Schizophrenia Research 164 (2015) 214–220

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Insight in paranoia: The role of experiential avoidance and internalized stigma Carmen Valiente a,⁎, Maria Provencio b,c, Regina Espinosa a,d, Almudena Duque a, Franziska Everts a,e a

Department of Clinical Psychology, School of Psychology, Complutense University of Madrid, Spain Psychiatry Department, Autonomous University of Madrid, Health Research Institute, University Hospital La Princesa, Madrid, Spain Carlos III Health Institute, Center for Biomedical Research on Mental Health, Madrid, Spain d Department of Psychology, School of Health Sciences, Camilo Jose Cela University, Madrid, Spain e San Juan de Dios Hospital, Ciempozuelos, Spain b c

a r t i c l e

i n f o

Article history: Received 22 January 2014 Received in revised form 10 March 2015 Accepted 11 March 2015 Available online 29 March 2015 Keywords: Insight Schizophrenia Persecutory delusions Internalized stigma Experiential avoidance Satisfaction with life

a b s t r a c t Evidence suggests that insight in psychosis has been related to treatment adherence, recovery and good prognosis, but also to depression, low self-esteem, and diminished quality of life. Thus, insight might not be advantageous under all circumstances. Internalized-stigma (i.e. self-acceptance of stigmatizing images of illness) and experiential avoidance (i.e. unwillingness to experience negative private events) have been proposed as moderating variables between insight, and psychological health variables and/or distress. We investigated the patterns of association of insight with satisfaction with life, self-esteem, depression, anxiety and psychotic psychopathology as moderated by self-stigmatizing beliefs and experiential avoidance, in a sample of 47 participants with persecutory beliefs and diagnosed with schizophrenia or other psychotic disorder. Moderation analyses confirm the importance of internalized-stigma and experiential avoidance. The presence of insight was associated with more depression when there were high levels of self-stigma. Whereas, the absence of insight was associated with a greater life satisfaction when there were high levels of experiential avoidance. To summarize, our results help understand the complex relationship between insight, psychological health variables and emotional distress, pointing to a differential pattern of moderation for negative and positive outcomes. We discuss the implications of these results for research and treatment of paranoia. © 2015 Elsevier B.V. All rights reserved.

1. Introduction A frequently proposed key condition for recovery is insight into the illness, defined as awareness of the phenomena and consequences derived from having a mental disorder (David, 1990; Amador, 2000; Lysaker et al., 2009). Lack of insight is one of the major defining characteristics of psychosis and a frequently observed aspect in persons suffering from schizophrenia spectrum disorders (Mintz et al., 2003; Lincoln et al., 2007). Insight is not an all-or nothing condition that someone can either possess or not (David, 1990; Amador et al., 1993; Mintz et al., 2003), but a complex, multi-component phenomenon that may vary in both its degree and the particular areas of personal and social concerns that it extends to (Amador et al., 1991). Appropriate insight has been connected to treatment adherence, treatment engagement, recovery and good prognosis (Karow et al., 2008), more realistic goals (Lysaker et al., 2001) and to promoting

⁎ Corresponding author at: School of Psychology, University Complutense of Madrid, Campus de Somosaguas, Madrid 28223, Spain. Tel.: +34 91 394 31 35; fax: +34 91 394 31 89. E-mail address: [email protected] (C. Valiente).

http://dx.doi.org/10.1016/j.schres.2015.03.010 0920-9964/© 2015 Elsevier B.V. All rights reserved.

positive social and health outcomes (McEvoy, 1998). In fact, in samples with schizophrenia, lower levels of insight have consistently been related to increased symptomatology and severity (Lincoln et al., 2007), poor psychosocial adjustment (McEvoy, 1998), poor social and vocational functioning (Lincoln et al., 2007), low treatment adherence (Mohamed et al., 2009) and negative prognosis (Barrett et al., 2010). Nevertheless, evidence is far from being conclusive, suggesting that insight might not be advantageous under all circumstances. Several studies have suggested that higher levels of insight are also associated with increased hopelessness and emotional distress (Kirmayer and Corin, 1998; Karow et al, 2008), depressed mood and lower selfesteem (Martens, 2009; Mohamed et al., 2009; Valiente et al., 2011a), lower subjective quality of life (Karow and Pajonk, 2006; Roseman et al., 2008), higher suicide risk (Hasson-Ohayon et al., 2006), lower physical health and vitality (Karow et al., 2007) as well as lower vocational status and less economic satisfaction (Hasson-Ohayon et al., 2006). Reviewing previous research on recovery, Andresen et al. (2003) have concluded that the elements of recovery from psychosis are a reflection of the core dimensions of psychological well-being as proposed by Ryff and Keyes (1995). Therefore variables such as hope, purpose in life and subjective well-being are very relevant elements in the process of recovery (Onken et al., 2007).

