Does CBT for Psychosis Have an Impact on Delusions by Improving Reasoning Biases and Negative Self-Schemas?
A Secondary Mediation Analysis of Data From an Effectiveness Trial
Abstract
Abstract. Cognitive-behavioral therapy for psychosis (CBTp) builds on theoretical models that postulate reasoning biases and negative self-schemas to be involved in the formation and maintenance of delusions. However, it is unclear whether CBTp induces change in delusions by improving these proposed causal mechanisms. This study reports on a mediation analysis of a CBTp effectiveness trial in which delusions were a secondary outcome. Patients with psychosis were randomized to individualized CBTp (n = 36) or a waiting list condition (WL; n = 34). Reasoning biases (jumping to conclusions, theory of mind, attribution biases) and self-schemas (implicit and explicit self-esteem; self-schemas related to different domains) were assessed pre- and post-therapy/WL. The results reveal an intervention effect on two of four measures of delusions and on implicit self-esteem. Nevertheless, the intervention effect on delusions was not mediated by implicit self-esteem. Changes in explicit self-schemas and reasoning biases did also not mediate the intervention effects on delusions. More focused interventions may be required to produce change in reasoning and self-schemas that have the potential to carry over to delusions.
References
2016). Feasibility and effects of a brief compassion-focused imagery intervention in psychotic patients with paranoid ideation: A randomized experimental pilot study. Clinical Psychology and Psychotherapy, 24, 348–358. https://doi.org/10.1002/cpp.2003
(1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic and statistical considerations. Journal of Personality and Social Psychology, 51, 1173–1182.
(2003). Self-esteem in schizophrenia: Relationships between self-evaluation, family attitudes, and symptomatology. Journal of Abnormal Psychology, 112, 92–99. https://doi.org/10.1176/appi.ajp.158.4.527
(2011).
(A cognitive conceptualization of negative symptoms . In A. T. BeckN. RectorN. StolarP. GrantEds., Schizophrenia: Cognitive theory, research, and therapy (pp. 1011–1022). New York, NY: Guilford Press.2014). From adversity to psychosis: pathways and mechanisms from specific adversities to specific symptoms. Social Psychiatry and Psychiatric Epidemiology, 49. https://doi.org/10.1007/s00127-014-0914-0
(2002). Retest-Reliabilität und faktorenanalytische Dimensionalität der FSKN
([Retest reliability and factor dimensions of the Frankfurt Self-Concept Scales (FSKN)] . Zeitschrift für Differentielle und Diagnostische Psychologie, 23, 367–380. https://doi.org/10.1024//0170-1789.23.4.3672001). Cognitive neuropsychiatric models of persecutory delusions. The American Journal of Psychiatry, 158, 527–539. https://doi.org/10.1176/appi.ajp.158.4.527
(2009). Strong claims and weak evidence: Reassessing the predictive validity of the IAT. Journal of Applied Psychology, 94, 567–582. https://doi.org/10.1037/a0014665
(2010). Statistik für Sozialwissenschaftler
([Statistics for sports scientists] . Berlin, Germany: Springer.2000). Stalking the perfect measure of implicit self-esteem: The blind man and the elephant revisited? Journal of Personality and Social Psychology, 79, 631–643. https://doi.org/10.1037/0022-3514.79.4.631
(2016). The importance of human relationships, ethics and recovery-orientated values in the delivery of CBT for people with psychosis. psychosis, 9, 1–10. https://doi.org/10.1080/17522439.2016.1259648
