Insight is a complex multidimensional construct which is shaped by individual psychology (i.e. motivation and denial) and the constraints of biology (as in cognitive impairment and anosognosia) and is influenced by social constructions of illness and culturally specific explanatory models (Reference Amador and DavidAmador & David, 2004). Lack of insight was found to be almost invariably associated with a diagnosis of acute schizophrenia across all countries and cultures surveyed within the World Health Organization International Pilot Study of Schizophrenia (Reference Amador, Strauss and YaleAmador et al, 1991). Standardised tools for the assessment and quantification of insight have been developed over the past 15 years (e.g. the Schedule for the Assessment of Insight (SAI; Reference DavidDavid, 1990; Reference Sanz, Constable and Lopez-IborSanz et al, 1998) and the Scale to Assess Unawareness of Mental Disorder (SUMD; Reference Amador, Strauss and YaleAmador et al, 1993)). These have been found to have clinical utility for diverse populations and patient groups worldwide, with little modification besides translation (Saravanan et al, 2003).
There is a consensus about the nature of insight emerging from systematic reviews and meta-analyses. For example, there is a weak but consistent inverse relationship between psychopathology and insight, with the exception of anxiety and low mood, which are positively associated with insight (Reference Mintz, Dobson and RomneyMintz et al, 2003; Reference David, Amador and DavidDavid, 2004). Intellectual ability, particularly executive functioning, seems to be related to insight (Reference Keshavan, Rabinowitz and DeSmedtKeshavan et al, 2004; Reference Morgan, David, Amador and DavidMorgan & David, 2004; Reference Aleman, Agrawal and MorganAleman et al, 2006). Another frequent observation is that patients are more able to recognise and label certain behaviours as the consequence of mental illness in others than they are the same behaviours in themselves (Reference McEvoy, Schooler and FriedmanMcEvoy et al, 1993; Reference Swanson, Freudenreich and McEvoySwanson et al, 1995; Reference Chung, Chen and LamChung et al, 1997; Reference StartupStartup, 1997). However, some authors (Reference Moodley and PerkinsMoodley & Perkins, 1993; Reference Johnson and OrrellJohnson & Orrell, 1995) have questioned what they regard as the Western conceptualisation of insight, arguing that it is overly biomedical and fails to allow for social constructions and culturally appropriate explanatory models of mental illness (for a discussion see Reference Saravanan, Jacob and PrinceSaravanan et al, 2004).
In this study we investigated the effect of culture, psychopathology and other clinical variables on insight of patients with schizophrenia in South India to determine which aspects are common across cultures and which are culture-specific. We tested the following hypotheses: (a) the relationship between insight and psychotic and depressive symptoms is similar to that in Western populations assessed in the same way; (b) a tendency to ascribe illness to another rather than oneself is inversely related to insight; (c) explanatory models, elicited in a standardised manner, are independent of clinician-rated insight.
METHOD
Study site
This study was carried out in the Department of Psychiatry, Christian Medical College, Vellore, which is in the north central part of Tamil Nadu. The total area of the Vellore district is 4314.29 km2 and is divided into 12 blocks with a total population of 3 026 432. The Department of Psychiatry and Community Health has worked within the Kaniyambadi Block for the past 40 years. The town of Vellore (10.54 km2) has a population of 175 061. The 100-bed hospital provides short-term care for patients with all types of psychiatric diagnoses from the town of Vellore and a much wider rural area beyond. The emphasis is on a multidisciplinary approach and eclectic care using a wide variety of pharmacological and psychological therapies. The hospital has a daily out-patient clinic in which 200–250 patients are seen. The study was approved by the ethics committees of the Christian Medical College, Vellore, and Institute of Psychiatry, London.
Sample
The study group consisted of patients with schizophrenia having their first contact with mental health services and living within a 100 km radius of the study site. Patients were carefully screened for a DSM–IV diagnosis of schizophrenia (American Psychiatric Association, 1994) and then interviewed at intake using the Structured Clinical Interview for DSM–III–R–Patient Version (SCID–P; Reference Spitzer, Williams and GibbonSpitzer et al, 1990) to confirm the diagnosis. Patients with a primary diagnosis of substance use disorder, mood disorder or organic mental disorder were excluded. Patients meeting inclusion criteria and providing written consent were interviewed as soon as possible after the start of treatment for psychosis, with all patients assessed within a week of the onset of treatment. Patients were informed that the purpose of the study was to assess their level of awareness about their illness, but were unaware of the specific hypotheses. A semi-structured interview was used to elicit data regarding demographic characteristics (age, gender, marital status, religion, education, employment, duration of illness and economic data).
