Personal narratives and recovery from schizophrenia

Self-concept and Narrative Identity in Youth at Clinical High Risk for Psychosis

BACKGROUND AND HYPOTHESIS

Disturbances of the narrative self and personal identity accompany the onset of psychotic disorders in late adolescence and early adulthood (a formative developmental stage for self-concept and personal narratives). However, these issues have primarily been studied retrospectively after illness onset, limiting any inferences about their developmental course.

STUDY DESIGN

Youth at clinical high risk for psychosis (CHR) (n = 49) and matched healthy comparison youth (n = 52) completed a life story interview (including self-defining memory, turning point, life challenge, and psychotic-like experience) and questionnaires assessing self-esteem, self-beliefs, self-concept clarity, and ruminative/reflective self-focus. Trained raters coded interviews for narrative identity themes of emotional tone, agency, temporal coherence, context coherence, self-event connections, and meaning-making (intraclass correlations >0.75). Statistical analyses tested group differences and relationships between self-concept, narrative identity, symptoms, and functioning.

STUDY RESULTS

CHR participants reported more negative self-esteem and self-beliefs, poorer self-concept clarity, and more ruminative self-focus, all of which related to negative symptoms. CHR participants narrated their life stories with themes of negative emotion and passivity (ie, lack of personal agency), which related to positive and negative symptoms. Reflective self-focus and autobiographical reasoning were unaffected and correlated. Autobiographical reasoning was uniquely associated with preserved role functioning.

CONCLUSIONS

This group of youth at CHR exhibited some, but not all, changes to self-concept and narrative identity seen in psychotic disorders. A core theme of negativity, uncertainty, and passivity ran through their semantic and narrative self-representations. Preserved self-reflection and autobiographical reasoning suggest sources of resilience and potential footholds for cognitive-behavioral and metacognitive interventions.

Narrative identity in addictive disorders: a conceptual review

Narrative identity allows individuals to integrate their personal experiences into a coherent and meaningful life story. Addictive disorders appear to be associated with a disturbed sense of self, reflected in problematic and disorganized self-narratives. In recent literature, a growing body of research has highlighted how narrative approaches can make a dual contribution to the understanding of addiction: on the one hand, by revealing crucial aspects of self structure, and, on the other, by supporting the idea that addiction is a disorder related to unintegrated self-states in which dissociative phenomena and the resulting sense of 'loss of self' are maladaptive strategies for coping with distress. This conceptual review identified the main measures of narrative identity, i.e., narrative coherence and complexity, agency, and emotions, and critically examines 9 quantitative and qualitative studies (out of 18 identified in literature), that have investigated the narrative dimension in people with an addictive disorder in order to provide a synthesis of the relationship between self, narrative and addiction. These studies revealed a difficulty in the organization of narrative identity of people with an addictive disorder, which is reflected in less coherent and less complex autobiographical narratives, in a prevalence of passivity and negative emotions, and in a widespread presence of themes related to a lack of self-efficacy. This review points out important conceptual, methodological and clinical implications encouraging further investigation of narrative dimension in addiction.

Between Meanings and Senses-Making Spaces: Agency and Ownership Emergence Formalization from Cultural-Historical Activity Theory Position, for an AI-Friendly Model

Sense of agency and sense of ownership are considered crucial in autonomous systems. However, drawbacks still exist regarding how to represent their causal origin and internal structure, either in formalized psychological models or in artificial systems. This paper considers that these drawbacks are based on the ontological and epistemological duality in mainstream psychology and AI. By shedding light on the cultural-historical activity theory (CHAT) and dialectical logic, and by building on and extending related work, this paper attempts to investigate how the noted duality affects investigating the self and "I". And by differentiating between the space of meanings and the sense-making space, the paper introduces CHAT's position of the causal emergence of agency and ownership by stressing the twofold transition theory being central to CHAT. Furthermore, a qualitative formalized model is introduced to represent the emergence of agency and ownership through the emergence of the contradictions-based meaning with potential employment in AI.

Relationship between personal recovery, autobiographical memory, and clinical recovery in people with mental illness in the acute phase

Aim

Narratives are important in psychiatric rehabilitation. People with a psychiatric diagnosis find it difficult to recall specific autobiographical memories of events that lasted less than a day. Although personal narratives play a central role in personal recovery, the factors influencing personal and clinical recovery, such as psychiatric symptoms and cognitive function, have not been fully explored. Therefore, this study examined the associations between personal recovery and autobiographical memory, age, psychiatric symptoms, and neurocognitive function.

Method

The Self-Identified Stage of Recovery, Parts A and B (SISR-A, SISR-B), Autobiographical Memory Test (AMT), Japanese version of the Brief Assessment Scale of Schizophrenia Cognitive Function, and Brief Psychiatric Symptom Rating Scale were administered to 40 individuals with psychiatric disorders who were undergoing psychiatric rehabilitation.

Results

A significant positive correlation was found between the total number of specific memories in the AMT and total SISR-B scores. A binary logistic regression analysis revealed that the total number of specific memories, especially high responsiveness to negative cue words, significantly predicted greater personal recovery. Age, psychiatric symptoms, and neurocognitive function did not significantly predict higher personal recovery.

Conclusion

In psychiatric rehabilitation, negative episodes should be treated with caution; however, they may also facilitate personal recovery.

An exploration of loneliness experienced by people living with mental illness and the impact on their recovery journey: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: There is evidence that social isolation and loneliness is more prevalent in people living with mental illness than in the general population. People living with mental illness frequently experience stigma, discrimination, rejection, repeated psychiatric admissions, low self-esteem, low self-efficacy, and increased symptoms of paranoia, depression, and anxiety. There is evidence of common interventions that can be used to improve loneliness and social isolation such as psychosocial skills training and cognitive group therapy. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper offers a comprehensive assessment of the evidence between mental illness, loneliness, and recovery. The results suggest that people living with mental illness experience elevated levels of social isolation and loneliness leading to poor recovery and quality of life. Social deprivation, social integration and romantic loneliness are related to loneliness, poor recovery, and reduced quality of life. A sense of belonging, ability to trust and hope are important aspects of improved loneliness, quality of life and recovery. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The existing culture in mental health nursing practice needs to be examined to address loneliness in people living with mental illness and its impact on recovery. Existing tools to research loneliness do not consider dimensions in loneliness experience as reflected in the literature. Practice needs to demonstrate an integrated approach to recovery, optimal service delivery and augmentation of evidence-based clinical practice to improve individual's loneliness, social circumstances, and relationships. Practice needs to demonstrate nursing knowledge in caring for people living with mental illness experiencing loneliness. Further longitudinal research is required to clearly understand the relationship between loneliness, mental illness, and recovery.

ABSTRACT

INTRODUCTION: To our knowledge, there are no previous reviews on the impact of loneliness experienced by people aged 18-65, who are living with mental illness and their recovery experience.

AIM/QUESTION

To explore the experience and impact of loneliness in people living with mental illness during recovery.

METHOD

An integrative review.

RESULTS

A total of 17 papers met the inclusion criteria. The search was conducted using four electronic databases: MEDLINE, CINAHL, Scopus and PsycINFO. Across these 17 papers, participants were most commonly, diagnosed with schizophrenia or psychotic disorders and recruited from community mental health services.

