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Journal of Psychiatric Research 46 (2012) 205e211

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Journal of Psychiatric Research

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Functional outcomes in schizophrenia: Understanding thecompetence-performance discrepancy

Maya Guptaa, Emma Bassetta, Felicia Ifteneb, Christopher R. Bowiea,b,*aDepartment of Psychology, Queen’s University, 62 Arch Street, Kingston, ON K7L 3N6, CanadabDepartment of Psychiatry, Queen’s University, 62 Arch Street, Kingston, ON K7L 3N6, Canada

a r t i c l e i n f o

Article history:Received 17 June 2011Received in revised form19 August 2011Accepted 1 September 2011

Keywords:SchizophreniaFunctional outcomesAdaptive behaviourInterpersonal behaviour

* Corresponding author. Department of PsychologyStreet, Kingston, ON K7L 3N6, Canada. Tel.: þ1 613 53

E-mail address: bowiec@queensu.ca (C.R. Bowie).

0022-3956/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.jpsychires.2011.09.002

a b s t r a c t

A problem in the study and treatment of functional disability in schizophrenia is that factors other thancompetence (what one can do) can limit real-world performance (what one does). We examinedpredictors of the competence-performance discrepancy in both adaptive and interpersonal domains.Patients with schizophrenia (N ¼ 96) were evaluated at baseline of a clinical treatment study. Discrep-ancy scores were created by considering each subject’s competence relative to their real-world perfor-mance in interpersonal and adaptive behaviour domains. Logistic regression analyses revealed that forthe interpersonal competence-performance discrepancy, living in a group home, better neurocognition,more time spent in the hospital since a first episode of psychosis, and a longer first hospitalizationpredicted a greater discrepancy between interpersonal competence and performance measures. Foradaptive behaviour, shorter time since most recent hospitalization, more depressive symptoms, greaternumber of months of first hospitalization, older age at baseline, younger age at first hospitalization, andmore time spent in the hospital since a first episode of psychosis predicted a greater adaptivecompetence-performance discrepancy. A different pattern of demographic and clinical features may limitthe extent to which patients are deploying interpersonal versus adaptive skills in everyday life.

� 2011 Elsevier Ltd. All rights reserved.

1. Introduction

Functional recovery has become an important treatmentpriority in schizophrenia. In response to the deinstitutionalizationmovement of the 1960s, more individuals with schizophrenia areliving independently in the community (Goering et al., 2000). Assuch, recovery in schizophrenia is no longer measured solely by anabsence of symptoms, but also by functional recovery, which can bedefined as the attainment of meaningful roles in the community(Andreasen et al., 2005). Recently proposed efforts to evaluatetreatment success go beyond symptom remission to focus on theimpact of the disease on the patient’s functioning and environment.Unfortunately, functional recovery is rarely attained and even lessfrequently maintained in schizophrenia, even when symptomaticremission is observed (Robinson et al., 1999). Deficits persist inmultiple areas, including work, independent living, participation incommunity activities, and interpersonal functioning (Green et al.,2004; Abdallah et al., 2009; Bowie et al., 2008).

Impairments in functioning can be grossly classified into twodistinct domains: adaptive and interpersonal behaviour. Adaptive

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behaviour refers to the instrumental everyday living skills that areimportant for functioning independently (Mausbach et al., 2008).Interpersonal behaviour refers to the social skills that are importantin initiating and maintaining social relationships (Meyer and Kurtz,2009). These are related but distinct outcomes for individuals withschizophrenia, as evidenced by a different pattern of predictors andseverity of deficits (Bowie et al., 2008).

