Lack of Insight in Psychosis: Theoretical Concepts and Clinical Aspects

Cognitive insight in individuals at ultra-high risk for psychosis compared to patients with first-episode psychosis and non-psychotic help-seeking youths

BACKGROUND

Defective insight is a hallmark of schizophrenia. Less is known about insight in emerging psychosis. In this study a widely used measure of cognitive insight, the Beck Cognitive Insight Scale (BCIS), has been applied to a sample including patients with first-episode psychosis (FEP), at ultra-high risk (UHR) for psychosis, and help-seeking youths without psychotic symptoms.

METHODS

The Comprehensive Assessment of At-Risk Mental State (CAARMS) interview was used to classify patients. Enrolled patients were assessed with the General Health Questionnaire-12 (GHQ-12), the Prodromal Questionnaire-16 (PQ-16), the Social and Occupational Functioning Assessment Scale (SOFAS), and the BCIS.

RESULTS

The sample included 212 participants (58%) with non-psychotic mental distress, 131 participants (36%) were UHR, and 22 (6%) were with FEP. Males and females were in equal proportion, mean age was 19.2 ± 2.6 years old (range: 15-25 years). Reliability (Cronbach's alpha) was good for clinical scales (>0.7) and acceptable (around 0.6) for the two BCIS subscales. The self-certainty subscale of the BCIS was more reproducible in factor analysis than the self-reflectiveness scale. Youths devoid of psychotic symptoms scored lower than UHR and FEP participants on the GHQ-12 and the PQ-16 and had better psychosocial functioning as measured by the SOFAS. Levels of cognitive insight did not differ between groups.

CONCLUSION

People in the early stages of psychosis may be still accessible to self-reflectiveness and more hesitant about the certainty of their beliefs than patients at more advanced stages of the illness, as those with fully displayed schizophrenia.

Well-informed but not aware: The P.A.C.T.® psychoeducation program for schizophrenia improves knowledge about, but not insight into, the illness

BACKGROUND

Most individuals with schizophrenia (SZ) have little to no insight regarding the presence of their illness. Psychoeducational programs are state-of-the-art interventions that consist in delivering stabilized patients with accurate knowledge about their illness and its treatment. Evidence suggests a significant relationship between levels of illness-related knowledge and insight in SZ patients. However, the effect of psychoeducation on these related outcomes needs to be explored further.

METHODS

In this open label study involving 30 French-speaking patients with SZ, we propose to compare levels of knowledge and insight before and after the French P.A.C.T.® psychoeducation program to investigate how this approach affects both outcomes. Knowledge levels were measured with the self-questionnaire "What do I know?". Insight levels were measured using the Scale to Assess Unawareness of Mental Disorder (SUMD). Symptoms were assessed with the Positive And Negative Syndrome Scale (PANSS).

RESULTS

A large significant improvement of knowledge was observed (p < 0.001; d = 0.77). By contrast, the analysis reported no significant effect of psychoeducation on insight (p = 0.86; d = 0.07). PANSS total scores were significantly decreased after treatment (p = 0.001; d = 0.66).

CONCLUSIONS

Although the P.A.C.T.® program is a promising tool for improving illness-related knowledge in SZ patients, its use is not sufficient to significantly improve insight levels.

Association of neurocognitive deficits and insight in schizophrenia

AIM

To evaluate the relationship between neurocognitive deficits and insight (clinical & cognitive) among patients with schizophrenia in clinical remission.

METHODOLOGY

60 patients with schizophrenia (diagnosed as per the DSM-IV criteria) in clinical remission were assessed on Beck Cognitive Insight scale (BCIS), Positive and Negative symptom scale (PANSS) and neurocognitive battery (Trail A and B, Stroop Test, Controlled Oral Words Association (COWA) and Tower of London (TOL).

RESULTS

Lower processing speed, low cognitive flexibility and poor executive functions as assessed by Trail A, Trail B and TOL respectively and higher verbal fluency (COWA) were associated with poor cognitive insight in the self-certainty domain. Poor executive functioning (3 moves problem of TOL) was associated with lower cognitive insight in the domain of self-reflectiveness. Clinical insight as assessed by item number 12 of general psychopathology subscale of PANSS did not have any association with any of the neurocognitive domains except for few subsets of executive functions as assessed by TOL. There was no correlation between clinical insight and cognitive insight. However, many of these correlations were weak and could be due to Type-1 error as significance of correlation was fixed at two tailed 0.05 level. Multiple regression analysis demonstrated cognitive flexibility as assessed by Trail B test and executive functions (3 moves and 5 moves problems of TOL) to be the significant predictors of self-certainty and self- reflectiveness domains of the cognitive insight.

