Insight and its clinical correlates in a sample of hospitalized psychotic patients

Nashaat A.M Abdel-Fadeel

doi:10.4103/ejpsy.ejpsy_36_18

ORIGINAL ARTICLE

Year : 2019 | Volume : 40 | Issue : 1 | Page : 48-57

Insight and its clinical correlates in a sample of hospitalized psychotic patients

Nashaat A.M Abdel-Fadeel
Department of Psychiatry, Faculty of Medicine, Minia University, Minia, Egypt

Date of Submission	08-Nov-2018
Date of Acceptance	02-Dec-2018
Date of Web Publication	9-May-2019

Correspondence Address:
Nashaat A.M Abdel-Fadeel
Department of Psychiatry, Faculty of Medicine, Minia University, Minia
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ejpsy.ejpsy_36_18

Abstract

Background Insight is a complex phenomenon including many dimensions, such as insight about the illness, about need for treatment, and about consequences of having that illness. Assessment of insight in psychiatric patients is important as it is implicated in the course of illness, adherence to treatment, and prognosis.
Objective The aim was to evaluate the level of insight in schizophrenia spectrum disorders and also in bipolar and major depressive disorders with psychotic features and to examine the relationship between level of insight and sociodemographic and illness-related characteristics, including severity of symptoms.
Patients and methods A total of 85 patients diagnosed with schizophrenia spectrum disorders (group 1) and 44 patients diagnosed with bipolar disorder with psychotic features and major depressive disorder with psychotic features (group 2) who were admitted to Minia Psychiatry Hospital in a period of 6 months were included in the study. Diagnosis was done using Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-5 research version. Level of insight was assessed using Scale to assess Unawareness of Mental Disorder assessing awareness of mental disorder, awareness of the need for treatment and awareness of social consequences of mental disorder. Severity of symptoms and psychopathology was assessed using Positive and Negative Syndrome Scale and Clinical Global Impression Scale (CGI).
Results Patients diagnosed with schizophrenia spectrum disorders (group 1) tended to have poorer insight than those with bipolar affective disorder (BAD) and major depressive disorder (MDD) with psychotic features (group 2) on admission and also on discharge. Levels of insight of both groups differed significantly on discharge when compared with their levels of insight on admission, but that difference was more profound in group 2. Stepwise multiple linear regression analysis predicting level on insight revealed that blunted affect, lack of judgment and insight, conceptual disorganization, and CGI severity of illness were the most implicated factors in determining insight on admission whereas CGI efficacy index, grandiosity, motor retardation, and passive/apathetic social withdrawal were factors determining insight on discharge.
Conclusion Patients diagnosed with schizophrenia spectrum disorders have poorer insight than those diagnosed with BAD and MDD with psychotic features. Predictors of insight differ on admission than on discharge.

Keywords: bipolar disorder, insight, major depressive disorder, schizophrenia spectrum disorders

How to cite this article:
Abdel-Fadeel NA. Insight and its clinical correlates in a sample of hospitalized psychotic patients. Egypt J Psychiatr 2019;40:48-57

How to cite this URL:
Abdel-Fadeel NA. Insight and its clinical correlates in a sample of hospitalized psychotic patients. Egypt J Psychiatr [serial online] 2019 [cited 2023 Oct 1];40:48-57. Available from: https://new.ejpsy.eg.net//text.asp?2019/40/1/48/257851

Introduction

Insight is a complex phenomenon including many dimensions, such as insight about the illness, need for treatment, and about consequences of having that illness (Amador et al., 1993). Assessment of insight in psychiatric patients is important as it is implicated in the course of illness, adherence to treatment, and prognosis (Yen et al., 2004).

Unawareness of mental disorder is associated with poor treatment compliance (Smith et al., 1999), impaired cognitive functioning (Matza et al., 2006), impaired social functioning (Pyne et al., 2001), poorer prognosis and higher relapse rates (David et al., 1995), and higher incidence of depression, low self-esteem, and poorer quality of life (Hasson-Ohayon et al., 2006; Staring et al., 2009).