Efforts to assess functioning in schizophrenia have progressedsubstantially in recent years; however a critical remaining issue iswhere to place the level of assessment. Methods employed includeself-report, clinician assessment, performance-based tasks, andthird party ratings of real-world behaviours. Although they offerlow burden, self-reports of functioning have poor validity inchronic mental disorders (Burdick et al., 2005; McKibbin et al.,2004; Bowie et al., 2007). Clinician-based ratings often simplyrequire the examiner to ask the patient to describe his or herfunctioning, making these ratings essentially a self-reportcompleted by a third party. Thus, performance-based assessmentsof competence and ratings made from observation of real-worldperformance are methods that have been promoted as optimalassessment methods in recent years (Harvey and Bellack, 2009;Harvey, 2009). Competence is assessed using laboratory-basedmeasures in which the participant demonstrates the ability toperform tasks in a neutral environment whereas performance is

M. Gupta et al. / Journal of Psychiatric Research 46 (2012) 205e211206

assessed through third party ratings of behaviour in the real-world.Although competence and performance have remarkably consis-tent modest correlations across different samples (Keefe et al.,2006; Bowie et al., 2008, 2010), performance is likely influencedby factors other than ability, and should be considered a distinctconstruct that needs to be differentially assessed. Understandingthe factors that predict the discrepancy between what one can do(competence) and what they actually do (performance) is a criticalstep if we hope to help those with schizophrenia move toward fullfunctional recovery.

Factors associated with under-performance in spite of demon-strated ability are referred to as rate limiters. Symptom-based ratelimiters in schizophrenia include positive and negative symptoms(Smith et al., 2002) and depressed mood (Bowie et al., 2006, 2010).Course of illness is another important factor that is associated withfunctioning inschizophrenia.Agreaternumberofpsychotic episodes,longer duration of untreated illness, and older age at illness onset arepredictive of poor psychosocial functioning (Stefanopoulou et al.,2011). Chronicity of the illness is related to more severe adaptivedeficits in the community (Bartels et al., 1997), lower frequency ofsocial contacts, less percentage of time employed, and greaterseverity of symptomatology (Strauss and Carpenter, 1974). Investi-gators have also focused on non-symptom rate limiters that areknown to impair functioning in schizophrenia. For example, inschizophrenia, neurocognition is themost robust predictor of currentfunctional status (Green,1996; Harvey et al.,1997; Bowie et al., 2006,2008). In fact, some research suggests that neurocognition is moreconsistently related to functioning than symptom severity (Kurtzet al., 2005; Velligan et al., 1997). Demographic variables are knownto be associatedwith functioning, for example, lower premorbid IQ isa risk factor for developing schizophrenia (Zammit et al., 2004) and isrelated to functional outcomes (vanWinkel et al., 2007).Higher levelsof educationpredict theprobabilityof career success in schizophrenia(Sakai et al., 2009) and are linked to better quality of life (Swansonet al., 1998). Living circumstances, including proximity to relativesand independence, are associatedwith better functional outcomes inschizophrenia (Harvey et al., 2007; Leung et al., 2008; Melle et al.,2000), but are difficult to obtain or maintain with hospital stays orliving in restrictive settings such as a group home. Although thesenon-symptom factors are correlates of functioning, it is unknownwhether they account for the discrepancy between an individual’scompetence and performance. The ability to predict and classifyindividuals as either performing or under-performing may haveimportant long-term clinical utility. Identifying potential predictorsof under-performance in schizophrenia is a first step toward identi-fying patientswhomay require additional services beyond functionalskills training.

This study aims to examine predictors of the functionalcompetence-performance discrepancy in community-dwellingpatients with schizophrenia. In this study, we examinedcompetence-performance discrepancies in both adaptive andinterpersonal domains.We hypothesize that demographic (youngerage, and lower premorbid IQ, and years of education), course ofillness (earlier and longer hospitalization), environmental (unem-ployment and living in a group home), neurocognitive, and clinicalsymptom (more severe negative, positive, depressive) variables willpredict the discrepancy between competence and performance.

2. Method

2.1. Participants

Participants (N ¼ 96) were assessed at baseline of a part ofa randomized controlled trial of cognitive remediation and func-tional skills training (Clinical Trial Registration Number:

NCT01175642). All participants were residing in the community.Inclusion criteria for the study included a diagnosis of schizo-phrenia or schizoaffective disorder, a reading level of at least Grade6 as assessed with the Wide Range Achievement Test e ReadingRecognition Subtest (WRAT3; Wilkinson, 1993), actively attendingoutpatient care with case management services, and between 18and 65 years of age. Exclusion criteria included alcohol or substanceabuse within three months of study entry, psychiatric hospitaliza-tionwithin threemonths of study entry, and othermedical illnessesor events associated with cognitive impairment (other thana schizophrenia-spectrum disorder).

