ORIGINAL RESEARCH published: 18 February 2021 doi: 10.3389/fpsyt.2020.596625 Cognitive Biases Questionnaire for Psychosis (CBQp): Spanish Validation and Relationship With Cognitive Insight in Psychotic Patients Lia Corral 1,2,3,4 , Javier Labad 2,5,6 , Susana Ochoa 2,7,8 , Angel Cabezas 1,2,3,4 , Gerard Muntané 1,2,3,4 , Joaquín Valero 1,2,3,4 , Vanessa Sanchez-Gistau 1,2,3,4 , Maribel Ahuir 2,6 , David Gallardo-Pujol 9,10 , Josep María Crosas 2,5,6 , Diego Palao 2,5,6 , Elisabet Vilella 1,2,3,4 and Alfonso Gutierrez-Zotes 1,2,3,4* 1 Institut Pere Mata, Hospital Universitari Institut Pere Mata of Reus, Reus, Spain, 2 Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain, 3 Institut d’Investigació Sanitària Pere Virgili (IISPV), Tarragona, Spain, 4 University of Rovira i Virgili, Tarragona, Spain, 5 Autonomous University of Barcelona, Barcelona, Spain, 6 Instituto de Investigación e Innovación Parc Taulí (I3PT), Barcelona, Spain, 7 Sant Joan de Déu Research Institute (IRSJD), Esplugues de Llobregat, Spain, 8 Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain, 9 Faculty of Psychology, University of Edited by: Barcelona, Barcelona, Spain, 10 Institute of Neurosciences, University of Barcelona, Barcelona, Spain Błażej Misiak, Wroclaw Medical University, Poland Reviewed by: Introduction: Cognitive biases are key factors in the development and persistence Katarzyna Prochwicz, of delusions in psychosis. The Cognitive Biases Questionnaire for Psychosis (CBQp) Jagiellonian University, Poland is a new self-reported questionnaire of 30 relevant situations to evaluate five types of Cristina Crocamo, University of Milano Bicocca, Italy cognitive biases in psychosis. In the context of the validation of the Spanish version of *Correspondence: the CBQp, our objectives were to (1) analyze the factorial structure of the questionnaire Alfonso Gutierrez-Zotes with a confirmatory factor analysis (CFA), (2) relate cognitive biases with a widely used gutierreza@peremata.com scale in the field of delusion cognitive therapies for assessing metacognition, specifically, Specialty section: Beck’s Cognitive Insight Scale (BCIS) (1), and, finally, (3) associate cognitive biases with This article was submitted to delusional experiences, evaluated with the Peters Delusions Inventory (PDI) (2). Schizophrenia, a section of the journal Materials and Methods: An authorized Spanish version of the CBQp, by a translation Frontiers in Psychiatry and back-translation procedure, was obtained. A sample of 171 patients with different Received: 19 August 2020 diagnoses of psychoses was included. A CFA was used to test three different construct Accepted: 28 December 2020 Published: 18 February 2021 models. Associations between CBQp biases, the BCIS, and the PDI were made by Citation: correlation and mean differences. Comparisons of the CBQp scores between a control Corral L, Labad J, Ochoa S, group and patients with psychosis were analyzed. Cabezas A, Muntané G, Valero J, Sanchez-Gistau V, Ahuir M, Results: The CFA showed comparative fit index (CFI) values of 0.94 and 0.95 for the Gallardo-Pujol D, Crosas JM, Palao D, models with one, two, and five factors, with root mean square error of approximation Vilella E and Gutierrez-Zotes A (2021) Cognitive Biases Questionnaire for values of 0.031 and 0.029. The CBQp reliability was 0.87. Associations between Psychosis (CBQp): Spanish Validation cognitive biases, self-certainty, and cognitive insight subscales of the BCIS were found. and Relationship With Cognitive Similarly, associations between total punctuation, conviction, distress, and concern Insight in Psychotic Patients. Front. Psychiatry 11:596625. subscales of the PDI were also found. When compared with the group of healthy doi: 10.3389/fpsyt.2020.596625 subjects, patients with psychoses scored significantly higher in several cognitive biases. Frontiers in Psychiatry | www.frontiersin.org 1 February 2021 | Volume 11 | Article 596625 Corral et al. Cognitive Biases Questionnaire for Psychosis Conclusion: Given the correlation between biases, a one-factor model might be more appropriate to explain the scale’s underlying construct. Biases were associated with a greater frequency of delusions, distress, conviction, and concern as well as worse cognitive insight in patients with psychosis. Keywords: cognitive bias, psychosis, delusion, cognitive insight, self-certainty INTRODUCTION negative events than patients without these symptoms, and this bias is still evident in remission phases (41). Cognitive biases are involved in the development and persistence A review article concludes that deficits in ToM may be of delusions (3–5). They occupy a central place in recent characteristic of schizophrenia because, despite being found in biopsychosocial models of psychosis (4, 6–8), both in terms patients with delusions, they seem to be more strongly associated of the content of thought (9, 10) and in the processes of with negative and disorganized symptoms than specifically with reasoning and meta-cognition (4, 11). Cognitive and training delusions (23). therapies in metacognition base their active principle of Although emotional-type biases have been associated with intervention regarding delusions on the modification of psychotic thinking (8, 42), few studies have linked Beck’s cognitive biases (12). Metacognitive training decreases described biases for emotional disorders with psychotic cognitive biases and improves positive symptomatology in symptoms. Nonetheless, biases such as dichotomous thinking, psychosis (13–19). emotional reasoning, and catastrophising have been associated People