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In conclusion, leaving aside methodological differences between studies, these conflicting findings might be understood bearing in mind additional underlying psychological processes, in particular intrapersonal features that could be moderating the relationship between insight and clinical outcome. In fact, it has been found that insight is associated with less subjective wellbeing only when it co-occurs with self-stigmatizing beliefs (Lysaker et al., 2007a; Staring et al., 2009). Internalized stigma (IS) refers to the devaluation, shame, secrecy, and withdrawal triggered by applying negative stereotypes to oneself (Corrigan, 1998). IS has been proposed to moderate the associations between insight and depression, low quality of life, and negative self-esteem in persons with schizophrenia (Lysaker et al., 2007a), revealing that patients with high insight and less perceived stigmatization had more positive outcomes and showed the least impaired social functioning (Lysaker et al., 2007a; Staring et al., 2009). Furthermore, other studies have shown that the association between insight and demoralization was stronger as IS increased (Cavelti et al., 2012). Consequently, insight and IS seem to jeopardize the development of positive self-expectancies of competence and success (Mak and Wu, 2006; Lysaker et al., 2009), leading to low self-esteem, hopelessness and lowered quality of life. Experiential avoidance (EA), a generalized psychological vulnerability construct, has also been identified as a moderating variable between insight and well-being (Valiente et al., 2011a). EA refers to an individual's tendency to suppress or change the form and frequency of undesirable private events such as emotions, thoughts, behaviors or bodily sensations, in order to cope with and regulate arising negative emotions (Hayes et al., 1996). EA has been associated with the development and persistence of psychological problems in general (Hayes et al., 2004), and seems to be implicated in paranoia as well (Udachina et al., 2009). In fact, active avoiding and suppressing represent a frequently used coping strategy in psychotic patients (Shergill et al., 1998) and paranoid patients devote a great deal of effort to avoid negative implications and to maintain a positive self-presentation (Valiente et al., 2011b). Paradoxically, subduing unwanted thoughts and emotions has proven to actually intensify intrusive thoughts, emotional distress, autonomic arousal and auditory hallucinations (Salkovskis and Campbell, 1994). In the current study, a single symptom approach, focusing on persecutory beliefs rather than psychotic symptoms in general, was used to ensure parsimony. In addition, persecutory delusions seemed to be an appropriate target given that they are a very common symptom and a key clinical manifestation in the schizophrenic spectrum disorders. The aim of the study was to investigate the relationship of insight with satisfaction with life, self-esteem, depression, anxiety and psychotic psychopathology, assuming that both IS and EA may be moderating these relationships. According to previous research, in our first hypothesis we predicted that lack of insight would be positively related to the severity of positive psychotic and anxiety symptoms, satisfaction with life and self-esteem, and negatively related to depression. Since research provides conflicting evidence for the functional consequences of insight into psychosis, in our second hypothesis, we predicted that the relationships between insight and mental health outcomes in paranoia would be moderated by the extent of IS. We expected to find poorer mental health outcomes when participants showed high levels of insight and high levels of IS. In our third hypothesis, we also predicted that these relationships would be moderated by the extent of EA. We expected to find better outcomes when participants showed low levels of insight and high EA, since low levels of insight together with a tendency to suppress undesirable private events, might result in a positive self-serving presentation of oneself.

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2. Method 2.1. Participants Participants were a convenience sample of inpatients of psychiatric units in two university hospitals. All participants were currently suffering from persecutory beliefs at the time of the study, as assessed by the Present State Examination (PSE-10, section 19, WHO, 1992) with a score of 1, 2 or 3 on any the persecutory ideation items (i.e. indicating presence of the symptom; transient, in multiple occasions or constant, respectively). Participants who showed signs of severe cognitive impairment and/or admitted active substance abuse during the clinical interview were excluded. All inpatients meeting the criteria were approached, and 9 out of 60 (15%) refused to participate. The remaining 51 participants volunteered to participate in the study after reading and signing a consent form. However, 4 of 51 (7.8%) were not included in the sample because they did not complete the protocol. The remaining 47 participants (27 men) included in the study met the DSM-IV-TR (APA, 2000) criteria for the following diagnostic categories: paranoid schizophrenia (n = 12), schizophreniform disorder (n = 5), schizoaffective disorder (n = 4), delusional disorder (n = 8), brief psychotic disorder (n = 13), and no specific psychotic disorder (n = 5). All patients received psychiatric treatment at the time of the study. The mean age of the entire group was 31 years (SD = 8.4). The mean age of illness onset was 27.8 years (SD = 6.9). Demographic features of the sample are presented in Table 1.

2.2. Psychiatric and psychological assessments All clinical participants were evaluated during a psychiatric hospitalization over a two-year period (2011–2012) using the following measures.

2.2.1. Schizophrenia symptoms The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) is a widely used scale to evaluate schizophrenia symptoms' severity. It has 30 items with a 7-point rating scale (1–7) and it consists of three subscales: positive symptoms (PANSS-P), negative symptoms (PANSS-N) and general psychopathology (PANSS-PG). The PANSS scales have shown good inter-rater reliability (Peralta and Cuesta, 1994).

