[Relationship between insight and self-reported quality of life among shizophrenic patients]. / Influence des troubles de la conscience sur l'auto-évaluation de la qualité de vie des patients souffrant de schizophrénie.

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.

[The Dintilhac report and its implications for forensic neuropsychological evaluation]. / Implication du rapport Dintilhac dans l'expertise neuropsychologique.

BACKGROUND: When preparing neuropsychological expert reports, the neuropsychologist is asked to make a precise assessment of the victims' cognitive dysfunction, generally after traumatic head injury. The expert is usually required to assess the nature of the neuropsychological deficits, their correlation with any brain lesions and their imputability to the accident or crime in question, to estimate a possible date of stabilisation and to evaluate the heads of damage. The basic principle of compensation for personal injury is to consider the circumstances in which the victim would have been if the prejudicial event (for example, the accident) had not occurred and to assess, on the basis of these various heads of damage, compensation for the injury suffered. While it is not the neuropsychologist's role to evaluate the compensation as such, he or she has however to specify which aspects of cognitive function are deficient and what impact this dysfunction has on a personal and occupational level. Until recently, compensation for personal injury, and notably for cognitive deficits, was assessed with reference to nine principal heads of damage, in particular the conventional concepts of total temporary disability (incapacité temporaire totale [ITT]), defined as the period during which the victim was temporarily unable to carry out their usual occupational and personal activities, and partial permanent disability (incapacité partielle permanente [IPP]), defined as a percentage and corresponding to the reduction, after stabilisation, in the victim's functional capacity - that is, their physical and psychological potential - here again from an occupational and personal viewpoint. However, concretely, the emphasis had shifted to take into account only the pecuniary aspects of injury relating to the domain of "having", that is the loss of income due to cessation of work, while the non-pecuniary aspects relating to the domain of "being" were often ignored. NEW CLASSIFICATION: The Dintilhac report has established a new classification of heads of physical damage which abandons these two ambiguous concepts of ITT and IPP. Damage now includes three categories: pecuniary and non-pecuniary; temporary and permanent and damage to direct and indirect victims. We define the new heads of damage to direct victims, illustrate them with examples from neuropsychological expert reports, compare the old and the new classifications and discuss the implications of the Dintilhac report for expert assessment. The report appears to remove the ambiguities previously mentioned, since ITT has been replaced by two new heads of damage which are clearly defined as pecuniary and non-pecuniary: "loss of present occupational income" (pertes de gains professionnels actuels [PGPA]) and "temporary functional deficiency" (déficit fonctionnel temporaire [DFT]), respectively. Similarly, IPP is replaced by two new heads of damage, which are also clearly defined as pecuniary and non-pecuniary and are the poststabilisation equivalents of PGDA and DFT: these are "loss of future earnings" (pertes de gains professionnels futurs [PGPF]) and "permanent functional deficiency" (déficit fonctionnel permanent [DFP]). Concerning the other heads of damage, the amendments introduced by the new classification do not basically modify the earlier concepts but are nevertheless more precise in certain respects. The "pretium doloris", or "price of pain", is replaced by "suffering sustained" (souffrances endurées [SE]) with little fundamental change. The same is true of "loss of amenity" (préjudice d'agrément [PA]). The term of "aesthetic impairment" (préjudice esthétique [PE]) also remains the same, but whereas it previously related only to permanent impairment, it now includes temporary impairment, before stabilisation. What was formerly termed "loss of sexual function" now consists of "loss of sexual function" (préjudice sexuel [PS]) as well as "loss of the prospect of founding a family" (préjudice d'établissement [PE]), allowing a finer distinction to be made between the damages sustained. The former "third party" (tierce personne) is now covered under the headings of "assistance by a third party" (assistance par tierce personne [ATP]), "expenses of accommodation conversion" (frais de logement adapté [FLA]) and "expenses of vehicle conversion" (frais de véhicule adapté [FVA]), which here again provides greater precision in the heads of compensation. Lastly, what was previously known as "loss of opportunity" (perte de chance) is divided into three different categories: "loss of education, whether at school, university or in training" (préjudice scolaire, universitaire ou de formation [PSU]), "loss of future occupational earnings" (perte de gains professionnels futurs [PGPF]) and in part the "occupational impact" (incidence professionnelle [IP]). CONCLUSION: In summary, these various heads of damage concerning direct victims that are proposed by the Dintilhac report result in a more detailed evaluation of compensation for personal injury. Assessment of a certain number of heads of damage is an integral part of the preparation of a neuropsychological expert report and the fact that these heads of damage are now better defined makes the expert's task easier. As the neuropsychologist, generally called upon to give an expert opinion, now has better knowledge of this new classification, he or she will be able to give clearer and fuller answers to the questions raised and so comply with the principle of civil law relating to compensation for personal injury: "compensate the injury, all the injury, but nothing except the injury".

