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. 2026 Mar 27;33(3):516–527. doi: 10.1111/jpm.70126

The Effect of Alexithymia, Metacognitive Beliefs and Self‐Efficacy on Disability in Patients With Schizophrenia: A Cross‐Sectional Study

Hatice Polat 1,✉, Kerim Uğur 2, Tunahan Sun 3
PMCID: PMC13139986  PMID: 41891428

ABSTRACT

Introduction

Schizophrenia is a chronic mental disorder and one of the leading causes of disability worldwide, with greater levels of disability being associated with lower general self‐efficacy. Reducing disability and enhancing self‐sufficiency in individuals diagnosed with schizophrenia are among the primary goals of treatment and care.

Aim

This study aimed to examine the effects of alexithymia and metacognitive beliefs on self‐efficacy levels and disability in individuals diagnosed with schizophrenia.

Methods

The study was conducted with 145 individuals under the age of 30 (67 individuals diagnosed with schizophrenia and 78 healthy controls) using a descriptive and correlational design. Data were collected using a sociodemographic data form, the Toronto Alexithymia Scale (TAS‐20), the Metacognition Questionnaire (MCQ‐30), the General Self‐Efficacy Scale (GSES) and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0).

Results

Compared to the control group, the patient group demonstrated significantly higher TAS‐20, MCQ‐30 and WHODAS 2.0 scores, and significantly lower GSES scores (p < 0.05). The patients' total MCQ‐30 scores were significantly associated with both WHODAS 2.0 and GSES scores (p < 0.05); however, TAS‐20 did not mediate the relationship between MCQ‐30 and WHODAS 2.0 (p > 0.05), whereas it showed a significant mediating effect in the relationship between MCQ‐30 and GSES (p < 0.05).

Discussion

Patients exhibited higher disability and lower general self‐efficacy than the control group. Cognitive‐behavioural and metacognitive therapeutic approaches targeting alexithymia may contribute to improved functioning and reduced disability in individuals with schizophrenia.

Implications for Practice

The findings improve understanding of factors related to disability and diminished general self‐efficacy in individuals with schizophrenia and may inform the development of targeted psychosocial interventions.

Relevance Statement

Self‐efficacy and disability are key determinants of recovery in schizophrenia. By demonstrating the roles of alexithymia and metacognitive beliefs, this study provides a conceptual framework to guide clinical practice and supportive care strategies.

Keywords: alexithymia, disability, metacognitive belief, schizophrenia, self‐efficacy

Summary

  • What is known on the subject?
    • ○
      Diagnosis of schizophrenia causes disability in individuals. Disability seriously affects the individual, family and society all over the world and in our country, and causes high social and economic costs.
  • What the paper adds to existing knowledge?
    • ○
      Our most important finding is that in our sample, which can be considered an early age group for the development of disability in schizophrenia, problems in metacognition directly affect general self‐efficacy and disability. It is also interesting that this situation is not affected by alexithymia, which is considered a structural feature. Although alexithymia did not have a mediating effect through metacognitive belief, it may have caused the development of disability by affecting general self‐efficacy.
  • What are the implications for practice?
    • ○
      The use of metacognitive therapy methods in schizophrenia and the application of therapy methods aimed at improving the ability to recognise and express emotions to patients will help both the development of metacognition and the recognition and management of alexithymia. This will also contribute to increasing self‐efficacy and reducing the disability.
  • Relevance of paper mental health nursing
    • ○
      This study underscores the importance of planning therapeutic interventions aimed at enhancing general self‐efficacy and reducing disability in individuals with schizophrenia, with psychiatric nurses playing an active role in this process. The integration of metacognitive therapeutic approaches into nursing care may facilitate patients' social adaptation and improve overall functioning. To support the effective implementation of these interventions, targeted training in metacognitive therapy methods for psychiatric nurses is recommended.

1. Introduction

Schizophrenia is a chronic mental illness characterised by positive, negative, cognitive and emotional symptoms, affecting approximately 1% of the global population and representing one of the leading causes of disability worldwide (He et al. 2022). Disability refers to a significant impairment resulting from mental or physical conditions that limit an individual's ability to perform basic functions and participate fully in society (Aydın and Şahin Altun 2023). In this context, disability encompasses difficulties in core domains such as cognition, mobility, self‐care, daily life activities and social participation (Aslan Kunt and Dereboy 2018). Disability associated with schizophrenia is a complex phenomenon. This complexity largely arises from the progressive functional impairments that may develop over the course of the illness. In schizophrenia, disability encompasses a broad range of cognitive, emotional and behavioural deficits that extend beyond core positive and negative symptoms and progressively compromise social functioning (Montemagni et al. 2024).

