2Katip Celebi University, Ataturk Research and Training Hospital, Department of Psychiatry, Izmir - Turkey
Objective: It is important to understand the etiology of impaired insight in schiophrenia in order to develop effective interventions to improve disorder awareness, treatment adherence, and recovery outcomes. The current study aims to explore the relationship of clinical domains and neurocognitive functions with different dimensions of clinical insight among patients with schizophrenia.
Methods: A total of 59 patients who met the diagnostic criteria for schizophrenia according to DSM-5 were recruited in the study. All patients were receiving outpatient treatment and were in fairly stable clinical conditions as defined by the absence of hospitalizations or changes in medication within the last three months. Patients were evaluated by Positive and Negative Symptoms Scale (PANSS), Scale to Assess Unawareness of Mental Disorder (SUMD), The Wisconsin Cart Sorting Test (WCST), Stroop-Test, Auditory Consonant Trigram Test (ACT) and Trail Making Test (TMT).
Results: Mean age was 41.1±10.3 years. Of the total 59 patients, 71.2% (n=42) were male and 28.8% (n=17) were female. Mean age of onset for illness was 24.6±7.6 years, mean duration of illness was 16.5±9.4 years and mean number of hospitalizations was 2.6±2.8. According to our findings, PANSS positive and general scores were predictors for SUMD-total score, PANSS general score and duration of illness were predictors for SUMD-awareness of mental illness score, PANSS positive and general scores were predictors for SUMD-awareness of the need for treatment score, PANSS general score and age of onset of schizophrenia were predictors for SUMD-awareness of the social consequences of disorder score.
Conclusion: This study examined clinical insight, psychopathology and various domains of neurocognitive functioning. Our results suggest that clinical insight is associated with positive and general symptoms but not with negative symptoms and neurocognitive impairment in patients with schizophrenia.
It has been shown that 50% to 80% of schizophrenia patients have partial or no insight about their disorders (1). In recent years, researchers have identified two types of insight: clinical and cognitive insight (2). Clinical insight is conceptualized and measured on the basis of being aware of the clinical manifestations of the disorder, such as having a mental disorder, being aware of the symptoms of the disease or treatment need (3). Cognitive insight, on the other hand, expresses the ability to distinguish oneself from others and to evaluate their own thoughts and interpretations (4). The nature and extent of the insights into the diseases of psychiatric patients may be meaningful; that is, poor insight may lead to delayed recognition of the disorder, inadequate compliance with treatment, and inadequate treatment response (5). In addition, poor insight has been associated with decreases in social (6) and occupational functioning (7) and deterioration in the quality of life (8). For all these reasons, understanding etiology of impaired insight in schizophrenia is important to improve insight in this population, and to develop effective intervention methods for treatment responses and compliance.
Although the mechanisms causing impaired insight are not fully known, possible etiological models have been asserted. First of these models considers poor insight among the primary findings of schizophrenia (9). However, controversial results have been found in past studies investigating this model (5). In the literature, there are studies that reported relationship between poor insight and positive findings (10) and negative findings (11). However, some studies did not find such relationship (12,13).
Another etiologic model has indicated poor insight as part of impaired neurocognitive function. Past research regarding this model revealed inconsistent findings. In some studies, there was a relationship between poor insight, executive functions (14,15) and memory impairment (16), whereas no relation was found in other studies (17,18). In a recent meta-analysis, neurocognitive impairment has been shown to have a significant but small effect on clinical insight (19).
The aim of this study is to investigate the relationship of psychotic findings and cognitive functions with clinical insight and its three dimensions in stable patients with chronic schizophrenia. Our first hypothesis is; there is a negative relationship between clinical insight and positive and negative symptoms. Our second hypothesis is; there is no correlation between clinical insight and cognitive functions due to our small sample size.
