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Psychiatry Research 209 (2013) 346352

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Is insight in schizophrenia multidimensional? Internal structure and


associations of the Greek version of the Schedule for the Assessment
of InsightExpanded
George Konstantakopoulos a,b,n, Dimitris Ploumpidis a, Panagiotis Oulis a,
Aggeliki Soumani a, Stavrina Nikitopoulou a, Konstantina Pappa a,
George N. Papadimitriou a, Anthony S. David b
a
Athens University Medical School, First Department of Psychiatry, Greece
b
Kings College, London, Institute of Psychiatry, Section of Cognitive Neuropsychiatry, UK

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.

1. Introduction suggest that patients with schizophrenia might be motivated to


deny their illness in order to maintain an optimistic outlook or
Lack of insight is a core feature of schizophrenia, which has been preserve their self-esteem. Thus, denial of illness as a defensive style
linked to severity of psychopathology (Mintz et al., 2003), poor or coping strategy might contribute to poor insight (Moore et al.,
social functioning (Lincoln et al., 2007; Erickson et al., 2011), poor 1999; Donohoe et al., 2004; Cooke et al., 2007).
treatment outcome (David et al., 1995; David, 2004), medication There is now a general agreement that insight is not an all-or-
non-adherence (Kemp and David, 1997; Dassa et al., 2010) and more none neither a unidimensional phenomenon based on illness
rehospitalizations (Lincoln et al., 2007). While mechanisms under- acceptance alone, but rather a multidimensional one (David,
lying insight impairment are still unknown, it has been found to be 1990). Indeed, several different components of the insight con-
associated with cognitive decits, especially lower IQ and executive struct have been proposed. David (1990), for example, suggested
dysfunction (Morgan and David, 2004; Aleman et al., 2006). On the that insight consists of three distinct but partially overlapping
other hand, the positive associations between insight and depres- dimensions, namely the ability to recognize that one has a mental
sion (Mintz et al., 2003) and suicidality (Crumlish et al., 2005), illness, compliance with treatment, and the capacity to relabel
possibly moderated by internalized stigma (Lysaker et al., 2007), unusual mental events as pathological. Others have also sug-
gested the specic attribution of ones symptoms to having a
mental illness (Amador et al., 1993) or the awareness of the
n
Corresponding author at: Athens University Medical School, First Department benets of taking the medication (McEvoy et al., 1989; Amador
of Psychiatry, Eginition Hospital, Vas. Soas av. 72-74, 11528 Athens, Greece.
Tel: 30 210764011; fax: 30 2107662829.
et al., 1993) as distinct major components of insight.
E-mail addresses: gekonst@otenet.gr, Based on these hypotheses, many multidimensional scales for
george.konstantakopoulos@kcl.ac.uk (G. Konstantakopoulos). the assessment of insight in psychosis have been developed.

