研究背景：精神分裂症作为一种严重的精神障碍，虽然其发病率相对较低，但是这一疾病在全球范围内都造成了沉重的负担，不仅对患者个人，而且对家庭和社会都带来了巨大的挑战。虽然中国正在积极采取措施应对这一挑战，但是由于精神疾病的污名化现象普遍，患者内在污名水平和自尊都遭受其影响，种种问题导致患者的规范就诊率低下，目前只有不到15%的精神分裂症患者能够实现工作能力与社会功能改善的治疗康复目标。因此，精神分裂症患者的治疗与康复难题亟需得到更广泛的关注，聚焦这类患者康复情况的影响因素，提高其治疗期望对于减轻该类患者疾病负担至关重要。

研究目的：本研究基于自我调节理论模型，聚焦精神分裂症患者，旨在探究疾病归因、内在污名、自尊与治疗期望之间的关系，同时探析不同人口社会学特征（如性别、年龄、婚姻状态等）和疾病特征在疾病归因、内在污名、自尊与治疗期望之间是否存在显著差异，重点检验内在污名与自尊在疾病归因与治疗期望之间是否存在链式中介效应。在此基础上，提供理论上的参考和借鉴，为提升患者治疗期望，提升自尊，降低内在污名的干预方案提供证据，以期进一步提升患者的治疗效果。

研究方法：本研究属于观察性研究中的横断面研究。首先，运用方便抽样的方法，从四家精神专科医院中接受治疗的患者中，由精神疾病专科医生对患者病情进行全面评估，筛选出病情稳定的患者。在此基础上，运用功能大体评定量表（Global Assesment of Functioning Scale）对患者进行评估后，选取意识清楚（功能得分>70分），可以进行正常沟通的患者进行问卷调查。针对选取出的患者，采用疾病认知问卷、工作相关治疗期望问卷、内在污名量表和自尊量表对变量进行测量。数据分析过程中，分类变量采用频数和百分比，以呈现样本人群的基本特征；连续变量采用平均值和标准差进行描述性分析，采用卡方检验、t检验、方差分析进行单因素分析；构建多元回归模型，探究疾病归因对治疗期望的影响效应，同时采用bootstrap中介效应检验方法来分析精神分裂症患者不同疾病归因类型对治疗期望的影响以及内在污名化水平和自尊在二者中所起的链式中介作用。

研究结果：统计分析结果发现，583名患者的疾病归因的平均得分从高到低依次是心理因素（2.61±1.03）、个人命运因素（2.15±1.23）、生理因素（1.70±0.72）、超自然因素（1.67±0.89），最后是风险因素（1.61±0.85）。疾病归因类型与内在污名化水平呈现显著正相关 [生理因素（r = 0.239, P < 0.001）、心理因素（r = 0.271, P<0.001）、超自然因素（r = 0.252, P<0.001）、风险因素（r = 0.111, P<0.01）、个人命运因素（r = 0.311, P<0.001）]，和自尊呈显著负相关[生理因素（r = -0.127, P<0.01）、心理因素（r = -0.202, P<0.001）、超自然因素（r = -0.185, P<0.001）、风险因素（r = -0.104, P<0.05）、个人命运因素（r = -0.218, P<0.001）]。中介效应分析显示，不同的疾病归因对患者治疗期望的直接效应均是显著的[生理因素（effect = -0.092）、心理因素（effect = -0.069）、超自然因素（effect = -0.215）、风险因素（effect = -0.047）、个人命运因素（effect = -0.074）]分别占各自总效应的38.66%、30.00%、60.22%、38.52%、37.19%；内在污名在五种疾病归因和治疗期望中起单独中介作用[生理因素（effect = -0.114）、心理因素（effect = -0.116）、超自然因素（effect = -0.101）、风险因素（effect = -0.051）、个人命运因素（effect = -0.092）]分别占各自总效应的47.90%、50.43%、28.29%、41.80%、46.23%。自尊在两者之间的单独中介作用并不显著。同时，内在污名和自尊在五种疾病归因和患者治疗期望之间均起到链式中介作用，效应值分别为-0.038、-0.036、-0.033、-0.016、-0.030，分别占各自总效应的15.97%、15.65%、9.24%、13.11%、15.08%。

研究结论：本研究为严重精神疾病患者全面康复的路径模型提供了实证支持，基于研究问题与结果，总结得出研究结论如下：（1）患者更倾向于把自己的精神分裂症的症状出现归因于心理原因，如家庭问题、性格等，不同人口学特征和疾病特征的精神分裂症患者的疾病归因类型和治疗期望存在显著差异。（2）精神分裂症疾病归因的五个维度：生理因素、心理因素、超自然因素、风险因素、个人命运因素对患者的治疗期望都有不同程度的负向影响。其中，超自然因素对治疗期望的影响更显著。具体而言，当精神分裂症患者更倾向于把自己的症状归因于超自然原因（例如生辰八字或鬼神）时，患者的治疗期望更低。（3）精神分裂症患者的内在污名和自尊在疾病归因对治疗期望的影响中起链式中介作用，即疾病归因通过施加不同程度的影响，增加精神分裂症患者的内在污名，降低患者的自尊，从而对其治疗期望产生负向影响。一旦精神分裂症患者开始对自己的疾病进行归因认知处理，则其治疗期望都会产生不同程度的下降。针对精神分裂症患者的干预方案设计应该以患者为中心，引导其将关注重点放在后续疾病恢复的过程，减少疾病归因、内在污名对于患者的负面影响，提高患者的治疗与康复效果。

Background: As a serious mental disorder, schizophrenia has a relatively low incidence rate, but it has caused a heavy burden worldwide, not only for individual patients but also for families and society. Most of the world's schizophrenia patients live in low- and middle-income countries, and China has one of the highest incidence rates of schizophrenia in the world. Although China is actively taking measures to cope with this adjustment, less than 15% of schizophrenia patients can achieve the treatment and rehabilitation goals of improving workability and social function. Therefore, the treatment and rehabilitation challenges faced by schizophrenia patients urgently need to be more widely understood. To achieve this goal, it is crucial to pay attention to the factors that influence the recovery of these patients and improve their treatment expectations to reduce the disease burden of these patients.

