Annotated Bibliograghy

Schizophrenia Research 165 (2015) 243–246

Contents lists available at ScienceDirect

Schizophrenia Research

journal homepage: www.elsevier.com/locate/schres

Jumping to conclusions and the persistence of delusional beliefs in first episode psychosis

M. Aurora Falcone a,b,⁎, Robin M. Murray b, Jennifer A. O'Connor b, Leanne N. Hockey b, Poonam Gardner-Sood b, Marta Di Forti b, Daniel Freeman c, Suzanne Jolley a

a King's College, London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, London, UK b King's College, London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, London, UK c University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford, UK

⁎ Corresponding author at: Department of Psychos Psychiatry, Psychology & Neuroscience, De Crespigny Tel.: +44 207 848 0100; fax: +44 207848 0287.

E-mail address: [email protected] (M.A. Falcon

http://dx.doi.org/10.1016/j.schres.2015.04.019 0920-9964/© 2015 Elsevier B.V. All rights reserved.

a b s t r a c t

a r t i c l e i n f o

Article history:

Received 29 November 2014 Received in revised form 28 February 2015 Accepted 15 April 2015 Available online 6 May 2015

Keywords: Psychosis Delusions Reasoning Jumping to conclusions Neuropsychology

Background: Cognitive biases may contribute to delusion persistence. We tested this in a longitudinal study of first episode psychosis (FEP). Methods: 34 FEP patients completed assessments of delusions and Jumping to Conclusions (JTC) at baseline and 12-month follow-up. Results: JTC was associated with baseline delusion severity (t(32) = 2.7, p = 0.01). Baseline delusions persisted at follow-up for 8/20 participants (40%), who all jumped to conclusions (8/8, 100%), compared to half of those with no or changeable delusions (14/26, 54%; χ2 (df = 1) = 5.7, p = 0.03; Phi = 0.4). Conclusion: Findings implicate cognitive biases in delusion persistence, and support the potential to reduce delu- sions through reasoning-focused interventions.

© 2015 Elsevier B.V. All rights reserved.

1. Introduction

The Jumping to Conclusions (JTC) bias is a tendency to make decisions with certainty based on limited data-gathering. There is substantial support for its presence in patients with delusions (Fine et al., 2007; Garety et al., 2011; So et al., 2012; Garety and Freeman, 2013; Jolley et al., 2014), and emerging evidence of associations with outcome and change in delusions, both as a potential marker for response to antipsy- chotic medication (Andreou et al., 2014; Menon et al., 2008; So et al., 2014) and a manipulable target of psychological intervention (e.g. Garety et al., 2014; Lincoln et al., 2014; Moritz et al., 2013; Sanford et al., 2013; Warman et al., 2013).

To date, only one study has investigated JTC and delusion persistence in first episode psychosis (FEP; Dudley et al., 2013). Dudley and col- leagues found persistent JTC and delusions to be associated at follow- up, but no baseline associations, providing only partial support for a maintaining role of JTC. Possible reasons for the failure to find baseline associations include subjective rating of delusions according to the di- mension of distress and low baseline rates of JTC and delusion severity. Our own previous work showed that, when using objective assessments

is Studies, PO 52, Institute of Park, London SE5 8AF, UK.

e).

of delusions, in a FEP group with rates of delusions and JTC comparable to those found in established psychosis, the baseline association of the JTC bias with delusion severity was replicated (Falcone et al., 2014).

The current study is a longitudinal follow-up of the same participants at 12-months. Our aim was to investigate the association of the JTC bias with delusion persistence, as persistent delusions are the targets of psychological intervention. We hypothesised firstly that we would replicate the association of JTC with delusion severity at baseline (i.e. during a psychotic episode) found in our larger sample, and secondly that the persistence of delusions at a clinical level of severity would be associated with the tendency to JTC.

2. Methods

2.1. Participants

Thirty-four participants (31% of the baseline sample (n = 108) re- ported by Falcone et al., 2014) completed measures of delusions and reasoning at both baseline and 12-month follow-up. All participants completing study measures at the two time points were included. Par- ticipants were assessed as part of the Genetics and Psychosis (GAP) study (Di Forti et al., 2012; O'Connor et al., 2012; Stilo et al., 2013; Wiffen et al., 2014) which was designed to identify genetic and environ- mental factors associated with psychosis. Ethical approval was granted by the joint Institute of Psychiatry and South London and Maudsley

Table 1 Demographic and clinical characteristics at baseline and follow-up.

