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Awareness of being a patient and its relevance to insight into illness in patients with schizophrenia
Awareness of Being a Patient and Its Relevance to Insight Into Illness in Patients With Schizophrenia Naoki Hayashi, Mitsuru Yamashina, and Yoshito Igarashi This article presents the development of the Awareness of Being a Patient Scale (ABPS), a 25-item selfreport scale to measure the awareness of schizophrenic patients. Awareness is defined in terms of a patient's psychological attitude toward the psychiatric situation, and is to be evaluated from the standpoint of Parsons' sick-role concept by assessing the recognition of the need for treatment and acceptance of the treatment situation. It is hypothesized that awareness is a factor in the motivation to receive treatment. Closely related to the awareness is the insight into illness, a clinical construct comprising a patient's understanding of psychotic illness and symptoms. There also seems to be an overlap between
them. However, the difference is that awareness principally pertains t o a patient's perspective, not addressing the precise understanding of illness and symptoms, while the frame of reference in assessing insight is from the viewpoint of psychiatry. In examining properties of the ABPS, it is demonstrated that the ABPS has satisfactory reliability, favorable concurrent validity, and significant value in discriminating between long-term stable outpatients and recently admitted and long-term hospitalized patients. This study indicates that the awareness of being a patient has clinical importance and the ABPS is an efficient means of measuring such awareness. Copyright © 1999 by W.B. Saunders Company
ONSIDERABLE NUMBERS of patients with schizophrenia are unable to acknowledge their illness and are thus noncompliant with psychiatric treatment.~,2 A focus of our clinical efforts for such patients is to motivate them to receive psychiatric treatment. The recent increase in the volume of literature on insight into illness is explained in part by a heightened interest in factors that facilitate treatment compliance. Insight can be an important bridge for treatment implementation and continuation. 3 However, a number of factors other than insight are involved in treatment compliance. One of the factors we examine in this report is the awareness of being a patient. Awareness is defined in terms of a patient's psychological attitude as a patient in a psychiatric situation. It is hypothesized that schizophrenic patients with poor insight can be motivated to receive psychiatric treatment when they are aware of their being a patient. The sociological studies performed by Parsons 4 depicted the meaning of being a patient by defining the concept of the sick-role of the pateint as a socially settled role. According to this theory, two essential tasks of the role on the part of the patient are to make an effort to recover from illness and, for this purpose, to cooperate with mental health workers. The concept is applicable to the awareness of being a patient, as it is an ideal type of patient attitude when the role is fulfilled. The awareness can be appraised in the two domains corresponding to the patient's tasks of the sick-role by asking to what extent patients recognize the need for treatment and to what extent they accept the
treatment situation and cooperate with mental health workers. Closely related to awareness is insight into illness, a useful clinical construct that comprises an understanding of illness and symptoms. 2,3 Insight into illness justifiably has a strong influence on the awareness of being a patient. Furthermore, there may be an overlap of content between awareness and insight into illness. David 5 and Birchwood et al 6 have proposed that the domain related to treatment compliance or recognition of the need for treatment be included in the concept of insight. They emphasize that insight is a multidimensional construct, including at least an awareness of illness, attribution of symptoms, and acknowledgment of the need for treatment, the last of which is the domain in common with awareness. However, awareness is distinguished from insight into illness in at least two respects. First, awareness is appraised primarily from the viewpoint of the sickrole of the patient, while insight into illness is evaluated in terms of agreement or disagreement with the view postulated from the psychiatry side. Second, it principally pertains to the patient's
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From the Department of Psychopathology; Tokyo Psychiatric Institute, Tokyo; Department of Psychiatry, School of Medicine, Juntendo University, Tokyo; and Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, Tokyo, Japan. Address reprint requests to Naoki Hayashi, Ph.D., Tokyo Psychiatric Institute, 2-1-8 Kamikitazawa Setagaya-ku, Tokyo, Japan 156-8585. Copyright © 1999 by W.B. Saunders Company 0010-440X/99/4005-0013510.00/0
ComprehensivePsychiatry, Vol. 40, No. 5 (September/October), 1999: pp 377-385
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perspective, and therefore does not address the precise u n d e r s t a n d i n g of illness and symptoms, which is the core of some basic definitions of insight.2,3,7 It should be stressed that the patient's perspective has certain clinical importance. Several researchers have investigated the relationship between the patient's perspective and treatment compliance. B u d d et al.8 showed that the perspective of the patient in terms of illness and neuroleptic medication, which they referred to as the health belief, had value in discriminating b e t w e e n treatm e n t - c o m p l i a n t and n o n c o m p l i a n t patients. Similarly, B u c h a n a n 9 found that patients' perspectives of themselves and their treatment could predict medication compliance. A n o t h e r point of view is that the patient's perspective is changeable in a psychosocial context. The patient's perspective, including the awareness of being a patient, usually has a long course of development. Lally 1° illustrated the formative process of identity as a patient a m o n g schizophrenic patients, which is a more developed form of awareness of b e i n g a patient. It is based on the various experiences patients have in the course of illness such as repeated admissions, receiving a disability pension, persistent psychotic symptoms, etc., which inexorably reveal the presence of illness to them. However, a n e w perspective is attained w h e n they accept their identity as a patient while preserving their self-esteem in a positive and realistic way. They find a w a y out from the demoralization caused b y the stigmatized view of their illness, b e c o m e able to cope with the disorder efficiently with the help of mental health workers, and have familiar feelings toward peer patients and the treatment situation. In this manner, patients can change their perspective and acquire the awareness to feel secure in their treatment, Therefore, it is suggested that some therapeutic interventions can facilitate acquirement of the awareness. The theme of this article is twofold. First, it illustrates the d e v e l o p m e n t and validity and reliability of the Awareness of Being a Patient Scale (ABPS), a 25-item self-report scale that we constructed with the aim o f evaluating awareness. Next, in the light of findings obtained in the former part of this study, the clinical significance of awareness is discussed with special reference to its relationship to insight into illness.
HAYASHI, YAMASHINA, AND IGAFIASHI METHOD
Development of the ABPS In the first stage of the scale development, we separated the concept of awareness into components that are thought to represent aspects conforming to the face-validity method. Two domains of components in accordance with Parsons's sick-role concept are the aspects of recognition of the need for psychiatric treatment and attitudes toward elements of the treatment situation, We composed items of the scale from descriptions in the actual statements and autobiographies of schizophrenic patients that are relevant to each component of awareness. Fifty-two items were selected for the original item set of the ABPS administered in the study. Items with inadequate reliability scores or judged to be noncontributory to reliability and factor-analytic studies were removed from the scale. Twentyfive items were selected for the final version and used in further analyses. The item descriptions of the final version pertain to the following areas of the patients' attitude: recognition of the need for treatment in general (items 8, 11, 17, 19, and 23), for neuroleptic medication (items 5 and 9), and for participation in treatment (items 18, 20, 21, and 25) and attitude toward psychiatric treatment (items 1, 2, 3, and 15), medication (items 22 and 24), treatment staff (items 4, 6, 7, and 12), and peer patients (items 10, 13, 14, and 16). The scale can be self-rated, but in the present study, our group administered it in interviews.
Scoring of the ABPS All ABPS items were scored on the following four-point scale: strongly agree, 4; mildly agree, 3; mildly disagree, 2; and strongly disagree, 1. The items were subdivided into two groups by the direction of scoring. Items of the first group (items 1, 2, 3, 4, 5, 7, 10, 13, 14, 16, 17, 19, 21, 24, and 25) were those for which an affirmative answer indicates greater (positive) awareness. Negative items (items 6, 8, 9, 11, 12, 15, 18, 20, 22, and 23) were those for which an affirmative answer indicates less (negative) awareness. The scale score was calculated by subtracting the negative item score from the total score of the other items. High ABPS scores show that the subject was more aware of being a patient; low scores mean the opposite.
Subjects Two hundred four patients with schizophrenia participated in the study. They were in a clinically stable condition and were currently receiving treatment at Tokyo Metropolitan Matsuzawa Hospital, a large psychiatric center in central Tokyo for regional psychiatric service and treatment of difficult patients. The diagnosis was made on the basis of case records according to DSM-III-R criteria. We obtained written informed consent from the subjects for inclusion in the study. Demographic and clinical data for the subjects are shown in Table 1. The subjects were mostly long-term users of psychiatric services with persistent psychotic symptoms and dysfunction.
