Anger expression styles in schizophrenia spectrum disorders: associations with anxiety, paranoia, emotion recognition, and trauma history.

Heightened levels of anger and dysregulated expression of anger have been associated with poorer outcomes and treatment response for persons with schizophrenia spectrum disorders. Less is known, however, about the psychological processes that determine the extent to which anger is expressed in a more versus less adaptive manner. To explore this issue, this study gathered reports of anger expression style in 88 persons with schizophrenia or schizoaffective disorder using the State-Trait Anger Expression Inventory, Second Edition. The authors additionally assessed anxiety, suspiciousness, emotion recognition, self-esteem, and cumulative trauma history. Correlations and multiple regression analyses showed that outward anger control, that is, the suppression of anger, was predicted by lower levels of suspiciousness, poorer emotion recognition, and reduced anxiety. Participants who endorsed greater anxiety and had experienced more traumatic events reported a heightened tendency to express anger both inwardly and outwardly.

Deficits in metacognitive capacity distinguish patients with schizophrenia from those with prolonged medical adversity.

Research has suggested that many with schizophrenia experience decrements in synthetic metacognition, or the abilities to form integrated representations of oneself and others and then utilize that knowledge to respond to problems. Although such deficits have been linked with functional impairments even after controlling for symptoms and neurocognition, it is unclear to what extent these deficits can distinguish persons with schizophrenia from others experiencing significant life adversity but without psychosis. To explore this issue we conducted logistic regression analysis to determine whether assessment of metacognition could distinguish between 166 participants with schizophrenia and 51 adults with HIV after controlling for social cognition and education. Metacognition was assessed with the Metacognitive Assessment Scale Abbreviated (MAS-A), and social cognition with the Bell Lysaker Emotion Recognition Test. We observed that the MAS-A total score was able to correctly classify 93.4% of the schizophrenia group, with higher levels of metacognition resulting in increased likelihood of accurate categorization. Additional exploratory analyses showed specific domains of metacognition measured by the MAS-A were equally able to predict membership in the schizophrenia group. Results support the assertion that deficits in the abilities to synthesize thoughts about oneself and others into larger representations are a unique feature of schizophrenia.

Capacities for theory of mind, metacognition, and neurocognitive function are independently related to emotional recognition in schizophrenia.

While many with schizophrenia spectrum disorders experience difficulties understanding the feelings of others, little is known about the psychological antecedents of these deficits. To explore these issues we examined whether deficits in mental state decoding, mental state reasoning and metacognitive capacity predict performance on an emotion recognition task. Participants were 115 adults with a schizophrenia spectrum disorder and 58 adults with substance use disorders but no history of a diagnosis of psychosis who completed the Eyes and Hinting Test. Metacognitive capacity was assessed using the Metacognitive Assessment Scale Abbreviated and emotion recognition was assessed using the Bell Lysaker Emotion Recognition Test. Results revealed that the schizophrenia patients performed more poorly than controls on tests of emotion recognition, mental state decoding, mental state reasoning and metacognition. Lesser capacities for mental state decoding, mental state reasoning and metacognition were all uniquely related emotion recognition within the schizophrenia group even after controlling for neurocognition and symptoms in a stepwise multiple regression. Results suggest that deficits in emotion recognition in schizophrenia may partly result from a combination of impairments in the ability to judge the cognitive and affective states of others and difficulties forming complex representations of self and others.

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.

Metacognitive mastery moderates the relationship of alexithymia with cluster C personality disorder traits in adults with substance use disorders.

Cluster C personality disorder traits have been observed in substance use disorders and linked with poorer outcome. One potential factor which may cause these disturbances in personality function is alexithymia, or the inability to name and express emotion. There may be other proximate factors which moderate the impact of alexithymia on the expression of cluster C traits, such as metacognitive mastery, which is the ability to use knowledge about mental states of self and others to cope with distress and solve social problems. To examine the possibility that mastery mediated the effects of alexithymia on cluster C traits, we assessed each of these constructs using the Metacognitive Assessment Scale Abbreviated, Toronto Alexithymia Scale and SCID II among 58 adults in an early phase of recovery from substance misuse disorders in a residential setting. Results of a multiple regression revealed that, after controlling for symptom severity and severity of substance misuse history, metacognitive mastery moderated the effect of alexithymia on number of cluster C traits. A median split and subsequent ANCOVA revealed that participants with higher levels of alexithymia and poorer metacognitive mastery had more cluster C traits than the other groups. These findings may have clinical implications, suggesting that patients with substance use disorders may benefit from treatment which addresses metacognitive mastery.

