Social disinterest attitudes and group cognitive-behavioral social skills training for functional disability in schizophrenia

Determinants of Disability Among Individuals Living with Schizophrenia Attending Psychiatric Follow-Up Clinic in Jimma, Southwest Ethiopia: An Institution-Based Case-Control Study

Background

Disability due to schizophrenia ends up with a higher degree of impairment in occupational, social and interpersonal functioning than other chronic illnesses. Despite severe and long-lasting schizophrenia associated disability, little has been explored so far to identify determinants of disability among individuals living with schizophrenia in Ethiopia.

Objective

To identify the determinants of disability among individuals living with schizophrenia attending the psychiatric follow-up clinic at Jimma Medical Center (JMC).

Methods

An institution-based unmatched case-control study was conducted among 98 Cases and 98 controls of individuals living with schizophrenia attending the JMC psychiatric clinic from September 1 to October 30, 2022. Consecutive sampling technique was used to recruit the required sample size of both groups. The cases group were participants who scored >12 total on the WHO Disability Assessment Scale version 2-0 (WHODAS 2-0) whereas the control group were those who scored 12 total on the WHODAS 2-0.

Results

Being jobless (AOR = 2.29; 95% CI: 1.10-4.77), longer than 5-year duration of illness without treatment (AOR = 3.13; 95% CI: 1.23-7.98), poor social support (AOR = 2.54; 95% CI: 1.04-6.22), negative symptoms (AOR = 2.45; 95% CI: 1.14-5.29), known family history of mental illness (AOR = 3.59; 95%: 1.67-7.73) and risky khat use (AOR = 4.37; 95% CI: 1.86-10.29) were found to be determinants of disability among schizophrenia patients.

Conclusion

Joblessness, longer than 5-year duration of illness without treatment, poor social support, negative symptoms, known family history of mental illness and risky khat use were found to be determinants of disability in schizophrenia patients. Interventions targeting reducing of disability and improving quality of life of schizophrenia patients should consider the aforementioned determinants.

The Effects of Remote Cognitive Training Combined With a Mobile App Intervention on Psychosis: Double-Blind Randomized Controlled Trial

BACKGROUND

Impairments in cognition and motivation are core features of psychosis and strong predictors of social and occupational functioning. Accumulating evidence indicates that cognitive deficits in psychosis can be improved by computer-based cognitive training programs; however, barriers include access and adherence to cognitive training exercises. Limited evidence-based methods have been established to enhance motivated behavior. In this study, we tested the effects of web-based targeted cognitive and social cognitive training (TCT) delivered in conjunction with an innovative digital smartphone app called Personalized Real-Time Intervention for Motivational Enhancement (PRIME). The PRIME app provides users with a motivational coach to set personalized goals and secure social networking for peer support.

OBJECTIVE

This study investigated whether deficits in cognition and motivation in people with a psychosis spectrum disorder (N=100) can be successfully addressed with 30 hours of TCT+PRIME as compared with 30 hours of a computer games control condition (CG) plus PRIME (CG+PRIME). Here, we describe our study procedures, the feasibility and acceptability of the intervention, and the results on all primary outcomes.

METHODS

In this double-blind randomized controlled trial, English-speaking participants completed all cognitive training, PRIME activities, and assessments remotely. Participants completed a diagnostic interview and remote cognitive, clinical, and self-report measures at baseline, posttraining, and at a 6-month follow-up.

RESULTS

This study included participants from 27 states across the United States and 8 countries worldwide. The study population was 58% (58/100) female, with a mean age of 33.77 (SD 10.70) years. On average, participants completed more than half of the cognitive training regimen (mean 18.58, SD 12.47 hours of training), and logged into the PRIME app 4.71 (SD 1.58) times per week. The attrition rate of 22% (22/100) was lower than that reported in our previous studies on remote cognitive training. The total sample showed significant gains in global cognition (P=.03) and attention (P<.001). The TCT+PRIME participants showed significantly greater gains in emotion recognition (P<.001) and global cognition at the trend level (P=.09), although this was not statistically significant, relative to the CG+PRIME participants. The total sample also showed significant improvements on multiple indices of motivation (P=.02-0.05), in depression (P=.04), in positive symptoms (P=.04), and in negative symptoms at a trend level (P=.09), although this was not statistically significant. Satisfaction with the PRIME app was rated at 7.74 (SD 2.05) on a scale of 1 to 10, with higher values indicating more satisfaction.

CONCLUSIONS

These results demonstrate the feasibility and acceptability of remote cognitive training combined with the PRIME app and that this intervention can improve cognition, motivation, and symptoms in individuals with psychosis. TCT+PRIME appeared more effective in improving emotion recognition and global cognition than CG+PRIME. Future analyses will test the relationship between hours of cognitive training completed; PRIME use; and changes in cognition, motivation, symptoms, and functioning.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02782442; https://clinicaltrials.gov/study/NCT02782442.

Mobile-Assisted Cognitive Behavioral Therapy for Negative Symptoms: Open Single-Arm Trial With Schizophrenia Patients

BACKGROUND

Negative symptoms are an important unmet treatment need for schizophrenia. This study is a preliminary, open, single-arm trial of a novel hybrid intervention called mobile-assisted cognitive behavioral therapy for negative symptoms (mCBTn).

OBJECTIVE

The primary aim was to test whether mCBTn was feasible and could reduce severity of the target mechanism, defeatist performance attitudes, which are associated with experiential negative symptoms and poor functioning in schizophrenia.

METHODS

Participants with schizophrenia or schizoaffective disorder (N=31) who met prospective criteria for persistent negative symptoms were enrolled. The blended intervention combines weekly in-person group therapy with a smartphone app called CBT2go. The app extended therapy group skills, including recovery goal setting, thought challenging, scheduling of pleasurable activities and social interactions, and pleasure-savoring interventions to modify defeatist attitudes and improve experiential negative symptoms.

RESULTS

Retention was excellent (87% at 18 weeks), and severity of defeatist attitudes and experiential negative symptoms declined significantly in the mCBTn intervention with large effect sizes.

CONCLUSIONS

The findings suggest that mCBTn is a feasible and potentially effective treatment for experiential negative symptoms, if confirmed in a larger randomized controlled trial. The findings also provide support for the defeatist attitude model of experiential negative symptoms and suggest that blended technology-supported interventions such as mCBTn can strengthen and shorten intensive psychosocial interventions for schizophrenia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03179696; https://clinicaltrials.gov/ct2/show/NCT03179696.

