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Psychiatry Research 243 (2016) 268277

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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
Mental Health Department, Corporaci Sanitria Parc Taul, Hospital Universitari UAB Sabadell, Barcelona, Catalonia, Spain
Department of Psychiatry and Forensic Medicine. Universitat Autnoma de Barcelona Bellaterra, Barcelona, Catalonia, Spain
Research Workgroup on Womens Mental Health, Catalan Society of Psychiatry & Mental Health Barcelona, Catalonia, Spain
Department of Research, Instituto Nacional de Psiquiatra Ramn de la Fuente Muiz, Ciudad de Mxico, Mexico
Research and Development Unit, Parc Sanitari San Joan de Du - CIBERSAM Sant Boi de Llobregat, Barcelona, Catalonia, Spain
Mental Health Department, Hospital Benito Menni Sant Boi de Llobregat, Barcelona, Catalonia, Spain
Department of Health and Clinical Psychology - Research Unit. Universitat Autnoma de Barcelona Bellaterra, Barcelona, Catalonia, Spain
Institut de Neuropsiquiatria i Addiccions, Hospital del Mar Barcelona, Catalonia, Spain
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
in awareness and attribution of particular symptoms. Women showed a worse awareness of thought
disorder and alogia and a higher misattribution of apathy. Higher cognitive and positive symptoms, early
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

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).
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).

0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved.
J. Cobo et al. / Psychiatry Research 243 (2016) 268277 269

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

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 centers who approved the study protocol reviewed the study de-
Sant Joan de Du; Benito Menni Hospital; and Corporaci Sanitria sign. Informed consent of the participants was obtained after the
Parc Taul). Any psychiatric or medical comorbidities were not nature of the procedures had been fully explained.
excluded, except for severe neurologic illness, severe traumatic
brain injury, or inability to comprehend the language. 2.3. Collection of data
There were 131 women and 270 men. Sixty-ve percent of
them had a diagnosis of schizophrenia. They were recruited from A questionnaire of sociodemographic and clinical data was
different in-patient settings and from community mental health designed by each of the participating centers. The psychopatho-
centers. Patients with a rst episode of psychosis, dened as less logical assessment was performed with the Positive and Negative
than 1 year of evolution of the disease were also included, but Syndrome Scale for Schizophrenia (PANSS) (Kay et al., 1987; Per-
most of the sample suffered from a chronic illness (Table 1). alta and Cuesta, 1994). The Five-PANSS Lidenmayers Factors
(Lindenmayer et al., 1995) were obtained Positive, Negative,
2.2. Procedure Cognitive, Depressive, and Excitement because of their psycho-
metric characteristics and their ability to differentiate isolated
All subjects were informed of the purpose of the study and psychopathological dimensions, particularly the Cognitive and
those who agree to participate were requested to sign the in- Depressive factors. Although slightly different models of PANSS
formed consent form. The evaluation began with a questionnaire factors have been proposed by different authors (Marder et al.,
of demographic and clinical data. Diagnosis was obtained follow- 1997; Emsley et al., 2003; Levine et al., 2007; Kumar et al., 2012),
ing DSM-IV criteria (American Psychiatric Association, 1994), recent studies have widely supported the relevance of the PANSS
conrmed by the Structured Clinical Interview for DSM-IV (SCID, Five-factor model, mainly because of the relevance of the cognitive
clinical version) (First et al., 1997). The investigation was carried factor (Rodriguez-Jimenez et al., 2013). It was decided to modify
out in accordance with the latest version of the Declaration of the original positive factor in order to exclude the insight-G12
Helsinki. The Institutional Review Boards of the participating item and to eliminate the covariabilities of insight assessed by
J. Cobo et al. / Psychiatry Research 243 (2016) 268277 271

