Unawareness of illness and its relationship with depression and self-deception in schizophrenia

Insight and equality: A systematic review and meta-analysis of socio-demographic associations

BACKGROUND

Insight into illness is often used in clinical and legal contexts, for example, as evidence of decision-making capacity. However, it is unclear whether this disadvantages certain groups protected under equality legislation. To our knowledge, this question has yet to be addressed systematically. Therefore, the present study reviews empirical studies that look at the relationship between insight and sociodemographic variables.

METHODS

A systematic search of six bibliographic databases (CENTRAL, CINAHL, Cochrane Library of Systematic Reviews, EMBASE, MEDLINE and PsycINFO) was conducted, which yielded 6,192 results. Study characteristics and outcomes (associations between insight and socio-demographic variables) were then extracted from 207 eligible studies. This included protected characteristics under the Equality Act (2010): age, sex, ethnicity, marital status and religion. Weighted confidence estimates were calculated and relevant moderators included in a random effects meta-analysis. A study protocol was registered prospectively on PROSPERO, ID: CRD42019120117.

RESULTS

Insight was not strongly associated with any sociodemographic variable. Better insight was weakly but significantly associated with white ethnicity, being employed, younger age and more years of education. The age associations were mostly explained by relevant moderating variables. For people with schizophrenia, the associations between sociodemographic variables and insight were comparable to associations with decision making capacity.

CONCLUSIONS

Our results suggest that insight is not strongly associated with any sociodemographic variables. Further research is needed to clarify potential associations, particularly with non-white ethnicity and proxies for social support.

The Role of Group Sharing: An Action Research Study of Psychodrama Group Therapy in a Psychiatric Inpatient Ward

Numerous studies point to the acute distress associated with the experience of coping with severe mental illness and psychiatric hospitalization. Another strand of research notes the therapeutic benefits of psychodrama and its efficacy in increasing empathy and self-awareness, improving interpersonal relationships, reducing stress and anxiety, and in treating particularly vulnerable populations for whom traditional psychotherapy’s usefulness is limited. The goal of this paper is to provide a framework for understanding the potential of group sharing in dealing with the experience of loneliness and distress, and to serve as a space for relatedness and self-expression in psychodrama group therapy. A qualitative action research study following an open inpatients’ psychodrama group in a psychiatric hospital in Israel demonstrates the role of group sharing in creating an accommodating space of self-expression, relatedness, and mutual support, which offers relief for the distress of psychiatric inpatients. Within the inpatients’ group, the participants used sharing to distribute the burden among the group members along with the resources to cope with it. The paper seeks to illuminate the unique contribution of a therapeutic tool rarely dealt with by the existing literature–the group sharing—in dealing with situations of acute mental distress.

Insight Into Illness and Psychological Defense Attitudes in People With Chronic Schizophrenia Using Markova's Insight Scale

ABSTRACT

Insight into illness is a multidimensional phenomenon, and various assessments are available. We focused on Markova's Insight Scale (IS) and investigated the relationship between insight, psychological defenses, and neurocognition in 38 patients with schizophrenia. Results showed that insight was significantly correlated with an immature defense style. Moreover, IS was significantly predicted by immature defense style after adjusting for clinical variables. Although insight is often assumed to be multidetermined with potential contributions from factors such as cognitive function and psychological defensive mechanisms, our results indicated that better insight assessed with the IS is more likely to reflect immature defenses. This may also be reflected in our result that a higher insight score correlated with earlier onset of illness. The insight score may reflect the immature psychological defensive attitudes of schizophrenia and may lead such patients to wish to comply with the views of clinicians.

The Patient Health Questionnaire-9 vs. the Hamilton Rating Scale for Depression in Assessing Major Depressive Disorder

Background: The Hamilton Rating Scale for Depression (HAMD-17) has been used for several decades to assess the severity of depression. Multiple studies have documented defects in this scale and deemed it unsuitable for clinical evaluation. The HAMD-6, which is the abbreviated version of HAMD-17, has been shown to be effective in assessing the core symptoms of depression with greater sensitivity than HAMD-17. And the Patient Health Questionnaire-9 (PHQ-9) is suggested as an effective alternative to the HAMD-17 because of its simplicity and ease-of-use. Methods: Research was completed involving 1,741 participants having major depressive disorder. Cronbach's alpha, intraclass correlation coefficient (ICC) and weighted Kappa analysis was used to determine the reliability of the scales. Pearson correlation analysis and factor analysis were used to analyze validity. Item response theory (IRT) was used to analyze psychological characteristics of items in both the HAMD-17 and PHQ-9. Results: Reliability analysis showed that the Cronbach's alpha of the HAMD-17, HAMD-6 and PHQ-9 were 0.829, 0.764, and 0.893 respectively, and the ICC of the three scales ranged from 0.606 to 0.744. The Kappa score of the consistency of depression severity assessment was 0.248. Validity analysis showed that the PHQ-9 was a single factor structure, and the total score of the scale was strongly correlated with the HAMD-17 (r = 0.724, P < 0.001). The IRT analysis showed that the discrimination parameters of the PHQ-9 were higher than that of the HAMD-17 in all dimensions. The HAMD-6 had the lowest measurement accuracy in distinguishing the severity of depression, while the PHQ-9 had the highest measurement accuracy. Conclusion: Results showed that the PHQ-9 was satisfactory in terms of reliability, validity and distinguishing the severity of depression. It is a simple, rapid, effective and reliable tool which can be used as an alternative to the HAMD-17 to assess the severity of depression.

The paradoxical role of insight in mental illness: The experience of stigma and shame in schizophrenia, mood disorders, and anxiety disorders

This study examined the factor structure of the Hungarian version of the Birchwood Insight Scale (BIS) and analyzed its association with socio-demographics, diagnosis, internalized stigma, and shame using confirmatory factor analysis (CFA) with covariates. Mentally ill patients (N = 200) completed self-report questionnaires. CFA supported a two-factor structure. While previous hospitalizations and diagnosis were associated with insight, insight predicted higher internalized stigma and shame. Efforts to increase insight should be matter of importance in the wider spectrum of mental diagnoses. However, such efforts should be conducted with special care as further research is needed to understand the impact of insight on wellbeing.

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.

The association between insight and depressive symptoms in schizophrenia: Undirected and Bayesian network analyses

Background.

Greater levels of insight may be linked with depressive symptoms among patients with schizophrenia, however, it would be useful to characterize this association at symptom-level, in order to inform research on interventions.

Methods.

