Insight et interventions psychoéducationnelles dans la schizophrénie

Poor insight is consistently present in schizophrenia and is among the most discriminating symptoms for differentiating schizophrenia from other mental disorders. Patients are unable to see the most obvious symptoms of their illness, despite the fact that their family members can recognize thought disorder, mania or hallucinations. Results suggest that lack of insight is a part of the disorder itself, rather than an adaptive strategy. Poor insight in schizophrenia has been described as a lack of awareness of suffering from an illness, of the symptoms of the illness, of the consequences of the disorder, and of the need for treatment. Similarly to some negative symptoms lack of insight predisposes to an increased number of relapses and hospitalizations, to deteriorating social skills and quality of social relationships, and to a worsening course of illness. Unawareness is among the best predictions of non-adherence to treatment. Patients do not want to take medicine for an illness they do not think they have. The ways in which patients think about their illness experiences have been associated with a variety of behaviours and emotional responses. In schizophrenia, the study of beliefs about mental illness has generally been centered on people's interpretations of experiences and how these interpretations contribute to the development and maintenance of symptoms. There are less studies of other beliefs such as the causes of the experience, beliefs about treatment, consequences, and how long the illness is likely to last. The need to understand the way in which a patient appraises his/her own experiences has been recognized. People who integrated their experiences more fully, accepting that they had experienced a psychotic episode, actually showed higher levels of depression. This may reflect the demoralization and stigma that patients associate with mental illness. Many clinicians believe that lack of insight is very often a consequence of denial, a defensive mechanism. Terms such as defensive denial, and lack of insight often reflect underlying conceptual differences. Psychoeducational interventions were developed to increase patients’ knowledge of, and awareness about their illness, there is a focus on knowledge. Education is a process by which a patient gains understanding through learning. Patients have a right to an accurate and complete knowledge regarding their illness and treatment. The assumption is that this increased knowledge and insight will enable patients to cope in a more effective way. Learning implies changes in behaviour, skill or attitude. There is some suggestion that psychoeducation may improve compliance with medication and have a positive effect on a patients’ quality of life. Psychoeducational approaches involve interaction between the caregiver and the mentally ill person. Patient education can take a variety of forms and objectives. It may take place in groups or on a one-to-one basis and it may involve the use of videotapes, self-help or other media. The goal may be to better manage the patient's treatment, illness or condition to help him/her attain an improved level of health. Psychoeducational interventions address the illness from a multidimensional viewpoint, including familial, social and pharmacological information. Patients are provided with support, information and management strategies. Interventions may include elements of behavioural training, social and life skills training, or education performed by professional caregivers. This review studies the links between insight and various psychoeducational interventions: health and treatment education, psychosocial skills training, familial intervention, and intervention focused on subjective illness experience.     

Mortalité et surmortalité dans la schizophrénie

The aim of the present communication is to present an overview on mortality in schizophrenic patients. Recent meta-analyses have confirmed high rates of mortality in schizophrenic patients and, notably, the gap observed in the last three decades between mortality in the general population and that of schizophrenic patients. In this population mortality rates due to non-natural causes, essentially suicide, are 12 times higher than that of the general population, natural causes of mortality being due to cardiovascular and respiratory diseases. Atypical antipsychotics have been incriminated in the high rate of mortality among schizophrenic patients. Prevention was focused firstly on a decrease of the risk of suicide and secondly on poor living habits (smoking, obesity). The importance of a regular follow-up of the somatic health of schizophrenic patients was discussed.     

Insight cognitif et schizophrénie

Schizophrenia is usually associated with severe and chronic lack of knowledge of mental illness. This lack of insight is found to be correlated to hypofrontality but not related to the disorder outcome or to the intelligence quotient. The cognitive insight was defined as the difference between self-reflectiveness and self-certainty. This ability is described as decreased in schizophrenia but increased in depression. Thus, schizophrenia with depressive comorbidity is associated with a higher level of insight. The authors discuss how greater awareness of psychotic illness can be lived as traumatic, which appears to be a risk factor for depression and suicide.     