Table 1 Demographic and clinical characteristics of the sample. Characteristic Sex: Women, n (%) Age, mean (SD) Marital status, n (%): Married Single Other Education, n (%): Primary School Secondary School University Other Employment, n (%): Student Never employed Unemployed for N1 year Unemployed for b1 year Employed Age at first diagnosis, mean (SD) Number of psychiatric hospitalizations across the life-span Number of psychiatric hospitalizations during the preceding year

Total sample (n = 47) 20 (42.6) 31 (8.4) 11 (23.4) 31 (66) 5 (10.6) 24 (51.1) 16 (34) 6 (12.8) 1 (2.1) 5 (10.9) 10 (21.7) 6 (13.3%) 6 (13) 19 (41.3) 27.8 (6.9) 1.56 (1.16) 1.03 (0.28)

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2.2.2. Insight The Scale to assess Unawareness of Mental Disorders (SUMD; Amador et al., 1993) is a rating scale completed by clinically trained research staff following a semi-structured interview and chart review. The SUMD has three general items that evaluate global awareness of having a mental disorder, of the achieved effects of medication, and of the social consequences, as well as specific insight into symptoms and their attribution. For the purposes of this study, we used the three general items, which are (a) awareness of mental disorder, (b) awareness of the consequences of mental disorder, and (c) awareness of the effects of treatment. Each of these items is rated on a 5-point scale ranging from 1 (complete awareness) to 5 (severe unawareness). The mean of these three items results in the global awareness domain and it was used in the moderation analysis as the independent variable for parsimony and because it is a more robust indicator of general insight than the individual SUMD insight domains.

2.3. Data analyses plan First, Pearson correlation analyses were used to explore the relationships between insight domains, and positive and negative symptoms, emotional distress, psychological health variables (i.e. satisfaction with life and self-esteem) and the variables used as moderators (insight and stigma). Second, we used regression (moderation) analysis to assess how insight (as measured by the SUMD global unawareness domain), stigma (as measured by the Stereotype Endorsement ISMI Scale) and their interaction predicted emotional distress and psychological health variables. Third, we used regression analysis to assess how insight, experiential avoidance (as measured by the AAQ-II) and their interaction predict emotional distress and psychological health variables. Moderation analyses were used following Hayes' (2013) guidelines. 3. Results

2.2.3. Internalized stigma The Internalized Stigma of Mental Illness-scale (ISMI; Ritsher et al., 2003) is an instrument to assess the subjective experience of stigma. It consists of 29 items with a 4-point rating scale and five subscales. The internal consistency of the total scale was α of .85, with α of .65 in the Alienation Subscale, α of .75 in the Stereotype Endorsement Subscale, α of .75 in the Perceived Discrimination Subscale, α of .74 in the Social Withdrawal Subscale and α of .67 in the Stigma Resistance Subscale. 2.2.4. Experiential avoidance The Acceptance and Action Questionnaire—II (AAQ-II; Bond et al., 2011) is a 10-item revision of the original 9-item AAQ that assesses the level of tolerance to distressing mental events such as body sensations, thoughts or emotions (e.g. “I'm afraid of my feelings”). Each item is rated on a 7-point Likert scale ranging from 1 (“never true”) to 7 (“always true”). These ratings are summed to obtain a total score. High scores indicate greater EA and psychological inflexibility. The internal consistency of this scale was α = .80. 2.2.5. Depressive symptoms The Beck Depression Inventory—II (BDI-II; Beck et al., 1996) is a 21item self-report measure of depressive symptom severity. Severity for each depression symptom is rated on a four-point scale, ranging from 0 to 3. The BDI-II total scores can range from 0 to 63. In our study the internal consistency was α = .92. 2.2.6. Anxiety symptoms The Beck Anxiety Inventory (BAI; Beck and Steer, 1990) is a 21-item self-report questionnaire designed to assess the major cognitive, affective and physiological anxiety symptoms. Each item is rated on a scale from 0 to 3. In the current study the internal consistency for this scale was α = .94. 2.2.7. Satisfaction with life The Satisfaction with Life Scale (SWLS; Diener et al., 1985) is a widely used measure to assess life satisfaction. It consists of 5 items with a 7-point rating scale. High scores indicate greater satisfaction with life. The internal consistency was α = .86 2.2.8. Self-esteem The Rosenberg Self-esteem Questionnaire (RSQ; Rosenberg, 1965) is a widely used measure of global self-esteem. It has 10 items and participants are required to indicate their agreement with the statements on a four-point Likert scale. The range of possible scores is 10–40, with higher scores indicating higher self-esteem. The internal consistency of this scale was α = .74.