Subject Assessment Factors that may affect the awareness were also evaluated in a major subsample of 136 subjects. There was no significant difference in demographic and clinical features between the
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Table 1. Demographic and Clinical Characteristics of the Subjects (meen -+ el)) Characteristic
Total Sample (N = 204)
Subsample (n = 136)
Sex ratio (Male/female; n, %) Inpatients/outpatients (n, %) Age at investigation (yr) Chronicity (yr) Age at onset (yr) Neuroleptic daily dose (mg)* Education (yr) Inpatient days in past 3 years Lifetime hospitalizations (n)
116 (57)/88 (43) 61 (30)/143 (70) 41.8 ± 11.8 (18-67) 16.9 _+ 10.7 (1-49) 25.8 ± 8.0 (12-59) 1,004 _+ 984 (50-4,200) 12.4 ± 2.4 (6-16) 300 _+ 419 (0-1,095) 3.5 ± 3.1 (0-15)
70 (51)/66 (49) 44 (32)/92 (68) 42.5 ± 11.0 (20-66) 16.9 _+ 9.1 (1-37) 25.6 - 8.0 (14-55) 1,027 ± 962 (50-4,200) 12.5 _+ 2.5 (6-16) 317 _+ 418 (0-1,095) 3.8 _+ 3.2 (0-15)
NOTE. The range of values is shown in parentheses. *Chlorpromazine equivalents.
subsample and the other subjects, with the exception of the sex ratio: the subsample had more female subjects. Current clinical symptoms and general functioning were rated according to the Positive and Negative Syndrome Scale (PANSS) 11 and Global Assessment Scale (GAS). 12 Social adjustment was assessed by the Social Adjustment Scale II (SAS II) 13 and self-esteem by Rosenberg's Self-Esteem Scale (RSES). 14 High scores for SAS II items indicate less social adjustment. The RSES was scored according to the Lickert format, indicating that a high score means high self-esteem. The GAS score, PANSS scores for the positive, negative, and general psychopathology subscales, and overall adjustment score for SAS II of the subjects (mean _+ SD) were 50.8 _+ 10.1, 16.9 _+ 6.1, 19.4 _+ 5.2, 36.6 ± 8.2, and 5.2 _+ 1.1, respectively. For the purpose of assessing insight into illness, we used PANSS item G12, i.e., lack of judgment and insight. This item includes examination of the patient's recognition of the psychiatric illness, symptoms, and need for treatment. In addition, three general items of Amador's insight scale, 15 a five-point scale on the current recognition of illness, effects of medication, and social consequences of illness, were rated. Treatment-compliant behavior of inpatient subjects was assessed by the ward nursing staff using the Therapeutic Alliance Scale (TAS), 16 a six-point scale with anchor scoring descriptions. A high score indicates less compliant behavior to inpatient treatment. Test-retest reliability for items of the ABPS was examined in a subsample of 32 patients. A reliability study for some of the other scales used in this study was also performed in a sample of 24 patients included in the 32-patient subsample. To test the interrater reliability of the SAS II, two raters made independent ratings of the scale on the basis of a single interview. RSES reliability was determined by a test-retest method together with a reliability study of the ABPS. With respect to the reliability of the PANSS rating, Igarashi et al. 17 reported that our research group attained a satisfactory level of interrater reliability for the assessment.
Data Analysis To examine the factor structure of ABPS, principalcomponents factor analysis with varimax rotation was performed. In the reliability studies of the scales in this study, the intraclass correlation coefficient (ICC) was calculated. Cronbach's alpha coefficient was used to assess the internal consistency of the ABPS and its subscales. To show concurrent
validity of the ABPS, correlations of the scale scores with scores for the lack of insight and other related clinical variables were sought (a = .05, two-tailed). To determine the value of the ABPS score for discriminating long-term stable outpatients from recently admitted and long-term hospitalized patients, logistic regression analysis was performed. Linear regression analyses were also performed to examine factors that affect scores on the ABPS and its subscales. The SPSS (Release 6.0) statistical package was used for data analysis (SPSS, Chicago, IL). RESULTS
Factor Structure of the ABPS F a c t o r - a n a l y t i c s t u d y o f 25 i t e m s o f the A B P S identified five factors w i t h e i g e n v a l u e s g r e a t e r t h a n 1. T h e v a r i a n c e e x p l a i n e d b y e a c h o f the e x t r a c t e d factors was as follows: f a c t o r 1, 19.7%; f a c t o r 2, 10.4%; f a c t o r 3, 8 . 2 % ; f a c t o r 4, 6 . 5 % ; a n d f a c t o r 5, 5.2%. A t w o - f a c t o r s o l u t i o n was s e l e c t e d b y i n s p e c tion o f the scree plot o f the factors a n d f o u n d to b e t h e o r e t i c a l l y m e a n i n g f u l . T a b l e 2 p r e s e n t s the rot a t e d f a c t o r structure that a c h i e v e d a c e r t a i n d e g r e e o f simplicity. All i t e m s e x c e p t o n e h a d a s u b s t a n t i a l l o a d i n g o n e i t h e r o f the factors. T h e t w o factors w e r e r e c o g n i t i o n o f the n e e d for t r e a t m e n t (factor 1) a n d a c c e p t a n c e o f the t r e a t m e n t s i t u a t i o n (factor 2). F a c t o r 1 w a s c o m p o s e d o f i t e m s i n d i c a t i n g w h e t h e r the patient a c k n o w l e d g e d the i n d i s p e n s a b i l ity o f p s y c h i a t r i c t r e a t m e n t . F a c t o r 2 was signific a n t l y r e l a t e d to i t e m s i n d i c a t i n g the s u b j e c t ' s attitude t o w a r d the p s y c h i a t r i c situation. T h e s e factors c o r r e s p o n d to the t w o d o m a i n s o f the p a t i e n t role d e f i n e d b y P a r s o n s . 4 S u b s c a l e 1 is c o m p o s e d o f 13 i t e m s a n d s u b s c a l e 2 12 i t e m s (Table 2). S u b s c a l e scores w e r e c a l c u l a t e d in the s a m e w a y as the o v e r a l l A B P S score, b y s u b t r a c t i n g the s u m o f n e g a t i v e i t e m scores f r o m t h e s u m o f the o t h e r i t e m scores. C o r r e l a t i o n coefficients b e t w e e n
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Table 2. Varimax-Rotated Factor Structure for A B P S Item Scores
Factor 1: Recognition of Need for Treatment
ABPS Items Subscale 1 (abbreviated items) I would be all right if I stopped treatment right now. (item 23) I will be able to stop treatment within a few years. (item 8) I will be able to stop taking medicine within a few years. (item 9) Treatment is an inseparable part of my life. (item 25) It is necessary for me to take medicine. (item 5) I feel coerced to receive treatment by others. (item 18) I need to be careful in daily life not to incur relapse. (item 21) I need to receive treatment for a rather long period. (item 17) I need to cooperate with hospital staff. (item 19) I do not want to admit that I need treatment. (item 11) Treatment can prevent future problems. (item 24) I feel coerced to take medicine by others. (item 20) Adverse effects of my medicine overwhelm its effects. (item 22) Subscale 2 (abbreviated items) The hospital (clinic) is a place for patients to learn about mental health. (item 3) The hospital staff is kind and caring. (item 7) I am ill-treated in hospital (clinic). (item 12) A mental hospital is a place for patients to rest. (item 2) I can express my feelings freely in the mental hospital. (item 4) Psychiatric treatment is helpful for my recovery. (item 1) Psychiatric treatment is of no use to me. (item 15) There are some patients who understand me well. (item 14) The hospital staffs are strict and hard on me. (item 6) Cooperating with other patients helps me improve my mental health. (item 16) I feel familiar with other patients as they are receiving treatment like me. (item 10) There are some patients who can be a good model for me, (item 13)
Factor2: Acceptance of Treatment Situation
-.776 -.702 -.701
.652 .535 - .495 .473 .472 .446 -.433 .431 -.371 -.365
-.351
.662 .565 -.553 .523 .523 .520 - .499 .444 -.442 .405 .403 .402
NOTE. Only items that loaded at -~.30 are shown.
the factor score of factor 1 and the subscale 1 score and the factor score of factor 2 and the subscale 2 score were .970 and .955, respectively.
Reliability of the ABPS For the purpose of assessing test-retest reliability of the ABPS and its subscales, ABPS interviews were performed on two occasions 10 to 17 days apart in the subsample of 32 patients. An acceptable level of test-retest reliability for each ABPS item was demonstrated, with a mean of .601 +_ .149 across ICCs of the items and a range of .351 to .869. ICCs for the ABPS, subscale 1, and subscale 2 were .877, .800, and .829, respectively. Cronbach's alpha was .817 for the overall ABPS, .803 for subscale 1, and .743 for subscale 2. These alpha coefficients indicate a satisfactory level of internal consistency for the scale and subscales. Correlation coefficients among the scores for the ABPS and its subscales were as follows: ABPS with subscale 1, .843; ABPS with subscale 2, .787; and subscale 1 with subscale 2, .333. Reliability studies for other scales used in this
study yielded good results. ICCs calculated in the interrater reliability study for the overall adjustment scale of the SAS II and in the test-retest trial of the RSES were .632 and .836, respectively.
Concurrent Validity of the ABPS In examining concurrent validity, evaluation of insight is another issue for consideration. For measuring insight, the lack of judgment and insight (PANSS G12) score was used. Correlation coefficients of the PANSS G12 score with the scores of Amador's scales on the concurrent recognition of illness, effects of medication, social consequences of illness, and the total were .737, .714, .690, and .844, respectively. These correlations indicate that the PANSS G12 score is an efficient measure reflecting assessments in the important domains of insight. The results of correlation analyses to assess concurrent validity of the ABPS are shown in Table 3. The ABPS and subscale 1 moderately correlated with the lack of judgment and insight (PANSS G12). These correlations endorse the relationship
AWARENESS OF BEING A PATIENT AND INSIGHT
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Table 3. Significant Correlation of ABPS Scores and Lack of Insight With Psychiatric Symptoms and Clinical Variables Parameter PANSS Positive subscale Negative subscale General psychopathology Lack of insight (G12) GAS score Inpatient days in past 3 years* Duration of outpatient treatment* Neuroleptic daily dose*ll Overall adjustment (SAS II) Self-esteem (RSES) Life satisfaction (SAS II item 52) TAS¶
ABPS -.213t -.285at
Subscale 1 Subscale2 -.169t -.226at
-.261at -.507§ .341§
-.526§ .311at
-.198t
-.168t
.180t
Lack of Insight
-.175t -.235at
.525§ .565§
-.273at
.561§
-.280at .235at
-.541§ .476§
.167t
-.476§ .262at
-.291at
-.212at
-.262at
.452at .300§
-.280~t -.385at
-.177t -.4431
-.271at
.260at .325t
NOTE. Pearson's correlation coefficient was used where data are not shown. Lack of insight is lack of judgment and insight (PANSS item G12). *Spearman's rank-order correlation coefficient: t P < .05, atP< .01, §P< .001. IIChlorpromazine equivalents. ¶n = 45 (only for inpatients).
