Quality of Life Impairment in Schizophrenia, Mood and Anxiety Disorders: New Perspectives on Research and Treatment

Quality of Life Impairment in Schizophrenia, Mood and Anxiety Disorders

Quality of Life Impairment in Schizophrenia, Mood and Anxiety Disorders New Perspectives on Research and Treatment Edited by

Michael S. Ritsner Associate Professor, Department of Psychiatry, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa Director, Acute Department, Sha’ar Menashe Mental Health Center, Israel Associate Editor, Quality of Life Research, Amsterdam, The Netherlands

and

A. George Awad Professor Emeritus, Department of Psychiatry and the Institute of Medical Science University of Toronto Chief of Psychiatry, Humber River Regional Hospital, Toronto, Ontario President, The International Society of CNS Clinical Trials and Methodology, Canada

A C.I.P. Catalogue record for this book is available from the Library of Congress.

ISBN 978-1-4020-5777-9 (HB) ISBN 978-1-4020-5779-3 (e-book) Published by Springer, P.O. Box 17, 3300 AA Dordrecht, The Netherlands. www.springer.com

Printed on acid-free paper

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CONTENTS

Contributors Foreword Part I

ix xiii

Key Methodological Issues

1. The Distress/Protection Vulnerability Model of Quality of Life Impairment Syndrome Michael S. Ritsner

3

2. Role of Dopamine in Pleasure, Reward and Subjective Responses to Drugs Lakshmi N.P. Voruganti and A. George Awad

21

3. Neuroendocrine Functions, Mood and Quality of Life Marianna Mazza and Salvatore Mazza

33

4. In the Mind of the Beholder Neuronal Mediators for the Effect of Emotional Experience on Quality of Life Talma Hendler, Roee Admon and David Papo

57

5. Cross-Cultural Quality of Life Research in Mental Health Monika Bullinger, Silke Schmidt and Dieter Naber

67

6. Measuring the Value of Health-Related Quality of Life Graeme Hawthorne

99

7. Comparison of Instruments for Measuring the Quality of Life Impairment Syndrome in Severe Mental Disorders Michael S. Ritsner v

133

Contents

vi 8. Integrative Bottom-Up Approach to HRQOL Measurement Ralf Pukrop and Andreas Bechdolf

143

Part II Quality of Life Impairment Syndrome in Severe Mental Disorders 9. Health Related Quality of Life in Subjects at Risk for a First Episode of Psychosis Andreas Bechdolf, Verena Veith, Ralf Pukrop and Joachim Klosterkötter

159

10. Quality of Life Impairment Syndrome in Schizophrenia Michael S. Ritsner and Anatoly Gibel

173

11. Insight and Quality of Life in Schizophrenia Spectrum Disorders Paul H. Lysaker and S. Louria

227

12. Quality of Life and Major Depression Marcelo T. Berlim and Marcelo P.A. Fleck

241

13. Quality of Life Impairment in Bipolar Disorder Erin E. Michalak Greg Murray Allan H. Young and Raymond W. Lam

253

14. Quality of Life Impairment in Anxiety Disorders Margaret A. Koury and Mark Hyman Rapaport

275

15. Quality of Life in Obsessive-Compulsive Disorder Julio Bobes, M.-P. García-Portilla, Maria-Teresa Bascarán, Pilar-Alejandra Sáiz, Maria-Teresa Bobes-Bascarán and Manuel Bousoño

