Cognitive Characteristics in “Difficult-to-Discharge” Inpatients with Serious Mental Illness: Attribution Biases are Associated with Suspiciousness Only for Those with Lower Levels of Insight

Despite advances in psychiatric rehabilitation (PR), a substantial number of individuals with serious mental illness (SMI) are institutionalized for extended periods. The cognitive characteristics of these individuals play a role in their institutionalized status. Consideration of individual cognitive characteristics, including “attribution biases” and insight into one's illness, has benefited PR in improving case conceptualization and treatment planning. Insight, or understanding one's illness, involves attributions about the causes of one's own behavior and experience, including psychiatric symptoms. Further, attribution biases may have a negative impact on such understanding, and consequently on engagement in rehabilitation. This exploratory study analyzed quantitative individual differences in attribution bias, understanding of illness, and psychiatric symptoms, to determine how these functional domains interact in people with SMI who are “difficult to discharge.” The results reveal an interaction between active positive symptoms, exaggerated externalizing attribution bias (attributing the cause of positive events to others), and understanding of illness. Among individuals with more impaired understanding of illness, attribution biases are associated with high levels of suspiciousness. However, among individuals with better understanding of illness, attribution biases and suspiciousness are not related. The dynamic relationship between attribution bias, positive symptoms, and understanding of illness sheds light on the variable nature of insight in SMI and supports utilizing these cognitive characteristics in case conceptualization, individualized treatment plans, and developing cognitively focused PR treatment modalities.