Impact of Delusions and Hallucinations on Clinical Insight Dimensions in Schizophrenia Spectrum Disorders.

INTRODUCTION: Insight in psychosis has been conceptualized as a continuous, dynamic, and multidimensional phenomenon. This study aims to determine the impact of delusions and hallucinations in different dimensions of clinical insight in schizophrenia spectrum disorders. METHODS: Cross-sectional multicenter study including 516 patients (336 men) diagnosed with schizophrenia spectrum disorders. Based on dichotomized scores of Positive and Negative Syndrome Scale (PANSS) items P1 (delusions) and P3 (hallucinations), patients were assigned to four groups according to current clear presence of delusions (scores 4 or above 4 in PANSS item P1) and/or hallucinations (scores 4 or above 4 in PANNS item P3). Insight was assessed using the three main dimensions of the Scale of Unawareness of Mental Disorder (SUMD). RESULTS: Around 40% of patients showed unawareness of illness; 30% unawareness of the need for treatment; and 45% unawareness of the social consequences of the disorder. Patients with current clear presence of delusions had higher overall lack of awareness, regardless of current clear presence of hallucinations. Similarly, the clear presence of delusions showed a greater predictive value on insight than the presence of hallucinations, although the implication of both in the prediction was modest. CONCLUSIONS: Our results confirm that lack of insight is highly prevalent in schizophrenia spectrum disorders, particularly when patients experience delusions. This study adds insight-related data to the growing symptom-based research, where specific types of psychotic experiences such as hallucinations and delusions could form different psychopathological patterns, linking the phenomenology of delusions to a lack of clinical insight.

Clinical insight in first-episode psychosis: Clinical, neurocognitive and metacognitive predictors.

OBJECTIVE: Poor insight is a major problem in psychosis, being detrimental for treatment compliance and recovery. Previous studies have identified various correlates of insight impairment, mostly in chronic samples. The current study aimed to determine clinical, neurocognitive, metacognitive, and socio-cognitive predictors of insight in first-episode psychosis. METHODS: Regression analyses of different insight dimensions were conducted in 190 patients with first-episode psychosis. Measures of clinical symptoms, neurocognition, metacognition, social cognition, and 'jumping to conclusions' bias were entered as predictors. RESULTS: Delusions, disorganisation, and certain negative symptoms were associated with unawareness in various domains, while depression was associated with greater awareness of illness. Deficit in theory of mind and self-reflective processes, as well as a 'jumping to conclusions' bias, contributed to poor insight. Several neuropsychological scores also contributed to this but their contribution was no longer observed in regression analyses that included all the previously identified clinical and cognitive predictors. A measure of perseverative errors was still associated with unawareness and misattribution of symptoms. CONCLUSION: In models that account for 28 % to 50 % of the variance, poor insight in first-episode psychosis is mainly associated with delusions and certain negative symptoms. At the cognitive level it does not appear to result from neuropsychological impairment but rather from altered reasoning bias and dysfunction in metacognitive processes. Therapeutic strategies specifically directed at these mechanisms could help improve the evolution of insight in first episode psychosis.

Exploring the relationship of insight with psychopathology and gender in individuals with schizophrenia spectrum disorders with structural equation modelling.

To model the influence of psychopathology on insight deficits in schizophrenia spectrum patients with a gender-stratified analysis. Five hundred sixteen patients (65.1% men) with schizophrenia spectrum disorders were evaluated in four centres of the metropolitan area of Barcelona (Catalonia). Psychopathological assessment was performed using different PANSS factors. Insight and its three main dimensions were assessed by means of the Scale of Unawareness of Mental Disorder: awareness of the disease (SUMD-1), of the effect of medication (SUMD-2) and of the social consequences of the disease (SUMD-3). Structural equation models (SEMs) were used to fix the model in the total sample and by gender. Additional analyses included age, duration of illness (DOI) and education status (ES). There were no significant differences between men and women in the three main dimensions of insight. The SEMs in the total sample showed a modest fitting capacity. Fitting improved after a gender-stratified analysis (particularly in women). In men, positive and excited symptoms were associated with poorer insight in all SUMD dimensions, whereas depressive symptoms were associated with better insight. ES in men was also associated with better SUMD-2 or SUMD-3. In contrast, in women, symptoms did not have a negative effect on SUMD-1 or SUMD-2. However, positive symptoms were associated with a poorer SUMD-3, whereas depressive symptoms were associated with better SUMD-3. Moreover, education level was also associated with a better SUMD-3. A gender approach improved the comprehension of the model, supporting the relevance of gender analysis in the study of insight.

A deeper view of insight in schizophrenia: Insight dimensions, unawareness and misattribution of particular symptoms and its relation with psychopathological factors.

