Schizophrenia Bulletin vol. 40 no. 6 pp.

13381346, 2014
doi:10.1093/schbul/sbu040
Advance Access publication April 17, 2014

Why Do Bad Things Happen to Me? Attributional Style, Depressed Mood, and
Persecutory Delusions in Patients With Schizophrenia

Department of Psychiatry and Psychotherapy, Philipps-University, Marburg, Germany; 2Department of Psychiatry and Psychotherapy,
Rhineland Friedrich Wilhelms University, Bonn, Germany; 3Department of Psychiatry and Psychotherapy, University of Cologne,
Nordrhein-Westfalen, Germany; 4Department of Psychiatry, Psychosomatics and Psychotherapy, University of Frankfurt, Hessen,
Germany; 5Clinic for Psychiatry and Psychotherapy, University of Duisburg- Essen, Nordrhein-Westfalen, Germany; 6Department of
Psychiatry and Psychotherapy, University of Dsseldorf, LVR-Clinic Dsseldorf, Nordrhein-Westfalen, Germany; 7Department of
Psychiatry and Psychotherapy, University of Tbingen, Baden-Wuertenberg, Germany; 8Department of Psychiatry and Psychotherapy,
University of Hamburg, Hamburg, Germany; 9Department of Psychology, University of Wuppertal, Nordrhein-Westfalen, Germany;
10
Hospital of Psychiatry and Psychotherapy, Fulda, Germany
1

*To whom correspondence should be addressed; Department of Psychiatry and Psychotherapy, Philipps-University of Marburg,
Rudolf-Bultmann-Street 8, D-35039 Marburg, Germany; tel:+49-6421-58-65359, fax: +49-6421-58-67099, e-mail:
[email protected]

Theoretical models postulate an important role of attributional style (AS) in the formation and maintenance
of persecutory delusions and other positive symptoms of
schizophrenia. However, current research has gathered conflicting findings. In a cross-sectional design, patients with
persistent positive symptoms of schizophrenia (n = 258)
and healthy controls (n=51) completed a revised version
of the Internal, Personal and Situational Attributions
Questionnaire (IPSAQ-R) and assessments of psychopathology. In comparison to controls, neither patients with
schizophrenia in general nor patients with persecutory delusions (n=142) in particular presented an externalizing and
personalizing AS. Rather, both groups showed a self-blaming AS and attributed negative events more toward themselves. Persecutory delusions were independently predicted
by a personalizing bias for negative events (beta=0.197,
P = .001) and by depression (beta=0.152, P = .013), but
only 5% of the variance in persecutory delusions could be
explained. Cluster analysis of IPSAQ-R scores identified
a personalizing (n=70) and a self-blaming subgroup
(n = 188), with the former showing slightly more pronounced persecutory delusions (P = .021). Results indicate
that patients with schizophrenia and patients with persecutory delusions both mostly blamed themselves for negative
events. Nevertheless, still a subgroup of patients could be
identified who presented a more pronounced personalizing
bias and more severe persecutory delusions. Thus, AS in
patients with schizophrenia might be less stable but more

determined by individual and situational characteristics

that need further elucidation.
Key words: schizophrenia/persecutory delusions/
positive symptoms/attributional style/depression/
negative emotions
Attributional style (AS) is defined as the way of inferring a causal explanation for important life events,1,2
either toward oneself (internal), toward other persons
(personal), or toward circumstances or fate (situational).
For example, if a friend starts a fight with me, it is possible to attribute this event to internal factors (I am a
bad person), to personal factors (He is annoyed quite
quickly), or to situational factors (We lived in different
parts of the country).
Analysis of AS in schizophrenia derived from the clinical insight that persecutory delusions can be viewed as
an excessive tendency to attribute negative events toward
other persons. Initial studies used the Attributional Style
Questionnaire (ASQ),3 an instrument originally developed for the assessment of AS in depression. These studies found that patients with persecutory delusions showed
more internal attributions for positive events and less
internal attributions for negative events, compared with
controls. This AS has been termed self-serving bias or
externalizing bias (EB).46 Because the ASQ showed quite

