Externalized attributional bias in the Ultra High Risk (UHR) for psychosis population
Introduction
The construct of locus of control of reinforcement (LOC) (Rotter, 1966) refers to the extent to which individuals believe that they can control events that affect them. An externalized LOC (i.e. control over situations is seen as external to a person) has been consistently demonstrated in patients with schizophrenia (Cash and Stack, 1973, Pryer and Steinke, 1973, Varkey and Sathyavathi, 1984) and paranoid patients (Rosenbaum and Hadari, 1985, Kaney and Bentall, 1989), with suggestion of a greater level in those with paranoid compared to other types of schizophrenia (Pryer and Steinke, 1973). Although externalized LOC has been found in individuals with depression (Benassi et al., 1988), it is more pronounced in those with schizophrenia (Pryer and Steinke, 1973, Goodman et al., 1994), and is also associated with fewer periods of recovery in schizophrenia (Harrow et al., 2009). There is limited research as to whether this is a state or trait phenomenon.
LOC is related to the more general construct of attributional style (style or biases that reflect how people typically infer the causes of events) (Bentall and Kinderman, 1999, Green et al., 2008). Whilst LOC focuses on responses to past or present events, attributional style also involves prediction of future events and takes into account situational factors. There is a degree of overlap between the two concepts. An externalized attributional style (as part of a triad of externalized, global and situational styles) or the so-called “self-serving bias” has been found in patients with schizophrenia and especially those with paranoid delusions (Bentall et al., 2001), although this is not a consistent finding (McKay et al., 2005). It is also unclear if this is a state or trait phenomenon (Bentall and Fernyhough, 2008, Lincoln et al., 2010). For example, an external–personal attribution for negative events is present in patients with acute paranoid symptoms but not in remitted paranoid patients (Aakre et al., 2009).
Such externalized attributional biases, including an externalized LOC, may be a psychological risk factor for psychotic symptoms or disorders (Bentall and Kinderman, 1999). The tendency of an individual to consider non-threatening negative events as external to their control may predispose them to persecutory thinking, or projecting responsibility for events onto others. Similarly, externalizing normal internal events and physical sensations may predispose to hallucinatory experiences, delusions and passivity phenomena.
There is emerging evidence for this theory. Externalized LOC, measured in adolescence in a genetic at risk cohort, is associated with a six fold increase in the risk of developing schizophrenia (Frenkel et al., 1995) and measured at age eight is associated with high levels of psychotic symptoms in early adolescence (Thompson et al., 2011). Non-clinical cohorts with high levels of “psychosis pronesness” have also been found to have greater externalized LOC compared to healthy controls (Levine et al., 2004, Cooper et al., 2008, Pickering et al., 2008). However, the risk of developing psychotic disorder in all these non-clinical samples is unclear.
The “Ultra High Risk” (UHR) (Yung et al., 1998) or also known as “clinical High Risk” (CHR) population represents a defined clinical population; those who present with a combination of either trait factors for psychosis and poor functioning, or low intensity or low frequency positive psychotic symptoms which are not severe enough to meet the threshold for a frank psychotic disorder. Criteria for the identification of this group have been developed and validated (Miller et al., 2003, Yung et al., 2005). The population is interesting in terms of at risk research; given the short term risk (12 months) of developing psychosis may be up to 400 times the population risk (Ruhrmann et al., 2010). The UHR population is therefore informative for risk factor research in psychotic disorders.
To date, two UHR studies have investigated externalized attributional biases and one study has examined LOC. In the first (An et al., 2010), the researchers used the Ambiguous Intentions Hostility Questionnaire to assess for attributional style, but did not adjust for differences in IQ (which influences attributional style (Krstev et al., 1999)) or other confounders. An attributional bias for perceiving hostility and blaming others was found and this was associated with paranoid symptoms. However, the second (DeVylder et al., 2012) found that both CHR patients and controls had a similar externalized-personalizing bias and that this was not related to symptoms including suspiciousness. The only study to investigate LOC in an “at risk” clinical group was a small pilot study (n=16) of a psycho-education intervention (Hauser et al., 2009). A reduction in fatalistic or externalized LOC with the educational intervention was found. However, there was no control group and clinical entry criteria was based on the “basic symptoms” criteria (Gross, 1989), an alternative set of criteria for identifying those at risk for psychosis.
Given the conflicting findings from attributional style studies and the lack of research on LOC in UHR populations, the primary aim of the current study was to investigate LOC in UHR individuals compared to a healthy control group to investigate presence of externalized LOC in the groups. We also aimed to perform an exploratory analysis of the relationship between LOC, symptoms and functioning in UHR individuals. It was hypothesized that UHR patients would have a more externalized LOC compared to controls and that LOC would be related to intensity of attenuated psychotic symptoms, especially paranoia/suspiciousness.
Section snippets
UHR group
The UHR group was recruited as part of a larger study investigating social cognitive skills in early psychosis, which has been described further elsewhere (Thompson et al., 2010, Thompson et al., 2012). The UHR patient group was recruited from Orygen Youth Health (OYH) in Melbourne, Australia. This is a public youth mental health service for 15–25 year olds serving the western metropolitan region of Melbourne. OYH receives referrals from a number of community sources including general
Sample characteristics
The majority of the UHR sample (22/30, 73.3%) met only criteria for the attenuated symptoms group, with small numbers meeting both the trait and attenuated symptoms criteria, (5/30, 16.7%), the trait criteria alone (2/30, 6.7%) or a combination of trait, attenuated symptoms and BLIPS (1/30, 3.3%). Table 2 shows the characteristics of the groups. There was no difference in the two groups in terms of age, gender or IQ. The UHR group had significantly fewer years of education compared to the
Discussion
This study aimed to investigate LOC in a UHR population. As hypothesized, we found that UHR individuals had a more externalized LOC than control participants. This difference remained statistically significant even after adjusting for the potential confounders of age, gender and IQ. Higher externalized LOC was correlated with negative and paranoid symptoms in the UHR group, but not overall psychopathology or depressive symptoms. Externalized LOC was correlated with lower social functioning
Role of funding source
The study was partly funded by a Pfizer Neurosciences Investigator Grant. The funding source had no input into any aspect of the study.
Declaration of interests
Dr Thompson has received unrestricted investigator-initiated trial funding from Janssen-Cilag and Astra-Zeneca. He also holds a Pfizer Neurosciences Research Grant which partly funded this study. Dr Nelson was supported by a Ronald Phillip Griffith Fellowship from the University of Melbourne and a NARSAD Young Investigator Award. Dr. Bartholomeusz is supported by a National Health and Medical Research Council (NHMRC) Clinical Postdoctoral Research Fellowships. Professor Yung currently receives
Acknowledgments
The authors would like to thank Marija Strmota for her help in data management.
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