2.2. Measures

2.2.1. DemographicsParticipant demographic information used in data analysis was

collected and rated using a structured rating scale, the Compre-hensive Assessment of Symptoms and History (CASH; Andreasenet al., 1992). Total duration of hospitalization was calculated asa proportion of the time residing in psychiatric inpatient settingsfollowing first episode of psychosis. Estimated premorbid intel-lectual functioning (Harvey et al., 2006) was assessed with theWRAT3 Reading Recognition Subtest (Wilkinson, 1993).

Independent living status was computed consistent withprevious work in a similar sample (Leung et al., 2008) by consid-ering the person’s housing situation (independent housing with orwithout others versus a group home or institutionalized housing)and their financial responsibility for their housing based on theirresponses to questions from the CASH (Andreasen et al., 1992).From this procedure, 40 subjects were living in independenthousing and at least partially responsible for its financial support,22 subjects were living in independent housing but were finan-cially dependent on other people or governmental support, and 20were living in supported housing.

2.2.2. NeurocognitionThe Neurocognitive Composite Score (NCS) from the Brief

Assessment of Cognition in schizophrenia (BACS; Keefe et al., 2004,2008) was used as a measure of neurocognition. This batterycomprises tests of verbal memory, psychomotor speed, processingspeed, executive functioning, working memory, and verbal fluency.The NCSwas calculated as a z-score (M¼ 0, SD¼ 1), with raw scorestransformed from the published norms of a healthy comparisonsample (Keefe et al., 2008).

2.2.3. Clinical symptomsSeverity of clinical symptoms was examined with the Positive

and Negative Syndrome Scale (PANSS; Kay et al., 1987). Aftera structured interview with the patient and informant, sevenpositive symptoms, seven negative symptoms, and sixteen generalaspects of psychopathology were rated on a seven-point Likertscale. Inter-rater reliability for the PANSS for our raters ranges from0.77 to 0.92 (p < .01). For the present analyses, we used the fivefactor model (White et al., 1997) to examine negative and positivesymptoms, presented as mean item score.

2.2.4. Interpersonal competenceInterpersonal competence was examined using the Social Skills

Performance Assessment (SSPA; Patterson et al., 2001a). The SSPA isa laboratory-based assessment created for use with individualswith schizophrenia. Participants are asked to engage in everydaysocial situations through role-play. After a brief practice session,participants initiate and maintain a conversation for 3 min in eachof two situations: greeting a new neighbour and calling a landlordto request a repair for a leak that has gone unfixed. The sessions are

M. Gupta et al. / Journal of Psychiatric Research 46 (2012) 205e211 207

audio recorded and scored by a trained rater who is unaware ofdiagnosis and all other data. Dimensions of social skills scoredinclude: interest, fluency, clarity, focus, negotiation ability, persis-tence, and social appropriateness. Raters were trained to the goldstandard ratings proposed by the instrument developers(ICC ¼ 0.86). In this paper, we report the mean item score for theSSPA, which ranges from 1 to 5.

2.2.5. Adaptive competenceAdaptive competence refers to skills that are important for

independent functioning (Mausbach et al., 2008). In this paper,adaptive competence was measured using the UCSD Performance-Based Skills Assessment Battery (UPSA; Patterson et al., 2001b). TheUPSA is designed to directly assess functional competence in severemental illnesses. This test was designed for outpatients andmeasures performance in a number of domains of everyday func-tioning through the use of props and standardized skills perfor-mance. Participants are examined with a series of role-play tasksfor their comprehension and planning of recreational activities,financial skills to handle money and pay checks, use of the tele-phone for instrumental communication, and use bus schedules andmaps to effectively use public transportation. We developed loca-tion specific measures for transportation/mobility and compre-hension/planning, as the initial version of the UPSA had itemsbased on San Diego activities. We also excluded the householdchores subtest because it was not portable enough to be used acrosstesting locations. These modified versions were used in previousreports with the UPSA (Bowie et al., 2006; McClure et al., 2007). Theraw scores for each domain are transformed to a prorated domainscore of 0e25; the resulting dependent variable is a total score of0e100.

