metacognitive training: a treatment program for delusions

Cognitive Biases Underlying Delusions

and the use of Metacognitive Training

for Psychosis

Todd S. Woodward, Ph.D.

Professor

Department of Psychiatry, UBC

&

BC Mental Health and Addictions

Research Institute (BCMHARI)

Extra/intracellular

/genetic

Schizophrenia: Research Model

Behaviour

Cognitive

Function

Neuroanatomy

Memory, Attention,

Executive Function

Impairments

Dysfunctional Neural

Networks


Networks

Biased Information Processing

Hallucinations, Delusions Poor Functional Outcome

proteins/lipids

neurotransmitters/neuroreceptors

genes

State (symptom ratings) Trait (diagnosis)

Schizophrenia: Treatment Model

Hallucinations, delusions

proteins/lipids


genes

State (symptoms)

Poor Functional Outcome

proteins/lipids

genes

Trait (diagnosis)


Memory, Attention,

Executive Function

Impairments

Metacognitive

Training (MCT)

Cognitive Behavioural

Therapy (CBT)

Cognitive

Rehabilitation (CR) Jumping to Conclusions

Disconfirmatory Evidence

Inefficient Functional

Brain Networks

Dorsal Anterior Cingulate (alert –

match/re-evaluate)

Rostrolateral Prefrontal Cortex (self-

reflect, change belief?)

Cognitive remediation therapy (CR) improves the

inefficient brain networks underlying the trait cognitive

impairments in schizophrenia.

Wykes, T., Huddy, V., Cellard, C., McGurk, S. R., &

Czobor, P. (2011). A meta-analysis of cognitive

remediation for schizophrenia: Methodology and effect

sizes. American Journal of Psychiatry, 168, 472-485.

Cognitive behavioural therapy (CBT) improves

delusions in schizophrenia by targeting cognitive biases

in relation to symptoms Wykes, T., Steel, C., Everitt, B., & Tarrier,

N. (2008). Cognitive behavior therapy for

schizophrenia: Effect sizes, clinical models,

and methodological rigor. Schizophrenia

Bulletin, 34, 523-537.

Conclusions: CBTp

had beneficial effect on

positive symptoms.

Meta-Analysis

Eichner & Berna (2016), Schizoprenia Bulletin

Awareness of thinking biases through MCT help

people with psychosis mute their symptoms

MCT had a beneficial effect on delusions.

Effect sizes were similar to those

reported with cognitive-behavioral

therapy.

Extra/intracellular

/genetic


Behaviour

Cognitive

Function

Neuroanatomy

Working Memory


Networks


Networks



proteins/lipids


genes

Trait (diagnosis) State (symptom ratings)

Functional Magnetic Resonance Imaging (fMRI)

Study of Working Memory

Network 3 – Task Positive and Negative

Red: activations; Blue: deactivations

Metzak, Riley, Wang, Whitman, Ngan, & Woodward (2011, Schizophrenia Bulletin)


Working Memory


Brain Networks


proteins/lipids


genes

Trait (diagnosis)

Extra/intracellular

/genetic


Behaviour

Cognitive

Function

Neuroanatomy

Memory, Attention,

Executive Function

Impairments


Brain Networks

Dysfunctional Brain

Networks



proteins/lipids


genes


Extra/intracellular

/genetic


Behaviour

Cognitive

Function

Neuroanatomy

Memory, Attention,

Executive Function

Impairments

?

?

Delusions Poor Functional Outcome

proteins/lipids


genes



Brain Networks

Extra/intracellular

/genetic


Behaviour

Cognitive

Function

Neuroanatomy

Memory, Attention,

Executive Function

Impairments

Inefficient Brain

Networks ?

Jumping to Conclusions

(not gathering enough

evidence before deciding)


proteins/lipids


genes


Fish Task

Jumping to Conclusions (JTC)

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Nonmatching Lake Matching Lake

Lik

elih

oo

d R

atin

gHealthy ControlsBipolar ControlsNon-Delusional SzDelusional Sz

Speechley,

Whitman &

Woodward

(2010). Journal

of Psychiatry

and

Neuroscience

Conclusion from delusions research

•Evidence that delusions could be formed due to hypersalience of

matches between a delusional idea (e.g., I think the CIA is spying

on me) and evidence (e.g., people are staring at me).

•This leads to jumping to conclusions because too much weight is

given to evidence-hypothesis (EVH) matches

Extra/intracellular

/genetic


Behaviour

Cognitive

Function

Neuroanatomy

Memory, Attention,

Executive Function

Impairments


Brain Networks ?

Hypersalience of evidence-

hypothesis matches


proteins/lipids


genes


Extra/intracellular

/genetic


Behaviour

Cognitive

Function

Neuroanatomy

Memory, Attention,

Executive Function

Impairments


Brain Networks ?

Self selection bias

(delusions are usually self-

generated ideas)


proteins/lipids


genes


Whitman, Menon, Kho & Woodward

(2013). Cognitive Neuropsychiatry.

