Personality as a predictor of the variability of insight in schizophrenia

Role of Clinical Insight at First Month in Predicting Relapse at the Year in First Episode of Psychosis (FEP) Patients

INTRODUCTION

Clinical insight constitutes a useful marker of the progress and outcome of the First Episode of Psychosis (FEP), and lack of insight has been associated with more severe psychopathology, treatment non-adherence, and rehospitalization/relapse. In this study, we aimed to further investigate the possible role of insight as a predictor of relapse, its relation to diagnosis, and other parameters of positive psychotic symptomatology (delusions, hallucinations, and suspiciousness).

METHODS

The Athens FEP study employed a prospective, longitudinal cohort design in which consecutive newly diagnosed patients with psychosis were interviewed and asked to voluntarily participate after completing informed consent. A total of 88/225 patients were examined at three different time points (baseline, month, and year). Their scores in the relevant items of the Positive and Negative Syndrome Scale (PANSS) were compared (G12 for insight, P1 for delusions, P3 for hallucinations, and P6 for suspiciousness), and they were further associated to diagnosis and the outcome at the end of the year (remission/relapse).

RESULTS

In total, 22/88 patients with relapse at the year had greater scores in G12 for both the month and the year, and this finding was corroborated after adjusting the statistical analysis for demographics, diagnosis, social environment, and depression via multiple logistic regression analysis. Moreover, delusions and suspiciousness were significantly higher in patients diagnosed with non-affective psychosis compared to those diagnosed with affective psychosis (p < 0.001) at the first month.

CONCLUSIONS

Lack of insight at the first month may serve as a predictor of relapse at the year.

Insight, personality, and symptoms among individuals with psychosis: Cross-sectional and longitudinal relationships

BACKGROUND

Reports on the relationship between clinical insight and psychotic symptoms have shown inconsistent results, and the association between clinical insight and personality has rarely been addressed. The aim of this study was to examine whether personality is correlated cross-sectionally with insight level, and longitudinally with change in insight, beyond symptoms.

METHODS

Participants were a sub-sample of the Dutch Genetic Risk and Outcome of Psychosis (GROUP) project. Two hundred and eleven participants diagnosed with non-affective psychotic disorders took part in the cross-sectional part of the study, of whom 136 took part in the three-year follow-up assessment. They were administered with self-report Birchwood insight scale and NEO-Five Factor Inventory, and clinicians assessed them according to PANSS and CDS symptoms scales.

RESULTS

Cross-sectional analysis showed baseline self-report insight was positively related to neuroticism and agreeableness and negatively related to extraversion. Longitudinal analysis showed change in level of self-reported insight was predicted by baseline-insight and change in symptoms of disorganization. Personality factors did not predict insight change (as measured either by self-report or by clinician assessment).

DISCUSSION

The cross-sectional findings showed self-report insight (as opposed to clinician-rated) is associated with personality traits, suggesting negative affect is related to higher level of insight and that having insight may be influenced by the wish to comply with views of professionals, or a tendency to cover up problems. The longitudinal findings imply that not personality but change in severity of symptoms of disorganization, and possibly other variables, predicts change in insight.

The influence of temperament and character on functioning and aspects of psychological health among people with schizophrenia

Research findings that link personality factors to functioning and symptoms in schizophrenia are inconsistent, and further studies are needed within the area. The purpose of this study was to investigate how personality, as measured by the Temperament and Character Inventory (TCI), was related to demographic factors, subtypes of diagnoses, level of functioning, and aspects of psychological health, including sense of coherence, perceived control, and self-esteem, among people with schizophrenia. Subjects were 104 individuals, aged 20–55 years, in psychiatric outpatient care. The results indicated that personality was not related to subtypes of diagnoses or demographic characteristics of the respondents, but to level of functioning and all aspects of psychological health. Especially self-directedness distinguished three groups of functioning and was highly correlated with the different aspects of psychological health. The article discusses how knowledge of schizophrenic patients’ personality structure might be used for tailoring psychiatric treatments.

Insight and risk of suicidal behaviour in two first-episode psychosis cohorts: Effects of previous suicide attempts and depression

BACKGROUND

The role of insight dimensions - illness recognition (IR), symptoms relabelling (SR), treatment compliance (TC) - in suicide risk in first-episode psychosis (FEP) remains unclear.