Objective: Based on the self-regulation theoretical model and focused on patients with schizophrenia, this study aimed to explore the relationship between causal attribution of illness, internalized stigma, self-esteem and treatment expectations, while also exploring these differences among different demographic and sociological groups (such as gender, age, marital status, etc.) and focusing on identifying whether there is a chain mediating effect of internalized stigma and self-esteem between disease attribution and treatment expectations. On this basis, it provided theoretical reference and attempts to propose intervention strategies to increase patients' treatment expectations, enhance self-esteem, and reduce internalized stigma to improve the patients' lives further.

Methods: This study was a cross-sectional study in observational research. First, using convenience sampling method, from the patients receiving treatment in four psychiatric hospitals, the psychiatrists evaluated the patients using the Global Assessment of Functioning Scale. They selected the patients who were conscious, stable and could communicate normally for the questionnaire survey. The Illness Perception Questionnaire, Internalized Stigma of Mental Illness Scale, the Work-Related Recovery Expectations Questionnaire, Internalized Stigma of Mental Illness Scale and the Self-Esteem Scale were used to evaluate the patients' beliefs, status and treatment effects. During data analysis, frequency and percentage were used for categorical variables to present the basic characteristics of the sample population; mean and standard deviation were used for descriptive analysis of continuous variables, and the chi-square test, t-test, and analysis of variance (ANOVA) were used for univariate analysis. A multiple regression model was constructed to explore the impact of disease attribution on treatment expectations. At the same time, the bootstrap mediation effect test method was used to investigate the mediating effects and chain mediating effects of internalized stigma and self-esteem between different types of disease attribution and treatment expectations in schizophrenia patients.

Results: Statistical analysis results showed that the average scores of disease attribution for 583 patients from highest to lowest are as follows: psychological factors (2.61±1.03) , personal destiny factors (2.15±1.23) , physiological factors (1.70±0.72), supernatural factors (1.67±0.89), and finally risk factors (1.61±0.85). The types of causal attribution of illness were significantly positively correlated with levels of internalized stigma (physiological factors: r = 0.239, P < 0.001; psychological factors: r = 0.271, P < 0.001; supernatural factors: r = 0.252, P < 0.001; risk factors: r = 0.111, P < 0.01; personal destiny factors: r = 0.311, P < 0.001) and significantly negatively correlated with self-esteem (physiological factors: r = -0.127, P < 0.01; psychological factors: r = -0.202, P < 0.001; supernatural factors: r = -0.185, P < 0.001; risk factors: r = -0.104, P < 0.05; personal destiny factors: r = -0.218, P < 0.001). Mediation effect analysis showed that the direct effects of different disease attributions on patients' treatment expectations were significant (physiological factors: effect = -0.092; psychological factors: effect = -0.069; supernatural factors: effect = -0.215; risk factors: effect = -0.047; personal destiny factors: effect = -0.074), accounting for 38.66%, 30.00%, 60.22%, 38.52%, and 37.19% of their respective total effects. Internalized stigma played an independent mediating role in the relationship between the five types of disease attributions and treatment expectations (physiological factors: effect = -0.114; psychological factors: effect = -0.116; supernatural factors: effect = -0.101; risk factors: effect = -0.051; personal destiny factors: effect = -0.092), accounting for 47.90%, 50.43%, 28.29%, 41.80%, and 46.23% of their respective total effects. The independent mediating role of self-esteem between the two was not significant. Meanwhile, internalized stigma and self-esteem jointly played a chain mediating role between the five types of disease attributions and patients' treatment expectations, with effect values of -0.038, -0.036, -0.033, -0.016, and -0.030, accounting for 15.97%, 15.65%, 9.24%, 13.11%, and 15.08% of their respective total effects.

Conclusions: Based on the results, these conclusions were made as follows: First, patients were more likely to attribute their symptoms of schizophrenia to psychological causes, such as family problems and personality. There are significant differences in causal attribution of illness and treatment expectation among schizophrenia patients with different demographic and illness characteristics. Second, the five dimensions of disease attribution: physiological factors, psychological factors, supernatural factors, risk factors, and personal destiny factors all had different degrees of negative impact on patients' treatment expectations. Supernatural factors had a more significant effect on healing expectations, with patients' treatment expectations being lower when patients with schizophrenia were more inclined to attribute their symptoms to supernatural causes, such as 'Bazi (Birthdates)' or 'Guishen (Ghosts and Gods) '. Third, schizophrenic patients' internalized stigma and self-esteem acted as chain mediators in the effects of causal attributions on treatment expectations, i.e., causal attributions negatively affected positive treatment expectancy by exerting varying degrees of negative influence, enhancing patients' intrinsic stigma, and lowering patients' self-esteem. Once patients begin to cognitively process their illness attributions, their treatment expectations are reduced to varying degrees. Subsequent intervention programs should be patient-centred, directing the patient's attention to focus on the subsequent process of recovery from the illness, and reducing the negative impact of illness attributions and intrinsic stigma on the patient.