Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Brief report
The relationship between insight and autobiographical memory for emotional events in schizophrenia Arlene G. MacDougall a,b,n, Margaret C. McKinnon b,c, Katherine A. Herdman b,1, Matthew J. King b,2, Michael Kiang b,d a Department of Psychiatry, Western University, London Health Sciences Centre—Victoria Hospital, 800 Commissioner’s Road East, London, ON, Canada N6A 5W9 b Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare Hamilton, West 5th Campus, 100 West 5th, Hamilton, ON, Canada L8N 3K7 c Homewood Research Institute, Homewood Health Centre, 150 Delhi Street, Guelph, ON, Canada N1E 6K9 d Department of Psychiatry, University of Toronto, Centre for Addiction and Mental Health, 250 College St., Toronto, ON, Canada M5T 1R8
art ic l e i nf o
a b s t r a c t
Article history: Received 24 July 2014 Received in revised form 7 October 2014 Accepted 29 December 2014
The relation of episodic and semantic memory for emotional- (positive, negative) and neutral-valenced autobiographical events to illness insight was examined in individuals with schizophrenia. Reduced recall of episodic details for negative events was significantly associated with impaired awareness of having a past mental disorder and its social consequences. Deficits in episodic memory for negative autobiographical events may underlie impaired insight in schizophrenia. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Autobiographical memory Schizophrenia Insight
1. Introduction People with schizophrenia often have impaired insight into their disorder (Amador and Gorman, 1998). Lack of insight predicts poorer treatment adherence (Beck et al., 2011) and worse outcomes (Drake et al., 2007; Lincoln et al., 2007). Insight has been conceptualized as a storied account or narrative of different aspects of illness and their consequences that requires different forms of awareness and the recognition of pertinent historical details such as a hospitalization (Lysaker et al., 2009, 2013). Patients with schizophrenia produce less coherent personal narratives (Raffard et al., 2010; Lysaker et al., 2005); and deficits in narrative identity are associated with aspects of poor insight (Lysaker et al., 2002, 2008). Construction of a coherent identity across time relies on autobiographical memory (Conway, 2005; Tulving, 2002) and the ability to synthesize these personal memories with future goals (McAdams and McLean, 2013). n Corresponding author at: Department of Psychiatry, Western University, London Health Sciences Centre—Victoria Hospital, 800 Commissioner's Road East, London, ON, Canada N6A 5W9. Tel.: þ1 519 685 8324; fax: þ1 519 667 6657. E-mail addresses: [email protected] (A.G. MacDougall), [email protected] (M.C. McKinnon), [email protected] (K.A. Herdman), [email protected] (M.J. King), [email protected] (M. Kiang). 1 Department of Psychology, York University, 4700 Keele Street, Toronto, ON, Canada M3J 1P3. 2 Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3.
Autobiographical memory recall is compromised in schizophrenia (e.g., Elvevåg et al., 2003; Riutort et al., 2003; Danion et al., 2005; McLeod et al., 2006; Cuervo-Lombard et al., 2007; D’Argembeau et al., 2008) with recent findings suggesting that recollection of negative autobiographical events is particularly affected (Neumann et al., 2007; MacDougall et al., unpublished results). It has been suggested that an impoverished autobiographical memory may hinder the ability to think in more complex ways about oneself or others (Dimaggio et al., 2012). This notion has led to the development of promising therapeutic approaches that consider the complex interplay of autobiographical memory and metacognitive impairments (Lysaker et al., 2011; Bargenquast and Schweitzer, 2013). Despite conceptualization of insight as an autobiographical narrative, there is little research on the relationship between insight and autobiographical memory performance in schizophrenia. Lalova et al. (2013) recently demonstrated that poor insight was more strongly related to inability to recall specific autobiographical memories than to other basic cognitive measures including general episodic memory. However, to date, no studies have explored the relation between insight in individuals with schizophrenia and the specific components of autobiographical memory recollection—episodic and semantic (Tulving 1972, 1985). Episodic memory involves the conscious recollection of temporally and spatially specific events that occurred in one's past and is associated with subjective sense of personal continuity across time (‘autonoetic consciousness’) (Tulving, 2002). By contrast, semantic
http://dx.doi.org/10.1016/j.psychres.2014.12.058 0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: MacDougall, A.G., et al., The relationship between insight and autobiographical memory for emotional events in schizophrenia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2014.12.058i