A total of 59 stable patients, followed up at outpatient clinics of Bozyaka Training and Research Hospital Community Mental Health Center, who met the criteria of schizophrenia diagnosis according to DSM-5, who were on medication treatment and who had no change in drug treatment, no hospitalization history within the last 3 months, were recruited in the study. The participants who were younger than 18 years old or older than 65 years old, who had a history of head trauma causing unconsciousness, who had a neurological disease, who have had alcohol or substance use disorders in the last year and who had mental retardation were not included in the study. Local ethics committee approval was obtained for the study. Informed written consents were obtained from all participants.
Patients were evaluated by using a Sociodemographic and clinical data form—structured by the authors—,Positive and Negative Symptoms Scale (PANSS), Scale to Assess Unawareness of Mental Disorder (SUMD), The Wisconsin Cart Sorting Test (WCST), Stroop-Test, Auditory Consonant Trigram Test (ACT) and Trail Making Test (TMT).
Positive and Negative Syndrome Scale (PANSS): It is a semi-structured interview scale with 30 items and seven points, was developed by Kay et al. (20). Seventeen psychiatric parameters take place in positive symptoms subscale, seven on the negative symptoms subscale and the remaining sixteen on the general psychopathology subscale. The Turkish reliability and validity study of the scale was conducted by Kostakoglu et al. (21).
Scale to Assess Unawareness of Mental Disorder (SUMD): It is a likert type scale applied by the clinician, and was developed by Amador et al. (22). In the statistical analyzes, the first three items—evaluating awareness of the disease, awareness of the treatment effect and awareness of the social outcomes—and the sum of the scores of these three items were used. Each item is scored from 1 to 5. High scores indicate weak insight. The Turkish reliability and validity study of the scale was performed by Bora et al. (23).
Wisconsin Card Sorting Test (WCST): WCST was developed by Heaton (24). WCST is considered to be sensitive to dorsolateral prefrontal cortex functions (25). The computer version was used in the study. Success in the WCST depends on understanding the mapping principle. For this test, 128 geometric pattern cards, each consisting of 3 groups according to color, shape, and quantity were used. There is no time limit. Turkish adaptation studies was carried out by Karakas et al. (26). The number of perseverative errors and the number of completed categories were used in the evaluation.
Stroop Test: It is a test that uses color naming in contrast to reading the word in order to study the ability to ignore agitator stimuli. In order to perform the test, just one visual feature must be selectively processed and the others must be blocked (27). The Stroop Test consists of four parts: saying the black printed words (color name), name the ink color of colorful squares or dots, saying the written word of color names printed in different colors, and naming the ink color of the words without saying the written word (color name). Turkish adaptation studies was carried out by Karakas et al. (26).
Auditory Consonant Trigram Test (ACT): It is a test that evaluates the working memory. The sum of the number of correctly remembered letters was used in the evaluation of the test. Turkish validity and reliability studies was performed (28).
Trail Making Test (TMT): It was developed by Reitan (29). The duration of section B was taken into consideration in our study (30).
All statistical analysis were performed using SPSS v 20.0 for Windows Statistical Package. The relevance of normal distributions of continuous variable was evaluated by Kolmogorov-Smirnov test. Since SUMD scores were not normally distributed, Spearman correlation coefficients were used to evaluate the relations between insight scores and age of disease onset, duration of disorders, number of hospitalization, PANSS scores, and neuropsychologic test scores. To determine predictors of clinical insight, linear regression analysis was performed. Insight scores, and the variables that correlated with PANSS score were included in these analyses. The p<0.05 values were considered statistically significant.
The mean age of the patients was 41.1±10.3 years. 71.2% (n=42) of the patients were male and 28.8% (n=17) were females. The average duration of education was 7.7±3.4 years. The mean age of onset was 24.6±7.6 years, the mean duration of illness was 16.5±9.4 years and the mean number of hospitalizations was 2.6±2.8. It was determined that 64.4% of the patients were single (n=38), 23.7% were married (n=14) and 11.9% (n=7) were divorced. When the treatments recieved in the last three months were examined it was found that; 44.1% (n=26) of the patients were using only atypical antipsychotics, 30.5% (n=18) were on a combination of atypical antipsychotics and antidepressants, 16.9% (n=10) were on atypical antipsychotics and typical antipsychotics, and 8.5% (n=5) were on atypical antipsychotics, typical antipsychotics, and antidepressants.
