The Relationship Between Illness Insight in Schizophrenia

Contents

Abstract

Acknowledgements

Abbreviations

Tables and Figures

1. Introduction
1.1. Schizophrenia
1.1.1. Diagnostic Characteristics of Schizophrenia
1.1.2. Etiology
1.1.2.1. Genetics
1.1.2.2. Environment
1.1.2.3. Neurobiology
1.1.2.4. Summery of the Causes
1.1.3. Treatment of Schizophrenia
1.1.4. Antipsychotic Medications
1.1.4.1. First Generation Antipsychotics
1.1.4.2. 2 nd Generation Antipsychotics
1.1.5. Psychological Treatment
1.1.6. Cognitive Behavioral Therapy for Schizophrenia
1.1.7. Family Therapy - Psychoeducation
1.1.8. Community Support System
1.1.8.1. Case Management
1.1.8.2. Clinical Case Management
1.2. High Service Users with Poor Illness Insight
1.2.1. Non-compliance with Medication
1.2.2. Improving Insight and Compliance with Medication

2. Review of the Research Literature
2.1. Illness Insight in Schizophrenia
2.1.1. The Importance of Insight in the Study of Schizophrenia
2.1.2. Defining Insight
2.1.3. Cognitive Psychological Approach to Insight or the Unawareness of Illness
2.1.3.1. Medical Science Understanding of Insight
2.1.3.2. Neuropsychology of Insight
2.1.3.2.1. Neurobehavioral
2.1.3.2.2. Summary
2.1.3.3. Cultural and Social Perspectives of Insight
2.1.3.3.1. Stigma of Illness
2.1.3.3.2. Cultural Construction
2.1.4. Insight Measurement
2.1.4.1. Insight Correlation Studies
2.1.4.2. Current State of Research in Definition and Measurement
2.2. Social Support and Health
2.2.1. Conceptual Differences
2.2.2. Social Support and Severe Mental Ilness
2.2.3. Facilitating Health Through Social Support in Schizophrenia
2.2.2.1. Clinical Case Management Model of Social Support Intervention
2.2.2.2. Social Support Needs
2.3. Measuring Social Support and Social Support Needs
2.3.1. Perspectives of Social Support Measurement
2.3.2. Social Support Measurements for Populations with Mental Illness
2.3.3. Social Networks
2.3.3.1. Social Interaction
2.3.3.2. Measuring the perceived adequacy of social support
2.4. Quality of Life in Mental Health
2.4.1. Objective and Subjective Approaches to QoL
2.4.2. Subjective Quality of Life as a Care and Treatment Outcome Indicator

3. Study Rationale
3.1. The Context of the Research Question
3.2. Insight and Treatment Prognosis
3.3. Insight and the Relationship to Treatment Outcomes for Schizophrenia
3.4. Insights: Relationship to Psychosocial Variables
3.5. Case Management
3.5.1. Case Management in Mental Health Community Support Services
3.5.2. The Effectiveness of Case Management Services in Mental Health
3.6. Supportive Therapy and Biopsychosocial Treatment of Schizophrenia
3.6.1. Supportive Therapy and Schizophrenia
3.6.2. Treatment with Supportive Therapy
3.7. Poor Illness Insight as an Obstacle to better Treatment Outcomes
3.7.1. Poor Illness Insight and the Most Prevalent Treatments for Schizophrenia
3.7.2. Poor Illness Insight and Therapeutic Goals

4. Methods
4.1. Study Design
4.1.1. Sample Inclusion/Exclusion Criteria
4.1.2. Sample Recruitment and Sample Size (N = 43)
4.2. Measures and Instrument
4.2.1. Description of the Measures and Instrument
4.2.1.1. The Berliner Inventory
4.2.1.2. Measurement Validation and Reliability
4.2.2. Schedule of Assessing Insight
4.2.2.1. Medication Compliance
4.2.2.1.1. The Berliner Lebensqualitatsprofil
4.2.2.1.2. Illness Insight - The Scales of Unawareness of a Mental Disorder
4.2.2.2. Global Assessment of Functioning
4.3. Procedures
4.3.1. Interview Setting
4.3.2. Case Manager Interview
4.3.3. Client/Consumer Interview
4.3.4. Develop Rapport to Establish a Working Relationship
4.3.5. Recording the Data
4.3.6. Debriefing
4.4. Statistical Data Analysis

5. Results
5.1. Sample Characteristics
5.1.1. Education
5.1.2. Hospitalization
5.1.3. Accommodations
5.1.4. Lenght of Community Psychiatric Support
5.1.5. Substance Abuse Co - morbidity
5.1.6. Medication
5.2. Correlations
5.2.1. Correlations of Insight Scores
5.2.2. Correlations of Insight Scores to Subjective Quality of Life, Needs Assessment, and Global Functioning
5.2.3. Insight and the Acceptance of Medication

6. Discussion
6.1. Sample Characteristics
6.2. Insight Correlations
6.3. The Correlation between Case Manager and Consumer Social Support Needs
6.4. The Correlation between the Consumers Subjective Quality of Life Needs for Social Support and Global Assessment of Functioning
6.5. Medication Compliance and Unawareness of Illness
6.5.1. A Possible Explanation for the Difference in Findings
6.6. Correlation between Case Manager Identified Needs for Social Support and Low Global Assessment of Functioning

7. Conclusion
7.1. The Study Hypothesis
7.2. Answer to Research Question
7.3. New Questions
7.4. Study Limitations
7.5. Recommendations
7.6. Outlook

Appendix: I - XII.
Appendix I.: Demographische und krankheitsbezogene Daten
Appendix II.: SAI Compliance Items
Appendix III.: SUMD- Symptom- Checkliste: Case manager
Appendix IV.: Berliner Bedurfnis- Inventar
Appendix V.: Global Assessment of Functioning - Beurteilung durch den Betreuer
Appendix VI.: Berliner Bedurfnis-Inventar (BeBi) - Fragen an Patienten/Klienten
Appendix VII.: Berliner Lebensqualitatsprofil - Zufriedenheitsfragen
Appendix VIII.: SUMD Questions for the Client/Patient
Appendix IX.: SUMD Symptom-Checkliste: Consumer
Appendix X.: SUMD-Symptoms and Attributions (4-20)
Appendix XI.: Interviewer - Global Assessment of Functioning - Beurteilung durch den Interviewer
Appendix XII.: Coding Form

References

Abstract

Objectives: The purpose of this study was to explore the relationship between Illness Insight in schizophrenia and the level of social adaptation, social support needs, and subjective life satisfaction, for consumers of community mental health support services. Methods: Samples (N=43) were recruited from community base independent service agencies providing case management services for mentally ill people in the western Berlin catchment area in Germany. Separate interviews were conducted with the case managers and their clients diagnosed with schizophrenia (ICD-10). Quantitative measurements were used to establish if there is a relationship between illness insight and the various psychosocial variables measured in this study. Results: Low illness insight correlated with low levels of social adaptation. Low social adaptation correlated inversely with the case managers’ assessment of more social support needs for their client. The clients’ low subjective life satisfaction correlated with higher client rated social support needs. The client and case manager rated social support needs correlated strongly. Conclusions: Low illness insight may be an indicator of low social adaptation that might require increased case manager engagement to meet more client social support needs. For this further research is essential.

Acknowledgements

I am extremely grateful to Dipl. Psych. Dr. Wolfgang Kaiser of the Outpatient Psychiatric Clinic at the Vivantes Hospital in Berlin^[1], Germany. Without his patience and guidance this Masters Thesis would not have been possible. His help in keeping the data safe and accurate, as well as his contribution with the statistical analyses of the collected data is more than appreciated.

