Psychiatry Research 243 (2016) 268277

Contents lists available at ScienceDirect

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

Insight and gender in schizophrenia and other psychoses

Jesus Cobo a,b,c,n, Lourdes Nieto c,d, Susana Ochoa c,e, Esther Pousa a,h, Judith Usall c,e,
Iris Baos e, Beatriz Gonzlez f, Isabel Ruiz g, Insight Barcelona Research Group1,
Ada I. Ruiz c,h,i
a
Mental Health Department, Corporaci Sanitria Parc Taul, Hospital Universitari UAB Sabadell, Barcelona, Catalonia, Spain
b
Department of Psychiatry and Forensic Medicine. Universitat Autnoma de Barcelona Bellaterra, Barcelona, Catalonia, Spain
c
Research Workgroup on Womens Mental Health, Catalan Society of Psychiatry & Mental Health Barcelona, Catalonia, Spain
d
Department of Research, Instituto Nacional de Psiquiatra Ramn de la Fuente Muiz, Ciudad de Mxico, Mexico
e
Research and Development Unit, Parc Sanitari San Joan de Du - CIBERSAM Sant Boi de Llobregat, Barcelona, Catalonia, Spain
f
Mental Health Department, Hospital Benito Menni Sant Boi de Llobregat, Barcelona, Catalonia, Spain
g
Department of Health and Clinical Psychology - Research Unit. Universitat Autnoma de Barcelona Bellaterra, Barcelona, Catalonia, Spain
h
Institut de Neuropsiquiatria i Addiccions, Hospital del Mar Barcelona, Catalonia, Spain
i
IMIM - Hospital del Mar Medical Research Institut Barcelona, Catalonia, Spain

art ic l e i nf o a b s t r a c t

Article history: This study aimed to evaluate gender differences in the decit of insight in psychosis and determine
Received 25 February 2015 inuences of clinical, functional, and sociodemographic variables. A multicenter sample of 401 adult
Received in revised form patients with schizophrenia and other psychotic disorders who agreed to participate was evaluated in
30 December 2015
four centers of the metropolitan area of Barcelona (Catalonia). Psychopathological assessment was per-
Accepted 25 April 2016
Available online 16 June 2016
formed using the Positive and Negative Syndrome Scale Lindenmayers Factors. Insight and its dimen-
sions were assessed by means of the Scale of Unawareness of Mental Disorder. Signicant differences
Keywords: were apparent neither between men and women in the three dimensions of insight, nor in the total
Schizophrenia awareness, nor in the total attribution subscales. However, statistically signicant differences were found
Psychosis
in awareness and attribution of particular symptoms. Women showed a worse awareness of thought
Gender
disorder and alogia and a higher misattribution of apathy. Higher cognitive and positive symptoms, early
Awareness
Psychopathology stage of the illness, and having been married explained decits of insight dimensions in women. In men,
Functionality other variables such as lower functioning, higher age, other psychosis diagnosis, and, to a lower extent,
Attribution higher scores in cognitive, positive, and excitative symptoms, explained decits of insight dimensions.
These data could help to design gender-specic preventive and therapeutic strategies.
& 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction antipsychotic medication (Drake et al., 2015; Sendt et al., 2015;

Novick et al., 2015). In addition, lack of insight has been found to
Lack of insight is a common feature in psychosis (Amador et al., be predictive of higher relapse rates, increased number of in-
1991). Their negative effects have been related to a generally poor voluntary hospital admissions, substance misuse, diminished
prognosis of schizophrenia, predisposing to non-adherence with psychosocial function, and a poorer course of illness (Amador and

n
Correspondence to: Salut Mental, Corporaci Sanitria i Universitria Parc Taul, Parc Taul, 1, 08208 Sabadell Barcelona, Catalonia, Spain.
E-mail address: jcobo@tauli.cat (J. Cobo).
1
Insight Barcelona Research Group: Mara Alberto (Mental Health Department, Hospital Mutua de Terrassa, Terrassa, Barcelona, Catalonia), Iris Baos (Research and
Development Unit, Parc Sanitari San Joan de Du - CIBERSAM, Sant Boi de Llobregat, Barcelona, Catalonia), Jess Cobo (Mental Health Department. Corporaci Sanitria Parc
Taul, Hospital Universitari UAB, Sabadell, Barcelona, Catalonia), Carles Garca-Ribera (Mental Health Department, Hospital Sant Pau, Barcelona, Catalonia), Beatriz Gonzlez
(Mental Health Department, Hospital Benito Menni, Sant Boi de Llobregat, Barcelona, Catalonia), Carmina Massons (Mental Health Department. Corporaci Sanitria Parc
Taul, Hospital Universitari UAB, Sabadell, Barcelona, Catalonia), Ferran Molins (Institut de Neuropsiquiatria i Addiccions, Centre Emili Mira, Parc de Salut Mar, Barcelona,
Catalonia), Lourdes Nieto (Department of Research; Instituto Nacional de Psiquiatra Ramn de la Fuente Muiz, Mxico D.F., Mexico), Susana Ochoa (Research and De-
velopment Unit, Parc Sanitari San Joan de Du - CIBERSAM, Sant Boi de Llobregat, Barcelona, Catalonia), Esther Pousa (Mental Health Department. Corporaci Sanitria Parc
Taul, Hospital Universitari UAB, Sabadell, Barcelona., Catalonia), Ada-Inmaculada Ruiz (Institut de Neuropsiquiatria i Addiccions. Parc de Salut Mar, Barcelona, Catalonia),
Isabel Ruiz (Department of Psychiatry and Forensic Medicine. Universitat Autnoma de Barcelona, Bellaterra, Barcelona, Catalonia), Judith Usall (Research and Development
Unit, Parc Sanitari San Joan de Du - CIBERSAM, Sant Boi de Llobregat, Barcelona, Catalonia).

