The Mediating Role of Internalized Stigma and Illness Knowledge in the Relationship Between Psychological Flexibility and Symptom Severity in Schizophrenia

Schizophrenia is a chronic mental illness that affects daily functioning and quality of life. Many patients experience internalized stigma, which worsens symptoms and quality of life. Psychological flexibility may help reduce stigma's negative effects. This study explores how psychological flexibility, internalized stigma, and illness knowledge relate to symptom severity in schizophrenia. We hypothesized that internalized stigma mediates the link between psychological flexibility and symptoms, and that greater illness knowledge leads to lower stigma and better outcomes. This cross-sectional study included patients diagnosed with schizophrenia at a Community Mental Health Center (CMHC) in Turkey. 253 participants completed standardized scales of psychological flexibility(AAQ-II), internalized stigma(ISMI), knowledge about schizophrenia(KASQ), and symptom severity(PANSS). Mediation analysis was performed using the PROCESS macro for SPSS to assess the indirect effects of stigma and illness knowledge on symptom severity. Psychological flexibility was significantly associated with lower levels of internalized stigma (β = -1.046, p < 0.001). Internalized stigma mediated the relationship between psychological flexibility and symptom severity(β = 0.506, p < 0.001), whereas illness knowledge had a protective effect on symptom severity(β = -1.582, p < 0.001). However, illness knowledge did not significantly mediate the relationship between psychological flexibility and stigma. The findings highlight the critical role of psychological flexibility in mitigating the negative impact of internalized stigma, suggesting that interventions aimed at enhancing flexibility could improve clinical outcomes. Psychoeducation programs may further reduce symtom severity by increasing ilness knowledge. Future research should explore longitudinal interventions targeting stigma reduction and psychological flexibility to enhance functional recovery in schizophrenia.