(2008). A cross-sectional survey of the frequency and characteristics of delusions in acute psychiatric wards. Australasian Psychiatry, 16, 87–91. https://doi.org/10.1080/10398560701633176
(1999). The psychosis of schizophrenia: Prevalence, response to atypical antipsychotics and prediction of outcome. Biological Psychiatry, 46, 361–364. https://doi.org/10.1016/S0006-3223(99)00040-2
(2005). Deutsche Übersetzung des Internal, Personal and Situational Attributions Questionnaire
([German translation of the Internal, Personal and Situational Attributions Questionnaire] . Unpublished manuscript, University of Bochum, Germany.2011). Implicit self-esteem: Nature, measurement, and a new way forward. Journal of Personality and Social Psychology, 100, 365–385. https://doi.org/10.1037/a0021341
(1986). Factor structure of the Dysfunctional Attitude Scale in a student population. Journal of Clinical Psychology, 42, 307–309. https://doi.org/10.1002/1097-4679(198603)42:2<307::AID-JCLP2270420213>3.0.CO;2-J
(2017). Assessment of functioning and disability in patients with schizophrenia using the WHO Disability Assessment Schedule 2.0 in a large-scale database. European Archives of Psychiatry and Clinical Neuroscience, 268, 65–75. https://doi.org/10.1007/s00406-017-0834-6
(1986). Die Frankfurter Selbstkonzeptskalen
([Frankfurt self-concept scales] . Göttingen, Germany: Hogrefe.2016). Psychosis, delusions and the “jumping to conclusions” reasoning bias: A systematic review and meta-analysis. Schizophrenia Bulletin, 42, 652–665. https://doi.org/10.1093/schbul/sbv150
(2016). Acceptance and efficacy of metacognitive training (MCT) on positive symptoms and delusions in patients with schizophrenia: A meta-analysis taking into account important moderators. Schizophrenia Bulletin, 42, 952–962. https://doi.org/10.1093/schbul/sbv225
(2005). Comparison of the performance of nonparametric and parametric MANOVA test statistics when assumptions are violated. Methodology, 1, 27–38. https://doi.org/10.1027/1614-1881.1.1.27
(2017). A meta-analysis of change in implicit bias. PsyArxPreprints. https://doi.org/10.17605/OSF.IO/DV8TU
(1995). Cognitive behaviour therapy for psychosis. Theory and practice. Chichester, UK: Wiley.
(2012). Negative cognition, depressed mood, and paranoia: A longitudinal pathway analysis using structural equation modeling. Schizophrenia Bulletin, 38, 1063–1073. https://doi.org/10.1093/schbul/sbr019
(2014). Advances in understanding and treating persecutory delusions: A review. Social Psychiatry and Psychiatric Epidemiology, 49, 1179–1189. https://doi.org/10.1007/s00127-014-0928-7
(2005). Psychological investigation of the structure of paranoia in a non-clinical population. The British Journal of Psychiatry, 186, 427–435. https://doi.org/10.1192/bjp.186.5.427
(2014). An early Phase II randomised controlled trial testing the effect on persecutory delusions of using CBT to reduce negative cognitions about the self: The potential benefits of enhancing self-confidence. Schizophrenia Research, 160, 186–192. https://doi.org/10.1016/j.schres.2014.10.038
(2013). The past and future of delusion research: From the inexplicable to the treatable. The British Journal of Psychiatry, 203, 327–333. https://doi.org/10.1192/bjp.bp.113.126953
(2001). A cognitive model of the positive symptoms of psychosis. Psychological Medicine, 31, 189–195. https://doi.org/10.1017/S0033291701003312
(2015). Cognitive mechanisms of change in delusions: An experimental investigation targeting reasoning to effect change in paranoia. Schizophrenia Bulletin, 41, 400–410. https://doi.org/10.1093/schbul/sbu103
(2010). Compassion-focused therapy: Distinctive features. London, UK: Routledge Chapman & Hall.