with delusions tend to show different reasoning biases. with delusional symptomatology (4, 8). The most researched biases are jumping to conclusions (JTC) Despite associations of internal emotional states with (3, 4, 20), attributional biases (21, 22), inflexibility in beliefs, and delusions, until the appearance of the Cognitive Biases theory of mind deficits (ToM) (3, 23). Questionnaire for Psychosis (CBQp) (18), there was no scale to The JTC bias in patients implies that they tend to consider specifically measure Beck’s biases in patients with psychosis. fewer data to arrive at a decision than healthy controls (23, 24), The CBQp (18) was developed to assess cognitive biases in which has been observed in between one-third and two-thirds of psychosis. It is based on the Blackburn Cognitive Styles Test (43), subjects with delusions (4, 25–28). which was designed to assess common cognitive distortions in JTC has also been found in healthy subjects with delusion-like depression and amended to provide appropriate scenarios for experiences (28), subjects at high risk of suffering from psychosis psychotic patients. For the validation of the CBQp, the structure, (29), subjects with active psychotic symptoms at the time of validity, and reliability of the scale was analyzed in a group of evaluation (4), and in a more attenuated manner in psychotic subjects with psychosis. The CBQp scores were compared with patients’ relatives (28, 30). Colbert and Peters (31) and Ross et al. those of depressed subjects and healthy controls. The results (32) also found a significant presence of JTC in healthy people showed adequate internal consistency and test–retest reliability. prone to delusions. The items of the scale had a bifactorial structure, implying The results of a meta-analysis imply that JTC supposes an that the five cognitive biases would not be independent. This increase in the probability of the appearance of delusions in result suggests the possibility that the CBQp evaluates a general psychosis (33). This bias was found in people with psychosis thinking bias rather than different cognitive errors. The scores who tended to look for less evidence when making decisions and obtained in the anomalous perception (AP) and threatening who used more “extreme responses” when compared with both events (TE) themes could be independently used. healthy subjects and subjects with other mental illnesses different Subjects with psychosis and those with depression obtained from psychosis. The meta-analysis likewise concludes that there higher total CBQp scores than healthy controls (18). Subjects is an inverse relationship between data search and the severity with active psychotic symptoms at the time of the evaluation of delusions. obtained higher scores than the asymptomatic subjects, showing Another meta-analysis implies that JTC would not be a modest associations between the CBQp scores, and the severity transdiagnostic phenomenon of psychosis (34). It is specifically of symptoms. The scores obtained in the theme of AP and associated with delusions rather than with the diagnosis of the intentionalizing (Int) bias suggest some specificity in schizophrenia and may contribute to its severity (35). Therefore, psychosis. The underlying construct of the CBQp could be JTC is a stable feature that increases the vulnerability to the specifically related to interpretation bias, not being associated development of delusions and can predict the changes over with reasoning, judgement, or decision-making processes (18). time (36). Catastrophising (Cat) and JTC biases predict delusional On the other hand, regarding attribution biases, some experiences not only in subjects with schizophrenia but also studies show evidence of an externalization–personalization in healthy subjects. In subjects diagnosed with schizophrenia, bias for negative events in people with persecution delusions the Cat bias was the best predictor of the total severity index in comparison with healthy controls (37–40). Patients with of delusions (measured by the PSYRATS), while the cognitive symptoms of paranoia have a greater personalization bias for dimension of these delusions was specifically related to JTC (44). Frontiers in Psychiatry | www.frontiersin.org 2 February 2021 | Volume 11 | Article 596625 Corral et al. Cognitive Biases Questionnaire for Psychosis Furthermore, Daalman et al. (45) compared clinical and test the scale structure of the Spanish version of the CBQp, healthy voice-hearers with controls, finding that most cognitive the questionnaire was administered to a sample of patients. biases prevalent in clinical voice-hearers, particularly with The patient sample consisted of 171 subjects with psychosis, of threatening event themes, were absent in healthy voice- whom 103 (60.23%) were men. The participants were outpatients hearers, except for emotional reasoning which may be (58%) and inpatients (42%). They were recruited from three specifically related to the vulnerability to develop auditory main sites: Hospital Universitari Institut Pere Mata (Reus), Parc verbal hallucinations (45). Tauli Hospital Universitari (Sabadell), and Parc Sanitari Sant Another recent study evaluated the impact of metacognitive Joan de Déu (Barcelona). Regarding the diagnoses, 84 (48.8%) training (MCT) on cognitive biases in people diagnosed with participants were diagnosed with schizophrenia, 39 (22.9%) had schizophrenia, finding improvements in the Cat, emotional an unspecified psychotic disorder, 28 (16.5%) had schizoaffective reasoning (ER), and JTC biases, with an important impact on disorder, seven (4.1%) had schizophreniform disorder, six the CBQp total score (46). These results suggest that one of (3.5%) had bipolar disorder, four (2.4%) had brief psychotic the first objectives of metacognitive training, to reduce cognitive disorder, and three (1.8%) had delusional disorder. There was biases (12), was reached in this sample of chronic patients (46). no significant difference in age between male (M = 32.44, The results of a recent study with an MCT and psychoeducation SD = 10.82) and female participants (M = 32.88, SD = 11.43) intervention in recent-onset psychosis imply the usefulness of the [t (169) = 0.25, p = 0.797]. CBQp to detect improvements in cognitive biases (47). Subsequently, to establish comparisons, the CBQp was Similarly, another study investigated the relationship between administered to a group of patients and healthy subjects. cognitive biases and the cognitive and emotional dimensions To ensure that the group of patients and healthy subjects of delusions in patients with schizophrenia spectrum disorders, were matched by sex and age, a subsample of 157 patients, controlling confounding variables such as hallucinations (48). of whom 95 (60.5%) were men, was compared with the The results show that the JTC bias was associated with group of controls with 30 participants. A control group of 30 both the delusion conviction and the associated emotional voluntary participants, of whom 17 (56.7%) were men, who discomfort. Only the emotional discomfort associated with had no diagnosed psychiatric disorder, was recruited from the auditory hallucinations was related to dichotomous thinking community (Tarragona, Cataluña). No significant differences (DT) and Int biases. These results are consistent with previous were found in terms of age between men (M = 31.71, SD = 6.70) results that found that JTC, measured by the CBQp, was related and women (M = 32.77, SD = 7.65; p = 0.405). No significant not only to clinical delusions but also to a non-clinical propensity differences were found in terms of sex between the two groups to delusions (44). (χ 2 = 0.155; p = 0.694). Information on the participants is All of these data support the idea that JTC may be relevant reported in Table 1. throughout the different stages of delusion formation (32, 33) and The CBQp was administered together with the Beck Cognitive could be a vulnerability–trait factor that could increase the risk of Insight Scale (BCIS) (1) and the Peters Delusions Inventory (2) to developing delusional experiences (44, 49, 50). the Institut Pere Mata patients’ group. BCIS was administered to This study translated to Spanish the Cognitive Biases both outpatients and inpatients, while PDI was only assessed in Questionnaire for Psychosis. Our objectives were to obtain the inpatient sample (Figure 1). the psychometric properties of the Spanish version of the All procedures were in accordance with the Declaration CBQp, specifically to (1) analyze the factorial structure of of Helsinki. Ethical approval was obtained from the local this questionnaire and obtain the descriptive statistics of each ethics committee (CEIm IISPV, www.iispv.cat). All the subjects dimension for patients with psychosis and controls, (3) obtain consented to participate in the study and signed an informed the reliability for internal consistency for each scale, (4) relate consent form after a complete explanation of all procedures. cognitive biases with a widely used scale in the field of delusion cognitive therapies for assessing metacognition, specifically Instruments Beck’s Cognitive Insight Scale (1), and (5) associate cognitive The CBQp (18) has a self-applied format with 30 descriptions biases with delusional experiences evaluated with the Delusions of everyday situations, 15 on AP and 15 on TE, in which the Inventory (PDI) (2). subject must choose between three options that best describe how he or she would think about that situation. Each group METHODOLOGY of statements covers five cognitive biases: Int, Cat, DT, JTC, and ER. There are three statements per bias for each topic. Participants and Procedures Each vignette includes a forced choice on a three-point scale This study had a cross-sectional design with a comparison group (1 = absence of bias, 2 = presence of bias with some qualification, based on cases and controls matched for sex and age. 3 = presence of bias). The subject must imagine himself or The validation of the CBQp was carried out in several herself in each situation and choose one of the three possible stages. Authorization for the Spanish adaptation of the CBQp answers. Cronbach’s alpha of the total CBQp was 0.89. The test– (18) was obtained from the authors (Peters E, personal retest was 0.94 for the psychosis group and 0.70 for the healthy communication, 2013). The linguistic and cultural adaptation controls (18). of the scale was carried out using the methodology of direct The BCIS (1) is a 15-item self-registration measure that and inverse translation (translation–back-translation) (51). To assesses how patients evaluate their own judgement. It consists Frontiers in Psychiatry | www.frontiersin.org 3 February 2021 | Volume 11 | Article 596625 Corral et al. Cognitive Biases Questionnaire for Psychosis TABLE 1 | Demographic information for the samples. Control vs. Psychosis Psychosis BCIS Groups Psychosis Controls Psychosis Psychosis Low CI High CI CFA PDI N 171 30 157 50 45 43 Gender (n) (%) 103M (60.2%) 17M (56.7%) 97M (39.5%) 30M (60%) 23M (51.1%) 31M (73.8%) 68F (39.8%) 13F (43.3%) 62F (60.5%) 20F (40%) 22F (48.9%) 11F (26.2%) p = 0.694 p = 0.029 Age in years (mean, SD) 32.17 (7.02) 33.01 (11.32) All p = 0.594 M 32.44 (10.82) 31.71 (6.70) 33.04 (10.97) 37.07 (10.15) 32.28 (11.51) 32.71 (11.29) F 32.88 (11.43) 32.77 (7.65) 32.95 (11.92) 37.30 (12.44) 36.02 (12.59) 30.18 (12.64) P = 0.445 p = 0.405 p = 0.961 p = 0.942 p = 0.152 p = 0.540 M, Male; F, Female; CFA, Confirmatory Factor Analysis; PDI, Peters Delusion Inventory; BCIS, Beck Cognitive Insight Scale; CI, Cognitive Insight. of the self-reflectiveness and self-certainty for patients were 0.68 and 0.60, respectively (1). The internal consistency for the Spanish version of the BCIS was 0.59 for self-reflectiveness and 0.62 for self-certainty. The intraclass correlation coefficients of test–retest reliability were 0.69 for self-reflectiveness, 0.72 for self-certainty, and 0.70 for the composite index (52). Given that both of these subscales are composed of <10 items, the levels of internal consistency of the BCIS were considered to be acceptable for research purposes (53, 54), even though both coefficients were less than the 0.70 value recommended by Nunnally (55). The Peters Delusion Inventory (2), with 21 items, consists of four scales to assess the presence/absence of delusional symptoms and their degree of conviction, preoccupation, and distress. For PDI, the Cronbach coefficient was 0.82. The test–retest reliability for the PDI yes/no and conviction scales was 0.78, while that for the distress and preoccupation scales was 0.81 (2). The Spanish version of the PDI had a Cronbach coefficient of 0.75 (56). Statistical Analysis The psychometric properties of the scale structure, reliability, and validity of the Spanish version of the CBQp were analyzed: 1. Confirmatory factor analysis (CFA) was used to evaluate three alternative models of the scale construct, i.e., a five-factor model hypothesizing that each factor represents a separate bias, a two-factor model in which each factor represents a theme (AP and TE), and, finally, a one-factor model in which a general thinking bias underlies the five types of cognitive biases. For the CFA, the sample size was estimated to be five participants per item (30 items), with a necessary sample of at least 150 participants (57, 58). We used the weighted least square mean and variance adjusted estimation method, which is a robust FIGURE 1 | Sample selection. estimator that does not assume normality and is the best option for modeling categorical or ordered data (59). To estimate the goodness of fit of the CFA, the estimators root mean square of two dimensions: self-reflectiveness (R) (nine items) and self- error of approximation (RMSEA), CFI, Tucker–Lewis index certainty (C) (six items). A composite index of cognitive insight is (TLI), and standardized root mean residual square (SRMR) were obtained as reflectiveness–certainty (IC = R—C) (subtraction of used according to the criteria of Hu and Bentler (60). Akaike’s self-certainty from self-reflectiveness). The Cronbach coefficients information criteria (AIC) (61) and Bayesian information criteria Frontiers in Psychiatry | www.frontiersin.org 4 February 2021 | Volume 11 | Article 596625 Corral et al. Cognitive Biases Questionnaire for Psychosis (BIC) (62) were also used to select the best model according to (Mdn = 21/Mdn = 20, U = 1,826, p = 0.051) maintained a trend information criteria. toward statistical significance. 2. Analysis of the internal consistency to test the reliability of the CBQp scale was performed by means of Cronbach’s alpha and Comparison Between Groups Based on Cognitive composite reliability. Insight 3. Several scales had a non-normal distribution. Differences The difference between the groups when the total sample was between two groups of patients, based on the highest and the divided into a group with an equal or higher score than lowest scores according to the mean on the BCIS, and between the mean and a group with a score below the mean on samples (psychotic and healthy groups) were analyzed for the the Cognitive Insight Scale (M = 6.42) (BCIS) is shown in CBQp scales through the Mann–Whitney U-test, which is robust Table 5. The Mann–Whitney U-test showed that the group with to non-normality. Comparisons between groups in terms of sex lower insight had a higher score than the group with higher and age were carried out by χ 2 and Student’s t-test, respectively. insight in the total score of the CBQp (Mdn = 44/Mdn = 39, Spearman’s rho correlations were used to evaluate the association U = 631.5, p = 0.005), TE (Mdn = 22/Mdn = 20, U = 664.5, between themes and biases of CBQp and the BCIS and PDI scales. p = 0.011), AP (Mdn = 20/Mdn = 19, U = 642, p = The CFA and reliability calculations were conducted with 0.006), Int (Mdn = 8/Mdn = 7, U = 685.5, p = 0.015), the lavaan package (63) running under R 3.6.0 software, and Cat (Mdn = 9/Mdn = 8, U = 653, p = 0.008), and JTC the mean differences and correlations were conducted with (Mdn = 10/Mdn = 9, U = 636, p = 0.005). There were no SPSS v.23. differences between the groups according to the level of cognitive insight in the DT (Mdn = 9/Mdn = 8, U = 777.5, p = 0.107) and ER (Mdn = 8/Mdn = 8, U = 778.5, p = 0.108) biases. RESULTS Scale Factor Structure Correlations Between CBQp Scores and BCIS and The statistics for the factorial model of the CBQp of one, two PDI Scales (TE and AP), and five factors (Int, Cat, DT, JTC, and ER) The significant correlations between the CBQp and the BCIS are shown in Table 2. Although somewhat better for the five- and PDI scales are shown in Table 6. A positive association was factor model (CFI = 0.952, TLI = 0.948, RMSEA = 0.029, obtained between self-certainty and both