Self‐efficacy, defined as an individual's belief in their ability to perform specific tasks or skills, is closely related to functional decline over time in patients with schizophrenia and plays a key role in motivating social, health‐related and independent living behaviours (Lee et al. 2021). Previous research has shown that low self‐efficacy is associated with negative symptoms and neurocognitive deficits, and that this relationship may jointly contribute to poorer psychosocial functioning (Wright et al. 2021). Another study demonstrated that improvements in self‐efficacy among individuals with schizophrenia predicted gains in several quality‐of‐life domains, particularly leisure satisfaction, participation in general activities and independence (Ritsner 2003). The primary goal of treatment in individuals diagnosed with schizophrenia is to achieve functional recovery while controlling the frequency and severity of psychotic episodes. In addition, treatment aims to minimise the negative impact of disability that may emerge over the course of the illness on overall functioning. Therefore, reducing disability and enhancing self‐efficacy should be considered central goals of treatment and care for individuals with schizophrenia. Accordingly, identifying factors associated with reduced disability and enhanced self‐efficacy—key determinants in alleviating functional limitations in schizophrenia—is of critical importance. One such factor is alexithymia, which has been widely examined in various clinical domains in schizophrenia.

Alexithymia is a condition characterised by difficulties identifying and describing emotions, impaired emotional communication, and a limited imaginative capacity. Alexithymia, sometimes referred to as ‘emotional expression deficiency’ or ‘emotional aphasia’, primarily manifests as difficulty recognising and identifying emotions, along with a tendency towards externally oriented thinking (Xiao et al. 2024, 1). Studies have shown that individuals with schizophrenia who exhibit alexithymia experience more severe negative symptoms and that alexithymia may represent a risk factor for the development of psychosis (van der Velde et al. 2015; İnanç et al. 2019; Peng et al. 2023; Xiao et al. 2024). The relationship between schizophrenia and alexithymia has received increasing attention in the literature. Research has demonstrated that the presence of alexithymia in schizophrenia may be associated with suicidal ideation, more severe depressive symptoms, anxiety and sleep disturbances (Demirkol et al. 2019; Alimoradi et al. 2022; Kalinin et al. 2022). However, the relationship between alexithymia and self‐efficacy or disability in schizophrenia has received relatively limited attention in the literature. One study reported that individuals with schizophrenia and alexithymia exhibited reduced social and daily functioning (Ospina et al. 2019). Huo et al. (2023) reported that individuals with chronic schizophrenia and alexithymia demonstrate poorer cognitive functioning compared to those without alexithymia. The association between alexithymia and a broad range of neurocognitive impairments in schizophrenia has been well documented. These impairments are particularly related to difficulties in emotion identification and thought externalisation, as well as deficits in executive functioning, processing speed, attention and verbal memory (Lysaker et al. 2011; Huo et al. 2023). Cognitive decline represents one of the most common consequences of schizophrenia progression and may result in occupational and social dysfunction, ultimately contributing to disability (Chen et al. 2020). Given its association with both cognitive deficits and negative symptoms, the relationship between alexithymia and self‐efficacy or disability in schizophrenia appears to be underexplored in the literature. Therefore, addressing alexithymia is essential when examining functioning and disability in individuals with schizophrenia.

One important concept that may negatively affect functioning and, consequently, disability in individuals diagnosed with schizophrenia is metacognitive beliefs. Metacognition refers to the ability to monitor and regulate one's own mental processes (Martiadis et al. 2023). However, metacognition should not be considered a unitary construct. Metacognition encompasses the beliefs, processes and strategies that enable individuals to ‘thinking about thinking’ (Wells and Matthews 1996; Lysaker et al. 2021; Taha et al. 2025, 73). It has been reported that individuals with schizophrenia experience significant difficulties in reflecting on their own mental activities as well as those of others (Lysaker et al. 2013). In schizophrenia, impairments in metacognitive functioning may lead to functional losses across multiple domains, including reduced insight, difficulties in understanding others' mental states, decision‐making problems and social isolation. These impairments may contribute to a fragmented sense of self by hindering the interpretation of experiences and the development of a coherent self‐perception (Montemagni et al. 2024). Individuals with schizophrenia exhibit significantly higher levels of dysfunctional metacognitive beliefs across all categories compared to nonpsychiatric control groups (Austin et al. 2015). Dysfunctional metacognitive beliefs have been associated with greater psychotic symptom severity and may intensify psychological distress in individuals with schizophrenia (Lysaker et al. 2019; Taha et al. 2025). Additionally, impairments in metacognitive reflectivity in schizophrenia have been suggested to hinder the maintenance of social relationships (Lysaker et al. 2013). One study reported that deficits in social cognition and metacognition in schizophrenia are associated with functional impairment (Lysaker et al. 2013). Given that metacognition involves cognitions about one's own cognitive processes and internal states (Lysaker et al. 2021), metacognitive deficits are thought to play a significant role in schizophrenia (Rouy et al. 2021). However, research focusing specifically on metacognitive processes in schizophrenia remains relatively limited (Rouy et al. 2021).

To the best of our knowledge, no previous study has investigated the effects of alexithymia and metacognitive beliefs on self‐efficacy levels and disability in individuals diagnosed with schizophrenia. To address this gap in the literature, the present study aims to examine the effects of alexithymia and metacognitive beliefs—considered structural characteristics in individuals with schizophrenia—on self‐efficacy levels and disability. Disability that emerges with aging significantly affects individuals, families and societies worldwide and is associated with substantial social and economic costs (Aslan and Hocaoğlu 2017). Additionally, disability is a common and expected consequence of schizophrenia, typically developing over time as a result of its long‐term impact on functioning. Therefore, to minimise the potential confounding effects of aging and long‐term illness chronicity on disability outcomes, this study was conducted with individuals under the age of 30 diagnosed with schizophrenia. This study is expected to contribute to the development of novel care planning strategies for psychiatric nurses by identifying factors that influence disability and self‐efficacy levels in individuals with schizophrenia.

