Insight and Psychosis: Awareness of Illness in Schizophrenia and Related Disorders PDF
Preview Insight and Psychosis: Awareness of Illness in Schizophrenia and Related Disorders
Amad_Fm.qxd 21/6/04 10:55 AM Page i Insight and Psychosis Amad_Fm.qxd 21/6/04 10:55 AM Page ii This page intentionally left blank Amad_Fm.qxd 21/6/04 10:55 AM Page iii Insight and Psychosis Awareness of illness in schizophrenia and related disorders SECOND EDITION Edited by Xavier F. Amador Columbia University, Teachers College and the National Alliance for the Mentally Ill, Arlington VA, USA and Anthony S. David Institute of Psychiatry, King’s College, London, UK 1 Amad_Fm.qxd 21/6/04 10:55 AM Page iv 1 Great Clarendon Street,Oxford OX2 6DP Oxford University Press is a department ofthe University ofOxford. It furthers the University’s objective ofexcellence in research,scholarship, and education by publishing worldwide in Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dar es Salaam Delhi Hong Kong Istanbul Karachi Kolkata Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi São Paulo Shanghai Taipei Tokyo Toronto Oxford is a registered trade mark ofOxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc.,New York © Oxford University Press,2004 The moral rights ofthe authors have been asserted Database right Oxford University Press (maker) First published 2004 All rights reserved.No part ofthis publication may be reproduced, stored in a retrieval system,or transmitted,in any form or by any means, without the prior permission in writing ofOxford University Press, or as expressly permitted by law,or under terms agreed with the appropriate reprographics rights organization.Enquiries concerning reproduction outside the scope ofthe above should be sent to the Rights Department, Oxford University Press,at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer A catalogue record for this title is available from the British Library ISBN 0 19 852568 0 (Pbk) 10 9 8 7 6 5 4 3 2 1 Typeset by Newgen Imaging Systems (P) Ltd., Printed in Great Britain on acid-free paper by Biddles Ltd.,King’s Lynn Amad_Fm.qxd 21/6/04 10:55 AM Page v Preface It has been over 12 years since we first conceived the idea ofcollecting together articles on the topic ofinsight in serious mental disorders,and 6 years since the first edition of Insight and Psychosiswas published.We could not have predicted the speed with which the field has developed and the breadth and diversity ofthe issues it has encompassed. Like most first-time projects the immediate satisfaction ofcontemplating the finished article was soon tempered by a growing awareness that things could have been done better,and that several areas were insufficiently covered or even omitted altogether.This awareness was sufficient to prompt us to plan a second edition and we were pleasantly surprised to learn that our publishers at Oxford University Press shared our vision.As well as consolidating the knowledge summarized in the first edition,there were three main areas that we felt this new edition should seek to address. The first is the now substantial body ofresearch literature on neuropsychological studies involving insight and indeed the more general application oftechniques from the cognitive neurosciences to this previously thought esoteric topic within psy- chopathology.The second main area concerns clinical relevance.Some critics ofthe concept ofinsight have drawn attention to this matter,which has served as a stimulus to us and others in the field.What is the point ofattempting to understand someaspect of psychopathology if,in the end,it makes no difference to the lives of the people weare caring for? The third,though related aspect was to broaden out the “stake- holders”who could contribute to the debate and discussion on the sort oftopics we chose to cover in the book.There has been a quiet revolution in both the theoretical and practical aspects ofmental health care,namely the rise ofthe consumer movement in the US,or “user movement”as it is called in the UK.This is particularly apposite in discussions ofinsight.Notions ofinsight have been caricatured as merely “agreeing with the doctor”,thus neglecting the validity ofother perspectives,particularly those of the individual labelled as the patient.So not only is the consumer voice relevant in this area as in all area ofmental health,it is actually central to our concept ofwhat consti- tutes insight into the psychoses. As mentioned,the publishers were very supportive ofthis new edition,but did lay down certain constraints.They advised that the second edition should be substantially newin comparison to the first,with brand new chapters and updates on all “old”chapters. So far so good.However,they also insisted that the total length ofthe second edition should not exceed,by too great a margin,that ofthe first.Inevitably this meant that certain chapters had to go to make room for new ones.The decisions on how this was to be effected were difficult and complex,although in most cases they were made for us by the contributors themselves,invariably driven by pressures ofwork and other commitments. Amad_Fm.qxd 21/6/04 10:55 AM Page vi vi PREFACE Before going through the contents ofthe second edition,we should start with noting that we have a new sub-title:“Awareness ofillness in schizophrenia and