themes, all the biases, SRMR = 0.093, AIC = 8846.898, and BIC = 9066.815), the and the total score of the CBQp: TE (rs = 0.30, p < 0.01), adjustment indices were also good and similar in the one-factor AP (rs = 0.34, p < 0.01), Int (rs = 0.40, p < 0.001), Cat (CFI = 0.947, TLI = 0.943, RMSEA = 0.031, SRMR = 0.096, (rs = 0.23, p < 0.05), DT (rs = 0.22, p < 0.05), JTC (rs = 0.21, AIC = 8852.954, and BIC=9041.454) and two-factor models p < 0.05), ER (rs = 0.30, p < 0.01), and total score (rs = 0.35, (CFI = 0.947, TLI = 0.943, RMSEA = 0.031, SRMR = 0.096, p < 0.01). The two themes and biases of the CBQp showed AIC = 8853.346, and BIC = 9044.987). The factors had negative associations with the Cognitive Insight Scale, with the significant positive correlations (rs = 0.66, p < 0.001) when exception of the DT and ER biases: TE (rs = −0.26, p < 0.05), analyzed as themes, with the association between biases in the AP (rs = −0.26, p < 0.05), Int (rs = −0.30, p <0.01), Cat range of 0.34–0.78 (p < 0.001). The item factor loadings in each (rs = −0.28, p < 0.01), and JTC (rs = −0.22, p < 0.05). Similarly, of the three models are presented in Table 3. Items 9, 19, and 27 the total CBQp score was negatively associated with cognitive had a factor loading < 0.3. insight (rs = −0.28, p < 0.01). The self-reflectiveness scale of the BCIS only showed an association with the catastrophising bias Reliability of the CBQp (rs = −0.25, p < 0.05). All the scales of the CBQp Cronbach’s alpha was 0.87 for the total scale (30 items), 0.76 for correlated positively with the scales of the PDI, with the exception the AP scale (15 items), and 0.78 (15 items) for the TE scale. The of the Int bias. The highest correlations were obtained between composite reliability was 0.92 for the total scale and 0.86 for both the total score of the CBQp, AP, and Cat and the frequency the AP and TE scales. of delusions, with the range of associations from 0.50 to 0.58 (p < 0.001). Validity Comparisons Between Patient and Control Samples DISCUSSION The descriptive statistics for the group of patients and the controls are shown in Table 4. The Mann–Whitney U- The objective of this study was to validate the Spanish version of test showed that the group with psychosis had a higher the CBQp questionnaire in a sample of patients with psychosis. score than the control group in the total score of the For this, the factorial structure of the different models of the CBQp (Mdn = 41/Mdn = 38, U = 1,705, p = 0.017), underlying construct in cognitive biases was analyzed. We aimed TE (Mdn = 21/Mdn = 20, U = 1,826, p = 0.051), to obtain the reliability of the scale and the relationship of AP (Mdn = 20/Mdn = 18, U = 1,725.5, p = 0.020), the biases with the BCIS for evaluating patients’ metacognitive Int (Mdn = 7/Mdn = 7, U = 1,758, p = 0.024), DT capacity and a widely used scale in the field of cognitive therapy (Mdn = 8/Mdn = 7, U = 1,655, p = 0.009), and ER for delusions. Finally, we analyzed the relationship between (Mdn = 8/Mdn = 7, U = 1,638, p = 0.006). The TE theme the biases and the PDI scale, an instrument to assess the Frontiers in Psychiatry | www.frontiersin.org 5 February 2021 | Volume 11 | Article 596625 Corral et al. Cognitive Biases Questionnaire for Psychosis TABLE 2 | Goodness of Fit for the Confirmatory Factor Analysis (CFA) (Psychosis group) (N = 171). CBQp CFI TLI RMSEA SRMR AIC* BIC* 1-factor model 0.947 0.943 0.031 (0.015–0.042) 0.096 8852.954 9041.454 2-factor model 0.947 0.943 0.031 (0.015–0.042) 0.096 8853.346 9044.987 5-factor model 0.952 0.948 0.029 (0.012–0.041) 0.093 8846.898 9066.815 CFI, Robust comparative fit index; RMSEA, Root mean square error of approximation; SRMR, Standardized root mean square residual; TLI, Tucker-Lewis index; AIC, Akaike’s Information Criteria; BIC, Bayesian Information Criteria. *Because of the nature of both AIC and BIC, they were computed from maximum-likelihood estimations of the models. TABLE 3 | Cognitive Biases Questionnaire for Psychosis (CBQp) factor loadings from the CFA. 2 Factors (Themes) 5 Factors (Biases) 1 Factor 1 (TE) 2 (AP) 1 (Int) 2 (Cat) 3 (DT) 4 (JTC) 5 (ER) CBQ1 0.434 0.436 – 0.439 – – – – CBQ2 0.432 – 0.436 – 0.426 – – – CBQ3 0.660 – 0.667 0.669 – – – – CBQ4 0.588 0.593 – – 0.578 – – – CBQ5 0.328 0.331 – – – 0.386 – – CBQ6 0.578 – 0.584 – – – 0.575 – CBQ7 0.590 0.593 – – 0.578 – – – CBQ8 0.737 – 0.744 – – – – 0.790 CBQ9 0.261 0.264 – – – – 0.265 – CBQ10 0.469 – 0.473 – 0.463 – – – CBQ11 0.536 0.540 – – – 0.621 – – CBQ12 0.711 0.717 – – 0.696 – – – CBQ13 0.526 0.529 – – – – – 0.564 CBQ14 0.513 – 0.517 – – 0.585 – – CBQ15 0.564 0.568 – – – 0.648 – – CBQ16 0.570 – 0.575 – – – – 0.612 CBQ17 0.436 – 0.442 – – – 0.433 – CBQ18 0.726 0.731 – – – – 0.723 – CBQ19 0.262 0.263 – – – – – 0.285 CBQ20 0.648 – 0.654 0.654 – – – – CBQ21 0.479 – 0.482 – – – 0.479 – CBQ22 0.580 0.584 – 0.587 – – – – CBQ23 0.450 – 0.453 0.455 – – – – CBQ24 0.794 0.800 – – – – – 0.852 CBQ25 0.802 – 0.810 – 0.786 – – – CBQ26 0.447 – 0.450 – – – – 0.480 CBQ27 0.212 – 0.213 – – 0.246 – – CBQ28 0.443 0.446 – 0.448 – – – – CBQ29 0.571 0.576 – – – – 0.571 – CBQ30 0.525 – 0.529 – – 0.598 – – TE, threatening events; AP, anomalous perceptions; Int, intentionalising; Cat, catastrophising; DT, dichotomous thinking; JTC, jumping to conclusions; ER, emotional reasoning. degree of conviction, preoccupation, and distress produced by of the themes could be used separately. In the Spanish version delusional symptoms. of the CBQp, we obtained a significant association between Related to the factor structure of the CBQp, our results imply the themes and between the biases. Given the