Awareness and Insight

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Original article

Subjective awareness of tardive dyskinesia and insight in schizophrenia

R. Emsley *, D.J.H. Niehaus, P.P. Oosthuizen, L. Koen, B. Chiliza, D. Fincham

Department of Psychiatry, Faculty of Health Sciences, University of Stellenbosch, PO Box 19063, Tygerberg 7505, Cape Town, South Africa

1. Introduction

Tardive dyskinesia (TD) is a frequent complication of conven-

tional antipsychotic treatment [15], and its incidence is higher

with second-generation antipsychotics than previously reported

[8]. Therefore, TD remains a significant clinical problem. It is

associated with social and vocational impairment and contributes

to the further stigmatisation of patients receiving antipsychotics

[24]. A striking feature of TD is that a large percentage of patients

display an apparent lack of concern or even unawareness of the

movement disorder, with reported rates ranging between 44 and

95% [1,25]. While the origins of this lack of awareness of TD are not

known, it has been associated with cognitive impairment [20], the

deficit syndrome [3,20] and greater severity of extrapyramidal

symptoms [5]. The phenomenon has been likened to anosognosia,

a neurological deficit characterised by unawareness of an

impairment, and associated with damage to specific brain areas

[25].

Poor insight into their mental illness is another common and

often striking symptom in schizophrenia, with an estimated 50 to

80% of such individuals not being convinced that they have a

disorder [10]. While previously considered a psychological defense

mechanism, lack of insight into mental illness has more recently

been proposed as a neurologically based condition related to

damage to specific brain areas [25], and also likened to

anosognosia [19]. It is therefore reasonable to hypothesise that

the lack of awareness of TD and lack of insight into mental illness

are manifestations of a common underlying dysfunction. Indeed,

this possibility has been proposed by Arango et al. [3] who

explored the relationship between awareness of TD and insight

into mental illness in 43 patients with schizophrenia and TD.

However, they found only a modest correlation between aware-

ness of TD and insight into mental illness, suggesting that the two

phenomena are not closely related. However, the authors pointed

out that their sample was underpowered and that further studies

with larger groups of patients are needed.

In the present study, we investigated whether poor awareness

of TD is related to poor insight into mental illness in a relatively

large sample of patients with schizophrenia and TD. We also

examined relationships between selected demographic and

clinical factors and these two phenomena. We hypothesised that

poor awareness of TD would be related to poor insight into mental

illness, and that the two phenomena would have similar

demographic and clinical correlates.

European Psychiatry xxx (2010) xxxxxx

A R T I C L E I N F O

Article history:

Received 13 August 2009

Received in revised form 14 December 2009

Accepted 29 December 2009

Keywords:

Insight

Schizophrenia

Tardive dyskinesia

Psychopathology

A B S T R A C T

Background: Lack of awareness of tardive dyskinesia (TD) and poor insight into mental illness are

common in schizophrenia, raising the possibilitythat these phenomenaare manifestations of a common

underlying dysfunction.

Methods: We investigated relationships between low awareness of TD and poor insight into mentalillness in 130 patients with schizophrenia and TD. We also examined selected demographic and clinical

correlates of these two phenomena.

Results: Sixty-six (51%) patients had no or low awareness of TD and 94 (72%) had at least mild

impairment of insight into their mental illness. Low awareness of TD was not significantly correlated

with greater impairment of insight into mental illness. Regression analyses indicated that the Positive

and Negative Syndrome Scale (PANSS) disorganised factor (b = 0.72, t= 11.88, p< 0.01) accounted for52%of thevariance in insight into mental illness (adjustedR2 = 0.55) (F[2, 127] = 81.00,p < 0.01) and the

Extrapyramidal Symptom Rating Scale (ESRS) dyskinesia subscale score (b = 0.47, t= 6.80, p < 0.01),

PANSS disorganised factor (b = 0.26, t= 3.73, p < 0.01), and ESRS parkinsonism subscale score

(b = 0.31, t= 4.55, p < 0.01) together accounted for 37% of the variance in awareness of TD (adjustedR2 = 0.37) (F[3, 126] = 26.87, p < 0.01).

Conclusion: The two phenomena appear to be dissociated, and may be domain-specific.

