Domains of awareness in schizophrenia

Tablet-Based Cognitive and Eye Movement Measures as Accessible Tools for Schizophrenia Assessment: Multisite Usability Study

BACKGROUND

Schizophrenia is a complex mental disorder characterized by significant cognitive and neurobiological alterations. Impairments in cognitive function and eye movement have been known to be promising biomarkers for schizophrenia. However, cognitive assessment methods require specialized expertise. To date, data on simplified measurement tools for assessing both cognitive function and eye movement in patients with schizophrenia are lacking.

OBJECTIVE

This study aims to assess the efficacy of a novel tablet-based platform combining cognitive and eye movement measures for classifying schizophrenia.

METHODS

Forty-four patients with schizophrenia, 67 healthy controls, and 41 patients with other psychiatric diagnoses participated in this study from 10 sites across Japan. A free-viewing eye movement task and 2 cognitive assessment tools (Codebreaker task from the THINC-integrated tool and the CognitiveFunctionTest app) were used for conducting assessments in a 12.9-inch iPad Pro. We performed comparative group and logistic regression analyses for evaluating the diagnostic efficacy of the 3 measures of interest.

RESULTS

Cognitive and eye movement measures differed significantly between patients with schizophrenia and healthy controls (all 3 measures; P<.001). The Codebreaker task showed the highest classification effectiveness in distinguishing schizophrenia with an area under the receiver operating characteristic curve of 0.90. Combining cognitive and eye movement measures further improved accuracy with a maximum area under the receiver operating characteristic curve of 0.94. Cognitive measures were more effective in differentiating patients with schizophrenia from healthy controls, whereas eye movement measures better differentiated schizophrenia from other psychiatric conditions.

CONCLUSIONS

This multisite study demonstrates the feasibility and effectiveness of a tablet-based app for assessing cognitive functioning and eye movements in patients with schizophrenia. Our results suggest the potential of tablet-based assessments of cognitive function and eye movement as simple and accessible evaluation tools, which may be useful for future clinical implementation.

Impact of Delusions and Hallucinations on Clinical Insight Dimensions in Schizophrenia Spectrum Disorders

INTRODUCTION

Insight in psychosis has been conceptualized as a continuous, dynamic, and multidimensional phenomenon. This study aims to determine the impact of delusions and hallucinations in different dimensions of clinical insight in schizophrenia spectrum disorders.

METHODS

Cross-sectional multicenter study including 516 patients (336 men) diagnosed with schizophrenia spectrum disorders. Based on dichotomized scores of Positive and Negative Syndrome Scale (PANSS) items P1 (delusions) and P3 (hallucinations), patients were assigned to four groups according to current clear presence of delusions (scores 4 or above 4 in PANSS item P1) and/or hallucinations (scores 4 or above 4 in PANNS item P3). Insight was assessed using the three main dimensions of the Scale of Unawareness of Mental Disorder (SUMD).

RESULTS

Around 40% of patients showed unawareness of illness; 30% unawareness of the need for treatment; and 45% unawareness of the social consequences of the disorder. Patients with current clear presence of delusions had higher overall lack of awareness, regardless of current clear presence of hallucinations. Similarly, the clear presence of delusions showed a greater predictive value on insight than the presence of hallucinations, although the implication of both in the prediction was modest.

CONCLUSIONS

Our results confirm that lack of insight is highly prevalent in schizophrenia spectrum disorders, particularly when patients experience delusions. This study adds insight-related data to the growing symptom-based research, where specific types of psychotic experiences such as hallucinations and delusions could form different psychopathological patterns, linking the phenomenology of delusions to a lack of clinical insight.

Examining the associations between difficulties in emotion regulation and symptomatic outcome measures among individuals with different mental disorders

Background

Difficulties in emotion regulation (ER) abilities have been found to play a central role in different psychiatric disorders. However, researchers rarely compare ER across different diagnostic groups. In the current study, we examined ER and its relation to functional and symptomatic outcome among three distinct diagnostic groups: people with schizophrenia (SCZ), people with emotional disorders (EDs; i.e., depression and/or anxiety), and individuals without any psychiatric diagnosis (controls).

Methods

Participants in this study comprised 108 adults who requested psychotherapy at a community clinic in the year 2015 and between 2017 and 2019. Clients were interviewed and filled out questionnaires measuring depression, distress, and difficulties in ER abilities.

Results

Results showed that individuals with psychiatric diagnoses reported higher levels of difficulties in ER abilities than did controls. Moreover, there were very few differences in levels of ER difficulty between SCZ and EDs. Further, the associations between maladaptive ER and psychological outcomes were significant in each diagnostic group, and especially for SCZ.

Conclusion

Our study indicates that difficulties in ER abilities partially have a transdiagnostic nature, and that these difficulties are associated with psychological outcomes among both clinical populations and controls. There were very few differences in levels of ER ability difficulties between SCZ and EDs, suggesting that the two groups share difficulties in relating and responding to emotional distress. The associations between difficulties in ER abilities and outcome were more robust and stronger among SCZ than the other groups, highlighting the potential contribution of targeting ER abilities in the treatment of schizophrenia.

Psychiatric patients' attitudes towards being hospitalized: a national multicentre study in Norway

BACKGROUND

The aim of the study was to explore patients' attitudes towards voluntary and involuntary hospitalization in Norway, and predictors for involuntary patients who wanted admission.

METHODS

A multi-centre study of consecutively admitted patients to emergency psychiatric wards over a 3 months period in 2005-06. Data included demographics, admission status (voluntary / involuntary), symptom levels, and whether the patients expressed a wish to be admitted regardless of judicial status. To analyse predictors of wanting admission (binary variable), a generalized linear mixed modelling was conducted, using random intercepts for the site, and fixed effects for all variables, with logit link-function.

RESULTS

The sample comprised of 3.051 patients of witch 1.232 (40.4%) were being involuntary hospitalised. As expected 96.5% of the voluntary admitted patients wanted admission, while as many as 29.7% of the involuntary patients stated that they wanted the same. The involuntary patients wanting admission were less likely to be transported by police, had less aggression, hallucinations and delusions, more depressed mood, less use of drugs, less suicidality before admission, better social functioning and were less often referred by general practitioners compared with involuntary patients who did not want admission. In a multivariate analysis, predictors for involuntary hospitalization and wanting admission were, not being transported by police, less aggression and less use of drugs.

CONCLUSIONS

Almost a third of the involuntary admitted patients stated that they actually wanted to be hospitalized. It thus seems to be important to thoroughly address patients' preferences, both before and after admission, regarding whether they wish to be hospitalized or not.

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.

Testing Efficacy of Relapse Prevention Intervention among Patients Diagnosed with Schizophrenia in Jordan

Relapse prevention is an essential component in sustaining positive treatment outcomes. The purpose of this study was to test the efficacy of a relapse prevention intervention on the ability of patients and their primary caregivers to self-detect and manage early warning signs of relapse, and its impact on relapse rate among patients diagnosed with schizophrenia. Quasi-experimental design; one group posttest only, repeated measure time-series design was employed. A total of 40 patients and their primary caregivers represented the sample in this study. The statistical analysis revealed that the effect of relapse prevention intervention on patients and their primary caregivers' ability to self-detect severity and manage early warning signs of relapse has sustainable and positive effect on patients and their primary caregivers from T1 to T3 (patients, M = 9.0-9.3; caregivers, M = 9.7-9.9). Also, positive effect of intervention detected on abilities of patients and primary caregivers to manage EWS from T1 to T3 (patients, M = 35-36.0; caregivers, M = 39.7-38.1). The analysis also showed a low relapse rate (14.9%). The study showed that relapse prevention interventions is effective and applicable approach that psychiatric nurses can use to ensure sustainable positive outcomes of psychiatric healthcare among patients with schizophrenia.