extremely high that the three factorial solutions had a good fit. In the study between-factor correlations in the two-factor and five-factor with the original version of the scale, the two- and five-factor models and the relatively small differences in fit, the principle models did not fit the data if independence was assumed in the of parsimony leads us to choose the one-factor model as the factors (18). With related factors, the two-factor model best fit best model explaining the data. A one-dimensional model of the underlying structure of the scale, suggesting that the scores the scale’s construct would be more parsimonious. Our results Frontiers in Psychiatry | www.frontiersin.org 6 February 2021 | Volume 11 | Article 596625 Corral et al. Cognitive Biases Questionnaire for Psychosis TABLE 4 | CBQp differences between patients with psychosis and controls. Psychosis Control z p (N = 157) (N = 30) CBQp Mdn M (sd) Mdn M (sd) Total score 41 43.17 (8.90) 38 38.90 (3.90) −2.396 0.017 Threatening events (TE) 21 22.25 (4.96) 20 20.07 (2.11) −1.954 0.051 Anomalous perceptions (AP) 20 20.92 (4.51) 18 18.83 (2.27) −2.331 0.020 Intentionalising (Int) 7 7.82 (1.87) 7 6.93 (0.94) −2.265 0.024 Catastrophising (Cat) 8 8.67 (2.26) 8 8 (1.46) −1.195 0.232 Dichotomous thinking (DT) 8 8.50 (2.23) 7 7.33 (0.92) −2.628 0.009 Jumping to conclusions (JTC) 9 9.79 (2.32) 9 9.23 (1.50) −0.945 0.345 Emotional reasoning (ER) 8 8.39 (2.44) 7 7.17 (1.48) −2.762 0.006 TABLE 5 | CBQp scale differences between groups based on Cognitive Insight. CBQp Low Cognitive Insight* High Cognitive Insight** (N = 45) (N = 43) Mdn M (SD) Mdn M (SD) Mann-Whitney U z p CBQ total 44 45.66 (10.51) 39 40 (6.07) 631.5 −2.80 0.005 Threatening events (TE) 22 23.42 (5.62) 20 20.55 (3.67) 664.5 −2.53 0.011 Anomalous perceptions (AP) 20 22.24 (5.36) 19 19.44 (3.12) 642 −2.73 0.006 Intentionalising (Int) 8 8.35 (2.42) 7 7.09 (1.28) 685.5 −2.43 0.015 Catastrophising (Cat) 9 9.33 (2.58) 8 7.97 (1.59) 653 −2.66 0.008 Dichotomous thinking (DT) 9 8.93 (2.52) 8 8.09 (1.77) 777.5 −1.61 0.107 Jumping to conclusions (JTC) 10 10.31 (2.66) 9 8.83 (1.67) 636 −2.80 0.005 Emotional reasoning (ER) 8 8.73 (2.43) 8 8 (2.32) 778.5 −1.60 0.108 *BCIS score ≥ 6.42; ** BCIS score < 6.42. are consistent with those obtained in the validation study of an average of 47.3 in the English version (18) compared to the German version of the CBQp. This study showed that the 43.19 in ours. On the other hand, a study that was carried one-factor model is the one with the best goodness of fit, also out with a spectrum of schizophrenic patients with or without showing good fit for two- and five-factor models (64). As has been delusions obtained scores of 60.91 and 58.98, respectively (44). justified previously, the CBQp evaluates a general thinking style In the threatening events and anomalous perceptions themes, two that underlies the cognitive biases previously recorded by Beck, previous studies with psychotic patients found higher scores with some variations depending on the type of situation (18). than our validation study (18, 44). These differences between Thus, the different biases seem to represent a general tendency studies could be due to the distinct composition of diagnoses to process information in a distorted and alarming way. and/or the severity, intensity, and frequency of delusions in the The reliability (internal consistency) for the CBQp (0.87) samples. In our study, the analysis was not controlled for the was satisfactory and similar to the English version (0.89) (18), severity of the symptomatology, so in future studies it would be Flemish version (0.86) (64), and Polish version (0.83) (46). On necessary to recruit homogeneous samples in terms of diagnoses the other hand, the reliability of the anomalous perceptions and the type and intensity of symptoms to establish more and threatening events themes, with Cronbach α of 0.76 and precise comparisons. 0.78, respectively, are in a “moderate–high” range of internal When compared with the healthy subjects’ group, the consistency (65). Additionally, elevated composite reliability psychotic patients scored significantly higher in the CBQp total points to the unidimensionality of a construct. In our case, the score, in AP theme, and in all the biases, except for Cat and composite reliability for the full scale was 0.92, suggesting that a JTC. These results are discordant with the differences found in single construct underlies all of the items. the English CBQp version, where all biases were significantly Analyzing descriptive statistics, the Spanish version of the higher in the group of subjects with psychosis (18). In our study, CBQp showed similar scores to those obtained with the English the absence of differences between the patients and the control version, although with some slightly lower values. Thus, for group in the TE theme and in both the Cat and JTC biases cognitive biases, our scores were approximately one point lower. could have two explanations. First, Beck’s cognitive biases were This difference is greater in the total score of the scale, with initially developed to define a depression-associated thinking Frontiers in Psychiatry | www.frontiersin.org 7 February 2021 | Volume 11 | Article 596625 Corral et al. Cognitive Biases Questionnaire for Psychosis TABLE 6 | CBQp correlations with BCIS and PDI scales. BCIS (N = 88) PDI (N = 50) CBQp Self-reflectiveness Self-certainty Cognitive Total Yes/No Distress Preoccupation Conviction insight Total score 0.35** −0.28** 0.56*** 0.55*** 0.55*** 0.58*** Threatening events (TE) 0.30** −0.26* 0.53*** 0.48*** 0.52*** 