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Insight, Psychopathology, and Interpersonal Relationships in Schizophrenia by Francisco J. Vaz, Agustin Bejar, and Mariano Casado

regarded as a symptom that can determine to a great extent the patient's adherence to medication (Van Putten et al. 1976; Lin et al. 1979; Bartko et al. 1988; McEvoy et al. 1989ft; Buchanan 1992; Kemp and Lambert 1995; Schwartz et al. 1997; Smith et al. 1999), the need for compulsory commitment (McEvoy et al. 1989a; David et al. 1992; Vaz et al. 1996), the global outcome of the illness (Amador et al. 1994; Schwartz et al. 1997, 1998a), and how the patient functions on a social and familial level (Lysaker et al. 1998; Baier and Murray 1999). Nevertheless, research has provided in some cases contradictory data, which could be due to differences in the design of the studies and other methodological factors (Cuffel et al. 1996; Browne et al. 1998; Garavan et al. 1998). In order to overcome these difficulties, the use of complex models to conceptualize insight has been proposed (Amador et al. 1991; Amador and Gorman 1998; Baier et al. 1998; Schwartz 1998ft; Smith et al. 1998, 1999), based on the notion that insight is a multidimensional phenomenon that includes elements of a psychological, psychopathological, neurocognitive, and interactional nature. This article analyzes the correlations between insight and psychopathology, insight and interpersonal relationships, and psychopathology and interpersonal relationships. Psychopathology and interpersonal relationships were chosen because of their clinical relevance, because there are numerous studies of interest in the literature, and because they could be considered as the extremes of a continuum going from the individual (psychopathology) to the social environment (interpersonal relationships).

Abstract Insight of patients with schizophrenia seems to be a complex phenomenon that includes elements of a psychological, psychopathological, neurocognitive, and interactional nature. The purpose of this research was to study two of these areas (psychopathology and interpersonal relationships) in order to determine their influence on insight and their interrelation. Eighty-two outpatients fulfilling DSM-IV criteria for schizophrenia were studied using the Schedule for the Assessment of Insight (SAI), the Positive and Negative Syndrome Scale (PANSS), and the Social Cognitions and Object Relations Scale (SCORS). Bivariate correlations and multiple regression tests were performed. The positive component of the PANSS and the understanding of social causality (SCORS) appeared as the most significant variables related to level of insight. Positive symptoms were inversely related to insight, whereas understanding of social causality was directly associated with an appropriate awareness of illness. These results support the idea that insight is a complex and multidimensional phenomenon. In this respect, the study of the psychopathological dimension of insight should be accompanied by the consideration of interactional and social factors, because awareness of illness can be considered ultimately as an index of concordance between patients' views of the illness and cultural standards regarding mental disorders. Keywords: Schizophrenia, insight, awareness of illness, psychopathology, social causality, interpersonal relationships. Schizophrenia Bulletin, 28(2):311-317,2002.

Methods

In recent years the study of insight in patients with schizophrenia and its relationship with other clinical items has received increasing attention in the literature. Research in this field has been motivated by early findings that suggested that insight might be responsible for some basic clinical phenomena. In this respect, insight has been

Sample. The sample consisted of 82 outpatients who fulfilled DSM-IV criteria for schizophrenia. Diagnoses were Send reprint requests to Prof. F.J. Vaz, Area de Psiquiatria, Facultad de Medicina de la Uex, Av. de Elvas s/n, 06071 BADAJOZ, Spain; email: [email protected].