Awareness of Instrumental Activities of Daily Living Disability: Pilot Study for Elderly Requiring Care and Caregivers

Aim

We aimed to investigate differences in the awareness of instrumental activities of daily living (IADL) disability between elderly patients with and without dementia requiring care.

Methods

We assessed 25 elderly individuals requiring care and their primary caregivers using the Lawton IADL scale, with score differences between the patients and their caregivers representing the level of impaired awareness of IADL disability.

Results

Among the participants, 80% exhibited impaired awareness of IADL disability. In terms of total score on the Lawton scale, there was no between-group difference in the occurrence of impaired awareness of IADL disability (p = 0.274, φ = 0.31). Contrastingly, regarding the subitems of the Lawton scale, the dementia group had a significantly higher number of participants with impaired awareness of responsibility for their own medications than the nondementia group (p = 0.030, φ = 0.47). Further, there were no significant between-group differences in the ability to use telephone, shopping, mode of transportation, or ability to handle finances.

Conclusions

It is important for caregivers to notice the emergence of impaired awareness among the elderly as soon as possible to ensure early diagnosis and treatment. The results of this study suggest the need for caregivers to take care of the elderly patients with the perspective that they may develop impaired awareness of responsibility for their own medications.

An Update on Clinical Insight, Cognitive Insight, and Introspective Accuracy in Schizophrenia-Spectrum Disorders: Symptoms, Cognition, and Treatment

INTRODUCTION

Poor insight, or unawareness of morbid changes in cognition, emotional states, or behavior, is commonly observed among people with schizophrenia. Poor insight represents a persistent barrier to wellness because it interferes with treatment and self-direction. Paradoxically, good insight may also be a barrier to health when awareness of these changes leads to depression or self-stigma.

AREAS COVERED

This paper builds upon this previous work by exploring these issues in schizophrenia separately as they have appeared in published research over the last three years in three different kinds of insight: clinical, cognition, and introspective accuracy. Specifically, studies are reviewed that address: the adverse effects of poor insight, the paradoxical effects of good insight, correlates with other forms of cognition, and emerging treatments.

EXPERT OPINION

The evidence continues to offer a nuanced picture of the complex effects of good insight in schizophrenia. Incremental improvements were also found in the development of novel integrative treatment approaches. This work also highlights the intricacy of the concept of insight, the need for further exploration of the effects of culture, and conceptual work that distinguishes the points of convergence and divergence of these forms of insight.

Psychometric properties of the BIRT Motivation Questionnaire (BMQ), a self-measure of avolition in individuals with schizophrenia

AIMS

Avolition defined as a lack of interest or engagement in goal-directed behavior plays a key role in everyday functioning in schizophrenia and is considered as one of the main contributors to the burden of disease. The aim of this study was to 1) validate the self-report BIRT Motivation Questionnaire (BMQ-S) seldom used before in schizophrenia 2) examine the degree of agreement between the BMQ-S and its informant-report version 3) to assess its ability to predict real-world outcome at 12 month follow-up.

METHODS

One hundred and twenty-two (51.9% inpatients) adults with a diagnosis of schizophrenia were included. Exploratory Factor analysis was performed on the BMQ-S to identify the underlying structure. Real life functioning was measured with the Global Assessment of Functioning scale (GAF). Convergent validity was assessed with the Scale for Assessment of Negative Symptom (SANS) and the Lille Apathy Rating Scale (LARS).

RESULTS

The main psychometric properties of the BMQ-S (internal consistency, test-retest reliability) were satisfactory. Exploratory factorial analysis revealed a 4-factor model which explained 76% of the overall variance. The BMQ-S correlated significantly with the LARS and the SANS avolition subscore suggesting adequate convergent validity. The correlation between the BMQ-S and the clinician-report version was 0.48. The global score and in particular the Initiation/disorganisation dimension was a significant predictor of global functioning at 12-months even when adjusted for age, chlorpromazine intake and depression.

CONCLUSION

Our findings indicate that the BMQ-S has satisfactory psychometric properties and that schizophrenia patients can reliably assess their lack of motivation. Self-evaluation of avolition should be considered in the overall prediction of real-world functioning in schizophrenia.

Impaired Self-Referential Cognitive Processing in Bipolar Disorder: A Functional Connectivity Analysis

Patients with bipolar disorder have deficits in self-referenced information. The brain functional connectivity during social cognitive processing in bipolar disorder is unclear. Electroencephalogram (EEG) was recorded in 23 patients with bipolar disorder and 19 healthy comparison subjects. We analyzed the time-frequency distribution of EEG power for each electrode associated with self, other, and font reflection conditions and used the phase lag index to characterize the functional connectivity between electrode pairs for 4 frequency bands. Then, the network properties were assessed by graph theoretic analysis. The results showed that bipolar disorder induced a weaker response power and phase lag index values over the whole brain in both self and other reflection conditions. Moreover, the characteristic path length was increased in patients during self-reflection processing, whereas the global efficiency and the node degree were decreased. In addition, when discriminating patients from normal controls, we found that the classification accuracy was high. These results suggest that patients have impeded integration of attention, memory, and other resources of the whole brain, resulting in a deficit of efficiency and ability in self-referential processing.

Delineating insight-processing-related functional activations in the precuneus in first-episode psychosis patients

Poor insight is a central characteristic of psychotic disorders, and it has been suggested to result from a general dysfunction in self-reflection. However, brain processing of clinical insight and more general self-reflection has not been directly compared. We compared tasks on (1) self-reflection on psychosis-related mental functioning (clinical insight, in patients only), (2) self-reflection on mental functioning unrelated to psychosis (general metacognition), and (3) semantic control during blood-oxygenation-level-dependent (BOLD) functional magnetic resonance imaging with 19 first-episode psychosis patients and 24 control participants. Arterial-spin-labeling (ASL) images were collected at rest. Clinical insight was evaluated with the Schedule for the Assessment of Insight. In patients, posterosuperior precuneus showed stronger activation during the insight task than during the semantic control task, while anteroinferior precuneus and posterior cingulate cortex (PCC) showed stronger activation during the insight task than during the general metacognition task. No significant group differences in brain activation emerged during the general metacognition task. Although the BOLD measures did not correlate with clinical insight measures, ASL-measured cerebral blood flow (CBF) values did correlate when extracted from the task-selective precuneus/PCC areas: higher CBF correlated with higher clinical insight scores. These results suggest that regions in the posteromedial cortex are selective for clinical insight.

Using a Meta-cognitive Wisconsin Card Sorting Test to measure introspective accuracy and biases in schizophrenia and bipolar disorder

People with schizophrenia (SCZ) and bipolar disorder (BD) have challenges in self-evaluation of their cognitive and functional performance (introspective accuracy). They also manifest response biases, with tendencies toward overestimation. This study aimed to examine objective test performance, momentary judgments of performance, momentary confidence, and subsequent global judgments of performance on a metacognitive version of the Wisconsin Card Sorting Test (WCST). This sample included 99 participants with SCZ and 67 with BD. After each of the 64 WCST trials, participants reported whether they believed their sort was correct and how confident they were in that judgment, they then received performance feedback. After completion of the entire task, participants generated a global performance judgment. On average, the SCZ group got 31 sorts correct, reporting being correct on 49 whereas the BD group got 37 trials correct but reported being correct on 53. For participants with BD, sorting performance correlated with trial x trial accuracy judgments, confidence, and predicted global judgments. For SCZ participants, performance minimally correlated with trial x trial accuracy judgments, confidence, and global judgments, while trial x trial confidence was strongly associated with trial x trial accuracy judgments (r = 0.58). Our findings suggest that confidence in participants with BD is correlated with task performance, whereas in SCZ confidence was entirely associated with self-generated performance judgments. SCZ participants manifested challenges with utilization of feedback. Global judgments of performance were predicted by task performance and confidence for BD participants, with performance and confidence judgments occurring prior to generation of the global performance judgments.

