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SCHIZOPHRENIA
.OO
PSYCHOPATHOLOGIC DOMAINS
AND INSIGHT IN
SCHIZOPHRENIA
Xavier F. Amador, PhD, and Jack M. Gorman, MD
From the Department of Psychiatry, Columbia University College of Physicians & Surgeons
(XFA, JMG); and Diagnosis and Evaluation Center for Psychotic Disorders (XFA); and
the New York State Psychiatric Institute, New York, New York, (XFA, JMG)
27
28
29
30
nia used by clinicians in the United States and United Kingdom.25,38 The
disagreement centered on the boundary between psychotic and mood
symptoms.
The 1970s saw an increased emphasis being placed on improving
the reliability of the diagnosis. This was achieved, in part, by formulating
operational criteria and by relying more on observable (or objective)
symptoms to make up the diagnosis. A major influence on these efforts
was the description of first rank symptoms by Kurt S ~ h n e i d e rSchnei.~~
der described eight first rank symptoms, all of which are disturbances
of experiences reported by patients and that were easy to comprehend
and identify in clinical practice. Schneider considered these symptoms as
being pathognomonic for diagnosing schizophrenia once known organic
factors were excluded, although their presence was not an obligatory
requirement for making the diagnosis. These first rank symptoms were
the first implements for an operational definition of schizophrenia, and
played an important role in many subsequent elaborations of diagnostic
criteria and in the construction of interviewing instruments such as the
Present State Examination (PSE)62and the Schedule for Affective Disorders and Schizophrenia (SADS).57Indeed, cross-sectional evaluations and
Schneiders first rank symptoms were given prominence in the PSE that
was used in the US/UK project mentioned above and in the International Pilot Study of S~hizophrenia.~~
Moreover, this conceptualization
of schizophrenia influenced the way the disorder was thought of by
mental health professionals throughout the world. This was followed by
development of operational criteria in 1972 by Feighner et alZ8(St. Louis
Criteria) and by Spitzer et all2 in 1978 (Research Diagnostic Criteria or
RDC). The Feighner and RDC diagnostic systems were the forerunners
of the DSM-III.7 The third edition of the DSM set up nonambiguous
diagnostic criteria that required an illness duration of at least 6 months,
provided exclusion criteria for disorders that shared many of the same
symptoms (i.e., affective disorders), and emphasized the presence of
psychotic symptoms, which were similar to Schneiders first-rank symptoms, during the active phases of the illness. This helped to narrow the
definition and improve upon the reliability of the diagnosis. Relatively
minor changes were made for the next version of this criteria.8 Essentially, this revision entailed a simplification of the criteria and a clearer
definition of the boundary between schizophrenia and delusional disorder.
Although the definitions of schizophrenia published in the DSMI11 and DSM-111-R improved on reliability by emphasizing the easily
identifiable positive psychotic symptoms, they have been criticized for
neglecting negative symptoms that are often the cause for significant
functional disability. Studies have shown that negative symptoms have
predictive power and that they can be identified and measured with
36
good reliability.lO,
To summarize, in the years following the early work of Kraepelin
and Bleuler, the field has continued to focus on many of the same
symptoms and course of illness features. The diagnostic process also
31
32
33
34
35
symptom groups tended to change during the course of a 2-year followup but independently from one another.
Negative symptoms tend to show a relatively poor response to
treatment with neuroleptics,32 although some of the newer compounds
show some promise. Negative symptoms have been found to be associated with cognitive irn~airment,'~
especially impairments in frontal lobe
ta~ks.4~
Because an association between negative symptoms and enlarged
brain ventricles has been reported, this has not been consistently repli~ a t e dAn
. ~ association
~
between negative symptoms and decreased frontal cerebral blood flow or metabolism has been more consistently replicated.'" 46, 64 Much of the available validating evidence tends to support
the negative symptom domain as a distinct entity because there is
relatively little data on the other domains.
The disorganization domain has been studied to a much lesser
extent. The tendency of most earlier studies to treat all positive symptoms as a unitary concept may have contributed to the inability to
find associations between the positive and disorganized domains and
validating variables. Liddle46has proposed that the disorganization domain may reflect dysfunction of the right ventral prefrontal cortex since
the positive domain is primarily a dysfunction of the medial temporal
lobe. However, the associations between these two domains and measures of neuro-cognitive function in these areas have not been conducted.
In summary, although the descriptive validity of the three domain
model is clearly established, the criterion validity is not. However, published studies that have examined the question of criterion validity are
promising.