Conclusion from delusions research

•Delusions could be formed due to hypersalience of matches

between a delusional idea (e.g., I think the CIA is spying on me)

and evidence (e.g., people are staring at me).

•The self-selection nature of most delusions may contribute to

hypersalience of evidence-hypothesis (EVH) matches.

1) The man has just built a fence for his dog.

2) The man is shopping for guard dogs.

3) The man has just escaped from the barking dog.

4) The man is playing with his neighbor’s barking dog.

1) The man has just built a fence for his dog.

2) The man is shopping for guard dogs.

3) The man has just escaped from the barking dog.

4) The man is playing with his neighbor’s barking dog. Lure

True

Lure

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1 2 3Rating Number

Mean

Rati

ngschiz: delusions

schiz: no delusions

bipolar controls

healthy controls

Lure Interpretations Bias Against Disconfirmatory Evidence (BADE)

Conclusions from delusions research

•Delusions could be formed due to hypersalience of a match

between evidence (e.g., people are staring at me) and a self-

selected delusional idea (e.g., I think the CIA is spying on me).

•Delusions may not be properly disconfirmed (e.g., that fact that

suspected recording devices are not found in the heat vents is not

integrated, because crackling on the phone line is a highly salient

confirmation of the CIA delusion).

•Delusions may be maintained and elaborated as evidence-

hypothesis matches broaden and intensify (e.g., a black van passing

by slowly suggests it is driven by an observant CIA agent).

•As with hallucinations, personalizing factors must interact with

hypersalience: expectations, hypervigilance, imagination/fantasy,

memories/trauma

Extra/intracellular

/genetic


Neuro-

anatomy

Memory, Attention,

Executive Function

Impairments


Brain Networks

?

Hypersalience of evidence matches to self selected

hypotheses, a bias against disconfirmatory

evidence + Personalizing factors


proteins/lipids


genes

State (symptom ratings) Trait (diagnosis) Behaviour

Cognitive

Function

Schizophrenia: Treatment Model

Hallucinations, delusions

proteins/lipids


genes

State (symptoms)


proteins/lipids

genes

Trait (diagnosis)


Memory, Attention,

Executive Function

Impairments

Metacognitive

Training (MCT)

Cognitive Behavioural

Therapy (CBT)

Cognitive

Rehabilitation (CR) Jumping to Conclusions

Disconfirmatory Evidence


Brain Networks

Dorsal Anterior Cingulate (alert –

match/re-evaluate)

Rostrolateral Prefrontal Cortex (self-

reflect, change belief?)

www.uke.de/mct

MCT uses a Knowledge Translation

Approach

• Group-based, interactive program with 8 core modules

(Powerpoint presentations with parallel versions A and B)

• Some of the MCT material was originally designed by

various researchers in the field of cognitive

neuropsychiatry (used with permission)

• The material is presented such that participants can

experience these cognitive biases

• These cognitive biases are discussed in relation to

everyday life and psychosis

MCT is Non-confrontational and Fun

• Avoid discussion of individuals’ delusions, but instead

discuss psychosis in general terms

• Use “fun” to capture attention and interest

• Provide applications to daily life

• Avoid repetitive “drill and practice” routines

Format

• Introduce cognitive biases targeted for the session

– Important to understand these cognitive biases and the

research behind it (upcoming slides)

• Work through examples

• Give summary, relevance to everyday life, relevance

to psychosis

• Homework is also available

Studies show that many people with psychosis make decisions on the basis of little information.

This type of decision making can easily lead to errors. Therefore, it is better to use a decision-making style that involves careful consideration of all available information.

The perception of reality for many people with psychosis is altered. Unlikely interpretations are considered that other people might disregard.

Why are we doing this?

In the following exercises you will be shown different paintings. Please try to identify the correct title for each painting and rule out “misfits”.

Discuss the pros and cons for each of the interpretations.

Please also state the degree of confidence in your judgment.

Pay special attention to features that clearly rule out one interpretation.

Exercise

a. Confession of adultery

b. Courtship

c. Announcement of a relative’s death

d. The flower seller

a. Confession of adultery

b. Courtship (Karl Zewy, 1896)

c. Announcement of a relative’s death

d. The flower seller

Welcome to

Metacognitive Training Unit 2:

Jumping to Conclusions I

Welcome to

The use of the pictures in this module has been kindly permitted by artists and copyright holders, respectively. For details (artist, title), please refer to the end of this presentation.

01/14 A © Moritz & Woodward www.uke.de/mct

We often make snap judgments on the basis of very complex information in our environment.

Sometimes, we come to a conclusion without 100% proof.

A happy medium should be found between:

• making a hasty decision (risk: poor decision)

and

• being overly accurate (problem: takes too much time).

Jumping to Conclusions

In the following you will see a series of pictures. It starts with only one detail of the picture. Then, another detail is added. This continues until the whole picture is revealed. Your task is to identify the object.

