2011) · Early Intervention in Psychiatry · doi:10.1111/j.1751-7893.2011.00264.x · Cited by 9
“In the quest to predict transition to clinical symptom development, vulnerability studies have tended to focus on individual symptoms, rather than diagnoses, as psychotic symptoms seem to have specific correlates, suggesting differential risk factors for these symptoms.(11,12) Delusions, a core feature of clinical psy…”
BackgroundEvaluating Cognitive Behavior Therapy for Psychosis
Kuipers, E. (2005) · Clinical Psychology Science and Practice · doi:10.1093/clipsy.bpi007 · Cited by 9
Self-citationWong, A. W. S., & Chen, E. Y. H. (2014) · Asian Journal of Psychiatry · doi:10.1016/j.ajp.2014.09.005 · Cited by 9
Schizophrenia and psychotic disorders
Bucci, S., & Tarrier, N. (2010) · Cambridge University Press eBooks · doi:10.1017/cbo9780511781919.012 · Cited by 9
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Psychotherapie der Schizophrenie
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Psychotic features in the general population. Risk factors for what?
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Theories of cognition, emotion and the social world: missing links in psychosis
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Self-citationInside out : on stereotype awareness, childhood trauma and stigma in psychosis
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“…psychological models have largely focused on anxiety and mood-related difficulties in mediating the impact of trauma on psychosis, suggesting that emotional distress as a result of adverse experiences may contribute to the onset of psychosis symptoms (Fisher et al., 2013; Garety et al., 2001).”
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“In terms of explaining the shared variance, a viable candidate for future research may be cognitive attribution styles, as cognitive biases have been associated with both emotional and behaviour problems and PEs (Garety et al., 2001; Zavos, Rijsdijk, Gregory, & Eley 2010).”
BackgroundSelf-citationEncoding style and its relationships with schizotypal traits and impulsivity during adolescence
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“The rationale relies on recent cognitive models of positive psychotic symptoms (Morrison et al., 1995; Garety et al., 2001) and empirical results highlighting that internally generated information in the form of internal schemata can readily interfere with the reality testing.”
Hillmann, T. E., Ascone, L., Kempkensteffen, J., & Lincoln, T. M. (2016) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2016.08.013 · Cited by 9
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Lopes, B., Bortolon, C., Macioce, V., & Raffard, S. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.00203 · Cited by 8
“Therefore, the mediation results of the French sample of teachers partially support the cognitive model for persecutory delusions proposed by Garety, Kuipers, Fowler, Freeman, and Bebbington (2) that proposed as observed in the French sample of teachers, that paranoia influences the presence of negative affect because…”
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“…an array of heterogeneous experiences that involve multiple sensory modalities (Oyebode, 2015, Pienkos et al. 2019) and a wide range of cognitive, emotional and unconscious processes (Garety et al. 2001; Longden et al. 2012;Martindale& Summers, 2013; Taylor & Harper, 2016; Pugh et al. 2018).”
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“The moderation analysis with confidence as response variable, subjective competence as predictor and group as moderator revealed a significant model [F(3,1,182) = 67.”
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“Cognitive theories of psychosis posit that reactions to abnormal experiences are mediated by maladaptive self-beliefs (Garety et al., 2001).”
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“These align with interpersonal threat beliefs and particular processing patterns characteristic of persecutory delusions (e.g. “jumping to conclusions”), the most severe form of paranoia (Freeman et al., 2002; P.A. Garety et al., 2001).”
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“Moreover, the presence of the experiences of seeing visions in our population was especially more frequent in those participants feeling anxious and depressed, which supports previous models of the association between affective and psychotic symptoms (Garety et al., 2001).”
ResultSchizophrenia and related disorders
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InfluentialAkers, N., Berry, K., & Taylor, C. D. J. (2025) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.70049 · Cited by 13
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“In turn, low self-esteem has been implicated in the development and maintenance of psychotic symptoms [4] as well as depressive symptoms [5, 6].”
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“Our findings also have to be interpreted in the light of the theoretical assumption that negative emotion merely represents one of many factors that are assumed to precede paranoid ideation in cognitive models (Garety et al. 2001).”
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“Those Black people who do construct negative schemata about themselves as a consequence of being in relation with people who make derogatory race-related remarks about some aspect of their own, or other people’s, physical person may develop cognitive vulnerabilities (Garety et al., 2001).”
BackgroundGarrett, M., Singh, A., Amanbekova, D., & Kamarajan, C. (2010) · Psychosis · doi:10.1080/17522439.2010.529618 · Cited by 7
“It is not a lack of awareness, but rather a mistaken metacognitive judgment about an experience of which the patient is aware that constitutes lack of insight for positive symptoms of psychosis (Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001 ).”
