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How to distinguish mental illness and neurodevelopmental disorders?

How to distinguish mental illness and neurodevelopmental disorders?

It looks like mental illness and neurodevelopmental disorders may look absolutely same if we superficially observe the behaviour.

Example:

  1. Anger, destructive behaviour can be either due to a mental illness (anxiety, panic disorder, mood disorders, etc) and also can be a meltdown that is seen in neurodevelopmental conditions (Autism, Aspergers, ADHD, SPD etc).

  2. Stereotypy and stimming behaviour can occur due to either mental illness like OCD and severe anxiety or it may have a neurodevelopmental origin.

  3. Anxiety itself, can be either of a psychological origin (such as either fear of something irrational, or just a state of fear), or it may have a neurodevelopmental origin such as the patient of ADHD or Aspergers or SPD can not handle a overstimulated state and may feel anxious if they have to wait for uncertain period.

There are a lot of other similarities between neurodevelopmental and psychological conditions.

Now suppose the scene a patient comes in the chamber of a General Physician/ Psychiatrist with complaints of restlessness, anxiety, depression, psychosomatic illness (nausea, headache, numbness), forgetfulness, lack of concentration etc. The general symptoms signal either a primarily psychological condition, or may have a neurodevelopmental origin. How the General Physician / psychiatrist should distinguish it?


As @BryanKrause said; mental illness and neurodevelopmental conditions are not distinctively separable.

Example: Neurodevelopmental hypothesis of schizophrenia, Obsessions and compulsions in Asperger syndrome and high-functioning autism Etc.


Mental health, neurodevelopmental, and family psychosocial profiles of children born very preterm at risk of an early-onset anxiety disorder

To compare the mental health and neurodevelopmental profiles of school-age children born very preterm, with and without an anxiety disorder, and to identify neonatal medical, psychosocial, and concurrent neurodevelopmental correlates.

Method

A regional cohort of 102 (51 males, 51 females) children born very preterm (mean [SD] gestation at birth=28wks [2], range=23–31wks) was studied from birth to age 9 years alongside a comparison group of 109 (58 males, 51 females) children born at term (mean [SD] gestation at birth=40wks [1], range=38–41wks). At age 9 years, all children underwent a neurodevelopmental evaluation while parents were interviewed using the Development and Well-Being Assessment to diagnose a range of DSM-IV childhood psychiatric disorders. Detailed information was also available about the children’s neonatal medical course and postnatal psychosocial environment, including maternal mental health and parenting.

Results

At age 9 years, 21% (n=21) of very preterm and 13% (n=14) of term-born children met diagnostic criteria for an anxiety disorder. Clinically-anxious children born very preterm were characterized by higher rates of comorbid mental health (odds ratio [OR]=11.5, 95% confidence interval [CI]=3.8–34.7), social (OR=6.2, 95% CI=2.1–18.4), motor (OR=4.4, 95% CI=1.6–12.2), and cognitive (OR=2.6, 95% CI=1.0–7.0) problems than those without an anxiety disorder. Concurrent maternal mental health and child social difficulties were the strongest independent correlates of early-onset child anxiety disorders.

Interpretation

Children born very preterm who developed an early-onset anxiety disorder were subject to high rates of comorbid problems. Findings highlight the importance of addressing both maternal and child mental health issues to optimize outcomes in this high-risk population.


How do you recognise if someone has a mental health issue, and what can you do about it?

At any one time, one in six of us in the UK experiences a common mental disorder such as depression or anxiety.

Many more suffer in silence but do not seek help. Suicide is the biggest cause of death for men under fifty, and for women under 34.

Increasingly, &lsquoMental Health First Aid&rsquo initiatives are being rolled out in workplaces across the UK. A notable case is Stirling Albion football club, one of the first in Scotland to train their staff to recognise some warning signs of mental health problems.

The aim is to prevent anyone at the club suffering in silence, and to identify and deal with problems before they become overwhelming. The initiative does not intend to train staff or players to become therapists, counsellors or psychiatrists but to provide simple tools so they can recognise the signs and symptoms and give appropriate help - something that anyone can do.

So how do you spot if someone has a mental health problem &ndash and what can you do to support them?

Some signs that someone might be at risk include:

  • Being withdrawn or lost in thought
  • Losing their sense of humour
  • Being erratic, unusually agitated, tearful, or, conversely, emotionless
  • Changes in appetite, weight or sleep patterns
  • Increased alcohol consumption

So if you think someone you know might be at risk of mental health difficulties, what should you do?

  • Start by saying you&rsquove noticed a change in their mood or behaviour - without being critical.
  • Say you&rsquore concerned and ask if they&rsquod like to talk.
  • Don&rsquot downplay their problems or say things like &ldquowhat do you have to be depressed about?&rdquo
  • Listen and give them space to describe how they&rsquore feeling.
  • Encourage them to see their GP or offer to go with them to see a health professional.
  • If you think they&rsquore at risk of suicide, you can call the emergency services, or call their GP for an emergency appointment.

If you recognise the early warning signs in someone, or know they are struggling with their mental health, these first steps can make an enormous difference to their health and their lives.

Another important element of mental health first aid is to address the stigma attached to mental health problems. People often feel more embarrassed or ashamed of acknowledging mental health issues than physical ones, and it&rsquos important to help them try to overcome these feelings and feel comfortable talking about their mental health.


Defining and measuring age at onset

This life-course view means that identifying the age at onset of mental disorders is important, but it is difficult. Reference Kessler, Amminger, Aguilar-Gaxiola, Alonso, Lee and Ustun 4 The classic psychiatric disorders of adult life often begin with non-specific symptoms. As studies of the evolution of symptoms become more detailed, it is clear that early psychopathologic changes can be transient and dynamic before crystallising into a syndrome fitting some operational category such as the American Psychiatric Association's DSM. Only in retrospect can a decision be taken as to whether the early features were in fact part of the eventual picture. In epidemiological terms this leads to enormous scope for error or bias in the recall or memory of events Reference Simon and VonKorff 5 some elements may be misattributed to illness and others simply forgotten. From a clinical point of view it is well known that the better the history, the earlier the age at onset can be dated. Furthermore, just as periods of low mood and occasional elation are part of normal life, it seems likely that some psychological experiences such as voice hallucination, hitherto considered psychopathological, are relatively common during certain developmental periods it is their persistence or coexistence with other features that marks them as significant. This is leading to conceptual difficulties with clinical concepts such as the prodrome that are at best meaningless or confusing when used at the population level, and may be damaging if they lead to interventions that have adverse benefit-to-harm profiles quite different from the clinical situation.

Retrospective accounts of age at onset for some disorders are more useful than others, and perfect for none. Despite the problems alluded to above, it is a reasonable (and useful) assumption that a large proportion of people with psychotic illness eventually receive treatment, especially given that in the definitions of some types of psychosis such as schizophrenia, disability and loss of function are included in their definition. Thus, a survey using retrospective accounts of age at onset for schizophrenia or a broader group of non-affective psychosis yields useful information. It also avoids contamination by the data for the vast majority of young people who may experience psychotic phenomena without ever being ill. However, this is at the cost of excluding the few people with incipient illness but not yet in contact with services and, for many years, of masking researchers to the extent of psychotic phenomena as part of normal experience for many decades epidemiologists regarded such phenomena simply as false positives. The retrospective approach is also hampered by the long duration of untreated psychosis in many with non-affective psychosis who eventually make service contact, but the alternative approach – using a community survey for incident illness – would be hugely inefficient given the relative rarity of cases and the fact that the illness itself means that affected people would be less likely to take part. Reference Perala, Suvisaari, Saarni, Kuoppasalmi, Isometsa and Pirkola 6 It is important to recognise that the retrospective approach in clinical samples yields a self-fulfilling estimate of the age at onset of psychotic disorders that are seen and treated in clinical services, not a broader phenotype that does not meet this threshold. That said, the method – especially when combined with population registers of treated mental disorder – can lead to definitive results. Reference Perala, Suvisaari, Saarni, Kuoppasalmi, Isometsa and Pirkola 6

Using retrospective accounts of age at onset from cohorts of treated individuals is not useful for less disabling mental disorders because most are never treated. In some areas such as cardiovascular disease and cancer it is effective to follow up large cohorts of individuals and track these outcomes which are relatively easy to measure. Reference Yan, Liu, Daviglus, Colangelo, Kiefe and Sidney 7 This is much more difficult for common mental disorders where the true incidence and age at onset need intensive study, but has been achieved for psychotic illness using population-based birth cohort studies where follow-up is achieved either through regular interviews and surveys, Reference Jones, Rodgers, Murray and Marmot 8 or through population registers. Reference Isohanni, Makikyro, Moring, Rasanen, Hakko and Partanen 9 Such studies are rare and usually problematic in some way as they were initiated for reasons other than mental health disorders. For these reasons, retrospective reports from carefully designed cross-sectional community surveys provide most evidence on age at onset for most mental health disorders.

Examples of each of these methodological approaches to age at onset are outlined below, taking different exemplar disorders. This is followed by a discussion as to whether the findings on age at onset in mental health disorders fit with what we know about brain development. One final comment about the definition of age at onset arises from modern accounts of many long-term conditions in the framework of life course models. Here, a model of cardiovascular disease in late adulthood might encompass genetic inheritance, the epigenetic modification of the genome by fetal environment and childhood nutrition, the importance of social context in the beginnings of cigarette smoking at school, followed by further genetic and behavioural aspects in the establishment of nicotine dependence and sedentary lifestyle. The example could go on but illustrates the gradual accretion of interacting components to a self-perpetuating cascade of causation. In the domain of mental health disorders the seeds of schizophrenia may be sown in early life, Reference Jones, Rodgers, Murray and Marmot 8 and early motor developmental abnormalities may betray important information as to the underlying neurobiology of psychotic symptoms in a later phase of development. Reference Ridler, Veijola, Tanskanen, Miettunen, Chitnis and Suckling 10 However, one would be hard pushed to say that later motor milestones were the beginning of schizophrenia. Thus, in this article, the onset of a disorder is defined as the onset of features that form part of the disorder and that are contiguous with its first expression.


The relationship between psychiatric illness and criminality has been the topic of intense debate and scrutiny in the recent past in light of multiple mass shootings in the United States. While the renewed focus and media attention on the importance of mental health in the aftermath of such tragedies is a positive development, the relationship between mental illness and criminality is too often conflated. The popular belief is that people with mental illness are more prone to commit acts of violence and aggression. The public perception of psychiatric patients as dangerous individuals is often rooted in the portrayal of criminals in the media as Ȭrazy" individuals. A large body of data suggests otherwise. People with mental illness are more likely to be a victim of violent crime than the perpetrator. This bias extends all the way to the criminal justice system, where persons with mental illness get treated as criminals, arrested, charged, and jailed for a longer time in jail compared to the general population. This activity reviews psychiatric illness and criminality and the role of the interprofessional team in caring for afflicted patients.

The relationship between psychiatric illness and criminality has been the topic of intense debate and scrutiny in the recent past in light of multiple mass shootings in the United States.  While the renewed focus and media attention on the importance of mental health in the aftermath of such tragedies is a positive development, the relationship between mental illness and criminality is too often conflated.

The popular belief is that people with mental illness are more prone to commit acts of violence and aggression. The public perception of psychiatric patients as dangerous individuals is often rooted in the portrayal of criminals in the media as 𠇌razy” individuals.  A large body of data suggests otherwise. People with mental illness are more likely to be a victim of violent crime than the perpetrator.[1] This bias extends all the way to the criminal justice system, where persons with mental illness get treated as criminals, arrested, charged, and jailed for a longer time in jail compared to the general population.[2]


Is It Addiction or Mental Illness? How to Tell the Difference

By now, it’s probably safe to say that it’s common knowledge that drugs have a profound effect on the brain, even to the point of mimicking mental illness. However, it might come as a surprise to learn that this profound effect can last anywhere from 6 months to 2 years from the last use. In other words, a diagnosis of a mental illness or psychological disorder that is made in this window of time is not necessarily accurate it might just be the residual effects of the substance or substances that were being abused. If you are concerned about a loved one’s erratic behavior, you might be wondering, Is it addiction or mental illness? How to tell the difference is outlined below.

Dual Diagnosis

First of all, it’s also important to know that often times, mental illness and addiction go hand-in-hand. A term used for this is dual diagnosis, which means that there are co-occurring disorders present: mental illness, such as depression, anxiety, bipolar disorder, or borderline personality disorder to name just a few, and a substance abuse disorder such as alcoholism or drug addiction.

Physicians report an increase in cases involving patients from all walks of life who are struggling with a combination of substance abuse and mental health problems. Experts estimate that at least 60% of people that are battling one of these conditions are actually battling both, substance abuse and mental illness.

Alan Manevitz, MD, a psychiatrist with New York-Presbyterian Hospital in New York says, “Mental health problems and substance abuse are often seen together because one makes you more vulnerable to the other.”

Often times, it’s a case of chicken-or-the-egg but, what complicates the issue is that whether or not the psychological disorder preceded the substance abuse drugs being introduced into the system have a majorly profound effect on the brain, so much so that a mental diagnosis made within two years from the last use is not always considered an accurate one. Doctors experience difficulty with diagnosing patients therefore, it’s nearly impossible for you to know whether your loved one is suffering from one condition or both.

Self-Medication

Substance abuse and drug addiction often go hand-in-hand and only serve to exacerbate an already existing psychological disorder. But people suffering with mental illness often turn to drugs as a form of self-medicating, in order to alleviate or numb their psychic pain and distress. Furthermore, it is known that the connection between mind and body is so strong that a psychological disorder can actually manifest in physical symptoms, such as is the case with depression and its commonly-associated aches and pains. This is noteworthy because it gives the person who struggles yet another reason or excuse to abuse drugs, such as painkillers, in order to treat the physical symptoms of their mental illness.

