Predicting domain-specific insight of schizophrenia patients from symptomatology, multiple neurocognitive functions, and personality related traits

Psychiatry Research 149 (2007) 59 – 69 www.elsevier.com/locate/psychres

Predicting domain-specific insight of schizophrenia patients from symptomatology, multiple neurocognitive functions, and personality related traits Michael S. Ritsner a,b,⁎, Haya Blumenkrantz a b

a Sha'ar Menashe Mental Health Center, Hadera, Israel Department of Psychiatry, the Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel

Received 26 August 2005; received in revised form 4 December 2005; accepted 1 January 2006

Abstract This study examines the contribution of various neurocognitive functions, clinical characteristics, and personality traits to the prediction of three insight dimensions. Clinically stable schizophrenia patients (n=107) residing in the community were evaluated using the Positive and Negative Syndrome Scale, the Scale for the Assessment of Unawareness of Mental Disorder, and a comprehensive battery of instruments to measure personality related variables and neurocognitive functioning. Step-wise multivariate regression analysis indicates significant association of variability in insight dimensions with neurocognitive functioning (20–41%), personality related traits (8–18% temperament factors, 4–7% self-constructs, 10–14% coping styles), severity of symptoms (about 7%), illness duration (6%), and education (about 5%). Poor insight was attributed to impairment in visual and movement skills, sustained attention, executive functions, intensity of autistic preoccupations and positive symptoms, as well as increased novelty seeking behavior, task and emotion oriented coping styles, better self-esteem, self-efficacy, and higher education. Better awareness was related to better performance of neurocognitive tasks, reward dependence behavior, avoidant coping style, and longer illness duration. Aside from common indicators for the various insight dimensions, we defined specific indicators for each insight dimension. Thus, insight dimensions in schizophrenia patients residing in the community were attributed to neurocognitive and personality related factors rather than to psychopathological symptoms. The findings enable better understanding of the multifactorial nature of insight and highlight targets for more effective intervention and rehabilitation. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Schizophrenia; Insight; Neurocognitive functions; Personality traits; Coping styles

1. Introduction Insight in schizophrenia has been defined as a complex phenomenon that includes the patient's ⁎ Corresponding author. Sha'ar Menashe Mental Health Center, Mobile Post Hefer 38814, Israel. Tel.: +972 4 6278750; fax: +972 4 6278045. E-mail address: [email protected] (M.S. Ritsner).

awareness of the disorder, its social consequences and the need for treatment (Amador et al., 1991). Most research in this area has focused almost exclusively on insight in relation to psychotic symptoms. Although several studies indicate a relationship between poor insight and severity of positive and/or negative symptoms (Schwartz, 1998; Cernovsky et al., 2004; Keshavan et al., 2004; Nakano et al., 2004), other studies have reported that the level of insight is

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unrelated to symptom severity (Peralta and Cuesta, 1994; Kim et al., 1997). Mohamed et al. (1999) concluded that unawareness of negative symptoms is associated with executive functioning in individuals with chronic schizophrenia, while unawareness of other symptoms (i.e., positive symptoms) may reflect dysfunction in other types of neuropsychological processes. A meta-analysis of 40 published English-language studies (Mintz et al., 2003) indicated that there was a small negative relationship between insight and global, positive and negative symptoms. There was also a small positive relationship between insight and depressive symptoms in schizophrenia. Much of the research in recent years has focused on understanding the relationship between neurocognitive impairment and insight. There is evidence regarding widespread neurocognitive dysfunction in patients with chronic schizophrenia, particularly in the areas of attention, memory, and executive functions (Heinrichs and Zakzanis, 1998). Such deficits appear to be present at early stages of the illness (Brewer et al., 2001; Hutton et al., 1998) and appear to be relatively stable over time (Rund, 1999). Several studies found no relationship between global neurocognitive functions and poor insight (Smith et al., 2000; Kim et al., 2003). Others reported that lack of awareness in schizophrenia is related to and possibly the result of a neurocognitive deficit involving prefrontal cerebral dysfunction (Young et al., 1998; Laroi et al., 2000). However, the extent to which this relationship is specific and independent of general cognitive impairment remains unclear. Firstepisode schizophrenia subjects with poor insight showed decreased right dorsolateral prefrontal cortex volumes relative to those with good insight (Shad et al., 2004). Contrarily, Arduini et al. (2003) concluded that insight dimensions do not appear to be associated with frontal impairment. Neurocognitive impairment failed to be a significant predictor of any dimension of insight among 89 patients with chronic schizophrenia (McCabe et al., 2002). Since the vast majority of literature in this area views insight as a product of disease process and therefore focuses on neurocognitive and clinical correlates, the contribution of personality related traits such as temperament, self-esteem, self-efficacy, and coping strategies or styles is less clear. However, research has indicated that stable personality differences exist among schizophrenia patients, and that they most likely predate the onset of illness (Kentros et al., 1997; Guillem et al., 2002; Szoke et al., 2002). Research findings have shown that the harm avoidance (HA) factor was higher, while reward dependence (RD) was lower in schizophrenia

