Elsevier

Psychiatry Research

Volume 206, Issues 2–3, 30 April 2013, Pages 151-157
Psychiatry Research

The relationship between internalized stigma, negative symptoms and social functioning in schizophrenia: The mediating role of self-efficacy

https://doi.org/10.1016/j.psychres.2012.09.056Get rights and content

Abstract

The broad aim of the present study was to gain a greater understanding of the processes that contribute to negative symptoms and social functioning in schizophrenia. More specifically, a theoretical model was proposed predicting that self-efficacy would mediate the relationship between internalized stigma and both negative symptoms and social functioning in schizophrenia. Initial analyses revealed that all variables were correlated. Specifically, internalized stigma was strongly correlated with negative symptoms, social functioning and self-efficacy. Furthermore, self-efficacy was strongly related to negative symptoms and moderately associated with social functioning. Further analyses however did not support the mediational role of self-efficacy. The theoretical and clinical implications of the findings, together with recommendations for future research, are outlined.

Introduction

Negative symptoms, broadly defined, are a fundamental component of schizophrenia. They refer to a decrease in, or absence of, particular behaviors or functions. Typical negative symptoms include affective flattening (reduced range of emotional expression), alogia (poverty of speech and thought), avolition (lack of ability to instigate or maintain goal orientated behavior), anhedonia (diminished interest or capacity to experience pleasure) (American Psychiatric Association, 2000) and asociality (Andreasen, 1982).

While negative symptoms represent an independent dimension from positive and disorganized symptoms (Harvey et al., 2006) they show some similarities to depression, which is prevalent in individuals diagnosed with schizophrenia (Lancon et al., 2000). For example, reduced interest or involvement in pleasurable activities, decreased energy or motivation, psychomotor retardation and concentration deficits are overlapping characteristics (Siris, 2000). However, research into the association between depression and negative symptoms has provided inconsistent results. Some researchers have found non-significant correlations between the two kinds of symptom (Herbener and Harrow, 2001; Oosthuizen et al., 2002) while others have reported significant associations (Fitzgerald et al., 2002, Perivoliotis et al., 2008). Since the current study was intended to account for variations in negative symptoms, which are independent of depression, the severity of depression was controlled. Much research has been devoted to identifying the factors that contribute to the etiology and maintenance of negative symptoms in schizophrenia. As noted by Rabinowitz et al. (2000), the area of neurocognition has received considerable attention, offering support for the relationship between deficits in executive functioning and negative symptomatology. However, an empirical review conducted by Green and Nuechterlein (1999) revealed that only 10–15% of the variance in negative symptoms was explained by executive functioning. Foussias and Remington (2010) reiterated this point by noting that, while correlations between neuropsychological function and negative symptoms have been reported, the relationship with precise cognitive deficits remains unclear. Thus, while they extend our understanding of negative symptoms, neurocognitive deficits seem to offer only a partial explanation.

More recently, research that has examined a range of psychological factors has provided further clarity and has largely been guided by the promising research that has supported the efficacy of Cognitive Behavior Therapy for individuals with schizophrenia. For example, a randomized controlled trial of Cognitive Behavior Therapy, conducted by Startup et al. (2004), found improvement in both positive and negative symptoms, as well as social functioning, 12 months after baseline, reporting effect sizes of 0.6–0.8. Importantly, the improvements in negative symptoms and social functioning remained evident at 2 years follow-up (Startup et al., 2005). Such results suggest that unhelpful beliefs play a role in relation to negative symptoms.

The importance of beliefs was also noted in a theoretical model developed by Rector et al. (2005) wherein it was hypothesized that dysfunctional attitudes and negative expectancies play significant roles in relation to negative symptoms. In particular, the researchers stressed that “the interaction of neurologic deficits, stressors, personality vulnerability, dysfunctional beliefs and negative expectancies” (p. 255) is instrumental in the development, manifestation and maintenance of negative symptoms in schizophrenia. Thus, the focus on psychological processes in relation to negative symptoms has not only highlighted the importance of psychological interventions but has been instrumental in developing a greater understanding of schizophrenia. Along similar lines, negative ideas regarding performance have also been shown to be associated with negative symptomatology (Perivoliotis et al., 2008). In line with this, the meditational role of defeatist ideas in relation to cognitive deficits, functioning and negative symptoms has also been investigated. Interestingly, defeatist beliefs were found to mediate the association between cognitive impairment and both functioning and negative symptoms (Grant and Beck, 2009). Furthermore, Beck et al. (2009) have argued that cognitive deficits promote the expression of “dysfunctional beliefs, negative expectancies, and pessimistic self-appraisals, that precipitate and maintain withdrawal from meaningful endeavors and diminish quality of life” (p. 27).

