ArticlePDF Available

Exploring Personal Recovery in Schizophrenia: The Role of Mentalization

MDPI
Journal of Clinical Medicine
Authors:

Abstract and Figures

Recovery is a broadly debated concept in the field of psychiatry research and in schizophrenia. 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 impact 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.
Content may be subject to copyright.
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.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
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 40.032 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.
References
1.
Slade, M.; Leamy, M.; Bacon, F.; Janosik, M.; Le Boutillier, C.; Williams, J.; Bird, V. International differences in understanding
recovery: Systematic review. Epidemiol. Psychiatr. Sci. 2012,21, 353–364. [CrossRef] [PubMed]
2.
Law, H.; Morrison, A.P. Recovery in psychosis: A Delphi study with experts by experience. Schizophr. Bull.
2014
,40, 1347–1355.
[CrossRef] [PubMed]
J. Clin. Med. 2023,12, 4090 10 of 12
3.
Cavelti, M.; Kvrgic, S.; Beck, E.M.; Kossowsky, J.; Vauth, R. Assessing recovery from schizophrenia as an individual process. A
review of self-report instruments. Eur. Psychiatry 2012,27, 19–32. [CrossRef] [PubMed]
4.
Salzer, M.S.; Brusilovskiy, E. Advancing recovery science: Reliability and validity properties of the Recovery Assessment Scale.
Psychiatr. Serv. 2014,65, 442–453. [CrossRef] [PubMed]
5.
Skar-Fröding, R.; Clausen, H.K.; Šaltyt
˙
e Benth, J.; Ruud, T.; Slade, M.; Sverdvik Heiervang, K. The Importance of Personal
Recovery and Perceived Recovery Support among Service Users with Psychosis. Psychiatr. Serv. 2021,72, 661–668. [CrossRef]
6.
Davidson, L.; Roe, D. Recovery from versus recovery in serious mental illness: One strategy for lessening confusion plaguing
recovery. J. Ment. Health 2007,16, 459–470. [CrossRef]
7.
Van Eck, R.M.; Burger, T.J.; Vellinga, A.; Schirmbeck, F.; de Haan, L. The Relationship Between Clinical and Personal Recovery in
Patients With Schizophrenia Spectrum Disorders: A Systematic Review and Meta-analysis. Schizophr. Bull.
2018
,44, 631–642.
[CrossRef]
8.
Leamy, M.; Bird, V.; Le Boutillier, C.; Williams, J.; Slade, M. Conceptual framework for personal recovery in mental health:
Systematic review and narrative synthesis. Br. J. Psychiatry 2011,199, 445–452. [CrossRef]
9.
Corrigan, P.W.; Salzer, M.; Ralph, R.O.; Sangster, Y.; Keck, L. Examining the factor structure of the recovery assessment scale.
Schizophr. Bull. 2004,30, 1035–1041. [CrossRef]
10.
Shanks, V.; Williams, J.; Leamy, M.; Bird, V.J.; Le Boutillier, C.; Slade, M. Measures of personal recovery: A systematic review.
Psychiatr. Serv. 2013,64, 974–980. [CrossRef]
11.
Gorwood, P.; Bouju, S.; Deal, C.; Gary, C.; Delva, C.; Lancrenon, S.; Llorca, P.M. Predictive factors of functional remission in
patients with early to mid-stage schizophrenia treated by long acting antipsychotics and the specific role of clinical remission.
Psychiatry Res. 2019,281, 112560. [CrossRef]
12.
Carpiniello, B.; Pinna, F.; Manchia, M.; Tusconi, M.; Cavallaro, R.; Bosia, M. Sustained symptomatic remission in schizophrenia:
Course and predictors from a two-year prospective study. Schizophr. Res. 2022,239, 34–41. [CrossRef] [PubMed]
13.
Lambert, M.; Karow, A.; Leucht, S.; Schimmelmann, B.G.; Naber, D. Remission in schizophrenia: Validity, frequency, predictors,
and patients’ perspective 5 years later. Dialogues Clin. Neurosci. 2010,12, 393–407. [CrossRef] [PubMed]
14.
Liberman, R.P.; Kopelowicz, A.; Ventura, J.; Gutkind, D. Operational criteria and factors related to recovery from schizophrenia.
