Introduction

Jumping to Conclusions in first-episode psychosis

Jumping to Conclusions (JTC) bias is a common cognitive bias in psychosis, characterized by making hasty judgments or interpretations without sufficient evidence or information1,2,3. This can lead to misunderstandings, misperceptions, and biased decisions in daily life4. Researchers have investigated JTC’s presence and role of the JTC in the early stages of the psychosis continuum5. One study found that individuals with lifetime affective dysregulation are more likely to progress to high levels of psychosis if JTC is present6. JTC is also observed in siblings of patients with schizophrenia spectrum disorders, indicating familial liability for psychosis6. In patients with early psychosis, JTC is associated with delusional ideation and overadaptation to counterevidence in probabilistic reasoning tasks7. Compared to healthy individuals and those with non-psychotic mental health problems, people with psychosis require less information before making decisions8 and first-episode psychosis (FEP)9. Regarding delusions, JTC is associated with more plausible delusion content, such as paranoid or reference types10,11, but also with more eccentric delusions, such as magical thinking and ideas of influence12. In FEP, JTC is related to poorer clinical outcomes, higher rates of mental health act detention and police intervention, and longer admissions13,14.

JTC not only affects clinical outcomes, but also intersects with neuropsychological, social cognition (SC), and metacognitive domains. In schizophrenia, hasty decision making is related to verbal and working memory15. Recently, JTC has been associated with deficits in attention, thinking speed, planning, problem-solving16, and lower general intelligence (IQ)9. Regarding SC deficits, people with FEP struggle to accurately interpret and understand social cues17, exhibit impaired emotional recognition (ER), and have an attributional style (AS) associated with negative internalization18. In metacognition (for further details on how metacognition is conceptualized in this study, please refer to Díaz-Cutraro et al. 19, studies report reduced levels of metacognitive mastery as JTC intensifies19,20,21. Similarly, Takeda et al. 22 showed that JTC bias correlates significantly with neurocognitive deficits, such as verbal memory, working memory, and motor speed, while decision confidence aligns with metacognitive abilities, such as evaluating the accuracy of one’s own judgments22.

The influence of sex in Jumping to Conclusions

Research has revealed sex differences in psychosis, which are crucial for understanding and treating men and women according to their specific needs23,24,25. Findings include a later onset in women than in men, with sex differences in symptomatology, comorbidity, and neurocognition, reflecting those in the general population26. Sex differences in the symptom responses to trauma were also found27. Women with psychosis who experienced child abuse reported more positive mood symptoms, while men showed more negative symptoms and substance use27.

Few studies have assessed sex differences in JTC response. Different cognitive and metacognitive profiles were observed between males and females. Dudley et al.28 found that males with FEP without JTC had a more benign illness course, while those with JTC had more clinical symptoms and neuropsychological impairments. Additionally, women tend to show attributional biases, such as personalizing bias (blaming others for negative events) and high levels of self-reflection but have very low self-esteem29. An early psychosis study found that a JTC response pattern in social judgments was linked to poorer overall task accuracy30. The association between SC and neurocognition (NC) also differs by sex; however, the relationship between these constructs and JTC has not been explored. Men and women process emotional recognition differently, but their relationship with the JTC remains unexamined31. Mixed findings exist regarding sex differences in JTC and NC psychosis. Some studies have reported sex-related differences in memory, working memory, processing speed, selective attention, and executive function32. However, other studies have not explicitly reported sex differences in metacognitive beliefs related to the JTC33. Dimaggio and Lysaker (2014) highlighted that metacognitive deficits, common in psychosis, impair self-awareness and the ability to understand others’ intentions34. Although sex-specific analyses were not detailed, these insights point to potential differences in how men and women engage in metacognitive processes. Takeda et al.22 noted that women with schizophrenia showed a higher prevalence of JTC bias than men, indicating that sex might influence how cognitive and metacognitive mechanisms interact with decision-making biases22.

