Article

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

Pepperdine University, Malibu, California, United States
Schizophrenia Research (Impact Factor: 3.92). 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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    • "The neuropsychological model argues that specific cognitive impairments are responsible for poor insight in schizophrenia [24,25]. Finally, the psychological denial model explains poor insight as the outcome of a coping strategy that is used to reduce the distress associated with a diagnosis of schizophrenia [26].There is limited support for the clinical model, partly because of the lack of testable hypotheses. Literature does provide evidence for the neuropsychological model and some preliminary support for the psychological denial model [23], but none of these models alone can account for the variance in insight. "
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    ABSTRACT: Insight is impaired in a majority of people with schizophrenia. Impaired insight is associated with poorer outcomes of the disorder. Based on existing literature, we developed a model that explains which processes may possibly play a role in impaired insight. This model was the starting point of the development of REFLEX: a brief psychosocial intervention to improve insight in schizophrenia. REFLEX is a 12-sessions group training, consisting of three modules of four sessions each. Modules in this intervention are: "coping with stigma", "you and your personal narrative", and "you in the present". REFLEX is currently evaluated in a multicenter randomized controlled trial. Eight mental health institutions in the Netherlands participate in this evaluation. Patients are randomly assigned to either REFLEX or an active control condition, existing of cognitive remediation exercises in a group. In a subgroup of patients, fMRI scans are made before and after training in order to assess potential haemodynamic changes associated with the effects of the training. REFLEX is one of the few interventions aiming specifically to improving insight in schizophrenia and has potential value for improving insight. Targeting insight in schizophrenia is a complex task, that comes with several methodological issues. These issues are addressed in the discussion of this paper. Current Controlled Trials: ISRCTN50247539.
    Full-text · Article · Oct 2011 · BMC Psychiatry
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    • "Ce qui était au départ vécu comme une expérience d'étrangeté, attribuée à des événements ou des circonstances externes, pourrait progressivement être compris et intégré à un processus pathologique de longue durée qui conduirait à une baisse de l'estime de soi. Ce point peut renvoyer aux interprétations psychodynamiques et cognitivistes, qui présentent le manque d'insight respectivement , comme un mécanisme de défense ou une distorsion de l'appareil cognitif visant à protéger l'estime de soi de l'individu et qui soulignent le rôle « adaptatif » du déficit lors de l'entrée dans la maladie [12] [29] [38]. Alors que certains auteurs ont montré qu'il existait un lien entre la présence d'une symptomatologie négative et des niveaux de qualité de vie altérés [34], dans notre étude, si l'on s'attache aux niveaux de conscience de la symptomatologie , positive ou négative, ils ne semblent pas liés à la qualité de vie tant au niveau de l'index global que des différents domaines isolés, en dehors de la conscience de « désorganisation de la pensée » qui entraîne une altération du « bien-être psychologique ». "
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    ABSTRACT: Background Shizophrenia is a long-lasting condition with either episodic or continuous evolution that can result in physical, psychological, and social problems related to both the disease itself and the potential side-effects of treatments. These various aspects should be taken into account when assessing the outcome of medical management of patients suffering from schizophrenia. Subjective criteria, such as quality of life (QoL) measurements, should be considered an important focus for evaluation in this population. A major subgroup of patients with schizophrenia lacks insight of having a mental disorder or symptoms of a mental disorder. Studies on the relationship between insight and QoL have produced inconsistent results. While some studies found positive associations between insight and QoL, others found negative ones. Some possible explanations for the discrepancies between these findings can be expressed: differing patients’ characteristics, heterogeneous insight or QoL measures, sample size and methodological differences. None of the previous research studies have looked at relationships between insight and QoL, as assessed respectively using the scale to assess unawareness of mental disorder (SUMD, a widely multidimensional insight questionnaire), and the S-QoL (a disease-specific patient-based instrument). Aim of the study The aim of this study was to assess the impact of insight into illness on the self-reported QoL as determined by schizophrenic patients, while taking into account the key confounding factors. Methodology This study incorporated a cross-sectional design and took place in the psychiatric department of a French public university teaching hospital (Marseille, France). The inclusion criteria were: diagnosis of schizophrenia or schizoaffective disorder (DSM-IV-R), age over 18, native French speaker, agreement to participate. The following data were recorded: sociodemographic parameters (age, gender, marital status, education level, occupational activity), clinical data (in- or out-patient, clinical form), and psychopathology (Positive And Negative Syndrome Scale, PANSS). Insight was assessed using the Scale to assess Unawareness of Mental Disorder (SUMD), a standardised expert-rating scale based on a patient interview describing nine domains. The S-QoL is a self-administered disease-specific instrument validated from patients’ views that includes 41 items and describes eight dimensions (psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy, and sentimental life), and yielding a global index score. Results One hundred and fifty-three patients were enrolled (mean age 37.6, standard deviation 11.2). Patients with good insight generally reported a lower global QoL score, whatever the insight domains. Insight of mental disorder is the most important domain affecting QoL levels. Psychological well-being, self-esteem, physical well-being, and autonomy scores were significantly lower for subjects with good insight. Multivariate analysis showed that insight of mental disorder is the only parameter linked to the S-QoL index. No links were found between other insight domains and S-QoL index. Conclusion Patients with good insight might realise consequences of their mental illness with restrictions in daily living and alteration of their QoL, while patients with poor insight might partially overrate their QoL and present themselves as more competent.