Try to avoid hasty decision-making, as well as prolonged decision-making… try to find a balance!

Discuss evidence for and against each alternative.

Task 1

Picture 1

Several alternative interpretations are provided.

Please discuss with the group how likely you find each option and whether you feel confident enough to make a decision.

• smiling face

• bowl

• boat

• sled

• rocking chair

• elephant’s head

What might be presented in this picture?

How confident are you?

Do you want to make a decision yet?

Empathy

Welcome to

Metacognitive Training Unit 4:

Module 4

Target domains: emotion perception, bias against disconfirmatory

evidence, jumping to conclusions

1.Man is enjoying a rock-festival.

2.Man is shouting something at his friend.

3.Man is calling for help after a flood disaster.

4.Man is angry because somebody threw mud on him.

Module 4



Joy!

1.Man is enjoying a rock-festival.

2.Man is shouting something at his friend.

3.Man is calling for help after a flood disaster.

4.Man is angry because somebody threw mud on him.

1.Man is passing the finish line in a marathon.

2.Man is angry.

3.Man is shouting for help because his shirt was stolen.

4.Man is worshipping the sun.

Module 4



Anger!

1.Man is passing the finish line in a marathon.

2.Man is angry.

3.Man is shouting for help because his shirt got stolen.

4.Man is worshipping the sun.

Studies show that many people with psychosis are more confident in false memories than people without psychosis.

At the same time the confidence for true memories (i.e., things that really happened) is decreased in psychosis.

This may lead to difficulties differentiating true from false memories and may obstruct a healthy, realistic view of the environment.

Why are we doing this?

Our capacity to memorize information is limited.

Example: approximately 40% of the details of a story we have heard half an hour ago cannot be actively recalled.

Advantage: Our brain is not overloaded with useless information. Mostly, irrelevant information is lost...but

Disadvantage: ...many important memories also vanish (appointments, memories from holidays, knowledge acquired in school...)

Memory

You will be shown complex scenes.

Afterwards you will be asked to recall what you saw in the picture and how confident you are in your judgement.

Memory

You will be shown complex scenes.

Afterwards you will be asked to recall what you saw in the picture and how confident you are in your judgement.

Try to recall as many details as possible!

Memory

What did you see? How confident are you?

beach umbrella

lifeguard

dog

ball

life-belt

water

hat

towel

beach umbrella

lifeguard

dog

ball

life-belt

water

hat

towel

= not presented

You will be presented complex scenes.

Try to detect what has been left out (missing details are later shown in blue).

Exercise Memory

• What do you typically find on a

• playground? ….

Playground

Playground

What did you see on the picture? How confident are you?

slide

carousel

kite

skateboard

ball

trees

swing

toys

sandbox

Playground

slide

carousel

kite

skateboard

ball

trees

swing

toys

sandbox

= not presented

Learning Objectives:

Our memories can play tricks on us! Especially for important events (argument,

eyewitness testimony, etc.), keep in mind:

If you cannot remember vivid details about an event: Don’t be too sure that your recollection is true. Seek additional information (e.g. a witness).

Memory

Transfer to everyday life

Three pictures illustrating a scenario will be shown to you, along with various interpretations.

The pictures are shown in reverse order, the final event being shown first.

After a picture is shown, you will be asked to rate the plausibility or likelihood of each of the provided interpretations.

These have to be reassessed each time a new picture is revealed for that scenario.

Please discuss with the group how confident you are in your rating.

Exercise

What might have happened?

1) The man is a shark hunter and has just killed a shark.

2) The man is doing research on sharks.

3) The man is testing his new shark style surfboard.

4) The man just scared everyone away with a fake shark head.

How probable do you find each option?





Has your judgement changed with the new picture?





Please re-rate the probability!





Learning Objectives:

Sometimes, events turn out very differently than expected. Quick decisions often lead to wrong conclusions!

You should always consider different interpretations and adjust your beliefs accordingly.

Seek as much information as possible to verify your judgment.

Changing Beliefs

Transfer to everyday life

“If I’m walking down the street and I hear a stranger swear, I might

think the person is angry at me. However, maybe he’s having a bad

day, on a cellphone, or talking to himself. Just because he said

something, doesn’t mean it has anything to do with me but may be

more to do with him or the situation or circumstance.”

“Before when I observed someone laughing, I used to think that he

was laughing at me. But without any evidence, I now realize, that I

cannot jump to conclusions that the person is laughing at me. He

may be laughing for many reasons; for example, sharing a joke with

someone.”

“By questioning myself, I can recognize symptoms more readily and

see experiences from different angles rather than seeing only my

point of view. MCT may not cure me, but it is a very useful wellness

tool.”

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N=47 MCT, N=49 COGPACK at three years (follow-up II). Sustained effects on delusional/positive symptoms, self esteem 30

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Study 6, 4 weeks, 6 months, 3 years

Moritz et al., 2014, JAMA Psychiatry

metacognitive training: a treatment program for delusions

Health & Medicine