Further, recent research by Avery et al. (2009) has demonstrated that, in addition to neurocognition, psychological variables are important in understanding negative symptoms. Specifically, the researchers examined the role of effort, cognitive expectancy appraisals (self-efficacy, perceptions of available resources, expectations of pleasure), and resigning coping style in explaining negative symptoms. Findings revealed that psychological variables contributed uniquely to all of the negative symptom subscales, apart from affective flattening, as well as contributing to the total negative symptom score and explained 9–19% of the variance.

The area of social cognition is also proving to be promising when examining negative symptoms of schizophrenia. As noted by Corrigan and Penn (2001), social cognition refers to the processes and functions that allow a person to understand, action, and benefit from the interpersonal world. Theory of Mind (ToM) is one such mental process and refers to one's ability to infer what others believe, think and intend (Koren et al., 2006). Research by Martino et al. (2007) assessed the relationship between negative symptoms and ToM by employing a ‘faux pas’ assessment, a task that requires subtle social reasoning (Stone et al., 1998). Specifically, as outlined by Stone et al. (1998) “to understand that a faux pas has occurred, one has to represent two mental states: that the person saying it does not know that they should not say it and that the person hearing it would feel insulted or hurt. Thus, there is both a cognitive component and empathic affective component” (p. 641). For example, Baron-Cohen et al. (1999) noted that a “a working definition of faux pas might be when a speaker says something without considering if it is something that the listener might not want to hear or know, and which typically has negative consequences that the speaker never intended” (p. 408). Notably, research findings by Martino et al. (2007) revealed a moderate to high correlation between negative symptoms and ToM and, in particular, a correlation of −0.68 with the total negative symptom score. While not directly related to the current aims, the present study will attempt to replicate such findings.

Poor social functioning is characteristic of schizophrenia (Rector et al., 2005, Bellack et al., 2007, Buchanan, 2007, Grant and Beck, 2009). Specifically, this concept refers to impaired social skills, care of oneself, interpersonal relationships and occupational functioning. Furthermore, unlike positive symptoms, negative symptomatology has been found to predict poor social functioning (Sayers et al., 1996, Rocca et al., 2009, Pratt et al., 2005, Buchanan, 2007, Grant and Beck, 2009). Furthermore, the conceptualization and assessment of social function is an important issue. While considerable research has examined the measurement of social functioning in schizophrenia, inconsistencies exist in terms of its definition and measurement (Burns and Patrick, 2007). In particular, considerable variations have existed with assessment scales in relation to measurement techniques, the specific domains assessed and the scoring methods used. In other words, details of psychometric properties have been lacking (Burns and Patrick, 2007).

Consequently, for the purpose of the current study, the Quality of Life Scale, Abbreviated (QOLSA) was used to assess social functioning. This scale, which assesses a combination of subjective and objective considerations, provides high accuracy regarding functioning in schizophrenia (Bilker et al., 2003). Specifically, subjective experience relates to one's life satisfaction, while objective considerations incorporate social and occupational functioning (Bilker et al., 2003).

The notion of internalized stigma has also received attention in the literature. Specifically, internalized stigma may be defined as one's personal experience of stigma and includes the psychological consequences of attributing to oneself stigmatizing beliefs, thoughts and feelings (Sibitz et al., 2011). Such experiences subsequently result in low self-worth, shame and ultimate withdrawal and isolation from society (Sibitz et al., 2011). While the relationship between internalized stigma and negative symptoms has been the subject of empirical research, inconsistent findings have been reported. For example, research by Lysaker et al. (2009) examined the relationship between negative symptoms and deficits in attention on one hand, and internalized stigma, hope and social functioning on the other. Findings revealed that higher levels of negative symptomatology were significantly correlated with lower self-esteem and increased internalized stigma. Conversely however, research undertaken by Lysaker et al. (2010) revealed that internalized stigma was associated with assessments of frequency of social interactions, both concurrently and prospectively, but not with negative symptoms. In addition, research by Yanos et al. (2008) found that internalized stigma impacts upon one's hope and self-esteem, thereby leading to poor recovery outcomes, whereas Lysaker et al. (2007) found that internalized stigma, only when combined with good insight, predicted poorer functioning. Recent research by Karidi et al. (2010) also explored the occurrence, and subsequent impact of, self-stigmatization on outpatients diagnosed with schizophrenia. Specifically, results indicated that not only was internalized stigma experienced by the great majority of patients, but such stigmatizing thoughts, feelings and beliefs were found to negatively impact upon their self-esteem, as well as social, vocational and personal relationships.

