[French translation and validation of the Scale to assess Unawareness of Mental Disorder (SUMD) in patients with schizophrenics]. / Traduction et validation française de l'échelle d'évaluation de la conscience des troubles mentaux des patients schizophrènes: the Scale to assess Unawareness of Mental Disorder (SUMD).

BACKGROUND: The Scale to assess Unawareness of Mental Disorder (SUMD) is a semi-structured interview based on a dimensional and quantitative approach of insight. Different forms of insight are assessed: global insight into mental illness, insight into symptoms and insight into symptom aetiology (i.e. attribution). The SUMD divides the recognition of mental disorders into two concepts: awareness of, and attribution for mental disorders. Awareness relates to the subject's ability to recognize that the phenomenon in question is present, whereas attribution refers to explanations as to cause or source of these signs or symptoms. Thus, the scale distinguishes between the recognition of a symptom and its explanation. For example, the scale allows the investigator to distinguish between a patient's ability to recognize visual hallucinations as such (false perceptions), from his/her ability to explain their cause (e.g. due to mental illness or not). OBJECTIVE: The aim of this study was to translate the SUMD (version 3.1 revised) and test its convergent validity among 43 French adult inpatients diagnosed with schizophrenia according to DSM-IV-TR criteria. METHODS: Awareness of mental disorder was assessed using the SUMD and the Hamilton Rating Scale for Depression (HAMD) insight item (item 17) respectively, as done in the original English validation study. The SUMD was translated into French then back-translated into English. The back-translation was performed by both English and French native speakers who had no prior knowledge of the scale (the back translation was reviewed by one of the SUMD's authors, Dr Amador, for accuracy). The SUMD manual (v.2/14/99) was also translated into French. Concerning the SUMD directions followed in this study, the first three SUMD items, which are called general items: G1 "Awareness of mental disorder", G2 "Awareness of the achieved effects of medication" and G3 "Awareness of the social consequences of mental disorder" were systematically rated. However, symptom items (four through 20) are not always relevant for every patient. Indeed, for each symptom-item on the scale, it must first be ascertained that the patient has exhibited the particular symptom during the period under investigation. Therefore, for every patient, the symptom checklist was completed prior to filling out the scale, in order to determine which symptom-items were relevant. In addition, symptom attribution items are rated only if the subject received a score between 1 and 3 on the awareness item. Two periods of time of insight were assessed: "current" insight involved rating the highest level of awareness obtained at the time of the interview for the psychopathology present at anytime during the past 7 days. "Past" insight was defined as the present level of awareness during the period of time preceding the current period of investigation. RESULTS: The French translation of the SUMD achieved good convergent validity with the insight item of the Hamilton rating scale for depression. DISCUSSION: The SUMD has proven to be a reliable and valid instrument to assess insight into schizophrenia. The more psychometrically sound rating tools we have at our disposal, many of which have been published in non French journals, the more we will be able to sharpen our assessment of insight into schizophrenia. We are facing an epistemic paradox in which quantification helps description, i.e. we need to have access to different rating tools to measure insight in order to improve our knowledge of the causes, course and treatment of poor insight into mental disorders.

Perceptual asymmetries in schizophrenia: subtype differences in left hemisphere dominance for dichotic fused words.

OBJECTIVE: Dichotic listening techniques have been used to study hemispheric dominance for language in schizophrenia. The authors' goal was to compare subjects with paranoid and undifferentiated subtypes of schizophrenia. METHOD: The Fused Rhymed Words Test was used to compare perceptual asymmetries in 16 patients with paranoid schizophrenia, 28 patients with undifferentiated schizophrenia, and 29 healthy comparison subjects. RESULTS: Patients with paranoid schizophrenia had the largest left hemisphere advantage and patients with undifferentiated schizophrenia had the smallest. The asymmetry of healthy subjects was intermediate. Hemisphere advantage varied as a function of gender only in the patients with undifferentiated schizophrenia. CONCLUSIONS: The findings support the hypotheses that undifferentiated schizophrenia is associated with underactivation of left hemisphere resources for verbal processing and that paranoid schizophrenia is characterized by preserved left hemisphere processing.