Data on depressive symptoms (Calgary Depression Scale for Schizophrenia) and insight (G12 item from the Positive and Negative Syndrome Scale) were obtained from 921 community-dwelling, clinically-stable individuals with a DSM-IV diagnosis of schizophrenia, recruited in a nationwide multicenter study. Network analysis was used to explore the most relevant connections between insight and depressive symptoms, including potential confounders in the model (neurocognitive and social-cognitive functioning, positive, negative and disorganization symptoms, extrapyramidal symptoms, hostility, internalized stigma, and perceived discrimination). Bayesian network analysis was used to estimate a directed acyclic graph (DAG) while investigating the most likely direction of the putative causal association between insight and depression.

Results.

After adjusting for confounders, better levels of insight were associated with greater self-depreciation, pathological guilt, morning depression and suicidal ideation. No difference in global network structure was detected for socioeconomic status, service engagement or illness severity. The DAG confirmed the presence of an association between greater insight and self-depreciation, suggesting the more probable causal direction was from insight to depressive symptoms.

Conclusions.

In schizophrenia, better levels of insight may cause self-depreciation and, possibly, other depressive symptoms. Person-centered and narrative psychotherapeutic approaches may be particularly fit to improve patient insight without dampening self-esteem.

Better insight seems associated with depressive symptoms in schizophrenia.

Network analyses were used to explore this association in a large sample.

Insight was associated with self-depreciation, guilt, and suicidal ideation.

Although cross-sectional, data suggest causal direction from insight to depression.

Evaluation of the association between insight and symptoms in a large sample of patients with schizophrenia

Background

The objective of the present study was to examine the association of insight into the illness with demographic variables and symptomatology in a sample of 1213 patients with schizophrenia.

Method

Data were collected with the Psychosis Evaluation tool for Common use by Caregivers (PECC), a semi-structured interview evaluating five symptom domains of schizophrenia and the insight items ‘awareness of having a mental disorder’ and ‘attributing symptoms to a mental disorder’.

Results

Insight was positively associated with educational level and inversely with overall symptom severity, and the positive, negative, excitatory and cognitive symptom domains. At symptom level, the items ‘delusions’, ‘grandiosity’, ‘poor rapport’, ‘social withdrawal’ and ‘guilt feelings’ showed the strongest associations with both insight items. Overall, correlations between insight and symptomatology were modest, explaining less than 30% of the variance in insight.

Conclusion

Lack of insight in schizophrenia is partially explained by clinical symptoms and demographic measures.

The Relation Between Empathy and Insight in Psychiatric Disorders: Phenomenological, Etiological, and Neuro-Functional Mechanisms

Lack of insight, i.e., unawareness of one's mental illness, is frequently encountered in psychiatric conditions. Insight is the capacity to recognize (psychical insight) and accept one's mental illness (emotional insight). Insight growth necessitates developing an objective perspective on one's subjective pathological experiences. Therefore, insight has been posited to require undamaged self-reflexion and cognitive perspective-taking capacities. These enable patients to look objectively at themselves from the imagined perspective of someone else. Preserved theory-of-mind performances have been reported to positively impact insight in psychosis. However, some patients with schizophrenia or obsessive-compulsive disorders, although recognizing their mental disease, are still not convinced of this and do not accept it. Hence, perspective-taking explains psychical insight (recognition) but not emotional insight (acceptance). Here, we propose a new conceptual model. We hypothesize that insight growth relies upon the association of intact self-reflexion and empathic capacities. Empathy (feeling into someone else) integrates heterocentered visuo-spatial perspective (feeling into), embodiment, affective (feeling into) and cognitive processes, leading to internally experience the other's thought. We posit that this subjective experience enables to better understand the other's thought about oneself and to affectively adhere to this. We propose that the process of objectification, resulting from empathic heterocentered, embodiment, and cognitive processes, generates an objective viewpoint on oneself. It enables to recognize one's mental illness and positively impacts psychical insight. The process of subjectification, resulting from empathic affective processes, enables to accept one's illness and positively impacts emotional insight. That is, affectively experiencing the thought of another person about oneself reinforces the adhesion of the emotional system to the objective recognition of the disease. Applying our model to different psychiatric disorders, we predict that the negative effect of impaired self-reflexion and empathic capacities on insight is a transnosographic state and that endophenotypical differences modulate this common state, determining a psychiatric disease as specific.

Perceived loss among people living with mental disorders: Validation of the personal loss from mental illness scale

OBJECTIVE

The development of mental illness often leads to pervasive losses in different areas of people's lives. However, previous research has tended to focus on the loss experienced by families while the examination of the loss experienced by individuals who are themselves coping with mental illness has been neglected. The present study tested the factor structure of the Hungarian version of the Personal Loss from Mental Illness (PLMI) scale, and analyzed its associations with age, gender, previous hospitalizations, marital status, loneliness, grief, and quality of life.

METHODS

Mentally ill patients (N = 200) with different diagnoses were recruited from a mental health center in Hungary, and completed self-report questionnaires. Confirmatory factor analysis (CFA) with covariates was conducted.

RESULTS

CFA analyses rejected the previous four-factor structure and suggested a single factor structure to be superior. Higher loss perception was predicted by higher loneliness, grief, and lower quality of life. Patients with mood disorders reported higher loss as compared to patients with other psychiatric diagnoses.

CONCLUSIONS

The present study stresses the magnitude of loss and raises the need to examine further the role of loss in coping and recovery. Asking patients about their feelings in clinical practice is of high importance.

Insight Into Illness and Defense Styles in Schizophrenia

Although the psychological denial model argues that poor insight is a result of defense mechanisms, the direct relationship between the two remains unclear. This study aimed to examine the relationship between insight into illness and defense mechanisms while considering cognitive dysfunction in schizophrenia. A total of 38 patients with schizophrenia were evaluated for level of insight (Schedule for the Assessment of Insight), defense mechanisms (Defense Style Questionnaire), neurocognitive function (Brief Assessment of Cognition in Schizophrenia), and psychotic symptoms (Brief Psychiatric Rating Scale). Regarding level of insight, partial correlation analysis controlling neurocognitive and psychotic variables showed that "recognition of illness" was positively correlated with immature defense styles and negatively correlated with mature defense styles. Stepwise regression analyses revealed that "recognition of illness" was significantly predicted by immature defense styles. Our findings suggest that patients who tend to use immature defense styles are more likely to accept their own mental illness.