Despite the limited evidence and contradictory findings, it remains essential to investigate whether various interrelated factors—clinical, cognitive, social cognitive, and metacognitive—differ by sex in their association with JTC. Building on prior research, this study expands the scope by examining sex differences not only among individuals exhibiting JTC, but also among those who do not present this bias. Through sex × JTC interaction analyses, we aimed to uncover nuanced distinctions in the neurocognitive, social cognitive, and metacognitive domains across these groups. This comprehensive approach provides deeper insights into how sex shapes the mechanisms underlying JTC and related constructs in FEP, paving the way for tailored and effective interventions.

Aim and hypothesis

Aims

(a) To assess sex differences in the prevalence of JTC among individuals with FEP, considering sociodemographic, clinical, neurocognitive, social-cognitive, and metacognitive variables.

(b) To analyze the interactions between JTC and sex, identifying specific patterns in the neurocognitive, social-cognitive, and metacognitive domains in individuals with and without JTC.

(c) To develop sex-specific explanatory models to understand the factors associated with the presence of JTC in women and men with FEP.

Hypothesis

(a) Women and men with FEP are expected to exhibit distinct patterns in sociodemographic, clinical, neurocognitive, social-cognitive, and metacognitive variables.

(b) Women and men are anticipated to differ in the associations between JTC and clinical, neurocognitive, social-cognitive, and metacognitive variables. These differences are expected to manifest in individuals with and without JTC, highlighting the role of sex as a key modulating factor in these domains.

(c) Regarding the explanatory models, in women, JTC is anticipated to be primarily explained by social, cognitive, and metacognitive factors. In men, the JTC is expected to be more strongly associated with neurocognitive variables.

Materials and methods

We performed a parallel multicenter clinical trial as described in detail by Ochoa et al.35. The sample consisted of 121 FEP36 patients who received treatment at one of the nine participating mental health centers: Servicio Andaluz de Salud (Jaén), Hospital Universitario Regional (Málaga), Hospital Regional de Santa Ana de Motril, Salut Mental Parc Taulí (Sabadell), Hospital de la Santa Creu i Sant Pau (Barcelona), Centro de Higiene Mental Les Corts (Barcelona), Institut d’Assistència Sanitària Girona, Hospital Clínico Universitario de Valencia, and Parc Sanitari Sant Joan de Déu (Coordinating Center).

Inclusion and exclusion criteria

The inclusion criteria for the study included diagnoses of schizophrenia, psychotic disorder not otherwise specified, delusional disorder, schizoaffective disorder, brief psychotic disorder, or schizophreniform disorder according to the DSM-IV-TR. Conversely, patients with traumatic brain injury, dementia, and intellectual disability (premorbid IQ < 70) were excluded. Participants were considered to meet the inclusion criteria if they had scores > 3 on the Positive and Negative Syndrome Scale (PANSS) for delusions, grandiosity, or suspiciousness items. Individuals between 17 and 45 years of age were included, although no specific age-related exclusion criteria were applied.

Assessment

Regarding the assessment, we included a sociodemographic questionnaire to perform a descriptive analysis of the sample and questionnaires considering JTC, SC, NC, metacognition, and clinical variables.

Jumping to Conclusions

We used the bead task-computer version, in which the person must decide on the probability of the extracted bead belonging to one of the two jars. In task 1, the probability is 85:15, and in tasks 2 and 3 (Salient Task), it is 60:40. In the last task, people must choose between positive and negative comments about “a person similar to you.” JTC was considered to be present when a decision was made after extracting one or two beads4,37. Female participants were categorized into JTC-women and non-JTC-women depending on whether they presented with JTC in this task. Similarly, males who made their decision after one or two beads were extracted were categorized as JTC-men, whereas men not presenting with JTC in this task were categorized as non-JTC-men.