METHOD

The AESOP (n = 181) and GAP (n = 112) FEP cohorts were followed-up over 10- and 5 years. Survival analysis modelled time to first suicidal event in relation to baseline scores on the Schedule for the Assessment of Insight, whilst adjusting for demographic, clinical, psychopathological and neuropsychological variables.

RESULTS

AESOP: those with previous suicide attempts scored higher on IR (7.6 ± 1.9 vs. 5.9 ± 3.0, p < 0.01) and total insight scores (TIS) (17.2 ± 5.0 vs. 13.4 ± 6.7, p = 0.03). IR (r = 0.23, p < 0.01), SR (r = 0.18, p = 0.04) and TC (r = 0.26, p < 0.01) correlated with depression. Univariable analyses: IR (HR = 1.14, 95% CI = 0.98-1.34, p = 0.09), TC (HR = 1.30, 95% CI = 0.99-1.71, p = 0.06) and TIS (HR = 1.06, 95% CI = 0.99-1.13, p = 0.08) were linked with suicidal behaviour. Multivariable regression models: depression (HR = 1.55, 95% CI = 1.22-1.97, p < 0.01) predicted suicidal behaviour. GAP: SR (6.4 ± 3.1 vs. 4.5 ± 3.4, p = 0.03) and TIS (16.8 ± 6.4 vs. 12.8 ± 7.4, p = 0.03) were higher in those with suicidal antecedents. IR (r = 0.32, p < 0.01) and SR (r = 0.27, p = 0.01) correlated with depression. Univariable analyses: TC (HR = 1.36, 95% CI = 1.01-1.83, p = 0.04) and TIS (HR = 1.06, 95% CI = 0.99-1.14, p = 0.08) were associated with suicidal behaviour. Multivariable regression models: previous suicide attempts (HR 5.17, 95% CI 1.32-20.29, p = 0.02) and depression (HR 1.16, 95% CI = 1.00-1.35, p = 0.04) predicted suicidal behaviour.

CONCLUSIONS

Suicide attempts prior to FEP and depression at that point were associated with baseline insight levels and predicted risk of suicidal behaviour over the follow-up, which was not linked with insight. This may explain the apparent association of insight with suicidality in FEP.

Genetic correlates of insight in schizophrenia

Insight in schizophrenia is clinically important as it is associated with several adverse outcomes. Genetic contributions to insight are unknown. We examined genetic contributions to insight by investigating if polygenic risk scores (PRS) and candidate regions were associated with insight.

METHOD

Schizophrenia case-only analysis of the Clinical Antipsychotics Trials of Intervention Effectiveness trial. Schizophrenia PRS was constructed using Psychiatric Genomics Consortium (PGC) leave-one out GWAS as discovery data set. For candidate regions, we selected 105 schizophrenia-associated autosomal loci and 11 schizophrenia-related oligodendrocyte genes. We used regressions to examine PRS associations and set-based testing for candidate analysis.

RESULTS

We examined data from 730 subjects. Best-fit PRS at p-threshold of 1e-07 was associated with total insight (R²=0.005, P=0.05, empirical P=0.054) and treatment insight (R²=0.005, P=0.048, empirical P=0.048). For models that controlled for neurocognition, PRS significantly predicted treatment insight but at higher p-thresholds (0.1 to 0.5) but did not survive correction. Patients with highest polygenic burden had 5.9 times increased risk for poor insight compared to patients with lowest burden. PRS explained 3.2% (P=0.002, empirical P=0.011) of variance in poor insight. Set-based analyses identified two variants associated with poor insight- rs320703, an intergenic variant (within-set P=6e-04, FDR P=0.046) and rs1479165 in SOX2-OT (within-set P=9e-04, FDR P=0.046).

CONCLUSION

To the best of our knowledge, this is the first study examining genetic basis of insight. We provide evidence for genetic contributions to impaired insight. Relevance of findings and necessity for replication are discussed.

Openness to experience shortens duration of untreated psychosis in Serbian clinical population

AIM

To determine duration of untreated psychosis (DUP) in patients with schizophrenia-spectrum disorders from Serbia and to analyse factors that potentially contribute to the treatment delay, with focus on personality traits.

METHODS

Fifty seven patients (males 54.4%; age = 29.9 ± 6.0 yrs; age at the illness onset = 24.9 ± 5.1 yrs; IQ = 93.5 ± 12.2) were included. The assessment consisted of Nottingham Onset Schedule (NOS), Premorbid Adjustment Scale (PAS) and NEO Personality Inventory (NEO-PI-R). We used Cox regression model to evaluate relationship between DUP and explanatory variables.

