Académique Documents
Professionnel Documents
Culture Documents
Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres
a r t i c l e i n f o a b s t r a c t
Article history: Despite the general agreement that insight is a multidimensional phenomenon, the studies on the
Received 14 November 2011 factorial structure of the scales for its assessment have yielded rather inconsistent results. The present
Received in revised form study aimed to assess the internal structure of the Schedule for the Assessment of Insight (SAI-E).
17 August 2012
Seventy-two chronic patients with schizophrenia were assessed with SAI-E. Hierarchical cluster
Accepted 12 February 2013
analysis and multidimensional scaling (MDS) were used to identify insight components and assess
their inter-relationships. The associations of the extracted components with demographic, clinical and
Keywords: cognitive characteristics were also examined. The SAI-E demonstrated good psychometric properties.
Unawareness of illness Three subscales of SAI-E were identied measuring awareness of illness, relabeling of symptoms, and
Psychosis
treatment compliance. Moreover, the MDS disclosed two underlying dimensions degree of specicity
Treatment compliance
and spontaneity within the insight construct. Treatment compliance was more strongly correlated
Psychopathology
Cognition with symptom relabeling than illness awareness. Excitement symptoms, global functioning and general
intelligence were correlated with all the components of insight. Depressive symptoms were more
strongly correlated with illness awareness. Impaired relabeling ability was linked to cognitive rigidity
and greater severity of disorganization and positive symptoms. Education and severity of negative
symptoms specically affect treatment compliance. Our results support the hypothesis that insight is a
multidimensional construct.
& 2013 Elsevier Ireland Ltd. All rights reserved.
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.psychres.2013.02.016
G. Konstantakopoulos et al. / Psychiatry Research 209 (2013) 346352 347
assessments were performed by the same physician rater (D.P.) with the exception individual item scores ranged from 0.76 to 0.92 and for the total
of SAI-E which was independently administered by another clinician (G.K.). The
score was 0.90. The Cronbachs alpha was 0.91 indicating a high
neuropsychological tests were administered to each participant within one week
after the clinical assessment. To assess interrater reliability, the 20 initial inter- level of internal consistency. The individual item testretest ICCs
views conducted by the rst author (G.K.) were audiotaped and independently ranged from 0.79 to 0.91 and for the total score was 0.88
rated by three other authors (P.O., A.S., and S.N.). The SAI-E was readministered to indicating high testretest reliability of the SAI-E. The insight
one half of the participants by the same interviewer one week later in order to item of the PANSS was strongly correlated with SAI-E total score
evaluate testretest reliability.
(r 0.72, p o0.001).
Table 2
Internal consistency, interrater and testretest reliability of SAI-E.
SAI-E Items Mean (S.D.) Corrected Itemtotal correlation Alpha if item deleted Interrater ICC Testretest ICC
0 5 10 15 20 25
+---------+---------+---------+---------+---------+
Fig. 1. Hierarchical cluster analysis: Wards method dendrogram which depicts the SAI-E items in 72 patients with schizophrenia. Horizontal distance reects the level of
dissimilarity between items.
4
excitement and all SAI-E subscales. Emotional distress and
2 7 depression were signicantly correlated with higher levels of
0.0
3 both awareness of illness and relabeling of symptoms. All insight
9 components were signicantly correlated with better psychoso-
5 cial functioning, as measured with GAF. The level of general
-0.5 Relabelling
6 of symptoms 10 intelligence, as measured with the vocabulary subscale of WAIS,
was associated with higher score in all SAI-E subscales. A positive
-1.0 correlation was observed between performance on WCST (cate-
Induced
Table 3
Correlations between insight dimensions and demographic, clinical or cognitive characteristics.