The Multiple Dimensions of Insight in Schizophrenia-Spectrum Disorders

The concept of insight is used to indicate the propensity of patients with schizophrenia and other severe mental disorders to recognize their illness and engage in treatment. Thus, insight may have notable consequences for the ill individual: Those who lack insight are at higher risk of nonadherence to treatments, negative clinical outcomes, and worse community functioning. Although insight is an intuitive concept, its essence remains difficult to capture. However, many rating scales are available to aid assessment, both for clinical and research purposes. Insight cannot be reduced to a symptom, a psychological mechanism, or a neuropsychological function. It is likely to have dynamic relationships with all these dimensions and with responses to personal events and contextual factors. In particular, social consequences of mental illness and explanatory models that are alternative to the medical model may fundamentally shape insight and treatment choice. Moreover, the cultural or individual stigmatization of mental illness may turn the acquisition of insight into a painful event and increase the risk of depression. Clinicians need to carefully evaluate and promote insight through a personalized approach to aid patient process of care and personal growth.

Psychodrama's Role in Alleviating Acute Distress: A Case Study of an Open Therapy Group in a Psychiatric Inpatient Ward

Numerous studies point to the acute distress associated with experiencing severe mental illness and psychiatric hospitalization. Another strand of research describes how the unique features of psychodrama group therapy are useful in fostering spontaneity and creativity, and their benefits in treating particularly difficult populations where traditional psychotherapy is limited. This paper provides a framework for understanding the potential of psychodrama group therapy to alleviate the experience of loneliness and distress in psychiatric inpatients. A case study of an open inpatients psychodrama group in a psychiatric hospital in Israel demonstrates the role of therapeutic means such as the doubling technique and group sharing phase in creating and reinforcing empathy, relatedness, and support, which may offer at least partial relief of the distress and loneliness of psychiatric inpatients. The unique contribution of this study is the intimate encounter that it provides to researchers and practitioners with the processes that take place within the setting of inpatients therapy group.

Overlap and distinction between measures of insight and self-stigma

Multiple studies on insight into one's illness and self-stigma among patients with serious mental illness and their relatives have shown that these constructs are related to one another and that they affect outcome. However, a critical exploration of the items used to assess both constructs raises questions with regard to the possible overlapping and centrality of items. The current study used five different samples to explore the possible overlap and distinction between insight and self-stigma, and to identify central items, via network analyses and principal component factor analysis. Findings from the network analyses showed overlap between insight and self-stigma exist with a relatively clearer observational distinction between the constructs among the two parent samples in comparison to the patient samples. Principal component factor analysis constrained to two factors showed that a relatively high percentage of items were not loaded on either factor, and in a few datasets, several insight items were loaded on the self-stigma scale and vice versa. The author discusses implications for research and calls for rethinking the way insight is assessed. Clinical implications are also discussed in reference to central items of social isolation, future worries and stereotype endorsement among the different study groups.

Relationship between insight and theory of mind in schizophrenia: A meta-analysis

Poor insight in schizophrenia has been associated with executive dysfunction and deficits in general cognitive ability. The overall outcome of available neurocognitive studies suggests that there is a significant but modest relationship between cognitive deficits and poor insight in schizophrenia. However, social cognitive abilities, particularly, theory of mind (ToM), might also play a role in poor insight in schizophrenia. A novel meta-analysis of the relationship between ToM and insight in schizophrenia was conducted. Current meta-analysis included 16 studies including 1085 patients with schizophrenia-spectrum disorders. There was a significant association between ToM and clinical insight (r=0.28, CI=0.20-0.36). By contrast, there was no significant relationship between ToM and cognitive insight. Current findings suggest that there is a small but significant relationship between ToM and clinical insight in schizophrenia. ToM impairment is one of the factors contributing to poor insight in schizophrenia.

Relationship of depression with cognitive insight and socio-occupational outcome in patients with schizophrenia

AIM

To evaluate the prevalence of depression using different measures in patients with schizophrenia and to study the relationship of depression in schizophrenia with cognitive insight and clinical insight, disability and socio-occupational functioning.

METHODS

A total of 136 patients with schizophrenia were evaluated for depression, cognitive insight and socio-occupational functioning.

RESULTS

Of the 136 patients included in the study, one-fourth ( N = 34; 25%) were found to have depression as per the Mini International Neuropsychiatric Interview (MINI). The prevalence of depression as assessed by Calgary Depression Scale for Schizophrenia (CDSS), Hamilton depression rating scale (HDRS) and Depressive Subscale of Positive and Negative Syndrome Scale (PANSS-D) was 23.5%, 19.9% and 91.9%, respectively. Among the different scales, CDSS has highest concordance with clinician's diagnosis. Sensitivity, specificity, positive predictive value and negative predictive value for CDSS was also higher than that noted for HDRS and PANSS-D. When those with and without depression as per clinician's diagnosis were compared, those with depression were found to have significantly higher scores on Positive and Negative Syndrome Scale (PANSS) positive and general psychopathology subscales, PANSS total score, participation restriction as assessed by P-scale and had lower level of functioning as assessed by Global Assessment of Functioning (GAF). No significant difference was noted on negative symptom subscale of PANSS, clinical insight as assessed on G-12 item of PANSS, disability as assessed by Indian Disability Evaluation and Assessment Scale (IDEAS) and socio-occupational functioning as assessed by Social and Occupational Functioning Assessment Scale (SOFS). In terms of cognitive insight, those with depression had significantly higher score for both the subscales, that is, self-reflective and self-certainty subscales as well as the mean composite index score.

CONCLUSION

Our results suggest that one-fourth of patients with schizophrenia have depression, compared to HDRS and PANSS-D, CDSS has highest concordance with clinician's diagnosis of depression and presence of depression is related to cognitive insight.

Is There More to Insight Into Illness in Schizophrenia Than Cognition? A Study Applying the Dynamic Wisconsin Card Sorting Test

Impaired insight is common in schizophrenia. Etiological models focusing on single determinants have not succeeded in explaining insight deficits. More complex models seem promising. This study tests Startup’s (1996) model of insight and cognition, predicting a curvilinear relationship and specific insight–cognition configurations. Patients with schizophrenia diagnoses (N = 248) were assessed with the Dynamic Wisconsin Card Sorting Test (WCSTdyn) and measures of psychopathology and premorbid intelligence. In a regression model connecting insight and WCSTdyn, the linear and quadratic term accounted for a small but significant proportion of variance. Cluster analysis yielded two cognitively high-functioning groups differing in insight and a group with impaired cognition and reduced insight. Results support Startup’s framework of multiple barriers to insight. Cognitive deficits seem to be one insight-limiting factor, but motivational influences on insight cannot be excluded. Research on therapeutic interventions should take these different pathways into account.