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Lewis, S. H., Sanderson, C., Gupta, A., & Klein, C. (2018) · Journal of Spirituality in Mental Health · doi:10.1080/19349637.2018.1520183 · Cited by 7
Paíno, M., Ordóñez-Camblor, N., Fonseca‐Pedrero, E., García-Álvarez, L., & Pizarro-Ruiz, J. P. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.528213 · Cited by 7
Gallagher, S. (2015) · Contributions to phenomenology · doi:10.1007/978-3-319-14090-2_8 · Cited by 7
“Still other accounts are hybrid, combining elements of top-down and bottomup explanations (e.g., Garety et al. 2001; Kapur 2003).”
BackgroundCognitive Behavioural Therapies for Psychosis
Johns, L., Isham, L., & Manser, R. (2019) · Elsevier eBooks · doi:10.1016/b978-0-12-815012-2.00015-8 · Cited by 10
Psychiatric Admissions for Psychosis in Malmö During the NATO Bombing of Kosovo
Zolkowska, K., Cantor-Graae, E., & Mcneil, T. (2003) · Journal of Nervous and Mental Disease · doi:10.1097/01.nmd.0000100926.46390.4c · Cited by 7
“Garety et al. (2001) suggest that distorted beliefs about the self or the outside world may become more permanently anchored in persons exposed to traumatic experiences or adverse environments.”
BackgroundAdvances in Cognitive Behavior Therapy for Psychosis
Turkington, D., Wright, N. P., & Tai, S. (2013) · International Journal of Cognitive Therapy · doi:10.1521/ijct.2013.6.2.150 · Cited by 7
Resilience, recovery style, and stress in early psychosis
Georgiades, A., Farquharson, L., & Ellett, L. (2014) · Psychosis · doi:10.1080/17522439.2014.936028 · Cited by 7
“…remaining variance in delusional severity may be partly accounted for by cognitive (reasoning biases, interpersonal beliefs about self/others) and affective (anxiety/depression) processes known to be important in the development and maintenance of positive psychotic symptoms (Garety et al., 2001).”
BackgroundThe Psychology of Schizophrenia
Dewan, M. J. (2016) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000000548 · Cited by 7
“…can be corrected by integrating insights from other models, for example, by paying attention to the interplay among social stressors, cognitive (Chadwick, 2006; Garety et al., 2001), metacognitive, and mentalizing deficits (Dimaggio et al., 2015; Lysaker et al., 2015; Salvatore et al., 2012)…”
BackgroundUne défense logique du modèle de Maher pour les délires polythématiques
Franceschi, P. (2009) · Philosophiques · doi:10.7202/000437ar · Cited by 7
“Il convient de mentionner également un quatrième type de modèle cognitif, qui souligne qu’un certain nombre de biais cognitifs (Garety et al., 2001) sont présents dans le mode de pensée des patients souffrant de schizophrénie.”
BackgroundDe-Rationalising DelusionsPreprint
Bell, V., Raihani, N., & Wilkinson, S. (2019) · doi:10.31234/osf.io/4p9zs · Cited by 7
Moussa‐Tooks, A. B., Sheffield, J. M., Freeman, D. H., & Brinen, A. P. (2023) · Clinical Case Studies · doi:10.1177/15346501231190920 · Cited by 6
“…external environment for threats such as being in a perceived wrong place, reactions (or perceived reactions) of others, presence of authority fi gures, and other system-based threats and microaggressions (cf. (Alang et al., 2022; Anglin & Lui, 2021; Freeman et al., 2001; Garety et al., 2001)).”
BackgroundSelf-citationRami, F. Z., Seo, H., Kang, C., Park, S., Li, L., Le, T.-H., Kim, S., Won, S., Chung, W., & Chung, Y. (2025) · Psychological Medicine · doi:10.1017/s0033291725000753 · Cited by 6
Characterizing the spiral: potential mechanisms in AI-associated delusions
Augustin, M., Pollak, T. A., & Morrin, H. (2026) · NPP—Digital Psychiatry and Neuroscience · doi:10.1038/s44277-026-00065-0 · Cited by 13
In the eye of the beholder? Oxytocin effects on eye movements in schizophrenia
Porffy, L., Bell, V., Coutrot, A., Wigton, R. L., D’Oliveira, T. C., Mareschal, I., & Shergill, S. S. (2019) · Schizophrenia Research · doi:10.1016/j.schres.2019.11.044 · Cited by 6
“…to the cognitive model of schizophrenia that proposes that hallucinations and delusions occur when anomalous experiences are misattributed in a way that has extreme and threatening personal meaning, which leads to increased levels of distress (Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001).”
