Delusions and decision-making style: Use of the Need for Closure Scale
Introduction
The idea that individuals with delusions have a high ‘need for closure’ (NFC) is theoretically and clinically appealing. Delusions are often attempts to make sense of a range of confusing and puzzling experiences, and difficulties dealing with uncertainty would be likely to facilitate rapid acceptance of explanations even if they are implausible. In cognitive-behavioural interventions patients are encouraged to be less certain in their judgements and to slow their decision-making processes down in order to consider other evidence and explanations. This can be conceptualised as an attempt to reduce closure. NFC is therefore one of a number of reasoning biases that may be implicated in delusion formation and persistence.
The NFC concept was operationalised by the social psychologist Arie Kruglanski in the development of his theory of lay epistemics. He views NFC as a motivated goal-driven process and defines it as ‘individuals’ desire for a firm answer to a question and an aversion toward ambiguity’ (Kruglanski & Webster, 1996). The Need for Closure Scale (NFCS) was developed for use in the general population (Webster & Kruglanski, 1994). This self-report measure contains five sub-scales: preference for order and structure (e.g. ‘I enjoy having a clear and structured mode of life.’); preference for predictability in future contexts (e.g. ‘I dislike unpredictable situations.’); decisiveness (e.g. ‘I usually make important decisions quickly and confidently.’); discomfort with ambiguity (e.g. ‘I dislike it when a person's statement could mean many different things.’); and closed-mindedness (e.g. ‘I do not usually consult many different opinions before forming my own view.’). The scale does not provide a simple unidimensional assessment of NFC. Neuberg, Judice, and West (1997) found that ‘three of the facets seem highly related to each other (Preference for Order, Preference for Predictibility, and Discomfort with Ambiguity), Close-Mindedness fits less well, and Decisiveness seems greatly out of place, even correlating negatively with the other facets at times.’ They argue that the NFCS assesses two separate dimensions: a desire for simple structure represented by the three closely related sub-scales and a preference for quick, decisive answers measured by the Decisiveness sub-scale. A cross-cultural study of the NFCS is consistent with this multi-dimensional view of the questionnaire (Mannetti, Pierro, Kruglanski, Taris, & Bezinovic, 2002).
There is an emerging empirical literature on delusions and NFC. Five studies have examined the NFCS in relation to delusional ideation in clinical and non-clinical groups. Colbert and Peters (2002) examined a non-clinical population. Seventeen people scoring high on delusional ideation were also found to have high NFCS total scores compared to 17 people with low delusional ideation. They also examined whether high NFC was associated with less data gathering (‘jumping to conclusions’) in a probabilistic reasoning task, but found no evidence for such a link in the non-clinical group. Bentall and Swarbrick (2003) used the NFCS with individuals with current delusions (), individuals with remitted delusions () and individuals with no psychiatric history (). The clinical groups had higher NFCS scores than the non-clinical group, but did not differ from each other. A further clinical study has been carried out by Colbert, Peters, and Garety (in press). They examined a total score for the sub-scales representing the ‘desire for simple structure’ in individuals with current delusions (), individuals with generalised anxiety disorder () and individuals without a psychiatric history (). The clinical groups again scored higher on the revised NFCS score than the non-clinical group, but did not differ from each other. NFC was associated with anxiety in the anxiety disorder group but not in the delusion group.
In a recent two-part non-clinical study, the association between NFC and paranoia was investigated by both questionnaire and experimental research designs. In the first part of the study, questionnaire measures of paranoia and NFC were completed by 300 students (Freeman, Dunn et al., 2005). Greater Discomfort with Ambiguity was found to be a predictor of paranoia. However, the methodological difficulty of questionnaire assessment of paranoia is that an unknown proportion of item endorsements will not correspond to ideas that sufficiently fulfill criteria for delusions. Therefore, in the second stage of the study virtual reality was used to generate paranoia experimentally (Freeman, Garety et al., 2005). Thirty of the students entered a virtual reality environment and were assessed for paranoia and for social anxiety towards five neutral computer characters. Predictors of paranoia and social anxiety were then examined. It was found that the NFCS sub-scales did not predict the unfounded paranoia generated in virtual reality. However, NFC was associated with social anxiety: higher scores for Preference for Predictability and Discomfort with Ambiguity and lower scores for Decisiveness were all associated with greater levels of social anxiety about the computer characters.