Loneliness and psychotic experiences in a general population sample

Increased loneliness has been associated with common mental disorders including psychotic disorders. However, as yet, little information is available on the association between loneliness and the occurrence of psychotic experiences (PEs), especially when adjusted for confounding factors. To address this deficit, the current study examined the relationship between PEs and loneliness in a general population sample in the United States (N = 974). We fitted three regression models to examine the associations between loneliness and PEs, using hierarchical adjustments for sociodemographic factors, adverse childhood experiences, and common mental disorders. Even at the highest level of adjustment, loneliness was significantly associated with increased odds for any PEs (OR = 1.25, 95% CI = 1.13-1.39). The same applied to the association between loneliness and delusional mood (OR = 1.29, 95% CI = 1.15-1.44). For delusion of reference and persecution, delusions of control, and hallucinations, there were no significant associations when adjusted for sociodemographic factors, adverse childhood experiences, and common mental disorders. These results suggest that increased loneliness is associated with PEs, particularly delusional mood. Future studies should employ longitudinal data and biological measures to examine potential causal relationships and underlying mechanisms.

[Problems in assessment of the effectiveness of psychosocial rehabilitation and treatment: area of psychosocial interventions, tools and evaluation criteria]

The literature review addresses the problems arising in assessing the effectiveness of psychosocial rehabilitation, selection of evaluation criteria and methodical tools most often used for this purpose. It is shown that for an objective assessment of the results of rehabilitation it is necessary to take into account the hierarchical structure of both the problems of evaluation and the information to be processed. This information includes both quantitative indicators (age, duration of disease, frequency of hospitalizations, results of biological study) and non-numerical (rank) indicators (severity of psychopathological symptoms, characteristics of compliance, social behavior and patient's environment). The proposed approach to assessing the results of rehabilitation of mental patients involves the development of specific criteria for the effectiveness of rehabilitation based on a multidimensional, hierarchical consideration of mental pathology with the inclusion of clinical and psychopathological, socio-environmental and personal indicators of patients in setting goals and objectives of rehabilitation.

Neurocognitive and theory of mind deficits and poor social competence in schizophrenia: The moderating role of social disinterest attitudes

Neurocognitive and theory of mind deficits, dysfunctional attitudes, and negative symptoms have all been linked to poor functioning in schizophrenia, but interactions among these factors have not been extensively examined. We investigated whether dysfunctional attitudes (e.g., defeatist performance beliefs and social disinterest attitudes) moderated associations between neurocognition and theory of mind and poor everyday functioning and social competence in 146 participants with schizophrenia. We examined whether cognitive deficits are more likely to influence functioning in participants with more severe dysfunctional attitudes. Social disinterest, but not defeatist performance, attitudes were found to moderate associations between cognitive deficits and social competence but not everyday functioning, such that neurocognition and theory of mind deficits were only associated with poorer social competence in participants with more severe social disinterest attitudes. In contrast, no significant moderation effects were found for defeatist performance beliefs. Findings indicate that deficits in abilities were less likely to impact social competence in participants with greater interest in socializing. It may be that greater motivation for socializing engenders increased practice and engagement in social interactions, which then leads to greater social competence despite poor cognitive abilities. Treatments that target social disinterest attitudes may lead to greater social competence and engagement.

Evidence for Interventions to Improve and Maintain Occupational Performance and Participation for People With Serious Mental Illness: A Systematic Review

OBJECTIVE

This systematic review evaluates the evidence for the effectiveness of interventions within the scope of occupational therapy to improve and maintain performance and participation for people with serious mental illness. Areas included in this review are activities of daily living, instrumental activities of daily living, leisure, social participation, and rest and sleep.

METHOD

Databases searched included MEDLINE, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews. Reviewers read and assessed citations, abstracts, and full-text articles for inclusion and analysis.

RESULTS

Sixty-one articles were selected for inclusion. The review yielded strong evidence for psychoeducation and occupation- and cognitive-based interventions, moderate evidence for skills-based interventions, and limited evidence for technology-supported interventions.

CONCLUSION

Results of this review support use of evidence-based practice within the scope of occupational therapy, inclusion of occupational therapy practitioners as mental health service providers, and continued research.

Social motivation in schizophrenia: How research on basic reward processes informs and limits our understanding

Limited quantity and quality of interpersonal exchanges and relationships predict worse symptomatic and hospitalization outcomes and limit functional recovery in people with schizophrenia. While deficits in social skills and social cognition contribute to much of the impairment in social functioning in schizophrenia, our focus on the current review is social motivation-the drive to connect with others and form meaningful, lasting relationships. We pay particular attention to how recent research on reward informs, and limits, our understanding of the construct. Recent findings that parse out key components of human motivation, especially the temporal nature of reward and effort, are informative for understanding some aspects of social motivation. This approach, however, fails to fully integrate the critical influence of uncertainty and punishment (e.g., avoidance, threat) in social motivation. In the current review, we argue for the importance of experimental paradigms and real-time measurement to capture the interaction between social approach and avoidance in characterizing social affiliation in schizophrenia. We end with suggestions for how researchers might move the field forward by emphasizing the ecological validity of social motivation paradigms, including dynamic, momentary assessment of social reward and punishment using mobile technology and other innovative tools.

Development of novel behavioral interventions in an experimental therapeutics world: Challenges, and directions for the future

Recently, the focus of funding mechanisms associated with clinical trials has changed to be consistent with an experimental therapeutics approach. While this approach holds considerable promise, the paradigm shift has presented challenges for behavioral trials in complex psychiatric illness such as schizophrenia, as molecular targets - the classic focus in experimental therapeutics paradigms - may not represent logical targets for many psychosocial interventions designed to treat multifaceted, multiply determined symptoms. Clear guidelines for alternate models have not been offered, leaving large numbers of clinical trials researchers unclear about how to frame their work. We address some of the challenges for behavioral interventions research, and offer guidance for the development of novel approaches to the application of a target engagement framework to behavioral clinical trials.

