Lack Of Insight In Schizophrenia Research Articles

RELASHIONSHIP BETWEEN CLINICAL AND THERAPEUTICAL CARACTERISTICS AND INSIGHT IN SCHIZOPHRENIA

Schizophrenia is a chronic disease which affects 1% of world population and represents a major public health issue. It is often associated with a severe and persistent lack of awareness of the disorder. Our prospective study was carried out at the psychiatric service of Mohammed VI Academic Medical Center in Marrakech on 100 patients hospitalized between August 2012 and February 2013, for schizophrenia diagnosed according to DSM-IV R criteria. The aim of our study was to assess their insight, and identify clinical and therapeutic features associated with this insight. Insight has been assessed by Birchwood insight scale. The bivariate analysis has identified some significant results: poor insight was associated with unvoluntary commitment status and poor treatment adherence.In conclusion, lack of insight in schizophrenia is an important dimension that can have an impact on the therapeutic alliance, treatment adherence and prognosis.

Paranoia, depression and lack of insight in schizophrenia: a suggestion for a mediation effect.

Delusional symptoms are heterogeneous and differentially related to insight, depression and another psychological construct, such as deservedness. In this study we explore models of relationships among these constructs, by hypothesizing that lack of insight could predict depression or paranoia, representing these variables outcome or mediator variables alternatively. We evaluated positive psychotic symptoms, depression, persecution, deservedness and insight in a clinical sample of 81 people with schizophrenia or other psychotic spectrum disorders. Using multiple regression analyses we found 2 significant models. In the first one the lack of insight is negatively associated with depression and negatively related to persecution that, as mediator, is positively associated with depression. In the second model, lack of insight is negatively associated with persecution and negatively related to depression that, as mediator, is positively associated with persecution. Persecution and depression could be not only predicted by insight but this prediction could also be mediated by the same variables. In both clinical models found in this study, insight does have a relevant role because the awareness about symptom/illness is crucial to the symptoms change. However, having good insight into schizophrenia can also be paradoxically associated with negative subjective states related to depression (the so-called "insight paradox").

Oligodendrocyte abnormalities in layer 5 in the inferior parietal lobule are associated with lack of insight in schizophrenia: a postmortem morphometric study

Oligodendrocyte abnormalities in layer 5 in the inferior parietal lobule are associated with lack of insight in schizophrenia: a postmortem morphometric study

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

ObjectiveLack 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. MethodsSeventy-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. ResultsOn 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. ConclusionsInsight in this sample of patients with chronic schizophrenia is significantly associated with clinical symptoms but not with neuropsychological functioning.

Deficit of perineuronal oligodendrocytes in the inferior parietal lobule is associated with lack of insight in schizophrenia

Background and Objectives: Previously we reported a significant reduction in the numerical density of oligodendrocytes and oligodendrocyte clusters in the inferior parietal lobule (IPL) in schizophrenia that was associated with lack of insight. We also found a significant decrease in the number of perineuronal oligodendrocytes (PnOl) in the prefrontal cortex in schizophrenia and therefore we hypothesized that there may also be a deficit of PnOl in the IPL in schizophrenia and that it could be associated with poor insight. Methods: We estimated the number of PnOl adjacent to pyramidal neurons in layer 3 of BA39 and BA40 in Nissl stained sections from 24 males with schizophrenia and 24 nor- mal male controls from the Stanley Parietal Collection. The schizophrenia group was di- vided into three subgroups based on level of insight: poor, fair or good. Results : We found a significant deficit of PnOl in layer 3 of BA39 and BA40 in the schizophrenia group as compared to the control group (p<0.01). In the control group but not in the schizophrenia group in BA39 the number of PnOl was significantly higher in the left hemisphere compared to the right hemisphere. In schizophrenia, in BA39 the number of PnOl was decreased in the subgroup with poor insight vs. controls. In BA40 the sub- groups with both poor and fair insight were decreased vs. controls (p<0.01). In BA40 the subjects with fair insight also differed from those with good insight (p<0.01). Conclusions: The reduction of PnOl in the IPL in schizophrenia is associated with im- paired insight and lack of hemispheric asymmetry.

