پیش بینی بهزیستن ذهنی در بیماران با علائم پارانوئید: آیا بینش لزوما سودمند است؟

Abstract In schizophrenia, poor insight has been associated with negative outcome. In fact, some studies have found insight to be associated with greater treatment adherence and lower levels of symptomatology, as well as better psychosocial functioning. However, others have found that insight into illness is associated with an increase in depression, low self-esteem, and possibly higher risk of suicide. We investigated the relationship between insight and well-being in a sample of 40 people presenting paranoid symptoms and diagnosed with schizophrenia or other psychotic disorder. Independent-samples t-tests revealed that compared to a paranoid group with high insight, paranoid participants with low insight had more self-acceptance, higher sense of autonomy and personal growth, and greater orientation towards gratification. Moderation analyses showed that when experiential avoidance was high, insight into paranoia had a detrimental effect on self-acceptance. Overall, our results support the need to explore which psychological variables moderate insight in patients with persecutory beliefs. We discuss the implications of these results for the research of paranoia.

. Introduction People diagnosed with schizophrenia spectrum disorders who appear to be unaware of their condition are considered to lack insight into their illness (David, 1991 and Amador, 2000) which is considered a defining characteristic of psychosis. The presence of insight is associated with enhanced mental health for developing realistic goals (Lysaker et al., 2001) and for promoting positive social and health outcomes (McEvoy, 1998), while lack of insight has been linked to poor therapeutic relationships (Amador et al., 1993), poor adherence to treatment (McEvoy et al., 1989) and less willingness to take prescribed medication (McEvoy et al., 1981). Evidence suggests that insight is not advantageous under all circumstances. Studies have reported contradictory findings about the effect of patient insight into psychosis on its clinical presentation and treatment. Some have underscored that insight in patients with schizophrenia is associated with fewer symptoms and better compliance with antipsychotic medication (Lysaker et al., 1998 and Mohamed et al., 2009). Others, however, have shown that rejection of a stigmatizing mental health label has some benefits (Schwartz, 2001). In fact, Kirmayer and Corin (1998) argued that an individual's insight into psychosis can lower self-esteem and increase despair, helplessness and hopelessness. Moreover, recent studies have reported that greater insight is significantly associated with an increase in depression, low self-esteem and possibly higher risk of suicide (Mohamed et al., 2009). The last decade has seen renewed research interest into the effects of insight on patient well-being and quality of life (QoL), but the data are not conclusive. In a sample of people with schizophrenia and schizoaffective disorders, Roseman et al. (2008) found that lack of insight predicted poor subjective QoL and directly influenced capacity to function. Similarly, Doyle et al. (1999) found significant positive correlations between insight into schizophrenia and subjective and objective QoL. However, Aghababian et al. (2003) found that schizophrenic patients with high insight evaluated their life more negatively and had lower self-esteem than those with low insight. Indeed, other investigations have found that insight is related to poor psychological adjustment (Amador et al., 1996) low emotional well-being (Hasson-Ohayon et al., 2006), and lower QoL in the physical domain (Yen et al., 2008). Likewise, Karow et al. (2008) found that patients in an acute phase of schizophrenia with more insight were better at recognizing the weaknesses associated with their illness, which worsened their QoL. Hasson-Ohayon et al. (2006) found that subjects with psychotic disorders who had more insight gave more negative assessments of their subjective well-being, job status and economic situation. These inconsistent findings draw attention to the need to search for factors that may moderate the relationship between insight and well-being. Hope and stigma have been identified as key moderating variables. For instance, Hasson-Ohayon et al. (2009) have found that hope increases the strength of association between insight and positive QoL. Lysaker et al. (2005) found that patients with high insight and high hope had more capacity to cope than those with high insight and low hope. Moreover, Lysaker et al. (2007) found a positive association between insight and hope, but only in those patients with low negative stigma. Thus, stigma has been proposed to moderate the associations between insight