Effects of the Indianapolis Vocational Intervention Program (IVIP) on defeatist beliefs, work motivation, and work outcomes in serious mental illness

Defeatist beliefs and amotivation are prominent obstacles in vocational rehabilitation for people with serious mental illnesses (SMI). The CBT-based Indianapolis Vocational Intervention Program (IVIP) was specifically designed to reduce defeatist beliefs related to work functioning. In the current study, we examined the impact of IVIP on defeatist beliefs and motivation for work, hypothesizing that IVIP would be associated with a reduction in defeatist beliefs and greater motivation for work. We also examined the effects of IVIP on these variables as well as work outcomes during a 12-month follow-up. Participants with SMI (n=64) enrolled in a four-month work therapy program were randomized to IVIP or a support therapy group (SG). Assessments were conducted at baseline, post-treatment (4months), and follow-up (1year). Compared to those in SG condition, individuals randomized to IVIP condition reported greater reductions in defeatist beliefs and greater motivation for work at follow-up, along with greater supported employment retention rates. Specifically treating and targeting negative expectations for work therapy improves outcomes, even once active supports of the IVIP program and work therapy are withdrawn.

From neurocognition to community participation in serious mental illness: the intermediary role of dysfunctional attitudes and motivation

BACKGROUND

Evidence for a relationship between neurocognition and functional outcome in important areas of community living is robust in serious mental illness research. Dysfunctional attitudes (defeatist performance beliefs and asocial beliefs) have been identified as intervening variables in this causal chain. This study seeks to expand upon previous research by longitudinally testing the link between neurocognition and community participation (i.e. time in community-based activity) through dysfunctional attitudes and motivation.

METHOD

Adult outpatients with serious mental illness (N = 175) participated, completing follow-up assessments approximately 6 months after initial assessment. Path analysis tested relationships between baseline neurocognition, emotion perception, functional skills, dysfunctional attitudes, motivation, and outcome (i.e. community participation) at baseline and follow-up.

RESULTS

Path models demonstrated two pathways to community participation. The first linked neurocognition and community participation through functional skills, defeatist performance beliefs, and motivation. A second pathway linked asocial beliefs and community participation, via a direct path passing through motivation. Model fit was excellent for models predicting overall community participation at baseline and, importantly, at follow-up.

CONCLUSIONS

The existence of multiple pathways to community participation in a longitudinal model supports the utility of multi-modal interventions for serious mental illness (i.e. treatment packages that build upon individuals' strengths while addressing the array of obstacles to recovery) that feature dysfunctional attitudes and motivation as treatment targets.

Rehabilitation Interventions to Promote Recovery from Schizophrenia: A Systematic Review

Only one out of seven patients recovers after a first episode of psychosis despite psychiatric care. Rehabilitation interventions have been developed to improve functional outcomes and to promote recovery. We conducted a systematic review of the effectiveness of the main psychiatric rehabilitation interventions following a search of the electronic databases Pubmed, ScienceDirect, and Google Scholar using combinations of terms relating to cognitive remediation, psychoeducation, cognitive-behavioral therapies, and schizophrenia. Eighty articles relevant to the topic of interest were found. According to results, cognitive remediation has been found to be effective in reducing the impact of cognitive impairment, social skills in the learning a variety of skills and to a lesser extent in reducing negative symptoms, psychoeducation in improving compliance and reducing relapses, and cognitive therapy in reducing the intensity of or distress related to positive symptoms. All psychosocial rehabilitation interventions should be considered as evidence-based practices for schizophrenia and need to become a major part of the standard treatment of the disease.

Development of a group and family-based cognitive behavioural therapy program for youth at risk for psychosis

OBJECTIVE

The onset of psychosis typically occurs during adolescence or early adulthood and can have a detrimental impact on social and cognitive development. Cognitive behavioural therapy (CBT) shows promise in reducing the risk of psychosis. Teaching families to apply CBT with their offspring may bolster therapeutic gains made in time-limited treatment. We developed a comprehensive group-and-family-based CBT (GF-CBT) program that aims to facilitate psychosocial recovery, decrease symptoms and prevent transition to psychosis in youth at risk. GF-CBT is grounded in ecological systems and cognitive theories, resilience models and research on information processing in delusions. The theoretical rationale and description of GF-CBT are presented together with a pilot study that evaluated the program's feasibility and explored participants' outcomes.

METHODS

Youth ages 16-21 at risk for psychosis and their families participated in an open trial with pre, post and 3-month follow-up assessments conducted by an independent evaluator. The Comprehensive Assessment of At-Risk Mental States was the primary clinical outcome measure.

RESULTS

All enrolled participants (n = 6) completed GF-CBT and all remitted from at-risk mental state (ARMS). As a group participants showed statistically significant decreases in attenuated psychotic symptoms, negative symptoms, depression, cognitive biases and improvements in functioning. Family members showed significant improvements in use of CBT skills, enhanced communication with their offspring, and greater confidence in their ability to help. Gains were maintained at follow-up.

CONCLUSIONS

GF-CBT may delay or prevent transition to psychosis in youth at risk, and potentially facilitate recovery from ARMS. More rigorous, controlled research is needed to further evaluate this program.

Pupillary Responses as a Biomarker of Diminished Effort Associated With Defeatist Attitudes and Negative Symptoms in Schizophrenia

BACKGROUND

The hypothesis that defeatist performance attitudes are associated with decreased goal-directed task effort and negative symptoms in consumers with schizophrenia was investigated by using pupillary responses as a biomarker of task effort. Pupillary dilation during cognitive tasks provides a biomarker of effort devoted to the task, with greater dilation indicating greater effort.

METHODS

Defeatist attitudes were assessed in 149 consumers with schizophrenia or schizoaffective disorder and 50 healthy control subjects, and consumers were divided into three groups (tertile split) with respect to severity of defeatist attitudes. Pupillary dilation responses were recorded during a digit-span task with three-, six-, and nine-digit spans.

RESULTS

Effort allocation (pupillary responses) to the task increased as the processing load increased from low (three-digit) to moderate (six-digit) demands in healthy control subjects and consumers with schizophrenia with mild and moderate severity of defeatist attitudes. In contrast, consumers with severe defeatist attitudes did not increase their effort when processing demands increased from low to moderate loads. These consumers showed significantly less effort in the six-digit condition relative to consumers with mild defeatist attitudes. Moreover, consumers with severe defeatist attitudes showed significantly greater severity of negative symptoms relative to consumers with mild defeatist attitudes and negative symptoms were significantly correlated with defeatist attitudes.

CONCLUSIONS

These results suggest a relationship between defeatist performance attitudes, goal-directed task effort indexed by pupillary responses, and negative symptoms in schizophrenia. The findings have implications for using cognitive therapy to reduce defeatist attitudes that may contribute to diminished effort and negative symptoms in schizophrenia.

