67 Change in symptom severity and personal recovery INTRODUCTION The relationship between severity of symptoms and personal recovery in patients with severe mental illness (SMI) remains subject of research and debate (1). Several authors suggest that improvement of symptom severity and personal recovery complement each other and should be equally acknowledged in clinical practice (2). Traditionally, symptomatic improvement has been the primary treatment goal. It corresponds to a reduction of psychiatric symptoms, as assessed with instruments such as the Positive and Negative Syndrome Scale (PANSS) for psychotic symptoms or the Brief Psychiatric Rating Scale (BPRS). In patients with schizophrenia spectrum disorders remission is defined as a score of mild or less on specific items of one of these symptom scales over a 6-month period. About the definition of recovery the Remission in Schizophrenia Working Group (RSWG) describes that this is “a more demanding and longer-term phenomenon than remission (3-5).” More recently, personal recovery has gained attention in research and in clinical practice. It is based on SMI patients’ personal narratives that indicate that living a productive and satisfying life is possible despite ongoing clinical symptoms (6-12). In two meta-analyses concerning patients with schizophrenia spectrum disorders it was found that symptom severity shows only a modest association with personal recovery. Evaluating specific symptom domains, affective symptoms have a stronger association with personal recovery than positive or negative symptoms (13, 14). So far, most research into the association between symptom severity and personal recovery has been cross-sectional, while recovery is a process that evolves over time. Longitudinal research is important to understand the development of the associations. This may inform professionals and patients concerning treatment choices. To our knowledge, only few studies evaluated the association between change in symptom severity and change in personal recovery or predictors of change in personal recovery in patients with psychotic disorders. Macpherson et al. investigated how clinical and recovery dimensions of outcome changed over the course of one year. They found that the correlation between change scores of overall clinical outcome and personal recovery was small and not statistically significant (15). Law et al. found that subjective recovery scores were only minimally predicted by symptoms and functioning and more by negative emotion, positive self-esteem and hopelessness (16). Castelein and colleagues used Markov chain modelling to examine the relationship between personal, clinical and societal recovery in people with schizophrenia spectrum disorders, defined recovery states and predicted transitions between states over time, based on up to 11 yearly measurements. They found a high recovery rate (38%) and a high probability of remaining in the same state (77-89%) (17). Austin et al. found that reduction 4
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