Dysfunctional Attitudes and Symptom Expression in Schizophrenia: Differential Associations With Paranoid Delusions and Negative Symptoms

Stress precedes negative symptom exacerbations in clinical high risk and early psychosis: A time-lagged experience sampling study

The experience sampling method (ESM) has revealed associations between fluctuations in stress and positive symptoms in psychosis. It is unknown, however, how negative symptoms including anhedonia respond to stress. Stress is divided according to its source: event-related stress stemming from negative events, and activity-related stress stemming from engaging in tasks beyond one's skill or control. Anhedonia is divided into consummatory and anticipatory anhedonia, reflecting a lack of pleasure in current and expected activities. This study uses ESM to determine whether each form of anhedonia increases in response to stress. Antipsychotic-naïve individuals with first episode psychosis (n = 39), clinical high-risk states for psychosis (n = 44), and healthy controls (n = 34) responded to daily prompts on a palmtop computer for up to ten days by indicating levels of stress and anhedonia. Time-lagged multilevel modelling was employed to explore increases in anhedonia following increases in stress while controlling for prior levels of anhedonia. Mean levels of anhedonia were also compared across groups. Only activity-related stress produced increases in anhedonia. This effect did not vary between groups. Clinical groups showed greater overall levels of anhedonia than healthy controls, but did not differ from each other. Anhedonia responds only to activity-related stressors, suggesting that this form of stress has a specific causal role in anhedonia. The results also provide further evidence for global increases in anhedonia in antipsychotic-naïve psychosis spectrum individuals.

Psychoeducational therapy with families of paranoid schizophrenia patients

AIM

The study aimed to measure the effectiveness of psychoeducational therapy on the burden of families of paranoid schizophrenia patients.

METHODS

An experimental research design was used in this study with an equivalent control group using 84 random allocation samples at a mental hospital in Semarang. The study instrument was the Indonesian version of the care burden scale (CBS). The Mann-Whitney test was used for the data analysis.

RESULTS

The findings obtained show the effectiveness of psychoeducational therapy on family burden in the experimental group as opposed to standard therapy in the control group (before: Z=-1.27; P=.092, and after: Z=-3.47; P=.002).

CONCLUSION

We conclude that family psychoeducational therapy, as given to the experiment group, can decrease the family burden for the family of a paranoid schizophrenia patient. The application of family psychoeducational therapy can serve as guidance for the psychiatric nurse in reducing the family burden in the care of patients with paranoid schizophrenia.

Understanding the Association Between Negative Symptoms and Performance on Effort-Based Decision-Making Tasks: The Importance of Defeatist Performance Beliefs

Effort-based decision-making paradigms are increasingly utilized to gain insight into the nature of motivation deficits. Research has shown associations between effort-based decision making and experiential negative symptoms; however, the associations are not consistent. The current study had two primary goals. First, we aimed to replicate previous findings of a deficit in effort-based decision making among individuals with schizophrenia on a test of cognitive effort. Second, in a large sample combined from the current and a previous study, we sought to examine the association between negative symptoms and effort by including the related construct of defeatist beliefs. The results replicated previous findings of impaired cognitive effort-based decision making in schizophrenia. Defeatist beliefs significantly moderated the association between negative symptoms and effort-based decision making such that there was a strong association between high negative symptoms and deficits in effort-based decision making, but only among participants with high levels of defeatist beliefs. Thus, our findings suggest the relationship between negative symptoms and effort performance may be understood by taking into account the role of defeatist beliefs, and finding that might explain discrepancies in previous studies.

Identifying the "Therapy Targets" for Treating the Negative Symptoms of Psychosis Using Cognitive Behavioral Therapy

The division of psychotic symptoms into positive and negative categories has largely divided the research on them. While the research on positive symptoms of psychosis has rapidly developed over the last three decades, the literature on negative symptoms has noticeably lagged behind. Negative symptoms have likely been ignored in the treatment literature because they were previously thought to remit following the treatment of positive symptoms. Recent evidence does not consistently support this theory and indicates that the different manifestations of negative symptoms require distinct approaches to treatment. The current review provides a re-evaluation of the theoretical literature on negative symptoms to inform and identify "treatment targets" to reduce them. The "treatment targets" are then translated into intervention strategies using a cognitive behavioral framework. A review of the empirical literature on cognitive behavior therapy for treating negative symptoms is then offered along with a critical discussion of where cognitive behavior therapy stands compared to other interventions and what research is still needed.

Trends in the Study of Motivation in Schizophrenia: A Bibliometric Analysis of Six Decades of Research (1956-2017)

Motivation in schizophrenia has been a key research aim for several decades. Motivation is a very complex process underlying negative symptoms that has been assessed and identified using very different instruments and terminologies. This study provides a comprehensive overview of the growing literature production and highlights an extensive set of variables to better understand the study of motivation. Electronic databases were searched in order to compile relevant studies of motivation in individuals with schizophrenia. The initial search identified 3,248 potentially interesting records, and of these, 161 articles published between 1956 and 2017 were finally included. Information such as year of publication, journal, country, and number of authors was codified. Variables related to sample characteristics, methodological aspects, and motivational terms were also extracted. The results revealed a significant growth trend in literature production, especially since the 2000s, with reward as the main term studied. In addition, questionnaires were identified as the preferred instrument to assess motivation in patients with schizophrenia. Other aspects such as country of publication, authors, journals of publication, and co-citation network analysis were also examined. The discussion offers recommendations for future research.