Cannabis, schizophrenia genetic risk, and psychotic experiences: a cross-sectional study of 109,308 participants from the UK Biobank

Cannabis is known to produce acute, transient psychotic-like experiences. However, it is unclear whether cannabis disproportionately increases the risk of specific types of psychotic experiences and whether genetic predisposition influences the relationship between cannabis use and psychotic experiences. In this cross-sectional study of 109,308 UK Biobank participants, we examined how schizophrenia polygenic risk modulates the association between self-reported cannabis use and four types of self-reported psychotic experiences (auditory hallucinations, visual hallucinations, persecutory delusions, and delusions of reference). Cohort-wide, we found a strong, dose-dependent relationship between cannabis use and all four types of psychotic experiences, especially persecutory delusions. Cannabis users' psychotic experiences tended to be earlier-onset and cause greater distress than non-users', but were not more likely to lead to help-seeking. Participants with high schizophrenia polygenic risk scores showed stronger associations between cannabis use and auditory hallucinations, visual hallucinations, and delusions of reference, as well as psychotic experiences overall. For instance, cannabis ever-use was associated with 67% greater adjusted odds of delusions of reference among individuals in the top fifth of polygenic risk, but only 7% greater adjusted odds among the bottom fifth. Our results suggest that cannabis use is a predictive risk factor for psychotic experiences, including early-onset and distressing experiences. Individuals genetically predisposed to schizophrenia may be especially vulnerable to psychotic experiences as a result of using cannabis, supporting a long-postulated hypothesis. This study exemplifies the utility of population-scale biobanks for elucidating gene-by-environment interactions relating substance use to neuropsychiatric outcomes and points to the translational potential of using polygenic risk scores to inform personalized harm reduction interventions.

Schizophrenia patients with poor clinical insight report less subjective memory problems

This study aimed to explore the relationships among clinical insight, subjective memory complaints, and objective memory performance in patients with schizophrenia. We recruited 205 patients with schizophrenia and 221 healthy controls in this study. The participants were administered a subjective-report scale on memory (the Prospective and Retrospective Memory Questionnaire), and several objective memory tasks measuring verbal memory, visual memory, and working memory. Clinical insight was measured with an item in the Positive and Negative Syndrome Scale. We found that when patients with schizophrenia were divided into subgroups with good and poor insight, both subgroups showed impairment in memory performance compared with controls. The schizophrenia patients with good insight reported similar memory complaints as controls whereas patients with poor insight reported less memory complaints than did the controls. These findings suggest that clinical insight may be related to subjective memory complaints, but not objective memory performance.

The association between insight and depressive symptoms in schizophrenia: Undirected and Bayesian network analyses

Background.

Greater levels of insight may be linked with depressive symptoms among patients with schizophrenia, however, it would be useful to characterize this association at symptom-level, in order to inform research on interventions.

Methods.

Data on depressive symptoms (Calgary Depression Scale for Schizophrenia) and insight (G12 item from the Positive and Negative Syndrome Scale) were obtained from 921 community-dwelling, clinically-stable individuals with a DSM-IV diagnosis of schizophrenia, recruited in a nationwide multicenter study. Network analysis was used to explore the most relevant connections between insight and depressive symptoms, including potential confounders in the model (neurocognitive and social-cognitive functioning, positive, negative and disorganization symptoms, extrapyramidal symptoms, hostility, internalized stigma, and perceived discrimination). Bayesian network analysis was used to estimate a directed acyclic graph (DAG) while investigating the most likely direction of the putative causal association between insight and depression.

Results.

After adjusting for confounders, better levels of insight were associated with greater self-depreciation, pathological guilt, morning depression and suicidal ideation. No difference in global network structure was detected for socioeconomic status, service engagement or illness severity. The DAG confirmed the presence of an association between greater insight and self-depreciation, suggesting the more probable causal direction was from insight to depressive symptoms.

Conclusions.

In schizophrenia, better levels of insight may cause self-depreciation and, possibly, other depressive symptoms. Person-centered and narrative psychotherapeutic approaches may be particularly fit to improve patient insight without dampening self-esteem.

Better insight seems associated with depressive symptoms in schizophrenia.

Network analyses were used to explore this association in a large sample.

Insight was associated with self-depreciation, guilt, and suicidal ideation.

Although cross-sectional, data suggest causal direction from insight to depression.

Brain Structural Correlates of Metacognition in First-Episode Psychosis

Metacognition is impaired in schizophrenia and is an important predictor of functional outcome, but the underlying neuropathology is not clear. Studies have implicated frontal regions and there is also some evidence that the hippocampus might play a pivotal role, but findings are inconsistent. We set out to more comprehensively investigate the neural underpinnings of insight in first-episode psychosis (FEP) using 2 metacognitive measures (the Beck Cognitive Insight Scale [BCIS]) and a perceptual metacognitive accuracy task alongside structural magnetic resonance imaging (MRI). We measured cortical thickness in insula and frontal regions, hippocampal (including subfield) volumes, hippocampal microstructure (using neurite orientation dispersion and density imaging [NODDI]), and fractional anisotropy in fornix. Relative to controls, FEP showed poorer metacognitive accuracy, thinner cortex in frontal regions and lower fornix integrity. In healthy controls (but not FEP), metacognitive accuracy correlated with cortical thickness in frontal cortex and insula. Conversely, in FEP (but not controls), metacognitive accuracy correlated with hippocampal volume and microstructural indices. Subicular hippocampal subregions were particularly implicated. No structural correlates of BCIS were found. These findings suggest that the neural bases of metacognition might differ in FEP: hippocampal (rather than frontal) integrity seems to be critical. Further, the use of objectively measured metacognitive indices seems to be a more powerful method for understanding the neurocircuitry of metacognition in FEP, which has the potential to inform therapeutic strategies and improve outcome in these patients.

The association of clinical insight and depression with quality of life in schizophrenia

This study assesses how insight influences depression and Quality of Life (QOL) in schizophrenia-spectrum outpatients and whether depression modifies the relationship between insight and QOL. 141 patients with schizophrenia or schizoaffective disorders with stable disease completed the EUROQOL-5D-5L and SQLS-R4, SAI-E and Calgary scales. Univariate and multivariate linear regression models were fitted to assess whether insight was related to QOL and/or depression. Higher levels of insight were (inversely) only related to EuroQOL-health but showed no relationship with depression. Depression showed an inversely strong relationship with EuroQOL-health. The relationship between clinical insight and QOL does not seem to be associated with depression.

Cognitive capacity similarly predicts insight into symptoms in first- and multiple-episode psychosis

BACKGROUND

Lack of insight is a frequent characteristic of psychotic disorders, both in patients who recently experienced a first episode of psychosis (FEP) and those who experience recurrent multiple episodes (MEP). Insight is a multifaceted construct: its clinical form notably includes the unawareness of being ill, of symptoms, and of the need for treatment. Cognitive capacity is among the key determinants of insight into symptoms, but less is known about whether stage of illness (FEP vs. MEP) moderates this association.

METHODS

Our aim is to evaluate the association between cognitive capacity and symptom unawareness using structural equation modeling and moderated multiple regression. A total of 193 FEP and MEP patients were assessed using the CogState battery and the Scale to Assess Unawareness of Mental Disorder.

RESULTS

Analyses suggest that cognitive capacity accounts for a relatively small proportion of the total variation in symptom unawareness (6.4%). There was no evidence to suggest a moderating effect of stage of illness on this association.

CONCLUSIONS

The effect of general cognitive capacity on symptom unawareness is relatively small, and this basic relation was unrelated to stage of illness. It is possible that stage of illness could moderate this association only for certain facets of insight not assessed in this study (e.g., unawareness of the need for treatment).

A randomized controlled trial of cognitive remediation for a national cohort of forensic patients with schizophrenia or schizoaffective disorder

BACKGROUND

Evidence is accumulating that Cognitive Remediation Training (CRT) is effective for ameliorating cognitive deficits experienced by patients with schizophrenia and accompanying functional impairment. There has been no randomized controlled trial of CRT using a nationally representative population of forensic patients, despite the significant cognitive deficits frequently present within this group.

