Psychiatry and Clinical Neurosciences
Blackwell Science, LtdOxford, UKPCNPsychiatry and Clinical Neurosciences1323-13162005 Blackwell Science Pty LtdDecember 2005596657660Original Article
Relationships in schizophrenicsK. C. Chen et al.
Correspondence address: Dr Yen Kuang Yang, Department of Psy-
chiatry, National Cheng Kung University, 138 Sheng Li Road, Tainan
70428 Taiwan. Email: email@example.com
Received 21 December 2004; revised 16 May 2005; accepted 29
The relationship among insight, cognitive function of
patients with schizophrenia and their relatives’
KAO CHING CHEN,
TZUNG LIEH YEH,
Department of Psychiatry,
CHING LIN CHU,
I HUI LEE,
Institute of Behavior Medicine, National Cheng Kung University Medical Center,
YEN KUANG YANG,
PO SEE CHEN,
AND RU BAND LU, md
Medically, insight is a multidimensional concept. Results of previous studies are inconclusive
regarding the relationship between insight and global and cognitive functions. The aim of this study
was to evaluate the relationship among insight, patients’ global function, cognitive function of
patients with schizophrenia and their key caregivers’ perception about this disorder. Thirty-one
patients with schizophrenia were recruited. Cognitive function such as memory index proved to be
a significant predictor for patients’ insight; environmental factors such as caregivers’ perception
was not. In addition to cognitive deficit, whether the other factors such as genetic variability, med-
ication use, environmental factors, and illness severity, etc., could influence insight of patients will
still be a controversial issue. Further multidimensional survey of the relationship with insight in a
larger and comprehensive design is necessary.
cognitive function, insight, relatives’ perception, schizophrenia.
Insight of patients with schizophrenia has been dis-
cussed for years due to its influences on patients’ ther-
apeutic management and prognosis. Researchers agree
that insight is not an one-dimensional construct; rather,
it is best conceptualized multidimensionally.
sions of insight that have been widely accepted include
awareness of symptoms, recognition that one suffers
from a mental illness, and acceptance of the need for
treatment. Recent empiric studies about patients’
unawareness of illness have suggested several areas for
further investigation, including the lack of insight that
may stem from a neurological deficit.
found poor Wisconsin Card Sorting Test (WCST) per-
formance inversely correlated with insight in schizo-
phrenic patients, and concluded that poor insight is
significantly related to schizophrenic psychopathology,
and confirmed that there is a relationship between
executive performance and insight.
In addition, patients with first-episode schizophrenia
and poor insight were also found to have higher levels
of perseverative errors on the WCST, suggesting that
poor insight in schizophrenia may be a function of spe-
cific prefrontally mediated neurocognitive deficits.
David summarized findings from studies assessing
insight in relation to IQ and other cognitive measures
and reported significant correlation between either IQ
or WCST performance and insight. Goodman
also reported that patients with positive attitudes
towards medication performed significantly better
than those with negative attitudes towards medication
on tests of verbal working memory (digit span for-
wards and backwards), inhibition and set shifting
(Penn Inhibition test), delayed object memory and
overall mental status (Mini Mental State Examina-
. suggested that deficits in insight
may be related to a generalized dysfunction of neural
networks involved in memory, learning, and executive
658K. C. Chen
contradictory results. Freudenreich
that frontal lobe cognitive deficits do not correlate to
symptoms awareness. McCabe
. also found no significant association between
cognitive impairments and total insight. In spite of the
possible relationship between cognitive deficits and
insight, lack of insight might be construed as part of
schizophrenic symptoms as well.
ences may also play a role in insight.
cognitive deficits and psychopathology in schizophren-
ics, the spectrum of psychosocial influences on the
insight of patients with schizophrenia, particularly the
environmental factors, may be correlated with the for-
mulation of insight, though they have seldom been
The insight of schizophrenic patients is a multidi-
mensional concept. In addition to the more widely
discussed dimensions such as cognitive deficits and psy-
chopathology, we chose to focus on caregivers’ percep-
tion as an environmental influence on insight
formation. We hypothesized that caregivers’ percep-
tion about schizophrenia may affect patients’ insight
either by interrupting drug adherence and other ther-
apeutic strategies, or by the high emotional expression
of caregivers which may also induce patients’ poor
social support and environmental maladjustment, even
The aim of this study was to evaluate the relationship
among insight, cognitive functions of patients with
schizophrenia and their key caregivers’ perception
about this disorder.
However, several studies have also reported
In addition to
Thirty-one patients (17 males and 14 females) with
schizophrenia, in accordance with diagnosis of DSM-
IV, were recruited from the outpatient clinic of
National Cheng Kung University Hospital, Tainan, Tai-
wan. Their mean age was 30.65 years (SD
mean duration of illness was 6.12 years (SD
and their frequency of admission was between zero and
eight times. Eight patients were drug naïve, 16 patients
received haloperidol (dose 7.21
verted chlorpromazine equivalent (CPZ) dose 360.6
218.8 mg/day), and seven patients received risperi-
done (dose 5.00
2.76 mg/day; converted CPZ mean
Informed consent was obtained from all participants.