293

Part III

Treatment and Rehabilitation Issues

16. Antipsychotic Medications, Schizophrenia and the Issue of Quality of Life A. George Awad and Lakshmi N.P. Voruganti

307

17. Quality of Life Outcomes of ECT Peter B. Rosenquist and W. Vaughn McCall

321

18. Quality of Life in Mental Health Services Sherrill Evans

333

Contents 19. Subjective Quality of Life in Relation to Psychiatric Rehabilitation and Daily Life Mona Eklund

vii

355

20. Cost-Utility Analysis Mojca Z. Dernovsek, Valentina Prevolnik-Rupel and Rok Tavcar

373

Index

385

CONTRIBUTORS

Roee Admon, Functional Brain Imaging Unit, Wohl Institute for Advanced Imaging TASMC, Medical Science, Faculty of Medicine, Tel Aviv University, Israel; [email protected] A. George Awad, MB, Bch, PhD, FRCPC, Professor Emeritus, Department of Psychiatry and the Institute of Medical Science University of Toronto, Chief of Psychiatry, Humber River Regional Hospital, Canada; [email protected] Maria-Teresa Bascarán, MD, Department of Psychiatry, University of Oviedo, Spain; [email protected] Andreas Bechdolf, MD, Consultant Psychiatrist, Cologne Early Recognition and Intervention Centre for mental crisis – FETZ, Department of Psychiatry and Psychotherapy, University of Cologne, Kerpenerstr. 6250937 Köln, Germany; [email protected] Marcelo T. Berlim, MD, MSc, Depressive Disorders Program and McGill Group for Suicide Studies, Douglas Hospital Research Centre, McGill University, Montréal, Quebec, Canada; [email protected] Julio Bobes, MD, PhD, Department of Psychiatry, University of Oviedo, Spain; [email protected] Maria-Teresa Bobes-Bascarán, PhD, Department of Psychiatry, University of Oviedo, Spain; [email protected] Manuel Bousoño, MD, PhD, Department of Psychiatry, University of Oviedo, Spain; [email protected] Monika Bullinger, MD, Professor, University Medical Centre of Hamburg Eppendorf Institute and Policlinic for Medical Psychology, Hamburg, Germany; [email protected] ix

x

Contributors

Mojca Z. Dernovsek, MD, PhD, Assistant Professor, University Psychiatric Hospital, Institute of Public Health of Republic of Slovenia, Ljubljana, Slovenia; [email protected] Mona Eklund, Professor, Department of Health Sciences, Division of Occupational Therapy, Lund University, Sweden; [email protected] Sherrill Evans PhD, Senior Lecturer in Social Work and Social Care; Centre for Carework Research, Department of Applied Social Sciences, University of Wales, Swansea; [email protected] Marcelo P.A. Fleck, MD, PhD, Professor, Department of Psychiatry and Forensic Medicine; Head, Mood Disorders Program Hospital de Clínicas de Porto Alegre, Brazil M.-P. García-Portilla, MD, PhD, Associate Professor, Department of Psychiatry, University of Oviedo, Spain; [email protected] Anatoly Gibel, MD, Senior Psychiatrists, Acute Department, Sha’ar Menashe Mental Health Center, Israel; [email protected] Graeme Hawthorne, A/Professor, Department of Psychiatry, The University of Melbourne, Australia; [email protected] Talma Hendler MD, PhD, Senior lecturer, Psychology Department and Faculty of Medicine, Tel Aviv University, Director, Functional Brain Imaging Unit, Wohl Institute for Advanced Imaging, Tel Aviv Sourasky Medical Center, Israel; [email protected] Joachim Klosterkötter, MD, Professor of Psychiatry, Chair, Director, Department of Psychiatry, and Psychotherapy, University of Cologne, Kerpenerstr. 6250937 Köln, Germany; [email protected] Margaret A. Koury, MS, Research Project Assistant, Cedars-Sinai Health System, Department of Psychiatry, Los Angeles, USA; [email protected] Raymond W. Lam, Professor and Head, Division of Clinical Neuroscience, Department of Psychiatry, University of British Columbia, Vancouver, Canada Shira Louria, MSW, Research assistant at the Roudebush VA Medical Center and a doctoral candidate at the University of Indianapolis, School of Psychological Science, USA

