Illness Insight Research Articles

Understanding Medications Non Adherence in a Sample of Egyptian Patients with Schizophrenia in Relation to Illness Severity and Insight

Understanding Medications Non Adherence in a Sample of Egyptian Patients with Schizophrenia in Relation to Illness Severity and Insight

Perceptual properties of obsessive thoughts are associated with low insight in obsessive-compulsive disorder.

Obsessions are traditionally defined as bothersome and repetitive thoughts that the patient is unable to resist. Preliminary evidence suggests that in a subgroup of patients with obsessive-compulsive disorder (OCD), obsessions are experienced as partially perceptual. The present study explored the frequency of perceptually laden obsessions and their relationship with illness insight and depression. Twenty-six patients with OCD were administered the newly developed Sensory Properties of Obsessions Questionnaire. Participants were asked to endorse on a 5-point Likert scale whether their obsessions were associated with perceptual features. Participants showed moderate symptom severity. A total of 73% affirmed that their obsessions contained perceptual features. The predominant perceptual channels were visual, tactile, and somatic (i.e., bodily sensations). The extent of perceptual aspects associated with obsessions was strongly correlated with lack of insight (Yale-Brown Obsessive-Compulsive Scale item 11) but not depression severity. The present study suggests that obsessive thoughts are frequently accompanied by perceptual sensations, which concurs with models assuming a continuum between hallucinations and intrusions. Apparently, the more "real" or authentic the obsessive thought is experienced, the less the afflicted person is able to dismiss its content as fully irrational or absurd.

Lack of insight 3 years after first-episode psychosis: An unchangeable illness trait determined from first presentation?

BackgroundLack of insight is recognized as a symptom that predisposes the individuals with psychosis to noncompliance with the treatment, leading to poorer course of illness. This study aimed to explore baseline predictors of disturbances on insight at follow-up. MethodsThree insight dimensions (insight of: ‘mental illness’, ‘need for treatment’ and ‘the social consequences of the disorder’) were measured with the Scale to Assess Unawareness of Mental Disorder (SUMD) in a cohort of 224 first-episode psychosis (FEP) patients at 3-year follow-up. Subgroups, good vs. poor insight, were compared on baseline clinical, neuropsychological, premorbid and sociodemographic characteristics. Regression models tested baseline predictors for each insight dimension. ResultsAt 3-year follow-up a high percentage of patients, 45%, 36% and 33% for each dimension, were found to remain lacking insight. Poor insight into having an illness was predicted by a diagnosis of schizophrenia and poor baseline insight of the social consequences; insight into the need for treatment was predicted by adolescent adjustment and depression at baseline; and insight into the social consequences of the disorder was determined by late adolescent adjustment and baseline insight of mental illness. ConclusionsOur findings support the hypothesis that long-term insight in psychosis seems to be, to some extent, determined from first presentation, showing trait-like properties. A subgroup of ‘lacking insight’ patients, which is characterized by a diagnosis of schizophrenia, lower levels of premorbid adjustment and less severe depressive symptoms at baseline might benefit from special interventions targeted at enhancing insight from their first contact with psychiatric services.

Measuring hope among families impacted by cognitive impairment.

The current exploratory investigation aims to establish the reliability and validity of a hope measure, the Herth Hope Index, among families impacted by early cognitive impairment (N = 96). Exploratory factor analysis was used to examine the dimensionality of the measure. Bivariate analyses were used to examine construct validity. The sample had moderately high hope scores. A two-factor structure emerged from the factor analysis, explaining 51.44% of the variance. Both factors exhibited strong internal consistency (Cronbach's alphas ranged from .83 to .86). Satisfaction with social support was positively associated with hope, supporting convergent validity. Neurocognitive status, illness insight, and depression were not associated with hope, indicating discriminant validity. Families impacted by cognitive impairment may maintain hope in the face of a potentially progressive illness, regardless of cognitive status. The Herth Hope Index can be utilized as a reliable and valid measure of hope by practitioners providing support to families impacted by cognitive impairment.

Illness insight and neurophysiological error-processing deficits in schizophrenia

Impaired illness insight in schizophrenia is associated with non-adherence and worse outcomes. Schizophrenia patients also exhibit error-monitoring deficits, which have been proposed to cause poor insight. To test this hypothesis, we examined whether schizophrenia patients' deficits in neurophysiological error-monitoring indices, the error-related negativity (ERN) and error positivity (Pe) event-related potential (ERP) amplitudes, are associated with impaired insight. ERPs were recorded in 18 schizophrenia patients and 18 normal comparison participants during a Stroop task. Patients' subnormal ERN and Pe amplitudes did not correlate with insight, suggesting that impaired insight in schizophrenia stems from neurocognitive mechanisms other than deficient error monitoring.

