Reappraising insight in psychosis. Multi-scale longitudinal study

Neuroimaging correlates of insight in non-affective psychosis: A systematic review and meta-analysis

OBJECTIVE

Neurological correlates of impaired insight in non-affective psychosis remain unclear. This study aimed to review and meta-analyze the studies assessing the grey matter volumetric correlates of impaired insight in non-affective psychosis.

METHODS

This study consisted of a systematic review of 23 studies, and a meta-analysis with SDM-PSI of the 11 studies that were whole-brain and reported maps or peaks of correlation of studies investigating the grey matter volumetric correlates of insight assessments of non-affective psychosis, PubMed and OVID datasets were independently reviewed for articles reporting neuroimaging correlates of insight in non-affective psychosis. Quality assessment was realized following previous methodological approaches for the ABC quality assessment test of imaging studies, based on two main criteria: the statistical power and the multidimensional assessment of insight. Study peaks of correlation between grey matter volume and insight were used to recreate brain correlation maps.

RESULTS

A total of 418 records were identified through database searching. Of these records, twenty-three magnetic resonance imaging (MRI) studies that used different insight scales were included. The quality of the evidence was high in 11 studies, moderate in nine, and low in three. Patients with reduced insight showed decreases in the frontal, temporal (specifically in superior temporal gyrus), precuneus, cingulate, insula, and occipital lobes cortical grey matter volume. The meta-analysis indicated a positive correlation between grey matter volume and insight in the right insula (i.e., the smaller the grey matter, the lower the insight).

CONCLUSION

Several brain areas might be involved in impaired insight in patients with non-affective psychoses. The methodologies employed, such as the applied insight scales, may have contributed to the considerable discrepancies in the findings.

Neuroimaging correlates of insight in non-affective psychosis: A systematic review and meta-analysis

OBJECTIVE

Neurological correlates of impaired insight in non-affective psychosis remain unclear. This study aimed to review and meta-analyze the studies assessing the grey matter volumetric correlates of impaired insight in non-affective psychosis.

METHODS

This study consisted of a systematic review of 23 studies, and a meta-analysis with SDM-PSI of the 11 studies that were whole-brain and reported maps or peaks of correlation of studies investigating the grey matter volumetric correlates of insight assessments of non-affective psychosis, PubMed and OVID datasets were independently reviewed for articles reporting neuroimaging correlates of insight in non-affective psychosis. Quality assessment was realized following previous methodological approaches for the ABC quality assessment test of imaging studies, based on two main criteria: the statistical power and the multidimensional assessment of insight. Study peaks of correlation between grey matter volume and insight were used to recreate brain correlation maps.

RESULTS

A total of 418 records were identified through database searching. Of these records, twenty-three magnetic resonance imaging (MRI) studies that used different insight scales were included. The quality of the evidence was high in 11 studies, moderate in nine, and low in three. Patients with reduced insight showed decreases in the frontal, temporal (specifically in superior temporal gyrus), precuneus, cingulate, insula, and occipital lobes cortical grey matter volume. The meta-analysis indicated a positive correlation between grey matter volume and insight in the right insula (i.e., the smaller the grey matter, the lower the insight).

CONCLUSION

Several brain areas might be involved in impaired insight in patients with non-affective psychoses. The methodologies employed, such as the applied insight scales, may have contributed to the considerable discrepancies in the findings.

Relationship between childhood trauma and level of insight in schizophrenia: A path-analysis in the national FACE-SZ dataset

INTRODUCTION

This study aimed was to investigate the relationship between different types of childhood trauma and the level of insight (i.e., awareness of having a psychiatric disorder) in subjects suffering from schizophrenia, as well as the putative role of clinical mediators.

METHODS

294 community-dwelling subjects with stable schizophrenia were included into FACE-SZ, a multicentre cross-sectional study. All patients were assessed by specialized multidisciplinary teams. The level of insight was assessed by the Scale to assess Unawareness of Mental Disorder (SUMD), and childhood trauma by the Childhood Trauma Questionnaire (CTQ). Path analyses from the five CTQ subscales (physical abuse and neglect, emotional abuse and neglect, and sexual abuse) and the SUMD, with current symptomatology (i.e., positive, negative, global psychopathology and depression) as mediator, was performed.

RESULTS

Physical neglect (β = 0.14) and abuse (β = 0.13) were significantly associated with poor insight. Negative symptoms were a clinical mediator of the relationship between physical neglect and poor insight. Moreover, positive (β = 0.21) and negative (β = 0.30) symptoms were associated with poor insight, whereas depression (β = -0.14) was associated with higher levels of insight.

DISCUSSION

For the first time, this study shows a significant relationship between childhood trauma, specifically physical neglect and abuse, and poor insight. The level of insight was linked to different clinical dimensions. Among subjects with schizophrenia, these results provide support for a role of childhood trauma in poorer management outcomes, and the need to provide treatment, including psycho-education that better targets the consequences of childhood trauma.

Changes in insight over the first 24 months of treatment in schizophrenia spectrum disorders

BACKGROUND

While insight in schizophrenia improves with treatment, significant impairments often persist. The degree of persistence is not well characterised.

AIMS

We assessed patient and clinician-rated changes in insight in acutely ill, minimally treated first-episode schizophrenia spectrum disorder patients over 24 months of standardised treatment with a depot antipsychotic.

METHOD

This single arm open label longitudinal cohort study included 105 participants with first-episode schizophrenia, schizophreniform or schizoaffective disorder. Insight was assessed at months 0, 6, 12 and 24 using the patient-rated Birchwood Insight Scale (BIS) and clinician-rated global insight item of the Positive and Negative Syndrome Scale (PANSS). Changes in insight over time were assessed using linear mixed-effect models for continuous repeated measures. Relationships between insight and psychopathology, functionality, cognition and quality of life were assessed with regression models.

RESULTS

There was significant improvement over time for the PANSS insight item (p < 0.0001). However, the only significant improvement for the BIS was with the Need for Treatment subscale (p = 0.01). There were no significant improvements noted for the Symptom Attribution (p = 0.7) and Illness Awareness (p = 0.2) subscales, as well as the BIS Total score (p = 0.6). Apart from depressive symptoms at baseline, there were no significant predictors of patient-rated insight.

CONCLUSIONS

Clinicians should note that, even when treatment is assured and response is favourable, fundamental impairments in patient-rated insight persist.