related disor- ders”.This is because the term insight is still subject to many different definitions and we did not want to lose potentially interested readers through a misunderstanding of the nature ofthe contents ofthe book.Furthermore,we have found that the term “psy- chosis”is generally falling out offavour in North American psychiatry,while it is still regarded as useful as a broad class ofdisorder in Europe and other parts ofthe world. Hence,as a compromise the sub-title serves to emphasize the breadth and scope ofthe clinical conditions we wish to discuss within the book,but also to underline the centrality ofschizophrenia in these discussions.Presumably ifwe ever get to a third edition we may have to broaden the remit to take account ofresearch and activity in other areas of psychiatry and neurology. The first chapter is by Amador and Kronengold.This again outlines,in more detail, the issue ofdescription and definition ofthe term insight in its different guises.Since the first edition there are now a number ofsemi-structured interviews,rating scales and other research instruments for researchers to choose from.Indeed,there is a suffi- cient array ofassessment instruments that a cool and objective assessment ofthe rela- tive strengths and weaknesses ofeach ofthese is long overdue.The conceptual history ofinsight and psychosis is,paradoxically,an area which continues to evolve.And the old adage regarding those who fail to acknowledge history being condemned to repeat it is as true in this context as any other.The same could be said for the philosophical interrogation that Bill Fulford gives insight in this new edition.Professor Fulford makes explicit his debt to German psychopathologists,Jaspers and Kraepelin,as well as British philosopher J.L.Austin. We are delighted to include in this new edition a chapter from the doyen ofcognitive approaches to psychopathology,Tim Beck.In his chapter (co-authored with Debbie Warman) we see how Beck’s immense clinical experience allows him to tease out the mechanisms underlying the appreciation and acceptance ofpsychotic symptoms in a way that has previously revolutionized the field ofaffective disorders.For Beck this represents, in some ways,a return to familiar territory,since his very first and tentative steps into what became cognitive therapy back in the 1950s (Beck,1952).Suzanne Jolley and Philippa Garety have developed a cognitive approach,which at least implicitly owes much to thinkers such as Beck.In this completely rewritten chapter on delusions they add an important review ofa range oftheories from social psychology,which forms the basis ofa new appraisal ofdelusional thinking.In particular,it is situated within a continuum model ofthe normal psychology ofbeliefand attribution.Whatever the rights or wrongs ofthis theoretical position,there is no doubt that it paves the way for psychological approaches to treatment which might have seemed hopeless and misguided merely a decade ago. One area that was perhaps neglected in the first edition was a full discussion of insight in affective disorders.This problem has been remedied by a brand new chapter from Ghaemi and Rosenquist.Nassir Ghaemi and colleagues have led an important Amad_Fm.qxd 21/6/04 10:55 AM Page vii PREFACE vii conceptual attack on insight and awareness in relation to mood,and his group is undoubtedly most influential in this regard.The authors combine both a quantitative meta-analytic approach to the published work in this field as well as a particularly enlightening philosophical stance to the existential dilemma ofself-knowledge. The second section ofthis edition ofInsight and Psychosisdeals with neuropsychology. This includes the study of people with neurological or neurobehavioral disorders whohave difficulties in the area ofinsight and awareness,a neurological approach to similar difficulties in people with so-called functional disorders,as well as a discussion of the application of neuroscientific tools,particularly neuroimaging in the under- standing ofinsight.The previous edition had two companion chapters by Bill Barr and Richard Keefe,which,in the interests ofhealthy integration and economy,we felt could be usefully combined into a single overarching essay.Frank Larøi was able to do this with the original authors’help,as well as bringing his own fresh perspective into this important aspect ofinsight research.Laura Flashman and Robert Roth,who have a background in neuropsychiatry,review neuroimaging work,particularly structural MRI,which has been employed to study people with schizophrenic disorders.They have then tried to relate measures ofbrain structure to various metrics applied to the insight concept.Flashman and colleagues have contributed original work to this field, which is bound to expand further in the coming years and will probably include more functionalneuroimaging studies in the not too distant future.Perhaps the biggest explosion in terms ofpublished research in this field has been in neuropsychological studies examining general and specific cognitive functions in people with psychotic disorders in relation to insight.Although the idea that insight in psychosis might be analogous to a neuropsychological deficit,perhaps of frontal lobe functioning,has been around at least since Aubrey Lewis’s review in 1934,it was with