METHODS

Sixty-five patients with schizophrenia or schizoaffective disorder were enrolled in a single blind randomized controlled trial of CRT versus treatment as usual (TAU); representing 94% of those eligible within a national forensic cohort. The primary outcome measure was the composite score of the MATRICS Consensus Cognitive Battery (MCCB). Secondary outcome measures included neurocognitive and social cognitive domains, symptoms, and 'real world' functioning. Patient satisfaction was examined using an exit interview. Participants were reassessed at 8 months follow up. All data were analyzed using an intention to treat design (ITT).

RESULTS

For the primary outcome measure, the MCCB composite score, there were significant differences between those who participated in CRT and those receiving TAU at both end of treatment and 8 months follow up (Cohen's d = 0.34. Significant improvements were observed in visual and working memory. Mediation analysis found that those who cognitively benefited from CRT had corresponding improved functioning, and more net positive therapeutic moves i.e. moves to units with lower security within the hospital. Ninety-six percent believed their cognitive gains positively affected their daily lives.

CONCLUSIONS

CRT may be an acceptable and efficacious intervention for forensic patients with schizophrenia or schizoaffective disorder.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02360813 . Trial registered Feb 4th 2015, last updated May 1st 2015.

Dimensions of insight in schizophrenia: Exploratory factor analysis of items from multiple self- and interviewer-rated measures of insight

OBJECTIVE

Insight in schizophrenia is regarded as a multidimensional construct that comprises aspects such as awareness of the disorder and recognition of the need for treatment. The proposed number of underlying dimensions of insight is variable in the literature. In an effort to identify a range of existing dimensions of insight, we conducted a factor analysis on combined items from multiple measures of insight.

METHOD

We recruited 165 participants with enduring schizophrenia (treated for >3years). Exploratory factor analysis was conducted on itemized scores from two interviewer-rated measures of insight: the Schedule for the Assessment of Insight-Expanded and the abbreviated Scale to assess Unawareness of Mental Disorder; and two self-report measures: the Birchwood Insight Scale and the Beck Cognitive Insight Scale.

RESULTS

A five-factor solution was selected as the best-fitting model, with the following dimensions of insight: 1) awareness of illness and the need for treatment; 2) awareness and attribution of symptoms and consequences; 3) self-certainty; 4) self-reflectiveness for objectivity and fallibility; and 5) self-reflectiveness for errors in reasoning and openness to feedback.

CONCLUSIONS

Insight in schizophrenia is a multidimensional construct comprised of distinct clinical and cognitive domains of awareness. Multiple measures of insight, both clinician- and self-rated, are needed to capture all of the existing dimensions of insight. Future exploration of associations between the various dimensions and their potential determinants will facilitate the development of clinically useful models of insight and effective interventions to improve outcome.

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.

The right occipital lobe and poor insight in first-episode psychosis

Lack of insight is a core feature of non-affective psychosis and has been associated with poorer outcomes. Brain abnormalities underlying lack of insight have been suggested, mostly in the frontal lobe, although previous research showed mixed results. We used a voxel-based morphometry (VBM) analysis in 108 first-episode non-affective psychosis patients to investigate the pattern of brain structural abnormalities related to lack of insight. In addition, 77 healthy volunteers were compared with the patients classified as having poor and good insight. The shortened version of the Scale to Assess Unawareness of Mental Disorder was used to evaluate insight. Patients with poor insight (n = 68) compared with patients with good insight (n = 40) showed a single significant cluster (kc = 5834; PcFWE = 0.001) of reduced grey matter volume (GMV) in the right occipital lobe extending to its lateral and medial surfaces, the cuneus, and the middle temporal gyrus. In addition, GMV at this cluster showed a negative correlation with the score of the SUMD (r = -0.305; p = 0.001). When comparing patients with poor insight with healthy subjects overall reductions of GMV were found, mainly in frontal and occipital lobes. Hence, poor insight in non-affective psychosis seems to be associated with specific brain abnormalities in the right occipital and temporal cortical regions. Dysfunction in any combination of these areas may contribute to lack of insight in non-affective psychosis. Specifically, the 'right' hemisphere dysfunction underlying impaired insight in our sample is consistent with previously reported similarities between lack of insight in psychosis and anosognosia in neurological disorders.

Stronger default mode network connectivity is associated with poorer clinical insight in youth at ultra high-risk for psychotic disorders

Impaired clinical insight (CI) is a common symptom of psychotic disorders and a promising treatment target. However, to date, our understanding of how variability in CI is tied to underlying brain dysfunction in the clinical high-risk period is limited. Developing a stronger conception of this link will be a vital first step for efforts to determine if CI can serve as a useful prognostic indicator. The current study investigated whether variability in CI is related to major brain networks in adolescents and young adults at ultra high-risk (UHR) of developing psychosis. Thirty-five UHR youth were administered structured clinical interviews as well as an assessment for CI and underwent resting-state magnetic resonance imaging scans. Functional connectivity was calculated in the default mode network (DMN) and fronto-parietal network (FPN), two major networks that are dysfunctional in psychosis and are hypothesized to affect insight. Greater DMN connectivity between the posterior cingulate/precuneus and ventromedial prefrontal cortex (DMN) was related to poorer CI (R²=0.399). There were no significant relationships between insight and the FPN. This is the first study to relate a major brain network to clinical insight before the onset of psychosis. Findings are consistent with evidence if a hyperconnected DMN in schizophrenia and UHR, and similar to a previous study of insight and connectivity in schizophrenia. Results suggest that a strongly connected DMN may be related to poor self-awareness of subthreshold psychotic symptoms in UHR adolescents and young adults.

The relationship between cognitive insight and cognitive performance among individuals with at-risk mental state for developing psychosis

Impairments in cognitive insight-the capacity to appraise and modify one's own distorted beliefs-are believed to be associated with the formation of psychosis. Nevertheless, the association between cognitive insight and cognitive function among people with at-risk mental state (ARMS) for developing psychotic illness has not been made clear. In this study, we used the Beck Cognitive Insight Scale (BCIS) to assess cognitive insight and the Brief Assessment of Cognition in Schizophrenia (BACS) and the Wisconsin Card Sorting Test (WCST) to assess cognitive functions. Fifty subjects with ARMS and 29 healthy volunteers were recruited as participants. The scores for the two groups on the BCIS, BACS, and WCST were compared and Spearman's rank correlations between the domains of the BCIS and cognitive performance were examined in each group. No significant differences were found in BCIS scores between these groups, whereas all of the cognitive function scores were poorer in the participants with ARMS. In the ARMS group, higher self-certainty on the BCIS was significantly correlated with lower performance in the mean number of categories achieved (ρ=-0.31, P=0.03) and perseverative errors of the Nelson type (ρ=0.29, P=0.04) on the WCST. This indicates that excessively high self-certainty might be linked with weaknesses in cognitive flexibility or set-shifting ability in people with ARMS.

A deeper view of insight in schizophrenia: Insight dimensions, unawareness and misattribution of particular symptoms and its relation with psychopathological factors

OBJECTIVE

1. To describe insight in a large sample of schizophrenia subjects from a multidimensional point of view, including unawareness of general insight dimensions as well as unawareness and misattribution of particular symptoms. 2. To explore the relationship between unawareness and clinical and socio-demographic variables.

METHODS

248 schizophrenia patients were assessed with the Positive and Negative Syndrome Scale (PANSS, five factor model of Lindenmayer) and the full Scale of Unawareness of Mental Disorder (SUMD). Bivariate associations and multiple linear regression analyses were used to investigate the relationship between unawareness, symptoms and socio-demographic variables.

