Social Psychiatry and Psychiatric Epidemiology

, Volume 47, Issue 10, pp 1685–1693 | Cite as

Understanding reduced activity in psychosis: the roles of stigma and illness appraisals

  • Anna Moriarty
  • Suzanne Jolley
  • Margie M. Callanan
  • Philippa Garety
Original Paper



Increasing activity and social inclusion for people with psychosis is a primary goal of mental health services. Understanding the psychological mechanisms underlying reduced activity will inform more carefully targeted and effective interventions. Anxiety, depression, positive symptom distress and negative symptoms all make a contribution, but much of the variance in activity remains unaccounted for and is poorly understood. Appraisals of illness impact on adjustment to illness: mood, engagement in treatment and quality of life are all affected. It is plausible that illness appraisals will also influence activity. This study investigated the extent to which three components of illness appraisal accounted for variance in activity.


50 people with psychosis completed measures of activity, positive and negative symptoms, anxiety and depression, cognitive functioning, stigma, insight and illness perceptions.


Multiple regression revealed that internalised stigma, but not insight or illness perception, was significantly correlated with reduced activity. 42% of the variance in activity was accounted for by stigma, negative symptoms, positive symptom distress and social support. Affect, cognitive functioning and positive symptoms were not associated with activity.


For people with psychosis, activity levels appear to be compromised particularly by fears of what others think of them and how they will be treated by others. Directly targeting these fears should improve the impact of psychological interventions on functioning. Specific, individualised cognitive behavioural interventions could be a useful adjunct to recovery-focused narrative therapies and complement public information campaigns to reduce discriminatory attitudes and behaviours.


Schizophrenia Social functioning Insight Discrimination 



This work was supported by the Department of Applied Psychology, Canterbury Christ Church University, Salomons Campus, in partial fulfilment of the award of doctorate in clinical psychology.