When examining internalized stigma, the construct of self-efficacy may provide further clarity. Specifically, self-efficacy refers to one's conviction that one has the capability of carrying out a specific task or behavior (Bandura, 1986) and has been found to contribute significantly to total negative symptom scores in schizophrenia, as well as predicting anhedonia specifically (Avery et al., 2009). The relationship between internalized stigma and self-efficacy however has been the focus of limited empirical investigation. Research by Vauth et al. (2007) examined the mediational role of self-efficacy and empowerment in relation to the psychological impact of internalized stigma and coping with stigma. Results revealed that internalized stigma contributed to 21% of the variance in self-efficacy. This is consistent with the argument raised by Beck et al. (2009) that internalized stigma may ultimately mould one's self-concept which, in turn, has the potential to detrimentally impact upon one's sense of self-efficacy. Along similar lines, research by Grant and Beck (2009) highlighted the relevance of defeatist performance beliefs. Specifically, the authors demonstrated that the association between cognitive deficits and negative symptoms, together with functioning, was mediated by one's pessimistic beliefs in relation to carrying out specific tasks. Such considerations have major implications for the treatment outcome of individuals diagnosed with schizophrenia. Furthermore, while defeatist beliefs and self-efficacy appear to be similar constructs, it is important to note that they are distinguished by the assessment process. Specifically, the assessment of defeatist convictions utilized by Grant and Beck (2009) examined generalized statements whereas the measurement of self-efficacy requires assessments to be specifically related to the task and situation (Bandura, 1986).

The broad aim of the current study is to gain a greater understanding of the processes that contribute to negative symptoms and poor social functioning for individuals diagnosed with schizophrenia. Specifically, the aim is to determine if self-efficacy mediates the relationships between internalized stigma and both negative symptoms and poor social functioning for those who have been admitted to inpatient psychiatric facilities. It is hypothesized that

  • (1)

    There will be significant positive relationships between internalized stigma and both negative symptoms and poorer social functioning.

  • (2)

    Higher levels of internalized stigma will be associated with lower self-efficacy.

  • (3)

    Greater self-efficacy will be associated with both less severe negative symptoms and better social functioning.

  • (4)

    Self-efficacy will act as a mediating variable between internalized stigma and both negative symptoms and social functioning.

Section snippets

Participants

Sixty patients diagnosed with a schizophrenia spectrum disorder, according to DSM-IV criteria, were recruited from six inpatient psychiatric facilities. All participants were 18 years of age or older and were capable of providing valid informed consent, confirmed by their treating psychiatrist. Participation was voluntary and all participants provided written consent following the provision of information regarding the research aims and procedures. Exclusion criteria consisted of evidence of

Descriptive statistics

Table 2 displays the means and standard deviations for the measures in this study.

Correlations

Negative symptoms and social functioning were strongly correlated with internalized stigma, as indicated in Table 3. There was also a strong negative correlation between internalized stigma and self-efficacy (Table 3). Specifically, high levels of internalized stigma were associated with lower self-efficacy.

As also shown in Table 3, there was a strong negative relationship between self-efficacy and negative

Discussion

A theoretical model to examine whether self-efficacy mediated the relationship between internalized stigma and both negative symptoms and social functioning in schizophrenia was proposed in the current study. Firstly, in order to determine if self-efficacy was in fact a mediating variable, it was necessary to confirm whether significant pathways existed between internalized stigma and both negative symptoms and social functioning. It was also necessary to ascertain whether a significant

References (42)

  • N.C. Andreasen

    Negative symptoms in schizophrenia. Definition and reliability

    Archives of General Psychiatry

    (1982)
  • A. Bandura

    Social Foundations of Thoughts and Action: A Social Cognitive Theory

    (1986)
  • S. Baron-Cohen et al.

    Recognition of Faux Pas by normally development children with children with Asperger Syndrome or high functioning autism

    Journal of Autism and Developmental Disorders

    (1999)
  • A.T. Beck et al.

    Schizophrenia: Cognitive Theory, Research, and Therapy

    (2009)
  • A.S. Bellack et al.

    Assessment of community functioning in people with schizophrenia and other severe mental illnesses: a white paper based on an NIMH-sponsored workshop

    Schizophrenia Bulletin

    (2007)
  • W.B. Bilker et al.

    Development of an abbreviated schizophrenia quality of life scale using a new method

    Neuropsychopharmacology

    (2003)
  • J.J. Blanchard et al.

    The structure of negative symptoms within schizophrenia: implications for assessment

    Schizophrenia Bulletin

    (2006)
  • R.W. Buchanan

    Persistent negative symptoms in schizophrenia: an overview

    Schizophrenia Bulletin

    (2007)
  • T. Burns et al.

    Social functioning as an outcome measure in schizophrenia studies

    Acta Psychiatrica Scandinavica

    (2007)
  • P.W. Corrigan et al.

    Introduction: framing models of social cognition and schizophrenia

  • J.R. Crawford et al.

    Estimation of premorbid intelligence in schizophrenia

    British Journal of Psychiatry

    (1992)
  • Cited by (67)

    View all citing articles on Scopus
    View full text