http://dx.doi.org/10.1016/j.psychres.2016.04.089
0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved.
 J. Cobo et al. / Psychiatry Research 243 (2016) 268277
David, 2004; Lincoln et al., 2007; Mohamed et al., 2009; Quee
et al., 2011; Wiffen et al., 2012; Ekinci and Ekinci, 2013). On the
other hand, there is also a small positive relationship between
clinical insight (Mintz et al., 2003) and cognitive insight (Palmer
et al., 2015) and depressive symptoms in schizophrenia. In addi-
tion, there is a debate suggesting that insight may represent a risk
factor for suicide in patients with schizophrenia (Lpez-Morigo
et al., 2012; Lpez-Morigo et al., 2014).
Insight is a multidimensional phenomenon that includes
awareness of having a mental disease, of the effects of medication,
of the social consequences of the disease, of specic signs and
symptoms, and attribution of symptoms to the disorder (Amador
et al., 1994; Amador and David, 2004; David et al., 2012). Aware-
ness of symptoms is the ability to recognize that a particular ex-
perience is strange or unusual, whereas the attribution of symp-
toms requires the capacity to interpret this experience as a
symptom related to the disease (Amador and David, 2004).
Great efforts have been made in order to understand the me-
chanisms of action of this complex phenomenon. Several studies
have examined the relationship between insight and positive,
negative, and global psychotic symptoms, as well as depression
(David et al., 1992; Amador et al., 1994; Kemp et al., 1995; Collins
et al., 1997; Kim et al., 1997; Mohamed et al., 1999; Moore et al.,
1999). A statistically signicant weak negative relationship has
been consistently reported between insight and positive, negative,
and global psychotic symptoms. With regard to depressive
symptoms, there seems to be a positive relationship with insight
(Mintz et al., 2003). Lack of insight, moreover, has been related
with neuropsychological impairment, metacognition, and Theory
of Mind (Aleman et al., 2006; Pousa et al., 2008). The relationship
with sociodemographic variables is controversial (Amador et al.,
1994; Ayesa-Arriola et al., 2011; Wiffen et al., 2012).
Schizophrenia and rst-episode psychosis are disorders with
considerable heterogeneity in several of its basic features. There is
great variability in clinical presentation, disease course and re-
sponse to both pharmacological and psychosocial treatment. Some
aspects of this heterogeneity may be gender related and gender
differences have been studied extensively in recent decades. Al-
though there are denite ndings, much uncertainty remains
about the extent of the differences (Riecher-Rssler et al., 1994;
Riecher-Rssler and Hfner, 2000; Abel et al., 2010; Ochoa et al.,
2011). The incidence of schizophrenia is higher in men, and most
studies also nd an earlier age of onset in men. In relation to
possible gender differences in clinical symptoms, it has been
suggested that men suffer more negative symptoms. In contrast,
women suffer more affective symptoms. Premorbid functioning
and outcome social functioning seem to be better in women.
Moreover, women have better remission and lower relapse rates
(Ochoa et al., 2011). Gender differences in cognitive functioning in
psychosis remain an issue, with lack of consensus in the gender-
related neuropsychological prole (Moriarty et al., 2001; Ochoa
et al., 2011; Ayesa-Arriola et al., 2014; Rodriguez-Jimenez et al.,
2015; Hui et al., 2014; Ittig et al., 2015).
Little is known about the role of gender in the decit of insight
in psychosis. A careful review of the previous literature was carried
out and there was a lack of studies specically devoted to the is-
sue. However, there were some previous studies that included
gender aspects of insight as collateral results or examined the role
of gender as a secondary analysis. All these dispersed data are next
reviewed. In the original article of Amador et al. (1994), insight
(assessed with the abbreviated version of the Scale to Assess Un-
awareness of Mental Disorders, SUMD) was unrelated to gender,
age, or educational level. Moriarty et al. (2001) did not nd dif-
ferences in item G12 (lack of judgment/insight) of the Positive and
Negative Syndrome Scale (PANSS). McEvoy et al. (2006) pro-
spectively studied young patients with a rst episode of psychosis
269
using the Insight and Treatment Attitudes Questionnaire, and
showed a better insight into the psychotic illness for women. In
the prospective study of Parellada et al. (2011), insight was eval-
uated in rst episode early-onset schizophrenia and other psy-
chosis using the SUMD: women correctly attributed psychotic
symptoms to the disorder, whereas men attributed symptoms to
other causes. Using the extended version of SUMD, Pru et al.
(2012) reported that both stigma and gender were strong pre-
dictors of insight, with a better insight in women. However, Par-
ellada et al. (2009), Ayesa-Arriola et al. (2011), also using the
SUMD, did not observe gender differences in rst episode psy-
chosis. Mutsatsa et al. (2006) using the Schedule for the Assess-
ment of Insight did not nd signicant gender differences in in-
sight in rst episode psychosis. Wiffen et al. (2012), using the
Schedule for the Assessment of Insight-Expanded version, found
no evidence of signicant gender differences in adult symptoma-
tically stable psychotic patients. These contradictory ndings may
be related to differences in the study populations as well as the
use of different instruments to assess insight and other related
variables. In addition, previous studies have tended to use rela-
tively small sample sizes and have studied gender differences in
global insight measures or dimensions. There is a lack of studies
focused on insight into specic psychotic symptoms.
Therefore, this study was designed with two objectives: a) to
assess gender differences in the decit of insight in patients with
schizophrenia and other psychosis, considering both general in-
sight dimensions as well as insight into specic symptoms; and b)
to assess the differential effect of clinical, sociodemographic, and
functional variables in the decit of insight in men and women.
Some outcome variables such as better remission and lower
relapse rates, a better social function, and a clinical prole with a
greater weight of affective symptoms (Ochoa et al., 2011) suggest
that women with a psychotic disorder may present a greater
awareness of the disorder than men. Exploring gender differences
on insight in a multidimensional way could offer a better under-
standing of the process, especially about the complexity of the
interaction between biologic and sociodemographic and cultural
aspects. In addition, therapeutic approaches could benet from the
results of the analysis.
Thus, the relationship between insight and gender in psychosis
remains unclear, although a better understanding of the impact of
gender on this crucial aspect of the disease may be of value to
target more effective interventions. On this basis, we established
the hypotheses that men and women will show differences in the
three main awareness dimensions of psychosis, and also that men
and women will exhibit differences related to insight, in particular
psychotic symptoms and their attribution. In addition, we hy-
pothesize that the variables that explain decit in awareness
would differ according to gender.
2. Methods
This was a cross-sectional multicenter study of patients with
schizophrenia and other psychotic disorders, attended between
2006 and 2011 in daily clinical practice, aimed at exploring the
descriptive characteristics of insight in a large sample of patients
at different stages of the illness and in different clinical settings in
the area of Barcelona.
2.1. Participants
The study sample included 401 patients with schizophrenia
and other psychotic disorders attended in four Mental Health
Departments of the metropolitan Area of Barcelona (Catalonia),
which constituted the Insight Barcelona Research Group (Institute
270 J. Cobo et al. / Psychiatry Research 243 (2016) 268277

Table 1.
Sociodemographic and clinical data of the sample (N 401).

Women (n 131) Men (n 270)

X SD Median X SD Median t p

Age (years) 36.9 14.5 36.8 35.0 12.1 34.1 1.428 0.135
Age at onset 24.5 9.3 21.7 21.4 6.1 20.0 4.027 o 0.001
Evolution of psychiatric disease (years) 13.1 13.4 9.2 13.6 11.4 11.4  0.418 0.676
Hospitalizations (lifetime) 2.7 2.4 2.0 2.9 2.9 2.0  0.580 0.562

Lidenmayers PANSS Factors

Modied Positive 15.7 6.2 16.0 14.5 5.7 15.0 1.819 0.070
Negative 18.1 9.5 16.0 19.7 8.8 19.0  1.589 0.113
Cognitive 16.4 6.4 15.0 16.7 6.5 16.0  0.305 0.760
Depressive 11.7 4.0 12.0 11.1 3.9 10.5 1.418 0.157
Excitement 9.5 4.0 9.0 9.9 4.6 9.0  0.791 0.430

SUMD
Total Awareness 2.8 1.2 2.7 2.6 1.2 2.5 1.084 0.279
Total Attribution 3.6 1.3 4.0 3.3 1.3 3.5 1.911 0.057
Awareness of Disease 3.0 1.7 3.0 2.8 1.6 3.0 1.378 0.169
Awareness of Effects of Medication 2.3 1.5 1.5 2.3 1.5 1.0 0.061 0.951
Awareness of Social Consequences 2.9 1.7 3.0 2.8 1.7 3.0 0.836 0.404
GAF 50.0 14.9 50.0 48.9 15.4 50.0 0.550 0.583
IQ 90.1 17.0 90.0 90.7 19.2 90.0  1.003 0.302
Marital Status n (%) n (%) 2
Single 75 (57.3) 201 (74.4) 24.294 o 0.001
Partner 30 (22.9) 23 (8.5)
Divorced 20 (15.2) 20 (7.4)
Missing 6 (4.6) 26 (9.7)
Level of Education 6.723 0.081
Read & write only 27 (20.6) 33 (12.3)
Primary 49 (37.4) 120 (44.4)
Medium and High 55 (42.0) 108 (40.0)
Missing 9 (3.3)
Diagnosis (DSM-IV) 16.827 0.001
Schizophrenia 70 (53.4) 193 (71.5)
Schizoaffective disease 22 (16.8) 20 (7.4)
Non-specic psychotic disease 32 (24.4) 39 (14.4)
Schizophreniform disease 7 (5.4) 18 (6.7)
Clinical program 0.743 0.389
Inpatient department 79 (60.3) 150 (55.6)
Outpatient department 52 (39.7) 120 (44.4)
Stage of the illness 9.488 0.002
First Episode Psychosis (FEP) 34 (25.9) 37 (13.7)
Evolutive or chronic stages 97 (74.1) 233 (86.3)

Modied Lindenmayer's Positive Factor: Lindenmayers Positive Factor without the PANSS general tem 12 (lack of insight). SUMD: Scle of the Unarawareness GAF: Total
score for the Global Assessment of Functioning scale; IQ: Estimated Intelligent Quotient. First Episode Psychosis (FEP): One or under one year of evolution of the disease.

