Introduction

The personal experience of health is complex and dynamic and relies on physical, social and mental factors [1]. According to the salutogenesis theory, an approach focusing on factors that support health and wellbeing, the experience of health is on a continuum from good health to poor health dependent on the individual’s internal and external coping resources [2]. Aron Antonovsky’s "Sense of Coherence (SOC)" theory is used to explain the apparent contradiction that people with severe illnesses report a subjective experience of good health.

According to this theory, the SOC comprises three theoretically separable but closely interwoven core components that include:

1) Comprehensibility: Refers to the extent to which a person perceives internal and external stimuli as rationally understandable and as information that is orderly, coherent, clear, structured rather than noise.

2) Manageability: Refers to the degree to which a person feels that there are resources at his/her disposal that can be used to meet the requirements of the stimuli that bombards him/her.

3) Meaningfulness: Refers to the extent to which a person feels that life has emotional meaning, that at least some of the problems faced in life are worth commitment and dedication, and are seen as challenges rather than as burdens [3].

These three core components can vary over time. A person can experience life as manageable but not explainable or meaningful, and later on as meaningful but not predictable and manageable [4]. A high SOC indicates the ability to make sense of the world, in a way that facilitates successful coping with the countless and complex stressors we confront throughout life [2].

Longitudinal studies of healthy teenagers [5], students [6]and unselected general population samples [7]show that a person's SOC is relatively stable throughout life. A 13-year follow-up study of 552 individuals followed from childhood to adulthood, found that SOC tended to increase with age and was most stable in those with a high SOC at study baseline [8]. While SOC is not seen as a personality trait, it is closely related to other personal resources such as self-esteem [9, 10]

Both quantitative and qualitative studies support the notion that a high SOC contributes to a high subjective quality of life [11]. Good health, and in particular, good mental health is also related to a high SOC. The original SOC theory takes the possibility of people refusing to acknowledge facts into account; i.e. the possibility of having a "false" SOC [3]. Loss of insight, especially the lack of awareness of positive- and cognitive symptoms, is common in patients with schizophrenia [12, 13]. Loss of insight could thus influence the association between SOC and mental health in schizophrenia. However, a study of 136 patients with schizophrenia or schizoaffective disorder, showed a statistically significant association between a low SOC and a high level of negative symptoms [14]. Another study of 120 patients with schizophrenia and schizoaffective disorder, showed a statistically significant association between low SOC and high levels of positive, negative and affective symptoms including anxiety, guilt feelings, tension and depressive mood [15].

Contemporary phenomenology distinguishes between the core- or basic self and the narrative self [16, 17]. The basic self is a pre-reflective level of selfhood. The basic self refers to the first-person quality of a person's experiences and is entirely implicit in–and inseparable from–the act of experiencing in itself, i.e. all subjective experience implies a self who is having the experience [18]. The concept of a basic self derives from the given fact that there is an implicit "ownership" of experience and in other words comprises the tacit awareness that "this is my experience". As the term indicate, the basic self is the foundation upon which other aspects of the self, such as the narrative self, are based. The narrative self exists on a reflective and articulated level. The narrative self is the experience of the self as having particular characteristics, personality traits, values and history [19].

Basic self-disturbances are disturbances in the basic, pre-reflective self [19]. BSDs affect a person's ability to have an adequate interpretation of his/her inner feelings and thoughts and diminish the feeling of ownership of one's body, movements and personal history. BSDs will thus likely affect how a person experiences his/her existence as comprehensive, manageable and meaningful, i.e. influence the person's SOC.

Both SOC and BSDs are closely linked to the clinical severity of mental illness [20–28], more knowledge about the relationship between SOC and BSDs give us insight into the challenges experienced by people with schizophrenia and other psychotic disorders. We here aim to investigate the relationship between BSDs and SOC in patients with psychotic disorders. To our knowledge, this is the first study that focuses directly this potential relationship. Our main hypothesis, as outlined above, is that patients with high level of BSDs will experience low SOC. Since high levels of BSDs are associated with high levels of symptoms and high levels of symptoms potentially associated with low SOC, we also investigate to what extent a putative association between BSDs and SOC is mediated by clinical severity, including the severity of symptoms of psychosis and functional loss.

Material and method

Results

Clinical and demographic data are shown in Table 1. The correlation matrix indicates a statistically significant correlation (p<0.01) between SOC and all clinical measures except PANSS NEG and PANSS DIS (Table 2). There were statistically significant differences (p < 0.01) in the EASE total score, GAF S, GAF F, PANSS POS and PANSS DIS between the two diagnostic groups, but no differences in the SOC-13 total score in bivariate analyses (Table 3).

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Table 1. Clinical and demographic data.

https://doi.org/10.1371/journal.pone.0230956.t001

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Table 2. Correlation between SOC-13, EASE, clinical measures.

https://doi.org/10.1371/journal.pone.0230956.t002

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Table 3. Independent samples t-test between the diagnostic groups (SZspect and non-SZspect).

https://doi.org/10.1371/journal.pone.0230956.t003

There was a statistically significant (negative) correlation between the SOC-13 total score and the EASE total score (r-0.54/p <0.001) (Table 4). The follow-up analyses indicated statistically significant negative correlations between the main parts of the EASE domain scores and the SOC components, with the highest r's for the associations between SOC and EASE domain 2, Self-awareness and presence (Table 4, in bold).

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Table 4. Correlations (Pearson’s r) between SOC-13 and EASE scores.

https://doi.org/10.1371/journal.pone.0230956.t004

We then investigated if clinical characteristics mediated the association between SOC and BSDs (EASE total score) (Table 5).