Change in self-stigma among persons with schizophrenia enrolled in rehabilitation: associations with self-esteem and positive and emotional discomfort symptoms.

Self-stigma is a barrier to the recovery of persons with schizophrenia. Little is known about whether participation in rehabilitation is naturalistically linked to declines in self-stigma, and if so, what is correlated with changes in self-stigma. The current study examined in a quasi-experimental design the rate of change of self-stigma and whether changes were correlated with self-esteem, positive symptoms, and emotional distress for persons enrolled in rehabilitation. Symptoms were measured using the Positive and Negative Syndrome Scale (Kay, Fizsbein, & Opler, 1987), self-esteem was measured with the Multidimensional Self-Esteem Inventory (Lysaker, Ringer, & Davis, 2008), and self-stigma was assessed using the Internalized Stigma of Mental Illness Scale (Ritsher, Otilingam, & Grajales, 2003). Seventy persons with schizophrenia who worked at least one month in a vocational rehabilitation program were assessed on all measures at baseline and five months later. Results indicated a 25% decrease in self-stigma for 38% of the sample; these individuals tended to have less emotional distress both at baseline and follow-up, and had higher levels of self-esteem at follow-up. No differences in positive symptoms were found for groups whose stigma did or did not decrease. Results suggest that decreases in self-stigma may be correlated with increased self-esteem, while higher levels of emotional distress may be a barrier to stigma reduction.

Development of personal narratives as a mediator of the impact of deficits in social cognition and social withdrawal on negative symptoms in schizophrenia.

Although negative symptoms are a barrier to recovery from schizophrenia, little is understood about the psychological processes that reinforce and sustain them. To explore this issue, this study used structural equation modeling to test whether the impact of social withdrawal and emotion recognition deficits upon negative symptoms is mediated by the richness or poverty of personal narratives. The participants were 99 adults with schizophrenia spectrum disorders. Social cognition was assessed using the Bell-Lysaker Emotional Recognition Task; social withdrawal, using the Quality of Life Scale; narrative coherence, using the Scale To Assess Narrative Development; and negative symptoms, using the Positive and Negative Syndrome Scale. The findings reveal that although social cognition deficits and social withdrawal are significantly associated with negative symptom severity, these relationships become nonsignificant when personal narrative integrity is examined as a mediating factor. These results indicate that the development of personal narratives may be directly linked to the severity of negative symptoms; this construct may be a useful target for future interventions.

Metacognitive and social cognition deficits in patients with significant psychiatric and medical adversity: a comparison between participants with schizophrenia and a sample of participants who are HIV-positive.

Research exploring metacognition and social cognition in schizophrenia has tended to use control groups experiencing relatively little adversity. Therefore, it remains unclear whether the deficits found among persons with schizophrenia are merely the result of greater life adversity. To explore this issue, we assessed metacognition and social cognition among 40 participants with schizophrenia and 25 adults with HIV. We chose to explore this phenomenon in people with HIV given the literature suggesting that this group experiences significant adversity. Measures of metacognition and social cognition included the Metacognition Assessment Scale (MAS), the Hinting test, and the Bell-Lysaker Emotion Recognition Test (BLERT). After controlling for education, years since diagnosis, and memory, the schizophrenia group performed more poorly on the MAS and the Hinting test. No differences were found on the BLERT. The results are consistent with the possibility that schizophrenia is linked to decrements in metacognition and some forms of social cognition.

Relationships between stereotyped beliefs about mental illness, discrimination experiences, and distressed mood over 1 year among persons with schizophrenia enrolled in rehabilitation.

PURPOSE: Research suggests stereotype endorsement or self-stigma serves as a barrier to functioning and well-being among persons with schizophrenia. Little is known about how stable self-stigma is and whether it is linked over time with related constructs such as discrimination experiences and psychological distress. METHODS: Stereotype endorsement and discrimination experiences were assessed using the Internalized Stigma of Mental Illness Scale and psychological distress was assessed using the Emotional Discomfort component of the Positive and Negative Syndrome Scale, at three points in time across 1 year. RESULTS: Path analyses indicated that the constructs of stereotype endorsement and discrimination experiences are stable over periods of 5-7 months and may fluctuate over 12 months. Further, the constructs of stereotype endorsement and discrimination experiences were related to one another concurrently, but analyses failed to detect a relationship over time. Neither construct was related to psychological distress over time. CONCLUSIONS: Self-stigma is a stable construct in the short term, and is distinct from related constructs such as discrimination experiences and psychological distress.

