The contribution of depression and denial towards understanding the unawareness of symptoms in schizophrenic out-patients

Promoting insight into delusions: Issues and challenges in therapy

During recent years, the role of non-pharmacological interventions in the management of psychotic symptoms, including delusions, has received increased recognition. However, a few factors such as the client's cognitive impairments and poor insight into the illness may create challenges for the therapist in conducting these interventions. Present paper discusses some of these issues and the steps a therapist can take to deal with them.

Training to recognise the early signs of recurrence in schizophrenia

BACKGROUND

Schizophrenia has a lifetime prevalence of less than one per cent. Studies have indicated that early symptoms that are idiosyncratic to the person with schizophrenia (early warning signs) often precede acute psychotic relapse. Early warning signs interventions propose that learning to detect and manage early warning signs of impending relapse might prevent or delay acute psychotic relapse.

OBJECTIVES

To compare the effectiveness of early warning signs interventions plus treatment as usual involving and not involving a psychological therapy on time to relapse, hospitalisation, functioning, negative and positive symptomatology.

SEARCH METHODS

Search databases included the Cochrane Schizophrenia Group Trials Register (July 2007 and May 2012) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were reviewed for inclusion. We inspected the UK National Research Registe and contacted relevant pharmaceutical companies and authors of trials for additional information.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing early warning signs interventions plus treatment as usual to treatment as usual for people with schizophrenia or other non-affective psychosis

DATA COLLECTION AND ANALYSIS

We assessed included studies for quality and extracted data. If more than 50% of participants were lost to follow-up, the study was excluded. For binary outcomes, we calculated standard estimates of risk ratio (RR) and the corresponding 95% confidence intervals (CI), for continuous outcomes, we calculated mean differences (MD) with standard errors estimated, and for time to event outcomes we calculated Cox proportional hazards ratios (HRs) and associated 95 % CI. We assessed risk of bias for included studies and assessed overall study quality using the GRADE approach.

MAIN RESULTS

Thirty-two RCTs and two cluster-RCTs that randomised 3554 people satisfied criteria for inclusion. Only one study examined the effects of early warning signs interventions without additional psychological interventions, and many of the outcomes for this review were not reported or poorly-reported. Significantly fewer people relapsed with early warning signs interventions than with usual care (23% versus 43%; RR 0.53, 95% CI 0.36 to 0.79; 15 RCTs, 1502 participants; very low quality evidence). Time to relapse did not significantly differ between intervention groups (6 RCTs, 550 participants; very low quality evidence). Risk of re-hospitalisation was significantly lower with early warning signs interventions compared to usual care (19% versus 39%; RR 0.48, 95% CI 0.35 to 0.66; 15 RCTS, 1457 participants; very low quality evidence). Time to re-hospitalisation did not significantly differ between intervention groups (6 RCTs; 1149 participants; very low quality evidence). Participants' satisfaction with care and economic costs were inconclusive because of a lack of evidence.

AUTHORS' CONCLUSIONS

This review indicates that early warning signs interventions may have a positive effect on the proportions of people re-hospitalised and on rates of relapse, but not on time to recurrence. However, the overall quality of the evidence was very low, indicating that we do not know if early warning signs interventions will have similar effects outside trials and that it is very likely that further research will alter these estimates. Moreover, the early warning signs interventions were used along side other psychological interventions, and we do not know if they would be effective on their own. They may be cost-effective due to reduced hospitalisation and relapse rates, but before mental health services consider routinely providing psychological interventions involving the early recognition and prompt management of early warning signs to adults with schizophrenia, further research is required to provide evidence of high or moderate quality regarding the efficacy of early warning signs interventions added to usual care without additional psychological interventions, or to clarify the kinds of additional psychological interventions that might aid its efficacy. Future RCTs should be adequately-powered, and designed to minimise the risk of bias and be transparently reported. They should also systematically evaluate resource costs and resource use, alongside efficacy outcomes and other outcomes that are important to people with serious mental illness and their carers.

