Johnson et al. provide a thought-provoking and insightful synthesis of ideas advancing our understanding of decision-making. We suggest that the reach of the Conviction Narrative Theory (CNT) affects far broader psychology fields than Johnson et al. propose. We argue for widening CNT's scope to neuropsychiatric disorders, psychotherapy, and their impact on public health.

Considering the CNT as it applies to generic decision-making under radical uncertainty may limit its impact. Difficulties tolerating uncertainty and resolving it are central in multiple neuropsychiatric disorders (Gillett, Bilek, Hanna, & Fitzgerald, Reference Gillett, Bilek, Hanna and Fitzgerald2018; Lebert, Turkington, Freeston, & Dudley, Reference Lebert, Turkington, Freeston and Dudley2021). Individuals often portray such difficulties using subjective reports, objective measures, or both. There are discrepancies between subjective reports and objective tasks assessing resolution of uncertainty or decision-making under uncertainty. Healthy adults' objective resolution of uncertainty may differ under certain conditions, but their subjective estimate of uncertainty remains constant in these different conditions (Linkovski, Rodriguez, Wheaton, Henik, & Anholt, Reference Linkovski, Rodriguez, Wheaton, Henik and Anholt2021). In other studies, the association between subjective intolerance of uncertainty (IU) and subjective anxiety severity was higher than the association between IU and objective decision-making under uncertainty (Luhmann, Ishida, & Hajcak, Reference Luhmann, Ishida and Hajcak2011). The CNT accounts for these discrepancies as the objective uncertainty measures include a finite set of options and the subjective measures assess IU in real life, where radical uncertainty is abundant.

The discrepancy between objective and subjective uncertainty measures is imperative for neuropsychiatric disorders. Difficulties resolving uncertainty are transdiagnostic and may serve as a treatment target but are often measured with subjective assessments (McEvoy, Hyett, Shihata, Price, & Strachan, Reference McEvoy, Hyett, Shihata, Price and Strachan2019). Multiple clinical cohorts report increased subjective IU (Gillett et al., Reference Gillett, Bilek, Hanna and Fitzgerald2018) and subjective IU predicts response to psychotherapy (Castriotta, Dozier, Taylor, Mayes, & Ayers, Reference Castriotta, Dozier, Taylor, Mayes and Ayers2019). Objective uncertainty measures most often include monetary decision-making or cognitive reasoning (Aranovich, Cavagnaro, Pitt, Myung, & Mathews, Reference Aranovich, Cavagnaro, Pitt, Myung and Mathews2017; Pushkarskaya et al., Reference Pushkarskaya, Tolin, Ruderman, Kirshenbaum, Kelly, Pittenger and Levy2015, Reference Pushkarskaya, Tolin, Ruderman, Henick, Kelly, Pittenger and Levy2017; Ruderman et al., Reference Ruderman, Ehrlich, Roy, Pietrzak, Harpaz-Rotem and Levy2016; Strauss et al., Reference Strauss, Fradkin, McNally, Linkovski, Anholt and Huppert2020; Zald & Treadway, Reference Zald and Treadway2017) as they are derived from rational approaches and are easily inferred. These tasks informed our understanding of neuropsychiatric disorders and hold some predictive validity to developing psychopathologies (Ruderman et al., Reference Ruderman, Ehrlich, Roy, Pietrzak, Harpaz-Rotem and Levy2016). Yet there are discrepancies between these objective tasks and subjective assessments. For example, hoarding disorder (HD) patients struggle with letting go of items, irrespective of their objective value (American Psychiatric Association, 2013). These patients have elevated subjective IU scores and often report struggling with uncertainty in their daily life (Wheaton, Abramowitz, Jacoby, Zwerling, & Rodriguez, Reference Wheaton, Abramowitz, Jacoby, Zwerling and Rodriguez2016). Objective decision-making tasks suggest that HD patients have intact decision-making under uncertainty, although they may be less flexible (Pushkarskaya et al., Reference Pushkarskaya, Tolin, Ruderman, Henick, Kelly, Pittenger and Levy2017) and that these patients are less sensitive to losses than healthy adults (Aranovich et al., Reference Aranovich, Cavagnaro, Pitt, Myung and Mathews2017). In real life however, HD patients may be extremely sensitive to losing items (Orr, Preston-Shoot, & Braye, Reference Orr, Preston-Shoot and Braye2019). This discrepancy may be reduced if we incorporate CNT principles in objective tasks. For example, using emotionally laden tasks yielded significant leaps in our understanding of neuronal mechanisms of HD (Tolin et al., Reference Tolin, Stevens, Villavicencio, Norberg, Calhoun, Frost and Pearlson2012). We hypothesize that experimental tasks using multiple decision options, affect-laden stimuli, and having individuals explain their narrative fragments or engage in affective valuation or simulation of decision outcomes will result in much greater differences between HD and non-HD cohorts.

