A multi-dimensional approach to insight and its evolution in first-episode psychosis: a 1-year outcome naturalistic study

A Longitudinal Study of Illness Awareness in Older Adults With Schizophrenia

OBJECTIVE

Impaired insight is common in schizophrenia and may be affected by changes that occur with aging. There have been a few nonprospective investigations of insight in older adults with schizophrenia (OAS). This study examines the temporal fluctuations that occur with insight-defined as "awareness of mental illness" (dichotomized into presence or absence)-along with associated factors that influence illness awareness (IA) in OAS.

METHODS

The sample consisted of 103 persons derived from an initial sample of 250 community-dwelling persons aged 55 and over with early-onset schizophrenia spectrum disorder. Mean follow-up was 53 months. We examined 27 potential predictor variables of IA along with 5 covariates in bivariate analysis. The significant variables were then examined using multiple regression analyses.

RESULTS

23% of persons transitioned between presence and absence of IA, 62% had persistent IA, and 15% never had IA. At baseline, fewer negative symptoms (blunted affect), higher cognitive functioning (conceptualization), younger age, higher educational levels, and more physical disorders were associated significantly with higher rates of IA at follow-up. Baseline IA did not predict any variables at follow-up.

CONCLUSION

IA is often unstable in later life, with nearly one-fourth of persons showing fluctuations. Although younger age predicted IA over time, other factors associated with aging, such as cognitive functioning and physical disorders, had additional independent effects on IA. The impact of IA on clinical and functional variables attenuated over time, suggesting that for many OAS, IA may have a limited role in enhancing long-term outcomes.

A multi-dimensional approach to the relationship between insight and aggressiveness in schizophrenia: Findings from the FACE-SZ cohort

BACKGROUND

Aggressiveness is a stigma frequently associated with schizophrenia. The role of insight as a risk factor of aggressiveness remains contradictory; mainly because single measures of these states mask their complexity and heterogeneity.

METHODS

This study was conducted on 666 patients aged 15 and above with a DSM-IV-TR diagnosis of schizophrenia spectrum disorder, drawn from the French national network of schizophrenia expert center database. Collected data comprised socio-demographics and standardized psychiatric assessments. Aggressiveness was evaluated using the Buss-Perry Aggression Questionnaire and insight using the Scale to assess Unawareness of Mental Disorder (SUMD) and Birchwood Insight Scale (BIS).

RESULTS

Hostility was the aggressiveness dimension the most strongly associated with SUMD insight dimensions. Patients aware of their illness were nearly twice as likely to show hostility than those seriously unaware (OR = 1.95, 95% CI.: 1.08-3.5), but not when further adjusting for depression. Similarly, those aware of the consequences of their illness and of their symptoms were more hostile. Patients moderately aware of illness consequences had a higher risk of both anger and physical aggressiveness than those unaware (OR = 2.63, 95% CI.: 1.42-4.86, OR = 2.47, 95% CI.: 1.33-4.60, respectively), even when adjusting for depression for anger.

CONCLUSION

Our study confirms that a multi-dimensional approach to insight and aggressiveness is essential to understand the types of links between these clinical states. Insight may trigger the expression of an underlying hostile tendency, maybe via depression and self-stigmatisation. This should be taken into account in therapeutic approaches to improve insight.

Psychosis: clinical insight and beliefs in immigrants in their first episode

AIM

Lack of insight into illness is frequent in psychotic disorders and seen as part of their primary pathology. The recognition of symptoms as psychotic, and beliefs about treatment alternatives, is also influenced by socio-cultural factors. Here we examined clinical insight into illness and beliefs about psychosis in immigrants in their first episode of psychosis compared with a reference group.

METHODS

A total of 277 first-episode psychosis participants were recruited to this cross-sectional study; 40 first- and 40 second-generation immigrants from Europe, Americas and Oceania (n = 37), Asia including Turkey (n = 28) or Africa (n = 15). The Birchwood Insight Scale was used to measure clinical insight and 'The Attitudes and Beliefs about Mental Health Problems' schizophrenia version to assess socio-cultural beliefs.