of Neuropsychiatry and Addiction - Parc de Salut Mar; Parc Sanitari
Sant Joan de Du; Benito Menni Hospital; and Corporaci Sanitria
Parc Taul). Any psychiatric or medical comorbidities were not
excluded, except for severe neurologic illness, severe traumatic
brain injury, or inability to comprehend the language.
There were 131 women and 270 men. Sixty-ve percent of
them had a diagnosis of schizophrenia. They were recruited from
different in-patient settings and from community mental health
centers. Patients with a rst episode of psychosis, dened as less
than 1 year of evolution of the disease were also included, but
most of the sample suffered from a chronic illness (Table 1).
2.2. Procedure
All subjects were informed of the purpose of the study and
those who agree to participate were requested to sign the in-
formed consent form. The evaluation began with a questionnaire
of demographic and clinical data. Diagnosis was obtained follow-
ing DSM-IV criteria (American Psychiatric Association, 1994),
conrmed by the Structured Clinical Interview for DSM-IV (SCID,
clinical version) (First et al., 1997). The investigation was carried
out in accordance with the latest version of the Declaration of
Helsinki. The Institutional Review Boards of the participating
centers who approved the study protocol reviewed the study de-
sign. Informed consent of the participants was obtained after the
nature of the procedures had been fully explained.
2.3. Collection of data
A questionnaire of sociodemographic and clinical data was
designed by each of the participating centers. The psychopatho-
logical assessment was performed with the Positive and Negative
Syndrome Scale for Schizophrenia (PANSS) (Kay et al., 1987; Per-
alta and Cuesta, 1994). The Five-PANSS Lidenmayers Factors
(Lindenmayer et al., 1995) were obtained Positive, Negative,
Cognitive, Depressive, and Excitement because of their psycho-
metric characteristics and their ability to differentiate isolated
psychopathological dimensions, particularly the Cognitive and
Depressive factors. Although slightly different models of PANSS
factors have been proposed by different authors (Marder et al.,
1997; Emsley et al., 2003; Levine et al., 2007; Kumar et al., 2012),
recent studies have widely supported the relevance of the PANSS
Five-factor model, mainly because of the relevance of the cognitive
factor (Rodriguez-Jimenez et al., 2013). It was decided to modify
the original positive factor in order to exclude the insight-G12
item and to eliminate the covariabilities of insight assessed by
 J. Cobo et al. / Psychiatry Research 243 (2016) 268277
both measures. Insight and its dimensions, that is, awareness of
the disorder, awareness of the effects of medication, awareness of
the social consequences of the disease, and awareness and attri-
bution of each different symptom were assessed by means of the
complete version of the Scale of Unawareness of Mental Disorder
(Amador et al., 1993; Ruiz et al., 2008). Scores in each dimension of
insight and in insight and attribution of particular symptoms go
from 1 to 5, with higher scores indicating worse insight and at-
tribution. It is important to note that insight into particular
symptoms are only scored if that symptom is present (equivalent
to a PANSS score of 3 in that symptom) and that attribution is only
scored when a patient has insight into that particular symptom
(scores from 1 to 3 in SUMD-awareness).
The Spanish version of the Positive and Negative Syndrome
Scale for Schizophrenia (Peralta and Cuesta, 1994) showed a good
interrater reliability, an appropriate construct validity, and held a
high criterion-related validity in relation to the Scale for the As-
sessment of Positive Symptoms (SAPS) (Andreasen, 1984) and the
Scale for the Assessment of Negative Symptoms (SANS) (Andrea-
sen, 1982). Unlike the original authors of the PANSS (Kay et al.,
1987), the Spanish version, widely used in our eld, showed a
modest internal consistency and an insufcient factorial validity of
the positive scale, indicating, as the authors pointed out, that it is
composed by several independent components. The Five-PANSS
Lidenmayer's Factors (Lindenmayer et al., 1995) Positive, Nega-
tive, Cognitive, Depressive, and Excitement in separate factor
analyses explaining 51.7% (at baseline of the study) and 56.2%
(after a washout of treatment) of the variances, respectively.
The Spanish complete version of the Scale of Unawareness of
Mental Disorder (Ruiz et al., 2008) was elaborated through a
standardized method (translationretrotranslation from the ori-
ginal English Scale. The Intraclass Correlation Coefcient (ICC) was
calculated for the reliability analysis and the Spearman correlation
coefcient between the SUMD scores and one independent score
of global insight for external validity (G12 item of the PANSS). The
ICC were all 4 0.70. Convergent validity with the independent
global measurement of insight was found for the general items of
awareness of mental disorder and awareness of the effects of
medication, and for the subscale on awareness of symptoms. Al-
though there are other valid and useful scales to assess clinical or
cognitive Insight, the SUMD was chosen in the present study on
the basis that it is the most widely used in clinical practice in our
setting and separately analyzes each symptom.
The Global Assessment of Functioning Scale (GAF) (Endicott
et al., 1976) measured functionality. Premorbid Intelligence Quo-
tient (IQ) was estimated by the Vocabulary subtest of the Verbal
subscale of Wechsler Adult Intelligence Scale (Wechsler et al.,
1997; Miralbell et al., 2010).
2.4. Statistical analysis
The normal distribution of data of the quantitative scales was
veried using the KolmogorovSmirnov test. Assessment of the
differences between men and women was performed using the
Student's t test for continuous data or chi-square test for catego-
rical variables. In comparisons between gender and insight in each
symptom where there were less than 60 patients, the Mann
Whitney U test was used. The Pearson's correlation coefcients
between insight and its dimensions with relevant psychopatho-
logical and outcome variables were calculated. Due to the number
of comparisons the level of signicance has been considered in a
p-value o0.01. A multiple regression analysis by gender was
performed using the stepwise method to assess the inuence of
gender in the explanation of insight. A rst model was performed
including only gender and a second was done including gender,
clinical, and sociodemographic variables. The inuence of gender
271
with regard to insight was assessed in a linear regression model
controlling by sociodemographic and clinical variables that were
different between men and women. Finally, an independent
multiple regression analysis using the stepwise method was per-
formed to assess the relationship between signicant clinical and
sociodemographic variables in the bivariant analysis and insight.
The IBM SPSS-Statistics version 19.0 was used for the analysis of
data.
3. Results
Table 1 shows sociodemographic and clinical data of the sam-
ple according to gender. None of the ve Lindermayer's factors
signicantly differed by gender. In addition, no signicant differ-
ences by gender were found in any of the three main insight di-
mensions nor in the total awareness and total attribution sub-
scales of the SUMD (Table 1). Moreover a lineal regression analysis
was performed in order to assess the inuence of gender in insight
dimensions controlling by clinical (PANSS-Lindermayer's factors,
GAF, diagnosis, years of evolution, and age of onset) and socio-
demographic variables (marital status, age) that are different be-
tween men and women. Gender was signicant only with regard
to the total attribution subscale, showing an r2 of 0.026 and a value
of B  0.437 (p 0.043).
By contrast, when awareness and attribution of each particular
psychotic symptom was explored separately, signicant differ-
ences between men and women were observed (Table 2). Women
showed a worse awareness of thought disorder and alogia.
Moreover, women showed higher misattribution in apathy.
Table 3 shows the correlations between insight and clinical
variables by gender. Insight dimensions in women signicantly
correlated with the global severity of psychopathology (total
PANSS), the modied-Positive, and the Cognitive Lindermayers
Factors. In men, signicant associations were found with the
modied-Positive and the Cognitive Lindermayer's Factors, except
for the total attribution. The Excitement Factor was related to total
awareness. Moreover, the Excitement Factor was related with
awareness of the effects of medication and of the disease. Some
sociodemographic and functional variables inuenced the results.
In addition, in women, age was only associated with the total
awareness of the illness and awareness of the effects of medica-
tion. In men, the duration of the illness, age, and functionality
were related to total awareness. Age and GAF were related with
awareness of the effects of medication in men.
Table 4 shows the clinical, functional, and sociodemographic
data that explained each of the insight dimensions by gender.
Higher cognitive and positive symptoms, early stage of the illness,
and having been married explain decits of insight dimensions in
women. On the other hand, in men, other variables such as lower
functioning; higher age; other psychosis diagnosis; and, to a lower
extent, higher scores in cognitive, positive, and excitative symp-
toms, explain decits of insight dimensions.
4. Discussion
The aim of this study was to assess gender differences in the
decit of insight, as well as to explore the relationship between
insight and clinical, sociodemographic, and functional variables by
gender in a large multicentric sample of patients with schizo-
phrenia and other psychotic disorders in different clinical settings.
No differences by gender were found in the three main insight
dimensions or in the total awareness and total attribution sub-
scales of the SUMD. By contrast, some signicant differences be-
tween men and women were found in awareness and attribution
272 J. Cobo et al. / Psychiatry Research 243 (2016) 268277

Table 2.
Differences between the sex groups in awareness and attribution of each one of the different psychotic symptoms.