Int. Rev. Psychiatry 2002,14, 256–272. [CrossRef]
15.
Yu, Y.; Xiao, X.; Yang, M.; Ge, X.P.; Li, T.X.; Cao, G.; Liao, Y.J. Personal Recovery and Its Determinants Among People Living with
Schizophrenia in China. Front. Psychiatry 2020,11, 602524. [CrossRef]
16.
Torgalsbøen, A.K. Sustaining full recovery in schizophrenia after 15 years: Does resilience matter? Clin. Schizophr. Relat. Psychoses
2012,5, 193–200. [CrossRef]
17.
Li, K.Y.; Wu, Y.H.; Chen, H.Y. Predictors of personal recovery for individuals with schizophrenia spectrum disorders living in the
community. Clin. Psychol. Psychother. 2023,30, 179–187. [CrossRef]
18.
Chang, Y.C.; Heller, T.; Pickett, S.; Chen, M.D. Recovery of people with psychiatric disabilities living in the community and
associated factors. Psychiatr. Rehabil. J. 2013,36, 80–85. [CrossRef]
19.
Song, L.Y. Predictors of personal recovery for persons with psychiatric disabilities: An examination of the Unity Model of
Recovery. Psychiatry Res. 2017,250, 185–192. [CrossRef]
20.
Wood, L.; Irons, C. Experienced stigma and its impacts in psychosis: The role of social rank and external shame. Psychol.
Psychother. 2017,90, 419–431. [CrossRef]
21.
Best, M.W.; Law, H.; Pyle, M.; Morrison, A.P. Relationships between psychiatric symptoms, functioning and personal recovery in
psychosis. Schizophr. Res. 2020,223, 112–118. [CrossRef] [PubMed]
22.
Tse, S.; Davidson, L.; Chung, K.F.; Ng, K.L.; Yu, C.H. Differences and similarities between functional and personal recovery in an
Asian population: A cluster analytic approach. Psychiatry 2014,77, 41–56. [CrossRef] [PubMed]
23.
Van Aken, B.; Wierdsma, A.; Voskes, Y.; Pijnenborg, G.; van Weeghel, J.; Mulder, C. The association between executive functioning
and personal recovery in people with psychotic disorders. Schizophr. Bull. Open 2022,3, sgac023. [CrossRef]
24.
Giusti, L.; Ussorio, D.; Tosone, A.; Di Venanzio, C.; Bianchini, V.; Necozione, S.; Casacchia, M.; Roncone, R. Is personal recovery in
schizophrenia predicted by low cognitive insight? Community Ment. Health J. 2015,51, 30–37. [CrossRef]
25.
Leendertse, J.C.P.; Wierdsma, A.I.; van den Berg, D.; Ruissen, A.M.; Slade, M.; Castelein, S.; Mulder, C.L. Personal Recovery
in People with a Psychotic Disorder: A Systematic Review and Meta-Analysis of Associated Factors. Front. Psychiatry
2021
,
12, 622628. [CrossRef]
26. Fonagy, P.; Bateman, A.W. Adversity, attachment, and mentalizing. Compr. Psychiatry 2016,64, 59–66. [CrossRef]
27.
Choi-Kain, L.W.; Gunderson, J.G. Mentalization: Ontogeny, assessment, and application in the treatment of borderline personality
disorder. Am. J. Psychiatry 2008,165, 1127–1135. [CrossRef] [PubMed]
28.
Lysaker, P.H.; Cheli, S.; Dimaggio, G.; Buck, B.; Bonfils, K.A.; Huling, K.; Wiesepape, C.; Lysaker, J.T. Metacognition, social
cognition, and mentalizing in psychosis: Are these distinct constructs when it comes to subjective experience or are we just
splitting hairs? BMC Psychiatry 2021,21, 329. [CrossRef]
29.
Vucurovic, K.; Caillies, S.; Kaladjian, A. Neural Correlates of Mentalizing in Individuals With Clinical High Risk for Schizophrenia:
ALE Meta-Analysis. Front. Psychiatry 2021,12, 634015. [CrossRef]
30.