  1. 1.
    Bebbington P, Bhugra D, Brughra T, Singleton N, Farrell M, Jenkins R, Lewis G, Meltzer H (2004) Psychosis, victimisation and childhood disadvantage. Br J Psychiatry 185:220–226PubMedCrossRefGoogle Scholar
  2. 2.
    Birchwood M, Iqbal Z, Upthegrove R (2005) Psychological pathways to depression in schizophrenia: studies in acute psychosis, post psychotic depression and auditory hallucinations. Eur Arch Psychiatry Clin Neurosci 255:202–212PubMedCrossRefGoogle Scholar
  3. 3.
    Birchwood M, Trower P, Brunet K, Gilbert P, Iqbal Z, Jackson C (2007) Social anxiety and the shame of psychosis: a study in first episode psychosis. Behav Res Ther 45(5):1025–1037PubMedCrossRefGoogle Scholar
  4. 4.
    Broadbent E, Petrie KJ, Main J, Weinman J (2006) The brief illness perception questionnaire. J Psychosom Res 60:631–637PubMedCrossRefGoogle Scholar
  5. 5.
    Brohan E, Elgie R, Sartorius N, Thornicroft G (2010) Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: the GAMIAN-Europe study. Schizophr Res 122:232–238PubMedCrossRefGoogle Scholar
  6. 6.
    Cavelti M, Kvrgic S, Beck EM, Rüsch N, Vauth R (2011) Self-stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders. Compr Psychiatry. doi: 10.1016/j.comppsych.2011.08.001
  7. 7.
    Cechnicki A, Angermeyer MC, Bielańska A (2011) Anticipated and experienced stigma among people with schizophrenia: its nature and correlates. Soc Psychiatry Psychiatr Epidemiol 46(7):643–650PubMedCrossRefGoogle Scholar
  8. 8.
    Clement S, Brohan E, Sayce L, Pool J, Thornicroft G (2011) Disability hate crime and targeted violence and hostility: a mental health and discrimination perspective. J Ment Health 20(3):219–225PubMedCrossRefGoogle Scholar
  9. 9.
    Cohen J (1988) Statistical power analysis for the behavioral sciences, 2nd edn. Erlbaum, HillsdaleGoogle Scholar
  10. 10.
    David AS (1990) Insight and psychosis. Br J Psychiatry 156:798–808PubMedCrossRefGoogle Scholar
  11. 11.
    Department of Health (2011) NHS operating framework. DH, LondonGoogle Scholar
  12. 12.
    Dickerson FB, Sommerville J, Origoni AE, Ringel NB, Parente F (2002) Experiences of stigma among outpatients with schizophrenia. Schizophr Bull 28:143–155PubMedCrossRefGoogle Scholar
  13. 13.
    Dixon LB, Dickerson F, Bellack AS et al (2009) The 2009 Schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophr Bull 36:48–70PubMedCrossRefGoogle Scholar
  14. 14.
    Evans-Lacko S, Brohan E, Mojtabai R, Thornicroft G (2011) Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries. Psychol Med 16:1–13Google Scholar
  15. 15.
    Folstein MF, Folstein SE, McHugh PR (1975) Mini mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12(3):189–198PubMedCrossRefGoogle Scholar
  16. 16.
    Fung KMT, Tsang HWH, Cheung W (2011) Randomized controlled trial of the self-stigma reduction program among individuals with schizophrenia. Psychiatry Res 189(2):208–214PubMedCrossRefGoogle Scholar
  17. 17.
    Fung KM, Tsang HW, Chan F (2010) Self-stigma, stages of change and psychosocial treatment adherence among Chinese people with schizophrenia: a path analysis. Soc Psychiatry Psychiatr Epidemiol 45(5):561–568PubMedCrossRefGoogle Scholar
  18. 18.
    Gaite L, Vázquez-Barquero JL, Borra C, Ballesteros J, Schene A, Welcher B, Thornicroft G, Becker T, Ruggeri M, Herrán A, EPSILON Study Group (2002) Quality of life in patients with schizophrenia in five European countries: the EPSILON study. Acta Psychiatr Scand 105(4):283–292PubMedCrossRefGoogle Scholar
  19. 19.
    Grant PM, Huh GA, Perivoliotis D, Stolar NM, Beck AT (2011) Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Arch Gen Psychiatry. doi: 10.1001/archgenpsychiatry.2011.129
  20. 20.
    Green MF, Kern RS, Braff DL, Mintz J (2000) Neurocognitive deficits and functional outcome in schizophrenia: are we measuring the ‘right stuff’? Schizophr Bull 26(1):119–136PubMedCrossRefGoogle Scholar
  21. 21.
    Green MF, Kern RS, Heaton RK (2004) Longitudinal studies of cognition and functional outcome in schizophrenia: implications for MATRICS. Schizophr Res 72(1):41–51PubMedCrossRefGoogle Scholar
  22. 22.
    Green MF, Bearden CE, Cannon TD, Fiske AP, Hellemann GS, Horan WP et al (2011) Social cognition in schizophrenia, Part 1: Performance across phase of illness. Schizophr Bull. advance access, doi: 10.1093/schbul/sbq171
  23. 23.
    Haddock G, McCarron J, Tarrier N, Faragher EB (1999) Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales. Psychol Med 29:879–889PubMedCrossRefGoogle Scholar
  24. 24.
    Hasson-Ohayon I, Kravetz S, Roe D, David A, Weiser M (2006) Insight into psychosis and quality of life. Compr. Psychiatry. 47(4):265–269PubMedCrossRefGoogle Scholar