Neuroimagerie de l’insight dans la schizophrénie : revue de la littérature

ObjectivesInsight in psychiatry has been defined and conceptualized in a number of ways but none of them was found to be self-explanatory. There has been an exponential rise in studies of insight, in part accelerated by the availability of several psychometric scales for measuring insight. Lack of insight has been associated in schizophrenia with low treatment adherence, a high number of relapses, increased number of hospital admissions, and subsequently poorer psychological and cognitive functioning. For this reason, there is considerable interest in understanding the underlying neural mechanisms of insight, which may have important implications for the development of future insight-oriented neuro-psychiatric treatment. Neuroimaging may be considered an important technique to help understand the anatomical, functional and metabolic neurocircuitry underlying poor insight in schizophrenia. Growing neuroimaging research provides evidence for underlying brain impairment in insight deficits in schizophrenia. In order to expose a panoramic view to the readers, this article reviews the neuroimaging studies conducted to date, which have investigated the neural bases of insight in schizophrenia. MethodsElectronic searches were performed in PubMed, PsycINFO, Sciencedirect and Web of Science databases, using the following keywords: Imaging; neuroimaging; Positron Emission Tomography (PET); spectroscopy; functional Magnetic Resonance Imaging (fMRI); structural Magnetic Resonance Imaging (MRI); Single Photon Emission Computed Tomography (SPECT); Voxel Based Morphometry (VBM); Diffusion Tensor Imaging (DTI); Computed Tomography (CT); Insight; schizophrenia; awareness of illness. Searches were also performed from the references of the systematic review articles on neurobiological correlates of insight in schizophrenia. Animal studies and single case reports were excluded. Twenty-five articles were selected for the present review. From these; 12 used structural MRI; 6 used VBM; 3 used fMRI; 2 used CT; 1 used DTI and 1 used VBM combined to DTI. ResultsThe search showed that studies in this area were published recently and that the neuroanatomic substrate of insight in schizophrenia has not yet been consolidated. This inconsistency could arise from the complex nature of insight and the use of a variety of insight assessments. Most of the studies analyzed in this review used structural neuroimaging techniques to assess brain abnormalities associated with poor insight. The functional neuroanatomy of insight has only recently been investigated and to our knowledge, there are only 3 studies that have examined brain activity with fMRI in relation to insight in schizophrenia. ConclusionThis review investigated the neural deficiencies underlying poor insight in schizophrenic patients. In spite of methodological differences among studies, results provide evidence of structural and functional brain abnormalities in frontal, parietal and temporal region related to insight deficits. Some studies have found a hemispheric asymmetry in relationship to poor in insight (the majority of brain abnormalities concern the right hemisphere). In addition, growing research indicated that the prefrontal cortex, particularly the dorsolateral prefrontal cortex, the anterior cingulated cortex, the insula, the precuneus and the cerebellum can also underlying insight in schizophrenia. It is interesting to mention that some authors have suggested that each dimension of insight can be specifically linked to certain brain structures. Taking together, data on the neuropsychological and neuroanatomical correlates of clinical insight suggested that lack of insight in schizophrenia could be conceived as a neurocognitive deficit, analogously to anosognosia in brain injury and dementia. On the contrary, to date, the neuroanatomical correlates of cognitive insight have been scarcely studied. Only two studies reported that Self-reflectiveness was positively related to gray matter volume of the right ventro-lateral prefrontal cortex, the BCIS composite index was positively correlated with total left hippocampal volume, and Self-certainty was inversely correlated with bilateral hippocampal volumes. However, it is important to note that neuroimaging research on cognitive insight in schizophrenia is in a preliminary, and the results on this are inconclusive. Further research is needed to better understand the causal relationships between brain abnormalities and degradation of insight in schizophrenia.