Papadea, D.; Dalla, C.; Tata, D.A. Exploring a Possible Interplay between Schizophrenia, Oxytocin, and Estrogens: A Narrative
Review. Brain Sci. 2023,13, 461. [CrossRef]
J. Clin. Med. 2023,12, 4090 11 of 12
31.
Fusar-Poli, L.; Rodolico, A.; Sturiale, S.; Carotenuto, B.; Natale, A.; Arillotta, D.; Siafis, S.; Signorelli, M.S.; Aguglia, E. Second-to-
Fourth Digit Ratio (2D:4D) in Psychiatric Disorders: A Systematic Review of Case-control Studies. Clin. Psychopharmacol. Neurosci.
2021,19, 26–45. [CrossRef] [PubMed]
32.
Weijers, J.; Ten Kate, C.; Debbané, M.; Bateman, A.; de Jong, S.; Selten, J.-P.C.; Eurelings-Bontekoe, E. Mentalization and psychosis:
A rationale for the use of mentalization theory to understand and treat non-affective psychotic disorder. J. Contemp. Psychother.
2020,50, 223–232. [CrossRef]
33.
Fett, A.K.; Viechtbauer, W.; Dominguez, M.D.; Penn, D.L.; van Os, J.; Krabbendam, L. The relationship between neurocognition
and social cognition with functional outcomes in schizophrenia: A meta-analysis. Neurosci. Biobehav. Rev.
2011
,35, 573–588.
[CrossRef] [PubMed]
34.
Velthorst, E.; Fett, A.J.; Reichenberg, A.; Perlman, G.; van Os, J.; Bromet, E.J.; Kotov, R. The 20-Year Longitudinal Trajectories of
Social Functioning in Individuals With Psychotic Disorders. Am. J. Psychiatry 2017,174, 1075–1085. [CrossRef]
35.
Boggian, I.; Lamonaca, D.; Ghisi, M.; Bottesi, G.; Svettini, A.; Basso, L.; Bernardelli, K.; Merlin, S.; Liberman, R.P. “The Italian Study
on Recovery 2” Phase 1: Psychometric Properties of the Recovery Assessment Scale (RAS), Italian Validation of the Recovery
Assessment Scale. Front. Psychiatry 2019,10, 1000. [CrossRef]
36.
Gori, A.; Arcioni, A.; Topino, E.; Craparo, G.; Lauro Grotto, R. Development of a New Measure for Assessing Mentalizing: The
Multidimensional Mentalizing Questionnaire (MMQ). J. Pers. Med. 2021,11, 305. [CrossRef]
37.
Holmberg, C.; Gremyr, A.; Torgerson, J.; Mehlig, K. Clinical validity of the 12-item WHODAS-2.0 in a naturalistic sample of
outpatients with psychotic disorders. BMC Psychiatry 2021,21, 147. [CrossRef]
38. Ustün, T.B.; Chatterji, S.; Kostanjsek, N.; Rehm, J.; Kennedy, C.; Epping-Jordan, J.; Saxena, S.; von Korff, M.; Pull, C. Developing
the World Health Organization Disability Assessment Schedule 2.0. Bull. World Health Organ. 2010,88, 815–823. [CrossRef]
39.
Konig, H.H.; Roick, C.; Angermeyer, M.C. Validity of the EQ-5D in assessing and valuing health status in patients with
schizophrenic, schizotypal or delusional disorders. Eur. Psychiatry 2007,22, 177–187. [CrossRef]
40.
Gori, A.; Craparo, G.; Giannini, M.; Loscalzo, Y.; Caretti, V.; La Barbera, D.; Manzoni, G.M.; Castelnuovo, G.; Tani, F.; Ponti,
L.; et al. Development of a new measure for assessing insight: Psychometric properties of the insight orientation scale (IOS).
Schizophr. Res. 2015,169, 298–302. [CrossRef]
41.
Rodolico, A.; Concerto, C.; Ciancio, A.; Siafis, S.; Fusar-Poli, L.; Romano, C.B.; Scavo, E.V.; Petralia, A.; Salomone, S.; Signorelli,
M.S.; et al. Validation of the Glasgow Antipsychotic Side-Effect Scale (GASS) in an Italian Sample of Patients with Stable
Schizophrenia and Bipolar Spectrum Disorders. Brain Sci. 2022,12, 891. [CrossRef] [PubMed]
42.