Baseline (n = 34)

Follow-up (n = 34)

p

Mean (SD) Age in years 27.9 (7.9) 29.1 (7.7) [Range] [18–50] [19–51] PANSS delusion severity 2.7 (1.4) 2.2 (1.6) t = 1.8 (df = 33),

p = 0.08 [Range] [1–6] [1–6]

n (%) JTC

85:15 14 (41) 13 (38) 60:40 9 (26) 10 (29) Either 15 (44) 14 (41) p = 1.0a

244 M.A. Falcone et al. / Schizophrenia Research 165 (2015) 243–246

NHS Foundation Trust Research Ethics Committee; all participants gave informed written consent. GAP clinical inclusion criteria were: a current diagnosis of first episode psychosis (determined by clinical interview according to OPCRIT and DSM-IV criteria (APA, 1994; McGuffin et al., 1991)); within six months of first contact with services; current psychotic symptoms, experienced for at least seven days; age 18–65 years. Exclusion criteria were: a history of moderate or severe learning disabilities, or current IQ b 70, as assessed by the Wechsler Adult Intelligence Scale—Third Edition (Wechsler, 1997); insufficient command of English to complete assessments; a history of previous contact with mental health services for psychosis; a primary diagnosis of alcohol or substance dependency or a known organic cause of psychosis.

Delusion presence 20 (59%) 13 (38%) p = 0.03a

Diagnosis Schizophrenia 8 (23) Schizophreniform disorder 5 (15) Psychotic disorder NOS 6 (18) Schizoaffective disorder 4 (12) Affective disorder with psychosis 11 (32)

Key: PANSS, Positive and Negative Syndrome Scale; JTC, Jumping to Conclusions. a McNemar test; NOS: not otherwise specified.

2.2. Measures

Demographic data were collected by self-report, supplemented by clinical records. The delusion item of the Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) provided ratings of mean delusion severity (from 1 (absent) to 7 (extremely severe)). Delusion presence (rating ≥3 (mild)) was dichotomised into persistent (present at baseline and 12-month follow-up) or not (absent/present only once).

Jumping to Conclusions (JTC): Two versions of the Probabilistic Rea- soning ‘Beads’ Task (Garety et al., 2005) were employed, with beads in 85:15 and 60:40 ratios. Participants were shown two jars containing coloured beads in opposite ratios (e.g., mainly black: 85 black and 15 orange beads; mainly orange: 85 orange and 15 black beads), then a series of beads, one at a time, drawn from one of the two jars randomly selected by the computer. Participants were asked to request as many beads as they needed to be certain of the jar of origin. Deciding after fewer than three beads was classified as JTC. As we were concerned with the potential for the bias to influence day-to-day decision- making, rather than its consistency between tasks, or over time, we con- sidered a single hasty decision on any task, at any time point to be evi- dence of the tendency to JTC, and rated this dichotomously (no JTC/JTC at least once; Garety et al., 2005; Jolley et al., 2014; So et al., 2012).

2.3. Analyses

Data were analysed using the Statistical Package for the Social Sciences Version 20.0 (IBM, 2011). Rates of JTC and delusions and delu- sion severity were compared at baseline and follow-up using McNemar tests and paired sample t-tests. For hypothesis one, severity of delusions between JTC groups at baseline was compared using independent sample t-tests. For hypothesis two, rates of JTC between those with and without persistent delusions were compared using Chi-square tests.

3. Results

Demographic and clinical characteristics are shown in Table 1. Participants were predominantly male (22/34, 65%) and of Black or Minority Ethnic (BME) background (23/34, 68%).

3.1. Hypothesis 1: JTC will be associated with the severity of delusions at baseline

The findings replicated our previous report (Falcone et al., 2014), with more severe delusions in those showing the JTC bias (JTC mean: 3.4 (SD 1.4); no JTC mean: 2.2 (SD 1.2), t = 2.7, df = 32, p = 0.01). Of the 20 participants with delusions at baseline, 55% (11/20) jumped to conclusions, compared to 29% of those without delusions (4/14).