Using Functional Analysis as a Framework to Guide Individualized Treatment for Negative Symptoms

Although numerous interventions are available for negative symptoms, outcomes have been unsatisfactory with pharmacological and psychological interventions producing changes of only limited clinical significance. Here, we argue that because negative symptoms occur as a complex syndrome caused and maintained by numerous factors that vary between individuals they are unlikely to be treated effectively by the present "one size fits all" approaches. Instead, a well-founded selection of those interventions relevant to each individual is needed to optimize both the efficiency and the efficacy of existing approaches. The concept of functional analysis (FA) can be used to structure existing knowledge so that it can guide individualized treatment planning. FA is based on stimulus-response learning mechanisms taking into account the characteristics of the organism that contribute to the responses, their consequences and the contingency with which consequences are tied to the response. FA can thus be flexibly applied to the level of individual patients to understand the factors causing and maintaining negative symptoms and derive suitable interventions. In this article we will briefly introduce the concept of FA and demonstrate-exemplarily-how known psychological and biological correlates of negative symptoms can be incorporated into its framework. We then outline the framework's implications for individual assessment and treatment. Following the logic of FA, we argue that a detailed assessment is needed to identify the key factors causing or maintaining negative symptoms for each individual patient. Interventions can then be selected according to their likelihood of changing these key factors and need to take interactions between different factors into account. Supplementary case vignettes exemplify the usefulness of functional analysis for individual treatment planning. Finally, we discuss and point to avenues for future research guided by this model.

Negative and paranoid symptoms are associated with negative performance beliefs and social cognition in 22q11.2 deletion syndrome

AIMS

22q11.2 deletion syndrome (22q11.2DS) is a neurogenetic condition associated with an increased risk of developing schizophrenia. Previous studies have shown that negative symptoms represent the most specific clinical characteristic of psychosis in 22q11.2DS and are strongly associated with outcome. However, the psychological mechanisms associated with these symptoms in this population are poorly understood. In accordance with recent conceptualizations in the field of schizophrenia, the present study aims at investigating whether negative symptoms are associated with the presence of negative performance beliefs and cognitive deficits.

METHODS

Thirty-five participants with 22q11.2DS and 24 typically developing individuals aged between 11 and 24 years were included in the study. Self-reported schizotypal symptoms (cognitive-perceptual, paranoid, negative and disorganization symptoms) and dysfunctional beliefs (negative performance beliefs and need for approval) were assessed. Measures of processing speed, verbal memory, working memory, executive functioning and face recognition were also extracted from a broad cognitive evaluation protocol.

RESULTS

Adolescents with 22q11.2DS reported significantly higher score on the negative dimension of the Schizotypal Personality Questionnaire than controls, even when controlling for the influence of anxiety/depression and intellectual functioning. Negative and paranoid symptoms were associated with the severity of negative performance beliefs and lower face recognition abilities. Mediation analyses revealed that negative performance beliefs significantly mediated the association between face recognition and negative/paranoid symptoms.

CONCLUSIONS

These findings suggest that negative performance beliefs and basic social cognitive mechanisms are associated with negative and paranoid symptoms in individuals with 22q11.2DS. Implications for intervention are discussed in this article.

Effects of the Indianapolis Vocational Intervention Program (IVIP) on defeatist beliefs, work motivation, and work outcomes in serious mental illness

Defeatist beliefs and amotivation are prominent obstacles in vocational rehabilitation for people with serious mental illnesses (SMI). The CBT-based Indianapolis Vocational Intervention Program (IVIP) was specifically designed to reduce defeatist beliefs related to work functioning. In the current study, we examined the impact of IVIP on defeatist beliefs and motivation for work, hypothesizing that IVIP would be associated with a reduction in defeatist beliefs and greater motivation for work. We also examined the effects of IVIP on these variables as well as work outcomes during a 12-month follow-up. Participants with SMI (n=64) enrolled in a four-month work therapy program were randomized to IVIP or a support therapy group (SG). Assessments were conducted at baseline, post-treatment (4months), and follow-up (1year). Compared to those in SG condition, individuals randomized to IVIP condition reported greater reductions in defeatist beliefs and greater motivation for work at follow-up, along with greater supported employment retention rates. Specifically treating and targeting negative expectations for work therapy improves outcomes, even once active supports of the IVIP program and work therapy are withdrawn.