Contributors

xi

Paul H. Lysaker, Ph.D., Staff Psychologist at the Roudebush VA Medical Center and Assistant Professor of Clinical Psychology in the Department of Psychiatry at the Indiana University School of Medicine, Department of Psychiatry, Indianapolis, USA; [email protected] Marianna Mazza, MD, PhD, Institute of Psychiatry, Catholic University of Sacred Heart, Rome, Italy; [email protected] or marianna.mazza@ rm.unicatt.it Salvatore Mazza, MD, Professor and Head, Neurophysiopathology Unit, Department of Neurosciences, Catholic University of Sacred Heart, Rome, Italy W. Vaughn McCall, MD, MPH, Professor and Chair, Wake Forest University School of Medicine, Medical Center Blvd., USA Erin E. Michalak, PhD, Assistant Professor, MSFHR Scholar & CIHR New Investigator, Mood Disorders Centre, Department of Psychiatry, University of British Columbia, Vancouver, Canada; [email protected] Greg Murray, PhD, Senior Lecturer and Clinical Psychologist, Faculty of Life and Social Sciences, Swinburne University of Technology, Hawthorn, Australia; [email protected] Dieter Naber, MD, Professor, University Medical Centre of Hamburg Eppendorf, Department of Psychiatry, Centre of Psychosocial Medicine, Hamburg, Germany David Papo, Functional Brain Imaging Unit, Wohl Institute for Advanced Imaging TASMC, Israel; [email protected] Valentina Prevolnik-Rupel, BA, MSc, Ministry of Health of Republic of Slovenia, Ljubljana, Slovenia Ralf Pukrop, PhD, ScMD, Associate Professor, Section of Experimental and Clinical Psychology, Department of Psychiatry and Psychotherapy, University of Cologne, Kerpenerstr. 6250937 Köln Germany; [email protected] Mark Hyman Rapaport, MD, Chairman, Department of Psychiatry, The Polier Endowed Chair in Schizophrenia, and Related Disorders, Cedars-Sinai Medical Center, Department of Psychiatry, Los Angeles, USA; [email protected] Michael S. Ritsner, MD, PhD, Associate Professor, Department of Psychiatry, The Rappaport Faculty of Medicine, Technion - Israel Institute of Technology; and Director, Acute Department, Sha’ar Menashe Mental Health Center, Israel; [email protected]

xii

Contributors

Peter B. Rosenquist, MD, Associate Professor, Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Medical Center Blvd., USA; [email protected] Pilar-Alejandra Sáiz, MD, PhD, Department of Psychiatry, University of Oviedo, Spain; [email protected] Silke Schmidt, PhD, University Medical Centre of Hamburg Eppendorf Institute and Policlinic for Medical Psychology, Hamburg, Germany Rok Tavcar, MD, PhD, Chair of Psychiatry, University Psychiatric Hospital, University of Ljubljana, School of Medicine, Ljubljana, Slovenia Verena Veith, Clinical Psychologist, Department of Psychiatry and Psychotherapy, University of Cologne, Kerpenerstr. 6250937 Köln, Germany; [email protected] Lakshmi N.P. Voruganti, Associate Professor, MD, MS, PhD, McMaster University, Hamilton, ON, Canada; [email protected] Allan H. Young, Professor and LEEF Chair in Depression Research, Associate Director of the Institute of Mental Health, Department of Psychiatry, University of British Columbia, Vancouver, Canada; [email protected]

