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Relationship between insight and theory of mind in schizophrenia:

A meta-analysis
Emre Bora
Dokuz Eyll University, Faculty of Medicine, Department of Psychiatry, Izmir, Turkey
Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne and Melbourne Health, Carlton South, Victoria 3053, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Poor insight in schizophrenia has been associated with executive dysfunction and decits in general cognitive
Received 18 January 2017 ability. The overall outcome of available neurocognitive studies suggests that there is a signicant but modest re-
Received in revised form 9 March 2017 lationship between cognitive decits and poor insight in schizophrenia. However, social cognitive abilities, par-
Accepted 10 March 2017
ticularly, theory of mind (ToM), might also play a role in poor insight in schizophrenia. A novel meta-analysis of
Available online xxxx
the relationship between ToM and insight in schizophrenia was conducted. Current meta-analysis included 16
studies including 1085 patients with schizophrenia-spectrum disorders. There was a signicant association be-
Schizophrenia tween ToM and clinical insight (r = 0.28, CI = 0.200.36). By contrast, there was no signicant relationship be-
Theory of mind tween ToM and cognitive insight. Current ndings suggest that there is a small but signicant relationship
Insight between ToM and clinical insight in schizophrenia. ToM impairment is one of the factors contributing to poor in-
sight in schizophrenia.
2017 Published by Elsevier B.V.

1. Introduction play a role in poor insight in schizophrenia (Cooke et al., 2005). Meta-
analytical evidence suggests that positive symptoms and general psy-
Poor insight into illness in schizophrenia is a very common and clin- chopathology are signicantly but only mildly (r = 0.250.27) associat-
ically relevant problem (Amador et al., 1994; David, 1990; David et al., ed with poor insight and state-dependent factors can explain a small
1992). Generally, the concept of poor insight refers to a multidimen- amount of the variance in the level of insight decits in schizophrenia
sional clinical construct (clinical insight) (Amador et al., 1994; Pousa (Mintz et al., 2003). Similarly, longitudinal studies provided only a mod-
et al., 2017). Poor clinical insight is an important problem as it leads to est evidence of a relationship between change in the level of insight and
delay in access to treatment and poor treatment compliance at follow- positive symptoms (Lincoln et al., 2007). Therefore, poor insight in
up (Ayesa-Arriola et al., 2011; Beck et al., 2011; Sendt et al., 2015). schizophrenia can be considered as a trait feature which can be modest-
Most patients with schizophrenia present with difculty in making ly exacerbated during acute psychosis. Persisting negative symptoms,
sense of their experiences such as hallucinations and/or they have un- denial and preference of some coping styles can contribute to insight
awareness of many aspects of their illness including the need for treat- decits persisting beyond psychotic episodes (Cooke et al., 2005;
ment and negative social consequences (Arango and Amador, 2011). In Cooke et al., 2007; Mintz et al., 2003; Moore et al., 1999). Cognitive im-
recent years, the eld of insight research in schizophrenia expanded be- pairment is another factor which can explain trait-related insight de-
yond the concept of clinical insight to a new metacognitive construct cits in schizophrenia. Meta-analyses of neuropsychological studies
(cognitive insight) (Beck et al., 2004). Cognitive insight is dened as pa- found a signicant but modest relationship between cognitive decits
tients' capacity and willingness to reect on their unusual experiences, and poor insight in schizophrenia (Aleman et al., 2006; Nair et al.,
and their level of certainty about their beliefs and interpretations 2014). In the most recent meta-analysis of 72 studies, estimated corre-
about their experiences are correct. Beck cognitive insight scale (BCIS) lation coefcient for the association between poor insight and cognitive
is the most commonly used scale to assess cognitive insight (Beck et impairment was rather small (r = 0.16) but signicant (Nair et al.,
al., 2004). 2014).
The insight is a complex concept and number of factors including se- Decits in social cognition, particularly impairment in theory of
verity of symptoms, psychological denial and neurocognitive decits mind (ToM), might be also relevant for explaining poor insight in
schizophrenia. ToM is the ability to attribute mental states (beliefs, in-
Dokuz Eylul Universitesi Tip Fakultesi, Psikiyatri Anabilimdali, Mithatpaa cad. no
tentions, thoughts, desires and emotions) to others and predict and un-
1606 inciralt yerlekesi, 35340 Balova/zmir, Turkey. derstand their actions based on their mental states (Premack and
E-mail addresses:, Woodruff, 1978). ToM is a multidimensional concept and one
0920-9964/ 2017 Published by Elsevier B.V.