SAI-E
r p r p r p r p
PANSS, Positive and Negative Syndrome Scale; CDSS, Calgary Depression Scale for Schizophrenia; GAF, Global Assessment of Functioning; WAIS, Wechsler Adult
Intelligence Scale; WCST, Wisconsin Card Sorting Test.
items on treatment compliance, acceptance of and spontaneous reviewed by David (2004). This divergence might be attributed to
request for treatment. the differences between the present sample and the samples of
The MDS made apparent two underlying dimensions within previous studies, since our sample was the only one consisted of
the insight construct. The rst dimension lies on a continuum of exclusively chronic voluntary outpatients. The close link between
insight from mere awareness of illness via relabeling of symptoms compliance and relabeling in our sample was additionally con-
to treatment compliance. Thus, this dimension may be inter- rmed on the basis of dissimilarities through HCA and MDS. More
preted as a continuous transition from more generic to more precisely, the treatment compliance cluster was found closer to
specic insight. The second dimension disclosed by MDS may be the symptom relabeling than to the illness awareness cluster on
considered to represent a degree of spontaneity of insight. the generic/specic dimension of MDS. In turn, this dimension
Spontaneous request for treatment along with patients aware- offers an explanation for the stronger association of treatment
ness of psychological changes and relabeling ability lie closer to compliance with symptom relabeling than with illness awareness
the spontaneous pole of this dimension, whereas acceptance of in our sample.
proposed treatment along with awareness of clinician-explained Positive and negative symptoms associated exclusively with
need for treatment and awareness of psychosocial consequences lower symptom relabeling and treatment compliance, respec-
of the illness lie closer to the induced insight pole. This may tively, while the disorganized symptoms were associated with
reect the fact that patients attitude towards illness and medica- both of these insight components as well as overall insight.
tion is only partially inuenced by the doctorpatient relationship A meta-analysis of relevant studies concluded that there was
and the therapeutic interactions in general. Consistent with this a weak but signicant negative relationship between insight (and
notion, recent studies identied distinct groups of patients with most of its dimensions) and both negative and positive symptoms
schizophrenia differing in the subjective adherence attitude in schizophrenia (Mintz et al., 2003). However, these associations
prole (Santone et al., 2008; Beck et al., 2011). Furthermore, the seemed to be moderated by the acute vs. chronic illness distinc-
two poles of the spontaneity dimension remind us of the active tion (David, 2004). Moreover, it has been suggested that more
and the passive attitudes towards the illness and the diagnosis specic symptoms might bear stronger relationships with insight
delineated in another study (Roe et al., 2008). More precisely, our than broad symptoms categories (Cooke et al., 2005). Conversely,
distinction between spontaneous and induced insight bears our ndings suggest that broad symptom categories, namely
some similarities to the distinction between integrative insight positive and negative syndrome, might bear stronger associations
and passive insight of illness and label proles of this study. with specic dimensions of insight. The strong association
The components we found have quite similar composition between cognitive and behavioral disorganization and insight
with the factors of SAI-E found in previous studies (David et al., found in our study conrms previous ndings in both chronic
2003; Dantas and Banzato, 2007a). However, in the factor- (Lincoln et al., 2007) and rst episode (Ayesa-Arriola et al., 2011)
structure found by David et al. (2003) the item awareness of patients with psychosis and it might indicate a central role of
the need for treatment was related to the treatment compliance cognition in insight impairment. On the other hand, the strong
factor whereas in the study by Dantas and Banzato (2007a) and negative association between insight and excitement, which was
the present study this item was found related to the awareness of also found in previous studies (Vaz et al., 2002; Sevy et al., 2004;
illness component. This may be due to the differences in the study Buchy et al., 2009), along with the strong positive association of
samples, since the former used a sample of rst episode psychosis insight with depressive and anxiety symptoms (Mintz et al.,
patients while the latter two used samples consisting of chronic 2003), suggest that affective or motivational factors also underlie
patients. The correlation coefcients between the components of denial of illness and symptoms (Cooke et al., 2005; Cooke et al.,
insight found in the present study were higher than those 2007). The association found between insight and psychosocial
reported by David et al. (2003). Moreover, treatment compliance functioning is consistent with the ndings of the majority of
was correlated more strongly with relabeling than illness aware- previous cross-sectional studies (Lincoln et al., 2007), also indi-
ness, contrary to the ndings of previous studies using SAI-E cating that all the components of insight have a signicant impact
G. Konstantakopoulos et al. / Psychiatry Research 209 (2013) 346352 351
on functioning. A strength of the current study is the assessment Aleman, A., Agrawal, N., Morgan, K.D., David, A.S., 2006. Insight in psychosis and
of insight independently of psychopathology and cognition, hence neuropsychological function: meta-analysis. British Journal of Psychiatry 189,
204212.
