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Keywords:

  • interpersonal behavior;
  • neurocognitive functions;
  • psychopathological symptoms;
  • schizophrenia;
  • self-efficacy

Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES

Aim:  The present study examined whether the self-efficacy of interpersonal behavior influenced the interpersonal behavior of schizophrenia patients using psychiatric day-care services.

Methods:  Thirty-nine patients with schizophrenia were examined with the Interpersonal Relations subscale of the Life Assessment Scale for Mentally Ill, the Self-efficacy Scale of Interpersonal Behavior, the Brief Assessment of Cognition in Schizophrenia–Japanese version, and the Positive and Negative Syndrome Scale.

Results:  The Life Assessment Scale for Mentally Ill score was significantly correlated with the self-efficacy of interpersonal behavior, and was also significantly correlated with neurocognitive functions and negative symptoms. However, the Self-efficacy Scale of Interpersonal Behavior score was not correlated with neurocognitive functions and negative symptoms. To examine the causal correlations between the above social, psychological and clinical factors, multiple regression analysis was performed with the self-efficacy of interpersonal behavior, neurocognitive functions, and negative symptoms as the independent variables and interpersonal behavior as the dependent variable. The self-efficacy of interpersonal behavior was found to contribute to interpersonal behavior as well as neurocognitive functions.

Conclusion:  The self-efficacy of interpersonal behavior contributed to the interpersonal behavior as well as the neurocognitive functions in the case of schizophrenia patients in the community. This suggested that interventions targeting the self-efficacy of interpersonal behavior, as well as those targeting neurocognitive functions, were important to improve the interpersonal behavior of schizophrenia patients undergoing psychiatric rehabilitation in the community.

FOR THE TREATMENT of schizophrenia, it is known that pharmacotherapy alone tends to produce only small improvements in psychosocial functioning, thereby suggesting the importance of adjunctive psychosocial rehabilitation intervention.1 In this area, cognitive–behavioral therapy, family intervention, social skills training and cognitive remediation were introduced as effective adjunctive therapies.2 However, although these therapies vary in the functional domains that they address, the importance of identifying the therapeutic targets (e.g. adherence, symptom reduction, functional capacity etc.) to benefit individual patients was suggested.3 Thus, therapeutic targets for the improvement of psychosocial functioning are important to enhance the treatment outcome of schizophrenia patients living in the community.

With respect to the diminished psychosocial functions in schizophrenia patients, the difficulty in promoting adaptive interpersonal relations (i.e. the disability of interpersonal behavior) has considerable effects on the patient's daily life. For instance, Skodlar et al. reported that solitude with inability to participate in human interaction and feelings of inferiority were the main sources of suicidal ideation in schizophrenia patients.4 Furthermore, Borge et al. indicated that feeling loneliness explained 35% of the variance in subjective well-being in a study targeting long-term patients, including schizophrenia patients (69%).5 Therefore, interpersonal behavior can be a critical therapeutic target of psychosocial rehabilitation intervention for schizophrenia patients living in the community. Review articles suggest that neurocognitive functions are strongly related to psychosocial functions.6,7 In addition, Lysaker et al. indicated that frequency of social interaction was predicted by fewer negative symptoms and better verbal memory.8 Moreover, Perlick et al. and Mohamed et al. confirmed that some neurocognitive deficits (e.g. processing speed, verbal memory, and reasoning etc.) contribute to decreased quality of life that related to interpersonal relations and social networks.9,10

On the other hand, a recent study proposed the necessity of subjective assessments of schizophrenia patients to examine their functional status.11 In the present study, we regarded ‘self-efficacy’ as a schizophrenia patient's subjective dimension. Self-efficacy is defined as the conviction that one can successfully execute her or his behavior to produce the required outcomes.12 It determines how much effort one will expend and how long one will persist in the face of obstacles and aversive experiences.12 Generally, a person with high self-efficacy tends to approach difficult tasks as challenges to be mastered rather than to be avoided. In contrast, a person with low self-efficacy tends to shy away from such tasks because he or she sees them as threats. Furthermore, self-efficacy is comprised of two dimensions: general self-efficacy and specific self-efficacy. The former refers to the ability to deal with a variety of stressful situations, and the latter refers to the ability to perform certain behaviors.