2010 Elsevier Masson SAS. All rights reserved.

* Corresponding author. Tel.: +27 21 9389227; fax: +27 21 9389738.

E-mail address: [email protected] (R. Emsley).

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EURPSY-2771; No. of Pages 4

Please cite this article in press as: Emsley R, et al. Subjective awareness of tardive dyskinesia and insight in schizophrenia. European

Psychiatry (2010), doi:10.1016/j.eurpsy.2009.12.006

0924-9338/$ see front matter 2010 Elsevier Masson SAS. All rights reserved.

doi:10.1016/j.eurpsy.2009.12.006
http://dx.doi.org/10.1016/j.eurpsy.2009.12.006mailto:[email protected]://dx.doi.org/10.1016/j.eurpsy.2009.12.006http://dx.doi.org/10.1016/j.eurpsy.2009.12.006http://dx.doi.org/10.1016/j.eurpsy.2009.12.006http://dx.doi.org/10.1016/j.eurpsy.2009.12.006mailto:[email protected]://dx.doi.org/10.1016/j.eurpsy.2009.12.006


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2. Methods

2.1. Participants

This was a post hoc analysis of baseline data obtained from the

participants in twoTD treatment studies[12,14]. In-and outpatients

from Stikland and Tygerberg Academic Hospitals, as well as

surrounding community clinics in the Greater Cape Town area

were screened for the presence of TD. To be included participants

hadto be between18 and 60 years of age, meet both Diagnosticand

Statistical Manual of Mental Diseases, Fourth Edition (DSM-IV) [2]

criteriaand Schoolers and Kanes criteria [29] for TD, have a Clinical

Global Impression (CGI) severity of TD score of !3, a DSM-IV

diagnosis of schizophrenia or schizoaffective disorder, and to have

receiveda fixeddose of antipsychotic medicationfor at leastthe past

6 weeks. Exclusion criteria comprised an unstable psychiatric

disorder, significant neurological disorder other than TD, other

significant medical illness, substance abuse, pregnancy, breast-

feeding and current use of clozapine. The initial clinical trials were

approved by the Institutional Review Board of the University of

Stellenbosch, and informed, written consent was obtained from all

participants. Approval to conduct the post hoc analysis was also

obtained from the Institutional Review Board.

2.2. Assessments

All participants underwent the following assessments: Demo-

graphic information, psychiatric history and examination and

medical history and examination. The duration of TD was assessed

on the basis of information provided by participants and their

family members and from the clinical files. Motor symptoms were

assessed by means of the Extrapyramidal Symptom Rating Scale

(ESRS) [6]. The level of awareness of, or concern for TD was

calculated by the sum of two items on the ESRS scale that rate the

patients subjective evaluation of the intensity of dyskinesia of

extremities (item 1.10) and tongue, jaw, lips or face (item 1.11),

each on a four-point scale (0 = absent; 1 = mild; 2 = moderate;

3 = severe) [6]. The ESRS dyskinesia score comprises the sum ofseven items on the ESRS scale. Severity of TD was assessed by the

total ESRS dyskinesia score and the CGI-TD scale. Other ESRS

subscale scores include those for parkinsonism, dystonia and an

item for akathisia [6].

Schizophrenia psychopathology was assessed by means of the

Positive and Negative Syndrome Scale (PANSS) [16]. For assessing

insight into mental illness we used a singleitem on thePANSS scale

(item G12). This item rates lack of judgement and insight into the

mental illness on a seven-point scale (one absent, seven extreme).

While a more comprehensive insight scale would have been

preferable, this single item has been used to assess insight

previously [18,27] and has shown a strong correlation with other

insight scales [28]. To explore correlations with schizophrenia

psychopathology we examined the following PANSS scores: PANSStotal (comprising the total score of all 32 items), and five

previously described factor-analysis derived symptom domains

(positive, negative, disorganised, excited and depression/anxiety

factors) [13]. The PANSS insight item (G12) was removed from the

items to which it may have contributed, i.e. PANSS total score and

PANSS positive score before analyses were conducted). Global

severity of psychosis was assessed by thePANSStotalscore andthe

CGI severity of psychosis (CGI-PSY) scale.