AWARENESS DEFICITS
In 1896, K r a e ~ l i ndescribed
~~
patients with dementia praecox as
being typically unaware of the gravity of their disorder. Any experienced
clinician knows that a substantial number of patients suffering from
schizophrenia do not believe they have an illness and are unaware of
the specific deficits caused by the disorder. Indeed, many of these individuals feel that the only thing they really suffer from is pressure
from relatives, friends, and doctors to accept treatment. Lack of insight
frequently obstructs treatment, as disagreement that treatment is even
necessary leads to patients feeling coerced to accept care for an illness
they do not believe they have. Large scale studies have suggested that
from 50% to more than 80% of all patients with schizophrenia do not
believe they have an illness.2,5, 22, 65 Owing to its prevalence and
disruption of the therapist-patient relationship, this type of discrepancy
in perspective, or what is commonly labeled poor insight has become
integral to our conception of schizophrenia.
Historically, the study of insight in schizophrenia has been plagued
by both conceptual ambiguities inherent in the term and the lack of
widely used standardized measures. The authors believe that this alone
36
AMADOR & G O W N
has accounted for the relatively minute amount of attention this domain
of psychopathology has received in the research literature. Indeed, over
the past decade investigators have begun to develop reliable methods to
assess the multiple dimensions of insight into illness, resulting in more
widespread use of these instruments and concomitant increase in the
number of published studies that focus on this domain. In the next
section, the authors describe recent innovations in the measurement of
insight and the results of studies that provide a clearer understanding
of the causes of poor insight and the role that awareness deficits play in
the expression of schizophrenia.
Measurement of Awareness Deficits
37
38
Previously, the authors argued that unawareness of illness in neurologic disorders (anosognosia) bears a striking resemblance to poor insight in schizophrenia, which includes both phenomenological and neuropsychologic similarities5 Patients with anosognosia frequently offer
confabulations or delusional explanations to explain observations that
contradict their belief that they are not ill. Similarly, individuals with
schizophrenia are frequently observed to attribute their hospitalizations
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40
AMADOR & G O W N
References
1. Amador XF, Carpenter WT, Kirkpatrick B, et al: The long-term stability of the deficit
syndrome in schizophrenia: A follow-up study. Presentation, Winter Workshop on
Schizophrenia Research, Crans Montana, Switzerland, March 1996
2. Amador XF, Flaum M, Andreasen NC, et al: Awareness of illness in schizophrenia,
schizoaffective and mood disorders. Arch Gen Psychiatry 51:826-836, 1994
3. Amador XF, Strauss D H The scale to assess unawareness of mental disorder (SUMD).
Columbia University and New York State Psychiatric Institute, New York, 1990
4. Amador XF, Strauss DH: Poor insight in schizophrenia. Psychiatric Quarterly,
64(4):305-318, 1993
5. Amador XF, Strauss DH, Yale SA, et al: Awareness of illness in schizophrenia. Schizophrenia Bulletin, 17113-132, 1991
6. Amador XF, Strauss DH, Yale SA, et al: The assessment of insight in psychosis. Am J
Psychiatry 150:873-879, 1993
7. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 3. Washington, DC, American Psychiatric Association, 1980
8. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, rev ed 3. Washington, DC, American Psychiatric Association, 1987
9. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, DC, American Psychiatric Association, 1994
10. Andreasen NC: Negative symptoms in schizophrenia: Definition and reliability. Arch
Gen Psychiatry, 39:784-788, 1982
11. Andreasen NC: The schedule for the assessment of positive symptoms (SAPS). Iowa
City, University of Iowa, 1983
12. Andreasen NC: The schedule for the assessment of negative symptoms (SANS). Iowa
City, University of Iowa, 1983
13. Andreasen NC, Amdt S, Allinger R, et al: Symptoms of schizophrenia: Methods,