minimizing contamination and bias. Amador, X.F., Strauss, D.H., Yale, S.A., Flaum, M.M., Endicott, J., Gorman, J.M., 1993.
Our ndings on correlates of insight are in agreement, at least Assessment of insight in psychosis. American Journal of Psychiatry 150,
to some extent, with those from previous studies that used factor- 873879.
American Psychiatric Association, 2000. Diagnostic and Statistical Manual of
analytically conrmed components of the SAI-E. In the study of Mental Disorders, 4th ed. American Psychiatric Publishing, Inc., Washington,
Dantas and Banzato (2007b) positive history of major depressive DC, Text revision.
episode was associated with relabeling of symptoms, treatment Ayesa-Arriola, R., Rodriguez-Sanchez, J.M., Morelli, C., Pelayo-Teran, J.M., Perez-
Iglesias, R., Mata, I., Martinez-Garcia, O., Pardo-Garcia, G., Vazquez-Barquero,
compliance and overall insight, while suicide risk was associated J.L., Crespo-Facorro, B., 2011. Insight dimensions in rst-episode psychosis
with illness awareness. We found a positive association between patients: clinical, cognitive, pre-morbid and socio-demographic correlates.
current depressive symptoms with overall insight and its compo- Early Intervention in Psychiatry 5, 140149.
Bazire, S., 2005. Psychotropic Drug Directory. Fivepin Limited, Wiltshire.
nents with the exception of treatment compliance. The correla-
Beck, E.M., Cavelti, M., Wirtz, M., Kossowsky, J., Vauth, R., 2011. How do socio-
tion between treatment compliance and years of education demographic and clinical factors interact with adherence attitude proles in
observed in the present study was not found by Dantas and schizophrenia? A cluster-analytical approach. Psychiatry Research 187, 5561.
Banzato (2007b). However, an association between medication Birchwood, M., Smith, J., Drury, V., Healy, J., Macmillan, F., Slade, M., 1994. A self-
report Insight Scale for psychosis: reliability, validity and sensitivity to change.
non-adherence and low educational level was reported in recent Acta Psychiatrica Scandinavica 89, 6267.
naturalistic studies (Dassa et al., 2010; Segarra et al., 2012). Borg, I., Groenen, P.J.F., 1997. Modern Multidimensional Scaling: Theory and
Morgan et al. (2010) found that lower performance-IQ was Applications. Springer Verlag, New York.
Brett-Jones, J., Garety, P., Hemsley, D., 1987. Measuring delusional experiences: a
linked to insight impairment and specically poor relabeling method and its application. British Journal of Clinical Psychology 26 (Pt 4),
ability in rst episode psychosis. In the present study, the general 257265.
intellectual ability was associated with all the components of Buchy, L., Torres, I.J., Liddle, P.F., Woodward, T.S., 2009. Symptomatic determinants
of insight in schizophrenia spectrum disorders. Comprehensive Psychiatry 50,
insight, however more strongly with relabeling. Moreover, decits 578583.
in mental exibility as estimated by WCST-perseverative errors Chang, J.S., Ahn, Y.M., Yu, H.Y., Park, H.J., Lee, K.Y., Kim, S.H., Kim, Y.S., 2009.
score was specically associated with lower relabeling of symp- Exploring clinical characteristics of bipolar depression: internal structure of
the bipolar depression rating scale. Australian and New Zealand Journal of
toms. This nding supports the notion that the identication of Psychiatry 43, 830837.
psychotic symptoms as pathological is the aspect of insight more Cooke, M., Peters, E., Fannon, D., Anilkumar, A.P., Aasen, I., Kuipers, E., Kumari, V.,
closely connected to cognitive functions (Morgan and David, 2007. Insight, distress and coping styles in schizophrenia. Schizophrenia
Research 94, 1222.