Validity of the Birchwood insight scale in patients with schizophrenia spectrum- and bipolar disorders

The aim of this study is to investigate the validity of the Norwegian version of the Insight Scale (IS) in large and representative samples of patients with schizophrenia spectrum disorders, bipolar I disorder and bipolar II disorder. A total of 997 participants were included (schizophrenia spectrum disorders: 557; bipolar I disorder: 282; bipolar II disorder: 138). Confirmatory factor analysis was conducted to investigate the construct validity and bivariate correlational analysis was applied to investigate convergent validity. Confirmatory factor analyses indicated a reasonable model fit to the original three-factor subscale structure of the IS in all three diagnostic groups. The IS total score and its subscales correlated significantly with both the insight items in the Young Mania Rating Scale and the Positive and Negative Syndrome Scale in both schizophrenia spectrum disorders and bipolar I disorder. In the bipolar II disorder group, however, the IS subscales correlated poorly with both the observer-rated measures. Our study supports the construct validity of the IS in both schizophrenia spectrum disorder- and bipolar disorder populations. The study also demonstrates that patients' self-reports of insight correspond to observer-based single item ratings of insight in bipolar I disorder and schizophrenia spectrum disorders.

Psychometric Properties of the Insight in Psychosis Questionnaire and its Correlation to Psychopathology in Indian Population

BACKGROUND

The present study attempted to standardize insight in psychosis questionnaire in India and correlate insight with psychopathology and functioning.

MATERIALS AND METHODS

A cross-sectional study was conducted in July and August 2016. The questionnaire was translated into Hindi following standard procedure. After ensuring that the patients fulfilled criteria for the study, consent was taken, and insight in psychosis questionnaire (Hindi version), positive and negative syndrome scale for schizophrenia, clinical insight rating scale, Present State Examination insight item, and the global assessment of functioning scale were applied. Appropriate statistical analyses were done.

RESULTS

The mean age of 53 patients included in the study was 33.42 ± 10.32 years. The majority of the patients were males, single and had <12 years of formal education and resided in joint families and urban areas. The mean duration of illness was 78.64 ± 86.16 months. The insight in psychosis questionnaire was found to have good internal consistency, split-half reliability, test-retest reliability, and convergent validity in the Indian population. Patients residing in the rural background had lower insight than those residing in urban areas, and patients having brief psychotic disorder had lower insight than those having schizophrenia. Insight was positively correlated with negative symptoms, general psychopathology, and total psychopathology but negatively correlated with positive symptoms. Psychopathology was negatively correlated with functioning.

CONCLUSIONS

The study of insight and its correlation with psychopathology and functioning should be an important area for research as insight is associated with outcome and prognosis among patients with psychosis.

Insight and treatment attitude in schizophrenia: comparison of patients on depot and atypical antipsychotics

Aims and Method

To establish if participants with schizophrenia receiving depot antipsychotics had less insight than similar participants receiving oral atypical antipsychotics. We assessed the difference between these two groups.

Results

Participants on oral antipsychotics had greater insight than those on depot antipsychotics (ITAQ, P=0.01). In the multiple regression analysis, only receiving depot antipsychotics contributed significantly to explaining variance in insight (adjusted R2=0.135, F=8.99, P=0.004).

Clinical Implications

Depot antipsychotics seem to be prescribed to a subgroup of people with schizophrenia who are likely to be less adherent because of lower levels of insight. These individuals are on significantly higher doses of antipsychotic medication. Clinicians should review their patients on depot antipsychotics at regular intervals.

Factors associated with complete discontinuation of medication among patients with schizophrenia in the year after hospital discharge

Medication discontinuation is a major risk factor for relapse in schizophrenic patients. The present study investigated the rate and clinical correlates of complete medication discontinuation in the year after hospital discharge. Data collected from 236 schizophrenia patients who were prescribed anti-psychotics documented socio-demographic characteristics, symptom severity, insight, and attitudes towards medication in the week before their discharge and the experience of caregiver burden for their primary caregiver as recorded at the time of hospitalization. Follow-up telephones call one-year after discharge documented whether they were regularly taking prescribed psychotropic medication or not. Logistic regression analysis was used to investigate factors that were independently associated with medication discontinuation. Altogether 25.8% of the sample discontinued medication in the one-year after discharge. Logistic regression analysis showed that shorter duration of illness, lack of health insurance, and poor insight at the time of discharge were significantly associated with complete discontinuation of medication (p<0.05). Patients discontinued their medication within a year after psychiatric hospitalization which was associated with a lack of insurance coverage, less insight into their illness and shorter duration of illness. Interventions that strengthen patient engagement in treatment through insurance coverage and insight, fostered through psychoeducational intervention, may increase medication compliance.

The impact of periventricular white matter lesions in patients with bipolar disorder type I

INTRODUCTION

White matter hyperintensities (WMHs) are one the most common neuroimaging findings in patients with bipolar disorder (BD). It has been suggested that WMHs are associated with impaired insight in schizophrenia and schizoaffective patients; however, the relationship between insight and WMHs in BD type I has not been directly investigated.

METHODS

Patients with BD-I (148) were recruited and underwent brain magnetic resonance imaging (MRI). Affective symptoms were assessed using Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale (HDRS17); the presence of impaired insight was based on the corresponding items of YMRS and HDRS17.

RESULTS

Multiple punctate periventricular WMHs (PWMHs) and deep WMHs (DWMHs) were observed in 49.3% and 39.9% of the cases, respectively. Subjects with lower insight for mania had significantly more PWMHs (54.6% vs 22.2%; p < 0.05) when compared to BD-I patients with higher insight for mania. The presence of PWMHs was independently associated with lower insight for mania: patients who denied illness according to the YMRS were 4 times more likely to have PWMHs (95% CI: 1.21/13.42) than other patients.

CONCLUSIONS

Impaired insight in BD-I is associated with periventricular WMHs. The early identification of BD-I subjects with PWMHs and impaired insight may be crucial for clinicians.

Is severity of family burden a correlate of length of stay?

It has been difficult to identify relevant correlates of inpatient psychiatric length of stay (LOS), but few have examined family burden as a potential factor. The present study investigated the association of several dimensions of family burden with LOS net of other factors. Dimensions of burden experienced by primary caregivers were evaluated in a sample of 602 psychiatric inpatients in a large hospital in Guangzhou, China within 1 week of admission. Factor analysis reduced the burden data to five factors. Bivariate association and multiple linear regression analyzes were used to investigate burden and other factors associated with LOS (average LOS=58.8 days, SD=44.3). Multiple regression analysis showed that in addition to having health insurance coverage, being diagnosed with schizophrenia, being unmarried, and not being employed; being perceived by family members as showing more violent behavior and causing higher levels of caregiver distress were independently associated with longer LOS.