Assessments
All assessment instruments were independently translated into the local language (Tamil) by two health professionals. The vernacular version thus obtained was then back-translated into English by two different bilingual professionals. The four translators then arrived at a consensus on the final vernacular version. Content, semantic, technical and conceptual equivalence of the Tamil version of the instruments was examined regularly during the process of translation. Assessments were administered by a local research psychiatrist trained in their use.
Insight
The expanded version of the Schedule of Assessment of Insight (SAI–E; Reference Kemp, David and BlackwellKemp & David, 1997; Reference Sanz, Constable and Lopez-IborSanz et al, 1998) was used for assessment of insight. This has been applied widely in Western and non-Western countries (Reference Kulhara, Chakrabarti and BasuKulhara et al, 1992; Reference Aga, Agarwal and GuptaAga et al, 1995) and comprises questions to assess three dimensions of insight: awareness, relabelling of symptoms and adherence, plus a ‘hypothetical contradiction’ item added to evaluate the person's capacity to consider another's perspective. Each dimension comprises two or three questions which are scored on a 3-point scale from 0 (no insight) to 2 (good insight), with a maximum total score of 24. The supplementary question is scored from 0 to 4 and this is added to the total score. This expanded version also includes items on awareness of change, difficulties resulting from the mental condition and insight into key symptoms.
Explanatory model interview
The Tamil version of the Short Explanatory Model Interview (SEMI; Reference Lloyd, Jacob and PatelLloyd et al, 1998; Reference Joel, Sathyaseelan and JayakaranJoel et al, 2003) was used to elicit patients' attributions of their presenting complaints; their previous help-seeking behaviour (including visiting a temple, a shamam/mantrawadi, a traditional healer, or a doctor); their causal models (e.g. previous deeds/karma, evil spirits, punishment by god, black magic, or disease); perceived consequences (change in the body or mind); and their expectations regarding the index consultation. The SEMI, which combines open-ended questions and a case vignette with a structured coding frame, has been used successfully in a variety of countries and cultures, including India (Reference Manoharam, John and JosephManoharam et al, 2001). The vignette described a young man with florid psychotic symptoms (see Appendix). Participants were asked the same range of questions regarding illness attribution for the vignette and the help-seeking they would advise for such a person.
Psychopathology
The Brief Psychiatric Rating Scale (BPRS; Reference Ventura, Green and ShanerVentura et al, 1993) and the Global Assessment of Functioning (GAF; Reference Endicott, Spitzer and FleissEndicott et al, 1976) were used to assess psychopathology. The BPRS total score and a depression subscale (investigating guilt, low mood and suicidality) were utilised.
RESULTS
Over a 1-year recruitment period, 196 patients with schizophrenia attended the Department of Psychiatry, Christian Medical College, Vellore, and 188 met the entry criteria. Of these, 37 were excluded because the severity of psychopathology precluded an interview, 14 did not attend and 6 refused consent, yielding a final sample of 131 participants. Demographic and clinical characteristics of the sample are given in Table 1. The vast majority were Hindu, with a predominance of young men living in rural areas, who had received formal education but were unemployed. Data were analysed with the Statistical Package for the Social Sciences, version 10.0. Age, gender, years of education and length of illness were not significantly correlated with BPRS and SAI–E total scores. There was no significant difference in insight between patients from urban and rural areas (mean total SAI–E score 5.5. v. 4.5); however, patients who came voluntarily had significantly higher scores (mean 7.0, s.d.=6.6) than those who attended involuntarily (mean 4.3, s.d.= 4.1; P=0.02).