Addressing defeatist beliefs in work rehabilitation

BACKGROUND

Adults with serious mental illness (SMI) may struggle with expectations of failure in vocational rehabilitation. These expectations can be global and trait-like or performance-specific and related to ability.

AIMS

To date, it has not been examined whether global or performance-specific defeatist beliefs are related to functional outcomes.

METHOD

The Indianapolis Vocational Intervention Program (IVIP) is a CBT intervention used to address expectations of failure and improve work performance. We examined the relationships between defeatist beliefs, self-esteem, social functioning, and work behaviors in 54 adults with SMI who completed IVIP within a work therapy program.

RESULTS

Baseline work-specific defeatist beliefs were related to baseline self-esteem, employment attitude, and work behaviors. Decline in work-specific defeatist beliefs was associated with better social functioning, self-esteem, and work behaviors. Decline in global defeatist beliefs was only associated with improvements in social functioning.

CONCLUSIONS

Performance-specific expectations about work may be an appropriate therapeutic target to enhance work outcome in SMI.

A structural equation modelling approach to explore the determinants of quality of life in schizophrenia

OBJECTIVE

This study aimed to analyse the relationships among psychotic symptoms, depression, neurocognition and functioning as determinants of quality of life (QoL) in patients with schizophrenia.

METHODS

In this cross-sectional study, we evaluated QoL with the Schizophrenia Quality of Life 18-item scale (S-QoL 18), neurocognition with multiple tests exploring memory, attention and executive functions, the severity of psychotic symptoms with the Positive and Negative Syndrome Scale (PANSS), depression with the Calgary Depression Scale for Schizophrenia (CDSS) and functioning using the Functional Remission Of General Schizophrenia (FROGS) scale. We used Structural Equation Modelling (SEM) to describe the relationships among the severity of psychotic symptoms, depression, neurocognition, functioning and QoL.

RESULTS

Two hundred and seventy-one outpatients with schizophrenia participated in our study. SEM showed good fit with χ(2)/df=1.97, root mean square error of approximation=0.06, comparative fit index=0.93 and standardized root mean square residuals=0.05. This model revealed that depression was the most important feature associated with QoL, mainly for the self-esteem, autonomy and resilience dimensions (direct path coefficient=-0.46). The direct path between functioning and QoL was also significant (path coefficient=0.26). The severity of psychotic symptoms and neurocognitive impairment were weakly and indirectly associated with QoL via functioning (path coefficients=-0.18 and 0.04, respectively).

CONCLUSIONS

This study contributes to a better understanding of the determinants of QoL in schizophrenia. Our findings should be considered in developing effective strategies for improving QoL among this population.

Psychodynamically Oriented Supportive Group Therapy With Psychotic Patients

This pilot study investigates the contribution of supportive psychodynamically oriented group psychotherapy to the clinical characteristics and functioning of psychotic patients. After a year of group psychotherapy using an intermediary object, the drawings of a number of psychotic patients were inspected separately so as to ascertain the improvement of psychopathological elements depicted. Two groups of 38 patients each, with similar psychopathology, clinical and demographic data were assessed before and after 1 year. One group participated in group psychotherapy, with or without an intermediary object; the other group received standard care. The study demonstrated improvement in functioning, quality of life, positive/negative symptoms, and relapses of hospitalizations for patients participating in group psychotherapy. Moreover, elements that indicate psychopathology declined in the drawings of the group in therapy with an intermediary object. Psychodynamically oriented group psychotherapy, with or without an intermediary object, could be an additional treatment option for psychotic patients.

Conceptualization and treatment of negative symptoms in schizophrenia

Negative symptoms of schizophrenia including social withdrawal, diminished affective response, lack of interest, poor social drive, and decreased sense of purpose or goal directed activity predict poor functional outcomes for patients with schizophrenia. They may develop and be maintained as a result of structural and functional brain abnormalities, particularly associated with dopamine reward pathways and by environmental and psychosocial factors such as self-defeating cognitions and the relief from overstimulation that accompanies withdrawal from social and role functioning. Negative symptoms are more difficult to treat than the positive symptoms of schizophrenia and represent an unmet therapeutic need for large numbers of patients with schizophrenia. While antipsychotic medications to treat the symptoms of schizophrenia have been around for decades, they have done little to address the significant functional impairments in the disorder that are associated with negative symptoms. Negative symptoms and the resulting loss in productivity are responsible for much of the world-wide personal and economic burden of schizophrenia. Pharmacologic treatments may be somewhat successful in treating secondary causes of negative symptoms, such as antipsychotic side effects and depression. However, in the United States there are no currently approved treatments for severe and persistent negative symptoms (PNS) that are not responsive to treatments for secondary causes. Pharmacotherapy and psychosocial treatments are currently being developed and tested with severe and PNS as their primary targets. Academia, clinicians, the pharmaceutical industry, research funders, payers and regulators will need to work together to pursue novel treatments to address this major public health issue.

A randomized pilot study of MOtiVation and Enhancement (MOVE) Training for negative symptoms in schizophrenia

INTRODUCTION

Among individuals with schizophrenia, those who have persistent and clinically significant negative symptoms (PNS) have the poorest functional outcomes and quality of life. The NIMH-MATRICS Consensus Statement indicated that these symptoms represent an unmet therapeutic need for large numbers of individuals with schizophrenia. No psychosocial treatment model addresses the entire constellation of PNS.

METHOD

51 patients with PNS were randomized into one of two groups for a period of 9 months: 1) MOtiVation and Enhancement (MOVE) or 2) treatment as usual. MOVE is a home based, manual-driven, multi-modal treatment that employs a number of cognitive and behavioral principles to address the broad range of factors contributing to PNS and their functional consequences. The components of MOVE include: Environmental supports to prompt initiation and persistence, in-vivo skills training to ameliorate deficits and encourage interaction, cognitive behavioral techniques to address self-defeating attitudes, in-vivo training in emotional processing to address affective blunting and problems in identifying emotions, and specific techniques to address the deficits in anticipatory pleasure. Patients were assessed at baseline and each 3 months with multiple measures of negative symptoms.

RESULTS

Repeated measures analyses of variance for mixed models indicated significant Group by Time effects for the Negative Symptom Assessment (NSA; p<.02) and the Clinical Assessment Interview for Negative Symptoms (CAINS; p<.04). Group differences were not significant until 9 months of treatment and were not significant for the Brief Negative Symptom Scale (BNSS).

CONCLUSION

Further investigation of a comprehensive treatment for PNS, such as MOVE, is warranted.