meaning, and mechanisms. Arch Gen Psychiatry 52341-351, 1995
14. Andreasen NC, Flaum M, Amdt S: The comprehensive assessment of symptoms and
history (CASH): An instrument for assessing diagnosis and psychopathology. Arch
Gen Psychiatry 49:615-623, 1992
15. Andreasen NC, Olsen S Negative versus positive schizophrenia: Definition and validation. Arch Gen Psvchiatrv 39:769-794, 1982
16. Arndt S, Alliger Ri, Andieasen NC: The distinction of positive and negative symptoms:
The failure of a two-dimensional model. Br J Psychiatry 158:317-322, 1991
17. Arndt S, Andreasen NC, Flaum M, et a1 A longitudinal study of symptom dimensions
in schizophrenia: Prediction and patterns of change. Arch Gen Psychiatry 52352-360,
1995
18. Bleuler E: Dementia praecox or the group of schizophrenias (1911). New York, Intemational Universities Press, 1950
19. Bleuler M: Longterm course of schizophrenic psychoses: Joint results of two studies
(German). Nervenarzt 47477483,1976
41
20. Bornstein RA, Nasrallah HA, Olson SC, et a1 Neuropsychological deficit in schizophrenia subtypes: Paranoid, nonparanoid and schizoaffective subgroups. Psychiatry Res
31:15-24, 1989
21. Buchanan RW, Strauss ME, Kirkpatrick B, et al: Neuropsychological impairments in
deficit versus non-deficit forms of schizophrenia. Arch Gen Psychiatry, 51:804-811,1994
22. Carpenter WT Jr, Bartko JJ, Carpenter CL, et a1 Another view of schizophrenia
subtypes. Arch Gen Psychiatry, 33:508-516, 1976
23. Carpenter WT Jr, Kirkpatrick B: The heterogeneity of the long-term course of schizophrenia. Schizophr Bull 14:645-651, 1988
24. Carpenter WT, Stephens JH: An attempted integration of information relevant to
schizophrenic subtypes. Schizophr Bull 5:490-506, 1979
25. Cooper SE, Kendell RE, Gurland BJ, et al: Psychiatric diagnosis in New York and
London. London, Oxford University Press, 1972
26. David A S Insight and psychosis. Br J Psychiatry 156:739-803, 1990
27. Endicott J, Nee J, Fleiss J, et al: Diagnostic criteria for schizophrenia: Reliabilities and
agreement between systems. Arch Gen Psychiatry 39:884-889, 1982
28. Feighner JP, Robins E, Guze SB, et a1 Diagnostic criteria for use in psychiatric research.
Arch Gen Psychiatry 26:51-63, 1972
29. Fenton WS, McGlashan TH: Natural history of schizophrenia subtypes: I. Longitudinal
study of paranoid, hebephrenic, and undifferentiated schizophrenia. Arch Gen Psychiatry 48969-977, 1991
30. Fenton WS, McGlashan T H Natural history of schizophrenia subtypes: 11. Positive and
negative symptoms and longtenn course. Arch Gen Psychiatry 48:978-986, 1991
31. Janzarik W Courses of schizophrenia: A structural dynamic interpretation (German).
Monographien aus dem Gesamtgebiet der Neurologie und Psychiatrie 1261-149, 1968
32. Johnstone EC, Crow TJ, Ferrier IN, et al: Adverse effects of anticholinergic medication
on positive schizophrenic symptoms. Psycho1 Med 13:513-527, 1983
33. Jorgensen P: Clinical course and outcome of delusional psychosis. Acta Psychiatrica
Scandinavica, 76:317-323, 1987
34. Kasapis C: Poor insight in schizophrenia: Neuropsychological and defensive aspects.
Dissertation Abstracts International vol 5f+11B, p 6395, 1995
35. Kasapis C, Amador XF, Yale SA, et al: Poor insight in schizophrenia: Neuropsychological and defensive aspects [abstract]. Schizophr Res 15:123, 1995
36. Kay SR, Opler LA, Lindenmeyer JP: The positive and negative syndrome scale
(PANSS): Rationale and standardization. Br J Psychiatry, l(suppl):59-65, 1989
37. Kay SR, Sevy S: Pyramidical model of schizophrenia. Schizophr Bull 16:537-545, 1990
38. Kendell RE, Cooper JE, Gourlay AG: Diagnostic criteria of American and British
psychiatrists. Arch Gen Psychiatry 26123-130, 1971
39. Kendler KS, Adler D: The pattern of illness in pairs of schizophrenic siblings. American
Journal of Psychiatry 141:509-513, 1984
40. Kendler KS, Gruenberg AM, Tsuang MT Subtype stability in schizophrenia. Am J
Psychiatry 142:827-832, 1985
41. Kendler KS, Gruenberg AM, Tsuang MT A family study of the subtypes of schizophrenia. Am J Psychiatry 145:57-62, 1988
42. Klimidis S, Stuart GW, Minas H, et al: Positive and negative symptoms in the psychoses: Re-analysis of published SAPS and SANS ratings. Schizophr Res 9:ll-18, 1993
