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Citation: Concerto, C.; Rodolico, A.;
Mineo, L.; Ciancio, A.; Marano, L.;
Romano, C.B.; Scavo, E.V.; Spigarelli,
R.; Fusar-Poli, L.; Furnari, R.; et al.
Exploring Personal Recovery in
Schizophrenia: The Role of
Mentalization. J. Clin. Med. 2023,12,
4090. https://doi.org/10.3390/
jcm12124090
Academic Editor: Giulia
Maria Giordano
Received: 20 May 2023
Revised: 9 June 2023
Accepted: 13 June 2023
Published: 16 June 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
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Attribution (CC BY) license (https://
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4.0/).
Journal of
Clinical Medicine
Article
Exploring Personal Recovery in Schizophrenia: The Role
of Mentalization
Carmen Concerto 1, † , Alessandro Rodolico 1, *,† , Ludovico Mineo 1, Alessia Ciancio 1, Leonardo Marano 1,
Carla Benedicta Romano 1, Elisa Vita Scavo 1, Riccardo Spigarelli 1, Laura Fusar-Poli 2, Rosaria Furnari 1,
Antonino Petralia 1and Maria Salvina Signorelli 1
1Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Catania,
95123 Catania, Italy; c.concerto@policlinico.unict.it (C.C.); alessia.ciancio@gmail.com (A.C.);
elisavita.scavo@tiscali.it (E.V.S.); petralia@unict.it (A.P.); maria.signorelli@unict.it (M.S.S.)
2
Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy; laura.fusarpoli@unipv.it
*Correspondence: alessandro.rodolico@phd.unict.it
† These authors contributed equally to this work.
Abstract:
Recovery is a broadly debated concept in the field of psychiatry research and in schizophre-
nia. Our study aims to understand the correlation between personal recovery from schizophrenia
and factors such as mentalization, disability, quality of life, and antipsychotic side effects; Methods:
Participants with schizophrenia (according to DSM-5 criteria) were consecutively recruited from the
Psychiatry Unit of the University of Catania, Italy. Participants were assessed with the Recovery
Assessment Scale (RAS), the Multidimensional Mentalizing Questionnaire (MMQ), the brief version
of the WHO Disability Assessment Schedule (WHO-DAS), the EuroQoL-5 dimensions-5 levels, the
Insight Orientation Scale (IOS) and the Glasgow Antipsychotic Side Effect Scale (GASS); Results:
81 patients were included. Our findings showed a positive correlation between RAS total scores
and MMQ scores, especially in “good mentalizing” subdomains. IOS scores also had a positive
association with RAS and MMQ scores. In contrast, poor mentalizing abilities negatively correlated
with WHO-DAS 2.0 scores. While antipsychotic side effects influenced functioning, they did not im-
pact perceived recovery. Conclusions: The study’s results identified potential predictors of personal
recovery from schizophrenia. These findings could contribute to creating tailored interventions to
facilitate the recovery process.
Keywords: schizophrenia; personal recovery; mentalization; insight
1. Introduction
Recently, the concept of recovery in psychiatric disorders, especially schizophrenia,
has garnered increasing attention. However, the quest for a comprehensive definition
of this construct continues to provoke discussion. Consistent with previous research on
patient outcomes, the theorization of recovery in schizophrenia has evolved from a perspec-
tive centered on symptom remission (clinical recovery-CR) and functional rehabilitation
(functional recovery-FR) to a more holistic and patient-oriented approach emphasizing the
personal dimension of the recovery process [1,2].
1.1. Personal Recovery
Personal recovery (PR) can be conceptualized as a continuous personal journey of
adaptation and growth to overcome the adverse personal and societal consequences associ-
ated with any mental disorder [
3
]. It encompasses various elements, such as spirituality,
empowerment, embracing the illness actively, finding hope, restoring a positive identity,
creating meaning in life, combating stigma, taking charge of one’s own life, and cultivating
supportive relationships [
4
]. PR concerns the individuals’ perceived capacity to manage
J. Clin. Med. 2023,12, 4090. https://doi.org/10.3390/jcm12124090 https://www.mdpi.com/journal/jcm
J. Clin. Med. 2023,12, 4090 2 of 12
mental illness, their sense of purpose, and their confidence in their ability to lead a ful-
filling life, irrespective of the disorder’s severity [
5
]. Thus, “being in recovery” might
result from a transformative process involving changes in unique and deeply subjective
domains of human experience [
6
]. Ever since its conceptualization, it has been observed
that PR does not necessarily correspond exactly with CR. In a 2018 systematic review and
meta-analysis aimed at investigating the relationship between CR and PR, only a significant
small to medium association was found between these two distinct concepts of recovery [
7
].
