Domains of awareness in schizophrenia

Insight and suicidality in first-episode psychosis: understanding the influence of suicidal history on insight dimensions at first presentation

AIM

Lack of insight is a cardinal feature of psychosis with crucial implications for outcome. Concerns have been raised regarding a link between insight and suicidality. This study aimed to test the relationship between suicidal behaviour preceding first-episode psychosis (FEP) and insight dimensions at treatment onset.

METHODS

A total of 112 FEP inpatients were recruited. Suicidal events prior to admission were recorded. Insight was assessed multidimensionally with the Schedule for the Assessment of Insight - Expanded version shortly after admission. Suicidal and non-suicidal patients were compared regarding scores on 'total insight' and three insight domains: 'awareness of mental illness', 'relabeling of psychotic experiences as abnormal' and 'compliance'. This analysis was also adjusted for a set of sociodemographic, clinical, neurocognitive and psychopathological variables.

RESULTS

Bivariate analyses demonstrated a direct association between previous suicidality and all insight domains. However, these associations did not survive multivariable regression models, which demonstrated gender (female), shorter duration of untreated psychosis (DUP) and psychopathological symptoms - depression and disorganization - to mediate the influence of suicidal history on insight, and therefore to underlie the latter.

CONCLUSIONS

Insight dimensions in FEP patients are influenced by having suicidal antecedents through some mediating variables such as gender, DUP and depression. Further prospective studies are needed to clarify the potential implications of these findings on the management of insight in FEP. As suicidal history is associated with greater levels of both depression and insight at first presentation, these three variables might be useful in predicting further suicidal events.

Relationship between cognition, clinical and cognitive insight in psychotic disorders: a review and meta-analysis

The neurocognitive theory of insight posits that poor insight in psychotic illnesses is related to cognitive deficits in cognitive self-appraisal mechanisms. In this paper we perform a comprehensive meta-analysis examining relationships between clinical insight and neurocognition in psychotic disorders. We have also completed a meta-analysis of studies examining 'cognitive insight', as measured by the Beck Cognitive Insight Scale (BCIS), and its relationship with neurocognitive function in patients with psychosis. The clinical insight analysis included data from 72 studies and a total population of 5429 patients. We found that insight in psychosis was significantly associated with total cognition (r=0.16, p<0.001), IQ (r=0.16, p<0.001), memory (r=0.13, p<0.001) and executive function (r=0.14, p<0.001). All of these correlations were stronger when examined in patients with schizophrenia only. In the BCIS analysis we included 7 studies and 466 patients in total. We found that no significant associations were found between the self-reflectiveness sub-component and neurocognition. By contrast there were significant correlations between the self-certainty subcomponent and memory (r=-0.23, p<0.001), IQ (r=-0.19, p<0.001) and total cognition (r=-0.14, p=0.01). We did not find evidence of significant publication bias in any analyses. Overall, our results indicate that there is a small but significant relationship between clinical insight, some aspects of cognitive insight and neurocognition. These findings reflect the complexity of the insight construct and indicate that while the neurocognitive model is important it is likely to be one of many which contribute to the understanding of this phenomenon.

Neuropsychological, clinical and cognitive insight predictors of outcome in a first episode psychosis study

The outcome of first episode psychosis (FEP) is highly variable and difficult to predict. We studied prospectively the impact of poor insight and neuropsychological deficits on outcomes in a longitudinal cohort of 127 FEP patients. Participants were assessed on 5 domains of cognitive function and 2 domains of insight (clinical and cognitive). At 12 months, patients were assessed again for symptom severity and psychosocial function. Regression analyses revealed that cognitive insight (a measure of self-reflectiveness and self-certainty) was the best baseline predictor of overall psychopathology at 12 months whereas executive function performance at admission to the study indicated later severity of negative symptoms. Other neuropsychological and insight measures were poor predictors of psychosocial function at 1 year. The results suggest that specific neuropsychological and insight factors have separate predictive capacities indicating that they are distinct psychological processes in psychosis. Cognitive insight proved to be a useful prognostic indicator, and should be considered for future studies and as a potential focus for treatment.

Spotlight on sibling involvement in schizophrenia treatment

OBJECTIVE

The purpose of this paper is to explore a literature gap--sibling involvement in the care and support of people with schizophrenia, and to make recommendations for filling the gap.

METHOD

The method used was observation and documentation of clinical notes over a ten-year period in an outpatient clinic for women with schizophrenia. Illustrative examples were selected from approximately 200 entries dealing with sibling relationships.

