Further support for the role of dysfunctional attitudes in models
of real-world functioning in schizophrenia
William P. Horan*, Yuri Rassovsky, Robert S. Kern, Junghee Lee, Jonathan K. Wynn, Michael F. Green
VA Greater Los Angeles Healthcare System, University of California, Los Angeles, United States
a r t i c l ei n f o
Received 31 August 2009
Received in revised form 2 November 2009
Accepted 3 November 2009
Structural equation modeling
a b s t r a c t
According to A.T. Beck and colleagues’ cognitive formulation of poor functioning in schizophrenia, mal-
adaptive cognitive appraisals play a key role in the expression and persistence of negative symptoms
and associated real-world functioning deficits. They provided initial support for this model by showing
that dysfunctional attitudes are elevated in schizophrenia and account for significant variance in negative
symptoms and subjective quality of life. The current study used structural equation modeling to further
evaluate the contribution of dysfunctional attitudes to outcome in schizophrenia. One hundred eleven
outpatients and 67 healthy controls completed a Dysfunctional Attitudes Scale, and patients completed
a competence measure of functional capacity, clinical ratings of negative symptoms, and interview-based
ratings of real-world functioning. Patients reported higher defeatist performance beliefs than controls
and these were significantly related to lower functional capacity, higher negative symptoms, and worse
community functioning. Consistent with Beck and colleagues’ formulation, modeling analyses indicated a
significant indirect pathway from functional capacity ? dysfunctional attitudes ? negative symp-
toms ? real-world functioning. These findings support the value of dysfunctional attitudes for under-
standing the determinants of outcome in schizophrenia and suggest that therapeutic interventions
targeting these attitudes may facilitate functional recovery.
Published by Elsevier Ltd.
There has recently been a fundamental shift in schizophrenia
treatment research from psychotic symptom management to the
considerably broader and more ambitious goal of ‘‘recovery” (Kern
et al., 2009). Although it has been defined in several ways, recovery
typically refers not only to remission of psychotic symptoms, but
also achievement of productive, sustained functioning in indepen-
dent living, vocational or educational activities, and satisfying
interpersonal relationships (Liberman et al., 2002). To facilitate
treatment development, much effort has been devoted to identify-
ing key determinants of poor functioning that can be targeted
through novel interventions. Among these factors, neurocognitive
deficits and negative symptoms have received the strongest sup-
port as important correlates of functioning (Green et al., 2000;
Kirkpatrick et al., 2006). However, the pathways through which
these variables are ultimately linked to functioning are complex,
and likely involve a host of intervening variables. A handful of re-
cent studies have used statistical modeling approaches, such as
structural equation modeling or path analysis, to delineate the
complex interplay among factors that ultimately lead to poor func-
tioning in the community (e.g., Bowie et al., 2006; Sergi et al.,
2006; Vauth et al., 2004). By testing theoretically-based models
of outcome, investigators can gain insights into the mechanistic
relations among the determinants of outcome, which can help
guide treatment development efforts.
Although several models of outcome have been proposed (Bel-
lack et al., 2007), one useful heuristic broadly distinguishes among
competence, performance, and intervening factors (Harvey et al.,
2007). Competence refers to what an individual can do or is capable
of doing under optimal circumstances and comprises several sub-
domains, including neurocognitive performance and capacity to
perform everyday living and social activities on laboratory-based
measures (i.e., ‘‘functional capacity”). Real-world performance, on
the other hand, refers to what one actually does in daily life in
the community. It is clear that competence does not fully predict
performance in the community. For example, neurocognitive mea-
sures typically account for a moderate proportion of the variance in
real-world functioning, with composite scores accounting for
about 20–40% of the variance in outcome (Green et al., 2000). Func-
tional capacity measures, while strongly related to neurocognitive
measures, demonstrate much weaker and more variable relations
0022-3956/$ - see front matter Published by Elsevier Ltd.
* Corresponding author. Address: VA Greater Los Angeles Healthcare System,
UCLA, Department of Psychiatry and Biobehavioral Sciences, 11301 Wilshire Blvd,
Bldg 210A, Los Angeles, CA 90073, United States. Tel.: +1 310 478 3711x44041; fax:
+1 310 268 4056.
E-mail address: firstname.lastname@example.org (W.P. Horan).
Journal of Psychiatric Research 44 (2010) 499–505
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