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Psychiatrike = Psychiatriki 2019There is now general agreement that lack of insight is not merely a fundamental aspect of delusions and hallucinations, or just a symptom of psychotic disorders but...
There is now general agreement that lack of insight is not merely a fundamental aspect of delusions and hallucinations, or just a symptom of psychotic disorders but rather a multi-dimensional construct. Several different components of insight have been proposed and empirically examined during the last three decades, such as the ability to recognize that one has a mental illness, the capacity to relabel unusual mental events as pathological, the specific attribution of one's symptoms to having a mental illness, awareness of illness' consequences, and compliance with treatment.1 Insight impairment is an important prognostic factor in schizophrenia, impacting negatively on medication adherence, treatment outcome, and social functioning.2 Although largely investigated in schizophrenia and other psychoses, insight impairments are observed in many, if not all, mental disorders. Varying levels of awareness of mental illness and/or of specific symptoms are expected in patients with bipolar disorders, Alzheimer disease and other neurocognitive disorders, obsessive-compulsive (OCD) and related disorders.1,3 While in DSM-5 an "insight" specifier was incorporated for OCD, body dysmorphic and hoarding disorder, patients' insight has been found ranging from good to absent in other disorders, such as depressive disorders,4 eating disorders,5 and even specific6 and social7 phobias. Moreover, impaired insight is a common reason that many people with clinical depression or anxiety disorders never seek appropriate treatment and most of the people with addictions and personality disorders fail to recognize and address their problems even when the consequences are devastating: personal suffering, broken relationships, and physical health problems. Depending on the disorder and reflecting different conceptual approaches, many different terms are used to describe lack of insight, such as poor self-awareness, denial, anosognosia (mainly in neurological deficits, e.g. hemiplegia), ego-syntonic symptoms, or even self-deception. At any rate, as an aspect of self-knowledge, insight has psychological (defense mechanisms, coping strategies), social and cultural facets. On the other hand, the attitudes and behaviours towards one's illness are products of inference processes and therefore can be influenced by cognitive dysfunctions. Previous research in schizophrenia showed correlations between neurocognitive functions and insight measures but the strength of this association is rather weak.8 Social cognition may be a crucial cognitive determinant of impaired insight in schizophrenia. The correct attitude toward morbid change in oneself relies on the capacity to reflect upon self from the perspective of the other (i.e., "to see ourselves as others see us"). This capacity is clearly linked to the ability to understand mental states (e.g., beliefs, knowledge, and intentions) of others, that is, theory of mind or mentalizing. Recent research has shown that mentalizing deficits may substantially contribute to insight impairment in schizophrenia.9 This effect could be further examined in the broader context of patient's failures in metacognition, i.e. the general ability to think about thinking, and their relationships with insight impairment in schizophrenia. Mentalizing and introspection are closely related developmentally and it is yet unclear which one is the primary ability: we are able to understand others and then apply this understanding to ourselves or we are able to reflect on ourselves and then apply this reflection to others. A recent line of research in schizophrenia is based on the distinction introduced by Beck et al10 between clinical insight (i.e., awareness of illness) and cognitive insight, which describes a metacognitive ability, specifically patients' flexibility towards their beliefs, judgements and experiences. The self-report Beck Cognitive Insight Scale (BCIS) examines two subcomponents: self-certainty, assessing overconfidence about being right (e.g. "I know better than anyone else what mycomponents: self-certainty, assessing overconfidence about being right (e.g. "I know better than anyone else what my problems are"), and self-reflectiveness, assessing willingness to accept external feedback and recognition of dysfunctionalreasoning style (e.g. "Some of the ideas I was certain were true turned out to be false"). Cognitive insight in thisform describes two related but distinct aspects of metacognition in patients with psychosis, differentially associated withclinical insight, symptoms, treatment outcomes, and functioning.11 Another method for assessment of similar metacognitiveskills also used in schizophrenia is a scale (Metacognition Assessment Scale - Abbreviated, MAS-A) that is administeredthrough a specific interview and examines the capacities of