Poster #T60 SERVICE SATISFACTION AND SPIRITUAL WELL-BEING AS PREDICTORS OF QUALITY OF LIFE AMONG PATIENTS WITH SCHIZOPHRENIA: A LONGITUDINAL STUDY USING A STRUCTURAL EQUATION MODEL APPROACH

Adherence to antipsychotics improves outcome in schizophrenia. There is a lack of consensus on which factors most influence adherence behaviour and methodological issues hinder interpretation of existing evidence. A rigorous systematic search designed to identify robustly implicated factors emerging from methodologically rigorous studies narrowed our search to 13 observational studies (total N=6235) relating to adherence, antipsychotics and schizophrenia. Studies varied significantly, with reported adherence rates ranging from 47.2% to 95%. Positive attitude to medication and illness insight were the only factors consistently associated with better adherence, while contradictory results were found for socio-demographic characteristics, symptom severity and side effects. Only distinct aspects of the therapeutic relationship and social support in younger patients were related to good adherence. Antipsychotic type or formulation and neurocognitive functioning did not appear to impact medication adherence. Despite greater methodological rigour in determining studies to include in the present systematic review, it remains difficult to guide clinicians in this vital area and most of the work discussed contained small sample sizes. Future research in this field should therefore prioritise prospective study designs over longer periods and larger samples in naturalistic settings, providing a more appropriate and clinically meaningful framework than widely used cross-sectional designs.

Depression in first episode psychosis: The role of subordination and shame

Depression in early psychosis is linked to poor outcome, relapse and risk of suicide, yet remains poorly understood. This article aims to examine the development of depression in acute and post psychotic phases of first episode psychosis (FEP), and its relationship to persecutors, voices, insight, and recovery. Data were gathered on 92 patients with acute FEP on depression course, severity and experience of positive symptoms, insight and appraisals of illness using validated semi-structured interviews and questionnaires. Measures were repeated at 12 months. Malevolent voices, use of safety behaviours and subordination to persecutors were associated with depression and suicidal behaviour in acute FEP. Loss, Shame, low level continuing positive symptoms and longer duration of untreated psychosis were associated with post psychotic depression. Negative appraisals remained stable despite recovery in other symptom domains. Thus, depression and risk in early psychosis may be propagated by the personal significance and content of positive symptoms experienced. When in recovery, low level symptoms, longer period of illness and negative appraisals are significant factors.

Cognitive functioning and insight in schizophrenia and in schizoaffective disorder.

The aim of this study was to investigate cognitive functioning and insight of illness in two groups of patients during their stable phases, one with schizophrenia and one with schizoaffective disorder. We recruited 104 consecutive outpatients, 64 with schizophrenia, 40 with schizoaffective disorder, in the period between July 2010 and July 2011. They all fulfilled formal Diagnostic and Statistical Manual of Mental disorders (DSM-IV-TR) diagnostic criteria for schizophrenia and schizoaffective disorder. Psychiatric assessment included the Clinical Global Impression Scale-Severity (CGI-S), the Positive and Negative Sindrome Scale (PANSS), the Calgary Depression Scale for Schizophrenia (CDSS) and the Global Assessment of Functioning (GAF). Insight of illness was evaluated using SUMD. Neuropsychological assessment included Winsconsin Card Sorting Test (WCST), California Verbal Learning Test (CVLT), Stroop Test and Trail Making Test (TMT). Differences between the groups were tested using Chi-square test for categorical variables and one-way analysis of variance (ANOVA) for continuous variables. All variables significantly different between the two groups of subjects were subsequently analysed using a logistic regression with a backward stepwise procedure using diagnosis (schizophrenia/schizoaffective disorder) as dependent variable. After backward selection of variables, four variables predicted a schizoaffective disorder diagnosis: marital status, a higher number of admission, better attentive functions and awareness of specific signs or symptoms of disease. The prediction model accounted for 55% of the variance of schizoaffective disorder diagnosis. With replication, our findings would allow higher diagnostic accuracy and have an impact on clinical decision making, in light of an amelioration of vocational functioning.