Sources of clinical distress in young people at ultra high risk of psychosis

BACKGROUND

Substantial controversy has been generated since the proposal to include "Attenuated Psychosis Syndrome" in DSM-5, based on research criteria used to identify young people at "ultra high risk" (UHR) for psychosis. The syndrome was ultimately included in the section for further research. The criteria specified that the person experienced attenuated psychotic symptoms (APS) that were sufficiently distressing to warrant clinical attention. Although APS are the main means of determining whether a person meets UHR criteria, clinical experience suggests that such symptoms are often not the main source of clinical distress in this patient group. However, little is known about the sources of distress in the UHR group. We aimed to assess the main sources of clinical distress in UHR patients at the time of referral to a specialized UHR clinic.

METHOD

Sources and intensity of distress in 73 UHR patients were gathered from treating clinicians. The association with transition to psychosis was explored.

RESULTS

Of the total sample, 89.04% fulfilled the APS UHR criteria. APS symptoms were reported to be distressing for 58.5% of this subsample, but social and functioning difficulties (78.1%) and depressive symptoms (58.9%) were the highest sources of distress leading UHR patients to seek help. Intensity of distress associated with APS, anxiety symptoms and substance use was associated with transition to psychosis.

CONCLUSIONS

APS were reported to be distressing for approximately half of UHR patients. The intensity of distress associated to these symptoms may be associated with increased risk for subsequent transition to full threshold psychotic disorder.

Adapted cognitive-behavioural therapy required for targeting negative symptoms in schizophrenia: meta-analysis and meta-regression

BACKGROUND

There is an increasing interest in cognitive-behavioural therapy (CBT) interventions targeting negative symptoms in schizophrenia. To date, CBT trials primarily focused on positive symptoms and investigated change in negative symptoms only as a secondary outcome. To enhance insight into factors contributing to improvement of negative symptoms, and to identify subgroups of patients that may benefit most from CBT directed at ameliorating negative symptoms, we reviewed all available evidence on these outcomes.

METHOD

A systematic search of the literature was conducted in PsychInfo, PubMed and the Cochrane register to identify randomized controlled trials reporting on the impact of CBT interventions on negative symptoms in schizophrenia. Random-effects meta-analyses were performed on end-of-treatment, short-term and long-term changes in negative symptoms.

RESULTS

A total of 35 publications covering 30 trials in 2312 patients, published between 1993 and 2013, were included. Our results showed studies' pooled effect on symptom alleviation to be small [Hedges' g = 0.093, 95% confidence interval (CI) -0.028 to 0.214, p = 0.130] and heterogeneous (Q = 73.067, degrees of freedom = 29, p < 0.001, τ 2 = 0.081, I 2 = 60.31) in studies with negative symptoms as a secondary outcome. Similar results were found for studies focused on negative symptom reduction (Hedges' g = 0.157, 95% CI -0.10 to 0.409, p = 0.225). Meta-regression revealed that stronger treatment effects were associated with earlier year of publication, lower study quality and with CBT provided individually (as compared with group-based).

CONCLUSIONS

The co-occurring beneficial effect of conventional CBT on negative symptoms found in older studies was not supported by more recent studies. It is now necessary to further disentangle effective treatment ingredients of older studies in order to guide the development of future CBT interventions aimed at negative symptom reduction.

[Evidence-based interventions in psychiatric rehabilitation: which ones should we prioritized and why?]

OBJECTIVE

This critical literature review describes current evidence-based psychiatric rehabilitation interventions.

METHOD

A brief description of recent meta-analyses and (or) literature reviews is presented for each targeted intervention, along with their revelance for psychiatric rehabilitation and their limits.

RESULTS

The interventions presented include: family interventions, cognitive-behavioural therapy for psychosis, social skills training, cognitive remediation, integrated treatment for substance misuse and mental disorders, and supported employment programs.

CONCLUSIONS

The psychiatric rehabilitation interventions presented in this article not only are based on empirical evidence but also offer clinical tools support the recovery of people with a severe mental illness.

A virtual reality-integrated program for improving social skills in patients with schizophrenia: a pilot study

BACKGROUND AND OBJECTIVES

Social skills training (SST) intervention has shown its efficacy to improve social dysfunction in patients with psychosis; however the implementation of new skills into patients' everyday functioning is difficult to achieve. In this study, we report results from the application of a virtual reality (VR) integrated program as an adjunct technique to a brief social skills intervention for patients with schizophrenia. It was predicted that the intervention would improve social cognition and performance of patients as well as generalisation of the learned responses into patient's daily life.

METHODS

Twelve patients with schizophrenia or schizoaffective disorder completed the study. They attended sixteen individual one-hour sessions, and outcome assessments were conducted at pre-treatment, post-treatment and four-month follow-up.

RESULTS

The results of a series of repeated measures ANOVA revealed significant improvement in negative symptoms, psychopathology, social anxiety and discomfort, avoidance and social functioning. Objective scores obtained through the use of the VR program showed a pattern of learning in emotion perception, assertive behaviours and time spent in a conversation. Most of these gains were maintained at four-month follow-up.

LIMITATIONS

The reported results are based on a small, uncontrolled pilot study. Although there was an independent rater for the self-reported and informant questionnaires, assessments were not blinded.

CONCLUSIONS

The results showed that the intervention may be effective for improving social dysfunction. The use of the VR program contributed to the generalisation of new skills into the patient's everyday functioning.

Domain-specific hedonic deficits towards social affective but not monetary incentives in social anhedonia

Anticipatory and consummatory dissociation of hedonic experience may manifest as anhedonia in schizophrenia. However, it is unclear if this temporal dissociation of pleasure experience is also relevant in other symptoms like social anhedonia in the schizophrenia disorder spectrum. The present study applied two incentive delay tasks involving different incentive types (money vs. social affective images) to a sample of 28 participants with elevated social anhedonia (SocAnh) and 38 healthy controls from a population of 476 college students. The results showed that the SocAnh group had comparable anticipatory sensitivity and consummatory pleasure towards monetary incentives as the controls; but they exhibited significant decrease in both anticipatory sensitivity and consummatory experience to positive social affective images. These findings demonstrate the presence of a domain-specific deficit in people with social anhedonia towards social affective information, and suggest that incentive types could confound the findings on the dissociation of anticipatory vs. consummatory hedonic capacities.