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made using a semistructured interview (Othmer and Othmer 1994), all the patients being evaluated by the same person. There were 52 male patients (63.4%) and 30 female patients (36.6%). The mean age was 34.8 years (standard deviation [SD] = 8.5; range = 16-53). There were 58 single patients (70.7%), 16 divorced patients (19.5%), and 8 married patients (9.8%). Eighty patients (97.6%) had been admitted to a hospital at least once, with a mean age at first admission of 24.3 years (SD = 6.1; range = 14-45) and an average of 3.5 admissions (SD = 2.3; range = 0-10). The mean time of evolution was 11.3 years (SD = 7.9; range = 0-30), and the mean time elapsed since the last admission was 4.6 years (SD = 5.5; range = 0-26). The subtypes of schizophrenia in the sample were paranoid type, 34 cases (41.5%); disorganized type, 10 cases (12.2%); catatonic type, 2 cases (2.4%); undifferentiated type, 3 cases (3.7%); and residual type, 33 cases (40.2%). Assessment Insight. The level of insight in the sample was assessed using a Spanish adaptation of the SAI (David 1990), translated into Spanish and previously validated by the authors (Bejar et al. 1996; Vaz et al. 1997). The SAI is a semistructured clinical interview with seven items scoring from 0 to 2 and a supplementary item scoring from 0 to 4. The SAI provides a global score and three dimensions of insight: (1) the acceptance of the need for treatment, (2) the awareness that one is suffering from a mental illness or condition, and (3) the ability to relabel mental events such as hallucinations and delusions as abnormal (David 1998). The four scores were considered for statistical analysis. Psychopathological status. The PANSS (Kay et al. 1990) was used to evaluate the psychopathological status of the patients; this method has been widely used by other authors, and its inclusion in our study made the comparison of our results possible. The Spanish version of the scale (PANSS-Spanish Adaptation, Kay et al. 1990) was used. The PANSS provides a score that reflects the global severity of the symptoms. In addition, five clinical dimensions were assessed following the method proposed by the authors of the scale: (1) negative component, (2) positive component, (3) excited component, (4) depressive component, and (5) cognitive component (Kay and Sevy 1990). The six scores were used for statistical analysis. Interpersonal relationships. For the evaluation of interpersonal relationships, the method proposed by Westen and associates was chosen (Westen et al. 1985, 1991; Westen 1990). This method has been used with adults and adolescents, and it has also been applied to the study of object relationships in borderline patients (Stuart et al. 1990; Westen 1990; Westen et al. 1990a, 199Ofc, 1990c). Based on the clinical use of the Thematic Apperception

Test (TAT), the Social Cognitions and Object Relations Scale (SCORS; Westen et al. 1985) isolates four dimensions of social interaction: (1) the complexity of representations of others, (2) the affect-tone of relationship paradigms, (3) the capacity for emotional investment in relationships and moral standards, and (4) the understanding of social causality. The first dimension assesses the level of complexity of the representations that the patient has regarding other people: the ability to differentiate between one's own and others' perspectives, awareness of the subjectivity of one's own and others' experiences, and so forth. The second dimension, the affect-tone of relationship paradigms, has to do with the tendency in the subject to experience others as benevolent or malevolent and his or her expectations about interpersonal relationships (defeating and threatening vs. safe and promising). The third dimension, the capacity for emotional investment in relationships and moral standards, is related to the ability to become personally committed to others, ranging from relationships based on need gratification to those based on mutuality, respect, and concern about others' needs. Finally, the fourth dimension, the understanding of social causality, is related to the logic, accuracy, and complexity of causal attributions made by the subject. Following the scoring manual of the SCORS (Westen et al. 1985), the TAT was used as a source of data. Ten TAT plates (six common for males and females, and four specific to each sex) were used, providing a score for each of the four dimensions described above. Statistics. Initially, a bivariate correlation test was performed using as variables the scores from the SAI, the PANSS, and the SCORS, to analyze the relationship between these. The scores from the SAI and the PANSS were obtained for all the patients, but because of its complexity, an appropriate application of the SCORS was possible in only 74 patients (90.2% of the sample). Taking into account the high number of comparisons, and in order to avoid type I errors, a Bonferroni adjustment was applied and only the p values under 0.001 were considered as significant. Next, a multiple regression test (stepwise method) was carried out, using as the dependent variable the global score of the SAI, and as independent variables the scores from the PANSS (global score and five basic components) and the four dimensions of the SCORS. The SPSS (version 9.0 for Windows) was used in all cases for statistical analysis.

Results Table 1 shows the mean values, the SDs, and the ranges obtained in the sample for the SAI and its subscales, the

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Table 1. Data from the SAI, the PANSS, and the SCORS

SAI Acceptance of the need for treatment Awareness of (mental) illness Ability to relabel psychotic symptoms as abnormal Total PANSS Positive component Negative component Excited component Depressive component Cognitive component Total SCORS Complexity of representations of others Affect-tone of relationship paradigms Capacity for emotional investment in relationships Understanding of social causality

Mean

SD

Range

2.1 3.3 1.4 8.1

0.9 1.9 1.5 4.1

0-4 0-6 0-4

3.0 3.2 2.2 2.4 2.7

1.1 0.7 0.9 0.7 0.8

83.9

15.5

2.0 2.8 1.7 1.8

0.5 0.5 0.4 0.6

1-16 1.4-5.6 1.2-4.9 1.0-4.4 1.0-4.2 1.0-4.3 49.0-113.0 1.6-3.5 1.9-3.8 1.1-2.6 1.0-3.1

Note.—PANSS = Positive and Negative Syndrome Scale; SAI = Schedule for the Assessment of Insight; SCORS = Social Cognitions and Object Relations Scale; SD = standard deviation.