patients than in healthy controls (Ritsner and Susser, 2004). Although there is growing evidence of the important influence of self-efficacy and self-esteem on outcomes in schizophrenia (Hultman et al., 1997; Lecomte et al., 1999; Ritsner et al., 2003a), to date, no study has been conducted to explore how insight may be associated with self-construct variables. With these issues in mind, several studies have found that poor insight of schizophrenia patients may result from their preference of denial and avoiding for coping strategies. Research has indicated that schizophrenia patients are not flexible in their use of coping strategies or styles (Wilder-Willis et al., 2002), tend to use maladaptive or emotion-oriented coping styles (Higgins and Endler, 1995), and rely more on passive avoidant strategies and less on active problem solving (Lysaker et al., 1999, 2004). Startup (1997) has suggested that there may be two independent paths to poor insight. In one path, people are unable to recognize that they are ill because neurocognitive impairments make it difficult to grasp the complexities of their schizophrenia. These persons are able to grasp only some of the facts of their illness and thus have moderately impaired insight. By contrast, in the other path, persons with intact neurocognitive abilities deny that they are ill because disavowing illness is less painful than acknowledging all it entails. This group is believed to have even worse insight than the first because persons among this group deny all aspects of their condition. Recently, Lysaker et al. (2003a) performed a cluster analysis on 64 persons with schizophrenia spectrum disorders and found three groups of patients: good insight-average executive function (n = 28), poor insight–average executive function (n = 13), and poor insight–poor executive function (n = 23). When self-reported coping styles were compared among groups, the poor insight–average executive function group endorsed a significantly greater preference for denial as a coping strategy than the poor insight–poor executive function group. Results suggest that denial may play a role in the unawareness of illness in some schizophrenia patients who have maintained average executive function. Given the mixed results involving the correlation of insight with clinical, and neurocognitive measures in schizophrenia, continued scientific exploration is warranted. This is especially true given the relatively small sample sizes and limited independent variables used in many recent studies that do not fully account for the complexity of the insight concept. There is also a need to pay more careful attention to how neurocognitive impairment together with symptom severity, personality traits (temperament, self-esteem, self-efficacy), and

M.S. Ritsner, H. Blumenkrantz / Psychiatry Research 149 (2007) 59–69

coping styles relate to the construct of domain specific insight. In order to examine these relationships, the present study aimed to investigate the prediction of patient's awareness of the disorder, its social consequences and the need for treatment in a group of stabilized schizophrenia patients, based on independent variables including multiple neurocognitive functions, symptom clusters, personality traits, and coping style ratings. We hypothesize that insight dimensions in schizophrenia patients residing in the community are attributed to neurocognitive and personality related factors rather than to psychopathological symptoms. 2. Method 2.1. Study design Participants were drawn from the patient population of Sha'ar Menashe Mental Health Center via the case register. Study inclusion criteria included age range of 18–65 years, men or women, DSM-IV criteria for chronic schizophrenia who were clinically stable and residing in the community. Evaluation was performed at stabilization phase defined as a clinically stable period lasting at least two months when symptomatology was in remission. Exclusion criteria included evidence of mental retardation, organic brain diseases, seizures, serious medical illness, substance abuse or dependence, pregnancy or lactation, low comprehension skills and poor cooperation. The Internal Review Board of Sha'ar Menashe Mental Health Center approved the study. Written informed consent of participants was obtained after the nature of the study was fully explained and prior to recruitment. 2.2. Participants We used a sample of 107 consecutively recruited DSM-IV schizophrenia patients. The study sample included 72.9% men (N = 78), with mean age 36.2 years (S.D. = 10.2, range 18–64), 59 (55.1%) were single, 26 (24.3%) were married, and the rest 22 (20.6%) were divorced, separated or widowed. According to DSM-IV, 85 patients had paranoid type of schizophrenia, 8 had residual type, 7 had undifferentiated type and 7 had disorganized type. All patients were physically healthy, with recent physical examinations, and blood and urine laboratory test results within the normal range. Patients received a variety of antipsychotic medications: 30 received first-generation agents (FGA), 50 received second-generation agents (SGA), and 27 patients were treated with a combination of FGAs and SGAs (CA,

