Insight in social behavioral dysfunction in schizophrenia: Preliminary study
*Miho Yoshizumi, MS, Department of Cognitive and Behavioral Science, Graduate School of Human and Environmental Studies, Kyoto University, Yoshida-Nihonmatsucho, Kyoto 606-8501, Japan. Email: firstname.lastname@example.org
Aim: Previous studies have demonstrated attenuated insight among schizophrenia subjects about having a mental disorder and about their psychopathology. Few studies, however, have investigated in detail patients' unconcern for their social behavioral problems.
Methods: Using the subjective and objective versions of the Frontal Systems Behavior Scale (FrSBe), the nature of awareness of social behavioral problems was investigated in chronic schizophrenia subjects.
Results: First, schizophrenia subjects were found to have problems in three major domains of social behavior: apathy, disinhibition, and executive dysfunction. Second, awareness, estimated by the difference between the subjective and objective ratings, was not uniformly disturbed in schizophrenia subjects, although it had a significant interaction with the subjects' estimated IQs: subjects with higher IQs had a tendency to overestimate their problems, while those with lower IQs had the opposite tendency. Third, the same pattern of interaction was demonstrated for the retrospective premorbid ratings of FrSBe.
Conclusion: Awareness among schizophrenia subjects of their social behavioral problems is affected by their cognitive capacity, and this applies not only to current behaviors but also to the retrospective estimation of their behaviors in the social domain.
EVER SINCE BLEULER, attenuated awareness, or impaired insight, has been regarded as one of the core features of the psychopathology of schizophrenia. Studies show that at least 50% of patients with schizophrenia are unaware of their disease.1 The concept of ‘insight’, in its broader sense, not only refers to knowledge of having a mental disorder, but it also includes the ability to re-label unusual mental events as pathological, adhere to treatment,2 and be aware of the consequences of the disorder for their social lives.
There is an abundance of studies on the association of insight with psychopathology in schizophrenia in the literature,3–7 and a meta-analysis indicated a negative relationship between insight and global, positive and negative symptoms, as well as a positive relationship between insight and depressive symptoms in schizophrenia.8 Poor insight is also a predictor of non-compliance with medication and poorer treatment outcome.9,10 In addition, poor insight has been demonstrated to be associated with poor compliance with rehabilitation and impairment in work performance in rehabilitation.11
Despite the clinical significance of poor insight in schizophrenia, its underlying mechanism is still poorly understood. One of the most widely supported ideas is that poor insight in schizophrenia is a reflection of enduring cognitive impairment. There are several sources that support this hypothesis. First, similarities between lack of insight in schizophrenia and anosognosia in neurological disorders imply that poor insight may have a neurological basis.12 Several studies have found that lack of awareness in schizophrenia is associated with impaired general intelligence (Wechsler Adult Intelligence Scale–Revised [WAIS-R]13–17) and prefrontal neurocognitive deficits.15,17 Some studies, however, were not able to demonstrate such associations.18,19
In order to capture multiple facets of insight in schizophrenia, the majority of recent studies15,20–22 have adopted the Scale to Assess Unawareness of Mental Disorder,23,24 which is a semi-structured interviewer-scored scale. In contrast to such interviewer-scored scales, however, a different principle of quantification of awareness that compares self-reported magnitudes of disabilities with observer-rated ones is also possible.25,26
The Frontal Systems Behavior Scale (FrSBe) was originally developed as an assessment tool to quantify behavioral problems in patients with frontal lobe damage.27 The FrSBe assesses a variety of daily behaviors mainly in the social domain. The FrSBe is composed of three subscales that assess apathy (poor initiation), disinhibition (distractibility, impulsivity) and executive dysfunction (poor planning and sequencing). Although originally developed for the assessment of subjects with frontal lobe damage, the FrSBe has been applied to a wide range of neuropsychiatric diseases involving social dysfunction, including Alzheimer's disease,28 multiple sclerosis,29 and schizophrenia.30
A novel and intriguing use of this scale is the simultaneous application of self and objective rating forms, from which the level of awareness can then be estimated by subtraction of the latter from the former.31 This provides, therefore, an estimation of awareness alternative to solely observer-rated awareness scales. Further, although previous studies have mainly demonstrated attenuated insight of patients into diagnosis or psychopathology,32 few studies have investigated in detail patient unconcern for their social behavioral problems. The FrSBe could therefore be used as an appropriate tool for such detailed characterization of awareness for multiple domains of social behavior.
