Reexamination of the relationships among neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in chronic schizophrenia

Reexamination of the relationships among neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in chronic schizophrenia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Reexamination of the relationships among neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in chronic schizophrenia Kunhua Lee, Chuan-Hsun Yu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4094734/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This study proposed and evaluated a theoretical model for exploring the relationships between neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in individuals with chronic schizophrenia. Method The study recruited 229 individuals given a diagnosis of schizophrenia from outpatient clinics and the day ward of a mental health hospital. After informed consent was obtained, the participants underwent assessments using the backward digit span, the digit symbol, and measures of self-defeatist beliefs, experiential negative symptoms, and social functioning. A structural equation model was applied to assess the fitness of the hypothesized model, with indices such as the goodness-of-fit index, comparative fit index, root mean square error of approximation, and standardized root mean square residual being used for model evaluation. Results The hypothesized model had an adequate fit. The study findings indicated that neurocognition might indirectly influence self-defeatist beliefs through its effect on experiential negative symptoms. Contrary to expectations, the study did not observe a direct influence of neurocognition, self-defeatist beliefs, or negative symptoms on social functioning. The revised model revealed the role of experiential negative symptoms in mediating the association between neurocognition and social functioning. However, self-defeatist beliefs did not significantly affect social functioning. Discussion Compared with the modification of beliefs, self-awareness training can help improve negative symptoms and thereby improve the performance of social functions. Future research should develop a hierarchical program of negative symptoms, from cognition rehabilitation to enhancement of self-awareness, and end with modifying maladaptive beliefs. neurocognition self-defeatist beliefs experiential negative symptoms social functioning schizophrenia Figures Figure 1 Figure 2 Introduction In a review article, (Mäkinen et al., 2008 ) reported that over half of individuals experiencing their first-episode of psychosis exhibit negative symptoms, with a third demonstrating persistent negative symptoms. These symptoms are associated with diminished subjective quality of life and hindered rehabilitation (Packer et al., 1997 ). Individuals with schizophrenia often face challenges in relationships with relatives and in maintaining daily functions, primarily because of feelings of apathy and a lack of motivation. (Correll & Schooler, 2020 ) indicated that negative symptoms can be prevented from progressing to a residual stage, underscoring the importance of understanding such symptoms’ psychopathology and treatment. Studies related to the psychopathology and treatment of negative symptoms have often emphasized the structure of these symptoms. The consensus conceptualization of negative symptoms involves two factors: expressive (alogia and blunted affect) and experiential (avolition, anhedonia, and asociality) negative symptoms (Glenthøj et al., 2020 ; Schlosser et al., 2015 ). The prior study reported that experiential negative symptoms more profoundly influence social functioning than expressive negative symptoms do (Marder & Galderisi, 2017 ). Researchers have used the positive and negative syndrome scale and social functioning to assess patients on the schizophrenia spectrum and have discovered experiential negative symptoms to significantly affect social functioning, everyday activities, and vocational functioning. By contrast, research has indicated expressive negative symptoms to have a negligible effect on social and vocational functioning (Harvey et al., 2017 ; Paul et al., 2023 ). Another study confirmed the substantial influence of experiential negative symptoms on quality of life in a study involving 275 participants with schizophrenia (Savill et al., 2016 ). Further validated the stronger effect of experiential over that of expressive negative symptoms on social functioning (Glenthøj et al., 2020 ). These findings raise the critical question of how experiential negative symptoms influence social functioning. The core symptoms of experiential deficits include asociality, anhedonia, and avolition, which are collectively categorized as avolition–apathy negative symptoms (AA; (Marder & Galderisi, 2017 ; Mäkinen et al., 2008 ). Research has indicated that a relationship exists between experiential negative symptoms and neurocognitive deficits (Chey et al., 2002 ; Hovington & Lepage, 2012 ; Sampedro et al., 2021 ). Neuroimaging research reveals associations between these symptoms and a propensity for selecting low-effort options, along with excessive effort-discounting, implicating brain regions such as the insula, hippocampus, amygdala, reward system, and frontal cortex (Galderisi et al., 2018 ). Patients with schizophrenia often exhibit withdrawal from interpersonal activities and diminished motivation for engaging in enjoyable activities. A case–control study by (Strauss et al., 2016 ) revealed that individuals with schizophrenia who experienced heightened levels of avolition and anhedonia exhibited less of an inclination towards seeking out rewarding experiences than did healthy controls. Furthermore, a study involving 58 patients with schizophrenia examined the relationships between neurocognitive function, AA, expressive deficit negative symptoms (DE), and real-life functioning. The study’s results indicated that when AA and DE were considered, the effect of neurocognition on real-life functioning diminished (Yang et al., 2021 ). Thus, neurocognitive function may be a distal factor in social functioning, whereas experiential negative symptoms could be a proximal factor. Evidence regarding the effect of experiential negative symptoms on social functioning, however, is not always consistent. A 3-year follow-up study indicated that the influence of these symptoms might fluctuate over time (Austin et al., 2019 ). In addition, (Kasanova et al., 2018 ) discovered that some patients with schizophrenia, despite having reduced engagement in social activities, experienced a certain amount of hedonism. (Harvey et al., 2017 ) identified other factors that could influence the relationship between experiential negative symptoms and social functioning. A review by (Marder & Galderisi, 2017 ) highlighted the role of dysfunctional beliefs, such as negative expectations about oneself, the future, or the environment, in diminishing the motivation of individuals with schizophrenia to engage in social activities. One study conducted a 1-year follow-up study investigating the effect of negative expectations on social withdrawal. The study revealed that negative expectations were predictive of poor social functioning, even after neurocognition was controlled for. This finding emphasizes the importance of considering the role of negative thoughts in social functioning (Grant & Beck, 2010 ). The cognitive–behavioral therapy (CBT) model of negative symptoms for schizophrenia indicates that defeatist performance beliefs may link neurocognition (i.e., memory, attention, and executive function), negative symptoms, and impaired functioning (Grant & Beck, 2009 ). Beck et al. ( 2018 ) reported that when individuals with schizophrenia fail to meet their own performance expectations, they are likely to doubt their abilities, which leads to frustration, reduced motivation, and exacerbated negative symptoms. (Ventura et al., 2014 ) observed that such patterns can impede daily functioning. However, studies have not consistently demonstrated a clear relationship between neurocognition, self-defeatist beliefs, negative symptoms, and social functioning. For example, a cross-sectional study by (Luther