RESULTS

Based on the most restrictive definition, the length of DUP in our sample was 77.8 ± 120.6 weeks (MED = 25.0 weeks). DUP was negatively associated with openness to experience (B = -0.804, P = 0.024).

CONCLUSIONS

We report the first evidence of DUP in Serbia, emphasizing that the personality domains are likely to impact the use of mental health care in persons with psychosis.

Insight in Psychiatry and Neurology: State of the Art, and Hypotheses

In spite of the increasing number of studies on insight in psychiatry and also in neurology and psychology, its nature is still elusive. It encompasses at least three fundamental characteristics: the awareness of suffering from an illness, an understanding of the cause and source of this suffering, and an acknowledgment of the need for treatment. As such, insight is fundamental for patients' management, prognosis, and treatment. Not surprisingly, the majority of available data, which have been gathered on schizophrenia, show a relationship between low insight and poorer outcomes. For mood disorders, however, insight is associated with less positive results. For other psychiatric disorders, insight has rarely been investigated. In neurology, the impaired ability to recognize the presence of sensory, perceptual, motor, affective, or cognitive functioning-referred to as anosognosia-has been related to damage of specific brain regions. This article provides a comprehensive review of insight in different psychiatric and neurological disorders, with a special focus on brain areas and neurotransmitters that serve as the substrate for this complex phenomenon.

Personality domains, duration of untreated psychosis, functioning, and symptom severity in first-episode psychosis

OBJECTIVES

Early-course psychotic disorders have been extensively studied in terms of phenomenology, but little is known about the influence of personality traits on clinical features of first-episode psychosis. The aim of this study was to explore how the "big five" personality domains (neuroticism, extraversion, openness, agreeableness, and conscientiousness) are associated with treatment delay (duration of untreated psychosis, DUP), functioning, and positive and negative symptom severity.

METHODS

Data for these analyses were obtained from 104 participants enrolled from psychiatric inpatient units in Atlanta, Georgia, between August 2008 and March 2011. The NEO Five-Factor Inventory (NEO-FFI) was used to assess personality domains, and all other variables were measured in a standardized and rigorous manner using psychometrically sound instruments. Correlational analyses and multiple linear regressions were carried out to examine the strength of associations between variables of interest.

RESULTS

Findings indicated that except for openness, all of the other personality variables contributed to some extent to the variance in DUP. Conscientiousness was positively correlated with functioning. Agreeableness was independently negatively associated with positive symptom severity and extraversion was independently negatively correlated with negative symptom severity.

CONCLUSIONS

We report the first evidence suggesting that DUP is in part driven by personality domains. Functioning and symptom severity are also associated with those domains. Personality should be taken into account in order to better understand the phenomenology of early-course psychotic disorders as well as treatment-seeking behaviors.

Insight and suicidality in first-episode psychosis: understanding the influence of suicidal history on insight dimensions at first presentation

AIM

Lack of insight is a cardinal feature of psychosis with crucial implications for outcome. Concerns have been raised regarding a link between insight and suicidality. This study aimed to test the relationship between suicidal behaviour preceding first-episode psychosis (FEP) and insight dimensions at treatment onset.

METHODS

A total of 112 FEP inpatients were recruited. Suicidal events prior to admission were recorded. Insight was assessed multidimensionally with the Schedule for the Assessment of Insight - Expanded version shortly after admission. Suicidal and non-suicidal patients were compared regarding scores on 'total insight' and three insight domains: 'awareness of mental illness', 'relabeling of psychotic experiences as abnormal' and 'compliance'. This analysis was also adjusted for a set of sociodemographic, clinical, neurocognitive and psychopathological variables.

RESULTS

Bivariate analyses demonstrated a direct association between previous suicidality and all insight domains. However, these associations did not survive multivariable regression models, which demonstrated gender (female), shorter duration of untreated psychosis (DUP) and psychopathological symptoms - depression and disorganization - to mediate the influence of suicidal history on insight, and therefore to underlie the latter.

CONCLUSIONS

Insight dimensions in FEP patients are influenced by having suicidal antecedents through some mediating variables such as gender, DUP and depression. Further prospective studies are needed to clarify the potential implications of these findings on the management of insight in FEP. As suicidal history is associated with greater levels of both depression and insight at first presentation, these three variables might be useful in predicting further suicidal events.