SUMD, PANSS and neurocognitive test scores are presented in Table 1.
The correlations between SUMD scores and clinical variables, PANSS and neuropsychological tests are presented in Table 2. SUMD total score had a negative correlation with age of onset of the disorders, and a positive correlation with PANSS positive and general scores. SUMD awareness of mental disorders score had a negative correlation with the disease duration, and a positive correlation with PANSS positive and general scores. It was determined that SUMD-awareness of effects of medication score had a negative correlation with the age of onset of the disorders, and a positive correlation with PANSS positive and general scores. SUMD-awareness of social consequences scores had a negative correlation with the age of onset of disorder, and a positive correlation with PANSS general scores.
Variables predicting clinical insight are given in Table 3. PANSS positive and overall scores were predictors for SUMD total score, PANSS overall score and disease duration were predictors for SUMD awareness of mental disorders score, PANSS positive and general scores were predictors for SUMD awareness of effects of medication and PANSS overall score and age of onset disorders were predictors for SUMD awareness of social consequences score.
This study evaluates factors that may be related to clinical insight, and it was determined that both the positive symptoms and the increase in the general symptoms predicted poorer clinical insight. These findings are consistent with previous studies. Amador et al. (1) reported that intrinsic strength strongly correlates with positive symptoms such as delusions and disorganization. In a survey of 96 patients with acute psychotic disorders Nieto et al. (31) also found that insight was associated with positive and general symptoms, but not with negative symptoms. In another study, it was reported that poor insight was associated with positive symptoms and violent behavior (32).
In a comparative study between schizophrenia patients with and without treatment history, a significant correlation was found between positive symptom scores and insight (33). Consistent with our study, Kim et al. (34) found correlations between positive symptoms (especially delusions, hallucinations, and scattered thoughts) and insight. A negative correlation between positive symptoms and insight was also found in a study conducted in Turkey (35). The relationship between the increase in positive symptoms and poorer insight is explained in various ways in the literature. The first explanation is: regarding the delusions, the most important part of the positive symptoms, it is considered that the same mechanism preventing the person to establish a causal relationship in the daily events, inhibits the establishment of cause-and-effect relationships for the events that are related to the disease as well, and therefore it should be expected that the patients could not have developed insight with regard to the disorder (11). The second possible explanation is that the insight in schizophrenia patients is impaired due to the reduced awareness of one’s own mental processes. In a recent functional brain imaging study in schizophrenia patients, a relationship was found between clinical insight and activation in the cortical midline structures and frontopolar cortex. These regions are suggested to be related to the assessment of mental processes in the healthy people (36). In the view of the fact that there was no correlation between insight and negative symptoms in our study, our findings are consistent with the statement that insight in schizophrenia patients may be part of positive symptoms. According to this hypothesis, poor insight in patients with schizophrenia is a special type of delusion, and the patients deny disorder persistently despite the obvious negativities in their life (37).
Contrary to our hypothesis, there was no relationship between negative findings and insight in our study. Conflicting results have been reported in studies investigating the relationship between insight and negative findings. Some studies have found a relationship between insight (10,11) and negative findings, while others have not found any relationship (31,35). The reasons for conflicting results between studies may be the use of different insight scales, small sample sizes, and the recruitment of patients with different clinical characteristics.