RESULTS

Around 40% of the sample showed unawareness of mental disorder, of the need for medication and of the social consequences. Levels of unawareness and misattribution of particular symptoms varied considerably. General unawareness dimensions showed small significant correlations with positive, cognitive and excitement factors of psychopathology, whereas these symptom factors showed higher correlations with unawareness of particular symptoms. Similarly, regression models showed a small significant predictive value of positive symptoms in the three general unawareness dimensions while a moderate one in the prediction of particular symptoms. Misattribution showed no significant correlations with any symptom factors.

CONCLUSIONS

Results confirm that insight in schizophrenia is a multi-phased phenomenon and that unawareness into particular symptoms varies widely. The overlap between unawareness dimensions and psychopathology is small and seems to be restricted to positive and cognitive symptoms, supporting the accounts from cognitive neurosciences that suggest that besides basic cognition poor insight may be in part a failure of self-reflection or strategic metacognition.

Cognitive screening and behavioural observation of functional ability in patients with multiple episode schizophrenia: an exploratory study

OBJECTIVES

To evaluate the usability of a neuropsychological screening instrument and two observation scales of everyday behaviour to describe cognitive and functional capacity of patients with multiepisode schizophrenia and considerable care needs, who frequently refuse to participate in cognitive testing or performance-based functional measurement.

SETTING

One psychiatric unit specialised in severe mental illness at the Sahlgrenska University Hospital, Gothenburg, Sweden.

PARTICIPANTS

Patients were included consecutively from date of admission to the unit.

INCLUSION CRITERIA

age 18-65 years, International Classification of Diseases 10 diagnoses F20.0-F20.9 (schizophrenia) or F25.0-F25.9 (schizoaffective disorder) since at least 5 years.

EXCLUSION CRITERIA

acute serious psychotic episodes or physical illness, alcohol or drug abuse during the year before the study, diagnosed cerebral disorder at admission to the unit, and insufficient ability to speak Swedish. 64 patients filled the criteria and 19 accepted participation: 14 males, 5 females, median age 56 years.

OUTCOME MEASURES

Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) scores, measured by a psychologist; Frontal Systems Behaviour Scale (FrSBe) Family Version and Functional Independence Measure (FIM) V.4.0 scores, measured by nursing staff. Non-parametric statistics were consistently applied to process the data.

RESULTS

Failure analysis showed differences regarding gender and subdiagnoses between participants and non-participants. All participants had BNIS scores indicating cognitive dysfunction. FrSBe group medians showed apathy and executive problems, indicating possible frontal lobe disturbance. FIM showed dependency on others for linguistic and social communication, everyday problem solving, and remembering persons and daily routines. Correlations between FrSBe and FIM (p≤0.01) suggested executive dysfunction being crucial to explain difficulties in performing activities of daily functioning.

CONCLUSIONS

Indications of considerable cognitive and functional difficulties found among the participants suggestedthat the instruments are clinically applicable for tentative assessment of cognitive and functional ability among patients with multiepisode schizophrenia and considerable care needs.

The metabolic basis of cognitive insight in psychosis: A positron emission tomography study

The purpose of this study was to investigate the relationship between cognitive insight and cerebral metabolism in patients suffering from psychosis. The Beck Cognitive Insight Scale (BCIS) was administered to 63 patients with psychosis undergoing Positron Emission Tomography investigation. The sample was divided into two groups considering the BCIS score. Data were analyzed using Statistical Parametric Mapping.

RESULTS

patients with low insight, compared to those with high insight, showed decreased metabolism in the right fusiform gyrus, left precuneus, superior temporal gyrus and insula bilaterally, as well as increased metabolism in the left orbito-frontal gyrus (all p<0.005). Our results suggest that reduced posterior (occipito-temporo-insulo-parietal) and increased anterior (orbitofrontal) cerebral metabolism may sustain low cognitive insight in psychosis.

Profiles of Relationships Between Subjective and Objective Cognition in Schizophrenia: Associations With Quality of Life, Stigmatization, and Mood Factors

Justification: Recent studies showed that neurocognitive insight difficulties occur in subjects with schizophrenia. However, little is known about the different profiles of neurocognitive insight, their relations with neurocognitive functioning, and their specific links with mood factors and outcomes. Aim: The study explored profiles of relationships between objective and subjective cognition in persons with schizophrenia spectrum disorders (SSD) and associations with quality of life (QoL), stigmatization, and mood factors. Method: Participants were 69 outpatients with an SSD. Cluster analysis (Ward method) was performed to explore profiles of interactions between subjective complaints and objective cognitive performances. Analyses of variance (ANOVAs) were then conducted to compare groups on anxiety and depression levels, stigmatization, and QoL. Results: Cluster analysis produced 3 groups: high cognitive impairment/moderate cognitive complaints (N = 26), good cognitive functioning/moderate cognitive complaints (N = 22), and moderate cognitive impairment/high cognitive complaints (N = 21). The second group has higher objective QoL, and the third group has higher levels of anxiety, depression, and stigmatization. Our results show that (a) not all patients with SSD have neurocognitive insight difficulties, (b) relation between objective and subjective cognition is not linear, and (c) differences between profiles may have theoretical and clinical implications.

Clinical and cognitive insight in patients with acute-phase psychosis: Association with treatment and neuropsychological functioning

BACKGROUND

The severity of psychopathology cannot fully explain deficits in the multi-dimensional construct of insight.

AIMS

The aim of this study was to evaluate the correlates and associations of clinical and cognitive insight in patients in an acute phase of psychosis and to analyse the impact of acute treatment on these variables.

METHODS

This study examined 47 inpatients who were recently hospitalized with acute exacerbation of schizophrenia. All subjects were assessed at both admission and discharge with the Positive and Negative Syndrome Scale (PANSS), Schedule for the Assessment of Insight-Expanded Version (SAI-E), Beck Cognitive Insight Scale (BCIS), and a neurocognition battery.

RESULTS

Patients with schizophrenia gained clinical insight after treatment. Cognitive insight did not change significantly after treatment. Insight showed significant negative correlations with positive symptoms and general psychopathology, but not with negative symptoms. Clinical insight was not associated with neuropsychological functioning in this cohort.

CONCLUSION

Gaining clinical insight in the acute phase of illness was associated with the remission of positive symptoms, but not with neuropsychological functioning. Some significant correlations between clinical and cognitive insights were detected, which suggests that cognitive insight contributes to clinical insight but is not treatment-dependent. Long-term treatment may be required to understand the contribution of insight to the outcome of patients with schizophrenia.

The "Insight Paradox" in Schizophrenia: Magnitude, Moderators and Mediators of the Association Between Insight and Depression

The so-called "insight paradox" posits that among patients with schizophrenia higher levels of insight are associated with increased levels of depression. Although different studies examined this issue, only few took in account potential confounders or factors that could influence this association. In a sample of clinically stable patients with schizophrenia, insight and depression were evaluated using the Scale to assess Unawareness of Mental Disorder and the Calgary Depression Scale for Schizophrenia. Other rating scales were used to assess the severity of psychotic symptoms, extrapyramidal symptoms, hopelessness, internalized stigma, self-esteem, and service engagement. Regression models were used to estimate the magnitude of the association between insight and depression while accounting for the role of confounders. Putative psychological and sociodemographic factors that could act as mediators and moderators were examined using the PROCESS macro. By accounting for the role of confounding factors, the strength of the association between insight into symptoms and depression increased from 13% to 25% explained covariance. Patients with lower socioeconomic status (F = 8.5, P = .04), more severe illness (F = 4.8, P = .03) and lower levels of service engagement (F = 4.7, P = .03) displayed the strongest association between insight and depression. Lastly, hopelessness, internalized stigma and perceived discrimination acted as significant mediators. The relationship between insight and depression should be considered a well established phenomenon among patients with schizophrenia: it seems stronger than previously reported especially among patients with lower socioeconomic status, severe illness and poor engagement with services. These findings may have relevant implications for the promotion of insight among patients with schizophrenia.