43. Kraepelin E: Lehrbuch der Psychiatrie, ed 5. Leipzig: Barth, 1896
44. Langfeldt G: Schizophrenia: Diagnosis and prognosis. Behav Sci 14:173-182, 1969
45. Lewis SW, Harvev I, Ron M, et al: Can brain damage protect against schizophrenia?
A case report of twins. Br J Psychiatry, 157600-603, 1990
46. Liddle PF: The symptoms of chronic schizophrenia: A re-examination of the positivenegative dichotomy. Br J Psychiatry 151:145-151, 1987
47. Liddle PF, Morris DL: Schizophrenic syndromes and frontal lobe performance. Br J
Psychiatry 158:340-345, 1991
48. Lysaker P, Bell M: Impaired insight in schizophrenia: Advances from psychosocial
treatment research. In Amador XF, David AS (eds): Insight and Psychosis. Chapter 15,
pp 307-316. New York, Oxford University Press, 1997
42
49. Malla AK, Norman RMG, Williamson P, Cortese L, Diar F: Three syndrome concept
of schizophrenia: A factor-analytic study. Schizophr Res 10:143-150, 1993
50. Maziade M, Roy M, Martinez M, et al: Negative psychoticism and disorganized
dimensions in patients with familial schizophrenia or bipolar disorder: Continuity and
discontinuity between the major psychoses. Am J Psychiatry 152:1458-1463, 1995
51. McEvoy JP, Apperson LJ, Appelbaum PS, et al: Insight in schizophrenia: Its relationship
to acute psychopathology. J Nerv Ment Dis 17743-47,1989
52. McGlashan TH, Carpenter WT Jr: Long-term follow-up studies of schizophrenia:
Editors intro. Schizophr Bull 14:497-500, 1988
53. McGuffin P, Farmer AF, Gottesman 11, et al: Twin concordance for operationally defined
schizophrenia: Confirmation of familiality and heritability. Arch Gen Psychiatry 41:541545, 1984
54. Perlata V, de Leon J, Cuesta MJ: Are there more than two syndromes in schizophrenia?
A critique of the positive-negative dichotomy. Br J Psychiatry 161:335-343, 1992
55. Pfohl B, Winokur G: The micropsychopathology of hebephrenic/catatonic schizophrenia. J Nerv Ment Dis 171:296-300, 1983
56. Schneider K: Clinical Psychopathology. New York, Grune & Stranon, 1959
57. Spitzer RL, Endicott J: Schedule for affective disorders and schizophrenia, ed 2.
Biornetrics Research, New York State Psychiatric Institute, New York, November, 1975
58. Spitzer RL, Endicott J, Robins E: Research diagnostic criteria: Rationale and reliability.
Arch Gen Psychiatry 35:773-782, 1978
59. Tsuang M, Winokur G: The Iowa 500: Field work in a 35-year follow-up of depression,
mania, and schizophrenia. Canadian Psychiatric Association Journal, 20:359-365, 1975
60. Van der Does AW, Dingemans PMAJ, Linszen DH, et al: A dimensional and categorical
approach to the symptomatology of recent-onset schizophrenia. J Nerv Ment Dis
181:744-749, 1993
61. Wilson WH, Ban TA, Guy W Flexible system criteria in chronic schizophrenia. Compr
Psychiatry 27259-265, 1986
62. Wing JK, Birley JL, Cooper JE, et al: Reliability of a procedure for measuring and
classifying present psychiatric state. Br J Psychiatry 113:499-515, 1967
63. Wing JK, Cooper JE, Sartorius N: The description and classification of psychiatric
symptoms. New York, Cambridge University Press, 1974
64. Wolkin A, Sanfilipo M, Wolf AP, et al: Negative symptoms and hypofrontality in
schizophrenia. Arch Gen Psychiatry 49:959-965, 1992
65. World Health Organization: Report of the international pilot study of schizophrenia.
Geneva, Switzerland, The Organization, 1973
66. World Health Organization: Mental disorders: Glossary and guide to their classification
in accordance with the ninth revision of the international classification of diseases.
Geneva, Switzerland, The Organization, 1978
67. World Health Organization: The ICD-10 classification of mental and behavioral disorders. Geneva, Switzerland, World Health Organization, 1992
68. Young DA, Davila R, Scher H: Unawareness of illness and neuropsychological performance in chronic schizophrenia. Schizophr Res 10:117-124, 1993