Social cognition

Attributional style was assessed using the Internal, Personal, and Situational Attributions Questionnaire (IPSAQ)38. The Hinting Task was used to assess Theory of Mind (ToM)39,40. Emotional recognition was assessed using the Emotional Recognition Test Faces41,42, which is composed of 20 photographs that express 10 basic and 10 complex emotions.

Neuropsychological function

The complutense verbal learning test (TAVEC)43 was used to assess different subtypes of memory and learning processes, including the learning curve, immediate memory, long-term memory, perseveration, and recognition. The Conners’ continuous performance test (CPT-II) was used to assess attention and response inhibition. We considered the missions, commissions, hit reaction times, and perseverations44. The Wechsler adult intelligence scale (WAIS)45 was used to assess short-term memory and working memory (digit subscale), and the premorbid estimated intelligence quotient (IQ) was calculated using the vocabulary subtest. The Trail making test46 A (TMT-A) was used to measure psychomotor speed, visuoperceptual abilities, and sustained attention. TMT B evaluated the working memory, cognitive flexibility (task-switching ability), and divided attention. A computerized version of the Wisconsin card sorting test (WCST)47 was used to measure executive functioning related to the ability to shift to a new pattern of behavior in response to changing conditions (set-shifting). The color-word Stroop test (STROOP) was used to assess cognitive inhibition and the capacity for resistance to interference through interference variables48.

Metacognition

We specifically assessed cognitive insight using the Beck Cognitive Insight Scale (BCIS)49,50. The BCIS consists of a self-administered scale with three subscales: self-reflectiveness, self-certainty, and a composite index.

Clinical variables

Psychotic Symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS)51,52. Peters et al. The Delusions Inventory (PDI)53,54 was used to measure the multidimensionality (distress, preoccupation, and convictions) of delusions using the present state examination to detect the extended psychosis phenotype in the general population54,55. The Self-Esteem Rating Scale (SERS-SF) is composed of 10 items assessing the positive and negative dimensions of self-esteem, and has demonstrated good psychometric properties in populations with schizophrenia56.

Statistical analyses

To address the first objective of exploring the differences in the prevalence of JTC in men and women, we conducted sample descriptive analysis and Student’s t-tests for both JTC and the variables of interest according to previous literature as described in the introduction section, and according to sex.

For the second objective, which was to analyze the relationships between JTC and SC, NC, and clinical variables and metacognition with respect to sex, we conducted an analysis of variance (ANOVA) to determine the differences between JTC and non-JTC participants by sex. In all cases, we checked for the presence of residuals outside the standard range (<2) and performed Levene’s test to assess the homogeneity of variances. In the presence of heteroscedasticity, we applied non-parametric tests (robust ANOVA). Post-hoc analyses were conducted using Tukey’s test, retaining only those comparisons with significant results (p < 0.05) while discarding trends.

Finally, to address the third objective, which was to identify the SC, NC, and clinical and cognitive insight/metacognitive variables that explain the presence of JTC in men and women separately, we performed logistic regressions. Variables that were significant or trended in ANOVA tests (Objective 2) were included in the stepwise logistic regression analysis, with progressive inclusion of variables to find the best model explaining the presence of JTC according to each sex. The criterion for variable inclusion was p < 0.1, with AIC decreasing by at least 2 points each time. The Hosmer–Lemeshow goodness-of-fit test was used to assess the model fit. All analyses were performed using R software version 4.3.2 5251.

Ethical aspects

The project was reviewed and approved by the research and ethics committees of the coordinating center and each participating center. The reference number for the coordinating center’s approval is PIC-187-18. All participants received the study information sheet containing detailed information and signed an informed consent form before enrolling in the study. Confidentiality was strictly maintained throughout all stages of the study. Data were securely stored, and all personal identifiers were removed to ensure anonymity. Participants were free to withdraw from the study at any time without affecting their treatment or care. The study was conducted in compliance with the Declaration of Helsinki and local regulations for research involving human participants. The study was also registered on ClinicalTrials.gov (Identifier: NCT02340559).