The neural basis of theory of mind and its relationship to social functioning and social anhedonia in individuals with schizophrenia

Theory of mind (ToM), the ability to attribute and reason about the mental states of others, is a strong determinant of social functioning among individuals with schizophrenia. Identifying the neural bases of ToM and their relationship to social functioning may elucidate functionally relevant neurobiological targets for intervention. ToM ability may additionally account for other social phenomena that affect social functioning, such as social anhedonia (SocAnh). Given recent research in schizophrenia demonstrating improved neural functioning in response to increased use of cognitive skills, it is possible that SocAnh, which decreases one's opportunity to engage in ToM, could compromise social functioning through its deleterious effect on ToM-related neural circuitry. Here, twenty individuals with schizophrenia and 18 healthy controls underwent fMRI while performing the False-Belief Task. Aspects of social functioning were assessed using multiple methods including self-report (Interpersonal Reactivity Index, Social Adjustment Scale), clinician-ratings (Global Functioning Social Scale), and performance-based tasks (MSCEIT—Managing Emotions). SocAnh was measured with the Revised Social Anhedonia Scale. Region-of-interest and whole-brain analyses revealed reduced recruitment of medial prefrontal cortex (MPFC) for ToM in individuals with schizophrenia. Across all participants, activity in this region correlated with most social variables. Mediation analysis revealed that neural activity for ToM in MPFC accounted for the relationship between SocAnh and social functioning. These findings demonstrate that reduced recruitment of MPFC for ToM is an important neurobiological determinant of social functioning. Furthermore, SocAhn may affect social functioning through its impact on ToM-related neural circuitry. Together, these findings suggest ToM ability as an important locus for intervention.

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Individuals with schizophrenia exhibited reduced recruitment of MPFC for ToM.

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MPFC and RTPJ activities correlate with measures of social functioning and ability.

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MPFC activity mediates the relationship between social anhedonia and functioning.

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Neural circuitry supporting ToM may represent an important area for remediation.

The prevalence of substance use disorders and psychiatric disorders as a function of psychotic symptoms

BACKGROUND

Psychotic symptoms represent one of the most severe and functionally impairing components of several psychological disorders. One group with particularly high rates of psychotic symptoms is chronic substance users. However, the literature on psychotic symptoms and substance use is quite narrow and has focused almost exclusively on drug-induced psychosis, neglecting the population of substance users with psychotic symptoms occurring independently of acute drug effects.

METHOD

The current study examined demographics, substance dependence, and psychiatric comorbidities among substance users with current (CurrSx), past (PastSx), and no psychotic symptoms (NoSx). Patients (n=685) were sequential admissions to a residential substance use treatment center from 2006 to 2009.

RESULTS

Compared to NoSx, those who endorsed CurrSx were significantly more likely to meet criteria for lifetime alcohol dependence and lifetime amphetamine dependence. CurrSx were more likely than PastSx to meet for lifetime cannabis dependence. Additionally, CurrSx were more likely to meet criteria for a comorbid psychiatric disorder compared to NoSx, and evidenced a greater number of current psychiatric disorders. NoSx were less likely than both CurrSx and PastSx to meet criteria for Borderline Personality Disorder.

CONCLUSION

Individuals with non-substance induced psychotic symptoms appear to meet criteria for specific substance use disorders and psychiatric disorders at higher rates than those without psychotic symptoms; these effects were most evident for those with current as opposed to past symptoms. Findings suggest that these individuals may need specialized care to address potential psychiatric comorbidities and overall greater severity levels relative to substance users without psychotic symptoms.

Ecological Momentary Assessment of social functioning in schizophrenia: impact of performance appraisals and affect on social interactions

Research concerning the complex interplay between factors that contribute to poor social functioning in schizophrenia has been hampered by limitations of traditional measures, most notably the ecological validity and accuracy of retrospective self-report and interview measures. Computerized Ecological Momentary Assessment (EMAc) permits the real-time assessment of relationships between daily life experiences, thoughts, feelings, and behaviors. In the current study, EMAc was used to record daily social interactions, subjective performance appraisals of these interactions (e.g., "I succeeded/failed"; "I was liked/rejected"), and affect in 145 individuals with schizophrenia or schizoaffective disorder. Participants completed electronic questionnaires on a personal digital assistant (PDA) four times per day for one week. Time-lagged multilevel modeling of the data revealed that more positive interaction appraisals at any point in a day were associated with greater positive affect which, in turn, was a strong predictor of more social interactions over subsequent hours. Social functioning, therefore, was linked to positive performance beliefs about social interactions that were associated with greater positive affect. The findings suggest a useful treatment target for cognitive behavioral therapy and other psychosocial interventions that can be used to challenge defeatist beliefs and increase positive affect to enhance social functioning in schizophrenia.

Cognitive rehabilitation therapies for Alzheimer's disease: a review of methods to improve treatment engagement and self-efficacy

Cognitive rehabilitation therapies for Alzheimer's disease (AD) are becoming more readily available to the geriatric population in an attempt to curb the insidious decline in cognitive and functional performance. However, people with AD may have difficulty adhering to these cognitive treatments due to denial of memory deficits, compromised brain systems, cognitive incapacity for self-awareness, general difficulty following through on daily tasks, lack of motivation, hopelessness, and apathy, all of which may be either due to the illness or be secondary to depression. Cognitive rehabilitation training exercises are also labor intensive and, unfortunately, serve as a repeated reminder about the memory impairments and attendant functional consequences. In order for cognitive rehabilitation methods to be effective, patients must be adequately engaged and motivated to not only begin a rehabilitation program but also to remain involved in the intervention until a therapeutic dosage can be attained. We review approaches to cognitive rehabilitation in AD, neuropsychological as well as psychological obstacles to effective treatment in this population, and methods that target adherence to treatment and may therefore be applicable to cognitive rehabilitation therapies for AD. The goal is to stimulate discussion among researchers and clinicians alike on how treatment effects may be mediated by engagement in treatment, and what can be done to enhance patient adherence for cognitive rehabilitation therapies in order to obtain greater cognitive and functional benefits from the treatment itself.