I would also like to acknowledge all of the consumers, case managers and their institutions allowing me to be part of their day. Hosting a research project, as I bitterly and surprisingly found out, is not something that can be taken for granted. Their kindness in allowing a stranger to come into their institution to interview them, and leave as a friend was awesome. Thank you!

A special word of thanks goes out to my own colleagues and our clients at the Freundeskreis Nervenklinik Spandau e. V. Their support and understanding these past three years, not only in the research phase of this Masters Thesis, but in putting up with me and all my new and for them weird ideas on this new thing called clinical social work is also very much appreciated.

Last, but not least. I especially thank my wife Eva, and son David for their support, understanding and encouragement. Without them, writing a Masters Thesis would be pointless.

A Dedication

To all of those experiencing the dreadful and sometimes amusing symptoms of schizophrenia. Whether you are aware of your illness or not, I admire your courage. May your recovery come soon!

Berliner Bedurfnis Inventar Berliner Lebensqualitatsprofil Client

Abbreviations

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Appendix 2:

Tables and Figures

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1. Introduction

"I am not mentally III, and I don’t need any help"; is one variation of what many mental health professionals will hear from their clients with schizophrenia (Amador & Johan- son, 2000). The professionals hearing this may often be those employed by community mental health support services to help these individuals claiming not to need any help. The fact that these clients are usually residents of supervised living programs makes their claim even more perplexing. When their case manager or key worker asks them why they are living here the worker usually receives an answer ranging from the delu­sional, "I’ve been placed here by aliens", to the more mundane, "where else should I live? I’ve no other place to go" (ibid).

Consequently, caring for someone who does not believe they are ill, as a family mem­ber, or as a member of a professional mental health care team can be very frustrating. Active psychotic symptoms make it difficult for any meaningful personal interaction for both the carer and the ill person. They tend to refuse to see a physician, do not take medication, and are frequently involuntarily committed to a psychiatric hospital for be­coming either a danger to themselves or others (McEvoy, 2004). The carer involved with this person quickly evolves into the helpless helper. If the carer is a family mem­ber, they tend to give up and ask the state to care for their loved one (Amador & Jo- hanson, 2000). As a case manager in a mental health team, it has been my experience that many co-workers react to these clients either with the "burned out syndrome” and as a result often quit their job, or become indifferent to their client by exclaiming, "there is nothing I can do the client lacks insight!” Some co-workers propose that the patient’s illness insightlessness is just typical of revolving door psychiatric patients; and seems a fact that the client and the mental health community support service just has to accept as a standard. Some others will feel challenged and want to understand why these individuals refuse, or are not able to recognize that they are mentally ill. They recog­nize their client’s obvious need for help, and try to find ways and means to make their offer of help acceptable and helpful for their insightless client.

There may be some truth to the old saying, "the first step to illness recovery is recog­nizing, or admitting that you are ill". This seems easy in terms of a somatic illness. People feeling or recognizing the discomfort of symptoms or signs of an illness, for example, people with chest pains or a skin rash will usually go visit an expert, the phy­sician. The physician performs diagnostic tests to arrive at a conclusion of what is ail­ing them and based upon the current best evidence, the physician prescribes a form of treatment intended to relieve the pain and perhaps restore them to or near to a pre- morbid state.

But, what if that organ responsible for recognizing illness itself is ill or impaired and not able to recognize what is wrong? If our brain is not working properly, would we be able to recognize in ourselves the symptoms or signs of an illness? Would we feel discom­fort? Could we?

The seed for this thesis was planted during the first semester of graduate school. It was then that we were introduced to the modern neurological and neuropsychological research using new neuro-scientific technologies. The results of this research taught us about the synaptic plasticity or the neuro-plasticity of the brain and that it is possible for the brain to hold this plasticity our entire lives and that the biopsychosocial experi­ence influences this neuro-plasticity. This knowledge provided the basis for wanting to explore if the social support interventions in clinical case management with clients with schizophrenia is related to their illness insight. Social support can be seen as a product of the clinical relationship in clinical case management. In this, Schore claims that the clinical relationship "acts as a growth promoting environment that supports the experi­ence-dependent maturation of the right brain, especially those areas that have connec­tions with the subcortical limbic structure that mediate emotional arousal” (1994, p. 473 cited in Applegate & Shapiro, 2005). These may be also areas of the brain affected in the schizophrenia disorder and perhaps causing illness insight (Lar0i et al., 2004). This suggests that neuro-scientific evidence supports the efficacy of certain tried-and-true social work approaches aimed at improving our client’s quality of life (Applegate & Shapiro, 2005).

1.1. Schizophrenia

Schizophrenia is a heterogeneous and complex illness. From the degree of blatant bizarre behavior, to intracellular processes, it has defied scientific explanation. Even now, investigators have not been able to identify one single factor characterizing all patients with schizophrenia (Walker et al., 2004), which has compelled researchers to investigate a wide spectrum of phenomena related to individuals diagnosed with schizophrenia. As a result, some researchers contend that their findings are signs and symptoms that contribute to the definition, or the diagnostic criteria for the schizo­phrenic syndrome or disorder. For example, research on substance abuse in schizo­phrenia proposes it not only to be a complication factor, but that certain aspects of the substances abusing behavior are common in schizophrenia and have diagnostic value for schizophrenia (Siris & Docherty, 1990). Insightlessness, or the unawareness of illness in schizophrenia has been seen by Amador, Strauss, Yale, et al., (1991) as a condition having prognostic and diagnostics implications, and have proposed that it be officially added as a diagnostic criterion.

The nature of schizophrenia contributes to it being considered among the most debili­tating of mental illnesses. It affects a person’s personality, perception, cognition, emo­tion, and behavior. Consequently, it causes disturbances to a person’s social, interper­sonal, and vocational functioning (Wong, 2006; Hofmann & Tompson, 2002). Schizo­phrenia is also a severe public health problem, with a lifetime prevalence rate of ap­proximately 1 %. The morbidity is severe and mortality is high; economic, social, and psychological impairment typically continue during the patient’s entire lifetime (An- dreasen & Carpenter, 1993; Keith et al., 1991; Kulhara & Chakrabarti, 2001; Torrey, 1987). In fact, in the United States, a 1992 report by the National Foundation for Brain Research, reported that the national societal cost of schizophrenia now exceeds that for cancer (cited by Schwartz, 1998).

Most cases of the schizophrenia are first diagnosed between the ages of 20 and 25, a stage in life when people typically attain independence from their parents, develop in­timate romantic relationships, and/or begin to pursue work or career goals (DeLisi, 1992). Schizophrenia can, therefore, have a profound, negative impact on the person’s opportunity for attaining social and occupational success, and the consequences can be devastating for the adult life course. Moreover, schizophrenia knows no boundaries; it occurs in all countries and within all ethic and social groups, although the prognosis may differ among countries (Kulhara & Chakrabarti, 2001).

1.1.1. Diagnostic Characteristics of Schizophrenia

Despite recent technological advancements in psycho-physiological assessment, the clinical characteristics of schizophrenia remain varied and puzzling to researchers. Something that has not changed since Kraepelin (1919) acknowledged that the signs and symptoms of what he called "dementia praecox” were very diversified. Bleuler (1911) even made reference to the "group of schizophrenias". Modern researchers have attempted to classify schizophrenia with more accuracy and effectiveness (Schwartz, 1998) offering subtype classifications that include paranoid, catatonic, he­bephrenic (i.e., disorganized), and residual subtypes, and common distinctions or specifiers that include good versus poor prognosis, acute versus chronic course, posi­tive versus negative versus mixed symptomatology, and deficit versus no deficit sub­types (Kendler et al., 1988; Kendler et al., 1989; Andreasen, 1990; Fenton & McGlashan, 1991).