Event-related brain potentials (ERPs) in schizophrenia for tonal and phonetic oddball tasks.

BACKGROUND: Prior studies using simple target detection ("oddball") tasks with pure tones have reported asymmetric reduction of the P3 event-related potential (ERP). This study investigated the time course and topography of ERPs recorded during both tonal and phonetic oddball tasks. METHODS: Event-related potentials of 66 patients (14 unmedicated) diagnosed with schizophrenia (n = 46) or schizoaffective disorder (n = 20) and 32 healthy adults were recorded from 30 scalp electrodes during two oddball tasks using consonant-vowel syllables or complex tones. Overlapping ERP components were identified and measured by covariance-based principal components analysis. RESULTS: Schizophrenic patients showed marked, task-independent reductions of early negative potentials (N1, N2) but not reduced P3 amplitude or abnormal P3 asymmetry. Task-related hemispheric asymmetries of the N2/P3 complex were similar in healthy adults and schizophrenic patients. Poorer task performance in patients was related to ERP amplitudes, but could not account for reductions of early negativities. CONCLUSIONS: The findings suggest that both patients and control subjects activated lateralized cortical networks required for pitch (right frontotemporal) and phoneme (left parietotemporal) discrimination. Task-independent reductions of negativities between 80 and 280 msec after stimulus onset suggest a deficit of automatic stimulus classification in schizophrenia, which may be partly compensated by later effortful processing.

Insight into illness in schizophrenia, schizoaffective disorder, and mood disorders with psychotic features.

OBJECTIVE: Deficits in insight have been found in one study to be more common and severe in patients with schizophrenia than in patients with schizoaffective and major depression with and without psychosis but not more severe than they are in patients with bipolar disorder. The goals of this study were to replicate this finding independently and to clarify whether patients with schizophrenia differ from patients with bipolar disorder in a larger study group. METHOD: Using the Scale to Assess Unawareness of Mental Disorder, the authors evaluated 29 inpatients with schizophrenia, 24 with schizoaffective disorder, and 183 with mood disorders with psychotic features (153 with bipolar disorder and 30 with unipolar depression). RESULTS: Patients with schizophrenia had poorer insight than patients with schizoaffective disorder and patients with psychotic unipolar depression but did not differ from patients with bipolar disorder. CONCLUSIONS: The lack of significant differences between patients with schizophrenia and patients with bipolar disorder was not a result of low statistical power. This replication and more detailed examination of diagnostic group differences in insight have clinical, theoretical, and nosological implications.

Cognitive-behavioral therapy in schizophrenia.

The authors review the literature on cognitive-behavioral approaches to the treatment of schizophrenia. They begin by providing a historical context to explain the recent resurgence of interest in this area. Next, they provide an overview of studies of cognitive-behavioral interventions that target poor insight, medication nonadherence, and refractory symptoms. Insight and nonadherence are emphasized because these are particularly common and problematic areas that present major stumbling blocks in the treatment of patients suffering from schizophrenia that are not yet sufficiently addressed by the interventions clinicians currently have in their treatment arsenal. The authors conclude that support exists for the efficacy of interventions derived from cognitive-behavioral approaches in improving some aspects of insight into illness, increasing adherence to medication, ameliorating the severity of symptoms, and mitigating other negative consequences of schizophrenia. Finally, the authors offer guidelines for future work in this area and emphasize the importance of identifying patients who are most likely to benefit from the use of cognitive-behavioral approaches.

Defending the unabomber: anosognosia in schizophrenia.

The use of recent psychiatric research in the defense of the 'Unabomber' (United States vs. Theodore Kaczynski) is a compelling example of how the gap between research and practice can have profound consequences on the practice of forensic psychiatry, psychology and the judicial process. In this case, educating the lawyers and the court about the research on poor insight in schizophrenia changed the defense strategy and ultimately the course of the trial.