Understanding and treating amotivation in people with psychosis: An experimental study of the role of guided imagery

Psychological models propose that the amotivational negative symptoms (ANS) of psychosis are influenced by expectations of future events; both anticipatory success (believing one can achieve something, AS) and anticipatory pleasure (mentally pre-creating potential future experiences of enjoyment, AP). Mental imagery manipulations have been shown to change expectations across a range of settings, and may therefore enhance psychological interventions for ANS in people with psychosis. We set out to investigate the impact of a guided imagery manipulation on AS and AP in this group. Forty-two participants with psychosis and ANS completed measures of ANS severity, before random allocation to either a positive or neutral imagery manipulation. AS and AP towards a dart-throwing task were measured before and after the manipulation. Greater ANS severity was associated with lower levels of AS, but not of AP, irrespective of task performance. AS, but not AP, improved during both positive and neutral imagery manipulations, with no effect of imagery type. Anticipatory success is a candidate psychological factor influencing the severity of ANS in psychosis that may be changed by guided imagery manipulation. Imagery interventions are feasible and acceptable for this group: further investigation is needed of their mechanism of action and potential to improve functioning.

Defeatist Performance Beliefs, Negative Symptoms, and Functional Outcome in Schizophrenia: A Meta-analytic Review

Negative symptoms are a strong predictor of poor functional outcome in people with schizophrenia. Unfortunately there are few effective interventions for either negative symptoms or functional outcome, despite the identification of potential mechanisms. Recent research, however, has elucidated a new potential mechanism for negative symptoms and poor functional outcome: defeatist performance beliefs (DPB), or negative thoughts about one's ability to successfully perform goal-directed behavior that can prevent behavior initiation and engagement. We conducted 2 meta-analyses examining the relationship between DPB and both negative symptoms (n = 10 studies) and functional outcome (n = 8 studies) in people with schizophrenia. We found a small effect size for the relationship between DPB and negative symptoms, regardless of how negative symptoms were measured. We also found a small effect size for the relationship between DPB and functional outcome, which was significantly moderated by the method of assessing DPB and moderated by the sex composition of the study at a trend level. These findings highlight the potential of targeting DPB in psychosocial interventions for both negative symptoms and functional outcome.

Predictors of improved functioning in patients with psychosis: The role of amotivation and defeatist performance beliefs

Defeatist performance beliefs (DPBs) are associated with the severe impairments in functioning of patients with negative symptoms of schizophrenia. This association has been found to be mediated by amotivation, a core aspect of negative symptoms. Although causality is assumed, longitudinal evidence for this is lacking. The current study aimed to extend previous findings by investigating both cross-sectional and longitudinal associations between DPBs, motivational impairments and functioning in a sample of patients with psychotic disorders (N=58). We hypothesized, that DPBs would be related to functioning in cross-sectional and longitudinal analyses and that this link would be mediated by motivational impairments. Data was assessed at baseline and post-treatment in a trial on the effects of cognitive behavior therapy for psychosis. At baseline, amotivation mediated the association between DPBs and functioning. From baseline to post-treatment, reduction of amotivation was associated with improvement of functioning significantly, whereas reduction of DPBs was unrelated to improvements in functioning or amotivation. The findings suggest that improvement in amotivation accounts for favorable treatment outcomes in regard to functioning but question the causal role of DPBs in negative symptoms and functioning.

Addressing defeatist beliefs in work rehabilitation

BACKGROUND

Adults with serious mental illness (SMI) may struggle with expectations of failure in vocational rehabilitation. These expectations can be global and trait-like or performance-specific and related to ability.

AIMS

To date, it has not been examined whether global or performance-specific defeatist beliefs are related to functional outcomes.

METHOD

The Indianapolis Vocational Intervention Program (IVIP) is a CBT intervention used to address expectations of failure and improve work performance. We examined the relationships between defeatist beliefs, self-esteem, social functioning, and work behaviors in 54 adults with SMI who completed IVIP within a work therapy program.

RESULTS

Baseline work-specific defeatist beliefs were related to baseline self-esteem, employment attitude, and work behaviors. Decline in work-specific defeatist beliefs was associated with better social functioning, self-esteem, and work behaviors. Decline in global defeatist beliefs was only associated with improvements in social functioning.

CONCLUSIONS

Performance-specific expectations about work may be an appropriate therapeutic target to enhance work outcome in SMI.

Additional support for the cognitive model of schizophrenia: evidence of elevated defeatist beliefs in schizotypy

OBJECTIVES

The cognitive model of poor functioning in schizophrenia posits that defeatist performance beliefs-overgeneralized negative beliefs about one's ability to perform tasks-develop prior to the onset of psychosis and contribute to the development and maintenance of negative symptoms and poor functioning. Although several studies with schizophrenia samples have provided support for the model, there is a paucity of research investigating these beliefs in individuals with schizotypy-those exhibiting traits reflecting a putative genetic liability for schizophrenia. This study had two aims: to examine whether defeatist performance beliefs (1) are elevated in schizotypy compared to controls and (2) are associated with decreased quality of life and working memory and increased negative but not positive schizotypy traits in the schizotypy group.

METHODS

Schizotypy (n=48) and control (n=53) groups completed measures of schizotypy traits, defeatist performance beliefs, quality of life, and working memory.