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV, 1994), presents specific criteria for determining the presence and quality of schizo­phrenia. It includes the characteristic symptoms of, dysfunction, duration, and differen­tial diagnostic exclusions. But, it also divides the course of schizophrenia into three phases: prodromal, active, and residual. In the prodromal phase, patients exhibit dete­rioration in their level of functioning without being actively psychotic. They also have mostly "negative” symptoms, such as anhedonia, apathy and feelings of emptiness. There may also be a disruption in sleep patterns. Their performance in school may deteriorate, and they may not be mindful about personal hygiene. Other indications of the prodromal phase are abrupt changes in behavior or lifestyle. In the active phase, the person is explicitly psychotic, with perhaps disorganized thinking, delusions, and hallucinations. In the residual phase, people with schizophrenia continue to be im­paired, but without severe psychotic symptoms (Preston, O’Neal, Talaga, 2001). The DSM-IV consequently defines schizophrenia as being "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom" (p. 2, cited by Wyatt in Lieberman & Murray, 2001).

The DSM uses the term "disorder" not only in its title, but additionally appending most of its diagnoses (e.g., schizophrenia disorder, bipolar disorder), and emphasizes that psychiatry deals with disorders.

The Manual of the International Statistics Classification of Diseases, Injuries and Causes of Death (ICD-10) clearly states that schizophrenia is a disorder, not a dis­ease. A point made despite the fact that the term disease is found in its title. The rea­son for this discrepancy may be based on the fact that the ICD system was originally a classification of causes of death (Wyatt, 2001).

Considering schizophrenia to be a disorder may be less specific than considering it to be a disease. Disease implies that there is something that can be observed physically (signs and symptoms), that there is something structurally, biochemically, or physio­logically abnormal about the body or a part of the body. So seen, Wyatt, (2001) defini­tion of a disease is a "distinct entity with a specific etiology, even though the etiology may not be completely known" (p. 2). The term disorder is often used synonymously with illness, although illness is normally used to indicate clinical manifestations, or what a patient experiences (symptoms). Disorder implies something about the course of illness, but not about the cause.

1.1.2. Etiology

Although there are a number of theories inciting debate on the etiology of schizophre­nia, the exact cause of schizophrenia remains unknown. This thesis will describe just those theories that pertain to the thesis question.

According to research, there is probably no one cause of schizophrenia, but interplay between biological predispositions and environmental factors that result in many causes. In this regard, the biological predisposition factors can be traced to studies of twins showing a rate of concordance much higher for monozygotic than for dizygotic twins (Preston, O’Neal, Talaga, 2001). Kety et al., (1971) tested the environmental factor in their study of adopted children, their adoptive and biological families. They found that schizophrenia is much more prevalent in the biological relatives than in the adoptive families of those adopted at birth who are later diagnosed schizophrenic, suggesting evidence of a large role for biological or genetic causes for schizophrenia.

1.1.2.1. Genetics

Findings from behavioural genetic studies of schizophrenia lead to the conclusion that the disorder involves multiple genes, instead of a single gene (Gottesman, 1991). It is based on several observations, particularly the fact that the pattern of familial trans­mission does not conform to what would be expected from a single genetic locus, or even a small number of genes (Walker et al., 2004). Instead, the genetic liability seems to involve multiple genes acting in concert, or susceptibility of numerous single genes acting independently. In testing this hypothesis, Kato et al., (2002) did not suc­ceed in identifying a genetic locus thought to be responsible for a significant proportion of cases of schizophrenia. Instead, researchers using molecular genetic techniques have identified a range of genes that seem to be responsible for a very small propor­tion of cases or of variance in liability (Walker et al., 2004). Candidate gene analyses, genome scans, and linkage studies have provided some evidence for the involvement of several specific genes, such as the serotonin type 2a receptor (5-HT2a) gene and the dopamine D3 receptor gene, and several chromosomal regions (i.e., regions on chromosomes 6,8,13, and 22), (Badner & Gershon, 2002; Mowry & Nancarrow, 2001).

There is no doubt that genetics play a role in the development of schizophrenia. Al­though the exact genetic mechanism leading to the development of schizophrenia is still not clear (Wong, 2006). Understanding the genetic role can help provide hope for people who are genetically predisposed to schizophrenia. Prenatal counseling can help identify this predisposition, and provide the knowledge that would help parents mini­mize exposure to the social and environmental factors associated with the develop­ment of schizophrenia Wong, 2006).

1.1.2.2. Environment

The environmental factors of schizophrenia, in a very broad definition, are considered by researchers to be everything but the biological/genetic factors. Among the environ­mental factors are social factors, nutritional, hormonal and chemical environment in the womb of the mother during pregnancy, up to the social dynamics and stress a person experiences, substance abuse, education, virus exposure and vitamin use (Schizo- phrenia.com. 2006).

1.1.2.3. Neurobiology

The neurobiological theories involving neurotransmitters and receptors explain the neurophysiological symptoms experienced in schizophrenia. In this, the dopamine model is an explanation for the abnormal dopaminergic activity in the brain. Dopamine neurons are located in a number of different brain regions. In the basal ganglia, these nerve cells help to regulate motor functioning. In areas of the limbic and reticular sys­tems, dopamine neurons appear to play an important role in emotional control and the screening of stimuli (Jentsch et al., 2000).

The dopamine model claims that the basic physiological pathology involves primarily overactive or hyper-reactive dopamine neurons. This excessive dopamine activity leads to behavioral agitation, a failure to adequately screen stimuli, and disorganization of perception and thought. This theory is supported by two observations: The first is that the potency of antipsychotic drugs has correlated closely with their ability to bind to and block the postsynaptic dopamine (D2) receptors in the mesolimbic system. The second observation is that drugs that increase dopamine activity (such as ampheta­mines) can produce a paranoid psychosis similar to paranoid schizophrenia and, if given to schizophrenic patients, amphetamines may exacerbate psychotic symptoms (Preston, O’Neal, Talaga, 2001).

1.1.2.4. Summary of the Causes

The following diagram is a generally accepted flowchart for the causes and origins of schizophrenia. It should be noted that neither biological nor environmental categories are considered completely determinant, as there is no precise amount of genetic or environmental input that determines if a person will or will not develop schizophrenia. Furthermore, each person and each situation is different. One person may develop schizophrenia because of a strong family predisposition for schizophrenia, another to significant prenatal or environmental stressors (Glick, 2005).

Figure 1 - Flowchart for the Development of Schizophrenia

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(Adapted from Glick, 2005)

Figure 2 illustrates the developmental origins of schizophrenia and the path to schizo­phrenia showing how the genetic and prenatal factors are thought to create a vulner­ability to schizophrenia. For example, it shows how the environmental exposures to social stress and/or isolation during childhood, drug abuse, etc. may further increase the risk, or trigger the onset of schizophrenia. In this illustration the early signs of schizophrenia risk are considered to be neurocognitive impairments, social anxiety and isolation "odd ideas". The abuse of DA drugs refers to dopamine affecting drugs (Glick, 2005).

