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Insight, self-stigma and psychosocial outcomes in Schizophrenia: a structural equation modelling approach

  • Y.-J. Lien (a1), H.-A. Chang (a2) (a3), Y.-C. Kao (a3) (a4), N.-S. Tzeng (a2) (a3), C.-W. Lu (a4) and C.-H. Loh (a5)...

Abstract

Aims.

Poor insight is prevalent in patients with schizophrenia and has been associated with acute illness severity, medication non-adherence and poor treatment outcomes. Paradoxically, high insight has been associated with various undesirable outcomes, including low self-esteem, depression and low subjective quality of life (QoL) in patients with schizophrenia. Despite the growing body of studies conducted in Western countries supporting the pernicious effects of improved insight in psychosis, which bases on the level of self-stigma, the effects are unclear in non-Western societies. The current study examined the role of self-stigma in the relationship between insight and psychosocial outcomes in a Chinese population.

Methods.

A total of 170 outpatients with schizophrenia spectrum disorders were recruited from two general university hospitals. Sociodemographic data and clinical variables were recorded and self-report scales were employed to measure self-stigma, depression, insight, self-esteem and subjective QoL. Structural equation modelling (SEM) was used to analyse the cross-sectional data.

Results.

High levels of self-stigma were reported by 39% of the participants (n = 67). The influences of insight, self-stigma, self-esteem and depression on subjective QoL were confirmed by the SEM results. Our model with the closest fit to the data (χ 2 = 33.28; df = 20; p = 0.03; χ 2/df = 1.66; CFI = 0.98; TLI = 0.97; RMSEA = 0.06) demonstrated that self-stigma might fully mediate the association of insight with low self-esteem, depression and poor subjective QoL. High insight into illness contributed to self-stigma, which caused low self-esteem and depression and, consequently, low QoL. Notably, insight did not directly affect self-esteem, depression or QoL. Furthermore, the association of insight with poor psychosocial outcomes was not moderated by self-stigma.

Conclusions.

Our findings support the mediating model of insight relevant to the poor psychosocial outcomes of individuals diagnosed with schizophrenia in non-Western societies, in which self-stigma plays a pivotal role. These findings elucidate the direct and indirect effects of insight on psychosocial outcomes and imply that identifying and correcting self-stigma in people with schizophrenia could be beneficial. Additional studies are required to identify whether several other neurocognitive or psychosocial variables mediate or moderate the association of insight with self-esteem, depression and QoL in patients with schizophrenia. Studies with detailed longitudinal assessments are necessary to confirm our findings.

Copyright

Corresponding author

*Address for correspondence: Y.-C. Kao, Department of Psychiatry, Tri-Service General Hospital Songshan Branch, 131 Jiankang Road, Songshan District, Taipei 10581, Taiwan. (Email: freud001@ms45.hinet.net, wheelis001@gmail.com)