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

Among them, the Insight and Treatment Attitudes Questionnaire Table 1


(ITAQ) (McEvoy et al., 1989), the Schedule for the Assessment of Demographic and clinical characteristics of patients with schizo-
phrenia (n 72).
Insight (SAI) (David, 1990) and its expanded version (SAI-E)
(Kemp and David, 1997), the Scale to Assess Unawareness of Mean (S.D.)
Mental Disorder (SUMD) (Amador et al., 1993), and the Birch-
wood self-report Insight Scale (IS) (Birchwood et al., 1994) are the Age (yr) 42.2 (8.8)
most well-known and widely used. Strong correlations between Education (yr) 10.9 (2.9)
Duration of illness (yr) 17.2 (9.2)
the total scores of these scales have been found (Sanz et al., 1998;
Drake and Lewis, 2003) indicating that they measure the same PANSS
Positive 21.7 (6.6)
construct. On the other hand, the vast majority of previous studies
Negative 25.9 (6.5)
on insight considered a priori that the hypothesized dimensions Disorganization 23.8 (7.2)
were represented by specic items of the scales, since the Excitement 18.0 (5.2)
evidence on their internal structure is relatively scarce and the Emotional distress 18.4 (6.7)
relevant ndings are rather inconsistent. The number of under- Total Score 78.5 (15.4)
CDSS 5.4 (3.7)
lying dimensions remains controversial and the internal consis- GAF 49.6 (10.2)
tency and validity of the subscales designed for the dimensional Antipsychotic daily dosage (mg)a 493 (229)
assessment largely unexplored raising doubts on the adequacy of Benzodiazepine daily dosage (mg)b 4.4 (9.1)
the proposed dimensions. For example, the factor analysis initi- Medication, n (%)
ally performed for ITAQ and a more recent study had yielded one Atypical antipsychotics 54 (75)
single factor (McEvoy et al., 1989; Weiler et al., 2000), whereas Typical antipsychotics 33 (45.8)
another analysis revealed two factors (medical help seeking and Anticholinergic agents 25 (34.7)
Antidepressants 22 (30.5)
perception of illness) (Wong et al., 1999). Similarly, the factor Benzodiazepines 17 (23.6)
analysis for SAI gave a single-factor solution (David et al., 1992),
whereas two studies on SAI-E (David et al., 2003; Dantas and PANSS, Positive and Negative Syndrome Scale; CDSS, Calgary
Banzato, 2007a) yielded three factors corresponding to the major Depression Scale for Schizophrenia; GAF, Global Assessment of
Functioning.
components of insight proposed by David (1990). Furthermore, a
Chlorpromazine equivalents.
one single factor was extracted by the exploratory (Birchwood b
Diazepam equivalents.
et al., 1994) but three factors were detected by the conrmatory
factor analysis of the self-report IS (Trauer and Sacks, 2000).
Factor analyses of SUMD (Hasson-Ohayon et al., 2006; Simon (see Table 1). Antipsychotic and benzodiazepine medication dosage was converted
into chlorpromazine and diazepam equivalents, respectively (Woods, 2003;
et al., 2006) and of both SAI-E and IS items (Cooke et al., 2007)
Bazire, 2005).
also gave three-factor solutions and found that the items measur-
ing symptom attribution mostly load on the awareness of illness
factor, which is the most frequently emerging insight dimension 2.2. Measures

along with awareness of symptoms.


The Greek version of SAI-E (available on request) was administered to all
Methodological reasons, such as the differences between the
participants. Translation was rened through translation and back translation
studies in the sample-size or patients diagnosis, might account between the rst author and the scales originator. SAI-E (Kemp and David, 1997)
for the inconsistent ndings. Moreover, because of the high item- is the expanded version of SAI, a semi-structured interview measuring the three
intercorrelations of the scales (David et al., 1992; Lincoln et al., major components of insight proposed by David (1990) in psychosis. SAI-E