and depression, low QoL, and negative self-esteem. In other words, patients with good insight and less perceived stigmatization were the most successful across various outcome parameters and they showed the least impaired social functioning (Lysaker et al., 2007 and Staring et al., 2009). Experiential avoidance (EA), as a mechanism to avoid negative self-implications, is another potential moderator between insight and well-being. Individuals who exhibit EA are intolerant of negative mental experiences (e.g., bodily sensations, thoughts and emotions) and they attempt to eliminate them. EA has been associated with the development and persistence of psychological problems and has been correlated with different types of psychopathology (Hayes et al., 2004). In fact, preliminary evidence has suggested that EA may be implicated in paranoia (Udachina et al., 2009). Patients with paranoid symptoms devote a great deal of effort to avoiding negative implications and to maintaining a positive self-presentation. Indeed, a robust finding in paranoia research is a tendency for patients with persecutory delusions to attribute negative events to causes external to the self (Kinderman and Bentall, 1997) that can be linked to dysfunctional strategies of self-esteem regulation observed in these patients (Thewissen et al., 2008). The new concept of enjoyment orientation can feed into well-being. How well an individual anticipates enjoying an action helps predict the likelihood that he or she will engage in that action (Freitas et al., 2001). The inability to experience pleasure, anhedonia, has been considered a dispositional feature essential in the development of schizophrenia (Meehl, 1987) and its negative outcomes (Fenton and McGlashan, 1994). Enjoyment orientation is likely to be linked to deficits in anticipatory pleasure that have been found in schizophrenia (Gard, et al., 2007), though it may not necessarily be linked to deficits in consummatory pleasure. 1.1. Study aims The primary goal of this study was to examine the relationship between well-being and insight into paranoia. We specifically formulated two hypotheses. First, in line with findings reported by Karow et al., 2008 and Hasson-Ohayon et al., 2006, we expected patients without insight would be less entrapped by their illness, and thus we hypothesized they would have more subjective well-being and more enjoyment orientation than those with insight. Our second hypothesis was that EA would moderate the relationship between insight and well-being: patients with a strong tendency to avoid negative self-experiences would experience more subjective well-being when insight is low than when insight is high. Patients without EA would report similar levels of well-being regardless of whether insight is low or high.

3. Results 3.1. Demographic characteristics Demographic variables were analyzed by Pearson chi-square tests (χ2) for qualitative variables, and by two-tailed independent-samples t-tests (t) for quantitative variables (see Table S2 in Supplementary Material). These analyses revealed that there were no significant differences between groups in gender, marital status, educational level, employment status or age. We also compared clinical variables between groups. Diagnoses did not differ significantly between groups (see Table S2 in Supplementary Material). In addition, there were no significant differences between groups in age at first diagnosis, in the number of psychiatric hospitalizations across their life-span, or in the number of psychiatric hospitalizations during the preceding year. 3.2. Current psychiatric symptomatology Two-tailed independent-samples t-tests were conducted to compare current psychiatric symptomatology for the high-insight and low-insight groups (see Table S3 in Supplementary Material). There were no significant differences between groups in PANSS-N, PANSS-PG, or BDI-II scores. However, our analysis revealed that the low-insight group showed significantly more positive symptoms than high-insight patients. In particular, the low-insight group showed significantly higher scores on the delusion sub-scale and the suspiciousness sub-scale. 