References

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Amador, XF, Flaum, M, Andreasen, NC, Strauss, DH, Yale, SA, Clark, SC, Gorman, JM (1994). Awareness of illness in schizophrenia and schizoaffective and mood disorders. Archives General Psychiatry 51, 826836.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of mental Disorders, 4th edn, Text Revision. American Psychiatric Association: Washington, DC.
Baron, RM, Kenny, DA (1986). The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology 51, 11731182.
Beck, AT, Steer, RA, Ball, R, Ranieri, W (1996). Comparison of Beck Depression Inventories-IA and -II in psychiatric outpatients. Journal of Personality Assessment 67, 588597.
Belvederi Murri, M, Respino, M, Innamorati, M, Cervetti, A, Calcagno, P, Pompili, M, Lamis, DA, Ghio, L, Amore, M (2015). Is good insight associated with depression among patients with schizophrenia? Systematic review and meta-analysis. Schizophrenia Research 162, 234247.
Bentler, PM, Bonett, DG (1980). Significance tests and goodness-of-fit in the analysis of covariance structures. Psychological Bulletin 88, 588600.
Berkout, OV, Gross, AM, Young, J (2014). Why so many arrows? Introduction to structural equation modeling for the novitiate user. Clinical Child and Family Psychology Review 17, 217229.
Bora, E, Schitoglu, G, Asiler, M, Atabay, I, Veznedaroglu, B (2007). Theory of mind and unawareness of illness in schizophrenia: is poor insight a mentalizing deficit? European Archives of Psychiatry and Clinical Neuroscience 257, 104111.
Boyd, JE, Adler, EP, Otilingam, PG, Peters, T (2014). Internalized Stigma of Mental Illness (ISMI) scale: a multinational review. Comprehensive Psychiatry 55, 221231.
Breitborde, NJ, Srihari, VH, Pollard, JM, Addington, DN, Woods, SW (2010). Mediators and moderators in early intervention research. Early Intervention Psychiatry 4, 143152.
Brohan, E, Elgie, R, Sartorius, N, Thornicroft, G (2010). Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: the GAMIAN-Europe study. Schizophrenia Research 122, 232238.
Cavelti, M, Kvrgic, S, Beck, EM, Rüsch, N, Vauth, R (2012 a). Self-stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders. Comprehensive Psychiatry 53, 468479.
Cavelti, M, Kvrgic, S, Beck, EM, Kossowsky, J, Vauth, R (2012 b). The role of subjective illness beliefs and attitude toward recovery within the relationship of insight and demoralization among people with schizophrenia spectrum disorders. Journal of Clinical Psychology 68, 462476.
Cavelti, M, Rüsch, N, Vauth, R (2014). Is living with psychosis demoralizing? Insight, self-stigma, and clinical outcome among people with schizophrenia across 1 year. The Journal of Nervous and Mental Diseases 202, 521529.
Chemerinski, E, Bowie, C, Anderson, H, Harvey, PD (2008). Depression in schizophrenia: methodological artifact or distinct feature of the illness? The Journal of Neuropsychiatry and Clinical Neurosciences 20, 431440.
Cheng, JJ, Ho, H, Chang, CJ, Lan, SY (1996). Positive and Negative Syndrome Scale (PANSS): establishment and reliability study of a Mandarin Chinese language version. Taiwanese Journal of Psychiatry 10, 251258.
Cheng, ST, Hamid, PN (1995). An error in the use of translated scales: the Rosenberg Self-Esteem Scale for Chinese. Perceptual and Motor Skills 81, 431434.
Chien, WT, Thompson, DR (2014). Effects of a mindfulness-based psychoeducation programme for Chinese patients with schizophrenia: 2-year follow-up. British Journal of Psychiatry 205, 5259.
Corrigan, PW, Calabrese, JD (2005). Strategies for assessing and diminishing self-stigma. In On the Stigma of Mental Illness: Practical Strategies for Research and social Change (ed. Corrigan, PW), pp. 239256. American Psychological Association: Washington, DC.
Deng, L, Yuan, KH (2015). Multi-group analysis for structural equation modeling with dependent samples. Structural Equation Modeling: a Multidisciplinary Journal 22, 552567.