The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: [email protected]

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StephanieMehl*,1,2, Martin W.Landsberg2, Anna-ChristineSchmidt2, MauriceCabanis1, AndreasBechdolf3,

JuttaHerrlich4, StephanieLoos-Jankowiak5, TiloKircher1, StephanieKiszkenow6, StefanKlingberg7,
MareikeKommescher3, SteffenMoritz8, Bernhard W.Mller5, GudrunSartory9, GeorgWiedemann10, AndreasWittorf7,
WolfgangWlwer6, and MichaelWagner2

Why Do Bad Things Happen to Me?

persecutory delusions indeed present a more monocausal AS in comparison to controls who might present a more balanced and multifactorial view. Finally,
in light of patients heterogeneity with regard to psychopathology, it is interesting to assess whether there are distinct subgroups of patients who might differ with regard
to theirAS.
In order to derive clear-cut evidence about the presence and clinical correlations of AS, we conducted a large
multicenter study with patients with positive symptoms
of schizophrenia and controls, employing a revised version of the IPSAQ that allows the subject to rate the
relative degree of the contribution of internal, personal,
and situational factors toward important life events
(IPSAQ-R).29,30 We hypothesize (1) that patients with
persistent positive symptoms and (2) especially patients
with persecutory delusions show a more pronounced EB,
PB, and monocausality bias in comparison to controls.
Furthermore, (3) we assumed that externalizing, personalizing, and monocausal AS are associated with delusions
of persecution and (4) that distinct subgroups of patients
who differ in their AS can be identified empirically.
Method
Participants
Participants were 258 patients with schizophrenia and 51
healthy controls from the Cognitive behavioural therapy
for persistent positive symptoms (CBTp) in psychotic
disorders Trial31 (ISRCTN29242879), a multicentered
randomized controlled trial investigating the efficacy of
CBTp for patients with schizophrenia in comparison to
supportive therapy. Patients were recruited from 6 different psychiatric settings; healthy controls were recruited
via press releases and matched with regard to age, gender,
and education to the first 51 patients that were already
recruited.
From the study sample (n = 330), several patients (n =
57) did not participate at this ancillary study: 9 patients
dropped out before they were asked to participate, 48
patients refused to be tested for the ancillary study. From
the remaining sample (n = 273), several patients (n =
15) were excluded because they did not understand the
instructions of the IPSAQ-R: They presented no causal
explanation for more than 3 items (n = 12), they stated I
dont know as a causal explanation for more than 3 situations (n = 2), or they wrote down the same causal explanation for more than 3 situations (n = 1). There were no
statistically significant differences between patients who
refused to be tested and those who endorsed testing with
regard to sociodemographic and clinical variables (all
P >.10).
Patients were diagnosed with a schizophrenia spectrum
disorder (schizophrenia [n=201], schizophreniform disorder [n=5], schizoaffective disorder [n=33], delusional
disorder [n=17]) as assessed with the Structured Clinical
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low reliability indices (Cronbachs alpha between .39 and