3.2. Hypothesis 2: JTC will be associated with the persistence of delusions at follow-up

Overall rates of JTC remained consistent, with two thirds showing the bias at least once (22/34; 65%), though only seven individuals showed the bias consistently (Table 2). Rates of delusions reduced, with a non-significant reduction in delusion severity (Table 1). Nearly half of those with delusions at baseline had persisting delusions at follow-up (8/20; 40%), and all those with persisting delusions jumped to conclusions at least once (8/8, 100%), compared to half of those with no (6/11) or changeable (8/15) delusions (14/26, 54%; χ2 (df = 1) = 5.7, p = 0.03; Phi = 0.4; Table 2).

4. Discussion

We tested associations of the JTC reasoning bias with delusion per- sistence in FEP. The prevalence and severity of delusions and rates of JTC in followed-up participants matched our previous, larger study (Falcone et al., 2014), suggesting that this subsample comprised repre- sentative participants. At baseline, during participants' first psychotic episode, the well-established association of delusion severity with JTC was replicated. Over time, rates of JTC remained stable, but individual participants showed variation in their data-gathering, with only a third never jumping to conclusions. Delusions mostly improved over time, but persisted for around half of participants. All participants with persisting delusions jumped to conclusions at least once, compared to only half of those with no or changeable delusions. The association of JTC with delusion persistence was significant, with a medium to large effect size. Limitations of the study include the small number of partic- ipants followed up from baseline (31%); that we did not control for the effects of medication or any other treatments; and that data on age of onset were not collected for this study. The mean delusion scores presented in Table 2 are based on small numbers, and are reported to explicate the results, rather than to represent a reliable statistical average. We operationalised JTC as a dichotomous variable, using the criterion of fewer than three beads to indicate the presence of the bias. Analyses of the number of draws to decision, or employing an alternative dichotomy, were not carried out, and may have given different results. Finally, notwithstanding the longitudinal design of the study, we did not test whether the bias precedes the development of delusions, and a causal role for the bias in the onset of delusions cannot be inferred from these results.

Table 2 Number of participants showing each pattern of change in Jumping to Conclusions (JTC) and delusions over time, with mean delusiona severity scores (SD) at baseline (BL) and follow-up (FU).

Delusion-free at least once Persistent Delusions

Total

No delusions at BL or FU

Delusions at BL only Delusions at FU only

No JTC BL 1.2 (0.4) 3.5 (0.5) 1.0 (–) – 2.3 (1.3) FU 1.2 (0.4) 1.5 (0.5) 6.0 (–) – 1.75 (1.4) n 5/11 6/12 1/3 0/8 12/34

JTC at least once BL 1.3 (0.5) 3.5 (0.8) 2.0 (0) 4.0 (1.2) 3.0 (1.4) FU 1.0 (0) 1.0 (0) 3.5 (0.7) 4.3 (0.9) 2.4 (1.7) n 6/11 6/12 2/3 8/8 22/34

- JTC at BL only BL 2.0 (–) 3.3 (0.6) – 4.5 (1.3) 3.8 (1.3) FU 1.0 (–) 1.0 (0) – 4.7 (1.0) 2.9 (2.1) n 1 3 0 4 8

- JTC at FU only BL 1.3 (0.5) 3.0 (–) – 3.0 (0) 2.0 (1.0) FU 1.0 (0) 1.0 (–) – 4.0 (0) 1.9 (1.5) n 4 1 0 2 7

- JTC at BL & FU BL 1.0 (–) 4.0 (1.4) 2.0 (0) 4.0 (1.4) 3.0 (1.5) FU 1.0 (–) 1.0 (0) 3.5 (0.7) 3.5 (0.7) 2.4 (1.4) n 1 2 2 2 7

Total BL 1.3 (0.5) 3.5 (0.7) 1.7 (0.6) 4.0 (1.2) 2.7 (1.4) FU 1.1 (0.3) 1.3 (1.4) 4.3 (1.5) 4.3 (0.9) 2.2 (1.6) n 11 12 3 8 34

Key: JTC, Jumping to Conclusions; BL, baseline; FU, follow-up. a Measured by the PANSS (Kay et al., 1987).