RESULTS

Analyses revealed that the schizotypy group reported significantly more defeatist performance beliefs than the control group. Within the schizotypy group, increased defeatist performance beliefs were significantly associated with greater negative schizotypy traits and lower quality of life. No significant associations were observed between defeatist performance beliefs and positive schizotypy traits and working memory.

CONCLUSIONS

Results generally support the theoretical validity of the cognitive model of poor functioning in schizophrenia and suggest that elevated defeatist performance beliefs may contribute to the manifestation of subclinical negative symptom traits and reduced quality of life among those with a latent vulnerability for schizophrenia.

Elucidating the role of Early Maladaptive Schemas for psychotic symptomatology

Although cognitive accounts postulate negative self-concepts as a causal factor in the emergence of psychotic symptoms, little is known about the role of specific self-schemas for psychotic symptomatology. Building on a differentiated and treatment-informed schema model, we aimed to elucidate the role of Early Maladaptive Schemas (EMS) for psychotic symptomatology, particularly their specificity to patients with psychosis and their association with positive versus negative symptoms. We assessed EMS with the Young Schema Questionnaire in patients with psychosis (n=81), patients with depression (n=28) as well as healthy participants (n=60). In the psychosis sample symptoms were rated using the Positive and Negative Syndrome Scale. In comparison to healthy participants, patients with either psychosis or depression showed a higher overall number and intensity of EMS whereas the psychosis and the depression sample did not significantly differ. The overall number and intensity of EMS were significantly associated with positive but not with negative symptoms. Contrary to previous findings, patients with psychosis and patients with depression did not differ in the EMS subscale Mistrust/Abuse. The results suggest that EMS are particularly relevant to positive symptoms. Our findings imply that addressing maladaptive schemas in patients with psychosis by making use of the schema-concept holds potential.

Development of the Positive Emotions Program for Schizophrenia: An Intervention to Improve Pleasure and Motivation in Schizophrenia

OBJECTIVES

The efficacy of drug-based treatments and psychological interventions on the primary negative symptoms of schizophrenia remains limited. Recent literature has distinguished negative symptoms associated with a diminished capacity to experience, from those associated with a limited capacity for expression. The positive emotions program for schizophrenia (PEPS) is a new method that specifically aims to reduce the syndrome of a diminished capacity to experience.

METHODS

The intervention's vital ingredients were identified through a literature review of emotion in schizophrenia and positive psychology. The program has been beta-tested on various groups of health-care professionals.

RESULTS

A detailed description of the final version of PEPS is presented here. The French version of the program is freely downloadable.

CONCLUSION

PEPS is a specific, short, easy to use, group-based intervention to improve pleasure, and motivation in schizophrenia. It was built considering a recovery-oriented approach to schizophrenia.

Distress related to subclinical negative symptoms in a non-clinical sample: Role of dysfunctional attitudes

Negative symptoms are a prominent feature of schizophrenia that are intimately linked to poor outcomes characterizing the illness. One mechanistic model suggests that these symptoms are produced and maintained, at least in part, through maladaptive attitudes. Beyond mechanisms, it remains phenomenologically unclear if these symptoms are particularly distressing. In the present study we examined whether subclinical negative symptoms evaluated in a non-clinical sample of young adults (N=370) were distressful or bothersome to participants and, further, whether these symptoms were associated with dysfunctional attitudes. We found that greater severity of subclinical negative symptoms such as amotivation and anhedonia were associated with higher ratings of distress specifically attributable to these symptoms. This relationship held even after controlling for severity of depressive symptoms. Moreover, greater negative symptom burden was associated with greater endorsement of defeatist performance beliefs. Negative symptoms expressed in the general population were found to be particularly distressing. Maladaptive cognitive schemas are implicated in the expression of these symptoms, as well as the amount of distress these symptoms instil. A greater understanding of the mechanisms underlying negative symptoms, including both neurobiological and cognitive, is needed in order to effectively develop treatment strategies for these disabling symptoms.

Expectancies of success as a predictor of negative symptoms reduction over 18 months in individuals with schizophrenia

Negative symptoms are often enduring and lead to poor functional outcomes in individuals with schizophrenia. The cognitive model of negative symptoms proposes that low expectancies of success contribute to the development and maintenance of negative symptoms; however, longitudinal investigations assessing these beliefs and negative symptoms are needed. The current study examined whether an individual's baseline expectancies of success - one's beliefs about future success and goal attainment - predicted negative symptoms reduction over 18 months in individuals with schizophrenia-spectrum disorders (n=118). Data were collected at baseline, 9 months, and 18 months as part of a randomized controlled trial of Illness Management and Recovery. A mixed effects regression analysis revealed a significant reduction in negative symptoms over time, with a significant interaction effect between time and baseline expectancies of success. After controlling for baseline negative symptoms, demographic variables, and treatment conditions, those with high and moderate baseline expectancies of success evidenced a significant reduction in negative symptoms at 18 months, while those with low baseline expectancies of success did not evidence reduced negative symptoms. Findings support the cognitive model of negative symptoms and suggest that expectancies of success may be a useful treatment target for interventions aimed at reducing negative symptoms.