In the current study, by the combined use of subjective and objective versions of the FrSBe, we estimated the level of awareness of the social behavioral problems of chronic schizophrenia subjects. In addition, the premorbid social behaviors of patients were estimated via retrospective use of both the self-rated and observer-rated versions of the FrSBe, and the resulting pattern of awareness for premorbid behavioral problems was compared with that of awareness for current behavioral problems.
Twenty six DSM-IV schizophrenia patients (all outpatients, all Japanese) were studied (Table 1). All of the patients were recruited from psychiatric services located in the southern part of Kyoto Prefecture, Japan. Diagnoses were based on the patient edition of the Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID).34,35 Exclusion criteria included serious neurological or endocrine disorder, a history of head injury leading to unconsciousness, any medical condition or treatment known to affect the brain, mental retardation, and substance misuse at the time of the study. Antipsychotic medication was prescribed to all patients. The Positive and Negative Syndrome Scale36,37 was used to assess clinical symptoms. In addition, 22 healthy comparison subjects matched to the patient group by age, gender, education, and estimated IQ were studied (Table 1). These control subjects had no history of psychiatric illness, as determined on the non-patient edition of the SCID.35,38 The exclusion criteria were the same as the patient group. The ethics committee of the Graduate School of Medicine of Kyoto University approved the study, and all subjects provided written informed consent.
Table 1. Subject characteristics
|Schizophrenia patients (current behavior; n = 26)|| || || || || || || || || || || |
| Age (years)||36.7||8.6|| ||33.5||6.7|| ||40.0||9.4|| ||−2.052|| |
| Gender (male/female)|| || ||11/15|| || ||5/8|| || ||6/7|| ||0.158|
| Handedness (right/left)|| || ||23/3|| || ||10/3|| || ||13/0|| ||3.391|
| Education (years)||13.9||2.6|| ||12.8||2.2|| ||15.0||2.6|| ||−2.336*|| |
| Age at onset (years)||26.7||9.4|| ||26.8||8.2|| ||28.1||7.4|| ||−0.428|| |
| Duration of Illness (years)||9.9||7.7|| ||6.9||5.3|| ||12.3||7.5|| ||−2.114|| |
| No. hospitalizations||1.5||1.6|| ||1.1||1.8|| ||1.9||1.3|| ||−1.147|| |
| Duration of hospitalization (months)||5.7||9.1|| ||4.3||5.5|| ||7.1||11.8|| ||−0.682|| |
| Drug (mg/day, haloperidol equivalent)||11.6||8.6|| ||13.0||7.8|| ||10.1||9.4|| ||0.847|| |
| PANSS Positive||14.5||5.5|| ||13.4||3.9|| ||15.5||6.7|| ||−1.005|| |
| PANSS Negative||15.5||5.1|| ||16.1||4.6|| ||14.9||5.6|| ||0.572|| |
| PANSS General||31.1||9.3|| ||31.0||8.2|| ||31.2||10.7|| ||−0.062|| |
| PANSS Total||61.1||18.1|| ||60.5||14.9|| ||61.7||21.4|| ||−0.170|| |
| Estimated VIQ (Vocabulary)||101.5||17.1|| ||88.1||10.1|| ||115.0||10.8|| ||−6.561*|| |
| Estimated PIQ (Block Design)||101.3||12.4|| ||94.6||13.1|| ||108.1||6.9|| ||−3.226*|| |
| Estimated IQ||101.4||12.8|| ||91.3||9.3|| ||111.5||5.8|| ||−6.647*|| |
| Hollingshead classes33||3.6||0.9|| ||3.8||0.8|| ||3.5||1.0|| ||0.869|| |
|Schizophrenia patients (premorbid behavior; n = 22)|| || || || || || || || || || || |
| Age (years)||35.9||8.5|| ||33.4||7.3|| ||38.5||9.2|| ||−1.443|| |
| Gender (male/female)|| || ||9/13|| || ||4/7|| || ||5/6|| ||0.188|
| Handedness (right/left)|| || ||19/3|| || ||8/3|| || ||11/0|| ||3.474|
| Education (years)||13.9||2.7|| ||12.9||2.4|| ||14.8||2.9|| ||−1.701|| |
| Age at onset (years)||27.6||7.9|| ||27.8||8.5|| ||27.4||7.8|| ||0.131|| |
| Duration of Illness (years)||8.5||6.9|| ||5.7||4.8|| ||11.3||7.7|| ||−2.040|| |
| No. hospitalizations||1.5||1.5|| ||1.2||1.9|| ||1.9||1.0|| ||−0.887|| |
| Duration of hospitalization (months)||6.6||9.6|| ||4.8||5.6|| ||8.7||12.8|| ||−0.837|| |
| Drug (mg/day, haloperidol equivalent)||11.1||8.4|| ||11.4||6.9|| ||10.8||10.1|| ||0.168|| |
| PANSS Positive||14.0||5.8|| ||12.6||3.8|| ||15.5||7.2|| ||−1.153|| |
| PANSS Negative||14.9||5.0|| ||15.6||4.6|| ||14.1||5.4|| ||0.721|| |
| PANSS General||29.5||9.2|| ||29.5||7.8|| ||29.5||10.8|| ||0.000|| |
| PANSS Total||58.5||18.5|| ||57.8||14.8|| ||59.1||22.3|| ||0.158|| |
| Estimated VIQ (Vocabulary)||101.4||16.5|| ||88.6||10.0|| ||114.1||10.7|| ||−5.764*|| |
