Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders

Insight and its relationship with stigma in psychiatric patients

BACKGROUND

The literature on insight has paid insufficient attention to the social experiences that are associated with receiving and endorsing a diagnosis of mental illness. The psychological and behavioral commitments associated with insight extend beyond agreeing with a diagnosis and accepting treatment to include taking on the identity of an individual diagnosed with mental illness. This study sought to examine the relationship between insight and stigma in psychiatric patients.

MATERIALS AND METHODS

Cross-sectional assessment of insight and stigma was done using the system adopted by Kaplan and Sadock in their comprehensive textbook of psychiatry and Felt Stigma Scale in 100 psychiatric patients (40 patients suffering from Bipolar affective disorder, 30 Schizophrenics, 20 Substance dependents and 10 with Obsessive Compulsive disorder).

RESULTS

It was found that the level of stigma felt by patients with insight was significantly higher than that felt by patients without insight.

CONCLUSION

Though there is a certain extent of stigma present in patients without insight, as is expected, the level of stigma increases as the patients develop insight.

The role of insight to alcohol use disorders in insight to schizophrenia

The aims of this study were to examine the difference in the level of insight into schizophrenia between patients with schizophrenia with and without comorbid alcohol use disorders (AUDs) and to examine the association between insight into schizophrenia and insight into AUDs in patients with comorbid schizophrenia and AUDs. A total of 51 schizophrenic subjects with comorbid AUDs and 67 schizophrenic subjects without AUDs were recruited into this study. The Schedule of Assessment of Insight-Expanded Version and the Hanil Alcohol Insight Scale were used to measure subjects' insight into schizophrenia and AUDs, respectively. Multiple regression analysis models were used to examine the association between insight into schizophrenia and comorbid AUDs in all subjects, as well as the association between insight into schizophrenia and insight into AUDs in the subjects with comorbid schizophrenia and AUDs. The results indicated that schizophrenic subjects with comorbid AUDs had a lower level of insight into schizophrenia than those without AUDs. Meanwhile, among subjects with comorbid schizophrenia and AUDs, those who had a higher level of insight into AUDs had a higher level of insight into schizophrenia. Based on the results of this study, we suggest that evaluating comorbid AUDs and the level of insight into AUDs is important when evaluating the level of insight into schizophrenia among patients with comorbid schizophrenia and AUDs.

Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders

OBJECTIVE

The mechanisms by which internalized stigma affects outcomes related to recovery among people with severe mental illness have yet to be explicitly studied. This study empirically evaluated a model for how internalized stigma affects important outcomes related to recovery.

METHODS

A total of 102 persons with schizophrenia spectrum disorders completed measures of internalized stigma, awareness of mental illness, psychiatric symptoms, self-esteem, hopefulness, and coping. Path analyses tested a predicted model and an alternative model for the relationships between the variables.

RESULTS

Results from model 1 supported the view that internalized stigma increases avoidant coping, active social avoidance, and depressive symptoms and that these relationships are mediated by the impact of internalized stigma on hope and self-esteem. Results from model 2 replicated significant relationships from model 1 but also supported the hypothesis that positive symptoms may influence hope and self-esteem.

CONCLUSIONS

Findings from two models supported the hypothesis that internalized stigma affects hope and self-esteem, leading to negative outcomes related to recovery. It is recommended that interventions be developed and tested to address the important effects of internalized stigma on recovery.

Insight and psychosis: comparing the perspectives of patient, entourage and clinician

BACKGROUND

The construct of insight in psychosis assumes congruence between patient and clinician views of the meaning of symptoms and experience. Current definitions and measures of insight do not give systematic attention to the impact of interpersonal, cultural and socio-economic contexts.

AIMS

We hypothesized that socio-cultural factors influence insight in patients with schizophrenia.

METHODS

We tested this hypothesis through comparison of insight in 18 triads, each composed of a patient, a family member and a clinician. The sample consisted of patients who were first diagnosed with psychosis in the last two years, and who were either immigrants from Africa or the Caribbean Islands, or Canadian born. Insight was assessed by analysis of narratives collected from patients, family members and clinicians for a research project on the negotiation of treatment. Each narrative was scored for insight along multiple dimensions with the Extracted Insight Scale (EIS), developed for this project.