Please cite this article as: Bora, E., Relationship between insight and theory of mind in schizophrenia: A meta-analysis, Schizophr. Res. (2017),
2 E. Bora / Schizophrenia Research xxx (2017) xxxxxx

component of ToM include perspective taking and reasoning about protagonists in 10 brief stories (Corcoran et al., 1995). Other ToM mea-
mental states of others and other component include decoding others' sures used in included studies were false belief tasks (stories and picture
mental states based on perceptual information (Sabbagh and Taylor, sequencing), Happe stories, Faux pas recognition and Yoni Task (Happe,
2000; Sabbagh et al., 2004; Bora and Kse, 2016). Perspective taking 1994; Shamay-Tsoory et al., 2007; Stone et al., 1998). All of these tasks
for understanding and taking account of the others' beliefs towards were measuring reasoning (perspective taking) aspect of ToM. Reading
the self is important for objective self-evaluation. Therefore, the per- mind in the eyes test (RMET) (Baron-Cohen et al., 2001) was the only
spective-taking component of ToM might be particularly relevant for in- measure for decoding aspect of ToM (Sabbagh et al., 2004; Bora and
sight in schizophrenia. Schizophrenia is associated with signicant Kse, 2016) used in studies investigating insight in schizophrenia. This
impairment in ToM (Frith, 1992; Corcoran et al., 1995; Bora et al., measure was not included in the meta-analysis as ToM-decoding was
2009; Bora and Pantelis, 2013). The outcome of studies investigating investigated only in very few studies investigating clinical (Bora et al.,
the relationship between ToM and insight in schizophrenia has been in- 2007) or cognitive insight (Giusti et al., 2013; Lysaker et al., 2011a).
consistent, with some studies nding a positive association (Bora et al.,
2007; Konstantakopoulos et al., 2014; Langdon and Ward, 2009), and 2.3. Statistical analyses
others found no signicant relationship (Drake and Lewis, 2003;
Stewart et al., 2010). The effect sizes for ToM-insight correlations (Pearson r coefcients)
The mixed ndings of studies investigating the relationship between were pooled to calculate a single effect size for each study when more
ToM and insight in schizophrenia might be related to the low statistical than one ToM tests were used. Meta-analyses were performed using
power as many of the available studies have small sample sizes. Also, packages in R environment (Metafor) (Viechtbauer, 2010). Pearson r
the heterogeneity of insight measures used might potentially have an correlations were analyzed after Fisher's Z transformation was applied
effect on the relationship between insight and neuropsychological as- (Hedges and Olkin, 1985). Effect sizes were weighted using the inverse
sessments (Nair et al., 2014). In this paper, a meta-analysis of the rela- variance method and a random effects model (DerSimonianLaird esti-
tionship between ToM impairment and poor insight in schizophrenia mate) (p-value for signicance b 0.05). Homogeneity of the distribution
was conducted for providing a reliable estimate of the strength of the of weighted effect sizes was tested with the Q-test. Tau-squared (2), an
potential relationship. The primary hypothesis of the current meta- estimate of between-study variance, was used as a measure of the mag-
analysis was that insight would be associated with ToM in schizophre- nitude of heterogeneity in the random effects model. The possibility of
nia. A secondary aim of this meta-analysis was to explore which type publication bias was assessed by inspection of funnel plot of Fisher's
of insight (clinical vs cognitive) would be more strongly associated Z-transformed correlation coefcient and standard error. For analyses
with ToM. including at least 6 studies, Egger's test was also used to assess asymme-
try of funnel plots.
2. Methods Subgroup analyses for different clinical insight scales were also con-
ducted. Meta-regression analyses were conducted to investigate the ef-