| Estimated PIQ (Block Design)||100.5||12.1|| ||93.6||12.5|| ||107.3||7.2|| ||−3.141*|| |
| Estimated IQ||100.9||12.8|| ||91.1||10.1|| ||110.7||5.7|| ||−5.593*|| |
| Hollingshead Classes33||3.6||0.9|| ||3.7||0.8|| ||3.5||1.0|| ||0.696|| |
|Healthy subjects (current behavior; n = 22)|| || || || || || || || || || || |
| Healthy subjects|| || || || || || || || || || || |
| Age (years)||36.3||10.5|| ||33.3||9.6|| ||39.3||11.03|| ||−1.361|| |
| Gender (male/female)|| || ||9/13|| || ||4/7|| || ||5/6|| ||0.415|
| Handedness (right/left)|| || ||21/1|| || ||10/1|| || ||11/0|| ||1.000|
| Education (years)||13.0||2.1|| ||12.8||2.0|| ||13.2||2.2|| ||−0.399|| |
| Estimated VIQ (Vocabulary)||97.7||18.5|| ||84.5||15.0|| ||110.9||10.4|| ||−4.768*|| |
| Estimated PIQ (Block Design)||111.1||16.5|| ||101.4||12.9|| ||120.9||14.1|| ||−3.395*|| |
| Estimated IQ||104.4||14.1|| ||93.0||9.4|| ||115.9||6.3|| ||−6.739*|| |
| Hollingshead Classes33||2.9||1.0|| ||2.8||1.0|| ||3.0||1.1|| ||−0.410|| |
Assessment: Behavioral and cognitive measures
The FrSBe is a behavior rating scale designed to measure behavioral changes associated with frontal lobe damage.27 Two versions of the FrSBe (Japanese version39) were administered, a self-rated and an observer-rated form. In the present study 18 first-degree relatives, three spouses, and five medical staff served as informants for the patients, and 13 first-degree relatives and nine spouses served as informants for the control subjects. The subject or informant rated the 46-items on a 5-point scale, generating the three subscales, namely, apathy (14 items), disinhibition (15 items), and executive dysfunction (17 items). In addition to questions about current behavioral problems, the FrSBe also includes questions about premorbid behavior. In the present study both the patients and informants assessed pre-illness behavior retrospectively. Because reliable informants were not available for some patients for premorbid ratings, data from only 22 patients were available from the 26 patients investigated (Table 1). The demographic characteristics of this 22-patient group did not substantially differ from the initial 26-patient group. The T scores of the FrSBe are linear transformations of the raw scores obtained in the normative sample, such that the distribution of the scores has a mean of 50 and a standard deviation of 10, with higher scores indicating more impairment.
As was adopted in a previous study,31 discrepancies between self and observer ratings were considered to be measures of the patients' awareness of their behavioral problems. Thus, in the following statistical analyses, the factor of the rater (self or observer) was considered a repeated-measures factor, and the results were interpreted as either ‘being excessively aware of one's behavioral problems’ when self-ratings were higher, or ‘lacking awareness of one's behavioral problems’ when observer ratings were higher.
A wide range of literature suggests that patients' cognitive capacity affects their awareness of illness.13,15,17,40,41 In the present study current estimated verbal and performance IQs were obtained from subtasks of the Vocabulary and Block Design in the WAIS-R. This particular short form of the WAIS-R was reported to correlate highly with the full version of the WAIS-R.42 The raw scores of the subtasks were first transformed into scaled scores by age correction and then further transformed into IQ-equivalent values. The resulting estimated verbal IQ and performance IQ scores were averaged, and this average was interpreted as an estimate of overall intelligence. Preliminary analysis indicated that estimated IQ was significantly correlated with all of the subscales of the FrSBe self-rating form, but not with the subscales of the FrSBe observer-rating form in the patient group. Due to this inhomogeneity of regression,43 both the patient and control groups were divided with respect to estimated IQ using the median split approach for analysis investigating possible effects of IQ on behavioral ratings. With the exception of education for the patient group, there were no differences in demographic data between high-IQ and low-IQ subjects (Table 1).