2.2.6. Functional behaviourReal-world behaviour was rated using the Specific Level of

Function Scale (SLOF; Schneider and Struening, 1983). This scale isa 43-item observer-rated report of patients’ behaviour and func-tioning across different domains of real-world functioning. In thisstudy, we examined the interpersonal relationships (e.g., initiating,accepting, and maintaining social contacts; effectively communi-cating) and participation in community activities domains (e.g.,shopping, using telephone, paying bills, use of leisure time, use ofpublic transportation). These two domains were selected for thepresent study because the items converge with the skills examinedwith the competence measures. Ratings by the third party infor-mant are made based on the amount of assistance required toperform real-world skills or frequency of the behaviour. Informantsare caseworkers who have indicated that they know the patient atleast “well” on the SLOF 5-point Likert scale. This scale has excellentinter-rater reliability, factorial validity, and internal consistency(Schneider and Struening, 1983). In this paper, we report the meanitem score for each of the SLOF domains, which has a possible rangeof 1e5.

2.2.7. Competence-performance discrepancyTwo groups were created for the Adaptive and Interpersonal

Discrepancies by comparing performance on the UPSA to ratings onthe SLOF Community Activities domain and performance on theSSPA to ratings on the SLOF Interpersonal Behaviour domain,respectively. Groups were created based on whether patients’scores on the competence scales were within 0.5 standard devia-tion units of the same range on the respective SLOF domain. The“Performing” group had SLOF performance rankings that werewithin 0.5 standard deviation units of the respective competencemeasure. The “Under-performing” group had performance rank-ings that were at least 0.5 standard deviation units lower than the

respective measure of competence, indicating real-world perfor-mance that was below the level of ability.

2.3. Data analysis

Forward entry multiple regression analyses were conducted toreport predictors of the competence and performance variablesindependent of their discrepancy. Multivariate Analysis of Variance(MANOVA) tests were conducted to test for significant differencesbetween the under-performing and performing groups on intervaldata. Chi-square tests were used to test for significant groupdifferences on ordinal data. We used binary logistic regressionanalyses to search for the variables that contributed to thecompetence-performance discrepancy for both interpersonal andadaptive behaviour. In these analyses, continuous and categoricalvariables that were significantly associated with the discrepancyscores on a zero-order basis were entered with the forward entrylikelihood ratio method. The categorical variable (living situation)was examined with the difference method for change contrasts.Probability of stepwise entry was set at 0.05 and removal at 0.10;classification cutoff was set at 0.5.

3. Results

3.1. Descriptive statistics and correlations among competence andperformance variables

Scores on the UPSA (M ¼ 62, SD ¼ 20), SSPA (M ¼ 3.3, SD ¼ 0.6),SLOF Activities (M¼ 4.2, SD¼ 0.5) and SLOF Interpersonal (M¼ 3.4,SD ¼ 0.8) suggested a mean impairment in the moderate rangewithout evidence of ceiling or floor effects. The UPSA was signifi-cantly correlated with the SLOF Activities Domain (r ¼ 0.509,p < 0.001) but not the SLOF Interpersonal Domain (r ¼ 0.003,p ¼ 0.97). The SSPA was significantly correlated with both the SLOFActivities (r ¼ 0.376, p ¼ 0.001) and SLOF Interpersonal (r ¼ 0.513,p < 0.001) Domains.

3.2. Prediction of competence and performance independently

Greater performance on the UPSA was predicted by betterneurocognition (R2 ¼ 0.28), shorter duration of first hospitalization(R2D ¼ 0.32), lower depressive symptoms (R2D ¼ 0.04), and lesstime in hospital since first episode of psychosis (R2D ¼ 0.02).Greater performance on the SSPAwas predicted by older age at firsthospitalization (R2 ¼ 0.19), lower depressive symptoms(R2D ¼ 0.16), and less time in hospital since first episode ofpsychosis (R2D ¼ 0.04). Better functioning on the SLOF ActivityDomain was predicted by the higher UPSA total score (R2 ¼ 0.32),younger age at baseline (R2D ¼ 0.12) and better neurocognition(R2D ¼ 0.07). Better functioning on the SLOF Interpersonal Domainwas predicted by the higher SSPA total score (R2 ¼ 0.14), fewernegative symptoms (R2D ¼ 0.13), and better neurocognition(R2D ¼ 0.07).