Characteristics of 131 patients with schizophrenia
| Characteristic | |
|---|---|
| Age, years: mean (s.d.) | 29.5 (7.2) |
| Gender, n (%) | |
| Male | 72 (55) |
| Female | 49 (45) |
| Religion, n (%) | |
| Hindu | 115 (87.8) |
| Muslim | 4 (3.1) |
| Christian | 11 (8.4) |
| Residence, n (%) | |
| Rural | 105 (80.2) |
| Urban | 26 (19.8) |
| Literacy, n (%) | |
| Illiterate | 22 (16.8) |
| Read only | 9 (6.9) |
| Read and write | 100 (76.3) |
| Age at onset of illness, years: mean (s.d.) | 27.8 (6.85) |
| Duration of illness, weeks: mean (s.d.) | 95.5 (134.2) |
| Status, n (%) | |
| Involuntary patient | 115 (87.8) |
| Voluntary patient | 16 (12.2) |
| GAF score: mean (s.d.) | 28.7 (8.19) |
| BPRS total score: mean (s.d.) | 56.7 (5.2) |
| SAI–E total score: mean (s.d.) | 4.7 (4.57) |
GAF, Global Assessment of Functioning; BPRS, Brief Psychiatric Rating Scale; SAI–E, Schedule for the Assessment of Insight – Expanded Version
Insight and psychopathology
There was no significant correlation between BPRS total score and SAI–E total score (Pearson's r=–0.13, P=0.1), general awareness (r=–0.05) or treatment adherence sub-scales (r=–0.15). However, a significant negative correlation was observed between the relabelling dimension of the SAI–E and BPRS total score (r=–0.2, P=0.04). Of the individual items on the BPRS, anxiety showed the strongest (positive) correlation with SAI–E total score and with the illness awareness items (r=0.25 and 0.28 respectively, P<0.01).
Explanatory models
Table 2 shows the relationship between insight and responses to the SEMI summarised according to major theme. The 18 patients who endorsed a disease explanation had significantly higher scores on the SAI–E, indicating greater insight. Most patients acknowledged social (but not occupational) dysfunction and that their well-being had been affected; and these had higher insight scores than those who did not. There was a significant inverse correlation between non-biomedical beliefs and insight scores. Patients who held such beliefs, most commonly regarding black magic (n=94), but also those who attributed their problems to evil spirits, previous deeds and punishment by god, tended to have lower insight scores. Patients were frequently unsure or unable to give a definite attribution of their illness and this tended to be associated with low insight scores.
Relationship between insight and explanatory models variables
| SEMI questions | Total number of responses | SAI–E total score Mean (s.d.) | F (P) 1 |
|---|---|---|---|
| Black magic | |||
| Yes | 94 | 4.1 (4.0) | |
| No | 26 | 7.7 (5.6) | 9.0 (0.001) |
| Not sure | 11 | 2.5 (2.6) | |
| Previous deeds | |||
| Yes | 12 | 5.7 (4.8) | |
| No | 78 | 5.8 (5.0) | 9.8 (0.001) |
| Not sure | 41 | 2.2 (1.9) | |
| Evil spirits | |||
| Yes | 22 | 3.6 (4.3) | |
| No | 80 | 5.7 (4.9) | 6.7 (0.002) |
| Not sure | 29 | 2.5 (2.0) | |
| Punishment by god | |||
| Yes | 13 | 4.0 (2.7) | |
| No | 71 | 5.8 (4.9) | 6.3 (0.003) |
| Not sure | 47 | 3.0 (3.8) | |
| Disease | |||
| Yes | 18 | 10.4 (6.1) | |
| No | 64 | 3.7 (3.4) | 21.4 (0.001) |
| Not sure | 49 | 3.8 (3.8) | |
| Social dysfunction | |||
| Yes | 110 | 5.1 (4.8) | |
| No | 13 | 2.9 (2.5) | 3.1 (0.05) |
| Not sure | 8 | 1.7 (1.4) | |
| Occupational dysfunction | |||
| Yes | 124 | 4.8 (4.6) | |
| No | 5 | 2.1 (2.5) | 1.2 (0.3) |
| Not sure | 2 | 2.0 (2.8) | |
| Well-being affected | |||
| Yes | 103 | 5.4 (4.7) | |
| No | 8 | 2.1 (3.0) | 6.1 (0.003) |
| Not sure | 20 | 2.1 (2.5) |
SEMI, Short Explanatory Model Interview; SAI–E, Schedule for Assessment of Insight – Expanded version
1. One-way analysis of variance (ANOVA)
Awareness of illness – case vignette
Patients were more likely to judge the person described in the vignette as having an illness or disease (n=63) than they were to make this attribution about themselves (n=18; χ2=13.9, d.f.=1, P<0.001), excluding those making attributions to neither (n=66). Slightly fewer patients judged the person described in the vignette to be suffering from the effects of black magic (n=81, 61.8%) than they themselves (n=94, 71.8%; 95% CI–21.3 to 1.4, NS).