Predictors of disability: A 5-year cohort study of first-episode schizophrenia

BackgroundThere is a dearth of information about the predictors of disability in schizophrenia from low and middle-income countries. This study attempted to investigate the impact of socio-demographic and clinical variables on disability in a cohort of first episode schizophrenia. MethodPatients diagnosed to have DSM IV schizophrenia (n=131) were assessed prospectively for psychopathology, functioning, insight and explanatory models of illness at baseline, 6, 12 and 60 months using standard instruments. Disability was assessed at 5 years. Multiple linear regression was employed to adjust for common confounders. ResultsWe could follow-up 95 (72.5%) patients. Sixty-five of these patients (68.4%) achieved remission. Disability scores at 5 years were associated negatively with episodic nature of illness at baseline, functional assessments at 6 and 12 months and return to pre-morbid level function. Disability correlated positively with psychopathology at 6 and 12 months and time spent in psychotic episodes. It was also associated with psychopathology, remission, insight and patient perspectives at the 5th year cross-sectional evaluation. While employment status at recruitment was not associated with disability, it was associated with unemployment at follow-up. ConclusionsDisability at 5 years was associated with illness variables – episodic nature of illness at baseline, psychopathology and functioning, duration in psychotic episode and return to pre-morbid function. Patient perspectives about their illness (insight and patient explanatory models) were only associated cross-sectionally at 60 months but not earlier and are more suggestive of a coping response rather than being predictive of outcome. The relationship between unemployment and disability suggests that they are products of the same disease process.

EPA-0882 - Prediction of diagnosis of early-onset schizophrenia spectrum disorders using support vector machines

Diagnosis of schizophrenia spectrum disorders (SSD) may be difficult in clinical practice, particularly during the first episodes of early-onset psychosis (FE-EOP). To develop a Support Vector Machine (SVM) algorithm as a predictive tool for diagnostic outcome in patients with FE-EOP, based on clinical and biomedical data at the emergence of the illness. Two-year, prospective longitudinal study, where 81 patients (9-17 years of age) with a FE-EOP and stable diagnosis at follow-up and 41 age and sex-matched healthy controls (HC) were included. Structured diagnostic interviews, clinical and cognitive scales, a MRI scan and biochemical tests were conducted at baseline. Three SVM classification algorithms were developed (SSD vs HC group, non-SSD vs HC group, and SSD vs non-SSD group). Jackknifing was used to validate the algorithms and to calculate performance estimates. Enhanced-Recursive Feature Elimination was performed in order to gain information about the predictive weight for diagnosis of each variable. The SSD-versus-non-SSD classifier achieved an overall accuracy of 83.1%, sensitivity of 86.6% and specificity of 77.8%. The variables during a FE-EOP with higher predictive value for a diagnosis of SSD were clinical variables such as negative symptoms preceding or during the psychotic onset, poor insight and duration of illness until first psychiatric contact. Biochemical, neuroimaging, and cognitive variables at baseline did not provide any additional predictive value. SVM may serve as a predictive tool for early diagnosis of SSD during a FE-EOP. The most discriminative variables during a FE-EOP for a future diagnosis of SSD are clinical variables.

Beyond words: Sensory properties of depressive thoughts

Verbal thoughts (such as negative cognitions) and sensory phenomena (such as visual mental imagery) are usually conceptualised as distinct mental experiences. The present study examined to what extent depressive thoughts are accompanied by sensory experiences and how this is associated with symptom severity, insight of illness and quality of life. A large sample of mildly to moderately depressed patients (N = 356) was recruited from multiple sources and asked about sensory properties of their depressive thoughts in an online study. Diagnostic status and symptom severity were established over a telephone interview with trained raters. Sensory properties of negative thoughts were reported by 56.5% of the sample (i.e., sensation in at least one sensory modality). The highest prevalence was seen for bodily (39.6%) followed by auditory (30.6%) and visual (27.2%) sensations. Patients reporting sensory properties of thoughts showed more severe psychopathological symptoms than those who did not. The degree of perceptuality was marginally associated with quality of life. The findings support the notion that depressive thoughts are not only verbal but commonly accompanied by sensory experiences. The perceptuality of depressive thoughts and the resulting sense of authenticity may contribute to the emotional impact and pervasiveness of such thoughts, making them difficult to dismiss for their holder.

Şizofreni hastalarında özkıyım girişimi ve özkıyım düşüncesinin, hastalık şiddeti, depresyon ve içgörü ile ilişkisi

