Unraveling interrelationships among psychopathology symptoms, cognitive domains and insight dimensions in chronic schizophrenia

Factors influencing the level of insight and treatment attitude: a cross-sectional study of 141 elderly patients of major depression in Guangzhou, China

Objective

To explore the insight, treatment attitude, and related influencing factors of hospitalized elderly patients suffering from major depression.

Methods

A total of 141 hospitalized elderly patients with depression were selected as the research objects. Insight was evaluated by the total score of the Insight and Treatment Attitude questionnaire (ITAQ). The data collected included sociodemographic characteristics, psychiatric symptoms, delirium status, social functioning, social support, suicide risk, and cognitive function.

Results

The sample included 74.5% of female patients, and the mean age was 67.53 (sd=7.19) years. The influencing factors of inpatients with depression included alcohol consumption, length of hospitalization, admission types, and the main caregivers (P<0.05). The various factors were further analyzed by linear regression, revealing that the insight and treatment attitude of elderly depressed hospitalized patients were mainly related to the Mini-Mental State Examination (MMSE) (β= 0.225, 95% CI 0.055-0.395, P=0.01), dependent on a caregiver (β=-5.810, 95% CI -8.086~-3.535, P<0.001), the type of admission (involuntary admission) (β=-3.365, 95% CI -5.448~-1.283, P=0.002), Functional Activities Questionnaire (FAQ) (β=-0.156, 95% CI -0.303~-0.010, P=0.037), and length of stay (≤28 days) (β=2.272, 95% CI 0.055~-4.489, P=0.045).

Conclusion

The level of insight was affected by cognitive function, involuntary admission, dependent on a caregiver, social function and length of stay. Future studies should focus on cognitive function recovery, observation of admission mode, and self-care ability in elderly patients with depression.

A Randomized Controlled Trial of the Effects of Early Intervention Services On Insight in First Episode Psychosis

BACKGROUND AND HYPOTHESIS

Impaired insight into one's illness is common in first episode psychosis (FEP), is associated with worse symptoms and functioning, and predicts a worse course of illness. Despite its importance, little research has examined the effects of early intervention services (EIS) on insight.

DESIGNS

This paper evaluated the impact of EIS (NAVIGATE) on insight compared to usual community care (CC) in a large cluster randomized controlled trial. Assessments were conducted at baseline and every 6 months for 2 years.

RESULTS

A multilevel regression model including all time points showed a significant time by treatment group interaction (P < .001), reflecting greater improvement in insight for NAVIGATE than CC participants. Impaired insight was related to less severe depression but worse other symptoms and functioning at baseline for the total sample. At 6 months, the same pattern was found within each group except insight was no longer associated with depression among NAVIGATE participants. Impaired insight was more strongly associated with worse interpersonal relationships at 6 months in NAVIGATE than in CC, and changes in insight from baseline to 6 months were more strongly correlated with changes in relationships in NAVIGATE than CC.

CONCLUSIONS

The NAVIGATE program improved insight significantly more than CC. Although greater awareness of illness has frequently been found to be associated with higher depression in schizophrenia, these findings suggest EIS programs can improve insight without worsening depression in FEP. The increased association between insight and social relationships in NAVIGATE suggests these 2 outcomes may synergistically interact to improve each other in treatment.

Relationships Between Multiple Dimensions of Insight and Neurocognition, Metacognition, and Social Cognition: A Meta-Analysis

ABSTRACT

Insight is a complex and multidimensional concept, and has a complex relationship with cognition. A meta-analysis of 102 studies of 9396 patients was conducted to determine the magnitude of the relationship between insight and neurocognition, higher-order cognition in multiple mental disorders. Insight has been found moderately related to higher-order cognition, but only weakly related to neurocognition. The different relationship has been found between the dimensions of insight and higher-order cognition. Almost none of the correlational coefficients of insight and cognitive domains were found to differ significantly among the different diagnostic groups. In conclusion, insight may be essentially related to higher-order cognition, but not to neurocognition. The orientation and expression of different dimensions of insight might be different, and the relationship of insight and cognition might not be explained by specific diagnosis.