Shared Risk Factors

Yet further understanding of both addiction and mental illness show that there are risk factors in common, leading to the development of both disorders.

Genetics. There are genetic factors that predispose, or make susceptible, a person to both addiction and other mental disorders and even to having a greater risk of a second disorder once the first one appears.

Environmental triggers. Stress, unresolved trauma, such as physical or sexual abuse, and early exposure to drugs are common environmental factors that can lead to addiction and mental illness.

Brain changes. The systems of the brain that respond to reward and stress are affected by drugs of abuse and also may show abnormalities in patients with certain mental disorders.

Development. Drug use disorders and other mental illnesses are developmental disorders, meaning they often begin in the adolescence or even younger—periods of time during which the brain experiences dramatic developmental changes. Therefore, early exposure to substances may change the brain in ways that increase the risk for psychological disorders. Early symptoms of a mental disorder may point to an increased risk for drug use later.

Is It Addiction or Mental Illness? How to Tell the Difference

The best way to find out whether your loved one is struggling with addiction or mental illness is to encourage them to see a doctor because a comprehensive approach is necessary in determining whether both conditions are present. Those who seek help for either drug abuse and/or addiction or another mental disorder should be evaluated for both and then treated accordingly.

  • Substance abuse can cause a mental illness
  • Mental illness can lead to substance abuse and addiction
  • Substance abuse and mental disorders are both caused by other common risk factors

If you or someone you love is displaying erratic behavior or thought patterns and you suspect that there is a substance abuse issue and/or mental illness present, help is available in the form of dual diagnosis treatment. Programs such as the one at Palm Partners are highly specialized and specifically designed to treat both addiction and mental illness simultaneously as this is the best way to help the individual who suffers. Please call toll-free 1-800-951-6135 to speak with an Addiction Specialist who can answer your questions. We are available 24/7.


Psychology

A consortium of psychiatrists and psychologists from universities around the world, co-led by Professor Bob Krueger and colleagues from Stony Brook University and the University of Notre Dame, has proposed a new approach to diagnosing mental disorders. The approach, articulated in a paper published in the Journal of Abnormal Psychology, is a classification system of a wide range of psychiatric problems based on scientific evidence, illness symptoms and impaired functioning. The diagnostic system addresses fundamental shortcomings of the fifth edition (2013) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the clinicians’ and researchers’ guidebook to mental illnesses.

Diagnosis of mental illness is important because it defines what treatment a patient should receive. Diagnosis also guides research efforts and is used by drug companies to develop new medications. The newly developed diagnostic approach is called the Hierarchical Taxonomy of Psychopathology (HiTOP). In the paper, titled “The Hierarchical Taxonomy of Psychopathology (HiTOP): A Dimensional Alternative to Traditional Nosologies,” (PDF) the consortium advances classification of psychopathology beyond the traditional diagnostic systems.

According to Krueger and his colleagues, substantial evidence has accumulated that suggest major changes to how mental illness is classified, but DSM-5 offered only modest refinements creating dissatisfaction in the research community. The National Institute of Mental Health (NIMH) produced an alternative model to guide mental health research efforts. This approach has also been controversial, as it focuses heavily on neurobiology and much less on investigating issues that are important for everyday psychiatric care, such as prognosis about illness course and selection of treatment.

As Krueger explains it, the DSM can be challenging to use in everyday practice. “It’s Byzantine,” he says. “It’s like the U.S. tax code. You can get lost in the complexity of its contents and still not find a compelling or accurate way to conceptualize your patient.”

“The HiTOP system has been articulated to address the limitations currently plaguing psychiatric diagnosis,” says lead author Kotov. “First, the system proposes to view mental disorders as spectra. Second, the HiTOP system uses empirical evidence to understand overlap among these disorders and classify different presentations of patients with a given disorder.”

For example, Kotov explained that mental health problems are difficult to put into categories, as they lie on the continuum between pathology and normality, much like weight and blood pressure. This is why the spectrum approach is needed. Applying an artificial boundary to distinguish mental illness from health problems results in unstable diagnoses, as one symptom can change the diagnosis from present to absent. It also leaves a large group of people with symptoms that do not reach the threshold untreated, although they suffer significant impairment.

Also, different DSM-5 diagnoses co-occur with surprising frequency, with most patients labelled with more than one mental health disorder at the same time. Extensive evidence indicates an underlying pattern of several major spectra that cause this overlap. Furthermore, diagnostic categories are so complex that often two patients with the same diagnosis do not share a single symptom in common.

The HiTOP solution to these fundamental problems is to classify mental illness at multiple levels of hierarchy: the broad level captures the major spectra and specific level reflects the tightly-knit dimensions within them. This approach allows doctors and researchers to focus on finer symptom in detail, or assess broader problems, as necessary.

A good example of this new classification is social anxiety disorder, which is considered a category in DSM-5. The HiTOP model describes social anxiety as a graded dimension, ranging from people who experience mild discomfort in a few social situations (i.e., when giving a talk in front of a large audience) to those who are extremely fearful in most situations. The HiTOP system recognizes that clinical levels of social anxiety are more intense but not fundamentally different from regular social discomfort.

Also, HiTOP does not treat it as a single problem but recognizes important differences between interpersonal fears (i.e., meeting new people) and performance fears (i.e., performing in front of an audience). Moreover, people with social anxiety are prone to other anxieties and depression, and the HiTOP model describes a broad spectrum called “internalizing,” which captures overall severity of such problems.

Overall, the authors emphasize that HiTOP adheres to the most up-to-date scientific evidence, rather than relying largely on decisions by committee (the approach used to construct the DSM-5). In the assessment of mental disorders, the HiTOP approach accounts for information on shared genetic vulnerabilities, environmental risk factors, and neurobiological abnormalities, such as differences in brain activity between the patients and healthy individuals.


Psychological and Cognitive Insight: How to Tell Them Apart and Assess for Each

Impaired insight may result from major mental illnesses such as schizophrenia and other psychiatric conditions, notably major mood disorders with psychotic features that are associated with diminished awareness of illness. Earn CME Credit by learning more about psychological and cognitive insight.

CATEGORY 1 CME

Premiere Date: April 20, 2021

Expiration Date: October 20, 2022

This activity offers CE credits for:

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

ACTIVITY GOAL

The goal of this article is to provide an overview of psychological and cognitive insight, including working definitions for these and other insight-related constructs. The etiologies of compromised insight are outlined. This article also highlights clinically relevant correlates of psychological and cognitive insight.

Learning Objectives:

1. Clarify the similarities and differences between psychological insight and cognitive insight

2. Identify and define different types of pseudo-insight

3. Review common etiologies of compromised insight

4. Discuss the role of rating scales and psychological/neuropsychological testing in the evaluation of insight

TARGET AUDIENCE

This continuing medical education (CME) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

ACCREDITATION/CREDIT DESIGNATION/FINANCIAL SUPPORT

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership Physicians’ Education Resource®, LLC and Psychiatric Times TM . Physicians’ Education Resource®, LLC is accredited by the ACCME to provide continuing medical education for physicians.

Physicians’ Education Resource®, LLC designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is funded entirely by Physicians’ Education Resource®, LLC. No commercial support was received.

OFF-LABEL DISCLOSURE/DISCLAIMER

This CME activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource®, LLC.

FACULTY, STAFF, AND PLANNERS’ DISCLOSURES

Neither the author, the peer reviewer, or the staff members of Physicians’ Education Resource®, LLC and Psychiatric Times TM have no relevant financial relationships with commercial interests.

For content-related questions, email us at [email protected] for questions concerning the accreditation of this CME activity or how to claim credit, please contact [email protected] and include “Psychological and Cognitive Insight: How to Tell Them Apart and Test for Each” in the subject line.

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The evaluation of patients’ insight into their own conditions has been a cornerstone of psychiatric practice for more than a century. 1 Most clinical studies and empirical investigations of insight have focused on patients’ so-called psychological insight (sometimes referred to as clinical insight) and its role in the assessment and treatment of schizophrenia and other psychotic disorders. Since the early 2000s, the construct of cognitive insight has emerged as a complementary form and, like psychological insight, is considered to have important implications for research and clinical practice. 2

Historically, assessment of patients’ psychological insight has played a prominent part in differential diagnosis, case formulation, treatment planning, and decision-making. It has been considered an integral component of the mental status examination, intake evaluations, progress/treatment notes, and case closing summaries.

Since the advent of the stress tolerance and coping skills era of psychotherapy in the early 1990s, the construct of insight has played a less significant role in diagnosis and treatment planning. Still, the construct of insight remains an important factor to consider when utilizing a stress tolerance and coping skills approach to assessment and psychotherapy.

Psychological and Cognitive Insight

The reality is that there is no consensus definition for psychological insight. Broad and vague definitions are vulnerable to subjective judgment, low inter-rater reliability, and a high number of false positives, resulting in the overdiagnosis of insight-related problems. Narrower definitions risk generating unacceptably high rates of false negatives. This can lead to underdiagnosis of both the level and the severity of impaired insight and the erroneous conclusion that a patient has enough insight to benefit from a range of treatment options.

From a historical perspective, 3 components stand out: awareness that one has a mental disorder, the ability to correctly attribute one’s symptoms to this condition, and the capacity to appreciate the need for treatment. 2 Additional components include an appreciation of the social and related consequences of one’s illness. 3 For the purpose of this discussion, psychological insight can be gauged by the criteria in Table 1. 4

Cognitive insight, unlike psychological insight, is a relatively recent arrival in the literature and has its genesis in the work of Aaron Beck, MD, and colleagues. 5 Cognitive insight comprises 2 components: self-reflection and self-certainty. The former refers to considering competing perspectives and entertaining alternative explanations for one’s beliefs, ideas, and perceptions. The latter is the ability to be self-critical with respect to the correctness of one’s beliefs, ideas, perceptions, and reasoning process. Self-certainty also includes a willingness to modify one’s conclusions about self and others in response to support and empathetic feedback. Criteria for cognitive insight are included in Table 2. 6

A Widespread Issue

Decreased insight is fairly common among patients with a broad range of mental health, neurodevelopmental, and neurocognitive disorders. Decrements in psychological and cognitive insight are associated with a number of difficulties for patients, their loved ones, and the practitioners involved in their care. Insight-related difficulties also have significant implications for diagnosis, case formulation, and treatment. In addition, clinicians need to carefully assess the adequacy of a patient’s level of psychological and cognitive insight in order to facilitate decision-making regarding informed consent to treatment, civil commitment, mandated outpatient treatment, child custody, parental fitness, work capacity, criminal responsibility, legal guardianship, estate planning, and assisted suicide.

What is generally referred to as impaired insight is prevalent among patients with schizophrenia, major mood disorders, and psychotic disorders. Although estimates vary, it seems at least 30% of these patients have compromised insight, which adversely affects their judgment and decision-making, response to treatment, functioning, and quality of life, as well as the attitudes and feelings of significant others. 7

Insight might impact treatment choices, including level of care, alliance building, choice of treatment modalities, treatment adherence, and the overall course and outcome. For example, if a patient has a history of nonadherence due to persistently impaired insight associated with a psychotic disorder, a long-acting injectable antipsychotic medication may be used to enhance adherence. 8 Patients with impaired insight are also more responsive to supportive psychotherapy with distress tolerance and coping skills components than to insight-based psychodynamically oriented psychotherapy.

As well, both psychological and cognitive insight figure prominently in psychoeducation for caregivers and nonpsychiatric health care providers regarding the psychosocial and medical needs of patients with diminished insight. 9

The Relationship Between Insights

Measures of psychological and cognitive insight correlate to a modest degree, suggesting that these 2 conceptualizations are relatively distinct (albeit overlapping) and complementary constructs. 2

Cognitive insight differs from psychological insight because of its emphasis on meta-cognitive capacities and, more specifically, the patient’s capacity for cognitive flexibility. These considerations encompass patients’ awareness of the possible fallibility of their perceptions, beliefs, ideas, and thinking processes. It also includes the ability to hear corrective feedback and then use it to correct the maladaptive reasoning that underlies faulty conclusions about oneself and others.

Moreover, because cognitive insight includes the ability to entertain alternative explanations or viewpoints, it may ultimately undergird psychological insight. As patients’ cognitive insight increases, they should be more aware of their illnesses and recognize salient symptoms and their real-world impact. In this regard, both of these types of insight may work in tandem to enhance self-understanding and treatment responsiveness.

Both psychological and cognitive insights are best understood as complex and interdependent multidimensional phenomena on a continuum and, hence, should be viewed as nonbinary. 10 Therefore, the question is not whether a patient possesses or lacks psychological or cognitive insight, but rather to what degree, if at all, they demonstrate self-awareness. In this regard, patients can have adequate or better insight into one or more aspects of their condition but not others.

For example, there is evidence that patients with schizophrenia appear to have better awareness of some of their psychiatric symptoms than of their associated cognitive difficulties. 7 Or, a patient may have a very limited understanding of the significance of their psychotic symptoms and decline intervention, but may be painfully aware of their depression and receptive to treatment for mood problems.

Thus, clinicians should use their estimation of a patient’s psychological and cognitive insights to create both a case-specific profile of strengths and weaknesses germane to psychological self-reflection and an estimation of the patient’s ability to work in a reasonably productive manner in treatment. 1

Psychological and cognitive insight are dynamic rather than static constructs. A patient’s insight profile may change over time in response to medical, psychological, and situational influences. A patient’s insight may also fluctuate due to the frequency, duration, type, and severity of neuropsychiatric symptoms.