.52)7 and cannot differentiate between external attributions
toward other persons (personal attributions) and toward
circumstances (situational attributions), Kinderman and
Bentall7 developed the Internal, Personal and Situational
Attributions Questionnaire (IPSAQ) and found that
patients with persecutory delusions blamed other persons
more often than circumstances for negative events, which
supports the personalizing bias (PB) hypothesis.8,9
Due to these findings, EB and PB were incorporated
into theoretical models as cognitive biases triggering
the development and maintenance of persecutory delusions1012 and positive symptoms in schizophrenia.1315
However, recent research has questioned these assumptions because several studies that used the IPSAQ and
compared patients with persecutory delusions and controls did not find the hypothesized EB and PB1621 or
even found a less pronounced EB.11 Studies that compared patients with schizophrenia and controls found a
more pronounced EB but an equivalent level of PB in
patients5,22 or no differences between patients and controls.23 Even in a recent meta-analysis, neither a pronounced EB nor a pronounced PB could be identified in
patients with schizophrenia (n = 212) in comparison to
controls.24
These inconsistent results could be explained by a
number of factors: First, previous studies in patients with
persecutory delusions were mostly of small sample size
(between 14 and 40 patients:),6,9 which may have obscured
or even exaggerated results with a medium or minor effect
size.25 The problem of small sample sizes is aggravated by
patients heterogenity with regard to psychopathology.
Consequently, a large-scale study is necessary in order to
address the question of whether EB and PB are associated with persecutory delusions and schizophrenia.
Second, some inconsistent results could be explained
by specific features of the questionnaires used. While
the IPSAQ by Kinderman and Bentall9 introduced the
important discrimination between personal and situational external attributions, it is not without problems
either, with regard to its limited reliability (0.610.76)7,26
and also with regard to its demand characteristics. The
IPSAQ forces a person to make a clear choice whether
an event is caused exclusively by internal, personal, or
situational factors even if a person (realistically) assumes
that an event is caused by multiple factors. Patients with
schizophrenia might have particular problems in making
such a decision because they often tend to decide spontaneously, without gathering a sufficient amount of information (jumping to conclusions bias).27,28 Thus, the use of
the original IPSAQ might lead to a distorted view of AS
in patients with schizophrenia, and possibly to inconsistent findings aswell.
Rather than enforcing respondents to choose between
3 attributional alternatives by method, it is interesting to study whether patients with schizophrenia and

S. Mehl etal

Measures
The IPSAQ-R29,30 consists of 16 items describing 8 positive and 8 negative situations. For each item, subjects
are asked to put themselves in the position of someone
experiencing the particular situation and to infer and
write down the most probable causal explanation for
it. They are then asked to estimate in percent whether
their causal explanation is due to internal, personal, or
situational factors. For example, if a person interprets
the item A friend says that he does not respect you in
the sense of I am a bad person, an estimation of the
causal explanation as 80% internal, 20% personal, and
20% situational would be consistent. If the percentage
estimations do not add up to 100%, they are rescaled so
that their sum equals 100%. First, for every item, the sum
of percentage estimations for internal, personal, and
situational attributions is computed (eg, 40% internal +
50% personal + 70% situational = 180%). In the next
step, the rescaled percentage estimations are computed
as follows: rescaled percentage estimation = (former
percentage estimation 100)/former sum of percentage
estimations (eg, rescaled percentage estimation=(40
100)/180=22.22%).
Six attributional scores are calculated by adding up
the rescaled percent ratings of internal, personal, and
situational attributions for positive and negative events.
Moreover, several biases are computed according to previous studies.7 EB only regards internal attributions and
is present when a person attributes more positive than
negative events toward internal causes, hence to himself/
herself. It is computed by subtracting the internal negative score from the internal positive score. The PB only
regards negative events and is present when a person
attributes negative events rather to personal than to situational factors. It is calculated by dividing the personal
negative score by the sum of personal negative score
and situational negative score. Moreover, in accordance
to Moritz et al,30 a monocausality bias was present if a
1340