DISCUSSION

The review revealed loneliness to be substantial in people living with mental illness and that loneliness affected their recovery, and their quality of life. The review identified many factors that contribute to loneliness including unemployment, financial strain, social deprivation, group housing, internalized stigma and mental illness symptoms. Individual factors such as social/community integration and social network size as well as an inability to trust, a sense of not belonging, hopelessness and lack of romance were also evident. Interventions targeting social functioning skills and social connectedness were found to improve social isolation and loneliness.

IMPLICATIONS FOR PRACTICE

It is vital for mental health nursing practice to employ an approach integrating physical health as well as social recovery needs, optimal service delivery and augmentation of evidence-based clinical practice to improve loneliness, recovery, and quality of life.

Being more satisfied with romantic relationship status is associated with increased mental wellbeing in people with experience of psychosis

Aims

Romantic relationships represent one of the most salient sources of social support. In general population studies, they are associated with both physical and psychological benefits. Research suggests that for people with psychosis, romantic relationships may also have a positive impact on a range of outcomes, but the reasons for these associations are still unclear. This study aims to investigate whether satisfaction with romantic relationships status is associated with better wellbeing outcomes in people with experience of psychosis and explore three possible psychological mediators of this relationship.

Methods

Participants who had previously sought support for psychosis (n = 190) completed an online survey including measures of relationship status satisfaction (the Satisfaction with Relationship Scale) as well as measures of psychotic symptoms (the CAPE-42), general well-being (Short Warwick-Edinburgh Mental Wellbeing Scale) and several psychological variables relevant to the pathway between romantic relationships and well-being outcomes, namely loneliness, internalised stigma, self-esteem and attachment.

Results

Fearful attachment and partner criticism were negatively associated with relationship status satisfaction. Having a partner was positively associated with relationship status satisfaction. Higher levels of relationship status satisfaction were associated with lower psychotic symptoms and higher mental wellbeing. This relationship was mediated by loneliness, internalised stigma, and self-esteem.

Conclusion

Mental health services should be mindful of the associations between romantic relationship satisfaction and wellbeing. Service users with a fearful attachment style may particularly benefit from support in this area.

The "Creativity Crisis" as a Mind in Crisis: A Cultural-Historical Activity Theory Position

Creativity is considered a global ability and crucial for ordinary-daily and special (e.g., science, aesthetic) activities. In this paper, from the position of Cultural-Historical Activity Theory (CHAT), we expand the debate about the creativity crisis and hypothesize that the noted crisis is only the tip of the iceberg represented by the crisis of the postmodern' incoherent mind, reflecting the crisis of self-realization as a leading activity in the individualistic epoch. By investigating creativity as an original functionality of the mind, two key titles are stressed. One is the halting of the activity system; two, it is the inconsistency between the objective meanings sphere and the subjective sense-making sphere. Both titles represent the epistemological rupture embedded in the mainstream culture and praxis rooted in the internal contradictions of individualism and post-modernism as worldview and practices, leading the mind to close its eyes on the contradictions which are the crucial source of grasping the internal content (abstraction and generalization) of the given experience, hence, a crucial source of creativity. Thus, it is considered that not only creativity is in crisis, but also the coherence of the mind as well, as an extreme result of the shattered postmodern existence.

Clinical insight in first episode psychosis: the role of metacognition

BACKGROUND

Poor clinical insight has been commonly reported in those with First Episode Psychosis (FEP) and thought to be influenced by a range of factors, including neurocognition and symptoms. Clinical insight may be compromised as a result of alterations in higher-level reflective processes, such as metacognitive ability and cognitive insight.

AIMS

To explore whether metacognitive ability and cognitive insight are associated with clinical insight while controlling for IQ, depression, and symptoms in FEP.

METHODS

60 individuals with FEP completed measures for clinical insight, metacognitive ability, cognitive insight, positive and negative symptoms, depression, and IQ.

RESULTS

Higher levels of metacognitive ability were associated with better clinical insight, even when controlling for IQ, depression, positive and negative symptoms, and medication. Integration subscale of metacognitive ability was most strongly associated with clinical insight. Cognitive insight was associated with clinical insight when controlling for covariates. However, when including metacognitive ability and cognitive insight in the predictive model, only metacognitive ability was significantly related to clinical insight.

DISCUSSION

Metacognitive ability, specifically the ability to describe one's evolving mental state to provide a coherent narrative, was significantly related to clinical insight, independent of covariates, and may be a potentially important target for intervention in FEP.

A pilot study of participatory video in early psychosis: Qualitative findings

For people with psychotic disorders, developing a personal narrative about one's experiences with psychosis can help promote recovery. This pilot study examined participants' reactions to and experiences of participatory video as an intervention to help facilitate recovery-oriented narrative development in early psychosis. Outpatients of an early psychosis intervention program were recruited to participate in workshops producing short documentary-style videos of their collective and individual experiences. Six male participants completed the program and took part in a focus group upon completion and in an individual semistructured interview three months later. Themes were identified from the focus group and interviews and then summarized for descriptive purposes. Prominent themes included impacts of the videos on the participants and perceived impacts on others, fulfilment from sharing experiences and expressing oneself, value of collaboration and cohesion in a group, acquiring interpersonal and technological skills, and recommendations for future implementation. Findings of this study suggest that participatory video is an engaging means of self-definition and self-expression among young people in recovery from early psychosis.

Activity system, schizotypal personality, and mentalization: A study between halted activity and COVID-19 conducted in Henan, China

The pandemic-related lifestyle has potentially imposed crucial disturbances on daily and long-term activities, which, in turn, were associated with thought disturbance. This study investigates how the characteristics of the activity system during pandemic-related restrictions are associated with other psychomental aspects. By focusing on PTSD, mentalization, and schizotypal personality, and by inquiring about the main components of the activity system of 852 college students (Zhengzhou, Henan, China)- including the goals orienting their activity, goals' terms and types, the motivation levels and sources, the activity type and engagement time, the flow of the activity, and how due to pandemic lifestyle-results revealed that the activity system's components have significant associations with PTSD, reflective function, and schizotypal traits. Additionally, some of the activity system's elements have a significant predictive role regarding schizotypal traits. The study considered that the life narrative during the pandemic has been disturbed; hence, this may have a crucial effect on mind coherence. Additionally, the outcomes from the pandemic context will support mental health interventions in other similar contexts where the life narrative is severely affected.

Internalized stigma mediates the relation between psychosis-risk symptoms and subjective quality of life in a help-seeking sample

Subjective quality of life can be compromised in individuals with psychosis-risk symptoms, with poorer quality of life being associated with worse functioning and later transition to psychosis. Individuals who experience psychosis-related symptoms also tend to endorse more internalized (or self-) mental health stigma when compared to controls, potentially contributing to delays in seeking treatment and increased duration of untreated psychosis, as well as interfering with treatment engagement and retention in those already receiving care. Despite these findings, and the growing recognition for prevention in earlier phases of psychotic illness, few studies have examined the relation between psychosis-risk symptoms, internalized stigma, and subjective quality of life in a younger, help-seeking sample. The present study examined whether internalized stigma mediates the relation between psychosis-risk symptoms and subjective quality of life in a transdiagnostic sample of youth (M age = 17.93, SD = 2.90) at clinical high-risk for psychosis (CHR), with early psychosis, or with non-psychotic disorders (N = 72). Psychosis-risk symptom severity was assessed using the Structured Interview for Psychosis-Risk Syndromes (SIPS). Internalized stigma was assessed using the Internalized Stigma of Mental Illness Inventory (ISMI), and subjective quality of life was assessed using the Youth Quality of Life Instrument - Short Form (YQOL-SF). Internalized stigma fully mediated the relation between psychosis-risk symptoms and subjective quality of life across the full sample (p < .05, f² = 0.06). Findings suggest that internalized stigma may be an important target in efforts to improve quality of life for individuals in early stages of psychosis.