In patients with schizophrenia, numerous studies have targeted general self-efficacy or the specific self-efficacy of inclusive community living skills.13,14 However, the specific self-efficacy of interpersonal behavior has not been examined closely to determine the influence on the patient's real-world interpersonal behavior in daily life. Specific self-efficacy has been found to have an effect on equivalent behavior in patients with chronic disease (e.g. continuous positive airway pressure adherence in obstructive sleep apnea, glycemic control in diabetes mellitus etc.).15,16 In schizophrenia patients, therefore, their self-efficacy would be worth examining more specifically to the equivalent behavior (e.g. interpersonal behavior, work behavior, medication adherence etc.).

The aim of the present study was to examine whether the self-efficacy of interpersonal behavior influenced real-world interpersonal behavior. To clarify this influence, we compared it with the influences of other factors that correlated with interpersonal behavior (e.g. neurocognitive functions and psychopathological symptoms). We hypothesized that specific self-efficacy as well as neurocognitive functions or psychopathological symptoms influenced real-world interpersonal behavior. If the influence of specific self-efficacy was confirmed in the interpersonal behaviors of schizophrenia patients, the importance of interventions for the specific self-efficacy of interpersonal behavior would be stressed in community rehabilitation settings.

METHODS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES

Subjects

The subjects consisted of 39 schizophrenia patients (25 men and 14 women, aged 20–60 years old). The mean age, mean years of education, mean duration of illness and mean duration of past hospitalizations were 44.0 ± 8.0, 12.6 ± 1.9, 17.0 ± 9.6 and 3.2 ± 4.9 years, respectively. All subjects were selected from users of two psychiatric day cares. The mean duration of utilization of the day care was 5.0 ± 3.2 years, and the frequency of utilization of the day care was 3.6 ± 1.4 days per week. Among the subjects, approximately 60% used the day-care service more than 4 days per week. Inclusion criteria were: (i) using the day care for over a month; (ii) over 20 years old; and (iii) no history of head injury, mental retardation, or serious medical disease, such as loss of consciousness. All subjects were diagnosed by trained psychiatrists with the ICD-1017 and were taking antipsychotic medications with a mean chlorpromazine equivalent dose of 1171 ± 989 mg/day. After explanations were provided about the present study (e.g. overview of the study, subject's rights, confidentiality of the study records), all subjects provided written consent to participate. The present study was approved by the Ethics Committee of the Sapporo Medical University.

Procedures

After each subject provided informed consent, they evaluated their own self-efficacy of their interpersonal behavior. Then, their neurocognitive functions were examined by a trained occupational therapist (first author, T.M.). One month later, the evaluation of interpersonal behavior was evaluated by trained day-care workers who observed the interpersonal behaviors of each subject over a month. In addition, psychopathological symptoms of the subjects were evaluated by their trained psychiatrists in attendance.

This survey was conducted from March 2009 to November 2009.

Evaluation of interpersonal behavior

Interpersonal behavior was measured using the Life Assessment Scale for the Mentally Ill–Interpersonal Relations (LASMI-I).18 The LASMI-I was developed to assess an individual's disabilities in daily life and contains 13 items. Subjects were rated using a 5-point scale (0–4), and the mean of all items in the LASMI-I was used as an index of the disability of interpersonal behavior in daily life (with higher scores indicating more severe disabilities). Assessment with the scale requires a month-long observation period. Therefore, day-care workers, including an occupational therapist, a nurse, or a psychiatric social worker who observed the interpersonal behaviors of each subject over a month, rated this scale. To enhance the reliability, evaluations of the interpersonal behavior of the subjects were made by one day-care worker, and then the evaluations were confirmed by another day-care worker who also observed the interpersonal behaviors of the same subjects.