person at least in 1 situation estimates that an event is

caused by 1 attributional factor by a minimum score of
80%. It was computed by counting the items that were
rated in this way. Range of Cronbachs alpha for attributional scores indicated sufficient to good internal consistency (between .71 and .81 [mean=.79] in patients and
between .75 and .83 [mean=.79] in controls).
The PANSS34 is a semistructured interview assessing
30 symptoms divided into 3 standard scales (positive
symptoms, negative symptoms, general psychopathology) using a 7-point Likert scale. PANSS rating was performed by trained raters, interrater reliability (correlation
R2) was satisfactory to high (.92 for the PANSS positive
scale and .86 for the PANSS negative scale).31
The Calgary Depression Rating Scale for Schizophrenia
(CDSS)36 was used in order to assess observer-rated
depressive symptoms.
Analysis
First, we used Fishers exact tests, Chi-square tests, t
tests, and ANOVAs in order to compare patients with
schizophrenia and controls and patients with persecutory
delusions (PD), patients without persecutory delusions
(Non-PD), and controls in sociodemographic and clinical variables. In case of group differences in specific variables, it was analyzed whether these variables are related
to AS, using Pearsons 2-tailed correlations. If these variables were related to AS, they were included as covariates
in all statistical analyses.
All IPSAQ-R scores were normally distributed within
all groups with the exception of EB and monocausality
bias, and inspection of the data revealed no outliers. In
order to investigate differences in AS and attributional
biases between patients with schizophrenia and controls
(Hypothesis 1), ANOVAs were performed using attributional scores and biases as dependent variables if Levene
tests indicated homogeneous variances, even if variables were not normally distributed, because parametric
tests show higher statistical power compared with nonparametric tests.37,38 In case of heterogeneous variances
(monocausality bias), nonparametric tests were used
(Mann-Whitney U test, Kruskal-Wallis test). We controlled these tests for important covariates by performing
a linear regression analysis using the covariate as predictor and monocausality bias as criterion and saved the
standardized residuum scores. These scores were included
as dependent variables in nonparametric tests. In order to
prevent alpha inflation, Bonferroni corrections were performed for each event type (eg, for positive events: P =
.05/3 attributional loci=0.017). The same procedure was
used in order to assess differences between patients with
persecutory delusions and controls in attribution biases
(Hypothesis2).
In order to investigate whether attribution biases are
associated with delusions of persecution (Hypothesis 3),

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Interview for DSM-IV32 according to DSM-IV-TR.33

Further inclusion criteria were persistent positive symptoms for at least the last 3 months and a minimum score
of 4 in the item P1 (delusions in general: n=219) or in
the item P3 (hallucinations: n=39) of the Positive and
Negative Syndrome scale (PANSS),34 age between 18 and
59, adequate language fluency and a verbal intelligence
quotient (IQ) > 80 in the German vocabulary IQ test
MWT-B.35 In line with other studies,9,17,18 exclusion criteria for controls were mental disorders in their lifetime.
Most of the patients (n = 142, 64.8%) presented delusions of persecution (defined as a minimum score of 4
in the PANSS item P6). All participants were informed
about the assessment and gave written informed consent.
The ethics committees at the 6 centers medical faculties
approved the study.

Why Do Bad Things Happen to Me?

Results
Table 1 shows sociodemographic and clinical data of
patients with schizophrenia, patients with persecutory
delusions (PD), patients without persecutory delusions
(Non-PD), and healthy controls. There were no statistically significant differences between patients with schizophrenia and controls and between PD, Non-PD, and
controls in terms of age, gender, or education. Compared
with controls, patients with schizophrenia showed significantly lower verbal intelligence scores (MWT-B).
Moreover, both PD and Non-PD showed a lower verbal
intelligence score in comparison to controls. In comparison to Non-PD, PD presented a more pronounced level of
positive symptoms and depressive symptoms, while both
groups were comparable in terms of negative symptoms.
As only the monocausality bias was related to verbal
intelligence (patient group: r = .215, P = .004; controls:
r = .338, P = .018), all group comparisons in monocausality bias were controlled for verbal intelligence.
Group Comparisons inAS
Results of comparisons between patients and controls in
AS are depicted in table2. Because most Levene tests indicated homogeneous variances (all P > .05), groups were
compared in their AS with ANOVAs. With regard to monocausality bias, we used a Mann-Whitney U tests because
the Levene test indicated heterogeneous variances. In comparison to controls, patients with schizophrenia presented
more internal attributions and less personal attributions
for negative events and a reduced EB. With regard to other
attributional scores, there were no statistically significant
differences between the 2 groups. The observed effect sizes
(partial eta)2 indicated large effects.
In the next step, patients with persecutory delusions
(PD: n = 142) were compared with controls. Again,
because all Levene tests (with the exception of the