2. Aim

This study aimed to examine the effects of alexithymia and metacognitive beliefs on self‐efficacy levels and disability in individuals diagnosed with schizophrenia. Research questions:

  1. Are there differences between individuals diagnosed with schizophrenia and the control group in terms of alexithymia, metacognitive beliefs, general self‐efficacy and disability?

  2. Do alexithymia levels and metacognitive beliefs affect disability in individuals diagnosed with schizophrenia?

  3. Do alexithymia levels and metacognitive beliefs in individuals diagnosed with schizophrenia affect general self‐efficacy?

3. Methods

3.1. Design

This study used a cross‐sectional, descriptive and correlational design. Data were collected over a defined period (December 2023–April 2024) at a single centre using a survey‐based approach. No experimental interventions were applied. The study examined the effects of alexithymia and metacognitive beliefs on self‐efficacy levels and disability in individuals diagnosed with schizophrenia.

3.2. Participants

The study population consisted of individuals who consecutively presented to the psychiatry outpatient clinic of Malatya Training and Research Hospital between December 2023 and April 2024, were diagnosed with schizophrenia according to DSM‐5 criteria and were aged between 18 and 30 years. The control group was recruited voluntarily from hospital staff who were not healthcare professionals and had no self‐reported history of psychiatric or neurological disorders. Accordingly, the control group consisted of healthy volunteers aged 18–30 years who worked at the hospital, were not healthcare personnel and had no medical or psychiatric conditions that could negatively affect functioning.

Sample size calculation was performed using G*Power software. Power analysis indicated that a minimum sample size of 128 participants (64 patients and 64 controls) was required, assuming an independent samples t‐test, a Type I error rate (α) of 0.05, a statistical power of 0.80 and an effect size of 0.35. Seventy‐two individuals diagnosed with schizophrenia were initially interviewed; however, five participants did not complete the data collection forms due to fatigue or lack of motivation. The final sample consisted of 145 participants, including 67 individuals with schizophrenia and 78 healthy controls. A convenience sampling method was used.

The inclusion criteria were: a diagnosis of schizophrenia according to DSM‐5 criteria; age between 18 and 30 years; being in remission (this is the period when the patient's treatment in the clinic is completed, active period symptoms are not observed, and insight is developed); willingness to cooperate; and a minimum of primary school education. Exclusion criteria included the presence of physical (e.g., speech or hearing impairment) or neurological disorders (e.g., multiple sclerosis, epilepsy, Parkinson's disease, dementia, stroke) that could interfere with completion of the assessment tools; comorbid psychiatric diagnoses (e.g., depression, intellectual disability, personality disorders or alcohol/substance use disorders); and significant communication difficulties.

Psychiatric diagnoses were established by the second author, a psychiatrist with 13 years of clinical experience, through face‐to‐face clinical interviews conducted in accordance with DSM‐5 diagnostic criteria. Both groups underwent mental health assessments conducted by the same psychiatrist, and only participants who met the study criteria were included in the analysis.

3.3. Data Collection Tools

3.3.1. Sociodemographic Form

The sociodemographic form developed by the researchers collected information on participants' sociodemographic characteristics, illness duration, history of leaving employment due to illness, and the presence of schizophrenia in first‐degree relatives. The variable ‘leaving work due to illness’ referred to an individual's inability to maintain employment due to a psychiatric condition and was considered an indicator related to functioning and disability. This variable was included to provide a more comprehensive assessment of the impact of schizophrenia on daily life and social functioning.

3.3.2. Toronto Alexithymia Scale (TAS‐20)

The Toronto Alexithymia Scale (TAS‐20) is a 20‐item Likert‐type self‐report scale scored on a 5‐point scale ranging from 1 (strongly disagree) to 5 (strongly agree) (Güleç et al. 2009). The scale was originally developed by Bagby et al. (1994). The scale comprises three subscales: difficulty identifying feelings, difficulty describing feelings and externally oriented thinking. Higher scores indicate greater levels of alexithymia. The Turkish validity and reliability of the scale were established by Güleç et al. (2009). Confirmatory factor analysis supported a three‐factor structure for the TAS‐20, consistent with previous validations across multiple languages. Exploratory factor analysis indicated that the scale explained 34.9% of the total variance. In the Turkish validation study, the internal consistency coefficient was reported as 0.78 (Güleç et al. 2009). In the present study, Cronbach's alpha was 0.86.