61

combined agents). Dosages for all FDA-approved antipsychotic agents were converted into mg/day chlorpromazine equivalents (CPZ; Woods, 2003). Anxiolytics were prescribed for 50 patients, antidepressants — for 8 patients, mood stabilizers — for 43 patients, and antiparkinson drugs were prescribed for 49 patients as clinically indicated. 2.3. Instruments Interviews were conducted face to face by two psychiatrists using the Structured Clinical Interview for DSM-IV Axis I Disorders, Patients Edition (First et al., 1995), medical records, and a consensus between two senior psychiatrists. Awareness of illness was assessed using the Scale to Assess Unawareness of Mental Disorder (SUMD; Amador and Strauss, 1990). For the purposes of this study the three central items of the SUMD were used: awareness of mental disorder (SUMD1); awareness of the consequences of mental disorder (SUMD2); and awareness of the effects of medication (SUMD3). Each item is rated on a 5-point Likert scale (1 = fully aware, 3 = somewhat aware, 5 = fully unaware). A score of three is considered the cutoff to consider an individual's level of insight sufficient to inquire about attribution (Amador and Strauss, 1990). Inter-rater reliability scores (n = 20 patients) were for SUMD1 = 0.97, SUMD2 = 0.92, SUMD3 = 0.95. Psychopathological symptom severity was assessed using the Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987). The PANSS five-factor model was used for analysis of schizophrenia psychopathology: positive, negative, activation, dysphoric mood and autistic preoccupations (White et al., 1997). In this study, interrater reliability coefficients based on 20 cases ranged from 0.79 to 0.91 with a mean of 0.84 across raters. Test–retest reliability was evaluated by computing intraclass correlation coefficients (ICCs) using 15 cases administered at a mean length of 9.4 days apart. ICCs were moderate, ranging from 0.68 to 0.89 with a mean of 0.76, indicating satisfactory reliability. Personality dimensions were measured with the Tridimensional Personality Questionnaire (TPQ; Cloninger, 1987), a 100-question self-report instrument that discriminated between different major temperament factors. According to Cloninger's dimensional model three independent factors can be used to describe temperament. One temperament factor, novelty seeking (NS), is viewed as a heritable bias in the activation or initiation of behaviors such as frequent exploratory activity in response to novelty, impulsive decision making, extravagance in approach to cues of reward,

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and quick loss of temper and active avoidance of frustration. A second temperament factor, harm avoidance (HA), is viewed as a heritable bias in the inhibition or cessation of behaviors, such as pessimistic worry in anticipation of future problems, passive avoidant behaviors such as fear of uncertainty and shyness of strangers, and rapid fatigability. The third temperament factor, reward dependence (RD), is viewed as a heritable bias in the maintenance or continuation of ongoing behaviors, and is manifest as sentimentality, social attachment, and dependence on approval of others (Cloninger, 1987). We used the Hebrew version of the TPQ, which was available from previous studies (Ritsner et al., 2003b; Ritsner and Susser, 2004). A number of self-construct variables were examined with the following standardized questionnaires. The General Self-Efficacy Scale (GSES) is a 10-item standard abridged version of the GSES for evaluating a sense of personal competence in stressful situations (Jerusalem and Schwarzer, 1992). Higher GSES total scores indicate better feelings of self-efficacy. The Rosenberg Self-Esteem scale is a well-known 10-item self-report questionnaire for measuring self-esteem and self-regard (RSES; Rosenberg, 1965). Higher RSES total scores indicate better self-esteem. Coping strategies were evaluated with the Coping Inventory for Stressful Situations (CISS; Endler and Parker, 1990). It consists of 48 statements concerning ways in which people could react to various difficult, stressful, or upsetting situations. They comprise three 16-item orthogonal factors of task-oriented (T) coping (e.g., “Think about how I have solved similar problems”, or “Analyze the problem before reacting”), emotion-oriented (E) coping (e.g., “Tell myself it is not really happening to me”, or “Blame myself for not knowing what to do”), and avoidance-oriented (A) coping. In the present study the patients were asked to indicate how often they currently used each of the 48 coping strategies on a 5-point scale ranging from 1 (“not at all”) to 5 (“very much”). The CISS has demonstrated high psychometric properties (Ritsner et al., 2006). For the present sample, self-report instruments demonstrated high reliability (Cronbach's α): TPQ dimensions (0.80–0.87), GSES (0.85), RSES (0.83), and CISS dimensions (0.79–0.87). 2.4. Neurocognitive functions Neurocognitive functions were assessed using tests from the computerized Cambridge Automated Neuropsychological Test Battery (CANTAB; Robbins et al., 1994; Sahakian and Owen, 1992). The CANTAB