For instance, a young adult with acute onset of a suspected substance-induced psychotic disorder may display a pattern of uniformly impaired insight, but within a few days of supportive and targeted psychiatric treatment, the same patient may demonstrate substantial improvement on one or more insight components or parameters. Conversely, if a patient has waxing and waning insight-related difficulties due to a major mood disorder with intermittent psychosis and then suffers mild head injuries, they may exhibit a more widespread, persistent, and severe profile of impaired insight, referable to postconcussive factors. Therefore, it is important to periodically reevaluate the adequacy of insight.

Additional Conceptualizations

ANOSOGNOSIA. Psychological and cognitive insight overlap with the construct of anosognosia, which is defined as unawareness or denial of illness. 11 This term is generally limited to the detrimental effects of medical conditions that impair central nervous system functioning and adversely affect a patient’s ability to recognize symptoms and their neurologic causes. It also has negative effects on daily functioning and quality of life. Problems with psychological and cognitive insight are considered an integral part of a patient’s neuropsychiatric status. Additionally, anosognosia might be extended to describe the insight-related difficulties of patients with neuropsychiatric disorders such as schizophrenia (Table 3). 3

PSEUDO-INSIGHT. This refers to patient reports suggesting greater recognition and understanding of their clinical status than is warranted based on history, collateral information, everyday functioning, recent/current life circumstances, and clinical judgment.

In some instances, pseudo-insight represents a form of positive impression management. Patients may display pseudo-insight when seeking greater autonomy from real or perceived control by family or caregivers. Successful impression management can sometimes lead to quicker discharge from inpatient-level care, reduced involvement or termination of outpatient services and mental health court, and the voiding of conditional discharges from state hospitals.

In extreme cases, pseudo-insight can be associated with iatrogenic effects. This can occur when caretakers attempt to achieve quicker and more substantial gains in self-understanding than can be realistically assimilated and productively utilized, leading to a potentially serious worsening of the patient’s clinical status.

Patients with psychotic disorders and personality disorders associated with a susceptibility to narcissistic injury (and accompanying precipitous loss of self-esteem, rage, dissociation, or transient psychosis) are especially vulnerable to destabilization in response to premature or overzealous efforts of clinicians to bolster insight. In particular, patients with borderline personality disorder are highly prone to negative therapeutic reactions, although this can also be observed in patients with other problematic personality patterns. 12

Pseudo-insight can also be a problem after an initial psychotic episode, when patients may experience postpsychotic depression (anxiety, depression, lowered self-esteem, increased hopelessness, suicidal preoccupation, and reduced subjective quality of life). A mix of true and pseudo-insight often accompanies and influences this phase. It has also been tied to the pernicious influence of stigma as a mediating variable, including what is referred to as self-stigma or internalized stigma. 10 Postpsychotic depression is often accompanied by a mix of accurate insight into one’s condition and pseudo-insight. The pernicious influence of stigma may be a mediating variable here, notably what is referred to as “internalized stigma.”

There is also a variant of pseudo-insight that may be more aptly termed “deceptive insight,” which involves persuasive and seemingly illuminating self-disclosures, frequently coupled with observations of others, that aim to manipulate and exploit others. Patients with salient antisocial or psychopathic traits frequently exhibit this form of pseudo-insight.

ALEXITHYMIA. Alexithymia, which roughly translates to “no words for feelings,” involves a striking inability to make sense of and report one’s feelings. 13 It is characterized by severe lifelong difficulty recognizing, labeling, describing, and expressing affective states, including psychological symptoms and other mental status change. These individuals have a characterological form of impaired insight, which may be aggravated by psychosocial or other stressors. It may worsen in response to the onset of neuropsychiatric disorder(s) of varied type.

USABLE INSIGHT. This concept refers to insight that flows from an ongoing treatment that is perceived as supportive and nonthreatening. It can be productively used by the patient to achieve desirable, real- world goals while maintaining hope for continued symptomatic and functional improvement. This insight has received increased attention in the literature on recovery trajectories in psychotic disorders. It potentially has broad application to many other psychiatric conditions, including substance use disorders, because improved insight appears to contribute to better treatment outcomes. 14

FEIGNED ILLNESS. Feigned illness involves an exaggerated and, in some instances, fabricated account of poor daily functioning secondary to psychiatric or medical disorders. It can include reports of difficulties or symptoms that are compatible with impaired insight. 15 This clinical presentation appears to reflect “negative impression management.” These patients may receive a diagnosis of malingering, when the motivation involves one or more external incentives, or of a factitious disorder, when the sick role is a salient motivating factor.

An Etiology of Insight

Impaired insight may result from major mental illnesses such as schizophrenia and other psychiatric conditions, notably major mood disorders with psychotic features that are associated with diminished awareness of illness. In many cases, limitations in insight are associated with long-standing neurodevelopmentally based cognitive and neuropsychological deficits, the onset of neurocognitive deficits during the prodromal psychotic phase, or a first episode of psychosis. 16

In the case of anosognosia, reduced insight can result from an acute or insidious medically induced mental status change, referable to central nervous system dysfunction. This includes an acute mental status change referable to a right hemisphere cerebral vascular accident, which has well-documented negative effects on insight, and the deleterious effects of progressive neurodegenerative diseases such as Alzheimer disease and the behavioral variant of frontotemporal neurocognitive disorder. 17-19

Impaired insight may also result from psychosocial or other stressors, which can heighten the effect of long-standing psychological defenses and associated coping strategies. That said, this explanation for diminished awareness of illness in schizophrenia and related disorders lacks clear empirical support and is not considered a sufficient explanation. 7

Two or more etiologies can have a synergistic effect. For instance, an older adult with significant personality disorder, primarily involving one or more insight-interfering defenses (eg, denial, omnipotence, externalization of blame, projection, and/or projective identification), might develop a neurodegenerative disorder, which is also associated with diminished insight. In these circumstances, it is easy to misattribute the limitations in insight to the neurologic disorder. In fact, the patient’s long-standing problematic defensive structure and coping mechanisms may be a contributory factor or even a sufficient explanation for the insight-related difficulties. This is not rare, especially early in the neurodegenerative disease process.

Along similar lines, limitations in insight frequently co-occur as part of the long-term baseline functioning of patients with neurodevelopmental disorders such as intellectual disability and autism spectrum disorder, even when these conditions are mild. Kindred conditions, like borderline intellectual functioning, are also highly associated with baseline decrements in insight. In some instances, this can lead to an overdiagnosis of an acquired impairment in insight.

A reliable history (via record review or collateral interviews with significant others) that includes neurodevelopmental status, personality patterns and traits, and general adaptation to life preceding illness onset is needed to determine the root cause of a patient’s impaired insight. Reports of previous psychological and neuropsychological test evaluations can also be helpful.

Correlates of Insight

Clinical literature and empirically based studies find many unfavorable consequences of impaired insight. 2 Most of this literature pertains to psychological insight involving patients with psychotic disorders, in particular schizophrenia. Impaired insight has many negative consequences for patients’ mental health, careers, and social lives (Table 4). 3,14,20,21

These negative consequences make intuitive sense and continue to influence clinical practice. However, there is only modest empirical support for many of them. Moreover, most of the research study data are correlational and, hence, insufficient to clearly establish cause and effect relationships. For example, is poor treatment adherence caused by decrements in insight or do difficulties with treatment adherence result in problems with insight? 14

Regarding schizophrenia and psychological insight, there are positive correlations between higher levels of insight and greater adherence to treatment. 14 Higher insight also correlates with improved indices of general mental health and better daily functioning over time. On the other hand, there are negative correlations between lower levels of insight and increased frequency of positive and negative psychotic symptoms, greater disorganized thinking, and increased rates of psychiatric hospitalization.

Additional empirical research on psychological insight is indicative of mixed findings regarding insight and indices of quality of life and functioning. Results have included both positive or negative correlations and no linkages between insight and these variables. 22

Empirical research on cognitive insight has found negative correlations between the self-reflectiveness component of cognitive insight (an indicator of higher cognitive insight) and positive symptoms of psychosis. 2 Notably, these symptoms are more frequent among patients with lower self-reflectiveness. Findings are also consistent with the expected linkage between the self-certainty component of cognitive insight (an indicator of lower cognitive insight) and positive symptoms of psychosis, which are more frequent among patients with higher self-certainty. There are mixed findings regarding the relationship between cognitive insight and indices of quality of life and adequacy of daily functioning.

There is a continuously expanding body of research on the cognitive and neuropsychological correlates of insight. As is true with most other research endeavors pertaining to insight, the most widely studied form of insight is psychological insight. Most investigations have involved patients with schizophrenia and related psychotic disorders. 23

With few exceptions, most studies of patients with schizophrenia report significant and persistent decrements in cognitive and neuropsychological functioning that encompasses general cognitive and intellectual abilities and skills, sustained attention and concentration, anterograde-episodic memory, and executive functioning. 24

Still, patients’ neurocognitive profiles show considerable heterogeneity, and small numbers of patients with schizophrenia have minimal or no discernible neurocognitive deficits based on detailed psychometric testing. 23

Cognitive and neuropsychological functioning should be related to the adequacy of psychological insight. That is, better neurocognitive functioning should be correlated with higher levels of insight, and worse neurocognitive functioning should be linked with lower levels of insight. Overall, studies offer reasonable evidence for this prediction and support the idea that cognitive and neuropsychological deficits are meaningfully related to decrements in accurate self-appraisal. 22

Still, the linkages are far from robust. This suggests that neurocognitive factors are probably not sufficient to explain the high base rates of impaired insight in schizophrenia and psychotic disorders. This underscores the importance of adopting a biopsychosocial perspective when it comes to understanding the relationship of insight to schizophrenia and other mental disorders, and when considering the development of effective strategies to augment insight. 23

Negative correlations have been reported between levels of psychological insight (specifically cognitive difficulties related to having a psychotic disorder) and degrees of neurocognitive impairment. 25

Finally, a review of the correlates of cognitive insight found fairly good support for an association between higher levels of self-certainty and worse neurocognitive functioning. 2 That review also highlights mixed findings when it comes to the expected positive correlation between the self-reflectiveness component of cognitive insight and neurocognitive functioning (namely, that higher levels of self-reflectiveness are associated with better neurocognition). More specifically, higher self-reflectiveness was associated with more compromised neurocognition. 2

Insight and the DSM-5

An innovative feature of the DSM-5 is the introduction of specifiers, which are designed to provide a more fine-grained description of a patient’s diagnostic status. A specifier for insight is based on the following classification: good or fair insight, poor insight, and absent insight or delusional beliefs. This specifier is indicated for 3 of the 9 disorders contained in the chapter titled “Obsessive-Compulsive and Related Disorders.” It remains unclear why only 3 diagnoses and this category of disorders have these specifiers, because many DSM-5 categories include conditions that can present with varying degrees of problematic insight, including neurodevelopmental disorders, dissociative disorders, somatic symptoms and related disorders, feeding and eating disorders, personality disorders, substance-related and addictive disorders, and neurocognitive disorders. 26

Assessment and Tracking Tools

There is no gold standard assessment protocol or tool(s) for evaluating insight, but there are a number of self-report and clinician rating scales that have been developed since the 1990s. 27 All have their strengths and weaknesses, and none are appropriate for all patients.

Most rating scales have been developed for the assessment of psychotic and related disorders and are not clearly applicable to patients with suspected or known decrements in insight. Some scales measure a limited number of components of awareness, judgment, and thinking germane to insight. For example, the Measure of Insight into Cognition-Clinician rating scale is specifically designed to assess insight related to cognitive difficulties and symptoms in patients with schizophrenia. 25

Similarly, many scales are not designed for longitudinal assessment over the course of treatment. Some are geared more to one form of insight than another. For example, the Beck Cognitive Insight Scale is designed for the assessment of cognitive insight, whereas most scales were developed for the evaluation of psychological insight. 5

Scales for the assessment of psychological insight intercorrelate reasonably well, which suggests that they are measuring comparable aspects of this construct. However, correlations between self-report and clinician and observer scales are modest, indicating that there are important discrepancies between patient self-appraisal and clinician judgment regarding insight. 14

Unfortunately, the majority of these instruments have, at best, a limited normative base. Many do not have operational criteria for classifications based on level of severity (eg, impaired/poor, fair, good), which would strengthen interscorer reliability. Moreover, few instruments generate empirically derived cut-off scores for classifications (normal versus abnormal, impaired versus intact) or involve score profiles offering clear guidelines for diagnosis and treatment planning and intervention.

Self-reported rating scales are not stand-alone instruments and should only be used to supplement findings from clinician-based rating scales, clinical and semi-structured interviews, and collateral data from record reviews and informants. Clinical judgment is needed to properly utilize these scales for diagnosis, treatment planning, and longitudinal assessment.

It may be necessary to perform formal psychological and neuropsychological testing. These tests include self-reporting instruments such as the Minnesota Multiphasic Personality Inventory-3 (MMPI-3), the Personality Assessment Inventory (PAI), and the Million Clinical Multiaxial Inventory-IV (MCMI-IV). They contain scales and indices relevant to the assessment of insight (including pseudo- and deceptive insight). Formal psychological and neuropsychological testing should be considered when the patient’s clinical status remains unclear following appropriate assessment or when there is some question about personality and psychodynamic or cognitive and neuropsychological factors that contribute to the patient’s insight-related difficulties/symptoms. Formal testing might also follow repeated unexplained stalemates in treatment or difficulties with treatment adherence that may reflect heretofore unappreciated problematic insight.

Directions for Future Research

The clinical and empirical study of insight has largely been confined to psychotic disorders utilizing the construct of psychological insight. Therefore, considerably less is known about insight (both psychological and cognitive) in relation to mood and other disorders like obsessive-compulsive disorder. 28 There are scant data bearing on the interface of insight with nonpsychotic disorders.