PANSS and its subscales, and the four dismensions of the SCORS. Table 2 shows the results of the correlation test (Pearson's correlation coefficent and bilateral signification). The stepwise regression test provided a two-step model. In the first step (adjusted r2 = 0.272; standard error = 3.54), the positive component of the PANSS was selected as the variable able to predict the values of the SAI (beta = -0.531; t = -5.312; p = 0.000). In the second step (adjusted r2 = 0.367; standard error = 3.30), two variables were chosen: the positive component of the PANSS (beta = -0.473; t = -4.994; p = 0.000) and the understanding of social causality dimension of the SCORS (beta = 0.326; t = 3.443;/? = 0.001).

Discussion Above all, we believe that our results confirm the utility of multidimensional models for the study and understanding of a multidimensional phenomenon, which insight seems to be. The consideration of different clinical areas and analysis of the interaction between them can give interesting results and allow us to interpret the data from research on a wider plane. We grouped for discussion the data from our correlation study into three areas, based on the correlations between insight and psychopathology, insight and interpersonal relationships, and psychopathology and interpersonal relationships.

313

It is clear that insight and psychopathology were strongly correlated in our study. The "awareness of illness" dimension in our patients had a negative correlation with the severity of the positive component of the syndrome. There was also a negative correlation between the ability to relabel psychotic symptoms as abnormal experiences and the severity of the illness in most of its dimensions (positive component, excited component, negative component, and global severity of the symptoms). Finally, lack of insight as a whole process (represented by the total SAI score) was related both with a higher severity of the positive component and with a higher global severity of the symptoms. It still remains unclear to what extent psychopathology and poor insight are associated. Research has produced contradictory data in this field, and the literature contains a number of studies in which the severity of psychopathology seems to be significantly associated with poor insight (Heinrichs et al. 1985; Bartk6 et al. 1988; Vaz et al. 1994). In some cases the positive symptoms are responsible for this association (Bejar et al. 1996; Collins et al. 1997; Dickerson et al. 1997; Kim et al. 1997; Schwartz 1998a, 1998c; Carroll et al. 1999), and in other cases the negative symptoms are responsible (Voruganti et al. 1997; Cuesta et al. 1998; Debowska et al. 1998). However, a significant number of studies have failed to show this association or have shown only a modest correlation (McEvoy et al. 1989a, 1989b; Cuesta and Peralta 1994; Michalakeas et al. 1994; Smith et al. 1998). But not all the symptoms seem to

0.027 0.809

-0.523 0.000 -0.539 0.000

0.034 0.762 -0.146 0.198 -0.057 0.610

0.770 0.000 0.854 0.000

-0.115 0.302

-0.415 0.000

-0.341 0.002

0.554 0.000

0.032 0.775

0.329 0.003

Positive

0.167 0.138

Negative

Total SAI score

Relabeling symptoms

0.130 0.244

0.158 0.157

-0.345 0.002

-0.390 0.000

-0.002 0.986

-0.370 0.001

Excited

0.354 0.001

0.407 0.000

0.275 0.013

0.418 0.000

0.142 0.203

0.377 0.000 0.401 0.000

-0.298 0.007

-0.451 0.000

-0.140 0.209

-0.139 0.213

Cognitive

-0.173 0.120

-0.363 0.001

0.121 0.280

-0.100 0.371

Depressive

0.585 0.000

0.767 0.000

0.632 0.000

0.650 0.000

0.476 0.000

-0.419 0.000

-0.547 0.000

-0.111 0.322

-2.77 0.012

Total PANSS

-0.502 0.000

-0.616 0.000

-0.045 0.702

-0.299 0.010

-0.521 0.000

-0.135 0.253

0.330 0.004

0.334 0.004

0.346 0.003

0.034 0.776

Complexity*

* n = 74; for the remaining items, n = 82.

Note.—PANSS = Positive and Negative Syndrome Scale; SAI = Schedule for the Assessment of Insight; SCORS = Social Cognitions and Object Relations Scale; p = significance.