Therefore, it was emphasized that when treating and evaluating outcomes of patients with
schizophrenic spectrum disorders, both CR and PR should be taken into account, but in
separate ways. As a complex and multifaceted construct, PR has been operationalized in
several different ways with various psychometric tools. In 2011, the CHIME framework
for PR was developed providing a coherent and robust structure able to orient research
and clinical efforts [
8
]. The acronym CHIME derives from the five key components of
the recovery process, namely “connectedness”, “hope and optimism about the future”,
“identity”, “meaning in life”, and “empowerment”. Although there is no consensus on
the gold-standard measurement tool for PR, the Recovery Assessment Scale (RAS) by
Corrigan et al. [
9
] is the most commonly referenced in the literature. In a systematic review
of PR measures [
10
], the RAS has shown the broadest array of psychometric properties,
appearing to fit well with the CHIME model.
1.2. Factors Influencing Personal Recovery
In contrast to the large amount of available evidence [
11
–
14
] on predictive factors
of clinical and functional recovery, relatively fewer studies have focused on the potential
determinants of its personal counterpart. Among the individual factors affecting PR, older
age and a lower level of education have been shown to act as negative predictors [
15
]. On
the other hand, resilience, intended as the inner strength needed to recover, endure, and
adapt to life’s pressures, could enhance the perceived recovery in people with a psychiatric
disorder, including schizophrenia [
16
,
17
]. Regarding the identification of social factors that
might impact PR, prior research indicates that aspects such as social support can have a
positive effect on the PR trajectory. In contrast, the stigma connected to mental illness is seen
to potentially negatively influence the course of PR [
17
–
20
]. Although there is a significant
positive correlation observed between FR—interpreted as the individual’s capacity to offset
cognitive functioning deficits—and PR, a substantial body of evidence suggests that these
domains are not coincidental and display discernible predictive factors along with distinct
relationships concerning symptomatology and intrinsic disease characteristics [
21
–
23
]. In
fact, although some studies have reported a positive correlation between PR and neurocog-
nitive function [
23
,
24
], a meta-analysis of the determinants of PR found that neurocognition,
in general, had no association with PR [
25
]. While the underlying aspects of PR imply the
necessity for a suitable level of reflective functioning, to the best of our knowledge, there
have been limited studies investigating the association between mentalization and PR in
schizophrenia. Mentalization, often referred to as the theory of mind (ToM), is commonly
defined as the “imaginative mental activity through which behavior is interpreted in terms
of mental states such as needs, feelings, beliefs and goals” [
26
]. This cognitive process,
which serves as a crucial aspect of social cognition, enables the attribution of mental states,
including beliefs, emotions, knowledge, and intentions, by thoroughly employing all avail-
able information sources. By integrating and synthesizing this information, it enables the
inference of the most appropriate mental state within a given context [
27
]. Thus, it plays
a crucial role in interpersonal relationships through its impact on the interpretation and
response to social information by individuals [
28
]. Importantly, mentalization is not only
a cognitive process but also has significant biological underpinnings. Research suggests
that mentalization is linked with specific brain structures and networks, notably the right
temporoparietal junction, the right middle temporal gyrus, and the left precuneus [
29
].
It has also been hypothesized that there is a reciprocity between sex hormones and so-
cial cognition in schizophrenia, where oxytocin, estrogens, and testosterone could have a
J. Clin. Med. 2023,12, 4090 3 of 12
role [
30
], and being exposed to these in fetal life might have an effect on the disorder [
31
].
An expanding body of literature has documented various deficits in both cognitive and
affective facets of mentalizing in individuals diagnosed with psychosis, and the anoma-
lies within this specific metacognitive domain are responsible for a significant portion of
the compromised social functioning and poor social outcomes observed [
32
–
34
]. In our
study, we aimed to assess the correlation between PR and independent variables, such as
mentalization, disability, quality of life, orientation, tendency toward introspection, and
antipsychotic (AP) side effects (SE) in a group of patients with schizophrenia. In particular,
we hypothesize that people with schizophrenia who have better mentalization capacity
and better orientation and tendency toward introspection might have a stronger subjective
experience of recovery.