3.1. Relationship between insight, and psychological health variables and distress As Table 2 shows, none of the insight domains were significantly related to general psychopathology, negative symptoms or depression. However, in our sample the unawareness of symptoms and of treatment needs subscales was significantly correlated with the severity of positive symptoms; the more unaware of symptoms and of treatment needs, the higher his/her scores on PANSS-P. Moreover, three of the SUMD insight domains were significantly related to anxiety severity; the more unaware of symptoms, of treatment needs and the higher the global unawareness, the lower his/her scores are on the BAI. Most of the insight domains were not significantly related either to life satisfaction or self-esteem. Only the unawareness of consequences SUMD subscale was significantly related to SWLS; the higher the scores on unawareness of the consequences, the more satisfaction with life. As Table 2 shows, most of the IS dimensions were not significantly related to insight domains. Only the unawareness of treatment needs SUMD subscale was significantly related to stigma resistance; the higher the scores on the unawareness of treatment needs, the higher the stigma resistance. 3.2. Is IS or EA moderating the relationship between insight and psychological health variables and distress? We carried out separated hierarchical multiple regression analyses to examine whether IS or EA moderated the association between insight (independent variable) and psychological health variables and distress (dependent variables) in our sample. When IS was the moderator, the interaction of insight and IS was only significant when depression was the dependent variable (β = − 0.33, p b .05) explaining an additional 7% of the variance (see Table 3). Fig. 1 depicts the interaction of insight and IS. Consistent with the second hypothesis, a simple slopes analysis (Aiken and West, 1991) showed that for patients with insight, the relationship between IS and depression was positive and approached significance (slope = 0.35, t = 1.81, p b .08). However, when patients were unaware, the relationship between IS and depression was significant and negative (slope = −0.48, t = −2.46, p b .02). As shown in Fig. 1, whereas participants low in IS presented similar levels of depression regardless of their level of insight, participants with high insight and high IS had the highest level of depression while those with low insight and low IS had the lowest level of depression (Fig. 1). When EA was the moderator, the interaction of insight and EA was only significant when satisfaction with life was the dependent variable (β = 0.11, p b .01) explaining an additional 15% of the variance (see Table 4). Fig. 2 depicts the interaction of insight and EA. Consistent with the third hypothesis, slope analysis (Aiken and West, 1991)

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Table 2 Correlations between insight domains and psychopathology, mental health and emotional distress outcomes, as well as moderator variables in paranoia. SUMD insight domain Unawareness of symptoms

Unawareness of treatment needs

Unawareness of consequences

Global unawareness

Psychopathology scores Positive Scale (PANSS-P) Negative Scale (PANSS-N) Psychopathology Scale (PANSS-PG)

.298⁎ .028 −.021

.364⁎ −.140 −.079

.072 −.014 −.022

.278 −.047 −.045

Emotional distress outcome scores Depression (BDI-II) Anxiety (BAI)

−.183 −.297⁎

−.277 −.409⁎⁎

−.235 −.241

−.265 −.358⁎

.275 .247

.152 .228

Mental health outcome scores Satisfaction with life (SWLS) Self-esteem (RSQ) Moderator variable scores Experiential avoidance (AAQ-II) Internalized stigma total (ISMI) Alienation (ISMI) Stereotype endorsement (ISMI) Discrimination experience (ISMI) Social withdrawal (ISMI) Stigma resistance (ISMI)

−.019 .170 −.039 .212 .114 .033 .287

.316⁎ .176

.285 .247

−.231 −.054 −.135 .143 −.014 −.084 −.094

.008 .261 .054 .278 .227 .094 .330⁎

−.095 .140 −.047 .240 .122 .014 .194

Note. SUMD, Scale to assess Unawareness of Mental Disorder; PANSS, Positive and Negative Syndrome Scale; BDI-II, The Beck Depression Inventory—II; BAI, The Beck Anxiety Inventory; SWLS, Satisfaction With Life Scale; RSQ, Rosenberg Self-esteem Questionnaire; AAQ-II, Acceptance and Action Questionnaire—II; ISMI, The Internalized Stigma of Mental Illness-scale. ⁎ p b .05. ⁎⁎ p b .01

showed that for patients with insight, the relationship between EA and satisfaction with life was significant and negative (slope = − 0.60, t = −3.63, p b .001). For patients without insight, the relationship between EA and satisfaction with life was positive and approached significance (slope = 0.38, t = 1.84, p b .08). As shown in Fig. 2, whereas participants low in EA presented similar levels of satisfaction with life regardless of their level of insight, the combination of high insight and high EA was associated with lower satisfaction with life while those with low insight and high EA had the highest level of satisfaction with life (Fig. 2). 4. Discussion The assessment of participants' satisfaction with life, self-esteem and emotional distress (i.e. depression and anxiety) and its relation with insight partially confirmed our first hypothesis. Our findings are consistent with other studies that have found that insight is associated with a mixture of positive and negative consequences (Kravetz et al., 2000;