Metacognition in schizophrenia: the relationship of mastery to coping, insight, self-esteem, social anxiety, and various facets of neurocognition.

OBJECTIVES. Deficits in metacognition, or the ability to think about thinking, are common in schizophrenia and associated with functional impairment. Unknown are what elements of function are affected by what aspects of metacognition. DESIGN. This study explored whether participants with differing capacities for Mastery, a domain of metacognition that reflects the ability to use knowledge about mental states to respond to psychological challenges, had difficulties in different elements of daily function. METHODS. Participants were 98 adults with schizophrenia or schizoaffective disorder in a non-acute phase, classified into three groups on the basis of ratings of their capacity for metacognitive Mastery using the Metacognitive Assessment Scale: low Mastery (those unable to plausibly represent psychological challenges), Intermediate Mastery (those able to plausibly represent psychological problems but cope primarily through passive measures or avoidance), and high Mastery (those able to cope with plausible problems through cognitive means). Participants completed assessments of coping preference, insight, self-esteem, and anxiety. RESULTS. Multivariate Analysis of Variance (MANOVA) and Analysis of Variance (ANOVA) revealed that the high-Mastery group had a greater preference for coping with stressors by thinking and talking about them, and greater insight than all other groups, and higher levels of feeling accepted by peers than the intermediate-Mastery group. The intermediate-Mastery group reported higher levels of resignation when facing stressors and more social phobia than the other two groups. These findings of Mastery group differences in self-esteem and anxiety persisted when neurocognition was controlled for in an Analysis of Covariance (ANCOVA). CONCLUSIONS. Mastery appears linked to coping preference, insight, self-esteem, and anxiety in a generally non-linear manner.

La relación entre el estigma y los síntomas positivos y de malestar emocional en la esquizofrenia / Associations of stigma with positive and emotional discomfort symptoms in schizophrenia

La investigación sugiere que el estigma se comporta como una barrera para la autoestima y el logro de un funcionamiento psicosocial adecuado en las personas con esquizofrenia. Es menos claro cómo las experiencias estigmatizadoras se asocian con los síntomas tanto en forma concurrente como prospectiva. Para evaluar este aspecto se valoraron los síntomas positivos y de malestar emocional mediante la escala para el síndrome positivo y negativo (Positive and Negative Syndrome Scale), y la experiencia estigmatizadora mediante la escala del estigma internalizado de la enfermedad mental (Internalized Stigma of Mental Illness Scale), en 75 personas con esquizofrenia en dos momentos separados por 5 meses. Los mayores niveles de estigma se asociaron con mayores niveles de síntomas positivos y de malestar emocional, tanto en forma concurrente como prospectiva. Los síntomas también se asociaron prospectivamente con el grado de estigma. Los resultados de la replicación de hallazgos previos indican que existe una relación estrecha entre la experiencia estigmatizadora y los síntomas. Ambos pueden exacerbarse recíprocamente dando lugar a un círculo vicioso.

Negative symptoms and poor insight as predictors of the similarity between client and therapist ratings of therapeutic alliance in cognitive behavior therapy for patients with schizophrenia.

Recent studies have found that clients with schizophrenia rate therapeutic alliance more highly than therapists. Unclear is whether there are clinical characteristics which predict the degree of difference in client and therapist ratings. To explore this, we correlated client and therapist ratings of therapeutic alliance with baseline assessments of positive negative, and disorganized symptoms and awareness of need for treatment. Participants were 40 adults with schizophrenia enrolled in a 6-month program of cognitive behavior therapy. Results indicated that clients produced higher ratings of therapeutic alliance than therapists and that therapist and client general ratings were more disparate when clients had fewer negative symptoms and better insight. Higher overall client ratings of therapeutic alliance were linked to lower levels of positive, negative, and disorganized symptoms and better awareness of need for treatment. Higher overall therapist ratings were linked only to lower levels of disorganized symptoms among clients.

Clinical and psychosocial significance of trauma history in schizophrenia spectrum disorders.

