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Schizophrenia Research 70 (2004) 187–194

Correlates of insight in first episode psychosis

Matcheri S. Keshavana,*, Jonathan Rabinowitzb, Goedele DeSmedtc,Phillip D. Harveyd, Nina Schoolere

aDepartment of Psychiatry, Western Psychiatric Institute and Clinic, Pittsburgh, PA, USAbSchool of Social Work, Bar-Ilan University, Ramat Gan, Israel

c International Clinical Research and Development, Janssen Research Foundation, Beerse, BelgiumdDepartment of Psychiatry, Mt. Sinai School of Medicine, New York, NY, USA

ePsychiatry Research, Long Island Jewish Medical Center, New Hyde Park, NY, USA

Received 15 August 2003; received in revised form 7 November 2003; accepted 12 November 2003

Available online 25 January 2004

Abstract

Impaired insight is common in schizophrenia and may be related to poor treatment adherence. Few studies have examined

the clinical and neurocognitive correlates of insight in early schizophrenia. Early course schizophrenia, schizoaffective, and

schizophreniform disorder patients (n = 535) were studied. The Positive and Negative Symptom Scale (PANSS) was used to

assess psychopathology, and a broad range of neuropsychological functions was assessed. Using hierarchical stepwise multiple

regression analyses, we examined the association of clinical, neurocognitive, and premorbid measures with the level of insight.

Impaired insight was associated with overall symptomatology, including positive, negative, and general psychopathology and

with deficits in cognitive functioning. In descending order of robustness, the significant variables were PANSS general

psychopathology ( p< 0.0001), Rey Auditory Verbal Learning Test ( p< 0.0004), Clinical Global Impression ( p < 0.005),

PANSS positive ( p < 0.007), and premorbid adjustment—general subscale ( p = 0.02). Among the PANSS general

psychopathology items, unusual thought content was most robustly associated with impaired insight ( p < 0.00000). Insight

impairment is very common in early schizophrenia, and appears to be associated with a broad range of psychopathology and

deficits in multiple cognitive domains. These observations suggest that deficits in insight may be related to a generalized

dysfunction of neural networks involved in memory, learning, and executive functions.

D 2003 Elsevier B.V. All rights reserved.

Keywords: Insight; First episode; Psychosis

1. Introduction researchers in psychotic disorders (Amador and David,

Over the past several years, there has been a great

deal of interest in the topic of insight among clinical

0920-9964/$ - see front matter D 2003 Elsevier B.V. All rights reserved.

doi:10.1016/j.schres.2003.11.007

* Corresponding author. UPMC Health System-Western Psychi-

atric Institute and Clinic, Room 984, 3811 O’Hara Street, Pittsburgh,

PA 15213, USA. Tel.: +1-412-624-2794; fax: +1-412-624-1459.

E-mail address: keshavanms@msx.upmc.edu (M.S. Keshavan).

1998). Insight into psychotic illness is multidimension-

al, and involves several aspects of clinical psychopa-

thology and cognition. Several studies have examined

clinical correlates of insight among chronic schizo-

phrenic patients, but the findings have been generally

inconsistent particularly in reference to correlations

with symptom severity (Buckley et al., 2001). Poor

insight has been associated with female gender (Peralta

M.S. Keshavan et al. / Schizophrenia Research 70 (2004) 187–194188

and Cuesta, 1998), poorer functioning (Dickerson et

al., 1997), premorbid impairment (Debowska et al.,

1998), prolonged illness duration (Drake et al., 2000),

and low levels (Carroll et al., 1999; Moore et al., 1999)

or high levels (Collins et al., 1997) of depression.

Impaired insight has been found to be correlated with

positive symptoms (Amador et al., 1994; Baier et al.,

2000; Kim et al., 1997), negative and disorganized but

not positive symptoms (Cuesta et al., 1998), negative as

well as positive symptoms (Debowska et al., 1998;

Kemp and Lambert, 1995), or with neither positive nor

negative symptoms (Schwartz and Petersen, 1999).

This variability in research findings may be at least

partially explained on the basis of small sample sizes,

different phases of the illness being studied, heteroge-

neous samples, inappropriate statistical methods, and

nonrandom sampling (Schwartz, 2000).

Although for years poor insight in schizophrenia

has been explained on the basis of various psycho-

logical phenomena, such as denial and willful prefer-

ence for psychosis, recent studies suggest that insight

deficits may reflect neurocognitive impairments per-

haps due to prefrontal and parietal lobe dysfunctions.