In sum, there are indications that NFC as assessed by the NFCS is high in people with delusions, and also people vulnerable to delusion development. However, it is not clear whether the presence of high levels of NFC is specifically related to delusional experience. There are indications that the NFC decision-making style may be associated with affect. Further, the relationship of NFC to other symptoms of psychosis has not been examined.
The primary aim of the current study was to administer the NFCS to a large sample of individuals with psychosis and to determine whether NFC is associated with delusion severity, other symptoms of psychosis, or affect. If NFC is high in individuals with psychosis then we wish to determine which aspects of their experiences such a decision-making style is related to. Of course, this is not to deny that there are likely to be interactions between symptoms. For example, there is increasing evidence that affect contributes to the development and maintenance of the symptoms of psychosis (e.g. Birchwood, 2003; Fowler, 2000; Freeman & Garety, 2003; Krabbendam, Janssen, Bijl, Vollebergh, & van Os, 2002; Turnbull & Bebbington, 2001). If NFC is associated with affect then it is likely to influence delusions, hallucinations, and negative symptoms indirectly.
There are thus two contending hypotheses. The first hypothesis (the direct route) is that NFC is specifically linked to delusional beliefs because NFC leads to rapid acceptance of explanations. This derives from the initial interest in NFC and delusions. The second hypothesis (the indirect route) is that NFC and delusions might be linked because affect is associated with both (i.e. affect is a mediating variable). NFC would be most closely associated with affect, which would then influence delusional experience. In the second hypothesis, NFC would be expected to be linked with other symptoms of psychosis because, like delusions, they are associated with affect (i.e. the relationship to delusions would be non-specific).
Rather than use a total score for NFCS, it was decided to investigate the dimensions of the NFCS separately. Similarly, we wished to go beyond a unidimensional assessment of delusions. A number of studies indicate that delusional experience is multi-dimensional, typically comprising delusional conviction, preoccupation, and distress (Garety & Hemsley, 1987; Harrow et al., 2004; Harrow, Rattenbury, & Stoll, 1988; Kendler, Glazer, & Morgenstern, 1983). Different processes may contribute to different dimensions of delusional experience (Freeman & Garety, 2004; Garety et al., in press). A multi-dimensional assessment of delusions was therefore included in the study. If NFC is particularly associated with decisions about delusion judgements (the direct route) then a particular association with delusion conviction would be expected. If NFC is particularly associated with distress (the indirect route) then the association is likely to be greater with the dimension of delusion distress.
Our secondary aim was to determine in a clinical group whether NFC is associated with a particular reasoning style—reduced data-gathering (‘jumping to conclusions’)—that is characteristic of a proportion of people with delusions (Garety & Hemsley, 1994). NFC might influence delusion development by affecting data gathering during formation of a belief. If the aim of an individual is to reduce ambiguity and reach a decision, then this is likely to curtail the gathering of data. The hypothesis would be that greater NFC would be associated with jumping to conclusions. This has not been studied in a clinical group. However, though plausible, such a link was not found in a non-clinical study (Colbert & Peters, 2002).
Section snippets
Participants
The clinical participants were 187 patients from the Psychological Prevention of Relapse in Psychosis (PRP) Trial (ISRCTN83557988). The PRP Trial is a UK multi-centre randomised controlled trial of cognitive behaviour therapy and family intervention for psychosis, designed to answer questions about both outcome and the psychological processes associated with psychosis. Studies of psychological processes in psychosis are incorporated into the baseline assessment of participating patients before
Clinical and demographic data
The mean age of the patient group was 37.5 years (SD=10.9). There were more male () than female () participants. The group comprised the following ethnicities: White (), Black—African (), Black—Caribbean (), Black—Other (), Indian (), Other ().
The case note diagnoses were schizophrenia (), schizo-affective disorder (), and delusional disorder (). The mean length of illness was 10.2 years (SD=8.4). The mean PANSS Positive symptom score was 17.8
Discussion
In a large-scale study it was confirmed that levels of NFC are altered not only in individuals with current delusions but also in individuals whose psychotic symptoms have remitted. This is consistent with the studies by Bentall and Swarbrick (2003), and Colbert et al. (in press). But, importantly, how does NFC—at least as measured by questionnaire—relate to the actual experiences of psychosis? Our results indicate its relationship to psychotic symptom presentation is indirect at best. NFC was
Acknowledgements
This work was supported by a programme grant from the Wellcome Trust (No. 062452). We wish to thank the patients taking part in the trial and the participating teams in the four NHS Trusts.
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