Schwartz, 2001; Staring et al., 2009; Valiente et al., 2011a). Consistent with a meta-analysis by Mintz et al. (2003) who found a small negative relationship between insight and symptomatology, our results confirmed that awareness of symptoms and treatment effects is negatively related to the severity of positive psychotic symptoms. However, our findings show that as unawareness of illness increased, patients with paranoia demonstrated less anxiety. This could suggest that accepting the illness was associated with uneasiness and not to relieve in these cases. Moreover, we found a low negative but not significant, association between poor insight and depression severity, which is in line with the findings of other studies (Lincoln et al., 2007a). Finally, we found a positive and significant association between poor insight and satisfaction with life and a positive but not significant association with, suggesting that acceptance of the illness is associated with dissatisfaction. Thus, patients with poor insight experience less anxiety (potentially also less depression) and more positive symptomatology and maybe more self-satisfaction. We cannot sustain whether it is a tradeoff of a psychological defense (Moore et al., 1999), or the natural conse-

Table 3 Regression analysis to assess how insight, stereotype endorsement and their interaction predict mental health and emotional distress outcomes.

Dependent variable: Satisfaction with life (SWLS) Unawareness of the illness (SUMD) Stereotype endorsement (ISMI) SUMD ∗ ISMI Dependent variable: Self-esteem (RSG) Unawareness of the illness (SUMD) Stereotype endorsement (ISMI) SUMD ∗ ISMI Dependent variable: depression (BDI-II) Unawareness of the illness (SUMD) Stereotype endorsement (ISMI) SUMD ∗ ISMI Dependent variable: anxiety (BAI) Unawareness of the illness (SUMD) Stereotype endorsement (ISMI) SUMD ∗ ISMI ⁎ p b .05.

R2

ΔR2

.09

.00

.08

.00

.18

.07

β

p

2.03 −.32 .22

.62 −.10 .02

.05⁎ .75 .83

1.88 −.99 −.25

.39 −.23 .02

.07 .33 .80

−1.08 .05 −.33

.03 .92 .05⁎

−2.15 .01 −1.59

.01⁎ .99 .12

t (each predictor)

−2.24 .11 −1.98

.20

.05

−2.81 .01 −.42

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30

24,13

25

Depression (BDI-II)

20

Aware (SUM D)

16,93 15 16,4

Unaware (SUM D)

9,98

10

5

0 Low Stereotype

High Stereotype

Stereotype Endorsement (ISMI) Fig. 1. Stereotype Endorsement Subscale (ISMI) as a moderator of the relationship between insight (SUMD) and depression (BDI-II). Note: BDI-II, The Beck Depression Inventory—II; ISMI, The Internalized Stigma of Mental Illness-scale; SUMD, The Scale to assess Unawareness of Mental Disorder.

quence of not accepting a label that is charged with negative connotations. We found evidence for IS and EA as moderators of the relationship between insight and some of the key dependent variables (i.e. depression and satisfaction with life). For high levels of self-stigma, high levels of insight were associated with high levels of depression, while low levels of insight were associated with low levels of depression, consistent with previous research about the negative impact of insight on subjective well-being only when accompanied by internalized stigma, i.e. when having interiorized and attached negative illness labels, stereotypes to oneself (Lysaker et al., 2007a; Staring et al., 2009). In fact, multiple studies have found internalized stigma to be related to depressed mood (Ritsher et al., 2003) and depression (Lysaker et al., 2007b; Vauth et al., 2007; Yanos et al., 2008). Thus, the findings of our sample suggest that individuals with a combination of high insight and high IS are at a higher risk of depression, but those with poor insight, even if stigmatized, tend to be more resistant to depression. When IS was low, the relationship between insight and depression

seemed to be absent. This result is in line with other studies that have found that self-explanations of the illness that are charged with negative connotations have negative consequences if one accepts the illness label (Lysaker et al., 2007a; Staring et al., 2009; Cavelti et al., 2012). It is important to highlight that our results indicate that insight does not seem to be related to negative emotional consequences such as depressed mood when such self-explanations of the illness are not stigmatized. Given the link between negative affect and the persistence of positive symptoms in schizophrenia spectrum disorders (MyinGermeys et al., 2001), it is essential to identify and question the stereotypes associated with mental illness. In addition, future research should explore further the pathological dynamics and their relationship not only with internalized, but also with externalized stigma. These findings underscore the importance of designing interventions to monitor and reduce negative stereotypes, in order to detect those at risk for depression and reduce their vulnerability and suffering. As therapists, it is essential to develop explanatory models that are individualized, less stigmatized and more positive in collaboration with our

Table 4 Regression analysis to assess how insight, experiential avoidance and their interaction predict mental health and emotional distress outcomes.