between the ABPS score and insight into illness. The ABPS and its subscales were only slightly correlated with the scores on PANSS subscales. In contrast, lack of judgment and insight showed moderate correlations with scores on the PANSS subscales and GAS. To examine the relationship of scores on the ABPS and lack of insight to the mood condition, correlations with the scores for grandiosity (PANSS P5) and depression (PANSS G6) were sought. A significant correlation only between grandiosity and lack of insight (.337, P < .001) was observed. The overall ABPS score correlated negatively with hospitalization days in the prior 3 years, and positively with duration of successive outpatient treatment and overall social adjustment (SAS II). Lack of judgment and insight had a moderate correlation with psychiatric inpatient days in the past 3 years and short duration of successive outpatient days, while the ABPS and its subscales showed only small but significant correlations with these variables. The neuroleptic daily dose was correlated only with lack of judgment and insight,
not with the ABPS and its subscales. These findings indicate that the lack of insight is more closely related to psychotic symptoms than the awareness of being a patient. Instead, the ABPS and its subscales had significant correlations with overall social adjustment, life satisfaction, self-esteem, and treatment-compliant behavior during hospitalization (TAS). These results suggest that psychosocial factors have substantial influence on the awareness of being a patient. The correlation patterns observed in the ABPS and lack of judgment and insight reflect the different makeup of the two indices: the former is comparatively related to psychosocial factors and the latter to psychiatric symptoms and illness severity. These analyses demonstrate the sound psychometric properties of the ABPS and its subscales: good test-retest reliability and internal consistency and favorable concurrent validity. Discriminant Value of the ABPS Table 4 shows the results of logistic regression analysis to test whether the ABPS score has the power to discriminate long-term stable outpatients without hospital admission for more than 2 years (n = 58) from recently admitted patients with more than 100 psychiatric inpatient days in the past 3 years (n = 39). As the variables, the scores for the positive and negative subscales of the PANSS, the RSES, life satisfaction on SAS II item 52, overall adjustment on the SAS II, and the ABPS were initially contained in the analysis. The forward stepwise procedure (P to enter = .05 and P to remove = .10) selected the scores for the ABPS and lack of judgment and insight as significant factors, and correctly classified 68% of 97 cases. Table 4. Stepwise Logistic Regression Analysis to Discriminate Between Long-Term Stable Outpatients and Recently Admitted and Long-Term Hospitalized Patients Parameter
B
SE
Wald
df
R
ABPS score Lack of insight
.056* -.695*
.026 .277
4.71 6.31
1 1
-.144 -.182
NOTE. Lack of insight is the score for lack of judgment and insight (PANSS item G12). Dependent variables were longterm stable outpatients without admission for more than 2 years (n = 58), =1, and recently admitted and long-term hospitalized patients who were admitted and had more than 100 inpatient days in the past 3 years (n = 39), =0. Independent variables were the scores for the positive and negative subscales of the PANSS, RSES score, life satisfaction (SAS II item 52), overall adjustment (SAS II), and overall ABPS score. * P < .05.
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HAYASHI, YAMASHINA, AND IGARASHI
This analysis shows that the ABPS score, juxtaposed with insight, is an index to discriminate between long-term stable outpatients and recently admitted and long-term hospitalized patients. The result indicates that the awareness of being a patient may be a clinical predictor similar to but possibly distinct from insight into illness.
Factors Affecting the ABPS Table 5 shows the results of multiple regression analyses using the scores on the ABPS and its subscales as dependent variables and the same forward stepwise procedure as the previous logistic regression analysis. The results indicated that the ABPS score is elevated by insight into illness and life satisfaction; subscale 1 score, by insight and high self-esteem; and subscale 2 score, by insight and low self-esteem. They seem to support an assumption that insight into illness has great influence on the awareness of being a patient. On the other hand, the effects of the RSES score on the subscales were confounding. It is supposed that self-esteem exerts an effect on the awareness in two ways: high self-esteem facilitates acceptance of the treatment situation while enhancing denial of the need for treatment. In the analysis with the overall ABPS score as a dependent variable, the effect of self-esteem was canceled and, instead, life satisfaction emerged as a weak but significant facilitating factor of the awareness.
Table 5. Stepwise Multiple Regression Analysis ofthe ABPS and Its Subscales Parameter ABPS Lack of insight Life satisfaction ABPS subscale 1 Lack of insight Self-esteem ABPS subscale 2 Lack of insight Self-esteem
B
SE B
Beta
df
Multiple R
-4.89 -1.43
.800 .678
-.465¢ -.159"
1,134 2, 133
.507 .529
-3.71 -.16
.500 .074
-.5415 -.156"
1,134 2, 133
.526 .548
-1.54 .25
.488 .073
-.254t .274t
1,134 2, 133
.300 .391
NOTE. Lack of insight is the score for lack of judgment and insight (PANSS G12). Self-esteem is the score for the RSES. Life satisfaction is the life satisfaction score (SAS II item 52). Independent variables were the scores on the positive and negative subscales (PANSS), self-esteem (RSES), life satisfaction (SAS II item 52), and overall adjustment (SAS ll). * P < ,05. t P < ,01. SP< ,001.
DISCUSSION
Insight into Illness and Awareness of Being a Patient The awareness of being a patient is introduced in this article as the psychological attitude of a patient toward the psychiatric situation, and is presumed to have clinical importance. By comparison to insight and other related concepts, the features of awareness will be delineated. The issue of defining insight in schizophrenic patients has not been resolved. The definition of the International Pilot Study of Schizophrenia, 2 "the patient capacity to acknowledge some awareness of having an emotional illness," is thought to be a common denominator of definitions. The classic notion of Jaspers 17 is that insight is "an ideal of correct awareness of illness" in which psychotic patients understand the symptoms and nature of the illness to the extent that their social background and intelligence allow. These basic notions place great emphasis on the understanding of illness and symptoms and seemingly not on the treatment compliance or recognition of the need for treatment. It is not inappropriate to consider treatmentcompliant behavior as a domain of the concept of insight, because it is fulfilled when the patient attains "an ideal of correct awareness of illness." This standpoint also meets a practical need to view insight as a factor for treatment compliance. However, the broad concept of insight produces a diversity of definitions or evaluations. Many researchers have included the recognition of the need for treatment in the definition. David 5 included the acknowledgment of the need for treatment, an aspect of treatment compliance, as a factor within insight in addition to awareness of illness and correct attribution of symptoms. Lin et al.18 contended that insight should be evaluated by acknowledgment of the need for treatment and medication. The scale used by McEvoy et al.19 concentrated on the awareness of the need for treatment and of having mental illness. The assessment of PANSS item G12 used in this study, although it was a single-item scale, addresses several related domains including recognition of the psychiatric illness, symptoms, and need for treatment, u Adhering to a basic definition of insight, in contrast, the insight scale devised by Amador et al. 15 emphasized the awareness and attribution of symptoms,
AWARENESS OF BEING A PATIENT AND INSIGHT
as well as the awareness of illness, perceived effects of medication, and social consequences of illness in the assessment of insight. Markova and Berrios 2° assumed a phenomenological position in defining insight. They considered insight to be a sort of self-knowledge, and contended that insight was assessed by patients' awareness of qualitative changes in themselves and the outside world. When the broad concept of insight is used, the awareness of being a patient has a considerable overlap with insight, particularly in the recognition of the need for treatment, the domain covered by subscale 1. Assessment of this recognition by the subscale had a moderate correlation with a lack of insight scored on the PANSS. This domain also has much in common with the health-belief concept presented by Budd et al., 7 which is composed of a patient's perspective on the likelihood of relapse, distress caused by relapse, and benefits of medication. On the other hand, acceptance of the treatment situation as assessed by ABPS subscale 2 was correlated with good social adjustment and high life satisfaction and self-esteem. This result seems to reflect the extent to which the patient feels secure in the situation. This relationship is consistent with Soskis and Bowers' result 21 that a positive and optimistic self-image is correlated with good social adjustment. With respect to the etiology of lack of insight, a number of causative factors ranging from psychodynamic factors to neurocognitive deficits have been argued. 3,5 This condition is due in part to the conceptual breadth or diversity of definitions of insight. It is necessary to clarify which factor is responsible for a certain aspect of lack of insight in order to make the evaluation more useful. In the case of the awareness of being a patient, psychosocial factors should be highlighted. The awareness addresses the patient's perspective in the treatment situation, which is supposed to be formed in a psychosocial context. In the correlation analyses of this study, awareness measured by theABPS seemed to have a psychosocial grounding. This finding supports the presumed makeup of the awareness.