It has been proposed that schizophrenia-related im-

pairment in insight might be similar to anosognosia

seen in neurological illnesses (Amador and David,

1998). Some studies show a relationship between

impaired insight and neurocognition (Mohamed et

al., 1999), but others do not (Carroll et al., 1999;

McCabe et al., 2002). Such inconsistencies again

might be related to variable methodology, particularly

small sample sizes and varying populations and

phases of illness studied (Smith et al., 2000).

Attitudes towards treatment and insight into the

illness may vary during the course of the illness; it is

therefore important to examine course-specific patterns

and correlates of insight in schizophrenia. Only a few

studies to our knowledge have examined first episode

psychotic patients (Drake and Lewis, 2003; Mintz et

al., 2003). Studies of this population allow us to

examine the association between insight, symptom-

atology, and neurocognition without the potential con-

founds of illness chronicity. We examined the

relationships between insight, clinical measures (posi-

tive, negative symptoms, general psychopathology,

and Clinical Global Impression), premorbid adjust-

ment, age of onset, illness duration, and cognitive

performance on a variety of tasks tapping into attention,

memory, and executive functions—known to be im-

paired in schizophrenia (Elvevag and Goldberg, 2000).

2. Methods

The data for this study were collected as part

of a multicenter trial sponsored by the Janssen

Research Foundation titled ‘‘Double-blind evaluation

of risperidone vs. haloperidol on the long-term

morbidity of early psychotic patients’’ (RIS-INT

35) conducted in 11 countries. Since the languages

differed across the sites, a systematic procedure

(Harvey et al., 2003) was used to ensure that the

translations of all of the tests were valid. Briefly, a

local expert was identified in each country where

English was not the language of assessment. This

expert assisted in the translation of the instructions

and test stimuli, with these translations then con-

firmed by backtranslation.

The data set at baseline included 535 subjects (155

females and 380 males; age 16–45 years) with a

DSM-IV diagnosis of schizophrenia (n = 264), schiz-

ophreniform (n = 231), or schizoaffective disorder

(n = 40). To be eligible, the patient had to have the

diagnosis of schizophrenia, schizophreniform, or

schizoaffective disorder for less than a year, and must

have received 12 weeks or less of lifetime exposure to

antipsychotic medication. Patients with a diagnosis of

axis I psychiatric disorder other than the above, those

with a current substance use disorder, those with

significant medical illness, pregnant women, and

those with mental retardation were excluded. Three-

quarters of the sample were white (n = 400), 12%

(n = 64) were black, 3% (n = 17) were Hispanic, 2%

(n = 11) were Oriental, and 8% (n = 43) were from

assorted other groups. Fourteen percent (n = 76) of the

sample had no high school education, 26.6% (n = 141)

had some high school education, 21.5% (n = 114)

completed high school, 29.9% (n = 159) completed

some post high school education, and 7.7% (n = 41)

completed college. All subjects provided written in-

formed consent after full description of the study. The

Institutional Review Boards of each of the participat-

ing sites approved the study.

Psychopathology was quantified using the Positive

and Negative Symptom Scale (PANSS) (Kay et al.,

1987). The PANSS provides total, positive symptoms,

M.S. Keshavan et al. / Schizophrenia Research 70 (2004) 187–194 189

negative symptoms, and general psychopathology

scale scores. The Lack of Insight and Judgment item

of the PANSS general psychopathology subscale

provides quantified (1–7 from absent to extreme)

information on insight at baseline prior to institution

of treatment. Overall severity of illness was rated

using the Clinical Global Impression (CGI) scale.

Premorbid adjustment was assessed using the Premor-

bid Adjustment Scale (PAS) (Cannon-Spoor et al.,

1982). PAS determines premorbid functioning during

four periods: childhood, early adolescence, late ado-

lescence, and adulthood.

