Abstract
Purpose
Previous studies have investigated the role of gender in clinical symptoms, social functioning, and neuropsychological performance in people with first-episode psychosis (FEP). However, the evidence of gender differences for metacognition in subjects with FEP is still limited and controversial. The aim of the present study was to explore gender differences in cognitive insight and cognitive biases in this population.
Methods
Cross-sectional study was carried out in a sample of 104 patients with FEP (35 females and 69 males) recruited from mental health services. Symptoms were assessed with the Positive and Negative Syndrome Scale, cognitive insight with the Beck Cognitive Insight Scale, and cognitive bias by the Cognitive Biases Questionnaire for Psychosis. The assessment also included clinical and sociodemographic characteristics.
Results
After controlling for potential confounders (level of education, marital status, and duration of psychotic illness) analysis of covariance revealed that males presented greater self-reflectiveness (p = 0.004) when compared to females. However, no significant differences were found in self-certainty and composite index of the cognitive insight scale, as in the cognitive biases assessed.
Conclusions
Gender was an independent influence factor for self-reflectiveness, being better for males. Self-reflectiveness, if shown to be relatively lacking in women, could contribute to the design of more gender-sensitive and effective psychotherapeutic treatments, as being able to self-reflect predicts to better treatment response in psychosis.
Similar content being viewed by others
References
Andreou C, Schneider BC, Balzan R, Luedecke D, Roesch-Ely D, Moritz S (2015) Neurocognitive deficits are relevant for the jumping-to-conclusions bias, but not for delusions: a longitudinal study. Schizophr Res Cogn 2. https://doi.org/10.1016/j.scog.2015.02.001
Aydın O, Lysaker PH, Balıkçı K et al (2018) Associations of oxytocin and vasopressin plasma levels with neurocognitive, social cognitive and meta cognitive function in schizophrenia. Psychiatry Res 270:1010–1016. https://doi.org/10.1016/J.PSYCHRES.2018.03.048
Ayesa-Arriola R, de la Foz VO-G, Setién-Suero E, Ramírez-Bonilla ML, Suárez-Pinilla P, Son JM, Vázquez-Bourgon J, Juncal-Ruiz M, Gómez-Revuelta M, Tordesillas-Gutiérrez D, Crespo-Facorro B (2020) Understanding sex differences in long-term outcomes after a first episode of psychosis. NPJ Schizophr 6:33. https://doi.org/10.1038/s41537-020-00120-5
Ayesa-Arriola R, Miguel-Corredera M, De La Foz VO-G, Neergaard KD, Correa-Ghisays P, Setién-Suero E, Crespo-Facorro B (2023) Education and long-term outcomes in first episode psychosis: 10-year follow-up study of the PAFIP cohort. Psychol Med 53:66–77. https://doi.org/10.1017/S0033291721001112
Ayesa-Arriola R, Rodriguez-Sanchez JM, Gomez-Ruiz E, Roiz-Santiáñez R, Reeves LL, Crespo-Facorro B (2014) No sex differences in neuropsychological performance in first episode psychosis patients. Prog Neuropsychopharmacol Biol Psychiatry 48. https://doi.org/10.1016/j.pnpbp.2013.09.009
Barajas A, Ochoa S, Obiols JE, Lalucat-Jo L (2015) Gender differences in individuals at high-risk of psychosis: a comprehensive literature review. ScientificWorldJournal 2015:430735. https://doi.org/10.1155/2015/430735
Beck A, Baruch E, Balter JM, Steer RA, Warman DM (2004) A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res 68:319–329. https://doi.org/10.1016/S0920-9964(03)00189-0
Bender R, Lange S (2001) Adjusting for multiple testing—when and how? Journal of Clinical Epidemiology 54(4):343–349. https://doi.org/10.1016/S0895-4356(00)00314-0
Benoit A, Harvey P-O, Bherer L, Lepage M (2016) Does the Beck Cognitive Insight Scale predict response to cognitive remediation in schizophrenia? Schizophr Res Treat 2016:e6371856. https://doi.org/10.1155/2016/6371856
Bora E, Erkan A, Kayahan B, Veznedaroglu B (2007) Cognitive insight and acute psychosis in schizophrenia. Psychiatry Clin Neurosci 61:634–639. https://doi.org/10.1111/j.1440-1819.2007.01731.x
Cobo J, Nieto L, Ochoa S, Pousa E, Usall J, Baños I, González B, Ruiz I, Ruiz AI (2016) Insight and gender in schizophrenia and other psychoses. Psychiatry Res 243. https://doi.org/10.1016/j.psychres.2016.04.089
Colás P, Villaciervos, P (2007). La interiorización de los estereotipos de género en jóvenes y adolescentes. Revista de Investigación Educativa, 25(1), Article 1.