Metacognitive knowledge and experience in recently diagnosed patients with bipolar disorder

INTRODUCTION

Metacognition, which refers to an individual's ability to assess their own cognitive ability or performance, is poorly understood in bipolar disorder. This study was conducted to evaluate two aspects of metacognitive ability in recently diagnosed patients with bipolar disorder: (a) metacognitive knowledge, pertaining to awareness of one's own general cognitive functioning; and (b) metacognitive experience, referring to awareness of one's cognitive performance on a specific, online cognitive task.

METHOD

Participants consisted of 50 clinically euthymic patients recently diagnosed with Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) bipolar I disorder who were within three months of resolution of their first manic episode, and a comparison group of 38 demographically similar healthy volunteers. To assess metacognitive knowledge, participants provided a general rating of their estimated cognitive ability prior to completing a neuropsychological battery, and self-ratings were compared to actual ability based on a composite score of overall cognitive functioning. To assess metacognitive experience, subjects provided a postdiction rating of their perceived memory performance after completing a list learning verbal memory test, and self-ratings were compared to actual memory performance. Measures of both relative and absolute accuracy of ratings were obtained.

RESULTS

Results indicated that patients showed diminished accuracy in rating their general cognitive ability, implying deficits in metacognitive knowledge. In contrast, patients were accurate in rating their online memory performance, suggesting intact metacognitive experience.

CONCLUSIONS

Findings suggest that in patients with bipolar disorder, intact task-specific cognitive self-appraisals may fail to generalize to or to modify inaccurate global cognitive self-appraisals. Further research using more comprehensive metacognitive tasks is warranted in bipolar disorder.

Self-reflection and set-shifting mediate awareness in cognitively preserved schizophrenia patients

BACKGROUND

Poor insight in schizophrenia has been linked to poor cognitive functioning, psychological processes such as denial, or more recently with impaired metacognitive capacity. Few studies, however, have investigated the potential co-dependency of multiple factors in determining level of insight, but such a model is necessary in order to account for patients with good cognitive functioning who have very poor awareness. As evidence suggests that set-shifting and cognitive insight (self-reflection (SR) and self-certainty) are strong predictors of awareness we proposed that these factors are key mediators in the relationship between cognition and awareness. We hypothesised that deficits specifically in SR and set-shifting determine level of awareness in the context of good cognition.

METHODS

Thirty schizophrenia patients were stratified by high and low awareness of illness and executive functioning scores. Cognitive insight, cognition, mood and symptom measures were compared between sub-groups.

RESULTS

A low insight/high executive functioning (LI-HE) group, a high insight/high executive functioning (HI-HE) group and a low insight/low executive functioning (LI-LE) group were revealed. As anticipated, the LI-HE patients showed significantly lower capacity for SR and set-shifting than the HI-HE patients.

CONCLUSIONS

This study indicates that good cognitive functioning is necessary but not sufficient for good awareness; good awareness specifically demands preserved capacity to self-reflect and shift-set. Results support Nelson and Narens' [1990. Metamemory: A theoretical framework and new findings. The Psychology of Learning and Motivation, 26, 125-173] model of metacognition by which awareness is founded on control (set-shifting) and monitoring (SR) processes. These specific factors could be targeted to improve insight in patients with otherwise unimpaired cognitive function.

Further insight into self-face recognition in schizophrenia patients: Why ambiguity matters

BACKGROUND

Although some studies reported specifically self-face processing deficits in patients with schizophrenia disorder (SZ), it remains unclear whether these deficits rather reflect a more global face processing deficit. Contradictory results are probably due to the different methodologies employed and the lack of control of other confounding factors. Moreover, no study has so far evaluated possible daily life self-face recognition difficulties in SZ. Therefore, our primary objective was to investigate self-face recognition in patients suffering from SZ compared to healthy controls (HC) using an "objective measure" (reaction time and accuracy) and a "subjective measure" (self-report of daily self-face recognition difficulties).

METHOD

Twenty-four patients with SZ and 23 HC performed a self-face recognition task and completed a questionnaire evaluating daily difficulties in self-face recognition. Recognition task material consisted in three different faces (the own, a famous and an unknown) being morphed in steps of 20%.

RESULTS

Results showed that SZ were overall slower than HC regardless of the face identity, but less accurate only for the faces containing 60%-40% morphing. Moreover, SZ and HC reported a similar amount of daily problems with self/other face recognition. No significant correlations were found between objective and subjective measures (p > 0.05).

LIMITATIONS

The small sample size and relatively mild severity of psychopathology does not allow us to generalize our results.

CONCLUSIONS

These results suggest that: (1) patients with SZ are as capable of recognizing their own face as HC, although they are susceptible to ambiguity; (2) there are far less self recognition deficits in schizophrenia patients than previously postulated.

Cardiac Coherence Training to Reduce Anxiety in Remitted Schizophrenia, a Pilot Study

Health care that addresses the emotional regulation capacity of patients with schizophrenia confronted with daily stress may contribute to a less anxious life. A psycho-physiological training [cardiac coherence training (CCT)] focusing on emotion regulation is known to decrease anxiety for healthy individuals. We performed a pilot cross sectional survey to explore the benefits of CCT for clinically stable patients with schizophrenia. Ten patients were enrolled in the program consisting of twelve weekly 1-h session programs monitored over a 2-month period. Standardised questionnaires were used before and after the intervention to assess anxiety, well-being outcomes, and how patients deal with stress and stressors. Results showed that this quite-well accepted intervention improved (or tended to improve) well-being outcomes, state-anxiety, and emotional stressors evaluation. The successful transformations were higher for patients with the highest clinical and emotional suffering. Thus, this pilot study revealed that CCT may help patients with schizophrenia to deal with anxiety in daily life.

Brain Correlates of Self-Evaluation Deficits in Schizophrenia: A Combined Functional and Structural MRI Study

Self-evaluation plays an important role in adaptive functioning and is a process that is typically impaired in patients with schizophrenia. Underlying neural mechanisms for this dysfunction may be associated with manifested psychosis. However, the brain substrates underlying this deficit are not well known. The present study used brain blood oxygen level dependent (BOLD) functional magnetic resonance imaging (fMRI) and gray matter voxel-based morphometry to explore the functional and structural brain correlates of self-evaluation deficits in schizophrenia. Eighteen patients with schizophrenia and 17 healthy controls were recruited and asked to judge whether a set of personality-trait adjectives were appropriate for describing themselves, a familiar other, or whether the adjectives were of positive or negative valence. Patients had slower response times for negative trait attributions than controls did; responses to positive trait attributions were faster than those for negative traits among the patient group, while no differences were observed in the control group. Control subjects showed greater activation within the dorsal medial prefrontal cortex (dMPFC) and the anterior cingulate cortex (ACC) than the patient group during the self-evaluation > semantic positivity-evaluation contrast. Patients showed greater activation mainly within the posterior cingulate gyrus (PCC) as compared to controls for the other-evaluation > semantic positivity-evaluation contrast. Furthermore, gray matter volume was reduced in the MPFC, temporal lobe, cuneus, and the dorsal lateral prefrontal cortex (DLPFC) among the patient group when compared to controls. The present study adds to previous findings regarding self- and other-referential processing in schizophrenia, providing support for neurobiological models of self-reflection impairment.

The relationship between cognitive insight and depression in psychosis and schizophrenia: a review and meta-analysis

Lack of insight is a commonly observed problem in patients with psychosis and schizophrenia. Clinical insight in patients has been associated with low mood. Cognitive insight is a recently defined concept, relating to the ability to self-reflect and the degree to which patients are over-confident regarding their interpretations of illness-related experiences, and is related to clinical insight. We therefore sought to investigate whether there is a positive relationship between cognitive insight and mood. A literature search identified 17 relevant papers published between 2004 and 2014. Our analysis indicated that there was a small but significant positive correlation between the composite index (CI) of the Beck Cognitive Insight Scale (BCIS) and depression scores, but this was driven by a significant positive relationship between depression and the BCIS self-reflection (SR) sub-scale, where low mood was related to higher SR scores. There was no significant relationship between the self-certainty sub-scale and depression. Post-hoc analysis indicated that different depression scales did not significantly affect the relationship with SR. Our results support the idea that cognitive insight is significantly related to mood in schizophrenia, and the effect size is similar to that between clinical insight and mood. Potential applications of this knowledge into treatment and rehabilitation are discussed and a model of cognitive insight is proposed.