Cognitive assessments were also conducted at

baseline, prior to initiation of study treatment, and

included abstraction and concept flexibility (Wiscon-

sin Card Sorting Test, WCST; categories, total errors),

verbal fluency, memory (Wechsler Memory Scale—

Revised visual reproduction immediate and delayed;

Rey Auditory Verbal Learning Test, RVLT; learning

trials 1–5), and attention/psychomotor speed (the

Computerized Continuous Performance Test, CPT d’

total, and the Wechsler Adult Intelligence Scale—

Revised (WAIS-R) Digit Symbol, raw score). To

further examine the relationship between cognitive

function and level of insight, we also obtained a

Table 1

Comparison of means (S.E.) of cognitive measures by level of insight

Level of insight

(high to low)

CPT d’

total

RVLT

learning

trials 1–5

WMS-R VR

delayed recall

total score

WMS-R VR

immediate recal

total score

1 0.85 (0.09) 46.33 (1.45) 30.53 (0.95) 33.23 (0.90)

n= 58 60 60 60

2 0.87 (0.09) 44.41 (1.45) 28.25 (1.11) 32.22 (0.80)

n= 56 64 63 64

3 0.80 (0.06) 43.09 (1.16) 26.53 (0.84) 31.05 (0.64)

n= 105 106 107 107

4 0.81 (0.06) 41.74 (1.01) 25.38 (0.89) 31.25 (0.62)

n= 145 158 154 157

5 0.65 (0.07) 39.31 (1.67) 25.43 (1.24) 29.61 (1.07)

n= 59 68 65 67

6 Mean 0.64 (0.10) 36.61 (1.83) 21.92 (1.55) 28.30 (1.07)

n= 44 49 50 50

Combined

significance

0.1910 0.0002 0.0014 0.0093

Linear 0.0210 0.0000 0.0000 0.0003

Quadratic 0.372 0.567 0.960 0.834

Overall significance on the multivariate test: F= 1.67, df = 45, 2145, p= 0

CPT=Continuous Performance Test; RVLT=Rey Verbal Learning Tes

Revised, Visual Reproduction; WCST=Wisconsin Card Sorting Test.

composite cognitive measure by adding the z-scores

of the cognitive measures.

Patients were divided into aggregate groups on the

basis of their level of insight and comparisons were

made between the resulting groups on demographic

(education, sex, age, and age of first symptoms),

premorbid, clinical (PANSS, CGI, and diagnosis),

and cognitive measures using General Linear Model

(GLM) MANOVA testing for linear and nonlinear

effects. A separate model was used for each domain

because there was a high correlation between variables

(e.g., the various cognitive measures). The significant

variables in each domain were entered into a stepwise

multiple regression to identify the variables, which

independently explained more of the variance. A final

stepwise regression model that included the variables

found to be significant in each domain was run.

3. Results

Almost 12% of the patients (n = 62) had no im-

pairment in insight, 12.4% (n = 66) had ‘‘minimal’’

impairment, 20.9% (n= 111) had ‘‘mild impairment,’’

31.4% (n = 167) had ‘‘moderate impairment,’’ 13.7%

l

VF category

fluency—

total score

VF letter

fluency—

total score

WAIS-R DS

raw score

WCST

categories

WCST

total errors

37.83 (1.49) 29.38 (1.49) 46.88 (1.67) 4.82 (0.21) 35.33 (2.64)

60 60 59 60 60

40.61 (1.65) 31.83 (1.59) 46.16 (1.74) 4.59 (0.24) 36.34 (3.03)

64 63 63 58 58

36.66 (1.08) 30.15 (1.12) 42.85 (1.31) 4.09 (0.21) 42.33 (2.42)

108 108 108 102 102

36.97 (0.89) 30.19 (0.94) 42.92 (1.2) 3.99 (0.18) 43.53 (2.06)

157 157 157 150 150

34.87 (1.39) 28.00 (1.40) 42.40 (1.70) 3.56 (0.29) 48.33 (3.37)

68 68 68 63 63

32.35 (1.39) 25.28 (1.49) 39.69 (1.74) 2.86 (0.34) 57.13 (3.82)

49 50 49 44 46

0.0023 0.0309 0.1425 0.0000 0.0000

0.0006 0.0131 0.0107 0.0000 0.0000

0.126 0.014 0.865 0.272 0.105

.0035.

t; VF =Verbal Fluency; WMS-RVR—Wechsler Memory Scale—

Fig. 1. The relation between the composite cognitive measure and insight showing a strong linear trend.