A.G. MacDougall et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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memory consists of facts that are time- and context-independent, and either personal or general in nature. Behavioral, neuropsychological, and neuroimaging techniques confirm that these two forms of memory are dissociable (e.g., Eslinger, 1998; Gardiner and Java, 1991; Levine et al., 2004; Mäntylä, 1993; McKinnon et al., 2006; Parkin and Walter, 1992; Svoboda et al., 2006). Accordingly, in the present study of persons with schizophrenia, we employed the Autobiographical Interview (AI; Levine et al., 2002), a measure that separates episodic and semantic components of autobiographical memory thus minimizing the potential for episodic recollection to be subject to contamination by semantic processing (McKinnon et al., 2008). It also utilizes cueing methods associated with improved recall in schizophrenia (Potheegadoo et al., 2014; MacDougall et al., unpublished results). Finally, given that emotional valence of recalled events (Dieleman and Röder, 2013; Holland and Kensinger, 2010) may be an important moderator in the relation between autobiographical memory and insight, we surveyed recollection of positive, negative and neutral events. We hypothesized that insight relies particularly on episodic autobiographical memory as opposed to semantic information that bears less relation to personal identity over time (Conway 2005; Tulving, 2002). Given that illness-related events are typically negative in nature, we further hypothesized that poor insight into having a mental disorder and its symptoms and social consequences would be specifically associated with impaired recall of negative personal events.
2. Methods 2.1. Participants Participants were 24 outpatients (18 to 60 years old) with schizophrenia (n¼14) or schizoaffective disorder (n¼ 10) recruited from clinics in Hamilton, Canada. The protocol was approved by the local Research Ethics Board. DSM-IV diagnoses were established using a best estimate approach based on the MINI (Sheehan et al., 1998) and information from records and clinicians. Exclusion criteria included current mood episode, lifetime substance dependence, substance abuse in the past 6 months or a self-reported neurological disorder.
2.4. The Autobiographical Interview (AI) In the AI (Levine et al., 2002), participants were asked to provide detailed descriptions of three events: highly positive, highly negative and neutral that were specific to time and place, in which they were personally involved in the past 2 years, but more than 1 week ago. Three levels of retrieval support are provided: free recall, general probe, and specific probe (Levine et al., 2002). Descriptions of events were recorded and transcribed. Analysis included segmenting each memory into informational details. Details were categorized as either ‘episodic’ or ‘semantic’, with autobiographical events unrelated to the main memory, repetitions or metacognitive statements being classified separately. Participants' memories were placed in a common pool and scored at random by three experienced scorers with high inter-rater reliability (see Levine et al., 2002). Total cumulative episodic and semantic details recalled were calculated by adding free recall plus probe conditions. 2.5. Insight Insight was assessed using the Scale to Assess Unawareness of a Mental Disorder (SUMD) (Amador et al., 1993). 2.6. Statistical analysis 2.6.1. Data transformation Log10 transformation was performed to correct the markedly positively skewed data and extreme outliers ( 7 3 S.D. from the mean) for autobiographical episodic and semantic variables across each valence. 2.6.2. Previous predictors of impaired insight in schizophrenia Previously reported predictors of insight, including age of onset (Ayesa-Arriola et al., 2011), symptom severity (Mintz et al., 2003; Sevy et al., 2004), and premorbid intelligence and working memory (Aleman et al., 2006), were correlated with each SUMD item using Spearman's Rank correlation coefficient. Only age at first admission, a proxy measure for age of onset, was found to be a significant predictor for awareness of current (rs ¼ 0.51, p ¼ 0.011) and past (rs ¼ 0.46, p ¼ 0.029) mental disorder and current (rs ¼ 0.42, p ¼ 0.039) and past (rs ¼0.43, p ¼0.043) achieved effects of medication. 2.6.3. Regression analysis The independent contribution of autobiographical memory performance for total episodic and total semantic details recalled for each of the positive, negative and neutral events to the SUMD items was assessed using multiple regression analyses. Age of first admission was also included as an independent variable in the regression analysis as indicated. Standard indicators for multicollinearity were found to be within acceptable values.