Hasson-Ohayon, I, Kravetz, S, Meir, T, Rozencwaig, S (2009). Insight into severe mental illness, hope, and quality of life of persons with schizophrenia and schizoaffective disorders. Psychiatry Research 167, 231238.
Hasson-Ohayon, I, Levy, I, Kravetz, S, Vollanski-Narkis, A, Roe, D (2011). Insight into mental illness, self-stigma, and the family burden of parents of persons with a severe mental illness. Comprehensive Psychiatry 52, 7580.
Hasson-Ohayon, I, Tuval-Mashiach, R, Morag-Yaffe, M, Gaziel, M, Schapir, L, Zalsman, G, Shoval, G (2014). Parents of adolescents with psychiatric disorders: insight into the disorder, self-stigma and parental stress. Comprehensive Psychiatry 55, 11061110.
Hopwood, CJ (2007). Moderation and mediation in structural equation modeling: applications for early intervention research. Journal of Early Intervention 29, 262272.
Kao, YC, Liu, YP (2010). The clinical applicability of the Self-Appraisal of Illness Questionnaire (SAIQ) to chronic schizophrenic patients. Psychiatric Quarterly 81, 215225.
Karow, A, Pajonk, FG, Reimer, J, Hirdes, F, Osterwald, C, Naber, D, Moritz, S (2008). The dilemma of insight into illness in schizophrenia: self- and expert-rated insight and quality of life. European Archives of Psychiatry and Clinical Neuroscience 258, 152159.
Kay, SR, Fiszbein, A, Opler, LA (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin 13, 261276.
Kim, SW, Kim, SJ, Yoon, BH, Kim, JM, Shin, IS, Hwang, MY, Yoon, JS (2006). Diagnostic validity of assessment scales for depression in patients with schizophrenia. Psychiatry Research 144, 5763.
Kline, RB (2011). Principles and Practice of Structural Equation Modeling, 3rd edn. The Guilford Press: New York.
Kuo, PJ, Chen-Sea, MJ, Lu, RB, Chung, MS, Kuo, CC, Huang, WC (2007). Validation of the Chinese version of the Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) in Taiwanese patients with schizophrenia. Quality Life Research 16, 15331538.
Lien, YJ, Kao, YC, Liu, YP, Chang, HA, Tzeng, NS, Lu, CW, Loh, CH (2015). Internalized stigma and stigma resistance among patients with mental illness in Han Chinese population. Psychiatric Quarterly 86, 181197.
Livingston, JD, Boyd, JE (2010). Correlates and consequences of internalized stigma for people living with mental illness stigma: a systemic review and meta-analysis. Social Science & Medicine 71, 21502161.
Lu, ML, Che, SS, Chang, SW, Shen, WW (2002). Reliability and validity of the Chinese version of the Beck Depression Inventory-II. Taiwanese Journal of Psychiatry 16, 301310.
Lv, Y, Wolf, A, Wang, X (2013). Experienced stigma and self-stigma in Chinese patients with schizophrenia. General Hospital Psychiatry 35, 8388.
Lysaker, PH, Bryson, GJ, Bell, MD (2002). Insight and work performance in schizophrenia. The Journal of Nervous and Mental Diseases 190, 142146.
Lysaker, PH, Roe, D, Yanos, PT (2007). 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. Schizophrenia Bulletin 33, 192199.
Lysaker, PH, Buck, KD, Salvatore, G, Popolo, R, Dimaggio, G (2009). Lack of awareness of illness in schizophrenia: conceptualizations, correlates and treatment approaches. Expert Review of Neurotherapeutics 9, 10351043.
Lysaker, PH, Vohs, J, Hillis, JD, Kukla, M, Popolo, R, Salvatore, G, Dimaggio, G (2013 a). Poor insight into schizophrenia: contributing factors, consequences and emerging treatment approaches. Expert Review of Neurotherapeutics, 13, 785793.
Lysaker, PH, Vohs, J, Hasson-Ohayon, I, Kukla, M, Wierwille, J, Dimaggio, G (2013 b). Depression and insight in schizophrenia: comparisons of levels of deficits in social cognition and metacognition and internalized stigma across three profiles. Schizophrenia Research 148, 1823.
Mak, WW, Wu, CF (2006). Cognitive insight and causal attribution in the development of self-stigma among individuals with schizophrenia. Psychiatric Services 57, 18001802.