Perfectionistic self-presentation and suicide in a young woman with major depression and psychotic features

A woman in her midtwenties with a history of major depressive disorder and a recent major depressive episode with mood-congruent psychotic features died by suicide. Two weeks before her death, she demonstrated exceptional elevations on the nondisplay of imperfection factor of Hewitt and Flett's Perfectionistic Self-Presentation Scale. Perfectionism and especially perfectionistic self-presentation have been strongly associated with suicide across several populations, accounting for unique variance in suicidality beyond depression and hopelessness. Yet interpersonal facets of perfectionism are not recognized as clinical risk factors for suicide. There is also a paucity of research on perfectionism in relation to psychotic symptoms. This case account illustrates the role of perfectionistic self-presentation in suicides that occur seemingly without warning and, to our knowledge, this is the first examination of perfectionistic self-presentation and suicide in a case where psychotic features occurred. This study, though single case-based, draws attention to perfectionism and perfectionistic self-presentation and their potential roles in suicide, especially when accompanied by other risk factors. Future research in this area may elucidate the role of perfectionism in suicide, singularly and in the context of a comprehensive clinical risk assessment, demonstrating whether perfectionism confers information about suicide risk beyond known clinical risk factors.

The role of dysfunctional attitudes in models of negative symptoms and functioning in schizophrenia

Neurocognitive impairment is associated with negative symptoms and poor real world functioning in schizophrenia. Dysfunctional attitudes (e.g., "If I fail partly, it is as bad as being a complete failure") have been found to mediate these relationships between neurocognition and negative symptoms and functioning. In this study, these relationships were examined in 179 participants with schizophrenia or schizoaffective disorder using structural equation modeling. Defeatist attitudes were found to mediate the relationship between neurocognition and negative symptoms but not the relationships between neurocognition and performance-based or self-reported functioning. A full model with the best fit showed mediation between neurocognition and self-reported functioning through two different pathways: One from neurocognition to functional skill capacity to real-world functioning, and a second from neurocognition to defeatist attitudes to negative symptoms to real-world functioning. These results may implicate skill deficits and defeatist attitudes as a separate treatment targets for negative symptoms and functioning in schizophrenia.

The relevance of self-esteem and self-schemas to persecutory delusions: a systematic review

BACKGROUND

Self-esteem is frequently targeted in psychological approaches to persecutory delusions (PD). However, its precise role in the formation and maintenance of PD is unclear and has been subject to a number of theories: It has been hypothesized that PD function to enhance self-esteem, that they directly reflect negative conceptualizations of the self, that self-esteem follows from the perceived deservedness of the persecution (poor-me versus bad-me-paranoia) and that the temporal instability of self-esteem is relevant to PD. In order to increase our understanding of the relevance of self-esteem to PD, this article systematically reviews the existing research on self-esteem in PD in the light of the existing theories.

METHODS

We performed a literature search on studies that investigated self-esteem in PD. We included studies that either investigated self-esteem a) within patients with PD or compared to controls or b) along the continuum of subclinical paranoia in the general population. We used a broad concept of self-esteem and included paradigms that assessed implicit self-esteem, specific self-schemas and dynamic aspects of self-esteem.

RESULTS

The literature search identified 317 studies of which 52 met the inclusion criteria. The reviewed studies consistently found low global explicit self-esteem and negative self-schemas in persons with PD. The studies therefore do not support the theory that PD serve to enhance self-esteem but underline the theory that they directly reflect specific negative self-schemas. There is evidence that low self-esteem is associated with higher perceived deservedness of the persecution and that PD are associated with instable self-esteem. Only few studies investigated implicit self-esteem and the results of these studies were inconsistent.

CONCLUSIONS

We conclude by proposing an explanatory model of how self-esteem and PD interact from which we derive clinical implications.

Dysfunctional attitudes and expectancies in deficit syndrome schizophrenia

The deficit syndrome was proposed over 20 years ago as a separate negative symptom syndrome within schizophrenia with a distinct neurobiological pathophysiology and etiology. Recent research, however, has indicated that psychological factors such as negative attitudes and expectancies are significantly associated with the broad spectrum of negative symptoms. Specifically, defeatist beliefs regarding performance mediate between neurocognitive impairment and both negative symptoms and functional outcome. Additionally, asocial beliefs predict asocial behavior and negative expectancies regarding future pleasure are associated with negative symptoms. The present study explored whether these dysfunctional beliefs and negative expectancies might also be a feature of the deficit syndrome. Based on a validated proxy method, 22 deficit and 72 nondeficit patients (from a pool of 139 negative symptom patients) were identified and received a battery of symptom, neurocognitive, and psychological measures. The deficit group scored significantly worse on measures of negative symptoms, insight, emotion recognition, defeatist attitudes, and asocial beliefs but better on measures of depression, anxiety, and distress than the nondeficit group. Moreover, the deficit group showed a trend for higher scores on self-esteem. Based on these findings, we propose a more comprehensive formulation of deficit schizophrenia, characterized by neurobiological factors and a cluster of psychological attributes that lead to withdrawal and protect the self-esteem. Although the patients have apparently opted-out of participation in normal activities, we suggest that a psychological intervention that targets these negative attitudes might improve their functioning and quality of life.