et al., 2018 ) provided evidence supporting the existence of an effect of self-defeatist beliefs on negative symptoms, whereas (Quinlan et al., 2014 ) indicated that defeatist beliefs mediated the relationship between neurocognition and negative symptoms. However, these two studies have reported no relationship between defeatist beliefs and daily functioning. Other studies, such as (Couture et al., 2011 ; Mervis et al., 2017 ), have reported self-defeatist thoughts to have a direct effect on social functioning. They observed that patients with schizophrenia had higher work motivation and retention rates after participating in CBT-based vocational intervention programs focused on reducing self-defeatist beliefs. Additionally, a neuroimaging study by (Milev et al., 2005 ) revealed that dysfunctional beliefs may mediate the relationship between negative symptoms and social functioning. Although studies on the topic have reported inconsistent results, the present study proposes that self-defeatist beliefs mediate the relationship between negative symptoms and social functioning. This hypothesis aligns with the CBT model of negative symptoms, in which maladaptation is considered to be a reaction to the consequences of negative symptoms, which are perpetuated by dysfunction beliefs (Beck et al., 2018 ; Campellone et al., 2016 ; Perivoliotis & Cather, 2009 ). This understanding of negative symptoms is supported by a randomized study by (Granholm et al., 2014 ), which found that changes in dysfunction correlated with improvements in social functioning. Few studies have investigated the relationships between neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning. (Saleh et al., 2021 ) argued that self-defeatist beliefs mediated the relationship between motivational and reward processing deficits and negative symptoms, particularly apathy and avolition, rather than that between alogia and blunted affect. A randomized clinical trial identified self-defeatist beliefs to play a mediating role in the relationship between experiential negative symptoms and social functioning (Granholm et al., 2018 ). The present study proposed and analyzed a hypothesized model of negative symptoms (Fig. 1 ) by using structural equation modeling (SEM). It examined the following hypothesized paths: (1) neurocognition may directly affect experiential negative symptoms; (2) neurocognition may directly influence self-defeatist beliefs; (3) experiential negative symptoms may directly influence self-defeatist beliefs; (4) self-defeatist beliefs may directly affect daily functioning; (5) neurocognition may influence social functioning; (6) experiential negative symptoms may directly affect social functioning; and (7) self-defeatist beliefs may mediate the relationship between experiential negative symptoms and social functioning. Method Participants and Procedure This cross-sectional study was approved by the Institutional Review Board of O O Hospital (OOO-IRB-11015) and involved 229 participants with schizophrenia who were recruited from the clinics and day ward of a mental health hospital (88 women, 38.4%). All participants provided informed consent. The inclusion criteria were as follows: (1) meeting the Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.; American Psychological Association, 2013) criteria for schizophrenia or schizoaffective disorders, (2) being literate, and (3) being able to communicate fluently and coherently. The exclusion criteria were as follows: (1) having delirium or dementia, (2) vividly psychotic symptoms, or (3) acute phase of illness. The average age of the participants was 52.16 years (standard deviation [SD] = 7.09). Measurements Demographics: The collected data included age, sex, educational attainment, age of onset, and history of chronic diseases. Neurocognition: The digit span and digit symbol tasks were administered to assess neurocognitive deficits. The backward scores of the digit span task indicated verbal working memory deficit and executive function impairment (Chey et al., 2002 ). The digit symbol task was used to measure processing speed impairments (Meyer et al., 2014 ). Self-defeatist beliefs: The dysfunctional attitude scale, comprising 5 items rated on a 7-point Likert scale, was used to assess self-defeatist beliefs (Weissman & Beck, 1978 ). Its applicability to patients with schizophrenia was validated and had high reliability (Lee & Yu, 2021 ). The principal component method with varimax rotation was used to test the model fit. Two subscales, the perfect (items 1, 2, 3, 4, 5, 6, 7, 8, 10, and 15) and high standard (items 9, 11, 12, 13, and 14) subscales, were identified as having total initial eigenvalues = 63.35%. The Cronbach’s α values for the perfect and high standard subscales were 0.93 and 0.88, respectively. Negative symptoms: This study used the scale for the assessment of negative symptoms (SANS), for which items are rated using a 6-point Likert scale. The SANS categorizes negative symptoms under five domains: alogia, affective flattening, avolition–apathy, anhedonia–asociality, and attentional impairment(Andreasen, 1982 ). In accordance with the two-factor model of negative symptoms (Paul et al., 2023 ), experiential negative symptoms were measured through anhedonia and avolition components. The reliability values for the five subscales for avolition–apathy and anhedonia–asociality were 0.82 and 0.64, respectively. Daily functioning: The personal and social performance (PSP) scale was used to assess daily functioning. The PSP scale is designed to evaluate social functioning deficits in schizophrenia, with higher scores indicating superior personal or social activity performance (Patrick et al., 2009 ). In this study, the Cronbach’s α for the PSP scale was 0.82. Analysis An SEM was used to assess the fit of the hypothesized model. The analysis included a correlation test to determine the distributions of the demographic data and measured variables and to investigate the relationships between these variables. The model’s goodness-of-fit was evaluated using the goodness-of-fit index (GFI > 0.9), comparative fitness index (CFI > 0.9), root mean square error of approximation (RMSEA < 0.05), and standardized root mean square residual (SRMR < 0.05; (Schermelleh-Engel et al., 2003 ). The significance level was set at 0.05. Bootstrap maximum likelihood was applied to investigate mediating effects. Results Demographic data The majority of the participants in this study were men, and more than half of the patients reported a history of hyperlipidemia (52.4%). Regarding education level, the largest proportion of participants had a junior high school education (42%). The average age of onset was 24.58 years, indicating long-term experience with schizophrenia in the study population (Table 1 ). Table 1 Distributions of demographic variables and measured variables Variables Means/S.D. N (%) Age 52.16/7.09 Chronic diseases Hypertension Diabetes Heart Disease Gastrointestinal diseases Hepatitis Hyperlipidemia Stroke 71/31.6 71/31 95/41.5 113/49.3 45/19.7 120/52.4 0/0 Gender Female Male 141/61.6 88/38.4 Educational level None Elementary school Junior high school Senior high school College Master above 21/9.4 78/34.8 94/42 25/11.2 6/2.7 0/0 Onset 24.58/8.72 Negative symptoms Experiential Expressive 11.08/4.14 13.82/5.30 Self-defeatist beliefs Perfect High standard 3.79/1.54 3.76/0.81 PSP 14.37/2.97 Backward of digit span 4.09/2.28 Digit Symbol 34.72/21.53 As indicated in Table 2 , the perfect subscale of self-defeatist beliefs was negatively correlated with experiential negative symptoms. Additionally, the digit symbol task and social functioning exhibited significant correlations with the high standard subscale of self-defeatist beliefs. Social functioning was negatively associated with experiential negative symptoms and the digit symbol task. Table 2 Correlation coefficients of measured variables 1 2 3 4 5 6 1 - 2 −0.19** - 3 0.9 0.31** - 4 −0.28** 0.16** 0.12 - 5 −0.19** 0.22** 0.15* 0.48** - 6 0.14* −0.04 −0.14* −0.12 −0.18* - 1: Experiential negative symptom; 2: perfect subscale of self-defeatist beliefs; 3: high standard subscale of self-defeatist beliefs; 4: backward digit span task; 