Dependent variable: satisfaction with life (SWLS) Unawareness of the illness (SUMD) Experiential avoidance (AAQ-II) SUMD ∗ AAQ-II Dependent variable: self-esteem (RSG) Unawareness of the illness (SUMD) Experiential avoidance (AAQ-II) SUMD ∗ AAQ-II Dependent variable: depression (BDI-II) Unawareness of the illness (SUMD) Experiential avoidance (AAQ-II) SUMD ∗ AAQ-II Dependent variable: anxiety (BAI) Unawareness of the illness (SUMD) Experiential avoidance (AAQ-II) SUMD ∗ AAQ-II ⁎ p b .05. ⁎⁎ p b .01

R2

ΔR2

.38

.15

.18

β

p

2.41 −.42 3.17

.59 −.05 .11

.02⁎ .68 .003⁎⁎

.02

1.68 −.92 1.09

.33 −.09 .03

.10 .36 .28

.23

.00

2.41 −.42 −.02

−.79 .49 −.02

.09 .04⁎ .80

.25

.01

−1.82 .45 −.09

.01⁎ .22 .38

t (each predictor)

−2.50 1.23 −.88

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30 22,1

Satisfaction with Life (SWLS)

25 24,97 20 20,05 15 15,49

Aware (SUM D)

10 Unaware (SUM D)

5

0 Low Avoidance

High Avoidance

Experientail Avoidance (AAQ-II) Fig. 2. Experiential avoidance (AAQ-II) as a moderator of the relationship between insight (SUMD) and satisfaction with life (SWLS). Note: SWLS, Satisfaction With Life Scale; AAQ-II, Acceptance and Action Questionnaire-II; SUMD, The Scale to assess Unawareness of Mental Disorder.

patients, focusing on strengths and the resilience of the individual to help them achieve a fuller recovery. For high levels of EA, high levels of insight were associated with low levels of satisfaction with life. Thus, individuals with high insight and high EA are likely to feel dissatisfied with their lives, while those with poor insight, even when they had strong tendency to suppress undesirable mental events, are more likely to feel satisfied. These results are in line with our previous results (Valiente et al., 2011a). It is striking, and should be the aim of future studies, to understand why being non-accepting towards mental events is associated with more satisfaction with life in paranoid patients with low insight. Research has found that suppression is associated with less satisfaction (Gross and John, 2003), which is consistent with our findings of low satisfaction in individuals with high insight. A possible explanation is that paranoid individuals without insight need to avoid undesirable private events to maintain their satisfaction, and thus they are likely to have a fragile satisfaction. Nonetheless, it has been argued that happy people function better and that satisfaction provides the energy necessary to face challenges in life (Diener and Biswas-Diener, 2008). Thus, recovery from psychosis might be enhanced by working actively on the individual's satisfaction by focusing on values as has been advocated by ACT approaches (Bach et al., 2012). Moreover, 3rd generation behavioral mindfulness interventions might also help individuals with psychosis to become more aware of their experiences and symptoms without having to rely on psychological avoidance. Our results help understand the multifaceted relationship between insight and mental health outcome and emotional distress and what has been referred to as the insight paradox (Lysaker et al., 2007a). The present study provides interesting results, but it is limited in several ways. First, our results are based on cross-sectional data making it impossible to draw conclusions about causality. Although we used a sound multidimensional measure of insight based on interview, revision of the chart and clinical judgment, the rest of the variables rely exclusively on self-report questionnaires. The study design does not allow studying the dynamic changes over time of the variable objects of study. In addition, since our sample is a quite homogenous sample of inpatients with persecutory delusions, results might not be representative of more heterogeneous groups of patients.

Role of funding source This study was supported by grants from the I+D+I Spanish Ministry of Education and Science, ref. PSI2009-13472 and ref. PSI2012-31494. The Spanish Ministry of Education and Science provided funding for research equipment, instruments and supplies and funding to support the research assistants working in our team and to disseminate the results of our study in scientific meetings. Contributors Carmen Valiente, Maria Provencio and Regina Espinosa designed the study and wrote the protocol. Carmen Valiente, Maria Provencio, Regina Espinosa and Almudena Duque managed the literature searches and analyses. Regina Espinosa, Almudena Duque and Franziska Everts undertook the statistical analysis, and Carmen Valiente and Franziska Everts wrote the first draft of the manuscript. All the authors contributed to and have approved the final manuscript. Conflict of interest There are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. Acknowledgments This study was supported by the grants from the I+D+I Spanish Ministry of Education and Science, ref. PSI2009-13472 and ref. PSI2012-31494. We thank Kathryn Fowler for her collaboration in proof-reading the final manuscript.