Long-acting injectable formulations of new-generation antipsychotics: a review from a clinical perspective

Antipsychotics are the mainstay of the long-term treatment of patients with schizophrenia. In this context, the evidence also supports the effectiveness of long-acting injections (LAIs) or depots of antipsychotics regarding their relapse-preventing properties. When a LAI formulation of risperidone was launched as the first second-generation depot, there was a renaissance of interest in these formulations. In the meantime, olanzapine, paliperidone, and aripiprazole have been approved by regulatory authorities as LAIs in various countries. All studies using the new-generation depots have shown a clear advantage over placebo regarding relapse prevention and symptom reduction. Safety profiles of the long-acting compounds are comparable to their oral formulations with the exception of olanzapine pamoate injections, which can sometimes lead to a post-injection delirium. Despite the fact that many treatment guidelines recommend LAI antipsychotics as an important treatment option for the long-term management of schizophrenia, they are still most frequently used in chronically ill patients with considerable compliance problems. It is imperative to overcome this indication bias in order to be able to utilize all available treatment options in the long-term management of schizophrenia. There is little evidence on comparisons between LAIs and their oral mother compounds, and even less concerning effectiveness comparisons between different depots. The purpose of this manuscript is to review the recent clinical evidence on new-generation depot antipsychotics.

Can insight be predicted in first-episode psychosis patients? A longitudinal and hierarchical analysis of predictors in a drug-naïve sample

Poor insight is a ubiquitous phenomenon in psychosis with great repercussions on clinical practise and the outcomes of patients. Poor insight comprises "state" and "trait" components. This paper targeted predictors of global insight and insight dimensions at baseline in the drug-naïve status of first-episode psychosis patients and during a 6-month follow up after episode remission. Seventy-seven consecutive and previously unmedicated patients with first-episode schizophrenia-spectrum disorders (FESSD) completed baseline and 6-month insight, premorbid, symptomatological and neuropsychological assessments. Insight measures served as dependent variables for a set of hierarchical multiple regression models. Premorbid personality abnormalities and duration of untreated psychosis (DUP) significantly predicted 'state' and 'trait' insight global scores. Duration of untreated psychosis (DUP) significantly predicted 'state' insight, measured as refusal of treatment at baseline. Moreover, premorbid personality abnormalities and DUP with minor contributions of demographic variables, cognitive functioning and psychopathological dimensions predicted 'trait insight', defined as insight after remission of the psychosis episode 'Insight improver' FESSD patients showed better late adolescent premorbid adjustment, lower personality disturbances (sociopathic, schizoid and schizotypy dimensions), shorter DUP, and lower positive, negative and disorganisation symptoms and better cognitive performance on the Trail Making B test at the 6-month follow-up assessment. Premorbid personality abnormalities and DUP were predictors of 'state' and 'trait' insight, both at global scores and dimension levels. Moreover, insight improvement in patients with FESSD was related to premorbid abnormalities (in both adjustment and personality), shorter DUP, fewer positive and negative symptoms and better performance in cognitive tests at the 6-month follow up.

Subjective quality of life in patients with chronic schizophrenia: relationships between psychosocial and clinical characteristics

BACKGROUND

Using the theoretical framework of quality of life (QOL), many studies have demonstrated that the beliefs individuals hold about their QOL are important in predicting health outcomes. This study tested the Taiwanese version of the World Health Organization Quality of Life-Brief (WHOQOL-BREF) assessment in schizophrenia patients. The WHOQOL-BREF is a cross-cultural and widely used measure for assessing health-related QOL. This brief version of the questionnaire derived from the concepts included in the 100-item WHOQOL questionnaire was adapted for use in Taiwan.

METHODS

In the current cross-sectional study, 104 patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for schizophrenia or schizoaffective disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria were recruited and independently interviewed using the Taiwanese version of the WHOQOL-BREF. Patients were also examined using various other scales assessing insight, symptom severity, general psychopathology, and antipsychotic-induced side effects. In addition, we analyzed demographic data, clinical variables, and several self-rating scales as correlates of the Taiwanese version of the WHOQOL-BREF.