2.3. Analyses

A Pearsons product-moment correlation coefficient matrix was

computed to identify variables that were correlated with insight

into mental illness and awareness of TD.

Two forced entry multiple linear regression analyses were then

conducted. The first assessed the amount of variance that variables

significantly correlated with insight into mental illness could

account for and the second assessed the amount of variance that

variables significantly correlated with awareness of TD could

explain.

3. Results

The sample comprised 130 subjects (84 men and 46 women)

aged 45 11 years, with a mean duration of psychosis of

17 11 years and duration of TD of 6 6 years. The mean PANSS

total score for the sample was 57 13; ESRS dyskinesia subscale

score was 12 5; CGI-PSY score was2.2 1.4;and CGI-TD was 4 1.

Sixty-six (51%) patients were assessed as having no or low subjective

awareness of TD (Score of 0.05) and consequently were not

included as predictors in the regression analyses.

Two forced entry multiple linear regression analyses were then

conducted. The first assessed the amount of variance that the

PANSS total score and the PANSS negative and disorganised factor

scores could account for in insight into mental illness. The second

analysis assessed the amount of variance that age, ESRS dyskinsia

subscale score, ESRS parkinsonism subscale score and PANSS

disorganised factor score could explain in awareness of TD. Asdepicted in Table 1, PANSS total score and PANSS negative factor

score were no longer associated with insight into mental illness

when linearly combined with the other predictors. As such, the

regression was performed again, this time with PANSS total score

and PANSS negative factor score removed from the analysis.

Similarly, agewas no longer associated with awareness of TD when

linearly combined with the other predictors. The regression was

performed again with age removed from the analysis.

Results indicated that the PANSS disorganised factor (b = 0.72,

t= 11.88,p< 0.01) accountedfor 52%of thevariance in insight into

mental illness (adjusted R2 = 0.55) (F[2, 127] = 81.00,p < 0.01). The

squared multiple correlation coefficient yielded an extremely large

effect size (2 = 1.12) [7]. The ESRS dyskinesia subscale score

(b = 0.47, t= 6.80, p< 0.01), PANSS disorganised factor (b = 0.26,t= 3.73, p < 0.01), and ESRS parkinsonism subscale score

(b = 0.31, t= 4.55, p < 0.01) together accounted for 37% of the

variance in awareness of TD (adjusted R2 = 0.37) (F[3, 126] = 26.87,

p < 0.01). The squared multiple correlation coefficient yielded a

very large effect size (2 = 0.63) [7].

Regarding the assumptions of parametric regression analysis,

Kolmogorov-Smirnovs tests of normality revealed that the

distributions of standardised residuals were normally distributed

for each analysis. Durbin-Watsons statistics revealed that the

standardised residuals were also independent in each analysis.

Cooks distance statistics indicated that no data points exerted

undue influence over the regression models. Examination of the

standardised residuals/standardised predicted values plots

showed that the assumptions of homoscedasticity and linearity

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were met for each analysis. Finally, Variance Inflation Factor (VIF)and tolerance statistics showed that there was no significant

multicollinearity in any of the analyses.

4. Discussion

This study highlights the very high rates of poor awareness of

TD, as well as impaired insight into mental illness in stablepatients

with schizophrenia. The rate of poor awareness of TD (52%) is

consistent with previous reports [1,3,5,20,23], asis the rateof poor

insight into their mental illness (72%) [3,11]. Our results suggest

that lack of awareness of TD and impaired insight into mental

illness are not manifestations of a common underlying patho-

physiology, insofar as they were not significantly correlated.

However, regression analyses indicated that the PANSS disorga-nised factor contributed substantially to both phenomena. This

was particularly the case for insight into mental illness where it

accountedfor themajorproportionof the variability,whereas with

awareness of TD additional factors (severity of TD and presence of

parkinsonism) also played a significant role. Our results are similar

to those of Arango et al. [3] who found only a modestly significant

association between insight into mental illness and lack of

awareness of TD. These authors proposed that the two phenomena

are dissociated, and domain specific. However, whereas in their

sample poor awareness of TD was associated with deficit

symptoms, in our study the strongest association was with

disorganised symptoms.