To investigate the group differences between patients and control subjects in the FrSBe scores, a mixed anova was applied with subscale and rater as within-subject factors and group as the between-subject factor. Next, to investigate possible effects of IQ on the awareness of the subjects, mixed three-way anovas were applied with subscale and rater as within-subject factors and estimated IQ (high IQ or low IQ) as the between-subject factor separately for patients and controls. Similar to the afore-described analysis for current behaviors, ratings for patients' premorbid behaviors were also analyzed with a three-way mixed anova. All statistical analyses were carried out with SPSS version 12.0 (SPSS, Chicago, IL, USA). Statistical significance was set at P < 0.05 (two-tailed test).
Characteristics of behavioral ratings
The main effect of group was significant but the other main effects and interactions were not: the schizophrenia subjects scored higher in the FrSBe than the control subjects, averaged over the raters (self or observer) and three subscales (Apathy, Disinhibition, Executive dysfunction; Table 2).
Table 2. Behavioral rating
|Schizophrenia patients (current behavior; n = 26)|
|Healthy subjects (current behavior; n = 22)|
|Schizophrenia patients (premorbid behavior; n = 22)|
Awareness of current behavioral problems and the effect of IQ
For the patients, the results showed a significant effect of subscale and a significant rater × IQ interaction, while the other main effects and interactions were not significant. Follow-up anovas applied separately to high- and low-IQ groups indicated a significant main effect of rater for the high-IQ group (F = 6.126, d.f. = 1,12, P = 0.029) but not for the low-IQ group (F = 2.264, d.f. = 1, 12, P = 0.158). Finally, separate comparisons applied to each subscale of the high- and low-IQ groups indicated a significant difference between self-rating and observer rating for the executive dysfunction subscale of the high-IQ subjects, while no significant differences were found for the other comparisons (Table 2). In other words, in the subjects with higher IQs, scores of the self-rated FrSBe showed a tendency to be higher than those of the observer-rated FrSBe, while in those with lower IQs the opposite pattern was observed.
In contrast, for the controls, the anova showed no significant main effects or interactions, including the rater × IQ interaction (F = 0.239, d.f. = 1, 20, P = 0.630).
Ratings for premorbid behaviors
Results showed a significant effect of rater and a significant rater × IQ interaction, while the other main effects and interactions were not significant. Follow-up anovas applied separately to the high- and low-IQ groups indicated a significant main effect of rater for the high-IQ group (F = 13.76, d.f. = 1, 10, P = 0.004) but not for the low-IQ group (F = 0.003, d.f. = 1, 10, P = 0.954). Finally, separate comparisons applied to each subscale of the high- and low-IQ groups indicated significant difference between self-ratings and observer ratings for the executive dysfunction subscales of the high-IQ subjects, while no significant differences were found for the other comparisons (Table 2). In other words, in the subjects with higher IQs, scores of the self rating FrSBe showed a tendency to be higher than those of the observer rating FrSBe, while in those with lower IQs, no such pattern was observed.
Overall, the present results can be interpreted as indicating that the subjects with higher IQs had a tendency to overestimate their premorbid problems compared with the observer, while those with lower IQs had no such tendency.
The major findings of the present study were as follows. First, patients with schizophrenia had profound problems with frontal lobe-related daily behaviors. Second, awareness of one's behavioral problems was not uniformly disturbed in schizophrenia subjects, although it interacted with their estimated IQs: subjects with higher IQs had a tendency to overestimate their problems, while those with lower IQs had the opposite tendency. Third, this pattern of association of awareness and estimated IQ was reproduced for the retrospective premorbid ratings of the FrSBe.
Group comparison of the FrSBe scores indicated that the schizophrenia subjects were assessed as having substantial behavioral problems both according to themselves and according to the observers in all three domains of frontal lobe-related behaviors. Velligan et al. applied a staff-rated version of the FrSBe to schizophrenia and control subjects and found that the schizophrenia subjects were significantly problematic in all three domains of frontal lobe related behaviors.30 The present results reconfirmed their results in the objective rating form. In addition, by applying the self-rating form simultaneously and demonstrating that the mean self-ratings of the FrSBe were comparatively as high as the observer ratings, we could further confirm that these three domains of frontal lobe-related behavioral problems of the schizophrenia patients were generally self-recognized.