  25. 25.
    Henry JD, von Hippel C, Shapiro L (2010) Stereotype threat contributes to social difficulties in people with schizophrenia. Br J Clin Psychol 49:31–41PubMedCrossRefGoogle Scholar
  26. 26.
    Holley J, Crone D, Tyson P, Lovell G (2011) The effects of physical activity on psychological well-being for those with schizophrenia: a systematic review. Br J Clin Psychol 50:84–105PubMedCrossRefGoogle Scholar
  27. 27.
    Horan WP, Kern RS, Tripp C, Hellemann G, Wynn JK, Bell M, Marder SR, Green MF (2011) Efficacy and specificity of Social Cognitive Skills Training for outpatients with psychotic disorders. J. Psychiatr. Res 45:1113–1122PubMedCrossRefGoogle Scholar
  28. 28.
    Jolley S, Garety P, Dunn G, White J, Aitken M, Challacombe F, Griggs M, Wallace M, Craig T (2005) A pilot validation study of a new measure of activity in psychosis. Soc Psychiatry Psychiatr Epidemiol 40:905–911PubMedCrossRefGoogle Scholar
  29. 29.
    Jolley S, Garety PA, Ellett L, Kuipers E, Freeman D, Bebbington PE, Fowler D, Dunn G (2006) A validation of a new measure of activity in psychosis. Schizophr Res 85:288–295PubMedCrossRefGoogle Scholar
  30. 30.
    Kay SR, Fiszbein A, Opler LA (1987) The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 13:261–276PubMedGoogle Scholar
  31. 31.
    Knight MTD, Wykes T, Hayward P (2006) Group treatment of perceived stigma and self-esteem in schizophrenia: a waiting list trial of efficacy. Behav Cogn Psychother 34:305–318CrossRefGoogle Scholar
  32. 32.
    Layard R, Clark D, Knapp M, Mayraz G (2007) Cost-benefit analysis of psychological therapy. CEPDP, 829. Centre for Economic Performance, London School of Economics and Political Science, LondonGoogle Scholar
  33. 33.
    Lee S (2002) The stigma of schizophrenia: a transcultural problem. Curr Opin Psychiatr 15:37–41CrossRefGoogle Scholar
  34. 34.
    Leiderman EA, Vazquez G, Berizzo C, Bonifacio A, Bruscoli N, Capria JI, Ehrenhaus B, Guerrero M, Guerrero M, Lolich M, Milev R (2011) Public knowledge, beliefs and attitudes towards patients with schizophrenia: Buenos Aires. Soc Psychiatry Psychiatr Epidemiol 46(4):281–290PubMedCrossRefGoogle Scholar
  35. 35.
    Lobban F, Barrowclough C, Jones S (2004) The impact of beliefs about mental health problems and coping on outcome in schizophrenia. Psychol Med 34:1165–1176PubMedCrossRefGoogle Scholar
  36. 36.
    Lysaker PH, Roe D, Yanos PH (2007) Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders. Schizophr Bull 33(1):192–199PubMedCrossRefGoogle Scholar
  37. 37.
    Lysaker PH, Davis LW, Warman DM, Strasburger A, Beattie N (2007) Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: associations across 6 months. Psychiatr Res 149(1):89–95CrossRefGoogle Scholar
  38. 38.
    Lysaker PH, Buck KD, Salvatore G, Popolo R, Dimaggio G (2009) Lack of awareness of illness in schizophrenia: conceptualizations, correlates and treatment approaches. Expert Rev Neurother 9:1035–1043PubMedCrossRefGoogle Scholar
  39. 39.
    Lysaker PH, Tunze C, Yanos PT, Roe D, Ringer J et al (2011) Relationships between stereotyped beliefs about mental illness, discrimination experiences, and distressed mood over 1 year among persons with schizophrenia enrolled in rehabilitation. Soc Psychiatry Psychiatr Epidemiol. doi: 10.1007/s00127-011-0396-2
  40. 40.
    Malla AK, Norman RM, Manchanda R, Townsend L (2002) Symptoms, cognition, treatment adherence and functional outcome in first-episode psychosis. Psychol Med 32(6):1109–1119PubMedCrossRefGoogle Scholar
  41. 41.
    Macinnes DL, Lewis M (2008) The evaluation of a short group programme to reduce self-stigma in people with serious and enduring mental health problems. J Psychiatr Ment Health Nurs 15:59–65PubMedCrossRefGoogle Scholar
  42. 42.
    National Institute for Clinical Excellence (2009) Core interventions in the treatment and management of schizophrenia in primary and secondary care. NICE, LondonGoogle Scholar
  43. 43.
    Norman RM, Windell D, Lynch J, Manchanda R (2011) Parsing the relationship of stigma and insight to psychological well-being in psychotic disorders. Schizophr Res 133(1–3):3–7PubMedCrossRefGoogle Scholar
  44. 44.
    Olbrich R, Voss E, Mussgay L, Pfeiffer H (1993) A weighted time budget approach for the assessment of cognitive and social activities. Soc Psychiatry Psychiatr Epidemiol 28:184–188PubMedCrossRefGoogle Scholar
  45. 45.
    Petrie K, Jago LA, Devcich DA (2007) The role of illness perceptions in patients with medical conditions. Curr Opin Psychiatr 20:163–167CrossRefGoogle Scholar