References Aiken, L.S., West, S.G., 1991. Multiple regression: Testing and interpreting interactions. Sage, Newbury, CA. Amador, X.F., 2000. I Am Not Sick, I Don't Need Help! Vida Press, Peconic, New York. Amador, X.F., Strauss, D.H., Yale, S.A., Gorman, J.M., 1991. Awareness of illness in schizophrenia. Schizophr. Bull. 17, 113–132. Amador, X.F., Strauss, D.H., Yale, S.A., Flaum, M.M., Endicott, J., Gorman, J.M., 1993. Assessment of insight in psychosis. Am. J. Psychiatry 150, 873–879. American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Author, Washington, DC (text rev). Andresen, R., Oades, L., Caputi, P., 2003. The experience of recovery from schizophrenia: towards an empirically validated stage model. Aust. N. Z. J. Psychiatry 37, 586–594. Bach, P., Hayes, S.C., Gallop, R., 2012. Long-term effects of brief acceptance and commitment therapy for psychosis. Behav. Modif. 36, 165–181. Barrett, E.A., Sundet, K., Faerden, A., Agartz, I., Bratlien, U., Romm, K.L., Mork, E., Rossberg, J.L., Steen, N.E., Andreassen, O.A., Melle, I., 2010. Suicidality in first episode psychosis is associated with insight and negative beliefs about psychosis. Schizophr. Res. 123, 257–262. Beck, A.T., Steer, R.A., 1990. Manual for the Beck Anxiety Inventory. Psychological Corporation, San Antonio, TX. Beck, A.T., Steer, R.A., Brown, G.K., 1996. Manual for the Beck Depression Inventory—II. Psychological Corporation, San Antonio, TX. Bond, F.W., Hayes, S.C., Baer, R.A., Carpenter, K.C., Guenole, N., Orcutt, H.K., Waltz, T., Zettle, R.D., 2011. Preliminary psychometric properties of the Acceptance and Action Questionnaire — II: a revised measure of psychological flexibility and acceptance. Behav. Ther. 42, 676–688.

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Cavelti, M., Beck, E.M., Kvrgic, S., Kossowsky, J., Vauth, R., 2012. The role of subjective illness beliefs and attitude toward recovery within the relationship of insight and depressive symptoms among people with schizophrenia spectrum disorders. J. Clin. Psychol. 68, 462–476. Corrigan, P.W., 1998. The impact of stigma on severe mental illness. Cogn. Behav. Pract. 5, 201–222. David, A.S., 1990. Insight and psychosis. Br. J. Psychiatry 156, 798–808. Diener, E., Biswas-Diener, R., 2008. The Science of Optimal Happiness. Blackwell Publishing, Boston. Diener, E., Emmons, R.A., Larsen, R.J., Griffin, S., 1985. The Satisfaction with Life Scale. J. Pers. Assess. 49, 71–75. Gross, J.J., John, O.P., 2003. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. J. Pers. Soc. Psychol. 85, 348–362. Hasson-Ohayon, I., Kravetz, S., Roe, D., David, A.S., Weiser, M., 2006. Insight into psychosis and quality of life. Compr. Psychiatry 47, 265–269. Hayes, A.F., 2013. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-based Approach. Guilford Press, New York, NY. Hayes, S.C., Wilson, K.G., Gifford, E.V., Follette, V.M., Strosahl, K., 1996. Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. J. Consult. Clin. Psychol. 64, 1152–1168. Hayes, S.C., Strosahl, K., Wilson, K.G., Bissett, R.T., Pistorello, J., Toarmino, D., et al., 2004. Measuring experiential avoidance: a preliminary test of a working model. Psychol. Rec. 54, 553–578. Karow, A., Pajonk, F.G., 2006. Insight and quality of life in schizophrenia: recent findings and treatment implications. Curr. Opin. Psychiatry 19, 637–641. Karow, A., Czekalla, J., Dittmann, R.W., Schacht, A., Wagner, T., Lambert, M., Schimmelmann, B.G., Naber, D., 2007. Association of subjective well-being, symptoms, and side effects with compliance after 12 months of treatment in schizophrenia. J. Clin. Psychiatry 68, 75–80. Karow, A., Pajonk, F.G., Reime, 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. Eur. Arch. Psychiatry Clin. Neurosci. 258, 152–159. Kay, S., Fiszbein, A., Opler, L., 1987. The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr. Bull. 13, 262–276. Kirmayer, L.J., Corin, E., 1998. Insight knowledge; cultural constructions of insight in psychosis. In: Amador, X.F., David, A.S. (Eds.), Insight and Psychosis. Oxford University Press, New York, pp. 193–220. Kravetz, S., Faust, M., David, M., 2000. Accepting the mental illness label, perceived control over the illness, and quality of life. Psychiatr. Rehabil. J. 23, 323–332. Lincoln, T.M., Lullmann, E., Rief, W., 2007. Correlates and long-term consequences of poor insight in patients with schizophrenia. A systematic review. Schizophr. Bull. 33, 1324–1342. Lysaker, P.H., Lysaker, J.T., Lysaker, J.T., 2001. Schizophrenia and the collapse of the dialogical self: recovery, narrative and psychopathology. Psychother. Theory Res. Pract. Train. 38, 252–261. Lysaker, P.H., Roe, D., Yanos, P.T., 2007a. 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. Schizophr. Bull. 33, 192–199. Lysaker, P.H., Davis, L.W., Warman, D.M., Strasburger, A., Beattie, N., 2007b. Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: associations across 6 months. Psychiatry Res. 149, 89–95. Lysaker, P.H., Yanos, P.T., Roe, D., 2009. The role of insight in the process of recovery from schizophrenia: a review of three views. Psychosis 1, 113–121. Mak, W.W., Wu, C.F., 2006. Cognitive insight and attribution on self-stigma of individuals with schizophrenia. Psychiatr. Serv. 57, 1800–1802. Martens, W.H., 2009. The role of self-complexity in reducing harmful insight among persons with schizophrenia. Theoretical and therapeutic implications. Am. J. Psychother. 63, 53–68.

