[Network analyses: Are we moving toward a new conceptualization and treatment of mental disorder?] / Les analyses par réseau : vers une nouvelle conceptualisation et prise en charge des troubles mentaux ?

In a break with categorical and dimensional approaches and thus the classical medical model, the network approach applied to psychopathology constitutes a holistic approach to mental disorders. In this approach, mental disorders are conceived as an interconnected system of symptoms in which symptoms are the cause of each other. It is suggested that the interaction between the different symptoms would result in a feedback loop that leads to the installation and maintenance of these symptoms/disorders. In addition, this approach proposes that co-morbidities are the result of symptom-symptom interactions that cross the diagnostic boundary and interact with symptoms from other psychiatric disorders. A growing number of studies have applied the network approach to elucidate causal interactions within the symptoms of depression, post-traumatic stress disorder, schizophrenia, or anxiety disorders. The overall objective of this review is to raise awareness among researchers and clinicians in psychiatry and clinical psychology of the network approach applied to psychopathology. To do this, we present the main concepts and principles of the network approach and its application in post-traumatic stress disorder. We also discuss recent criticisms of this approach and its clinical applications.

[The clinic of apathy in schizophrenia: a critical review of the issue]. / L'apathie dans la schizophrénie: une revue clinique et critique de la question.

INTRODUCTION: Today the concept of apathy is subject to many questions. This psychological state is present and predominant in different disorders such as neurodegenerative and psychiatric diseases or neurological acquired disorders. Apathy is a part of the clinical vocabulary, however, we can note that in the literature there remains confusion in its definition, and we can find an amalgam with other clinical symptoms. OBJECTIVES: The aim of this review is to provide a clarification of the concept of apathy in clinical practice in schizophrenia as well as to highlight the gaps that exist. LITERATURE FINDINGS: Apathy belongs to the negative symptoms of schizophrenia. For its understanding, it is necessary to define apathy as a multidimensional syndrome (cognitive, emotional, and behavioral) manifesting as a quantitative reduction of voluntary behaviors directed toward one or several goals. However, at present, we are witnessing a reductionist and simplistic conception of the syndrome of apathy and this especially in the Anglo-Saxon literature. Several authors reduce apathy to its behavioral component, so in other words, to avolition/amotivation. Avolition refers to a loss of self-initiated and spontaneous behaviors. In this definition only observable behavior is taken into account and not the underlying mechanisms (cognitive and emotional). In order to understand the syndrome of apathy, it is necessary to have a holistic and multidimensional outlook. Some authors have proposed diagnostic criteria for apathy by taking into account the different dimensions of apathy. Moreover not only is apathy confused with avolition, but it is also still difficult to distinguish it from depression. Apathy and depression share common clinical signs (i.e. loss of interest), but they also have distinct clinical signs (lack of motivation for apathy, and suicidal ideation for depression). Authors have shown that the presence of one symptom (apathy or depression) does not predict the presence of the other. An apathetic patient does not have to be necessarily in a depressive state and vice versa. However, to our knowledge, there is no data capable of distinguishing depression from apathy in schizophrenia, and knowing what is the part of one and the other when the patient has both symptoms. In addition, we can see that the confusion that persists between those two symptoms also stems from assessment tools. Indeed, some assessment tools such as the Montgomery and Asberg Depression Rating Scale (MARDS) have an apathy subscale. Therefore, this scale does not only evaluate depression. Regarding the assessment of apathy in schizophrenia, there are specific and nonspecific tools. Nonspecific tools define apathy differently. For this reason, authors have proposed to measure apathy by using analytic factors of negative symptoms. In this case, apathy is going to be assessed by the factor "motivation/pleasure" including anhedonia, asociality and avolition. This factor will provide the possibility of a better assessment of apathy. Concerning specific scales (like AES), there are gaps such as a lack of standardization in the execution and the quotation. Furthermore, no scale takes into account the factors causing apathy. CONCLUSION: Knowing the reasons for apathy is necessary because this syndrome is frequent in schizophrenia, and it is found in the different phases of this disease (prodromal, first episode psychosis, and chronic). In addition, apathy has significant functional consequences on the patient's quality of life, as well as on his or her global functioning. Indeed, apathy impacts on his or her social and professional life. Patients with schizophrenia have a loss of autonomy, less employment and social withdrawal. Consequently, interest in its drug or treatment it is obvious. However, drug and non-drug treatments are not specific to apathy and therefore little effective on this syndrome. Implications to stimulate future research are presented.

[Evolution of the concept of apathy: the need for a multifactorial approach in schizophrenia]. / Évolution du concept d'apathie: nécessité d'une approche multifactorielle dans la schizophrénie.