Predictors of schizophrenia spectrum disorders in early-onset first episodes of psychosis: a support vector machine model

Identifying early-onset schizophrenia spectrum disorders (SSD) at a very early stage remains challenging. To assess the diagnostic predictive value of multiple types of data at the emergence of early-onset first-episode psychosis (FEP), various support vector machine (SVM) classifiers were developed. The data were from a 2-year, prospective, longitudinal study of 81 patients (age 9-17 years) with early-onset FEP and a stable diagnosis during follow-up and 42 age- and sex-matched healthy controls (HC). The input was different combinations of baseline clinical, neuropsychological, magnetic resonance imaging brain volumetric and biochemical data, and the output was the diagnosis at follow-up (SSD vs. non-SSD, SSD vs. HC, and non-SSD vs. HC). Enhanced recursive feature elimination was performed for the SSD vs. non-SSD classifier to select and rank the input variables with the highest predictive value for a diagnostic outcome of SSD. After validation with a test set and considering all baseline variables together, the SSD vs. non-SSD, SSD vs. HC and non-SSD vs. HC classifiers achieved an accuracy of 0.81, 0.99 and 0.99, respectively. Regarding the SSD vs. non-SSD classifier, a combination of baseline clinical variables (severity of negative, disorganized symptoms and hallucinations or poor insight) and neuropsychological variables (impaired attention, motor coordination, and global cognition) showed the highest predictive value for a diagnostic outcome of SSD. Neuroimaging and biochemical variables at baseline did not add to the predictive value. Thus, comprehensive clinical/cognitive assessment remains the most reliable approach for differential diagnosis during early-onset FEP. SVMs may constitute promising multivariate tools in the search for predictors of diagnostic outcome in FEP.

Insight in inpatients with schizophrenia: relationship to symptoms and neuropsychological functioning

OBJECTIVE

Lack of insight into illness has long been recognized as a central characteristic of schizophrenia. Although recent theories have emphasized neurocognitive dysfunction as a central impairment in schizophrenia it remains unclear whether the lack of insight in schizophrenia is more strongly associated with measures of symptom severity or neuropsychological dysfunction.

METHODS

Seventy-four consecutive inpatients with chronic schizophrenia were enrolled in a cross-sectional study. All subjects were assessed with the Positive and Negative Syndrome Scale (PANSS, five-factor model), the Insight and Treatment Attitudes Questionnaire (ITAQ), and the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB). Bivariate association and multiple linear regression analyses were used to investigate the relationship between insight and both symptoms and neurocognition.

RESULTS

On bivariate correlation, the positive, negative, disorganized and excited factors of the PANSS showed a negative correlation with insight but there was no significant association between the MCCB total score or any component subscale and insight. Multiple regression analysis showed that positive symptoms, disorganized/concrete symptoms and excited symptoms contributed to awareness of mental illness; positive and disorganized/concrete symptoms were significant contributors to awareness of the need for treatment; but there were no significant associations with the MCCB.

CONCLUSIONS

Insight in this sample of patients with chronic schizophrenia is significantly associated with clinical symptoms but not with neuropsychological functioning.

The VAGUS insight into psychosis scale--self-report and clinician-rated versions

The aim of this study was to develop self-report and clinician-rated versions of an insight scale that would be easy to administer, sensitive to small changes, and inclusive of the core dimensions of clinical insight into psychosis. Ten-item self-report (VAGUS-SR) and five-item clinician-rated (VAGUS-CR) scales were designed to measure the dimensions of insight into psychosis and evaluated in 215 and 140 participants, respectively (www.vagusonline.com). Tests of reliability and validity were performed. Both the VAGUS-SR and VAGUS-CR showed good internal consistency and reliability. They demonstrated good convergent and discriminant validity. Both versions were strongly correlated with one another and with the Schedule for the Assessment of Insight and Birchwood Insight Scale. Exploratory factor analyses identified three possible latent components of insight. The VAGUS-CR and VAGUS-SR are valid, reliable and easy to administer. They are build on previous insight scales with separate clinician-rated and self-report versions. The VAGUS-SR exhibited a multidimensional factor structure. Using a 10-point Likert scale for each item, the VAGUS has the capacity to detect small, temporally sensitive changes in insight, which is essential for intervention studies with neurostimulation or rapidly acting medications.

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.

Qualitative investigation of targets for and barriers to interventions to prevent psychosis relapse

BACKGROUND

Early signs based relapse prevention interventions for psychosis show promise. In order to examine how they might be improved we sought to better understand the early relapse process, service users' abilities to identify early signs, and any potential facilitators and barriers to early signs interventions.

METHODS

Data from in-depth interviews with a convenience sample of service users with psychosis varying in gender, age, duration of mental health problems, and time since last relapse were analysed using a thematic approach. Interview transcripts were coded inductively and relationships between emerging themes were examined by the research team to provide a thorough synthesis of the data.

RESULTS

Three central themes emerged from the analysis: 1) recognising risk factors (how risk factors were identified and linked to relapse, and reactions to such risk factors); 2) identifying early signs (issues related to both recognising and recalling signs of relapse); 3) reacting to deterioration (participants' thoughts and feelings in response to early signs, including help seeking and its challenges).

CONCLUSIONS

There was considerable variation in the attention participants had paid to pre-relapse signs, the ease with which they were able to recall them, and their reactions to them. For many, there were substantial barriers to help seeking from services. A family or friend confidant was an important means of assistance, although the supportive presence of significant others was not always available. Based on these results, a number of recommendations about facilitating service users' recognition of early signs and targeting potential accelerants of relapse are made.

Insight in mental illness: an educational review

Insight is an elusive concept in psychiatry with a long history of divergent definitions and methods of measurements. Although insight was previously presumed to be a binary construct that an individual could possess or lack, there is an emerging consensus that insight is a multi-dimensional construct consisting of a spectrum of phenomena. Over recent years there has been increasing interest in the topic of insight, especially in relation to psychotic disorders where insight is frequently diminished. In this educational review we will discuss the history associated with the construct of insight, current theories in relation to insight, the association of insight with clinical symptoms and prognosis with particular reference to psychosis, the various methods of measuring insight, the aetiology of insight and present deficiencies in our understanding of insight.

Insight in stable schizophrenia: relations with psychopathology and cognition

OBJECTIVE

This study evaluated the relationship among insight, sociodemographic and clinical variables, symptoms and cognitive functions in a population of outpatients with stable schizophrenia, in order to identify possible contributing factors to awareness.

METHOD

Two-hundred and seventy-six consecutive outpatients with stable schizophrenia were enrolled in a cross-sectional study. All subjects were assessed by psychiatric scales and interview, and a wide neuropsychological battery. A factor analysis was performed to identify cognitive factors and multiple regression analyses were executed to test the contribution of variables considered to insight.