both measures. Insight and its dimensions, that is, awareness of with regard to insight was assessed in a linear regression model
the disorder, awareness of the effects of medication, awareness of controlling by sociodemographic and clinical variables that were
the social consequences of the disease, and awareness and attri- different between men and women. Finally, an independent
bution of each different symptom were assessed by means of the multiple regression analysis using the stepwise method was per-
complete version of the Scale of Unawareness of Mental Disorder formed to assess the relationship between signicant clinical and
(Amador et al., 1993; Ruiz et al., 2008). Scores in each dimension of sociodemographic variables in the bivariant analysis and insight.
insight and in insight and attribution of particular symptoms go The IBM SPSS-Statistics version 19.0 was used for the analysis of
from 1 to 5, with higher scores indicating worse insight and at- data.
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 3. Results
scored when a patient has insight into that particular symptom
(scores from 1 to 3 in SUMD-awareness). Table 1 shows sociodemographic and clinical data of the sam-
The Spanish version of the Positive and Negative Syndrome ple according to gender. None of the ve Lindermayer's factors
Scale for Schizophrenia (Peralta and Cuesta, 1994) showed a good signicantly differed by gender. In addition, no signicant differ-
interrater reliability, an appropriate construct validity, and held a ences by gender were found in any of the three main insight di-
high criterion-related validity in relation to the Scale for the As- mensions nor in the total awareness and total attribution sub-
sessment of Positive Symptoms (SAPS) (Andreasen, 1984) and the scales of the SUMD (Table 1). Moreover a lineal regression analysis
Scale for the Assessment of Negative Symptoms (SANS) (Andrea- was performed in order to assess the inuence of gender in insight
sen, 1982). Unlike the original authors of the PANSS (Kay et al., dimensions controlling by clinical (PANSS-Lindermayer's factors,
1987), the Spanish version, widely used in our eld, showed a GAF, diagnosis, years of evolution, and age of onset) and socio-
modest internal consistency and an insufcient factorial validity of demographic variables (marital status, age) that are different be-
the positive scale, indicating, as the authors pointed out, that it is tween men and women. Gender was signicant only with regard
composed by several independent components. The Five-PANSS to the total attribution subscale, showing an r2 of 0.026 and a value
Lidenmayer's Factors (Lindenmayer et al., 1995) Positive, Nega- of B  0.437 (p 0.043).
tive, Cognitive, Depressive, and Excitement in separate factor By contrast, when awareness and attribution of each particular
analyses explaining 51.7% (at baseline of the study) and 56.2% psychotic symptom was explored separately, signicant differ-
(after a washout of treatment) of the variances, respectively. ences between men and women were observed (Table 2). Women
The Spanish complete version of the Scale of Unawareness of showed a worse awareness of thought disorder and alogia.
Mental Disorder (Ruiz et al., 2008) was elaborated through a Moreover, women showed higher misattribution in apathy.
standardized method (translationretrotranslation from the ori- Table 3 shows the correlations between insight and clinical
ginal English Scale. The Intraclass Correlation Coefcient (ICC) was variables by gender. Insight dimensions in women signicantly
calculated for the reliability analysis and the Spearman correlation correlated with the global severity of psychopathology (total
coefcient between the SUMD scores and one independent score PANSS), the modied-Positive, and the Cognitive Lindermayers
of global insight for external validity (G12 item of the PANSS). The Factors. In men, signicant associations were found with the
ICC were all 4 0.70. Convergent validity with the independent modied-Positive and the Cognitive Lindermayer's Factors, except
global measurement of insight was found for the general items of for the total attribution. The Excitement Factor was related to total
awareness of mental disorder and awareness of the effects of awareness. Moreover, the Excitement Factor was related with
medication, and for the subscale on awareness of symptoms. Al- awareness of the effects of medication and of the disease. Some
though there are other valid and useful scales to assess clinical or sociodemographic and functional variables inuenced the results.
cognitive Insight, the SUMD was chosen in the present study on In addition, in women, age was only associated with the total
the basis that it is the most widely used in clinical practice in our awareness of the illness and awareness of the effects of medica-
setting and separately analyzes each symptom. tion. In men, the duration of the illness, age, and functionality
The Global Assessment of Functioning Scale (GAF) (Endicott were related to total awareness. Age and GAF were related with
et al., 1976) measured functionality. Premorbid Intelligence Quo- awareness of the effects of medication in men.
tient (IQ) was estimated by the Vocabulary subtest of the Verbal Table 4 shows the clinical, functional, and sociodemographic
subscale of Wechsler Adult Intelligence Scale (Wechsler et al., data that explained each of the insight dimensions by gender.
1997; Miralbell et al., 2010). Higher cognitive and positive symptoms, early stage of the illness,
and having been married explain decits of insight dimensions in
2.4. Statistical analysis women. On the other hand, in men, other variables such as lower
functioning; higher age; other psychosis diagnosis; and, to a lower
The normal distribution of data of the quantitative scales was extent, higher scores in cognitive, positive, and excitative symp-
veried using the KolmogorovSmirnov test. Assessment of the toms, explain decits of insight dimensions.
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 4. Discussion
symptom where there were less than 60 patients, the Mann
Whitney U test was used. The Pearson's correlation coefcients The aim of this study was to assess gender differences in the
between insight and its dimensions with relevant psychopatho- decit of insight, as well as to explore the relationship between
logical and outcome variables were calculated. Due to the number insight and clinical, sociodemographic, and functional variables by
of comparisons the level of signicance has been considered in a gender in a large multicentric sample of patients with schizo-
p-value o0.01. A multiple regression analysis by gender was phrenia and other psychotic disorders in different clinical settings.
performed using the stepwise method to assess the inuence of No differences by gender were found in the three main insight
gender in the explanation of insight. A rst model was performed dimensions or in the total awareness and total attribution sub-
including only gender and a second was done including gender, scales of the SUMD. By contrast, some signicant differences be-
clinical, and sociodemographic variables. The inuence of gender 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.