Interest has arisen in the role stressors play in the development and outcome of schizophrenia. This article examines one such stressor - trauma experienced prior to the onset of illness. We discuss research on the incidence, types and correlates of trauma in schizophrenia, and review work suggesting trauma may increase risk for schizophrenia. Studies are further detailed that have examined links between trauma and heightened levels of positive symptoms and anxiety, and poorer social, vocational and treatment outcomes. Here, literature on approaches to addressing trauma among persons with schizophrenia is presented, along with a commentary that points to the need for research on how trauma might increase the risk for the development of schizophrenia and worsen the symptoms and treatment outcome of individuals in recovery from this illness.

Personal narratives and recovery from schizophrenia.

It has been recently argued that recovery from schizophrenia may involve the recapturing or developing one's personal narrative. Unknown is whether the fullness of the narrative accounts of persons with schizophrenia form about their lives is indeed uniquely linked to wellness in daily life, that is, independent of other factors including symptoms, hope, self-esteem and general intellectual functioning. To explore this issue the current study correlated assessments of personal narratives using the Scale to Assess Narrative Development with the Quality of Life Scale for 103 adults with schizophrenia spectrum disorders. General assessments of personal narrative were associated with the quality and quantity of social relationships, even after controlling for positive and negative symptoms, self report of hope and self-esteem and a test of general intellectual function. The domains of social connectedness within narratives were most closely linked with frequency of social relationships and the domains of Agency and Social Worth were mostly closely linked with quality of social relationships after the effects of symptoms, hope, self-esteem and general intellectual function were accounted for statistically.

Associations of social anxiety and self-esteem across six months for persons living with schizophrenia spectrum disorders.

OBJECTIVE: Social anxiety is commonly found in schizophrenia and is linked with heightened symptoms and lower self-esteem. The purpose of this paper is to examine how social anxiety and self-esteem influence one another over time. METHODS: We have assessed social anxiety, symptoms, and self-esteem at two points, six months apart, for 39 participants with schizophrenia or schizoaffective disorder. RESULTS: Concurrent measures of social anxiety and self-esteem were closely correlated with one another. Multiple regressions indicated that baseline self-esteem was significantly correlated with social anxiety six months later, independent of the influence of social anxiety at baseline. Social anxiety at baseline did not predict self-esteem at six months when baseline self-esteem was controlled for statistically. CONCLUSIONS: Lower self-esteem may be a risk factor for the development of social anxiety in individuals with schizophrenia. Clinical and theoretical implications are discussed.

Participant evaluation of a CBT program for enhancing work function in schizophrenia.

OBJECTIVES: While much has been written about the benefits of CBT for persons with schizophrenia, little has been published to date exploring participant evaluations of these programs. This paper reports on participant evaluations of such a program. METHODS: Forty-four participants with schizophrenia or schizoaffective disorder were surveyed regarding their satisfaction with a 6-month weekly group and individual CBT intervention developed as an adjunct to work therapy or the control condition support group during a randomized controlled feasibility study. RESULTS: Results suggest that all participants, those receiving the CBT intervention and the support group, were satisfied with their program, on average rating the program between "good" and "excellent." However, in comparison, the CBT intervention was associated with greater participant satisfaction than support alone, particularly the perception of the overall quality of services and assistance with problem-solving. CONCLUSIONS: It appears that participant evaluations can function as a source of useful data for evaluation of CBT interventions for persons who have schizophrenia. However, further study is needed to more fully identify and understand aspects of CBT that participants with schizophrenia evaluate as particularly positive or negative and to explore acceptable trade-offs among them.

Associations of awareness of illness in schizophrenia spectrum disorder with social cognition and cognitive perceptual organization.

Although impairment in flexibility of abstract thought has been linked to poor insight in schizophrenia, little is known about the association of other cognitive processes to insight. To explore the possibility that social cognition and perceptual organizational capacity are linked to insight, we assessed awareness of illness and administered the Thematic Apperception Test and Rorschach Inkblot Test to 31 adult participants with schizophrenia. Partial correlations controlling for perseverative errors on the Wisconsin Card Sorting Test revealed that lesser capacities to organize and make sense of ambiguous stimuli, to distinguish between one's own and other's perspectives, and to formulate logical accounts of behavior and social exchange predicted poorer awareness of psychiatric symptoms. With replication, results may suggest that to attain awareness of illness, some with schizophrenia may need assistance making sense of the social world and organizing the complexities of their experience of illness.