Clinical Significance of the Awareness of Being a Patient One of the values that insight into illness has in clinical psychiatry is that it is a factor for treatment compliance and outcome. A follow-up study by McEvoy et al. 22 found that patients with greater
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insight were less likely to be admitted. Buchanan, 9 Kemp and David, 23 and Schwartz et al.24 showed that insight has predictive value for treatment compliance and outcome. Heinrichs et alY reported that patients who are aware of the relapse process are less likely to be readmitted. Studies by Lin et al., ~8 Bartko et al., 26 and Cuffel et al. 27 have noted that a lack of insight relates to medication noncompliance. The notion that lack of insight relates to compliance and prognosis is explained in part by its close relationship to the severity of psychotic illness. When illness is severe, the probability of readmission and noncompliance increases. Kay and Sevy,28 Kim et al., 29 and Fleming et al., 3° as well as the present study, showed that the lack of insight has a strong correlation with psychotic symptomatology, whereas the awareness of being a patient and other perspectives of the patient do not relate as closely to symptoms. The perspective of the psychotic patient also plays a role in treatment compliance and outcome. Soskis and Bowers 21 found that an optimistic and positive view of oneself and psychiatric treatment is predictive of good posthospital social adjustment at follow-up evaluation. Buchanan 9 confirmed these findings in a 2-year follow-up study on schizophrenic patients, and added recognition of the need for medication as another factor for treatment compliance. Budd et al., 8 on the basis of their health-belief model, reported that the perspective on illness and medication had a stronger effect on medication compliance than insight. In the present study, the ABPS score, as well as lack of insight, successfully discriminated long-term stable outpatients from recently admitted and long-term hospitalized patients. This finding suggests that awareness is a factor for the prevention of readmission, in addition to insight. The formative process of the awareness of being a patient is also an issue for discussion. The awareness is a result of a complicated psychosocial process that occurs over the long course of the illness. It is supposed that the process requires a long period because of the impairment of insight and the fact that the aversive experiences of having a psychotic illness are not easily incorporated within the identity. In the earliest stage of illness, awareness may be affected mainly by the degree of insight. However, in later stages, the awareness can develop, even if patients have only poor insight, on the basis of deliberate efforts to cope with the
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illness and to cooperate with mental health workers. Awareness is thought to be more susceptible to change in the psychosocial condition than insight, and can therefore be a focus of psychosocial intervention.
Self-Esteem and the Awareness of Being a Patient The self-esteem of the patient is important in the clinical consideration of the awareness of being a patient and insight. Preservation of self-esteem is of utmost priority for patients in the course of illness. Gaining insight or awareness of being a patient presents a crisis of self-esteem for the patient. There are studies indicating that schizophrenic patients with good insight into their illness have lower self-esteem (Thompson, 31 Warner et al., 32 and Taylor and Perkins 33) and are more depressed (David et al. 34 and Amador et al. 35) than those with poor insight. In the present study, this association was not significant. Instead, in line with the report by Bartko et al.,26 lack of insight was significantly correlated with grandiosity. Considering that the awareness is affected more by psychosocial factors than insight is, the relationship with self-esteem is clearer. In the trial of this study to find factors for awareness by regression analyses, self-esteem showed an effect on awareness in a paradoxical way: high self-esteem facilitated acceptance of the treatment situation while enhancing denial of the need for treatment. This finding is in accordance with the findings of previous studies 31-33 that self-esteem is correlated negatively with acceptance of the sick label and positively with social functioning. Regarding the overall ABPS score, life satisfaction emerged as a significant facilitating factor for awareness instead of self-esteem. This result suggests that psychoso-
cial intervention which improves life satisfaction and facilitates realistic self-esteem helps to advance the awareness. There are several limitations of this study that need to be mentioned. First, the data for the study are from a cross-sectional investigation, which restricts the value of the findings. To ascertain the data in a longitudinal investigation is indispensable. Next, no systemic sampling procedure was used. The subject sample of this study shifted to chronic and severe cases. The sample is not representative of schizophrenic patients in general. The results of this study may need to be verified in different patient populations. Lastly, this study is not exempted from the limitations of studies that use a self-report scale. For instance, the possibility that ABPS scores were influenced by the responses made in a socially desirable manner cannot be ignored. Despite these limitations, the results of this study are presumed to be valid. They are consistent with previous studies on the patient's perspective and insight while supporting the hypothesized concept of the awareness of being a patient. The awareness measured by the ABPS was substantially correlated with insight into illness and indices related to treatment compliance, and had significant value in discriminating between long-term stable outpatients and long-term hospitalized patients when juxtaposed with insight into illness. These findings indicate that the awareness of being a patient has a clinical importance similar to but possibly distinct from that of insight into illness. It is considered that the awareness of being a patient is a pregnant concept for future investigation into schizophrenic patients' perspectives on their psychiatric situation and treatment compliance.
REFERENCES 1. Amador XF, Flaum M, Andreasen NC, Strauss DH, Yale SA, Clark SC, et al. Awareness of illness in schizophrenia and schizoaffective and mood disorders. Arch Gen Psychiatry 1994; 51:826-836. 2. World Health Organization. Report of the International Pilot Study of Schizophrenia. Vol. 1., Geneva, Switzerland: World Health Organization, 1973. 3. Amador XF, Strauss DH, Yale SA, Gorman JM. Awareness of illness in schizophrenia. Schizophr Bull 1991; 17:113-132. 4. Parsons T. Social structure and Personality. New York, NY: Free Press, 1964. 5. David AS. Insight and psychosis. Br J Psychiatry 1990;156: 798-808. 6. Birchwood M, Smith J, Dmry V, Healy J, Macmillan F,
Slade M. A self-report insight scale for psychosis: reliability, validity and sensitivity to change. Acta Psychiatr Scand 1994;89: 62-67. 7. Jaspers K. Allgemeiner Psychopathologie. Berlin, Germany: Springer-Verlag, 1913. 8. Budd RJ, Hughes ICT, Smith JA. Health beliefs and compliance with antipsychotic medication. Br J Clin Psychol 1996;35:393-397. 9. Buchanan A. A two-year prospective study of treatment compliance in patients with schizophrenia. Psychol Med 1992; 22:787-797. 10. Lally SJ. "Does being in here mean there is something wrong with me?" Schizophr Bull 1989;15:253-265. 11. Kay SR, Opler LA, Fiszbein A. Positive and Negative
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Syndrome Scale. Toronto, Ontario, Canada: MultiHealth Systems, 1991. 12. Endicott J, Spitzer RL, Fleiss JL. The GlobalAssessment Scale: a procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 1976;33:766-771. 13. Schooler NR, Hogarty GE, Weissman MM. Social Adjustment Scale II (SAS II). In: Hargreaves WA, Attkinson CC, Sorensen JE (eds): Resource Materials for Community Mental Health Program Evaluators. Washington, DC: US Department of Health, Education and Welfare, 1979;290-330. 14. Rosenberg M. Conceiving the Self, Reprint Edition. Melbourne, FL: Krieger, 1986. 15. Amador XF, Strauss DH, Yale SA, Flaum M, Endicott J, Gorman JM. Assessment of insight in psychosis. Am J Psychiatry 1993;150:873-879. 16. Clarkin JE Hurt SW, Crilly JL. Therapeutic alliance and hospital treatment outcome. Hosp Community Psychiatry 1987; 38:871-875. 17. Igarashi Y, Hayashi N, Yamashina M, Otsuka N, Kuroki N, Anzai N, et al. Interrater reliability of the Japanese version of the Positive and Negative Syndrome Scale (PANSS). Psychiatry Clin Neurosci 1998;52:467-470. 18. Lin IF, Spiga R, Fortsch W. Insight and adherence to medication in chronic schizophrenics. J Clin Psychiatry 1979;40: 430-432. 19. McEvoy JP, Aland J Jr, Wilson WH, Guy W, Hawkins L. Measuring chronic schizophrenic patients attitudes toward their illness and treatment. Hosp Community Psychiatry 1981 ;32:856858. 20. Markova IS, Berrios GE. The meaning of insight in clinical psychiatry. Br J Psychiatry 1992;160:850-860. 21. Soskis DA, Bowers MB. The schizophrenic experience: a follow-up study of attitude and posthospital adjustment. J Nerv Ment Dis 1969;149:443-449. 22. McEvoy JP, Freter S, Everett G, Geller JL, Appelbaum P, Apperson LJ, et al. Insight and the clinical outcome of schizophrenic patients. J Nerv Ment Dis 1989; 177:48-51. 23. Kemp R, David A. Psychological predictors of insight
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and compliance in psychotic patients. Br J Psychiatry 1996; 169: 444-450. 24. Schwartz RC, Cohen BN, Grubaugh A. Does insight affect long-term inpatient treatment outcome in chronic schizophrenia? Compr Psychiatry 1997;38:283-288. 25. Heinrichs DW, Cohen BP, Carpenter WT. Early insight and the management of schizophrenic decompensation. J Nerv Ment Dis 1985;173:133-138. 26. Bartko G, Herczeg I, Zador G. Clinical symptomatology and drug compliance in schizophrenic patients. Acta Psychiatr Scand 1988;77:74-76. 27. Cuffel BJ, Alford J, Fischer EP, Owen RR. Awareness of illness in schizophrenia and outpatient treatment adherence. J Nerv Ment Dis 1996;184:653-659. 28. Kay SR, Sevy S. Pyramidal model of schizophrenia. Schizophr Bull 1990;16:537-545. 29. Kim Y, Sakamoto K, Kamo T, Sakamura Y, Miyaoka H. Insight and clinical correlates in schizophrenia. Compr Psychiatry 1997;38:117-123. 30. Fennig S, Everett E, Bromet EJ, Jandorf L, Fennig SR, Tanenberg-Karant M, et al. Insight in first-admission psychotic patients. Schizophr Res 1996;22:257-263. 31. Thompson EH. Variation in the self-concept of young adult chronic patients: chronicity reconsidered. Hosp Community Psychiatry 1988;39:771-775. 32. Warner R, Taylor D, Powers M, Hyman J. Acceptance of the mental illness label by psychotic patients: effects on functioning. Am J Orthopsychiatry 1989;59:398-409. 33. Taylor KE, Perkins RE. Identity and coping with mental illness in long-stay psychiatric rehabilitation. Br J Clin Psychol 1991;30:73-85. 34. David AS, Os JV, Jones P, Harvey I, Foerster A, Fahy T. Insight and psychotic illness: cross-sectional and longitudinal associations. Br J Psychiatry 1995;167:621-628. 35. Amador XF, Friedman JH, Kasapis C, Yale S, Flaum M, Gorman JM. Suicidal behavior in schizophrenia and its relationship to awareness of illness. Am J Psychiatry 1996;153:11851188.