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Table 5. Multiple linear regression models with SOC-13 total score as dependent variable.

https://doi.org/10.1371/journal.pone.0230956.t005

The results of the regression analysis showed a statistically significant association between SOC and BSDs, in the direction that high levels of BSDs contributed to low levels of SOC. The analysis also indicated that the association between SOC and BSDs was independent of diagnostic group, and not mediated by levels of clinical symptoms or dysfunction. The level of clinical insight did not confound the analyses.

Discussion

In line with our hypothesis, we found a statically significant association between SOC and BSDs, in the direction that patients with high levels of BSDs had low levels of SOC. The association was strongest for EASE domain 2: Self-awareness and presence. As expected, we also found associations between SOC, BSDs and clinical characteristics. However, the association between SOC and BSDs was not mediated by clinical symptoms, dysfunction, level of insight or diagnostic group.

BSDs comprises a disordered experience of thoughts, feelings, and sensations with consequential fundamental loneliness, despite access to relationships with others [26, 44, 45]. This counteracts trust in- and access to the person's own and others' resources and abilities, that are needed to handle difficult situations. The experience of loss of common sense makes everyday life appear as complicated and unnatural. Even trivial tasks have to be thought through in a deliberate and careful (rather than an automatic and intuitive) fashion [19, 46, 47], creating uncertainty around the performance of actions others take for granted. The experience that life is coherent, consistent and predictable is thus influenced in a negative way. BSDs also comprise a diminished first-person perspective, disrupting awareness of own actions and reducing the ability to be touched, moved or motivated by other people, events or situations [48]. This impaired awareness may weaken the experience of personal involvement in own life and the experience of life as meaningful.

In particular EASE domain 2 (i.e. self-awareness and presence) comprises changes in the experience of a normally tacit and pre-reflective self-presence. The items included in this domain are thus associated with diminished potentials for activity and pleasure, diminished engagement in the world and experiences of alienation [33]. The SOC concept includes predictability, manageability and meaningfulness. It is difficult to experience life as predictable in the context of experiencing the world as unnatural and strange, to experience life as manageable in the context of actively monitoring inner life and external reality and to experience meaningfulness in the context of severe estrangement.

Significant associations between two apparently different concepts can be based on overlapping criteria. There are, however, major differences in the way BSDs and SOC are assessed. The EASE manual is a comprehensive, in-depth interview made to elicit information about BSDs as complex, and often unexpressed, experiences or phenomena. The interviewer explores these phenomena together with the patient beyond the immediate answer to the question. The use of a particular word or metaphor is examined to grasp the patient’s interpretation of the underlying phenomenon that can be literal, concrete or outside of the usual understanding of a concept [33]. The SOC-13, on the other hand, is a short self-report questionnaire assessing the person's global experience of comprehensibility, manageability and meaningfulness [4]. The self-report form precludes any further exploration of the answers, and mainly captures the person’s immediate response to the question. There are questions in the SOC-13 and EASE-interview that appear closely related at first glance. SOC: "How often do you have the feeling that you are in an unfamiliar situation and do not know what to do?” EASE: “Have you ever experienced that you no longer understand natural things in life, that it is difficult to understand situations, people and objects?” The follow-up clarifications in the EASE interview, however, counteract the use of overlapping criteria.

The findings also support the notion that BSDs and SOCs relate to different types of self-awareness: While BSDs are associated with the basic level of the self, SOC is associated with the narrative level. This assumption is the basis for interpreting BSDs as independent contributors to poor SOC, in patients with psychosis. The results of the multiple linear regression analyses also indicate that the association between BSDs and SOC is not confounded or mediated by clinical symptoms or social dysfunction. However, the correlational nature of this study precludes firm conclusions regarding the direction of the associations, or causality. SOC theory is used to explain the apparent contradiction that people with severe illnesses have a subjective experience of good health. In this study, there was a negative association between the level of symptomatology and the level of SOC. It is also of interest that lack of clinical insight contributed to a lower SOC, and did not influence the association between BSDs and SOC. Also, while some participants reported both high symptom levels and high SOC, this discrepancy was not explained by a lack of insight.

Experience of health is linked to personal history and influenced by access to resources and the impact of illness. Both BSDs and SOC captures subjective experiences and needs to be specifically explored by clinicians wanting to understand the subjective world of their patients. By taking a salutogenic position, the clinician and the patient can explore how different challenges in life, including the presence of BSDs, impact the experience of health and coherence. This exploration can serve as the basis for identifying resources and initiating interventions that strengthen the patient's experience of health.

Strengths of this study include: That the sample was broadly recruited from the Norwegian national health service offering public mental health care to all individuals with mental illness with few exclusion criteria. The participants represent a comprehensive, near to epidemiological sample.

Limitations include: While the current SOC-13 form is thought to be easier to use for patients with mental disorders, the use of the original form with a seven-point Likert scale could potentially give richer data through a wider range of scores. In addition, the study has no explicit measure of the subjective experience of health, which could have strengthened the study.

Conclusion

This study is the first to demonstrate a statistically significant association between BSDs and SOC. The association is particularly high between SOC and the EASE domain 2, self-awareness and presence. The association is not influenced by diagnostic category, clinical symptoms and social dysfunction. Further research exploring this relationship, including the direction of the association, potential indications of causality and implications for treatment is needed.

Acknowledgments

The authors thank the patients for participating in the study. We will also thank psychologist Kristoffer Grimstad, Håkon Johansen, MD, Ulf Benckert, MD, Shermin Sani, MD and Zina Abood, MD, for conduction the SCID-I interviews.