monocausality bias) indicated homogeneous variances

(all P > .05), groups were compared in their AS with
ANOVAs. With regard to monocausality bias, we used
Mann-Whitney U tests because the Levene test indicated
heterogeneous variances. As depicted in table 3, results
were largely comparable to those in the full sample; in
comparison to controls, patients showed fewer personal
attributions for negative events and a reduced EB. The
observed effect sizes indicated large effects. With regard
to other attributional scores, there were no statistically
significant differences between the 2 groups.
Associations Between AS and Delusions of Persecution
First, bivariate correlation analysis revealed that persecutory delusions were associated with a pronounced PB
(r = .164, P = .008) and with more severe depression
(CDSS sum: r = .130, P = .037). Sociodemographic and
other clinical variables were not related to persecutory
delusions. In the next step, we performed a multivariate
regression analysis using PB and depression as predictors and persecutory delusions as criterion variable. The
model was statistically significant [F(2,254) = 8.013, P
.001, adjusted R2 = .052)], and both depression ( = .152;
P = .013) and PB ( =.197; P = .001) were significant
predictors, the amount of explained variance in delusions
of persecution indicated a small effect size. Including the
interaction between PB and depression as predictor did
not explain a significant amount of variance (P > .10), in
comparison to the first model.
Cluster Analyses
Finally, a hierarchical cluster analysis was performed.
Inspection of squared Euclidian distance led to a plausible 2-cluster solution (Cluster 1: 188 patients, Cluster
2: 70 patients). As depicted in table4, patients in the first
cluster presented a less pronounced PB, compared with
controls. In comparison to controls and patients in the
first cluster, patients in the second cluster presented a
more pronounced PB.
In the next step, clusters were compared with regard
to sociodemographic and clinical variables using t tests
(2-tailed). There was only 1 statistically significant difference between the 2 clusters: Patients in the second cluster showed more pronounced delusions of persecution
[PANSS P6: Cluster 1: mean = 3.40 (SD = 1.48), Cluster
2: mean = 3.87 (SD = 1.31); F(1,256) = 5.462, P = .02,
partial eta2 =.021); group differences were of medium
effect size.
Discussion
In comparison to controls, patients with schizophrenia
and patients with persecutory delusions showed a selfblaming AS and attributed negative events more toward
themselves in comparison to positive events. Nevertheless,
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we first examined bivariate relations between sociodemographic variables, delusions of persecution (PANSS
item P6), and attribution biases using Pearsons 2-tailed
correlations. Second, all variables that showed a statistically significant association with persecutory delusions
were included into the multivariate regression analysis
(ENTER method) predictors and persecutory delusions were included as criterion. Multivariate regression
analysis was controlled for multicollinearity by investigating the variance inflation factors and tolerance statistics. Finally, we analyzed whether there are distinct
subgroups of patients with a comparable AS who could
be identified empirically by a hierarchical cluster analysis
(Hypothesis 4). The Wards method was used, and the 6
IPSAQ-R scores in the patient sample were included as
cluster variables and squared Euclidian distance as distance measure.

15.03 (9.97)
17.44 (3.50)
13.90 (4.21)
32.94 (6.94)
4.21 (1.18)
3.52 (1.46)
5.47 (4.66)

Duration of illness
PANSS POS
PANSS NEG
PANSS GEN
PANSS P1
PANSS P6
CDSS

21 (41.2%)
13 y: 26, 10
y: 23, 9 y: 2
35.77 (9.47)
114.88 (15.38)
F(1,307)=0.152, P=.284
F(1,307)=11.053, P .001

P=.969a
2 (5)=10.223, P=.069

Test Statistics

14.50 (9.51)
18.50 (3.30)
14.19 (4.23)
34.01 (7.12)
4.57 (.81)
4.56 (.71)
6.22 (5.00)

58 (40.85%)
High: 75, medium: 40,
low: 30, none: 2
37.75 (9.6)
105.98 (15.57)

Patients With
Persecutory Delusions
(PD) (n=142); n
(%)/M (SD)

15.44 (10.14)
15.94 (3.33)
13.56 (3.95)
31.70 (6.64)
3.74 (1.36)
2.11 (.82)
4.58 (3.90)

49 (42.24%)
High: 61, medium: 35,
low: 18 2
37.32 (9.62)
107.13 (14.49)

Patients Without
Persecutory Delusions
(Non-PD) (n=116); n
(%)/M (SD)