5: digit symbol task; 6: PSP; *: p < 0.05; **: p 0.90); CFI = 1.000 (> 0.9); RMSEA = 0.000 (< 0.05); SRMR = 0.0397 (< 0.05). Among the hypothesized paths, that from neurocognition to experiential negative symptoms (t = − 3.40, p < 0.001) and that from experiential negative symptoms to self-defeatist beliefs (t = − 0.238, p = 0.02) were significant. Unexpectedly, several paths (neurocognition ∀ self-defeatist beliefs, neurocognition ∀ social functioning, experiential negative symptoms ∀ social functioning, and self-defeatist beliefs ∀ social functioning) did not reach significance (Fig. 2 ). Revised model of negative symptoms Two nonsignificant paths (neurocognition ∀ self-defeatist beliefs and neurocognition ∀ social functioning) were removed from consideration, leading to the establishment of a revised model (neurocognition ∀ experiential negative symptoms, experiential negative symptoms ∀ self-defeatist beliefs ∀ social functioning, and experiential negative symptoms ∀ social functioning). The revised model had improved fit indices: χ 2 = 30.89, p = 0.47; GFI = 0.97 (> 0.90); CFI = 1.00 (> 0.90); RMSEA = 0.000 (< 0.05); SRMR = 0.048 (< 0.05). All hypothesized paths were significant, with the exception of that from self-defeatist beliefs to social functioning (Table 3 ). Table 3 Coefficients of paths in the revised model Path t p Neurocognition ∀ Experiential negative symptom −3.28 0.001** Experiential negative symptoms ∀ Self-defeatist beliefs −3.04 0.002** Experiential negative symptoms ∀ Social functioning 2.308 0.021* Self-defeatist beliefs ∀ Social functioning 0.11 0.92 *: p < 0.05; **: p < 0.01. Discussion This study proposed a hypothesized model to investigate the relationships between self-defeatist beliefs, negative symptoms, neurocognition, and social functioning by using an SEM. The proposed model demonstrated a satisfactory GFI, and the revised version of the model supported the effect of experiential negative symptoms on social functioning. However, the results did not confirm a mediating effect of self-defeatist beliefs on the association between experiential negative symptoms and social functioning, which was an unexpected finding. The current study has several key findings. First, the appropriate GFI in our hypothesized model aligns with the CBT model of negative symptoms, indicating a relationship between experiential negative symptoms and self-defeatist beliefs (Grant & Beck, 2010 ). However, our results did not reveal a mediating effect of self-defeatist beliefs in the relationship between experiential negative symptoms and social functioning. This could be attributed to differing degrees of negative symptom severity and neurocognitive function levels in our study population. A cross-sectional study investigated the effect of different levels of neurocognition and negative symptoms in chronic schizophrenia and revealed associations between moderate experiential negative symptoms, impaired cognitive function, and social functioning (Strassnig et al., 2018 ). According to the CBT model, individuals with schizophrenia might struggle more with daily challenges and social interactions than do those without because such individuals may have stronger self-defeatist beliefs arising from worsening negative symptoms and impaired neurocognitive functions (Reddy et al., 2018 ). Furthermore, although the past study provided valuable insights into the role of negative symptoms and neurocognition in schizophrenia, they did not investigate the effect of self-defeatist beliefs on these factors (Strassnig et al., 2018 ). Therefore, future studies should investigate the combined effects of experiential negative symptoms, neurocognitive function, and self-defeatist beliefs on social functioning in schizophrenia. Second, the revised model highlights the effect of experiential negative symptoms on social functioning, indicating that negative symptoms significantly contribute to neurocognitive deficits (Hovington & Lepage, 2012 ; Kasanova et al., 2018 ). However, the current model did not incorporate social cognition. Studies, such as (Sergi et al., 2007 ), have indicated that social awareness may mediate the influence of neurocognition on negative symptoms. Therefore, future studies should investigate the relationships among neurocognition, social cognition, belief systems, and negative symptoms. Third, our findings revealed that neurocognition does not directly influence self-defeatist beliefs, which contradicts the findings of (Grant & Beck, 2009 ). Theoretically, neurocognitive deficits in individuals with schizophrenia might impede expected performance of specific behaviors, leading to the development of negative self-schema and subsequent withdrawal and motivation deficits. These withdrawal behaviors are similar to negative symptoms. Therefore, self-defeatist beliefs may stem more from attributions for behaviors associated with negative symptoms than from neurocognitive dysfunction itself. Future experimental or longitudinal studies should investigate the relationship between neurocognitive intervention, self-defeatist beliefs, and negative symptoms. Fourth, our findings indicate that neurocognition has a direct influence on experiential negative symptoms, a conclusion supported by neuroimaging studies (İnce & Üçok, 2018 ). Neuroimaging evidence suggests that an association exists between neurocognitive deficits and the dorsolateral prefrontal cortex and cortico-striatal circuitry, which may explain why cognitive rehabilitation was reported to improve negative symptoms (Bellucci et al., 2003 ). A clinical trial on neurocognitive remediation for schizophrenia reported that patients with schizophrenia (n = 47) demonstrated enhancements in working memory, inhibition, theory of mind, and negative symptoms after 20 weeks relative to that of those receiving standard treatment (Sampedro et al., 2021 ). However, to our knowledge, research investigating the effect of cognitive rehabilitation on experiential negative symptoms and its integration with changes in self-defeatist beliefs remains limited. Future outcome studies or longitudinal research could explore these relationships. Fifth, the revised model confirms the relationship between experiential negative symptoms and social functioning; this finding aligns with the two-factor model of negative symptoms (Glenthøj et al., 2020 ). Negative symptoms are related to social functioning and self-defeatist beliefs (Ventura et al., 2014 ). Therefore, according to the CBT framework for negative symptoms, therapists can employ two main strategies for assisting individuals with schizophrenia. One involves revising self-defeatist beliefs through reality testing or seeking alternative thoughts. The other involves emotional regulation through mindfulness-based practices. Mindfulness training can enable individuals with schizophrenia to become more aware of and attuned to their feelings and can thereby improve their life experiences (Lee, 2019 ). Additional comparative studies assessing the outcomes of mindfulness-based interventions versus cognitive rehabilitation could clarify the distinct effects of neurocognition and belief systems on negative symptoms. Sixth, our results did not corroborate previous results regarding the effect of self-defeatist beliefs on social functioning (Campellone et al., 2016 ). Research has indicated that self-defeatist beliefs can exacerbate negative cognition, influence affect management (e.g., rumination and mindfulness), and lead to a lower likelihood of pursuing goal-oriented behaviors (Abram et al., 2022 ). Future research should therefore investigate the potential moderating role of self-defeatist beliefs on the relationships between negative symptoms, social functioning, and mood status. In summary, the present study partially confirms the effect of negative symptoms on self-defeatist beliefs and elucidates the relationships between neurocognition, experiential negative symptoms, and social functioning. These findings offer insights into the potential mechanisms underlying the CBT model of negative symptoms, and they may guide the development of different intervention approaches to ameliorate these symptoms. However, several limitations