FOREWORD

Over the past few decades health-related quality of life (HRQL) has emerged as the new image of medicine viewed from a psychosocial perspective. The concept of Quality of Life has attracted a good deal of interest, not only from a clinical perspective but also from psychosocial, health economics as well as cultural aspects. More recently, the neurobiological brain substrates that modulate many aspects of subjective experiences, which is relevant to quality of life such as affect, mood, cognition, pleasure, reward responses as well as feeling of wellbeing and satisfaction has been explored and elucidated. Such increased interest in HRQL is highlighted by the large number of recent publications. Over the past 10 years at least 350 papers were published describing aspects of HRQL in the psychiatric and mental field. Among them 78% dealt with HRQL in schizophrenia and schizoaffective disorders, 21% with major depression, 14% with anxiety disorders and 4% with bipolar disorder. It is gratifying to witness the enhanced interest and popularity in HRQL research and publications, yet the field continues to suffer from conceptual inconsistencies as well as a good deal of methodological limitations. It is worrisome that we still do not have a clear understanding of the concept itself as applied to mental health and illness as well as the complex array of its determinants. Similarly there is a lag in the application of quality of life data in improving clinical practice. For some time the field has been mostly concerned about measurement of quality of life with less interest devoted in developing testable conceptual models for different disorders, at different stages of illness and for specific populations. Fortunately this state of affairs has been changing over the past decade with the introduction of a number of theoretical and conceptual models, refining methodology and looking beyond the assessment of quality of life. Though quality of life by itself constitutes an important outcome in the management of psychiatric disorders, one can construe quality of life also as a mediator of other important outcomes. Historically and traditionally quality of life has always been approached as mostly a psychosocial construct, yet the recent advances in neuroscience has added important knowledge about the genesis of such constructs such as pleasure, satisfaction as well as the broad aspects of affective states, insight and cognitive abilities; all are relevant to the person’s ability to correctly interpret their feelings and perceptions of their quality of life. In this context, this book contributed to by some xiii

xiv

Foreword

of the most active researchers and clinicians in the field; provides new perspectives not only clarifying some of the ongoing controversies but also proposing new models and different perspectives. The book is organized in three major sections: Key Methodological Issues, Quality of Life Impairment in Severe Mental Disorders and Treatment and Rehabilitation Issues. Though the selection of diverse topics has been mostly guided by the current state of the art and the issues that require further discussion, one can not assume that these are the only important issues at this time. Similarly as in publications contributed to by diverse authors from diverse orientations and academic backgrounds it is inevitable to avoid differences of approaches and opinions as well as some overlap. Indeed we consider such diversity as a measure of strength for this book. We also believe that this book probably is the first of its kind to go beyond the psychosocial aspects of quality of life and delve into the neurobiological basis for emotions, feelings and satisfaction. We sincerely hope that this book will further knowledge in the complex field of quality of life as well as to be of interest to a broad spectrum of readers including clinicians, researchers and policy makers in the fields of mental health and rehabilitation. We certainly believe that enhancement of quality of life of our patients is in the best interest of patients, their families, clinicians and the society as a whole. Michael S Ritsner A. George Awad Editors, 2006

PART I KEY METHODOLOGICAL ISSUES

CHAPTER 1 THE DISTRESS/PROTECTION VULNERABILITY MODEL OF QUALITY OF LIFE IMPAIRMENT SYNDROME Current evidence and future research directions

MICHAEL S. RITSNER Department of Psychiatry, The Rappaport Faculty of Medicine, Technion - Israel Institute of Technology and Acute Department, Sha’ar Menashe Mental Health Center, Israel Abstract:

In this chapter the author describes the conceptual basis of the health related quality of life (HRQL) impairment syndrome in severe mental disorders (SMD) such as schizophrenia, schizoaffective, mood and anxiety disorders. He presents the evidence for its validity, and identifies some likely directions for future research and development. Based on the author’s and his team research contributions and complementary theoretical considerations, the author explores four issues in this chapter: the quality of life concept, interpreting HRQL findings, conceptualizing HRQL impairment in the framework of the Distress/Protection Vulnerability Model (DPV), and implications for future research. Evidence for the concept’s validity is assessed, followed by a discussion of the possible evolvement of the concept, to encompass biologic domains. Finally, there is a review of the research implications of the HRQL impairment concept and the DPV model followed by a discussion of some major areas of unresolved questions for future research

Keywords: Health related quality of life, Schizophrenia, Schizoaffective, Mood disorders, Distress/Protection Vulnerability model