The Fear of Others: A Pilot Study of Social Anxiety Processes in Paranoia

Background and Aims:There is good reason to consider the role of social anxiety processes in paranoia; both the research and clinical literature indicate significant overlap between the two presentations. The aim of this study was to explore cognition and behaviour that are typically associated with social phobia, in people with paranoia, and then to draw out theoretical and clinical implications.Method:We used a cross-sectional between-subjects design to compare participants with persecutory delusions (without social phobia), social phobia, a clinical control group with panic disorder, and a non-clinical control group. Ten to 15 people were recruited to each of four groups, with a final total of 48 participants. Each person completed measures of automatic thoughts, underlying assumptions, core beliefs and behaviour, and took part in a semi-structured interview designed to assess process (self-consciousness and attentional focus) and metacognitive beliefs.Results:Surprisingly, measures of cognition and behaviour yielded no systematic differences between people with persecutory delusions and social phobia.Conclusions:People with persecutory delusions may experience overt and underlying cognition typically associated with social phobia, and behave in similar ways in response to perceived social threat. These initial results indicate: (i) that larger scale research is now warranted in order to draw firm conclusions about social anxiety processes in paranoia; (ii) more specific hypotheses to be tested; and (iii) a clinical model of paranoia, based on the cognitive model of social phobia, which might now usefully be validated.

The Fear of Others: A Qualitative Analysis of Interpersonal Threat in Social Phobia and Paranoia

Background and Aims: The cognitive models indicate that people with social phobia and paranoia share a common fear of others. While we recognize clinical differences, it is likely that some of the same psychological processes contribute to the maintenance of both presentations, yet the nature and extent of these similarities and differences are not yet clearly understood. This study explored threat experiences in people with social phobia and persecutory delusions in order to elucidate these aspects of the respective cognitive models. Method: Accounts of interpersonal threat experiences were examined in nine people with social phobia and nine people with persecutory delusions. Verbatim transcripts were analyzed using thematic analysis. Results: Three major themes emerged from the data: participants’ experience of threat, reactions while under threat, and subsequent reflections. Narrative coherence emerged as a superordinate theme. Typical fear responses were found in both groups, particularly in their reactions to threat. The key differences were in participants’ perceptual experiences, ability to stand back from the threat following the event, and narrative coherence. Conclusions: The findings are discussed in relation to current cognitive models of social phobia and paranoia. Theoretical and clinical implications are drawn out, and highlight the need to examine attentional and metacognitive processes more closely if we are to understand the maintenance of perceived threat in these groups, and means of alleviating associated distress.

Negative symptoms and social cognition: identifying targets for psychological interventions

BACKGROUND

How to improve treatment for negative symptoms is a continuing topic of debate. Suggestions have been made to advance psychological understanding of negative symptoms by focusing on the social cognitive processes involved in symptom formation and maintenance.

METHODS

Following the recommendations by the National Institute of Mental Health workshop on social cognition in schizophrenia, this study investigated associations between negative symptoms and various aspects of social cognition including Theory of Mind (ToM), attribution, empathy, self-esteem, and interpersonal self-concepts in 75 patients with schizophrenia spectrum disorders and 75 healthy controls.

RESULTS

Negative symptoms were significantly associated with difficulties in ToM, less readiness to be empathic, lower self-esteem, less self-serving bias, negative self-concepts related to interpersonal abilities, and dysfunctional acceptance beliefs. Different aspects of social cognition were mildly to moderately correlated and interacted in their impact on negative symptoms: Difficulties in ToM were associated with negative symptoms in persons with low but not in persons with medium or high levels of self-esteem. Taken together, the social cognition variables and their hypothesized interaction explained 39% of the variance in negative symptoms after controlling for neurocognition and depression.

CONCLUSIONS

The results highlight the relevance of self-concepts related to social abilities, dysfunctional beliefs, and global self-worth alone and in interaction with ToM deficits for negative symptoms and thereby provide a helpful basis for advancing psychosocial interventions.

Negative expectancy appraisals and defeatist performance beliefs and negative symptoms of schizophrenia

Negative symptoms have clear functional implications in schizophrenia and are typically unresponsive to current treatments. The cognitive model of negative symptoms suggests that dysfunctional beliefs are influential in the development and maintenance of negative symptoms and schizophrenia. The current study reports on a preliminary investigation of a new measure of Negative Expectancy Appraisals (specifically beliefs about limited probability of success and perception of limited cognitive resources), and also evaluates whether dysfunctional beliefs are more closely linked to particular subdomains of negative symptoms. Sixty two individuals with schizophrenia completed measures of dysfunctional beliefs and were rated on negative symptoms. Analyses indicated that the endorsement of beliefs regarding low expectations for success and perception of limited resources (Negative Expectancy Appraisals) are robustly associated with diminished experience negative symptoms (avolition, asociality, and anhedonia), but are not associated with negative symptoms reflecting diminished expressivity (blunted affect, alogia). Similarly, Defeatist Performance Beliefs are modestly related to diminished experience, but not diminished expression, negative symptoms. Negative Expectancy Appraisals were also robustly linked to depressive symptoms. Results from the current study provide evidence that dysfunctional beliefs are clearly relevant to consider in relation to negative symptoms, and may represent a fruitful treatment target.

