This study further supports the contribution of dysfunctional attitudes to poor outcome in schizophrenia as proposed by Beck and colleagues’ cognitive formulation. Patients reported substantial elevations of both defeatist beliefs and need for acceptance, reflecting strongly held maladaptive beliefs about their capacity to engage in productive activities and the importance of how they are perceived by others. Among patients, these attitudes were significantly related to variables that are more typically studied in models of outcome, including negative symptoms, real-world functioning, and functional capacity. Furthermore, modeling analyses were consistent with the notion that defeatist beliefs play a key intervening role in an indirect pathway from what one can do (competence) to what one actually does in the community (performance). These findings support the value of dysfunctional attitudes for understanding the determinants of outcome in schizophrenia and suggest that therapeutic interventions targeting these attitudes may facilitate functional recovery.
This study extends prior research by demonstrating that lower competence as defined by level of performance on the UPSA, a functional capacity measure that is strongly related to neurocognitive functioning (Harvey et al., 2007
), is associated with higher dysfunctional attitudes. This finding bolsters support for Beck and colleagues’ model, which proposes that patients develop dysfunctional attitudes as a consequence of discouraging life experiences engendered by competence limitations. One interpretation of these findings is that the patients’ high levels of defeatist beliefs reflect a “defeatist-realist” attitude that corresponds to the well-documented cognitive and functional capacity limitations associated with schizophrenia (Harvey et al., 2007
). However, recent evidence that many people with schizophrenia demonstrate substantial impairment on objective cognitive tests yet fail to report difficulties on self-evaluations of cognitive functioning appears at odds with this interpretation (e.g., (Medalia, Thysen, & Freilich, 2008
)); such unrealistically positive self-evaluations would not be expected to lead to defeatism. Thus, consideration of other patient characteristics, such as insight into cognitive and functional capacity, may be needed to fully understand this relationship.
The SEM analyses provide the first direct support for the predicted relations among dysfunctional attitudes, negative symptoms, and real-world functioning in Beck and colleagues’ model. The initial set of analyses indicated that negative symptoms mediate the relation between dysfunctional attitudes and functioning, consistent with the theory that dysfunctional attitudes contribute to lower levels of interest and motivation to engage in productive activities (as reflected by SANS ratings), which ultimately manifests in poor real-world functioning. This conceptualization fits well with theoretical models of the cognition-motivation interface, particularly the expectancy-value theory of motivation (Eccles & Wigfield, 2002
), and the importance of motivational factors is increasingly recognized in schizophrenia (Barch, Yodkovik, Sypher-Locke, & Hanewinkel, 2008
; Choi, Mogami, & Medalia, in press
In an expanded model, the UPSA did not demonstrate a significant direct relation to real-world functioning. This result is consistent with the conceptualization of the UPSA as a functional competence measure of what one is capable of doing rather than a measure of actual real-world functioning (Harvey et al., 2007
). However, UPSA scores did demonstrate a significant indirect relation to functioning via the intervening variables of dysfunctional attitudes and negative symptoms. This suggests that dysfunctional attitudes are more proximally related to real-world functioning than competence limitations. Clinically, this implies that addressing dysfunctional attitudes will likely be important for optimal generalization of any benefits from basic skills training interventions. Although rehabilitation programs may help patients develop new skills, patients’ willingness to actually apply these skills in daily life may be significantly limited by deeply engrained dysfunctional attitudes about their capacities and relationships. Indeed, a recent group-based psychosocial treatment study of people with schizophrenia demonstrated that improvements in a specific type of dysfunctional beliefs, namely social disinterest attitudes, were associated with better real-world functioning at the conclusion of treatment (Granholm, Been-Zeev, & Link, in press
). Thus, addressing dysfunctional attitudes may facilitate generalization of newly acquired skills, which has historically been disappointing in psychosocial treatments for schizophrenia.
The current study built on Grant and Beck’s initial study of dysfunctional attitudes by using larger samples, a more objective measure real-world functioning, a measure of functional capacity, and a more powerful statistical modeling approach. While generally consistent with their findings, the current results differed in two ways. First, whereas their study found a stronger pattern of correlations for defeatist beliefs than need for acceptance, the pattern and strength of correlations in this study were relatively comparable for both scales. Second, the magnitudes of the correlations in the current study were generally smaller. Our lower correlations with functional outcome may be attributable to the more objective outcome measure used in the current study. The discrepancy for negative symptoms is more challenging to explain as both studies used the SANS and evaluated chronically ill outpatients. This difference could partly reflect sample characteristics, as the patients in our study were generally older and were partially recruited through a Veterans Administration facility.
The current study should be interpreted in light of several limitations. First, all analyses are cross-sectional and therefore cannot establish any causal relations. Although the modeling analyses followed theoretically based predictions and converge with earlier empirical findings, alternative relations are logically possible (e.g., negative symptoms could lead to dysfunctional attitudes). Second, there are many different reasons why an individual may function poorly and the current study focused on only a subset of potentially relevant determinants. Including additional variables, such as neurocognitive and social cognitive functioning, insight, and broader socio-environmental factors, can provide a more comprehensive test of the role of dysfunctional attitudes, but will require larger sample sizes for SEM analyses. Third, this study examined medicated, chronically ill outpatients, many of whom had lengthy histories of inactivity and low productivity. It will be useful to evaluate whether these finding generalize to recent-onset and prodromal patients.
One potentially fruitful direction for future research is to develop new instruments to assess dysfunctional attitudes associated with negative symptoms and functioning in schizophrenia. According to the Beck and colleagues’ formulation (Beck et al., 2009
; Rector et al., 2005
), specific negative symptoms are differentially associated with particular beliefs, expectancies, and social attitudes. The development of new measures based on this model could help maximize reliability and robustness of relations with alternative measures, improve measurement precision in model evaluation, and guide treatment development efforts. Models of outcome that incorporate variables grounded in cognitive therapy are particularly appealing because they may be amenable to intervention through well-established therapeutic principles. The current findings are consistent with recent recommendations that multimodal treatment approaches are needed to address the multiple determinants of poor real-world functioning (Kern et al., 2009
). A combination of social skills training to address basic social competence limitations plus CBT to address dysfunctional beliefs that undermine motivation to actually use newly developed skills may be particularly effective. Efforts to integrate these complementary approaches have already begun (e.g., (Granholm et al., 2007
)) and further development of interventions to address dysfunctional beliefs may help achieve the ambitious goal of functional recovery.