(1998). Measuring individual differences in implicit cognition: The Implicit Association Test. Journal of Personality and Social Psychology, 74, 1464–1480. https://doi.org/10.1037/0022-3514.74.6.1464
(2003). Understanding and using the Implicit Association Test I: An improved scoring algorithm. Journal of Personality and Social Psychology, 85, 197–216. https://doi.org/10.1037/0022-3514.85.2.197
(2007). Explicit and implicit cognition: A preliminary test of a dual-process theory of cognitive vulnerability to depression. Behaviour Research and Therapy, 45, 1155–1167. https://doi.org/10.1016/j.brat.2006.09.003
(2003). The cognitive-behavioural treatment of low self-esteem in psychotic patients: A pilot study. Behaviour Research and Therapy, 41, 317–332. https://doi.org/10.1016/S0005-7967(02)00013-X
(1985). Skala dysfunktionaler Einstellungen – eine deutsche Version der Dysfunctional Attitude Scale (DAS)
([German version of the Dysfunctional Attitude Scale (DAS)] . Diagnostica, 31, 312–323.2014). Statistical mediation analysis with a multicategorical independent variable. British Journal of Mathematical and Statistical Psychology, 67, 451–470. https://doi.org/10.1111/bmsp.12028
(2014). Schizophrenia: An integrated sociodevelopmental-cognitive model. Lancet, 383(9929), 1677–1687. https://doi.org/10.1016/S0140-6736(13)62036-X
(1988). Probabilistic judgements in deluded and non-deluded subjects. The Quaterly Journal of Experimental Psychology, 40, 801–812. https://doi.org/10.1080/14640748808402300
(2014). Cognitive-behavioural therapy for the symptoms of schizophrenia: Systematic review and meta-analysis with examination of potential bias. The British Journal of Psychiatry, 204, 20–29. https://doi.org/10.1192/bjp.bp.112.116285
(2017). A longitudinal mediation analysis of the effect of negative-self schemas on positive symptoms via negative affect. Psychological Medicine, 28, 1–11. https://doi.org/10.1017/S003329171700277X
(2014). Cognitive behavioural therapy versus other psychosocial treatments for schizophrenia. Cochrane Database of Systematic Reviews, 4, CD008712. https://doi.org/10.1002/14651858.CD008712.pub2
(1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13, 261–276. https://doi.org/10.1093/schbul/13.2.261
(1992). Positive and Negative Syndrome Scale (PANSS). New York, NY: Multi Health Systems Inc.
(2013). The impact of social stress on self-esteem and paranoid ideation. Journal of Behaviour Therapy and Experimental Psychiatry, 44, 122–128. https://doi.org/10.1016/j.jbtep.2012.07.010
(2013). The relevance of self-esteem and self-schemas to persecutory delusions: A systematic review. Comprehensive Psychiatry, 54, 766–789. https://doi.org/10.1016/j.comppsych.2013.03.002
(1996). A new measure of causal locus: The Internal, Personal and Situational Attributions Questionnaire. Personal and Individual Differences, 20, 261–264. https://doi.org/10.1016/0191-8869(95)00186-7
(1997). Causal attributions in paranoia and depression: Internal, personal, and situational attributions for negative events. Journal of Abnormal Psychology, 106, 341–345. https://doi.org/10.1037/0021-843X.106.2.341
(2010). Reliability of implicit self-esteem measures revisited. European Journal of Personality, 25, 239–251. https://doi.org/10.1002/per.792
(1999). Efficacy of a self-esteem module in the empowerment of individuals with schizophrenia. Journal of Nervous and Mental Disease, 187, 406–413. https://doi.org/10.1097/00005053-199907000-00003
(2006). Kognitive Verhaltenstherapie der Schizophrenie: Ein individuenzentrierter Ansatz zur Veränderung von Wahn, Halluzinationen und Negativsymptomatik
([Cognitive-behavioral therapy for schizophrenia: A person-centered approach to changing delusions, hallucinations, and negative symptoms] . Göttingen, Germany: Hogrefe.2015). Dealing with feeling: Specific emotion-regulation skills predict responses to stress in psychosis. Psychiatry Research, 228, 216–222. https://doi.org/10.1016/j.psychres.2015.04.003
(2013). Can paranoid thoughts be reduced by targeting negative emotions and self-esteem? An experimental investigation of a brief compassion focussed intervention. Cognitive Therapy and Research, 37, 390–402. https://doi.org/10.1007/s10608-012-9470-7
(2009). Die Erfassung von Wahn und Halluzinationen in der Normalbevölkerung. Deutsche Adaptationen des Peters et al. Delusions Inventory (PDI) und der Launay Slade Hallucination Scale (LSHS-R)