The study protocols were approved by the Ethical
Committee for Human Research at National Cheng
Kung University Medical Center.
4.38 mg/day; con-
Patients’ insight about their mental problems was
measured with the Scale of Assessment of Insight
(SAI), which consists of three dimensions: treatment
adherence, recognition of illness, and re-labeling of
psychotic phenomena as pathological.
bal functioning was assessed using the Global Assess-
ment of Functioning (GAF) Scale, and their memory
and attention functioning was assessed by the Wech-
sler Memory Scale-Revised (WMS-R). The key care-
giver of each patient in this study was defined
according to the following criteria: (i) living with the
patient; (ii) entitled to decide treatment mode and
medication; and (iii) responsible for the daily care of
the patient. Environmental influence on the insight of
patients’ key caregivers was measured using the fol-
lowing scales: (i) Knowledge of Schizophrenia (KOS);
and (ii) Perceived Cause of illness (PCI). Knowledge
of Schizophrenia is a 14-item questionnaire that
assesses the key caregivers’ knowledge of four aspects
of the disease including: symptoms, causes, treat-
ments, and community rehabilitation related to schi-
zophrenia. Internal consistency was estimated by
Cronbach’s alpha (0.79). PCI is a self-reported ques-
tionnaire compiled with reference to a study by
Krauss. This scale consists of five causes of illness
and assesses caregivers’ perceptions of the cause of
disease including biological, psychodynamic, environ-
mental, moral, and supernatural. In this study, we
changed this scale into a dichotomy containing biolog-
ical and non-biological causes (psychodynamic, envi-
ronmental, moral and supernatural origin). At least
three specific questions of biological cause scored
equal to or more than 3 to reach the standard of
illness caused by biological factors. In order to be
assigned as ‘biological attribution’ of the disease, the
caregiver has to score at least 3 on the three specific
questions about biological cause. Its internal consis-
tency estimated by Cronbach’s alpha ranged from 0.50
Partial correlation analyses while controlling for age
were performed on GAF Scale, memory and attention
functioning and relatives’ perception with patients’
insight. Linear regression was used to assess the con-
tribution of these above mentioned factors, including
GAF Scale, memory and attention functioning, and
relatives’ perception, to SAI while controlling the con-
founding variable, CPZ. All analyses were performed
using the SPSS computer package (SPSS Inc., Chicago,
Relationships in schizophrenics 659
After partialling out age, two correlations remained
significant: the positive correlation between insight and
GAF Scale, and the positive correlation between
insight and general and verbal memory indices
(Table 1). PCI and KOS from patients’ key caregivers
did not correlate with the scores of insight (SAI). The
linear regression model included patients’ GAF Scale,
verbal memory index, PCI and KOS as independent
variables, CPZ dosage as a control variable, and SAI
as the dependent variable. Linear regression ana-
lyses showed that when CPZ dosage (
0.91) was included in the regression
model, only verbal memory
0.03) contributed to SAI.
Our findings showed that the insight of schizophrenic
patients does correlate with their memory and atten-
tion functioning, which is consistent with the results of
several studies. It is known that a high degree of
correlation exists between insight and drug adherence
and help-seeking behaviors in patients with mental dis-
It has also been demonstrated that cognitive
appraisal of the disease, included that of key caregiv-
ers, may be related to consequent help-seeking behav-
iors in mental disease. However, we did not find a
significant correlation between insight and environ-
mental influence such as caregivers’ perception. This
result supports Simon
ship between insight and psychosocial adjustment of
patients with schizophrenia. Instead, we found that
memory (and/or attention) function significantly cor-
related with insight formation. Patients’ cognitive
functions may have a biological origin and may be inti-
mately related to patients’ insights, while caregivers’
perception may only affect the physical environment of
patients, including therapeutic strategy, drug adher-
ence, and symptom fluctuations. Caregivers’ percep-
tion is only one of a multitude of environmental
influences on patients.
Results of the study indicated that cognitive deficit is
the only significant factor in the total scores of insight.
Patient insight may be influenced by multidimensional
factors, particularly cognitive functioning. Studies on
the cognitive functions of healthy individuals such as
the memory system have mentioned that dopamine
receptor densities in striatum decline with age.
Among all the memory subscales in WMS-R, verbal
memory index has significant correlation with D
receptor density while holding age constant.
after partialling out the CPZ effect in this study, our
results still showed that verbal memory index was the
only factor that had a significant positive correlation
with insight. It is possible that insight formation may be
related to verbal memory index because verbal mem-
ory is associated with all types of functional outcome.
