Purpose: Impaired insight is commonly seen in psychosis and some studies have proposed that is a biologically based deficit. Support for this view comes from the excess of neurological soft signs (NSS) observed in patients with psychoses and their neural correlates which demonstrate a degree of overlap with the regions of interest implicated in neuroimaging studies of insight. The aim was to examine the relationship between NSS and insight in a sample of 241 first-episode psychosis patients.Method: Total scores and subscale scores from three insight measures and two NSS scales were correlated in addition to factors representing overall insight and NSS which we created using principal component analysis.Results: There were only four significant associations when we controlled for symptoms. "Softer" Condensed Neurological Evaluation (CNE) signs were associated with our overall insight factor (r = 0.19, P = 0.02), with total Birchwood (r = -0.24, P < 0.01), and the Birchwood subscales: recognition of mental illness (r = -0.24, P < 0.01) and need for treatment (r = -0.18, P = 0.02). Total Neurological Evaluation Scale (NES) and recognition of the achieved effects of medication were also weakly correlated (r = 0.14, P = 0.04).Conclusion: This study does not support a direct link between neurological dysfunction and insight in psychosis. Our understanding of insight as a concept remains in its infancy. (C) 2011 Published by Elsevier Masson SAS.

IntroductionThe use of physical coercion and involuntary admission is one of the most controversial practices in medicine, it is now understood that perceived coercion is multidimensional and is associated with procedural justice and perceived pressures, and not simply related to the legal status of the patient.ObjectivesWe sought to determine the rate of physical coercion used and the perceived pressures and procedural justice experienced by the person at the time of involuntary admission and whether this influenced future engagement with the mental health services.MethodsOver a 15 month period, people admitted involuntarily were interviewed prior to discharge and at one year follow-up.Results81 people participated in the study and 81% were interviewed at one year follow-up. At the time of involuntary admission, over half of people experienced at least one form of physical coercion and it was found that the level of procedural justice experienced was unrelated to the use of physical coercive measures. A total of 20% of participants intended not to voluntarily engage with the mental health services upon discharge and they were more likely to have experienced lower levels of procedural justice at the time of admission. At one year following discharge, 65% of participants were adherent with outpatient appointments and 18% had been readmitted involuntarily. The level of procedural justice experienced at admission did not predict future engagement with services.ConclusionsThis study demonstrates that the use of physical coercive measures is a separate entity from procedural justice and perceived pressures.

AIMS AND METHOD This study looked at patient aggressive behaviour on an Irish psychiatric intensive care unit, and whether it was related to diagnosis, patient’s insight and symptomatology. Each aggressive incident was recorded throughout the patient’s stay using the Staff-Observed Aggression Scale.RESULTS Ninety-nine individuals were admitted to the unit during the study. We recorded 82 aggressive incidents, with most occurring during the daytime and on weekdays. There was no statistical difference in BPRS scores between the aggressive and non-aggressive groups. The aggressive patient group had a lower insight score than the non-aggressive group ( P <0.05) as measured on the Schedule of the Assessment of Insight. However, when gender and verbal aggression only were included in the analysis, the difference in insight was less significant ( P =0.07).CLINICAL IMPLICATIONS Aggression is common on a psychiatric intensive care unit. Low levels of insight in patients may increase the risk of aggression.

BackgroundThe outcome of schizophrenia appears to be more favourable than once thought. However, methodological issues, including the reliance on diagnosis at first presentation have limited the validity of outcome studies to date.MethodWe conducted a first-episode follow-up study of 97 patients with DSM-IV schizophrenia over the first 4 years of illness. First presentation and follow-up assessments were compared using pairedttests and a forced-entry regression analysis was used to determine prognostic variables.ResultsThere were significant improvements in positive and negative symptoms and global assessment of functioning between first presentation and follow-up. At first presentation, fewer negative symptoms (t=−3.40,p<0.01), more years spent in education (t=3.25,p<0.01), and a shorter duration of untreated psychosis (DUP) (t=−2.77,p<0.01) significantly predicted a better outcome at follow-up.ConclusionsThe outcome of schizophrenia may not be as pessimistic as once thought and most patients did not display a downward deteriorating course of illness. This study supports the relationship between DUP and outcome beyond the early stages of illness.

Background There has been controversy as to whether early intervention in psychosis can improve the outcome of the disorder.Aims To establish if there is an association between duration of untreated psychosis and the 4-year outcome of persons with a first episode of psychosis. Method Prospective naturalistic follow-up study of the outcome of consecutive first presentations with DSM-IV psychosis attending a community-based psychiatric service.Results. A longer duration of untreated psychosis was associated with a significantly poorer functional and symptomatic outcome 4 years later. For schizophrenia and schizophreniform disorder, each increment in duration of untreated psychosis was associated with a 7.8 point decrease in global functioning and an increase in positive symptoms scores by 1.9 points.Conclusions This study extends the findings of short-term follow-up studies by confirming an association between duration of untreated psychosis and 'mid-term' outcome.