OBJECTIVE: 1. To describe insight in a large sample of schizophrenia subjects from a multidimensional point of view, including unawareness of general insight dimensions as well as unawareness and misattribution of particular symptoms. 2. To explore the relationship between unawareness and clinical and socio-demographic variables. METHODS: 248 schizophrenia patients were assessed with the Positive and Negative Syndrome Scale (PANSS, five factor model of Lindenmayer) and the full Scale of Unawareness of Mental Disorder (SUMD). Bivariate associations and multiple linear regression analyses were used to investigate the relationship between unawareness, symptoms and socio-demographic variables. RESULTS: Around 40% of the sample showed unawareness of mental disorder, of the need for medication and of the social consequences. Levels of unawareness and misattribution of particular symptoms varied considerably. General unawareness dimensions showed small significant correlations with positive, cognitive and excitement factors of psychopathology, whereas these symptom factors showed higher correlations with unawareness of particular symptoms. Similarly, regression models showed a small significant predictive value of positive symptoms in the three general unawareness dimensions while a moderate one in the prediction of particular symptoms. Misattribution showed no significant correlations with any symptom factors. CONCLUSIONS: Results confirm that insight in schizophrenia is a multi-phased phenomenon and that unawareness into particular symptoms varies widely. The overlap between unawareness dimensions and psychopathology is small and seems to be restricted to positive and cognitive symptoms, supporting the accounts from cognitive neurosciences that suggest that besides basic cognition poor insight may be in part a failure of self-reflection or strategic metacognition.

Insight and gender in schizophrenia and other psychoses.

This study aimed to evaluate gender differences in the deficit of insight in psychosis and determine influences of clinical, functional, and sociodemographic variables. A multicenter sample of 401 adult patients with schizophrenia and other psychotic disorders who agreed to participate was evaluated in four centers of the metropolitan area of Barcelona (Catalonia). Psychopathological assessment was performed using the Positive and Negative Syndrome Scale Lindenmayers' Factors. Insight and its dimensions were assessed by means of the Scale of Unawareness of Mental Disorder. Significant differences were apparent neither between men and women in the three dimensions of insight, nor in the total awareness, nor in the total attribution subscales. However, statistically significant differences were found in awareness and attribution of particular symptoms. Women showed a worse awareness of thought disorder and alogia and a higher misattribution of apathy. Higher cognitive and positive symptoms, early stage of the illness, and having been married explained deficits of insight dimensions in women. In men, other variables such as lower functioning, higher age, other psychosis diagnosis, and, to a lower extent, higher scores in cognitive, positive, and excitative symptoms, explained deficits of insight dimensions. These data could help to design gender-specific preventive and therapeutic strategies.

Spanish adaptation of the Markova and Berrios Insight scale.

INTRODUCTION: The aim of this study was to adapt the Markova and Berrios Insight scale in Spanish and to analyze its psychometric properties and relationships to the severity of the psychotic symptoms. METHODOLOGY: A translation-backtranslation of the original scale was elaborated and a panel of professionals participated to assess conceptual equivalence and naturality. This is a 30-item self-administered scale with response options Yes/No. A total of 170 psychotic patients were assessed according to DSM-IV-TR diagnostic criteria. Confirmatory factor analysis validated the structure originally proposed. Internal consistency was evaluated using Cronbach's Alpha Coefficient and the Intraclass Correlation Coefficient (ICC). We calculated the association between variables with Spearman's rank correlation coefficient. RESULTS: The 4-factors structure originally proposed by Markova and Berrios was verified. Cronbach's alpha coefficient value for the whole scale was 0.824, indicating good internal consistency. The ICC value was 0.855. There were no statistically significant relationships between severity of psychotic symptoms and the lack of insight. CONCLUSIONS: The Spanish adaptation of the Markova and Berrios Insight Scale has good internal and external reliability. It is simple and easy to perform and very sensitive to change.

Adaptación al castellano de la escala de Insight de Marková y Berrios / Spanish adaptation of the Markova and Berrios Insight scale

Introducción. El objetivo de este estudio fue realizar la adaptación al castellano de la escala de Insight de Markováy Berrios, así como analizar sus propiedades psicométricas y su relación con la gravedad de la sintomatología psicótica. Metodología. Se utilizó un método de traducción-retrotraducción y la participación de un panel de profesionales para valorar equivalencia conceptual y naturalidad. Se trata de una escala de autoaplicación de 30 ítems con opciones de respuesta Sí/No. Fueron valorados 170 pacientes psicóticos según criterios DSM-IV-TR. Mediante análisis factorial confirmatorio se validó la estructura propuesta originalmente. La consistencia interna se evaluó a través del Coeficiente Alfa de Cronbach y el Coeficiente de correlación intraclase (CCI). La asociación entre las variables se analizó con el coeficiente de correlación de Spearman. Resultados. La estructura de 4 factores propuesta originalmente se verifica en gran medida. El valor del Coeficiente alfa de Cronbach para toda la escala fue de 0.824 indicando una buena consistencia interna. El valor del CCI fue de 0.855.No se observaron relaciones estadísticamente significativas entre la gravedad de la sintomatología psicótica y el déficit de insight valorado con la escala de Marková y Berrios. Conclusiones. La versión castellana de la Escala de Insightde Marková y Berrios presenta validez de constructo, buena consistencia interna, buena validez externa, es sencilla ,de fácil aplicación y de fiabilidad temporal (AU)