self-reflectivity, understanding of the other individuals'mental states, and using metacognitive knowledge to respond to psychosocial challenges. Lysaker and colleaguesfound recently that metacognitive deficits assessed with MAS-A predict impaired insight in schizophrenia independentof symptoms.12 It is questionable whether BCIS and other methods used so far to assess self-reflection in psychoses arevalid and useful for patients with non-psychotic disorders.11 However, the metacognitive conceptualization of insightmight contribute to a new research framework for insight impairments across mental disorders. According to this approach, poor insight is in part a failure of self-reflection, i.e. the process by which we synthesizeand comprehend ideas about ourselves. This may be due to general deficits in metacognitive abilities (self-reflectivity,mentalizing) or may represent limited, domain-specific, or transient dysfunctions in metacognitive processes. Insight hasto be thought of as a relational concept, that is insight into something: insight into illness, current syndrome, specificsymptoms, pathological personality traits, social difficulties etc.1,3 In an integrated model of insight across mental disorders,aspects of metacognition interacting with multiple other (clinical, neurocognitive, emotional, and social) factorsdetermine patient's ability to correctly process information into self-awareness. The identification of these factors andtheir interactions may be a fruitful field in the research of insight.
Topics: Cognition Disorders; Humans; Mental Disorders; Metacognition; Schizophrenic Psychology; Self Concept
PubMed: 31115349
DOI: 10.22365/jpsych.2019.301.13 -
Behavioral Sciences (Basel, Switzerland) Nov 2018Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system through which patients can suffer from sensory, motor,... (Review)
Review
Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system through which patients can suffer from sensory, motor, cerebellar, emotional, and cognitive symptoms. Although cognitive and behavioral dysfunctions are frequently encountered in MS patients, they have previously received little attention. Among the most frequently impaired cognitive domains are attention, information processing speed, and working memory, which have been extensively addressed in this population. However, less emphasis has been placed on other domains like moral judgment. The latter is a complex cognitive sphere that implies the individuals' ability to judge others' actions and relies on numerous affective and cognitive processes. Moral cognition is crucial for healthy and adequate interpersonal relationships, and its alteration might have drastic impacts on patients' quality of life. This work aims to analyze the studies that have addressed moral cognition in MS. Only three works have previously addressed moral judgement in this clinical population compared to healthy controls, and none included neuroimaging or physiological measures. Although scarce, the available data suggest a complex pattern of moral judgments that deviate from normal response. This finding was accompanied by socio-emotional and cognitive deficits. Only preliminary data are available on moral cognition in MS, and its neurobiological foundations are still needing to be explored. Future studies would benefit from combining moral cognitive measures with comprehensive neuropsychological batteries and neuroimaging/neurophysiological modalities (e.g., functional magnetic resonance imaging, tractography, evoked potentials, electroencephalography) aiming to decipher the neural underpinning of moral judgement deficits and subsequently conceive potential interventions in MS patients.
PubMed: 30453483
DOI: 10.3390/bs8110105 -
BMC Medical Ethics Mar 2021Chronic kidney disease is a significant cause of global deaths. Those who progress to end-stage kidney disease often commence dialysis as a life-extending treatment. For... (Review)
Review
BACKGROUND
Chronic kidney disease is a significant cause of global deaths. Those who progress to end-stage kidney disease often commence dialysis as a life-extending treatment. For cognitively impaired patients, the decision as to whether they commence dialysis will fall to someone else. This scoping review was conducted to map existing literature pertaining to how decisions about dialysis are and should be made with, for, and on behalf of adult patients who lack decision-making capacity. In doing so, it forms the basis of a larger body of work that is exploring how these decisions ought to be made.
METHODS
To identify relevant papers, searches were conducted on Ovid MEDLINE(R), Embase, PsychINFO, The Cochrane Library, and Web of Science. Inclusion criteria were then applied, requiring that papers: report on empirical studies about how decisions about dialysis are made and/or discuss how decisions about dialysis should be made with, for, and on behalf of adult patients who lack decision-making capacity; be published from 1961 onwards; and be published in English. This resulted in 27 papers eligible for inclusion.