Brain event-related potentials (ERPs) in schizophrenia during a word recognition memory task.

Impairments of recognition memory for words and attenuation of the ERP 'old-new' effect have been found in patients with left medial temporal lobe damage. If left temporal lobe dysfunction in schizophrenia involves medial structures (e.g. hippocampus), then schizophrenic patients might show similar abnormalities of verbal recognition memory. This study recorded ERPs from 30 electrode sites while subjects were engaged in a continuous word recognition memory task. Results are reported for 24 patients having a diagnosis of schizophrenia (n = 16) or schizoaffective disorder (n = 8) and 19 age-matched healthy controls. Both patients and controls showed the expected 'old-new' effect, with greater late positivity to correctly recognized old words at posterior sites, and there was also no significant difference between groups in P3 amplitude. However, accuracy of word recognition memory was poorer in patients than controls, and patients showed markedly smaller N2 amplitude. Reduced amplitudes of N2 and N2-P3 were associated with poorer performance, with highest correlations over the left inferior parietal (N2) and left medial parietal (N2-P3) region. Moreover, patients failed to show significantly greater left than right hemisphere amplitude of N2-P3 at posterior sites, which was seen for healthy controls. These findings suggest that impaired word recognition in schizophrenia may arise from a left lateralized deficit at an early stage of processing, beginning at 200-300 ms after word onset.

Suicidal behavior in schizophrenia: characteristics of individuals who had and had not attempted suicide.

OBJECTIVE: This study compares demographic and clinical characteristics of 52 individuals with schizophrenia or schizoaffective disorder who had attempted suicide with those of 104 individuals with schizophrenia or schizoaffective disorder who had not made a suicide attempt. METHOD: Participants were interviewed with the Diagnostic Interview for Genetic Studies. RESULTS: Most suicide attempts were of moderate to severe lethality, required medical attention, and involved significant suicidal intent. Individuals who had and had not attempted suicide did not differ with respect to demographic variables, duration of illness, rate of depression, or substance abuse. The two groups are affected differentially when depressed. CONCLUSIONS: Biopsychosocial assessments and interventions are essential for reducing the risk for suicidal behavior in individuals with schizophrenia.

Stability of the diagnosis of deficit syndrome in schizophrenia.

OBJECTIVE: Primary, enduring negative symptoms have been distinguished from negative symptoms more generally and are used to define the deficit syndrome of schizophrenia. Although the validity of the deficit syndrome has been demonstrated by using brain imaging, neuropsychological, illness outcome, and developmental history data, the stability of this diagnostic category has not been tested prospectively by using direct patient assessments. METHOD: Forty-three outpatients with schizophrenia and schizoaffective disorder were categorized into deficit and nondeficit groups an average of 3.8 years after having been previously categorized. RESULTS: There was 83% agreement between initial and blind follow-up designations of deficit status and 88% agreement on the nondeficit categorization. CONCLUSIONS: These results provide evidence for the long-term stability of the deficit syndrome in patients with schizophrenia and the reliability of the deficit/nondeficit categorization when diagnosed by those with appropriate training. Furthermore, they validate the method of categorizing deficit patients by using cross-sectional and retrospective data.

Summer birth and the deficit syndrome of schizophrenia.

OBJECTIVE: Patients with the deficit syndrome differ from other patients with schizophrenia relative to physiological correlates, course of illness, and response to treatment. Because of the abnormal seasonality of birth among persons with schizophrenia, the authors examined the relation between this risk factor and the deficit syndrome. METHOD: Findings in two clinical groups suggested an increase in summer births among deficit syndrome patients. The association between summer birth and the deficit syndrome was then examined in a catchment area study of first-admission patients with psychosis. RESULTS: In the catchment area sample, summer birth was also significantly associated with the deficit syndrome; negative symptoms broadly defined were not. CONCLUSIONS: These findings add to the increasing evidence that 1) patients with the deficit syndrome have a disease with an etiopathophysiology separate from that of other patients with what is now called schizophrenia and 2) the correlates of broadly defined negative symptoms are different from those for the deficit syndrome. The previously reported association between winter birth and schizophrenia appears to apply to nondeficit schizophrenia only.