AWARENESS ATTRIBUTION

Women Men Women Men

n Mean SD Mean SD t, z p n Mean SD Mean SD t, z p

Hallucinations 168 2.8 1.7 2.3 1.8 2.0 0.04 108 3.3 1.5 2.5 1.8 2.3 0.02
Delusions 307 3.9 1.5 3.4 1.7 2.3 0.02 126 3.0 1.7 2.5 1.6 1.398 0.165
Thought disorder 233 3.7 1.6 3.1 1.7 2.9 0.004 115 3.1 1.7 2.9 1.5 0.376 0.707
Inappropriate affect 179 3.2 1.8 2.9 1.8 0.964 0.336 88 3.2 1.7 2.8 1.7 0.974 0.333
Unusual appearance 51 3.5 1.6 3.8 1.7 1.115 0.267a 15 3.0 1.4 3.0 2.0 0 1a
Stereotyped behaviors 59 3.7 1.8 2.9 1.8  1.713 0.087a 28 4.0 1.6 2.7 1.8  1.497 0.175a
Poor social judgment 129 3.9 1.5 3.5 1.7 1.150 0.253 47 3.4 1.6 2.9 1.6  0.894 0.371a
Poor control of aggressive impulses 137 2.6 1.7 3.0 1.7  1.373 0.172 81 2.9 1.8 2.9 1.6  0.047 0.962
Poor control in sexual impulses 28 3.2 1.6 3.0 1.9  0.121 0.910a 14 3.5 1.7 1.3 0.8 2.7 0.043a
Alogia 243 3.9 1.5 3.1 1.8 3.4 o 0.001 108 3.5 1.6 3.0 1.7 1.156 0.250
Affective blunting 205 2.7 1.8 2.7 1.8 0.115 0.909 129 3.6 1.7 3.3 1.6 0.849 0.397
Apathy 243 1.8 1.4 2.0 1.5  1.356 0.177 193 3.8 1.5 3.2 1.6 2.6 0.009
Anhedonia 220 2.2 1.6 2.6 1.7  1.580 0.116 151 3.6 1.7 3.3 1.6 0.909 0.365
Attention problems 269 1.9 1.4 1.9 1.5 0.097 0.923 215 3.1 1.6 3.0 1.6 0.450 0.653
Disorientation 68 3.8 1.6 2.8 1.9 2.2 0.02 31 4.3 1.3 3.0 1.7  2.072 0.053a
Unusual eye contact 83 3.4 1.9 3.2 1.8 0.277 0.782 36 3.6 1.7 3.1 1.8 0.555 0.588a
Poor social relationships 270 2.0 1.6 2.3 1.7  1.613 0.109 200 3.8 1.5 3.5 1.5 1.497 0.136

a
U-Mann Whitney analysis. Level of signicance: o0.01.

of particular psychotic symptoms. Although decits in insight
seem to be similar in men and women, different variables are
implied in the level of insight by gender. In women, insight di-
mensions were mainly explained by positive and cognitive
symptoms as well as by stage of the illness and marital status,
whereas, in men, other factors such as general functioning, age,
and diagnosis mostly explained insight dimensions. To our
knowledge, this is the rst study exploring gender differences in a
large clinical series of patients with psychosis. The present results
may help to better understand and characterize the phenomenon
of insight in these patients.
4.1. Gender differences in clinical, sociodemographic, and functional
variables
In agreement with other authors (Abel et al., 2010; Ochoa et al.,
2012), some differences by gender in clinical features and outcome
relevant to the comprehension of the impact of gender in the ill-
ness were documented. No signicant gender differences were
found in the severity of psychotic symptoms (Larsen et al., 1996;
Addington et al., 1996; Usall et al., 2001; Barajas et al., 2007;
Ayesa-Arriola et al., 2011; Barajas et al., 2012). An earlier age of
onset of psychosis in men is the most commonly found observa-
tion in psychosis (Goldstein and Link, 1998; Galderisi et al., 2012;
Ochoa et al., 2012). In the present study, the subset of rst episode
psychosis was more prevalent in women. It has been reported that
rst episode psychosis is more prevalent in women (Barajas et al.,
2013), although other studies do not support these data (McEvoy
et al., 2006; Ayesa-Arriola et al., 2011; Parellada et al., 2011). The
age at onset is relevant, because inuences future social func-
tioning (Ochoa et al., 2006). On the other hand, no signicant
differences by gender were found in functionality, although pre-
vious studies have found better performances in women (Usall
et al., 2001; Usall et al., 2002; Ochoa et al., 2012). The use of a
general scale to assess functionality in this study, instead of a more
detailed instrument, may explain this discrepancy. Finally, no
gender differences in lifetime number of hospitalizations were
found, which is consistent with previous data (Usall et al., 2001;
Usall et al., 2003). There is a complex interaction between symp-
toms, social factors, and gender in social functioning in schizo-
phrenia (Vila-Rodriguez et al., 2011).

Table 3.
Pearson correlations between insight and its dimensions with the psychotic symptoms.

Lindenmayers PANSS Factors

Total PANSS Modied Positive Negative Cognitive Depressive Excitative

Coef p value Coef p value Coef p value Coef p value Coef p value Coef p value

Women n Awareness of Disease 0,403 o0,0001 0,584 o 0,0001 0,185 0,038 0,408 o 0,0001 0,125 0,164 0,108 0,229
131 Awareness of the Effects of 0,319 o0,0001 0,420 o 0,0001 0,164 0,066 0,316 o 0,0001 0,067 0,453 0,176 0,049
medication
Awareness of Social consequences 0,394 o0,0001 0,487 o 0,0001 0,206 0,021 0,388 o 0,0001 0,117 0,192 0,108 0,228
Total Awareness 0,350 o0,0001 0,511 o 0,0001 0,096 0,286 0,372 o 0,0001 0,011 0,900 0,178 0,047
Total Attribution 0,248 0,008 0,284 0,002 0,134 0,150 0,238 0,011  0,007 0,942  0,043 0,649

Men n 270 Awareness of Disease 0,256 o0,0001 0,422 o 0,0001 0,049 0,438 0,187 0,003 0,002 0,971 0,214 0,001
Awareness of the Effects of 0,323 o0,0001 0,402 o 0,0001 0,096 0,129 0,259 o 0,0001 0,104 0,101 0,297 o0,0001
medication
Awareness of Social consequences 0,270 o0,0001 0,348 o 0,0001 0,146 0,021 0,248 o 0,0001  0,023 0,723 0,146 0,021
Total Awareness 0,392 o0,0001 0,450 o 0,0001 0,164 0,010 0,359 o 0,0001 0,053 0,407 0,351 o0,0001
Total Attribution 0,128 0,055 0,136 0,040 0,049 0,465 0,131 0,049 0,027 0,683 0,034 0,610

Modied Lindenmayer's Positive Factor: Lindenmayer's Positive Factor without the PANSS General tem 12 (lack of insight).
Table 4.
Lineal regressions of insight and psychotic symptoms, age, functionality (total score of the Global Assessment of Functioning scale, GAF). stage of the illness, diagnosis and marital status.

Women n Modied Linden- Lindenmayer's Lindenmayer's Age GAF Stage of the Diagnosis Marital
131 mayer's Positive Cognitive Excitative illness status

B pvalue (CI) B pvalue (CI) B pvalue (CI) B pvalue (CI) B pvalue (CI) B pvalue (CI) B pvalue (CI) B pvalue (CI) R2 of the
model

J. Cobo et al. / Psychiatry Research 243 (2016) 268277

Awareness of Disease 0.093 0.001 (0.041; 0.078 0.003 (0.028; 0.963 0.003 0.608 0.037 0.302
0.144) 0.128) (0.329; (0.036; 1.179)
1.598)
Awareness of the Effects 0.77 0.001 (0.033; 0.098
of medication 0.122)
Awareness of Social con- 0.083 0.002 (0.030; 0.060 0.024 (0.008; 0.216
sequencesof the disease 0.136) 0.111)
Total Awareness 0.055 0.003 (0.019; 0.042 0.019 (0.007; 0.449 0.032 0.257
0.091) 0.077) (0.040;
0.858)
Total Attribution 0.051 0.011 (0.012; 0.056
0.089)

Men n Awareness of Disease 0.069 0.001 (0.029; 0.059 0.027 (0.007; 0.116
270 0.109) 0.112)
Awareness of the Effects  0.029 0.001 0.095
of medication (  0.045; 0.012)
Awareness of Social con- 0.059 0.010 (0.014; 0.042 0.036 (0.003; 0.087
sequences of the disease 0.104) 0.082)
Total Awareness 0.026 0.001  0.029 0.001 0.248
(0.010; (  0.043; 0.015)
0.041)
Total Attribution  0.576 0.005 0.039
(  0.980;  0.173)

CI: Condence Interval. Modied Lindenmayer's Positive Factor: Lindenmayer's Positive Factor without the PANSS general tem 12 (insight). GAF: Total score of the Global Assessment of Functioning Scale. Stage of the ilness: First
Episode Psychosis (one or under one year of evolution of the disease) vs Evolutive or chronic stages. Diagnosis: Schizophrenia vs Other psychosis; Marital status: Married sometimes vs Single.