2.2. Neurocognitive assessments
3. Results Pre-morbid intelligence was assessed using the Wechsler Test of Adult Reading (WTAR; Weschler, 2001). The Letter-Number Span task (LNS; Gold et al., 1997) assessed working memory.
2.3. Symptom assessments Symptoms were assessed using the Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1984a) and Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984b). Group characteristics are shown in Table 1.
Table 1 Characteristics of the study sample (mean 7 S.D. given where applicable). Schizophrenia patients (n¼24) Age, years Age at first admission, years Sex Years of education WTAR standardized score LNS forward (total score) SANS total SAPS total
44.5 7 7.8 25.0 7 9.0 14 male, 10 female 14.0 7 2.8 96.5 7 13.1 12.17 3.2 9.0 7 2.8 6.9 7 4.0
Episodic memory performance for the negative-valenced event was a significant independent predictor of awareness of social consequences of past mental disorder (B¼ 3.02, S.E.¼ 1.13, t¼ 2.68; p¼0.016) and neared significance as a predictor of awareness of having a past mental disorder (B¼ 3.18, S.E.¼1.53, t¼ 2.08; p¼0.055). No other autobiographical memory performance variables significantly predicted SUMD item scores.
4. Discussion As hypothesized, poorer recall of episodic, but not semantic details, of negative events (but not positive or neutral events) predicted impaired awareness of having a past mental disorder and its social consequences. Furthermore the relationship between insight and autobiographical memory performance was significant, whereas correlations among insight, severity of illness, and basic cognitive measures were not. These results are consistent with Lalova et al. (2013) finding that episodic autobiographical memory performance predicts illness insight, and clarify that this relation appears specific to negative event recall. Our study findings are limited by the small sample size and number of participants per predictor. Furthermore, we did not
Please cite this article as: MacDougall, A.G., et al., The relationship between insight and autobiographical memory for emotional events in schizophrenia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2014.12.058i
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restrict the events being recalled to those that are illness-related nor did we determine which of the events recalled were illnessrelated. Future studies that limit recall to illness-related experiences that can be reliably classified in terms of emotional valence are necessary to more specifically evaluate the hypothesized link between negative episodic recall and illness insight deficits in schizophrenia. Due to the chronicity of our patient sample, it was difficult for us to determine accurately the age of onset of illness, and age of first admission was used as a proxy. Later age at first admission was correlated with poorer awareness of mental disorder and effects of medication. Although the direction of this relationship is different from that reported for age of onset in a study of first episode patients (Ayesa-Arriola et al., 2011), another study of more chronic patients suggests that older age of onset may lead to poorer acceptance of illness and need for treatment (Rocca et al., 2008). Our results are consistent with insight in schizophrenia reflecting a narrative account of challenges related to mental illness (Lysaker et al., 2009). A profound impairment (i.e., despite retrieval supports) in ability to recall details of temporally and spatially specific illness-related events would consequently impede development of a coherent narrative of experiences related to having a mental illness. Given the availability of interventions that enhance autobiographical memory recall (Blairy et al., 2008; Ricarte et al., 2012) and recent work suggesting such interventions may be capable of improving insight (Lalova et al. 2013), targeting autobiographical memory as part of an integrated treatment approach seems worthy of further study.
Funding source This study was funded by the Regional Medical Associates Research Scholarship Fund at McMaster University. The study sponsor had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
Acknowledgments We would like to thank Dr. Ross Norman and Ms. Sandra Pennie who assisted with the preparation of the manuscript. References Aleman, A., Agrawal, N., Morgan, K.D., David, A.S., 2006. Insight in psychosis and neuropsychological function: meta-analysis. Br. J. Psychiatry 189, 204–212. Amador, X.F., Gorman, J.M., 1998. Psychopathologic domains and insight in schizophrenia. Psychiatr. Clin. N. Am. 21 (1), 27–42. 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. Andreasen, N.C., 1984a. The Scale for the Assessment of Negative Symptoms. University of Iowa, Iowa City. Andreasen, N.C., 1984b. The Scale for the Assessment of Positive Symptoms. University of Iowa, Iowa City. Ayesa-Arriola, R., Rodriguez-Sanchez, J.M., Morelli, C., Pelayo-Teran, J.M., PerezIglesias, R., Mata, I., Martinez-Garcia, O., Pardo-Garcia, G., Vazquez-Barquero, J.L., Crespo-Facorro, B., 2011. Insight dimensions in first-episode psychosis patients: clinical, cognitive, pre-morbid and socio-demographic correlates. Early Interv. Psychiatry 5 (2), 140–149. Bargenquast, R., Schweitzer, R.D., 2013. Enhancing sense of recovery and selfreflectivity in people with schizophrenia: a pilot study of Metacognitive Narrative Psychotherapy. Psychol. Psychother.: Theory Res. Pract. 87, 338–356. Beck, E.M., Cavelti, M., Kvrgic, S., Kleim, B., Vauth, R., 2011. Are we addressing the ‘right stuff’ to enhance adherence in schizophrenia? Understanding the role of insight and attitudes towards medication. Schizophr. Res. 132 (1), 42–49. Blairy, S., Neumann, A., Nutthals, F., Pierret, L., Collet, D., Philippot, P., 2008. Improvements in autobiographical memory in schizophrenia patients after a cognitive intervention. Psychopathology 41, 388–396. Conway, M.A., 2005. Memory and the self. J. Mem. Lang. 53, 594–628.