Figure 2 - Developmental Origins of Schizophrenia

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(Adapted from Glick, 2005)

1.1.3. Treatment of Schizophrenia

Recent research findings on the treatment of schizophrenia have advanced both clini­cal practice and theories of etiology. Based on the evidence, the contemporary ideal treatment is a combination of medication, psychological therapy, and community sup­port (Walker et al., 2004). Integrating all three of these aspects, the biopsychosocial vulnerability - stress model that was originally developed for understanding, assessing, and treating people with schizophrenia (Yank, Bently, & Hargrove, 1993), emphasizes the interactive effects of the genetic and dopamine models, the stress and cognitive impairments models, as well as the social and environmental factors in determining the severity and the course of treatment in a mental illness like schizophrenia (Wong, 2006).

Wong, (2006) sees this model expressed in the following manner:

[Excessive dopamine secretion →

Presence of positive and negative symptoms X
Cognitive dysfunction →

Lower stress threshold] + Environmental stress X
Inadequate personal and environmental protectors →

Schizophrenia (p. 123).

The strength of this model is its conceptual link between biological, psychological, and the social factors involved in the development of schizophrenia. It also provides a broad framework not only showing how these factors interact with each other, but what role personal and environmental protectors play in the development and or the preven­tion of schizophrenia. It also allows a conceptual starting point to incorporate psycho­logical and psychosocial models of treatment and intervention within this framework (Wong, 2006; Tarrier & Haddock, 2002; Fowler, Garety, Kuipers, 1995).

1.1.4. Antipsychotic Medications

Antipsychotic medications are the primary form of treatment used to treat the positive and negative symptoms found in schizophrenia. These medications are considered an important, if not essential, component in treating the psychotic symptoms of schizo­phrenia. Medication treatment emphasises, not only the resolution of the symptoms but also relapse prevention. As schizophrenia is a disorder in which relapse is extremely common (Preston, O’Neal, & Talaga, 2001), and estimating that following a psychotic episode and subsequent recovery, 70 % of the patients will relapse within a year if treated with either placebo or no medication at all. With continued antipsychotic treat­ment the relapse rate can drop to 30 to 40 %. Research suggests that low-dose and intermittent treatment is associated with poorer outcome, as measured by the number of hospitalizations (Carpenter et al., 1990; Kane, 1990).

When left untreated, there is now evidence to support that being psychotic is damag­ing to the brain (Loebel et al., 1992). It is thought that the more the dopamine circuits are used, the more the psychotic pathways become etched into the brain. Loebel et al., (1992) studied the relationships between duration of illness and clinical outcome in a group of untreated, first-episode schizophrenic patients. The study results showed pa­tients who had been psychotic for longer periods before treatment, tended to have poorer treatment responses. Preston, O’Neal, and Talaga, (2001) see this as being consistent with observations that prolonged hallucinogen or stimulant abuse is associ­ated with incomplete clearing of mental status. Indicating some type of stimulate phe­nomena or toxic effect of psychosis and supports the need for prompt treatment with antipsychotic medications.

1.1.4.1. First Generation Antipsychotics

Today, there are two major classes of antipsychotic medication. The conventional an­tipsychotic medication, first used in the 1950’s, is referred to as typical or first genera­tion antipsychotics (Walker et al., 2004). The first and most prominent of the first gen­eration antipsychotic medications is Chlorpromazine (Thorazine). During the three decades following its inception, various other typical antipsychotics were also released and used in the treatment of schizophrenia and other psychotic disorders (Ninan, 1989). Most are given as tablets or syrup. Some, like zuclopenithixol, and flupenthixol are available as long-lasting depot injections (Marder, 1986). All of them are thought to reduce the dopamine activity by blocking dopamine receptors, especially the D2 sub­type, and all have a similar effect on the positive symptoms of schizophrenia. They differ only in their side-effect profiles (Preston, O’Neal, & Talaga, 2001).

The side effects induced by the first generation antipsychotics or, neuroleptics can be devastating for many individuals. In fact, many individuals with schizophrenia discon­tinue their medication because of the side effects (Wong, 2006). Most side effects are induced movement abnormalities that are both early and late emerging motor side ef­fects (Sadock & Sadock, 2000). The early emerging extrapyramidal syndromes include pseudoparkinsonism, dystonic reactions, and akathisia. The most common of the late emerging syndrome is tardive dyskinesia. What causes these side effects is not known, but it is assumed to be associated with excessive dopamine D2 receptor blockading since the motor symptoms typically decline following the discontinuation of medication.

1.1.4.2. 2 nd Generation Antipsychotics

Atypical antipsychotics, or the second-generation neuroleptics, are a relatively recent development in medication for people with schizophrenia. These include clozapine, risperidone, olanzapine, and quetiapine (Marder, 1986). Their side effects are milder than the first generation neuroleptics. The most commonly prescribed atypicals are risperidone and olanzapine (Wong, 2006). Although clozapine is particularly effective for people who have failed to respond to other neuroleptics, it is usually given as a last resort due to its link with a rare but potentially lethal side effect causing agranulocyto­sis. Physicians prescribing clozapine for their patients are required by law in most countries to monitor the patient’s blood. Other side effects induced by atypicals include weight gain, drowsiness, rapid heartbeat, and dizziness when changing position (Marder, 1986).

Several theories exist to explain why atypical antipsychotics are less likely than the typical antipsychotics to cause extrapyramidal side effects. The potency of the atypical, which block both dopamine D2 and serotonln 5-HT2A receptors, might be responsible. It has also been suggested that reduced serotonergic function in the brain, which can be achieved by blocking the 5-HT2A receptors, reduces extrapyramidal side effects (Richelson, 1999). Others have theorized that the unique action of the atypical antipsy­chotic derives from their low affinity for the dopamine D2 receptor. These drugs, com­pare to dopamine itself, are loosely bound to, and rapidly released from the dopamine D2 receptors, whereas the typical antipsychotics bind to the D2 receptors with greater affinity than dopamine (Seeman, 2002).

1.1.5. Psychological Treatment

Improved pharmacological treatments have allowed for greater engagement in and benefits from psychological interventions. Subsequently, reducing both the positive and negative symptoms of schizophrenia with modern antipsychotic medication has en­abled patients to contribute more to the process of their own rehabilitation through psychotherapeutic approaches (Hoffmann & Tompson, 2002). This improvement has helped clinicians utilize psychological interventions to help their patients reduce resid­ual symptoms, avoid symptom relapses, lessen life stress, create coping strategies and establish a greater quality of life (Falloon, 2002).

Although psychotherapy in general has long been associated with the nonsomatic treatment for schizophrenia, until recently little data was available to support its efficacy (Fenton, 2000). Dynamic forms of therapy have been described as being too investiga­tive, uncovering, analytical, or insight-oriented in nature. They have been associated in the past to negative research findings on their treatment effectiveness, this leading to recommendations for a moratorium on their use as a therapy for schizophrenia (Mue- ser & Berenbaum, 1990). Hogarty (2002) argues, however, that the recommendations were based more on the various problems in the design of the evaluative studies, than in the lack of effectiveness of psychotherapy. The studies were criticized for flaws in their choice of controls, high attrition, therapist experience, equivocal diagnoses, small samples, a failure to access tangible support or control for medication, and more im­portantly, their conceptual relevance of the study of therapy for schizophrenia. Other authors have suggested recent evidence-based credibility for therapies involving social skills training, a version of cognitive-behavioral therapy, as well as individual psycho­social approaches for clients with acute and severe forms of schizophrenia (Bellack, 1989; Bellack, Mueser, Gingerich, Agresta, 2004; Wong, 2006).