RESULTS

Immigrants did not differ from the reference sample in clinical insight. After controlling for education level, first-generation immigrants were less likely to recognize psychotic symptoms (odds ratio (OR) 2.9; Wald = 8.977, degrees of freedom (d.f.) 1, P = 0.003) and viewed hospitalization (OR 5.2; Wald = 20.388, d.f. 1, P = 0.001) and treatment by a psychiatrist (OR 4.9; Wald = 6.609, d.f. 1, P = 0.01)) as less beneficial than the reference group. Immigrants from Asia held more alternative explanations (OR 0.3; Wald = 6.567, d.f. 1, P = 0.010). There were significantly stronger associations between clinical insight and socio-cultural beliefs in the reference group.

CONCLUSIONS

Socio-cultural beliefs about psychosis in immigrants in first-episode psychosis call for more tailored information to this group, and emphasize the importance of treatment interventions involving both a cultural and personal perspective of insight.

Is there a link between biological parents' insight into their offspring's schizophrenia and their cognitive functioning, expressed emotion and knowledge about disorder?

BACKGROUND

Recent studies suggest that parents' awareness of their offspring's schizophrenia could influence their offspring's insight. Low patient insight is linked to impairment of specific cognitive abilities, and biological parents of schizophrenia patients have impaired capacities in these same domains. However, little is known about what specific socio-demographic, affective or cognitive factors may influence biological parents' awareness of their offspring's disease.

METHOD

Data were drawn from 41 patient-parent dyads. Insight was assessed with a modified version of Amador's Scale to assess Unawareness of Mental Disorders, exploring dimensions of parents' awareness and attribution of their offspring's illness and symptoms.

RESULTS

Higher educational levels, better working memory and executive functioning of parents were associated with better attribution of their offspring's symptoms to schizophrenia.

CONCLUSIONS

Parents' insight into their offspring's schizophrenia is associated with cognitive abilities. This must be taken into account when developing family interventions.

Insight as a social identity process in the evolution of psychosocial functioning in the early phase of psychosis

BACKGROUND

Awareness of illness (insight) has been found to have contradictory effects for different functional outcomes after the early course of psychosis. Whereas it is related to psychotic symptom reduction and medication adherence, it is also associated with increased depressive symptoms. In this line, the specific effects of insight on the evolution of functioning over time have not been identified, and social indicators, such as socio-occupational functioning have barely been considered. Drawing from social identity theory we investigated the impact of insight on the development of psychosocial outcomes and the interactions of these variables over time.

METHOD

The participants, 240 patients in early phase of psychosis from the Treatment and Early Intervention in Psychosis Program (TIPP) of the University Hospital of Lausanne, Switzerland, were assessed at eight time points over 3 years. Cross-lagged panel analyses and multilevel analyses were conducted on socio-occupational and general functioning [Social and Occupational Functioning Assessment Scale (SOFAS) and Global Assessment of Functioning (GAF)] with insight, time and depressive symptoms as independent variables.

RESULTS

Results from multilevel analyses point to an overall positive impact of insight on psychosocial functioning, which increases over time. Yet the cross-lagged panel analysis did not reveal a systematic positive and causal effect of insight on SOFAS and GAF scores. Depressive symptoms seem only to be relevant in the beginning of the treatment process.

CONCLUSIONS

Our results point to a complex process in which the positive impact of insight on psychosocial functioning increases over time, even when considering depressive symptoms. Future studies and treatment approaches should consider the procedural aspect of insight.

Insight in bipolar mania: evaluation of its heterogeneity and correlation with clinical symptoms

BACKGROUND

Studies on insight in bipolar mania are not numerous and usually consider insight as a unitary construct.