RESULTS
Of note, the majority of papers originated in the United States. There was wide variation across the included papers. Extracted data were grouped under the following themes: involving various parties (patient involvement, family dominance, and wider communication); objectivity about care options (including difficulties with family detachment); cultural sensitivity; medical versus non-medical factors; managing nonadherent patients; and the role and prevalence of substituted judgement. The literature shows that there is inconsistency in the principles and processes surrounding decisions made about dialysis with, for, and on behalf of adult patients who lack decision-making capacity.
CONCLUSIONS
This scoping review demonstrates that there is significant variation in both the practice and theory of dialysis decision making with, for, and on behalf of cognitively impaired adult patients. Complexity arises in considering who should get a say, how influential their say should be in a decision, and what factors are most relevant to the decision. A lack of up-to-date literature exploring this issue is highlighted, with this scoping review providing a useful groundwork from which further research can be undertaken.
Topics: Adult; Communication; Decision Making; Humans; Kidney Failure, Chronic; Patient Participation; Renal Dialysis
PubMed: 33663482
DOI: 10.1186/s12910-021-00591-w -
International Journal of Environmental... Nov 2021Powered mobility devices (PMD) promote independence, social participation, and quality of life for individuals with mobility limitations. However, some individuals would... (Review)
Review
BACKGROUND
Powered mobility devices (PMD) promote independence, social participation, and quality of life for individuals with mobility limitations. However, some individuals would benefit from PMD, but may be precluded access. This is particularly true for those with cognitive impairments who may be perceived as unsafe and unable to use a PMD. This study explored the relationships between cognitive functioning and PMD use. The objectives were to identify cognitive functions necessary to use a PMD and describe available PMD training approaches.
METHODS
A scoping review was undertaken.
RESULTS
Seventeen studies were included. Four examined the predictive or correlational relationships between cognitive functioning and PMD use outcomes with intellectual functions, visual and visuospatial perception, attention, abstraction, judgement, organization and planning, problem solving, and memory identified as having a relation with PMD use outcome in at least one study. Thirteen others studied the influence of PMD provision or training on users' PMD capacity and cognitive outcomes and reported significative improvements of PMD capacities after PMD training. Six studies found improved cognitive scores after PMD training.
CONCLUSIONS
Cognitive functioning is required to use a PMD. Individuals with heterogeneous cognitive impairment can improve their PMD capacities. Results contribute to advancing knowledge for PMD provision.
Topics: Cognition; Humans; Mobility Limitation; Quality of Life; Self-Help Devices; Social Participation
PubMed: 34886194
DOI: 10.3390/ijerph182312467 -
Degenerative Neurological and... 2018Multiple sclerosis (MS) is a disease that heavily affects postural control, predisposing patients to accidental falls and fall-related injuries, with a relevant burden... (Review)
Review
Multiple sclerosis (MS) is a disease that heavily affects postural control, predisposing patients to accidental falls and fall-related injuries, with a relevant burden on their families, health care systems and themselves. Clinical scales aimed to assess balance are easy to administer in daily clinical setting, but suffer from several limitations including their variable execution, subjective judgment in the scoring system, poor performance in identifying patients at higher risk of falls, and statistical concerns mainly related to distribution of their scores. Today we are able to objectively and reliably assess postural control not only with laboratory-grade standard force platform, but also with low-cost systems based on commercial devices that provide acceptable comparability to gold-standard equipment. The sensitivity of measurements derived from force platforms is such that we can detect balance abnormalities even in minimally impaired patients and predict the risk of future accidental falls accurately. By manipulating sensory inputs (dynamic posturography) or by adding a concurrent cognitive task (dual-task paradigm) to the standard postural assessment, we can unmask postural control deficit even in patients at first demyelinating event or in those with a radiologic isolated syndrome. Studies on neuroanatomical correlates support the multifactorial etiology of postural control deficit in MS, with the association with balance impairment being correlated with cerebellum, spinal cord, and highly ordered processing network according to different studies. Postural control deficit can be managed by means of rehabilitation, which is the most important way to improve balance in patients with MS, but there are also suggestions of a beneficial effect of some pharmacologic interventions. On the other hand, it would be useful to pay attention to some drugs that are currently used to manage other symptoms in daily clinical setting because they can further impair postural controls of patients with MS.