1.1.6. Cognitive Behavioral Therapy for Schizophrenia

Cognitive behavior therapy (CBT) for schizophrenia draws on Beck’s (1976) premises of cognitive therapy. In this version CBT is used to help psychotic patients deal directly with their symptoms. Whereby the patient and therapist identify specific psychotic symptoms such as hallucinations, and delusions and target them for intervention (Dickerson, 2000). The few published randomised controlled trials of CBT with schizo­phrenia patients indicate that it is effective in reducing hallucinations and delusions in medication - resistant patients, and as a complement to pharmacotherapy in acute psychosis (Bustillo et al., 2001).

In addressing the underlying theory, Beck (1979) explains that the way people feel and behave is determined by how they perceive and structure their experiences. CBT is understood as an insight-oriented therapy, and emphasizes the recognition of, and the changing of negative thoughts and maladaptive beliefs. Fundamentally, the cognitive development of emotional problems contains (1) automatic thoughts, (2) intermediate beliefs, and (3) core beliefs (Beck, 1995). Automatic thoughts are seen as reflexive self-statements or images that individuals involuntarily experience throughout life. They can be distorted from reality, and are then classified under different types of cognitive distortions such as absolutist thoughts, arbitrary inferences, and overgeneralizations (Wong, 2006). Basically, an individual experiencing negative automatic thoughts mis­understands a situation and negatively distorts the reality of the situation. How this can come about is strongly influenced by the person’s schema that includes both interme­diate beliefs and core beliefs. Intermediate beliefs are rules, assumptions, and atti­tudes a person holds. Core beliefs are a person’s underlying, foundational beliefs that influence both intermediate beliefs and automatic thoughts (Tarrier & Haddock, 2002). Wong (2006) offers an example, of a person’s appraisal of himself or herself as inade­quate, and possibly holding such rules and assumptions as "Whatever I have accom­plished is because someone else has made it possible" and "No matter how hard I try, I can never make it" (p. 37). These are examples of intermediate beliefs that may lead to experiencing various types of cognitive distortions, or automatic thoughts. According to Beck (1995), core beliefs influence a person’s intermediate beliefs and automatic thoughts.

Tarrier (2001) states that the initial influences on the development of CBT for psycho­sis and schizophrenia were based on the theoretical mechanisms thought fundamental to coping strategies. Focusing on the idea that coping is the process of appraisal in which the person evaluates a set of circumstances or experiences as being a problem, then attempts to cope with these, and subsequently evaluates the relative success of the attempt. The beliefs that people with schizophrenia have about their symptoms and the appraisal of these symptoms are important factors in determining how well they cope and whether they will keep trying to cope (Kinney, 2000). This is based on the widely recognized idea that the use of personal resources such as coping strategies is important in buffering against psychotic symptoms (Tarrier & Haddock, 2002), and is found aligned with the vulnerability - stress model of psychosis, that perceives coping and self-efficacy as important personal protective factors (Nuechterlein, 1987). Re­search in CBT for schizophrenia has provided consistent findings that patients with the disorder do attempt to overcome or cope with relentless positive psychotic symptoms, with at least some success (Breier &Strauss, 1983; Brenner et al., 1987; Carr, 1988; Cohen & Berk, 1985, Falloon & Talbot, 1981; Kinney, 2000; Romme & Escher, 1989; Tarrier, 1987). Consequently, since a number of patients used coping strategies, it was naturally thought that they would, through CBT, further benefit from the systematic training in coping skills combined with stimulating an awareness of the background and context of their symptoms (Tarrier & Haddock, 2002).

However, CBT has been criticized in that it is not applicable for many of the people with severe and persistent forms of schizophrenia, since many of these people do not possess the needed level of cognitive competence required for this type of interven­tion. It has been seen that these individuals quite often do not understand or have diffi­culty in self-examining their own cognitive processes. Moreover, people who are beset with emotions do not seem to benefit from a cognitive therapy because they have an immediate need to deal with their emotional and not their cognitive problems (Wong, 2006).

1.1.7. Family Therapy - Psychoeducation

Bustillo et al. (2001), in a meta-analysis of research literature reported that a growing amount of research supports the use of family therapy with psychoeducation and be­havioural components. Although not a direct intervention involving only the client diag­nosed with schizophrenia, but an intervention also dealing directly with the client’s fam­ily or social support system. This type of psychoeducation not only provides family members with basic information about the illness and its consequences, it also teaches the family members (and patient) about the nature of the illness and its probable causes, its major symptoms and, of course, the importance of medication and the na­ture of the side effects, the role of the family in relapse (e.g. expressed emotion, EE) and relapse prevention, and other similar factors. It intends to recruit the family to help in the treatment/recovery process by reducing stress in the family and any negative feelings towards the patient (Goldstein et al., 1978; Hogarty et al., 1986; Leff et al., 1982). Other family psychoeducational approaches attempt to alter family interactions more directly by teaching the family communication and problem-solving skills. In addi­tion to didactic psychoeducation, this approach places great emphasis on modelling, role-playing, and repeated practice of new behaviors. The treatment is also conducted invivo, which enhances the participation of more family members (Falloon et al., 1982).

Bustillo et al. (2001), claim that these kinds of family therapies reduce caregiver bur­den and improve the family members ability to cope and provide knowledge about schizophrenia, thus reducing the risk of relapse for individuals with schizophrenia.

1.1.8. Community Support System

Ever since the psychiatric deinstitutionalization of the 1960’s and 1970’s in developed countries, these countries have introduced various types of community based mental health programs for persons with mental illness (Bellack, 1989; Wong, 2006). The in­ception of these programs was based on the notion that in-vivo training in community living is a better treatment modality for persons with mental illness than hospital care (Test & Stein, 2000). Resulting in the realization that many people with schizophrenia will need help in every aspect of their lives. In this regard, people with schizophrenia have been shown to need help in understanding their illness, taking their medication regularly, avoiding relapse, finding jobs, housing, and medical care, and responding to situations that most people manage with ease. They need to avoid both unreasonable hopes, and unwarranted fears, and become used to a way of life that makes demands without condemning them to demoralizing isolation and neglect. They require individual help to determine what is protective and what is empowering for greater independence (Harvard Mental Health Letter, 2001). This experience has lead to the development of community mental health systems offering an array of services including; assertive outreach, psychiatric crisis assessment and treatment teams, halfway houses, small group homes, supervised individual living, rehabilitative and sheltered employment (Test & Stein, 2000).

In particular, community mental health models of care for the individual with schizo­phrenia are based on the understanding that schizophrenia is typically a multiply handi­capping, lifelong disorder (Strauss & Carpenter, 1981). The majority of these clients will have residual handicaps even when the primary symptoms are under control. As many as one third will have only a minimal recovery and will remain substantially dys­functional for their entire lives. Most will remain dependent on community mental health care and in the social services systems throughout their lives (Bellack, 1989). Treat­ment is therefore long-term and provided for in a multiple services system of care. The treatment goals include the management of medication, finances, and symptoms, teaching living and coping skills, and enhancing the client’s quality of life (Schooler & Spohn, 1982). Treatment models are no longer based on an infectious disease model of illness, in which treatment is viewed as a short-term process dealing with a tempo­rary disturbance, but on a chronic illness model that is multidimensional, multidiscipli­nary, and has a long-term focus on the management of symptoms and disabilities (Bel- lack, 1989).

1.1.8.1. Case Management

Accessing treatment is a difficult feat for the person impaired with schizophrenia (Sur- ber, 1994). Case management services have thus been developed in response to this fragmentation of psychiatric care and the need to coordinate services (Rossler, et al., 1995; Jinnett, 2001). Although called differently in various countries, case manage­ment services are found in the USA, Canada and Hong Kong (Wong, 2006; Rapp, 2006; Floersch, 2002; Surber, 1994). They are called key workers and approved men­tal health social workers in the UK (Samele & Murray, 2001) and Bezugsbetreuer in Germany (Kauder - Aktion Psychisch Kranke, 1999). These services are considered basic services in the modern community mental health service delivery system. Inta- gliata (1982) identified some of the main components of case management, including assessment of needs, planning comprehensive services, arranging delivery of ser­vices, monitoring and assessing those services, evaluation and follow-up. The main objective is to enhance the continuity of care and its accessibility, accountability and efficiency. Despite this clarity of purpose, case management approaches are enor­mously varied and confusing (Bachrach, 1989).