Psychopathology and Poor Clinical Insight in Psychotic Patients: Does the Diagnosis Matter?

ABSTRACT

Poor clinical insight is one of the most common features of schizophrenia spectrum disorders and plays a critical role in prognosis and treatment. Considering the biological and phenomenological overlap between schizophrenia and bipolar I disorder with psychotic features (BID) and increasing incidents of methamphetamine-induced psychotic disorder (MIPD) patients in Iran, it is necessary to have a clear picture of insight among these three groups. The aim of the present study was to compare clinical insight and other aspects of illness among three different disorders: schizophrenia, BID, and MIPD. In addition, we sought to examine the relationship of the severity of psychotic symptoms with clinical insight in each group. A total of 115 male inpatients, including 48 persons diagnosed with schizophrenia, 35 persons diagnosed with BID, and 32 persons diagnosed with MIPD, were selected. All participants completed the Scale to Assess Unawareness of Mental Disorder and the Positive and Negative Syndrome Scale. The results of analysis of variance indicated that schizophrenia patients reported higher rates of illness duration and number of hospital admissions in comparison to the MIPD and BID groups. In addition, persons diagnosed with BID reported more of these outcomes than MIPD groups. However, the three groups showed similar patterns in terms of age of onset and educational, marital, and occupational statuses. The results also revealed that awareness of the disorder was more impaired in schizophrenia patients compared with BID and MIPD patients and in MIPD compared with BID groups. However, the level of awareness of the effect of medication, the awareness of social consequences, and the total score of clinical insight were similar across the three diagnostic groups. As expected, poor clinical insight was correlated with high levels of positive, negative, and cognitive symptoms in the schizophrenia group; with high levels of positive, cognitive, and depressive symptoms in the BID group; and with high levels of positive and excitement symptoms in MIPD. In addition, hierarchical linear regression analyses revealed that only cognitive symptoms in the schizophrenia group and excitement symptoms in the MIPD group significantly predicted the overall score of clinical insight. In the BID group, both cognitive and depressive symptoms significantly predicted clinical insight. These findings suggest that there are differing levels of poor clinical insight in schizophrenia, MIPD, and BID and that poor clinical insight found within each group may have different antecedents.

Patients and physician’s self-assessment regarding clinical stability in severe mental disorders: a cross-sectional study

ABSTRACT Objective This study explores the relationship between patients’ self-assessment and physicians’ evaluation regarding clinical stability. Methods This cross-sectional study was carried out at the general outpatient clinic of the Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB-UFRJ) in a large sample (1,447) of outpatients, of which 67.9% were patients with severe mental disorders (SMD). We collected information using a structured questionnaire developed for this purpose, filled in by the patient’s physician. Clinical stability was assessed by means of five psychiatric instability criteria and by the physician’s global clinical impression over the six previous months. The patients’ self-assessment was based on a question about how they evaluated their health status: stable/better, worse, does not know. For the analyses, patients’ self-evaluation was considered as our standard. Results The sample was composed of 824 (57%) women with an average age of 49 years. The most prevalent diagnoses within the SMD category corresponded to 937 patients, of whom 846 (90.3%) assessed themselves as stable/better. The physicians’ evaluations agreed more with patients with bipolar disorders and less with schizophrenics regarding stability. As for patients with depressive disorder, physicians agreed more with them regarding instability. Conclusion The data analysis confirms our hypothesis that the self-assessment made by patients with SMD was accurate regarding their health condition, and that the self-assessment made by patients who considered themselves stable agree with the physicians’ evaluation.

Co-occurring Deficits in Clinical and Cognitive Insight in Prolonged Schizophrenia-Spectrum Disorders: Relationship to Metacognitive Deficits

