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

Abstract

Research has paradoxically linked awareness of illness to both better function outcomes and lesser hope and self-esteem. One possible explanation for these findings is that acceptance of having schizophrenia may impact outcomes differently depending on the meanings the person attaches to this acceptance, particularly whether he or she accepts stigmatizing beliefs about mental illness. To explore this possibility we performed a cluster analysis of 75 persons with schizophrenia spectrum disorders based on single measures of insight using the Positive and Negative Syndrome Scale, internalized stigma using the Internalized Stigma of Mental Illness Scale, and compared groups on concurrent assessments of hope and self-esteem. Three groups were produced by the cluster analyses: low in sight/mild stigma (n = 23), high insight/minimal stigma (n = 25), and high insight/moderate stigma (n = 27). As predicted, analysis of variance-comparing groups revealed that the high insight/moderate stigma group had significantly the lowest levels of hope on the Beck Hopelessness Scale and self-esteem using the Multidimensional Self-esteem Inventory. As predicted, the high insight/minimal stigma group also had significantly less impaired social function than the other groups. Implications for assisting persons to come to cope with awareness of illness and stigma are discussed.

Insight in schizophrenia spectrum disorders: relationship with behavior, mood and perceived quality of life, underlying causes and emerging treatments

“…Replicating earlier research 75 , several groups have found that the link between insight and depression was mediated by self-stigma [82][83][84] . Others have suggested that, beyond stigma, a generally negative appraisal of one's future 85 and tendency to ruminate 79 influence the effects of insight on mood.…”

“…In what may be referred to as the "insight paradox", earlier research suggested that good clinical insight may produce distress and compromise well-being 75 . Consistent with this, studies of diverse samples continue to find good insight to be correlated with depression and related constructs such as hopelessness 29,52,74,[76][77][78][79] .…”

Associations of multiple domains of self-esteem with four dimensions of stigma in schizophrenia

“…With replication this might suggest that a useful element of counseling for persons with schizophrenia might involve both assisting them to address stigma when they encounter it in routine life but also to openly explore concerns about how stigma affects the counseling relationship (c.f. Lysaker et al, 2007b). As with all unexpected findings though, further research is necessary before any weight is afforded these speculations.…”

Exploratory study of the association between insight and Theory of Mind (ToM) in stable schizophrenia patients

“…Consistent with this model, there is considerable evidence from cross-sectional studies to suggest that possessing good insight in psychosis is associated with measures of distress, such as depression (see Lincoln, Lüllmann & Rief, 2007), hopelessness (Carroll et al, 2004, Eneman & Sabbe, 2006Schwartz, Apter & Zalsman, 2006;Lysaker, Roe & Yanos, 2007), anxiety (Lysaker & Salyers, 2007) and suicidability (Schwartz et al, 2004, Crumlish et al, 2005Pompili et al, 2007). Although some longitudinal studies suggest that increases in insight are associated with worsening measures of distress and depression (Carroll et al, 1999;Iqbal et al, 2000;Schartz, 2001;Drake et al, 2004;Lincoln, Lüllmann & Rief, 2007), the existing evidence is still weak so that the direction of causality needs to be explored in future well designed longitudinal studies.…”