F(2,306)=0.742, P=.477
F(2,306)=5.511, P=.004;
PD, Non-PD < HC
F(1,256)=.617, P=.433
F(1,256)=38.550, P .001
F(1,256)=1.538, P=.216
F(1,256)=7.141, P=.008
F(1,256)=37.840, P .001
F(1,256)=591.897, P .001
F(1,256)=8.372, P=.004

X2 (2)=.158, P=.924
2 (10)=16.119, P=.096

Test Statistics

Note: MWT-B = Mehrfachwahl-Wortschatz-Intelligenztest-B (MWT-B), a German vocabulary IQ test; PANSS=Positive and Negative Syndrome scale; PANSS
POS=PANSS positive scale sum score; PANSS NEG=negative scale sum score; PANSS GEN=PANSS general psychopathology sum score; PANSS P1=item delusions in
general mean score; PANSS P6=item persecution/suspiciousness mean score; CDSS: Calgary Depression Scale for Schizophrenia sum score.
a
Fishers exact test.
b
education grade completed after 9years=Hauptschulabschluss, education grade completed after 10years=Realschulabschluss, education grade completed after 13years
= Abitur (A-level or high school equivalent).

107 (41.5%)
13 y: 135, 10 y: 74,
9 y: 48, none: 3
37.44 (9.54)
107.29 (14.88)

Gender (female)
Education grade
completedb
Age (y)
Verbal IQ

Healthy Controls
(HC) (n=51); n
(%)/M (SD)

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1342

Patients With
Schizophrenia
(n=258); n (%)/M
(SD)

Table1. Means, Standard Ddeviations, and Comparisons of Patients With Sschizophrenia and Controls Regarding Sociodemographic and Clinical Variables

S. Mehl etal

Why Do Bad Things Happen to Me?

Table2. Comparisons Between Patients and Controls in the Scores of the Internal, Personal and Situational Attributions Questionnaire
Revised Version
Healthy
Controls (n=51)

Statistics

53.58 (15.10)
28.22 (12.84)
18.20 (11.75)
43.33 (16.05)
36.18 (14.69)
20.49 (12.97)
10.25 (17.64)
.64 (.20)
2.20 (3.45)

54.50 (13.69)
30.86 (11.64)
14.64 (9.86)
36.43 (11.46)
43.68 (15.63)
19.89 (13.17)
18.07 (15.77)
.69 (.18)
1.59 (2.30)

F(1,307)=.972, P=.325, partial eta2=.003

F(1,307)=2.842, P=.093, partial eta2=.009
F(1,307)=2.919, P=.089, partial eta2=.009
F(1,307)=5.857, P=.016, partial eta2=.019
F(1,307)=14.911, P .001, partial eta2=.047
F(1,307)=.000, P=.983, partial eta2=.000
F(1,307)=8.284, P=.004, partial eta2=.026
F(1,307)=2.649, P=.105, partial eta2=.009
U=5626.000, P=.367

ANOVA with Bonferroni corrections for all positive events: P = .05/3=.17.

ANOVA with Bonferroni corrections for all negative events: P = .05/3=.17.
c
Separate ANOVAs
d
Mann-Whitney U tests using residual scores of monocausality bias (controlled for the influence of verbal intelligence [MWT-B]).

Table3. Comparisons Between Patients With Persecutory Delusions and Controls in the Scores of the Internal, Personal and Situational
Attributions Questionnaire Revised Version

Internal positive scorea

Personal positive scorea
Situational positive scorea
Internal negative scoreb
Personal negative scoreb
Situational negative scoreb
Externalizing biasc
Personalizing biasc
Monocausality biasd

Patients with persecutory

delusions (n=142)

Healthy
controls (n=51)

Statistics

52.54 (14.39)
29.77 (13.09)
17.69 (11.24)
42.77 (15.13)
37.65 (14.18)
19.58 (12.67)
9.77 (16.64)
.66 (.19)
1.86 (3.06)

54.50 (13.69)
30.86 (11.64)
14.64 (9.86)
36.43 (11.46)
43.68 (15.63)
19.89 (13.17)
18.07 (15.77)
.69 (.18)
1.59 (2.30)

F(1,195)=1.793, P=.182, partial eta2=.009

F(1,195)=.692, P=.407, partial eta2=.004
F(1,195)=2.141, P=.145, partial eta2=.011
F(1,195)=5.301, P=.022, partial eta2=.026
F(1,195)=9.147, P=.003, partial eta2=.045
F(1,195)=.162, P=.688, partial eta2=.001
F(1,195)=9.993, P=.002, partial eta2=.049
F(1,195)=.837, P=.361, partial eta2=.004
U=2966.500, P=.180

ANOVA with Bonferroni corrections for all positive events: P = .05/3=.17.