Table 1 Mean values and 95% confidence interval of key variables Independent variables

Age, yr. Education, yr. Age of onset, yr. Number admissions Illness duration, yr. Awareness of mental disorder (SUMD1) Awareness of the consequences of mental disorder (SUMD2) Awareness of the effects of medication (SUMD3) PANSS, total Negative Positive Activation Dysphoric mood Autistic preoccupations TPQ temperament scales: Novelty seeking Harm avoidance Reward dependence CISS coping styles: Task oriented coping Emotion oriented coping Avoidance oriented coping Self-constructs: Self-efficacy Self-esteem Antipsychotic medication, total First generation agents (FGA) Second generation agents (SGA)

Mean

S.D.

95% Confidence interval (CI)

36.2 11.2 23.7 9.0 12.4 3.0

10.2 2.4 8.3 8.7 8.6 1.6

34.3 10.7 22.2 7.3 10.8 2.7

38.2 11.7 25.3 10.7 14.1 3.3

2.4

1.4

2.2

2.7

2.4

1.2

2.1

2.6

92.1 33.2 13.6 16.7 12.4 20.2

17.1 7.7 4.2 4.8 3.6 4.0

88.8 31.7 12.8 15.8 11.7 19.5

95.3 34.7 14.4 17.6 13.1 21.0

14.2 15.3 12.8

5.4 6.8 3.2

13.2 14.0 12.2

15.3 16.6 13.4

58.5 42.0 45.3

14.4 12.6 15.5

55.7 39.5 42.3

61.3 44.4 48.2

29.9 29.7 571.9 330.9 241.0

7.4 6.9 454.0 490.1 226.6

28.5 28.4 484.8 237.0 197.5

31.3 31.0 658.9 424.8 284.4

CPZ equivalent dose, mg/day.

battery consists of a series of interrelated computerized tests administered via a touch sensitive screen. The nonverbal nature of the CANTAB tests makes them largely language independent and culture free. Overall 13 neuropsychological tests were grouped into five cognitive domains: visual and movement skills, attention, memory, learning, sustained attention and executive function: Motor Screening (MOT), Big/Little Circle (BLC), Reaction Time (RTI), Matching to Sample Visual Search (MTS), Delayed Matching to Sample (DMS), Pattern Recognition Memory (PRM), Spatial Recognition Memory (SRM), Spatial Span (SSP), Rapid visual information processing (RVP), Spatial working memory (SWM), Intra/Extra Dimensional Set Shift (IED), and Stockings of Cambridge (SOC). These tests are run on an IBM-compatible personal computer with a touch-sensitive screen. Neuropsychological testing lasts approximately 2 h. Subjects complete the tests in a fixed order with a break half-way through the testing session.

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63

45 Awareness of mental disorder

39.3

40

(SUMD1)

Awareness of the consequences of mental disorder

37.4

Awareness of the effects of medication

35

(SUMD2)

(SUMD3)

31.8 29

30

Percent

25.2

25 20.6

21.5

20

17.8 14

15

12.1

12.1 12.1

11.3

10.2

10 5.6

5 0 1

2

3

4

5

SUMD ratings Fig. 1. Distribution of 107 patients according to awareness of schizophrenia (SUMD1), awareness of the consequences of schizophrenia (SUMD2) and awareness of the effects of medication (SUMD3). Scaling: 1 = fully aware, 3 = somewhat aware, 5 = fully unaware.