Debbané, M.; Salaminios, G.; Luyten, P.; Badoud, D.; Armando, M.; Solida Tozzi, A.; Fonagy, P.; Brent, B.K. Attachment,
Neurobiology, and Mentalizing along the Psychosis Continuum. Front. Hum. Neurosci. 2016,10, 406. [CrossRef] [PubMed]
43.
Thibaudeau, É.; Cellard, C.; Turcotte, M.; Achim, A.M. Functional Impairments and Theory of Mind Deficits in Schizophrenia: A
Meta-analysis of the Associations. Schizophr. Bull. 2021,47, 695–711. [CrossRef]
44.
Dimopoulou, T.; Tarazi, F.I.; Tsapakis, E.M. Clinical and therapeutic role of mentalization in schizophrenia-a review. CNS Spectr.
2017,22, 450–462. [CrossRef]
45.
Mazza, M.; Di Michele, V.; Pollice, R.; Casacchia, M.; Roncone, R. Pragmatic language and theory of mind deficits in people with
schizophrenia and their relatives. Psychopathology 2008,41, 254–263. [CrossRef] [PubMed]
46.
Greig, T.C.; Bryson, G.J.; Bell, M.D. Theory of mind performance in schizophrenia: Diagnostic, symptom, and neuropsychological
correlates. J. Nerv. Ment. Dis. 2004,192, 12–18. [CrossRef] [PubMed]
47.
Achim, A.M.; Thibaudeau, É.; Huot, A.; Cellard, C.; Roy, M.A. What areas of everyday functioning are affected by theory of mind
deficits in recent-onset schizophrenia spectrum disorders? Early Interv. Psychiatry 2023,17, 57–64. [CrossRef]
48.
Gori, A.; Topino, E. Exploring and Deepening the Facets of Mentalizing: The Integration of Network and Factorial Analysis
Approaches to Verify the Psychometric Properties of the Multidimensional Mentalizing Questionnaire (MMQ). Int. J. Environ. Res.
Public Health 2023,20, 4744. [CrossRef]
49.
Swenson, C.R.; Choi-Kain, L.W. Mentalization and Dialectical Behavior Therapy. Am. J. Psychother.
2015
,69, 199–217. [CrossRef]
50.
Bateman, A.W.; Fonagy, P.E. Handbook of Mentalizing in Mental Health Practice; American Psychiatric Publishing, Inc.: Washington,
DC, USA, 2012.
51.
Achim, A.M.; Ouellet, R.; Roy, M.A.; Jackson, P.L. Mentalizing in first-episode psychosis. Psychiatry Res.
2012
,196, 207–213.
[CrossRef]
52.
Lysaker, P.H.; Pattison, M.L.; Leonhardt, B.L.; Phelps, S.; Vohs, J.L. Insight in schizophrenia spectrum disorders: Relationship
with behavior, mood and perceived quality of life, underlying causes and emerging treatments. World Psychiatry
2018
,17, 12–23.
[CrossRef] [PubMed]
53.
Ballespí, S.; Vives, J.; Sharp, C.; Chanes, L.; Barrantes-Vidal, N. Self and Other Mentalizing Polarities and Dimensions of Mental
Health: Association With Types of Symptoms, Functioning and Well-Being. Front. Psychol.
2021
,12, 566254. [CrossRef] [PubMed]
54.
Bighelli, I.; Wallis, S.; Reitmeir, C.; Schwermann, F.; Salahuddin, N.H.; Leucht, S. Effects of psychological treatments on functioning
in people with Schizophrenia: A systematic review and meta-analysis of randomized controlled trials. Eur. Arch. Psychiatry Clin.
Neurosci. 2022,273, 779–810. [CrossRef] [PubMed]
55.
Lysaker, P.; Yanos, P.T.; Roe, D. The role of insight in the process of recovery from schizophrenia: A review of three views.
Psychosis 2009,1, 113–121. [CrossRef]
J. Clin. Med. 2023,12, 4090 12 of 12
56.