Associations between personal recovery and service user-rated versus clinician-rated clinical recovery, a cross-sectional study

BACKGROUND

This study examined the relationship between service user-rated personal recovery and clinician-rated and service user-rated clinical recovery. The relationships between different subdomains of clinical recovery and personal recovery were also assessed.

METHODS

In total, 318 mental health service users with a psychosis diagnosis and their clinicians from 39 sites across Norway completed standardized questionnaires regarding personal recovery, clinical symptoms and psychosocial functioning. Regression models were used to investigate the relationship between personal and clinical recovery.

RESULTS

Overall, clinical recovery was positively associated with personal recovery, when rated both by service users and by clinicians. Personal recovery was associated with lower levels of depression, self-harm and problems with relationships when rated by the service users. Among the subdomains rated by the clinicians, personal recovery was associated with fewer problems with relationships and higher aggressiveness.

CONCLUSIONS

These findings suggest that affective symptoms are associated with personal recovery, indicating the need for greater focus on depression treatment among people with psychosis. Improving social connections is of importance for personal recovery, and might be an area where clinicians and service users can meet and find agreement on important treatment goals.

Facilitating and hindering factors of personal recovery in the context of Soteria-A qualitative study among people with (early episode) psychosis

OBJECTIVE

The objective of this study was to gain insight into patients' experiences of how personal recovery (PR) is facilitated or hindered in the context of an early episode psychosis setting (Soteria). We thereby aimed to contribute to the understanding of how care settings may promote or hinder the process of PR in people with (acute) psychosis.

METHOD

This study used a qualitative method, consisting of semi-structured in-depth interviews with people who had been admitted to a Soteria house in the Netherlands. Interview transcripts were analyzed following the Grounded Theory approach.

RESULTS

Five themes emerged from the data illustrating how Soteria facilitated or impeded PR. The experience of togetherness in contact with staff and peers, feeling at home, and being active facilitated PR, while the emphasis put on medication by staff was experienced as hindering, and attention to spirituality was missed.

CONCLUSION

In addition to the literature that identified factors associated with PR in psychosis, the current study gives a sense of how this can be put into practice. By offering treatment within a normalizing, holding environment, with emphasis on equality, close contact, optimism, active structured days, open-mindedness toward spirituality, and the role of medication, PR can be facilitated without detracting from guideline-based treatment aimed at symptomatic recovery. Similarities with existing concepts are discussed.

Trajectories of loneliness and objective social isolation and associations between persistent loneliness and self-reported personal recovery in a cohort of secondary mental health service users in the UK

BACKGROUND

Loneliness is a frequent and distressing experience among people with mental health problems. However, few longitudinal studies have so far investigated the trajectories of loneliness and objective social isolation, and the extent to which both issues may impact mental health outcomes among mental health service users. Therefore, this study aims to describe the trajectories of loneliness and objective social isolation and their associations with self-rated personal recovery among people leaving crisis resolution teams (CRTs).

METHODS

A total of 224 participants receiving care from CRTs (recruited for a large multi-site randomised controlled trial) were included in this longitudinal cohort study. They completed the eight-item University of California at Los Angeles Loneliness Scale (ULS-8), Lubben-Social Network Scale (LNSN-6), and the Questionnaire about the Process of Recovery (QPR) (primary outcome) at baseline, 4- and 18-month follow-up, as well as baseline sociodemographic and clinical variables.

RESULTS

We compared groups who were persistently lonely (at all time points), intermittently lonely (at one or two time points) and never lonely. After adjusting for all potential confounders and baseline predictive variables, persistent severe loneliness was associated with worse personal recovery at 18-month follow-up compared with the never lonely (reference group) (coef. = - 12.8, 95% CI -11.8, - 3.8, p < .001), as was being intermittently lonely (coef. = - 7.8, 95% CI -18.8, - 6.8, p < .001). The persistently objectively social isolated group (coef. = - 9.8, 95% CI -15.7, - 3.8, p = .001) also had poorer self-rated recovery at 18-month follow-up than those who were not socially isolated at any timepoint (i.e., reference category).

CONCLUSION

Results suggest that both persistent loneliness and objective social isolation are associated with poorer self-rated recovery following a crisis, compatible with a causal relationship. These findings suggest a potential role for interventions aimed at alleviating loneliness and objective social isolation in improving recovery outcomes for people with mental health symptoms. Increased awareness of both issues among health practitioners is also warranted.

Narrative identity in the psychosis spectrum: A systematic review and developmental model

Individuals with schizophrenia-spectrum disorders face profound challenges as they attempt to maintain identity through the course of illness. Narrative identity-the study of internalized, evolving life stories-provides a rich theoretical and empirical perspective on these challenges. Based on evidence from a systematic review of narrative identity in the psychosis spectrum (30 studies, combined N = 3859), we argue that the narrative identities of individuals with schizophrenia-spectrum disorders are distinguished by three features: disjointed structure, a focus on suffering, and detached narration. Psychotic disorders typically begin to emerge during adolescence and emerging adulthood, which are formative developmental stages for narrative identity, so it is particularly informative to understand identity disturbances from a developmental perspective. We propose a developmental model in which a focus on suffering emerges in childhood; disjointed structure emerges in middle and late adolescence; and detached narration emerges before or around the time of a first psychotic episode. Further research with imminent risk and early course psychosis populations would be needed to test these predictions. The disrupted life stories of individuals on the psychosis spectrum provide multiple rich avenues for further research to understand narrative self-disturbances.

Storying the Past and the Future: Agency and Communion Themes Among Individuals With Schizophrenia and Depression

ABSTRACT

Research has linked disturbances in narrative identity with schizophrenia and other psychiatric disorders. One such disturbance is diminished agency and communion themes in past life stories. However, projecting oneself into the future is also central to identity and potentially impacts recovery. Hence, we examined themes of agency and communion in both past and future life stories and related themes to psychosocial functioning in 20 individuals with schizophrenia, 20 individuals with depressive disorder, and 19 nonpsychiatric controls. Participants were asked to describe up to 10 past and future chapters in their life stories and were assessed on psychosocial functioning and neurocognition. Chapters were coded for agency and communion themes. Both clinical groups displayed diminished agency and communion themes in past but not future life story chapters compared with the nonpsychiatric controls. Furthermore, agency themes in future chapters explained variance in psychosocial functioning after controlling for neurocognition. The results suggest that constructing a narrative identity to foster agency and communion in both past and future chapters may be an important part of recovering from schizophrenia and depression.