BACKGROUND: Schizophrenia is a chronic and severe mental illness that affects over 1% of the population, characterized by multiple symptom dimensions. One of this class of symptoms, "negative symptoms", have received more attention over the last few years. Negative symptoms, including among others blunted affect, withdrawal or apathy, are particularly important for recovery and are associated with negative functional outcomes, such as inability to get an employment and conduct normal daily living activities. While positive symptoms are usually treated by antipsychotic drugs, negative symptoms are usually persistent, which indicates the need for better treatment. The aim of this article is to highlight recent scientific progress on apathy and to explore current multidimensional approaches of this concept in schizophrenia. Apathy is a symptom frequently encountered in schizophrenia and in many neurological disorders. Therefore, it can be regarded as a transnosographic symptom. LITERATURE FINDINGS: A long time considered as a loss of motivation (psychological concept hard to define), recent descriptive and etiological models have proposed to consider apathy as a multidimensional phenomenon. Marin et al., have proposed a model of apathy in reference to the motivation concept. Marin et al.'s apathy model is composed of three dimensions: firstly, cognitive dimension, secondly, sensory-motor dimension and thirdly, affective dimension. These authors propose to differentiate "apathy syndrome" from "apathy symptom". "Apathy syndrome" resulting from a lack of motivation whereas "apathy symptom" results from cognitive and/or emotional/affective disorders. In addition, Marin et al. propose that apathy syndrome corresponds to the "lack of motivation" not attributable to diminished level of consciousness, cognitive impairment or emotional distress. Following this proposal, Levy and Dubois propose to define apathy as a quantitative reduction of self-generated, voluntary and purposeful behaviors. It is therefore observable and can be quantified. Levy and Dubois have proposed an apathy model considering: firstly, apathy as a syndrome related to reduction in goal-directed behaviors; secondly, anatomically, apathy can be secondary to dysfunctions or lesions of the prefrontal cortex. Since the prefrontal cortex is functionally and anatomically heterogeneous, subtypes of apathy occur in diseases affecting the basal ganglia, because these diseases disrupt associative and limbic pathways from/to the prefrontal cortex; thirdly, from a pathophysiological point of view, apathy may be explained by the impact of lesions or dysfunctions of the basal ganglia, because these lesions or dysfunctions lead to a loss of temporal and spatial focalization, both of which result in a diminished extraction of the relevant signal within the frontal cortex, thereby inhibiting the capacity of the frontal cortex to select, initiate, maintain and shift programs of action.

Video self-confrontation as a therapeutic tool in schizophrenia: A randomized parallel-arm single-blind trial.

BACKGROUND: Lack of insight is a barrier to treating psychosis. Preliminary studies have suggested that showing people videos of their psychotic behaviour may improve personal insight. This clinical trial aimed to assess the effect of video self-confrontation. METHODS: Inpatients between 18 and 65 years old with schizophrenia or schizoaffective disorder were filmed upon admission to two psychiatric hospitals while experiencing acute psychosis. After stabilization, individuals were randomized 1:1 to the "self-video" group where they watched their own video or to the "no video" control group. The primary outcome was the Scale to assess Unawareness of Mental Disorder (SUMD) at 48 h by a blinded assessor. Secondary objectives included psychotic and depressive symptoms, medication adherence and functioning using the Functional Remission of General Schizophrenia. Patients were followed up for four months. RESULTS: 60 participants were randomized and the level of insight did not differ between groups at 48 h (p = 0.98). There was no impact on SUMD subscores or the other insight questionnaires at any timepoint, nor on psychopathology or medication adherence. At one month, the level of functioning of those in the "self-video" group (n = 23) was higher (61.8 vs 53.5, p = 0.02), especially concerning "Treatment" and "Daily life". No adverse effects were reported. After video self-confrontation, people expressed more positive than negative emotions and were less lost to follow-up. CONCLUSION: Video self-confrontation did not change levels of insight, but may have a therapeutic impact nonetheless, by improving levels of self-care and adherence to care, indicating that this innovative therapeutic tool requires further study. TRIAL REGISTRATION NUMBER: NCT02664129.

[Learning potential and cognitive remediation in schizophrenia]. / Potentiel d'apprentissage et revalidation cognitive dans la schizophrénie.