M.S. Keshavan et al. / Schizophrenia Research 70 (2004) 187–194190

(n = 73) had ‘‘moderate–severe impairment,’’ 9.4%

(n= 50) had ‘‘severe’’ impairment, and three patients

had ‘‘extreme’’ impairment in insight. For the purpo-

ses of the analysis, the last two groups were combined

(50 + 3). There was a significant linear difference in

cognitive functioning, symptomatology, and premor-

bid functioning by level of insight in a MANOVA

model presented in Table 1. shows the analysis of the

cognitive variables. There were significant linear

differences on seven of the nine cognitive measures;

specifically, there were differences on the cognitive

assessments of abstraction and concept flexibility

(Wisconsin Card Sorting Test, WCST; categories,

total errors), verbal fluency, memory (Wechsler Mem-

ory Scale—Revised visual reproduction immediate

and delayed; and the Rey Auditory Verbal Learning

Test, RVLT; learning trials 1–5) but not on the two

measures of attention/psychomotor speed [Computer-

ized Continuous Performance Test, CPT d’ total, and

Table 2

Comparison of means (S.E.) of symptom measures by level of insight

Level of insight Sample Positive and Negative Symp

(high to low) sizeGeneral psychopathology

1 62 31.66 (1.24)

2 66 36.79 (1.26)

3 111 37.96 (0.80)

4 167 42.76 (0.67)

5 73 45.47 (1.15)

6 53 49.43 (1.15)

Combined significance 0.0000

Linear 0.0000

Quadratic 0.9688

Multivariate test: F = 8.03, df = 20, 2100, p= 0.0000.

CGI =Clinical Global Impression scale.

the Wechsler Adult Intelligence Scale—Revised

(WAIS-R) Digit Symbol, raw score]. The relationship

between the composite cognitive measure and insight

(Fig. 1) showed a strong linear trend (combined

significance, df = 5, 523, F = 5.11, p< 0.0001; linear

term, df = 1, F = 24.45, p < 0.0001; deviation from

linearity, df= 4, F = 0.39, p = 0.82), suggesting that

less insight is associated with lower cognitive func-

tioning. Stepwise linear regression of the significant

cognitive variables found that when used together, the

significant measures were the Rey Auditory Verbal

Learning Test (learning trials 1–5) (standardized

coefficient = 0.18, t = 3.74, p = 0.0002) and WCST

(categories, total errors) (standardized coef-

ficient =� 0.156, t = 3.17, p= 0.002).

There was a significant linear association between

insight and the three PANSS subscales (positive,

negative, and general psychopathology) and the

CGI in a MANOVA presented in Table 2. Including

tom Scale CGI

Negative Positive

16.84 (0.86) 16.02 (0.73) 3.87 (0.13)

20.18 (0.81) 16.83 (0.67) 4.05 (0.13)

20.16 (0.54) 19.41 (0.46) 4.24 (0.08)

22.37 (0.56) 21.40 (0.46) 4.59 (0.06)

23.62 (0.87) 22.45 (0.70) 4.88 (0.09)

25.94 (0.87) 25.02 (0.70) 5.25 (0.09)

0.0000 0.0000 0.0000

0.0000 0.0000 0.0000

0.9899 0.6574 0.1705

Table 3

Comparison of means (S.E.) of Premorbid Adjustment Scale by level of insight

Level of insight

(high to low)

Childhood

(up to age 11 years)

Early adolescence

(ages 12–15 years)

Late adolescence

(ages 16–18 years)

Adulthood

(age 19 years and above)

General Average premorbid

(by mean)

1 Mean 0.24 (0.02) 0.27 (0.02) 0.34 (0.02) 0.39 (0.03) 0.33 (0.02) 0.31 (0.02)

n= 62 62 60 55 62 62

2 Mean 0 (0) 0.28 (0.02) 0.37 (0.03) 0.37 (0.04) 0.38 (0.02) 0.34 (0.02)

n= 65 65 65 56 65 65

3 Mean 0.28 (0.015) 0.33 (0.015) 0.38 (0.02) 0.39 (0.02) 0.41 (0.02) 0.36 (0.01)

n= 110 110 110 97 110 110

4 Mean 0.29 (0.01) 0.34 (0.01) 0.41 (0.01) 0.45 (0.02) 0.43 (0.01) 0.39 (0.01)

n= 167 167 166 149 167 167

5 Mean 0.28 (0.02) 0.33 (0.02) 0.40 (0.03) 0.42 (0.03) 0.44 (0.02) 0.37 (0.02)

n= 72 72 71 63 72 72

6 Mean 0.30 (0.03) 0.35 (0.03) 0.41 (0.03) 0.46 (0.04) 0.50 (0.03) 0.40 (0.02)

n= 52 52 50 46 52 52

Combined

significance

0.2995 0.1013 0.3943 0.1352 0.0000 0.0131

Linear 0.0209 0.0087 0.0542 0.0333 0.0000 0.0004

Quadratic 0.8157 0.6261 0.5912 0.6385 0.8971 0.9379

Multivariate test: F = 1.52, df = 30, 2295, p= 0.035.

