Awareness of multiple dimensions of insight into schizophrenia: A comparison of patients with their relatives and clinicians

AIM: The aim of this thesis was to explore insight in schizophrenia from the perspectives of patients, relatives and clinicians. Insight scales were examined in order to collate items that were comprehensive with respect to key dimensions of insight but also sufficiently simple to allow use in everyday psychiatric practice. Background "Insight" describes the person's understanding of the nature of their mental illness. Assessment of insight for people with schizophrenia has always been an essential part of clinical practice. Often there are differences in understanding of the illness between patients, their relatives and their clinicians. Patients and relatives can feel that clinicians do not consider their views when making clinical decisions. Insight is multidimensional, more than just saying, "I have mental illness". It was postulated that the quality and range of what constitutes a lack of insight may vary according the viewpoint of the assessor. Another question was whether the scope of currently available insight scales was sufficient to encompass dimensions felt to be important to patients and relatives. The assessment of insight also has a transactional quality - the views of patients, relatives and clinicians interact in a dynamic fashion. There has been little direct assessment of the role of relatives in considering insight into psychosis, and limited consideration of the transactional nature of assessments of patient's insight. This study has a unique perspective. It looks at the assessment of patient's awareness of various dimensions of insight from three points of view patient, relative and clinician. STUDY DESIGN: Through consideration of the theoretical underpinnings and practical applications of existing Insight Measures, conducting focus groups of patients and relatives, and seeking expert opinion, the candidate proposed six dimensions of insight into schizophrenia to be studied in this three-way comparison: Awareness of the presence of symptoms or a change Acknowledgement it is a mental illness Expressed intention to or acknowledgement of the need to do something about the mental illness Actively engaging in (appropriate) treatment for the mental illness Patient's awareness of effects of their mental illness on the self Patient's awareness of effects of their mental illness on other people As no existing Insight Measure catered for multiple views over all of these dimensions, a number of new measures to supplement existing measures were devised. In this study, patients (n=39) with Schizophrenia or Schizoaffective disorder were assessed soon after admission to an acute psychiatry unit. They were invited to nominate a relative or significant other (n=28) who had close contact with the patient. Relatives were separately interviewed about the patient insight. The clinician's view of patient illness was assessed using Schedule for the Assessment of Insight Expanded Version (SAI-E), and the Scale to Assess Unawareness of Mental Disorder (SUMD). The patient's view was assessed by the New Insight Measure for patients (New IM) and the self-rated Markova & Berrios Scales. The SUMD and Markova & Berrios Scales were adapted for the relative assessment of patient awareness (SUMD-rel and M&Brel). Other measures assessed psychopathology (PANSS) and various clinical and demographic variables (Diagnostic Interview for Psychosis; DIP). In order to select appropriate measures for the clinician's view, the existing Insight Measures were also compared. A three-way comparison of views of patient awareness across the six dimensions was conducted. The clinical utility of all measures was considered. The measures were repeated at follow-up one year later. RESULTS: The new insight measures were generally easy to use and understood by the patients and relatives. There was some variation in scores for each of the six dimensions of insight reported by patients, relatives and clinicians indicating that they saw the dimensions as different. There was a high positive correlation for Acknowledgement it is a mental illness for all three reporters across time, but this was less consistent for the other dimensions. The key findings were that the patients and the clinician showed a significant positive correlation for Awareness of the effects of the illness on themself, while patients and relatives showed a significant positive correlation for Awareness of the effects of illness on others. These findings have relevance for clinical interaction and decision-making. There was limited change in overall insight scores or the pattern of correlations over the follow-up period, despite changes in psychopathology and mental health act status. DISCUSSION AND CONCLUSIONS: The study describes, for the first time, the similarities and differences in insight when assessed by patients, relatives and clinicians. When differences arise between patients, families and/or clinicians, these need not be dismissed as poor understanding on the relative's or patient's part. Family members have different views about patients' insights. The implications for clinical understanding of this are discussed. The proposed six dimensions of insight seen from the viewpoint of patient, relative and clinician are easily understood. The overall perspective developed in this thesis could inform a lexicon to describe aspects of clinical assessment and decision-making in areas such as compulsory treatment, compliance with treatment or understanding the effects of illness on self or others' all areas where insight into illness is usually considered