ORIGINAL ARTICLE Hopelessness in Schizophrenia: The Impact of Symptoms and Beliefs About Illness Ross G. White, PhD,* Muriel McCleery, MRCPsych,† Andrew I. Gumley, PhD,‡ and Ciaran Mulholland, MD† Abstract: Risk factors for the development of hopelessness in schizophrenia remain poorly understood. This study investigated how psychiatric symptom levels and beliefs about illness might be linked to hopelessness in 100 patients with DSM-IV schizophrenia. Participants were assessed on the Beck Hopelessness Scale (BHS), the Calgary Depression Scale for Schizophrenia (CDSS), the Per- sonal Beliefs about Illness Questionnaire (PBIQ), the Brief Psychi- atric Rating Scale (BPRS), and the Scale for the Assessment of Negative Symptoms (SANS). Severe levels of hopelessness were found in 25% of the sample. There were significant differences between the hopeless and nonhopeless participants on the PBIQ subscales, SANS and BPRS. Differences on the PBIQ subscales remained significant when depression scores were controlled for. The total CDSS score, the “humiliating need to be marginalized” PBIQ subscale, and total BPRS score contributed significantly to a model accounting for 60% of the variance in hopelessness scores. Processes potentially implicated in the emergence of hopelessness in schizophrenia are discussed. Key Words: Schizophrenia, hopelessness, depression, beliefs about illness. (J Nerv Ment Dis 2007;195: 968 –975) L evels of depression have been shown to be elevated in individuals diagnosed with schizophrenia (Rooke and Birchwood, 1998). The somatic features of the depressive syndrome (e.g., insomnia, retardation) can prove particularly difficult to disentangle from negative symptoms (Mulholland and Cooper, 2000; Siris, 2000). Consequently, somatic symp- toms have limited utility for identifying depression in indi- viduals with schizophrenia. Becker (1988) noted that whereas the somatic symptoms of depression occurred with equal frequency in depressed and nondepressed patients with schizophrenia, the cognitive aspects of major depression (hopelessness, helplessness, worthlessness, suicidal thinking, guilt, and anxiety) were significantly more common in de- pressed compared with nondepressed schizophrenia patients. This highlights the potential importance of cognitive symp- toms not only for identifying, but also understanding depres- sion in schizophrenia. It has been suggested that persons with schizophrenia experience a diminished sense of their lives as a series of comprehensible events (Gallagher, 2003; Lysaker and Ly- saker, 2002) and that they may cease to understand them- selves as being meaningfully connected to others (Lysaker et al., 2003; Roe et al., 2004). Roe and Ben-Yishai (1999) also highlighted how people with schizophrenia may struggle to see themselves as being more than the sum of their disorder. Gilbert (1992) has proposed that an individual’s perception of their social attractiveness and acceptability from others con- firm a sense of social rank within a given social and inter- personal environment. It is now known, from both animal and human studies, that depressed states are often trig- gered by social losses (Bowlby, 1980; Brown et al., 1995; Kendler et al., 2003). The social rank theory of depression states that involuntary subordination is highly linked to depression (Gilbert, 1992, 2000). This model was devel- oped by Price (1972) who noted early ethological obser- vations that depressed-like states occur in animals and humans who have been defeated and lose rank. In both animal and human groups, low-ranking individuals seem to be at increased risk from psychological and physical disorders linked to the stress of occupying that position (Wilkinson, 1996). The social rank model helps explain why human depression is significantly associated with subjective experiences of low self-esteem, elevated sub- missive behavior, and beliefs that others are being critical/ rejecting of the self (Allan and Gilbert, 1997; Buunk and Brenninkmeyer, 2000; Gilbert et al., 2002). The social rank theory suggests that certain situations are likely to be depressogenic including: a direct attack on the individual’s self-esteem (loss), events that undermine the person’s rank, attractiveness or status (humiliation), and entrapment in a punishing situation or disbelief in the ability of the individual to reaffirm an identity or sense of belonging (entrapment). Rooke and Birchwood (1998) have demon- strated that themes of loss, entrapment and humiliation (as assessed by the Personal Beliefs about Illness Question- From the *School of Psychology, The Queen’s University of Belfast, Northern Ireland, UK; †Division of Psychiatry and Neuroscience, The Queen’s University of Belfast, UK; and ‡Department of Psychological Medicine, The University of Glasgow, UK. Send reprint requests to: Dr. Ross White, Trainee Clinical Psychologist, Psychological Medicine, Academic Centre, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 0XH, Scotland. E-mail: ross_white7@hotmail.com. Copyright © 2007 by Lippincott Williams & Wilkins ISSN: 0022-3018/07/19512-0968 DOI: 10.1097/NMD.0b013e31815c1a1d The Journal of Nervous and Mental Disease • Volume 195, Number 12, December 2007 968