2004) and especially mental exibility (Laroi et al., 2000).
Cooke, M.A., Peters, E.R., Kuipers, E., Kumari, V., 2005. Disease, decit or denial?
Overall, the present study found that insight components were Models of poor insight in psychosis. Acta Psychiatrica Scandinavica 112, 417.
strongly associated with different aspects of the illness and thus Crumlish, N., Whitty, P., Kamali, M., Clarke, M., Browne, S., McTigue, O., Lane, A.,
justies their separate delineation. Illness awareness was more Kinsella, A., Larkin, C., O0 Callaghan, E., 2005. Early insight predicts depression
and attempted suicide after 4 years in rst-episode schizophrenia and
strongly correlated with depression. Impaired relabeling ability schizophreniform disorder. Acta Psychiatrica Scandinavica 112, 449455.
was linked to cognitive rigidity and greater severity of positive Dantas, C.R., Banzato, C.E., 2007a. Inter-rater reliability and factor analysis of the
and disorganized symptoms. Treatment compliance was strongly Brazilian version of the Schedule for the Assessment of Insight-Expanded
Version (SAI-E). Revista Brasileira de Psiquiatria 29, 359362.
associated with higher educational level and less severe negative Dantas, C.R., Banzato, C.E., 2007b. Predictors of insight in psychotic inpatients.
symptoms. Schizophrenia Research 91, 263265.
Study limitations include the exclusively chronic patient- Dassa, D., Boyer, L., Benoit, M., Bourcet, S., Raymondet, P., Bottai, T., 2010. Factors
associated with medication non-adherence in patients suffering from schizo-
composition of our sample and the narrow area of cognitive phrenia: a cross-sectional study in a universal coverage health-care system.
functions assessed. Thus, further research is needed on the Australian and New Zealand Journal of Psychiatry 44, 921928.
components of insight and their correlates in the acute phases David, A., Buchanan, A., Reed, A., Almeida, O., 1992. The assessment of insight in
psychosis. British Journal of Psychiatry 161, 599602.
of the illness. Moreover, further investigation of possible associa-
David, A., van Os, J., Jones, P., Harvey, I., Foerster, A., Fahy, T., 1995. Insight and
tions between insight components and a broad area of cognitive psychotic illness. Cross-sectional and longitudinal associations. British Journal
decits in patients with chronic schizophrenia is warranted. of Psychiatry 167, 621628.
David, A.S., 1990. Insight and psychosis. British Journal of Psychiatry 156, 798808.
Our results support the hypothesis that insight is a multi-
David, A.S., 2004. The clinical importance of insight: an overview. In: Amador, X.F.,
dimensional construct. The three distinct but interrelated com- David, A.S. (Eds.), Insight and Psychosis. Oxford University Press, Oxford,
ponents of insight identied in chronic schizophrenia appear to pp. 359392.
be differentially associated with clinical and cognitive aspects of David, A.S., Morgan, K.D., Maller, R., Leff, J., Murray, R.M., 2003. Insight: unitary or
multi-dimensional phenomenon? Schizophrenia Research 60, 14.
the disorder. Future research focusing on the components of Donohoe, G., Donnell, C.O., Owens, N., O0 Callaghan, E., 2004. Evidence that health
insight might offer evidence crucial in developing new therapeu- attributions and symptom severity predict insight in schizophrenia. Journal of
tic interventions to improve insight at different stages of Nervous and Mental Disease 192, 635637.
Drake, R.J., Lewis, S.W., 2003. Insight and neurocognition in schizophrenia.
schizophrenia. Schizophrenia Research 62, 165173.