This study, which does not find a significant relationship between insight and neurocognitive functions, is consistent with other larger studies that have not established a relationship between insight and executive functions, memory, and attention (10,17,18). However, in a recent meta-analysis, a significant but small relation was found between neurocognitive functions and clinical insight (19). The small sample size in our study may be one of the reasons for not finding a relationship between insight and neurocognitive tests. Another reason could be that the schizophrenia patients in our study may have different clinical characteristics. For example, Quee et al. (38) reported different correlations between insight and neurocognitive tests during different periods of disorders. Since we recruited stable patients with chronic schizophrenia into our study, the likelihood of finding a relationship between insight and neurocognitive functions in newly emerging disease or in patients with psychotic relapse could not be excluded. In conclusion, our findings suggest that neurocognitive impairment has no or mild effect in impaired clinical insight in stable patients with chronic schizophrenia.
There are many limitations in our study. First, due to cross-sectional nature of our study, the necessity of elucidating the cause-and-effect relationship between variables by a follow-up study. Our second limitation is that it is impossible not to exclude the possible effects of treatment on clinical insight since all of our patients were on antipsychotic treatment. Other limitations are that the sample group predominantly consisted of males who were usually in their 40s, having a long disease duration and it was a group that accepted treatment. For these reasons, it is not known to what extent the findings may be generalized to; different stages of the disease, female patients, first episode of the disease, patients that do not receive regular treatment. Studies in newly diagnosed, young patients with no medication use will make an important contribution to elucidating the factors associated with insight.
Conflict of Interest: Authors declared no conflict of interest.
Financial Disclosure: Authors declared no financial support.
1. Amador XF, Gorman JM. Psychopathologic domains and insight in schizophrenia. Psychiatr Clin North Am 1998; 21:27-42. [CrossRef]
2. Lysaker PH, Roe D, Yanos PT. Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders. Schizophr Bull 2007; 33:192-199. [CrossRef]
3. Amador XF, Flaum M, Andreasen NC, Strauss DH, Yale SA, Clark SC, Gorman JM. Awareness of illness in schizophrenia and schizoaffective and mood disorders. Arch Gen Psychiatry 1994; 51:826-836. [CrossRef]
4. Beck AT, Baruch E, Balter JM, Steer RA, Warman DM. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res 2004; 68:319-329. [CrossRef]
5. Lincoln TM, Lüllmann E, Rief W. Correlates and long-term consequences of poor insight in patients with schizophrenia. A systematic review. Schizophr Bull 2007; 33:1324-1342. [CrossRef]6. Erol A, Delibas H, Bora O, Mete L. The impact of insight on social functioning in patients with schizophrenia. Int J Soc Psychiatry 2015; 61:379-385. [CrossRef]7. Lysaker PH, Bryson GJ, Bell MD. Insight and work performance in schizophrenia. J Nerv Ment Dis 2002; 190:142-146. [CrossRef]
8. Rocca P, Castagna F, Mongini T, Montemagni C, Bogetto F. Relative contributions of psychotic symptoms and insight to quality of life in stable schizophrenia. Psychiatry Res 2010; 177:71-76. [CrossRef]
9. Collins AA, Remington GJ, Coulter K, Birkett K. Insight, neurocognitive function and symptom clusters in chronic schizophrenia. Schizophr Res 1997; 27:37-44. [CrossRef]
10. Chan KK. Associations of symptoms, neurocognition, and metacognition with insight in schizophrenia spectrum disorders. Compr Psychiatry 2016; 65:63-69. [CrossRef]
11. Mingrone C, Rocca P, Castagna F, Montemagni C, Sigaudo M, Scalese M, Rocca G, Bogetto F. Insight in stable schizophrenia: relations with psychopathology and cognition. Compr Psychiatry 2013; 54:484-492. [CrossRef]12. Greenberger C, Serper MR. Examination of clinical and cognitive insight in acute schizophrenia patients. J Nerv Ment Dis 2010; 198:465-469. [CrossRef]13. Wiffen BD, Rabinowitz J, Lex A, David AS. Correlates, change and “state or trait” properties of insight in schizophrenia. Schizophr Res 2010; 122:94-103. [CrossRef]
