Suspicious Minds Nigel Blackwood Institute of Psychiatry, Kings College London

1. Suspicious Minds Nigel Blackwood Institute of Psychiatry, Kings College London

2. Cognitive Neuropsychiatry Psychopathology Cognitive/Psychological Abnormality Functional Neuroanatomy/Neurochemistry

3. Persecutory Delusions: the categorical approach ‘A false judgement; it is held with incomparable subjective certainty; there is an imperviousness to other experiences and to compelling counter-argument; the content is impossible’ Jaspers, 1913

4. Persecutory Delusions:the dimensional approach Aberrant determination of self-relevance Jumping-to-conclusions reasoning bias Self-serving attributional bias Mentalising errors Blackwood Am J Psych 2001

5. Neuroimaging of reality distortion Liddle 1992; Kaplan 1993; Ebmeier 1993; Sabri 1997

6. The determination of self-relevance In the deluded state, ambiguous social data are suffused with potential meaning for the self Patients with persecutory delusions selectively attend to threat-related stimuli (Bentall 1989; Fear 1996; Leafhead 1996) Patients with persecutory delusions make inflated estimates of the likelihood of future threatening events (Corcoran, 2006)

7. The determination of self-relevance

8. Abnormal cingulate gyrus activation in the determination of self-relevance Normal subjects> deluded subjects, self>other Ventral anterior cingulate 0,34,4 Z=4.06 Impaired self-reflection in the deluded state

9. Abnormal cingulate gyrus activation in the determination of self-relevance Deluded subjects> normal subjects, self>other Posterior cingulate 8, -46, 14 Z=3.60 Ambiguously self-relevant material is encoded as emotionally salient to a greater extent in the deluded state

10. Abnormal cingulate gyrus activation in the determination of self-relevance This accounts for the deluded patient’s subjective experience that a greater array of ambiguous social data is suffused with potential meaning for the self: erroneous resolution of this ambiguity in favour of the default ‘this is salient’ position occurs when self-states are not adequately represented Blackwood Psych Med 2004

11. The jumping-to-conclusions reasoning bias Inductive inferences aid decision making under conditions of uncertainty They employ judgements of probability or likelihood Deluded subjects show a data gathering bias in inductive reasoning tasks The bias is more pronounced with emotionally salient material

12. The jumping-to-conclusions reasoning bias

13. The cerebellum and decision making under uncertainty From motor control to inferential thought Pegboard task Kim 1994 Conceptual reasoning task derived from WCST Rao 1997 Formation and application of inductive categorisation rule Goel 2000 Internal working models of uncertain events in the world Blackwood Cognitive Brain Research 2004

14. Impaired cerebellar modulation of inductive inferences in the deluded state Normal subjects> deluded subjects, probabilistic reasoning>counting Left Lobule VI Cerebellar Cortex -8, -68, -20 Z=3.04 ‘Dysmetria of thought’ may account for the jumping-to-conclusions reasoning bias in the deluded state

15. Self-serving attributional bias Humans use causal attributions to infer the most likely cause of events in the social world The self-serving bias describes the tendency of normal subjects to attribute the causation of positive events internally (‘I am responsible’) and negative events externally (‘Other people or situational factors are responsible’) Patients with persecutory delusions show an exaggeration of this self-serving bias

16. Self-serving attributional bias

17. Self-serving attributional bias

18. The dorsal striatum and the self-serving attributional bias Normal subjects (n=8) Right caudate nucleus 8 –7 17 6.82 Left caudate nucleus -6 –1 17 5.41 The attributions in the self-serving bias are motivated social beliefs Blackwood Neuroimage 2003

19. Mentalising abnormalities in psychosis A domain specific problem (False beliefs vs false maps, Pickup 2001) Poor performance: under vs over mentalising? Poor performance: explicit vs implicit? A problem with conscious reflection upon states of mind?

20. Mentalising in psychosis Which part(s) of the network involving medial prefrontal cortex (paracingulate cortex), TPJ in the STS and temporal poles is (are) compromised in the psychotic state?

21. How are these abnormalities inter-related? Anticipation of threat (Anticipation social events task) Explanatory style (ASQ) Self-esteem (Nugent & Thomas) Emotion (HADS) ToM (intentional deception to 2nd order level) JTC (beads in bottle and social variant) IQ (WAIS vocabulary, matrix reasoning, digit span) Bentall, Archives General Psychiatry, in press

22. ToMD GLOB PAR The cognitive structure of persecutory delusions across diagnoses PARB ANTIC STAB .92 .85 .60 COG_P DEP_S .78 .46 -.39 .68 JTC .82 .72 -.07 .72 INTFUN EMDYS

23. Cognitive Neuropsychiatry PersecutoryDelusion Dopamine sensitisation

24. CBT approaches Specificity and durability? eg Kuipers 1997; Tarrier 1993; Sensky 2000 Developing alternative explanations of Sx Peripheral questioning, graded reality testing, inference chaining New approaches

25. Cognitiveneuropsychiatric models of persecutory delusions Cognitive neuropsychiatric models help to bridge the explanatory gap between functional neuroanatomy/chemistry and psychopathology A functional neuroanatomy of mentalising abnormalities in psychosis remains to be established CBT and cognitive remediation may be useful adjuncts to antipsychotic medication…tailored approaches to the fundamental deficits may be of particular benefit Questions? n.blackwood@iop.kcl.ac.uk

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