M.S. Keshavan et al. / Schizophrenia Research 70 (2004) 187–194 191

three PANSS subscales and the CGI in a stepwise

linear regression, we found that the significant

measures were general psychopathology (standard-

ized coefficient = 0.29, t = 5.65, p < 0.00001), CGI

(standardized coefficient = 0.14, t = 2.78, p < 0.006),

and PANSS positive subscale (standardized coeffi-

cient = 0.15, t = 2.72, p < 0.007). In view of the

strong relation between PANSS general psychopa-

thology subscale and insight, we conducted a mul-

tiple regression of all items from this scale with

insight item as the dependent variable. Unusual

thought content (G9) showed the highest predictive

value (b = 0.31, p < 0.00000), followed by uncooper-

ativeness (b = 0.20, p < 0.00000).

On the Premorbid Adjustment Scale, we found a

significant association of general premorbid function-

ing scales, but not by specific age groups in a

MANOVA presented in Table 3. There were no

significant linear associations between insight and

age (linear F = 0.10, df = 1, p = 0.75), age of onset

(linear F = 1.69, p = 0.19, df = 1), or education (linear

F = 0.27, df = 1, p = 0.61), and no significant differ-

ence was seen between males and females (F = 0.22,

df = 1, p = 0.64).

A final stepwise linear regression model of the

significant variables from each domain found that all

of the variables found significant in each domain-

specific model were significant in the final model as

well with the exception of WCST categories and total

errors. In descending order, the variables in the model

were PANSS general (standardized coefficient = 0.27,

t= 5.13, p < 0.0001), CGI (standardized coefficient =

0.15, t = 2.84, p = 0.005), RVLT learning test (learning

trials 1–5) (standardized coefficient =� 0.14, t= 3.56,

p < 0.0004), PANSS positive (standardized coeffi-

cient = 0.15, t= 2.70, p < 0.007), and Premorbid Ad-

justment Scale—General (standardized coefficient =

0.09, t = 2.35, p = 0.02). All of the variables together

accounted for 30% of the variance (R2 = 0.296) in

insight.

4. Discussion

Our findings suggest that impaired insight is very

common in first episode schizophrenia and schizo-

affective patients; significant impairments were seen

in nearly two-thirds of the patients. Very few studies

have examined insight in first episode patients (Fen-

nig et al., 1996; Thompson et al., 2001). Thompson

et al. (2001) compared first episode patients to

multiepisode patients and found that the former

group had less awareness of illness than the latter.

This suggests that insight may improve during the

illness following the first episode. Longitudinal pro-

spective studies are needed to verify such state-

M.S. Keshavan et al. / Schizophrenia Research 70 (2004) 187–194192

related change, and the factors that may underlie the

acquisition of insight.

While several studies have examined the relation-

ship between insight and cognitive performance, the

literature has been somewhat inconsistent. Some have

failed to find a relationship between poor insight and

global cognitive functioning (Cuesta and Peralta,

1994; Dickerson et al., 1997; Kemp and David,

1996; Smith et al., 2000). However, these studies

are difficult to interpret because of low statistical

power (Cuesta and Peralta, 1994), the use of only

global cognitive performance (Kemp and David,

1996), or an exclusive focus to examine prefrontally

mediated cognitive functions (Lysaker and Bell, 1994;

Young et al., 1993; Young et al., 1998). Additionally,

most previous studies examining the relation between

insight and neurocognition have examined chronic or

multiepisode patients. However, Drake and Lewis

(2003) found an association between perseverative

errors on WCST and poor insight, even in a relatively

small sample of early course (within 5 years of onset)

psychotic patients. In our study, we examined the

relationship between insight and a broad range of

cognitive functions in a large homogeneous group of

early course patients. While cognitive performance

measures reflecting prefrontal functions (such as

WCST and CPT) were significantly correlated with

impaired insight, cognitive measures that may reflect

the functioning of other brain regions such as the

temporal lobe (RVLT learning test) were more strong-

ly correlated with insight. This suggests that impaired

insight in schizophrenia may be mediated by a broad

range of cognitive dysfunctions caused by a distrib-

uted neuronal network disorder involving the associ-

ation cortex structures (Andreasen et al., 1999;

McCarley et al., 1999; Pearlson et al., 1996). While

a recent study has suggested that poor insight is

associated with specific frontal regions (Flashman et

al., 2001) as well as overall reductions in brain

volume (Flashman et al., 2000), other brain regions

have to be examined as well.