3.3. How is insight into paranoia related to well-being? Two-tailed independent-samples t-tests were conducted to explore the effect of insight level on dimensions of well-being and enjoyment orientation. Our analysis revealed that the low-insight group showed higher levels of all SPWB dimensions than the high-insight group. These differences were significant for SPWB autonomy, SPWB self-acceptance and SPWB personal growth. In short, participants with low insight were more satisfied with their self-determination, more likely to accept themselves despite knowing their limitations, and more willing to develop their potential. There was no significant difference in EA scores between groups. In contrast, there were significant differences between groups in the degree of orientation to enjoyment as measured by the EOS. The participants with low insight had higher self-reported orientation to enjoyment of daily experiences than did the high-insight participants (Table 1). Table 1. Comparison of psychological well-being dimensions and experiential measures (EOS and AAQ-II) between groups. Well-being measure Entire group (n = 40) High insight (n = 19) Low insight (n = 21) t P SPWB scores, mean (S.D.) Autonomy 33.69 (7.6) 30.72 (5.2) 36.24 (8.49) − 2.40⁎ 0.02 Positive relations with others 34.03 (8.14) 31.89 (5.92) 35.86 (9.40) − 1.55 0.13 Self-acceptance 33.10 (6.68) 30.22 (6.26) 35.57 (6.14) − 2.69⁎⁎ 0.01 Environmental mastery 31.82 (7.52) 29.44 (5.63) 33.86 (8.43) − 1.89 0.07 Purpose in life 31.26 (7.67) 29.44 (7.48) 32.81 (7.66) − 1.38 0.18 Personal Growth 32.28 (7.93) 29.5 (6.61) 34.67 (8.33) − 2.12⁎ 0.04 AAQ-II scores, mean (S.D.) 36.47 (11.84) 38.59 (12.91) 34.76 (10.92) 0.99 0.33 EOS scores, mean (S.D.) 29.63 (6.97) 26.88 (6.12) 32.22 (6.86) − 2.43⁎ 0.02 Note: SPWB, Scales of Psychological Well-Being; AAQ-II, Acceptance and Action Questionnaire-II; and EOS, Enjoyment Orientation Scale. ⁎ p < 0.05. ⁎⁎ p < 0.01. Table options Hierarchical multiple regression analyses for each of the SPWB dimensions were used to examine whether EA moderated the association between insight and dimensions of well-being. To control for the possible effect of mood on well-being, mood (BDI-II) was entered at Step 1, lack of insight (as a continuous variable) and EA at Step 2 and the interaction between insight and EA at Step 3. However, mood as measured by the BDI-II did not have any significant effect on any of the well-being dimensions (data not shown); thus, it was removed from the regression analyses. Our model was statistically significant for the SPWB dimension of autonomy and self-acceptance. There was no moderation effect on the SPWB dimension of autonomy. However, the interaction of EA and insight was statistically significant for the SPWB dimension of self-acceptance (Table 2). Table 2. Regression analysis to assess how well insight, EA and their interaction predict well-being dimensions. R2 ΔR2 t (each predictor) β p DV: Autonomy Step 1. 0.16⁎ 0.16⁎ Lack of insight (PANSS) − 0.67 − 0.30 0.51 EA(AAQ-II) − 1.06 − 0.33 0.30 Step 2. 0.23⁎ 0.06 Lack of insight * AAQ-II 1.65 0.83 0.11 DV: Positive relations with others Step 1. 0.06 0.06 Lack of insight (PANSS) − 1.03 − 0.49 0.31 EA(AAQ-II) − 1.14 − 0.38 0.26 Step 2. 0.13 0.07 Lack of insight * AAQ-II 1.62 0.87 0.12 DV: Self-acceptance Step 1. 0.22⁎⁎ 0.22⁎⁎ Lack of insight (PANSS) − 1.63 − 0.67 0.11 EA(AAQ-II) − 3.23 − 0.95 0.00 Step 2. 0.35⁎⁎ 0.13⁎⁎ Lack of insight * AAQ-II 2.56 1.18 0.01 DV: Environmental mastery Step 1. 0.08 0.08 Lack of insight (PANSS) − 0.58 − 0.28 0.57 EA(AAQ-II) − 1.29 − 0.43 0.21 Step 2. 0.12 0.04 Lack of insight * AAQ-II 1.21 0.65 0.24 DV: Purpose in life Step 1. 0.05 0.05 Lack of Insight (PANSS) − 1.40 − 0.66 0.17 EA(AAQ-II) − 1.51 − 0.49 0.14 Step 2. 0.15 0.10* Lack of insight * AAQ-II 1.96 1.04 0.05 DV: Personal Growth Step 1. 0.11 0.11 Lack of insight (PANSS) − 0.34 − 0.16 0.74 EA(AAQ-II) − 0.78 − 0.25 0.44 Step 2. 0.14 0.03 Lack of insight * AAQ-II 1.11 0.59 0.28 Note: SPWB, Scales of Psychological Well-Being; BDI-II, Beck Depression Inventory II; PANSS, Positive and Negative Syndrome Scale; EA, Experiential Avoidance; AAQ-II, Acceptance and Action Questionnaire-II; and DV, Dependent Variable. ⁎ p < 0.05. ⁎⁎ p < 0.01. Table options To assess the ability of EA to moderate the impact of insight on SPWB self-acceptance, insight and EA were entered at Step 1 and they explained 22% of the variance [ΔR2 = 0.22, ΔF (2, 36) = 4.93, p = 0.01]. At Step 2, the interaction insight * EA was entered and found to explain an additional 13% of the variance on self-acceptance after controlling for each of the independent variables [ΔR2 = 0.13, ΔF (2, 36) = 6.57, p = 0.01]. This interaction made a unique and significant contribution to the final model (β = 1.19; p = 0.01; Table 2). The level of self-acceptance as a dimension of well-being (SPWB) was negatively associated with EA. As shown in Fig. 1, whereas participants low in EA presented similar levels of self-acceptance regardless of their level of insight, the combination of high insight and high EA was associated with lower self-acceptance ( Fig. 1). Experiential avoidance (AAQ-II) as a moderator of the relationship between ... Fig. 1. Experiential avoidance (AAQ-II) as a moderator of the relationship between insight (PANSS) and self-acceptance (SPWB). Procedures by Aiken and West, 1991 and Dawson and Richter, 2006 were used to plot the interaction effects.