3.3.3. Metacognition Questionnaire (MCQ‐30)

The 30‐item short form of the Metacognition Questionnaire (MCQ‐30) was developed by Wells and Cartwright‐Hatton (2004). The Turkish validity and reliability study of the scale was conducted by Tosun and Irak (2008). Each item of the MCQ‐30 is rated on a 4‐point Likert‐type scale ranging from 1 (strongly disagree) to 4 (strongly agree). Total scores range from 30 to 120, with higher scores indicating greater levels of dysfunctional metacognitive beliefs. The MCQ‐30 consists of five factors: positive beliefs, uncontrollability and danger, cognitive confidence, need to control thoughts and cognitive awareness (Tosun and Irak 2008). Factor analysis was used to assess the construct validity of the MCQ‐30. Principal component analysis (PCA) was used as the factor extraction method. The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was 0.89, indicating excellent suitability for PCA (Bartlett's test of sphericity: χ 2 = 9165.11, p = 0.001). Following Varimax rotation, the five‐factor solution explained 52.44% of the total variance. In the Turkish validation study, the internal consistency coefficient was reported as 0.86 (Tosun and Irak 2008). In the present study, Cronbach's alpha for the MCQ‐30 was 0.88.

3.3.4. General Self‐Efficacy Scale (GSES)

The General Self‐Efficacy Scale (GSES) was originally developed by Jerusalem and Schwarzer and later revised by the same authors, with the number of items reduced to 10 (Schwarzer and Jerusalem 1995). The scale is a four‐point Likert‐type measure, scored from 1 (not at all true) to 4 (exactly true). Total scores range from 10 to 40. Higher scores indicate greater levels of general self‐efficacy. Aypay (2010) conducted a Turkish validity and reliability study of the scale. PCA and Varimax rotation were used to assess the structural validity of the scale. Component analysis revealed a two‐factor structure with eigenvalues greater than 1. Factor analysis indicated that the identified factor explained 47% of the total variance, supporting the construct validity of the scale. Most adaptations of the scale in different languages exhibit a unidimensional structure (Aypay 2010). The present study also supported a unidimensional structure. The internal consistency coefficient was reported as 0.83 in the Turkish validation study (Aypay 2010). In the present study, Cronbach's alpha for the GSES was 0.92.

3.3.5. Disability Assessment Schedule (WHODAS 2.0)

The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a semi‐structured interview consisting of 36 items. The scale assesses six domains covering activities considered important across diverse cultural contexts. These domains include: (1) understanding and communicating (DAS1), (2) mobility (DAS2), (3) self‐care (DAS3), (4) interpersonal relationships (DAS4), (5) life activities (DAS5) and (6) participation in society (DAS6). For each domain, respondents are asked to rate the level of difficulty experienced during the previous month, with responses scored on a 5‐point scale ranging from 1 (none) to 5 (extreme). During scoring, domain scores are weighted according to the number of items, and both domain scores and the total WHODAS 2.0 score are calculated on a scale ranging from 0 to 100. Higher WHODAS 2.0 scores indicate greater levels of disability and poorer functioning. The scoring formula is as follows: DAS1 = [(D 1.1 + … + D1.6) − 6/24] × 100; DAS2 = [(D2.1 + … + D2.5) − 5/20] × 100; DAS3 = [(D3.1 + … + D3.4) − 4/16] × 100; DAS4 = [(D4.1 + … + D4.5) − 5/20] × 100; DAS5 = [(D5.2 + … + D5.5 + D5.8 + … + D5.11) 8/32] × 100; DAS6 = [(D6.1 + … + D6.8) − 8/32] × 100; DAST = [((D1.1 + … + D4.5 + D5.2 + … + D5.5 + D5.8 + … + D5.11 + … + D6.8) − 36)/144] × 100. The validity and reliability of the WHODAS 2.0 in individuals with schizophrenia were established by Uluğ et al. (2001). Construct validity analyses demonstrated a strong correlation between the screening questions and the total WHODAS 2.0 score (r = 0.94, p < 0.001), with domain scores also showing high intercorrelations and strong associations with the total score. In the schizophrenia validation study, the internal consistency coefficient was reported as 0.94 (Uluğ et al. 2001). In the present study, Cronbach's alpha for the WHODAS 2.0 was 0.91.

The WHODAS 2.0 is designed to provide a comprehensive assessment of disability across six domains of functioning and participation. The Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) recommends using the WHODAS 2.0 to assess functional impairment (Chen et al. 2020). Accordingly, this instrument was selected for use in the present study.

3.3.6. Collection of Data

Before the interviews, participants were informed about the purpose of the study and the estimated duration of the interview, and both written and verbal informed consent were obtained. Data were collected through face‐to‐face interviews conducted by the second author, Dr. K.U. in a designated interview room at the psychiatry outpatient clinic. Each interview lasted approximately 45–60 min.

3.4. Data Analysis

Statistical analyses were performed using SPSS version 25, and the level of statistical significance was set at p < 0.05. Normality of the data distribution was assessed using skewness and kurtosis values. Data were considered normally distributed when skewness and kurtosis values were within ±3 (Shao 2002). Descriptive statistics and chi‐squared tests were used to compare sociodemographic variables between groups, while independent samples t‐tests were applied to compare mean scale scores. Mediation analyses were conducted using Hayes' PROCESS macro (Model 4). In the first mediation model, MCQ‐30 was specified as the independent variable, WHODAS 2.0 as the dependent variable, and TAS‐20 as the mediator (Table 3). In the second model, MCQ‐30 was specified as the independent variable, GSES as the dependent variable, and TAS‐20 as the mediator (Table 4). The mediating role of alexithymia was examined in both models.

