September 19, 2007

Schizophrenia: Insight Improves Patient Outcome?

How many times have we rolled our eyes when being told that knowing that you have a problem is half the way to solving the problem itself? Well Psychiatrists, when interviewing their patients for the first time, typically search for this element of awareness or as they would term it, "insight". The rationale would be that those patients who had insight into their illness would do better in the future compared to those who had no insight.

There have been a lot of hypotheses tossed around to explain this phenomenon over the years. Earlier this year, the British Journal of Psychiatry published an article titled "Neurocognitive basis of insight in Schizophrenia" in which the authors suggest an association existing between lack of insight of illness and ‘executive dysfunction’. The executive system is a concept that psychologists have come up with to group-together certain sophisticated activities of the brain, such as planning and ‘thinking out of the box’ (or ability to think with flexibility), both essentially needed to solve problems. If a person has a difficulty in performing tasks that require one or more of these activities, it is implied that the person has demonstrated executive dysfunction.

The authors looked at articles published by others before them and found that there can be multiple reasons contributing to lack of insight in a patient diagnosed with Schizophrenia. For instance, a patient may not be able to understand the social consequences of his illness or the need for treatment, which could lead to why this patient may not try to stay regular with prescribed medications and follow-up visits with the Psychiatrist. It is also just as possible that even though a patient may recognize his own symptoms, he might not be able to add them up and realize that this is all part of the main diagnosis of Schizophrenia. The authors figured that it is possible that lack of insight can reflect a cognitive impairment, in which case it might be important that the approach to treating such a patient should be altered and customized as much as possible. They decided to try out their own experiment to see if unawareness of one’s illness is truly due to a brain dysfunction.

Methods: 56 patients (51 males and 5 females) were recruited. The recruits were subjected to a three-part experiment. The first part was in the form of an interview in which a single patient would be assessed on three criteria of insight: adherence to treatment; awareness of illness and relabelling of psychotic phenomena.

The second part was a test to measure executive function using the Wisconsin Card Sort Test (WCST): Initially, a number of stimulus cards are presented to the participant. He or she is then given a stack of additional cards and asked to match each one to one of the stimulus cards, thereby forming separate piles of cards for each. The participant is not told how to match the cards; however, he or she is told whether a particular match is right or wrong. So the participant is expected to independently figure out how the cards have been grouped.

To measure working (or ‘short term’) memory, the patients were subjected to the Hopkins Verbal Learning Test (Revised). The term ‘working memory’ implies that there is some structure within the brain that acts as a temporary storage for storing and manipulating information, very similar to how the modern-day computer operates.

Results: As anticipated, the authors found that the patients could be clustered into three groups:
Aware, correct attributers – 43%* (this group scored high on ‘awareness of illness’ and ‘relabelling of symptoms’)
Aware, incorrect attributers – 25%* (this group scored highly on ‘awareness of illness’, but low on ‘relabelling of symptoms’)
Unaware – 32% * (scoring low on both ‘awareness of illness’ and ‘relabelling of symptoms’)

(*NOTE: It is crucial to remember that the total number of recruits were only 56. This means that the sample number of patients here is small and any group features, including percentage-distribution is not necessarily representative of the entire population of Schizophrenics in the world. The only way to get a better idea of the larger population is by conducting the experiment with a larger sample of recruits)

Conclusion: The authors were careful to point out that their battery of statistical analyses did not contribute to a convincing argument about the characteristics of one group against another, but a pattern of some difference could be detected between Aware, correct attributers and Unaware with reliable certainty. They proceeded to focus their discussion on the comparison of these two groups.

The Aware, correct attributers seemed to have an intact executive system and working memory. The Unaware seemed to suffer from executive impairment and demonstrate a trend (due to the lack of a clear convincing argument, as alluded to above) suggestive of impaired working memory.

The authors claim that their study suggests ‘executive function’ is the major player in insight of illness when compared to ‘working memory’. The higher the awareness of their clinical symptoms, the better the executive skills seemed to be.

They recommend that future studies should seriously consider the three groups that have been outlined in this study and executive function should be regarded as an indicator of insight. They also suggest that it might be worthwhile to focus on improving insight through psychotherapy and education in helping those patients who are aware of their illness but misattribute their symptoms (i.e. the second of the three groups above).

Source Journal Article: Neurocognitive basis of insight in schizophrenia, The British Journal of Psychiatry


Perhaps this is due to my poor mastering of the english language, but I don't understand this heading: "Insight improves outcome" (??)
It would seem to me that the poorer the insight, (the) worse is the compliance to the treatment and, as a consequence, it also entails poorer outcome. But, as far as I know, when insight in the illness is poor to begin with, efforts to significantly "improve" it were not very successful until now!
Jean Desclin

Posted by: Jean Desclin at September 23, 2007 01:47 AM

As a patiant myself, I have greatly benefited by doing my own research on schizophrenia as well as analizing myself. In fact I was analizing myself even before I was taking medication. I had a great discussion with someone about what I percieved to be real and how logical it all seemed to be. He told me "that's not logic, that's convoluted logic". This impressed on my mind. Later I discovered that I "had lost my ability to 'suppose'". Anything that I imagined could be true all of a sudden was true. If I hadn't began to analize myself this way when I was psycotic I would have never ended up in the hospital and I would never have recovered as quickly as I have. Plus I wouldn't be combating schizophrenia by lowering stress levels and focusing on my emotional well-being which is all very important

Posted by: Tim Martin at September 23, 2007 05:49 PM

I agree with Jean. Either the insight is there from the beginning and the willingness to comply with medications, or it is not.
My son has always been med compliant but unfortunately I don't know why otherwise I would pass that information on to other families.
I think it was because he trusted me implicitly, but I'm not sure of the reason. It could be that he did have insight all along and nothing to do with trusting me.

Posted by: Glesgalass at November 2, 2007 05:31 AM

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