landmark studies in the early 1990s that the field really took off.For example,Young and colleagues (Young et al.,1993) found a correlation between various measures from the Wisconsin Card Sorting test,a classical executive function test,and a measure ofinsight derived from Amador’s scale for the assessment ofunawareness ofmental disorder.There have now been over 30 studies ofthis kind,which have been systematically reviewed and summarized by Morgan and David in another new addition to this volume. In part three we look at the wider aspects and implications ofinsight.Again,critics ofsome formulations ofinsight see it as ignoring important cultural and sociological influences.Laurence Kirmayer and colleagues have refined their previous chapter and show how an anthropological perspective allows constructive questioning of the meanings psychiatrists and patients might attach to their experience,which can be summarized in assessments ofinsight,while at the same time showing the diversity of such experiences in different settings.To quote: Viewed this way,an individual may reject a medical explanation,not because they lack insight but because they are giving priority to maintaining social relations and positions that otherwise might be damaged or lost. Amad_Fm.qxd 21/6/04 10:55 AM Page viii viii PREFACE Similarly,a particular setting,namely Japan,allows a fascinating “case study”,so to speak,where eastern and western concepts ofpsychopathology have met and have at times rubbed against each other in not wholly constructive ways.Dr Yoshi Kim out- lines the sociopolitical context to these phenomenological debates and adds some recent empirical data on the opinions of psychiatrists in the UK and Japan on the importance ofinsight in their clinical work and classificatory schemes. While on the one hand we may seek to demonstrate that insight is not an all or none phenomenon,nevertheless,lack ofinsight or poor insight is a reality with very import- ant and at times destructive consequences.Different perspectives on this are offered by psychiatrist and activist Fuller Torrey.He discusses the relationship between insight as a predictor ofviolence and also as an element in public understanding or misunder- standing ofpsychiatric disorders,which might be called stigma.Finally in this section, Ken Kress offers a very provocative proposition,namely that insight or the lack ofit is, in his view,the best justification for involuntary treatment,superior,he argues,to notions ofcompetence and capacity.Many may question Kress’s faith in the reliability and validity ofinsight as currently conceived in psychiatry,but few will deny the clarity and force ofhis arguments. In the fourth and final part ofthe new edition ofInsight and Psychosis,Alec Buchanan and Simon Wessely update their chapter on delusions,action and insight.This deals with some ofthe same issues considered by Torrey in the previous chapter,but is avowedly clinical in orientation.The relationship between actions,including aggression,as moti- vated by for example,delusions,is a particular clinical problem faced by general and forensic psychiatrists.Buchanan and Wessely’s thorough treatment ofthis issue will satisfy both academics and clinicians.The same can be said ofJoe McEvoy’s revised chapter oncompliance or adherence with medication and its relationship to insight.This is per- haps the most obvious area ofclinical relevance where research and conceptual under- standing ofinsight can have a tangible influence on clinical psychiatry.Lack ofadherence to medication is a pervasive problem throughout the whole ofmedicine and needs to be understood from all sides.Beliefs and understanding about one’s illness are a crucial motivator in seeking medical help,and have recently been the target oftherapeutic inter- ventions in their own right.Ofcourse,treatment ofschizophrenia and related disorders is not merely a matter oftaking the appropriate medication.Psychosocial rehabilitation is just as essential and is equally prone to the beliefs and motivations ofindividuals con- cerned.Paul Lysaker and Morris Bell have contributed a considerable programme of empirical work on this very question,which they review in a thoroughly updated chapter. As noted earlier on in the Introduction,the views ofconsumers in this area are crucial and were unfortunately overlooked in the first edition.Fred Frese has the dual qualifica- tion ofbeing a psychologist and a consumer,and his description ofhis own experiences and struggle to understand them are both moving and informative. Pulling some ifnot all ofthese strands together has been a challenging,but reward- ing task.We thank all ofthe contributors for their creativity and discipline in helping Amad_Fm.qxd 21/6/04 10:55 AM Page ix PREFACE ix us meet our targets and fulfil our aspirations for this volume.Finally,we acknowledge the part played by our publishers,Richard Marley initially,and later Carol Maxwell for their support. A.S.D. X.F.A. References Beck,A.T.(1952).Successful out-patient psychotherapy ofa chronic schizophrenic with a delusion based on borrowed guilt.Psychiatry,15,305–12. Young,D.A.,Davila,R.and Scher,H.(1993).Unawareness ofillness and neuropsychological performance in chronic schizophrenia.Schizophrenia Research,10,117–24.
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