in this study warrant consideration. First, the cross-sectional design prevented us from making causal inferences regarding the relationships between the variables. Longitudinal research could provide more comprehensive insights into such causality. Second, this study did not include biological markers or neuroimaging data; including such information could enrich future studies. Third, the sample size was somewhat limited; subsequent research with a larger sample size could further validate the current findings. Despite these limitations, the present study provides valuable directions for future research into the effect of self-defeatist beliefs on negative symptoms in schizophrenia. Declarations Conflicts of interest None of the authors have any conflicts of interest to declare. Author Contribution Dr. Kun-Hua Lee was responsible for writing proposals, analyzing data, and writing the manuscript. Mr. Chuan-Hsun Yu was responsible for grant applications, administrative events, and final manuscript review. Data availability statement The data sets generated and analyzed during this study are not publicly available because of the privacy considerations of the Institutional Review Board. However, they can be obtained from the corresponding author upon reasonable request. References Abram SV, Weittenhiller LP, Bertrand CE, McQuaid JR, Mathalon DH, Ford JM, Fryer SL (2022) Psychological dimensions relevant to motivation and pleasure in schizophrenia. 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J Psychiatr Res 104:124–129 Strauss GP, Whearty KM, Morra LF, Sullivan SK, Ossenfort KL, Frost KH (2016) Avolition in schizophrenia is associated with reduced willingness to expend effort for reward on a Progressive Ratio task. Schizophr Res 170(1):198–204 Ventura J, Subotnik KL, Ered A, Gretchen-Doorly D, Hellemann GS, Vaskinn A, Nuechterlein KH (2014) The relationship of attitudinal beliefs to negative symptoms, neurocognition, and daily functioning in recent-onset schizophrenia. Schizophr Bull 40(6):1308–1318 Weissman AN, Beck AT (1978) Development and validation of the Dysfunctional Attitude Scale. A preliminary investigation Yang Z, Lee SH, Rashid A, See NA, Dauwels YM, Tan J, B. L., Lee J (2021) Predicting real-world functioning in schizophrenia: the relative contributions of neurocognition, functional capacity, and negative symptoms. Front Psychiatry 12:639536 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4094734","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":280018668,"identity":"e6a76d9e-f4b7-41bc-9232-957b3e2ac27c","order_by":0,"name":"Kunhua Lee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYBACCQYGNiBlwcDA3gAWSICKEtQCpHgOgPgGMC0GRGiRSCBSi+SM3GOPeWok5PglX6dJMO74k2dwgPngbR6GP4kNOLRIS+SlG/MckzCWnJ272YDxjEGxwQG2ZGseBgOcWuQkcsykedgkEjfczt34gLHNIHHDAR6gCINBLn4t/yTq9988u+EARAv/N7xapEFaeNskEgwkeOG2sOHVItnzxkxybp+E4YwzQL8kthknzjzMZmw5x8C4HpcWieM5ZhJvvtnI87ef3SbxsU0use9488MbbyrkjHHoQAMJIIIZROCOllEwCkbBKBgFRAAA+1JOF0ApnhgAAAAASUVORK5CYII=","orcid":"","institution":"National Tsing Hua University","correspondingAuthor":true,"prefix":"","firstName":"Kunhua","middleName":"","lastName":"Lee","suffix":""},{"id":280018669,"identity":"a3afbe3b-f325-4397-98a3-9130deab528c","order_by":1,"name":"Chuan-Hsun Yu","email":"","orcid":"","institution":"Yuli Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chuan-Hsun","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2024-03-13 16:33:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4094734/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4094734/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53019565,"identity":"86c3429c-1dd7-401b-87e0-d87ca31347e5","added_by":"auto","created_at":"2024-03-19 16:23:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35915,"visible":true,"origin":"","legend":"\u003cp\u003eHypothesized model\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4094734/v1/7cad8fcc5840e2c833f8873b.png"},{"id":53018454,"identity":"0cd478d9-08d0-48cc-964e-c6bd01c1919a","added_by":"auto","created_at":"2024-03-19 16:15:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":42738,"visible":true,"origin":"","legend":"\u003cp\u003eCoefficients of hypothesized model; *: \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05; **: \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.01.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4094734/v1/91f137bdf3b798360903ba3d.png"},{"id":53298972,"identity":"cc73ea94-3ac7-4783-9f3b-8fdf0d313cb3","added_by":"auto","created_at":"2024-03-23 08:38:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":270539,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4094734/v1/b361bde4-e7f7-4e75-b127-35cbbb689f92.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eReexamination of the relationships among neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in chronic schizophrenia\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn a review article, (Mäkinen et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) reported that over half of individuals experiencing their first-episode of psychosis exhibit negative symptoms, with a third demonstrating persistent negative symptoms. These symptoms are associated with diminished subjective quality of life and hindered rehabilitation (Packer et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). Individuals with schizophrenia often face challenges in relationships with relatives and in maintaining daily functions, primarily because of feelings of apathy and a lack of motivation. (Correll \u0026amp; Schooler, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) indicated that negative symptoms can be prevented from progressing to a residual stage, underscoring the importance of understanding such symptoms’ psychopathology and treatment.\u003c/p\u003e \u003cp\u003eStudies related to the psychopathology and treatment of negative symptoms have often emphasized the structure of these symptoms. The consensus conceptualization of negative symptoms involves two factors: expressive (alogia and blunted affect) and experiential (avolition, anhedonia, and asociality) negative symptoms (Glenthøj et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Schlosser et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The prior study reported that experiential negative symptoms more profoundly influence social functioning than expressive negative symptoms do (Marder \u0026amp; Galderisi, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eResearchers have used the positive and negative syndrome scale and social functioning to assess patients on the schizophrenia spectrum and have discovered experiential negative symptoms to significantly affect social functioning, everyday activities, and vocational functioning. By contrast, research has indicated expressive negative symptoms to have a negligible effect on social and vocational functioning (Harvey et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Paul et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Another study confirmed the substantial influence of experiential negative symptoms on quality of life in a study involving 275 participants with schizophrenia (Savill et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Further validated the stronger effect of experiential over that of expressive negative symptoms on social functioning (Glenthøj et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese findings raise the critical question of how experiential negative symptoms influence social functioning. The core symptoms of experiential deficits include asociality, anhedonia, and avolition, which are collectively categorized as avolition–apathy negative symptoms (AA; (Marder \u0026amp; Galderisi, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Mäkinen et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Research has indicated that a relationship exists between experiential negative symptoms and neurocognitive deficits (Chey et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Hovington \u0026amp; Lepage, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Sampedro et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Neuroimaging research reveals associations between these symptoms and a propensity for selecting low-effort options, along with excessive effort-discounting, implicating brain regions such as the insula, hippocampus, amygdala, reward system, and frontal cortex (Galderisi et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients with schizophrenia often exhibit withdrawal from interpersonal activities and diminished motivation for engaging in enjoyable activities. A case–control study by (Strauss et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) revealed that individuals with schizophrenia who experienced heightened levels of avolition and anhedonia exhibited less of an inclination towards seeking out rewarding experiences than did healthy controls. Furthermore, a study involving 58 patients with schizophrenia examined the relationships between neurocognitive function, AA, expressive deficit negative symptoms (DE), and real-life functioning. The study’s results indicated that when AA and DE were considered, the effect of neurocognition on real-life functioning diminished (Yang et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Thus, neurocognitive function may be a distal factor in social functioning, whereas experiential negative symptoms could be a proximal factor.