them. However, the difference is that awareness principally pertains t o a patient's perspective, not addressing the precise understanding of illness and symptoms, while the frame of reference in assessing insight is from the viewpoint of psychiatry. In examining properties of the ABPS, it is demonstrated that the ABPS has satisfactory reliability, favorable concurrent validity, and significant value in discriminating between long-term stable outpatients and recently admitted and long-term hospitalized patients. This study indicates that the awareness of being a patient has clinical importance and the ABPS is an efficient means of measuring such awareness. Copyright © 1999 by W.B. Saunders Company
ONSIDERABLE NUMBERS of patients with schizophrenia are unable to acknowledge their illness and are thus noncompliant with psychiatric treatment.~,2 A focus of our clinical efforts for such patients is to motivate them to receive psychiatric treatment. The recent increase in the volume of literature on insight into illness is explained in part by a heightened interest in factors that facilitate treatment compliance. Insight can be an important bridge for treatment implementation and continuation. 3 However, a number of factors other than insight are involved in treatment compliance. One of the factors we examine in this report is the awareness of being a patient. Awareness is defined in terms of a patient's psychological attitude as a patient in a psychiatric situation. It is hypothesized that schizophrenic patients with poor insight can be motivated to receive psychiatric treatment when they are aware of their being a patient. The sociological studies performed by Parsons 4 depicted the meaning of being a patient by defining the concept of the sick-role of the pateint as a socially settled role. According to this theory, two essential tasks of the role on the part of the patient are to make an effort to recover from illness and, for this purpose, to cooperate with mental health workers. The concept is applicable to the awareness of being a patient, as it is an ideal type of patient attitude when the role is fulfilled. The awareness can be appraised in the two domains corresponding to the patient's tasks of the sick-role by asking to what extent patients recognize the need for treatment and to what extent they accept the
treatment situation and cooperate with mental health workers. Closely related to awareness is insight into illness, a useful clinical construct that comprises an understanding of illness and symptoms. 2,3 Insight into illness justifiably has a strong influence on the awareness of being a patient. Furthermore, there may be an overlap of content between awareness and insight into illness. David 5 and Birchwood et al 6 have proposed that the domain related to treatment compliance or recognition of the need for treatment be included in the concept of insight. They emphasize that insight is a multidimensional construct, including at least an awareness of illness, attribution of symptoms, and acknowledgment of the need for treatment, the last of which is the domain in common with awareness. However, awareness is distinguished from insight into illness in at least two respects. First, awareness is appraised primarily from the viewpoint of the sickrole of the patient, while insight into illness is evaluated in terms of agreement or disagreement with the view postulated from the psychiatry side. Second, it principally pertains to the patient's
C
From the Department of Psychopathology; Tokyo Psychiatric Institute, Tokyo; Department of Psychiatry, School of Medicine, Juntendo University, Tokyo; and Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, Tokyo, Japan. Address reprint requests to Naoki Hayashi, Ph.D., Tokyo Psychiatric Institute, 2-1-8 Kamikitazawa Setagaya-ku, Tokyo, Japan 156-8585. Copyright © 1999 by W.B. Saunders Company 0010-440X/99/4005-0013510.00/0
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perspective, and therefore does not address the precise u n d e r s t a n d i n g of illness and symptoms, which is the core of some basic definitions of insight.2,3,7 It should be stressed that the patient's perspective has certain clinical importance. Several researchers have investigated the relationship between the patient's perspective and treatment compliance. B u d d et al.8 showed that the perspective of the patient in terms of illness and neuroleptic medication, which they referred to as the health belief, had value in discriminating b e t w e e n treatm e n t - c o m p l i a n t and n o n c o m p l i a n t patients. Similarly, B u c h a n a n 9 found that patients' perspectives of themselves and their treatment could predict medication compliance. A n o t h e r point of view is that the patient's perspective is changeable in a psychosocial context. The patient's perspective, including the awareness of being a patient, usually has a long course of development. Lally 1° illustrated the formative process of identity as a patient a m o n g schizophrenic patients, which is a more developed form of awareness of b e i n g a patient. It is based on the various experiences patients have in the course of illness such as repeated admissions, receiving a disability pension, persistent psychotic symptoms, etc., which inexorably reveal the presence of illness to them. However, a n e w perspective is attained w h e n they accept their identity as a patient while preserving their self-esteem in a positive and realistic way. They find a w a y out from the demoralization caused b y the stigmatized view of their illness, b e c o m e able to cope with the disorder efficiently with the help of mental health workers, and have familiar feelings toward peer patients and the treatment situation. In this manner, patients can change their perspective and acquire the awareness to feel secure in their treatment, Therefore, it is suggested that some therapeutic interventions can facilitate acquirement of the awareness. The theme of this article is twofold. First, it illustrates the d e v e l o p m e n t and validity and reliability of the Awareness of Being a Patient Scale (ABPS), a 25-item self-report scale that we constructed with the aim o f evaluating awareness. Next, in the light of findings obtained in the former part of this study, the clinical significance of awareness is discussed with special reference to its relationship to insight into illness.
HAYASHI, YAMASHINA, AND IGAFIASHI METHOD
Development of the ABPS In the first stage of the scale development, we separated the concept of awareness into components that are thought to represent aspects conforming to the face-validity method. Two domains of components in accordance with Parsons's sick-role concept are the aspects of recognition of the need for psychiatric treatment and attitudes toward elements of the treatment situation, We composed items of the scale from descriptions in the actual statements and autobiographies of schizophrenic patients that are relevant to each component of awareness. Fifty-two items were selected for the original item set of the ABPS administered in the study. Items with inadequate reliability scores or judged to be noncontributory to reliability and factor-analytic studies were removed from the scale. Twentyfive items were selected for the final version and used in further analyses. The item descriptions of the final version pertain to the following areas of the patients' attitude: recognition of the need for treatment in general (items 8, 11, 17, 19, and 23), for neuroleptic medication (items 5 and 9), and for participation in treatment (items 18, 20, 21, and 25) and attitude toward psychiatric treatment (items 1, 2, 3, and 15), medication (items 22 and 24), treatment staff (items 4, 6, 7, and 12), and peer patients (items 10, 13, 14, and 16). The scale can be self-rated, but in the present study, our group administered it in interviews.
Scoring of the ABPS All ABPS items were scored on the following four-point scale: strongly agree, 4; mildly agree, 3; mildly disagree, 2; and strongly disagree, 1. The items were subdivided into two groups by the direction of scoring. Items of the first group (items 1, 2, 3, 4, 5, 7, 10, 13, 14, 16, 17, 19, 21, 24, and 25) were those for which an affirmative answer indicates greater (positive) awareness. Negative items (items 6, 8, 9, 11, 12, 15, 18, 20, 22, and 23) were those for which an affirmative answer indicates less (negative) awareness. The scale score was calculated by subtracting the negative item score from the total score of the other items. High ABPS scores show that the subject was more aware of being a patient; low scores mean the opposite.
Subjects Two hundred four patients with schizophrenia participated in the study. They were in a clinically stable condition and were currently receiving treatment at Tokyo Metropolitan Matsuzawa Hospital, a large psychiatric center in central Tokyo for regional psychiatric service and treatment of difficult patients. The diagnosis was made on the basis of case records according to DSM-III-R criteria. We obtained written informed consent from the subjects for inclusion in the study. Demographic and clinical data for the subjects are shown in Table 1. The subjects were mostly long-term users of psychiatric services with persistent psychotic symptoms and dysfunction.
Subject Assessment Factors that may affect the awareness were also evaluated in a major subsample of 136 subjects. There was no significant difference in demographic and clinical features between the
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Table 1. Demographic and Clinical Characteristics of the Subjects (meen -+ el)) Characteristic
Total Sample (N = 204)
Subsample (n = 136)
Sex ratio (Male/female; n, %) Inpatients/outpatients (n, %) Age at investigation (yr) Chronicity (yr) Age at onset (yr) Neuroleptic daily dose (mg)* Education (yr) Inpatient days in past 3 years Lifetime hospitalizations (n)
116 (57)/88 (43) 61 (30)/143 (70) 41.8 ± 11.8 (18-67) 16.9 _+ 10.7 (1-49) 25.8 ± 8.0 (12-59) 1,004 _+ 984 (50-4,200) 12.4 ± 2.4 (6-16) 300 _+ 419 (0-1,095) 3.5 ± 3.1 (0-15)
70 (51)/66 (49) 44 (32)/92 (68) 42.5 ± 11.0 (20-66) 16.9 _+ 9.1 (1-37) 25.6 - 8.0 (14-55) 1,027 ± 962 (50-4,200) 12.5 _+ 2.5 (6-16) 317 _+ 418 (0-1,095) 3.8 _+ 3.2 (0-15)
NOTE. The range of values is shown in parentheses. *Chlorpromazine equivalents.