Expectancy-value theory in persistence of learning effects in schizophrenia: role of task value and perceived competency

Expectancy-value theory, a widely accepted model of motivation, posits that expectations of success on a learning task and the individual value placed on the task are central determinants of motivation to learn. This is supported by research in healthy controls suggesting that beliefs of self-and-content mastery can be so influential they can predict the degree of improvement on challenging cognitive tasks even more so than general cognitive ability. We examined components of expectancy-value theory (perceived competency and task value), along with baseline arithmetic performance and neuropsychological performance, as possible predictors of learning outcome in a sample of 70 outpatients with schizophrenia randomized to 1 of 2 different arithmetic learning conditions and followed up after 3 months. Results indicated that as with nonpsychiatric samples, perceived self-competency for the learning task was significantly related to perceptions of task value attributed to the learning task. Baseline expectations of success predicted persistence of learning on the task at 3-month follow-up, even after accounting for variance attributable to different arithmetic instruction, baseline arithmetic ability, attention, and self-reports of task interest and task value. We also found that expectation of success is a malleable construct, with posttraining improvements persisting at follow-up. These findings support the notion that expectancy-value theory is operative in schizophrenia. Thus, similar to the nonpsychiatric population, treatment benefits may be enhanced and better maintained if remediation programs also focus on perceptions of self-competency for the training tasks. Treatment issues related to instilling self-efficacy in cognitive recovery programs are discussed.

Is fear of others linked to an uncertain sense of self? The relevance of self-worth, interpersonal self-concepts, and dysfunctional beliefs to paranoia

The assumption that a low sense of self-worth can give rise to paranoid delusions is relevant from a therapeutic perspective, but research has been inconsistent. The present study sought to investigate how interpersonal self-concepts and global self-worth relate to psychotic and depressive psychopathology in persons with psychosis. Participants with psychosis (n=83) and healthy controls (n=33) were assessed for global self-worth, interpersonal self-concepts, and dysfunctional beliefs using the Frankfurt Self-Concept Scale and the Dysfunctional Attitude Scale. Symptoms were assessed with the Positive and Negative Syndrome Scale, the Peters et al. Delusions Inventory, the Paranoia Checklist, and the Beck Depression Inventory. We hypothesized that perceived threat to self-worth, as expressed in dysfunctional acceptance beliefs and negative interpersonal self-concepts, would be uniquely associated with persecutory delusions. In contrast, low global self-worth would be strongly associated with symptoms of depression. Multiple regression analyses were used to investigate the association between symptoms and self-concepts. As expected, low global self-worth was associated with depression, whereas the more specific perception of not being accepted by relevant others was most clearly related to psychotic symptoms. Almost half of the variance in paranoia scores was explained by negative interpersonal self-concepts and the interaction between negative interpersonal self-concepts and dysfunctional acceptance beliefs. Thus, cognitive interventions for delusions might be improved by focusing more on interpersonal self-concepts.

Asocial beliefs as predictors of asocial behavior in schizophrenia

Poor social and vocational outcomes have long been observed in schizophrenia, and therapeutic outcomes have been modest. Most studies have identified neurocognition and emotion perception as important contributors to social functioning. Recent research has suggested that personal beliefs, attitudes, and expectancies contribute to negative symptoms. However, the impact of specific beliefs and expectancies on social withdrawal in schizophrenia has not been examined. The present study explored: 1. whether asocial beliefs made a significant contribution to social functioning after accounting for neurocognitive performance and emotion perception; and, 2. whether asocial beliefs predicted asocial behavior in a longitudinal design. 123 outpatients diagnosed with schizophrenia or schizoaffective disorder completed tests of neurocognitive performance, emotion perception, asocial beliefs, symptomatology, and functional outcome. A subset of 13 outpatients was retested one year after the initial assessment. Hierarchical regression indicated that asocial beliefs accounted for 18% of the variability in social functioning. Depression and negative symptoms explained another 9% of the dispersion. Contrary to expectations, neurocognition and emotion perception accounted for less than 1% of the variance. In the longitudinal study, baseline asocial beliefs predicted asocial behavior one year later. Asocial beliefs predict poor social functioning in schizophrenia, and may be modifiable by psychological interventions.

Evaluation sensitivity as a moderator of communication disorder in schizophrenia

BACKGROUND

Communication disturbance (thought disorder) is a central feature of schizophrenia that predicts poor functioning. We investigated the hypothesis that memory and attention deficits interact with beliefs about the gravity of being rejected (i.e. evaluation sensitivity) to produce the symptoms of communication disorder.