RESULTS

There was a significant correlation of insight on the EIS between patients and family members (r= 0.51, p= 0.03) but not between patient and clinician or family and clinician. The mean levels of insight across the three groups were comparable. Qualitative analysis of the illness narratives suggested that insight was based on the meanings constructed around psychotic experiences and that the process of interpreting and attributing psychotic experiences reflected each person's cultural background, life experiences, and other social determinants, especially stigma.

CONCLUSION

Forms of insight can occur in the context of discordance or disagreement with the clinician's opinion. We present a testable model of the sociocultural determinants of insight that can guide future studies.

Insight in first episode psychosis: who is measuring what?

AIMS

To compare different self-administered or clinician-rated insight scales in an FEP population.

METHODS

A self-administered measure (Beck Cognitive Insight Scale - BCIS) and clinician-rated scales (Scale of Unawareness of Mental Disorder - SUMD and Positive And Negative Symptoms Scale - PANSS-G12 insight item) were completed by 38 patients with a diagnosis of FEP.

RESULTS

The scales had good internal consistency and only the clinician-rated scales were intercorrelated (SUMD - awareness of mental disorder and PANSS-G12 items (r=0.657, P<0.001)). Moreover, we observed a significant association of SUMD and PANSS positive and general subscales and a trend association for BCIS and PANSS negative subscale.

CONCLUSION

Differential associations observed between insight and symptoms may suggest different clinical predictive values for each measure. Our results suggest the necessity to qualify the term 'insight' when discussing research results, most notably with respect to who is rating and what aspect of insight is being rated.

Associations of multiple domains of self-esteem with four dimensions of stigma in schizophrenia

Research suggests global self-esteem among persons with schizophrenia may be negatively affected by stigma or stereotyped beliefs about persons with severe mental illness. Less clear however, is whether particular dimensions of self-esteem are linked to particular domains of stigma. To examine this we surveyed a range of self-esteem dimensions including lovability, personal power, competence and moral self-approval and four domains of stigma: Stereotype endorsement, Discrimination experience, Social withdrawal and Stigma rejection. Participants were 133 adults with diagnoses of schizophrenia or schizoaffective disorder. Stepwise multiple regressions controlling for a possible defensive response bias suggested that aspects of self-esteem related to lovability by others were more closely linked with lesser feelings of being alienated from others due to mental illness. Aspects of self-esteem related to the ability to manage one's own affairs were more closely associated with the rejection of stereotypes of mental illness. A sense of being able to influence others was linked to both the absence of discrimination experiences and the ability to ward off stigma. Implications for treatment are discussed.

Unawareness of illness in neuropsychiatric disorders: phenomenological certainty versus etiopathogenic vagueness

Awareness of illness is a form of self-knowledge concerning information about the pathological state, its functional consequence, and the way it affects the patient and his interaction with the environment. Unawareness of illness has raised much interest for its consequences on compliance with treatment, prognosis, and the patient's quality of life. This review highlights the great complexity of this phenomenon both at phenomenological and etiopathogenic levels in stroke, traumatic brain injury, psychosis, dementias, and mood disorders. In particular, the clinical expression is characterized by failure to acknowledge being ill, misattribution of symptoms, and noncompliance with treatment. Unawareness of illness may also be linked with characteristics that are peculiar to each individual disturbance, such as symptom duration and cognitive impairment. Despite a long-lasting interest in the clinical characteristics of unawareness, only recently has the focus of research investigated pathogenic mechanisms, with sometimes controversial results. The vast majority of studies have pointed out a remarkable involvement of the right hemisphere. Specifically, functional and structural changes of the dorso-lateral prefrontal cortex and some other frontal areas have often been found to be associated with awareness deficit, as well as parieto-temporal areas and the thalamus, although to a lesser extent. These data indicate the present difficulty of localizing a specific cerebral area involved in unawareness and suggest the existence of possible brain circuits responsible for awareness. In conclusion, phenomenological manifestations of poor awareness are well outlined in their complexity, whereas neuroanatomic and neuropsychological findings are still too vague and sparse and need further, greater efforts to be clarified.

