دیدی نسبت به بیماری در بیماران و مراقبین در طول روان پریشی زودرس: یک مطالعه مقدماتی

Background Impaired insight into illness is common during early psychosis and has been associated with treatment delays and poorer long-term outcomes. The relationship between patients' insight into illness and their caregivers' knowledge about psychosis is putatively associated with treatment outcome but there is limited research about this. This pilot study was designed to test the hypothesis that caregivers' levels of insight into illness is associated with patients' insight into illness in early psychosis and would be related to caregivers' levels of critical, rejecting attitudes toward patients. Methods Patients with schizophrenia or schizoaffective disorder within 5 years of psychosis onset (n = 14) and caregivers (n = 14) of the patients' choosing were studied. Insight into illness was assessed in patients using the Scale to assess Unawareness of Mental Disorder (SUMD). Caregiver insight into illness was assessed with a modified version of the SUMD with questions rephrased to probe caregivers' understanding of the patients' illness. Caregivers' critical attitudes toward patients were assessed with the Patient Rejection Scale (PRS). Results Significant correlations were found between patients' and caregivers' awareness of need for treatment (r = .55, p = .02), awareness of symptoms (r = .48, p = .04) and between caregivers' awareness of illness and critical attitudes toward patients (r = .65, p = .01). Conclusions These findings suggest that caregivers' emotional characteristics and levels of insight into illness may be related to insight into illness in patients. Implications for family psychoeducational approaches to impairments of insight into illness during early psychosis are discussed.

Impaired insight into illness is one of the most common symptoms of psychotic disorders (Sartorious et al., 1972). Recent studies of early psychosis (i.e., the first 5 years of illness) document that 70%–90% of individuals exhibit at least some degree of reduced insight into illness (Mutsatsa et al., 2006 and Thompson et al., 2001), with moderate to severe levels of impairment occurring in 30%–50% (Keshavan et al., 2004 and Thompson et al., 2001). Poor insight into illness often complicates the course of treatment in early psychosis. Research over the past two decades has found that impaired insight into illness is reliably related to longer duration of untreated psychosis (de Haan et al., 2002), medication nonadherence (Hill et al., 2010), greater symptom severity (Mintz et al., 2004), and poorer functional outcomes (Mohamed et al., 2009). Understanding the determinants of poor insight into illness may contribute to the development of treatment guidelines for managing the risks associated with impaired insight into illness in the early course of psychotic disorders. Most contemporary conceptualizations of insight into illness are multidimensional and define it as awareness of having a mental illness, awareness of the need for and effects of treatment with medication, awareness of the psychosocial consequences of having a mental disorder, and awareness and attributions regarding specific psychotic symptoms (Amador and Kronengold, 1998). Recent research has documented modest but significant relationships between levels of impaired insight into illness and cognitive deficits (Aleman et al., 2006 and Keshavan et al., 2004) and less consistently with symptom severity (Mintz et al., 2003) among individuals with early and chronic psychotic disorders. Although caregivers are increasingly recognized as playing an important role in the treatment of individuals with early psychosis, the relationship between caregivers' knowledge about psychosis and patients' insight into illness has not been studied. Caregivers are often the first to become aware of their loved one's illness (Judge et al., 2005). After the onset of psychosis, caregivers commonly play a critical role in supporting medication adherence, treatment engagement, and encouraging improved social functioning (Sin et al., 2005). Greater caregiver involvement during early psychosis has been linked to improved medication adherence and fewer days spent hospitalized (Penn et al., 2005), and less involvement has been associated with longer duration of untreated psychosis and increased risk of medication non-adherence (Rabinovitch, et al., 2009). Research on ‘expressed emotion’ (EE) and family psychoeducation (FPE) lend additional support for the idea that greater caregiver understanding about psychosis may lead to increased patient insight into illness. Ample research has demonstrated a reliable relationship between high-EE in caregivers (primarily reflected in critical caregiver attitudes toward patients) and increased patient relapse rates (Bebbington and Kuipers, 1994 and Brent and Giuliano, 2007). Early EE research found that a key characteristic of high-EE relatives was that they were commonly unaware that their affected family member was suffering from a mental illness (Vaughn and Leff, 1981). Conversely, it has been found that low-EE caregivers are not only less critical, but tend to make attributions that reflect an understanding of their relative's illness (e.g., ‘he's doing the best he can, but his illness makes it hard for him to make decisions’) (Brewin et al., 1991). Further, low-EE has been associated with greater treatment adherence and improved clinical course (Sellwood et al., 2003). Expressed emotion research linking caregivers' lack of knowledge about psychosis with high-EE and poorer patient outcomes has, in turn, provided an important evidence base for the development of family psychoeducation treatment interventions for schizophrenia. Numerous studies have now shown that improved caregiver understanding of psychosis during FPE is associated with reductions in relapse rates among patients with chronic schizophrenia (McFarlane et al., 2003). Although not directly tested, it has been posited that improvement in patient insight into illness as a consequence of increased caregiver knowledge about psychosis during FPE may partly mediate better clinical outcomes (McFarlane and Lukens, 1998). That is, greater caregiver insight into illness and less caregiver criticism may have a de-stigmatizing effect on patients' beliefs about mental illness and create a social environment that fosters improved patient insight into illness. This pilot study of patient–caregiver dyads explored relationships among caregivers' insight into illness and emotional characteristics and levels of insight into illness and symptomatology among outpatients with early psychosis. Cognitive abilities potentially influencing the capacity for insight into illness (e.g., estimated verbal IQ, speed of processing) were also assessed in both caregivers and patients. For the purposes of this study, we defined ‘caregiver insight into illness’ as a construct comprising a caregiver's level of awareness regarding a patient having a mental illness, the effects of and needs for treatment in the patient, the psychosocial consequence of the patient's illness, and awareness and attributions of the patient's specific symptoms. We tested two hypotheses: 1) that caregivers' insight into illness would be associated with caregivers' levels of criticism toward patients; and 2) that the degree of caregiver insight into illness would be associated with levels of insight into illness in patients with early psychosis.