RESULTS

Our results showed that positive and negative symptoms, executive functions, verbal memory-learning were contributors of awareness of mental illness; positive and negative symptoms explained variability in awareness of the need for treatment; positive symptoms and executive functions contributed to awareness of the social consequences of disorder.

CONCLUSIONS

These results suggested that insight was partially influenced by positive and negative symptoms and by cognitive functions. A complex system of overlapping variables may underlie impaired insight, contributing to a different extent to specific dimensions of poor insight in patients with stable schizophrenia.

Systematic review reveals heterogeneity in the use of the Scale to Assess Unawareness of Mental Disorder (SUMD)

The Scale to Assess Unawareness of Mental Disorder (SUMD) is one of the most widely used instruments to measure insight into mental disorders. The aim of this study was to review all studies using the SUMD in the last 20 years. We performed an electronic search of MEDLINE using PubMed to identify all relevant studies published from 1993 to 2012. The following data were extracted from each article: characteristics of the SUMD (version, rating scale, scoring, and item/dimension used), methodological aspects (country, language, subject inclusion criteria, and sample size), and statistical methods to analyse insight. Of the 133 articles screened, 100 studies were included in the review. Fifty-two studies were published over the past five years. The SUMD was rarely used in its entirety, and the use of selected items or subscales was heterogeneous across studies. The studies also varied in terms of response modalities and in the use of 3- or 5-point Likert scales. The calculation of insight scores was highly variable and included the following: treating items as categorical or continuous variables, separate analysis of individual items, items expressed in terms of the sum total or the mean scores, and a range of score values used to define insight. This paper provides a systematic review of studies using the SUMD and reveals important differences in the versions used, the methods of calculation, and the interpretation of scores across studies. The use of a modified SUMD may compromise the psychometric properties of the scale, lead to erroneous conclusions, and prevents comparison of results across studies. Our review underlines the need for the standardised use of the SUMD.

Frontotemporoparietal asymmetry and lack of illness awareness in schizophrenia

INTRODUCTION

Lack of illness awareness or anosognosia occurs in both schizophrenia and right hemisphere lesions due to stroke, dementia, and traumatic brain injury. In the latter conditions, anosognosia is thought to arise from unilateral hemispheric dysfunction or interhemispheric disequilibrium, which provides an anatomical model for exploring illness unawareness in other neuropsychiatric disorders, such as schizophrenia.

METHODS

Both voxel-based morphometry using Diffeomorphic Anatomical Registration through Exponentiated Lie Algebra (DARTEL) and a deformation-based morphology analysis of hemispheric asymmetry were performed on 52 treated schizophrenia subjects, exploring the relationship between illness awareness and gray matter volume. Analyses included age, gender, and total intracranial volume as covariates.

RESULTS

Hemispheric asymmetry analyses revealed illness unawareness was significantly associated with right < left hemisphere volumes in the anteroinferior temporal lobe (t = 4.83, P = 0.051) using DARTEL, and the dorsolateral prefrontal cortex (t = 5.80, P = 0.003) and parietal lobe (t = 4.3, P = 0.050) using the deformation-based approach. Trend level associations were identified in the right medial prefrontal cortex (t = 4.49, P = 0.127) using DARTEL. Lack of illness awareness was also strongly associated with reduced total white matter volume (r = 0.401, P < 0.01) and illness severity (r = 0.559, P < 0.01).

CONCLUSION

These results suggest a relationship between anosognosia and hemispheric asymmetry in schizophrenia, supporting previous volume-based MRI studies in schizophrenia that found a relationship between illness unawareness and reduced right hemisphere gray matter volume. Functional imaging studies are required to examine the neural mechanisms contributing to these structural observations.

Relationships between psychopathological variables and insight in psychosis risk syndrome and first-episode and multiepisode schizophrenia

Insight may vary across psychosis risk syndrome (PRS), first-episode schizophrenia (FES), or multiepisode schizophrenia (MES). We aimed to compare insight domains (awareness, relabeling, and compliance) in PRS, FES, and MES groups and to correlate scores with psychopathological measures. Insight was assessed in 48 (14 PRS, 16 FES, and 18 MES) patients using the Schedule for the Assessment of Insight-Expanded Version. We conducted psychopathological assessment through the Brief Psychiatric Rating Scale (BPRS). In the whole group, the BPRS psychosis factor correlated with all insight domains. In the MES group, the more severe the anxiety/depression, the higher the insight score in the symptom relabeling domain. Insight did not differ significantly between the PRS, FES, and MES groups. Our results suggest that, across different phases of the illness, lack of insight behaves like a trait and is modulated by positive symptom severity. Anxiety and depression may be associated with increased insight in patients with chronic schizophrenia.

Failures of metacognition and lack of insight in neuropsychiatric disorders

Lack of insight or unawareness of illness are the hallmarks of many psychiatric disorders, especially schizophrenia (SCZ) and other psychoses and could be conceived of as a failure in metacognition. Research in this area in the mental health field h as burgeoned with the development and widespread use of standard assessment instruments and the mapping out of the clinical and neuropsychological correlates of insight and its loss. There has been a growing appreciation of the multi-faceted nature of the concept and of the different 'objects' of insight, such as the general awareness that one is ill, to more specific metacognitive awareness of individual symptoms, impairments and performance. This in turn has led to the notion that insight may show modularity and may fractionate across different domains and disorders, supported by work that directly compares metacognition of memory deficits and illness awareness in patients with SCZ, Alzheimer's disease and brain injury. The focus of this paper will be on the varieties of metacognitive failure in psychiatry, particularly the psychoses. We explore cognitive models based on self-reflectiveness and their possible social and neurological bases, including data from structural and functional MRI. The medial frontal cortex appears to play an important role in self-appraisal in health and disease.

Exploring the structure of psychopathological symptoms: a re-analysis of AMDP data by robust nonmetric multidimensional scaling

This paper investigates the structure of psychopathological symptoms. Based on AMDP symptom profiles, a symptom space was calculated by robust nonmetric multidimensional scaling (NMDS) and the symptom structures of a sample dating from 1980 and a sample from 2002/2003 were compared. The method of NMDS presented in this study allows results from other studies to be confirmed and complemented. The symptom factors identified in the past by factor-analytic studies were replicated as clusters in two-dimensional symptom maps. Additionally, some theoretically assumed clusters of symptoms were detected that were not found in previous factor analysis approaches. From the results, which are depicted in a continuous space, new insights can be gained, especially with regard to questions of categorical and dimensional classifications. The comparison of the structural aspects of the symptomatology across more than two decades resulted in only small divergences and allows conclusions to be drawn about the stability of these structures and consequently of the symptom clusters and dimensions.