14. Chan SK, Chan KK, Lam MM, Chiu CP, Hui CL, Wong GH, Chang WC, Chen EY. Clinical and cognitive correlates of insight in first-episode schizophrenia. Schizophr Res 2012; 135:40-45. [CrossRef]
15. Chan SK, Chan KK, Hui CL, Wong GH, Chang WC, Lee EH, Tang JY, Chen EY. Correlates of insight with symptomatology and executive function in patients with first-episode schizophrenia-spectrum disorder: a longitudinal perspective. Psychiatry Res 2014; 216:177-184. [CrossRef]
16. Keshavan MS, Rabinowitz J, DeSmedt G, Harvey PD, Schooler N. Correlates of insight in first episode psychosis. Schizophr Res 2004; 70:187-194. [CrossRef]
17. Simon V, De Hert M, Wampers M, Peuskens J, van Winkel R. The relation between neurocognitive dysfunction and impaired insight in patients with schizophrenia. Eur Psychiatry 2009; 24:239-243. [CrossRef]
18. Stefanopoulou E, Lafuente AR, Saez Fonseca JA, Huxley A. Insight, global functioning and psychopathology amongst in-patient clients with schizophrenia. Psychiatr Q 2009; 80:155-165. [CrossRef]
19. Nair A, Palmer EC, Aleman A, David AS. Relationship between cognition, clinical and cognitive insight in psychotic disorders: a review and meta-analysis. Schizophr Res 2014; 152:191-200. [CrossRef]
20. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987; 13:261-276. [CrossRef]
21. Kostakoglu AE, Batur S, Tiryaki A, Gogus A. Reliability and validity of the Turkish version of the positive and negative syndrome scale (PANSS). Turkish Journal of Psychology 1999; 14:23-34. (Turkish)
22. Amador XF, Strauss DH, Yale SA, Flaum MM, Endicott J, Gorman JM. Assessment of insight in psychosis. Am J Psychiatry 1993; 150:873-879. [CrossRef]
23. Bora E, Ozdemir F, Ozaskinli S. The reliability and validity of the abbreviated Scale of Unawareness of Mental Disorder. Psychiatry in Turkiye 2006; 8:74-80.
24. Heaton R. The Wisconsin card sorting test manual. Odesa, FL: Psychological Assessment Resources 1981.
25. Weinberger DR, Berman KF, Zec RF. Physiologic dysfunction of dorsolateral prefrontal cortex in schizophrenia. I. Regional cerebral blood flow evidence. Arch Gen Psychiatry 1986; 43:114-124. [CrossRef]26. Karakas S, Irak M, Ersezgin OU. Intra test and inter tests relations of Wisconsin Card Sorting Test (WCST) and Stroop Test, TBAG form scores. Xth National Psychology Congress Abstract Book, 1998, 44. (Turkish)
27. Golden CJ. Stroop Color and Word Test. Chicago, IL; Stoelting, 1978.
28. Anil EA, Kivircik BB, Batur S, Kabakci E, Kitis A, Guven E, Basar K, Turgut TI, Arkar H. The Turkish version of the Auditory Consonant Trigram Test as a measure of working memory: a normative study. Clin Neuropsychol 2003; 17:159-169. [CrossRef]
29. Reitan RM. Validity of the Trail making Test as an indicator of organic brain damage. Percept Mot Skills 1958; 8:271-276. [CrossRef]30. Turkes N, Can H, Kurt M, Elmastas Dikec B. A Study to Determine the Norms for the Trail Making Test For the Age Range of 20-49 in Turkey. Turk Psikiyatri Derg 2015;26:189-196. (Turkish)
31. Nieto L, Cobo J, Pousa E, Blas-Navarro J, García-Parés G, Palao D, Obiols JE. Insight, symptomatic dimensions, and cognition in patients with acute-phase psychosis. Compr Psychiatry 2012; 53:502-508. [CrossRef]
32. Ekinci O, Ekinci A. Association between insight, cognitive insight, positive symptoms and violence in patients with schizophrenia. Nord J Psychiatry 2013; 67:116-123. [CrossRef]
33. Tirupati S, Padmavati R, Thara R, McCreadie RG. Insight and psychopathology in never-treated schizophrenia. Compr Psychiatry 2007; 48:264-268. [CrossRef]
34. Kim Y, Sakamoto K, Kamo T, Sakamura Y, Miyaoka H. Insight and clinical correlates in schizophrenia. Compr Psychiatry 1997; 38:117-123. [CrossRef]
35. Danki D, Dilbaz N, Okay IT, Telci S. Insight in schizophrenia: relationship to family history, and positive and negative symptoms. Turk Psikiyatri Derg 2007; 18:129-136. (Turkish)
36. Raij TT, Riekki TJ, Hari R. Association of poor insight in schizophrenia with structure and function of cortical midline structures and frontopolar cortex. Schizophr Res 2012; 139:27-32. [CrossRef]
37. Branković S. Boredom, dopamine, and the thrill of psychosis: psychiatry in a new key. Psychiatr Danub 2015; 27:126-137.