The aim of this study was to identify the features of first episode schizophrenia that predict adherence antipsychotic medication at six-month follow-up. We used validated instruments to assess clinical and socio-demographic variables in all patients with first episode schizophrenia from a defined geographical area admitted to a Dublin psychiatric hospital over a four-year period ( N = 100). At six-month follow-up ( N = 60) we assessed adherence to medication using the Compliance Interview. One third of patients with schizophrenia were non-adherent with medication within six months of their first episode of illness. High levels of positive symptoms at baseline, lack of insight at baseline, alcohol misuse at baseline and previous drug misuse predict non-adherence. These results indicate that an identifiable subgroup of patients with first episode schizophrenia is at high risk of early non-adherence to medication. While high positive symptom scores pre-date and predict non-adherence in most patients, reduced insight is the best predictor of non-adherence in patients who do not misuse alcohol or other drugs.

This research attempts to explore empirically the relationship between lack of illness and neuropsychological performance in a group of chronic schizophrenic subjects. Thirty one chronic schizophrenics were administered the recently developed Scale to Assess Unawareness of Mental Disorder (SUMD) and 3 neuropsychological tests that have demonstrated ability to assess frontal lobe performance: the Wisconsin Card Sorting Test (WCST), Verbal Fluency Test and Trails A and B. The number of categories completed and the percent perseverative responses on the WCST were found to significantly correlate with lack of illness awareness as measured by the SUMD. These two WCST variables were also able to significantly discriminate between subjects of high versus low awareness. A discriminant function analysis found that a linear combination of WCST percent perseverative responses and symptom severity could successfully categorize 84% of the aware versus unaware subjects. These results are taken to support the hypothesis that at least in some of its manifestations lack of awareness among chronic schzophrenics has an organic etiology probably mediated by the frontal lobes.

ResumenEl propósito de este estudio era identificar los rasgos de la esquizofrenia de primer episodio que predicen el cumplimiento de la medicación antipsicótica en el seguimiento a los 6 meses. Utilizamos instrumentos validados para evaluar las variables clínicas y sociodemográficas en todos los pacientes con esquizofrenia de primer episodio de un área geográfica definida ingresados en un hospital psiquiátrico de Dublín durante un periodo de cuatro años (n = 100). En el seguimiento a los 6 meses (n = 60) evaluamos el cumplimiento de la medicación utilizando la Entrevista de Cumplimiento. Un tercio de los pacientes con esquizofrenia no tomaba la medicación a los seis meses de su primer episodio de enfermedad. Los niveles elevados de síntomas positivos en la linea de base, la falta de conciencia de la enfermedad en la línea de base, el uso inadecuado de alcohol en la línea de base y el uso inadecuado anterior de drogas predicen el incumplimiento. Estos resultados indican que un subgrupo identificable de pacientes con esquizofrenia de primer episodio tiene un riesgo alto de incumplimiento temprano de la medicación. Aunque las puntuaciones altas de síntomas positivos preceden y predicen el incumplimiento en la mayoría de los pacientes, la reducción de la conciencia de la enfermedad es el mejor predictor del incumplimiento en los pacientes que no utilizan inadecuadamente el alcohol u otras drogas.

OBJECTIVE:The objective of this study was to determine the stability of a diagnosis of psychosis four years after the first-episode diagnosis.METHODS:The study was a prospective four-year follow-up study (1995 to 1999) of 147 patients with schizophrenia, affective disorder, and other psychoses who presented with a first episode of psychosis in an epidemiologic catchment area in Ireland. All diagnoses were made on the basis of the Structured Clinical Interview for DSM-IV.RESULTS:One quarter of the patients evidenced a change in diagnosis at follow-up. The most common change was to a diagnosis of schizophrenia. The positive predictive values of schizophrenia and bipolar affective disorder were 97 percent and 80 percent, respectively. Fewer years spent in education, lower levels of initial psychopathology, and presence of comorbid alcohol or substance abuse were associated with change in diagnosis at follow-up.CONCLUSIONS:Among the diagnoses studied, schizophrenia was the most stable diagnosis after four years. The greatest instability occurred in the categories of drug-induced psychosis and psychosis not otherwise specified.

OBJECTIVE:To map the development of insight in the 4 years after presentation with first-episode schizophrenia and schizophreniform disorder and to determine the effects of evolving insight on depression and the likelihood of attempted suicide.METHOD:We assessed 101 individuals at presentation, 6 months and 4 years. We measured insight, including recognition of mental illness, recognition of need for treatment and ability to relabel psychotic symptoms. We measured depression and recorded all suicide attempts.RESULTS:Insight improved with time. Recognition of mental illness at 6 months predicted depression and attempted suicide at 4 years.CONCLUSION:Six months after presentation, the greater the acknowledgement by people that they had a mental illness, the more depressed they were at 4 years and the greater the likelihood that they would attempt suicide by 4 years. This may have implications for disclosure of diagnosis.