[Development and validation of a self rating quality of life scale: the S-QoL]. / Développement et validation d'un instrument d'auto-évaluation de la qualité de vie des patients souffrant de schizophrénie: la S-QoL.

INTRODUCTION: Evaluation of subjective quality of life in schizophrenia is a recent phenomenon. Few subjective quality of life questionnaires are available and validated, especially in French. Most of the available scales are hetero questionnaires based on experts' opinion. We describe the development and the validation of a new self-rating questionnaire of quality of life for schizophrenic patients, the S-QoL. The S-QoL was based on Calman's approach to the subject's point of view. The S-QoL is a multidimensional instrument. Generation of the items was based on three series of semi-directive interviews with patients' various types (hospitalized, ambulatory, acute phase, stabilized...). Synthesis of the interviews permitted the elaboration of a pre-questionnaire of 97 items. SETTING: A first version of the questionnaire (V0) was used in a sub-group of 141 schizophrenic patients. After a preliminary study of the psychometric properties a first questionnaire (V1) of 53 items was elaborated. A second experimental study was performed in a group of 207 patients. A shorter version (41 items) was developed and a validation study was conducted. Eight dimensions were isolated. METHODS: Nomological validity was studied with clinical parameters (clinical severity, psychotic symptomatology, global functioning) correlated with the S-QoL. The trait validity was estimated by measuring the correlation of the S-QoL with two other instruments: the QoLi and the SF 36. The test-retest reliability was estimated on a subgroup of 53 patients stabilized in a 30-day period. RESULTS: The coefficients of correlation were from 0.64 to 0.79. The acceptability of the S-QoL was good (missing rate of data lower than 10% for all the scores and the rate of spontaneous refusal between 8 and 12%). The average time of completion was 13.6 +/- 10.8 minutes. Sensitivity to change was studied in a population of 46 patients between day 0 and day 30. The S-QoL was also sensitive to the change. The S-QoL measures the impact of schizophrenia on quality of life of the individuals suffering from the disease. CONCLUSION: The S-Qol is a new self-administered questionnaire able to follow the evolution of the disease. S-Qol covers domains that differ from areas tapped in other measures of quality of life. The use of the S-QoL in the assessment of the efficacy of the clinical programme will be evaluated.

[The influence of memory disorders on self-evaluation of subjective quality of life among schizophrenic patients]. / Inluence des troubles mnéstique sur l'auto-évaluation de la qualité de vie subjective des patients schizophrènes.

INTRODUCTION: For the past few years, in the field of psychiatric disorders, measurements of subjective quality of life are integrated as an important criterion of judgment. The use of standardized questionnaires, based on the patients point of view has become widespread. However, in schizophrenic patients, cognitive impairement, and notably memory, is often advanced as a limit to the use of the self-reported questionnaires. METHODS: In this preliminary study, we investigated in 53 schizophrenic patients, the impact of memory impairment, specifically the episodic memory, on quality of life, taking into account confounding socio-demographic and clinical factors. The memory was assessed using the BEM 84. The patient's subjective quality of life was assessed by the self-reported questionnaire S-QoL. RESULTS: No correlation was found between memory efficiency and quality of life level: patients with severe and non-severe impairment scored all the S-QoL domains similarly. DISCUSSION: However, the majority of schizophrenic patients could be considered as deficient on a wide assortment of neuropsychological evaluations, in particular in the attention and executive functions. The influence of the whole cognitive impairment of life must be confirmed.

Development and validation of a patient-based health-related quality of life questionnaire in schizophrenia: the S-QoL.

We developed a self-administered instrument to assess health-related quality of life (HRQL) among people with schizophrenia. The S-QoL, based on Calman's approach to the subject's point of view, is a multidimensional instrument that is sensitive to change. The scale is a 41-item questionnaire with eight subscales (psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy and sentimental life) and a total score. In-depth interviews with patients determined the pertinent issues for item development. The validation study, performed with 207 patients, showed high internal consistency reliability, reproducibility and responsiveness. Construct validity was confirmed using established clinical and HRQL measures. S-QoL covers domains that differ from areas tapped in other measures, with greater responsiveness. The S-QoL is an efficient instrument for the measurement of the impact of schizophrenia on individuals' lives.