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.

Third-person Diagnostic Interview on the Cognitive Insight Level of Psychotic Patients with an Insight at the Denial Level

OBJECTIVES

According to the previous findings, the third-person technique improved the clinical insight of psychotic patients, therefore the present study aims to examine the effect of a third-person interview compared to a first-person interview on the level of cognitive insight of psychotic patients with an insight at the denial level.

MATERIALS AND METHODS

In this study, using interviews and questionnaires, a total number of 44 patients of Razi Psychiatric Educational and Treatment Center with an insight at the denial level being assessed using diagnostic interviews were divided randomly into two groups. Then, the two groups of patients' cognitive insights were evaluated using Beck Cognitive Insight Scale.

RESULTS

The findings indicated that in psychotic patients with an insight at the denial level, the third-person technique of interview compared to the first-person had little effect on the improvement of overall cognitive insight and its components, including self-reflection and self-assurance; however, this effect was not strong enough to make a significant difference between the two groups of patients.

CONCLUSION

According to the study findings, we can conclude that the third-person interview compared to the first-person interview has no effect on the improvement of the cognitive insight of psychotic patients with an insight at the denial level. This finding is consistent with the previous studies indicating that although the theory of mind has some correlations with the clinical insight of patients, it has no effect on their cognitive insight.

Insight in paranoia: The role of experiential avoidance and internalized stigma

Evidence suggests that insight in psychosis has been related to treatment adherence, recovery and good prognosis, but also to depression, low self-esteem, and diminished quality of life. Thus, insight might not be advantageous under all circumstances. Internalized-stigma (i.e. self-acceptance of stigmatizing images of illness) and experiential avoidance (i.e. unwillingness to experience negative private events) have been proposed as moderating variables between insight, and psychological health variables and/or distress. We investigated the patterns of association of insight with satisfaction with life, self-esteem, depression, anxiety and psychotic psychopathology as moderated by self-stigmatizing beliefs and experiential avoidance, in a sample of 47 participants with persecutory beliefs and diagnosed with schizophrenia or other psychotic disorder. Moderation analyses confirm the importance of internalized-stigma and experiential avoidance. The presence of insight was associated with more depression when there were high levels of self-stigma. Whereas, the absence of insight was associated with a greater life satisfaction when there were high levels of experiential avoidance. To summarize, our results help understand the complex relationship between insight, psychological health variables and emotional distress, pointing to a differential pattern of moderation for negative and positive outcomes. We discuss the implications of these results for research and treatment of paranoia.

Is good insight associated with depression among patients with schizophrenia? Systematic review and meta-analysis

Among patients with schizophrenia, better insight may be associated with depression, but the findings on this issue are mixed. We examined the association between insight and depression in schizophrenia by conducting a systematic review and meta-analysis. The meta-analysis was based on 59 correlational studies and showed that global clinical insight was associated weakly, but significantly with depression (effect size r=0.14), as were the insight into the mental disorder (r=0.14), insight into symptoms (r=0.14), and symptoms' attributions (r=0.17). Conversely, neither insight into the social consequences of the disorder nor into the need for treatment was associated with symptoms of depression. Better cognitive insight was significantly associated with higher levels of depression. The exploratory meta-regression showed that methodological factors (e.g. the instrument used to assess depression and the phase of the illness) can significantly influence the magnitude of the association between insight and depression. Moreover, results from longitudinal studies suggest that the relation between insight and depression might be stronger than what is observed at the cross-sectional level. Finally, internalized stigma, illness perception, recovery attitudes, ruminative style, and premorbid adjustment seem to be relevant moderators and/or mediators of the association between insight and depression. In conclusion, literature indicates that among patients with schizophrenia, better insight is associated with higher levels of depressive symptoms. Thus, interventions aimed at promoting patients' insight should take into account the clinical implications of these findings.

Quality of life in schizophrenia spectrum disorders: associations with insight and psychopathology

Therapeutic interventions in chronic mental illness face the important challenge to pursuit the quality of life (QOL) of patients. Insight into chronic mental illness, though a prerequisite for treatment adherence and a positive therapeutic outcome, has shown adverse associations with subjective QOL. This study aims to explore the contribution of psychopathological symptoms on the ambiguous role of insight on QOL. Seventy-two outpatients with schizophrenia spectrum disorders were assessed using the positive and negative syndrome scale, the scale to assess unawareness of mental disorder, and the WHOQOL-100 instrument for the assessment of quality of life. Insight was found to associate inversely with quality of life. Among psychopathological symptoms, depressive symptoms were the strongest negative contributor on QOL. Mediation analysis revealed that the effects of awareness of the consequences of illness on QOL were largely mediated by depressive symptoms (full mediation for the effect on physical and psychological domain and partial mediation for the effect on independence and environment domain of the QOL). Our results suggest that the inverse relationship between insight and subjective quality of life is partially mediated by depressive symptoms. We discuss theoretical and therapeutic implications of the findings, in conjunction with similar recent research data.

Relative contributions of negative symptoms, insight, and coping strategies to quality of life in stable schizophrenia

The purpose of this cross-sectional study was to examine the relative contributions of negative symptomatology, insight, and coping to quality of life (QOL) in a sample of 92 consecutive outpatients with stable schizophrenia referring to the Department of Neuroscience, Psychiatric Section, University of Turin, Struttura Semplice di Coordinamento a Valenza Dipartimentale (SSCVD), Department of Mental Health ASL TO1, Molinette, Italy, in the period between July 2009 and July 2011. In order to assess the specific effect of negative symptoms on QOL and the possible mediating role of insight and coping, two mediation hypotheses were tested, using multiple regression analyses specified by Baron and Kenny (1986). Our findings suggest that (a) higher negative symptoms predict a worse Quality of Life Scale (QLS) intrapsychic foundations (IF) subscale score; (b) attribution of symptoms and coping-social diversion have a direct and positive association with QLS-IF; (c) patients high in negative symptoms are less likely to use attribution of symptoms and coping-social diversion; and (d) attribution of symptoms and coping-social diversion act as partial mediators in the negative symptoms-QOL relationship. The prediction model accounts for 45.3% of the variance of the QLS-IF subscale score in our sample. In conclusion, our results suggest that insight and coping-social diversion substantially contribute to QOL in patients with higher negative symptoms. These factors are potentially modifiable from specific therapeutic interventions, which can produce considerable improvements in the QOL of this population.