0.53*** Anomalous perceptions (AP) 0.34** −0.26* 0.51*** 0.56*** 0.51*** 0.55*** Intentionalising (Int) 0.40*** −0.30** Catastrophising (Cat) −0.25* 0.23* −0.28** 0.52*** 0.50*** 0.50*** 0.57*** Dichotomous thinking (DT) 0.22* 0.35* 0.35* 0.35* 0.29* Jumping to conclusions (JTC) 0.21* −0.22* 0.47** 0.50*** 0.45** 0.50*** Emotional reasoning (ER) 0.30** 0.42** 0.46** 0.47** 0.46** ***p < 0.001; **p < 0.01; *p < 0.05. style, having a broad emotional component and not just a To our knowledge, the association between cognitive biases psychotic cognitive–perceptual component, which could justify (CBQp) and cognitive insight (BCIS) has not been studied. As the presence of these biases in a healthy population. Thus, it an expected result, in our study, both the themes and the biases would have been interesting to evaluate depressive and anxiety were related to the self-certainty dimension of the BCIS, which mood in both samples to identify the subjects’ tendency to measures the degree of conviction in the “reality” of the delusion a distorted thinking style due to emotional issues. In future contents of patients, showing more self-certainty based on a studies, it would be necessary to control emotional variables for greater presence of biases. Except for emotional reasoning and evaluating the specificity of these cognitive biases to psychosis. dichotomous thinking, all CBQp scales were associated with On the other hand, the number of subjects in our control sample cognitive insight. Previous studies have also obtained results was 30, which, although similar to the original validation study, pointing out JTC’s association with self-certainty (74), supporting could subtract representativeness from the comparison between the idea of overconfidence about one’s own decisions in psychotic patients and controls. patients (1). On the other hand, other studies did not find any It should be noted that the only previous study that provides association between JTC and the BCIS scales (self-reflection, self- the exploration of differences between a sample of patients and certainty, and cognitive insight index) (75). It should be noted controls related to CBQp scores is the validation study of Peters that these studies used probabilistic tasks for assessing cognitive et al. (18). When they compared the psychosis group with a group biases and not the CBQp (74, 75). of subjects with depression, no significant differences between the In our results, except for ER and DT, the CBQp scores were groups regarding the TE theme were obtained. Similarly, other associated with cognitive insight, showing that it decreased with non-intuitive results were obtained, as the cognitive biases of a greater presence of biases. Similarly, when the sample was JTC and PD were superior in the depression group than in the divided into two groups concerning cognitive insight (high/low), psychosis group (18). These results could imply, as mentioned the group with less insight showed a greater presence of cognitive above, that CBQp could be assessing negative-emotionality biases (CBQp total score) as well as higher scores in both themes content biases. (TE and AP) and Int, Cat, and JTC biases of the questionnaire. We would like to highlight that our validation study sample Cognitive insight would respond to the objectivity, reflexivity, had a similar proportion of men and women. To date, few and openness of the subject to external feedback (1), suggesting studies have analyzed the presence of sex differences concerning a greater presence of cognitive biases and a lower personal ability cognitive biases in psychosis, finding no significant differences to detect them, associated with low cognitive insight. (66, 67). However, de Vos et al. (66) suggest the possibility of Moreover, the results supporting the improvement of a subtle effect of sex differences related to delusion-associated cognitive biases and cognitive insight after MCT (46, 76) suggest cognitive biases, which is necessary to carry out more extensive that there may be common thought and information processing studies with more statistical power to detect it (65). Indeed sex mechanisms for both mental phenomena. Specifically, several differences in cognitive biases could be expected because of these studies show JTC’s decrease after MCT (17, 46, 47), sometimes biases’ link to neuropsychological performance (19, 68, 69) and by the simple fact of making the subjects aware of the presence global functioning (70) and the previously found differences of biases (13, 77, 78), which would go in the line of achieving between men and women concerning these domains (71, 72). adequate cognitive insight. Nevertheless, it would be necessary to These differences have also been found in affective symptoms continue expanding the evidence in this field, analyzing the role (72) and awareness and attribution of psychotic symptoms (73). of cognitive biases in insight formation processes. Therefore, although our control sample’s size is small, it could Regarding delusional symptoms, in our study, both themes be representative, using similar male and female percentages to and all biases, except intentionalizing, were associated with the those used in the psychosis group. PDI scales. These results suggest that not only a greater presence Frontiers in Psychiatry | www.frontiersin.org 8 February 2021 | Volume 11 | Article 596625 Corral et al. Cognitive Biases Questionnaire for Psychosis of delusional symptomatology but also increased concomitant the severity of the symptomatology. Subsequent studies should conviction, concern, and distress are involved