273
274 J. Cobo et al. / Psychiatry Research 243 (2016) 268277
4.2. Gender differences in insight dimensions
Levels of insight were found to be relatively poor, similar to
previous reports (Carpenter et al., 1973; Carpenter et al., 1976;
Amador et al., 1994). The analysis of gender differences in the
decit of insight showed an absence of global gender differences
in the three main insight dimensions, as well as in the total
awareness and total attribution of symptoms. Although previous
studies on this topic are scarce and have used different insight
conceptualizations and explored different patient proles, similar
data in patients with schizophrenia were reported (Amador et al.,
1994; Moriarty et al., 2001; Ayesa-Arriola et al., 2011; Wiffen et al.,
2012). However, using regression analysis, Pru et al. (2012) de-
tected gender to be one of the variables explaining insight in
schizophrenia. Using the same approach, our study only showed
signicant results when gender was considered together with
clinical and sociodemographic variables and only in the total at-
tribution subscale.
On the other hand, reports on gender differences in insight in
rst episode psychosis or early stage of the illness are somewhat
contradictory. No gender differences have been found in several
studies (Mutsatsa et al., 2006; Ayesa-Arriola et al., 2011; Wiffen
et al., 2012), although McEvoy et al. (2006) observed that young
female patients within their rst episode of psychosis had a better
insight. However, they used a self-report insight measure, which
may explain differences with other studies. Moreover, Parellada
et al. (2011) found women to have a better insight in total
awareness and total attribution of symptoms, suggesting that this
might have been due to the better metalizing abilities in women,
which is consistent with data reported by Das et al. (2012).
However, a great proportion of studies with rst episode psychosis
included patients younger than 18 years of age (Parellada et al.,
2011); therefore, this could explain differences with our results.
Other possible factors could be the heterogeneity of diagnosis in
the non-schizophrenia spectrum rst episode group (Parellada
et al., 2011), the short evolution of the illness (Parellada et al.,
2011; Ayesa-Arriola et al., 2011; Wiffen et al., 2012), or the re-
levance of the evolutive maturation of cognitive and metacogni-
tive resources in child and adolescent samples (Frommann et al.,
2011; Barbato et al., 2013; Gur et al., 2014; Vohs et al., 2015). In
addition, our sample is composed of adult, mature persons with a
wide range of age, mostly evolutive patients. All of these char-
acteristics make our sample different from rst episode psychosis,
at-risk samples, or mainly early-stage schizophrenia and other
psychoses samples.
4.3. Gender differences in insight of each particular symptom
None of the previous studies that were reviewed had assessed
gender differences in the awareness and attribution of each par-
ticular symptom separately. When this was carried out in the
present study, women had a worse awareness of suffering some of
the core symptoms of psychosis, such as thought disorder and
alogia. On the other hand, when attribution was explored in pa-
tients with awareness of a particular symptom, it was found that
women made signicantly more erratic attributions of their apa-
thy as compared to men.
These results could help sensitize doctors and mental health
staff for gender differences and, thus, benet therapeutic inter-
ventions. Despite some trial-based evidence suggesting no clear
and convincing advantage for Cognitive-Behavioral Therapy (CBT)
and other psychological therapies for people with schizophrenia
(Jones et al., 2012; Jauhar et al., 2014), we found enough evidence
to support the research on CBT and perhaps other psychological
interventions for some specic symptoms in schizophrenia and
other psychosis, including insight (Pijnenborg et al., 2013). As the
authors pointed out, different interventions had a global medium
effect on insight (d .34, 95% condence interval [CI], 0.120.57).
The effects of CBT, adherence therapy, and psycho-education were
small to moderate, but not signicant, probably due to a lack of
power (Pijnenborg et al., 2013). The authors proposed that insight
could be a potential therapeutic target and subsequently capable
of modication (and improvement) by several psychological
treatments. As the authors pointed out in the meta-analysis,
comprehensive intervention programs consisting of multiple
components may be particularly promising (Pijnenborg et al.,
2013).
On the other hand, some previous studies with CBT also found
improvements of both clinical and insight symptoms. Turkington
et al. (2006) founded a clinically signicant change of 25% or more
in insight and negative symptoms in an intervention with CBT, but
previous studies on the effect of CBT in symptoms have to be taken
into account that, in most of them, insight was also a secondary
measure and not a target of the intervention.
With regard to gender differences in CBT outcomes in schizo-
phrenia, Brabban et al. (2009) also reported relevant data. In the
CBT group, only female gender was found to strongly predict a
reduction in overall symptoms (p .004, odds ratio [OR] 2.39,
95% CI, 1.334.30) and increase in insight (p .04, OR 1.84, 95%
CI, 1.033.29) (Brabban et al., 2009). Additionally, a contemporary
study founded a moderate improvement of insight in CBT (Penn
et al., 2009). We proposed that gender aspects would be included
in the planning of future CBT and other therapies devoted to in-
sight in schizophrenia and other psychosis. Our results suggested
that, among others, therapeutic interventions on insight in women
had to be focused on clinical symptoms, whereas in men they had
to be more focused on psychosocial aspects.
With regard to the impact of insight on depression and the risk
of suicidality, as we pointed out in the introduction, there is also a
small positive relationship between clinical insight (Mintz et al.,
2003) and cognitive insight (Palmer et al., 2015) and depressive
symptoms in schizophrenia. In addition, we pointed out that there
is a debate suggesting that insight may represent a risk factor for
suicide in patients with schizophrenia. As shown in recent studies,
if there is an association between such risk and insight, it appears
to be mediated by other variables such as depression, duration of
untreated psychosis, and, above all, hopelessness (Lpez-Morigo
et al., 2012; Lpez-Morigo et al., 2014). On the other hand, im-
provements in insight during psychological treatments for psy-
chotic disorders did not seem to be associated with increased
depression (Pijnenborg et al., 2013). In our sample, we did not
detect any gender-based differences in the depressive Linden-
mayers PANSS factor (Table 1) or in the anhedonia symptom
(Table 2). When we analyzed separately the inuence of the dif-
ferent clinical and sociodemographic factors by gender (Table 3),
the depressive Lindenmayers PANSS factor did not inuence the
insight dimensions in both sexes.
A strength of the present study has been the conduct of a
symptom-by-symptom analysis. In previous studies, this type of
analysis has not been conducted, as it is very difcult with com-
mon sample sizes because not all patients have the same symp-
toms; therefore, groups in which awareness and attribution of
each particular symptom can be explored tend to be too small. The
importance of studying insight in each particular symptom has
been repeatedly pointed out, since it has been suggested that the
nature of insight into each psychotic symptom may vary widely
(Rossell et al., 2003; David et al., 2012). For example, being aware