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Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Brief report
The relationship between insight and autobiographical memory for emotional events in schizophrenia Arlene G. MacDougall a,b,n, Margaret C. McKinnon b,c, Katherine A. Herdman b,1, Matthew J. King b,2, Michael Kiang b,d a Department of Psychiatry, Western University, London Health Sciences Centre—Victoria Hospital, 800 Commissioner’s Road East, London, ON, Canada N6A 5W9 b Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare Hamilton, West 5th Campus, 100 West 5th, Hamilton, ON, Canada L8N 3K7 c Homewood Research Institute, Homewood Health Centre, 150 Delhi Street, Guelph, ON, Canada N1E 6K9 d Department of Psychiatry, University of Toronto, Centre for Addiction and Mental Health, 250 College St., Toronto, ON, Canada M5T 1R8
art ic l e i nf o
a b s t r a c t
Article history: Received 24 July 2014 Received in revised form 7 October 2014 Accepted 29 December 2014
The relation of episodic and semantic memory for emotional- (positive, negative) and neutral-valenced autobiographical events to illness insight was examined in individuals with schizophrenia. Reduced recall of episodic details for negative events was significantly associated with impaired awareness of having a past mental disorder and its social consequences. Deficits in episodic memory for negative autobiographical events may underlie impaired insight in schizophrenia. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Autobiographical memory Schizophrenia Insight
1. Introduction People with schizophrenia often have impaired insight into their disorder (Amador and Gorman, 1998). Lack of insight predicts poorer treatment adherence (Beck et al., 2011) and worse outcomes (Drake et al., 2007; Lincoln et al., 2007). Insight has been conceptualized as a storied account or narrative of different aspects of illness and their consequences that requires different forms of awareness and the recognition of pertinent historical details such as a hospitalization (Lysaker et al., 2009, 2013). Patients with schizophrenia produce less coherent personal narratives (Raffard et al., 2010; Lysaker et al., 2005); and deficits in narrative identity are associated with aspects of poor insight (Lysaker et al., 2002, 2008). Construction of a coherent identity across time relies on autobiographical memory (Conway, 2005; Tulving, 2002) and the ability to synthesize these personal memories with future goals (McAdams and McLean, 2013). n Corresponding author at: Department of Psychiatry, Western University, London Health Sciences Centre—Victoria Hospital, 800 Commissioner's Road East, London, ON, Canada N6A 5W9. Tel.: þ1 519 685 8324; fax: þ1 519 667 6657. E-mail addresses: [email protected] (A.G. MacDougall), [email protected] (M.C. McKinnon), [email protected] (K.A. Herdman), [email protected] (M.J. King), [email protected] (M. Kiang). 1 Department of Psychology, York University, 4700 Keele Street, Toronto, ON, Canada M3J 1P3. 2 Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3.