Rodríguez‐Cano, R., Lotre, K., von Soest, T., Rognli, E. B., & Bramness, J. G. (2024) · BJPsych Open · doi:10.1192/bjo.2024.22 · Cited by 6
“28 In addition, diminished social self-efficacy may negatively affect individuals ’ self-assessment of their social skills, potentially enhancing feelings of loneliness.”
BackgroundGayer-Anderson, C. E., Knowles, G., Beards, S., Turner, A. M., Stanyon, D., Davis, S., Blakey, R., Lowis, K., Dorn, L., Ofori, A., et al. (2024) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-024-02701-6 · Cited by 10
“Our findings are consistent with prominent theories that an accumulation of early adverse experiences create an enduring cognitive vulnerability, characterised by negative schematic models of the self/others [42].”
Lucjan, P., Bird, T., Murray, C., & Lorimer, A. (2024) · Aging & Mental Health · doi:10.1080/13607863.2024.2372072 · Cited by 6
“Secondly, it drew from the cognitive models of loneliness (Cacioppo & Hawkley, 2009) and psychosis (e.g. Garety et al., 2001), and growing empirical evidence of the role of social cognition in both loneliness (Spithoven et al., 2017) and psychosis (Allott & Lin, 2020; Livet et al., 2020).”
Pelizza, L., Leuci, E., Quattrone, E., Azzali, S., Pupo, S., Paulillo, G., Pellegrini, P., & Menchetti, M. (2024) · Schizophrenia Research · doi:10.1016/j.schres.2024.09.015 · Cited by 6
“Individual psychotherapy was developed on the cognitive-behavioral modules for psychotic disorders proposed by Garety et al. (2001).”
BackgroundBallesio, A., Musetti, A., Zagaria, A., Manari, T., Filosa, M., & Franceschini, C. (2021) · Sleep Epidemiology · doi:10.1016/j.sleepe.2021.100019 · Cited by 6
Livet, A., Pétrin-Pomerleau, P., Pocuca, N., Afzali, M. H., Potvin, S., & Conrod, P. (2022) · Early Intervention in Psychiatry · doi:10.1111/eip.13297 · Cited by 6
“cognitive biases) in the onset and maintenance of positive PLE (Garety et al., 2001; Moritz et al., 2017).”
BackgroundLoizou, S., Fowler, D. G., & Hayward, M. (2022) · Clinical Psychology Review · doi:10.1016/j.cpr.2022.102191 · Cited by 6
“This has been corroborated by a plethora of research, showing that voice hearers who perceive themselves in a negative light (e.g., inferior), also tend to view voices as powerful, giving rise to distress (Birchwood et al., 2000; Birchwood et al., 2004; Gilbert et al., 2001; Paulik, 2012).”
BackgroundSelf-citationCowan, H. R., Damme, K. S. F., & Mittal, V. A. (2022) · Schizophrenia · doi:10.1038/s41537-022-00279-z · Cited by 7
Humiliation and state anxiety as predictors of attenuated psychosis in a community sample
Toh, W. L., Lee, S. J., Rancie, T., Penita, P., Moseley, P., & Rossell, S. L. (2023) · Current Psychology · doi:10.1007/s12144-023-04490-8 · Cited by 6
“…suggested such adverse events occurring within a maladaptive family context, involving early negative parental relations, familial bullying, or neglectful parenting, may manifest as persecutory ideation in later life (Bentall et al., 2014; Bentall et al., 2012b; Garety et al., 2001; Lopes, 2013).”
Sánchez‐Gistau, V., Cabezas, Á., Manzanares, N., Solé, M., Corral, L., Vilella, E., & Gutiérrez‐Zotes, A. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1127535 · Cited by 6
“A substantial body of research has demonstrated that cognitive biases contribute to the processes of reasoning and metacognition (Garety et al., 2001; Freeman, 2007; Morrison et al., 2007; Bob et al., 2016).”
BackgroundAnomalous experiences and schizotypy: which comes first? The Hermit Crab syndrome hypothesis
Mathijsen, F. P. (2015) · Mental Health Religion & Culture · doi:10.1080/13674676.2015.1004627 · Cited by 6
“This is particularly the case for individuals who are socially isolated, who have a dichotomous style of thinking (Garety et al., 2001) and experience feelings of hopelessness and uncontrollability (Birchwood & Iqbal, 1998).”