Law, H.; Shryane, N.; Bentall, R.P.; Morrison, A.P. Longitudinal predictors of subjective recovery in psychosis. Br. J. Psychiatry
2016,209, 48–53. [CrossRef]
57.
Wood, L.; Alsawy, S. Recovery in Psychosis from a Service User Perspective: A Systematic Review and Thematic Synthesis of
Current Qualitative Evidence. Community Ment. Health J. 2018,54, 793–804. [CrossRef]
58.
Werner, S. Subjective well-being, hope, and needs of individuals with serious mental illness. Psychiatry Res.
2012
,196, 214–219.
[CrossRef]
59.
Ponce-Correa, F.; Caqueo-Urízar, A.; Berrios, R.; Escobar-Soler, C. Defining recovery in schizophrenia: A review of outcome
studies. Psychiatry Res. 2023,322, 115134. [CrossRef]
Disclaimer/Publisher’s Note:
The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.
... Previous research investigated self-reflection as a predictor of well-being [24], and suggested that this ability could be impaired in individuals with psychosis [6,37,58,59]. In schizophrenia, impaired self-reflection has been identified and shown to have a direct correlation with disease insight [59], while mentalization, of which self-reflection is a component, was found to be positively linked with recovery in psychotic patients [60]. Deficits in metacognitive skills [61], alongside specific aspects of anosognosia such as deficits in self-monitoring related to frontal lobe dysfunction [62] and impaired awareness of illness associated with fronto-temporo-parietal asymmetry [63] have been identified in psychotic patients. ...
... ρ c = −0.735). Our research adds to previous findings [6,58,60,92], suggesting that reflective insight might alleviate mental pain in patients with psychosis, or alternatively, that mental pain might hinder a patient's genuine understanding of their inner self. Our mediation analysis further highlighted the role of SRIS-I scales as a mediator in the increasing PAS, suggesting a pivotal role in the dynamics of mental pain. ...
Article
Full-text available
Understanding the cognitive processes that contribute to mental pain in individuals with psychotic disorders is important for refining therapeutic strategies and improving patient outcomes. This study investigated the potential relationship between mental pain, mind wandering, and self-reflection and insight in individuals diagnosed with psychotic disorders. We included individuals diagnosed with a ‘schizophrenia spectrum disorder’ according to DSM-5 criteria. Patients in the study were between 18 and 65 years old, clinically stable, and able to provide informed consent. A total of 34 participants, comprising 25 males and 9 females with an average age of 41.5 years (SD 11.5) were evaluated. The Psychache Scale (PAS), the Mind Wandering Deliberate and Spontaneous Scale (MWDS), and the Self-Reflection and Insight Scale (SRIS) were administered. Statistical analyses involved Spearman’s rho correlations, controlled for potential confounders with partial correlations, and mediation and moderation analyses to understand the indirect effects of MWDS and SRIS on PAS and their potential interplay. Key findings revealed direct correlations between PAS and MWDS and inverse correlations between PAS and SRIS. The mediation effects on the relationship between the predictors and PAS ranged from 9.22% to 49.8%. The largest statistically significant mediation effect was observed with the SRIS-I subscale, suggesting that the self-reflection and insight component may play a role in the impact of mind wandering on mental pain. No evidence was found to suggest that any of the variables could function as relationship moderators for PAS. The results underscore the likely benefits of interventions aimed at reducing mind wandering and enhancing self-reflection in psychotic patients (e.g., metacognitive therapy, mindfulness). Further research will be essential to elucidate the underlying mechanisms.
Article
Full-text available
Background: Personal recovery is a major goal in the field of mental health and welfare, and recovery support is of great importance. However, there has not yet been a full exploration of the direct relationship between personal recovery and occupational engagement and occupational and cognitive dysfunction, which are commonly treated within the field of occupational therapy. The aim of this study was to identify factors that influence recovery. Methods: Included in the study were 30 of our patients with schizophrenia or mood disorders. Recovery was measured by the Japanese version of the Recovery Assessment Scale (RAS), occupational engagement by the Self-completed Occupational Performance Index (SOPI), occupational dysfunction by the Screening Tool for the Classification of Occupational Dysfunction (STOD), and cognitive function by the Brief Assessment of Cognition in Schizophrenia (BACS). Correlation between each variable was examined by performing multiple regression analysis with RAS and SOPI as dependent variables. Results: RAS had significant correlation with many domains of SOPI and with the occupational alienation domain of STOD, but not with BACS. SOPI and anti-anxiety medication dose affected RAS, while SOPI was affected by the occupational marginalization domain of STOD and the executive function domain of BACS. Conclusions: Important factors in supporting recovery were focusing on the individual’s independent decision-making and executive functioning, and helping the individual identify and engage in meaningful occupations.