People diagnosed with schizophrenia have been broadly observed to experience deficits in clinical and cognitive insight; however, less is understood about how these deficits are related. One possibility is that these deficits co-occur among people when other deficits in cognition are present, such as in executive function, social cognition, and metacognition, which may either promote the development of both forms of poor insight or allow one to negatively influence the other. To explore this possibility, we conducted a cluster analysis using assessments of clinical and cognitive insight among 95 adults with a schizophrenia spectrum disorder. As predicted, this analysis yielded a group with concurrently poor clinical and cognitive insight (n = 36). Additional groups were found with concurrently good clinical and cognitive insight (n = 28) and poor clinical insight and good cognitive insight (n = 31). Groups were then compared on assessments of executive function, social cognition, and metacognition. The group with concurrently lower levels of cognitive and clinical insight had significantly poorer metacognition relative to the other groups. In particular, they tended to form more fragmented and less integrated ideas about themselves and others. No differences were found for executive function or social cognition. The result may suggest that while clinical and cognitive insight is partially orthogonal phenomena, relatively lower levels of metacognition, or difficulties forming integrated ideas about oneself and others, maybe a condition leading to the confluence of lower clinical and cognitive insight. Interventions targeting metacognition may be of particular use for this group.

Exploring the relationship of insight with psychopathology and gender in individuals with schizophrenia spectrum disorders with structural equation modelling

To model the influence of psychopathology on insight deficits in schizophrenia spectrum patients with a gender-stratified analysis. Five hundred sixteen patients (65.1% men) with schizophrenia spectrum disorders were evaluated in four centres of the metropolitan area of Barcelona (Catalonia). Psychopathological assessment was performed using different PANSS factors. Insight and its three main dimensions were assessed by means of the Scale of Unawareness of Mental Disorder: awareness of the disease (SUMD-1), of the effect of medication (SUMD-2) and of the social consequences of the disease (SUMD-3). Structural equation models (SEMs) were used to fix the model in the total sample and by gender. Additional analyses included age, duration of illness (DOI) and education status (ES). There were no significant differences between men and women in the three main dimensions of insight. The SEMs in the total sample showed a modest fitting capacity. Fitting improved after a gender-stratified analysis (particularly in women). In men, positive and excited symptoms were associated with poorer insight in all SUMD dimensions, whereas depressive symptoms were associated with better insight. ES in men was also associated with better SUMD-2 or SUMD-3. In contrast, in women, symptoms did not have a negative effect on SUMD-1 or SUMD-2. However, positive symptoms were associated with a poorer SUMD-3, whereas depressive symptoms were associated with better SUMD-3. Moreover, education level was also associated with a better SUMD-3. A gender approach improved the comprehension of the model, supporting the relevance of gender analysis in the study of insight.

Without insight accompanied with deteriorated brain functional alterations in healthy individuals with auditory verbal hallucinations: a pilot study

Few studies have reported on brain functional differences between healthy individuals with auditory verbal hallucinations (Hi-AVH) with and without insight, so we designed a study to address this knowledge gap. We enrolled 12 Hi-AVH with insight, 15 Hi-AVH without insight, and 15 AVH-free controls (Healthy controls). Global functional connectivity density (gFCD) mapping was used to estimate brain networks. We found that the most common alterations in both Hi-AVH groups were increased gFCD in superior parietal lobule and superior temporal gyrus. We also found that distinct brain functional patterns of Hi-AVH without insight comprised lower gFCD in the frontal lobe oculomotor area, dorsolateral prefrontal cortex, supramarginal gyrus, primary auditory cortex, sensorimotor cortex, ventral anterior, and posterior cingulate Our pilot findings support the hypothesis that abnormal reciprocal action in the circuits for processing perception, memory, language, and attentional control may be pathological features of auditory verbal hallucinations.

Meta-analysis of the positive and Negative Syndrome Scale (PANSS) factor structure