L’insight et les croyances relatives aux médicaments influencent l’observance médicamenteuse dans la schizophrénie

Background

Even effective drugs are useless when not taken. The aim of this study is to assess whether attitudes toward treatment were a better predictor of compliance than insight in schizophrenia.

Methods

Ninety-eight inpatients diagnosed with schizophrenia were evaluated within 1 week after being admitted to a psychiatric ward.

Results

Forty-nine percent of patients were non-compliant. Assessing jointly DAI and insight scores optimized the prediction of compliance to antipsychotic medication: results from a logistic regression indicated that compliance is better predicted by DAI factor 2 score “patient's assessment of need for medications” combined to SUMD G1 insight score “insight into mental disorder” (ROC AUC = 0.776).

Discussion

It is possible that there is a conceptual overlap between patient's assessment of need for medication and clinical insight.

Conclusion

Clinical insight and attitudes toward treatment are stronger predictors of compliance when combined.     

La pensée et le langage par le corps dans la schizophrénie

Connections between body and psyche are regularly studied in the field of psychosis. One of the reasons of that recurrence is the fact that schizophrenic psychosis deconstructs the discursive system and exposes its bodily roots. In the first part of this paper, we remind several authors (Dolto, Pankow, Aulagnier, Golse, Delion, Piaget, Stern i.e.), whose works are showing how the mind develops on the basis of sense - and bodily experiences. In the second part, we examine the specificity of the schizophrenia as regression to the autoerotism and we mention Freud's idea of the “organ's language”. The organ's language represents the use of bodily symbols into the discourse; those symbols have to be interpreted like dreams. Finally, two clinical examples illustrate those elements. We examine the idea that, even if the nosographic category “schizophrenia” has not necessarily to be defended, there is perhaps a common clinical feature defined by the place of the body in the discourse.     

Production d’émotions faciales dans la schizophrénie

Converging evidences revealed that facial pattern recognition is severely impaired in schizophrenia. The present article focuses on recognition of their own facial expression by patients with schizophrenia. It seems that schizophrenia is related with a dissociation between facial expression and emotional feeling. Recent experimental data are discussed.     

Les personnes atteintes de schizophrénie et la rechute

Introduction

In schizophrenia, relapse is a common event that affects more than half the patients within 2 years after a first episode [10]. It is a real setback for them and their relatives. Surprisingly, we do not have much information on how patients and their relatives experience the relapse.

Method

A national survey was conducted among 316 schizophrenic outpatients treated with antipsychotics, and 82 of their relatives. The survey assessed the following four aspects: disease history, last relapse history, hospitalization experiences, and relapse prevention.

Results

Regarding the disease history, the average psychiatric follow-up was 13 years and patients had been hospitalized five times on average. Relatives reported approximately the same history. Regarding the last relapse, 9/10 of relatives reported that this relapse led to hospitalization and 69% of patients understood that their hospitalizations were due to relapse. 4% of patients and 7% of relatives identified the end of the treatment as a precursor to relapse. While a lack of compliance was found in about four relapses out of 10. It has also been shown that patients confided primarily in the medical team and the relatives thought to be the first confidant of patients. Regarding the experience of hospitalization, 87% of patients and 86% of relatives judged the hospitalization useful. For both, hospitalization represented a solving step to manifestations of relapse. Regarding the relapse prevention, almost three patients out of four thought they knew what to do in order to avoid a new relapse, while only 52% of the relatives thought patients knew what to do for this matter. For more than one third of the patients, the last relapse (3 years ago) was still a painful event. Avoiding a new relapse was considered very important or important by 91% of patients and 100% of relatives. Relatives felt that regular appointments with the medical team helped avoid relapses. Fifty-nine per cent of relatives have said it was difficult to verify whether or not the treatment was taken by a schizophrenic patient. Relatives’ opinion on the injectable treatment was favorable and approximately 50% of the patients declared knowing of injectable treatments. Among these 72% felt that such treatment was reassuring, 69% said it was simpler than oral therapy, and 67% thought it was the most suitable to check the compliance. Only 31% considered it restricting for the patient, against 54% who were considering it not restricting. Finally 57% of patients were willing to take an injectable treatment in order to prevent further hospitalization.