TABLE 3.

Total, direct and indirect effects of TAS‐20 mediator variable on MCQ (X) and WHO‐DAS‐II (Y) in the patient group.

Effects Coefficient (β) Standard error (SE) t value p Confidence interval (LLCI − ULCI)
Total effect (MCQ → WHO‐DAS II) 0.5515 0.2082 2.6491 p < 0.05 [0.1357, 0.9672]
Direct effect (MCQ → WHO‐DAS II) 0.5961 0.2385 2.4995 p < 0.05 [0.1197, 1.0725]
Indirect effect (via MCQ → WHO‐DAS II, TAS‐20) −0.0446 0.1113 −0.4018 p > 0.05 [−0.2720, 0.1707]
Fully standardized indirect effect Effect BootSE BootLLCI BootULCI
TAS‐20 −0.0253 0.0626 −0.1578 0.0925
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Note:  P‐values in bold were considered statistically significant (p < 0.05).

TABLE 4.

Total, direct and indirect effects of TAS‐20 mediator variable on MCQ (X) and GSES (Y) in the patient group.

Effects Coefficient (β) Standard error (SE) t‐value p Confidence interval (LLCI − ULCI)
Total impact (MCQ → GSES) −0.1470 0.0631 −2.3293 p < 0.05 [−0.2731, −0.0210]
Direct effect (MCQ → GSES) −0.0103 0.0629 −0.1633 p > 0.05 [−0.1360, 0.1154]
Indirect impact (via MCQ → GSES, TAS‐20) −0.1368 0.0494 −2.7688 p < 0.05 [−0.2484, −0.0557]
Fully standardised indirect effect Effect BootSE BootLLCI BootULCI
TAS‐20 −0.2582 0.0845 −0.4384 −0.1104
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Note:  P‐values in bold were considered statistically significant (p < 0.05).

3.5. Ethical Considerations

Ethical approval for the study was obtained from the Malatya Turgut Özal University Non‐Interventional Clinical Research Ethics Committee (Session No. 34, September 14, 2023). All participants were informed about the purpose of the study and the voluntary nature of participation, and written informed consent was obtained prior to data collection. Participants were also informed that their personal information would remain confidential and would not be disclosed to third parties. The study was conducted in accordance with the principles of the Declaration of Helsinki.

4. Results

Sociodemographic characteristics of the participants are presented in Table 1. The patient and control groups were compared in terms of age, gender and marital status, and no statistically significant differences were observed between the groups for these variables (p > 0.05). However, statistically significant differences were found between the groups with respect to education level, employment status, place of residence, living arrangements, history of schizophrenia in first‐degree relatives and monthly income level (p < 0.05). The mean duration of illness in the schizophrenia group was 5.89 ± 2.68 years.

TABLE 1.

Comparison of sociodemographic characteristics of the groups.

Descriptive characteristic Group of individuals with schizophrenia Control group Significance
Number (n) Percentage (%) Number (n) Percentage (%)
Gender
Female 19 28.35 31 39.75 p > 0.05
Male 48 71.65 47 60.25
Education level
Primary education 27 40.30 7 9.00 p < 0.05
High school 25 37.30 42 53.80
University 15 22.40 29 37.20
Marital status
Single 57 85.10 59 75.6 p > 0.05
Married 10 14.90 19 24.4
Employment status
Unemployed 46 68.70 39 50.00 p < 0.05
Employed 21 31.30 39 50.00
Place of residence
City 45 67.20 44 56.40 p < 0.05
District‐town 14 20.90 30 38.50
Village 8 11.90 4 5.10
Who does s/he live with?
Family 64 95.50 63 80.80 p < 0.05 *
Single 2 3.00 13 16.70
Friend 1 1.50 0 —
Other 0 — 2 2.60
Schizophrenia in family
Yes 32 47.80 1 1.3 p < 0.05
No 35 52.20 77 98.7
Leaving work due to illness
Yes 25 37.30
No 42 62.70
Duration of illness (years) Mean ± SD
5.89 ± 2.68
Ages Mean ± SD Mean ± SD p > 0.05**
26.13 ± 3.49 25.76 ± 3.62
Total monthly income (1000) Mean ± SD Mean ± SD p < 0.05 **
12.59 ± 12.72 24.94 ± 26.44
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Note:  P‐values in bold were considered statistically significant (p < 0.05).

*

Fisher's exact chi‐squared test.

**

Independent t‐test.

Comparisons of TAS‐20, GSES, MCQ‐30 and WHODAS 2.0 scores between the groups are presented in Table 2. Significant differences were observed between the groups in all TAS‐20 subscale scores and total scores, the total GSES score, and all MCQ‐30 subscale and total scores (p < 0.05). With respect to disability, statistically significant differences were found between the groups in the total WHODAS 2.0 score and in the DAS1, DAS2, DAS3, DAS4 and DAS6 domain scores (p < 0.05). In contrast, no significant difference was observed for the DAS5 (life activities) subscale (p > 0.05).