Insight in schizophrenia: from conceptualization to neuroscience

Lack of insight into illness is a prevalent and distinguishing feature of schizophrenia, which has a complex history and has been given a variety of definitions. Currently, insight is measured and treated as a multidimensional phenomenon, because it is believed to result from psychological, neuropsychological and organic factors. Thus, schizophrenia patients may display dramatic disorders including demoralization, depression and a higher risk of suicide, all of which are directly or indirectly related to a lack of insight into their illness, and make the treatment difficult. To improve the treatment of people with schizophrenia, it is thus crucial to advance research on insight into their illness. Insight is studied in a variety of ways. Studies may focus on the relationship between insight and psychopathology, may view behavioral outcomes or look discretely at the cognitive dysfunction versus anatomy level of insight. All have merit but they are dispersed across a wide body of literature and rarely are the findings integrated and synthesized in a meaningful way. The aim of this study was to synthesize findings across the large body of literature dealing with insight, to highlight its multidimensional nature, measurement, neuropsychology and social impact in schizophrenia. The extensive literature on the cognitive consequences of lack of insight and the contribution of neuroimaging techniques to elucidating neurological etiology of insight deficits, is also reviewed.

Addressing non-adherence to antipsychotic medication: a harm-reduction approach

This paper discusses the evidence base for interventions addressing non-adherence to prescribed antipsychotics. A case study approach is used, and the extent to which adherence improvement interventions might be used in collaboration with a specific patient is considered. The principles and application of harm-reduction philosophy in mental health are presented in a planned non-adherence harm-reduction intervention. This intervention aims to acknowledge the patient's ability to choose and learn from experience and to reduce the potential harm of antipsychotic withdrawal. The intervention evaluation method is outlined.

Self-perceived cognitive functioning does not correlate with objective measures of cognition in schizophrenia

BACKGROUND

Growing interest in the study of self-perceived cognitive deficits in schizophrenia has been recently observed. The authors validated in a previous study the Subjective Scale To Investigate Cognition into Schizophrenia Tunisian Arabic Version (SSTICS_tun_arab), a self-questionnaire established to collect cognitive complaints in patients with schizophrenia.

OBJECTIVE

The aim of the present study was to explore the relationship between the SSTICS_tun_arab scores and objective cognitive performances.

METHODS

One hundred four patients with schizophrenia spectrum disorders were administered measures of the Positive and Negative Syndrome Scale, the Global Assessment Functioning Scale, and the Calgary Depression Scale as well as measures of the SSTICS_tun_arab and a cognitive battery.

RESULTS

No correlations were found between objective neuropsychologic performances and scores of the SSTICS_tun_arab.

CONCLUSIONS

Our findings support the hypothesis of independence of self-perceived cognitive functioning from objective neuropsychologic deficits in schizophrenia. They also suggest that insight of mental illness seems to be not a unitary concept but more likely to be divided in different aspects including cognitive insight.

Can insight be predicted in first-episode psychosis patients? A longitudinal and hierarchical analysis of predictors in a drug-naïve sample

Poor insight is a ubiquitous phenomenon in psychosis with great repercussions on clinical practise and the outcomes of patients. Poor insight comprises "state" and "trait" components. This paper targeted predictors of global insight and insight dimensions at baseline in the drug-naïve status of first-episode psychosis patients and during a 6-month follow up after episode remission. Seventy-seven consecutive and previously unmedicated patients with first-episode schizophrenia-spectrum disorders (FESSD) completed baseline and 6-month insight, premorbid, symptomatological and neuropsychological assessments. Insight measures served as dependent variables for a set of hierarchical multiple regression models. Premorbid personality abnormalities and duration of untreated psychosis (DUP) significantly predicted 'state' and 'trait' insight global scores. Duration of untreated psychosis (DUP) significantly predicted 'state' insight, measured as refusal of treatment at baseline. Moreover, premorbid personality abnormalities and DUP with minor contributions of demographic variables, cognitive functioning and psychopathological dimensions predicted 'trait insight', defined as insight after remission of the psychosis episode 'Insight improver' FESSD patients showed better late adolescent premorbid adjustment, lower personality disturbances (sociopathic, schizoid and schizotypy dimensions), shorter DUP, and lower positive, negative and disorganisation symptoms and better cognitive performance on the Trail Making B test at the 6-month follow-up assessment. Premorbid personality abnormalities and DUP were predictors of 'state' and 'trait' insight, both at global scores and dimension levels. Moreover, insight improvement in patients with FESSD was related to premorbid abnormalities (in both adjustment and personality), shorter DUP, fewer positive and negative symptoms and better performance in cognitive tests at the 6-month follow up.

Subjective and Objective Cognitive Dysfunction in Schizophrenia - is there a Link?

Cognitive dysfunction is a well recognized symptom of schizophrenia, as well as patients having poor insight into their illness. The subjective scale to investigate cognition in schizophrenia (SSTICS) is one of several scales that have been developed to study subjective cognitive dysfunction and has been compared to patients’ objective cognitive level. A literature search was performed using PubMed, psychINFO, Web of Science, and cross-referencing to find 26 articles which used 14 different subjective cognitive dysfunction scales to investigate the relationship between subjective and objective measures of cognition in schizophrenia. Although the majority of studies using the SSTICS found significant correlations between subjective and objective measures of cognition, the findings from the other scales were less clear. From this review, the issue of whether or not schizophrenic patients have good cognitive insight remains unsure. However, due to the heterogeneous nature of the study designs and their outcome measures, continued work in this area with consistency on these points is necessary; on the path to better provide management options for a very debilitating component of this illness.

Appreciating symptoms and deficits in schizophrenia: right posterior insula and poor insight

Poor insight is one of the most prominent clinical features of psychosis. Loss of insight in schizophrenia is characterised by abnormalities in awareness and attribution of the origin of pathological mental phenomena. Converging lines of investigations suggest that in healthy individuals, right posterior insula plays an important role in awareness and self-attribution of mental phenomena, contributing to the emergence of a sense of self (Craig, 2002; Farrer et al., 2003). In addition, neuroimaging studies investigating brain morphometry in schizophrenia have consistently reported deficits in the structure of insula (Glahn et al., 2008; Ellison-Wright and Bullmore, 2010). In the present study, we investigated the relationship between the morphometry of posterior insula and degree of insight in a sample of 57 patients in a stable phase of illness using high resolution Magnetic Resonance Imaging. We measured the cortical surface area and local white matter volume of posterior insula. A significant inverse relationship was found between right posterior insular structure and degree of insight in schizophrenia. No such relationship was noted for left posterior insula. Our results highlight the importance of a predominantly right-sided network that includes posterior insula as the neural basis of insight. Abnormalities in interoceptive awareness and self-appraisal of emotional states may contribute to the loss of insight seen in schizophrenia.