FINDINGS

Siblings constitute an important segment of the social network of persons with schizophrenia, although they do not usually take an active part in their brother or sister's care until parents are no longer able to cope alone. The role of primary caregiver appears to be a stressful one for siblings. The closest sibling bonds were those between sisters, and in most cases, the eldest girl in the family assumed the caregiver role. This depended, however, on the family's means, values, and cultural traditions, as well as on the personal attributes and life circumstances of the siblings. Financial, human, and social capital were critical determinants of sibling involvement. Sharing responsibilities and negotiating the distribution of required caretaking tasks was often the most effective way of dealing with the burden of care giving.

CONCLUSION

Although some clinical recommendations can be made, specificities that distinguish this population and the effectiveness of sibling caregiving need to be further researched.

The denial of aggression in violent patients with schizophrenia

BACKGROUND

There is no literature investigating denial of aggression in schizophrenia. Our goal was to study this phenomenon and to determine what deficits are associated with it.

METHODS

102 inpatients with schizophrenia were divided into three groups: (1) patients with a documented history of violent crime who denied it on extensive interviews ("deniers"); (2) those with such a history who admitted to it; and (3) those without violent crime. Patients were administered a psychometrically validated self-report scale of aggression, the Buss-Perry Aggression Questionnaire (BPAQ), the Positive and Negative Syndrome Scale and a comprehensive neurocognitive battery. They were followed for twelve weeks during which all violent incidents were recorded.

RESULTS

The deniers were significantly more impaired in executive function, but not in any other cognitive domain. They did not evidence more severe psychotic symptoms or greater lack of insight in their psychosis, but this lack of insight was strongly related to hostility and suspiciousness. Their denial of aggression was also evidenced in a significantly lower self-reported BPAQ aggression score. In the patients who admitted to violent crimes, baseline BPAQ aggression score predicted subsequent aggression; in the deniers, it was negatively related to subsequent aggression.

CONCLUSION

Denial of aggression is associated with executive dysfunction which facilitates a misappraisal of the surrounding world as threatening and hostile. For those who admit to crimes, self-reported aggression predicts future aggression. In contrast, in the deniers, the extent of denial is related to future aggression. The denial itself is a marker of greater aggressive tendencies.

Happiness in first-episode schizophrenia

Happiness is a core dimension of a person's life, related to both functioning and success. As patients with schizophrenia experience marked functional deficits, it would be informative to investigate their level of happiness. There are limited data currently available, perhaps due to the longstanding belief that anhedonia is an inherent feature of this illness. The present study set out to specifically assess happiness in schizophrenia in relation to both clinical and functional measures of outcome.

METHOD

Thirty-one first-episode remitted patients and 29 age- and sex-matched controls participated in the study. Patients' clinical status was assessed and a series of self-report questionnaires were used to measure levels of happiness, life satisfaction, success and functioning in both patients and controls.

RESULTS

Patients experienced marked functional impairment versus healthy controls (p<0.001), while reporting comparable levels of happiness (p=0.113) and satisfaction with life (p=0.350). In the patient group, we found that higher happiness ratings were significantly associated with less depression, less negative symptoms, less social withdrawal, greater life satisfaction, and higher social and occupational functioning. Both cognitive functioning and insight had no significant direct effects on ratings of happiness in the patient group.

CONCLUSIONS

Despite marked functional impairment, individuals with first-episode schizophrenia are as happy as controls. Mechanisms that might allow for this are discussed, as are the implications for rehabilitation efforts that assume an individual holds to the same drives and goals as before the illness onset and/or is unhappy with their present functional status.

Failures of metacognition and lack of insight in neuropsychiatric disorders

Lack of insight or unawareness of illness are the hallmarks of many psychiatric disorders, especially schizophrenia (SCZ) and other psychoses and could be conceived of as a failure in metacognition. Research in this area in the mental health field h as burgeoned with the development and widespread use of standard assessment instruments and the mapping out of the clinical and neuropsychological correlates of insight and its loss. There has been a growing appreciation of the multi-faceted nature of the concept and of the different 'objects' of insight, such as the general awareness that one is ill, to more specific metacognitive awareness of individual symptoms, impairments and performance. This in turn has led to the notion that insight may show modularity and may fractionate across different domains and disorders, supported by work that directly compares metacognition of memory deficits and illness awareness in patients with SCZ, Alzheimer's disease and brain injury. The focus of this paper will be on the varieties of metacognitive failure in psychiatry, particularly the psychoses. We explore cognitive models based on self-reflectiveness and their possible social and neurological bases, including data from structural and functional MRI. The medial frontal cortex appears to play an important role in self-appraisal in health and disease.