Corral L, Labad J, Ochoa S, Cabezas A, Muntané G, Valero J, Sanchez-Gistau V, Ahuir M, Gallardo-Pujol D, Crosas JM, Palao D, Vilella E, Gutierrez-Zotes A (2021) Cognitive Biases Questionnaire for Psychosis (CBQp): Spanish validation and relationship with cognitive insight in psychotic patients. Front Psychiatry 11. https://doi.org/10.3389/fpsyt.2020.596625
Cotton SM, Lambert M, Schimmelmann BG, Foley DL, Morley KI, McGorry PD, Conus P (2009) Gender differences in premorbid, entry, treatment, and outcome characteristics in a treated epidemiological sample of 661 patients with first episode psychosis. Schizophr Res 114:17–24. https://doi.org/10.1016/j.schres.2009.07.002
Davies G, Greenwood K (2020) A meta-analytic review of the relationship between neurocognition, metacognition and functional outcome in schizophrenia. J Ment Health 29:496–505. https://doi.org/10.1080/09638237.2018.1521930
De Vos C, Leanza L, Mackintosh A, Lüdtke T, Balzan R, Moritz S, Andreou C (2019) Investigation of sex differences in delusion-associated cognitive biases. Psychiatry Res 272. https://doi.org/10.1016/j.psychres.2018.12.121
Díaz-Cutraro L, García-Mieres H, López-Carrilero R, Ferrer M, Verdaguer-Rodriguez M, Barrigón ML, Barajas A, Grasa E, Pousa E, Lorente E, Ruiz-Delgado I, González-Higueras F, Cid J, Palma-Sevillano C, Moritz S, Spanish Metacognition Group, Ochoa S (2021) Jumping to conclusions is differently associated with specific subtypes of delusional experiences: an exploratory study in first-episode psychosis. Schizophr Res 228:357–359. https://doi.org/10.1016/j.schres.2020.12.037
Díaz-Cutraro L, López-Carrilero R, García-Mieres H, Ferrer-Quintero M, Verdaguer-Rodriguez M, Barajas A, Grasa E, Pousa E, Lorente E, Barrigón ML, Ruiz-Delgado I, González-Higueras F, Cid J, Mas-Expósito L, Corripio I, Birulés I, Pélaez T, Luengo A, Beltran M et al (2022) The relationship between jumping to conclusions and social cognition in first-episode psychosis. Schizophrenia 8:1–7. https://doi.org/10.1038/s41537-022-00221-3
Dudley R, Taylor P, Wickham S, Hutton P (2016) Psychosis, delusions and the “jumping to conclusions” reasoning bias: a systematic review and meta-analysis. Schizophr Bull 42:652–665. https://doi.org/10.1093/schbul/sbv150
Dudley REJ, John CH, Young AW, Over DE (1997) The effect of self-referent material on the reasoning of people with delusions. Br J Clin Psychol 36:575–584. https://doi.org/10.1111/j.2044-8260.1997.tb01262.x
Engen MJ, Simonsen C, Melle I, Færden A, Lyngstad SH, Haatveit B, Vaskinn A, Ueland T (2019) Cognitive functioning in patients with first-episode psychosis stratified by level of negative symptoms: a 1-year follow-up study. Psychiatry Res 281:112554. https://doi.org/10.1016/j.psychres.2019.112554
Falcone MA, Murray RM, Wiffen BDR, O’Connor JA, Russo M, Kolliakou A, Stilo S, Taylor H, Gardner-Sood P, Paparelli A, Jichi F, Forti MD, David AS, Freeman D, Jolley S (2015) Jumping to conclusions, neuropsychological functioning, and delusional beliefs in first episode psychosis. Schizophr Bull 41. https://doi.org/10.1093/schbul/sbu104
Ferrer-Quintero M, Fernández D, López-Carrilero R, Birulés I, Barajas A, Lorente-Rovira E, Luengo A, Díaz-Cutraro L, Verdaguer M, García-Mieres H, Gutiérrez-Zotes A, Grasa E, Pousa E, Huerta-Ramos E, Pélaez T, Barrigón ML, Gómez-Benito J, González-Higueras F, Ruiz-Delgado I et al (2022) Males and females with first episode psychosis present distinct profiles of social cognition and metacognition. Eur Arch Psychiatry Clin Neurosci 272:1169–1181. https://doi.org/10.1007/s00406-022-01438-0
García-Mieres H, Jesús-Romero RD, Ochoa S, Feixas G (2020a) Beyond the cognitive insight paradox: self-reflectivity moderates the relationship between depressive symptoms and general psychological distress in psychosis. Schizophr Res 222. https://doi.org/10.1016/j.schres.2020.05.027
