What is the Role of Affect in

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What is the Role of Affect in
Delusion Formation ?
Vaughan Bell School of Psychology, Cardiff
University
Hadyn Ellis, Peter Halligan
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Outline

• Defining issues and phenomenology
• Affect and delusions Prevalence and
  co-occurrence
• Affect and delusions, theoretical approaches
• Defence models of delusion
• Direct models
• Metacognitive role for affect ?
• Neuropsychological correlates

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What is a Delusion ?

• The DSM defines a delusion as a belief that is
• False, based on incorrect inference about
  external reality.
• Firmly sustained, despite what almost everybody
  else believes...
• and despite what constitutes incontrovertible
  and obvious proof or evidence to the contrary
• The belief is not one ordinarily accepted by
  other members of the person's culture or
  subculture.

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What is a Delusion ?

• Every criterion of this definition has been
  criticised (Spitzer, 1990 Bell, Halligan
  Ellis, 2003)
• Including the assumption that delusions are
  beliefs (famously by Berrios, 1991)
• But despite these defining issues there is
  clearly something to explain

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Case 1
A 22-year-old woman had the delusion that
thoughts and feelings emanating from her mothers
unconscious were being carried in raindrops that
fell on her air conditioner. When the raindrops
hit the air conditioner they made a noise, and
simultaneously these thoughts and feelings merged
with her own unconscious. This merging had
resulted in her own mental illness.
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Case 2
AQ, a 36 year old woman with a previous diagnosis
of bipolar affective disorder was admitted to
hospital concerned that she was being tracked by
cameras that had been placed around her house,
that were transmitting images of her across
radio, television and the internet. AQ had also
experienced beams of light coming into her
house which she believed were being controlled
via the internet and were involved in her
surveillance. After admission to the hospital
ward, she voiced concerns about being watched by
beams of light and was suspicious of the electric
lights in her room. AQ was subsequently diagnosed
as having a manic episode with psychotic symptoms.
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Affective Disturbance in Delusions

• Often difficult to pin-down as cross-sectional
  studies often group participants using concepts
  like psychosis or schizophrenia, rather than
  delusions per se.
• However, despite these drawbacks, it is obvious
  there is a clear link between delusions and
  emotion.

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Co-occurrence and Prevalence

• Bowman and Raymond (1931) 58 of admissions with
  manic-depressive psychoses had delusions.

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Disturbed Affect in Psychosis

• Experience sample of delusional patients
• Myin-Germeys et al (2001) intensity of delusion
  was associated with lower negative affect.
• Psychotic outpatients
• Steer et al (2003) 18 were severely anxious on
  the Beck Anxiety Inventory.
• Prodrome of paranoid schizophrenia
• Gourzis et al (2002) depressed mood (10),
  anxiety (22) and anger (48) in prodrome (x
  14.6 months).

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Delusions in Mood Disorder

• General population survey
• Ohayon and Schatzberg (2002) 10.7 with feelings
  of worthlessness or guilt had delusions.
• Depressed patients
• Cassano et al (2004) total manic items endorsed
  by unipolar patients predicted delusional
  ideation.
• Delusional depression
• Seretti et al (2000) treating the mood disorder
  without antipsychotics reduces delusions.

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Defence Models of Delusion

• One of the first was from Freud (1911) who
  analysed Schrebers Memoirs of my Nervous
  Illness.

• Freud argued that delusions resulted from the
  sublimation of homosexual desire.
• Unsurprisingly, psychological theory has since
  moved on, although the psychoanalytic angle is
  not dead.

• Adler (1914) argued that paranoia occurs due to
  blaming others, to mask an inferiority-complex.

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Bentalls Attributional Model

• Like Adler, Bentall (1994) argued that
  persecutory delusions are an extreme self-serving
  attribution bias (see Mezulis et al, 2004).
• The result of trying to prevent low self-esteem
  thoughts entering consciousness by making
  excessive external-personal attributions for
  negative events.
• This has now been reformulated (Bentall et al,
  2001) to include mood effects of actual-self /
  ideal self discrepancies.
• And relies on the distinction between explicit
  and implicit self-esteem.