3.3. Group differences

One-way MANOVAs were conducted to determine group(under-performers versus performers) differences on variousdemographic, course of illness, symptom, and cognition variables.For the interpersonal competence-performance discrepancy,significant differences were found with the under-performinggroup having higher estimated premorbid intellectual func-tioning, younger age at first hospitalization, more months inhospital, less impaired neurocognition, and more severe depressivesymptoms, ps < 0.05 (See Table 1).

Table 1MANOVAs for the interpersonal behaviour and adaptive behaviour competence-performance discrepancies.

Interpersonal behaviour Adaptive behaviour

Performers Under-performers Performers Under-performers

M SD M SD F p M SD M SD F p

Age 39.7 9.3 37.1 10.8 .28 0.59 40.2 8.8 36.9 11.1 6.9 0.010Premorbid IQa 43.8 4 46.3 5 7.2 0.009 46.7 5.2 43.6 3.7 7.7 0.007Education (yrs) 12.9 1.3 13.7 2 3.6 0.06 13.9 1.9 12.8 1.3 7.9 0.006Age at hospitalization 20.2 3.6 15.2 4 8 0.007 20.5 3 16.3 3.1 5.1 0.027Months in hospital 22.2 34.3 43.6 36.5 5.9 0.017 25.7 20.4 42.2 23.6 10.4 0.003Neurocognition (z-score) �1.8 0.92 �1.2 0.74 10.2 0.002 �1.2 0.71 �1.7 1 4.6 0.036Negative symptomsb 2.6 0.85 2.7 0.81 0.1 0.704 2.4 0.66 3 0.88 9.4 0.003Positive symptomsc 2.9 0.82 2.8 0.93 0.8 0.36 2.5 0.7 3.2 0.97 10.1 0.002Depressive symptomsd 0.29 0.15 0.72 0.19 6.9 0.01 0.31 0.19 0.58 0.17 3.38 0.07

a WRAT mean score.b PANSS negative symptoms mean item score.c PANSS positive symptoms mean item score.d BDI mean item score.

M. Gupta et al. / Journal of Psychiatric Research 46 (2012) 205e211208

For the adaptive competence-performance discrepancy, theunder-performing group was younger in age, had lower estimatedpremorbid intellectual functioning, more impaired neurocognition,fewer years of education, earlier first hospitalization andmore timein hospital, and more severe clinical symptoms, ps < 0.05 (seeTable 1).

3.4. Chi-square tests

For the interpersonal discrepancy, under-performers are morelikely to either live alone or in a supervised group home,O2¼ 22.8,df ¼ 2, p < 0.001. For the adaptive discrepancy, under-performersare more likely to receive disability and less likely to beemployed, O2 ¼ 6.8, df ¼ 1, p ¼ 0.009. Adaptive under-performersare also more likely to live in a supervised group home, O2 ¼ 6.1,df ¼ 2, p ¼ 0.047.

3.5. Logistic regression analyses

For interpersonal behaviour, living in a group home, lowerneurocognition, more time spent in the hospital since a firstepisode of psychosis, and a longer first hospitalization, entered asseparate steps, were related to a greater interpersonal competence-performance discrepancy (see Table 2). The fourth and final step ofthe logistic regression yielded a �2 log likelihood of 73.89,a Nagelkerke R square of .51, and a Hosmer and Lemeshow signif-icance value of .15, and c2 (df ¼ 1) ¼ 8.90, p ¼ 0.003.