Insight among psychotic patients with auditory hallucinations

Poor insight in psychosis has been described as a seeming lack of awareness of the deficits, consequences of the disorder, and of the need for treatment. The aim of this study is to investigate whether patients with auditory hallucinations have less insight than those without hallucinations, and to determine which hallucination characteristics are related to patient insight. Using the PANSS and PSYRATS, the authors have evaluated the lack of insight data corresponding to 168 psychotic patients divided into three groups: patients with a history of nonpersistent hallucinations, patients with persistent hallucinations, and patients without hallucinations. Patients with persistent hallucinations showed significantly less insight than patients without persistent hallucinations and patients without hallucinations, the farther away the hallucination is located, the greater the lack of patient insight. Patients who hear the hallucination inside their head rather than outside show better insight, possibly because such patients can understand the voice as being created by their own mind.

Combining the categorical and the dimensional perspective in a diagnostic map of psychotic disorders

We introduce a diagnostic map that was calculated by robust non-metric multidimensional scaling based on AMDP symptom profiles of patients with schizophrenic and affective disorders to demonstrate a possibility to combine the categorical and the dimensional perspective at the same time. In the diagnostic map, a manic, a depressive, and a non-affective cluster clearly emerged. At the same time, the mania dimension (r = 0.82), the depression dimension (r = 0.68), and the apathy dimension (r = 0.74) showed high multiple regression values in the map. We found substantial overlaps of the diagnostic groups with regard to the affective spectrum but irrespective of the ICD-10 classification. Within this sample, we found the association and quality of mood symptoms to be a structuring principle in a diagnostic map. We demonstrate that this approach represents a promising way of combining the categorical and the dimensional perspective. As a practical implementation of these findings, a multidimensional diagnostic map could serve as an automated diagnostic tool based on psychopathological symptom profiles.

Measurement of psychiatric treatment adherence

OBJECTIVE

Nonadherence to medications for mental disorders substantially limits treatment effectiveness and results in higher rates of relapse, hospitalization, and disability. Accurate measurement of medication adherence is important not only in adherence research but also in clinical trials in which medications are being evaluated and in clinical practice where failure to detect nonadherence results in premature medication changes, unnecessary polypharmacy, and greater likelihoods of functional deteriorations and hospitalizations. This is a review of psychiatric treatment adherence methods and measures arising from a meeting on "Methodological Challenges in Psychiatric Treatment Adherence Research" held on September 27-28, 2007, in Bethesda, MD, and organized by the National Institute of Mental Health (NIMH).

METHODS

This paper reviews the range of modalities currently available for assessing adherence behavior including pill counts, pharmacy records, technology-assisted monitoring, biological assays, and a range of self-report and interviewer-rated scales. Measures of adherence attitudes are also reviewed.

RESULTS

Each of the adherence measures described are imperfect estimates of actual medication ingestion, but each provides informative estimates of adherence or the attitudinal factors associated with adherence. Measure selection depends on a range of factors including the patient sample, the context in which the measure is being used, and the clinical outcomes expected from various levels of nonadherence. The use of multiple measures of adherence is encouraged to balance the limitations of individual measures.

CONCLUSION

While adherence assessment has become increasingly sophisticated in recent years, there remains a need for refinement and expansion on currently available methods and measures.

Methodological challenges in psychiatric treatment adherence research

Reflecting an increasing awareness of the importance of treatment adherence on outcomes in psychiatric populations, the National Institute of Mental Health (NIMH) convened a panel of treatment adherence researchers on September 27-28, 2007 to discuss and articulate potential solutions for dealing with methodological adherence research challenges. Panel discussions and presentations were augmented with targeted review of the literature on specific topics, with a focus on adherence to medication treatments in adults with serious mental illness. The group discussed three primary methodological areas: participants, measures, and interventions. When selecting patients for adherence-enhancing interventions (AEIs), a three-tier model was proposed that draws from the universal (targeting all patients receiving medication treatment for a specific condition, regardless of current adherence), selective (targeting patients at risk for nonadherence), and indicated (targeting patients who are currently nonadherent) prevention model and emphasizes careful patient characterization in relevant domains and appropriate matching of interventions to the selected population. Proposals were also made to reduce problematic selection biases in patient recruitment and retention. The panel addressed the pros and cons of various methods that can be used to measure adherence, and concluded that it is appropriate to use multiple measures whenever possible. Finally, the panel identified a broad range of intervention approaches, and conditions under which these interventions are likely to be most effective at reducing barriers to adherence and reinforcing adherence behavior.

Correlates, change and 'state or trait' properties of insight in schizophrenia

BACKGROUND

The associations of insight into illness and clinical and socio-demographic variables in schizophrenia have been examined, yet little attention has been given to premorbid functioning, insight change and outcomes.

OBJECTIVES

We examined these associations in a large cohort of recent onset schizophrenia spectrum disorder patients.

METHODS

This was a prospective 6-month, open-label, multicentre, phase IV trial in 303 subjects with recent onset (<or=2 years) schizophrenia treated with risperidone long-acting injection (RLAI). Insight (Schedule for the Assessment of Insight - Expanded), treatment efficacy (Positive and Negative Syndrome Scale, Clinical Global Impression) and quality of life (Short Form-36) were assessed at baseline and after 2, 4 and 6 months. The Premorbid Adjustment Scale was administered at baseline.

RESULTS

Insight was positively associated with better premorbid functioning, more education and schizoaffective disorder versus schizophrenia. Insight improved modestly, but significantly throughout treatment, particularly illness beliefs. Baseline insight was negatively correlated with quality of life and positive symptoms and positively correlated with anxiety/depression. It was not significantly associated with change in symptom severity or time in trial, but was positively associated with age.

CONCLUSIONS

Insight, at least in this stable, comparatively high-insight sample, improved during treatment but this is not closely related to improvement in psychotic symptoms. Insight appears to have trait-like qualities demonstrated by association with premorbid factors. While insight is generally a favorable attribute and is associated with fewer psychotic symptoms, it is also associated with increased depression and lower perceived quality of life. Some components of insight are more amenable to improvement; particularly the ability to adopt less fixed illness attributions.