The effects of aging on insight into illness in schizophrenia: a review

OBJECTIVES

Impaired insight into illness is a prevalent feature of schizophrenia, which negatively influences treatment adherence and clinical outcomes. Little is known about the effects of aging on insight impairment. We aimed to review the available research literature on the effects of aging on insight into illness in schizophrenia, in relation to positive, negative, and cognitive symptoms. Ultimately, we propose a trajectory of insight in schizophrenia across the lifespan.

METHOD

A systematic Medline® literature search was conducted, searching for English language studies describing the relationship of insight into illness in schizophrenia with aging.

RESULTS

We identified 62 studies. Insight impairment is associated with illness severity, premorbid intellectual function (i.e. IQ), executive function, and memory. Insight impairment improves modestly during midlife, worsening again in late life. It tends to fluctuate with each episode of psychosis, likely in relation to worsening positive symptoms that improve with antipsychotic treatment. The relationship between insight impairment and cognitive dysfunction appears to attenuate with age, while the relationship with lower premorbid intellectual function is preserved. The association between impaired insight and negative symptoms is unclear.

CONCLUSIONS

The available literature suggests that the course of insight impairment follows a U-shaped curve, where insight impairment is severe during the first episode of psychosis, modestly improves over midlife, and declines again in late life. Future studies are required to investigate the trajectory of insight into illness and its core domains across the lifespan from prodromal phase to late life.

Testing trait depression as a potential clinical domain in schizophrenia

The DSM-5 includes depression as a dimension of psychosis. We tested whether persistent experience of depression, called 'trait depression', is a clinical feature separate from psychosis and several well-known, trait-like deficits of schizophrenia. 126 individuals with schizophrenia and 151 control participants completed the Maryland Trait and State Depression questionnaire, with a subset completing measures of cognition and functional capacity, and diffusion tensor imaging (n=73 patients and 102 controls for imaging analysis). Subjectively experienced, longitudinal trait depression is significantly higher in patients with schizophrenia compared with controls. Higher trait depression scores were associated with more severe psychosis. Surprisingly, individuals with higher trait depression manifested less cognitive and global functioning deficits. In addition, trait depression scores were positively associated with fractional anisotropy of white matter. Trait depression appears to be a highly relevant clinical domain in the care of patients with schizophrenia that also has distinct relationships with some other known traits of the disease. Trait depression may be an important contributor to the clinical heterogeneity of schizophrenia.

Metacognitive training for schizophrenia: a multicentre randomised controlled trial

A psychotherapeutic approach for schizophrenia is now recommended as an adjuvant for psychopharmacology, since antipsychotic medications only have a partial impact especially as regards positive symptoms and insight. In addition, cognitive distortions and the lack of metacognitive skills might increase positive symptoms leading to poor social functioning. This underlines the need for specific approaches which target cognitive processes relevant for insight, and abilities in metacognition. Metacognitive training (MCT) is a structured group intervention, which enhances a patient's reflection on cognitive biases and improves problem-solving. The aim of our study was to assess MCTs' short term impact on insight, symptoms and quality of life. Fifty patients with schizophrenia or schizoaffective disorders and persistent positive symptoms (delusions or hallucinations) were enrolled in the study. After baseline assessment participants were randomised either to supportive therapy or MCT. Both groups used the same design (1h-session twice a week during 8weeks) although the basic knowledge given to participants was different between interventions. Participants were assessed at eight weeks based on the Scale to Assess Unawareness of Mental Disorder, Positive and Negative Syndrome Scale (PANSS), Psychotic Symptom Rating Scales, the Calgary Depression Scale for Schizophrenia and the Quality of Life Scale. Between-group differences were significant in favour of MCT on the PANSS positive scale. Between-group differences in post- and pre-test values showed a trend in favour of MCT for insight on hallucinations. Results of our study indicate that the MCT has an effect on reducing positive symptomatology, and a trend impact on insight and social functioning.

Der Beitrag subjektiver Krankheitsrepräsentationen zur Erklärung beeinträchtigter Krankheitseinsicht bei Schizophrenie

Theoretischer Hintergrund: Die Genese von Defiziten der Krankheitseinsicht bei Schizophrenie wird bisher unzureichend und teilweise widersprüchlich erklärt. Mehrfaktorielle Einsichtsmodelle, die inkonsistente Befunde integrieren, existieren kaum. Fragestellung: Kann ein typologischer Ansatz und die Erweiterung um die gesundheitspsychologische Perspektive subjektiver Krankheitskonzepte bisherige klinisch-psychiatrische Einsichtsmodelle verbessern? Methode: Für 95 Personen mit Diagnosen aus dem Schizophrenie-Spektrum wurden Krankheitseinsicht, subjektive Krankheitskonzepte, Symptomatik und Neurokognition querschnittlich erhoben. Ergebnisse: Eine einsichtige, kognitiv intakte sowie zwei uneinsichtige Subgruppen (kognitiv beeinträchtigt vs. unbeeinträchtigt) wurden clusteranalytisch identifiziert. Letztere ließ sich anhand von mehr Positivsymptomen, Bewertungen von verringerter Kontrollierbarkeit und emotionaler Bedeutung ihrer Problematik multinomial vorhersagen (R2N = .56). Schlussfolgerungen: Der Einschluss subjektiver Krankheitskonzepte in klinisch-psychiatrische Einsichtsmodelle erscheint fruchtbar. Neben einer defizitbasierten Uneinsichtigkeit lassen sich angesichts spezifischer Krankheitsbewertungen motivationale Einsichtsbarrieren vermuten.

Neural correlates of insight in dreaming and psychosis

The idea that dreaming can serve as a model for psychosis has a long and honourable tradition, however it is notoriously speculative. Here we demonstrate that recent research on the phenomenon of lucid dreaming sheds new light on the debate. Lucid dreaming is a rare state of sleep in which the dreamer gains insight into his state of mind during dreaming. Recent electroencephalogram (EEG) and functional magnetic resonance imaging (fMRI) data for the first time allow very specific hypotheses about the dream-psychosis relationship: if dreaming is a reasonable model for psychosis, then insight into the dreaming state and insight into the psychotic state should share similar neural correlates. This indeed seems to be the case: cortical areas activated during lucid dreaming show striking overlap with brain regions that are impaired in psychotic patients who lack insight into their pathological state. This parallel allows for new therapeutic approaches and ways to test antipsychotic medication.

The relationship between insight and theory of mind in schizophrenia

INTRODUCTION

It has been proposed that theory of mind (ToM) deficits underlying difficulties in taking the perspective of others may substantially contribute to insight impairment in schizophrenia. The present study aimed to explore the effect of ToM deficits on insight impairment independently of co-existent neurocognitive deficits and symptom severity in chronic schizophrenia.