[Deactualization and orthostrophy. Phenomenological psychopathology of receding delusions]

In this article we develop a phenomenological psychopathology of receding delusions in persons with a diagnosis of schizophrenia. Drawing on Klaus Conrad's (1905-1961) descriptions of beginning schizophrenia and an in-depth single case study, we develop descriptions of the process of receding delusions as opposed to ongoing delusions in the manner of a double-orientation to reality. We distinguish two stages in this process of social recovery and term these stages deactualization and orthostrophy. We argue that delusional convictions lose importance and persuasive power if they are no longer supported by corresponding value apprehensions or perceptions and perception-like experiences (i.e. hallucinations). Consequently, we propose that the process of receding delusions proceeds in layers comparable to a regression of the process of upcoming delusions. Lastly we discuss both stages of receding delusions (deactualization and orthostrophy) and ongoing delusions (double-orientation to reality) as possible continuous manners of social recovery concerning delusional psychosis (diagnosis of schizophrenia) and argue for specific interventions according to these different continuous manners.

The impact of insight on social functioning in patients with schizophrenia

BACKGROUND

It is still unclear whether insight has a direct association with social functioning in schizophrenia, independent of its association with symptoms.

AIM

This study aimed to investigate the relationship of insight and its dimensions with social functioning in schizophrenia.

METHODS

A total of 170 outpatients with schizophrenia were included in this study. All patients were evaluated with the Scale to Assess Unawareness of Mental Disorder (SUMD), Positive and Negative Syndrome Scale (PANSS) and Personal and Social Performance Scale (PSP). Patients with impaired insight and patients with unimpaired insight were compared for PSP score through independent samples t test. Pearson's correlation analysis was used to determine the correlations between study variables. Multiple stepwise linear regression analysis was used in order to determine the variables that predict social performance.

RESULTS

The PSP score of patients with impaired insight was significantly lower than that of patients with unimpaired insight. There were significant correlations between insight dimensions and PSP score. PANSS negative scale score, awareness of achieved effects of medication and awareness of anhedonia/asociality were significant predictors of social performance.

CONCLUSION

Insight has a significant impact on social functioning in schizophrenia, and some, but not all, insight dimensions have direct impact on social performance, independent of their association with symptoms.

Deficits in emotion based decision-making in schizophrenia; a new insight based on the Iowa Gambling Task

BACKGROUND

Defective decision-making is a symptom of impaired cognitive function observed in patients with schizophrenia. Impairment on the Iowa Gambling Task (IGT) has been reported in patients with schizophrenia, but these results are inconsistent among studies.

METHODS

We differentiated subjects based on whether they expressed certainty at having deciphered an advantageous strategy in the course of the task. We investigated this impairment using the IGT in patients with schizophrenia and performed analysis different to standard advantageous decks minus disadvantageous decks in all 100 card choices, [C+D]-[A+B](1-100). We examined the effects on behavior after receiving a big penalty.

RESULTS

Results were dependent on participants utilizing with or without certainty, the best strategy for positive gain. Schizophrenic patients without certainty failed to show card choice shift, from disadvantageous to advantageous decks. Differences in card choices on the IGT were clearly shown between patients with schizophrenia and normal controls by the use of improvement from block 1 to blocks 3-5, [C+D]-[A+B]([41-100]-[1-20]) (P<0.001), rather than by the composite value of blocks 3-5, [C+D]-[A+B](41-100) (P=0.011). The deficit of emotion-based learning in schizophrenia without uncertainty were related to scores on the SANS and S5 attention. In addition, S1 affective flattering and S4 anhedonia-asociality were also related to these deficits. For a while, normal controls showed a smooth shift from disadvantageous to advantageous decks after big penalties, with or without a certainty for strategy. However, patients with schizophrenia failed to show switching from disadvantageous to advantageous decks, even after big penalties, under the same conditions.

CONCLUSIONS

Our results highlight certainty of strategy and behavior after a big penalty, as two points of difference between patients with schizophrenia and normal controls in the accumulation of net scores.

Internalized stigma and its psychosocial correlates in Korean patients with serious mental illness

We aimed to examine internalized stigma of patients with mental illness in Korea and identify the contributing factors to internalized stigma among socio-demographic, clinical, and psychosocial variables using a cross-sectional study design. A total of 160 patients were recruited from a university mental hospital. We collected socio-demographic data, clinical variables and administered self-report scales to measure internalized stigma and levels of self-esteem, hopelessness, social support, and social conflict. Internalized stigma was identified in 8.1% of patients in our sample. High internalized stigma was independently predicted by low self-esteem, high hopelessness, and high social conflict among the psychosocial variables. Our finding suggests that simple psychoeducation only for insight gaining cannot improve internalized stigma. To manage internalized stigma in mentally ill patients, it is needed to promote hope and self-esteem. We also suggest that a relevant psychosocial intervention, such as developing coping skills for social conflict with family, can help patients overcome their internalized stigma.

Neurocognitive insight and executive functioning in schizophrenia

INTRODUCTION

This study explored whether integrity of executive functioning is required for good neurocognitive insight (NI) in subjects with schizophrenia.

METHODS

NI was measured by subtracting executive difficulties (errors in the Modified Card Sorting Task) from executive cognitive complaints (Subjective Scale to Investigate Cognition in Schizophrenia) in 40 outpatients with schizophrenia and 42 normal controls. The schizophrenia sample was a priori divided into two subgroups on the basis of executive level. Multivariate analyses were conducted to compare groups and to control for potential confounding factors.

RESULTS

Only the schizophrenia dysexecutive subgroup had a poorer NI compared to normal controls. Group differences remained significant after adjustment for potential confounding factors (education, depression, anxiety and self-esteem).

CONCLUSION

These results provide support for the hypothesis that executive dysfunctioning is a limiting factor for NI, independently from depressive and anxiety symptoms.

La conscience des déficits neurocognitifs dans la schizophrénie : une méta-analyse

Contexte La schizophrénie est un trouble allant de pair avec un manque d’autocritique par rapport aux délires et aux hallucinations. En contrepartie, on en sait beaucoup moins en ce qui concerne la conscience des patients par rapport à leurs déficits cognitifs, qui sont des symptômes clés de ce trouble psychiatrique. Afin de faire la synthèse de l’état de la connaissance à ce sujet, nous avons effectué une méta-analyse de 22 études comprenant 1609 patients. Les analyses ont révélé que les patients rapportent davantage de plaintes subjectives que les sujets sains. La corrélation entre la cognition subjective et objective s’est avérée faible toutefois. Les études utilisant la Scale to Investigate Cognition in Schizophrenia ont produit des corrélations plus fortes que celles utilisant d’autres échelles de plaintes subjectives. La relation entre la cognition subjective et les symptômes dépressifs s’est avérée comparable à la relation entre la cognition subjective et la cognition objective. Enfin, une relation faible a été observée entre la cognition subjective et l’autocritique par rapport aux symptômes positifs. Les résultats de la présente méta-analyse montrent que les patients atteints de la schizophrénie se plaignent de déficits cognitifs, mais qu’ils n’ont pas une représentation claire de la nature de ceux-ci, ce qui confirme l’existence de déficits méta-cognitifs dans la schizophrénie.

Cognitive deficit awareness in schizophrenia: absent, intact, or somewhere in-between?

INTRODUCTION

Cognitive impairment is a pervasive feature of schizophrenia, and is a major determinant of the functional disability that is characteristic of the disorder. However, research investigating whether patients with schizophrenia show a deficit awareness remains unclear. The present study aimed to replicate and extend previous research comparing subjective and objective measures of cognition.

