Awareness of own and others' schizophrenic illness
Introduction
A large proportion of people suffering from schizophrenia appear to have only a partial awareness, or no awareness at all, that they are suffering from a mental illness (Amador et al., 1994). This is often referred to as lack of insight. Although insight has important clinical implications, theories which attempt to explain variations in insight have met with only limited or inconsistent support (Ghaemi and Pope, 1994). One possibility that has received little attention so far is that individuals' unawareness of their own mental illness might be part of a general inability to recognize mental illness wherever it occurs, in oneself or in others. Such difficulties, if they exist, might be the result of one or more of the varied cognitive deficits that have been found to be associated with schizophrenia (e.g., Heaton et al., 1994), even among neuroleptic-naive, first episode patients (Saykin et al., 1994). Studies of covariations between insight and performance on a variety of neuropsychological tests have obtained inconsistent results (Kemp and David, 1996). However, out of eight studies in which general intelligence or vocabulary (as an indicator of premorbid intelligence) have been assessed, significant associations with insight have been found in five studies (David et al., 1992; Young et al., 1993; Lysaker and Bell, 1994; Lysaker et al., 1994; David et al., 1995), or six if one-tailed tests are used (MacPherson et al., 1996), and non-significant associations have been found in only two (Takai et al., 1992; Cuesta and Peralta, 1994). Thus, if individuals with poor insight into their own mental illness tend to have low intelligence, as the evidence suggests, they may have difficulty in recognizing mental illness in others.
Relationships between insight and recognition of illness in others appear to have been investigated in only one previous study. McEvoy et al. (1993)prepared eight brief hypothetical case descriptions (vignettes), each of which portrayed individuals suffering from just one symptom associated with schizophrenia. These were then rated by 26 individuals suffering from schizophrenia or schizo-affective disorder to indicate the extent to which the vignettes implied that the person described was mentally ill. When these ratings were compared with the patients' own insight, the only correlations that were significant were those for the descriptions of hallucinatory behaviour and suspiciousness. The less insight the patients had into their own illness the less likely they were to recognize that these symptoms imply a mental illness. The correlations for the vignettes depicting conceptual disorganization, unusual thought content, avolition–apathy, anhedonia–asociality, affective flattening, and alogia were all non-significant and, if the Bonferroni correction is applied to adjust the significance level for eight comparisons, then not even the two apparently significant correlations were truly so.
One reason why McEvoy et al. (1993)did not obtain better results may be that their vignettes were not convincing. For example, the descriptions of negative symptoms are hard to distinguish from descriptions of normal sloth, introversion, or aging. The validity of the vignettes was not assessed, nor were the ratings of the patients compared with those of normal controls. Furthermore, each vignette described only one symptom, whereas the presence of a single symptom is generally insufficient for a diagnosis of mental illness according to the most widely accepted criteria.
The aim of the present study was to use an improved method to test the hypothesis that schizophrenic patients with poor insight into their own illnesses have greater difficulty in recognizing mental illness in others than patients with better insight. Vignettes were used for this test, but in this case only positive symptoms were described and the vignettes were constructed according to a factorial design in which the presence versus absence of the symptoms was systematically varied. The vignettes were first validated against the opinions of qualified mental health professionals and the ratings of patients with high versus low insight were compared with the ratings of matched normal controls.
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Participants
Forty-four patients who were receiving depot neuroleptic medication at two outpatient clinics were invited to take part in the the study. The 20 males and eight females who agreed to participate were all suffering from schizophrenia according to DSM-III-R (American Psychiatric Association, 1987) criteria. Their diagnoses were initially made by their consultant psychiatrists and were confirmed by the author using all available information from direct assessment, informants, and past medical
Results
In order to assess the validity of the Eight People test, the responses of the professionals were analysed in a 2×2×2 ANOVA with repeated measures on each factor. Highly significant main effects were found for the presence versus absence of delusions (F(1,32)=60.9, p<0.001), hallucinations (F(1,32)=99.0, p<0.001), and thought disorder (F(1,32)=19.9, p<0.001). The interaction between delusions and hallucinations was also significant (F(1,32)=45.3, p<0.001), but the remaining interactions were
Discussion
Contrary to expectations, no clear evidence was found that schizophrenic patients with poor insight into their own illnesses have greater difficulty in recognizing mental illness in others than patients with better insight, normal controls or mental health professionals, even though insight among the patients was found to correlate with verbal intelligence (as estimated by the Spot-the-Word test). These results are in disagreement with the conclusions of the only previous systematic study that
Acknowledgements
The author is employed by Clwydian Community Care NHS Trust, on a joint appointment with the University of Wales, Bangor. He is grateful to Sue Ambrose, Hilary Hall and Sue Bendix for their dedicated work administering tests and collating data.
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2015, European PsychiatryCitation Excerpt :It is a particular form of unawareness that persists in the midst of other relatively intact forms of awareness [27]. Independent of their lack of awareness of illness they may respond in a fully adaptive manner to other life demands, meaningfully appraise their own physical health [24] and/or plainly recognize the symptoms of others who are mentally ill [42]. More recently, interest has arisen in an additional dimension of insight referred to as cognitive insight.