Poster #S192 EXAMINING THE IMPACT OF NEUROCOGNITIVE AND LANGUAGE IMPAIRMENTS ON FORMAL THOUGHT DISORDER IN SCHIZOPHRENIA

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

EPA-0321 – Impact of improved insight in schizophrenia: a double-blind lurasidone and quetiapine xr study

Introduction Lack of insight in schizophrenia is frequently associated with deficits in self-assessment of cognitive and functional abilities, as well as quality of life outcomes. Objective The aim of this analysis was to evaluate the impact of treatment-related improvement in illness awareness on changes in cognition and functional outcomes in a double-blind, controlled study. Methods Clinically unstable patients with schizophrenia (N=488) were randomized to once-daily, fixed dose treatment with lurasidone 80 mg (LUR 80), lurasidone 160 mg (LUR 160), quetiapine XR 600 mg (QXR) or placebo (PBO), followed by a 12-month, double-blind extension. Impairment of insight (G12 ‘lack of judgment and insight’), cognitive performance, quality of well-being (QWB scale), and UPSA-B were assessed at baseline, week-6 and month-6 of extension (32 weeks). Mixed effects model was applied. Results PANSS insight scores were significantly improved for all treatment groups compared to placebo after 6 weeks. Improvement in insight at week-32 was significantly greater in subjects treated with lurasidone compared with quetiapine XR. Improved insight at week-6 was a significant mediator for the effect of LUR160 (vs. placebo) on neurocognitive composite score (p Conclusion Improvement in insight at week-32 was significantly greater in subjects treated with lurasidone compared with quetiapine XR. Our findings suggest treatment-related improvement in illness awareness had significant impact on cognition and functional outcomes in a doubleblind, controlled study.

“Assisted Outpatient Treatment”: An Example of Newspeak?: In Reply

Back to table of contents Previous article Next article LettersFull Access“Assisted Outpatient Treatment”: An Example of Newspeak?: In ReplyE. Fuller Torrey, M.D., and Jonathan Stanley, J.D.E. Fuller TorreySearch for more papers by this author, M.D., and Jonathan StanleySearch for more papers by this author, J.D.Published Online:1 Nov 2013https://doi.org/10.1176/appi.ps.641109AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: Roskes claims that “assisted outpatient treatment” and “involuntary outpatient commitment” are the same and accuses us of making “a deliberate attempt to make the intervention seem less coercive and therefore more palatable.” In fact, the term “assisted outpatient treatment” was coined by one of us (JS) in collaboration with the staff of the Treatment Advocacy Center to differentiate it from involuntary outpatient commitment. The difference is subtle but important.To illustrate: take two people with active tuberculosis who refuse their prescribed antituberculosis medication and are thus potentially dangerous to other people. The first doesn’t like the side effects and therefore refuses it. The second has Alzheimer’s disease and anosognosia and refuses because he doesn’t think he has tuberculosis and believes the nurse is trying to poison him. In many states, public health laws permit the involuntary medication of both individuals.In the first case, we assume that the man has a normally functioning brain and can make informed choices. Forcing him to take medication is truly involuntary treatment. In the second, we know that the man does not have a normally functioning brain and suspect he cannot make informed choices. Forcing him to take medication is assisting him to make the choice we think he would make if he had a normally functioning brain.Most individuals with serious mental illness on assisted outpatient treatment have anosognosia. There are now 20 neuroimaging studies showing subtle differences between the brains of individuals with schizophrenia who have anosognosia and those who do not. A recently published study, done on postmortem brains, even shows oligodendrocyte cellular differences between brains of individuals with and without anosognosia (1). Another factor that differentiates assisted outpatient treatment from truly involuntary treatment is that many individuals are retrospectively grateful that they received assisted outpatient treatment. In an assessment of Kendra’s Law, for example, 81% of individuals surveyed said that assisted outpatient treatment had helped them get and stay well (2). Individuals subjected to truly involuntary treatment are rarely retrospectively grateful.It is unfortunate that Roskes practices in Maryland, one of only five states without an assisted outpatient treatment law. He thus has not had an opportunity to observe its proven effectiveness in reducing rehospitalization, victimization, incarceration, homelessness, and violent behavior (3). In addition, two studies have now shown that the use of assisted outpatient treatment results in significant cost savings to states (4,5).The authors are affiliated with the Treatment Advocacy Center, Arlington, Virginia.References1 Vostrikov VM, Kolomeets NS, Uranova NA: Reduced oligodendroglial density in the inferior parietal lobule and lack of insight in schizophrenia. European Journal of Psychiatry 27:111–121, 2013Crossref, Google Scholar2 Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment. Albany, New York State Office of Mental Health, March 2005Google Scholar3 Torrey EF: American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. New York, Oxford University Press, 2013Google Scholar4 Tsai G: Assisted outpatient treatment: preventive, recovery-based care for the most seriously mentally ill. Resident’s Journal 7(6):16–18, 2012. Available at psychiatryonline.org/data/Journals/AJP/23626/ajp_169_n6_ResJournal.pdfGoogle Scholar5 Swanson JW, Van Dorn RA, Swartz MS, et al.: The cost of assisted outpatient treatment: can it save states money? American Journal of Psychiatry (Epub ahead of print, July 30, 2013)Google Scholar FiguresReferencesCited byDetailsCited ByFrontiers in Cellular and Infection Microbiology, Vol. 9Is the Evidence Strong Enough to Warrant Long-Term Antipsychotic Use in Compulsory Outpatient Treatment?Shawn S. Barnes, M.D., and Nicolas Badre, M.D.15 March 2016 | Psychiatric Services, Vol. 67, No. 7 Volume 64Issue 11 November 2013Pages 1179-1180 Metrics PDF download History Published online 1 November 2013 Published in print 1 November 2013