The neuropsychiatry of depression after brain injury

Biological aspects of depression after brain injury, in particular traumatic brain injury (TBI) and stroke, are reviewed. Symptoms of depression after brain injury are found to be rather non-specific with no good evidence of a clear pattern distinguishing it from depression in those without brain injury. Nevertheless symptoms of disturbances of interest and concentration are particularly prevalent, and guilt is less evident. Variabilitiy of mood is characteristic. The prevalence of depression is similar after both stroke and TBI with the order of 20-40% affected at any point in time in the first year, and about 50% of people experience depression at some stage. There is no good evidence for areas of specific vulnerability in terms of lesion location, and early suggestions of a specific association with injury to the left hemisphere have not been confirmed. Insight appears to be related to depressed mood with studies of TBI indicating that greater insight over time post-injury may be associated with greater depression. We consider that this relationship may be due to depression appearing as people gain more awareness of their disability, but also suggest that changes in mood may result in altered awareness. The risk of suicide after TBI is reviewed. There appears to be about a three to fourfold increased risk of suicide after TBI, although much of this increased risk may be due to pre-injury factors in terms of the characteristics of people who suffer TBI. About 1% of people who have suffered TBI will commit suicide over a 15-year follow-up. Drug management of depression is reviewed. There is little specific evidence to guide the choice of antidepressant medication and most psychiatrists would start with a selective serotonin reuptake inhibitor (SSRI). It is important that the drug management of depression after brain injury is part of a full package of care that can address biological as well as psychosocial factors in management.

Can delusions be self-assessed? Concordance between self- and observer-rated delusions in schizophrenia

Several multi-dimensional self-report scales have been developed to assess delusional ideation in the general population. However, self-ratings of positive symptoms in patients with psychosis are often considered unreliable due to neuro-cognitive disturbance and lack of insight. This study tested associations of self- and observer-rated delusions as well as factors associated with discrepancies. Observer-rated delusions were assessed in 80 in- and outpatients with schizophrenia spectrum disorders by trained raters with the Positive and Negative Syndrome Scale. Self-rated delusions were assessed with the Peters et al. Delusions Inventory and the Paranoia Checklist. Correlations between self- and observer-rated overall delusions ranged from 0.49 to 0.57. Associations between specific delusions of persecution and grandiosity were moderate but unique. Good concordance of ratings was not restricted to outpatients or patients with fewer positive symptoms. Patients with lower self- than observer ratings of delusions were characterised by fewer years of education, lower functioning, more negative symptoms and less insight. The results indicate that patients can reliably provide information with regard to the presence and type of delusional beliefs. Thus, patient ratings are a valid additional source of diagnostic information.

Call it a monster for lack of anything else: narrative insight in psychosis

Individuals diagnosed with schizophrenia often appear to be unaware of having an illness or actively reject their diagnostic label. It is unclear, however, how this lack of awareness relates to important outcomes. Broadening the definition of awareness to include "narrative insight" may clarify this issue. The objective of this study was to identify profiles of narrative insight and test how these relate to standardized measure of insight. Sixty-five individuals with schizophrenia spectrum disorders participated in an assessment that included the Scale of Unawareness of Mental Disorder (SUMD) and an in-depth semi-structured interview. Qualitative analysis revealed 5 central themes related to insight on the basis of which each interview was then rated. Cluster analysis of these ratings resulted in 4 profiles of narrative insight: (1) accepts illness/rejects label, (2) rejects illness/searches for a name (3) passive insight of illness and label, and (4) integrative insight. The SUMD differentiated between individuals assigned to profile 2 who showed low insight to their illness and those assigned to the other profiles of narrative insight, but could not differentiate between them. Results support the claim that illness narratives are multifaceted and that traditional measures of insight may not be sensitive to different ways in which people understand their illness.

Recognition of mental illness and suicidality among individuals with serious mental illness

This preliminary study investigated the association of insight (defined as a patient's recognition of having a mental illness) with depression and suicidality among individuals with schizophrenia (N = 1009), bipolar I disorder (N = 297), and recurrent major depression (N = 162). Participants completed interviews at 2 time periods, 6-months apart. Individuals who were recognized having a mental illness reported significantly greater depression than those who denied having a mental illness. Recognition of mental illness was significantly related, both retrospective and prospectively, with suicidal ideation and attempts. No significant differences were found between the diagnostic groups in these relationships. Although there are many clinical benefits associated with insight, these findings suggest there may possibly be cause for concern in attempting to increase insight among individuals with a serious mental illness. However, current evidence suggests that certain forms of treatment may be beneficial in improving insight, while resulting in a decrease in negative affect, rather than an increase.

Increased sensitivity to antidepressants of D3 dopamine receptor-deficient mice in the forced swim test (FST)