Evaluation of the self-efficacy of interpersonal behavior

The self-efficacy of interpersonal behavior was measured using the Self-efficacy Scale of Interpersonal Behavior developed by Fukui et al.19 This scale was developed to assess an individual's self-efficacy of interpersonal behaviors used frequently in daily life (e.g. compromise, ask for assistance, refuse to comply with other's request)20,21 and contains 16 items. Subjects rated using a 4-point scale (0–3), and the sum of all items in this scale was used as an index of the self-efficacy of interpersonal behavior in daily life (with higher scores indicating higher self-efficacy).

Examination of neurocognitive functions

Neurocognitive functions were examined using the Brief Assessment of Cognition in Schizophrenia–Japanese-language version (BACS-J).22 The BACS-J includes brief assessments of verbal memory, working memory, motor speed, verbal fluency, attention, and executive function. The primary measures from each test of the BACS-J were standardized by creating z-scores whereby the subject's mean of healthy control was set to zero and the standard deviation set to one. The composite score was calculated by averaging the z-scores of all six measures.

Evaluation of psychopathological symptoms

Psychopathological symptoms were measured using the Positive and Negative Syndrome Scale (PANSS).23 The PANSS includes subscales reflecting positive and negative symptoms, and each subscale contains seven items. Subjects were rated from 1–7 (with higher scores indicating more severe symptoms), and the sum of all items in each subscale was used as an index of positive symptom score, and negative symptom score, respectively.

Statistical analysis

In order to study the correlations between variables (interpersonal behavior, self-efficacy of interpersonal behavior, neurocognitive functions, and psychopathological symptoms), Spearman's rank correlation coefficients were calculated. Because of a deviation from normal distribution in some variables (Executive function score in BACS-J and PANSS Positive score), product–moment correlation coefficient was not used for analysis.

Furthermore, in order to examine the extent of the effect of the self-efficacy of interpersonal behavior on interpersonal behavior, multiple regression analysis using a forced entry method was performed. The variables that had a statistically significant correlation with interpersonal behavior were regarded as the independent variables, and the interpersonal behavior was considered as the dependent variable.

SPSS version 16.0 (SPSS, Chicago, IL, USA) was used for the analysis, and the level of significance was set at 0.05.

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES

Social, psychological, and clinical variables

The results of the LASMI-I, Self-efficacy Scale of Interpersonal Behavior, BACS-J, and PANSS are presented in Table 1.

Table 1.  Social, psychological, and clinical variables in 39 patients with schizophrenia
 Mean ± SDMin.Max.
  1. BACS-J, Brief Assessment of Cognition in Schizophrenia–Japanese-language version; LASMI-I, Life Assessment Scale for the Mentally Ill–Interpersonal Relations; PANSS, Positive and Negative Syndrome Scale.

LASMI-I1.03 ± 0.450.082.08
Self-efficacy Scale of Interpersonal Behavior32.90 ± 7.6318.0047.00
BACS-J   
 Composite score−1.63 ± 1.02−4.190.25
 Verbal memory−1.68 ± 1.17−4.920.59
 Working memory−1.23 ± 1.10−3.741.26
 Motor speed−2.11 ± 1.67−5.890.89
 Verbal fluency−0.93 ± 1.19−3.691.53
 Attention−2.22 ± 1.05−4.120.12
 Executive function−1.59 ± 1.86−6.220.81
PANSS   
 Positive16.05 ± 6.097.0037.00
 Negative18.92 ± 5.899.0032.00

Correlation coefficients

The correlation coefficients between the score of LASMI-I and Self-efficacy Scale of Interpersonal Behavior, BACS-J, and PANSS and between the score of Self-efficacy Scale of Interpersonal Behavior and BACS-J and PANSS are listed in Table 2. The LASMI-I score was significantly correlated with the scores of all variables except for the score of the PANSS positive scale. These correlation coefficients suggested that patients with high self-efficacy, high neurocognitive functions, or fewer symptoms tended to behave well in interpersonal situations. On the other hand, the score of Self-efficacy Scale of Interpersonal Behavior was not significantly correlated with the scores of BACS-J and PANSS.

