Cited by 794Schizophrenia research and treatmentMental Health and PsychiatryHallucinations in medical conditions

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Cognitive approaches to delusions: a critical review of theories and evidence.

Garety, Philippa A., Freeman, Daniel·1999·British Journal of Clinical Psychology

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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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Background
Cognitive Behavioural Therapy for Psychosis
Hunter, E. C. M., Johns, L., Onwumere, J., & PETERS, E. R. (2014) · Springer eBooks · doi:10.1007/978-3-642-45257-4_10 · Cited by 3
Development and Preliminary Evaluation of a Social Cognition Intervention for Outpatients with Schizophrenia Spectrum Disorders
Roberts, D. L. (2019) · Carolina Digital Repository (University of North Carolina at Chapel Hill) · doi:10.17615/87wh-yh18 · Cited by 3
THE RELATION BETWEEN FUNCTIONAL ANATOMY OF THE FACE AND THREAT PERCEPTION EVOKED BY FACIAL EXPRESSION OF ANGER IN SCHIZOPHRENIA
Baskak, N. S., Özateş, M. E., Herdi, O., Sonel, E., Ulusan, A., & Başkak, B. (2018) · Nöro Psikiyatri Arşivi · doi:10.29399/npa.21632 · Cited by 3
“Cognitive models of psychosis refer to a jumping to conclusion bias (27).”
Background
Reduced Jumping to Conclusion Bias after Experimentally Induced Enhancement of Subjective Body Boundaries in Psychosis
Lyons, N., Dietrich, D. E., Graser, J., Juckel, G., Koßmann, C., Krauß, H., Müller, B. W., & Michalak, J. (2021) · Psychopathology · doi:10.1159/000513271 · Cited by 3
A psychometric investigation of the Chinese version of the Internal, Personal and Situational Attributions Questionnaire (C-IPSAQ)
Gao, B., Wang, Y., Zhu, Y., Tian, Q., Chen, Z., Cohen, Z. L., Landa, Y., & Mueser, K. T. (2018) · Translational Psychiatry · doi:10.1038/s41398-018-0314-4 · Cited by 3
Does ego threat increase paranoia?
Cicero, D. C. (2007) · doi:10.32469/10355/5019 · Cited by 3
Paranoid Personality Disorder
Lewis, K. C., & Ridenour, J. M. (2017) · Springer eBooks · doi:10.1007/978-3-319-28099-8_615-1 · Cited by 3
Schizophrenia Spectrum and Other Psychotic Disorders
Combs, D. R., Mueser, K. T., Morales, S., & Smith, C. (2018) · Wiley eBooks · doi:10.1002/9781394258970.ch6 · Cited by 3
Deterritorialising mental health: unfolding service user experience
Tucker, I. M. (2006) · Loughborough University Institutional Repository (Loughborough University) · Cited by 3
Developing a mechanism-based therapy for acute psychiatric inpatients with psychotic symptoms: an Intervention Mapping approach
Gussmann, E., Lucae, S., Falkai, P., Padberg, F., Egli, S., & Kopf-Beck, J. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1160075 · Cited by 2
“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).”
Background
Relationships among subclinical psychotic symptoms in young adults over time
Wright, A. C., Cather, C., Mueser, K. T., Farabaugh, A. H., Terechina, O., D, M. F. M., & Holt, D. J. (2022) · Psychiatry Research · doi:10.1016/j.psychres.2022.114617 · Cited by 2
Psychotherapy for Delusional Disorder: Theoretical Models and Therapeutic Techniques
Le, T., & Ruffalo, M. L. (2025) · American Journal of Psychotherapy · doi:10.1176/appi.psychotherapy.20240061 · Cited by 2
Therapy process factors in early psychosis: The effect of working alliance on clinical symptoms and cognitive biases in Ultra High Risk young people
Bagrowska, P., Wannan, C., Polari, A. R., Yuen, H. P., Amminger, P., Kerr, M., Spark, J., Wallis, N., Shumway, M., Carter, C., et al. (2025) · Schizophrenia Research · doi:10.1016/j.schres.2025.07.031 · Cited by 2
“…include cognitive biases, such as jumping to conclusions (JTC) and belief inflexibility (reasoning biases), attention to threat and aberrant salience (attentional biases), as well as external attributions and personalizing (attributional biases) (Garety and Freeman, 1999; Livet et al., 2020).”
Testing the Trower and Chadwick model of paranoia: Is ‘poor-me’ and ‘bad-me’ paranoia acting as a defence?
Marley, C., Jones, J., & Jones, C. A. (2017) · Psychiatry Research · doi:10.1016/j.psychres.2017.09.077 · Cited by 2