From perception to functional outcome in schizophrenia: modeling the role of ability and motivation

CONTEXT Schizophrenia remains a highly disabling disorder, but the specific determinants and pathways that lead to functional impairment are not well understood. It is not known whether these key determinants of outcome lie on 1 or multiple pathways. OBJECTIVE To evaluate theoretically based models of pathways to functional outcome starting with early visual perception. The intervening variables were previously established determinants of outcome drawn from 2 general categories: ability (ie, social cognition and functional capacity) and beliefs/motivation (ie, defeatist beliefs, expressive and experiential negative symptoms). We evaluated an integrative model in which these intervening variables formed a single pathway to poor outcome. DESIGN This was a cross-sectional study that applied structural equation modeling to evaluate the relationships among determinants of functional outcome in schizophrenia. SETTING Assessments were conducted at a Veterans Administration Medical Center. PARTICIPANTS One hundred ninety-one clinically stable outpatients with schizophrenia or schizoaffective disorder were recruited from the community. RESULTS A measurement model showed that the latent variables of perception, social cognition, and functional outcome were well reflected by their indicators. An initial untrimmed structural model with functional capacity, defeatist beliefs, and expressive and experiential negative symptoms had good model fit. A final trimmed model was a single path running from perception to ability to motivational variables to outcome. It was more parsimonious and had better fit indices than the untrimmed model. Further, it could not be improved by adding or dropping connections that would change the single path to multiple paths. The indirect effect from perception to outcome was significant. CONCLUSIONS The final structural model was a single pathway running from perception to ability to beliefs/motivation to outcome. Hence, both ability and motivation appear to be needed for community functioning and can be modeled effectively on the same pathway.

A brief cognitive-behavioural social skills training for stabilised outpatients with schizophrenia: a preliminary study

Achieving social functioning and achieving social competence are two main objectives of psychosocial interventions for people suffering from schizophrenia. The present preliminary study presents a novel approach of social skills training (SST) based on the proposals of Kopelowicz et al. (Kopelowicz, A., Liberman, R. P., and Zarate, R., 2006. Schizophr. Bull. 32 (1): S12-23) that link the treatment to seven specific target behaviours: social perception, social information processing, responding and sending skills, affiliative skills, interactional skills, and behaviour governed by social norms. Thirty-one stabilised outpatients were randomly assigned to one of two groups, SST (n=13) or treatment-as-usual (n=18) (TAU; case management, medication adherence, psychotherapy, leisure engagement, and family support) and were assessed at baseline in cognitive performance, clinical symptomatology, social cognition, and psychosocial functioning. These outcomes were evaluated across post-treatment and at the 6-month follow-up appointment. SST subjects showed improvements in psychopathology, social discomfort, social cognition (self-regulation statements during interactions), social withdrawal, interpersonal communication, and quality of life compared with the TAU group. At the 6-month follow-up, results were maintained for negative symptoms, social discomfort, and some functioning outcomes. Neuropsychological variables were also examined, as mediators of benefit from skills training. Results support the efficacy of the brief SST for outpatients with schizophrenia and show the need to implement empirically supported interventions in mental health services to enhance patients' social functioning and quality of life.

Psychosocial treatments for schizophrenia

The current state of the literature regarding psychosocial treatments for schizophrenia is reviewed within the frameworks of the recovery model of mental health and the expanded stress-vulnerability model. Interventions targeting specific domains of functioning, age groups, stages of illness, and human service system gaps are classified as evidence-based practices or promising practices according to the extent to which their efficacy is currently supported by meta-analyses and individual randomized controlled trials (RCTs). Evidence-based practices include assertive community treatment (ACT), cognitive behavior therapy (CBT) for psychosis, cognitive remediation, family psychoeducation, illness self-management training, social skills training, and supported employment. Promising practices include cognitive adaptive therapy, CBT for posttraumatic stress disorder, first-episode psychosis intervention, healthy lifestyle interventions, integrated treatment for co-occurring disorders, interventions targeting older individuals, peer support services, physical disease management, prodromal stage intervention, social cognition training, supported education, and supported housing. Implications and future directions are discussed.

Cognitive-behavioral therapy for schizophrenia: a critical evaluation of its theoretical framework from a clinical-phenomenological perspective

BACKGROUND

Cognitive-behavioral therapy (CBT) has played an increasingly important role in psychotherapy for schizophrenia since the 1990s, but it has also encountered many theoretical and practical limitations. For example, methodologically rigorous meta-analyses have recently found only modest overall effect sizes of CBT treatment, and therefore questions have emerged about forwhat and for whom it actually works.

METHOD

The focus of the present paper is to elucidate the theoretical assumptions underlying CBT for schizophrenia and to examine their consistency with abnormalities of experience and self-awareness frequently reported by schizophrenia patients and systematically studied in phenomenological psychopathology from the beginning of the 20th century.

RESULTS

We argue that a strong theoretical emphasis on cognitive appraisals with only subsidiary attention devoted to affective and behavioral processes - as is characteristic of many forms of CBT - cannot satisfactorily account for the complex subjective experiences of schizophrenia patients. We further argue that certain theoretical strategies widely employed in CBT to explore and explain mental disorders, which involve atomization and, at times, a reification of mental phenomena, can be problematic and may result in a loss of explanatory potential. Finally, we provide a detailed account of how negative symptoms and delusions are conceptualized in CBT and consider the question of how these concepts fit the actual phenomenology of schizophrenia.

CONCLUSION

We suggest that further advancement of CBT theory and practice can benefit from a dialogue with phenomenological psychiatry in the search for effective psychotherapeutic strategies for schizophrenia patients.

Utility of the World Health Organization Disability Assessment Schedule II in schizophrenia

AIM

The World Health Organization Disability Assessment Schedule II (WHODAS II) was developed for assessing disability. This study provides data on the validity and utility of the Spanish version of the WHODAS II in a large sample of patients with schizophrenia.

METHODS

The sample included 352 patients with a schizophrenia spectrum disorder. They completed a comprehensive assessment battery including measures of psychopathology, functionality and quality-of-life. A sub-sample of 36 patients was retested after six months to assess its temporal stability.

RESULTS

Participation in society (6.3%) and Life activities (4.0%) were the domains with the highest percentage of missing data. The internal consistency (Cronbach's alpha) of the total scale was 0.94, and the test-retest stability reached an intraclass correlation coefficient of 0.92. It became apparent that the six primary factor models represent a better fit with reality than other competing models. Relationships between the WHODAS and measures of symptomatology, social and work-related functionality, and quality-of-life were in the expected direction and the scale was ultimately found to be able to differentiate among patients with different degrees of disease severity and different work status.

CONCLUSIONS

Assessment of disability using appropriate tools is a crucial aspect in the context of mental health and, in this regard, the Spanish version of the WHODAS II shows ample evidence of validity in patients with schizophrenia. The most important contribution of this study is that it is the first analyzing the Spanish version of the WHODAS II (36-item version) in a large sample of patients with schizophrenia.

