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Cognitive approaches to delusions: a critical review of theories and evidence.
Abstract
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.
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“delusional patients “jump to conclusions” in the first version, while they are more willing to revise their decision in light of contradictory evidence in the second (Garety and Freeman, 1999).”
From The Computational Anatomy of Psychosis (2013) · cites this paper as Garety and Freeman, 1999
In the citing paper
“The concept of MCT by Moritz and Woodward was originally inspired by research on cognitive biases in psychosis (65) and aims to convey metacognitive knowledge and raise metacognitive awareness for dysfunctional thought patterns (60, 122).”
From Developing a mechanism-based therapy for acute psychiatric inpatients with psychotic symptoms: an Intervention Mapping approach (2023) · cites this paper as [65]
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van Os, J. (2003) · Epidemiology and Psychiatric Sciences · doi:10.1017/s1121189x00003067 · Cited by 155
Complementary group Metacognitive Training (MCT) reduces delusional ideation in schizophrenia.
Moritz, S., Veckenstedt, R., Bohn, F., Hottenrott, B., Scheu, F., Randjbar, S., Aghotor, J., Köther, U., Woodward, T. S., Treszl, A., et al. (2013) · Schizophrenia Research · doi:10.1016/j.schres.2013.10.007 · Cited by 146
“All rights reserved. http://dx.doi.org/10.1016/j.schres.2013.10.007 Contents lists available at ScienceDirect Schizophrenia Research j ourna l homepage: www.e lsev ie r .com/ locate /schres Garety and Freeman, 1999; Bell et al., 2006; van der Gaag, 2006; Freeman, 2007).”
BackgroundInfluentialReasoning Anomalies Associated With Delusions in Schizophrenia
Langdon, R. A., Ward, P. B., & Coltheart, M. (2008) · Schizophrenia Bulletin · doi:10.1093/schbul/sbn069 · Cited by 147
Freeman, D. H., Gittins, M., Pugh, K., Antley, A., Slater, M., & Dunn, G. (2008) · Psychological Medicine · doi:10.1017/s0033291708003589 · Cited by 157
“…content are more likely to become of a delusional intensity when there are accompanying biases in reasoning such as reduced data gathering (‘ jumping to conclusions ’) (Garety & Freeman, 1999; Van Dael et al. 2006) and a failure to consider alternative explanations (Freeman et al. 2004).”
BackgroundThe Psychology of Persecutory Ideation II
Freeman, D. H., Garety, P. A., Bebbington, P., Slater, M., Kuipers, E., Fowler, D. G., Green, C., Jordan, J., Ray, K., & Dunn, G. (2005) · The Journal of Nervous and Mental Disease · doi:10.1097/01.nmd.0000161686.53245.70 · Cited by 147
“Individuals with delusions typically require only one item before making a decision in this task, indicating the presence of a data gathering bias (Garety and Freeman, 1999).”
BackgroundBoredom and Psychotic Disorders: Cognitive and Motivational Issues
Todman, M. (2003) · Psychiatry · doi:10.1521/psyc.66.2.146.20623 · Cited by 156
“Indeed, even under circumstances where training in leisure-seek- (e.g., Garety and Freeman 1999).”
BackgroundReligion, Culture and Mental Health
Loewenthal, K. M. (2006) · Cambridge University Press eBooks · doi:10.1017/cbo9780511490125 · Cited by 145
A Randomized Experimental Investigation of Reasoning Training for People With Delusions
Ross, K., Freeman, D. H., Dunn, G., & Garety, P. A. (2009) · Schizophrenia Bulletin · doi:10.1093/schbul/sbn165 · Cited by 150
“The evidence also shows that this is a data gathering bias rather than a deficit in probabilistic reasoning.(19) The reasoning bias is specifically associated with level of delusional conviction.”