Objective: At this study, it is aimed to determine criteria to predict the suicidal risks of schizophrenic patients and to explore the correlation of suicide attempt and suicidal ideation with insight, depression and severity of illness as well. Method: Randomly selected 104 inpatients between 20 and 65 years of age, treated with a diagnosis of schizophrenia according to DSM-IV-TR criteria at Bakirkoy Training and Research Hospital for Psychiatry, Neurology and Neurosurgery were included, and patients were examined at the period of first 72 hours of admission. The patients were evaluated with Schedule for Assessing the Three Components of Insight (SAI), Positive and Negative Syndrome Scale (PANSS), and Calgary Depression Scale for Schizophrenia (CDSS). Results: Depression scores were higher in the patients who had suicide attempt compared to those without suicide attempt. Depression and insight scores of the patients who had suicidal ideation were found to be higher compared to those without suicidal ideation. In the logistic regression analysis, CDSS was found to be the determinant of suicide attempt and suicidal ideation, PANSS negative total score was found to be the determinant of suicidal ideation, and self destructive behavior was found to be the determinant of suicide attempt. Conclusion: As depression was the common factor that determines the suicidal ideation and suicide attempts, suicidal ideation should be inquired more carefully and in more detail in the presence of depressive symptoms in patients with schizophrenia. We consider that CDSS can be easily applied and can determine the depression in patients with schizophrenia and the treatment of depression with eligible methods in turn, decreases risk of suicide.

Predictors of insight in first-episode schizophrenia: A 5-year cohort study from India

There is a dearth of data on the predictors of insight in schizophrenia. This study attempted to assess the predictors of insight in a cohort of first-episode schizophrenia followed up over 5 years. Patients diagnosed to have Diagnostic and statistical manual of mental disorders (4th ed.; DSM-IV) schizophrenia (n = 131) were assessed prospectively for insight, psychopathology and explanatory models of illness over a 5-year period using standard instruments. Multiple linear regression and generalized estimating equations (GEE) were employed to assess predictors of insight. We could follow up 95 (72.5%) patients, 5 years after recruitment. A total of 65 of these patients interviewed at 60 months (68.4%) achieved remission. Cross-sectional evaluations suggest a relationship between insight, psychosis rating and explanatory models of illness with good insight and medical models associated with good outcome. However, baseline and early illness data do not predict insight scores at 5 years. Serial longitudinal assessment of insight is negatively associated with Brief Psychiatric Rating Scale (BPRS) scores and positively associated with the number of nonmedical explanatory models of illness held by patients. These findings argue that insight and explanatory models of illness are secondary to psychopathology, course and outcome. They are dependent on the trajectory of the person's illness, are not independent of the condition and call for multifaceted understanding of the issues.

Ethnicity and Service Engagement Among Involuntary Patients

Ethnicity and Service Engagement Among Involuntary Patients

Poor insight into schizophrenia: contributing factors, consequences and emerging treatment approaches

Poor insight or unawareness of illness has been commonly observed in schizophrenia and has been long recognized as a potent barrier to treatment adherence and a risk factor for a range of poorer outcomes. Paradoxically, the achievement of insight often poses a different set of problems including depression and low self-esteem. One barrier to the treatment of poor insight has been a lack of understanding of the phenomenon, which causes poor insight to develop and persist over time. Without knowing what promotes poor insight, treatment to date has had little to offer beyond the supportive provision of information. To explore these issues, this article reviews emerging literature on the correlates of poor insight in schizophrenia, and newly developing ways of conceptualizing insight. It then details a number of innovative integrative group and individual treatment approaches in the early stages of development, which take into account some of the potential causal forces behind poor insight, including deficits in neurocognition, social cognition, metacognition and heightened self-stigma. A plan for further research is presented to develop a model of the factors whose interaction influences insight, and to refine and test integrative treatments.

FACTORS IMPACTING DECISIONS TO DECLINE OR ADHERE TO ANTIDEPRESSANT MEDICATION IN PERINATAL WOMEN WITH MOOD AND ANXIETY DISORDERS

To identify specific quantitative and qualitative factors that govern the decision to adhere or decline antidepressant medication in antenatal women with moderate-to-severe mood and anxiety disorders. Fifty women (30 adherers, 20 decliners) were recruited between 18 and 34 weeks gestation in a tertiary care clinic for perinatal mothers. They were prospectively monitored 4 weeks apart up to 1-month postpartum on the: Hamilton Anxiety Scale, Hamilton Depression Scale, Mood Disorders Insight Scale, Antidepressant Compliance Questionnaire, Penn State Worry Questionnaire, and NEO Personality Inventory. Qualitative interviews were conducted at baseline. Hierarchical linear modeling determined illness trajectories of the two groups. Significantly different course of illness was observed in adherers versus decliners. Adherers had healthier attitudes toward depression and compliance with medication (P < .005). Decliners had less illness insight (P < .001) and cited fear of fetal exposure, and thought medication was unwarranted. Pregnant women experienced significantly divergent illness trajectories depending on if they accepted antidepressant medication therapy for their illness. Risk perception, attitudes, and illness insight impacted decisions surrounding adherence and decline.