The logistic regression analysis to predict adaptive behaviourrevealed the following significant predictors: shorter time sincemost recent hospitalization, more depressive symptoms, greaternumber of months of first hospitalization, older age at baseline,younger age at first hospitalization, and greater percent of time

Table 2Predictors of interpersonal competence-performance discrepancy in logistic regression a

Step B S.E. Wald d

1 Living situation �2.04 0.60 11.58 12 Neurocognition 0.88 0.38 5.47 1

Living situation �2.06 0.63 10.67 13 Neurocognition 0.99 0.40 6.12 1

Living situation �2.33 0.70 11.27 1% time in hospital since FEP �0.01 0.01 1.06 1

4 Neurocognition 1.18 0.43 7.60 1Living situation �2.00 0.73 7.43 1No. months first hospitalization �0.06 0.03 4.74 1% time in hospital since FEP �0.01 0.01 1.12 1

spent in hospital since a first episode of psychosis, as separate steps,were related to a greater adaptive competence-performancediscrepancy (see Table 3). The sixth and last step of the logisticregression yielded a �2 log likelihood of 69.84, a Nagelkerke Rsquare of .52, a Hosmer and Lemeshow significance value of .34,and c2 (df ¼ 1) ¼ 4.84, p ¼ 0.028.

Given that wewere interested in correctly identifying thosewhounder-perform in spite of demonstrated ability, we also display thepositive predictive value (PPV), negative predictive value (NPV),sensitivity, and specificity for interpersonal (Table 2) and adaptivebehaviour (Table 3). In these tables, B is the coefficient for theconstant in the null model, which represents the magnitude of theeffect for each predictor. S.E. is the standard error around thecoefficient for the constant. The Wald chi-square statistic tests thenull hypothesis that the constant equals zero (this hypothesis isrejected when the p-value is smaller than the critical p-value of0.05). Exp(b) is the exponentiation of the B coefficient, which is anodds ratio for the predictors. The positive predictive value (PPV)predicts the proportion of participants who have ‘under-perform-ing’ tests results that are actually under-performers, whereas thenegative predictive value (NPV) predicts the proportion of partici-pants who have ‘performing’ test results that are actuallyperformers. Sensitivity is the ability of an assessment to correctlyclassify an participants as under-performers, whereas specificity isthe ability of a test to correctly classify participants as performers.

4. Discussion

In this study, we sought to examine factors that predicted thelikelihood that outpatients with schizophreniawould not engage inreal-world behaviours to the degree expected given their ability toperform the skills necessary for those behaviours on laboratory-

nalysis.

f p Exp(B) PPV NPV Sensitivity Specificity

0.001 0.13 0.68 0.79 0.68 0.700.019 2.410.001 0.13 0.68 0.76 0.77 0.670.013 2.700.001 0.100.303 0.99 0.70 0.79 0.79 0.700.006 3.270.006 0.130.029 0.940.289 0.99 0.77 0.79 0.81 0.75

Table 3Predictors of adaptive competence-performance discrepancy in logistic regression analysis.

Step B S.E. Wald df p Exp(B) PPV NPV Sensitivity Specificity

1 Last hospitalization 0.01 0.01 5.34 1 0.021 1.01 0.19 0.94 0.67 0.642 Last hospitalization 0.01 0.01 5.74 1 0.017 1.01

BDI �0.86 0.35 6.18 1 0.013 .43 0.47 0.82 0.62 0.713 Last hospitalization 0.01 0.01 6.14 1 0.013 1.01

BDI �0.87 0.35 6.08 1 0.014 0.42No. months of firsthospitalization

0.03 0.01 4.31 1 0.038 1.03 0.47 0.82 0.62 0.71

4 Age at baseline 0.07 0.03 6.08 1 0.014 1.07Last hospitalization 0.01 0.01 3.65 1 0.056 1.01BDI �0.87 0.38 5.41 1 0.020 0.42No. months of firsthospitalization

0.04 0.02 6.85 1 0.009 1.04 0.59 0.84 0.70 0.76

5 Age at baseline 0.08 0.03 8.26 1 0.004 1.09Age at first hospitalization �.08 0.03 7.66 1 0.006 0.92Last hospitalization 0.01 0.01 4.40 1 0.036 1.01BDI �0.80 0.40 3.99 1 0.046 0.45No. months of firsthospitalization