METHOD

Seventy-four individuals diagnosed with schizophrenia or schizo-affective disorder completed a battery of tests assessing neurocognition (attention, working and verbal memory, abstraction), symptomatology (positive, negative and affective), functioning, and dysfunctional beliefs.

RESULTS

Patients with communication deviance (n=33) performed more poorly on the neurocognitive tests and reported a greater degree of sensitivity to rejection than patients with no thought disorder (n=41). In a logistic regression analysis, evaluation sensitivity moderated the relationship between cognitive impairment and the presence of communication disorder. This finding was independent of hallucinations, delusions, negative symptoms, depression and anxiety.

CONCLUSIONS

We propose that negative appraisals about acceptance instigate communication anomalies in individuals with a pre-existing diathesis for imperfect speech production.

Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia

Poor social and vocational outcomes have long been observed in schizophrenia. Two of the most consistent predictors are negative symptoms and cognitive impairment. We investigate the hypothesis that cognitive content--defeatist beliefs regarding performance--provides a link between cognitive impairment, negative symptoms, and poor functioning in schizophrenia. A total of 77 individuals (55 patients diagnosed with schizophrenia or schizoaffective disorder and 22 healthy controls) participated in a cross-sectional study of psychopathology. Tests of memory, abstraction, attention, and processing speed, as well as current psychopathology, functioning, and endorsement of defeatist beliefs, were employed. Greater neurocognitive impairment was associated with elevated defeatist belief endorsement, higher negative symptom levels, and worse social and vocational functioning. Notably, statistical modeling indicated that defeatist belief endorsements were mediators in the relationship between cognitive impairment and both negative symptoms and functioning. These effects were independent of depression and positive symptom levels. The results add to the emerging biopsychosocial understanding of negative symptoms and introduce defeatist beliefs as a new psychotherapeutic target.

The role of effort, cognitive expectancy appraisals and coping style in the maintenance of the negative symptoms of schizophrenia

The aim of the present study was to assess the role of psychological factors, specifically effort, coping, and negative expectancy appraisals, in addition to executive functioning and depression, in accounting for negative symptoms broadly defined. Fifty inpatients with acute schizophrenia participated in a study with a cross-sectional design. All of the psychological variables had significant partial correlations with some of the measures of negative symptoms when depression was controlled. A series of multiple regression analyses indicated that executive functioning only made a significant unique contribution to the prediction of affective flattening, whereas psychological factors made unique contributions to the variance in each of the negative symptom subscales apart from affective flattening, as well as to the negative symptom total score, accounting for 9% to 19% of the variance. These results suggest that, in addition to neuropsychological variables, psychological variables are important for understanding negative symptoms in acute schizophrenia.

Cognitive approaches to schizophrenia: theory and therapy

A theoretical analysis of schizophrenia based on a cognitive model integrates the complex interaction of predisposing neurobiological, environmental, cognitive, and behavioral factors with the diverse symptomatology. The impaired integrative function of the brain, as well as the domain-specific cognitive deficits, increases the vulnerability to aversive life experiences, which lead to dysfunctional beliefs and behaviors. Symptoms of disorganization result not only from specific neurocognitive deficits but also from the relative paucity of resources available for maintaining a set, adhering to rules of communication, and inhibiting intrusion of inappropriate ideas. Delusions are analyzed in terms of the interplay between active cognitive biases, such as external attributions, and resource-sparing strategies such as jumping to conclusions. Similarly, the content of hallucinations and the delusions regarding their origin and characteristics may be understood in terms of biased information processing. The interaction of neurocognitive deficits, personality, and life events leads to the negative symptoms characterized by negative social and performance beliefs, low expectancies for pleasure and success, and a resource-sparing strategy to conserve limited psychological resources. The comprehensive conceptualization creates the context for targeted psychological treatments.

The negative symptoms of schizophrenia: a cognitive perspective

Recent reports of improvement in the negative symptoms of schizophrenia following targeted cognitive interventions have prompted interest in the cognitive underpinnings of these symptoms. This review integrates current experimental research with the phenomenological accounts of patients participating in cognitive therapy for these specific symptoms. We propose that, in addition to the well-established role of neurobiological factors in their development and maintenance, specific cognitive appraisals and beliefs play a role in the expression and persistence of negative symptoms. This cognitive model of negative symptoms is based on a diathesis-stress formulation: a continuum of predispositional traits from the premorbid personality to the full-blown negative symptomatology, the incorporation of negative social and performance attitudes within these traits, and low expectancies for pleasure or success in goal-oriented activities. We suggest that negative symptoms represent, in part, a compensatory pattern of disengagement in response to threatening delusional beliefs, perceived social threat, and anticipated failure in tasks and social activities. A psychological aspect of this motivational and behavioural inertia appears to be the patient's perception of limited psychological resources--a perception that motivates patients to conserve energy by minimizing investment in activities requiring effort.