Imagine you feel healthy and believe you look fine, but you’re forced to go to the doctors, take medication and stay in bed because others believe you’re ill with flu and in ‘denial’. It would be quite confusing, wouldn’t it?
This denial, or lack of awareness, of illness may seem a strange concept in physical health issues; however it is quite common in mental illnesses such as Psychosis and Schizophrenia. In fact, it is believed that in up to 80% of cases patients with these conditions are unaware that they have a mental illness. This means that when patients have unusual mental experiences such as hearing voices or holding paranoid beliefs, they are unable to understand them as symptoms of an illness. Lack of awareness often leads to problems for patients as it can result in resistance to medications (why take medicine when you don’t think you’re ill?) and so causes increased levels of distress. It also causes problems for doctors when attempting to administer treatment – clearly patients who don’t want to take their medication are going to be more difficult treat. If treatment plans are not followed, patients can end up requiring longer stays in hospital and their chances of relapse and readmission are increased. As well as being unpleasant for patients to be stuck in hospital, it also costs the hospital more money. Even when patients are allowed to return home, they often require a certain degree of care; while a loved one can provide this, often a lack of awareness can cause a greater burden and distress for these people as well.
It makes sense to try and increase a patients awareness of their illness, because that way we can reduce their distress, increase their willingness to take the recommended medication,and increase their chance of recovery. Some research has linked better patient awareness with lower mood, however we don’t yet know if the depression results in increased awareness or vice versa. Other than this there is not much evidence to suggest what causes this lack of awareness, or much agreement on ways to improve it.
This is where my research comes in. My PhD focuses on a possible link between lack of awareness and thinking processes called ‘metacognition’. Metacognition sounds complicated, but really it’s just ‘thinking about your own thinking’. If someone has high metacognitive abilities, they are good at knowing about their own ‘mind’. For example, if someone with high metacognitive abilities has a poor memory they are likely to admit it when asked. This person will probably also take precautions to avoid their poor memory being a problem, such as making lists of things to do. Interestingly, patients with poor illness awareness are quite bad at rating their own skills and memory. When compared to ratings made about them by a close relative, patients will often rate their memory, everyday skills and problem solving deficiencies as being much less severe than they really are.
The task we are using to measure metacognition is a relatively new instrument, and has only previously been used in healthy, non-psychiatric participants. It works by asking people to rate how confident they are that they have answered correctly on each trial, so they are rating their awareness of their performance. In the non-psychiatric population these confidence ratings have a strong relationship with the volume and connections of specific regions in the frontal area of the brain, where increased confidence in accurate performance is related to increased volume and connections. This is especially interesting because lack of awareness in patients can be related to reduced volume and connections in similar frontal areas of the brain.
My work therefore proposes that patients who have a lack of awareness about their mental illness will also have lower metacognitive skills, which could be related to their brain structure in the frontal areas of the brain. This research is exciting, because if our prediction is correct it opens up new opportunities for treatment.
Research into metacognition in school children has shown that ‘metacognitive training’ can increase children’s ability to think about their thinking. If lack of awareness in patients with Schizophrenia is related to metacognitive ability, then we could potentially offer a similar type of training to improve their metacognitive skills. The big advantage to improving these skills is that it could result in patients better understanding their unusual mental experiences as symptoms which can be relieved with treatment.
This research is in its infancy, but the results could lead to treatment options that greatly improve patients’ quality of life and the overall outcome of their treatment at a substantially reduced cost.”