BackgroundEllett, L., Freeman, D. H., & Garety, P. A. (2007) · Schizophrenia Research · doi:10.1016/j.schres.2007.10.027 · Cited by 143
So, S. H., Freeman, D. H., Dunn, G., Kapur, S., Kuipers, E., Bebbington, P., Fowler, D. G., & Garety, P. A. (2011) · Journal of Abnormal Psychology · doi:10.1037/a0025297 · Cited by 143
Attachment states of mind, mentalization, and their correlates in a first‐episode psychosis sample
MacBeth, A. M., Gumley, A. I., Schwannauer, M., & Fisher, R. (2011) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1348/147608310x530246 · Cited by 140
Roberts, D. L., Combs, D. R., Willoughby, M. T., Mintz, J., Gibson, C. M., Rupp, B., & Penn, D. L. (2014) · British Journal of Clinical Psychology · doi:10.1111/bjc.12044 · Cited by 140
“One challenge is that hostile attributional bias exists only within a subset of individuals with schizophrenia (Bentall et al., 2009; Garety & Freeman, 1999), and therefore treatment effects may not be detectable within a full schizophrenia sample.1 Therefore, future efforts to improve this domain…”
BackgroundControl theory and psychopathology: an integrative approach.
Mansell, W. (2005) · Psychology and Psychotherapy: Theory, Research and Practice · doi:10.1348/147608304x21400 · Cited by 133
Reeve, S., Emsley, R., Sheaves, B., & Freeman, D. (2017) · Schizophrenia Bulletin · doi:10.1093/schbul/sbx103 · Cited by 131
Negative Symptoms and Social Cognition: Identifying Targets for Psychological Interventions
Lincoln, T. M., Mehl, S., Kesting, M.-L., & Rief, W. (2011) · Schizophrenia Bulletin · doi:10.1093/schbul/sbr066 · Cited by 127
The role of subclinical paranoia on social perception and behavior
Combs, D. R. (2003) · Schizophrenia Research · doi:10.1016/s0920-9964(03)00051-3 · Cited by 129
“However, such attributional biases are not always shown (e.g., Combs et al., 2003; Martin and Penn, 2002; discussed in Garety and Freeman, 1999) and are more likely to be manifest when a group with depression is included in the design.”
BackgroundMethodInfluentialMoritz, S., & Woodward, T. S. (2014) · Cited by 125
Penn, D. L., Mueser, K. T., Tarrier, N., Gloege, A., Cather, C., Serrano, D., & Otto, M. W. (2004) · Schizophrenia Bulletin · doi:10.1093/oxfordjournals.schbul.a007055 · Cited by 122
“…of emotion perception (Penn et al. 1997; Hellewell and Whittaker 1998; Mandal et al. 1998; Edwards et al. 2002), theory of mind tasks (i.e., the ability to make inferences about others' intentions and states of minds; Corcoran 2001), and attributional style (Garety and Freeman 1999; Bentall 2001).”
BackgroundInfluentialDunn, G., Emsley, R., Liu, H., Landau, S., Green, J., White, I. R., & Pickles, A. R. (2015) · Health Technology Assessment · doi:10.3310/hta19930 · Cited by 124
Social Cognition and Neurocognition: Effects of Risperidone, Olanzapine, and Haloperidol
Sergi, M. J., Green, M. F., Widmark, C., Reist, C., Erhart, S. M., BRAFF, D. L., Kee, K. S., Marder, S. R., & Mintz, J. (2007) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2007.06091515 · Cited by 121
Varieties of confabulation and delusion
Kopelman, M. D. (2009) · Cognitive Neuropsychiatry · doi:10.1080/13546800902732830 · Cited by 120
“However, Gilboa et al. (2006) found that other difficult discriminations (unrelated to temporal context) can also produce a high rate of false positive identifications by confabulators; and in preliminary observations, Bajo, Fleminger, and Kopelman (2008) showed that most (83%), but not all, confabulators produce the…”
Belief inflexibility in schizophrenia
Woodward, T. S., Moritz, S., Menon, M., & Klinge, R. (2008) · Cognitive Neuropsychiatry · doi:10.1080/13546800802099033 · Cited by 121
“…of reasoning (Maher, 1988), recent work has revealed a number of aberrations in logical thinking and data gathering in schizophrenia patients with current or past delusional ideas (for reviews see Bell, Halligan, & Ellis, 2006; Blackwood, Howard, Bentall, & Murray, 2001; Garety & Freeman, 1999).”
