افسردگی و بینش در اسکیزوفرنی: مقایسه سطح اختلالات در شناخت اجتماعی و فراشناخت و داغ ننگ درونی شده در سرتاسر سه پروفایل

While research has paradoxically linked insight to greater emotional distress and depression in schizophrenia, little is known why and for whom insight can result in depression. One possibility is that internalized stigma and deficits in social cognition and metacognition are risk factors for insight to convert to depression. To explore this possibility we assessed insight, depression, internalized stigma, social cognition and metacognition for sixty five persons with schizophrenia spectrum disorders. We then performed a cluster analysis based on insight and depression scores. Three groups were produced by the cluster analysis: Good insight/Mild depression (n = 22); Fair insight/Moderate depression (n = 26) and Poor insight/Minimal depression (n = 17). As predicted, ANOVA comparing groups revealed the three groups differed in social cognition, and the metacognitive mastery aspect of metacognition. Those with fair insight and moderate depression reported more internalized stigma than those with poor insight and minimal depression. Persons with good insight and mild depression had higher levels of social cognition and metacognitive mastery than the other two groups. These differences persisted when controlling for neurocognition and symptom severity. These findings point to the possibility that future research should examine whether bolstering metacognitive and social cognitive capacities may have a protective effect as persons are assisted to achieve insight.

Unawareness of illness or lack of insight has been commonly observed in schizophrenia (Amador et al., 1994) and is a longstanding barrier to treatment adherence and a risk factor for poorer outcome (Schwartz, 1998, Francis and Penn, 2001, Olfson et al., 2006 and Erickson et al., 2011). Paradoxically high insight may also be a risk factor for negative emotional experiences, such as depression (Mintz et al., 2003), lowered self-esteem (Warner et al., 1989), and decreased quality of life and hope (Kravetz et al., 2000, Hasson-Ohayon et al., 2006 and Hasson-Ohayon et al., 2009), though other investigators have failed to find an association (Ekinci et al., 2012). Pijnenborg et al. (2013b) did not find an association between insight change in therapy and depression in a meta-analysis, but also did not examine the relationship between insight and depression per se. The confluence of depression and insight in schizophrenia poses a number of issues. Among the most important of these concerns are the factors that cause insight to lead or not to lead to distress. Answers to this question are vital for clinicians working with who might naturally be at risk for depression as they struggle to achieve greater levels of awareness of their psychiatric needs (Buck et al., in press). To respond to these challenges it has been suggested that persons may be at risk to develop depression in the face of insight if they hold stigmatized views of what it means to have a mental illness (Roe and Kravetz, 2003). Research has suggested that greater internalized stigma predicts demoralization in persons with schizophrenia (Yanos et al., 2008) and that insight is more likely to be linked to depression and lesser meaning in life when persons have higher levels of internalized stigma (Lysaker et al., 2007, Cavelti et al., 2012 and Ehrlich-Ben Or et al., in press). Improved insight is also more likely to cause distress when persons hold negative beliefs about the course of illness (Cavelti et al., 2013). Among parents of persons with severe mental illness, internalized stigma was found to mediate the relation between insight and family burden (Hasson-Ohayon et al., 2011). Two additional factors that might influence the relationship of insight and depression are social cognition and metacognition. Social cognition refers to processes involved in thinking about social interactions such as theory of mind, emotion processing and attributional style (Green and Leitman, 2008). Metacognition refers to a spectrum of activities which involves thinking about thinking and stretches from consideration of discrete psychological phenomenon (e.g. specific thoughts and feelings) to the synthesis of discrete perceptions into an integrated representation of self and others (Lysaker et al., 2013). While the literature has yet to fully detangle the constructs of social cognition and metacognition, it should be noted that they share a unique interest in cognitive processes as applied to interpersonal experience. They may diverge however in that metacognition is more interested in the synthesis of complex psychological experiences into representations which themselves may then vary not necessarily by their absolute accuracy but by their complexity, adaptiveness and flexibility. In other words metacognition may be more a matter of meaning making rather than correct identification of component elements of social exchange. Deficits in social cognition and metacognition have been commonly observed in schizophrenia. Social cognition and metacognition are widely understood as core processes which allow persons to recognize their personal challenges, identify their own thoughts and feelings, regulate emotional pain and on the basis of all of that formulate and pursue meaningful goals (Brüne et al., 2011). As such deficits in social cognition and metacognition might leave persons less able to name and regulate the painful emotions that arise with a growing awareness of schizophrenia. Additionally, they might leave persons less able to borrow from others' positive perceptions and support (e.g. detect others' hope that particular problems can be dealt with) and ultimately less able to develop personally meaningful ways to respond to the challenges of their condition, all culminating in demoralization and depressed mood. Evidence supporting these possibilities includes findings that deficits in metacognitive mastery, or the ability to use metacognitive knowledge to respond to psychological challenges, are linked to lower self-esteem and greater social anxiety as well as difficulties forming meaningful ideas about the consequences of mental illness (Lysaker et al., 2011a and Lysaker et al., 2011b). The impact of insight upon mood has been linked to the ability to cope with distress (Cooke et al., 2007). Poorer perspective taking has also been linked to poorer insight (Pijnenborg et al., 2013a). To explore the possible roles stigma, social cognition and metacognition play in the confluence and lack of confluence of depression and insight in schizophrenia we examined the social cognitive and metacognitive profiles of participants with high insight who had greater vs. lesser depression and also compared those to participants with low insight. We anticipated that examining the social cognitive and metacognitive profiles of different groups could offer important information about the types of persons who do and do not develop depression in the face of insight. We predicted that participants with high insight and relatively higher levels of depression would report greater internalized stigma as well as have lower levels of social cognition and metacognition. We included two measures of metacognition: metacognitive mastery and alexithymia, and three domains of social cognition: emotion recognition, emotional regulation and mental state reasoning. We chose metacognitive mastery specifically as it involves the application of metacognitive knowledge to solving psychological problems and hence would seem especially pertinent to persons knowing how to respond to distress that might emerge from awareness. To rule out the possibility that group differences were the result of symptom severity or neurocognitive capacity, we included measures of these constructs.