2.1. Study selection fect of demographic (age and ratio of males) and clinical variables on
the strength of the association between ToM and insight. The clinical
PRISMA guidelines were used in conducting this meta-analysis variables included were the duration of illness, positive and negative
(Moher et al., 2009). A literature search was conducted using the data- symptoms and general psychopathology as measured with PANSS (Pos-
bases PubMed and Scopus to identify the relevant studies (January 1980 itive and Negative Syndrome Scale). Meta-regression analyses per-
to December 2016) using the combination of keywords as follows: formed with a random-effects model were conducted using the
(schizophrenia AND (Theory of mind) AND (insight OR unaware- restricted-information maximum likelihood method with a signicance
ness)). Reference lists of published reports were also searched for addi- level set at p b 0.05.
tional studies. Inclusion criteria for the studies were: (1) correlations
between ToM and clinical or cognitive insight were investigated in a
sample of patients with schizophrenia spectrum disorders; (2) reported 3. Results
sufcient data to calculate the effect size and standard error for the
strength of relationship between insight and ToM; (3) a valid measure The selection process is summarized in Fig. 1. One rst-episode
of clinical insight or BCIS (cognitive insight) was used. The clinical in- study which included patients with affective psychosis (Wiffen et al.,
sight scales used in studies investigating the relationship between 2013) and another study which reported non-parametric correlation
ToM and insight included Positive and Negative Syndrome Scale coefcients (Pousa et al., 2008) were excluded. A total of 16 studies
(PANSS G12) (Kay et al., 1987), the schedule for the assessment of in- consisting of 1085 patients with schizophrenia spectrum disorders
sight-extended (SAI-E) (Kemp and David, 1996), the Scale to Assess Un- (72.2% males, mean age = 35.7) were included in the meta-analysis
awareness of Mental Disorder (SUMD) (Amador et al., 1993) the (Table 1). Nine of the studies included only schizophrenia patients
Birchwood insight scale (BIS, Birchwood et al., 1994). BIS and BCIS scales and others also included some patients with other schizophrenia-spec-
were self-report measures, other scales were expert-rated instruments. trum disorders. The vast majority of patients included have a diagnosis
Correlation coefcients for cognitive insight and clinical insight were of schizophrenia (n = 876, 80.7%). 159 patients (14.7%) had a diagnosis
coded separately. In addition to the coding of effect size for clinical in- of schizoaffective disorder and 50 patients had other SSD diagnoses (de-
sight, correlation coefcients for each of the four different clinical in- lusional disorder, schizophreniform disorder and psychotic disorder
sight scales (three expert-rated and one self-rated) were coded NOS).
separately. Other than total insight score, correlation coefcients for
three dimensions of insight including awareness of illness, awareness 3.1. Clinical insight
for the need for treatment, relabeling of symptoms were also coded.
ToM was signicantly correlated with level of insight (r = 0.28, CI =
2.2. ToM tasks 0.200.36) (Fig. 2; Table 2). For studies that used samples only
consisting of patients with schizophrenia, the mean weighted correla-
Several different ToM tasks have been utilized across studies, and tion co-efcient between insight and ToM was r = 0.34 (CI = 0.21
the Hinting task was the most commonly used measure (Corcoran et 0.46, Z = 4.96, p b 0.001, Q = 13.3, p = 0.06). All of three subdomains
al., 1995). The Hinting task is a theory of mind (ToM) assessment that of insight were signicantly correlated with ToM. Mean weighted corre-
requires clients to make social judgments about the intentions of lations were r = 0.32 (CI = 0.140.48) for relabeling of symptoms, r =