Mardia, KV, Foster, K (1983). Omnibus tests of multinormality based on skewness and kurtosis. Communications in Statistics -Theory and Methods 12, 207221.
Margariti, M, Ploumpidis, D, Economou, M, Christodoulou, GN, Papadimitriou, GN (2015). Quality of life in schizophrenia spectrum disorders: associations with insight and psychopathology. Psychiatry Research 225, 695701.
Marks, KA, Fastenau, PS, Lysaker, PH, Bond, GR (2000). Self-Appraisal of Illness Questionnaire (SAIQ): relationship to researcher-rated insight and neuropsychological function in schizophrenia. Schizophrenia Research 45, 203211.
Maxwell, SE, Cole, DA (2007). Bias in cross-sectional analyses of longitudinal mediation. Psychological Methods 12, 2344.
Mintz, AR, Dobson, KS, Romney, DM (2003). Insight in schizophrenia: a meta-analysis. Schizophrenia Research 61, 7588.
Mittal, D, Sullivan, G, Chekuri, L, Allee, E, Corrigan, PW (2012). Empirical studies of self-stigma reduction strategies: a critical review of the literature. Psychiatric Services 63, 974981.
Mohamed, S, Rosenheck, R, He, H, Yuping, N (2014). Insight and attitudes towards medication among inpatients with chronic schizophrenia in the US and China. Social Psychiatry & Psychiatric Epidemiology 49, 10631070.
Ritsher, J, Otilingam, PG, Grajales, M (2003). Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Research 121, 3149.
Rosenberg, M (1979). Conceiving the Self. Basic Books: New York.
Schrank, B, Amering, M, Hay, AG, Weber, M, Sibitz, I (2014). Insight, positive and negative symptoms, hope, depression and self-stigma: a comprehensive model of mutual influences in schizophrenia spectrum disorders. Epidemiology and Psychiatric Sciences 23, 271279.
Sibitz, I, Unger, A, Woppmann, A, Zidek, T, Amering, M (2011 a). Stigma resistance in patients with schizophrenia. Schizophrenia Bulletin 37, 316323.
Sibitz, I, Amering, M, Unger, A, Seyringer, ME, Bachmann, A, Schrank, B, Benesch, T, Schulze, B, Woppmann, A (2011 b). The impact of the social network, stigma, and empowerment on the quality of life in patients with schizophrenia. European Psychiatry 26, 2833.
Staring, AB, Van der Gaag, M, Van den Berge, M, Duivenvoorden, HJ, Mulder, CL (2009). Stigma moderates the associations of insight with depressed mood, low self-esteem, and low quality of life in patients with schizophrenia spectrum disorders. Schizophrenia Research 115, 363369.
Valiente, C, Provencio, M, Espinosa, R, Chaves, C, Fuentenebro, F (2011). Predictors of subjective well-being in patients with paranoid symptoms: is insight necessarily advantageous? Psychiatry Research 189, 190194.
Xia, J, Merinder, LB, Belgamwar, MR (2011). Psychoeducation for schizophrenia. Cochrane Database of Systemic Reviews 15, CD002831.
Xiang, YT, Wang, Y, Wang, CY, Chiu, HF, Chen, Q, Chan, SS, Lai, KY, Lee, EH, Ungvari, GS (2012). Association of insight with sociodemographic and clinical factors, quality of life, and cognition in Chinese patients with schizophrenia. Comprehensive Psychiatry 53, 140144.
Yang, LH, Purdie-Vaughns, V, Kotabe, H, Link, BG, Saw, A, Wong, G, Phelan, JC (2013). Culture, threat, and mental illness stigma: identifying culture-specific threat among Chinese-American groups. Social Science & Medicine 88, 5667.
Yanos, PT, Roe, D, Markus, K, Lysaker, PH (2008). Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatric Services 59, 14371442.
Yanos, PT, Roe, D, Lysaker, PH (2010). The impact of illness identity on recovery from severe mental illness. American Journal of Psychiatric Rehabilitation 13, 7393.
Yanos, PT, Roe, D, Lysaker, P (2011). Narrative enhancement and cognitive therapy: a new group-based treatment for internalized stigma among persons with severe mental illness. International Journal of Group Psychotherapy 61, 577595.

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