BackgroundEffects of Appraisals of Anomalous Experience on Distress in People at Risk of Psychosis
Taylor, H. E., Parker, S., Mansell, W., & Morrison, A. P. (2012) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465812000227 · Cited by 6
Social cognition and paranoia in forensic inpatients with schizophrenia: A cross-sectional study
Bratton, H., O’Rourke, S. J., Tansey, L., & Hutton, P. (2016) · Schizophrenia Research · doi:10.1016/j.schres.2016.12.004 · Cited by 6
“A recent review concluded that although ToM difficulties are consistently found in people with schizophrenia, the association with negative and disorganisation symptoms is stronger than that with persecutory delusions (Garety and Freeman, 2013).”
Delusional Beliefs in the Clinical Context
Upthegrove, R., & Stoljarova, A. A. (2018) · Springer eBooks · doi:10.1007/978-3-319-97202-2_1 · Cited by 6
Steenhuis, L. A., Pijnenborg, G. H. M., van Os, J., Aleman, A., Nauta, M. H., & Bartels‐Velthuis, A. A. (2019) · PLoS ONE · doi:10.1371/journal.pone.0213165 · Cited by 9
“We hypothesize that an individual with increasing social functioning difficulties may have less positive social experiences and may develop less social skills, potentially rendering an individual more vulnerable to the development of paranoia [32] and delusional ideation [33].”
BackgroundBaumeister, D., Peters, E., Pruessner, J., Howes, O., & Chadwick, P. (2022) · Schizophrenia Research · doi:10.1016/j.schres.2019.07.019 · Cited by 6
Beliefs about voices in voice-hearers: the role of schema functioning
Davenport, B., Jackson, M. C., Grange, J. A., & Rydon‐Grange, M. (2020) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465820000399 · Cited by 7
Morimoto, C., Nakamura, Y., Kuwabara, H., Abe, O., Kasai, K., Yamasue, H., & Koike, S. (2021) · Biological Psychiatry Global Open Science · doi:10.1016/j.bpsgos.2021.05.010 · Cited by 6
The profile of unusual beliefs associated with metacognitive thinking and attributional styles
Coleman, E. P., Croft, R. J., & Barkus, E. (2022) · PsyCh Journal · doi:10.1002/pchj.528 · Cited by 8
“, 2007; Kiran & Chaudhury, 2009), it follows that misinterpretation of social interactions and events will affect daily functioning (Garety et al., 2001; Morrison, 2001).”
BackgroundTschöke, S., Uhlmann, C., & Steinert, T. (2011) · Neuropsychiatry · doi:10.2217/npy.11.27 · Cited by 6
Function and meaning in religious delusions: a theoretical discussion from a case study
Saavedra, J. (2012) · Mental Health Religion & Culture · doi:10.1080/13674676.2012.745493 · Cited by 7
Conceptual Challenges in the Neuroimaging of Psychiatric Disorders
Kanaan, R., & McGuire, P. K. (2011) · Philosophy, psychiatry & psychology · doi:10.1353/ppp.2011.0051 · Cited by 7
“At the very least, translating psychosis into the language of cognitive neuropsychology is likely to be highly complex, though not impossible (see, for example, Garety et al. 2001), and the prospect of decomposing and localizing such an account by brain–regional deficits seems remote.”
Background
Metadata
- Authors
- GARETY, P. A., KUIPERS, E., FOWLER, D., FREEMAN, D., & BEBBINGTON, P. E.
- Affiliations
- University of East Anglia (GB)
- Venue
- Psychological Medicine
- Publisher
- Cambridge University Press (CUP)
- Published
- 2001-02
- Volume
- 31
- Issue
- 2
- Pages
- 189-195
- ISSN
- 0033-2917 (ISSN-L)
- 1469-8978
- OpenAlex
- W2162176680
- Cited by
- 1,546
- References
- 46
- Citations by year
- 2026: 62 · 2025: 68 · 2024: 48 · 2023: 66 · 2022: 62 · 2021: 77 · 2020: 72 · 2019: 77 · 2018: 76 · 2017: 87 · 2016: 67 · 2015: 74 · 2014: 86 · 2013: 90 · 2012: 65
- FWCI
- 16.11
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Psychological Medicine (publishedVersion)
- PubMed (publishedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Research Portal (King's College London) (submittedVersion)
- UEA Digital Repository (University of East Anglia) (submittedVersion)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Life Sciences › Neuroscience › Cognitive Neuroscience › Hallucinations in medical conditions
- Keywords
- psychosis, positive symptoms, cognitive models, cognitive processes, symptom maintenance, social factors, neurobiological factors, levels of explanation, phenomenology
- MeSH terms
- Cognition Disorders, Humans, Psychological Theory, Psychotic Disorders, Self Concept, Social Environment
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