Factors associated with insight
A stepwise conditional logistic regression analysis was performed with total insight score as the dependent variable, entering psychopathology, endorsed explanatory models, pathways to care and other clinical variables, controlling for age, gender and education and other demographic factors. This identified causal attribution (disease as a positive predictor and black magic as a negative predictor), the perceived consequences item of the SEMI and presence of help-seeking as factors significantly associated with insight (Table 3).
Factors associated with level of insight in schizophrenia 1
| Variable | Unadjusted odds ratio (95% CI) | Adjusted odds ratio 2 (95% CI) | P |
|---|---|---|---|
| Help-seeking (0=no, 1=yes) | 5.64 (1.6–16.8) | 4.9 (1.97–12.2) | 0.001 |
| Attribution to disease (0=no, 1=yes) | 10.2 (3.4–30.3) | 9.4 (3.1–29.0) | 0.005 |
| Attribution to black magic (0=no, 1=yes) | 0.3 (0.12–0.73) | 0.36 (0.12–0.94) | 0.04 |
| Awareness of change in body or mind (0=no, 1=yes) | 8.8 (1.1–67.8) | 9.7 (1.2–75.9) | 0.03 |
SAI–E, Schedule for the Assessment of Insight – Expanded version
1. SAI–E total scores were dichotomised into high and low groups (with the median as the cut-off point)
2. Adjusted using conditional logistic regression with gender, age, years of schooling, location of residence (rural v. urban) and marital status (currently married v. not currently married)
DISCUSSION
This study examined the relationship between insight, psychopathology and explanatory models of illness and showed that insight in patients with schizophrenia from South India shows many of the same clinical, psychopathological and cognitive associations as in Western populations.
Psychopathology
There was some evidence to support the hypothesis that insight is related to the psychopathology of schizophrenia. We found a weak but significant inverse correlation between total BPRS score and the relabelling dimension of insight, and a positive relationship between insight total score and indices of anxiety and worry. Given that correlations were in opposite directions, it is not surprising that the overall correlation was non-significant, although the weight of psychosis items has usually outweighed the mood/anxiety items in previous studies (for review see Reference David, Amador and DavidDavid, 2004). Nevertheless this pattern is in line with studies carried out in both high- and low- and middle-income countries (Reference Kulhara, Chakrabarti and BasuKulhara et al, 1992; Reference Aga, Agarwal and GuptaAga et al, 1995; Reference Mintz, Dobson and RomneyMintz et al, 2003; Reference David, Amador and DavidDavid, 2004). The strength of the correlations was modest, bolstering the argument that insight and psychopathology are not merely two sides of the same coin. Lower insight scores were seen in patients brought to the clinic involuntarily, as expected from previous studies (Reference McEvoy, Applebaum and AppersonMcEvoy et al, 1989; Reference David, Buchanan and ReedDavid et al, 1992). The lack of correlation with scores of social functioning is again in line with some (Reference Bartko, Herczeg and ZadorBartkó et al, 1988; Reference SchwartzSchwartz, 1998; Reference Simon, Berger and GiacominiSimon et al, 2004) but not all previous studies (Reference Amador, Flaum and AndreasenAmador et al, 1994; Reference Trauer and SacksTrauer & Sacks, 2002), and might reflect the particularly low levels of social functioning (and small variance) in this patient sample. As in previous studies, duration of illness and gender were not determinants of insight.
The association between insight and symptoms of anxiety – assessed somewhat crudely using the BPRS – may be predicted on the basis of previous work (Reference Amador, Friedman and KasapisAmador et al, 1996; Reference Mintz, Dobson and RomneyMintz et al,2003; Reference Rathod, Kingdon and SmithRathod et al, 2005), but the direction of causality is by no means clear. The received wisdom is that anxiety and lowered mood are a reaction to illness awareness, but it is equally plausible that anxiety leads to a more self-critical attitude, akin to ‘depressive realism’. Whatever the explanation, this pattern of associations appears not to be culturally specific.