TABLE 2.

Intergroup comparison of TAS‐20, GSES, MCAS and WHO‐DAS II scale scores.

Scale/subscale Group of individuals with schizophrenia (n = 67) X ± SD Control group (n = 78) X ± SD Statistical testing and significance
TAS‐20
Difficulty recognising emotions 22.44 ± 7.48 13.23 ± 4.30

t: 8.89

p < 0.05

Difficulty verbalising emotions 15.71 ± 4.64 11.07 ± 3.09

t: 6.95

p < 0.05

Extraverted thinking 25.29 ± 4.94 22.51 ± 3.63

t: 3.80

p < 0.05

Total 63.46 ± 14.01 46.82 ± 8.43

t: 8.48

p < 0.05

MCQ‐30
Positive beliefs 14.37 ± 4.49 12.12 ± 4.04

t: 3.16

p < 0.05

Cognitive confidence 15.25 ± 5.02 11.26 ± 4.20

t: 5.20

p < 0.05

Uncontrollability and danger 20.29 ± 5.85 15.23 ± 4.56

t: 5.74

p < 0.05

Cognitive awareness 17.71 ± 3.78 16.43 ± 3.20

t: 2.20

p < 0.05

Need to control thoughts 13.31 ± 3.30 10.38 ± 3.02

t: 5.57

p < 0.05

Total 80.95 ± 14.98 65.44 ± 12.16

t: 6.87

p < 0.05

GSES
Total 22.68 ± 7.933 31.79 ± 6.06

t: −7.66

p < 0.05

WHO‐DAS II
DAS1 49.87 ± 22.93 14.42 ± 17.81

t: 10.26

p < 0.05

DAS2 38.20 ± 27.53 8.52 ± 14.96

t: 7.88

p < 0.05

DAS3 35.07 ± 30.07 7.69 ± 16.45

t: 6.64

p < 0.05

DAS4 51.41 ± 26.88 13.20 ± 15.49

t: 10.26

p < 0.05

DAS5 15.53 ± 27.01 8.25 ± 16.61

t: 1.91

p > 0.05
DAS6 62.45 ± 22.66 22.99 ± 21.99

t: 10.61

p < 0.05

Total 16.23 ± 26.47 8.76 ± 14.08

t: 2.07

p < 0.05

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Note:  P‐values in bold were considered statistically significant (p < 0.05).

Mediation regression analysis indicated that the total effect of MCQ‐30 on WHODAS 2.0 was statistically significant (β = 0.551, SE = 0.208, t = 2.649, p < 0.05). When TAS‐20 was included in the model, the direct effect of MCQ‐30 on WHODAS 2.0 remained statistically significant (β = 0.596, SE = 0.238, t = 2.499, p < 0.05), indicating that the association between MCQ‐30 and disability was largely direct. The indirect effect was not statistically significant (β = −0.044, SE = 0.111, t = −0.401, p > 0.05), suggesting that TAS‐20 did not mediate the relationship between MCQ‐30 and WHODAS 2.0 (Table 3). Overall, these findings indicate that metacognitive beliefs have a significant and predominantly direct effect on disability in patients with schizophrenia, independent of alexithymia.

In contrast, mediation analysis examining the relationship between MCQ‐30 and GSES demonstrated a significant mediating role of TAS‐20. The total effect of MCQ‐30 on GSES was statistically significant and negative (β = −0.147, SE = 0.063, t = −2.329, p < 0.05). After inclusion of TAS‐20 in the model, the direct effect of MCQ‐30 on GSES was no longer statistically significant (β = −0.010, SE = 0.062, t = −0.163, p > 0.05). However, the indirect effect through TAS‐20 was statistically significant (β = −0.136, SE = 0.049, t = −2.768, p < 0.05), indicating that the association between metacognitive beliefs and self‐efficacy operates primarily through alexithymia (Table 4).

5. Discussion

In the present study, the effects of alexithymia and metacognitive beliefs on self‐efficacy and disability in individuals with schizophrenia were examined. Alexithymia and metacognitive awareness are considered essential for social competence and overall functioning. Deficiencies in these processes are therefore likely to affect functional outcomes adversely (Kolavarambath et al. 2020). Individuals with schizophrenia may experience disability not only due to difficulties in family relationships, interpersonal interactions, or occupational functioning but also as a result of impairments in cognitive and perceptual processes (Nowak et al. 2016).