Table 2.  Correlations between clinical indices
 LASMI-ISelf-efficacy scale of interpersonal behavior
ρPρP
  1. *P < 0.05; **P < 0.01.

  2. BACS-J, Brief Assessment of Cognition in Schizophrenia–Japanese-language version; LASMI-I, Life Assessment Scale for the Mentally Ill–Interpersonal Relations; PANSS, Positive and Negative Syndrome Scale.

Self-efficacy scale of interpersonal behavior−0.40*0.012
BACS-JComposite score−0.64**<0.0010.030.840
Verbal memory−0.41**0.0090.040.821
Working memory−0.48**0.0020.200.220
Motor speed−0.51**0.001−0.050.786
Verbal fluency−0.33*0.040−0.030.853
Attention−0.57**<0.001−0.130.440
Executive function−0.53**<0.001−0.040.792
PANSSPositive0.130.4430.000.991
Negative0.42**0.007−0.060.704

From these correlation coefficients, we suggest that the self-efficacy of interpersonal behavior, neurocognitive functions, and negative symptoms influence interpersonal behavior in daily life.

Multiple regression analysis

To examine the above model, multiple regression analysis was performed with self-efficacy of interpersonal behavior, neurocognitive functions, and negative symptoms as the independent variables, and interpersonal behavior as the dependent variable. Before the analysis, the BACS-J composite score was adapted as an index of neurocognitive functions to prevent a decline in the goodness-of-fit of the regression model. None of the independent variables had a deviation from normal distribution and bias of frequency from statistical examination (Shapiro–Wilk test and check of histogram). Since the correlations between independent variables (Self-efficacy Scale of Interpersonal Behavior score, BACS-J composite score, and PANSS negative score) were not very strong (|r| > 0.90), multiple regression analysis was performed using the forced entry method to test this model. As a result, the model had a sufficient goodness-of-fit (anovaP < 0.001; adjusted R2 = 0.55). The LASMI-I score was significantly predicted by the Self-efficacy Scale of Interpersonal Behavior score and the BACS-J composite score (Table 3).

Table 3.  Multiple regression analysis (forced entry method)
 βP
  • **

    P < 0.01.

  • Adjusted R2 = 0.55, anovaP < 0.001.

  • BACS-J, Brief Assessment of Cognition in Schizophrenia–Japanese-language version; PANSS, Positive and Negative Syndrome Scale.

Self-efficacy scale of interpersonal behavior−0.45**<0.001
BACS-J composite score−0.58**<0.001
PANSS Negative0.080.538

DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES

In the present study, the score for the Self-efficacy Scale of Interpersonal Behavior correlated with the score of LASMI-I, and multiple regression analysis indicated that the score of the Self-efficacy Scale of Interpersonal Behavior as well as BACS-J composite score predicted the LASMI-I score. From these results, the influence of the self-efficacy of interpersonal behavior on real-world interpersonal behavior as well as that of neurocognitive functions was confirmed in schizophrenia patients undergoing rehabilitation in psychiatric day-care services.

Generally, in schizophrenia patients, a significant positive correlation between the self-efficacy of social behavior (including both interpersonal behavior and the management of psychopathological symptoms) and social function was reported.24 In particular, in schizophrenia patients living in the community, a significant positive correlation between the self-efficacy for living skills and the social function was reported.25 The present study examined a more specific aspect of self-efficacy than the above studies. The results of the present study, which focused on interpersonal behavior, suggest that the self-efficacy of a certain behavior influences the behavior in schizophrenia patients. On the other hand, it might be suggested that interpersonal behavior influences the self-efficacy of interpersonal behavior, as well. However, Bandura emphasized that a human's self-efficacy was an important factor for determining their behavior.12 Some experimental studies reported that the self-efficacy of a certain behavior was positively related to the accomplishment of the behavior and also related to the effort required to challenge the behavior.26,27 The present study suggests that this positive correlation can be applied to schizophrenia patients living in the community. Beebe et al. indicated that motivational intervention made patients with schizophrenia spectrum disorders increase self-efficacy for exercise.28 Therefore, it is also suggested that the self-efficacy of a certain behavior is an important and noteworthy therapeutic target in the community rehabilitation.

