Neurocognitive basis of insight in schizophrenia

People with schizophrenia have been categorised into three groups: those with full insight (aware, correct attributers); those aware of being unwell, but who misattributed their symptoms (aware, incorrect attributers); and those unaware of being ill (unaware).

Cluster analysis of 'awareness of illness' and 'relabelling of symptoms' scores on the Schedule for the Assessment of Insight confirmed three distinct subgroups. The unaware group were impaired on executive and memory tests, whereas those in the aware, misattributing group were cognitively intact.

INTRODUCTION

Lack of insight in psychiatric illness may comprise multiple processes such as self-awareness, attribution of illness, social consequences of illness and perceived need for treatment (David, 1990; Amador et al, 1994; Morgan & David, 2004), some of which may be amenable to treatment. However, poor insight may result from cognitive impairment (for review, see Aleman et al, 2006). If lack of insight is underpinned by cognitive impairment, then it may require a therapeutic approach which is different from that currently offered (Henry & Ghaemi, 2004). Flashman & Roth (2004) proposed a classification of insight that divided patients into three groups: those with full insight (aware, correct attributers); those aware of being unwell, but who misattributed their symptoms (aware, incorrect attributers); and those unaware of being ill (unaware). These authors suggested that unawareness of illness was caused by brain dysfunction.

If true, this implies that the aware, misattributing group might be cognitively intact, and therefore might be helped by psychoeducation or psychotherapy. We predicted that cluster analysis would yield three groups that would be consistent with this model. In addition, we tested the hypothesis that unawareness would be associated with cognitive impairment, whereas cognitive function would be intact in those who misattributed illness.

Findings support an association between unawareness of illness and executive dysfunction, and highlight the separation of symptom misattribution from unawareness of illness [more...]

British Journal of Psychiatry, 06/01/07