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

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Abstract

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.

Introduction

There has recently been a fundamental shift in schizophrenia treatment research from psychotic symptom management to the considerably broader and more ambitious goal of “recovery” (Kern et al., 2009). Although it has been defined in several ways, recovery typically refers not only to remission of psychotic symptoms, but also achievement of productive, sustained functioning in independent living, vocational or educational activities, and satisfying interpersonal relationships (Liberman et al., 2002). To facilitate treatment development, much effort has been devoted to identifying key determinants of poor functioning that can be targeted through novel interventions. Among these factors, neurocognitive deficits and negative symptoms have received the strongest support as important correlates of functioning (Green et al., 2000, Kirkpatrick et al., 2006). However, the pathways through which these variables are ultimately linked to functioning are complex, and likely involve a host of intervening variables. A handful of recent studies have used statistical modeling approaches, such as structural equation modeling or path analysis, to delineate the complex interplay among factors that ultimately lead to poor functioning in the community (e.g., Bowie et al., 2006, Sergi et al., 2006, Vauth et al., 2004). By testing theoretically-based models of outcome, investigators can gain insights into the mechanistic relations among the determinants of outcome, which can help guide treatment development efforts.

Although several models of outcome have been proposed (Bellack et al., 2007), one useful heuristic broadly distinguishes among competence, performance, and intervening factors (Harvey et al., 2007). Competence refers to what an individual can do or is capable of doing under optimal circumstances and comprises several sub-domains, including neurocognitive performance and capacity to perform everyday living and social activities on laboratory-based measures (i.e., “functional capacity”). Real-world performance, on the other hand, refers to what one actually does in daily life in the community. It is clear that competence does not fully predict performance in the community. For example, neurocognitive measures typically account for a moderate proportion of the variance in real-world functioning, with composite scores accounting for about 20–40% of the variance in outcome (Green et al., 2000). Functional capacity measures, while strongly related to neurocognitive measures, demonstrate much weaker and more variable relations with real-world functioning, ranging from moderate to small and non-significant (Harvey et al., 2007). To account for such discrepancies, multiple intervening factors such as motivation, willingness to take risks, and self-efficacy, as well as socio-environmental variables, including disability compensation policies and cultural factors, have been proposed. Clarification of these intervening variables may be particularly informative for treatment development, as they may be amenable to interventions that bridge the gap between competence and performance.

A promising recent development is Beck and colleagues’ cognitive formulation of poor functioning in schizophrenia (Beck et al., 2009, Rector et al., 2005). This model proposes that competence limitations do not – in and of themselves – directly contribute to poor real-world functioning. Instead, the model proposes that competence and performance are only indirectly related through a causal pathway that involves multiple intervening variables, including cognitive and motivational factors. According to this model, neurocognitive deficits and related limitations in the capacity to perform daily activities contribute to discouraging life circumstances, such as difficulties performing at work or school, or engaging in conversations with family and friends. These discouraging experiences engender negative attitudes, self-beliefs, and expectancies. These attitudes, in turn, contribute to the decreased motivation, interest, and engagement in productive or enjoyable activities that manifest clinically as negative symptoms. For example, an affected individual may not initiate or persist in goal-directed behaviors (avolition) due to negative self-efficacy beliefs (“Nothing will ever work out for me”) or may withdraw (asociality) to avoid feeling overwhelmed or shamed due to negative interpersonal beliefs (“No one can understand me or care for me”). Ultimately, these negative expectancies and diminished levels of interest and motivation lead to poor real-world functioning. Thus, the model proposes an indirect pathway from functional capacity limitations  dysfunctional attitudes  negative symptoms  real-world outcome.

Only one published study, to our knowledge, has attempted to identify the determinants of outcome in schizophrenia using constructs from this model. Grant and Beck (2009) found that schizophrenia patients differed from healthy controls on two subscales derived from the Dysfunctional Attitudes Scale (Weissman, 1978) (i.e. Defeatist Performance Beliefs and Dysfunctional Need for Acceptance). A path analysis indicated that defeatist beliefs partially mediated the relationship between neurocognition and negative symptoms. Also, a separate path analysis showed that dysfunctional beliefs partially mediated the association between neurocognition and quality of life. Although these findings provide encouraging initial evidence for the relevance of dysfunctional attitudes, the study had a relatively small sample that prevented the use of sophisticated modeling techniques. In addition, the functional outcome measure largely tapped aspects of subjective, intrapsychic functioning that are closely related to negative symptoms (anhedonia, motivation, empathy); high colinearity (r = .81) and shared content between the outcome and negative symptom measures precluded modeling their relations to dysfunctional attitudes simultaneously. Finally, incorporating measures of functional capacity could help test more comprehensive models of how dysfunctional attitudes contribute to poor outcome.

This study was designed to further test the contribution of dysfunctional attitudes to poor functioning by evaluating three research questions in a relatively large sample of outpatients with schizophrenia or schizoaffective disorder and healthy controls. First, we sought to replicate Grant and Beck’s finding that patients report higher scores than healthy controls on the DAS subscales. Second, within the clinical sample, we used Structural Equation Modeling to simultaneously evaluate direct and indirect relations between dysfunctional attitudes, negative symptoms, and functional outcome within a single model. Based on Beck and colleagues’ formulation, we predicted that negative symptoms would mediate the relation between dysfunctional attitudes and real-world functioning. Third, in line with the competence/performance framework, we predicted that a measure of functional capacity for daily activities, namely the UCSD Performance-based Skills Assessment (UPSA) (Patterson et al., 2001), would improve the model fit through a direct relationship to dysfunctional attitudes. Based on the literature (Harvey et al., 2007), we did not make any predictions about direct relationships between the UPSA and both negative symptoms and real-world functioning.

Section snippets

Participants

One hundred and eleven patients were recruited from outpatient treatment clinics at the Veterans Affairs (VA) Greater Los Angeles Healthcare System and through presentations in the community. Patients met criteria for schizophrenia (n = 97) or schizoaffective disorder (n = 12) based on the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First et al., 1996). Ninety patients were receiving atypical antipsychotic medications, 8 were receiving typical antipsychotic medications, 6 were

Demographic and clinical information

As shown in Table 1, patients and controls did not significantly differ in sex composition or parental education level. However, the patients were older and had lower education levels than controls. (This project attempted to match subjects on parental education, not personal education). Preliminary analyses within the patient group indicated that age did not significantly correlate with any other study variable, and that there were no significant differences between patients with schizophrenia

Discussion

This study further supports the contribution of dysfunctional attitudes to poor outcome in schizophrenia as proposed by Beck and colleagues’ cognitive formulation. Patients reported substantial elevations of both defeatist beliefs and need for acceptance, reflecting strongly held maladaptive beliefs about their capacity to engage in productive activities and the importance of how they are perceived by others. Among patients, these attitudes were significantly related to variables that are more

Contributors

William P. Horan, Yuri Rassovsky, Robert S. Kern, Junghee Lee, Jonathan K. Wynn, Michael F. Green,

University of California, Los Angeles, VA Greater Los Angeles Healthcare System.

Role of funding source

This research was supported by Research Grants MH077141 (to W.P.H.), MH43292 and MH65707 (to M.F.G.) from the National Institute of Mental Health, and by the Department of Veterans Affairs, Veterans Integrated Service Network 22, Mental Illness Research Education and Clinical Center.

Conflict of interest statement

None of the authors had a conflict of interest.

Acknowledgements

We thank Shelly Crosby, Lisa Mancini, Mark McGee, Poorang Nori, Cory Tripp, and Christen Waldon for their assistance with data collection.

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