Conclusion

This study brings us a better understanding of patients’ and relatives’ experience of relapse. These results demonstrate the potential impact of relapse on the patients and their relatives and highlight their motivation to avoid further relapses. Also revealed, the lack of importance given to the link between compliance and relapse by patients and relatives. These results underscore the complexity of this disease management in which each player has a key role.     

La fonction cicatrisante du délire dans la schizophrénie

Psychoanalytic epistemology considers psychosis to be linked to the resurgence of traumatic experiences that have not been assimilated by subjectivity. The hallucinatory return of this primitive agony faces the psychotic subject with a driving encroachment that attacks his body and disintegrates its unitary organisation. Considering this reliving of traumatic experiences, the authors will present schizophrenic delusion less as a pathological result than as a subjective response that aims to treat the psychic over tension, which fractures the subject's body identity. Based on several clinical studies, this article will question the healing effect of delusion in schizophrenia. It is therefore concerned with investigating the different functions of delusion and identifying their incidence on the subject's body image. Using the different clinical examples cited, the authors will then attempt to develop certain therapeutic applications, which contribute to a possible reduction of the body disintegration phenomena in schizophrenia.     

De la médiation picturale dans le traitement de la schizophrénie

With schizophrenic patients, the use of the pictorial mediation during individual session of psychotherapy makes easier the display of the transferential y counter-transferential relationship. These creations are truly a way to say what the patient is unable to express differently. The use of a media: mediator, mediation, malleable medium, constitutes a first level of symbolization. It is used as an intermediary between nonsense feelings and their elaboration through the speech. In addition, these pictorial productions throw light on the question of ideality in psychosis and on this kind of archaic transference of the narcissistic pathologies.     

Approche neurocognitive des troubles du vécu dans la schizophrénie

Lived experiences mentioned by patients with schizophrenia can be addressed with neurocognitive models. In particular, these models allow us to better understand self-consciousness and social cognition impairment that is a core feature of schizophrenia. Abnormal brain functioning related to this impairment has been shown. These data show that these symptoms are related to specific neurocognitive correlates. They shed a new light on the understanding of schizophrenic symptoms.     

La reconnaissance visuelle des émotions faciales dans la schizophrénie chronique

We studied the visual recognition of the facial emotions, on 20 chronic and institutionalized schizophrenics. They were paired in age, sex, educational level with a reference group. We used the MARIE battery which uses a binary pairing in a continuum of intermediate images. The recognition of the disgust is decreased followed by the fear. The surprise is the least overdrawn. The recognition of anger and the bipolar series (emotion-emotion) is strictly identical to that of the controls.     

Insight et comportements violents chez les patients souffrant d’une schizophrénie

Schizophrenia is associated in popular belief with violent behaviour. In recent years, many studies conducted on this topic have found an increased risk of violence in subjects with mental disorders. However, violent behaviour in patients with schizophrenia is also multifactorial. Some studies report that risk of violent behaviour increased in patients with schizophrenia with poor insight, but others did not confirm this idea. The picture is not clear, and prospective studies should be conducted on this topic.     

Pour une thérapie de l’identité dans la schizophrénie

Schizophrenia, more than a disruption or dissociation of personality, is a break of identity which means an attack on human freedom. Whatever reported to a loss on the set of roles, or of natural evidence, it legitimizes a support for an identity therapy, based on the power to heal, the return to the role performance, and the mobilization of life histories. If schizophrenia is a state of extreme autonomy, if we consider it as the moment of repeated birth of identity, it involves the essential problem of subjectivity, which is the “power to create meaning”. Then the central therapeutic principle must establish the favourable conditions to the dynamics of identity formation of the patient. This therapy of identity is established in a praise of patience, which includes the need to structure a therapeutic framework forming a support to the everyday life, and organizes the time of the meeting in order to satisfy this particular requirement of have to build not so much the future rather than the past. The therapeutic team must be attentive to the movement of individuation, and works to ensure relational availability, to soften the rules of community functioning while firmly maintaining the main direction of care program, and to initiate a frequent renewal of treatment plan in the context of chemotherapeutic stabilization that can be considered as a premedication.     