2. Materials and Methods
Participants (81) were consecutively recruited from the Psychiatry Unit of the Univer-
sity of Catania, Italy from September 2021 to April 2022. All patients presented a DSM-5
diagnosis of schizophrenia. Inclusion criteria were: age
≥
18 years; being an outpatient;
diagnosis of schizophrenia based on DSM-5 criteria; absence of positive symptoms at the
time of recruitment (defined with a score
≤
3 on the Positive and Negative Syndrome Scale
[PANSS]); the presence of good insight (PANSS g12-lack of judgment and insight
≤
3); and
the ability to read and understand the informed consent documentation. We considered
the following as exclusion criteria: concomitant organic diseases; use of psychoactive sub-
stances; and other neurological conditions. All patients were taking a second-generation
AP as their primary medication. All participants gave their informed consent for data col-
lection. The study was conducted in accordance with the Declaration of Helsinki and was
approved by the University of Catania review board. Each participant was asked to fill out
a socio-demographic form including socioeconomic variables and
psychological variables
.
The following questionnaires were administered:
•
The Recovery Assessment Scale (RAS) was used to define patients’ perceived recovery.
It is a 41-item self-administered tool structured as a Likert scale from 1 (completely
disagree) to 5 (completely agree), designed to assess perceived recovery in psychiatric
patients. Five factors of recovery can be depicted as Personal Trust and Hope, Willing-
ness to Ask for Help, Goal and Success Orientation, Dependence on Others, and Not
being Dominated by Symptoms [4,35].
•
The Multidimensional Mentalizing Questionnaire (MMQ) measures the mentalizing
processes. It is a 33-item self-rated tool covering different core aspects of mentalization
that embraces a multidimensional construct with 4 dimensions: automatic-controlled
mentalizing, self/other-oriented mentalization, internal-external mentalizing, and
cognitive/affective mentalization. The response format is on a five-point Likert scale
from 1 = “Not at all” to 5 = “A great deal”. It can be possible to define scores on
positive (reflexivity, ego-strength, and relational attunement) and negative (relational
discomfort, distrust, and emotional dyscontrol) subscales as well as an overall MMQ
score by summing all the items after having reversed those included in the negative
subscales [36].
•
The brief version of the WHO Disability Assessment Schedule (WHO-DAS) 2.0 is a
12-item self-rated scale used to measure disability levels in clinical practice [
37
,
38
]. All
the questions refer to the prior thirty days, asking for the level of difficulty in doing
daily activities, ranging from “No difficulty”, equal to 1, to “Extreme or cannot do”,
equal to 5. The sum of the items is proportional to the functional impairment. The
following six “life areas” can be evaluated: Cognition, Mobility, Self-care, Getting
along, Life activities, and Participation.
•
The EuroQoL-5 dimensions-5 levels (EQ-5D-5L) was administered to assess quality
of life [
39
]. It is a self-report screening tool consisting of two sections. The first part
contains five Likert-level questions regarding movement capacity, self-care, common
activities, pain, and anxiety/depression; the second part is a visual analog scale (VAS)
J. Clin. Med. 2023,12, 4090 4 of 12
in which patients indicate their perceived health ranging from 0 to 100, where higher
is better.
•
The Insight Orientation Scale (IOS) is a 7-item self-report scale designed to measure
a person’s orientation and tendency toward insight, which refers to the understand-
ing or awareness of one’s thoughts, emotions, and behaviors. Each item is rated
on a Likert scale ranging from 1 (not at all) to 5 (a great deal), focused on seven
core aspects of the construct: level of consciousness, problem solving, restructur-
ing (behavior change), awareness, complexity (abstraction, depth), surprise, and
self-reflectiveness (thoughtfulness) [40].
•
The Glasgow Antipsychotic Side Effect Scale (GASS) is a 22-item self-rated ques-
tionnaire used to assess AP-induced SE. For each item, it is possible to indicate the
frequency of the reported SE (Never, Once, A few times, and Every day, scored as 0,
1, 2, and 3, respectively) and then the level of distress that the SE determines (scored
from 1 to 10). The first twenty questions refer to the prior week, while the last two
questions (on changes in menstrual periods and weight gain) refer to the previous
3 months. The total scale score is given by the sum of the item frequency [41].
