159 General discussion The finding that clinical or functional recovery and personal recovery show a limited correlation suggests that recovery from the patient perspective really means more than remission of symptoms or better functioning. Roosenschoon et al. also concluded that clinical recovery does not appear to be a prerequisite for functional or personal recovery (7). The link between affective symptoms and personal recovery might partially be explained by overlapping constructs, such as hope, optimism, motivation and empowerment. With longer duration of illness, demoralization might also start playing a role (8). Why psychotic symptoms are only very modestly associated with personal recovery is interesting. This highlights the idea that ongoing symptoms do not necessarily interfere with living a satisfying life. Although reduced patient insight into the severity of symptoms and the consequences for daily life might play a role in this association, the question is whether this is relevant, because personal recovery is by its nature a subjective experience. Also, a study found no association between insight and any type of recovery (7). Some have suggested to shift from the current conceptualization of clinical illness insight defined as a patient conformity to medical views, towards a narrative approach of insight, which allows patients to find meaningful explanations that align better with the complexity of their experiences (9). Besides that, several authors found that many patients with psychosis experience at least some of their psychotic symptoms as positive and do not want them to disappear completely (1012). Finding meaning in life and making sense of individual experiences are, from a personal recovery perspective, more important than accepting an illness explanation (13). Also, studies show a substantial part of patients report positive consequences of their psychosis (e.g. having learned something they can use in further life) (14). The relationship between clinical and personal recovery over time In our follow-up study, described in chapter 4, we found that overall change in symptom severity explained 31.8% of the variance of change in personal recovery. Again, change in depression/anxiety symptom severity showed the most substantial association with change in personal recovery. Furthermore, only symptom severity of depression/anxiety at baseline significantly predicted positive change in personal recovery after three years. Not many longitudinal studies on the relationship between clinical and personal recovery have been published. Symptomatic and functional, as well as personal recovery parameters do in some studies show little change over time and seem relatively stable (6, 15-17). Longer-term studies show more variation (18, 19). In our own study personal recovery did change significantly over the course of three years, but there are substantial differences between participants in change of symptoms and personal recovery over time. The association between affective symptom severity and personal recovery was also observed in other studies (20, 21). The finding that 8
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