Evidence exists for a dopaminergic system dysregulation in mood disorders. In particular, depression may be accompanied by a relative fall of brain dopamine (DA) availability, while the increase of dopamine D2/D3 receptors (D2R/D3R) binding may reflect a compensatory change following primary reduction of mesolimbic DA levels. It is well established that D3Rs, acting as autoreceptors, inhibit DA synthesis and release, although lack of selective compounds have limited the progress in understanding D3Rs role in mood disorders. Aim of this study was to assess the behavioral responses of D3R-deficient (D3(-/-)) mice tested in the forced swim test (FST) and to evaluate their sensitivity to the treatment with different antidepressant drugs. Different groups of mice received one injection of the tricyclic compound, clomipramine (1, 5 and 10 mg/kg) or of one the selective serotonin reuptake inhibitors (SSRIs), paroxetine, sertraline or citalopram (1, 4 and 16 mg/kg), 30 min prior the behavioral test. Vehicle-injected wild type (WT) mice and D3(-/-) animals were used as controls and submitted to the same experimental procedure. In a preliminary experiment, vehicle-injected D3(-/-) mice, but not their littermates, failed to show an increased immobility time in FST as compared to intact controls, suggesting an increased resistance to injection-induced stress in the former. Clomipramine 1 mg/kg failed to affect behavioral responses of both D3(-/-) mice and WT animals. After the 5 mg/kg dose, D3(-/-) and WT mice showed a better performance in FST than vehicle-injected controls, with a lower immobility time exhibited by D3(-/-) mice than that shown by WT animals. No difference was found between WT mice treated with the highest dose of clomipramine (10 mg/kg) and the respective controls, although D3(-/-) mice exhibited a decreased immobility time as compared to vehicle-injected controls. In contrast to WT animals, when treated with 1 mg/kg sertraline and the 4 mg/kg dose of every SSRI D3(-/-) mice exhibited a decreased immobility time in FST in comparison to vehicle-injected controls. Furthermore, 16 mg/kg doses of citalopram, paroxetine or sertraline induced a greater reduction of immobility time in D3(-/-) mice than in WT-treated animals as compared to their respective controls. These data suggest that D3(-/-) mice, as being more resistant to stressful procedure than WT littermates, are more sensitive to antidepressants in FST paradigm than the former. Although the present data do not allow any conclusion on the neurochemical base of this difference, it might be possible that the greater sensitivity to antidepressants depends on a higher DA levels in mesolimbic pathways following the lack of D3Rs.

Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders

Research has paradoxically linked awareness of illness to both better function outcomes and lesser hope and self-esteem. One possible explanation for these findings is that acceptance of having schizophrenia may impact outcomes differently depending on the meanings the person attaches to this acceptance, particularly whether he or she accepts stigmatizing beliefs about mental illness. To explore this possibility we performed a cluster analysis of 75 persons with schizophrenia spectrum disorders based on single measures of insight using the Positive and Negative Syndrome Scale, internalized stigma using the Internalized Stigma of Mental Illness Scale, and compared groups on concurrent assessments of hope and self-esteem. Three groups were produced by the cluster analyses: low in sight/mild stigma (n = 23), high insight/minimal stigma (n = 25), and high insight/moderate stigma (n = 27). As predicted, analysis of variance-comparing groups revealed that the high insight/moderate stigma group had significantly the lowest levels of hope on the Beck Hopelessness Scale and self-esteem using the Multidimensional Self-esteem Inventory. As predicted, the high insight/minimal stigma group also had significantly less impaired social function than the other groups. Implications for assisting persons to come to cope with awareness of illness and stigma are discussed.

Hope, awareness of illness, and coping in schizophrenia spectrum disorders: evidence of an interaction

Controversy exists regarding whether awareness of schizophrenia is linked with healthier or poorer psychosocial function. This study examined whether hope might interact with insight to affect function at the level of active versus avoidant coping preferences among 96 persons with schizophrenia spectrum disorders. Factorial multivariate analysis of variance comparing groups classified on the basis of hope and insight scores revealed a significant interaction between hope and insight (Wilks lambda = 2.7; p< 0.05). Post hoc analyses indicated that persons with high insight and high hope demonstrated the most adaptive coping preferences, whereas those with high insight and lower hope demonstrated the least.

Personal narratives of illness in schizophrenia: associations with neurocognition and symptoms

Controversy exists regarding whether unawareness/denial of illness in schizophrenia results from neurocognitive deficits or a rejection of stigmatized social roles. One possibility is that some elements of a narrative of mental illness are primarily a matter of personal/social construction while others may be uniquely curtailed by neurocognitive deficits. Accordingly, we gathered narratives of illness among 52 persons with schizophrenia spectrum disorders using a semi-structured interview. Ratings of the plausibility, adequacy of detail, and temporal conceptual organization of each narrative were correlated with assessments of neurocognition, symptoms, and traditional insight measures. Degree of plausibility was significantly related to performance on the Wisconsin Card Sorting Test (WCST), a measure of executive function and levels of Positive symptoms on the Positive and Negative Syndrome Scale (PANSS). When entered into a regression to predict plausibility, positive symptoms and WCST performance made unique contributions (R2 = .51, p < .0001). Higher levels of Positive symptoms were associated with poorer temporal conceptual organization within narratives. Adequacy of detail within narratives of illness was related to traditional insight measures but not neurocognition or symptoms.