  46. 46.
    Purvis RG, Ohlsen RI, O’Toole MS, Pilowsky LS, Brown RG (2004) Realworld functional outcome in schizophrenia: a goal-directed behaviour model. Schizophr Res 62(1):200Google Scholar
  47. 47.
    Reitan RM (1958) Validity of the trail making test as an indication of organic brain damage. Percept. Motor Skill 8:271–276Google Scholar
  48. 48.
    Ritscher JB, Otilingam PG, Grajales M (2003) Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatr Res 121:31–49CrossRefGoogle Scholar
  49. 49.
    Roe D, Hasson-Ohayon I, Derhi O, Yanos PT, Lysaker PH (2010) Talking about life and finding solutions to different hardships: a qualitative study on the impact of narrative enhancement and cognitive therapy on persons with serious mental illness. J Nerv Ment Dis 198(11):807–812PubMedCrossRefGoogle Scholar
  50. 50.
    Rose D, Willis R, Brohan E, Sartorius N, Villares C, Wahlbeck K, Thornicroft GINDIGO, Group Study (2011) Reported stigma and discrimination by people with a diagnosis of schizophrenia. Epidemiol Psychiatr Sci 20(2):193–204PubMedCrossRefGoogle Scholar
  51. 51.
    Rüsch N, Corrigan PW, Powell K, Rajah A, Olschewski M, Wilkniss S, Batia K (2009) A stress-coping model of mental illness stigma: I. Predictors of cognitive stress appraisal. Schizophr Res 110(1-3):59–64PubMedCrossRefGoogle Scholar
  52. 52.
    Rüsch N, Corrigan PW, Wassel A, Michaels P, Olschewski M, Wilkniss S, Batia K (2009) A stress-coping model of mental illness stigma: II. Emotional stress responses, coping behavior and outcome. Schizophr Res 110(1–3):65–71PubMedCrossRefGoogle Scholar
  53. 53.
    Sibitz I, Unger A, Woppmann A, Zidek T, Amering M (2011) Stigma resistance in patients with schizophrenia. Schizophr Bull 37(2):316–323PubMedCrossRefGoogle Scholar
  54. 54.
    SS SP (2007) SPSS Base 16 user’s guide. SPSS Inc., ChicagoGoogle Scholar
  55. 55.
    Staring ABP, van der Gaag M, van den Berge M, Duivenvoorden HJ, Mulder CL (2009) Stigma moderates the associations of insight with depressed mood, low self-esteem, and low quality of life in patients with schizophrenia spectrum disorders. Schizophr Res 115(2–3):363–369PubMedCrossRefGoogle Scholar
  56. 56.
    Theodore K, Johnson S, Chalmers-Brown A, Doherty R, Harrop C, Ellett L (2011) Quality of life and illness beliefs in individuals with early psychosis. Soc. Psychiatry Psychiatr Epidemiol. doi: 10.1007/s00127-011-0360-1
  57. 57.
    Thornicroft G, Rose D, Kassam A, Sartorius N (2007) Stigma: ignorance, prejudice or discrimination? Br J Psychiatr 190:192–193CrossRefGoogle Scholar
  58. 58.
    Uçok A, Brohan E, Rose D, Sartorius N, Leese M, Yoon CK, Plooy A, Ertekin BA, Milev R, Thornicroft G, The INDIGO Study Group (2012) Anticipated discrimination among people with schizophrenia. Acta Psychiatr Scand 125(1):77–83PubMedCrossRefGoogle Scholar
  59. 59.
    Watson PWB, Garety PA, Weinman J, Dunn G, Bebbington PE, Fowler D, Freeman D, Kuipers E (2006) Emotional dysfunction in schizophrenia spectrum psychosis: the role of illness perceptions. Psychol Med 36:761–770PubMedCrossRefGoogle Scholar
  60. 60.
    Wing JK, Brown GW (1970) Institutionalism and Schizophrenia: a comparative study of three mental health hospitals 1960–1968. Cambridge University Press, LondonCrossRefGoogle Scholar
  61. 61.
    World Health Organisation (2001) The World Health Report 2001—Mental Health: New Understanding, New Hope. WHO, GenevaGoogle Scholar
  62. 62.
    World Health Organisation (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Description and Diagnostic Guidelines. WHO, GenevaGoogle Scholar
  63. 63.
    Yang LH, Lo G, Wonpat-Borja AJ, Singla DR, Link BG, Phillips MR (2011) Effects of labeling and interpersonal contact upon attitudes towards schizophrenia: implications for reducing mental illness stigma in urban China. Soc Psychiatry Psychiatr Epidemiol. doi: 10.1007/s00127-011-0452-y
  64. 64.
    Yanos PT, Roe D, Lysaker PH (2011) Narrative enhancement and cognitive therapy: a new group-based treatment for internalized stigma among persons with severe mental illness. Int J Group Psychother 61(4):577–595PubMedCrossRefGoogle Scholar
  65. 65.
    Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–367PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Anna Moriarty
    • 1
    • 3
  • Suzanne Jolley
    • 2
  • Margie M. Callanan
    • 1
  • Philippa Garety
    • 2
  1. 1.Department of Applied PsychologyCanterbury Christ Church UniversityCanterburyUK
  2. 2.Department of Psychology, Institute of PsychiatryKing’s College LondonLondonUK
  3. 3.CAMHS Tier 2BromleyUK

Personalised recommendations