245M.A. Falcone et al. / Schizophrenia Research 165 (2015) 243–246

Our findings do support a maintaining role for the JTC bias in delusions. They also support the growing evidence base showing the effectiveness of targeted interventions to modify JTC, such as the Maudsley Review Training Programme (Waller et al., 2011), Metacognitive Training (MCT; Moritz et al., 2014a, 2014b) and Social Cognition and Interaction Training (SCIT; e.g. Roberts et al., 2014), in reducing delusion persistence and improving outcomes for people with psychosis.

We thank the study participants for their time, and the GAP team. This work was supported by the NIHR Biomedical Research Centre

for Mental Health at the South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, Psychology & Neuroscience, King's College London; the Institute of Psychiatry, Psychology & Neuroscience at King's College London; and the Psychiatry Research Trust. DF is sup- ported by a Medical Research Council Senior Clinical Fellowship.

Role of the funding source This work was supported by the NIHR Biomedical Research Centre for Mental Health

at the South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, Psy- chology & Neuroscience, King's College London; the Institute of Psychiatry, Psychology & Neuroscience at King's College London; and the Psychiatry Research Trust. DF is supported by a Medical Research Council Senior Clinical Fellowship (G0902308).

Acknowledgement We thank the study participants for their time, and the GAP team.

References

American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV). American Psychiatric Association, Washington, DC.

Andreou, C., Moritz, S., Veith, K., Veckenstedt, R., Naber, D., 2014. Dopaminergic modula- tion of probabilistic reasoning and overconfidence in errors: a double-blind study. Schizophr. Bull. 40 (3), 558–565.

Di Forti, M., Iyegbe, C., Sallis, H., Kolliakou, A., Falcone, M.A., Paparelli, A., Murray, R.M., 2012. Confirmation that the AKT1 (rs2494732) genotype influences the risk of psychosis in cannabis users. Biol. Psychiatry 72 (10), 811–816.

Dudley, R., Daley, K., Nicholson, M., Shaftoe, D., Spencer, H., Cavanagh, K., Freeston, M., 2013. ‘Jumping to conclusions’ in first-episode psychosis: a longitudinal study. Br. J. Clin. Psychol. 52 (4), 380–393.

Falcone, M.A., Murray, R.M., Wiffen, B.D.R., O'Connor, J.A., Russo, M., Kolliakou, A., Jolley, S., 2014. Jumping to conclusions, neuropsychological functioning, and delu- sional beliefs in first episode psychosis. Schizophr. Bull. 41 (2), 411–418.

Fine, C., Gardner, M., Craigie, J., Gold, I., 2007. Hopping, skipping or jumping to conclu- sions? Clarifying the role of the JTC bias in delusions. Cogn. Neuropsychiatry 12 (1), 46–77.

Garety, P.A., Freeman, D., 2013. The past and future of delusions research: from the inex- plicable to the treatable. Br. J. Psychiatry 203 (5), 327–333.

Garety, P.A., Freeman, D., Jolley, S., Dunn, G., Bebbington, P.E., Fowler, D.G., Dudley, R., 2005. Reasoning, emotions, and delusional conviction in psychosis. J. Abnorm. Psychol. 114 (3), 373–384.

Garety, P.A., Freeman, D., Jolley, S., Waller, H., Dunn, G., 2011. Jumping to conclusions: the psychology of delusional reasoning. Adv. Psychiatr. Treat. 17, 332–339.

Garety, P., Waller, H., Emsley, R., Jolley, S., Kuipers, E., Bebbington, P., Freeman, D., 2014. Cognitive mechanisms of change in delusions: an experimental investigation targeting reasoning to effect change in paranoia. Schizophr. Bull. 41 (2), 400–410.

IBM Corp. Released, 2011. IBM SPSS Statistics for Windows, Version 20.0. IBM Corp., Armonk, NY.

Jolley, S., Thompson, C., Hurley, J., Medin, E., Butler, L., Bebbington, P., Garety, P., 2014. Jumping to the wrong conclusions? An investigation of the mechanisms of reasoning errors in delusions. Psychiatry Res. 219 (2), 275–282.

Kay, S.R., Fiszbein, A., Opler, L.A., 1987. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr. Bull. 13 (2), 261–276.

Lincoln, T.M., Rief, W., Westermann, S., Ziegler, M., Kesting, M.L., Heibach, E., Mehl, S., 2014. Who stays, who benefits? Predicting dropout and change in cognitive behaviour therapy for psychosis. Psychiatry Res. 216 (2), 198–205.