Please cite this article as: Bora, E., Relationship between insight and theory of mind in schizophrenia: A meta-analysis, Schizophr. Res. (2017),
E. Bora / Schizophrenia Research xxx (2017) xxxxxx 3

Fig. 1. Flow diagram for meta-analysis of studies investigating relationship between ToM and insight.

0.27 (CI = 0.180.36) for awareness of illness and r = 0.22 (CI = 0.10 3.2. Cognitive insight
0.34) for recognition for need of treatment (Table 2).
Total scores of each of the four insight scales were signicantly cor- ToM was not signicantly correlated with cognitive insight (r =
related with ToM (r = 0.220.35). The distribution of effect sizes was 0.12, CI = 0.060.30) and its subscales (r = 0.060.10). The distribu-
homogeneous for all total and subdomain insight measures except tion of effect sizes was homogeneous for cognitive insight measures
relabeling of symptoms (Q = 17.2, p = 0.004, I2 = 71%, 2 = 0.04) (Table 2). There was no evidence of funnel plot asymmetry for cognitive
(Table 2). There was no evidence of publication bias for any measure insight.
in funnel plots (inspection and Egger's test for asymmetry).
Meta-regression analyses found no signicant effect of age
(Z = 0.31, p = 0.76), gender (Z = 1.18, p = 0.24), duration of ill- 4. Discussion
ness (Z = 0.89, p = 0.37) and duration of education (Z = 0.32,
p = 0.75) on strength of correlation between ToM and clinical insight. The current meta-analysis sought to provide a systematic overview
The level of correlation between ToM and clinical insight were not sig- of research into the relationship between insight and ToM. Overall,
nicantly affected by PANSS negative symptoms (Z = 0.99, p = there was a modest but signicant relationship between ToM and clin-
0.32), general psychopathology (Z = 1.54, p = 0.13) and PANSS pos- ical insight. However, ToM was not signicantly correlated with cogni-
itive symptoms (Z = 1.61, p = 0.11). tive insight.

Please cite this article as: Bora, E., Relationship between insight and theory of mind in schizophrenia: A meta-analysis, Schizophr. Res. (2017),
4 E. Bora / Schizophrenia Research xxx (2017) xxxxxx

Table 1
Characteristics of the studies included in the meta-analysis.

Studies N Age Male Insight Insight domains ToM Outcome

Bora et al. (2007) 58 Sch 32.6 71% SUMD Aware illness False belief Insight is related to ToM
Aware need treat
Aware consequences
Symptom attribute
Drake and Lewis 33 SSD 29.4 76% SUMD, SAI-E, BIS, ITAQ, Aware illness Visual joke Not correlated
(2003) Davidhizar insight scale Aware need treat
Factor analysis Symptom attribute
Erdil (2008) 89 Sch 36 63% SUMD Aware illness A ToM battery including Modest but signicant
Aware need treat false belief stories and relationship between poor
Aware consequences pictures and faux pas, irony insight and ToM decit
Symptom attribute
Giusti et al. (2013) 20 Sch 36.2 70% BCIS Cognitive insight Happe stories Not correlated
Konstantakopoulos 58 Sch 42.3 59% SAI-E Aware illness False belief, hinting Signicantly correlated
et al. (2014) Aware need treat Faux pas
Symptom attribute
Langdon et al. 34 Sch 36.3 64% SAI-E Aware illness Picture sequencing Not correlated
(2006) Aware need treat
Symptom attribute
Langdon and Ward 30 SSD 38.5 63% SAI-E Aware illness Picture sequencing Signicant relationship
(2009) Aware need treat Jokes
Symptom attribute Happe stories
Lysaker et al. 36 SSD 50.4 91% BCIS Cognitive insight Hinting No relationship
Lysaker et al. 65 SSD 46.3 86% SUMD Aware illness Hinting ToM is signicantly related
(2011b) Aware need treat to level of insight
Aware consequences
Ng et al. (2015) 193 SSD 46.2 64% BIS Aware illness Hinting BIS: awareness of illness
BCIS Aware need treat related to ToM
Symptom attribute BCIS not related
Cognitive insight
Pijnenborg et al. 46 Sch 27.4 74% PANSS Clinical insight Faux pas Signicant relationship
Popolo et al. 37 Sch 27.2 89% PANSS Clinical insight Hinting Hinting is related to both
(2016) BCIS Cognitive insight Picture sequencing clinical and cognitive
Picture sequencing is
related to cognitive insight
Quee et al. (2011) 270 SSD 27.7 82% PANSS Clinical insight Hinting Signicant relationship
Sakarya (2012) 30 Sch 31.9 60% BIS Clinical insight False belief, faux pas No signicant relationship
Stewart et al. 30 SSD 39.4 77% SAI-E Clinical insight False belief No signicant relationship
Zhang et al. (2016) 56 Sch 27.5 54% PANSS Clinical insight Yoni Related to clinical but not
BCIS Cognitive insight cognitive insight

BCIS: Beck cognitive insight scale; BIS: Birchwood insight scale; SAI-E: schedule for the assessment of insight-expanded.
SUMD: the Scale to Assess Unawareness of Mental Disorder, PANSS = Positive and Negative Syndrome Scale (PANSS G12), Sch = schizophrenia, SSD = schizophrenia spectrum disorders,
insight and treatment attitudes questionnaire.