ANOVA with Bonferroni corrections for all negative events: P = .05/3=.17.
c
Separate ANOVAs.
d
Mann-Whitney U tests using residual scores of monocausality bias (controlled for the influence of verbal intelligence [MWT-B]).
a

persecutory delusions were independently predicted by

a pronounced PB and by depression. Finally, in a cluster analysis of IPSAQ-R scores, a personalizing and a
self-blaming subgroup could be identified, with the former showing slightly more severe persecutory delusions.
With regard to a self-blaming AS, our results are in
striking contrast to previous studies that used the classic IPSAQ and reported a comparable23 or even more
pronounced EB in patients with schizophrenia5,22 or in
patients with persecutory delusions.1620 Nevertheless,
our results are in line with 1 previous study that used the
classic IPSAQ and reported a self-blaming AS in patients
with persecutory delusions.9 Moreover, in concordance
with our results, patients with schizophrenia belonging to
a black ethnic group blamed themselves more for social
disadvantages, whereas other patients attributed them
toward other persons.39

Several points should be made regarding these results:

Because the internal consistency scores in our study are
quite satisfactory and our patient sample is more than 4
times larger than previous studies, measure errors are less
likely tooccur.
One explanation for these inconsistent results might lie in
different demand characteristics of the measures used. The
forced choice that is required in the classic IPSAQ could
induce an exaggerated externalizing and personalizing AS
in patients with schizophrenia: Because they are asked to
decide between internal, personal, and situational causes
for important life events, they might be overstrained, show
their well-known jumping to conclusions bias,28 and make
their decision based on intuitive and heuristic judgements
associated with the faster but more error-prone System
1 according to Kahneman and Fredericks dual-process
theory of judgments4042 or the intuitive route of thinking
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Internal positive scorea

Personal positive scorea
Situational positive scorea
Internal negative scoreb
Personal negative scoreb
Situational negative scoreb
Externalizing biasc
Personalizing biasc
Monocausality biasd

Patients With
Positive Symptoms
(n=258)

S. Mehl etal

Table4. Comparisons of the 2 Clusters and Controls in Their Attributional Style in the Internal, Personal and Situational Attributions
Questionnaire, Revised Version
Patients in
Cluster 2 (C2)
(n=70)

Healthy
Controls
(n=51)

Internal positive scorea,b

Personal positive scorea,b

54.70 (16.0)
23.45 (10.44)

49.61 (12.50)
41.07 (10.87)

54.50 (13.69)
30.86 (11.64)

Situational positive scoreb,c

Internal negative scorec,d
Personal negative scorec,d
Situational negative scorec,d
Externalizing biasa
Personalizing biasc
Monocausality biasd,e

21.85 (11.56)
46.59 (16.59)
29.02 (11.15)
24.09 (12.68)
8.11 (17.32)
.57 (.17)
1.78 (2.97)

9.32 (6.20)
40.87 (14.19)
49.19 (12.47)
9.94 (6.49)
8.74 (18.50)
.84 (09)
4.94 (4.40)

14.64 (9.86)
36.43 (11.46)
43.68 (15.63)
19.89 (13.17)
18.07 (15.77)
.69 (.18)
1.52 (2.27)

Statistics
F(2,306)=3.856, P=.022, partial eta2=.025
F(2,306)=61.083, P .001,
partial eta2=.287, C2> C1, HC, HC > C1
Chi2=75.469, P .001, C1> C2,HC, HC > C1
Chi2= 10.100, P=.006, C1> HC
Chi2=118.981, P .001, C2> C1, HC, HC > C1
Chi2=73.769, P .001, C1> C2, HC > C2
F(2,306)=4.147, P=.017, partial eta2=.027, C1< HC
Chi2=118.396, P .001, C2> C1, HC, HC > C1
Chi2=3.993, P=.136