A key research agenda should include the development of empirically validated strategies to enhance cognitive and psychological insight across a range of disorders. Future research should help clinicians reliably differentiate state-related from trait-related decrements in insight. Promising interventions include psychoeducation (with both patients and caregivers), cognitive-behavioral approaches, motivational interviewing, and cognitive remediation. 7,24,29

Future research should aim to better understand the therapeutics of insight, including whether specific interventions may be more effective in enhancing insight with certain patient groups. Further, it would be useful to understand which approaches may be more efficacious than others with certain components of impaired insight and during different phases of illness and stages of treatment. 3,30

As for nonpsychotic disorders, it would be helpful to ascertain the base rates of compromised psychological and cognitive insight in these patients, and whether there are any clinically relevant differences in the level and pattern of insight-related difficulties between psychotic and nonpsychotic disorders and, more generally, across diagnostic categories.

To address these gaps in knowledge, it would be highly desirable to have clinician and patient rating scales that generate score profiles for both psychological and cognitive insight.

Rating scales that are germane to both forms of insight could help to determine whether measuring both at once would improve incremental validity. Multiple-form rating scales could contribute to more successful treatment planning and outcomes among one or more patient groups than rating scales that address only one type of insight.

Work groups tasked with the development of an updated DSM should consider inclusion of a clinical and research review of insight and its application to differential diagnosis.

Dr Pollak is a clinical and neuropsychologist, Emergency Services, Seacoast Mental Health Center, Portsmouth, New Hampshire and an allied health professional, Department of Medical Services, Section of Psychiatry, Exeter Hospital, Exeter, New Hampshire. He reports no conflicts of interest regarding the subject matter of this article.

1. Riggs SE, Grant PM, Perivoliotis D, Beck AT. Assessment of cognitive insight: a qualitative review. Schizophr Bull. 201238(2):338-350.

2. Van Camp LSC, Sabbe BGC, Oldenburg JFE. Cognitive insight: a systematic review. Clin Psychol Rev. 201755:12-24.

3. Lehrer DS, Lorenz J. Anosognosia in schizophrenia: hidden in plain sight. Innov Clin Neurosci. 201411(5-6):10-17.

4. Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007357(18):1834-1840.

5. Beck AT, Baruch E, Balter JM, et al. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res. 200468(2-3):319-329.

6. Beck AT, Warmer PM. Cognitive insight: theory and assessment. In: Amador XF, David AS, eds. Insight and Psychosis: Awareness of Illness in Schizophrenia. Oxford University Press 2004:79-87.

7. Baier M. Insight in schizophrenia: a review. Curr Psychiatry Rep. 201012(4):356-361.

10. Lien YJ, Chang HA, Kao YC, et al. Insight, self-stigma and psychosocial outcomes in schizophrenia: a structural equation modelling approach. Epidemiol Psychiatr Sci. 201827(2):176-185.

8. Parmentier B. Second-generation long-acting injectable anti-psychotics: a practical guide. Curr Psychiatry. 202019:25-32.

9. Sin J, Gillard S, Spain D, et al. Effectiveness of psychoeducational interventions for family careers of people with psychosis: a systematic review and meta-analysis. Clin Psychol Rev. 201756:13-24.

11. Vallar G, Ronchi R. Anosognosia for motor and sensory deficits after unilateral brain damage: a review. Restor Neurol Neurosci. 200624(4-6):247-257.

12. Seinfeld J. A Primer of Handling the Negative Therapeutic Reaction. Jason Aronson 2002.

13. Hemming L, Haddock G, Shaw J, Pratt D. Alexithymia and its associations with depression, suicidality, and aggression: an overview of the literature. Front Psychiatry. 201910:203.

14. Lincoln TM, Lüllmann E, Rief W. Correlates and long-term consequences of poor insight in patients with schizophrenia: a systematic review. Schizophr Bull. 200733(6):1324-1342.

15. Joshi KG, Gehle ME. Dealing with deception: how to manage patients who are “faking it.” Curr Psychiatry. 201918:16, 24.

16. Miller JJ, Pollak J. Prodromal psychosis and first episode psychosis: risk factors and clinical assessment strategies. Arch Med Psychol. 201910:17-34.

17. Kortte K, Hillis AE. Recent advances in the understanding of neglect and anosognosia following right hemisphere stroke. Curr Neurol Neurosci Rep. 20099(6):459-465.

18. Starkstein SE, Jorge R, Mizrahi R, Robinson RG. A diagnostic formulation for anosognosia in Alzheimer’s disease. J Neurol Neurosurg Psychiatry. 200677(6):719-725.

19. Mendez MF, Shapira JS. Loss of emotional insight in behavioral variant frontotemporal dementia or “frontal anosodiaphoria”. Conscious Cogn. 201120(4):1690-1696.

20. Arango C, Amador X. Lessons learned about poor insight. Schizophr Bull. 201137(1):27-28.

21. Cleary SD, Bhatty S, Broussard B, et al. Measuring insight through patient self-report: an in-depth analysis of the factor structure of the Birchwood Insight Scale. Psychiatry Res. 2014216(2):263-268.

22. Ouzir M, Azorin JM, Adida M, et al. Insight in schizophrenia: from conceptualization to neuroscience. Psychiatry Clin Neurosci. 201266(3):167-179.

23. Aleman A. Neurocognitive basis of schizophrenia: information processing abnormalities and clues for treatment. Adv Neurosci. 20142014:104920.

24. Ahmed AO, Hanson MC, Lindenmayer JP. Cognitive remediation services for people with schizophrenia: considerations for health care practitioners. J Health Serv Psychol. 201844:80-89.

25. Medalia A, Thysen J. Insight into neurocognitive dysfunction in schizophrenia. Schizophr Bull. 200834(6):1221-1230.

26. Maremmani AG, Rovai L, Rugani F, et al. Correlations between awareness of illness (insight) and history of addiction in heroin-addicted patients. Front Psychiatry. 20123:61.

27. Casher MI, Bess, JD. Determination and documentation of insight in psychiatric inpatients. Psychiatric Times. 201229(4).

28. Nasrallah HA. Psychosis as a common thread across psychiatric disorders. Curr Psychiatry. 201918:12, 14.

29. Hasan AA, Belkum CV. Psychoeducational interventions for people with schizophrenia: findings from the systematic reviews. Issues Ment Health Nurs. 201940(6):518-534.

30. McGorry PD. Stage-specific treatment of psychotic disorders. Psychiatric Times. 202037(6):14-15. ❒


How to distinguish mental illness and neurodevelopmental disorders? - Psychology

7 October 2019 9am

Event type Conference

Resource for London, 356 Holloway Road, London, N76PA

This conference focusses on assessment and diagnosis in children with neurodevelopmental problems, and is delivered by ACAMH’s Neurodevelopmental Special Interest Group (SIG).

Neurodevelopmental disorders are a neglected area of mental health practice, little mentioned in recent government policy documents. The evidence base is strong in theory but often hard to put into practice at the front line. This conference looks at addressing this.

About the day

There is growing professional recognition that neurodevelopmental conditions are both common, and intimately inter-connected. There is therefore a need for local services to integrate their approach and services to provide holistic, comprehensive neurodevelopmental assessment to a large number of children in their local population. This is challenging enough in any financial climate, but with severe funding constraints in place it becomes a significant difficulty. On top of that, there is professional and wider societal debate about how we should be assessing, and specifically about the value of diagnosis.

By bringing together experts from paediatrics, psychiatry, psychology, education, occupational therapy and speech and language therapy, this conference tackles these problems head-on, in a collaborative multi-professional day of challenging talks and open discussion.

Key takeaways

  • How to structure assessment so that it can be targeted at the right children, and available to all who would benefit
  • How to integrate assessment across health and education effectively and efficiently.
  • Have an understanding of the rationale, limitations and usefulness of diagnosis in neurodevelopmental difficulties.
  • Understand how to integrate neurodevelopmental assessment with assessment of vulnerability or mental health difficulties
  • Learn about new ways of framing and diagnosing difficulties in this are.

Who is it for

This day would be beneficial to those who work in a health setting, such as CAMHS professionals, Paediatricians, Occupational Therapists, Speech and Language Therapists and General Practioners. Additionally, those that work in the education sector, including educational psychologists, SENCOs, hospital school staff, and those that work with children affected with mental health issues who are looking to update their skills and knowledge on this subject.

Programme

09.00 Introduction: Can we deliver neurodevelopmental assessment to all the children and young
people who need it? How? Dr. Max Davie

09.30 The Journey: How can we make the family’s journey through assessment easier and less
stressful? Mary Busk
How can we integrate assessment across education, health and social care? Amanda LeComber

11:00 Disentangling diagnosis
Why diagnose? Why refrain from diagnosing? Dr. Mark Lovell
When does needs assessment end and diagnosis begin? Sally Payne
How does diagnosis and formulation fit together- when do you choose which? Dr. Lauren Breese

Panel Q&A facilitated by Dr. Max Davie

13.30 Workshop sessions (choice of 2 from 3)
a) Getting neurodevelopmental assessment right in socially vulnerable kids. Led by Dr. Carmen Pinto
b) Integrating mental health and neurodevelopmental assessments. Led by Dr. Ann Oszividjian
c) Managing diagnosis: multiplicity removal, grey areas Led by Dr. Mark Lovell
Coffee between workshop sessions

15.15 Closing plenary
Developmental language disorder: how will the new kid on the block fit in? Professor Courtenay Norbury

16.00 Faculty Q&A
Facilitated by Dr Max Davie, with Mary Busk, Dr Lauren Breese, Amanda LeComber, Courtenay Norbury, Dr Mark Lovell, and Sally Payne

Prices

This includes and ACAMH CPD certificate, which is emailed to you after attending the event, plus lunch and refreshments throughout the day.

The events we organise are not profit-making, many are subsidised through our other commercial activities, without which they would not be able to run. As a charity, any surplus that we make is invested back into the business to benefit our Members and the sector. Members get a discounted rate and we hope you consider joining.

ACAMH Publications / Digital Members £52.50
ACAMH Members (Platinum, Gold, Silver, Bronze) £99
Neurodevelopmental SIG Members £129

Non-member: £149

About the speakers

Mary Busk

Mary is a Family Carer Advisers in the Improving Health and Quality Team, part of the Learning Disability Programme for NHS England. Mary is also involved with the CYP part of the Transforming Care programme. Mary previously co-founded the National Network of Parent Carer Forums and was the Steering Group member for London.

Dr Lauren Breese
Lauren is a Senior Clinical Psychologist experienced in assessment, formulation and evidence-based psychological intervention working one to one with children, adolescents and adults, as well as with families, organisations and systems. She is experienced in using CBT and systemic family therapy, as well as mindfulness, ACT, CFT and DBT. Lauren has specialist experience in working with children, adolescents and adults with a neurodevelopmental disorder (ASD, ADHD, ID) and co-morbid mental health problems and/ or behavioural disorder.

Dr. Max Davie

Max is a Consultant Community Paediatrician, working in Lambeth as part of Guy’s and St Thomas’ Hospital NHS Trust Community services. He has a special interest in the assessment and diagnosis of neurodevelopmental conditions in school-age children, and in the mental health of paediatric patients more generally. He is the convenor of the Paediatric Mental Health Association. He is involved with the RCPCH MindEd and disability e-portal projects.

Dr Ann Ozsivadjian
Ann is Principal Clinical Psychologist at Evelina London Children’s Hospital, Guy’s and Thomas’ NHS Foundation Trust. She trained in clinical psychology at Oxford and has worked in the Complex Paediatric Neurodevelopmental Disability Service at the Children’s Neurosciences Centre, Evelina Children’s Hospital (Guy’s and St Thomas’ NHS Foundation Trust) for 14 years since qualification. Her
clinical and research interests include assessment and treatment of mental health difficulties in ASD, and cognitive pathways to anxiety in ASD.

Dr. Sally Payne

Sally is an experienced Paediatric Occupational Therapist with a demonstrated history of working in community healthcare settings. A skilled clinician, Sally is also skilled in research, leadership, teaching and writing for academic and practitioner journals. Strong healthcare services professional with a Doctor of Philosophy (PhD) in Occupational Therapy focusing on the lived experience of adolescents with DCD/dyspraxia from Coventry University.

Amanda Lecomber

Amanda has over 17 years experience as a qualified teacher. She was a class teacher in a large primary school in South London, before becoming the Special Educational Needs Co-Ordinator. She then worked for Worcestershire Learning and Behaviour Support Team as an Outreach Behaviour Support Teacher. In 2007, Amanda moved to Kent and worked as a Specialist Teacher for the Specialist Teaching and Learning Service. She currently works in Hampshire on a school based Wellbeing and Mental Health project. Amanda has extensive experience of working in schools and supporting staff to identify needs and barriers to learning. She has a particular interest in ADHD, having been diagnosed with ADHD as an adult.

Dr. Mark Lovell

Mark is a dual trained Consultant Child and Adolescent Learning Disability Psychiatrist working for 1 of the UK’s largest LD CAMHS teams. He works for Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and covers the South Tees area along with a multidisciplinary team. He is a member of the Child and Adolescent Intellectual Disability Psychiatry Network (CAIDPN) and has particular
interests in Autism and Challenging Behaviour within the context of Intellectual Disabilities.

Professor Courtenay Norbury

Courtenay is Professor of Developmental Disorders of Language and Communication at Psychology and Language Sciences, University College London. Her current research focuses on language disorders and how language interacts with other aspects of development. She is leading SCALES, a population study of language development and disorder from school entry. She is also a founding member of the RADLD campaign.