In the present study, metacognitive beliefs were found to have a direct effect on disability, whereas no significant effect was transmitted through alexithymia. In other words, disability in individuals with schizophrenia may be more strongly related to deficits in monitoring or regulating their own mental processes than to difficulties in recognising and expressing emotions. Studies in individuals with schizophrenia indicate that most experience deficits in metacognitive performance. These deficits are considered a fundamental obstacle to functioning in schizophrenia (Kolavarambath et al. 2020; Lysaker et al. 2013; Quiles et al. 2013). Dysfunctional metacognitive beliefs have been shown to intensify psychological distress in individuals with schizophrenia (Lysaker et al. 2019; Taha et al. 2025). Research on metacognition suggests associations with complex functional outcomes, including occupational functioning, psychosocial adaptation, empathy and motivation (Wright et al. 2020; Jones et al. 2020; Bonfils et al. 2020; Luther et al. 2020; Lysaker et al. 2020). Taha et al. (2025) emphasised an inverse relationship between dysfunctional metacognitive beliefs and levels of psychosocial functioning. Interventions targeting metacognitive deficits may alter systems that perpetuate disability, leading to improvements in underlying factors without directly addressing all causal mechanisms (Lysaker et al. 2020). The use of WHODAS 2.0 in this study allowed for a multifaceted assessment of deficits across all functional domains and enabled evaluation of the influence of metacognitive beliefs on these impairments.

The literature contains conflicting findings regarding the role of alexithymia, in contrast to the results of the present study. Alexithymia has been reported to predict functional outcomes in schizophrenia beyond the contribution of neurocognition and other aspects of social cognition (Kimhy et al. 2012; Kimhy et al. 2016). In a study comparing individuals with schizophrenia and bipolar disorder to healthy controls, Ospina et al. (2019) reported that difficulties in identifying emotions predicted both general daily functioning (i.e., WHODAS) and social functioning across the entire sample. However, alexithymia—including difficulties in identifying emotions and externally oriented thinking—predicted social functioning only in the bipolar disorder group. In a study conducted in individuals with schizophrenia, emotion recognition and metacognitive processes were not associated with each other and did not influence social functioning (Kolavarambath et al. 2020).

One key indicator of self‐efficacy in coping with illness is the ability to regulate emotions (Lee et al. 2021; Faramarzi and Khafri 2017). Individuals who can recognise their emotions, understand their implicit content and express their emotional states are better able to cope with life's challenges (Faramarzi and Khafri 2017). In the present study, metacognitive beliefs did not have a direct effect on self‐efficacy; however, they influenced self‐efficacy indirectly through alexithymia, which served as a statistically significant mediator. In other words, while metacognitive beliefs alone may not directly affect self‐efficacy, their negative impact becomes evident in the presence of alexithymia among individuals with schizophrenia. This association may be related to difficulties in recognising and expressing emotions among individuals with schizophrenia who exhibit both alexithymia and dysfunctional metacognitive beliefs. An important association between alexithymia and self‐efficacy has been documented in the literature (Mallinckrodt and Wei 2005). In general, individuals with higher self‐efficacy demonstrate stronger abilities to recognise and regulate emotions (Zhang et al. 2022). Core features of alexithymia—such as limited imagination, externally oriented thinking, and difficulties in recognising and processing emotions—are frequently observed in individuals with low self‐efficacy (Chung et al. 2016; Velotti et al. 2019). Therefore, the mediating effect of alexithymic characteristics on self‐efficacy in individuals with schizophrenia may be explained by these underlying mechanisms. To our knowledge, no previous study has examined the relationship between alexithymia and self‐efficacy in individuals with schizophrenia. In a non‐clinical sample of university students, alexithymia was identified as a significant negative predictor of self‐efficacy (Faramarzi and Khafri 2017). The present findings appear to be consistent with the existing literature in this regard. Future studies examining this relationship specifically in individuals with schizophrenia may contribute to a more comprehensive understanding of this issue.

Studies on social cognition in individuals with schizophrenia indicate difficulties in emotion identification, reflecting deficits in both social cognition and metacognition (Lysaker et al. 2013). In the present study, TAS‐20 total and subscale scores were significantly higher in individuals with schizophrenia compared with the control group. These findings support previous evidence of emotion recognition deficits in individuals with schizophrenia (Xiao et al. 2024). In addition, mean MCQ‐30 scores were higher in the schizophrenia group than in the control group. This finding suggests that individuals with schizophrenia exhibit higher levels of dysfunctional metacognitive beliefs compared to controls. Consistent with these findings, previous research has reported lower metacognitive performance in individuals with schizophrenia compared to control groups across various cognitive domains (Rouy et al. 2021).

Self‐efficacy—defined as belief in one's ability to complete activities or manage symptoms—is often reduced in individuals with schizophrenia (Wright et al. 2021). In the present study, self‐efficacy levels were lower in individuals with schizophrenia than in the control group, consistent with previous literature. Self‐efficacy may influence functioning both directly and indirectly through negative symptoms (Fortuna et al. 2018; Rector et al. 2005). A study conducted in older age groups reported that self‐efficacy has both direct and indirect effects on functioning in schizophrenia (Wright et al. 2021). Although the present study was conducted in a younger sample, these findings provide a comparative framework, suggesting that the relationship between self‐efficacy and functioning remains important across different age groups. In a study of individuals with severe mental illness receiving inpatient treatment, self‐efficacy was reported to mediate the relationship between symptom severity and participation in daily activities (Probst et al. 2018). However, all participants in the present study were outpatients at the time of data collection. Therefore, this evidence should be interpreted as supportive of the potential role of self‐efficacy in functioning across different clinical contexts, rather than as a direct comparison.

