Revised 11 December 2019 Presentation 12/13/2019

Cognitive : Effects on mental disorders and treatment Keith Harris, PhD

13 December 2019

Lucia Heffernan

Presentation take-aways . What are cognitive biases and ? - Common cognitive biases - Why we evolved them and why they’re useful . Mismatch to the modern world - The world the mind was made for - Fine-tuning in childhood and early experience . Contributing factors in (several) mental disorders - Potential impact on treatment - Therapeutic strategies and work-arounds

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Also interesting but not addressed today . Heuristics and intuition in everyday life . The socio-cultural facilitation of (some) cognitive biases . Cognitive distortions in personality disorders . The neurological underpinnings of cognitive biases . Cognitive biases in sales and politics . The of behavioral economics . Cognitive shortcuts in other species (hominins & dolphins)

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What are cognitive biases?

- Cognitive biases are a of automatic (unconscious) tendencies to distort perceptions or situations in a predictable direction or manner - Cognitive biases evolved because they’re useful - But in some cases, these lead to problematic inferences and maladaptive responses to

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Background

- The concept of cognitive biases was introduced by the cognitive psychologists Amos Tversky and Danny Kahneman in 1972

- Initially eleven “cognitive illusions” - Familiar examples: (1) Tendency to generalize from small samples (2) Misunderstanding of laws of chance (3) Overconfidence based on limited

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Example of a typical cognitive

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A (partial) current list of identified biases

Ambiguity effect Ben Franklin effect Continued influence effect Anchoring or focalism Berkson's paradox Contrast effect Anthropocentric thinking Courtesy bias Anthropomorphism Cross-race effect Choice-supportive bias Cryptomnesia bias fade Declinism Availability cascade Decoy effect Availability Default effect Backfire effect Denomination effect Conservatism Disposition effect Consistency bias Distinction effect bias Context effect Dread aversion

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(What’s important?) (What to attend to?)

(What’s too complex (What needs immediate or ambiguous?) action?)

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https://upload.wikimedia.org/wikipedia/commons/6/65/Cognitive_bias_codex_en.svg

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Expert Decision-Making

The Recognition-primed Decision (RPD) Model

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What our cognitive apparatus evolved to do Despite widespread claims to the contrary, the human mind is not worse than rational . . . but may often be better than rational … - Cosmides and Tooby, 1994

The issue “is not whether the cognitive feature is accurate or logical, but rather how well it solves a particular problem.” - Haselton, Nettle & Murray, 2016

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The world the mind was made for Human life until perhaps 10,000 years ago: - Small communities (e.g., hunter-gatherer bands) - Sustained personal relationships with relations and nonrelations - Minimal privacy of behaviors or feelings - The complex social dynamics found in small, intensely-bound groups - Expectations that all members contribute (no freeloaders) - Capacity for shared intentionality, and collectively-shared intentionality: close collaboration - Generalized competence along with some division of labor - Lifelong ties to an adult partner with allowance for separation and repairing (in most groups, pair-bonding) - Sense of real and meaningful connection to the immediate environment

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Need for cognitive efficiency

Early human environments presented complex cognitive demands with little tolerance for error or delay

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Why cognitive biases evolved - Signal from noise (pattern recognition) - Limited information Opportunity cost - Need for speed Assessment of Situation - Social complexity No Risk Risk - Risk aversion Actual Situation No Risk True negative False Positive - Cognitive costs - Survival of the most Risk False negative True Positive competent

Danger, perhaps mortal

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The algorithm as a modern metaphor

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Genetic susceptibility and early environment

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“Scripts” first form in childhood

- Our adult interpersonal behaviors, feelings and thoughts are often influenced by automated cognitive “scripts” that may rely on innate cognitive and emotional tendencies - These are first formed through experience and observation (shaping) in childhood - These scripts can be very useful or very problematic in adulthood - A cognitive script is a sequence of emotions, thoughts and/or behaviors elicited by specific contexts

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Clinical issues with biases and scripts Common scripts and cognitive biases can be involved in various psychiatric issues or mental disorders - Thought disorders (e.g., psychoses) - Mood disorders (i.e., depressive disorders) - Personality disorders - Phobias - Eating disorders - Etc.