ANOVA.
Bonferroni corrections for all positive events: P = .05/3=.17.
c
Kruskal-Wallis test.
d
ANOVA with Bonferroni corrections for all negative events: P = .05/3=.17.
e
Kruskal-Wallis test using residual scores of monocausality bias (controlled for the influence of verbal intelligence [MWT-B]).
a

100%
90%
80%
70%
60%

Situational attributions

50%

Personal attributions

40%

Internal attributions

30%
20%
10%
0%
Patients: Positive
Controls:
Patients:
Controls:
Events
Positive Events Negative Events Negative Events

Fig.1. Proportional attributions of causes for positive and negative events in patients with schizophrenia and controls.

according to Nelsons 2 routes model of responding to a

situation for patients with schizophrenia.43 This might be
reflected in the low internal consistency scores of the classic IPSAQ (between .61 and.76).7,26
In contrast, we used the IPSAQ-R, so our patients
were not forced to choose among internal, personal, and
situational causes but were asked to rate the probability
of these causes. It is likely that this kind of probability
judgement might require more analytic reasoning and the
use of higher cognitive capacities that are linked to the
less error-prone System 2 of Kahneman and Fredericks
dual-process theory.4042 Moreover, it might activate the
more rational route of thinking according to Nelsons
model.43
Thus, if our hypothesis of 2 different causal attribution
processes, a rational and an intuitive process is correct
and the IPSAQ-R activates a more rational process, the
assessment with the IPSAQ-R sheds light on the presence
1344

of a self-blaming AS for negative events in patients with

schizophrenia/persecutory delusions. Moreover, we
assessed a population of psychological help seekers who
might present a pronounced level of insight that is often
linked to depression and self-stigmatization.44,45 Thus,
these patients might truly blame mostly themselves for
negative life events.
Nevertheless, a second subgroup of patients could be
identified by cluster analysis. These patients presented a
more pronounced PB and more severe persecutory delusions. Moreover, multivariate regression analysis indicated that patients who presented a PB and depression
are more likely to show more severe persecutory delusions as well. On the one hand, the IPSAQ-R might not
trigger a more rational attribution process in all patients,
thus, a small subgroup performed causal attributions in a
more intuitive way and presented a pronounced PB. On
the other hand, these patients might correctly assume that

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Patients in
Cluster 1 (C1)
(n=188)

Why Do Bad Things Happen to Me?

persecution or involved in their etiology, it must be noted

that all analyses are based on cross-sectional associations.
Hence, it can be assumed that a PB could follow from
delusions of persecution or merely be an attribute of them
aswell.
Several important conclusions can be drawn from
our results. In comparison to controls, patients with
schizophrenia in general and patients with persecutory
delusions in particular showed a self-blaming AS for
negative events. Nevertheless, a subgroup of patients
could be identified who presented a more pronounced
PB and more severe persecutory delusions as well. Thus,
AS in patients with schizophrenia might be less stable but
more determined by individual and situational characteristics that need further elucidation.
Funding
German Federal Ministry of Education and Research
(BMBF: 01GV0618, 01GV0620).
Acknowledgments
We thank all members of the POSITIVE study: S.Baal,
J.Berning, S.Beulen, G.Buchkremer, A.Bch, B.Conradt,
Y.Eikenbusch, W.Gaebel, A.Gawronski, J.Gttgermans,
A.Herold, U.Jakobi-Malterre, I.. Lengsfeld, W.Maier,
K.Platt, B.Pohlmann, A.Rotarska-Jagiela, S.Sickinger,
H. Smoltczyk, S. Unsld, A. Vogeley, A. Witt, and
L. Zipp. The study was part of the BMBF research
program Research Networks on Psychotherapy. The
authors have declared that there are no conflicts of
interest in relation to the subject of this study.
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