Results

Descriptive analysis and sex differences

To address the first objective of this study, we analyzed sex differences in the prevalence of Jumping to Conclusions (JTC) and its association with sociodemographic, clinical, neurocognitive, and social-cognitive variables.

Sociodemographic and clinical variables

Table 1 presents the descriptive statistics of the sample stratified by sex, including the sociodemographic and clinical characteristics. In bivariate analyses, women in the sample demonstrated a significantly higher socioeconomic status (SES) than men (p = 0.03). SES was calculated as a composite score combining educational attainment, employment status, and area of residence, with higher scores indicating a greater socioeconomic advantage. However, the observed SES difference between men and women was not significant after controlling for the other variables in the regression models (Table 1).

Table 1 Descriptive analysis of the sample by sex.
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No significant sex differences were observed in terms of age (p = 0.05), number of hospitalizations (p = 0.22), or suicide attempts (p = 0.32). Regarding clinical variables, the mean antipsychotic dose, expressed as chlorpromazine equivalents, was higher in men (541.89 ± 722.10 mg) than in women (398.21 ± 330.10 mg), although this difference was not statistically significant (p = 0.14). Similarly, delusional conviction, anxiety, and worry (PDI subscales) and general, positive, and negative symptomatology (PANSS scores) did not differ significantly by sex.

Prevalence of JTC and sex differences in patterns

The prevalence of JTC was comparable between men and women, with 13.1% of men and 16.2% of women exhibiting JTC in at least one task (p = 0.68). While the prevalence rates themselves were not significantly different, women tended to exhibit higher SES scores and were older. Statistical analyses were conducted to assess the influence of these variables on JTC, but no significant associations were found; therefore, these variables were not included in subsequent ANOVA analyses.

Relationship between JTC and social cognition (SC), neurocognition (NC), metacognition, and clinical variables by sex

To address the second objective, we analyzed the relationships between JTC and SC, NC, metacognitive, and clinical variables, and examined their interactions with sex. Below, we describe the findings for each domain (See Table 2).

Table 2 ANOVA tests assess the interaction between JTC*sex and social cognition and metacognition.
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Social cognition and metacognition

For SC, no statistically significant differences were observed in emotional recognition across the tasks. A trend toward significance was noted in the theory of mind (Hinting Task) within the salient task. Regarding attributional style, significant sex-JTC interactions were identified in positive and negative internal attributional styles. Women with JTC demonstrated higher scores in positive internal attributional style during the 60:40 task (p = 0.028, η² = 0.036) and the salient task (p = 0.032, η² = 0.079) compared to non-JTC-women. In contrast, JTC-women exhibited more pronounced negative internal attributional style scores relative to non-JTC-women and non-JTC-men in the 60:40 task (p = 0.002, η² = 0.076), with a trend also observed in the salient task (p = 0.09).

In terms of metacognition, JTC-men exhibited greater self-certainty than non-JTC-men did during the salient task (p = 0.025, η² = 0.041). These findings highlight the presence of distinct patterns in attributional biases and metacognitive rigidity associated with JTC, which differ significantly by sex.

Intragroup differences in social cognition and metacognition based on JTC and sex (post hoc analysis)

Post hoc analyses further explored the differences identified in the ANOVAs, revealing specific patterns (see Fig. 1). In the positive internal attributional style, JTC-women scored significantly higher than non-JTC-women on both the 60:40 (p = 0.031, η² = 0.036) and salient tasks (p = 0.032, η² = 0.079). For negative internal attributional style, JTC-women attributed events more negatively to themselves than non-JTC-men (p = 0.047, η² = 0.076) and non-JTC-women (p = 0.0016, η² = 0.076), with a trend toward significance in the salient task (p = 0.09). Regarding metacognition, JTC-men demonstrated significantly higher self-certainty, indicating greater cognitive rigidity, than non-JTC-men during the salient task (p = 0.025, η² = 0.041). These findings highlight nuanced intragroup differences in social cognition and metacognition associated with JTC and sex.