\u003c/p\u003e \u003cp\u003eEvidence regarding the effect of experiential negative symptoms on social functioning, however, is not always consistent. A 3-year follow-up study indicated that the influence of these symptoms might fluctuate over time (Austin et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In addition, (Kasanova et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) discovered that some patients with schizophrenia, despite having reduced engagement in social activities, experienced a certain amount of hedonism. (Harvey et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) identified other factors that could influence the relationship between experiential negative symptoms and social functioning. A review by (Marder \u0026amp; Galderisi, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) highlighted the role of dysfunctional beliefs, such as negative expectations about oneself, the future, or the environment, in diminishing the motivation of individuals with schizophrenia to engage in social activities.\u003c/p\u003e \u003cp\u003eOne study conducted a 1-year follow-up study investigating the effect of negative expectations on social withdrawal. The study revealed that negative expectations were predictive of poor social functioning, even after neurocognition was controlled for. This finding emphasizes the importance of considering the role of negative thoughts in social functioning (Grant \u0026amp; Beck, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). The cognitive–behavioral therapy (CBT) model of negative symptoms for schizophrenia indicates that defeatist performance beliefs may link neurocognition (i.e., memory, attention, and executive function), negative symptoms, and impaired functioning (Grant \u0026amp; Beck, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Beck et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) reported that when individuals with schizophrenia fail to meet their own performance expectations, they are likely to doubt their abilities, which leads to frustration, reduced motivation, and exacerbated negative symptoms. (Ventura et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) observed that such patterns can impede daily functioning. However, studies have not consistently demonstrated a clear relationship between neurocognition, self-defeatist beliefs, negative symptoms, and social functioning.\u003c/p\u003e \u003cp\u003eFor example, a cross-sectional study by (Luther et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) provided evidence supporting the existence of an effect of self-defeatist beliefs on negative symptoms, whereas (Quinlan et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) indicated that defeatist beliefs mediated the relationship between neurocognition and negative symptoms. However, these two studies have reported no relationship between defeatist beliefs and daily functioning. Other studies, such as (Couture et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Mervis et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), have reported self-defeatist thoughts to have a direct effect on social functioning. They observed that patients with schizophrenia had higher work motivation and retention rates after participating in CBT-based vocational intervention programs focused on reducing self-defeatist beliefs. Additionally, a neuroimaging study by (Milev et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) revealed that dysfunctional beliefs may mediate the relationship between negative symptoms and social functioning.\u003c/p\u003e \u003cp\u003eAlthough studies on the topic have reported inconsistent results, the present study proposes that self-defeatist beliefs mediate the relationship between negative symptoms and social functioning. This hypothesis aligns with the CBT model of negative symptoms, in which maladaptation is considered to be a reaction to the consequences of negative symptoms, which are perpetuated by dysfunction beliefs (Beck et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Campellone et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Perivoliotis \u0026amp; Cather, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). This understanding of negative symptoms is supported by a randomized study by (Granholm et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), which found that changes in dysfunction correlated with improvements in social functioning.\u003c/p\u003e \u003cp\u003eFew studies have investigated the relationships between neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning. (Saleh et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) argued that self-defeatist beliefs mediated the relationship between motivational and reward processing deficits and negative symptoms, particularly apathy and avolition, rather than that between alogia and blunted affect. A randomized clinical trial identified self-defeatist beliefs to play a mediating role in the relationship between experiential negative symptoms and social functioning (Granholm et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe present study proposed and analyzed a hypothesized model of negative symptoms (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) by using structural equation modeling (SEM). It examined the following hypothesized paths: (1) neurocognition may directly affect experiential negative symptoms; (2) neurocognition may directly influence self-defeatist beliefs; (3) experiential negative symptoms may directly influence self-defeatist beliefs; (4) self-defeatist beliefs may directly affect daily functioning; (5) neurocognition may influence social functioning; (6) experiential negative symptoms may directly affect social functioning; and (7) self-defeatist beliefs may mediate the relationship between experiential negative symptoms and social functioning.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Method","content":"\u003cp\u003eParticipants and Procedure\u003c/p\u003e\u003cp\u003eThis cross-sectional study was approved by the Institutional Review Board of O O Hospital (OOO-IRB-11015) and involved 229 participants with schizophrenia who were recruited from the clinics and day ward of a mental health hospital (88 women, 38.4%). All participants provided informed consent. The inclusion criteria were as follows: (1) meeting the \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders\u003c/em\u003e (Fifth ed.; American Psychological Association, 2013) criteria for schizophrenia or schizoaffective disorders, (2) being literate, and (3) being able to communicate fluently and coherently. The exclusion criteria were as follows: (1) having delirium or dementia, (2) vividly psychotic symptoms, or (3) acute phase of illness. The average age of the participants was 52.16 years (standard deviation [SD] = 7.09).\u003c/p\u003e\u003cp\u003eMeasurements\u003c/p\u003e\u003cp\u003eDemographics: The collected data included age, sex, educational attainment, age of onset, and history of chronic diseases.