Social causality p (bilateral)

Affect-tone p (bilateral)

Complexity of representations p (bilateral)

Total PANSS score p (bilateral)

Cognitive component p (bilateral)

Depressive component p (bilateral)

Excited component p (bilateral)

Negative component p (bilateral)

Positive component p (bilateral)

Total SAI score p (bilateral)

Relabeling of symptoms p (bilateral)

Awareness of illness p (bilateral)

Need for treatment p (bilateral)

Awareness of illness

Table 2. Bivariate correlations between the scores of the PANSS, the SAI, and the dimensions of the SCORS

to

lizophrer lia Bulletin, Vo1. 28, N(



be equally relevant, and in general some schizophrenia symptoms—such as better mood or absence of suicidal thoughts, disorganization, avolition-apathy, affective blunting, hostility, and poor rapport—are specifically associated with poor insight (McEvoy et al. 1993; Amador et al. 1996; Vaz et al. 1996; Cuesta et al. 1998; Carroll et al. 1999). In this respect, the global results of our study have confirmed some previous clinical findings, such as the association of psychopathology, and more specifically of positive symptoms, with lack of insight (Heinrichs et al. 1985; Bartko et al. 1988; Vaz et al. 1994; Bejar et al. 1996; Collins et al. 1997; Dickerson et al. 1997; Kim et al. 1997; Schwartz 1998a, 1998c; Carroll et al. 1999). Our results show how some clinical dimensions of the schizophrenia syndrome have a correlation with the interactional world of the patients. The negative component of the PANSS correlated negatively with the four subscales of the SCORS, revealing that patients with negative symptoms had less complex representations of others, their interpersonal environment was more defeating and threatening, they had greater difficulty understanding social causality, and they tended to be less commited in social relationships and to withdraw from interpersonal experiences. On the other hand, the severity of the cognitive component of the PANSS strongly correlated with lower complexity in the representation of others, and with poorer understanding of social causality, so cognitive deterioration tended to be associated with the lower scores in the subscales of the SCORS that are considered "more cognitive" (i.e., the ability to represent others in a complex way and the ability to share with others complex schemes of social causality). Although the quality of interpersonal relationships (represented in this case by the SCORS ratings) could be regarded as an indirect measure of cognitive functioning, we believe that they reflect a more complex phenomenon, which includes not only the cognitive dimension of social interaction, but also the emotional dimension, represented by the patients' attitudes toward others and their emotional involvement in interpersonal relationships.

Finally, we consider that our results help show the interaction between insight and the two selected clinical areas (psychopathology and social interaction) and help explain, at least partially, why contradictory data have been often found when simple models have been used for the study of insight. Thus, if we analyze the two variables selected in the regression test (positive component and understanding of social causality), we can observe how the severity of the positive symptoms seems to be directly associated with lack of insight, whereas the severity of the negative symptoms seems to correlate with a more deteriorated interpersonal interaction, causing the patient to apply less complex representations of reality, to reduce the affect-tone of relationships and emotional investment in others, and in particular causing the patient to apply more primitive and distorted schemes in order to interpret social causality. In fact, social causality seems to be a powerful dimension that influences level of insight and may be affected by the severity of the negative symptoms. If we consider that insight is a phenomenon that can be regarded not only as an index of the patient's capacity to perceive and correctly interpret his or her pathological manifestations, but also as an index of the concordance between the patient's attitudes toward the illness and the cultural standards regarding mental disorders (Wing et al. 1964), our findings are fully concurrent with this view and reaffirm the need to continue working in this field, developing theoretical models that reflect the complexity of insight as a multidetermined phenomenon, and testing these models through clinical research to assess their ability to explain what we observe in clinical practice.

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Acknowledgments This research was supported by grant PB-94-1023 (Direccion General de Investigation Cientifica y Tecnica, Ministerio de Sanidad/Ministerio de Education y Cultura, Spain).

Vaz, F.J.; Bejar, A.; Casado, M.; and Penasa, B. Conciencia de enfermedad y sindrome positivo/negativo en la esquizofrenia. Adas Luso-Espaholas de Neurologia, Psiquiatria y Ciencias Afines, 25:153-158, 1997.

The Authors

Vaz, F.J.; Casado, M.; and Bejar, A. Actitudes hacia la enfermedad y el tratamiento en dos poblaciones de pacientes esquizofrenicos. Psiquiatria Publica, 8:227-235, 1996.

Francisco J. Vaz, M.D., Ph.D., is Psychiatrist and Associate Professor of Psychiatry, Department of Psychiatry; Agustin Bejar, M.D., Ph.D., is Psychiatrist, Department of Psychiatry; and Mariano Casado, M.D., Ph.D., is Forensic Surgeon and Assistant Professor, Department of Forensic Medicine, University of Extremadura School of Medicine, Badajoz, Spain.

Vaz, F.J.; Casado, M.; Salcedo, M.S.; and Bejar, A. Psicopatologia y conciencia de enfermedad durante la fase aguda de la esquizofrenia. Revista de Psiquiatria de la Facultad de Medicina de Barcelona, 21:66-74, 1994.

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