A meta-analysis of the results of 45 factor analyses (n = 22,812) of the Positive and Negative Syndrome Scale (PANSS) was conducted. Meta-analyses of the PANSS was conducted using both a co-occurrence similarity matrix and reproduced correlations. Both methods produced similar results. Five factors (Positive Symptoms, Negative Symptoms, Disorganization, Affect and Resistance) emerged clearly across both analyses. The factors and the items defining them were Positive Symptoms (P1 Delusions, G9 Unusual thought content, P3 Hallucinatory behavior, P6 Suspiciousness and persecution, P5 Grandiosity), Negative Symptoms (N2 Emotional withdrawal, N1 Blunted affect, N4 Passive apathetic social withdrawal, N6 Lack of spontaneity, N3 Poor rapport, G7 Motor retardation, G16 Active social avoidance), Disorganization often termed Cognitive (P2 Conceptual disorganization, G11 Poor attention, N5 Difficulty in abstract thinking, G13 Disturbance of volition, N7 Stereotyped thinking, G5 Mannerisms/posturing, G15 Preoccupation, G10 Disorientation), Affect often termed Depression-Anxiety (G2 Anxiety, G6 Depression, G3 Guilt feelings, G4 Tension, G1 Somatic concern) and a small fifth factor that might be characterized as Resistance or Excitement/Activity (P7 Hostility, G14 Poor impulse control, P4 Excitement, G8 Uncooperativeness). Items G1, G4, G10, P5, G5, G15 may not be core items for the PANSS factors and G12 lack of judgment is not a core item. Results of the PANSS meta-analyses were relatively similar to those for meta-analysis of both the BPRS and BPRS-E all of which contain the original 18 BPRS items. The PANSS is distinguished by a much larger number of items to clearly define and measure Negative Symptoms as well as a sufficient number of items to much more clearly identify a Disorganization factor than the BPRS or BPRS-E.

The Multiple Dimensions of Insight in Schizophrenia-Spectrum Disorders

The concept of insight is used to indicate the propensity of patients with schizophrenia and other severe mental disorders to recognize their illness and engage in treatment. Thus, insight may have notable consequences for the ill individual: Those who lack insight are at higher risk of nonadherence to treatments, negative clinical outcomes, and worse community functioning. Although insight is an intuitive concept, its essence remains difficult to capture. However, many rating scales are available to aid assessment, both for clinical and research purposes. Insight cannot be reduced to a symptom, a psychological mechanism, or a neuropsychological function. It is likely to have dynamic relationships with all these dimensions and with responses to personal events and contextual factors. In particular, social consequences of mental illness and explanatory models that are alternative to the medical model may fundamentally shape insight and treatment choice. Moreover, the cultural or individual stigmatization of mental illness may turn the acquisition of insight into a painful event and increase the risk of depression. Clinicians need to carefully evaluate and promote insight through a personalized approach to aid patient process of care and personal growth.

The Effects of Add-on Fronto-Temporal Transcranial Direct Current Stimulation (tDCS) on Auditory Verbal Hallucinations, Other Psychopathological Symptoms, and Insight in Schizophrenia: A Randomized, Double-Blind, Sham-Controlled Trial

BACKGROUND

The efficacy of fronto-temporal transcranial direct current stimulation in treating auditory verbal hallucinations and other psychopathological symptoms of schizophrenia patients has been examined in a small number of clinical trials with limited sample sizes, but the results are mixed. Fronto-temporal transcranial direct current stimulation has also been demonstrated to enhance patients' insight into their mental illness in an open-label pilot study. The current investigation aimed to investigate the therapeutic effects of fronto-temporal transcranial direct current stimulation on the severity of auditory verbal hallucinations, other schizophrenia symptoms, and insight in a large double blind, randomized, sham-controlled trial.

METHODS

Sixty patients with medication-refractory auditory verbal hallucinations were randomized over 2 conditions: transcranial direct current stimulation with 2-mA, twice-daily sessions for 5 consecutive days, with anodal stimulation to the left prefrontal cortex and cathodal stimulation to the left temporo-parietal junction, and sham treatment.

RESULTS

Fronto-temporal transcranial direct current stimulation failed to cause significant changes in the severity of auditory verbal hallucinations and other schizophrenia symptoms. The levels of insight into illness (effect size=0.511, P<.001) and positive symptoms (effect size=0.781, P<.001) were largely promoted by 5 days of transcranial direct current stimulation relative to sham treatment. The beneficial effects on the 2 insight dimensions remained 1 month after transcranial direct current stimulation.

CONCLUSIONS

Fronto-temporal transcranial direct current stimulation is not more effective for auditory verbal hallucinations and other schizophrenia symptoms than sham treatment. But the results of transcranial direct current stimulation-associated improvement in awareness of illness and positive symptoms show promise and provide a new direction for future research into insight promotion interventions in schizophrenia.