The CNT framework aligns with psychotherapeutic interventions. Working with clients to expose, expand, and alter their narratives is a common goal of many psychotherapies (Goldblatt, Briggs, Lindner, Schechter, & Ronningstam, Reference Goldblatt, Briggs, Lindner, Schechter and Ronningstam2015; Rhodes, Reference Rhodes2013). In HD, first-line psychotherapies aim to modify thoughts, beliefs, and decision-making processes assigned to items and to the self (Mathews et al., Reference Mathews, Mackin, Chou, Uhm, Bain, Stark and Delucchi2018; Steketee & Frost, Reference Steketee and Frost2013; Tolin, Frost, & Steketee, Reference Tolin, Frost and Steketee2007). The CNT may define these thoughts, beliefs, and decision-making processes as narratives or narrative fragments. In line with CNT principles, current treatments have therapists or volunteers aiding HD clients assess their narratives of items and verbally simulate outcomes of their decisions in their homes – such practices may increase affective reasoning and widen the narrative fragments (Crone, Angel, Isemann, & Norberg, Reference Crone, Angel, Isemann and Norberg2020; Linkovski et al., Reference Linkovski, Zwerling, Cordell, Sonnenfeld, Willis, La Lima and Rodriguez2018; Muroff & Otte, Reference Muroff and Otte2019). The CNT suggests that narratives bind processes and perception to guide actions (target article). Therapists may work with clients on explicitly communicating new narrative fragments, which in turn will modify clients' narrative and alter their actions in a more profound way.

CNT discusses shared narratives and their role in economic outcomes. Neuropsychiatric disorders are a leading cause in reducing economic productivity (Chen, Kuhn, Prettner, & Bloom, Reference Chen, Kuhn, Prettner and Bloom2018; James et al., Reference James, Abate, Abate, Abay, Abbafati, Abbasi and Murray2018; Wittchen et al., Reference Wittchen, Jacobi, Rehm, Gustavsson, Svensson, Jönsson and Steinhausen2011). Economic models suggest that major depressive disorder alone costs the US economy 326 billion dollars per year (Greenberg et al., Reference Greenberg, Fournier, Sisitsky, Simes, Berman, Koenigsberg and Kessler2021). These disorders are associated with societal stigma (Chasson, Guy, Bates, & Corrigan, Reference Chasson, Guy, Bates and Corrigan2018; Corrigan, Reference Corrigan2004) which is internalized and affects treatment-seeking and informing mental health status with employers (Clement et al., Reference Clement, Schauman, Graham, Maggioni, Evans-Lacko, Bezborodovs and Thornicroft2015; Schnyder, Panczak, Groth, & Schultze-Lutter, Reference Schnyder, Panczak, Groth and Schultze-Lutter2017). Increasing help-seeking behaviors may lessen the economic burden of neuropsychiatric disorders. Extrapolating the CNT suggests that changing the shared narrative of mental health may reduce the economic costs of neuropsychiatric disorders.

To summarize, we propose that CNT can benefit how we study and treat neuropsychiatric disorders and help decision-makers and health systems lessen the global burden these disorders cause.