Dr. Carmen Pinto
Carmen is a Consultant Child and Adolescent Psychiatrist with the Conduct Problems Service and the Adoption and Fostering Service. She also works for the Children & Adolescent Looked-After Service, part of Lambeth Child and Adolescent Mental Health Services (CAMHS). Her post combines her two interests of attachment and CBT and she went on to sit a Postgraduate Diploma (PgDip) in CBT
for Children and Adolescents at the Institute of Psychiatry.


Mental Disorder | Definition, Classification

A mental disorder is defined as a change that takes place in an individual’s thinking pattern and emotions which easily interferes with the performance of his day to day activities, mostly due to disturbances taken place in the brain. There are many types of mental disorders, and anxiety and depression are two of them.

An adverse health condition becomes to be known as a ‘disorder’ when it starts impeding one’s daily activities. Similarly, any condition which involves a disturbed brain will also be considered as a disorder, if his ways of thinking and feelings interfere with his normal lifestyle. Psychologists have introduced several concepts to categorize mental disorders depending on various assessments and diagnosis. For example, ICD-10 Chapter V- Mental and Behavioral Disorders, a subdivision of International Classification of Diseases compiled up by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) created by American Psychiatric Association (APA) are known to be the universal tools of information and assessment in the fields of psychology and psychiatry.


Is It Addiction or Mental Illness? How to Tell the Difference

By now, it’s probably safe to say that it’s common knowledge that drugs have a profound effect on the brain, even to the point of mimicking mental illness. However, it might come as a surprise to learn that this profound effect can last anywhere from 6 months to 2 years from the last use. In other words, a diagnosis of a mental illness or psychological disorder that is made in this window of time is not necessarily accurate it might just be the residual effects of the substance or substances that were being abused. If you are concerned about a loved one’s erratic behavior, you might be wondering, Is it addiction or mental illness? How to tell the difference is outlined below.

Dual Diagnosis

First of all, it’s also important to know that often times, mental illness and addiction go hand-in-hand. A term used for this is dual diagnosis, which means that there are co-occurring disorders present: mental illness, such as depression, anxiety, bipolar disorder, or borderline personality disorder to name just a few, and a substance abuse disorder such as alcoholism or drug addiction.

Physicians report an increase in cases involving patients from all walks of life who are struggling with a combination of substance abuse and mental health problems. Experts estimate that at least 60% of people that are battling one of these conditions are actually battling both, substance abuse and mental illness.

Alan Manevitz, MD, a psychiatrist with New York-Presbyterian Hospital in New York says, “Mental health problems and substance abuse are often seen together because one makes you more vulnerable to the other.”

Often times, it’s a case of chicken-or-the-egg but, what complicates the issue is that whether or not the psychological disorder preceded the substance abuse drugs being introduced into the system have a majorly profound effect on the brain, so much so that a mental diagnosis made within two years from the last use is not always considered an accurate one. Doctors experience difficulty with diagnosing patients therefore, it’s nearly impossible for you to know whether your loved one is suffering from one condition or both.

Self-Medication

Substance abuse and drug addiction often go hand-in-hand and only serve to exacerbate an already existing psychological disorder. But people suffering with mental illness often turn to drugs as a form of self-medicating, in order to alleviate or numb their psychic pain and distress. Furthermore, it is known that the connection between mind and body is so strong that a psychological disorder can actually manifest in physical symptoms, such as is the case with depression and its commonly-associated aches and pains. This is noteworthy because it gives the person who struggles yet another reason or excuse to abuse drugs, such as painkillers, in order to treat the physical symptoms of their mental illness.

Shared Risk Factors

Yet further understanding of both addiction and mental illness show that there are risk factors in common, leading to the development of both disorders.

Genetics. There are genetic factors that predispose, or make susceptible, a person to both addiction and other mental disorders and even to having a greater risk of a second disorder once the first one appears.

Environmental triggers. Stress, unresolved trauma, such as physical or sexual abuse, and early exposure to drugs are common environmental factors that can lead to addiction and mental illness.

Brain changes. The systems of the brain that respond to reward and stress are affected by drugs of abuse and also may show abnormalities in patients with certain mental disorders.

Development. Drug use disorders and other mental illnesses are developmental disorders, meaning they often begin in the adolescence or even younger—periods of time during which the brain experiences dramatic developmental changes. Therefore, early exposure to substances may change the brain in ways that increase the risk for psychological disorders. Early symptoms of a mental disorder may point to an increased risk for drug use later.

Is It Addiction or Mental Illness? How to Tell the Difference

The best way to find out whether your loved one is struggling with addiction or mental illness is to encourage them to see a doctor because a comprehensive approach is necessary in determining whether both conditions are present. Those who seek help for either drug abuse and/or addiction or another mental disorder should be evaluated for both and then treated accordingly.

  • Substance abuse can cause a mental illness
  • Mental illness can lead to substance abuse and addiction
  • Substance abuse and mental disorders are both caused by other common risk factors

If you or someone you love is displaying erratic behavior or thought patterns and you suspect that there is a substance abuse issue and/or mental illness present, help is available in the form of dual diagnosis treatment. Programs such as the one at Palm Partners are highly specialized and specifically designed to treat both addiction and mental illness simultaneously as this is the best way to help the individual who suffers. Please call toll-free 1-800-951-6135 to speak with an Addiction Specialist who can answer your questions. We are available 24/7.


The relationship between psychiatric illness and criminality has been the topic of intense debate and scrutiny in the recent past in light of multiple mass shootings in the United States. While the renewed focus and media attention on the importance of mental health in the aftermath of such tragedies is a positive development, the relationship between mental illness and criminality is too often conflated. The popular belief is that people with mental illness are more prone to commit acts of violence and aggression. The public perception of psychiatric patients as dangerous individuals is often rooted in the portrayal of criminals in the media as Ȭrazy" individuals. A large body of data suggests otherwise. People with mental illness are more likely to be a victim of violent crime than the perpetrator. This bias extends all the way to the criminal justice system, where persons with mental illness get treated as criminals, arrested, charged, and jailed for a longer time in jail compared to the general population. This activity reviews psychiatric illness and criminality and the role of the interprofessional team in caring for afflicted patients.

The relationship between psychiatric illness and criminality has been the topic of intense debate and scrutiny in the recent past in light of multiple mass shootings in the United States.  While the renewed focus and media attention on the importance of mental health in the aftermath of such tragedies is a positive development, the relationship between mental illness and criminality is too often conflated.

The popular belief is that people with mental illness are more prone to commit acts of violence and aggression. The public perception of psychiatric patients as dangerous individuals is often rooted in the portrayal of criminals in the media as 𠇌razy” individuals.  A large body of data suggests otherwise. People with mental illness are more likely to be a victim of violent crime than the perpetrator.[1] This bias extends all the way to the criminal justice system, where persons with mental illness get treated as criminals, arrested, charged, and jailed for a longer time in jail compared to the general population.[2]


Psychological and Cognitive Insight: How to Tell Them Apart and Assess for Each

Impaired insight may result from major mental illnesses such as schizophrenia and other psychiatric conditions, notably major mood disorders with psychotic features that are associated with diminished awareness of illness. Earn CME Credit by learning more about psychological and cognitive insight.

CATEGORY 1 CME

Premiere Date: April 20, 2021

Expiration Date: October 20, 2022

This activity offers CE credits for:

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

ACTIVITY GOAL

The goal of this article is to provide an overview of psychological and cognitive insight, including working definitions for these and other insight-related constructs. The etiologies of compromised insight are outlined. This article also highlights clinically relevant correlates of psychological and cognitive insight.

Learning Objectives:

1. Clarify the similarities and differences between psychological insight and cognitive insight

2. Identify and define different types of pseudo-insight

3. Review common etiologies of compromised insight

4. Discuss the role of rating scales and psychological/neuropsychological testing in the evaluation of insight

TARGET AUDIENCE

This continuing medical education (CME) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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The evaluation of patients’ insight into their own conditions has been a cornerstone of psychiatric practice for more than a century. 1 Most clinical studies and empirical investigations of insight have focused on patients’ so-called psychological insight (sometimes referred to as clinical insight) and its role in the assessment and treatment of schizophrenia and other psychotic disorders. Since the early 2000s, the construct of cognitive insight has emerged as a complementary form and, like psychological insight, is considered to have important implications for research and clinical practice. 2

Historically, assessment of patients’ psychological insight has played a prominent part in differential diagnosis, case formulation, treatment planning, and decision-making. It has been considered an integral component of the mental status examination, intake evaluations, progress/treatment notes, and case closing summaries.

Since the advent of the stress tolerance and coping skills era of psychotherapy in the early 1990s, the construct of insight has played a less significant role in diagnosis and treatment planning. Still, the construct of insight remains an important factor to consider when utilizing a stress tolerance and coping skills approach to assessment and psychotherapy.

Psychological and Cognitive Insight

The reality is that there is no consensus definition for psychological insight. Broad and vague definitions are vulnerable to subjective judgment, low inter-rater reliability, and a high number of false positives, resulting in the overdiagnosis of insight-related problems. Narrower definitions risk generating unacceptably high rates of false negatives. This can lead to underdiagnosis of both the level and the severity of impaired insight and the erroneous conclusion that a patient has enough insight to benefit from a range of treatment options.

From a historical perspective, 3 components stand out: awareness that one has a mental disorder, the ability to correctly attribute one’s symptoms to this condition, and the capacity to appreciate the need for treatment. 2 Additional components include an appreciation of the social and related consequences of one’s illness. 3 For the purpose of this discussion, psychological insight can be gauged by the criteria in Table 1. 4

Cognitive insight, unlike psychological insight, is a relatively recent arrival in the literature and has its genesis in the work of Aaron Beck, MD, and colleagues. 5 Cognitive insight comprises 2 components: self-reflection and self-certainty. The former refers to considering competing perspectives and entertaining alternative explanations for one’s beliefs, ideas, and perceptions. The latter is the ability to be self-critical with respect to the correctness of one’s beliefs, ideas, perceptions, and reasoning process. Self-certainty also includes a willingness to modify one’s conclusions about self and others in response to support and empathetic feedback. Criteria for cognitive insight are included in Table 2. 6

A Widespread Issue

Decreased insight is fairly common among patients with a broad range of mental health, neurodevelopmental, and neurocognitive disorders. Decrements in psychological and cognitive insight are associated with a number of difficulties for patients, their loved ones, and the practitioners involved in their care. Insight-related difficulties also have significant implications for diagnosis, case formulation, and treatment. In addition, clinicians need to carefully assess the adequacy of a patient’s level of psychological and cognitive insight in order to facilitate decision-making regarding informed consent to treatment, civil commitment, mandated outpatient treatment, child custody, parental fitness, work capacity, criminal responsibility, legal guardianship, estate planning, and assisted suicide.

What is generally referred to as impaired insight is prevalent among patients with schizophrenia, major mood disorders, and psychotic disorders. Although estimates vary, it seems at least 30% of these patients have compromised insight, which adversely affects their judgment and decision-making, response to treatment, functioning, and quality of life, as well as the attitudes and feelings of significant others. 7

Insight might impact treatment choices, including level of care, alliance building, choice of treatment modalities, treatment adherence, and the overall course and outcome. For example, if a patient has a history of nonadherence due to persistently impaired insight associated with a psychotic disorder, a long-acting injectable antipsychotic medication may be used to enhance adherence. 8 Patients with impaired insight are also more responsive to supportive psychotherapy with distress tolerance and coping skills components than to insight-based psychodynamically oriented psychotherapy.

As well, both psychological and cognitive insight figure prominently in psychoeducation for caregivers and nonpsychiatric health care providers regarding the psychosocial and medical needs of patients with diminished insight. 9

The Relationship Between Insights

Measures of psychological and cognitive insight correlate to a modest degree, suggesting that these 2 conceptualizations are relatively distinct (albeit overlapping) and complementary constructs. 2

Cognitive insight differs from psychological insight because of its emphasis on meta-cognitive capacities and, more specifically, the patient’s capacity for cognitive flexibility. These considerations encompass patients’ awareness of the possible fallibility of their perceptions, beliefs, ideas, and thinking processes. It also includes the ability to hear corrective feedback and then use it to correct the maladaptive reasoning that underlies faulty conclusions about oneself and others.

Moreover, because cognitive insight includes the ability to entertain alternative explanations or viewpoints, it may ultimately undergird psychological insight. As patients’ cognitive insight increases, they should be more aware of their illnesses and recognize salient symptoms and their real-world impact. In this regard, both of these types of insight may work in tandem to enhance self-understanding and treatment responsiveness.

Both psychological and cognitive insights are best understood as complex and interdependent multidimensional phenomena on a continuum and, hence, should be viewed as nonbinary. 10 Therefore, the question is not whether a patient possesses or lacks psychological or cognitive insight, but rather to what degree, if at all, they demonstrate self-awareness. In this regard, patients can have adequate or better insight into one or more aspects of their condition but not others.

For example, there is evidence that patients with schizophrenia appear to have better awareness of some of their psychiatric symptoms than of their associated cognitive difficulties. 7 Or, a patient may have a very limited understanding of the significance of their psychotic symptoms and decline intervention, but may be painfully aware of their depression and receptive to treatment for mood problems.

Thus, clinicians should use their estimation of a patient’s psychological and cognitive insights to create both a case-specific profile of strengths and weaknesses germane to psychological self-reflection and an estimation of the patient’s ability to work in a reasonably productive manner in treatment. 1

Psychological and cognitive insight are dynamic rather than static constructs. A patient’s insight profile may change over time in response to medical, psychological, and situational influences. A patient’s insight may also fluctuate due to the frequency, duration, type, and severity of neuropsychiatric symptoms.