For a description of the nature of these tests, the performance measures used and how the test scores are derived, see (http://www.cantab.com/cantab/site/home. acds). Performance of neurocognitive tests of schizophrenia patients was presented both as mean raw scores and the standard z-score that compared each patient with the mean performance of healthy subjects matched by age and sex. Z-scores were calculated by CANTAB program on basis of the extensive normative database included into CANTAB. 2.5. Data analysis Step-wise multivariate regression analysis with backward selection procedure was used to identify the predictor variables most highly associated with the variability of SUMD1, SUMD2, and SUMD3 index ratings (dependent variables). The initial set of independent variables for step-wise selection procedure included raw scores of 13 neuropsychological tests and other key variables obtained in the present study. The NCSS-2000 PC program was used for all analyses (Hintze et al., 2001). 3. Results As summarized in Table 1, the descriptive statistics suggest that there are broad ranges of variability in background and clinical variables. When participants

classified as having high-partial to full insight (SUMD scores 2 and 1), or no to low-partial insight (i.e., a score ≥ 3; higher score indicates worse insight), we found that 62.6% of participants met criteria for poor awareness into schizophrenia, 48.6% — for poor awareness in social consequences of the disorder, and 42% for poor awareness of the effects of medication (Fig. 1). Table 2 depicts outcome metrics for CANTAB tasks in 107 schizophrenia patients. As can be seen, there are patients with normal and reduced levels of performance of neurocognitive tasks compared with the mean performance of healthy adult subjects matched by age and sex (Fig. 2). Thus, the descriptive findings indicate that our sample included individuals with a reasonable level of variance of key variables. We used multiple regression analysis with step-wise backward selection, removing statistically insignificant variables, to determine a parsimonious set of factors that predict scores of each SUMD dimension from independent variables depicted in Tables 1 and 2. As a result, three best-fitted models were obtained and are presented in Table 3. Patterns predicting SUMD dimension scores are presented below. The first model revealed that visual and movement skills (β = 0.21–0.30), and executive function (SWM, β = −0.23), positive symptoms (β = 0.23), temperament factors (NS, β = 0.24; and RD, β = − 0.19), task-oriented coping (β = 0.29), self-esteem (β = 0.25), education

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Table 2 Outcome metrics for CANTAB tasks in 107 schizophrenia patients Task (independent variables) Visual and movement skills Motor Screening (MOT) Big/Little Circle (BLC) Reaction Time (RTI) Attention and memory Matching to Sample Visual Search (MTS) Delayed Matching to Sample (DMS) Pattern Recognition Memory (PRM) Spatial Recognition Memory (SRM) Spatial Span (SSP) Learning and memory Paired Associates Learning (PAL) Sustained attention Rapid Visual Information Processing (RVP) Executive function Spatial Working Memory (SWM) Intra/Extra Dimensional Set Shift (IED)

Stockings of Cambridge (SOC)

Measure

Mean

Latency, msec. Total correct Simple RT Choice RT Movement time

1504 39.5 715.7 534.9 579.9

410 1.4 186.2 196.9 203.7

1425 39.3 680.0 496.4 540.1

1583 39.8 761.4 573.4 619.7

Number correct Latency, msec. Total correct Number correct Number correct Span length

44.8 3557 17.0 17.3 13.7 4.5

4.6 1894 5.3 3.9 2.6 1.2

43.9 3195 16.0 16.6 13.2 4.3

45.7 3921 18.0 18.1 14.2 4.8

7.0 67.0

1.4 51.9

6.7 57.1

7.3 77.0

11.5 568.3

2.9 200.7

10.9 529.6

12.0 606.9

54.8 37.8 8.3 23.4 7423 1758 6.6

22.3 3.8 1.4 13.0 7374 1771 1.9

50.5 37.1 8.0 20.9 5975 1410 6.2

59.1 38.5 8.6 25.9 8872 2106 7.0

Stages completed Total errors, adj. Total hits Latency, msec. Between errors Strategy Stages completed Total errors, adj. Initial thinking time Subsequent thinking time Minimum moves

(β = 0.20), and illness duration (β = − 0.23) were significant indicators of awareness into schizophrenia. This model accounted for 36% of the total variance in SUMD1 ratings; 20.1% of variability in SUMD1 ratings was explained by neurocognitive functions (13.3% by visual and movement skills, 6.8% by executive function), while 11% — by temperament factors, 9.9% — by coping styles, 7.4% — by self-esteem, 7.2% — by positive symptoms, 6% — by illness duration, and 5.6% — by education. Thus, better performance in executive functions (SWM), higher reward dependence scores, and longer illness duration was associated with better awareness into schizophrenia, while poorer insight is associated with deficits in visual and movement skills (MOT, RTI), more severe positive symptoms, higher novelty seeking, task oriented coping, self-esteem scores, and education. The second model assumes that neurocognitive functions (41%), coping styles (13.5%), and temperament factors (8%) explain variability in awareness of the consequences of schizophrenia ratings. Specifically, visual and movement skills (β = 0.22), attention and memory (β = 0.19), sustained attention (β = − 0.21), executive function (SWM, β = − 0.26; SOC: initial

S.D.