DEFINING QUALITY OF LIFE There are numerous definitions for “Quality of life” (QOL) however, there is no satisfactory definition as yet using both subjective and objective aspects of quality. A number of existing definitions lack clarity and create confusion depending on whether the approach used is subjective or objective. Broadly speaking, the subjective approach centers on issues such as life satisfaction, satisfaction with defined needs, happiness, self-realization and growth. On the other hand the objective approach focus on living conditions, economic and social indicators. Calman 1 suggests that QOL measures the gap, at a particular point in time between the hopes and expectations of the individual and the individual’s present experiences. According to Maslow’s theory in order to reach self-actualization it is 3 M.S. Ritsner and A.G. Awad (eds.), Quality of Life Impairment in Schizophrenia, Mood and Anxiety Disorders, 3–19. © 2007 Springer.

4

Chapter 1

necessary to go through a hierarchical needs process 2 . His theory uses the concept of human needs as a basis for development of happiness and true being. Besides such well-known needs as food, sex, and social relations, Maslow talks about a more abstract need to realize oneself. He defines five needs, organized hierarchically: physiological, safety, belonging, love, self-esteem and the need for selfactualization 3 . HEALTH RELATED QUALITY OF LIFE Since many valued aspects of life, like income, freedom and quality of the environment, etc are not usually considered “health related”, the term health-related quality of life (HRQL) came to refer to the physical, psychological, and social domains of health. Those domains are seen as distinct areas that are influenced by the person’s experiences, beliefs, expectations, and perceptions 4 . One common element across the various definitions of HRQL is the individual’s subjective sense of well-being. It is often postulated that HRQL and subjective well-being are determined by various dimensions of physical, social, and role functioning. In other words, HRQL includes dimensions of physical and social functioning: mental health and general health perceptions including such important concepts as energy, fatigue, pain, and cognitive functioning 5 . HRQL is multidimensional in the sense that the subjects may simultaneously evaluate several dimensions to arrive at an overall judgment. Two persons with the same mental health status may have different HRQL levels since elements such as differences in personality and illness related factors influence a person’s perception of health and satisfaction with life. Perceptions of HRQL are based on a cognitive process, which involves identifying the relevant domains comprising QOL, determining which domains are self relevant to one and integrating separate domain assessments into an overall quality of life assessment 6 . Each domain of health has many components that need to be measured. Because of this multidimensionality, there is an almost infinite number of states of health, all with differing qualities. HRQL is a heterogeneous concept, as reflected in the different perceptions of this construct by psychiatrists and their patients. Such differences are obviously dependant on whether observer rated or self-reporting instruments are used. HRQL differs somewhat from subjective well-being, in that the latter concerns itself primarily with affective states, both positive and negative. A HRQL assessment is much broader and although affect-laden, represents the subjective evaluation of oneself in the context one’s social and physical world 7 . Self-reported and observerrated HRQL data provide distinct types of information, and appear to have different indicators for HRQL 8,9 . The discrepancy between subjective and objective measures of HRQL signifies a genuine difference rather than an anomaly related to the patient’s psychiatric condition 10 . Indeed, Kaiser et al. 11 found that psychopathology was the only robust predictor of subjective HRQL but overall the impact seemed to be moderate and did

The distress/protection vulnerability model

5

not affect the patient’s subjective HRQL ratings. Correlations between subjective and objective measures of HRQL among severely mentally ill patients ranged from very low to insignificant 12,13 . There are several limitations in the interpretation of self reported measures of HRQL, namely, self-report bias, the lack of universally accepted measures, the lack of reliability and validity data for many of the scales, and difficulty in generalizing findings from the various instruments. Observer-rated instruments include mostly negative and deficit symptom items. There is a general consensus regarding the importance of using both self-reported and observer-rated measures of HRQL.