Statistical Analyses
We reported the mean and standard deviation for all variables. If a variable was found
to be non-normally distributed, we also included the median and interquartile range in
our report. We used the Kolmogorov-Smirnov test to examine the normality distribution
of continuous variables. To summarize categorical variables, we displayed both the count
and percentage of each category. We calculated a correlation matrix using Spearman
correlation coefficients to evaluate the relationship between variable pairs. Since many
of the variables did not follow a normal distribution, we utilized Spearman’s correlation
rather than Pearson’s correlation for the whole correlation matrix. Multiple univariate
regression models were run to investigate the association between multiple variables (age,
gender, education, marital status, having children, work, illness duration, hospitalizations,
WHO-DAS 2.0 total score, EQ-5D-5L-VAS total score, IOS total score, MMQ total score,
and GASS total scores) and the RAS total score and its sub-domains. We reported the
model ANOVA p-value and its adjusted R
2
values. We set the alpha level beforehand to
0.05 and implemented the Bonferroni correction by dividing the alpha level by the number
of variables evaluated for demographics and psychometric questionnaire items in the
correlation matrix.
3. Results
Our study included 81 patients diagnosed with schizophrenia, where more than half
were male (53) and the rest were female (28). The average age of the participants was
44.2 years (S.D.: 13), and their education level varied: 12% completed elementary school;
36% attended secondary school; 41% completed high school, and 11%completed their
graduation. Most of the participants were single (77%) and only a few (19) had children.
We found that only a quarter of the participants were employed. More details about
illness-related variables and psychometric scores are reported in Table 1.
The correlation matrix in Table 2suggests a good internal consistency of the individual
psychometric instruments; the Cronbach
α
of the psychometric instrument we used was
0.888 for the WHO-DAS 2.0, 0.851 for the IOS, 0.85 for the MMQ, 0.838 for the GASS, 0.966
for the RAS total score, 0.894 for the Self Trust RAS sub-scale, 0.84 for the Help RAS sub-
scale, 0.869 for the Success RAS sub-scale, 0.756 for Other Trust sub-scale and 0.759 for the
Not-overwhelmed RAS sub-scale. The IOS score showed a positive correlation with both
the RAS total score and the self-trust, help, and success RAS subscales. Similarly, there was a
correlation between IOS and MMQ total scores as well as the MMQ reflexivity, ego-strength,
and relational attunement sub-dimensions. On the one hand, the RAS total score, as well as
several of its sub-scales, have been found to be positively associated with both the MMQ
total score and the “good mentalizing” subdomains, including reflexivity, ego-strength, and
J. Clin. Med. 2023,12, 4090 5 of 12
relational attunement. On the other hand, this correlation is not present with any of the “bad
mentalizing” sub-scales. The MMQ subscales related to poor mentalizing abilities, such as
relational discomfort, distrust, and emotional dyscontrol, showed a negative correlation
with WHO-DAS 2.0 scores. This indicates that a lack of mentalizing ability can hinder an
individual’s overall level of functioning. Finally, we checked the impact of AP-SE with
GASS, finding it influenced functioning but not perceived recovery.
Table 1. Illness-related variables and psychometric scores.
Variables Mean Standard
Deviation Median Inferior IQ Superior IQ
Illness Duration Years * 13.80 9.68 6 12 20
Hospitalizations * 2.43 3.84 0 1 3
WHODAS Cognition * 3.88 2.15 2 3 5
WHODAS Mobility * 3.99 2.26 2 3 6
WHODAS Selfcare * 2.91 1.78 2 2 3
WHODAS Getting Along * 3.74 2.12 2 3 5
WHODAS Life Activities * 3.89 2.10 2 3 5
WHODAS Participation * 4.30 1.85 3 4 6
WHODAS Total * 22.70 9.52 15 20 28
EQ-5D-5L-VAS 68.62 24.14 50 75 85
RAS Self Trust * 31.53 7.93 28 33 37
RAS Help * 11.65 2.86 10 12 14
RAS Success * 18.74 4.81 16 20 22
RAS Other Trust * 14.72 3.73 13 15 17
RAS Not Overwhelmed * 9.22 3.31 7 9 12
RAS Total * 146.69 31.44 135 150 166
IOS Total 21.25 6.39 - - -
MMQ Reflexivity 27.69 8.51 - - -
MMQ Ego-strength 15.91 5.83 - - -
MMQ Relational attunement 12.84 4.29 - - -
MMQ Relational discomfort * 19.64 4.61 18 21 23
MMQ Distrust * 14.01 3.82 12 15 17
MMQ Emotional dyscontrol * 15.17 3.95 13 16 18
MMQ Total 105.27 17.18 - - -
GASS Total * 15.07 10.55 6 13 21
RAS: Recovery Assessment Scale; WHODAS: World Health Organization Disability Assessment Scale; EQ-5D-5L-
VAS: EuroQol 5-Dimension 5-Level Visual Analog Scale; IOS: Insight Orientation Scale; MMQ: Multidimensional
Mentalizing Questionnaire; GASS: Glasgow Antipsychotics Side Effect Scale; non normally distributed variables
are marked with “*”.