([The Assessment of delusions and hallucinations in the general population. German adaptations of the Peters et al. Delusions Inventory (PDI) and the Launay Slade Hallucination Scale (LSHS-R)] . Diagnostica, 55, 29–40. https://doi.org/10.1026/0012-1924.55.1.292010). From stress to paranoia: An experimental investigation of the moderating and mediating role of reasoning biases. Psychological Medicine, 40, 169–171. https://doi.org/10.1017/S003329170999095X
(2017). The relevance of emotion regulation in explaining why social exclusion triggers paranoia in individuals at clinically high risk to psychosis. Schizophrenia Bulletin. Advance online publication. https://doi.org/10.1093/schbul/sbx135
(2010). Can delusions be self-assessed. Concordance between self- and observer rated delusions in schizophrenia. Psychiatry Research, 178, 249–254. https://doi.org/10.1016/j.psychres.2009.04.019
(2012). Moving from efficacy to effectiveness in cognitive behavioral therapy for psychosis: A randomized clinical practice trial. Journal of Consulting and Clinical Psychology, 80, 674–686. https://doi.org/10.1037/a0028665
(2010). The jumping to conclusions bias in delusions: Specificity and changeability. Journal of Abnormal Psychology, 119, 40–49. https://doi.org/10.1037/a0018118
(2017). Negative affect and a fluctuating jumping to conclusions bias predict subsequent paranoia in daily life: An online experience sampling study. Behaviour Therapy and Experimental Psychiatry, 56, 106–112. https://doi.org/10.1016/j.jbtep.2016.08.014
(1977). Self-schemata and processing information about the self. Personality and Social Psychology, 35, 63–78. https://doi.org/10.1037/0022-3514.35.2.63
(2007). Mediation Analysis. Annual Review of Psychology, 58, 593–614. https://doi.org/10.1146/annurev.psych.58.110405.085542
(2015). Why do bad things happen to me? Attributional style, depressed mood, and persecutory delusions in patients with schizophrenia. Schizophrenia Bulletin, 40, 1338–1346. https://doi.org/10.1093/schbul/sbu040
(2010). Social performance is more closely associated with theory of mind and autobiographical memory than with psychopathological symptoms in clinically stable patients with schizophrenia-spectrum disorders. Psychiatry Research, 178, 276–283. https://doi.org/10.1016/j.psychres.2009.10.004
(2015). Does cognitive behavior therapy for psychosis (CBTp) show a sustainable effect on delusions? A meta-analysis. Frontiers of Psychology, 6, 1450–1459. https://doi.org/10.3389/fpsyg.2015.01450
(2011). Further evidence for the efficacy of a metacognitive group training in schizophrenia. Behavior Research and Therapy, 49, 151–157. https://doi.org/10.1016/j.brat.2010.11.010
(2007). Metacognitive training in schizophrenia: From basic research to knowledge translation and intervention. Current Opinion in Psychiatry, 20, 619–625. https://doi.org/10.1097/YCO.0b013e3282f0b8ed
(2010). What are the components of CBT for psychosis? A Delphi study. Schizophrenia Bulletin, 36, 136–142. https://doi.org/10.1093/schbul/sbp118
(2018). Psychology’s renaissance. Annual Review of Psychology, 69, 511–534. https://doi.org/10.1146/annurev-psych-122216-011836
(2018). A systematic review of trials targeting depression and anxiety in patients with delusions: An emotion-focused perspective. Zeitschrift für Psychologie, 226, 142–151. https://doi.org/10.1027/2151-2604/a000331
(2004). Measuring delusional ideation: The 21-item Peters et al. Delusions Inventory (PDI). Schizophrenia Bulletin, 30, 1005–1022. https://doi.org/10.1093/oxfordjournals.schbul.a007116
(1999). Measurement of delusional ideation in the normal population: Introducing the PDI (Peters et al. Delusions Inventory). Schizophrenia Bulletin, 25, 553–576. https://doi.org/10.1093/oxfordjournals.schbul.a007116
(2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behaviour Research Methods, Instruments, & Computers, 36, 717–731. https://doi.org/10.3758/BF03206553
(1978). Does the chimpanzee have a ‘theory of mind’? Behavioural and Brain Science, 4, 515–526. https://doi.org/10.1017/S0140525X00076512
(2005). Rotten to the core: Neuroticism and implicit evaluations of the self. Self and Identity, 4, 361–372. https://doi.org/10.1080/15298860500241852
(1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press.
