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'The Cognitive Neuropsychological Understanding of Persecutory Langdon, R; McKay, R; Coltheart, M (2008). The cognitive neuropsychological understanding of persecutory delusions. In: Freeman, D; Bentall, R; Garety, P. Persecutory delusions: assessment, theory, and treatment. New York, 221-236. Postprint available at: http://www.zora.uzh.ch University of Zurich Posted at the Zurich Open Repository and Archive, University of Zurich. Zurich Open Repository and Archive http://www.zora.uzh.ch Originally published at: Freeman, D; Bentall, R; Garety, P 2008. Persecutory delusions: assessment, theory, and treatment. New York, Winterthurerstr. 190 221-236. CH-8057 Zurich http://www.zora.uzh.ch Year: 2008 The cognitive neuropsychological understanding of persecutory delusions Langdon, R; McKay, R; Coltheart, M Langdon, R; McKay, R; Coltheart, M (2008). The cognitive neuropsychological understanding of persecutory delusions. In: Freeman, D; Bentall, R; Garety, P. Persecutory delusions: assessment, theory, and treatment. New York, 221-236. Postprint available at: http://www.zora.uzh.ch Posted at the Zurich Open Repository and Archive, University of Zurich. http://www.zora.uzh.ch Originally published at: Freeman, D; Bentall, R; Garety, P 2008. Persecutory delusions: assessment, theory, and treatment. New York, 221-236. The cognitive neuropsychological understanding of persecutory delusions Abstract In considering the contribution of cognitive neuropsychology to the understanding of persecutory delusions, we shall proceed in this chapter as follows: First, we shall consider the contribution of the more conventional clinical neuropsychological approach to the study of delusions. After all, cognitive neuropsychology developed as a hybrid of clinical neuropsychology (the psychological study of brain-injured people) and cognitive psychology (the study of the mental information-processing procedures that people use to perform such activities as speaking and understanding speech, and recognizing objects). Second, we shall outline the cognitive neuropsychological approach with brief reference to its history. Third, we shall describe how this approach has been applied to the study of delusions with reference to our two-deficit cognitive neuropsychological model of monothematic delusions. Finally we shall evaluate the applicability of this model to the explanation of other delusions that are not so obviously neuropsychological; here we shall focus on persecutory delusions. The cognitive neuropsychological understanding of persecutory delusions Robyn Langdon, Ryan McKay and Max Coltheart 1 • Dr Robyn Langdon, ARC Research Fellow, Macquarie Centre for Cognitive Science, Macquarie University, Sydney NSW 2109, Australia and Schizophrenia Research In- stitute (SRI), NSW, Australia; Telephone: +61 (0) 2 9850 6733; E-mail: [email protected]. • Dr Ryan McKay, Research Fellow, Institute for Empirical Research in Economics, University of Zurich, Blümlisalpstrasse 10, Zurich CH – 8006, Switzerland; Tele- phone: +41 (0) 44 63 43665; Email: [email protected]. • Professor Max Coltheart, ARC Federation Fellow and Scientific Director of the Mac- quarie Centre for Cognitive Science, Macquarie University, Sydney NSW 2109, Aus- tralia; Telephone: +61 (0) 2 9850 8086; E-mail: [email protected]. 2 In considering the contribution of cognitive neuropsychology to the understanding of persecutory delusions, we shall proceed in this chapter as follows: First, we shall consider the contribution of the more conventional clinical neuropsychological approach to the study of delusions. After all, cognitive neuropsychology developed as a hybrid of clinical neuropsychology (the psychological study of brain-injured people) and cognitive psychology (the study of the mental information-processing procedures that people use to perform such activities as speaking and understanding speech, and recognizing objects). Second, we shall outline the cognitive neuropsychological approach with brief reference to its history. Third, we shall describe how this approach has been applied to the study of delusions with reference to our two-deficit cognitive neuropsychological model of monothematic delusions. Finally we shall evaluate the applicability of this model to the explanation of other delusions that are not so obviously neuropsychological; here we shall focus on persecutory delusions. The clinical neuropsychology of delusions Conventional clinical neuropsychological studies proceed by administering standard batteries of tasks that are known to reliably demonstrate performance deficits in patients with identifiable lesions. The primary clinical aims include: (a) specifying which cognitive abilities have been impaired and which remain intact, consequent to the brain injury, so as to target remediation; and (b) identifying the likely sites of underlying neuropathology so as to assist in diagnosis. Standard neuropsychological batteries typically carve up cognition into relatively coarse-grained domains – e.g. executive function (linked to frontal brain regions) and spatial abilities (linked to parietal regions). Most conventional clinical neuropsychological studies do not, however, adopt a symptom- focused approach so as to identify the neuropsychological impairments that are associated with a particular symptom - say delusions. More often, the focus will be on a particular diagnostic category, regardless of symptomatology, or, if clinical symptoms are of interest, researchers will examine the associations between neuropsychological impairments and characteristic clusters of symptoms. Delusions might be of interest but they will be grouped together with other co-occurring symptoms so as to form a symptom cluster. If we consider first those clinical neuropsychological studies that have adopted a symptom- focused approach so as to investigate delusions, these studies are more common when the 3 delusions occur in the context of known neurological illness. Such delusions are termed ‘organic’ (or such patients are referred to as suffering ‘organic psychoses’) and are distinguished traditionally from ‘functional’ delusions (or the ‘functional psychoses’, including e.g. schizophrenia). In the latter case, there is less consensus concerning the nature and the role (if any, for some researchers) of underlying neuropathy. A common example of this type of work is the clinical neuropsychological study of delusions in dementia. Results from such studies generally indicate that delusions in dementia are associated with greater cognitive impairment and a more rapid cognitive decline (Haupt, Romera & Kurz, 1996). There are also indications of more specific associations with executive function and semantic memory deficits (Fischer, Ladowsky-Brooks, Millikin, Norris, Hansen & Rourke, 2006). The focus of this volume, however, is persecutory delusions, and although persecutory delusional themes are seen in the organic psychoses, they are also very common in the functional psychoses. Clinical neuropsychological studies of psychotic conditions that focus, in some regard, on delusions, are most common in the field of schizophrenia research (see e.g. Heinrichs & Zakzanis, 1998, and Bilder, Goldman, Robinson et al., 2000, for reviews). These studies do not, however, examine associations with single symptoms (including delusions); they focus instead on symptom clusters, in particular the positive and negative symptoms of schizophrenia. Delusions are grouped together, for example, with hallucinations and positive thought disorder, all of which are considered ‘positive’ due to the presence of something which is abnormal. Negative symptoms (e.g. apathy) are instead characterized by the absence of something that should normally be present. The general finding from clinical neuropsychological studies of schizophrenia is that, whenever associations are found between neuropsychological impairment and symptoms, it is the negative symptoms and not the positive symptoms that are involved (see e.g. Addington & Addington, 1999, 2000). Even when we turn to the few clinical neuropsychological studies of the functional psychoses that have adopted more of a symptom-focused approach to investigate delusions, there is still little to suggest a critical contribution from neuropsychological impairment. Baddeley, Thornton, Chua and McKenna (1996), for example, compared memory (episodic and semantic) and executive function in 5 patients with schizophrenia who were currently delusional and 5 patients who were no longer delusional; these authors found few differences between the groups. Mortimer, Bentham. McKay, et al. (1996) adopted instead a correlational approach with two much larger samples (N’s of 79 and 67) yet still found no evidence that 4 impairments of general intellectual ability, memory, or executive function were associated with delusions in schizophrenia. While we are aware of no clinical neuropsychological studies that have focused even more specifically on persecutory delusions (e.g. to compare persecutory deluded patients and non- persecutory deluded patients), several studies have categorised patients according to diagnostic subtypes or differing symptom profiles so as to compare ‘paranoid’ and ‘non- paranoid’ subgroups (see e.g. Hill, Ragland, Gur & Gur, 2001; Savage, Jackson & Sourathathone, 2003). Generally speaking these studies report that, even when differences are found, it is the paranoid individuals who appear less neuropsychologically impaired (see Bentall & Taylor, 2006, for discussion). So what are we to take from these more conventional, clinical neuropsychological
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