Family involvement moderates the relationship between perceived recovery orientation of services and personal narratives among Chinese with schizophrenia in Hong Kong: a 1-year longitudinal investigation

PURPOSE

Family has been found to have an influential role on clinical and recovery outcomes of people with schizophrenia. While recovery-oriented services can facilitate service users to develop a rich and positive identity, it is unclear how different levels of family involvement may interact with recovery-oriented services in affecting personal recovery. The present study aimed to examine how family involvement moderates the relationship between perceived recovery-orientation of services and personal narratives of Chinese people in Hong Kong who had recent onset of schizophrenia spectrum disorder longitudinally.

METHOD

Multi-method approach (semi-structured interview, researcher ratings, self-report measures) was adopted. 167 participants completed assessments at baseline; 93 and 68 of them were retained at 6-month and 12-month follow-up assessment, respectively.

RESULTS

Baseline perceived recovery orientation of services significantly predicted richer personal narratives at 6-month follow-up when baseline family involvement was optimal (B = 0.26, p = 0.03, 95% CI [0.02-0.48]). As to 12-month assessment, baseline perceived recovery orientation of services significantly predicted poorer personal narratives when family was perceived as under-involved at baseline (B = - 0.45, p = 0.02, 95% CI [- 0.88 to - 0.07]).

CONCLUSION

Without proper family involvement, recovery-oriented services could be ineffectual in facilitating the development of rich personal narratives for Chinese people in Hong Kong.

Narrative Identity, Metacognition, and Well-Being in Patients With Schizophrenia or HIV

It has been proposed that schizophrenia reflects disturbances in personal identity, which include sense of personal agency, sense of belonging within a social group, and metacognition. Less is known about how these different processes are related to one another and to well-being outcomes. To study this, we measured themes of agency and communion in narrative identity in 29 individuals with schizophrenia and 29 individuals with HIV. All participants had previously been assessed on metacognitive abilities using the Indiana Psychiatric Illness Interview (IPII) and completed scales measuring hopelessness and self-esteem. For the present study, themes of agency and communion were coded from the IPII transcripts. Results indicated that participants with schizophrenia had lower levels of agency and communion compared with participants with HIV. More presence of agency and communion themes were related to better metacognitive abilities as well as less hopelessness and higher self-esteem across groups. Agency predicted variance in hopelessness after controlling for metacognitive abilities. The results suggest that although the construction of narrative identity may depend on metacognitive abilities, agency themes predict outcomes beyond metacognition.

Participatory video as a novel recovery-oriented intervention in early psychosis: A pilot study

BACKGROUND

Personal narrative plays an important role in the process of recovery from psychotic illnesses. Participatory video is a novel, active intervention that can be used as a tool for fostering narrative development among people with psychosis.

AIM

To assess the feasibility, acceptability and potential clinical utility of participatory video as an innovative tool for promoting recovery in early psychosis.

METHODS

Ten outpatients of an early psychosis intervention programme were recruited to participate in 13 biweekly workshops to plan, film and produce documentary-style videos of their experiences. Feasibility was measured through recruitment and retention. Acceptability was measured through workshop attendance and client satisfaction. Clinical outcomes were assessed at baseline, post intervention and 3 months post intervention.

RESULTS

The participatory video intervention was feasible and associated with a high degree of satisfaction for participants who completed the workshops (n = 6). At 3-month follow-up, participants exhibited significant reductions (p < .05) in tension, self-stigma and negative perceptions of hoped-for selves.

CONCLUSIONS

The findings of this pilot study suggest that participatory video is feasible and acceptable for individuals with early psychosis. This study also provides important pilot data supporting a larger trial investigating the effectiveness of participatory video as a recovery-oriented intervention.

Nonmedical Interventions for Schizophrenia: A Review of Diet, Exercise, and Social Roles

Schizophrenia is a major mental illness with a disease course that is influenced by lifestyle. The risk-benefit ratio for alternative interventions is more favorable than for antipsychotics in long-term treatment. Dietary interventions may target autoimmune features, vitamin or mineral deficiencies, abnormal lipid metabolism, gluten sensitivity, or others. Examples of interventions involving diet, physical activity, or physical processes or social interventions including talk therapy exist in the literature. Notwithstanding, the general utility of these types of interventions remains inconclusive, awaiting long-term randomized trials. A perspective that separates the cause of the disease from its symptoms may be helpful in treatment planning and is warranted to distinguish between short-term and long-term recovery goals.

Recovery and its correlates in patients with schizophrenia

Little information is available from India, on psychological recovery in patients with schizophrenia. Accordingly, this study aimed to evaluate the correlates and stages of the psychological recovery of patients with schizophrenia. 100 patients, in clinical remission, were evaluated on Stages of Recovery Instrument (STORI), Functional Social Support Questionnaire, WHO Quality of life-BREF, Ways of Coping Checklist, Internalised Stigma of Mental Illness Scale, Scale to Assess Unawareness of Mental Disorder and Knowledge of mental illness scale. Majority of the patients (N = 50) belonged to the stage-5 (Growth), and this was followed by those in the stage-4 (stage of rebuilding; N = 22) and stage-3 (stage of preparation; N = 16) of recovery. A higher stage of recovery was associated with lower stigma in all the domains except stigma resistance. Higher use of confrontative coping and accepting responsibility was associated with a higher score in the awareness stage of recovery. In terms of insight, higher awareness about the effect of medication was associated with a higher stage of recovery. Higher disability in the domain of self-care was seen in the lower stage of recovery. Better quality of life in the physical health domain was associated with being in a higher stage of recovery. To conclude, findings of the present study suggest that stigma plays a significant role in determining the outcome in the form of personal recovery. These findings suggest that to organize the services to promote personal recovery, clinicians should not only aim at symptom amelioration but also must focus on stigma to promote psychological recovery.

Personal perspectives on patient and public involvement - stories about becoming and being an expert by experience

Patient and public involvement activities bring 'lay participants' and their accounts of lived experiences to the centre of health service development and delivery. For individuals, these accounts can provide an important resource, offering a sense of control and an opportunity to re-frame past events. Furthermore, as involvement activities and the use of personal accounts have become more prominent, it is timely to examine the involvement process from the perspective of the 'lay participants'. Hence, the aim of this study is to explore how people become involved and how they construct the accounts of their lived experience. We analyse the stories of people with lived mental illness or caring experiences, who have become experts by experience (n = 13). We argue that becoming an expert by experience can help to re-contextualise past experiences and support the re-discovery of skills and expertise, leading experts by experience to construct both professionalised and politicised identities. The process has the potential to enforce narratives that portray illness experiences as motivators for social action and change. Additionally, we claim that the stories experts by experience share with health services and the public are not 'lay accounts' or ad hoc tales, but accounts constructed to serve specific purposes.

Cognitive and metacognitive factors predict engagement in employment in individuals with first episode psychosis

BACKGROUND

Research has demonstrated that cognitive abilities predict work outcomes in people with psychosis. Cognitive Remediation Programs go some way in improving work outcomes, but individuals still experience difficulty maintaining employment. Metacognition has been demonstrated to predict work performance in individuals with schizophrenia, but this has not yet been applied to First Episode Psychosis (FEP). This study assessed whether metacognition, intellectual aptitude and functional capacity can predict engagement in work and number of hours of work within FEP.

METHODS

Fifty-two individuals with psychosis, from an Early Intervention in Psychosis service, completed measures of IQ, metacognition (Metacognitive Assessment Interview), functional capacity (UPSA), and functional outcome (hours spent in structured activity per week, including employment).