Psychopathologic domains and insight in schizophrenia.

The earlier conceptualization of positive and negative symptom topologies for schizophrenia has given way to more complex models that propose three-and-four dimensions of psychopathology. These constructs may relate to neurobiologic heterogeneity and discrete symptom clusters have been shown to have distinct anatomical and cognitive correlates. Insight is an excellent example and the understanding of insight at psychopathologic and cognitive levels has facilitated new approaches to treatment and enhanced medication compliance.

Characterization of psychotic conditions. Use of the domains of psychopathology model.

BACKGROUND: Previous factor analytic studies of patients with schizophrenia have consistently demonstrated the presence of 3 psychopathological domains labeled positive, negative, and disorganized. This study examined whether similar domains can be seen in disorders other than schizophrenia, and the degree to which such domains are independent of diagnostic categorization. METHODS: Data from the Diagnostic and Statistical manual of Mental Disorders, Fourth Edition (DSM-IV) field trial involving 221 patients with schizophrenia and 189 patients with nonschizophrenia diagnoses were factor analyzed to study the nature of psychopathological domains in the 2 groups. Differential associations between each domain and selected clinical variables were assessed. RESULTS: Factor analysis yielded a similar 3-factor model of positive, negative, and disorganization domains for patients with schizophrenia as well as other diagnoses. Differential associations found between individual domains and clinical variables (premorbid functioning and negative domain; absence of remissions and disorganization domain) were similar in both schizophrenia and nonschizophrenia groups. CONCLUSIONS: The 3 psychopathological domains previously described in schizophrenia are not specific for that diagnosis. Differential associations found between individual domains and clinical variables were not limited by diagnostic categorization. The results suggest that these domains are not unique to schizophrenia and may each correspond to a discrete pathophysiologic condition.

Effects of clozapine on plasma catecholamines and relation to treatment response in schizophrenia: a within-subject comparison with haloperidol.

We conducted a within-subject comparison of the effects of clozapine and haloperidol on plasma levels of neurotransmitters and metabolites, and related changes in specific plasma neurochemicals with clozapine response. The subjects were 14 inpatients with schizophrenia or schzoaffective disorder, who were refractory to haloperidol and at least one other typical antipsychotic medication. Subjects underwent, in the following order: a 6-week "fixed, flexible dose" haloperidol trial, followed by a 2-4 week medication-free phase, and a 6-week clozapine trial. Plasma levels of norepinephrine (NE), homovanillic acid (HVA), and 3-methoxy-4-hydroxyphenylglycol (MHPG), and objective clinical ratings of total, positive, negative, and depressive symptoms were obtained at the end of each phase. As expected, we found a substantial increase of plasma NE with clozapine but not with haloperidol. However, the increase in NE was not associated with improvement in total or positive symptomatology. There was some evidence for an association between improvement in negative symptoms and increased HVA on clozapine, as well as diminished HVA during the medication-free phase. The implications of these data for understanding the mechanisms of action of clozapine are discussed.

Suicidal behavior in schizophrenia and its relationship to awareness of illness.

OBJECTIVE: Suicidal behavior is prevalent in individuals with schizophrenia. Although a relationship between greater awareness of illness and suicidal behavior has been posited, the question has not been systematically studied. The purpose of this study was to examine the relationship between suicidal behavior and various aspects of insight in 218 patients with schizophrenia. METHOD: Patients who were participating in the DSM-IV field trial for schizophrenia were assessed with the Scale to Assess Unawareness of Mental Disorder and an instrument that was developed for the field trial study that measured multiple aspects of psychopathology, including suicidal behavior. RESULTS: The prevalence of suicidal thoughts and behavior found in this study was consistent with previous published reports. Schizophrenia patients with recurrent suicidal thoughts and behavior were generally more aware of their negative symptoms and delusions than were nonsuicidal patients. Contrary to expectations, general awareness of having a mental disorder did not predict suicidal behavior. CONCLUSIONS: The notion that insight may be associated with greater suicidality was partially supported.