For instance, a young adult with acute onset of a suspected substance-induced psychotic disorder may display a pattern of uniformly impaired insight, but within a few days of supportive and targeted psychiatric treatment, the same patient may demonstrate substantial improvement on one or more insight components or parameters. Conversely, if a patient has waxing and waning insight-related difficulties due to a major mood disorder with intermittent psychosis and then suffers mild head injuries, they may exhibit a more widespread, persistent, and severe profile of impaired insight, referable to postconcussive factors. Therefore, it is important to periodically reevaluate the adequacy of insight.

Additional Conceptualizations

ANOSOGNOSIA. Psychological and cognitive insight overlap with the construct of anosognosia, which is defined as unawareness or denial of illness. 11 This term is generally limited to the detrimental effects of medical conditions that impair central nervous system functioning and adversely affect a patient’s ability to recognize symptoms and their neurologic causes. It also has negative effects on daily functioning and quality of life. Problems with psychological and cognitive insight are considered an integral part of a patient’s neuropsychiatric status. Additionally, anosognosia might be extended to describe the insight-related difficulties of patients with neuropsychiatric disorders such as schizophrenia (Table 3). 3

PSEUDO-INSIGHT. This refers to patient reports suggesting greater recognition and understanding of their clinical status than is warranted based on history, collateral information, everyday functioning, recent/current life circumstances, and clinical judgment.

In some instances, pseudo-insight represents a form of positive impression management. Patients may display pseudo-insight when seeking greater autonomy from real or perceived control by family or caregivers. Successful impression management can sometimes lead to quicker discharge from inpatient-level care, reduced involvement or termination of outpatient services and mental health court, and the voiding of conditional discharges from state hospitals.

In extreme cases, pseudo-insight can be associated with iatrogenic effects. This can occur when caretakers attempt to achieve quicker and more substantial gains in self-understanding than can be realistically assimilated and productively utilized, leading to a potentially serious worsening of the patient’s clinical status.

Patients with psychotic disorders and personality disorders associated with a susceptibility to narcissistic injury (and accompanying precipitous loss of self-esteem, rage, dissociation, or transient psychosis) are especially vulnerable to destabilization in response to premature or overzealous efforts of clinicians to bolster insight. In particular, patients with borderline personality disorder are highly prone to negative therapeutic reactions, although this can also be observed in patients with other problematic personality patterns. 12

Pseudo-insight can also be a problem after an initial psychotic episode, when patients may experience postpsychotic depression (anxiety, depression, lowered self-esteem, increased hopelessness, suicidal preoccupation, and reduced subjective quality of life). A mix of true and pseudo-insight often accompanies and influences this phase. It has also been tied to the pernicious influence of stigma as a mediating variable, including what is referred to as self-stigma or internalized stigma. 10 Postpsychotic depression is often accompanied by a mix of accurate insight into one’s condition and pseudo-insight. The pernicious influence of stigma may be a mediating variable here, notably what is referred to as “internalized stigma.”

There is also a variant of pseudo-insight that may be more aptly termed “deceptive insight,” which involves persuasive and seemingly illuminating self-disclosures, frequently coupled with observations of others, that aim to manipulate and exploit others. Patients with salient antisocial or psychopathic traits frequently exhibit this form of pseudo-insight.

ALEXITHYMIA. Alexithymia, which roughly translates to “no words for feelings,” involves a striking inability to make sense of and report one’s feelings. 13 It is characterized by severe lifelong difficulty recognizing, labeling, describing, and expressing affective states, including psychological symptoms and other mental status change. These individuals have a characterological form of impaired insight, which may be aggravated by psychosocial or other stressors. It may worsen in response to the onset of neuropsychiatric disorder(s) of varied type.

USABLE INSIGHT. This concept refers to insight that flows from an ongoing treatment that is perceived as supportive and nonthreatening. It can be productively used by the patient to achieve desirable, real- world goals while maintaining hope for continued symptomatic and functional improvement. This insight has received increased attention in the literature on recovery trajectories in psychotic disorders. It potentially has broad application to many other psychiatric conditions, including substance use disorders, because improved insight appears to contribute to better treatment outcomes. 14

FEIGNED ILLNESS. Feigned illness involves an exaggerated and, in some instances, fabricated account of poor daily functioning secondary to psychiatric or medical disorders. It can include reports of difficulties or symptoms that are compatible with impaired insight. 15 This clinical presentation appears to reflect “negative impression management.” These patients may receive a diagnosis of malingering, when the motivation involves one or more external incentives, or of a factitious disorder, when the sick role is a salient motivating factor.

An Etiology of Insight

Impaired insight may result from major mental illnesses such as schizophrenia and other psychiatric conditions, notably major mood disorders with psychotic features that are associated with diminished awareness of illness. In many cases, limitations in insight are associated with long-standing neurodevelopmentally based cognitive and neuropsychological deficits, the onset of neurocognitive deficits during the prodromal psychotic phase, or a first episode of psychosis. 16

In the case of anosognosia, reduced insight can result from an acute or insidious medically induced mental status change, referable to central nervous system dysfunction. This includes an acute mental status change referable to a right hemisphere cerebral vascular accident, which has well-documented negative effects on insight, and the deleterious effects of progressive neurodegenerative diseases such as Alzheimer disease and the behavioral variant of frontotemporal neurocognitive disorder. 17-19

Impaired insight may also result from psychosocial or other stressors, which can heighten the effect of long-standing psychological defenses and associated coping strategies. That said, this explanation for diminished awareness of illness in schizophrenia and related disorders lacks clear empirical support and is not considered a sufficient explanation. 7

Two or more etiologies can have a synergistic effect. For instance, an older adult with significant personality disorder, primarily involving one or more insight-interfering defenses (eg, denial, omnipotence, externalization of blame, projection, and/or projective identification), might develop a neurodegenerative disorder, which is also associated with diminished insight. In these circumstances, it is easy to misattribute the limitations in insight to the neurologic disorder. In fact, the patient’s long-standing problematic defensive structure and coping mechanisms may be a contributory factor or even a sufficient explanation for the insight-related difficulties. This is not rare, especially early in the neurodegenerative disease process.

Along similar lines, limitations in insight frequently co-occur as part of the long-term baseline functioning of patients with neurodevelopmental disorders such as intellectual disability and autism spectrum disorder, even when these conditions are mild. Kindred conditions, like borderline intellectual functioning, are also highly associated with baseline decrements in insight. In some instances, this can lead to an overdiagnosis of an acquired impairment in insight.

A reliable history (via record review or collateral interviews with significant others) that includes neurodevelopmental status, personality patterns and traits, and general adaptation to life preceding illness onset is needed to determine the root cause of a patient’s impaired insight. Reports of previous psychological and neuropsychological test evaluations can also be helpful.

Correlates of Insight

Clinical literature and empirically based studies find many unfavorable consequences of impaired insight. 2 Most of this literature pertains to psychological insight involving patients with psychotic disorders, in particular schizophrenia. Impaired insight has many negative consequences for patients’ mental health, careers, and social lives (Table 4). 3,14,20,21

These negative consequences make intuitive sense and continue to influence clinical practice. However, there is only modest empirical support for many of them. Moreover, most of the research study data are correlational and, hence, insufficient to clearly establish cause and effect relationships. For example, is poor treatment adherence caused by decrements in insight or do difficulties with treatment adherence result in problems with insight? 14

Regarding schizophrenia and psychological insight, there are positive correlations between higher levels of insight and greater adherence to treatment. 14 Higher insight also correlates with improved indices of general mental health and better daily functioning over time. On the other hand, there are negative correlations between lower levels of insight and increased frequency of positive and negative psychotic symptoms, greater disorganized thinking, and increased rates of psychiatric hospitalization.

Additional empirical research on psychological insight is indicative of mixed findings regarding insight and indices of quality of life and functioning. Results have included both positive or negative correlations and no linkages between insight and these variables. 22

Empirical research on cognitive insight has found negative correlations between the self-reflectiveness component of cognitive insight (an indicator of higher cognitive insight) and positive symptoms of psychosis. 2 Notably, these symptoms are more frequent among patients with lower self-reflectiveness. Findings are also consistent with the expected linkage between the self-certainty component of cognitive insight (an indicator of lower cognitive insight) and positive symptoms of psychosis, which are more frequent among patients with higher self-certainty. There are mixed findings regarding the relationship between cognitive insight and indices of quality of life and adequacy of daily functioning.

There is a continuously expanding body of research on the cognitive and neuropsychological correlates of insight. As is true with most other research endeavors pertaining to insight, the most widely studied form of insight is psychological insight. Most investigations have involved patients with schizophrenia and related psychotic disorders. 23

With few exceptions, most studies of patients with schizophrenia report significant and persistent decrements in cognitive and neuropsychological functioning that encompasses general cognitive and intellectual abilities and skills, sustained attention and concentration, anterograde-episodic memory, and executive functioning. 24

Still, patients’ neurocognitive profiles show considerable heterogeneity, and small numbers of patients with schizophrenia have minimal or no discernible neurocognitive deficits based on detailed psychometric testing. 23

Cognitive and neuropsychological functioning should be related to the adequacy of psychological insight. That is, better neurocognitive functioning should be correlated with higher levels of insight, and worse neurocognitive functioning should be linked with lower levels of insight. Overall, studies offer reasonable evidence for this prediction and support the idea that cognitive and neuropsychological deficits are meaningfully related to decrements in accurate self-appraisal. 22

Still, the linkages are far from robust. This suggests that neurocognitive factors are probably not sufficient to explain the high base rates of impaired insight in schizophrenia and psychotic disorders. This underscores the importance of adopting a biopsychosocial perspective when it comes to understanding the relationship of insight to schizophrenia and other mental disorders, and when considering the development of effective strategies to augment insight. 23

Negative correlations have been reported between levels of psychological insight (specifically cognitive difficulties related to having a psychotic disorder) and degrees of neurocognitive impairment. 25

Finally, a review of the correlates of cognitive insight found fairly good support for an association between higher levels of self-certainty and worse neurocognitive functioning. 2 That review also highlights mixed findings when it comes to the expected positive correlation between the self-reflectiveness component of cognitive insight and neurocognitive functioning (namely, that higher levels of self-reflectiveness are associated with better neurocognition). More specifically, higher self-reflectiveness was associated with more compromised neurocognition. 2

Insight and the DSM-5

An innovative feature of the DSM-5 is the introduction of specifiers, which are designed to provide a more fine-grained description of a patient’s diagnostic status. A specifier for insight is based on the following classification: good or fair insight, poor insight, and absent insight or delusional beliefs. This specifier is indicated for 3 of the 9 disorders contained in the chapter titled “Obsessive-Compulsive and Related Disorders.” It remains unclear why only 3 diagnoses and this category of disorders have these specifiers, because many DSM-5 categories include conditions that can present with varying degrees of problematic insight, including neurodevelopmental disorders, dissociative disorders, somatic symptoms and related disorders, feeding and eating disorders, personality disorders, substance-related and addictive disorders, and neurocognitive disorders. 26

Assessment and Tracking Tools

There is no gold standard assessment protocol or tool(s) for evaluating insight, but there are a number of self-report and clinician rating scales that have been developed since the 1990s. 27 All have their strengths and weaknesses, and none are appropriate for all patients.

Most rating scales have been developed for the assessment of psychotic and related disorders and are not clearly applicable to patients with suspected or known decrements in insight. Some scales measure a limited number of components of awareness, judgment, and thinking germane to insight. For example, the Measure of Insight into Cognition-Clinician rating scale is specifically designed to assess insight related to cognitive difficulties and symptoms in patients with schizophrenia. 25

Similarly, many scales are not designed for longitudinal assessment over the course of treatment. Some are geared more to one form of insight than another. For example, the Beck Cognitive Insight Scale is designed for the assessment of cognitive insight, whereas most scales were developed for the evaluation of psychological insight. 5

Scales for the assessment of psychological insight intercorrelate reasonably well, which suggests that they are measuring comparable aspects of this construct. However, correlations between self-report and clinician and observer scales are modest, indicating that there are important discrepancies between patient self-appraisal and clinician judgment regarding insight. 14

Unfortunately, the majority of these instruments have, at best, a limited normative base. Many do not have operational criteria for classifications based on level of severity (eg, impaired/poor, fair, good), which would strengthen interscorer reliability. Moreover, few instruments generate empirically derived cut-off scores for classifications (normal versus abnormal, impaired versus intact) or involve score profiles offering clear guidelines for diagnosis and treatment planning and intervention.

Self-reported rating scales are not stand-alone instruments and should only be used to supplement findings from clinician-based rating scales, clinical and semi-structured interviews, and collateral data from record reviews and informants. Clinical judgment is needed to properly utilize these scales for diagnosis, treatment planning, and longitudinal assessment.

It may be necessary to perform formal psychological and neuropsychological testing. These tests include self-reporting instruments such as the Minnesota Multiphasic Personality Inventory-3 (MMPI-3), the Personality Assessment Inventory (PAI), and the Million Clinical Multiaxial Inventory-IV (MCMI-IV). They contain scales and indices relevant to the assessment of insight (including pseudo- and deceptive insight). Formal psychological and neuropsychological testing should be considered when the patient’s clinical status remains unclear following appropriate assessment or when there is some question about personality and psychodynamic or cognitive and neuropsychological factors that contribute to the patient’s insight-related difficulties/symptoms. Formal testing might also follow repeated unexplained stalemates in treatment or difficulties with treatment adherence that may reflect heretofore unappreciated problematic insight.

Directions for Future Research

The clinical and empirical study of insight has largely been confined to psychotic disorders utilizing the construct of psychological insight. Therefore, considerably less is known about insight (both psychological and cognitive) in relation to mood and other disorders like obsessive-compulsive disorder. 28 There are scant data bearing on the interface of insight with nonpsychotic disorders.