RESULTS

Twenty-six participants (22 males, 4 females) were employed and twenty-six (22 males, 4 females) were not employed. IQ and metacognition were significantly associated with whether the individual was engaged in employment [IQ (p = .02) and metacognition (p = 006)]. When controlling for IQ, metacognition (differentiation subscale) remained significant (p = .04). Next, including only those employed, no cognitive nor metacognitive factors predicted number of hours in employment.

DISCUSSION

This is the first study to directly assess metacognition as a predictor of work hours for individuals with FEP. This study highlights the importance of enhancing metacognitive ability in order to improve likelihood of, and engagement in, employment for those with FEP.

Social cognitive group treatment for impaired insight in psychosis: A multicenter randomized controlled trial

PURPOSE

The majority of people with schizophrenia has impaired insight, which is related to a poorer outcome. In this study, we evaluate a new psychosocial intervention 'REFLEX' aimed at improving insight in people with schizophrenia. REFLEX focuses on targeting stigma-sensitivity, perspective taking and self-reflection in people with schizophrenia and low insight. Primary objective is to improve insight and subsequently to improve functional outcome and symptoms.

METHOD

A total of 121 people diagnosed with schizophrenia according to DSM IV criteria with impaired insight was included in 2012-2015 from seven sites in a multicenter randomized controlled trial. REFLEX was compared to an active control condition consisting of group-wise simplified cognitive remediation training. Primary outcome of the study were the preconditions of insight: internalized stigma, self-reflection, mental flexibility and perspective taking. Clinical insight and cognitive insight were secondary outcomes.

RESULTS

Although perspective taking, self-reflection, mental flexibility and stigma sensitivity remained unchanged after the intervention, results showed a significant improvement of clinical insight in both conditions directly after treatment (SAI-E Rater, p < .001, PANSS G12, p < .005) and at follow-up (SAI-E Rater, p < .01, SAI-E interview, p < .001, PANSS G12, p < .0001). Improvement of clinical insight directly after treatment was larger in the REFLEX condition (SAI-E Rater, p < .05). Other outcomes (self-esteem, quality of life and depression) remained unchanged.

CONCLUSION

Though insight improved in both conditions, REFLEX was not superior to simplified drill-and-practice cognitive remediation training. Nevertheless, this study indicates that structured interventions can significantly improve insight. Further research on the underlying mechanisms of both conditions is needed, as insight is unlikely to improve spontaneously in chronic patients.

Three-Year Follow-Up Study Exploring Metacognition and Function in Individuals With First Episode Psychosis

Introduction: Research has demonstrated that functional outcome in psychosis is predicted by factors such as neurocognition, functional capacity, symptoms and, more recently, metacognition. Metacognitive ability has been demonstrated to mediate between neurocognition and functional outcome in First Episode Psychosis (FEP). Whether metacognition also predicts longer-term recovery in first episode psychosis is unknown. This study assessed whether neurocognition, functional capacity and metacognitive ability in FEP predicted functional outcome three years later. Methods: Eighty individuals with First Episode Psychosis were re-contacted after an average 3 years (range: 26-45 month follow-up) from baseline. Twenty-six participants (33%) completed completed measures of neurocognition, metacognition, functional capacity, functional outcome (hours spent in structured activity per week) and psychopathology at baseline and at follow-up. Results: Individual regression analyses demonstrated neurocognition, functional capacity, and metacognitive ability at baseline significantly predicted functional outcome at three years. However, when baseline functional outcome was controlled, only metacognitive ability was a significant predictor of change in functional outcome from baseline to follow-up, p < 0.001. This model explained 72% (adjusted r ² = 0.69) of the variance in functional outcome at follow-up. Negative symptoms did not change the model. Discussion: This study demonstrated that better metacognitive ability significantly predicted improvement in functioning in FEP across a 3-year period. This highlights the potential value of clinical interventions that focus on improving metacognitive ability at first point of illness to maximize recovery.

Content Matters, a Qualitative Analysis of Verbal Hallucinations

Auditory verbal hallucinations have traditionally especially been researched from a form-based approach, with content getting much less attention. In this article, we argue for the importance of looking at content to get a fuller understanding of the hallucinatory experience. Guided by Lacanian psychoanalysis, we conducted a thematic and a narrative analysis on interviews with 10 schizophrenic patients about their hallucinations. We discerned five themes in the data, which were based on Lacanian theory and had to do with existential questions: parenthood and authority, sexuality and relationships, gender identity, life in the light of death, and what does the other want? Furthermore, we added a theme for unclassified content. Narratively, we found that participants constructed a story of four steps about their hallucinatory experiences. These steps were disturbing events in the past posing an existential question, triggering event, period of confusion, and hearing voices that allude to existential themes. Participants succeed in different degrees in integrating their hallucinatory experiences in their own life history. These stories can be situated on a continuum by making use of three prototypical narrating styles: the meta-delusional, delusional, and chaotic narrative type. Overall, our analysis shows that hallucinations can both be thematically and narratively organized, by making use of a theoretical framework like Lacanian psychoanalysis. Our research demonstrates that hallucinatory contents are not random but are about existential issues imbedded in a life narrative. Future research would benefit of integrating content and form-based approaches.

Themes of unfulfilled agency and communion in life stories of patients with schizophrenia

We examined themes of agency and communion in life stories of individuals with schizophrenia. Twenty-four individuals diagnosed with schizophrenia and 24 control participants matched on age, gender, and education described their life stories in a free format. The life stories were coded for the presence of agency and communion themes and whether or not the themes captured fulfillment of agency and communion needs. In addition, the temporal macrostructure was coded. Individuals with schizophrenia described their life stories with similar levels of temporal macrostructure as controls, but they expressed more themes focusing on unfulfilled agency and communion needs. We suggest possible avenues for using these insights to improve recovery in schizophrenia.

Development and validation of a scale for self-efficacy for personal recovery in persisting mental illness

The personal recovery movement in mental health has emphasised consumers' individual responsibility and autonomy in defining and directing their own recovery journey. Self-efficacy, or an individual's belief that they can achieve their desired outcomes, is likely to be a key predictor of recovery success. However, there is no established measure of self-efficacy for personal recovery. The Self-Efficacy for Personal Recovery Scale was developed and its psychometric properties evaluated as part of a broader research program investigating a recovery-focused digital intervention in psychosis. Scale reliability and validity were investigated in a sample of 178 adults with persisting psychosis, and test-retest reliability was evaluated in a subset of 32 participants. The scale showed high internal consistency, test-retest reliability, and convergent validity, including correlating positively with hope, personal recovery, and generalised self-efficacy, whilst showing independence from social desirability, insight, and positive symptoms. This measure may be useful for research into the processes underlying recovery, and for understanding how self-efficacy for personal recovery may be enhanced in people with severe mental illness.

Autonomous motivation and quality of life as predictors of physical activity in patients with schizophrenia

AIM

Being physically active is a complex behaviour in patients with schizophrenia. Several factors were identified as barriers to achieving active behaviours in this population. Therefore, the purpose of this study was to investigate among a number of barriers what predicts the most on physical activity (PA) in patients with schizophrenia.