McEvoy, J.P., 1998. The relationship between insight in psychosis and compliance with medication. In: Amador, X.F., David, A.S. (Eds.), Insight and Psychosis. Oxford University Press, Oxford, pp. 298–306. Mintz, A.R., Dobson, K.S., Romney, D.M., 2003. Insight in schizophrenia: a meta-analysis. Schizophr. Res. 61, 75–88. Mohamed, S., Rosenheck, R., McEvoy, J., Swartz, M., Stroup, S., Lieberman, J.A., 2009. Crosssectional and longitudinal relationships between insight and attitudes toward medication and clinical outcomes in chronic schizophrenia. Schizophr. Bull. 35, 336–346. Moore, O., Cassidy, E., Carr, A., Callaghan, E.O., 1999. Unawareness of illness and its relationship with depression and self-deception in schizophrenia. Eur. J. Psychiatry 14, 264–269. Myin-Germeys, I., van Os, J., Schwartz, J., Stone, A., Delespaul, P., 2001. Emotional reactivity in daily life stress in psychosis. Arch. Gen. Psychiatry 58, 1137–1144. Onken, S.J., Craig, C.M., Ridgway, P., Ralph, R.O., Cook, J.A., 2007. An analysis of the definitions and elements of recovery: a review of the literature. Psychiatr. Rehabil. J. 31, 9–22. Peralta, V., Cuesta, M.J., 1994. Psychometric properties of the positive and negative syndrome scale (PANSS) in schizophrenia. Psychiatry Res. 53, 31–40. Ritsher, J.B., Otilingam, P.G., Grajales, M., 2003. Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Res. 121, 31–49. Roseman, A.S., Kasckow, J., Fellows, I., Osatuke, K., Patterson, T.L., Mohamed, S., Zisook, S., 2008. Insight, quality of life, and functional capacity in middle-aged and older adults with schizophrenia. Int. J. Geriatr. Psychiatry 23, 760–765. Rosenberg, M., 1965. Society and the Adolescent Self-image. Princeton University Press, Princeton, NJ. Ryff, C.D., Keyes, C.L.M., 1995. The structure of psychological well-being revisited. J. Pers. Soc. Psychol. 69, 719–727. Salkovskis, P.M., Campbell, P., 1994. Thought suppression induces intrusion in naturally occurring negative intrusive thoughts. Behav. Res. Ther. 32, 1–8. Schwartz, R.C., 2001. Self-awareness in schizophrenia: Its relationship to depressive symptomatology and broad psychiatric impairments. J. Nerv. Ment. Dis. 189, 401–403. Shergill, S.S., Murray, R.M., McGuire, P.K., 1998. Auditory hallucinations: a review of psychological treatments. Schizophr. Res. 32, 137–150. Staring, A.B., Van der Gaagm, M., Van den Berge, M., Duivenvoorden, H.J., Mulder, C.L., 2009. Stigma moderates the associations of insight with depressed mood, low selfesteem, and low quality of life in patients with schizophrenia spectrum disorders. Schizophr. Res. 115, 363–369. Udachina, A., Thewissen, V., Myin-Germeys, I., Fitzpatrick, S., O'kane, A., Bentall, R.P., 2009. Understanding the relationships between self-esteem, experiential avoidance, and paranoia: structural equation modelling and experience sampling studies. J. Nerv. Ment. Dis. 197, 661–668. Valiente, C., Provencio, M., Espinosa, R., Chaves, C., Fuentenebro, F., 2011a. Predictors of subjective well-being in patients with paranoid symptoms: is insight necessarily advantageous? Psychiatry Res. 189, 190–194. Valiente, C., Cantero, D., Vázquez, C., Sánchez, A., Provencio, M., Espinosa, R., 2011b. Implicit and explicit self-esteem discrepancies in paranoia and depression. J. Abnorm. Psychol. 120, 691–699. Vauth, R., Kleim, B., Wirtz, M., Corrigan, P.W., 2007. Self-efficacy and empowerment as outcomes of self-stigmatizing and coping in schizophrenia. Psychiatry Res. 150, 71–80. World Health Organization (WHO), 1992. Schedules for clinical assessment in psychiatry (SCAN-1). Wordl Health Organization (WHO), Geneva. Yanos, P.T., Roe, D., Markus, K., Lysaker, P.H., 2008. Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatr. Serv. 59, 1437–1442.