García-Mieres H, Montesano A, Villaplana A, Trujillo A, Salla M, Paz C, Ochoa S, Feixas G (2020b) Common and differential dimensions of personal identity between psychosis and depression: the relevance of gender and depressive mood. J Psychiatr Res 127:48–56. https://doi.org/10.1016/j.jpsychires.2020.05.015
González LE, López-Carrilero R, Barrigón ML, Grasa E, Barajas A, Pousa E, González-Higueras F, Ruiz-Delgado I, Cid J, Lorente-Rovira E, Pélaez T, Ochoa S (2018) Neuropsychological functioning and jumping to conclusions in recent onset psychosis patients. Schizophr Res 195. https://doi.org/10.1016/j.schres.2017.09.039
Gutiérrez-Zotes JA, Valero J, Cortés MJ, Labad A, Ochoa S, Ahuir M, Carlson J, Bernardo M, Cañizares S, Escartin G, Cañete J, Gallo P, Salamero M (2012) Adaptación española de la Escala de Insight Cognitivo de Beck (EICB) en esquizofrénicos. Actas Esp Psiquiatr 40:2–9
Heitz U, Studerus E, Menghini-Müller S, Papmeyer M, Egloff L, Ittig S, Navarra A, Andreou C, Riecher-Rössler A (2019) Gender differences in first self-perceived signs and symptoms in patients with an at-risk mental state and first-episode psychosis. Early Interv Psychiatry 13(3):582–588. https://doi.org/10.1111/eip.12528
Ittig S, Studerus E, Papmeyer M, Uttinger M, Koranyi S, Ramyead A, Riecher-Rössler A (2015) Sex differences in cognitive functioning in at-risk mental state for psychosis, first episode psychosis and healthy control subjects. Eur Psychiatry 30:242–250. https://doi.org/10.1016/j.eurpsy.2014.11.006
Kao Y-C, Liu Y-P, Lien Y-J, Lin S-J, Lu C-W, Wang T-S, Loh C-H (2013) The influence of sex on cognitive insight and neurocognitive functioning in schizophrenia. Prog Neuropsychopharmacol. Biol Psychiatry 44:193–200. https://doi.org/10.1016/j.pnpbp.2013.02.006
Kay SR, Fiszbein A, Opler LA (1987) The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr Bull 13:261–276. https://doi.org/10.1093/schbul/13.2.261
Kern RS, Nuechterlein KH, Green MF et al (2008) The MATRICS consensus cognitive battery, Part 2: co-norming and standardization. Am J Psychiatry 165:214–220. https://doi.org/10.1176/appi.ajp.2007.07010043
Leucht S, Samara M, Heres S, Davis JM (2016) Dose equivalents for antipsychotic drugs: the DDD method. Schizophr Bull 42(Suppl 1):S90–S94. https://doi.org/10.1093/schbul/sbv167
Lysaker PH, Carcione A, Dimaggio G, Johannesen JK, Nicolò G, Procacci M, Semerari A (2005) Metacognition amidst narratives of self and illness in schizophrenia: associations with neurocognition, symptoms, insight and quality of life. Acta Psychiatr Scand 112:64–71. https://doi.org/10.1111/j.1600-0447.2005.00514.x
Lysaker PH, Vohs J, Hasson-Ohayon I, Kukla M, Wierwille J, Dimaggio G (2013) Depression and insight in schizophrenia: comparisons of levels of deficits in social cognition and metacognition and internalized stigma across three profiles. Schizophr Res 148:18–23. https://doi.org/10.1016/j.schres.2013.05.025
MacBeth A, Gumley A, Schwannauer M, Carcione A, McLeod HJ, Dimaggio G (2016) Metacognition in first episode psychosis: item level analysis of associations with symptoms and engagement. Clin Psychol Psychother 23:329–339. https://doi.org/10.1002/cpp.1959
McEvoy JP, Johnson J, Perkins D, Lieberman JA, Hamer RM, Keefe RSE, Tohen M, Glick ID, Sharma T (2006) Insight in first-episode psychosis. Psychol Med 36:1385–1393. https://doi.org/10.1017/S0033291706007793
McLean BF, Mattiske JK, Balzan RP (2017) Association of the jumping to conclusions and evidence integration biases with delusions in psychosis: a detailed meta-analysis. Schizophr Bull 43:344–354. https://doi.org/10.1093/schbul/sbw056