Improved insight affects social outcomes in involuntarily committed psychotic patients: A longitudinal study in the Netherlands

BackgroundLack of insight in schizophrenia is associated with negative social outcomes mediated by symptom severity, but longitudinal studies show contradicting findings. MethodAfter commencement of court-ordered admission, adult patients were enrolled in a prospective study. A relatively homogeneous group of 133 patients with schizophrenia or related psychotic disorders was selected to evaluate the impact of illness insight and symptom severity on social outcomes. Interviews at baseline and after 6 and 12months included objective and subjective indicators of insight and social outcomes. Multilevel analyses were used to estimate the effect of insight and change in social outcomes controlling for symptom severity. ResultsIn 12-month follow-up, patients involuntarily hospitalized showed improvement in illness insight, symptom level, and social functioning, and had stable quality of life scores. Illness insight was associated with change in outcomes, independent from symptom severity. Results of the change analyses suggest that in time the association between insight and functioning becomes stronger. In contrast, insight scores were negatively associated with self-report quality of life ratings and markedly ill patients had a more negative perception of their quality of life. ConclusionsImprovement in illness insight was associated with improvement in social functioning, but this was not reflected in improved self-perceived quality of life. Illness insight could result in worrying about relationships, living situation, health and finances. For severely mentally ill patients additional strategies must be found to improve social outcomes. Researchers should be more aware of varying effects for researcher-rated versus self-report indicators of insight and social outcome.

Purpose and effectiveness of psychoeducation in patients with bipolar disorder in a bipolar clinic setting

This article reviews psychological therapies in the treatment of bipolar disorder, in particular psychoeducation, and how the inclusion of four fundamental principles - patient/therapist communication, flow of information, patient involvement and a trusting relationship - can improve patient outcomes. The content of this article is based on the proceedings of a 1-day standalone symposium in November 2011 exploring how to establish a bipolar clinic within the context of existing services in the UK's National Health Service. Certain psychological interventions have emerged as beneficial add-on treatments to pharmacotherapy in bipolar disorder and are associated with greater stabilisation of symptoms, fewer relapses and longer time to relapse. Psychoeducation is a simple approach to support prevention of future episodes by delivering behavioural training to improve illness insight, early symptom identification and development of coping strategies. Empowering patients to actively participate in their treatment provides independence, counteracts the current disconnect of therapist and patient, and increases awareness and understanding of the challenges of living with and treating bipolar disorder. Psychoeducation enables patients to understand bipolar disorder, get actively involved in therapy planning, and be aware of methods for episode prevention, therefore effectively contributing to improved treatment outcomes and patient quality of life.

Self-efficacy and functional status in schizophrenia: Relationship to insight, cognition and negative symptoms

Self-efficacy, defined as the confidence one has in the ability to perform a behavior or specific task, has been introduced as a crucial motivational factor for successfully carrying out social and everyday living skills (Bandura, 1977, 1997). Few studies have assessed its role in functioning in schizophrenia. The current study was designed to investigate whether degree of illness insight determined whether self-efficacy was a mediator of the relationship between two key illness features, negative symptoms and cognition, and functional skills. Sixty-nine individuals with schizophrenia were administered measures of self-efficacy, cognition, symptoms, insight and performance-based measure of everyday living and social skill. Results revealed that self-efficacy was only linked to measures of functional skills when illness insight was intact. There was evidence of moderation of confounding effects such that when self-efficacy was controlled, the relationship between negative symptoms and measures of everyday life skills became non-significant, but only when illness insight was intact. These findings emphasize the importance of including illness insight in models of the role of self-efficacy in functioning in schizophrenia.

A controlled trial of a needs‐based, nurse‐led psychoeducation programme for Chinese patients with first‐onset mental disorders: 6 month follow up

The study reported herein a randomized controlled trial was conducted to test the effectiveness of a nurse‐led, needs‐based psycho‐education program for Chinese patients with first‐onset mental illness over a 6‐month follow‐up. Ninety‐six families of Chinese patients with schizophrenia newly referred to one outpatient clinic in Hong Kong were randomly assigned to a nurse‐led psycho‐education program or usual outpatient care, each comprising 48 subjects. The patients’ mental health, illness insight, self‐efficacy, services utilization, and hospitalization rates were measured at recruitment and at one week and six months post‐intervention. The patients in the psycho‐education program reported significantly greater improvements in mental health, insights into treatment and illness, and hospitalization rates over the 6‐month follow‐up, when compared with those who received usual care. The findings provide evidence that the needs‐based, nurse‐led psycho‐education program can improve the health conditions and treatment insights of Chinese out‐patients with first‐onset mental illness.