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Events
Attribution / Self-representation 1
Positive
Negative
Internal bias
High
Ideal-self comparison
Self-esteem / mood
Internal bias
Low
Search self representations
Benign external situational
Stored self-knowledge
Attribution
Internal
External personal
Beliefs about others (inc paranoia)
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Events
Attribution / Self-representation 2
Positive
Negative
Internal bias
High
Ideal-self comparison
Self-esteem / mood
Internal bias
Low
Search self representations
Benign external situational
Stored self-knowledge
Attribution
Internal
External personal
Beliefs about others (inc paranoia)
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Events
Attribution / Self-representation 3
Positive
Negative
Internal bias
High
Ideal-self comparison
Self-esteem / mood
Internal bias
Low
Search self representations
Benign external situational
Stored self-knowledge
Attribution
Internal
External personal
Beliefs about others (inc paranoia)
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Criticisms of Bentalls Model

• Largely, the poorly defined concept of
  self-esteem, which has probably led to equivocal
  findings in patient with persecutory delusions
• They have included
• High self-esteem (Candido and Romney, 1990)
• High self / ideal-self discrepancy (Kinderman and
  Bentall, 1996)
• Low self-esteem (Freeman et al, 1998)

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Mahers One Stage Model

• Maher (1988/99) has argued that delusions arise
  from normal reasoning applied to anomalous
  experience.
• Anomalous experience.
• Causing an arousal of anxiety, tension or fear.
• Explanation of experience by normal reasoning.
• Reduction in anxiety.
• Persistence of explanation to defend against
  further anxiety.

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Jonathan Miller video clip
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Intolerance of Ambiguity

• Studies have shown that intolerance to ambiguity
  is associate with delusional ideation.
• For example in
• Delusional people with paranoid schizophrenia
  (McReynolds et al, 1964)
• People with persecutory delusions (Bentall and
  Swarbrick, 2003)
• People high in delusional ideation (Colbert and
  Peters, 2002)

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Direct Models

• These argue that emotion directly influence the
  formation and maintenance of delusions.
• Rather than delusions being a response to
  unpleasant emotion (defence), or
• being emotion being the result of a delusional
  belief (consequence).

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Institute of Psychiatry Model

• For non-affective psychoses the following is
  proposed (recent summary in Freeman and Garety,
  2004)
• Hemsley (1994) - memories of input regularities
  influence current perception.
• These influences are weakened as per the
  stress-vulnerability model.
• This disrupts assessment of the significance of
  incoming stimuli, causing novel or unexpected
  stimuli to enter consciousness.
• The mismatch between predictions of the world and
  perception causes arousal.

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Institute of Psychiatry Model

• Similarly Gray (1982) Behavioural Inhibition
  Model, proposes that unexpected stimuli causes
• BI, arousal, increased attention to environment.
• Depending on appraisal this might be experienced
  as anxiety or pleasurable arousal.
• Garety and Hemsley (1994) - this might affect
  information processing, e.g. inferential
  reasoning biases in delusional patients.
• Further delusional explanation may arise from the
  attempt to explain the seemingly unexplained
  arousal.

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Shared Themes

• For affective psychoses, Freeman and Garety
  (2003, 2004) note the similarity in themes
  between certain emotions and delusions

Adapted from Freeman and Garety (2003)
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Shared Themes Criticisms

• Connections between delusions and emotions (and
  vice versa) seem underdetermined and simplistic.
• Some delusions seem not to have a reliable
  emotion (e.g. religious, lycanthropic).
• Freeman and Garety dismiss religious delusions as
  being secondary elaborations of emotional states.
• They appear to be specific explanations that
  draw on pre-existing beliefs concerning religion
• Despite the fact that a delusional must not be
  an article of religious faith, i.e. not
  established dogma
• Also sensed presence (Cook and Persinger, 1997)

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Shared Themes Criticisms

• Mono-delusional conditions (e.g. Cotard delusion)
  have also been cited as difficult to assimilate
  into this framework.
• Standard explanation
• Person is depressed, perceptual input loses
  meaning due to lack of emotional modulation, lack
  of meaning leads person to believe they are dead.
• Klee (2004) has argued that the emotion may not
  necessarily be that specific.
• Why dead ? And not that they are, for example,
  made out of clay ?