Although there is availability of psychotropic drugs that are effective in treating symptoms of schizophrenia and bipolar disorder, patients do not substantially benefit from them because of nonadherence (Oehl et al., 2000).

Poor insight is a core feature of schizophrenia (Lehrer and Lorenz, 2014). Approximately 50 to 80% of patients with schizophrenia lack insight into their mental disorder either partially or totally (Carpenter et al., 1973) and that impairment of insight is related to the severity of positive symptoms (Comparelli et al., 2013).

Deficits of insight are also common in patients with bipolar (Pini et al., 2001) and depressive disorders (Yen et al., 2005). Moreover, lack of insight is an important factor affecting treatment compliance in bipolar disorder (Comparelli et al., 2013).

Manic patients with psychotic symptoms have poorer insight than those with psychotic unipolar depression (Fennig et al., 1996) with higher levels of impairment of insight being found with higher symptom severity (Michalakeas et al., 1994).

Furthermore, deficits in awareness of illness are severe in manic patients with psychotic symptoms, whereas only having modest correlations with severity of psychotic symptoms (Amador et al., 1994). Moreover, McGorry and McConville (1999) found that some insight dimensions were not consistently correlated with psychotic symptomatology.

Insight impairment has been explained as an expression of brain deficits, part of primary psychiatric illness or a form of denial to avoid awareness of illness (Cooke et al., 2005).

Owing to the importance of insight especially in psychotic patients, the idea of the current study emerged to study insight in hospitalized psychotic patients on admission and discharge, representing two states of psychiatric illnesses (acute phase and remission), and to evaluate the factors correlating with and affecting the level of insight in sociodemographic and illness-related characteristics together with severity of symptoms as measured by Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression Scale (CGI).

Patients and methods

The study was conducted in Minia Psychiatry Hospital through the collaborative teaching and research project with Psychiatry Department, Minia University.

Participants of the study

All psychotic patients who were admitted to Inpatient Department in duration of 6 months were recruited. Those patients included schizophrenia spectrum disorders (schizophrenia, schizoaffective, and schizophreniform disorders), bipolar disorder with psychotic features, and major depressive disorder with psychotic features. We included males and females whose age was between 18 and 50 years, whereas excluded those discharged against medical advice or for other medical or surgical reasons.

For the purpose of statistical analysis of our data, we classified our sample into two groups:

Group 1: it included patients diagnosed with schizophrenia spectrum disorders.
Group 2: it included patients diagnosed with bipolar affective disorder and major depressive disorder with psychotic symptoms.

Procedure and tools of the study

Patients were evaluated through semistructured interviews to evaluate sociodemographic and illness-related characteristics such as age, sex, education, marital status, birth order, occupation, duration of illness, and age of onset of illness.
The official diagnosis was done using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-5 Research Version (Firstet al., 2015).
Insight was assessed using the Scale to assess Unawareness of Mental Disorder (SUMD) (Amadoret al., 1994) which is the most comprehensive scale for the assessment of insight. We used the three general items of the scale: awareness of mental disorder, awareness of the achieved effects of medication, and awareness of the social consequences of mental disorder. The SUMD derives from Amador’s complex model of insight and includes a symptom checklist in addition to the three general items. Furthermore, SUMD scoring includes subscales that relate the general items to specific symptom constellations (Amadoret al., 1994).
Assessment of clinical symptoms and psychopathology was done using the PANSS (Kayet al., 1987) through a semistructured interview covering items for positive symptoms, negative symptoms, and general psychopathology.
Global functioning and overall severity of illness of patients were assessed by using the CGI (Guy, 1976) that provides an overall clinician-determined summary measure tracking clinical progress across time.

Statistical analysis

We had a separate coded file for each participant including all data. Statistical analysis was done through descriptive statistics, comparisons, correlations, and stepwise multiple linear regression analysis, predicting insight using the statistical package for the social sciences (SPSS) Version 19.0 for Windows (IBM SPSS statistics for windows; IBM Corporation, Armonk, New York, USA) (IBM Corp., 2010).

Results

According to the eligibility criteria of the study, our total sample included 85 patients diagnosed with schizophrenia spectrum disorders and 44 patients diagnosed with bipolar I and major depressive disorders with psychotic symptoms.

