Insight, psychopathology and global functioning in schizophrenia in urban Malawi

Insight, psychopathology and functioning are related in schizophrenia,but it is unclear whether insight relates independently tofunctioning after controlling for psychopathology. Equally,any such relationship may vary culturally. We investigatedthe relationship between insight, psychopathology and functioningin 60 patients with schizophrenia in Mzuzu, a town in Malawi. After controlling for psychopathology, functioning was associatedwith the `symptom relabelling' dimension of insight (P=0.01).This preliminary finding suggests that symptom-focused psychoeducationmight be appropriate for African patients with schizophrenia.

INTRODUCTION

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INTRODUCTION

Insight is a core concept in psychosis, and its relationshipto psychopathology and functioning in schizophrenia continuesto be examined (Amador & David, 2004). Insight correlatesclosely with symptom severity (Mintz et al, 2003), but itis unclear whether insight has an association with functionaloutcome independent of its association with psychotic symptoms.

Most insight research has been carried out in the West, butconcepts of mental illness vary across cultures (Saravanan et al, 2004)and the findings of Western insight studies do not automaticallyapply elsewhere. Although a literature is emerging in Asia (Kim et al, 1997; Tharyan & Saravanan, 2000), the sole Africanstudy that examined insight related it only to adherence (Adewuya et al, 2006).To address this deficit, we investigated the relationship ofthe dimensions of insight to psychopathology and particularlyfunctioning among 60 Malawians with schizophrenia.

METHOD

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METHOD

The study centre was the St John of God Community Mental HealthService in Mzuzu. Mzuzu is the largest town in northern Malawi,with a population of over 100 000. Tumbuka is spoken by allMzuzu residents, and English by most. Christianity, the mainreligion, coexists with traditional spiritual beliefs. Thesebeliefs influence perceptions of mental illness and of individual symptoms. The traditional explanation for mental illness isulowi, bewitchment, whereas auditory hallucinations are typicallyinterpreted as the voices of deceased ancestors. Traditionalhealers, sing'anga, are frequently consulted. The sample comprisedthe first 60 people with schizophrenia, schizophreniform disorderor schizoaffective disorder recruited to a randomised controlledtrial of carer education. We received ethical approval fromthe National Health Sciences Research Committee, Lilongwe, and obtained written informed consent from participants.

We diagnosed participants using the Structured Clinical Interviewfor DSM–IV–TR (SCID; First et al, 2002). Duringthis interview we assessed illness duration and the type oftreatment sought at onset, and rated functioning with the GlobalAssessment of Functioning scale (GAF; SCID Axis V). Insightwas rated using the Schedule for Assessment of Insight (SAI; David, 1990). The SAI rates three dimensions of insight: treatmentadherence (SAI–TA), recognition of illness (SAI–RI)and symptom relabelling (SAI–SR). Symptom relabellinginvolves the recognition of a psychotic symptom and the understandingthat it is a pathological event. The sub-scale totals are summed for a total insight score. To measure psychopathology, we usedthe Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984)and the Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1983).

Two researchers collaborated with four staff members from StJohn of God centre on translating instruments into Tumbuka.After independent translations, a consensus meeting was heldat which definitive translations were agreed. Adequate interraterreliability ( ${kappa}$ >0.8) was achieved on all measures, post-translation.

We used bivariate correlations to identify relationships betweeninsight, psychopathology and functioning. We entered unadjustedcorrelates of SAPS, SANS and GAF as independent variables intohierarchical stepwise regression models with SAPS, SANS andGAF as dependent variables. We added total insight to eachmodel before replacing it with each insight dimension in turn.For each dependent variable, the best regression model wasthat with the largest R² value.

RESULTS

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RESULTS

Clinical and demographic characteristics of the sample are shownin Table 1. Of those with a diagnosis other than schizophrenia(n=6), 4 had schizophreniform disorder and 2 had schizoaffectivedisorder.

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Table 1 Characteristics of the sample (n=60)

Scores on SAI–SR were correlated with SAI–TA ( ${rho}$ =0.32, P=0.01). SAI–RI and SAI–SR scores were highly correlated ( ${rho}$ =0.62, P<0.001). SAI–RI and SAI–TA scores were related at a trend level ( ${rho}$ =0.24, P=0.06).

In bivariate correlations, SAPS total score was inversely associatedwith SAI total score ( ${rho}$ =–0.39, P=0.002), SAI–SR ( ${rho}$ =–0.46, P<0.001) and SAI–TA ( ${rho}$ =–0.31, P=0.02). After stepwise regression, correlates of SAPS totalscore were SAI–SR (R² change=0.15, P=0.002) and durationof illness (R² change=0.06, P=0.04). Longer illness correlatedwith more severe symptoms. The SANS total score was correlatedwith SAI–TA ( ${rho}$ =–0.31, P=0.02), and SAI–TAwas the only independent variable in the regression model predictingSANS total (R² change=0.11, P=0.01).

In bivariate correlations, GAF correlated positively with totalinsight ( ${rho}$ =0.47, P<0.001), SAI–SR ( ${rho}$ =0.48, P<0.001),SAI–TA ( ${rho}$ =0.46, P<0.001) and SAI–RI ( ${rho}$ =0.31, P=0.02).The best regression model explained 64% of GAF variance. Itcomprised SAPS total (R² change= 0.33, P<0.001), SANS total(R² change =0.23, P<0.001), SAI–SR (R² change= 0.05,P=0.01) and lifetime cannabis misuse (R² change=0.04, P=0.01).

DISCUSSION

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DISCUSSION

This was a study of the relationship between insight, psychopathologyand functioning in an urban Malawian population among whomtraditional beliefs were widely held, as indicated by the proportionof patients initially seeking traditional treatments. Low scoreson recognition of illness and symptom relabelling may reflectparticipants' attribution of illness and individual symptomsto ulowi or ancestors. Our principal finding was that insightcorrelated positively with global functioning, independent of confounders. This finding is in keeping with most Western studies (Pini et al, 2001; Lysaker et al, 2007). In finding a positivecorrelation between symptom relabelling and functioning, wediffer with Mutsatsa et al (2006), but we also differed inmethodology. Theirs was a first-episode sample, whereas ourswas a prevalence sample, and they measured social functioning,whereas we measured global functioning.

Two explanations offer themselves for the relationship betweenrelabelling and functioning. First, the ability to relabelsymptoms may be related to improved cognitive performance,which is itself associated with improved functioning (Morgan & David, 2004).Alternatively, the functional impairment caused by psychoticsymptoms may relate to the meaning given to the symptoms aswell as to the symptoms themselves. Although our study designcannot show causation, one interpretation could be that psychoticsymptoms are functionally harmful regardless of their perceivedorigin, but it is more harmful to believe that an ancestoris communicating with you than to know that you are experiencinga hallucination. Understanding the origin of psychotic symptomsmay ameliorate functional harm, even when the symptoms themselvespersist. This preliminary finding suggests that symptom-focusedpsychoeducation might be appropriate for this population.

REFERENCES

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