Manic and depressive symptoms and insight in first episode psychosis

Insight impairment is common early in the course of psychosis. Most studies have focused on the relationship between insight and depression, although manic symptoms are also frequent in psychoses. The main aim of this study was to examine the relationship between insight dimensions and manic and depressive symptoms in first-episode psychosis. A group of inpatients in their first psychotic episodes (n=124) were evaluated using the Scale to Assess Unawareness of Mental Disorder, Young Mania Rating Scale and Hamilton Depression Rating Scale. To study the effect of clinical, manic and depressive symptoms on insight, awareness of mental disorder, awareness of the achieved effects of medication, and awareness of the social consequences of having a mental disorder were modelled using ordinal logistic regression techniques. Results showed that greater awareness of mental disorder was significantly related to higher age at first episode together with higher scores for negative and depressive symptoms. The opposite was found to be true in presentations with a higher severity of disease and manic symptoms. The model fitting unawareness of the achieved effects of medication identified the same significant variables, except in the case of negative symptoms. Finally, the model assessing the social consequences of having a mental disorder showed unawareness to be greater when manic symptoms and disease severity were high.

Subjective awareness of tardive dyskinesia and insight in schizophrenia

BACKGROUND

Lack of awareness of tardive dyskinesia (TD) and poor insight into mental illness are common in schizophrenia, raising the possibility that these phenomena are manifestations of a common underlying dysfunction.

METHODS

We investigated relationships between low awareness of TD and poor insight into mental illness in 130 patients with schizophrenia and TD. We also examined selected demographic and clinical correlates of these two phenomena.

RESULTS

Sixty-six (51%) patients had no or low awareness of TD and 94 (72%) had at least mild impairment of insight into their mental illness. Low awareness of TD was not significantly correlated with greater impairment of insight into mental illness. Regression analyses indicated that the Positive and Negative Syndrome Scale (PANSS) disorganised factor (β=0.72, t=11.88, p<0.01) accounted for 52% of the variance in insight into mental illness (adjusted R(2)=0.55) (F[2, 127]=81.00, p<0.01) and the Extrapyramidal Symptom Rating Scale (ESRS) dyskinesia subscale score (β=0.47, t=6.80, p<0.01), PANSS disorganised factor (β=-0.26, t=-3.73, p<0.01), and ESRS parkinsonism subscale score (β=0.31, t=4.55, p<0.01) together accounted for 37% of the variance in awareness of TD (adjusted R(2)=0.37) (F[3, 126]=26.87, p<0.01).

CONCLUSION

The two phenomena appear to be dissociated, and may be domain-specific.

Insight, social functioning and readmission to hospital in patients with schizophrenia-spectrum disorders: prospective associations

It has been claimed that insight is capable of predicting important clinical outcomes among people with schizophrenia. However, the supporting evidence is sparse. Although many cross-sectional studies have been undertaken, only prospective studies can provide convincing evidence. The aims of the present research were to assess the ability of insight to predict subsequent readmissions to hospital and social functioning. Patients with schizophrenia-spectrum disorders (N=90) were recruited at the time of an acute psychotic episode and then re-assessed after 6, 12, and 24 months. Assessments included insight, three measures of social functioning, and symptoms of psychosis. There was no evidence that having been readmitted to hospital since a previous assessment was associated with insight at the previous assessment. None of the associations between insight at one assessment and social functioning at subsequent assessments was significant. Changes in insight were associated with changes in contemporary functioning, but it was found that changes in insight made no significant contributions to changes in functioning which were independent of changes in symptoms. The general aim of improving clinical outcomes would probably be better met with interventions designed to improve functioning rather than interventions to improve insight.

Outcome of first-episode schizophrenia in India: longitudinal study of effect of insight and psychopathology

BACKGROUND

Transcultural studies have found lack of insight to be an almost invariable feature of acute and chronic schizophrenia, but its influence on prognosis is unclear.

AIMS

To investigate the relationship between insight, psychopathology and outcome of first-episode schizophrenia in Vellore, India.

METHOD

Patients with a DSM-IV diagnosis of schizophrenia (n = 131) were assessed prospectively at baseline and at 6-month and 12-month follow-up. Demographic and clinical measures included insight, psychopathology, duration of untreated psychosis (DUP) and social functioning. Linear and logistic regression was used to measure predictors of outcome.

RESULTS

Follow-up data were available for 115 patients at 1 year. All achieved remission, half of them with and half without residual symptoms. Changes in psychopathology and insight during the first 6 months and DUP strongly predicted outcome (relapse or functional impairment), controlling for baseline measures.

CONCLUSIONS

Outcome of schizophrenia in this setting is driven by early symptomatic improvement and is relatively favourable, in line with other studies from low- and middle-income countries. Early improvement in insight might be a useful clinical guide to future outcome. Reduction of DUP should be a target for intervention.

A comparison of insight into clinical symptoms versus insight into neuro-cognitive symptoms in schizophrenia

BACKGROUND

Schizophrenia is associated with neuropsychological deficits that have been linked to poor functional outcome. To address this problem, pharmacologic and behavioral treatments are being developed for cognitive impairments, but they will not be well utilized if people with schizophrenia do not perceive a need for treatment.

AIMS

This study compared whether people with schizophrenia have a similar degree of insight into neuro-cognitive symptoms as clinical symptoms, and whether neuro-cognitive and clinical symptoms are similarly related to degree of insight into these two aspects of the illness.

METHOD

Seventy-one patients with schizophrenia were administered measures of clinical and neuro-cognitive status as well as clinician rated measures of insight into clinical and neuro-cognitive symptoms.

RESULTS

Patients had significantly less insight into their neuro-cognitive symptoms than their clinical symptoms. On average, patients had good insight into clinical symptoms and partial insight into neuro-cognitive symptoms. Neuropsychological variables were related to insight into clinical symptoms, but not insight into neuro-cognition. Clinical variables were not significantly related to either type of insight.

CONCLUSIONS

Insight is not a unitary concept and the differences between awareness of neuro-cognition and awareness of clinical symptoms suggest that they have to be addressed separately in treatment. Specific education about cognitive symptoms may be necessary to improve awareness of this aspect of the schizophrenia.

Enrollment in mental health courts: voluntariness, knowingness, and adjudicative competence

Mental health courts (MHCs) are rapidly expanding as a form of diversion from jails and prisons for persons with mental illness charged with crimes. Although intended to be voluntary, little is known about this aspect of the courts. We examined perceptions of voluntariness, and levels of knowingness and legal competence among 200 newly enrolled clients of MHCs at two courts. Although most clients claimed to have chosen to enroll, at the same time, most claimed not to have been told the court was voluntary or told of the requirements prior to entering. The majority knew the "basics" of the courts, but fewer knew more nuanced information. A minority also were found to have impairments in legal competence. Implications are discussed.