The modest effect of ToM impairment on poor insight was highly slightly stronger correlation with ToM compared to other cognitive
signicant and can have implications in understanding complex con- functions including executive functions (Nair et al., 2014).
cept of insight in schizophrenia. These ndings suggest that the ability Decreased self-reectiveness and increased self-certainty (reduced
to take the perspective of others for understanding their mental states cognitive insight) can also contribute to impaired clinical insight in
is also important for self-awareness. Decits of schizophrenia patients schizophrenia (Beck and Warman, 2004; Cooke et al., 2010). However,
in understanding and taking account of others beliefs and opinion ToM performance was not signicantly correlated with cognitive in-
about behavioral change in themselves contributes to poor insight. sight in schizophrenia. One's over-condence in judgments that
However, ToM impairment seems to one of the factors contributing to make and recognition of one's own fallibility are not necessarily direct
poor insight in schizophrenia. Many patients can understand that others reections of ability to take the perspective of others and understand
think that patients have a mental illness but they might disagree with their mental state. ToM and cognitive insight are factors that both
their perspective. Denial and other psychological defenses can contrib- seem to be independently associated with clinical insight in
ute to poor awareness in schizophrenia (Cooke et al., 2005; Cooke et schizophrenia.
al., 2007; Moore et al., 1999). Clinical symptoms and general cognitive Another consideration is the potential effect of moderator variables
decits are also likely contributing to poor insight in schizophrenia. such as neurocognition, depression and internalized stigma on the rela-
The effect size of the correlation between clinical insight and ToM was tionship between ToM and insight. Decits in ToM and neurocognition
in the same range with effect sizes of correlation of ToM and positive in schizophrenia have a complex relationship in schizophrenia (Bora
and negative symptoms in schizophrenia (Mintz et al., 2003). When et al., 2016). While ToM impairment in schizophrenia is partly second-
compared to ndings of meta-analyses investigating the relationship ary to executive dysfunction and general intellectual impairment, it is a
between insight and neurocognition, the clinical insight might have a mostly separable aspect of cognitive impairment in schizophrenia (Hoe

Please cite this article as: Bora, E., Relationship between insight and theory of mind in schizophrenia: A meta-analysis, Schizophr. Res. (2017),
E. Bora / Schizophrenia Research xxx (2017) xxxxxx 5

Fig. 2. Forest plot of effect sizes and 95% condence intervals for clinical insight and ToM using random effects model.

et al., 2012; Sergi et al., 2007; van Hooren et al., 2008). Therefore, it is be a curvilinear relationship between insight and neurocognitive func-
important to address the question of whether ToM makes a contribu- tions in schizophrenia (Startup, 1996; Cooke et al., 2007).
tion to insight independent of neurocognition in schizophrenia. A num- It is also important to consider the effect of diagnosis within schizo-
ber of studies have found that ToM impairment makes a signicant phrenia-spectrum disorders on the strength of the relationship between
contribution to poor clinical insight beyond non-social cognitive decits ToM and level of insight. Current ndings might be potentially more ap-
and symptoms (Bora et al., 2007; Konstantakopoulos et al., 2014; plicable to schizophrenia as 80% of patients in the current meta-analysis
Langdon and Ward, 2009; Lysaker et al., 2011b; Ng et al., 2015). However, had a diagnosis of schizophrenia. Current results also indicated that
further studies are needed to investigate distinct contributions of ToM in there was a slightly stronger relationship between ToM and level of in-
comparison to neurocognition and clinical symptoms to different aspects sight in schizophrenia only subgroup of studies than all schizophrenia-
of the complex construct of insight. The heterogeneity of insight measures spectrum disorders sample. Therefore, it is necessary to conduct further
also had no signicant effect on the relationship between ToM and clinical studies investigating the role of ToM in insight decits in other schizo-
insight. In all subgroup analyses for different insight scales (including self- phrenia spectrum disorders such as schizoaffective disorder.
report), ToM impairment and poor insight were correlated. On the other The current meta-analysis has a number of limitations. The sample
hand, previous meta-analyses suggest that there is also a small positive size was small, especially for cognitive insight. The heterogeneous
relationship between depressive symptoms and having better insight in nature of tools used to investigate clinical insight was another limita-
schizophrenia (Belvederi Murri et al., 2015; Palmer et al., 2015). Depres- tion. However, ToM was signicantly associated with insight in schizo-
sive symptoms and internalized stigma in schizophrenia might be phrenia in all of the four subgroup analyses for different insight
among the moderators of the relationship between insight and social cog- measures. Also, it was possible to conduct a meta-analysis for three
nitive abilities (Lysaker et al., 2013). In the current meta-analysis, general different aspects of insight. It was not possible to investigate the effect
psychopathology and positive and negative symptoms had no signicant of decoding aspect of ToM on insight in schizophrenia. However, none
effect on the relationship between ToM and insight. These ndings sug- of the available studies that investigated the correlation of clinical
gest that the relationship between ToM and insight is not mediated by (Bora et al., 2007) or cognitive insight (Giusti et al., 2013; Lysaker et
symptomatology. Another point to be considered by the future studies al., 2011a) with ToM found a signicant relationship. The lack of
is the possibility of a non-linear relationship between insight, ToM and relevant information about factors that can affect the relationship
other variables. For example, some studies suggested that there might between ToM and insight including, co-morbidity, antipsychotic use