Introduction. The aim of this study was to adapt the Markova and Berrios Insight scale in Spanish and to analyze its psychometric properties and relationships to the severity of the psychotic symptoms. Methodology. A translation-backtranslation of the original scale was elaborated and a panel of professionals participated to assess conceptual equivalence and naturality. This is a 30-item self-administered scale with response options Yes/No. A total of 170 psychotic patients were assessed according to DSM-IV-TR diagnostic criteria. Confirmatory factor analysis validated the structure originally proposed. Internal consistency was evaluated using Cronbach’s Alpha Coefficient and the Intraclass Correlation Coefficient (ICC).We calculated the association between variables with Spearman’s rank correlation coefficient. Results. The 4-factors structure originally proposed by Markova and Berrios was verified. Cronbach’s alpha coefficient value for the whole scale was 0.824, indicating good internal consistency. The ICC value was 0.855. There were no statistically significant relationships between severity of psychotic symptoms and the lack of insight. Conclusions. The Spanish adaptation of the Markova and Berrios Insight Scale has good internal and external reliability. It is simple and easy to perform and very sensitive to change (AU)

Changes in the prescription of psychotropic drugs in the palliative care of advanced cancer patients over a seven-year period.

CONTEXT: Psychiatric disorders are frequently underdiagnosed and undertreated in advanced cancer patients. OBJECTIVES: To assess changes in the prescription of psychotropic drugs in terminally ill patients. METHODS: All patients with advanced disease receiving palliative care between 2002 and 2009 were eligible. The consumption of benzodiazepines, antipsychotics, and antidepressants for the years 2002, 2006, and 2009 was compared. Data on the percentage and profile of psychotropic drugs prescribed were collected. RESULTS: The study population included 840 patients (241 in 2002, 274 in 2006, and 325 in 2009). The percentage of patients treated with psychotropic drugs increased from 82.2% in 2002 to 90.2% in 2009 (P = 0.006) and the mean number of drugs per patient from 1.66 in 2002 to 2.16 in 2006 (P = 0.003), and to 2.35 in 2009 (P<0.001). Benzodiazepines were prescribed to 72.6% of patients in 2002 and 84% in 2009 (P = 0.001), with lorazepam and midazolam as the most frequently used medications. The use of antipsychotics increased from 26.1% in 2002 to 37.2% in 2006 (P = 0.007) and to 40% in 2009 (P = 0.001), with haloperidol and risperidone as the most commonly prescribed. Antidepressants were prescribed to 17.8% in 2002, 28.1% in 2006 (P = 0.006), and 27.1% in 2009 (P = 0.010), with mirtazapine, citalopram, escitalopram, and duloxetine as the most frequent. CONCLUSION: Between 2002 and 2009, there was a significant increase in the use of psychotropic drugs and a change in the profile of drugs prescribed.

Exploratory study of the association between insight and Theory of Mind (ToM) in stable schizophrenia patients.

BACKGROUND: Poor insight and impairment in Theory of Mind (ToM) reasoning are common in schizophrenia, predicting poorer clinical and functional outcomes. The present study aimed to explore the relationship between these phenomena. METHODS: 61 individuals with a DSM-IV diagnosis of schizophrenia during a stable phase were included. ToM was assessed using a picture sequencing task developed by Langdon and Coltheart (1999), and insight with the Scale to Assess Unawareness of Mental Disorder (SUMD; Amador et al., 1993). Multivariate linear regression analysis was carried out to estimate the predictive value of insight on ToM, taking into account several possible confounders and interaction variables. RESULTS: No direct significant associations were found between any of the insight dimensions and ToM using bivariate analysis. However, a significant linear regression model which explained 48% of the variance in ToM was revealed in the multivariate analysis. This included the 5 insight dimensions and 3 interaction variables. Misattribution of symptoms--in aware patients with age at onset >20 years--and unawareness of need for medication--in patients with GAF >60--were significantly predictive of better ToM. CONCLUSION: Insight and ToM are two complex and distinct phenomena in schizophrenia. Relationships between them are mediated by psychosocial, clinical, and neurocognitive variables. Intact ToM may be a prerequisite for aware patients to attribute their symptoms to causes other than mental illness, which could in turn be associated with denial of need for medication.

Theory of mind deficits in chronic schizophrenia: evidence for state dependence.

There is evidence that people with schizophrenia show specific deficits in theory of mind (ToM). However, it is a matter of debate whether these are trait or state dependent, and the nature of the relationship between ToM deficits and particular symptoms is controversial. This study aimed to shed further light on these issues by (1) examining ToM abilities in 61 individuals with chronic schizophrenia during a stable phase as compared with 51 healthy controls matched by gender, age, educational level and current IQ, and (2) exploring the relationship between ToM and symptoms. Second order verbal stories and a non-verbal picture-sequencing task were used as ToM measures. Results showed no differences in ToM performance between patients and controls on either measure. Subsequent subgrouping of patients into remitted and non-remitted showed a worse performance of non-remitted patients only on second order ToM tasks. Specific ToM deficits were found associated with delusions. Association with negative symptoms was found to be less specific and accounted for by illness chronicity and general cognitive impairment. The results from the present study are in line with models which hypothesise that specific ToM deficits in schizophrenia are state dependent and associated with delusions. Such associations may also be task specific.