\u003c/p\u003e\u003cp\u003eNeurocognition: The digit span and digit symbol tasks were administered to assess neurocognitive deficits. The backward scores of the digit span task indicated verbal working memory deficit and executive function impairment (Chey et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). The digit symbol task was used to measure processing speed impairments (Meyer et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSelf-defeatist beliefs: The dysfunctional attitude scale, comprising 5 items rated on a 7-point Likert scale, was used to assess self-defeatist beliefs (Weissman \u0026amp; Beck, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e1978\u003c/span\u003e). Its applicability to patients with schizophrenia was validated and had high reliability (Lee \u0026amp; Yu, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The principal component method with varimax rotation was used to test the model fit. Two subscales, the perfect (items 1, 2, 3, 4, 5, 6, 7, 8, 10, and 15) and high standard (items 9, 11, 12, 13, and 14) subscales, were identified as having total initial eigenvalues = 63.35%. The Cronbach’s α values for the perfect and high standard subscales were 0.93 and 0.88, respectively.\u003c/p\u003e\u003cp\u003eNegative symptoms: This study used the scale for the assessment of negative symptoms (SANS), for which items are rated using a 6-point Likert scale. The SANS categorizes negative symptoms under five domains: alogia, affective flattening, avolition–apathy, anhedonia–asociality, and attentional impairment(Andreasen, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1982\u003c/span\u003e). In accordance with the two-factor model of negative symptoms (Paul et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), experiential negative symptoms were measured through anhedonia and avolition components. The reliability values for the five subscales for avolition–apathy and anhedonia–asociality were 0.82 and 0.64, respectively.\u003c/p\u003e\u003cp\u003eDaily functioning: The personal and social performance (PSP) scale was used to assess daily functioning. The PSP scale is designed to evaluate social functioning deficits in schizophrenia, with higher scores indicating superior personal or social activity performance (Patrick et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). In this study, the Cronbach’s α for the PSP scale was 0.82.\u003c/p\u003e\u003cp\u003eAnalysis\u003c/p\u003e\u003cp\u003eAn SEM was used to assess the fit of the hypothesized model. The analysis included a correlation test to determine the distributions of the demographic data and measured variables and to investigate the relationships between these variables. The model’s goodness-of-fit was evaluated using the goodness-of-fit index (GFI \u0026gt; 0.9), comparative fitness index (CFI \u0026gt; 0.9), root mean square error of approximation (RMSEA \u0026lt; 0.05), and standardized root mean square residual (SRMR \u0026lt; 0.05; (Schermelleh-Engel et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). The significance level was set at 0.05. Bootstrap maximum likelihood was applied to investigate mediating effects.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDemographic data\u003c/p\u003e \u003cp\u003eThe majority of the participants in this study were men, and more than half of the patients reported a history of hyperlipidemia (52.4%). Regarding education level, the largest proportion of participants had a junior high school education (42%). The average age of onset was 24.58 years, indicating long-term experience with schizophrenia in the study population (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistributions of demographic variables and measured variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeans/S.D.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52.16/7.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic diseases\u003c/p\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003cp\u003eHeart Disease\u003c/p\u003e \u003cp\u003eGastrointestinal diseases\u003c/p\u003e \u003cp\u003eHepatitis\u003c/p\u003e \u003cp\u003eHyperlipidemia\u003c/p\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71/31.6\u003c/p\u003e \u003cp\u003e71/31\u003c/p\u003e \u003cp\u003e95/41.5\u003c/p\u003e \u003cp\u003e113/49.3\u003c/p\u003e \u003cp\u003e45/19.7\u003c/p\u003e \u003cp\u003e120/52.4\u003c/p\u003e \u003cp\u003e0/0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e141/61.6\u003c/p\u003e \u003cp\u003e88/38.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eElementary school\u003c/p\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003cp\u003eSenior high school\u003c/p\u003e \u003cp\u003eCollege\u003c/p\u003e \u003cp\u003eMaster above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21/9.4\u003c/p\u003e \u003cp\u003e78/34.8\u003c/p\u003e \u003cp\u003e94/42\u003c/p\u003e \u003cp\u003e25/11.2\u003c/p\u003e \u003cp\u003e6/2.7\u003c/p\u003e \u003cp\u003e0/0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.58/8.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative symptoms\u003c/p\u003e \u003cp\u003eExperiential\u003c/p\u003e \u003cp\u003eExpressive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.08/4.14\u003c/p\u003e \u003cp\u003e13.82/5.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-defeatist beliefs\u003c/p\u003e \u003cp\u003ePerfect\u003c/p\u003e \u003cp\u003eHigh standard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.79/1.54\u003c/p\u003e \u003cp\u003e3.76/0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.37/2.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBackward of digit span\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.09/2.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDigit Symbol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34.72/21.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs indicated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the perfect subscale of self-defeatist beliefs was negatively correlated with experiential negative symptoms. Additionally, the digit symbol task and social functioning exhibited significant correlations with the high standard subscale of self-defeatist beliefs. Social functioning was negatively associated with experiential negative symptoms and the digit symbol task.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation coefficients of measured variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.19**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.31**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.28**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.16**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.19**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.22**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.15*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.48**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.14*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.14*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.18*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e1: Experiential negative symptom; 2: perfect subscale of self-defeatist beliefs; 3: high standard subscale of self-defeatist beliefs; 4: backward digit span task; 5: digit symbol task; 6: PSP; *: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **: p\u0026thinsp;\u0026lt;\u0026thinsp;0.01.