2007), factor analysis, which is based on correlations, might not assesses multiple aspects of insight, including: (1) awareness of psychological
changes, (2) awareness of having a nervous condition, (3) recognition of mental
be the best method to assess the internal structure of these scales.
illness, (4) patients explanation of his/her mental condition, (5) awareness of the
The aim of the present study was to assess the internal psychosocial consequences of the illness, (6) awareness of the need for treatment,
structure of the SAI-E, which is one of the most comprehensive (7) awareness of symptoms, (8) ability to relabel symptoms as pathological, (9) a
measures of insight in psychosis. Statistical techniques based on supplementary hypothetical contradiction item which evaluates patients capa-
city to take into account another persons perspective (Brett-Jones et al., 1987),
dissimilarities were used for the rst time instead of factor
(10) acceptance of treatment (including passive acceptance), and (11) sponta-
analysis in order to optimize the detection of insight components neous request for treatment. Items 16, 10, and 11 are rated from 0 to 2, while
and their inter-relationships. Moreover, we examined the asso- items 79 are rated from 0 to 4, with higher scores indicating better insight. All
ciations of the extracted components with demographic, clinical the items are summed to reach a total score, ranging from 0 to 28. The scale has
and cognitive correlates of insight found in previous studies. proven validity and reliability in patients with psychosis (Sanz et al., 1998;
Morgan et al., 2010).
Symptoms of schizophrenia were rated using the Positive and Negative
Syndrome Scale (PANSS) (Kay et al., 1987). We scored the PANSS across ve
2. Methods
subscales corresponding to the following symptomdimensions: positive, nega-
tive, disorganization, excitement, and emotional distress (van der Gaag et al.,
2.1. Participants 2006), excluding the insight item of the scale (general scale item 12). Depressive
symptoms were separately assessed with the Calgary Depression Scale for
Since multiple clinical and cognitive factors might affect differentially insight Schizophrenia (CDSS) (Addington et al., 1992). The Global Assessment of Function-
into psychosis across phases of the illness (Tranulis et al., 2008; Quee et al., 2011), ing (GAF) scale was used as a measure of patients level of functioning (Endicott
we focused our investigation on a sample composed exclusively of patients with et al., 1976).
chronic schizophrenia. Seventy-two patients (42 male and 30 female) were The Vocabulary subscale of the Wechsler Adult Intelligence ScaleRevised
recruited from the outpatient services of the Byron-Kessariani Community Mental (WAIS-vocabulary) (Wechsler, 1981) was used to estimate general intelligence
Health Centre based on the following criteria: (a) diagnosis of schizophrenia (Groth-Marant, 1999). Executive functioning was assessed with the Wisconsin
according to the DSM-IV-TR criteria (American Psychiatric Association, 2000) and Card Sorting Test 64-version (WCST) (number of categories completed and
(b) duration of illness of at least 3 yr. Exclusion criteria for participation in the number of perseverative errors) (Kongs et al., 2000).
study were mental retardation, personal or family history of any neurological
disorder, history of head injury, alcohol or substance abuse in the preceding
6 months. Diagnosis of schizophrenia was conrmed using the Structured Clinical 2.3. Procedures
Interview for DSM-IV Axis I Disorders (First et al., 1997). Basic demographic
and clinical data were obtained from the participants medical records. All the The local Ethical Committee approved the research protocol and patients
patients were taking an antipsychotic medication at the time of assessment provided written consent for their participation in the study. All clinical
348 G. Konstantakopoulos et al. / Psychiatry Research 209 (2013) 346352