A key research agenda should include the development of empirically validated strategies to enhance cognitive and psychological insight across a range of disorders. Future research should help clinicians reliably differentiate state-related from trait-related decrements in insight. Promising interventions include psychoeducation (with both patients and caregivers), cognitive-behavioral approaches, motivational interviewing, and cognitive remediation. 7,24,29

Future research should aim to better understand the therapeutics of insight, including whether specific interventions may be more effective in enhancing insight with certain patient groups. Further, it would be useful to understand which approaches may be more efficacious than others with certain components of impaired insight and during different phases of illness and stages of treatment. 3,30

As for nonpsychotic disorders, it would be helpful to ascertain the base rates of compromised psychological and cognitive insight in these patients, and whether there are any clinically relevant differences in the level and pattern of insight-related difficulties between psychotic and nonpsychotic disorders and, more generally, across diagnostic categories.

To address these gaps in knowledge, it would be highly desirable to have clinician and patient rating scales that generate score profiles for both psychological and cognitive insight.

Rating scales that are germane to both forms of insight could help to determine whether measuring both at once would improve incremental validity. Multiple-form rating scales could contribute to more successful treatment planning and outcomes among one or more patient groups than rating scales that address only one type of insight.

Work groups tasked with the development of an updated DSM should consider inclusion of a clinical and research review of insight and its application to differential diagnosis.

Dr Pollak is a clinical and neuropsychologist, Emergency Services, Seacoast Mental Health Center, Portsmouth, New Hampshire and an allied health professional, Department of Medical Services, Section of Psychiatry, Exeter Hospital, Exeter, New Hampshire. He reports no conflicts of interest regarding the subject matter of this article.

1. Riggs SE, Grant PM, Perivoliotis D, Beck AT. Assessment of cognitive insight: a qualitative review. Schizophr Bull. 201238(2):338-350.

2. Van Camp LSC, Sabbe BGC, Oldenburg JFE. Cognitive insight: a systematic review. Clin Psychol Rev. 201755:12-24.

3. Lehrer DS, Lorenz J. Anosognosia in schizophrenia: hidden in plain sight. Innov Clin Neurosci. 201411(5-6):10-17.

4. Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007357(18):1834-1840.

5. Beck AT, Baruch E, Balter JM, et al. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res. 200468(2-3):319-329.

6. Beck AT, Warmer PM. Cognitive insight: theory and assessment. In: Amador XF, David AS, eds. Insight and Psychosis: Awareness of Illness in Schizophrenia. Oxford University Press 2004:79-87.

7. Baier M. Insight in schizophrenia: a review. Curr Psychiatry Rep. 201012(4):356-361.

10. Lien YJ, Chang HA, Kao YC, et al. Insight, self-stigma and psychosocial outcomes in schizophrenia: a structural equation modelling approach. Epidemiol Psychiatr Sci. 201827(2):176-185.

8. Parmentier B. Second-generation long-acting injectable anti-psychotics: a practical guide. Curr Psychiatry. 202019:25-32.

9. Sin J, Gillard S, Spain D, et al. Effectiveness of psychoeducational interventions for family careers of people with psychosis: a systematic review and meta-analysis. Clin Psychol Rev. 201756:13-24.

11. Vallar G, Ronchi R. Anosognosia for motor and sensory deficits after unilateral brain damage: a review. Restor Neurol Neurosci. 200624(4-6):247-257.

12. Seinfeld J. A Primer of Handling the Negative Therapeutic Reaction. Jason Aronson 2002.

13. Hemming L, Haddock G, Shaw J, Pratt D. Alexithymia and its associations with depression, suicidality, and aggression: an overview of the literature. Front Psychiatry. 201910:203.

14. Lincoln TM, Lüllmann E, Rief W. Correlates and long-term consequences of poor insight in patients with schizophrenia: a systematic review. Schizophr Bull. 200733(6):1324-1342.

15. Joshi KG, Gehle ME. Dealing with deception: how to manage patients who are “faking it.” Curr Psychiatry. 201918:16, 24.

16. Miller JJ, Pollak J. Prodromal psychosis and first episode psychosis: risk factors and clinical assessment strategies. Arch Med Psychol. 201910:17-34.

17. Kortte K, Hillis AE. Recent advances in the understanding of neglect and anosognosia following right hemisphere stroke. Curr Neurol Neurosci Rep. 20099(6):459-465.

18. Starkstein SE, Jorge R, Mizrahi R, Robinson RG. A diagnostic formulation for anosognosia in Alzheimer’s disease. J Neurol Neurosurg Psychiatry. 200677(6):719-725.

19. Mendez MF, Shapira JS. Loss of emotional insight in behavioral variant frontotemporal dementia or “frontal anosodiaphoria”. Conscious Cogn. 201120(4):1690-1696.

20. Arango C, Amador X. Lessons learned about poor insight. Schizophr Bull. 201137(1):27-28.

21. Cleary SD, Bhatty S, Broussard B, et al. Measuring insight through patient self-report: an in-depth analysis of the factor structure of the Birchwood Insight Scale. Psychiatry Res. 2014216(2):263-268.

22. Ouzir M, Azorin JM, Adida M, et al. Insight in schizophrenia: from conceptualization to neuroscience. Psychiatry Clin Neurosci. 201266(3):167-179.

23. Aleman A. Neurocognitive basis of schizophrenia: information processing abnormalities and clues for treatment. Adv Neurosci. 20142014:104920.

24. Ahmed AO, Hanson MC, Lindenmayer JP. Cognitive remediation services for people with schizophrenia: considerations for health care practitioners. J Health Serv Psychol. 201844:80-89.

25. Medalia A, Thysen J. Insight into neurocognitive dysfunction in schizophrenia. Schizophr Bull. 200834(6):1221-1230.

26. Maremmani AG, Rovai L, Rugani F, et al. Correlations between awareness of illness (insight) and history of addiction in heroin-addicted patients. Front Psychiatry. 20123:61.

27. Casher MI, Bess, JD. Determination and documentation of insight in psychiatric inpatients. Psychiatric Times. 201229(4).

28. Nasrallah HA. Psychosis as a common thread across psychiatric disorders. Curr Psychiatry. 201918:12, 14.

29. Hasan AA, Belkum CV. Psychoeducational interventions for people with schizophrenia: findings from the systematic reviews. Issues Ment Health Nurs. 201940(6):518-534.

30. McGorry PD. Stage-specific treatment of psychotic disorders. Psychiatric Times. 202037(6):14-15. ❒


How to distinguish mental illness and neurodevelopmental disorders? - Psychology

7 October 2019 9am

Event type Conference

Resource for London, 356 Holloway Road, London, N76PA

This conference focusses on assessment and diagnosis in children with neurodevelopmental problems, and is delivered by ACAMH’s Neurodevelopmental Special Interest Group (SIG).

Neurodevelopmental disorders are a neglected area of mental health practice, little mentioned in recent government policy documents. The evidence base is strong in theory but often hard to put into practice at the front line. This conference looks at addressing this.

About the day

There is growing professional recognition that neurodevelopmental conditions are both common, and intimately inter-connected. There is therefore a need for local services to integrate their approach and services to provide holistic, comprehensive neurodevelopmental assessment to a large number of children in their local population. This is challenging enough in any financial climate, but with severe funding constraints in place it becomes a significant difficulty. On top of that, there is professional and wider societal debate about how we should be assessing, and specifically about the value of diagnosis.

By bringing together experts from paediatrics, psychiatry, psychology, education, occupational therapy and speech and language therapy, this conference tackles these problems head-on, in a collaborative multi-professional day of challenging talks and open discussion.

Key takeaways

  • How to structure assessment so that it can be targeted at the right children, and available to all who would benefit
  • How to integrate assessment across health and education effectively and efficiently.
  • Have an understanding of the rationale, limitations and usefulness of diagnosis in neurodevelopmental difficulties.
  • Understand how to integrate neurodevelopmental assessment with assessment of vulnerability or mental health difficulties
  • Learn about new ways of framing and diagnosing difficulties in this are.

Who is it for

This day would be beneficial to those who work in a health setting, such as CAMHS professionals, Paediatricians, Occupational Therapists, Speech and Language Therapists and General Practioners. Additionally, those that work in the education sector, including educational psychologists, SENCOs, hospital school staff, and those that work with children affected with mental health issues who are looking to update their skills and knowledge on this subject.

Programme

09.00 Introduction: Can we deliver neurodevelopmental assessment to all the children and young
people who need it? How? Dr. Max Davie

09.30 The Journey: How can we make the family’s journey through assessment easier and less
stressful? Mary Busk
How can we integrate assessment across education, health and social care? Amanda LeComber

11:00 Disentangling diagnosis
Why diagnose? Why refrain from diagnosing? Dr. Mark Lovell
When does needs assessment end and diagnosis begin? Sally Payne
How does diagnosis and formulation fit together- when do you choose which? Dr. Lauren Breese

Panel Q&A facilitated by Dr. Max Davie

13.30 Workshop sessions (choice of 2 from 3)
a) Getting neurodevelopmental assessment right in socially vulnerable kids. Led by Dr. Carmen Pinto
b) Integrating mental health and neurodevelopmental assessments. Led by Dr. Ann Oszividjian
c) Managing diagnosis: multiplicity removal, grey areas Led by Dr. Mark Lovell
Coffee between workshop sessions

15.15 Closing plenary
Developmental language disorder: how will the new kid on the block fit in? Professor Courtenay Norbury

16.00 Faculty Q&A
Facilitated by Dr Max Davie, with Mary Busk, Dr Lauren Breese, Amanda LeComber, Courtenay Norbury, Dr Mark Lovell, and Sally Payne

Prices

This includes and ACAMH CPD certificate, which is emailed to you after attending the event, plus lunch and refreshments throughout the day.

The events we organise are not profit-making, many are subsidised through our other commercial activities, without which they would not be able to run. As a charity, any surplus that we make is invested back into the business to benefit our Members and the sector. Members get a discounted rate and we hope you consider joining.

ACAMH Publications / Digital Members £52.50
ACAMH Members (Platinum, Gold, Silver, Bronze) £99
Neurodevelopmental SIG Members £129

Non-member: £149

About the speakers

Mary Busk

Mary is a Family Carer Advisers in the Improving Health and Quality Team, part of the Learning Disability Programme for NHS England. Mary is also involved with the CYP part of the Transforming Care programme. Mary previously co-founded the National Network of Parent Carer Forums and was the Steering Group member for London.

Dr Lauren Breese
Lauren is a Senior Clinical Psychologist experienced in assessment, formulation and evidence-based psychological intervention working one to one with children, adolescents and adults, as well as with families, organisations and systems. She is experienced in using CBT and systemic family therapy, as well as mindfulness, ACT, CFT and DBT. Lauren has specialist experience in working with children, adolescents and adults with a neurodevelopmental disorder (ASD, ADHD, ID) and co-morbid mental health problems and/ or behavioural disorder.

Dr. Max Davie

Max is a Consultant Community Paediatrician, working in Lambeth as part of Guy’s and St Thomas’ Hospital NHS Trust Community services. He has a special interest in the assessment and diagnosis of neurodevelopmental conditions in school-age children, and in the mental health of paediatric patients more generally. He is the convenor of the Paediatric Mental Health Association. He is involved with the RCPCH MindEd and disability e-portal projects.

Dr Ann Ozsivadjian
Ann is Principal Clinical Psychologist at Evelina London Children’s Hospital, Guy’s and Thomas’ NHS Foundation Trust. She trained in clinical psychology at Oxford and has worked in the Complex Paediatric Neurodevelopmental Disability Service at the Children’s Neurosciences Centre, Evelina Children’s Hospital (Guy’s and St Thomas’ NHS Foundation Trust) for 14 years since qualification. Her
clinical and research interests include assessment and treatment of mental health difficulties in ASD, and cognitive pathways to anxiety in ASD.

Dr. Sally Payne

Sally is an experienced Paediatric Occupational Therapist with a demonstrated history of working in community healthcare settings. A skilled clinician, Sally is also skilled in research, leadership, teaching and writing for academic and practitioner journals. Strong healthcare services professional with a Doctor of Philosophy (PhD) in Occupational Therapy focusing on the lived experience of adolescents with DCD/dyspraxia from Coventry University.

Amanda Lecomber

Amanda has over 17 years experience as a qualified teacher. She was a class teacher in a large primary school in South London, before becoming the Special Educational Needs Co-Ordinator. She then worked for Worcestershire Learning and Behaviour Support Team as an Outreach Behaviour Support Teacher. In 2007, Amanda moved to Kent and worked as a Specialist Teacher for the Specialist Teaching and Learning Service. She currently works in Hampshire on a school based Wellbeing and Mental Health project. Amanda has extensive experience of working in schools and supporting staff to identify needs and barriers to learning. She has a particular interest in ADHD, having been diagnosed with ADHD as an adult.

Dr. Mark Lovell

Mark is a dual trained Consultant Child and Adolescent Learning Disability Psychiatrist working for 1 of the UK’s largest LD CAMHS teams. He works for Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and covers the South Tees area along with a multidisciplinary team. He is a member of the Child and Adolescent Intellectual Disability Psychiatry Network (CAIDPN) and has particular
interests in Autism and Challenging Behaviour within the context of Intellectual Disabilities.

Professor Courtenay Norbury

Courtenay is Professor of Developmental Disorders of Language and Communication at Psychology and Language Sciences, University College London. Her current research focuses on language disorders and how language interacts with other aspects of development. She is leading SCALES, a population study of language development and disorder from school entry. She is also a founding member of the RADLD campaign.