There are two main models of case management: the service brokerage model and the clinical case management model (Holloway, 1991). The case manager using the brokerage model is usually an office-based administrator with no health or social ser­vice background. They act as an enabler, systems coordinator, a broker of services that direct activities and interventions to the client’s environment. Even though these activities are important in service delivery, the brokerage model is focused on systema­tizing service and is impersonal. It minimizes the uniqueness of the complex needs of a client. It overlooks the importance of the case manager/client relationship, where service provision includes a therapeutic dimension (Balancio, 1994). Controlled studies of the brokerage model, have confirmed it is of limited use and value to persons with schizophrenia (Franklin, et al., 1987; Curtis, et al., 1992).

1.1.8.2. Clinical Case Management

In contrast, the clinical case management model deals with all aspects of the client's physical and social environment including; housing, psychiatric treatment, general health care, social welfare and pension payments, transportation, families and social networks (Kanter, 1989). It also includes interventions in the client’s environment, with the client in his /her environment when the client is unable to satisfy his or her own needs in their environment. The clinical case manager uses both clinical skills and bro­kering or resource management skills in dealing with the client’s environment (Balan- cio, 1994). In this, Kanter (1989) defines clinical case management as a, "process of providing comprehensive treatment to individuals with severe mental illness who either at some stage of their illness or over a long period of time, are unable to function autonomously. It is a treatment modality that inte­grates psychological treatment, medication, psychosocial rehabilitation, and environmental support" (p. 4).

Most models of clinical case management with the seriously mentally ill are based on three principles: firstly, a view that clients are a heterogeneous group of individuals struggling with a debilitating illness in a context unique them, secondly, the employ­ment of a broad definition of what is therapeutic, implying that the care and treatment for this client group integrates a wide and varied interventional approach, thirdly, the provisions for care and treatment are relied upon and dependent on the clinician/client relationship (Watson, 1983, 1987; in Surber, 1994).

1.2. High Service Users with Poor Illness Insight

There is no gold standard to determine what high service use is in mental health care. Implied in the label "high service user” is the frequency of psychiatric rehospitalization. For around a third of the people with schizophrenia this means on average rehospitali­zation of 2 times per year (Amador & Kronengold, 2004). High service users have been variously defined as individuals with more than one hospitalization in a 4, 6, or 12 month period (Ellison, et al., 1989). But whatever the standard is, most of the those termed high service users have been diagnosed with schizophrenia (Spooren, et al., 1997; Sullivan, et al., 1993; Dhossche & Ghani, 1998), and have a history of previous hospitalization (Arfken, et al., 2004; Spooren, et al., 1997), a need for medication (Ar- fken, et al., 2004), and lack social support or are homeless (Arfken, et al., 2004; Saar- ento et al., 1998; Dhossche & Ghani, 1998).

1.2.1. Non-compliance with Medication

Non-compliance or the nonadherence to antipsychotic medications is a common prob­lem in the clinical management of schizophrenia (Surber, 1994; Wong, 2006). Com­pared to those patients or clients who are compliant, those who are non-compliant have a greater risk of re-experiencing symptoms (Robinson, et al., 1999), psychiatric rehospitalization (Svarstad et al., 2001) homelessness (Drake et al., 1991; Opler et al., 1994), and violence (Swanson et al., 2000). The primary reason for non-compliancy is attributed to the lack of insight or the unawareness of having a mental illness (Loffler et al., 2003; Smith et al., 1999).

1.2.2. Improving Insight and Compliance with Medication

Research is in the beginning stages of developing effective interventions to improve insight and treatment compliance. In a recent study involving controlled trials, a brief cognitive intervention showed improvement in insight into illness and reduced symptom severity when compared with the standard form of treatment (Turkington et al., 2002). A trial with compliancy therapy, a form of cognitive behavioral therapy, reported im­proved medication compliancy in a mixed sample of psychotic patients. The same re­sults were not substantiated when the sample was limited to patients with schizophre­nia (Kemp et al., 1996; Kemp et al., 1998; O’Donnell et al., 2003). Psychoeducation has been shown to have little effect on insight (Pekkala & Merinder, 2002) or compli­ancy (Zygmunt et al., 2002).

The unawareness of illness leading to treatment non-compliance, rehospitalization or high service use is widespread among clients with schizophrenia. Psychological ap­proaches aimed to improve insight and medication compliancy have thus far not proven to be effective. Family psychoeducational approaches, and daily professional contact supervising medication intake appear to be more effective (Olfson et al., 2006).

2. Review of the Research Literature

2.1. Illness Insight in Schizophrenia

Illness insight has been gaining importance in schizophrenia research. Studies have investigated the phenomenology, psychology, neuropsychology, as well as the cultural and societal views of insight. These studies have presented the scientific community with a range of new knowledge and explanations about illness insight in schizophrenia (Amador, & Kronengold, 2004).

2.1.1. The Importance of Insight in the Study of Schizophrenia

In an overview of the importance for the study of insight in schizophrenia, McGorry, and McConville (2000) reported „Severely impaired insight is regarded as a defining characteristic of psychotic disorders, at least in certain phases of the illness, and pro­moting insight is viewed as an important goal of treatment” (p.1). Almost one-third of those diagnosed with schizophrenia will deny being ill or appear to be unaware of their mental illness (Amador et al., 1994; Carpenter et al., 1973). The World Health Organi­zations’ pilot study of schizophrenia reported the lack of insight assessed by the ser­vice providers was so common that it considered insight a hallmark of schizophrenia (ibid). Similarly, others found people with schizophrenia lacking the awareness of their illness are more likely to be noncompliant with medication treatment (Amador & Strauss, 1993; Bartko et al., 1988; Lin et al., 1979; McEvoy et al., 1989a; Nageotte et al., 1997) and not seek help for their mental health problems (Koegel et al., 1999; Sul­livan et al., 2000) that consequently lead them to inadequate or no treatment, and a high rate of rehospitalization (Heinrichs et al., 1985; Kent & Yellowless, 1994; McEvoy et al., 1989b). Accordingly, the awareness of illness in schizophrenia is an important clinical factor because the lack of illness awareness may increase the demand for more expensive inpatient services and therefore increase overall healthcare cost (Pyne et al., 2001).

2.1.2. Defining Insight

A major challenge to empirical studies on insight has been the absence of a universally accepted definition of insight and the means to assess it. Traditional psychoanalytical oriented definitions have focused on two distinct types of insight: intellectual insight (referring to a person’s capacity to identify how conflicts and developmental issues relate to psychiatric symptoms), and emotional insight (referring to the more profound capacity to achieve a „therapeutic effective understanding” of unconscious motivations and conflicts and their relationship to change; David, 1990; Martin, 1952; Richfield, 1954; Zilboorg, 1952). Dynamic definitions regard insight as a defense mechanism or coping strategy used to avoid dealing with the difficult realization of being mentally ill (McGlashan et al., 1976). Others have simply used a broader notion of insight, stress­ing merely an importance of someone believing he or she has a mental disorder, as reflected by its use during mental status examinations in the recording of either good insight” or „poor insight”(Goldberg, Greene-Paden, Lehman, Gold, 2001).