Fig. 1: Intragroup differences in social cognition and metacognition by sex and JTC status (post hoc analysis).
figure 1

The graph illustrates standardized mean scores across groups (JTC-Men, Non-JTC-Men, JTC-Women, Non-JTC-Women) for three variables: Positive Internal Attributional Style, Negative Internal Attributional Style, and Self-Certainty. Significant post hoc comparisons are highlighted: JTC-Women scored significantly higher than Non-JTC-Women in Positive Internal Attributional Style during the 60:40 and Salient tasks (p = 0.031, η² = 0.036; p = 0.032, η² = 0.079, respectively). In Negative Internal Attributional Style, JTC-Women attributed events more negatively to themselves compared to Non-JTC-Men (p = 0.047, η² = 0.076) and Non-JTC-Women (p = 0.0016, η² = 0.076). For Self-Certainty, JTC-Men exhibited significantly higher scores compared to Non-JTC-Men in the Salient task (p = 0.025, η² = 0.041), reflecting greater cognitive rigidity. Error bars represent standard deviations. Statistical significance is denoted by *p < 0.05.

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Exploring general differences between women and men on neurocognition and clinical variables

We analyzed various neuropsychological domains to explore the interaction between sex and JTC across the three tasks (see Table 3). No significant differences were observed in attention across the tasks. Regarding executive function, cognitive inhibition capacity and processing speed (Stroop) did not show significant differences; however, problem-solving (WCST) errors exhibited a marginally significant trend (p = 0.0656). Similarly, processing speed, visuomotor coordination, and cognitive flexibility showed a marginally significant trend in TMT A (p = 0.064), whereas TMT B revealed statistically significant differences (p = 0.002), indicating an interaction between sex and JTC. For verbal memory and learning (TAVEC), significant interactions between sex and JTC were found in multiple domains, including immediate recall and the middle and final segments of the list (recency), with consistent differences observed across tasks. Notably, JTC-women outperformed JTC-men in recency recall across all tasks (p < 0.05). In terms of clinical variables, JTC-men scored significantly higher on self-esteem than non-JTC-men (p = 0.046), while no significant differences were observed in psychotic or depressive symptoms. These findings highlight the distinct patterns in neurocognition and clinical variables shaped by the interaction between sex and JTC.

Table 3 ANOVA tests assessing the interaction between JTC*sex and neurocognition and clinical variables.
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Intragroup differences considering JTC, sex, neurocognition and clinical variables

Post hoc analyses provided further insights into these differences (see Fig. 2). In TMT B, JTC-men took significantly longer to complete the task than did non-JTC-men, JTC-women, and non-JTC-women (p = 0.002, partial η² = 0.034). In immediate recall (TAVEC), non-JTC-women performed significantly better than non-JTC-men in the 85.15 task (p < 0.01, partial η² = 0.159), with similar significant differences observed in the 60.40 task (p = 0.041, partial η² = 0.041) and salient tasks (p = 0.006, partial η² = 0.045). These findings also extended to the middle and final segments of the list (recency), where women generally outperformed men, with significant differences observed across tasks. Immediate interference recall displayed a trend toward significance, further supporting the pattern of superior memory performance in women compared with men. These results highlight the nuanced cognitive and clinical differences shaped by the interaction between sex and JTC, revealing specific patterns in problem solving, processing speed, and memory performance.

Fig. 2: Intragrup differences in neurocognitive performance by sex and Jumping to Conclusions (JTC) bias.
figure 2

The graph illustrates mean scores across neurocognitive tasks, comparing four groups: Non-JTC-Men, JTC-Men, Non-JTC-Women, and JTC-Women. Significant differences were observed in several tasks: TMT_B (processing speed and cognitive flexibility), Immediate Memory, and Mid List Recall. Asterisks (*) indicate statistically significant post hoc comparisons (p < 0.05). Error bars represent standard deviations. These findings underscore the interaction between sex and JTC in shaping cognitive performance.