Moritz S, Klein JP, Desler T, Lill H, Gallinat J, Schneider BC (2017) Neurocognitive deficits in schizophrenia. Are we making mountains out of molehills? Psychol Med 47. https://doi.org/10.1017/S0033291717000939
Moritz S, Lysaker PH (2018) Metacognition — what did James H. Flavell really say and the implications for the conceptualization and design of metacognitive interventions. Schizophr Res 201:20–26. https://doi.org/10.1016/j.schres.2018.06.001
Moritz S, Mahlke CI, Westermann S, Ruppelt F, Lysaker PH, Bock T, Andreou C (2018) Embracing psychosis: a cognitive insight intervention improves personal narratives and meaning-making in patients with schizophrenia. Schizophr Bull 44. https://doi.org/10.1093/schbul/sbx072
Nuechterlein KH, Green MF, Kern RS et al (2008) The MATRICS consensus cognitive battery, Part 1: test selection, reliability, and validity. Am J Psychiatry 165:203–213. https://doi.org/10.1176/appi.ajp.2007.07010042
Ochoa S, López-Carrilero R, Barrigón ML, Pousa E, Barajas A, Lorente-Rovira E, González-Higueras F, Grasa E, Ruiz-Delgado I, Cid J, Birulés I, Esteban-Pinos I, Casañas R, Luengo A, Torres-Hernández P, Corripio I, Montes-Gámez M, Beltran M, Apraiz AD et al (2017) Randomized control trial to assess the efficacy of metacognitive training compared with a psycho-educational group in people with a recent-onset psychosis. Psychol Med 47:1573–1584. https://doi.org/10.1017/S0033291716003421
Ochoa S, Usall J, Cobo J, Labad X, Kulkarni J (2012) Gender differences in schizophrenia and first-episode psychosis: a comprehensive literature review. Schizophr Res Treat 2012:916198. https://doi.org/10.1155/2012/916198
Pa G, Dr H, Wessely S (1991) Reasoning in deluded schizophrenic and paranoid patients. J Nerv Ment Dis 179:194–201. https://doi.org/10.1097/00005053-199104000-00003
Penney D, Joober R, Malla A, Lepage M (2020) Understanding sex differences in cognitive insight across first-and-multiple episode psychosis. Schizophr Res 218:276–282. https://doi.org/10.1016/j.schres.2019.12.024
Peralta V, Cuesta M (1994) Psychometric properties of the Positive and Negative Syndrome Scale (PANSS) in schizophrenia. Psychiatry Res 53:31–40. https://doi.org/10.1016/0165-1781(94)90093-0
Perivoliotis D, Grant PM, Peters ER, Ison R, Kuipers E, Beck AT (2010) Cognitive insight predicts favorable outcome in cognitive behavioral therapy for psychosis. Psychosis 2:23–33. https://doi.org/10.1080/17522430903147520
Peters ER, Moritz S, Schwannauer M, Wiseman Z, Greenwood KE, Scott J, Beck AT, Donaldson C, Hagen R, Ross K, Veckenstedt R, Ison R, Williams S, Kuipers E, Garety PA (2014) Cognitive biases questionnaire for psychosis. Schizophr Bull 40. https://doi.org/10.1093/schbul/sbs199
Premkumar P, Peters ER, Fannon D, Anilkumar AP, Kuipers E, Kumari V (2011) Coping styles predict responsiveness to cognitive behaviour therapy in psychosis. Psychiatry Res 187:354–362. https://doi.org/10.1016/j.psychres.2010.12.029
Pu C, Qiu Y, Zhou T, Yang F, Lu Z, Wang C, Deng H, Zhao J, Shi C, Yu X (2019) Gender differences of neurocognitive functioning in patients with first-episode schizophrenia in China. Compr Psychiatry 95:152132. https://doi.org/10.1016/j.comppsych.2019.152132
Riecher-Rössler A, Butler S, Kulkarni J (2018) Sex and gender differences in schizophrenic psychoses—a critical review. Arch Womens Ment. Health 21:627–648. https://doi.org/10.1007/s00737-018-0847-9
Rodriguez V, Ajnakina O, Stilo SA, Mondelli V, Marques TR, Trotta A, Quattrone D, Gardner-Sood P, Colizzi M, Wiffen BD, Dazzan P, Forti MD, Falcone MA, David AS, Murray RM (2019) Jumping to conclusions at first onset of psychosis predicts longer admissions, more compulsory admissions and police involvement over the next 4 years: the GAP study. Psychol Med 49:2256–2266. https://doi.org/10.1017/S0033291718003197
