Insight and Awareness

Question 1

What is anosagnosia?

Answer 1

Lack of awareness of a neurological deficit or psychiatric condition

Question 2

Who was the first documented case of anosognosia?

Answer 2

Ursula M

Unaware of visual loss (Anton’s Syndrome)

Question 3

How does a lesion resulting in hemianopia WITH anosognosia differ from one WITHOU?

Answer 3

Much larger, reaching into parietal lobe

(Attached ‘awareness’ system)

Question 4

What is the spectrum of insight?

Answer 4

Objective deficits (e.g., hemiplegia) to subjective experiences (e.g., delusions)

Question 5

Insight is modular or a general system?

Answer 5

Modular

I.e. may have insight into some functions but not others (many different insight systems as opposed to just one)

(At least in neurology)

Question 6

How is insight into memory impairment in Alzheimer’s?

Answer 6

▪️ Will often overestimate ability
▪️ As will informants to some extent
▪️ Not very good at learning and adjusting awareness

Question 7

How is insight into memory impairment in schizophrenia?

Answer 7

Tend to be very accurate at predicting ability = insight into impairment

Question 8

What can we infer from intact insight into memory deficits in schizophrenia?

Answer 8

Insight is modular - they can still have insight into other deficits even if they don’t have insight into their delusions and hallucinations

Question 9

What factors relate to greater insight/awareness and what does this tell us about insight?

Answer 9

▪️ Better executive functioning
▪️ Better working memory
▪️ Lower mood

(suggests although modular, there are some general factors too)

Question 10

How does depression relate to insight and why?

Answer 10

Individuals with greater insight and awareness tend to have lower mood

▪️ Greater awareness of problems?
▪️ Depressive realism?

Question 11

How does carer burden relate to insight and awareness?

Answer 11

Greater carer burden associated with lower awareness

Harder to care for people who lack insight?

Question 12

What are the three components of insight?

Answer 12

▪️ Awareness of illness (“I am sick”)
▪️ Compliance/adherence to treatment (“This tablet will help”)
▪️ Ability to re-label symptoms (“The voices aren’t real”)

All overlap, can have one without the other
Very good insight = all three

Question 13

What are the hypothesised constituents of insight?

Answer 13

▪️ Psychopathology
▪️ Neurobiological?
▪️ General intellect
▪️ Executive function
▪️ Personality
▪️ Culture
▪️ Family/peer attitudes
▪️ Unknown

Question 14

How does cognition relate to insight?

Answer 14

More severe insight deficits associated with lower general cognition (including IQ)

Well replicated BUT small/modest effect size?

Question 15

What is the Cognitive Model of Insight?

Answer 15

▪️ Cognitive system is constantly processing perceptions, memories etc
▪️ Executive function controls how we process
▪️ All of this is monitored by appraisal system (metacognition)

Question 16

Is insight a lack of knowledge?

Answer 16

No!

If give mentally ill individual vignette describing someone with similar symptoms, they can say that the person is mentally ill but they cannot recognise that they are like them (cannot apply knowledge to themselves?)

Question 17

What is the overall conclusions of insight and brain structure and volume?

Answer 17

Quite inconsistent

Some find it in temporal lobes, some in frontal lobes, and some find nothing at all

Question 18

How does grey matter density differ in those with low vs high insight in psychosis?

Answer 18

Most deficits in the midline medial band, particularly at the front

▪️ Medial frontal
▪️ Anterior cingulate
▪️ Possibly posterior cingulate

Question 19

What areas of cortical thickness have been associated with awareness of mental disorder in FEP?

Answer 19

Left frontal and temporal poles

Question 20

What areas of cortical thickness have been associated with awareness of need for treatment in FEP?

Answer 20

Left frontal, parietal, and temporal poles

Question 21

How do you summarise the brain correlates found with lack of insight?

Answer 21

▪️ Generally quite diffuse
▪️ Recurring involvement of medial/midline structure

Question 22

What white matter deficits have been associated with symptoms of unawareness?

Answer 22

Fronto-temporal

Question 23

What white matter deficits have been associated with misattribution of symptoms?

Answer 23

Temporal-parietal

Question 24

What brain activation has been found with fMRI during self-appraisal and self-reflection?

Answer 24

Activation of the Cortical Midline System (CMS):
▪️ Medial prefrontal cortex
▪️ Anterior cingulate
▪️ Possibly posterior cingulate and rDLPFC

Question 25

How does medial (CMS) activation in relation to insight and illness awareness differ across illness types?

Answer 25

Generally the same!

Question 26

How does medial frontal activation for other- and self-appraisal differ between SCZ and HC?

Answer 26

▪️ Both activate same amount when appraising others
▪️ Increased activation in HC with self-appraisal but no change for SCZ

Question 27

Is there a genetic component to insight?

Answer 27

Possibly

Those with highest polygenic burden for SCZ have highest risk for poor insight (3.2% of variance?)

Question 28

Can tDCS be used for insight?

Answer 28

Yes - appears to show some transient improvements