“These mixed findings have led to the proposal that there may be distinct subgroups of paranoia with different psychological processes involved in their formation and maintenance (Garety and Freeman, 1999; Kinderman, 1994; Trower and Chadwick, 1995).”
Background
Reasoning biases and delusional ideation in the general population: A longitudinal study
Kuhn, S. A. K., Andreou, C., Elbel, G., Lieb, R., & Zander-Schellenberg, T. (2023) · Schizophrenia Research · doi:10.1016/j.schres.2023.03.009 · Cited by 2
Paranoia and Data-Gathering Biases in Autism
Bennert, K., Brosnan, M., Canning, A., Roberts, G., & Russell, A. (2024) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-024-06301-w · Cited by 2
Aetiology and Risk Factors of Schizophrenia
Kuşman, A. (2024) · IntechOpen eBooks · doi:10.5772/intechopen.1005178 · Cited by 2
The End of the Game: Peter Green and the blues of psychosis
Nosari, G., Calorio, F., POVETEVA, E., Callari, A., Pini, C., Esposito, C. M., & Giovanna, G. (2026) · Minerva Psychiatry · doi:10.23736/s2724-6612.26.02692-8 · Cited by 2
Autistic Thinking
Kleiger, J. H., & Weiner, I. B. (2019) · Rorschachiana Journal of the International Society for the Rorschach · doi:10.1027/1192-5604/a000117 · Cited by 2
Self-Processing and Self-Face Reaction Time Latencies: A Review
Gallup, G. G., & Platek, S. M. (2021) · Brain Sciences · doi:10.3390/brainsci11111409 · Cited by 2
“The literature has been fairly consistent in showing that schizophrenics perform worse on theory of mind tasks than non-psychiatric and psychiatric controls, as well as patients in remission [51].”
Result
Treatment of Schizophrenia in the 21st Century: Towards a more Personalised Approach
Hunter, R. (2012) · InTech eBooks · doi:10.5772/36078 · Cited by 2
“Research on positive symptoms has led to the hypothesis that there are specific cognitive biases affecting reasoning, attribution style and impaired self-worth (e.g. see Garety and Freeman, 1999).”
Background
Reasoning in Anxiety, OCD and Related Disorders: Can Formal Reasoning Theories Inform Us About Psychopathology?
Kieron, P., & Pélissier, M. (2011) · InTech eBooks · doi:10.5772/21359 · Cited by 2
“In their critical review of cognitive approaches to delusions, Garety and Freeman (1999) compare three main theories of development and maintenance of delusional disorder.”
Influential
Neural Substrates of Emotion Dysfunctions in Patients with Schizophrenia Spectrum Disorders
Pauly, K. D., & Habel, U. (2011) · Springer eBooks · doi:10.1007/978-94-007-0837-2_18 · Cited by 2
“However, literature is inconsistent – especially in the context of self-attribution of positive results, with some studies also reporting an accordant negative bias in patients with schizophrenia spectrum disorders [ 83 , 84].”
Result
Origen y destino de la teoría de la mente: su afectación en trastornos distintos del espectro autista
López-Santín, J. M., & Altable, C. R. (2005) · Psiquiatría Biológica · Cited by 2
Cognitive Behaviour Therapy and Recovery from Acute Psychosis: Case Studies of Two Contrasting Styles
Startup, M. (2006) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-005-9002-9 · Cited by 2
“They tend to have an externalising bias which leads them to see their problems as originating outside themselves ( Garety & Freeman, 1999 ).”
Background
Cognitieve gedragstherapie voor patiënten met postpsychotische demoralisatie
Staring, A. B. P., & Berg, N. V. D. (2010) · Directieve therapie · doi:10.1007/s12433-010-0241-x · Cited by 2
Investigating Schizotypy and Crime‐Based Reasoning with Qualitative Methods
Wilkinson, D., Caulfield, L., & Jones, T. J. (2013) · The Howard Journal of Criminal Justice · doi:10.1111/hojo.12059 · Cited by 4

Authors: Garety, P. A., & Freeman, D.
Affiliations: University of London (GB)
Corresponding author: Garety, Philippa A.
ORCID: Garety, Philippa A.
Freeman, Daniel
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
DOI: 10.1348/014466599162700
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
Licence: onlinelibrary.wiley.com/termsAndConditions#vor (vor, 4224 d)
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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Cognitive approaches to delusions: a critical review of theories and evidence.

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