CONCLUSIONS

The present study suggests that poor cognitive flexibility and executive dysfunction are associated with poor cognitive insight but the impact of poor neurocognitions on the clinical insight is not very significant.

Demographic and clinical characteristics of patients involuntarily hospitalized in an Italian psychiatric ward: a 1-year retrospective analysis

BACKGROUND

In Italy, psychiatric compulsory treatments are regulated by Law 180 of 13-5-1978 that establishes three criteria: 1) acute psychiatric conditions requiring urgent treatment, 2) patient's refusal of treatment, 3) inpatient treatment is necessary and cannot be postponed.

AIM

To highlight demographic and clinical risk factors for involuntary treatments.

METHODS

We retrospectively collected all hospitalizations in the Service of Psychiatric Diagnosis and Treatment of a northern Italian town from 1-1-2015 to 31-12-2015. We statistically compared demographic and clinical variables related to voluntarily and involuntarily admitted patients and their hospitalizations.

RESULTS

We divided our sample into patients voluntarily hospitalized (PVH=236) and involuntarily (PIH=160) according to their voluntary (VH= 304) and involuntary (IH=197) hospitalizations. PIH were older than PVH and, more frequently, lived alone and were unemployed (p<0.001). "Acute worsening of psychopathology" for IH and "Suicidality" for VH were the prevalent reasons (p<0.001). IH was longer than VH (p<0.001). Among PIH, the most frequent diagnoses were "Schizophrenia and Other Psychosis" (ICD-9-CM) and "Ineffective Impulse Control + Disturbed Personal Identity" (NANDA-I) (p<0.001). During hospitalizations, PIH more often than PVH presented aggressive behavior (p<0.001). At discharge, PIH were more frequently sent to another psychiatric ward or protected facility with long-acting injectable antipsychotics (p<0.001).

CONCLUSIONS

Our involuntarily admitted patients were affected by severe psychiatric disorders with social maladjustment and required complex therapeutic and rehabilitative programs to counteract aggressive behaviour, poor therapeutic compliance and prolonged hospitalizations. The assessment of patients' characteristics can help clinicians recognize who are at risk for compulsory treatment and prevent it.

Voluntary or involuntary acute psychiatric hospitalization in Norway: A 24h follow up study

The Norwegian Mental Health Care Act states that patients who are involuntarily admitted to a hospital must be reevaluated by a psychiatrist or a specialist in clinical psychology within 24h to assess whether the patient fulfills the legal criteria for the psychiatric status and symptoms. International research on the use of coercive hospitalization in psychiatry is scarce, and an investigation of Norway's routine re-evaluation of involuntarily referred patients may expand knowledge about this aspect of psychiatric treatment. The aim of this study was to investigate the extent to which Involuntarily Hospitalized (IH) patients were converted to a Voluntary Hospitalization (VH), and to identify predictive factors leading to conversion. The Multi-center Acute Psychiatry study (MAP) included all cases of acute consecutive psychiatric admissions across twenty Norwegian acute psychiatric units in health trusts in Norway across 3months in 2005-06, representing about 75% of the psychiatric acute emergency units in Norway. The incident of conversion from involuntarily hospitalization (IH) to voluntary hospitalization (VH) was analyzed using generalized linear mixed modeling. Out of 3338 patients referred for admission, 1468 were IH (44%) and 1870 were VH. After re-evaluation, 1148 (78.2%) remained on involuntary hospitalization, while 320 patients (21.8%) were converted to voluntary hospitalization. The predictors of conversion from involuntary to voluntary hospitalization after re-evaluation of a specialist included patients wanting admission, better scores on Global Assessment of Symptom scale, fewer hallucinations and delusions and higher alcohol intake.

CONCLUSION

The 24h re-evaluation period for patients referred for involuntary hospitalization, as stipulated by the Norwegian Mental Health Care Act, appeared to give adequate opportunity to reduce unnecessary involuntary hospitalization, while safeguarding the patient's right to VH.