Dr. Carmen Pinto
Carmen is a Consultant Child and Adolescent Psychiatrist with the Conduct Problems Service and the Adoption and Fostering Service. She also works for the Children & Adolescent Looked-After Service, part of Lambeth Child and Adolescent Mental Health Services (CAMHS). Her post combines her two interests of attachment and CBT and she went on to sit a Postgraduate Diploma (PgDip) in CBT
for Children and Adolescents at the Institute of Psychiatry.


Mental Disorder | Definition, Classification

A mental disorder is defined as a change that takes place in an individual’s thinking pattern and emotions which easily interferes with the performance of his day to day activities, mostly due to disturbances taken place in the brain. There are many types of mental disorders, and anxiety and depression are two of them.

An adverse health condition becomes to be known as a ‘disorder’ when it starts impeding one’s daily activities. Similarly, any condition which involves a disturbed brain will also be considered as a disorder, if his ways of thinking and feelings interfere with his normal lifestyle. Psychologists have introduced several concepts to categorize mental disorders depending on various assessments and diagnosis. For example, ICD-10 Chapter V- Mental and Behavioral Disorders, a subdivision of International Classification of Diseases compiled up by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) created by American Psychiatric Association (APA) are known to be the universal tools of information and assessment in the fields of psychology and psychiatry.


Mental health, neurodevelopmental, and family psychosocial profiles of children born very preterm at risk of an early-onset anxiety disorder

To compare the mental health and neurodevelopmental profiles of school-age children born very preterm, with and without an anxiety disorder, and to identify neonatal medical, psychosocial, and concurrent neurodevelopmental correlates.

Method

A regional cohort of 102 (51 males, 51 females) children born very preterm (mean [SD] gestation at birth=28wks [2], range=23–31wks) was studied from birth to age 9 years alongside a comparison group of 109 (58 males, 51 females) children born at term (mean [SD] gestation at birth=40wks [1], range=38–41wks). At age 9 years, all children underwent a neurodevelopmental evaluation while parents were interviewed using the Development and Well-Being Assessment to diagnose a range of DSM-IV childhood psychiatric disorders. Detailed information was also available about the children’s neonatal medical course and postnatal psychosocial environment, including maternal mental health and parenting.

Results

At age 9 years, 21% (n=21) of very preterm and 13% (n=14) of term-born children met diagnostic criteria for an anxiety disorder. Clinically-anxious children born very preterm were characterized by higher rates of comorbid mental health (odds ratio [OR]=11.5, 95% confidence interval [CI]=3.8–34.7), social (OR=6.2, 95% CI=2.1–18.4), motor (OR=4.4, 95% CI=1.6–12.2), and cognitive (OR=2.6, 95% CI=1.0–7.0) problems than those without an anxiety disorder. Concurrent maternal mental health and child social difficulties were the strongest independent correlates of early-onset child anxiety disorders.

Interpretation

Children born very preterm who developed an early-onset anxiety disorder were subject to high rates of comorbid problems. Findings highlight the importance of addressing both maternal and child mental health issues to optimize outcomes in this high-risk population.


How do you recognise if someone has a mental health issue, and what can you do about it?

At any one time, one in six of us in the UK experiences a common mental disorder such as depression or anxiety.

Many more suffer in silence but do not seek help. Suicide is the biggest cause of death for men under fifty, and for women under 34.

Increasingly, &lsquoMental Health First Aid&rsquo initiatives are being rolled out in workplaces across the UK. A notable case is Stirling Albion football club, one of the first in Scotland to train their staff to recognise some warning signs of mental health problems.

The aim is to prevent anyone at the club suffering in silence, and to identify and deal with problems before they become overwhelming. The initiative does not intend to train staff or players to become therapists, counsellors or psychiatrists but to provide simple tools so they can recognise the signs and symptoms and give appropriate help - something that anyone can do.

So how do you spot if someone has a mental health problem &ndash and what can you do to support them?

Some signs that someone might be at risk include:

  • Being withdrawn or lost in thought
  • Losing their sense of humour
  • Being erratic, unusually agitated, tearful, or, conversely, emotionless
  • Changes in appetite, weight or sleep patterns
  • Increased alcohol consumption

So if you think someone you know might be at risk of mental health difficulties, what should you do?

  • Start by saying you&rsquove noticed a change in their mood or behaviour - without being critical.
  • Say you&rsquore concerned and ask if they&rsquod like to talk.
  • Don&rsquot downplay their problems or say things like &ldquowhat do you have to be depressed about?&rdquo
  • Listen and give them space to describe how they&rsquore feeling.
  • Encourage them to see their GP or offer to go with them to see a health professional.
  • If you think they&rsquore at risk of suicide, you can call the emergency services, or call their GP for an emergency appointment.

If you recognise the early warning signs in someone, or know they are struggling with their mental health, these first steps can make an enormous difference to their health and their lives.

Another important element of mental health first aid is to address the stigma attached to mental health problems. People often feel more embarrassed or ashamed of acknowledging mental health issues than physical ones, and it&rsquos important to help them try to overcome these feelings and feel comfortable talking about their mental health.


Defining and measuring age at onset

This life-course view means that identifying the age at onset of mental disorders is important, but it is difficult. Reference Kessler, Amminger, Aguilar-Gaxiola, Alonso, Lee and Ustun 4 The classic psychiatric disorders of adult life often begin with non-specific symptoms. As studies of the evolution of symptoms become more detailed, it is clear that early psychopathologic changes can be transient and dynamic before crystallising into a syndrome fitting some operational category such as the American Psychiatric Association's DSM. Only in retrospect can a decision be taken as to whether the early features were in fact part of the eventual picture. In epidemiological terms this leads to enormous scope for error or bias in the recall or memory of events Reference Simon and VonKorff 5 some elements may be misattributed to illness and others simply forgotten. From a clinical point of view it is well known that the better the history, the earlier the age at onset can be dated. Furthermore, just as periods of low mood and occasional elation are part of normal life, it seems likely that some psychological experiences such as voice hallucination, hitherto considered psychopathological, are relatively common during certain developmental periods it is their persistence or coexistence with other features that marks them as significant. This is leading to conceptual difficulties with clinical concepts such as the prodrome that are at best meaningless or confusing when used at the population level, and may be damaging if they lead to interventions that have adverse benefit-to-harm profiles quite different from the clinical situation.

Retrospective accounts of age at onset for some disorders are more useful than others, and perfect for none. Despite the problems alluded to above, it is a reasonable (and useful) assumption that a large proportion of people with psychotic illness eventually receive treatment, especially given that in the definitions of some types of psychosis such as schizophrenia, disability and loss of function are included in their definition. Thus, a survey using retrospective accounts of age at onset for schizophrenia or a broader group of non-affective psychosis yields useful information. It also avoids contamination by the data for the vast majority of young people who may experience psychotic phenomena without ever being ill. However, this is at the cost of excluding the few people with incipient illness but not yet in contact with services and, for many years, of masking researchers to the extent of psychotic phenomena as part of normal experience for many decades epidemiologists regarded such phenomena simply as false positives. The retrospective approach is also hampered by the long duration of untreated psychosis in many with non-affective psychosis who eventually make service contact, but the alternative approach – using a community survey for incident illness – would be hugely inefficient given the relative rarity of cases and the fact that the illness itself means that affected people would be less likely to take part. Reference Perala, Suvisaari, Saarni, Kuoppasalmi, Isometsa and Pirkola 6 It is important to recognise that the retrospective approach in clinical samples yields a self-fulfilling estimate of the age at onset of psychotic disorders that are seen and treated in clinical services, not a broader phenotype that does not meet this threshold. That said, the method – especially when combined with population registers of treated mental disorder – can lead to definitive results. Reference Perala, Suvisaari, Saarni, Kuoppasalmi, Isometsa and Pirkola 6

Using retrospective accounts of age at onset from cohorts of treated individuals is not useful for less disabling mental disorders because most are never treated. In some areas such as cardiovascular disease and cancer it is effective to follow up large cohorts of individuals and track these outcomes which are relatively easy to measure. Reference Yan, Liu, Daviglus, Colangelo, Kiefe and Sidney 7 This is much more difficult for common mental disorders where the true incidence and age at onset need intensive study, but has been achieved for psychotic illness using population-based birth cohort studies where follow-up is achieved either through regular interviews and surveys, Reference Jones, Rodgers, Murray and Marmot 8 or through population registers. Reference Isohanni, Makikyro, Moring, Rasanen, Hakko and Partanen 9 Such studies are rare and usually problematic in some way as they were initiated for reasons other than mental health disorders. For these reasons, retrospective reports from carefully designed cross-sectional community surveys provide most evidence on age at onset for most mental health disorders.

Examples of each of these methodological approaches to age at onset are outlined below, taking different exemplar disorders. This is followed by a discussion as to whether the findings on age at onset in mental health disorders fit with what we know about brain development. One final comment about the definition of age at onset arises from modern accounts of many long-term conditions in the framework of life course models. Here, a model of cardiovascular disease in late adulthood might encompass genetic inheritance, the epigenetic modification of the genome by fetal environment and childhood nutrition, the importance of social context in the beginnings of cigarette smoking at school, followed by further genetic and behavioural aspects in the establishment of nicotine dependence and sedentary lifestyle. The example could go on but illustrates the gradual accretion of interacting components to a self-perpetuating cascade of causation. In the domain of mental health disorders the seeds of schizophrenia may be sown in early life, Reference Jones, Rodgers, Murray and Marmot 8 and early motor developmental abnormalities may betray important information as to the underlying neurobiology of psychotic symptoms in a later phase of development. Reference Ridler, Veijola, Tanskanen, Miettunen, Chitnis and Suckling 10 However, one would be hard pushed to say that later motor milestones were the beginning of schizophrenia. Thus, in this article, the onset of a disorder is defined as the onset of features that form part of the disorder and that are contiguous with its first expression.


Psychology

A consortium of psychiatrists and psychologists from universities around the world, co-led by Professor Bob Krueger and colleagues from Stony Brook University and the University of Notre Dame, has proposed a new approach to diagnosing mental disorders. The approach, articulated in a paper published in the Journal of Abnormal Psychology, is a classification system of a wide range of psychiatric problems based on scientific evidence, illness symptoms and impaired functioning. The diagnostic system addresses fundamental shortcomings of the fifth edition (2013) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the clinicians’ and researchers’ guidebook to mental illnesses.

Diagnosis of mental illness is important because it defines what treatment a patient should receive. Diagnosis also guides research efforts and is used by drug companies to develop new medications. The newly developed diagnostic approach is called the Hierarchical Taxonomy of Psychopathology (HiTOP). In the paper, titled “The Hierarchical Taxonomy of Psychopathology (HiTOP): A Dimensional Alternative to Traditional Nosologies,” (PDF) the consortium advances classification of psychopathology beyond the traditional diagnostic systems.

According to Krueger and his colleagues, substantial evidence has accumulated that suggest major changes to how mental illness is classified, but DSM-5 offered only modest refinements creating dissatisfaction in the research community. The National Institute of Mental Health (NIMH) produced an alternative model to guide mental health research efforts. This approach has also been controversial, as it focuses heavily on neurobiology and much less on investigating issues that are important for everyday psychiatric care, such as prognosis about illness course and selection of treatment.

As Krueger explains it, the DSM can be challenging to use in everyday practice. “It’s Byzantine,” he says. “It’s like the U.S. tax code. You can get lost in the complexity of its contents and still not find a compelling or accurate way to conceptualize your patient.”

“The HiTOP system has been articulated to address the limitations currently plaguing psychiatric diagnosis,” says lead author Kotov. “First, the system proposes to view mental disorders as spectra. Second, the HiTOP system uses empirical evidence to understand overlap among these disorders and classify different presentations of patients with a given disorder.”

For example, Kotov explained that mental health problems are difficult to put into categories, as they lie on the continuum between pathology and normality, much like weight and blood pressure. This is why the spectrum approach is needed. Applying an artificial boundary to distinguish mental illness from health problems results in unstable diagnoses, as one symptom can change the diagnosis from present to absent. It also leaves a large group of people with symptoms that do not reach the threshold untreated, although they suffer significant impairment.

Also, different DSM-5 diagnoses co-occur with surprising frequency, with most patients labelled with more than one mental health disorder at the same time. Extensive evidence indicates an underlying pattern of several major spectra that cause this overlap. Furthermore, diagnostic categories are so complex that often two patients with the same diagnosis do not share a single symptom in common.

The HiTOP solution to these fundamental problems is to classify mental illness at multiple levels of hierarchy: the broad level captures the major spectra and specific level reflects the tightly-knit dimensions within them. This approach allows doctors and researchers to focus on finer symptom in detail, or assess broader problems, as necessary.

A good example of this new classification is social anxiety disorder, which is considered a category in DSM-5. The HiTOP model describes social anxiety as a graded dimension, ranging from people who experience mild discomfort in a few social situations (i.e., when giving a talk in front of a large audience) to those who are extremely fearful in most situations. The HiTOP system recognizes that clinical levels of social anxiety are more intense but not fundamentally different from regular social discomfort.

Also, HiTOP does not treat it as a single problem but recognizes important differences between interpersonal fears (i.e., meeting new people) and performance fears (i.e., performing in front of an audience). Moreover, people with social anxiety are prone to other anxieties and depression, and the HiTOP model describes a broad spectrum called “internalizing,” which captures overall severity of such problems.

Overall, the authors emphasize that HiTOP adheres to the most up-to-date scientific evidence, rather than relying largely on decisions by committee (the approach used to construct the DSM-5). In the assessment of mental disorders, the HiTOP approach accounts for information on shared genetic vulnerabilities, environmental risk factors, and neurobiological abnormalities, such as differences in brain activity between the patients and healthy individuals.