J. Clin. Med. 2023,12, 4090 6 of 12
Table 2. Correlation matrix.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Age 1 -
Illness Duration Years 2 0.558 -
WHODAS
Cognition 3 0.026 −0.059 -
WHODAS
Mobility 4−0.032 0.040 0.548 -
WHODAS Selfcare 5 0.119 0.123 0.422 0.419 -
WHODAS Getting Along 6 −0.027 −0.050 0.64 0.477 0.438 -
WHODAS Life Activities 7 0.053 −0.025 0.725 0.483 0.401 0.604 -
WHODAS Participation 8 −0.110 −0.135 0.514 0.477 0.278 0.573 0.542 -
WHODAS Total 9 0.007 0.011 0.816 0.74 0.555 0.797 0.823 0.77 -
EQ-5D-5L-VAS 10 0.013 −0.147 −0.229 −0.356 −0.159 −0.322 −0.29 −0.352 −0.378 -
RAS Self Trust 11 −0.033 −0.214 −0.150 −0.204 −0.363 −0.324 −0.215 −0.348 −0.343 0.57 -
RAS Help 12 −0.210 −0.171 −0.164 −0.083 −0.287 −0.158 −0.069 −0.089 −0.151 0.305 0.585 -
RAS Success 13 0.028 −0.055 −0.045 −0.109 −0.149 −0.173 −0.044 −0.186 −0.159 0.287 0.672 0.564 -
RAS Other Trust 14 0.052 −0.065 0.160 0.083 0.017 0.069 0.197 0.075 0.135 0.194 0.467 0.43 0.488 -
RAS Not Overwhelmed 15 0.016 −0.175 0.035 −0.139 −0.28 −0.027 −0.034 −0.161 −0.133 0.160 0.52 0.222 0.323 0.349 -
RAS Total 16 −0.005 −0.175 −0.045 −0.179 −0.263 −0.198 −0.107 −0.276 −0.236 0.468 0.904 0.661 0.771 0.644 0.625 -
IOS Total 17 −0.029 −0.051 −0.125 −0.103 −0.255 −0.224 −0.110 −0.039 −0.148 0.297 0.607 0.503 0.501 0.376 0.348 0.65 -
MMQ Reflexivity 18 −0.039 −0.084 0.085 0.077 −0.063 0.054 0.070 0.117 0.077 0.101 0.5 0.474 0.502 0.478 0.387 0.621 0.714 -
MMQ Ego-strength 19 −0.099 −0.140 −0.165 −0.23 −0.374 −0.242 −0.256 −0.215 −0.307 0.423 0.684 0.302 0.473 0.242 0.513 0.642 0.69 0.566 -
MMQ Relational attunement 20 0.051 −0.016 −0.011 0.083 −0.102 0.030 0.009 0.006 0.027 0.099 0.365 0.291 0.422 0.356 0.392 0.464 0.629 0.696 0.535 -
MMQ Relational discomfort 21 0.087 0.019 −0.423 −0.252 −0.210 −0.413 −0.321 −0.369 −0.385 0.257 0.142 0.036 0.061 −0.161 −0.104 0.008 −0.007 −0.277 −0.039 −0.189 -
MMQ Distrust 22 0.073 −0.019 −0.233 −0.195 −0.085 −0.171 −0.186 −0.263 −0.231 0.157 0.004 −0.020 0.073 −0.139 −0.195 −0.027 −0.080 −0.255 −0.120 −0.101 0.657 -
MMQ Emotional dyscontrol 23 0.131 −0.053 −0.4 −0.382 −0.293 −0.433 −0.334 −0.427 −0.46 0.382 0.096 −0.066 −0.083 −0.165 0.070 −0.031 −0.111 −0.331 0.054 −0.196 0.577 0.381 -
MMQ Total 24 0.080 −0.054 −0.278 −0.153 −0.324 −0.269 −0.248 −0.224 −0.286 0.343 0.602 0.425 0.527 0.316 0.379 0.611 0.729 0.696 0.732 0.695 0.28 0.241 0.234 -
GASS Total 25 −0.096 0.040 0.413 0.456 0.222 0.425 0.438 0.562 0.578 −0.398 −0.291 −0.025 −0.081 0.086 −0.079 −0.203 −0.036 0.154 −0.152 0.078 −0.395 −0.315 −0.393 −0.182 -
RAS: Recovery Assessment Scale; WHODAS: World Health Organization Disability Assessment Scale; EQ-5D-5L-VAS: EuroQol 5-Dimension 5-Level Visual Analog Scale; IOS: Insight
Orientation Scale; MMQ: Multidimensional Mentalizing Questionnaire; GASS: Glasgow Antipsychotics Side Effect Scale; underlined and bold text represent the significant correlations
between variables (after Bonferroni correction, p< 00016).