MODEL FOR CLINICAL TRIALS Despite the increasing importance of quality of life in the mental health field, the theoretical conceptualization of the construct remains poorly developed. The rationale for a HRQL assessment in psychiatric research should be outlined in an analytic model that tests the relationship between predictors and response variables. In 1997, Awad and associates 14 reported on the development of a conceptual integrative model of HRQL in medicated persons with schizophrenia. According to that model, HRQL is the outcome of interaction between the three major determinants (symptoms, side effects, and psychosocial performance) and with several modulators such as personality characteristics, premorbid adjustment, values and attitudes toward health and illness, resources and their availability. Testing validity of this model indicated that the severity of symptoms was the main predictor of HRQL, explaining 32% of its variance, while neuroleptic side effects explained 17%. The contribution of psychosocial indicators and modulators, however, was not significant. Since this model continues to be the only model that is specific to the effects of medication and, as such, is the most applicable to clinical trials with medications, broadening the model to make it applicable to other social or vocational interventions seemed to be warranted.

MEDIATIONAL MODEL In 1998, Zissi, Barry, and Cochrane 15 proposed a model, which links subjective HRQL with self-related constructs. They tested this model on a group of 54 longterm psychiatric hostel residents in Greece using a modified version of Lehman’s Quality of Life Interview. The results indicated that perceived improvements in lifestyle, greater autonomy and positive self-concept were significantly and directly associated with better quality of life. In contrast, no direct relationship was found between objective indicators and subjective quality of life. The authors concluded that the extended mediational model of HRQL for individuals with long-term mental health problems appears to have important implications for the planning and delivery of mental health programmes. However, this model needs further development, testing and validation.

6

Chapter 1

DISTRESS/PROTECTION MODEL In 2000, Ritsner and associates 16 proposed a Distress/Protection Model of HRQL in severe mental disorders. The model, initially based on findings from a sample of 210 inpatients consecutively admitted to closed, open and rehabilitation wards, postulated that subjective HRQL is an outcome of the interaction of an array of distress factors, on the one hand, and protection factors, on the other. It suggests that satisfaction with HRQL decreases when distress factors outweigh protection factors, and vice versa. The data included measures of satisfaction with general and domain-specific HRQL such as physical health, subjective feelings, leisure activities, social relationships, general activities, medication, as well as severity of psychopathology, adverse events, psychological distress, expressed emotions, personality traits, self-constructs, coping styles, and perceived social support. The model includes a greater number of quality of life domains and would, therefore, allow for easy integration of HRQL items into one of the distress or protection factor categories and could provide practitioners with an easily recognized outline for use in their clinical work. In order to validate the Distress/Protection model, two kinds of multivariate analyses were conducted using cross-sectional and longitudinal data. First, an exploratory factor analysis confirmed the main postulate of the model regarding distress and protection factors underlying the general HRQL (n = 339 patients; Table 1). The first and second factors (named ‘distress’) with a harmful effect on the general HRQL included severity of emotional distress, somatization, illness, symptoms and side effects, insight and emotionally oriented coping. The third factor (named ‘protection’) was constructed using task and avoidance coping styles, self-efficacy, self-esteem, and social support. HRQL scores associated significantly with first and third factors. Two distress and protection factors accounted for 42.4%, 26% and 27.9% of the total variance of the 29 variables, respectively. The factor structure did not change when we used data obtained from a follow up sample (n = 199). Next, the hierarchical multiple regression analysis was applied in order to predict general Q-LES-Qindex scores for schizophrenia patients (Table 2). In the first step, when distress and demographic variables were simultaneously entered into the regression analysis, the distress factors’ model accounted for 40% of the total variance in Q-LES-Qindex scores. This model included two distress variables, three PANSS factors and age accounted for 16.4%, 10.1%, and 2%, respectively. The protective factors’ model consisting of 5 predictors (self-esteem, self-efficacy, two coping styles and social support) explained 46% of the total variance. Finally, the combined distress/protection model that fit the data best (R2 = 058), revealed that the protective pattern (self-esteem, self-efficacy, avoidance coping styles and social support) accounted for 18.2% of the variance, while distress patterns (emotional distress, somatization, negative and depressive symptoms) explained only 11.6%. When patients were re-examined about 16 months later, similar analysis revealed that the combined distress/protection model that fits the data best (R2 = 072), include two protection factors (self-efficacy, and social support) and two distress factors (emotional distress and depressive symptoms) factors.