As shown in [Table 1], the mean age of patients was 33.2 years, and most were males (76.7%). Moreover, 55% of them were single, 29.5% were married, and 14.7% were divorced. The mean birth order and number of years of completed education were 2.9 and 9, respectively. Approximately half of the patients were manual workers, 31% never had a job, whereas only 20.2% were skilled or professional workers.

Table 1 Sociodemographic characteristics of the whole sample (N=129)

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As shown in [Figure 1], approximately two-thirds of our patients (65.9%) were diagnosed with schizophrenia spectrum disorders followed by bipolar disorder with psychotic symptoms (28.7%), and then major depressive disorder with psychotic symptoms (5.4%).

Figure 1 Individual diagnoses of patients according to structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-5.

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As shown in [Table 2], on admission, awareness of achieved effects of medications is significantly better in the group of bipolar affective disorder (BAD) and major depressive disorder (MDD) than in schizophrenia spectrum disorders (P=0.02). On discharge, awareness of achieved effects of medications, awareness of the social consequences of mental disorders, and the total score were lower in the group of BAD and MDD (indicating better insight), than those with schizophrenia spectrum disorders, and these differences were statistically significant (P=0.005, 0.001, and 0.02 respectively).

Table 2 Comparison between patients with schizophrenia spectrum disorders and patients with mood and related disorders (BAD+MDD) regarding insight variables on admission and discharge

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As shown in [Table 3], patients of both groups had better insight on discharge than on admission, and these differences were statistically significant in most SUMD variables. The difference between admission and discharge was more represented in the group of BAD and MDD than in the group of SSDs.

Table 3 Comparison within the group of schizophrenia and related disorders and the group of mood and related disorders regarding insight according to Scale to assess Unawareness of Mental Disorder on admission and discharge

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As shown in [Table 4], correlations between insight variables on admission and sociodemographic and illness characteristics were not statistically significant except in the domain of awareness of achieved effects of medications where the older was the age and age at onset of illness, the poorer was insight about effects of treatment (P=0.018 and 0.005, respectively).

Table 4 Correlations of variables of insight on admission with some sociodemographic and illness characteristics in the whole sample

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[Table 5] shows the relationship between variables of insight and positive symptoms on admission and discharge. Poor insight on admission (SUMD total score) was related to the severity of conceptual disorganization and hallucinatory behavior (P=0.000 and 0.022, respectively) whereas on discharge, positive symptoms significantly affecting insight were delusions, conceptual disorganization, and grandiosity (P=0.000, 0.001, and 0.000, respectively).

Table 5 Correlations of variables of insight with positive symptoms as measured by positive subscale items of Positive and Negative Syndrome Scale on admission and discharge in the whole sample

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Poorer insight was related to severity of negative symptoms on admission and discharge, as shown in [Table 6], where significant positive correlations were found between SUMD total score and most of negative subscale items of PANSS on both admission and discharge. Only few significant correlations were found between negative subscale items and the three general items of SUMD.

Table 6 Correlations of variables of insight with negative symptoms as measured by negative subscale items of Positive and Negative Syndrome Scale on admission and discharge

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As shown in [Table 7], on admission, there were significant positive correlations between the total score of SUMD and some psychopathology subscale items of PANSS (motor retardation, uncooperativeness, disorientation, poor attention, lack of judgment and insight, disturbance of volition, and active social avoidance) whereas significant negative correlations were found with items of tension and depression. On discharge, there were significant positive correlations between the total score of SUMD and items of motor retardation, uncooperativeness, unusual thought content, disorientation, poor attention, lack of judgment and insight, disturbance of volition, preoccupation, and active social avoidance.

Table 7 Correlations of variables of insight with items of general psychopathology subscale of Positive and Negative Syndrome Scale on admission and discharge

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Poor awareness of mental disorder on admission was significantly correlated with lower scores of anxiety, guilt feeling, tension, and depression and higher scores of lack of judgment and insight and poor impulse control, whereas on discharge was significantly correlated with higher scores of motor retardation, uncooperativeness, and unusual thought content.