In the present study, regarding the correlations between the self-efficacy of interpersonal behavior and clinical factors, the self-efficacy of interpersonal behavior was not correlated to all neurocognitive functions (including composite score) and psychopathological symptoms. This might be due to the deficit of reflective thinking that is emphasized as an antecedent factor for self-efficacy.29 For instance, schizophrenia patients tended to have high confidence that they answered correctly even though they gave an incorrect response during a recognition task and a general knowledge task.30,31 From this, it can be thought that schizophrenia patients have difficulty in appropriately rating their own performance. If schizophrenia patients have such difficulty during a reflective thinking process, they might not recognize their own experiences appropriately, including causes of failures in interpersonal behaviors, because of their neurocognitive impairments or psychopathological symptoms. In this case, patients might not be burdened with a decline of self-efficacy. In addition, the deficit of reflective thinking was not correlated with neurocognitive functions or psychopathological symptoms.32 Therefore, these results highly suggest the possibility that the self-efficacy for interpersonal behavior is not correlated with neurocognitive functions and psychopathological symptoms.

In the present study, we could not find the influence of negative symptoms on interpersonal behavior with the multiple regression analysis even though these two factors were correlated significantly. However, previous studies confirmed that negative symptoms contributed to interpersonal relations by using the PANSS negative syndrome subscale modified version.9,10 This version did not include some items which reflect the subjects' cognitive processing during the interview, such as ‘difficulty in abstract thinking’. In our study, negative symptoms were assessed by PANSS negative syndrome scale original version because we intended to notice the correlation between self-efficacy for interpersonal behavior and negative symptoms. Since the original version includes items reflecting some dimensions of neurocognitive functions, the influence of negative symptoms on interpersonal behavior may be comprised in the influence of neurocognitive function on interpersonal behavior. Therefore, this might bring a statistical redundancy into our multiple regression analysis, thus probably resulting in masking the possibility that negative symptoms influence the interpersonal behavior of schizophrenia patients.

The present study had several limitations. First, it is possible that the interpersonal behavior in the present study did not reflect the subjects' whole range of behaviors in the community because their interpersonal behaviors were assessed by day-care workers mainly during the day-care services. However, the results of the present study could be helpful for interventions aimed to improve interpersonal behavior in the day-care setting, which is important to enhance their adherence to day-care utilization. Second, because of the relatively small sample size, the influence of the self-efficacy of interpersonal behavior could not be compared with that of each particular neurocognitive function (e.g. memory function, attention, executive function). However, in the present study, neurocognitive function should be interpreted as the general correctness or speed of information processing because the BACS-J composite score, the measure of neurocognitive functions, reflects these two properties. To extensively examine the influence of particular neurocognitive functions on interpersonal behavior, further studies are necessary by recruiting more subjects and using other statistical methods, such as path analysis etc.

In summary, the self-efficacy of interpersonal behavior was found to contribute to interpersonal behavior as well as neurocognitive functions in the case of schizophrenia patients in the community. From this, it was suggested that interventions that target the self-efficacy of interpersonal behavior, as well as neurocognitive functions and psychopathological symptoms, are important to improve the interpersonal behavior of schizophrenia patients undergoing psychiatric rehabilitation in the community. More precisely, sources of self-efficacy (i.e. enactive mastery experience, vicarious experience, verbal persuasion, physiological and affective states)33 should be taken into greater consideration in rehabilitation settings. At the same time, some factors specific to schizophrenia patients that were not taken into account in the present study might also influence self-efficacy. Therefore, further investigations are necessary to explore these factors.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES

The authors thank the staff of the doctor's office and the Department of Rehabilitation in Asahiyama Hospital for their assistance in the assessment of the variables of the present study. The authors have no direct financial support relevant to this study.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. ACKNOWLEDGMENTS
  7. REFERENCES
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