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHypothesized model\u003c/p\u003e \u003cp\u003eThe SEM results indicated adequate model fit, with the following index values: χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;28.86, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.472; GFI\u0026thinsp;=\u0026thinsp;0.975 (\u0026gt;\u0026thinsp;0.90); CFI\u0026thinsp;=\u0026thinsp;1.000 (\u0026gt;\u0026thinsp;0.9); RMSEA\u0026thinsp;=\u0026thinsp;0.000 (\u0026lt;\u0026thinsp;0.05); SRMR\u0026thinsp;=\u0026thinsp;0.0397 (\u0026lt;\u0026thinsp;0.05). Among the hypothesized paths, that from neurocognition to experiential negative symptoms (t\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;3.40, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and that from experiential negative symptoms to self-defeatist beliefs (t\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.238, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02) were significant. Unexpectedly, several paths (neurocognition \u0026forall; self-defeatist beliefs, neurocognition \u0026forall; social functioning, experiential negative symptoms \u0026forall; social functioning, and self-defeatist beliefs \u0026forall; social functioning) did not reach significance (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eRevised model of negative symptoms\u003c/p\u003e \u003cp\u003eTwo nonsignificant paths (neurocognition \u0026forall; self-defeatist beliefs and neurocognition \u0026forall; social functioning) were removed from consideration, leading to the establishment of a revised model (neurocognition \u0026forall; experiential negative symptoms, experiential negative symptoms \u0026forall; self-defeatist beliefs \u0026forall; social functioning, and experiential negative symptoms \u0026forall; social functioning). The revised model had improved fit indices: χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;30.89, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.47; GFI\u0026thinsp;=\u0026thinsp;0.97 (\u0026gt;\u0026thinsp;0.90); CFI\u0026thinsp;=\u0026thinsp;1.00 (\u0026gt;\u0026thinsp;0.90); RMSEA\u0026thinsp;=\u0026thinsp;0.000 (\u0026lt;\u0026thinsp;0.05); SRMR\u0026thinsp;=\u0026thinsp;0.048 (\u0026lt;\u0026thinsp;0.05). All hypothesized paths were significant, with the exception of that from self-defeatist beliefs to social functioning (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCoefficients of paths in the revised model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePath\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurocognition \u0026forall; Experiential negative symptom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperiential negative symptoms \u0026forall; Self-defeatist beliefs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.002**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperiential negative symptoms \u0026forall; Social functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.021*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-defeatist beliefs \u0026forall; Social functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **: p\u0026thinsp;\u0026lt;\u0026thinsp;0.01.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study proposed a hypothesized model to investigate the relationships between self-defeatist beliefs, negative symptoms, neurocognition, and social functioning by using an SEM. The proposed model demonstrated a satisfactory GFI, and the revised version of the model supported the effect of experiential negative symptoms on social functioning. However, the results did not confirm a mediating effect of self-defeatist beliefs on the association between experiential negative symptoms and social functioning, which was an unexpected finding.\u003c/p\u003e \u003cp\u003eThe current study has several key findings. First, the appropriate GFI in our hypothesized model aligns with the CBT model of negative symptoms, indicating a relationship between experiential negative symptoms and self-defeatist beliefs (Grant \u0026amp; Beck, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). However, our results did not reveal a mediating effect of self-defeatist beliefs in the relationship between experiential negative symptoms and social functioning. This could be attributed to differing degrees of negative symptom severity and neurocognitive function levels in our study population. A cross-sectional study investigated the effect of different levels of neurocognition and negative symptoms in chronic schizophrenia and revealed associations between moderate experiential negative symptoms, impaired cognitive function, and social functioning (Strassnig et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). According to the CBT model, individuals with schizophrenia might struggle more with daily challenges and social interactions than do those without because such individuals may have stronger self-defeatist beliefs arising from worsening negative symptoms and impaired neurocognitive functions (Reddy et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Furthermore, although the past study provided valuable insights into the role of negative symptoms and neurocognition in schizophrenia, they did not investigate the effect of self-defeatist beliefs on these factors (Strassnig et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Therefore, future studies should investigate the combined effects of experiential negative symptoms, neurocognitive function, and self-defeatist beliefs on social functioning in schizophrenia.\u003c/p\u003e \u003cp\u003eSecond, the revised model highlights the effect of experiential negative symptoms on social functioning, indicating that negative symptoms significantly contribute to neurocognitive deficits (Hovington \u0026amp; Lepage, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Kasanova et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). However, the current model did not incorporate social cognition. Studies, such as (Sergi et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), have indicated that social awareness may mediate the influence of neurocognition on negative symptoms. Therefore, future studies should investigate the relationships among neurocognition, social cognition, belief systems, and negative symptoms.\u003c/p\u003e \u003cp\u003eThird, our findings revealed that neurocognition does not directly influence self-defeatist beliefs, which contradicts the findings of (Grant \u0026amp; Beck, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Theoretically, neurocognitive deficits in individuals with schizophrenia might impede expected performance of specific behaviors, leading to the development of negative self-schema and subsequent withdrawal and motivation deficits. These withdrawal behaviors are similar to negative symptoms. Therefore, self-defeatist beliefs may stem more from attributions for behaviors associated with negative symptoms than from neurocognitive dysfunction itself. Future experimental or longitudinal studies should investigate the relationship between neurocognitive intervention, self-defeatist beliefs, and negative symptoms.\u003c/p\u003e \u003cp\u003eFourth, our findings indicate that neurocognition has a direct influence on experiential negative symptoms, a conclusion supported by neuroimaging studies (İnce \u0026amp; \u0026Uuml;\u0026ccedil;ok, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Neuroimaging evidence suggests that an association exists between neurocognitive deficits and the dorsolateral prefrontal cortex and cortico-striatal circuitry, which may explain why cognitive rehabilitation was reported to improve negative symptoms (Bellucci et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). A clinical trial on neurocognitive remediation for schizophrenia reported that patients with schizophrenia (n\u0026thinsp;=\u0026thinsp;47) demonstrated enhancements in working memory, inhibition, theory of mind, and negative symptoms after 20 weeks relative to that of those receiving standard treatment (Sampedro et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, to our knowledge, research investigating the effect of cognitive rehabilitation on experiential negative symptoms and its integration with changes in self-defeatist beliefs remains limited. Future outcome studies or longitudinal research could explore these relationships.\u003c/p\u003e \u003cp\u003eFifth, the revised model confirms the relationship between experiential negative symptoms and social functioning; this finding aligns with the two-factor model of negative symptoms (Glenth\u0026oslash;j et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Negative symptoms are related to social functioning and self-defeatist beliefs (Ventura et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Therefore, according to the CBT framework for negative symptoms, therapists can employ two main strategies for assisting individuals with schizophrenia. One involves revising self-defeatist beliefs through reality testing or seeking alternative thoughts. The other involves emotional regulation through mindfulness-based practices. Mindfulness training can enable individuals with schizophrenia to become more aware of and attuned to their feelings and can thereby improve their life experiences (Lee, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Additional comparative studies assessing the outcomes of mindfulness-based interventions versus cognitive rehabilitation could clarify the distinct effects of neurocognition and belief systems on negative symptoms.