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).

2.4. Statistical analysis


3.2. Internal structure of SAI-E
Intraclass correlations (ICCs) were used to evaluate interrater and testretest
reliability of the SAI-E and Pearsons product moment coefcient r was used to
determine inter-item correlations and correlations between each item and the
The HCA solution is displayed in Fig. 1. The elbow criterion
total score minus that item. Cronbachs alpha was estimated in order to examine suggested that the optimal number of clusters was three. The rst
the internal consistency of the scale and its subscales. The concurrent validity was cluster included SAI-E items on awareness of psychological
examined through the Pearsons r values between SAI-E total score and the score changes, awareness of having a nervous condition, recognition
on the PANSS general scale item 12.
of illness, explanation of the mental condition, awareness of the
We used hierarchical cluster analysis (HCA) and multidimensional scaling
(MDS) to assess the internal structure of the SAI-E. HCA and MDS can produce psychosocial consequences and the need for treatment. The
heuristic illustrations of the relationships between diverse items giving useful second one included items on awareness and relabeling of
information unattainable through the statistical techniques based on correlations, symptoms, hypothetical contradiction, whereas the two treat-
such as factor analysis (Kemmler et al., 2002; Chang et al., 2009). ment compliance items clustered together.
The aim of HCA was to clarify the non-overlapping cluster structure of the SAI-
The internal structure of the SAI-E, as determined on the MDS
E. Therefore, Wards method was used, which is designed to optimize the
minimum variance within clusters, and is advantageous in the conditions of map, is shown in Fig. 2. The solution of the MDS procedure turned
cluster overlap over other clustering techniques. The optimal number of clusters out to be two-dimensional. The normalized raw stress was 0.025 and
was determined according to the elbow criterion in the percentage of variance the Tuckers j was 0.987, indicating the solution identied was
explained by the clusters, plotting the agglomeration coefcient against the
robust. Partitioning the MDS space according to the rst dimension
number of clusters (Everitt, 1993).
MDS analysis was also used to examine the potential components of insight (dimension 1) was consistent with the results of HCA, since the three
and their interrelationships. MDS converts the degree of dissimilarity between clusters were clearly identied on the MDS map. The location of the
two items into the geometric distance between two points in a space of a given items along the second axis (dimension 2) offers additional informa-
number of dimensions (Kruskal and Wish, 1978), which we shall refer to as an tion on the cluster properties. Awareness of need for treatment is
MDS map. MDS solutions can provide the most parsimonious model with the
placed at a large distance of all the other items of the Awareness of
least possible dimensions. The location of the items on the MDS map can be used
for the detection of clusters of items or individual items (Kemmler et al., 2002). illness cluster. It is also obvious that the level of dispersion within
Moreover, the dimensions of the MDS map might reect features of the construct Treatment compliance is higher compared to the other two clusters.
under study that underlie the structure of the scale. We used the MDS proximity Finally, the two dimensions revealed are amenable to interpretation.
scaling (PROXSCAL) procedure and the Euclidean distance as a measure of
The rst dimension reects the degree of specic insight: from the
(dis)similarities. In order to select the optimal number of dimensions, the
normalized raw stress was used as a badness-of-t measure and the Tuckers j
generic awareness of illness to the more specic relabeling of
coefcient of congruence as a goodness-of-t measure (Borg and Groenen, 1997). symptoms and treatment compliance. The second dimension could
The SAI-E item scores were entered in both HCA and MDS after z transformation. be considered as representing the degree of spontaneity of insight.
Pearsons coefcients r were computed in order to assess strength of associa- The longer distances along this dimension are between more
tions between insight overall and extracted components and other variables.
clinician-related aspects of insight (acceptance of treatment, aware-
The alpha level was set at 0.05. Statistical analyses were performed using SPSS
version 15.0. ness of need for treatment, awareness of psychosocial consequences)
and more spontaneous ones (spontaneous request for treatment,
relabeling of symptoms, awareness of psychological changes).
3. Results According to the results of HCA and MDS, in the following
analysis we used three subscales of SAI-E: Awareness of illness
3.1. SAI-E reliability and validity (items 16), Relabeling of symptoms (items 79), and Treatment
compliance (items 1011). The Cronbachs alpha for the rst two
Table 1 shows the demographic and clinical characteristics of subscales was 0.92 and 0.89, respectively, indicating a high level
the sample. The mean SAI-E total score was 18.06 (S.D. 7.52, of internal consistency. Although the alpha coefcient for Treat-
range 428). Table 2 shows the results of reliability analysis of ment compliance subscale was lower (0.61), the internal consis-
SAI-E. The interrater reliability was good as the ICCs for the tency of this subscale is acceptable, since it consists of only two

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

1. Awareness of psychological changes 1.47 (0.74) 0.75 0.90 0.89 0.88


2. Awareness of nervous condition 1.74 (0.56) 0.67 0.90 0.91 0.82
3. Recognition of illness 1.50 (0.66) 0.77 0.90 0.90 0.89
4. Explanation of mental condition 1.24 (0.85) 0.88 0.89 0.76 0.87
5. Awareness of consequences 1.21 (0.76) 0.63 0.90 0.78 0.86
6. Awareness of need for treatment 1.68 (0.53) 0.66 0.90 0.92 0.90
7. Awareness of symptoms 2.44 (1.44) 0.86 0.89 0.81 0.84
8. Relabeling of symptoms 1.41 (1.38) 0.77 0.89 0.88 0.79
9. Hypothetical contradiction 2.44 (1.43) 0.76 0.90 0.91 0.89
10. Acceptance of treatment 1.65 (0.54) 0.35 0.91 0.85 0.86
11. Request for treatment 1.29 (0.75) 0.53 0.91 0.83 0.91

ICC, intraclass correlations.