subsample and the other subjects, with the exception of the sex ratio: the subsample had more female subjects. Current clinical symptoms and general functioning were rated according to the Positive and Negative Syndrome Scale (PANSS) 11 and Global Assessment Scale (GAS). 12 Social adjustment was assessed by the Social Adjustment Scale II (SAS II) 13 and self-esteem by Rosenberg's Self-Esteem Scale (RSES). 14 High scores for SAS II items indicate less social adjustment. The RSES was scored according to the Lickert format, indicating that a high score means high self-esteem. The GAS score, PANSS scores for the positive, negative, and general psychopathology subscales, and overall adjustment score for SAS II of the subjects (mean _+ SD) were 50.8 _+ 10.1, 16.9 _+ 6.1, 19.4 _+ 5.2, 36.6 ± 8.2, and 5.2 _+ 1.1, respectively. For the purpose of assessing insight into illness, we used PANSS item G12, i.e., lack of judgment and insight. This item includes examination of the patient's recognition of the psychiatric illness, symptoms, and need for treatment. In addition, three general items of Amador's insight scale, 15 a five-point scale on the current recognition of illness, effects of medication, and social consequences of illness, were rated. Treatment-compliant behavior of inpatient subjects was assessed by the ward nursing staff using the Therapeutic Alliance Scale (TAS), 16 a six-point scale with anchor scoring descriptions. A high score indicates less compliant behavior to inpatient treatment. Test-retest reliability for items of the ABPS was examined in a subsample of 32 patients. A reliability study for some of the other scales used in this study was also performed in a sample of 24 patients included in the 32-patient subsample. To test the interrater reliability of the SAS II, two raters made independent ratings of the scale on the basis of a single interview. RSES reliability was determined by a test-retest method together with a reliability study of the ABPS. With respect to the reliability of the PANSS rating, Igarashi et al. 17 reported that our research group attained a satisfactory level of interrater reliability for the assessment.
Data Analysis To examine the factor structure of ABPS, principalcomponents factor analysis with varimax rotation was performed. In the reliability studies of the scales in this study, the intraclass correlation coefficient (ICC) was calculated. Cronbach's alpha coefficient was used to assess the internal consistency of the ABPS and its subscales. To show concurrent
validity of the ABPS, correlations of the scale scores with scores for the lack of insight and other related clinical variables were sought (a = .05, two-tailed). To determine the value of the ABPS score for discriminating long-term stable outpatients from recently admitted and long-term hospitalized patients, logistic regression analysis was performed. Linear regression analyses were also performed to examine factors that affect scores on the ABPS and its subscales. The SPSS (Release 6.0) statistical package was used for data analysis (SPSS, Chicago, IL). RESULTS
Factor Structure of the ABPS F a c t o r - a n a l y t i c s t u d y o f 25 i t e m s o f the A B P S identified five factors w i t h e i g e n v a l u e s g r e a t e r t h a n 1. T h e v a r i a n c e e x p l a i n e d b y e a c h o f the e x t r a c t e d factors was as follows: f a c t o r 1, 19.7%; f a c t o r 2, 10.4%; f a c t o r 3, 8 . 2 % ; f a c t o r 4, 6 . 5 % ; a n d f a c t o r 5, 5.2%. A t w o - f a c t o r s o l u t i o n was s e l e c t e d b y i n s p e c tion o f the scree plot o f the factors a n d f o u n d to b e t h e o r e t i c a l l y m e a n i n g f u l . T a b l e 2 p r e s e n t s the rot a t e d f a c t o r structure that a c h i e v e d a c e r t a i n d e g r e e o f simplicity. All i t e m s e x c e p t o n e h a d a s u b s t a n t i a l l o a d i n g o n e i t h e r o f the factors. T h e t w o factors w e r e r e c o g n i t i o n o f the n e e d for t r e a t m e n t (factor 1) a n d a c c e p t a n c e o f the t r e a t m e n t s i t u a t i o n (factor 2). F a c t o r 1 w a s c o m p o s e d o f i t e m s i n d i c a t i n g w h e t h e r the patient a c k n o w l e d g e d the i n d i s p e n s a b i l ity o f p s y c h i a t r i c t r e a t m e n t . F a c t o r 2 was signific a n t l y r e l a t e d to i t e m s i n d i c a t i n g the s u b j e c t ' s attitude t o w a r d the p s y c h i a t r i c situation. T h e s e factors c o r r e s p o n d to the t w o d o m a i n s o f the p a t i e n t role d e f i n e d b y P a r s o n s . 4 S u b s c a l e 1 is c o m p o s e d o f 13 i t e m s a n d s u b s c a l e 2 12 i t e m s (Table 2). S u b s c a l e scores w e r e c a l c u l a t e d in the s a m e w a y as the o v e r a l l A B P S score, b y s u b t r a c t i n g the s u m o f n e g a t i v e i t e m scores f r o m t h e s u m o f the o t h e r i t e m scores. C o r r e l a t i o n coefficients b e t w e e n
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Table 2. Varimax-Rotated Factor Structure for A B P S Item Scores
Factor 1: Recognition of Need for Treatment
ABPS Items Subscale 1 (abbreviated items) I would be all right if I stopped treatment right now. (item 23) I will be able to stop treatment within a few years. (item 8) I will be able to stop taking medicine within a few years. (item 9) Treatment is an inseparable part of my life. (item 25) It is necessary for me to take medicine. (item 5) I feel coerced to receive treatment by others. (item 18) I need to be careful in daily life not to incur relapse. (item 21) I need to receive treatment for a rather long period. (item 17) I need to cooperate with hospital staff. (item 19) I do not want to admit that I need treatment. (item 11) Treatment can prevent future problems. (item 24) I feel coerced to take medicine by others. (item 20) Adverse effects of my medicine overwhelm its effects. (item 22) Subscale 2 (abbreviated items) The hospital (clinic) is a place for patients to learn about mental health. (item 3) The hospital staff is kind and caring. (item 7) I am ill-treated in hospital (clinic). (item 12) A mental hospital is a place for patients to rest. (item 2) I can express my feelings freely in the mental hospital. (item 4) Psychiatric treatment is helpful for my recovery. (item 1) Psychiatric treatment is of no use to me. (item 15) There are some patients who understand me well. (item 14) The hospital staffs are strict and hard on me. (item 6) Cooperating with other patients helps me improve my mental health. (item 16) I feel familiar with other patients as they are receiving treatment like me. (item 10) There are some patients who can be a good model for me, (item 13)
Factor2: Acceptance of Treatment Situation
-.776 -.702 -.701
.652 .535 - .495 .473 .472 .446 -.433 .431 -.371 -.365
-.351
.662 .565 -.553 .523 .523 .520 - .499 .444 -.442 .405 .403 .402
NOTE. Only items that loaded at -~.30 are shown.
the factor score of factor 1 and the subscale 1 score and the factor score of factor 2 and the subscale 2 score were .970 and .955, respectively.
Reliability of the ABPS For the purpose of assessing test-retest reliability of the ABPS and its subscales, ABPS interviews were performed on two occasions 10 to 17 days apart in the subsample of 32 patients. An acceptable level of test-retest reliability for each ABPS item was demonstrated, with a mean of .601 +_ .149 across ICCs of the items and a range of .351 to .869. ICCs for the ABPS, subscale 1, and subscale 2 were .877, .800, and .829, respectively. Cronbach's alpha was .817 for the overall ABPS, .803 for subscale 1, and .743 for subscale 2. These alpha coefficients indicate a satisfactory level of internal consistency for the scale and subscales. Correlation coefficients among the scores for the ABPS and its subscales were as follows: ABPS with subscale 1, .843; ABPS with subscale 2, .787; and subscale 1 with subscale 2, .333. Reliability studies for other scales used in this
study yielded good results. ICCs calculated in the interrater reliability study for the overall adjustment scale of the SAS II and in the test-retest trial of the RSES were .632 and .836, respectively.
Concurrent Validity of the ABPS In examining concurrent validity, evaluation of insight is another issue for consideration. For measuring insight, the lack of judgment and insight (PANSS G12) score was used. Correlation coefficients of the PANSS G12 score with the scores of Amador's scales on the concurrent recognition of illness, effects of medication, social consequences of illness, and the total were .737, .714, .690, and .844, respectively. These correlations indicate that the PANSS G12 score is an efficient measure reflecting assessments in the important domains of insight. The results of correlation analyses to assess concurrent validity of the ABPS are shown in Table 3. The ABPS and subscale 1 moderately correlated with the lack of judgment and insight (PANSS G12). These correlations endorse the relationship
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381
Table 3. Significant Correlation of ABPS Scores and Lack of Insight With Psychiatric Symptoms and Clinical Variables Parameter PANSS Positive subscale Negative subscale General psychopathology Lack of insight (G12) GAS score Inpatient days in past 3 years* Duration of outpatient treatment* Neuroleptic daily dose*ll Overall adjustment (SAS II) Self-esteem (RSES) Life satisfaction (SAS II item 52) TAS¶
ABPS -.213t -.285at
Subscale 1 Subscale2 -.169t -.226at
-.261at -.507§ .341§
-.526§ .311at
-.198t
-.168t
.180t
Lack of Insight
-.175t -.235at
.525§ .565§
-.273at
.561§
-.280at .235at
-.541§ .476§
.167t
-.476§ .262at
-.291at
-.212at
-.262at
.452at .300§
-.280~t -.385at
-.177t -.4431
-.271at
.260at .325t
NOTE. Pearson's correlation coefficient was used where data are not shown. Lack of insight is lack of judgment and insight (PANSS item G12). *Spearman's rank-order correlation coefficient: t P < .05, atP< .01, §P< .001. IIChlorpromazine equivalents. ¶n = 45 (only for inpatients).