Our data showed robust relationships between

insight impairment and all three domains of PANSS

psychopathology (positive, negative, and general).

This contrasts with previous studies as discussed

earlier, which have tended to find relationships one

or other (Amador et al., 1994; Cuesta et al., 1998;

Debowska et al., 1998; Kemp and Lambert, 1995;

Kim et al., 1997). Studies finding no relationships

between psychopathology and insight tend to have

comprised of relatively small sample sizes (Flashman

et al., 2001; Laroi et al., 2000; McEvoy et al., 1996),

suggesting the possibility that negative findings may

be related to low statistical power to detect subtle

effects. Additionally, first episode patients who have

high levels of both insight impairments as well as

symptomatology may offer sufficient variance and are

better suited to find the predicted relationships be-

tween psychopathology and insight. Interestingly,

among the PANSS general psychopathology items,

unusual thought content (G9) was most highly asso-

ciated with insight. This is not surprising since the G9

item has been found to be closely related to the

positive and disorganized symptom factor in schizo-

phrenia (Brazo et al., 1996). Unusual thought pro-

cesses may lead to impairments in insight either by a

pattern of denial or misattribution of the symptom

experiences; it remains to be determined whether this

path to insight is related to, or independent of,

symptom unawareness that may be mediated by

cognitive impairments (Lysaker et al., 2003).

Thus, cognitive impairment specifically on meas-

ures of abstraction and concept flexibility, verbal

fluency, as well as symptomatology and poor pre-

morbid functioning are associated with poor insight

early in the course of schizophrenia. Insight in

schizophrenia is important because of its implica-

tions for treatment adherence. Nonadherence occurs

in over 80% among schizophrenia patients (Corrigan

et al., 1990) and is particularly prominent in first

episode patients (Novak-Grubic and Tavcar, 1999).

Early psychoeducation (Pekkala and Merinder,

2001) and psychotherapeutic interventions such as

motivational interviewing (Bustillo et al., 2001;

Kemp et al., 1998) can improve treatment adherence

in schizophrenia. However, not all studies confirm

the efficacy of psychosocial treatments in improving

treatment adherence in schizophrenia (O’Donnell et

al., 2003); clearly, impaired insight as well as

cognitive deficits are among the well-known predic-

tors of poor treatment adherence. Knowledge of the

prevalence and correlates of impaired insight at

illness onset can guide the clinical approach and

also provide the framework for later reassessment of

the degree of treatment-related change. Poor insight

in patients with unusual thought content and delu-

M.S. Keshavan et al. / Schizophrenia Research 70 (2004) 187–194 193

sions may potentially improve with cognitive behav-

ioral techniques (Turkington et al., 2002); on the

other hand, patients with illness unawareness related

to impaired cognitive function might have improve-

ments in insight with cognitive remediation treat-

ments (Bell et al., 2001; Hogarty and Flesher, 1999).

However, one cannot be too optimistic about the

effectiveness of such treatments, since many factors,

including structural and functional brain alterations,

are likely to be involved in the pathogenesis of

insight deficits. Pharmacological interventions that

may address cognitive impairments are also worth

considering in our efforts to improve insight. The

possibility that novel antipsychotics may have dif-

ferential therapeutic effects on insight is also worth

examining in large-scale clinical trials.

The strengths of this study include the large sample

size and the choice of early course schizophrenia

patients. Limitations include the cross-sectional nature

of this data analyses and the use of data from a single

item on PANSS to ascertain the level of insight,

making it difficult to tease apart the correlates of the

different dimensions of insight. However, our findings

are meaningful for clinicians in practice who need to

make brief global assessments of insight and judg-

ment. Further, the fact that there were a number of

differential correlations with level of insight argues

against the interpretation that this single item is not

reliable enough to identify variation in insight levels.

Future studies need to separately examine the corre-

lates of the specific components of impaired insight

(i.e., unawareness and misattribution) (McEvoy et al.,

1996; McGorry and McConville, 2000) in schizophre-

nia. Also needed are longitudinal evaluations of state-

related changes in insight and their relation to im-

paired cognition.

Acknowledgements

This work was supported by the Janssen Research

Foundation (RIS-INT 35). The authors would like to

thank Michael Davidson, Robin Emsley, and Patrick

McGorry for their advice as well as all the principal

investigators of the RIS-INT 35 Study, Janssen

Research Foundation, International Clinical Research

and Development (Beerse, Belgium) for their contri-

bution to the data collected.

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