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Logistic regression analysis

For the third objective, we aimed to identify the independent variables that explain the presence of Jumping to Conclusions (JTC), defined as performing JTC in at least one of the three Beads Task tasks, in both men and women separately (see Fig. 3). Using stepwise logistic regression, we found that the variables explaining the presence of JTC in women were the negative internalization of events and visuospatial speed. The fitted model demonstrated an overall good fit according to the Hosmer–Lemeshow test (p = 0.900, p = 0.900, p = 0.900), indicating no evidence of a lack of fit to the observed data. After evaluating different cut-off points for the predicted probability of JTC, a cut-off point of 0.3 was selected, yielding a sensitivity of 50%, specificity of 77%, accuracy of 71%, and positive predictive value (PPV) of 36%. This suggests that negative event internalization and visuospatial speed are significant predictors of JTC in women with a model that adequately fits the observed data.

Fig. 3: Results of logistic regression analyses for predicting Jumping to Conclusions (JTC) by sex.
figure 3

In women, significant predictors included negative internalization of events and visuospatial speed. In men, significant predictors were total errors in executive function tasks (WCST) and immediate recall of the middle segment of the list (TAVEC). The models demonstrated good fit to the observed data according to the Hosmer–Lemeshow test.

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In males, the variables explaining the presence of JTC were total errors observed in executive functions assessed with the WCST and immediate recall, as measured by the TAVEC. The total number of errors observed in executive functions (WCST) showed a significant negative association with JTC (Estimation = −0.08682, z = −2.355, p = 0.01852), whereas immediate recall of the middle segment of the list showed a significant positive association with JTC (Estimation = 0.08337, z = 3.026, p = 0.00248). The adjusted model showed a good overall fit according to the Hosmer–Lemeshow test (p = 0.9009), suggesting no lack of fit to the data. After evaluating various cutoff points for the predicted probability of JTC, a cut-off point of 0.3 was selected, providing a sensitivity of 50%, specificity of 77%, accuracy of 71%, and positive predictive value of 36%. This analysis indicates that errors observed in executive function and recall of the middle segment of the list are significant predictors of JTC in men, with a model that fits the observed data adequately.

Discussion

This study provides a nuanced understanding of sex differences in the Jumping to Conclusions (JTC) bias and its relationship with neurocognition, social cognition, and metacognition in first-episode psychosis (FEP). Our findings reveal distinct mechanisms underlying JTC in men and women, with important implications for clinical practice and intervention strategies.

The prevalence of JTC was similar between men (13.10%) and women (16.22%); however, the underlying mechanisms driving this bias differed significantly. Women with JTC exhibited stronger tendencies toward both positive and negative internal attributional styles compared to non-JTC women in the 60:40 task (p = 0.028, η² = 0.036) and salient task (p = 0.032, η² = 0.079). Particularly noteworthy was their more pronounced negative internal attributional style compared with both non-JTC women and non-JTC men in the 60:40 task (p = 0.002, η² = 0.076). This pattern suggests that women’s decision-making processes in JTC are particularly associated with attributional styles, as evidenced by the more pronounced negative internal attributional patterns in our analyses. The tendency of women to attribute negative events to themselves may be linked to higher emotional reactivity and a more socially driven processing style, suggesting a more complex relationship with external cues in the environment29,57.

In contrast, men with JTC demonstrated greater cognitive rigidity, as evidenced by increased self-certainty compared to non-JTC men in the salient task (p = 0.025, η² = 0.041). Their neurocognitive profile was characterized by significant deficits in cognitive flexibility, with JTC-men taking notably longer to complete the Trail Making Test Part B compared to all other groups (p = 0.002, η² = 0.034). These findings extend previous work by Takeda et al.22, who identified relationships between JTC and neurocognition, but did not explore sex-specific patterns. In addition, Moritz et al. 58,59,60,61 proposed that reduced metacognitive awareness and overconfidence in errors may predispose individuals to cognitive rigidity and fixed beliefs such as delusions. This aligns with our findings, suggesting that men’s tendency toward increased certainty in decision making, despite cognitive rigidity, may reflect a desire for closure or simplicity in processing ambiguous information.