Article
Full-text available
Schizophrenia is characterized by symptoms of psychosis and sociocognitive deficits. Considering oxytocin's antipsychotic and prosocial properties, numerous clinical, and preclinical studies have explored the neuropeptide's therapeutic efficacy. Sex differences in the clinical course of schizophrenia, as well as in oxytocin-mediated behaviors, indicate the involvement of gonadal steroid hormones. The current narrative review aimed to explore empirical evidence on the interplay between schizophrenia psychopathology and oxytocin's therapeutic potential in consideration of female gonadal steroid interactions, with a focus on estrogens. The review was conducted using the PubMed and PsychINFO databases and conforms to the Scale for the Assessment of Narrative Review Articles (SANRA) guidelines. The results suggest a potential synergistic effect of the combined antipsychotic effect of oxytocin and neuroprotective effect of estrogen on schizophrenia. Consideration of typical menstrual cycle-related hormonal changes is warranted and further research is needed to confirm this assumption.
Article
Full-text available
Mentalization is a complex and multifaceted trans-theoretical and trans-diagnostic construct that has found increasing application in the clinical context. This research aimed at deepening the psychometric properties of the Multidimensional Mentalizing Questionnaire (MMQ), a 33-item theoretically based self-report questionnaire allowing for a comprehensive assessment of mentalizing, by integrating factor analysis and network analysis approaches. A sample of 1640 participants (M age = 33 years; SD = 13.28) was involved in the research. The six-factor structure was confirmed for the MMQ, and both the total and the subdimensions demonstrated good reliability. The network analysis has further enriched these results, showing the central role of the items attributable to Emotional Dysregulation or Reflexivity in influencing the network as well as the contribution of aspects related to Relational Discomfort in managing the flow of communication flow. Such findings may have useful clinical implications and emphasize the usefulness of the MMQ in both research and clinical practice.
Article
Full-text available
Functioning is recognized as a key treatment goal in alleviating the burden of schizophrenia. Psychological interventions can play an important role in improving functioning in this population, but the evidence on their efficacy is limited. We therefore aimed to evaluate the effect of psychological interventions in functioning for patients with schizophrenia. To conduct this systematic review and meta-analysis, we searched for published and unpublished randomized controlled trials (RCTs) in EMBASE, MEDLINE, PsycINFO, BIOSIS, Cochrane Library, WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and the Study register of the Cochrane Schizophrenia Group. The outcome functioning was measured with validated scales. We performed random-effects pairwise meta-analysis to calculate standardized mean differences (SMDs) with 95% confidence intervals (CIs). We included 58 RCTs (5048 participants). Psychological interventions analyzed together (SMD = – 0.37, 95% CI – 0.49 to – 0.25), cognitive behavioral therapy (30 RCTs, SMD = – 0.26, 95% CI – 0.39 to – 0.12), and third wave cognitive-behavioral therapies (15 RCTs, SMD = – 0.60, 95% CI – 0.83 to – 0.37) were superior to control in improving functioning, while creative therapies (8 RCTs, SMD = 0.01, 95% CI – 0.38 to 0.39), integrated therapies (4 RCTs, SMD = – 0.21, 95% CI – 1.20 to 0.78) and other therapies (4 RCTs, SMD = – 0.74, 95% CI – 1.52 to 0.04) did not show a benefit. Psychological interventions, in particular cognitive behavioral therapy and third wave cognitive behavioral therapies, have shown a therapeutic effect on functioning. The confidence in the estimate was evaluated as very low due to risk of bias, heterogeneity and possible publication bias.