METHODS

A total of 114 patients (28♀) with schizophrenia were included. Body mass index (BMI) was calculated. Autonomous and controlled motivation (Behavioural Regulation in Exercise Questionnaire - 3), self-esteem (Rosenberg Self-esteem scale), quality of life (World Health Organization Quality of Life Scale - Brief version) and functional exercise capacity (6-minute walk test - 6MWT) were evaluated. Multiple Regression Analysis was applied to assess the effect of these variables on Total PA per week (International Physical Activity Questionnaire - short version).

RESULTS

Autonomous motivation and domains of quality of life were positively correlated with Total PA per week. Stepwise multiple regression analyses showed that of all the candidate factors to predict PA, autonomous motivation and global domain of quality of life were found as significant predictors.

CONCLUSION

Our findings help to understand the importance of autonomous motivation and quality of life for PA in patients with schizophrenia. Knowledge about these predictors may provide guidance to improve PA behaviour in this population.

Narrative development and supported employment of persons with severe mental illness

Background: While the relationship between objective recovery and work among persons with severe mental illness (SMI) is well-established, few studies have examined the link between subjective recovery and employment.Aims: The study investigated the prospective relationship between narrative development at the start of supported employment (SE) and positive work outcomes.Methods: The authors employed a time-limited, mixed-method longitudinal design to examine the relationship between the baseline narrative development of 38 SE participants with SMI and employment outcomes eight months later, as well as whether narratives evolved over the course of the study.Results: While narrative development was unrelated to work for the 59% of participants who were employed at the end of the study, unemployed individuals showed more developed baseline narratives overall, as well as enriched baseline emotional connectedness and social worth. Higher emotional connectedness at the start of SE programs was predictive of fewer hours worked eight months later, controlling for executive functioning, negative symptoms and self-esteem. Although workers showed no narrative changes over time, those without work demonstrated increased agency over the eight months of the study.Conclusion: Further research is warranted to clarify the relationship between richer personal narratives and unemployment.

Narrative research on mental health recovery: two sister paradigms

BACKGROUND

Despite the breadth of narrative studies on individuals with severe mental illness, the suitability of narrative inquiry to exploring mental health recovery (MHR) has not been examined.

AIMS

(1) Examining the appropriateness of narrative inquiry to studying MHR; (2) assessing the extent to which narrative studies on MHR conform to the unique features of narrative research, as a distinctive form of qualitative inquiry.

METHODS

Review of empirical, theoretical and methodological literature on recovery and narrative inquiry.

RESULTS

Considering the perspectives of recovery and narrative as paradigms, the similarity between their ontology and epistemology is shown, evident in 10 common emphases: meaning, identity, change and development, agency, holism, culture, uniqueness, context, language and giving voice. The resemblance between these "sister" paradigms makes narrative methodology especially fruitful for accessing the experiences of individuals in recovery. Reviewing narrative studies on MHR suggests that, currently, narrative research's uniqueness, centered on the holistic principle, is blurred on the philosophical, methodological and textual levels.

CONCLUSIONS

Well-established narrative research has major implications for practice and policy in recovery-oriented mental health care. The narrative inquiry paradigm offers a possible path to enhancing the distinctive virtues of this research, realizing its potential in understanding and promoting MHR.

Validation of Hindi version of Stages of Recovery Instrument

OBJECTIVES

To translate the Stages of Recovery Instrument (STORI) and evaluate its psychometric properties, demographic, and clinical correlates among patients with schizophrenia.

MATERIALS AND METHODS

The English version of the scale was translated into Hindi using the World Health Organization methodology. The Hindi version was completed by thirty patients with schizophrenia on two occasions, 4-7 days apart. Another thirty patients completed both Hindi and English version within a gap of 4-7 days. In addition, 100 patients completed the Hindi version of STORI once for studying the demographic and clinical correlates of recovery.

RESULTS

Hindi version of STORI demonstrated good internal consistency (α = 0.854) for the full scale and also for all the five stages of recovery (α = 0.745 to 0.756) as described in the scale. Split-half reliability of the scale was also good, as reflected by a high Spearman-Brown coefficient (0.781) and Guttmann's split-half coefficient (0.778). All the items of the scale showed high test-retest reliability and cross-language equivalence. Correlation between different stages and correlation between the allocated stage and different stages reflected good concurrent and construct validity of the subscales described as various stages of recovery. In general, demographic and clinical variables did not have any significant correlation with stages of recovery. However, those with lower level of general psychopathology scores showed significant correlation with higher stages of recovery.

CONCLUSIONS

Hindi version of STORI has good psychometric properties.

Self-continuity across time in schizophrenia: An exploration of phenomenological and narrative continuity in the past and future

BACKGROUND

Disorders of the self, such as a reduced sense of personal continuity in time, are a core symptom of schizophrenia, but one that is still poorly understood. In the present study, we investigated two complementary aspects of self-continuity, namely phenomenological and narrative continuity, in 27 patients with schizophrenia, and compared them with 27 control participants.

METHODS

Participants were asked to identify important past events and to narrate a story from their life that included these events. They were also asked to imagine important events that might happen in their personal future and to build a narrative of their future life. The vividness of these important life events and the proportion of self-event connections in the narratives were used as a measure of phenomenological and narrative continuity, respectively.

RESULTS

Our study showed patients with schizophrenia experienced less vivid representations of personally significant events (p = .02) for both temporal directions (past and future) (p < .001). In addition, their ability to make explicit connections between personal events and self-attributes in life narratives was also impaired (p = .03), but only in the case of past narratives (p < .001).

CONCLUSIONS

These results shed new light on the cognitive mechanisms underlying self-disorders in schizophrenia. The clinical and therapeutic implications of these findings are discussed.

Metacognition moderates the relationship between dysfunctional self-appraisal and social functioning in prolonged schizophrenia independent of psychopathology

OBJECTIVES

Both dysfunctional self-appraisal and metacognitive deficits, or impairments in the ability to form complex and integrated ideas about oneself and others, may contribute to social deficits in schizophrenia. Little is known, however, about how they interact with each other. In this study, we examined the hypothesis that both higher metacognition and more positive self-appraisal are necessary for increased social functioning.

METHODS

Concurrent assessments of self-appraisal, metacognition, and social functioning were gathered from 66 adults with schizophrenia in a non-acute phase of disorder. Three forms of self-appraisal were used: self-esteem, hope and self-efficacy. Metacognition was assessed using the Metacognitive Assessment Scale-Abbreviated, and social functioning with the Quality of Life Scale. Measures of psychopathology, neurocognition and social cognition were also gathered for use as potential covariates.

RESULTS

A single index of self-appraisal was generated from subjecting the assessments of self-appraisal to a principal components analysis. Linear regression analyses revealed that after controlling for severity of psychopathology, metacognition moderated the effect of the self-appraisal factor score upon social functioning. A median split of metacognition and the self-appraisal index yielded four groups. ANCOVA analyses revealed that participants with higher levels of metacognition and more positive self-appraisal had greater capacities for social relatedness than all other participants, regardless of levels of positive and negative symptoms. Correlational analyses revealed that metacognition but not self-appraisal was related to the frequencies of social contact independent of the effects of psychopathology. Assessments of social cognition and neurocognition were not significantly linked with social dysfunction.

CONCLUSION

Greater social functioning is made possible by a combination of both more positive self-appraisals and greater metacognitive capacity. Individuals with schizophrenia who struggle to relate to others may benefit from interventions which address both their beliefs about themselves and their capacity for metacognition.