Poor awareness of effects of medications on admission was significantly correlated with lower scores of guilt feeling and depression and higher scores of lack of judgment and insight and preoccupation whereas on discharge was significantly correlated with higher scores of unusual thought content and preoccupation.

Poor awareness of social consequences of mental disorder on admission was significantly correlated with lower scores of guilt feeling and depression and higher scores of lack of judgment and insight whereas on discharge was significantly correlated with higher scores of uncooperativeness, unusual thought content, and lack of judgment and insight.

As shown in [Table 8], the independent variables predicting insight on admission according to stepwise multiple linear regression analysis were scores of blunted affect followed by depression, passive/apathetic social withdrawal, CGI severity of illness, lack of judgment and insight, poor attention, and conceptual disorganization.

Table 8 Stepwise multiple linear regression analysis predicting insight (total score of Scale to assess Unawareness of Mental Disorder) on admission

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As shown in [Table 9], the independent variables predicting insight on discharge according to stepwise multiple linear regression analysis were scores of CGI efficacy index, grandiosity, motor retardation, passive/apathetic social withdrawal, stereotyped thinking, lack of judgment and insight, active social avoidance, disturbance of volition, depression, and blunted affect.

Table 9 Stepwise multiple linear regression analysis predicting insight (total score of Scale to assess Unawareness of Mental Disorder) on discharge

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Discussion

Poor insight is a core feature of schizophrenia (Lehrer and Lorenz, 2014). Deficits of insight are also common in patients with bipolar (Pini et al., 2001) and depressive disorders (Yen et al., 2005). Insight impairment was viewed as an expression of brain deficits, part of primary psychiatric illness, or a form of denial of illness (Cooke et al., 2005).

Our study confirmed results of previous studies that did not find statistically significant relationships between insight variables and sociodemographic characteristics (Armstrong et al., 2002) except for awareness of achieved effects of medications, where poorer awareness of achieved effects of medications was related to older age of patients and older age at onset of illness. Correlations between insight variables on admission and sociodemographic and illness characteristics were not statistically significant except in the domain of awareness of achieved effects of medications where the older was the age and age at onset of illness, the poorer was insight about effects of treatment (P=0.018 and 0.005, respectively). That could be explained as insight might be a part of illness or directly related to patients’ psychopathology.

On admission, there were no statistically significant differences between patients of the group of schizophrenia spectrum disorders and the group of bipolar and major depressive disorders regarding insight variables except for awareness of achieved effects of medications. That was in agreement with Michalakeas et al. (1994) who found that patients with BAD and MDD have insight deficits as found in schizophrenia. Moreover, these deficits were severe in manic patients with psychotic symptoms (Amador et al., 1994). Moreover, Arduini et al. (2003) found that insight impairment in schizophrenia was similar to that found in bipolar disorder with psychotic features.

However, on discharge, there were statistically significant differences between the two groups regarding most insight variables (awareness of achieved effects of medications, awareness of the social consequences of mental disorders, and the total score of SUMD; P=0.005, 0.001, and 0.02, respectively). This was in agreement with several studies that concluded that impairment of insight was more severe in patients diagnosed with schizophrenia than in patients diagnosed with major depressive disorder with or without psychotic features (Pini et al., 2001) or bipolar disorder with psychotic features (Pini et al., 2004). These differences in the level of insight between admission and discharge especially in the group of MDD and BAD may be explained by rapid improvement of manic and depressive symptoms when compared with the chronic nature of symptoms in schizophrenia spectrum disorders.

Patients of both groups had better insight on discharge than on admission, and these differences were statistically significant in most SUMD variables. This was in agreement with Novick et al. (2015) who reported improvement of the level of insight after therapeutic interventions in their sample of schizophrenia and bipolar disorder. However, the differences in insight variables between admission and discharge were more represented in the group of BAD and MDD than in the group of SSDs and that replicates findings of other studies stating that insight significantly improved with resolution of symptoms especially manic symptoms (Yen et al., 2003; Mokhtarzadeh et al., 2016). It is likely that there are fluctuations in the level of insight according to the phase of illness (Armstrong et al., 2002). Moreover, in schizophrenia, insight has ‘trait’ features showing its deficits during phases of remission of illness (Wiffen et al., 2010).