METHODS

Fifty-eight chronic patients with schizophrenia and 56 matched healthy participants were assessed with the Schedule for the Assessment of Insight (SAI-E) along with a series of ToM tasks and a comprehensive battery of neuropsychological measures. Symptoms were measured with the Positive and Negative Syndrome Scale and the Calgary Depression Scale for Schizophrenia.

RESULTS

ToM impairment explained a substantial proportion of variance in overall insight and its three major components: awareness of illness, relabelling of symptoms and treatment compliance. Moreover, the effect of ToM deficits on insight remained significant even after controlling for all neurocognitive factors and symptom ratings. Regression analysis showed that symptoms and cognitive deficits also contribute to impaired insight in schizophrenia. General intellectual ability was negatively associated with both overall insight and relabelling of symptoms. Executive functions were negatively associated with relabelling.

CONCLUSION

Our findings confirm that ToM deficits negatively affect insight independently of neurocognitive deficits and symptom severity in chronic schizophrenia. The effect of ToM deficits on insight should be further examined in the broader context of the failures in metacognition and their relationships with insight impairment in schizophrenia.

Do psychosis patients with poor insight show implicit awareness on the emotional stroop task?

BACKGROUND

The insight into psychosis can be assessed reliably by clinicians from interviews with patients. However, patients may retain implicit awareness of illness while lacking explicit awareness.

SAMPLING AND METHODS

In a sample of first-episode psychosis patients, we used a test of processing of mental illness-related and other negative words as a measure of implicit awareness to see how this varied in relation to insight. An emotional-counting Stroop task tested reaction times to words of three types: psychosis-related (e.g. 'crazy'), general negative (e.g. 'cancer') and neutral (e.g. 'oyster'). Data were available from 43 patients and 23 healthy controls. Patients' insight was assessed using the Schedule for the Assessment of Insight (SAI-E).

RESULTS

Patients reacted slower than controls to words across all conditions, and both patients and controls reacted slower to salient and negative words than neutral words. There was a near significant interaction between word type and group (Wilks' lambda = 0.53, p = 0.055); patients experienced greater interference from negative rather than psychosis-related words (p = 0.003), and controls experienced greater interference from salient rather than negative words (p = 0.01). Within the patient group, there was a correlation between insight and interference on salient words (r = 0.33, p = 0.05), such that those with less insight experienced less interference on psychosis-related words.

CONCLUSIONS

Psychosis-related words were less threatening and less self-relevant to psychosis patients with less insight. This suggests that the lack of awareness such patients have of their illness is genuine and more likely to be mediated by lower-level information processing mechanisms than strategies such as conscious, motivated denial.

Is insight in schizophrenia multidimensional? Internal structure and associations of the Greek version of the Schedule for the Assessment of Insight-Expanded

Despite the general agreement that insight is a multidimensional phenomenon, the studies on the factorial structure of the scales for its assessment have yielded rather inconsistent results. The present study aimed to assess the internal structure of the Schedule for the Assessment of Insight (SAI-E). Seventy-two chronic patients with schizophrenia were assessed with SAI-E. Hierarchical cluster analysis and multidimensional scaling (MDS) were used to identify insight components and assess their inter-relationships. The associations of the extracted components with demographic, clinical and cognitive characteristics were also examined. The SAI-E demonstrated good psychometric properties. Three subscales of SAI-E were identified measuring awareness of illness, relabeling of symptoms, and treatment compliance. Moreover, the MDS disclosed two underlying dimensions--degree of 'specificity' and 'spontaneity'--within the insight construct. Treatment compliance was more strongly correlated with symptom relabeling than illness awareness. Excitement symptoms, global functioning and general intelligence were correlated with all the components of insight. Depressive symptoms were more strongly correlated with illness awareness. Impaired relabeling ability was linked to cognitive rigidity and greater severity of disorganization and positive symptoms. Education and severity of negative symptoms specifically affect treatment compliance. Our results support the hypothesis that insight is a multidimensional construct.

Insight in stable schizophrenia: relations with psychopathology and cognition

OBJECTIVE

This study evaluated the relationship among insight, sociodemographic and clinical variables, symptoms and cognitive functions in a population of outpatients with stable schizophrenia, in order to identify possible contributing factors to awareness.

METHOD

Two-hundred and seventy-six consecutive outpatients with stable schizophrenia were enrolled in a cross-sectional study. All subjects were assessed by psychiatric scales and interview, and a wide neuropsychological battery. A factor analysis was performed to identify cognitive factors and multiple regression analyses were executed to test the contribution of variables considered to insight.

RESULTS

Our results showed that positive and negative symptoms, executive functions, verbal memory-learning were contributors of awareness of mental illness; positive and negative symptoms explained variability in awareness of the need for treatment; positive symptoms and executive functions contributed to awareness of the social consequences of disorder.

CONCLUSIONS

These results suggested that insight was partially influenced by positive and negative symptoms and by cognitive functions. A complex system of overlapping variables may underlie impaired insight, contributing to a different extent to specific dimensions of poor insight in patients with stable schizophrenia.

Social cognition and clinical insight in schizophrenia and bipolar disorder

The association between clinical insight and social cognition assessed with an emotion perception task was investigated in schizophrenia (n = 29) and bipolar I disorder (n = 19). Persons with schizophrenia had reduced auditory emotion perception compared with individuals with bipolar I disorder, but levels of visual emotion perception and clinical insight were comparable. In the schizophrenia group, clinical insight was moderately associated with auditory and visual emotion perception (r = 0.36-0.44) and negative symptoms (r = -0.33). Better insight was associated with better social cognition and fewer negative symptoms. In the bipolar I disorder group, clinical insight showed small associations with social cognition (largest r = -0.28) and moderate to large associations with positive, negative, manic, and depressive symptoms. Poorer insight was associated with higher symptom load. Social cognition seems to be of importance for clinical insight in schizophrenia, whereas symptoms are important in bipolar I disorder.