Reduced oligodendroglial density in the inferior parietal lobule and lack of insight in schizophrenia

Background and Objectives: Alterations and deficits of oligodendrocytes reported in the grey and white matter in schizophrenia may contribute to neuronal disconnectivity. Prefrontal-parietal functional disconnections have been implicated in diverse clinical symptoms of schizophrenia, including poor insight. We studied the effects of schizophrenia diagnosis and insight on numerical density (Nv) of oligodendrocytes in the inferior parietal lobule (IPL). Methods: Nissl-stained sections from the Stanley �Parietal Collection� from male schizophrenia subjects (n = 24) having poor, fair, or good insight and healthy matched controls (n = 24) were examined. The Nv of oligodendrocytes was estimated in layer 3 of BA 39 and BA 40 of the IPL and in white matter underlying layer 6 by optical dissector method. Results: In BA 39 we found a significant 15% decrease in the Nv of oligodendrocytes in layer 3 in the schizophrenia group. Nv of oligodendrocytes in the poor+fair insight subgroup was 20% lower compared to controls (p< 0.05) and to good insight subgroup (p = 0.055). Nv of oligodendrocytes in the good insight subgroup did not differ from the control group. A significant lateralization of oligodendrocyte density was detected in layer 3 (L>R) only in the control group. There were no significant group differences in the Nv of oligodendrocytes in BA 40 or in the white matter underlying BA 39/40 areas. Conclusions: Lack of insight in schizophrenia may be associated with a deficit of oligodendroglia in the grey matter of IPL.

Insight, Neurocognition, and Schizophrenia: Predictive Value of the Wisconsin Card Sorting Test

Lack of insight in schizophrenia is a key feature of the illness and is associated with both positive and negative clinical outcomes. Previous research supports that neurocognitive dysfunction is related to lack of insight, but studies have not examined how neurocognition relates to change in insight over time. Therefore, the current study sought to understand how performance on the Wisconsin Card Sorting Test (WCST) differed between participants with varying degrees of change in insight over a 6-month period. Fifty-two patients with schizophrenia or schizoaffective disorder were administered the WCST and Positive and Negative Syndrome Scale (PANSS) at baseline, and the PANSS was again administered at a 6-month follow-up assessment. Results indicated that while neurocognition was related to insight at baseline, it was not related to subsequent change in insight. The implications of findings for conceptualization and assessment of insight are discussed.