RESULTS

As predicted, age, onset of illness, insight measures, symptom severity, general psychopathology, and antipsychotic-induced side effects were all significantly related to the QOL scores. Multiple regression analyses revealed that depressive symptoms, antipsychotic-induced parkinsonism side effects, hopelessness, and age at illness onset were the 4 strongest predictors of subjective QOL in schizophrenia patients. These variables accounted for 39.2% of the total variance of this QOL model.

CONCLUSIONS

The results suggest that the WHOQOL-BREF is a promising model for mental assessing health problems in schizophrenia patients. Furthermore, the present findings highlight the importance of understanding the complex nature of the concept of QOL. Our study also supports the belief that different domains of QOL are likely to have different predictors.

Premorbid personality and insight in first-episode psychosis

BACKGROUND

Insight in psychosis and schizophrenia is considered a complex biopsychosocial phenomenon. Premorbid personality is regarded by some authors as part of the substrate to many psychiatric phenomena, but it is not clear if this applies to insight.

AIM

To examine longitudinal relationships between personality traits and insight dimensions in first-episode psychosis.

METHODS

One hundred consecutive antipsychotic-naïve first-episode nonaffective psychotic patients admitted to hospital were included in the study. Eighty-one patients completed at 1 month a premorbid personality evaluation, plus baseline, and 6-month insight assessments. We used the Assessment and Documentation of Psychopathology inventory for assessing insight dimensions (not feeling ill, lack of insight, and refusal of treatment) and the Personality Assessment Schedule for ascertaining 5 dimensions of premorbid personality (schizoid, passive-dependent, anancastic, sociopathic, and schizotypy).

RESULTS

At baseline, personality dimensions did not show any association with insight dimensions, with the exception of schizotypy traits. At 6 months, schizoid and sociopathic personality showed a significant association with not feeling ill (r = .30, P ≤ .007; r = .27, P = .01) and lack of insight (r = .36, P = .001; r = .41, P < .001), respectively. When we calculated insight change, schizoid and sociopathic personality had moderate correlation with the lack of insight dimension (r = -.34, P = .002; r = .38, P < .001, respectively). After applying partial correlations for potential confounders and Bonferroni correction, the associations remained significant. Moreover, using a regression model, sociopathic and schizoid personality significantly predicted lack of insight at 6 months and change from baseline to the 6 months assessment.

CONCLUSIONS

Sociopathic and schizoid personality dimensions were not only significantly associated with lack of insight at 6 months but also predicted change on lack of insight over 6 months. Therefore, exploring premorbid personality traits at the beginning of a psychotic episode may be helpful in identifying patients at high risk for lack of insight during the initial course of the illness.

Insight: demographic differences and associations with one-year outcome in schizophrenia and schizoaffective disorder

BACKGROUND

Insight is increasingly seen as an important variable for study in psychotic illness, particularly in relation to treatment adherence. This study aims to quantify the association of insight with outcome, sociodemographic variables and diagnosis in a large stable patient sample.

METHOD

Data are from a one-year, open-label, international, multicenter trial (n=670) of long-acting risperidone in adult symptomatically stable patients with schizophrenia or schizoaffective disorder. Psychopathology and insight were quantified using the Positive and Negative Syndrome Scale (PANSS). Patients were assessed at four time points over the year of the study.

RESULTS

31.2% of the sample showed clinically significant deficits in insight at baseline. There were no differences based on sex, but significant differences in age and diagnosis, with oldest patients and schizophrenia patients (cf., schizoaffective disorder) showing more deficits. Baseline insight impairment was correlated with change in PANSS score at one year (r=-0.243, p<0.001). Recursive partitioning showed that, of those whose symptoms improved, those whose insight also improved were more likely to complete the trial.

CONCLUSIONS

Insight is important above and beyond the effects of symptoms for predicting continuation in drug trials. This may have implications for the design and analysis of such trials, as well as suggesting the importance of targeting insight in treatment to increase likelihood of adherence to treatment. There also appear to be small but significant differences in insight based on age and diagnosis within the schizophrenia spectrum.

Insight, quality of life, and functional capacity in middle-aged and older adults with schizophrenia

OBJECTIVE

The quality of life (QOL) for individuals with schizophrenia is determined by a number of factors, not limited to symptomatology. The current study examined lack of insight as one such factor that may influence subjective QOL or functional capacity. It was hypothesized that insight would significantly interact with symptom severity to influence subjective QOL. Insight was not expected to influence the relation between symptom severity and functional capacity.