The Webster’s New World Dictionary defines insight as „The ability to see and under­stand clearly the inner nature of things; intuition. And a clear understanding of the inner nature of some specific thing" (p. 389). The Random House Dictionary of the English Language offers another, although similar definition in defining insight as „The recogni­tion of sources of emotional difficulty ... an understanding of the motivational forces behind one’s actions, thoughts, or behavior" (pp. 986-987). While not addressing the illness of schizophrenia, both of these English language definitions connote a psycho­logical understanding of the phenomenon of insight. Implying a persons’ ability of cog­nizant self-introspection, or being able to recognize something internally that one can­not see or touch (Berrios & Markova, 2004).

2.1.3. Cognitive Psychological Approach to Insight or the Unaware­ness of Illness:

The cognitive psychology approach to defining insight differentiates between cognitive insight and clinical insight (Beck & Warman, 2004). Defining clinical insightlessness as the patients’ „limited capacity to evaluate their anomalous experiences and their cogni­tive distortions" (ibid. p. 79). Which can better be explained as the patient’s inability to self corrects specific misinterpretations or be responsive to corrective feedback. This inability is thought to contribute to the development of delusions and the impairment seen in clinical insight. Ultimately leading to designating the lack of awareness in a mental illness and the needing of treatment as, „clinical insight”. Clinical insight fo­cuses on those areas of clinical phenomenology thought necessary for diagnosis and pharmacological treatment.

Beck and Warman, (2004) explain cognitive insight as the second level of cognitive appraisal dealing with the distancing from and the re-evaluating of distorted beliefs and misinterpretations. The higher or upper level cognitive process, metacognition, is the patient’s ability to recognize his/her misinterpretations and still be able to re-evaluate them.

For the cognitive model, impaired insight plays a significant role in the formation and maintenance of psychopathology. If the anomalous beliefs are intense enough to sup­plant the normal reality testing that is already diluted in psychosis, accordingly, the patient that intensely believes that his/her abnormal experience originates from an ex­ternal source has to rely on their impaired recognition of the deviant features of their experience. For the cognitive model it is highly important to which degree the anoma­lous beliefs influence the misinterpretations of the progressive experience and envi­ronmental interactions. It stresses the importance of characteristics like that of the prominence of certain misinterpretations, their regularity, their extent of conviction, and their resistance to corrective feedback (Tarrier & Haddock, 2002). In this it is thought in how intensely the patient perceives and experiences these misinterpretations is more important to the patient’s well-being and social adjustment than the schizophrenic symptom itself. Stressing, to what extent the patient beliefs corrupt the information processing and the patient’s ability to see the resulting cognitive products (interpreta­tion, predictions, doubts, etc.) objectively (ibid). Then some patients have the ability to agree with an illness explanation for their symptoms, and find the explanation sensible, or intellectual insight, but not necessarily resulting in any meaningful change in their fundamental belief system, or cognitive insight (Beck & Rector, 2003).

The key cognitive problem for patients with schizophrenia is not only persistent symp­toms distorting their experiencing of reality, but their relative inability to detach them­selves from those distortions and their relative resistance to corrective feedback. In contrast, those with non-psychotic illnesses such as depression or panic disorders also misinterpret events. The depressive patient for example, may misinterpret, or over in­terpret social interaction as a sign of rejection and personal inadequacy (Beck et al., 1979). Patients experiencing a panic disorder might misinterpret physical sensations as a sign of a serious disease (Beck & Emery, 1985). Still both the depression and panic disorder patients retain their ability to reflect on their experiences and to recog­nize that they were incorrect. Whereas this ability is to various extents seriously im­paired in schizophrenia. Components of this deficiency relative to schizophrenia are described by Beck and Warman (2004) as an "impairment of objectivity about the cog­nitive distortions, loss of ability to put these into perspective, resistance to corrective information from others, and overconfidence in conclusions" (p. 80).

The deficiencies described in either clinical or cognitive insight for individuals experi­encing schizophrenia are not absolute. Beck and Warman (2004) further state that these patients do have a limited ability in the process of cognitive correction. Suggest­ing the testing of the patients potential for cognitive insight might be found exploring the patient’s ability to test and correct misinterpretations not involving delusions or hal­lucinations. In this regard they recommend testing simple everyday prejudices reflect­ing those prejudices proven wrong. In this manner it is possible to strengthen a number of the cognitive domains involved in the individual’s appraisal of their experiences. In this sense, suggesting it is possible to influence the patient’s illness insight to improve outcome (Jolley & Garety, 2004).

2.1.3.1. Medical Science Understanding of Insight

Berrios & Markova (2004), report that a medical understanding of insight, including its derivatives; insightlessness, loss of awareness of illness or incapacity to gain it in the first place, has historically been, and still is very difficult to find. They criticize medical science for not being able to come close to a consensual definition. They find this sur­prising in contrast with the wide agreement in medical science of convergence in the meaning of delusion and other symptoms of psychosis. In this regard the medical sci­entific community has yet to agree on the meaning of insight in psychosis, and is still struggling to agree on a definition converging the meaning of the word, concept, and behavior in a medical understanding of what insight and its derivatives represent (Ber­rios & Markova, 2004).

Although without a universally accepted definition, current medical science describes insight by referring to the concept of a person’s particular state of mind evident from the person’s speech and behavior (Berrios & Markova, 2004). Both psychiatry and psy­chology use various terms to describe the behavior exhibited by the patient lacking illness insight. "Poor insight", "sealing over", "defensive denial", "attitude of illness", "indifference reaction", "evasion", and "external attribution" all are terms based on dif­ferent biomedical or psychological theoretical conceptualizations. Describing the lack of illness insight as ranging in terms from a psychological defense to a cognitive deficit. All these terms correspond to the various conceptual orientations of the authors in­volved in the research efforts. For example the cognitive psychologist will study the underlying etiological basis of insightlessness by examining external attributions (Wciorka, 1988), while the psychodynamic theorist study defense mechanisms (Schwartz, 1998).

2.1.3.2. Neuropsychology of Insight

Neurologist have for over a century been describing the struggle many patients have with motor abilities, vision, language, and various cognitive functions while utterly un aware of their impairments (Babinski, 1914; Wernicke, 1900; Kleist, 1960). In studying awareness impairment disorders modern neuroscience utilizes a range of methodol­ogy. Ranging from the least invasive but imprecise inferential methods of neuropsy­chology, to the recent advancements in new technologies such as the positron emis­sion tomography (PET) scans and the functional magnetic resonance imaging (fMRI). Enabling the neurosciences to study less invasively the biological derivation of such mental phenomena as emotion, memory, and levels of consciousness. The growing use of these advance technologies contributes to increasing the human sciences’ comprehensive and advanced understanding of how the brain functions through active brain exploration, and offers new explanations on the subjective phenomenon called the mind (Applegate & Shapiro, 2005).

As a result of this combined research, neuropsychology considers unawareness of impairment, regardless if the etiology is psychiatric or neurological, to be a phenomena of effects from focal or diffuse brain dysfunction, or psychological defense mecha­nisms preventing these symptoms from consciousness (Lar0i et al., 2004). It specifi­cally implies frontal lobe dysfunction in unawareness of illness in schizophrenia and in neurological awareness disorders. An implication that has been partly supported by research from other neuroscientific disciplines using modern diagnostic technologies and reporting frontal and pre - frontal areas of the cortex as being primary areas of dysfunction in schizophrenia as in neurological awareness disorders (Devous et al., 1985; Rubin et al., 1991; Raine et al., 1992; Seidman et al., 1994). These implications have lead researchers from other disciplines studying the supporting mechanisms of unawareness in schizophrenia to look closer at neuropsychological theories and mod­els of awareness disorders (David, 1990; Amador et al., 1991).