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Direct Models of Normal Belief

• But Frijda et al (2000) have noted that
• Emotions can awaken, intrude into, and shape
  beliefs, by creating them, by amplifying or
  altering them, and by making them resistant to
  change
• Clore and Gasper (2000) have noted a number of
  ways this may happen with normal belief.
• Emotion as attention (selective attention bias)
• Intensity and goal focus (positive feedback loop)
• Emotion as information (feelings as evidence)

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Clore and Gasper (2000)
Belief / attention / information cycle.
Directs
Modifies
Information sampling
Attention
Guides
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Affective Bias and Delusion

• Good evidence that affect based attention /
  reasoning biases are increased in delusional
  patients compared to psychiatric /
  non-psychiatric controls, e.g
• Emotional stroop (Bentall and Kaney, 1989)
• Threat word recall (Bentall et al, 1995)
• Conditionals and syllogisms (Kemp et al, 1997)
• Inferential reasoning (Dudley et al, 1997
  although see Young and Bentall, 1997)
• Threat perception / visual scan-paths (Phillips
  et al, 2000)

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Clore and Gasper (2000)
Attentional funnelling effect of emotion.



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Goal Focus

• For example Freeman et al (2000) found a high
  prevalence (100) of safety behaviours in people
  with persecutory delusions.
• As well as the well known bias for confirmatory
  evidence
• ...there seems to be a bias to avoid
  disconfirmatory evidence as well.
• Delusional people avoid situations which would
  disconfirm their delusions.

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Feelings as Evidence

• Capgras delusion is a delusional belief that
  (usually) close relatives have been replaced by
  identical looking impostors.
• Ellis et al (1997) showed that Capgras patients
  show a reduced automatic response to familiar
  faces.
• i.e. they have a distorted feeling of knowing
  (Bruce and Young, 1986) for faces.
• Perhaps in a similar way to Damasios (1998)
  controversial somatic marker hypothesis.
• Or, some other form of metacognitive process

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Affect as Metacognition ?

• Might feeling of knowing / familiarity share
  processing or resources with aspects of affect ?
• Nelson (1999) defines metacognition in terms of
• Monitoring gathering information about
  cognitive state
• Control self-regulation process.
• This has strong parallels with recent models of
  emotion.

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Phillips et als (2003) Model

• Koriat (2000) argues that metacognition can tap
  into implicit (experience based) knowledge and
  render it into qualitative subjective feeling
  useful for consciously directed behaviour.
• And that behaviour outcome can feedback to
  modulate the subjective feeling.

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Neuropsychological Evidence

• Neuropsych evidence from Goel and Dolan (2003)

RL PFC

• They asked people to complete belief-congruent or
  incongruent syllogisms during fMRI.
• Right lateral PFC was activated when belief-bias
  was overcome, consistent with its monitoring
  role.
• VMPFC was activated when logical reasoning was
  overcome, a region implicated in affective
  processing.

VMPFC

• They suggest the effects of belief-bias on
  reasoning might be mediated through emotional
  processing.

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Neuropsychological Evidence

• Goel and Dolan (2003) conjecture that
• the right PFC involvement in correct response
  trials is critical in detecting and / or
  resolving the conflict between belief and logic
• However, evidence from lesion studies and
  psychosis-continuum studies is not clear cut
• Lesion studies typically implicate R hem damage
• PFC and / or R hemisphere lesions in
  content-specific delusions (Galloy and
  Richardson, 1994)
• Anosognosia (Venneri and Shanks, 2004)
• Alzheimer delusions (Staff et al, 1999)

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Neuropsychological Evidence

• Although psychosis-continuum studies typically
  find relatively greater activation in the RH
• Magical ideation (Leonhard and Brugger, 1998)
• Belief in ESP (Brugger et al, 1993)
• Schizotypy (Kravetz et al, 1998)
• And the imaging studies on people with
  persecutory delusions has shown mixed results on
  asymmetries and functional differences (Blackwood
  et al, 2001)
• Although medial temporal and ventral striatal
  limbic areas seem important.

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Summary

• Affective disturbance is common in people with
  delusions, and delusions are common in people
  with affective disorders.
• Two main theories have attempted to explain the
  role of affect in delusion formation
• Defence theories
• Direct theories
• There may be a metacognitive or epistemic role
  for affect that could explain its role in
  delusions.