Public Release: 

'But doctor, I'm not ill' -- insight in psychotic patients

European College of Neuropsychopharmacology

How do you convince someone with schizophrenia or other psychotic disorders that they are ill if they don't want to believe it? If you don't recognize that you are ill, you may resist treatment, but is there something which causes this lack of awareness? Awareness of illness, also known as 'insight', is a serious problem in the treatment of psychotic patients. Now work being presented at the ECNP Congress in Amsterdam investigates whether concentrations of a marker of brain cell dysfunction are associated with impaired insight.

Past studies have indicated that an area at the front of the brain called the prefrontal cortex may be associated with poor insight. In addition, numerous studies found reduced levels of a neurometabolite called N-acetylaspartate (NAA) in the prefrontal cortex of patients with a psychotic disorder. Reduced NAA is thought to reflect impaired functioning, damage or loss of brain cells.

A group of researchers from Groningen in the Netherlands worked with 80 patients with psychotic disorders. They measured their levels of insight using standard questionnaires (the Birchwood Insight Scale, and one item of the Positive and Negative Syndrome Scale), and then measured the concentrations of various neurometabolites in the dorsolateral prefrontal cortex, using a technique called 1H-MRS (Proton Magnetic Resonance Spectroscopy, an image processing which shows the local chemical environment rather than anatomical structures).

They found that patients with poorer insight had a significantly lower level of NAA in the prefrontal cortex, while no significant relation was found between levels of other neurometabolites in the prefrontal cortex and insight.

As presenting author, Daouia Larabi said: "NAA is seen as a marker for brain cell density and viability. What we found is a specific association between decreased NAA concentrations and impaired insight: basically, the lower the levels of NAA in the prefrontal cortex, the worse patients' insight is. It should be noted that our study was correlational. Therefore, we cannot draw conclusions about whether one causes the other".

"It's important to understand what causes lack of insight. People with poor insight tend to drop out of treatment, have poorer functioning in general and have worse prognosis. If you are convinced that you are not ill, you won't want to be treated. We hope our findings will help in a better understanding of the neurobiology of impaired insight. This may help in the development of new treatment options such that insight, and consequently patients' likely course of their condition, can be improved".

Commenting, Dr Andreas Meyer-Lindenberg, Editor-in-chief of European Neuropsychopharmacology and member of the ENP executive board, said:

"Biological research in recent years has moved beyond diagnoses towards trying to understand clinical features of the illness that are important to patients and their families, and this work on insight is a good example. Insight is highly relevant for the prognosis of people with schizophrenia and psychosis, and linking it to dysfunction in a specific brain system, if replicated, may point to new therapeutic or diagnostic approaches in the future"


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