J. Clin. Med. 2023,12, 4090 7 of 12
We conducted multiple univariate regression analyses to examine the relationship
between demographic variables and psychometric scales with the RAS total score and
its sub-scales (Table 3). All regression models we tested were statistically significant and
had high adjusted-R2values that ranged between 0.146 and 0.482. Our findings indicated
that the Self-Trust subscale of the RAS was inversely correlated with illness duration,
but directly correlated with the IOS and MMQ total scores. Furthermore, the RAS Help
subscale was directly associated with the IOS total score, the RAS Success subscale with
the MMQ total score, and the RAS Other-Trust subscale with the WHODAS total score.
We also found that illness duration was inversely correlated with the Not-Overwhelmed
subscale of the RAS. Lastly, the RAS total score was positively correlated with the Insight
and Mentalization scales scores.
Table 3. Multiple regression analyses of RAS total and RAS sub-scales scores.
RAS Self Trust RAS Help RAS Success RAS Other
Trust
RAS Not
Overwhelmed RAS Total
Model Adjusted-R20.482 0.209 0.281 0.146 0.167 0.447
Model ANOVA p-value >0.001 0.005 >0.001 0.029 0.017 <0.001
βtβtβtβtβtβt
(Constant) 0.851 2.137 0.336 0.175 0.317 0.943
Age 0.108 0.937 −
0.097
−0.68 −
0.034
−
0.251
0.12 0.812 0.2 1.372 0.11 0.928
Gender 0.164 1.947 0.169 1.625 −
0.018
−
0.179
0.191 1.763 0.195 1.823 0.143 1.642
Education −
0.049
−
0.524
0.084 0.727 0.155 1.399 0.044 0.362 −
0.121
−
1.015
0.038 0.393
Marital Status −
0.134
−
1.404
−
0.162
−
1.372
0.002 0.02 −
0.007
−
0.059
−
0.032
−
0.267
−0.09 −
0.918
Children −
0.002
−
0.017
0.117 0.946 0.125 1.055 0.001 0.011 −
0.024
−
0.187
0.064 0.616
Work 0.123 1.325 0.163 1.414 0.13 1.185 0.136 1.137 0.179 1.517 0.176 1.829
Illness Duration −0.241 −2.21 −
0.034
−
0.249
−0.02 −
0.158
−
0.082
−
0.586
−0.316 −2.284 −
0.193
−
1.708
Hospitalizations 0.146 1.598 0.074 0.651 0.181 1.681 0.118 1.007 0.058 0.496 0.154 1.627
WHODAS Total 0.007 0.065 −
0.035
−
0.274
0.027 0.222 0.286 2.149 −
0.018
−
0.141
0.076 0.713
EQ-5D-5L-VAS 0.156 1.493 0.058 0.448 0.026 0.215 0.016 0.116 −
0.164
−
1.235
0.051 0.469
IOS Total 0.286 2.232 0.397 2.512 0.151 1.005 0.255 1.552 0.17 1.046 0.35 2.646
MMQ Total 0.307 2.157 0.063 0.357 0.395 2.359 0.18 0.987 0.317 1.757 0.305 2.074
GASS Total −
0.058
−
0.554
0.12 0.931 −
0.001
−
0.008
0.008 0.063 0.019 0.142 −
0.019
−
0.176
RAS: Recovery Assessment Scale; WHODAS: World Health Organization Disability Assessment Scale; EQ-5D-
5L-VAS: EuroQol 5-Dimension 5-Level Visual Analog Scale; IOS: Insight Orientation Scale; MMQ: Multidi-
mensional Mentalizing Questionnaire; GASS: Glasgow Antipsychotics Side effect Scale; p-value
≤
0.05 for the
highlighted cells.