Does affective blunting in schizophrenia reflect affective deficit or neuromotor dysfunction?

Schizophrenia inpatients withdrawn from all neuroleptic medication were administered measures of affective blunting, diminished affective experience, and neuromotor dysfunction. The correlations among the measures provided support for the hypothesis that measures of affective blunting reflect both neuromotor and affective deficits. Because the interpretation of such measures is therefore ambiguous, measures of diminished affective experience may have greater validity in research on affective deficits in schizophrenia than measures of blunted affective expression.

The deficit syndrome in the DSM-IV Field Trial. Part II. Depressive episodes and persecutory beliefs.

Patients with the deficit syndrome are remarkable for their decrease in interest in social relationships, suggesting they have an abnormality in those brain regions controlling social behavior and social cognition. To further assess social behavior and social cognition in this group of patients, we examined the relationships among three aspects of the psychopathology: suspiciousness; major depressive episodes; and the deficit syndrome. These features of psychopathology were examined in two clinical samples: stable outpatients from a research clinic (the MPRC sample), and patients in the DSM-IV Field Trial. In both samples, patients with history of a depressive episode had more severe suspiciousness than those without such a history; other psychotic symptoms were not associated with depressive episodes. In the MPRC sample, patients with the deficit syndrome exhibited less severe suspiciousness than nondeficit patients; in the Field Trial sample, this same comparison had a nonsignificant trend in the same direction. In the Field Trial sample, patients with the deficit syndrome also had less severe delusions with a predominantly social content than did nondeficit patients. These findings suggest suspiciousness is a risk factor for major depression in schizophrenia, and that the decreased interests in social relationships exhibited by deficit syndrome patients is reflected in the content of their delusions.

The deficit syndrome in the DSM-IV Field Trial: I. Alcohol and other drug abuse.

Drug abuse is common in schizophrenia. Previous studies suggested patients with the deficit syndrome have a lower risk of drug abuse than do patients without deficit features. We distinguished deficit and nondeficit groups in the DSM-IV Field Trial dataset, and compared the two groups relative to current and lifetime (worst ever) severity of alcohol, cannabis, and other drugs of abuse. Deficit syndrome patients had a lower severity of current use of alcohol and other drugs, but the two groups did not differ significantly relative to cannabis use. Deficit patients also had less severe lifetime use of all three classes of drugs. These findings could not be attributed to differences between the deficit and nondeficit groups in demographics, severity of psychotic symptoms, chronicity of illness, or the quality of information available for the two groups. Deficit categorization and drug abuse were independently associated with poor level of function. Negative symptoms broadly defined were weaker predictors of drug abuse than was the deficit/nondeficit categorization. These findings further support the validity of the deficit syndrome of schizophrenia. Within schizophrenia, groups with relatively high or low risk for substance abuse can be identified.

Delineation of acute and transient psychotic disorders in a developing country setting.

BACKGROUND: We examined whether acute transient psychoses can be distinguished from schizophrenia and the affective disorders. METHOD: We studied 46 cases of nonaffective acute psychosis in the Chandigarh Acute Psychosis Study. With respect to separation from schizophrenia, we examined the distribution of duration of the episode. With respect to separation from affective disorders, we assessed the frequency of affective symptoms. RESULTS: Duration was bimodal, suggesting the presence of two distinct conditions of short and long duration. Affective symptoms were minimal, suggesting that these were not atypical affective syndromes. CONCLUSIONS: Acute transient psychoses conform neither with schizophrenia of brief duration nor with atypical affective psychosis, and thus require separate classification as proposed in the ICD-10.