Endicott, J., Spitzer, R.L., Fleiss, J.L., Cohen, J., 1976. The global assessment scale. A
procedure for measuring overall severity of psychiatric disturbance. Archives
of General Psychiatry 33, 766771.
Acknowledgments Erickson, M., Jaafari, N., Lysaker, P., 2011. Insight and negative symptoms as
predictors of functioning in a work setting in patients with schizophrenia.
Psychiatry Research 189, 161165.
We thank the clinicians and the nursing staff at the Byron- Everitt, B.S., 1993. Cluster Analysis. Edward Arnold, London.
Kessariani Community Mental Health Centre for their assistance First, M., Spitzer, R., Gibbon, M., Williams, J., 1997. Structured Clinical Interview for
DSM-IV Axis I Disorders, Research Version, Patient Edition. New York State
with participant recruitment, as well as the participants
Psychiatric Institute, Biometrics Research, New York.
themselves. Groth-Marant, G., 1999. Handbook of Psychological Assessment, 3rd ed. J. Wiley,
New York.
Hasson-Ohayon, I., Kravetz, S., Roe, D., David, A.S., Weiser, M., 2006. Insight into
psychosis and quality of life. Comprehensive Psychiatry 47, 265269.
References
Kay, S.R., Fiszbein, A., Opler, L.A., 1987. The positive and negative syndrome scale
(PANSS) for schizophrenia. Schizophrenia Bulletin 13, 261276.
Addington, D., Addington, J., Maticka-Tyndale, E., Joyce, J., 1992. Reliability and Kemmler, G., Holzner, B., Kopp, M., Dunser, M., Greil, R., Hahn, E., Sperner-
validity of a depression rating scale for schizophrenics. Schizophrenia Unterweger, B., 2002. Multidimensional scaling as a tool for analysing quality
Research 6, 201208. of life data. Quality of Life Research 11, 223233.
352 G. Konstantakopoulos et al. / Psychiatry Research 209 (2013) 346352
Kemp, R., David, A., 1997. Insight and compliance. In: Blackwell, B. (Ed.), Santone, G., Rucci, P., Muratori, M.L., Monaci, A., Ciarafoni, C., Borsetti, G., 2008.
Treatment Compliance and the Therapeutic Alliance, pp. 6184. Attitudes toward medication in inpatients with schizophrenia: a cluster
Kongs, S.K., Thompson, L.L., Iverson, G.L., Heaton, R.K., 2000. Wisconsin Card analytic approach. Psychiatry Research 158, 324334.
Sorting Test-64 card version: Professional Manual. Psychological Assessment Sanz, M., Constable, G., Lopez-Ibor, I., Kemp, R., David, A.S., 1998. A comparative
Resources, Odessa, FL. study of insight scales and their relationship to psychopathological and
Kruskal, J.P., Wish, M., 1978. Multidimensional Scaling. Sage, Newbury Park, CA. clinical variables. Psychological Medicine 28, 437446.
Laroi, F., Fannemel, M., Ronneberg, U., Flekkoy, K., Opjordsmoen, S., Dullerud, R., Segarra, R., Ojeda, N., Pena, J., Garcia, J., Rodriguez-Morales, A., Ruiz, I., Hidalgo, R.,
Haakonsen, M., 2000. Unawareness of illness in chronic schizophrenia and its Buron, J.A., Eguiluz, J.I., Gutierrez, M., 2012. Longitudinal changes of insight in
relationship to structural brain measures and neuropsychological tests. rst episode psychosis and its relation to clinical symptoms, treatment
Psychiatry Research 100, 4958. adherence and global functioning: one-year follow-up from the Eiffel study.