4. Discussion
4.1. Findings from the Study
Our study evaluated the associations between a patient-centric viewpoint on recovery
and clinical factors in individuals diagnosed with schizophrenia. Results showed that self-
reported PR was positively correlated with mentalization. The MMQ subscales “reflexivity”,
“ego-strength”, and “relational attunement” were found as the main predictive factors
explaining the PR, suggesting that people with schizophrenia who have better mentalization
capacity also have a stronger subjective experience of recovery.
4.2. Correlation between Mentalization Abilities and Other Variables
In psychosis, the integration of sensory and metacognitive information is commonly
impaired [
42
,
43
]. A considerable line of research in schizophrenia has highlighted alter-
ations in the mentalization process, and this might explain some aspects of the patients’
social dysfunction and poor social outcomes [
34
,
44
]. Deficits in ToM have been observed
in psychotic patients with compromised social behavior [
32
,
45
,
46
] and with functional
impairment especially in circumstances in which patients needed to cooperate with oth-
ers [
47
]. For instance, it has been observed that individuals with psychosis may develop
firm beliefs about others’ intentions based just on their physical observable behavior, losing
the capacity to consider alternative perspectives [
42
]. In our study, we adopted a novel tool
to investigate the mentalizing processes as a multidimensional construct [
48
]. The instru-
ment includes domains of “good” and “poor” mentalization. Good mentalizing ability is
J. Clin. Med. 2023,12, 4090 8 of 12
theorized as the effect of a steadiness between these polarizations that is able to guarantee
a flexible use of each dimension according to requirements [
49
]; meanwhile, mentalizing
difficulties are the result of inequalities, poor combination, or unwarranted divergence
in the diverse polarities [
50
]. Our results showed that “good mentalizing” subdomains
of the MMQ were positively correlated with the IOS total score, suggesting that the ten-
dency to understand the profound meaning of one’s life events, with the ability to analyze
one’s experiences and the ability to manage daily difficulties with a sense of efficacy and
realistic confidence, might influence the ability to discern personal desires and protective
strategies, along with the capacity to engage with others. There is increasing evidence
that functioning difficulties in schizophrenia are linked to social cognition deficits [
33
].
Mentalization is a key area of social cognition that has been found to be closely linked to
general functioning [
51
,
52
]. We found that the “poor mentalization” domains, including
relational discomfort, distrust, and emotional dyscontrol, had a negative correlation with
the WHO-DAS scores. In this case, the scoring of the “poor mentalization” sub-domains
of the MMQ has been reversed, meaning that higher values denote better mentalization
skills. Concurrently, a higher WHO-DAS score signifies lower functional ability. Given
the inverse correlation between these two scales, it follows that enhancement in these
“poor mentalization” MMQ domains (interpreted as an improvement due to the inverted
values) corresponds to an increase in overall functioning (or a decrease in the WHO-DAS
score). In this regard, a previous study by Bellaspìet al. on healthy subjects observed that
mentalization was positively associated with self-esteem as well as with general, social,
and role functioning, suggesting that good mentalization skills are correlated with global
measures of mental health [
53
]. A recent meta-analysis by Thibaudeau et al. exploring the
associations between ToM and different domains of functioning in schizophrenia showed a
strong association between mentalization abilities and functioning in areas involving social
interactions such as social functioning and productive activities [
43
]. Most interventions
in mental healthcare aim to reduce symptoms and improve functioning [
54
]. With regard
to PR, these interventions may also benefit from focusing on mentalization. Our findings
suggest that interventions aimed at improving mentalization ability may enhance PR in
individuals with schizophrenia. Indeed, mentalization is commonly targeted to restore
mental health, making it a common factor in most psychological treatments. In our study,
we also found an advantageous role of IOS on PR, suggesting that a better perception of
recovery was correlated with individual awareness of their own thoughts, emotions, and
behaviors. It was suggested that self-esteem and hope are important elements of recov-
ery [
55
]. Certain emotional and personological features may influence PR. Law et al. [
56
]
demonstrated that substantial emotional distress and elevated feelings of hopelessness are
unfavorable indicators of PR, whereas a positive sense of self-esteem serves as a favorable
one. In the systematic review and meta-analysis by Leendertse et al. [
25
], the authors inves-
tigated factors associated with the PR-scale total scores in people with psychotic disorders.
