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Department of Psychiatry, 116H, Roudebush VA Medical Center, 1481 West 10th St., Indianapolis, IN 46202, USA
b
Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
c
Department of Psychology, Indiana University Purdue University at Indianapolis, Indianapolis, IN, USA
d
Department of Community Mental Health, University of Haifa, Haifa, Israel
Received 26 January 2007; received in revised form 20 April 2007; accepted 27 April 2007
Abstract
Observations that diminishment of self-experience is commonly observed in schizophrenia have led to the suggestion that the
deepening of self-experience may be an important domain of recovery. In this study we examined whether internalized stigma and
deficits in metacognition are possible barriers to the development of richer self-experience. Narratives of self and illness were
obtained using a semi-structured interview from 51 persons with schizophrenia spectrum disorder before entry into a rehabilitation
research program. The quality of self-experience within those narratives was rated using the Scale to Assess Narrative
Development (STAND). These scores were then correlated with concurrent assessments of stigma using the Internalized Stigma of
Mental Illness Scale (ISMIS) and metacognition using the Metacognition Assessment Scale (MAS). A stepwise multiple regression
controlling for age, social desirability and awareness of illness revealed that higher STAND ratings were significantly associated
with greater ratings of metacognitive capacity and lesser ratings of stereotype endorsement. Results suggest that qualities of selfexperience expressed within personal narratives of schizophrenia may be affected by internalized stigma and deficits in the capacity
to think about one's own thinking and the thinking of others.
2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Schizophrenia; Recovery; Stigma; Narrative; Metacognition; Insight
1. Introduction
Evidence has steadily accumulated over the last 30
years that many people with schizophrenia spectrum
disorders achieve partial or full recovery (Corrigan, 2003;
Harding et al., 1992; Roe, 2001; Spaniol et al., 2002;
Corresponding author. Department of Psychiatry, 116H, Roudebush VA Medical Center, 1481 West 10th St., Indianapolis, IN 46202,
USA. Fax: +1 317 988 3578.
E-mail address: plysaker@iupui.edu (P.H. Lysaker).
0165-1781/$ - see front matter 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2007.04.023
32
2. Methods
2.1. Participants
Participants were 46 adult men and 5 women with
DSM-IV diagnoses of schizophrenia (n = 31) or schizoaffective disorder (n = 20) as confirmed by the
Structured Clinical Interview for DSM-IV (SCID).
The participants comprised the full sample of persons
enrolled in a larger study seeking to develop a
cognitive behavioral therapy targeting working function in schizophrenia. All were recruited from the
outpatient Psychiatry Service of a VA Medical Center
or Community Mental Health Center and were in a
post-acute phase of illness as defined by having no
hospitalizations or changes in medication or housing in
the month before entering the study. Excluded from the
study were participants with mental retardation or
active substance abuse. The mean age and education of
the sample were 48.49 (S.D. = 9.2) and 12.67 (S.D. =
2.6) years, respectively. Participants had, on average,
5.94 lifetime psychiatric hospitalizations (S.D. = 6.6)
with the first occurring on average at the age of 27.20
(S.D. = 9.9). Ethnic breakdown was as follows: Caucasian, n = 22; African-American, n = 28; and Latino,
n = 1.
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2.2. Instruments
2.2.1. Scale to Assess Unawareness of Mental Disorder
(SUMD; Amador et al., 1994)
The SUMD is a rating scale completed by clinically
trained research staff following a semi-structured interview and chart review. For the purposes of this study, we
used the sum of the three central items of the SUMD: (a)
awareness of mental disorder; (b) awareness of the
consequences of mental disorder; and (c) awareness of
the effects of medication. Each of these items is rated on
a five-point scale that ranges from 1 (complete
awareness) to 5 (severe unawareness). The total
score can accordingly range from 3 to 15. Assessment
of interrater reliability for raters in this study was in the
good to excellent range (intraclass r = 0.90).
2.2.2. The Vocabulary subtest (VS; Wechsler, 1997)
The VS is a subtest of the WAIS III that assesses
participants' knowledge of vocabulary by presenting
words for participants to define in increasing order of
difficulty. This subtest has been widely used to assess
global verbal intellectual function. Age-corrected scaled
scores are generated with the expected population mean
being 10.
34
35
2.4. Analyses
Analyses were planned in five phases. First, we
sought to determine if the STAND, MAS and ISMIS
scores were linked with demographic variables including age, education, diagnosis, and hospitalization
history. Second, univariate correlations were conducted
to determine whether the STAND, MAS or ISMIS
scores were linked with the variables identified as
possible confounds: the SUMD, VS, and MCSDS
scores. Third, univariate correlations were conducted
to determine whether the STAND was associated with
the MAS and ISMIS scores. Fourth, in the case that both
the MAS and any of the ISMIS scores were linked with
the STAND, a stepwise multiple regression was planned
in which potential confounds would be forced to enter
first as covariates and then MAS and ISMIS Stereotype
Endorsement scores would be allowed to enter to predict
the STAND total score. Finally, exploratory correlations
were planned to examine associations between indivi-
Table 1
Mean and standard deviations
Score
15
15
15
15
520
09
08
03
09
029
14
14
14
015
033
36
Table 2
Stepwise multiple regression predicting the Scale to Assess Narrative
Development total from measures of metacognition, insight and stigma
(n = 51)
Independent variables
Partial Model df
Ra
Ra
Education b
Social Desirability scale a
Scale to Assess Awareness
of Mental Disorders total b
Metacognition
assessment total c
Stereotyped Self-Stigma
scale c
0.06
0.06
(1,49)
3.04 0.09
0.19
0.25
(2,47)
6.28 0.004
0.16
0.41
0.11
0.52
Table 3
Pearson correlations and their statistical significance comparing STAND subscales with the MAS subscales and ISMIS Stereotype Endorsement score
STAND
subscales
Understanding
one's own mind
MAS subscales
Understanding
the others' minds
Decentration
Mastery
ISMIS Stereotype
Endorsement
Illness Awareness
Alienation
Agency
Social Worth
0.49 (0.0001)
0.36 (0.01)
0.28 (0.05)
0.21 (0.14)
0.21 (0.14)
0.42 (0.002)
0.18 (0.20)
0.38 (0.006)
0.19 (0.17)
0.32 (0.02)
0.27 (0.06)
0.32 (0.02)
0.60 (0.0001)
0.44 (0.001)
0.47 (0.001)
0.39 (0.003)
0.29 (0.05)
0.21 (0.14)
0.31 (0.03)
0.36 (0.009)
37
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