Autobiographical memory recall is compromised in schizophrenia (e.g., Elvevåg et al., 2003; Riutort et al., 2003; Danion et al., 2005; McLeod et al., 2006; Cuervo-Lombard et al., 2007; D’Argembeau et al., 2008) with recent findings suggesting that recollection of negative autobiographical events is particularly affected (Neumann et al., 2007; MacDougall et al., unpublished results). It has been suggested that an impoverished autobiographical memory may hinder the ability to think in more complex ways about oneself or others (Dimaggio et al., 2012). This notion has led to the development of promising therapeutic approaches that consider the complex interplay of autobiographical memory and metacognitive impairments (Lysaker et al., 2011; Bargenquast and Schweitzer, 2013). Despite conceptualization of insight as an autobiographical narrative, there is little research on the relationship between insight and autobiographical memory performance in schizophrenia. Lalova et al. (2013) recently demonstrated that poor insight was more strongly related to inability to recall specific autobiographical memories than to other basic cognitive measures including general episodic memory. However, to date, no studies have explored the relation between insight in individuals with schizophrenia and the specific components of autobiographical memory recollection—episodic and semantic (Tulving 1972, 1985). Episodic memory involves the conscious recollection of temporally and spatially specific events that occurred in one's past and is associated with subjective sense of personal continuity across time (‘autonoetic consciousness’) (Tulving, 2002). By contrast, semantic
http://dx.doi.org/10.1016/j.psychres.2014.12.058 0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: MacDougall, A.G., et al., The relationship between insight and autobiographical memory for emotional events in schizophrenia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2014.12.058i
A.G. MacDougall et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
2
memory consists of facts that are time- and context-independent, and either personal or general in nature. Behavioral, neuropsychological, and neuroimaging techniques confirm that these two forms of memory are dissociable (e.g., Eslinger, 1998; Gardiner and Java, 1991; Levine et al., 2004; Mäntylä, 1993; McKinnon et al., 2006; Parkin and Walter, 1992; Svoboda et al., 2006). Accordingly, in the present study of persons with schizophrenia, we employed the Autobiographical Interview (AI; Levine et al., 2002), a measure that separates episodic and semantic components of autobiographical memory thus minimizing the potential for episodic recollection to be subject to contamination by semantic processing (McKinnon et al., 2008). It also utilizes cueing methods associated with improved recall in schizophrenia (Potheegadoo et al., 2014; MacDougall et al., unpublished results). Finally, given that emotional valence of recalled events (Dieleman and Röder, 2013; Holland and Kensinger, 2010) may be an important moderator in the relation between autobiographical memory and insight, we surveyed recollection of positive, negative and neutral events. We hypothesized that insight relies particularly on episodic autobiographical memory as opposed to semantic information that bears less relation to personal identity over time (Conway 2005; Tulving, 2002). Given that illness-related events are typically negative in nature, we further hypothesized that poor insight into having a mental disorder and its symptoms and social consequences would be specifically associated with impaired recall of negative personal events.
2. Methods 2.1. Participants Participants were 24 outpatients (18 to 60 years old) with schizophrenia (n¼14) or schizoaffective disorder (n¼ 10) recruited from clinics in Hamilton, Canada. The protocol was approved by the local Research Ethics Board. DSM-IV diagnoses were established using a best estimate approach based on the MINI (Sheehan et al., 1998) and information from records and clinicians. Exclusion criteria included current mood episode, lifetime substance dependence, substance abuse in the past 6 months or a self-reported neurological disorder.
2.4. The Autobiographical Interview (AI) In the AI (Levine et al., 2002), participants were asked to provide detailed descriptions of three events: highly positive, highly negative and neutral that were specific to time and place, in which they were personally involved in the past 2 years, but more than 1 week ago. Three levels of retrieval support are provided: free recall, general probe, and specific probe (Levine et al., 2002). Descriptions of events were recorded and transcribed. Analysis included segmenting each memory into informational details. Details were categorized as either ‘episodic’ or ‘semantic’, with autobiographical events unrelated to the main memory, repetitions or metacognitive statements being classified separately. Participants' memories were placed in a common pool and scored at random by three experienced scorers with high inter-rater reliability (see Levine et al., 2002). Total cumulative episodic and semantic details recalled were calculated by adding free recall plus probe conditions. 2.5. Insight Insight was assessed using the Scale to Assess Unawareness of a Mental Disorder (SUMD) (Amador et al., 1993). 2.6. Statistical analysis 2.6.1. Data transformation Log10 transformation was performed to correct the markedly positively skewed data and extreme outliers ( 7 3 S.D. from the mean) for autobiographical episodic and semantic variables across each valence. 2.6.2. Previous predictors of impaired insight in schizophrenia Previously reported predictors of insight, including age of onset (Ayesa-Arriola et al., 2011), symptom severity (Mintz et al., 2003; Sevy et al., 2004), and premorbid intelligence and working memory (Aleman et al., 2006), were correlated with each SUMD item using Spearman's Rank correlation coefficient. Only age at first admission, a proxy measure for age of onset, was found to be a significant predictor for awareness of current (rs ¼ 0.51, p ¼ 0.011) and past (rs ¼ 0.46, p ¼ 0.029) mental disorder and current (rs ¼ 0.42, p ¼ 0.039) and past (rs ¼0.43, p ¼0.043) achieved effects of medication. 2.6.3. Regression analysis The independent contribution of autobiographical memory performance for total episodic and total semantic details recalled for each of the positive, negative and neutral events to the SUMD items was assessed using multiple regression analyses. Age of first admission was also included as an independent variable in the regression analysis as indicated. Standard indicators for multicollinearity were found to be within acceptable values.