(2006).
(Relationships among causes . In E. SusserS. SchwartzA. MorabiaE. BrometEds., Psychiatric epidemiology: Searching for causes of mental disorders (pp. 62–74). Oxford, UK: Oxford University Press.2002). Mediation in experimental and nonexperimental studies: new procedures and recommendations. Psychological Methods, 7, 422–445. https://doi.org/10.1037/1082-989X.7.4.422
(2018). The predictive value of early maladaptive schemas in paranoid responses to social stress. Clinical Psychology and Psychotherapy, 25, 65–75. https://doi.org/10.1002/cpp.2128
(1993). A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients: I. Outcome. The British Journal of Psychiatry, 162, 524–532. https://doi.org/10.1192/bjp.162.4.524
(2008). Fluctuations in self-esteem and paranoia in the context of daily life. Journal of Abnormal Psychology, 117, 143–153. https://doi.org/10.1037/0021-843X.117.1.143
(2011). Emotions, self-esteem, and paranoid episodes: An experience sampling study. The British Journal of Clinical Psychology, 50, 178–195. https://doi.org/10.1348/014466510X508677
(2007). How CBT may improve social functioning in schizophrenia. Progress in Neurology and Psychiatry, 11, 19–21. https://doi.org/10.1002/pnp.13
(2014). Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. The American Journal of Psychiatry, 171, 523–538. https://doi.org/10.1176/appi.ajp.2013.13081159
(2014). The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: A meta-analysis. Schizophrenia Research, 156, 30–37. https://doi.org/10.1016/j.schres.2014.03.016
(2011). Symptom domains and neurocognitive functioning can help differentiate social cognitive processes in schizophrenia: A meta-analysis. Schizophrenia Bulletin, 39, 102–111. https://doi.org/10.1093/schbul/sbr067
(2003). Eine revidierte Fassung der deutschsprachigen Skala zum Selbstwertgefühl von Rosenberg
([A revised German version of the Rosenberg Self-Esteem Scale] . Zeitschrift für Diffentielle und Diagnostische Psychologie, 24, 3–7. https://doi.org/10.1024//0170-1789.24.1.32008). Validity of a happiness Implicit Association Test as a measure of subjective well-being. Journal of Research in Personality, 42, 490–497. https://doi.org/10.1016/j.jrp.2007.07.005
(2015). Thinking well: A randomised controlled feasibility study of a new CBT therapy targeting reasoning biases in people with distressing persecutory delusional beliefs. Journal of Behavioural Therapy and Experimental Psychiatry, 48, 82–89. https://doi.org/10.1016/j.jbtep.2015.02.007
(2011). Targeting reasoning biases in delusions: A pilot study of the Maudsley Review Training Programme for individuals with persistent, high conviction delusions. Journal of Behaviour Therapy and Experimental Psychiatry, 42, 414–421. https://doi.org/10.1016/j.jbtep.2011.03.001
(1978, November). Development and validation of the Dysfunctional Attitudes Scales. Paper presented at the 12th Annual Convention of the Association for Advancement of Behavior Therapy, Chicago, IL
(1997). Strukturiertes Klinisches Interview für DSM-VI (SKID)
([Structured clinical interview for DSM-IV (SKID)] . Göttingen, Germany: Hogrefe.2008). Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34, 523–537. https://doi.org/10.1093/schbul/sbm114
(1990). Cognitive therapy for personality disorders. Sarasota, FL: Professional Ressources Press.
(1999). Cognitive therapy for personality disorders: A schema-focused approach. Sarasota, FL: Professional Ressources Press.
(2003). Schema therapy: A practitioner’s guide. New York, NY: Guilford Press.
(