What is intriguing about the present results is the interaction of level of insight and the cognitive capacities of the schizophrenia subjects. Patients with lower cognitive capabilities were found to underestimate their behavioral problems, that is, they were less aware of their behavioral problems in all three domains of frontal lobe-related behaviors. In contrast, those with higher cognitive capabilities were found to overestimate their behavioral problems.
Although poor insight is apparently associated with poor cognitive functioning in schizophrenia,44 previous studies have indicated that such an association would not be so simplistic. That is, only a limited domain of insight would be associated with limited domains of neurocognition.21 It has even been suggested that what underlies poor insight in schizophrenia is not cognitive functioning but metacognitive domains.45 Thus, the present results demonstrating an interaction between cognitive function and awareness should not be regarded as conclusive with respect to the issue of insight–cognition association. What is new in the present study, however, is that such an association was found not in a restricted domain of social behavior but over a wide range of social behaviors. That is, patients with lower cognitive functioning tended to be less aware of their disinihibitory and apathetic behaviors as well as of executive dysfunction in their social lives. One possible interpretation of such an interaction is that there are factors characteristic of schizophrenia psychopathology that affect patient awareness in two opposite directions. In other words, the candidate factor that attenuates patient awareness is a general cognitive dysfunction, while in the other direction, the factors are discouragement and hopelessness after a long-lasting disease. In the present subjects, therefore, the former factor (general cognitive dysfunction) can be concluded to have mainly affected the awareness of the low-IQ subjects, while the latter factors (discouragement and hopelessness) mainly affected the awareness of the high-IQ subjects.
One might argue that the aforementioned interaction between cognitive function and awareness simply reflects the possible association of cognition and awareness in the general population, that is, that low-IQ subjects would, in general, underestimate their behavioral problems more than high-IQ subjects. The present results show, however, that the level of awareness of behavioral problems does not depend on cognitive function in healthy subjects, suggesting that the aforementioned interactions could be characteristic of schizophrenia subjects. To address this issue of disease specificity further, disease control groups (e.g. those with depression or those with traumatic brain injury) should be included and directly compared with schizophrenia subjects. Furthermore, due to a possible floor effect caused by the lower raw scores in the healthy subjects for both the self-rated and observer-rated forms, these results, that is, the differential pattern of cognition–awareness interaction between schizophrenia and healthy subjects, should not be taken as conclusive.
The FrSBe also allows for the retrospective assessment of premorbid behaviors. In the present study an association between cognitive capacity and insight was also found for the retrospective assessment of premorbid behaviors. Patients with higher cognitive capacities overestimated their past behavioral problems compared with those with lower cognitive capacities. Although rarely a focus of previous insight studies,46 the question of whether patients subjectively evaluate or devaluate their own previous social lives would clearly affect their subjective sense of quality of life. Thus, such an aspect of awareness has potential clinical relevance and should constitute a target of insight study in the future.
The main limitation of the present study was its small sample size. Another limitation was that the cognitive profiles of the subjects were not fully evaluated using a neuropsychological test battery including assessment of frontal lobe function. Thus, the present study should be regarded as preliminary.
Another aspect that was not investigated in the current study is the question of to what the patients were attributing their disturbed social behavior. Lack of awareness could be divided into three levels:47 knowledge of a specific deficit, emotional response to that specific deficit, and ability to comprehend the impact or consequences of the deficit in daily life, among which the present study investigated the third level. Unfortunately, due to the study design we could not verify the interrelationship among these different levels of awareness, that is, whether the schizophrenia patients were appropriately noticing that their behavioral disturbance stemmed from their mental disorder. The use of an extended questionnaire would be necessary to capture this point.
Nonetheless, the present study is the first to investigate awareness of schizophrenia subjects for a wide range of social behaviors. Moreover, an association of awareness with cognitive capacity was demonstrated. What is interesting from a wider perspective is that such an association applies not only to current behaviors but also to the retrospective estimation of one's behaviors in the social domain. In this context, it would also be interesting to verify how schizophrenia patients feel about the influence of their mental disease on social behavior in their future lives. In our next study we will investigate such aspects of insight. The present results showed that low-IQ subjects tended to underestimate their premorbid social behavioral problems, while high-IQ subjects tended to overestimate them. We speculate that not only the proper assessment of current illness or symptoms, but also the proper evaluation of one's premorbid social life is required for patients to fully realize their mental illness and effectively cope with it. Thus, the present preliminary data suggest that such a facet of insight is modulated by the cognitive capacity of patients.
This research was supported by the Uehara Memorial Foundation, Research Group for Schizophrenia, Japan.