PubMed: 30050386
DOI: 10.2147/DNND.S135755 -
Scientific Reports Oct 2020Idiopathic epilepsy (IE) is the most common chronic neurological condition in dogs, characterised by recurrent seizure activity and associated with negative behavioural...
Idiopathic epilepsy (IE) is the most common chronic neurological condition in dogs, characterised by recurrent seizure activity and associated with negative behavioural and cognitive changes. We hypothesised that IE would negatively impact putative affective state, with dogs with IE exhibiting a more pessimistic judgement bias and more negative attention bias than controls. Dogs were tested in a previously-validated spatial judgement bias task, and a novel auditory attention bias task testing attention to sounds with different valence or salience (neutral, novel pre-habituated, threatening). Sixty-eight dogs (IE = 33, Control = 35) were tested, of which n = 37 acquired the spatial discrimination and responses to judgement bias probes were tested (IE = 19, Control = 18), and n = 36 were tested for responses to sounds (IE = 20, Control = 16). Study groups did not significantly differ by age, sex, breed or neuter-status (p > 0.05). Main effects of study group were not significant in judgement bias (F = 0.20, p = 0.658) or attention bias tasks (F = 1.64, p = 0.184). In contrast with our hypotheses, there was no evidence that IE altered cognitive biases in this study population; however, dogs with IE were significantly more likely to be unable to learn the spatial discrimination task (p = 0.019), which may reflect IE-related cognitive deficits. Developing methods to test affective state without excluding cognitively impaired individuals is a future challenge for animal welfare science.
Topics: Animal Welfare; Animals; Attentional Bias; Behavior, Animal; Dogs; Emotions; Epilepsy; Female; Judgment; Male
PubMed: 33082493
DOI: 10.1038/s41598-020-74777-4 -
Journal of Vision Jun 2021Our visual experience appears uniform across the visual field, despite the poor resolution of peripheral vision. This may be because we do not notice that we are missing...
Our visual experience appears uniform across the visual field, despite the poor resolution of peripheral vision. This may be because we do not notice that we are missing details in the periphery of our visual field and believe that peripheral vision is just as rich as central vision. In other words, the uniformity of the visual scene could be explained by a metacognitive bias. We deployed a confidence forced-choice method to measure metacognitive performance in peripheral as compared to central vision. Participants judged the orientation of gratings presented in central and peripheral vision, and reported whether they thought they were more likely to be correct in the perceptual decision for the central or for the peripheral stimulus. Observers were underconfident in the periphery: higher sensory evidence in the periphery was needed to equate confidence choices between central and peripheral perceptual decisions. When performance on the central and peripheral tasks was matched, observers were still more confident in their ability to report the orientation of the central gratings over the one of the peripheral gratings. In a second experiment, we measured metacognitive sensitivity, as the difference in perceptual sensitivity between perceptual decisions that are chosen with high confidence and decisions that are chosen with low confidence. Results showed that metacognitive sensitivity is lower when participants compare central to peripheral perceptual decisions compared to when they compare peripheral to peripheral or central to central perceptual decisions. In a third experiment, we showed that peripheral underconfidence does not arise because observers based confidence judgments on stimulus size or contrast range rather than on perceptual performance. Taken together, results indicate that humans are impaired in comparing central with peripheral perceptual performance, but metacognitive biases cannot explain our impression of uniformity, as this would require peripheral overconfidence.
Topics: Humans; Judgment; Metacognition; Vision, Ocular; Visual Fields; Visual Perception
PubMed: 34106222
DOI: 10.1167/jov.21.6.2