Mobile Assessment and Treatment for Schizophrenia (MATS): a pilot trial of an interactive text-messaging intervention for medication adherence, socialization, and auditory hallucinations

Mobile Assessment and Treatment for Schizophrenia (MATS) employs ambulatory monitoring methods and cognitive behavioral therapy interventions to assess and improve outcomes in consumers with schizophrenia through mobile phone text messaging. Three MATS interventions were developed to target medication adherence, socialization, and auditory hallucinations. Participants received up to 840 text messages over a 12-week intervention period. Fifty-five consumers with schizophrenia or schizoaffective disorder were enrolled, but 13 consumers with more severe negative symptoms, lower functioning, and lower premorbid IQ did not complete the intervention, despite repeated prompting and training. For completers, the average valid response rate for 216 outcome assessment questions over the 12-week period was 86%, and 86% of phones were returned undamaged. Medication adherence improved significantly, but only for individuals who were living independently. Number of social interactions increased significantly and a significant reduction in severity of hallucinations was found. In addition, the probability of endorsing attitudes that could interfere with improvement in these outcomes was also significantly reduced in MATS. Lab-based assessments of more general symptoms and functioning did not change significantly. This pilot study demonstrated that low-intensity text-messaging interventions like MATS are feasible and effective interventions to improve several important outcomes, especially for higher functioning consumers with schizophrenia.

Examining a cognitive model of persecutory ideation in the daily life of people with schizophrenia: a computerized experience sampling study

Contemporary theoretical models of paranoia suggest that negative emotions, perceptual anomalies, and recent life events are important predictors of experiencing persecutory ideation. In the current experience sampling study, these factors are examined prospectively for the first time as predictors of the occurrence of persecutory ideation, as well as persecutory belief conviction, and associated distress in real time in the context of daily life. One hundred and forty five community-dwelling participants with schizophrenia or schizoaffective disorder completed self-report assessments generated by a personal digital assistant multiple times a day for 1 week. Their responses were time lagged to allow examination of dynamic prospective relationships between variables as they occur within days. Approximately half of the participants reported having some persecutory thoughts, with a total of 378 reported occurrences of persecutory thoughts across participants during the week. Negative emotional states of anxiety and sadness were significant predictors of the occurrence of subsequent persecutory ideation, but hallucinations and recent life events were not. In a subsample of people who had multiple persecutory thoughts, anxiety was a significant predictor of belief conviction and associated distress, while sadness was only predictive of distress. The findings are consistent with recent cognitive theory that proposes a causal role for negative emotional states in the formation and maintenance of persecutory ideation and suggest that persecutory ideation may be addressed indirectly by interventions targeting anxiety and depression.

The challenges of fitting an item response theory model to the Social Anhedonia Scale

This study explored the application of latent variable measurement models to the Social Anhedonia Scale (SAS; Eckblad, Chapman, Chapman, & Mishlove, 1982), a widely used and influential measure in schizophrenia-related research. Specifically, we applied unidimensional and bifactor item response theory (IRT) models to data from a community sample of young adults (n = 2,227). Ordinal factor analyses revealed that identifying a coherent latent structure in the 40-item SAS data was challenging due to (a) the presence of multiple small content clusters (e.g., doublets); (b) modest relations between those clusters, which, in turn, implies a general factor of only modest strength; (c) items that shared little variance with the majority of items; and (d) cross-loadings in bifactor solutions. Consequently, we conclude that SAS responses cannot be modeled accurately by either unidimensional or bifactor IRT models. Although the application of a bifactor model to a reduced 17-item set met with better success, significant psychometric and substantive problems remained. Results highlight the challenges of applying latent variable models to scales that were not originally designed to fit these models.

The 2nd Schizophrenia International Research Society Conference, 10-14 April 2010, Florence, Italy: summaries of oral sessions

The 2nd Schizophrenia International Research Society Conference, was held in Florence, Italy, April 10-15, 2010. Student travel awardees served as rapporteurs of each oral session and focused their summaries on the most significant findings that emerged from each session and the discussions that followed. The following report is a composite of these reviews. It is hoped that it will provide an overview for those who were present, but could not participate in all sessions, and those who did not have the opportunity to attend, but who would be interested in an update on current investigations ongoing in the field of schizophrenia research.

Is it the symptom or the relation to it? Investigating potential mediators of change in acceptance and commitment therapy for psychosis

Cognitive and behavioral interventions have been shown to be efficacious when used as an adjunct to pharmacotherapy for psychotic disorders. However, little previous research has investigated potential mediators of change in psychological treatments for psychosis. Acceptance and mindfulness-based therapies do not focus on directly reducing the psychotic symptoms themselves, but instead attempt to alter the patient's relationship to symptoms to decrease their negative impact. The current study examined this issue with data from a previously published randomized trial comparing brief treatment with Acceptance and Commitment Therapy (ACT) versus treatment as usual for hospitalized patients with psychotic symptoms (Gaudiano & Herbert, 2006a). Results showed that the believability of hallucinations at posttreatment statistically mediated the effect of treatment condition on hallucination-related distress. Hallucination frequency did not mediate outcome. The current study is a first step toward understanding the potential mechanisms of action in psychological treatments for psychosis.

Further support for the role of dysfunctional attitudes in models of real-world functioning in schizophrenia

According to A.T. Beck and colleagues' cognitive formulation of poor functioning in schizophrenia, maladaptive cognitive appraisals play a key role in the expression and persistence of negative symptoms and associated real-world functioning deficits. They provided initial support for this model by showing that dysfunctional attitudes are elevated in schizophrenia and account for significant variance in negative symptoms and subjective quality of life. The current study used structural equation modeling to further evaluate the contribution of dysfunctional attitudes to outcome in schizophrenia. One hundred eleven outpatients and 67 healthy controls completed a Dysfunctional Attitudes Scale, and patients completed a competence measure of functional capacity, clinical ratings of negative symptoms, and interview-based ratings of real-world functioning. Patients reported higher defeatist performance beliefs than controls and these were significantly related to lower functional capacity, higher negative symptoms, and worse community functioning. Consistent with Beck and colleagues' formulation, modeling analyses indicated a significant indirect pathway from functional capacity-->dysfunctional attitudes-->negative symptoms-->real-world functioning. These findings support the value of dysfunctional attitudes for understanding the determinants of outcome in schizophrenia and suggest that therapeutic interventions targeting these attitudes may facilitate functional recovery.