METHODS

Participants were middle-aged and older outpatients who met diagnostic criteria for schizophrenia or schizoaffective disorder, and subsyndromal depression. Insight, psychopathology, and subjective QOL were assessed via semi-structured interviews and functional capacity was assessed via performance-based measures.

RESULTS

Insight interacts with negative symptom severity to predict subjective QOL. Severity of negative symptoms and insight contribute directly to functional capacity.

CONCLUSIONS

Individuals with intact insight may be better able to manage their symptoms, resulting in improved QOL. Treatment implications for improving the QOL of middle age and older adults with schizophrenia are discussed.

Exploratory study of the association between insight and Theory of Mind (ToM) in stable schizophrenia patients

BACKGROUND

Poor insight and impairment in Theory of Mind (ToM) reasoning are common in schizophrenia, predicting poorer clinical and functional outcomes. The present study aimed to explore the relationship between these phenomena.

METHODS

61 individuals with a DSM-IV diagnosis of schizophrenia during a stable phase were included. ToM was assessed using a picture sequencing task developed by Langdon and Coltheart (1999), and insight with the Scale to Assess Unawareness of Mental Disorder (SUMD; Amador et al., 1993). Multivariate linear regression analysis was carried out to estimate the predictive value of insight on ToM, taking into account several possible confounders and interaction variables.

RESULTS

No direct significant associations were found between any of the insight dimensions and ToM using bivariate analysis. However, a significant linear regression model which explained 48% of the variance in ToM was revealed in the multivariate analysis. This included the 5 insight dimensions and 3 interaction variables. Misattribution of symptoms--in aware patients with age at onset >20 years--and unawareness of need for medication--in patients with GAF >60--were significantly predictive of better ToM.

CONCLUSION

Insight and ToM are two complex and distinct phenomena in schizophrenia. Relationships between them are mediated by psychosocial, clinical, and neurocognitive variables. Intact ToM may be a prerequisite for aware patients to attribute their symptoms to causes other than mental illness, which could in turn be associated with denial of need for medication.

Personality characteristics and attachment in first episode psychosis: impact on social functioning

Research has suggested those with chronic schizophrenia are impaired in social functioning, and that those early in the illness also exhibit these impairments. However, the factors underlying and contributing to social dysfunction have not yet been well delineated, particularly within a first episode sample. The current study sought to investigate the role of attachment style and personality characteristics in the social dysfunction of those diagnosed with a first episode of psychosis. Ninety-six participants experiencing a first episode of psychosis were compared with control participants from 2 different samples on attachment and personality variables. Results suggested that those with a first episode of psychosis may experience more problematic attachment in peer relationships compared with nonclinical controls, and that the type and amount of differences observed may vary by gender. In addition, those experiencing a first episode of psychosis report different levels of the "big five" personality traits when compared with nonclinical controls. Finally, within the first episode sample, both personality and attachment appear to contribute variance to 3 domains of social functioning: social and individual living skills, inappropriate community behavior, and quality of life. These findings have implications for the functional significance of these psychological constructs.

Predicting domain-specific insight of schizophrenia patients from symptomatology, multiple neurocognitive functions, and personality related traits

This study examines the contribution of various neurocognitive functions, clinical characteristics, and personality traits to the prediction of three insight dimensions. Clinically stable schizophrenia patients (n=107) residing in the community were evaluated using the Positive and Negative Syndrome Scale, the Scale for the Assessment of Unawareness of Mental Disorder, and a comprehensive battery of instruments to measure personality related variables and neurocognitive functioning. Step-wise multivariate regression analysis indicates significant association of variability in insight dimensions with neurocognitive functioning (20-41%), personality related traits (8-18% temperament factors, 4-7% self-constructs, 10-14% coping styles), severity of symptoms (about 7%), illness duration (6%), and education (about 5%). Poor insight was attributed to impairment in visual and movement skills, sustained attention, executive functions, intensity of autistic preoccupations and positive symptoms, as well as increased novelty seeking behavior, task and emotion oriented coping styles, better self-esteem, self-efficacy, and higher education. Better awareness was related to better performance of neurocognitive tasks, reward dependence behavior, avoidant coping style, and longer illness duration. Aside from common indicators for the various insight dimensions, we defined specific indicators for each insight dimension. Thus, insight dimensions in schizophrenia patients residing in the community were attributed to neurocognitive and personality related factors rather than to psychopathological symptoms. The findings enable better understanding of the multifactorial nature of insight and highlight targets for more effective intervention and rehabilitation.