Implication du stress oxydant dans la physiopathologie de la schizophrénie : revue de la literature

Background

Schizophrenia is a devastating psychiatric disorder with a broad range of behavioural and biologic manifestations. There are several clinical characteristics of the illness that have been consistently associated with poor premorbid adjustment, long duration of psychosis prior to treatment and prominent negative symptoms. The etiopathogenic mechanisms of lack of insight in patients with schizophrenia are to date unknown, although several hypotheses have been suggested. A point of convergence for the theoretical models occurs with regard to the neuronal membrane. Neuronal membrane contains a high proportion of polyunsaturated fatty acid and is the site for oxidative stress. Oxidative stress is a state when there is unbalance between the generation of reactive oxygen species and antioxidant defence capacity of the body. It is closely associated with a number of diseases including Parkinson's disease, Alzheimer-type dementia and Huntington's chorea. Accumulating evidence points to many interrelated mechanisms that increase production of reactive oxygen or decrease antioxidant protection in schizophrenic patients.

Objectives

This review aims to summarize the perturbations in antioxidant protection systems during schizophrenia, their interrelationships with the characteristic clinics and therapeutics and the implications of these observations in the pathophysiology of schizophrenia are discussed.

Literature findings

In schizophrenia there is evidence for deregulation of free radical metabolism, as detected by abnormal activity of critical antioxidant enzymes (superoxide dismutase, glutathione peroxidase and catalase). Many studies conclude in the decrease in the activity of key antioxidant enzymes in schizophrenia. A few studies have examined levels of non enzymatic antioxidants such as plasma antioxidant proteins (albumin, bilirubine, uric acid) and trace elements. How showed decreased levels in schizophrenic patients. Others studies have provided evidence of oxidative membrane damage by examining levels of lipid peroxidation products. Such abnormalities have been associated with certain clinical symptoms and therapeutic features. Negative symptoms have been associated with low levels of GSH-Px. Positive symptoms have been positively correlated with SOD activity. Plasma TAS was significantly lower in drug-free and haloperidol treated patients with schizophrenia. A low erythrocyte SOD activity has been found in never-treated patients, but with haloperidol treatment, SOD activity increased.

Discussion

These results demonstrate altered membrane dynamics and antioxidant enzyme activity in schizophrenia. Membrane dysfunction can be secondary to free a radical-mediated pathology, and may contribute to specific aspects of the schizophrenia symptomatology. Membrane defects can significantly alter a broad range of membrane functions and presumably modify behavior through multiple downstream biological effects. Phospholipid metabolism in the brain may be perturbed in schizophrenia, with reduced amounts of phosphatidylcholins and phosphatidylethanolamine in post-mortem brain tissue from schizophrenic patients, and large amounts of lipofuscin-like materiel in the oligodendrocytes. The existence of these products within cell membranes results in an unstable membrane structure, altered membrane fluidity and permeability and impaired signal transduction. Recent findings suggest that multiple neurotransmitter systems may be faulty. CNS cells are more vulnerable to the toxic effects of free radicals because they have a high rate of catecholamine oxidative metabolic activity. Neurotransmitters, like glutamate, can induce the same metabolic processes that increase free radical production and can lead to impaired dopamine-glutamate balance. These results question the role of this imbalance in the biochemical basis evoked in the etipathogenic mechanisms of schizophrenia, as well as the role of antioxidants in the therapeutic strategy and their implication in preventive and early intervention approaches in populations at risk for schizophrenia.     

Insight et qualité de vie subjective chez les personnes souffrant de schizophrénie

The evaluation of subjective quality of life constitutes one of the indicators of the health conditions of the patients suffering from schizophrenia. The relations between insight and quality of life are contradictory in the literature. These differences can be explained by several factors: populations of studies, instruments of the insight and/or quality of life very diverse and often not very valid, factors of confusion. Among the factors of confusion, it seems that the cognitive disorders play a central role as certain studies show it. There remains however difficult to know how these various factors interact between them.