2.2. Neurocognitive assessments
3. Results Pre-morbid intelligence was assessed using the Wechsler Test of Adult Reading (WTAR; Weschler, 2001). The Letter-Number Span task (LNS; Gold et al., 1997) assessed working memory.
2.3. Symptom assessments Symptoms were assessed using the Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1984a) and Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984b). Group characteristics are shown in Table 1.
Table 1 Characteristics of the study sample (mean 7 S.D. given where applicable). Schizophrenia patients (n¼24) Age, years Age at first admission, years Sex Years of education WTAR standardized score LNS forward (total score) SANS total SAPS total
44.5 7 7.8 25.0 7 9.0 14 male, 10 female 14.0 7 2.8 96.5 7 13.1 12.17 3.2 9.0 7 2.8 6.9 7 4.0
Episodic memory performance for the negative-valenced event was a significant independent predictor of awareness of social consequences of past mental disorder (B¼ 3.02, S.E.¼ 1.13, t¼ 2.68; p¼0.016) and neared significance as a predictor of awareness of having a past mental disorder (B¼ 3.18, S.E.¼1.53, t¼ 2.08; p¼0.055). No other autobiographical memory performance variables significantly predicted SUMD item scores.
4. Discussion As hypothesized, poorer recall of episodic, but not semantic details, of negative events (but not positive or neutral events) predicted impaired awareness of having a past mental disorder and its social consequences. Furthermore the relationship between insight and autobiographical memory performance was significant, whereas correlations among insight, severity of illness, and basic cognitive measures were not. These results are consistent with Lalova et al. (2013) finding that episodic autobiographical memory performance predicts illness insight, and clarify that this relation appears specific to negative event recall. Our study findings are limited by the small sample size and number of participants per predictor. Furthermore, we did not
Please cite this article as: MacDougall, A.G., et al., The relationship between insight and autobiographical memory for emotional events in schizophrenia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2014.12.058i
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restrict the events being recalled to those that are illness-related nor did we determine which of the events recalled were illnessrelated. Future studies that limit recall to illness-related experiences that can be reliably classified in terms of emotional valence are necessary to more specifically evaluate the hypothesized link between negative episodic recall and illness insight deficits in schizophrenia. Due to the chronicity of our patient sample, it was difficult for us to determine accurately the age of onset of illness, and age of first admission was used as a proxy. Later age at first admission was correlated with poorer awareness of mental disorder and effects of medication. Although the direction of this relationship is different from that reported for age of onset in a study of first episode patients (Ayesa-Arriola et al., 2011), another study of more chronic patients suggests that older age of onset may lead to poorer acceptance of illness and need for treatment (Rocca et al., 2008). Our results are consistent with insight in schizophrenia reflecting a narrative account of challenges related to mental illness (Lysaker et al., 2009). A profound impairment (i.e., despite retrieval supports) in ability to recall details of temporally and spatially specific illness-related events would consequently impede development of a coherent narrative of experiences related to having a mental illness. Given the availability of interventions that enhance autobiographical memory recall (Blairy et al., 2008; Ricarte et al., 2012) and recent work suggesting such interventions may be capable of improving insight (Lalova et al. 2013), targeting autobiographical memory as part of an integrated treatment approach seems worthy of further study.
Funding source This study was funded by the Regional Medical Associates Research Scholarship Fund at McMaster University. The study sponsor had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
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