Article
Full-text available
Antipsychotics are a class of psychotropic drugs that improve psychotic symptoms and reduce relapse risk. However, they may cause side effects (SE) that impact patients' quality of life and psychosocial functioning. Therefore, there is a need for practical tools to identify them and possibly intervene. The objective of the present study was to translate into Italian the Glasgow Antipsychotic Side Effect Scale (GASS), which is suggested as the questionnaire of choice to collect SE reported by patients treated with antipsychotics. We administered the GASS and the Udvalg for Kliniske Undersøgelser (UKU) SE scale-which is considered the gold standard-to 100 stable patients with schizophrenia and bipolar spectrum disorders. We measured the structural validity, internal consistency, concurrent criterion validity, construct validity, and clinical feasibility. GASS was characterized by modest structural validity and good internal consistency. The binary correlations concerning the presence of specific symptoms investigated with the GASS and the UKU were strong or relatively strong for only half of them. The GASS total scale score was inversely related to patients' quality of life and psychosocial functioning. The GASS is useful to briefly assess the burden of antipsychotic SE (~5 min) but is not optimal in identifying them.
Article
Full-text available
Background Recovery in psychotic disorder patients is a multidimensional concept that can include personal, symptomatic, societal and functional recovery. Little is known about the associations between personal recovery (PR) and functional recovery (FR). FR involves a person’s ability to recover or compensate for impaired cognition, such as executive functions, and the loss of skills. Method In this cross-sectional study (the UP’S study), we used measures of executive functioning and personal recovery to assess a cohort of people with a psychotic disorder. PR was measured using the Recovering Quality of Life (ReQOL) and Individual Recovery Outcomes (I.ROC). FR was assessed using two forms of assessment. The Behavioral Rating Inventory of Executive Functioning Adult version (BRIEF-A) was used for self-rated executive functioning, and the Tower of London (TOL) for performance-based executive functioning. Regression models were calculated between executive functioning (BRIEF-A and TOL) and PR (ReQOL and I.ROC). Model selection was based on the Wald test. Results The study included data on 260 participants. While total scores of BRIEF-A had a small negative association with those of the ReQOL (β = -0.28, p > 0.001) and the I.ROC (β = -0.41, p >0.001), TOL scores were not significantly associated with the ReQOL scores (β = 0.03, p = 0.76) and the I.ROC scores (β = 0.17, p = 0.17). Conclusion Self-reported EF, which measures the accomplishment of goal pursuit in real life was associated with PR. However, processing efficiency and cognitive control as measured by performance-based EF were not.
Article
Full-text available
Research using the integrated model of metacognition has suggested that the construct of metacognition could quantify the spectrum of activities that, if impaired, might cause many of the subjective disturbances found in psychosis. Research on social cognition and mentalizing in psychosis, however, has also pointed to underlying deficits in how persons make sense of their experience of themselves and others. To explore the question of whether metacognitive research in psychosis offers unique insight in the midst of these other two emerging fields, we have offered a review of the constructs and research from each field. Following that summary, we discuss ways in which research on metacognition may be distinguished from research on social cognition and mentalizing in three broad categories: (1) experimental procedures, (2) theoretical advances, and (3) clinical applications or indicated interventions. In terms of its research methods, we will describe how metacognition makes a unique contribution to understanding disturbances in how persons make sense of and interpret their own experiences within the flow of life. We will next discuss how metacognitive research in psychosis uniquely describes an architecture which when compromised – as often occurs in psychosis – results in the loss of persons’ sense of purpose, possibilities, place in the world and cohesiveness of self. Turning to clinical issues, we explore how metacognitive research offers an operational model of the architecture which if repaired or restored should promote the recovery of a coherent sense of self and others in psychosis. Finally, we discuss the concrete implications of this for recovery-oriented treatment for psychosis as well as the need for further research on the commonalities of these approaches.
Article
Schizophrenia is a chronic disorder with a heterogenous course and different ways in which recovery is measured or perceived. Recovery in schizophrenia is a complex process that it can be defined either from a clinical perspective focused on sustained symptom and functional remission, or from a patient-focused one, as a self-broadening process aimed at living a meaningful life beyond mental illness. Until now, studies analysed these domains separately, without examining their mutual relations and changes over time. Therefore, this meta-analysis aimed to examine the relationship of global measures of subjective recovery with each of the components of clinical recovery such as symptom severity and functioning, in patients with schizophrenia spectrum disorders. The results showed that the association between different indicators of personal recovery and remission are weak and inverse (dIG+ = -0.18, z = -2.71, p < 0.01), however, this finding is not substantial according to the sensitivity indicators. With respect to functionality and personal recovery, there was a moderate relationship (dIG+ = 0.26, z = 7.894, p < 0.01) with adequate sensitivity indices. In addition, a low consensus exists between subjective measures that are more related to the patient's perspective and clinical measures based on experts and clinician's viewpoint.
