‘I’m not ill’: How awareness of illness is a new trend in psychosis research

How patients understand their mental illness can strongly affect treatment, progress of illness and outcome in psychosis. ‘Clinical insight’ is patients’ awareness and understanding that they are ill; if a patient has poor insight into their illness it can lead to problems relating to treatment and recovery. It was previously believed that lack of insight was a coping strategy, however recently it is more widely believed to be an actual symptom. In recent years research into patients insight into their illness has increased, focusing on the biological causes such as changes or differences in brain structure.

A popular and robust way of measuring a patient’s awareness and understanding  (hereby referred to as ‘insight’) of their illness was proposed by David (1990) whereby you measure:

1.       A patient’s acknowledgement that they are ill.

This one is fairly self explanatory; if they don’t think they’re ill they have poor insight.

2.       How well a patient is sticking with their medication.

If a patient doesn’t take their medication all the time, or refuses completely, this can often suggest that they don’t believe they are ill and so have poor insight.

3.       A patient’s ability to relate symptoms to being ill.

Sometimes patients will admit they are ill and take medication as prescribed, but still believe their symptoms are real; this is also an indicator of poor insight.

This idea can be more confusing, so here’s an example:

Patient ‘x’ has ‘persecutory delusions’ that MI5 have planted a chip in his brain. He claims to believe he is ill, and will take his medication. Both of these actions imply ‘x’ has good insight into his illness. However he also believes that his illness is due of the ‘MI5 chip’ in his brain, and therefore his illness is not a problem with him personally, but a reaction to the chip. This additional piece of information clearly highlights that acceptance of his diagnosis and taking his medication only tells us half the story of x’s insight. Therefore the need for this three point measure of insight is crucial.
A recent study by Parellada et al (2011) found that awareness of illness in patients was worse 2 years after diagnosis of Schizophrenia Spectrum Disorders than in other psychotic disorders. However this disagrees with previous research by Saeedi et al (2007) who found that after a first diagnosis of psychosis the number of patients with good insight into their illness rose from 60% at diagnosis to about 80% after a year and this was stable 2 years after diagnosis. However both studies agree that poorer insight was related to a more severe psychosis, and to poorer cognitive functioning at the time ofdiagnosis. Clearly this is a complex symptom of psychosis and more studies need to be carried out.

Abnormal structure of the frontal lobe can lead to poorer awareness of illness.

For this reason in the last 5 years research has begun to focus on the biological basis of insight in psychosis patients. There is strong evidence for a difference in patients brain structure that affects their awareness of illness. The hope is to use this information to develop methods of either improving levels of insight or better ways of treating patients with poor insight. Often patients have less brain matter in key areas of their frontal lobe (front area of the brain) than in non-psychotic patients and healthy people. A reduced amount of grey matter and fewer connections between white matter and grey matter in the frontal areas of the brain can affect cognition (our ability to perform logical tasks and memory) and patients’ awareness of illness.
However the two kinds of problem are not directly related; ie a patient can have better insight into their cognitive problems, such as poor memory, than into their clinical symptoms, such as associating the voices they hear to the illness rather than god speaking to them. This is believed to be because the two mental processes are similar but not exactly the same, and are dealt with in different areas of the frontal lobe.

More research needs to be done, but hopefully a better understanding of the underlying problems of psychosis patients’ awareness of their illness will lead to better treatment outcomes in the future.

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