Systematic review reveals heterogeneity in the use of the Scale to Assess Unawareness of Mental Disorder (SUMD)

The Scale to Assess Unawareness of Mental Disorder (SUMD) is one of the most widely used instruments to measure insight into mental disorders. The aim of this study was to review all studies using the SUMD in the last 20 years. We performed an electronic search of MEDLINE using PubMed to identify all relevant studies published from 1993 to 2012. The following data were extracted from each article: characteristics of the SUMD (version, rating scale, scoring, and item/dimension used), methodological aspects (country, language, subject inclusion criteria, and sample size), and statistical methods to analyse insight. Of the 133 articles screened, 100 studies were included in the review. Fifty-two studies were published over the past five years. The SUMD was rarely used in its entirety, and the use of selected items or subscales was heterogeneous across studies. The studies also varied in terms of response modalities and in the use of 3- or 5-point Likert scales. The calculation of insight scores was highly variable and included the following: treating items as categorical or continuous variables, separate analysis of individual items, items expressed in terms of the sum total or the mean scores, and a range of score values used to define insight. This paper provides a systematic review of studies using the SUMD and reveals important differences in the versions used, the methods of calculation, and the interpretation of scores across studies. The use of a modified SUMD may compromise the psychometric properties of the scale, lead to erroneous conclusions, and prevents comparison of results across studies. Our review underlines the need for the standardised use of the SUMD.

Insight, psychosis, and depression in Africa: a cross-sectional survey from an inpatient unit in Ghana

Few studies of the relationship of insight to psychopathology have been conducted in non-Western populations. This study examined the relationships between insight and depression, anxiety, and positive and negative symptoms on patients with schizophrenia resident in a psychiatric hospital in Ghana. A sample of 49 participants, (37 men and 12 women), with DSM-IV defined schizophrenia took part in semistructured interviews consisting of the Hamilton Rating Scales for Depression (HAM-D) and Anxiety (HAM-A); the Schedule for the Assessment of Insight - Expanded Version (SAI-E) and the Positive and Negative Syndrome Scale (PANSS). Bivariate correlations between variables were examined and those significantly correlated with an insight domain were included in multiple regression models. Variables associated with the total insight score were age, gender, anxiety symptoms, depression symptoms, and treatment compliance. In the final model, HAM-D positively predicted total SAI-E score, whilst PANSS-pos was negatively associated with total SAI-E score. The results are broadly consistent with those found in Western samples regarding insight and depressive symptoms. Implications of these results for competing theories of insight in psychoses are discussed. Patients able to identify themselves as ill may be aware of their affective symptoms.

"I am sane but he is mad": Insight and illness attributions to self and others in psychosis

We attempted to explore whether lack of insight in patients with psychosis is related to their genuine inability to recognise symptoms of mental illness as opposed to denial. We addressed this by examining participants' judgments of illness in vignettes in which they were either the protagonist or were commenting on others' behaviour. We recruited 44 first episode psychosis patients and 23 healthy controls to make judgements of specially constructed vignettes describing psychotic symptoms. Insight, Theory of Mind (ToM) and IQ was also measured. Patients' and controls' rating of vignettes overall did not differ significantly with respect to their attribution of mental illness. Patients and controls rated 2nd person vignettes similarly; patients were less likely to attribute mental illness to a character described in the 3rd person. This effect correlated with insight scores. Vignette judgments were significantly correlated with ToM performance but this was moderated by IQ. In conclusion, patients with lower insight tend to make the same attributions to others as to themselves, whilst healthy controls tend to think of mental illness as something seen in other people. There was no support for a 'denial' explanation for lack of insight in these patients.

Lack of Insight in Psychosis: Theoretical Concepts and Clinical Aspects

Background: Different theories concerning pathways to insight have been proposed which underpin the numerous assessment measures. Cognitive behavioural therapy (CBT) is one treatment approach that has been used to improve insight. Aims: The aim of this review was to promote a greater focus on developing effective CBT strategies to ameliorate insight in psychosis through the exploration of the concept of insight in psychosis and evaluation of research in the area. Method: A comprehensive search and review of published studies examining the impact of CBT on insight in psychosis was conducted. We searched the databases PubMed, Medline, PsychInfo, the Psychology and Behavioral Sciences Database, and CINAHL with limits set to 10 years, humans, and English language. We hand-searched reference lists of major studies on insight, and theoretical review papers. We filtered our results according to relevance and chose 50 papers for final consideration. Results: The multidimensionality of insight is reflected in the variety of different insight measures in clinical use. Research findings on the impact of CBT on insight are conflicting. Cognitive insight and clinical insight appear to be different concepts that are not fully captured by existing measurement scales. Conclusions: The conflicting results found in research examining the impact of CBT on insight may be partially explained by the different theories underpinning insight in psychosis communicated through psychoeducation in CBT. Furthermore, the use of more than one insight assessment measure may capture the complexity of insight more effectively. Qualitative research with service users would enrich the knowledge in this area.

Subjectivity and schizophrenia: another look at incomprehensibility and treatment nonadherence

Psychiatry is in a time of crisis. The absence of significant breakthroughs to actionable etiological knowledge has left the discipline in a state of uncertainty and worries are being voiced about its status and future. In our view, the stagnation can be, at least in part, ascribed to an excessive, behaviorist-oriented, epistemological, and ontological simplification of psychopathology. The aim of this phenomenological study is to articulate the notion of the 'disordered self' in schizophrenia, a notion that we believe constitutes an important step forward in grasping its essential pathogenetic structures. Through the framework of self-disorders, we analyze two domains of the psychopathology of schizophrenia, seeking to recast their puzzling nature into more useful clinical and scientific terms. First, we examine the so-called schizophrenic incomprehensibility (bizarre gestalt, bizarre delusions, and 'crazy actions') and argue that grasping the altered framework for experiencing, associated with the disordered self, makes these phenomena appear comprehensible to a considerable extent. Second, we explore the issue of treatment noncompliance and provide a novel account of 'poor insight' into illness. We propose that poor insight into schizophrenia is not simply a problem of insufficient self- reflection due to psychological defenses or impaired metacognition, but rather that it is intrinsically expressive of the severity and nature of self-disorders. The instabilities of the first-person perspective throw the patient into a different, often quasisolipsistic, ontological-existential framework. We argue that interventions seeking to optimize the patients' compliance might prove more efficient if they take the alterations of the patients' ontological-existential framework into account.

Effects of event-specific memory training on autobiographical memory retrieval and depressive symptoms in schizophrenic patients

BACKGROUND AND OBJECTIVES

This report describes the effects of a specific event group-based training programme on autobiographical memory, self-consciousness of memory retrieval, and depression symptoms in a sample of 24 schizophrenic patients (experimental group).

METHODS

Twenty-six matched schizophrenic patients who participated in social skills and occupational therapy group sessions constituted the active control group. Participants in the experimental group were trained to complete a diary with specific daily memories, followed by patients' ratings of the associated emotional arousal of those entries. During training, significant specific events from childhood, adolescence, adulthood and the previous year were also reviewed.