From "logographic" to normal reading: the case of a deaf beginning reader.

Visual word recognition of a profoundly deaf girl (AH) with developmental reading disorders was explored using an experimental technique that measures performance as a function of eye fixation within a word. AH's fixation-dependent word recognition profile revealed that she was inferring the identity of words using a "logographic" reading strategy (i. e., using salient visual features). Following this observation a special training program that enhances the understanding of grapheme-phoneme relations was applied. After few months of training, AH's reading skills improved, while her fixation-dependent performance changed to become like that of normal readers. We discuss the impact of our technique for the early diagnosis of reading impairments.

Insight into illness, neurocognition and quality of life in schizophrenia.

OBJECTIVE: The aim of this study was to assess the impact of insight into illness on self-reported quality of life (QoL) for patients with schizophrenia. METHODS: This cross-sectional study was conducted in the psychiatric department of a French public university teaching hospital. The data collected included socio-demographic information, clinical characteristics, medications, cognitive performance assessments, insight into illness, and the S-QoL 18. A multivariate analysis using multiple linear regressions was performed to determine variables potentially associated with QoL levels. RESULTS: One hundred and thirteen outpatients with stable schizophrenia were enrolled in our study. Significant associations were found between QoL and socio-demographic characteristics: a higher QoL was associated with marital status (in couple) and employment. Concerning insight into illness, lower QoL levels were associated with better awareness of the mental disorder, whereas higher QoL levels were associated with better awareness of positive and negative symptoms. Elementary neuropsychological measures were not statistically associated with QoL. CONCLUSION: Insight into illness, marital status and employment were the most important features associated with QoL, whereas there was no evidence that elementary neurocognition directly influenced QoL. The different facets of insight into illness should be considered to guide the development of specific interventions intended to improve QoL. Moreover, this study highlights the need for clinicians to pay more attention to the personal impact of schizophrenia, especially upon family life and work.

Developing normal reading skills: aspects of the visual processes underlying word recognition.

Visual word recognition performance of first graders (mean age: 6.6 years) through fifth graders (mean age: 10.8 years) was investigated using an experimental technique that is known to elicit the "viewing position effect" in skilled readers. The results showed that this effect, which consists of a systematic variation of performance as a function of fixation position within words, emerged early at the end of the 1st year of reading instruction. Visual field asymmetries in recognizing individual letters in words were also observed starting from first grade. Effects of word familiarity were obtained as early as in second grade. In contrast to skilled readers, children showed a marked word-length effect, which persisted through the first 5 years of instruction. No other qualitative differences between beginning and skilled readers were apparent. Hence, the basics of reading skills, as measured by the present technique, seem to be attained very early during acquisition. Further experience mainly reduces the time a reader needs to extract visual information from print.

Factorial structure of the Positive and Negative Syndrome Scale (PANSS): a forced five-dimensional factor analysis.

We conducted a study on 205 schizophrenic patients in order to explore the factorial structure of the Positive and Negative Syndrome Scale (PANSS). We first documented the validity and reliability of the five-dimensional structure of the PANSS, initially derived from the work of Kay and Sevy and completed by Lindenmayer et al. Some items (stereotyped thinking, mannerisms and posturing, poor attention, lack of judgement, disturbance of volition, and preoccupation) appeared to contribute little to the constitution of the dimensions initially described by Kay and Sevy. Those items were not taken into account in the forced five-dimensional factor analysis. We therefore investigated further the psychometric properties of the PANSS using only the retained items. The validity and reliability of this new five-dimensional structure are discussed.

An exploration of the psychometric properties of the French version of the Positive and Negative Syndrome Scale.

The psychometric properties of the French version of the Positive and Negative Syndrome Scale (PANSS) were studied in a population of 85 patients diagnosed with schizophrenia in accordance with Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria. The results of the study of the properties (internal consistency and principal-component analysis) of the initial structure with 3 scales (positive, negative, and general psychopathology) led us to investigate other factorial structures. We thus isolated a 5-factor structure (negative, hostility, positive, disorganization, and anxiety), explaining 54.7% of the total variance. The internal consistency of the 5 factors isolated was good (0.79, negative factor; 0.71, hostility factor; 0.77, positive factor; 0.66, disorganization factor; and 0.61, anxiety factor). The 3-subscale structure of the PANSS is discussed.