BACKGROUND: Many studies have stressed the importance of neurocognitive deficits in schizophrenia that represent a core feature of the pathology. Cognitive dysfunctions are present in 80% of schizophrenic patients, including deficits in attention, memory, speed processing and executive functioning, with well-known functional consequences on daily life, social functioning and rehabilitation outcome. Recent studies have stressed that cognitive deficits, rather than the positive or negative symptoms of schizophrenia, predict poor performance in basic activities of daily living. If it is possible to reduce psychotic symptoms and to prevent relapses with antipsychotic medication, it is not yet possible to have the same convincing impact on cognitive or functional impairments. Cognitive remediation is a new psychological treatment which has proved its efficacy in reducing cognitive deficits. A growing literature on cognitive rehabilitation suggests possibilities that in schizophrenia, specific techniques are able to enhance an individual's cognitive functioning. LITERATURE FINDINGS: Presently, two distinct and complementary cognitive remediation methods have been developed: the compensatory and the restorative approaches: (A) restorative approaches attempt to improve function by recruiting relatively intact cognitive processes to fill the role of those impaired, or by using prosthetic aids to compensate for the loss of function; (B) in contrast, in the restorative approach cognitive deficits are targeted directly through repeated practice training. However, results concerning cognitive remediation remain inconsistent. It is clear that not all individuals with schizophrenia display cognitive impairment, and even among those who do, the specific pattern of cognitive functioning varies. Moreover, traditional neurocognitive assessment, with a single or static administration of cognitive measures, provides moderately good prediction of skills acquisition in schizophrenia. Among other factors such as motivation, awareness of having a disease and acuteness of symptomatology, some studies have exposed that a cognitive variable, learning potential could mediate in part the effectiveness of cognitive remediation. DISCUSSION: The concept of learning potential is used to explain some of the observed variability in cognitive functioning. Learning potential is the ability to attain and utilize cognitive skills after cognitive training: it is assessed by individual variation in performance across three consecutive administrations of the Wisconsin Card Sorting Test (WCST): a pretest with standard instruction procedures, a training phase with expanded instruction and a post test with only standard instruction. Three learner subtypes can be identified: "learners" who perform poorly at the pretest but improve performance during the post-test, "non-retainers" who perform poorly at pre-test and do not improve at post-testing and "high achievers" who perform well in the initial pretest and maintain their good performance across the other two administrations. The assessment of learning potential could predict, with other psychological measures such as insight and motivation, the most effective neurocognitive rehabilitation program for an individual patient, and could help the clinician to optimize patient outcome through appropriate individual management. CONCLUSION: Indeed, learning potential could represent a good cognitive predictor and indicator for rehabilitation in schizophrenia for clinicians and should be used in cognitive assessment practice. However, the individuals most likely to benefit from cognitive remediation, and whether changes in cognitive function translate into functional improvements, are as yet unclear.

A multi-dimensional approach to the relationship between insight and aggressiveness in schizophrenia: Findings from the FACE-SZ cohort.

BACKGROUND: Aggressiveness is a stigma frequently associated with schizophrenia. The role of insight as a risk factor of aggressiveness remains contradictory; mainly because single measures of these states mask their complexity and heterogeneity. METHODS: This study was conducted on 666 patients aged 15 and above with a DSM-IV-TR diagnosis of schizophrenia spectrum disorder, drawn from the French national network of schizophrenia expert center database. Collected data comprised socio-demographics and standardized psychiatric assessments. Aggressiveness was evaluated using the Buss-Perry Aggression Questionnaire and insight using the Scale to assess Unawareness of Mental Disorder (SUMD) and Birchwood Insight Scale (BIS). RESULTS: Hostility was the aggressiveness dimension the most strongly associated with SUMD insight dimensions. Patients aware of their illness were nearly twice as likely to show hostility than those seriously unaware (OR = 1.95, 95% CI.: 1.08-3.5), but not when further adjusting for depression. Similarly, those aware of the consequences of their illness and of their symptoms were more hostile. Patients moderately aware of illness consequences had a higher risk of both anger and physical aggressiveness than those unaware (OR = 2.63, 95% CI.: 1.42-4.86, OR = 2.47, 95% CI.: 1.33-4.60, respectively), even when adjusting for depression for anger. CONCLUSION: Our study confirms that a multi-dimensional approach to insight and aggressiveness is essential to understand the types of links between these clinical states. Insight may trigger the expression of an underlying hostile tendency, maybe via depression and self-stigmatisation. This should be taken into account in therapeutic approaches to improve insight.

[Lack of insight in schizophrenia: a review]. / La conscience des troubles (insight) dans la schizophrénie : une revue critique Partie II : modèles explicatifs et hypothèses psychopathologiques.

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.

[Lack of insight in schizophrenia: a review. Part I: theoretical concept, clinical aspects and Amador's model]. / La conscience des troubles (insight) dans la schizophrénie : une revue critique. Partie I : insight et schizophrénie, caractéristiques cliniques de l'insight.

INTRODUCTION: Schizophrenia is the psychiatric disorder in which the awareness of pathology (or insight) is most frequently altered. LITERATURE FINDINGS: 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. DISCUSSION: 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. ASSESSMENT TOOLS: 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. CONCLUSION: 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.