Mental illness stigma in the Israeli context: deliberations and suggestions

BACKGROUND

In this paper we deliberate mental illness stigma in the Israeli context and suggest ways to reduce it, emphasizing the community's role in the rehabilitation of persons with mental illness.

MATERIAL

A literature review of Israeli and international literature of mental illness stigma.

DISCUSSION

Community mental health, in addition to its traditional focus on developing community-based services, should focus also on community-based interventions such as the delivery of anti-stigma interventions.

CONCLUSIONS

Providing individualized rehabilitation services in the community while addressing stigma-induced social barriers may create a better recovery ground for Israelis with mental illness.

Insight, psychopathology and global functioning in schizophrenia in urban Malawi

Insight, psychopathology and functioning are related in schizophrenia, but it is unclear whether insight relates independently to functioning after controlling for psychopathology. Equally, any such relationship may vary culturally. We investigated the relationship between insight, psychopathology and functioning in 60 patients with schizophrenia in Mzuzu, a town in Malawi. After controlling for psychopathology, functioning was associated with the ;symptom relabelling' dimension of insight (P=0.01). This preliminary finding suggests that symptom-focused psychoeducation might be appropriate for African patients with schizophrenia.

Insight, distress and coping styles in schizophrenia

BACKGROUND

The stigma and negative societal views attached to schizophrenia can make the diagnosis distressing. There is evidence that poor insight into symptoms of the disorder and need for treatment may reflect the use of denial as a coping style. However, the relationships between insight and other coping styles have seldom been investigated.

METHOD

We examined the associations between insight, distress and a number of coping styles in 65 outpatients with schizophrenia (final n=57) in a cross-sectional study.

RESULTS

We found that (i) awareness of symptoms and problems correlated with greater distress, (ii) 'preference for positive reinterpretation and growth' coping style correlated with lower distress and with lower symptom awareness (re-labelling), (iii) 'preference for mental disengagement' coping style correlated with greater distress and lower awareness of problems, and (iv) 'social support-seeking' coping style correlated with greater awareness of illness, but not distress. No relationship occurred between the use of 'denial' as a coping style and insight or distress.

CONCLUSIONS

Our findings demonstrate that awareness of illness and related problems is associated with greater distress in schizophrenia. However, this investigation has not supported a simple psychological denial explanation for this relationship, as complex relationships emerged between different dimensions of insight and coping styles. The negative association between 'positive reinterpretation and growth' and distress suggests that adopting this style may lead to re-labelling symptoms in a less distressing way. Avoidant and isolating styles of coping both appear unhelpful. Psychological interventions should aim to promote more active coping such as discussing a mental health problem with others.

Recent developments in psychosocial treatments for schizophrenic patients

Pessimistic views regarding the course and outcome of schizophrenia have been replaced by an emphasis on recovery. The concept of recovery emphasizes the need to provide access to treatments and services that are effective in both decreasing manifestations of the disorder and in assisting individuals to lead maximally productive and personally meaningful lives. To this end, the schizophrenia Patient Outcomes Research Team (PORT) published an updated consensus list of evidence-based practices that includes 14 recommendations, six of which describe psychosocial treatments (family interventions, supported employment, assertive community treatment, skills training, cognitive therapy and token economy programs). This paper reviews the schizophrenia PORT committee recommendations for psychosocial evidence-based practices, and discusses future needs and potential confounds that can have an impact on the effectiveness of these approaches. Among these potential confounds, the heterogeneity of individuals diagnosed with schizophrenia, variations in quality and integrity of implementation and the degree to which services listed are truly accessible and available as needed are paramount. The PORT psychosocial recommendations are an excellent foundation in the process of identifying evidence-based practices that can foster social recovery; they are not a comprehensive list. More innovation and research on psychosocial therapies remains to be accomplished in order to improve the chances for social recovery of patients diagnosed with schizophrenia.