G. Konstantakopoulos et al. / Psychiatry Research 209 (2013) 346352 349

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.

age, duration of illness, and antipsychotic medication dosage,


owing to the sample homogeneity in these respects. A signicant
1.5
Spontaneous

positive correlation was found between the educational level and


Treatment
compliance treatment compliance. Positive symptoms were associated only
1.0 11 with lower level of symptom relabeling, negative symptoms only
Awareness
with lower level of treatment compliance, whereas disorganiza-
of illness tion was negatively associated with both relabeling and compli-
0.5
1 8 ance. Strong negative correlations were found between
Dimension 2

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

gories and perseverative errors scores) and relabeling of symp-


toms, as well as between WCST categories score and awareness of
-1.5 illness. SAI-E total score was inversely related to disorganization
-1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 and excitement, and positively to emotional distress, depression,
Dimension 1 psychosocial functioning, WAIS-vocabulary and WCST-categories.
Generic Specific

Fig. 2. Two-dimensional plot from multidimensional scaling analysis of SAI-E 4. Discussion


items in 72 patients with schizophrenia. The circles are drawn to indicate groups
of items according to the clusters revealed by HCA. SAI-E items: (1) awareness of
psychological changes, (2) awareness of nervous condition, (3) recognition of
Our ndings conrm that the SAI-E has good interrater
mental illness, (4) explanation of mental condition, (5) awareness of the psycho- reliability as has been already reported by previous studies
social consequences, (6) awareness of need for treatment, (7) awareness of (Dantas and Banzato, 2007a; Morgan et al., 2010). We also
symptoms, (8) relabeling of symptoms, (9) hypothetical contradiction, (10) examined for the rst time the internal consistency and the
acceptance of treatment and (11) request for treatment.
testretest reliability of SAI-E and found that both of them were
very good. Moreover, the high correlation of total SAI-E score with
items. The strongest correlation was observed between Aware- independent ratings of insight supports the validity of the scale.
ness of illness and Relabeling of symptoms (r 0.74, p o0.001). Using HCA and MDS we detected clusters of SAI-E in accordance
Treatment compliance was more strongly correlated with Rela- with the major components of insight proposed by David (1990).
beling of symptoms (r 0.61, p o0.001) than Awareness of The items on awareness of psychological changes, psychosocial
illness (r 0.34, p 0.003). consequences of the illness, and need for treatment incorporated
into the awareness of illness component. Although awareness of
3.3. Associations between insight dimensions and demographic, need for treatment showed a higher degree of dissimilarity than
clinical and cognitive characteristics the other items of this cluster, it cannot be considered as a separate
component of insight. The ability to take into account the views of
Table 3 shows correlations of SAI-E subscale and total scores the others as estimated with the hypothetical contradiction item
with demographic, clinical, and neuropsychological variables. No was linked to the ability to relabel the symptoms as pathological.
signicant correlation was found between SAI-E subscales and Interestingly, there was a relatively weak link between the two
350 G. Konstantakopoulos et al. / Psychiatry Research 209 (2013) 346352

Table 3
Correlations between insight dimensions and demographic, clinical or cognitive characteristics.

SAI-E

Awareness of illness Relabeling of symptoms Treatment Compliance Total score

r p r p r p r p

Age  0.15 0.208  0.11 0.358  0.03 0.802  0.15 0.208


Education 0.20 0.092 0.09 0.452 0.37 0.001 0.21 0.077
Duration of illness  0.07 0.559  0.20 0.087  0.18 0.123  0.19 0.106
Antipsychotic daily dosage 0.18 0.128  0.11 0.358 0.07 0.559 0.03 0.802
PANSS-Positive  0.03 0.777  0.25 0.036  0.04 0.714  0.12 0.299
PANSS-Negative  0.00 0.933  0.15 0.208  0.35 0.002  0.13 0.288
PANSS-Disorganization  0.21 0.083  0.43 o 0.001  0.31 0.008  0.36 0.002
PANSS-Excitement  0.42 o 0.001  0.57 o 0.001  0.33 0.004  0.54 o 0.001
PANSS-Emotional distress 0.41 o 0.001 0.23 0.048 0.02 0.868 0.28 0.016
CDSS 0.47 o 0.001 0.26 0.025  0.04 0.714 0.35 0.003
GAF 0.31 0.007 0.46 o 0.001 0.42 o 0.001 0.44 o 0.001
WAIS-vocabulary 0.29 0.014 0.39 0.001 0.30 0.009 0.37 0.001
WCST-categories 0.34 0.003 0.35 0.002 0.23 0.052 0.36 0.002
WCST-perseverative errors  0.08 0.493  0.29 0.013  0.05 0.677  0.19 0.104

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

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to some extent, with those from previous studies that used factor- 873879.
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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
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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.
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