that one is convinced of a delusional thought that is in fact untrue
may be of a different nature that being aware of one's avolition.
The large sample of patients of the present research allowed
studying this aspect.
 J. Cobo et al. / Psychiatry Research 243 (2016) 268277
4.4. The impact of different factors on insight dimensions in men and
women
Clinical positive and cognitive symptoms were the factors that
mainly explained insight dimensions in women in the multiple
regression analysis. In men, the impact of psychopathological
measures in insight is lower, and other factors such as age, diag-
nosis, and psychosocial functioning emerge as possible mediators
of insight dimensions. Therefore, while men and women in the
present sample showed a similar clinical severity of symptoms
with no apparent differences in their level of insight in the three
main insight dimensions, different factors explained the phe-
nomenology of insight according to gender. These results suggest
that interventions addressed to improve insight of the illness
should be different in women than in men. Psycho-educational
interventions should be carried out in women with greater pre-
sence of positive and cognitive symptoms, irrespective of their
functional impairment. The role of gender in insight needs to be
taken into consideration (Pru et al., 2012). Gender differences in
psychological factors, health service seeking, or neurocognitive
functions could determine the gender differences observed in in-
sight (Dindia et al., 1992; Levinson and Ifrah, 2010).
Our results partially conrm our initial hypothesis. We detected
some signicant differences between men and women affected by
a psychotic disorder in several clinical aspects (age of onset, di-
agnosis, and stage of the illness), but not in others (functionality
and severity of symptoms). On the other hand, men and women
showed no differences in global awareness and attribution of
psychotic disorder but exhibited certain signicant differences
related to insight in particular psychotic symptoms and attribu-
tion. The way different clinical, functional, and sociodemographic
variables inuence insight dimensions depends partly on the
gender, as each gender shows a different pattern of inuences for
each dimension.
In our opinion, research samples in schizophrenia and other
psychoses had to be analyzed including men and women together,
but also in a separate way, separating men from women, because
the impact of different variables could change by gender (Ochoa
et al., 2011). After stratication by sex, our results showed a dif-
ferent impact of clinical sociodemographic and outcome variables
in insight in men and women. Until today, most (but not all) of the
studies in schizophrenia and other psychosis included samples
with a majority of men. The global results in theses samples had a
bias toward the detection of relevant factors for men, and perhaps
not really for women. Our results supported this gender approach
in schizophrenia and other psychosis.
4.5. Strengths and limitations
The present study is original in studying dimensions of insight
and awareness and attribution of each particular symptom, and
this was only possible by the use of a large multicenter study
population. However, limitations of the study include the cross-
sectional design and the lack of control for treatment and for
cognitive variables, which are known to modulate the impact of
psychopathological variables on insight (Nieto et al., 2012).
The main objective of the present study was to determine the
inuence of gender in insight, and time of evolution as well as
stage of the illness were used only as control variables. This is an
important limitation. On the other hand, an early stages of the
illness partially inuenced decits of insight dimensions but only
in women (Table 4). We hope these data can help future analysis,
underscoring the relevance of a separate analysis by gender. In
future studies, subsampling analysis depending on illness duration
will be necessary.
The study of these gender differences in the expression of
275
insight allows us to have a better understanding of insight phe-
nomena. The gender approach in schizophrenia and other psy-
chosis research could contribute to a better comprehension of the
illness, as gender could inuence several relevant factors in the
illness, as age of onset, functionality, outcomes, cognition or clin-
ical expressions, and metacognitive variables including insight.
4.6. Conclusions
No gender differences in the three main dimensions of insight
in psychosis were found, neither in awareness nor in attribution of
symptoms when assessed globally. However, gender differences
appear in awareness and attribution of particular symptoms when
assessed separately, with women showing higher levels of un-
awareness and misattribution than men. On the other hand, a
different pattern of clinical, sociodemographic, and functional
variables seem to affect insight in men and women differently.
This gender analysis supports not only the multidimensional view
of insight but also the need to study the awareness and attribution
of each symptom separately, as well as the differential inuences
of functional, cultural, and clinical factors in the phenomenology
of insight in psychosis. A greater understanding of gender differ-
ences in psychosis could help in the design of more effective
preventive and therapeutic psychiatric and psychosocial strategies.
Role of the funding sources
None related to the present study.
Conicts of interest
None related to the present study.
Acknowledgments
We thank Marta Pulido, for editing the initial manuscript and
editorial assistance. We thank Carles Garca-Ribera, for his com-
ments and suggestions and for editing the nal version of the
manuscript.
References
Abel, K.M., Drake, R., Goldstein, J.M., 2010. Sex differences in schizophrenia. Int. Rev.
Psychiatry 22, 417428.
Addington, D., Addington, J., Patten, S., 1996. Gender and affect in schizophrenia.
Can. J. Psychiatry 41, 265268.
Aleman, A., Agrawal, N., Morgan, K.D., David, A.S., 2006. Insight in psychosis and
neuropsychological function: meta-analysis. Br. J. Psychiatry 189, 204212.
Amador, X.F., David, A.S., 2004. Insight and psychosis: Awareness of Illness in
Schizophrenia And Related Disorders, Second edition. Oxford University., New
York.
Amador, X.F., Strauss, D.H., Yale, S.A., Gorman, J.M., 1991. Awareness of Illness in
Schizophrenia. Schizophr. Bull. 17, 113132.
Amador, X.F., Strauss, D.H., Yale, S.A., Flaunm, M.M., Endicott, J., Gorman, J.M., 1993.
Assessment of insight in psychosis. Am. J. Psychiatry 150, 873879.
Amador, X.F., Flaum, M., Andreasen, N.C., Strauss, D.H., Yale, S.A., Clark, S.C., Gor-
man, J.M., 1994. Awareness of Illness in Schizophrenia and Schizoaffective and
Mood Disorders. Arch. Gen. Psychiatry 51, 826836.
American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental
Disorders, Fourth edition.,. American Psychiatric Press, Washington, DC.
Andreasen, N.C., 1982. Negative symptoms in schizophrenia. Denition and relia-
bility. Arch. Gen. Psychiatry 39, 784788.
Andreasen, N.C., 1984. Scale for the Assessment of Positive Symptoms (SAPS).
University Of Iowa., Iowa City.
Ayesa-Arriola, R., Rodriguez-Sanchez, J.M., Gomez-Ruiz, E., Roiz-Santiez, R., Re-
eves, L.L., Crespo-Facorro, B., 2014. No sex differences in neuropsychological
performance in rst episode psychosis patients. Prog. Neuropsychopharmacol.
276 J. Cobo et al. / Psychiatry Research 243 (2016) 268277
Biol. Psychiatry 48, 149154.
Ayesa-Arriola, R., Rodrguez-Snchez, J.M., Morelli, C., Pelayo-Tran, J.M., Prez-Ig-
lesias, R., Mata, I., Martnez-Garcia, O., Pardo-Garcia, G., Vazquez-Barquero, J.L.,
Crespo-Facorro, B., 2011. Insight dimensions in rst-episode psychosis patients:
clinical, cognitive, pre-morbid and socio-demographic correlates. Early Interv.
Psychiatry 5, 140149.
Barajas, A., Baos, I., Ochoa, S., Usall, J., Villalta, V., Dolz, M., Snchez, B., Haro, J.M.,
Grupo, G.E.N.I.P.E., 2007. Age of onset of rst psychotic episode: are there any
clinical differences between men and women? Psiquiatr. Biolgica 14, 136141.
Barajas, A., Baos, I., Ochoa, S., Usall, J., Huerta, E., Dolz, M., Snchez, B., Villalta, V.,
Foix, A., Obiols, J., Haro, J.M., 2012. Gender differences in incipient psychosis.
Eur. J. Psychiatry 24, 176194.
Barajas, A., Ochoa, S., Baos, I., Dolz, M., Villalta-Gil, V., Vilaplana, M., Autonell, J.,
Snchez, B., Cervilla, J.A., Foix, A., Obiols, J.E., Haro, J.M., 2013. Spanish validation
of the PAS-S (GENIPE Group, Usall, J.). Compr. Psychiatry 54, 187194.
Barbato, M., Penn, D.L., Perkins, D.O., Woods, S.W., Liu, L., Addington, J., 2013. Me-
tacognitive functioning in individuals at clinical high risk for psychosis. Behav.
Cognit. Psychother. 42 526-234.
Brabban, A., Tai, S., Turkington, D., 2009. Predictors of outcome in brief cognitive
behavior therapy for schizophrenia. Schizophr. Bull. 35, 859864.
Carpenter, W.T., Jr, Strauss, J.S., Bartko, J.J., 1973. Flexible system for the diagnosis of
schizophrenia: report from the WHO International Pilot Study of Schizophrenia.
Science 182, 12751278.
Carpenter, W.T., Jr, Bartko, J.J., Carpenter, C.L., Strauss, J.S., 1976. Another view of
schizophrenia subtypes. A report from the international pilot study of schizo-
phrenia. Arch. Gen. Psychiatry 33, 508516.
Collins, A.A., Remington, G.J., Coulter, K., Birkett, K., 1997. Insight, neurocognitive
function and symptom clusters in chronic schizophrenia. Schizophr. Res. 27,
3744.
Das, P., Lagopoulos, J., Coulston, C.M., Henderson, A.F., Malhi, G.S., 2012. Mentalizing
impairment in schizophrenia: a functional MRI study. Schizophr. Res. 134,
158164.
David, A., Buchanan, A., Reed, A., Almeida, O., 1992. The assessment of insight in
psychosis. Br. J. Psychiatry 161, 599602.
David, A.S., Bedford, N., Wiffen, B., Gilleen, J., 2012. Failures of metacognition and
lack of insight in neuropsychiatric disorders. Philos. Transl. R. Soc. B . http://dx.
doi.org/10.1098/rstb.2012.0002.
Dindia, K., Allen, M., 1992. Sex differences in self-disclosure: a meta-analysis. Psy-
chol. Bull. 112, 106124.
Drake, R.J., Nordentoft, M., Haddock, G., Arango, C., Fleischhacker, W.W., Glenthj,
B., Leboyer, M., Leucht, S., Leweke, M., McGuire, P., Meyer-Lindenberg, A., Ru-
jescu, D., Sommer, I.E., Kahn, R.S., Lewis, S.W., 2015. Modeling determinants of
medication attitudes and poor adherence in early nonaffective psychosis: im-
plications for intervention. Schizophr. Bull. 41, 584596.
Ekinci, O., Ekinci, A., 2013. Association between insight, cognitive insight, positive
symptoms and violence in patients with schizophrenia. Nord. J. Psychiatry 67,
116123.
Emsley, R., Rabinowitz, J., Torreman, M., 2003. The RIS-INT-35 Early Psychosis
Global Working Group. The factor structure for the Positive and Negative
Syndrome Scale (PANSS) in recent-onset psychosis. Schizophr. Res. 61, 4757.
Endicott, J., Spitzer, R.L., Fleiss, J.L., Cohen, J., 1976. The global assessment scale. A
procedure for measuring overall severity of psychiatric disturbance. Arch. Gen.
Psychiatry 33, 766771.
First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W., 1997. Structured clinical in-
terview for DSM-IV (SCID) axis I disordersStructured clinical interview for
DSM-IV (SCID) axis I disorders. American Psychiatric Press., Washington, DC.
Frommann, I., Pukrop, R., Brinkmeyer, J., Bechdolf, A., Ruhrmann, S., Berning, J.,
Decker, P., Riedel, M., Mller, H.J., Wlwer, W., Gaebel, W., Klosterktter, J.,
Maier, W., Wagner, M., 2011. Neuropsychological proles in different at-risk
states of psychosis: executive control impairment in the earlyand additional
memory dysfunction in the lateprodromal state. Schizophr. Bull. 37, 861873.
Galderisi, S., Bucci, P., Uok, A., Peuskens, J., 2012. No gender differences in social
outcome in patients suffering from schizophrenia. Eur. Psychiatry 27, 406408.
Goldstein, J., Link, B., 1998. Gender and the expression of schizophrenia. J. Psy-
chiatry Res. 22, 141155.
Gur, R.C., Calkins, M.E., Satterthwaite, T.D., Ruparel, K., Bilker, W.B., Moore, T.M.,
Savitt, A.P., Hakonarson, H., Gur, R.E., 2014. Neurocognitive growth charting in
psychosis spectrum youths. JAMA Psychiatry 71, 366374.
Hui, C.L., Leung, C.M., Chang, W.C., Chan, S.K., Lee, E.H., Chen, E.Y., 2014. Examining
gender difference in adult-onset psychosis in Hong Kong. Early Interv. Psy-
chiatry . http://dx.doi.org/10.1111/eip.12167 (Epub ahead of print).
Ittig, S., Studerus, E., Papmeyer, M., Uttinger, M., Koranyi, S., Ramyead, A., Riecher-
Rssler, A., 2015. Sex differences in cognitive functioning in at-risk mental state
for psychosis, rst episode psychosis and healthy control subjects. Eur. Psy-
chiatry 30, 242250.
Jauhar, S., McKenna, P.J., Radua, J., Fung, E., Salvador, R., Laws, K.R., 2014. Cognitive-
behavioural therapy for the symptoms of schizophrenia: systematic review and
meta-analysis with examination of potential bias. Br. J. Psychiatry 204, 2029.
Jones, C., Hacker, D., Cormac, I., Meaden, A., Irving, C.B., 2012. Cognitive behaviour
therapy versus other psychosocial treatments for schizophrenia. Cochrane
Database Syst. Rev., 4.
Kay, S.R., Fiszbein, A., Opler, L.A., 1987. The positive and negative syndrome scale
(PANSS) for schizophrenia. Schizophr. Bull. 13, 261276.
Kemp, R.A., Lambert, T.J., 1995. Insight in schizophrenia and its relationship to
psychopathology. Schizophr. Res. 18, 2128.
Kim, Y., Sakamoto, K., Kamo, T., Sakamura, Y., Miyaoka, H., 1997. Insight and clinical
correlates in schizophrenia. Compr. Psychiatry 38, 117123.
Kumar, A., Khess, C.R.J., 2012. Factor analysis of positive and negative syndrome
scale in schizophrenia: an exploratory study. Indian J. Psychiatry 54, 233238.
Lpez-Morigo, J.D., Ramos-Ros, R., David, A.S., Dutta, R., 2012. Insight in schizo-
phrenia and risk of suicide: a systematic update. Compr. Psychiatry 53,
313322.
Lpez-Morigo, J.D., Wiffen, B., OConnor, J., Dutta, R., Di Forti, M., Murray, R.M.,
David, A.S., 2014. Insight and suicidality in rst-episode psychosis: under-
standing the inuence of suicidal history on insight dimensions at rst pre-
sentation. Early Interv. Psychiatry 8, 113121.
Larsen, T.K., McGlashan, T.H., Moe, L.C., 1996. First-episode schizophrenia - I. Early
course parameters. Schizophr. Bull. 22, 241256.
Levine, S.Z., Rabinowitz, J., 2007. Revisiting the 5 dimensions of the positive and
negative syndrome scale. J. Clin. Psychopharmacol. 27, 431436.
Levinson, D., Ifrah, A., 2010. The robustness of the gender effect on help seeking for
mental health needs in three subcultures in Israel. Soc. Psychiatry Psychiatr.
Epidemiol. 45, 337344.
Lincoln, T.M., Lullmann, E., Rief, W., 2007. Correlates and long-term consequences
of poor insight in patients with schizophrenia. A systematic review. Schizophr.
Bull. 33, 13241342.
Lindenmayer, J.P., Grochowski, S., Hyman, R.B., 1995. Five factor model of schizo-
phrenia: replication across samples. Schizophr. Res. 14, 229234.
Marder, S.R., Davis, J.M., Chouinard, G., 1997. The effects of risperidone on the ve
dimensions of schizophrenia derived by factor analysis: combined results of the
North American trials. J. Clin. Psychiatry 58, 538546.
McEvoy, J.P., Johnson, J., Perkins, D., Lieberman, J.A., Hamer, R.M., Keefe, R.S., Tohen,
M., Glick, I.D., Sharma, T., 2006. Insight in rst-episode psychosis. Psychol. Med.
36, 13851393.
Mintz, A.R., Dobson, K.S., Rommey, D.M., 2003. Insight in schizophrenia: a metaa-
nalysis. Schizophr. Res. 61, 7588.