    Full-text · Article · Jun 2011 · L Encéphale
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    • "Ce qui était au départ vécu comme une expérience d'étrangeté, attribuée à des événements ou des circonstances externes, pourrait progressivement être compris et intégré à un processus pathologique de longue durée qui conduirait à une baisse de l'estime de soi. Ce point peut renvoyer aux interprétations psychodynamiques et cognitivistes, qui présentent le manque d'insight respectivement , comme un mécanisme de défense ou une distorsion de l'appareil cognitif visant à protéger l'estime de soi de l'individu et qui soulignent le rôle « adaptatif » du déficit lors de l'entrée dans la maladie [12] [29] [38]. Alors que certains auteurs ont montré qu'il existait un lien entre la présence d'une symptomatologie négative et des niveaux de qualité de vie altérés [34], dans notre étude, si l'on s'attache aux niveaux de conscience de la symptomatologie , positive ou négative, ils ne semblent pas liés à la qualité de vie tant au niveau de l'index global que des différents domaines isolés, en dehors de la conscience de « désorganisation de la pensée » qui entraîne une altération du « bien-être psychologique ». "
    [Show abstract] [Hide abstract]
    ABSTRACT: Shizophrenia is a long-lasting condition with either episodic or continuous evolution that can result in physical, psychological, and social problems related to both the disease itself and the potential side-effects of treatments. These various aspects should be taken into account when assessing the outcome of medical management of patients suffering from schizophrenia. Subjective criteria, such as quality of life (QoL) measurements, should be considered an important focus for evaluation in this population. A major subgroup of patients with schizophrenia lacks insight of having a mental disorder or symptoms of a mental disorder. Studies on the relationship between insight and QoL have produced inconsistent results. While some studies found positive associations between insight and QoL, others found negative ones. Some possible explanations for the discrepancies between these findings can be expressed: differing patients' characteristics, heterogeneous insight or QoL measures, sample size and methodological differences. None of the previous research studies have looked at relationships between insight and QoL, as assessed respectively using the scale to assess unawareness of mental disorder (SUMD, a widely multidimensional insight questionnaire), and the S-QoL (a disease-specific patient-based instrument). The aim of this study was to assess the impact of insight into illness on the self-reported QoL as determined by schizophrenic patients, while taking into account the key confounding factors. This study incorporated a cross-sectional design and took place in the psychiatric department of a French public university teaching hospital (Marseille, France). The inclusion criteria were: diagnosis of schizophrenia or schizoaffective disorder (DSM-IV-R), age over 18, native French speaker, agreement to participate. The following data were recorded: sociodemographic parameters (age, gender, marital status, education level, occupational activity), clinical data (in- or out-patient, clinical form), and psychopathology (Positive And Negative Syndrome Scale, PANSS). Insight was assessed using the Scale to assess Unawareness of Mental Disorder (SUMD), a standardised expert-rating scale based on a patient interview describing nine domains. The S-QoL is a self-administered disease-specific instrument validated from patients' views that includes 41 items and describes eight dimensions (psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy, and sentimental life), and yielding a global index score. One hundred and fifty-three patients were enrolled (mean age 37.6, standard deviation 11.2). Patients with good insight generally reported a lower global QoL score, whatever the insight domains. Insight of mental disorder is the most important domain affecting QoL levels. Psychological well-being, self-esteem, physical well-being, and autonomy scores were significantly lower for subjects with good insight. Multivariate analysis showed that insight of mental disorder is the only parameter linked to the S-QoL index. No links were found between other insight domains and S-QoL index. Patients with good insight might realise consequences of their mental illness with restrictions in daily living and alteration of their QoL, while patients with poor insight might partially overrate their QoL and present themselves as more competent.
    Full-text · Article · Jun 2011 · L Encéphale
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