Psychological approaches to understanding and promoting recovery in psychosis and bipolar disorder: a mixed-methods approach

Background

Recovery in mental health is a relatively new concept, but it is becoming more accepted that people can recover from psychosis. Recovery-orientated services are recommended for adult mental health, but with little evidence base to support this.

Objectives

To facilitate understanding and promotion of recovery in psychosis and bipolar disorder (BD), in a manner that is empowering and acceptable to service users.

Method

There were six linked projects using qualitative and quantitative methodologies: (1) developing and piloting a service user-defined measure of recovery; (2) a Delphi study to determine levels of consensus around the concept of recovery; (3) examination of the psychological factors associated with recovery and how these fluctuate over time; (4) development and evaluation of cognitive–behavioural approaches to guided self-help including a patient preference trial (PPT); (5) development and evaluation of cognitive–behavioural therapy (CBT) for understanding and preventing suicide in psychosis including a randomised controlled trial (RCT); and (6) development and evaluation of a cognitive–behavioural approach to recovery in recent onset BD, including a RCT of recovery-focused cognitive–behavioural therapy (RfCBT). Service user involvement was central to the programme.

Results

Measurement of service user-defined recovery from psychosis (using the Subjective Experience of Psychosis Scale) and BD (using the Bipolar Recovery Questionnaire) was shown to be feasible and valid. The consensus study revealed a high level of agreement among service users for defining recovery, factors that help or hinder recovery and items which demonstrate recovery. Negative emotions, self-esteem and hope predicted recovery judgements, both cross-sectionally and longitudinally, whereas positive symptoms had an indirect effect. In the PPT, 89 participants entered the study, three were randomised, 57 were retained in the trial until 15-month follow-up (64%). At follow-up there was no overall treatment effect on the primary outcome (Questionnaire about the Process of Recovery total;p = 0.82). In the suicide prevention RCT, 49 were randomised and 35 were retained at 6-month follow-up (71%). There were significant improvements in suicidal ideation [Adult Suicidal Ideation Questionnaire; treatment effect = –12.3, 95% confidence interval (CI) –24.3 to –0.14], Suicide Probability Scale (SPS; treatment effect = –7.0, 95% CI –15.5 to 0) and hopelessness (subscale of the SPS; treatment effect = –3.8, 95% CI –7.3 to –0.5) at follow-up. In the RCT for BD, 67 participants were randomised and 45 were retained at the 12-month follow-up (67%). Recovery score significantly improved in comparison with treatment as usual (TAU) at follow-up (310.87, 95% CI 75.00 to 546.74). At 15-month follow-up, 32 participants had experienced a relapse of either depression or mania (20 TAU vs. 12 RfCBT). The difference in time to recurrence was significant (estimated hazard ratio 0.38, 95% CI 0.18 to 0.78;p < 0.006).

Conclusions

This research programme has improved our understanding of recovery in psychosis and BD. Key findings indicate that measurement of recovery is feasible and valid. It would be feasible to scale up the RCTs to assess effectiveness of our therapeutic approaches in larger full trials, and two of the studies (CBT for suicide prevention in psychosis and recovery in BD) found significant benefits on their primary outcomes despite limited statistical power, suggesting definitive trials are warranted.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Idea density in the life-stories of people with schizophrenia: Associations with narrative qualities and psychiatric symptoms

Disordered speech and language deficits are well-documented in schizophrenia-spectrum disorders. Researchers often assess speech samples using manualized rating systems, though recently computerized language assessment methods have been used more frequently in the study of speech from people with schizophrenia. Most typically, these computerized assessments measure aspects of expressivity (i.e., pause durations, prosody) or use word-count technology; less attention has focused on similar methods that can capture more sophisticated aspects of linguistic complexity (e.g., idea density). The primary objective of the present study was to assess idea density - via a computerized measure - in the life-story narratives of people with schizophrenia (n=32) compared to a group of community control participants (n=15). In the schizophrenia group, we also examined associations between idea density, narrative qualities rated via a manualized measure, and psychiatric symptoms. Our findings indicate that idea density is diminished in individuals with schizophrenia compared to controls. Further, our results suggest that though people with schizophrenia with richer idea density tended to have more developed insight into illness, they also had higher levels of depression, anxiety, and avolition. Implications of these results and suggestions for future research are discussed.

Understanding Universal Elements in Mental Health Recovery: A Cross-Examination of Peer Providers and a Non-Clinical Sample

In our study, we examined underlying human elements embedded in mental health recovery, by exploring shared positive change among peer providers with serious mental illnesses in recovery and a normative sample in spiritual growth following adversity. We conducted secondary analysis based on two independent qualitative study samples consisting of 31 American peer providers and 27 Israeli adults. We identified three shared and two distinct enablers of positive change: peer groups, significant mentor, self-transcendent experiences. Distinct enablers were having meaningful task/role (clinical sample) and deliberate choice to commit to change in face of uncertainty (non-clinical sample). Enablers facilitated positive processes of meaning making and enhancement of agency. Enablers provided opportunities to which the person responded and made use of--thus, enacting a positive reinforcement of change processes. The findings highlight the value of examining mental health recovery in a broad holistic perspective and have implications for practice.

Subjective distress in a representative sample of outpatients with psychotic disorders

BACKGROUND

The affective burden of psychotic disorder has been increasingly recognised. However, subjective reports of distress and its covariates, especially those related to service use, remain under-investigated in patients with psychosis.

METHODS

This study investigated subjective distress and its covariates in a representative sample of 401 outpatients with a confirmed diagnosis of psychotic disorders in Brazil. Distress was assessed using the corresponding domain of a standardised measure of need - the Camberwell Assessment of Need.

RESULTS

Distress was reported as a need by 165 (41%) patients, being met in 78 (20%) and unmet in 87 (22%). Hierarchical logistic regression showed that the presence of distress as a need was predicted by attendance at psychotherapy (OR=3.49, CI=1.62-7.53), presence of suicidal ideation (OR=2.89, CI=1.75-4.79), non-attendance at psychosocial rehabilitation (OR=2.84, CI=1.31-6.19), and higher psychopathology (OR=1.09, CI=1.06-1.12). An unmet need was predicted by family not accompanying patients to treatment (OR=2.60, CI=1.05-6.44) and higher psychopathology (OR=1.05, CI=1.02-1.09).

LIMITATION

The use of a cross-sectional design and a single questionnaire domain to evaluate distress are the main limitations.

CONCLUSIONS

Subjective distress is a common unmet need in psychosis, and can be treated. The main clinical implication is that subjective distress in psychosis may be impacted on by family engagement and psychosocial interventions.

The Role of Interpersonal Connection, Personal Narrative, and Metacognition in Integrative Psychotherapy for Schizophrenia: A Case Report

The recovery movement has not only challenged traditional pessimism regarding schizophrenia but also presented opportunities for the possibilities for psychotherapy for people with the disorder. Though in the past psychotherapy models were often pitted against one another, recently there have been emergent reports of a range of integrative models sharing an emphasis on recovery and a number of conceptual elements. These shared elements include attention to the importance of interpersonal processes, personal narrative, and metacognition, with interest in their role in not only the disorder but also the processes by which people pursue recovery. This article explores one application of this framework in the psychotherapy of a woman with prolonged experience of schizophrenia and significant functional impairments.