Article
Introduction: Personal recovery is a complex construct frequently used as outcome measure in people with schizophrenia spectrum disorders. This study examined potential predictors of personal recovery using the two most common assessment tools for people with schizophrenia spectrum disorders living in the community: the Chinese version of the Questionnaire about the Process of Recovery and the Chinese version of the Recovery Assessment Scale. Methods: Ninety-one individuals (57 women) diagnosed with schizophrenia spectrum disorders participated in the study (mean age: 47.41 ± 9.41 years). All participants lived in the community and received community psychiatric services. The participants were evaluated via interviews, questionnaires, and standardized assessments. Potential predictors included four domains: personal, disease-related, functional, and social. Stepwise multiple linear regression was used to analyze the potential predictors of the recovery and recovery assessment scale. Results: Resilience and social support were the only significant predictors of the Chinese versions of the Questionnaire about the Process of Recovery and Chinese version of the Recovery Assessment Scale. The primary predictor of the Chinese version of the Questionnaire about the Process of Recovery was social support from family and institutional staff. Conversely, resilience was the major predictor of the Chinese version of the Recovery Assessment Scale. Discussion: For people with schizophrenia spectrum disorders living in the community, social support and resilience significantly predicted personal recovery. Age, educational level, and disease-related and functional factors were not significant predictors of personal recovery. Therefore, it is important to develop successful personal recovery-oriented practices that enhance resilience and promote social support.
Article
Aim: Functional recovery is now a recognized treatment goal for schizophrenia. It is therefore important to better understand the cognitive and psychological factors that influence functioning. Theory of mind (ToM) deficits are common in schizophrenia and have been linked to greater impairments in functioning. The current study aimed to identify which specific areas of functioning are linked to ToM in a group of 54 patients with a recent-onset of a schizophrenia spectrum disorder. Methods: ToM was assessed with the Combined Stories Test (COST). Several areas of functioning were rated based on an extensive semi-structured interviews. Results: Among the different areas of functioning that were examined, ToM showed a significant, positive relationship with ratings for productive activities (e.g. work or school) as well as with collaboration to psychiatric care. Conclusion: These results suggest that ToM can impair functioning especially in situations in which patients need to collaborate with others, including the interactions with the clinical team.
Article
Background Although remission is a priority target in psychosis, reported rates show a marked variation across studies and instability over time. Such variability, partly due to methodology, emphasizes the need to define the optimal assessment procedure, as well as to identify reliable predictors. This study aims to: 1. longitudinally compare remission status according to different criteria; 2. identify predictors of duration and stability. Methods 112 patients with schizophrenia or schizoaffective disorder underwent comprehensive clinical evaluations, with 24-month follow-up. Remission was assessed using three criteria: Remission in Schizophrenia Working Group (RSWG) vs Positive and Negative Syndrome Scale (PANSS) positive and negative scales (PANSS-PN) vs total score (PANSS-T). Kaplan-Meier survival analysis was used for longitudinal comparison, regression models to identify predictors of duration and stability. Results At enrolment 50% of patients were in remission according to RSWG, while only 23.2% reached the other criteria. PANSS-T cumulative remission rates showed the greatest stability. Stable remission according to RSWG criteria was predicted by negative symptoms, while no significant predictors emerged for PANSS-T. Remission duration was predicted by negative, positive and cognitive symptoms and treatment dosage for RSWG criteria, while for PANSS-T the predictors were cognitive symptoms and duration of illness. Conclusion Results are in line with previous literature on remission rates and further support the role of basal clinical predictors. In addition, this study shows that more stringent criteria are more stable over time, suggesting their predictive value and the relevance of their use to optimize evaluations also in clinical settings.