The sex-specific nature of the JTC was further confirmed through logistic regression analysis. For women, the presence of JTC was best explained by a model incorporating negative internal attributional style and visuospatial speed (Hosmer–Lemeshow test, p = 0.900). For men, the model highlighted the importance of Wisconsin Card Sorting Test errors and immediate recall performance on the Hosmer–Lemeshow test (p = 0.901). These distinct profiles suggest different pathways to hasty decision-making between the sexes. Women’s JTC appears to be driven by more emotional and attributional factors, whereas men’s JTC is rooted more in neurocognitive deficits, particularly in executive function and memory processes.

Interestingly, non-JTC women performed significantly better than non-JTC men in terms of immediate recall across multiple tasks (85:15 task: p < 0.01, η² = 0.159; 60:40 task: p = 0.041, η² = 0.041; salient task: p = 0.006, η² = 0.045). This suggests that preserved verbal memory might serve as a protective factor against JTC in women, whereas its impairment could contribute to the development of JTC in men. These differences in cognitive performance are in line with previous studies that highlight the impact of memory functioning on cognitive biases in psychosis30,34. Women’s enhanced verbal memory ability might buffer against overinterpretation or Jumping to Conclusions, whereas the memory deficits observed in men with JTC may exacerbate inadequate decision-making, particularly in emotionally charged or ambiguous situations.

These findings have important implications for clinical practice. The sex-specific mechanisms underlying JTC suggest that therapeutic interventions should be tailored to address these differences. For women, therapeutic approaches may focus on addressing attributional styles and enhancing metacognitive awareness. Training in reflective thinking, similar to interventions such as SlowMo therapy62,63,64, could help women develop more balanced decision-making processes by focusing on slowing down their judgment processes, particularly in emotionally laden situations. For men, interventions targeting cognitive flexibility and verbal memory may be beneficial. Cognitive remediation strategies that focus on improving executive functions, such as those employed in neurocognitive rehabilitation programs, may help men with JTC to enhance their cognitive flexibility and decision-making capabilities35. Furthermore, the development of sex-specific modules that address these underlying neurocognitive and metacognitive differences would optimize the treatment outcomes.

Integrated approaches that incorporate both cognitive remediation and social cognitive training with different emphases based on sex could be particularly beneficial in clinical settings. Training in social cognition, including exercises aimed at improving emotion recognition and theory of mind31, may be more beneficial for women as they seem to be more sensitive to the social dimensions of decision-making. For men, interventions that focus on improving executive functioning and memory biases may be more effective in addressing the cognitive rigidity accompanying JTC20. The personalization of these treatments, depending on the cognitive and social profiles of individuals, is crucial for optimizing outcomes.

Limitations and further directions

Despite these contributions, this study had several limitations. The cross-sectional design of our study limits causal inferences, and although our sample size provided sufficient power for our primary analyses, larger samples might reveal additional subtle differences. Future research should explore the longitudinal impact of these sex-specific JTC patterns on functional outcomes and evaluate the effectiveness of tailored interventions through randomized controlled trials. Longitudinal studies would allow for a better understanding of the trajectory of these cognitive biases and their long-term effects on psychosis progression.

Conclusions

This study represents a significant advancement in our understanding of the sex-specific mechanisms of JTC in FEP. Our findings support the development of sex-specific interventions while highlighting the potential for integrated therapeutic approaches. This study contributes to the growing evidence supporting personalized medicine in psychosis and underscores the importance of considering sex differences in both research and clinical practice.