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

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

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

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)
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;
Total Attribution 0.051 0.011 (0.012; 0.056

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)
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.

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

4.2. Gender differences in insight dimensions authors pointed out, different interventions had a global medium
effect on insight (d .34, 95% condence interval [CI], 0.120.57).
Levels of insight were found to be relatively poor, similar to The effects of CBT, adherence therapy, and psycho-education were
previous reports (Carpenter et al., 1973; Carpenter et al., 1976; small to moderate, but not signicant, probably due to a lack of
Amador et al., 1994). The analysis of gender differences in the power (Pijnenborg et al., 2013). The authors proposed that insight
decit of insight showed an absence of global gender differences could be a potential therapeutic target and subsequently capable
in the three main insight dimensions, as well as in the total of modication (and improvement) by several psychological
awareness and total attribution of symptoms. Although previous treatments. As the authors pointed out in the meta-analysis,
studies on this topic are scarce and have used different insight comprehensive intervention programs consisting of multiple
conceptualizations and explored different patient proles, similar components may be particularly promising (Pijnenborg et al.,
data in patients with schizophrenia were reported (Amador et al., 2013).
1994; Moriarty et al., 2001; Ayesa-Arriola et al., 2011; Wiffen et al., On the other hand, some previous studies with CBT also found
2012). However, using regression analysis, Pru et al. (2012) de- improvements of both clinical and insight symptoms. Turkington
tected gender to be one of the variables explaining insight in et al. (2006) founded a clinically signicant change of 25% or more
schizophrenia. Using the same approach, our study only showed in insight and negative symptoms in an intervention with CBT, but
signicant results when gender was considered together with previous studies on the effect of CBT in symptoms have to be taken
clinical and sociodemographic variables and only in the total at- into account that, in most of them, insight was also a secondary
tribution subscale. measure and not a target of the intervention.
On the other hand, reports on gender differences in insight in With regard to gender differences in CBT outcomes in schizo-
rst episode psychosis or early stage of the illness are somewhat phrenia, Brabban et al. (2009) also reported relevant data. In the
contradictory. No gender differences have been found in several CBT group, only female gender was found to strongly predict a
studies (Mutsatsa et al., 2006; Ayesa-Arriola et al., 2011; Wiffen reduction in overall symptoms (p .004, odds ratio [OR] 2.39,
et al., 2012), although McEvoy et al. (2006) observed that young 95% CI, 1.334.30) and increase in insight (p .04, OR 1.84, 95%
female patients within their rst episode of psychosis had a better CI, 1.033.29) (Brabban et al., 2009). Additionally, a contemporary
insight. However, they used a self-report insight measure, which study founded a moderate improvement of insight in CBT (Penn
may explain differences with other studies. Moreover, Parellada
et al., 2009). We proposed that gender aspects would be included
et al. (2011) found women to have a better insight in total
in the planning of future CBT and other therapies devoted to in-
awareness and total attribution of symptoms, suggesting that this
sight in schizophrenia and other psychosis. Our results suggested
might have been due to the better metalizing abilities in women,
that, among others, therapeutic interventions on insight in women
which is consistent with data reported by Das et al. (2012).
had to be focused on clinical symptoms, whereas in men they had
However, a great proportion of studies with rst episode psychosis
to be more focused on psychosocial aspects.