White matter integrity and lack of insight in schizophrenia and schizoaffective disorder

Objective Poor insight into illness is commonly associated with schizophrenia and has implications for the clinical outcome of the disease. A better understanding of the neurobiology of these insight deficits may help the development of new treatments targeting insight. Despite the importance of this issue, the neural correlates of insight deficits in schizophrenia remain poorly understood. Method Thirty-six individuals diagnosed with schizophrenia or schizoaffective disorder underwent diffusion tensor imaging (DTI). The subjects were assessed on two dimensions of insight (symptom awareness and attribution of symptoms) using the Scale to Assess Unawareness of Mental Disorder (SUMD). Level of psychosis was assessed with the Positive and Negative Syndrome Scale (PANSS). Results White matter abnormalities in the right superior frontal gyrus, left middle frontal gyrus, bilateral parahippocampal gyrus, adjacent to the right caudate head, right thalamus, left insula, left lentiform nucleus, left fusiform gyrus, bilateral posterior cingulate, left anterior cingulate, right cingulate gyrus, left lingual gyrus, and bilateral claustrum were associated with symptom unawareness. Misattribution of symptoms was related to deficits in the white matter adjacent to the right lentiform nucleus, left middle temporal gyrus, and the right precuneus. Conclusions Impaired insight in schizophrenia implicates a complex neural circuitry: white matter deficits in fronto-temporo brain regions are linked to symptom unawareness; compromised temporal and parietal white matter regions are involved in the misattribution of symptoms. These findings suggest the multidimensional construct of insight has multiple neural determinants.

Insight dimensions in first-episode psychosis patients: clinical, cognitive, pre-morbid and socio-demographic correlates

To investigate pre-morbid, socio-demographic, clinical and cognitive variables as predictors of insight in a large and representative sample of first-episode psychosis patients. The abbreviated Scale to Assess Unawareness of Mental Disorder was used to assess insight dimensions. Patients with good and poor insight were independently compared on insight dimensions and logistic regression analyses were conducted to identify explanatory variables associated with each insight dimension. The patients with good and poor insight of having a mental disorder differed in duration of untreated psychosis, diagnosis and attention, but only attention appeared as a predictor. The insight of the need for medication groups showed differences in age of onset, depression, severity of disorganized symptoms and hospitalization rate.Nevertheless, age of onset and disorganized symptoms seem to be the predictors. Groups of insight of the social consequences differed in duration of untreated psychosis, the negative and disorganized symptoms severity, disability, education, diagnosis and hospitalization rate.However, exclusively, the severity of disorganized symptoms seems to predict insight of social consequences. When independently analysed, the three insight dimensions showed different rates of affectation and different predictors. These results suggest that there must be different mechanisms underlying the lack of insight. First-episode psychosis is a crucial period for treatment adherence formation, an issue strongly associated with good insight. Thus, a more accurate evaluation of the predictors of lack of insight into each dimension is warranted to achieve a better comprehension of the lack of insight in schizophrenia and in turn, to implement treatment programmes seeking to improve it.

Gray matter volume deficits and correlation with insight and negative symptoms in first-psychotic-episode subjects

To determine brain areas reduced in first episode of psychotic subjects and its association with lack of insight and negative symptoms. Twenty-one drug naive first-episode subjects and 20 controls underwent a structural MRI scan and were clinically assessed. Optimized voxel-based-morphometry analysis (VBM) was implemented to find between-group differences and correlations between GM volume and: (i) lack of insight and (ii) negative symptoms. Patients showed GM reduction in prefrontal and left temporal areas. A significant correlation was found between insight and GM volume in the cerebellum (corrected P = 0.01), inferior temporal gyrus (corrected P = 0.022), medial superior frontal gyrus (corrected P < 0.001), and inferior frontal gyrus (corrected P = 0.012), as the insight decreased, the volume decreased. Negative symptoms correlated with decreased GM volume at cerebellum (corrected P = 0.037) and frontal inferior regions (corrected P < 0.001), the more negative symptoms, the less volume. Our findings support an association between prefrontal, temporal, and cerebellar deficits and lack of insight in schizophrenia and confirm previous findings of GM deficits in patients since the first episode of psychosis.

