Article

Is unawareness of psychotic disorder a neurocognitive or psychological defensiveness problem?

Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA 90095-6968, USA.
Schizophrenia Research (Impact Factor: 4.43). 07/2005; 75(2-3):147-57. DOI: 10.1016/j.schres.2004.12.005
Source: PubMed

ABSTRACT We examined whether deficits in attention and perceptual encoding as well as psychological defensiveness were associated with impaired awareness of disorder in schizophrenia. The Scale for Unawareness of Mental Disorder (SUMD) was administered to 52 outpatients with a recent onset of schizophrenia approximately 1-2 months following hospital discharge. Two versions of the Continuous Performance Test (CPT) were used to measure attentional impairment--the Degraded Stimulus CPT (DS-CPT) and a memory-load version (3-7 CPT). Three scales from the Minnesota Multiphasic Personality Inventory were used as indicators of psychological defensiveness: Scales L (Lie), K (Correction), and R (Repression). The Classification and Regression Tree (CART) program, a nonparametric statistical method, was used to identify relationships among multiple predictor variables and to provide optimal splitting scores for each predictor variable. Different combinations of poor target discrimination (d') on the 3-7 CPT and a cautious response style on the DS-CPT were associated with the three levels of overall unawareness of having a mental disorder. For nonpsychotic patients, better target discrimination (d') on the 3-7 CPT tended to be associated with better awareness of having a mental disorder. In contrast, unawareness among the patients who were psychotic at the time of the SUMD administration was not discriminated by attentional measures, but was associated with a combination of two measures of psychological defensiveness from the MMPI reflecting guardedness, psychological suppression, attempting to present oneself in a socially desirable light, and social acquiescence. Generally similar associations were found for two other dimensions of poor insight: unawareness of the beneficial effects of antipsychotic medication, and inability to attribute unusual thoughts and hallucinatory experiences to a mental disorder.

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    ABSTRACT: 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.
    L Encéphale 10/2008; 34(5):511-6. · 0.60 Impact Factor
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    ABSTRACT: Background 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. Literature findings 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. Discussion 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.
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    ABSTRACT: Insight, neurocognición y psicopatología en esquizofrenia Introducción. La investigación de los últimos años ha intentado hallar variables mediadoras entre neuro-cognición y desempeño funcional en esquizofrenia, pro-poniéndose el insight como una posible variable. Dife-rentes autores han encontrado relaciones entre insight y diversos aspectos del desempeño funcional, y entre in-sight y sintomatología, aunque no hay unanimidad en la clase de relación existente. La falta de consenso podría explicarse por la definición de insight utilizada. El pre-sente artículo valora el insight de manera uni y multidi-mensional y establece su relación con variables cogniti-vas y psicopatológicas. Métodos. La muestra la constituyen 94 sujetos diag-nosticados de esquizofrenia según criterios CIE-10 que acuden a un centro de rehabilitación psicosocial. La va-loración cognitiva se realizó mediante una versión abre-viada de la Batería Neuropsicológica Test Barcelona y el Wisconsin Card Sorting Test. Para valorar la sintomato-logía se usó la Escala de Síndromes Positivo y Negativo (PANSS). El insight fue evaluado mediante el ítem de la PANSS y mediante una entrevista semiestructurada que recogía diferentes componentes del mismo. Resultados. Se encontraron dos factores de insight, uno que incluye un conocimiento preciso de la enferme-dad y sus consecuencias y otro que hace referencia a un reconocimiento inespecífico de padecer una enfermedad y necesitar tratamiento. Cada factor mostró una relación estadísticamente significativa con funciones cognitivas superiores y con sintomatología positiva. Conclusiones. Los datos encontrados apoyan una re-lación entre insight y bajo rendimiento cognitivo.