between the ABPS score and insight into illness. The ABPS and its subscales were only slightly correlated with the scores on PANSS subscales. In contrast, lack of judgment and insight showed moderate correlations with scores on the PANSS subscales and GAS. To examine the relationship of scores on the ABPS and lack of insight to the mood condition, correlations with the scores for grandiosity (PANSS P5) and depression (PANSS G6) were sought. A significant correlation only between grandiosity and lack of insight (.337, P < .001) was observed. The overall ABPS score correlated negatively with hospitalization days in the prior 3 years, and positively with duration of successive outpatient treatment and overall social adjustment (SAS II). Lack of judgment and insight had a moderate correlation with psychiatric inpatient days in the past 3 years and short duration of successive outpatient days, while the ABPS and its subscales showed only small but significant correlations with these variables. The neuroleptic daily dose was correlated only with lack of judgment and insight,
not with the ABPS and its subscales. These findings indicate that the lack of insight is more closely related to psychotic symptoms than the awareness of being a patient. Instead, the ABPS and its subscales had significant correlations with overall social adjustment, life satisfaction, self-esteem, and treatment-compliant behavior during hospitalization (TAS). These results suggest that psychosocial factors have substantial influence on the awareness of being a patient. The correlation patterns observed in the ABPS and lack of judgment and insight reflect the different makeup of the two indices: the former is comparatively related to psychosocial factors and the latter to psychiatric symptoms and illness severity. These analyses demonstrate the sound psychometric properties of the ABPS and its subscales: good test-retest reliability and internal consistency and favorable concurrent validity. Discriminant Value of the ABPS Table 4 shows the results of logistic regression analysis to test whether the ABPS score has the power to discriminate long-term stable outpatients without hospital admission for more than 2 years (n = 58) from recently admitted patients with more than 100 psychiatric inpatient days in the past 3 years (n = 39). As the variables, the scores for the positive and negative subscales of the PANSS, the RSES, life satisfaction on SAS II item 52, overall adjustment on the SAS II, and the ABPS were initially contained in the analysis. The forward stepwise procedure (P to enter = .05 and P to remove = .10) selected the scores for the ABPS and lack of judgment and insight as significant factors, and correctly classified 68% of 97 cases. Table 4. Stepwise Logistic Regression Analysis to Discriminate Between Long-Term Stable Outpatients and Recently Admitted and Long-Term Hospitalized Patients Parameter
B
SE
Wald
df
R
ABPS score Lack of insight
.056* -.695*
.026 .277
4.71 6.31
1 1
-.144 -.182
NOTE. Lack of insight is the score for lack of judgment and insight (PANSS item G12). Dependent variables were longterm stable outpatients without admission for more than 2 years (n = 58), =1, and recently admitted and long-term hospitalized patients who were admitted and had more than 100 inpatient days in the past 3 years (n = 39), =0. Independent variables were the scores for the positive and negative subscales of the PANSS, RSES score, life satisfaction (SAS II item 52), overall adjustment (SAS II), and overall ABPS score. * P < .05.
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HAYASHI, YAMASHINA, AND IGARASHI
This analysis shows that the ABPS score, juxtaposed with insight, is an index to discriminate between long-term stable outpatients and recently admitted and long-term hospitalized patients. The result indicates that the awareness of being a patient may be a clinical predictor similar to but possibly distinct from insight into illness.
Factors Affecting the ABPS Table 5 shows the results of multiple regression analyses using the scores on the ABPS and its subscales as dependent variables and the same forward stepwise procedure as the previous logistic regression analysis. The results indicated that the ABPS score is elevated by insight into illness and life satisfaction; subscale 1 score, by insight and high self-esteem; and subscale 2 score, by insight and low self-esteem. They seem to support an assumption that insight into illness has great influence on the awareness of being a patient. On the other hand, the effects of the RSES score on the subscales were confounding. It is supposed that self-esteem exerts an effect on the awareness in two ways: high self-esteem facilitates acceptance of the treatment situation while enhancing denial of the need for treatment. In the analysis with the overall ABPS score as a dependent variable, the effect of self-esteem was canceled and, instead, life satisfaction emerged as a weak but significant facilitating factor of the awareness.
Table 5. Stepwise Multiple Regression Analysis ofthe ABPS and Its Subscales Parameter ABPS Lack of insight Life satisfaction ABPS subscale 1 Lack of insight Self-esteem ABPS subscale 2 Lack of insight Self-esteem
B
SE B
Beta
df
Multiple R
-4.89 -1.43
.800 .678
-.465¢ -.159"
1,134 2, 133
.507 .529
-3.71 -.16
.500 .074
-.5415 -.156"
1,134 2, 133
.526 .548
-1.54 .25
.488 .073
-.254t .274t
1,134 2, 133
.300 .391
NOTE. Lack of insight is the score for lack of judgment and insight (PANSS G12). Self-esteem is the score for the RSES. Life satisfaction is the life satisfaction score (SAS II item 52). Independent variables were the scores on the positive and negative subscales (PANSS), self-esteem (RSES), life satisfaction (SAS II item 52), and overall adjustment (SAS ll). * P < ,05. t P < ,01. SP< ,001.
DISCUSSION
Insight into Illness and Awareness of Being a Patient The awareness of being a patient is introduced in this article as the psychological attitude of a patient toward the psychiatric situation, and is presumed to have clinical importance. By comparison to insight and other related concepts, the features of awareness will be delineated. The issue of defining insight in schizophrenic patients has not been resolved. The definition of the International Pilot Study of Schizophrenia, 2 "the patient capacity to acknowledge some awareness of having an emotional illness," is thought to be a common denominator of definitions. The classic notion of Jaspers 17 is that insight is "an ideal of correct awareness of illness" in which psychotic patients understand the symptoms and nature of the illness to the extent that their social background and intelligence allow. These basic notions place great emphasis on the understanding of illness and symptoms and seemingly not on the treatment compliance or recognition of the need for treatment. It is not inappropriate to consider treatmentcompliant behavior as a domain of the concept of insight, because it is fulfilled when the patient attains "an ideal of correct awareness of illness." This standpoint also meets a practical need to view insight as a factor for treatment compliance. However, the broad concept of insight produces a diversity of definitions or evaluations. Many researchers have included the recognition of the need for treatment in the definition. David 5 included the acknowledgment of the need for treatment, an aspect of treatment compliance, as a factor within insight in addition to awareness of illness and correct attribution of symptoms. Lin et al.18 contended that insight should be evaluated by acknowledgment of the need for treatment and medication. The scale used by McEvoy et al.19 concentrated on the awareness of the need for treatment and of having mental illness. The assessment of PANSS item G12 used in this study, although it was a single-item scale, addresses several related domains including recognition of the psychiatric illness, symptoms, and need for treatment, u Adhering to a basic definition of insight, in contrast, the insight scale devised by Amador et al. 15 emphasized the awareness and attribution of symptoms,
AWARENESS OF BEING A PATIENT AND INSIGHT
as well as the awareness of illness, perceived effects of medication, and social consequences of illness in the assessment of insight. Markova and Berrios 2° assumed a phenomenological position in defining insight. They considered insight to be a sort of self-knowledge, and contended that insight was assessed by patients' awareness of qualitative changes in themselves and the outside world. When the broad concept of insight is used, the awareness of being a patient has a considerable overlap with insight, particularly in the recognition of the need for treatment, the domain covered by subscale 1. Assessment of this recognition by the subscale had a moderate correlation with a lack of insight scored on the PANSS. This domain also has much in common with the health-belief concept presented by Budd et al., 7 which is composed of a patient's perspective on the likelihood of relapse, distress caused by relapse, and benefits of medication. On the other hand, acceptance of the treatment situation as assessed by ABPS subscale 2 was correlated with good social adjustment and high life satisfaction and self-esteem. This result seems to reflect the extent to which the patient feels secure in the situation. This relationship is consistent with Soskis and Bowers' result 21 that a positive and optimistic self-image is correlated with good social adjustment. With respect to the etiology of lack of insight, a number of causative factors ranging from psychodynamic factors to neurocognitive deficits have been argued. 3,5 This condition is due in part to the conceptual breadth or diversity of definitions of insight. It is necessary to clarify which factor is responsible for a certain aspect of lack of insight in order to make the evaluation more useful. In the case of the awareness of being a patient, psychosocial factors should be highlighted. The awareness addresses the patient's perspective in the treatment situation, which is supposed to be formed in a psychosocial context. In the correlation analyses of this study, awareness measured by theABPS seemed to have a psychosocial grounding. This finding supports the presumed makeup of the awareness.
Clinical Significance of the Awareness of Being a Patient One of the values that insight into illness has in clinical psychiatry is that it is a factor for treatment compliance and outcome. A follow-up study by McEvoy et al. 22 found that patients with greater
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insight were less likely to be admitted. Buchanan, 9 Kemp and David, 23 and Schwartz et al.24 showed that insight has predictive value for treatment compliance and outcome. Heinrichs et alY reported that patients who are aware of the relapse process are less likely to be readmitted. Studies by Lin et al., ~8 Bartko et al., 26 and Cuffel et al. 27 have noted that a lack of insight relates to medication noncompliance. The notion that lack of insight relates to compliance and prognosis is explained in part by its close relationship to the severity of psychotic illness. When illness is severe, the probability of readmission and noncompliance increases. Kay and Sevy,28 Kim et al., 29 and Fleming et al., 3° as well as the present study, showed that the lack of insight has a strong correlation with psychotic symptomatology, whereas the awareness of being a patient and other perspectives of the patient do not relate as closely to symptoms. The perspective of the psychotic patient also plays a role in treatment compliance and outcome. Soskis and Bowers 21 found that an optimistic and positive view of oneself and psychiatric treatment is predictive of good posthospital social adjustment at follow-up evaluation. Buchanan 9 confirmed these findings in a 2-year follow-up study on schizophrenic patients, and added recognition of the need for medication as another factor for treatment compliance. Budd et al., 8 on the basis of their health-belief model, reported that the perspective on illness and medication had a stronger effect on medication compliance than insight. In the present study, the ABPS score, as well as lack of insight, successfully discriminated long-term stable outpatients from recently admitted and long-term hospitalized patients. This finding suggests that awareness is a factor for the prevention of readmission, in addition to insight. The formative process of the awareness of being a patient is also an issue for discussion. The awareness is a result of a complicated psychosocial process that occurs over the long course of the illness. It is supposed that the process requires a long period because of the impairment of insight and the fact that the aversive experiences of having a psychotic illness are not easily incorporated within the identity. In the earliest stage of illness, awareness may be affected mainly by the degree of insight. However, in later stages, the awareness can develop, even if patients have only poor insight, on the basis of deliberate efforts to cope with the
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illness and to cooperate with mental health workers. Awareness is thought to be more susceptible to change in the psychosocial condition than insight, and can therefore be a focus of psychosocial intervention.