included patients younger than 18 years of age (Parellada et al.,
With regard to the impact of insight on depression and the risk
2011); therefore, this could explain differences with our results.
of suicidality, as we pointed out in the introduction, there is also a
Other possible factors could be the heterogeneity of diagnosis in
small positive relationship between clinical insight (Mintz et al.,
the non-schizophrenia spectrum rst episode group (Parellada
2003) and cognitive insight (Palmer et al., 2015) and depressive
et al., 2011), the short evolution of the illness (Parellada et al.,
symptoms in schizophrenia. In addition, we pointed out that there
2011; Ayesa-Arriola et al., 2011; Wiffen et al., 2012), or the re-
is a debate suggesting that insight may represent a risk factor for
levance of the evolutive maturation of cognitive and metacogni-
suicide in patients with schizophrenia. As shown in recent studies,
tive resources in child and adolescent samples (Frommann et al.,
if there is an association between such risk and insight, it appears
2011; Barbato et al., 2013; Gur et al., 2014; Vohs et al., 2015). In
to be mediated by other variables such as depression, duration of
addition, our sample is composed of adult, mature persons with a
untreated psychosis, and, above all, hopelessness (Lpez-Morigo
wide range of age, mostly evolutive patients. All of these char-
acteristics make our sample different from rst episode psychosis, et al., 2012; Lpez-Morigo et al., 2014). On the other hand, im-
at-risk samples, or mainly early-stage schizophrenia and other provements in insight during psychological treatments for psy-
psychoses samples. chotic disorders did not seem to be associated with increased
depression (Pijnenborg et al., 2013). In our sample, we did not
4.3. Gender differences in insight of each particular symptom detect any gender-based differences in the depressive Linden-
mayers PANSS factor (Table 1) or in the anhedonia symptom
None of the previous studies that were reviewed had assessed (Table 2). When we analyzed separately the inuence of the dif-
gender differences in the awareness and attribution of each par- ferent clinical and sociodemographic factors by gender (Table 3),
ticular symptom separately. When this was carried out in the the depressive Lindenmayers PANSS factor did not inuence the
present study, women had a worse awareness of suffering some of insight dimensions in both sexes.
the core symptoms of psychosis, such as thought disorder and A strength of the present study has been the conduct of a
alogia. On the other hand, when attribution was explored in pa- symptom-by-symptom analysis. In previous studies, this type of
tients with awareness of a particular symptom, it was found that analysis has not been conducted, as it is very difcult with com-
women made signicantly more erratic attributions of their apa- mon sample sizes because not all patients have the same symp-
thy as compared to men. toms; therefore, groups in which awareness and attribution of
These results could help sensitize doctors and mental health each particular symptom can be explored tend to be too small. The
staff for gender differences and, thus, benet therapeutic inter- importance of studying insight in each particular symptom has
ventions. Despite some trial-based evidence suggesting no clear been repeatedly pointed out, since it has been suggested that the
and convincing advantage for Cognitive-Behavioral Therapy (CBT) nature of insight into each psychotic symptom may vary widely
and other psychological therapies for people with schizophrenia (Rossell et al., 2003; David et al., 2012). For example, being aware
(Jones et al., 2012; Jauhar et al., 2014), we found enough evidence that one is convinced of a delusional thought that is in fact untrue
to support the research on CBT and perhaps other psychological may be of a different nature that being aware of one's avolition.
interventions for some specic symptoms in schizophrenia and The large sample of patients of the present research allowed
other psychosis, including insight (Pijnenborg et al., 2013). As the studying this aspect.
J. Cobo et al. / Psychiatry Research 243 (2016) 268277 275