95% Confidence interval (CI)

thinking time, β = 0.34; subsequent thinking time, β = − 0.25), temperament factors (RD, β = − 0.25), task(β = 0.29), and emotion- (β = 0.26) oriented coping styles show marked contribution to the prediction of the total variance in SUMD2 ratings (34%). Better awareness of the consequences of schizophrenia related to higher sustained attention (RVP), and better performance in executive functions (SWM, SOC), and higher reward dependence scores. Contrarily, impaired neurocognitive functions (RTI, SSP, SOC) and higher scores on taskand emotion-oriented coping style scales predicted poorer awareness of the consequences of the disorder. The third model that best fit the data explains 48% of the variability in awareness of the effects of medication ratings. In this model, 31.7% of the SUMD3 variance was explained by neurocognitive functions (10.6% by visual/movement skills, 12.0% by attention/memory, 9.1% by executive function, SWM), while 17.8% — by temperament factors, 13.5% — by coping styles, 6% — by autistic preoccupations, 4.8% — by education, and 3.9% — by self-efficacy. Better awareness of the effects of medication was predicted by better visual and movement skills (total correct, BLC), better executive functions (strategy, SWM), higher reward dependence,

M.S. Ritsner, H. Blumenkrantz / Psychiatry Research 149 (2007) 59–69 4

Motor skills

150

LearningSustained attention

Attention and memory

65

Executive function

140

2

130 120

0

100 1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

-2

90

Z-score

80

-4

70 60

-6

Number of patients

110

50 40

-8

30 20

-10

CANTAB tasks

Mean value

Minimum value

Maximum value

Number of impaired patients

10

Fig. 2. Profile of neurocognitive functions of 107 schizophrenia patients. The standard z-score is given as the number of standard deviations from the mean performance computed relative to an extensive CANTAB database of raw score for normal, healthy adult subjects matched by age and sex. A positive value indicates performance better than average in healthy control subjects. Variables (task; number of control subjects): 1—percent correct (BLC; n = 301), 2—five-choice movement time (RTI; n = 248), 3—five-choice reaction time (RTI; n = 248); 4—percent correct (MTS; n = 1161), 5—total number correct (MTS; n = 287); 6—percent correct (all delays, DMS; n = 1164), 7—percent correct (PRM; n = 984); 8—percent correct (SRM; n = 985); 9—span length (SSP; n = 693); 10—(total errors, adjusted, PAL; n = 1252), 11—RVP A' (n = 175), 12—between errors (SWM; n = 696), 13—strategy (SWM; n = 683), 14—stages completed (IED; n = 707), 15—total errors (IED; n = 700); 16—initial thinking time (SOC; n = 679), 17—subsequent thinking time (SOC; n = 679), 18—problem solving in minimum moves (SOC; n = 686).

and avoidance coping scores. Lack of visual and movement skills (movement time, RTI), attention and memory (number correct, MTS), higher scores on autistic preoccupations (PANSS), novelty seeking, task coping, self-efficacy, and higher education were associated with poor insight regarding the medication. 4. Discussion The main assumption in the present study was that the main insight dimension scores are associated with neurocognitive and personality related factors rather than with illness related variables. In order to test this assumption, we examined the contribution of a number of neurocognitive functions, symptomatology, personality related traits, and background variables to the prediction of three insight dimensions in 107 chronic schizophrenia patients, who were clinically stable and residing in the community. The descriptive findings indicate that our sample included individuals with a reasonable level of variance of key variables. Approximately 42–63% of these patients demonstrated moderate to lack of insight as measured by three SUMD dimensions, quite similar with previous studies (Wilson et al., 1986; Amador et al., 1994).

Principle results from the study indicate that: (1) SUMD dimension scores are attributed to neurocognitive (20–41%), and personality related (22–39%) factors rather than to psychopathological symptoms (about 7%), illness duration (6%), and education (about 5%); (2) poor insight is attributed to impairment in visual and movement skills, sustained attention, and executive functions, intensity of autistic preoccupations and positive symptoms, but increased novelty seeking behavior, task and emotion oriented coping styles, better self-esteem, self-efficacy, and higher education; (3) better awareness related to better performance of neurocognitive tasks, reward dependence behavior, avoidant coping style, and longer illness duration; and (4) in addition to common factors (neurocognitive functioning, novelty seeking, reward dependence, task oriented coping style, and education), each insight dimension also had specific indicators: positive symptoms, illness duration and self-esteem for SUMD1, sustained attention, and emotion oriented coping style for SUMD2, and autistic preoccupations, avoidance coping, and self-efficacy for SUMD3. More specifically, the results suggest that the contribution of neurocognitive functions to the variability of SUMD scores increased from awareness into

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Table 3 Summary of multiple regression analysis to predict ratings of domain-specific insight among 107 schizophrenia patients Dependent variables and model's properties

Independent variables

Awareness of schizophrenia Model: R2 = 0.36, Adj. R2 = 0.29, F = 5.3, df = 10, P b 0.001

Education (yr.)