38. Quee PJ, van der Meer L, Bruggeman R, de Haan L, Krabbendam L, Cahn W, Mulder NC, Wiersma D, Aleman A. Insight in psychosis: relationship with neurocognition, social cognition and clinical symptoms depends on phase of illness. Schizophr Bull 2011; 37:29-37. [CrossRef]
2Katip Çelebi Üniversitesi, Atatürk Araştırma ve Eğitim Hastanesi, Psikiyatri Kliniği, İzmir - Türkiye
Amaç: Şizofrenide bozulmuş içgörünün etiyolojisini anlamak; içgörü kazandırmak, tedavi uyumu ve tedavi yanıtları için etkili müdahale yöntemleri geliştirmek açısından önemlidir. Çalışmamızda, şizofreni hastalarında, klinik özellikler ve bilişsel işlevler ile klinik içgörünün farklı boyutları arasındaki ilişkinin araştırılması amaçlanmıştır.
Yöntem: Çalışmaya DSM-5’e göre şizofreni tanı kriterlerini karşılayan 59 hasta alınmıştır. Tüm olguların ilaç tedavisi sürmektedir ve son 3 ay içinde hastane yatışı ve ilaç tedavisinde değişiklik olmamıştır. Hastalar pozitif ve negatif sendrom ölçeği (PANSS), Akıl Hastalığına İçgörüsüzlük Ölçeği (AHİÖ), Wisconsin Kart Eşleme Testi (WKET), Stroop Testi, İşitsel Üçlü Sessiz Harf Sıralaması Testi (İÜSHST) ve İz Sürme Testi ile değerlendirilmiştir.
Bulgular: Ortalama yaş 41.1±10.3 yıl olarak saptanmıştır. Çalışmaya alınan hastaların %71.2’si erkek (s=42) ve %28.8’i (s=17) kadındır. Hastalığın ortalama başlangıç yaşı 24.6±7.6 yıl, hastalığın ortalama süresi 16.5±9.4 yıl ve ortalama hastanede yatış sayısı 2.6±2.8 olarak saptanmıştır. PANSS pozitif ve genel puanlarının AHİÖ toplam puanı için, PANSS genel puanı ve hastalık süresinin AHİÖ-hastalığın farkında olma puanı için, PANSS pozitif ve genel puanlarının AHİÖ-tedavi etkisinin farkında olma puanı için ve PANSS genel puanı ve hastalık başlangıç yaşının AHİÖ-sosyal sonuçların farkında olma puanı için öngördürücü olduğu saptanmıştır.
Sonuç: Klinik içgörü ile ilişkili olabilecek etkenlerin değerlendirildiği bu çalışmada, şizofreni hastalarında klinik içgörünün pozitif ve genel semptomlarla ilişkili olduğu ancak, negatif semptomlar ve nörokognitif bozulma ile ilişkili olmadığı saptanmıştır.