Table 2
Mean weighted effect sizes for the relationship between ToM and insight in schizophrenia spectrum disorders.

Test Sample Sch r 95% CI Z p Q-test Q-test (p) 2 I2 Bias

Clinical insight
Total score 14 1029 0.28 0.200.36 6.7 b0.001 19.9 0.10 0.01 35 0.43
SUMD 3 212 0.31 0.100.49 2.9 0.04 4.9 0.09 0.02 59
SAI-E 4 152 0.35 0.140.53 3.2 0.002 5.3 0.15 0.02 43
PANSS 4 409 0.26 0.090.42 2.9 0.004 6.7 0.08 0.02 55
BIS 3 521 0.22 0.140.30 5.1 b0.001 0.3 0.87 0 0
Illness 7 171 0.27 0.180.36 5.5 b0.001 7.4 0.29 0 19 0.76
Treatment 8 201 0.22 0.100.34 3.5 b0.001 13.5 0.06 0.02 48 0.33
Symptoms 6 106 0.32 0.140.48 3.4 b0.001 17.2 0.004 0.04 71 0.34

Cognitive insight (BCIS)

Total score 3 113 0.12 0.060.30 1.3 0.21 0.9 0.63 0 0
Self-reectivity 4 288 0.10 0.020.21 1.6 0.10 0.4 0.95 0 0
Self-certainty 4 288 0.06 0.070.19 1.0 0.34 3.3 0.35 0 8

r = effect size of correlation, Bias = p value of the Egger's test, BCIS: Beck cognitive insight scale; BIS: Birchwood insight scale; SAI-E: schedule for the assessment of insight-expanded.
SUMD: the Scale to Assess Unawareness of Mental Disorder, PANSS = Positive and Negative Syndrome Scale (PANSS G12).

Please cite this article as: Bora, E., Relationship between insight and theory of mind in schizophrenia: A meta-analysis, Schizophr. Res. (2017),
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Contributors Giusti, L., Mazza, M., Pollice, R., Casacchia, M., Roncone, R., 2013. Relationship between
EB conducted the analyses and wrote the manuscript. self-reectivity, theory of mind, neurocognition, and global functioning: an investiga-
tion of schizophrenic disorder. Clin. Psychol. 17, 6776.
Happe, F.G.E., 1994. An advanced test of theory of mind: understanding of story charac-
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dren and adults. J. Autism Dev. Disord. 24, 129154.
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Hoe, M., Nakagami, E., Green, M.F., Brekke, J.S., 2012. The causal relationships between
Conict of interest neurocognition, social cognition and functional outcome over time in schizophrenia:
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Kay, S., Fishbein, A., Opler, L., 1987. The positive and negative syndrome scale (PANSS) for
Acknowledgements schizophrenia. Schizophr. Bull. 13, 261275.
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