4.4. The impact of different factors on insight dimensions in men and insight allows us to have a better understanding of insight phe-
women nomena. The gender approach in schizophrenia and other psy-
chosis research could contribute to a better comprehension of the
Clinical positive and cognitive symptoms were the factors that illness, as gender could inuence several relevant factors in the
mainly explained insight dimensions in women in the multiple illness, as age of onset, functionality, outcomes, cognition or clin-
regression analysis. In men, the impact of psychopathological ical expressions, and metacognitive variables including insight.
measures in insight is lower, and other factors such as age, diag-
nosis, and psychosocial functioning emerge as possible mediators 4.6. Conclusions
of insight dimensions. Therefore, while men and women in the
present sample showed a similar clinical severity of symptoms No gender differences in the three main dimensions of insight
with no apparent differences in their level of insight in the three in psychosis were found, neither in awareness nor in attribution of
main insight dimensions, different factors explained the phe- symptoms when assessed globally. However, gender differences
nomenology of insight according to gender. These results suggest appear in awareness and attribution of particular symptoms when
that interventions addressed to improve insight of the illness assessed separately, with women showing higher levels of un-
should be different in women than in men. Psycho-educational awareness and misattribution than men. On the other hand, a
interventions should be carried out in women with greater pre- different pattern of clinical, sociodemographic, and functional
sence of positive and cognitive symptoms, irrespective of their variables seem to affect insight in men and women differently.
functional impairment. The role of gender in insight needs to be This gender analysis supports not only the multidimensional view
taken into consideration (Pru et al., 2012). Gender differences in of insight but also the need to study the awareness and attribution
psychological factors, health service seeking, or neurocognitive of each symptom separately, as well as the differential inuences
functions could determine the gender differences observed in in- of functional, cultural, and clinical factors in the phenomenology
sight (Dindia et al., 1992; Levinson and Ifrah, 2010). of insight in psychosis. A greater understanding of gender differ-
Our results partially conrm our initial hypothesis. We detected ences in psychosis could help in the design of more effective
some signicant differences between men and women affected by preventive and therapeutic psychiatric and psychosocial strategies.
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 Role of the funding sources
showed no differences in global awareness and attribution of
psychotic disorder but exhibited certain signicant differences None related to the present study.
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 Conicts of interest
gender, as each gender shows a different pattern of inuences for
each dimension. None related to the present study.
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 Acknowledgments
the impact of different variables could change by gender (Ochoa
et al., 2011). After stratication by sex, our results showed a dif-
We thank Marta Pulido, for editing the initial manuscript and
ferent impact of clinical sociodemographic and outcome variables
editorial assistance. We thank Carles Garca-Ribera, for his com-
in insight in men and women. Until today, most (but not all) of the
ments and suggestions and for editing the nal version 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.

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