Notes on the Presentation by Dr. Xavier Amador  

Researchers are currently looking at "psychotic disorders" that range from affective disorders such as manic depression to schizophrenia. All are broad patterns of brain disfunction that lead to similar patterns of symptomatology, such as the inability to separate fact from fiction (delusions), false perceptions, disorganized speech and behavior, and the inability to care for oneself.
    
There are many misperceptions about schizophrenia. People do not understand that it is a brain disorder typified by structural and functional abnormalities. The brain "circuits" that are affected impact the way the person thinks and believes.

When most commitment laws were passed, our understanding of these disorders was based primarily on psychoanalytic notions of mental illness. Dr. Amador was taught that patients with psychotic disorders who had poor insight felt stigmatized and were defending themselves.

(Videotaped presentation of Dr. Amador's discussion with a paranoid schizophrenic.)

Those with closed brain injuries tend to confabulate who they are and what they do. They have a concept of themselves that is in many ways stranded in time at that point just before the injury to the brain. The same is true for those with mental illness, they perceive themselves to be in the state they were in before they became ill.

The number one reason people with psychotic disorders do not take their medicine is poor insight into their illness. Noncompliance rates run about 50%. Perhaps as many as 80,000 West Virginians have schizophrenia or a bipolar disorder, half of these do not think they are ill or are unaware of many facets of their illness. Therefore, they are very unlikely to take their medication.

Most mental illnesses are chronic with exacerbations and periods of remissions. There are very few cases of complete remission. Failure to treat psychotic episodes resulted in worsening of the mental illness, poorer response to medication, and increased overall severity of the illness. One theory is that psychosis is essentially toxic to the brain. Therefore, aggressive treatment is indicated.

Research out of Long Island Jewish Hospital shows that first-psychotic-break patients have a much better course of illness if they get treated early on. Those who get treated late do much worse.

What is poor insight? There are three theories: defensiveness, an alternative belief system, or a neuropsychological deficit (the most likely explanation).

This is an exploding area of research. The evidence shows that it is not denial or attitude. A World Health Organization Study showed that 81% to 89% of patients studied had poor insight. This may be an overestimation but shows that those with mental illness often think they are not ill. The DSM IV's field trials indicated that as many as 60% of schizophrenics have moderate to severe unawareness of their illness. "Unawareness" is tricky to test. It is not an all or none phenomenon.

A patient can have some awareness, and that awareness can wax and wane. Patients may also not recognize the signs and symptoms of their illness. Certain aspects of poor insight may be protective in terms of suicide ideation.

The Etiology of Poor Insight

Anosognosia: failure to recognize a disease
Anostephoria: an emotional indifference to a disease

The brain areas implicated in both anosognosia and anostephoria, the frontal and temporal lobes, are the same as those implicated in schizophrenia. The frontal lobes of the brain do not function properly in those with schizophrenia. The brains of schizophrenics show physical changes in these areas as well. There is a very high correlation between decreased levels of insight and brain disfunction.

There is a neurological basis for severe deficits in awareness of illness. Schizophrenics can be defensive and in denial, but like people who have strokes, they can develop anosognosia. Anosognosia appears in patients with stroke damage to the frontal lobes. Patients may be paralyzed by a stroke on one side of their body and not be aware of it. This is an example of self-concept stranded in time because of a brain injury, like a computer file that is not updated.

Our laws, the legal profession and the public does not understand what science understands about brain disorders. Moreover, overcoming the stigma against psychiatry will also be a problem. Overcoming both will be necessary to bring about change.