METHODS

. Thirty patients with a diagnosis of schizophrenia or schizoaffective disorder were administered the subjectively assessed Schizophrenia Cognitive Rating Scale (SCoRS) and the objective Brief Assessment of Cognition in Schizophrenia (BACS), which each assess overall global functioning and four specific neurocognitive domains (i.e., Verbal Memory, Working Memory, Processing Speed, and Reasoning and Problem Solving). Because deficit awareness may influence the likelihood of patients engaging in treatments designed to improve cognitive functioning, patients' attitudes towards such therapies were also contrasted with these subjective and objective measures of cognitive functioning.

RESULTS

Patients' subjective appraisals did not significantly correlate with the objective neuropsychological assessments for global functioning or any specific neurocognitive domains. However, patients accurately deduced that their memory domains were more impaired than the other domains, and there was a trend for patients to exaggerate their Reasoning and Problem Solving deficits. This suggests that patients show some level of deficit awareness, when overestimating "deficits" for domains that are not impaired. Finally subjective, but not objective, measures of cognitive functioning correlated significantly with willingness to participate in cognitive-enhancing therapies.

CONCLUSIONS

These results suggest that although patients' perceptions of their cognitive function are no substitute for objective neuropsychological test data, patients do possess a level of deficit awareness which may, in turn, influence willingness to participate in interventions such as cognitive rehabilitation.

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.

Cognitive insight in schizophrenia patients and their biological parents: a pilot study

BACKGROUND

Clinical insight in schizophrenia patients is partly associated with familial environment but has been poorly studied to date. We aimed to explore (1) the relationship between parents' cognitive insight and their offspring's; (2) the relationship between parents' cognitive insight and their clinical insight into the disease of their offspring; and (3) the clinical and cognitive determinants of cognitive insight in parents.

METHODS

Cognitive insight was assessed in 37 patient-biological parent pairs/dyads with the Beck Cognitive Insight Scale (BCIS). Other measures included the Scale to assess Unawareness of Mental Disorder and cognitive assessments.

RESULTS

We found no significant association between parents' cognitive insight and their offspring's. Conversely, a positive association between parents' cognitive insight and parents' insight into their offspring's symptoms was found. Better awareness of their offspring's specific symptoms was associated with lower levels of overconfidence in one's beliefs and with BCIS total score. BCIS Self-Certainty and BCIS total score were associated with better executive functioning and verbal comprehension.

CONCLUSIONS

Better insight into their offspring's symptoms is associated with cognitive insight in biological parents of schizophrenia patients. Our results support the integration of cognitive intervention targeting parents' cognitive flexibility in family psychoeducational programs and provide an important first step towards developing a more refined understanding of the factors involved in insight into symptoms of illness in parents of schizophrenia patients.

Preserved strategic grain-size regulation in memory reporting in patients with schizophrenia

BACKGROUND

Cognitive and introspection disturbances are considered core features of schizophrenia. In real life, people are usually free to choose which aspects of an event they recall, how much detail to volunteer, and what degree of confidence to impart. Their decision will depend on various situational and personal goals. The authors explored whether schizophrenia patients are able to achieve a compromise between accuracy and informativeness when reporting semantic information.

METHODS

Twenty-five patients and 23 healthy matched control subjects answered general knowledge questions requiring numerical answers (how high is the Eiffel tower?), freely at first and then through a metamemory-based control. In the second phase, they answered with respect to two predefined intervals, one narrow and one broad; attributed a confidence judgment to both answers; and afterward selected one of the two answers. Data were analyzed using analyses of variance with group as the between-subjects factor.

RESULTS

Patients reported information at a self-paced level of precision less accurately than healthy participants. However, they benefited remarkably from the framing of the response and from the metamemory processes of monitoring and control to the point of improving their memory reporting and matching healthy subjects' accuracy.

CONCLUSIONS

In spite of their memory deficit during free reporting, after accuracy monitoring, patients strategically regulated the grain size of their memory reporting and proved able to manage the competing goals of accuracy and informativeness. These results give some cause for optimism as to the possibility for patients to adapt to everyday life situations.

Self-awareness in neurodegenerative disease relies on neural structures mediating reward-driven attention

Accurate self-awareness is essential for adapting one's tasks and goals to one's actual abilities. Patients with neurodegenerative diseases, particularly those with right frontal involvement, often present with poor self-awareness of their functional limitations that may exacerbate their already jeopardized decision-making and behaviour. We studied the structural neuroanatomical basis for impaired self-awareness among patients with neurodegenerative disease and healthy older adults. One hundred and twenty-four participants (78 patients with neurodegenerative diseases including Alzheimer's disease, behavioural variant frontotemporal dementia, right-temporal frontotemporal dementia, semantic variant and non-fluent variant primary progressive aphasia, and 46 healthy controls) described themselves on the Patient Competency Rating Scale, rating observable functioning across four domains (daily living activities, cognitive, emotional control, interpersonal). All participants underwent structural magnetic resonance imaging. Informants also described subjects' functioning on the same scale. Self-awareness was measured by comparing self and informant ratings. Group differences in discrepancy scores were analysed using general linear models, controlling for age, sex and disease severity. Compared with controls, patients with behavioural variant frontotemporal dementia overestimated their functioning in all domains, patients with Alzheimer's disease overestimated cognitive and emotional functioning, patients with right-temporal frontotemporal dementia overestimated interpersonal functioning, and patients with non-fluent aphasia overestimated emotional and interpersonal functioning. Patients with semantic variant aphasia did not overestimate functioning on any domain. To examine the neuroanatomic correlates of impaired self-awareness, discrepancy scores were correlated with brain volume using voxel-based morphometry. To identify the unique neural correlates of overlooking versus exaggerating deficits, overestimation and underestimation scores were analysed separately, controlling for age, sex, total intracranial volume and extent of actual functional decline. Atrophy related to overestimating one's functioning included bilateral, right greater than left frontal and subcortical regions, including dorsal superior and middle frontal gyri, lateral and medial orbitofrontal gyri, right anterior insula, putamen, thalamus, and caudate, and midbrain and pons. Thus, our patients' tendency to under-represent their functional decline was related to degeneration of domain-general dorsal frontal regions involved in attention, as well as orbitofrontal and subcortical regions likely involved in assigning a reward value to self-related processing and maintaining accurate self-knowledge. The anatomic correlates of underestimation (right rostral anterior cingulate cortex, uncorrected significance level) were distinct from overestimation and had a substantially smaller effect size. This suggests that underestimation or 'tarnishing' may be influenced by non-structural neurobiological and sociocultural factors, and should not be considered to be on a continuum with overestimation or 'polishing' of functional capacity, which appears to be more directly mediated by neural circuit dysfunction.

Correlates of insight with symptomatology and executive function in patients with first-episode schizophrenia-spectrum disorder: a longitudinal perspective

The present study aimed to examine the relationships of insight with symptomatology and executive function, both cross-sectionally and longitudinally in patients with first-episode schizophrenia-spectrum disorders. Ninety-two medication-naïve patients were recruited and 71 completed the assessments. Insight, symptoms and executive function were assessed at baseline, 6 months and 1 year. Insight was measured with the abridged version of Scale of Unawareness of Mental Disorder (SUMD). Symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS). Executive function was measured with the Modified Wisconsin Card Sorting Test (MCST). The most significant improvement of insight and symptomatology was found over the first 6 months, whereas the perseverative errors of MCST were significantly improved between 6 and 12 months. Differential correlations of perseverative errors of the MCST and PANSS scores with SUMD were found at different time points. This suggests the involvement of different mechanisms in insight deficit at different stages of the illness. The baseline MCST perseverative errors were correlated significantly with the SUMD total score at 6 months and the change of SUMD scores over the first 6 months. Although the variance explained was small, it suggests better set-shifting capacity facilitates the improvement of insight at an early stage of the illness.