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Thought Disorders

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Representative thought disorder indications - Illogical thinking - Loose associations or obscurity of speech - Incoherence - Tangentiality - Circumstantiality - Delusions - Poor reality contact - Unusual beliefs

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Cognitive biases in thought disorders Deficits in “theory of mind” are possibly associated with - Difficulties with (e.g., “Hostile ”) - Illusion of transparency - Paranoia Cognitive impairments may underlie - Jumping to conclusions - Intentionalizing - Catastrophizing - - Dichotomous thinking - Increased need for closure - Intolerance of ambiguity

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Complications for treatment Challenges - Establishing therapeutic alliance - Cognitive processing impairments - Dearth of social-interaction possibilities - Over-reliance of patients on the treatment system General principles - Faulty cognitions in psychosis are important, comprehensible, and modifiable - Effective treatment is directed toward decreasing distress and increasing well-being

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Treatment process and goals Pre-treatment assessment - Comprehensive psych-social history and current situation - Evaluation of cognitive functioning - Consideration of patient’s family and support system - Consultation with patient’s psychiatrist (and GP if needed) Treatment aims regarding faulty cognitive biases - Map maladaptive cognitive biases onto symptoms and problems - Work on biases must be integrated with other treatments - The most malleable biases are usually addressed first

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Illustrative case: Arthur Presenting problems involving cognitive distortions - Auditory hallucinations - Delusions - Unusual beliefs Brief history - Onset in early adolescence - Social withdrawal - Family discord following onset of symptoms

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Course of care: Arthur Relevant assessment issues - Need for multiple sources of information - Patient’s limited insight - Patient’s limited investment Treatment aims regarding cognitive distortions - Therapeutic alliance - Increased tolerance for ambiguity - Decreased conviction regarding false perceptions - Develop new cognitive habits

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Paranoid perceptions in psychosis

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Depressive Disorders

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Examples of cognitive biases in depression

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Cognitive biases in depressive disorders Attentional biases - Sensitivity to the “spotlight” effect - Gaze bias (a form of attentional bias) Interpretive biases - Negative interpretation of ambiguous stimuli - Negative self-serving bias Memory biases - Increased retention of negative information - Rumination and inverted “adverse- event fading bias”

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Common symptoms in depressive disorders - Prolonged sadness - Irritable or anxious mood - Lack of interest in normal activities - Feelings of guilt, rumination, thought insertion - Sense of worthlessness - Feelings of alienation or hopelessness - Etc.

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Neurological view of maladaptive cognitions

Belzung, C., Willner, P., & Philippot, P. (2015). Depression: From psychopathology to pathophysiology. Current Opinion in Neurobiology, 30, 24–30. https://doi.org/10.1016/j.conb.2014.08.013 35

Treatment of depressive disorders Challenges - Readiness of patient to participate in therapy - Problematic attachment issues that interfere with therapeutic alliance - Many people aren’t very good at accurate introspection (insight) General approach - Cognitive-behavioral framework - Interpersonal or psychodynamic alliance

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Treatment of depressive disorders (cont’d) Pre-treatment assessment - Comprehensive psych-social history - Evaluation of client’s emotional functioning - Identification of problematic cognitive biases and scripts Therapeutic aims regarding faulty cognitive biases - Person recognizes the problematic automatic tendencies when they are triggered - Patient exerts the effort needed to modify those maladaptive scripts that are amenable to change - Patient learns to compensate for scripts that can’t be changed

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Illustrative case: Maria Presenting problems - Depressed mood - Interpersonal difficulties - Problems on the job Brief history - Distant, disengaged parents - Frequent family moves - Surreptitious self-cutting in adolescence - Dependent / avoidant personality features - Occasional lapses into emotional reactivity

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Course of care: Maria Relevant cognitive biases and scripts - Confirmation bias - Negative attribution bias - Learned helplessness Treatment aims regarding problematic cognitive biases and scripts (or schemas) - Recognize and accept cognitive distortions - Improve reality-testing skills (cognitive habits) - Develop tolerance for discomfort - Adapt real world behaviors (compensation) - Embrace a perspective of “depressive realism” 39

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Summary . Cognitive biases and “scripts” are universal - They often facilitate interpersonal skills and decision-making - Sometimes they become problematic for everyone - They can exacerbate or contribute to psychiatric conditions . Mismatch to the modern world - The human mind is quite adaptable but was initially designed for a different way of life - Our biases and scripts are fine-tuned in childhood by family & . Treatment considerations - It’s helpful to identify cognitive biases and scripts during treatment planning - Therapeutic change and compensations are often possible

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Questions, suggestions and feedback

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