In the present study, disability levels were higher in individuals with schizophrenia than in the control group. In addition, unemployment rates were higher in the schizophrenia group compared to controls. In the present study, 37.3% of individuals with schizophrenia reported leaving their jobs due to mental illness. This information was based on self‐reported responses to the item ‘leaving work due to illness’ included in the sociodemographic data form developed by the researchers. Schizophrenia has adverse effects on nearly all domains of functioning. Cognitive, social and motor functions decline due to the disease's pervasive effects (Harvey et al. 2012). These impairments are likely to contribute to reduced employment rates among individuals with schizophrenia (Kharawala et al. 2022). The present findings are consistent with previous studies reporting that increased disability and reduced functioning are associated with higher unemployment rates in individuals with schizophrenia (Fakorede et al. 2020; Harvey 2014; Harvey et al. 2012; Liu et al. 2015).

6. Strength and Limitations

To the best of our knowledge, this is the first study to investigate the effects of alexithymia and metacognitive beliefs on self‐efficacy and disability in individuals with schizophrenia. In addition, potential age‐related effects on disability were minimised by restricting the sample to individuals under 30 years of age. Accordingly, identifying factors such as alexithymia and metacognitive beliefs that may contribute to disability in the context of mental illness represents a key strength of the study.

Several limitations of the present study should be acknowledged. First, although the minimum sample size calculated by power analysis was achieved, the relatively limited sample size and cross‐sectional design preclude causal interpretation of the findings. Furthermore, small sample sizes within certain sociodemographic subcategories (e.g., primary school graduates in the control group) may have limited the sensitivity of statistical analyses, particularly for categorical comparisons.

The study did not assess clinical variables such as the frequency and duration of psychotic episodes, hospitalisation history, treatment adherence or social support. These factors may influence disability and functioning in individuals with schizophrenia and should be considered when interpreting the findings. Additionally, the use of a single‐centre convenience sample limits the generalisability of the findings.

Another important limitation is the absence of a standardised measure assessing schizophrenia symptom severity (e.g., PANSS). Although participants were in remission and followed on an outpatient basis during data collection, individual differences in symptom severity may have influenced alexithymia, metacognitive beliefs, self‐efficacy perceptions and disability levels. Given the close association of negative and cognitive symptoms with self‐efficacy and functioning, failure to assess symptom severity may have affected both the magnitude and direction of the observed correlations. Therefore, symptom severity should be considered a potential confounding variable when interpreting the findings.

Another limitation of the study is that self‐efficacy was assessed as a general construct rather than a domain‐specific one. GSES used in this study assesses general coping ability and perceived self‐efficacy; however, it may not adequately capture self‐efficacy specific to complex functional domains such as employment participation, symptom management or adaptation to psychosocial interventions. In complex‐task situations, domain‐specific self‐efficacy measures may provide more sensitive and precise assessments. Therefore, reliance on a general self‐efficacy measure may have led to underestimation or misrepresentation of effects related to specific functional domains. Future studies incorporating both general and domain‐specific self‐efficacy measures—such as those related to employment, symptom management and treatment adherence—may allow for a more nuanced assessment of these relationships.

Finally, the lack of randomisation in sample selection resulted in significant sociodemographic differences between the schizophrenia and control groups. Differences in educational level, in particular, should be considered potential confounding factors that may influence alexithymia, metacognitive beliefs and self‐efficacy perceptions. Accordingly, the potential impact of sociodemographic group differences should be considered when interpreting the findings.

7. Implications for Practice

In the present study, metacognitive beliefs were found to have a direct effect on disability, whereas no significant effect was mediated through alexithymia. In addition, metacognitive beliefs did not exert a direct effect on self‐efficacy but influenced self‐efficacy indirectly through alexithymia, which served as a mediating variable. Low self‐efficacy and increased disability in schizophrenia are known to affect recovery and social adaptation adversely. The application of cognitive‐behavioural and metacognitive therapeutic approaches targeting alexithymia may enhance functioning and reduce disability in individuals with schizophrenia. The active involvement of psychiatric nurses in the planning and implementation of these interventions may contribute to more structured care and support recovery processes in individuals with schizophrenia. Longitudinal studies with larger sample sizes are needed to further elucidate these relationships. In addition, examining the effects of alexithymia, metacognitive beliefs and self‐efficacy on disability across other psychiatric disorders may further contribute to the literature.

Author Contributions

Study conception/design: Hatice Polat, Kerim Uğur. Data collection/analysis: Hatice POLAT, Kerim Uğur. Drafting of manuscript: Hatice POLAT, Kerim Uğur, Tunahan Sun. Critical revisions for important intellectual content, supervision: Hatice Polat, Kerim Uğur, Tunahan Sun. Statistical expertise: Hatice Polat, Kerim Uğur. Administrative/technical/material support: Hatice Polat, Kerim Uğur, Tunahan Sun.

Funding

The authors have nothing to report.

Ethics Statement

The study approval was obtained from the Malatya Turgut Özal University Non‐Interventional Clinical Research Ethics Committee (Number: 34; Date: 14.09.2023).

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgements

We would like to thank Assoc. Prof. Dr. Fatma Kızılkaya for her fund of knowledge and support in the statistical analysis part of the study.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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