RESULTS

After 10 weeks of group-based sessions, the experimental group demonstrated an increase in their degree of specificity for autobiographical retrievals, had a higher level of consciousness of their memories and showed a decrease in their depression scores. Significant changes in measurements of retrieval specificity and autonoetic awareness were maintained when changes in emotional symptomatology were statistically controlled.

LIMITATIONS

The present study did not assess the impact of autobiographical memory training on the positive and negative symptoms of schizophrenia.

CONCLUSIONS

These results suggest that cognitive training strategies based on event-specific autobiographical memory training should be considered for inclusion in intervention programs for schizophrenic patients.

Rumination, Depressive Symptoms and Awareness of Illness in Schizophrenia

Background: Depressive symptoms are common in schizophrenia. Previous studies have observed that depressive symptoms are associated with both insight and negative appraisals of illness, suggesting that the way in which the person thinks about their illness may influence the occurrence of depressive responses. In affective disorders, one of the most well-established cognitive processes associated with depressive symptoms is rumination, a pattern of perseverative, self-focused negative thinking. Aims: This study examined whether rumination focused on mental illness was predictive of depressive symptoms during the subacute phase of schizophrenia. Method: Forty participants with a diagnosis of schizophrenia and in a stable phase of illness completed measures of rumination, depressive symptoms, awareness of illness, and positive and negative symptoms. Results: Depressive symptoms were correlated with rumination, including when controlling for positive and negative symptoms. The content of rumination frequently focused on mental illness and its causes and consequences, in particular social disability and disadvantage. Depressive symptoms were predicted by awareness of the social consequences of mental illness, an effect that was mediated by rumination. Conclusions: Results suggest that a process of perseveratively dwelling upon mental illness and its social consequences may be a factor contributing to depressive symptoms in people with chronic schizophrenia.

The neuropsychiatry of depression after brain injury

Biological aspects of depression after brain injury, in particular traumatic brain injury (TBI) and stroke, are reviewed. Symptoms of depression after brain injury are found to be rather non-specific with no good evidence of a clear pattern distinguishing it from depression in those without brain injury. Nevertheless symptoms of disturbances of interest and concentration are particularly prevalent, and guilt is less evident. Variabilitiy of mood is characteristic. The prevalence of depression is similar after both stroke and TBI with the order of 20-40% affected at any point in time in the first year, and about 50% of people experience depression at some stage. There is no good evidence for areas of specific vulnerability in terms of lesion location, and early suggestions of a specific association with injury to the left hemisphere have not been confirmed. Insight appears to be related to depressed mood with studies of TBI indicating that greater insight over time post-injury may be associated with greater depression. We consider that this relationship may be due to depression appearing as people gain more awareness of their disability, but also suggest that changes in mood may result in altered awareness. The risk of suicide after TBI is reviewed. There appears to be about a three to fourfold increased risk of suicide after TBI, although much of this increased risk may be due to pre-injury factors in terms of the characteristics of people who suffer TBI. About 1% of people who have suffered TBI will commit suicide over a 15-year follow-up. Drug management of depression is reviewed. There is little specific evidence to guide the choice of antidepressant medication and most psychiatrists would start with a selective serotonin reuptake inhibitor (SSRI). It is important that the drug management of depression after brain injury is part of a full package of care that can address biological as well as psychosocial factors in management.

Failures of metacognition and lack of insight in neuropsychiatric disorders

Lack of insight or unawareness of illness are the hallmarks of many psychiatric disorders, especially schizophrenia (SCZ) and other psychoses and could be conceived of as a failure in metacognition. Research in this area in the mental health field h as burgeoned with the development and widespread use of standard assessment instruments and the mapping out of the clinical and neuropsychological correlates of insight and its loss. There has been a growing appreciation of the multi-faceted nature of the concept and of the different 'objects' of insight, such as the general awareness that one is ill, to more specific metacognitive awareness of individual symptoms, impairments and performance. This in turn has led to the notion that insight may show modularity and may fractionate across different domains and disorders, supported by work that directly compares metacognition of memory deficits and illness awareness in patients with SCZ, Alzheimer's disease and brain injury. The focus of this paper will be on the varieties of metacognitive failure in psychiatry, particularly the psychoses. We explore cognitive models based on self-reflectiveness and their possible social and neurological bases, including data from structural and functional MRI. The medial frontal cortex appears to play an important role in self-appraisal in health and disease.

Stigma as a predictor of insight in schizophrenia

Insight in schizophrenia can be seen as a multifactorial phenomenon. Although multifactorial pathways have also been suggested for insight formation, motivational explanations have rarely been tested. The present study explores stigma as one possible determinant of a motivated lack of insight in integrated models of insight formation. It examines the contribution of socio-demographic and clinical variables, neurocognitive functions, symptoms, and stigma to the prediction of insight into illness. Patients diagnosed with schizophrenia spectrum disorders (N=111) participated in a comprehensive battery of instruments to measure insight dimensions, stigma, neurocognitive functions, symptoms, socio-demographic and clinical variables. Blockwise multiple regression analysis indicates significant association of variability in insight dimensions with gender (7%) and stigma (i. e., stereotype agreement: 5%). Our findings demonstrate an incremental validity of stigma, which indicates a motivational pathway of insight formation. This study enables better understanding of the multifactorial nature of insight, which should be considered in therapeutic interventions to improve insight. The roles of gender and neurocognitive functions in insight formation are also discussed.

Insight in schizophrenia-course and predictors during the acute treatment phase of patients suffering from a schizophrenia spectrum disorder

BACKGROUND

To analyse insight of illness during the course of inpatient treatment, and to identify influencing factors and predictors of insight.

METHODS

Insight into illness was examined in 399 patients using the item G12 of the Positive and Negative Syndrome Scale ("lack of insight and judgement"). Ratings of the PANSS, HAMD, UKU, GAF, SOFAS, SWN-K and Kemp's compliance scale were performed and examined regarding their potential association with insight. The item G12 was kept as an ordinal variable to compare insight between subgroups of patients.

RESULTS

Almost 70% of patients had deficits in their insight into illness at admission. A significant improvement of impairments of insight during the treatment (p<0.0001) was observed. At admission more severe positive and negative symptoms, worse functioning and worse adherence were significantly associated with poorer insight. Less depressive symptoms (p=0.0004), less suicidality (p=0.0218), suffering from multiple illness-episodes (p<0.0001) and worse adherence (p=0.0012) at admission were identified to be significant predictors of poor insight at discharge.

CONCLUSION

The revealed predictors might function as treatment targets in order to improve insight and with it outcome of schizophrenia.