Explanatory models
Insight was also evaluated indirectly using a vignette that forms part of the SEMI. In line with our second hypothesis, a pattern was seen wherein the person in the vignette was readily labeled as having a mental illness whereas patients rarely used this attribution for themselves. This pattern has been observed in other vignette studies in the UK, USA and Asia (Reference McEvoy, Schooler and FriedmanMcEvoy et al, 1993; Reference Swanson, Freudenreich and McEvoySwanson et al, 1995; Reference Chung, Chen and LamChung et al, 1997; Reference StartupStartup, 1997). The self–other comparison overcomes the criticism levelled at cultural comparisons in psychiatry that the ‘content’ of attributions, delusions, hallucinations etc. may differ but that this is a relatively trivial consideration. Previous vignette studies show that the ‘medical model’ is an available heuristic to people with major mental illness, including those in South India. This is not surprising given the high levels of literacy and rapid cultural transition – first through colonisation and subsequently through globalisation – affecting that part of the world. It is of course highly likely that complex illness attributions of the kind elicited have been around in Asia for centuries, but here we are talking about a narrower Western biomedical model. The pattern of responses in relation to self and others might be described as an example of self-serving bias, a common, perhaps universal, defensive cognitive style (Reference Pronin, Gilovich and RossPronin et al, 2004). It is understandable that a person might be uncomfortable in ascribing to themself a diagnosis of mental illness, given the stigma that this carries and, perhaps, implications of blame. However, the alternative explanations of behaviour such as black magic or past misdeeds are not value free. The meaning and implications of mental illness within cultures are clearly varied, and we are undertaking further detailed qualitative work to explore this.
Finally, we tested the hypothesis that indigenous explanatory models or ‘emic perspectives’ would be independent of insight. The study showed that the expression of culturally appropriate illness attributions (e.g. evil spirits, black magic, etc.) was common. Adherence to such ideas was deemed, at best, not consistent with high levels of insight or, at worst, indicative of poor insight as judged by psychiatrists from the same culture. In the case of black magic, this illness attribution predicted significantly lower levels of insight in the multiple regression analysis after controlling for other factors. However, the same analysis revealed a strong association between awareness of the consequences of illness, early help-seeking and level of insight, elicited separately through the open-ended SEMI in a way that did not rely upon the conventions of a psychiatric interview. This supports the notion that insight or an awareness of illness that is adaptive in terms of appropriate help-seeking might easily be missed if the assessment of insight is undertaken in a rigid culturally insensitive way (Reference Saravanan, Jacob and PrinceSaravanan et al, 2004).
Our results compliment a recent study of second-generation minority ethnic groups in the UK of West African, Caribbean and Bangladeshi origin. This study found that there was an association between attribution of illness to supernatural phenomena – not invoked by the White UK comparison group – and poorer insight as assessed using the SEMI (Reference McCabe and PriebeMcCabe & Priebe, 2004). We also noted a tendency for those who were unsure whether disease or supernatural forces accounted for their state to have low insight scores. This might imply that any attribution is better than none.
Conclusions
We have shown that insight is amenable to study in a non-Western setting using standard assessment instruments. Patients with schizophrenia, wherever they are, appear to vary in their willingness to accept an illness attribution for their state, but are more likely to do so if they are anxious and if considering someone else's predicament rather than their own. However, the study supports a more inclusive conceptual model for assessing insight which emphasises help-seeking. This will be of value not just for clinical and research work in non-Western countries but for a richer understanding of the experience of the individual in their cultural context (Reference White, Bebbington and PearsonWhite et al, 2000; Reference McCabe and PriebeMcCabe & Priebe, 2004). Understanding the relationship between cultural variations of insight and prevailing belief systems will be a step forward in designing interventions to enhance engagement of patients with mental health services in Western and non-Western countries.
APPENDIX
Case vignette
‘I'd like to ask your opinion about some other peoples' visit to the doctor. I'd like to read a short account of their problems and then ask you a few questions about them.'
Mr M.E. was hospitalised at the age of 18. He was single and lived with his parents. His relatives described that he functioned quite well as a child and that he was well adjusted at school until the age of 11–12. At that age he became preoccupied with strange ideas and for this reason he saw a psychiatrist weekly for about 1 month. This treatment, which did not include any mediction, had a positive effect on his worries, but he became more withdrawn and participated in fewer social activities in the months to come. Before hospitalisation he felt that others could hear his thoughts and he also felt that a ‘satanic’ group living in his native place were persecuting him. In a mysterious way he felt that this group did ‘black magic’ against him and that they could influence his body from a long distance. He could feel this as a pain in his stomach. These symptoms lasted for several months. At the time of hospitalisation he felt that his brain was damaged and ‘empty’, and that ‘someone’ was inserting thoughts into his head. He was withdrawn and preoccupied with the idea that the ‘black magic’ that they had done might have destroyed his brain tissue.
Acknowledgements
We thank the participants and staff of the Christian Medical College, Vellore, for their cooperation and commitment to the study. B.S. was supported by a grant from the Wellcome Trust.
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