2.1.3.2.1. Neurobehavioral

Research by Stuss and Benson (1986) lead to their neurobehavioral theoretical con­cept describing the role of the frontal lobes in awareness disorders. Conceiving of a hierarchical model of frontal lobe functioning that considers self-awareness a mecha­nism at the highest level of activity. In this model individuals are thought to monitor their overall brain functioning and environmental interaction using this self-awareness mechanism. Although Stuss and Benson (ibid) do not perceive the self-awareness mechanism as being part of the other frontal executive functions involved in planning and sequencing complex behaviors. According to them the frontal lobe functions are responsible for directing more basic fixed functional systems that are located in the posterior/basal brain regions. These regions include cognitive processes similar to at­tention, memory, language, and perception (Stuss & Benson, 1987). Adding to this, Lar0i et al., (2004) suggested that neurological conditions like that of anosognosia might be a result of disturbances in the relationship between the self-awareness sys­tem and a number of posterior/basal operations.

In view of the disturbances in the self-awareness system that may lead to the neuro­logical condition of anosognosia, the majority of the neuropsychological theories of awareness disturbances are seen as having a relationship to a theoretically conceived error monitoring system (Goldberg & Barr, 1991). The error monitoring systems proc­ess is thought to have three fundamental components: (1) „An internal representation of a desired output; (2) feedback regarding the output; and (3) a comparison between the desired output and feedback regarding the actual output” (Goldberg & Barr, 1991; cited in Lar0i et al., 2004 p. 145). These same three components are seen exploited in understanding the mechanism fundamental to the awareness of neurological deficits. Goldberg and Barr (ibid) suggested that a failure in any one or in any combination of each of the three components might be the cause of the various types of awareness disturbances. In this regard, Goldberg and Barr, (ibid) report that a majority of the „neuropsychological theories of awareness are attributed either implicitly or explicitly to disturbance in one or more components of this three stage mechanism” (p.145). As such, this three stage mechanism may correspond to the "intention" and "monitoring" systems seen important in the Frith cybernetic model that have been studied in direct reference to variety of behavioural phenomena and manifestations of a range of symp­toms associated with schizophrenia. In this model, self-awareness plays a major role, and understands schizophrenia as a disturbance in metarepresentation, and sees metarepresentation as central to awareness (Frith, 1992).

2.1.3.2.2. Summary

Overall, the neuropsychological research findings suggest that unawareness of illness in psychosis is caused by the abnormality of the prefrontal and parietal cortices and involving cortical and subcortical neural pathways. These findings have been substan­tiated in part by the emergence of functional neuroimaging studies that have been to date limited in their studies of unawareness in healthy adults (Flashman & Roth, 2004). Amador et al., (1991) draw support from the body of related neurological research for their hypothesis presented in 1991: i.e., "that in those schizophrenia patients with se­vere and persistent unawareness of illness, the lack of insight is a symptom of the dis­order stemming from neurological deficit" (p. 25).

In the last revision of the Diagnostical Statistical Manuel states in the schizophrenia and related disorders section of the DSM IV-TR (American Psychiatric Association Press, 2000, p.304):

"A majority of individuals with schizophrenia lack insight regarding the fact that they have a psychotic illness. Evidence suggest that poor insight is a manifestation of the illness itself, rather than a coping strategy. It may be comparable to the lack of awareness of neurological deficits seen in stroke, termed anosognosia. This symptom predisposes the individual to noncompli­ance with treatment and has been found to be predictive of ... increased number of involuntary hospital admissions, poorer psychosocial functioning, and a poorer course of illness" (cited p. 25 by Amador & Kronengold, 2004).

Amador and Kronengold (2004) argue that unawareness of illness in schizophrenia can be seen separately as both a neurological deficit and a psychological defense that may involve various coping strategies. Moreover, they content that just as the diagnos­tic criteria for „delusion” is a false belief that persist over time despite evidence to the contrary, "the time has come to label unawareness that is severe, persist over time despite evidence to the contrary and is associated with cognitive deficits, anosognosia. In other words, patients with such severe deficits in insight should be diagnosed as having anosognosia for schizophrenia" (p. 26).

2.1.3.3. Cultural and Social Perspectives of Insight

Determining insight in a schizophrenic illness solely on the basis of the awareness of illness, the awareness that psychotic symptoms are abnormal, and the acceptance of prescribed treatment, can be seen as ignoring the social and cultural determinants of insight. Neglecting the social and cultural aspects of insight, presents mental health professionals, and psychiatry in particular with an incomplete diagnostic picture of the patient. Then taking into account the patients culture, ethnicity, religion (or beliefs), gender, education, and social class is an important dimension in how the patient inter­prets their psychotic symptom and illness (Kirmayer et al., 2004). Considering this as­pect of illness insight provides the mental health professional with a more complete, or a holistic biopsychosocial illness diagnosis, lending to a more accurate assessment of the patients level of illness unawareness (ibid).

2.1.3.3.1. Stigma of Illness

Disagreeing with the view that insight reflects illness awareness and medication com­pliance. Johnson and Orrell (1995) suggest that the negative stigma of having a men­tal illness, prevalent in most cultures and societies, is the reason for most denial of illness. The stigma of a mental illness causes individuals with schizophrenia to deny many of their symptoms in an attempt to protect their social status and community rela­tionships. From this perspective, these individuals express insightlessness of the medical explanation of their illness because their social status and social relationships are more important for them. Which can be understood as an example of a social cop­ing strategy in support of the theory defining poor insight as a psychological defense.

2.1.3.3.2. Cultural Construction

Schizophrenic symptoms can be seen as socially and culturally representative. The cognitive realization of symptoms as something anomalous involves a series of attribu­tions that give them some kind of meaning (Beck & Warman, 2004). But finding the meaning of the attribution is not found in isolation. It is found in association with other meanings in the extended social and cultural environmental network that influences the perception of the meaning that is attributed to being an illness in a given culture (Corin et al., 1993; Good & Good, 1980; Kirmayer, 1989). Bowers (1974) describes, "ac­counts of the onset of psychosis reveal a situation of chaos and confusion, where the crucial question for the person and his or her entourage is what interpretations are at hand to organize experience" (p. 204 cited by Kirmayer et al., 2004). The ability to la­bel those initial confusing feelings as a symptom of an illness is only possible after searching for cultural attributional meanings in the immediate social environment. Many ethnic minorities may have for example some very different views and under­standings for what accounts for schizophrenia. Carter (2002) compares this to what is seen in some African-American communities that frequently use religious or super­natural explanations for symptoms of schizophrenia and other psychotic illnesses. Others living in more modern secular societies use perhaps magical applications of technology like radio waves, lasers, and microelectronics to explain their symptoms. Still, there are others who accept explanations from professional sources in their com­munity, but in each case there is a representation of cultural conceptions (Kirmayer et al., 2004).

Some cultural conceptions of mental illness represent beliefs and practices not neces­sarily in agreement with general psychiatric theory and practice. They may even dis­courage the use of standard psychiatric treatment. But, by disregarding these beliefs and practices, and counting them as an indication of poor insight, a mental health prac­titioner not only would be devaluing the patient, but also would have an inaccurate di­agnosis, and be jeopardizing the development of a therapeutic alliance and the possi­bility of treatment (ibid).

[...]

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^[1] Vivantes Psychiatric Outpatient Clinic in Berlin, Spandau.