Lincoln, T.M., Lullmann, E., Rief, W., 2007. Correlates and long-term consequences European Psychiatry 27, 4349.
of poor insight in patients with schizophrenia. A systematic review. Schizo- Sevy, S., Nathanson, K., Visweswaraiah, H., Amador, X., 2004. The relationship
phrenia Bulletin 33, 13241342. between insight and symptoms in schizophrenia. Comprehensive Psychiatry
Lysaker, P.H., Roe, D., Yanos, P.T., 2007. Toward understanding the insight paradox: 45, 1619.
internalized stigma moderates the association between insight and social Simon, A.E., Berger, G.E., Giacomini, V., Ferrero, F., Mohr, S., 2006. Insight,
functioning, hope, and self-esteem among people with schizophrenia spec-
symptoms and executive functions in schizophrenia. Cognitive Neuropsychia-
trum disorders. Schizophrenia Bulletin 33, 192199.
try 11, 437451.
McEvoy, J.P., Apperson, L.J., Appelbaum, P.S., Ortlip, P., Brecosky, J., Hammill, K.,
Tranulis, C., Lepage, M., Malla, A., 2008. Insight in rst episode psychosis: who is
Geller, J.L., Roth, L., 1989. Insight in schizophrenia. Its relationship to acute
measuring what? Early Intervention in Psychiatry 2, 3441.
psychopathology. Journal of Nervous and Mental Disease 177, 4347.
Trauer, T., Sacks, T., 2000. The relationship between insight and medication
Mintz, A.R., Dobson, K.S., Romney, D.M., 2003. Insight in schizophrenia: a meta-
adherence in severely mentally ill clients treated in the community. Acta
analysis. Schizophrenia Research 61, 7588.
Moore, O., Cassidy, E., Carr, A., O0 Callaghan, E., 1999. Unawareness of illness and its Psychiatrica Scandinavica 102, 211216.
relationship with depression and self-deception in schizophrenia. European van der Gaag, M., Hoffman, T., Remijsen, M., Hijman, R., de Haan, L., van Meijel, B.,
Psychiatry 14, 264269. van Harten, P.N., Valmaggia, L., de Hert, M., Cuijpers, A., Wiersma, D., 2006. The
Morgan, K.D., David, A.S., 2004. Neuropsychological studies of insight in patients ve-factor model of the Positive and Negative Syndrome Scale II: a ten-fold
with psychotic disorders. In: Amador, X.F., David, A.S. (Eds.), Insight and cross-validation of a revised model. Schizophrenia Research 85, 280287.
Psychosis. Oxford University Press, Oxford, pp. 177193. Vaz, F.J., Bejar, A., Casado, M., 2002. Insight, psychopathology, and interpersonal
Morgan, K.D., Dazzan, P., Morgan, C., Lappin, J., Hutchinson, G., Suckling, J., Fearon, relationships in schizophrenia. Schizophrenia Bulletin 28, 311317.
P., Jones, P.B., Leff, J., Murray, R.M., David, A.S., 2010. Insight, grey matter and Wechsler, D., 1981. Wechsler Adult Intelligence ScaleRevised. Psychological
cognitive function in rst-onset psychosis. British of Journal of Psychiatry 197, Corporation, New York.
141148. Weiler, M.A., Fleisher, M.H., McArthur-Campbell, D., 2000. Insight and symptom
Quee, P.J., van der Meer, L., Bruggeman, R., de Haan, L., Krabbendam, L., Cahn, W., change in schizophrenia and other disorders. Schizophrenia Research 45,
Mulder, N.C., Wiersma, D., Aleman, A., 2011. Insight in psychosis: relationship 2936.
with neurocognition, social cognition and clinical symptoms depends on Wong, S.S., Lee, S., Wat, K.H., 1999. A preliminary communication of an insight
phase of illness. Schizophrenia Bulletin 37, 2937. scale in the assessment of lithium non-adherence among Chinese patients in
Roe, D., Hasson-Ohayon, I., Kravetz, S., Yanos, P.T., Lysaker, P.H., 2008. Call it a Hong Kong. Journal of Affective Disorders 55, 241244.
monster for lack of anything else: narrative insight in psychosis. Journal of Woods, S.W., 2003. Chlorpromazine equivalent doses for the newer atypical
Nervous and Mental Disease 196, 859865. antipsychotics. Journal of Clinical Psychiatry 64, 663667.