OBJECTIVE

Evaluate how different facets of insight are affected in bipolar mania and investigate correlations between insight for each specific object in bipolar disorder and manic symptomatology.

METHOD

A group of 165 bipolar patients were followed during a year, with 51 patients having manic episodes according to DSM-IV-TR criteria. Patients underwent a clinical assessment and insight was evaluated through the Insight Scale for Affective Disorders.

RESULTS

The study found that insight regarding symptoms is worse than insight of having bipolar disorder, social relationships and self esteem. Moreover, poor global insight (total ISAD) correlates with more severe changes in mood, speech and thought structure, with worse insight about symptoms correlating with the same alterations and also with more severe symptoms of agitation/energy.

LIMITATIONS

Although a large sample of bipolar patients was followed up, the final sample composed of patients with at least one manic episode was relatively smaller. Moreover, the fact that the study was performed in a university hospital may have led to selection biases.

CONCLUSION

Results suggest that patients with BD are reasonably capable of identifying that their condition implies consequences but have more impaired awareness of their energy and activity levels. A lower level of insight specifically about symptoms correlates with more severe symptoms of agitation/energy, which suggests a psychomotor nucleus able to impair insight in mania.

Is good insight associated with depression among patients with schizophrenia? Systematic review and meta-analysis

Among patients with schizophrenia, better insight may be associated with depression, but the findings on this issue are mixed. We examined the association between insight and depression in schizophrenia by conducting a systematic review and meta-analysis. The meta-analysis was based on 59 correlational studies and showed that global clinical insight was associated weakly, but significantly with depression (effect size r=0.14), as were the insight into the mental disorder (r=0.14), insight into symptoms (r=0.14), and symptoms' attributions (r=0.17). Conversely, neither insight into the social consequences of the disorder nor into the need for treatment was associated with symptoms of depression. Better cognitive insight was significantly associated with higher levels of depression. The exploratory meta-regression showed that methodological factors (e.g. the instrument used to assess depression and the phase of the illness) can significantly influence the magnitude of the association between insight and depression. Moreover, results from longitudinal studies suggest that the relation between insight and depression might be stronger than what is observed at the cross-sectional level. Finally, internalized stigma, illness perception, recovery attitudes, ruminative style, and premorbid adjustment seem to be relevant moderators and/or mediators of the association between insight and depression. In conclusion, literature indicates that among patients with schizophrenia, better insight is associated with higher levels of depressive symptoms. Thus, interventions aimed at promoting patients' insight should take into account the clinical implications of these findings.

The effects of aging on insight into illness in schizophrenia: a review

OBJECTIVES

Impaired insight into illness is a prevalent feature of schizophrenia, which negatively influences treatment adherence and clinical outcomes. Little is known about the effects of aging on insight impairment. We aimed to review the available research literature on the effects of aging on insight into illness in schizophrenia, in relation to positive, negative, and cognitive symptoms. Ultimately, we propose a trajectory of insight in schizophrenia across the lifespan.

METHOD

A systematic Medline® literature search was conducted, searching for English language studies describing the relationship of insight into illness in schizophrenia with aging.

RESULTS

We identified 62 studies. Insight impairment is associated with illness severity, premorbid intellectual function (i.e. IQ), executive function, and memory. Insight impairment improves modestly during midlife, worsening again in late life. It tends to fluctuate with each episode of psychosis, likely in relation to worsening positive symptoms that improve with antipsychotic treatment. The relationship between insight impairment and cognitive dysfunction appears to attenuate with age, while the relationship with lower premorbid intellectual function is preserved. The association between impaired insight and negative symptoms is unclear.

CONCLUSIONS

The available literature suggests that the course of insight impairment follows a U-shaped curve, where insight impairment is severe during the first episode of psychosis, modestly improves over midlife, and declines again in late life. Future studies are required to investigate the trajectory of insight into illness and its core domains across the lifespan from prodromal phase to late life.