Awareness of the consequences of schizophrenia Model: R2 = 0.34, Adj. R2 = 0.27, F = 4.9, df = 9, P b 0.001

Awareness of the effects of medication Model: R2 = 0.37, Adj. R2 = 0.29, F = 4.8, df = 11, P b 0.001

Illness duration (yr.)

Positive symptoms Temperament: Novelty seeking Reward dependence Task oriented coping Self-esteem Visual/movement skills: (latency, MOT) (simple RT, RTI) Executive function (strategy, SWM) Temperament:

Reward dependence

Coping styles: Task oriented coping Emotion oriented coping Visual/movement skills (movement time, RTI) Attention/memory (span length, SSP) Sustained attention (total hits, RVP) Executive function: (strategy, SWM) (initial thinking time, SOC) (subsequent thinking time, SOC) Education (yr.) Autistic preoccupations

Temperament: Novelty seeking Reward dependence Coping styles: Task coping Avoidance coping Self-efficacy Visual/movement skills: (total correct, BLC) (movement time, RTI) Attention/memory (number correct, MTS)

βa

Partial R2 (%; adjusted for rest) b

t

P

0.20

2.4

0.020

5.6

−0.23

2.5

0.015

6.0

0.23

2.7

0.008

7.2

0.24 −0.19 0.29 0.25

2.5 2.2 3.2 2.8

0.013 0.032 0.002 0.007

6.3 4.7 9.9 7.4

0.30 0.21 −0.23

3.1 2.1 2.6

0.003 0.041 0.010

9.0 4.3 6.8

−0.25

2.7

0.007

8.0

0.19 0.26 0.22

2.1 2.9 2.4

0.038 0.005 0.019

4.8 8.7 6.2

0.19

2.0

0.045

4.5

−0.21

2.2

0.028

5.4

−0.26 0.34 −0.25

2.7 3.4 2.3

0.009 0.001 0.022

7.6 11.4 5.9

0.20

2.1

0.035

4.8

0.22

2.4

0.018

6.0

0.36 −0.19

3.7 2.1

0.001 0.040

13.2 4.6

0.32 −0.28 0.22

2.4 2.7 1.9

0.017 0.009 0.058

6.1 7.4 3.9

−0.17 0.24

1.8 2.6

0.072 0.011

3.6 7.0

0.35

3.5

0.001

12.0

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67

Table 3 (continued) Dependent variables and model's properties

Independent variables

βa

t

P

Executive function: (strategy, SWM)

−0.27

3.0

0.004

Partial R2 (%; adjusted for rest) b 9.1

Abbreviates: Motor Screening (MOT), Big/Little Circle (BLC), Reaction Time (RTI), Matching to Sample Visual Search (MTS), Delayed Matching to Sample (DMS), Pattern Recognition Memory (PRM), Spatial Recognition Memory (SRM), Spatial Span (SSP), Paired Associates Learning (PAL), Rapid visual information processing (RVP), Spatial working memory (SWM), Intra/Extra Dimensional Set Shift (IED), Stockings of Cambridge (SOC). a β is a standardized regression coefficient. b Partial R2 reflects the percentage of variation in the insight explained by each independent variable adjusted to the effects of rest independent variables.