0.06 0.02 9.01 1 0.003 1.06 0.69 0.82 0.71 0.80

6 Age at baseline 0.09 0.03 8.01 1 0.005 1.09Age at first hospitalization �0.11 0.04 8.35 1 0.004 0.89Last hospitalization 0.01 0.01 5.15 1 0.023 1.01BDI �0.85 0.43 3.87 1 0.049 0.43No. months of firsthospitalization

0.06 0.02 9.75 1 0.002 1.06

% time in hospitalsince FEP

0.01 0.01 0.96 1 0.328 1.01 0.69 0.82 0.71 0.80

M. Gupta et al. / Journal of Psychiatric Research 46 (2012) 205e211 209

based assessments. In this sample, like previous samples, thestrength of the relationship between interpersonal and adaptivecompetence and their corresponding observer ratings of real-worldperformance on those domains was modest, suggesting that someother factors might limit the extent to which individuals apply theiracquired skills in the real-world. A novel contribution of this studywas the consideration of demographic and course of illness vari-ables, which had strong relationships with both competence andperformance measures, along with traditional measures of cogni-tion and symptoms. We sought to determine whether these factorsmight serve to limit the degree to which outpatients with schizo-phrenia utilize their skills in the real-world.

Logistic regression analyses were conducted in order to deter-mine the predictors of under-performance in schizophrenia. Noclinical symptom domains appeared to limit the extent to whichperformance in interpersonal behaviour corresponded tolaboratory-based assessment of those social skills. Somewhatsurprisingly, better neurocognitive functioning predicted classifi-cation of those who under-performed in the interpersonal domain.A possible explanation for this surprising finding is that individualswho under-perform interpersonally are cognitively intact enoughto acquire interpersonal skills but that external factors limit theirability to translate these acquired skills to everyday life. Forexample, in the current sample, interpersonal under-performancewas related to living alone or in a supervised group home, whichmay limit their opportunities to deploy these skills in the real-world. A pattern of early and more severe course of illness, infer-red from a longer time during first hospitalization and more timehospitalized since then, also predicted the likelihood that individ-uals with schizophrenia who lived in the community at the time ofassessment had greater social skills than actual instances ofsocialization. An important systemic consideration that emergedfrom these analyses is the likelihood that living in more restrictivesettings (e.g., supervised group home) is associated with limiteduse of social skills in the real-world, even when these skills aredemonstrated in a laboratory setting.

In the adaptive functioning domain, greater depressivesymptom severity was the only symptom variable that predicted

under-performance on everyday tasks such as household activi-ties and recreational outings. Older age at baseline was the onlydemographic variable that predicted adaptive under-performance. Several factors related to the initial episode ofillness were associated with under-performance in adaptivefunctioning, including being hospitalized at a younger age andspending more time in the hospital at that first hospitalization.Other factors related to the course of illness were also importantpredictors of under-performance, including being in the hospitalmore recently and spending more time hospitalized throughoutthe illness.

4.1. Limitations

There are several limitations to consider in the current study.First, our measure of performance, the case manager ratings of theSLOF, has limitations. Observation of real-world behaviour inschizophrenia may be the ideal way to measure functioning,although it is often impractical and costly (Robson, 2002). An issuewith real-world observation is that it often relies heavily on thirdparty reports, which are not always accurate and representativemeasures of the individual’s behaviour during varied contexts(Pyne et al., 2003). In addition, even real-world observations areconfounded if subjects know that they are being monitored(Robson, 2002). The instruments that were used to measurecompetence and performance do not have identical item overlap,thereforewe acknowledge that some of the discrepancymay not bedue to the factors we explored but rather to differences in specificcontent between the instruments or the reliability of the instru-ments. It is also important to acknowledge that the direction ofcausality between indicators of illness and the acquisition of anddeployment of functional skills cannot be determined by thepresent analyses. In addition, other rate limiters that were notconsidered in this study that might affect the competence-performance discrepancy include the integrity of participants’social network, defeatist beliefs, and perceived or actual level ofstigmatization. Finally, since all participants in this study were

M. Gupta et al. / Journal of Psychiatric Research 46 (2012) 205e211210

community-dwelling outpatients with schizophrenia, our findingsmay not generalize to different samples such as inpatients.