in cognitive biases. analyze the biases according to the type and intensity of the Jumping to conclusions has a similar association with both delusions. Third, given the emotional component in Beck’s emotional and cognitive dimensions. Some authors suggest that it biases, it would have been appropriated to control for mood would be more related to delusions’ conviction (4). Other authors state with the CBQp. Finally, diagnostic heterogeneity and the (44, 48) also found an association between JTC and the cognitive limited availability of sociodemographic data could limit the dimension of delusions (conviction and worry). They obtained generalization of the study’s results. The healthy subjects’ sample similar results concerning the emotional dimension (distress) was selected from health professionals’ environment. In future (48), and this hypothesis was refuted in our study. Although studies, it would be necessary to analyze the descriptive statistics correlations are similar, catastrophising would be associated first of biases in a broader sample of the general population. This with the cognitive dimension of delusions (conviction) and would ensure more representativeness of the results, being able second with the emotional dimension (distress). Similarly, the to establish cutoff points regarding to the healthy population and hypothesis of previous studies (79–81), which suggests that Cat is facilitating data generalization. related to the distress caused by delusions, would be confirmed. In this sense, our findings delve into the idea that cognitive DATA AVAILABILITY STATEMENT biases assessed by CBQp are related not only to the cognitive dimension of delusions but also to the emotional dimension. The raw data supporting the conclusions of this article will be This could imply that deficits in the metacognitive components made available by the authors, without undue reservation. of information processing in psychosis should be assumed from the cognitive–emotional state of patients. However, some studies ETHICS STATEMENT with CBQp found no relationship between cognitive biases and the emotional dimension of delusions (44), while others found The studies involving human participants were reviewed no relationship with either dimension (48). Therefore, more and approved by Comitè Ètic d’Investigació Clínica Institut evidence is needed. d’investigació Sanitària Pere Virgili (CEIm IISPV de Reus). The In summary, the Spanish version of the CBQp has replicated patients/participants provided their written informed consent to the factorial model of the general thinking style construct participate in this study. of a tendency to process information in a distorted and alarming way. The questionnaire has excellent reliability. The AUTHOR CONTRIBUTIONS themes and cognitive biases of the questionnaire have been associated with greater delusional symptomatology and, equally, LC, JL, SO, AG-Z, and AC designed the study and participated in with worse metacognition when assessed by cognitive insight. the linguistic adaptation of the Spanish version of the CBQp. DG- Therefore, the psychometric properties and validation of the P, GM, JL, and AG-Z performed the data analysis. JL, SO, AG-Z, Spanish version of the CBQp guarantee that this instrument VS-G, DP, JMC, JV, and EV participated in the interpretation of can be used as an assessment of cognitive biases in the data. LC, JL, AC, MA, and AG-Z participated in the acquisition, Spanish language. Given the importance of cognitive biases analysis and interpretation of data. LC and AG-Z wrote the paper in cognitive and metacognitive therapies of psychosis (12), with input from all authors. All authors discussed the results instruments such as the CBQp, designed in a format based and contributed to the final manuscript, revised the manuscript on everyday situations, are very useful in the evaluation of content, and approved the final version of the manuscript. these biases in the previous phase or in the maintenance of delusions. FUNDING This study has several limitations. First, the low factor weight of three questionnaire items implies a worse association of these This work was funded by the Health Department of Catalonia, items with their theoretical factor. However, this result could PERIS call (SLT006/17/00231). be a limitation from psychometry’s point of view, but this does not necessarily mean that these items need to be excluded; ACKNOWLEDGMENTS these items could provide relevant information concerning the clinical construct, and because of this, they are useful in We wish to thank Emmanuelle R. Peters for her support and bias measurement. 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This is an Investigation of sex differences in delusion-associated cognitive biases. open-access article distributed under the terms of the Creative Commons Attribution Psychiatry Res. (2019) 272:515–20. doi: 10.1016/j.psychres.2018.12.121 License (CC BY). The use, distribution or reproduction in other forums is permitted, 67. Gonzalez LE, Lopez-Carrilero R, Barrigon ML, Grasa E, Barajas A, Pousa provided the original author(s) and the copyright owner(s) are credited and that the E, et al. Neuropsychological functioning and jumping to conclusions original publication in this journal is cited, in accordance with accepted academic in recent onset psychosis patients. Schizophr Res. (2018) 195:366–71. practice. No use, distribution or reproduction is permitted which does not comply doi: 10.1016/j.schres.2017.09.039 with these terms. Frontiers in Psychiatry | www.frontiersin.org 11 February 2021 | Volume 11 | Article 596625