Large positive associations with PR were found for meaning in life, empowerment, and
hope. We found that self-trust, help, and success RAS subscales were positively associated
with the IOS total scale. This is in line with qualitative studies, which indicated that PR
from the point of view of people with psychotic disorders can be defined in terms of faith,
hope, agency, and spirituality [
57
,
58
]. The impact of disease-related characteristics on PR
has also been investigated. Chang et al. (2013), [
18
] reported that disease duration was
a significant predictor of PR in people with psychiatric disabilities and that a better PR
status would be exhibited by patients with a longer disease duration of illness. Conversely,
we found that the self-trust RAS subscale was inversely correlated with illness duration.
It might depend on the highly individual process of PR that poses the patient as the one
primarily responsible for his or her individual recovery experience [
59
]. The functioning
measured by the WHO-DAS and antipsychotic side effects, assessed by the GASS, were
significantly correlated, indicating that the side effects of antipsychotics can substantially
impact an individual’s level of functioning. However, when examining personal recovery,
as measured by RAS, we found no significant correlation with functioning. This suggests
J. Clin. Med. 2023,12, 4090 9 of 12
that an individual’s perceived recovery process is not directly associated with their func-
tional status, highlighting the importance of understanding and addressing these constructs
independently in the context of treatment and care for schizophrenia.
4.3. Limitations
The current study is not without its limitations. As is common with cross-sectional
studies, our research may be subject to temporal bias due to the snapshot nature of data
collection. We have not monitored patients longitudinally, which limits our understanding
of potential changes and trends over time. We endeavored to create a consistent and
homogeneous sample by selecting patients with stable schizophrenia, but this approach
may have inadvertently narrowed the scope of our findings, potentially restricting their
generalizability to a wider schizophrenia population. A further limitation involves the
potential cognitive impairment in our patient group. We did not incorporate measures
to account for this factor in our study design. Consequently, any cognitive deficits could
have influenced the accuracy of the responses on self-administered scales, potentially
introducing bias into our data. Finally, we predominantly relied on self-administered
scales without clinician measures for most of our assessments. While this approach has
certain advantages, it also introduces the potential for social desirability bias, as patients
may respond in ways they perceive as socially acceptable rather than providing entirely
accurate responses. These limitations highlight areas for further refinement in future
research endeavors.
5. Conclusions
Recovery from schizophrenia is a multifaceted process that encompasses numerous
elements. The ability to interpret mental states is crucial for understanding human behavior
and social interactions. Therapeutic strategies designed to bolster cognitive abilities could
potentially boost PR among individuals diagnosed with schizophrenia. The process of
mentalization might serve as a mitigating factor in functional outcomes, thereby offering a
promising approach to rehabilitation efforts targeting deficient interpersonal functioning.
Author Contributions:
Conceptualization, C.C. and A.R.; data curation, A.R., A.P. and M.S.S.; formal
analysis, A.R. and L.F.-P.; investigation, L.M. (Ludovico Mineo), A.C., L.M. (Leonardo Marano),
C.B.R., E.V.S., R.S. and R.F.; methodology, C.C., A.R. and L.F.-P.; project administration, A.R., A.P. and
M.S.S.; supervision, A.P. and M.S.S.; writing—original draft, C.C., A.R., L.M. (Ludovico Mineo) and
A.C.; writing—review and editing, C.C. and A.R. All authors have read and agreed to the published
version of the manuscript.
Funding:
AR research activity was funded by “POC Sicilia 2014-20—Avviso 37/2020” project number
G67C20000210002. MS was supported by a Starting Grant (Project: TDPsy) from the University of
Catania in the context of the PIano di inCEntivi per la RIcerca di Ateneo 2020/2022 (PIACERI).
Institutional Review Board Statement:
The study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of Azienda
Ospedaliero Universitaria—Policlinico “G. Rodolico” (protocol code 1521—4 August 2021).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the
study. Written informed consent has been obtained from the patient(s) to publish this paper.
Data Availability Statement:
The data presented in this study are available on reasonable request
from the corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.
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