\u003c/p\u003e \u003cp\u003eSixth, our results did not corroborate previous results regarding the effect of self-defeatist beliefs on social functioning (Campellone et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Research has indicated that self-defeatist beliefs can exacerbate negative cognition, influence affect management (e.g., rumination and mindfulness), and lead to a lower likelihood of pursuing goal-oriented behaviors (Abram et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Future research should therefore investigate the potential moderating role of self-defeatist beliefs on the relationships between negative symptoms, social functioning, and mood status.\u003c/p\u003e \u003cp\u003eIn summary, the present study partially confirms the effect of negative symptoms on self-defeatist beliefs and elucidates the relationships between neurocognition, experiential negative symptoms, and social functioning. These findings offer insights into the potential mechanisms underlying the CBT model of negative symptoms, and they may guide the development of different intervention approaches to ameliorate these symptoms. However, several limitations in this study warrant consideration. First, the cross-sectional design prevented us from making causal inferences regarding the relationships between the variables. Longitudinal research could provide more comprehensive insights into such causality. Second, this study did not include biological markers or neuroimaging data; including such information could enrich future studies. Third, the sample size was somewhat limited; subsequent research with a larger sample size could further validate the current findings. Despite these limitations, the present study provides valuable directions for future research into the effect of self-defeatist beliefs on negative symptoms in schizophrenia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of interest\u003c/h2\u003e \u003cp\u003eNone of the authors have any conflicts of interest to declare.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDr. Kun-Hua Lee was responsible for writing proposals, analyzing data, and writing the manuscript. Mr. Chuan-Hsun Yu was responsible for grant applications, administrative events, and final manuscript review.\u003c/p\u003e\u003ch2\u003eData availability statement\u003c/h2\u003e \u003cp\u003eThe data sets generated and analyzed during this study are not publicly available because of the privacy considerations of the Institutional Review Board. However, they can be obtained from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbram SV, Weittenhiller LP, Bertrand CE, McQuaid JR, Mathalon DH, Ford JM, Fryer SL (2022) Psychological dimensions relevant to motivation and pleasure in schizophrenia. Front Behav Neurosci\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndreasen NC (1982) Negative symptoms in schizophrenia: definition and reliability. Arch Gen Psychiatry 39(7):784\u0026ndash;788\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAustin SF, Lysaker PH, Jansen JE, Trauelsen AM, Nielsen H-GL, Pedersen MB, Haahr UH, Simonsen E (2019) Metacognitive capacity and negative symptoms in first episode psychosis: Evidence of a prospective relationship over a 3-year follow-up. 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Schizophr Res 176(2\u0026ndash;3):387\u0026ndash;391\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchermelleh-Engel K, Moosbrugger H, M\u0026uuml;ller H (2003) Evaluating the fit of structural equation models: Tests of significance and descriptive goodness-of-fit measures. Methods Psychol Res online 8(2):23\u0026ndash;74\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchlosser DA, Campellone TR, Biagianti B, Delucchi KL, Gard DE, Fulford D, Stuart BK, Fisher M, Loewy RL, Vinogradov S (2015) Modeling the role of negative symptoms in determining social functioning in individuals at clinical high risk of psychosis. Schizophr Res 169(1\u0026ndash;3):204\u0026ndash;208\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSergi MJ, Rassovsky Y, Widmark C, Reist C, Erhart S, Braff DL, Marder SR, Green MF (2007) Social cognition in schizophrenia: relationships with neurocognition and negative symptoms. 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Schizophr Bull 40(6):1308\u0026ndash;1318\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeissman AN, Beck AT (1978) Development and validation of the Dysfunctional Attitude Scale. A preliminary investigation\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang Z, Lee SH, Rashid A, See NA, Dauwels YM, Tan J, B. L., Lee J (2021) Predicting real-world functioning in schizophrenia: the relative contributions of neurocognition, functional capacity, and negative symptoms. Front Psychiatry 12:639536\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"neurocognition, self-defeatist beliefs, experiential negative symptoms, social functioning, schizophrenia","lastPublishedDoi":"10.21203/rs.3.rs-4094734/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4094734/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study proposed and evaluated a theoretical model for exploring the relationships between neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in individuals with chronic schizophrenia.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThe study recruited 229 individuals given a diagnosis of schizophrenia from outpatient clinics and the day ward of a mental health hospital. After informed consent was obtained, the participants underwent assessments using the backward digit span, the digit symbol, and measures of self-defeatist beliefs, experiential negative symptoms, and social functioning. A structural equation model was applied to assess the fitness of the hypothesized model, with indices such as the goodness-of-fit index, comparative fit index, root mean square error of approximation, and standardized root mean square residual being used for model evaluation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe hypothesized model had an adequate fit. The study findings indicated that neurocognition might indirectly influence self-defeatist beliefs through its effect on experiential negative symptoms. Contrary to expectations, the study did not observe a direct influence of neurocognition, self-defeatist beliefs, or negative symptoms on social functioning. The revised model revealed the role of experiential negative symptoms in mediating the association between neurocognition and social functioning. However, self-defeatist beliefs did not significantly affect social functioning.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eCompared with the modification of beliefs, self-awareness training can help improve negative symptoms and thereby improve the performance of social functions. Future research should develop a hierarchical program of negative symptoms, from cognition rehabilitation to enhancement of self-awareness, and end with modifying maladaptive beliefs.\u003c/p\u003e","manuscriptTitle":"Reexamination of the relationships among neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in chronic schizophrenia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-19 16:15:48","doi":"10.21203/rs.3.rs-4094734/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f10535a4-99f7-4406-91b0-e57ec082b98b","owner":[],"postedDate":"March 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-23T08:30:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-19 16:15:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4094734","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4094734","identity":"rs-4094734","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}