Pia andTamietto [27] reviewed current thinking regarding the

pathogenesis of impaired insight in schizophrenia and suggest twomain possibilities. First, impaired insight may be a neurological

deficit reflecting underlying frontal lobe damage. They cite reports

of an association with impairments in cognitive executive

functions and neuro-imaging abnormalities (for references see

[27]) in support of this hypothesis. Similarly, Shad et al. [30]

reviewed studies investigating insight and neurocognitive perfor-

manceand structuralimaging data in schizophrenia and concluded

that findings are consistent with a relationship between impaired

insight and anosognosia. They propose an insight-anosognosia

model involving specific cognitive dysfunctions, primarily medi-

ated by frontal cortex (dorsolateral prefrontal cortex and

orbitofrontal cortex) and to a lesser extent the parietal cortex.

The second possibility is that impaired insight is a symptom of

the illness as a whole, or perhaps linked to specific symptom

domains. Whereas an earlier study [21] concluded that very littleof impaired insight was related to the acute psychopathology, two

more recent studies in first-episode schizophrenia samples found

poor insight to be associated with higher scores on PANSS total,

positive, negative and general psychopathology scales [22,26].

Lack of insight has also been modestly associated with positive

symptoms and with negative symptoms [4,12,17], thought-

broadcasting, delusions of grandeur and sexual delusions [11].

More evidence linking poor insight to positive symptoms comes

from the published PANSS factor analyses of the symptom

structure of schizophrenia. In a review of such studies it was

found that the PANSS lack of insight item (G12) loaded with the

positive factor [13]. Finally, Cuesta et al. [9] found that higher

negative and disorganisation symptom scores at baseline were

associated with less improvement in insight over time, andconcluded that insight and psychopathology are probably semi-

independent domains.

Other factors that could be linked to lack of awareness of TD

insofar an association has previously been reported include the

deficit syndrome [3], a diagnosis of schizophrenia (as opposed to

bipolar disorder), poorer cognitive function [20], higher levels of

extrapyramidal symptoms [5] and greater severity of TD [27].

The most likely explanation of the inconsistent findings across

studies is that multiple factors play a role in impairing both insight

into mental illness and awareness of TD. Also, small samples and

different assessment instruments are likely to have contributed.

Limitations of our study include its retrospective nature and the

fact that specific instruments to assess levels of insight and lack of

awareness of TD were not employed. However, strengths includethe large sample of patients with TD and the use of validated

instruments for assessing movement disorders and psychopathol-

ogy.

5. Conclusions

Our findings support and extend those of previous studies

suggesting that lack of awareness of TD and impaired insight into

mental illness are not closely related, and that both phenomena

are, at least partially, related to the disorganised symptom domain.

Future studies should, in addition to investigating the cognitive

and neurobiological underpinnings of poor awareness of TD, assess

awareness levels in movement disorders not associated with

psychosis, such as senile dyskinesia.

Table 1

Results of forced entry multiple regression analyses for variables predicting insight into mental illness and awareness of tardive dyskinesia.

Variables R2 Adj. R2 F B SE b t p 2

Insight into mental illness

Regression 1 0.57 0.55 41.71 0.00** 1.32

PANSS total 0.01 0.01 0.11 0.63 0.52

Negative factor 0.03 0.02 0.17 1.41 0.15

Positive factor 0.07 0.02 0.25 2.49 0.01*

Disorganised factor 0.22 0.03 0.66 7.49 0.00**

Regression 2 0.56 0.55 81.00 0.00** 1.27Positive factor 0.05 0.01 0.20 3.21 0.00**


Awareness of tardive dyskinesia

Regression 1 0.39 0.37 20.35 0.00** 0.63

Age 0.00 0.00 0.06 0.93 0.35

Dyskinesia score 0.12 0.02 0.46 6.49 0.00**


Parkinsonism score 0.05 0.01 0.30 4.40 0.00**

Regression 2 0.39 0.37 26.87 0.00** 0.63

Dyskinesia score 0.13 0.01 0.47 6.80 0.00**


Parkinsonism score 0.05 0.01 0.31 4.55 0.00**

*:p


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Awareness and Insight

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