The association of insight with psychotic symptoms, depression, and cognition in early psychosis: a 3-year follow-up

Recent research has begun to examine the level of insight following a first episode of psychosis since this may have implications for outcome. Insight was investigated in 278 individuals consecutively admitted to a comprehensive early psychosis treatment program. Insight, symptoms and cognition were assessed on admission and after one, two and three years. Sixty percent had good insight at baseline and this improved significantly to 80% at one year. Insight remained good at years 2 and 3 with 78.6% and 82.8%, respectively, having good insight. A comparison of those with good to those with poor insight revealed that at each assessment point those with poor insight had significantly higher ratings on positive, negative and general psychopathology symptoms (all at p<0.001). Additionally those with good insight had significantly higher levels of depression at baseline (p=0.001). With respect to cognition when using a composite cognitive factor there was a significant advantage for the good insight group at one year (p=0.01). Overall results show that a significant proportion of individuals have good insight following a first episode of psychosis. For this group depression may be a significant concern at least upon initial presentation. Those with poor insight have increased symptoms throughout the first three years and possibly poorer cognitive functioning.

Determinants of functioning and well-being among individuals with schizophrenia: an integrated model

Outcomes for health conditions are typically the result of multiple factors; however, studies tend to focus on a narrow class of variables. Functioning and well-being outcomes for schizophrenia are diverse and have resisted simple explanation; however, prior research has not offered an integrated understanding of the relative contributions of enduring and episodic environmental factors, personal resources and psychiatric factors, and cognitive appraisal and coping, on functioning and well-being outcomes in schizophrenia. The present article sets out an integrated model of the determinants of functioning and well-being among individuals with schizophrenia. To examine evidence that bears on the model, literature on hypothesized relationships is reviewed to identify areas for which there is strong evidence and areas where more research is needed. The article suggests areas for further research, and directs researchers and practitioners toward areas of intervention that can enhance functioning and well-being for persons diagnosed with schizophrenia.

Mourning, insight, and reduction of suicide risk in schizophrenia

Literature on the assessment of suicide risk in individuals with schizophrenia is summarized, including the risk factors shared in common with the general population, illness-specific risk factors, and times of heightened risk in the course of the illness. Because depression emerges as a significant risk factor, it is differentiated from conditions that can mimic depression: mourning, aprosodia, and negative symptoms. Because insight or awareness of illness carries risk, as does the lack of insight, the psychological and neurocognitive components of impaired and of accurate insight are described. Finally, the role of mourning in the attainment of accurate, usable insight that can reduce suicidal risk is described.

Correlates of coping styles in psychotic illness

BACKGROUND

Both integration and sealing over have been identified as global, clinically distinct coping styles with the psychotic illness and integration was found to be associated with a better outcome. We studied a series of potential correlates of these coping styles.

SAMPLING AND METHODS

A total of 75 psychiatric patients in a recovery phase after a psychotic episode were studied. All patients filled out the Frankfurt Self-Concept Inventory and the Parental Bonding Instrument; the Integration/Sealing over Scale and the Positive and Negative Syndrome Scale were completed by an investigator for all patients during a semistructured interview. Besides, some sociodemographic and clinical data were collected.

RESULTS

A relationship was found between the integrative coping style and absence of negative symptoms, housing with partner or alone indicating more social competence and a diagnosis of psychotic illness other than (paranoid) schizophrenia.

CONCLUSIONS

As only 25% of the variance were explained, other--still unknown--factors are also of importance.

Insight in early psychosis: a 1-year follow-up

Insight was investigated in 180 individuals consecutively admitted to a comprehensive early psychosis treatment program. Insight was assessed on admission and after 3, 6 and 12 months. Insight improved significantly over 12 months, and was negatively correlated with both positive and negative symptoms, and positively correlated with depressive symptoms at admission. There were no associations with cognition.

Rehabilitative residential treatment in patients with severe mental disorders: personality features associated with short-term outcome

The aims of this study were to evaluate the outcome of inpatients with severe psychiatric disorders after 6 months of multimodal residential treatment. Ninety-one subjects admitted to residential prolonged treatment at an Italian rehabilitative complex were included in the study. Within 6 months, the program of treatment was effective in reducing symptoms and improving the patients' psychosocial functioning. The study of personality can be useful to "dose" symptomatic (pharmacological and psychotherapeutic) and rehabilitative treatments in the therapy program.

