Monthly Archives: April 2011

‘I’m not ill’: How awareness of illness is a new trend in psychosis research

How patients understand their mental illness can strongly affect treatment, progress of illness and outcome in psychosis. ‘Clinical insight’ is patients’ awareness and understanding that they are ill; if a patient has poor insight into their illness it can lead to problems relating to treatment and recovery. It was previously believed that lack of insight was a coping strategy, however recently it is more widely believed to be an actual symptom. In recent years research into patients insight into their illness has increased, focusing on the biological causes such as changes or differences in brain structure.

A popular and robust way of measuring a patient’s awareness and understanding  (hereby referred to as ‘insight’) of their illness was proposed by David (1990) whereby you measure:

1.       A patient’s acknowledgement that they are ill.

This one is fairly self explanatory; if they don’t think they’re ill they have poor insight.

2.       How well a patient is sticking with their medication.

If a patient doesn’t take their medication all the time, or refuses completely, this can often suggest that they don’t believe they are ill and so have poor insight.

3.       A patient’s ability to relate symptoms to being ill.

Sometimes patients will admit they are ill and take medication as prescribed, but still believe their symptoms are real; this is also an indicator of poor insight.

This idea can be more confusing, so here’s an example:

Patient ‘x’ has ‘persecutory delusions’ that MI5 have planted a chip in his brain. He claims to believe he is ill, and will take his medication. Both of these actions imply ‘x’ has good insight into his illness. However he also believes that his illness is due of the ‘MI5 chip’ in his brain, and therefore his illness is not a problem with him personally, but a reaction to the chip. This additional piece of information clearly highlights that acceptance of his diagnosis and taking his medication only tells us half the story of x’s insight. Therefore the need for this three point measure of insight is crucial.
A recent study by Parellada et al (2011) found that awareness of illness in patients was worse 2 years after diagnosis of Schizophrenia Spectrum Disorders than in other psychotic disorders. However this disagrees with previous research by Saeedi et al (2007) who found that after a first diagnosis of psychosis the number of patients with good insight into their illness rose from 60% at diagnosis to about 80% after a year and this was stable 2 years after diagnosis. However both studies agree that poorer insight was related to a more severe psychosis, and to poorer cognitive functioning at the time ofdiagnosis. Clearly this is a complex symptom of psychosis and more studies need to be carried out.

Abnormal structure of the frontal lobe can lead to poorer awareness of illness.

For this reason in the last 5 years research has begun to focus on the biological basis of insight in psychosis patients. There is strong evidence for a difference in patients brain structure that affects their awareness of illness. The hope is to use this information to develop methods of either improving levels of insight or better ways of treating patients with poor insight. Often patients have less brain matter in key areas of their frontal lobe (front area of the brain) than in non-psychotic patients and healthy people. A reduced amount of grey matter and fewer connections between white matter and grey matter in the frontal areas of the brain can affect cognition (our ability to perform logical tasks and memory) and patients’ awareness of illness.
However the two kinds of problem are not directly related; ie a patient can have better insight into their cognitive problems, such as poor memory, than into their clinical symptoms, such as associating the voices they hear to the illness rather than god speaking to them. This is believed to be because the two mental processes are similar but not exactly the same, and are dealt with in different areas of the frontal lobe.

More research needs to be done, but hopefully a better understanding of the underlying problems of psychosis patients’ awareness of their illness will lead to better treatment outcomes in the future.

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Music as Medicine: How enjoying music can help stroke recovery

Research by Soto et al, 2009 has indicated that listening music can reduce visual neglect in stroke patients. This may seem like a strong claim to make, but the results speak for themselves.

Brain damage as a result of a stroke can lead to impaired visual awareness, usually by ignoring the space on one side of their body, and in severe cases this can also lead to neglecting limbs. This in turn leads to problems interacting with objects in the environment. This is clearly a big problem when related to rehabilitation and recovery after a stroke; if you aren’t paying attention to half of your visual environment, how do you get around in your daily life safely? Simple acts of crossing the road can become a serious problem if you don’t pay attention to any traffic coming from one direction.

In the past 20 years there have been many different suggestions on how to draw patients’ attention back to their neglected side of vision. These include the use of prism glasses, which cause patients’ line of vision to be moved towards the neglected side, and reducing vision on patients ‘good’ side of vision to increase their dependence on the ‘bad’ side. Most methods have shown in some cases to have an effect, but often these take training, time and effort to work, which can often be a problem for recovering patients.

Listening to pleasant music can reduce visual neglect

 

Soto et al found improvements in patients’ recovery can be achieved quickly and with less effort.  The study involved patients with visual neglect carrying out a number of tasks which, to be completed successfully, required attention to be paid to both sides of vision. Patients performed the tasks whilst listening to either their preferred type of music, a disliked type of music or no music.

Listening to pleasant music has been shown to improve our emotional state. In healthy individuals positive mood has been shown to enhance our ability to solve problems and increase visual attention.  

This study showed that listening to a preferred type of music was related to improved performance on all tasks, meaning that patients were using more information from their neglected side of vision than with no music.

When tasks were then performed in an MRI scanner it was clear that listening to preferred music increased neural activity in ‘emotional areas’ of patients’ brains, and this was strongly associated with improved performance on the tasks. This finding suggests that the increased activity in patients’ emotional brain areas also boosts neural activity in areas related to attention processes,  and so increased the levels of attention that patients paid to their neglected side.

This study highlights that patients’ mood after a stroke is important to a successful recovery and that sometimes a simple intervention can be just as effective as training and effort. Hopefully such a simple act of listening to music will lead to better recovery outcomes for stroke patients in the future.

 

 

Original article by:

Soto D., et al. (2009) Pleasant music overcomes the loss of awareness in patients with visual neglect. PNAS (in press). Published online 23 March; DOI: 10.1073/pnas.0811681106

My Brain…in Brief

I’m a neuroscience nerd so I love a bit of fMRI.

During my masters the easiest way to get participants (other than paying them) was to do an MRI study and offer participants a picture of their brain to take home afterwards! It wasn’t to hard to persuade me to get in the scanner…and the results are seen below!

Insanium in the Cranium

I’m told I have a good head size for scanning…small. You’ll see I managed to fit my nose AND some neck into the coil, I’ll take it as a win.

Despite the size of my head I’m told my Cerebellum is quite big…I’ve not progressed to MRI analysis yet so I can’t be sure, but I’ll take it as a compliment. If anyone can shed any light on the subject however I’d be grateful.

Anyone looking to get into MRI should try being a volunteer for a brain imaging study so you can get chatting with the researcher, it could lead to a placement or project opportunity.

Happy Scanning!