Evaluation of the association between insight and symptoms in a large sample of patients with schizophrenia

Background The objective of the present study was to examine the association of insight into the illness with demographic variables and symptomatology in a sample of 1213 patients with schizophrenia. Method Data were collected with the Psychosis Evaluation tool for Common use by Caregivers (PECC), a semi-structured interview evaluating five symptom domains of schizophrenia and the insight items ‘awareness of having a mental disorder’ and ‘attributing symptoms to a mental disorder’. Results Insight was positively associated with educational level and inversely with overall symptom severity, and the positive, negative, excitatory and cognitive symptom domains. At symptom level, the items ‘delusions’, ‘grandiosity’, ‘poor rapport’, ‘social withdrawal’ and ‘guilt feelings’ showed the strongest associations with both insight items. Overall, correlations between insight and symptomatology were modest, explaining less than 30% of the variance in insight. Conclusion Lack of insight in schizophrenia is partially explained by clinical symptoms and demographic measures.

La conscience des troubles ( insight) dans la schizophrénie : une revue critique : Partie II : modèles explicatifs et hypothèses psychopathologiques

Relative to other psychiatric disorders, patients with schizophrenia are often unaware of the consequences of their disease and their need for treatment. These deficits in awareness referred in general in the English literature as "poor insight", have been the focus of many clinical studies over recent years. This phenomenon, which is considered as fundamental in clinical evaluations of schizophrenia, should be understood as a multidimensional process rather than a dichotomic phenomenon, as is presently the case. The links between insight deficits and responses to vocational rehabilitation efforts represent a major interest in research, including those related to medication compliance and clinical outcome. To conduct such studies, various evaluation tools have been developed, enabling the assessment of insight, of its time-course and of its components in psychosis and schizophrenia spectrum disorders. The Scale to Assess Unawareness of illness in Mental Disorders (SUMD) developed by Amador and Strauss appears to be the most frequently used scale for the evaluation of awareness of the disorder in schizophrenia. Although the model proposed by Amador and Strauss is considered as the privileged model in the multidimensional approach of insight, it corresponds only to a phenomenological analysis of this concept. In the second part of this article, we thus review the current models attempting to explain the lack of insight in schizophrenia. Four current explanatory models of lack of insight will be described as follows: resulting either from adaptation or defence mechanisms to environmental stressors, resulting from cognitive bias of data processing, resulting from neuropsychological functional deficits and resulting from metacognitive deficits. Several hypotheses concerning these deficits arise from clinical studies. Although coping, and defence mechanisms to the consequences and stigmatization of the disease were hardly studied, the fact that poor insight does not appear related to the severity of symptomatology or to the emotional state of the patients argue against this hypothesis. Conversely, a considerable body of literature emphasized how unawareness may result from cognitive deficits. Research in neuropsychology and cognitive psychology has provided consistent results concerning the link between deficit in executive functions, frontal lobe dysfunction and poor insight. Recent studies on bias in cognitive information treatment and social cognition theories currently open new prospects.

La conscience des troubles ( insight) dans la schizophrénie : une revue critique : Partie I : insight et schizophrénie, caractéristiques cliniques de l’ insight