Regarding the relationship between insight variables and positive symptoms on admission and discharge, in agreement with a meta-analysis including 40 studies that revealed that there were small negative associations between insight and positive symptoms (Mintz et al., 2003), our study found that poor insight on admission (higher SUMD total score) was significantly correlated with the severity of only conceptual disorganization and hallucinatory behavior (P=0.000 and 0.022, respectively) within the seven positive subscale items of PANSS, whereas on discharge, positive symptoms significantly correlated with insight were delusions, conceptual disorganization, and grandiosity (P=0.000, 0.001 and 0.000, respectively). These results were partially contradictory to results of other studies in which insight and psychopathology did not show any consistent relationships (Cuesta et al., 2000; Armstrong et al., 2002). Insight impairments found in remission phases of schizophrenia shed light on the idea that poor insight may not be strongly associated with severity of positive symptoms (Ceskova et al., 2007).

In agreement with Tharyan and Saravanan (2000), poorer insight in our study was related to severity of negative symptoms on admission and discharge where significant positive correlations were found between SUMD total score and most of negative subscale items of PANSS on both admission and discharge. However, this was not in agreement with the results of some studies such as Soriano-Barceló et al. (2016), which failed to find correlations between insight and negative symptoms. This could be explained by cultural influence of the sample in the study by Soriano-Barceló as this study was conducted in a region in Peru where some culture-bound syndromes as ‘Susto’ are highly prevalent with spiritual and magical explanation of symptoms (Bernal-Garcia, 2010).

In agreement with Nieto et al. (2012) who reported significant correlations between insight and general symptoms, our study found significant positive correlations between the total score of SUMD and some psychopathology subscale items of PANSS on admission (motor retardation, uncooperativeness, disorientation, poor attention, lack of judgment and insight, disturbance of volition, and active social avoidance), whereas significant negative correlations were found with items of tension and depression. On discharge, there were significant positive correlations between the total score of SUMD and items of motor retardation, uncooperativeness, unusual thought content, disorientation, poor attention, lack of judgment and insight, disturbance of volition, preoccupation, and active social avoidance.

The independent variables predicting poor insight on admission according to stepwise multiple linear regression analysis were higher scores of blunted affect followed by lower scores for depression, then higher scores of passive/apathetic social withdrawal, CGI severity of illness, lack of judgment and insight, poor attention, and conceptual disorganization. This was in agreement with the results of other studies that found strong associations between insight and negative symptoms, such as blunted affect, social withdrawal and poor attention (Blanchard et al., 2011), depression (Sanz et al., 1998), CGI severity of illness (Novick et al., 2015), and conceptual disorganization (Mintz et al., 2003).

The independent variables predicting poor insight on discharge according to stepwise multiple linear regression analysis were higher scores of CGI efficacy index, grandiosity, motor retardation, passive/apathetic social withdrawal, stereotyped thinking, lack of judgment and insight, active social avoidance, and disturbance of volition, then lower scores of depression, and finally, higher scores of blunted affect. Higher CGI efficacy index scores indicate more severe adverse effects and less treatment response (Guy, 1976); in our study, it comes on the top of predictors of poor insight on discharge.

Predictors of insight on discharge in our study were in line with the results of De Hert et al. (2009) who found that grandiosity and social withdrawal had strong associations with insight, and Sanz et al. (1998), who found that insight was related strongly to the presence of grandiosity (inversely) and depression (positively).

Moreover, many of the factors predicting insight on discharge are considered negative symptoms. Negative symptoms are known to have limited and less satisfactory treatment options than positive symptoms (Murphy et al., 2006). So, persistence of negative symptoms on discharge may explain our findings that many negative symptoms were among the predictors of insight on discharge. This was in agreement with Tirupati et al. (2007) who found that poor insight was significantly correlated with negative symptoms in treated patients.

Finally, persistence of the item ‘lack of judgment and insight’ from general psychopathology subscale of PANSS as a predictor of insight on admission and also on discharge indicates its validity in measuring insight and its significant correlation with SUMD.[42]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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