4.2. Implications

The findings from the current study, although cross-sectionaland not necessarily causal, might lend support to the importanceof early intervention programs that focus on independent func-tioning and community integration. Previous studies have reportedthat in the early stages of schizophrenia, medication alone is not aseffective as when combined with a multi-tiered psychosocialintervention that includes skills training, psychoeducation, familyintervention, and cognitive behavioral therapy (Guo et al., 2010).The present study revealed that an early and severe course of illnessis a significant predictor of the competence-performance discrep-ancy in both interpersonal and adaptive domains. Interventionduring the early stages of the illness is considered important(Birchwood et al., 1998) andmay help to decrease functional under-performance in individuals with schizophrenia by promoting theattainment and development of interpersonal and adaptive skills ata critical developmental window. Furthermore, although thedeinstitutionalization movement has helped to promote moreindependent living, hospitalized patients might be at risk forrestrictive development of their abilities following discharge due toenvironmental factors, such as living in more restrictive settings,where opportunities to employ acquired skills may be limited. Thecontinued development of efforts that consider both skill utiliza-tion and environmental factors (e.g., living situation) remains animportant health care issue.

The results support an emerging literature base (Bowie et al.,2010; Chemerinski et al., 2008; Conley et al., 2007); that suggeststhat depressive symptoms for those with schizophrenia play animportant role in the realization of one’s adaptive functionalpotential. Effective psychotherapeutic approaches to treatingsymptoms of depression in schizophrenia-spectrum conditions(e.g., Turkington et al., 2006) have recently emerged; it will beinteresting to examine whether the competence-performance gapcould be closed with the targeting of defeatist beliefs and affiliateddepressive symptoms.

These findings have methodological implications as well. Theysupport the notion that the competence to perform tasks andeveryday real-world performance are distinct constructs thatshould be differentially assessed in order to gain a fuller under-standing of recovery in schizophrenia. Many reports that examinethe predictors of functional outcomes have focused exclusively onsymptom and cognitive variables, though some include basicdemographic factors such as age and gender. Few papers, however,have examined multiple indicators of course of illness and livingcircumstances. The present results suggest that these variableswarrant consideration as potential rate limiters in the promotion offunctional recovery in schizophrenia.

With the continued push for more independent living, it hasbecome increasingly important to understand the barriers manyindividuals with schizophrenia face in attaining full functionalrecovery. The ability to predict and classify individuals as eitherperforming or under-performing may have long-term clinicalimplications for behavioural treatment in schizophrenia. Thecurrent study is a first step in identifying predictors of a functionalcompetence-performance discrepancy and may help to identifyindividuals who are need of additional supports beyond symptomreduction and skills training in order to translate skills learned intreatment to everyday behaviour. The current study highlights theneed for the treatment of functional disability in schizophrenia tobe multi-tiered, systematically targeting both patient and societalfactors, if we hope to see real-world behavioural change.

Role of funding source

Funding for this study was provided by a NARSAD YoungInvestigator Award to CRB; additional support was provided bya Canadian Foundation for Innovation (CFI) Leaders OpportunityFund to CRB, and Ontario Ministry of Research and Innovation(MRI) Award to CRB. NARSAD, CFI and MRI had no role in studydesign, in the collection, analysis and interpretation of data, in thewriting of the report, or in the decision to submit the paper forpublication.

Contributors

Authors 1 wrote the first draft of the manuscript, excluding theIntroduction which was written by Author 2. Authors 1 & 4undertook the statistical analysis. Author 2 managed literaturesearches and contributed to manuscript writing. Author 3contributed to the writing of the manuscript. All authors havecontributed to and have approved the final manuscript.

Conflict of interestAll authors declare that they have no conflicts of interest.

Acknowledgments

We thank Stephanie Taillefer (BScH) who assisted with codingand data entry. We also thank Jeremy Stewart, Sylvia Magrys,Shannon Xavier, and Hannah Anderson for their assistance in datacollection.

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