BackgroundBentall, R. (2006) · Medical Hypotheses · doi:10.1016/j.mehy.2005.09.026 · Cited by 119
Bottom-Up or Top-Down: Campbell's Rationalist Account of Monothematic Delusions
Bayne, T., & Pacherie, É. (2004) · Philosophy, psychiatry & psychology · doi:10.1353/ppp.2004.0033 · Cited by 118
Symptom Dimensions of the Psychotic Symptom Rating Scales in Psychosis: A Multisite Study
Woodward, T. S., Jung, K., Hwang, H., Yin, J., Taylor, L., Menon, M., Peters, E., Kuipers, E., Waters, F., Lecomte, T., et al. (2014) · Schizophrenia Bulletin · doi:10.1093/schbul/sbu014 · Cited by 116
“For example, the preoccupation, conviction and disruption items on the DS could all be affected by a cognitive bias such as a bias against disconfirma-tory evidence 32 or jumping to conclusions bias (JTC), 33,34 contributing to the formation of the D-FRQ dimension.”
BackgroundWaller, H., Freeman, D., Jolley, S., Dunn, G., & Garety, P. (2011) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2011.03.001 · Cited by 120
“Experimental research has consistently found that people with delusions are more likely to jump to conclusions than non-delusional controls (see reviews by Fine, Gardner, Craigie, & Gold, 2007; Freeman, 2007; Garety & Freeman, 1999).”
Stanghellini, G., & Lysaker, P. H. (2007) · American Journal of Psychotherapy · doi:10.1176/appi.psychotherapy.2007.61.2.163 · Cited by 116
Ventura, J., Wood, R. C., Jimenez, A. M., & Hellemann, G. (2013) · Schizophrenia Research · doi:10.1016/j.schres.2013.10.015 · Cited by 114
“The evidence seems to indicate that specific symptom types might be related in differential ways to separate social cognitive processes, but how they “map onto” facial recognition is less clear (Corcoran et al., 1995; Garety and Freeman, 1999; Greig et al., 2004; Couture et al., 2010).”
BackgroundPerceived Racism as a Predictor of Paranoia Among African Americans
Combs, D. R., Penn, D. L., Cassisi, J. E., Michael, C., Wood, T., Wanner, J. L., & Adams, S. (2005) · Journal of Black Psychology · doi:10.1177/0095798405283175 · Cited by 113
“The PAI contained items related to persecutory ideation and malevolent intention (Combs & Penn, 2004; Freeman & Garety, 2000; Garety & Freeman, 1999).”
BackgroundResult
Metadata
- Authors
- Garety, P. A., & Freeman, D.
- Affiliations
- University of London (GB)
- Corresponding author
- Garety, Philippa A.
- Venue
- British Journal of Clinical Psychology
- Publisher
- Wiley
- Published
- 1999-06
- Volume
- 38
- Issue
- 2
- Pages
- 113-154
- ISSN
- 0144-6657 (ISSN-L)
- 2044-8260
- OpenAlex
- W2169951193
- Cited by
- 794
- References
- 93
- Citations by year
- 2026: 9 · 2025: 9 · 2024: 13 · 2023: 22 · 2022: 13 · 2021: 24 · 2020: 26 · 2019: 20 · 2018: 32 · 2017: 29 · 2016: 39 · 2015: 27 · 2014: 60 · 2013: 52 · 2012: 45
- FWCI
- 10.72
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- British Journal of Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- 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
- delusions, theory of mind deficits, jumping to conclusions bias, attributional style, self-discrepancy, cognitive therapy, schizophrenia
- MeSH terms
- Mental Disorders, Cognition Disorders, Cognitive Dissonance, Delusions, Female, Humans, Male, Models, Psychological, Paranoid Disorders, Personality, Self Concept, Cognitive Behavioral Therapy
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