Association of poor insight in schizophrenia with structure and function of cortical midline structures and frontopolar cortex

BACKGROUND

Poor insight is a central characteristic of psychosis and schizophrenia. Accumulating evidence indicates that cortical midline structures (CMS) and frontopolar cortex (FPC), both of which are associated with insight-related processing in healthy subjects, are among the most affected brain structures in schizophrenia. However, the hypothesis that direct associations between function of these brain regions and poor insight in schizophrenia exist has not been tested previously.

METHODS

We studied 21 patients with schizophrenia and 17 healthy control subjects with structural and functional magnetic resonance imaging during a clinical insight task and a comparable control task. We assessed the level of insight, depression, positive and negative symptoms, and neurocognitive function, then adjusted correlation between insight and insight-task-related brain activation for potential confounders. Voxel-based morphometry was used to compare brain volumes between groups.

RESULTS

Insight correlated strongly with the activation of the CMS and the FPC during the clinical insight tasks, independently of potential confounders. The CMS activation was stronger during the insight task than during the control task in patients. The functional correlates of insight matched the distribution of cortical volume reduction in the patient group.

CONCLUSIONS

These findings suggest a link between known regional brain abnormalities and the manifestation of poor insight in schizophrenia. The contribution of CMS to insight may be related to self-referential processing and that of FPC to the integration of multiple cognitive processes that are necessary for accurate evaluation of one's mental illness.

Cognitive decision modelling of emotion-based learning impairment in schizophrenia: the role of awareness

Individuals with schizophrenia often lack insight or awareness. Resulting impairment has been observed in various cognitive domains and, recently, linked to problems in emotion-based learning. The Iowa Gambling Task (IGT) has been used to assess emotion-based decision-making in patients with schizophrenia, but results have been inconclusive. The current study further investigates emotion-based decision-making in schizophrenia by elucidating the unique contribution of awareness. Twenty-five patients with schizophrenia and 24 healthy controls were assessed with a modified version of the IGT recording awareness at regular intervals. Symptom assessment, medication and medical history were recorded for the clinical group. Patients with schizophrenia underperformed on the IGT compared to controls. Subjective awareness levels were significantly lower in the schizophrenia group and were associated with hallucination severity. Cognitive decision modelling further indicated that patients with schizophrenia had impaired attention to losses, compared to controls. This parameter was positively correlated with awareness. We also found that positive symptoms altered awareness levels and suggest that this disruption may contribute to sub-optimal decision-making. Overall, a lack of awareness may be an important aspect in understanding impaired social cognitive functioning and emotion-based learning observed in schizophrenia.

Awareness of cognitive impairment in schizophrenia and its relationship to insight into illness

BACKGROUND

Patients with schizophrenia have been found to show unawareness of cognitive impairment. However, its frequency and its relationship to lack of insight into illness are uncertain.

METHOD

Forty-two patients with chronic schizophrenia were given tests of executive function and memory. Awareness of cognitive impairment was measured by means of discrepancy scores--differences between patient and psychologist ratings of memory and frontal/executive failures in daily life. Insight into illness was assessed using the Scale to Assess Unawareness of Mental Disorder (SUMD).

RESULTS

A majority of the patients were found to underestimate their cognitive impairment; however, some overestimated it. Unawareness of cognitive impairment and lack of clinical insight loaded on different factors in a factor analysis, but these two factors were themselves correlated.

CONCLUSIONS

The findings suggest that both unawareness and overestimation of cognitive impairment characterise patients with schizophrenia, although the former is more common. Awareness of cognitive impairment occurs independently of insight into illness at the clinical level, although the two phenomena may be linked at a deeper level.

Appreciating symptoms and deficits in schizophrenia: right posterior insula and poor insight

Poor insight is one of the most prominent clinical features of psychosis. Loss of insight in schizophrenia is characterised by abnormalities in awareness and attribution of the origin of pathological mental phenomena. Converging lines of investigations suggest that in healthy individuals, right posterior insula plays an important role in awareness and self-attribution of mental phenomena, contributing to the emergence of a sense of self (Craig, 2002; Farrer et al., 2003). In addition, neuroimaging studies investigating brain morphometry in schizophrenia have consistently reported deficits in the structure of insula (Glahn et al., 2008; Ellison-Wright and Bullmore, 2010). In the present study, we investigated the relationship between the morphometry of posterior insula and degree of insight in a sample of 57 patients in a stable phase of illness using high resolution Magnetic Resonance Imaging. We measured the cortical surface area and local white matter volume of posterior insula. A significant inverse relationship was found between right posterior insular structure and degree of insight in schizophrenia. No such relationship was noted for left posterior insula. Our results highlight the importance of a predominantly right-sided network that includes posterior insula as the neural basis of insight. Abnormalities in interoceptive awareness and self-appraisal of emotional states may contribute to the loss of insight seen in schizophrenia.