Schizophrenia is the psychiatric disorder in which the awareness of pathology (or insight) is most frequently altered.A review of the literature shows that between 50 and 80% of patients with schizophrenia do not believe they have a disorder. Studies published on this subject over the two last decades stressed the specificity of this phenomenon in schizophrenic patients, taking into account both its prevalence and its clinical consequences comparatively to other mental disorders. If in bipolar disorders a lack of insight is linked with the intensity and acuteness of symptomatology, there is only a limited relationship between these factors in schizophrenia, thus making lack of insight a trait rather than a state-related symptom.Though defined for a very long time as a dichotomic phenomenon, the recent interest on insight in psychosis and the development of assessment tools for its evaluation have made it possible to underline its multifactorial and dynamic characteristics. Although lack of insight related to pathologies may vary across time in bipolar disorders, the results of clinical studies suggest that this phenomenon remains stable in schizophrenia. CONCEPTUAL PROPOSALS: In this review, we will reconsider the evolution of this concept in psychiatry and its definition. The clinical characteristics, which are specifically associated with the lack of insight in schizophrenia will be outlined. We will describe more specifically the model of Amador and Strauss and their assessment tool: the Scale to Assess Unawareness of Mental Disorder (SUMD). This model developed since the 1990s takes into account the time-related evolution of insight, and can be applied both to bipolar and psychotic disorders.The SUMD has six general items and four subscales. The general items estimate the three most widely used definitions of insight: awareness of having a mental disorder, awareness of the achieved effects of medication and awareness of the social consequences of having a mental disorder, and include assessment of both current and past-time periods. Four other subscales, each composed of 17 items, assess awareness and attribution of specific current and retrospective symptoms as well as deficits associated with severe mental disorders. Insight, thus, appears as a multidimensional and continuous phenomenon, since patients' awareness may apply only to part of their symptoms and vary over time. In this article, we will review existing scales assessing insight in schizophrenia. The deficiency of available scales validated in French limits the number of scientific publications concerning this important aspect of the clinical evaluation of schizophrenic patients. THERAPEUTICAL ASPECTS: Finally, interventions to improve insight in patients with schizophrenia are presented. Recent studies have shown cognitive behavioural therapy (CBT) to be of benefit in the treatment of poor insight in schizophrenia.Evidence suggests that early diagnosis and treatment of schizophrenia leads to better prognosis. An important suggestion from theses studies may be that psychosocial therapy needs to focus on explanations that are in tune with the culture, rather than focus on diagnostic labels.

Lack of Insight in Schizophrenia

People with schizophrenia commonly lack insight, that is, they are unaware of their illness and the consequences thereof. One of the most important consequences of lack of insight is a failure to recognise the need for treatment, leading to treatment nonadherence. With several scales that now enable objective measurement of insight, it is possible to examine correlates of insight change, including course of illness and treatment adherence. Specific interventions, both pharmacological and psychotherapeutic, have been developed to enhance illness insight and treatment adherence. The extent to which second-generation antipsychotic medications, including a recently released long-acting formulation, improve insight and/or enhance treatment adherence remains to be determined.

Unawareness in schizophrenia: Neuropsychological and neuroanatomical findings

The lack of insight in schizophrenia has so far been interpreted as a primary symptom of the illness, namely a defensive mechanism rather than a neurologically-based condition. However, recent findings have emphasized its relationship with damage to specific brain areas as well as the domain specificity in which it may occur. This supports a neuropsychological interpretation of the lack of insight in schizophrenia. The present article reviews the foregoing data, and takes into account the most relevant anatomo-clinical results. There is evidence that the lack of insight in schizophrenia may occur as a neurological disease per se following brain damage that seems related to frontal lobe areas. Additionally, it could either be related to all aspects of the disease or be domain-specific, occurring for one kind of symptom but not for others. These data indicate several analogies with the phenomenon called anosognosia for a neurological deficit.

Lack of insight in schizophrenia is not a dysexecutive phenomenon

It is unclear how well performance on recently developed, specialized executive tests, reflects problems that patients and their relatives complain of in real life. The ecological validity of four specialised tests of executive function: the Hayling and Brixton Tests, and the Zoo Map and Key Search sub-tests from the Behavioural Assessment of Dysexecutive Syndrome (BADS) battery, was assessed against the Dysexecutive Questionnaire from the BADS in a sample of 59 severely brain injured individuals. Results indicated that only the Hayling C was significantly negatively correlated (r = −.26, P < .05) with the informant version of the Dysexecutive Questionnaire. An index of insight was not correlated with any of the executive tests. It is concluded that these tests have limited ecological validity when used to assess patients following severe head trauma.