The distress/protection vulnerability model

7

Table 1. Factor loadings after Varimax rotation of variable values among 339 patients with severe mental disorders1 Variables

Factor 1 Factor 2 Factor 3 (eigenvalue=5.43) (eigenvalue=3.32) (eigenvalue=3.57) ‘distress’ ‘symptoms’ ‘protective’

General quality of life(Q-LES-Qindex )2 Illness severity (CGI)3 General functioning (GAF)4 Symptoms: Negative symptoms (PANSS)5 Positive symptoms Activation symptoms Dysphoric mood Autistic preoccupations Insight: Observer-rated6 Self-report7 Side effects: Number of Adverse Symptoms (DSAS)8 Mental Distress Index Somatic Distress Index Emotional Obssesiveness distress: (TBDI)9 Hostility Sensitivity Depression Anxiety Paranoid ideation Somatization (BSI)10 Self-esteem (RSES)11 Self-efficacy (GSES)12 Coping Task oriented coping styles: (CISS)13 Emotion oriented coping Avoidance coping Social Family support support: (MSPSS)14 Friend support Other significant support

04695 −01389 00115 −01106 −01044 −01674 −05793 −01397 −03455 −04266 −05886

−00453 06777 −04232 06339 07225 07497 01760 07352 −04445 −02409 01613

06102 −00759 00792 −02542 00384 −01244 −00726 −01508 −00428 −02237 00533

−05945 −05525 −06272

01326 00013 00126

00457 00297 −03312

−04526 −06554 −07068 −06938 −05173 −06225 03212 02507 −00108

01127 00112 −00822 009601 01203 00855 00769 00600 01222

−00657 −02570 −03454 −02459 −02150 −01112 04585 06268 06893

−05873

00088

01181

−01014 −00209

00250 −01757

06758 05228

01333 −00262

−00619 −01575

04971 05497

Factors’ contribution (%)

424%

260%

279%

1 Variables with an absolute loading greater than the amount set in the minimum loading option (≥ 040) were selected; expressed emotion, age, education, age of onset and illness duration were removed to avoid augmenting scores. 2 Q-LES-Q- the Quality of Life Enjoyment and Life Satisfaction Questionnaire; 3 CGI- the Clinical Global Impression scale; 4 GAF - the Global Assessment of Functioning Scale; 5 PANSS - the Positive and Negative Syndromes Scale; 6 ITAQ – the Insight and Treatment Attitudes Questionnaire; 7 IS – the Insight Self-report Scale; 8 DSAS - the Distress Scale for Adverse Symptoms; 9 TBDI - the Talbieh Brief Distress Inventory; 10 BSI - the Brief Symptom Inventory; 11 RSES - the Rosenberg Self-Esteem scale; 12 GSES the General Self-Efficacy Scale; 13 CISS - the Coping Inventory for Stressful Situations; 14 MSPSS - the Multidimensional Scale of Perceived Social Support (for references see Appendix, Chapter 10).

021 028 −016 018 021

−021 −014 −008 −013 021 015 019 020

Protective factors’ model Self-efficacy Self-esteem Emotion oriented coping Avoidance coping Social support

Distress/protection model Emotional distress Somatization Negative symptoms Depressive symptoms Self-efficacy Self-esteem Avoidance coping Social support 0002 0011 0023 0005 0001 0012 0002 0009

0001 0001 0005 0006 0001

0001 0025 0001 0009 0023 – – 0032

49 25 12 30 53 26 36 67

44 78 33 32 59

142 22 50 29 22 – – 20

R2 = 058 adj. R2 = 056 F=38.4, df=8,236 p