schizophrenia (about 20%), to awareness of the medication (32%) and awareness of social consequences of the disorder (41%). Consistent with data of previous research (Young et al., 1998; Laroi et al., 2000; Buckley et al., 2001; Keshavan et al., 2004), we found that insight dimension ratings were related to the impairment in executive functions (SWM, SOC), attention and memory (RVP, SSP, MTS), visual and movement skills (MOT, RTI, BLC). However, these findings contradict those that did not find significant associations (Laroi et al., 2000; Goldberg et al., 2001; McCabe et al., 2002). Personality is a broad concept involving both basic neurophysiological and potentially genetically determined traits (i.e. temperament), developmental aspects of personality (i.e. self-related factors), and coping strategies with stressful situations. The present findings suggest that contribution of personality related traits to the variance of three SUMD dimension scores was 8– 18% for temperament factors, 4–7% for self-constructs, and 10–14% for coping styles. Moreover, among these factors two different patterns were determined: (1) poor insight is associated with increased novelty seeking behavior, self-esteem and self-efficacy, task- and emotion-oriented coping styles and (2) a better insight is related to reward dependence and avoidance coping scores. In the light of these results, one might have hypothesized that unawareness may be associated with novelty seeking behavior, and that self-efficacy and selfesteem serve as adaptive and protective factors to facilitate coping with stressful situations. Further testing of this hypothesis is warranted. It should be noted that regarding avoidance coping our findings are inconsistent with the suggestion that partial poor insight in patients with schizophrenia results in a preference for a generally avoidant coping strategy (Lysaker et al., 2003b). This study supports the findings of a previous study that found a relationship between poor insight with greater severity of negative and positive symptoms (Schwartz, 1998; Cernovsky et al., 2004; Keshavan et al., 2004; Nakano et al., 2004). However, the contribu-

tion of positive symptoms (7.2%), and autistic preoccupations (6%) may explain a small portion of the variability in SUMD1 and SUMD3 ratings, respectively. Overestimation of the contribution of positive symptoms in a previous study (25%; McCabe et al., 2002) may be explained by lack of additional factors such as personality traits, and coping styles among independent variables. The present results did not confirm the suggestion (Moore et al., 1999) that the presence of depressive symptomatology in schizophrenia is related to the level of insight, and contingent at least in part on the absence of self-deception as denial. We found that illness duration is associated with awareness of schizophrenia (6%). First-episode patients with a schizophrenia spectrum disorder were less aware of having a mental illness than multiple-episode patients (Thompson et al., 2001). Following the first episode of psychosis, patients may become less defensive, and possibly more skilled in using medical terms to describe their illness. The present study also reveals that higher education is a negative indicator and accounts for about 5% of the variance of the SUMD1 (5.6%), and SUMD2 (4.8%) scores, quite consistent with a previous study that reported that the number of years of education explained a significant proportion of insight (Macpherson et al., 1996). Several studies have reported contradictory findings regarding the relationship between insight levels and types of antipsychotic agents (Pallanti et al., 1999; Buckley et al., 2001; Aguglia et al., 2002). FGAs and SGAs did not significantly predict insight in the present study. Consistent with a previous study (Goldberg et al., 2001) no relationship was found between level of insight and age, age of onset, and gender. Taken together, the present findings are consistent with the stress-vulnerability model (Zubin and Spring, 1977). We assume that insight among schizophrenia patients appears to be a rather trait-like condition rather than a state-dependent phenomenon. This assumption is in accordance with evidence that: (1) neurocognitive

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impairment is already evident in the premorbid or prodromal stages of the disorder (Kurtz, 2005); (2) cognitive impairment is not secondary to psychotic symptoms, negative symptoms, or socioeconomic status (Reichenberg, 2005); (3) first episode schizophrenia patients exhibit cognitive deficits often equivalent to those seen in patients with a more chronic course of the illness (Heinrichs and Zakzanis, 1998; Addington and Addington, 2002); and (4) temperament types associated with distress, self-constructs, and emotion-oriented coping represent a complex trait marker for underlying vulnerability to schizophrenia (Ritsner and Susser, 2004). There are several possible limitations in evaluating these results. First, most participants were men. Second, we did not analyze the effects of psychosocial interventions. Third, there is no data for psychotic patients who were included in the study. Next, it should also be noted that several of the independent measures including personality traits and coping styles were based on subjective self-reports and therefore may be subject to response bias. Finally, the cross-sectional nature of this study precludes drawing causal conclusions and maintains the possibility that repeated measures of key variables and additional associations might have emerged among the patients. Findings of this study have important clinical implications. In as much as controlling morbid symptoms may be important clinical goals, findings presented here suggest that the contribution of these factors to patients' insight is very limited. Future studies should test the mediating effect of personality traits and coping styles between neurocognitive functions and insight. Further longitudinal research is needed to investigate stability of predictive values of neurocognitive functions, personality, coping styles, and symptom severity for insight measures in schizophrenia notwithstanding our appreciation of the technical difficulty of such an undertaking. Acknowledgement The authors acknowledge the dedicated editorial assistance of Rena Kurs.

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