نگرش نسبت به اسکیزوفرنی پایدار: روابط با آسیب شناسی روانی و شناخت

Objective This study evaluated the relationship among insight, sociodemographic and clinical variables, symptoms and cognitive functions in a population of outpatients with stable schizophrenia, in order to identify possible contributing factors to awareness. Method Two-hundred and seventy-six consecutive outpatients with stable schizophrenia were enrolled in a cross-sectional study. All subjects were assessed by psychiatric scales and interview, and a wide neuropsychological battery. A factor analysis was performed to identify cognitive factors and multiple regression analyses were executed to test the contribution of variables considered to insight. Results Our results showed that positive and negative symptoms, executive functions, verbal memory-learning were contributors of awareness of mental illness; positive and negative symptoms explained variability in awareness of the need for treatment; positive symptoms and executive functions contributed to awareness of the social consequences of disorder. Conclusions These results suggested that insight was partially influenced by positive and negative symptoms and by cognitive functions. A complex system of overlapping variables may underlie impaired insight, contributing to a different extent to specific dimensions of poor insight in patients with stable schizophrenia.

Lack of insight or awareness of illness is a hallmark feature of schizophrenia and has become an increasingly important area of investigation [1]. Eighty to 85% of the patients show either partial or no insight of the disorder [2], [3], [4] and [5]. Poor insight has a strong impact on clinical outcome [6] and [7], treatment compliance [7], [8], [9], [10] and [11], number of hospitalizations [12] and [13], social and interpersonal functioning [14] and [15], and vocational rehabilitation [16]. The identification of demographic and clinical factors associated with lack of insight has proved complicated. Some authors found evidence that age of onset of the disorder [17], female gender [18] and [19] and lower educational level [19], [20] and [21] were associated with poor insight, yet others didn't find evidence for an association [6], [13], [22], [23] and [24]. Regarding psychopathology, largely inconsistent results have been produced by various studies which analysed lack of insight in patients with schizophrenia and its relationship with the severity of symptoms. Unawareness of illness has been associated with greater levels of positive [20], [25] and [26] and negative symptoms [20], [25], [26], [27] and [28], especially in the early stages of illness [29], although inverse or no direct relationships have also been reported [13] and [30]. Similarly, studies examining the associations between impaired insight and depression are controversial, with some investigators finding no significant relationships [6], while more recent research has found a positive relationship between the degree of insight and depressive symptoms [31], [32], [33] and [34]. For instance, weak to modest relationships have been reported between insight and anxiety [34], [35] and [36]. In recent years much of the research has focused on understanding the relationship between neurocognitive impairment and insight [20]. There is evidence regarding widespread neurocognitive dysfunction in patients with stable schizophrenia, particularly in the areas of attention, memory, and executive functions [37]. While some of the studies reported a significant association between impaired insight and executive functioning [5], [24], [38], [39], [40], [41], [42] and [43], memory [20], [29], [33] and [44] or attention [16], other studies did not find these associations [22], [26], [42], [45], [46] and [47]. Such inconsistencies may be due to methodological differences, such as use of different and non-standardized insight and/or cognitive measures, and failure to assess or control for global cognitive status, and diagnostic and psychopathological variability within the study subjects [48]. In order to focus our attention on insight, we analysed a sample of outpatients with stable schizophrenia with the following aims: 1. To investigate the relationships among insight, sociodemographic and clinical variables, symptoms and cognitive functions. 2. To analyse which variables were contributing factors to three different dimensions of insight: patient's awareness of the disorder, awareness of need for treatment and awareness of the social consequences of disorder.

Taken together the results of our study supported that insight was partially influenced by positive and negative symptoms and by cognitive functions in our sample. A complex system of overlapping variables may underlie impaired insight and these variables may contribute to a different extent to specific dimensions of poor insight. Understanding poor insight is not only an intriguing theoretical challenge, but also it has implications for prognosis and treatment [78]. Recent studies have shown that cognitive behavioural therapy improves insight in schizophrenia [79] and [80], leading the patient to recognize errors in his/her thinking and to increase flexibility in thinking about experiences [81], [82] and [83]. Recently, attention moved from clinical insight to cognitive insight or the ability to monitor and correct one's erroneous convictions, whose neuroanatomical correlates in schizophrenia have also been identified, i.e. reduced volume of the right-ventrolateral prefrontal cortex, an area involved in generating and maintaining in working memory different hypotheses about the self [84]. Cognitive insight is considered to reflect the metacognitive underpinnings of poor insight [85] and [86]. Indeed, it has been suggested that different kinds of deficits in metacognition, or the ability to think about thinking, may play a unique and possibly moderating role in the development of poor insight [87]. To acknowledge the point of view of the other and to reflect upon one's own experiences are closely related. Both presuppose the capacity to establish a dialogue, either with oneself or with another person, and to take a reflexive stance over one's own thoughts and feelings and the thoughts of the others. Self-reflectivity, which reflects introspection and willingness to observe one's own mental productions and to consider alternative explanations was the metacognition domain most closely linked to insight [85]. An important suggestion from studies on the cognitive aetiology of insight is that neuropsychological interventions should, indeed, be developed. Improved insight is certainly a fundamental target to improve functional outcome and quality of life in individuals with a diagnosis of schizophrenia, and should be among the primary goals of any clinical intervention [73].