The linguistics of schizophrenia: thought disturbance as language pathology across positive symptoms

We hypothesize that linguistic (dis-)organization in the schizophrenic brain plays a more central role in the pathogenesis of this disease than commonly supposed. Against the standard view, that schizophrenia is a disturbance of thought or selfhood, we argue that the origins of the relevant forms of thought and selfhood at least partially depend on language. The view that they do not is premised by a theoretical conception of language that we here identify as 'Cartesian' and contrast with a recent 'un-Cartesian' model. This linguistic model empirically argues for both (i) a one-to-one correlation between human-specific thought or meaning and forms of grammatical organization, and (ii) an integrative and co-dependent view of linguistic cognition and its sensory-motor dimensions. Core dimensions of meaning mediated by grammar on this model specifically concern forms of referential and propositional meaning. A breakdown of these is virtually definitional of core symptoms. Within this model the three main positive symptoms of schizophrenia fall into place as failures in language-mediated forms of meaning, manifest either as a disorder of speech perception (Auditory Verbal Hallucinations), abnormal speech production running without feedback control (Formal Thought Disorder), or production of abnormal linguistic content (Delusions). Our hypothesis makes testable predictions for the language profile of schizophrenia across symptoms; it simplifies the cognitive neuropsychology of schizophrenia while not being inconsistent with a pattern of neurocognitive deficits and their correlations with symptoms; and it predicts persistent findings on disturbances of language-related circuitry in the schizophrenic brain.

Stages of recovery in early psychosis: Associations with symptoms, function, and narrative development

OBJECTIVES

This study sought to explore the links between recovery stages, symptoms, function, and narrative development among individuals with a recent onset of psychosis.

DESIGN

A qualitative longitudinal study was conducted including quantitative data at baseline.

METHODS

Forty-seven participants were administered the Indiana Psychiatric Illness Interview three times over 9 months and content analysis was performed. Participants also completed the Social Functioning Scale, the Brief Psychiatric Rating Scale--Expanded, the California Verbal Learning Test, and the Trailing Making Test at baseline. Descriptive discriminant analysis was performed.

RESULTS

Results suggested that participants were mostly in the first two stages of recovery (moratorium, awareness) and that being in the awareness, rather than moratorium, stage was associated, to a different extent, with richer narrative development, better levels of psychosocial function, less negative and positive symptoms, and more years of education. Furthermore, recovery appeared to be a stable process over the assessment period.

CONCLUSIONS

Recovery is a complex concept including objective and subjective aspects. In the recovery path of persons recently diagnosed with psychosis, social engagement, narrative development, and occupational functioning seem to be particularly important aspects. This study is a first step, and future research is needed with larger and more diverse participant pools, and assessments conducted over longer periods of time.

PRACTITIONER POINTS

As greater level of social engagement was the most robust predictor of membership in the awareness versus moratorium stage, treatment of early psychosis should include interventions targeting social relations and social skills. As greater narrative development was the second most robust predictor, enhancing it via psychotherapy could be a pertinent clinical goal.

Consumer perspectives on the concept of recovery in schizophrenia: A systematic review

Subjective descriptions of recovery from schizophrenia may be different from clinical recovery measures. The aim of the review was to identify the consumer perspectives of recovery from schizophrenia. Twenty-five studies within the period of 2000-2013, including qualitative and quantitative studies were reviewed by using different search strategies. An integrated method was used and the findings were coded and related themes were identified under five areas, namely, process orientation, self orientation, family orientation, social orientation, and illness orientation. Recovery was considered as both process and outcome. Patient or client-based definitions of recovery mainly involved factors related to personal wellbeing and social inclusion, that were seemingly distant from the clinical recovery measures. Incorporating consumer descriptions of recovery in recovery oriented services can increase the outcome of the services.

Experiences of community-dwelling persons recovering from severe mental illness

This qualitative study explored experiences of recovery from severe mental illness based on semi-structured interviews with sixteen persons diagnosed with schizophrenia spectrum disorders using psychiatric rehabilitation facilities. The participants' transcripts revealed two major themes: (1) ongoing efforts to live better and (2) inconsistent self-acceptance as a person living with a mental illness. The participants were aware of their responsibility to live with integrity. They all had hopes and goals, were able to respond to social cues, and considered what they could do independently. They wanted to be recognized as people who adapted successfully in society while inconsistently perceiving themselves as either sick or healthy. It is necessary to examine approaches that support the identities of persons who have been treated for schizophrenia and allow them to live comfortable within their communities.

Is personal recovery in schizophrenia predicted by low cognitive insight?

Recovery is a widely discussed concept in the field of research, treatment, and public policy regarding serious mental illness, and mainly schizophrenia. Aim of our study was to assess the relationship between personal recovery and prediction variables, as psychopathology, neurocognition, clinical and cognitive insight, and social functioning in inpatients affected by schizophrenia, with a special interest on cognitive insight. We assessed 76 inpatients affected by schizophrenia at their hospital discharge. Instruments included the Beck Cognitive Insight Scale, the Insight Scale and the Recovery Assessment Scale to assess the cognitive and clinical insight, and personal recovery. The neurocognitive assessment was represented by a single factor score produced by a principal components analysis of a neurocognitive test battery. Social functioning was measured also. Low self-reflectiveness of cognitive insight represented the best predictors of personal recovery. The relationship between cognitive insight and recovery found in this study may contribute to develop tailored interventions, taking into account the personal sense of recovery, despite the psychopathological evaluation.

Anxious and avoidant attachment styles and indicators of recovery in schizophrenia: associations with self-esteem and hope

OBJECTIVES

Having an insecure attachment style in schizophrenia has been linked to treatment response and symptom severity in schizophrenia. This study sought to further examine whether attachment style is related to subjective indicators of recovery including hope and self-esteem, independent of symptom level and secondly, whether attachment style in schizophrenia differs from attachment style of persons facing adversity in the form of a prolonged non-psychiatric medical illness.

DESIGN

Participants were 52 men with schizophrenia, and 26 with HIV/AIDS who had no history of experiencing severe mental illness. These groups were compared in terms of their endorsement of attachment style.

METHODS

All participants were administered the Experiences in Close Relationships measure of adult attachment style. The schizophrenia group was also given the Rosenberg Self-Esteem Scale to assess self-esteem, the Beck Hopelessness Scale as a measure of hope, and the Positive and Negative Syndrome Scale, as an assessment of symptoms.

RESULTS

Avoidant attachment in the schizophrenia group was linked with higher levels of hopelessness while anxious attachment was linked to lower levels of self-esteem. The association between anxious attachment and self-esteem persisted after controlling for severity of positive, negative, and depressive symptoms in a stepwise multiple regression analyses. Compared to the HIV/AIDS group, participants with schizophrenia had significantly higher levels of anxious attachment but not avoidant attachment style.

CONCLUSIONS

Attachment style may impact attainment of key subjective domains of recovery in schizophrenia such as self-esteem, independent of symptom severity.

PRACTITIONER POINTS

If self-esteem and/or hopelessness are identified as a focus of treatment, focusing on attachment style may be an important treatment component. Therapist understanding of patients' attachment style may allow for a better understanding of resistance in the therapeutic relationship. Helping persons with schizophrenia to recognize and change how they tend to relate to others may promote gains in subjective elements of recovery.