Insight, global functioning and psychopathology amongst in-patient clients with schizophrenia

To explore whether cognitive impairment and global functioning can predict the degree of insight into illness as well as whether insight is mediated by specific symptom dimensions of psychopathology in schizophrenia. A dimensional/cross sectional approach was used. A mixed group of clients (n = 36) were assessed as part of a routine clinical evaluation. The Wechsler Adult Intelligence Scale (WAIS) was used as a measure of intellectual performance, the Brief Symptom Inventory (BSI) was used as a measure of general psychopathology while the Global Assessment of Functioning (GAF) scale assessed clients' psychosocial functioning; insight was assessed with the Insight and Treatment Attitudes Questionnaire (ITAQ). The correlation matrix of all outcome variables was examined; confounding effects of illness duration were tested by partial correlation analyses. GAF correlated with insight (rho = 0.41, P = 0.01) and the interpersonal sensitivity dimension of BSI (rho = -0.38, P = 0.03. Insight correlated positively with the anxiety (rho = 0.38, P = 0.03) and psychoticism (rho = 0.36, P = 0.04) dimensions of BSI. Our results suggest that insight is part of the phenomenology in schizophrenia, not being determined by neurocognitive disturbances. Improved insight was associated with more frequent psychotic symptoms endorsement, higher levels of anxiety and less severe psychopathological symptoms and difficulties in psychosocial functioning; clients with more pronounced difficulties in their personal and social interactions exhibited worse psychosocial functioning and more severe psychopathological symptoms.

Creating a map of psychiatric patients based on psychopathological symptom profiles

BACKGROUND

In the current debate about the categorical or dimensional classification of mental disorders many fruitful methods to illustrate one or the other aspect are employed, and suggestions are made to combine the two perspectives.

METHODS

We present such an approach to combine both perspectives at the same time. Based on psychopathological AMDP-symptom profiles, a map of psychiatric patients was calculated by robust nonmetric multidimensional scaling (NMDS).

RESULTS

The sample from the Ludwig-Maximilians University in Munich included the records of patients, who were admitted and discharged in 2002 and 2003 with a diagnosis of either paranoid schizophrenia, (F20.00, N = 24), bipolar affective disorder, current episode manic without psychotic symptoms (F31.1, N = 32) or severe depressive episode without psychotic symptoms (F32.2, N = 78). In the resulting map of patients we found a clear categorical distinction according to the diagnostic groups, but also high regression values of AMDP-syndromes (manic syndrome: r = 0.83, depressive syndrome: r = 0.68, and paranoid-hallucinatory syndrome, r = 0.62).

DISCUSSION

The map of psychiatric patients presents an approach to consider the categorical and dimensional aspects at the same time. We were able to identify meaningful delineations between diagnostic clusters as well as continuous transitions. This method allows the whole psychopathological profile of each individual patient to be considered and also to identify misdiagnosed cases at a glance.

Cross-sectional and longitudinal relationships between insight and attitudes toward medication and clinical outcomes in chronic schizophrenia

BACKGROUND

We evaluated the cross-sectional and longitudinal association of measures of both insight and attitudes toward medication to outcomes that included psychopathology and community functioning.

METHODS

Clinical Antipsychotic Trial of Intervention Effectiveness (CATIE) was a large 18-month follow-up study pharmacotherapy of people with schizophrenia. Insight was measured using the Insight and Treatment Attitudes Questionnaire and attitudes toward medication by the Drug Attitude Inventory. Widely known scales were used to assess symptoms of schizophrenia and depression and community functioning. Medication adherence was globally assessed by the treating psychiatrist using several sources of information. Bivariate correlations and mixed model regression analyses were used to test the relationship of insight and medication attitudes to outcomes at baseline and during the follow-up period. Regression models were used to evaluate the relationship between change in insight and medication attitudes and changes outcomes.

RESULTS

There was a significant relationship at baseline between insight and drug attitudes and symptoms of schizophrenia and depression, as well as with community functioning. Higher levels of insight at baseline were significantly associated with lower levels of schizophrenia symptoms at follow-up while more positive medication attitudes were significantly associated with both lower symptom levels and better community functioning. Change in insight scores over time was associated with declining schizophrenia symptoms but increasing levels of depression. Change toward more positive medication attitudes was associated, independently of changes in insight, with significant decreases in psychopathology, improvement in community functioning, and greater medication compliance.

CONCLUSION

Greater patient understanding of their illness and more positive attitudes toward medication may improve outcomes. Educational interventions that affect these attitudes may be an important part of psychosocial rehabilitation and/or recovery-oriented services.

The causal model of insight in schizophrenia based on the Positive and Negative Syndrome Scale factors and the structural equation modeling

We used structural equation modeling to formulate a causal model of insight in schizophrenia patients that explains the inconsistent results of the studies on the relationship between insight and psychopathology. The Positive and Negative Syndrome Scale was used to assess 342 patients with acute stage schizophrenia and 5 factors were identified through factor analysis with which a causal model of insight was constructed. Our model, where positive, negative, and autistic preoccupation (cognitive) factors were the primary predictors of insight with the activation factor mediating between positive and autistic preoccupation factors and insight, was found to show a perfect fit by most goodness-of-fit indices and to be superior to other alternative models. Specifically, positive, negative, and autistic preoccupation factors each had some predictive power for insight and the activation factor played a partial mediating role for the positive factor and a moderating role for the autistic preoccupation factor.

Insight into neurocognitive dysfunction in schizophrenia

Insight into psychotic symptoms is typically poor in schizophrenia; however, it is not known whether insight into neurocognitive impairment is similarly impaired. Most people with schizophrenia experience cognitive dysfunction, and the deficits in attention, memory, and critical thinking have been associated with poor functional outcome. As new treatments are developed for the cognitive impairments, it will be important to know whether patients will be receptive to yet another therapy. Insight is an important factor in treatment compliance and treatment outcome; however, it is not known if patients have insight into their cognitive dysfunction. In order to assess insight into neuro cognitive dysfunction, 75 subjects were administered the Measure of Insight into Cognition-Clinician Rated, a newly created measure based on the Scale to Access the Unawareness of Mental Disorder, that assesses insight into cognitive impairment. Subjects were also administered the Brief Assessment of Cognition in Schizophrenia and Independent Living Scale-Problem Solving to objectively assess neuropsychological status and problem-solving skills needed for independent living. Results demonstrated that virtually all subjects had cognitive impairment, yet insight into their neuro cognitive symptoms was limited. This finding has potential implications for treatment programs seeking to improve cognitive functioning in schizophrenia.