ResumenTener un diagnóstico de esquizofrenia es un factor de riesgo para el ingreso no voluntario en la asistencia hospitalaria psiquiátrica, pero tenemos una comprensión limitada de por qué algunos pacientes precisan un ingreso no voluntario y otros no. Intentamos identificar los predictores del ingreso no voluntario en el primer episodio de esquizofrenia. Utilizamos instrumentos validados para evaluar las variables clínicas y sociodemográficas en todos los pacientes (n = 78) con primer episodio de esquizofrenia de un área geográfica definida ingresados en un hospital psiquiátrico de Dublín durante un periodo de 4 años. No se pudo distinguir a los pacientes no voluntarios (n = 17) de los voluntarios (n = 61) de acuerdo con la edad, el género, la situación de convivencia, el estado civil, el abuso de drogas o la duración de la psicosis no tratada. Ni los síntomas positivos ni los negativos fueron predictores útiles del tipo de ingreso. La falta de insight fue un fuerte predictor del ingreso de tipo no voluntario.

This study aimed to identify the incidence and clinical correlates of aggression and violence in first episode psychosis. We prospectively recruited subjects with a first episode of DSM-psychosis presenting from a geographically defined catchment area to a secondary referral psychiatric service over a four-year period (n=157). We used the Modified Overt Aggression Scale to retrospectively assess aggression (a hostile or destructive mental attitude, including verbal aggression, physical aggression and/or violence) and violence (the exercise of physical force), blind to diagnosis. One in three patients with psychosis was aggressive at the time of presentation. One patient in 14 engaged in violence that caused, or was likely to cause, injury to other people. Aggression was independently associated with drug misuse (odds ratio (OR) 2.80, 95% confidence interval 1.12–6.99) and involuntary admission status (OR=3.62, 95% CI 1.45–9.01). Violence in the week prior to presentation was associated with drug misuse (OR=2.75, CI 1.04–7.24) and involuntary admission status (OR=3.21, CI 1.21–8.50). Violence in the week following presentation was associated with poor insight (OR 2.97, CI 1.03–8.56) and pre-contact violence (OR 3,82, CI 1.34–10.88). In patients with schizophrenia, violence in the week following presentation was associated with drug misuse (OR=7.81, CI 1.33–45.95) and high psychopathology scores (OR=20.59, CI 1.66–254.96). Overall, despite a high rate of verbal aggression, physical violence towards other people is uncommon in individuals presenting with first episode psychosis.

Objective: The purpose of the study was to determine if a dose-response relationship exists between obstetric adversity and age at first presentation with schizophrenia.Method: The Dublin Psychiatric Case Register was used to identify subjects with schizophrenia. Data on obstetric complications, social class of origin, and family history of psychiatric illness were obtained for those subjects.Results: A total of 409 patients with ICD-9 schizophrenia were identified. Patients with a history of obstetric complications presented earlier to psychiatric services. As the number of complications increased, the mean age at first presentation decreased. This effect was independent of social class of origin and family history of psychiatric illness.Conclusions: Obstetric adversity exerts an independent influence on the age at first presentation with schizophrenia, in a dose-response manner. This finding supports the existence of a causal relationship between obstetric adversity and age at first presentation with schizophrenia.

ResumenLa esquizofrenia se asocia con desarrolló neural alterado. Evaluamos los signos neurológicos menores (SNM) y las anomalías dermatoglíficas (recuento total de crestas a-b [RTCAB] y recuento total crestas digitales [RTCD]) en 15 pares de gemelos concordantes y dis-cordantes para esquizofrenia. Las diferencias intrapar en las puntuaciones tanto de SNL como de RTCAB fueron significativamente mayo-res en los pares discordantes comparado con los pares monocigóticos concordantes. No hubo diferencias significativas en las puntuaciones de SNM y RTCAB entre los sujetos con esquizofrenia y los co-gemelos sin la enfermedad. Sin embargo, los gemelos discordantes monocigóticos con esquizofrenia tenían recuentos de crestas a-b (RCAB) mayores en su mano derecha comparado con sus co-gemelos sin la enfermedad. Estos hallazgos indican que un acontecimiento ambiental no identificado que actúa entre las semanas 6 y 15 de la gestación afecta al desarrollo de los gemelos monocigóticos que continúan hasta desarrollar esquizofrenia, pero no tiene un efecto correspondiente en sus co-gemelos que no desarrollan la enfermedad. El efecto de este acontecimiento sobre los perfiles dermatoglíficos parece laterali-zado a la mano derecha en los gemelos afectados.

There is enduring debate about the validity of subjective measures of quality of life derived from people with psychiatric disorders and particularly from those with psychosis. We evaluated patients with established psychosis 4 years after their first episode. We compared subjective and objective measures of quality of life and evaluated the influence of insight on the individual's interpretation of their quality of life. Subjective measures of quality of life were derived using the World Health Organization Quality of Life Scale—Brief Version, and objective measures of quality of life were derived using the Quality of Life Scale by Heinrichs et al. We measured Insight using the Insight Scale. There were robust correlations between subjective and objective assessments of quality of life. This was most marked for psychological symptoms. Self-report measures are valid and should form part of the overall assessment of quality of life among patients with psychotic disorders.