Regarding the correlation between D
and verbal memory index,
receptor density may play an important role
in verbal memory, which may be related to insight
Several limitations exist in this study. First, our sam-
ple size was relatively small. Second, the two scales we
used to evaluate the perceptions of the caregivers may
not fully reveal their families’ perception about the dis-
order. Third, our study is cross-sectional. The causal
relationship between multidimensional factors and
insight deserves to be further examined in a prospec-
tively designed study with a larger sample.
who found no relation-
a plausible explanation is
This work was partially supported by a grant from the
National Cheng Kung University Hospital (NCKUH-
CM-94-109). The authors are grateful to Ms Linda J
Chang, Shu Chuan Lin, and Mr Mitchell Chen and Pro-
fessor AS David for their invaluable assistance in the
preparation of this manuscript.
cognitive function and relatives’ PCI, KOS scores (
Correlations between schizophrenic patients’ SAI,
Verbal memory index
Visual memory index
General memory index
Delayed recall index
Biological cause (
Non-biological cause (
Knowledge of Schizophrenia; PCI, Perceived Causes of
Illness; SAI, Scale of Assessment of Insight; WMS-R,
Wechsler Memory Scale-Revised.
Partial correlation coefficients after controlling for age.
Analyzed as a dummy variable (0, non-biological cause; 1,
Global Assessment of Functioning; KOS,
660K. C. Chen Download full-text
1. Saravanan B, Jacob KS, Prince M, Bhugra D, David AS.
Culture and insight revisited.
2. David AS, Kemp R. Five perspectives on the phenome-
non of insight in psychosis.
3. Vaz FJ, Bejar A, Casado M. Insight, psychopathology,
and interpersonal relationships in schizophrenia.
4. Sevy S, Nathanson K, Visweswaraiah H, Amador X. The
relationship between insight and symptoms in schizo-
5. Shad MU, Muddasani S, Prasad K, Sweeney JA, Kesha-
van MS. Insight and prefrontal cortex in first-episode
6. Rossell SL, Coakes J, Shapleske J, Woodruff PW, David
AS. Insight: its relationship with cognitive function, brain
volume and symptoms in schizophrenia.
7. David AS. ‘To see oursels as others see us’. Aubrey
Br. J. Psychiatry
8. Goodman C, Knoll G, Isakov V, Silver H. Negative atti-
tude towards medication is associated with working
memory impairment in schizophrenia patients.
9. Keshavan MS, Rabinowitz J, DeSmedt G, Harvey PD,
Schooler N. Correlates of insight in first episode psycho-
10. Freudenreich O, Deckersbach T, Goff DC. Insight into
current symptoms of schizophrenia. Association with
frontal cortical function and affect.
11. McCabe R, Quayle E, Beirne AD, Anne Duane MM.
Insight, global neuropsychological functioning, and
symptomatology in chronic schizophrenia.
Br. J. Psychiatry
J. Nerv. Ment.
12. Aleman A, de Haan EH, Kahn RS. Insight and neu-
rocognitive function in schizophrenia.
2002; 14: 241–242.
13. Cuesta MJ, Peralta V. Lack of insight in schizophrenia.
Schizophr. Bull. 1994; 20: 359–366.
14. Smith TE, Hull JW, Israel LM, Willson DF. Insight,
symptoms, and neurocognition in schizophrenia and
schizoaffective disorder. Schizophr. Bull. 2000; 26: 193–
15. Simon AE, Berger GE, Giacomini V, Ferrero F, Mohr S.
Insight in relation to psychosocial adjustment in schizo-
phrenia. J. Nerv. Ment. Dis. 2004; 192: 442–445.
16. Upthegrove R, Oyebode F, George M, Haque MS.
Insight, social knowledge and working memory in schizo-
phrenia. Psychopathology 2002; 35: 341–346.
17. American Psychiatric Association. Diagnostic and Statis-
tical Manual of Mental Disorders DSM-IV-TR, Fourth
Edition, Text Revision. American Psychiatric Associa-
tion, Weshington, DC, 2000.
18. David AS. Insight and psychosis. Br. J. Psychiatry 1990;
19. Krauss MW. Measures of stress and coping in families.
In: Weiss HB, Jacobs FH (eds). Evaluting Family Pro-
grams. Aldine de Gruyter, New York, 1988; 177–194.
20. Rickelman BL. Anosognosia in individuals with schizo-
phrenia: toward recovery of insight. Issues Ment. Health
Nurs. 2004; 25: 227–242.
21. Yang YK, Hsieh HH, Wu AC, Yeh TL, Chen CC. Help-
seeking behaviors in relatives of schizophrenics in Tai-
wan. Gen. Hosp. Psychiatry 1999; 21: 303–309.
22. Chen PS, Yang YK, Lee Y-S et al. Correlation
between different memory systems and striatal dopam-
ine D2/D3 receptor density: a single photon emission
computed tomography study. Psychol. Med. 2005; 35:
23. Green MF. What are the functional consequences of
neurocognitive deficits in schizophrenia? Am. J. Psychi-
atry 1996; 153: 321–330.