A cognitive investigation of schizophrenic delusions

Psychiatry Interpersonal & Biological Processes (Impact Factor: 3.05). 12/1979; 42(4):312-9.
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Delusions have traditionally been regarded as unmodifiable false beliefs. Both Freud (1911) and Jaspers (1968) argue that there is a unidirectional relationship between a delusional belief and consensually validatable realtiy: the delusion structures reality in accordance with the delusion's demand. In contrast, we postulate that there is a bidirectional interaction between the delusion and external events. We believe that external events might modify the rigid belief when there is a dramatic incongruity between specific beliefs and selected events. The following investigation was motivated by a desire to understand more clearly how some overtly delusional patients come to lose their delusions during the course of treatment for schizophrenia. Do delusions simply melt away under the influence of major tranquilizers, or does the delusional patient play some active part in assessing the validity of this belief?

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    • "In regard to research on dimensions of delusions, while we have focused on three dimensions, other important dimensions or characteristics of delusions also have become the subject of research and analysis (Hole et al. 1979; Rudden et al. 1982; Kendler et al. 1983; Garety and Hemsley 1994; Appelbaum et al. 1999). Some of these other dimensions include extension (Hole et al. 1979; Kendler et al. 1983; Brockington 1991; Appelbaum et al. 1999), fixity of ideas (Eisen et al. 1998), negative affect (Appelbaum et al. 1999), mood-congruent versus -incongruent delusions (Coryell and Tsuang 1985; Tohen et al. 1992; Harrow et al. 20006), and interference (Garety and Hemsley 1987). "
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    ABSTRACT: We studied three characteristics or dimensions of delusions in schizophrenia patients living in the community, including their influence on work and community functioning. The 149-patient sample included 57 delusional schizophrenia and nonschizophrenia outpatients, 50 nondelusional outpatient controls, and 42 delusional inpatient controls. The data indicated the strength and prominence of acute-phase psychopathology on characteristics of delusions, with large significant differences in intensity of delusions between the acute inpatient phase and the postacute inpatient and outpatient phases. Contrary to some views, the data indicate that the overall presence of any delusions in general, and the various dimensions of delusions, both influence work performance and community functioning, with the greater part of the variance due to the presence of delusions in general. Despite their outpatient status, delusional outpatients showed surprisingly poor self-monitoring about whether others would regard their delusional ideation as unrealistic. Schizophrenia and affectively disordered patients with high emotional commitment to their delusions showed significantly poorer work functioning and were significantly more likely to be rehospitalized (p < 0.05), indicating the important impact on functioning of patients' feelings of immediacy and urgency about their unrealistic beliefs.
    Full-text · Article · Jan 2004 · Schizophrenia Bulletin
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    • "This relative independence of most of the variables measured here also has implications for the assessment of delusions and of change in delusions It is not sufficient to assess one or two elements only, since the key elements do not appear to be strongly related and may not change at the same rate Kendler et al also make this point, noting that Hole et al ( 1979) found that individual dimensions of delusional experience often change independently of one another during the course of a psychotic episode. However while individual variables are not, for the most part, strongly correlated, the principal components analysis generated 4 components, or groups of variables which clustered together, (see Table 3) The first component, labelled distress, had high loading on resistance, worry and unhappiness The second, with high loadings on conviction, self-evidentness and, negatively, on absurdity, appeared to represent the belief strength The third component, labelled obtrusiveness consisted mostly of high loadings on the degree of preoccupation and (negatively) of dismissibility, while the final component loaded mostly on reassurance seeking, and thus was labelled concern The results of this principal component analysis suggested that there may be at least 4 processes which underlie these 11 elements of delusional experience It is not possible, at this stage, to speculate on their clinical significance ; however in assessing change in a delusion it may be valuable to assess at least 3 or 4 variables, 1 drawn from each of these 3 or 4 clusters, rather than simply assessing conviction alone (e g Watts et al 1973 ; Milton et al 1978) or conviction and preoccupation alone (e g Hole et al 1979 ; Hartman and Cashman 1983). The factors extracted by Kendler et al ( 1983), from the 5 dimensions measured, were those of delusional involvement with high loadings on conviction and pressure (preoccupation) and of delusional construct with high loadings on extension (the degree to which the belief involves different areas of one's life), disorganisation and bizarreness These factors do not relate clearly to the components presented here; this is however understandable since, in the Kendler et al study rather fewer measures were taken, and none of distress; furthermore , the variables were observer and not self-rated It is a matter of debate, perhaps, whether the delusional experience is best assessed by observers or by self-report. "
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    ABSTRACT: The characteristics of delusional experience were examined in a mixed group of 55 patients considered to be deluded; 11 belief characteristics were assessed by self-rating: conviction, preoccupation, interference, resistance, dismissibility, absurdity, self-evidentness, reassurance seeking, worry, unhappiness and pervasiveness. Only on level of conviction did no subject show a low score; on other dimensions there was considerable inter-subject variability. A principal components analysis indicated 4 components: distress, belief strength, obtrusiveness and concern. It is argued that delusions are most usefully regarded as multi-dimensional and, while characterised by conviction, vary considerably on other important dimensions.
    Full-text · Article · Feb 1987 · European Archives of Psychiatry and Neurological Sciences
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    ABSTRACT: Cognitive behavior therapy has been demonstrated in a number of randomized controlled trials to be efficacious for the treatment of psychosis. Emerging evidence suggests the usefulness of related mindfulness/acceptance-based approaches for this population. The current study was designed to replicate and extend previous findings by Bach and Hayes (2002). Psychiatric inpatients with psychotic symptoms were randomly assigned to enhanced treatment as usual or enhanced treatment as usual plus individual sessions of Acceptance and Commitment Therapy (ACT). Results revealed greater improvements in the ACT group at post-treatment on clinician-rated affective symptoms and global improvement, and self-rated distress associated with hallucinations and impairment in social functioning. Overall large effect size improvements were demonstrated in both groups pre- to post-treatment, with medium effect sizes differences between groups favoring the ACT condition. In addition, significantly more participants in the ACT condition reached clinically significant improvements in overall symptoms at posttreatment. At 4-month follow-up, 45% of participants in the ETAU only group had been rehospitalized compared to only 28% of those in the ACT group. Results suggested that believability in hallucinations mediated the relationship between symptom frequency and distress. Improvement in believability of hallucinations over time was only observed in the ACT condition, and change in believability predicted change in associated distress after controlling for change in frequency of hallucinations. Results are viewed as largely consistent with the findings of Bach and Hayes and warrant future investigations with larger samples. Future research should continue to investigate possible mechanisms of action in effective psychosocial treatments for psychosis.
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