Self-Esteem and the Awareness of Being a Patient The self-esteem of the patient is important in the clinical consideration of the awareness of being a patient and insight. Preservation of self-esteem is of utmost priority for patients in the course of illness. Gaining insight or awareness of being a patient presents a crisis of self-esteem for the patient. There are studies indicating that schizophrenic patients with good insight into their illness have lower self-esteem (Thompson, 31 Warner et al., 32 and Taylor and Perkins 33) and are more depressed (David et al. 34 and Amador et al. 35) than those with poor insight. In the present study, this association was not significant. Instead, in line with the report by Bartko et al.,26 lack of insight was significantly correlated with grandiosity. Considering that the awareness is affected more by psychosocial factors than insight is, the relationship with self-esteem is clearer. In the trial of this study to find factors for awareness by regression analyses, self-esteem showed an effect on awareness in a paradoxical way: high self-esteem facilitated acceptance of the treatment situation while enhancing denial of the need for treatment. This finding is in accordance with the findings of previous studies 31-33 that self-esteem is correlated negatively with acceptance of the sick label and positively with social functioning. Regarding the overall ABPS score, life satisfaction emerged as a significant facilitating factor for awareness instead of self-esteem. This result suggests that psychoso-
cial intervention which improves life satisfaction and facilitates realistic self-esteem helps to advance the awareness. There are several limitations of this study that need to be mentioned. First, the data for the study are from a cross-sectional investigation, which restricts the value of the findings. To ascertain the data in a longitudinal investigation is indispensable. Next, no systemic sampling procedure was used. The subject sample of this study shifted to chronic and severe cases. The sample is not representative of schizophrenic patients in general. The results of this study may need to be verified in different patient populations. Lastly, this study is not exempted from the limitations of studies that use a self-report scale. For instance, the possibility that ABPS scores were influenced by the responses made in a socially desirable manner cannot be ignored. Despite these limitations, the results of this study are presumed to be valid. They are consistent with previous studies on the patient's perspective and insight while supporting the hypothesized concept of the awareness of being a patient. The awareness measured by the ABPS was substantially correlated with insight into illness and indices related to treatment compliance, and had significant value in discriminating between long-term stable outpatients and long-term hospitalized patients when juxtaposed with insight into illness. These findings indicate that the awareness of being a patient has a clinical importance similar to but possibly distinct from that of insight into illness. It is considered that the awareness of being a patient is a pregnant concept for future investigation into schizophrenic patients' perspectives on their psychiatric situation and treatment compliance.
REFERENCES 1. Amador XF, Flaum M, Andreasen NC, Strauss DH, Yale SA, Clark SC, et al. Awareness of illness in schizophrenia and schizoaffective and mood disorders. Arch Gen Psychiatry 1994; 51:826-836. 2. World Health Organization. Report of the International Pilot Study of Schizophrenia. Vol. 1., Geneva, Switzerland: World Health Organization, 1973. 3. Amador XF, Strauss DH, Yale SA, Gorman JM. Awareness of illness in schizophrenia. Schizophr Bull 1991; 17:113-132. 4. Parsons T. Social structure and Personality. New York, NY: Free Press, 1964. 5. David AS. Insight and psychosis. Br J Psychiatry 1990;156: 798-808. 6. Birchwood M, Smith J, Dmry V, Healy J, Macmillan F,
Slade M. A self-report insight scale for psychosis: reliability, validity and sensitivity to change. Acta Psychiatr Scand 1994;89: 62-67. 7. Jaspers K. Allgemeiner Psychopathologie. Berlin, Germany: Springer-Verlag, 1913. 8. Budd RJ, Hughes ICT, Smith JA. Health beliefs and compliance with antipsychotic medication. Br J Clin Psychol 1996;35:393-397. 9. Buchanan A. A two-year prospective study of treatment compliance in patients with schizophrenia. Psychol Med 1992; 22:787-797. 10. Lally SJ. "Does being in here mean there is something wrong with me?" Schizophr Bull 1989;15:253-265. 11. Kay SR, Opler LA, Fiszbein A. Positive and Negative
AWARENESS OF BEING A PATIENT AND INSIGHT
Syndrome Scale. Toronto, Ontario, Canada: MultiHealth Systems, 1991. 12. Endicott J, Spitzer RL, Fleiss JL. The GlobalAssessment Scale: a procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 1976;33:766-771. 13. Schooler NR, Hogarty GE, Weissman MM. Social Adjustment Scale II (SAS II). In: Hargreaves WA, Attkinson CC, Sorensen JE (eds): Resource Materials for Community Mental Health Program Evaluators. Washington, DC: US Department of Health, Education and Welfare, 1979;290-330. 14. Rosenberg M. Conceiving the Self, Reprint Edition. Melbourne, FL: Krieger, 1986. 15. Amador XF, Strauss DH, Yale SA, Flaum M, Endicott J, Gorman JM. Assessment of insight in psychosis. Am J Psychiatry 1993;150:873-879. 16. Clarkin JE Hurt SW, Crilly JL. Therapeutic alliance and hospital treatment outcome. Hosp Community Psychiatry 1987; 38:871-875. 17. Igarashi Y, Hayashi N, Yamashina M, Otsuka N, Kuroki N, Anzai N, et al. Interrater reliability of the Japanese version of the Positive and Negative Syndrome Scale (PANSS). Psychiatry Clin Neurosci 1998;52:467-470. 18. Lin IF, Spiga R, Fortsch W. Insight and adherence to medication in chronic schizophrenics. J Clin Psychiatry 1979;40: 430-432. 19. McEvoy JP, Aland J Jr, Wilson WH, Guy W, Hawkins L. Measuring chronic schizophrenic patients attitudes toward their illness and treatment. Hosp Community Psychiatry 1981 ;32:856858. 20. Markova IS, Berrios GE. The meaning of insight in clinical psychiatry. Br J Psychiatry 1992;160:850-860. 21. Soskis DA, Bowers MB. The schizophrenic experience: a follow-up study of attitude and posthospital adjustment. J Nerv Ment Dis 1969;149:443-449. 22. McEvoy JP, Freter S, Everett G, Geller JL, Appelbaum P, Apperson LJ, et al. Insight and the clinical outcome of schizophrenic patients. J Nerv Ment Dis 1989; 177:48-51. 23. Kemp R, David A. Psychological predictors of insight
385
and compliance in psychotic patients. Br J Psychiatry 1996; 169: 444-450. 24. Schwartz RC, Cohen BN, Grubaugh A. Does insight affect long-term inpatient treatment outcome in chronic schizophrenia? Compr Psychiatry 1997;38:283-288. 25. Heinrichs DW, Cohen BP, Carpenter WT. Early insight and the management of schizophrenic decompensation. J Nerv Ment Dis 1985;173:133-138. 26. Bartko G, Herczeg I, Zador G. Clinical symptomatology and drug compliance in schizophrenic patients. Acta Psychiatr Scand 1988;77:74-76. 27. Cuffel BJ, Alford J, Fischer EP, Owen RR. Awareness of illness in schizophrenia and outpatient treatment adherence. J Nerv Ment Dis 1996;184:653-659. 28. Kay SR, Sevy S. Pyramidal model of schizophrenia. Schizophr Bull 1990;16:537-545. 29. Kim Y, Sakamoto K, Kamo T, Sakamura Y, Miyaoka H. Insight and clinical correlates in schizophrenia. Compr Psychiatry 1997;38:117-123. 30. Fennig S, Everett E, Bromet EJ, Jandorf L, Fennig SR, Tanenberg-Karant M, et al. Insight in first-admission psychotic patients. Schizophr Res 1996;22:257-263. 31. Thompson EH. Variation in the self-concept of young adult chronic patients: chronicity reconsidered. Hosp Community Psychiatry 1988;39:771-775. 32. Warner R, Taylor D, Powers M, Hyman J. Acceptance of the mental illness label by psychotic patients: effects on functioning. Am J Orthopsychiatry 1989;59:398-409. 33. Taylor KE, Perkins RE. Identity and coping with mental illness in long-stay psychiatric rehabilitation. Br J Clin Psychol 1991;30:73-85. 34. David AS, Os JV, Jones P, Harvey I, Foerster A, Fahy T. Insight and psychotic illness: cross-sectional and longitudinal associations. Br J Psychiatry 1995;167:621-628. 35. Amador XF, Friedman JH, Kasapis C, Yale S, Flaum M, Gorman JM. Suicidal behavior in schizophrenia and its relationship to awareness of illness. Am J Psychiatry 1996;153:11851188.