Miralbell, J., Soriano, J.J., Lpez-Cancio, E., Arenillas, J.F., Dorado, L., Barrios, M.,
Cceres, C., Alzamora, M.T., Torn, P., Pera, G., Dvalos, A., Matar, M., 2010.
Vascular risk factors and cognitive performance in patients 50 to 65 years-old.
Neurologa 25, 422429.
Mohamed, S., Fleming, S., Penn, D.L., Spaulding, W., 1999. Insight in schizophrenia:
its relationship to measures of executive functions. J. Nerv. Ment. Dis. 187,
525531.
Mohamed, S., Rosenheck, R., McEvoy, J., Swartz, M., Stroup, S., Lieberman, J.A., 2009.
Cross-sectional and longitudinal relationships between insight and attitudes
toward medication and clinical outcomes in chronic schizophrenia. Schizophr.
Bull. 35, 336346.
Moore, O., Cassidy, E., Carr, A., OCallaghan, E., 1999. Unawareness of illness and its
relationship with depression and self-deception in schizophrenia. Eur. Psy-
chiatry 14, 264269.
Moriarty, P.J., Lieber, D., Bennett, A., White, L., Parrella, M., Harvey, P.D., Davis, K.L.,
2001. Gender differences in poor outcome patients with lifelong schizophrenia.
Schizophr. Bull. 27, 103113.
Mutsatsa, S.H., Joyce, E.M., Hutton, S.B., Barnes, T.R., 2006. Relationship between
insight, cognitive function, social function and symptomatology in schizo-
phrenia: the West London rst episode study. Eur. Arch. Psychiatry Clin. Neu-
rosci. 256, 356363.
Nieto, L., Cobo, J., Pousa, E., Blas-Navarro, J., Garca-Pars, G., Palao, D., Obiols, J.E.,
2012. Insight, symptomatic dimensions and cognition in acute-phase psychotic
patients. Compr. Psychiatry 53, 502528.
Novick, D., Montgomery, W., Treuer, T., Aguado, J., Kraemer, S., Haro, J.M., 2015.
Relationship of insight with medication adherence and the impact on outcomes
in patients with schizophrenia and bipolar disorder: results from a 1-year
European outpatient observational study. BMC Psychiatry 15, 189.
Ochoa, S., Usall, J., Cobo, J., Labad, X., Kulkarni, J., 2012. Gender Differences in
Schizophrenia and First-Episode Psychosis: A Comprehensive Literature Re-
view. Rev. Schizophr. Res. Treat., 916198.
Ochoa, S., Usall, J., Villalta-Gil, V., Vilaplana, M., Marquez, M., Valdelomar, M., Haro,
J.M., 2006. Inuence of age at onset on social functioning in outpatients with
schizophrenia (NEDES Group). Eur. J. Psychiatry 20, 157163.
Palmer, E.C., Gilleen, J., David, A.S., 2015. The relationship between cognitive insight
and depression in psychosis and schizophrenia: a review and meta-analysis.
Schizophr. Res. 166, 261268.
Parellada, M., Fraguas, D., Bombn, I., Otero, S., Castro-Fornieles, J., Baeza, I., Gon-
zalez-Pinto, A., Graell, M., Soutullo, C., Paya, B., Arango, C., 2009. Insight cor-
relates in child- and adolescent-onset rst episodes of psychosis: results from
the CAFEPS study. Psychol. Med. 39, 14331445.
Parellada, M., Boada, L., Fraguas, D., Reig, S., Castro-Fornieles, J., Moreno, D., Gon-
zalez-Pinto, A., Otero, S., Rapado-Castro, M., Graell, M., Baeza, I., Arango, C.,
2011. Trait and state attributes of insight in rst episodes of early-onset schi-
zophrenia and other psychoses: a 2-year longitudinal study. Schizophr. Bull. 37,
3851.
Penn, D.L., Meyer, P.S., Evans, E., Wirth, R.J., Cai, K., Burchinal, M., 2009. A rando-
mized controlled trial of group cognitive-behavioral therapy vs. enhanced
supportive therapy for auditory hallucinations. Schizophr. Res. 109, 5259.
Peralta, V.M., Cuesta, M.J., 1994. Validacin de la escala de los sndromes positivo y
negativo (PANSS) en una muestra de esquizofrnicos espaoles. Actas Luso Esp.
de. Neurol. y. Psiquiatr. 22, 171177.
Pijnenborg, G.H., van Donkersgoed, R., David, A.S., Aleman, A., 2013. Changes in
insight during treatment for psychotic disorders: a meta-analysis. Schizophr.
Res. 144, 109117.
Pousa, E., Du, R., Blas-Navarro, J., Ruiz, A.I., Obiols, J.E., David, A.S., 2008.
 J. Cobo et al. / Psychiatry Research 243 (2016) 268277
Exploratory study of the association between insight and Theory of Mind (ToM)
in stable schizophrenia patients. Cognitive. Neuropsychiatry 13, 210232.
Pru, L., Wiedl, K.H., Waldorf, M., 2012. Stigma as a predictor of insight in schizo-
phrenia. Psychiatry Res. 198, 187193.
Quee, P.J., van der Meer, L., Bruggeman, R., de Haan, L., Krabbendam, L., Cahn, W.,
Mulder, N.C., Wiersma, D., Aleman, A., 2011. Insight in psychosis: relationship
with neurocognition, social cognition and clinical symptoms depends on phase
of illness. Schizophr. Bull. 37, 2937.
Riecher-Rssler, A., Hfner, H., 2000. Gender aspects in schizophrenia: bridging the
border between social and biological psychiatry. Acta Psychiatr. Scand. 102,
5862.
Riecher-Rssler, A., Hfner, H., Stumbaum, M., Maurer, K., Schmidt, R., 1994. Can
estradiol modulate schizophrenic symptomatology? Schizophr. Bull. 20,
203214.
Rodriguez-Jimenez, R., Bagney, A., Mezquita, L., Martinez-Gras, I., Sanchez-Morla, E.
M., Mesa, N., Ibaez, M.I., Diez-Martin, J., Jimenez-Arriero, M.A., Lobo, A., San-
tos, J.L., Palomo, T., 2013. Cognition and the ve-factor model of the Positive and
Negative Syndrome Scale in schizophrenia. Schizophr. Res. 143, 7783.
Rodriguez-Jimenez, R., Dompablo, M., Bagney, A., Santabrbara, J., Aparicio, A.I.,
Torio, I., Moreno-Ortega, M., Lopez-Anton, R., Lobo, A., Kern, R.S., Green, M.F.,
Jimenez-Arriero, M.A., Santos, J.L., Nuechterlein, K.H., Palomo, T., 2015. The
MCCB impairment prole in a Spanish sample of patients with schizophrenia:
effects of diagnosis, age, and gender on cognitive functioning. Schizophr. Res. .
http://dx.doi.org/10.1016/j.schres.2015.09.013 (Epub ahead of print)
Rossell, S.L., Coakes, J., Shapleske, J., Woodruff, P.W., David, A.S., 2003. Insight: its
relationship with cognitive function, brain volume and symptoms in schizo-
phrenia. Psychol. Med. 33, 111119.
Ruiz, I.A., Pousa, E., Duo, R., Crosas, M.J., Cuppa, S., Garca-Ribera, C., 2008.
Adaptacin al espaol de la escala de valoracin de la no conciencia de
277
trastorno mental (SUMD). Actas Esp. de. Psiquiatr. 36, 111119.
Sendt, K.V., Tracy, D.K., Bhattacharyya, S., 2015. A systematic review of factors in-
uencing adherence to antipsychotic medication in schizophrenia-spectrum
disorders. Psychiatry Res. 225, 1430.
Turkington, D., Kingdon, D., Rathod, S., Hammond, K., Pelton, J., Mehta, R., 2006.
Outcomes of an effectiveness trial of cognitive-behavioural intervention by
mental health nurses in schizophrenia. Br. J. Psychiatry 189, 3640.
Usall, J., Ochoa, S., Araya, S., Mrquez, M., 2003. Gender differences and outcome in
schizophrenia: a 2-year follow-up study in a large community sample. Eur.
Psychiatry 18, 282284.
Usall, J., Haro, J., Ochoa, S., Mrquez, M., Araya, S., 2002. Inuence of gender on
social outcome in schizophrenia (NEDES Group). Acta Psychiatr. Scand. 106,
337342.
Usall, J., Araya, S., Ochoa, S., Busquets, E., Gost, A., Mrquez, M., 2001. Gender dif-
ferences in a sample of schizophrenic outpatients. Compr. Psychiatry 42,
301305.
Vila-Rodriguez, F., Ochoa, S., Autonell, J., Usall, J., Haro, J.M., 2011. Complex inter-
action between symptoms, social factors, and gender in social functioning in a
community-dwelling sample of schizophrenia. Psychiatr. Q. 82, 261274.
Vohs, J.L., Lysaker, P.H., Lifck, E., Francis, M.M., Leonhardt, B.L., James, A., Buck, K.D.,
Hamm, J.A., Minor, K.S., Mehdiyoun, N., Breier, A., 2015. Metacognitive capacity
as a predictor of insight in rst-episode psychosis. J. Nerv. Ment. Dis. 203,
372378.
Wechsler, D., 1997. Wechsler Adult Intelligence Scale-III. Psychological Corporation,
San Antonio, TX.
Wiffen, B.D., Rabinowitz, J., Fleischhacker, W.W., David, A.S., 2012. Fleischhacker, W.
W., David, A.S., 2012. Insight: demographic differences and associations with
one-year outcome in schizophrenia and schizoaffective disorder. Clin. Schi-
zophr. Relat. Psychoses 4, 169175.