Baseline personality functioning correlates with 6 month outcome in schizophrenia

OBJECTIVE

The assessment of outcome in schizophrenic patients should consider both the response to treatment and the recovery of social skills. The aim was to evaluate the outcome and related psychostructural and clinical factors in schizophrenic patients after they underwent 6 months of residential multimodal treatment.

METHOD

Fifty-two schizophrenic patients enrolled in a multimodal treatment program were included in the study. Symptomatology and social functioning were assessed with the Brief Psychiatric Rating Scale (BPRS) and the Social and Occupational Functioning Assessment Scale (SOFAS). The Karolinska Psychodynamic Profile (KAPP) was used for the psychostructural evaluation.

RESULTS

After 6 months there was a significant improvement in the global scores of BPRS, SOFAS, and some areas of KAPP. The personality (KAPP) and social-occupational functioning (SOFAS) at baseline (T0) correlated with the global score of BPRS at 6 months (T6); moreover, SOFAS at T6 correlated with BPRS and KAPP at T0 and with the illness duration.

CONCLUSION

The better the personality functioning in schizophrenic patients the better seems to be the response to treatment, with regard to symptoms as well as rehabilitation. Personality assessment might be useful for the individualisation of therapies, even within the context of a standardised program.

Insight in schizophrenia: a meta-analysis

There has been an increase in the study of insight in schizophrenia in the last 20 years. Insight is operationally defined according to five dimensions which include: the patient's awareness of mental disorder, awareness of the social consequences of disorder, awareness of the need for treatment, awareness of symptoms and attribution of symptoms to disorder. Despite the development of psychometrically sound measurement tools, the results from previous studies have been inconclusive regarding the nature of the relationship between insight and symptomatology. A meta-analysis of 40 published English-language studies was conducted to determine the magnitude and direction of the relationship, or effect size, between insight and symptom domains in schizophrenia and to determine moderator variables that were associated with the variations in effect sizes across studies. Results indicated that there was a small negative relationship between insight and global, positive and negative symptoms. There was also a small positive relationship between insight and depressive symptoms in schizophrenia. Acute patient status and mean age of onset of the disorder moderated the relationship between insight and symptom clusters. The possible reasons for the effect sizes being modest, the examination of the role of moderator variables and directions for future research are provided.

Insight, global neuropsychological functioning, and symptomatology in chronic schizophrenia

It is proposed that poor insight in schizophrenia may be explained by neuropsychological dysfunction and linked to the negative syndrome, which in turn may be related to structural neurological impairment. This study tested the hypothesis that poor insight is related to global neuropsychological impairment and negative symptoms in 89 patients with chronic schizophrenia. No significant association was found between total insight and cognitive impairment. When the dimensions of insight-treatment compliance, awareness of illness, and symptom attribution-were analyzed separately, symptom misattribution was modestly correlated with frontal impairment. However, in subsequent multiple regression analyses, cognitive impairment failed to be a significant predictor of this or any other dimension of insight. Symptoms, particularly positive ones, accounted for approximately one quarter of the variance in symptom misattribution and the total insight score. These results suggest that neuropsychological functioning cannot account for the variance in insight, and that only one quarter of the variance in symptom misattribution can be explained by symptomatology. Future research could also address the role of psychosocial factors in modulating the expression of insight.

Reappraising insight in psychosis. Multi-scale longitudinal study

BACKGROUND

Many patients suffering from psychosis are unaware of their disorder and symptoms.

AIMS

To investigate whether insight changes with time, and how it relates to patients' psychopathology, and to examine the correlations between insight scales in patients with psychoses.

METHODS

Seventy-five consecutively admitted in-patients with schizophrenia, affective disorder with psychotic symptoms, or schizoaffective disorder were examined after remission of an acute episode and at follow-up (> 6 months). Three different scales were used to assess insight.

RESULTS

To some extent, insight into past episodes improved over time in patients with psychosis, regardless of diagnosis. Few significant relationships between insight and psychopathology remained stable at follow-up. The higher the negative and disorganisation dimensions at baseline, the less did attitudes to treatment vary when tested at follow-up. No predictive value for variability of psychopathological dimensions was found for insight dimensions. The insight scales used were highly intercorrelated, suggesting that they measure the same construct.

CONCLUSIONS

Insight and psychopathology seem to be semi-independent domains.