Insight into current symptoms of schizophrenia. Association with frontal cortical function and affect

OBJECTIVE

Examine whether frontal lobe dysfunction or affective experiences correlates with lack of symptom awareness in schizophrenia.

METHOD

A total of 122 consecutive adult schizophrenia outpatients were assessed cross-sectionally with standard rating scales of psychopathology and of insight, and underwent neuropsychological assessment with a battery of tests sensitive to frontal lobe dysfunction. Correlational analyses were used to determine relationships between variables.

RESULTS

About 62% of patients had at least partial awareness of symptoms. Anxiety correlated modestly with insight into the abnormal nature of positive and negative symptoms. No cognitive variable was significantly correlated with symptom awareness.

CONCLUSION

The pathological nature of symptoms is better recognized by patients who experience dysphoric affect. Neither severity of psychotic symptoms nor frontal lobe cognitive deficits correlates to symptom awareness. Lack of insight, which can be partial for symptoms of the illness, might be a non-reducible symptom of schizophrenia.

Insight in schizophrenia: a meta-analysis

There has been an increase in the study of insight in schizophrenia in the last 20 years. Insight is operationally defined according to five dimensions which include: the patient's awareness of mental disorder, awareness of the social consequences of disorder, awareness of the need for treatment, awareness of symptoms and attribution of symptoms to disorder. Despite the development of psychometrically sound measurement tools, the results from previous studies have been inconclusive regarding the nature of the relationship between insight and symptomatology. A meta-analysis of 40 published English-language studies was conducted to determine the magnitude and direction of the relationship, or effect size, between insight and symptom domains in schizophrenia and to determine moderator variables that were associated with the variations in effect sizes across studies. Results indicated that there was a small negative relationship between insight and global, positive and negative symptoms. There was also a small positive relationship between insight and depressive symptoms in schizophrenia. Acute patient status and mean age of onset of the disorder moderated the relationship between insight and symptom clusters. The possible reasons for the effect sizes being modest, the examination of the role of moderator variables and directions for future research are provided.

Predicting engagement with services for psychosis: insight, symptoms and recovery style

BACKGROUND

Treatment non-adherence and service disengagement are commonly attributed to impaired insight. There is evidence that recovery style (i.e. psychological adjustment) may underlie service engagement.

AIMS

We examined whether insight, psychotic symptoms or individuals' recovery style ('integration' v. 'sealing-over') predicts service engagement.

METHOD

Fifty patients with schizophrenia were assessed during acute psychosis and at 3-month and 6-month follow-ups. Measures included recovery style, psychosis symptoms, insight and service engagement.

RESULTS

Sealing-over at 3 months following onset of an episode of psychosis predicted low service engagement at 6 months. Neither insight nor symptoms predicted engagement. The clear shift from integration to sealing-over within the first 3 months was independent of changes in symptoms or insight. Sealing-over between 3 and 6 months was associated with improvement in psychosis symptoms.

CONCLUSIONS

Recovery style contributed more to engagement than did insight, appears to be dynamic in the short term and is orthogonal to insight. Overall, this study demonstrated the importance of addressing psychological adjustment to psychosis as well as illness status when investigating treatment engagement in people with psychosis.

Insight, global neuropsychological functioning, and symptomatology in chronic schizophrenia

It is proposed that poor insight in schizophrenia may be explained by neuropsychological dysfunction and linked to the negative syndrome, which in turn may be related to structural neurological impairment. This study tested the hypothesis that poor insight is related to global neuropsychological impairment and negative symptoms in 89 patients with chronic schizophrenia. No significant association was found between total insight and cognitive impairment. When the dimensions of insight-treatment compliance, awareness of illness, and symptom attribution-were analyzed separately, symptom misattribution was modestly correlated with frontal impairment. However, in subsequent multiple regression analyses, cognitive impairment failed to be a significant predictor of this or any other dimension of insight. Symptoms, particularly positive ones, accounted for approximately one quarter of the variance in symptom misattribution and the total insight score. These results suggest that neuropsychological functioning cannot account for the variance in insight, and that only one quarter of the variance in symptom misattribution can be explained by symptomatology. Future research could also address the role of psychosocial factors in modulating the expression of insight.

Motivational interviewing to improve insight and treatment adherence in schizophrenia

Poor insight and low treatment adherence are common features among persons with schizophrenia that are often related to poor outcome. While insight is a multidimensional phenomenon, common measures of insight have shortcomings and do not include all items relevant for insight and compliance. Different causes of poor insight and compliance such as neurocognitive deficits and psychological coping mechanisms are considered and also the role of awareness in the context of health behavior theory and the stages of change-model. Motivational Interviewing can, with specific modifications for persons with schizophrenia, successfully increase their insight and compliance, because it allows them to explore their own goals and to take a more active role in treatment.