McGuffin, P., Farmer, A., Harvey, I., 1991. A polydiagnostic application of operational criteria in studies of psychotic illness—development and reliability of the opcrit system. Arch. Gen. Psychiatry 48 (8), 764–770.

Menon, M., Mizrahi, R., Kapur, S., 2008. Jumping to conclusions and delusions in psychosis: relationship and response to treatment. Schizophr. Res. 98 (1-3), 225–231.

Moritz, S., Veckenstedt, R., Bohn, F., Hottenrott, B., Scheu, F., Randjbar, S., Roesch-Ely, D., 2013. Complementary group Metacognitive Training (MCT) reduces delusional ideation in schizophrenia. Schizophr. Res. 151 (1-3), 61–69.

Moritz, S., Andreou, C., Schneider, B.C., Wittekind, C.E., Menon, M., Balzan, R.P., Woodward, T.S., 2014a. Sowing the seeds of doubt: a narrative review on metacognitive training in schizophrenia. Clin. Psychol. Rev. 34 (4), 358–366.

Moritz, S., Veckenstedt, R., Andreou, C., Bohn, F., Hottenrott, B., Leighton, L., Roesch-Ely, D., 2014b. Sustained and “sleeper” effects of group metacognitive training for schizo- phrenia a randomized clinical trial. JAMA Psychiatry 71 (10), 1103–1111.

O'Connor, J.A., Wiffen, B.D.R., Reichenberg, A., Aas, M., Falcone, M.A., Russo, M., David, A.S., 2012. Is deterioration of IQ a feature of first episode psychosis and how can we measure it? Schizophr. Res. 137 (1-3), 104–109.

Roberts, D.L., Combs, D.R., Willoughby, M., Mintz, J., Gibson, C., Rupp, B., Penn, D.L., 2014. A randomized, controlled trial of Social Cognition and Interaction Training (SCIT) for outpatients with schizophrenia spectrum disorders. Br. J. Clin. Psychol. 53 (3), 281–298.

Sanford, N., Lecomte, T., Leclerc, C., Wykes, T., Woodward, T.S., 2013. Change in jumping to conclusions linked to change in delusions in early psychosis. Schizophr. Res. 147 (1), 207–208.

So, S.H.-W., Freeman, D., Dunn, G., Kapur, S., Kuipers, E., Bebbington, P., Garety, P.A., 2012. Jumping to conclusions, a lack of belief flexibility and delusional conviction in psy- chosis: a longitudinal investigation of the structure, frequency, and relatedness of reasoning biases. J. Abnorm. Psychol. 121 (1), 129–139.

So, S.H.-W., Peters, E.R., Swendsen, J., Garety, P.A., Kapur, S., 2014. Changes in delusions in the early phase of antipsychotic treatment—an experience sampling study. Psychiatry Res. 215 (3), 568–573.

Stilo, S.A., Di Forti, M., Mondelli, V., Falcone, A.M., Russo, M., O'Connor, J., Morgan, C., 2013. Social disadvantage: cause or consequence of impending psychosis? Schizophr. Bull. 39 (6), 1288–1295.

Waller, H., Freeman, D., Jolley, S., Dunn, G., Garety, P., 2011. Targeting reasoning biases in de- lusions: a pilot study of the Maudsley Review Training Programme for individuals with persistent, high conviction delusions. J. Behav. Ther. Exp. Psychiatry 42 (3), 414–421.

246 M.A. Falcone et al. / Schizophrenia Research 165 (2015) 243–246

Warman, D.M., Martin, J.M., Lysaker, P., 2013. Jumping to conclusions and delusions: the impact of discussion of the bias on the bias. Schizophr. Res. 150 (2-3), 575–579.

Wechsler, D., 1997. Wechsler Memory Scale—Third Edition: Administration and Scoring Manual. The Psychological Corporation, San Antonio, TX.

Wiffen, B.D.R., O'Connor, J.A., Russo, M., Falcone, M.A., Joseph, C., Kolliakou, A., David, A.S., 2014. Do psychosis patients with poor insight show implicit awareness on the emo- tional Stroop task? Psychopathology 47 (2), 93–100.