Salas-Sender M, López-Carrilero R, Barajas A, Lorente-Rovira E, Pousa E, Barrigón ML, Grasa E, Ruiz-Delgado I, González-Higueras F, Cid J, Aznar A, Pélaez T, Birulés I, Moritz S, Ochoa S (2019) Gender differences in response to metacognitive training in people with first-episode psychosis. J Consult Clin Psychol. https://doi.org/10.1037/ccp0000468
Sánchez-Cubillo I, Periáñez JA, Adrover-Roig D et al (2009) Construct validity of the Trail Making Test: role of task-switching, working memory, inhibition/interference control, and visuomotor abilities. J Int Neuropsychol Soc 15:438–450. https://doi.org/10.1017/S1355617709090626
Schmitt DP, Long AE, McPhearson A et al (2017) Personality and gender differences in global perspective. Int J Psychol 52:45–56. https://doi.org/10.1002/ijop.12265
Seeman M (2021) Sex differences in schizophrenia relevant to clinical care. Expert Rev Neurother. 21. https://doi.org/10.1080/14737175.2021.1898947
Semerari A, Carcione A, Dimaggio G, Falcone M, Nicolò G, Procacci M, Alleva G (2003) How to evaluate metacognitive functioning in psychotherapy? The metacognition assessment scale and its applications. Clin Psychol Psychother 10. https://doi.org/10.1002/cpp.362
Spreen O, Strauss E (1998) A compendium of neuropsychological tests: administration, norms, and commentary, 2nd edn. Oxford University Press, New York
Van De Mortel TF, Research Online G (2008) Faking it: social desirability response bias in self-report research. Aust J Adv Nurs 25:40–48
Ventura J, Subotnik KL, Han S, Hellemann GS, Green MF, Nuechterlein KH (2023) The relationship between sex and functional outcome in first-episode schizophrenia: the role of premorbid adjustment and insight. Psychol Med 1–10. https://doi.org/10.1017/S0033291723000442
Vila-Rodriguez F, Ochoa S, Autonell J, Usall J, Haro JM (2011) Complex interaction between symptoms, social factors, and gender in social functioning in a community-dwelling sample of schizophrenia. Psychiatr Q 82:261–274. https://doi.org/10.1007/s11126-011-9168-0
Vohs JL, Leonhardt BL, James AV, Francis MM, Breier A, Mehdiyoun N, Visco AC, Lysaker PH (2018) Metacognitive reflection and insight therapy for early psychosis: a preliminary study of a novel integrative psychotherapy. Schizophr Res 195:428–433. https://doi.org/10.1016/j.schres.2017.10.041
World Medical Association (2013) World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 310(20): 2191–2194. https://doi.org/10.1001/jama.2013.281053
Acknowledgements
We specially thank all the participants for their generosity of time and effort.
Funding
This work was supported by the Spanish Ministry of Health Carlos III (PI14/00044, PI18/ 00212, PI17/00111), the Fondo Europeo de Desarrollo Regional (FEDER), Health Department of Catalonia, PERIS call (SLT006/17/00231), Progress and Health Foundation of the Andalusia (PI-0193/2014), Obra Social La Caixa (RecerCaixa call 2013), and a research personal (FI18/00028).
Data availability Due to confidentiality issues, access to data will only be granted on request (S.O.; susana.ochoa@sjd.es; J.U.; judith.usall@sjd.es).
Author information
Authors and Affiliations
Consortia
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no competing interests.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Victoria Espinosa and Naomi Naides share first authorship
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Espinosa, V., Naides, N., López-Carrilero, R. et al. The influence of gender in cognitive insight and cognitive bias in people with first-episode psychosis: an uncontrolled exploratory analysis. Arch Womens Ment Health (2024). https://doi.org/10.1007/s00737-024-01425-5
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s00737-024-01425-5